bluuebunny/crossref_metadata_2025 huggingface dataset:
Description of Reported Outbreaks of Communicable Diseases in Day-Care Centers in New York State: 1987 to 1991
Authors: Kondracki Stanley F. , Schulte Elaine E. , Birkhead Guthrie S.
Published: December 2021

It is generally accepted that infectious diseases are common in day-care centers. However, only 24 outbreaks among 3179 licensed and unlicensed day-care centers were reported to the New York State Department of Health between January 1, 1987, and December 31, 1991. Of the 24 outbreaks reported, 18 (75.0%) were gastrointestinal (giardiasis, seven; shigellosis, five; salmonellosis, one; Escherichia coli 0157-H7, two; viral, three), three (12.5%) were due to Haemophilus influenza type B (Hib) meningitis, two (8.3%) were due to hepatitis A, and one (4.1%) was due to ringworm. Most of the morbidity was associated with the seven giardiasis outbreaks and involved 66 cases with attack rates ranging from 6.5% to 45.7%. Outbreaks were reported in all months of the year. No distinct seasonal trends were observed except for giardiasis, where six of the eight outbreaks were reported in the fall months. In the 5-year review period, three Hib outbreaks (two or more cases in the same setting) were reported in 1988 to 1989 but none in 1990 to 1991, perhaps due to increased vaccine use. As expected, hospitalization rates were highest (100%) for Hib cases. Recommendations include improving outbreak surveillance and reporting, improving training efforts directed toward enteric disease prevention, and enforcing day-care requirements for Hib vaccination. These recommendations should be added to existing New York State day-care-center licensing requirements.
Child Care in the United States and Industrialized Nations
Authors: Howes Carollee , Droege Kristin
Published: December 2021

Although the US does subsidize a portion of child-care services via tax credits for the middle class and subsidized care for low-income families, it has no parental-leave policy, no national system of child-care services, and no national standards of quality. This nonsystem of child care is in great contrast to the situation in most industrialized nations, which do have parental-leave and child-care systems with quality standards acceptable to most American experts. We believe that the greatest obstacle to such a system within the US lies in the premise that children are the responsibility of individual families and that responsible mothers will remain home to care for them. This is ironic in a country that claims to believe in diversity and parental choice. Our nonsystem of child care fails to serve the diverse needs of families and greatly restricts parents' choices.
Child Care and Child Health: Use of Population Surveys
Authors: Cain Virginia S.
Published: December 2021

While the health of children in the US has been a long-standing issue, concern has heightened as children are increasingly found in some type of child-care arrangement. Trends in a number of social forces in the US have resulted in more children spending greater amounts of time in the care of someone other than their parents. As children move out of the home into group-care settings such as day-care centers on preschools, they are in contact with many more children and the possibility of exposure to a variety of infectious diseases. Several studies have examined childhood disease within the context of center-based care.1-3 However, most preschool children are not in center-based care.4 A more general study of the health of children in child care requires an approach that provides data on children in a variety of child-care arrangements and covers a broader age range than that found in most day-care centers. This paper argues that the population-based sample-survey approach to the study of the health of children in child care provides the necessary breadth. However, there is a clear need for improving measurement of critical variables.

SOCIAL TRENDS

While researchers increasingly have become concerned with the child-care arrangements of children of nonemployed women, it is the revolution in women's labor-force participation that has driven the increase in use of child care in the last two decades. Among children under 6 years of age, the percentage with mothers in the labor force has increased from 29% in 1970 to 53% in 1990.5,6
American Public Health Association/American Academy of Pediatrics National Health and Safety Guidelines for Child-Care Programs: An Overview
Authors: Chang Albert
Published: December 2021

Caring for Our Children represents a model collaboration of government, voluntary health associations, and individuals in a national aspiration to create in every child-care setting a safe, healthful, and nurturing environment for our children, our most valuable resource and our future.
The Pharmacokinetics of Injectable Allopurinol in Newborns With the Hypoplastic Left Heart Syndrome
Authors: McGaurn Susan Phillips , Clancy Robert R. , Davis Lisa E. , Krawczeniuk Motria M. , Murphy John D. , Jacobs Marshall L. , Norwood William I.
Published: December 2021

Objective. The purpose of this investigation was to determine the pharmacokinetic disposition of intravenous allopurinol and its metabolite oxypurinol in neonates with the hypoplastic left heart syndrome (HLHS) and to evaluate the subsequent degree of xanthine oxidase inhibition using serum uric acid as a marker.

Methods. Pharmacokinetic data were evaluated in 12 stable preoperative neonates with HLHS after a single intravenous allopurinol administration of 5 mg/kg or 10 mg/kg. Pharmacokinetic parameters were determined for elimination half-life, clearance, volume of distribution, and mean residence time. Xanthine oxidase inhibition, measured by serum uric acid reduction, was also measured.

Results. Pharmacokinetic parameters revealed no statistically significant differences between a 5-mg/kg and 10-mg/kg dose of intravenous allopurinol on elimination half-life, clearance, volume of distribution, and mean residence time. Mean serum uric acid levels were significantly reduced from baseline by 39.99 and 42.94%, respectively, in the 5- and 10-mg/kg treatment groups.

Discussion. The enzyme xanthine oxidase plays a key biochemical role in the generation of toxic oxygen-derived free radicals during ischemia-reperfusion conditions. Allopurinol and its active metabolite oxypurinol inhibit xanthine oxidase, and significantly reduce the conversion of hypoxanthine to xanthine and xanthine to uric acid. Cell injury may be caused by toxic oxygen free radicals produced by ischemia-reperfusion injury such as could occur during the repair of HLHS under hypothermic total circulatory arrest. We hypothesize that allopurinol may provide protection from cellular injury in this clinical context.
Pediatric Firearm Injuries, Kansas City, 1992: A Population-Based Study
Authors: Dowd M. Denise , Knapp Jane F. , Fitzmaurice Laura S.
Published: December 2021

Objective. To determine the morbidity, mortality, and epidemiologic features of pediatric powder-firearm injuries in a defined urban population.

Design and setting. A population-based, descriptive epidemiologic study was conducted of firearm injuries to children in a mid-size urban community (total population: 435 178) in 1992. The population was 56% white and 39% black. Data from prehospital care providers, all city and adjacent community hospitals, and medical examiner and police records were searched for cases of firearm injury. The 1990 United States census provided denominator data.

Case definition. Subjects were all 0- to 16-year-old residents of Kansas City, Missouri who sought medical treatment at a hospital for a powder-firearm injury or who presented to the medical examiner with a fatal firearm injury in calendar year 1992.

Results. Seventy-two children met the case definition, for an incidence of 70 per 100 000 persons per year. There were 12 (16.7%) fatalities, for a mortality rate of 11.7 per 100 000 persons per year. Almost 10% of the patients sustained permanent disability. Mean and median ages of the patients were 14.9 years and 15.8 years, respectively; 79% were male and 82% were black. The majority of the children (63%) lived in census tracts with a high proportion of families in poverty. Black males had the highest rates of firearm injury, with a 1-year incidence of 233 per 100 000 persons per year. At younger than 12 years, the rates were equal among the races; however, for those 12 years and older, black adolescents had 13 times the risk of white adolescents (541 compared to 42 per 100 000 persons per year). The majority (71%) of injuries were due to assaults, with drive-by shootings the most frequent circumstance. The majority of unintentional injuries occurred to adolescents as the result of an unplanned discharge of a handgun as it was being placed in or removed from concealment. Among the patients, 39% were admitted to the hospital and 26% required surgery.

Conclusions. 1) Black male adolescents had the highest risk of firearm injury or fatality. 2) The majority of victims lived in census tracts characterized by poverty. 3) Injuries were alarmingly severe. 4) Interpersonal violence was the leading contributor to fatal and nonfatal injuries. 5) Unintentional injuries characteristically occurred during the process of weapon concealment. 6) The leading contributor to injury and death was the interaction of adolescents and guns, particularly handguns. The main implication for firearm-injury prevention in this population is the limiting of access to guns by adolescents. In addition, measures aimed at preventing violent behavior, such as education in nonviolent methods of conflict resolution, should be explored.
The Association of Consensual Sexual Intercourse During Childhood With Adolescent Health Risk and Behaviors
Authors: Resnick Michael D. , Blum Robert Wm.
Published: December 2021

Objective. The association of childhood sexual intercourse, excluding sexual abuse, with adolescent health and risk behaviors was examined using the urban component of a statewide study on adolescent health, risky behaviors, and resiliency factors.

Methodology. A specialized cohort design was used to derive a two-group sample. Index cases consisted of all adolescents who indicated that they had first intercourse at or before age 10 years, and controls were adolescents who either had not yet had intercourse or had done so at age 16 years or older. To avoid confounding with issues of sexual abuse, all adolescents who also indicated a history of sexual abuse on the survey were removed from the analysis, so that the comparison could focus on health and behavioral correlates of respondents who did not define their childhood sexual intercourse as constituting abuse. Comparisons were conducted separately for girls and boys.

Results. A significantly greater proportion of index cases than controls indicated problem substance use by parents, poor school performance, gang involvement, frequent and unprotected sexual intercourse, history of pregnancy involvement, desire to leave the home, history of mental health treatment, emotional distress, and suicidal involvement. Logistic regression revealed significant group differences including academic risk, gang involvement, frequency of sexual intercourse, and history of mental health treatment. Correct group classification with the logit model was approximately 90% for both girls and boys.

Conclusions. The results underscore the importance of childhood sexual intercourse as an indicator of other health-compromising behaviors and risk factors. Clinicians should be alert to this clustering of risk behaviors in their psychosocial assessment of young people.
How Should Physicians Approach the Problems of Their Patients?
Authors: Bellet Paul S.
Published: December 2021

During a recent seminar with pediatric residents to discuss the role of empathy in the doctor-patient relationship, the following dialogue occurred.

Resident: It is fine and terrific to talk about how useful empathy can be, but it does not work when children with reactive airway disease have parents who continue to smoke. I feel strongly that people should not smoke. When these children wheeze, their parents bring them to the Emergency Department and we have to see them and deal with the same problem over and over again.

Physician: Have you talked to the parents to try and understand their feelings about smoking and whether they believe it influences their child's wheezing?
Letter to the Editor
Authors: Hall James W.
Published: December 2021

In their recent Pediatrics artide entitled "Universal Screening for Infant Hearing Impairment: Not Simple, Not Risk-Free, Not Necessarily Beneficial, and Not Presently Justified," Bess and Paradise comment on the performance of the auditory brainstem response (ABR) as a screening procedure, and quote an estimate from the 1993 National Institutes of Health Conference Statement on Early Identification of Hearing Impairment that "for every child with significant hearing impairment, more than 100 babies are referred." Bess and Paradise then comment that "the same concerns necessarily apply to a recently devised, automated ABR instrument," and reference my Handbook of Auditory Evoked Responses in support of their contention.
Evidence of Early Adrenal Insufficiency in Babies Who Develop Bronchopulmonary Dysplasia
Authors: Watterberg Kristi L. , Scott Susan M.
Published: December 2021

Objectives. To test the cortisol response to adrenocorticotrophic hormone (ACTH) in a population of very low birth weight newborns at the end of the first week of life, and to evaluate the relationship of this response to the subsequent development of bronchopulmonary dysplasia and to the total length of oxygen dependence.

Methods. Appropriate for gestational age newborns <1500 g birth weight were enrolled prospectively. Response to ACTH stimulation was tested on days 5, 6, or 7. Baseline cortisol, stimulated cortisol, and magnitude of response were compared between babies who developed bronchopulmonary dysplasia (BPD), defined as oxygen dependence at 28 days, and those who recovered without BPD.

Results. In this population, the cortisol response to ACTH increased with increasing birth weight (P < .001). Using birth weight as a cofactor, analysis of variance showed that patients who developed BPD (n = 34, BW 974 ± 192 g, mean ± S.D.) had significantly reduced responses to ACTH at 5 to 7 days of age compared to those who recovered (n = 25, BW 1251 ± 194 g), P = .006. Additionally, 84% of patients who recovered without BPD, but only 26% of BPD patients, achieved a prospectively defined positive cortisol response to ACTH (≥9 µg/dL; P < .005). Supplemental oxygen was discontinued at a younger postconceptional age in babies with a positive cortisol response to ACTH (P < .01) and fewer of those babies were on supplemental oxygen at 36-week postconceptional age (P < .01).

Conclusions. At the end of the first week of life, infants who subsequently developed BPD and prolonged oxygen dependence had significantly lower cortisol secretion in response to ACTH than infants who recovered without BPD. We speculate that these babies may be unable to secrete adequate amounts of cortisol in a setting of increased stress, leaving them vulnerable to continuing lung injury.
Homeopathic Diarrhea Trial
Authors: Carlston Michael
Published: December 2021

The interesting and potentially important trial of homeopathic treatment of acute diarrhea by Jacobs (Pediatrics, May 1994) was impressive overall. However, the article also included apparent errors in Table 6. The total number of patients listed under "Days of Diarrhea Prior Before Entry" does not equal the totals listed at the top of the table for active and placebo groups (39 vs 40 and 38 vs 41, respectively). In the same table, the patient numbers for "Prior Days > 1, >5" under placebo equals 22, not 19 as the section indicates. A correction or explanation would be appreciated.
AN ODORLESS WAY OF TESTING DIAPERS
Authors: L. J. F.
Published: December 2021

How do diaper manufactures test new products?

Not necessarily with teams of volunteer babies.

What scientists have spent considerable time and money to come up with is synthetic feces. And now they are patented.

The invention belongs to the Kimberly-Clark Corporation, the Dallas-based company that makes, among other things, diapers, training pants, incontinence garments and baby wipes.

"...technicians have some objection to handling the real thing," explained Richard Yeo, a senior research scientist who developed the synthetic compound with another Kimberly-Clark researcher, Debra Welchel. "The real thing is a form of biologically hazardous material. Also, it's a bit difficult to obtain, even from infants."

Technicians tried to get around the problem by using mashed potatoes, peanut butter, or canned pumpkin pie mix. Messy, yes, but apparently not chemically accurate enough for science. The foods broke down too quickly, their liquids and solids separating faster than human wastes tend to do.

"The compound comes in a dry mix to which water is added for the desired consistency. The mix is made up of water-soluble components like polyvinyls, starches, natural gums, and gelatins and insoluble ones like fibers and resins. It is usually brown. Kimberly-Clark is making the compound for its labs and has no plans to sell it to anybody else.
BLUE CROSS IN THE RED
Authors: L. J. F.
Published: December 2021

Here's a question for the health care reformers at the White House: Who's going to run the health plans of the future national system? They are clearly going to need stronger boards of trustees and regulators than those that sat by while the losses—and the expense accounts—mounted at the Washington area's Blues.
"110- Buzz Number"
Authors: Bustamente Sergio A.
Published: December 2021

The article entitled "Graduate Medical Education and Pediatric Work Force Issues and Princples" produced by the Task Force on Graduate Medical Education Reform claims to represent the "consensus opinion of the American pediatric community." It is apparent to me that some issues addressed require discussion and, in my opinion, have not reached "consensus" status at all. Let me start with issues that continue to be debated and are far from consensus as mentioned by the Task Force.
A Longitudinal Study of Hymenal Morphology in the First 3 Years of Life
Authors: Berenson Abbey B.
Published: December 2021

Objective. To document the effects of aging on hymenal morphology during the first 3 years of life in a cohort of nonabused girls.

Methods. Using a longitudinal design, we examined and photographed the external genitalia of 134 girls at 2 months or less and near 3 years of age; 42 of these girls were also examined near 1 year of age. The prevalence of each hymenal characteristic was calculated at each time, and differences were analyzed using the z statistic and McNemar change tests. Measurements of transhymenal diameters and the inferior rims were compared using a paired t-test.

Results. Hymenal configuration in 65% (87 of 134) of the subjects changed between birth and 3 years, usually from annular or fimbriated to crescentic. External ridges observed at birth usually resolved by 3 years, whereas intravaginal ridges were observed more often in 3-year-olds (P = .00). Analysis by race showed that the prevalence of both superior and lateral notches decreased in whites, whereas the prevalence of intravaginal ridges changed only in blacks (P = .00). Sixty-eight percent (15 of 22) of the tags present at birth were not observed at 3 years, while nine tags formed during this period. Changes observed between 1 and 3 years included increases in the mean horizontal (P = .00) and vertical (P = .02) transhymenal diameters and in the prevalence of the crescentic configuration (P = .04).

Conclusions. Changes in hymenal morphology, which may vary by race, occur in the first 3 years of life. Alterations are more pronounced in the first year than in years 2 and 3. Physicians should understand the effects of aging on the hymen's appearance to differentiate normal development from post-traumatic or infectious changes.
Advertising in Pediatrics
Authors: Ahmad Syed Rizwanuddin , Wolfe Sidney M.
Published: December 2021

Four misleading advertisements published recently in Pediatrics have prompted us to write to you about the need for screening ads in your journal. Two of the ads involved antidiarrheals, namely loperamide (Imodium A-D; last appeared on page A24 in the December 1993 issue) and attapulgite (Donnagel; page A49 in the January 1994 issue), which have been banned or withdrawn in several countries for use in children because of safety reasons and lack of evidence of efficacy.1-3
The "Guns" Debate
Authors: Christoffel Katherine Kaufer
Published: December 2021

I was surprised for two reasons to see Dr Suter's letter to the editor in the September issue of Pediatrics sharply criticizing the article by Senturia et al.1 First, the article's authors had not been given the opportunity to respond to the letter before publication. Second, the letter quickly digressed from the article it was discussing, and turned to repeated mentions of "Christoffel's HELP." I assume Suter is referring to me and to the Handgun Epidemic Lowering Plan (HELP) Network. HELP is not mine, but I do chair its Steering Committee.
Short-Course Amphotericin B Therapy for Candidemia in Pediatric Patients
Authors: Donowitz Leigh G. , Hendley J. Owen
Published: December 2021

Objective. To determine the efficacy of short-course (7 to 14 days of therapy after the last positive blood culture) amphotericin B therapy for candidemia in children.

Design. Case series.

Setting. Tertiary care university medical center in Virginia.

Patients. Thirty patients younger than 17 years of age who had candidemia between 1983 and 1990.

Measurements and results. The charts of 30 children with 31 episodes of candidemia were retrospectively reviewed for patient data, dates of positive and negative cultures for Candida from blood and other sites, dates of removal of the intravascular catheters, duration and dosage of amphotericin B administration, and outcome. Eight patients had persistent candidemia and died. Five patients were treated not in accordance with the short-course recommendations. Two had relapses; 1 was cured with catheter removal alone, and 2 were successfully treated with 26 and 30 days of amphotericin B therapy. Eighteen episodes (two episodes in 1 patient) of candidemia were cured using 7 to 14 days of amphotericin B therapy after the last positive blood culture.

Conclusions. Once the bloodstream is sterilized, and there is no other evidence of invasive fungal disease, 7 to 14 additional days of amphotericin B at a dose of 0.5 mg/kg per day seems adequate for treatment of candidemia in children.
Jacobi Address—Pediatrics: Where Do We Go From Here?
Authors: Strain James E.
Published: December 2021

It is only fitting that Dr Jacobi is honored by the presentation of an annual award by the American Academy of Pediatrics and the American Medical Association. In 1860, Dr Jacobi became the first teacher at the New York Medical College to give systematic instruction on diseases of children. He was later appointed Clinical Professor of Diseases of Children at Columbia University College of Physicians and Surgeons where he was succeeded by L. Emmett Holt who himself became a forceful leader and teacher of pediatrics. It is said that the entire history of American Pediatrics during the second half of the 19th century was reflected in Jacobi and his writings. Through his efforts the Section on Pediatrics of the American Medical Association was established in 1880. He was elected the first president of the American Pediatric Society in 1888 and also served as president of the New York Academy of Medicine. Samuel S. Adams said of him, "Jacobi pressed the button which set pediatrics in motion." From that beginning, pediatrics has grown into a highly regarded branch of medicine, whose future is bright. It is that future that I want to talk about today.

But before I do, I would like to acknowledge two individuals who are no longer with us, but who influenced me most in my professional life. The first is Dr Harold Palmer, former Medical Director of Denver Children's Hospital, an extremely competent pediatric pathologist who taught me the science of medicine. The second is Dr Henry Kempe, a colleague and close friend, whose keen intellect and understanding of the needs of children was an inspiration to all who knew him.
BRONCHIAL ASTHMA AND HYPERREACTIVITY AFTER EARLY CHILDHOOD BRONCHIOLITIS OR PNEUMONIA
Authors: Welch Mike
Published: December 2021

The risk of asthma after infantile bronchiolitis is definitely increased over the risk in the general population. A long-term follow-up of bronchiolitis patients found 15% go on to have asthma. Furthermore, the presence of bronchial hyperreactivity in these patients is four times as frequent as overt clinical asthma. Infants with pneumonia are also at increased risk for bronchial hyper-reactivity at a later time but not as likely to develop clinical asthma.
REASSESSING THE THERAPEUTIC RANGE FOR THEOPHYLLINE ON LABORATORY REPORT FORMS: THE IMPORTANCE OF 5-15 µg/mL
Authors: Kamada Alan K.
Published: December 2021

The therapeutic utility of theophylline and the recommended range for serum concentrations are debated in a series of three editorials by noted contributors in this area. In the first, it is pointed out that the role of theophylline has evolved into an "adjunctive" therapy for asthma and chronic obstructive pulmonary disease. Serum concentrations of 10 to 15 µg/mL do not sacrifice significant clinical benefit, whereas there is increased risk for adverse effects at higher concentrations. Changing laboratry report forms to designate a lower therapeutic range of 5 to 15 µg/mL for an increased margin of safety (with >20 µg/mL continuing as the lower limit of the toxic range) is advocated and a stepwise approach for implementing this change is proposed.

The second paper supports the view that theophylline remains more important than a third- or fourth-line agent in the treatment of asthma, particularly in selected patients. A higher target serum concentration range of 10 to 15 µg/mL may be desirable in more severe asthmatics (requiring oral steroids despite treatment with inhaled steroid), those with nocturnal symptoms, acute exacerbations requiring hospitalization and mechanical ventilation, and in patients for whom this is a more economical or preferable therapy. In these patients a serum concentration of 5 µg/mL may be too low to achieve sufficient benefit. Designation of "10 to 15 µg/mL (5 to 20)" as the therapeutic range is suggested to emphasize the midrange as the target while indicating that levels between 5 and 20 µg/mL are acceptable, although not ideal from either an efficacy or safety standpoint.

In the third and final viewpoint presented, much data supporting the efficacy of theophylline in the treatment of chronic asthma and its relationship to serum concentrations are presented. Evidence for potential anti-inflammatory effects of theophylline is also reviewed. Severe toxicity, a rare event, is noted to be not a result of serum concentrations slightly above the therapeutic range, but from massive overdosage and/or drug interactions or concomitant illnesses that alter elimination of the drug. No changes in the recommended therapeutic range of theopylline, which might alter its effectiveness, are proposed. Rather, more careful use and monitoring through education of prescribers is advocated.
Foley Catheter and Esophageal Foreign Bodies
Authors: Arnold James E. , Radkowski Diana
Published: December 2021

Dr Schunk and colleagues1 have provided a very clear presentation of their use of the Foley catheter with fluoroscopic guidance for removal of esophageal foreign bodies in children. They cite their high success rate and relative safety and infer that this is the procedure of choice based primarily on cost reduction. They properly point out that fluoroscopic-guided catheter extraction should be applied only to blunt foreign bodies that have been lodged for 3 days or less, and there should be no history of esophageal disease.
Letters to the Editor
Authors: Conners Gregory P. , Chamberlain James M. , Ochsenschlager Daniel W.
Published: December 2021

We enjoyed reading the paper by Schunk et al1 regarding the removal of esophageal foreign bodies using the fluoroscopic Foley catheter technique. We feel, however, that their sentence "Because of the potential for serious complications all impacted foreign bodies should be removed" deserves further clarification.

Impacted is defined as "pressed firmly together so as to be immovable."2 Therefore, a foreign body that is impacted in the esophagus is one that will not pass to the stomach without an intervention.
Letters to the Editor
Authors: Nelson Fredric P.
Published: December 2021

The information in the October 1994 supplement to Pediatrics concerning corporal punishment is fatally flawed scientifically, linguistically, and logically. Wissow states that, "A convincing body of scientific evidence suggests that corporal punishment is more harmful than helpful to children."1 This is simply not true. Baumrind, in her 10-year study on socialization, found that, "Authoritative parenting [where spanking is used] is associated with optimal child development, both in social responsibility and in individual initiative."2 Straus wrote in 1992 that, "The assumption that spanking is harmless if done in moderation by loving parents has never been adequately tested."3 The converse must be true.
Child Health 2000: New Pediatrics in the Changing Environment of Children's Needs in the 21st Century
Authors: Haggerty Robert J.
Published: December 2021

Pediatric practice in the next millennium will require greater knowledge of new morbidities, such as acquired immunodeficiency syndrome and social and behavioral disorders, reemergent old disorders, such as tuberculosis, and disorders rarely seen of late in the United States but now being brought here by recent immigrants, such as malaria and other parasitic diseases. Diversity in ethnic and cultural backgrounds and beliefs will continue to increase, and it will need to be understood to prevent and treat diseases of children effectively. Although the current antagonism toward immigrants may lead to a decrease in this particular source of diversity, changes in family structure—such as divorce, gay and lesbian couples as parents, and corporate pressure on families—will continue, requiring pediatricians to understand and to accept this diversity if they are to be the health care providers of children. The increased isolation of individuals from society and separation from families of origin will require pediatricians to be more active in communities and schools and to participate with other disciplines and social support groups. At the same time, the advancement of science and technology will continue to drive what the pediatrician does. Increased survival of children who previously had fatal illnesses will mean more emphasis on care of children who have chronic illnesses. Pediatricians will need to be partners with others in the exciting new fields of risk assessment and prevention of psychosocial disorders.
How Can Pediatric Care Be Provided in Underserved Areas? A View of Rural Pediatric Care
Authors: Broffman Gregg
Published: December 2021

Building on the concept that the future is not what it used to be, this article will address the delivery of primary care pediatrics in rural America. I will discuss the demographic differences that exist today between urban and rural areas, the differences in practice style and lifestyle in different geographic arenas, and the unique hardships created by those differences. The strengths and opportunities that are available now and that will be in the future will be reviewed. I will discuss the application of those opportunities in an attempt to construct a framework for a successful transition into the "new future."
Responder—The Outlook for Pediatrician Incomes Under Managed Care
Authors: Flint Samuel S.
Published: December 2021

Dr Hirsch analyzed a number of issues related to the economic viability of pediatric practice. I have chosen to explore one issue for my response: the outlook for pediatrician incomes under managed care. Dr Hirsch offers a disconcerting scenario. First, the demand for pediatricians is at risk, because managed care plans may want to substitute family physicians (one-stop shopping appeal) and pediatric nurse practitioners (perceived less costly substitutes) for primary care pediatricians. Second, price and premium cutting by managed care plans to maintain their market share eventually must result in lower compensation for all providers. Even now, there is evidence of price cutting for large employers in areas with high managed care penetration (Winslow R. Employer costs slip as workers shift to HMOs. Wall Street Journal. February 14, 1995, page A3). Logically, price cutting should proliferate to smaller purchasers and to all geographic regions. The conclusion is that pediatrician incomes, or at least their per-service compensation, is likely to decline as managed care becomes the norm.

This compelling theory has some supporting evidence, but I am considerably more upbeat. Although the restructuring of office practice as described by Dr Hirsch may be painful, I contend that the specialty, because it has already accomplished much of this reengineering, is preparing well for its inevitable total transformation. My optimism is based on an examination of the recent past. In 1994, more than 50 million Americans were enrolled in health maintenance organizations (HMOs),1 and an estimated 100 million were enrolled in managed care of some form.2
The Computerization of Ambulatory Pediatric Practice
Authors: Zurhellen William M.
Published: December 2021

With the shift in pediatrics toward emphasis on preventive care and anticipatory guidance, especially in this era of care- and cost-management, quality care is becoming increasingly synonymous with good information processing. To achieve our maximum effectiveness as clinicians as well as businesspersons, because pediatrics is a business, we must learn to use the tool that the rest of the business world has long ago discovered and implemented: computerization. Most important, we must apply this technology not only to the business of medicine, but to the practice of medicine itself, for that is where our future and the future of our children lie.

From the perspective of someone who has been there, I will discuss what computerized information access and information processing has allowed us to accomplish in practice, and I will give a glimpse of what medicine will be like when we all can manipulate medical information so rapidly that it enables us to practice true preventive care aggressively, to give anticipatory guidance and parent education in a timely manner, and to assess and monitor the progress of our children effectively.
Les Nouveaux Miserables: Modem Victims of Social Asphyxia
Authors: Smith David R.
Published: December 2021

During the past 30 years, social and economic barriers to health care services have increased for many Americans, especially for the nation's most vulnerable populations. Health status actually has declined for certain populations during this time. Meanwhile, national attention has been focused primarily on containing health care costs and on devising strategies for reforming the financing of health care rather than strategies for achieving improvements in the health status of the population.

Existing methods of financing health care services, health research priorities, the increasing centralization and compartmentalization of health care services, and the recent failure of national health reform all serve to hinder this nation's progress towards developing a comprehensive and accountable health care system focused on promoting and achieving improved health as well as treating sickness. Recent changes in the health care marketplace, however, including a growing movement toward measuring the outcomes of medical treatments and an emphasis on improving the quality of services, have increased interest among payers and providers of health care services in investing in preventive services. Health maintenance organizations and other integrated health care delivery systems are beginning to devise incentives for increasing preventive care as well as for containing costs.

The transformation of the nation's current medical care system into a true health care system will require innovative strategies designed to merge the existing fragmented array of services into coordinated and comprehensive systems for delivering primary and preventive health care services in community settings. The community-Oriented Primary Care concept successfully blends these functions and has achieved measurable results in reducing health care costs and improving access to preventive services for identified populations. There is flexibility in existing funding sources to promote preventive services in various public and private health care settings and to assist in the transformation from a disease-oriented medical care system to one focused on health.
Hospitals' Responses to Universal Infant Hepatitis B Vaccination Recommendations
Authors: Hurie Marjorie B. , Saari Thomas N. , Proctor Mary E. , Davis Jeffrey P.
Published: December 2021

Objective. To assess the extent to which hospitals in a midwestern state with low acute hepatitis B virus (HBV) morbidity offered hepatitis B (Hep B) vaccine to all infants, whether offering infants Hep B vaccine was associated with hospital geographic location or size, as measured by the number of births, and how hospital staff resolved key programmatic issues.

Methods. The managers of hospital newborn nurseries (N = 110) were surveyed by mail. The written response rate was 72%; all of the nonresponders were interviewed by telephone. The outcome measured was the number of hospitals offering Hep B vaccine to all infants by geographic region and hospital size.

Results. Sixty-five percent of the hospitals routinely offered Hep B vaccine to all infants; these hospitals accounted for 80% of reported Wisconsin births. In univariate analysis, the decision to offer infants Hep B vaccine was associated with both hospital size and hospital location. After controlling for size, hospitals in the northeastern region were eight times more likely (relative risk, 8.21; 95% confidence interval, 1.30, 51.79) to offer infants Hep B vaccine than hospitals in the southeastern (referent) region. Regional differences in reported rates of acute HBV infection do not explain this finding, because morbidity in the northeastern region (1 per 100 000) is among the lowest in Wisconsin. Although more than 80% of hospitals with Hep B vaccination programs required written informed consent for vaccination, had standing orders for administering Hep B vaccine to infants whose mothers' hepatitis B surface antigen (HBsAg) test results were known, and had mechanisms to notify the infants' physicians that the infants had been vaccinated, only 38% had standing orders for testing mothers whose HBsAg test results were unknown.

Conclusions. Hospitals are not necessarily deterred from implementing infant Hep B vaccination programs by low community HBV morbidity. Hospitals should develop policies to assure that parturient women with unknown HBsAg status are screened and their infants are appropriately treated.
Analysis of Homeopathic Treatment of Childhood Diarrhea
Authors: Sampson Wallace , London William
Published: December 2021

The article entitled "Treatment of Acute Childhood Diarrhea With Homeopathic Medicine: A Randomized Clinical Dual in Nicaragua" by Jacobs et al (Pediatrics. 1994;93:719-725) reported a study of the efficacy of homeopathy in the treatment of acute childhood diarrhea. Children with diarrhea were entered into the study if the diarrhea was not severe (type C severe diarrhea patients were sent to a hospital). Oral rehydration therapy was begun, and subjects were randomly assigned to receive either homeopathic preparations or placebos. The preparations were determined by a computerized therapeutic scheme. This scheme depended on a family observer's answers to questions from an "experienced homeopathic practitioner." The article purports to show a statistically significant difference favoring the treatment group over the controls. The report has faults of 1) purpose, 2) method, 3) diagnosis and treatment selection, 4) results interpretation, and 5) authors' editorial comments. The reported difference between treatment and control groups are of dubious significance. This article argues that the study's conclusion that homeopathy is effective for childhood diarrhea is unwarranted.

Homeopaths claim that homeopathy is an "alternative" medical system. The authors justify their research in the hope that homeopathy would have public health importance. If true, one would presume the system to be equal to or better than oral rehydration therapy. Therefore, even if it were positive, this study would not prove homeopathy to be an alternative to the standard treatment of childhood diarrhea.

METHODS

Government agencies do not routinely assay homeopathic products. Homeopathic products have been found to be adulterated with active material.1-3
Learning-disabled Males With a Fragile X CGG Expansion in the Upper Premutation Size Range
Authors: Hagerman Randi J. , Staley Louise W. , O'Conner Rebecca , Lugenbeel Kellie , Nelson David , McLean Scott D. , Taylor Annette
Published: December 2021

There is a broad spectrum of clinical involvement in both boys and girls affected by fragile X syndrome. Although this disorder is best known as the most common inherited cause of mental retardation, it also can manifest as learning disabilities in individuals with IQs in the broad range of normal. Boys are usually retarded, and girls are usually learning disabled with fragile X syndrome.1 The responsible gene, fragile X mental retardation 1 (FMR1), was isolated in 1991, and the mutation was found to involve expansion of a trinucleotide (CGG) repeat segment. Individuals with fragile X syndrome have a CGG expansion of more than 200 repeats associated with hypermethylation of both the expansion and an adjacent CpG island (full mutation).2,3
AMERICAN TRANSPLANTS IN 1994
Authors: L. J. F.
Published: December 2021

[See Table in Source Pdf.]
MATERNAL DEATH AND GROSS NATIONAL PRODUCT (GNP)
Authors: Student
Published: December 2021

. . . viewed from [the] perspective of the consequences on maternal health, the Italian GNP per capita of over $20,000 translates into a lifetime risk of dying during pregnancy and childbirth of 1 in 17,360, whereas the respective figures for Mali, West Africa, are $310 and 1 in 7. A 66-fold difference in GNP manifests as nearly 2500-fold difference in maternal death.
Universal Access to Good-quality Education and Care of Children From Birth to 5 Years
Authors:   COMMITTEE ON EARLY CHILDHOOD, ADOPTION AND DEPENDENT CARE
Published: December 2021

CHILDREN IN EARLY CARE AND EDUCATION PROGRAMS

All families with children need child care at one time or another, and increasingly, parents seek child care so they can work outside of the home. During the past two decades, the proportion of mothers of young children entering the labor force nearly doubled, reaching 68% in 1992, with a concomitant dramatic increase in the number of children younger than 5 years who receive some form of out-of-home child care. Currently, about 80% of children entering school have had regular care in either child care centers (nonresidential settings that provide care and education for any number of children), nursery schools or preschools, their own homes, the homes of relatives, or, most frequently, family day cane homes (the homes of the care givers in which care and education are provided for either a small [1 to 6] or large [7 to 12] number of children). The types of child care arrangements and the extent to which they are used vary according to the child's age and the income, education, and employment status of the parents. Older preschool children, children whose mothers have more than high school educations, and children whose families' incomes are higher are more likely to be enrolled in center-based care. Unemployed parents also tend to use care in centers rather than cane in the child's or another family's home, presumably because subsidized center-based child care programs are available for them. Overall, however, poor families are less likely to make use of preschool programs for their 3- to 4-year-old children than are more affluent families.
In Reply: Inhaled Nitric Oxide Trials: "Vive la différence!"
Authors: ABMAN STEVEN H. , KINSELLA JOHN P.
Published: December 2021

Dr Davidson misinterprets our recent commentary on the pathophysiology of persistent pulmonary hypertension of the newborn (PPHN) and potential therapeutic role of inhaled nitric oxide (I-NO) as suggesting the lack of a need for multiple studies that investigate different questions regarding its efficacy. In contrast, we clearly state that "multicenter studies play vital roles in improving clinical care, and the absence of such studies may lead to the inappropriate use of ineffective or harmful therapies."
Postdischarge Utilization of Medical Services by High-risk Infants: Experience in a Large Managed Care Organization
Authors: Cavalier Stevan , Escobar Gabriel J. , Fernbach Stephen A. , Quesenberry Charles P. , Chellino Marie
Published: December 2021

Background. Infants discharged from intensive care nurseries are a high-risk infant (HRI) population known to have increased utilization of medical services. Most studies tracking HRIs have been based on data obtained from individual chart review or direct patient contact. Given the high cost of such studies, it is desirable to develop less costly methods to track such infants.

Objectives. Our goals were: (1) to identify an HRI cohort at two neonatal intensive care units; (2) to identify a control group of infants not meeting HRI criteria; and (3) to measure outpatient and inpatient utilization in both cohorts using computerized files in a managed care organization.

Methods. Using California Children's Services criteria as our starting point, we established an HRI definition. From a 1-year birth cohort of 7579 infants at two facilities, we identified 250 infants meeting the HRI definition at two neonatal intensive care units during 1990. We then matched the HRIs with a cohort of 896 randomly selected control newborns (those not meeting the HRI definition). Using organizational computer files and state of California death certificate tapes, we followed these infants until February 28, 1992. We measured the number of hospitalizations, total number of hospital days, and total number of outpatient visits and expressed these outcomes as rates per person-year. We also measured postdischarge mortality.

Results. The rate of hospitalization in the HRI group was 6.07 times (95% confidence interval [CI], 4.74-7.77) that in the control group. The utilization of hospital days by the HRI population (hospital days per 1000 person-months) was 13.24 times higher (95% CI, 11.00-16.04). The outpatient visit rate was 1.40 times higher (95% CI, 1.36-1.45) in the HRI population.

Conclusion. Our findings in a large managed care organization corroborate previous studies showing that hospitalization rates are significantly higher among HRIs. In our study population, outpatient utilization was significantly higher as well. Our study also demonstrates the feasibility of using computerized files to study outcomes in selected pediatric populations. These methods can be used for epidemiologic studies, interventional trials, and planning for resource allocation.