bluuebunny/crossref_metadata_2025 huggingface dataset:
Jaundice in the Newborn
Authors: Maisels M. Jeffrey
Published: December 2021

Pediatricians are confronted daily with the problem of the jaundiced newborn infant. The newborn infant is unique because (a) some elevation of serum bilirubin concentration is found in virtually all babies in the first few days of life, (b) the serum bilirubin concentration frequently rises to levels that are almost never encountered outside of the neonatal period, and (c) the newborn period remains the only time in which an elevated plasma bilirubin concentration per se represents a threat to the well-being of the organism.

FETAL AND NEONATAL BILIRUBIN METABOLISM

Chemical Structure and Properties of Bilirubin

Bilirubin IXα (so called because it is derived from cleavage at the α position of the heme ring of ferropro-toporphyrin IX) is the end product of the catabolism of heme, of which the major source is circulating hemoglobin. Recent observations on the stereochemistry and conformation of the bilirubin molecule are helpful in understanding the potential neurotoxicity of bilirubin as well as the mechanism of phototherapy.1 The isomer, bilirubin IXα(Z,Z), is the major form of bilirubin as it exists in the blood where it is tightly bound to albumin. When this form of bilirubin takes up two hydrogen ions, it forms bilirubin IXα(Z,Z) acid, which is an involuted structure containing intramolecular hydrogen bonds.
Cytogenetics in the Practice of Pediatrics
Authors: Gerald Park S.
Published: December 2021

The best known chromosomal abnormalities are alterations in the number of chromosomes. This type of chromosomal alteration is found in approximately 5% of all fetuses, most of whom are unable to survive pregnancy. Because of this selection process, only 0.6% of living newborns have a chromosomal abnormality. Approximately half of this group is grossly clinically abnormal. The remainder may not exhibit any clinical disturbance until later in childhood or at the time of reproduction.

The pediatrician must have sufficient knowledge of the overt cytogenetic syndromes to suspect the probable diagnosis. The pediatrician must also be sufficiently informed of the origins of chromosomal abnormalities to participate in the genetic counseling of the parents. Further, many of the recently recognized cytogenetic abnormalities are subtle and difficult to detect. Their demonstration will only be possible if the pediatrician is alert to the clinical situations in which they are likely to occur.

HUMAN CHROMOSOMES

The chromosomes which are seen through the microscope are chromosomes that have replicated. They are bipartite bodies, each half (or sister chromatid) is identical with the other half (Fig 1). The process of preparing the chromosomes for examination involves arresting cell division so that the chromosome does not undergo the normal process of division. The two chromatids touch each other at the constricted region known as the centromere.
Live Measles Vaccine Not a Cause of Atypical Measles Syndrome
Authors: Amler Robert William , Rapkin R. H. ,   colleagues
Published: December 2021

In the August issue of PIR (3:55, 1981)1 there is an abstract regarding atypical measles which we believe is misleading and may deter vaccination of a group of adolescents for whom live measles vaccine is indicated. We have received calls from a number of concerned pediatricians and believe the abstract should be corrected. The author states that the atypical measles syndrome is a possible consequence of administering live measles vaccine to former recipients of killed measles vaccine. Although severe local reactions and occasionally systemic reactions do occur following administration of live measles vaccine to former recipients of killed measles vaccine, there is no evidence that the live vaccine causes classic atypical measles syndrome.

Three patients, referred to as having severe systemic reactions by Krause et al,2 experienced fever to 103 F (39.4 C), malaise, marked local pain, swelling and erythema seven days following vaccination; these reactions lasted an average of eight days. However, the abstract was incorrect because these patients did not develop the atypical measles syndrome. Although the reactions were more severe than reactions that might be observed in persons who had never received killed measles vaccine, they were substantially less severe than the atypical measles syndrome. Atypical measles is characterized by high fever, pneumonitis (often with pulmonary consolidation and pleural effusion), pedal and hand edema, and an unusual rash which may be maculopapular, petechial, vesicular or urticarial. The rash is often most concentrated on the extremities.3 Revaccination with live measles vaccine is indicated for former recipients of killed measles vaccine to induce permanent immunity to measles, so that the atypical measles syndrome does not develop when the vaccinee is exposed to natural measles. Revaccination will not cause the syndrome. Atypical measles has occasionally been reported in individuals exposed to natural measles who had previously received live measles virus vaccine within a few months of receiving inactivated measles vaccine.4-6 This raises the possibility that the temporary immunity conferred by the killed vaccine precluded an adequate immunologic response to the live measles virus vaccine. Therefore, persons who received live measles vaccine within three months of receiving inactivated measles vaccine should also be revaccinated with live measles vaccine. Killed measles vaccine was used in the United States between 1963 and 1967 when an estimated 1,836,000 doses were distributed. Persons vaccinated with an unknown type of measles vaccine during that period should also be revaccinated with live measles vaccine as the unknown vaccine may have been killed measles vaccine.
Fungal Infections in Children
Authors: Esterly Nancy Burton
Published: December 2021

Fungal disorders are some of the most common cutaneous infections of childhood and adolescence. Despite their frequency and the ease with which an infectious agent can be correctly identified, fungal lesions are readily mistaken for other diseases or misdiagnosed in patients with entirely different skin conditions. One of the chief reasons for inaccurate diagnosis is a preconceived notion on the part of the physician as to how the lesions should look clinically. In fact, cutaneous fungal infections are extremely pleomorphic in appearance and can be macular and scaly, papular, pustular, vesiculobullous, or nodular. Their morphology may also be altered by self-medication, by treatment prescribed by another physician, or by an immunologic deficit in the host.

Even the most experienced physician will be baffled by these lesions some of the time. Studies assessing clinical acumen by verification with culture data demonstrate a significant degree of error in diagnosis, particularly in nondermatologic settings. Fortunately, most of these mistakes are preventable if three simple procedures are carried out. A Wood's lamp examination and a KOH preparation can be performed rapidly in the office and may provide all of the confirmatory evidence necessary for certain diagnosis. A positive culture of a properly obtained specimen is additional unqualified evidence of a fungous infection.
Depression in Children and Adolescents
Authors: Schowalter John E.
Published: December 2021

CASE HISTORY

Ted is a 10-year-old only child who was brought to his pediatrician with the following history. He was well until about two months before referral at which time he began to lose interest in things. This was manifested by poor concentration, a falling off of school performance, a disinterest in friends, and a decrease in appetite. Ted's teacher was the first to note the personality change and urged the parents to get a medical checkup. Physical examination findings were normal, but Ted seemed sad. History revealed no recent illnesses or incidents likely to be disturbing, but it was learned that Ted's mother and maternal grandfather had suffered multiple depressions, and each had been hospitalized for this on one occasion. Ted said that he felt sad lately, but did not know why. He commented that he never felt this way before and had never thought of hurting himself. When asked, he said he feared he would never feel better, but hoped that he would. The pediatrician diagnosed a major depressive episode. After a discussion with Ted and his mother about depression, the pediatrician made the referral to a child psychiatrist.

Every adult has felt depressed. It is part of the human condition. Sometimes the cause of the depression is clear; sometimes the depression seems to appear for no apparent reason.
Study of the Malformed Fetus and Infant
Authors: Opitz John M.
Published: December 2021

Humans sustain a reproductive loss of approximately two of every three fertilizations; prenatally, much of this death is associated with malformations that are mainly due to chromosome abnormalities. Up to half of all pre- and postimplantation ova in man may have chromosome defects that are more than 98% lethal. The earlier the stage of development at the time of the spontaneous abortion the greater is the number of malformations and chromosome defects; nearly 80% of embryos that reach a 2-week stage of development have a chromosome defect, as do more than 60% of those developing to 12 weeks, approximately 6% of stillborn infants, and 0.6% of all live-born infants. Even nonchromosomally caused single congenital defects have a high prenatal death rate. Besides chromosome defects, multifactorial traits and single gene (mendelian) mutations are the next most common class of congenital defects. Prior fetal wastage with or without prematurity of previous live-born infants increases the risk of subsequent fetal loss; the greater the number of preceding spontaneous abortions the smaller is the chance of a subsequent live-born child.

One fourth of all stillborn fetuses have one or more than one malformation or a syndrome, in many cases associated with a substantial risk of recurrence. After "certain diseases of early infancy" (mostly prematurity and hyaline membrane disease) congenital malformations remain the most important cause of infant mortality (60% of which occurs by the seventh day of life).

It is important for pediatricians to take much greater cognizance of the amount of genetic disease involved in fetal wastage and infant death, to collaborate more effectively with obstetricians, pathologists, anatomists, and geneticists in determining diagnosis and risk of recurrence, and to counsel more accurately those who have lost a fetus or infant. Such fetuses and infants deserve the same meticulous examination, evaluation, and documentation as an older malformed child being brought in for diagnostic, prognostic, and genetic counseling. A fetal loss may cause as much sorrow as an infant death; this grief must be addressed explicitly but gently and sympathetically before any other considerations are put before the parents as they decide on whether or not to create a new life.
A Workbook Exercise on Necrotizing Enterocolitis
Authors: Burg Fredric D. , Polin Richard A.
Published: December 2021

Readers will immediately notice that the following article departs from the usual style in medical journals. We all recognize that active learning is far better than passive, but this is difficult to achieve in the usual journal article. Drs Burg and Polin have developed a sequential workbook approach in the following article which will require your active participation. We believe that it will result in better learning, but would appreciate reader comment.

R.J.H.

The following are a series of exercises aimed to help you in: (1) identifying the factors that cause necrotizing enterocolitis (NEC); (2) Explaining the pathophysiology of NEC; (3) developing a proper approach to diagnosing necrotizing enterocolitis in the neonate; and (4) managing a newborn with this disease.

EXERCISE 1

Factors That Contribute to Development of Necrotizing Enterocolitis

Please read through the following case history.

K.W. was a 1,600-gm girl delivered to a 17-year-old primigravida by emergency cesarean section for fetal distress at 31 weeks' gestation. Apgar scores at one and five minutes were 2 and 5. The infant was given 3 mEq of sodium bicarbonate through an umbilical vein (UV) catheter in the delivery room and then intubated. Following admission to the intensive care nursery an umbilical arterial (UA) catheter was inserted and positioned at L-1.
Bonding and Screening: Myth and Reality
Authors: CHAMBERLIN ROBERT W.
Published: December 2021

McCall's article in this issue raises questions about two recent developments in pediatrics—the effectiveness of bonding and screening for development. These are emotional issues with partisans on both sides. I have been asked to respond to McCall's comments as a "neutral observer."

The thrust of McCall's arguments is that the long-term importance of both early mother-infant contact and detecting and treating early developmental lags has been overrated and this has created some iatrogenic problems. He points out that many children with early developmental lags turn out to be normal and that many mothers who do not undergo early and extended contact with their infant at birth still manage to develop a warm and loving relationship with their child.
Hypertension in Children
Authors: Goldring David , Hernandez Antonio
Published: December 2021

The pathogenesis of primary hypertension remains unknown despite extensive investigative contributions. Evidence is mounting that the disease may have its inception in childhood or possibly in infancy. What is needed are long-term longitudinal studies to determine whether the child with primary hypertension eventually becomes the adult hypertensive. A method for the identification of the hypertensive either by specific chemical or physiologic characteristics is very much needed.

Nonpharmacologic therapeutic intervention needs careful evaluation, especially in the pediatric patient, to determine whether the disease can be arrested. A thorough study of pediatric patients with primary hypertension should be strongly encouraged. It may be that the solution to the complex puzzle of primary hypertension may have a higher probability of being solved at the inception of the disease in infancy or childhood rather than in the later irreversible stage in adulthood.
What the General Pediatrician Should Know About Developmental Anomalies
Authors: Opitz John M.
Published: December 2021

It would be a "fallacy of misplaced emphasis" to devote this review only to facts, data, and specific syndromes. A necessary minimum of developmental biology will be presented; however, the main focus will be on method, ie, on effective use of eyes and intellect to learn "phenotype analysis," which is the analysis of normal and abnormal developmental variability.

In spite of the valiant efforts of the late David W. Smith,1 pediatric education on this subject remains handicapped in several major ways:

1. Overemphasis on the metabolic and biochemical aspects of disease and lack of expertise in methods of morphologic analysis by staff and faculty lead to lack of confidence in ability to do a complete physical examination and to interpret structural changes correctly;

2. Excessive preoccupation with the abnormal without encouraging study of the normal frequently results in over-interpretation and misinterpretation of normal variants as minor anomalies and the persistence of that offensive nonentity—"the funny looking kid (FLK)";

3. Lack of instruction in anthropometric methods results in frequent failure to quantitate and to interpret physical traits accurately and leads to such erroneous statements as "height at birth..." (length is meant); "this microcephalic child had large ears" (head is small, ears are normal); "this Down syndrome child had a highly arched palate" (palate height is normal in the Down syndrome, it is length that is mostly severely reduced);
Clinical Informatics Sub-Specialty Board Certification
Authors: Lehmann Christoph U. , Shorte Vanessa , Gundlapalli Adi V.
Published: December 2021

Increased funding for health information technology and the advance of electronic health records in hospitals and practices have created the need for a new specialist: the clinical informatician. Clinical informatics was recognized in 2011 as the latest subspecialty in medicine by the American Board of Medical Specialties. This article reviews the need for this new specialty as well as the steps necessary for its creation. The content and training requirements for clinical informatics are discussed as well as eligibility criteria for taking the board examination. Training programs as well as board preparation are addressed along with the expected impact that this new field will have on the practice of medicine.
A Pediatrician's Primer for School Health Activities
Authors: Nader Philip R.
Published: December 2021

This paper provides a basic approach to school health for the pediatrician. The Task Force on Pediatric Education predicts that knowledge and skills concerning school health will be included in the future among those basic skills common to the preparation of all who aspire to the specialization of pediatrics.
Viral Hepatitis in School-Aged Children
Authors: Chilton Lance
Published: December 2021

Hepatitis A is a common disease in children, usually passed by the fecal-oral route. Because of its route of transmission, day care centers, especially those caring for infants and toddlers in diapers, are a likely site of passage of the disease, unlike schools, where transfer of HAV occurs uncommonly. The pediatrician encountering a case of HA must ascertain (1) that other possible aiagnoses have been eliminated, (2) whether the patient or a sibling attends a day care center, and (3) the likelihood of a common source outbreak associated with contaminated food or drink. Public health help should be sought to determine that all wider implications of the patient's disease have been taken into account. In some instances, immunoglobulin use may be indicated beyond the usual group of family and sexual contacts. In many cases, the pediatrician will be asked to stretch the indications for immunoglobulin prophylaxis; the forces may be so strong as to force mass immunoglobulin administration even if inschool transmission is unlikely. There is no specific treatment for hepatitis; previously prescribed diets and restrictions of activity are unnecessary. Recovery without complications occurs in the vast majority of patients, especially children, with HA.

Hepatitis B and non-A, non-B hepatitis are less common than HA in children, except those in certain groups. Those infected have a 10% likelihood of contracting chronic active hepatitis; with HB, a chronic carrier state contributes substantially to the epidemiology of the disease. The same is likely to hold true for non-A, non-B hepatitis. In patients with needle-stick, blood product, or sexual xposure to HB, standard immunoglobulin or HBIG is recommended as prophylaxis; for those exposed to NANB, immunoglobulin may be given. A vaccine to give active protection against HB exists; one is being developed for HA as well.
Use of Human Immune Serum Globulins
Authors: Stiehm E. Richard
Published: December 2021

Pediatric practitioners administer γ-globulin frequently, usually following hepatitis exposure or prior to foreign travel. Administration of γ-globulin, or human immune serum globulin (HISG), its official name, is also indicated in several other situations.

HISG is used intermittently to prevent a specific infection in normal subjects, and it is continuously to prevent recurrent infections in immunocompromised subjects. Two types of HISG preparations are available: standard human immune serum globulin for general use and special human immune serum globulin with a known antibody content for specific illnesses (Table 1). In addition, some animal sera and antitoxins are still used for certain infections (eg, diphtheria), poisonings (eg, snake bites or botulism), or immunosuppression (eg, antilymphocyte globulin). Recently (September 81), human immune serum globulin for intravenous use has been licensed.

SOME PROPERTIES OF IMMUNOGLOBULIN G

The immunoglobulins or "γ-globulins" are the proteins of the plasma and tissue made in lymphoreticular tissues that have antibody activity.1 Although there are six classes of immunoglobulin—IgG, IgM, IgA, IgD, IgE, and secretory IgA—only IgG is present in significant quantities in HISG.

IgG is a glycoprotein with a molecular weight of 150,000 distributed equally between the serum and the tissues. The IgG molecule is Y-shaped with two combining sites, one at the end of each arm.
Breast-Feeding and Herpes
Authors: Fulginiti Vincent A.
Published: December 2021

Dr McNiel of Fort Dodge, Iowa writes: "Our infection committee noticed that in the new edition of the report of the Committee on Infectious Disease (Red Book) that mothers with active genital herpes may now breast-feed infants. Recent articles in Pediatric Infectious Diseases (1:81, 1982)and in Pediatrics in Review (2:259, 1981) show that herpes is still a devastating illness to most newborns who get it. Roughly 90% of babies who get neonatal herpes are either dead or damaged and with treatment the outlook is for better survival, but still a large percent of the survivors are damaged. If they consider it such a devastating infection in the newborn, I do not understand this change in recommendation from strict isolation to allowing infants to breast-feed. It seems a pretty big risk to consider that the mother will keep her hands off of her lesions while breast-feeding her infant and not touch her infant with contaminated hands.

Do you have any data or are you aware of any data on why the American Academy changed their recommendations?"

Reply: Dr McNiel's infection committee spotted one of the controversial areas of infectious diseases practice. The issue the committee faced was broader than just breast-feeding; it concerned the degree of contact permissible between an infected person and a newborn infant. Herpes in the newborn generally is a disease transmitted just prior to or at the time of delivery, following direct contact of the infant with herpes virus-rich lesions in the genital tract. There are exceptions, of course, in which caretakers appear to have been the source for infants after birth. Even in these circumstances direct contact appeared necessary (kissing an infant, etc).

Given this background, we were faced with the dilemma of what to do for the maternal-infant pair postdelivery. On the one hand, direct contact with lesions or with fingers contaminated with herpes carried a small but significant risk. On the other hand, as pediatricians we wished to encourage appropriate mother-infant contact, including breast-feeding.

Our experts advised us that: (1) The risk postdelivery was very low; some claimed there was no risk at all, that infants were infected during birth or not at all. (2) If the nipple and surrounding skin were unaffected, breast-feeding was not contraindicated. (3) To further reduce the minimal (if any) risk, primary lesions should be covered and thorough handwashing taught and practiced. Hence, our recommendation in the Red Book.
Menstrual Problems During Adolescence
Authors: Litt Iris F.
Published: December 2021

Medical interest in menstrual absence is antedated by that of the philosophers and theologians (Aristotle, Plato). The importance of menses induction in early medical teaching is underscored by the observation that 14% of all drugs listed by Dioscovides of Ana Zarbos in the first half of the second century AD were supposedly capable of inducing menses. It was, even in antiquity, recognized that cessation of menses was an early sign of pregnancy, yet amenorrhea was regarded as a systemic disease that required immediate intervention. Although there have been sizable gains in our understanding of amenorrhea, modernday physicians often face a comparable dilemma in approaching its differential diagnosis and determining a course of action. This article is written in order to simplify this process and, in so doing, to assist the pediatrician in dealing with the adolescent patient with amenorrhea, as well as other common menstrually related problems, such as menometrorrhagia and dysmenorrhea.

AMENORRHEA

In order to understand absence of menses, it is first necessary to visualize the mechanisms responsible for its presence. The first prerequisite for normal menses is presence of a functionally and anatomically intact cerebral-hypothalamic-pituitary-ovarian-uterine axis. This system is apparently capable of cyclic menses from birth, the reasons for its quiescence until puberty remaining an intriguing mystery.
Running Away
Authors: Schowalter John E.
Published: December 2021

As you begin reading this review, it is quite possible that you are wondering why you are doing so. What do runaways have to do with pediatricians or pediatricians with runaways? It may seem a subject more fitting for a Sunday newspaper supplement and, indeed, it oftentimes has been one. It has also been the subject of such alarming movies as Harddcore with George C. Scott. Statistics are certainly scary. One reads of 1 or 2 million runaways a year and of the estimated 4,000 to 7,000 teenaged prostitutes working in the Times Square area of New York City. This recent publicity is somewhat overwhelming, and is in stark contrast to the benign, romantic image of the runaway with which many of us grew up. This more comfortable runaway is Huck Finn, Tom Sawyer, the young rascal who runs away to join the circus, or the young adult telephone man in Tennessee Williams' The Glass Menagerie who falls in love with long distance. In addition, some of the professional writings about runaways suggest that the older views are more accurate. They express the importance for some adolescents to get away and work out their own destinies outside of the perhaps repressive or chaotic atmosphere of their families.
Burns in Children: 1982
Authors: Guzzetta Philip C. , Randolph Judson
Published: December 2021

Burns constitute a major cause of childhood death and disability. Prevention of these injuries remains the most effective method of dealing with them and is the responsibility of all persons caring for children. Despite all therapeutic advances, 3% of children admitted to our burn unit die of their injury; many more suffer significant physical and psychological morbidity. Care for these patients is best provided by a multidisciplinary unit with many professionals working together as a team from the day of injury until the child reaches adulthood.
End-Stage Renal Disease in Children
Authors: Weiss Robert A. , Edelmann Chester M.
Published: December 2021

The pediatrician should be able to identify chronic renal failure and to determine a specific etiobogic diagnosis for most patients with CRF, based upon age and mode of presentation, examination of the urine, anatomic evaluation of the urinary tract, and, if indicated, relatively simple laboratory tests, such as antinuclear antibody and serum complement. While referral to a pediatric urologist is indicated for diagnosis and management of congenital malformations of the urinary tract, consultation with the pediatric nephrologist is advisable for the child who requires a renal biopsy for definitive diagnosis, as well as to plan future management, including diet, drug therapy, dialysis, and transplantation. The primary care pediatrician should retain responsibility for implementing the medical recommendations of the pediatric urologist or nephrologist and should resume his full role for the child who has undergone successful renal transplantation.
Approach to the Febrile Patient with No Obvious Focus of Infection
Authors: Long Sarah S.
Published: December 2021

The summary in Table 1 could be used as a mental checklist for the pediatrician who examines a child with fever. Whether the pediatrician opts to "keep the rules" or appropriately decides to "break the rules," knowledge of the guidelines will help him to focus his approach and to adopt attitudes of caution in certain circumstances. The body of knowledge of infectious agents chemotherapeutic agents has burgeoned over the past 40 years; the rules have changed very little. Thus, the rules might also serve as standards against which "new discoveries" that dictate departure from an established mode of clinical practice would have to be weighed.

The adage, "Name the bug before you choose a drug," is especially germaine to pediatrics. Potential pathogens or "bugs" continually change as the patient's age, exposure, and immunity change. The serious diseases they cause mandate that initial treatment be given with the best "drugs." The age-related causes of bacterial meningitis presented in Table 2 could serve as a primer for age-related causes of other invasive disease as well. For bone, joint, and soft tissue infection as well as for septicemia without a focus the age line for group B Streptococcus and H influenzae would be extended upward and S aureus would be added for all ages. Although the relative importance of each pathogen for each clinical entity might vary, therapeutic considerations would be appropriately served by a schema such as this.

Unfortunately, the susceptibility of pathogens to antimicrobial agents will continue to change. Fortunately, new and potentially better therapeutic agents will continue to be discovered or invented. When new problems of antibiotic resistance emerge or when superior therapeutic modalities are proved, the pediatrician must be knowledgeable of such events and be prepared for change.
Asthma: Use of Oral Bronchodilators
Authors: SMITH THOMAS F. , BARTON M.
Published: December 2021

I have enjoyed Pediatrics in Review since its inception and my letter is prompted by the Comment on the abstract of the article by Lee (Comparison of oral and aerosol adrenergic bronchodilators in asthma [J Pediatr 99:805, 1981]) which appears in the July issue (PIR 5:18, 1983). It is my conclusion from data in the original article that aerosol bronchodilator therapy in children with asthma is both efficacious and reasonable. I do not believe the data warrant abandoning oral adrenergic agonists in the treatment of patients with asthma. Lee suggests that, in some patients, combining both the aerosol and the oral routes was frequently accompanied by "unpleasant side effects."
Infantile Apnea
Authors: McBride John T.
Published: December 2021

There is presently no test capable of predicting an infant's risk for SIDS: there is no screening test for susceptibility to SIDS. The nature of a child's apneic episode is somewhat predictive of that infant's risk for subsequent unexpected death. Early signs suggesting respiratory center dysfunction are upper airway obstruction during sleep and hypoventilation during sleep. The most common causes of frequent "false" apnea alarms are poor lead placement, defective lead wires, improper sensitivity settings, and shallow breathing. Clearance of methylxanthines is lower in infancy than later in childhood; lower doses are necessary to avoid toxicity in infants. The relationship of infantile apnea to SIDS has not been firmly established. Infants who have had choking episodes and associated respiratory pauses are, in general, at no increased risk of sudden unexpected death. Apnea associated with acute viral or bacterial infections has not been shown to be a risk factor for subsequent SIDS.
Conjunctivitis in Infancy and Childhood
Authors: Hammerschlag Margaret R.
Published: December 2021

Conjunctivitis is one of the most common afflictions affecting the eyes. Practically every microorganism, from viruses to bacteria have been implicated as causes of conjunctivitis. Depending upon the etiologic agent, conjunctivitis may range from a mild self-limited infection to one that can destroy vision and even be life-threatening.

This review will be divided into two sections covering conjunctivitis in older infants and children and ophthalmia neonatorum, which has a different epidemiology.

CONJUNCTIVITIS BEYOND THE NEONATAL PERIOD

Epidemiology and Etiology

Bacterial infection probably accounts for most of acute conjunctivitis in children. The organisms thought to be most common are Staphylococcus aureus, Haemophilus species including H influenzae and H aegyptius, and Streptococcus pneumoniae (Table I). Bacterial infection is frequently characterized by a purulent or mucopurulent discharge which is usually the source of transmission of infection. Towels and other commonly used articles may spread the infection from one person to another.

Although Staph aureus has traditionally been assumed to be a pathogen, the organism is frequently isolated from the conjunctivae of individuals without conjunctivitis.1,2 In a recent prospective study of acute conjunctivitis in children,1 Staph aureus was isolated from 24% of the children with acute conjunctivitis and 16% of the control subjects, a nonsignificant difference. It has been hypothesized that the increased isolation rate of Staph aureus seen in conjunctivitis may be secondary to the wetter environment of the infected eye rather than a direct cause of the infection.
Ethical Issues in the Care of Handicapped, Chronically III, and Dying Children
Authors: Fost Norman C.
Published: December 2021

There is presently broad consensus that involuntary sterilization of an incompetent patient should be done only in the following unusual circumstances, and then only after approval by a court:

1. If the progeny would be so severely damaged that their lives would be arguably worse than nonexistence (eg, a disorder such as Lesch-Nyhan syndrome), OR a retarded female's physical or psychologic health would be seriously jeopardized by a pregnancy and/or abortion (eg, severe heart or lung disease), AND

2. There are no alternative, less restrictive ways of avoiding pregnancy (such as segregation, supervision, behavior control, or reversible forms of contraception), AND

3. There has been a court order, following a process designed to ensure that the procedure is necessary to protect the interests of the patient.
Dealing with Chronic Illness in Childhood
Authors: Swartz Donald R.
Published: December 2021

Most pediatricians treat Children who are well or who, at worst, have an acute but Curable illness. Children with chronic illnesses don't fit. Our appointment schedules aren't structured to deal with them and they clash with our "health and normality" mind-set. Chronic diseases, incurable and possibly lethal, conflict with our need to heal, and the obvious pain and dismay of the parents is painful and dismaying to us as well. Practice might be more comfortable without them. Yet no group of patients can benefit more from the understanding of healthy development and knowledge of management of disease that are combined in today's pediatrician. The child with chronic illness is not just a case of a specific medical condition; he or she is also a child, with all of the development, psychosocial, and physical needs that are characteristic of children in general.

This discussion will focus on the ways in which a child and his or her family may be affected by chronic disease, and what the responses of each to chronic disease are likely to be. The physician's responses will also be examined, as well as how the physician caring for a child with chronic illness can facilitate the adjustments and adaptations that will allow the child and his or her family to attain their greatest potential for a normal and fulfilling life.
Childhood Dermatomyositis and Polymyositis
Authors: Spiro Alfred J.
Published: December 2021

Childhood dermatomyositis has been recognized as a clinicopathologic entity for approximately two decades. Polymyositis in the pediatric age group, as in adults, is not a singly defined entity, as it may occur with or without evidence of one of the collagen vascular diseases. Because of overlap of some features of both disorders the terms "polymyositis" and "polymyositis—dermatomyositis Complex" have sometimes been used to include both of these disorders.

INCIDENCE

Polymyositis and dermatomyositis are uncommon disorders; even in a referral center, there may be only two or three cases seen per year. The limited number of epidemiologic studies have included both adults and children and have combined several types of inflammatory myopathy. By this imperfect method, the annual incidence of new cases has varied from 1 to 7.7 per million persons. There is an increased incidence in the second and seventh decades of life, with a lower incidence in the third decade. Most reports of dermatomyositis have shown a preponderance of girls. Onset most commonly occurs at school age, but children in their second year of life have been affected.

PATHOGENESIS

Studies of muscle biopsies from patients with juvenile dermatomyositis have demonstrated that the basic lesion involves the endothelial cells of intramuscular capillaries, arterioles, and veins.
Clinical Approach to the Child with Scoliosis
Authors: Jones Marilyn C.
Published: December 2021

Although most children with scoliosis are otherwise structurally normal, spinal curvature may represent one feature in a broader problem of altered development with a specific prognosis and a specific risk of occurrence in siblings and children of the affected individual. A clinical approach to the evaluation of the child with scoliosis is proposed based upon the age of recognition of the curvature and a detailed physical examination.

Scoliosis is defined as a lateral curvature of the spine. In contrast to curves in the anteroposterior dimension (kyphosis and lordosis), scoliosis is never present in the normal spine. Although mild degrees of curvature are often asymptomatic, marked scoliosis produces severe disability and shortens lifespan by interfering with pulmonary mechanics, resulting in hyperventilation, pulmonary hypertension, and eventually, pulmonary and cardiac failure. Early diagnosis and promptly instituted treatment are effective in reducing long-term morbidity. It is critical to recognize that scoliosis is not a diagnosis. It is a description of a particular structural alteration which may be produced by a variety of pathogenetic mechanisms and which has many different etiologies. The vertical stability of an individual is maintained as a consequence of normal vertebral bodies, intervertebral disks, ligamentous and muscular attachments, and normal neuromuscular function. Alteration in any one of the above may lead to scoliosis.
Rubella Reimmunization
Authors: SCHMITT BARTON D. , BRUNELL PHILIP A.
Published: December 2021

In the October 1980 issue (PIR 1980;2:126), Katz recommended that a second rubella immunization be given to 12-year-old girls. In the February 1983 issue (PIR 1983;4:256), Johnson recommended that the polio booster be given to all youngsters at age 12 years.

I went back to the recent AAP "Red Book" and could not find a similar recommendation. I reviewed Pediatrics for up-dated guidelines from the Committee on Infectious Diseases and could find no backing for the above two recommendations. What should standard practice be in 1984?

Reply: An article summarizing a report of the Institute of Medicine, concerning poliovirus vaccines, appeared in the New England Journal of Medicine (1977;297:249).
Cervical Adenitis
Authors: Margileth Andrew M.
Published: December 2021

Children with acutely tender and inflamed cervical lymph nodes are observed commonly by family physicians and pediatricians. Cervical lymphadenitis is usually associated with a systemic viral illness and subsides within a few days to 2 weeks. Bacterial adenitis, seen less often, is usually due to (β-hemolytic streptococcal or to staphylococcal infection. However, when a neck node remains enlarged following a systemic illness or when a nontender regional cervical node (adenopathy) persists longer than 2 or 3 weeks with or without associated illness, the physician and parents become worried. Concern is enhanced if the nodes increase in size or number. Infection and inflammation are the most common causes for persistent chronic (3 or more weeks' duration) lymphadenopathy in children. Whereas neoplasm is rare (1.4%) in the child or adolescent less than 17 years of age with a superficial lump on any part of the body, maligancy (Hodgkin disease, lymphoma, neuroblastoma) was found in 31 (13%) of 239 enlarged cervical nodes in similar-aged children at the same institution. Congenital and acquired cysts, pilomatrixomas, and benign neoplasms (lipoma, neurofibroma, lymphangioma) account for the majority of noninflammatory lesions in the neck in children and adolescents. However, most cervical lymphadenopathy in children is due to adenitis or reactive hyperplasia in response to an infection.
Use of Oral Fluids in Treatment of Diarrhea
Authors: Klish William J.
Published: December 2021

The practicing physician cannot help but be somewhat surprised by the current interest and publicity given to oral rehydration therapy for diarrheal disease. Indeed, oral rehydration therapy has been used to some extent by all physicians who deal with diarrhea, and the history of its use as a folk remedy is probably as long as the history of diarrheal illness. Why, then, has interest in this rather mundane therapy reemerged? Only recently have we begun to understand how oral fluids are absorbed, and this has resulted in changes in the composition and indications for use of these fluids.

Even though the need for fluid intake during an episode of diarrhea has appeared always to have been a part of folk medicine, the medical profession did not consider this practice until the early 19th century. In 1832, after William O'Shoughnessy, an Irish physician, described the chemical composition of the stools in cholera, Thomas Latta of Scotland attempted to treat cholera by the intravenous infusion of water and salts. Of the 15 cases he reported in The Lancet, five patients survived. Latta was criticized severely for this therapy, but it was pointed out (in discussion in The Lancet) that these five patients were saved from almost certain death.
Viral Hepatitis: 1985 Update
Authors: Krugman Saul
Published: December 2021

During the past two decades extraordinary advances in hepatitis research have clarified the etiology and natural history of the disease. At least four types of hepatitis have been identified: A, B, D (delta), and non-A, non-B. Hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis D virus (HDV) have been characterized. Serologic tests have been developed to detect the antigens and antibodies associated with these three hepatitis infections. As of the present time, the non-A, non-B viral agents have not been identified. Therefore, non-A, non-B hepatitis is diagnosed by excluding other viral causes of hepatitis, such as hepatitis A virus, hepatitis B virus, Epstein-Barr virus (EBV), cytomegalovirus (CMV), and others. A recent report indicating that non-A, non-B hepatitis may be caused by a retrovirus, if confirmed, may provide a specific marker of this infection.

The course of viral hepatitis is variable; it may be an asymptomatic, anteric infection, or it may be an acute illness characterized by fever, malaise, anorexia, nausea, abdominal pain, and jaundice. Most patients recover completely, but occasionally the infection may be complicated by chronic hepatitis, cirrhosis, and, occasionally, by a fulminant fatal outcome.

This review will be devoted predominantly to a discussion of the diagnostic and prophylactic aspects of hepatitis A and hepatitis B viral infections.
Department of Corrections
Authors: Springate James E. , Donn Steven M.
Published: December 2021

A reader asks:

I recently had the opportunity to read Donn and Banagale's informative article entitled, "Neonatal Hyperammonemia" (Pediatrics in Review 1984; 5:203-208).

I am somewhat confused by Table 5 which lists the ingredients for 1.5% dextrose-bicarbonate peritoneal dialysate. The use of a total of 167 mEq/L of sodium seems nonphysiologic and combination of calcium and bicarbonate, if I remember correctly, leads to precipitation.

Dr. Donn replies:

There was an error in Table 5 in our review article. Unfortunately, the error was missed by both authors, internal reviewers, and external reviewers as well. As indicated, the total sodium concentration of the dialysis solution is too high. The total sodium concentration, the combination of sodium chloride and sodium bicarbonate should approximate 132 to 136 mEq/L. At the present time, our special peritoneal dialysis solution contains 95 mEq/L of sodium chloride and 40 mEq/L of sodium bicarbonate for a total of 135 mEq/L. This is certainly within the physiologic realm and avoids problems with sodium flux.

With regard to concern about the precipitation of calcium and bicarbonate, the concentrations of both calcium chloride and sodium bicarbonate are low enough that they do not exceed the solubility product and, therefore, remain in solution.
Disaccharidase Deficiency
Authors: Ulshen Martin H.
Published: December 2021

Disaccharidases are enzymes of the small intestine, and they are essential for normal carbohydrate digestion. Carbohydrates are an important dietary component, providing about half of the calories in a typical Western diet. The smallest carbohydrate units, the monosaccharides, are the building blocks for more complex sugars and starches. The monosaccharides of dietary importance include glucose, galactose, and fructose. Carbohydrates are present in an average diet, primarily in the form of dissacharides (two monosaccharides linked together) and starches (glucose polymers). The disaccharide lactose is the major carbohydrate in milk and accounts for about 40% of the caloric content of human milk as well as commercial cow milk formula. Lactose is composed of the monosaccharides glucose and galactose; sucrose is composed of glucose and fructose. During the first year of life, juices and solids are introduced into the diet in increasing amounts and, therefore, sucrose and starches provide an increasing proportion of the dietary calories. By the adult years, about 50% of dietary carbohydrate is ingested in the form of starch, and lactose is often a minor component of the diet.

Among the dietary carbohydrates, only the monosaccharides can be transported intact across the luminal surface of the small intestine. The moroe complex carbohydrates must undergo digestion prior to assimilation.
Diseases of the Scalp
Authors: Rasmussen James E.
Published: December 2021

The scalp is far more important than its small surface area would suggest. It is usually the first part the infant presents to the world and is responsible for much cosmetic concern throughout life. In the general scheme of organization, regional dermatology is an easy way to categorize many diseases. This article will review several regional dermatoses that affect the scalp more commonly than other sites. There will be no attempt to discuss all diseases that may occur on the scalp, particularly those that have more important or characteristic manifestations at other body sites.

Diseases of the scalp can be conveniently grouped into those that are congenital, those that are acquired, and those that are associated with normal or abnormal amounts of hair loss (Table 1). The reader will rapidly appreciate that it is difficult to separate some diseases of the scalp from primary hair disorders, particularly when the mouth of the follicle or the hair root is the primary target.

It is also useful to organize scalp diseases in a roughly chronologic sequence from birth through maturity and senescence (Table 2). Diseases that commonly occur prior to puberty are frequently not seen after that time; they are replaced by a variety of problems related to hormonal changes.