bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving Medical Student Interviewing Skills
Authors: Brown Janice E. , O'Shea John S.
Published: December 2021

In an attempt to identify methods of improving interviewing skills, 14 pediatric medical students (group 1) were randomly assigned to receive feedback concerning an audiovisually taped interview and to participate in a didactic session on interviewing skills. Seventeen students (group 2) had feedback sessions only, and 31 (group 3) had neither feedback nor didactic sessions. Each student was taped while interviewing a simulated mother both before and after receiving the assigned input. Group 1 improved more than group 3 in organizational abilities and more than either group 2 or group 3 in obtaining histories of present illnesses. Improvements in rapport, organization and information eliciting abilities were correlated with the amount of time taken for the interviews. Differences observed between the three groups in the pre-input interviews, which were carried out within several days of the students' becoming aware of their group assignments, stress the need of obtaining pre-input evaluations routinely in assessing medical education techniques.
Familial, Dexamethasone-Suppressible, Normokalemic Hyperaldosteronism
Authors: Grim C. E. , Weinberger M. H.
Published: December 2021

An 8-year-old boy was found to be hypertensive on routine exam (144/88). His brother (age 6) and father (age 31) were also found to have elevated blood pressure. Detailed investigations first revealed a low renin level without hypokalemia. Further study revealed that all three patients had low plasma renin activity and nonsuppresible plasma aldosterone levels after saline infusion. Serum potassium was almost always normal. A trial of dexamethasone therapy normalized blood pressure, and plasma and urinary aldosterone decreased to low levels and renin levels increased. Therapy with spironolactone and prednisone also normalized blood pressure. However, the amount of prednisone required to maintain normotension resulted in Cushingoid features and has been discontinued. Studies in the father suggest that the aldosterone production by his adrenals is hyperresponsive to adrenocorticotropic hormone (ACTH). Renin levels should be determined in all hypertensive children and their hypertensive parents. If renin is low and plasma aldosterone fails to be suppressed by saline infusion, a trial of dexamethasone would seem indicated before other investigations are carried out.
Naloxone Use in Newborns
Authors: Segal Sydney , Anyan Walter R. , Hill Reba M. , Kauffman Ralph E. , Mofenson Howard , Pruitt Albert W. , Shinefield Henry R. , Singer Harvey S. , Weinberger Miles M.
Published: December 2021

Naloxone hydrochloride (Narcan) is a pure narcotic antagonist that is the drug of choice in the treatment of central nervous system and cardiores-piratory depression due to narcotic agonist drugs. It has virtually no agonist activity and therefore produces no narcotic effect even when administered in greater than recommended doses, in contrast to nalorphine hydrochloride and levallorphan tartrate, which have mixed agonist-antagonist activity.

In 1975 the FDA approved a dosage form of naloxone in a concentration of 0.02 mg/ml that was specifically designed for use in newborns whose mothers receive narcotic analgesics during labor and who are born with narcotic-induced respiratory depression; this drug was marketed for general prescription use. Three years after its introduction, the role of naloxone in the management of the depressed newborn merits clarification. In addition, recent information regarding opiate receptors and endogenous opioids raises questions concerning the long-term safety of naloxone in neonates. A review of available published and unpublished data pertaning to naloxone use in the newborn infant by the Committee on Drugs forms the basis for the following commentary and recommendations.

EFFICACY

The potent narcotic antagonist activity of naloxone is well documented in infants and children as well as in adults. Naloxone has been effectively used postoperatively to reverse respiratory depression in infants and children who received narcotics for analgesia.1,2 Additional cases have been reported in which naloxone was successfully and safely used to treat children who were poisoned with narcotic agonists such as diphenoxylate hydrochloride (Lomotil),3,4 methadone hydrochloride, 57 and propoxyphene hydrochloride (Darvon).8

Most of the controlled clinical trials to study the safety and efficacy of naloxone in treating respiratory depression in the narcotic-exposed newborn have been carried out on full-term, healthy infants whose mothers received morphine or meperidine hydrochloride during labor, but who showed no overt clinical evidence of respiratory or CNS depression at birth.
Natural Course of Febrile Seizures
Authors: Huttenlocher Peter R.
Published: December 2021

The article by Nelson and Ellenberg about prognosis in children with febrile seizures (Pediatrics 61:720, 1978) implies that febrile seizures are essentially benign and, in most instances, do not require long-term anticonvulsant drug therapy. While this may well be true, it is not possible to draw such a conclusion from the data presented. It should be pointed out that Nelson and Ellenberg do not report the natural course of children with febrile seizures.
An Outbreak of Toxoplasmosis Linked to Cats
Authors: Stagno Sergio , Dykes Aubert C. , Amos Catherine S. , Head Robert A. , Juranek Dennis D. , Walls Kenneth
Published: December 2021

Clinical, serologic, and epidemiologic evidence documents an outbreak of toxoplasmosis involving ten of 30 members of an extended family. The index patient had unusual clinical manifestations including brain abscesses, progressive chorioretinitis, seizures, neurologic deficits, hepatosplenomegaly, pneumonitis, and eosinophilia. Toxoplasmosis was confirmed by demonstrating the organism in brain tissue and cerebrospinal fluids; clinical and serologic evidence also indicated infection with Toxocara (visceral larva migrans). This outbreak of toxoplasmosis was confined largely to preschoolaged children. Of the 11 such children, seven (68%) were seropositive, six of whom had high acute-phase titers (≥1024) to Toxoplasma and a disease consistent with acute toxoplasmosis. All six of the latter group required specific chemotherapy. Geophagia was associated statistically with acute toxoplasmosis among the children; it also increased the risk of infection with Toxocara and enteroparasites. Two school-aged children and two adults had serologic evidence of acute toxoplasmosis, but only one of the group was symptomatic. Epidemiologic evidence indicates that this outbreak was probably caused by ingesting oocysts from cat feces. We suggest that the severe and unusual clinical manifestations of the index patient resulted from simultaneous infection with Toxoplasma and Toxocara.
Smoke Detectors: Reducing Deaths and Injuries Due to Fire
Authors: Reisinger Keith S.
Published: December 2021

The United States leads all nations in the incidence of deaths due to fire. In the past two decades significant technologic advances have resulted in the development of inexpensive and reliable smoke detectors. These detectors can provide early warning to allow sleeping residents easy exit when a fire occurs in the home. Currently, there are three major types of early warning devices: heat detectors, photoelectric smoke detectors, and ionization smoke detectors. Heat detectors sound an alarm in response to rapid increases in temperature and/ or ambient temperatures above 135 F. Photoelectric smoke detectors are particularly effective for smoldering fires, because they are less influenced by the smaller particles of combustion emitted during household cooking or from automobile exhaust than are ionization smoke detectors. The ionization smoke detectors respond more quickly than photoelectric smoke detectors to fast burning fires and have been proved effective in sounding an early alarm in the vast majority of home fires. For best all-around fire protection, a home should have more than one type of detector. Detectors should be located on the ceiling or high on the ceiling of every level of the house close to each bedroom. Properly installed and maintained smoke detectors can reduce the tragic consequences of home fires, but even greater gains can be made by combining these early warning systems with a reduction in home fire hazards and in practicing a well planned fire escape route.
Albumin-Collodion Activated Charcoal Hemoperfusion in the Treatment of Severe Theophylline Intoxication in a 3-Year-Old Patient
Authors: Chang Thomas M. S. , Espinosa-Meléndez Enrique , Francoeur Thomas E. , Eade Norman R.
Published: December 2021

During treatment for asthma, a 3-year-old, 15-kg child was given 750 mg of theophylline in error. Within three hours she was treated with albumin-collodion activated charcoal (ACAC) hemoperfusion. Immediately before treatment her serum theophylline level was 74 µg/ml. At the end of three hours of hemoperfusion, her theophylline level had fallen to 14.4 µg/ml and four hours later it was 8.8 µg/ml. The ACAC hemoperfusion system completely removed all the theophylline passing through it without saturation, and the total amount of drug removed was 500.8 mg (more than two thirds of the dose administered). The technique described is an efficient and rapidly effective method for the treatment of potentially lethal theophylline intoxication. For maximum effectiveness, it must be instituted as soon after intoxication as possible.
Presidential Address: The Ambulatory Pediatric Association, May 1, 1979
Authors: Comerci George D.
Published: December 2021

I consider myself especially privileged to have served as your president for the past year and now to have the honor of addressing the membership at this our 19th annual meeting of the Ambulatory Pediatric Association. I feel especially privileged because this association has expressed its confidence in a clinician-teacher with rather meager academic credentials, as might be judged by the memberships of other academic societies.

I consider my fellowship in ambulatory pediatrics to have been my four years of private general pediatric practice. Following my "fellowship," Dr Arthur McElfresh, then Professor and Chairman of Pediatrics at St Louis University, accepted me into his Department as an Assistant Professor and Director of Ambulatory Pediatric and Emergency Services. I never expressed my gratitude to him prior to his untimely death in 1977, first, for accepting me into academic pediatrics from private practice, and second, for the guidance and counseling that he provided me.

There are issues and concerns that touch each of us involved in academic general pediatrics. In this presentation I will address those that I consider relevant to our membership, indeed, some that I believe critical to the survival of the academic generalist. The question of why there must be generalists on medical school faculties should be addressed. Must all faculty do research, and is it possible to be a good teacher without being involved in original research? Must all inquiry and scholarly contributions be based on reproducible data and numbers, and must one do research in order to qualify as a scholar?
New Developments in Hyperphenylalaninemia
Authors: O'Brien Donough , Berlow Stanley , Donnell George , Justice Parvin , Kaufman Seymour , Levy Harvey L. , McCabe Edward R. B. , Snyderman Selma
Published: December 2021

In recent years it has become apparent that hyperphenylalaninemia in newborn infants may be caused by a variety of defects in the enzyme phenylalanine hydroxylase or by an abnormality in either the enzyme dihydropteridine reductase (DHPR) or the synthesis of dihydrobiopterin (BH2) (Figure). Despite the rarity of the latter conditions1 there are important implications for management in making this diagnosis. It has been suggested that all new cases of hyperphenylalaninemia now be screened for these variants.2 The purpose of the Task Force was to define the feasibility of this course at the present time.

BACKGROUND

The hepatic system for conversion of phenylalanine to tyrosine is complex and consists of at least two essential enzymes, phenylalanine hydroxylase (catalyzing reaction 1) and dihydropteridine reductase (catalyzing reaction 2), and an essential, nonprotein cofactor, tetrahydrobiopterin3: (1) Phenylalanine + O2 + tetrahydrobiopterin → tyrosine + H2O + quinonoid dihydrobiopterin; (2) nicotinamide adenine dinucleotide (reduced form) + H+ + quinonoid dihydrobiopterin → nicotinamide adenine dinucleotide (oxidized form) + tetrahydrobiopterin.

Most cases of hyperphenylalaninemia detected by newborn infant screening programs are caused by deficiencies of phenylalanine hydroxylase ranging from the severe "classic phenylketonuria (PKU)" to the more benign "hyperphenylalaninemic variant." The patients with classic PKU usually respond to a diet low in phenylalanine. However, of the estimated 400 cases of classic PKU detected annually in the United States, up to 3% may show progressive neurologic deterioration despite adequate dietary treatment. The elevated phenylalanine in these infants may be caused by either DHPR deficiency or a deficient synthesis of BH2 or to other still unidentified causes.
Estimates of Need and Recommendations for Personnel in Neonatal Pediatrics
Authors: Brann Alfred W. , Cassady George
Published: December 2021

The American Academy of Pediatrics Committee on the Fetus and Newborn, as a technical advisory committee, and the Section on Perinatal Pediatrics, representing pediatricians with a special interest in neonatology, have examined current practice and manpower needs in neonatal pediatrics. This effort has been undertaken to provide current objective information and to make recommendations regarding personnel numbers and distribution.

Advances in perinatal knowledge have resulted in major technological achievements and improved care of pathophysiologic states as well as enhanced understanding of emotional aspects of the human birthing experience. General acceptance of perinatal regionalization and formal recognition of perinatology as a subspecialty, including sub-boards of Neonatal-Perinatal Medicine of the American Board of Pediatrics and Maternal-Fetal Medicine of the American Board of Obstetrics and Gynecology, have occurred in this decade. In March 1977, an ad hoc group of neonatologists, with representation from obstetrics, nursing, government, and voluntary organizations, met to quantify US neonatal manpower needs. Progress was made in conceptualizing aspects of the problem, but a consensus regarding validity of conclusions was not reached and a formal report not written. The concerns leading to and from that conference, plus later communications to the Section and Committee, emphasized an acute need for additional effort. It is not the purpose of this statement to directly address the issue of structure, content, and quality of training programs in Neonatal-Perinatal Medicine; this is a consideration of the sub-board.

NEED FOR SUBSPECIALIST

NEONATOLOGISTS

Manpower needs to care for sick infants can be estimated from different data such as total number of births; estimates of infants requiring special care, especially the low-birth-weight or prematurity rate; perinatal mortality rates; and aspects of provider services, including number of beds available for neonatal care and length of stay.
Renal Stones and Intravenous Fielding
Authors: Pascual Jose F.
Published: December 2021

Adelman et al1 report nephrolithiasis as another complication that may be seen associated with total parenteral nutrition (TPN). The authors implicate parenteral calcium infusion as the cause of calcium phosphate calculi in their patient.

Another possible etiologic factor in renal stone formation is that of hypophosphatemia. Urinary excretion of pyrophosphate, a potent inhibitor of calcium crystal formation, is decreased in the presence of hypophosphatemia, thus favoring calculi formation. It has also been shown that a decrease in cellular phosphate in the renal cortex2 may stimulate increased formation of 1,25(OH)2D3, which in turn will cause an increase in urinary calcium excretion.3
Pulmonary Echinococcosis: A Pediatric Disease of the Southwestern United States
Authors: Katz Robert , Murphy Shirley , Kosloske Ann
Published: December 2021

Three cases of pulmonary echinococcosis in native American children emphasize the need to consider the diagnosis in the differential diagnosis of mass lesions of the chest when the appropriate environmental conditions are present. Two children presented with a non-productive cough, while one was asymptomatic. Surgery is the treatment of choice for pulmonary echinococcal cysts. All three children did well after thoracotomy, and one child has a normal roentgenogram six years after surgery. Recent evidence seems to indicate that transmission of the Echinococcus among native Americans in the Southwest is increasing, and thus human echinococcal disease may be of increasing clinical importance.
Ventriculoperitoneal Shunt-Associated Infection Due to Haemophilus influenzae
Authors: Patriarca Peter A. , Lauer Brian A.
Published: December 2021

We report two children with ventriculoperitoneal shunt infections due to Haemophilus influenzae, type b. One child was cured with systemic and intraventricular antimicrobial therapy alone. The other child had persistently positive ventricular fluid cultures, ultimately required shunt removal in addition to antimicrobial therapy, and still had a relapse, which responded to antimicrobial therapy alone. In treating children with this problem we recommend removal of the shunt apparatus unless there is prompt sterilization of ventricular fluid and clinical improvement. Systemic antimicrobial therapy should be continued for two to four weeks.
Insulin Receptors in Cystic Fibrosis: Increased Receptor Number and Altered Affinity
Authors: Lippe Barbara M. , Kaplan Solomon A. , Neufeld Naomi D. , Smith Angeline , Scott Marilyn
Published: December 2021

Patients with cystic fibrosis are known to have pancreatic disorganization with associated pancreatic exocrine insufficiency. Endocrine hormonal secretion is also affected but diminution in insulin secretion is rarely accompanied by overt diabetes. We studied seven patients with cystic fibrosis to determine their carbohydrate tolerance and the status of peripheral monocyte insulin receptors. Oral glucose tolerance tests showed the presence of mild hyperglycemia and diminished insulin secretion. Mean insulin receptor sites per cell were markedly increased above controls, 25,000 vs 13,100 sites per cell while receptor affinity was diminished. The increase in receptor number could be a consequence of the insulinopenia and/or the decreased body weight of the patients and serve as a compensatory mechanism maintaining a degree of relative insulin sensitivity. Ultimate carbohydrate tolerance may be a function of the patient's ability to maintain increased receptor numbers in the face of hypoinsulinemia and impaired receptor affinity.
Experimental Power: The Other Side of the Coin
Authors: Berwick Donald M.
Published: December 2021

The article by Mitchell et al,1 in this issue of Pediatrics is laudable in many respects, including the rigor of its methodology. In a paragraph on page 974, the reader will find one particularly valuable nugget. There the authors write, "...clinically important differences... were unlikely to have been missed. Specifically, for GCI (general cognitive index) a difference of 15 points would have been found 91% of the time, and a difference of 20 points 99% of the time, while a difference of 10 points would be found 64% of the time."

That is pure gold. Not only do the authors tell us that their study failed to find a certain effect (a difference in GCI between cases and comparisands), but they then tell us how likely it was, given the size and design of their study, that they missed an effect which we might care about.
Letters to the Editor
Authors: Goldman Steven L. , Brady June P. , Dumpit Fe M.
Published: December 2021

We appreciate Dr Kattwinkel's concerns and we would like to clarify several of his comments:

1. Comparison of work of breathing—Dr Kattwinkel correctly points out that, by adding the PE 20 sampling catheter, we have increased the resistance of the nasal prongs over their resistance when used clinically. In fact, the catheter does increase the measured resistance of the nasal prongs by about 36%. We must concur that work of breathing measured with the nasal prongs would have been less if the sampling catheter was not present.
Circumcision Disasters
Authors: Woodside Jeffrey R.
Published: December 2021

The article by Cleary and Kohl (Pediatrics 64:301, 1979) describes an unusual and disastrous complication of infant circumcision. We recently cared for a neonate who developed a similar infection of the perineum, genitalia, and abdominal wall following routine circumcision.1 On admission, three days after circumcision, he was lethargic, hypotensive, thrombocytopenic, and had multiple skin emboli. His genitalia had a bluish discoloration and there was a subtle induration of the skin of the lower abdominal wall.
Morphologic Evidence of Accelerated Closure of the Ductus Arteriosus in Preterm Infants
Authors: King Donald T. , Emmanouilides George C. , Andrews James C. , Hirose Frank M.
Published: December 2021

In preterm infants, closure of the ductus arteriosus (DA) is often delayed, especially in those with respiratory distress syndrome (RDS). However, it has been suggested that functional closure of the DA may occur as early as 24 hours of age in some preterm infants exposed to intrauterine stress, and this is usually associated with decreased incidence of RDS. This suggests that accelerated maturation of the DA as well as of the lungs occurs in utero. Accordingly, histologic evidence of accelerated maturation of the DA was sought in a prospective autopsy study of 55 preterm infants ranging in gestational age from 19 to 32 weeks. There were four infants with clinically closed DA which showed histologic evidence of closure. The birth weight of these four infants ranged from 750-1,100 gm, the gestational age ranged from 24-32 weeks, and age of death was 39 hours to 6 days. The immediate causes of death were intracerebral hemorrhage or intrapulmonary hemorrhage, or both. Obstetric complications included chronic second trimester vaginal bleeding, abruptio placenta, malnutrition, diabetes, pulmonic stenosis of moderate degree, and chronic hypertension. These findings support the hypothesis that in some preterm infants exposed to chronic intrauterine stress, maturation of the DA is accelerated. This may result clinically in effective postnatal closure of the DA.
Chronic Vitamin A Intoxication in Infants Fed Chicken Liver
Authors: Mahoney C. Patrick , Margolis M. Theodore , Knauss Thomas A. , Labbe Robert F.
Published: December 2021

Twin female infants were fed 120 gm of chicken liver homogenate daily for four months. They developed irritability, vomiting, and bulging anterior fontanelles. Computed tomograms of the brain revealed enlarged ventricles in both infants and dilated subarachnoid spaces in one. Plasma vitamin A concentrations were elevated. After all sources of vitamin A intake were stopped, the infants recovered without sequelae. The chicken liver homogenate contained 36,000 IU of vitamin A per 120 gm. Since infants often receive 4,000 units of vitamin A daily from fortified milk and vitamin supplements, they probably cannot be fed 60 gm of chicken liver safely more often than once weekly.
Marital Stress and Medical Training: An Experience with a Support Group for Medical House Staff Wives
Authors: Bergman Anne Sturmthal
Published: December 2021

This paper reports on a support group for medical house staff wives. This informal group revealed prevailing feelings of depression, anger, frustration, and impotence in coping with their spouses' training period. All participants agreed that the group had been a positive experience, allowing them to express anger in a safe place, and not to their husbands. They also stated that the group validated the fact that their concerns were in fact real and shared by many women. Although it is unclear what the responsibility of a training program is to wives of physicians in training, this group demonstrated that not only were physicians stressed, but their wives were as well. Further study of the impact of the training experience on both physician and spouse would be helpful in determining appropriate methods of intervention to reduce feelings of stress and depression for both physician and spouse during the training period.
Gram-Negative Sepsis in Neonates: A Nursery Outbreak Due to Hand Carriage of Citrobacter diversus
Authors: Parry Michael F. , Hutchinson Joan H. , Brown Nathaniel A. , Wu Chii-Huei , Estreller Lillian
Published: December 2021

An outbreak of Citrobacter diversus infections occurred in a newborn nursery at a 350-bed community hospital during September and October 1978. Two infants developed sepsis and meningitis and nine additional infants had asymptomatic umbilical colonization. These infants did not differ from control, noncolonized infants with respect to numerous clinical and environmental variables. Surveillance cultures failed to implicate an environmental source for the Citrobacter. However, cultures of nursery personnel identified a handcarrier whose removal eliminated neonatal colonization with C diversus and decreased the number of isolates of certain other enteric bacteria found on umbilical stumps. Factors implicated in the perpetuation of the carrier state in this nurse included marked dermatitis from repeated hand washing and hand care practices involving the overnight use of plastic gloves and nutritive hand cream. The mode of transmission within the nursery appeared to be from nurse's hands to infant's umbilicus. Use of triple dye on umbilical stumps and chlorhexidine hand washing preparations did not eliminate this cycle. Surgical manipulation of colonized umbilical stumps may have been responsible for illness in two infants.
Bacteriology of Aspiration Pneumonia in Children
Authors: Brook Itzhak , Finegold Sydney M.
Published: December 2021

Aspiration pneumonia in adults has been shown to involve anaerobes about 90% of the time. Studies of the bacteriology of aspiration pneumonia in children done in the past have either failed to exclude the oral and upper respiratory tract flora or have not utilized proper anaerobic culture techniques or both. In the present study, 74 institutionalized children with aspiration pneumonia were studied by percutaneous transtracheal aspiration. Their average age was 8 years. Fifty-two patients had pneumonitis, 12, necrotizing pneumonia, and 10, lung abscess. Only one patient (with lung abscess) had a complicating empyema. There was an average of five bacteria isolated per specimen—2.8 anaerobes and 2.2 nonanaerobes. The predominant anaerobic isolates were Grampositive cocci, Bacteroides melaninogenicus, and fusobacteria; there were ten patients who yielded members of the Bacteroides fragilis group. The predominant nonanaerobes were α-hemolytic streptococci, Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus. Thus, aspiration pneumonia in children, as in adults, commonly involves anaerobic bacteria. When aspiration occurs in a medical institution, nosocomial pathogens which are aerobic or facultative will also often be involved, in both children and adults.
Rhabdomyosarcoma of the Middle Ear: A Wolf in Sheep's Clothing
Authors: Schwartz Richard H. , Movassaghi Nasser , Marion Edward D.
Published: December 2021

A 3-year-old boy with inflammatory granulation tissue in the ear canal and typanometric evidence of middle-ear effusion was examined. Subsequently, rhabdomyosarcoma of the middle ear was diagnosed. The insidious, deceptive presentation of this common pediatric tumor in an uncommon location is discussed with indication that early diagnosis and aggressive multimodal antitumor therapy seems to be improving the hitherto gloomy prognosis for these highly lethal middle-ear neoplasms.
Intra-arterial Infusions and Intestinal Necrosis in the Rabbit: Potential Hazards of Umbilical Artery Injections of Ampicillin, Glucose, and Sodium Bicarbonate
Authors: Book Linda Sue , Herbst John J.
Published: December 2021

Umbilical artery catheters are frequently employed for administration of medications. When the catheter tip is positioned adjacent to major aortic tributaries or inadvertently in the mesenteric arteries, high concentrations of infused substances may perfuse the intestine. Injections of saline, 50% dextrose, 10% dextrose, 8.4% sodium bicarbonate, and 100 mg/ml ampicillin were made into a branch of the mesenteric artery supplying 10 to 15 cm of rabbit ileum. The intestine was then examined two to five days later. All segments of intestine perfused with saline and 10% dextrose were grossly and microscopically normal. In each of the eight sites perfused with 50% dextrose, intestinal necrosis was noted (P < .001). Four of eight sites perfused with ampicillin had hemorrhage and villus atrophy (P < .001). Of the eight sites perfused with sodium bicarbonate, three had necrosis with hemorrhage and five had villus edema. The data indicate that intra-arterial infusions of high concentrations of sodium bicarbonate, glucose, and ampicillin produce serious lesions in an animal model. This suggests that appropriate precautions should be exercised when administering medications through the umbilical artery catheter.
Nocturnal Oxygen Saturation in Normal and Asthmatic Children
Authors: Chipps Bradley E. , Mak Hailen , Schuberth Kenneth C. , Talamo Jonathan H. , Menkes Harold A. , Scherr Merle S.
Published: December 2021

At sea level, it appears that oxygen desaturation does not occur in normal children at night and that the desaturation that occurs in moderately severe asthmatic children with therapeutic levels of theophylline does not approach dangerously low levels.
Prenatal Diagnosis for Pediatricians
Authors: Scriver Charles R. , Feingold Murray , Holtzman Neil A. , Mamunes Peter , Nadler Henry L. , Manley Audrey F. , Oakley Godfrey , Simpson Joe Leigh , Childs Barton
Published: December 2021

Pediatricians should be familiar with the principles of antenatal diagnosis and how they should be applied to specific problems in genetic counseling, diagnosis, and management in clinical practice. At the same time, pediatricians should be familiar with the resources for the new technology available to them in their region, and they should assure themselves that the performance of antenatal diagnosis meets current standards.
Status Asthmaticus
Authors: Honicky Richard E.
Published: December 2021

The article by Harfi, Hanissian, and Crawford on the treatment of status asthmaticus in children with high doses and conventional doses of methylprednisolone, which appeared in the June 1978 issue of Pediatrics, was most disturbing both from the methodologic approach and the subsequent discussion. Failure to measure theophyllin levels during this study of at least 65 hours duration appears to be quite illogical since most, if not all, the aminophyllin has been metabolized and excreted in six to eight hours.
Oral and Inhaled Salbutamol in the Prevention of Exercise-Induced Bronchospasm
Authors: Francis Paul W. J. , Krastins Inese R. B. , Levison Henry
Published: December 2021

Oral salbutamol in a dose of 0.15 mg/kg of body weight was compared to a total dose of 0.2 mg of salbutamol aerosol in its ability to produce bronchodilation and to prevent exercise-induced bronchospasm (EIB) in 16 asthmatic children in a single-blind crossover study. The degree of bronchodilation seen 120 minutes after the oral salbutamol was equal to that seen 40 minutes after the salbutamol aerosol as assessed by peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), forced expiratory flow during the middle half of the FVC (FEF25-75%), and maximum expiratory-flow after 75% of the FVC had been expired (V25). With respect to changes in PEF and FEV1, both active agents were equally effective in blocking EIB following a standardized treadmill exercise test. However, in assessing changes in FEF25-75%, and V25 following exercise, the aerosol was slightly but significantly more effective than the oral preparation in blocking EIB. Oral salbutamol was clinically effective in preventing EIB for 4.9 to 5.8 hours. The aerosol route has the advantages of a faster onset of action, fewer side effects, and greater protection against EIB with respect to small airways function. Nevertheless, for patients who are unable to use a metered aerosol, oral salbutamol is a useful alternative both as a bronchodilator and in preventing EIB.
Infantile Water Intoxication at Home
Authors: Schulman Joseph
Published: December 2021

Water intoxication in infants living at home has been considered an unusual entity.1-4 This paper describes two infants who were seen because of seizures. It appears that the metabolic derangements were a consequence of parental error. In view of the similarity between these and previously reported cases,1-4 including the context of parental poverty, the problem and population at risk may be more common than previously recognized.

CASE REPORTS

Case 1

T.W. is a 5-month-old boy with no previously known health problems. After being irritable for most of the afternoon, he developed generalized seizures in the evening. His temperature was 97 F rectally, blood pressure 70 mm Hg by palpation, pulse rate was 132 beats per minute, and respirations 20/min.
A Comparison of Three Antibiotic Regimens for Eradication of Haemophilus influenzae Type b from the Pharynx of Infants and Children
Authors: Horner Douglas B. , McCracken George H. , Ginsburg Charles M. , Zweighaft Teresa C.
Published: December 2021

The communicability of Haemophilus influenzae type b has recently been shown to be comparable to that of Neisseria meningitidis.1,2 The secondary attack rate of H influenzae type b disease is approximately 2% in young contacts of an index case, an observation that has stimulated investigators to attempt to identify effective chemoprophylactic regimens. Elsewhere in this issue are two studies reporting successful use of rifampin in eradicating H influenzae type b from the pharynx of infants and children who were exposed to patients with the disease.3,4 Other regimens have not been effective.5,6

The purpose of this brief communication is to report our results with three antimicrobial agents that were given in an attempt to eliminate pharyngeal carriage of H influenzae type b in infants and children.
DR MORRILL WYMAN'S TREATMENT OF THE OLDEST SON OF PRESIDENT ELIOT OF HARVARD ABOUT 1870
Authors: C. T. E.
Published: December 2021

President Charles William Eliot (1834-1926), one of Harvard's greatest presidents, must have been so impressed with the treatment of his oldest son by Dr Morrill Wyman (1812-1903) that he could vividly describe it in an address almost a half a century later. Dr Wyman who received his MD from the Harvard Medical School in 1837 was a greatly loved and admired physician during the more than 60 years he practiced in Cambridge, Massachusetts.

In addressing the Cambridge Historical Society in 1917, Eliot described the visit to Dr Wyman's office as follows:

I remember taking to him one day my oldest boy, Charles, then perhaps ten or twelve years old, on whose neck I had noticed a small protuberance. Dr. Wyman looked at it, felt of it, and said—he was a man of quick observation and quick speech—"That is a wen. You had better have it right out." He said that to the boy, and immediately produced a lancet. In half a minute the little growth was out; and the doctor applied a simple dressing. Then he remarked to Charles, "There, that will cost you two dollars, because you have come to my office, but if you had gone in to get that done by a surgeon in Boston he would have charged you twenty-five dollars"; which I have no doubt was an underestimate of the probable Boston charge.1
The Association of Inflammatory Bowel Disease and X Chromosomal Abnormality
Authors: Arulanantham Karunyan , Kramer Michael S. , Gryboski Joyce D.
Published: December 2021

Five patients with inflammatory bowel disease (IBD) had abnormalities of the X chromosome (the Turner syndrome). Based on the estimated prevalence rate of 1:10,000 live female births for the Turner syndrome and 1:50,000 for IBD, random association of these two conditions would be expected in 1:500 million live female births. Given these odds, the findings in these five patients would suggest a clinical association not based on pure chance and unlikely to be accounted for by Berkson's or other referral bias. It is speculated that abnormal immune mechanism could possibly increase the susceptibility of patients with the Turner syndrome to develop IBD. Both conditions cause growth failure. Awareness of the association has clinical importance in identifying the cause of growth failure in a child with either X chromosomal abnormality or IBD.
Fetal Calcitropic Hormones and Neonatal Calcium Homeostasis
Authors: Pitkin Roy M. , Cruikshank Dwight P. , Schauberger Charles W. , Reynolds W. Ann , Williams Gerald A. , Hargis Gary K.
Published: December 2021

Ionic calcium (Ca2+), total calcium, magnesium, phosphorus, albumin, immunoreactive parathyroid hormone (PTH), and immunoreactive calcitonin (CT) were measured in maternal and cord blood at term delivery of 96 women near term with predominantly normal pregnancies. Calcium, magnesium, phosphorus, and albumin were measured in the infants at 24 hours of age. Umbilical Ca2+ levels exceeded maternal values significantly (2.82 ± 0.15 vs 2.23 ± 0.09 mEq/liter, P < .001), as did calcium, magnesium, phosphorus, and albumin levels. The relative fetal hypercalcemia was associated with significantly higher CT levels in fetus than in mother (248 ± 68 vs 209 ± 54 pg/ml, P < .05) but PTH concentrations did not differ significantly between the two circulations. Within the fetal circulation, levels of each component did not differ except for PTH which was in higher concentration in venous than in arterial blood (5.50 ± 1.81 vs 4.93 ± 1.71 µl-eq/ml, P < .05). Stepwise multiple regression analysis, utilizing neonatal Ca level as the dependent variable, identified one clinical feature (duration of pregnancy) and six laboratory data as significant independent variables, accounting in sum for 35% of the variation in neonatal calcium level. The significant laboratory variables, in order of entry into the model, were maternal PTH, umbilical venous PTH, maternal phosphorus, umbilical venous magnesium, neonatal albumin, and neonatal magnesium. These results indicate that the normal fetus responds to hypercalcemia in late intrauterine life by increasing CT secretion but not by suppressing PTH output. The umbilical PTH level is one of several factors at birth which correlates significantly with calcium concentration at 24 hours of age.
Iron-Fortified Formulas and Gastrointestinal Symptoms in Infants: A Controlled Study
Authors: Oski Frank A. , Bennett Richard , Campbell James , Charles Walter , Cirincione F. James , Corwin Robert , Daniels Daniel , Hartenstein Hans , Roberts Fred , Starr George , Stewart Neil , Stockman Arthur , Trust Stuart
Published: December 2021

In an attempt to determine whether ironfortified infant formulas produced gastrointestinal symptoms in infants, we fed two similar formulas, one with and one without iron fortification, to a group of 93 term infants upon discharge from the nursery on the third day of life. Infants were fed the formulas for a period of 42 days while their mothers kept detailed daily records of all gastrointestinal symptoms. A total of 49 infants were fed the non-iron-fortified formula and 44 infants were fed the iron-fortified formula. Review of the records revealed no differences in the number of stools per day, the description of the stools, the number of days without stools, the incidence or frequency of colic, spitting-up, or vomiting. We conclude that the feeding of iron-fortified formulas to infants does not produce an increased incidence of gastrointestinal symptoms or signs.
Bacteremia in Private Pediatric Practice
Authors: Baron Michael A. , Fink Howard D.
Published: December 2021

The capillary white blood cell count and differential, a test easily done in office practice, was used in unexplained febrile illness of infants and toddlers to help distinguish those babies most likely to have bacteremia who would benefit from blood culture and early bacteriologic diagnosis. Four criteria were used as indicators suggestive of bacterial infection: white blood cell count ≥15,000/cu mm, total segmented neutrophils ≥10,000/cu mm, total band cells ≥500/cu mm, and total polymorphonuclear leukocytes (segmented neutrophils plus band cells) ≥10,500/cu mm. These measurements were found helpful in separating a small group of bacteremic babies at high risk of complications from a large group of babies who recovered without antibiotic treatment and without complications. There were 146 febrile illnesses recorded in babies 3 to 24 months of age; bacteremia was proven in eight of these. Three or four blood cell count criteria were fulfilled in seven of the eight bacteremic babies and in only ten (7.2%) of the remaining 138 febrile illnesses (P < .001 by χ2 test).
Monitoring and Management of Increased Intracranial Pressure in Reye Syndrome: Results in 29 Children
Authors: Shaywitz Bennett A. , Rothstein Peter , Venes Joan L.
Published: December 2021

This article reports the outcome of 29 children with Reye syndrome admitted to Yale-New Haven Hospital since initiating a regimen incorporating intracranial pressure (ICP) monitoring, controlled respiration, and administration of mannitol and barbiturates. The majority of the children were in stage 3 coma and 24/29 had ICP monitored via an intraventricular catheter. Evidence of severe disease characterized by blood ammonia concentrations >500 µg/100 ml, and difficulty controlling ICP manifested by the need to administer numerous doses of mannitol were exhibited by 17 of the children, and longer hospitalizations were required for them. The earliest and most reliable indicator of severity was the degree of elevation of the blood ammonia concentration; other laboratory values (SGOT, lactic dehydrogenase, creatine phosphokinase), while related to each other, did not reliably predict severity. ICP monitoring was maintained for a median duration of eight days and ICP was most difficult to control for the first few days of the illness. Two children died during the acute illness (2/29, mortality 6.9%) and there were significant neurologic residua in three children (10.3%). The outcome using our present management technique was clearly superior to previous management at our own institution when considering the most severely affected children. Prior to ICP monitoring (1967-1974) we experienced a 60% mortality in children with blood ammonia >500 µg/100 ml; in this present series we noted two deaths and two children with significant residua in the group of 17 children with blood ammonia >500 µg/100 ml, an overall salvage rate of 11/15 (73.3%). At the present time we are not able to determine which measure or combination of measures is necessary or whether addition to or modification of the treatment protocol might be more effective. Resolution of such issues must await the results of a prospective, multi-institutional collaborative project.
CSF Lactate Levels in High Risk Neonates with and without Asphyxia
Authors: Mathew Oommen P. , Bland Harold , Boxerman Stuart B. , James Elizabeth
Published: December 2021

Determination of CSF lactate levels were performed in 150 nonasphyxiated and 46 asphyxiated high risk neonates. Statistical analysis of log lactate levels of nonasphyxiated infants showed significant relationship to gestational and postnatal ages (P <.0001 and <.0002, respectively). CSF lactate elevation was seen in 16/29 infants studied within eight hours of asphyxia in contrast to 0/17 infants studied after eight hours (P <.001). Higher incidence of CSF lactate elevation was seen in term infants (7/8), infants with fetal distress (13/17), and very low Apgar scores (11/18). Seven of eight infants with markedly elevated lactate levels had both fetal distress and very low Apgar scores. CSF lactate determination in the immediate postasphyxial period appears to be an objective way of assessing the severity of cerebral hypoxia.
Oxygen Consumption and Insensible Water Loss in Premature Infants Under Radiant Heaters
Authors: Marks Keith H. , Gunther Robert C. , Rossi John A. , Maisels M. Jeffrey
Published: December 2021

Oxygen consumption (Vo2), carbon dioxide production (Vco2), and insensible water loss (IWL) were measured simultaneously in nine nondistressed, appropriately grown, premature infants less than 2 weeks old, nursed in a conventional, blow-warmed incubator, and were compared with measurements made on the same infants under a radiant heater. The infants had a pronounced increase (148% on average) in IWL when under the radiant heater (P < .001) whereas Vo2 increased by only 4.6% (P = .073). Abdominal skin temperature (servocontrolled to maintain 36.5 C) and esophageal temperature were the same under both conditions, but ambient air temperature was 0.7 C higher in the incubator (P < .05). Although a positive correlation was found between the increase in IWL and the change in Vo2 (r = .75, P < .01), the large increase in IWL (and, therefore, evaporative heat loss) under the radiant heater is out of proportion to, and cannot be accounted for, by the change in metabolic heat production. The heat transfer processes involved in maintaining body temperature constant under these conditions require further study.
Nutritional Balance Studies in Very-Low-Birth-Weight Infants: Enhanced Nutrient Retention Rates by an Experimental Formula
Authors: Shenai Jayant P. , Reynolds John W. , Babson S. Gorham
Published: December 2021

An experimental infant formula developed to meet the specific nutritional needs of very-low-birth-weight infants was evaluated by 96-hour balance studies in ten preterm infants (birth weight: 1,130 to 1,530 gm). The formula contained 23.2 gm/liter of protein (whey protein/casein ratio, 60:40), 44.1 gm/liter of fat (50% medium-chain triglycerides) and 85.0 gm/liter of carbohydrate (50% lactose, 50% Polycose), and provided relatively higher amounts of calcium, phosphorus, vitamin D, and electrolytes than are in human milk. All infants were fed 150 ml/kg/day (120 calories/kg/day) by intermittent gavage. Balance studies were carried out nine days following establishment of oral intake. The mean (±SEM) nutrient retention rates revealed by balance studies in these infants (calcium, 170 ± 4 mg/kg/day; phosphorus, 78 ± 3 mg/kg/day; nitrogen, 426 ± 8 mg/kg/day; sodium, 1.4 ± 0.1 mEq/kg/day) were comparable to normal fetal accretion rates. The mean (±SEM) fat absorption was 92.5 ± 0.9%. No clinical intolerances or biochemical abnormalities were observed, and adequate postnatal growth was achieved in all infants. The diet proved to be nutritionally advantageous and safe for very-low-birth-weight infants.
Symptomatic Splenic Hamartoma: A Report of Two Cases and Review of the Literature
Authors: Iozzo Renato V. , Haas Joel E. , Chard Ronald L.
Published: December 2021

Two cases of large, multiple splenic hamartomas in children with pancytopenia, bone marrow hyperplasia, lymphadenopathy, hepatosplenomegaly, frequent infections, growth retardation, and fever are reported. These symptoms were relieved by splenectomy, and have not recurred during follow-up periods of one year and nine years. The sharply circumscribed lesions comprised large portions of the resected spleens and were composed of dilated vascular channels filled with mononuclear cells and immunoblasts. The lesions lacked splenic cords or trabeculae, lymphoid follicles, Reed-Sternberg cells, and granulomas or other evidence of infection. Splenic hamartomas are usually single small lesions found incidentally at necropsy or laparotomy. Splenic hamartomas associated with symptoms and hypersplenism are large, and often confluent multiple tumors. Recognition of their benign nature is important in light of the current practice of laparotomy for staging and diagnosis of malignant conditions.