bluuebunny/crossref_metadata_2025 huggingface dataset:
Chronic Inflammatory Bowel Disease in Childhood
Authors: O'Gorman Molly , Lake Alan M.
Published: December 2021

Definition

Chronic inflammatory bowel disease (IBD) of childhood is generally defined as either ulcerative colitis (UC) or Crohn disease (CD). The inflammation of UC is restricted to the mucosal lining of the colon, with the colonic involvement beginning universally in the rectum and extending proximally continuously. Although proctitis, persistent isolated involvement of the rectum, is common in adults (40%), it is rare in children (<10%). In contrast, the enteric inflammation of CD is transmural and involves any level of the intestinal tract discontinuously. The intervals of relatively normal bowel are termed "skip areas." In CD, characteristic lesions range from oral ulcerations to perianal lesions, although the most frequently involved area is the terminal ileum of the small bowel, a process termed ileitis.

Recognition of these conditions by pediatricians is important because the peak incidence of IBD is in the second decade. Fewer than 5% of patients are diagnosed prior to age 5 years. In many children presenting with isolated colitis, the diagnosis of the chronic inflammation of IBD is established by biopsy before a clinical distinction between UC and CD can be established. These children carry the diagnosis of chronic nonspecific colitis or colitis type indeterminant. In our experience, the disease in approximately 50% of these children evolves within 5 years into more classic cases of UC or CD.
INDEX OF SUSPICION
Authors: Menna Vincent J. , Smith Summer , Liptak Gregory S.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 2-month-old breast-fed boy is brought to the office with a 2-day history of constipation, poor feeding, lethargy, wheezing, and a temperature of 101°F (38.3°C). In the office his temperature is recorded at 98.8°F (37.1°C) rectally. The infant does not appear lethargic, and the only significant physical finding is tearing of the left eye. Because of the history of fever, a complete blood count is obtained, which is normal. The infant is discharged home with a diagnosis of conjunctivitis and possible viremia. He returns within 48 hours and is found to be hypotonic with a poor gag reflex, weak suck, and weak cry. Despite his normal temperature a septic evaluation is initiated.

Case 2 Presentation

A 17-year-old boy complains of bilateral hip pain that has bothered him for the past year.
Tropical Pediatrics
Authors: Fischer Philip R.
Published: December 2021

Tropical pediatrics often is more a study of the consequences of poverty than of exotic infections. Pediatricians involved with the care of children in or from the tropics must deal with poverty, place an appropriate emphasis on preventive medicine, and seek to bridge their own cultural and linguistic barriers. Malaria, diarrheal disease, and malnutrition account for a large part of pediatric morbidity and mortality in tropical countries. P falciparum can cause severe malarial disease. Treatment must be initiated promptly; resistance to antimalarial drugs is possible. Hygienic and nutritional prevention of diarrhea must be coupled with widespread use of oral rehydration therapy for acute cases of diarrhea. Identification and early treatment of mildly malnourished children can prevent some of the mortality of overt marasmus and kwashiorkor.
Near-Drowning
Authors: Fiser Debra H.
Published: December 2021

Definition

Drowning is defined as death caused by submersion, whereas near-drowning connotes survival for some time period following submersion. The following remarks pertain to the near-drowning victim who presents for acute medical management.

Epidemiology

Because reporting of near-drowning incidents is incomplete, most of the available epidemiologic information focuses on drowning deaths, which number more than 6500 per year in the United States. Data from King County, Washington, however, suggest that near-drownings slightly out-number drownings. Drowning rates are highest for children under the age of 5 years and between the ages of 15 and 24 years. Males drown 4 times more frequently than females. African-Americans and low-income groups also are affected disproportionately, except for those drownings involving boats and residential swimming pools, which more often are owned by middle class groups.

Drownings peak during the summer months and are most common in the southern and western United States and Alaska. Forty to 45% of all drownings occur while the victim is swimming and 12% to 29% are boat-related. Alcohol plays a substantial role in these deaths.

Between one half and three quarters of all drownings occur in lakes, ponds, rivers, and the ocean. More than 40% of all submersions in these bodies of water involve older adolescents or young adults.
A Clinical Overview of Systemic Lupus Erythematosus in Childhood
Authors: Lang Bianca A. , Silverman Earl D.
Published: December 2021

Systemic lupus erythematosus (SLE) is an autoimmune disorder resulting in inflammation of multiple organ systems. Although SLE is not common in children, it must be considered in the differential diagnosis of any child who has multisystem disease. The onset of SLE in children may be acute, with severe disease affecting one or more major organ systems, or it may be insidious, with intermittent symptoms of fever, malaise, rashes, arthritis, or pleuritis. SLE also must be considered if a child is found to have a positive antinuclear antibody (ANA) test result. Although almost all children who have SLE have a positive result, this laboratory test alone does not establish the diagnosis of SLE.

Classification Criteria

Eleven disease manifestations are included in the revised classification criteria for SLE established by the American College of Rheumatology (Table 1). These criteria were established as a classification tool to guide in selecting patients for clinical and laboratory studies rather than as a diagnostic system. Nevertheless, they have proven useful in the assessment of both pediatric and adult patients who may or may not have SLE.

Epidemiology

Childhood onset of SLE accounts for approximately 20% of all cases. The annual incidence in the United States is approximately 0.6 cases per 100 000 total population, with higher rates found in the African-American, Oriental, and Hispanic populations.
IgG Subclasses: Importance in Pediatric Practice
Authors: Shackelford Penelope G.
Published: December 2021

Although many clinical studies provide evidence of a relation between IgG subclass deficiency and increased susceptibility to infection, a direct cause-and-effect relationship clearly does not exist. Each patient must be managed in the full context of clinical symptomatology, reliable measurement of IgG subclasses, and evaluation of specific antibody production. Future studies may clarify the factors that stimulate and regulate the production of IgG subclasses and improve our understanding of their role in the health of children.
Otitis Media
Authors: Howie Virgil M.
Published: December 2021

Definitions

When the diagnosis of otitis media has been made on the basis of skilled clinical observation and the tympanic membrane is intact, it is practical to assume that an effusion is present. However, this can be confirmed only by recovery of fluid from the middle ear on tympanocentesis or myringotomy. Several methods will confirm the diagnosis of effusion with the indicated accuracy, as generally reported in the literature (Table 1).

Acute Otitis Media

A common error in the diagnosis of otitis media with effusion (OME) is equating an "injected" or "red" eardrum with OME. Acute otitis media may present with an injected drum, but the critical factor is not drum color but the presence of fluid in the middle ear cavity. The drum frequently is suffused and red when an infant or toddler is crying from either fear or pain during the otoscopic examination. A bulging eardrum, on the other hand, usually is regarded as defining acute otitis media (also called suppurative or purulent otitis media) with or without symptoms (pain, sleeplessness, fever, irritability) of systemic illness.

Experienced clinicians try to avoid the "red ear" error with either tympanometry or acoustic reflectivity (Table 1) or by careful removal of all external ear contents to visualize fully the landmarks (eg, both ends of the malleolus) and their mobility with the pneumatic otoscope.
Physical Abuse of Children: An Update
Authors: Sirotnak Andrew P. , Krugman Richard D.
Published: December 2021

Now, more than ever, physicians must be willing to suspect child abuse and report their concerns. New information from the past decade warns us that reports of violence against children continue to increase. We are learning that MRI imaging of the head may, in some cases, help date subdural hematomas, but long-term developmental follow-up studies of "shaken" infants are lacking. Intentional thoracic and abdominal injuries carry a high mortality. Finally, new information in the field of child abuse—in particular, physical abuse—is slow to come. Lack of funding for basic medical child abuse research and lack of trained researchers in the field are the two most important barriers.20

Preventive intervention at the community and family level needs to be supported by both the pediatrician and the local and national government leaders. As the U.S. Advisory Board on Child Abuse and Neglect says, "We need to make it as easy for parents to pick up the telephone and get help before they abuse their child as it is now for their neighbor or physician to pick up the telephone and report them after it has happened." Child health practitioners may be in the best position to implement such a policy.
INDEX OF SUSPICION
Authors: Friedman Elliott M. , Rotta Alexandre T. , Menna Vincent J.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 13-year-old girl comes to you because it is so painful for her to urinate that she has developed acute urinary retention. Over the past 6 months she has had recurrent mild abdominal cramps; exactly 1 month ago she experienced a similar episode of dysuria. At that time she was able to urinate and was diagnosed by positive culture as having a urinary tract infection, for which she was treated.

While preparing to catheterize her, you notice that this young woman is Tanner stage 5 in breast and pubic hair development, yet she states that she has never had a menstrual period. Her mother recalls her own menarche at age 11 years. Observations during the procedure allow you to determine the underlying cause of her problems.
Epstein-Barr Virus Infection
Authors: Durbin William A. , Sullivan John L.
Published: December 2021

Introduction

Virtually all humans become infected with Epstein-Barr virus (EBV). The vast majority of these infections are inapparent, occur early in life, and are associated with lifelong latent infection and persistent shedding of virus.

Epidemiology

The prevalence of antibody to EBV has been determined in many age groups throughout the world. In developing and tropical areas, infection takes place early in life and is inapparent, with most children demonstrating antibody by age 6 years. Infection is believed to be related to hygiene and crowding as well as to cultural patterns that lead to exposure to saliva (eg, prechewing of food). In contrast, infection in Western Europe and the United States in childhood is less common, with only 35% to 50% of 5-year-olds demonstrating antibody.

Infectious mononucleosis (IM) emerges as a significant clinical entity only in populations where a sizable percentage of young adults lack immunity to EBV. Thus, IM is unknown among college freshman in Thailand or the Philippines, virtually all of whom have antibody to EBV at the time of admission. On the other hand, in schools in the USA and England, where the susceptibility percentage is in the range of 35% to 50%, infection is seen commonly. In such university settings, approximately 12% of susceptible students become infected with EBV during the freshman year.
Eating Disorders in Adolescence
Authors: Harper Gordon
Published: December 2021

Eating disorders challenge the pediatrician in several ways. The treatment course can be long, and the patient's response may be frustrating. Patients find it hard to trust professionals (as they find it hard to trust themselves) and present their situation in provocative terms (eg, "I know what I need to eat; the only problem is that my parents are giving me a hard time.") that ignore the cultural, familial, developmental, and physiological roots of the disorders and minimize the patient's own confusion. The impression projected by the patient that she is "in control" can make it hard to view her sympathetically. Being "in control" of an emaciated body or of chaotic eating is part of the problem.

Unpleasant feelings, such as shame, blame, frustration, inadequacy, rage, and guilt, are felt routinely by patients, parents, and professionals. The risk of serious injury or death is great. The differential diagnosis includes many other serious disorders first presenting in adolescence. For all these reasons, the eating disorders are an important part of pediatric practice, and the pediatrician monitoring the patient's physical well-being and overall development is an indispensable part of the team.

The eating disorders are "model" disorders, whose management requires understanding the physical, physiological, psychological, familial, and cultural dimensions of a teenager's life.
INDEX OF SUSPICION
Authors: Falaki Najla N. , Shannon Michael , Policastro Anthony M.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations with discussions.

Case 1 Presentation

A 7-month-old boy is brought to your office because of swelling in his neck. He has a history of recurrent ear infections and had tympanostomy tubes inserted 2 weeks ago. Some ear drainage has been noted in the last few days. The child has had a recurrent rash on his face and scalp as well as a stubborn diaper rash that has not responded to nystatin ointment. He has had no fever and has been active and feeding well.

On examination, the child appears healthy, and his temperature is 36.5°C (97.8°F) rectally. There is a seborrhealike maculopapular rash on his forehead and scalp, with some interspersed petechiae; inflamed skin is noted in the perineal area.
The Importance of Amy Lynn
Authors: Menna Vincent J.
Published: December 2021

Recently I became a grandfather for the first time, certainly not an unusual event. However, the gestation and birth of this little girl made me more keenly aware of my responsibilities and role as a physician and specifically as a pediatrician. Preoccupation with the practice of medicine and life in general may have clouded the memory of my own children as infants.

In clinical residency, we often would distance ourselves emotionally from seriously ill patients by various defense mechanisms; it was difficult to experience children dying and their parents' grief. Too often, we would use terms or expressions that would be abhorrent to the lay public.
Fever in Children
Authors: Nizet Victor , Vinci Robert J. , Lovejoy Frederick H.
Published: December 2021

Fever is the most common presenting complaints in pediatric practice, accounting for 10% to 20% of office and emergency room visits.

Pathophysiology of Fever

Three pathophysiologic bases exist for fever. The first involves the raising of the hypothalamic set point in the central nervous system. Infection, collagen vascular disease, and malignancies are most commonly responsible. This type of fever is lowered by antipyretics and physical removal of heat. A second type of fever is a result of heat production exceeding heat loss as, for example, in salicylate overdose, hyperthryroidism, excessive environmental temperature, and malignant hyperthermia. The third type of fever is caused by defective heat loss, as seen with ectodermal dysplasia, heat stroke, and poisoning via anticholinergic drugs. Antipyretics are ineffective for the second and third types of fever.

Biologic Process of Fever Reduction

Fever occurs as a result of a number of complex biologic interactions. Exogenous pyrogens, including viruses, bacteria, fungi, antigen-antibody complexes, and drugs, are engulfed by phagocytic leukocytes, leading to the production of an endogenous pyrogen called interleukin-1 (Fig. 1). This compound (also known as lymphocyte-activating factor), in conjunction with interleukin-2, is responsible for increasing the number of helper T cells and initiating the production of prostaglandins in the hypothalamus. Helper T cells are instrumental in fighting infections; prostaglandins are responsible for producing fever.
Atopic Dermititis and Ichthyosis Vulgaris
Authors: Rabinowitz Linda G. , Esterly Nancy B.
Published: December 2021

Atopic dermatitis remains a common skin problem in the pediatric age group. General approaches to management focus on reducing inflammation and pruritus as well as preventing xerosis. Ichthyosis vulgaris is the most common form of the ichthyoses and often is associated with atopic dermatitis. Recognition of these conditions is necessary to institute therapy that will alleviate the discomfort experienced by affected individuals.
Neonatal Hyperbilirubinemia
Authors: H R J
Published: December 2021

We planned to publish a comprehensive review article on neonatal jaundice in this issue. Concurrently, the Academy's Committee on Practice Parameters is developing a statement on this topic. Because it was not complete by the time this issue had to be "put to bed," readers and pediatricians (especially subspecialists) taking the recertification examination in 1995 should look for publication of the parameters, and Pediatrics in Review will publish the review at a later date.
Neonatal Resuscitation
Authors: Wimmer John E.
Published: December 2021

Introduction

Prompt, skillful resuscitation of distressed neonates in the immediate postpartum period is one of the most important responsibilities of the practicing pediatrician. The potential for death or life-long morbidity is high in these Vulnerable infants, but it can be reduced dramatically by effective intervention. Because many of these situations are unpredictable, all deliveries should be attended by at least one person skilled in neonatal resuscitation, and additional help should be readily available.

Although a certain amount of practice is needed to master and maintain the necessary manual dexterity skills, the vast majority of neonatal resuscitations are relatively simple procedures. Most depressed infants respond to ventilation with oxygen; only a few require chest compressions or medication. Vascular access usually is not needed, and most infants can be ventilated adequately by bag and mask. Advance preparation and adherence to a few basic principles are the keys to effective intervention.

The role of the pediatrician should go beyond maintaining expertise in neonatal resuscitation and responding to emergencies. Pediatricians should be teachers and role models for obstetricians, nurses, and other health professionals involved in perinatal care. They should be participate in planning for and monitoring the performance of neonatal resuscitation. They also must provide acute care and follow-up for resuscitated infants.
INDEX OF SUSPICION
Authors: Leopold John C. , Sirotnak Andrew P. , Ryan Joseph , Menna Vincent J.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 13-year-old boy who has been in good health previously comes to the pediatric clinic with a history of a pruritic red rash that comes and goes for several hours after he has been swimming. This rash has been a problem for the last 5 days.

Two days ago, after swimming, he developed a diffuse rash together with periorbital edema and a burning sensation on his back. He suddenly became lightheaded and collapsed into his mother's arms, losing consciousness briefly. By the time he arrived at the emergency department, the rash was gone and his examination was normal. No treatment was prescribed.

Yesterday, while washing the family car with cold soapy water, his right arm and hand swelled and turned solidly red in a "glove" distribution.
Intestinal Obstruction in the Newborn
Authors: Ross Arthur J.
Published: December 2021

Obstruction of an infant's gastrointestinal (GI) tract can occur anywhere from the esophagus to the anus. For purposes of this review, the newborn infant will be defined as an infant from birth to 30 days of age. Both congenital and acquired obstructions will be addressed. In each instance, the epidemiology, pathogenesis, clinical aspects, and management of the disorder will be considered.

Esophageal Atresia

EPIDEMIOLOGY AND PATHOGENESIS

Esophageal atresia, or interruption of the esophagus, generally occurs in association with a tracheoesophageal fistula (EA - TEF). The most common anatomic arrangement is a blind proximal esophageal pouch that has a distal tracheoesophageal fistula (Figure 1). This is seen in 85% to 90% of infants who have this anomaly. Seen less commonly is pure esophageal atresia that does not have a tracheoesophageal fistula and tracheoesophageal fistula that does not have an esophageal atresia (H-type tracheoesophageal fistula). These latter two conditions occur in approximately 10% of newborns who have these types of anomalies. Other anatomic arrangements, such as an esophageal atresia that has a fistula between the upper pouch and trachea or esophageal atresia that has a fistula to both pouches, are seen in only a tiny fraction of these infants.

EA - TEF occurs in approximately 1 in 4000 live births.
Consultation with the Specialist
Authors: Neilson Ian R.
Published: December 2021

Witnessing the ingestion of a foreign body by a toddler is alarming and immediately raises several questions. What are the risks of aspiration and airway obstruction? Where do foreign bodies get stuck? Are investigations necessary in the absence of symptoms? How long can objects be watched at different locations? What complications can result? When should objects be removed and which procedure should be used? When can cathartics or enemas be given safely?

Predisposing Factors

The peak age range for foreign body ingestion is 6 months to 3 years. There are underlying social, developmental, or psychiatric risk factors in up to 30% of cases. Ingestions in older children usually are accidental. Symptoms occasionally can suggest an underlying abnormality such as an esophageal stricture or might be related to a previous surgical procedure such as the repair of an esophageal atresia or a pyloromyotomy for pyloric stenosis. Children who have had esophageal atresia repaired also have associated dysmotility of the distal segment.

The Need For Radiologic Investigations

The nature of the ingested foreign body obviously influences management. Directed questions or a search of the home for missing objects often will reveal the nature of the ingested object. The presence of symptoms such as choking, dysphagia, substernal discomfort, persistent cough, or of physical findings such as drooling mandates a radiologic search for foreign bodies from oropharynx to anus.
INDEX OF SUSPICION
Authors: Conners Gregory P , Sheeran Paul W. , Miller Harry S.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 16-year-old right-handed girl comes to you complaining of a "funny bend" in her left ring finger. She first noticed it 2 days ago, after a martial arts practice session during which she was blocking kicks with her bare hands. After practice, she had pain and considerable ecchymosis in the distal portion of her finger and was unable to extend her distal interphalangeal joint (DIP) fully. The finger has not improved after 2 days of rest, ice, and ibuprofen. She denies other medical or orthopedic problems and has been taking no other medications.

On physical examination, the DIP joint of her left ring finger assumes a position of 30 degrees of flexion at rest; she can flex the joint fully but is unable to extend it beyond the resting position.
Amphotericin B
Authors: Abadi Jacobo
Published: December 2021

There are many circumstances in which pediatricians today may be involved in the care of patients at risk for systemic fungal infection. Among those at risk are children receiving chemotherapy for neoplastic disease, children infected with human immunodeficiency virus (HIV), and children undergoing immunosuppressive therapy for chronic illnesses or after transplantation. Available since 1960, amphotericin B (Am B) remains the treatment of choice for most serious fungal infections.

A fermentation product of the soil actinomycete Streptomyces nodosus, Am B binds selectively to ergosterol in the cell membrane of susceptible fungi, inducing changes in permeability that can produce lethal cell injury. Pharmacokinetic studies have sown that Am B is absorbed poorly when taken orally, necessitating intravenous administration.
Osteomyelitis
Authors: Roy Dennis R.
Published: December 2021

Osteomyelitis, defined as an inflammation of bone generally caused by a pyogenic organism, is a common disorder of childhood. Infection most commonly is caused by blood-borne bacteria that localize in the metaphysis. Trauma or surgery also may result in direct inoculation or implantation of bacteria into the bone, or an adjacent focus of infection might extend directly to the bone, resulting in osteomyelitis.

The etiology of acute hematogenous osteomyelitis is not understood completely. Bacteremia in childhood occurs frequently, if not daily; thus, the presence of bacteria alone may not explain why infection begins. Recent trauma coincidental with a bacteremia has been postulated. The presence of an intercurrent illness (ie, chicken pox) or infection may introduce a larger number of organisms or different pathogenic bacteria into the system or alter the immune system, making the host more susceptible.

An understanding of the anatomy of bone and the pathogenesis of osteomyelitis is essential to appreciate the protean manifestations of the disorder.

Pathogenesis

In acute hematogenous osteomyelitis, infection is localized in the metapahysis. The circulation of the bone predisposes this region to the infection. Epiphyseal and metaphyseaal blood supplies generally are separate. The blood supply to the metaaphysis originagtes when the nutrient arteries send small terminala branches that end at the growth plate.
Poverty and Health
Authors: Racine Andrew D.
Published: December 2021

The effect of poverty on the health of children is profound and enduring. Although the United States ranks seventh in per capita income among the world's industrial societies, at least one in five American children currently lives in a family whose income is below the federal poverty level. The extent to which material deprivation of this magnitude harms these children can be measured through a variety of instruments, including vital statistics, population surveys based on parental report, and health examination surveys.

Wise and Meyers provided a recent overview of the relationship between poverty and child health. They characterized a dual mechanism by which poverty may increase the risk of ill health among children: It can increase the probability of adverse events occurring and it can augment the impact that these events have on the children to whom they occur.
Cerebral Palsy
Authors: Taft Lawrence T.
Published: December 2021

To be classified as cerebral palsy (CP), there must be difficulty in neuromotor control, a nonprogressive brain lesion, and an injury to the brain that occurred before it was fully mature. The term "cerebral palsy" should be used only if a static encephalopathy exists. If there is any question that a progressive central nervous system disorder exists, the term "cerebral palsy" should not be used diagnostically until the status of the lesion is clarified.

Although the primary abnormality must be a motor deficit, often there are many associated symptoms of cerebral dysfunction present.

Incidence and Prevalence

The prevalence of CP has changed very little over the past 40 years, in spite of many technological advances that have decreased mortality in compromised preterm and full-term infants. The prevalence rate has been estimated to be between 2 and 5 per 1000 live births. At 12 months of age, the prevalence rate was estimated to be 5.2 per 1000, but at 7 years of age, the rate was estimated to be 2 per 1000 live births. This indicates that many children who showed signs or experienced symptoms suggesting a motor disorder did not have CP on follow-up.

The past 3 decades have seen an increased survival rate of very small preterm infants, resulting in a change in the percentage rates of the different clinical types of motor disabilities among patients classified as having CP.
Consultation with the Specialist
Authors: Vadasz Andrew G. , Epstein Leon G.
Published: December 2021

Many general pediatricians feel that the assessment of an infant or child who has a developmental delay and possible neurologic impairment is one of their most difficult challenges. Frequently the parents or relatives, during the course of a well-child visit, first voice concerns about the failure to attain or master one or more expected developmental milestones. Other times the pediatrician is the first to note a problem with development in one or more areas. One of the most important tasks for the pediatrician is to be able to identify the subset of patients who may have a progressive rather than a static neurologic process and to refer them promptly for further evaluation of a possible neurodegenerative disorder.

In the past, the diagnosis of a childhood neurodegenerative disease was associated with a sense of hopelessness; frequently, the need for a definitive diagnosis was questioned. Breakthroughs in our understanding of the genetic and biochemical basis of many of these disorders, together with advances in enzyme replacement and gene therapy, have made antenatal diagnosis, treatments, and even cures a reality.

The numerous types of central nervous system (CNS) degenerative diseases encountered in children go beyond the scope of a few pages and are covered well in the standard texts (see the excellent chapter by Johnson and Rapin in Rudolph's Pediatrics, 19th ed, 1991).
Antibiotic Drug Levels
Authors: Rosenberg Michael G.
Published: December 2021

In the past, efficacy, as defined by controlled clinical trials, was the primary factor in the selection of a particular antibiotic regimen. Today, as the number of antimicrobial agents approved for clinical use has grown almost exponentially, efficacy rarely is emphasized in published clinical trials. More commonly they demonstrate therapeutic equivalence rather than superiority of new compounds to previously accepted regimens. For this reason, the two criteria that now factor most prominently into the selection of equally effective antibiotics are relative toxicity and cost.

Three major classes of antibiotics used throughout the world in the treatment of serious pediatric infectious diseases are chloramphenicol (CAP) and its derivatives, aminoglycosides (AGs), and vancomycin and related glycopeptides.
The Child Who Has A Limp
Authors: Renshaw Thomas S.
Published: December 2021

A limp is defined generically as any deviation of child's walking pattern from the expected normal pattern for the child's age. Limping more commonly is unilateral than bilateral, and its many causes range in severity from malfitting shoes to highly malignant bone tumors.

Specific reasons for limping fall into one or more of three categories: pain, weakness, and structural abnormalities. An antalgic gait may be caused by such painful conditions as synovitis of a major weight-bearing joint; infection of bone, joint, or soft tissue; neoplasia; or trauma from such things as repetitive microtrauma, a torn knee cartilage, or a chronic stress fracture. Musclle weakness can result from disuse atrophy or from a neurologic or a primary muscle disease. The structural or mechanical causes include limb length inequality, joint stiffness, and articular surface deformity.

The anatomic origin of the limp may be the foot, ankle, leg, knee, thigh, hip, spine, or even the abdomen. It follows, therefore, that a careful and thorough history and physical examination are mandatory for the child who has a limp and that all of theses anatomic areas be evaluated carefully.

The history should include the duration of the limp, the child's or parents' perception of its site of origin, if possible, and whether pain is associated.
Preparing for Pediatric Emergencies
Authors: Seidel James
Published: December 2021

• A 2-week-old infant stops breathing in your waiting room.

• A frantic mother comes to the office carrying her 2-year-old son, who has just aspirated a balloon.

• A 6-year-old is brought to the office with a partial thickness burn of the right arm.

• A mother calls the office and states that her 15-month-old child bit into an electrical cord.

• A 5-year-old boy falls from a tree at school and is brought into the office.

• A 9-year-old girl has an anaphylactic reaction to a penicillin injection.

• A 5-year-old boy cuts his foot on a piece of rusty metal in a barnyard and has only had two tetanus immunizations.

These scenarios all can occur in the office. The literature, as well as a periodic survey done by the American Academy of Pediatrics, suggests that many offices are not prepared to manage these and other emergencies. In some practices, the staff have not received formal training in cardiopulmonary resuscitation (CPR), even though ill patients are seen regularly and injectable medications are dispensed.

Staff and Office Preparation

The issues that are important in preparing for an emergency involve: staff education; equipment and supplies; management guidelines, protocols, and procedures; and resuscitation practice sessions.

STAFF EDUCATION

All office staff should be trained in basic life support, including foreign body removal, rescue breathing, and chest compressions.
Choanal Atresia
Authors: Menasse-Palmer Lisa , Bogdanow Anna , Marion Robert W.
Published: December 2021

Choanal atresia is an abnormality of canalization during development of the nasal passages. It involves bone and/or soft tissue and may result in either partial (choanal stenosis) or complete obstruction of the posterior nasal airway. The most widely accepted mechanism for the development of choanal atresia is the persistence of the oronasal membrane beyond the sixth week of gestation, but abnormal migration of cephalic neural crest cells following neural tube closure also has been implicated.

The incidence of choanal atresia is 1 in 7000 to 8000 live births. It is more common in females (2:1), more likely to be bony or cartilaginous than membranous (9:1), and more commonly unilateral and right-sided (2:1).
Separation Anxiety
Authors: Jellinek Michael S. , Kearns M. Elyce
Published: December 2021

Fear in reaction to danger potentially leads to life-saving "fight or flight." Anxiety is intrinsic to fear, and the young infant experiences anxiety during the earliest inevitable separations from caretakers. Over time, a child learns to experience anxiety in anticipation of fear, whether this fear is based on a true impending danger or a separation (eg, being left to fall asleep at bedtime).

Bowlby, recognizing the infant's life and death dependency on a caretaker, defined separation as the "basic anxiety of infancy." The mother's leaving is so potentially dangerous that the infant responds with a piercing cry that reflects both protest and anxiety while calling forth the mother's return. This cry is a paradigm for what we all face when we experience the inevitable losses of loved ones or even our own hopes.

Anxiety secondary to separation can continue beyond the expected age and interfere with a child's ability to function. Separation anxiety disorder may prevent a child from achieving critical developmental milestones, such as leaving his or her parent to play with friends or go to school. The early recognition of unwarranted or excessive separation anxiety may help limit potentially serious dysfunction.

Separation anxiety can be expected to begin to ease for most children at 18 months of age with the cognitive mastery of object permanence and the growing security of consistent caretaking.
Proper Use of the Clinical Microbiology Laboratory
Authors: Christenson John C. , Overall James C.
Published: December 2021

The interaction between clinicians and microbiology laboratory staff has to be one of mutual benefit. The more the laboratory personnel know about your patients, the more meaningful and thorough will be the results. Communication is the key to success. Visit the microbiology laboratory and get to know the staff. The clinician also needs to be familiar with and use the most commonly used diagnostic tests for individual bacterial pathogens appropriately.
Thumbsucking
Authors: Rosenberg Maris D.
Published: December 2021

Thumbsucking is a form of non-nutritive sucking occurring as early as the 29th week of gestation; it is seen commonly in infants and peaks at 18 to 21 months of age. Developmentally normal children possess an inherent biological drive for sucking, the explanation for which can be found in both psychoanalytic and learning theory. Psychoanalytic theory contends that non-nutritive sucking represents a biological drive resulting from pleasurable stimulation of the lips and mouth; learning theory proposes that the infant learns to associate sucking with pleasurable feelings such as satiety or being held. Whatever the theoretical basis, thumbsucking generally is viewed as a biological drive that develops into a habit, which in the majority of cases resolves by age 4 years, but can persist much longer.
Antifungal Drugs
Authors: Cross J. Thomas , Hickerson Steven L. , Yamauchi Terry
Published: December 2021

Introduction

Fungi have been recognized as pathogens for many years. However, the incidence of fungal infections in the pediatric population has increased substantially due to the increased use of broad-spectrum antibiotics, immunosuppressive agents, hyperalimentation products, and central venous catheters in addition to the acquired immunodeficiency syndrome (AIDS) epidemic. The physician involved with the care of children should know the agents effective against these pathogens (Table 1). Amphotericin B has a long history of both efficacy and toxicity because it was the only available systemic agent for many years. With the introduction of ketoconazole, fluconazole, and itraconazole over the past decade, the decision of which agent to use has become much more difficult. Clinical trials are underway to help answer these questions, but until these are completed, the clinician must weigh the risks and benefits of therapy for each patient individually.

Amphotericin B

BACKGROUND

Amphotericin B is entering its fourth decade as an antifungal agent. Since its introduction in the mid-1950s, it has been the cornerstone of management of systemic fungal infections. Even with the introduction of the azoles, it continues to be the treatment of choice for many conditions.

CHEMISTRY, MECHANISM OF ACTION

Streptomyces nodosus, a soil actinomycete, is the source of the amphotericins A and B. Amphotericin B is the commercially available product, and it may contain a small amount (<5%) of amphotericin A.
Acute Renal Failure: Therapy
Authors: Sehic Azra , Chesney Russell W.
Published: December 2021

General Therapy for Acute Renal Failure In most cases of ARF without complication, treatment should be conservative and largely supportive. It requires careful and precise management. All patients will require close monitoring, many of them within intensive care settings.

Supportive care includes stabilizing the patient, monitoring input and output strictly weighing daily, determining electrolyte values frequently, preventing sepsis via reducing the number of intravenous lines and removing an indwelling urinary catheter, culturing periodically, and using antibiotics when indicated clinically. It is important to adjust medication dosage according to renal function and to avoid nephrotoxins whenever possible. Because serum creatinine values increase daily, it is best to calculate drug doses based on GFR <10 mL/min per 1.73 m2, rather than on the serum creatinine level.

Conservative therapy may be symptomatic or specific. Symptomatic therapy consists of treating the underlying prerenal conditions that led to renal failure; maintaining the fluid and electrolyte balance; initiating therapy for complications such as hyperkalemia, hypertension, acidosis, and infection; and instituting appropriate nutrition. Specific therapy consists of using medications for specific underlying causes and may include steroids (conventional or high-dose pulse steroid therapy) and other immunosuppressive agents, anticoagulation agents, plasmapheresis, or intravenous immunoglobulin.

THERAPY FOR PRERENAL FAILURE

Rapid volume replacement and treatment of the underlying condition that resulted in prerenal failure are the cornerstones of therapy.
Diaper Dermatitis
Authors: Singalavanija Srisupalak , Frieden Ilona J.
Published: December 2021

Epidemiology

Diaper rashes are among the most common skin disorders of infancy. In one survey of 1089 infants, diaper dermatitis occurred in 50%; however, only 5% had severe rash. The peak incidence of diaper dermatitis is between 9 and 12 months of age. The relation between age and the frequency of diaper dermatitis may result from several factors, including dietary changes from breast milk to formula milk and solid foods during the first 12 months of life. Breastfed infants have fewer diaper rashes than do formula-fed infants. The incidence of diaper dermatitis is 3 to 4 times higher in infants who have diarrhea.

The frequency and severity of diaper dermatitis are significantly lower when the mean number of diaper changes per day is eight or more, regardless of diaper type. Infants using superabsorbent disposable diapers have a significantly lower frequency and severity of diaper rash when compared with infants using cloth diapers.

Diaper Types

There currently are two types of diapering systems: reusable cloth diapers and single use (disposable) diapers. Cloth diapers provide containment through multiple layers of cotton fabric, usually aided by the use of plastic or cloth overpants. Nearly all disposable paper diapers now contain an absorbent gelling material within the cellular core.
Infective Endocarditis
Authors: Danilowicz Delores
Published: December 2021

A high level of suspicion is of utmost importance in the diagnosis of endocarditis, particularly in the patient at risk who may have received antibiotic treatment for the prodrome. Treatment with adequate levels of a bactericidal drug based on an identified organism will give the highest percentage of cures. Early treatment may prevent damage to cardiac structures and lessen further complications related to emboli or progressively enlarging vegetations. The combination of a high-risk patient with either resistant bacterial endocarditis or fungal

[See table in the PDF file]

endocarditis carries a higher morbidity and will account for most of the mortality. Although not an ideal answer, SBE prophylaxis is justified from observations in animals and should be recommended strongly to the parents and to the patient as she or he gets older.

Because an increasing number of children survive their congenital heart defects but remain at risk for acquiring SBE and because an increasing number of preterm infants and neonates are exposed to indwelling catheters, the pediatrician will continue to see IE presenting as both a diagnostic dilemma and an acute treatment problem. The emergence of children who are human immunodeficiency virus-positive or who have acquired immunodeficiency syndrome has increased the group at immunologic risk, as has an increasing population of children surviving organ transplants. These children can present more often with infections caused by nosocomial, resistant agents because of their frequent hospitalizations, and they may have a variety of opportunistic infections from organisms that normally are not pathogens. Unfortunately, a higher mortality rate can be expected among these children.

The diagnosis of IE is made even more of a challenge because it accounts for only about 1/1000 to 1/4500 hospital admissions to pediatric services. In tertiary care hospitals that have an active pediatric cardiac service, the numbers may be higher. The most important element in diagnosing endocarditis remains its early consideration as a possibility in any child who has a persistent unexplained febrile illness and its being the first consideration in a high-risk child.