bluuebunny/crossref_metadata_2025 huggingface dataset:
Retraction of the Umbilicus During Voiding as an Initial Sign of a Urachal Anomaly
Authors: ROWE PETER C. , GEARHART JOHN P.
Published: December 2021

The early identification and surgical correction of urachal anomalies helps to avoid potentially serious sequelae, including infection, rupture of urachal cysts into the peritoneal cavity, and neoplastic change in adult life.1-5 Retraction of the umbilicus during urination has not been described as a physical finding in those with urachal anomalies, but it was an important clinical clue in the patient we describe below.

PATIENT REPORT

A 12-year-old boy complained of pain at the umbilicus, beginning just after he started to urinate and persisting until approximately 30 seconds after he had finished voiding. The pain had begun abruptly 3 days earlier. It caused him to bend forward and was accompanied by retraction of the umbilicus.
Sample Size: Profound Implications of Mundane Calculations
Authors: Lantos John D.
Published: December 2021

Controversies in the design of clinical trials excite a small but feisty group of academicians. On one side of the controversy is a group I call the "rigorists," who argue that clinical medicine must be based only on facts that are established by scientifically rigorous clinical trials.1,2 Arguments for scientific rigor have an attractive purity about them that is both mathematical and moral. The simple certainties of statistical science can lead one to believe that, if only we would live by them, we would achieve not only low P values but universal peace and harmony as well. Thus, it may be considered not just good science but an ethical requirement of good research that studies be of sufficient size to give statistically significant results.

No moral argument can confront such assertions head on. Nobody argues, for example, that studies ought to be of insufficient size to give meaningful results. Instead, on the other side of this debate we find a group whom I call "apologists," who make arguments about why, even though scientific rigor is the highest good, other considerations sometimes dictate that medical practice be based on knowledge that falls short of the highest scientific standards. These arguments can be based on the physician's primary loyalty to his or her patient,3-5 to the difficulties in deciding whether or not a sufficient state of uncertainty about the relative merits of two treatments exists to ethically justify clinical trials,6,7 or on the special difficulties in obtaining informed consent or randomizing patients in particular populations.8-10
Chronic Fatigue in Children: Illness or Disease?
Authors: CARTER BRYAN D. , EDWARDS JOSEPH F. , MARSHALL GARY S.
Published: December 2021

To the Editor.—

Recently, Van Aerde1 strongly criticized the study by Smith and colleagues2 on grounds that the authors confused the symptom "chronic fatigue" with "chronic fatigue syndrome (CFS)," because many of their patients failed to meet published criteria3 for CFS. In this regard, it is useful to differentiate "illness" from "disease," as recently done by Green and Stuy.4 "Illness" can be viewed as a disvalued change that occurs in a person's state of being, whereas "disease" more specifically refers to a detrimental series of biological or pathogenetic events.
A Whistleblower's Perspective on the Needleman Case
Authors: SCARR SANDRA
Published: December 2021

To the Editor.—

It is remarkable that Herbert Needleman continues to attack me as a whistleblower in his case. Dr Ernhart and I reported suspicions of his misconduct.1 His colleagues at the University of Pittsburgh found him guilty of deliberate misrepresentations2 in his publications.

From October 1990 to the present, Dr Needleman's continuing troubles with scientific integrity have resulted from inquiries and investigations conducted serially by 1) Dr Ernhart and me, 2) the Office of Scientific Integrity at the National Institutes of Health (NIH-OSI), 3) the Inquiry Panel at the University of Pittsburgh, 4) the Hearing Board at the University of Pittsburgh, and 5) the Office of Research Integrity (ORI) at the Office of the Secretary of Health and Human Services (successor to NIH-OSI).
Day Care for the Child With Acquired Immunodeficiency Syndrome and the Child of the Drug-Abusing Mother
Authors: Heagarty Margaret C.
Published: December 2021

In time, history may very well show that in this nation the decade of the 1980s was one of the most disastrous periods of all time for children, especially urban poor children. Not only did the number of children living in poverty increase dramatically, but two new agents, one viral and the other chemical, were introduced into urban disadvantaged communities. These two agents have had serious effects on the lives, the growth and development, indeed on the very survival of large numbers of children living in our major cities. The two agents are the human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), and the chemical agent, cocaine, or its less expensive version, crack. Both AIDS and drug addiction, especially to cocaine, have had profound effects on the lives of many families and children. The affected children, who are now entering the day-care systems of our cities, pose new problems and dilemmas for the physicians, teachers, and administrators responsible for these programs.

AIDS

By August 1991 more than 3000 children with AIDS had been reported to the Centers for Disease Control.1 Most were infected in the perinatal period by transmission of HIV from an infected mother. They are, for the most part, of African-American or Hispanic ethnicity. They are both disadvantaged and poor. While children with AIDS can be found in virtually all regions of the nation, especially in the urban setting, pediatric AIDS continues to cluster in four areas: New York, New Jersey, Florida, and California.

Because of maternal transmission of HIV antibody, all infants of infected pregnant women will be antibody positive at birth, but only about 30% of these infants will in fact develop AIDS.
Single-Dose Intramuscular Ceftriaxone for Acute Otitis Media in Children
Authors: Green Steven M. , Rothrock Steven G.
Published: December 2021

This study evaluated the efficacy of a single dose of intramuscular ceftriaxone for acute otitis media in children, using amoxicillin as a control. (There is currently no established single-dose treatment for this condition.) In a prospective, randomized, double-blind, clinical trial, 233 children, aged 5 months to 5 years, with uncomplicated acute otitis media were randomly assigned to receive either a single intramuscular injection of ceftriaxone (50 mg/kg) plus placebo oral suspension for 10 days, or a placebo injection plus amoxicillin oral suspension (40 mg/kg per day divided three times per day) for 10 days in a double-blind fashion. Demographic and clinical characteristics were similar in both groups. Treatment was successful in 107 of 117 given amoxicillin (91%, 95% confidence interval 86% to 97%) and 105 of 116 given ceftriaxone (91%, 95% confidence interval 85% to 96%). Rates of improvement, failure, relapse, and reinfection were similar in both groups, as were the otoscopic and tympanometric evaluations at the 14- and 60-day follow-up visits. It is concluded that a single intramuscular injection of ceftriaxone (50 mg/kg) is as effective as 10 days of oral amoxicillin for the treatment of uncomplicated acute otitis media in children.
Ensuring Quality, Affordable Child Care: Mobilizing for Action
Authors: Schroeder Patricia , Reder Nancy D.
Published: December 2021

In October 1990, Congress passed legislation authorizing two new major federal programs to subsidize child care for low- and moderate-income families and to improve the quality of care. The provisions were included in the Omnibus Budget Reconciliation Act of 1990,1 a multilayered funding and taxing measure enacted by Congress in the waning days of the 101st Congress.

The battle to secure federal financial support for affordable, quality child care took nearly 20 years. The new law is significant, not just because it will provide hundreds of millions of federal dollars to help financially strapped families pay for child care, but because it represents an acknowledgment of the need for a federal child care policy. The legislation that ultimately passed, however, reflects a substantial compromise with the Act for Better Child Care (the "ABC bill") as it was originally drafted, particularly with respect to the provisions that address the aspects of child care concerned with quality. (The legislation was originally introduced in the 100th Congress as the Act for Better Child Care of 1987 by Senator Dodd (D-CT) and Rep Dale Kildee (D-MI). It was reintroduced in the 101th Congress (S 5/HR 30) but was folded into the Budget Reconciliation Act as Congress rushed to finish work on the bill and ensure its passage as part of the more comprehensive funding measure.)

Proponents of the ABC bill had originally hoped that the legislation would include federal health and safety standards for child care providers. However, the Bush administration opposed federal standards, even provisions that would have required the Department of Health and Human Services (HHS) to draft model standards that states would then be encouraged to use as guidelines.
Nine-Year Outcome of the Vermont Intervention Program for Low Birth Weight Infants
Authors: Achenbach Thomas M. , Howell Catherine T. , Aoki Melanie F. , Rauh Virginia A.
Published: December 2021

Twenty-four low birth weight children who had received an experimental intervention (LBWE) during the neonatal period, 31 control children who had received no treatment (LBWC), and 36 normal birth weight children were compared. The intervention involved seven hospital sessions and four home sessions in which a nurse helped mothers adapt to their LBW babies. At age 9, LBWE children scored significantly higher than LBWC children on the Kaufman Mental Processing Composite, Sequential, Simultaneous, Achievement, Arithmetic, and Riddles scales, after statistical adjustments for socioeconomic status. The LBWE children had also advanced more rapidly in school than had LBWC children. Parent (Child Behavior Checklist) and teacher (Teacher's Report Form) ratings of school functioning were more favorable for LBWE than LBWC children, with especially strong effects on Teacher's Report Form scores for academic performance and the attention problems syndrome. At age 9, LBWE children were not significantly inferior to normal birth weight children on any measure. These results bear out a progressive divergence between the LBWE and LBWC children that first became statistically significant in cognitive scores at age 3. The findings suggest that the intervention prevented cognitive lags among LBW children and that this eventually had a favorable effect on academic achievement, behavior, and advancement in school. The progression from no significant differences between LBWE and LBWC children on early cognitive and achievement scores to significant and pervasive differences in later functioning argues for long-term follow-up periods to evaluate properly the power of behavioral interventions to compensate for biological risks.
Appropriateness of Hospitalization in a Canadian Pediatric Hospital
Authors: Gloor Jane E. , Kissoon Nianjan , Joubert Gary I.
Published: December 2021

Allocation of limited resources in the Canadian health care system is hampered by a lack of studies addressing the appropriateness of the pediatric patient days in hospital. The authors retrospectively reviewed one hospital day per month in 1988, using a Pediatric Appropriateness Evaluation Protocol previously used in the United States. Of 878 inpatients, 852 charts were reviewed, and 26 charts were unavailable for study. The patients ranged in age from premature newborns to 20 years old. There were 475 medical days, 359 surgical days, and 18 patients to other services. Statistical significance was tested using the χ2 test for contingency tables. Twenty-four percent of patient days were inappropriate. Younger children and shorter lengths of stay were more likely to result in appropriate hospital days. For infants younger than 60 days, 11% of days in hospital were inappropriate, 21% of days for infants between 2 months and 1 year of age, 25% for children between 1 and 5 years, and 36% for children older than 5 years of age. Children hospitalized 2 days or less had inappropriate hospital days accounting for 16% of the reviewed days. This increased to 33% for 3 to 14 days of hospitalization. Inappropriate hospital days did not vary significantly from month to month. Surgical patients had more appropriate hospital days than medical patients. Admission route (elective, emergency, or transferred from another hospital) did not affect the appropriateness of the subsequent day reviewed. It is concluded that inappropriate hospitalization in a Canadian pediatric hospital occurs only slightly more frequently than in an American pediatric hospital. Factors other than funding mechanisms are important contributors to inappropriate hospitalization.
Prevalence of Respiratory Symptoms in Children With Atopic Dermatitis Attending Pediatric Dermatology Clinics
Authors: Salob Stacy P. , Atherton David J.
Published: December 2021

A postal questionnaire, completed by parents, was used to study the prevalence of respiratory symptoms in 250 children with atopic dermatitis who had attended pediatric dermatology clinics in London within the past 5 years. A response rate of 84% was achieved. Each child had a control matched for age and sex, whose parents filled in an identical questionnaire. The prevalence of wheezing was 76% in the atopic dermatitis group and 12% in the control group. Of the children with atopic dermatitis who wheezed, 87% had been given a diagnosis of asthma by a doctor, compared with 40% of the control children who wheezed. Overall, 68% of the children with atopic dermatitis had been given a diagnosis of asthma by a doctor. This prevalence of respiratory symptoms and of diagnosed asthma is substantially higher than has been shown in previous studies. As the test population consisted of children who had been referred to a tertiary center for management of their skin disease, this higher prevalence may partially reflect the increased severity of atopic dermatitis in the study group, as well as the heightened awareness of the association between these two diseases by their parents and physicians.
Cost Assessment of the Evaluation of Heart Murmurs in Children
Authors: Danford David A. , Gumbiner Carl , Nasir Arwa
Published: December 2021

Echocardiography available directly to primary care physicians represents an alternative strategy to pediatric cardiology consultation for childhood heart murmur evaluation. A decision analysis model compared the costs of two diagnostic strategies: (1) echocardiography first, referral to the cardiologist if appropriate; and (2) cardiologist evaluates murmur, echocardiography if appropriate. The model incorporated probability of heart disease, frequency of cardiologist-ordered echocardiography, and echocardiography results established by review of 388 records of consecutive patients evaluated for murmurs in a pediatric cardiology clinic. Echocardiography-first strategy costs were $257 greater than referral-strategy costs. Referral-strategy advantages were not highly sensitive to changes in model assumptions. Pediatric cardiology consultation is the preferred approach provided (1) consultation costs are moderate, (2) echocardiography costs are moderate to high, and (3) the rate at which the cardiologist orders echocardiography for patients with innocent murmurs is low.
The Changing Role and Responsibilities of a Chairman—Letters
Authors: CROOK WILLIAM G.
Published: December 2021

To the Editor.—

I found Dr Brent's article in the July issue of Pediatrics (1992;90:50-57) informative and delightful. He said, "The chairman of today is more like a parent, satisfied with long-term rewards and muted faculty appreciation." This comment reminded me of my chief at Vanderbilt, the late Amos Christie who was such a parent to all of "his boys." He sat down with the interns and residents and listened in an unhurried manner. Not only when we were on the house staff, but during our visits back to Vanderbilt over the years.
Discharge Milk Samples
Authors: AUERBACH KATHLEEN G.
Published: December 2021

To the Editor.—

The work of Dungy et al (Effect of Discharge Samples on Duration of Breast-feeding. Pediatrics. 1992;90:233-237) adds to our knowledge of the complexities of human lactation and breast-feeding behavior. It also raises several questions, including the following:

1. Why were six women who were practicing mixed feeding in the hospital included with the rest of the sample, all of whom were characterized as exclusively breast-feeding?

2. What were the mothers' plans pertaining to employment1 with regard to their plans to breast-feed exclusively or partially; to use a bottle for night feedings; and to use a breast pump?

3. Which breast pump was provided? Some baby milk manufacturers distribute breast pumps.
Comparison of Stool Containment in Cloth and Single-Use Diapers Using a Simulated Infant Feces
Authors: Kubiak Mary , Kressner Bernhardt , Raynor William , Davis James , Syverson Rae Ellen
Published: December 2021

Single-use diapers and cloth diapers with vinyl pants were compared for their relative abilities to contain stool within the diaper. Artificial feces with carbon black as an additive allowed a quantitative measure of fecal containment by image analysis in 60 infants. This method showed complete containment of feces in the diaper in 50% of the single-use diapers whereas only 10% of the cloth diapers showed complete containment. In infants where the border of the vinýl pants was used as the boundary of containment with the cloth diapers, complete containment occurred only 33% of the time. Fluorescein dye ratings for containment/leakage in 69 infants showed that 83% of single-use diapers and 30% of the cloth diapers were rated as having no or minor leakage of feces. Cultures were taken of laundered vinyl pants that had previously been used over cloth diapers to determine microbial contamination. Thirty-nine percent of the pants contained Gram-negative, lactose-fermenting bacilli indicating fecal contamination. This study comparing single-use and cloth diapers for containment of artificial feces by use of image analysis and fluorescein dye ratings showed better containment by single-use diapers. The study also raises the question of possible spread of feces-borne pathogens by the vinyl pants used over cloth diapers, particularly in a day-care center.
Evaluation of Febrile Infant
Authors: LEVIN JAMES E.
Published: December 2021

To the Editor.—

Lieu et al are to be congratulated for their comprehensive use of decision analysis to model the common problem of the evaluation and treatment of the febrile infant 1 to 3 months of age.1 One of the great strengths of this method is that it can promote discussion and research by making explicit all assumptions about the effectiveness of diagnostic tests and treatments. I would like to thank Dr Lieu for fostering this discussion by making available to me the mathematical representations of this model after its publication.
Familial Vesicoureteral Reflux
Authors: NOE H. NORMAN , PEEDEN J. N.
Published: December 2021

In Reply.—

We are happy to address Dr Roscelli's concerns regarding our paper on familial reflux screening; we are not in complete agreement with him, however. First of all, the incidence of vesicoureteral reflux in the healthy human being is accepted as being 0.4% to 1.8%.1 The only study to show a significantly higher rate was the Kollerman study referred to by Dr Roscelli. This study has been roundly criticized because it was performed with high pressure injection, and it is the only such study to show a high rate of reflux in healthy children.
Beyond Pediatrics: The Health and Survival of Disadvantaged Children E. H. Christopherson Lectureship on International Child Health
Authors: Werner David
Published: December 2021

As an uncertified "village health worker," for me it is a great honor to speak at the annual meeting of the American Academy of Pediatrics. Yet I feel uneasy. Today as we convene, 60 000 children will die unnecessarily, of undernutrition and the disease of poverty.

As pediatricians living in today's "new world order," you are faced with a daunting and in some ways paradoxical challenge. This is partly because the health and well-being of children is to such a large extent determined by factors outside the realm of medicine and pediatrics. It is also because pediatricians, along with so many other resources, are unequally and unfairly distributed. Ninety percent of all pediatricians are in North America and Western Europe, which claim only 15% of the world's children. This means that the vast majority of children—and certainly those in greatest need—live in places where there is no pediatrician.

Please don't get me wrong! I'm not suggesting you catch the next plane to Calcutta to play "great white doctor" in the City of Joy. In the long run, you can probably do much more for children of poor countries by standing up for their health and rights here at home.

If I were asked what American pediatrician in recent times has made the biggest contribution to the future health and well-being of the world's children, I would suggest Dr Benjamin Spock. Not because of his famous books on baby care, but because of his infamous protests and civil disobedience in opposition to militarism, nuclear arms, environmental destruction, social injustice, and the institutionalized inequities that compromise the health, survival, and prospects for the future of so many of our planet's children.
Evaluation of a Promotional Strategy to Increase Bicycle Helmet Use by Children
Authors: Parkin Patricia C. , Spence Laura J. , Hu Xiaohan , Kranz Katherine E. , Shortt Linda G. , Wesson David E.
Published: December 2021

Bicycle-related head injuries are an important cause of death and disability, despite the availability of helmets. The objective of this study was to evaluate the effectiveness of a school-based bicycle helmet promotion program in increasing helmet use by children while controlling for secular trends. Two high-income and two low-income schools in an urban Canadian community were selected to receive a bicycle helmet promotion intervention, with the remaining 18 schools serving as controls. Approximately 1800 observations of bicycling children were made at randomly selected observational sites 2 to 5 months after the intervention to assess changes in behavior. Helmet use at all observation sites tripled from 3.4% (1990, preintervention) to 16% (1991, postintervention). In the high-income intervention area, observed helmet use rose dramatically from 4% to 36% in contrast to the more modest increase in the high-income control area from 4% to 15%. In the low-income intervention area, there was a modest increase from 1% to 7%, but it did not differ from the increase in the low-income control area from 3% to 13%. The program was highly successful in children of high-income families but not in children of low-income families. Developing strategies for low-income families remains a priority.
Issues Involved in the Definition and Classification of Chronic Health Conditions
Authors: Perrin Ellen C. , Newacheck Paul , Pless I. Barry , Drotar Dennis , Gortmaker Steven L. , Leventhal John , Perrin James M. , Stein Ruth E.K. , Walker Deborah K. , Weitzman Michael
Published: December 2021

The need for a widely applicable definition of chronic conditions for research, policy, and program development has led to an extensive review of the development of such definitions, the considerations involved in their use, and some recommendations for a new approach. This paper examines some of the methodologic and conceptual issues related to defining and classifying chronic conditions and describes some consequences resulting from decisions made about these issues. While most examples are taken from child health applications, the basic concepts apply to all age groups. The dominant method for identifying and classifying children as having a chronic condition has relied on the presence of an individual health condition of lengthy duration. This condition-specific or "categorical" approach has increasingly seemed neither pragmatically nor conceptually sound. Thus, the development of a "generic" approach, which focuses on elements that are shared by many conditions, children, and families, is recommended. Such a definition might reflect the child's functional status or ongoing use of medical services over a specified time period. In addition, it is suggested that conditions be classified based on the experience of individual children, thus emphasizing the tremendous variability in expression of seemingly similar conditions.
The Physician-Doctor Relationship
Authors: Christoffel Katherine Kaufer
Published: December 2021

Judging from discussions in medical journals and at professional meetings, pediatricians and other physicians are increasingly aware of their relationships with patients, patients' families, medical co-workers, laboratory personnel, insurance company representatives, legislators, regulators, lawyers, reporters, students, and spouses. There is, however, little discussion of a central relationship that affects all the others: the physician-doctor relationship. It arises because "physician" is not a description of a person, but rather of a role that a person—the doctor—plays.

PHYSICIANS AND DOCTORS

The doctor's coat, stethoscope, and title are a costume that facilitates the performance of the role of physician. It helps the doctor and others to suspend disbelief that this person is a physician: objective; busy yet available; knowledgeable, skilled; undaunted by always private, sometimes smelly, and occasionally fatal problems. These traits of the physician are often important to filling the role, because they allow patients to entrust themselves to the physician, and the doctor to accept the trust and to go on when the going gets tough.

But the traits of the physician contrast sharply with those of the person who fills the role of physician—the doctor. That person is, like other people, subjective, unavailable when busy, often ignorant and unskilled for the job in hand, and likely to be upset by personal and life-threatening problems. The discrepancy between the traits of the doctor (a person) and the physician (a role the person plays) gives rise to a rélationship (the physician-doctor relationship) that is central to what physicians do. Understanding this central relationship is likely to be both important and interesting.
Hair-Grooming Syncope Seizures
Authors: LEWIS DONALD W. , FRANK L. MATTHEW
Published: December 2021

Pediatricians are commonly consulted to evaluate children following their first, apparently unprovoked, convulsion. Keenly aware of the old adage that "all that shakes isn't epilepsy," we are ever mindful of the common mimickers of epileptic seizures that include breath-holding spells, benign paroxysmal vertigo, hyperventilation syndromes, narcolepsy-cataplexy, night terrors, and syncopal events. We present the clinical features of 15 children referred for evaluation of witnessed convulsions at home with similar histories of seizures precipitated by hair grooming and accompanied by presyncopal symptoms.

METHODS

The records of children referred to our neurology clinics from 1982 to 1992 for evaluation of seizures in temporal relationship to hair grooming were retrospectively reviewed.
Perianal Findings in Infants 18 Months of Age or Younger
Authors: BERENSON ABBEY B. , SOMMA-GARCIA ANA , BARNETT STEPHEN
Published: December 2021

Due to the recent increase in the number of cases of suspected sexual assault, a need has arisen for better knowledge and understanding of the genital anatomy in the prepubertal girl. In spite of the fact that abuse involving the rectum has been reported in up to 40% of young girls assaulted,1 little normative data exists on the appearance of the anorectal region. In the single study of perianal findings in nonabused girls, McCann et al2 documented that findings previously reported to be suggestive of sexual abuse, including erythema, smooth areas, skin tags, and anal dilation, commonly occurred in 161 female subjects up to 11 years old.
Acellular Pertussis Vaccine Booster
Authors: BLENNOW MARGARETA , GRANSTROM MARTA
Published: December 2021

The editors of Pediatrics have asked us to comment on the study by Pichichero et al,1 because our report of booster vaccination with this vaccine, published in Pediatrics in 1989,2 raised some questions with regard to the safety of the vaccine. The present study, with a design similar to ours, showed different and far more encouraging results: no serious systemic reactions; the same rate of local reactions as in our study but with no (or few) large local reactions in the group of children who received the acellular vaccine for both primary and booster vaccination; and better immunogenicity of the acellular booster in children who received the acellular vaccine only than in the children who received whole-cell vaccine for their primary series (in contrast to the opposite result in our study).
Sudden Infant Death Syndrome and Sleeping Position
Authors: KATTWINKEL JOHN , BROOKS JOHN G. , MYERBERG DAVID
Published: December 2021

In Reply.—

Dr Nichols describes a baby who was found dead in the supine position after having been placed prone. The presence of lymphocytes and milk globules in the lung suggests that this baby may have been experiencing chronic aspiration. The relationships of these findings to the baby's death and sleeping position are thought-provoking and open to several interpretations. Is Dr Nichols proposing that the chronic aspiration was occurring in the baby's usual prone position, but that death did not occur until the baby rolled supine?
Screening for Treatable Disorders
Authors: ARNOLD GEORGIANNE
Published: December 2021

To the Editor.—

I wish to commend Dr Ellen Wright Clayton on her thoughtful commentary concerning issues in state newborn screening programs. The trauma of false-positive tests on families and the availability of a state-owned "DNA bank" consisting of newborn screening blotters are both issues which require consideration. I also share her grave concerns about society or state intervention in the rights of parents who carry genetic disorders to procreate. However, I take exception to the concept that parents should be allowed to choose whether or not their children will be screened for treatable disorders.
The Lead Debate
Authors: MUSHAK PAUL
Published: December 2021

To the Editor.—

March 1993 marks the fourteenth anniversary of Prof Herbert Needleman's landmark publication on the neurobehavioral effects of low-level lead exposures in asymptomatic children.1 This study provided the major impetus to the subsequent huge number of well-done epidemiological, experimental toxicological, and mechanistic studies on lead from around the world. (More than 1500 health-relevant lead papers were indexed in Chemical Abstracts for 1991 alone.) These studies, in turn, provided the wherewithal for an informed, scientific expert consensus that childhood lead poisoning from low-level exposures is a major environmental health problem.2-7
Lactic Acid and Breast-Feeding
Authors: WALKER MARSHA
Published: December 2021

To the Editor.—

I read the article, "Infant Acceptance of Postexercise Breast Milk" (Pediatrics 1992;89:1245-1247). Although it may be noteworthy that postexercise breast milk contains higher levels of lactic acid which change its taste, does this observation necessitate the recommendation to give a breast-fed baby supplemental feedings after the mother exercises? If the mother feeds the baby before exercising and the baby requires another feeding after the exercise, it is highly unlikely that he will suffer from caloric deprivation or malnutrition if he does not take a full feeding at that time.
Pediatric Poisoning Hazards
Authors: WOOLF ALAN , LIEBELT ERICA , LOVEJOY FREDERICK H.
Published: December 2021

To the Editor.—

Drs Litovitz and Manoguerra, through their research recently reported in Pediatrics,1 have performed an important service for those of us interested in the prevention of early childhood poisoning. By analyzing calls according to their frequency and the risk of a fatal or near-fatal outcome after an acute poisoning, employing a "hazard score," the authors catalog and compare various potentially toxic agents ranking them for preventability. However the authors have neglected to discuss some limitations of their research which have an important bearing on its interpretation and the applicability of their results and conclusions to public policies concerned with poisoning prevention.
Pediatric Poisoning Hazards
Authors: LITOVITZ TOBY , MANOGUERRA ANTHONY
Published: December 2021

In Reply.—

Drs Woolf, Liebelt, and Lovejoy offer an interesting commentary on this study, and we certainly concur with a number of their points. We regret any impression that these data are infallible, an impression which might have been conveyed by our failure to discuss the validity of the American Association of Poison Control Centers (AAPCC) pediatric dataset. This is an area which remains to be studied.

However, we assert that their statements regarding the limited accuracy of the death data in the AAPCC dataset have not been substantiated and are based erroneously on published comparisons which are limited to fatal adult poisonings.1,2
Stewart Smiled
Authors: BAXTER JIM K.
Published: December 2021

To the Editor.—

Stewart smiled during the spinal tap that lasted only moments. Kneeling down close, I whispered that I was proud of him, and a great little smile lit the room. It had not been that long since this procedure had my 4-year-old son surrounded by the strong arms of nurses in the great lock and shout down, straight from the eighteenth century.

Somewhere in the weeks that followed our diagnosis of acute lymphocytic leukemia, somewhere lost in that downpour of emotions and medical forms, my wife and I agreed to enroll Stewart in a study that would compare two different sedation drugs and their effects during lumbar punctures and bone marrow tests.
Ethnocultural Variations in the Prevalence and Impact of Childhood Chronic Conditions
Authors: Newacheck Paul W. , Stoddard Jeffrey J. , McManus Margaret
Published: December 2021

Chronic physical and mental illnesses are an important contributor to childhood morbidity. National survey data indicate that childhood chronic illnesses result in more than 35 million bed days and 40 million school absence days annually.1 There is also evidence to suggest that the burden of chronic illness is growing for children.2-4 Specifically, advances in diagnosis and treatment have dramatically changed mortality rates for children with chronic conditions, with the result that many children with life-threatening chronic conditions now survive into adulthood.5,6 In addition, a new class of childhood conditions, often referred to as the "new morbidities," has emerged in recent years.4,7

Despite concern about the welfare of this population, relatively little is known about the prevalence of childhood chronic conditions or their impact, especially for minority youth. Past studies have often categorized minority populations into the general and nonspecific category of "nonwhite." Alternatively some studies have reported results only for white and black children; hence published information is particularly sparse on chronic illness among Hispanic, Asian, and Native American children.

Previous studies that have examined racial and ethnic variations in the prevalence of childhood chronic conditions can be divided into those that are based on household interviews, those based on medical records, and those based on birth-defects-monitoring systems. The results for some of the larger studies are summarized in Table 1. Excluded from this table are disease-specific studies.

Only a few household interview studies have reported results concerning racial and ethnic differences in prevalence of chronic conditions. One of the earliest household interview studies to explore racial differences derived data from a survey of parents in Alamance County, North Carolina.8
Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media
Authors: Duncan Burris , Ey John , Holberg Catharine J. , Wright Anne L. , Martinez Fernando D. , Taussig Lynn M.
Published: December 2021

Objective. This study was designed to assess the relation of exclusive breast-feeding, independent of recognized risk factors, to acute and recurrent otitis media in the first 12 months of life.

Methods. Records of 1220 infants who used a health maintenance organization and who were followed during their first year of life as part of the Tucson Children's Respiratory Study were reviewed. Detailed prospective information about the duration and exclusiveness of breast-feeding was obtained, as was information relative to potential risk factors (socioeconomic status, gender, number of siblings, use of day care, maternal smoking, and family history of allergy). Acute otitis media and recurrent otitis media, defined as three or more episodes of acute otitis media in a 6-month period or four episodes in 12 months, were the outcome variables.

Results. Of the 1013 infants followed for their entire first year, 476 (47%) had at least one episode of otitis and 169 (17%) had recurrent otitis media. Infants exclusively breast-fed for 4 or more months had half the mean number of acute otitis media episodes as did those not breast-fed at all and 40% less than those infants whose diets were supplemented with other foods prior to 4 months. The recurrent otitis media rate in infants exclusively breast-fed for 6 months or more was 10% and was 20.5% in those infants who breast-fed for less than 4 months. This protection was independent of the risk factors considered.

Conclusion. These findings suggest that exclusive breast-feeding of 4 or more months protected infants from single and recurrent episodes of otitis media.
Tracking of Serum Cholesterol and Lipoprotein Levels From the First Year of Life
Authors: Kallio Markku J. T. , Salmenperä Leena , Siimes Martti A. , Perheentupa Jaakko , Miettinen Tatu A.
Published: December 2021

Objective. To examine the development of tracking of serum cholesterol concentration from birth to childhood.

Design. In a longitudinal study of healthy children, concentrations of total serum cholesterol and triglyceride were determined at birth (n = 193); at 2 (n = 192), 4 (n = 192), 6 (n = 190), 7.5 (n = 118), 9 (n = 188), and 12 months (n = 196); and at 5 years of age (n = 162). Concentrations of cholesterol—very-low-density lipoprotein, low-density lipoprotein, high-density lipoprotein-2 (HDL2), and HDL3—were determined at 2, 6, 9, and 12 months (n = 36) and at 5 years (n = 162).

Results. The correlation coefficients of total cholesterol levels during the first year of life with the level at 5 years of age were as follows: at birth .04, at 2 months .36 (P < .001), at 4 months .26 (P < .001), at 6 months .28 (P < .001), at 7.5 months .25 (P < .001), at 9 months .35 (P < .001), and at 12 months .48 (P < .001). The correlation for exclusively breast-fed children between 6 months and 5 years of age was r = .37, P < .001, while that for children receiving partially breast milk, formula, or solid foods was r = .12, P = not significant (NS), and between 9 months and 5 years r = .38, P < .01, and r = .28, P < .05, respectively. The correlation coefficients of the lipoprotein levels between ages 12 months and 5 years were as follows: low-density lipoprotein cholesterol .58 (P < .001), total HDL cholesterol .30 (P < .05), HDL2 cholesterol .34 (P < .05), HDL3 cholesterol .17 (P = NS), very-low-density lipoprotein cholesterol .24 (P = NS), total triglyceride .37 (P < .05), and triglyceride-very-low-density lipoprotein .37 (P < .05). Of the children whose total serum cholesterol level was above the 90th percentile at birth, or at 2, 4, 6, 7.5, 9, or 12 months, 6%, 35%, 29%, 30%, 31%, 33%, and 45%, respectively, were above the 90th percentile at 5 years of age. In retrospect, 45% of the children whose serum cholesterol level was above the 90th percentile at 5 years were above the 90th percentile at the age of 12 months and 80% were in the highest quartile.

Conclusions. The results indicate that tracking of serum cholesterol concentration during the first year of life is stronger when examining children who are receiving a relatively homogenous diet, such as exclusive breast-feeding, and weaker as children are weaned to formula and solid foods. After the weaning process is completed, children's relative serum cholesterol levels have become established and the tracking of serum cholesterol is of the same magnitude as for older children and adolescents.
Impact of Improved Survival of Very Low Birth Weight Infants on Recent Secular Trends in the Prevalence of Cerebral Palsy
Authors: Bhushan Vidya , Paneth Nigel , Kiely John L.
Published: December 2021

Objective. To review recent secular trends in the prevalence of cerebral palsy in industrialized countries that have population-based cerebral palsy registries and to estimate such time-trends for the United States, where until recently such registries were absent.

Data sources. Recent epidemiologic studies of cerebral palsy published in peer-reviewed journals in English, and US vital data bearing on the principal demographic determinants of cerebral palsy—birth rates, the birth weight distributions, birth weight-specific mortality risk, and cerebral palsy risk among survivors.

Results. Most epidemiologic studies from industrialized countries show a rise in the childhood prevalence of cerebral palsy in recent decades, largely because of the increasing contribution of children of low and very low birth weight to its prevalence. The only demographic determinant of cerebral palsy prevalence that is changing rapidly in the United States is survival of low birth weight and very low birth weight infants. Based on the magnitude of change in the survival of low and very low birth weight infants, it is estimated that childhood prevalence of cerebral palsy rose about 20% between 1960 and 1986 in the United States.

Conclusion. An apparently unavoidable side effect of the increasing success of newborn intensive care is a moderate rise in the childhood prevalence of cerebral palsy.
Prone or Supine Body Position and Sleep Characteristics in Infants
Authors: Kahn A. , Groswasser J. , Sottiaux M. , Rebuffat E. , Franco P. , Dramaix M.
Published: December 2021

Objective. To evaluate the potential relation between body position and sleep characteristics in normal infants.

Patients. Two groups of 3-month-old healthy infants were evaluated: 40 infants who usually slept supine, and 40 who usually slept prone. The two groups were matched for gender, gestational age, postnatal age, birth weight, and total recording time.

Recording techniques. The 80 infants were studied polygraphically during one night in the pediatric sleep laboratory. They were allowed to fall asleep in their usual sleep position, and every 3 hours were gently turned from prone to supine, or from supine to prone.

Results. In each group, 6 infants were excluded from the analysis, because they woke up after having been turned over. In both groups, no significant difference was seen between the prone and the supine body positions for the following variables: number of sleep state changes; number of gross body movements; percent of rapid eye movement sleep; saturation with oxygen, arterial blood levels; number and duration of acid esophageal reflux; rectal temperature; mean respiratory rates; water evaporation rates from the forehead skin; and number or duration of central or of obstructive apneas. In both groups of infants, prone body position was associated with a significant increase in sleep duration (+ 6%) and in non-rapid eye movement sleep (+25%) and a significant decrease in number of arousals (–40%) and in their duration (–43%).

Conclusions. No explanation has been found for the sleep-promoting effect of prone body positioning. The finding could be of interest to the study of infants' sleep quality, as well as to the potential relation between body positions and sudden death during sleep.
Estimation of Central Osteopenia in Children With Chronic Polyarthritis Treated With Glucocorticoids
Authors: Kotaniemi Antero , Savolainen Anneli , Kautiainen Hannu , Kröger Heikki
Published: December 2021

Study objective. To investigate the degree and determinants of osteopenia in juvenile chronic polyarthritis.

Design. Retrospective case-control study of central bone mineral density.

Setting. Rheumatism Foundation Hospital and Kuopio University Hospital, Finland.

Subjects. A sample of 43 girls aged 7 to 19 with juvenile chronic polyarthritis treated with systemic glucocorticoids and a control sample of 44 healthy girls matched for age.

Main outcome measures. Bone mineral density and bone size (width) measured by dual-energy x-ray absorptiometry and bone volumetric density calculated as an approximation of true bone density at both the lumbar spine and femoral neck.

Results. The girls with juvenile chronic arthritis had reduced bone mineral density, bone size, and bone volumetric density at both the lumbar spine and femoral neck (statistically significant findings, P = .022 for the bone size of the femoral neck and P < .001 for the other parameters). At the spine, the mean bone mineral density was 80%, the mean bone size 89%, and the mean bone volumetric density 89% of the values in the control group. At the femoral neck, the values were 78%, 93%, and 83%, respectively. The groups were matched for age, but the girls with arthritis were smaller and lighter. In the juvenile arthritis group, the femoral bone mineral density and bone volumetric density and the spinal bone width correlated negatively with the mean glucocorticoid dose.

Conclusion. Axial bone mineral density is clearly reduced in severe juvenile polyarthritis and is mediated by both decreased bone volumetric density and diminished growth.
Coagulopathy Screening in Children With Heparinized Central Venous Catheters
Authors: Ellis Robert
Published: December 2021

Objective. To develop a method of screening for coagulopathy using blood drawn through heparinized central venous catheters.

Methods. Prothrombin time (PT) and activated partial thromboplastin time (APTT) were determined in paired blood samples with and without the addition of protamine, using an automated photo-optical method. A concentration of 4 µg/mL of citrated whole blood was chosen, based on preliminary experiments. This is sufficient to neutralize the expected heparin contamination in samples drawn through heparinized catheters while causing only a slight prolongation in APTT (due to the anticoagulant effect of protamine). Seventeen paired samples were drawn by venipuncture in patients without known coagulopathy. Twenty-five samples were drawn through heparinized central venous catheters. The first 5 mL of blood drawn from a catheter was discarded to avoid gross heparin contamination. Four samples from patients with coagulopathy were also analyzed with and without the addition of 2.5 µg/mL of heparin.

Results. Protamine increased PT by 9.0 ± 0.8% and APTT by 9.0 ± 3.4% (mean ± SD) in the samples drawn by venipuncture. For samples drawn through heparinized catheters, 52% had a prolonged APTT 44% a prolonged PT, and 68% had at least one prolonged test. With the addition of protamine, and after correction for the 9% mean increase in PT and APTT, 4% of samples had a prolonged APTT, 12% had a prolonged PT, and 16% had at least one prolonged test (P = .00006, .014, and .0001). All four samples from patients with coagulopathy were correctly identified as abnormal after the addition of protamine, with or without added heparin.

Conclusions. A protamine-supplemented APTT test on blood drawn through a heparinized catheter may be an adequate screening test for coagulopathy. This procedure reduces discomfort in patients with an indwelling catheter by avoiding venipuncture.