bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors Associated With Delay in Diagnosis of Childhood Amblyopia
Authors: Campbell Lynn R. , Charney Evan
Published: December 2021

The prevention of permanent visual impairment from amblyopia is an important goal of pediatric vision screening. Unfortunately, many cases of amblyopia are not diagnosed until the child is too old to benefit maximally from treatment. A review of patient records from the practice of a private pediatric ophthalmologist confirmed that late detection is a frequent occurrence among children with amblyopia who have had good access to health care. A case-control study was then used to identify factors associated with delayed diagnosis, in which children with an adverse outcome (diagnosed at or after 5 years of age) were compared with those with an optimal outcome (diagnosed before 5 years of age). The chart review identified 161 children with amblyopia who participated in this study; 75 had late diagnoses (case patients) and 86 served as control patients. Children with early diagnoses more often had the following characteristics: a positive family history of strabismus, greater degrees of strabismus (when strabismus was present), higher maternal educational level, greater parental suspicion that an eye problem existed, and an increased chance that the parents requested the eye examination that led to the diagnosis. The parents of children with late diagnoses expressed less concern over the seriousness of amblyopia but were more likely to report that their children had suffered adverse consequences of amblyopia. When diagnosed early, amblyopia was more often detected by the child's primary health care provider. Physicians of the children with early diagnoses more often reported compliance with both the American Academy of Pediatrics guidelines for vision screening in infancy and referral for vision problems. Late detection of amblyopia appears to be a multifactorial problem involving characteristics of the child's visual problem, the family, and the medical system. Consideration of these factors should help to improve early identification of childhood amblyopia.
Sucrose as an Analgesic for Newborn Infants
Authors: Blass Elliott M. , Hoffmeyer Lisa B.
Published: December 2021

The effectiveness of sucrose as an analgesic agent for newborn infants was assessed during two standard painful hospital procedures: blood collection via heel lance and circumcision. Infants who drank 2 mL of a 12% sucrose solution prior to blood collection cried 50% less during the blood collection procedure than did control infants who had received 2 mL of sterile water. Crying of infants who ingested sucrose returned to baseline levels within 30 to 60 seconds after blood collection whereas control infants required 2.5 to 3.0 minutes to return to baseline. Like findings were obtained for infants who received sucrose on a pacifier prior to and during circumcision. Specifically, control infants who underwent a standard circumcision procedure without intervention cried 67% of the time. A water-moistened pacifier reduced crying to 49% (P < .01). Crying was reduced further to 31% (P < .05) by providing infants with a sucrose-flavored pacifier to suck. These findings, which parallel results obtained in studies of pain in infant rats, provide a potent yet simple, benign intervention to help alleviate stress and pain routinely experienced by human infants.
Graft versus Host Disease After Blood Transfusions in a Premature Infant
Authors: FUNKHOUSER A. W. , VOGELSANG G. , ZEHNBAUER B. , TUNNESSEN W. W. , BESCHORNER W. E. , SANDERS M. , GRAEBER J. E.
Published: December 2021

Transfusion-associated graft versus host disease (GVHD) has been reported primarily in adults with immunodeficiency secondary to malignancy and in children with severe combined immune deficiency, Wiskott-Aldrich syndrome or erythroblastosis fetalis after intrauterine transfusion and exchange transfusions.1-8 We have recently seen a premature, but otherwise apparently normal, infant in whom GVHD developed after simple blood transfusion. Engraftment of foreign lymphocytes from one donor was documented by HLA typing and recombinant DNA techniques leading to early treatment of the GVHD in this premature infant and making this case unique.

CASE REPORT

The patient was a white female, 855 g birthweight, born after 252/7 weeks' gestation to an O+, human immunodeficiency virus-negative, healthy 20-year-old woman.
Acute Myocarditis Simulating Myocardial Infarction in a Child
Authors: HOYER MARK H. , FISCHER DONALD R.
Published: December 2021

Pediatric chest pain usually occurs in benign conditions. However, this case portrays the dramatic electrocardiographic appearance of acute myocardial ischemia in a boy with biopsy-proven myocarditis who had only mild chest pain. This underscores the need for eliciting a detailed history when evaluating a patient with chest pain. If the pain cannot be clearly attributed to chest wall phenomena, or if there are historical or physical findings suggestive of an arrhythmia or angina, then further investigation with a chest radiograph and a 12-lead electrocardiogram is recommended. Myocarditis must be considered in the differential diagnosis of any child whose electrocardiogram is indistinguishable from an acute myocardial infarction.
Aseptic Meningitis in the Decennium of Borrelia burgdorferi Infection (Lyme Disease)
Authors: AUFRICHT CHRISTOPH , TENNER WILLI , STANEK GEROLD
Published: December 2021

To the Editor.—

A 7-year-old boy with a 2-week history of fatigue, sore throat, and swelling of the right cheek was admitted to our hospital in May 1989. He had no history of intoxication, trauma, fever, or bite. He lived in Vienna and did not travel outside Austria.1 His mother was concerned about his irritability and emotional liability.

Physical examination revealed mild hyperemia of his pharynx and ear drums. There were enlarged cervical lymph nodes and mild nuchal rigidity.
Early Intubation and MAS
Authors: WISWELL THOMAS E.
Published: December 2021

In Reply.—

I appreciate the comments of Dr Traverse. His opinions and practices closely reflect my own. I, too, am unaware of proven long-term sequelae which can be attributed directly to intubating meconium-stained infants once or twice.1 Additionally, I attempt to remove meconium from the upper airway in all meconium-stained infants, be they vigorous or healthy, or the meconium thick or thin. During the past 5 years, fully one third of infants with the meconium aspiration syndrome (MAS) admitted to our Neonatal Intensive Care Unit had not been intubated and had their tracheae suctioned.
Survival With Birth Weight of Less than 500 Grams
Authors: MORO GUIDO , MINOLI IOLANDA
Published: December 2021

To the Editor.—

Advances in perinatal medicine during the recent years have resulted in reduction in mortality and a significant improvement in long-term outcome of babies with a birth weight between 700 and 1000 g. A nonaggressive attitude, however, has been recommended1-4 in babies with a birth weight less than 700 g. This may not be justified.

CASE REPORT

Valentina L. was born in the Provincial Maternity Hospital of Milan on May 7, 1988, after 27 weeks of gestation.
Breast-feeding Among Women Attending Women, Infants, and Children Clinics in Georgia, 1987
Authors: MacGowan Robin J. , MacGowan Carol A. , Serdula Mary K. , Lane J. Michael , Joesoef Riduan M. , Cook Frances H.
Published: December 2021

Breast-feeding is an important determinant of the health and nutritional status of children, particularly in lower socioeconomic populations. A major goal of the Georgia Special Supplemental Food Program for Women, Infants, and Children (WIC) is to increase the practice of breast-feeding among the women it serves. Breast-feeding practices were determined among a random sample of 404 women from a cohort of 2010 who attended WIC prenatal clinics in Georgia in 1986 and were expected to deliver in February 1987. Respondents were interviewed 6 months postpartum. Of these women, 24% initially breast-fed, but only 6% continued for 6 months or longer. The initiation of breast-feeding was associated with greater maternal education and with being married. The adjusted odds of breast-feeding for mothers who were married or living as married were 3.0 (95% confidence interval, 1.7 to 5.3) times greater than for mothers who were not married or living as married. Mothers with more than 12 years, 12 years, or 10 to 11 years of education were 5.2 (1.8 to 15.3), 2.7 (1.0 to 6.9), and 2.5 (0.9 to 6.9) times more likely, respectively, to breast-feed than mothers with 9 or fewer years of education. After adjustment was made for marital status and education, the remaining variables (ethnicity, parity, age, and employment status) did not influence the initiation of breast-feeding in this low-income population. The need for vigorous promotion of breast-feeding by the Georgia WIC program is emphasized by the low rate of initiation and short duration of breast-feeding in this low-income population.
Bovine Surfactant Replacement Therapy in Neonates of Less Than 30 Weeks' Gestation: a Randomized Controlled Trial of Prophylaxis Versus Treatment
Authors: Dunn Michael S. , Shennan Andrew T. , Zayack Denise , Possmayer Fred
Published: December 2021

The influence of the timing of surfactant replacement therapy for the treatment of neonatal respiratory distress syndrome was evaluated in a study of 182 neonates of less than 30 weeks' gestation who were randomly assigned prior to delivery to one of three study groups: control (dummy instillation of air given at birth), early surfactant (surfactant given at birth), or late surfactant (surfactant given at <6 hours of age). Subjects in the late surfactant group could avoid treatment if they had a clear chest roentgenogram and required no supplemental oxygen at a mean airway pressure of less than 7 cm of water. All treated neonates were eligible to receive up to three additional doses during the first 5 days of life. The three groups were comparable with respect to birth weight, gestational age, and other perinatal parameters with the exception of a lower cord arterial pH and 1-minute Apgar score in the early surfactant group. Of the 60 neonates randomly assigned to late treatment, 29 (48%) were deemed surfactant sufficient and thereby avoided treatment; the other 31 received their first dose at a mean age of 2.9 hours. There was a significant improvement in gas exchange during the first week of life in both surfactant groups compared with the control group, reflected by differences in fraction of inspired oxygen, arterial/alveolar Po2, and ventilation index (peak pressure x rate on the ventilator) (P < .001). Surfactant therapy also resulted in a lower incidence of pulmonary air leak and severe chronic lung disease (defined as requirement for respiratory support beyond 36 weeks post-conceptional age). There were no differences between early and late surfactant groups in any of these parameters. The only statistically significant difference between the surfactant groups was that the early group had a higher incidence of mild chronic lung disease (respiratory support beyond 28 days of age) than the late treatment group (P < .005). Neonates in the late treatment group were extubated earlier and had a shorter neonatal intensive care unit stay than control neonates (P < .05), whereas those in the early group were not significantly different from control neonates in these parameters. It is concluded that replacement therapy with bovine lung surfactant extract in neonates of less than 30 weeks' gestation results in decreased oxygen and ventilatory requirements during the first week of life and a lower incidence of pulmonary air leak and severe chronic lung disease. Comparable short-term effects were seen whether a prophylactic or treatment approach was used, but there was a lower incidence of mild chronic lung disease with late treatment. There appears to be no clinical justification for routinely using a prophylactic approach to surfactant replacement therapy in this population of neonates.
Hypertension First Seen as Facial Paralysis: Case Reports and Review of the Literature
Authors: SIEGLER RICHARD L. , BREWER EILEEN D. , CORNELI HOWARD M. , THOMPSON JOEL A.
Published: December 2021

Facial paralysis was first described in a hypertensive patient by Moxon1 more than a century ago. Subsequently, there have been reports2-8 that have included a number of children, and facial palsy is mentioned in standard pediatric references9,10 as a rare feature of hypertension. Even so, practitioners may fail to recognize that facial (seventh cranial nerve) paralysis can be the initial feature of severe hypertension in children. To increase the level of awareness, we describe three severely hypertensive children who were first seen with facial paralysis between 1980 and 1988. In one of these children the diagnosis of hypertension was delayed.
I Am My Keeper; I Am My Brother's Keeper
Authors: FOSARELLI PATRICIA D.
Published: December 2021

In response to a 1987 General Assembly bill, all political jurisdictions in Maryland were required to conduct a needs assessment for school-age child care. The bill did not dictate how the assessment was to have been done; therefore, different jurisdictions solicited somewhat different information. Baltimore City, the ninth largest city in the United States (population = 790 000), selected grades in 60 and 10 randomly selected elementary and middle schools, respectively, to distribute approximately 10 000 surveys to parents for completion. The results were startling.

Overall, when parents were not at home, 4.3%, 20.4%, and 41.2% of 5- through 8-, 9- through 11-, and 12- through 14-year-olds, respectively, were in their own care, and another 25.4%, 37.2%, and 42.3% of 5- through 8-, 9- through 11-, and 12-through 14-year-olds, respectively, were home with only a sibling (age undetermined).1
Poverty, WIC, and Promotion of Breast-feeding
Authors: KRAMER MICHAEL S.
Published: December 2021

Among the health benefits of breast-feeding, one of the most important is a reduction in infant morbidity and mortality from infectious illnesses. The magnitude of the benefit, however, appears to be conditional on socioeconomic factors. For example, the protective effect is far more striking in developing countries than in developed countries.1,2 Even within developing country settings, poor sanitation, overcrowding, and other concomitants of severe poverty are associated with increased protective effects.3 In countries like the United States, with a sizable poor population, it seems reasonable to assume that infants born in poverty, who experience the highest rates of morbidity and mortality (especially in the postneonatal period), would benefit most from being breast-fed.
"Smokeless Cigarettes" and Other Nicotine Delivery Devices
Authors:   Committee on Substance Abuse
Published: December 2021

BACKGROUND

In recent years, the Food and Drug Administration (FDA) has asserted its right to regulate a number of nicotine-containing products by recognizing them as drugs or drug delivery systems under the Food, Drug, and Cosmetic Act. These products include "Favor Smokeless Cigarettes," a nicotine vapor inhaler,1(p12) and Nicorette, a nicotine-containing chewing gum.(p13)

A leading tobacco company recently introduced a new nicotine delivery device that circumvented FDA regulation by claiming that it was a cigarette.2 By definition, a cigarette is primarily a small quantity of fine tobacco rolled in paper (usually rice paper), cylindrical in shape, for smoking.1(p10) In contrast, this nicotine delivery device had the outer paper covering of a regular cigarette, but the cylinder was a metal chamber filled with pellets of alumina mixed with nicotine extracted from tobacco, a flavoring agent, and glycerol. Tobacco was not burned. Instead, when the device was ignited, a distal charcoal tip heated the glycerol, forming an aerosol that was inhaled by the user. The mouthpiece was made, in part, of tobacco leaves, and leaf tobacco was used to insulate the metal chamber, but these were never consumed.2

This product was intended to provide the user with the sensations and enjoyment of cigarettes without burning tobacco.1(p11-12) However, it was at least as effective as conventional cigarettes at delivering carbon monoxide and nicotine,2 a substance with well-recognized pharmacologic, toxic, and addictive properties.3-5

There is a potential market for this product of more than 50 million tobacco users who are addicted to nicotine. Most of these users would like to stop smoking or have tried to stop smoking,5 and they may erroneously perceive similar devices as safe alternatives to cigarettes.
Serious Error
Authors: WARE JANICE
Published: December 2021

In Reply.—

I write in response to your letter regarding an error in Table 5 of my recently published follow-up report of surfactant-treated infants.1 Dr Jain, Vidyasagar, and Raju are correct in noting an error in the citation for the source of their surfactant material. The correct text should have stated that their material was obtained from bovine lung preparations rather than therapeutic abortions. We thank the authors for pointing out this discrepancy.
25% "Error Rate" in Ear Temperature Sensing Device
Authors: FREED GARY L. , FRALEY J. KENNARD
Published: December 2021

To the Editor.—

We read with interest the recent article by Kenney et al1 regarding the acceptability of the FIRST temp (Intelligent Medical Systems, Inc., Carlsbad, CA) tympanic membrane infrared temperature sensing device as a clinical tool for pediatricians.1 The authors conclude that the instrument provides body temperature measurements consistent with traditionally used methods (glass-mercury thermometer). We take exception with the analysis used to reach such a conclusion.

The authors present their data as mean differences between FIRST temp and conventional methods with 95% confidence intervals around the mean.
25% "Error Rate" in Ear Temperature Sensing Device
Authors: KENNEY RICHARD D. , FORTENBERRY JAMES D. , SURRATT S. SUZETTE , RIBBECK BETH M.
Published: December 2021

In Reply.—

We thank Freed and Fraley for their helpful comments as based on a different manner of data presentation. We agree that reporting standard deviations would have been more informative than reporting confidence intervals (standard error of the mean). However, the following frequency table of absolute value of the differences between the two devices demonstrates that 75% of tympanic membrane thermometer readings were within 0.5°C of

[See table in the PDF file]

glass-mercury thermometer readings and more than 95% are within 1°C.
Fetal Vascular Disruption With Prenatal Exposure to Cocaine or Methamphetamine
Authors: HOYME H. EUGENE
Published: December 2021

In Reply.—

Dr Bays has pointed out that congenital limb reduction defects associated with prenatal exposure to cocaine may be quite common. I would agree that such limb and digital disruptions are occasional accompaniments of fetal exposure to maternal cocaine abuse. However, the exact magnitude of individual fetal risk for prenatal vascular disruption associated with such exposure remains to be delineated.

One must take the percentage of cocaine-exposed children in this report as the minimal number of exposed because many of the medical records did not record prenatal drug exposure.
Prospective Observations of 100 High-Risk Neonates by High-Field (1.5 Tesla) Magnetic Resonance Imaging of the Central Nervous System II. Lesions Associated With Hypoxic-Ischemic Encephalopathy
Authors: Keeney Susan E. , Adcock Eugene W. , McArdle Craig B.
Published: December 2021

One hundred neonates determined prospectively to be at risk for neurologic handicap underwent magnetic resonance imaging with a high-field (1.5 T) imager. Thirty-three demonstrated a total of 37 lesions consistent with hypoxic-ischemic encephalopathy, including periventricular leukomalacia (n = 12), basal ganglia hemorrhage (n = 5), multicystic encephalomalacia (n = 5), and focal parenchymal hemorrhage (n = 15). Diagnoses by ultrasonography and computed tomography were compared with those by magnetic resonance imaging in 29 and 17 infants, respectively. Ultrasonography agreed more frequently with magnetic resonance imaging than did computed tomography. Ultrasonography detected 79% of lesions demonstrated by magnetic resonance imaging whereas computed tomography detected only 41%. Periventricular leukomalacia was seen most often in preterm infants, basal ganglia hemorrhage and multicystic encephalomalacia primarily occurred in term infants, and focal parenchymal hemorrhage occurred at all gestational ages. Basal ganglia hemorrhage and multicystic encephalomalacia were strongly associated with histories of perinatal asphyxia, seizures, and early abnormal neurologic status. All infants with basal ganglia hemorrhage (5/5) and multicystic encephalomalacia (5/5) and the majority with periventricular leukomalacia (9/12) and focal parenchymal hemorrhages (9/15) had developmental abnormalities at discharge.
Amoxicillin or Myringotomy or Both for Acute Otitis Media: Results of a Randomized Clinical Trial
Authors: Kaleida Phillip H. , Blatter Mark M. , Reisinger Keith S. , Wald Ellen R. , Casselbrant Margaretha L. , Bluestone Charles D. , Rockette Howard E. , Paradise Jack L. , Supance John S.
Published: December 2021

A total of 536 infants and children with acute otitis media were randomly assigned to one of six consistent year-long regimens involving the treatment of nonsevere episodes with either amoxicillin or placebo, and severe episodes with either amoxicillin, amoxicillin and myringotomy, or, in children aged 2 years or older, placebo and myringotomy. Nonsevere episodes had more favorable outcomes in subjects assigned to treatment with amoxicillin than with placebo, as measured by the proportions that resulted in initial treatment failure (3.9% vs 7.7%, P = .009) and the proportions in which middle-ear effusion was present at 2 and 6 weeks after onset (46.9% vs 62.5%, P < .001; and 45.9% vs 51.5%, P = .09, respectively). In subjects whose entry episode was nonsevere, those assigned to amoxicillin treatment had less average time with effusion during the succeeding year than those assigned to placebo treatment (36.0% vs 44.4%, P = .004), but recurrence rates of acute otitis media in the two groups were similar. In the 2-year-and-older age group, severe episodes resulted in more initial treatment failures in subjects assigned to receive myringotomy alone than in subjects assigned to receive amoxicillin with, or without, myringotomy (23.5% vs 3.1% vs 4.1%, P = .006). In the study population as a whole, severe episodes in subjects assigned to receive amoxicillin alone, and amoxicillin with myringotomy, had comparable outcomes. It is concluded that children with acute otitis media should routinely be treated with amoxicillin (or an equivalent antimicrobial drug). The data provide no support for the routine use of myringotomy either alone or adjunctively.
Impedance Tympanometry and Acoustic Reflectometry at Myringotomy
Authors: Babonis Thomas R. , Weir Michael R. , Kelly Patrick C.
Published: December 2021

A total of 220 ears undergoing myringotomy and pressure-equalizing tube placement were studied with impedance tympanometry and acoustic reflectometry in a direct comparison for detection of middle-ear effusion. Impedance tympanometry and acoustic reflectometry were equally accurate, detecting the presence or absence of middle-ear effusion in 73% and 72% of ears, respectively. The presence of effusion in ears with tympanographic patterns other than type A and type B was not consistently and reliably predicted. The higher sensitivity of impedance tympanometry (90%) compared with that for acoustic reflectometry (58%) contrasted with the opposite findings for specificities (54% vs 88%). It is concluded that impedance tympanometry and acoustic reflectometry measure different events at the tympanic membrane and their utility lies in the fact that they complement each other. These instruments can aid the experienced otoscopist in confirming a clinical impression and assist the less experienced clinician in validating or improving otoscopic skills.
Clinical-Physiologic Correlations in Acute Asthma of Childhood
Authors: Kerem Eitan , Canny Gerard , Reisman Joseph , Bentur Lea , Levison Henry , Tibshirani Rob , Schuh Suzanne
Published: December 2021

Seventy-one patients who presented to the emergency room with acute asthma were evaluated to determine the relationship between common clinical signs and spirometric and transcutaneous arterial oxygen saturation (Sao2) measurements. Prior to treatment, a physical examination was performed, a clinical score assigned, and pulmonary function and Sao2 were measured. Although forced expiratory volume in 1 second (FEV1) and Sao2 had strong correlation with the overall clinical score (r2 = .47, .49 respectively), many patients with low clinical scores and apparent mild clinical disease had low FEV1 values (as low as 20% predicted). Of the individual components of the clinical score (ie, heart rate, respiratory rate, pulsus paradoxus, accessory muscle use, dyspnea, and wheezing), the degree of accessory muscle use correlated most closely with lung function followed by the degree of dyspnea and wheezing. Similarly, the degree of accessory muscle use correlated most closely with Sao2 followed by dyspnea and respiratory rate. Significant correlation (r2 = .59) was found between Sao2 and FEV1, although the range of Sao2 value for a given FEV1 was wide and some patients with low FEV1 values had normal Sao2 values. These results show that although clinically apparent severe disease and hypoxemia were always associated with low FEV1, their absence does not exclude the presence of airflow obstruction. It is concluded that for the optimal evaluation of acute asthma in children in the emergency room, clinical evaluation should be used in conjunction with objective laboratory measurements.
Failure to Detect Surfactant Protein-Specific Antibodies in Sera of Premature Infants Treated With Survanta, A Modified Bovine Surfactant
Authors: Whitsett Jeffrey A. , Hull William M. , Luse Susan
Published: December 2021

Serum from premature infants enrolled in either single-dose or multidose surfactant replacement studies with bovine lung-based exogenous surfactant (Survanta) were analyzed for antibodies reactive with mixtures of bovine surfactant proteins SP-B and SP-C. Sera from 404 premature infants enrolled in single-dose studies and 1024 premature infants enrolled in multidose studies were analyzed, representing a total of 987 samples and 2743 serum samples, respectively. The sera were obtained from treated and control infants at the time of treatment and 1 week, 4 weeks, and 6 months thereafter. Polyclonal antisera generated in rabbits against the small molecular weight proteins were uniformly reactive with the bovine surfactant test antigens; however, antibodies reacting with the surfactant proteins were never detected by immunoblot analysis with the infant sera. Antibodies against common human viral antigens were readily detected in infant serum samples. The horseradish-peroxidase conjugated second antibodies (antihuman immunoglobin G or antihuman immunoglobins A, G, and M) used in the studies were highly reactive with both immunoglobin G and immunoglobin M classes of human antibodies. Therefore there was failure to detect specific immunological responses to the bovine surfactant proteins present in Survanta after single or multiple doses of exogenous surfactant administered in the perinatal period.
Procedures, Pain, and Parents
Authors: BAUCHNER HOWARD
Published: December 2021

During the past decade certain types of pain in children have been the subject of much research and discussion. The pain associated with cancer, sickle cell disease, and the preoperative and post-operative periods have all been extensively studied and reviewed.1-4 Less information is available about acute pain inflicted in emergency rooms. Children commonly undergo procedures such as venipuncture, intravenous cannulation, lumbar puncture, and manipulation of fractures in emergency rooms without the benefit of any analgesia.

What techniques are available to reduce the pain and anxiety that children feel when they undergo procedures? Traditionally, physicians have tried to reduce pain by using pharmacological agents.
Guidelines for Pediatric Cardiology Diagnostic and Treatment Centers
Authors:   Section on Cardiology
Published: December 2021

This document describes the clinical and physical environment in which the pediatric patient with heart disease can undergo accurate and safe diagnostic and therapeutic procedures. Effective utilization of facilities, development of new technologies, and deployment of personnel capable of providing care for the fetus, infant, child, and young adult with heart disease are outlined. Guidelines in this statement update a previous document published in 19781; these current guidelines are in concert with those developed by the Joint Commission on Accreditation of Health Care Organizations2 and are intended for use by health planning agencies and health service organizations to evaluate existing pediatric cardiac centers and to establish the need for new centers.2-5

Young patients with heart disease have unique medical problems that can be met best by a team with training and expertise in the management of such pediatric patients. The primary purpose of this document is to recommend guidelines by which evaluation and treatment can be accomplished safely and effectively and to offer mechanisms to assist in assuring excellence in the quality of pediatric cardiology care.

GENERAL BACKGROUND

Pediatric cardiology patients require continuity and expertise in patient care. A pediatric cardiologist, along with the patient's primary physician, should provide a continuing care program. In some centers, pediatric cardiologists who have expertise in the management of patients with congenital heart disease may provide new or continuing care for adults with congenital heart defects; in others, an orderly transfer of medical management between pediatric and adult cardiologists will provide the best care for older patients.
Community-wide Outbreak of Group G Streptococcal Pharyngitis
Authors: Gerber Michael A. , Randolph Martin F. , Martin Nancy J. , Rizkallah Munir F. , Cleary P. Patrick , Kaplan Edward L. , Ayoub Elia M.
Published: December 2021

Although several outbreaks of group G β-hemolytic streptococcal (GGBHS) pharyngitis have been described, doubt still remains regarding the etiologic role of GGBHS in acute pharyngitis beyond a limited number of situations. In the winter/spring of 1986/87, throat cultures were obtained from 222 consecutive children seen at a private pediatric office with acute pharyngitis and group A β-hemolytic streptococci (GABHS) were recovered from 91 children (41%) and GGBHS from 56 children (25%). One patient had both GABHS and GGBHS isolated. This isolation rate of GGBHS was dramatically greater than in previous and subsequent years, and 67% of the GGBHS isolates occurred during an 8-week period. Results of DNA fingerprinting of the 57 isolates of GGBHS demonstrated that 43 (75%) appeared to be the same strain. The patients with GGBHS were comparable to those with GABHS with respect to clinical findings, antistreptolysin-O titer response, and clinical response to antibiotic therapy. However, patients with GGBHS were significantly older (P < .05). This is the first well-documented, community-wide outbreak of GGBHS pharyngitis and the first respiratory outbreak of GGBHS pharyngitis in a pediatric population. GGBHS may be a more important cause of acute, treatable pharyngitis than had been previously recognized.
Role of a Soy-Based Lactose-Free Formula in the Outpatient Management of Diarrhea
Authors: Santosham Mathuram , Goepp Julius , Burns Barbara , Reid Raymond , Sack R. Bradley , O'Donovan Crosson , Pathak Radha
Published: December 2021

The introduction of a soy-based, lactose-free formula during the acute phase of diarrheal illness in infants has been shown to reduce stool output and duration of diarrhea in hospitalized patients. In the United States, most infants with acute diarrhea are treated as outpatients. In the present study, infants with diarrhea who were treated as outpatients were randomly assigned to receive either a soy-based, lactose-free formula alternating with oral rehydration solution from the beginning of therapy ("early feeding") or oral rehydration solution alone for the first 24 hours of therapy, followed by a soy-based, lactose-free formula alternating with oral rehydration solution (control group). Twenty-nine infants were randomly assigned to the early-feeding group and 27 to the control group. Twenty-one (72%) of 29 in the early-feeding group resolved their diarrhea at the end of 48 hours of therapy compared with 12 (44%) of 27 in the group fed oral rehydration solution only (P = .02). It is concluded that the introduction of a soy-based, lactose-free formula from the beginning of therapy for acute diarrhea in children treated as outpatients is safe and may shorten duration of diarrhea while maintaining adequate caloric intake.
Race and Birth Weight: The Chinese Example
Authors: Yip Ray , Li Zhu , Chong Wan-Hwa
Published: December 2021

In several studies a race-specific variation in birth weight was suggested between black infants and white infants. The following were compared: (1) the birth weight of Chinese infants born in mainland China, Taiwan, and the United States; and (2) the birth weight of Chinese infants and white infants born in the United States controlled for sociodemographic background. Similarilar birth weight distributions and incidence of low birth weight were found among Chinese infants born in the three areas with markedly different economic conditions. The women in all three areas appear to have met the basic health and nutritional needs for adequate fetal growth. Similar incidence of low birth weight with different birth weight distribution was found among infants born in the United States to two Chinese parents, to one Chinese parent and one white parent, and to two white parents. The variation in birth weight is greater for white infants than for Chinese infants and, consequently, more white infants had larger birth weight. The possibility of race-specific influences on birth weight distribution is suggested by these findings.
Use of Multiple Visits to Increase Blood Pressure Tracking Correlations in Childhood
Authors: Gillman Matthew W. , Rosner Bernard , Evans Denis A. , Smith Laurel A. , Taylor James O. , Hennekens Charles H. , Keough Mary Ellen
Published: December 2021

Previous studies of childhood blood pressure have shown tracking correlations, which estimate the magnitude of association between initial and subsequent measurements, to be lower than corresponding adult values. Inasmuch as this disparity could arise from failing to account for a larger week-to-week variability in children, blood pressure was measured for 4 successive years, on four weekly visits in each year, and with three measurements at each visit, using a random-zero sphygmomanometer, in a cohort of 333 schoolchildren aged 8 through 15 at entry. Ninety percent of subjects had measurements in 1 or more years of follow-up. For all follow-up periods (1, 2, and 3 years from baseline), the Pearson correlation coefficient (r) for both systolic and diastolic blood pressure rose substantially with the number of weekly visits used to calculate each subject's yearly blood pressure (P < .0001). For systolic pressure, the 3-year r values for 1, 2, 3, and 4 visits were .45, .55, .64, and .69, respectively. For diastolic pressure (Korotkoff phase 4), the corresponding values were .28, .41, .47, and .54. These higher multiple-visit estimates of tracking approximate published adult values and raise the possibility that prediction of adult blood pressure from childhood measurements may be improved by averaging readings from multiple weekly visits.
On Making a Difference
Authors: Green Morris
Published: December 2021

A question being much discussed today, here and elsewhere, is how to be helpful to all children and their families, especially those who are highly vulnerable and at special risk. It is a question that also intrigued Abraham Jacobi, a vigorous advocate for children and a vocal opponent of practices and conditions he viewed as inimical to their best interests.

Now, as in Jacobi's day, the privileged status that society confers on the professions carries implicitly, and increasingly explicitly, the charge that they remain responsive to the needs of the times. In the case of pediatricians, there is the expectation that we will do whatever is in our individual or collective power to help children and their families master the rapid changes and risks that confront them today. Pediatricians are being challenged increasingly to become involved in social as well as biomedical issues and to promote healthy adaptation as well as growth and development.

PEDIATRICS AND ADAPTATION

These remarks on the potential role of pediatricians in promoting adaptation to developmental, social, educational, and psychosocial issues call for an extension of their traditional role in helping children and parents cope with biomedical problems.1,2 As exemplified in Table 1, such adaptation may be biomedical or psychosocial and prospective, concurrent, or rehabilitative. For successful adaptation to occur, the child or adolescent must advance from the "Risk" box in Figure 1 to the one labeled "Mastery." Those who end in the box labeled "Maladaptation" are life's losers, penalized by symptoms, poor functioning, and unhappy families.
A Survey of Community (Out-of-Hospital) Sites Used in Pediatric Training
Authors: ALPERT JOEL J. , BLODGETT FREDERICK M. , GARGAS DONALD C. , JENKINS RENEE , KAPLAN DAVID W. , KOHRT ALAN , LEVINE GILBERT , O'HARE DONNA
Published: December 2021

A survey was completed of US pediatric residency programs about the use of community sites in training. A total of 85% of program directors responded and reported a wide use of the 21 identified survey sites. Further study is needed to determine the appropriate contribution that community sites can make to pediatric training.
Cardiac Tumors and the Nevoid Basal Cell Carcinoma Syndrome
Authors: COTTON JOHN L. , KAVEY RAE-ELLEN W. , PALMIER CATHERINE E. , TUNNESSEN WALTER W.
Published: December 2021

Nevoid basal cell carcinoma syndrome is a multisystem disease with a wide range of initial symptoms that can be seen at any age. The most characteristic features are vertebral or rib anomalies, intracranial falx calcification, multiple basal cell carcinomas, odontogenic keratocysts of the jaw, and palmar and/or plantar pits. Pediatricians need to be aware that if any one of these major anomalies is seen, this diagnosis should be considered.

There now appears to be an established association between cardiac tumors and nevoid basal cell carcinoma syndrome. Primary cardiac tumors have been associated with cerebral tuberous sclerosis and neurofibromatosis,20,21 and evaluation of cardiac status is recommended when these genetically determined syndromes are diagnosed. This communication should serve to alert pediatricians to the need for complete cardiac evaluation and genetic counseling when a diagnosis of nevoid basal cell carcinoma is made.
Pollakiuria, Extraordinary Daytime Urinary Frequency: Experience in a Pediatric Practice
Authors: BASS LEE W.
Published: December 2021

Pollakiuria1,2 (pollakis: Greek, meaning often), or increased daytime frequency of urination, has been reported recently.3-5 This article documents pollakiuria with a prospective 1-year study in a general pediatric practice; compares its incidence with that of lower urinary tract infections in the same practice; describes a method of determining etiology; notes anxiety-producing situations, such as fear of death, as possible precipitating factors; and discusses an approach to therapy. The desirability and practicality of avoiding invasive and/or expensive procedures is emphasized.

Pollakiuria, with urination as often as every 5 to 10 minutes, occurs during the waking hours only, and most commonly in children of preschool or kindergarten age.
Management Strategies for Perinatal Hypoxic-Ischemic Encephalopathy
Authors: MOODLEY MANIKUM , ADHIKARI MIRIAM
Published: December 2021

To the Editor.—

The paper by Dr Vanucci1 (Pediatrics. June 1990) addresses an important issue in neonatal medicine

[See table in the PDF file]

namely the management of hypoxic-ischemic encephalopathy (HIE). The review is comprehensive and lucid, and the section on "new management strategies" comes at a time when considerable interest has been directed toward this form of therapy. HIE remains a major problem in developing countries where the incidence may be as high as 4% to 6% compared with about 0.2% to 0.9% in the developed world.1-3
Water Temperature and Drowning
Authors: NICHTER MARK A , EVERETT PERRY B. , SALTIEL ALBERT
Published: December 2021

To the Editor.—

We read with interest the report by Quan et al.1 The authors described normal or near-normal neurologic outcomes after cardiopulmonary arrest in 8 of 38 victims. We are encouraged by these results and agree that early, effective cardiopulmonary resuscitation is the most effective treatment for pediatric submersion victims. Several additional factors, however, must be considered when interpreting the results of this study.

Quan et al describe the King County, Washington climate as "temperate" and note that "submersion victims in this region did not receive the potentially beneficial rapid cooling that icy waters may provide."
Water Temperature and Drowning
Authors: QUAN LINDA , WENTZ KIM R.
Published: December 2021

In Reply.—

Dr Nichter et al propose that the normal or mildly impaired survival of five asystolic children in our series was due to the rapid induction of hypothermia by the cold waters of the Puget Sound area. However, we reported that hypothermia (rectal temperature <34°C) was not associated with increased survival. In addition, the data in the Table show that none of these five children experienced cold-water submersions.

The ambient temperatures and thus possibly swimming pool temperatures in this temperate area's summers are certainly less warm than Florida's.
Etiology of Autism: Genetic Influences
Authors: Folstein Susan E. , Piven Joseph
Published: December 2021

Infantile autism was first described by Kanner in 1943.1 Based on the observation that symptoms often began shortly after birth and always by two or three years of age, Kanner believed that autism was caused by an unknown, inborn defect. Because this syndrome was so severe and peculiar, it seemed unlikely to be an understandable outcome of a child's life experiences. In the years since Kanner first described this disorder, research findings have supported his initial interpretations. It is now generally accepted that autism has a biologic cause, and considerable research has been carried out with the aim of uncovering its nature. Both hereditary factors and the prenatal and perinatal environment have been considered. This paper will review the role of genetic factors in the cause of autism; the role of the prenatal and perinatal environment is considered in the paper by Nelson.51

Three types of genetic associations have been described: (1) the familial aggregation of autism, per se—autism is more common in the sibs of affected children; (2) the familial aggregation of other disorders in the family members of autistic children—a variety of disorders that are mild, but probably conceptually related, have recently been described in relatives; and (3) autism appears in association with a few particular disorders of known genetic etiology.

FAMILIAL AGGREGATION OF AUTISM

Population and Family Studies

In most case series and a few population-based studies, the prevalence of autism in the siblings of autistic children has been estimated to be about 2% to 3%.2,3 While this number is small, it is 50 to 100 times greater than the expected rate of autism of 4 to 5 per 10 000 in the population.4,5
Systemic and Other System Disorders
Authors: OSTROM NANCY K.
Published: December 2021

Pathophysiology

TOXIC SHOCK SYNDROME ASSOCIATED WITH STAPHYLOCOCCUS AUREUS SINUSITIS

Ferguson MA, Todd JK. J Infect Dis. 1990;161:953-955.

Purpose of the Study

This study was performed to highlight, through case reviews, the potential for toxic shock syndrome to occur in pediatric patients as a result of Staphylococcus aureus sinusitis.

Study Population

The case studies involved 3 patients between 8 and 14 years of age.

Methods

The study was carried out by case review of medical records.

Findings

Three cases of toxic shock syndrome with sinusitis as their sole focal site of infection were reviewed. Two of the cases had culture documentation of S aureus with a positive nasal culture and good response to antistaphylococcal therapy. Blood and other cultures were negative. All three cases manifested fever, rash, desquamation, and hypotention or orthostatic dizziness, as well as three or more minor criteria demonstrating involvement of other organ systems. The third case, without sinus culture, represented recurrent sinusitis associated with recurrent toxic shock syndrome. All three cases responded to usual therapy for toxic shock syndrome including fluid volume, support, and antistaphylococcal antibiotics.

Conclusions

The authors concluded that sinusitis can be a nonmenstrual site of S aureus infection underlying toxic shock syndrome in pediatric patients. They noted other similar situations such as nasal surgery or nasal packing which had been associated with toxic shock syndrome perhaps due to similar focal growth conditions promoting optimal toxin production. The authors recommended aspiration of sinuses in such cases, not only for diagnosis but as an important therapeutic procedure.
Sleep Apnea in Infants Who Succumb to The Sudden Infant Death Syndrome
Authors: Schechtman Vicki L. , Harper Ronald M. , Wilson Adrian J. , Southall David P.
Published: December 2021

Previous studies have shown the frequency of respiratory pauses to be altered in groups of infants at risk for the sudden infant death syndrome (SIDS). In this study, we assess the frequency of apneic pauses during quiet sleep and rapid eye movement sleep in control infants and infants who subsequently died of SIDS. Sleep states were identified in 12-hour physiological recordings of SIDS victims and matched control infants, and the number of respiratory pauses from 4 to 30 seconds in duration was computed for quiet sleep and rapid eye movement sleep. SIDS victims 40 to 65 days of age showed significantly fewer apneic pauses than did age-matched control infants across the two sleep states. Fewer short respiratory pauses accounted for most of the reduction in number of apneic events in the SIDS victims during both sleep states. During the first month of life, SIDS victims did not differ significantly from control neonates on this measure. The finding that this respiratory difference exists during the second month of life, just before the period of maximal risk for SIDS, but not earlier, may have implications for the etiology of SIDS deaths.