bluuebunny/crossref_metadata_2025 huggingface dataset:
Fluctuating Blood Pressure and Intraventricular Hemorrhage
Authors: MIALL-ALLEN VIVIENNE
Published: December 2021

In Reply.—

We would like to thank JM Perlman and JJ Volpe for their comments on our recent article.1 They were surprised that we did not observe the "excessive" levels of blood pressure fluctuation (coefficient of variation up to 30% or more) which they obtained for cerebral blood flow velocity in infants at greatest risk of developing IVH (Perlman et al2,3). We were surprised by this too; and, as we commented in the discussion, this disparity is difficult to explain.
Solar Intensity and Sun Protection
Authors: WEINSTOCK MARTIN A.
Published: December 2021

In Reply.—

Drs Weyrauch and Boiko cite the examples of Charleston, SC (33 latitude and 862 BTU per day solar radiation in July) and Spokane, WA (48 and 1314 BTU) to illustrate that factors other than latitude affect the overall intensity of solar radiation. Other complexities are worth noting. Cloud cover affects the average intensity of solar radiation, but the peak intensity on sunny days may be particularly relevant for melanoma. Furthermore, it is likely that the short wavelength ultraviolet component of sunlight is primarily responsible for the ability of the sun to cause melanoma, and this component is more dependent than other wavelengths on latitude.1
Dangers of Arterial Catheters in Critically III Neonates
Authors: WEINBERG GERARD , BRION LUC P. , VEGA-RICHF CARLOS R.
Published: December 2021

To the Editor.—

We read with interest the recent article in Pediatrics.1 The authors present a case of aortic thrombosis associated with umbilical catheterization in a newborn delivered to a cocaine-addicted mother. We agree with the authors that the presence of an arterial catheter is the most likely cause of the arterial thrombosis, whereas cocaine may have had an additional vasoconstrictive effect. It would be interesting to know whether any placental infarct had been noted at the time of delivery.
Protective Efficacy of Haemophilus influenzae Type b Polysaccharide Vaccine
Authors: Shapiro Eugene D. , Berg Anne T.
Published: December 2021

There has been uncertainty and controversy about the protective efficacy of Haemophilus influenzae type b polysaccharide vaccine almost since it first was licensed in the United States. This article will briefly review the available epidemiologic data about the protective efficacy of this vaccine in children with no recognized underlying illnesses.

H influenzae type b polysaccharide vaccine was licensed in the United States in April 1985, based on the results of a randomized clinical trial that was conducted in Finland.1 That study indicated that the vaccine's protective efficacy was 90% against invasive disease caused by H influenzae type b in children 18 to 71 months of age. Authorities recommended that all children receive the vaccine at 2 years of age and that it be administered to children up to the age of 60 months.2,3 The Immunization Practices Advisory Committee also recommended that children at increased risk (such as those who attend group day care) receive the vaccine at 18 months and again at 24 months of age because of its inconsistent immunogenicity when administered to 18-month-old children.2

Soon after its licensure, however, reports of vaccine failures began to appear. In some instances the vaccine failure could be attributed to an identifiable immune deficiency.4,5 However, Granoff et al6 reported 54 apparently normal children who had received the H influenzae type b polysaccharide vaccine but subsequently developed invasive disease caused by H influenzae type b. The majority of these children had normal serum concentrations of total immunoglobulins, IgG2, hemolytic complement, and antibody to tetanus toxoid (a T-cell-dependent antigen).
Comparative Immune Responses to Haemophilus influenzae Type b Polysaccharide and a Polysaccharide-Protein Conjugate Vaccine
Authors: Kim Kwang Sik , Wong Victor K. , Adler Robert , Steinberg Evan A.
Published: December 2021

Haemophilus influenzae type b is the most common cause of bacterial meningitis in children in the United States. Antibody to the capsular polysaccharide of this organism, polyribosylribitol-phosphate (PRP), is important in protecting against invasive disease. In 1985, H influenzae type b vaccine containing only PRP was licensed in the United States for use in children 24 to 59 months of age.

Studies conducted in the United States and Finland have shown that PRP vaccine is safe and immunogenic in children older than 18 months of age.1,2 In Finland, an efficacy of approximately 80% was obtained when PRP vaccine was used to prevent invasive disease caused by H influenzae type b in children older than 24 months of age.3 The immunogenicity of the PRP vaccine in children 18 to 23 months of age, however, was not clearly established. Reported rates of seroconversion after receipt of a single dose of PRP vaccine ranged from 20% to 75%1.3-5

The purpose of our studies was to evaluate the immunogenicity y of PRP vaccines and of conjugate vaccine (PRP-Neisseria meningitidis outer membrane protein complex [PRP-OMPC]) in children from the Los Angeles area.

First, we conducted a randomized, prospective study to compare the immunogenicity of the PRP vaccines produced by three manufacturers. A total of 147 healthy children between the ages of 18 and 58 months were recruited from Childrens Hospital of Los Angeles and Kaiser Foundation Hospital, Los Angeles, to receive, according to a prepared randomization schedule, 25 µg of the following PRP vaccines: Hib-Immune, lot 184-669, 190-654; Hib-Vax, lot 7L91071, 7D91043; or b-CAPSA I, lot M087BD, M068BC.
Haemophilus influenzae Type b Conjugate Vaccine (Meningococcal Protein Conjugate) (PedvaxHIBTM): Clinical Evaluation
Authors: Ahonkhai Vincent I. , Lukacs Linda J. , Jonas Leslie C. , Matthews Holly , Vella Philip P. , Ellis Ronald W. , Staub Joan M. , Dolan Kathleen T. , Rusk Cynthia M. , Calandra Gary B. , Gerety Robert J.
Published: December 2021

Although systemic infections caused by Haemophilus influenzae type b occur worldwide, detailed epidemiologic data are available in but a few countries.1-3 The public health impact of morbidity, mortality, and serious sequelae from disease caused by H influenzae type b has stimulated the search for control strategies. In the United States now, active immunoprophylaxis is largely favored over treatment or prophylaxis with antibiotics. This preference stems from three major observations: that high mortality and morbidity persist despite the availability of potent antimicrobial agents, that antibiotic-resistant strains of H influenzae type b have emerged, and that implementation of antimicrobial prophylaxis on a large scale has been unsatisfactory. Moreover, universal vaccination has been projected as offering a higher economic benefit than other control strategies.4

A matter of more proximate importance, however, is the search for H influenzae type b vaccines that will confer protection to all age groups, including infants younger than 18 months of age and subpopulations specifically at risk for invasive disease caused by H influenzae type b. Haemophilus b conjugate vaccine (meningococcal protein conjugate), PedvaxHIBTM (PRP-OMPC), is a conjugate H influenzae type b vaccine developed at Merck Sharp & Dohme Research Laboratories that now is undergoing extensive clinical evaluation to assess its prospects for disease control when first administered in early infancy. This is an interim report of results obtained in studies conducted in diverse locations throughout the United States.

METHODS

Study protocols were approved by Merck Sharp & Dohme Research Laboratories and the Institutional Review Board of each center. Written informed consent was obtained from the parents of subjects at the time of enrollment into each study.
Opsonophagocidal Activity in Sera From Infants and Children Immunized With Haemophilus influenzae Type b Conjugate Vaccine (Meningococcal Protein Conjugate)
Authors: Gray Barry M.
Published: December 2021

Immunization with Haemophilus influenzae type b capsular polysaccharide (polyribosylribitol-phosphate [PRP]) has resulted in limited and variable antibody radioimmunoassay in infants younger than 2 years of age. Although an H influenzae type B vaccine has been in use for several years, it is not used now for the age group at greatest risk for disease. In an effort to enhance immunogenicity, PRP has been coupled to various carrier proteins and to an outer membrane protein complex (OMPC) from Neisseria meningitidis group B.1,2 The latter approach has yielded a vaccine that elicits a good antibody response after a single 15-µg dose of vaccine in infants as young as 2 months of age, as measured by radioimmunoassay and immune bacteriolysis.3,4 In this report we describe the results of a pilot study using this H influenzae type B conjugate vaccine, PedvaxHIB, in children from 2 months to 4 years of age. Three different vaccine lots were examined for consistency of response. Sera were measured for antibody levels by radioimmunoassay and for functional activity using an opsonophagocytic assay using human adult neutrophils. These assays correlated well and demonstrated the excellent immune response and biologic activity of sera from infants vaccinated with this unique H influenzae type B conjugate vaccine.

MATERIALS AND METHODS

Subjects

Infants and children were part of a multicenter study to assess the safety and immunogenicity of PedvaxHIB.3 They ranged in age from 2 to 51 months and were from various socioeconomic backgrounds and geographic areas of the United States. All were in good health, and informed consent was obtained from the parents of all participants.
Microbiology of Empyema in Children and Adolescents
Authors: Brook Itzhak
Published: December 2021

The microbiology of empyema was studied in 72 children and adolescents whose specimens yielded bacterial growth after inoculation for aerobic and anaerobic bacteria. A total of 93 organisms, 60 aerobic or facultative and 33 anaerobic, were isolated. Aerobic bacteria was isolated in 48 (67%) patients, anaerobic bacteria in 17 (24%), and mixed aerobic and anaerobic bacteria in 7 (10%). The predominant aerobic or facultative bacteria were Haemophilus influenzae (15 isolates), Streptococcus pneumoniae (13), and Staphylococcus aureus (10). The predominant anaerobes were Bacteroides sp (15 isolates, including 7 Bacteroides fragilis group and 5 Bacteroides melaninogenicus group), anaerobic cocci (9), and Fusobacterium sp (6). β-lactamase activity was detected in at least one isolate in 20 (37%) of the 54 tested patients. These included all 8 tested S aureus and 7 B fragilis group, 3 of 10 H influenzae, 2 of 4 B melaninogenicus group, and 1 of 2 Klebsiella pneumoniae. Most cases of S pneumoniae and H influenzae were associated with pneumonia. The recovery of anaerobic bacteria was mostly associated with the concomitant diagnosis of aspiration pneumonia, lung abscess, subdiaphragmatic abscess, and abscesses of dental or oropharyngeal origin. The data highlight the importance of anaerobic bacteria in selected cases of empyema in children and adolescents.
Pulmonary Function Testing Reference Values and Interpretations in Pediatric Training Programs
Authors: Pattishall Edward N.
Published: December 2021

A questionnaire was sent to all pediatric training programs to evaluate the use of pulmonary function reference standards and the interpretation of pulmonary function test results. Responses were obtained from 107 of 130 institutions, and 94 of these had pulmonary function laboratories available. Of the 94, 60 used one of three reference standards. The primary reason the reference standards were chosen was either unknown or because they came with the spirometer (24), were recommended by another person or were those used in that person's training (34), or were thought to be the best standards available or most applicable to the population to be tested (31). To define abnormality, most used an 80% predicted cutoff for forced vital capacity, forced expiratory volume in 1 second, and forced expiratory flow at 25% to 75% vital capacity. For a change in an individual through time, most used a 10% change for forced vital capacity, forced expiratory volume in 1 second, and forced expiratory flow at 25% to 75% vital capacity. Thirteen used statistical methods to define abnormal individuals and none used statistical methods to define a significant change over time. Although there are a few guidelines for reference standards and interpretations of pulmonary function tests, it appears that most laboratories are not using those guidelines and that further guidelines and education are needed.
Role of Stereotactic Radiosurgery With a Linear Accelerator in Treatment of Intracranial Arteriovenous Malformations and Tumors in Children
Authors: Loeffler Jay S. , Rossitch Eugene , Siddon Robert , Moore Matthew R. , Rockoff Marc A. , Alexander Eben
Published: December 2021

Between 1986 and 1988, 16 children were treated for 10 arteriovenous malformations and 6 recurrent intracranial tumors with stereotactic radiation therapy using a modified Clinac 6/100 linear accelerator. The median age of our patients was 10.5 years. For the group with arteriovenous malformation, follow-up ranged from 6 months to 37 months (median was 20 months). No patient bled during the follow-up period. Five of eight patients with follow-up longer than 12 months have achieved complete obliteration of their arteriovenous malformation by angiogram. The four remaining patients who have not achieved a complete obliteration are awaiting their 2-year posttreatment angiogram. The other patient has been treated within the year and have not yet been studied.

Five of the six recurrent tumor patients are alive with a median follow-up of 8 months. The remaining patient was controlled locally, but he died of recurrent disease outside the area treated with radiosurgery. The radiographic responses of these patients have included three complete responses, two substantial reductions in tumor volume (>50%) and one stabilization. Despite previous radiotherapy, there have been no significant complications in these patients.

We conclude that stereotactic radiation therapy using a standard linear accelerator is an effective and safe technique in the treatment of selected intracranial arteriovenous malformations and tumors in children. In addition, stereotactic radiosurgery may have unique applications in the treatment of localized primary and recurrent pediatric brain tumors.
Stature and Weight Status of Children in an Urban Kindergarten Population
Authors: Kumanyika Shiriki K. , Huffman Sandra L. , Bradshaw Mary Ellen , Waller Hattie , Ross Alan , Serdula Mary , Paige David
Published: December 2021

To assess the prevalence of growth problems among school entrants in an urban population who were not preselected on poverty or other nutritional risk criteria, we analyzed height and weight measurements for 5170 4- and 5-year-old children (91.9% black, 5.5% white, and 2.6% Hispanic) who enrolled in District of Columbia public school kindergartens in the Fall of 1985. Compared to the National Center for Health Statistics reference, the white girls and boys were of average height, Hispanic girls were of average height, and Hispanic boys were shorter than average. The black girls and boys were taller than average. In light of published evidence for black-white differences in the timing and duration of growth, we tentatively attributed this tall stature to advanced skeletal maturation of the black children relative to the predominantly white United States population growth standards. Underweight was virtually absent in this population. Excess overweight was noted in all sex-racial/ethnic subgroups, particularly among Hispanic children. However, the extent to which overweight (high weight-for-height percentile) represents obesity in kindergartenaged children and in different racial/ethnic groups needs clarification before the implications of the finding of excess overweight can be fully understood. Overall, the growth of these children was on a par with the National Center for Health Statistics growth reference population.
Postneonatal Circumcision: Population Profile
Authors: Larsen Gordon L. , Williams Scott D.
Published: December 2021

Because postneonatal circumcision includes the risk of general anesthesia and costs more than elective neonatal circumcision, a retrospective study was performed to describe the population currently undergoing postneonatal circumcision and to identify the factors influencing decisions that lead to this procedure. A chart review and follow-up telephone survey were done to gather information concerning patients admitted for postneonatal circumcision to two Salt Lake City hospitals during a 2-year period. From the 135 patients eligible for analysis, two distinct groups emerged: the "sick" group (n = 52)—those who had neonatal complications, and the "well" group (n = 83)—those with no neonatal complications. The median age at circumcision was 5.5 months for the boys in the sick group and 35 months for the boys in the well group (P < .001, Student's t test). During the neonatal period, 32% of families in the well group received anticircumcision advice from their primary care physician. The decision in favor of circumcision was made by two thirds of the families of sick infants before their sons were 6 weeks of age. Other surgery was performed concurrent with the circumcision in 44% of patients in the sick group and 24% of patients in the well group (P < .0001, χ2). Balanitis, phimosis, or a physician's recommendation were listed as the primary reason for postneonatal circumcision by 50% of patents in the well group. Phimosis was listed by the surgeon as an indication for postneonatal circumcision in 65% of all patients's charts, although only 13% of parents listed phimosis as an indication for their children's circumcision. According to this profile of two distinct populations of postneonatal circumcision patients, pediatricians may be able to reduce the incidence of this procedure by providing support of individual preferences and objective information regarding circumcision to families of healthy infants during the neonatal period; by anticipating and facilitating the decisions surrounding neonatal circumcision for families of sick infants; and by educating families of uncircumcised boys about foreskin care and development during regular well-child visits.
Screening Adolescents for Depression and Parent-Teenager Conflict in an Ambulatory Medical Setting: A Preliminary Investigation
Authors: Schubiner Howard , Robin Arthur
Published: December 2021

Because more than 60% of adolescent visits to physicians last less than 10 minutes, simple screening devices to identify persons at risk for social morbidity are needed. The result of a pilot screening instrument for depression and parent-teenager conflict is described. A seven-item questionnaire (three items for depression and four items for parent-teenager conflict), the Beck Depression Inventory (BDI), and the Conflict Behavior Questionnaire (CBQ), were administered to 226 adolescents at a high-risk adolescent health center. After the visit, the provider rated each patient on a five-point Likert scale for level of depression and parent-teenager conflict. The screening questionnaire and the provider ratings were compared with the BDI and CBQ for sensitivity, specificity, and predictive value. A majority of the subjects (61% for depression and 63% for parent-teenager conflict) had no positive screening responses and, of these, less than 3% were classified as being depressed or having parent-teenager conflict by the BDI or CBQ. There were three or four positive screening responses (three responses for the depression questions and 20 responses for the parent-teenager conflict questions) among 23 adolescents and all of these scored in the abnormal range on the BDI or CBQ. Approximately one third of the subjects had intermediate responses. With one positive response, the predictive value for depression and parent-teenager conflict was 17% and 24%, respectively, whereas with two positive responses the predictive values were 56% and 26%. It was shown by receiver operating characteristic curves that the combined sensitivity and specificity of the screening questionnaire was superior to that of the physician ratings. In this study it was demonstrated that a simple seven-item instrument for depression and parent-teenager conflict can quickly and accurately classify the two thirds of patients with very high or very low scores and provide likelihoods of these problems for the remaining one third of patients who score in the intermediate ranges. This instrument can aid providers in efficient assessment of social morbidity factors in their adolescent patients.
Medically Uninsured Children in the United States: A Challenge to Public Policy
Authors: Oberg Charles N.
Published: December 2021

This article is an examination of the nature and extent of the problem presented by medically uninsured children in the United States. First, the characteristics of the uninsured population are explored with a description of how age, family income, and employment status disproportionately affect families with children. Second, the Medicaid program and its historically inadequate response to this growing problem of uninsured children is examined. Third, the relationship between insurance status and the health and development of children is discussed. Finally, recent public policy initiatives that have been enacted or proposed to address this inequity in the present health care system are reviewed with a recommendation to establish a "Universal Maternal and Child Health Program."
Adoption of Hepatitis B Virus-Infected Foreign-Born Children
Authors: SOKOL RONALD J.
Published: December 2021

To the Editor.—

Hostetter et al1 confirmed recent reports2-5 of the relatively high incidence of hepatitis B virus (HBV) infection among foreign-born children who are adopted in the United States. Approximately 5% to 15% of adopted infants from Asia, India, and Central/South America are found to have active HBV infection or to be asymptomatic carriers.1-5 Although some information is provided to prospective parents by adoption agencies discussing the possibility of a number of diseases (including HBV infection) in the foreign-born infants, few parents, in our experience, felt that they were adequately informed about the true risk and the potential social and medical consequences of HBV infection before the placement of the child in their home.
Antibodies to Human Immunodeficiency Virus in the Breast Milk of Healthy, Seropositive Women
Authors: Bélec Laurent , Bouquety Jean-Claude , Georges Alain J. , Siopathis Max R. , Martin Paul M. V.
Published: December 2021

Reports of rare cases of suspected transmission of the human immunodeficiency virus (HIV) from mother to children by breast milk have been recently published. To study the factors that possibly limit HIV transmission through breast-feeding, milk samples obtamed from 15 healthy, seropositive mothers and 4 serobegative control subjects were studied for the presence of anti-HIV antibodies. All samples from seropositive women contained IgG antibody against envelope glycoproteins gpl6O and/or gpl20, and 11 of 15 samples contamed IgA antibodies against gpl60. IgA antibodies against other viral antigens were more rarely recovered, except against the internal proteins of the virus, p18 and p25. The finding of IgA antibodies to HIV-1 in breast milk establishes that the virus elicits a local immune response in heterosexual, seropositive women. The role of local antibodies in the postnatal transmission of HIV remains to be determined.
Sexual Behavior Among Hispanic Female Adolescents in the United States
Authors: DuRant Robert H. , Pendergrast Robert , Seymore Carolyn
Published: December 2021

The purpose of this study was to identify factors associated with sexual activity in a national representative sample of Hispanic female adolescents. The subjects included all (n = 202) 15-to 19-year-old Hispanic female adolescents from the 1982 National Survey of Family Growth subdivided into Mexican-American (n = 119), Puerto Rican (n = 34), Central/South American (n = 23), Cuban (n = 9), and other Hispanic (n = 17) background groups. A total of 42% of the young women were sexually active. More Cubans (69.0%) and Central/South Americans (55.6%) reported sexual activity than the other groups, but the differences were not statistically significant. With multiple regression analysis, a significant amount of variation (total R2 = 0.367, P ≤ .001) in sexual activity was explained by the following variables: not being in school (22.5%), no religious affiliation (4.4%), age (3.3%), less church attendance (3.0%), older age at menarche (1.9%), and not living with both parents at age 14 years (1.9%). These findings suggest that maintaming social continuity in the areas of school, church affiliation and involvement, and family structure, as well as physical maturity are associated with Hispanic adolescent girls not becoming sexually active.
Risk of Seizure Recurrence Following a First Unprovoked Seizure in Childhood: A Prospective Study
Authors: Shinnar Shlomo , Berg Anne T. , Moshé Solomon L. , Petix Maryann , Maytal Joseph , Kang Harriet , Goldensohn Eli S. , Hauser W. Allen
Published: December 2021

In a prospective study, 283 children who presented with a first unprovoked seizure were followed for a mean of 30 months from the time of first seizure. Subsequent seizures were experienced by 101 children (36%). The cumulative risk of seizure recurrence for the entire study group was 26% at 12 months, 36% at 24 months, 40% at 36 months, and 42% at 48 months. The cumulative risk of recurrence in the 47 children with a remote symptomatic first seizure was 37%, 53%, and 60% at 12, 24, and 36 months, respectively, compared with a cumulative risk of 24%, 33%, and 36% at 12, 24, and 36 months, respectively, in the 236 children who had had an idiopathic first seizure (P < .01). In children with an idiopathic first seizure, the electroencephalogram was the most important predictor of recurrence. The cumulative risk of recurrence in the 81 children with abnormal electroencephalograms was 41%, 54%, and 56% at 12, 24, and 36 months, respectively, but only 15%, 23%, and 26% at 12, 24, and 36 months, respectively, in the 138 children with normal electroencephalograms (P < .001). A history of epilepsy in a first-degree relative was a significant risk factor only in idiopathic cases with abnormal electroen-cephalograms. In children with a remote symptomatic first seizure, either a history of prior febrile seizures or the occurrence of a partial seizure were significant predictors of recurrence. Age at first seizure and duration of seizure did not affect recurrence risk in either the idiopathic or remote symptomatic group. A total of 84% of the children were not treated with antiepileptic drugs or were treated for less than 2 weeks. Only 9% were treated for longer than 3 months. Treatment did not affect the risk of recurrence. The results suggest that, even without treatment, the majority of children with a first unprovoked seizure will not experience a recurrence. Children with an idiopathic first seizure and a normal electroen-cephalogram have a particularly favorable prognosis.
Replacing the Work of Pediatric Residents: Strategies and Issues
Authors: CHAPMAN DANIEL D. , HODGMAN JOAN E. , JOHNSON ROBERT L. , MATLIN NANCY M.
Published: December 2021

In this issue, Honigfeld et al1 discuss manpower strategies adopted by nine hospitals that either discontinued or significantly reduced their pediatric residency programs. Several of the hospitals surveyed had a significant pediatric inpatient population and two thirds had a Neonatal Intensive Care Unit. The loss of resident positions represented a major manpower crisis for these institutions. The 16 hospitals that originally met the study guidelines in 1986 to 1987 represent only a small fraction of the existing 234 accredited training programs.
Cousin Cases of Kawasaki Disease Suggesting Person-to-Person Transmission
Authors: IMADA YOSHIO , KAWASAKI TOMISAKU , NAKAMURA YOSIKAZU
Published: December 2021

To the Editor.—

Kawasaki disease is a disease of unknown etiology affecting infants and young children. Its epidemiology as observed in Japan and in many other countries suggests that the etiology is infectious.1

We wish to report two cases of Kawasaki disease in first cousins that strongly suggest person-to-person transmission.

The first patient was a Japanese boy, aged 3 years and 8 months, living in Tokyo. He had been in excellent health until February 17, 1989 when he had a sudden fever which continued for 6 days.
Esophagitis, Epiglottitis, and Cocaine Alkaloid ("Crack"): "Accidental" Poisoning or Child Abuse?
Authors: KHARASCH SIGMUND , VINCI ROBERT , REECE ROBERT
Published: December 2021

Acute effects of cocaine abuse have been frequently described in the medical literature. Myocardial infarction, angina, chest pain, dysrhythmias, pneumothorax, seizures, and hypertension are not uncommonly seen with the growing number of drug abusers in this country.1,2 Other systemic effects of cocaine toxicity, including malignant hyperthermia, rhabdomyolysis, and cerebral vascular accidents have been described with acute cocaine intoxication.3

With the recent cocaine alkaloid ("crack") epidemic, a new spectrum of medical as well as social consequences have occurred. Teenage violence and death have been given emphasis by the lay press as accounts of drug wars continue to appear in print. There is little information, however, identifying children as victims of abuse and neglect while they are in the care of persons abusing crack.
Pediatric Dermatology Update
Authors: Krowchuk Daniel P. , Tunnessen Walter W. , Hurwitz Sidney
Published: December 2021

The Society for Pediatric Dermatology conducted its 14th Annual Meeting in Quebec City, Quebec, Canada, June 21 to 24, 1989, and the Section on Dermatology of the American Academy of Pediatrics met during the Academy's Annual Fall Meeting in Chicago, Illinois, October 13, 1989. Topics presented at these meetings that are of interest to pediatricians are presented in summary form below.

MEETING OF THE SOCIETY FOR PEDIATRIC DERMATOLOGY

Advances in the Treatment of Hemangiomas

Hemangiomas occur in approximately 10% of infants and children. Although most of these lesions have a benign course, various complications may occur. Raised hemangiomas (capillary or cavernous forms) may obstruct the airway or visual fields, trap platelets, or be responsible for cardiac failure. Both raised and flat hemangiomas (port wine stains) may be of considerable cosmetic significance. Until recently, few options existed for the treatment of these vascular nevi. However, advances in the understanding of vascular proliferation offer the promise of new and more effective therapeutic modalities.

Judah Folkman, MD, Professor of Surgery, Pediatric Surgery, and Anatomy of Harvard Medical School, reviewed the biochemical basis of angiogenesis and discussed the potential role of angiogenesis inhibitors in the treatment of hemangiomas. Although the mechanisms of initiation and proliferation of hemangiomas are not yet entirely understood, possible treatment appears to be relatively close at hand. A number of naturally occurring substances have been identified that possess the ability to halt capillary proliferation. The most potent of these are a group of cortisol metabolites termed angiogenic steroids, of which tetrahydrocortisol is a major example.
Contraception and Adolescents
Authors:   Committee on Adolescence
Published: December 2021

Pediatricians should be active participants in the effort to reduce the negative consequences of adolescent sexual activity. Preventive measures include counseling teenagers and their families on responsible sexual decision-making, including abstinence, and providing contraceptive services for sexually active patients, when requested. In previous statements, the American Academy of Pediatrics has addressed the impact of adolescent pregnancy,1 counseling the pregnant adolescent,2 and management of sexually transmitted diseases.3 This statement provides information on adolescent sexual and contraceptive behavior, and it presents guidelines for counseling teenagers on sexual activity and contraceptive methods, including abstinence. Because of differences in the needs and circumstances of each adolescent, the practitioner should use these guidelines to develop an individualized approach suitable for young persons. Due to concern about acquired immunodeficiency syndrome, among other risks, a renewed emphasis on careful and informed decision-making regarding sexual activity is reflected in this revised statement.

ADOLESCENT SEXUAL AND CONTRACEPTIVE BEHAVIOR

Since 1970, there has been a distinct increase in the percentage of adolescents reporting nonmarital sexual activity. By 14 years of age, 10% to 20% of boys and 5% to 10% of girls report having had sexual intercourse. By 17 years of age, approximately half of all adolescents are reported to have had intercourse at least once. By 19 years of age, the majority are reported to have done so.4

The factors most strongly associated with age at first intercourse appear to be biology (age at onset of puberty), opportunity (dating behavior), peer group influences, personal expectations (academic achievement, educational goals, religiousness), and family characteristics (parental support and controls).5
Half-Dose Immunization for Diphtheria, Tetanus, Pertussis
Authors: BERNBAUM JUDY , POLIN RICHARD A.
Published: December 2021

In Reply.—

We appreciate your comments regarding our article in which we reported on the response of preterm infants to half-dose diphtheria, tetanus, pertussis immunizations. Although your points are well taken, it would be difficult logistically to carry out a study in which the serologic responses to 6 (or more) doses of half-dose vaccine are measured. At the very least, it would be hard to obtain informed parental consent. In our study, we attempted to show how poor the serologic response was to a reduced dosage of vaccine.
Half-Dose Immunization for Diphtheria, Tetanus, Pertussis
Authors: PLOTKIN STANLEY A.
Published: December 2021

In Reply.—

I am afraid the Red Book Committee can give no encouragement to the practice of reducing the dosage of diphtheria, tetanus, pertussis vaccine. Although giving six doses might result in good immune responses, the risk of sensitization may also be increased. Moreover, if a child has the mild reactions described by Dr Rogers, why not give full doses? Low-grade fever occurs in almost half of the recipients of diphtheria, tetanus, pertussis vaccine, and about half also have fretfulness.
Persistent Bacteremia
Authors: NOEL GARY J. , EDELSON PAUL J.
Published: December 2021

To the Editor.—

The recent article by Patrick et al1highlights a problem of increasing clinical importance. However, their approach to the issues these patients raise is short of the usually meticulous standards we have come to associate with this group.

The differential diagnosis of persistent bacteremia is in general quite straightforward: (1) inappropriate or inadequate antibiotics, (2) a potentially drainable or removable focus of infection, or (3) endocarditis.

We and others have shown that these same categories apply in the case of coagulase-negative staphylococci.
Drugs and Breast Milk
Authors: NEWMAN JACK
Published: December 2021

To the Editor.—

The American Academy of Pediatrics Committee on Drugs has performed an invaluable service in publishing and updating the "Transfer of Drugs and Other Chemicals into Human Milk."1 This service is one for which we who try to advise breast-feeding women can only be grateful. Although there are some medications about which not everyone would agree, I was shocked to find that nicotine (smoking) was included in Table 2 (Drugs of Abuse That Are Contraindicated During Breast-feeding).
Breast-Feeding Frequency During the First 24 Hours After Birth in Full-Term Neonates
Authors: Yamauchi Yoshitada , Yamanouchi Itsuro
Published: December 2021

The relation between the frequency of breast-feeding and intake, weight loss, meconium passage, and bilirubin levels was studied in 140 healthy, full-term, breast-fed, Japanese neonates born vaginally without complications. Factors affecting the frequency of breast-feeding were also evaluated. Mothers nursed their neonates, on average, 4.3 ± 2.5 (SD) times (range 0 to 11) during the first 24 hours after birth, and this frequency increased significantly to 7.4 ± 3.9 times during the next 24 hours (P < .001). There was a significant correlation between the frequency of breast-feeding during the first and second 24 hours after birth (r = .69, P < .001). The frequency of breast-feeding during the first 24 hours correlated significantly with frequency of meconium passage (r = .37, P < .01), maximum weight loss (r = -.22, P < .05), breast milk intake on day 3 (r = .50, P < .01) and day 5 (r = .34, P < .05), transcutaneous bilirubin readings on day 6 (r = -.18, P < .05), and weight loss from birth to time of discharge (day 7) (r = -.32, P < .01). There was a strong dose-response relationship between feeding frequency and a decreased incidence of significant hyperbilirubinemia (transcutaneous bilirubin readings ≥23.5) on day 6. The time of birth also affected the frequency of breast-feeding during the first 24 hours. Neonates born between midnight and 6:00 AM were nursed more frequently than those born between 1:00 PM and midnight (5.1 ± 2.4 vs 3.9 ± 2.3 times, P < .05). The results demonstrate that frequent suckling in the first days of life has numerous beneficial effects on the breast-fed, full-term newborn.
Side Effects of Metlyiphenidate in Children With Attention Deficit Hyperactivity Disorder: A Systemic, Placebo-Controlled Evaluation
Authors: Barkley Russell A. , McMurray Mary B. , Edelbrock Craig S. , Robbins Kathryn
Published: December 2021

The frequency and severity of 17 side effects presumably associated with stimulant medication were assessed during a rigorous, triple-blind, placebo-controlled, crossover evaluation of methylphenidate, 0.3 and 0.5 mg/kg twice a day, in 83 children with attention deficit hyperactivity disorder. Side effects were rated by parents and teachers at the end of each weekly drug condition. Three children (3.6%) had side effects that were sufficiently serious to warrant immediate discontinuation of medication. Parent ratings indicated that only the side effects of decreased appetite, insomnia, stomachaches, and headaches increased significantly in frequency and severity during the two active medication doses as compared with the placebo condition. Fewer than half of the children experienced these side effects and among those who did, ratings of mean severity remained in the mild range. Teacher ratings showed little change over drug conditions, except on ratings of staring, sadness, and anxiety, which declined with increasing dose of medication. Surprisingly, a high frequency of these behavior side effects were reported during the placebo condition. Stimulant medication within this therapeutic range, therefore, results in few, generally mild side effects. However, the wide variation in individual responses and the high rate of these behaviors during placebo treatment argue for the systematic monitoring of side effects before and during pediatric trials of stimulant medication.
Hypothalamic-Pituitary-Adrenal Axis Function in Very Low Birth Weight Infants Treated With Dexamethasone
Authors: Alkalay Arie L. , Pomerance Jeffrey J. , Puri Asha R. , Lin Berwyn J.C. , Vinstein Arnold L. , Neufeld Naomi D. , Klein Alan H.
Published: December 2021

The effect of dexamethasone therapy on hypothalamic-pituitary-adrenal axis function was prospectively investigated in very low birth weight infants with bronchopulmonary dysplasia. Ten infants (mean ± SD birth weight 825 ± 265 g, gestation 25.8 ± 1.9 weeks, postnatal age 33.1 ± 17.7 days) initially received intravenous dexamethasone, 0.5 mg/kg per day for 3 days, and then were weaned over a period of 45 ± 19.0 days to a replacement dose, followed by a metyrapone test. Morning plasma cortisol and 11-deoxycortisol levels were measured before and after an oral metyrapone dose given at midnight. Five infants (group A: birth weight 876 ± 313 g, gestation 26.2 ± 1.3 weeks, age of entry 31.8 ± 22.8 days) had normal metyrapone test results, and five infants (group B: 778 ± 234 g, 25.4 ± 2.5 weeks, 34.4 ± 13.4 days) had suppressed test results. Group A infants, in comparison with group B infants, had higher basal cortisol plasma levels (14.52 ± 12.53 and 3.00 ± 1.38 µg/dL, P = .047), higher postmetyrapone 11-deoxycortisol plasma levels (3.11 ± 3.93 and 0.55 ± 0.51 µg/dL, P = .028), larger differences between basal and postmetyrapone cortisol levels (7.10 ± 4.67 and 2.12 ± 1.31 µg/dL, P = .047), and larger differences between basal and postmetyrapone 11-deoxycortisol levels (2.99 ± 3.93 and 0.29 ± 0.25 µg/dL, P = .009). The hypothalamic-pituitary-adrenal axis function in group B infants eventually returned to normal when they continued to receive low-dose dexamethasone therapy after a period of 36.8 ± 16.6 days. The results suggest that dexamethasone therapy given for several weeks or more may be associated with prolonged suppression of hypothalamic-pituitary-adrenal axis function in a substantial number of very low birth weight infants with bronchopulmonary dysplasia. Evaluation of hypothalamic-pituitary-adrenal axis function before discontinuation of dexamethasone therapy is necessary to ensure proper adrenal secretory response.
Direct Hyperbilirubinemia Associated With Chioral Hydrate Administration in the Newborn
Authors: Lambert George H. , Muraskas Jonathan , Anderson Craig L. , Myers Thomas F.
Published: December 2021

To test the hypothesis that chioral hydrate can cause direct hyperbilirubinemia (DHB) in the newborn, two retrospective analyses of the medical records of patients admitted to a neonatal intensive care unit during an 18-month period were conducted. In one analysis of 14 newborns who had nonhemolytic DHB, 10 did not have an identified cause of DHB, and all 10 had received chloral hydrate. In the second retrospective study, all newborns who received chloral hydrate were divided into groups according to whether or not DHB had developed. The newborns with DHB, compared with those without DHB, had received a higher total accumulative dose of chloral hydrate (1035 ± 286 vs 183 ± 33 mg/kg [±1 SEM], respectively). In the patients with DHB, the direct serum bilirubin levels increased 6.8 ± 0.8 days after the chioral hydrate administration began and resolved after the chloral hydrate was discontinued or markediy decreased. These data support the hypothesis that prolonged use of chloral hydrate in newborns can be associated with DHB.
The Influence of Perinatal Instruction About Breast-Feeding on Neonatal Weight Loss
Authors: AVOA AWUTSE , FISCHER PHILIP R.
Published: December 2021

It is normal for newborn babies to lose weight during the first days of life.1 Although much of this weight loss is thought to be due to changes in the volume and distribution of water in the body,2 it is clear that feeding practices also influence the degree of weight loss.3,4

In North America, breast-fed babies lose 6.9% of their birth weight before beginning to gain weight.3 Bottle-fed American babies, on the other hand, lose only about 4.2%.3 In Lesotho, breast-fed babies lose just 3% of their birthweight.5 These findings prompted questions about the factors that influence the degree of neonatal weight loss.
Coagulase-Negative Staphylococcal Bacteremia in Neonates: Confusion Continued
Authors: EDWARDS MORVEN S.
Published: December 2021

Colonization of neonates with coagulase-negative staphylococci occurs predictably during the first weeks of life, serving as a potential source of bacteremia in very low birth weight infants.1,2 Clinical features alone are insufficient to distinguish sepsis caused by neonatal pathogens other than coagulase-negative staphylococci3 or to differentiate sepsis from noninfectious disorders in these tiny patients. Inasmuch as coagulase-negative staphylococci are the most frequent blood culture isolates from patients in most neonatal intensive care units4,5 and are a cause of substantial morbidity,6 the statement of Freeman et al7 that "blood cultures positive for coagulase-negative staphylococci are almost four times as likely to be perceived as clinically significant if obtained from extremely premature infants" is not surprising.
Antacid Poisoning
Authors: BRAND JOSEPH M.
Published: December 2021

In Reply.—

It is suggested by our case study that antacids containing magnesium be used with great caution in very low birth weight infants, especially because the efficacy using antacids containing magnesium for treating or preventing gastric hemorrhage has not been demonstrated in this group.
Speak up for Children
Authors: LEE JUNE PATRICIA
Published: December 2021

To the Editor.—

In the February 1990 issue of Pediatrics, The New York Times was quoted in "Pro-Life? Then Pay Up."1 They are correct in implying that those of us who are pro-life bear a responsibility to the children of teenagers. However, the article is in error when it states that "The cruelest irony of the antiabortion movement is that many of its proponents have so little interest in the health and welfare of the resulting children after they are born."1
Nutrition and Growth Analysis of Very Low Birth Weight Infants
Authors: Fenton Tanis R. , McMillan Douglas D. , Sauve Reg S.
Published: December 2021

The growth and nutrition of 220 very low birth weight infants were reviewed after comprehensive data on all infants in the hospital were entered into the Neonatal Intensive Care Unit Audit Data Base for 2 years prospectively. Fluid and energy (parenteral and oral) intakes were compared in four birth weight categories (1, ı750 g; 2, 751 to 1000 g; 3, l001 to 1250 g; 4, 1251 to 1500 g). Parenteral nutrition was the major source of first nutrition for the small infants, but seldom did it alone provide adequate nutrition for very low birth weight infants. The age of the first nutrition (parenteral and/or oral nutrition other than dextrose) decreased with increasing birth weight. The age of the first oral feedings was later for the infants of the lower birth weights but enteral feeding became the major nutrition for all weight categories by the second week of life. During the first 50 days the infants accumulated a deficit of 3780 to 5460 kJ relative to their estimated need of 504 kJ/kg per day, with the smaller infants accumulating a significantly larger deficit. The growth of infants appropriate for gestational age and of infants small for gestational age differed from each other and from the commonly used graph of Dancis et al (J Pediatr. 1948;33:570-572).
Social Competence and Behavior Problems in Premature Children at School Age
Authors: Ross Gail , Lipper Evelyn G. , Auld Peter A.M.
Published: December 2021

Social competence and behavior problems of 87 children born weighing < 1501 g were measured using the Child Behavior Checklist when the children were 7 to 8 years old. Both premature boys and girls had significantly lower Social Competence scores than the normative samples of their respective sexes. Only premature boys had significantly higher Behavior Problems scores, with significantly higher scores on behaviors associated with conduct disorders. Premature children in each of three social class groups had significantly lower Social Competence scores and higher Behavior Problems scores than normative children. Furthermore, there was an interaction between prematurity and social class on Behavior Problems scores, with the greatest discrepancy in scores between premature and normative children in the lower-class group. Relative to other predictors, IQ score best explained Social Competence scores and family stability best explained Behavior Problems scores in the premature sample.