bluuebunny/crossref_metadata_2025 huggingface dataset:
Hypoglycemia, Hypotonia, and Cardiomyopathy: The Evolving Clinical Picture of Long-Chain Acyl-CoA Dehydrogenase Deficiency
Authors: Treem William R. , Hyams Jeffrey S. , Stanley Charles A. , Hale Daniel E. , Leopold Harris B.
Published: December 2021

Inherited defects in fatty acid oxidation, which have been described and diagnosed with increasing frequency in the last decade, are most commonly attributed to a deficiency in the activity of medium-chain acyl-CoA dehydrogenase. Few cases of the related enzyme defect of long-chain acyl-CoA dehydrogenase activity have been reported. An infant with documented long-chain acyl-CoA dehydrogenase deficiency is described with a detailed metabolic profile, long-term clinical follow-up, and response to treatment. This patient is compared with the seven previously published cases of this disorder in order to stress the unique features of the initial presentation, more subtle late manifestations of the disease, and clinical and biochemical differentiation from the more common medium-chain acyl-CoA dehydrogenase deficiency. This report stresses the enlarging spectrum of the clinical presentation and natural history of this defect in fatty acid oxidation.
Tilt Test for Diagnosis of Unexplained Syncope in Pediatric Patients
Authors: Thilenius Otto G. , Quinones Jose A. , Husayni Tarek S. , Novak Janet
Published: December 2021

Thirty-five teenage patients with a history of presyncope or syncope underwent passive head-up tilting to reproduce symptoms of syncope. If tilting alone did not induce syncope, isoproterenol infusion was given to increase heart rate to 150 to 160 beats per minute. In 80% of patients with a history of syncope, identical symptoms could be reproduced during tilting: an abrupt fall in blood pressure combined with profound nodal bradycardia, ranging from 32 to 86 beats per minute. These symptoms were quickly reversed by returning the patient to the supine position. For patients with frequent occurrences of syncope, especially when there was a history of trauma sustained during these episodes, a therapeutic regimen of either β blockers or 9α-fluorocortisol was begun. The mechanism of this common cause of syncope in childhood is neurocardiogenic in response to venous pooling and catecholamine-induced tachycardia. The tilt test is an excellent and cost-effective test for the workup of unexplained syncope in childhood.
Outcome of ≤800-Gram Birth Weight Infants
Authors: HOFFMAN EDWARD L. , BENNETT FORREST C.
Published: December 2021

In Reply.—

We welcome the comments of Drs Kilbride and Daily, former teachers of Dr Hoffman. As survival of extremely low birth weight infants has increased,1 more attention has been focused on neurodevelopmental morbidity trends in this birth weight group. Conclusions are hampered by the small numbers in follow-up studies, the lack of standardization of confounding variables across different study sites, and the continuing changes and improvements in prenatal, perinatal, and neonatal care. Drs Kilbride and Daily's early study period, 1980 to 1982, is later than the study period of Dr Bennett et al,2 1977 to 1980.
Fetal Vascular Disruption With Prenatal Exposure to Cocaine or Methamphetamine
Authors: BAYS JAN
Published: December 2021

To the Editor.—

Hoyme et al1 have described seven children from four states with congenital limb reduction defects associated with prenatal exposure to cocaine. I am concerned that digit and limb reduction following cocaine or methamphetamine exposure in utero may be much more common than the nine existing case reports1,2 indicate and that a Ross Laboratories patient education brochure is correct in stating, "cocaine can make a baby have missing fingers."3

We began recognizing cocaine-exposed infants in 1986.
Childhood Urolithiasis: Experiences and Advances
Authors: Gearhart John P. , Herzberg Gilbert Z. , Jeffs Robert D.
Published: December 2021

Between June 1979 and June 1989, 54 children with urolithiasis were evaluated and treated at the Johns Hopkins Children's Center. The most common symptoms were flank or abdominal pain (58%) and gross hematuria (28%). In 46 children (86%), stones were secondary to a preexisting condition and in only 8 (14%) no apparent cause of stone formation could be found. Thirty-six patients (66%) had a solitary stone, most commonly found in the kidney. Urinary tract infections were present in 25 (47%) of the patients who had stones. Stones composed either of calcium oxalate or struvite were the most frequently recovered in these patients with infections. Twenty-one patients (39%) spontaneously passed their stones whereas 23 (43%) required either surgery or extracorporeal shock-wave lithotripsy to resolve stones. Ten (20%) showed recurrence of their urolithiasis, with follow-up examination periods ranging from 1 month to 10 years. Recent advances in the management of urolithiasis and their applicability to the pediatric population are discussed.
Night Waking During Infancy: Role of Parental Presence at Bedtime
Authors: Adair Robin , Bauchner Howard , Philipp Barbara , Levenson Suzette , Zuckerman Barry
Published: December 2021

Night waking occurs commonly in infants and young children. The goal of this study is to determine whether parents who report being present when their infant falls asleep at bedtime are more likely to report increased frequency of night waking by the infant. Mothers were consecutively recruited when they brought their infants to the clinic for their 9-month well-child visit. A total of 122 mothers agreed to participate and completed a questionnaire consisting of closed-ended, forced choice questions about their infant's feeding and sleeping behavior, and demographic and psychosocial characteristics. For 33% of the mothers, a parent was routinely present when the infant went to sleep. The entire sample of infants averaged 4.1 night wakings during the week prior to questionnaire completion. Infants whose parents were present at bedtime were significantly more likely to wake at night than infants whose parents were not present (6.2 vs 3.1, P = .01). Frequent night waking (seven or more wakings in the prior week) occurred in 28% of the sample. More of the infants whose parents were present experienced frequent night waking compared with infants whose parents were not present (40% vs 22%, P < .04). When potential confounding variables were controlled by multivariate analysis, parents being present when the child went to sleep was independently associated with night waking (P < .03). The association of parental presence at bedtime and night waking has implications for preventing and managing disruptive night waking in infancy.
Ingestion of a Laryngoscope Light Bulb During Delivery Room Resuscitation
Authors: NAUMOVSKI LOUIE , SCHAFFER KEVIN , FLEISHER BARRY
Published: December 2021

To the Editor.—

Neonatal resuscitation involves management of the airway and at times requires laryngoscopy and endotracheal intubation. These procedures can be associated with iatrogenic complications, one of which is described below.

The patient was intubated at the referring hospital because of meconium staining of the amniotic fluid. He required mechanical ventilation and was transported to our hospital. A bullet-shaped radiopaque object was noted on the chest roentgenogram from the referring hospital. Its presence was confirmed on subsequent films at our hospital (Figure).
Managing Hemangiomas
Authors: ENJOLRAS ODILE
Published: December 2021

In Reply.—

We read carefully the two papers from Alkalay et al1 and Hurvitz et al,2 and thank them for their letter to the editor.

They emphasize the efficacy of cyclophosphamide therapy for vascular tumors in infancy. In our series of 25 cases,3 all 25 infants had hemangiomas, defined4 by a postnatal cellular and capillary proliferation, either cutaneous or cutaneous and visceral, undergoing rapid growth and then slow spontaneous regression. Liver localizations appeared to be particularly life-threatening (three of our infants died).
Problem With Pulse Oximeters
Authors: ALBERSHEIM SUSAN , RODE TIM
Published: December 2021

To the Editor.—

We have discovered recently a major problem with the pulse oximeters which we have been using in our Neonatal Intensive Care Unit. We felt that there was some urgency in alerting other neonatologists and pediatricians to this problem.

The incident which led us to discover this problem involved a low birth weight infant who on admission was stabilized according to our Nursery protocol. In these very small neonates, who are at greatest risk of skin breakdown and yet require close monitoring, we recently have used the Fastrac monitor (SensorMedics Corporation, Anaheim, CA) which combines transcutaneous Pco2 and pulse oximetry.
Technology's Children: Report of a Statewide Census of Children Dependent on Medical Supports
Authors: Palfrey Judith S. , Walker Deborah K. , Haynie Marilynn , Singer Judith D. , Porter Stephanie , Bushey Barbara , Cooperman Paula
Published: December 2021

In April 1987, a census of children dependent on medical technology was carried out in Massachusetts to determine the one-month point prevalence. All medical and educational providers in the state who were likely to interact with such children were contacted and asked to complete a two-sided data form on youngsters (aged 3 months to 18 years) with tracheostomies, supplementary oxygen, respirators, suctioning, gastric feeding, central venous lines, ostomies, ureteral diversion, urethral catheterization and dialysis. Nearly 1250 children were found meeting these criteria. Capture-recapture analysis set the lower bound for technology dependence at 0.08% of the state's children. An analysis of the organ systems involved showed that 57% of the children had neurologic involvement—13% multisystem, 7% gastrointestinal-metabolic, 4% renal-genitourinary, and 3% musculoskeletal. Less than 1% of the children were reported as having immunologic or "other" disorders. Review of putative etiologies indicated that 45% of the children had congenital anomalies, 33% chronic medical diseases, 9% perinatal conditions, 7% hereditary-genetic disorders, 5% injuries, 2% infections, and 3% "other." The substantial prevalence of technology dependency among children creates challenges at the social, economic, and policymaking levels. It will be important to carry out systematic reporting and monitoring activities throughout time and across sites. This census is an example of one such statewide effort.
Outbreak of Kawasaki Syndrome in Denver, Colorado: Association With Rug and Carpet Cleaning
Authors: Rauch Alan M. , Hurwitz Eugene S. , Schonberger Lawrence B. , Glode Mary P. , Wiggins James W. , Rodriguez Juan G. , Hopkins Richard S.
Published: December 2021

Between October 1984 and January 1985, the largest outbreak of Kawasaki syndrome reported to date in the continental United States (62 cases) occurred in the Front Range of the Rocky Mountains, extending from Colorado Springs, Colorado, to Cheyenne, Wyoming. Fifty-two (84%) of these Kawasaki syndrome patients lived in the Denver metropolitan area. A case-control study revealed that 16 (62%) of 26 Kawasaki syndrome patients compared with 10 (20%) of 49 matched control subjects had a history of exposure to shampooed (19%) or spot-cleaned (81%) rugs or carpets within 30 days of the Kawasaki syndrome onset date (odds ratio = 5, P < .01). The time of exposure to shampooed or spot-cleaned rugs or carpets for 9 of 10 Kawasaki syndrome patients who had a single exposure and for all 6 Kawasaki syndrome patients who had multiple exposures were clustered within an interval 13 to 30 days before the onset of illness. Although the reason for this unusually large outbreak remains obscure, it is the third in which a statistically significant association between Kawasaki syndrome and rug or carpet cleaning has been found.
Family History: A Special Opportunity for Psychosocial Intervention
Authors: ZUCKERMAN BARRY
Published: December 2021

Family history traditionally has been important in the diagnosis of rare genetic disorders. Recently, due to the development of potential interventions, the role of family history has expanded to identify potential risk factors for myocardial infarction or the presence of certain genetically determined birth defects. I would like to suggest that routine family history be expanded to highlight two common mental health problems that affect children: major depression and alcoholism. Major depression occurs in 3% of adult men and 4% to 9% of adult women.1 Alcoholism occurs in 1 of 8 adults in the United States,2 and 1 of 6 children has an alcoholic parent.3 Identification of these problems in parents and grandparents provides a special opportunity for intervention by pediatricians during health care supervision visits or when examining children with behavioral or developmental problems.

The presence of either disorder in one or both parents is a good predictor of future psychiatric disorder in the child. Although some specificity of transmission has been shown, children may develop other problems.4 Two possible mechanisms may account for the transmission of either of these problems. The first is genetic transmission.
Prenatal and Perinatal Factors in the Etiology of Autism
Authors: Nelson Karin B.
Published: December 2021

This paper will review studies on prenatal and perinatal factors and the etiology of autism. It will focus on whether identified risk factors have been consistent from report to report, the extent to which identified risk factors are likely to be causal, and the extent to which identification of these factors can contribute to the development of strategies for the prevention of autism.

Autism is one of a group of disorders often described as the developmental disabilities. Other disorders in this group are mental retardation, cerebral palsy, epilepsy, and learning disorders. Like these other disorders, autism is delineated by a set of observable dysfunctions and to some extent also by a shared natural history.

Like these other disorders, autism is not a disease in the sense of having known biologic markers or known major etiologic factors in common. It is probable that autism is not the result of a single etiologic factor.

Before examining the literature on autism, it may be useful to consider briefly what is known about maternal, pregnancy, and birth factors in the other developmental disabilities.

EXPERIENCE WITH OTHER DEVELOPMENTAL DISABILITIES

Contrary to expectations based on a hypothetical "continuum of reproductive causality," different developmental disabilities often have different major predictors. For example, the major known predictors of mental retardation and learning disorders are family characteristics such as educational level of the parents and measures of socioeconomic status.1,2 These characteristics are not important risk factors for cerebral palsy3 or epilepsy.4,5 Low birth weight is related to cerebral palsy but not to epilepsy in persons without cerebral palsy.6
Intelligence at Six Years in Relation to Neonatal Bilirubin Level: Follow-up of The National Institute of Child Health and Human Development Clinical Trial of Phototherapy
Authors: Scheidt Peter C. , Graubard Barry I. , Hoffman Howard J. , Bryla Dolores A. , Nelson Karin B. , Hirtz Deborah G. , Gartner Lawrence M.
Published: December 2021

Results of the National Institute of Child Health and Human Development Randomized Controlled Trial of Phototherapy were examined for the relationship of neonatal bilirubin level to neurological and developmental outcome at 6-year follow-up. This analysis focused on 224 control children with birth weight of less than 2000 g. Bilirubin levels were maintained below previously specified levels by the use of exchange transfusion only (24%). Rates of cerebral palsy were not significantly higher for children with elevated maximum bilirubin level than for those whose level remained low. No association was evident between maximum bilirubin level and IQ (Full Scale, Verbal, or Performance) by simple correlation analysis (r = -.087, P = .2 for Full Scale) or by multiple linear regression adjusting for factors that covary with IQ (β = -.15, P = .58). IQ was not associated with mean bilirubin level, time and duration of exposure to bilirubin, or measures of bilirubin-albumin binding. Thus, over the range of bilirubin levels permitted in this clinical trial, there was no evidence of bilirubin toxicity to the central nervous system. Measures used to control the level of bilirubin in low birth weight neonates appear to prevent effectively the risk of bilirubin-induced neurotoxicity.
Hypochloremic Metabolic Alkalosis From Ingestion of A Chloride-Deficient Infant Formula: Outcome 9 and 10 Years Later
Authors: Malloy Michael H. , Willoughby Anne , Berendes Heinz , Graubard Barry , Rhoads George G. , Moss Howard , McCarthy Mary , Gwyn Susan , Vietze Peter
Published: December 2021

In 1978 and 1979 two infant formulas, Neo-Mull-Soy and Cho-Free, were found to be deficient in chloride. The Centers for Disease Control received reports that hypochloremic metabolic alkalosis (HMA) had developed in 141 children as a result of exposure to these formulas. Thirty-five of these children were examined at 9 and 10 years of age and compared with a group of 32 children who were exposed to the chloride-deficient formulas but were not reported to experience HMA and a group of 61 children who received chloride-sufficient soy formulas in infancy. The control children were matched to the HMA children on sex, race, age, and maternal education. Growth characteristics, performance on the Wechsler Intelligence Scale for Children-Revised (WISC-R), the Boston Naming Test, the Rey-Osterrieth Test, the Clinical Evaluation of Language Fundamentals-Revised (CELF-R), and subtests from several other speech and language tests were compared across the groups. After adjustment for family income and the level of the father's education, significantly lower scores were observed in the HMA children on the WISC-R Arithmetic subtest (mean = 10.5) compared with the soy control children (mean = 12.0, P < .05) and on the WISC-R Coding subtest (mean = 9.0) compared with the soy control children (mean = 10.8, P < .01). All the WISC-R subtest scores were, however, within the normal range. Although no significant differences occurred on the CELF-R between groups, the risk of an HMA child falling below the range expected for a standard population was increased on the CELF-R Composite Total, Receptive, and Expressive Language scores: risk ratios = 2.14, 2.14, and 3.03 respectively. Significant differences were observed between the children exposed, both HMA and non-HMA children, and the soy control children for behavioral problems as determined by the Achenbach Childhood Behavioral Checklist. It is concluded that as a group, children with documented HMA appear to have recovered from their growth failure and have normal cognitive development. They may, however, be at risk for deficits in language skills that require expressive language abilities.
Review of Intubation in Severe Laryngotracheobronchitis
Authors: McEniery Julie , Gillis Jonathan , Kilham Henry , Benjamin Bruce
Published: December 2021

Of 208 children who required relief of severe airway obstruction due to laryngotracheobronchitis by an artificial airway (nasotracheal intubation or tracheostomy) during a 10-year-period, 181 (87%) were intubated and later extubated. Twenty-seven children (13%) had tracheostomies performed. The tracheostomies were for severe subglottic narrowing precluding the passage of an adequate size endotracheal tube in 10 children, and for severe endotracheal tube trauma in 17 children. Five children developed acquired subglottic stenosis (2.4% of 208) and 1 of these has a retained tracheostomy. One child died of cardiac disease. The remaining 202 children had no long-term complications of laryngotracheobronchitis, intubation, or tracheostomy. It is concluded that nasotracheal intubation is a satisfactory artificial airway for laryngotracheobronchitis. Endoscopic evaluation in a selected group of these children will identify those with significant intubation trauma or severe subglottic narrowing in whom continued intubation may cause permanent subglottic damage. The low incidence of acquired subglottic stenosis in this series supports the practice of selective endoscopy and tracheostomy.
Knowledge and Attitudes of Day Care Center Parents and Care Providers regarding Children Infected with Human lmmunodeficiency Virus
Authors: Morrow Ardythe L. , Benton Melanie , Reves Randall R. , Pickering Larry K.
Published: December 2021

It was hypothesized that parents and child care providers are not prepared to accept children infected with human immunodeficiency virus (HIV), who are increasing in number, into the day care center setting. To determine their knowledge and attitudes toward HIV transmission, 219 parents in 4 day care centers and 176 care providers in 12 day care centers were given confidential questionnaires. More than 98% of respondents knew that sex and needle sharing can transmit HIV; 84% of parents and 77% of care providers knew that contact with blood can transmit HIV. There was, however, uncertainty about transmission via many common contacts in day care centers: human bites, urine, stool, tears, and vomit; kissing; sharing of food and eating utensils; and diaper changing areas. Only 43% of parents said they would allow their child to stay in the same room with a child who was infected with HIV. In a multiple logistic regression model, the unwillingness of parents to have their child stay in the same room with a child who was infected with HIV was significantly (P < .0001) associated with black ethnicity, beliefs that such a child is likely to infect others (40%) and is dangerous to others (58%), and fear of their child being exposed to HIV (86%). Care providers' unwillingness to care for a child infected with HIV in the classroom (48%) was significantly (P < .0001) associated with beliefs that such a child is likely to infect others (44%) and that common day care center contacts can transmit HIV (62%). Most parents and care providers wanted to be informed if a child infected with HIV was in the classroom. A serious effort will be needed to educate parents and care providers if children who have been infected with HIV are to be accepted into the day care center setting routinely.
Neonatal Adenovirus Infection: Four Patients and Review of the Literature
Authors: Abzug Mark J. , Levin Myron J.
Published: December 2021

Four newborns with adenovirus infection are described, and the profile of neonatal adenovirus disease is outlined based on the cases of these newborns and nine previously described. Characteristic historical features included prolonged rupture of membranes, maternal illness, vaginal delivery, and onset of illness within the first 10 days of life. Clinical findings included lethargy, fever or hypothermia, anorexia, apnea, hepatomegaly, bleeding, and progressive pneumonia. Thrombocytopenia, coagulopathy, and hepatitis were typical laboratory manifestations. Illness was severe and generally unremitting; only two survivors have been reported. Pathologic changes were prominent in lung, liver, and brain. Virus isolates, predominantly serotypes 3, 7, 21, and 30 were obtained from multiple sites and organs. Epidemiologic evidence suggests that viral acquisition from the mother, perhaps via the birth canal, is a major mode of transmission. Neonatal adenovirus infection, which is frequently disseminated and generally fatal, should be considered in the differential diagnosis of neonatal sepsis and pneumonia.
Role of Flexible Bronchoscopy and Bronchoalveolar Lavage in the Diagnosis of Pediatric Acquired Immunodeficiency Syndrome-Related Pulmonary Disease
Authors: Birriel Jose A. , Adams Jose A. , Mavunda Kunjana , Goldfinger Sue , Vernon Donald , Holzman Bernard , McKey Robert M. , Saldana Mario A.
Published: December 2021

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage was performed in 16 pediatric patients with the acquired immunodeficiency syndrome (AIDS) and deterioration in pulmonary function suggestive of opportunistic infection. In 62% of the patients Pneumocystis carinii was identified. Culture results showed a pure growth of Pseudomonas aeruginosa for one patient in addition to the Pneumocystis carinii. Bronchoscopy with lavage was well tolerated, with few complications even among patients with significant tachypnea and hypoxia. Because of its relative safety and effectiveness, this procedure should be considered the first invasive measurement used for evaluation of parenchymal lung disease in this population of patients.
Characteristics of Neonatal Intensive Care Unit Patients in North Carolina: A Cross-Sectional Survey
Authors: Stiles Alan D. , Metzguer Karen , O'Hale Ann , Cefalo Robert C.
Published: December 2021

A shortage of neonatal intensive care facilities has been encountered in some areas of the country including North Carolina. To examine possible solutions to this health care delivery problem, a cross-sectional survey of all the neonatal intensive care units in North Carolina was performed to examine characteristics of patients occupying the beds in these facilities. It was found that a substantial amount of chronic care is now occurring in neonatal intensive care beds, with 38% of occupants of neonatal intensive care beds being 31 days of age or older and 3% being mechanically ventilated at 91 days of age or older. In addition, according to criteria established for this study, a substantial number of "convalescent" patients (32%) were occupying beds in neonatal intensive care units. It is concluded that an increase in both intermediate/convalescent care beds and establishment of chronic care facilities in North Carolina, rather than an increase in intensive care beds in these units, would alleviate the shortage of neonatal intensive care facilities. Further, the characteristics of the population occupying neonatal intensive care unit beds should be considered by health planners in addition to occupancy rate, when new facilities are being established.
The Adequacy of Physician Reimbursement for Pediatric Care Under Medicaid
Authors: McManus Margaret , Kelly Rebecca , Flint Samuel
Published: December 2021

This article examines 1989 Medicaid physician reimbursement for pediatric care in 47 states and the District of Columbia. To assess the adequacy of payment, several state reimbursement policies were analyzed, including physician payment methods, frequency of payment updates, and fee data for five common evaluation and management codes and two Early and Periodic Screening, Diagnosis, and Treatment visit categories. Physician payment rates were evaluated to determine overall state and regional patterns of Medicaid reimbursement. They were also compared with regional private market fee data and average national Medicare fees to assess their adequacy. The majority of state Medicaid programs used fixed fee schedules as their physician reimbursement method. Nearly one fourth of states that update their fees overall by physician specialty have not adjusted their rates since 1985 or before. Medicaid reimbursement rates for five commonly used evaluation and management Physicians' Current Procedural Terminalogy (4th ed) office visit codes and Early and Periodic Screening, Diagnosis, and Treatment screening and follow-up examinations varied substantially across states and among regions. States in the West paid the highest rates for most office visits, while Northeastern states generally paid the least. A comparison of Medicaid payment rates with private market fee data revealed that Medicaid payments for established patients averaged less than two thirds of market rates for pediatricians, family physicians, and general practitioners. New patient care is reimbursed somewhat better. Regional variations are substantial. In addition, a comparison of Medicaid payment rates with 1988 Medicare fee data showed that average Medicaid reimbursement rates were less than four fifths of average allowed Medicare charges. Policy implications include the need to increase Medicaid rates so that they are much closer to private insurance and Medicare rates, particularly in the Northeast and in selected states, in order to increase participation by pediatric providers in Medicaid. In addition, efforts to evaluate reimbursement relative to level of service, as used in Medicare's resource-based relative value scales, deserve further research. Finally, comparable access to comprehensive pediatric care especially in underserved urban areas will require not only improvements in physician reimbursement but also more deliberate efforts to affect the maldistribution of mainstream medical care. Approaches to measure the impact of enhanced reimbursement on access to care by Medicaid-eligible children are discussed.
Envenomation by the Scorpion Centruroides exilicauda (C sculpturatus): Severe and Unusual Manifestations
Authors: BERG ROBERT A. , TARANTINO MICHAEL D.
Published: December 2021

Scorpion envenomation continues to be a common occurrence in the southwestern United States. The only medically important scorpion in the United States is Centruroides exilicauda (also known as C sculpturatus), a scorpion found mainly in Arizona, but also found in parts of Texas, New Mexico, California, and northern Mexico.1

Envenomation by C exilicauda is clinically significant because of potent neurotoxins injected from the terminal tail segment of the scorpion into its prey.2 Clinical effects include tachycardia, local pain, restlessness, roving eye movements, hypertension, respiratory distress, tachypnea, hypersalivation, slurred speech, and stridor. These signs and symptoms are usually more severe in children, especially those younger than 5 years of age.3,4
Peer Problems in Tourette's Disorder
Authors: Stokes Aidan , Bawden Harry N. , Backman Joan E. , Dooley Joseph M. , Camfield Peter R.
Published: December 2021

To explore the social adjustment and peer relationships of children with Tourette's disorder, 29 patients with mild to moderate Tourette's disorder were studied. Children underwent neuropsychological testing. The patients completed self-esteem scales and their parents and teachers completed behavior rating scales. Peer relationships were examined with the Pupil Evaluation Inventory, which is a sociometric questionnaire completed by the child's classmates and provides measures of aggression, withdrawal, and likability. As a group, Tourette's disorder patients were significantly more withdrawn, more aggressive, and less popular than their classmates. Thirty-five percent of the children with Tourette's disorder received the lowest rating in the class on one or more of the Pupil Evaluation Inventory factors. These social problems were not predicted by the frequency or duration of tics. A clinical diagnosis of attention-deficit hyperactivity disorder and teachers' ratings on the summary scale of the Child Behavior Checklist and the Pupil Evaluation Inventory did predict poor adjustment. It is concluded that social adjustment is a major difficulty for many children with Tourette's disorder, irrespective of tic severity.
The Great God Cholesterol
Authors: HOLTZMAN NEIL A.
Published: December 2021

Several recent reports maintain that healthy children with elevated concentrations of cholesterol and low-density lipoprotein cholesterol (LDL-C) in their blood will prove to be adults with high levels and, consequently, at high risk of coronary artery disease (CAD).1-3 Two of these studies advocate screening of all children for elevations of cholesterol1,2; one of them goes so far as to call healthy children with elevated LDL-C concentrations "severely affected."1 This is unjustified.

Consider the data: Two studies have tracked cholesterol levels from childhood into adulthood.4,5 In the Beaver County study, only 48% of 11- to 14-year-olds whose cholesterol levels were at or above the 80th percentile had levels in that range 9 years later.
Surfactant Replacement Therapy for Respiratory Distress Syndrome
Authors:   Committee on Fetus and Newborn
Published: December 2021

It is now clearly established that respiratory distress syndrome (RDS) is associated with prematurity-related surfactant deficiency. Since its discovery,1 there has been a considerable amount of research defining the biochemical composition of surfactant and its relationship to pulmonary function. A considerable amount of research has also been performed on animals to formulate the scientific basis for surfactant replacement therapy in premature infants to prevent or reduce the severity of RDS.

Clinical trials began with the rescue therapy by Fujiwara et al2 and were followed by several single institution or multicenter trials using bovine, human, or synthetic surfactants. Many of these clinical trials have been published,3-11 and others have been submitted for publication. Many of these trials were randomized, and the form of surfactant therapy was either prevention (endotracheal instillation of surfactant at birth) or rescue (treatment after RDS is diagnosed). Based on the published data, it appears that in both prevention and rescue trials, there is early improvement in respiratory status as evidenced by decreased inspired oxygen concentration and mean airway pressure requirements during the first 3 days of life. Some, but not all, published series suggest a reduction in mortality rates and incidence of pulmonary air leaks3,7 during the first 28 days of life, but none of the published series appear to show an improvement in the incidence of such morbidities as bronchopulmonary dysplasia, necrotizing enterocolitis (NEC), infections, patent ductus arteriosus (PDA), and intraventricular hemorrhage (IVH). In fact, one series showed increased incidence of NEC in the surfactant-treated group,6 the European trial showed an increased incidence of IVH,12 and one series showed an increased incidence in PDA9 in the surfactant-treated group.
Increasing Incidence of Retinopathy of Prematurity
Authors: KATZMAN GERALD H.
Published: December 2021

To the Editor.—

In the article by Gibson et al,1 the increasing numbers of cases of blinding retinopathy of prematurity (ROP) seen in infants weighing less than 1000 g (ELBW) is attributed to improved survival. For the ELBW infants, 1-year survival was 19% from 1970 through 1979 and 36% from 1980 through 1986. Interestingly, in Toledo we had a similar experience regarding survival. The ELBW neonatal survival was 23% in 1975 through 1979 and 62.5% in 1981.2
Setting the Optimal Erythrocyte Protoporphyrin Screening Decision Threshold for Lead Poisoning: A Decision Analytic Approach
Authors: DeBaun Michael R. , Sox Harold C.
Published: December 2021

Erythrocyte protoporphyrin (EP) was introduced in the 1970s as an inexpensive screening test for lead poisoning. As greater knowledge of lead poisoning has accumulated, the recommended EP level at which further evaluation for lead poisoning should be initiated has been lowered from ≥50 µg/dL to ≥35 µg/dL. The purpose of this study was to evaluate the utility of this EP threshold. A receiver operator characteristic curve was constructed to assess the relationship between the true-positive rate and false-positive rate of EP at various decision thresholds. The receiver operator characteristic curve was constructed with data from the second National Health and Nutrition Examination Survey from 1976 to 1980, which included 2673 children 6 years of age or younger who had both blood lead and EP level determinations. Decision analysis was then used to determine the optimal EP decision threshold for detecting a blood lead level ≥25 µg/dL. The receiver operator characteristic curve demonstrated that EP is a poor predictor of a blood lead level ≥25 µg/dL. At the currently recommended EP decision threshold of 35 µg/dL, the true-positive rates and false-positive rates of EP are 0.23 and 0.04, respectively. As a result of the inadequate performance of EP screening for lead poisoning, when the prevalence of lead poisoning is greater than 8%, there is no EP decision threshold that optimizes the relationship between the cost of screening normal children and the benefit of detecting lead-poisoned children. Erythrocyte protoporphyrin measurement is not sufficiently sensitive to be recommended uniformly as a screening test for lead poisoning.
A Physicians's Guide to Preventing Tobacco Use During Childhood and Adolescence
Authors: Epps Roselyn Payne , Manley Marc W.
Published: December 2021

Physicians who care for children can and should help patients avoid the use of tobacco. Physicians are well aware of the health hazards associated with tobacco use, inasmuch as smoking is the chief, single cause of premature mortality in this country. Each day, more than 3000 children in the United States begin to use tobacco. Physicians who care for children have patients at vastly different stages of intellectual and social maturity. Both the theory and practical details of tobacco-related interventions differ among infants, children, and adolescents. The physician is in a unique position to intervene in the early stages. Anticipatory guidance—the practice of providing counsel regarding potential problems—is a key part of health care for the young. If physicians provide messages about tobacco use that are appropriate to the patient's age and developmental stage, the potential for broad public health impact is great. Based on a series of clinical trials, the National Cancer Institute developed a manual to assist physicians in helping their patients stop smoking. The recommendations in this manual include four physician activities that begin with the letter A (four A's): Ask, Advise, Assist, and Arrange follow-up. For physicians who treat children, a fifth A, Anticipatory guidance, is added.
Group A β-Hemolytic Streptococcal Balanitis: It May Be More Common Than You Think
Authors: KYRIAZI NICHOLAS C. , COSTENBADER CYNTHIA L.
Published: December 2021

Group A β-hemolytic Streptococcus can cause balanitis in prepubertal males, and its incidence is probably greater than previously reported in the pediatric literature. We suggest the routine inclusion of a GABHS-selective culture in any case where a discharge or irritation is present on the glans or foreskin, especially if a recent streptococcal infection has been documented, whether on not sexual abuse is being considered. Finally, we hope to stimulate interest for further in-depth study of balanitis caused by GABHS.
The Surfactant Era—Starting Off Right!
Authors: LUCEY JEROLD F.
Published: December 2021

Neonatologists often are criticized because of the empiric nature of our specialty and our past history of iatrogenic disasters. Very few, if any, current therapies have been proven to be of value by the "gold standard" evidence of large, randomized control trials. Now, at long last, we seem to have gotten it right. The most exciting new therapy in decades, surfactant replacement therapy, has been introduced into neonatal care, and it has been done correctly. It's taken nearly 40 years to advance from basic research, animal studies, small human pilot studies, to the final stage of gold standard evidence from more than 33 randomized trials involving thousands of low birth weight infants.
Corporal Punishment in Schools
Authors:   Committee on School Health
Published: December 2021

It is estimated that corporal punishment is administered between 1 and 2 million times a year in schools in the United States.1 Thirty states have statutes that allow school officials to use corporal punishment.

The American Academy of Pediatrics believes that corporal punishment may affect adversely a student's self-image and his or her school achievement, and that it may contribute to disruptive and violent student behavior.2-4 Alternative methods of behavioral management have been shown to be more effective than corporal punishment.2-4 It is also recognized that physical force or constraint by a school official may be required in selected situations to protect students or staff from physical injury or to disarm a student. In carefully selected circumstances, the use of physical force or constraint may also be justified to prevent property damage.

The American Academy of Pediatrics urges parents, educators, school administrators, school board members, legislators, and other adults to seek (1) the legal prohibition by all states of corporal punishment in schools and (2) the employment of alternative methods of managing student behavior.
A Comparative Review of Developmental Screening Tests
Authors: FELT BARBARA , STANCIN TERRY
Published: December 2021

To the Editor.—

In a recent article entitled "A Comparative Review of Developmental Screening Tests"1 Glascoe et al focused on an urgent problem: practitioners' need for guidance in defining approaches and selecting instruments for the developmental screening of infants and young children in accordance with Public Law 99-457.2 This is one of the first attempts in the pediatric literature to review and recommend developmental screening devices. However, significant problems with the methods of test selection and evaluation limit one's ability to draw useful conclusions from this study.
The Future of Primary Care
Authors: ALPERT JOEL J.
Published: December 2021

In Reply.—

Dr Lobeck's and Dr Moscola's letters to the editor regarding my article on "The Future for Pediatric Education" are thoughtful and challenging. Dr Lobeck is disturbed because he finds pediatrics too discipline-specific and not paying sufficient attention to the larger issue of primary care in general. As a result, Dr Lobeck says, pediatrics has given up a leadership position in primary care that it held in the sixties and has turned the field over to general internal medicine and family practice.
Teen Suicide
Authors: ADLER RICHARD S. , JELLINEK MICHAEL S.
Published: December 2021

In Reply.—

Dr Sahler's positive reaction to our article is appreciated.

We agree that suicide is often a district-wide event. A school system should be vigilant for at-risk children of all grade levels and be prepared to assist them. In large school districts, however, it may not be prudent to notify parents of grade schoolers unlikely to have contact with the victim. There seems to be a trade-off between attempting to trace every possible at-risk contact of the victim and casting too wide a net.
The BPD Problem
Authors: MERRITT T. A. , NORTHWAY W. , BOYNTON B. R. , EDWARDS D. K. , HALLMAN M. , BERRY C.
Published: December 2021

To the Editor.—

Sinkin and co-workers1 undertook the laudable goal of attempting to predict the risk of "bronchopulmonary dysplasia" (defined solely as a requirement for supplemental oxygen at 28 days) to select better infants who might benefit from interventions to reduce the frequency of this chronic lung disease. Other investigators have defined risk of bronchopulmonary dysplasia (BPD) in the first days to weeks of life using similar statistical analyses,2,3 cytopathology,4 detection of elevated proteases in airway secretions,5-7 measurement of airways mechanics,8,9 and clinical and radiographic scores.10,11
Television and the 3- to 10-Year-Old Child
Authors: Bernard-Bonnin Anne-Claude , Rousseau Elizabeth , Masson Pierre , Gilbert Sophie , Maheux Brigitte
Published: December 2021

A questionnaire on the use of television was administered to the parents of 387 children aged between 3 and 10 years. All families owned at least one television set and 57.6% of families owned two or more sets, with one in the child's bedroom in 10.6% of cases. Television was turned on all day in 16% of cases, mostly in families with low level of parental education (P < .01). Television was on at mealtime in 54.5% of cases; 45.2% of children were watching television for between 7 to 16 hours per week, and the heavy viewers belonged to families with low levels of maternal education (P < .05). About one third of children watched television without any interdiction set by their parents. According to age, from 28% to 40% of children watched violence on television. Parents believed that television facilitates learning (65.3%) but were concerned about violence (22.7%) and commercials (7.4%). Finally, 63.3% of parents reported that they would like to obtain more information about television use. According to this survey, many children are watching television without any limits being set by their parents and are witnessing violent scenes at an impressionable and vulnerable age. The pediatrician should include at routine office visits parental guidance on the mediation of television effects through coviewing, content discussion with children, and program selection.
Dog Bites in Urban Children
Authors: Avner Jeffrey R. , Baker M. Douglas
Published: December 2021

As a result of a perceived increase in pit bull injuries, all children who presented to The Children's Hospital of Philadelphia during 1989 for evaluation of dog bite injuries were prospectively studied. Epidemiologic information was collected from parents, either at the time of visit or by phone on the following day. A total of 168 children were enrolled; the mean age was 8 years. Males outnumbered females 1.5:1. Most (61%) injuries occurred in or around the home and involved dogs known to the patient (77%). Types of injuries included abrasions (33%), punctures (29%), and lacerations (38%). Thirteen bites had associated complications; nine developed infection. Twelve (7%) children required admission to the hospital. More than 12 different purebreeds or crossbreeds were identified as perpetrators, including German shepherds (n = 35), pit bulls (n = 33), rottweilers (n = 9), and Dobermans (n = 7). Most (54%) animals were contained (ie, leashed, fenced, in-house) at the time of injury. Fewer (46%) were provoked prior to biting. Significantly more pit bull injuries (94% vs 43%, P < .001) were the consequence of unprovoked attacks and involved freely roaming animals (67% vs 41%, P < .01). Children aged 5 or younger were more likely to provoke animals prior to injury than were older children (69% vs 36%, P < .001). It is recommended that families with young children be the target of pet safety education and that measures be sought that would lead to early identification of a potentially dangerous dog and restrict ownership.
Intergenerational Equity and Public Spending
Authors: Benjamin A. E. , Newacheck Paul W. , Wolfe Hannah
Published: December 2021

Both inside and outside of government, it has been widely held that the recent growth in spending for programs for older persons has come at the expense of commitments to programs for other vulnerable groups, especially children.1,2 What had emerged a decade ago as concerns about the "graying of the federal budget"3 and "uncontrollable spending"4 for aging had by the mid-1980s developed a more pointed focus, involving the costs to one disadvantaged group (ie, children) or benefits to another (ie, the elderly):

Both old and young rely heavily on the government for needed ... services. However, the ability of the government to provide these services ... has shrunk, while the elderly continue to expand in number and power. The net result is almost inevitably more for the old, less for the young.5

Growing concern over issues of intergenerational equity are rooted in a number of distinct but related trends in population, prosperity, and health. First, there is growing awareness and evidence that the demographic composition of America has changed significantly as the fertility rate has fallen from its postwar peak in 1957 to a level barely half that by 1985,6 while both the numbers and longevity of elderly Americans have grown steadily. Bureau of the Census projections suggest the population older than 65 years of age will increase some 17% by the year 2000. In contrast, projections indicate that the population younger than 18 years will increase at only one fifth the rate of the elderly into the next century.7