bluuebunny/crossref_metadata_2025 huggingface dataset:
Annual Summary of Vital Statistics—1991
Authors: Wegman Myron E.
Published: December 2021

Between 1990 and 1991, provisional data show that the infant mortality rate decreased again, from 9.1 to 8.9, a decline of 2% in contrast to the 7% decline from 1989 to 1990. Birth, death, and marriage rates were also lower, but the divorce rate stayed at about the same level as in 1990. Natural increase in the population, excess of births over deaths, was less than 2 million, 4% less than the increase in 1990.

Detailed analysis of changes and of the influence of factors like age and race requires final data; at the time of preparation of this report final birth and death data were available only through 1989. For a variety of reasons, including staff shortages and delays in receipt of state data by the National Center for Health Statistics (NCHS), final data for 1990, which would usually have been available in late August 1992, are not expected before early 1993.

Unlike recent years, the decline in the infant mortality rate was only in the neonatal component, which decreased 3.6%. Postneonatal mortality increased, for the first time in many years, by 1.6%, suggesting that the decline in the total is related more to therapeutic advances in neonatology than to improved prevention.

Internationally, newly independent Latvia was added to the list of countries with rates less than 15, but Costa Rica was deleted. With the reunification of Germany the list shrank to 28 and, by default, the United States moved up from 21st to 20th.

Some 12.5 million births, less than 9% of the world total, took place in countries with under-5 mortality rates of less than 20 per 1000. At the other end of the scale, 42% of the world's births occurred in countries with under-5 mortality rates of more than 140 per 1000. The median under-5 mortality rate for those countries in 1990 was 189 per 1000, meaning that almost 20% of the infants born alive in these countries died before their fifth birthday.
Fever Revisited
Authors: Kluger Matthew J.
Published: December 2021

It has been 12 years since I last wrote a Commentary on fever for Pediatrics.29 As I pointed out in that review, fever, which occurs in response to infection or trauma, should be differentiated from "hyperthermia." During fever, the host behaves as if the temperature around which it is regulating (its thermoregulatory "set-point") were elevated. As such, during the rising phase of fever, the infected person will often shiver (increases heat production), will be peripherally vasoconstricted (a response that reduces heat loss), and will crawl under the covers or wear heavier clothing (behavioral responses that decrease heat loss). During hyperthermia, the core body temperature is above the thermoregulatory set-point, and the individual uses both physiological and behavioral means to lower body temperature. This is what happens as a result of exercising, particularly in a warm environment, or as a result of sitting in a sauna. When a fever "breaks" it is thought that the thermoregulatory set-point has returned toward normal, and it is at this time that the individual is hyperthermic. This is why the person will feel warm and will sweat during defervescence.

Since 1974 it has been known that fever has had a long phylogenetic history.63 Fevers occur not only in infected birds and mammals, but also in infected reptiles, amphibians, fishes, and even insects (Table 1). The thermoregulatory set-point has risen in the infected "cold-blooded" organisms; and as a result, they behaviorally seek a warmer microclimate. Individuals who have tropical fish may have noticed that when their fish are sick, they tend to congregate near the light (or heat source). I suspect this is an attempt to get their body temperatures up to their raised thermoregulatory set-point.

WHAT CAUSES THE RISE IN THERMOREGULATORY SET-POINT?

Most evidence indicates that some stimulus (eg, bacterial endotoxin or viruses) causes the release of an endogenous pyrogen (EP), a small molecular weight protein, from macrophages. EP travels through the circulation to the brain, where in the anterior hypothalamus it causes a rise in set-point, presumably by causing an increase in prostaglandin E2. Shortly after the first cytokines were identified, most investigators working in the area of temperature regulation and fever concluded that the cytokine, interleukin-1 (IL-1), was the circulating EP. IL-1, of which there are two forms: α and β, are thought to be responsible for numerous immune and nonimmune host-defense responses.
Poisoning Prevention Knowledge and Practices of Parents After a Childhood Poisoning Incident
Authors: Woolf Alan D. , Saperstein Arlyne , Forjuoh Samuel
Published: December 2021

This study investigated the effectiveness of a poison center-initiated mailed intervention on improving the preventive practices of families whose preschool child had recently experienced a poisoning incident. A low-cost, mailed poisoning prevention packet consisting of telephone stickers, a $1 coupon for syrup of ipecac, one slide-style cabinet lock, a nine-step checklist for "poison-proofing" the home, pamphlets, and a cover letter was tested prospectively on a population of parents calling a poison center for advice about possible poisoning exposures involving their preschool children. Parents without ipecac 1 week after the incident were randomized so that half received the mailed intervention. A "blind" follow-up telephone interview was conducted 3 months later. Of the 336 original families enrolled in the study, 301 (90% retention) completed the follow-up interview. Those who had received the intervention were more likely to have a telephone sticker than control families (78% vs 39%; P < .0001) and were more likely to be using at least one slide lock in the home (59% vs 40%; P < .001). However, intervention families were no more likely to have ipecac on hand than control families (57% vs 52%; P = not significant) and did not indicate a higher rate of compliance with suggested changes in other behaviors and practices to prevent poisonings. A poisoning recurrence rate of 3.7% was seen in the total sample during the 3-month period of surveillance; there was no difference between groups in recurrence rate. Even after a poisoning event, parents may not be sufficiently motivated to take poisoning prevention measures on their own. Poison centers can serve as lead agencies in developing effective prevention technologies for reaching out to large numbers of high-risk families. One such technology is a mailed intervention, which can be effective if it removes barriers to compliance with poisoning prevention advice.
Persistent Pulmonary Hypertension in Premature Neonates With Severe Respiratory Distress Syndrome
Authors: Walther Frans J. , Benders Manon J. , Leighton John O.
Published: December 2021

Cardiac catheterization studies have demonstrated that Doppler-derived flow velocities in the ductal flow jet and the left pulmonary artery accurately predict the aortopulmonary pressure difference and left-to-right shunt size in newborns. To assess the presence of persistent pulmonary hypertension in premature newborns with various degrees of respiratory distress syndrome (RDS) severity, we estimated pulmonary artery pressure from the aortopulmonary pressure difference and pulmonary blood flow from the left pulmonary artery flow velocity with color-flow-directed, pulsed Doppler echocardiography. Seventy-nine premature neonates were divided into three groups—no or mild RDS (n = 27), severe RDS (n = 38), and fatal RDS (n = 14)—and compared with a group of healthy term neonates (n = 34). In premature and term neonates with no/mild RDS the mean ± SEM aortopulmonary pressure difference increased from 7.3 ± 0.4 and 6.6 ± 0.5 mm Hg to 22.8 ± 1.4 and 21.4 ± 1.1 mm Hg over the first 24 hours (P < .001). The mean aortopulmonary pressure difference was 0.9 ± 0.3 mm Hg during the first 72 hours in neonates with fatal RDS, but increased from 1.5 ± 0.3 mm Hg at 4 hours to 7.4 ± 0.6 at 24 hours and 21.5 ± 0.7 mm Hg at 72 hours of age in neonates with severe RDS. Left pulmonary artery velocity time integrals were 18.3 ± 0.5 cm in premature and 18.8 ± 0.5 cm in term neonates with no/mild RDS at 12 hours vs 11.2 ± 0.4 cm in neonates with severe and 9.9 ± 0.5 cm in neonates with fatal RDS (P < .001). At 36 hours of age pulmonary blood flow velocity in neonates with severe RDS had caught up with that of those with no/mild RDS, but was only 11.6 ± 0.6 cm in neonates with fatal RDS (P < .001). These data indicate that persistent pulmonary hypertension and large right-to-left shunts via the ductus are common findings in small premature neonates with severe RDS and are predictive of early demise.
Systemic Infections Due to Streptococcus pneumoniae Relatively Resistant to Penicillin in a Children's Hospital: Clinical Management and Outcome
Authors: Tan Tina Q. , Mason Edward O. , Kaplan Sheldon L.
Published: December 2021

Streptococcus pneumoniae isolates relatively (0.1 µg/mL < minimum inhibitory concentration < 1.0 µg/mL) resistant to penicillin (RRP) have been recovered worldwide, but reports of therapy and outcome of systemic infections due to these strains are limited. This retrospective study of prospectively identified patients reviews the clinical features, management, and outcome of 19 children with systemic infections due to S pneumoniae. From January 1, 1989 to December 31, 1991, 13 of 244 blood (5.3%) and 4 of 32 cerebrospinal fluid (12.5%) pneumococcal isolates were relatively resistant to penicillin. The serotypes were as follows: 14 (12 isolates), 6 (4 isolates), 19 (2 isolates), 23 (1 isolate). One peritoneal fluid isolate and one joint fluid isolate were also relatively resistant to penicillin. The mean age of the 19 patients was 30 months (range 5 to 104 months), and five children had underlying disorders. Eleven children (nine inpatients) were treated initially with a parenteral cephalosporin. Six patients were treated as outpatients, and all had (occult) bacteremia. Three of these patients received ceftriaxone intramuscularly in the emergency department; five were treated with amoxicillin/clavulanic acid, and one received amoxicillin. Seven of 13 children treated in the hospital became afebrile in 48 hours. Three others were afebrile from the time of admission. Repeat blood cultures obtained within 24 to 48 hours after therapy was initiated were sterile in 10 children. All but one child responded to initial therapy. The recovery of S pneumoniae isolates relatively resistant to penicillin has increased in our hospital during the last 3 years. This large series of systemic infections in children due to pneumococci relatively resistant to penicillin supports the general recommendations that bacteremia alone can be adequately treated, in most cases, with penicillins or cephalosporins and that third generation cephalosporins are generally adequate therapy for meningitis due to these organisms.
Tocopherol Levels in Infants ≤1000 Grams Receiving MVI Pediatric
Authors: AMORDE-SPALDING KAREN , D'HARLINGUE ARTHUR E. , PHILLIPS BARRY L. , BYRNE WILLIAM J. , CHENG K. STEVE , COOK NANCY E. , IRIAS JULIAN J.
Published: December 2021

Achieving vitamin E sufficiency in the premature infant during parenteral nutrition requires early intravenous vitamin E supplementation. The optimal dose of intravenously administered vitamin E has not been determined. The antioxidant properties of vitamin E have led to its prophylactic use in the prevention of retinopathy of prematurity and intraventricular hemorrhage in premature infants, with variable results.1-4 Risks associated with pharmacologic doses of vitamin E include necrotizing enterocolitis and sepsis, and such adverse effects may be related to high plasma vitamin E levels.3

A plasma vitamin E level of 0.5 mg/dL is considered sufficient in premature infants.5 Johnson recomended that vitamin E levels in premature infants be maintained in a range of 1.0 to 3.0 mg/dL.
Even Advantaged Children Show Cognitive Deficits From Low-Level Lead Toxicity
Authors: CUMMINS SUSAN K. , GOLDMAN LYNN R.
Published: December 2021

Over the past fifteen years, knowledge of the spectrum of lead neurotoxicity has increased dramatically. Since 1979, when Needleman and colleagues1 showed that deciduous tooth lead levels were inversely related to intellectual performance and behavior in school-age children, many well-designed epidemiological studies have confirmed that low-level, subclinical lead exposure in early life is associated with decrements in childhood cognitive performance.2 These human findings cohere with substantial primate evidence, which consistently demonstrates measurable and long-lasting neurodevelopmental deficits from exposure to low levels of lead.3

In response to compelling evidence of neurotoxicity from low-level lead exposure, the United States Centers for Disease Control (CDC) issued a revised lead statement—Preventing Lead Poisoning in Young Children—in October 1991.4
Predicting Preschool Behavior Problems From Temperament and Other Variables in Infancy
Authors: Oberklaid Frank , Sanson Ann , Pedlow Robert , Prior Margot
Published: December 2021

There is uncertainty about the relationship between difficult temperament in infancy and reported problem behaviors later in childhood. In this study data from a large, representative community cohort (total N studied = 1583) were used to determine whether preschool behavior problems (at age 4 to 5 years) could be predicted from difficult temperament and other variables in infancy. Maternal ratings of difficult temperament on the Revised Infant Temperament Questionnaire predicted only 17.5% of those with preschool behavior problems, a percentage not significantly greater than the 14% of the total sample rated as having problems. There was some improvement in prediction when difficult temperament was added to other variables such as male sex (28%). However, mothers' overall rating of temperament was a more powerful predictor of preschool behavior problems, both alone (26.0%) and in combination with other variables such as perinatal stress (36.8%), male sex (29.5%), and non-Australian parent (29.4%). Similarly, maternal reports of infant behavior problems was a more powerful predictor of preschool behavior problems both alone (21.8%) and in combination with male sex (24.6%), low socioeconomic status (26.1%), non-Australian parent (21.8%), and nurse's overall rating of temperament (21. 8%). The best consistent predictor of later problems was the combination of mothers' overall rating of temperament and maternal reports of infant behavior problems (27.0%), especially when combined with other infant variables such as perinatal stress (35.3%), male sex (31. 5%), and non-Australian parent (30.0%). It is concluded that difficult temperament in infancy, as traditionally conceptualized and measured on the Revised Infant Temperament Questionnaire, is not on its own significantly associated with behavior problems at 4 to 5 years of age. Of far greater importance for clinicians is the significant relationship between preschool behavior problems and maternal perceptions of difficult temperament and behavior in infancy.
Foreign Body Ingestions in Children: Risk of Complication Varies With Site of Initial Health Care Contact
Authors: Paul Ronald I. , Christoffel Katherine Kaufer , Binns Helen J. , Jaffe David M. ,   The Pediatric Practice Research Group
Published: December 2021

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) Patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (x2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.
Thrombocytopenia Associated With Acute Hepatitis B Infection
Authors: ROMERO RENE , KLEINMAN RONALD E.
Published: December 2021

Acute hepatitis B virus (HBV) infection in childhood is often subclinical. Fever, abdominal pain, anorexia, and jaundice are the most common findings in those 10% to 20% of children who are symptomatic.1 Rarely, urticarial rashes or arthralgias may precede these common symptoms and serum transaminase elevations.2 In this report, we describe the first case of isolated thrombocytopenia associated with acute HBV infection occurring in a child. The findings provide further supporting evidence for the ability of HBV to cause hematologic derangements. Since immune thrombocytopenic purpura (ITP) of childhood is a relatively common disorder, often following acute viral infections, isolated thrombocytopenia occurring in the setting of acute HBV infection can present diagnostic difficulties, with significant therapeutic implications.
Could the Childhood Vaccine Act Be Bad?
Authors: HALL CAROLINE BREESE
Published: December 2021

In Reply.—

The immediate problem of cost is certainly a barrier to the acceptability of the hepatitis B universal infant and adolescent immunization program. Whereas I agree that the mechanism of sole purchase may result in the detrimental and devastating effects you suggest, is it not possible to suggest that various groups of physicians or clinics combine to seek bulk purchase rates from all manufacturers? Could we encourage the various manufacturers to offer lowered bulk purchase rates, concurrently encouraging and sustaining commercial competitiveness? My assumption would be that the lowered bulk purchase price would not be detrimental to the manufacturer and their needed resources for production and research, as costs could be saved in distribution, sales, and greater use of the vaccines.
Mythology of Lead Poisoning
Authors: NEEDLEMAN HERBERT L.
Published: December 2021

In Reply.—

I thank Dr Lakatos for his generous comments. His finding that DPA reduces bilirubin levels in neonates is intriguing; whether this is related to neonatal lead levels is unknown. Considerable work needs to be done before chelation can be considered as a therapy for newborn lead burdens.

Banner et al are concerned about the "mythology surrounding the issue of lead poisoning and its treatment," but they manage to propagate a few new myths of their own.
Questions about Bilirubin
Authors: SALERNO MARK , ZACKIN MICHAEL , CHARNEY EVAN
Published: December 2021

To the Editor.—

We are responding to the recent article entitled "Hyperbilirubinemia in Low Birth Weight Infants and Outcome at 5 Years of Age"1 as well as its predecessor "Hyperbilirubinemia in Preterm Infants and Neurodevelopmental Outcome at 2 Years of Age."2

Both articles are equally impressive for the quality of follow-up and the careful analysis of the data. However, there are several questions that merit clarification:

1. Three hundred sixty-one children from the original cohort died within the first 2 years of life, or 27% of the original cohort.
Day Care and Teenage Mothers: Nurturing the Mother-Child Dyad
Authors: McAnarney Elizabeth R. , Lawrence Ruth A.
Published: December 2021

Children of adolescent mothers do not fare well cognitively or behaviorally over time. Both short-term and long-term studies corroborate these findings. Our preliminary data help us focus on the vulnerabilities and strengths of young mothers in their interactions with their children. We suggest, on the basis of these preliminary data, that intervention be directed toward nurturing the young mother and her infant or child in a day-care setting so that she can better learn to nurture her child. The gains to young mothers and children as well as to society will be substantial if we can decrease the very distressing morbidity observed long-term in the children of adolescent mothers.
The Pediatrician's Role in Helping Parents With Out-of-Home Child Care
Authors: Donahoe Eileen Chamberlain , Donahoe John Joseph
Published: December 2021

The purpose of this paper is to identify a variety of parental concerns about child care and to suggest ways in which pediatricians and child care specialists could help ensure that children receive the best care possible.

Most parents are well aware that the decisions they make about their child's care are central to the child's well-being. Children in full-time care spend a significant portion of their day in the child care setting. Just as a good home is important to children's development, the quality of the child's day care will impact his or her physical health, mental development, and emotional security.

Generally, parents choose a child care arrangement with the hope and belief that the care will be beneficial. Despite good intentions and much expended energy, the care of the child does not always turn out to be optimal. There are often competing concerns about cost and quality, and gaps between what is sought and what is available. Furthermore, many parents experience a high degree of stress about their child care. Some of the stress stems from the complicated logistics associated with getting their child to and from child care. Much of it, however, is caused by the underlying worry that the care may turn out to be detrimental to the child.

Pediatricians and child care specialists could be of great help to parents, both in teaching them how to make better choices about child care and in alleviating much of the stress they feel about it. As a group, pediatricians are unique in that they have both wide access to parents and a high degree of credibility in terms of matters related to the welfare of children.
International Perspectives on Child Care Policies and Programs
Authors: Kamerman Sheila B.
Published: December 2021

Child development research is more extensive and more sophisticated in the United States than in any other country in the world. US policy makers have access to more and better information about the factors known to enhance or impede good child development than those in almost any other country. Nonetheless, the United States lags far behind almost all the major advanced industrialized countries with regard to supply, quality, and affordability of out-of-home child care services for children under the age at which compulsory school begins (5, 6, or 7 years).

This paper provides a brief overview of child care internationally, primarily in northern and western Europe, the leaders in this field. The objective is to document the availability and quality of child care services and related policies in these countries. The paper begins by defining the terms that will be used in discussing child care internationally. The major focus is on identifying and describing the policy choices that the advanced, industrialized, western countries have made regarding child care for young children of different ages (preschoolers and infants).

DEFINING THE TERMS

The child care programs I will describe include preschools (kindergartens, prekindergartens, compensatory early-education programs, nursery schools); day-care centers (nurseries, creches); and family-day-care-homes (both regulated and unregulated). Relative care, occasional baby-sitting, and care provided within a child's own home are not included in this discussion, nor are programs for children with special needs (handicapped children). Nor, because of space limitations, are before- and after-school programs covered.

The major cross-national differences have to do with the financing of services and the extent of the role of the public sector; the predominance of the education, health, or social welfare system in delivering the services; the proportion of children of different ages served by these programs; whether services are limited to the children of working mothers; and the quality of the care provided.
Putting a Child in Day Care: Issues for Working Parents
Authors: Brazelton T. Berry
Published: December 2021

In 1981, more than half the mothers in the United States were employed outside the home. By 1990, it was predicted that 70% of children would have two working parents. The number has been increasing each year since World War II, and 10 times as many mothers of small children work now as did in 1945. Now it is more culturally acceptable than even before for mothers to have jobs.

Even so, there is still a strong bias against mothers leaving their babies in substitute care unless it is absolutely necessary. Society does not yet whole-heartedly support working mothers and their choices about substitute care.

We do not have enough studies yet to know about the issues for the infant. The studies we do have are likely to be biased or based on experiences in special, often privileged populations. We need to know when it is safest for the child's future development to have to relate to two or three caregivers; what will be the effects of a group care situation on a baby's development; when babies are best able to find what they need from caregivers other than their parents; when parents are best able to separate from their babies without feeling too grieved at the loss. In a word, we need information on which to base general guidelines for parents. For it could be that the most subtle, hard-to-deal-with pressure on young adults comes indirectly from society's ambivalent and discordant attitudes, which create a void of values in which the building and nurturing of a family becomes very difficult.
Situational and Sociodemographic Characteristics of Children Infected With Human Immunodeficiency Virus From Pediatric Sexual Abuse
Authors: Gellert George A. , Durfee Michael J. , Berkowitz Carol D. , Higgins Kathleen V. , Tubiolo Vincent C.
Published: December 2021

This study assessed the situational and sociodemographic characteristics of children infected with human immunodeficiency virus (HIV) from pediatric sexual abuse. A letter of inquiry was sent to 2147 professionals across health and social service disciplines involved with child abuse assessment, treatment, and prevention. Respondents working in programs where HIV antibody testing of abuse victims occurs and who had identified HIV infection in one or more abused children were sent a survey to assess the demographics of victims, the family/living situation where abuse occurred, alternative risks for HIV infection, bases for diagnosis of sexual abuse and for HIV antibody testing, and profiles of the perpetrator and type of abuse. Of 5622 estimated HIV antibody tests conducted during 113 198 sex abuse assessments, 28 children were infected with HIV and lacked any alternative transmission route to that of sexual abuse. A total of 41 HIV-infected children with a history of sexual abuse were identified. Thirteen cases had alternative risk factors and were excluded from analysis. Sixty-four percent of the 28 victims with sexual abuse as the sole risk factor were female and 71% were African-American. The mean age was 9 years. Coinfection with another sexually transmitted disease (STD) occurred in 9 (33%) cases. Sexual abuse was diagnosed on the basis of a victim disclosure in 21 (75%) cases. The basis for HIV antibody testing was physical findings suggestive of HIV infection in 9 (32%) cases, HIV-seropositive or high-risk perpetrator in 6 (21%) and 2 (7%) cases, respectively, and the presence of another STD in the victim in 4 (14%) cases. Perpetrators were a child's parent in 10 (42%) cases and another relative in 6 (25%) cases. Perpetrators had behavioral risk factors for or signs/symptoms of HIV infection in 14 (58%) cases. The serostatus of perpetrators was known at time of abuse assessment in 16 (67%) cases and all were seropositive. Duration and form of abusive acts were variable, with 3 victims reporting a single episode and 13 (68%) reporting 6 or more episodes. Penile vaginal and/or rectal penetration was reported in only 50% of cases. It is concluded that sexual abuse must be considered as a potential, although infrequent, mode of transmission of HIV infection in children. Children who have been abused should be evaluated selectively for HIV infection particularly if the perpetrator is known to be HIV seropositive or engages in HIV high-risk behavior, if abuse occurred in a geographic area of high disease prevalence, and if the child has symptoms of HIV infection or another STD. Children who are found to be HIV infected and lack risk factors such as prior transfusion or maternal (perinatal) infection should be assessed for pediatric sexual abuse.
Hispanic Children With Asthma: Morbidity
Authors: Wood Pamela R. , Hidalgo Humberto A. , Prihoda Thomas J. , Kromer Megan E.
Published: December 2021

Hispanic children represent a large and growing segment of the poor and disadvantaged children in our country. Asthma and other chronic respiratory diseases have a significant impact on poor children. Yet there are few descriptions of the specific morbidities and barriers to health that Hispanic children with asthma encounter, and data on predictors of morbidity among these children are unavailable. The purpose of this study is to describe the morbidity associated with asthma in Hispanic children and to identify factors that predict morbidity. A group of Hispanic children with moderate asthma followed in the clinics of the University of Texas Health Science Center at San Antonio were studied. Children aged 6 to 16 years with at least two acute-care visits or one hospitalization for asthma during the previous year were enrolled. Data sources included standardized questionnaires, spirometry, medical records, and school attendance records. Seventy-eight Hispanic children were enrolled in the study (mean age = 9.4 ± 2.7 [SD]; 62% male). Fifty-two (67%) of children had been hospitalized previously. The other morbidity variables (mean ± SD) were number of days/week impaired (1.1 ± 1.2), number of days absent from school per year (13 ± 9.6), number of acute-care visits per year (3.3 ± 2.4), and number of hospital admissions per year (0.6 ± 0.8). The mean forced expiratory volume in 1 second/forced vital capacity was 79.3% (±9.1) and the mean forced expiratory flow, mid-expiratory phase, percent predicted was 69.9% (±25. 1). Thirty-four children (44%) were exposed to cigarette smoke in the home. Parents answered an average of 86% (±12%) of questions about asthma correctly, but they made more errors in answering medication questions. Mean Impact-on-Family score was high (45.6 ± 6.4). Multiple regression analysis showed that Total Impact-on-Family scores were significantly increased if there was a smoker in the household and decreased when knowledge about asthma was high. Spirometry results (n = 45) did not predict any of the morbidity variables. This study identifies two factors associated with morbidity in Hispanic children with asthma that must be addressed in an intervention program: knowledge about asthma and parental smoking in the home.
Patterns of Smokeless Tobacco Use by Young Adolescents
Authors: Gottlieb Anita , Pope Sandra K. , Rickert Vaughn I. , Hardin Brian H.
Published: December 2021

The use of smokeless tobacco products by adolescents has reportedly increased. The purpose of this study was to examine the use of smokeless tobacco by young adolescents across geographic locations and to look at patterns of use and variables associated with continued use beyond experimentation. Participants were 2018 students in sixth through ninth grades. Forty-five percent were male and 76% were white. Use of smokeless tobacco products was reported by 12% of the total population, and 25% reported smoking. Smokeless tobacco use was associated with cigarette smoking, alcohol use, and parental substance abuse. Those reporting alcohol use were more than four times more likely to be users of smokeless tobacco than nondrinkers. We found increased age, being male, being white, smoking, drinking, perceived effects of smokeless tobacco use, and friends' smoking behavior to be significantly associated with continued use beyond experimentation. Smokeless tobacco use was reportedly greater in rural areas. Adolescents who reported initiating use between 6 and 8 years of age were using on a more frequent basis than those who had initiated use when older. This study demonstrated the need for targeting elementary schools for educational interventions aimed at reducing smokeless tobacco use.
Toxic Hydroperoxides in Intravenous Lipid Emulsions Used in Preterm Infants
Authors: Helbock Harold J. , Motchnik Paul A. , Ames Bruce N.
Published: December 2021

The unsaturated fatty acids that make up a large component of the lipid emulsion Intralipid are highly susceptible to peroxidation, and the products of this reaction could explain the toxicity that has been associated with the administration of some emulsions. Lipid peroxidation produces hydroperoxides, which can alter arachidonic acid metabolism or react to form organic free radicals, which then stimulate a cascade of damage to endogenous lipids. The lipid hydroperoxides and their breakdown products are also mutagens and carcinogens. To determine the degree of lipid peroxidation in Intralipid, we measured the lipid hydroperoxide content of three lots of 20% Intralipid using high-performance liquid chromatography with chemiluminescence detection. The average concentration was 290 ± 29 µmol/L (SEM) lipid hydroperoxides (n = 15), a large portion of which was made up of trilinoleate derivatives. Measurements made on Intralipid samples collected from the end of the intravenous tubing after a 20-hour infusion cycle were not significantly different from measurements made on newly opened bottles. The lipid hydroperoxide content of some lipid emulsions may represent a clinically significant risk to premature infants, particularly those with preexisting lung disease.
Primary Hyperlipidemia in a Pediatric Population: Classification and Effect of Dietary Treatment
Authors: Polonsky Sheldon M. , Bellet Paul S. , Sprecher Dennis L.
Published: December 2021

Patients seen at a pediatric lipid clinic over a 27-month period were reviewed retrospectively to evaluate types of primary lipid disorders and effect of dietary treatment at the first follow-up visit. One hundred eighty-two patients were classified into one of four categories: (1) elevated low-density lipoprotein cholesterol (LDL-C) with LDL-C > 95th percentile (32%); (2) isolated triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) abnormalities, with TG > 95th percentile and/or HDL-C < 5th percentile (30%); (3) borderline LDL-C, TG, or HDL-C (29%); (4) normal (9%). The American Heart Association Step-One Diet was prescribed for all patients older than 2 years, and they received extensive nutritional and risk-management counseling. Of these patients, 59 (32%) returned for at least one follow-up visit and mean changes in lipid values between initial and first follow-up visits were evaluated. Levels of LDL-C decreased by 24 mg/dL in 22 patients with elevated LDL-C levels. Triglyceride levels decreased by a mean of 22 mg/dL and HDL-C increased by a mean of 4 mg/dL in 21 patients with isolated TG/HDL-C abnormalities. Levels of LDL-C tended to rise in this group, but not to a significant degree. A new finding of this report is that screening for total cholesterol results in the identification of many children with TG or HDL-C abnormalities alone and that the Step-One Diet appears to be effective in improving both TG and HDL-C levels in these patients.
Does Television Viewing Increase Obesity and Reduce Physical Activity? Cross-sectional and Longitudinal Analyses Among Adolescent Girls
Authors: Robinson Thomas N. , Hammer Lawrence D. , Wilson Darrell M. , Killen Joel D. , Kraemer Helena C. , Hayward Chris , Taylor C. Barr
Published: December 2021

To examine the relationships between hours of television viewing and adiposity and physical activity among female adolescents, a cohort study with follow-up assessments 7, 14, and 24 months after baseline was conducted. All sixth- and seventh-grade girls (N = 971) attending four northern California middle schools were eligible to participate. Six hundred seventy-one students had sufficient data for baseline cross-sectional analyses, and 279 students in a no-intervention cohort had sufficient data for longitudinal analyses. The baseline sample had a mean age of 12.4 years and was 43% white, 22% Asian, 21% Latino, 6% Pacific Islander, 4% black, 2% American Indian, and 2% other. Hours of after-school television viewing, level of physical activity, and stage of sexual maturation were assessed with self-report instruments. Height, weight, and triceps skinfold thickness were measured and body mass index (ratio of weight [in kilograms] to height [in meters] squared) and triceps skinfold thickness were adjusted by level of sexual maturity for the analyses. Baseline hours of after-school television viewing was not significantly associated with either baseline or longitudinal change in body mass index or triceps skinfold thickness. Baseline hours of after-school television viewing was weakly negatively associated with level of physical activity in cross-sectional analyses but not significantly associated with change in level of physical activity over time. All results were essentially unchanged when adjusted for age, race, parent education, and parent fatness. Among adolescent girls, television viewing time appears to have only weak, if any, meaningful associations with adiposity, physical activity, or change in either over time.
Listening to Parents
Authors: O'CONNELL DENIS F. X.
Published: December 2021

To the Editor.—

I found the article by Wood et al1 to be very interesting. The quality of health care for both the poor and nonpoor is an important issue. Under "Discussion," five potential explanations are given, and later in the article it is mentioned that adequate comprehension and retention of information are additional crucial elements to the physician-family partnership. I feel that the latter is a primary explanation and should be listed with the other potential explanations.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: BRENT ROBERT L.
Published: December 2021

In Reply.—

I would like to thank the scores of readers who wrote and called to tell me how much they enjoyed and appreciated the article dealing with the role of academic clinical chairmen.1

Dr Strasburger emphasizes one of the points addressed in my article. As stated, this article "is directed toward deans and search committees, because they frequently have criteria for selecting chairmen that do not include the personal qualities discussed in this manuscript." If any changes are to be instituted in the charge to search committees they would have to be determined by the dean and faculty.
The Vermont-Oxford Trials Network: Very Low Birth Weight Outcomes for 1990
Authors:   The Investigators of the Vermont-Oxford Trials Network Database Project
Published: December 2021

This report describes the Vermont-Oxford Trials Network, a voluntary collaborative research network, and summarizes the outcomes and medical interventions for very low birth weight infants at participating centers in 1990. The Vermont-Oxford Trials Network included 36 centers in 1990 (11% university hospitals, 44% university affiliates, 44% nonaffiliated) with a total of 2961 infants weighing 501 to 1500 g (median 73 infants, range 5 to 172). Eighty percent of the infants were inborn and 65% were white. The overall network frequencies for selected interventions and outcomes were as follows: prenatal care, 90%; a complete course of antenatal corticosteroids, 12%; cesarean section, 56%; surfactant therapy, 49%; postnatal steroids for chronic lung disease, 16%; high-frequency ventilation, 4%; patent ductus arteriosus, 31%; necrotizing enterocolitis, 6%; bacterial sepsis, 16%; and intraventricular hemorrhage, 26%. By 28 days, 15% of the infants had died and 8% had been transferred, whereas by discharge 18% had died and 18% had been transferred. There were marked variations among the centers in the frequencies of different medical interventions and in the frequencies of various clinical outcomes. The Vermont-Oxford Trials Network is a unique collaborative research group composed of a broad range of neonatal intensive care units. During 1990 there were considerable differences among the centers in the interventions used and patient outcomes observed. The investigators plan to devote the resources of the Network to a research program of randomized trials and outcome studies so that effective interventions can be identified and the quality of neonatal intensive care can be continuously improved.
Recent Improvement in Outcome Using Transcatheter Embolization Techniques for Neonatal Aneurysmal Malformations of the Vein of Galen
Authors: Friedman Deborah M. , Verma Rajiv , Madrid Mary , Berenstein Alejandro , Wisoff Jeffrey H.
Published: December 2021

Vein of Galen malformations may present as congestive heart failure in the neonate and are usually fatal if untreated. Early studies using transcatheter embolization techniques, in a series of 22 patients, had a 50% mortality rate and a 37% incidence of severe mental retardation in survivors. Modifications of embolization techniques and neonatal care have improved the outlook in a more recent series of 11 patients. The diagnosis was established within 3 days of life in 91% of the cases. No mortality occurred, and 6 of the patients were functionally normal at up to 30 months' follow-up. Although two patients had severe neurologic deficits and/or a seizure disorder, only one case was possibly temporally associated with the embolization procedure. Some developmental delay was noted in one other patient. These improvements result, in part, from modifications of the treatment protocol, including earlier diagnosis, avoidance of digoxin, improvement in the application of newer microcatheters and acrylic polymers (n-butylcyanoacrylate), avoidance of overly aggressive neurosurgical procedures, and the use of stable central vascular access for total parenteral nutrition accompanying other general improvements in neonatal care.
Site of Upper Airway Obstruction in Infants Following an Acute Life-Threatening Event
Authors: Ruggins N. R. , Milner A. D.
Published: December 2021

Twenty-five patients were screened following an acute life-threatening event for the presence of obstructive and mixed apnea. Simultaneous cardiorespiratory monitoring with fiberoptic laryngoscopy was performed to identify the site of upper airway obstruction during these episodes. In 3 of these subjects, who had been born prematurely, obstruction was observed at the laryngeal level, with the arytenoid masses and aryepiglottic folds closing over across the vocal cords. Such closure was also observed during periodic breathing, which was found to be prominent in 4 of the infants studied. The possible role of laryngeal reflexes as a mechanism for these events is discussed.
Changes in Carbohydrate Composition in Human Milk Over 4 Months of Lactation
Authors: Coppa Giovanni V. , Gabrielli Orazio , Pierani Paolo , Catassi Carlo , Carlucci Antonio , Giorgi Pier L.
Published: December 2021

This study aimed to examine the carbohydrate content (monosaccharides, lactose, and oligosaccharides) of human milk over 4 months of lactation to determine whether any changes occurred over time. Milk samples from 46 mothers, who delivered at term, were collected at 4th, 10th, 30th, 60th, 90th, and 120th days after delivery. Carbohydrates were measured by high-pressure liquid chromatography. Mean lactose concentration (±SD) increased from 56 ± 6.06 g/L on day 4 to 68.9 ± 8.16 g/L on day 120. Oligosaccharide level decreased from 20.9 ± 4.81 g/L to 12.9 ± 3.30 g/L, respectively. Monosaccharides represented only 1.2% of total carbohydrates. The changes in carbohydrate composition found indicate that carbohydrate synthesis by the mammary gland is a dynamic process. The physiological and biological relevance of human milk oligosaccharides is also discussed.
Are Children Born to Young Mothers at Increased Risk of Maltreatment?
Authors: Stier David M. , Leventhal John M. , Berg Anne T. , Johnson Lyla , Mezger JoAnne
Published: December 2021

Previous case-control or cross-sectional studies have provided conflicting results about whether children of teenage mothers are at increased risk of maltreatment compared with children of older mothers. This study is the first to examine this question using a longitudinal, cohort design and the first to address important methodologic issues such as detection bias. Subjects were 219 consecutive index children born to inner-city women who were 18 years or younger and 219 sociodemographically similar comparison children born to women 19 years or older. Data were collected by reviewing the medical records of each child through the fifth birthday. Three outcomes were examined: maltreatment, poor growth, and a change in the child's primary caretaker. Maltreatment was ascertained by having two experts, one of whom was blind to the group status, review each injury documented in the records. Predefined criteria were used to distinguish unintentional injuries from maltreatment (abuse, neglect, or sexual abuse). Maltreatment occurred more frequently in the children of young mothers (12.8%) than in the comparison group (6.4%) (risk ratio [RR] = 2.00; 95% confidence interval [CI] = 1.17, 3.64). Poor growth, defined by growth criteria, occurred in 6.9% of the index group and in 4.1% of comparison children (RR = 1.67; 95% CI = 0.75, 3.73). A change in the child's primary caretaker, either because of placement in foster care or because the mother left the home, occurred in 12.8% of the index group and in 3.2% in comparison children (RR = 4.00; 95% CI = 1.80, 8.87). Children of teenage mothers, compared with children of older mothers, are at increased risk of maltreatment and of changes in their primary caretakers.
Pectus Excavatum
Authors: LILLY JOHN R. , BAILEY WM. CARL
Published: December 2021

To the Editor.—

Dr Asnes' Letter to the Editor (Pediatrics 1992;89:979) which recounts the painful story of a 17-year-old college applicant with pectus excavatum and his difficult passage through childhood and adolescence evokes sympathy and sadness. The patient's struggle with taunts, ridicule, and humiliation and his final accommodation to the physical and psychological impact of his deformity command our respect and admiration. The poignant lesson Dr Asnes draws is that the pediatrician not only has an obligation to attend the physical growth of his patient, but also to "observe, monitor, and nurture" emotional growth.
Evaluation of Febrile Infant
Authors: LIEU TRACY , BASKIN MARC , FLEISHER GARY
Published: December 2021

In Reply.—

We appreciate Dr Levin's contribution to our analysis for febrile infants and agree that including the imperfect sensitivity of the CSF cell count in identifying meningitis improves the model's completeness. However, taken in perspective, the addition does not substantially alter our findings. In the original analysis, All Sepsis Tests + IV Antibiotics prevented 78% of sequelae, and All Sepsis Tests + IM Ceftriaxone prevented 76% of sequelae.1 Rodewald's study2 reported that a CSF cell count ≥6 had a sensitivity of 98.4% in identifying bacterial meningitis.