bluuebunny/crossref_metadata_2025 huggingface dataset:
Care of Uncircumcised Penis
Authors: WISWELL THOMAS E.
Published: December 2021

In Reply.—

Dr Watson addresses an important question—what is the proper method of hygiene in the noncircumcised male infant? Our position has long been that there should be no forceful retraction of the prepuce and that the external surface of the foreskin should be gently cleansed as other parts of the body are. All military health care providers we have communicated with advocate similar philosophies and have done so for many years. Thus, we do not believe that in the population we described that vigorous cleaning and prepuce manipulation were "scientific interventions" that contributed to the increased incidence of urinary tract infection in the uncircumcised boy.1,2
Acute Poststreptococcal Polymyalgia With Trismus
Authors: GREMSE DAVID A. , WALTERSPIEL JUAN N.
Published: December 2021

Acute poststreptococcal polymyalgia is an infrequently described entity that may follow infection with group A streptococci.1 Hallmarks of this condition are diffuse pain and exquisite tenderness of skeletal muscles without concomitant arthritis or elevated plasma concentrations of muscle enzymes. We recently cared for two children in whom acute poststreptococcal polymyalgia was associated with trismus. It is important to recognize this condition and distinguish it from tetanus.

CASE REPORTS

Case 1

A 6-year-old black boy was previously healthy until five days prior to admission when fever, sore throat, back pain, and malaise developed. On the day of admission, generalized rigidity and difficulty swallowing occurred.
Keep the 18-Month Health Supervision Visit
Authors: LYBARGER CONNIE , MURPHY NANCY
Published: December 2021

To the Editor.—

In the April 1987 issue of Pediatrics, two important editorials were published. One, by Landrigan and Graef1 was on pediatric lead poisoning. The other, by Haggerty,2 was related to retaining the 18-month health supervision visit despite a recent change in immunization policies. We wish to point out a connection between these two commentaries; the 18-month health supervision visit provides an ideal opportunity to screen children for lead toxicity and to educate parents about lead poisoning.

Blood lead levels previously thought to be safe have been found to be associated with irreversible neurologic damage.1
Growth Charts for Children With Down Syndrome: 1 Month to 18 Years of Age
Authors: Cronk Christine , Crocker Allen C. , Pueschel Siegfried M. , Shea Alice M. , Zackai Elaine , Pickens Gary , Reed Robert B.
Published: December 2021

Centile charts for assessment of stature and weight reflecting expected deficient size and growth rate of home-reared children with Down syndrome are presented for two age intervals, 1 to 36 months and 2 to 18 years, based on 4650 observations on 730 children. Data were pooled and used to estimate five centiles which were smoothed using a flexible mathematical function. These data corroborate other studies of growth in children with Down syndrome demonstrating deficient growth rate throughout the growing period, but most marked in infancy and again at adolescence. Children with Down syndrome in the present sample were taller than those from institutionalized samples at all ages throughout the growing period. Children with moderate or severe congenital heart disease on average were 1.5 to 2.0 cm shorter and about 1 kg lighter than those without or with only mild disease. Mean weight and weight divided by stature squared show that children with Down syndrome have a tendency to be overweight beginning in late infancy and throughout the remainder of the growing years.
Maternal Responses to the Sexual Abuse of Their Children
Authors: De Jong Allan R.
Published: December 2021

To define categories of maternal response and determine their relationship to variable features of the abuse situation, a questionaire was administered to mothers of 103 children returning for a routine 2- to 3-week follow-up of a sexual abuse episode. Three categories of response were identified: nonsupportive, supportive without emotional changes, and supportive with emotional changes. Nonsupportive mothers (n = 32) believed that the abuse complaint was a lie, a misunderstanding, or the child's fault. They rarely considered pressing charges or requested counseling. Supportive mothers (n = 71) believed that the child was telling the truth and that the assailant was primarily responsible. Anger, fear, anxiety, and guilt were commonly expressed. Thirty-nine of the supportive mothers reported behavior or mood changes including sleep, appetite, or somatic complaints and recurrent crying. Most were pressing charges (79%) and sought counseling for themselves (74%) and their children (82%). The 32 supportive mothers without behavior or mood changes also frequently pressed charges (88%) but sought counseling for themselves (6%) and the children (53%) less often (P < .001). Individual personality and coping mechanisms may determine the maternal response. Maternal emotional responses do not appear to be related to variable features of the abuse situation but are significantly related to the approach to subsequent psychologic and legal issues.
Vitamin Dosages for Premature Infants
Authors: GREENE HARRY L. , PHILLIPS BARRY L.
Published: December 2021

In Reply.—

As indicated on p 533 of our article,1 the original recommendations given by the AMA Nutrition Advisory Group in 1975 indicated that, for premature infants, 10% of a vial should be given for each kilogram of body weight. By the time a pediatric formulation was manufactured according to the Nutrition Advisory Group guidelines, several investigators believed that 10% of a vial would not supply the needs of very low birth weight infants for vitamins A, D, and E. For this reason, an ad hoc committee was organized in 1983 by the FDA to make new recommendations for premature infants.
Discharging the Jaundiced Infant From the Hospital: Risky for the Infant or Physician?
Authors: WENNBERG RICHARD P. , AHLFORS CHARLES E.
Published: December 2021

To the Editor.—

Term infants with idiopathic unconjugated hyperbilirubinemia who are otherwise well are probably at less risk for bilirubin encephalopathy than they are for having congenital hypothyroidism or galactosemia. Because approximately 10% of children have a neurologic deficit of some type, however, it is tempting to blame such deficits on newborn jaundice, particularly if the parents perceive (often in retrospect) that the attending physician was not sufficiently attentive to the problem.

Social and financial pressures have minimized the hospital stay of newborns, resulting in increased risk for undetected hyperbilirubinemia with subsequent increased risk for litigation should a jaundiced infant manifest neurologic or developmental handicaps.
Screening for Neuroblastoma
Authors: WEINBLATT MARK
Published: December 2021

To the Editor.—

This correspondence is in regard to the recent article by Woods and Tuchman about neuroblastoma screening and the commentary by McWilliams.1,2

Woods and Tuchman make a strong case for the institution of mass screening for neuroblastoma in infants to diagnose the tumors at an earlier and more treatable stage of their disease. The feasibility of this type of screening has been successfully demonstrated for other diseases (eg, galactosemia, hypothyroidism, and phenylketonuria) with resultant decreased morbidity and mortality.
Screening for Neuroblastoma
Authors: WOODS WILLIAM G. , TUCHMAN MENDEL
Published: December 2021

In Reply.—

Dr Weinblatt has raised several issues that were addressed in our paper1 concerning the value of screening North American infants for neuroblastoma. Dr Weinblatt is concerned that the Japanese may be diagnosing neuroblastoma in many children whose tumors would have spontaneously regressed. The prevalence of preclinically detected tumors noted by Sawada et al, one in 17,600,2 is one third to one half the rate expected in any given year,3 not sixfold as calculated by Dr Weinblatt.
Group B Streptococcal Cellulitis in Infants: A Disease Modified by Prior Antibiotic Therapy or Hospitalization?
Authors: Rand Thomas H.
Published: December 2021

Among 78 cases of group B streptococcal infections in children hospitalized at our institution during 1981 to 1985, five cases of cellulitis in infants were identified. Age at onset was 4 to 11 weeks. Group B streptococci were isolated from each of two aspirate cultures, all four blood cultures obtained before administering antibiotics, and none of four spinal fluid cultures obtained. All five infants had previously been treated with IV antibiotics in the hospital. Two infants had been previously treated for group B streptococcal infections (one each meningitis and neonatal sepsis). In contrast, among the 29 other patients with late-onset (2 weeks of age or older) group B streptococcal infection, four had prior treatment with IV antibiotics (P < .001). These data suggest that hospitalization and/or parenteral antibiotic therapy may be a risk factor for development of group B streptococcal cellulitis.
Psychosocial Functioning in Children and Young Adults With Juvenile Arthritis
Authors: Ungerer Judy A. , Horgan Barbara , Chaitow Jeffrey , Champion G. David
Published: December 2021

A questionnaire survey of 363 children and young adults with juvenile arthritis was conducted to assess the relations among disease severity, psychosocial functioning, and adjustment in three age groups—primary school, high school, and young adult. Parents were surveyed separately to determine which characteristics of the ill child at different ages most significantly impact the well-being of the family. Indices of psychologic functioning and disease severity were associated with adjustment in the primary school and high school groups, whereas measures of social relationships were strongly associated with adjustment only in the high school group. Relations among measures of psychologic functioning, social relationships, disease severity, and adjustment in young adults were minimal. Level of disease severity was associated with the presence of financial concerns, emotional problems, and physical strain in parents of high school children and young adults. The results emphasize the importance of using a developmental model for understanding the adjustment of individuals with chronic juvenile arthritis and their families.
Simultaneous Administration of Measles-Mumps-Rubella Vaccine With Booster Doses of Diphtheria-Tetanus-Pertussis and Poliovirus Vaccines
Authors: Deforest Adamadia , Long Sarah S. , Lischner Harold W. , Girone Joseph A. C. , Clark Janet L. , Srinivasan Ranganathan , Maguire Tobi G. , Diamond Susan A. , Schiller Ruth P. , Rothstein Edward P. , Schlackman Neil , Hipp Thomas J. , Souder Ronald L. , Bernier Roger H.
Published: December 2021

The safety and efficacy of simultaneous administration of measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), and trivalent oral poliovirus (OPV) vaccines in a test group of 405 children were compared with the safety and efficacy of sequential administration of the same vaccines in a control group of 410 children given MMR followed by booster doses of DTP and OPV 2 months later. The study was double blind and placebo controlled with respect to DTP and OPV. Seroconversion rates to measles, mumps, and rubella exceeded 96% in both groups. Geometric mean titers to measles (P = .05) and rubella (P = .004) were higher in the test group, and titers of antibodies to the other seven antigens were similar in both groups. Clinical reaction data were analyzed in 248 of 405 test children and 249 of 410 control children. The rates of serious vaccine-associated reactions were low and similar in the two groups. Some minor side effects were reported more frequently in the test group, but these differences were judged to be related to study design rather than to differences in the safety of the two vaccine schedules. The results indicate that the safety and serologic efficacy of administering MMR simultaneously with reinforcing doses of DTP and OPV in the second year of life is equivalent to the safety and efficacy observed after administering these antigens separately.
Parental Attitudes About Confidentiality in a Pediatric Oncology Clinic
Authors: Patno Karyn M. , Young Paul C. , Dickerman Joseph D.
Published: December 2021

Children and parents who attend pediatric oncology clinics often develop close relationships with other patients and may question clinic staff about another child's disease, therapy, or status. To assess parental attitudes concerning the dissemination of information by the clinic staff, questionnaires were mailed to the parents of all 154 patients who have attended pediatric oncology clinic since 1972. There were 100 (65%) responses including 77 from 99 living (78%) and 23 from 55 deceased patients (42%). Parents were asked whether clinic staff should respond completely to questions from other clinic parents regarding six aspects of their child's cancer. Percentages of parents who favored complete information sharing without their explicit consent about each of the aspects were as follows: diagnosis, 83%; medication/side effects, 85%; laboratory results, 66%; general status, 87%; occurrence of relapse, 77%; development of terminal phase, 67%. Neither the survival status (living v deceased) nor whether the patient was receiving therapy or not affected responses significantly. Benefit from receiving information about other children from clinic staff was reported by 82% of parents.
Suicide and Suicide Attempts in Adolescents and Young Adults
Authors:   Committee on Adolescence
Published: December 2021

Suicide is the third leading cause of death during adolescence and the second leading cause in young adults. It is preceded in frequency only by accidental deaths and homicide. Recent statistics indicate that the number of adolescent suicides has increased dramatically in the past decade, resulting in more than 5,000 deaths annually for youths between 15 and 24 years of age. For adolescents 15 to 19 years of age, suicide rates have actually tripled in the years between 1960 to 1980.1 Among children and younger teenagers between ages 5 and 14 years, suicides increased from 205 deaths in 1983 to 232 in 1984.2 As distressing as these data are, they may represent underreporting. Furthermore, many experts believe that numerous "accidental" deaths are actually suicides.3

Suicide affects young people from all races and socioeconomic groups. For every suicide completed, between 50 and 200 are attempted. Adolescent boys succeed in killing themselves more often than girls, although adolescent girls make more nonfatal attempts. This difference appears to be related, in part, to the methods favored by each sex. Boys are more likely to complete suicide because they use more lethal methods, such as firearms or hanging. These methods leave little chance for rescue. In contrast, adolescent girls more commonly attempt suicide by ingesting pills. Recently, however, there has been a trend toward the use of more lethal methods among girls.

"Cluster suicide" has also emerged in recent years. This phenomenon refers to the occurrence of multiple suicides during a short perioed of time in the same geographic location.4
Chloride-Deficient Formulas
Authors: BARNESS LEWIS A.
Published: December 2021

To the Editor.—

In addition to the numerous caveats described in the paper by Willoughby et al (Pediatrics 1987;79:851-857), a number of other serious criticisms should be noted. General recommendations for the use of soy bean formula frequently included the assumption that some risk factor existed in the child, limiting the use of milk-based formulas. Indeed, in the 20 infants reported by Willoughby et al, 11 are said to have had other risk factors, such as hyperbilirubinemia in six, ventricular septal defects in two, and one each with low birth weight, twinning, and Pierre-Robin anomalad.
Galactosemia—To Screen or Not to Screen?
Authors: HARRIS RUTH C.
Published: December 2021

In Reply.—

Norway has discontinued galactosemia screening because only 1 case has been identified per 96,000 infants screened. Members of a recent workshop on galactose screening1 in the United States reported that 37 states had an average incidence of 1:62,000 or 312 cases identified per 19 million infants screened. However, there was an incidence range from 1:30,000 to 1:191,000 from state to state.

Those states using both an enzyme assay and a measure of galactose content in the blood identified more enzyme defects, and, in general, laboratories with the longest experience appeared to be better able to recognize abnormalities in the screens.
Neurologic Events Following Diphtheria-Tetanus-Pertussis Immunization
Authors: Walker Alexander M. , Jick Hershel , Perera David R. , Knauss Thomas A. , Thompson Robert S.
Published: December 2021

The frequency of serious neurologic events following the administration of 106,000 doses of diphtheria-tetanus-pertussis vaccine at Group Health Cooperative of Puget Sound was determined using a population-based case-control study with disease ascertainment through pharmacy and hospitalization records. There were no cases of acute unexplained encephalopathies in close temporal relation to vaccination. There was the new onset of one serious seizure disorder in the three days following immunization, with 1.13 expected on the basis of chance alone.
Growth Failure in Infants With Bronchopulmonary Dysplasia: Nutrition and Elevated Resting Metabolic Expenditure
Authors: Kurzner Sharon I. , Garg Meena , Bautista Daisy B. , Bader David , Merritt Russell J. , Warburton David , Keens Thomas G.
Published: December 2021

The mechanisms underlying growth failure in infants with bronchopulmonary dysplasia are poorly understood. Thirteen infants with bronchopulmonary dysplasia at 6 months of corrected age and 12 full-term healthy control infants matched for age or size were studied. Resting oxygen consumption was measured during natural sleep, and an estimation of the resting metabolic expenditure by indirect calorimetry was performed. Growth parameters were measured, and a nutritional profile including dietary intake, stool analysis, and serum albumin, cholesterol, glucose, and prealbumin was obtained. Seven of the 13 infants with bronchopulmonary dysplasia had growth failure (defined as length and weight less than the tenth percentile of the Babson growth curves). These infants had lower birth weight, lower gestational age, and a greater number of days spent in supplemental oxygen or on mechanical ventilation. There was no statistical difference between the bronchopulmonary dysplasiagrowth failure and bronchopulmonary dysplasia-normal growth infants for dietary intake or stool or serum analyses. However, serum prealbumin showed a significant linear correlation with body weight in infants with bronchopulmonary dysplasia. Resting metabolic expenditure was elevated in infants with bronchopulmonary dysplasia with growth failure and was inversely correlated with body weight in all infants with bronchopulmonary dysplasia. Thus, infants with bronchopulmonary dysplasia and growth failure have increased metabolic demands and decreased prealbumin values suggesting a relative state of protein-calorie malnutrition.
Mortality in Very Preterm and Very Low Birth Weight Infants According to Place of Birth and Level of Care: Results of a National Collaborative Survey of Preterm and Very Low Birth Weight Infants in the Netherlands
Authors: Verloove-Vanhorick S. Pauline , Verwey Robert A. , Ebeling Marij C. A. , Brand Ronald , Ruys Jan H.
Published: December 2021

As part of a collaborative project in the Netherlands in 1983, for which data were collected on 1,338 newborn infants (<32 weeks' gestation and/or <1,500 g birth weight), all infants were assigned to one of three levels of care according to hospital of birth. Considerable centralization was achieved by antenatal and neonatal transport. Although the uncorrected mortality rates were similar, the mortality odds (adjusted for four and 22 potential confounding perinatal factors, respectively) were significantly higher in level 1 and level 2 hospitals compared with level 3 hospitals (tertiary perinatal care centers). By extending the facilities for full perinatal intensive care in level 3 centers and thus providing optimal care for all such infants, the overall mortality rate is expected to decrease further.
Behavioral Responsiveness in Preterm Infants With Intraventricular Hemorrhage
Authors: Garcia-Coll Cynthia T. , Emmons Laura , Vohr Betty R. , Ward Alison Monds , Brann Benjamin S. , Shaul Phillip W. , Mayfield Steven R. , Oh William
Published: December 2021

Preterm infants with varying degrees of intraventricular hemorrhage (none, n = 21; grade I to II, n = 22; grade II to IV, n = 24) and a group of full-term infants (n = 21) were compared with regard to behavioral responsiveness and parental reports of the infant's temperament. Behavioral responsiveness was assessed during the presentation of 15 visual, auditory, and tactile stimuli at 3 months of age (corrected age for preterm infants). Summary scores for positive and negative responsiveness, as well as sociability, soothability, and overall activity levels, were derived from behavioral observations by coders who were unaware of the infant's characteristics. The Bates Infant Characteristic Questionnaire was completed by the main care giver and scored on four summary variables: fussy-difficult, unadaptable, dull, and unpredictable. Preterm infants, regardless of the presence or severity of intraventricular hemorrhage, showed less positive responses and less overall activity in response to stimulation. Infants with grade I to II intraventricular hemorrhage were less sociable and more difficult to soothe than fullterm control infants. Individual differences in positive, negative, sociability, and soothability were related to the questionnaire scores of fussy-difficult and unadaptability. Both prematurity and degree of intraventricular hemorrhage affect behavioral responsiveness and these individual differences are related to parental reports of the infant's temperament.
Attempted Suicide by Insulin Overdose in Insulin-Dependent Diabetic Adolescents
Authors: Kaminer Yifrah , Robbins Douglas R.
Published: December 2021

Two cases of attempted suicide by insulin overdose in adolescent girls with insulin-dependent diabetes mellitus were observed. It is possible that suicidal insulin overdose in adolescents is more common than reports suggest and that it may often be unrecognized.
Nursing Interval and Maternal Responsivity: Effect on Early Infant Crying
Authors: Barr Ronald G. , Elias Marjorie F.
Published: December 2021

In industrialized societies, the unique pattern of crying in the first three months is "unexplained" but thought to be due to different biobehavioral factors from later crying behavior. To increase the range of the feeding and caretaking behaviors hypothesized to be relevant determinants of early crying, home observations and diary records were analyzed from samples of two subcultures of American middle-class women (LaLeche League and "standard care" mothers; each n = 16) differing primarily in such practices. Both during and after the early crying stage, frequently fed infants cried or fretted less often (8.1 v 15.8 episodes per hour at 2 months of age; 10.7 v 16.6 episodes per hour at 4 months of age), and fewer of them exhibited rhythmic crying behavior (four v 11 at 2 months; eight v 13 at 4 months) during observations. However, only during the early crying period at 2 months were interval between feedings and maternal response latency shown to be independent determinants of cry/fret frequency (overall r2 = .35, P = .01), each factor accounting for approximately half of the explained individual variance. Furthermore, feeding interval was the only variable associated with rhythmic crying behavior at 2 months of age (r2 = .20; P = .01). In similar analyses at 4 months, there were no significant relationships with later crying or fretting. The results suggest that, in the presence of variation in feeding practice greater than that which is typical for our society, feeding interval may be a significant factor in early (but not later) crying behavior; furthermore, this effect is independent of and additive to the soothing effect of short response latency.
Enteral Drug Administration Practices: Report of a Preliminary Survey
Authors: Leff Richard D. , Roberts Robert J.
Published: December 2021

This study was initiated to determine whether there is sufficient variation in enteral drug administration practices in hospitalized pediatric patients to result in adverse therapeutic consequences. A survey was developed and administered to nurses from three pediatric and six general hospitals. A total of 317 pediatric nurses responded. Results of the survey confirmed that the primary responsibility for administering enteral medications resides with the nurse. It also documented that many elements in the administration of enteral medications vary significantly among nurses, although nursing personnel expressed confidence in the efficacy of their individual drug administration techniques. Further quantitative evaluations of the efficacy of practices of enteral drug administration must be performed before meaningful standardization of drug administration techniques can be accomplished.
Pruritic Rash Associated With Cat Scratch Disease
Authors: Daye Susanne , McHenry John A. , Roscelli John D.
Published: December 2021

Cat scratch disease is a benign, self-limited illness characterized by regional lymphadenopathy that usually occurs in association with a history of contact with a cat. Cases of cat scratch disease with skin manifestations that included erythema nodosum; erythema multiforme; erythema marginatum; and nonspecific maculopapular, petechial, and morbilliform rashes have been reported. No case of pruritic rash associated with cat scratch disease has been previously reported. In fact, one authority specifically states that the rash of cat scratch disease is nonpruritic. We report a well-documented case of cat scratch disease in which the patient's principal symptom was a pruritic rash. It is possible that this rash was the result of an immunologic reaction to the infectious agent of cat scratch disease. We conclude that cat scratch disease should be included in the differential diagnosis of pruritic rashes in children.
Concurrent and Predictive Validity of the Yale Children's Inventory: An Instrument to Assess Children With Attentional Deficits and Learning Disabilities
Authors: Shaywitz Sally E. , Shaywitz Bennett A. , Schnell Carla , Towle Virginia R.
Published: December 2021

The Yale Children's Inventory rating scales for completion by parents were developed to improve the ability of clinicians and researchers to evaluate the school-related problems of children. The inventory consists of 11 narrow-band and two broad-band scales, the Behavioral and the Cognitive. The concurrent and predictive validity of the Yale Children's Inventory scales are reported in a school-based sample of 103 boys. External criterion variables were obtained from parents, teachers, and standardized tests administered to the children. We found that the Attention scale overlaps both broad-band domains, indicating the importance and the intrinsic relationship of attention to both behavioral and cognitive functions, which supports the Diagnostic and Statistical Manual of Mental Disorders, ed 3 nosology for disorders of attention and activity regulation. It also increases the number of children whose assessment may be enhanced by the availability of systematic parent report forms.
Neonatal Arytenoid Dislocation
Authors: ROBERTS DION , MCQUINN TIM , BECKERMAN ROBERT C.
Published: December 2021

Arytenoid dislocation is a well-described injury in adults.1-6 We report here what we believe is the first neonatal case and contrast the findings and course to those previously described.

CASE REPORT

A 2,640-g girl was born at 38 weeks' gestation by spontaneous delivery after labor complicated by the passage of meconium-stained amniotic fluid. She was intubated with a 3.0-mm oral endotracheal tube without a stylet. No meconium was found below the vocal cords. Apgar scores at 1, 5, and 10 minutes were 5, 7, and 9, respectively. When the baby was admitted to the nursery, she was described as having pink color, a strong cry, no retractions, a cardiac rate of 136 beats per minute, and a respiratory rate of 48 breaths per minute.
Coronary Risk Incidence of Obese Adolescents: Reduction by Exercise Plus Diet Intervention
Authors: Becque M. Daniel , Katch Victor L. , Rocchini Albert P. , Marks Charles R. , Moorehead Catherine
Published: December 2021

The incidence of coronary heart disease risk factors and the effects of 20 weeks of diet and exercise were studied in 36 obese adolescents. Values for the following risk factors were determined: serum triglyceride level, high-density lipoprotein-cholesterol level, total cholesterol level, systolic and diastolic BP, maximum work capacity, obesity, and presence of coronary heart disease in the family history. Of the subjects, 97% had four or more risk factors. Two subjects possessed all eight risk factors. The adolescents were randomly assigned to either a control, diet therapy and behavior change, or exercise, diet therapy, and behavior change group. From pre- to posttreatment, a 14.8% and 41.4% reduction in multiple risk was noted for the latter two groups, respectively. No significant difference between the control group and the diet and behavior change group was found. In contrast, the exercise-diet-behavior change group reduced multiple risk (P < .01) more than either of the other groups.It was concluded that obese adolescents are at high risk for the development of coronary heart disease and that exercise in addition to moderate dietary restriction can result in the reduction of multiple coronary heart disease risk.
Elemental Mercury Exposure
Authors: VOGT RICHARD L.
Published: December 2021

In Reply.—

Dr Swinehart describes a case of mercury toxicity in a child of a furnace operator who worked in a mercury smelter. In Vermont we identified mercury exposure in workers and children as measured by urinary mercury content (Pediatrics 1987;79:935-938). We failed, however, to find clinical cases of mercurialism. As stated in our article, engineering and clothing barriers will help to protect workers and workers' children at home from mercury and other heavy metal exposure.
Relaxation and Examination for Sexual Abuse
Authors: HERMAN-GIDDENS MARCIA , FROTHINGHAM THOMAS E.
Published: December 2021

In Reply.—

We appreciate the comments by Drs Hansen and Palmer with regard to the patient's state of relaxation during the genital examination. Although we did not use the word "relaxation" in our discussion, we thought we covered this issue by stressing the cooperation of the child, pointing out that one cannot do an adequate examination on a resisting child and that several seconds are required with a cooperative patient, after the labia are spread and being held properly, for the hymenal or vaginal tissues to optimally separate.
Infant Temperament, Sleep Organization, and Nighttime Parental Interventions
Authors: Keener Marcia A. , Zeanah Charles H. , Anders Thomas F.
Published: December 2021

Objective measures of sleep-wake organization derived from time-lapse video recordings were compared with parental perceptions of infant temperament in 23 infants 6 months of age. Although both mothers' and fathers' ratings of infant temperament were correlated with variables reflecting sleep continuity, results for fathers were much more striking. Infants who required care giving during the night were rated as significantly more difficult and arrhythmic by fathers than by mothers. All infants awakened during the night. Some of them soothed themselves and returned to sleep; however, others signaled and required care giving interventions from their parents before returning to sleep. No differences in variables reflecting the biology of sleep distinguished "signaling" infants and "self-soothing" infants, although feedings at bedtime (breast or bottle) were more common in the signaling group.
Oral and Written Language Abilities of XXY Boys: Implications for Anticipatory Guidance
Authors: Graham John M. , Bashir Anthony S. , Stark Rachel E. , Silbert Annette , Walzer Stanley
Published: December 2021

Previous studies of XXY boys suggest that they are at risk for certain communication disorders involving oral and written language. In this study, the language, reading, and spelling skills of a group of 14 XXY boys identified during neonatal cytogenetic screening were compared with those of a group of 15 control children. The two groups were matched for age, grade, race, parity, birth weight, parental age and education, and socioeconomic status. The mean age of the XXY group was 9 years 7 months and that of the control group was 9 years 3 months. The mean academic grade level for both groups was at the transition between third and fourth grade. There was selective reduction in verbal IQ scores for the XXY group and no significant differences apparent between groups for performance IQ scores. The decrease in verbal IQ was associated with a reduced full-scale IQ and also with significant problems in expressive language, auditory processing abilities, and auditory memory. Word-finding difficulties and problems in the production of syntax were major components of the specific expressive language deficit. Except for difficulties in the understanding of complex sentence structures, the receptive language skills of XXY boys did not differ significantly from those of the control group. These reductions in speech and language abilities correlated with decreased achievement by the XXY group on a variety of reading and spelling tasks. These results suggest that difficulty learning how to read and spell may be due to a preexistent language disability. Early attention to such expressive language problems may be essential to ameliorate secondary maladaptive behaviors due to chronic language-related learning disabilities.
Influence of Birth Weight on Mortality From Infectious Diseases: A Case-Control Study
Authors: Victora C. G. , Smith P. G. , Vaughan J. P. , Nobre L. C. , Lombardi C. , Teixeira A. M. B. , Fuchs S. M. , Moreira L. B. , Gigante L. P. , Barros F. C.
Published: December 2021

The association between birth weight and infant mortality from infectious diseases was investigated in a population-based case-control study in two urban areas in southern Brazil. All deaths of children, seven to 364 days of age, occurring in a year were studied and the parents of the 357 infants dying of an infectious cause were interviewed, as were the parents of two neighborhood control infants for each case. Low birth weight infants (<2,500 g) were found, after allowing for confounding factors, to be 2.3 (90% confidence interval = 1.6 to 3.4) times more likely to die of an infection than those of higher birth weight. The odds ratios were 2.0 (1.1 to 3.6) for deaths due to diarrhea, 1.9 (1.0 to 3.6) for respiratory infections, and 5.0 (1.3 to 18.6) for other infections. These estimates of the risks associated with low birth weight are considerably lower than those from studies in developed countries.
Bladder Fungus Ball: A Reversible Cause of Neonatal Obstructive Uropathy
Authors: Baetz-Greenwalt Barbara , Debaz B. , Kumar Mary L.
Published: December 2021

Very low birth weight infants often have multiple predisposing conditions for the development of invasive candidiasis. In patients with systemic candidiasis, the kidney is vulnerable to the formation of cortical abscesses or obstructive intrarenal masses ("fungus balls"), usually at the ureteropelvic junction. Ureteropelvic junction obstructive fungal uropathy necessitates invasive debridement to restore renal function. A very low birth weight infant, infected with Candida, was first seen with hypertension, renal insufficiency, and urine cultues positive for fungus; obstructive bladder fungus ball was diagnosed by ultrasography. Mechanical disruption with amphotericin B bladder irrigation was accomplished via ultrasographic guidance, relieving renal obstruction and insufficiency. Systemic antifungal therapy was completed with amphotericin B and flucytosine. The first reported case of bladder obstructive fungal uropathy in a neonate is added to a review of 16 cases of neonatal renal obstructive uropathy.
Atlantoaxial Instability in Individuals With Down Syndrome: A Fresh Look at the Evidence
Authors: Davidson Ronald G.
Published: December 2021

In 1984, the Committee on Sports Medicine of the American Academy of Pediatrics published in this journal a statement on the remarkably high incidence of atlantoaxial instability among individuals with Down syndrome. On the assumption that this instability, demonstrable through a specified series of lateral x-ray films of the neck, constituted a predisposition to cervical spine dislocation with subsequent spinal cord compression, the Academy supported and made more specific a series of recommendations that had originated from the Kennedy Foundation a year previously. In essence, for those persons who are found to have the radiographic sign of instability, participation in sports should be restricted. Because the implementation of these recommendations could deprive tens of thousands of individuals with Down syndrome of activities that are emotionally and physically beneficial and because of the rarity of reported cervical dislocations associated with injury, a case review was done. Included were those cases cited as support for the recommendations along with additional reports that had been omitted and a few cases reported subsequently. Little support for the hypothesis that atlantoaxial "instability" is a predisposing factor to "dislocation" was found, although much was found to indicate an urgent need for carefully designed longitudinal studies. Because nearly all of the cases of actual dislocation were preceded by at least several weeks of readily detectable physical signs, a physical examination with careful attention to neurologic signs prior to participation in sports is more predictive of potential or impending dislocation than the radiologic criteria currently recommended.
Sn-Protoporphyrin: A Consideration of the First Clinical Trial in Human Neonates
Authors: STEVENSON DAVID K. , VREMAN HENDRIK J.
Published: December 2021

The history of new treatment modalities for neonates1 suggests that cautious optimism is warranted even when one considers the first successful trial of a novel and exciting strategy for the chemoprevention or treatment of neonatal hyperbilirubinemia with tin protoporphyrin (Sn-protoporphyrin). Kappas et al2 and Drummond and Kappas3 were the first to show that this synthetic protoporphyrin is effective in decreasing plasma bilirubin levels in both adult and neonatal animals and humans.

In the April issue of Pediatrics, Kappas et al,2 reported the results of administering as many as three doses (0.75 µmol/kg per dose) of Sn-protoporphyrin to human neonates with hyperbilirubinemia due to hemolytic disease caused by ABO incompatibility.
Light Versus Tin?
Authors: MAISELS M. JEFFREY
Published: December 2021

One of the first steps in the formation of bilirubin from hemoglobin is an oxidative process in which the α-methene bridge of the heme porphyrin ring is opened and carbon monoxide and bilirubin are formed. This oxidation is catalyzed by the enzyme microsomal heme oxygenase. Following earlier observations from their laboratory, Drummond and Kappas1 demonstrated that tin protoporphyrin (Sn-protoporphyrin) was the most potent of several synthetic metalloporphyrins that competitively inhibited heme oxygenase. By competing with this enzyme, Sn-protoporphyrin inhibits the conversion of heme to bilirubin and is effective in preventing or ameliorating experimental and naturally occurring jaundice in the neonatal animal and adult human.
Haemophilus influenzae Type b Vaccines: Lessons for the Future
Authors: WARD JOEL I. , BROOME CLAIRE V. , HARRISON LEE H. , SHINEFIELD HENRY , BLACK STEVEN
Published: December 2021

In recent months much controversy has focused on interpretations of new data concerning the safety and efficacy of Haemophilus influenzae type b vaccines.1-3 These controversies led the Infectious Disease Committee (Redbook Committee) of the Academy of Pediatrics (AAP) on Nov 13, 1987, to issue by telegram a change in recommendations for the H influenzae type b polysac-charide vaccine. Then, on Dec 22, 1987, the US Food and Drug Administration (FDA) licensed a new, more immunogenic, H influenzae type b conjugate vaccine (Prohibit-Connaught). The aim of this commentary is (1) to provide some background to these events, (2) to elucidate some of the difficulties involved in evaluating vaccines after licensure, (3) to present an alternative interpretation of available data regarding the polysaccharide vaccine, and (4) to comment on the new H influenza type b conjugate vaccine.
Haemophilus influenzae Type b Vaccines: Lessons From the Past
Authors: DAUM ROBERT S. , MARCUSE EDGAR K. , GIEBINK G. SCOTT , HALL CAROLINE B. , LEPOW MARTHA L. , MCCRACKEN GEORGE H. , PETER GEORGES , PHILLIPS CAROL F. , WRIGHT HARRY T. , PLOTKIN STANLEY A.
Published: December 2021

The Committee on Infectious Diseases of the American Academy of Pediatrics attempts to provide "guidelines that complement the physician's clinical judgment and facilitate the making of well reasoned decisions. Unanswered scientific questions, the complexity of medical practice, new information, and inevitable differences of opinion between experts result in inherent limitations"1 in this process.

With regard to the first-generation Haemophilus b polysaccharide vaccines (HBPV or PRP), the Committee issued a statement on Nov 13, 1987 (PedComm: AAP Member Alert), in which its concern regarding the preliminary efficacy estimates derived from "case-control" studies performed by several investigative groups in various areas in the United States was expressed.
What Is `Significant' and DTP Reactions
Authors: EDEN ALVIN N.
Published: December 2021

To the Editor.—

The possible association between diphtheria-tetanus-pertussis (DTP) and sudden infant death syndrome (SIDS) is of enormous concern to all of us. Therefore, I read with a great deal of interest the article by Hoffman et al (Pediatrics 1987;79:598-611). Based on the information the authors presented in their detailed report, there appears to be absolutely no relationship between a DTP shot and the subsequent occurrence of SIDS. This was good news to me until I read the last sentence in the article.
Granulocyte Transfusions
Authors: BALEY JILL E. , STORK EILEEN K. , WARKENTIN PHYLLIS I. , SHURIN SUSAN B.
Published: December 2021

To the Editor.—

We would like to point out an inaccuracy in the commentary written by Dr Cairo1 in which he states that the three different groups in our study "should have required separate randomizations." In fact, the groups were not mixed. They were separately randomized and analyzed. Only after they were considered separately and no differences were found in outcome were the three groups combined for a total population.

Also, although the average age of presentation was older than that in the studies by either Christensen et al2 or Cairo et al,3 we only included children with over-whelming sepsis, those who were in shock and who required mechanical ventilation.
Granulocyte Transfusions
Authors: CAIRO MITCHELL S.
Published: December 2021

In Reply.—

The comments raised by Baley et al are well taken and bring up one of the most important variables in the role of granulocyte transfusion in neonatal sepsis. Most of the studies to date have involved small numbers of patients in single institutions. This has prevented us from accumulating a large enough population of patients to adequately assess the role of either buffy coat transfusions or leukapheresed transfusions in this clinical setting.

My comments in the commentary suggested that, with only eight patients in a group of preterm infants with presumed sepsis and only five patients with presumed sepsis with birth weights greater than 1,500 g, the numbers are essentially too small to determine any statistical significance between the role of buffy coat transfusions or supportive care.
Oxybutynin Efficacy in the Treatment of Primary Enuresis
Authors: Lovering John S. , Tallett Susan E. , McKendry James B. J.
Published: December 2021

The effectiveness of oxybutynin in the treatment of primary enuresis was evaluated in a double-blind study. A total of 30 children (25 boys, five girls), at least 6 years of age, with primary enuresis and no daytime incontinence or history of other urinary tract problems were selected at random from an enuresis clinic population. The study was explained to the families and they were told how to keep records of nocturnal bed-wetting episodes and side effects. The patients were treated with a 10 mg of oxybutynin at suppertime for 28 days. Before or after the treatment period, all children received an identical placebo for 4 weeks. Two-sided paired t tests were used to compare frequency of nocturnal enuresis. Frequency during the drug regimen did not differ significantly from that during the placebo study. There were no differences in findings between boys and girls or between children who had previously taken imipramine and those who had not. The study showed no evidence that oxybutynin is effective in treating primary enuresis.
Esophageal Motor Abnormalities in Children and Adolescents With Scleroderma and Mixed Connective Tissue Disease
Authors: Flick Jonathan A. , Boyle John T. , Tuchman David N. , Athreya Balu H. , Doughty Robert A.
Published: December 2021

To determine the frequency and nature of esophageal motor abnormalities in children and adolescents with scleroderma syndromes and mixed connective tissue disease, esophageal manometry was performed on seven patients with progressive systemic sclerosis, four patients with mixed connective tissue disease, and two patients with linear scleroderma. A total of 73% of patients with progressive systemic sclerosis and mixed connective tissue disease had symptoms of esophageal dysfunction. A significant association between the presence of Raynaud phenomenon and esophageal symptoms was noted. Esophageal motor abnormalities were detected in 73% of patients with progressive systemic sclerosis and mixed connective tissue disease; these abnormalities were characterized by decreased lower esophageal sphincter pressure and abnormal peristalsis in the distal two thirds of the esophageal body. They resemble those described among adults with progressive systemic sclerosis and mixed connective tissue disease but were not related to disease duration or to the presence of Raynaud phenomenon. Patients with linear scleroderma did not have esophageal symptoms and demonstrated only nonspecific motor abnormalities that did not worsen during several years of follow-up.
Systolic or Diastolic Blood Pressure Significance
Authors: WEISMANN DOUGLAS N.
Published: December 2021

The importance of hypertension has been recognized from the complications it produces in adults, mainly stroke, congestive heart failure, myocardial infarction, and renal failure.1-10 Similar health consequences have been reported in a few children with severe hypertension. As a result of these health concerns, children's health care providers have been encouraged to determine and record blood pressures of their young patients. It has become customary to consider hypertension in adults in terms of an empirically designated diastolic blood pressure. Is this practice valid? Should this practice be applied to children? Unfortunately, these questions cannot be answered in reference to children, because there have been no long-term studies relating height of blood pressure to vascular sequelae in children.