bluuebunny/crossref_metadata_2025 huggingface dataset:
Curious Neurologic Sequelae in Galactosemia
Authors: Lo Warren , Packman Seymour , Nash Sylvia , Schmidt Kathleen , Ireland Steven , Diamond Ivan , Ng Won , Donnell George
Published: December 2021

Two siblings with classic transferase deficiency galactosemia that was detected at birth have been treated with lactose restriction since the neonatal period. Both patients developed a unique and progressive neurologic syndrome of mental retardation, tremor, and ataxia. Careful review of the family history and medical records, the absence of metabolic disturbances other than those related to galactosemia, and the aggregate physical findings and neurodiagnostic studies ruled out other neurologic disorders in these siblings. It is therefore proposed that these patients represent a subgroup of transferasedeficient galactosemic patients, who develop characteristic neurologic sequelae with conventional dietary management. The existence of this subgroup should be considered in evaluations of therapeutic responses in cohorts of patients with galactosemia. Further, galactosemia should be included in the differential diagnosis of tremor and ataxia in the setting of mental retardation.
Prevention of Perinatal Transmission of Chronic Hepatitis B Surface Antigen (HBsAg) Carrier State
Authors: CHIN JAMES
Published: December 2021

In Reply.—

It is well documented that the risk of a pregnant woman—who is a hepatitis B surface antigen (HBsAg) carrier and who also has detectable hepatitis Be antigen (HBeAg)—transmitting a hepatitis B virus (HBV) infection to her infant at birth, which would result in chronic HBsAg carriage, is very high (up to 90%). Women who are HBsAg positive but HBsAg negative and who have no detectable antibody to HBeAg (anti-HBe) are considered of intermediate infectivity.
Effect of Acidosis on Bilirubin Deposition in Rat Brain
Authors: Bratlid Dag , Cashore William J. , Oh William
Published: December 2021

The effect of metabolic and respiratory acidosis on bilirubin and albumin entry into the brain was studied in 24 awake and unanesthetized rats. Hyperbilirubinemia was established by infusion of unconjugated bilirubin at a rate of 30 mg/kg/h for three hours. After two hours, metabolic acidosis was produced in eight rats by infusion of 0.5 N hydrochloric acid at a rate of 0.02 mL/g/h. This reduced the pH level to 7.03 ± 0.01 (mean ± SEM) with a normal value for Pco2. Respiratory acidosis was produced in another group of eight animals who breathed 20% CO2 in a balanced gas mixture for the last hour of the study period. This resulted in a reduction of pH to 7.04 ± 0.01 with Pco2 of 100.4 ± 2.3 mm Hg. A third group of eight rats served as controls and were given equal volumes of saline infusion. No increase in brain bilirubin or brain albumin was found in the group with metabolic acidosis, but in the group with respiratory acidosis both bilirubin and albumin concentrations in the brain increased significantly. No significant differences were found between the groups in serum total or apparent unbound bilirubin, albumin, or osmolality. The results indicate that a brief period of acidosis per se does not increase bilirubin entry into the brain, but hypercarbia does so by opening of the blood-brain barrier.
Marijuana: A Crude Drug with a Spectrum of Underappreciated Toxicity
Authors: Schwartz Richard H.
Published: December 2021

The unthinkable happened to our family. Our son Keith, aged 15 years, experimented with marijuana and quickly became obsessed with getting "high." Keith soon sought out only those friends of a similar ilk and within a few months we began to notice progressive fatigue, disinterest in family life and school work (grades plummeted), loss of academic and vocational goals, a couldn't-care-less attitude, and compulsive dishonesty.

Keith had always been a difficult child but we were hopeful that time and love would help him outgrow his poor self-image and impulsive behaviors. Perhaps, without marijuana, we might have seen him mature and become a motivated selfsufficient citizen without the need for intensive drug rehabilitation.

For the past 8 months, Keith has been a client at a unique drug rehabilitation program, Straight, Inc, where he is learning that he is a worthwhile, basically good person; that his family loves and needs him; and that he will have a life-long fight against the seductive malignant influence of alcohol, marijuana, and other drugs. He is making progress. We take one day at a time.

The word marijuana derives from the indigenous Mexican or Central-American word maraguango, a general term meaning any intoxicating substance.1 Marijuana, the dried particles of leaves, small stems, flowers, and achenes (seeds), is a crude drug which owes its psychoactive properties primarily to Δ9-THC, a mixture of nine psychoactive isomers produced by resin-secreting glands of the medicinal varieties of the hemp plant (Cannabis sativa).2 These glands are particularly abundant in the upper leaves and flowering tops of plants of both sexes but are highest in the pistillate (female) plants.
Persistence of Diminished Bone Mineral Content Following Renal Transplantation in Childhood
Authors: Chesney Russell W. , Rose Philip G. , Mazess Richard B.
Published: December 2021

Bone mineral content (BMC) was measured in the nondominant arm of 18 children (aged 37/12 to 17½ years) for a total 783 months after renal transplantation. Using photon absorptiometry, 89 measurements were made; 17 of the 18 patients had a functioning graft and one patient died. Significant demineralization, a BMC greater than -2 SD below appropriate control volumes, was found in 11 of 18 patients (62%) and 55 of 89 measurements (61%). Bone loss was progressive; among the 16 patients followed for more than 6 months, ten showed a decline of more than 0.5 SD in BMC, five had no change, and only one showed improvement. No relationship was found between BMC and the use of furosemide, type of transplant (15 living, seven cadaver), prior renal disease (six with glomerulonephritis, 11 tubulointerstitial), need for a second graft (five patients), chronic anticonvulsant therapy, or serum calcium and phosphate values. BMC was slightly correlated (P < .05) with alkaline phosphatase values. BMC was more strongly correlated with serum creatinine (y = -0.48x + 1.25, r = -.042, P < .001) and prednisone dose (mg/kg/d) (y = -0.65x + 0.481, r = -.543, P < .001) in an inverse relationship. Patients whose serum creatinine value was less than 1 mg/dL had a BMC of -0.71 ± 0.34 SD; those with serum creatinine value greater than 2 mg/dL had BMC of -3.32 ± 0.31 SD, different at P < .001. Patients receiving daily prednisone therapy had a significantly lower BMC than those receiving alternate-day therapy (-3.11 ± 1.23 SD v -1.72 ± 1.29 SD, P < .005).
The Melkersson-Rosenthal Syndrome
Authors: Wadlington William B. , Riley Harris D. , Lowbeer Leo
Published: December 2021

The Melkersson-Rosenthal syndrome consists of recurrent swelling of the lip or face, intermittent facial palsy, and fissured tongue. Lengthy intervals may occur between those various manifestations. Four white female patients with this disorder are described. First identified in Europe, the condition is now increasingly recognized in this country. The cause is unknown. The pathology, clinical features, and management of this unusual disorder are discussed.
Recurrence of Rheumatic Fever During Prophylaxis with Monthly Benzathine Penicillin G
Authors: Nordin James D.
Published: December 2021

A 9-year-old girl had apparent recurrence of rheumatic fever while receiving monthly benzathine penicillin injections. A review of pharmacokinetc studies on the subject suggests that this is a real risk. A need for review of the current recommendations for rheumatic fever prophylaxis is suggested.
Suctioning and Cerebral Blood Flow
Authors: TREVATHAN EDWIN
Published: December 2021

To the Editor.—

The report by Perlman and Volpe1 meticulously describes a relationship between suctioning of the preterm infant and temporally associated increases in intracranial pressure and cerebral blood flow velocity. Perlman and Volpe further suggest that the increased pressure-flow stresses on the cerebral capillary beds, associated with suctioning, could precipitate intraventricular hemorrhage (IVH) in preterm infants. Surprisingly, Perlman and Volpe decided not to use the incidence of IVH as a measurement of outcome. The failure to obtain ultrasound studies before suctioning is unfortunate, because a totally new prospective study is now indicated, rather than a simple extension of their reported study. In spite of the lack of ultrasound data prior to suctioning, further analysis of the present data would be helpful.
Apnea of Infancy and Subsequent Neurologic, Cognitive, and Behavioral Status
Authors: Deykin Eva , Bauman Margaret L. , Kelly Dorothy H. , Hsieh Chung-Cheng , Shannon Daniel
Published: December 2021

A pilot study investigated the neurologic, cognitive, and behavioral consequences of nonfatal infancy apnea. Fifteen formerly apneic, monitored children were compared with age-similar siblings and with agesex matched playmates. Significant impairment in gross motor development and mild cognitive deficiencies were observed when those who had had apnea were compared with their siblings but not when contrasted with their playmates. Lack of difference between those who had had apnea and playmates might have been due to a selection bias involving assortive friendships. The frequency and the severity of apneic episodes were associated but neither one showed a clear gradient of risk for poor outcome in the areas under study, indicating the possibility that apnea may have a threshold effect on subsequent development.
Intravenous Vitamin E and Deaths in the Intensive Care Unit
Authors: BODENSTEIN CARL J.
Published: December 2021

To the Editor.—

Three patients in our neonatal intensive care unit during December 1983 are described below. The outcome for these patients was very unusual for our nursery and prompted investigation of any new practices started recently. The case histories briefly reviewed as follows:

Patient 1. This white male neonate had birth weight of 1,021 g and estimated gestational age of 30 weeks. Apgar scores were 5 and 7. He had hyaline membrane disease requiring the use of a ventilator and he was weaned to room air in seven days, although he later required ventilation for apnea.
Suctioning and Cerebral Blood Flow
Authors: PERLMAN JEFFREY M. , VOLPE JOSEPH J.
Published: December 2021

In Reply.—

Marshall misread a critical piece of information in the text. His interpretation of the data would be correct, if the intracranial pressure, arterial blood pressure, and cerebral blood flow velocity changes occurred simultaneously. However, as we stated in the text (see section on "Temporal Features of Changes with Suctioning"), the intracranial pressure fell to base-line values immediately following suctioning, whereas the changes in arterial blood pressure and cerebral blood flow velocity occurred more slowly over an approximately two-minute period.
Neonatal Screening for Phenylketonuria
Authors: KOCH RICHARD , TWELMEYER DEBRA
Published: December 2021

To the Editor.—

The article by McCabe et al1 reported the findings from a large survey consisting of data gathered from completed questionnaires obtained from 26 countries. The data involved an analysis of serial blood phenyalanine concentrations obtained from newborns during the first 2 weeks of life, who were siblings of known patients with classic phenylketonuria (PKU). The authors should be applauded on their efforts, which represent a significant compilation of data on the important issue of newborn screening.
Neonatal Screening for Phenylketonuria
Authors: MCCABE EDWARD R. B. , MCCABE LINDA
Published: December 2021

In Reply.—

The comments of Koch and Twelmeyer and of Berlow are appreciated as they allow us to reemphasize points made in our recent article1 on newborn screening for phenylketonuria (PKU) and permit us to address additional relevant issues. Koch and Twelmeyer have stated that "only two of the 26 countries reported false-negative results involving the Guthrie test" and therefore these false-negative results "could be treated as outliers" affecting "the conclusion reached as a result of this survey."
Risk Factors for Diabetic Retinopathy in Youth
Authors: Malone John I. , Grizzard W. Sanderson , Espinoza Luis R. , Achenbach Karl E. , Van Cader Thomas C.
Published: December 2021

Retinal microvascular abnormalities were evaluated in 74 insulin-dependent diabetic youths by fluorescein angiography on two or more occasions spanning at least 4 years. Half of this group showed progression of the retinal vascular abnormalities from a stage of no significant abnormalities to at least background retinopathy with more than ten microaneurysms. Proliferative retinopathy requiring laser photocoagulation occurred in 14% (10/74). Insulin administration (once or twice a day) and glycemic control as reflected by hemoglobin A1C were identical in those with progression and in those with no progression of retinopathy. More females than males in this age group developed progressive retinopathy (P < .036). Human lymphocyte antigen (HLA) types DR3 and DR4 in combination occurred more frequently (P < .001) in those with progression of retinopathy than in those without progression. Teenaged, female, insulin-dependent diabetics with both HLA DR3, and DR4, were at increased risk for developing proliferative retinopathy.
Focal Segmental Glomerulosclerosis and Progressive Renal Failure Associated with a Unilateral Kidney
Authors: Thorner Paul S. , Arbus Gerald S. , Celermajer David S. , Baumal Reuben
Published: December 2021

Persistent proteinuria, chronic renal failure, and focal segmental glomerulosclerosis developed in three children with solitary kidneys. Two of these children were born with unilateral kidneys. The third had bilateral reflux and underwent a unilateral nephrectomy and reimplantation of the remaining ureter; persistent proteinuria developed 7 years later. It is postulated that hyperperfusion of a critical number of glomeruli during childhood may be the mechanism responsible for the production of focal segmental glomerulosclerosis in these patients.
Legionellosis in Children with Leukemia in Relapse
Authors: Kovatch Anthony L. , Jardine David S. , Dowling John N. , Yee Robert B. , Pasculle A. William
Published: December 2021

Two children with legionellosis complicating a relapse of acute lymphoblastic leukemia are reported. A 5-year-old boy with pneumonia had Legionella pneumophila cultured from a tracheal aspirate following a rapid deterioration in his respiratory status and intubation. This child had severe and irreversible granulocytopenia and died in spite of therapy with erythromycin and rifampin added five days later. Combination antimicrobial therapy is suggested for immunosuppressed children with legionellosis if resolution of neutropenia is not readily anticipated. Culture of Legionelli sp from respiratory tract secretions or sputum, as reported for the first time in the pediatric literature, should be attempted in all children in whom this infection is suspected. A 13-year-old boy with pneumonia recovered in spite of therapy with antimicrobial agents not proven to be effective against the legionellae. Clinical improvement coincided with increase in absolute granulocyte count. A retrospective diagnosis was made when seroconversion to Legionella ella micdadei (< 1:16 to 1:1,024) was determined during a survey of unselected sera from 255 hospitalized children. This is the first documented case of Pittsburgh pneumonia described in a child.
Tics and Vocalizations in Children Treated with Carbamazepine
Authors: Neglia Joseph P. , Glaze Daniel G. , Zion Thomas E.
Published: December 2021

Three patients are reported who, following the initiation of carbamazepine therapy for seizure control, either experienced the onset of Tourette's syndrome or a worsening of their tics and vocalizations. Blood levels of carbamazepine were within the therapeutic range, and no patient showed clinical signs of intoxication. Tics and vocalizations did not resolve following discontinuation of carbamazepine therapy. Carbamazepine may trigger the onset of Tourette's syndrome in susceptible patients.
Age at Death Used to Assess the Effect of Interhospital Transfer of Newborns
Authors: Paneth Nigel , Kiely John L. , Susser Mervyn
Published: December 2021

In New York City, newborn units classified as level 1 (no intensive care) frequently transfer low-birth-weight infants to units classified as level 3 (complete intensive care), but level 2 units (those with intermediate levels of care) transfer rarely. As deaths occurring in the first hours of life are unlikely to be affected by infant transport services, early (first four hours), late (four hours to 28 days), and overall neonatal death rates were separately examined at each of the three levels of care for singleton live-births weighing 501 to 2,250 g. As previously reported, overall neonatal mortality (adjusted for birth weight, gestational age, sex, and race) for births at level 1 units (163.0/1,000) and level 2 units (168.1/1,000) was similar, and rates for births at level 3 (128.0/1,000) were significantly lower. Mortality up to four hours, and from four hours to 28 days, however, differed between level 1 and level 2 units. Among early deaths, the mortality for level 1 births was 68.0/1,000, significantly higher than both the rate for level 2 births (46.0/1,000) and for level 3 births (40.6/1,000). Between four hours and 28 days, mortality relative to level 3 improved for level 1 births, but worsened for level 2 births. For infants with birth weight <1,251 g, for whom transport rates from level 1 units are highest, mortality in level 1 births was higher than in level 2 births only until 18 hours of life; thereafter, level 2 mortality was higher. These results could not be explained by any of eight additional variables examined in a multivariate model, nor by live birth/fetal death misclassification. Early deaths constituted 30% of neonatal mortality in this population. Thus, infant transport cannot replace maternal selection for place of delivery. However, the excess mortality after four hours seen at level 2 units might be avoided by more frequent referral of sick infants to level 3 services.
Predicting Measles Susceptibility
Authors: DALES LORING G. , CHIN JAMES
Published: December 2021

Elsewhere in this issue, Scott et al1 present results of their study which found that the historical criteria developed by the US Public Health Service Immunization Practices Advisory Committee (ACIP) for detecting students who were susceptible to measles performed very poorly in a school measles outbreak. The ACIP criteria designate as susceptible persons born since 1956 who have no documentation of immunization, who have no physician-Venified history of measles infection, who last received measles vaccine before their first birthday, or who were last immunized (at age 12 months or older) before 1968 with measles virus vaccine that could have been either live or inactivated.
Theophylline Poisoning
Authors: WEINBERGER MILES
Published: December 2021

To the Editor.—

The conclusions in the recent letter by Kossoy et al1 and the reply by Sahney2 regarding the original report3 suggesting conservative treatment of high theophylline levels until neurologic signs are present do not adequately consider the high frequency of mortality and serious neurologic sequelae once theophylline-induced seizures occur.4,5 Unfortunately, the chemical success of charcoal hemoperfusion after the onset of seizures has not been matched by the desired clinical results.6 Although the risks of vigorous intervention in a patient not yet having serious symptoms must be considered, the small number of cases reported without serious consequences should not provide great reassurance given the potentially serious outcome, ie, death or brain damage, that commonly follows onset of the seizures even in the presence of subsequent dialysis and otherwise optimal intensive care.
The American Privilege To Disagree
Authors: SILVERMAN WILLIAM A.
Published: December 2021

To the Editor.—

Your correspondent from the US Office of Special Education and Rehabilitative Service1 has implied that the Declaration of Independence is the source of inspiration for the present government's new policy of social control when a severely malformed infant is born. The unprecedented intrusion of government into the privacy of the family circle is a gross shift toward totalitarianism—I am amazed that we are asked to believe the oppressive policy is as American as apple pie.
Echocardiographic Study of Premature Infants
Authors: JOHNSON GREGORY L. , Chandler Albert B.
Published: December 2021

In Reply.—

Levine has correctly pointed out an important potential source of error in performing echocardiographic measurements in small infants. Measurements of aortic root dimension in the multicenter study we reported were, indeed, performed utilizing the outer-to-inner (ie, leading edge) method as recommended by the American Society of Echocardiography and noted in the methods portion of our manuscript. Due to the reduction in figure size associated with publication, our figure 1 (Pediatrics 1984;72:865) appears, at first glance, to demonstrate inner-to-inner measurement as Levine points out.
Bronchiolitis as a Possible Cause of Wheezing in Childhood: New Evidence
Authors: McConnochie Kenneth M. , Roghmann Klaus J. , Klein Suzanne J. , Mclnery Thomas K. , MacWhinney James B. , Miller Robert L. , Nazarian Lawrence F.
Published: December 2021

A historical cohort study was performed in order to assess the hypothesis that even mild bronchiolitis in infancy is a predictor of wheezing later in childhood. Subjects who had experienced bronchiolitis and a matched control group were compared in terms of reported wheezing 8 years later. A highly significant difference was found between the bronchiolitis group and the control group in terms of current wheezing (P < .0001, relative risk 3.24). This difference was maintained after adjusting for many potentially confounding variables including family history of allergy and other allergic manifestations in the child. Results suggested that 13.6% of a normal practice population in the age range 6 to 9 years currently wheeze, but that 44.1% of children who experienced bronchiolitis currently wheeze. Based on the incidence of bronchiolitis (4.27/100 children in their first 2 years of life) and the relative odds for wheezing derived from a logistic regression model including variables that measured passive smoking, genetic tendency to wheeze, and bronchiolitis, calculations of attributable risk suggested that wheezing in 9.4% of the population of children who currently wheeze was attributable to bronchiolitis.
Automatic Passenger Protection Systems
Authors:   Committee on Accident and Poison Prevention
Published: December 2021

THE ISSUES

Despite safety improvements to the motor vehicle and roadway and despite educational and legislative measures to promote safe driving, crash injuries remain the leading cause of death and serious injury for children, adolescents, and young adults. Annually, nonpedestrian motor vehicle mishaps claim more than 18,000 lives of Americans less than 25 years of age.1 The vast majority die as occupants of passenger cans. Teenage boys and young male adults are at greatest risk with annual death rates exceeding 100/100,000 population for licensed drivers aged less than 25 years. One out of every one hundred 15-year-old boys will die in a motor vehicle crash before reaching age 25 years.2

To deal with the silent "highway epidemic," the American Academy of Pediatrics launched the "First Ride—Safe Ride" program in 1980. Increasing the use of car seats by newborns was an appropriate Academy project goal as pediatricians can be particularly effective in counseling new parents. The "Every Ride—Safe Ride" program will expand this effort to deal with the more difficult task of reducing occupant injuries to older children and adolescents. This program will promote safe and responsible driving behavior and encourage the use of car seats and automobile seat belts (active restraints).

Seat belts, when used, can reduce the likelihood of a crash fatality by about 50%. Car seats can be even more effective, and there is some evidence that, when properly used, they can reduce the likelihood of death by 90% and serious injury by 70%. However, despite past educational efforts, seat belt use rates are in the 10% to 15% range and even with car seat use laws enacted in most states, actual use rates in excess of 30% to 40% have not been demonstrated.
Guidelines for Urgent Care in School
Authors:   Committee on School Health
Published: December 2021

Minor injuries and illnesses can occur in children during the course of the school day. They are usually well handled by the nurse in consultation with the school medical advisor; true medical emergencies are quite rare. Many school systems, however, have part-time school medical advisors and nurses who cover more than one school building and may not be readily available. Therefore, the burden of emergency recognition and management may fall on teachers, principals, or other personnel in the local school. Inappropriate and delayed care may result in increased morbidity or possible death. Finally, consideration must be given to the question of malpractice or assault charges being filed by the families of inappropriately treated children.

In order to solve this problem, it is important for school administrators in consultation with the school medical advisor and nursing service to formulate a guide for emergency care. The Committee on School Health of the American Academy of Pediatrics suggests the following:

1. Every school district should have an identified, qualified administrator with decision-making status.

2. An emergency care manual and standing orders for first aid should be written and made available to nurses, athletic staff, and faculty volunteers. A sample manual1 is available from the Connecticut State Department of Health (540 Nortontown Rd, Guilford, CT 06437 [$ 8.50]).

3. The school nurse in each building should be the key person to carry out the program as she or he is most familiar with the student's health problems. All nurses should be trained in a program of emergency care developed by physicians, emergency medical technicians, and/or other nurses with special training in emergency care.
Care of Infants with Myelomeningocele
Authors: ROBINOW MEINHARD , PINA GLORIA , TURK MARGARET A.
Published: December 2021

To the Editor.—

The article on myelomeningocele by Gross et al1 seems to us a step backward. The authors claim to have followed the selection criteria of Shurtleff et al2 and "to a lesser extent those considered significant by Lorber.3 It should be noted that Shurtleff et al considered only 11.3% (36/319) unsuitable for active treatment, whereas Gross et al recommend nonintervention for nearly half (48%) of their infants.

The criteria of Lorber were based on treatment and rehabilitation facilities available at that time in Britain. Those were the days of less effective shunt procedures, the time before computed tomographic (CT) scans, ultrasonography and shuntograms, before intermittent catheterization and artificial sphincters, to name only a few of the advances of the past decade.
Cystic Fibrosis Study Questioned
Authors: ATER JOANN
Published: December 2021

In Reply.—

Wagener and colleagues make a valid point that increase in plasma volume can be an appropriate response to hypoxia, without the development of polycythemia. This probably is a factor contributing to the inappropriately low hemoglobin values we found in our patients with cystic fibrosis. However, as in anything in medicine, there is rarely a single reason for any clinical observation. Our finding that some of our patients with low iron stores, as reflected by low serum ferritin values, had a significant increase in hemoglobin values with oral iron therapy, provides good evidence that iron deficiency may be one factor limiting the development of polycythemia in these patients.
Equation Error
Authors: MCCORMICK KENNETH
Published: December 2021

To the Editor.—

I believe there is an error in the article entitled "A System for Individualized Dosing of Intravenous Aminophylline Using a Programmable Calculator" by J. Chris Mitsuoka and Richard J. Fleck (Pediatrics 1984;73:64-67). In the first equation, the first term Cpo e-Ke(t-t') should be Cpo e-Ke(t + t') if t represents the time elapsed after the infusion has commenced.

The paper is confusing as to exactly what t represents; the authors state "duration of therapy" but does therapy begin with the loading dose or with the infusion.
Septic Dermatitis of the Neonatal Scalp and Maternal Endomyometritis with Intrapartum Internal Fetal Monitoring
Authors: Wagener Marilyn M. , Rycheck Russell Rule , Yee Robert B. , McVay Joanne F. , Buffenmyer Carol L. , Harger James H.
Published: December 2021

During a 3-month period, 1,062 mother-infant pairs were studied for infections following internal fetal monitoring during labor. Six infants (0.56%) developed septic scalp dermatitis at the site of the spiral electrode application. Factors associated with septic scalp dermatitis included the number of vaginal examinations, the use of an intrauterine pressure catheter or of more than one spiral electrode, and fetal scalp blood sampling. Maternal diabetes and endomyometritis were also associated with an increased risk of scalp infection. The duration of spiral electrode use and duration of ruptured membranes were not significant risk factors. Endomyometritis was documented in 41 mothers, an overall incidence of 3.9%. In women whose babies were delivered by cesarean section, the incidence of endomyometritis was 28/117 (23.9%). Using multivariate analysis by logistic regression, endomyometritis was associated with the number of vaginal examinations during labor but not with the duration of internal monitoring, duration of labor, or duration of ruptured membranes.
Physician Involvement Strategies to Promote the Medical Home
Authors: SIA CALVIN C. J. , PETER MARGO I.
Published: December 2021

The changing nature of childhood morbidity has been addressed by a number of pediatricians.1-3 The "new morbidity" heralds an era of pediatrics characterized by prevention and early intervention strategies in the care of young children. In 1987, Surgeon General C. Everett Koop, MD, established a national agenda to promote optimal services for children with special health care needs.4 He issued a call to action for professionals to develop and provide services that are family centered, community based and coordinated. Richard M. Narkewicz, MD, immediate past president of the American Academy of Pediatrics (AAP), called this "a timely and commendable goal that the AAP shares" and advocated for pediatricians to provide a medical home for all children.5
Morbidity Is Decreased by Neonatal Intensive Care
Authors: ETCHES PHILIP C. , ROBERTSON CHARLENE M. T.
Published: December 2021

To the Editor.—

A recent annotation by "Student" (Pediatrics 1989;83:180) is a quote from a letter from Johnson and MacFarlane in The Lancet of July 16, 1988, stating that, in geographically defined populations, a reduction in the level of morbidity among low birth weight survivors has not yet been demonstrated. We believe that there are, however, some encouraging signs.

There is a report from the Federal Republic of Germany1 describing a reduction in the frequency of neurologic sequelae in a very low birth weight population, born between 1977 and 1983, from a neonatal intensive care unit.
More on Risks of Circumcision
Authors: WILLIAMS H. STEPHEN
Published: December 2021

To the Editor.—

The diligent and thoughtful efforts of Wiswell and his collaborators in pursuing the original observation of Ginsburg and McCracken,1 that urinary tract infections in male infants occurred more frequently among those who were uncircumcised, have led to some rethinking of previous recommendations regarding routine circumcision. In the most recent report, Wiswell and Geschke2 neatly summarize the minimal risk of properly performed circumcisions and provide important new information regarding the serious threat to health and life itself that urinary tract infections pose to afflicted uncircumcised male neonates.
Rearing Children in Hospital Facilities ("Boarder Babies")
Authors: FOMUFOD ANTOINE K. , STREET ANNE A.
Published: December 2021

To the Editor.—

It is a tragic realism that many hospitals in major cities in this country are having to care for newborn babies and infants abandoned by their biologic parents and immediate relatives. The problem of child abandonment is not an entirely new one for hospitals; it is the explosive increase in the frequency of occurrence and the escalating numbers of these infants in recent times that make it an issue that urgently needs to be addressed.
Cough as a Risk Factor for Neonatal Intraventricular Hemorrhage
Authors: PERLMAN JEFFREY
Published: December 2021

In Reply.—

The purpose of the study cited by Dr Argent et al was to elucidate potential mechanisms for the fluctuations in arterial blood pressure observed previously. We agree with the authors that the cough-like Valsalva maneuvers contribute significantly to the circulatory variablility. The data also indicate the close temporal relationship between apneic pauses and stable blood pressure. We support the statement of the authors that ventilator support should be optimized before paralysis. Moreover, other "less noxious" interventions, such as sedation, might have similar beneficial effects regarding stabilization of blood pressure.
Quality-Protein Maize as the Sole Source of Dietary Protein and Fat for Rapidly Growing Young Children
Authors: Graham George G. , Lembcke Jorge , Morales Enrique
Published: December 2021

Earlier studies demonstrated that quality protein maize (QPM), with increased lysine and tryptophan and decreased leucine contents, was more digestible and supported 45% greater nitrogen retention than common maize. Ten recovering malnourished children (ages 13 to 29 months, height-ages 5 to 15 months, weight-ages 3 to 11 months) have now received 90% of their diet energy and 100% of protein and fat from QPM. Energy intake was adjusted to allow them to reach the 50th centile of weight-for-length (according to the National Center for Health Statistics) in 90 days (two completed 60 days only). Growth was compared with that of 10 children receiving modified cow's milk formula (CMF). Energy intakes (QPM 110 ± 15, CMF 106 ± 12, corrected for absorption to 94 and 97 kcal/kg.d), crude energy costs of gain (43 ± 9 and 40 ± 10, corrected to 37 and 37 kcal/g), linear growth (1.23 ± 0.24 and 1.33 ± 0.26 cm/mo), gains in height-age (3.1 ± 0.7 and 3.3 ± 1.2 mo), weight gain (2.6 ± 0.6 and 2.6 ± 0.8 g/kg.d), and final sums of fat folds (24.3 ± 3.5 and 27.2 ± 2.9 mm) were not different. Gains in weight-age were greater (7.5 ± 2.3 vs 5.4 ± 1.6 months, P < .05) and serum albumin decreased (4.10 ± 0.24 to 3.77 ± 0.31 g/dL, P < .01) during QPM feeding. Plasma-free total essential amino acids and ratio of these to total essential amino acids were less after QPM than after CMF diets. Equal growth rates with QPM and CMF diets offer great potential for developing- and developed-country children.
Long-Term Trends in Blood Lead Levels Among Children in Chicago: Relationship to Air Lead Levels
Authors: Hayes Edward B. , Orbach Hyman G. , Fernandez Alina M. , Lyne Sheila , Matte Thomas D. , McElvaine Michael D.
Published: December 2021

Objectives. To evaluate trends in blood lead levels among children in Chicago from 1968 through 1988, and to determine the impact of the changes in the Centers for Disease Control and Prevention (CDC) blood lead level of concern.

Methods. We reviewed a systematic sample of blood lead screening records of the Chicago Department of Health Laboratory for high-risk children aged 6 months to 5 years. Median blood lead levels for each quarter of the years 1974 through 1988 were determined and regressed against mean air lead levels recorded at air-monitoring stations in Chicago during the same period.

Results. Median blood lead levels declined from 30 µg/dL in 1968 to 12 µg/dL in 1988, and were strongly associated with declining average air lead levels (r = .8, P < .001) from 1974 through 1988. A regression model using log-transformed data predicted a decline of 0.56 µg/dL in the median blood lead level with each 0.1 µg/m3 decline in the mean air lead level when the air lead level was near 1.0 µg/m3; the predicted slope was steeper at lower air lead levels. Despite the nearly 20-fold reduction in air lead levels, the median blood lead level of 12 µg/dL in 1988 indicates substantial continuing lead exposure. The CDC blood lead level of concern was lowered twice from 1968 to 1988, but due to the decline in blood lead levels, fewer than 30% of the children were above the level of concern throughout most of the study.

Conclusion. Although substantial lead exposure persists in Chicago, reductions in airborne lead emissions seem to have contributed to a long-term decline in the median blood lead level of high-risk Chicago children.
The Influence of Apolipoprotein E Polymorphism on Plasma Concentrations of Apolipoprotein B and A-I During the First Year of Life
Authors: Herrmann Wolfgang , Hanf Sigrid , Reißner Jürgen , Kaffarnik Hans , Motzny Sabine , Steinmetz Armin
Published: December 2021

Apolipoprotein (apo)E polymorphism has been shown to be associated with different serum levels of cholesterol, apoB, and apoE. In clarifying the degree of influence of the apoE isoforms, investigations in an early stage of life are useful. The aim of the study was to investigate the plasma levels of apoB and apoA-I as structural proteins of low and high density lipoproteins, in relation to apoE phenotypes during the first year of life. Conclusions about the relationship between apoE phenotype and the development of the lipoprotein patterns can be drawn. The concentrations of apoB and apoA-I in capillary plasma as well as the apoE phenotype were estimated in 199 newborns (7 days old) and in follow-up investigations of a subgroup of 45 at 1, 4, 12, 24, and 52 weeks. The phenotype frequencies were as follows: 70% apoE 3/3, 16% apoE 3/4, 10% apoE 2/3, 2.5% apoE 2/2, and 1.5% apoE 4/2. The plasma concentrations of apoB and apoA-I in the newborns (7 days old) averaged 55% of the adult value and increased toward the end of the first year of life up to approximately 85%. The course of the plasma concentrations of apoB and apoA-I in relation to the apoE phenotype showed that, beginning at 24 weeks, the apoB levels were significantly lower for the phenotype E 2/2 and in tendency also for the phenotype E 2/3 in comparison with E 3/3. At the end of the first year of life, the apoB levels in infants with apoE phenotype 2/2 increased only by 50% and yielded 0.59 g/L. But the apoB levels of infants with other apoE phenotypes (apoE 2/3, 3/3, 4/2, 4/3) increased during the same period related to their phenotype between 78% ad 90% (absolute 0.71 to 0.91 g/L). In contrast, apoA-I concentrations were independent of the apoE phenotype. It is concluded that already in infancy apoE polymorphism influences the metabolism of apoB- and apoE-containing lipoproteins.
PREVALENCE AND CORRELATES OF THE PREMENSTRUAL SYNDROME IN ADOLESCENCE
Authors: Raja Shyamala Nada , Feehan Michael , Stanton Warren R. , McGee Rob
Published: December 2021

In a longitudinal study of their health and development, 384 15-year-old females reported their experience of symptoms indicative of premenstrual syndrome (PMS). The prevalence of these symptoms is reported and a group of adolescents is identified with the syndrome (14%). PMS was associated with current self-reported anxiety, inattention, and poor health. Preadolescent self-report and maternal ratings of physical and mental health did not significantly predict adolescent PMS. The results suggest that the experience of PMS in adolescence may be mediated by perceived health status; the roles of mental health and maternal influence in the development of adolescent PMS may be minimal.
Epidural Analgesia in the Management of Severe Vaso-Occlusive Sickle Cell Crisis
Authors: Yaster Myron , Tobin Joseph R. , Billett Carol , Casella James F. , Dover George
Published: December 2021

Objectives. To determine whether continuous epidural analgesia could effectively decrease pain and thereby improve the management of severe vaso-occlusive crisis in children with sickle cell disease who were unresponsive to conventional analgesic therapy.

Design. Retrospective observational study.

Setting. A tertiary care hospital with a large pediatric sickle cell patient referral population.

Patients. The study describes nine children in 11 painful vaso-occlusive crises, unresponsive to high-dose systemic opioids, nonsteroidal anti-inflammatory drugs, and adjunctive measures, who underwent continuous epidural analgesia to control pain.

Outcome Measures. Subjective pain scores, arterial oxygen saturation monitoring, and plasma lidocaine levels.

Methods. Placement of an epidural catheter for the administration of a continuous infusion of local anesthetic, alone, or in combination with fentanyl, in the management of vaso-occlusive crisis.

Results. At initiation of epidural analgesic therapy, 8 of 9 patients reported severe pain (8 to 10 on a scale of 0 to 10, 0 = no pain, 10 = the worst pain they ever experienced). Analgesia was immediate (pain score 0 to 2) in 8 of 9 patients, and continuously effective in 9 of 11 crises. Five patients required either the addition of fentanyl or changing the local anesthetic from lidocaine to bupivacaine to maintain analgesia for 2 to 5 days. In 7 of 9 patients, oxygen saturation dramatically increased from 87 to 95% to 99 to 100% after epidural analgesia was initiated. In all patients, plasma lidocaine levels ranged from 1.1 to 4.6 mg/L and dose-related toxicity did not occur. One patient developed hypotension secondary to high sympathetic blockade (T-4), one had an inadvertent dural puncture during insertion of the catheter, one had the epidural catheter removed for fever, and one achieved analgesia only transiently. There were no other complications, and epidural analgesia was not associated with sedation, respiratory depression, or limitation of movement. All epidural catheters were cultured on removal, and colonization did not occur.

Conclusions. Epidural analgesia with local anesthetics administered alone or in combination with fentanyl effectively and safely treats the pain of sickle cell vaso-occlusive crisis unresponsive to conventional pain management and does so without causing sedation, respiratory depression, or significant limitation on ambulation. Furthermore, early treatment of painful crisis with this technique may improve oxygenation, a critical factor in the evolution of further sickling.
Speculations on Antineuronal Antibody-Mediated Neuropsychiatric Disorders of Childhood
Authors: Swedo Susan E. , Leonard Henrietta L. , Kiessling Louise S.
Published: December 2021

Several converging lines of evidence suggest that some behavioral and neurological abnormalities of childhood may be mediated through antineuronal antibodies.1-3 These antineuronal antibodies appear to arise in response to group A [beta]-hemolytic streptococcal (GABHS) infections and to cross-react with cells within the central nervous system (CNS).4 Based on clinical observations of children with Sydenham's chorea, Tourette's syndrome (TS), and/or obsessive-compulsive disorder (OCD), we hypothesize that neuroimmunological dysfunction secondary to anti-neuronal antibodies may result in behavioral disturbances, such as anxiety, emotional lability, obsessive compulsive symptoms, hyperactivity, and sleep disturbances; and neurological abnormalities, such as motor and phonic tics, ballismus, chorea, and choreiform movements.
Issues of Confidentiality in Adoption: The Role of the Pediatrician
Authors:   Committee on Early Childhood, Adoption, and Dependent Care
Published: December 2021

Adoption practices in the United States have been designed to protect each member of the adoption triad. Traditionally they preserve the anonymity and privacy of the birth parents. These practices have supported the concept that adoptive parents need to establish a relationship with their new child without concern of unwanted interference by members of the child's birth family. In addition, they emphasize protecting adopted children from potentially disturbing facts about their birth families and/or psychological confusion that might arise from any continued relationship with their birth families.

To protect confidentiality in adoption, all records of the adoption proceedings are sealed. The child's original birth certificate is sealed, and a new one is issued that typically contains only the child's adoptive name and substitutes the names of the adoptive parents for the birth parents. The original birth certificate and adoption records can be opened only by a court order and only for "just cause." Recently, however, three states have developed open adoption records, and more than 30 other states have developed mutual consent registries.1 The exact statutes regarding mutual consent registries vary from state to state, but the basic concept allows adult adoptees and birth parents to register their desire to meet each other. If a mutual consent is achieved, identifying information can be released and a meeting may be facilitated. Some states require both parties to register independently. Other states allow a state agency to locate the birth parent(s) to determine whether consent will be granted to release information to the adult adoptee.1
Mood and Affect Disorders
Authors: Tang Michael H. , Pinsky Elizabeth G.
Published: December 2021

Depressive disorders are common in children and adolescents, with estimates for depressive episodes as high as 18.2% for girls and 7.7% for boys by age 17 years, and are a major cause of morbidity and even mortality. The primary care pediatrician should be able to (1) diagnose depressive disorders and use standardized instruments; (2) ask about suicide, self-harm, homicide, substance use, mania, and psychosis; (3) triage the severity of illness; (4) be aware of the differential diagnosis, including normal development, other depressive disorders, bipolar disorders, and comorbid disorders, such as anxiety and substance use; (5) refer to evidenced-based psychotherapies; (6) prescribe first-line medications; and (7) provide ongoing coordination in a medical home. Pediatric bipolar disorders and the new disruptive mood dysregulation disorder (DMDD) diagnoses are controversial but not uncommon, with prevalence estimates ranging from 0.8% to 4.3% in children at various ages. Although the pediatrician is not likely to be prescribing medications for children with bipolar disorder and DMDD diagnoses, all clinicians should be familiar with common neuroleptics and other mood stabilizers, including important potential adverse effects. Basic management of depressive and bipolar disorders is an important skill for primary care pediatricians.