bluuebunny/crossref_metadata_2025 huggingface dataset:
Cognition, Communication, and Hearing in Young Children With Cleft Lip and Palate and in Control Children: A Longitudinal Study
Authors: Jocelyn Leslie J. , Penko Maureen A. , Rode Helga L.
Published: December 2021

Objective. To compare a group of children with cleft lip and palate (CLP) with a group of noncleft, matched control children on measures of congnitive development, speech and language abilities, and audiologic status at 12 and 24 months of age.

Design. Using a prospective, longitudinal study design, a group of 16 children with CLP and a group of 16 noncleft control children matched for race, sex, birth order, and socioeconomic status were compared using the Bayley Scales of Infant Development, the Receptive-Expressive Emergent Language Scale, the Sequenced Inventory of Communication Development—Revised (SICD-R), the Preschool Language Scale—Revised (PLSR), the mean length of utterance, audiometric evaluation, and impedance screening at 12 and 24 months of age. All were free of other congenital abnormalities or known causes of neurodevelopmental dysfunction.

Results. Children with CLP had lower mental developmental index (MDI) and psychomotor developmental index scores than control children. They had lower language comprehension scores on the SICD-R and PLS-R and lower expressive language scores on the Receptive-Expressive Emergent Language Scale, SICD-R, and PLS-R than control children. The group with CLP had a significantly higher number of children with abnormal tympanogram results or ventilation tubes at 12 and 24 months. There was a positive correlation between language test scores at 24 months and MDI scores at 24 months (r = .73 to .85). Seventy-five percent of children with CLP who had hearing loss at 12 months had MDI scores more than 1 SD below the mean versus 0% of children with normal hearing. There was a relationship between hearing status at 12 months and comprehension and expressive language scores at 24 months.

Conclusions. Children with CLP had significantly lower scores on tests of cognition, comprehension, and expressive language abilities than matched control children at 12 and 24 months of age. They also had a higher frequency of middle-ear disease and ventilation tubes than control children, although no significant difference in hearing sensitivity was found between groups. Early identification and treatment of these delays may reduce subsequent verbal deficits, hearing loss, and academic difficulties.
Antenatal Phenobarbital Therapy and Neonatal Outcome I: Effect on Intracranial Hemorrhage
Authors: Shankaran Seetha , Cepeda Eugene , Muran Geraldine , Mariona Federico , Johnson Samuel , Kazzi S. Nadya , Poland Ronald , Bedard Mary P.
Published: December 2021

Objective. To evaluate the effect of antenatal phenobarbital (PB) therapy on neonatal intracranial hemorrhage (ICH) in preterm infants.

Design. Prospective, randomized, controlled trial.

Setting. Single institution study.

Subjects and Interventions. Women in preterm labor (<35 weeks' gestation) were assigned to control and treatment groups. The treatment group received 10 mg/kg (maximum, 1000 mg) PB intravenously, followed by 100 mg orally daily, until delivery. Neonates did not receive PB after birth. Head sonograms were performed on days 3, 7, and 14 and at discharge. Hemorrhage was classified as mild, moderate, or severe by a single reader.

Outcome Measures. Incidence of neonatal ICH in all infants, infants weighing less than 1250 g, and infants of multiple gestations.

Results. The study population comprised 110 women, 60 in the control group and 50 in the PB group. Neonates in the control group (n = 74, including 10 pairs of twins and 2 sets of triplets) were comparable to those in the treatment group (n = 62, including 7 pairs of twins, 1 set of triplets, and 1 set of quadruplets) regarding birth weight, gestational age, and other clinical risk factors for ICH. There was a trend for the incidence of any grade of hemorrhage to be lower in the PB group (22% [14 of 62]) compared with the control group (35% [26 of 74]). Moderate and severe hemorrhages were significantly lower in the PB group (1.6% [1 of 62]) compared with the control group (9.4% [7 of 74]). Among infants weighing less than 1250 g, overall ICH was lower in the PB group (23% [6 of 261) compared with the control group (51% [18 of 35]). Among multiple-gestation infants, overall ICH was 4.7% (1 of 21) in the PB group, compared with 31% (8 of 26) in the control group.

Conclusions. Antenatal PB therapy results in a significant decrease in moderate and severe ICH in infants born at less than 35 weeks' gestation. Antenatal PB therapy also resulted in a decrease in the incidence of all grades of ICH in infants weighing less than 1250 g and infants born of multiple gestations.
Percutaneous Endoscopic Gastrostomy in Children: Influence on Gastroesophageal Reflux
Authors: Launay V. , Gottrand F. , Turck D. , Michaud L. , Ategbo S. , Farriaux J. P.
Published: December 2021

Objective. Few data exist in the literature about the relationship between percutaneous endoscopic gastrostomy (PEG) and gastroesophageal reflux (GER) in children, and the data that do exist are contradictory. The aim of the present study was to evaluate the effect of PEG on GER.

Methods. Twenty children underwent PEG for enteral nutrition. They were 55 ± 55 months old and weighed 13 ± 10 kg. A pH study was performed before and after PEG without treatment when GER status was unknown (n = 10) or under treatment (n = 10) if previous GER was demonstrated. In these cases, the pH study was performed under the same treatment before and after PEG.

Results. Six pH studies had abnormal results before PEG. After PEG, the GER of these 6 children significantly improved after the treatment was intensified (n = 5) or spontaneously normalized (n = 1). Results of 13 pH studies that were previously normal remained normal. Only one child with a normal reflux index before PEG had GER after it. For the 20 children, the mean reflux index did not change significantly after PEG (5.5% vs 5.6%).

Conclusion. Contrary to surgical gastrostomy, PEG does not worsen GER. Therefore, GER is not a contraindication to PEG.
The New Edition of the Guide to Clinical Preventive Services
Authors: Wilson Modena , Berwick Donald M. , DiGuiseppi Carolyn
Published: December 2021

Preventive services compose a large portion of primary care pediatrics, and pediatricians by their nature and training seem extraordinarily disposed toward clinical prevention. Therefore, when the first edition of the Guide to Clinical Preventive Services appeared in 1989 from the US Preventive Services Task Force (USPSTF), the negative reaction of the organized pediatric community was disappointing.

The second edition of that guide has just been released, and we three pediatricians, who have worked hard during the past 5 years as members and staff of the second task force, hope for a far more positive reaction from our colleagues this time around.
Pool Cue Chalk: A Source of Environmental Lead
Authors: Miller Mary Beth , Curry Steven C. , Kunkel Donald B. , Arreola Patricia , Arvizu Ernest , Schaller Kristina , Salmen Dennis
Published: December 2021

Lead compounds are used as coloring agents for numerous products. Two cases of children with elevated blood lead concentrations encountered by the authors suggested that pool cue chalk may serve as a source of environmental lead. The objective of this study was to determine lead content of various brands and colors of pool cue chalk. Atomic absorption analyses were conducted of 23 different types of pool cue chalk for lead content. Three of 23 types of pool cue chalk contained more than 7000 ppm (mg/kg) lead: one manufacturer's green and tangerine chalk and another manufacturer's green chalk. It was concluded that some brands of pool cue chalk contain relatively large amounts of lead and could contribute to childhood lead poisoning.
Hypoglycemia and Cortisol Deficiency Associated With Low-dose Corticosteroid Therapy for Asthma
Authors: Carrel Aaron L. , Somers Stephanie , Lemanske Robert F. , Allen David B.
Published: December 2021

Glucocorticoids are a cornerstone of the anti-inflammatory treatment of asthma. To minimize adverse effects of oral glucocorticoids (OGC), clinicians have used alternate-day oral or inhaled corticosteroids (IC), both generally considered safe for chronic asthma therapy in children. Although reversible growth suppression occasionally occurs, the general consensus is that, despite detectable biochemical alterations, these modes of therapy are not associated with clinically significant adrenal insufficiency.1 We report the occurrence of hypoglycemia due to cortisol deficiency during combination alternate-day oral and inhaled corticosteroids.

CASE HISTORY

A 3½-year-old boy with asthma was found one morning to be unarousable, limp, and blue around the lips.
A Review of the Rationale and Advantages of Various Mixtures of Benzathine Penicillin G
Authors: Bass James W.
Published: December 2021

Intramuscular benzathine (BZ) penicillin G has been accepted as the gold standard for treatment of patients with streptococcal pharyngitis since it was first introduced in 1952. Unfortunately, it has been associated with pain and tenderness at the site of injection. Efforts to lessen this by combining it with varied quantities of procaine (PC) penicillin G have been successful, decreasing the incidence of significant local reactions to 5% to 10%, little more than that seen with PC penicillin alone. A preparation containing 600 000 U BZ penicillin G and 600 000 U PC penicillin in 2 mL has been marketed since the mid-1950s as CR Bicillin 600/600 but the content of BZ penicillin G has been considered adequate only for children who weigh <60 pounds. This prompted the evaluation of a preparation containing 900 000 U BZ penicillin G plus 300 000 U PC penicillin G in a 2-mL injection. Of 400 children with streptococcal pharyngitis 100 each received this preparation, 600 000 U BZ penicillin G alone in 1 mL, 1.2 million U BZ penicillin G alone in 2 mL or 600 000 U BZ penicillin G plus 600 000 U PC penicillin G in 2 mL Clinical response was equal in all four groups; all patients were well in 36 to 48 hours. The two preparations containing PC penicillin G had significantly less severe local reactions and throat cultures were negative in all by 48 hours; it remained positive in some patients who received BZ penicillin G alone after 72 hours. The cure rate in patients receiving the 900 000/300 000 combination of BZ and PC penicillin G was equal to that in patients who received 1.2 million U BZ penicillin G with these added advantages. This combination offers optimal parenteral treatment for streptococcal pharyngitis in all children who weigh <140 pounds and it has been marketed for this purpose since 1976.
Letter To The Editor
Authors: Doctor Allan , Harper Marvin B. , Fleisher Gary R.
Published: December 2021

We agree with Dr Goldsmith's caution in projecting trends from any case series. We would also like to take this opportunity to present the incidence of group A β-hemolytic streptococcus (GABHS) complications in children with varicella-zoster virus (VZV) at our institution since the data collection period of our prior study.1 In 1994, there were four children with GABHS bacteremia, none with VZV; in addition, four children were hospitalized with GABHS complications (cultures of sterile sites other than blood) during VZV infection (two with osteomyelitis, two with deep abscesses).
PREDICTORS OF ATOPY IN NEWBORN BABIES
Authors: Sicherer Scott H. , Wood Robert A.
Published: December 2021

No single parameter or combination of parameters seemed suitable for general screening. However, a combination of family history, assessment of skin dryness, and cord blood IgE could be used to identify newborns at high risk of allergy for participation in prevention studies.
ASTHMA AND WHEEZING IN THE FIRST SIX YEARS OF LIFE
Authors: Wood Robert A.
Published: December 2021

The majority of infants with wheezing have transient conditions associated with diminished airway function at birth and do not have increased risks of asthma or allergies later in life. In a substantial minority of infants, however, wheezing episodes are a precursor of future asthma.
HIV-1 MESSENGER RNA IN PERIPHERAL BLOOD MONONUCLEAR CELLS AS AN EARLY MARKER OF RISK FOR PROGRESSION TO AIDS
Authors: Szefler Stanley J.
Published: December 2021

The expression of HIV-1 mRNA in peripheral blood mononuclear cells is a strong independent marker for future HIV disease progression, even in persons with normal T cell subsets.
ONSET OF CLINICAL SIGNS IN CHILDREN WITH HIV-1 PERINATAL INFECTIONS
Authors: Sánchez Miguel A. , Hanson I. Celine
Published: December 2021

In this natural history study of perinatal HIV infection, the probability of remaining asymptomatic at 1 year was low (< 20%). Most children manifested clinical symptoms by 6 months; infants with severely depressed CD4 counts had even earlier onset of symptoms. No correlation was noted for maternal HIV risk, maternal clinical status at birth, infant sex, birth weight, gestational age or delivery mode, and timing of onset of any clinical sign. A distinction between rapid/slow progressors by CD4 count and onset of clinical symptoms is proposed; however, only scant data are provided for the slowest progressors (children > 5 years). Further clarification of such a distinction will likely impact future therapeutic intervention.
APOPTOTIC NEURONS IN BRAINS FROM PEDIATRIC PATIENTS WITH HIV-1 ENCEPHALITIS AND PROGRESSIVE ENCEPHALOPATHY
Authors: Church Joseph A.
Published: December 2021

These findings suggest that neuronal apoptosis is a potential mechanism for the loss of neurons in HIV-associated brain disease.
HUMAN IMMUNODEFICIENCY VIRUS TYPE 1 REPLICATION CAN BE INCREASED IN PERIPHERAL BLOOD OF SEROPOSITIVE PATIENTS AFTER INFLUENZA VACCINATION
Authors: Church Joseph A.
Published: December 2021

Purpose of the Study. Immune activation in vitro and in vivo appear to upregulate human immunodeficiency virus (HIV) replication. The purpose of this study was to determine the effect of influenza vaccination on HIV replication in clinically stable adults with HIV.

Study Population. Thirty-four HIV-seropositive adult patients with intermediate stage disease were entered into the study. Twenty patients received influenza vaccination and 14 did not.

Methods. Blood was collected on three occasions during the month before influenza vaccination, during the first week, the second week, and 4 to 6 weeks after vaccination. Samples from each patient were batched and quantitative polymerase chain reaction (PCR) analysis was used to measure HIV DNA and RNA in peripheral blood mononuclear cells.

Results. Influenza vaccination did not increase HIV DNA in the peripheral blood of these patients. However, vaccination was associated with a greater than fourfold increase in HIV RNA in 50% of vaccinated patients. Peak increases in HIV RNA occurred one to two weeks postvaccination and returned to baseline at later points. At more than 3 years mean follow-up, the pattern of virologic response to influenza vaccination (increased HIV RNA vs no increase) did not predict clinical outcome.

Reviewer's Comments. The transient increase in HIV replication after influenza vaccination in adults has also been seen on other adult studies with pneumococcal vaccination. Although in these studies increased viremia was transient, the situation for perinatally-infected children receiving repeated multiple vaccinations over the first 2 years of life is yet to be determined.
Parents' Attitudes Toward School-based Hepatitis B Vaccination of Their Children
Authors: Woodruff Bradley A. , Unti Lisa , Coyle Karin , Boyer-Chuanroong Lynda
Published: December 2021

Objective. As part of a larger hepatitis B vaccination program in San Francisco, hepatitis B vaccine is offered to seventh-grade students in selected middle schools. We investigated attitudes and beliefs about hepatitis B, hepatitis B vaccine, and school-based vaccination among parents of eligible students.

Methods. A survey was conducted of random samples of parents who consented, refused, or did not respond to a request for vaccination consent.

Results. A larger proportion of persons who signed a vaccination consent or refusal form were biological parents and were Asian or white than parents who did not return a signed form. The most common reason for refusing vaccination, given by 84% of refusing parents, was that their children had already been vaccinated against hepatitis B. These parents recognized the severity and duration of hepatitis B virus infection as much as parents consenting to vaccination. About one third of parents who refused vaccination did not agree that schools were good places to vaccinate children. Overall, 116 parents (40%) consulted someone before deciding to consent or refuse; 95 (33%) spoke with a health professional. Most parents not returning signed consent or refusal forms reported that they never received forms from their children or that they returned signed forms to their children, who never delivered them to school.

Conclusions. Most parents accepted school-based vaccination, and obtaining parental consent for schoolbased vaccination was possible. Nonetheless, new approaches may be needed for those students and parents who do not comply with the consent process.
Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A Working Group Report from the National High Blood Pressure Education Program
Authors:   National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents
Published: December 2021

Background. The "Report of the Second Task Force on Blood Pressure Control in Children—1987" developed normative blood pressure (BP) data for children and adolescents. These normative data are used to classify BP levels. Since 1987, additional BP data in children and adolescents, the use of newer classes of drugs, and the role of primary prevention of hypertension have expanded the body of knowledge regarding the classification and treatment of hypertension in the young.

Objective. To report new normative BP data in children and adolescents and to provide additional information regarding the diagnosis, treatment, and prevention of hypertension in children.

Methods. A working group was appointed by the director of the National Heart, Lung, and Blood Institute as chair of the National High Blood Pressure Education Program (NHBPEP) Coordinating Committee. Data on children from the 1988 through 1991 National Health and Nutrition Examination Survey III and nine additional national data sets were combined to develop normative BP tables. The working group members produced initial draft documents that were reviewed by NHBPEP Coordinating Committee representatives as well as experts in pediatrics, cardiology, and hypertension. This reiterative process occurred for 12 draft documents. The NHBPEP Coordinating Committee discussed the report, and additional comments were received. Differences of opinion were adjudicated by the chair of the working group. The final report was sent to representatives of the 44 organizations on the NHBPEP Coordinating Committee for vote. It was approved unanimously by the NHBPEP Coordinating Committee on October 2, 1995.

Conclusions. This report provides new normative BP tables for children and adolescents, which now include height percentiles, age, and gender. The fifth Korotkoff sound is now used to define diastolic BP in children and adolescents. New charts have been developed to guide practicing clinicians in antihypertensive drug therapy selection. The primary prevention of hypertension in these age groups is discussed. A statement on public health considerations in the treatment of children and adolescents is provided.
Research and Public Policy
Authors: Eron Leonard D.
Published: December 2021

Professor Hyman has reviewed for us all the research that has been done on the effects of corporal punishment in the schools.1 It is actually a meager record because of the reasons he has mentioned, many of them ethical, demographic, and religious. Whatever research has been published on the effects of corporal punishment, however, would indicate that although the practice is widespread in the United States, corporal punishment is not an effective means of discipline and has many harmful effects on the recipient of the punishment, both physical and psychological. Certainly there are enough data, which Dr Hyman has assembled over 20 years, to warrant the measures he advocates to get the message out to the public as well as to concerned professionals, and to formulate public policy aimed at eliminating corporal punishment in our schools as well as all other settings, including the home.

And to those cynics who are skeptical about what influence psychological research findings can have on public policy, my own personal experience over 40 years with research on the effects of viewing television violence on aggressive behavior of children indicates that psychological and sociological research findings can have a profound influence. But changing behavior takes persistence and time. There are too many vested interests who favor the status quo and are threatened by change. There are also many professionals who very often have not done any research in the area, but consider themselves authorities, as well as lay persons who are convinced that the old way of doing things is the only right way.
Letter To The Editor
Authors: Stein Martin T.
Published: December 2021

The concept for a prenatal visit, when a primary care pediatriclan meets with a family before delivery, was developed many years before the development of neonatology as a subspecialty. Guidelines for this visit, developed by the AAP Committee on Psychosocial Aspects of Child and Family Health reflects this historical legacy and emphasizes multiple levels of anticipatory guidance. Dr. Grylack correctly points out that prenatal counseling has distinct advantages for parents who are preparing to deliver a premature infant or a full-term infant with a known congenital anomaly that may require intensive care after birth.
Our Society Is Not More Violent
Authors: BERGMAN ABRAHAM B.
Published: December 2021

The proposition that our society as a whole has become increasingly violent is now firmly imbedded into the psyche of the American public. As counterpoint to the unremitting tales of crimes in our newspapers and telecasts, waves of "experts" are brought forth to lament how each particular act of mayhem typifies the violent culture in which we live. Multidisciplinary conferences on violence are a growth industry.

There is much wrong with this depiction of the violence "epidemic" (medical metaphors are popular these days), not the least of which is that it is inaccurate. If the term means hurtful actions and behaviors between human beings, I contend that there is considerably less overall violence in the 1990s than occurred 100, 50, or even 25 years ago.
The Perspective of the Community Pediatrician
Authors: Young Lynda M.
Published: December 2021

As the focus of health care moves to the outpatient setting, residency programs are seeking alternative training sites for teaching ambulatory primary care. The community pediatrician's office is an excellent location for residents to learn from preceptors who have been trained to teach them. Residents experience a variety of office and practice management issues not otherwise taught in the traditional hospital-based clinics. Pediatrician preceptors, because of commitment to the communities in which they live and practice, are role models for residents. Academic centers have the resources and expertise to train preceptors to become better teachers. The benefits to both preceptors and academic centers, the problems encountered, and suggestions for creating an exciting and innovative teaching program are discussed.
NO EVIDENCE, OR NOT ENOUGH EVIDENCE?
Authors: Student
Published: December 2021

When we are told that "there's no evidence that A causes B," we should first ask whether absence of evidence means simply that there is no information at all. If there are data, we should look for quantification of the association rather than just a P value. Where risks are small, P values may well mislead: confidence intervals are likely to be wide, indicating considerable uncertainty.
Breast-Feeding
Authors: Lawrence Ruth A.
Published: December 2021

The pediatrician plays a crucial role in the success of breast-feeding by providing well-researched, practical advice and support to the lactating woman, beginning in the prenatal period and continuing until total weaning. The pediatrician can provide much needed support and affirmation when the mother is sabotaged by well-meaning friends and relatives who are misinformed about the value or techniques of breast-feeding. Mothers state that their pediatrician is the most important member of the support team but also the one most apt to obstruct success with inappropriate advice. An understanding of lactation as a physiologic process will provide a sound basis for anticipatory guidance.
Recurrent Infections
Authors: Hong Richard
Published: December 2021

Recurrent infections constitute a major challenge to primary care physicians. Primary immunodeficiency or other alterations of the host defense system are extremely rare. In the case of recurrent respiratory infections, particularly of the lungs, a diagnosis will result much more often from ordering a sweat chloride test than a serum immunoglobulin level.

RECURRENT RESPIRATORY INFECTIONS

The major reason for referral to our clinic for investigation of the immune system is a complaint of too many upper respiratory tract infections. Each respiratory infection in a young child means loss of sleep for child and parents, expenditure of time at the physician's office, and possible loss of income in addition to the expense of medication and office visits. The child is often irritable and his or her misery clouds the home atmosphere. With repeated episodes of this sort each year, it is small wonder that parents want relief.

The average number of upper respiratory tract infections experienced by healthy children is approximately 9 to 10 per year. At least 100 viruses can cause the common cold. Accordingly, even when a child has a normal immune system establishing immunity to each virus or virus subtype, it can take many years for a broad enough immunity to develop to diminish the frequency of infection due to newly encountered respiratory viruses.
INDEX OF SUSPICION
Authors: Tejeda David M. , Kaplan Jessica , Andrews John S. , DeAngelis Catherine , Sehgal Neeru
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

The parents of a 22-month-old boy complain that he has been increasingly clumsy and cranky for the past 7 days. He initially developed a stumbling gait and now prefers to crawl; he no longer can sit on his own. The child has been afebrile but has had a cough for several weeks. He has been on antibiotics for otitis media (with a presumed labyrinthitis) for 5 days. There have been no other recent illnesses, and he has not been ill in the past.

On examination, the child appears irritable and has occasional jerking movements of his extremities. His temperature is 36.3°C, pulse is 128 beats/min, and blood pressure is 84/40 mm Hg. Chaotic, irregular eye movements are present.
Pulmonary Function Testing in Pediatric Practice
Authors: Mueller Gary A. , Eigen Howard
Published: December 2021

Pulmonary function testing is an important tool in the evaluation of children who have or are suspected of having lung disease. Of particular importance, pulmonary function testing provides objective and reproducible measurements, which then can be used to follow the response to therapy. The measurements of air flow and lung volumes are the mechanical pulmonary function tests used most commonly. However, measurements of the efficiency of gas exchange also are considered a test of pulmonary function and can be assessed by such methods as arterial blood gas and oximetry. This article focuses on those tests readily available to the pediatrician in the office or hospital.

Measuring pulmonary function regularly is analogous to measuring blood pressure in patients who have hypertension, allowing the physician to follow a measurement directly associated with the pulmonary disease process. As with other clinical tests, pulmonary function measurements are most effective when used to answer a specific question about the patient. For example, in a child who presents having a persistent cough and a family history of asthma, the diagnosis may be asthma, and the question "Does the child have airflow obstruction consistent with asthma?" can be answered by spirometry.

Spirometry

The parameters commonly measured in the assessment of respiratory function are lung volumes, air flows and timed volumes, and airway reactivity.
Tonsillopharyngitis 1994
Authors: Denny Floyd W.
Published: December 2021

Acute infections of the upper respiratory tract, including those of the tonsils and pharynx, are the most common affliction of humans; their tendency to occur with much greater frequency in children makes them especially important to the pediatrician. A host of microbial agents can cause these infections, but only a few are responsive to antimicrobial agents. Because of the paucity of definitive laboratory tools that allow easy recognition of the cause of most acute respiratory infections, it is important for the practicing pediatrician to have other methods to aid in the clinical management of children who have these infections. This review will discuss the etiology and epidemiology of acute respiratory infections that involve primarily the tonsils and pharynx, with emphasis on how this knowledge can guide clinicians in their management. The groundwork for this approach will be laid by suggesting a classification of upper respiratory tract infections that involve the tonsils and pharynx. Causative agents will be enumerated and put into perspective. The major factors associated with the occurrence of acute upper respiratory tract infections will be discussed. Finally, treatment of the patient who has tonsillopharyngitis will be presented.

Uncomplicated acute tonsillopharyngitis will be emphasized primarily and the role of complications only mentioned.
INDEX OF SUSPICION
Authors: Cron Randy , Ho Laurette , Bradford Bradley
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A previously healthy 6-month-old girl is seen at the office for evaluation of fussiness and infrequent urination. The child has not voided in the past 9 hours despite her usual fluid intake. She is afebrile, with no focus of infection found on careful physical examination. A palpable mass is felt in the suprapubic area. Her external genitalia are normal.

Renal and pelvic ultrasonography reveal an echo-free area superior to a normal lower renal ureteral segment on the left side, with a circular echo free area at the lower end of the ureter extending into and taking up about one quarter of the space within a distended bladder.

Case 2 Presentation

A 4-year-old boy is seen in your office with a 4-day history of sore throat and low-grade fever.
Trace Elements in Nutrition
Authors: Shah Heena A.
Published: December 2021

Trace elements other than iron only recently have gained importance in infant nutrition. Zinc and copper are two of the most essential trace elements. Zinc is a constituent of more than 100 metalloenzymes and plays an important role in growth, reproduction, tissue repair, and cellular immunity. Copper is a component of several metalloenzymes and is required for oxidative metabolism.

Nutritional deficiencies of zinc now are recognized as being fairly prevalent throughout the world. Symptomatic zinc deficiency among infants can be attributed to several factors. It can be secondary to low zinc concentration in breast milk, low stores (as in prematurity), malabsorption (as in acrodermatitis enteropathica), or absence or inadequate amount in parenteral nutrition.
Leukocyte Disorders: Quantitative and Qualitative Disorders of the Neutrophil, Part 1
Authors: Boxer Laurence A. , Blackwood R. Alexander
Published: December 2021

Introduction

Neutrophils form the first line of defense against most bacterial and fungal pathogens after disruption of the skin and mucous membranes. Once tissue is invaded by microorganisms, a variety of vasoactive and chemotactic mediators are released by the involved tissue. In response to these chemotactic peptides, neutrophils, normally found in the circulation, adhere to the inflamed endothelium and migrate to the site of infection where the phagocytes ingest and kill the invading microorganisms. Neutrophils also release a variety of cytokines that may modify the neutrophils' own responses as well as interact with other elements of the immune system. Neutrophils, therefore, are both important effectors and regulators of the host defense system. Because of the complexity of this defense system and the major role played by neutrophils, both primary and acquired defects in neutrophil number or function result in persistent as well as recurrent infections.

Primary defects in neutrophil number or function are relatively rare, but they must be considered in a child who presents with recurrent infections. Early identification and management of affected children lead to decreased morbidity and mortality. Although care predominantly has been supportive in the past through the use of prophylactic and therapeutic antibiotics, specific therapies now are becoming available to reduce the frequency of infections in some diseases.
Diaphragmatic Hernia
Authors: Cairns Anne Marie , Ewig Jeffrey M.
Published: December 2021

Congenital diaphragmatic hernia (CDH), with an incidence of approximately 1 in 3000 births, occurs secondary to defective fusion of the pleuroperitoneal membranes during embryonic development. The most common form is the posterolateral hernia through the foramen of Bochdalek, with a left-to-right ratio of approximately 8:1.

The space-occupying effect of the bowel during pulmonary development results in hypoplasia of the ipsilateral lung. This process also may cause hypoplasia to a lesser degree of the contralateral lung, secondary to severe mediastinal shift. Bohn and co-workers assessed alveolar number by postmortem morphometric analysis of five infants who died after surgical repair for CDH. A severe reduction in alveolar number was noted in both the ipsilateral and contralateral lung, although the changes in the ipsilateral lung were more pronounced.
Hyperkalemia
Authors: Roberts Kenneth B.
Published: December 2021

Potassium is the major intracellular cation; only a very small fraction of total body potassium is in the intravascular space. Increased potassium concentration in serum is infrequent in pediatrics, but it can be life-threatening because of its effect on membrane potentials, particularly of heart muscle.

The serum potassium concentration is affected primarily by the kidney. Potassium is filtered by the glomerulus, then reabsorbed and secreted by the tubule. Processes that interfere with filtration or secretion (eg, acute on chronic glomerulonephritis, interstitial nephritis) may cause hyperkalemia; processes that interfere with reabsorption may cause hypokalemia.

The most common cause of an increased serum potassium is "pseudohyperkalemia" due to hemolysis or to tissue hypoxia distal to the placement of a tourniquet.
The Biological Aspects of Puberty
Authors: Kulin Howard E. , Müller Jørn
Published: December 2021

Normal Pubertal Development

SOMATIC CHANGES

Puberty is characterized by an increase in growth rate and the appearance of striking somatic sex differences. The onset of these changes actually antedates the appearance of secondary sex characteristics by a few years. Thus, sexual maturation is a considerably longer process than the period of visible changes induced by marked incremental increases in gonadal hormones. Unlike boys, girls augment their body fat noticeably at 7 years of age; by 16 years of age girls have twice as much fat as boys.

Total body water reflects lean body mass, which is made up primarily of muscle and skeletal tissues. At 9 years of age, total body water increases significantly in boys and signals the onset of more rapid growth in lean body mass. Muscle mass in boys doubles between the ages of 10 and 17 years, and skeletal mass doubles between ages 12 and 16 years. During adolescence boys exceed girls in all body measurements except hip width and body fat.

The changes in body constituents during puberty are reflected more impressively by increases in height and weight. The initiation of the adolescent growth spurt precedes the onset of secondary sex characteristics by approximately 1 year in boys and girls.
Sleep Problems Among Infants and Young Children
Authors: Blum Nathan J. , Carey William B.
Published: December 2021

Parental concerns about their young children's sleep are among the most frequent behavior problems discussed with pediatricians. In view of this high prevalence, it is important to review the origins of these problems and emerging information about how best to manage them.

Definition

Sleep disorders among children can be classified as dyssomnias, parasomnias, and disruptions secondary to other conditions. The dyssomnias are disturbances in the amount or timing of the sleep. They include intrinsic sleep disorders such as narcolepsy and sleep apnea, interactional sleep disorders such as excessive night waking, and sleep phase disorders, when the time the parents assign for sleep and the child's period of needing it are not synchronous. Parasomnias, on the other hand, are abnormal behaviors that occur during sleep, such as night terrors, nightmares, sleep walking, and sleep talking. Sleep also can be disturbed as the result of various mental and physical conditions, including asthma, epilepsy, and anxiety disorders.

The dyssomnias (sleep refusal and night waking) and parasomnias (night terrors and nightmares) of infancy and early childhood are the most common complaints of parents to pediatricians. Sometimes, however, parents may not seek help for these problems; at other times, they may be concerned by what actually is normal sleep behavior.
Evaluation of Hypercholesterolemia in Childhood
Authors: Starc Thomas J. , Deckelbaum Richard J.
Published: December 2021

For many adults, the risk of atherosclerosis can be reduced by intervention and treatment of known risk factors. Direct proof that similar intervention will be effective in children is not available. However, evidence suggests that prevention beginning in childhood will lead to a decrease in incidence of heart disease later in life. The majority of families are eager to take steps to prevent heart disease in their children, especially if there is a family history of early heart disease. It is the role of the pediatrician to identify those children at risk for early heart disease and to initiate advice on reducing risk factors.
INDEX OF SUSPICION
Authors: Edwards Whitney C. , Khalak Rubia , Gadawski Robert , Babl Franz E. , Hyams Jeffrey S. , Justinich Christopher J.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 7-year-old boy is seen in the pediatric clinic. He has been ill for 3 weeks with fever, pharyngitis, and rash. Diagnosed as having streptococal pharyngitis and scarlet fever, he was treated with antibiotics without relief. Ten days ago, he developed vomiting, diarrhea, and right-sided abdominal pain. When given paregoric, his vomiting worsened. Six days ago he was admitted to a community hospital for treatment of dehydration. During his 3-day admission, his white blood cell count and his liver enzymes were elevated. At the time of discharge, he was no longer vomiting, but he had blisters on his hands and feet.

Two days ago, the vomiting, diarrhea, and abdominal pain recurred. Findings on abdominal ultrasonography were normal.
Cyanosis in the Newborn Infant
Authors: Kitterman Joseph A.
Published: December 2021

The presence of cyanosis in a newborn infant indicates the presence of potentially serious and life-threatening disease. There are only five physiologic abnormalities that produce arterial desaturation, although numerous different clinical entities may result in cyanosis. In all but a few cases, an accurate diagnosis can be made with the use of clinical and relatively simple laboratory data. In addition to supportive treatment, specific therapy should be directed at the underlying cause of cyanosis. The prognosis depends upon the nature of the clinical condition responsible for cyanosis; in most cases, the prognosis for survival and normal development is good.
Transient Erythroblastopenia
Authors: Oski Frank A.
Published: December 2021

Transient erythroblastopenia is a common occurrence. It can be recognized only through the performance of reticulocyte counts in anemic patients. Transient erythroblastopenia of childhood is a benign, self-limited disorder. Appreciation of its clinical and laboratory findings can enable the physician to provide needed reassurance to parents and reduce the need for unnecessary diagnostic procedures and ill-advised therapy.
Vancomycin in Pediatrics
Authors: Greenfield Mark D. , Smith Arnold L.
Published: December 2021

Vancomycin, a complex glycopeptide antibiotic, has achieved somewhat limited use since its introduction in 1956. It has excellent antibacterial activity against a variety of Gram-positive organisms, including those resistant to semisynthetic penicillins such as methicillin. Because of its higher potential for adverse side effects, such as thrombophlebitis and ototoxicity, it should be reserved for illnesses associated with methicillin-resistant staphylococci or in patients who have serious allergies to the penicillins. It has shown excellent effectiveness in a wide range of serious infections due to Gram-positive bacteria. Vancomycin should be administered intravenously, except in the case of staphylococcal or pseudomembranous colitis associated with C difficile in which oral administration is the appropriate route. In infections with enterococci, combination with an aminoglycoside is indicated as synergism occurs. It is excreted by the kidney; extra care must be taken in treating patients with renal failure. Dosing in anephric patients undergoing dialysis is greatly simplified by its prolonged half-life and is usually necessary only every seven to 14 days. Monitoring the serum concentration is desirable in all patients receiving vancomycin to ensure an efficacious, but nontoxic level.
Wilson's Disease
Authors: Riely Caroline A.
Published: December 2021

Wilson's disease (hepatolenticular degeneration) is a relatively rare cause of illness in the pediatric age group. But, as a chronic life-threatening disease that is treatable, even "curable," its investigation should be thoroughly pursued by the pediatrician. The recognition of Wilson's disease provides the opportunity to prevent this illness in presymptomatic family members. Therefore, Wilson's disease should be included in the differential diagnosis of all forms of liver disease in pediatrics and appropriately excluded.

The clinical findings that are compatible with a diagnosis of Wilson's disease are protean, and confirming or denying this diagnosis is often difficult. In order to appreciate these problems, it is necessary first to understand the normal physiology of copper in the body and the derangements in this homeostasis that characterize Wilson's disease (Fig 1).

COPPER HOMEOSTASIS

Normal

Copper is absorbed from the diet in excess of the body's requirement for it. Many foods contain copper, but chocolate, nuts, mushrooms, liver, and shellfish are particularly rich sources. Once absorbed, copper is transported free in the blood to the liver. Here, a certain fraction is incorporated in an irreversible fashion into ceruloplasmin. This copper-containing protein separates in the α2-globulins, can be an acute-phase reactant, increasing in concentration in response to stress. Alternatively, in the presence of hepatic failure with decrerased protein synthesis, its concentration in blood decreases. Ceruloplasmin is an oxidative enzyme used in a variety of pathways, including the oxidation of ferrous to ferric ions.
Metabolic Bone Diseases
Authors: Chesney Russell W.
Published: December 2021

Upon viewing a skeleton, one thinks of bone as an inert framework upon which the remainder of the body is constructed. Nothing could be more incorrect, since bone is a dynamic living organ which is capable of constant turnover, weight-bearing, and sustaining the remarkable stresses incurred in running, jumping, and other daily activities. Bone is constantly being formed and reformed (modeled and remodeled), is continuously serving as a reservoir of the divalent minerals (calcium, phosphate, and magnesium), and, in children, is constantly undergoing growth. In this article, the disorders that affect bone will be reviewed. These conditions fall under the general rubric metabolic bone disease and generally comprise a group of disorders in which impaired formation, enhanced resorption, or altered turnover of bone prevails (Table 1).

The human skeleton is composed of a collagen-containing (and noncollagen protein-containing) matrix, or osteoid, upon which is deposited a crystalline mineral phase. This mineral component of bone contains calcium and phosphate in various inorganic chemical compounds, the major one being hydroxyapatite. However, this hydroxyapatite is deep within bone trabeculae and ordinarily inaccessible. The rapidly exchangeable pool and accessible mineral phase of bone is composed of newly formed, but incomplete, hydroxyapatite crystals and amorphous calcium phosphate.1
Evaluation of the Child with Asymptomatic Proteinuria
Authors: Feld Leonard G. , Schoeneman Morris J. , Kaskel Frederick J.
Published: December 2021

Asymptomatic proteinuria is defined as the discovery of proteinuria on a routine examination without evidence of clinical disease. The prevalence is dependent on the age and sex of the child, as well as the circumstances under which the testing is performed. In the majority of cases, patients have transient or orthostatic proteinuria. The physician can assure the patient and parents that the prognosis is excellent. However, appropriate long-term follow-up is essential. On the other hand, persistent proteinuria represents a spectrum from a benign disorder to a disease which can progress to end-stage renal failure.