bluuebunny/crossref_metadata_2025 huggingface dataset:
The Acute Management of Paroxysmal Supraventricular Tachycardia in Children
Authors: Erickson Lars C. , Cocalis Mark W.
Published: December 2021

Supraventricular tachycardia (SVT) in children is a common disturbance of cardiac rhythm that is usually managed without difficulty by using a methodical approach. Technically, the term SVT refers to any rapid rhythm originating in or involving the atria or atrioventricular (AV) node. The most common type of SVT treated in the pediatric clinic is a reentrant rhythm involving the AV node or a bypass tract (paroxysmal SVT [PSVT]). This type of SVT is characterized by sudden onset and cessation, very little beat-to-beat variability, and rates usually well beyond 220 beats/minute. Reentrant rhythms are susceptible to vagal maneuvers, pharmacologic intervention, and electrical cardioversion. Other types of SVT include atrial flutter (rare in children) and automatic tachycardias, which tend to vary in rate over time and start and stop more gradually. It is important to distinguish automatic tachycardias from PSVT because they do not resolve with vagal maneuvers or electrical cardioversion and because they are notoriously difficult to manage with medications. The automatic tachycardia most frequently confused with PSVT is sinus tachycardia, which usually requires no treatment.

The first step in evaluation is to check the hemodynamic status. A small proportion of children who have PSVT may present with shock. If the child is hypotensive or has poor capillary refill, one must start immediate measures to restore effective perfusion, including securing reliable intravenous (IV) access and supine positioning.
Giardiasis
Authors: Seidel James
Published: December 2021

Giardiasis is caused by infection with the protozoan parasite Giardia lamblia, also called Giardia intestinalis in Europe.

Epidemiology

Giardia infections are ubiquitous, and outbreaks occur in developed and underdeveloped nations throughout the world. Infection results from ingestion of cysts, usually contained in water or food, on hands, or on fomites contaminated with feces. The parasite is found in about 4% of stool specimens submitted to laboratories in the United States and is the most common parasite isolated. The exact prevalence of the infection in the United States is not known because it is not reportable in all states and may be difficult to isolate in the laboratory. Epidemic giardiasis in day care centers was first reported in 1977, with infection rates varying from 0 to 25%. Most children have symptoms. Chronic passage of cysts by some preschool children in day care facilities is found 5 to 6 months after the initial diagnosis, either because of continued transmission or chronic infection. Prevalence rates decline when children are toilet-trained. Sexual transmission may occur in heterosexual or homosexual contacts.

Campers and hikers are at risk because of vertical transmission from animals, and waterborne outbreaks in national parks have been reported. In addition, many outbreaks have been attributed to municipal water supplies that have not been treated with flocculation or filtration.
Gastroenteritis
Authors: Northrup Robert S. , Flanigan Timothy P.
Published: December 2021

Diarrheal disease is so common and so often short-lived and apparently benign that neither physicians nor parents may give it the attention it deserves. Unfortunately, this lack of concern plays an important role in the high mortality rate from diarrhea among children in developing countries. It also contributes to the high numbers and costs of hospitalizations for diarrhea in the United States.

This review focuses on acute infectious diarrhea and on persistent diarrhea. These two conditions begin similarly, but persistent diarrhea by definition persists for longer than 14 days. It emphasizes appropriate management, particularly oral rehydration therapy (ORT) and current recommendations regarding feeding during diarrhea, and addresses new information about pathogens that cause both acute and persistent diarrhea. Although ulcerative colitis, Crohn disease, and other causes of chronic diarrhea must be considered in the differential diagnosis of acute or persistent diarrhea, a thorough discussion of chronic diarrhea is beyond the scope of this article. Information from developing countries as well as from the US and other developed countries is included.

Epidemiology

Gastroenteritis, both acute and persistent, may occur as often as 15 times per year in a child, although rates of 3 to 5 episodes annually are seen more commonly in most developing countries.
Myelodysplasia in Childhood and Adolescence
Authors: Blum Robert Wm. , Pfaffinger Kathleen
Published: December 2021

The Nature of the Condition

Myelomeningocele—also commonly referred to as meningomyelocele—is a defect of neural tube formation that is akin embryologically to anencephalus. The larger category, spina bifida, includes the benign condition of spina bifida occulta; myelodysplasia is inclusive of all neural tube anomalies. Myelomeningocele is the most common major congenital anomaly in the United States, having an incidence, until recently, of 4 per 1000 births (see Epidemiology).

Approximately 80% of all children born having myelomeningocele have associated hydrocephalus. Likewise, nearly all of these children are born having Arnold-Chiari (or Chiari II) malformation of the midbrain and upper spinal cord, which is associated with displacement of the inferior cerebellar vermis, caudal fourth ventricle, and medulla oblongata into the spinal canal. The Arnold-Chiari malformation may cause its own symptom complex, including lower cranial nerve dysfunction, sensory loss, and spasticity.

The extent of neurologic, urologic, and orthopedic involvement depends primarily on the level of the lesion (Table 1). Additionally, the work of Luthy et al strongly suggests that if the condition is diagnosed prenatally, infants delivered via cesarean section have significantly less paralysis at 2 years of age than do those who have comparable lesions and who are delivered vaginally.

Additional complicating factors and associated findings of myelomeningocele may include:
Acne Vulgaris: Pathogenesis and Management
Authors: Hurwitz Sidney
Published: December 2021

Acne, a problem well known to pediatricians and general practitioners alike, never should be dismissed as being of no consequence, with the reassurance that the patient will outgrow it. The psychological scars of individuals affected with severe forms of this disorder often are far deeper and more disastrous than the blemishes appearing on the cutaneous surface. For years the treatment of acne was hindered by: 1) mythical concepts of etiology, 2) a lack of concern for the physical and emotional trauma of those afflicted with severe forms of this disorder, and 3) the perpetuation of ineffective therapeutic regimens based on misconceptions and misinformation. Although the basic cause of acne remains unknown, considerable data concerning its pathogenesis and treatment accumulated in recent years now allow a rational and therapeutically successful approach to its management. Therapy must be individualized, however, with variations and modifications appropriate to the fluctuating severity of the disorder. Today, this goal can be achieved easily by proper selection of available medications, coupled with the cooperation of the patient and the knowledge, continued interest, and enthusiasm of the physician and his or her staff.

Etiology

Although generally considered a disorder of adolescence, acne vulgaris, a chronic inflammatory process at the pilosebaceous follicles, usually begins 1 or 2 years prior to the onset of puberty as a result of androgenic stimulation of the sebaceous glands.
The Cephalosporin Antibiotics
Authors: Darville Toni , Yamauchi Terry
Published: December 2021

Introduction

The first cephalosporin released for clinical use was cephalothin in 1964. Since that time, more than 20 cephalosporin antibiotics have been introduced. These are the most commonly prescribed antibiotics in the United States and account for the largest share of hospital expenditures. To determine which agent to use for an infection in a particular patient involves weighing competing claims of improved antibacterial spectrum, side effects, pharmacokinetics, and cost. This review will address these issues, as well as the basic mechanisms of action of the cephalosporins and their mechanisms of bacterial resistance. In addition, instances in which cephalosporins serve as appropriate alternatives or in which they offer distinct advantages over previously available antimicrobial agents will be described.

Chemistry and Mechanism of Action

Cephalosporins resemble penicillins (Fig.1) in that they have a β-lactam structure, but the five-member thiazolidine ring characteristic of the penicillins is replaced by a six-member dihydrothiazine ring (Fig. 2). The dihydrothiazine ring of the cephalosporins provides the molecule with the ability to resist bacterial enzymes; the antibacterial activity emanates from the β-lactam ring shared by penicillins and cephalosporins. Modifications at position 7 of the cephalosporin nucleus generally affect the antibacterial spectrum, and substitutions at position 3 of the dihydrothiazine ring alter the pharmacokinetics and metabolic parameters of the drug.
Consultation with the Specialist
Authors: Kveton John F.
Published: December 2021

Otitis media is the most common infectious disease seen in the pediatric population. Hearing loss is a well-recognized sequela of otitis media, whether acute or chronic. In acute cases, hearing generally returns as the resulting effusion resolves, which may take up to several months. Hearing loss in chronic otitis media often resolves during quiescent stages of the disease; persistent hearing loss that fails medical management is best treated through surgical intervention. Tympanosotomy tube insertion effectively recovers hearing in cases of chronic middle ear effusions, whereas tympanoplasty and ossiculoplasty, often in conjunction with mastoidectomy, are necessary for chronic draining ears. Hearing loss may occur in the absence of otitis media. In such cases the clinician must be aware of the potential ramifications of the hearing loss for the child as well as the proper method of evaluating such a patient.

Background

During the first 5 years of childhood, the ability to hear is related intimately to the degree of speech and language acquisition as well as to the development of emotional, social, and academic skills. It is estimated that a normal-hearing 5-year-old child has a vocabulary of 5000 to 26 000 words, whereas a profoundly hearing-impaired child has a vocabulary of 200 words. The effects on reading ability are equally astounding, with the average reading achievement for hearing-impaired 16-year-olds at the third- or fourth-grade level.
Cocaine: A Review
Authors: Wootton John , Miller Sheldon I.
Published: December 2021

Epidemiology

Although there has been an encouraging decline in the number of Americans using cocaine in recent years, cocaine use remains at epidemic proportions. The National Household Survey on Drug Abuse showed a decrease from 12 million "past year" users in 1985 to 8 million in 1988. In 1988, the National Institute on Drug Abuse (NIDA) estimated that 30 million Americans had tried cocaine. Of that 30 million, 20% had gone on to become regular users and 5% had developed a compulsive pattern of use. In 1988 among 12- to 17-year-olds, cocaine use in the previous year was highest in Hispanics at 4%, followed by 3% in whites and 1% in African-Americans. However, the Drug Abuse Warning Network has documented a dramatic increase in the number of admissions to hospital emergency rooms as a result of cocaine use. In 1984, the number was 8831; it jumped to 46 020 in 1988.

The ready availability of "crack" cocaine in the US in 1985 may well be responsible for this dramatic increase of documented medical emergencies arising from cocaine use. Although the use of cocaine has decreased, the preferred method of ingestion—smoking—has increased. Sniffing of the drug has decreased. Concurrently, cocaine, which was once called the "champagne" of abused drugs, has dropped significantly in cost on the streets.
Cholestatis in Infancy
Authors: Mews Catherine , Sinatra Frank R.
Published: December 2021

It is imperative that serum bilirubin fractionation be performed in any infant whose jaundice is prolonged to identify the infant who has cholestasis. Conjugated hyperbilirubinemia always is pathologic, and a well-organized and expedient diagnostic evaluation should be undertaken to identify those conditions that are treatable medically or surgically if they are recognized early. The complications of prolonged cholestasis need to be recognized and the appropriate medical therapy instituted to allow patients to maximize their growth potential, avoid the problems of nutrient deficiencies, and maintain a reasonable quality of life. Hepatic transplantation now offers the opportunity for long-term survival for infants whose liver disorders previously were fatal.
Consultation with the specialist
Authors: Bergman Ira
Published: December 2021

Increased intracranial pressure (ICP) is both a symptom of serious intracranial pathology and a cause of irreversible neurologic injury. The following case history highlights the importance of prompt diagnosis and treatment of increased ICP.

Case History

An 18-month-old white male developed fever and lethargy. On physical examination he had nuchal rigidity and was lethargic but could be fully aroused. His cerebrospinal fluid (CSF) contained 1279/mm3 white blood cells, of which 90% were polymorphonuclear cells; the CSF glucose level was 5 mg/dL and protein was 63 mg/dL. Gram stain revealed Gram-negative rods. The child was treated with ceftriaxone. Five hours later, he had four generalized seizures. Serum sodium was 114 mEq/L, and an infusion of 3% saline at 80 mL/h was begun. Immediately following the seizures, the child was comatose but withdrew to pain. Thirty minutes later, he developed decerebrate posturing bilaterally and irregular respirations and had a dilated unreactive left pupil. He was given mannitol, pancuronium, and pentobarbital and was intubated and hyperventilated. Almost immediately the pupils became 3 mm in size bilaterally and equally reactive. A computed tomographic (CT) scan was obtained (Figure 1A). Twenty-four hours later, the child opened his eyes to mild stimulation and responded specifically to localized pain. The cerebral CT scan was repeated (Figure 1B).
Consultation with the specialist
Authors: Rabinowitz Ronald , Hulbert William C.
Published: December 2021

Introduction

The term cryptorchidism originates from the Greek kryptos (concealed) and orchis (testis). The definition of the term cryptorchidism is appropriate; not only is the testis concealed, but so is much information regarding this common condition.

More than 200 years ago, John Hunter described descent of the testis during the last 3 months of gestation and reported that testes that remain in the abdomen are unhealthy and do not function well. He also discussed the possibilities of failure to descend causing testicular abnormality and testicular abnormalities causing failure to descend.

Cryptorchidism represents the most common genital abnormality seen by pediatric urologists. The incidence is 1 in 125 boys. The incidence is much higher in premature infants (1 in 3), and the lower the birth weight, the greater the incidence of cryptorchidism. This condition is seen in approximately 1 in 30 full-term infants, but in many of them, the testicles will descend during the first few months of life. There is a higher incidence of cryptorchidism associated with many chromosomal and single gene defects as well as with multiple malformation syndromes. In addition, there is a higher incidence of cryptorchidism in the siblings and sons of those who have or had cryptorchidism.

We will describe the anatomy of both the cryptorchid and retractile testis and discuss the embryology of testicular descent, with an emphasis on hormonal factors.
Cervical Adenopathy
Authors: Chesney P. Joan
Published: December 2021

Definition

Enlargement of cervical lymph glands is common in children and in most cases represents a transient response to a benign local or generalized infection, most often of viral etiology. The increase in size may involve a single node or a localized group of nodes (regional adenopathy); it may be unilateral or bilateral; and it may be acute, subacute, or chronic in onset and course. Almost all normal children have small palpable cervical, axillary, and inguinal nodes. About 5% have small palpable suboccipital nodes. Distinctly uncommon are palpable postauricular, supraclavicular, epitrochlear, or popliteal nodes or radiologic evidence of mediastinal or abdominal adenopathy. The increase in size of a node may be the result of one of two processes: 1) proliferation of cells intrinsic to the node, including lymphocytes, plasma cells, monocytes, or histiocytes; or 2) infiltration of cells external to the node, such as malignant cells or neutrophils, having the potential for developing necrosis and suppuration.

In some instances the cause of the adenopathy may be obvious, such as in the case of lymph glands draining an obvious source of infection. In other cases of unexplained neck masses, congenital and neoplastic causes also must be considered before the etiology is assumed to be infectious.
Prevention of Allergic Disorders
Authors: Solomon William R.
Published: December 2021

Allergic disease produces substantial pediatric morbidity and individual dysfunction, making its mechanisms an appropriate target for clarification and preventive strategies. Disease expression seems to reflect a constellation of determinants that controls IgE production variably, affects specific function of target organs, and determines exposure to putative allergens. Bases for the two former factors are being defined rapidly and appear to be controlled genetically. Therefore, although stronger eugenic motivation will be required to exploit even present information for effective prevention, parental phenotypes can provide a rough indication of post-conceptive risk.

Despite many divergent data, current evidence fails to support the value of gestational strategies undertaken to prevent allergic disease in the newborn; however, this risk apparently may be reduced by avoiding postnatal allergens. The protection afforded seems to be allergen-specific rather than somehow serving to abate "the allergic tendency." Evidence increasingly is persuasive that sensitization to pollens, foods, and possibly other agents is prone to occur in the first 6 to 12 months of life. Strategies that exclude potent food allergens from the diets of high-risk infants appear to reduce the occurrence of atopic dermatitis, but seem far less able to influence respiratory symptoms. Efforts to limit exposure to potent inhalant allergens (eg, dust mites, animal "danders") are now also feasible and offer quite effective secondary and, perhaps, primary prevention. Trials of these strategies and clarification of other domestic contaminant effects on child health offer "homely" but valid and potentially useful approaches to reducing the impact of allergic disease.
Tonsils and Adenoids: An Update
Authors: Deutsch Ellen S. , Isaacson Glenn C.
Published: December 2021

Pediatricians frequently face the decision of whether to recommend that a child undergo a tonsillectomy, an adenoidectomy, or both. The reputation and the indications for these procedures have evolved over the years and continue to evoke controversy. The total number of tonsillectomies and adenoidectomies performed in the United States has decreased substantially over the past 30 to 40 years, although the proportion of procedures performed for obstructive sleep apnea (OSA) has increased. We will address the indications (Table), techniques, and complications of tonsillectomies and adenoidectomies, as well as current ideas concerning OSA.

The palatine tonsils, adenoids, and lingual tonsils comprise a circle of lymphoid tissue in the nasopharynx and oropharynx, sometimes referred to as Waldeyer ring (Fig. 1). Although this tissue is immunologically active, no postoperative immune deficits generally have been acknowledged other than an increased risk of complications from polio1 prior to the availability of polio vaccines.

Clinical Aspects

The most common problems attributed to the tonsils and adenoids are recurrent infection and OSA, or its milder manifestation, adenotonsillar hypertrophy with obstruction. Chronic middle ear disease can be related to adenoid pathology.

OBSTRUCTIVE SLEEP APNEA

OSA either is becoming more common in children or is being recognized more frequently. Sleep disturbances, cor pulmonale, pulmonary hypertension, and congestive heart failure are potential complications of OSA.
How to Use PIR for Renewal of Certification
Authors: H R J
Published: December 2021

During 1995, many pediatricians will participate for the first time in the Pediatric Renewal of Certification Program (PRCP). Since Pediatrics in Review (PIR) and the Pediatrics Review and Education Program (PREP) began in 1979, their material has been integrated with the American Board of Pediatrics (ABP) renewal of certification program. The ABP sets the educational objectives (now called content specifications) and develops the examinations. The American Academy of Pediatrics (AAP) develops PREP education materials, PIR, and the Self-Assessment Exercise based on these.

Each year PIR covers about 1000 of the more than 4000 content specifications, including at least half of the 900 selected as the basis each year for the cognitive examination.
Melanomas in Children
Authors: Orlow Seth J.
Published: December 2021

Although rare, melanomas do occur in children and adolescents. Pediatricians should be aware of the clinical features of melanoma and the risk factors for developing this malignancy. Children at high risk for melanoma should have at least annual cutaneous examinations in search of suspicious lesions. If a lesion is suspected of being a melanoma, it should be removed surgically and submitted for pathologic examination. Education of parents and children about the deleterious effects of ultraviolet light affords a means of counteracting the increasing incidence of melanoma at the grassroots level. The use of sunscreens, hats, and other protective clothing and the judicious timing of daily solar exposure should serve to prevent sunburning, limit tanning, and decrease the incidence of melanoma and other more common cutaneous malignancies, such as basal cell carcinoma and squamous cell carcinoma.
BACK TO BASICS
Authors: Fong Chin-To
Published: December 2021

Many inborn errors of intermediary metabolism present during periods of poor oral intake or intercurrent illness. Under these conditions, the body switches to a predominantly catabolic state, when glycogen, fat, and protein are mobilized as alternative energy sources. If a genetic defect already exists in any of these catabolic pathways, the problem is accentuated because the catabolic state demands a high flux of metabolite through these pathways. Therefore, a cardinal principle in the management of children who have IEM is to prevent them from lapsing into a catabolic state. This can be done through: 1) aggressive nutrition management to promote positive nitrogen balance and decrease accumulation of toxic metabolites, and 2) immunizations to minimize the possibility of viral or bacterial illness. When catabolism does occur, high-dose glucose infusion is a potent method for turning off the catabolic state.

This simplistic view of the catabolic pathways neglects many details in each of the metabolic pathways and diseases cited in the article and questions. Nevertheless, it should provide a useful framework for explaining some of the clinical findings encountered in caring for this special group of patients. A partial list of more commonly encountered IEMs is contained in the Table. The different parts of the biochemical pathways discussed previously are combined into Figure 6.
Management of Fatal Illness and Death in Children or Their Parents
Authors: Barakat Lamia P. , Sills Richard , LaBagnara Susan
Published: December 2021

Assisting families facing a death necessitates constant reevaluation of each family's adaptation to the illness. Protracted terminal illness is particularly difficult because the prolonged stress, suffering, and pain may be much more difficult to cope with than the death itself. Successful management requires acknowledging the families' emotions, assuring them that their responses are normal, and providing them a balanced perspective through supportive, honest, and open communication. In so doing, the pediatrician can help families predict reactions, manage problems, and avoid long-term psychological consequences.
Muscular Dystrophy
Authors: Spiro Alfred J.
Published: December 2021

Several varieties of muscular dystrophy can be distinguished on clinical, genetic, morphologic, and physiologic grounds. The classification includes Duchenne and Becker muscular dystrophies, both X-linked disorders; facioscapulohumeral muscular dystrophy, which is autosomal dominant; and limb-girdle muscular dystrophy, generally autosomal recessive.

Duchenne muscular dystrophy (DMD), which occurs in approximately 1 in 3500 live male births, has no recognizable signs or symptoms at birth. However, markedly elevated serum creatine kinase always is demonstrable, even at birth. A molecular diagnosis can be made at any time in the patient's lifetime by demonstrating the defect in the dystrophin gene, the absence of dystrophin in a muscle biopsy, and the characteristic morphologic abnormalities.
What's New in Cardiology
Authors: Baldwin H. Scott
Published: December 2021

Congenital heart diseases occur with a frequency of 0.5 to 1 case per 1000 live births, accounting for more than 50% of reported birth defects. In addition, they are the leading cause of infant mortality in the first year of life. Significant progress in the diagnosis and treatment of most defects has been made in the past few years. In addition, new experimental evidence suggests that we soon may be able to identify the genes involved in disturbed cardiac anatomy and function. The following is a brief overview of some of the more recent developments that have made an important impact on the contemporary management of the child who has congenital heart disease.

Transcatheter Ablation of Pediatric Tachyarrhythmias: A Cure Without Medication

The prevalence of tachyarrhythmias within the general pediatric population is such that virtually every practitioner is faced with diagnostic and management considerations that involve patients from birth through adolescence. Fortunately, most tachyarrhythmias can be managed with relatively benign pharmacologic therapies. However, there is a subset of patients who do not respond to "simple" medical intervention, requiring multiple or more potent antiarrhythmic medications that may involve frequent or prolonged hospitalizations for monitoring and optimization of therapeutic regimens. These medications also may cause significant side effects and often result only in a decrease, not elimination, of the arrhythmia.
Cytomegalovirus Infections
Authors: Hanshaw James B.
Published: December 2021

The term cytomegalovirus (CMV) was proposed by Weller and his colleagues in 1960 to replace the names cytomegalic inclusion disease and salivary gland virus for two reasons: 1) the virus usually involved other organs, and 2) the term salivary gland virus had been used to designate unrelated agents that were recovered from bats.

Cytomegaloviruses belong to the class of herpesviruses, which includes the herpes simplex viruses 1 and 2, varicella-zoster virus, Epstein-Barr virus (EBV), human herpesvirus 6, the cause of roseola, and human herpesvirus 7, a virus in search of a disease. These viruses are known for their wide distribution in humans and a propensity for latency and reactivation during the lifetime of the host.

There apparently are no clearly distinct CMV serotypes, but strain differences have been noted in cross-neutralization tests and by molecular analysis of CMV viral DNA. Restriction enzyme analysis of DNA from CMV isolates has proven to be of great value in our understanding of the epidemiology of CMV infection because of the striking similarity of DNA fragments from common sources.

Epidemiology

CMV infection is ubiquitous, and evidence of seroconversion has been found in all populations tested to date. Antibody prevalence is influenced by age, socioeconomic group, geography, and cultural practices.
Clinical Manifestations of Scleroderma
Authors: Haber Patricia L.
Published: December 2021

Scleroderma is a connective tissue disease of unknown etiology. Its most characteristic feature is thickening of the skin due to increased collagen deposition. However, the disease may involve multiple other organ systems. Two broad categories of scleroderma have been defined: localized and systemic. Although all forms of scleroderma are rare, localized scleroderma occurs more frequently than systemic sclerosis and has a more favorable prognosis.

Several types of localized scleroderma exist. Morphea is characterized by the presence of one or more patches of hard, ivory-colored skin lesions. They begin with erythema and progress to nonpitting edema before becoming sclerotic. The margins of active lesions often have a violaceous hue. Underlying muscle fibrosis and atrophy may occur.
Retinopathy of Prematurity
Authors: Phelps Dale L.
Published: December 2021

Retinopathy of prematurity is a common disorder among extremely low-birthweight preterm infants and may cause total vision loss in as many as 2% to 4% of those weighing less than 2 pounds at birth. Regular examinations begun in the neonatal intensive care unit permit early detection and treatment of progressive ROP and allow a reduction in visual impairment.

Infants whose ROP has regressed should continue to receive regular ophthalmologic follow-up for the detection and treatment of myopia and strabismus and, if they have cicatricial sequelae, late retinal detachments as teens or adults. Early intervention and special education programs are important for the children whose vision loss is significant.
Consultation with the Specialist
Authors: Kenna Margaret A.
Published: December 2021

Hoarseness in children is very common and usually self-limiting, but there are several very serious and potentially life-threatening causes of hoarseness that always should be considered. A careful history and physical examination usually can suggest underlying etiologies, with the definitive diagnosis usually made at the time of airway endoscopy. The following case and subsequent discussion attempt to clarify some of these issues.

Case Report

An 8-year-old boy presented to the emergency room with a 2-week history of increasing hoarseness, accompanied in the past 5 days by some respiratory distress. On physical examination he was alert and cooperative, with a hoarse but understandable voice and moderate inspiratory and expiratory stridor. Further history revealed that 6 weeks earlier he had been admitted to the pediatric intensive care unit with severe asthma that required 8 days of intubation and mechanical ventilation. He had done well after discharge for about 4 weeks, when his symptoms of hoarseness and then stridor developed.

Differential Diagnosis

The entities causing hoarseness can be divided primarily into congenital, neurogenic, neoplastic, inflammatory, physiologic, and traumatic (Table).

The most common overall etiology is laryngitis associated with an upper respiratory infection (URI), which generally is benign and self-limiting. Vocal nodules are the acquired lesions encountered most frequently and usually are not associated with airway compromise.
Chronic Cough
Authors: Ewig Jeffrey M.
Published: December 2021

Cough is a reflex that protects the lungs from aspirating food or inhaling irritants. It is a key component of the nonimmune pulmonary defense system. The cough that accompanies most common respiratory infections usually resolves in 7 to 10 days and rarely is a cause of concern. The patient who has frequent viral infections may complain of a "chronic" cough, but a careful history will reveal a shorter duration of repetitive episodes with coughs resolving completely in between infections. Chronic cough usually is defined as lasting for more than 3 to 4 weeks. Chronic cough is a symptom, not a diagnosis, and the underlying cause should be ascertained.
Blindness and Visual Impairment
Authors: Kaminer Ruth K. , McMahon Eugene
Published: December 2021

The identification and treatment of children who have significant visual impairments are critical to their health and future well-being. "Legal blindness" occurs if a patient has central visual acuity of 20/200 or less in the better eye with corrective glasses or a visual field that is no greater than 20 degrees in the better eye. To determine eligibility for special education services, states must adopt a definition of visual impairment consistent with the Individuals with Disabilities Education Act (IDEA). For educational purposes, this includes students who have a visual disability that, even with correction, affects their educational performance adversely. The term includes both partially seeing and blind children.
Pleural Effusions: Diagnostic Considerations
Authors: Ewig Jeffrey M.
Published: December 2021

The presence of fluid in the pleural space can be seen in a variety of disorders. Presenting symptoms include dyspnea, pleuritic chest pain, and ipsilateral shoulder pain if pleural involvement occurs at the central portion of the diaphragm. Physical examination findings include chest asymmetry, diminished breath sounds, dullness to percussion, and decreased tactile fremitus. In an upright patient, the radiographic appearance of pleural fluid includes blunting of the costophrenic angle, straightening or a more lateral peak of the hemidiaphragm contour, simulation of an elevated hemidiaphragm, or a distance of greater than 2 cm between the gastric air bubble and the lung.
INDEX OF SUSPICION
Authors: Friedman Elliott M. , Turner Teri , Deeb Danuta
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 6-week-old boy who has had no prenatal or newborn problems and has been well previously is brought to the emergency department because he suddenly has developed respiratory distress. On examination, the baby is lethargic, obviously cyanotic, and breathing at 36 breaths/min with intercostal retractions, nasal flaring, and grunting. His temperature is 94°F (34.4°C), heart rate is 140 beats/min, and blood pressure is 78/48 mmHg. Other positive signs include cool extremities and a capillary refill time of 4 sec. He is aerating his lungs well and his breath sounds are clear. No heart murmurs are heard and no hepatosplenomegaly is noted. His femoral and brachial artery pulses are equal but of diminished strength.

An intravenous line is put into an external jugular vein; the state of shock precludes a peripheral cannulation and the external jugular veins are prominent.
Consultation with the Specialist
Authors: Johnson Robert L.
Published: December 2021

Adolescence is a time set aside in our culture for our children to learn how to be adults. Throughout history this societal responsibility has been satisfied in various ways by different cultural groups. Alex Hailey, in his book Roots, describes the ancient African adolescence of the young Kunta Kinte:

At 12 years of age the boys of the village were separated from their families and taken to a camp in the jungle. Over a period of 6 weeks, the men of the community taught the boys all the lessons of adulthood. At the end of the encampment they were tested to determine if they had learned these lessons of adulthood. Those boys who successfully passed the test were granted adult status and circumcised as a visible sign of their manhood. These young people who left their village as boys returned to their society as men.

Adolescents in our culture must accomplish the same task of adolescence as the young Kunte Kinte. They must:

1. Emancipate themselves within the structure that gave them nurture and support during their childhood (usually the family or some similar surrogate structure);

2. Establish their sexual identity—make decisions about maleness and femaleness and love-object gender;

Establish their intellectual identity and place themselves within the religious, cultural, ethnic, moral, and political constructs of our society;
Adverse Food Reactions
Authors: Goldstein Harris
Published: December 2021

Adverse food reaction is the broad descriptive term given to clinically abnormal responses that occur after the ingestion of food or food additives. These responses can be divided into those that do not involve the immune system (food intolerance) and those that are mediated by the immune system (food allergy or hypersensitivity). There are many causes of food intolerance, including the presence of toxic contaminants such as histamine in scombroid fish; the pharmacologic properties of the food, as with tyramine in cheese; a metabolic dysfunction in the patient, such as lactase deficiency; and idiosyncratic responses. The term food allergy is used to describe responses mediated by the host immune system, independent of any physiologic effect of the food or food additive.
Acute Conjunctivitis
Authors: Gigliotti Francis
Published: December 2021

Conjunctivitis, or inflammation of the conjunctiva, usually occurs as a result of infection or allergy. It is an exceedingly common occurrence, certainly the most common acute disease of the eye seen by primary care physicians of children. When it occurs in the neonatal period, it has been given the appellation ophthalmia neonatorum; in older infants and children, it sometimes is called "pink eye." This review covers the etiology, epidemiology, pathogenesis, diagnosis, and therapy of conjunctivitis in infants and children.

Etiology

Neonatal conjunctivitis occurs in 1.6% to 12% of newborns during the first month of life. The chemical irritation from antimicrobial prophylaxis against bacterial infection is the most frequent cause, followed by Chlamydia trachomatis infection. Other important pathogens in this setting are Haemophilus influenzae and Streptococcus pneumoniae. It is unusual to isolate any of these organisms from healthy eyes. Various streptococci and Staphylococcus aureus have been isolated not only from significant numbers of infected eyes, but also from a substantial number of healthy eyes, leaving their exact role less clear. Rarely, gram-negative organisms such as Escherichia coli, Klebsiella, or Pseudomonas sp have been implicated as causes of neonatal conjunctivitis, especially in infants in intensive care units.

Neisseria gonorrhoeae no longer is a major cause of neonatal conjunctivitis in this country because of the mandated use of neonatal ocular prophylaxis.
Neonatal Seizures
Authors: Stafstrom Carl E.
Published: December 2021

Definitions and Epidemiology

A seizure is a sudden, paroxysmal discharge of a population of neurons that causes a transient alteration in neurologic function. This alteration may involve abnormal motor activity, sensory symptoms, a change in the level of alertness, alteration in autonomic function, or any combination of these. When a seizure occurs in the neonatal period, several special considerations arise (Table 1). A seizure in a newborn almost always reflects significant nervous system pathology, and recognizing and treating seizures properly may prevent subsequent chronic neurologic impairment. It is important not to confuse seizures with epilepsy. A seizure is a single event and may be due to a transient abnormality that will not recur (eg, hypoglycemia). Epilepsy is the condition of unprovoked recurrent seizures. Many neonatal seizures are transient events that will not progress to epilepsy. Ictal refers to clinical (based on visual observation) or electrical (based on the electroencephalogram [EEG]) activity occurring during a seizure (Table 2).

Seizures occur in about 0.2% to 1.4% of all newborns. However, the incidence is much higher among certain high-risk groups. About 20% of newborns whose birthweight is less than 2500 g have seizures, with a higher incidence among sicker preterm infants. Incidence also depends on etiology; as many as 50% of newborns who have severe hypoxic-ischemic encephalopathy (HIE) develop neonatal seizures.
Poststreptococcal Acute Glomerulonephritis
Authors: Simckes Ari M. , Spitzer Adrian
Published: December 2021

Postinfectious glomerulonephritis (PIGN) is by far the most common cause of acute glomerulonephritis (AGN) in children. Numerous infectious agents, including bacteria, viruses, fungi, and parasites, have been implicated in PIGN. However, nephritogenic strains of group A betahemolytic streptococci are the most frequent culprits. Clinical manifestations of this syndrome, including hematuria, proteinuria, oliguria, fluid overload, and azotemia, are the result of proliferative and inflammatory changes of the renal glomeruli secondary to immunologic injury.

In addition to PIGN, the differential diagnosis of a child who has AGN must include primary glomerular diseases such as membranoproliferative glomerulonephritis (MPGN), hereditary nephritis (Alport syndrome), and immunoglobulin (Ig)A nephropathy, as well as systemic diseases such as systemic lupus erythematosus, Henoch-Schönlein purpura, and hemolytic-uremic syndrome.
Developmental Dislocation of the Hip: A Clinical Overview
Authors: Mooney James F. , Emans John B.
Published: December 2021

Introduction

The most common musculoskeletal evaluation in the neonatal period and infancy is assessing the child's hips. Treatment of hip dislocation is most successful when begun early, making it imperative that all children undergo repeated, careful hip examinations beginning in infancy until walking age. Those physicians entrusted with the initial examination should have a clear understanding of the etiology, prevalence, and presentation of developmental dysplasia of the hip as well as the appropriate physical examination for this entity.

Historically, the term "congenital dislocation/dysplasia of the hip" (CDH) has been used. Reports illustrating cases of late diagnosis of hip abnormalities in patients who previously have had normal clinical and/or radiographic examinations as well as recognition of the wide spectrum of abnormalities from dislocation to dysplasia have led the orthopedic and pediatric communities to adopt the term developmental dislocation/dysplasia of the hip (DDH). This term now is preferred.

Definitions and Categorization

Hip dislocation can be categorized as "typical" or "teratologic." Teratologic dislocations are uncommon and usually are associated with neuromuscular abnormality, arthrogryposis, or myelomeningocele and typically are high, fixed dislocations. In contrast, "typical" DDH occurs in neurologically normal infants and encompasses a wide spectrum of deformity and presentation. It is important to recognize that previously stable hips may become unstable during infancy, and repeated examinations are needed until the child is of walking age.
Quality Improvement: An ACQIP Exercise on the Management of Acute Asthma—Part 2
Authors: Smith-Ross Shannon , Honigfeld Lisa ,   Staff of the Division of Quality Care
Published: December 2021

Last month's issue of Pediatrics in Review contains the questions asked of participants in the Ambulatory Care Quality Improvement Program (ACQIP) exercise on the management of acute exacerbations of asthma in children. The answers of those who completed that exercise, which was part of the 1993-1994 program, are summarized in this article. In addition, pointers for clinicians are presented as well as practical "pearls of wisdom" from subscribers. Readers who wish to evaluate their own practices may use this exercise and should consider enrollment in the ongoing ACQIP program. Further information may be obtained through the Division of Quality Care of the American Academy of Pediatrics.

[See table in the PDF file]

Quality Pointers for the Office Management of Acute Exacerbations of Asthma in Children

TREATMENT

Goals of Treatment: General treatment goals include helping patients to maintain "normal" pulmonary function rates, maintain normal activity levels, prevent chronic and troublesome symptoms (eg, nocturnal coughing or dyspnea), prevent recurrent exacerbations of asthma, and avoid adverse effects from asthma medications.

The principal goal of management for the acute exacerbation is the recognition of early indicators, such as a worsening peak expiratory flow rate or forced expiratory volume over 1 second or an increase in symptoms, and early treatment to reverse these symptoms.
Consultation with the Specialist
Authors: Poland Ronald L.
Published: December 2021

The specialized care that very-low-birthweight (VLBW) infants (< 1500 g or < 3 lb, 5 oz) need at birth is facilitated best by prior maternal transfer to a tertiary center. However, we cannot always anticipate preterm births soon enough to allow for safe transfer. Accordingly, attending pediatricians should be prepared to evaluate and stabilize such infants prior to transfer to a neonatal intensive care unit. Evaluation starts with the maternal history and the Apgar scores and continues until transfer is accomplished. It consists of frequent assessment of cardiorespiratory function, glucose homeostasis, and the infant's potential for serious infection. Stabilization includes controlling the infant's temperature, supporting cardio-respiratory functions as needed, supplementing glucose, and initially managing potentially life-threatening infections, when applicable. Other problems, such as central nervous system depression or serious malformations, also may require attention.

Clinical Evaluation

The clinical evaluation of the VLBW infant differs from that of the term infant in several ways. For instance, the Apgar score generally has a range narrower than 0 to 10. Because of neurologic immaturity, Apgar scores greater than 6 in VLBW infants are unusual. This difference is due primarily to decreased tone and reactivity compared with that of term infants, but skin color also is less uniform and respiratory effort more variable in this group.
Staphylococcal Scalded Skin Syndrome
Authors: Pollack Shoshannah
Published: December 2021

Staphylococcal Scalded Skin Syndrome (SSSS) is the most severe manifestation in the spectrum of Staphylococcus aureus exotoxin-mediated disease in skin. The disease is characterized by erythema and exfoliation and is mediated by exotoxins elaborated primarily by phage group II S aureus.

SSSS affects children, especially infants. Both sporadic and epidemic cases occur. Older children and adults rarely are affected. Immature renal function, leading to a reduced ability to clear bacterial exotoxin, may account for the increased susceptibility of neonates, according to Elias and Fritsch. Renal and immunologic dysfunction predispose to the disease in older individuals.

SSSS begins abruptly with tender erythema of the skin. Within 12 to 14 hours, the attachment between the stratum corneum and underlying epidermis becomes weak.