bluuebunny/crossref_metadata_2025 huggingface dataset:
Letter to the Editor
Authors:   The European Concerted Action on Otoacoustic Emissions
Published: December 2021

As is the case with the recommendation from the National Institutes of Health Consensus Meeting on Early Hearing Screening, the opinion of the European Concerted Action on Otoacoustic Emissions is to consider it necessary to test sensitivity, specificity, and predictive values of otoacoustic emissions as basis for early hearing screening and subsequent identification of hearing impairment in children in preparation for an earlier and thus optimal rehabilitation of the hearing-impaired. Like Bess and Paradise, we had no doubts about "the desirability of identifying infants with congenital hearing impairment promptly" based on the fact that an untreated hearing loss in "the crucial period for language and speech learning" permanently would reduce "verbal language skills," "the developing auditory nervous system" and in consequence "have harmful effects on social, emotional, cognitive, and academic developments."
International Conference on Child Day-Care Health: Opening Remarks
Authors: Ching-Li Hu
Published: December 2021

It is important to recall the definition of health embodied in the Constitution of the World Health Organization (WHO) over 45 years ago: "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition." Among the Organization's mandated functions is "to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment." The challenge of that task is no less today than it was then.

Historically, societies have evolved various patterns of family structure for social and economic functions. In preindustrial societies there evolved a great concordance between these functions, with many of the health, developmental, and socialization functions taking place first within the family and then within the immediate community. The rapid social changes of both the industrial and information revolutions have changed drastically the functions of the family, and have shifted many of the health, developmental, and social functions to nonfamily institutions, from which families are often excluded or marginally involved.

Much of the international attention to child health in this last decade has been directed at simple interventions to prevent the nearly 13 million deaths each year of children under 5: universal child immunization; the control of diarrheal and acute respiratory diseases; and infant and young child nutrition, particularly breast-feeding.
Overview of Policies Affecting Vaccine Use in Child Day Care
Authors: Cochi Stephen L.
Published: December 2021

Vaccination policies for preschool-age children, including those in child day care, have undergone frequent changes within the past several years in response to the development of new vaccines (DTaP, Hib conjugate vaccines), the changing epidemiology of vaccine-preventable diseases (measles), and the establishment of new objectives for the control and elimination of vaccine-preventable diseases (Hib, hepatitis B). The acquisition and spread of vaccine-preventable diseases can be minimized in child day-care settings by vaccinating all children, establishing a continuing system by which all children remain fully vaccinated on schedule, providing educational materials to parents about the recommended schedule of routine Childhood vaccines, and implementing new recommendations for vaccine use.
Spanking Infants and Toddlers: Maternal Belief and Practice
Authors: Socolar Rebecca R. S. , Stein Ruth E. K.
Published: December 2021

Objective. To describe maternal beliefs and practices of spanking infants and toddlers and the relations between factors affecting these beliefs and practices.

Design. Cross-sectional survey.

Setting. Site 1 was an inner-city teaching hospital pediatric clinic. Site 2 was a private pediatrician's office in a nearby suburban neighborhood.

Participants. Mothers of children less than 4 years old in the waiting area. Site 1: n = 104; site 2: n = 100.

Selection. Systematic sample of convenience.

Methods. Mothers were interviewed using a 20-minute structured questionnaire. Measures were constructed to assess beliefs (Cronbach's α = .90) and practices about spanking and approach to discipline (α > .71).

Results. Belief in spanking correlated significantly (P < .001) with belief in negative approach (r = .52) and with the practice (r = .46) and severity (r = .34) of spanking. Nineteen percent of the mothers believed that there are times when it is appropriate to spank a child less than 1 year old, and 74% believed this about children 1 to 3 years old. Forty-two percent reported that they had spanked their own child in the past week. Mothers believed more strongly in spanking for dangerous misbehaviors than for annoying ones (P < .001). Belief in spanking and negative approach were stronger for older toddlers (P < .001). Belief in and frequency of spanking were more common at the inner-city site (P < .001).

Conclusions. The belief in and practice of spanking are prevalent in disciplining very young children. The context of the spanking affects beliefs and practices. The finding that belief and practice of spanking are highly correlated suggests that belief rather than impulse largely explains spanking of children less than 4 years old. The high correlation between spanking and negative approach toward discipline raises questions about whether negative consequences of spanking are the result of spanking per se, the negative approach toward the child, or both.
Historical Overview of Antenatal Steroid Use
Authors: Avery Mary Ellen
Published: December 2021

In a field moving as fast as this one, history could be defined as everything that appeared through last month's publications; however, I chose to focus on events that occurred mostly before 1985. The important and ever-accelerating basic science supports the fact that giving antenatal glucocorticoids in the event of preterm labor could be considered a physiologic rather than a pharmacologic intervention, in as much as one role of the fetal adrenal cortex is to increase the cortisol levels in the weeks before term birth. In fact the adrenal gland at birth is 10 to 20 times larger than in the adult, relative to body weight.1
The Recommended Childhood Immunization Schedule of the United States
Authors: Hall Caroline Breese
Published: December 2021

The complexity of our current schedule for routine immunization of children is expanding and experienced by both physician and parent. Over nearly two decades in the 1970s and 1980s only one new vaccine was added to the routine immunization for children. However, in the last few years since 1989, the schedule routinely recommended for children has been augmented by eight to ten new doses or vaccines. The confusion has been compounded by differences in the schedules developed by the American Academy of Pediatrics' (AAP) Committee on Infectious Diseases and that of the Centers for Disease Control Advisory Committee on Immunization Practices (ACIP).
A Novel Cause of Error in Capnographic Confirmation of Intubation in the Neonatal Intensive Care Unit
Authors: Roberts William A. , Maniscalco William M.
Published: December 2021

Failure to recognize esophageal intubation can result in hypoxia and may lead to permanent neurologic injury. Clinical criteria commonly used to comfirm endotracheal intubation can fail to identify esophageal misplacement.1-9 The risk of this error has been reduced in the operating room by using capnography, which is both sensitive and specific for correct endotracheal intubation.4,6,7,10-12 Capnography is able to identify errant tube placements more rapidly and specifically than clinical indicators alone.10 We report here a novel cause of error in the capnographic findings at intubation in a neonate.

CASE REPORT

A 26-week gestational age, 690-g neonate was accidentally extubated during routine care.
Letters to the Editor
Authors: Kaminer Ruth , Perrin James M.
Published: December 2021

Dr Chesky's commitment to eliciting parental concerns and systematic developmental-behavioral screening in his practice has won our admiration. The use of standardized inventories filled out by the parent for the screening and assessment of developmental and behavioral problems is an excellent option for some patient populations. However, this method requires, besides the commitment on the part of the pediatrician, parents who are literate and can answer 84 questions in a reasonable period of time and staff who will score the screening form before the physician sees the child.
Letters to the Editor
Authors: Jacobs Jennifer
Published: December 2021

Mr Shoultz's letter typifies the conventional knee-jerk response to homeopathic medicine—"We don't understand how it works, therefore it must be a fraud." This type of thinking is the antithesis of the scientific method. In science, one must observe what occurs in the universe, then set out to determine causality.

It is true that the mechanism of action of homeopathic medicines is not understood. Indeed, as Mr Shoultz points out, homeopathic theory is inconsistent with current scientific belief.
Diverting Managed Care Medicaid Patients From Pediatric Emergency Department Use
Authors: Gadomski Anne M. , Perkis Victoria , Horton Lisa , Cross Sheila , Stanton Bonita
Published: December 2021

Objective. To evaluate the health outcomes of managed care Medicaid children with non-emergent conditions who were not authorized to be seen in the Pediatric Emergency Department (PED) by their primary care provider.

Design. Consecutive case surveillance from 6/29/92 to 2/2/93.

Setting. University based PED (17,500 visits/year) in inner city Baltimore.

Participants. Cases were MAC children denied authorization to be seen for non-emergent conditions in the PED. Age and complaint matched MAC children were selected from the university based Pediatric Ambulatory Center (PAC) and from non-emergent PED visits (PED-seen) in order to compare utilization rates after denial.

Intervention. The Maryland Access to Care (MAC) Medicaid program (started in 12/91) emphasizes primary care and appropriate health care utilization by incorporating the following elements of managed care: assignment to primary care provider, gatekeeping, mandatory enrollment and fee for service.

Methods. Consecutive case surveillance from 6/29/92 to 2/2/93 was used to evaluate the health outcomes of MAC children denied authorization for non-emergent care in a university based PED. One week following denial, a pediatric nurse practitioner contacted the patient's caretaker and the MAC provider to ascertain health outcome. Medicaid claims data was used to compare the six month health care utilization of the denied group to age and complaint matched children seen in the PED (PED-seen) or in a primary care clinic (PAC).

Results. 216 MAC patients were not authorized for a PED visit by their MAC providers. 123 (57%) saw their MAC provider within one week of the denied PED visit. 40 (18%) were not seen because their presenting complaint had resolved completely. No adverse health outcomes occurred because of delay in health care delivery. The subsequent ER utilization rate of the denied group was the same as the PED-seen comparison group, and significantly higher than that of the PAC group (P = .002). The denied group was hospitalized at a significantly higher rate relative to these comparison groups (P = .003).

Conclusions. Diverting Medicaid children classified as non-emergent in an ER to their MAC providers can be a safe practice short-term. However, denial of a PED visit has no impact on subsequent ER utilization by Medicaid participants and may be associated with higher hospitalization rate. Gatekeeping in this setting does not necessarily change the health care seeking behavior of these patients.
Biological Rhythmicity in Preterm Infants Prior to Discharge From Neonatal Intensive Care
Authors: Glotzbach Steven F. , Edgar Dale M. , Ariagno Ronald L.
Published: December 2021

Objective. The study of biological rhythms and the influence of environmental factors in the timing and synchronization of different rhythmic events have important implications for neonatal health. Preterm infants in the neonatal intensive care unit (NICU) are deprived of the patterned influences of maternal sleep, temperature, heart rate, and hormonal cycles. The impact of the NICU and nursing interventions on the development of the circadian system was studied in 17 stable preterm infants in the Intermediate Intensive Care Nursery at Stanford University for three consecutive days at about 35 weeks postconceptional age.

Outcome measurements. Rectal temperature, abdominal skin temperature, heart rate, and activity were simultaneously recorded at 2-minute intervals during each 3-day study by a small microcomputer (Vitalog).

Results. Very low amplitude circadian rhythms were found for rectal and skin temperatures (maximum range 36.8 to 37.0°C); population mean values for heart rate (158 bpm) and activity (3.5 counts per 2-min bin) did not differ significantly as a function of time of day. Rectal temperature, averaged in 6-hour bins over the 24-hour day as a function of both postconceptional age and postnatal age, was significantly higher during the first part of the circadian cycle. In all infants, rhythmicity in each variable was dominated by ultradian periodicities that were coincident with feedings and related interventions; moreover, several physiological variables charted during feeding differed significantly from values obtained during periods in which caregiving interventions did not occur.

Conclusion. Quantitative data on the preterm infant circadian system may facilitate evaluation of factors that improve therapeutic responses, recovery, and outcome of neonatal intensive care patients.
Letters to the Editor
Authors: Wald Ellen R. , Dashefsky Barry
Published: December 2021

We appreciate the support offered in the letter by Drs Mitchell, Newth, and Joffe. We are hopeful that continued questioning of the recently published guidelines on the use of ribavirin for respiratory syncytial virus infection will lead to a change in the recommendations.
Pediatric Adenoidal Hypertrophy and Nasal Airway Obstruction: Reduction With Aqueous Nasal Beclomethasone
Authors: Demain Jeffrey G. , Goetz David W.
Published: December 2021

Objective. Pediatric adenoidal obstruction of the nasal airway is associated with significant morbidity and is a frequent indication for surgery. Because efficacious medical alternatives to adenoidectomy are lacking, we assessed the potency of standard-dose topical nasal beclomethasone in reduction of adenoidal obstruction of the nasal airway.

Methods. Seventeen children, 5 to 11 years of age, exhibiting chronic obstructive nasal symptoms and a group mean (±SE) adenoid/choana ratio of 91 ± 1% on rhinoscopic examination, completed an 8-week, double-blind, placebo-controlled crossover study of standard- dose aqueous nasal beclomethasone (total 336 µg/day) in the treatment of adenoidal hypertrophy. In a 16-week, open-label, follow-on study, subjects received beclomethasone 1 spray in each nostril twice daily (168 µg/day).

Results. Over the initial 4 weeks, improvements in the mean adenoidal obstruction of the choanae were significantly greater in the group receiving beclomethasone than in the group receiving placebo (right, -14.0% vs. + 0.4%, P = .0002) (left, -15.0% vs. -2.0%, P = .0006). In the subsequent crossover 4 weeks, a significant beclomethasone carryover effect resulted in further adenoid size reduction in both treatment groups. All patients demonstrated a decrease in adenoid size with beclomethasone treatment, compared with a mixed response to placebo. Over the full 8-week crossover study, the mean (±SE) obstructive symptom score after beclomethasone treatment (20.5 ± 3.0) was significantly improved compared to patients' initial (43.1 ± 2.9) and placebo scores (31.1 ± 4.2, P ≤ .05), despite the active drug carryover effect into the placebo treatment period. Significant improvements in adenoidal obstruction and symptom scores over the 8-week crossover study were enhanced in the subsequent 16-week open-label period (P = .0001). By 24 weeks, an 82% reduction in group mean nasal obstruction symptom score accompanied a 29% mean reduction in adenoid/choana ratio. No clinical or demographic characteristic predicted a patient's degree of response to treatment.

Conclusions. Properly administered aqueous nasal beclomethasone in standard doses can significantly reduce adenoidal hypertrophy and nasal airway obstructive symptoms in children.
THE ESSENCE OF BEING A DOCTOR HAS CHANGED
Authors: L. J. F.
Published: December 2021

Disability coverage ... is going through some rehabilitation of its own these days.

... the changes are being prompted by a record number of claims from physicians, among the biggest buyers of individual disability insurance. The surge, which partly reflects declining job satisfaction among doctors, is resulting in deteriorating profits—and, in some cases, losses—for insurers. Many now are moving toward a major overhaul of such coverage.

Individual disability insurance, which generates $3 billion a year in premiums for the insurance industry, provides replacement income for people unable to work as a result of accident on illness. The length of coverage under the policy can range from short-term to indefinitely. Many companies provide their workers with some type of disability insurance, but self-employed people, primarily doctors and lawyers, have to buy their own coverage.

Doctors have long been among the most favored customers of disability insurers because their job satisfaction generally translated into short absences from work as a result of accident or illness. Insurers viewed them as extraordinarily profitable bets for replacement-income insurance.

But lately, many doctors, especially specialists, have lost enthusiasm for their work, according to insurers and industry analysts. A big reason, they say, is that managed-care organizations, concerned with controlling costs, monitor doctors more closely and squeeze their incomes.

"There's no question oven the last year and a half the essence of being a doctor has changed," says Elaine Rosen, a senior vice president at Unum. The job isn't as entrepreneurial as it used to be. "It's a phenomenon in the world of disability-income insurance that people will tough it out and go to work everyday if they are satisfied and motivated, but if satisfaction starts to "dwindle" they're more inclined to opt for the disability rolls," she says.
Evaluation of An End-Tidal CO2 Detector During Pediatric Cardiopulmonary Resuscitation
Authors: Bhende Mananda S. , Thompson Ann E.
Published: December 2021

Objective. To determine the utility of a disposable colorimetric end-tidal CO2 detector during pediatric cardiopulmonary resuscitation (CPR) for (1) confirming endotracheal tube (ETT) position, and (2) assessing the relationship between end-tidal CO2 recorded by this method and outcome of pediatric CPR.

Design/setting. Prospective observations during CPR in a university children's hospital.

Participants. Forty children (28 male, 12 female) aged 1 week to 10 years (25 children aged ≤1 year, mean age 27.2 months, median 7 months), weighing 2.5 to 40 kg (31 children weighing ≤15 kg, mean 10.94 kg, median 7 kg) who underwent a total of 48 endotracheal intubations during CPR.

Methods. After intubation, ETT position was verified by usual clinical methods including direct visualization. The device was attached between the ETT and ventilation bag, the patient was manually ventilated, and a first reading was obtained. Any color change from purple (Area A, end-tidal CO2 < 0.5%) to tan or yellow (Area B or C, end-tidal CO2 ≥ 0.5%) was considered to be positive for airway intubation. CPR was conducted as pen Pediatric Advanced Life Support guidelines. A second reading was obtained when the decision to discontinue CPR was made.

Results. All nine esophageal tube positions were correctly identified by the detector. Thirty-three of 39 tracheal tube positions were correctly identified (P < .001). For verifying ETT position, the device had a sensitivity of 84.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 60%. Readings were obtained at the end of CPR in 25 patients. All 13 patients who regained spontaneous circulation and survived to ICU admission had a second reading in the C range, while none of the 12 patients with a second reading in the A or B range survived. Both the first and second end-tidal CO2 readings in the C range correlated significantly with short-term survival (P = .01 and P < .001, respectively). Two patients were eventually discharged from the hospital.

Conclusions. During CPR a positive test confirms placement of the ETT within the airway, whereas a negative test indicates either esophageal intubation or airway intubation with poor or absent pulmonary blood flow and requires an alternate means of confirmation of tube position. The detector may be of prognostic value for return of spontaneous circulation and short-term survival.
CHEATERS BEATING SYSTEM PROFS: VIOLATORS ESCAPE PENALTIES
Authors: L. J. F.
Published: December 2021

Although it's unclear whether cheating is on the rise on Vermont campuses, the process of going after offenders is so time-consuming and unwieldy that many offenders go unpunished, professors say.

According to University of Vermont Sociology Professor Steve Berkowitz's 1990 survey of more than 800 randomly chosen UVM studtents, 16.5% of them have cheated on one or more academic assignments.

Chemistry Professor Bill Meyer, however, calls the judicial process "laughable." He said he wishes for a return to the times when professors were allowed to discipline those caught cheating.

"The thing that turns people off is, if someone wants to fight it, even though it's pretty abundantly clear they are guilty, they spend a lot of time, money and effort, and escape," Meyer said. He likened professors' experiences to those of rape victims who then have to go on trial to prove their character.

"It's often the professors that come in red-faced and nervous," said Cooke, a mathematics and statistics professor. "The students come in angry and confident, as if they know it's the professor who's on trial."
PAYING GERMANS TO HAVE GERMAMS
Authors: L. J. F.
Published: December 2021

Many experts believe that over-population is one of the greatest threats facing humanity and the earth on which we live. Governments around the world are seeking ways to stop population explosions that threaten to overwhelm their economies and social structures.

Germans, however, have precisely the opposite concern. Women have all but stopped having children, especially in states carved from the former East Germany. The birth rate in Brandenburg has fallen by more than two-thirds since 1989—the state had 38 000 births that year, 12 000 last year—and the drops in other eastern German states are almost as dramatic.

Last week, to encourage childbearing, Brandenburg announced plans to pay parents $650 for every baby they produce. At least two other eastern states are considering adopting the Brandenburg system of incentive payments.
Hockey Helmets, Face Masks, and Injurious Behavior
Authors: Murray Teena M. , Livingston Lori A.
Published: December 2021

Objective. To educate physicians about factors that contribute to injurious behaviors in ice hockey and to propose that the medical community play a role in advocating change within the sport.

Methods. A review of relevant literature on the topic was conducted, with information drawn from scientific journal publications, conference proceedings, theses, and newspaper publications.

Results. The introduction of mandatory head and facial protection has been effective in virtually eliminating ocular, facial, and dental injuries in youth hockey, but it has also been problematically linked with an increase in catastrophic spinal injuries. Players adopt a false sense of security when donning the equipment, leading them to take excessive and unwarranted risks because of the protection they are supposedly afforded. The addition of these protective devices has also altered how officials perceive game situations, leading them to be more lenient in administering penalties. The net result has been an increase in illegal and injurious behaviors, such as checking from behind.

Conclusion. Physician advocacy may play an important role in effecting change within the sport.
Pain Relief
Authors: Yaster Myron
Published: December 2021

Even when their pain is obvious, children frequently receive no treatment, or inadequate treatment, for pain and painful procedures.1 Numerous studies have documented that children receive far fewer doses of analgesic medication than adults do for similar pain problems.2,3 Procedure-related pain (eg, intravenous catheter insertion, bone marrow aspiration, lumbar puncture, etc) requires special attention because it is among the most difficult types of pain to deal with, both by the patient who experiences it and the health care professionals who must inflict it.4,5 Unfortunately, the most frequent response of physicians and nurses to procedure-related pain is denial, which is made easy because children can be physically restrained, are not routinely asked if they are in pain, and are unable to withdraw consent to stop a procedure.
Use of Fruit Juice in the Diets of Young Children
Authors: Klish William J.
Published: December 2021

Fruit juice is a modern addition to the infant's diet due to the development of technology for juice extraction and an adequate supply of fruit. It has been marketed as healthy, natural, and nutritious. As a result, parents (in trying to do what is best for their infants) have been feeding juices in increasing quantities. In 1992, $164 million was spent on bottled baby juice in the United States according to Information Resources, Inc, a marketing company that tracks the consumer industry. For the past several decades, pediatricians have recognized that excessive consumption of fruit juice has been associated with diarrhea, gassiness, stomachaches, and other abdominal complaints.
A Randomized, Controlled Trial of a School-based, Multi-faceted AIDS Education Program in the Elementary Grades: the Impact on Comprehension, Knowledge and Fears
Authors: Schonfeld David J. , O'Hare Linda L. , Perrin Ellen C. , Quackenbush Marcia , Showalter Donald R. , Cicchetti Domenic V.
Published: December 2021

Objective. Several educational theorists have suggested that young children are unlikely to benefit from detailed instruction regarding AIDS prevention because of inherent developmental cognitive limitations. This study aims to determine whether AIDS education in the elementary grades can advance young children's understanding of this illness.

Methods. A randomized, controlled trial was used to measure the impact of a 3-week, multifaceted AIDS education program on conceptual understanding, factual knowledge, and fears about AIDS in 189 students in grades kindergarten through 6th. The ASK (AIDS Survey for Kids), a standardized, semistructured interview that measures conceptual understanding, factual information, and fears about AIDS, was administered before and after the intervention.

Results. Children in the intervention group, as compared to those in the control group, showed significant (P < .0001) gains in their level of understanding of the concepts of causality and prevention of AIDS. These results were unaffected by controlling for grade, gender, race, socioeconomic status, and verbal fluency. The gains in children's understanding of causality of AIDS represented at least 2 years' growth in the level of conceptual sophistication and persisted at a follow-up evaluation several months later. After the intervention, more children (P < .001) in the intervention group than in the control group accurately identified causes of AIDS in response to open-ended questions: germ/germ theory (41% vs 13%), mother-to-infant transmission (54% vs 15%), blood transmission (83% vs 40%), and sexual transmission (56% vs 30%). Fewer than half as many children in the intervention group responded incorrectly to each of five direct questions about transmission of HIV through casual contact. The intervention did not increase children's fears about the illness.

Conclusions. A short, developmentally based, multifaceted AIDS education program in the elementary grades can advance children's conceptual understanding and factual knowledge about AIDS and decrease their misconceptions about casual contact as a means of acquiring the illness, without increasing their fears. Significant advances in conceptual understanding about AIDS can be achieved through direct educational interventions.
The Contribution of Level of Cognitive Complexity and Pubertal Timing to Behavioral Risk in Young Adolescents
Authors: Orr Donald P. , Ingersoll Gary M.
Published: December 2021

Purpose. To determine the unique contributions of cognitive complexity and pubertal timing to participation in behavioral risk (substance use, sexual activity, school and legal problems) among young adolescents.

Design. Cross-sectional with cohort replication.

Methods. Two cohorts of middle school students in grades eight and nine in a midwestern school district completed a self-report questionnaire in 1987 and 1989. Measures of behavioral and emotional risk, cognitive complexity and pubertal timing relative to peers were included.

Results. Complete data were available for 817 and 796 students in each cohort year. Gender, race, level of cognitive complexity and pubertal timing each contributed significantly to the variance in behavioral risk independent of chronological age (P < .0001). Boys, whites, those at lower levels of cognitive complexity and those who began pubertal maturation earlier than peers, were at significantly greater risk. Adolescents who demonstrated higher levels of cognitive complexity and those who began puberty later compared to peers participated in a smaller array of risk behaviors, independent of chronological age.

Implications. Pediatricians should consider adolescents at lower levels of cognitive complexity (concrete thinking) and those who begin puberty earlier at greater risk for participation in health risk behaviors. Preventive health counseling tailored to the needs of this group may be most beneficial.
Cerebral Oxygenation and Hemodynamics During Induction of Extracorporeal Membrane Oxygenation as Investigated by Near Infrared Spectrophotometry
Authors: Liem K. D. , Hopman J. C. W. , Oeseburg B. , de Haan A. F. J. , Festen C. , Kollée L. A. A.
Published: December 2021

Objective. To investigate cerebral oxygenation and hemodynamics in relation to changes in some relevant physiologic variables during induction of extracorporeal membrane oxygenation (ECMO) in newborn infants.

Methods. Twenty-four newborn infants requiring ECMO were studied from cannulation until 60 minutes after starting ECMO. Concentration changes of oxyhemoglobin (cO2Hb), deoxyhemoglobin (cHHb), total hemoglobin (ctHb), and (oxidized-reduced) cytochrome aa3 (cCyt.aa3) in cerebral tissue were measured continuously by near infrared spectrophotometry. Heart rate (HR), transcutaneous partial pressures of oxygen and carbon dioxide (tcPo2 and tcPco2), arterial O2 saturation (saO2), and mean arterial blood pressure (MABP) were measured simultaneously. Intravascular hemoglobin concentration (cHb) was measured before and after starting ECMO. In 18 of the 24 infants, mean blood flow velocity (MBFV) and pulsatility index (PI) in the internal carotid and middle cerebral arteries were also measured before and after starting ECMO using pulsed Doppler ultrasound.

Results. After carotid ligation, cO2Hb decreased whereas cHHb increased. After jugular ligation, no changes in cerebral oxygenation were found. At 60 minutes after starting ECMO, the values of cO2Hb, saO2, tcPo2, and MABP were significantly higher than the precannulation values, whereas the value of cHHb was lower. There were no changes in cCyt.aa3, tcPco2, and HR, whereas cHb, decreased. The MBFV was significantly increased in the major cerebral arteries except the right middle cerebral artery, whereas PI was decreased in all measured arteries. Cerebral blood volume, calculated from changes in ctHb and cHb, was increased in 20 of 24 infants after starting ECMO. Using multivariate regression models, a positive correlation of ΔctHb (representative of changes in cerebral blood volume) with ΔMABP and a negative correlation with ΔtcPo2 were found.

Conclusions. The alterations in cerebral oxygenation after carotid artery ligation might reflect increased O2 extraction. Despite increase of the cerebral O2 supply after starting ECMO, no changes in intracellular O2 availability were found, probably because of sufficient preservation of intracellular cerebral oxygenation in the pre-ECMO period despite prolonged hypoxemia. The increase in cerebral blood volume and cerebral MBFV may result from the following: (1) reactive hyperperfusion, (2) loss of autoregulation because of prolonged hypoxemia before ECMO and/or decreased arterial pulsatility, or (3) compensation for hemodilution related to the ECMO procedure.
Evaluation of Airway Complications in High-Risk Preterm Infants: Application of Flexible Fiberoptic Airway Endoscopy
Authors: Downing Gregory J. , Kilbride Howard W.
Published: December 2021

Objectives. We sought to determine factors that would predict the development of subglottic stenosis (SGS) and tracheomalacia (TM) in preterm infants. The utility of a semiquantitative measurement of airway dimensions was assessed in relation to signs of airway complications. We also sought to determine from a high-risk population of infants those likely to have abnormal findings identified by bronchoscopic examination.

Methods. Prospective airway endoscopy was performed for preterm infants who were intubated for 7 days or more or who demonstrated chronic oxygen needs beyond 28 days after birth and 36 weeks postconceptional age. Subjects were 117 preterm (less than 36 weeks' gestation) infants from two level III intensive care nurseries. Endoscopy was used to classify the type and degree of airway injury. Subglottic stenosis was defined subjectively and compared with an objective measurement using subglottic spatial relations described as a trans- subglottic/vocal cord ratio (TSG/VC). Clinical signs and symptoms and other risk factors were evaluated as significant predictors of SGS and TM, identified by bronchoscopy.

Results. Moderate or severe airway abnormalities were identified in 32 patients (27.3%); 13 with SGS, 17 with TM, and 2 with both. All but one infant with TSG/VC less than 0.83 had signs and symptoms of airway dysfunction. Variables more commonly found in patients with SGS included greater number of intubations, use of inappropriately large endotracheal tubes, and longer duration of intubation. Higher averaged mean airway pressure during the first week after birth and lower gestational age were clinical features associated with TM.

Conclusions. Flexible bronchoscopic evaluation of a high-risk population demonstrated a higher incidence of moderate or severe SGS or TM than previously suspected. Subglottic stenosis and TM appear to have different etiologies based on different factors associated with their development. The TSG/VC ratio correlated well with obstructive symptoms and may represent a means to quantitate clinically subglottic narrowing. Infants with chronic lung disease who have persistently elevated partial pressure of carbon dioxide, apnea, or phonation abnormalities are most likely to have airway abnormalities identifiable by bronchoscopy.
CLARIFICATION:

CHANGE IN RECOMMENDED DOSE OF ENGERIX-B FOR ADOLESCENTS
Authors: Gindler Jacqueline
Published: December 2021

The commentary entitled "The Recommended Childhood Immunization Schedule of the United States"1 that appeared in the January 1995 issue of Pediatrics stated that infants born to hepatitis B surface antigen (HBsAg)-positive mothers should receive immunoprophylaxis with 0.5 mL of hepatitis B immune globulin (HBIG) and 0.5 mL of hepatitis B vaccine administered at separate sites. Hepatitis B vaccines licensed in the United States are produced by Merck & Co and SmithKline Beecham Pharmaceuticals, and are available in various concentrations. The recommended infant dose of hepatitis B vaccine varies by manufacturer and HBsAg status of the mother (see Table). Merck & Co recommends 2.5 µg of Recombivax HB for infants of HBsAg-negative mothers and 5.0 µg for infants of HBsAg-positive mothers; SmithKline Beecham recommends 10 µg of Engerix-B regardless of the mother's HBsAg status. Providers should know the HBsAg status of an infant's mother and consult the product package insert for the recommended vaccine dose.

Providers should also be aware that the Food and Drug Administration has recently lowered the age-appropriate dose of Engerix B from 20 µg to 10 µg for adolescents 11 to 19 years of age (see Table).
Letters to the Editor
Authors: Jaskiewicz Julie A.
Published: December 2021

The young febrile infant continues to perplex clinicians. Dr Young suggests that it is not simply the well appearing febrile infant, but the well appearing infant with normal tests and no focus of infection that is the true dilemma for the clinician. He suggests that it is this subset of febrile infants that should be studied when trying to determine what to do, or not do, with a febrile infant. This is a reasonable approach to the problem.
REPORTS TELL PARENTS HOW SCHOOLS PERFORM
Authors: L. J. F.
Published: December 2021

School children throughout New York City are taking home report cards this month—not their own, but those of their schools. The reports were ordered by Schools Chancellor Ramon C. Cortines, who has said that schools can be improved through more involvement by parents.

The three-page annual reports, similar to those issued in New Jersey and other states, compare various aspects of a school's performance against the school system's.

Report cards like these have been gaining in popularity throughout the country as a means of making schools more accountable to parents and other groups.

"It's getting to be a pretty wide-spread practice," said Kathy Christy, a spokes-woman for the Education Commission of the States, a national clearinghouse for school statistics. "What parents want to know is, even though my child got straight As, how is my school or my district doing compared to other schools?"

About forty-two states require that schools report to one central office about their performance or student achievement, she said, although not all require that they make such information available to parents.
Contribution of Heritable Disorders to Mortality in the Pediatric Intensive Care Unit
Authors: Cunniff Christopher , Carmack Janet L. , Kirby Russell S. , Fiser Debra H.
Published: December 2021

Objectives. To determine the percentage of patients dying in the pediatric intensive care unit (PICU) who have heritable disorders and to compare vital statistics classification of underlying cause of death with underlying heritable disorder identified from medical record review.

Design. Retrospective medical record review.

Setting. The PICU of a university-affiliated hospital.

Methods. Medical records were reviewed for all deaths occurring in the PICA over a 5-year period. Further review, including hospital course, clinical findings, and the presence or absence of a genetic evaluation, was accomplished for those patients found to have a chromosome abnormality, recognized syndrome, single major malformation, or unrecognized syndrome. Underlying cause of death classification obtained from the Center for Health Statistics, Arkansas Department of Health was reviewed to determine the frequency with which the underlying heritable disorder was recorded.

Results. Fifty-one of 268 (19%) deaths during the study period were in patients with heritable disorders. Of these 51 patients, eight (16%) had chromosome abnormalities, 17 (33%) had a recognized syndrome, 15 (29%) had a single primary defect in development, and 11 (22%) had an unrecognized syndrome. Genetic evaluation was carried out on 45% of patients, with the frequency of evaluation differing between categories of patients with heritable conditions. When underlying cause of death from vital statistics classification was reviewed, 21 of 51 (41%) records did not include the underlying heritable disorder.

Conclusions. Heritable disorders are a frequent cause of mortality in the PICU. Vital statistics classification of underlying cause of death in this population often fails to identify heritable disorders, leading to an underascertainment of these conditions in mortality statistics. Improved cause of death classification procedures will be necessary to target public health interventions to etiology-specific populations.
Children, Adolescents, and Advertising
Authors:   Committee on Communications
Published: December 2021

The following is a correction to the AAP Policy Statement entitled "Childen, Adolescents, and Advertising" that appeared in the February 1995 issue of Pediatrics (1995:95:295-297).

Under the heading entitled Beer and Wine on page 296, the statistic should have read "In 1993, 3137 young people who were 16 to 24 years of age died in alcohol-related motor vehicle crashes."

Also, on page 297, Reference 19 should be changed to the following: National Center for Statistics and Analysis. National Highway Traffic Safety Administration. Traffic Safety Facts 1993: A Compilation of Motor Vehicle Crash Data From the Fatal Accident Reporting System and the General Estimates System. Washington, DC: National Center for Statistics and Analysis; 1993. US Department of Transportation publication DOT HS 808 169.
Adolescents' Misinterpretation of Health Risk Probability Expressions
Authors: Cohn Lawrence D. , Schydlower Manuel , Foley John , Copeland Randolph L.
Published: December 2021

Objective. To determine if differences exist between adolescents and physicians in their numerical translation of 13 commonly used probability expressions (eg, possibly, might).

Design. Cross-sectional.

Setting. Adolescent medicine and pediatric orthopedic outpatient units.

Participants. 150 adolescents and 51 pediatricians, pediatric orthopedic surgeons, and nurses.

Measurement. Numerical ratings of the degree of certainty implied by 13 probability expressions (eg, possibly, probably).

Results. Adolescents were significantly more likely than physicians to display comprehension errors, reversing or equating the meaning of terms such as probably/possibly and likely/possibly. Numerical expressions of uncertainty (eg, 30% chance) elicited less variability in ratings than lexical expressions of uncertainty (eg, possibly).

Conclusion. Physicians should avoid using probability expressions such as probably, possibly, and likely when communicating health risks to children and adolescents. Numerical expressions of uncertainty may be more effective for conveying the likelihood of an illness than lexical expressions of uncertainty (eg, probably).
Prenatal Tobacco and Marijuana Use Among Adolescents: Effects on Offspring Gestational Age, Growth, and Morphology
Authors: Cornelius Marie D. , Taylor Paul M. , Geva Diklah , Day Nancy L.
Published: December 2021

Objective. This longitudinal study examined the effects of tobacco and marijuana use during pregnancy on the gestational age, growth, and morphology of 310 offspring of adolescents. Data were collected during 1990 through 1993.

Methodology. The adolescents were drawn from a prenatal clinic in Pittsburgh, PA. They were interviewed at mid-pregnancy and at delivery to obtain information on tobacco, marijuana, and other substance use before and during pregnancy. Infants were examined 24 to 36 hours after birth.

Results. The average maternal age was 16.1 (range 12 to 18 years); 70% were African-American. Prenatal tobacco use was associated with reduced birth weight, length, head and chest circumferences, and ponderal index, but not gestational age or the number of morphological abnormalities. Prenatal marijuana exposure was associated with reduced gestational age. Among whites, first trimester marijuana exposure was associated with an increased rate of minor physical anomalies. Prenatal marijuana exposure was not associated with any growth outcomes.

Conclusions. These effects of prenatal tobacco and marijuana use were prominent despite lower levels of prenatal exposure in the offspring of adolescent mothers as compared with the offspring of adult mothers from the same clinic. Young maternal age may increase the offspring's risk of negative effects from prenatal tobacco and marijuana exposure.
Specification of the Neurobehavioral Phenotype in Males with Fragile X Syndrome
Authors: Baumgardner Thomas L. , Reiss Allan L. , Freund Lisa S. , Abrams Michael T.
Published: December 2021

Objective. A controlled clinical study was designed to identify the neurobehavioral profile that is specific to males with fragile X syndrome.

Design. Thirty-one males with fragile X syndrome and 30 age and IQ-matched male controls were evaluated with instruments that assess multiple domains of adaptive functioning and problem behaviors. The Vineland Adaptive Behavior Scales and the Aberrant Behavior Checklist were selected for their dimensional scaling of behavioral ratings.

Results. Parent and Teacher versions of the Aberrant Behavior Checklist demonstrated a profile of behaviors specific to males with fragile X syndrome characterized by significantly higher levels of hyperactivity, stereotypic movements, and unusual speech. The Vineland Adaptive Behavior Scales revealed no fragile X-specific profile of adaptive skills development.

Conclusions. The distinct pattern of aberrant behaviors observed among males with fragile X emphasizes the importance of drawing subtype distinctions within the classification of individuals with mental retardation on the basis of underlying etiology. For clinical research, specifying the fragile X phenotype is a vital part in the effort to elucidate the neurodevelopmental pathways of normal behavior and psychopathology. Understanding the fragile X symptom pattern is essential for designing symptom-specific treatment interventions, as well as for research into the efficacy of interventions strategies.