bluuebunny/crossref_metadata_2025 huggingface dataset:
Are the King County SIDS Data Generalizable?
Authors: HAAS JOEL E.
Published: December 2021

In Reply.—

Dr Brooks aptly cautions that one may not appropriately base intergroup comparisons on criteria used to define the groups. We specifically indicated our intention not to do so in pointing out the folly of such "circular reasoning" in the manuscript's penultimate paragraph. We do not cite the statistical significance of SIDS intergroup differences. We do wish to emphasize the lack of differences in 5-minute Apgar score and growth velocity when the "classic SIDS" group is compared to appropriate controls.
Prenatal Detection of Neuroblastoma: A Ten-Year Experience From the Dana-Farber Cancer Institute and Children's Hospital
Authors: Ho Peter T.C. , Estroff Judy A. , Kozakewich Harry , Shamberger Robert C. , Lillehei Craig W. , Grier Holcombe E. , Diller Lisa
Published: December 2021

Objectives. To assess the relative frequency of, the clinical and pathological correlates in, and the prognosis of the subset of infants with neuroblastoma who were identified initially by prenatal ultrasonography.

Design. Retrospective review of all patients with neuroblastoma evaluated between 1982 and 1992.

Setting. Large, urban, tertiary care children's hospital in Boston, Massachusetts.

Patients. Eleven infants with neuroblastoma initially detected with prenatal sonograms were identified.

Results. Nine patients had adrenal tumors; two had thoracic paraspinal tumors. Typical diagnostic evidence for neuroblastoma including a palpable abdominal mass and elevations in urinary catecholamines were not commonly seen postnatally. These patients had multiple favorable prognostic indicators including low stage of disease (10/11), favorable biological markers including cellular DNA content (5/5) and N-myc oncogene copy number (5/5), and histopathology suggestive for neuroblastoma in situ (7/11). All patients were treated by surgical resection. One patient exhibited progression of disease postoperatively, but demonstrated a complete clinical response to multiagent chemotherapy. Overall survival in our population was excellent with no deaths seen at a mean follow-up of 37 months (range 3 to 120 months).

Conclusions. Patients with neuroblastoma identified by prenatal ultrasonography generally, although not exclusively, follow a clinically favorable course in which surgical resection is curative. Chemotherapy is not indicated unless substantial progression of disease occurs.
The Treatment of Nocturnal Enuresis—Where Are We Now?
Authors: RAPPAPORT LEONARD
Published: December 2021

Nocturnal enuresis is a common problem in childhood that occurs in approximately 8% of 8-year-olds. Although our knowledge about the etiology, treatment, and benefits of treatment in enuresis has grown, expert consensus in these three areas remains elusive. During the past several years pediatricians have been confronted with a considerable amount of publicity and advertising related to the treatment of enuresis with desmopressin acetate (DDAVP). The information surge regarding enuresis has left many pediatricians confused as to appropriate intervention strategies to be considered in the management of this very common childhood malady.

ETIOLOGY OF NOCTURNAL ENURESIS—WHAT DO WE KNOW?

Although there clearly are diseases and structural abnormalities that can cause enuresis, the etiology in most children with enuresis remains unclear.
Guidelines for the Administration of Medication in School
Authors:   Committee on School Health
Published: December 2021

Many children and adolescents are able to attend school because of the effectiveness of their medication. The health circumstances requiring medication are diverse. Medication may be essential for continued functioning, either as a component of an elaborate treatment plan for the student with a complex disability or as the only treatment necessary for a student to maintain or regain control of his/her chronic illness. In rare instances medications may be necessary for life-threatening emergencies. For most students, the use of medication will be a convenient benefit to control acute minor or major illnesses, allowing a timely return to the classroom with minimal interference to the student and to others. A student may also symptomatically benefit from nonprescription medications.

SCHOOL POLICY

The school board and the school superintendent, in conjunction with other school personnel and in collaboration with the physician or medical advisory committee for each school (district), should develop a policy for the administration of medication in the school setting. The guidelines should indicate what age and/or class levels are included, such as kindergarten through grade 12 or, alternatively, separate guidelines for different grades. Individual school districts also should seek the advice of counsel as they assume the responsibility for giving medication during school hours. Liability coverage should be provided for the staff, including nurses, teachers, athletic staff, principals, superintendents, and members of the school board. Any student who must take medication during regular school hours should do so in compliance with the school's regulations.

The American Academy of Pediatrics recommends that each school include or consider the following sections in its medication policy.
Ceftriaxone for Otitis Media
Authors: HOBERMAN ALEJANDRO , PARADISE JACK L. , KALEIDA PHILLIP H.
Published: December 2021

To the Editor.—

Green and Rothrock have not made the case for their assertion that "a single intramuscular injection of ceftriaxone is as effective as 10 days of oral amoxicillin for the treatment of uncomplicated acute otitis media (AOM)."1,p28 Of the many methodological limitations that render their study results questionable, the most important follow.

First, given the study's overly general eligibility criteria, many of the children enrolled may not actually have had AOM. The criteria consisted of at least one symptom (fever, otalgia, or irritability), at least one sign ("discoloration," bulging, impaired mobility, or opacity of the eardrum), and an "abnormal" tympanogram, defined as any type other than NL or TR-s.2
Ceftriaxone for Otitis Media
Authors: GREEN STEVEN M , ROTHROCK STEVEN G
Published: December 2021

In Reply.—

Dr Brauer worries that our report documenting the efficacy of single-dose ceftriaxone for acute otitis media (AOM) will result in widespread microbial resistance to this drug. We feel this exceedingly unlikely, because ceftriaxone has been in widespread use for a decade with no evidence of impaired efficacy. Additionally, single injections of low-dose ceftriaxone have been standard antigonococcal therapy for several years, again with no diminution in efficacy. Finally, ceftriaxone is recommended only for a limited number of AOM cases, ie, those in which compliance with 10 full days of oral antibiotics is believed to be unlikely.
Can Seizures Be the Sole Manifestation of Meningitis in Febrile Children?
Authors: Green Steven M. , Rothrock Steven G. , Clem Kathleen J. , Zurcher Raymond F. , Mellick Laura
Published: December 2021

Objective. It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis.

Design. Retrospective case series.

Setting and patients. 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period.

Main outcome measures. Signs and symptoms of meningitis in patients having associated seizures.

Results. Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found.

Conclusion. In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.
Childhood Injury Prevention Counseling in Primary Care Settings: A Critical Review of the Literature
Authors: Bass Joel L. , Christoffel Katherine Kaufer , Widome Mark , Boyle William , Scheidt Peter , Stanwick Richard , Roberts Kenneth
Published: December 2021

Objectives. The American Academy of Pediatrics (AAP) believes that health education, through office-based counseling, can contribute to childhood injury prevention. This report presents the results of a critical review of the scientific literature on the effectiveness of primary care-based counseling to prevent childhood unintentional injury.

Methods. A panel selected from the AAP Committee and the AAP Section on Injury and Poison Prevention searched the English-language scientific literature for all articles about childhood unintentional injury prevention counseling. A standardized format was developed to record data on each study. Two members of the panel independently reviewed each article. Articles that were original reports and in which unintentional injury prevention counseling took place in a primary care setting were included. Articles were encoded and analyzed by computer and then grouped by quality of evidence using the US Preventive Services Task Force (USPSTF) method of categorizing results of medical care evaluation. Articles were rated by strength of study design in order to compare studies within each USPSTF group.

Results. Twenty articles met the criteria for inclusion. Of these, 18 showed positive effects of injury prevention counseling including five randomized/controlled, 10 non-randomized/controlled, two multiple time series, and one descriptive study. In 15 of the positive studies, physicians performed the counseling. Positive outcomes as measured by increased knowledge, improved behavior, or decreased injury occurrence were reported for both motor vehicle and non-motor vehicle injuries.

Conclusions. The literature review supports the recommendation of the AAP to include injury prevention counseling as part of routine health supervision. This recommendation has implications for health care reimbursement and care content.
PLAN TO SPEED APPROVAL OF DRUGS: MAKERS WOULD PAY FEES TO U.S
Authors: L. J. F.
Published: December 2021

WASHINGTON, Aug. 10—The Government and the drug industry are near an agreement to require the companies to pay fees that would be used by the Food and Drug Administration to hire 600 new examiners and speed approval of drugs, officials on both sides said today.

The agreement, being worked out by Congressional staff members, is intended to resolve what both the Government and industry have said for the last few years is a catastrophe waiting to happen: the number of drug applications is rapidly increasing, especially because of the boom in biotechnology products, some of which might save lives if they were available. But the F.D.A. has not had enough staff members to keep up.

Advocates of people with AIDS, cancer and rare diseases have all pressed for quicker approval of potentially life-saving drugs, for time can be crucial in treatment.
EVEN MT. EVEREST IS CROWDED
Authors: L. J. F.
Published: December 2021

If the top of Mount Everest sounds a safe bet for those in search of solitude and tranquility, think again. On May 12th this year so many climbers were waiting to reach the summit that a queue formed. By the end of the day 32 people had stood on top of the world. More climbers conquered Everest this year than in the quarter century after Hillary and Tenzing's first ascent in 1953.

Base camp at the foot of the mountain was particularly crowded and squalid; unseemly fights broke out between mountaineers from different countries. Even halfway up the mountain the squabbling continued. Leaders of teams from New Zealand and America complained that a group of Russians had strayed from their designated route and cut in front of them.
`One-Touch' Electrically Operated Motor Vehicle Windows: A Potential Hazard for Children
Authors: HENNES HALIM M.
Published: December 2021

In the United States, traumatic injury is the leading cause of death in children 1 to 19 years of age. In 1986, fatalities from motor vehicle-related injuries accounted for 47% of all deaths from unintentional injury. Motor vehicle manufacturers continually introduce new convenience features to attract buyers. The "one-touch" electrically operated driver side window has become a popular convenience feature. This feature allows the driver to roll his or her window up or down by touching the control switch once in the desired direction. On some motor vehicles, window closing can be activated with a remote control device. This case report is presented to alert parents and health care providers of the potential hazard of this new feature.
Toward Improving the Outcome of Pregnancy, 1993: Perinatal Regionalization Revisited
Authors: LITTLE GEORGE A. , MERENSTEIN GERALD B.
Published: December 2021

Toward Improving the Outcome of Pregnancy: The 90s and Beyond (TIOP II) was released by The March of Dimes Birth Defects Foundation (MOD) in May of this year. A predecessor, TIOP I, released in 1976 by the MOD, is considered to be the cornerstone document for the structure of the regional perinatal care system present in the United States today.

Revisitation of our approach to perinatal care took place because we know we have a persistent problem with perinatal outcomes in the United States. Our perinatal statistics lag behind those reported by many other nations. We know we should do better and are becoming frustrated with relative lack of progress. Infant mortality is an indicator that has attracted professional concern and national initiatives. It has been placed on local political agendas and discussed frequently in the media of cities such as Boston and Washington.
Pediatric Surgery: The Long Road to Recognition
Authors: Koop C. Everett
Published: December 2021

Before 1946, when I completed my training in general surgery, I knew very little about the field that eventually became known as pediatric surgery. I knew that children did not get a fair shake in surgery; that was amply proved during my internship and residency. Surgical patients came from the adult world, and children had a difficult time competing with them. Surgeons in general were frightened of children, and they distrusted the ability of anesthetists to wake children up after putting them to sleep, a position not far from that of many anesthetists. The younger and smaller the patient, the more significant the hazard. I knew, also, that in the United States and in Europe, where some surgery of children was more successfully carried out, it fell usually into one of the specialties, especially orthopedics. In those days there was a need for such specialization in the treatment of diseases that are no longer problems: tuberculosis of the bone, osteomyelitis, and polio.

I wish I could say that my knowledge of the sad state of child surgery as I saw it in Philadelphia made me determined to bring about changes for the better. Actually, during the last year of my general surgery training at the Hospital of the University of Pennsylvania, I was invited to become surgeon in chief of the Children's Hospital of Philadelphia. Pediatric surgery was thrust upon me. Nevertheless, I was excited about the chance to make surgery safer for children, and I entered my career with that goal.
Adolescents and Human Immunodeficiency Virus Infection: The Role of the Pediatrician in Prevention and Intervention
Authors:   TASK FORCE ON PEDIATRIC AIDS
Published: December 2021

The incidence of human immunodeficiency virus (HIV) infection among adolescents is both significant and rising, and concern about this disease is increasingly evident among adolescents, their parents, and health professionals. Such concern evolves from multiple factors including not only the number of adolescents who have been reported to have the acquired immunodeficiency syndrome (AIDS), but also the uncertainty as to how many youths have been infected with the virus but remain asymptomatic; the risk of becoming infected through either heterosexual behavior, homosexual behavior, or substance abuse; and the need to implement effective preventive strategies.

EPIDEMIOLOGY

By the end of December 1992, a total of 946 cases of AIDS in persons aged 13 through 19 had been reported to the Centers for Disease Control. Although adolescents account for less than 1% of the total reported cases of AIDS, 20% of total cases occur in young adults aged 20 through 29.

The long latency period between infection with HIV and the emergence of clinical AIDS, often in excess of 5 years, suggests that many of these young adults were first infected during their adolescence. For others, who become infected as young adults, the sexual or drug use behaviors that placed them at risk for infection had their onset during adolescence.

Although national cross-sectional seroprevalence studies have not been conducted, data from selected populations of adolescents provide some information about the rate of infection among segments of the adolescent population. Since October 1985, the Department of Defense has tested applicants for military service for HIV infection. The Prevalance rate for 17- to 19-years-old screened between October 1985 and March 1989 was 0.34 per 1000.
In Reply: Hair Burning Syncope
Authors: LEWIS DONALD W.
Published: December 2021

Doctors White and Toor help to expand the spectrum of "Hair-Grooming Syncope Seizures" with their report of "hair burning syncope" and once again show that history is the most sensitive diagnostic tool. Their patients might easily have been diagnosed as having complex partial seizures if limited histories had only included the report of foul odor followed by loss of consciousness. Clearly, the noxious stimulus of one's hair being on fire might be sufficient to precipitate a vasovagal event followed by an hypoxic seizure.

Although these cases are all from Virginia-North Carolina, I am confident that this is a widespread phenomenon, with certain cultural biases depending on hair-grooming customs.
Human Immunodeficiency Virus Seropositivity in Adolescents With Syphilis
Authors: McCabe Edward , Jaffe Leslie R. , Diaz Angela
Published: December 2021

Objective. The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection among innercity, minority group adolescents.

Methods. From August 1989 through June 1990, serum from all positive serologic tests for syphilis, obtained from patients attending a comprehensive adolescent health center in an acquired immunodeficiency syndrome epicenter and its two school-based clinics, were frozen without patient identifiers and were subsequently screened for HIV by enzyme-linked immunosorbent assay with confirmatory Western blot for positives. In addition, a retrospective chart review was performed for all patients with a positive serologic test for syphilis during the study period.

Results. Of the 59 specimens with a positive syphilis serologic test, 9 (15.3%) were HIV seropositive. Of the patients with syphilis, 57.4% were black and 42.6% were Hispanic; 16.4% were male (mean age 18.1) and 83.6% were female (mean age 17.8). Only 1 subject (female) was an injection drug user; 4 of the male subjects self-identified as having had sex with other males. Of the subjects, 27.8% had primary, 19.7% had secondary, and 52.5% had latent syphilis at the time of diagnosis. A prior or concurrent sexually transmitted disease was present in 90% of the males and 80% of the females; gonorrhea was the most prevalent sexually transmitted disease in the males (89%) and chlamydia was most prevalent in the females (35%). A history of chancroid and/or herpes was present in 16.4% of the subjects.

Conclusions. It is concluded that the diagnosis of syphilis in an adolescent is a risk factor for HIV infection. All sexually active adolescents should be routinely screened for syphilis, regardless of sexual practices. Those with syphilis should be specifically counseled about their increased risk for HIV infection and the importance of consistent condom use, and they should be referred for formal HIV pretest counseling.
Capillary Refill: Is It a Useful Clinical Sign?
Authors: BARAFF LARRY J.
Published: December 2021

Capillary refill is a clinical sign popularized in the past 15 years. Intuitively it is a measure of peripheral perfusion which is likely to be a function of cardiac output and peripheral vascular resistance. It is a semiquantitative test, with a value of < 2 seconds generally considered to be normal.

In 1980, Champion et al1 proposed capillary refill as one of five elements of the Trauma Score. Two seconds was defined as the upper limit of normal. After the publication of the Trauma Score and the inclusion of capillary refill as a formal means of evaluation of not only trauma patients but of many other classes of patients, including children,2,3 my colleagues and I made the bedside observation that capillary refill was not a reliable clinical sign.
Unlisted Ingredients
Authors: KAO NEIL L.
Published: December 2021

To the Editor.—

Studies by Kumar et al1,2 demonstrate clearly the number and potential importance of unlisted ingredients. Reactions triggered by these excipients may in fact account for many reported adverse drug reactions, including reactions to antihistamines and corticosteroids, originally thought to be caused by the primary medications. When patients suspected of having a hypersensitivity disease are evaluated for the etiologic factor, excipients should be included among the suspected causative agents. For example, in a patient evaluated recently for the etiology of urticaria, we determined that his toothpaste was the etiologic agent.
Comparison of Prophylaxis and Rescue Treatment With Curosurf in Neonates Less than 30 Weeks' Gestation: A Randomized Trial
Authors: Egberts Johannes , de Winter J. Peter , Sedin Gunnar , de Kleine Martin J.K. , Broberger Ulf , van Bel Frank , Curstedt Tore , Robertson Bengt
Published: December 2021

Objective. The aim of this randomized clinical trial was to evaluate the immediate effects of prophylactic administration of Curosurf and to compare outcomes after prophylactic or expectant management.

Study design. Porcine surfactant (Curosurf, 200 mg/kg body weight) was administered intratracheally within 10 minutes of birth to preterm neonates with a gestational age of 26 to 29 weeks (n = 75); rescue-eligible neonates (n = 72) were initially subjected to a sham maneuver. The primary end points of the trial, evaluated at the age of 6 hours, were to obtain (1) a 40% decrease in the ratio between transcutaneous oxygen tension (tcPo2) (kPa) and fraction of inspired oxygen (Fio2), and (2) a 50% decrease in the incidence of radiologically verified respiratory distress syndrome (RDS). After 6 to 24 hours, a similar dose of surfactant was given to the neonates of both the prophylaxis and the rescue-eligible group, if they needed mechanical ventilation with an Fio2 ≥ 0.6.

Results. At 6 hours the prophylaxis group had, in comparison with the rescue-eligible group, significantly higher tcPo2/Fio2 ratios (mean ± SD: 39.7 ± 15.3 vs 28.1 ± 18.1; P < .001) and less severe RDS by radiological scoring (χ2 = 14.9; P = .005). Severe RDS was present in 19% of the prophylactically treated neonates versus 32% in the rescue-eligible group (P < .05). The prophylaxis group needed shorter periods of Fio2 > 0.40 than the rescueeligible neonates (P < .01), and eight neonates of the prophylaxis group (11%) versus 23 of the rescue-eligible group (32%) qualified for rescue treatment with surfactant in the interval 6 to 24 hours (P < .01). There were no differences in the incidence or severity of pneumothorax, pulmonary interstitial emphysema, cerebral hemorrhage, periventricular leukomalacia, patent ductus arteriosus, in the duration of mechanical ventilation or time in supplemental oxygen, or in mortality.

Conclusions. Subgroup analysis revealed (1) that administration of corticosteroids reduced the risk of developing neonatal RDS as effectively as did surfactant prophylaxis at birth, and (2) that prophylaxis was effective especially in neonates with gestational age <28 weeks or birth weight <1000 g, in male neonates, and in neonates who had received no antenatal treatment with corticosteriods. Our data indicate that prophylactic treatment with surfactant should be considered in high-risk neonates fulfilling these latter criteria.
Ocular Sequelae in Premature Infants
Authors: Page Jacqueline M. , Schneeweiss Suzan , Whyte Hilary E. A. , Harvey Patricia
Published: December 2021

Objective. The authors report on the incidence of myopia and strabismus at 12 and 24 months postterm in a cohort of 190 premature infants with birth weights of less than 1251 g born in 1986 and 1987.

Methods. The neonatal and follow-up eye charts of a cohort of 190 premature infants were retrospectively reviewed. All 138 children who survived the neonatal period had at least one eye examination between day 28 and 42 of life that documented the presence and staging of retinopathy of prematurity (ROP) according to the International Classification of ROP. No infants received cryotherapy. Eye examinations conducted at 12 and 24 months postterm included assessment of vision, fundus, ocular motility, anterior segment abnormality, and refractive error. Eyes were refracted using cycloplegic retinoscopy. Strabismus was detected using the Hirschberg and cover tests. Eye reports were available for 80% (n = 110) at 12 months and 36% (n = 50) at 24 months.

Results. Fifty-three percent of the cohort exhibited ROP in the neonatal period; 12% of these progressed to stage 3 or 4 ROP. Myopia was observed in 16% (18/110) of the cohort at 12 months of age; 4.5% (5/110) measured more than 4.0 diopters of myopia. Children with birth weights of less than 751 g were 3.2 times more likely than those with birth weights between 751 and 1000 g and 10 times more likely than those with birth weights between 1001 and 1250 g to develop myopia in the first year of life. The likelihood of myopia at 12 months doubled with each increment in ROP stage. Of the 50 children reexamined at 24 months postterm, more than 80% demonstrated deteriorating vision. The incidence of myopia increased to 38% (19/50) overall, with 24% (12/50) of the cohort showing severe myopia. Astigmatism and anisometropia were highly correlated with severe myopia. Strabismus was seen with increasing frequency through the second year of life. All children with grade III or IV intraventricular hemorrhage in the neonatal period developed esotropia.

Conclusion. This study emphasizes the significant roles of low birth weight, ROP, and intraventricular hemorrhage in the development of myopia and strabismus. Follow-up to 2 years of life is recommended given the demonstrated deterioration our cohort.
Adolescent Gestational Weight Gain and Birth Weight
Authors: Stevens-Simon Catherine , MCAnarney Elizabeth R. , Roghmann Klaus J.
Published: December 2021

Objective. To examine the relationship among maternal age, prepregnancy weight, gestational weight gain, and birth weight in 141 low-income black adolescents and their infants.

Study sample. One hundred forty-one consecutively enrolled, low-income, black adolescents who entered prenatal care prior to their 23rd week of gestation, were free of chronic diseases, took no regular medications, had no known uterine anomalies, and gave birth to one live neonate.

Results. After controlling for prepregnancy weight and other potentially confounding variables, we found a significant relationship between gestational weight gain and infant birth weight among younger adolescents (<16 years old at conception), but not among older adolescents (16 through 19 years old at conception); younger adolescents contributed more of their gestational weight gain to their fetuses than did older adolescents. Among younger adolescents the rate of maternal weight gain during the entire gestation was significantly correlated with birth weight (r = .40; P < .01), whereas for older adolescents only maternal weight gain during the second half of gestation was significantly correlated with birth weight (r = .25, P < .05).

Conclusions. The data do not support the thesis that younger adolescents compete with their fetuses for nutrients; in fact, younger study adolescents transferred more of their gestational weight gain to their fetuses than did older adolescents.
Maternal Smoking Before and After Pregnancy: Effects on Behavioral Outcomes in Middle Childhood
Authors: Fergusson David M. , Horwood L. John , Lynskey Michael T.
Published: December 2021

Objective. The aim of this research was to examine the extent to which maternal smoking before and after pregnancy was associated with childhood disruptive behaviors when due allowance was made for potentially confounding factors which may have been associated with both maternal smoking habits and childhood problem behaviors.

Methods. During the course of a 15-year longitudinal study of a birth cohort of 1265 New Zealand children, the following measures were obtained: (1) measures of daily cigarette intake during pregnancy and after pregnancy; (2) measures of childhood disruptive behaviors including conduct problems and attention deficit behaviors based on both maternal and teacher report data; and (3) measures of a series of potentially confounding family, social, parental, and related factors.

Results. Before adjustment for confounding, maternal smoking both before and after pregnancy was found to be associated with significant increases in rates of childhood problem behaviors: children whose mothers smoked in excess of 20 cigarettes per day had mean problem behavior scores that were between 0.16 and 0.56 standard deviations higher than those of children whose mothers were nonsomkers. The results were then adjusted using regression methods to take account of (1) correlations between pregnancy and postpregnancy smoking and (2) potentially confounding factors. The results of regression adjustment suggested that maternal smoking during pregnancy was associated with small but statistically detectable increases in rates of childhood problem behaviors, with children whose mothers smoked in excess of 20 cigarettes per day having mean scores that were 0.10 to 0.36 standard deviations higher than those of the offspring of nonsmokers, even after adjustment for a series of confounding factors. However, smoking after pregnancy was not significantly associated with increased rates of childhood problem behavior after adjustment for sources of confounding.

Conclusion. The results are generally consistent with the hypothesis that smoking during pregnancy may be associated with small but detectable increases in the risks of problem behaviors in childhood. This suggests that possible adverse effects on childhood behavioral adjustment should be added to the growing list of adverse consequences of parental smoking for childhood health and well-being.
Safety and Immunogenicity of a Combined Diphtheria, Tetanus, Pertussis and Haemophilus influenzae Type b Vaccine in Young Infants
Authors: Paradiso Peter R. , Hogerman Deborah A. , Madore Dace Viceps , Keyserling Harry , King James , Reisinger Keith S. , Blatter Mark M. , Rothstein Edward , Bernstein Henry H. ,   Pennridge Pediatric Associates, Hackell Jill
Published: December 2021

Objective. To study the safety and immunogenicity of a combined diphtheria-tetanus-pertussis (DTP)-Haemophilus influenzae type b (HbOC) vaccine (TETRAMUNE) in infants as young as 2 months of age as compared to separate administration of DTP and HbOC.

Methods. Two-month-old infants were randomized to receive three doses 2 months apart of either DTP-HbOC as a single 0.5-mL injection or to receive 0.5 mL of DTP and HbOC concurrently in separate legs. Local and systemic adverse reactions were monitored within 72 hours of each immunization, and immunogenicity of each of the four vaccine components was measured.

Results. The incidence of both local and systemic adverse events following the tetravalent vaccine was similar to the incidence following separate vaccine administration. After three doses of vaccine, the response to each of the vaccine components was higher in the combined vaccine when compared to separate administration. In the case of the Haemophilus influenzae type b component, this enhancement was also seen after two doses. The response to the combined vaccine was consistent among the three lots tested as was the enhancement over separate administration.

Conclusions. The DTP-HbOC vaccine was safe and immunogenic in young infants and was generally more immunogenic than separate vaccination with DTP and HbOC. The use of such a combined vaccine reduces the number of injections given to young infants by half and is an important step toward improving vaccine delivery.
Varicella-Zoster Virus Infection in Romanian Children Infected With the Human Immunodeficiency Virus
Authors: Leibovitz Eugene , Cooper David , Giurgiutiu Dana , Coman Gabriela , Straus loanna , Orlow Seth J. , Lawrence Robert
Published: December 2021

Objective. Varicella-zoster virus (VZV) infections can cause severe disease in immunocompromised individuals. To evaluate the spectrum of VZV infections in human immunodefidency virus (HIV)-infected children, we retrospectively analyzed all the cases of VZV infection in a cohort of children cared for at a hospital for infectious diseases in Bucharest, Romania.

Methods. The records of 391 HIV-infected children admitted to the acquired immunodeficiency syndrome pavilion of Colentina Hospital during the period January 1, 1991, through March 31, 1992, were reviewed for evidence of VZV infection. The diagnosis of varicella or zoster was made clinically and information was collected concerning course of the illness, number of skin lesions, and clinical evidence of complications. Lymphocyte subpopulation typing, as an estimate of immune function, was performed by either a standard fluorescent activated flow cytometric method or by immunofluorescent technique.

Results. Thirty-eight cases of varicella (9.7%) and seven cases of zoster (1.8%) were adequately documented among the 391 records reviewed. The duration of varicella was prolonged; in 57% of the children it was greater than 10 days. Forty percent of children with varicella developed a complication, including superinfection of the skin, pneumonia, or thrombocytopenia. None of the children developed clinical hepatitis or encephalitis. Two children (5%) died during varicella, both of respiratory failure. None of the 7 children with zoster had chronic, recurrent, or disseminated lesions. Lymphocyte subset analysis was available for 22 of 38 children with varicella and 3 of 7 children with zoster. Fifteen of the 22 children had normal, age-adjusted, absolute CD4 counts within 3 months of the diagnosis of varicella. All 3 children with zoster who had lymphocyte subset analysis had low CD4 counts and absolute numbers. None of the 45 children received antiretroviral therapy and only 1 child with varicella and 1 with zoster received acyclovir.

Conclusions. The spectrum of VZV infection in this hospitalized group of HIV-infected children was broad. The majority (57%) experienced a prolonged course of disease and a higher rate of complications than normal children hospitalized with varicella.
Papular-Purpuric Gloves and Socks Syndrome: A Characteristic Viral Exanthem
Authors: STONE MARY SEABURY , MURPH JODY R.
Published: December 2021

In 1990, Harms et al1 reported a unique dermatosis occurring in the spring in five Swiss young adults. These individuals had acral edema and a characteristic fine papular eruption containing petechiae confined primarily to the hands and feet, with sharp demarcation at the ankles and wrists. In several of the patients fever, lymphadenopathy, leukopenia, and oral lesions ranging from erythema to erosions were associated with the eruption. Although each of the patients had been recently taking a variety of medications, the authors thought that a drug etiology was unlikely. This characteristic eruption associated with fever and lymphopenia suggested the possibility of an unusual viral exanthem.
ΔF508 Genotype Does Not Predict Disease Severity in an Ethnically Diverse Cystic Fibrosis Population
Authors: Lester Lucille A. , Kraut Jerome , Lloyd-Still John , Karrison Theodore , Mott Carol , Billstrand Chris , Lemke Amy , Ober Carole
Published: December 2021

Objective. As part of a study to determine population-based frequencies of CFTR mutations in an ethnically diverse, midwestern cystic fibrosis (CF) population, clinical histories were studied in 119 CF patients.

Methodology. We sought to examine the association between genotype as characterized by the ΔF508 and 11 other commonly occurring mutations and clinical parameters including age at diagnosis, clinical presentation, sweat chloride level, chest roentgenogram score, clinical scores, pulmonary function test results, percent weight for height, and presence of associated CF complications.

Results. Age at diagnosis of CF was significantly associated with homozygosity for ΔF508 (mean age at diagnosis ± SE: 1.7 ± 0.3 years for ΔF508/ΔF508 vs 3.9 ± 0.9 years for ΔF508/other and other/other; P = .03). No other age-adjusted clinical parameter was significantly associated with ΔF508 or any other genotype.

Conclusion. These data suggest that in this sample of CF patients, ΔF508 genotype is not predictive of disease severity. The lack of association between disease severity and genotype in this ethnically diverse sample may reflect the presence of more severe undetected mutations in our sample, or the effects of modifying genes at other, non-CF loci.
Screening for Tuberculosis in Infants and Children
Authors:   Committee on Infectious Diseases
Published: December 2021

CURRENT STATUS OF INFECTION AND DISEASE

In 1992 the reported number of cases of tuberculosis (TB) was increased to 26 673 in the United States, an increase of 1.5% from 1991. Although a decline of approximately 5% to 6% occurred from 1981 to 1984, during the period of 1985 to 1992 the number of reported cases increased by 20.1%. The largest increase in TB cases by age group occurred in the 25- to 44-year-old cohort (54.5% increase in 1985 to 1992), whereas cases increased 36.1% among children 0 to 4 years old and 34.1% among children 5 to 14 years old.1 This recent increase in the number of reported cases of tuberculosis and the changing epidemiology of this disease in children have necessitated a reevaluation of the appropriate use and type of skin test for the diagnosis.2

Within the general population there are groups at varying risk for infection and for progression to disease (Table 1). To achieve significant progress toward reducing the number of future cases of TB, it is necessary to have the following: 1) identification of high-risk groups, with Mantoux tuberculin skin testing of persons in those groups; 2) evaluation to determine the actual presence of disease in those persons identified as infected; and 3) provision of appropriate therapy for both those with positive Mantoux tests and those with active disease.3 Therefore, the emphasis should be to identify targeted high-risk populations for annual skin testing rather than routinely screening all persons. Routine screening would indude a vast number of individuals at low risk.
Medicaid Policy Statement
Authors:   Committee on Child Health Financing
Published: December 2021

The American Academy of Pediatrics recognizes the achievements of the Medicaid program in improving access to health care services for poor children. Despite recent legislative expansions to extend eligibility to more poor and disabled children and to broaden the scope of preventive and treatment services in all states, several additional program improvements are needed to eliminate the following barriers to access:

1. Federal and state fiscal crises are creating major roadblocks to Medicaid program implementation and expansion.

2. Thousands of poor children will not be eligible for Medicaid until October 1, 2001.1

3. Only a portion of those who are potentially eligible for Medicaid apply for coverage, and many eligible children do not utilize services.

4. Fewer Medicaid funds are available for primary and preventive care because of the increasing need for long-term care services.

5. Early and periodic screening, diagnosis and treatment (EPSDT)/preventive health services are being received by too few children and the implementation of expanded service coverage under EPSDT, granted in 1989, is subject to a great deal of inconsistent state interpretation.

6. Inadequate provider reimbursement reduces children's access to health care services.

The Academy has developed the "Children First" proposal which calls for the elimination of Medicaid and replaces it with a one-class, private insurance system of universal access to health care for all children through age 21 and for all pregnant women.2 However, until the "Children First" proposal, or a similar health care reform initiative is implemented, the Academy recommends the following policy actions to improve the current Medicaid program.
Hepatitis B Immunization: Pediatrician's Perspective
Authors: Jacobs Stephen
Published: December 2021

In a recent article Freed et al1 report their study of physicians reactions to the recommendations for hepatitis B immunization of infants. Hall and Margolis, in their commentary,2 expand on Freed's conclusion that the problem with the acceptance of these recommendations was caused by inadequate education. There is, however, another conclusion that might be drawn: that the 68% of physicians who believed that hepatitis B immunization was inappropnate were right and the recommendations were instead incorrect.
Use of Nonhuman Milks in the Dietary Management of Young Children With Acute Diarrhea: A Meta-Analysis of Clinical Trials
Authors: Brown Kenneth H. , Peerson Janet M. , Fontaine Olivier
Published: December 2021

Objective. To assess the effects of continued feeding of nonhuman milks or formulas to young children during acute diarrhea on their treatment failure rates, stool frequency and amount, diarrheal duration, and change in body weight.

Methods. A total of 29 randomized clinical trials of 2215 patients were identified by computerized bibliographic search and review of published articles. Data were abstracted and analyzed using standard meta-analytic procedures.

Results. Among studies that compared lactose-containing milk or formula diets with lactose-free regimens, those children who received the lactose-containing diets during acute diarrhea were twice as likely to have a treatment failure as those who received a lactose-free diet (22% vs 12%, respectively; P < .001). However, the excess treatment failure rates occurred only in those studies that included patients whose initial degree of dehydration, as reported by authors, was severe, or that were conducted before 1985, when appropriate diarrhea treatment protocols were first widely accepted. Among studies of patients with mild diarrhea, all but one of which were completed after 1985, the overall treatment failure rates in the lactose groups were similar to the rates in the lactose-free groups (13% vs 15%). These results suggest that children with mild or no dehydration and those who are managed according to appropriate treatment protocols, such as that promoted by the World Health Organization, can be treated as successfully with lactose-containing diets as with lactose-free ones. The pooled information from studies that compared undiluted lactose-containing milks with the same milks offered at reduced concentration concluded that (1) children who received undiluted milks were marginally more likely to experience treatment failure than those who received diluted milk (16% vs 12%, P = .05), (2) the differences in stool output were small and of limited clinical importance, and (3) children who received the undiluted milk diets gained 0.25 SD more weight than those who received the diluted ones (P = .004). In addition, as with the previous set of studies, there were no differences in the pooled treatment failure rates between the respective groups in those studies of mildly dehydrated patients conducted after 1985 (14% vs 12%).

Conclusions. The vast majority of young children with acute diarrhea can be successfully managed with continued feeding of undiluted nonhuman milks. Routine dilution of milk and routine use of lactose-free milk formula are therefore not necessary, especially when oral rehydration therapy and early feeding (in addition to milk) form the basic approach to the clinical management of diarrhea in infants and children.
PSYCHIATRIC EFFECTS OF EXPOSURE TO SUICIDE AMONG THE FRIENDS AND ACQUAINTANCES OF ADOLESCENT SUICIDE VICTIMS
Authors: Brent David A. , Perper Joshua , Moritz Grace , Allman Christopher , Friend Amy , Schweers Joy , Roth Claudia , Balach Lisa , Harrington Kelly
Published: December 2021

The friends and acquaintances (N = 58) of 10 adolescent suicide victims were interviewed 6 months after the death of the victims, and the rates of psychiatric disorders that had onset after the death were compared with the 6-month incidence of psychopathology in 58 demographically and psychiatrically matched unexposed controls. The exposed group showed higher rates of any new onset major depressive disorder, but the rate of incident suicide attempts was the same in both groups. The median onset of incident depression among the exposed group was within the first month after exposure, and the majority of those exposed youth with incident depression were still depressed at interview 6 months after the death. Adolescent friends and acquaintances of suicide victims experience considerable psychiatric morbidity subsequent to exposure to suicide, most consistent with pathological grief.
JUDGE LIFTS CALIFORNIA BAN ON IQ TESTS FOR BLACK CHILDREN
Authors: L. J. F.
Published: December 2021

A federal judge in San Francisco ruled that any parent can arrange for the use of IQ testing in assessing students' learning disabilities, despite arguments that the tests discriminate against minorities.

Judge Robert F. Peckham issued a summary judgment ruling in favor of the families of nine black schoolchildren in California. The families were challenging the constitutionality of a statewide ban on the use of standardized intelligence tests for black children in California special-education classes.

The state Department of Education in 1986 banned the use of IQ tests for assessing black students, but the ban did not apply to students from other minority groups. Later, black students seeking access to programs for gifted students were exempted from the tests as well.