bluuebunny/crossref_metadata_2025 huggingface dataset:
VITAMIN A POISONING
Authors: GRIBETZ DONALD , SILVERMAN SAMUEL H. , SOBEL ALBERT E.
Published: December 2021

Two cases of hypervitaminosis A have been presented together with a review of experimental and clinical literature.

The first case presented the highest reported fasting plasma vitamin A level, the increase being chiefly due to a high vitamin A alcohol fraction. This elevated level of alcoholic vitamin A probably denotes large stores of vitamin A in the liver and data have been given to show that it is a better index of hypervitaminosis A than is the total vitamin A level. In addition, evidence has been presented that the toxic factor in hypervitaminosis A is the permanent elevated plasma vitamin A level.

The similarity between the experimental studies in animals and the observations in the authors' first case has been shown.

The important points necessary for making a diagnosis of hypervitaminosis A have been discussed and several similar conditions have been differentiated.

It cannot be emphasized too strongly that excess vitamin intake may be as dangerous as a deficient intake.
A Ten-Year Retrospective Study of Pink and Yellow Neonatal Hyaline Membrane Disease
Authors: Turkel Susan Beckwitt , Mapp John R.
Published: December 2021

Since it was first described several years ago, yellow bilirubin staining of the pulmonary membranes in neonatal hyaline membrane disease has apparently become more common. In a retrospective study of neonatal autopsy experience, it was found that as more of the premature infants survived longer, yellow hyaline membrane disease was a more frequent finding, increasing from 7% of all newborns having hyaline membrane disease at autopsy in 1970 to 50% in 1980. In comparing 499 cases with eosinophilic hyaline membranes with 168 cases of yellow membranes, newborns with bilirubin staining of the pulmonary membranes were found to be more premature (P < .02), had smaller autopsy weight (P < .002), and survived longer (P < .00001). When multiple clinical parameters were compared between a group of infants with yellow membranes and a group of infants with pink membranes who were matched for gestational age, year of birth, and length of survival, no differences were found between the two groups. No correlation was found between kernicterus and yellow staining of the pulmonary hyaline membranes in the first years of the study, but there was a strong correlation in the last 5 years, coincident with the increase in the rate of yellow hyaline membrane disease found at autopsy. The gross bilirubin staining of the brain was the secondary type of kernicterus, not toxic bilirubin encephalopathy. The observation of bilirubin staining in the lung and in the brain correlates with prolonged survival in some very small premature infants. This does not appear to be a manifestation of bilirubin toxicity, but rather a marker of prior tissue damage.
Homosexuality and Adolescence
Authors:   Committee on Adolescence
Published: December 2021

In 1974, the American Psychiatric Association ended its classification of homosexuality as a mental disorder, labeling it rather as an alternate choice of sexual expression. This decision was based on the beliefs of the majority that there were insufficient data to label such individuals as being ill and that the deleterious social consequences of the pathologic designation were so grievous as to demand the declassification.1

Although theories regarding the etiology of homosexuality have been based on genetic, hormonal, psychological, and environmental models, there is little reason to believe that any one of the arguments alone explains all homosexual orientation or behavior.2 Homosexuality has existed in most societies for as long as recorded descriptions of sexual beliefs and practices have been available. Although little agreement exists concerning the etiology of homosexuality, and any definition of terms will be arbitrary, some operational definitions are necessary (Table).3

Four assertions can be made regarding homosexuality during the teenage years:

1. Some homosexual experimental behavior is experienced by many adolescents. This may include fondling of the body or genitalia or mutual masturbation. In the vast majority of cases these homosexual encounters do not predispose to later obligatory homosexuality, but appear to be a common exploratory behavior en route to conventional heterosexual development.

2. Homosexual4 characteristics appear to be established before adolescence. Although many individuals do not participate in overt homosexual play during childhood, the self-conscious psychological state probably often exists before adolescence.

3. Some previously heterosexually oriented adolescents will become involved in homosexual activities if circumstances reinforce this behavior or if heterosexual alternatives are not available.
Flow-Volume Curves in Infants with Lung Disease
Authors: Godfrey S. , Bar-Yishay E. , Arad I. , Landau L. I. , Taussig L. M.
Published: December 2021

Partial expiratory flow-volume maneuvers have been performed on nine occasions on six infants with a variety of pulmonary problems using a new tech nique for thoracic compression. The infants were placed within an inflatable bag that was, itself, within a canvas bag. By sudden controlled inflation of the inner bag at end inspiration, partial expiratory flow-volume curves were generated and recorded by means of a face mask and pneumotachograph. By comparing these flow results with those airway resistance and lung volume measurements obtained from the infants in whole body plethysmography and by noting the effect of inhaling a helium/oxygen gas mixture, it was possible to partition the airway obstruction between large and small airways. The presence of small airway obstruction was noted in the absence of changes in airway resistance or lung volume in several instances. A complete evaluation of airway function should include this test of forced expiration for greater understanding and treatment of lung disease in infancy.
Intellectual, Neuropsychological, and Achievement Outcomes in Children Six to Eight Years After Recovery from Haemophilus influenzae Meningitis
Authors: Taylor H. Gerry , Michaels Richard H. , Mazur Paula M. , Bauer Roberta E. , Liden Craig B.
Published: December 2021

Twenty-four grade school children who had sustained an earlier episode of Haemophilus influenzae type b meningitis were tested, along with a group of 24 school-aged siblings. Evaluations consisted of tests of IQ, academic achievement, and neuropsychological skills. Parents completed forms rating each child's behavioral adjustment and temperament. Available school-administered standardized achievement tests were also obtained. Information relating to the episode of meningitis was extracted from the medical charts of each child who had had meningitis in order to investigate the relationship ship of these parameters to developmental outcome. Results showed that, compared with nearest-age siblings, children who had had meningitis scored lower on performance IQ and full-scale IQ. The group that had had meningitis also performed more poorly on several neuropsychological tasks. However, the groups did not differ in verbal IQ, and they performed comparably on all academic measures. Significant behavioral adjustment problems were absent from both groups, and there were no notable differences in temperament. Although findings support the existence of postmeningitis sequelae, the selective nature of the deficiencies observed indicate that prognosis for children in the age range examined may be better than that suggested by earlier studies.
Cholesteatoma Medial to an Intact Tympanic Membrane in 34 Young Children
Authors: Schwartz Richard H. , Grundfast Kenneth M. , Feldman Bruce , Linde Richard E. , Hermansen Karen L.
Published: December 2021

Thirty-five cholesteatomas medial to intact eardrums were treated in 34 children between 1976 and 1982. Six (18%) children had never had a documented episode of otitis media. Seventeen (50%) children, in whom the lesion was diagnosed at an early stage, underwent simple excision of the cholesteatoma without the need for extensive middle ear surgery. Findings from postoperative audiograms were normal for all such children. Cholesteatoma has recurred in eight (23%) children to date. Most recurrences were diagnosed 15 months or less after surgery. Routine careful otoscopic examination is essential in order to discover cholesteatoma at an early stage and to avoid hearing loss and the need for extensive otomastoid surgery. In order to perform an accurate examination of the eardrum, a halogen-illuminated otoscope and pneumo-otoscopy should be used by the pediatrician routinely. Particular attention should be paid to the posterior-superior quadrant of the tympanic membrance where a cholesteatoma is usually located.
Effects of Kidney Transplantation on Cognitive Performance in a Pediatric Population
Authors: Fennell Robert S. , Rasbury Wiley C. , Fennell Eileen B. , Morris Mary K.
Published: December 2021

The cognitive functioning of 20 children and adolescents with end-stage renal disease was assessed 1 to 3 weeks prior to the onset of hemodialysis, and at 1 month and 1 year after successful kidney transplantation, and results were compared with those of a matched control group. A battery of intelligence, achievement, problem solving, learning, memory, and attention tasks were administered. Both groups had significantly improved scores over time on most measures. The group with renal disease exhibited significantly greater improvement than the control group from initial testing to 1 month after transplantation on the performance IQ and full-scale IQ as well as in mathematics achievement. This significant difference was not maintained, however, at 1 year after transplantation. Cognitive performance was less impaired the later the onset of renal failure or the fewer the years in end-stage renal disease. BUN nitrogen, serum creatinine levels, and BP did not consistently correlate with any of the cognitive or academic achievement measures.
Apnea Documentation for Determination of Brain Death in Children
Authors: Rowland Thomas W. , Donnelly Joseph H. , Jackson Anthony H.
Published: December 2021

Discontinuing ventilatory support for determination of respiratory drive is a recognized means of assessing clinical brain death. Methodology must include a means for assuring adequate oxygenation during the test as well as providing sufficient duration for appropriate hypercarbia. Nine patients with other findings of clinical brain death were prospectively assessed with a standardized apnea test protocol. None demonstrated spontaneous respirations. Whereas adequate oxygenation was maintained in each case, wide variability was evident in degree of hypercarbia and acidosis.
Effect of Maternal-Fetal Platelet Incompatibility on Fetal Development
Authors: PALCHAK ANDREW E. , ASTER RICHARD H. , GOTTSCHALL JEROME , OPITZ JOHN M.
Published: December 2021

To the Editor.—

The effects on the fetus of maternal-fetal incompatibility involving RBC antigens are well known. Similar effects involving platelet antigens are less well known. We should like to call attention to the dramatic and potentially lethal results of such incompatibility which currently, unless suspected, often is undiagnosed.

Recently, we studied a young married woman who has been pregnant four times. At 19 years of age, she had a first trimester therapeutic abortion. At 22 years of age, she aborted spontaneously a set of twins at 13 weeks; these twins were not studied and the pathogenesis of their demise is unknown.
Mortality and Infectious Disease Associated with Infant-Feeding Practices in Developing Countries
Authors: Jason Janine M. , Nieburg Phillip , Marks James S.
Published: December 2021

This review examines the available studies bearing on the relation between infant-feeding mode and infectious illness in the populations of less-developed countries.

A companion critical review of studies of the relationship of infant-feeding methods and infection in industrialized countries has concluded that, although laboratory studies provide biologic plausibility for a lower infection rate in breast-fed infants, an effect, if present, is apparently modest.39 The strongest evidence for a protective effect of breast-feeding in industrialized countries is for gastrointestinal (diarrheal) illness. In this review of studies among populations in developing countries we found the evidence for an important protective effect of breast-feeding against infectious illness to be much stronger. This conclusion was reached despite serious problems in the design of many of the studies reviewed.

One characteristic that distinguishes populations in less-developed countries from those of industrialized ones is the infant mortality. Even today, infant mortality for much of the world is up to ten times higher than infant mortality in the United States and Northern Europe.46 This undoubtedly reflects differences in sanitation, nutrition, housing, and other indicators of socioeconomic status. Much of the difference in rates of infant and child mortality and morbidity is attributable to high rates of infectious illness, especially gastrointestinal disease. Thus, in these populations, the positive effects of breast-feeding are of greater potential importance for the health of the infant population and should be easier to detect in clinical and epidemiologic studies.

In this review we will address the following key questions: (1) whether the method of infant feeding (breast v other) is associated with differences in rates of mortality, both overall and infectious, and in rates of infectious morbidity in less-developed countries;
Human Milk Protein and Medium-Chain Triglyceride Oil Supplementation of Human Milk: Plasma Amino Acids in Very Low-Birth-Weight Infants
Authors: Rönnholm Kai A. R. , Simell Olli , Siimes Martti A.
Published: December 2021

Fifty-one very low-birth-weight infants (birth weight <1,520 g) randomly fed either human milk or human milk supplemented with human milk protein and/or with medium-chain triglyceride (MCT) oil were observed. Plasma amino acids from these infants were studied at 2, 8, and 10 weeks. Medium-chain triglyceride oil supplementation had minimal or no influence on plasma amino acids. Human milk protein supplementation resulted in increased concentrations of all amino acids at all ages studied. The concentrations were 1.5- to threefold as compared with values in infants not given protein supplements. However, the concentrations of methionine, tyrosine, phenylalanine, and lysine remained far below values considered harmful. The age at which maximal plasma amino acid concentrations in infants given human milk protein supplementation occur coincides with the age of the lowest serum albumin concentrations in infants fed only human milk. This suggests that high plasma amino acid concentrations may hasten albumin synthesis in very low-birth-weight infants.
Changes in Auditory Brainstem Responses in Hyperbilirubinemic Infants Before and After Exchange Transfusion
Authors: Nwaesei Chukwuma G. , Van Aerde John , Boyden Marilyn , Perlman Max
Published: December 2021

Auditory brainstem responses (ABR) were evoked, before and after exchange transfusion, in an effort to determine whether hyperbilirubinemia is associated with acute effects on brainstem function of neonates. Nine full-term infants with hemolytic disease received exchange transfusion for conventional serum bilirubin concentration indications (mean 22.3 ± 1.4 mg/dL. In three infants, wave-absence before exchange transfusion was followed by appearance of the waves after exchange tranfusion. Other significant alterations observed in the group after exchange transfusion were increase of wave amplitudes and reduction of interpeak latencies (brainstem transmission time 5.80 ± 0.36 ms after exchange transfusion compared with 6.25 ± 0.30 ms before exchange transfusion, P < 0.001). These improvements are considered to have been brought about by removal of bilirubin from the body and from the brainstem during exchange transfusion. Acute brainstem toxicity appears to occur in a percentage of infants with hyperbilirubinemia at serum levels commonly seen in clinical practice. These changes appear to be rapidly reversible with exchange transfusion.
Trampoline-Related Quadriplegia: Review of the Literature and Reflections on the American Academy of Pediatrics' Position Statement
Authors: Torg Joseph S. , Das Marianne
Published: December 2021

A review of the world's literature documenting cervical spine injuries has been made in an attempt to determine common factors regarding patient characteristics, environment, injury mechanisms, and pathology. The policy statements and safety guidelines of both the American Academy of Pediatrics and athletic administrative bodies have been reviewed in order to evaluate what effect, if any, these policies and guidelines have had on documented injuries. On the basis of this review, it is believed that the AAP was ill-advised in altering its position on the use of trampolines. The opinion is presented that both the trampoline and minitrampoline are dangerous devices when used in the best of circumstances, and their use has no place in recreational, educational, or competitive gymnastics.
Upper Gastrointestinal Endoscopy in Infants: Diagnostic Usefulness and Safety
Authors: Hargrove Charles B. , Ulshen Martin H. , Shub Mitchell D.
Published: December 2021

Although fiberoptic, upper gastrointestinal (UGI) endoscopy has become an accepted diagnostic technique in the older child and adult, concerns about safety have limited the use of this procedure in infants. A 1-year experience with 49 upper gastrointestinal endoscopies in infants less than 25 months of age is reported. There were varied indications for the procedures, including upper gastrointestinal hemorrhage and obstruction, but evaluation for esophagitis secondary to gastroesophageal reflux was most common. Procedures were performed without sedation in 45% of all infants studied, including 87% of infants less than 3 months of age; procedures were well tolerated. General anesthesia was used on only three occasions. A thorough examination was always possible, and biopsies were taken whenever indicated. Only one complication, transient bradycardia, occurred in a critically ill infant. This experience demonstrates that upper gastrointestinal endoscopy is a safe and effective diagnostic aid in infants, and it can often be performed with little or no sedation.
Protective Factors in Milk and the Development of the Immune System
Authors: Hanson Lars Å. , Ahlstedt Staffan , Andersson Bengt , Carlsson Barbro , Fällström Sven P. , Mellander Lotta , Porras Oscar , Söderström Tommy , Edén Catharina Svanborg
Published: December 2021

The neonate is immature in certain immunologic functions. The slow development of secretory immunoglobin A (IgA) seems to be compensated by selective transfer of secretory IgM into exocrine secretions on mucous membranes during the first few months of life. Secretory IgA and secretory IgM antibodies against Escherichia coli and poliovirus are already found in the neonate, possibly in response to the maternal anti-idiotypic IgG antibodies transplacentally exposing the fetus. Via such a mechanism, food antibodies could occur before direct food exposure in the infant. Human milk provides large amounts of antibodies (as a crude comparison, about 50 times the amount of antibodies given to a patient with hypogammaglobulinemia). The milk antibodies, dominated by secretory IgA, protect especially against intestinal infections. The milk also contains oligosaccharide analogues to epithelial receptors for bacteria. They, as well as a number of milk components such as lactoferrin and lysozyme, may contribute to host defense. The food antibodies in human milk may influence the infant's immune response to foreign food proteins introduced during weaning.
Childhood Death and Poverty: A Study of All Childhood Deaths in Maine, 1976 to 1980
Authors: Nersesian William S. , Petit Michael R. , Shaper Ruth , Lemieux Don , Naor Ellen
Published: December 2021

All child deaths occurring from 1976 to 1980 in Maine were studied. All children who were participating in social welfare programs (Medicaid, Food Stamps, or Aid to Families with Dependent Children [AFDC]) at the time of death were categorized as children from "low-income" families. This group of children had an overall death rate 3.1 times greater than children who were not on a social welfare program at the time of death. Children from low-income families were at higher risk for disease-related deaths (3.5:1), accidental deaths (2.6:1), and homicide deaths (5.0:1), but not for suicides. These data suggest that excess mortality is occurring among infants and children from low-income families in spite of Medicaid and other poverty programs and that this excess mortality has important public health and social policy implications. Pediatricians and others interested in the well-being of children should support improvement of current health care delivery and social welfare programs, because the current system is failing to provide an optimal health outlook for every child.
In Vivo Sensitivity Test in Otitis Media: Efficacy of Antibiotics
Authors: Howie Virgil M. , Dillard Ruth , Lawrence Barbara
Published: December 2021

During a 10-year period, antibiotics were assigned in random, double-blind fashion in six combinations to treat 948 episodes of otitis media in children. Exudate from the middle ear of all patients was cultured before treatment. Three follow-up visits were conducted; the first follow-up visit was three to five days after the start of therapy, and the second and third visits were 14 and 31 days after onset of treatment. Exudates were recultured for 75% of the patients on the first follow-up visit. Comparison of treatment results showed that triple sulfonamide combined with either phenoxymethyl penicillin, or benzathine and procaine penicillin G given intramuscularly (IM) was as effective as was ampicillin or amoxicillin. Phenoxymethyl penicillin and cyclacillin alone were usually effective against pneumococci but relatively ineffective against Haemophilus influenzae. Cefaclor and trimethoprim-sulfamethoxazole produced unsatisfactory results in about half the cases caused by pneumococci or H influenzae. Although production of β-lactamase by some otitis-causing Haemophilus and Staphylococcus species may explain the ineffectiveness of some treatments, the percentage of organisms positive for β-lactamase was too small to be responsible for the poor results with certain drugs.
Sleep Problems Seen in Pediatric Practice
Authors: Lozoff Betsy , Wolf Abraham W. , Davis Nancy S.
Published: December 2021

To determine whether sleep problems commonly seen in pediatric practice, such as conflicts at bedtime and night waking, are associated with more pervasive disturbances in the child or family, two groups of healthy children were studied. Interview data from a pilot sample were examined to identify factors that might be important in sleep problems, and then the results were validated with data from the second sample. The two samples included 96 white children between 6 months and 4 years of age. In each group, approximately 30% had a sleep problem by the criteria that night waking involving parents or bedtime struggles occurred three or more nights a week for the month preceding the interview, accompanied by conflict or distress. Five experiences distinguished children with sleep problems from those without: an accident or illness in the family, unaccustomed absence of the mother during the day, maternal depressed mood(s), sleeping in the parental bed, and maternal attitude of ambivalence toward the child. These experiences correctly classified 100% of pilot and 83% of validation sample children as having a sleep problem or not. The similarity of findings in the two samples attests to the potential importance of sleep problems as an early childhood symptom. Bedtime conflicts and night waking seem to be quantifiable, easily ascertainable behavior patterns that could alert pediatric health professionals to the existence of more pervasive disturbances in child and family.
The `Dynamic Transcutaneous Po2 Histogram' or How to Deal with Immense Quantities of Monitoring Data
Authors: FALLENSTEIN F. , BUCHER H. U. , HUCH R. , HUCH A.
Published: December 2021

Monitoring of transcutaneous oxygen pressure (Po2) is a routine procedure in the management of sick newborn infants. The clinician frequently requires information on trends in transcutaneous Po2 and variability in relation to clinical procedures. However, long-term measurement of transcutaneous Po2 presents problems with documentation and analysis of the data (Fig 1).1-9

PRINCIPLE OF TRANSCUTANEOUS Po2 HISTOGRAM

To analyze transcutaneous Po2 information in a simple and efficient way, one can observe the frequency distribution of measured transcutaneous Po2 values within a desired time interval, instead of examining a long paper chart from a trend recorder. This method is shown in Fig 2.
White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship
Authors: Levy David. R.
Published: December 2021

Effective communication between doctor and patient, a skill not emphasized in medical education programs, is essential for patient satisfaction and optimal patient care. In many teaching hospitals, the doctor is commonly white and middle class and the patient black and indigent. Racial differences, even in the absence of social class differences, may have a negative impact on the quality of the doctor-patient relationship. The impact of racism is reviewed, and recommendations to enhance the relationship between white doctors and black patients, are made.
Neonatal High-Frequency Jet Ventilation: Four Years' Experience
Authors: Boros Stephen J. , Mammel Mark C. , Coleman J. Michael , Lewallen Patrick K. , Gordon Margaret J. , Bing Dennis R. , Ophoven Janice P.
Published: December 2021

During a 4-year period, 34 neonates were treated with high-frequency jet ventilation (HFJV) using two different HFJV systems. Twenty-three of the neonates had severe pulmonary air leaks, five had congenital left-sided diaphragamatic hernias, and six had end-stage respiratory failure without pulmonary air leaks. The two HFJV systems performed similarly in all pathologic conditons. Following HFJV, arterial blood gas values improved in 28 of the 34 patients (82%). Eleven patients (32%) ultimately survived. Of 23 patients with pulmonary air leaks, 17 (74%) improved, nine (39%) survived. One infant with diaphragmatic hernia and one with end-stage respiratory failure survived. Ten of 12 patients (85%) who died following eight or more hours of HFJV had significant tracheal histopathology in the region of the endotracheal tube tip. The lesions ranged from moderate erythema to severe necrotizing tracheobronchitis with total tracheal obstruction. HFJV can be useful in the treatment of severe pulmonary air leaks in neonates and may prove useful in the treatment of congenital diaphragmatic hernias. However, HFJV produces inflammatory injuries in the proximal trachea. More clinical and laboratory studies are needed to define the relative risks and benefits of this new therapy.
Neurologic Manifestations of Schoenlein-Henoch Purpura: Report of Three Cases and Review of the Literature
Authors: Belman Anita Lesgold , Leicher Carol R. , Moshé Solomon L. , Mezey Andrew P.
Published: December 2021

Three patients developed prominent neurologic symptoms and signs associated with Schoenlein-Henoch purpura. A 71/2-year-old boy was seen with status epilepticus after a 2-week history of generalized headaches, irritability, and intermittent colicky abdominal pain. A left hemiparesis and a left homonymous hemianopia with a right gaze preference that were present on initial examinations gradually resolved, but a mild left arm paresis persisted. Cutaneous, renal, and joint involvement followed initial CNS manifestations. The second patient, a 7-year-old girl, had a complex partial seizure with secondary generalization and a postictal hemiparesis seven days after presentation with classic signs of Schoenlein-Henoch purpura. Behavioral changes were noted during the acute phase of the illness. The third patient, a 13-year-old boy, developed signs of a left brachial plexopathy and transient weakness of his right leg during a complicated course of Schoenlein-Henoch purpura. Review of the world literature indicates that headaches and mental status changes are the most frequent neurologic complications of Schoenlein-Henoch purpura, followed by seizures, focal neurologic deficits, mononeuropathies, and polyradiculoneuropathies. The vasculitis of Schoenlein-Henoch purpura can involve the nervous system and may add significantly to the morbidity of the illness.
Cardiac Decompensation Following Verapamil Therapy in Infants with Supraventricular Tachycardia
Authors: Epstein Michael L. , Kiel Ernest A. , Victorica Benjamin E.
Published: December 2021

Three infants with supraventricular tachycardia and congestive cardiac failure were given verapamil intravenously. In two of the infants, the rhythm was converted to sinus, but the third infant required direct current cardioversion. However, each infant demonstrated hemodynamic decompensation shortly after verapamil administration and required cardiopulmonary resuscitation. All three patients were stabilized and their tachycardia was controlled with digoxin. All three were doing well at the time of follow-up evaluation, and there was no evidence of structural heart disease. The risk of cardiac decompensation in infants with supraventricular tachycardia and congestive cardiac failure should be kept in mind prior to administration of verapamil. Alternative methods for conversion of supraventricular tachycardia should be considered.
Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants
Authors: WISWELL THOMAS E. , SMITH FRANKLIN R. , BASS JAMES W.
Published: December 2021

In a recent report of 100 infants less than 8 months of age with urinary tract infection, it was noted that 95% of the male infants were not circumcised.1 The authors speculated from this observation that the uncircumcised male infant may have an increased susceptibility to urinary tract infection, but commented that the incidence of urinary tract infection in uncircumcised compared with circumcised infants was unknown. We report the results of a study documenting the incidence of unnary tract infection during the first year of life in a large cohort of infants born at our institution over an 18-month period and we also document the incidence of urinary tract infection in circumcised compared with uncircumcised male infants.
Epidemiologic Study of Infant Botulism in Pennsylvania: Report of the Infant Botulism Study Group
Authors: Long Sarah S.
Published: December 2021

The majority of the almost 400 confirmed cases of infant botulism in the United States have occurred in California, Pennsylvania, and Utah. In Pennsyvania, 44 of 53 (83%) cases occurred within a geographic area of Southeastern Pennsylvania which represents one tenth of the Commonwealth's area and one third of the population at risk for infant botulism. In Southeastern Pennsylvania, a map of the residences of cases circumscribes a discrete ring around Philadelphia. A case-control study performed to seek host-related risk factors, identifies the significant associations of botulism with infants who are white, breast-fed, and born at term into two-parent families with hospitalization insurance. County control studies were performed to identify differences in host-related factors between areas of high and low prevalence of botulism. Although some "protection" could be afforded Philadelphia infants by their feeding and family characteristics, the differences in case rates between Philadelphia and the botulism "ring counties" cannot be explained entirely by host-related factors. Further, the absence of botulism in counties just outside of the botulism "ring," where infants were found to have identical potential risk factors, suggests that an uneven distribution of botulinal spores in the environment is the most significant determinant of case rate.
Epstein-Barr Virus Infectious Mononucleosis in Children
Authors: Sumaya Ciro Valent , Ench Yasmin
Published: December 2021

Between 1976 and 1982, 113 children aged 6 months to 16 years with documented Epstein-Barr virus-induced infectious mononucleosis were studied prospectively, and in most instances serially. An unexpected finding was the large number of young children, less than 4 years old, with this disease. Children with infectious mononucleosis, in particular the very young, tended to have more rashes, significant neutropenia, abdominal pain (older children only), and possibly hepatosplenomegaly than have been reported in adult patients. The intensity of the characteristic relative atypical lymphocytosis found in peripheral blood was age-related; it was less in the very young. Findings of failure to thrive, otitis media, and episodes of recurrent tonsillopharyngitis appeared to be unique or more closely associated with childhood disease. Complications such as thrombocytopenia with hemorrhagic manifestations, significant airway obstruction, and neurologic problems occurred more frequently whereas jaundice occurred less frequently than noted in adult patients. Six children, all less than 4 years old, developed pneumonia during the disease course. The increased availability of Epstein-Barr virus-specific testing should continue to expand our knowledge of this disease in children of all ages.
Epstein-Barr Virus Infectious Mononucleosis in Children
Authors: Sumaya Ciro Valent , Ench Yasmin
Published: December 2021

An investigation was performed to address the need to establish the rate of positive heterophil antibody responses, oropharyngeal isolation of Epstein-Barr virus (EBV), and the evolving pattern of EBV-specific antibody responses among children with documented EBV-infectious mononucleosis. Findings showed that the rate of heterophil antibody responses appeared to increase progressively with advancing age from infancy up to 4 years, after which the rates approached values similar to that reported in young adult patients. The rapid slide test detected a heterophil antibody response as frequently as the Paul-Bunnell-Davidsohn horse cell test, except in children less than 4 years old. The decreased sensitivity found with the rapid slide test in the very young was associated with their less intense heterophil response. The younger group of children also developed a lower acute mean titer and, as a result, a decreased persistence of immunoglobulin M antibody to EBV-capsid antigen, whereas they had more frequent responses to EBV-early antigen directed to restricted component than both the older subjects and adults reported elsewhere. Antibodies to EBV-nuclear antigen, characteristically a late-onset antibody, tended to develop earlier than noted in adult patients. In contrast, the prevalence and continued excretion of EBV from oropharyngeal secretions was similar to that reported in adult patients. It is speculated that these age-related differences in host responses are associated with the ontogeny of the immunologic system.
Safety of a Higher Loading Dose of Phenobarbital in the Term Newborn
Authors: Donn Steven M. , Grasela Thaddeus H. , Goldstein Gary W.
Published: December 2021

The conventional loading dose of phenobarbital for newborn infants with hypoxic-ischemic seizures, 20 mg/kg, often fails to control convulsive activity. To determine the safety of a higher loading dose and to establish the pharmacokinetic parameters of a higher loading dose, ten severely asphyxiated term newborns were given 30 mg/kg of phenobarbital intravenously over 15 minutes. The mean serum concentration of phenobarbital two hours after loading was 30.0 ± 3.2 µg/mL, the apparent volume of distribution was 0.97 ± 0.18 L/kg, total clearance was 0.08 ± 0.03 mL/min/kg, and mean serum half-life was 148 ± 55 hours. The higher loading dose was not associated with any short-term adverse effects on cardiorespiratory function, even in spontaneously breathing infants.
Recommendations for Using Pneumococcal Vaccine in Children
Authors:   Committee on Infectious Diseases
Published: December 2021

A 23-valent pneumococcal polysaccharide vaccine licensed in the United States in 1983 replaces the 14-valent polysaccharide vaccine licensed in 1977. This statement contains new data about pneumococcal vaccine and its effectiveness that have become available since 1977 and new recommendations regarding its use in children.

PNEUMOCOCCAL DISEASE

Streptococcus pneumoniae (pneumococcus) is the most common cause of acute otitis media, and it is a frequent cause of bacterial pneumonia, bacterial meningitis, and sinusitis in children. Pneumococcus is the most common cause of bacteremia in infants and children aged 1 to 24 months; some of these children with fever and bacteremia have no evidence of a primary focus of infection.

Mortality from pneumococcal disease is highest in patients who have bacteremia or meningitis and in patients with certain underlying medical conditions. Patients at increased risk of developing severe pneumococcal disease, because of impaired immunologic response to pneumococcus, are those with sickle cell anemia, Hodgkin disease, congenital or acquired immunodeficiency, nephrotic syndrome, and splenic dysfunction, and those who have had splenectomy or organ transplantation. Certain other patients also may be at greater risk of suffering severe pneumococcal infections, such as some patients with diabetes mellitus, congestive heart failure, chronic pulmonary disease, and renal failure. Patients with CSF leakage complicating skull fracture or neurosurgical procedure may have recurrent pneumococcal meningitis.

To date, 83 pneumococcal types have been identified by the serologic properties of their capsular polysaccharides. Certain of these polysaccharides share physicochemical and antigenic properties. Ten serotypes account for the majority of pneumococcal infections in children and adults.
Absence of Major Side Effects of Nifedipine Following Treatment of Duchenne Dystrophy
Authors: MOXLEY RICHARD T.
Published: December 2021

Abnormal calcium accumulation in skeletal muscle due to altered sarcolemmal integrity may be important in the pathogenesis of Duchenne muscular dystrophy. To evaluate the potential beneficial effect of a calcium channel-blocking agent on the course of Duchenne muscular dystrophy, 105 patients were randomly selected for a double-blind 18-month study utilizing treatment with nifedipine (n = 54) or placebo (n = 51). Muscle strength, contractures, functional ability, cardiopulmonary changes, and laboratory data were monithred; the detailed results are published elsewhere.
Complications Resulting from Use of Arterial Catheters: Retrograde Flow and Rapid Elevation in Blood Pressure
Authors: Butt Warwick W. , Gow Robert , Whyte Hilary , Smallhorn Jeffrey , Koren Gideon
Published: December 2021

Arterial catheters, routinely used in neonatal intensive care units, have been associated with serious complications. In the present studies, retrograde blood flow occurring during routine flushing of peripheral and umbilical catheters is described. This retrograde flow is associated with a significant elevation of blood pressure at distant sites. These phenomena depend on the volume flushed and on the velocity of the flushing process. These phenomena can be prevented by flushing a small volume of 0.5 mL for a period of five seconds.
Association of Septic Shock Caused by Early-Onset Group B Streptococcal Sepsis and Periventricular Leukomalacia in the Preterm Infant
Authors: Faix Roger G. , Donn Steven M.
Published: December 2021

Early-onset group B streptococcal sepsis frequently produces shock in preterm infants, a condition also felt to be contributory to the development of periventricular leukomalacia. During a 2-year study period, 628 preterm infants who were admitted to the neonatal intensive care unit underwent serial sonographic brain scanning; periventricular leukomalacia was diagnosed in eight infants (1.2%). The four infants (100%) who survived group B streptococcal sepsis with septic shock developed periventricular leukomalacia, whereas none of the four survivors (0%) of septic shock caused by other organisms and three of 27 survivors (11%) of shock not caused by infection developed periventricular leukomalacia. Because of the frequency of this lesion, it is suggested that all preterm survivors of group B streptococcal sepsis with septic shock should have serial sonography screening for detection of periventricular leukomalacia. Early detection will not assure cure but may facilitate prognostication, follow-up, and earlier institution of rehabilitative therapy to produce a better outcome.
Neonatologist Versus General Pediatrician
Authors: BERGESON PAUL S.
Published: December 2021

In Reply.—

Dr. Scanlon's remarks are timely and appropriate. There are no easy answers to the dilemmas Dr Scanlon raises. Indeed, neonatologists commonly are available on an around-the-clock basis in the neonatal intensive care unit (NICU). This availability may well be one significant factor responsible for the decrease in neonatal mortality rates seen in recent years.

The Committee on Hospital Care (COHC) of the American Academy of Pediatrics has observed in its statement that "the neonatologist is much more available to the newborn than is the private pediatrician."
Management of Infants With Severe Respiratory Failure and Persistence of the Fetal Circulation, Without Hyperventilation
Authors: Wung Jen-Tien , James L. Stanley , Kilchevsky Eitan , James Edward
Published: December 2021

The successful management of 15 infants suffering from persistence of fetal pulmonary circulation and in severe respiratory failure is presented. The treatment regimen focused on minimizing barotrauma. Infants were intubated nasotracheally and ventilated with intermittent mandatory ventilation. Peak inspiratory pressures were determined by the clinical assessment of chest excursion. Ventilator settings and fractional inspiratory oxygen (FiO2) were selected to maintain a PaO2 between 50 and 70 mm Hg; PaCO2 was not a controlling parameter and was allowed to increase as high as 60 mm Hg. Hyperventilation and muscle relaxants were not used. High ventilator rate was used in ten infants who required high inspiratory pressure to maintain chest excursion, with a favorable response in five. Tolazoline was given to 14 infants of whom ten showed an improvement in oxygenation; dopamine was given to three infants who were oliguric. All infants survived, and only one infant developed chronic lung disease which was defined by the infant's need for supplemental oxygen beyond 30 days of life.
Monitoring Patients in Pediatric Intensive Care
Authors: Pollack Murray M. , Ruttimann Urs E. , Glass Nancy L. , Yeh Timothy S.
Published: December 2021

All admissions to a 16-bed multidisciplinary pediatric intensive care unit (PICU) were evaluated during two time periods totaling 13.5 months. Daily evaluations of therapeutic and monitoring care modalities were accomplished with the Therapeutic Intervention Scoring System (TISS) and daily assessments of severity of illness were done by using the Physiologic Stability Index. Of the 822 patients included in this study, 226 (27.5%) never received a therapy that could only be given in the PICU. These patients were known as the monitoring group and used 7.5% (297/3,969) of the bed days. The percentage of Therapeutic Intervention Scoring System points used by the monitoring patients was 3.6% (3,575/100,109). All patients who were monitored survived; 213 (94.2%) were classified as low mortality risk based on their level of physiologic stability. These data indicate that a significant percentage of PICU patients never receive a therapy that requires the PICU but only receive monitoring and routine care techniques. Significant reductions in PICU use could occur with more efficient usage.
Familial Vocal Cord Dysfunction
Authors: Cunningham Michael J. , Eavey Roland D. , Shannon Daniel C.
Published: December 2021

Vocal cord paralysis is a common cause of neonatal stridor. Familial vocal cord dysfunction, however, is unusual. All three siblings in one family had neonatal stridor. Vocal cord dysfunction was confirmed after endoscopic examination in two of the children; a temporary tracheotomy was required by one child. Results of evaluation, including pulmonary function tests, suggest discrete dysfunction localized to the neuromuscular pathway responsible for vocal cord abduction. Endoscopy is of prime importance in the diagnosis of vocal cord dysfunction. In considering therapy, the physician must weigh both the potentially life-threatening nature of vocal cord paralysis, as well as the likelihood of eventual spontaneous resolution of many familial and idiopathic cases.
Extracorporeal Circulation in Neonatal Respiratory Failure: A Prospective Randomized Study
Authors: WARE JAMES H. , EPSTEIN MICHAEL F.
Published: December 2021

Bartlett et al,1 in last month's issue of Pediatrics, report the results of an innovative clinical trial of extracorporeal membrane oxygenation (ECMO) in the treatment of infants with respiratory failure. The authors report that, prior to introducing ECMO, infants meeting their criteria for respiratory failure had an 80% or greater chance of early death despite optimal conventional care. Because continued randomization in a 50-50 fashion would have presented ethical problems if early results were very favorable to ECMO, the investigators employed an "adaptive allocation" scheme, that is, a design that modified the treatment assignment probabilities according to results for previously randomized patients. The design chosen was a "randomized play-the-winner" design.2
Health Hazards of Cow's Milk
Authors:   Swiss Pediatric Association,   Committee on Nutrition, TÖNZ O.
Published: December 2021

To the Editor.—

In a recent Pediatrics' supplement, Oski1 reviewed potential hazards of bovine milk-feeding and came to the conclusion that:

Whole bovine milk should not be fed to infants during the first year of life because of its association with occult gastrointestinal bleeding, iron deficiency anemia, and cow's milk allergy. The consumption of whole milk after the first year of life should be discouraged because of its potential role in a variety of disorders including atherosclerosis, recurrent abdominal pain of childhood, cataracts, milk-borne infections, and juvenile delinquency.
Recurrent Bacterial Meningitis: Coronal Thin-Section Cranial Computed Tomography to Delineate Anatomic Defects
Authors: Steele Russell W. , McConnell James R. , Jacobs Richard F. , Mawk John R.
Published: December 2021

Three patients with histories of recurrent bacterial meningitis were previously examined with skull and sinus radiographs, routine cranial computed tomography, intrathecal radioisotope tracer studies, and immunologic evaluation. None of these studies were diagnostic. Pneumococcal vaccine and prophylactic penicillin therapy were ineffective in preventing recurrent episodes in two cases. Thin-section (2-mm) direct coronal computed cranial tomography demonstrated anatomic defects in all three patients. The use of metrizamide cisternography was not necessary to diagnose the defects. All patients had basiethmoidal encephaloceles which were repaired surgically. Direct coronal computed tomography offers a relatively easy noninvasive method for delineating anatomic abnormalities in patients with recurrent meningitis.