bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrographic Seizures in Preterm and Full-Term Neonates: Clinical Correlates, Associated Brain Lesions, and Risk for Neurologic Sequelae
Authors: Scher Mark S. , Aso Kosaburo , Beggarly Marquita E. , Hamid Marie Y. , Steppe Doris A. , Painter Michael J.
Published: December 2021

Electrographically confirmed seizures in preterm and term neonates were compared with respect to clinical correlates, incidence, associated brain lesions, and risk for neurologic sequelae. Over a 4-year period, 92 neonates from a neonatal intensive care unit population of 4020 admissions at a large obstetric hospital with 40845 livebirths had electrographically confirmed seizures. Sixty-two neonates were preterm and 30 were full-term for gestational age. Chi-square calculations were used to compare the two groups. While the incidence of seizures for all neonates admitted to a neonatal intensive care unit was 2.3%, outborn neonates were more likely to have seizures than inborn neonates. Preterm neonates of ≤30 weeks gestational age had a seizure frequency of 3.9%, which was significantly higher than that of older preterm neonates and full-term neonates. Clinical criteria contemporaneous with electrographic seizures were noted in only 28 (45%) of 62 preterm, and 16 (53%) of 30 full-term neonates. Subtle seizures coincident with electrographically confirmed seizures were the most predominant clinical type for both term and preterm neonates (71% and 68%, respectively). The distribution of clonic, myoclonic, and tonic seizures was also similar for both groups. Autonomic signs coincident with electrographically confirmed seizures (ie, blood pressure, heart rate, oxygenation, respiration changes) were more frequently observed in preterm than full-term neonates with subtle seizures; 7 (37%) of 19 compared with 1 (6%) of 16. Electrical seizures without clinical correlates were noted more frequently than electroclinical seizures for both populations. Fifteen (54%) of 28 of the preterm coincident group and 10 (63%) of 16 of the full-term group had isolated electrographic seizures without clinical seizures on the same or other records, in addition to exhibiting electroclinical seizures. More preterm neonates had a later onset of seizures (>48 hours of life) than term neonates (53% vs 13%, respectively). Ischemic brain lesions were noted in 23 (77%) of 30 of full-term compared with 24 (39%) of 62 preterm neonates. Intraventricular hemorrhange with ventriculomegaly or intraparenchymal involvement was seen in 26 (45%) of 72 preterm neonates compared with 1 (3%) of 30 full-term neonates. Mortality was greater in the preterm than in the term populations, 36 (58%) of 52, compared with 10 (30%) of 30, and a normal outcome was documented in 9 (25%) of 36 preterm neonates compared with 12 (60%) of 30 full-term survivors. However, the incidence of surviving preterm neonates epilepsy developed was the same as the fullterm survivor group at a mean age of 6 ½ years. While the electroclinical expression of neonatal seizures occurs in both preterm and full-term populations, clinical correlates, incidence, etiologic factors, and outcome factors differ between the two populations.
Questions about Bilirubin
Authors: STEIN MICHAEL L.
Published: December 2021

To the Editor.—

The collaborative study of Dr van de Bor and associates1 on the effects of hyperbilirubinemia in low birth weight infants in the March issue of Pediatrics was a beautifully executed study that inexplicably has left out a critical piece of information.

There are no details as to the etiology of the hyperbilirubinemia, ie, ABO or Rh incompatibility or so-called physiological.

Because there is considerable discussion concerning the potential pathogenicity of bilirubin as it relates to the source of this material, this information should be included in the analysis of hyperbilirubinemia effects.
Modified Chickenpox in Children Immunized With the Oka/Merck Varicella Vaccine
Authors: Watson Barbara M. , Piercy Sharon A. , Plotkin Stanley A. , Starr Stuart E.
Published: December 2021

Oka/Merck varicella vaccine has been studied in this institution since 1981. Persistence of antibody for 6 to 8 years has been demonstrated; however, cases of chickenpox have been seen in immunized children. The severity of chickenpox in healthy children who have received Oka/Merck varicella vaccine since 1981 is described. All vaccinees who developed chickenpox-like rashes more than 6 weeks postimmunization were exammined. Of 2163 vaccinees, 164 were examined, of whom 114 had rashes consistent with chickenpox. When sera were available (46%), antibody studies uniformly confirmed varicella-zoster virus infection. Chickenpox occurred 2 to 96 months (median of 44 months) postimmunization. The range for the number of skin lesions was 1 to 285 (median 18) in seroconverters. Symptoms included itching in 39%, fever in 9%, headaches in 7%, lymphadenopathy in 3%, and malaise in 2%; 54% were asymptomatic, except for the rash. The median time to total healing was 5 days. The median time lost from school was 2 days. Thirteen of the children in whom infections developed had failed to seroconvert after immunization. Their infections were similar in severity to those of children who had seroconverted originally. When varicella was introduced into families as a result of chickenpox in an immunized family member (index case), the rate of secondary chickenpox among immunized siblings was 12.2%. Eleven such secondary cases were similar in severity to the 9 index cases. It is concluded that chickenpox is generally mild in previously immunized children.
Overtreatment of Neonates
Authors: HUNT ANDREW D.
Published: December 2021

To the Editor.—

Dr Silverman's elegant paper raises questions that have resisted resolution and have serious implications for practice and political involvement of pediatrics in the United States.

Regarding ethics in the neonatal intensive care unit (NICU) he mentions the ". . . fulfillment of an eager team's dream of rescue bring(ing) about the real-life enactment of a family's worst nightmare . . ." Brody1 recently has developed the concept of the "Rescue Fantasy" undergirding many of medicine's heroic ministrations.
The Pediatrician's Role in Setting Standards of Day Care for Children
Authors: Wender Esther H.
Published: December 2021

The goal of pediatric practice is to promote optimal health, growth, and development of infants, children, and adolescents, and pediatric training is aimed at this goal. Thus, pediatrics has long been involved in establishing optimal health practices affecting nutrition, supervision of the environment, preventive health services, and the promotion of practices that optimally enhance social and emotional development. These generic areas of expertise apply in unique ways to children cared for in groups, especially very young children. A large body of research has been produced by pediatricians and other health professionals that addresses the specific health needs of infants and children in group care. Studies have especially addressed the spread and control of infectious disease and the prevention of injury in groupcare settings. Pediatric research, often in collaboration with psychologists, educators, and other professionals, has also addressed issues pertinent to optimal cognitive stimulation and behavioral management of the developing child, as well as the prevention of abusive practices. Thus, much of what constitutes the body of pediatric knowledge is crucial to the optimal care of young children in group settings.

In the traditional practice of pediatrics, pediatricians apply their expertise to the care of individual children in the context of the family. The unwritten contract for pediatric care is between the parents and the pediatrician on behalf of the child. However, the school, day-care, or other community-based programs become an extension of the family, and the pediatrician relates to those community programs on behalf of children and their families. What the pediatrician recommends on behalf of the individual child becomes a recommendation to the program as well as to the child's family.
Scandinavian Experience in Providing Alternative Care
Authors: Hwang C. Philip
Published: December 2021

What are Swedes like? Recently, this question received a great deal of attention in the Swedish media, because of an article published in the Daily Mail by an English journalist, Geoffrey Levy. He described Swedes as being lazy, sick, and totally unable to enjoy anything nice in life. In addition, Swedish cars are wrecks, Swedes dress sloppily, and, if you do not want to work, you do not need to—but you are still fully paid. Finally, he described family policy in Sweden: "Just imagine a country where mothers as well as fathers can stay at home 12 months, with almost full pay after a baby is born, or a country where the state pays almost 6000 pounds for every child that goes to a day-care center—this would be totally impossible in Britain."

How did the Swedish public react to Geoffrey Levy's article? Surprisingly, most people agreed with his description of the Swedes. Yes, we are lazy, too many people are sick, and we are unable to enjoy the good things in life. There was only one major issue where most people disagreed with Geoffrey Levy. Very few were negative about family policy in Sweden. On the contrary, most people took parental leave, the possibility of staying at home with a sick child, and publicly funded day care for granted.

In the first part of this presentation, I will describe family policy in Sweden and, in particular, how the society supports and provides care for children under school age (which in Sweden starts at 6-7).
Risk Factors for Delayed Immunization in a Random Sample of 1163 Children From Oregon and Washington
Authors: Bobo Janet Kay , Gale James L. , Thapa Purushottam B. , Wassilak Steven G. F.
Published: December 2021

Despite extensive study of vaccine safety and decades of effort to immunize infants and toddlers, little is known about the comprehensiveness of vaccine coverage in US children younger than 2 years of age. Provider and parent data from a population-based sample of 1163 children from two states were analyzed to assess coverage rates at three ages and to evaluate characteristics of children and their families that predict failure to immunize on schedule. Overall, 78% of the children had received their first dose of diphtheria and tetanus toxoids with pertussis vaccine (DTP) and their first dose of oral poliovirus (OPV) by 92 days of age. Similarly, 77% had received their third dose of DTP and their second dose of OPV by their first birthday. However, by their second birthday only 60% had received the full series of four doses of DTP, three doses of OPV, and one dose of the measles, mumps, and rubella vaccines. When considered singly, several variables including child birth order, family income, maternal education, and marital status significantly predicted failure to immunize on schedule. In multivariate logistic models, only birth order and maternal education consistently predicted vaccine status at each of the three ages. Compared with first-born children, those who were later-born were 1.7 times more likely to be incompletely immunized at 2 years of age (95% confidence interval: 1.2, 2.3). Children of more educated mothers were significantly less likely to be underimmunized at all ages. These data highlight the general need to continue promoting immunizations to the broad population of US parents and a specific need to aggressively target children who are later-born or have unmarried, low-income, or poorly educated mothers.
Estimates of Fatal Child Abuse and Neglect, United States, 1979 Through 1988
Authors: McClain Philip W. , Sacks Jeffrey J. , Froehlke Robert G. , Ewigman Bernard G.
Published: December 2021

The results of recent surveys in the United States have suggested a rising tide of fatalities due to child abuse or neglect (CAN). Because these surveys lack consistency in case definition and are incomplete in coverage, the use of death certificate data to estimate the number of CAN deaths was explored. To estimate these deaths among children 0 through 17 years old for 1979 through 1988, three models were formulated, each comprising six coding categories: (1) deaths coded explicitly as due to CAN, (2) homicides, (3) injury deaths of undetermined intentionality, (4) accidental injury deaths, (5) sudden infant death syndrome fatalities, and (6) natural-cause deaths. Research studies and crime data were relied on to estimate the proportions of deaths in categories 2 through 6 that were actually due to CAN, and other assumptions were varied to create a range of estimates. For the 10-year period, the estimated mean annual CAN fatalities ranged from 861 to 1814 for ages 0 through 4, and from 949 to 2022 for ages 0 through 17. Child abuse and neglect death rates did not increase over the period; in fact, they were relatively stable for ages 0 through 17 and showed a modest decline for 0 through 4. Ninety percent of fatal CAN occurs among children younger than 5 years old, and 41% occurs among infants. About 85% of CAN deaths are recorded as due to other causes. It is concluded that the magnitude of fatal CAN can be estimated from death certificates. It is recommended that the death coding system be modified to make CAN identification easier and that this study's methodology be refined to provide the basis for ongoing surveillance.
Common Pulmonary Vein Atresia: The Role of Extracorporeal Membrane Oxygenation
Authors: Dudell Golde G. , Evans Marva L. , Krous Henry F. , Spicer Robert L. , Lamberti John J.
Published: December 2021

Common pulmonary vein atresia is a rare form of cyanotic congenital heart disease in which the pulmonary veins join to form a blind confluence that does not communicate with the heart or the major systemic veins. Twenty-one cases have been reported since the lesion was first described in 1962; only two patients with this lesion have survived. Over a 4-year period, common pulmonary vein atresia was diagnosed in five newborns referred to the San Diego Regional Extracorporeal Membrane Oxygenation Program. All five improved dramatically as a result of venoarterial bypass. Congenital heart disease was diagnosed at autopsy in the initial case and by cardiac ultrasound and/or catheterization in the others. Surgical repair was attempted in three neonates; all three required continued extracorporeal membrane oxygenation support postoperatively because of pulmonary hypertension and severe pulmonary parenchymal disease. One infant died of respiratory insufficiency at 3 months of age. The other two survived and were discharged from the hospital. The diagnostic and therapeutic dilemmas posed by this lesion and the life-saving potential for extracorporeal membrane oxygenation in this rapidly fatal cardiac anomaly are the bases of this report.
Severe Acquired Protein C Deficiency in Purpura Fulminans Associated With Disseminated Intravascular Coagulation: Treatment With Protein C Concentrate
Authors: GERSON WILLIAM T. , DICKERMAN JOSEPH D. , BOVILL EDWIN G. , GOLDEN ELIZABETH
Published: December 2021

Purpura fulminans (PF) defines an acute, often lethal syndrome of disseminated intravascular coagulation (DIC) with rapidly progressive hemorrhagic necrosis of the skin due to dermal vascular thrombosis.1-7 It is indicative of a severe disturbance in hemostasis now recognized to involve the protein C system in many cases.1,2,5,8-12 Purpura fulminans is usually seen in three clinical settings: (1) in the newborn period as a manifestation of homozygous protein C deficiency, or rarely protein S deficiency13,14; (2) in individuals with acute, severe viral or bacterial infection where an acquired deficiency in protein C activity is documented1-3,5-8,10,12,15; and (3) as a rare, postinfectious syndrome with a history of an antecedent" preparatory disease," most commonly a viral or bacterial illness involving the skin (eg, varicella or scarlet fever), with the sudden development, during an otherwise unremarkable convalescence, of progressive purpura and necrosis.3-5,7,10,12
Adolescent Health Status Measurement: Development of the Child Health and Illness Profile
Authors: Starfield B. , Ensminger M. , Riley A. , McGauhey P. , Skinner A. , Kim S. , Bergner M. , Ryan S. , Green B.
Published: December 2021

This report describes the early stages in the development and testing of an instrument, known as the CHIP (Child Health and Illness Profile), for assessing the health of individuals aged 11 through 17. The purpose of the instrument is to assess health in epidemiologic surveys, to determine the existence of systematic differences in health in subpopulations (including the socioeconomically disadvantaged), and to provide a basis for assessing the impact of changes in health services or health policies. An instrument consisting of six domains with 25 subdomains was developed based on the literature, the involvement of focus groups and expert panels, and pretesting in four groups of teenagers known to differ in their health. The results of work with panels of experts suggest that the instrument has content validity. Most domains and subdomains had acceptable reliability as measured by α coefficients. Differences in the scores of individuals in the four groups were in the predicted directions, suggesting that the instrument also has construct validity. Additional research is under way to establish other aspects of validity as well as reliability in school populations of adolescents as well as specific clinical settings.
Smoking Policies of Licensed Child Day-Care Centers in the United States
Authors: Nelson David E. , Sacks Jeffrey J. , Addiss David G.
Published: December 2021

The authors analyzed data from a national survey of 2003 directors of licensed child day-care centers to determine employee smoking policies, measure compliance with state and local employee smoking regulations for child day-care centers and state clean indoor air laws, and to estimate the extent of exposure to environmental tobacco smoke in these settings. Forty states regulated employee smoking in child day-care centers, but only three states required day-care centers to be smoke-free indoors. More than 99% of licensed child day-care centers had employee smoking policies that complied with the appropriate state or local smoking regulations. Nearly 55% of centers were smoke-free indoors and outdoors, and 26% were smoke-free indoors only. The best predictors of more stringent employee smoking policies were location in the West or South, smaller size, independent ownership, or having written smoking policies. Despite the presence of strong smoking policies at the majority of licensed child day-care centers, more than 752000 children in the United States are at risk for environmental tobacco smoke exposure in these settings. Health care professionals and parents should insist that child day-care centers be smoke-free indoors and, preferably, smoke-free indoors and outdoors.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: MESROBIAN HRAIR-GEORGE
Published: December 2021

To the Editor.—

I greatly enjoyed the special article entitled: "The Changing Role and Responsibilities of Chairmen in Clinical Academic Departments: The Transition from Autocracy" (Pediatrics. 1992;90:50-57). It was realistic but refreshing and very useful to young academic people contemplating chairmanship positions.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: RILEY HARRIS D.
Published: December 2021

To the Editor.—

I enjoyed the article, "The Changing Role and Responsibility of Chairmen in Clinical Academic Departments: The Transition from Autocracy" which appeared in Pediatrics (1992;90:50-57). It contains much of interest. It is hard to believe that Dr Brent has been chairman for some 26 years at Jefferson.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: GABBE STEVEN G.
Published: December 2021

To the Editor.—

I recently read an excellent article in the July issue of Pediatrics (1992;90:50-57). This paper, "The Changing Role and Responsibilities of Chairmen in Clinical Academic Departments: The Transition from Autocracy," contains many important lessons and guidelines. I was interested in reference 16 in that paper, which describes a faculty development form. When I pulled the abstract in Pediatric Research, the purpose of the form was described but not the form itself. Would Dr Brent be willing to share this form with me? I believe it would be extremely helpful, particularly in guiding our junior faculty.
Prolonged Clinical Use of a Heme Oxygenase Inhibitor: Hematological Evidence for an Inducible but Reversible Iron-Deficiency State
Authors: Kappas Attallah , Drummond George S. , Galbraith Richard A.
Published: December 2021

The heme oxygenase inhibitor tin (Sn4+)-mesoporphyrin, administered to two 17-year-old Crigler-Najjar type I patients during a 400-day study to lower plasma bilirubin levels, also produced changes, beginning ~50 days after initiation of treatment, in hematological and iron metabolism indices consistent with the development of iron deficiency anemia. These indices were responsive to iron supplementation and re verted to normal after termination of inhibitor treatment. Tin-mesoporphyrin enhances biliary heme excretion and inhibits intestinal heme oxygenase when administered orally or parenterally; the changes in blood indices could thus reflect, in part, blockade of heme catabolism and therefore of uptake of heme-derived iron, by intestinal epithelium. This action of the inhibitor suggests that such agents may facilitate studies involving aberrant metabolism of heme-derived iron in humans and that they merit further investigation with respect to their potential value in enhancing iron disposal in certain disorders such as those related, for example, to transfusion-induced iron overload states.
Psychological Sequelae of Medical Complications During Pregnancy
Authors: Burger JoAnne , Horwitz Sarah McCue , Forsyth Brian W.C. , Leventhal John M. , Leaf Philip J.
Published: December 2021

To determine whether mothers with complicated pregnancies are at increased risk of postpartum depression and whether their children are at increased risk of being perceived as vulnerable, the investigators conducted an interview survey of mothers of 1095 children aged 4 to 8 in a community-based sample of primary care pediatric practices. The offspring were viewed as vulnerable by 17% of the women with severe pregnancy complications and 9% of the women without pregnancy complications (relative risk = 1.88; 95% confidence interval = 1.11, 2.63). Women with a severe complication of pregnancy were significantly more likely to report postpartum depression than those without a complication (27% vs 11%; relative risk = 2.45; 95% confidence interval = 1.55, 3.01). These relationships persisted after adjustment for prematurity, neonatal hospitalization, and demographic factors. It is concluded that pregnancy complications may place a woman at increased risk of postpartum depression and may have important effects on a mother's long-term perceptions of her child's vulnerability to illness.
Endotracheal Administration of Tolazoline in Hypoxia-Induced Pulmonary Hypertension
Authors: Curtis Jerri , O'Neill J. Timothy , Pettett Gary
Published: December 2021

Study objective. To compare the pulmonary and systemic vascular responses to intravenously (IV) and endotracheally (ET) administered tolazoline (Tz) in newborn lambs with hypoxia-induced pulmonary hypertension.

Design. Randomized, controlled study design.

Methods. Twenty lambs, 2 to 7 days of age, were anesthetized, intubated, and surgically catheterized for continuous physiologic monitoring and cardiac output meassurements using radiolabeled microspheres. After a postoperative stabilization period, the lambs were ventilated with a hypoxic gas mixture which was titrated to increase mean pulmonary artery pressure (MPAP) 30% to 50% above baseline. Each animal was randomly assigned to receive either IV-Tz (2 mg/kg), ET-Tz (4 mg/kg), or ET-saline (Sal, control group).

Results. ET-Tz significantly (P < .05) reduced MPAP, PVRI (pulmonary vascular resistance index), MPAP/mean artery pressure (MAP) and PVRI/systemic vascular resistance index (SVRI), but not SVRI. IV-Tz lowered (P < .05) MPAP, PVRI, and PVRI/SVRI but also produced significant reductions in MAP and SVRI while only transiently decreasing MPAP/MAP. MPAP/MAP and PVRI/SVRI ratios were consistently lower in the ET-Tz animals than either the IV-Tz or ET-Sal animals.

Conclusions. Our results suggest that ET-Tz produced a more selective pulmonary vascular response than IV-Tz and may warrant further investigation for potential clinical applications.
Ceftriaxone for Otitis Media
Authors: BRAUER HOWARD
Published: December 2021

To the Editor.—

I am responding to the article about the use of ceftriaxone for acute otitis media published by Green and Rothrock in Pediatrics in January 1993.1

Although the results of treatment using intramuscular ceftriaxone were comparable with those using oral amoxicillin, and parent response to this was highly favorable, the use of ceftriaxone for this indication is grossly inappropriate.

In recent years, the emergence of resistant strains of microorganisms has become a very serious problem.
Controlled Trial of Oral Prednisone in the Emergency Department Treatment of Children With Acute Asthma
Authors: Scarfone Richard J. , Fuchs Susan M. , Nager Alan L. , Shane Steven A.
Published: December 2021

Background. Recent studies have shown that the use of parenteral corticosteroids in the emergency department decreases the hospitalization rate for patients with acute asthma. We studied the efficacy of oral corticosteroids in the emergency department treatment of moderately ill children with acute asthma.

Methods. Emergency department patients aged 1 through 17 years whose chief complaint was acute asthma were assigned a pulmonary index, based on clinical evaluation. Those with a moderate exacerbation (pulmonary index = 9 through 13) received either 2 mg/kg of oral prednisone or placebo in a randomized, double-blind fashion. Patients in each group were then treated with an identical regimen of frequent aerosolized albuterol, for up to a maximum of 4 hours.

Results. Seventy-five patients were assessed. Overall, 11 (31%) of 36 in the prednisone group required hospitalization compared with 19 (49%) of 39 in the placebo group (P = .10). Among the sickest patients (initial pulmonary index > 10), 7 (32%) of 22 prednisone-treated patients required hospitalization compared with 13 (72%) of 18 placebo-treated patients (P < .05). Among patients who had a suboptimal response to initial β2-agonist therapy and who therefore would have been hospitalized had treatment been restricted to 2 hours, 9 (45%) of 20 in the prednisone group ultimately required hospitalization when duration of care was extended 2 additional hours compared with 15 (83%) of 18 in the placebo group (P < .05). In addition, prednisone-treated patients had a significantly greater improvement in median pulmonary index (5.0 vs 3.0, P < .001).

Conclusions. These data demonstrate that oral prednisone, within 4 hours of its administration, reduced the need for hospitalization among a subset of children treated in the emergency department for acute asthma.
COMPETING FOR LESS MONEY—THE FUTURE IS HERE
Authors: L. J. F.
Published: December 2021

Strong interest in a contest for which less money is the prize reflects the scramble taking place among hospitals for an edge in an increasingly competitive market. In the 1980s, administrators recouped losses from skimpy Medicare reimbursements by jacking up prices to corporate and other private customers. Now, big companies and business coalitions are squeezing hospital margins by negotiating volume discounts. At the same time, a glut of empty hospital beds in most cities is intensifying competition for patients. Hospitals that can't deliver cost-effective care will be losers in this decade—and so will the doctors affiliated with them.
Cardiomyopathy From Ipecac Administration in Munchausen Syndrome by Proxy
Authors: GOEBEL JENS , GREMSE DAVID A. , ARTMAN MICHAEL
Published: December 2021

In the United States, serum of ipecac is the emetic of choice in poisoning victims if induction of vomiting is indicated. It is readily available without prescription and has been intentionally administered on a long-term basis in cases of self-abuse or abuse by caretakers. Signs and symptoms of chronic ipecac poisoning include protracted vomiting and diarrhea as well as skeletal and cardiac myopathy. We report two cases of ipecac cardiomyopathy due to Munchausen syndrome by proxy (MSBP) in children with longstanding vomiting and diarrhea.

CASE REPORTS

Case 1

At the age of 29 months, a white, previously healthy boy doveloped appendicitis and underwent appendectomy.
Trends in AIDS Epidemic
Authors: SHORR ANDREW F.
Published: December 2021

Futterman et al provide interesting insight into the spread of the human immunodeficiency virus (HIV) among adolescents in New York City and into the impact the acquired immunodeficiency syndrome (AIDS) has had on this population. In their conclusion, however, they misrepresent the data regarding HIV and AIDS among youth. More specifically, they write, "Reported AIDS cases among adolescents increased by over 77% over the past two years. . ."

By using cumulative percent data for AIDS cases, they distort the true picture. The actual data reveal that the number of AIDS cases in this population has dropped during the past year.
In Reply: Trends in AIDS Epidemic
Authors: FUTTERMAN DONNA
Published: December 2021

Andrew Shorr's letter addresses the question of the appropriate methods for describing trends in the HIV epidemic among adolescents. Although we stand by the statement that cumulative AIDS cases among adolescents aged 13 to 19 years increased 77% from the end of 1989 (n = 449) through the end of 1991 (n = 787), we agree that annual trend data are also important in understanding epidemics and disease transmission. It should be noted that there is both a lag in reporting AIDS cases and undereporting, so the decrease in 1991 may be artifactual. However, the important fact is that relying only on incident AIDS case data among adolescents may be misleading and underestimate the problem.
The Principles for Family-Centered Neonatal Care
Authors: Harrison Helen
Published: December 2021

As the author of The Premature Baby Book (St Martin's Press, 1983), I have received hundreds of letters and telephone calls over the past decade from parents of babies treated in neonatal intensive care units (NICUs). Many of these parents express unqualified gratitude for the skilled staff and new technologies that saved the lives of their children. Others, however, voice concern, even anguish, over the way they and their babies were treated in the NICU. These parents tell of difficulties obtaining accurate information about their babies' conditions, treatments, and prognoses; of parental exclusion from medical and ethical decision-making; of the overtreatment of marginally viable babies and the undertreatment of babies' pain; of concerns about the relentless nursery environment and the use of poorly validated therapies; of unnecessary impediments to the nursing and nurturing of babies in the NICU; and of frustration over inadequate discharge planning, follow-up, and services for NICU survivors.4-16

In 1991 I sent some letters and articles that I had received from these parents to Dr Jerold Lucey, Editor of Pediatrics. Dr Lucey immediately proposed that the two of us convene a conference in which a small group of parents and physicians could discuss the problems described by parents and explore possible solutions.

At Dr Lucey's request, I assembled a group of articulate parents who were knowledgeable about the NICU from personal experience and from their work in support organizations, disability rights groups, and hospital ethics committees. Because I wanted a group that would be sympathetic to the concerns of medical professionals, I made an effort to choose parents with a background in health care or with a spouse or close family member in the medical profession.
Effects of Biological and Social Factors on the Cognitive Development of Very Low Birth Weight Children
Authors: Weisglas-Kuperus Nynke , Baerts Wim , Smrkovsky Mila , Sauer Pieter J.J.
Published: December 2021

Objective. To investigate the effects of biological and social factors on the cognitive development of very low birth weight children, a longitudinal follow-up study was conducted from birth to 3.6 years of age.

Methodology. The study group consisted of a cohort of 79 surviving high-risk, very low birth weight infants. Neonatal cerebral ultrasonographic findings and a neurological score were used as indicators of biological risk. A sociodemographic risk score and the Home Observation for Measurement of the Environment inventory were used as indicators of social risk. Cognitive development was assessed at ages 1 and 2 years by the Mental scale of the Bayley Scales of Infant Development and at age 3.6 years by the Kaufman Assessment Battery for Children.

Results. The mean mental index at 1 year of age was 96 (SD 19), at 2 years of age 86 (SD 26), and at 3.6 years of age for intelligence 87 (SD 13) and for achievement 86 (SD 14). In a stepwise multiple regression analysis of biological as well as social factors, the neurological score alone was the best predictor for cognitive development at 1 year of age, explaining 46% of the variance. From 2 years of age onward, the best predictors for cognitive development were the neurological score together with the home environment, explaining 46% of the variance for the Mental Developmental Index at age 2, 34% for intelligence, and 56% for achievement at age 3.6.

Conclusions. Children at high biological risk were able to catch up on their cognitive delay in a highly stimulating home environment. Children at low as well as high biological risk in a less stimulating home environment showed a decline in cognitive development. For these children, early intervention programs might be important in the prevention of cognitive disabilities.
Prevalence of Cerebral Palsy: Estimations, Calculations and Neonatal Care
Authors: Sola Augusto , Piecuch Robert E.
Published: December 2021

Dr Bhushan et al1 published a very interesting article in the June issue of Pediatrics which should be helpful in planning for health care delivery to patients with cerebral palsy. We have performed further analysis on the estimations and calculations they reported and would like to make some comments and add some results with a somewhat different perspective.

Prevalence has been classically defined as the "percent of a population being studied that is affected with a particular disease at a given time"2 or as "the ratio between the number of people who have the disease at one point in time with the number of people at risk at that time."3
Letter to the Editor
Authors: Hoberman Alejandro , Wald Ellen R.
Published: December 2021

Dr Murray correctly points out that the concerns of office-based pediatricians regarding regulations imposed by the Clinical Laboratory Improvement Amendments (CLIA) and Occupational Safety and Health Administration (OSHA) greatly affect the likely implementation of "new laboratory procedures" within the private practice sector. Although these regulatory agencies, on the one hand, intend to assure quality control when evaluating specimens and on the other hand, safety for patients and employees, they are often perceived as obstacles to effective care.
Controversies Concerning Vitamin K and the Newborn
Authors: Israels L. G.
Published: December 2021

The vitamin K Ad Hoc Task Force1 recommends that vitamin K1 be administered as a single intramuscular dose of 0.5 to 1.0 mg as prophylaxis for hemorrhagic disease of the newborn. This dose is based on the fact that it corrects the prolonged prothrombin time and has been in general use in North America for more than 40 years. It also undoubtedly has reduced the incidence of hemorrhage which may be a fatal or disabling event.
Vigintiphobia, Unbound Bilirubin, and Auditory Brainstem Responses
Authors: Funato Masahisa , Tamai Hiroshi , Shimada Seiichi , Nakamura Hajime
Published: December 2021

Objective. The management of nonhemolytic hyperbilirubinemia in term newborns is controversial. To evaluate the usefulness of serum unbound bilirubin concentrations (UBCs) in the management of hyperbilirubinemia, we compared the concentrations with abnormal auditory brainstem responses (ABRs).

Methods. ABRs and serum UBCs in 37 hyperbilirubinemic term newborns (total bilirubin concentrations [TBCs] ≥20 mg/dL and direct bilirubin concentrations <2 mg/dL) were measured before treatment with either phototherapy or exchange transfusions. Eight of these newborns had blood incompatibilities. These hyperbilirubinemic newborns were divided into three groups according to the findings of ABR: group A, normal ABR (n = 18); group B, prolonged latency of wave I only (n = 8); and group C, prolonged interpeak latency of wave I-III/I-V and/or poor amplitude (n = 11).

Results. The peak TBC was significantly different between groups A and C (22.8 ± 2.2 mg/dL and 25.4 ± 2.5 mg/dL, respectively; P < .05), though there were no differences between groups A and B and between groups B and C. The peak UBCs in groups B (1.27 ± 0.7 µg/dL) and C (1.34 ± 0.37 µg/dL) were significantly higher than in group A (0.78 ± 0.26 µg/dL) (P < .05 and P < .01, respectively), though there was no significant difference in the peak UBC between groups B and C. Abnormal ABR findings were more clearly associated with the level of UBC at 1.0 µg/dL than that of TBC at 23 mg/dL by multiple logistic regression analysis (odds ratio 16.6, P = .0026, vs 4.2, P = .1272).

Conclusions. These results suggest that measuring UBC may help in evaluating the possible risk of bilirubin encephalopathy in full-term newborns when there is vigintiphobia (fear of 20).
Theoretical Cost Effectiveness of Management Options for Children With Persisting Middle Ear Effusions
Authors: Berman Stephen , Roark Robert , Luckey Dennis
Published: December 2021

Objective. The purpose of this theoretical study is to assess the cost effectiveness of options involving observation, antibiotics alone, corticosteroids alone, corticosteroids plus antibiotics, and surgery to clear persisting middle ear effusions during three visits.

Methodology. In a hypothetical case the expected average per patient expenditures are calculated using the efficacy rates determined by the meta-analysis of randomized controlled clinical trials involving corticosteroids plus an antibiotic (six trials), corticosteroids alone (three trials), and antibiotic alone (four trials). In this analysis, all children whose bilateral middle ear effusions persist for 12 weeks despite medical management are referred for ventilating tubes.

Results. The most cost-effective intervention combination is corticosteroid plus an antibiotic at visit 1 (6 weeks after diagnosis of acute otitis media) followed by a second antibiotic in nonresponders at visit 2 (9 weeks after diagnosis of acute otitis media) and referral for ventilating tubes in nonresponders at visit 3 (12 weeks after diagnosis of acute otitis media). The expected average expenditures per case to clear the bilateral middle ear effusions is $600.91 based on reimbursement of private practice charges and $350.27 based on Medicaid reimbursement (all payments to providers are based on 1992 data from Colorado). The difference in the expected average total expenditures per case between this most cost-effective approach versus the use of sequential courses of antibiotics followed by surgery is $372.81 ($973.72 - $600.91) with full reimbursement of private practice charges and $202.57 ($552.84 - $350.27) with Medicaid re imbursement. In clearing the middle ear effusion, the average estimated travel expenses per case is $21.46, and lost parental wages per case are $45.12. When the expenditures associated with an additional 6-month follow-up period are included, the expected average per case expenditures is $1088.54 with reimbursement of private practice charges and $659.00 with Medicaid reimbursement. The difference in the expected average per case expenditures to clear the effusions and follow-up for 6 months between the most cost-effective approach using corticosteroids plus antibiotics at the 6- and 9-week visits followed by surgery in nonresponders at 12 weeks versus sequential courses of antibiotics is $405.30 ($1493.84 - $1088.54) with reimbursement of private practice charges and $217.32 ($876.32 - $659.00) with Medicaid reimbursement.

Recommendations. Although the analysis does not consider risks, side effects, and parental or provider preferences, the findings suggest that the implementation of cost-effective clinical guidelines can potentially reduce national expenditures for managing persistent middle ear effusions.
Pain Relief Can Reduce Hypoxemia in Distressed Neonates During Routine Treatment Procedures
Authors: Pokela Marja-Leena
Published: December 2021

Objective. To determine whether the use of opioids could reduce the hypoxemia and hemodynamic instability associated with routine intensive care procedures in neonates with respiratory distress.

Design. Randomized and placebo-controlled study.

Methods. Physiological, plasma β-endorphin, cortisol, and glucose responses to routine treatment procedures were studied in 84 mechanically ventilated distressed neonates randomized into groups receiving 1 mg/kg meperidine or 0.9% saline 15 minutes before tracheal suction or routine nursing care.

Results. The duration of hypoxemia (transcutaneous partial pressure of 02 <6.6 kPa (<50 mm Hg) and/or arterial blood oxygen saturation <80%) during treatment procedures was significantly longer in the saline group (mean 82 vs 36 seconds, P = .001) and distress quantified by a novel behavioral scoring method was much higher. Changes in arterial blood pressure, heart rate, or plasma β-endorphin, cortisol, and glucose concentration did not show any statistically significant differences between the groups.

Conclusion. Newborns with respiratory difficulties often suffer from hypoxemia during essential treatment procedures. The use of opioid analgesia may reduce the duration of hypoxemia and the associated distress and, therefore, may improve the long-term results of neonatal intensive care.
Prospective, Controlled Study of Developmental Outcome in Survivors of Extracorporeal Membrane Oxygenation: The First 24 Months
Authors: Wildin Susan R. , Landry Susan H. , Zwischenberger Joseph B.
Published: December 2021

Objective. Survivors of venoarterial extracorporeal membrane oxygenation (ECMO) are considered to be at risk for developmental disabilities, but there are few controlled outcome studies. A prospective, controlled study of outcome was performed to quantify the degree and frequency of developmental disabilities in ECMO survivors compared with a matched control group.

Methods. From May 1987 through November 1990, 40 of 47 neonates treated with ECMO survived at the University of Texas Medical Branch in Galveston. Longitudinal developmental data were collected, using the Bayley Scales of Infant Development, on 22 ECMO infants and 29 healthy term control infants at 6, 12, and 24 months. Language was assessed at 24 months using the Sequenced Inventory of Communication Development. An additional 13 ECMO infants had developmental data for at least one time point.

Results. Healthy term infants performed significantly better than ECMO infants on the Bayley Scales of Infant Development at 6 and 24 months and on the Sequenced Inventory of Communication Development at 24 months. Mean scores of ECMO infants were well within the average range and 77% of the ECMO infants were developmentally normal.

Conclusions. These data suggest that early developmental morbidity in ECMO survivors is low, considering the severity of their neonatal illness.
Excess Fruit Juice Consumption as a Contributing Factor in Nonorganic Failure to Thrive
Authors: Smith Melanie M. , Lifshitz Fima
Published: December 2021

Objective. To determine whether excessive consumption of fruit juice is a contributing factor in nonorganic failure to thrive in early childhood.

Methods. Eight patients, aged 14 to 27 months, referred for failure to thrive were evaluated by medical history, physical examination, and biochemical assessment. Growth patterns were reviewed and anthropometric measurements including skinfold thickness and midarm circumference were obtained. Diet history included 3-day food records and 24-hour diet recalls. An open-ended interview explored factors associated with fruit juice consumption. Breath hydrogen testing of fructose, sorbitol, or fruit juice was performed in three children who had a history of diarrhea or gastrointestinal complaints. Nutritional intervention focused on reducing fruit juice consumption and increasing the energy and nutrient density of the children's diets.

Results. In each case, deterioration of weight and linear growth progression coincided with excessive juice consumption. All children exhibited weights <5th percentile and five also had lengths <-5th percentile. Weight-for-length deficits ranged from 11% to 25%. Two patients demonstrated low arm muscle mass and five children had diminished fat stores. Organic disease was ruled out in all cases. Three children had iron deficiency. The children's diets were hypocaloric, providing 78% to 92% of recommended energy intake for age and weight. Dietary intake included considerable juice consumption (12 to 30 oz/d). Fruit juice, primarily apple juice, contributed 25% to 60% of daily energy intake. As a result, food consumption was reduced; lowering dietary protein, fat, and micronutrient intakes. Excessive juice was consumed for various reasons including children's preferences, parental health beliefs, behavioral feeding difficulties, and financial considerations. Breath hydrogen testing revealed malabsorption of fructose and/or sorbitol. After nutritional intervention, dietary intake increased to 96% to 116% of recommended intakes. Weight gain increased significantly in the first month and persisted for follow-up of 5 to 18 months.

Conclusions. These findings indicate that large intakes of fruit juices may displace more calorie- and nutrient-dense foods. Additionally, fructose and sorbitol malabsorption may occur. Excess fruit juice consumption may present a contributing factor in nonorganic failure to thrive.
THE HEALTH PLAN MISSES THE POINT
Authors: L. J. F.
Published: December 2021

It is often difficult for laypeople to appreciate that good medicine does not reduce the percentage of people with illnesses in our population; it increases that percentage. There are proportionally more people in the United States with arteriosclerotic heart disease, diabetes, essential hypertension and other expensive chronic diseases than there are in Iraq, Nigeria or Colombia. Good medicine keeps sick people alive ...

The vast expansion of the concept of health can be demonstrated in surgery, orthopedics, mental health, gynecology—indeed, in any field of medicine. People do not have operations on their knees or elbows merely to continue to be employable, for example; most of us do not work at jobs requiring physical strength. Many such operations are performed strictly so that the patient can continue to lead a "normal" life, to be able to play golf or ski. Are these justifiable medical expenses? If one is free of pain except on the tennis court, is one "ill"? ...

We are also wrong to assume that medical technology, like CD players and personal computers, will become cheaper as the industry matures. When what is being improved is life expectancy, all the rules change; people are willing to pay substantially more money for relatively minor improvements. Medical technology will therefore continue to be expensive simply because it pays for companies to market a 5 percent improvement even though it might be 100 percent more expensive.