bluuebunny/crossref_metadata_2025 huggingface dataset:
Lead Poisoning: From Screening to Primary Prevention
Authors:   Committee on Environmental Health
Published: December 2021

Knowledge of the extent and seriousness of childhood lead poisoning has vastly expanded since the last statement regarding lead poisoning by the American Academy of Pediatrics in 1987.1 Blood lead levels once thought to be safe have been shown to be associated with IQ deficits, behavior disorders, slowed growth, and impaired hearing.2 In fact, lead poisoning is, according to the Department of Health and Human Services, "the most important environmental health problem for young children."3 The rapid development of the scientific database requires recognition by physicians of the significance of effects at lower levels and a change in clinical practice.

During the last 30 years the Centers for Disease Control and Prevention (CDC) has revised downward the definition of the blood level at which lead poisoning occurs from 60 µg/dL whole blood in the early 1960s, to 30 µg/dL in 1975, and 25 µg/dL in 1985. The 1991 CDC statement "Preventing Lead Poisoning in Young Children" recommended lowering the community intervention level to 10 µg/dL and setting several action levels (Table 1).2 In 1987 the American Academy of Pediatrics stated that lead levels greater than 25 µg/dL were unacceptable for children.1 The Academy now recognizes that impairment of cognitive function begins to occur at levels greater than 10 µg/dL, even though clinical symptoms are not seen. In the late 1970s, the average blood lead level for US children was 16 µg/dL.4 The mean blood lead level for US children has declined since 1976 due to the phaseout of lead in gasoline5 and the reduction of lead in food, and it is now between 4 and 6 µg/dL.6
More to Be Learned From Crigler-Najjar Patients
Authors: GALBRAITH RICHARD A. , DRUMMOND GEORGE S. , KAPPAS ATTALLAH
Published: December 2021

In Reply.—

We thank Dr Hansen for his comments on our study in Crigler-Najjar patients published recently in Pediatrics. A collaborative study of this rare genetic disease does seem in order as Dr Hansen indicates; to the extent that such a study might involve an examination of the efficacy of the heme oxygenase inhibitor tin-mesaporphyrin for ameliorating (with other therapeutic modalities) hyperbilirubinemia in this syndrome, we would be happy to collaborate with other investigators and to provide some resources for the study as required.
Hypoxaemia in infants with bronchopulmonary dysplasia
Authors: SINGER LYNN T.
Published: December 2021

In Reply.—

We appreciate the comments of Poets et al that weaning infants with BPD from supplemental O2 should proceed with caution, because episodes of desaturation may have numerous detrimental consequences. The main challenge appears to be to a specific O2 saturation which avoids these problems as well as the need for unnecessary O2 administration. For this reason we were reluctant to make a specific recommendation in our article.1 Although we cannot disagree with maintenance of a baseline O2 saturation of 93% to 94%, an additional recommendation may need to be made for periods of oral feeding when ventilation is further compromised in infants with BPD.
Parents Often Urge Overtreatment
Authors: PHOON COLIN K.
Published: December 2021

To the Editor.—

Having recently worked in a neonatal intensive care unit at a tertiary care facility, I read Dr Silverman's essay1 with great interest. His perception that many "seriously compromised" neonates are overtreated is justified. However, he emphasized the role of the medical profession In overtreatment, while he sided with parents who have been angry with and resentful of their child's outcome. Although the medical establishment can rightly be blamed for overtreatment in many instances, my experience with who exactly is overtreating is somewhat different.
Prevalence and Natural History of Cryptorchidism
Authors: Berkowitz Gertrud S. , Lapinski Robert H. , Gazella Jacqueline G. , Dolgin Stephen E. , Bodian Carol A. , Holzman Ian R.
Published: December 2021

Objective. A prospective hospital-based cohort study was conducted to determine the prevalence rates of cryptorchidism at birth, 3 months, and 1 year of age.

Design. A total of 6935 consecutive male neonates delivered at Mount Sinai Hospital in New York City between October 1987 and October 1990 were examined at birth for cryptorchidism. Standardized examination and classification criteria were used. Infants classified as cryptorchid at birth were reexamined at 3 months and 1 year after the expected date of delivery.

Results. Of 6935 neonates assessed at birth, 255(3.7%) were found to be cryptorchid at birth. The rates were significantly elevated for low birth weight, preterm, small-for-gestational age, and twin neonates. The overall rate had declined to 1.0% by the 3-month assessment and 1.1% at the 1-year assessment. Although the rates at the 1-year assessment tended to be higher for low birth weight and preterm infants, no significant group differences were observed.

Conclusions. Since the prevalence rates in this study are similar to those reported several decades ago, these data provide no evidence that the rate of cryptorchidism has increased either at birth or by 1 year of age. Furthermore, most testes that descend spontaneously do so within the first 3 months after the expected date of delivery.
Patient Satisfaction and Side Effects With Levonorgestrel Implant (Norplant) Use in Adolescents 18 Years of Age or Younger
Authors: Berenson Abbey B. , Wiemann Constance M.
Published: December 2021

Objectives. Levonorgestrel implants (Norplant) have recently been approved for use in the United States. Adolescents may be especially suited for this method of contraception because of its long duration of action and lack of dependence on patient compliance for efficacy. To date, however, its use in young patients has not been investigated. This study was undertaken to compare side effects and satisfaction with this new method during the first 6 months of use among adolescents and adults.

Methods. Twenty-one adolescents 18 years of age or younger and 30 adults 19 years or older participated in this study. Information on side effects and satisfaction was obtained from clinic records and a structured interview conducted 6 months after insertion.

Results. The most frequent reason adolescents gave for selecting Norplant was convenience. None of the adolescents were upset by the insertion process or by its appearance in the arm, although 10 (48%) reported that it was visible. The most frequent side effect reported by both adolescents (71%) and adults (53%) was abnormal menstrual bleeding. Weight gain was reported by 8 adolescents (38%), 3 of whom attributed it to an increase in their appetite. Other side effects commonly reported by adolescents included emotional disturbances (33%) and headaches (38%), whereas adults reported acne (27%) and mastalgia (37%). Only 1 adolescent (5%) and 1 adult (3%) reported experiencing no side effects. A similar percentage of adolescents (8%) compared with adults (6%) requested removal of the implant because of side effects during the 6-month period. Overall satisfaction was expressed by 86% (18/21) of adolescents, all of whom stated that they preferred Norplant to their previous contraceptive method.

Conclusions. This investigation demonstrates that levonorgestrel implants are well tolerated by most young patients. Clinicians involved in the care of adolescents should consider Norplant as an appropriate option of birth control for this population.
Nasogastric Drip Feeding as the Only Treatment of Neonatal Maple Syrup Urine Disease
Authors: PARINI ROSSELLA , SERENI LUCIA PICENI , BAGOZZI DONATA CLERICI , CORBETTA CARLO , RABIER DANIEL , NARCY CATHERINE , HUBERT PHILIPPE , SAUDUBRAY JEAN MARIE
Published: December 2021

The ideal management for severe metabolic decompensation in maple syrup urine disease (MSUD) is still debated. Most papers published in the past 20 years suggest the use of extracorporeal techniques combined with adequate caloric intake1-5 As renal clearance is poor,6 repeated and prolonged blood exchange transfusions (ETs), peritoneal dialysis, and hemodialysis have proved useful in removing branched-chain amino and keto acids (BCAAs, BCKAs) from plasma.3,7,8 However, single case reports have described good results in patients given nutritional treatment alone,9-11 and recently it has been suggested that extracorporeal techniques should be used only in selected cases, when diagnosis is made after 8 to 10 days of life and the condition is presumably life-threatening.12,13
Heart Murmurs. If You Allow for Mistakes Costs Are Even Higher!
Authors: TOEWS WARREN H.
Published: December 2021

To the Editor.—

I read with the recent article by Danford et al regarding "cost assessment of heart murmur evaluation." I agree completely with the authors that echocardiographic evaluation of heart murmurs is more costly than referral to a pediatric cardiologist.

In this study, the authors utilized echocardiograms ordered at their own institution, presumably performed by technicians trained and experienced in the evaluation of children for congenital heart disease, and interpreted by pediatric cardiologists trained and experienced in interpretation of pediatric echocardiograms.
Are Parents' Self-reported Total Cholesterol Levels Useful in Identifying Children With Hyperlipidemia? An Examination of Current Guidelines
Authors: Resnicow Ken , Cross Donna
Published: December 2021

Objective. Recently, the American Academy of Pediatrics (AAP) Committee on Nutrition adopted the recommendation of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents (NCEP) that children and adolescents with a family history of premature cardiovascular disease or parental hypercholesterolemia (≥240 mg/dL) be screened for hyperlipidemia. The rationale for using parental hypercholesterolemia as a screening trigger is based on sensitivity estimates using parents' actual lipid values. However, in clinical practice pediatricians may often have to rely on parents' self-reported cholesterol levels to determine a child's family risk history. This study examines the feasibility and utility of parental self-reported cholesterol levels as a means of identifying children with elevated total cholesterol levels.

Methods. As part of a school-based risk factor screening program that included total cholesterol measurement, conducted in nine elementary schools between 1989 and 1991, parents of participating children were asked if they had their cholesterol tested in the past year and if they had, to provide their total cholesterol values.

Results. If only the children who had one parent with a self-reported total cholesterol value ≥240 mg/dL would have been screened, between 90% and 93% of children with elevated total cholesterol values, either ≥170 mg/dL or ≥200 mg/dL, would have been missed.

Conclusions. These data suggest that parents' self-reported cholesterol values are an ineffective means of identifying children with elevated total cholesterol and modification of the current AAP and NCEP guidelines for selective cholesterol screening in children may be warranted.
Changes in Cerebral Hemodynamics and Oxygenation in the First 24 Hours After Birth Asphyxia
Authors: van Bel Frank , Dorrepaal Caroline A. , Benders Manon J.N.L. , Zeeuwe Petra E.M. , van de Bor Margot , Bergen Howard M.
Published: December 2021

Objective. To investigate whether or not postasphyctic cerebral hypoperfusion and decreased cerebral metabolism occur in the perinatally asphyxiated neonate, as has been reported in adults and newborn animals.

Methods. Using near-infrared spectroscopy, we monitored changes in oxyhemoglobin (HbO2), deoxyhemoglobin (HbR), total hemoglobin (HbO2 + HbR, which represents changes in cerebral blood volume [CBV]), and cytochrome oxidase (Cytaa3, which indicates changes in oxidation level of this intracerebral mitochondrial enzyme). Thirty-one neonates (gestational age >34 weeks), divided into three groups, were monitored between 2 and 12 hours or between 12 and 24 hours of life. Group I consisted of healthy newborns: N = 8 (2 to 12 hours) and N = 5 (12 to 24 hours). Patients in group II were moderately asphyxiated newborns but neurologically normal in the first 24 hours of life: N = 6 (2 to 12 hours) and N = 3 (12 to 24 hours). Group III consisted of severely asphyxiated newborns with an abnormal neurologic behavior within 24 hours after birth: N = 5 (2 to 12 hours) and N = 4 (12 to 24 hours).

Results. From 2 to 12 h, CBV levels in groups I and II were stable. In group III CBV decreased in all infants. This decrease in CBV was associated with a drop in both HbO2 and HbR. Cytaa3 was stable in groups I and II, but showed a marked decrease in two of the five infants of group III. There was a positive relationship between CBV and mean arterial blood pressure in groups II and III. Between 12 and 24 hours, all groups showed stable CBV and Cytaa3 patterns. A positive relation existed now between transcutaneous Pco2 and CBV in groups II and III.

Conclusions. CBV, HbO2 HbR, and Cytaa3 decreased in the first 12 hours of life in severely asphyxiated neonates who subsequently developed neurologic abnormalities. We therefore suggest that posthypoxic-ischemic reperfusion injury of the brain during early neonatal life occurs in neonates with severe birth asphyxia.
Effects of Repeated Application of Emollient Cream to Premature Neonates' Skin
Authors: Lane Alfred T. , Drost Sharon S.
Published: December 2021

Objective. Emollient cream moisturizers are often used on premature newborns in neonatal intensive care units without accurate knowledge of the risks or benefits to the neonate.

Design. We prospectively compared premature neonates treated with a water-in-oil emollient cream for up to 16 days to untreated premature neonates.

Setting. The study was completed in a neonatal intensive care unit on neonates admitted for respiratory distress and/or possible sepsis.

Patients. Thirty-four neonates, between 29 and 36 weeks estimated gestational age, entered the study.

Interventions. One-half of the neonates were treated twice a day with an water-in-oil emollient cream, and the other half served as controls.

Outcome Measures. The skin condition of the neonates' hands, feet, and abdomen was evaluated on entering the study and twice a week. Fungal cultures and quantitative bacterial cultures were obtained from the axilla and abdomen on entering the study and twice a week.

Results. The mean gestational age of the treated neonates was 32.3 weeks, whereas the mean gestational age of the control neonates was 32.5 weeks. The neonates treated with emollient cream demonstrated statistically less dermatitis of their hands (day 2 through day 11), their feet (day 2 through day 16), and their abdomen (day 7 through day 11). Fungal cultures and quantitative bacterial cultures of the abdomen and axilla were equivalent in both groups.

Conclusions. These studies document that emollient cream moisturizer therapy of premature neonates decreases dermatitis without changing the microbiological flora.
Head-Upright Tilt Table Testing in Children With Unexplained Syncope
Authors: Samoil Daniela , Grubb Blair P. , Kip Katrinka , Kosinski Daniel J.
Published: December 2021

Recurrent syncope in the young patient can be an anxiety-provoking experience that is often difficult to diagnose. Head-upright tilt table testing has emerged as a method for provoking episodes of vasodepressor syncope in predisposed individuals and thereby establishing a diagnosis. Currently indicated in the evaluation of young patients with recurrent unexplained syncope, it has also proven useful in differentiating convulsive syncope from epilepsy. Further studies will be needed to better define its role in the evaluation and management of recurrent syncope in children and adolescents.
Nosocomial Legionella Pneumonia in the Neonate
Authors: HOLMBERG ROBERT E. , PAVIA ANDREW T. , MONTGOMERY DIANNE , CLARK J. MICHAEL , EGGERT LARRY D.
Published: December 2021

Since first being identified in 1976 as the cause of epidemic pneumonia at a Philadelphia American Legion convention, Legionella pneumophila has been recognized as an important cause of community-acquired and nosocomial pneumonia in adults1,2 Reports of Legionella pneumonia in childhood are unusual, however. The incidence of Legionella infection in children is unknown, as the diagnosis is rarely considered. Serosurveys in normal children have shown that by 5 years of age, 20% to 50% of children have at least 1:64 antibody titers to Lp1, suggesting that early exposure may be common.3,4 Nevertheless, fewer than 4% of normal children with community-acquired pneumonia have a fourfold rise in convalescent antibody to Legionella.3-6
Turner Syndrome With Unusual Conotruncal Defect
Authors: ROSTI LUCA , FESTA PIERLUIGI , FRIGIOLA ALESSANDRO , ROSTI DARIO
Published: December 2021

The Turner syndrome is a frequently occurring chromosomal syndrome. It is characterized by X monosomy, mosaicism 45X/46XX, partial deletion of X chromosome, and various rearrangements of X chromosome, leading to several clinical features and congenital anomalies: short stature, webbing of the neck (pterygium colli), nuchal cystic hygroma, hypogonadism, with absent ovarian tissue, and renal anomalies.1 Congenital heart defects occur often in the Turner syndrome1,2; there is a high prevalence of coarctation of the aorta3-5 and bicuspid aortic valve6; ventricular septal defects, atrial septal defects, and hypoplastic left heart syndrome are less frequent.7,8

Conotruncal defects have never been reported, to our knowledge, in patients with the Turner syndrome.
The Pediatrician's Role in Promoting the Health of Patients in Early Childhood Education and/or Child Care Programs
Authors:   Committee on Early Childhood, Adoption, and Dependent Care
Published: December 2021

American families are changing; more parents are working, and most young children are being cared for in some form of child care.1 To promote optimal child health and development, pediatricians should work not only with parents, but also with other caregivers, agencies, and organizations that are part of the child's and family's support system. This statement discusses the roles pediatricians should play in the care of infants and young children enrolled in early childhood education and child care settings.

ADVISING FAMILIES

Beginning at the prenatal visit and at each subsequent visit, the pediatrician should review the plans and arrangements that parents may have made for alternative care of their children. The child's adaptation to these arrangements should be reviewed.2 The pediatrician should discuss with parents how they are balancing their work and family life. As a trusted family advisor, the pediatrician can help parents identify, evaluate, and choose among their child care options.

Adjusting Work and Schedules and Getting Help From Employers

When both parents work, they can sometimes coordinate their work hours to share the child's care or make arrangements with their employers to provide some child care at the work site. One or both parents might be able to arrange for part-time work while the children are very young. Some parents may want to share care with another family by staggering work and child care hours. Some families have relatives who are able and willing to provide good-quality, low-cost child care. One or both parents may be eligible for financial help from their employers for child care in community facilities.
Residency Training and Continuing Medical Education in School Health
Authors:   Section on School Health
Published: December 2021

Children between the ages of 5 and 18 spend a significant amount of their time in school. School health is a vital part of pediatric practice and an important concern for pediatric graduate medical education. There are few substantiated data, however, to suggest that residents entering pediatric practice or academic medicine are exposed to school health in a significant way. Many pediatricians, upon entering practice, find that they are consulted by school systems and parents whose children have problems related to school. Pediatricians find themselves unprepared for this new role and express the need for postgraduate education in school health.1-4

The American Academy of Pediatrics Task Force on Pediatric Education5 and the most recent report from the Pediatric Residency Review Committee have both underscored the appropriateness and importance of education in school health as an important part of the residency curriculum.6 The American Academy of Pediatrics believes that education in school health should be an important part of graduate medical education for pediatric residents and of continuing medical education for practicing pediatricians.

Many advances in pediatrics that affect the well-being of the child relate directly to the school setting. Increased attention to federal legislation (Section 504 of PL 93-112, the Rehabilitation Act of 1973; parts B and H of PL 102-119, the Individuals with Disabilities Education Act), health education including education about the prevention of drug and alcohol abuse and acquired immunodeficiency syndrome, new approaches to screening and health services in the schools, immunization requirements, physical fitness, and knowledge about the school environment—all are important aspects of school health and areas in which many residents and/or pediatricians have had little or no training or experience.
The Lead Controversy
Authors: ASCHNER MICHAEL
Published: December 2021

To the Editor.—

Dr Herbert Needleman's frightful description of his investigative ordeal, unnecessary as it may have been, will hopefully serve as an eye opener to the scientific community. It reemphasizes that where there is money at stake there is advocacy language on both sides. Anyone can seriously attack any statistical risk assessment on the premise that if a compound has no effect on a given measurement, about 1 of 20 studies to report such an association would be on the basis of change.
Is Neonatal Medicine in the United States Out of Step?
Authors: SILVERMAN WILLIAM A.
Published: December 2021

Here are the results of an informal survey which suggest that the number of neonatologists is disproportionately high in the United States: the ratio of neonatologists to liveborn infants may be two to six times higher than in six other countries examined (Table). The rough estimates raise some disturbing questions that can only be answered by formal surveys in each country which include the annual cost of neonatal intensive care (as percent of gross domestic product) and the compensation of neonatologists.

In recent years, most of the discussion about the limits of neonatal intensive care has been focused on ethical issues. As costs of medical care have soared throughout the world, questions are now raised about the economic limits of this activity. For example, compared with the United States, has the rest of the world set more realistic financial limits on neonatal intensive care by controlling the number of neonatologists and their compensation? Is the relative surfeit of neonatologists explained by a disproportionate number of high-risk neonates in the United States, or is the number of practitioners market-driven in our laissez-faire medical system? These and other unsettling questions may be ignored, but they will not go away.
Pediatrics Welcomes Two New Overseas Editions: The Arab World and the Portuguese
Authors:   ARAB WORLD EDITION ADVISORY BOARD
Published: December 2021

Pediatrics currently has a circulation of 55 000 in the United States. Over the last several years we have quietly been enlarging our overseas editions. We now have more than 25 000 subscribers in other countries. An increasing number of our published articles are from other countries. Our Spanish-language edition in Spain, our first and oldest overseas edition, is thriving. Our Italian-language edition in Italy is in its fourth year and is rapidly growing. Last year it began to include Pediatrics in Review and commentaries by Italian authorities. PIR is published in Spanish in Argentina and is widely distributed in South America. Our English edition in India is in its fourth year and is growing slowly but steadily.
Hair Burning Syncope
Authors: WHITE LARRY E. , TOOR SVINDER S.
Published: December 2021

We read the report "Hair-Grooming Syncope Seizures" by our colleagues Drs Lewis and Frank (Pediatrics. 1993;91:836-838), and waxed nostalgic regarding a cluster of similar cases which we aptly named "hair burning syncope." During an 18-month period in the late 1980s, several girls came to our outpatient clinic and emergency departments with generalized seizure activity following or in the midst of hair grooming using a hot curling (or uncurling) iron. After the first few cases, a clear pattern emerged: the patients were all black girls, aged 8 to 14 years; hair-grooming with a hot iron and various hair "gels" was always involved; the patient was seated or standing, with the groomer behind the patient; the parent was not directly supervising the activity; seizures were generalized, brief, and associated with brief postictal confusion.
Different Views on Adolescent Abortion
Authors: THORREZ DAVID C. , BOYER DEBRA L. , HARRISON MARK
Published: December 2021

In their survey of American Academy of Pediatrics on adolescent abortion published in March 1993, Fleming and O'Connor state that 48.8% supported parental notification, 43.3% did not favor access to abortion for all of the reasons identified in the questionnaire, and 35.4% believed abortion should clearly be restricted in some circumstances.

They concluded that these numbers provide a "mandate" for the Academy to support legislation encouraging adolescent abortion. Rather, it seems clear to us that these numbers indicate that it is inappropriate for the Academy to take sides on a political issue over which its membership is so obviously divided. There is no consensus, and no "mandate."
`GENE THERAPY' FOR GAUCHER'S DISEASE SHOWS PROMISING RESULTS IN TEST ON MICE
Authors: L. J. F.
Published: December 2021

University of Pittsburgh researchers reported promising results in mice with a potential "gene therapy" for Gaucher's disease that eventually may replace Ceredase, a Genzyme Corp. drug whose high cost has sparked controversy.

The study indicated it would be possible to transfer a gene into certain cells of people with the disease that would permanently correct a genetic defect underlying their disorder. The potential treatment, however, is at least several years away from widespread use in patients, and its development may face economic stumbling blocks.
SMOKING ISSUE IS HEATING UP CUSTODY SUITS
Authors: H. B.
Published: December 2021

Parental concern about secondhand smoke is adding a new wrinkle to some custody and divorce battles.

Estranged spouses are taking an increasingly aggressive court stance when a child is exposed to cigarette smoke of one parent. Secondhand smoke has become a point of contention in custody cases in more than a dozen states, almost all involving children with respiratory ailments such as asthma and allergies.

And smoking may become an issue in many more custody cases, according to some lawyers. Recent medical reports have cited the heightened likelihood of respiratory disease and middle-ear infection even in healthy children exposed to secondhand smoke. In at least one case a judge has been asked to rule that exposing a child with medical problems to cigarette smoke constitutes child abuse.
Utility of Routine Laboratory Testing for Detecting Intra-abdominal Injury in the Pediatric Trauma Patient
Authors: Isaacman Daniel J. , Scarfone Richard J. , Kost Susanne I. , Gochman Robert F. , Davis Holly W. , Bernardo Lisa M. , Nakayama Don K.
Published: December 2021

Objective. To assess the prevalence of laboratory abnormalities (complete blood cell count, electrolytes, blood urea nitrogen, creatinine, glucose, aspartate aminotransferase, alanine aminotransferase, amylase, lipase, urinalysis [U/A]) and the sensitivity and specificity of the physical examination (PE) and screening laboratory tests for identifying intra-abdominal injury (IAI) in moderately injured pediatric patients.

Design, participants, and setting. Phase I: Retrospective review of 285 consecutive level II (moderately injured) trauma patients seen at a children's hospital emergency department/pediatric trauma center. All patients were received directly from the scene and had the following data recorded: mechanism of injury, Glasgow coma score, trauma score, pediatric trauma score, systematically recorded PE findings, laboratory results, and injuries detected during hospitalization. Phase II: To confirm the sensitivity of the PE and U/A found in phase I, the model was applied to 91 additional trauma patients identified by International Classification of Diseases, 9th revision (ICD-9) codes as having IAI.

Intervention. None.

Results. Phase I: A total of 3939 tests were ordered for the 285 patients entered in phase I. Aspartate aminotransferase and alanine aminotransferase values were obtained in 59% of patients; glucose level was obtained in 78% of patients; complete blood cell count, U/A, and levels of electrolytes, blood urea nitrogen, creatinine, amylase, and lipase were obtained in more than 85% of patients. The overall prevalence of laboratory abnormalities was 5.7%. Fourteen patients (4.8%) were identified who had a total of 23 significant IAIs (9 pancreatic, 6 splenic, 5 renal, 3 hepatic). The PE combined with U/A showing more than five red blood cells per high-power field had a sensitivity of 100%, specificity of 64%, positive predictive value of 13%, and negative predictive value of 100% for the detection of IAI. The presence of laboratory abnormalities suggesting injury did not increase the sensitivity of the model and significantly decreased both specificity and positive predictive value. Phase II: The PE combined with U/A identified an abnormality in 89 (97.8%) of 91 cases (95% confidence interval = 94.8% to 100%).

Conclusions. In the moderately injured pediatric trauma patient, (1) there is a low prevalence of laboratory abnormalities; (2) the PE combined with U/A is a highly sensitive screen for IAI; and (3) in patients with a normal PE of the abdomen and a normal U/A, laboratory testing seldom identifies unsuspected IAI.
Investigation and Review of Unexpected Infant and Child Deaths
Authors:   Committee on Child Abuse and Neglect and Committee on Community Health Services
Published: December 2021

A significant proportion of infant and child deaths are preventable. Of the 55 861 deaths of children aged 14 and younger in the United States in 1989, more than three fourths occurred in children under the age of 2 years.1 Approximately one third of the latter were unexpected, including those due to sudden infant death syndrome (SIDS) or trauma, or deaths that were otherwise unexplained. Child abuse deaths occur in greatest numbers among infants, followed by those in toddlers and preschool children.2 Children younger than 6 years of age are most vulnerable to abuse because of their small size, incomplete verbal skills, and often limited contact with adults other than their primary caretakers.3

With few exceptions, throughout the United States there is no uniform system for the investigation of infant and child deaths. Many jurisdictions lack appropriately trained pathologists, interagency collaboration hat would facilitate sharing of information about the family, and a surveillance system to evaluate data regarding infant deaths. As a result, progress in the understanding of SIDS is inhibited, cases of child abuse and neglect may be missed, familial genetic diseases go undiagnosed, public health threats may be unrecognized, and inadequate medical care may be undetected. Lack of adequate infant and child death investigation is an impediment to preventing illness, injury and death of other children at risk.

Adequate death investigation requires the participation of numerous individuals including medical examiner/coroner, public health officials, the patient's physician, the pathologist, and personnel from agencies involved with child welfare and social services and law enforcement.
Hearing Loss Not Associated With DTP Vaccination or Fever
Authors: Nuss ROGER C. , EAVEY ROLAND D. , EVANS GEOFFREY
Published: December 2021

To the Editor.—

The Vaccination Injury Compensation (VIC) Program is a federal effort to fairly and quickly settle injury and death claims after vaccinations. Should a recognized vaccine side effect be present and the petitioner is able to satisfy various statutory requirements, an automatic payment is made by the government without litigation against the physician or vaccine manufacturer. However, should a claim be made that is not a previously recognized vaccine injury, a decision is made by a special master of the US Court of Federal Claims with the help of experts but without a jury.
Circumcision in Children Beyond the Neonatal Period
Authors: Wiswell Thomas E. , Tencer Heather L. , Welch Catharine A. , Chamberlain John L.
Published: December 2021

Objective. Although many boys are circumcised after the newborn period, there are limited data concerning the proportion of uncircumcised infants who subsequently have the procedure, as well as minimal information about characteristics of this population.

Population. Data and medical records of boys born in Us Army hospitals from 1985 through 1992 were reviewed. General information regarding a portion of the 32 072 boys who were not circumcised during their neonatal hospitalization, but subsequently had the procedure, is reported. In addition, specific details are presented about 476 boys who were circumcised after their birth hospitalization.

Results. The postneonatal circumcision frequency rate of these children increased significantly over this period (P < .0001), particularly after the 1989 American Academy of Pediatrics statement on circumcision. In general, most boys were not circumcised as neonates because of parental choice (55%) or because of a complicated neonatal course (32%). "Sleeve" and "freehand" resection were the most common methods of circumcision (93%), and general anesthesia was used in 91% of the boys. The mean age at postneonatal circumcision was 2.92 years. Common reasons for the ensuing procedure included parental choice (39%), coincidence with other surgery (27%), recurrent balanoposthitis (23%), and urinary tract infections (7%). Complications occurred in 8 of the 476 boys whose specific records were reviewed. These included excessive bleeding (3), malignant hyperthermia (2), aspiration pneumonia (1), large hematoma development (1), and postoperative fever (1).

Conclusions. An increasing number of boys are circumcised beyond the neonatal period, and the procedure performed at this time can be associated with substantial complications. This information may be of use when performing informed-consent counseling for neonatal circumcision.
Left-handedness as a Risk Factor for Unintentional Injury in Children
Authors: Graham Charles J. , Dick Rhonda , Rickert Vaughn I. , Glenn Robert
Published: December 2021

Objective. To determine whether left-handedness is a risk factor for unintentional injury among children and adolescents.

Design. Case-control study.

Setting. Pediatric emergency department of Arkansas Children's Hospital.

Patients. 265 patients sustaining unintentional trauma aged 6 to 18 years and 494 control patients who did not have trauma were given a questionnaire to determine handedness, past unintentional injury, and parental perception of injury proneness.

Results. The frequency of left-handedness in the trauma group (18.1%) was significantly greater than frequency of 10.5% in the control group (P < .003, odds ratio = 1.80, 95% confidence interval 1.20 to 2.72). Multivariate analysis revealed handedness as the only significant vanable between trauma and control (P < .04). The proportion of left-handers who had been hospitalized previously for injury treatment (20.0%) was larger than the proportion of right-handers, (12.0%) (P < .026, odds ratio = 1.84, 95% confidence interval 1.03 to 3.27). More parents of left-handens rated their child as "more clumsy than average' than parents of right-handens (26.0% vs 15.2%, P < .007).

Conclusions. Left-handedness appears to be a risk factor for unintentional injury in children and adolescents in a pediatric emergency department population.
Clinical Survey of Natural Varicella Compared With Breakthrough Varicella After Immunization With Live Attenuated Oka/Merck Varicella Vaccine
Authors: Bernstein Henry H. , Rothstein Edward P. ,   Pennridge Pediatric Associates, Watson Barbara M. , Reisinger Keith S. , Blatter Mark M. , Wellman Catherine O. , Chartrand Stephen A. , Cho Iksung , Ngail Angela , White C. Jo
Published: December 2021

Objective. To prospectively characterize varicella occurring in children previously immunized with a live attenuated varicella vaccine (breakthrough varicella) through daily observation by medical personnel and to compare it with natural varicella followed in the same manner.

Design. A blinded clinical survey.

Setting. Four pediatric practices (two private; two hospital-based).

Participants. Healthy 12-month-old through 17-year-old children with chickenpox were studied; 92 had natural varicella and 58 had breakthrough varicella.

Selection procedures and interventions. Study personnel, unaware of vaccination status, documented the clinical characteristics of each patient in the office or at the patient's home each day from enrollment until the day after the total number of lesions increased less than 10%. A standard form documenting number and description of lesions, temperature, duration of illness, and associated clinical complaints was completed each day by the same study personnel. Acute and convalescent sera were obtamed on breakthrough cases.

Measurements and results. Antibody to varicellazoster virus was measured by the glycoprotein-based enzyme-linked immunosorbent assay. Of those with sera available, 85% were serologically confirmed. Eighty-seven percent of enrollees had a known exposure to chickenpox, with at least two thirds of each group having a greater than 4-hour or a household exposure. The numbers of total and vesicular lesions were significantly higher in the natural varicella group, regardless of exposure status (P = .021 to <. 001). The group with break-through varicella had a significantly lower incidence of fever (P < .001) and a significantly shorter duration of illness (P < .001). Other associated constitutional complaints and complications were not significantly different between groups.

Conclusion. Varicella in vaccine recipients is clinically modified and significantly less severe than natural disease.
The New National Institutes of Health Strategic Plan
Authors: BATTAGLIA FREDERICK C.
Published: December 2021

I have just received the final version of the National Institutes of Health (NIH) strategic plan. There was a considerable delay between the last of the regional conferences and the completion of the strategic plan. The regional conferences provided an opportunity for NIH staff and a wide variety of biologic scientists to meet and discuss aspects of NIH planning. The process almost inevitably left most of us hankering for more in-depth discussion of individual topics. At the regional planning sessions, the topics were discussed in concurrent sessions whereas many of the scientists attending would have preferred input in several of the sessions addressing closely related topics.
Henoch-Schönlein Purpura in Infants
Authors: AMITAI YONA , GILLIS DAVID , WASSERMAN DROR , KOCHMAN RONIT HAIMOV
Published: December 2021

Henoch-Schönlein purpura (HSP) usually affects children older than 2 years. Its occurrence in infants is considered rare.1 Infantile HSP has distinct features. Previous reports emphasized the presence of edema2-8 and the paucity of gastrointestinal and renal symptoms.2 Facial purpura has been reported by some authors.3-8 We describe seven infants with HSP, where the most common features were edema and diffuse purpura involving the face and ears, and discuss the possible mechanisms for this unusual site of the purpura.

PATIENTS AND METHODS

During 1978 through 1992, 145 children with HSP were hospitalized at the Departments of Pediatrics of the Hadassah University Hospitals at Mount Scopus and Ein Karem, Jerusalem.
Shaken Baby Syndrome: Inflicted Cerebral Trauma
Authors:   Committee on Child Abuse and Neglect
Published: December 2021

The shaken baby syndrome is a clearly definable medical condition. It requires integration of specific clinical management and community intervention in an interdisciplinary fashion.
Provision of Related Services for Children With Chronic Disabilities
Authors:   Committee on Children With Disabilities
Published: December 2021

Since 1975 all children with disabilities specifically delineated by law have had available to them "a free, appropriate public education that includes special education and related services to meet their unique needs." This access has been made possible by the passage of Public Law 94-142,1 The Education for All Handicapped Children Act of 1975. This law was amended in October 1990 with passage of Public Law 101-476, The Individuals With Disabilities Education Act (IDEA). Part B of Public Law 101-476 primarily details the identification and provision of services for children with disabilities. Unfortunately, the implementation of Part B of this law has been limited for many children by a number of significant and complex issues.

The term "related services" as currently defined in Part B of the IDEA includes the following:

... transportation and such developmental, corrective, and other supportive services (including speech pathology and audiology, psychological services, physical and occupational therapy, recreation and social work services, and medical and counseling services, including rehabilitation counseling, except that such medical services shall be for diagnostic and evaluation purposes only) as may be required to assist a child with a disability to benefit from special education.

Health care providers frequently view the related services listed above as medically necessary and/or helpful for children with disabilities without the proviso that these services must be necessary for special education. This difference in perspective and interpretation by pediatricians and parents often leads to misunderstandings, frustrations, conflicts, and problems in the development and implementation of related services within school programs for children with disabilities.
Statistics and Swedish `Sambos'
Authors: WEGMAN MYRON E.
Published: December 2021

In Reply.—

Family stability has a strong influence on infant mortality. Dr Allen has a valid point in drawing attention to the differences between Sweden and the United States. On the other hand, quantifying such differences is not easy. There is evidence that the US too has a significant number of couples living together without a marriage certificate. indeed, the Census Bureau, beginning with the 1980 census, I believe, introduced the term POSSLQ "person of opposite sex sharing living quarters" as an alternative to single or married.
Bike Dangers
Authors: SCHUBERT JOHN
Published: December 2021

To the Editor.—

The excellent article, "The Bicycle: A Developmental Toy versus a Vehicle"1 is a much-needed look at the causes of, and misconceptions concerning, bicycle accidents. However, one statement requires comment.

The authors say, "Environmental modifications such as bicycle lanes [and] separating bicyclists from traffic...are proven injury reduction measures..."1,p755 Not! Although that statement may seem so obviously true that there would be little need to justify it, it is in fact a dangerous mistake.
Bike Dangers
Authors: AGRAN PHYLLIS , WINN DIANE
Published: December 2021

In Reply.—

It's refreshing that a bicycle accident reconstruction expert took the time to review and comment on our recent publication. In the public health and medical fields, separating children from traffic is frequently recommended as a measure to minimize contact between children and motor vehicles. Mr Schubert's comments, however, illustrate the need for multidisciplinary approaches to injury prevention. Traffic engineers and others involved in bicycle safety issues, for example, can provide expertise in this area of injury control.
Near Infrared Spectroscopy Research
Authors: DELPY D. T. , FERRARI M.
Published: December 2021

To the Editor.—

In a recent issue of this journal (Pediatrics. 1993;91:414-417), Dr Deborah Hirtz reported on a Workshop on Near Infrared Spectroscopy (NIRS), organized by the National Institute of Neurological Disorders and Stroke (NINDS).

NIRS is becoming increasingly accepted as a method for noninvasive monitoring of cerebral hemodynamics and oxygenation in the newborn and recently in the fetus during labor. However, as Dr Hirtz carefully pointed out there are still many technical problems to be solved, and considerable controversy about the quantitation and interpretation of MRS data especially the redox state of cytochrome oxidase.
Think Globally; Act Locally
Authors: HARDY JANET B. , DUGGAN ANNE K.
Published: December 2021

In Reply.—

Dr Fischer's letter makes a valid point. Many of us do not provide an adequate description of the populations from which our data are derived. Also, we need to be cognizant that health conditions may differ greatly from one country to another and, within a given country, from one ethnic group and social class to another. That said, it does not seem to us appropriate to try to frame all presentations in a global context.
Office Lab Regulations vs Research
Authors: Murray Patrick E.
Published: December 2021

As a pediatrician in a private group practice, published reports of new or different office laboratory screening techniques pose some problems for us that may not be readily apparent to hospital-or medical center-based physicians. I would like to use the recent, and I think excellent article by Hoberman et al,1 on a enhanced urinalysis technique as an example to point out these difficulties.

I feel certain that all pediatricians in private practice are now aware of the regulation of office laboratories by Federal law under the Clinical Laboratory Improvement Act (CLIA) and the work-place requirements of the Occupational Safety and Health Administration (OSHA).
‘New’ Diapers and Vaginal Discharge
Authors: Goldweber Robert T.
Published: December 2021

Twice during the past 2 years I have examined infants with what appeared to be a clear gelatinous vaginal discharge of unsure etiology. Recently I discovered the cause when I examined the contents of a swollen diaper lining after my child had spent some time in a pool.

Since 1987 the newest generation of disposable diapers contain a substance called Absorbant Jelly Material that when dry is a granule similar in appearance to salt. It is a polyacrylate cross-linked polymer of acrylic acid and sodium acrylate and is widely found in the lining of diapers in the US, Japan, and Europe.