bluuebunny/crossref_metadata_2025 huggingface dataset:
Newborn Screening for Congenital Hypothyroidism: Recommended Guidelines
Authors:   AAP Section on Endocrinology and Committee on Genetics, and American Thyroid Association Committee on Public Health
Published: December 2021

Congenital hypothyroidism (CH) represents one of the most common preventable causes of mental retardation. The fetal hypothalamic-pituitary-thyroid axis begins to function by midgestation and is mature in the term infant at delivery. If fetal hypothyroidism develops, untoward effects may be demonstrated in certain organ systems, including the central nervous system and skeleton. However, most infants with CH appear normal at birth. Recent data suggest that the hypothyroid fetus is protected to a certain extent by placental transfer of maternal thyroid hormone; serum thyroxine (T4) levels in the cord blood of athyroid fetuses approximate one third of maternal levels.1 In addition, studies in animal models of hypothyroidism demonstrate increased levels of brain iodothyronine deiodinase, the enzyme which converts T4 to triiodothyronine (T3). In the hypothyroid fetus, this increased enzyme acting on T4 of maternal origin is sufficient to produce near normal fetal brain T3 concentrations.2 Thus, it appears that early detection and treatment of congenital hypothyroidism should have the potential to completely reverse the effects of fetal hypothyroidism in all but the most severe cases, for example, athyreotic infants born to mothers with thyroid problems resulting in inadequate placental transfer of maternal thyroid hormone.

Since the development of pilot screening programs for CH in Quebec and Pittsburgh in 1974,3 newborn screening for CH has become routine in essentially all developed countries of the world and is under development in Eastern Europe, South America, Asia, and Africa. In North America it is estimated that more than 5 million newborns are screened, with approximately 1400 infants with congenital hypothyroidism detected annually.
Skeptical About Importance of Low Levels of Lead
Authors: CUNNINGHAM ROBERT D.
Published: December 2021

To the Editor.—

Drs Cummins and Goldman1 lament that despite what they feel is "strong evidence of lead's neurotoxic effects, many remain skeptical that low-level, subclinical lead exposure in early childhood impacts subsequent cognition and that the Centers for Disease Control's (CDC) aggressive approach to eradicating lead poisoning, including universal screening, is warranted."

Recently Wasserman et al2 published the results of a study performed on the populations of two Yugoslav towns, one of which was the site of a lead smelter, whereas the other town was relatively "lead-free."
On the Association of Unilateral Thalamic Hemorrhage and Urinary Tract Infection
Authors: ROOMAN R. , VAN REEMPTS P. , VAN OVERMEIRE B. , MAHIEU L.
Published: December 2021

To the Editor.—

Two years ago Roland et al reviewed a group of full-term newborns with late-onset thalamic hemorrhage/intraventricular bleeding.1 The pathogenesis of this condition remains unclear but in the series of patients described by Roland et al, we noticed that urinary tract infection was the most common complicating factor. We recently treated a full-term newborn with late-onset unilateral thalamic hemorrhage associated with a urinary tract infection.

The child was born after an uncomplicated pregnancy at 40 weeks of gestation.
Stepping Up the Treatment of Children With Asthma
Authors: FURUKAWA CLIFTON T.
Published: December 2021

In response to the increase in asthma morbidity and mortality noted in the 1980s, the National Heart, Lung, and Blood Institute convened an expert panel and published its recommendations as the National Asthma Education Program in 1991.1 Comprehensive guidelines were developed focusing on four components of asthma management:

1. Objective measures of lung function

2. Pharmacologic therapy

3. Environmental measures to control allergens and irritants

4. Patient education

This commentary addresses issues related to pharmacologic therapy. The guidelines of this component of asthma management focus on treatment of inflammation, rather than on bronchodilation. Because corticosteroids are the most effective anti-inflammatory agents used to treat asthma, there has been a shift to using inhaled corticosteroids.
Surfactant Replacement Therapy: Prophylaxis or Treatment?
Authors: DUNN MICHAEL S.
Published: December 2021

After extensive preclinical and clinical testing, surfactant replacement therapy for premature neonates has become routine in modern neonatal intensive care units. Even though "everyone's doing it," there is nevertheless wide variation in how this therapy is applied. Future studies will be needed to help sort out some of the unresolved issues such as the best preparation, optimal delivery method, how best to ventilate the surfactant-treated neonate, when to retreat with surfactant, and the role of adjunctive therapies such as indomethacin or corticosteroids.

Considerable controversy also exists over when surfactant should be administered. This issue has been studied in some depth, both in animals and premature neonates.
Bronchiolitis Obliterans: A Complication of Group B Streptococcal Disease Treated With Extracorporeal Membrane Oxygenation
Authors: MAYOCK DENNIS E. , O'ROURKE P. PEARL , KAPUR RAJ P.
Published: December 2021

Group B streptococcus (GBS) is a common cause of severe infection in neonates. In the first days of life, GBS infection presents with sepsis, pneumonia, and cardiovascular collapse. Of those infected, between 25% and 75% will succumb to the disease.1 Nearly half of the children who survive neonatal GBS sepsis suffer significant long-term neurologic morbidity including seizures, mental retardation, hearing disorders, blindness, cerebral palsy, and developmental delays.1,2

The survivors of early-onset GBS pneumonitis appear to have a minimal risk of chronic pulmonary disease, but this has not been studied thoroughly. We describe a neonate with early-onset GBS sepsis and pneumonitis who developed severe respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support.
Pediatric Services for Infants and Children With Special Health Care Needs
Authors:   Committee on Children With Disabilities
Published: December 2021

The discipline of infant and child development has expanded greatly during the last 3 decades.1 Much of this growth is due to new knowledge regarding special services that can improve early development of children with, or at risk for, disabilities.2 Passage of Public Law 101-476, the Individuals With Disabilities Education Act (IDEA) revising Public Law 99-457,3 particularly Part H, coupled with existing federal child care mandates and increasing public expression of concern regarding all forms of child care, shows a significant national commitment to the concept that early services are critical if children with disabilities are to reach their full potential.4

While there may be debate over the relative importance of environmental vs hereditary factors in a child's developmental outcome, any approach used to promote child development must consider how these factors interact. A child's intelligence, temperament, and motor skills combine in a complex fashion with family and peers, to influence his or her development. There is much to learn about how to positively influence child/caregiver/societal interactions. As work in the area of early intervention* grows, attempts to prove that such efforts can help a child with disabilities overcome innate cognitive and motor skill limitations have met with inconsistent and often controversial results.5 Improved outcomes are most likely to occur when services are based on the premise that parents or primary caregivers are the most important factors influencing a child's development. All services, even those as clear-cut as a specific health intervention, must follow this premise.6-8

Future studies documenting successful outcomes of programs influencing child development—namely measures of effects on cognitive and motor development—need to be expanded to include at least the following variables:
Guidelines and Levels of Care for Pediatric Intensive Care Units
Authors:   Committee on Hospital Care and Pediatric Section of the Society of Critical Care Medicine
Published: December 2021

Pediatric critical care medicine has matured dramatically during the past two decades. Knowledge of the pathophysiology of life-threatening processes and the technologic capacity to monitor and treat pediatric patients suffering from them have advanced rapidly during this period. Along with the scientific and technical advances has been the evolution of the pediatric intensive care unt (PICU), where the special needs of critically ill or injured children can be met by pediatric specialists.

In 1985, the American Board of Pediatrics recognized the new subspecialty of Pediatric Critical Care Medicine and established criteria for subspecialty certification. The American Boards of Medicine, Surgery, and Anesthesiology gave similar recognition to the subspecialty. In 1990, the Residency Review Committee of the Accreditation Council for Graduate Medical Education completed its first accreditation of Pediatric Critical Care Medicine Training Programs.

In view of these developments, the Pediatric Section of the Society of Critical Care Medicine and the American Academy of Pediatrics Section on Critical Care Medicine and Committee on Hospital Care believe that existing published1 guidelines should now be revised for the pediatric intensive care unit. This policy represents the consensus of the three above-mentioned groups who believe the recommendations that follow are current, necessary, and attainable in 1993. The guidelines are not intended as a statement of the ideal or ultimate requirements for PICUs. We expect standards for PICUs to rise as critical care medicine continues to develop and appropriately trained providers become more readily available.

In view of these developments, the Pediatric Section of the Society of Critical Care Medicine and the American Academy of Pediatrics Section on Critical Care Medicine and Committee on Hospital Care believe that existing published1 guidelines should now be revised for the pediatric intensive care unit.
Hypoxaemia in infants with bronchopulmonary dysplasia
Authors: POETS CHRISTIAN F. , SAMUELS MARTIN P. , SOUTHALL DAVID P.
Published: December 2021

To the Editor.—

Singer et al recently described severe oxygen desaturation in infants with bronchopulmonary dysplasia (BPD) who were breathing room air. On average, Sao2 was <80% for 37% of (post-feeding) time in their study.1 They concluded from these findings that the current clinical practice of weaning preterm infants from additional inspired oxygen when average Sao2 is at or more than 88% to 90% should be reassessed.

We wish to point out that, in addition to the data presented by Singer et al, there is further evidence to suggest that the practice of accepting an average Sao2 of 88% to 90% in preterm infants should be reviewed.
Antineuronal Antibodies in Movement Disorders
Authors: Kiessling Louise S. , Marcotte Ann C. , Culpepper Larry
Published: December 2021

Objective. To determine whether children with recent onset of movement disorders (Tourette syndrome, motor and/or vocal tics, chorea, choreiform movements) show evidence of serological antibodies directed against the human central nervous system as previously documented in research on Sydenham's chorea.

Methods. Serum antibodies against previously frozen human caudate nucleus sections were analyzed using a blinded design and immunofluorescent staining methods. The sera of one group of 50 children referred for evaluation of attention deficit hyperactivity disorder, behavior disorders, and learning disabilities (24 with an associated movement disorder) seen between June 1989 and June 1990 were analyzed. The study was replicated in 33 children (21 with an associated movement disorder) seen between June 1990 and November 1990.

Results. In the original sample of 50 children, those with movement disorders were significantly more likely to have evidence of antineuronal antibodies than were those without movement disorders (odds ratio [OR] 4.80, 95% confidence interval [CI] 2.58 to 8.93). Results of the replication were similar (OR 6.00, 95% CI 2.56 to 14.03). For the total group, the OR was 5.50, (95% CI 3.54 to 8.99), which is highly significant. The percentage of children with a movement disorder whose sera were strongly positive for antineuronal antibodies (44%) was very similar to that previously found in children with Sydenham's chorea (46%). Children with movement disorders were also more likely than children without movement disorders to have at least one antistreptococcal titer elevated.

Conclusions. The data strongly suggest an association between antecedent group A β-hemolytic streptococcal infection as inferred from elevated antistreptococcal titers and the presence of serum antineuronal antibodies, which may, in turn, be linked to childhood movement disorders.
Aerosol Beclomethasone Dipropionate Compared With Theophylline as Primary Treatment of Chronic, Mild to Moderately Severe Asthma in Children
Authors: Tinkelman David G. , Reed Charles E. , Nelson Harold S. , Offord Kenneth P.
Published: December 2021

Objective. To compare the benefits and adverse reactions of theophylline and beclomethasone (BDP) in the long-term control of mild to moderate chronic asthma in children.

Design. Multicentered, double-blind, double-placebo, randomized, controlled trial.

Patients. One hundred ninety-five children between the ages of 6 and 16 years with mild to moderate asthma.

Intervention. Treatment with either BDP, 84 µg four times a day, or sustained-release theophylline administered twice daily in doses adjusted for optimum control of symptoms.

Main outcome measures. Daily diary record of symptoms, peak flow rates, supplemental bronchodilator and glucocorticoid treatment, doctor and hospital visits, absence from work and school, and side effects.

Results. Aerosol BDP and sustained-release theophylline were effective primary treatments for mild to moderate chronic asthma. Beclomethasone resulted in comparable symptom control with less bronchodilator use and fewer courses of systemic steroids than did theophylline. Side effects were observed significantly more frequently with theophylline than with BDP. Growth velocity suppression was noted with BDP and was more pronounced in boys. Suppression was not associated with alterations in cortisol measurements either at baseline or following stimulation.

Conclusions. Both theophylline and BDP are effective therapy for mild to moderate asthma. Caution must be used with the administration of BDP in children because of possible growth velocity suppression.
Malaria in Children in Chicago
Authors: Emanuel Benjamin , Aronson Neil , Shulman Stanford
Published: December 2021

Objective. To review the experience of a large children's hospital and two community hospitals in Chicago in which malaria was diagnosed in children during a recent 6-year period.

Methods. Retrospective medical record review covering the years 1985 to 1990.

Results. Twenty cases of childhood malaria were diagnosed, generally in patients hospitalized for fever unresponsive to oral antibiotics also associated with splenomegaly, with presumptive diagnoses of malignancy, typhoid fever, acute appendicitis, or urinary tract infection. History of recent immigration to the United States or travel to a malaria-endemic area was frequently not elicited until several days into hospitalization, thus delaying diagnosis and therapy.

Conclusions. Because malaria in the United States pediatric population has increased as a result of foreign immigration and overseas travel, pediatricians must be alert to the possibility of malaria in febrile children, and the importance of antimalarial prophylaxis should be communicated to parents of children traveling to endemic areas.
Cerebral Oxygen Metabolism in Newborns
Authors: Altman Denis I. , Perlman Jeffrey M. , Volpe Joseph J. , Powers William J.
Published: December 2021

Objective. A better understanding of the developmental changes in brain energy metabolism that occur in human neonates is critically important for designing rational treatment strategies that ensure an adequate supply of nutrients to the brain and minimize deleterious side effects of therapeutic interventions in sick newborns.

Methods. Cerebral metabolic rate for oxygen (CMRO2) was measured with positron emission tomography in 11 sick newborns of different gestational ages.

Results. In five preterm infants, mean hemispheric CMRO2 was 0.06 to 0.54 mL 100 g-1 min-1. Two of these preterm infants with virtually absent CMRO2 (0.06 mL 100 g-1 min-1) had minimal or no evidence of parenchymal brain injury detected in the newborn period. In six term infants, mean hemispheric CMRO2 was 0.0 to 1.3 mL 100 g-1 min-1. Two with no neurological disease had mean hemispheric CMRO2 of 0.4 and 0.7 mL 100 g-1 min-1 and were normal at 6 and 7 months, respectively.

Conclusions. CMRO2 in four newborns who had minimal or no detectable brain injury was considerably below the threshold for brain viability in adults of 1.3 mL 100 g-1 min-1. This indicates that energy requirements in fetal and newborn brain are minimal or can be met by nonoxidative metabolism.
Decreasing Mortality Associated With the Introduction of Surfactant Therapy: An Observational Study of Neonates Weighing 601 to 1300 Grams at Birth
Authors: Horbar Jeffrey D. , Wright Elizabeth C. , Onstad Lynn ,   Members of the National Institute of Child Health and Human Development Neonatal Research Network
Published: December 2021

Objective. To determine whether the introduction of surfactant therapy was associated with decreased mortality for high-risk preterm neonates weighing 601 to 1300 g at birth.

Design. Before-after observational study.

Setting. Eight tertiary care neonatal intensive care units participating in the National Institute of Child Health and Human Development Neonatal Research Network.

Patients. The outcomes for neonates with birth weight 601 to 1300 g admitted in the 2 years before surfactants became available (n = 2780) were compared with those of neonates admitted in the year beginning 2 months after surfactants became available (n = 1413).

Main outcome measures. The primary outcome measure was in-hospital mortality; secondary outcome measures included durations of assisted ventilation, length of hospitalization, and neonatal morbidity.

Results. Forty percent of neonates in the postsurfactant group received surfactant (range 28% to 69% at the centers). Mortality decreased from 27.8% before to 19.9% after surfactant therapy was introduced (Mantel-Haenszel x2 = 31.4, P = .001). The adjusted odds ratio for mortality after surfactants became available was 0.73 (95% confidence interval 0.55 to 0.95). The duration of assisted ventilation and length of hospitalization increased after surfactants were introduced (P = .0001 for both outcomes).

Conclusion. Mortality for neonates weighing 601 to 1300 g decreased after surfactant therapy was introduced, suggesting that the efficacy of surfactants demonstrated in randomized controlled trials will translate into effectiveness in routine clinical care.
Driving-Related Risks and Outcomes of Attention Deficit Hyperactivity Disorder in Adolescents and Young Adults: A 3- to 5-Year Follow-up Survey
Authors: Barkley Russell A. , Guevremont David C. , Anastopoulos Arthur D. , DuPaul George J. , Shelton Tern L.
Published: December 2021

Objective. To determine whether teenagers and young adults with attention deficit hyperactivity disorder (ADHD) have more motor vehicle citations and crashes and are more careless drivers than their normal peers.

Design. A comparison of two groups of teenagers and young adults (ADHD and normal) followed up 3 to 5 years after original diagnosis.

Setting. A university medical center clinic for ADHD patients.

Patients. Thirty-five subjects with ADHD and 36 control subjects between 16 and 22 years of age, all of whom were licensed drivers.

Main outcome measures. Parent ratings of current symptoms of ADHD, oppositional defiant disorder, and conduct disorder, a survey of various negative driving outcomes, and a rating scale of driving behavior.

Results. Subjects with ADHD used less sound driving habits. This deficiency was associated with greater driving-related negative outcomes in all categories surveyed. Subjects with ADHD were more likely than control subjects to have had auto crashes, to have had more such crashes, to have more bodily injuries associated with such crashes, and to be at fault for more crashes than control subjects. They were also more likely to have received traffic citations and received more such citations than control subjects, particularly for speeding. The subgroup of teenagers with ADHD having greater comorbid oppositional defiant disorder and conduct disorder symptoms were at highest risk for such deficient driving skills/habits and negative driving-related outcomes.

Conclusions. ADHD, and especially its association with oppositional defiant disorder/conduct disorder, is associated with substantially increased risks for driving among teenagers and young adults and worthy of attention when clinicians counsel such patients and their parents.
Postexposure Prophylaxis of Varicella in Family Contact by Oral Acyclovir
Authors: Asano Yoshizo , Yoshikawa Tetsushi , Suga Sadao , Kobayashi Ikuko , Nakashima Toshihiko , Yazaki Takehiko , Ozaki Takao , Yamada Akira , Imanishi Jiro
Published: December 2021

Objective. To determine whether varicella can be prevented by administration of oral acyclovir (ACV) during the incubation period of the disease.

Subjects and methods. ACV (40 or 80 mg/kg daily in four divided doses) was given orally to 25 exposed infants and children for 7 days, starting 7 to 9 days after exposure from the index case in their families. Their clinical features were compared with those of 25 age-matched control subjects who had been exposed in their families but did not receive ACV. A fluorescent antibody to membrane antigen assay was used for determination of the antibody to varicella-zoster virus, and a nested polymerase chain reaction method was used for detection of viremia.

Results. Among the 25 who received ACV, 4 (16%) developed the disease and 1 (4%) had a fever. On the other hand, all of 25 control subjects developed the disease and 17 (68%) had a fever. The incidence of fever and the severity of skin rashes were significantly lower (P < .01) in the subjects who received oral ACV than in the control group. Seroconversion was observed in 84% of subjects who received ACV In some cases, varicella-zoster virus DNA was detected by polymerase chain reaction amplification in peripheral blood mononuclear cells from blood drawn approximately 14 days after exposure.

Conclusions. Varicella can be prevented or modified by administration of oral ACV late in the incubation period.
Effect of Dietary Fiber (Soy Polysaccharide) on the Severity, Duration, and Nutritional Outcome of Acute, Watery Diarrhea in Children
Authors: Brown Kenneth H. , Perez Fernando , Peerson Janet M. , Fadel James , Brunsgaard Grete , Ostrom Karin M. , MacLean William C.
Published: December 2021

Objective. To assess the effects of dietary fiber (soy polysaccharide) on the severity, duration, and nutritional outcome of acute, watery childhood diarrhea.

Methods. A total of 34 hospitalized Peruvian male infants between 2 and 24 months of age were randomly assigned to receive a soy-protein isolate, lactose-free formula with added soy polysaccharide (group SF, n = 19) or the same diet without added fiber (group S, n = 15). The consumption of formulas, stool amount and consistency, absorption of macronutrients, and change in anthropometric status were measured.

Results. Children in both groups were initially similar with regard to age, nutritional status, and prior duration and severity of diarrhea. Four patients in group SF (21%) and two in group S (13%) failed therapy because of recurrent dehydration or severe purging (P = .67). Formula intakes increased slightly during hospitalization (P = .03), but did not vary by dietary group (P = .73). Stool outputs declined significantly (P < .001) during hospitalization, but there were no significant differences by dietary group in either stool wet weight (P = .83) or dry weight (P = .87). Estimated median durations of liquid stool excretion after hospitalization were 43 hours in group SF and 163 hours in group S (P = .003). There were no significant differences in fractional or net absorption of macronutrients or change in anthropometric status by dietary group.

Conclusions. Soy polysaccharide, while not affecting stool output, macronutrient absorption, or nutritional status during acute, watery childhood diarrhea, significantly and markedly reduced the duration of liquid stool excretion.
Correlation Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children
Authors: Stambouly Joseph J. , Kahn Ellen , Boxer Robert A.
Published: December 2021

Study objective. To examine the correlation between clinical diagnoses and autopsy findings in children who die in the pediatric intensive care unit (PICU).

Design. Retrospective chart review.

Setting. PICU of a university-affiliated hospital.

Patients. A consecutive sample of patients who died in the PICU and had autopsies performed.

Measurements and main results. Of 193 patients who died during the 7½year study period, 50 (6%) had autopsies performed. The mean age was 34.7 months (range 15 hours to 17 years), and the mean length of stay in the PICU was 12.2 days (range 2 hours to 60 days). Major admitting diagnoses included postoperative cardiac surgery (19), nonoperative cardiac disease (7), hematologic/malignant disorder (5), and acquired immunodeficiency syndrome (5). There were 5 cases (10%) where autopsy revealed a major finding that, if known prior to death, would have altered clinical management and might have resulted in cure or prolonged survival. In another 9 patients (18%) the autopsy revealed major findings that, if known prior to death, would not have altered management. Eight of these findings related to the cause of death and 2 of them involved the basic disease. There was no correlation between new findings and either patient age or length of stay in the PICU.

Conclusions. Despite modern diagnostic techniques, the autopsy continues to reveal valuable and unsuspected information.
Effectiveness and Safety of an Haemophilus influenzae Type b Conjugate Vaccine (PRP-T) in Young Infants
Authors: Vadheim Constance M. , Greenberg David P. , Partridge Susan , Jing Jennie , Ward Joel I. ,   Kaiser-UCLA Vaccine Study Group
Published: December 2021

Objective. To study the safety, immunogenicity, and protective efficacy of the Haemophilus influenzae capsular polysaccharide tetanus conjugate vaccine (PRP-T).

Design. Randomized, double-blind, controlled clinical trial.

Setting. Southern California Kaiser-Permanente Health Plan.

Participants. 10 317 infants 6 to 15 weeks of age, with no known immune dysfunction, exposure to hepatitis B, or contraindication to diphtheria-tetanus-pertussis (DTP) vaccination were enrolled between August 1989 and September 1990.

Intervention. Infants were randomized to receive either PRP-T or a recombinant hepatitis B control vaccine (in addition to DTP at approximately 2, 4, and 6 months of age.

Outcome measures. Adverse reactions occurring during the first 72 hours and between doses (including hospitalizations and outpatient visits) were measured using parental reporting/interviews and review of records. Invasive disease caused by H influenzae was ascertained from the time of enrollment until December 31, 1990.

Results. In October 1990, the study was prematurely terminated because of licensure of other H influenzae vaccines recommended for routine infant use. The rates of systemic and local reactions occurring within 72 hours of each vaccine dose were generally similar for infants given PRP-T and hepatitis B, but some reaction rates (local reactions, fever ≥ 120°F, irritability, crying) were significantly higher in the PRP-T group. In the month following receipt of vaccine, PRP-T-vaccinated infants experienced five definite seizures compared with three in the hepatitis B control group. Within 48 hours of vaccination, three seizures (two definite and one possible), which were thought to be related to vaccination, occurred in the PRP-T group, compared with none in the control group (P < .13). Overall morbidity, mortality and hospitalization rates were similar in the two vaccine groups. Three cases of invasive disease caused by H influenzae occurred in the control group; none occurred in the PRP-T group.

Conclusions. The PRP-T vaccine is safe and appears to be effective in preventing invasive disease caused by H influenzae type b.
Steroids and Varicella
Authors: REICHES NANCY A. , JONES JAMES F.
Published: December 2021

Reasons for adverse outcomes of infectious diseases are always under scrutiny. We expect infectious illnesses to have a specific course and outcome. Outcomes outside of the expected range are unacceptable, although the natural course of each infection includes them. Adverse outcomes that are products of medical invention are of particular import because they imply changes inpractice.

One such situation is corticosteroid-induced fatal or severe varicella-zoster virus (VZV) infections. This topic, although not new, has received considerable interest because of recent warnings by the Food and Drug Administration.1 Case reports, retrospective studies, and reviews that have appeared since the 1950s suggest that high-dose (<1 to 2 mg/kg per day) but not low-dose (5 to 20 mg/day) systemic use of corticosteroids in both immunocompetent and particularly in immunosuppressed patients may be associated with severe or fatal outcome, particularly if the drugs are given immediately prior to or during the incubation period.
Guidelines for Ophthalmologic Examinations in Children With Juvenile Rheumatoid Arthritis
Authors:   Section on Rheumatology and Section on Ophthalmology
Published: December 2021

Chronic, nongranulomatous iridocyclitis is an important complication of juvenile rheumatoid arthritis (JRA).1-3 First reported by Ohm in 1910, the association between iridocycitis and JRA has become well established. The intraocular inflammation referred to as iridocyclitis primarily affects the iris and ciliary body. Overall, the reported incidence of iridocyditis varies from 2% to 21% in children with JRA.4 The morbidity of iridocydlitis includes cataracts, glaucoma, band keratopathy, and loss of vision.5,6 Diagnosis of early iridocycitis is usually not possible by routine direct ophthalmoscopy. Sitlamp examination detects the signs of active anterior chamber inflammation. Guidelines for the schedule of routine serial sitlamp examination are suggested for early detection of iridocycitis.

The presentation of eye involvement in JRA may be asymptomatic or of an insidious onset. The outcome has improved in the past 20 years. The majority of children have a relatively good visual prognosis if the iridocycitis is detected and treated early.6

RISK FACTORS FOR IRIDOCYCLITIS

Articular Features

The diagnosis of JRA describes a heterogeneous group of arthritic conditions with onset of disease before age 16 years. There are three major subtypes of JRA: systemic onset, polyarticular onset, and pauciarticular onset, defined by the clinical manifestations in the first 6 weeks of the disease.7 Fewer than 2% of children with systemic-onset JRA have iridocycitis.4,5 Children with polyarticular disease are at moderate risk, with 7% to 37% incidence of iridocyditis. The majority of children with iridocycitis have pauciarticular disease.1-3,5 The onset of the iridocyclitis may precede the onset of the arthritis in approximately 6% of cases.
Nipple Confusion
Authors: MULFORD CHRIS
Published: December 2021

To the Editor.—

In their recent artide "Single Daily Bottle Use in the Early Weeks Postpartum and Breast-Feeding Outcomes,"1 Cronenwett et al report that many American women who want to breast-feed choose partial breast-feeding rather than exclusive breast-feeding. The reasons the authors give are: (1) mothers intending to work outside the home, (2) fathers wanting to feed the baby, (3) mothers wanting to avoid 24-hour responsibility for feedings, and (4) fear that the baby will refuse to take a bottle at some later time if not taught early and kept in practice.
Nipple Confusion
Authors: HEERY LEE B.
Published: December 2021

To the Editor.—

I read with interest the article by Cronenwett et al on the effect of early bottle supplementation on breast-feeding outcome.1 That article made the important point that motivated, breast-feeding mothers can use supplemental bottles to allow them more freedom to be away from their infants, to give the father the opportunity to feed, and to facilitate return to work.

However, I am concerned about the impact that article may have on advice given by health care providers who do not read the article carefully, particularly the excellent discussion of the limitations of the study.
Nipple Confusion
Authors: FREDRICKSON DOREN
Published: December 2021

To the Editor.—

I wish to comment on the study reported by Cronenwett et al,1 which was a fascinating prospective study among married white women who planned to breast-feed. Women were randomly selected to perform either exdusive breast-feeding or partial breast-feeding with bottled human milk supplements to determine the impact of infant temperament and limited bottle-feeding on breast-feeding duration.

The authors admit that small sample size and lack of statistical power make a false-negative possible.
Artifacts Causing Artifacts
Authors: KAPLAN MICHAEL , GLUSTEIN JOSEPH Z
Published: December 2021

To the Editor.—

Neonatologists frequently contend with artifacts produced by medical equipment causing unwanted shadows on chest and abdominal radiographs. These artifacts are frequently caused by monitoring equipment and respiratory tubing. We have not yet encountered cases of religious artifacts causing such distorting images.

Recently, two infants being ventilated on open radiant warmer incubators and x-rayed on the same day, were found to have rectangular semiopaque outlines on their radiographs (Fig 1). A search of all the medical and radiographic equipment did not reveal the origin of these artifacts.
SIDS and Homicide
Authors: BASS MILLARD , HASS RITA
Published: December 2021

To the Editor.—

Dr Reece's discussion on differentiating between unexpected death due to the sudden infant death syndrome (SIDS) and one due to homicide1 focuses on the medical literature regarding this topic. May we comment on this diagnostic dilemma based on our experience in pediatric forensic pathology? It is certainly true that the recently expanded definition of SIDS now includes a negative death-scene investigation as an integrated part of this diagnosis.2 However, from a historical perspective, there has been a fundamental misunderstanding about the term "death-scene investigation" in sudden, unexplained infant death.
Questions Improvement!
Authors: STRASBURGER VICTOR C.
Published: December 2021

To the Editor.—

Cheers to Dr Wender et al1 for having the good sense to update the survey of pediatricians originally undertaken by the 1978 American Academy of Pediatrics Task Force on Pediatric Education, but their concept of what constitutes "significant improvement" leaves me mystified! In their sample of graduates of pediatric residency training programs since 1984, the following percentages of physicians found their residency training experiences to be insufficient:

Care of adolescents, 50.9%

Psychosocial problems, 50.1%

Interviewing and counseling, 33.3%
Questions Improvement!
Authors: WENDER ESTHER H.
Published: December 2021

In Reply.—

Dr Strasburger is correct to be appalled at the continuing high rates of perceived inadequacy of pediatric residency training in psychosocial issues and in adolescent medicine, as was documented in our recent article.1 But our study did reveal that there has been movement in the right direction during the 10 years of pediatric training since the Task Force report, especially in the five most recent years of training. Our figures showed, for example, that in 1978, when pediatricians were surveyed for the Task Force report, 66% felt that their training in adolescent medicine was insufficient.
Should Chloral Hydrate Be Banned?
Authors: Steinberg Alfred D.
Published: December 2021

Objective. Current federal regulations of potentially carcinogenic environmental chemicals are based on the assumption that risks for humans can be extrapolated from the effects of chronic high-dose exposure of rodents. It is assumed that all chemicals induce cancer by a genotoxic mechanism (direct interaction with DNA) and that humans metabolize chemicals by the same pathways as the test rodents. Trichloroethylene, a former medicine, is now regulated because of rodent studies. Its major metabolite, chloral hydrate, widely used as a sedative in both adults and children, is in danger of being banned by comparable studies. This paper assesses the safety of chloral hydrate.

Design. Analysis of the literature regarding the metabolic, toxicologic, and epidemiologic data on trichloroethylene and chloral hydrate.

Results. The dose-response relationship for carcinogenesis of chioral hydrate and other chemicals in its metabolic breakdown pathway is nonlinear in rodents: very high doses given chronically, sufficient to cause cellular necrosis, are necessary for induction of malignancies. In addition, epidemiologic data on people exposed to substantial amounts of trichloroethylene (which is metabolized to chloral hydrate) show no increase in mortality or cancers.

Conclusions. The assumptions underlying current regulatory practices for environmental chemicals are not applicable to the medicinal use of chloral hydrate. Instead, a threshold model is appropriate. The data do not suggest the need to ban chloral hydrate as a medicine; however, possible modifications in its use are suggested.
How Aggressive Should Delivery Room Cardiopulmonary Resuscitation Be for Extremely Low Birth Weight Neonates?
Authors: DAVIS DEBORAH J.
Published: December 2021

The neonatology staff attending high-risk deliveries are often faced with difficult ethical decisions. One of these is whether or not to perform cardiopulmonary resuscitation on extremely low birth weight neonates in the delivery room. Unfortunately, there is a paucity of information in the medical literature addressing this dilemma. To determine whether guidelines for resuscitation of the extremely low birth weight neonate could be set, I undertook a chart review of all neonates born with a birth weight of 1000 g or less in our institution.

METHODS

All babies born at the Ottawa General Hospital who weighed 1000 g or less at birth were identified through the neonatal intensive care unit logbook, which records all births at which a neonatal physician is in attendance.
Linea Vestibularis: Follow-up of a Normal Genital Structure
Authors: KELLOGG NANCY D. , PARRA JUAN M.
Published: December 2021

Keen observation and precise documentation have become increasingly important in the physical evaluation of a child who may have been sexually abused. The task of proper interpretation of these

[See table in the PDF file]

physical findings depends on the recognition of normal anatomy.

Much work has been done to differentiate normal anatomic variants from physical changes resulting from injury.1-7 In a recent study, healthy female newborns were examined to establish the presence of a white midline streak in the posterior vestibule.8 In the initial phase of this study, 123 newborns were examined. A white linear structure in the mid-posterior vestibule, termed linea vestibularis (LV), was found in 10% (n = 13) of the group and a white spot in the mid-posterior vestibule, termed partial linea vestibularis (PLV), was found in 14% (n = 17) of the group.
Conception and Creation of the American Academy of Pediatrics
Authors: Hughes James G.
Published: December 2021

In the latter years of the 19th century, and to an increasing degree in the first decades of the 20th, there arose in the United States and elsewhere a growing concern for the health and welfare of women and children, especially pregnant mothers and infants. Compared with current figures, maternal and infant mortality rates were extremely high, and there were virtually no widespread programs to avoid malnutrition and a host of preventable diseases and disabilities in childhood. Isolated instances of good maternal and infant programs existed, but it became obvious that our country needed national programs to improve child health and welfare.
Use of Ribavirin in the Treatment of Respiratory Syncytial Virus Infection
Authors:   Committee on Infectious Diseases
Published: December 2021

Ribavirin is an antiviral drug that was approved by the Food and Drug Administration in 1986 for aerosol treatment of serious respiratory syncytial virus (RSV) infections in hospitalized children. Ribavirin has a broad spectrum of antiviral activity in vitro, where it inhibits replication of RSV, influenza, parainfluenza, adenovirus, measles, Lassa fever, and Hantaan viruses. Proof of efficacy for human infection has been obtained in double-blind placebo-controlled studies of RSV,1,2 Lassa fever, and Korean hemorrhagic fever. Presently, only anecdotal reports support the efficacy of this drug for treatment of measles or parainfluenza. Ribavirin treatment for RSV infections has been controversial because of the aerosol route of administration, concern for potential toxicity for exposed persons, cost, and the unpredictable and highly variable course of illness in the absence of specific therapy. These issues necessitate ongoing review of ribavirin therapy and the following updated recommendations by the American Academy of Pediatrics.

BACKGROUND

RSV Disease

Respiratory syncytial virus is the most important cause of lower respiratory tract disease in infants and young children. Disease usually appears in yearly outbreaks in the winter or spring, and essentially all children become infected during their first 3 years of life. The number of infected infants who require hospitalization has been estimated to range from 1 to 50 per 1000 in different locations. Currently, the mortality rate in hospitalized infants who previously were healthy is low (less than 1%). In infants with underlying diseases, however, the mortality can be much higher. Conditions that increase the risk of severe or fatal RSV infection are cyanotic or complicated congenital heart disease (including pulmonary hypertension); underlying pulmonary disease, especially bronchopulmonary dysplasia; prematurity; and immunodeficiency disease or therapy causing immunosuppression at any age.
Lead Poisoning: Twenty Years After
Authors: SACHS HENRIETTA , MOEL DONALD I.
Published: December 2021

To the Editor.—

In October 1991, the Centers for Disease Control decreased the blood lead level PbB) from 25 to 10 µg/dL and designated it as abnormal because of "overwhelming and compelling scientific evidence"1 that 10 µg/dL is associated with adverse neurobehavioral development. We have evidence to the contrary, obtained in a long-term follow-up of severely lead-poisoned children whom we treated before 1972 for PbBs between 80 and 470 µg/dL (mean, 150.3 ± 77.1 µg/dL); their mean age was 28 months.
Homosexuality and Adolescence
Authors:   COMMITTEE ON ADOLESCENCE
Published: December 2021

Pediatricians should be aware that some of the youths in their care may be homosexual or have concerns about sexual orientation. Caregivers should provide factual, current, nonjudgmental information in a confidential manner. These youths may present to physicians seeking information about homosexuality, STDs, substance abuse, or various psychosocial difficulties. The pediatrician should ensure that each youth receives a thorough medical history and physical examination (including appropriate laboratory tests), as well as STD (including HIV) counseling and, if necessary, appropriate treatment. The health care professional should also be attentive to various potential psychosocial difficulties and offer counseling or refer for counseling when necessary.

The American Academy of Pediatrics reaffirms the physician's responsibility to provide comprehensive health care and guidance for all adolescents, including gay and lesbian adolescents and those young people struggling with issues of sexual orientation. The deadly consequences of AIDS and adolescent suicide underscore the critical need to address and seek to prevent the major physical and mental health problems that confront gay and lesbian youths in their transition to a healthy adulthood.
In Reply: Different Views on Adolescent Abortion
Authors: FLEMING GRETCHEN V. , O'CONNOR KAREN
Published: December 2021

This is in reply to several letters that have been received by Pediatrics commenting on our article published in Pediatrics in March 1993, entitled "Adolescent Abortion: Views of the Membership of the American Academy of Pediatrics" (91:561-565).

The letter from Patricia Lee June, MD, makes several points that merit further discussion. First, she defends the safety of childbirth to adolescents, based on maternal mortality statistics. This is certainly justified, but, as we pointed out in the paper, the risks of adolescent pregnancy are seen more clearly instead in problems of social functioning.
COURTS LET UTILIZATION REVIEW FIRMS OFF THE HOOK—AND LEAVE DOCTORS ON
Authors: L. J. F.
Published: December 2021

One of the most striking—and disturbing—changes under way in medicine is the rapid erosion of the physician's authority for managing the patient. More and more allied health professionals and organizations such as HMOs and PPOs clamor for the right to direct patient care.

Yet when it comes to assuming some of the risk for malpractice suits, these groups want the burden to remain entirely on the doctor.

Another claimant to knowing better than doctors what patients need: the utilization review firm. UR companies have made doctors' lives miserable by denying hospitalization, demanding earlier discharge, and generally questioning every aspect of patient management.

When a malpractice suit arises, though, the UR firms all too often deny any responsibility. How? They say they're just interpreting the benefits a plan offers. This and other forms of legal hairsplitting leave the doctor holding the malpractice bag.