bluuebunny/crossref_metadata_2025 huggingface dataset:
Sleep Problems in Early Childhood: Continuities, Predictive Factors, and Behavioral Correlates
Authors: Zuckerman Barry , Stevenson James , Bailey Veira
Published: December 2021

A longitudinal study, based on interviews with 308 middle-class, preponderantly white mothers, provided an opportunity to evaluate the continuity, predictive factors, and behavioral correlates of sleep problems in young children. When their children were 8 months old, 10% of the mothers reported that their babies woke three or more times per night, 8% reported that the babies took an hour or more to settle after waking, 5% complained that their own sleep was severely disrupted by the child, and 18% reported at least one of these problems. At 3 years of age, 29% of the children had difficulty getting to bed and/or falling asleep or staying asleep. Of children with a sleep problem at 8 months of age, 41% still had a problem at 3 years of age, whereas only 26% of children without a problem at 8 months of age had a problem at 3 years of age (P < .001). Among children with sleep problems at 8 months of age, mothers' depressed feelings were the only measured demographic or psychosocial factor associated with persistent sleep problems (P = .02). A separate analysis indicated that these depressed feelings did not appear to be a consequence of the child's sleep problem. Future studies should evaluate how maternal depression interacts with other factors to result in persistent sleep problems. Children with persistent sleep problems were more likely to have behavior problems, especially tantrums (P < .02) and behavior management problems (P < .01), than were children without persistent sleep problems (P < .02). They were not more likely to have fears, anxiety, or other behavior problems measured by the Behavior Screening Questionnaire.
Defecation Dynamics and Behavior Profiles in Encopretic Children
Authors: Loening-Baucke Vera , Cruikshank Brenda , Savage Cassie
Published: December 2021

The social competence and behavioral profiles of 38 encopretic children were evaluated, and the social competence and behavioral ratings were correlated with physiologic abnormalities found during anorectal manometric and EMG evaluation and with treatment outcome. When defecation was studied, 66% of encopretic children were not able to defecate rectal balloons and 63% were not able to relax the external anal sphincter during defecation attempts. Total social competence and behavior problem scores were not different for boys able and unable to defecate balloons. Total social competence scores were significantly lower in girls unable to defecate balloons than in those able to (P < .006), whereas behavior problem scores were similar in girls able to and unable to defecate. We found that persistence of encopresis at 6-month and 12-month follow-up was not related to the social competence (P > .2) or behavioral scores (P > .2) but was significantly related to the inability to defecate (P < .01) and to the inability to relax the external sphincter during defecation attempts (P < .03).
Clinical Spectrum of Intrinsic Renovascular Hypertension in Children
Authors: Daniels Stephen R. , Loggie Jennifer M. H. , McEnery Paul T. , Towbin Richard B.
Published: December 2021

In the past two decades, 853 children and adolescents have been evaluated for elevated BP as inpatients and outpatients by the hypertension service at Children's Hospital Medical Center, Cincinnati. Most children with hypertension secondary to coarctation of the aorta and all children with glomerulonephritis are managed by other services and are not included in that total. In a retrospective study, 27 children (3%) were identified as having hypertension secondary to intrinsic renal arterial stenosis. The age at presentation ranged from 5 months to 20 years. The mean BP at that time was 171.6/114.2 mm Hg. Ten categories of causes were identified, including fibromuscular dysplasia, arteritis, Williams syndrome, neurofibromatosis, congenital malformations, blunt abdominal trauma, surgical vascular trauma-irradiation, thrombosis, congenital rubella syndrome, and unknown. Overall, symptoms were notcommon. However, findings of end-organ response, such as left ventricular hypertrophy and retinal vascular abnormalities were prevalent. This is not surprising given the mean BP level at presentation. Physical examination, laboratory tests, and radiologic evaluations (exclusive of renal angiography) were not useful in detecting or identifying the location and extent of the renovascular lesions. Fourteen patients were treated surgically, and 13 were managed medically. The outcome was variable for both treatment modalities. The management of renovascular hypertension in children must be individualized depending on the cause, location, and severity of the lesion, as well as the size of the child. Some forms of renovascular pathology, particularly the arteritides, may resolve spontaneously, and children with these entities should have their BP treated medically until the inflammatory process has subsided. In selected patients, surgery often decrease the BP and may lead to a cure. However, a successful outcome is by no means assured.
Preparing Residents for the Doctor Denver
Authors: GARGAS DONALD C.
Published: December 2021

At 10 weeks she could grasp a rattle, at 6 months she imitated speech sounds, and at 2 years she pedaled her first tricycle. She had aced the Denver Developmental Screening Test.

Now, at age 30 years, she is about to face yet another growth and development hurdle: The Doctor Denver. Will she ace it again? Or could there be a "delay"?

She is verbal, assertive, confident, current, and highly skilled. The newly trained, board-eligible physician represents high-tech, state-of-the-art medicine. But how well prepared, as a person, is the young physician to make the critical transition from university medicine to community practice?
Pediatrics and Poverty
Authors: GRAHAM GEORGE G.
Published: December 2021

To the Editor.—

In his commentary on "Pediatrics and Poverty" (Pediatrics 1987;79:567-569), Dr Oberg expresses alarm about the increase in the percentage of children defined as living in poverty, being "malnourished," being homeless, and lacking health insurance. He quotes assertions about "an increasing incidence of low birth weight and preterm infants, failure to thrive, and an increase in infant mortality." This "grim situation" is attributed to "the severe recession of the early 1980s," to "recent budgetary reductions which we have witnessed during the last 4 to 5 years," and to the "reduction since 1981" in "low-income benefit programs."
Larger Numbers Needed
Authors: ALTSCHUL MARTIN S.
Published: December 2021

To the Editor.—

In a letter to Pediatrics Cunningham1 suggested that there might be methodologic problems with the study of urinary tract infection and circumcision by Wiswell et al.2 Wiswell responded with further retrospective data.3,4 In an effort to shed more light on this subject, I have collected data on all cases of infants younger than 1 year of age with urinary tract infection admitted to Northwest Region Kaiser Foundation Hospitals from 1979 through 1985.
Transcutaneous Arterial Oxygen Tension and Retrolental Fibroplasia
Authors: WILLARD D. , MESSER J.
Published: December 2021

To the Editor.—

According to Rooth et al1 transcutaneous monitoring of the newborn gives a reliable indication of arterial oxygen tension, if correctly used. We have evidence2 confirming such a point of view, often considered as controversial in the United States. Since 1980, we have used this system of monitoring, without any additional blood control, on every oxygen-dependent newborn treated in our neonatal care unit with few exceptions.

From January 1980 to July 1986, 1,672 premature infants (approximately one third of whom weighed less than 1,500 g) were assessed by means of indirect ophthalmoscopy to rule out classical forms of retinopathy.
Tracking of Body Composition Variables
Authors: Harsha David W. , Smoak Carey G. , Nicklas Theresa A. , Webber Larry S. , Berenson Gerald S.
Published: December 2021

Height, weight, and skinfold measurements were obtained on a cohort of 447 children from birth (weight) or 6 months of age (height and skinfold) and monitored yearly thereafter until 7 years of age. At age 7 years, 250 remained for follow-up screening. A significant degree of tracking was found for all variables from age 1 to age 7 years. Height and weight tracked most strongly (age 1- to 7-year correlations = .42 and .44, respectively), whereas skinfold tracked somewhat lower (.28). Earlier levels of each anthropometric variable were the best predictor of later levels of that parameter. Implications for early detection and treatment of growth abnormalities are discussed.
Blood Pressure
Authors: Burke Gregory L. , Voors Antonie W. , Shear Charles L. , Webber Larry S. , Smoak Carey G. , Cresanta James L. , Berenson Gerald S.
Published: December 2021

BP was measured in 440 children followed longitudinally from birth to 7 years of age in Bogalusa, LA. Levels, trends, and determinants of BP were evaluated in this newborn cohort. Both systolic and diastolic BP levels remained relatively constant between the ages of 6 months and 7 years. BP levels varied between the different instruments, and differences were also noted between measures obtained using the same instrument before and after venipuncture. White children were noted to have slightly higher levels of systolic and diastolic BP pressure at 6 months and 1 year of age, even after adjustment for body size. Significant prediction of year 7 BP rank occurred as early as 6 months of age for systolic and at 1 year of age for diastolic BP levels. Body size was inconsistently related to BP levels from ages 6 months through 4 years, but the relationship was stronger and more consistent with changes in body size. Of interest is the relatively constant levels of indirect BP during this period of rapid growth, as measured by currently available instruments. These data emphasize the importance of cardiovascular risk factor measurement during early life and of the need to improve methods of indirect BP measurement in infancy.
Coronary Artery Involvement in Kawasaki Syndrome in Manhattan, New York: Risk Factors and Role of Aspirin
Authors: Ichida Fukiko , Fatica Nunzia S. , Engle Mary Allen , O'Loughlin John E. , Klein Arthur A. , Snyder Michael S. , Ehlers Kathryn H. , Levin Aaron R.
Published: December 2021

Since January 1980, 110 children having 113 attacks of Kawasaki syndrome were studied. Age at onset was 7 weeks to 12 years (mean 36/12 years, median 29/12 years); 77% were younger than 5 years of age; the male to female ratio was 1.8; racial distribution was 52% white, 19% black, 14% Hispanic, and 16% Asian. Protocol of management consisted of high-dose aspirin (100 mg/kg/d) until afebrile, and then 81 mg every day until free of coronary aneurysm. Two-dimensional echocardiograms were done weekly during the acute stage, at 2 and 6 months after onset, and yearly if a coronary abnormality was detected. At 1 month, 51 coronary arterial abnormalities were present in 25 patients. Risk factors for a coronary abnormality were duration of fever greater than or equal to 2 weeks, level of platelet count, marked elevation of ESR, and age younger than 5 years. No statistically significant difference in incidence of aneurysms was detected between patients on high-dose aspirin and those on medium- or low-dose aspirin.
Long-Stay Pediatric Intensive Care Unit Patients: Outcome and Resource Utilization
Authors: Pollack Murray M. , Wilkinson James D. , Glass Nancy L.
Published: December 2021

Outcome, resource utilization, and health care characteristics of patients staying in a multidisciplinary pediatric intensive care unit (PICU) for more than 13 days (long-stay patients) were analyzed. Of 647 children admitted consecutively, 46 were long-stay patients. Compared with short-stay patients, long-stay patients were significantly younger and sicker and had a higher incidence of chronic disease. Most important, long-stay patients had significantly higher PICU mortality rates (17.4% v 7.3%, P < .05) and hospital mortality rates (23.9% v 8.7%, P < .01) than short-stay PICU patients. Although only 7.1% of the patient sample, long-stay patients consumed approximately 50% of all PICU resources. One-year follow-up on those long-stay patients surviving their hospitalization revealed that 58% had died or were severely disabled. Long-stay patients had relatively poor prognoses and consumed health care resources in excess of their numeric proportions.
Growth of Immigrant Children in the Newcomer Schools of San Francisco
Authors: Schumacher Laurie B. , Pawson I. Guy , Kretchmer Norman
Published: December 2021

A semilongitudinal study on growth and development was initiated on immigrant and refugee school-aged children in San Francisco. Anthropometric values (height, weight, arm circumference, and triceps and subscapular skinfolds) were collected soon after their arrival in the United States and repeated at 3-month intervals for 1 year. Data were analyzed by age-gender cohorts. z Score calculations for measures of height-for-age, weight-for-age, and weight-for-height demonstrated a significant overall deficiency in height-for-age and weight-for-age at the time of the first measurement. Comparisons with a US standard indicated that most of the children were between the fifth and 25th percentiles in these measures. There were fewer children who were significantly deficient in weight-for-height. Calculations for median growth rate indicated that most cohorts exhibited a median growth velocity that was close to or exceeded the median for US white children. There was also significant improvement in weight-for-age. The results indicated that these immigrant and refugee children accelerated their growth markedly in an optimum nutritional environment and were in a period of catch-up growth.
Sociocultural Perspective on Child Occupant Protection
Authors: Foss Robert D.
Published: December 2021

During the past decade substantial effort has been devoted to increasing the use of child safety restraints. This has involved educational programs and, more recently, legislation mandating restraint use by children. Neither of these approaches has had major documented effects on proper restraint use. Misuse is currently high and use decreases dramatically among toddlers and older children. It is maintained that the complexity of the problems of nonuse and misuse has not been fully recognized. A more comprehensive perspective on the issue is presented, focusing on the social and cultural issues involved in attempting to change parental behavior regarding their children's use of restraints. A structured approach to programs for the promotion of safety restraint use suggested by this perspective is presented, highlighting actions that are already being taken and those that need to be taken to develop a comprehensive attack on both nonuse and misuse of safety restraints.
Naproxen-Associated Renal Failure in a Child With Arthritis and Inflammatory Bowel Disease
Authors: Laxer Ronald M. , Silverman Earl D. , Balfe J. Williamson , Poucell S. , Baumal Reuben
Published: December 2021

Renal failure occurred in a 14-year-old girl with peripheral arthritis associated with inflammatory bowel disease while she was being treated with naproxen. She had previously received aspirin and tolmetin sodium and had no complications. A renal biopsy showed a severe tubulointerstitial nephritis. Although her renal function improved somewhat with corticosteroid treatment, it worsened when the steroids were discontinued. This case emphasizes that renal failure can develop insidiously in children on nonsteroidal anti-inflammatory drug therapy and that such children must be monitored closely for signs of nephrotoxicity.
Ascendency of the Black Bottle (Activated Charcoal)
Authors: GREENSHER JOSEPH , MOFENSON HOWARD C. , CARACCIO THOMAS R.
Published: December 2021

Previous well-established guidelines for the management of poisonous ingestions in children are undergoing significant change. The time-honored practice of syrup of ipecac-induced vomiting as the primary means of gastrointestinal decontamination now frequently yields to the administration of activated charcoal. Practitioners and emergency room physicians who are increasingly relying on advice from and participation in treatment by regional poison control centers need to understand the rationale behind what many consider contradictions to accepted teaching.

A case in point was a recent letter to the American Academy of Pediatrics from a pediatrician questioning the treatment of an ingestion of poison in a toddler.
Care Practices and Bronchopulmonary Dysplasia Debate
Authors: KELLER JACOB , AVERY MARY ELLEN
Published: December 2021

In Reply.—

We appreciate the opportunity to clarify the issues raised by Barry et al. We tested the significance of the differences among centers in the incidence of chronic lung disease, adjusted for sex, race, and birth weight, by computing two multiple logistic regression models. The first model included only sex, race, and birth weight as independent variables. The second model additionally included seven dummy variables representing the eight centers. Twice the difference in the log likelihoods in the two models has a χ2 distribution with 7 df under the null hypothesis of no center differences.
Adolescent Varicocele
Authors: KASS EVAN J.
Published: December 2021

In Reply.—

Until objective guidelines are established, I would be opposed to a more aggressive approach to the adolescent varicocele because not all of these children are at risk for future problems. At the present time, we are primarily concerned about individuals with a large varicocele, particularly when there is volume loss of the testis ipsilateral to the varicocele.

Surgical ligation of a large varicocele is routinely performed as a brief outpatient procedure with the aid of optical magnification to facilitate ligation of the multiple venous collaterals so often found in individuals with a large vanicocele.
Gastroesophageal Reflux Associated With Nemaline Myopathy of Infancy
Authors: Berezin Stuart , Newman Leonard J. , Schwarz Steven M. , Spiro Alfred J.
Published: December 2021

A severe infantile form of nemaline myopathy has a high mortality rate when untreated because of subsequent malnutrition and respiratory failure. Three infants with this condition demonstrated persistent vomiting, poor weight gain, and recurrent pneumonias. Esophageal manometry demonstrated decreased lower esophageal sphincter pressures and low amplitude peristalsis; 24-hour esophageal pH monitoring revealed significant gastroesophageal reflux. Medical therapy was ineffective in relieving symptoms. After antireflux surgery, vomiting and respiratory symptoms ceased, and there was no longer significant gastroesophageal reflux during pH monitoring. Our experience indicates that in some infants with nemaline myopathy a severe form of gastroesophageal reflux develops that is not responsive to medical therapy. Early surgical intervention may decrease life-threatening complications associated with gastroesophageal reflux in these infants.
Educational Late Effects in Long-Term Survivors of Childhood Acute Lymphocytic Leukemia
Authors: Peckham Virginia C. , Meadows Anna T. , Bartel Nettie , Marrero Osvaldo
Published: December 2021

Records of levels of school achievement in long-term survivors of childhood acute lymphocytic leukemia were obtained for 23 children who had received 2,400-rad cranial irradiation and intrathecal methotrexate and standard chemotherapeutic agents 8 to 10 years previously. The children had been evaluated with standardized tests of intelligence at the time of diagnosis and periodically thereafter. Declines in IQ and cognitive dysfunctions have been previously described. School placements, educational histories, attendance records, learning strengths and weaknesses, social/emotional adjustments, and grade level achievements in reading and mathematics as measured by standardized achievement tests are reported here. Children achieved less than the expected levels in both reading and mathematics given both pretreatment and most recent IQ scores. Neither sex nor initial IQ were related to achievement scores. Children experienced difficulty with attention/concentration, memory, sequencing, and comprehension when performing school tasks. Individual children showed different degrees of dysfunction, but results of this study suggest that there are patterns of specific learning disabilities rather than global retardation. A small number of children achieved greater than expected levels, indicating that individualized instruction, tutoring, and parental support may reduce some learning deficits. Early educational intervention is recommended for similarly treated patients.
Mediastinal Emphysema in an Adolescent With Anorexia Nervosa and Self-Induced Emesis
Authors: Overby Kim J. , Litt Iris F.
Published: December 2021

A case of asymptomatic pneumomediastinum in a 14-year-old girl with anorexia nervosa and self-induced emesis is reported to emphasize the atypical aspects of this case and the importance of differentiating benign from potentially life-threatening sources of mediastinal air. Individuals who engage in purging behavior are not only at increased risk for both alveolar (primary pneumomediastinum) and esophageal perforation (Boerhaave syndrome) but may also obscure or delay the diagnosis by denying symptoms and/or previous emesis. Because esophageal perforation is serious, the presence of free mediastinal air in a patient with a known or suspected history of emesis should provoke prompt radiographic evaluation of the upper gastrointestinal tract.
Glycoprotein Filament Removal From Human Milk Fat Globules by Heat Treatment
Authors: Buchheim Wolfgang , Welsch Ulrich , Huston Gail E. , Patton Stuart
Published: December 2021

Freeze-etch electron microscopy was applied to milk fat globules to observe surface details. A remarkable array of filaments, approximately 0.5 µm in length, was seen on human, but not bovine, globules. Heating human globules removed the filaments that were identified as high molecular weight glycoproteins by freezeetch and gel electrophoretic analysis of the heating medium. Extraction of these globule glycoproteins was slight at 60°C for one minute but substantial and tending to plateau at 80°C for one minute. Such heat-induced alterations of the milk fat globule surface provide an alternative or additional explanation to milk lipase inactivation as the cause of reduced milk fat absorption from heated milk by the preterm infant.
Religious Exemptions From Child Abuse Statutes
Authors:   Committee on Bioethics
Published: December 2021

Children sometimes die or become disabled when they fail to receive medical treatment because of the strongly held religious or philosophical beliefs or practices of their parents. The numbers of such incidents of neglect are hard to ascertain reliably, but there are increasingly frequent reports in the mass media. We believe the reported cases represent the most extreme examples of a larger problem. According to newspaper reports, the following are some specific cases that have come to recent attention: (1) A 4-year-old girl in Sacramento, CA, died of bacterial meningitis; her only treatment was spiritual healing by a Christian Science practitioner (Sacramento Bee, April 21, 1984). (2) Two children died of pneumonia and meningitis in Indiana. Both sets of parents were prosecuted for withholding medical care from their children. The parents belonged to the Faith Assembly, a sect that relies exclusively on faith healing (Medical World News, Oct 4, 1984). (3) A 2½-year-old boy died in Boston of bowel obstruction in April 1986 following five days of treatment by a Christian Science practitioner and nurse (Boston Globe, April 10, 1986). (4) A 16-month-old Santa Monica, CA, boy died of bacterial meningitis; his only treatment was prayer by a Christian Science practitioner. (Los Angeles Times, April 30, 1984). (5) Parents of a 13-month-old boy in Coshocton, OH, who died with bacterial (Streptococcus pneumoniae) pericarditis were tried and released because of religious exemption protection. The child had received no medical care because the parents were members of the Christ Assembly, a group that believes in healing by prayer (Columbia Citizen-Journal, June 15, 1984).
Call It Asthma
Authors: PLAUT THOMAS F. , JONES EMLEN H. , MARSH DAVID R. , GOTTSEGEN DAVID N.
Published: December 2021

To the Editor.—

The childhood wheezing season is here again. With it comes advice from many quarters for pediatricians to eradicate the symptoms with inhaled adrenergic drugs or theophylline, but "don't call it asthma." Call it a wheezing-associated respiratory illness,1 a wheezing problem, or bronchitis to avoid upsetting parents with the word "asthma."

We diagnose wheezing as asthma in almost every child older than 1 year of age in whom bronchodilators cause an abatement of symptoms or a 20% increase in the peak expiratory flow rate.
Meeting the Health Care Needs of Suburban Youth: Review of a Clinical Service
Authors: Fisher Martin , Marks Andrea , Trieller Katherine
Published: December 2021

The demographic and medical data from the first 1,000 patients registered at a suburban adolescent health service were reviewed and the findings compared with the results of an initial survey performed in the same community and other health services located in urban communities. Most of the patients were white (92%), girls (82%), and 16 to 18 years of age (63%) and had parents who graduated from high school (59%) or college (28%). They reported higher rates of participation in health-risk behaviors, including smoking (50%), drinking (60%), drug use (67%), and sexual intercourse (83%), than their peers. Seventy-two percent of the patients sought medical attention for sexuality-related or gynecologic concerns, including contraception (39%), pregnancy determination (20%), and evaluation of possible sexually transmitted disease (9%), and 28% sought attention for general medical or emotional needs, including checkups or immunizations (11%), nutritional or weight problems (4%), and emotional issues or substance abuse (4%). Management of sexuality-related issues differed from that reported in urban settings, whereas laboratory screening tests indicated that problems were similar to those in other settings. Many problems described in an initial survey of youth in the community were not seen at the adolescent health service. We conclude that a suburban-based health service may meet certain health care needs of the higher risk youth of the community but that ultimate care for adolescents remains with the private physicians in this setting.
Injuries to Children Younger Than 1 Year of Age
Authors: Rivara Frederick P. , Kamitsuka Michael D. , Quan Linda
Published: December 2021

The circumstances and characteristics of emergency room-treated injuries in children younger than 1 year of age were studied and unintentional injuries were compared with those caused by abuse. Unintentional injuries were seen 15 times more frequently in an emergency room than injuries caused by abuse. The majority of unintentional injuries were minor, although skull fractures and fractures of the clavicle did occur. In contrast, injuries caused by abuse were commonly multiple and severe and were more likely to result in long-term disability. Results of this study indicate that unintentional injuries are rarely serious and that closed head injury, rib or lower extremity fractures, and abdominal injuries are usually indicative of abuse.
Behavioral Pediatrics: A Time for Research
Authors: Haggerty Robert J.
Published: December 2021

There are many children with problem behaviors who are not being helped, in large measure because we do not know enough about the causes of their problems or the effectiveness of therapy for them. The study of office visits by Starfield et al1 demonstrated that at least 15% of children have psychosomatic problems and another 5% to 10% social and behavioral problems (Table 1). The cause and impact of these problems are like the interrelated layers of an onion, with biologic and social environmental forces interacting to ultimately affect the functioning of the child. These are not new problems. Although the term "the new morbidity" has been applied to many of them, most are not "new." In colonial times in America, one third of the women were pregnant at the time of their marriage. Premarital conception was an issue then as it is now. It is only the solution or consequences that are different today. The great frequency of these problems yesterday and today, the serious impact that they have, and the failure to treat or prevent most of these problems suggest that a major effort should be placed on research.

Advocating research does not mean that we should scrap current service programs as advocated by some2 or isolate the research worker from the stress and difficulty of coping with clinical problems and real people. Romano3 said, "clinical medicine is not a spectator sport," and I would add that clinical research in behavioral pediatrics cannot be a spectator sport but is best done by those who are actively caring for children with problem behaviors.
Pediatricians' Opinions of Mothers
Authors: Tellerman Kenneth , Medio Franklin
Published: December 2021

The purpose of this study was to determine factors that influence pediatricians' opinions of mothers. The degree to which mother-physician interactions, mother-child interactions, and maternal demographic variables influence pediatricians' opinions of mothers was assessed with a 54-item questionnaire. Questionnaires were mailed to 470 Chicago-based American Academy of Pediatrics Fellows; 268 (57%) of the questionnaires were returned and, of these, 230 were suitable for analysis. A majority of pediatricians reported that their opinions were "greatly" positively influenced by mothers who communicate clearly (60%), understand recommendations (56%), follow recommendations (68%), and keep appointments (58%). In comparision, significantly fewer pediatricians' opinions were "greatly" influenced by mothers who are friendly to them (38%) or who like them (34%) (χ2, P < .001). Pediatricians were also "greatly" influenced by mothers who seem safety conscious (67%), use car restraints (57%), and keep immunizations updated (61%). Female pediatricians, in contrast to men, were significantly more influenced by mothers who "respond to their crying infants" and who "try to calm an anxious child" (χ2, P < .05). Pediatricians' opinions of mothers appear to be greatly influenced by maternal compliance, communications skills, and cognitive abilities, as well as by mothers who promote health and safety. Affective variables such as friendliness seem less important. Female pediatricians appear more influenced by mothers who actively console their children.
Changing Patterns in the Diagnosis of Hypertrophic Pyloric Stenosis
Authors: Breaux Charles W. , Georgeson Keith E. , Royal Stuart A. , Curnow Adrian J.
Published: December 2021

The records of 216 infants who had surgical correction of hypertrophic pyloric stenosis between 1980 and 1984 at the Children's Hospital of Alabama were reviewed. A significant increase in the reliance on upper gastrointestinal roentgenographic series and abdominal sonography for confirmation of the diagnosis of hypertrophic pyloric stenosis was noted in our patients when compared to previous reports. Despite the preoperative presence of a palpable pyloric mass in 192 (89%) of the patients, 174 (81%) had a diagnostic imaging procedure. Similar high rates of imaging studies were noted when the records of patients with hypertrophic pyloric stenosis from 1980 and 1984 were reviewed at three other institutions. Palpation of a hypertrophied pylorus is diagnostic of hypertrophic pyloric stenosis. Careful physical examination makes diagnostic imaging unnecessary in the majority of infants with symptoms suggesting hypertrophic pyloric stenosis. Diagnostic imaging for suspected hypertrophic pyloric stenosis should be used only for those infants with persistent vomiting in whom careful and repeated physical examinations fail to detect a palpable pyloric mass.
Interaction of Iron Deficiency and Lead and the Hematologic Findings in Children With Severe Lead Poisoning
Authors: Clark Margaret , Royal Joyce , Seeler Ruth
Published: December 2021

Microcytic anemia, long considered an effect of lead poisoning, may in fact result from coexisting iron deficiency. In this study, how RBC size, hemoglobin, and zinc protoporphyrin vary as a function of iron status in a group of children with high lead levels was examined. Charts of all children (N = 51) admitted to Cook County Hospital for treatment of lead poisoning in 1981 to 1983 were reviewed for data on age, blood lead level, hemoglobin concentration, MCV, transferrin saturation and zinc protoporphyrin level. The mean lead level was 86 µg/dL and the range was 63 to 190 µg/dL. Children with transferrin saturation values less than 7% had a mean MCV of 56 pµL, hemoglobin of 8.9 g/dL, and zinc protoporphyrin of 693 µg/dL; for those with saturations of 7% to 16%, the values were 61 µL, 10.1 g/dL, and 581 µg/dL, respectively; the children with saturations greater than 16% had normal mean MCVs and hemoglobin concentrations (74 µL and 11.4 g/dL) and a mean zinc protoporphyrin value of 240 µg/dL (P < .0005). Multiple linear regression was used to correct for effect of age, and transferrin saturation remained the most important predictor of MCV, hemoglobin, and zinc protoporphyrin levels; the addition of lead did not improve the models. Results of this study suggest that iron deficiency is strongly associated with some of the observed toxicities of lead. Also, lead poisoning can exist without producing microcytosis or anemia, and zinc protoporphyrin concentration may not be a sensitive indicator of lead level in the absence of iron deficiency.
Homozygous Protein C Deficiency: Observations on the Nature of the Molecular Abnormality and the Effectiveness of Warfarin Therapy
Authors: Peters Charles , Casella James F. , Marlar Richard A. , Montgomery Robert R. , Zinkham William H.
Published: December 2021

An infant with severe homozygous protein C deficiency was brought to medical attention because of purpura fulminans and severe bilateral vitreous hemorrhages in the neonatal period. Infusions of fresh frozen plasma were given for 8 months. On two occasions, attempts to decrease the frequency of fresh frozen plasma infusions to less than twice a day led to episodes of microangiopathic hemolysis, fibrinolysis, and acute renal failure. Infarction of skin and subcutaneous tissues did not recur. Both episodes were controlled after reinstitution of fresh frozen plasma. Complications of therapy with fresh frozen plasma included hyperproteinemia and hypertension. Warfarin therapy was instituted when the baby was 8 months of age, followed by a gradual withdrawal of fresh frozen plasma therapy. The dose of warfarin required to maintain the prothrombin time in a range of 1.8 to 2.2 times normal varied considerably during short periods, a phenomenon that may have been due to several factors: hypercatabolism of the drug with prolonged administration, abnormality of liver function, variation in levels of serum albumin, fluctuations in drug dosage secondary to oral administration, and variations in dietary vitamin K. Protein C determinations by immunologic and functional assays consistently showed detectable but reduced protein C antigen levels with undetectable activity levels, suggesting that a dysproteinemia rather than a deficiency of synthesis is responsible for the child's coagulopathy.
Right Atrial Thrombus Formation Screening Using Two-Dimensional Echocardiograms in Neonates With Central Venous Catheters
Authors: Marsh David , Wilkerson Shirley A. , Cook Larry N. , Pietsch John B.
Published: December 2021

Two-dimensional echocardiograms were used to prospectively screen 49 patients with 56 central venous catheters for right atrial thromboses from October 1985 to May 1986. All but four patients received a two-dimensional echocardiogram prior to insertion of the catheter. Once the catheters were in place, two-dimensional echocardiograms were performed no later than 3 weeks after insertion and then every 14 days until the catheter was removed. A single thrombus was detected 79 days after catheter placement (an incidence of 1.8%). Previous recommendations for weekly screening with two-dimensional echocardiogram were based on case reports alone. The 95% confidence limits for a negative two-dimensional echocardiogram result suggest that the initial two-dimensional echocardiogram screen for thrombus be obtained no sooner than 3 weeks after catheter insertion. In addition, significant gastrointestinal disease requiring operative intervention was present in 10 of 11 previous case reports as well as in our patient. Further studies with larger sample sizes are needed to determine whether subgroups of infants exist who are at a relatively higher risk for right atrial thrombus formation.
Plastic Handguns That Resemble Toy Guns: New Technology Creates a Uniquely Hazardous Product
Authors: WINTEMUTE GAREN J. , TERET STEPHEN P. , KRAUS JESS F.
Published: December 2021

Pediatricians are well aware that handguns are a hazard for children.1-3 This hazard exists, in part, because children cannot reliably differentiate between realistic toy guns and real guns.2-5 Moreover, children holding toy guns have on occasion appeared to highly trained adults to be truly armed, often with tragic results2 (Time Magazine, April 20, 1987, p 33; Sacramento Bee, July 31, 1987, p 1).

It is less well known that real handguns made almost entirely of plastic may soon enter the marketplace, making the differentiation of real guns from toy guns immensely more difficult. The physical characteristics of these guns, and the likelihood of their promotion as a new means of personal and household defense, will almost certainly result in increased shootings of children (and of others by children).
Nerds Cereal and Red Stools
Authors: GUTGESELL MARGARET E. , DOUGHERTY JANET
Published: December 2021

To the Editor.—

Bright red stools are an alarming sign at any age. In a previously well child, such stool can produce marked anxiety in both patient and parent. We are writing to report a case of such stools following the ingestion of the cereal "Nerds."

A 5-year-old boy was brought to the pediatric night clinic at the Children's Medical Center of the University of Virginia, with the chief complaint of blood in stool. About one hour prior to arrival in the clinic, he passed a bright red-orange stool.
Bacteremia: Occult or Nonoccult?
Authors: RUBIN LORRY G.
Published: December 2021

In Reply.—

In our study we sought to evaluate the efficacy of bacterial antigen detection in highly febrile young children with occult or "unsuspected" bacteremia, ie, patients whose presentations did not necessarily mandate IV antibiotic therapy, but in whom parenteral a antibiotic therapy would be indicated if bacteremia could be reliably diagnosed at the initial ambulatory visit. The patients referred to by Dr Mauro, those with no focus of infection, constitute a small proportion of occult bacteremic patients (although a group at relatively high risk for bacteremia).
Lack of Adverse Reactions to Iron-Fortified Formula
Authors: Nelson Steven E. , Ziegler Ekhard E. , Copeland Amy M. , Edwards Barbara B. , Fomon Samuel J.
Published: December 2021

Some physicians are reluctant to recommend feeding of iron-fortified formulas to infants because of a fear of adverse reactions. In crossover studies, parents' records were compared with regard to their infant's behavior (fussiness, cramps, regurgitation, flatus, colic) and stool characteristics during periods when iron-fortified formulas were fed and periods when noniron-fortified formulas were fed. No statistically significant feeding-related difference was noted except for stool color.
Breast-Feeding Incidence and Duration in Black and White Women
Authors: Kurinij Natalie , Shiono Patricia H. , Rhoads George G.
Published: December 2021

The influence of sociodemographic factors on the incidence and duration of breast-feeding was evaluated in 668 black and 511 white women delivering their first child in the metropolitan Washington, DC, area. Breast-feeding rates were 84% among white and 49% among black women. Maternal educational level was strongly associated with breast-feeding, whereas the effect of ethnicity was moderate. Women with some college or some graduate school education had adjusted odds of breast-feeding that were 2.6 (95% confidence limit 1.9 to 3.7) and 5.2 (95% confidence limit 2.7 to 10.2) times higher than women with a high school education or less. In contrast, the adjusted odds of breast-feeding were 2.0 (95% confidence limit 1.4 to 3.1) times higher for white women compared with black women. The odds of breast-feeding increased among black women if they attended childbirth classes, were married, or were older. Among black women, the frequency of breast-feeding decreased sharply by 1 month postpartum. Breast-feeding duration for black v white women was 74% v 90% at 1 month, 44% v 72% at 4 months, and 26% v 50% at 7 months postpartum. The majority of black women (53%) used formula supplements in the hospital, which was the only factor significantly related to a shortened duration in this group (P < .01). The high rate of formula supplementation among black women and its strong association with shortened duration of breast-feeding point to a need for more advice and support and less reliance on formula during the hospital stay.
Health Assessment and Screening During Adolescence
Authors: RUBIN STEVEN E.
Published: December 2021

To the Editor.—

In the recommendations for health screening for Adolescence (Pediatrics 1987;88:146), vision testing is appropriately recommended. However, it is suggested by the authors that these patients be referred to optometrists or ophthalmologists if abnormalities are detected. As you know, optometrists are not physicians and hence do not receive the same degree of intensive training received by ophthalmologists and pediatric ophthalmologists, and they are not licensed to practice medicine or surgery. In my opinion, the level of care delivered by such a nonphysician does not approach that which can be delivered by physician specialists and subspecialists.
Photophysical Properties of Sn-Porphyrins: Potential Clinical Implications
Authors: Delaney John K. , Mauzerall David , Drummond George S. , Kappas Attallah
Published: December 2021

The photophysical properties of Sn-protoporphyrin and two of its synthetic analogues, Sn-mesoporphyrin and Sn-diiododeuteroporphyrin, were examined. All three compounds are potent competitive inhibitors of heme oxygenase, the rate-limiting enzyme in the catabolism of heme to bilirubin, and can suppress completely or diminish significantly experimentally induced or naturally occurring forms of jaundice in animals or man. The results of these studies show that all three compounds have long-lived triplet states which are quenched by molecular oxygen both in solution and when incorporated in liposomes. However, the addition of quenching groups such as iodine to the porphyrin macrocycle results in a marked (approximately 60%) decrease in the triplet yield and a threefold decrease in the triplet lifetime. The triplet yield was shown to be independent of the excitation wavelength, and as a result, the metalloporphyrins were extremely poor photosensitizers when excited in the spectral region commonly used in phototherapy. In the presence of serum albumin, the triplet state of Sn-protoporphyrin was not quenched by oxygen. These results indicate that Sn-porphyrins can be custom designed with considerably reduced photosensitizing properties for potential clinical use as inhibitors of bilirubin production.
Annual Meeting of the Section on Pediatric Urology
Authors: GLASSBERG KENNETH I.
Published: December 2021

The Section on Urology of the American Academy of Pediatrics met for three days in conjunction with the 55th Annual Meeting of the Academy n Washington, DC. Papers of interest to the pediatrician are summarized herein according to topic. The number of basic research papers is continuing to increase, and this in no small part is due to the encouraging influence of the recipient of this year's Pediatric Urology Medal, F. Douglas Stephens.

FETAL OBSTRUCTIVE UROPATHY

The majority of cases of hydronephrosis diagnosed in the newborn are first detected prenatally by in utero ultrasound. It is important to realize that not all cases of renal pelvic distension represent obstruction. Of 100 cases of abnormal antenatal renal ultrasound, Ahmed and LeQuesare found that surgery was necessary in 48 infants. The remainder either had normal kidneys on imaging studies after birth or the dilation was insignificant or decreased with time. The most common abnormality seen was ureteropelvic junction obstruction. Schwarz and coauthors evaluated the efficacy of antenatal ultrasound in diagnosing hydronephrosis at various times during gestation and found a low sensitivity before 20 weeks and a high sensitivity between 35 and 40 weeks. They found that the fetal hydronephrotic kidney did well in utero, leading them to believe that most cases of hydronephrosis should not be tampered with but instead should be dealt with postnatally.

Elder and coauthors reviewed the literature to determine whether in utero treatment of fetal obstructive uropathy has been effective. They found numerous instances of misdiagnosis and complications that included inadequate shunt drainage or migration (20%), onset of premature labor within 48 hours (10%), chorioamnionitis (6%), and urinary ascites (6%).
Palpable Lymph Nodes
Authors: BAMJI MAHRUKH , STONE RICHARD K. , KAUL ADITYA , USMANI GHAZALA , SCHACHTER FRANCES FUCHS , WASSERMAN EDWARD
Published: December 2021

In Reply.—

The observations of Dr Embree et al are indeed iteresting. The fact that axillary lymph nodes were palpable in 27.7% of infants in their survey is noteworthy. In our study, axillary nodes were found in 1% of neonates 0 to 72 hours of age. The discrepancy may be due to differences in environmental or genetic factors of the two groups (different ethnic groups examined). Infants with positive serologic tests for syphilis were excluded from our study population.
Head Circumference Data
Authors: ROCHE ALEX F. , GUO SHUMEI , MUKHERJEE DEBABRATA , MOORE WILLIAM M.
Published: December 2021

In Reply.—

The comments made by Drs Wember and Manz are of interest and help us to clarify some points made in our paper that may have been obscure. The percentiles in figs 1 and 2 were calculated from the raw data and not from the means and standard deviations on the assumption of normality of the distributions. The data in table 1 for the means suggest that a slow increase in head circumference may be occurring in boys near the age of 18 years.
Clinical Spectrum of Mucolipidosis Type IV
Authors: WEITZ RAPHAEL , KOHN GERTRUDE
Published: December 2021

To the Editor.—

We read with interest the presentation by Amir et al1 concerning the clinical spectrum and natural history of mucolipidosis type IV. Based on their experience with 20 patients, they try to provide guidelines for the clinical diagnosis of this lysosomal storage disease. It appears that severe visual impairment (due mainly to corneal opacities, myopia, and retinal degeneration) and psychomotor retardation are the cardinal features of this entity.

However, corneal clouding and mild motor delay in their early stages may frequently be missed by even experienced pediatricians and we recently examined a 15-month-old boy who was referred to us for evaluation of a possible congenital myopathy.