bluuebunny/crossref_metadata_2025 huggingface dataset:
Blunt Trauma to the Abdomen
Authors: Haller J. Alex
Published: December 2021

Serious injuries remain the number one cause of death among American children. Major trauma is responsible for more than 50% of the mortality in children between the ages of 1 and 14 years. The majority of these life-threatening injuries result from blunt trauma rather than from penetrating injuries, which are much more common in adults. The most common causes of blunt trauma to children are: motor vehicle crashes when a child is either a pedestrian, bicycle rider, or automobile occupant; falls from windows or farm buildings and machinery; and house fires. Children die in motor vehicle crashes as a result of multiple systems injuries, of which the most serious is to the head.

Major blunt trauma to the abdomen frequently is associated with this series of injuries. This is a difficult injury to evaluate because often there are few signs of external damage to reflect the life-threatening trauma to internal abdominal organs. In addition, as noted previously, children commonly have associated head injuries and are unconscious at the time of evaluation, which makes early diagnosis and definitive treatment even more difficult, often resulting in disastrous delays in specific treatment.

The pathophysiology of blunt injuries to the abdomen results from energy transfer of compression and crush forces or from rapid deceleration/acceleration forces, which cause shearing stresses within the abdomen.
Hypnosis: Teaching Children Self-Regulation
Authors: Sugarman Laurence I.
Published: December 2021

Hypnosis applies and strengthens a child's naturally enhanced ability to focus his or her concentration and imagination to change symptoms, physiology, and behavior. This field of naturalistic psychology is supported both experimentally and clinically. It can be incorporated into all clinical encounters, increasing therapeutic rapport, the young person's self-esteem, and efficiency. It is most effective when introduced before fearful responses become conditioned, and it can reduce the amount of medication required for relief of symptoms. This capacity can grow with the child, allowing him or her to approach future challenges with equanimity.

It has been said, "All hypnosis is not therapy, but all therapy is hypnosis."30 Hypnosis training teaches us the sensitivity to language, to our patients' states of awareness, and to the power of our own positive expectancy and rapport that underlies what we call the "art of medicine."
Multicultural Issues in Pediatric Practice
Authors: Kinsman Sara B. , Sally Mitchell , Fox Kenneth
Published: December 2021

A Gap?

NT, an 11-year-old Vietnamese female, presented to the adolescent clinic with a 1-month history of dysfunctional uterine bleeding. She was accompanied by her older sister and grandfather. Although her grandfather was the most proficient English speaker in the home, the older sister was asked to help translate questions regarding her younger sister's menstrual and sexual history. The most likely diagnosis appeared to be anovulatory dysfunctional uterine bleeding. The appropriate laboratory evaluation was undertaken to exclude other etiologies, and oral hormonal therapy was prescribed to stop the vaginal bleeding. To assure that the patient understood the need for hormonal therapy, the health-care team asked if the grandfather could be present when directions for the medications were reviewed. The patient agreed. She asked no questions as the treatment plan was discussed.

One week later at a follow-up visit, the patient continued to experience vaginal bleeding and admitted to not having taken her oral contraceptive medication. She was admitted to the hospital with a significantly decreased hemoglobin level. During her hospital admission, nurses noted that the patient was pleasant and congenial, but she refused to take the hormonal therapy and secretly would hide the medication in her mouth so that she could throw it away later.
PERIPHERAL BRAIN
Authors: Pysher Theodore J. , Bach Phillip R.
Published: December 2021

Historical Perspective and Current Status of the Multitest Chemistry Profile

The development of a single instrument that could reproducibly sample a specimen, mix it with the required reagents at appropriate intervals, and analyze the resulting reaction revolutionized the chemical analysis of clinical specimens. Not long after its development, several of these Auto AnalyzersTM, each dedicated to measuring a different analyte, were linked, and the Sequential Multiple Analyzer (SMATM) was born. Because these systems were automated, they could perform the analyses for which they were designed at less expense, with greater precision, and in less time than when the tests were performed by hand. Moreover, it was claimed that the integration of the measurement of these chemical markers of disease into the routine health maintenance examination would lead to earlier detection of disease and improved patient care.

These early multitest analyzers had only limited application in pediatrics because they required so large a specimen. The SMA-12TM, for example, required 3 mL of serum for each 12-test panel. Two developments, however, made the multitest chemistry analyzer accessible to pediatric-sized samples-microcomputes and ever smaller components. The early multitest analyzers were marvels of creative plumbing in which each specimen ran the full course of the instrument and, therefore, the same amount had to be sampled whether one or all of the 6, 12, or 24 available tests were requested.
Movement Disorders in Childhood
Authors: Pranzatelli Michael R.
Published: December 2021

Clinical Aspects

Dyskinesias are abnormal involuntary movements. The common dyskinesias include tics, chorea, tremor, dystonia, myoclonus, and hyperactivity (Table 1). Several other less common dyskinesias also are important to recognize. The diagnosis of the type of movement disorder is clinical. When the movements are episodic and not seen by the pediatrician, obtaining a home videotape is recommended. Most patients who have movement disorders, with the exception of tic disorders, should be referred to a neurologist, but it is important for the pediatrician to be able to identify them and to be informed on issues relevant to management.

THE MOST COMMON DYSKINESIAS

Tic disorders include motor (myoclonic and dystonic), vocal (phonic), and sensory tics. Tics may be simple or complex (Table 2). Myoclonic tics are jerks; dystonic tics are postures. Children who have vocal tics such as throat clearing, coughing, or sniffing may be referred to allergists or ear, nose, and throat specialists before the correct diagnosis is made. Sensory tics are peculiar sensations. Tics are increased by stress, decreased by activities that require concentration, exhibit a fluctuating pattern, and are less noticeable during sleep. The patient can suppress the movements or vocalizations voluntarily for minutes or hours, but then is unable to control the movements or the vocalizations.
INDEX OF SUSPICION
Authors: Conners Gregory P. , Lin Angela E. , Rivera Juan A.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

An 18-year-old girl comes to your office complaining of a sore nose. She reports that the tip of her nose has been red and tender for the past few days and seems to be worsening. Because of the erythema, she was not allowed to do her usual volunteer work at a local nursing home. Her health has been good and she denies having any recent upper respiratory infections. She has not had fever and is taking no medication. She recalls having a similar nasal condition at least once before; it was not as uncomfortable and cleared up without treatment.

On physical examination, she is afebrile, and all other vital signs are normal. The tip of her nose is slightly but noticeably swollen, and the medial margin of her right nostril is moderately erythematous.
Acute Epididymitis and Orchitis in Children
Authors: Tennenbaum Steven , Kim Daniel
Published: December 2021

Acute epididymitis and orchitis result in pain and swelling of the contents of the scrotal sac. The differential diagnoses include torsion of the spermatic cord, torsion of the appendix testis, hernia, hydrocele, and trauma. All providers of pediatric health care should understand the etiology and recognize the presenting signs and symptoms of epididymitis and orchitis, conditions that must be distinguished promptly in the emergency setting to avoid the risk of gonadal loss or unnecessary scrotal exploration.

Epididymitis results from inflammation of the epididymis with resultant pain, swelling, and redness of the scrotal skin. Most often a specific cause cannot be identified, although it has been hypothesized that both viral and coliform bacterial infections can inflame the epididymis.
Consultation with the Specialist
Authors: Smith Sherilyn , Sweetser Marianne T. , Wilson Christopher B.
Published: December 2021

Infections are the most frequent illness encountered in children by the pediatrician and, for most patients, represent normal life events. However, the child who has unduly frequent, persistent, or severe infections or who has infection(s) due to microbes that normally are nonpathogenic may represent the exceptional patient who has an immunologic defect. The causative organisms and the age at which the infections begin to occur may provide clues to the nature of the immunologic defect.

Components of the Immune System and Their Function in Host Defense

The immune system can be divided into two components based on the specificity with which microbes are discriminated from self. The innate or natural immune system is responsible for a rapid, efficient, and nonspecific response to invading microbes. It can be viewed as the first line of defense and is comprised of epithelial barriers, the spleen, phagocytic cells, natural killer (NK) cells, the complement system, and other proteins that aid with opsonization. Abnormalities in this part of the immune system generally predispose to infections from organisms that are ubiquitous and usually of low virulence. The second part of the immune system, the inducible or adaptive portion, is responsible for specific, amplifiable, and long-lived responses to foreign antigens.
Wilson Disease
Authors: Ozuah Philip O.
Published: December 2021

Wilson disease (hepatolenticular degeneration) is an autosomal recessive, inherited disorder of copper metabolism resulting in excessive accumulation of copper in the liver, brain, and other organs of the body. The manifestations of the disease are related directly to this accumulation of copper. Copper homeostasis normally is a product of the balance between intestinal absorption of dietary copper and hepatic biliary excretion of excess copper. In Wilson disease, incorporation of hepatic copper into ceruloplasmin is defective and excretion of copper in the bile is reduced. A low level of ceruloplasmin, which until a few years ago was erroneously considered to be the basis for the disease, is a consequence of the underlying metabolic defect.
Chronic Asthma: An Update
Authors: Kemper Kathi J.
Published: December 2021

Case Scenario

Having just changed insurance carriers, a mother brings her 13-year-old son to your office for a routine physical examination. He has no current complaints except for chronic asthma. His past medical history is significant for several hospitalizations for asthma. His only current medication is an albuterol inhaler that he uses two to three times daily. Further questioning about home remedies reveals that in an effort to cut down on his chronic use of medication, he recently started taking the herbal remedies Ma huang and Dong quai as well as vitamin and mineral supplements. He wants to know how safe and effective these therapies are and if you have any other suggestions to help him with his symptoms and avoid another hospitalization.

Because of its severity and complexity, asthma and its treatment are often frustrating for patients, families, and clinicians. Out of desperation, many patients and families turn to alternative therapies, such as nutrition, herbs, and Chinese medicine. With the growing interest in and use of alternative therapies, practitioners would do well to become familiar with them, their side effects, and potential benefits. Traditional medical management also has changed; modern therapy emphasizes anti-inflammatory rather than bronchodilator medication. This review focuses on modern management of chronic asthma symptoms and highlights recent evidence about the effectiveness and side effects of alternative treatments.
Enhancing Patient Compliance in Pediatrics
Authors: Liptak Gregory S.
Published: December 2021

The Challenge

Pediatric care has become exceedingly complex, but no matter how technologically advanced treatments become, they can be only as effective as compliance with their use. Compliance, or adherence, defined as the extent to which a person's behavior coincides with medical or health advice, is crucial for the treatment of illness, the prevention of disease, and the promotion of health.

Unfortunately, noncompliance is extremely common. For example, in a study of the use of penicillin for acute otitis media and "strep" throat, Charney et al1 found that only 43% of the children complied with the regimen. Gordis and associates2 found that compliance with penicillin used for chronic rheumatic fever prophylaxis was only 36%. Eney and Goldstein3 showed that compliance with theophylline in children being evaluated in an emergency department for asthma was only 11%.

Compliance decreases over the course of treatment, not only for long-term interventions, but for brief ones as well. For example, Bergman and Werner4 found that 56% of individuals being treated with penicillin for streptococcal pharyngitis had stopped taking the medication by day 3, 71% by day 6, and 82% by day 9 of the treatment course.

Although compliance is so important, it is largely neglected in medical education, including pediatric residency training.
Nephrogenic Diabetes Insipidus
Authors: Benchimol Corrine
Published: December 2021

Nephrogenic diabetes insipidus (NDI) is a disorder, either congenital or acquired, in which antidiuretic hormone (ADH) secretion is normal, but the ability to concentrate urine is reduced because of insensitivity of the collecting tubule to ADH. The antidiuretic action of arginine vasopressin requires binding of the hormone to the renal type V2 receptor on the basolateral membrane of the collecting duct principal cell. Binding results in activation of adenylate cyclase, generation of cAMP, and increased reabsorption of water across the apical membrane of the renal collecting duct cell. The defect in NDI may be located at any of the steps from binding of vasopressin to the final effect of the hormone on the luminal membrane.
Infant Botulism
Authors: Glatman-Freedman Aharona
Published: December 2021

Infant botulism was first described in 1976. It is caused by Clostridium botulinum, a gram-positive anaerobic bacillus found most commonly in soil and agricultural products. The organism forms spores and during growth and germination releases a potent neurotoxin that is responsible for the illness. Eight neurotoxins have been recognized, but infant botulism is caused primarily by organisms producing toxin types A and B.

Although adult-type botulism occurs by ingesting food contaminated with botulinus toxin, infant botulism seems to result from ingestion of spores that germinate and release the toxin inside the infant's colon. The toxin is absorbed from the gastrointestinal tract, travels via the blood stream, and binds irreversibly to peripheral cholinergic nerve synapses, where it prevents the release of acetylcholine.
Umbilical Cord Blood
Authors: H R J
Published: December 2021

Expectant parents have a new choice—to save and preserve their newborn's umbilical cord blood. Cord blood potentially is a life-saving material. Until now, it had been discarded as medical waste. Cord blood banking gives parents the opportunity to preserve this invaluable material for the future health needs of the infant or potentially other family members.
Violence
Authors: Schwarz Donald F.
Published: December 2021

Violence affects children and adolescents widely. Pediatricians see many of these effects and need to be prepared to address them. A key role for providers in addressing violence, however, lies in working to prevent it. In this endeavor, the provider must be knowledgeable about the risk factors and vigilant for discerning these risks during office visits. Family factors, peer group issues, other risky behaviors, and weapons availability and use all are within the range of topics that a provider might choose to address. At the same time, pediatricians have a key role to play as advocates for children in working with community partners to increase supports for children and families, to institute new programs to prevent violence, and to help remove firearms from the hands of children and youth.
The Pediatrician's Role in Caring for the Developmentally Disabled Child
Authors: Liptak Gregory S.
Published: December 2021

Definition

The term "developmental disabilities" is used to describe a broad array of conditions that delay development and includes individuals who have "mental retardation." In 1992, the American Association on Mental Retardation defined mental retardation as an intelligence quotient (IQ) less than 70 or 75, with onset before age 18 years and limitations in two or more of the following adaptive skills: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work. This definition assumes that the testing performed was sensitive to differences in culture, language, communication, and behaviors and that the child's broadly defined environment was considered. Developmental disabilities may be isolated, as in the child whose vision is impaired, or may be multiple, as in the child whose fine motor, gross motor, and social functioning are delayed.

Epidemiology

Mental retardation has a prevalence of 10 in 1000 children. Specific common conditions and their prevalence per 1000 children include: cerebral palsy, 2; Down syndrome, 1; hearing impairment, 1; visual impairment, 1; and fragile X syndrome, 1. Delayed development is more frequent among children from low socioeconomic conditions. Developmental disabilities are encountered commonly in pediatric practice: Horwitz et al found that 5.3% of the patients encountered in a study of pediatric practices had cognitive and language disorders and that 4.0% had motor abnormalities.
Quality Improvement: An ACQIP Exercise on the Management of Otitis Media
Authors: Sebring Robert H. ,   Staff of the Division of Quality Care
Published: December 2021

As part of Pediatrics in Review's ongoing focus on quality improvement, we present a self-assessment exercise taken from the American Academy of Pediatrics' Ambulatory Care Quality Improvement Program (ACQIP). Tabulated responses of pediatricians who completed this exercise as part of the ACQIP program are presented on pages 253 to 254, allowing readers to see how their own answers compare and providing material for thought and discussion. Readers are encouraged to participate in the ACQIP program. Additional information can be obtained by calling or writing the Division of Quality Care, American Academy of Pediatrics, Box 927, Elk Grove Village, IL 60009-0927.

Monitoring Otitis Media

EDUCATIONAL OBJECTIVES

This exercise and the follow-up materials should help you identify areas of improvement in how your practice monitors and documents information for children with acute or chronic otitis.

INSTRUCTIONS

Beginning with tomorrow's appointments, answer the questions below for the most recent, but not the current episode of otitis media in the first 10 patients you see who are younger than 4 years of age and experiencing at least their second episode of otitis. You will need to review charts to answer the questions. Put a check in each box in which you find the information in your medical record listed.
Consultation with the Specialist
Authors: Brooks John G.
Published: December 2021

Infants who experience apparent life-threatening events (ALTEs) usually generate enormous anxiety among family members and other caretakers and present diagnostic, management, and counseling challenges for the pediatrician. Important considerations for the primary care provider include the following:

1. What is the prognostic significance of the frightening event, particularly in relation to sudden infant death syndrome (SIDS)?

2. Which mechanisms and specific diagnoses should be considered as possible causes of ALTEs?

3. Which infants who present after an ALTE require hospitalization, and what diagnostic evaluation is appropriate?

4. What is the role for home cardiorespiratory monitors, and what is appropriate follow-up for infants who have suffered an ALTE?

Definition

ALTE should be considered a chief complaint rather than a specific diagnosis. In the standard established in 1986 by the National Institutes of Health (NIH) Consensus Development Conference on Infantile Apnea and Home Monitoring, ALTE is defined as "an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases the observer fears that the infant has died." Previously used terminology, such as "aborted crib death" or "nearmiss SIDS," should be abandoned because it implies a possibly misleading close association between this type of event and SIDS.
Extending the Boundaries of Medicine
Authors: H R J
Published: December 2021

Readers may be surprised to see the article "Separation or Synthesis: A Holistic Approach to Therapeutics" in this issue. There are no core content statements related to this article. Yet, from time to time, I exercise my editorial prerogative to publish something that is outside the usual—to stimulate, to look ahead to what may be important in the future, and to provoke our readers.

There is a great deal of interest today in alternative medicine. An article in The New England Journal of Medicine reports that nearly one third of Americans use some form of alternative medical therapy.1 There is now an Office of Alternative Medicine at the National Institutes of Health supporting grants in this field, and some health insurance companies recently began providing (for an added premium) coverage for these therapies.
Tracheomalacia
Authors: Paston Francine , Bye Michael
Published: December 2021

Tracheomalacia (TM) is flaccidity of the tracheal wall caused by defective cartilaginous rings, resulting in reduced anterior posterior airway caliber. A relatively uncommon and usually benign lesion, TM manifests as a wheeze, stridor, and occasionally respiratory difficulty.

TM can result from either primary or secondary defects. Primary defects are intrinsic to the tracheal wall and most often are idiopathic, although some may result from endotracheal intubation. In preterm infants, primary TM may occur from positive pressure ventilation, and pathology distal to the endotracheal tube may be observed while the infant still is intubated.

Secondary TM results from external compression of the airway by a mass, such as a mediastinal tumor or a vascular ring.
Dosing Errors in the Use of Antiepileptic Drug Suspensions
Authors: Bunch Bonnie L. , Shelov Steven P.
Published: December 2021

Liquid forms of antiepileptic drugs (AEDs) may be syrups or elixirs (in which the AED is in solution in water or alcohol, respectively) or suspensions. Suspensions consist of finely divided medication dispersed in an inactive carrier.

The following are common reasons for the use of liquid forms of AEDs: 1) ease of measurement of doses that do not correspond to available tablet or capsule form; 2) ease of administration to children or adults who are unable to swallow or chew capsule, tablet, or chewable tablet forms of the drug; and 3) for persons who must receive all enteral medications through nasogastric or gastrostomy tubes.
Behavioral Problems and Their Prevention
Authors: Chamberlin Robert
Published: December 2021

In this article we will review two broad areas of knowledge (individual differences and parenting) that are directly or indirectly related to behavioral problems in young children and one specific problem area (toilet training).

INDIVIDUAL DIFFERENCES

One of the major advances in preventive pediatrics over the last ten years has been the recognition of how individual differences in the behavior and temperament of children affect parents and parenting. Although most parents with more than one child have intuitively recognized that all children are not alike, it is only fairly recently that many of us, as physicians, have acknowledged the fact that difficult children are not necessarily the result of bad parenting.

One of the most clinically useful ways of looking at individual differences has come from the research of Thomas and Chess. These investigators became interested in why, in many families, only one child would get into difficulty while the others were doing fine. Preliminary studies strongly suggested that environmental variables alone could not account for the range of variation in behavior seen within a single family context.

These observations led to a formal research project in which 136 children were followed from 3 months of age into adolesence. The study focused on how these babies differed from one another in the earliest months of life and the implications of these differences for the parents taking care of these infants.
Precursors of School Failure
Authors: Oberklaid Frank , Levine Melvin D.
Published: December 2021

School failure is pervasive. Its impact extends beyond the classroom and can contribute to emotional turmoil, social difficulties, delinquent behavior and lifelong maladjustment. School failure does not qualify as a disease, a syndrome, or a unique pathogenetic process. It is rather the product of constitutional predispositions that have interacted with environmental factors and life events in an ongoing process. Intrinsic handicaps may be subtle. Their outward manifestations are likely to vary from child to child and evolve with age, shaped by neurologic maturation, experience, and changing external expectations.

Children with school problems form a heterogeneous group with diverse etiologies, symptom complexes, diagnostic findings and service needs. Nine common precursors of school failure are suggested in this review. Although presented individually, these precursors are not necessarily discrete, nor are they mutually exclusive; they may themselves stem from multiple factors. They are conceptualized as "risk factors" that may predispose to or foreshadow later failure. These, in turn, interact with a set of variables we have characterized as sources of "developmental buoyancy." The latter may neutralize or counteract early susceptibility to academic problems. Individual children may have one or multiple identifiable precursors of variable severity and differ in the extent to which they can minimize or overcome these potential predispositions to school failure.
Skin Tests in the Diagnosis of Allergic Conditions
Authors: Kravis Lillian P.
Published: December 2021

Allergic disorders may be classified into four main categories of immunologic hypersensitivity reactions: type I, immediate or anaphylactic; type II, cytotoxic; type III, involving immune complexes; and type IV, delayed or cell mediated. Type I reactions are those most commonly encountered in clinical allergy. They may be well defined by skin testing, provided the patients to be tested are carefully selected and the tests are applied properly and interpreted critically.

Major indications for direct skin testing are: (1) to separate atopic from nonatopic patients; (2) to help in identifying specific allergens in atopic persons; and (3) to reassess the allergic profile in patients receiving immunotherapy. Other indications for skin-testing, of more limited applicability, include: (1) screening for hypersensitivity to vaccines; (2) testing for reactivity to drugs (and particularly penicillin); (3) testing for immediate and delayed reactions in such conditions as bronchopulmonary aspergillosis; and (4) in evaluation of patients with reactions to insect stings.

Skin-testing has limited usefulness in early infancy, in chronic urticaria, in the investigation of food allergies, in atopic dermatitis not accompanied by other manifestations of atopy, or in allergic reactions to drugs other than penicillin.

A checklist to be consulted prior to performing or interpreting skin tests should include: (1) assurance of the potency of the extract used in testing; (2) knowledge of the nonspecific irritant properties of any extracts used for testing; (3) history of administration of antihistamine drugs or epinephrine prior to testing; and (4) the correlation of skin test results with clinical history.

The help of a qualified allergist should be sought if: (1) skin test results are at variance with the historical data; or (2) systemic reactions are induced by skin testing; or (3) the patient fails to respond to the therapy dictated by the skin test results.

Alternatives or supplements to skin-testing include RAST testing and measurement of histamine release from sensitized leukocytes. These have rendered passive transfer testing (PK or Prausnitz-Küstner) substantially obsolete.

Direct allergy skin testing remains the most sensitive, most specific, and most reliable method presently available to the physician for investigation of IgE-mediated allergic disorders.
Editorial: Further Comments on the Evaluation of Febrile Children
Authors: MCCARTHY PAUL L.
Published: December 2021

In a recent review in PIR, a sequence for the clinical and laboratory evaluation of Children ≤24 months with high fever was detailed.1 A key skill in assessing febrile children was described and termed "optimal observation." This assessment is performed prior to physical examination and, combined with laboratory evaluation, supplements data gathered from the physical examination. The review stimulated many comments from readers who questioned the need for such a vigorous approach. This interest is not surprising since fever in the young child is a common pediatric problem and also a diagnostic challenge.

Most discussion focused on three issues: (1) the occurrence of bacteremia in patients seen in private practice: most practitioners doubt that it occurs as frequently among private patients as among clinic patients; (2) the cost of a laboratory evaluation of a young, febrile child; (3) the data on which optimal assessment is based.
Persistence of the Fetal Circulation
Authors: Goetzman Boyd W. , Riemenschneider Thomas A.
Published: December 2021

Persistence of the fetal circulation (PFC) was initially described as a syndrome of central cyanosis in term newborn infants resulting from right-to-left shunting of blood via persisting fetal channels which mimicked structural heart disease. Subsequently, this abnormal hemodynamic pattern has been recognized as a complication of a spectrum of neonatal disease. The designation PFC has achieved wide acceptance; however, other terminology may be encountered, including persistence of the transitional circulation and persistent pulmonary hypertension of the newborn.

PATHOPHYSIOLOGY

Muscular pulmonary arterioles are constricted in the term fetus. If these vessels fail to dilate at birth, or if constriction recurs, pulmonary hypertension (PHN) ensues, with consequent elevation of right ventricular and right atrial pressures. Right-to-left (R→L) shunting of blood across the foramen ovale occurs when right atrial pressure exceeds left atrial pressure. R→L shunting through the ductus arteriosus requires pulmonary arterial pressure to exceed systemic pressure, as well as patency of the ductus (see Fig 1).

PHN may independently be responsible for myocardial dysfunction by imposing an abnormal workload on the right ventricle or by adversely affecting right coronary artery blood flow with consequent subendocardial ischemia. The physiology of PFC is presented schematically in Fig 2.

There are two potential pathways to PFC (see Fig 3).
Mental Retardation: Biologic Aspects of Concern to Pediatricians
Authors: Opitz John M.
Published: December 2021

1. Approximately 3% of the population (6 to 7 million persons in the United States) is mentally retarded. Of these, severe mental retardation (IQ <50) occurs in about 10% (3 or 4 per 1,000 persons) and mild mental retardation (IQ 50 to 70) in 90%.

2. The high familial occurrence, the continuously variable phenotype shading into normality, and various genetic studies suggest that most of mild mental retardation represents the left end of the normal IQ distribution curve. Virtually no such cases can be found in the group of the severely retarded, either within or outside the institutions, suggesting that the majority of severe mental retardation represents discontinuous phenotypes due to chromosomal, environmental, mendelian, and multifactorial causes.

3. Some mild mental retardation represents syndromal occurrence (ie, mild PKU, rubella syndrome, Klinefelter syndrome); however, in most cases no anomalies are found, chromosomes are normal, height and head circumference fall within normal limits, and few have neurologic deficits, such as cerebral palsy and/or seizures. In the mildly retarded, personal, emotional and psychosocial problems predominate. The severely retarded are a biologically different group with a high incidence of gross neurologic disturbances, growth failure, abnormal head circumference, single or multiple malformations, and metabolic diseases.

4. The severely retarded are generally infertile, the mild retarded less fertile than average; however, a small minority among the latter contributes a disproportionately large number of retarded offspring to the next generation.

5. Most mental retardation can be evaluated on an outpatient basis for causal, pathogenetic, and prognostic factors. The evaluation can be economic, quick, reliable, painless, and efficient in most instances; however, CNS degenerative diseases may require a brief inpatient stay for biochemical evaluation. By all odds the most informative items in the work-up of the retarded are the (family and past) history and the (physical and neurologic) examination. Metabolic screening is usually not indicated in the malformed, neither are cytogenetic studies in the nonmalformed.

6. All patients with mental retardation deserve a diagnostic/causal evaluation and their families prognostic/genetic counseling.

7. Some 70% of mental retardation in the general population can be attributed to genetic causes. Genetic counseling in severe mental retardation is to prevent recurrence in siblings; in the mildly retarded much greater emphasis is placed on the prevention of retarded offspring.
Neural Tube Defects
Authors: GOLDEN GERALD S.
Published: December 2021

A reader of the article "Neural Tube Defects" (PIR 1:187, December 1979) raised three questions: (1) Is there not newer information to indicate that the risk of recurrence is half of what has been previously quoted in the literature? (2) Does the sensory level defect follow the motor function? (3) Does not intermittent catheterization and drug therapy in the management of urologic problems produce a higher percentage of continence than is presented in this paper?

Dr Golden responds as follows: The question of recurrence risk in this country is not clean. Although it is generally recognized that the incidence is lower than in England, data for recurrence risk are not available.
Management of Perinatal Death
Authors: Speck William T. , Kennell John H.
Published: December 2021

Death in the peninatal period is a common occurrence, about one in 100 deliveries. Grief reactions in parents always occur following such deaths—with frequent symptoms of distress or changes in behavior. It appears to help parents overcome the grief to view or hold their dead child, name it, allow grief to be expressed, have a funeral, and avoid tranquilizing medications, and for the physician to meet with the parents soon after the death to discuss findings of the autopsy, three or four days later and again six months after the death. It is unwise for parents to have another baby until the grieving has been completed.
Management of Septic Shock
Authors: Yabek Steven M.
Published: December 2021

The mortality among children with septic shock continues to be unacceptably high. Timely diagnosis and the use of appropriate monitoring and therapeutic modalities should help reverse this trend. The important areas of management include treating the underlying infection, ensuring adequate ventilation, restoring and maintaining acid-base and electrolyte balance, and the restoration of normal hemodynamics and organ perfusion by judicious use of plasma volume expanders and inotropic/vasoactive agents such as dopamine.
Viral Hepatitis in Pregnancy: Problems for the Clinician Dealing with the Infant
Authors: Stevens Cladd E. , Krugman Saul , Szmuness Wolf , Beasley R. Palmer
Published: December 2021

Stokes and colleagues first described transmission of hepatitis B virus (HBV) infection from a mother who was an HBV carrier to an infant born by cesarean section in 1954. Evidence of clinical hepatitis with jaundice, detected at 2 months of age, was later complicated by chronic active hepatitis. The infant died at 18 months of age with advanced cirrhosis of the liver.

In the past decade tests have been developed that are specific for hepatitis B antigens and antibodies and they have enabled physicians to identify acute hepatitis B infection during pregnancy, as well as the presence of a chronic carrier state. Thus it has been possible to assess the effect of maternal HBV infection on the newborn infant. The attack rate of HBV infection in infants has been reported to range between 10% and 70%. Infection is usually detectable by 1 to 3 months of age. Although most infections are asymptomatic, fulminant hepatitis is seen on rare occasions. Of major significance is the tendency for the infected infants to become chronic HBV carriers with possible progression to chronic active hepatitis, cirrhosis, and rarely hepatoma.

Hepatitis A virus (HAV) infection has not been a problem in the newborn. Hepatitis A is now an uncommon infection among adults in Western countries while in developing areas it is primarily a disease of childhood.
Intraventricular Hemorrhage in Premature Infants
Authors: Volpe Joseph J.
Published: December 2021

Four major varieties of intracranial hemorrhage can be recognized in the neonatal period: (1) subdural hemorrhage, (2) primary subarachnoid hemorrhage, (3) intracerebellar hemorrhage, and (4) periventricular-intraventricular hemorrhage.1 Subdural hemorrhage, often related to obstetrical trauma, now is an uncommon lesion in most medical centers. Primary subarachnoid hemorrhage, although very common, is rarely of major clinical importance, because of its venous origin and self-limited course. Intracerebellar hemorrhage, commonly observed at postmortem examination of the small premature infant but rarely documented during life, is of uncertain clinical significance. Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. The enormous importance of this lesion is linked to the remarkable improvements in recent years in neonatal intensive care and, as a consequence, in survival rates for small premature infants. Because periventricular-intraventricular hemorrhage is characteristic of the premature infant (particularly the infant less than approximately 32 weeks gestation), the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities.

INCIDENCE

The remarkably high incidence of periventricular-intraventricular hemorrhage is demonstrated dramatically by studies in which premature infants were subjected to computed tomography (CT) scan routinely within the first week of life (Table 1). Thus, 40% to 45% of all such infants exhibited periventricular-intraventricular hemorrhage.2,3
Nocturnal Enuresis
Authors: Smith Leigh R.
Published: December 2021

Enuresis has long been a problem for children, parents, and physicians. Much has been written on the subject from various points of view. A brief review of the subject is presented, followed by a description of the author's approach to the problem. The emphasis is on removing enuresis from the category of a disease to be cured and placing it among those conditions which may be considered variations of normal development. The physician's role is to help resolve family problems which result from misconceptions about enuresis and to avoid overinvestigation of a largely self-limiting condition.

Nocturnal enuresis may be defined simply as wetting the bed at night beyond the age at which most children have stopped. Parents often consider enuresis a disease to be cured. The condition is seldom bothersome to the child, however, until parent, sibling, peer, or relative makes him feel that he is different from other children.

The concept of nocturnal enuresis as a disease is often reinforced by textbooks and literature which define a specific age after which bedwetting is unusual and which convey the impression that the etiology is frequently organic. The age most often assigned as an end point to bedwetting is 5 to 6 years, or school age.1-3
Hyponatremia in Children
Authors: Kelsch Robert C. , Oliver William J.
Published: December 2021

Hyponatremia is usually recognized following an electrolyte screen since it is not symptomatic, except in its severest degrees. The pathophysiologic implications of hyponatremia and its therapy are quite varied. The purpose of this review is to present a diagnostic plan which in most instances will resolve the therapeutic dilemma. This approach is a minor modification of that developed by Schrier and Berl1 for evaluating hyposmolar states.

GENERAL PRINCIPLES

The occurrence of hyponatremia indicates a failure of those receptor and effector mechanisms designed to assure that the quantity of water in the body will closely relate to the amount of solute in the major bodywater spaces. The principal sensors are designed to recognize osmolar changes, not changes in sodium concentration. Nevertheless, measurement of serum sodium concentration is the most readily available tool for estimation of disturbances in osmolality. Fanestil2 has recorded 14 formulae designed to estimate osmolality from serum sodium concentration or sodium, glucose, and urea concentrations. The simplest of these formulae, osmolality = 2 x Na+ + 10, is satisfactory in the vast majority of clinical circumstances occurring in pediatrics. Diabetes mellitus is the only relatively common state that requires the use of alternate formulations to correct for hyperglycemia. The contribution to serum osmolality by glucose can be approximated by adding to the above formula 1 mOsm for each 18 mg/100 ml of blood glucose above the level of 100 mg/100 ml.
Medical Issues in Sports Medicine
Authors: Smith Nathan J.
Published: December 2021

Today's children live in an environment that prompts an increasing interest in medical issues related to recreational activities and sports participation. The restrictive urban environment, in which most children live, allows for little self-directed play and much of the play of school-aged children is rigidly regulated and organized by adults. The affluence and abundant leisure time of today's adults supports and allows for their involvement in much of children's play. The most readily identified models accepted for the play and games of young people are the varsity and professional sports so prominently displayed through the mass media. Little concern has been given for the appropriateness of these games for the very young; yet they have become the "play" and the games of millions of very young American children. The general secular advance of maturational status allows children of certain highly motivated parents to become highly competent and even elite athletes at younger and younger ages.

Only in the past two decades have organized sports come to make up much of the play opportunity for the elementary school-aged child. More than 17 million young people, many of them preadolescent and as young as 5 or 6 years of age, participate in community-based youth sports programs that are highly organized and generously supported.
Harmful Chemicals and Drugs in Breast Milk
Authors: Smith David S.
Published: December 2021

The pediatrician should be aware of the fact that nearly all drugs used in the therapy of lactating women may be found in varying amounts in breast milk. Mothers who must take antithyroid drugs, chloramphenicol, lithium, methadone, most anticancer drugs, radioactive pharmaceuticals and antiinfective agents such as the tetracyclines and metronidazole should not nurse their infants while receiving therapy. It has been our experience that in most instances safer alternative drugs may be selected after discussions with obstetricians, family physicians, and internists. The use of other drugs merits a certain degree of caution; nursing the infant before a dose is given may help to minimize exposure to the infant. Interruption of breast-feeding should be infrequent.
The Schoolchild with Encopresis
Authors: Levine Melvin D.
Published: December 2021

Often, a schoolchild with encopresis feels desperate, lacking a most primitive form of control, harboring a painful secret, susceptible to exposure and peer ridicule, wounded by the disdainful remarks of parents and siblings, and perplexed over why he messes. Often children with encopresis receive inconsistent care; management may vacillate from intentional disregard of the problem to active coercion or vindiction. Parents may be baffled by conflicting advice from neighbors, teachers, grandparents, pharmacists, and even pediatricians.

Most "accidents" occur in the late afternoon (commonly 3:00 to 7:00 PM). Unlike enuresis, nocturnal encopresis is rare and more difficult to treat successfully. Many children insist (correctly) that they do not receive a "signal" or feel the call to use a bathroom. They may plan furtively to conceal their shameful out-flow, burying underwear in the garden or sequestering soiled clothing in trash cans and behind dressers!

Encopresis is defined as the deposition of formed or semiformed stools in a child's underwear (or other unorthodox sites), occurring after the age of 4 years on a regular basis. Some authors differentiate between encopresis and fecal soiling, basing the distinction on the extent to which full-bowel movements are passed.1 This classification, however, often does not conform to clinical experience, since longstanding cases commonly fluctuate over time in patterns of incontinence and stool consistency.
Pediatrics in the Community
Authors: Kaczorowski Jeffrey
Published: December 2021

Our inaugural story for Pediatrics in the Community was in the January 2007 edition of Pediatrics in Review. Dr Robert Haggerty provided the historical rationale for community pediatrics training (CPT) as part of that feature. Now, 1 year later, we asked Dr Jeff Kaczorowski, Director of the CPTI at the American Academy of Pediatrics (AAP), to describe the present and future of CPT. As the stories in this series have shown, some residents are having wonderful community experiences already and making a difference in the lives of children in their communities. The challenge is how to make such experiences available to all pediatric residents and pediatricians.—C. Andrew Aligne, MD, MPH, Section Editor