bluuebunny/crossref_metadata_2025 huggingface dataset:
Milk Production by Mothers of Premature Infants: Influence of Cigarette Smoking
Authors: Hopkinson Judy M. , Schanler Richard J. , Fraley J. Kennard , Garza Cutberto
Published: December 2021

The volume of milk produced by mothers who smoked cigarettes (n = 11) and control subjects who did not smoke (n = 29) was compared after the delivery of their preterm infants (28 to 32 weeks gestation). Milk production was significantly less among those who smoked, with or without adjusting for age, race, parity, gravidity, weight-for-height, prior nursing experience, customary alcohol and caffeine intake, infant birth weight, and pumping frequency. Each mother maintained her milk production using an electrical breast pump and without the stimulus of her infant suckling at the breast. Daily frequency and duration of breast pump usage were similar in the two groups. At 2 weeks postpartum, 24-hour milk volumes were 406 ± 262 mL for mothers who smoked and 514 ± 338 mL for control subjects. Between 2 to 4 weeks postpartum, the mean change in 24-hour milk volume (milliliters per 24 hours) of control subjects increased (+113 ± 179 mL, P < .005), whereas milk volume of mothers who smoked cigarettes remained unchanged (-47 ± 122 mL, P = .25). The percentage change in milk volume between 2 and 4 weeks for the combined groups was significantly related to four factors: pumping frequency, change in daily pumping frequency, day of initiation of pumping, and smoking status. Total and protein nitrogen, lactose, calcium, and phosphorous concentrations did not differ in milks from mothers who smoked cigarettes and mothers who did not smoke. Fat concentrations were lower in the milk from mothers who smoked cigarettes. Reduced milk volume and fat concentrations may explain the reported early weaning of breast-fed infants by women who smoke cigarettes.
Child Care for Children With Special Needs
Authors: Fewell Rebecca R.
Published: December 2021

Most children with special needs are more like normally developing children than they are different from them. They share the same zest for discovery, love for stories and music, and delight in dressing in adult clothes. They, too, need to learn to run and play, solve problems, have conversations with friends, and attend to their personal needs.

Finding an opening in a child care center can be a long, frustrating experience for families, particularly when employment is essential to cover basic needs. The problem of locating a satisfactory place increases tenfold when children have special needs. After learning that a prospective child has special needs, a child care center director will turn his or her attention to the impact the child's needs might have on center operations. The director fails to recall the commonalities these children share with other enrolled children. Multiple, abortive efforts to locate placement exacerbate family stress. In desperation, parents may drop the criteria they had believed to be important in selecting placement, feeling relieved and grateful that, at last, they can go to work.

To address this problem, we will first examine the characteristics of young children with special needs and indicate the prevalence of the problem. The traditional delivery models for early intervention and for child care will be reviewed, and barriers that inhibit provision for children with special needs in child care facilities will be noted. Some current models and practices that are effective will be reviewed. Finally, recommendations will be made for policy makers and providers of services.
Childhood Asthma and Poverty: Differential Impacts and Utilization of Health Services
Authors: Halfon Neal , Newacheck Paul W.
Published: December 2021

Data from the 1988 National Health Interview Survey on Child Health showed that 4.3% of all children younger than 17 years of age had asthma, with poor children demonstrating a slightly greater prevalence than nonpoor (4.8 poor vs 4.2 nonpoor). This poor/nonpoor differential was even greater for children younger than 6 years old (4.2 vs 3.1). Poor children were also more likely to have had more than 7 bed days in the past year because of their asthma. Measures of health service utilization showed that poor children had 40% fewer doctor visits (3.2 vs 5.4) and had 40% more hospitalizations in the previous year (10.6% vs 7.4%). Although more than 90% of all children had a usual source of routine and/or sick care, poor children were more likely to receive routine care in a neighborhood health center (15.1% vs 1.6%) or hospital-based clinic (11.1% vs 2.8%) than in a doctor's office (67.2% vs 91.1%) and, when sick, then were more than four times more likely to report an emergency department as a usual source of care (8.1% vs 1.7%). Diminished accessibility to appropriate outpatient health services for poor children with asthma was associated with increased morbidity, measured by hospitalization, and bed days. These findings have significant implications for the development of comprehensive models of care and the potential role that community clinics could play with increased funding as a result of Medicaid changes that were instituted as part of the 1989 Omnibus Budget Reconciliation Act.
Are There Good Ways to Give `Bad News'?
Authors: Krahn Gloria L. , Hallum Ann , Kime Cetrelia
Published: December 2021

There has been considerable speculation about the inevitability of parental dissatisfaction with being informed about their child's disability. Mothers and fathers of 24 infants with a recently diagnosed disability were interviewed regarding their preferences for how to be told the "bad news." Qualitative analyses revealed nine themes of parental preferences for how to communicate difficult information. Parents affirmed communication themes previously discussed in the literature, such as being told early and together, and identified new ones, such as affective tone and physical contact with their baby. The importance of these themes is presented for this sample. Recommendations for how to present "bad news" can be concisely drawn from these findings. Results suggest that parental dissatisfaction with the process of telling is not inevitable.
Cost-Effectiveness of Screening and Cryotherapy for Threshold Retinopathy of Prematurity
Authors: Javitt Jonathan , Cas Ronald Dei , Chiang Yen-pin
Published: December 2021

Background. Retinopathy of prematurity (ROP) is the leading cause of blindness among premature infants. A recent National Eye Institute-sponsored prospective, multicenter trial investigating the use of cryotherapy for treatment of ROP demonstrates a significant reduction in blindness and low vision for patients with sight-threatening (stage 3+) ROP.

Method. A microsimulation model is presented to determine the cost-effectiveness of cryotherapy for ROP. Simulations are performed for three subpopulations of premature infants with birth weights 500 through 749 g, 750 through 999 g, and 1000 through 1249 g, and for three screening strategies—weekly, biweekly, and monthly.

Results. Appropriately timed screening for and treatment of ROP is predicted to result in a gain of 3899 to 4648 quality-adjusted-life-years and a net governmental budgetary savings of $38.3 to $64.9 million for each annual US birth cohort of 28 321 premature infants (500 through 1249 g). The cost per quality-adjusted-life-year gained is $2488 to $6045, depending on different screening strategies.

Conclusions. Of greatest importance is the finding that properly timed screening and treatment for ROP is not only cost saving but may save approximately 320 infants per year from a lifetime of blindness.
Prevalence of Rotavirus on High-Risk Fomites in Day-Care Facilities
Authors: Butz Arlene M. , Fosarelli Patricia , Dick James , Cusack Timothy , Yolken Robert
Published: December 2021

Study objective. The objective of this study was to determine the prevalence of rotavirus contamination on environmental surfaces in day-care environments, using the polymerase chain reaction technique.

Design. High-risk fomites were identified in two day-care centers and sampled biweekly during a 6-month study period. Water samples from water-play tables in each center were also collected during the study period. During an infectious disease outbreak, fomites were sampled from the rooms in which the outbreak occurred. Reverse transcriptase/polymerase chain reaction was carried out for viral detection of rotavirus from the fomites, and standard bacteriologic measures were used to detect bacteria in samples from water-play tables.

Results. A total of 96 fomite samples were tested for presence of rotavirus from the two centers, of which 18/96 (19%) tested positive for rotavirus. The timing of the positive samples differed between the two centers. In the center that housed infants, a peak of rotavirus-positive fomites coincided with two enteric outbreaks. Rotavirus contamination was found on the telephone receiver, drinking fountain, water-play table, and toilet handles in both centers. Bacteria in large quantities were also identified in water-play table samples.

Conclusions. Moist surfaces including the telephone, water fountains, and water-play tables are common sources of rotavirus contamination within the day-care environment. Until a safe and affordable drug or vaccine against rotavirus is available for general use, avoidance of rotaviral infections is the most effective method for the prevention of rotavirus gastroenteritis.
Aseptic Meningitis in Infants Younger Than 2 Years of Age: Acute Illness and Neurologic Complications
Authors: Rorabaugh Mary Lou , Berlin Linda E. , Heldrich Frederick , Roberts Kenneth , Rosenberg Leon A. , Doran Timothy , Modlin John F.
Published: December 2021

Objective. We report the clinical features and cerebrospinal fluid (CSF) laboratory values for 277 children younger than 24 months of age with aseptic meningitis who were prospectively evaluated at three Baltimore hospitals between July 1986 and December 1990. A major objective was to define the incidence, etiology, and outcome of neurologic complications occurring during the acute illness.

Methods. Cases were identified by surveillance in the ambulatory care departments of each of the three hospitals, pertinent historical and clinical data were obtained by interview of the parents and by review of the medical records, initial CSF laboratory values were recorded, and appropriate specimens were submitted to determine the viral etiology. A subset of 216 children who participated in a long-term natural history study were followed periodically with neurologic examinations and formal neurodevelopmental testing.

Results. Most cases occurred in very young infants; 63.5% of patients were 8 weeks of age or younger, and 84.1% were younger than 16 weeks of age. In this very young cohort, the dominant symptoms were fever and irritability; only 8.7% had evidence of meningeal irritation at the initial examination. The acute illness was complicated by either complex seizures, physical evidence of increased intracranial pressure, or coma in 25 (9.0%) cases. Within the age group under study, these complications were each significantly more likely to occur in patients older than 12 weeks of age than in younger infants. The risk of neurologic complications was similar among infants infected with group B coxsackieviruses and echoviruses, the two major enterovirus classes observed to cause disease. Acute central nervous system (CNS) complications could not be correlated with extremely abnormal CSF laboratory indices. Importantly, there was no risk of long-term neurologic sequelae attributable to acute CNS complications.

Conclusions. While approximately 9% of infants and children younger than 2 years of age with aseptic meningitis experience acute CNS complications in the form of complex seizures, increased intracranial pressure, or coma, the prognosis for long-term cognitive development appears to be as favorable as the prognosis for children with aseptic meningitis who do not experience these complications.
Parents in Jail
Authors: Kemper Kathi J. , Rivara Frederick P.
Published: December 2021

Objective. To determine the number of children in the United States with parents incarcerated in jail and to describe the characteristics of these parents and their criminal histories.

Setting. Inmates of local jails accounting for 36.5% of the incarcerated population of the US in 1989.

Participants. Personal interviews with 5675 inmates randomly selected from 393 553 inmates of 3312 local jails in 1989.

Results. 44 263 (36%) inmates had children younger than the age of 15. Fathers outnumbered mothers 10-fold; the majority were in their 20s or 30s, unmarried, and poorly educated. The vast majority of parents had a record of prior offenses, and substance abuse accounted for one third of the incarcerations. Substance abuse was reported by 84% of inmates and 95% had sought prior treatment for alcohol, drug, or other mental health problems.

Conclusions. Nearly 1 of 50 children in the US has a parent in jail. Parental imprisonment is not rare, is often chronic, and is strongly associated with other psychosocial and health problems in the family. Screening for parental imprisonment potentially should be included as part of a comprehensive biopsychosocial assessment.
Nocturnal Enuresis Secondary to Heart Block: Report of Cure by Cardiac Pacemaker Implantation
Authors: BERUL CHARLES I. , MURPHY JOHN D.
Published: December 2021

This report describes an unusual case of secondary nocturnal enuresis presumptively secondary to progressive bradycardia from complete heart block. Congenital complete heart block occurs in approximately 1 of 22 000 livebirths and is typically associated with structural congenital heart disease or maternal collagen vascular diseases.6 It can be entirely asymptomatic during infancy and childhood, depending in part on the escape rate and rhythm and other hemodynamic variables. The case described above was not diagnosed until the patient coincidentally underwent cardiac monitoring. The picture was confusing initially, as a tricyclic antidepressant medication had been ingested. Heart block is one of the known cardiovascular effects of tricyclic antidepressant overdose.7 However, the conduction disturbance should have resolved as the drug was excreted from the body. As children with congenital complete heart block get older, the ventricular escape rate typically decreases. In addition, as activity increases with age, more demand is placed for cardiac output. The resting end-diastolic volume is increased to elevate stroke volume in compensation for lower heart rate. As the escape rate decreases and the metabolic demand increases, patients with congenital complete heart block then may begin to develop symptoms. Typical symptoms in children include dizzyness, Stokes-Adams syncopal attacks, fatigue, daytime somnolence, and other somatic complaints.8 Bed-wetting has not been reported as an initial symptom, but in this case is likely secondary to the excessive somnolence and difficulty with arousal. Although congenital complete heart block is not the first diagnosis to consider in the patient with secondary nocturnal enuresis, and cardiac pacemaker implantation is generally not the treatment of choice for bed-wetting, in this particular patient, we felt that imipramine would not have been a wise choice for therapy of enuresis.
Desmopressin Acetate and Nocturnal Enuresis: How Much Do We Know?
Authors: Moffatt M. E.K. , Harlos S. , Kirshen A. J. , Burd L.
Published: December 2021

Objectives. Desmopress in acetate (DDAVP) is promoted to treat nocturnal enuresis but indications for its use are unclear. We reviewed all randomized controlled trials to determine (1) short- and long-term efficacy, (2) responders, (3) dose-response curve, (4) side effects, and (5) comparative efficacy with other treatments.

Methods. A Medline search of the English language literature from January 1966 to August 1992, supplemented by contact with the drug companies, yielded 18 articles which were true randomized controlled trials (11 cross-over and 7 parallel studies).

Results. The 18 randomized controlled trials included 689 subjects for most of whom some other type of treatment had failed. All studies found decreased mean frequency of wetting ranging from 10% to 91%, but only 24.5% of subjects achieved short-term dryness. One study of DDAVP responders directly tested long-term dryness and 21% stayed dry. In three studies that incidentally reported on long-term effects 5.7% stayed dry after stopping DDAVP. There was wide variation in the type of patient included. Seven studies addressed prognostic factors. Children more than 9 years old and with fewer initial wet nights do better. Four studies seem to include almost exclusively monosymptomatic children with nocturnal enuresis (ie, primary nocturnal enuresis, positive family history, and no urinary symptoms). Results were no better than those which included mixed symptoms. Five studies attempted to address the dose-response issue. Despite some methodological issues, there is probably some dose-response effect. Side effects were infrequent in the 589 subjects who received DDAVP as opposed to placebo. No cases of water intoxication and no significant shifts in electrolytes were reported in the four studies which measured them. Nasal stuffiness, headache, epistaxis, and mild abdominal pain seem to be the only side effects noted, and these were uncommon. Only one study compared DDAVP with conditioning alarms. Alarm patients had 10% fewer wet nights and a better long-term result.

Conclusions. DDAVP reduces wet nights in children for whom other treatments have failed but it produces complete dryness in a minority, and this is often a temporary effect. The literature focuses on short-term efficacy. The true role of DDAVP will be known when samples are carefully selected, prognostic factors are examined, and more comparisons with other treatments are conducted focusing on long-term outcomes. On the basis of current knowledge, DDAVP is inferior to conditioning alarms as a primary therapy.
Use of Chloral Hydrate For Sedation in Children
Authors:   Committee on Drugs and Committee on Environmental Health
Published: December 2021

Publicity about the possible carcinogenicity of chloral hydrate along with the suggestion that alternative sedatives should be used in children has generated concern among physicians, dentists, and their patients.1,2 Replacement of chloral hydrate with other sedatives would represent a major change in practice because it is one of the drugs most widely employed to sedate young children undergoing dental and medical procedures and imaging studies. This statement will assist the practitioner in making an informed decision regarding the use of chloral hydrate by summarizing (1) information pertaining to the potential for carcinogenesis associated with use of chloral hydrate, (2) the risk/benefit considerations of available sedatives, and (3) risks associated with prolonged sedation with chloral hydrate.

EVIDENCE FOR CARCINOGENESIS OF CHLORAL HYDRATE

Some of the concern regarding potential carcinogenicity of chloral hydrate is based on the assumption that chloral hydrate is a reactive metabolite of trichloroethylene, an industrial solvent, and is responsible for the carcinogenicity of trichloroethylene.1,2 However, the validity of this assumption is open to question. Although chloral hydrate is a metabolite of trichloroethylene, there is evidence that the carcinogenicity of trichloroethylene is due to a reactive intermediate epoxide metabolite rather than chloral hydrate.3 As is the case for most chemical carcinogens, trichloroethylene is carcinogenic in some laboratory animal species but not in others.4 Multiple epidemiologic studies in humans have failed to document an increase in cancer incidence associated with trichloroethylene exposure,5-10 although the ability of these studies to detect small increases in risk of cancer is limited.

There are no studies pertaining to chloral hydrate-associated carcinogenicity in humans.
Routine Evaluation of Blood Pressure, Hematocrit, and Glucose in Newborns
Authors:   Committee on Fetus and Newborn
Published: December 2021

It is the practice in many newborn nurseries to measure routinely, upon admission, each neonate's blood pressure by cuff oscillometry, blood glucose level by Dextrostix or Chemstrips, and hematocrit value via heel stick. Blood pressure is measured to screen for hypertension or hypotension; blood glucose, for hypoglycemia; and hematocrit, for anemia or polycythemia.

The routine testing of all newborns for a particular disorder before clinical manifestations are evident (universal screening) should result in a positive benefit-cost ratio. The following criteria should be considered in evaluating the benefit-cost ratio for any universal screening.

Incidence. There should be a high enough incidence of the disorder to justify screening for it unless the outcome of the disorder, if left undetected and untreated, would result in such significant morbidity that even with a relatively low incidence the benefit-cost ratio of screening would be positive (eg, phenylketonuria screening).

Methodology. The screening methodology should have a very high sensitivity so that there will be no, or a very low percentage of, subjects reported as being negative who are actually positive. The methodology should also have a high specificity so that there will be relatively few infants who are reported as being positive who are actually negative. The specificity need not be as high as the sensitivity since a true-positive test can be confirmed using a more specific methodology. In addition, the methodology should be relatively simple, cost-effective, accurate, and reproducible.

Natural History. The disorder for which infants are being screened should be a clearly defined entity with a well-described natural history.
The Futility of the Chest Radiograph in the Febrile Infant Without Respiratory Symptoms
Authors: Bramson Robert T. , Meyer Theo L. , Silbiger Martin L. , Blickman Johan G. , Halpern Elkan
Published: December 2021

Objective. Major pediatric textbooks advocate a chest radiograph as part of the diagnostic evaluation for a sepsis workup for febrile infants less than 3 months old. Very few studies have addressed the value of performing a chest radiograph in this situation. Two studies previously published lack the numbers to statistically justify a conclusion about the need to perform a chest radiograph in the febrile infant.

Methods. Evaluated were 197 febrile infants 3 months old or less with a history, physical examination, chest radiograph, and other laboratory studies to determine the cause of their fever. This group of infants was combined with the group of infants from two similar studies published previously in the literature using cumulative meta-analysis. The combined group resulted in 617 infants.

Results. The combined group of infants had 361 infants who had no clinical evidence of pulmonary disease on history or physical examination. All 361 infants had normal chest radiograph. These results gave a 95% confidence interval that the chance of a positive chest radiograph in a patient with no pulmonary symptoms would occur less than 1.02% of the time.

Conclusions. The generally advocated policy of obtaining a chest radiograph as part of the sepsis workup in febrile infants should be discontinued, and chest radiographs should be obtained only in febrile infants who have clinical indications of pulmonary disease.
Breast-Feeding and the Risk of Life-Threatening Rotavirus Diarrhea: Prevention or Postponement?
Authors: Clemens J. , Rao M. , Ahmed F. , Ward R. , Huda S. , Chakraborty J. , Yunus M. , Khan M. R. , Ali M. , Kay B. , van Loon F. , Sack D.
Published: December 2021

Purpose. To assess the relationship between breast-feeding and the risk of life-threatening rotavirus diarrhea among Bangladeshi infants and children younger than 24 months of age.

Design. Case-control study.

Setting. A rural Bangladesh community.

Participants. One hundred two cases with clinically severe rotavirus diarrhea detected in a treatment centerbased surveillance system during 1985 and 1986, and 2587 controls selected in three surveys of the same community during the same calendar interval.

Outcomes. Cases and controls were compared for the frequency of antecedent breast-feeding patterns.

Results. Compared with other feeding modes, exclusive breast-feeding of infants was associated with significant protection against severe rotavirus diarrhea (relative risk (RR) = 0.10; 95% confidence interval [CI] = 0.03,0.34). However, during the second year of life, the risk of this outcome was higher in breast-fed than in non-breast-fed children (RR = 2.85; 95% CI = 0.37,21.71), and no overall protection was associated with breast-feeding during the first 2 years of life (RR = 2.61; 95% CI = 0.62,11.02).

Conclusions. Although exclusive breast-feeding appeared to protect infants against severe rotavirus diarrhea, breast-feeding per se conferred no overall protection during the first 2 years of life, suggesting that breast-feeding temporarily postponed rather than prevented this outcome. While not detracting from efforts to promote breast-feeding to alleviate the burden of diarrhea due to nonrotaviral enteropathogens, our findings cast doubt on whether such efforts will impact on the problem of severe rotavirus diarrhea.
Preventing Developmental Delays: Is Developmental Screening Sufficient?
Authors: Frankenburg William K.
Published: December 2021

Developmental screening, a secondary form of prevention, is designed to facilitate early identification and treatment of children in whom a developmental problem has been diagnosed. Ideally, this is accomplished through the administration of a quick, simple, economical procedure that is designed to identify children having a high probability of being delayed. Unfortunately, no single, brief developmental screening test exists that has equal accuracy in identifying the wide gamut of developmental problems in areas such as cognition, language, speech, motor, and social development. In addition, the child's changing development over time limits the predictive accuracy of any such test.

Despite these limitations, developmental screening, like a growth measurement, has value as an aide in developmental surveillance, because it enables its user to combine its results with those of parent concerns, child observations, immunizations, and anticipatory guidance to promote the child's development. This process, rather than waiting for the child to be deviant, is a primary prevention approach that aims to assure that every child receiving such surveillance develops to his or her maximum potential. The DENVER II is designed to assist in this program.
Selective Intrapartum Prophylaxis for Group B Streptococcus Colonization: Management and Outcome of Newborns
Authors: Pylipow Mary , Gaddis Monica , Kinney Janet S.
Published: December 2021

Objective. Intrapartum antibiotic prophylaxis (IAP) in mothers with group B streptococcus (GBS) colonization presents difficult neonatal management decisions. IAP was instituted in response to an increased incidence of early-onset GBS sepsis (EOGSS), and a study was conducted to evaluate the outcome of these newborns.

Methods. A study was undertaken at Truman Medical Center-East, a county hospital with a level 1 nursery. During the 20-month study period, prenatal GBS cultures were obtained on all mothers in their third trimester of pregnancy. At time of delivery, GBS-positive women who had at least one risk factor were to receive IAP. Risk factors included fever and/or amnionitis, premature labor, and prolonged rupture of membranes defined as >6 hours. Screening laboratory tests were performed on all newborns whose mothers received IAP. Only the newborns with positive screening laboratory tests or symptoms of sepsis received further laboratory evaluation and antibiotic treatment.

Results. During the study, 2040 mothers gave birth to 2054 newborns. Three hundred thirty-two mothers (16.3%) were colonized with GBS and 122 (37.0%) had at least one risk factor. IAP was given to 70 GBS-positive mothers. Thirty-three (27%) GBS-positive mothers with risk factors did not receive IAP for logistical reasons. Eleven full-term newborns had EOGBSS. For case newborns, the mean duration of ruptured membranes was 13.7 hours (range 2.5 to 28 hours). Vertical transmission occurred as follows: Cutaneous colonization was found in 33 (12.5%) newborns born to 261 mothers who received no IAP, and symptomatic EOGBSS was diagnosed in 9 (3.4%). Mothers who received one dose (n = 43) had three (6.9%) newborns with GBS colonization and two (4.7%) asymptomatic newborns with EOGBSS. No newborns born to 28 mothers who received two doses IAP had GBS colonization or were ill. Cutaneous vertical transmission was reduced (P = .03). Newborns born to GBS-positive mothers with one or more risk factors who received IAP had significantly less EOGBSS (P < .05) than those who did not receive IAP.

Conclusions. Selective IAP was administered safely to 21% of GBS-positive women, or 3.5% of all deliveries. IAP prevented EOGBSS when it could be given to GBS-positive mothers with a risk factor. Accurate identification of mothers with GBS colonization and their risk factors is essential for effective use of IAP. Earlier institution of IAP after rupture of membranes may reduce the risk of EOGBSS and the need for extensive infant evaluation.
Drug Trafficking Among African-American Early Adolescents: Prevalence, Consequences, and Associated Behaviors and Beliefs
Authors: Stanton Bonita , Galbraith Jennifer
Published: December 2021

Objective/Methodology. Drug trafficking by minority youths in low-income, urban areas has received considerable publicity from the mass media in the past half-decade. However, there has been correspondingly little exposition of this problem in the medical literature. This review was undertaken to provide an overview of the epidemiology and consequences of drug trafficking among urban youths and to describe factors associated with drug trafficking.

Results. Existing data indicate that approximately 10% of male, urban, African-American early adolescents report having engaged in drug trafficking, with a higher percent of youths reporting having been asked to sell drugs and/or indicating that they expect to become involved in drug trafficking. Rates increase with advancing age. Reported rates of drug trafficking are comparable with rates of tobacco and alcohol use among early adolescents and are substantially higher than use rates of illegal drugs. Drug trafficking is associated with increased mortality, accounting for one third to one half of homicide-related deaths in some studies. The practice is also associated with other health-risk behaviors, including nonfatal violence, substance use, and incarceration. Perceived social pressures by family members and/or peers to engage in drug trafficking and the belief that a youth's wage-earning potential is limited to drug trafficking are highly correlated with involvement in this activity.

Conclusions. Drug trafficking is a prevalent risk behavior among adolescents that has several negative health consequences.
Pediatric Subspecialty Training, Certification, and Practice: Who's Doing What
Authors: Brotherton Sarah E.
Published: December 2021

Objective. To examine the extent of pediatric subspecialty training, certification, and practice among general and subspecialty pediatricians and to determine how the diversity of pediatric careers may affect physician workforce supply estimates.

Method. A sample of 4 000 sell-designated pediatricians and pediatric subspecialists from the American Medical Association's Physician Masterfile were surveyed in 1991 by the American Academy of Pediatrics. Seventy-six percent of the sample responded to the 6-page questionnaire on practice characteristics, training, and demographic information.

Results. Two-thirds of pediatricians are not subspecialty trained (66.3%), 15.1% are certified subspecialists, 11.3% are trained but not subboard certified, and 7.3% are subspecialty trained in an area with no certification exam. Subspecialty training did not always predict subspecialty practice; 19% of pediatricians without subspecialty training spend some time in a subspecialty, and 13% of those who are subspecialty trained practice general pediatrics exclusively. Certified subspecialists and those who cannot as yet become certified are most likely to practice their subspecialty. One-fourth of those trained in a certifiable subspecialty but who remain uncertified practice general pediatrics exclusively. The proportion of direct patient care time spent overall, and the proportion of direct patient care time spent in the subspecialty are also related to subspedalty certification and training/practice consistency.

Conclusion. Pediatric workforce supply projections should incorporate more than certification and training information in calculating estimates, as the practice of general and subspecialty pediatrics is very diverse and accommodating of integrative styles.
Pediatricians and Sleep Disorders: Training and Practice
Authors: Mindell Jodi A. , Moline Margaret L. , Zendell Steven M. , Brown Lawrence W. , Fry June M.
Published: December 2021

Objective. A series of studies were conducted to investigate pediatricians' training, knowledge, and practices regarding sleep and sleep disorders in children and adolescents.

Method and results. Study 1, a national survey of 156 pediatric residency programs, found that pediatricians receive a mean of 4.8 hours of instruction on sleep and sleep disorders, although the mode and median hours of instruction is 0 hours. In Study 2, 88 pediatricians completing a questionnaire concerning general knowledge about sleep disorders in children and adolescents received a mean score of 71.8% (range, 40% to 93%). Pediatricians appear to know the most about developmental issues and sleep hygiene and the least about specific disorders such as narcolepsy and parasomnias. In the third study, 183 pediatricians were surveyed about their actual beliefs and practices regarding young children's sleep problems. Together, those surveyed reported that approximately 25% of their patients experience some type of sleep problem. Most pediatricians recommend behavioral interventions, although 14.8% of pediatricians report prescribing pharmacological treatments, and 48.9% inform parents that their child is likely to outgrow the problem.

Conclusions. The results of these studies support the need for more education in sleep and sleep disorders in children and adolescents within medical schools, pediatric residency programs, and the practicing pediatric community.
Aminohydroxy Propylidene Bisphosphonate (APD) Treatment Improves the Clinical Skeletal Manifestations of Gaucher's Disease
Authors: Samuel Ruth , Papapoulos Socrates E. , Liberman Uri A. , Katz Kalman , Yosipovitch Zvi , Zaizov Rina
Published: December 2021

Objective. To evaluate the long-term effects and safety of aminohydroxy propylidene bisphosphonate (APD) treatment on the frequency and severity of the clinical skeletal manifestations of Gaucher's disease.

Methodology. Five adolescents who suffered from recurrent bone crisis episodes and atraumatic bone fractures due to Gaucher's disease were treated with APD for 14 to 83 months.

Results. During the 6 years before treatment, the patients suffered from 6 to 17 bone crisis episodes, or 1 to 2.8 episodes per patient per year. Three patients were free from bone crisis episodes during 14 to 32 months of ADP treatment, while two patients had two such episodes during 60 and 83 months of APD treatment (these represent a decrease in bone crisis episodes from 1 and 2.8 per year to 0.4 and 0.3 per year, respectively). Although four patients suffered from 1 to 3 atraumatic bone fractures during the 6 years preceding treatment (a total of 10 fractures), only one patient sustained a fracture on APD treatment (total of 219 months of treatment). Using APD was not associated with clinical side effects, biochemical aberrations, significant changes in liver and kidney function, or changes in serum levels of the hormones regulating mineral metabolism. In all patients, a band-like metaphyseal sclerosis appeared on radiography of the long bone. However, APD did not interfere with bone growth.

Conclusions. The marked clinical improvement in the clinical skeletal manifestations of Gaucher's disease and the absence of toxic side effects in adolescent patients treated with APD support previous findings in three adult patients on the efficacy of APD and indicate possibilities for its use in inducing prolonged remissions in affected patients.
Integrated School Health Services
Authors:   Task Force on Integrated School Health Services
Published: December 2021

When integrated school health services are implemented according to an assessment of community needs and resources, and with adequate attention to quality assurance and evaluation, they may be a way to expand access to health care services for under-served populations. They can also become a coordinated extension of an ongoing medical care home. This approach may be an effective vehicle for integrating psychosocial care and education with medical care.

Pediatricians practicing in public and private sectors should become actively involved in any community effort to develop an integrated school health services initiative. The well-designed integrated health services program, when coupled with comprehensive school health education, could significantly advance the state of health of the nation's children, youth, and families.
Inhaled Nitric Oxide in Congenital Hypoplasia of the Lungs Due to Diaphragmatic Hernia or Oligohydramnios
Authors: Karamanoukian Hratch L. , Glick Philip L. , Zayek Michel , Steinhorn Robin H. , Zwass Maurice S. , Fineman Jeffrey R. , Morin Frederick C.
Published: December 2021

Objective. We determined whether inhaled nitric oxide (NO) could improve systemic oxygenation in human neonates with hypoplastic lungs.

Methods. A multicenter nonrandomized investigation was performed to study the efficacy of short-term NO inhalation. Inhaled NO was administered at 80 ppm to nine neonates without evidence of structural cardiac disease by echocardiography. Lung hypoplasia was due to congenital diaphragmatic hernia (CDH) in eight patients and to oligohydramnios in one patient. A total of 15 trialS of NO inhalation were performed in these nine patients. Eight trials in seven patients were performed before extracorporeal membrane oxygenation ((ECMO); one patient had two trials) and seven trials were performed in five patients after decannulation from ECMO (two patients had two trials each).

Results. NO inhalation before ECMO did not change postductal Pao2 (42 ± 3 mmHg vs 42 ± 4 mmHg), oxygen saturation (Spo2; 89% vs 88%) or oxygenation index (31 ± 4 cm H2O/torr vs 31 ± 4 cm H2O/torr) for the group. All patients required ECMO support, which lasted from 5 to 17 days (mean 9). After decannulation from ECMO, NO inhalation increased postductal Pao2 from a median of 56 mm Hg (range 41 to 94) to a median of 113 mm Hg (range 77 to 326), P < .05. It decreased the oxygenation index from a median of 23 cm H2O/torr (range 11 to 70) to a median of 11 cm H2O/torr (range 4 to 21), P < .05. It increased SPO2 from 91% to 96% (P < .05) and pH from 7.48 ± .03 to 7.50 ± .03.

Conclusion. In our patients with hypoplastic lungs, inhaled NO was effective only after ECMO. This could be due to maturational changes such as activating the endogenous surfactant system. Inhaled NO may be effective in neonates with hypoplastic lungs who have recurrent episodes of pulmonary hypertension after ECMO, even if they were previously unresponsive.
Screening for Developmental Disabilities: A Suggestion!
Authors: Chesky Robert H.
Published: December 2021

As a private practitioner with some interest in periodic, standardized preschool developmental screening, I appreciated the recent position statement on this subject (Pediatrics, May 1994) by the Committee on Children with Disabilities.

At least in my locale, it doesn't seem to me that we practicing pediatricians (myself included) have exactly covered ourselves with glory with respect to this important area of health supervision. Thus, perhaps pediatricians may benefit from "regular," "periodic," "formal" American Academy of Pediatrics reminders that inaccurate developmental assessments may deny preschool children needed (and now often publicly funded) early intervention and special education services.
Training Pediatric Residents to Prevent Tobacco Use
Authors: Klein Jonathan D. , Portilla Maria , Goldstein Adam , Leininger Linda
Published: December 2021

Objective. To assess the effectiveness and acceptability of incorporating the National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence into pediatric training.

Design. Preintervention and postintervention self-reported surveys for residents receiving training and postintervention baseline surveys for those residents not receiving training. Measures include: (1) a self-reported knowledge, attitude, and behavior survey of residents; and (2) physician behavior reports from parent exit interviews.

Setting. A hospital-based pediatric residency program and continuity clinic.

Subjects. Pediatric residents and parents of pediatricpatients seen for well child examinations.

Interventions. Structured NCI smoking cessation curriculum modified for delivery during scheduled teaching activities.

Results. The NCI training was acceptable and perceived as important by residents. Many did not recall receiving the materials or training. Trained residents who remembered the intervention improved their smoking cessation counseling effectiveness. Most patients' parents think it appropriate for physicians to ask; however, most reported not having been asked about smoking or environmental smoke exposure.

Conclusions. For residents to learn effective prevention counseling strategies, systematic, reinforced preventive educational curricula must become an institutionalized part of residency training.
Return of Spontaneous Respiration in an Infant Who Fulfilled Current Criteria to Determine Brain Death
Authors: Okamoto Ken , Sugimoto Tsuyoshi
Published: December 2021

It is generally assumed that the child's brain is more resistant to insults leading to death. Current guidelines for brain death, therefore, avoid application of these standards to young children.1 The determination of brain death in children, however, has become increasingly important, and different sets of new guidelines for children have been recently published.1-4 Especially, the recommendations of a special task force, consisting of representatives from neurologic organizations and the American Academy of Pediatrics, were published in five major journals.4 Those primary distinctions were three separate longer observation periods depending on the child's age and the necessity for two corroborating electroencephalograms (EEGs) or one EEG with a corroborating cerebral radionucleotide angiogram.
The Prevention of Coronary Artery Aneurysm in Kawasaki Disease: A Meta-analysis on the Efficacy of Aspirin and Immunoglobulin Treatment
Authors: Durongpisitkul Kritvikrom , Gururaj Vymutt J. , Park Joon M. , Martin Clyde F.
Published: December 2021

Objective. Varying observations have been made concerning the use of aspirin (ASA) and/or intravenous immunoglobulin (IVIG) in the prevention of coronary artery aneurysm (CAA) in children with Kawasaki disease. A meta-analysis of published articles on the subject was conducted to evaluate the reported efficacy of these therapies.

Methods. All published studies in all languages from 1967 through 1993 obtained from MEDLINE and EMBASE were considered, and a defined set of inclusion and exclusion criteria selected the studies for analysis. These studies were grouped based on whether the children in the studies received: (1) ASA alone, (2) low IVIG (≤1 g/kg) and ASA, (3) high IVIG (>1 g/kg) and ASA, (4) single IVIG (>1 g/kg) and ASA, (5) high IVIG and low ASA (≤80 mg/kg), or (6) high IVIG and high ASA (> 80mg/kg). Studies that satisfied the test for homogeneity were subjected to further analysis. The best estimate of the true proportion of CAA as well as the 95% confidence interval for each group were calculated at 30 and 60 days. Hypothesis testing was conducted to determine the statistical significance of the calculated difference in each compared treatment group.

Results. The best estimate of true proportion of CAA and the 95% confidence interval in each group at 30 and 60 days were: (1) ASA group, 30 days, 22.8% (20.6%, 25%); 60 days, 17.1% (13.6%, 20.7%); (2) low-IVIG group, 30 days, 17.3% (14.3%, 20.2%); 60 days, 11.1% (8.7%, 13.6%); (3) high-IVIG group, 30 days, 10.3% (8.3%, 12.3%); 60 days, 4.4% (2.8%, 6%); (4) single-IVIG group, 30 days, 2.3% (0.5%, 4.2%); 60 days, 2.4% (0.5%, 4.2%); (5) high-IVIG-low-ASA group, 30 days, 13% (9%, 17%); 60 days, 4.8% (2.3%, 7.4%); and (6) high-IVIG-high-ASA group, 30 days, 9.1% (6.9%, 11.4%); 60 days, 4% (2%, 6.1%).

Conclusion. The incidence of CAA both at 30 and 60 days was significantly lower in low-IVIG than in ASA and in high-IVIG than in low-IVIG groups. Also, the incidence was lower in the single-IVIG than in the high-IVIG group, but this was noted at 30 days and not at 60 days. There was no statistically significant difference in the incidence of CAA both at 30 and 60 days between the high-IWIG-low-ASA and high-IVIG-high-ASA groups.
Benefit of Primary Prophylaxis Before 18 Months of Age in Reducing the Incidence of Pneumocystis carinii Pneumonia and Early Death in a Cohort of 112 Human Immunodeficiency Virus-infected Infants
Authors: Thea Donald M. , Lambert Genevieve , Weedon Jeremy , Matheson Pamela B. , Abrams Elaine J. , Bamji Mahrukh , Straus Walter L. , Thomas Pauline A. , Krasinski Keith , Heagarty Margaret ,   New York City Perinatal HIV Transmission Collaborative Study Group
Published: December 2021

Objective. To determine the effectiveness of primary prophylaxis in preventing Pneumocystis carinii pneumoni (PCP) in children with perinatally acquired human immunodeficiency virus 1 (HIV-1) infection.

Methods. We conducted a retrospective analysis of a cohort of infants followed from birth at six metropolitan hospitals and one outpatient clinic for pregnant, drugusing women in New York City. Outcomes measured were histologically confirmed PCP and/or death. The potential confounding effect of the infant's stage of illness, as determined by CD4 count, was controlled by including all CD4 determinations as time-dependant covariates in a Cox proportional hazards analysis. Cases were censored at PCP onset, death, loss to follow-up, and 18 months of age.

Results. One hundred twelve HIV-infected children were enrolled at birth between 1986 and 1993. Sixty of these were tracked beyond 18 months of age; of the others, 21 died before this age, 4 were considered lost to follow-up, and 27 had not reached 18 months of age at the last visit. Only 3 cases (4%) of confirmed PCP occurred among the 70 children who received primary PCP proprophylaxis before 18 months of age, compared with 12 cases (28%) among 42 children not receiving PCP prophylaxis at any point before 18 months of age. The Kaplan-Meier estimated incidence of PCP in the first year among children not receiving prophylaxis was 25% (95% confidence interval [CI], 12 to 39). Using Cox methods, the unadjusted risk of PCP among infants not receiving prophylaxis, relative to those receiving it, was 4.1 (95% CI, 1.1 to 15); the relative risk was 4.4 (95% CI, 1.2 to 17) adjusting for the percentage of CD4-positive lymphocytes and 5.1 (95% CI, 1.3 to 20) adjusting for the absolute number of CD4-positive cells. Eight of 26 deaths were caused by PCP, and the likelihood of early death was significantly diminished if PCP prophylaxis was given (relative risk controlling for absolute CD4 cells, 2.57; 95% CI, 1.1 to 6.1).

Conclusions. We report evidence that primary antimicrobial PCP prophylaxis is highly effective in decreasing the frequency of PCP and early death in infants with perinatal HIV infection. These findings support the evised National Pediatric HIV Resource Center and Centers for Disease Control and Prevention guidelines for PCP prophylaxis in children.