bluuebunny/crossref_metadata_2025 huggingface dataset:
Preventing Low Birth Weight, Child Abuse, and School Failure: The Need for Comprehensive, Community-Wide Approaches
Authors: Chamberlin Robert W.
Published: December 2021

Based on numerous examples from this country and abroad, we now have a reasonable idea of how we can reduce substantially the incidence of low-weight births, child abuse, adolescent pregnancy, school failure, and school dropout. The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community-wide approach focused on preventing low- and medium-risk families from becoming high-risk as well as providing intensive services to those who already have reached a high-risk status. The best results can be obtained when all levels of government and the private sector work together. In this partnership, the best outcomes appear to result when the state and federal governments, private corporations, or both provide technical assistance, additional funding as needed, and help in setting program standards, and when the community maintains local control over establishing priorities and implementation strategies. However, to reach these goals and to maintain program support over the long time periods needed to show positive results (4 to 8 years), it is necessary to become skilled in social marketing techniques to turn program need into demand and to develop a strong local and statewide advocacy group to facilitate passage of needed legislation and prevent funding cutbacks.

Pediatricians can modify their practices to make them more supportive to families and can work with other community leaders to bring about the changes in attitudes and about the changes in attitudes and funding priorities at the state and community levels that will be necessary to develop more effective preventive programs.
INDEX OF SUSPICION
Authors: Robertson William O. , Menna Vincent J.
Published: December 2021

Clinicians often form a diagnostic impression at the time of a patient's first consultation. Usually, the initial impression is correct because commonly encountered illnesses come to mind and are, of course, most likely to be responsible. Sometimes, however, a less familiar disorder is responsible and will not be detected or will be diagnosed only after a prolonged delay unless the physician maintains a suspicion of the unusual.

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

An 11-day-old infant — his mother's fourth — had an entirely normal delivery but was noted to be jaundiced on the fifth day of life. He was admitted to the hospital for phototherapy. The baby never had a bilirubin exceeding 17 mg/dL, but during the hospitalization he was diagnosed as having "apneic episodes" and was started on theophylline; he went home on that medication.
Assessment of Growth and Development During Infancy and Early Childhood
Authors: Vaughan Victor C.
Published: December 2021

A prime function of the pediatrician is to monitor the developmental status of his or her patients. Sensitive monitoring demands a broad knowledge of developmental processes and issues and the ability to assess the data made available from the clinical examination accurately and efficiently.

Areas of Developmental Assessment

Developmental assessment is made in four broad areas during early childhood: physical or physiologic, neurodevelopmental, cognitive, and psychosocial.

PHYSICAL OR PHYSIOLOGIC DEVELOPMENT

This area comprises the changes in physical size, shape, and function that come with age. Many of these changes can be measured, such as height, weight, skinfold thickness, head circumference, body surface area, blood counts, enzyme activities, and hormone levels. These measurements can be compared with standard values that indicate the range of normal findings.

NEURODEVELOPMENTAL MATURATION

This area comprises changes in behavior that evolve with the passage of time, particularly those changes that depend primarily upon maturation. They include some reflex activities and many gross and fine motor skills, including visuomotor and other intersensory functions. These behaviors are assessed primarily by observation, often informally, but sometimes (when more critical appraisal is required) in a carefully structured setting.

COGNITIVE DEVELOPMENT

Cognitive development and neurodevelopmental maturation are closely related, and it is sometimes difficult to distinguish between them in the infant and young child.
Prenatal Diagnosis and Carrier Detection by DNA Analysis
Authors: Cutting Garry R. , Antonarakis Stylianos E.
Published: December 2021

During the past 10 years, enormous strides have been made both in our ability to detect abnormal genes and in the number of genes that can be analyzed. The introduction of the polymerase chain reaction (PCR), a method that can enrich a region of DNA by a million-fold, enables gene diagnosis to be performed within hours instead of weeks and is moving DNA testing increasingly from the research bench to the hospital laboratory. The human genome is estimated to have about 100 000 genes, and almost 5000 of these genes have been categorized. The list of identified genes now includes those responsible for a number of relatively common genetic disorders, including cystic fibrosis, Duchenne muscular dystrophy, hemophilia A, sickle cell disease, and neurofibromatosis. At the present time, more than 200 genetic diseases can be diagnosed using DNA techniques. A sample of these is shown in the Table.

Inheritance of Abnormal Genes

Because individuals inherit one set of chromosomes from each parent, there are two genes at each locus, with the exception of genes on the X chromosome because there is only one X chromosome in males. Disorders produced by an abnormality in only one gene are termed dominant (eg, neurofibromatosis), whereas disorders that occur only when both genes are affected are termed recessive (eg, cystic fibrosis).
INDEX OF SUSPICION
Authors: Chapman Daniel D. , McCormick Marie C.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A prepubertal 12-year-old boy who is obese (192 lbs, 68 in) is seen in the office for pain in the anterior and medial aspect of the left knee. The knee is not tender to palpation and has a range of motion equal to the normal right knee. He is in a weight-reduction program consisting of an 1800-calorie diet and supervised exercise four times per week. No history of trauma is elicited.

Case 2 Presentation

During the past 2 months, you have seen an 8-month-old boy twice for ear infections. At the last visit, 3 weeks ago, he also had a rash over his buttocks and in the perianal area that you treated with zinc oxide cream.
Gastroesophageal Reflux
Authors: Orenstein Susan R.
Published: December 2021

Gastroesophageal reflux is an important problem in children for several reasons. It occurs frequently; sometimes features perplexing and misleading symptoms; causes significant morbidity; and defies rapid, simple, and curative therapy. Thus, it is an important disorder for pediatricians to understand.

Definitions

Gastroesophageal reflux is the return of gastric contents into the esophagus. Confusion sometimes has resulted from failure to distinguish between gastroesophageal reflux as a single event and as a condition, as well as from failure to distinguish between a physiologic and a pathologic condition. A gastroesophageal reflux episode is a single instance of return of gastric contents into the esophagus. Confusion between this single event and the pathologic condition of gastroesophageal reflux disease has been perpetuated by the habit of diagnosing "gastroesophageal reflux" (meaning gastroesophageal reflux disease) on the basis of a single episode of reflux seen on a barium fluoroscopic study or during scintigraphic evaluation. It is important to understand that virtually all people reflux occasionally. The distinction between this physiologic gastroesophageal reflux and pathogenic gastroesophageal reflux (ie, gastroesophageal reflux disease) can be made either by demonstrating an abnormal quantity of reflux (increased frequency or duration of episodes compared to asymptomatic individuals) or by demonstrating that detrimental effects (such as malnutrition, esophagitis, or respiratory disease) have resulted from reflux.
Pelvic Inflammatory Disease in Adolescents
Authors: Paradise Jan E. , Grant Linda
Published: December 2021

Pelvic inflammatory disease (PID) is a general term referring to infection and inflammation of the upper genital tract, primarily involving the fallopian tubes and uterus. Other terms for PID in common use include endometritis (infection of the uterus) and salpingitis (tubal infection with inferred endometrial involvement). This article reviews the epidemiology, diagnosis, and management of PID in adolescents.

Epidemiology of Pelvic Inflammatory Disease

Of the estimated 1.25 million women in the United States who acquire PID each year, 16% to 20% are adolescents. Of women who have had PID, one out of three experienced her first episode before she was 19 years of age. Two factors confer a particularly high risk of acquiring PID on adolescents: multiple sexual partners and a high prevalence of sexually transmitted infections.

Adolescent girls in the United States begin sexual activity at a mean age of 16.2 years. In 1988, 26% of 15-y-old women, 51% of 17-y-old women, and 75% of 19-y-old women reported having had premarital sexual intercourse. Three fourths of these sexually active adolescents had had two or more sexual partners, and 45% had had four or more sexual partners. It is not surprising that young women with more than one sexual partner during a 3- to 6-mo interval are more than four times as likely to develop PID than are those who have only one partner.
Pediatric Neurodiagnostic Tests: A Modern Perspective
Authors: Ferry Peggy C.
Published: December 2021

The past decade has witnessed unprecedented advances in our ability to study the pediatric nervous system by various imaging and electrophysiologic recording techniques. A profusion of imaging devices and "brain mapping" machines have been developed and aggressively marketed to neurologists. The pediatric practitioner now has a veritable "Chinese menu" of various neurodiagnostic tests from which to choose in evaluating a child who has a neurologic complaint. The quality of the images obtained from newer studies, particularly magnetic resonance imaging (MRI), is truly astounding, and it is tempting to order such a study when evaluating almost any child with a neurologic problem.

Deciding which test to order as a screening procedure, which one might be most useful as a secondary examination, or which study should be performed as the most definitive diagnostic procedure can be difficult. These questions may result in a "shotgun" approach or a "full diagnostic onslaught,"1 with all available tests being done when one or two might have been sufficient.

The pediatrician's dilemma during the modern era is clear: Despite the increased quality of images now available, the newer tests are expensive (Table 1), and their overuse in the pediatric population has contributed significantly to the higher costs of evaluating children who have neurologic disorders.
Office Care of Wounds
Authors: Lease John G.
Published: December 2021

All children experience a variety of minor injuries, the vast majority of which can be cared for easily by a competent parent. Wounds of a larger scope, wounds of a complex nature, or wounds with secondary complications require consultation with the pediatrician. Knowledge of the principles of treatment is essential and must be tailored to individual parental abilities, home environment, and emotional concerns. The purpose of this article is to outline common problems and to give suggestions for efficient office management.

Tetanus Prophylaxis

All wounds, regardless of etiology or size, should be considered as potential sources of tetanus. Therefore, it is incumbent upon the primary provider to ensure adequacy of tetanus prophylaxis (Table).

Lacerations

Pediatricians see a variety of lacerations. Those which do not come to medical attention through the emergency department are usually within the scope of the primary provider. Occasional surgical referral may be necessary because of the nature of location of the wound.

If bleeding has not ceased by the time of initial presentation, a small gauze dressing should be applied with direct, constant pressure for 15 min. Large, bulky dressings are inefficient for applying pressure at the exact bleeding site. Careful documentation should include location, orientation, depth, and exact length of the laceration.
Care of the Normal Newborn
Authors: Kendig James W.
Published: December 2021

A variety of changes have occurred recently in perinatal care that influence the role of the pediatrician. These include new prenatal assessment techniques (ultrasonography and fetal electronic monitoring), an increased attention to the ambiance of delivery with family participation, and more rapid hospital discharge. This review will focus on the role of the general pediatrician in the care of the normal newborn in this new setting.

Prenatal Pediatric Visit

The pediatrician's role in the care of the normal newborn should begin with the prenatal pediatric visit during the third trimester of the pregnancy. This visit usually occurs in the pediatric office; some practitioners can schedule time for a home visit. This first meeting between parents and pediatrician frequently serves as the foundation for two decades of mutual trust, confidence, and communication. The topics that should be discussed and recorded at this visit are listed in Table 1. Serious potential problems identified during this visit may require discussion with obstetrical and neonatal colleagues.

The prenatal visit should include discussions about maternal nutrition; the hazards of alcohol, cigarette smoking, and other drugs to the unborn baby; and the dangers of passive smoking once the infant is home. The pediatrician should inquire about maternal illnesses and medications.
Consultation with the Specialist
Authors: Goldbloom Richard B.
Published: December 2021

When it comes to much that has been written about the association between behavior and allergy, the term "scientific literature" may be one of the major oxymorons of the current era. Megatons of forest products have been consumed in examining and reexamining the possible associations between children's behavior and consumption of sugar, artificial sweeteners, food additives and colorings, and assorted specific foods. Generally speaking, conviction has taken precedence over scientific evidence. A review of publications on the subject yields a conglomeration of positive, negative, and inconclusive results (mostly the latter two). Evaluation of such studies is complicated by pervasive methodologic design errors, the major ones being lack of double-blinding in test situations and the assumption of guilt (ie, causality) by statistical association.

Beliefs

Both physician and parental belief in a linkage between food and behavior begins during the child's early infancy. Excessive crying ("colic") is the most common problem leading to formula change, which leads many parents and doctors to believe that the infant is allergic to cow milk, especially if the crying seems to decrease following the change, although such allergy rarely is proven. As Forsythe and colleagues 1 have noted, changing an infant's formula may not be an innocuous practice, especially if it leads to an erroneous belief that the infant has some intrinsic abnormality, thereby altering the parent's perceptions of the child's vulnerability.
Amphetamine and Methamphetamine During the 1990s
Authors: Morgan John P.
Published: December 2021

A 1981 review of toxicity and illicit use of amphetamine noted that governmental actions had diminished the diversion of pharmaceutical amphetamine and methamphetamine. Much of the illicit market prior to 1972 had been supplied by diversion of legitimately manufactured material, chiefly through careless (or even criminal) wholesaling. Following the reduced availability of diverted amphetamine, a number of events transpired. A market of fake "look-alike" products evolved. These were produced in formulations that resembled popular amphetamine products and that contained available over-the-counter stimulants, such as ephedrine and caffeine. Between 1980 and 1982, a very popular "triple product" appeared that contained caffeine, ephedrine, and phenylpropanolamine. The look-alike problem was diminished by a series of actions taken by the federal Food and Drug Administration in 1984 that outlawed the legal marketing of any such combinations.

Illicit synthesis and marketing of methamphetamine continues. Although distribution remains limited chiefly to southern California, it has clinical importance. While a volatile version of methamphetamine ("ice") has received wide exposure in the American media, its true clinical impact apparently remains limited.

Definitions and Terminology

Amphetamine refers to a unique chemical, for which there are a number of precise terms: methylphenethylamine, phenylisopropylamine, and 2-amino-1-phenylopropane. Use of the term "amphetamines" is careless; there is no basis for using the plural term.
Prenatal Diagnosis
Authors: DiLiberti John H. , Greenstein Mark A. , Rosengren Sally Shulman
Published: December 2021

The enormous progress witnessed in the field of prenatal diagnosis during the past two decades is likely to continue into the future. Improved imaging techniques are likely to enhance the resolution of noninvasively obtained fetal images considerably over their current excellent quality. Although this undoubtedly will be true for ultrasonography, the increased speed of magnetic resonance equipment may offer a new realm of imaging possibilities. Computerized image processing, analysis, and three-dimensional reconstructions all should make interpretation of fetal images easier and more understandable to the nonspecialist. Advances in molecular genetics will continue to accelerate, greatly expanding the range and accuracy of prenatal diagnosis.

The alert pediatrician who is sensitive to genetic issues may, by early detection of pediatric disorders and careful family history assessment, be in a position to identify families at risk for serious genetic conditions and provide the opportunity to make informed decisions on reproductive options that avert a major tragedy. The pediatrician, working with obstetric colleagues, should be part of a team effort to support families going through prenatal testing. Familiarity with these rapidly changing technologies will make it far easier to support the family needing additional explanation about prenatal diagnosis issues.
Childhood Tuberculosis During the 1990s
Authors: Starke Jeffrey R.
Published: December 2021

Despite the availability of effective antituberculosis drugs, tuberculosis remains an important cause of morbidity, mortality, and healthcare expenditures in the United States. It is estimated that more than 10 million people in the United States are infected with the tubercle bacillus. More than 26 000 new cases of clinical tuberculosis occur every year, 1600 of which occur in children. Factors that serve to sustain tuberculosis in the United States include infection with the human immunodeficiency virus (HIV), influx of foreign-born individuals at increased risk of developing tuberculosis, and poverty and poor access to medical care experienced by large segments of the population.

The Centers for Disease Control (CDC) has a goal of eliminating tuberculosis from the United States by the year 2010. If this goal is to be achieved, programs must focus on children because they are the future reservoir for the disease. Tuberculosis cases in children are important public health markers for a community insofar as they represent ongoing transmission of the disease and at least a partial failure of current tuberculosis control efforts.

Epidemiology of Childhood Tuberculosis

The incidence of tuberculosis in the United States declined steadily for a 25-y period until 1985, when it leveled off (Fig 1). More than 26 000 cases of tuberculosis were diagnosed in the United States during 1991; almost 1600 cases occurred in children <15 y.
Croup and Related Disorders
Authors: Custer Joseph R.
Published: December 2021

The airway of children is vital, but easily obstructed because it is narrow. Although there are many potential causes of upper airway obstruction (Table 1), a few diagnoses predominate. For example, in one study of 322 children presenting with stridor, 89% of cases were caused by croup, 8% by epiglottitis, and 2% by nonbacterial tracheitis.1 This review will cover these common airway infections as well as obstruction caused by inhalation of foreign bodies, spasmodic croup, and retropharyngeal abscess. Each of these diseases can progress to critical airway obstruction and hypoxia, causing organ damage or death.

Individuals caring for children must be prepared to diagnose and treat airway emergencies expeditiously. Appropriate management of acute upper airway obstruction tests the organization of emergency care systems. Successful management of airway emergencies requires a team approach, including the skills of the primary physician and the staff of the emergency department, radiology department, and operating room (eg, anesthesiologist, otolaryngologist). Management of these cases can be anticipated, and prospective protocols can and should be established. Regional intensive care units, transport teams, emergency room personnel, primary care physicians, anesthesiologists, and otolaryngologists can agree on a prospective management scheme such as that outlined in Table 2.

The issue of airway protection prior to or during transport to a tertiary care institution is controversial.
Role of the General Pediatrician in the Management of Human Immunodeficiency Virus Infection in Children
Authors: Rand Thomas H. , Meyers Alan
Published: December 2021

Human immunodeficiency virus (HIV) infection is a chronic progressive disease affecting an estimated 20 000 children in the United States. Management of this infection and its complications is evolving rapidly and requires the coordinated services of a number of disciplines, which may be facilitated by centers having programs in pediatric HIV infection. However, much of the care for an HIV-infected child can be supervised by a primary care physician, particularly during the early phase of infection, when anticipatory health monitoring is emphasized. Many pediatricians have had no experience with HIV infection during residency training, and those who have may have cared only for inpatients who had advanced immunodeficiency. The trend in medical care for HIV infection is toward early detection and management, as in other chronic diseases of childhood. This review summarizes those aspects of HIV infection most likely to be encountered in general pediatric practice.

There are several distinct problems in the delivery of care for infants and children who are infected with HIV:

1) At this time, HIV infection is a progressive, ultimately fatal disease. Interventions are directed at preserving function and quality of life.

2) HIV is an infectious disease. Preventing transmission should be addressed at every opportunity, both to point out activities having potential for transmission and to reassure families of the safety of other types of contact.
Consultation with the Specialist
Authors: Duncan Charles C.
Published: December 2021

Skull fractures may be divided into the three following general categories: linear fracture of the cranial vault, depressed fractures, and basilar skull fractures. Neurologic care of infants and children should be based on neurologic condition rather than the presence or absence of a fracture. In other words, decisions regarding hospitalization should be based on the history and examination rather than the presence or absence, for example, of a linear calavarial vault fracture.

Linear Fracture of the Cranial Vault

Linear calavarial vault fractures in infants may be somewhat less common than in older children, but they occur with similar force because of the flexibility of the thinner bone. When fractures do occur, a sufficiently large loss of blood due to significant subgaleal or intracranial bleeding may cause shock. Hence, hematocrits need to be measured frequently in minor head injuries in infants who have skull fractures; other assessments of blood volume may need to be made as indicated clinically.

Depressed Fractures

The flexibility of the skull also leads to a higher incidence of depressed fractures or so called "ping pong" fractures, where the normal convex contour of the cranial vault is reversed in the presence of minimal or no break. Some ping pong fractures may elevate spontaneously, but the majority will remain depressed unless elevated surgically.
Managing Patients Who Have Asthma: The Pediatrician and the School
Authors: Majer Lani Smith
Published: December 2021

In addition to the medical and health education challenges faced by pediatricians managing patients who have asthma, school-based asthma management is a concern. This article is a companion to the Pediatrics in Review article "Managing Patients with Asthma: The Pediatrician as Emergency Physician, Chronic Illness Specialist, and Teacher" (1992;13:213-215). School-based management has become necessary and more complex with the increased awareness of the school's responsibilities and increased emphasis on aggressive preventive care. Effective management of asthma at school is critical because it can:

• promote a supportive learning environment,

• promote optimal school performance by controlling symptoms and medication side effects, thereby reducing absences,

• provide the necessary support in the event of an emergency, and

• enable students to achieve full participation in physical activities.

This article will review the steps used by practicing pediatricians to manage patients who have asthma in school effectively (Table).

Evaluation of School Policies and Programs

A complete asthma management plan includes a detailed evaluation of asthma management in the school. The evaluation determines whether appropriate school policies are in place for proper asthma management. Critical issues include environmental control, medication administration, asthma monitoring, emergency care, attendance, and physical and health education. Appropriate environmental control policies eliminate or minimize identified allergens and irritants from the school.
Sexuality in Children
Authors: Haka-Ikse Katerina , Mian Marcellina
Published: December 2021

When factors shaping children's personality and behavior are considered, there is a tendency to overlook sexuality. In the broadest sense, sexuality is part of human development from birth onward, going through various stages before reaching adult meaning and expression. It is not limited to experiencing sexual feelings and procreating; it also involves the capacity for intimacy, affiliation, communication, mutual respect, and responsibility. These faculties are at least as important as the physical aspects, and their expressions imply complex social and emotional developmental processes. Unfolding sexuality must be supported externally so that it can reach maturity without major conflicts or distortions.

The pediatrician involved with children and their families on a continuing basis is in a position to inform and assist parents and children in the healthy development of children's sexuality. Pediatric intervention can take the form of anticipatory guidance, counseling whenever specific questions or concerns arise, and referral, as necessary, to other therapeutic resources.

Healthy Development of Sexuality

In all developmental stages, sexuality is intertwined with other basic developmental issues, such as formation of secure attachments, a positive self-concept, sense of trust and respect for others, realistic freedom from shame and guilt, and motivation to achieve.

Good parenting is fundamental to all these issues.
Poisoning in Children and Adolescents
Authors: Woolf Alan D.
Published: December 2021

Definition

A poisoning can be defined as the exposure of the victim to an agent that, by transference of chemical or radiant energy, can cause symptoms and signs of organ dysfunction leading to injury or death.

Epidemiology

Childhood poisonings continue to challenge the diagnostic and treatment skills of the pediatrician. Of more than 1.7 million poisoning exposures reported to 72 poison centers in the United States in 1990, 60.8% involved children less than 6 years of age (Table 1). Fortunately, young children account for fewer than 4% of poisoning-related fatalities. Generally, childhood poisonings involve products in use and occur when a parent is distracted. The profile of a toddler at high risk for repeated poisonings is one who is active, is inquisitive, and has oral behaviors. Frequently, these children are described as negativistic; a power struggle between parents and child over putting forbidden objects in the mouth may be evident. Parents of these children may be socially isolated, burdened with physical or psychiatric problems, and hampered by insecurities regarding their own competence as parents.

Clinical Aspects

TOXIN INFORMATION

The history and physical examination are of paramount importance in reaching the correct diagnosis of the poisoned child. The pediatrician must find out what toxin(s) might be implicated in the poisoning: the exact ingredients and their concentrations.
Consultation with the Specialist
Authors: Poland Ronald L.
Published: December 2021

Routine eye prophylaxis for newborn infants against gonococcal ophthalmia is a standard procedure in perinatal centers around the world. Gonococcal ophthalmia is a purulent eye disease that has its usual onset between the second and fifth days of life. Prior to the introduction of routine eye prophylaxis, it was a common cause of blindness in infancy. The use of 1% silver nitrate drops as prophylaxis against gonococcal ophthalmia soon after birth has reduced its incidence in the United States to less than 0.03% of infants.

The success of 1% silver nitrate prophylaxis depends somewhat on the use of proper technique. Each eyelid is wiped gently with sterile cotton prior to administration of the agent. Two drops of the solution are introduced into each conjunctival sac and not rinsed out; rinsing has been shown to reduce effectiveness. Because of the successful introduction of silver nitrate prophylaxis, Neisseria gonorrheae is no longer the most common infectious cause of conjunctivitis in newborn infants.

Although silver nitrate prophylaxis is a highly effective preventive measure, it has its drawbacks—primarily in the form of chemical conjunctivitis. Chemical conjunctivitis is a nonpurulent inflammation of the eye, with 1) swelling and a watery discharge occurring within several hours of instilling 1% silver nitrate, 2) a maximum inflammatory response around 48 hours, and 3) clearing by the fourth day in the absence of secondary infection.
Consultation with the specialist
Authors: McBride John T.
Published: December 2021

Snoring is the audible consequence of the pharyngeal airway collapsing when one inspires. Snoring can disrupt sleep, cause a variety of important but nonspecific symptoms, and suggest the presence of the obstructive sleep apnea syndrome, which can lead to cor pulmonale and sudden death. Therefore, the review of systems for a child at any age should include questions regarding snoring and breathing during sleep. Most normal children snore at one time or another, and many, particularly those who have nasal allergies, snore almost nightly. Pediatricians should be able to identify which snoring children do not require treatment or referral, which are candidates for tonsillectomy or adenoidectomy, and which should be referred for polysomnography (sleep study) or more specialized evaluation.

Physiologic Sources of the Problem

Snoring and obstructive sleep apnea do not represent structural upper airway narrowing alone, but rather an imbalance between the degree of airway narrowing and the ability of the respiratory centers in the brainstem to use the muscles of the pharynx and tongue to maintain airway patency. For each child who has tonsillar hypertrophy and who snores, there are many who have larger tonsils who do not snore because they use their pharyngeal muscles to keep the airway open during sleep.
BACK TO BASICS
Authors: Rubenstein Jeffrey S.
Published: December 2021

The last 20 years have seen an explosion in our knowledge of the autonomic nervous system and our ability to manipulate its parasympathetic and sympathetic portions pharmacologically to achieve therapeutic goals. This article will briefly review the structure and function of the autonomic nervous system, with particular focus on the sympathetic branch. Included in the review is a discussion of the major receptors of the sympathetic system, concentrating on their intracellular mechanism of action, their effects on major target organ systems, and some commonly used pharmacologic agents that influence these organ systems through their actions on sympathetic receptors.

Structure and Function of the System

The autonomic (or involuntary) nervous system innervates the heart, visceral organs, blood vessels, smooth muscles, and glands. It can be divided functionally into the parasympathetic and sympathetic systems, which have opposing functions. All autonomic nerve pathways consist of two nerves in sequence. Presynaptic nerves begin in the central nervous system and transmit impulses to the postsynaptic nerves. Postsynaptic nerves then carry impulses to the effector organ.

Actions of the parasympathetic nervous system include bradycardia, vasodilation in skeletal muscle and skin, contraction of bronchial smooth muscle, increased gastrointestinal motility, pupillary miosis, and contraction of the bladder detrusor coupled with relaxation of the bladder trigone (necessary for spontaneous voiding).
Hearing Disorders
Authors: Rapin Isabelle
Published: December 2021

Definition

Hearing is the usual channel for acquisition of this most important of human attributes, language. Language enables humans to communicate at a distance and across time and has played a decisive role in the development of society and its many cultures. Language is the major channel through which children learn about what is not immediately evident, and it plays a central role in thinking and cognition. Because speech is the chief vehicle for communication in all families (except those in which the parents are deaf), deafness is a profound handicap whose effects greatly transcend the inability to speak. Responsibility for detecting hearing loss in infancy rests on the primary physician, inasmuch as early diagnosis and appropriate habilitation will prevent the most serious consequences of infantile hearing loss: growing up without language.

Two primary types of hearing loss are attributable to disease of the ear: conductive hearing loss, a deficiency in the transduction of energy in the form of sound waves in air to hydraulic waves in the inner ear; and sensorineural hearing loss, inadequate transduction of these waves to neural activity. Other disorders of hearing include cortical hearing impairment and perceptual disorders. Although much is said about perceptual disorders by educators, such disorders probably play a minor role in the genesis of learning disabilities and will not be addressed in this review, which focuses on severe-to-profound hearing losses.
Disordered Control of Breathing in Infants and Children
Authors: Carroll John L. , Marcus Carole L. , Loughlin Gerald M.
Published: December 2021

Introduction

Breathing must be tightly regulated so that the amount of oxygen inhaled and carbon dioxide exhaled matches precisely the metabolic needs of the body. Acute malfunction of breathing control mechanisms, even for a few seconds, may lead rapidly to serious physiologic derangements, with death as the final outcome if the system fails to recover. Chronic malfunction of breathing control mechanisms may lead to chronically abnormal blood gases (eg, hypoxemia), with such consequent complications as developmental delay or cor pulmonale. Because the upper airway is shared for breathing, eating, drinking, and talking, control of breathing also encompasses coordination of these actions in such a way that all are carried out effectively. The upper airway also must be actively held open during sleep or it will collapse during the inspiratory phase of breathing. Tone and activity of the muscles that maintain upper airway patency are controlled, in part, by the respiratory control systems. Malfunction of upper airway control mechanisms may play a role in obstructive sleep apnea. Thus, respiratory control not only refers to the control of gas exchange, but encompasses breathing pattern, apnea, respiratory protective reflexes, and upper airway control—specifically, maintenance of upper airway patency.

This review will cover infant apnea and home cardiorespiratory monitoring, apparent life-threatening events (ALTEs) and home monitoring, obstructive sleep apnea syndrome (OSAS) in children, central hypoventilation syndromes, and hyperventilation syndromes.
Medical Record Documentation of Chronic Abdominal Pain
Authors: Shah H.
Published: December 2021

Name: Martha McCue1

Date of birth: June 24, 19842

Drug allergies: None known3

Immunizations: Complete4

Thursday, December 3, 1992

CHIEF COMPLAINT: "She's been having stomach aches since summer."

PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts "lots of days." Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually "in middle." No obvious relation to meals; "can happen anytime." Not sure if it wakes her up, "but sometimes I have bad dreams." Pain lasts "a long time." Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can't remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic.

PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.
Fluid and Electrolytes: Clinical Aspects
Authors: Hellerstein Stanley
Published: December 2021

Dr Daniel C. Darrow, a clinician and one of the investigators whose contributions helped lay the foundation of modern fluid therapy, made the following observation in his book, A Guide to Learning Fluid Therapy: "Fluid therapy inevitably is carried out by rules which achieve results without requiring continual resort to complicated scientific reasoning. The chief difficulty is that no simple rules based on body weight or surface area meet the varying physiological requirements by infants, children, and adults. Nevertheless, by recognizing that body size has two dimensions, the same general rules apply at all ages to patients of different weights."

The dimensions of body size pertinent to fluid therapy are caloric production and weight. The usual ongoing fluid expenditures—maintenance fluids—are related to energy production, while restoration of normal body composition in patients with water and electrolyte deficits on excesses are related to changes in body weight. It should be added that when fluids for a patient are prescribed based on "convenient rules," the physician must be aware of the assumptions that renal function is not significantly impaired and that the homeostatic mechanisms for conservation and excretion of water and solute are intact. If this is not the case, the provision of water and electrolytes must be based on assessment of ongoing fluid expenditures.
Vulvovaginitis in the Child and Adolescent
Authors: Vandeven Andrea M. , Emans S. Jean
Published: December 2021

Adolescents and children experiencing vaginal discharge and irritation present frequently in a pediatric practice. Although there are distinct differences in the epidemiology of vulvovaginitis in the child and adolescent, a standard approach to evaluation can be followed in both the prepubertal and postpubertal child.

Definitions

In practice, the terms vulvitis, vaginitis, and vulvovaginitis often are used interchangeably by physicians in diagnosing inflammatory conditions of the lower female genital tract. Although the infection or irritation may have been localized at onset, by the time of presentation it may have become generalized. Vulvitis may occur alone or be accompanied by a secondary vaginitis. Conversely, a child may acquire a primary vaginal infection, and the discharge may cause maceration of the vulva and a secondary vulvitis. Presenting symptoms of vulvovaginitis can include genital irritation, pain and inflammation, vaginal discharge, and dysuria. Thus, a variety of presenting complaints are due to vulvovaginitis.

Epidemiology and Pathogenesis

Familiarity with the anatomy and normal developmental changes of the female genital tract is essential to understanding the etiology of and pre-disposing factors for vulvovaginitis.

During the newborn period, the vagina is well-estrogenized from maternal hormones. The desquamation of the estrogen-induced hypertrophic vaginal epithelium, together with mucus from the stimulated cervix, produces the physiologic white discharge seen in the neonate.
Hypertension in Childhood and Adolescence
Authors: Jung Flavia F. , Ingelfinger Julie R.
Published: December 2021

Hypertension

The prevalence of hypertension in childhood is low (1% to 3%), and the majority of affected children have only mild elevations of blood pressure (BP), which are thought to be early manifestations of primary hypertension. A minority of hypertensive children (about 10%) have more marked elevations in BP, and these individuals often have secondary hypertension. Of those children who have a definable cause for their hypertension, 80% to 90% have renal or renovascular disease as an underlying cause. Therefore, the strategy for evaluating a child for secondary causes of hypertension generally is aimed at finding renal or renovascular disease as well as less common causes. The major conditions associated with sustained hypertension are listed in Table 1; causes of acute hypertension are listed in Table 2.

Measuring Blood Pressure

A number of children who do not actually have hypertension exhibit "high" BP upon the initial examination. Many of these children are large for their chronologic age, and usually their BP has been measured with an inappropriately small cuff. Falsely elevated pressures may be obtained with a cuff that is too small, but falsely positive low BP is rare, even if the cuff is too large. When used on an upper extremity, the BP cuff should cover at least two thirds of the upper arm; the internal bladder should encircle at least 80% of the arm circumference to avoid inaccurately high readings.
INDEX OF SUSPICION
Authors: Berera Geeta , Magill Frank B. , Oblender Melanie
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

The parents of a 6-year-old boy would like your opinion regarding a tonsillectomy and adenoidectomy for their son. His speech development has been delayed, and even now, despite 2 years of therapy, he is difficult to understand. The child had experienced recurrent ear infections for which pressure equalization tubes were placed 4 years ago. Physical examination reveals bilateral serous otitis media and a bifid uvula. The tonsils appear normal for his age. His speech has a hypernasal quality. An audiologic evaluation reveals bilateral conductive hearing loss. You see a pattern that suggests an underlying condition with important therapeutic implications.

Case 2 Presentation

A 6-week-old infant is brought to the emergency room because of bleeding from the umbilicus for 8 hours.
Consultation with the Specialist
Authors: Yamauchi Terry
Published: December 2021

Introduction

The enterococci, normal inhabitants of the human and animal bowel flora, were considered for years to be nonvirulent microorganisms. Over the past decade, however, the role of enterococci in human disease has taken on new importance. Serious diseases, such as bacteremia, which is associated with significant mortality, and endocarditis, are prime examples of human enterococcal infections. More recently, the wide-spread use of antimicrobial agents has led to the emergence of multiresistant microorganisms, previously considered to be nonpathogenic, as significant agents in human diseases.

Morphologically, enterococci are gram-positive cocci that grow in chains and resemble streptococci. Previously, enterococci were placed in the Lancefield Group D streptococci genus; currently, they are in a new bacterial genus classification Enterococcus (Table).

Clinical Diseases

Enterococci may cause serious infections in the hospitalized patient and have been reported as the third leading cause of nosocomial infections in the United States. The recovery of enterococci from the urinary tract, surgical wounds, and the blood documents the importance of these bacteria in hospital-acquired infections.

[See table in the PDF file]

The urinary tract is the most common site infected by enterococci. Surgical instrumentation, intervention, and catheterization are invasive procedures that place the patient at risk for enterococcal infection.