bluuebunny/crossref_metadata_2025 huggingface dataset:
Iron Status and Infant Feeding Practices in an Urban Ambulatory Center
Authors: Sadowitz P. David , Oski Frank A.
Published: December 2021

The relationship of infant feeding practices to iron status was examined in a group of 280 infants, 9 to 12 months of age, attending a "well-baby" clinic. Of this group, 7.6% were found to be iron depleted, 19.7% were iron deficient without anemia, and 8.2% were iron deficient with anemia. The incidence of iron-deficiency anemia was significantly greater in the black infants than the white infants (14.3% v 2.7%). The introduction of whole cow's milk into the diet had occurred prior to 6 months of age in 29.2% of the infants, and 62.1% of these infants had laboratory evidence of nutritional iron inadequacy, as contrasted with only 21.8% of those with iron deficiencies fed cow's milk after 6 months of age. Of the 21 infants with iron-deficiency anemia, 19 (90.5%) had been fed whole cow's milk prior to 6 months of age. Iron deficiency remains a nutritional problem for infants in an urban setting and is largely a result of the early introduction of whole cow's milk into the diet.
The Use of TORCH Titers
Authors: Leland Diane , French Morris L. V. , Kleiman Martin B. , Schreiner Richard L.
Published: December 2021

Of 603 patients undergoing serologic tests for Toxoplasma, syphilis, rubella, cytomegalovirus, and herpes simplex (TORCH tests) during a 4-year period, 381 (63%) were infants younger than 6 months and 110 (18%) were either the mothers of those infants or pregnant women. The remaining 112 (19%) were older infants and children, male adults, or nonpregnant female adults. Of 381 infants less than 6 months of age who were tested, 323 (85%) had only a single TORCH test. Of 35 (9%) infants who had follow-up titers, 16 (46%) had a specific titer requested whereas in 19 (54%) the entire TORCH battery was repeated. Follow-up titers were infrequently (25%) requested when initial titers were elevated. Infection with a TORCH agent was not confirmed serologically in any of the 603 patients. The pattern of TORCH test use has a poor diagnostic return.
Nutrient and Mineral Retention and Vitamin D Absorption in Low-Birth-Weight Infants: Effect of Medium-Chain Triglycerides
Authors: Huston Robert K. , Reynolds John W. , Jensen Christine , Buist Neil R. M.
Published: December 2021

A randomized prospective study of the effect of medium-chain triglycerides (MCT) upon the absorption and retention of major minerals and nutrients, as well as upon 25-hydroxy vitamin D levels, was performed in low-birth-weight infants. Ten infants received a highcalcium and vitamin D-containing formula, which contained 50% of its fat as MCT, while ten other infants received a similar formula in which all the fat was in long-chain triglycerides. There was a five-day delay in reaching full oral feeding volumes, and therefore there was a delay in the onset of the balance study in the MCT group, primarily due to gastrointestinal symptoms. There was a significant improvement in the percent of fat absorption (P < .05) with MCT, but no difference in the percent of absorption or retention of calcium, phosphorus, sodium, or nitrogen. 25-Hydroxy vitamin D levels decreased in both groups after full oral feeding volumes had been established, but all values were within normal ranges. At the high intake levels of calcium and vitamin D given to the infants, MCT did not increase major mineral or nutrient absorption.
Methylphenidate Hydrochloride Given With or Before Breakfast: II. Effects on Plasma Concentration of Methylphenidate and Ritalinic Acid
Authors: Chan Ying-Pui Mick , Swanson James M. , Soldin Steven S. , Thiessen J. J. , Macleod Stuart M. , Logan William
Published: December 2021

Methylphenidate HCl (Ritalin) is often prescribed for the treatment of hyperactivity and is usually administered orally 30 minutes to 1 hour before meals, based on an assumption that meals may interfere with the absorption or metabolism of the drug. Seven boys who were taking methylphenidate regularly for the treatment of hyperactivity were hospitalized and given their established dose of the drug intravenously or orally, either with breakfast or in a fasted state. Blood samples were taken to determine the pharmacokinetics of the drug in each condition. Few differences between the "fed" and "fasted" states were noted, but the statistically significant differences indicated that meals accelerate rather than impede the absorption of methylphenidate.
Evolving Hypopituitarism in Children with Central Nervous System Lesions
Authors: Hanna Cheryl E. , LaFranchi Stephen H.
Published: December 2021

At the time children with suspected hypopituitarism are seen with a subnormal growth rate, it is expected that testing will demonstrate growth hormone (hGH) deficiency. Seven patients with organic CNS lesions—three with histiocytosis X, one with septo-optic dysplasia, one with neonatal meningitis, one with an anterior encephalocele and meningitis, and one with neurofibromatosis who had normal growth hormone concentrations (> 7 ng/mL) despite a subnormal growth rate—were studied. Subsequent retesting 0.5 to 4.6 years later demonstrated the development of growth hormone deficiency. Four of the patients had evidence of other pituitary hormone deficiencies at the time of initial testing whereas two subsequently developed other deficiencies. The initial subnormal growth rate in these children may be secondary to their organic CNS lesion or an evolving hypopituitarism, perhaps with deficient somatomedin generation. These studies point out the need for continued observation and retesting in such patients.
Early Contact, Social Support, and Mother-Infant Bonding
Authors: Anisfeld Elizabeth , Lipper Evelyn
Published: December 2021

A study was designed to explore further the hypothesis that a period of close contact between mother and infant immediately after birth facilitates the establishment ishment of a close bond. The study investigated whether the effects of extra contact interact with other variables present in the labor and delivery situation and with the extent of social support available to the mother. Two sets of procedures for the immediate postpartum period were established and mothers were randomly assigned to one of these conditions. Twenty-nine mothers experienced extracontact procedures in which the baby was placed on the mother's abdomen for 1 hour. Thirty mothers received routine care procedures in which the baby was shown to the mother and then taken to the nursery. Observations of maternal behavior during a feeding were made two days after birth by an observer blind to the randomization status of the mother. The mothers who received extra contact exhibited significantly more affectionate behavior toward their infants than did the mothers who received routine care. The extracontact treatment produced more affectionate behaviors in the mothers who had less social support than in those who had more social support. The extra contact was equally effective for multiparous and primiparous mothers. Mothers of female infants exhibited more affectionate behavior to their infants regardless of which postpartum procedures the mothers had experienced.
Unusual Manifestations of Histoplasmosis in Childhood
Authors: Weinberg Geoffrey A. , Kleiman Martin B. , Grosfeld Jay L. , Weber Thomas R. , Wheat Lawrence J.
Published: December 2021

Nine previously healthy children were seen with unique, and in several instances, unreported manifestations of acute histoplasmosis. Presenting manifestations included: obstructive airway disease; subacute parotitis; unilateral cervical lymphadenopathy; anterior mediastinal mass-simulating neoplasm; immune hemolytic anemia; a cutaneous lesion with regional lymphadenopathy; mediastinal mass and pericardial effusion; pulmonary infarction; and a symptom complex of cervical lymphadenopathy, CSF pleocytosis, arthritis, and interstitial nephritis. In eight children histoplasmosis was not initially considered, and the correct diagnosis was made only after complex, and sometimes invasive, diagnostic evaluation and considerable delay. All patients recovered fully without antifungal therapy. Reports of uncontrolled trials of new antifungal agents for treatment of histoplasmosis in immunocompetent hosts should be cautiously evaluated.
Apparent Meningococcemia: Clinical Features of Disease Due to Haemophilus influenzae and Neisseria meningitidis
Authors: Jacobs Richard F. , Hsi Steven , Wilson Christopher B. , Benjamin Denis , Smith Arnold L. , Morrow Robert
Published: December 2021

To determine the etiology of apparent meningococcemia, all cases of sepsis with coagulopathy, purpura, and/or adrenal hemorrhage (Waterhouse-Friderichsen syndrome) with and without shock occurring over a 12-year period were reviewed. A total of 42 cases were identified; 30 cases were caused by Neisseria meningitidis and 12 cases were caused by Haemophilus influenzae. Compared with patients with disease caused by H influenzae, patients with meningococcal disease were older, more often male, more often contracted the disease in winter-spring, and had a longer duration of antecedent symptoms; however, none of these differences was statistically significant. All patients were febrile (>38°C) and appeared toxic. Similar proportions in each group had shock and disseminated intravascular coagulopathy at the time of admission. Ten of 12 patients with H influenzae infection compared with 15/30 (P < .05) with meningococcal infection were lethargic or comatose at the time of admission. Nine of 12 patients with H influenzae infection died compared with 5/30 with meningococcal disease (P < .005); the mean time from onset of symptoms to death with H influenzae infection (20.7 ± 11.4 [SE] hours) was significantly shorter (P < .05) than with meningococcal infection (120 ± 74.4 hours). Children with clinical signs of sepsis and with purpura, petechiae, or coagulopathy may have N meningitidis or H influenzae as etiologic agents. Initial antibiotic therapy should be directed against these pathogens.
Growth Failure and Inflammatory Bowel Disease: Approach to Treatment of a Complicated Adolescent Problem
Authors: Rosenthal Susan R. , Snyder John D. , Hendricks Kristy M. , Walker W. Allan
Published: December 2021

Severe retardation of linear growth occurs in a minority of children with Crohn's disease. It appears to be associated with increased disease activity and decreased caloric intake. Why some children are affected and others are not is unknown, but some degree of growth retardation is probably more prevalent than is generally appreciated. The use of somatomedin-C levels may be of some future value in predicting which children will be affected. Growth failure is often difficult to treat and requires vigorous medical and nutritional support. No current treatment is without attendant problems. Proper and frequent assessment of growth and development will help ensure intervention while growth potential still exists in these children.

Large cooperative studies are needed to compare the effects of various treatment plans on the growth velocity and ultimate stature of children with Crohn's disease-related growth retardation.
Optimism and Myths
Authors: GEME JOSEPH W.ST.
Published: December 2021

In Reply.—

Klein expresses his point of view with clarity and intensity. That is important. I am optimistic about pediatrics and its future. That is important to me. I also believe that the optimism is reasonable. There is an increasing sense of competition between pediatrics and family medicine. The same seems to be true for internal medicine and family medicine. The competition in the spheres of educational program and clinical performance is healthy. We will continue to learn from each other and the roles of the pediatrician, internist, and family physician will evolve as a function of our knowledge, our clinical competence, the desires of our patients, and, perhaps, our enthusiasm about what we do.
Disseminated Fungal Infections in Very Low-Birth-Weight Infants: Clinical Manifestations and Epidemiology
Authors: Baley Jill E. , Kliegman Robert M. , Fanaroff Avroy A.
Published: December 2021

In 1979 and 1980, an apparent increase in the occurrence of disseminated fungal infections was observed. The clinical features of such infections in very low-birth weight infants are poorly described, and diagnosis is often delayed. Over a 24-month period, a discrete group of ten clinically diagnosed and four autopsy-diagnosed cases of systemic fungal infections in very low-birth-weight infants was observed. Prior to developing systemic fungal illness, these infants required prolonged total parenteral nutrition, central arterial or venous catheters, and multiple courses of broad-spectrum antibiotics for documented or suspected bacterial sepsis. The clinically diagnosed disseminated fungal infection (ten infants) was noted at a mean age of 33 days with one or more of the following: respiratory deterioration, abdominal distension, guaiac positive stools, carbohydrate intolerance, candiduria, endophthalmitis, meningitis, abscesses, erythematous rash, temperature instability, and hypotension. These signs and symptoms were seen as chronic or were intermittent in clinical course. In contrast, the autopsy-diagnosed disseminated fungal infection (four infants) was present at an earlier age with fewer recognizable predisposing factors and a more acute onset of infection. Nevertheless, in both groups the diagnosis of systemic candidal infection was delayed, due to an inability to consistently recover the organism from blood, CSF, or urine. The neonatologist caring for the very low-birth-weight infant needs to become more aware of these clinical entities. A high index of suspicion and ancillary diagnostic evaluation, such as retinoscopy or tissue biopsy, may be indicated in the critically ill, culture-negative patient.
Disseminated Fungal Infections in Very Low-Birth-Weight Infants: Therapeutic Toxicity
Authors: Baley Jill E. , Kliegman Robert M. , Fanaroff Avroy A.
Published: December 2021

The improved survival of very low-birth-weight infants, who require prolonged hospitalization and many invasive procedures, increases the risks for nosocomial illnesses, such as disseminated fungal infections. In a 2-year period, systemic fungal infections were clinically diagnosed in ten infants. This necessitated the institution of antifungal therapy in extremely premature infants (mean birth weight 788 g, mean gestational age 28 weeks) despite the paucity of knowledge about the pharmacokinetics and toxicity of these drugs in the very immature patient. Despite the absence of reported toxicity in infants and older children, severe nephrotoxicity was commonly observed with oliguria/anuria, temporally related to the administration of amphotericin B in seven of these infants. Additional evidence of nephrotoxicity included either a rise in creatinine levels (≥1.3 mg/dL), an increase in BUN (≥30 mg/dL), hypokalemia (≤2.9 mEq/L), or hyperkalemia (≥6.0 mEq/L). Six of these seven drug-toxic infants died. Interruption of amphotericin B therapy, with reinstitution at a lower dose, was the most successful factor in alleviating the anuria. There is an urgent need for detailed pharmacokinetic and toxicity studies of antifungal agents in immature infants.
Cognitive Development of Unselected Girls with Complete and Partial X Monosomy
Authors: Bender Bruce , Puck Mary , Salbenblatt James , Robinson Arthur
Published: December 2021

The cognitive development of nine girls with 45,X and 45,X variant karyotypes, seven 45,X mosaics, and nine 46,XX control subjects (ages 8 to 17 years) followed since birth was evaluated. The nonmosaic group was slightly delayed in walking, had a moderately decreased full-scale and performance IQ, demonstrated a striking deficit in perceptual organization and fine motor execution, but had generally average language skills. Three nonmosaic girls with low intelligence were identified and one subject had above average intelligence. Intelligence was not correlated with the presence of physical stigmata. No obvious developmental differences were found between the three girls with 45,X variant, two with partial Xq deletions and one with a ring X chromosome, and the six girls with 45,X genotype. The 45,X mosaic group did not experience early developmental delays and was not significantly different from control subjects on any IQ score. A large amount of variability between subjects was noted, which could be partially attributed to family characteristics and socioeconomic conditions. Whereas this study corroborates previous findings of specific intellectual deficits in 45,X populations, it emphasizes the need for caution in estimating the cognitive development of any X and partial X monosomic infant.
Reasons for the Absence of a History of Recurrent Genital Infections in Mothers of Neonates Infected with Herpes Simplex Virus
Authors: Yeager Anne S. , Arvin Ann M.
Published: December 2021

Thirty-one cases of neonatal herpes simplex (HSV) infection were evaluated to determine how often mothers of infected infants lacked a history of recurrent genital infections and the reasons for its absence. A history of recurrent genital infections was elicited from eight (26%) of the mothers. Nine (29%) of the mothers had primary infections; three of these were oral and six were genital. The mother was not the source of infection in three (9.6%) cases. In eleven (35%) cases, the mother had antibody to HSV but did not have a history or findings of primary or recurrent infection. Two of these mothers had positive cervical or vaginal cultures, but neither had genital lesions typical of HSV in the perinatal period. Two mothers had recurrent HSV infections documented later. The source of the HSV infection remained uncertain in 23% of cases including two in which only the father had a history of recurrent genital infection. When mothers with primary infections in the perinatal period were excluded, the HSV neutralization titers of the mothers of infected infants were similar to the titers of the mothers with recurrent genital infections whose infants were not infected. In contrast, the infected infants had titers fourfold lower than their mother's titer as well as fourfold lower than the 16 infants exposed to HSV who remained uninfected. This discrepancy suggests that the mothers may have had a rise in titer late in pregnancy or that placental transport of antibody was limited. Although 26% of the mothers of infected infants had recurrent genital infections, only three (9.6%) had an easily elicitable history. Most cases of neonatal HSV infection will not be avoidable until the epidemiology of primary maternal infection and of nonmaternal sources of infection is understood and the identification of women with HSV who are never symptomatic is improved.
Retrolental Fibroplasia and Vitamin E in the Preterm Infant—Comparison of Oral Versus Intramuscular:Oral Administration
Authors: Hittner Helen M. , Speer Michael E. , Rudolph Arnold J. , Blifeld Cindy , Chadda Prabhujeet , Holbein M. E. Blair , Godio Louis B. , Kretzer Frank L.
Published: December 2021

To evaluate the efficacy of four early intramuscular injections of vitamin E given in addition to continuous minimal oral vitamin E supplementation, 168 very low-birth-weight infants (≤1,500 g) have enrolled in a randomized, double-masked, clinical study. All infants received vitamin E orally, 100 mg/kg/d. In addition, on days 1, 2, 4, and 6, seventy-nine infants received vitamin E intramuscularly, 15, 10, 10, and 10 mg/kg, respectively. On the same days, 89 control infants received placebo intramuscular injections. Multivariate analysis of the 135 infants who survived ≥10 weeks showed no significant difference in the development of severe retrolental fibroplasia between these two supplementation schedules (P = .86). Plasma vitamin E levels never exceeded a mean of 3.3 mg/100 mL, and no toxicity was observed. Ultrastructural analyses of seven pairs of whole eye donations from infants receiving IM vitamin E demonstrated identical kinetics of gap junction formation between adjacent spindle cells as compared with 13 pairs of whole eye donations from control infants (P > .3). Therefore, oral vitamin E supplementation affords retinal protection against the development of severe retrolental fibroplasia when initiated on the first day of life and maintained continuously until retinal vascularization is complete.
Aeromonas hydrophila: A Treatable Cause of Diarrhea
Authors: KIPPERMAN HARRY , EPHROS MOSHE , LAMBDIN MORRIS , WHITE-ROGERS KAREN
Published: December 2021

Aeromonads are bacteria, found in water and soil, which cause a wide spectrum of human infections in normal and compromised hosts.1 Although primarily gastrointestinal pathogens, aeromonads also cause trauma-related infections of skin, soft tissue, muscle and bone, as well as non-trauma-related infections, including endocarditis.1-4 Gastrointestinal infections due to Aeromonas sp are frequently identified in Southeast Asia, India, and Australia3,5-7 but rarely in the United States.2,8 This report describes a case of profuse watery diarrhea due to Aeromonas hydrophila in a child from Maine.

CASE REPORT

A 5-month-old female infant with Down's syndrome and Hirschsprung's disease developed diarrhea and vomiting.
Protest Views of Singer
Authors: BONGIOVANNI ALFRED M.
Published: December 2021

Editor's Note:

A Commentary represents an individual's opinion. Commentaries are often controversial. They are not AAP policy statements. No matter how often this is pointed out some individuals persist in condemning or threatening the Editor and the AAP when we publish commentaries that are contrary to their views. Some individuals seem to believe that the journal should not print views that differ from their own. The AAP's official position on life-sustaining treatment for seriously ill newborns was stated in the October 1983 issue of Pediatrics.
Biostatistics Articles Needed
Authors: JACOBS STEPHEN E.
Published: December 2021

To the Editor.—

I read with great interest Hayden's article, "Biostatistical Trends in Pediatrics: Implications for the Future" (Pediatrics 1983;72:84-87). While emphasizing the importance of the care with which journal editors review the statistical analyses employed in the articles published, the author does not dwell on the readers' low level of knowledge.

The editorial by Feinstein, "Prophylactic and Remedial Therapy for the Intellectual Ailments of `Biostatistics,' " in the same issue (Pediatrics 1983;72:131-133) reiterates the points made in the article.
Biostatistics Articles Needed
Authors: HAYDEN GREGORY F.
Published: December 2021

In Reply.—

As Jacobs suggests, his experience is far from unique. Many physicians have had little or no training in biostatistics and research design and, therefore, feel ill-prepared to understand the methods of published studies. Responding to this need, several medical schools have recently developed new courses in clinical epidemiology and biostatistics. This trend, if it continues and spreads, should help to relieve the problem in the years ahead.

For a more immediate solution, I applaud Jacobs' enthusiasm for a series of biostatistical tutorials, and note that three prominent journals have already published, or announced their intentions to publish, such articles.1-3
An Outbreak of Clostridium difficile Necrotizing Enterocolitis
Authors: MATHEW OOMMEN P. , BHATIA JATINDER S. , RICHARDSON C. JOAN
Published: December 2021

To the Editor.—

Han et al1 present some interesting epidemiologic observations on an outbreak of necrotizing enterocolitis (NEC). These investigators conclude that Clostridium difficile may be implicated as an etiologic factor in the reported outbreak of NEC "based on the remarkably strong association of the toxin and/or organism in 12/13 cases of NEC; and the absence of organism and very limited presence of toxin in the unaffected controls (2/17)." One wonders about the causal relationship between C difficile and NEC when this conclusion is viewed in the context of high colonization rate2,3 in babies in intensive care and the lack of association2,4 between C difficile and NEC reported by others.
Epidemiology of Injuries in a Large, Urban School District
Authors: Boyce W. Thomas , Sprunger Lewis W. , Sobolewski Sue , Schaefer Catherine
Published: December 2021

Injuries represent the single greatest threat to the health and well-being of US children. A large number of childhood injuries are sustained in schools, yet little is currently known of the epidemiologic features of school-related injuries. A surveillance of injuries occurring in a large, urban school district during a 2-year period was conducted. Nurses in each of the district's 96 schools completed reporting forms on all injuries meeting standardized criteria, and both principals and nurses completed questionnaires on school characteristics that were judged potentially important to the injury rate in individual schools. A total of 5,379 injuries were reported, among the district's 55,000 students, for an overall injury rate of 49 injuries/1,000 student-years. Injury rates were higher for boys than girls at all age levels. Self-caused and sports-related injuries comprised nearly half of all those reported, and 14% were related to use of playground or sports equipment. Eighteen percent of injuries were severe, and playground- and equipment-related injuries were significantly more likely to be severe (P < .001). Rates of injury among individual schools varied markedly, with schools at the two extremes separated by a 25-fold difference in rates. Higher overall injury rates were found in schools with longer hours, alternative educational programs, less experienced school nurses, and lower student-to-staff ratios (P < .0001).
Effect of Pneumothorax-lnduced Systemic Blood Pressure Alterations on the Cerebral Circulation in Newborn Dogs
Authors: Batton Daniel G. , Hellmann Jonathan , Nardis Elizabeth E.
Published: December 2021

Pneumothorax has been associated with intraventricular hemorrhage in premature infants, although the mechanism for this relationship is not clear. Because alterations in cerebral blood flow are believed to be important in the pathogenesis of intraventricular hemorrhage, the effect of induced pneumothorax and subsequent evacuation on the cerebral circulation in 16 newborn dogs was evaluated. Continuous Doppler ultrasound was used to monitor changes in cerebral blood velocity. Pneumothorax was induced by slow infusion (5 cc/kg/min) or rapid infusion (5 to 10 seconds) of air to reduce mean arterial blood pressure to half of base-line levels. Both methods of pneumothorax induction resulted in significant elevations of central venous pressure and intrapleural pressure, whereas mean arterial blood pressure and cerebral blood velocity decreased significantly. In each group, the pneumothorax was evacuated either by slow withdrawal of air (10 cc/kg/min) or as rapidly as possible. Rapid evacuation of air resulted in an immediate increase in mean arterial blood pressure and cerebral blood velocity to supranormal levels. Slow evacuation led to a more gradual normalization of mean arterial blood pressure and cerebral blood velocity. It is suggested that the precipitous increases in mean arterial blood pressure and cerebral blood velocity following rapid evacuation of a tension pneumothorax may account for the observed association between pneumothorax and intraventricular hemorrhage in premature infants.
Rationale for Grading Intracranial Hemorrhage in Premature Infants
Authors: Kuban Karl , Teele Rita Littlewood
Published: December 2021

There is a high incidence of hemorrhage in the germinal matrix and ventricular system in premature infants. Existing systems of grading the extent of hemorrhage into germinal matrix and ventricles of premature babies have limitations. It is necessary to consider correlations of structure (neuroanatomy by ultrasound) with function (outcome of patient). It is suggested that a standardized worksheet for evaluation of cranial ultrasound usage in premature infants be adopted. Such a worksheet allows uniformity of data collection and permits a more efficient method for evaluating correlations of structure with function.
Phototherapy in Full-Term Infants with Hemolytic Disease Secondary to ABO Incompatibility
Authors: Osborn Lucy M. , Lenarsky Carl , Oakes Raymond C. , Reiff Michael I.
Published: December 2021

Current guidelines for treatment of hemolytic disease of the newborn make no differentiation between ABO and Rh incompatibility. A protocol that prolonged the observation period in full-term, ABO-incompatible infants with positive Coombs' tests who were otherwise healthy was tested. Postponement of treatment made it possible to determine more accurately which infants needed phototherapy. This dramatically decreased the number of infants treated without increasing their risk of requiring exchange transfusion.
Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease
Authors:   Ad Hoc Task Forces on Home Care of Chronically III Infants and Children
Published: December 2021

Many infants, children, and adolescents with long-term, serious health problems are confined to hospitals for prolonged treatment during recovery, and such patients are rehospitalized frequently. Hospitalized patients usually lack the normal, interpersonal family relationships that are important to growth and development. Combining the benefits of home care with optimal medical treatment and support is a challenge requiring development of innovative programs between hospitals, physicians, parents, and communities.

Although home care programs for patients with chronic diseases have been implemented, objective data about the efficiency, risks, benefits, and cost of these programs are limited. Careful planning and coordination of family, hospital, and community resources are essential for home care programs, and initial guidelines for program development and assessment are needed.

The goal of a home care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities.

PROGRAM DEVELOPMENT

Comprehensive planning for all aspects of home health care is essential to minimize physical and emotional risk to the patient, adverse effects on the family members, or unforseen financial burdens. Because of the many factors to be considered, a multidisciplinary team interested in implementation of home health care should be organized. The team should include a pediatrician and may include other physicians (eg, generalists, community physicians, neonatologists, intensivists); nurses; occupational, physical, and speech therapists; developmentalists; child life workers; nutritionists; social workers; teachers; home care providers (eg, nursing providers outside the hospital and equipment providers); parents; and insurers.
Fetal Research
Authors:   Committee on Research
Published: December 2021

In the past several decades, we have witnessed astounding improvements in the health of infants and children as a result of successes in translating knowledge derived from laboratory and clinical research into effective therapies for the fetus and newborn. Improvements in survival and reduction in newborn suffering would not have been possible without direct evaluation of the safety and efficacy of these therapies in the pregnant woman and fetus. For example, work done with pregnant women and their fetuses has led directly to the current Rh screening programs and the use of Rhogam, and has resulted in a marked decrease in pregnancy wastage and newborn morbidity due to erythroblastosis.

The outcome of thousands of pregnancies has been improved as a result of the evaluation of fetal lung maturity by lecithin-sphingomyelin ratio (L/S ratio) and the administration of glucocorticosteroids to enhance lung maturity in infants at risk for hyaline membrane disease. Again, in these studies validation of normal developmental profiles and evaluation of safety and efficacy were required.

Our current success in monitoring pregnancy outcome is based on the safe evaluation of normal growth and our ability to detect adverse genetic and environmental influences in the developing fetus. We now can recognize fetal hypoxia during pregnancy and at delivery by knowledge of fetal heart rate profiles obtained by fetal research. Even the effects of noninvasive measures such as maternal bed rest and improved nutrition on fetal outcome in the pregnancy complicated by maternal hypertension must be assessed by continued fetal research.
Use of Tricyclic Medications in Children
Authors: WOODY ROBERT C. , LIVINGSTON RICHARD , WEINBERG WARREN A.
Published: December 2021

To the Editor.—

The recent report by Rauber and Maroncelli summarizing the results of a mail survey of pediatricians and family practitioners regarding their knowledge and usage of tricyclic medications1 demonstrates two points: (1) the pediatricians surveyed rarely (0.9%) used tricyclic medications for psychopharmacologic purposes in their practices, and (2) their knowledge of the toxic side effects (defined by Rauber and Maroncelli as tachycardia and seizures) is limited (67%). The authors state that the standard use of tricyclic medications, such as imipramine for enuresis, represents "the use of a dangerous drug for the treatment of a nonlethal disease."
Peripheral Lesions of the Retina in the Premature Newborn
Authors: WILLARD D. , MESSER J. , GERHARD J. P. , TEMPE D.
Published: December 2021

To the Editor.—

Lucey and Dangman1 showed why a multifactorial explanation of the retinopathy of prematurity seems likely. However, data on the actual role of oxygen, in carefully matched groups, are still lacking. Our survey may contribute to this investigation.

The results of a biomicroscopic investigation of the retina were assessed in two groups of prematurely born children who weighed less than 1,500 g at birth. A Goldman's contact glass made it possible to observe the especially at risk peripheral retina.
Pediatric Clinicians' Support for Parents Makes a Difference: An Outcome-Based Analysis of Clinician-Parent Interaction
Authors: Wasserman R. C. , Inui T. S. , Barriatua R. D. , Carter W. B. , Lippincott P.
Published: December 2021

Pediatric clinicians frequently must offer support (eg, reassurance) to anxious, stressed parents. Supportive clinician behaviors were studied to determine their impact on parents. Forty initial health supervision visits to a pediatric clinic were videotaped through a oneway mirror. Mothers were interviewed immediately before and 1 week after the visits to ascertain changes in concerns, opinions of clinicians, perceptions of infants, and self-confidence. Mothers also completed a postvisit satisfaction questionnaire. Coders blinded to these outcomes identified and enumerated three supportive clinician behaviors: encouragement, reassurance, and empathy. Analyses compared visit outcomes according to high and low levels of maternal exposure to clinician support. Mothers exposed to high levels of encouragement had significant improvement in their opinions of clinicians and higher satisfaction (P = .02). Mothers exposed to high levels of empathy had higher satisfaction and greater reduction in concerns (P < .05). No significant differences in outcome were found for exposure to reassurance. Differences in visit outcomes were not related to either maternal demographic factors or clinician type (pediatricians v pediatric nurse practitioners). These results suggest that pediatric clinicians' support for parents makes a difference. Additional outcome-based analyses are needed to identify the full range of effective pediatric communication.
Value of Radiologic Skeletal Survey in Assessment of Abused Children
Authors: Ellerstein Norman S. , Norris Kimberly J.
Published: December 2021

The usefulness of the radiologic skeletal survey in the assessment of children who were suspected of being abused on neglected was studied. During a 2½-year period at one pediatric hospital, 331 skeletal surveys were performed to aid in the evaluation of possible child maltreatment. Of the 331 surveys, 38 (11.5%) showed evidence of trauma. But, in 30 of the 38 skeletal surveys, trauma was either previously known or suspected by the examiner. Therefore, in only eight cases did the skeletal survey provide new information that was helpful in the investigation of possible abuse or neglect which would have remained undiscovered without the skeletal survey. The age, sex, and clinical signs of the subjects were analyzed in an attempt to identify factors that might predict skeletal surveys with positive radiologic findings. Consideration is given to the costs and risks of skeletal surveys v potential benefits.
Pathogenesis and Prevention of Necrotizing Enterocolitis: A Hypothesis Based on Personal Observation and a Review of the Literature
Authors: Kosloske Ann M.
Published: December 2021

The hypothesis is, that necrotizing enterocolitis (NEC) of the neonate occurs by the coincidence of two of three pathologic events: (1) intestinal ischemia, (2) colonization by pathogenic bacteria, and (3) excess protein substrate in the intestinal lumen. NEC is more likely to appear following quantitative extremes, ie, severe ischemia highly pathogenic flora, or marked excess of substrate. NEC develops only if a threshhold of injury, sufficient to initiate intestinal necrosis, is exceeded. The hypothesis is derived from previous theories by Santulli, which implicated all three events, and by Lawrence, in which a single event, abnormal bacterial colonization, was considered sufficient to induce NEC. This hypothesis may explain both typical occurrences of NEC among high-risk premature infants in neonatal intensive care units (NICUs), and atypical occurrences among infants considered at low-risk, eg, previously healthy term infants, infants fed breast milk exclusively, and infants never fed. It may further explain why NEC fails to develop in most high-risk infants in NICUs. Preventive measures might include: (1) pharmacologic stabilization of intestinal perfusion, (2) modification of the intestinal flora, or (3) feeding colostrum or other protective substances. Each theoretical benefit is accompanied by potential risks. The prevention of NEC may require favorable intervention in two of the three pathologic events.
Intraventricular Hemorrhage and Vitamin E in the Very Low-Birth-Weight Infant: Evidence for Efficacy of Early Intramuscular Vitamin E Administration
Authors: Speer Michael E. , Blifeld Cindy , Rudolph Arnold J. , Chadda Prabhujett , Holbein M. E. Blair , Hittner Helen M.
Published: December 2021

To determine whether early intramuscular vitamin E supplementation influences the incidence of intraventricular hemorrhage (IVH) in infants with birth weight ≤1,500 g, data were analyzed from 134 infants enrolled on a protocol to evaluate the efficacy of intramuscular plus oral vitamin E v oral supplementation alone in the treatment of retrolental fibroplasia. All 134 infants received, via nasogastnic tube, 100 mg/kg/d of vitamin E daily (dl-α-tocopheryl acetate in MCT [medium-chain triglyceride] oil; 150 mosM) for at least 8 weeks with the first dose administered within the first eight hours of life. Sixty-four patients received, in addition, intramuscular vitamin E on days 1, 2, 4, and 6 of life and 70 patients received placebo injections in a randomized double-blind fashion. In the first week, vitamin E plasma levels were significantly higher in the 64 patients given intramuscular vitamin E. In spite of this difference no change in the incidence of sepsis or necrotizing enterocolitis was observed. Both the incidence and severity of intraventricular hemorrhage were reduced significantly in the patients given intramuscular vitamin E as compared to the patients given placebo (P = .013 and P = .04, respectively). The data suggest that vitamin E, a natural antioxidant, may play an important role in protecting the CNS microcirculation from the effects of hypoxic/ischemic injury.
Vitamin E and CNS Hemorrhage
Authors: PHELPS DALE L.
Published: December 2021

Preventing handicaps in premature infants is a pressing goal, and vitamin E has been offering some hope for the prevention of one of the most emotionally distressing sequelae, blindness. The report of Speer et al1 confirms the observation of Chiswick et al2 that vitamin E may also reduce severe CNS hemorrhage, one of the other major handicapping conditions faced by the premature infant. Naturally, we welcome this information, but in our eagerness to find a cure, we must not blunt the sharp edge of critical examination of the data. Extreme caution must be still be exercised for the following reasons: (1) some questions have been raised about the data to be examined; (2) a third study suggests the opposite result3; and (3) there are significant differences in the vitamin E formulations that were used and those available for use in the United States.
Differentiation of Chronic Salicylism from Reye Syndrome
Authors: QUINT PETER A. , ALLMAN FRANK D.
Published: December 2021

Since the discovery of salicylate in 1763, overdosage, whether acute or chronic, has frequently been described.1-3 Within the last few years, strong similarities have been noted between salicylism and Reye syndrome.4-6 The difficulty in differentiating the two is manifest by several published case reports and retrospective reviews.4,7,8 In fact, it has been suggested from pathologic findings that salicylate ingestion may cause the structural damage seen in children with Reye syndrome.7 We present a well-documented case of chronic salicylism that closely mimicked Reye syndrome, but could be differentiated from Reye syndrome on the basis of serum amino acid profile and electron microscopy.
Phenobarbital Side Effects: Hyperactivity with Speech Delay
Authors: LEVENSTEIN DAVID , GUTGESELL MARGARET E. , PERCY PHYLLIS
Published: December 2021

To the Editor.—

Hyperactivity is a reported side effect of phenobarbital usage,1 but we are unaware of any reports of language delay accompanying the hyperactivity. We are writing to draw your attention to an interesting series of cases.

D.R. had been receiving therapeutic levels of phenobarbital for more than 2 years, because he had had two seizures before 1 year of age (the first with fever). Developmental testing after 1 year of age revealed mild mental retardation and delays in all areas.
Who Provides Health Care to Children and Adolescents in the United States?
Authors: Starfield Barbara , Hoekelman Robert A. , McCormick Marie , Benson Paul , Mendenhall Robert C. , Moynihan Christy , Radecki Stephen
Published: December 2021

Face-to-face visits by children and adolescents in office-based practice in the mid-1970s were studied. Pediatricians, family physicians, and general practitioners accounted for 35%, 6%, and 30%, respectively, of all child visits. Although 40% to 45% of preventive and medical encounters were with pediatricians, only 12% of visits for minor surgery, 20% of visits for psychosocial problems, and 9% of visits for combined medical-surgical reasons were to pediatricians. Only in very young children did pediatricians provide a substantial proportion of care for each of the types of visits. For some common diagnoses (acne, refractive error) most care was provided by specialists other than primary care specialists, but less than 16% of all preventive care visits (including routine eye examinations) was provided by specialists other than primary care physicians. A substantial proportion of the prenatal care and management of minor trauma was provided by family physicians and general practitioners. Although the limitations of the study (including an average response rate of 55%, exclusion of certain specialties and institutional physicians, sampling at different times of the year, lack of control for area of location of practice, and lack of information about response rates of different types of physicians within each specialty) preclude definitive conclusions, the findings raise important questions for future study.
Written Explanation of Temperament Scores
Authors: LITTLE DAVID L.
Published: December 2021

Most parents find it worthy of their time to complete the Carey and McDevitt Infant Temperament Questionnaire1 and review the results with the pediatrician.2 This subjective approval is encouraging but the question arises, "Does it improve parenting?" Prior to measuring parenting changes, a standard method of presenting temperament data to parents had to be developed. A brief, inexpensive instrument was needed but none was found.

A written explanation form was developed (Table 1). The definitions were derived from various sources,3,4 including the Carey and McDevitt Questionnaire. The parents' ratings of this form are presented and discussed. The form should be useful for clinicians using temperament measurements in their practices.
Cytomegalovirus-Associated Hemophagocytic Syndrome
Authors: DANISH ELIZABETH H. , DAHMS BEVERLY B. , KUMAR MARY L.
Published: December 2021

Virus-associated hemophagocytic syndrome, first described by Risdall and co-workers in 1979,1 is a rare histiocytic proliferative syndrome characterzed by fever, hepatosplenomegaly, pancytopenia, and erythrophagocytosis by histiocytes that appear benign by histologic criteria. The clinical course and pathologic findings may be identical with another histiocytic disorder, familial erythrophagocytic lymphohistiocytosis, which occurs predominantly in infants. Diagnosis of virus-associated hemophagocytic syndrome depends entirely on evidence of concurrent viral infection, usually of the herpes group. Epstein-Barr virus has been associated with this syndrome in the few cases reported in children without underlying disease, whereas cytomegalovirus (CMV) has been implicated in immunosuppressed patients. We report a case of fatal CMV-associated hemophagocytic syndrome which occurred in a previously healthy infant.
High-Altitude Pulmonary Edema with Absent Right Pulmonary Artery
Authors: Rios Billy , Driscoll David J. , McNamara Dan G.
Published: December 2021

High-altitude pulmonary edema potentially is fatal. Adults with unilateral absence of a right pulmonary artery are particularly susceptible to high-altitude pulmonary edema. The occurrence of high-altitude pulmonary edema was documented in a child with congenital absence of the right pulmonary artery. Improvement occurred only upon descent to low altitude. Physicians should be aware of this life-threatening condition in children ascending to high altitude, particularly in individuals with unilateral absence of a pulmonary artery.
Progressive Diaphyseal Dysplasia: Evaluation of Corticosteroid Therapy
Authors: Naveh Yehezkel , Alon Uri , Kaftori Joseph K. , Berant Moshe
Published: December 2021

Progressive diaphyseal dysplasia is characterized clinically by crippling leg pain, fatigue, headache, poor appetite, muscle weakness, and waddling gait. Twelve affected patients, aged 2 years 4 months to 40 years, were treated with intermittent courses of low doses of prednisone given in a single dose on alternate mornings for periods ranging from 6 months to 10 years. The average initial dose of prednisone was 0.6 mg/kg/d, and average maintenance dose was 0.3 mg/kg/d. Relief of all crippling symptoms was achieved in all patients. No untoward serious side effects have been observed, and the growth of children was not slowed. However, corticosteroid therapy should be restricted to patients suffering from crippling pain. The mechanism through which steroids act remains undefined.
Overpsychologized
Authors: GERSH MARVIN J.
Published: December 2021

To the Editor.—

Cohen's article on the Society for Behavioral Pediatrics1 affords me a long-awaited opportunity to offer some personal comments on behavioral pediatrics. I am in the twilight of a pediatric career (these comments could hasten the night) and my long association with and the mutual respect I share with Cohen and the others involved, allows me to express another point of view without being labeled "hostile." The editor may find my remarks tangential to Cohen's article, but nevertheless, I believe they are relevant to the future of behavioral science in pediatrics.