bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the Effectiveness of a Pavement Stencil in Promoting Safe Behavior Among Elementary School Children Boarding School Buses
Authors: Burke Georgine S. , Lapidus Garry D. , Zavoski Robert W. , Wallace Lou , Banco Leonard I.
Published: December 2021

Objective. The majority of school busrelated fatalities among children attending elementary school in the United States occur as children board or alight from buses. Injuries occur during boarding when children enter the street and are struck by buses or other vehicles. This study evaluated the effectiveness of a stencil in the shape of a school bus applied to the pavement at a bus stop in improving safe behaviors at bus stops. Specifically, we assessed the frequency of children running toward the bus as it approached or entered the street.

Methods. Elementary school bus stops with similar roadways, traffic profiles, and numbers of children boarding participated in the study. Stops were randomly assigned to an intervention group, in which children were instructed to remain within a safe area during boarding that was demarcated by a pavement stencil, or an education-only group, in which the safe area was demarcated by some existing environmental feature. Both groups received education about safe boarding procedures. Observers rated behavior at each stop daily for 5 consecutive weeks. Data were analyzed as bivariate odds of any unsafe behavior in the education-only group.

Results. One hundred forty-five observations from seven bus stops with stencils and 174 daily observations from six education-only stops were completed. Observations of children in the education-only group were twice as likely to show unsafe behavior while waiting (odds ratio [OR], 2.1;95% confidence interval [CI], 1.3-3.6) and during boarding (OR, 2.1; 95% CI, 1.2-3.9). ORs were significantly higher in the education-only group for boys, girls, and children in grades 4 through 6. When no adult was present, there was a greater likelihood of unsafe behavior among all children in the education-only group while waiting (OR, 16.1; 95% CI, 3.9-72.4) and during boarding (OR, 15.0;95% CI, 3.2-81.4). The presence of an adult at the stop did not have an independent effect on behavior. Children at education-only stops located on roadways with high traffic volume were more likely to engage in unsafe behavior while waiting (OR, 8.0;95% CI, 3.8-17.3) and during boarding (OR, 4.9; 95% CI, 2.2-11.0). No differences were observed during boarding between stencil and education-only groups when 10 or more children were at the stops.

Conclusion. The pavement stencil, when accompanied by education about safe boarding, may represent a cost-effective approach to reducing unsafe behavior at bus stops by children of elementary school age.
Respiratory Characteristics During Sleep in Healthy Small-for-Gestational Age Newborns
Authors: Curzi-Dascalova Lilia , Peirano Patricio , Christova Emilia
Published: December 2021

Objective. Small-for-gestational age (SGA) infants born with intrauterine growth retardation (IUGR) differ from appropriate-for-gestational age (AGA) infants by: a) alterations in a number of neurologic and neurophysiologic characteristics; b) modified heart rate variability during the neonatal period; and c) increased morbidity rates during the first months of life. However, there are no data on the impact of IUGR on respiratory function control at birth.

Methods. We studied 57 newborns who were 35 to 36, 37 to 38, and 39 to 41 weeks' conceptional age (CA): 31 were AGA and 26 were SGA. All were clinically and neurologically normal at birth and none exhibited abnormal events during the first year of life. Polygraphic recordings were performed between two meals during the normal postnatal stay in the maternity ward.

Results. During both active sleep (AS) and quiet sleep (QS), SGA infants in all CA groups had significently higher values for the incidence of 2 to 4.9 seconds and 5 to 9.9 seconds central respiratory pauses (RP), the apnea index (AI) [AI = % of nonbreathing time], and the time spent with periodic breathing (PB), as compared with AGA infants Respiratory frequency was usually similar in SGA and AGA infants. In addition, the trend of age-related respiratory modifications was disturbed in SGA infants, as compared with AGA infants: at 39 to 41 weeks CA, SGA infants had no significant decreases in RP, AI, or PB, and no increase in respiratory frequency. However, between-state differences were similar in both groups. In all AGA and SGA infant groups respiratory frequency seemed to be an individual characteristic: infants who breathed faster during AS breathed faster during QS, and vice-versa.

Conclusion. Our data demonstrate significant modifications in the establishment of respiratory rhythm control in SGA infants, whereas the patterns of state-related and subject-dependent breathing characteristics were similar in SGA and AGA infants. We speculate that the dysregulation of respiratory function control maturation observed in healthy SGA infants may be related to subtle brainstem modifications attributable to the decreased blood supply and chronic hypoxia associated with IUGR.
Morbidity and Mortality in Children Associated With the Use of Tobacco Products by Other People
Authors: DiFranza Joseph R. , Lew Robert A.
Published: December 2021

Objective. To evaluate the impact of adult tobacco use on the health of children.

Design. A literature review identified relevant research reports. Meta-analysis was used to compute a pooled risk ratio for each condition studied. The risk ratios were combined with data on exposure rates to produce estimates of the population-attributable risk.

Results. Each year, among American children, tobacco is associated with an estimated 284 to 360 deaths from lower respiratory tract illnesses and fires initiated by smoking materials, more than 300 fire-related injuries, 354 000 to 2.2 million episodes of otitis media, 5200 to 165 000 tympanostomies, 14 000 to 21 000 tonsillectomies and/or adenoidectomies, 529 000 physician visits for asthma, 1.3 to 2 million visits for coughs, and in children younger than 5 years of age, 260 000 to 436 000 episodes of bronchitis and 115 000 to 190 000 episodes of pneumonia.

Conclusions. The use of tobacco products by adults has an enormous adverse impact on the health of children. Although more research is needed in several areas, action to reduce the morbidity and mortality among childdren should not be delayed. New laws and policies are needed to grant children protection from bodily injury and death attributable to the use of tobacco products by others.
Preliminary Experience With Intestinal Transplantation in Infants and Children
Authors: Filston Howard C. , Colombani Paul M.
Published: December 2021

The report from the University of Nebraska Medical Center Departments of Surgery and Pediatrics by Langnas et al1 documenting their success with intesfinal transplantation in infants and children confirms comparable data from the University of Pittsburgh Transplantation Service that intestinal transplantation is a clinically viable alternative to long-term total parenteral nutrition (TPN) in infants and children with inadequate intestinal function. Most patients considered for intestinal transplantation today are those with end-stage liver disease and short bowel syndrome. They are usually quite debilitated, are in the early stages of multiple organ failure, and have spent much of their recent lives under acute care management in the hospital.
Practice and Guidelines
Authors: Benjamin John T.
Published: December 2021

As a former practicing pediatrician turned academic, I found the article entitled "The Management of Febrile Infants by Primary-Care Pediatricians in Utah: Comparison with Published Practice Guidelines"1 interesting if not disturbing. Three case scenarios were sent to 194 pediatricians: a 3-week-old infant with fever, a 2-month-old infant with rales and bilateral otitis media, and a 20-month-old infant with fever. Ninety-four pediatricians responded and their workups and approaches to treatment compared to ‘practice guidelines" developed by Baraff et al.2
PROTECTION OF PATIENTS' RIGHTS TO PRIVACY INTERNATIONAL COMMITTEE OF MEDICAL JOURNAL EDITORS
Authors: L. J. F.
Published: December 2021

The following statement was agreed by the International Committee of Medical Journal Editors (the Vancouver Group) at its meeting last week in San Francisco. It is a complete revision of the initial guidelines on this subject issued in 1991.

Patients have rights to privacy that should not be infringed without informed consent. Identifying information should not be published in written descriptions, photographs, or pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that the patient should be shown the manuscript to be published.

Identifying details should be omitted if they are not essential, but patient data should never be altered or falsified in an attempt to attain anonymity. Complete anonymity is difficult to achieve, and informed consent should be obtained if there is any doubt. For example, masking of the eye region in photographs of patients is inadequate protection of anonymity.

The requirement for informed consent should be included in the journal's instructions for authors. When informed consent has been obtained it should be indicated in the published article.

Members of the committee are: Frank Davidoff (Annals of Internal Medicine), Richard Smith (British Medical Journal), Bruce P. Squires (Canadian Medical Association Journal), George Lundberg, Richard Glass (JAMA), Richard Horton (Lancet), Martin Van Der Weyden (Medical Journal of Australia), Robert Utiger (New England Journal of Medicine), Richard G. Robinson (New Zealand Medical Journal), Magne Nylenna (Tidsskrift for den Norske Laegeforening), Linda Clever (Western Medical Journal), and Lois Ann Colaianni (National Library of Medicine).
Do Parents and Professionals Agree on the Developmental Status of High-risk Infants?
Authors: Kim M. Marie , O'Connor Kathleen Steel , McLean Jennifer , Robson Ann , Chance Graham
Published: December 2021

Objectives. To examine the degree of agreement between parental reporting of the development of high-risk infants and professional assessment by a multidisciplinary team.

Methods. The developmental status of 196 infants discharged from neonatal intensive care units (NICUs) was assessed by their parents using the Infant Monitoring Questionnaire (IMQ) at 4, 8, or 12 months' corrected age. On the same day, a clinical assessment was done by a multidisciplinary team consisting of a developmental pediatrician, physical therapist, and psychologist. The κ statistic was used to measure agreement between the assessments. Logistic regression was used to investigate factors that might influence agreement.

Results. Both the IMQ and the multidisciplinary team classified infants as developing normally ("normal"), being at risk for abnormal development ("suspect"), or developing abnormally ("abnormal"). Although the same proportion of children fell into the three categories by both assessments, parents and the multidisciplinary team showed poor agreement with respect to the classification of individual infants (k = 0.276). No infant or family characteristic was found to have an influence on agreement.

Conclusions. For a group of high-risk infants discharged from NICUs, the agreement between parental assessment of developmental status using the IMQ and the professional assessment by a multidisciplinary team is poor in the first year of life. We do not recommend the use of this questionnaire as a substitute for clinical assessment of biologically at-risk infants discharged from NICUs. However, it may be useful for those groups of infants for whom no other information is available or as an adjunct to clinical assessment when infants are not behaving typically because of an unfamiliar setting or concurrent illness.
Growth and Physical Outcome of Children Conceived by In Vitro Fertilization
Authors: Saunders Kerryn , Spensley John , Munro Judith , Halasz George
Published: December 2021

Objective. To determine the growth and physical outcome at 2 years of age for children born after assisted reproductive techniques in the state of Victoria.

Design. Using a case-matched control study between January 1991 and July 1993, 314 children (196 singletons, 47 sets of twins, 8 sets of triplets) conceived after in vitro fertilization (IVF) and related techniques at the Monash IVF and Royal Women's Hospital Reproductive Biology Unit and 150 control children (113 singletons, 17 sets of twins, 1 set of triplets) randomly selected from the general population using the Victorian Perinatal Data Collection Unit records were enrolled to be examined for minor dysmorphic and major organ abnormalities. Singleton and twin cases were matched for plurality and gestation and date of birth. Triplets were not matched.

Results. IVF status was not a significant independent factor for physical outcomes, including malformation rates, nor for days of hospitalization postdischarge and operations. There was no significant interaction between IVF status and mean percentiles for weight and head circumference. The IVF group had a greater mean length percentile. Twins in both groups had significantly poorer physical outcomes than singletons on some measures.

Conclusion. This study did not demonstrate an independent IVF effect on the growth and physical outcome of children at 2 years of age when matched for plurality and gestation. The poor outcomes where noted were related to the effects of multiple births. These findings must be viewed in context of the response rates and therefore representativeness of the data. The need for longitudinal studies is demonstrated.
Natural History of Human Immunodeficiency Virus Disease in Perinatally Infected Children: An Analysis From the Pediatric Spectrum of Disease Project
Authors: Barnhart Huiman X. , Caldwell M. Blake , Thomas Pauline , Mascola Laurene , Ortiz Idith , Hsu Ho-Wen , Schulte Joann , Parrott Robert , Maldonado Yvonne , Byers Robert ,   Pediatric Spectrum of Disease Clinical Consortium
Published: December 2021

Objective. To describe the progression of human immunodeficiency virus (HIV) disease through clinical stages from birth to death among a large number of perinatally infected children.

Methods. The Pediatric Spectrum of Disease (PSD) project, coordinated by the Centers for Disease Control and Prevention (CDC), has conducted active surveillance for HIV disease since 1988 in seven geographic regions. PSD data are collected from medical and social service records every 6 months through practitioners at each participating hospital clinic. We analyzed data from perinatally HIV-infected children born between 1982 and 1993. The natural history of HIV disease was divided into five progressive stages using the clinical categories in the CDC 1994 pediatric HIV classification system: stage N, no signs or symptoms; stage A, mild signs or symptoms; stage B, moderate signs or symptoms; stage C, severe signs or symptoms; and stage D, death. A five-stage Markov model was fitted to the PSD data. To compare the estimates from the PSD project with the published estimates, we also fitted an alternative Markov model using acquired immunodeficiency syndrome (AIDS; 1987 case definition) in place of stage C and also calculated standard Kaplan-Meier estimates.

Results. A total of 2148 perinatally HIV-infected children were included in the analysis. The estimated mean times spent in each stage were: N, 10 months; A, 4 months; B, 65 months; and C, 34 months. We estimated that a child born with HIV infection has a 50% (95% confidence interval [CI], 40%-60%) chance of severe signs or symptoms developing by 5 years of age and a 75% (95% CI, 68%-82%) chance of surviving to 5 years of age. For a child in stage B, there is a 60% (95% CI, 49%-71%) chance of severe signs or symptoms developing within the next 5 years and a 65% (95% CI, 56%-73%) chance of surviving 5 more years. The estimated mean time from birth to stage C was 6.6 (95% CI, 5.7-7.5) years, and the estimated mean survival time from birth was 9.4 (95% CI, 8.1-10.7) years. From the alternative Markov model, the estimated mean time from birth to AIDS was 4.8 (95% CI, 4.5-5.2) years.

Conclusion. Markov modeling using the revised pediatric classification system allowed us to describe the natural history of HIV disease in children before diagnosis of AIDS. On average, children progress to moderate symptoms in the second year of life and then remain moderately symptomatic for more than half of their expected lives, underscoring their need for clinical care before the onset of AIDS. The results from the Markov model are useful in family counseling, health care planning, and clinical trial designs.
Methylene Blue-induced Phototoxicity: An Unrecognized Complication
Authors: Porat Rachel , Gilbert Steve , Magilner David
Published: December 2021

Objective. To describe photosensitization after prenatal exposure to a toxic amount of methylene blue and to alert pediatricians that, in a review of the literature, photosensitization (which this dye is capable of) has not been reported as a complication of prenatal exposure.

Design and Patients. A descriptive report of physical findings and significant laboratory tests in a very low birth weight preterm infant with prenatal exposure to methylene blue and a comparison of this reported case with previously described patients' complications and treatment.

Setting. Neonatal intensive care unit.

Intervention. Monitoring of laboratory tests to assess for methylene blue toxicity: two exchange transfusions for methemoglobinemia, hemolytic anemia, and hyperbilirubinemia; phototherapy for hyperbilirubinemia; and pathologic examination of skin bullae.

Results. Within hours of exposure to phototherapy, redness developed on all exposed areas of the patient's skin (which was initially deep blue), followed by bullae and desquamation of about 35% of the total skin surface area. The desquamation of erythematous areas continued even after discontinuation of phototherapy. Complete re-epithelialization was attained by 3 weeks of age. In addition to this newly observed complication, the patient had other previously described toxic effects.

Conclusion. We have reported a previously unrecognized complication associated with high prenatal exposure to methylene blue and treatment with phototherapy. Methylene blue phototoxicity may be related to the high prenatal dose of the dye relative to patient's small size and young gestational age.
Recurrent Thrombocytopenic Purpura After Repeated Measles-Mumps-Rubella Vaccination
Authors: Vlacha Vasiliki , Forman Edwin N. , Miron Dan , Peter Georges
Published: December 2021

In a review of adverse events associated with childhood vaccines, the Vaccine Safety Committee of the Institute of Medicine (IOM) in 1993 concluded that a causal relationship exists between live-virus measles-mumps-rubella (MMR) vaccination and thrombocytopenia.1 This finding was based on case reports of temporally associated onset of acute thrombocytopenia purpura and MMR vaccination,2,3 population-based surveillance of adverse vaccine reactions in Sweden4 and Finland,5 and demonstrated decreases in platelet concentrations after measles vaccination with the Edmonston B strain.6 The IOM committee also noted that children with prior histories of thrombocytopenia may be at an increased risk of recurrence after MMR vaccination.
Avian Mite Dermatitis
Authors: Baselga Eulalia , Drolet Beth A. , Esterly Nancy B.
Published: December 2021

Avian mites are known to infest humans accidentally, causing a dermatitis characterized by widespread pruritic papular lesions. Because of the lack of awareness of this phenomenon and the small size of the mite, this diagnosis is often missed. We report two siblings with a papular eruption secondary to contact with avian mites identified as Dermanyssus gallinae.

CASE REPORT

A young college student awakened one morning in August with severe pruritus and a generalized eruption. On examination in the clinic, she was noted to have numerous wheals (50 to 100), most densely distributed on her waist, thighs, shoulders, and ankles, but involving most areas of the body.
Promotion of Healthy Weight-control Practices in Young Athletes
Authors:   Committee on Sports Medicine and Fitness
Published: December 2021

Many athletes engage in unhealthy weight-control practices. This new policy statement urges pediatricians to attempt to identify and help these athletes and provides information about how to support sound nutritional behavior.

Athletes may engage in unhealthy weight-control practices, particularly in sports in which thinness or "making weight" is judged important to success, such as body building, cheerleading, dancing (especially ballet), distance running, diving, figure skating, gymnastics, horse racing, rowing, swimming, weight-class football, and wrestling.1-3 Some athletes may use extreme weight-loss practices that include overexercising; prolonged fasting; vomiting; using laxatives, diuretics, diet pills, other licit or illicit drugs, and/or nicotine; and use of rubber suits, steam baths, and/or saunas. The majority of these disordered eating behaviors do not meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria4 for anorexia nervosa or bulimia nervosa.

In two surveys of 208 female collegiate athletes, 32% and 62% practiced at least one of the following unhealthy weight-control behaviors: self-induced vomiting, binge eating more than twice weekly, and using laxatives, diet pills, and/or diuretics.5,6 Of 713 high school wrestlers in Wisconsin, 257 (36%) demonstrated two or more behaviors related to bulimia nervosa.7 In a survey of 171 collegiate Indiana wrestlers concerning their behaviors in high school, 82% had fasted for more than 24 hours, 16% had used diuretics, and 9.4% had induced vomiting at least once a week.8 Many athletes are secretive about these potentially harmful practices.

Disordered eating may have a negative short-term impact on athletic performance. Athletes who lose weight rapidly by dehydration are probably impairing their athletic performance, especially if it involves strength or endurance,9 and these strength deficits may persist even after rehydration.10
To the Editor
Authors: Milburn Michael A.
Published: December 2021

I am writing concerning Sampson and London's article, "Analysis of Homeopathic Treatment of Childhood Diarrhea" (Pediatrics November 1995) that critically reviewed the article by jacobs et al, "Treatment of Acute Childhood Diarrhea with Homeopathic Medicine: A Randomized Clinical Trial in Nicaragua" (Pediatrics May 1994).

The primary problem with the criticisms that Sampson and London raise is that they have not thought through the implications of their arguments. Thus, plausible sounding objections that they offer often lead, upon careful scrutiny, to the opposite conclusion that the authors proclaim.
Reappraisal of Lytic Cocktail/Demerol, Phenergan, and Thorazine (DPT) for the Sedation of Children
Authors: Parks Bruce R. , Snodgrass S. Robert
Published: December 2021

We were disappointed in the AAP statement by the Committee on Drugs entitled Reappraisal of Lytic Cocktail/Demerol, phenergan, and Thorazine (DPT) for the Sedation of Children (Pediatrics 1995;95:598-602). The Committee identified many problems associated with this traditional drug mixture but refused to bite the bullet and acknowledge that its time is past. Their unqualified endorsement of ketamine and propofol use by nonanesthesiologists also concerns us.

The lytic cocktail contains a long-acting opiate with a tendency to activate seizures and two long-acting neuroleptics.
Prevention of Traumatic Deaths to Children in the United States: How Far Have We Come and Where Do We Need to Go?
Authors: Rivara Frederick P. , Grossman David C.
Published: December 2021

Objective. To describe the changes in injury mortality from 1978 to 1991 and determine the number of preventable deaths with currently available intervention strategies.

Methods. Comparison of injury mortality data for children and adolescents 0 to 19 years in 1978 and 1991. Review of the literature to determine the effectiveness of currently available prevention strategies and application of these to deaths in 1991.

Results. The injury death rate declined by 26% over the 14-year period. Death rates of unintentional injuries decreased by 39%, with declines in all categories of unintentional injuries. Homicides increased by 67% and suicides by 17%; nearly all of this increase was in deaths from firearms. If currently available prevention strategies were fully used, 6640 deaths could have been prevented, a further 31% decrease.

Conclusions. Although great strides have been made in preventing deaths from trauma, the application of currently available prevention strategies could save a large number of additional lives. However, the increasing problem of intentional injury will partly counterbalance the success in unintentional injury control.
Normal Birth Weight Intensive Care Unit Survivors: Outcome Assessment
Authors: Gray James E. , McCormick Marie C. , Richardson Douglas K. , Ringer Steven
Published: December 2021

Rationale/Objective. Although the short-and long-term outcome of low birth weight neonatal intensive care unit (NICU) survivors has been extensively studied, much less information is available for normal birth weight (NBW) infants (greater than or equal to 2500 g) who require NICU care.

Methods. To address this issue, we retrospectively examined the neonatal hospitalizations and 6-month health status of 521 consecutive NBW admissions to a single NICU. Information on the neonatal hospitalization was obtained from a review of medical records. Postdischarge health status was collected by using telephone survey techniques.

Results. NBW infants comprised 88.1% of births in this hospital and 35.4% of NICU admissions during the study period. The in-hospital mortality rate for this group was 2%. The median length of stay was 7.7 days (range 1 to 110 days) with median hospital charges of $5222 (range $565 to $317,820). Only 59% of infants required active intensive care therapy; the remainder received only intensive monitoring. The need for intensive therapy on admission day along with the presence of prematurity and congenital anomalies were significant predictors of hospital charges (R2 = 0.31, P < .01). After initial discharge, 10.1% of these infants required rehospitalization in the first 6 to 8 months of life. The rate of readmission among infants with congenital anomalies was over 30%. In addition to its association with neonatal resource consumption, the presence of congenital anomalies along with low 5-minute Apgar scores was associated with higher postdischarge resource use, as measured by frequency of physician visits, need for special medical items, and rate of rehospitalization (P < .05).

Conclusions. NBW infants represent a significant percentage of NICU admissions, but for many of these patients NICU admission could be avoided if alternative care settings that provided intensive monitoring were available. In addition, these infants also incur higher rates of postdischarge use of medical care.
Phenylketonuria: Plasma Phenylalanine Responses to Different Distributions of the Daily Phenylalanine Allowance Over the Day
Authors: van Spronsen Francjan J. , van Dijk Theo , Smit G. Peter A. , van Rijn Margreet , Reijngoud Dirk-Jan , Berger Ruud , Heymans Hugo S. A.
Published: December 2021

Objective. To achieve smooth control of plasma phenylalanine concentrations in phenylketonuric patients, it is advocated to divide the daily intake of natural protein and amino acid supplements equally over the meals. However, this may be quite an encumbrance for the patient. We, therefore, investigated whether a breakfast with an unequal daily distribution results in an undue rise in the plasma phenylalanine concentration.

Design. Plasma phenylalanine concentrations were measured in seven patients with phenylketonuria in response to three tests with breakfast and lunch, representing an equally or unequally divided daily distribution of the individually tailored phenylalanine intake. Breakfast contained 25%, 50%, or 75%, whereas lunch contained 30% or 10% of the individual daily phenylalanine allowance, respectively.

Results. Plasma phenylalanine concentrations showed postprandial increases of up to 26% above baseline. Generally, phenylalanine returned to baseline during the test and remained within the target range if baseline phenylalanine was within that range. Two patients having baseline values in the upper target range showed a rise just above the target range for 60 minutes on an unequal daily distribution of phenylalanine. In another patient treated similarly, plasma phenylalanine did not return to baseline during the test.

Conclusions. Unequal distributions of the daily phenylalanine allowance are justified, provided that the patient is in good clinical condition, adjusted to the diet adequately, and the daily allowance is not exceeded. At this time, however, we cannot recommend this unequal daily distribution for daily practice.
Clinical and Pathologic Aspects of Cardiomyopathy From Ipecac Administration in Munchausen's Syndrome by Proxy
Authors: Schneider Douglas J. , Perez Angel , Knilans Timothy E. , Daniels Stephen R. , Bove Kevin E. , Bonnell Harry
Published: December 2021

Syrup of ipecac is an important component of the emergency management of acute toxic ingestion in children. It is generally safe for acute emergency use, and is recommended for first aid kits in homes with children. However, there are important toxic effects of excessive or long-term ingestion of syrup of ipecac. Cardiomyopathy is a potentially fatal, but often reversible, toxic manifestation of ipecac abuse, most commonly occurring in patients with bulimia. Another setting in which ipecac abuse occurs is Munchausen's syndrome by proxy. We report two cases, one fatal, of cardiomyopathy from ipecac toxicity secondary to Munchausen's syndrome by proxy.
Policy on the Development of Immunization Tracking Systems
Authors:   Committee on Practice and Ambulatory Medicine
Published: December 2021

The American Academy of Pediatrics in its role as advocate for children supports public and private cooperation in the development of immunization tracking systems (ITSs) insofar as they benefit children. All ITSs as they are developed:

• Should prospectively articulate their goals and desired outcomes, including documenting immunization status and the mechanics of immunization, increasing rates of immunization, decreasing cost of immunization, and facilitating immunization opportunities;

• Must accurately document each child's current immunization status;

• Must preserve children's and their health care provider's right to confidentiality;

• Should ensure that data will be available to health care providers 24 hours a day, 7 days a week, so that health care providers can take advantage of all opportunities to immunize;

• Should ensure that data will not be used for sanctions against health care providers;

• Must ensure that data input and access mechanisms enable providers to supply and access data easily, without having to purchase specialized hardware or expensive software; input and access software mechanisms need to enable all providers to supply data to and retrieve data from the ITS;

• Should entitle health care providers to be reimbursed or the cost of providing data to the ITS;

• Must ensure that data reflecting evidence of incomplete immunizations will not be used to deny a child access to care or eligibility for benefits by any insurance plan;

• Must be studied and/or evaluated to determine their effectiveness at increasing immunization rates and decreasing costs; if such systems do not fulfill these goals, they should be eliminated; and
Letter To The Editor
Authors: Carraccio Carol , Blotny Krystyna , Fisher Margaret C.
Published: December 2021

Dr Scarano's point regarding potential bias introduced by red blood cells (RBCs) in the cerebrospinal fluid (CSF) is well taken. Review of the actual numbers of RBCs in the CSF shows that 50.5% of patients had <5 cells/mm3 and an additional 23.5% had <100 cells/mm3 and only 4.2% had >500 cells/mm3. We excluded all patients with "bloody taps," which we defined as >1000 RBCs/mm3 in the CSF. Since the majority of patients had less than 100 RBCs in their CSF, we feel that the potential for bias resulting from blood contamination of the CSF is minimal.
Antibiotic Resistance: Relationship to Persistence of Group A Streptococci in the Upper Respiratory Tract
Authors: Gerber Michael A.
Published: December 2021

Despite the use of penicillin for more than 40 years in treating GABHS infections, there has been no significant change in the in vitro susceptibility of GABHS to penicillin. Reported failures to eradicate GABHS from the upper respiratory tracts of patients with pharyngitis and the apparent resurgence of serious Group A streptococcal infections and their sequelae probably are not related to the emergence of penicillin resistance. Although erythromycin resistance in GABHS had been a major problem in Japan and continues to be a major problem in Finland, it has not been a problem in this country. The susceptibility of GABHS to the newer macrolide antibiotics appears to be similar to that of erythromycin. Comprehensive, community-wide programs to continuously monitor for erythromycin resistance in GABHS would be difficult to justify. However, because little is known about how erythromycin resistance in GABHS is acquired or spread, it would be reasonable to periodically monitor isolates of GABHS for erythromycin resistance. A substantial proportion of GABHS are currently resistant to tetracyclines and these agents are inappropriate for treating GABHS infections. Although little recent information is available about the susceptibility of GABHS to sulfonamides, these agents have been shown to be ineffective in eradicating GABHS from the upper respiratory tract regardless of the in vitro sensitivities. GABHS have not been shown to be resistant to any of the commonly used oral cephalosporins; however, there is a great deal of variability among these agents in their activity against GABHS. Clindamycin resistance in GABHS has remained unusual. This agent is an alternative for treating GABHS infections due to macrolide-resistant strains in patients who cannot be treated with beta-lactam antibiotics.

There is no reason, based on the in vitro susceptibilities of GABHS, to change the current recommendations for treating GABHS infections with penicillin and for using erythromycin for patients who are allergic to penicillin.
Are the Currently Recommended Doses of Benzathine Penicillin G Adequate for Secondary Prophylaxis of Rheumatic Fever?
Authors: Currie Bart J.
Published: December 2021

Objective. To review the literature on dose and regimens of intramuscular benzathine penicillin G (BPG) for secondary prophylaxis of recurrent rheumatic fever.

Setting. For over 40 years BPG has been the gold standard for secondary prophylaxis, usually as a dose of 1 200 000 U (900 mg). Although studies have suggested that BPG injections every 3 weeks are superior to injections every 4 weeks, implementation of an every 3 weeks regimen can be problematic with regards to both patient compliance (adherence) and an increased burden on health resources.

Findings. Some of the earliest studies of BPG suggested that larger doses resulted in prolongation of detectable penicillin levels. A recent study assessing plasma penicillin levels after BPG doses of 1 200 000 U, 1 800 000 U, and 2 400 000 U suggested there may be benefits in a BPG regimen every 4 weeks with doses higher than the standard 1 200 000 U.

Conclusions. Further studies of higher dose BPG regimens seem justified. In addition, further work is needed on quality and storage options for different BPG preparations; location and method of BPG injections; the importance of weight differences between individuals; and ways of improving access to and compliance with BPG regimens.
Rheumatic Fever Prevention in Industrializing Countries: Problems and Approaches
Authors: Snitcowsky Rachel
Published: December 2021

Editor's Note The problems resulting from Group A streptococcal infections remain largely unsolved in many of the industrialized countries of the world at the close of the 20th century. The fact that Group A streptococcal infections had assumed almost the role of a nuisance in the United States and Europe, before the beginning of the mid-1980s and 1990s resurgence, stands in marked contrast to the spectrum of streptococcal-related diseases in other parts of the world. Confirmatory epidemiologic data are often difficult to locate, but there is little doubt about the existence and the general magnitude of the problem.

Because of this, the World Health Organization (WHO) has targeted Group A streptococcal infections and their sequelae for additional attention. During the last decade the WHO has invested considerable effort toward their control. The need for cost-effective primary and secondary rheumatic fever public health prevention programs is greater in those countries where the magnitude of the problem may be inversely proportional to available resources. Approaches considered routine in North America, in Europe, and in some countries of Latin America and Asia often are nonexistent in industrializing countries where as little as less than $5 per person per year may be reserved for total health care.

With these issues in mind, the following perspective was invited to bring these unique problems related to Group A streptococcal infections and their sequelae into focus and to offer suggestions for realistic approaches under less than ideal conditions. We are grateful to Dr Snitcowsky for her comments.
INTRODUCTION
Authors: Kaplan Edward L.
Published: December 2021

During the second World War, and even almost a decade later at the conclusion of the Korean Conflict during the 1950s, infections caused by the Group A beta hemolytic streptococcus and their nonsuppurative sequelae were major problems for practicing physicians as well as for public health authorities. Epidemics of scarlet fever were ever present; quarantine signs could be seen prominently displayed in the windows of the homes of schoolchildren. Many schoolchildren had at least one schoolmate who was homebound and bedridden for months with rheumatic fever. The perceived threat of Group A streptococcal infections was of concern to the lay public, especially to parents of schoolchildren. For the medical community the presence of rheumatic fever hospitals in many cities, institutions like the Harriet Lane Home in Baltimore, the Irvington House in New York, the House of the Good Samaritan in Boston, and La Rabida Hospital in Chicago, served to reinforce the need for increasing the understanding and control of these infections. If those facts about Group A streptococci and children were not sufficiently impressive, the large numbers of individual cases and even outbreaks occurring in military troops during the second World War and during the Korean Conflict further emphasized the issue.

In fact, before the second World War, relatively little was understood about the epidemiology and pathogenesis of these infections and their sequelae. The laboratory studies of Rebecca Lancefield and others, which allowed more precise identification and characterization of Group A streptococci, and the accompanying clinical observations provided the foundation for early control measures.
Ketorolac-induced Acute Renal Failure in a Previously Healthy Adolescent
Authors: Buck Marcia L. , Norwood Victoria F.
Published: December 2021

Ketorolac has become an important component of analgesic regimens for children as well as adults because of its lack of adverse effects on respiratory, cardiovascular, and neurologic function. Although initially used parenterally in hospitalized patients, the development of an oral ketorolac dose form extended its use to the outpatient setting, where its potency has been considered an advantage over traditional therapies.1-3

Several cases of hyperkalemia and oliguric acute renal failure associated with ketorolac use have been reported in the medical literature.4-12 Elderly hospitalized patients receiving large doses of ketorolac intramuscularly (IM) after major surgery seem to be at greatest risk.
Health Supervision for Children With Fragile X Syndrome
Authors:   Committee on Genetics
Published: December 2021

This set of guidelines is designed to assist pediatricians in caring for children with fragile X syndrome confirmed by DNA analysis (Table). Occasionally pediatricians are called on to advise a pregnant woman who has been informed of a prenatal diagnosis of fragile X syndrome. Therefore, guidelines are also offered for this situation.

Fragile X syndrome is usually diagnosed during childhood and is characterized by developmental delay or mental retardation, characteristic physical features, and abnormal behavioral patterns.1,2 The distinctive fragile site on the X chromosome was first described in 1969 as a discontinuous site on the long arm of the X chromosome present after cell culture under folate-deficient conditions. In 1977 the relationship of this site to X-linked mental retardation was noted, and fragile X syndrome began to be defined. Since that time, the cytogenetic, molecular, and clinical features of the condition have been more clearly defined,3 and it is now recognized as the most common hereditary cause of mental retardation. Its frequency has been estimated to be approximately per 2500 to 1 per 1250 males and 1 per 5000 to 1 per 1600 females.

The phenotype of fragile X syndrome in males often has a number of distinctive, recognizable features, including developmental delay or mental retardation, a prominent forehead, a long, thin face and a prominent jaw that appear late in childhood or early adolescence, large protuberant and slightly dysmorphic ears, and the presence of or ultimate development of macro-orchidism. This phenotype can be very subtle, is not always apparent, and becomes more identifiable with age.2
Comments From Another Student of Gamble and Darrow on Fluids
Authors: Schwartz Robert
Published: December 2021

Holliday's historical review of fluid and electrolyte pathophysiology represents thoughtful and timely comments. I agree with his thoughts as applied to diarrheal dehydration. However, his strong advocacy of oral rehydration therapy (ORT) in diarrheal dehydration should not be interpreted as relevant to other disorders of fluid and electrolyte pathophysiology.

The successful use of ORT in the third world, coincident with scientific understanding of cholera toxin effects on sodium-glucose transport in the intestine, has provided both a scientific and practical basis for practical recommendations.
SAFE ADMINISTRATION OF THE MEASLES VACCINE TO CHILDREN ALLERGIC TO EGGS
Authors: Wood Robert A.
Published: December 2021

The MMR vaccine can be safely administered in a single dose to children with allergy to eggs, even those with a history of anaphylaxis.
CROSS-REACTING ALLERGENS IN NATURAL RUBBER LATEX AND AVOCADO
Authors: Sachs Martin
Published: December 2021

There is considerable cross-reactivity between natural rubber latex and avocado. This cross-reactivity explains the type I hypersensitivity reactions to natural rubber latex and avocado in patients with a preexisting allergy to either allergen.
RELATION OF EXPOSURE TO AIRWAY IRRITANTS IN INFANCY TO PREVALENCE OF BRONCHIAL HYPERRESPONSIVENESS IN SCHOOLCHILDREN
Authors: Parry David E. , Lemanske Robert F.
Published: December 2021

This study confirms an association between early wheezy bronchitis and BHR, which is not necessarily equatable to asthma. Other studies of BHR prevalence in children and exposure to outdoor pollutants have yielded conflicting results. The dose-response relation in this study was demonstrable for exposure in infancy, but not in older children.
USING QUALITY-CONTROL ANALYSIS OF PEAK EXPIRATORY FLOW RECORDINGS TO GUIDE THERAPY FOR ASTHMA
Authors: Szefler Stanley J.
Published: December 2021

Individualized action points can be derived for patients with asthma by applying quality-control analysis to peak flow recordings. These action points are more sensitive in detecting exacerbations of asthma and have fewer false-positive results.
EFFICACY OF FREQUENT NEBULIZED IPRATROPIUM BROMIDE ADDED TO FREQUENT HIGH-DOSE ALBUTEROL THERAPY IN SEVERE CHILDHOOD ASTHMA
Authors: Joos Thad H.
Published: December 2021

Purpose of the Study. High-dose nebulized albuterol has become the standard of treatment for the severely wheezing asthmatic child. The role, dose, and frequency of administration of ipratropium bromide in this same group of children requires further definition.

Methods. From the Emergency Department of the Hospital for Sick Children in Toronto, Ontario, Canada, 120 children 5 to 17 years of age with severe asthma as determined by a forced expiratory volume in 1 second (FEV1) of less than 50% predicted normal were equally divided and entered into a double-blinded, placebo-controlled treatment protocol. All groups received 0.15 mg albuterol/kg/dose nebulized every 20 minutes χ3. Group 1 had 250 µg of ipratropium bromide added to each treatment. Group 2 had the same amount of ipratropium bromide added to only the initial aerosol with a like amount of saline added to aerosols 2 and 3. Group 3 had only saline added to each aerosol. No corticosteroids were administered to any patient in the first hour. The entire cohort was meticulously monitored for oxygen saturation, heart rate, respiratory rate, accessory muscle use, cyanosis, wheezing and pulmonary function test parameters by a skilled research nurse.

Results. As expected, all patients improved to a degree but those with the lowest FEV1s who were treated with ipratropium in each aerosol responded the best and were admitted to the hospital less frequently. No serious untoward side effects were observed in any patient.

Reviewer's Comment. I feel the article is a must read for all physicians caring for acutely wheezing asthmatic children.
OLDER CHILDREN AND ADOLESCENTS LIVING WITH PERINATALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Authors: Gern James E.
Published: December 2021

Approximately one fourth of the children living past 9 years of age with HIV infection are asymptomatic, and the remainder are living with significant chronic symptoms. Progression of immunologic impairment and symptoms were evident during the follow-up period.
PEDIATRIC HUMAN IMMUNODEFICIENCY VIRUS INFECTION: RECENT EVIDENCE ON THE UTILIZATION AND COST OF HEALTH SERVICES
Authors: Church Joseph A.
Published: December 2021

Lower utilization is reported than in prior research on pediatric HIV. Increasing experience in the clinical management and expanded ambulatory care may have contributed to a reduction in inpatient services utilized and total costs since the mid 1980s.