bluuebunny/crossref_metadata_2025 huggingface dataset:
Sleep Disturbance in Preschool-Aged Hyperactive and Nonhyperactive Children
Authors: Kaplan Bonnie J. , McNicol Jane , Conte Richard A. , Moghadam H. K.
Published: December 2021

In spite of inadequate laboratory demonstrations of sleep problems in children with attention deficit disorder with hyperactivity, the belief persists that such problems exist. Sleep restlessness is, in fact, one of the criteria in the Diagnostic and Statistical Manual of Mental Disorders, ed 3, definition of attention deficit disorder with hyperactivity, and sleep problems are listed on two major checklists often used for describing the symptoms of this disorder. In a series of three studies, sleep problems were investigated in preschool-aged children with attention deficit disorder relative to control children without the disorder. Results of the first two studies demonstrated clearly that parents of hyperactive children considered their children to have many more sleep problems than did parents of the control children. Parental daily documentation, which is less likely to be affected by reporting bias, was used in the third study. Although the results of the third study supported the finding of increased frequency of night wakings in these children, there was no difference in total sleep time or sleep onset latency between the two groups. Two other significant group differences (enuresis and night sweats) were primarily due to subgroups of children with attention deficit disorder and hyperactivity. The greater number of sleep wakings, which disrupt parents' sleep, may be responsible for the clinical reports that these children are poor sleepers.
Commercial Discharge Packs and Breast-Feeding Counseling: Effects on Infant-Feeding Practices in a Randomized Trial
Authors: Frank Deborah A. , Wirtz Stephen J. , Sorenson James R. , Heeren Timothy
Published: December 2021

A randomized controlled trial was conducted to evaluate two interventions for prolonging the duration of breast-feeding in a multiethnic sample of 343 low-income urban women. One intervention compared research breast-feeding bedside counseling by a trained counselor, who also made eight telephone calls during the first 3 months of the infant's life, with the routine breastfeeding counseling provided in the hospital by nurses. The other intervention compared commercial discharge packs provided by formula companies with research discharge packs designed to be consistent with the WHO Code of Marketing of Breastmilk Substitutes. When infants were 4 months old, a telephone interviewer unaware of treatment status contacted 95% (324/343) of the women to determine the infants' feeding and health histories. Compared with routine counseling, research counseling delayed the first introduction of solid foods to the infant's diet (P = .03, one-tailed) but did not exert a statistically significant effect on breast-feeding by 4 months' postpartum. Women who received the research discharge pack, compared with those who received the commercial pack, were more likely to prolong exclusive breast-feeding (P = .004, one-tailed), to be partially breast-feeding at 4 months postpartum (P = .04, onetailed), and to delay the daily use of solid foods in the infant's diet (P = .017, one-tailed). Among the women who received research counseling, the research discharge pack was associated with lower rates of rehospitalization of infants than was the commercial pack (1% v 14%; P = .014, two-tailed). We conclude that in high-risk maternity populations, commercial discharge materials for breast-feeding women should be replaced by materials consistent with the WHO Code.
Monitoring Theophylline Therapy Using Citric Acid-Stimulated Saliva in Infants and Children With Asthma
Authors: Aviram Micha , Tal Asher , Ben-Zvi Zvi , Gorodischer Rafael
Published: December 2021

Saliva stimulation is required for measurement of drugs in saliva. Chewing on a piece of paraffin, which is the method usually used for saliva stimulation, requires cooperation of the patient and, thus, is inapplicable in infants and young children. To assess the value of determining theophylline concentrations from noninvasively obtained saliva in this age group, we studied the theophylline plasma to saliva concentration ratio in citric acid-stimulated saliva. Theophylline concentration was measured in 137 simultaneously obtained paired specimens of plasma and saliva from 68 patients 2½ months to 14 years of age treated with theophylline for asthma (dosage 20.8 ± 5.2 mg/kg/d, mean ± SD). Saliva secretion was stimulated by placing citric acid crystals on the tongue. A strong and highly significant correlation was observed between both determinations (r = .96; P < .01). The plasma to saliva ratio was 1.78 ± 0.22 (mean ± SD), with theophylline concentrations between 3.1 and 32.1 µg/mL of plasma. The ratio of estimated to actual plasma theophylline concentrations was 1.02 ± 0.12 (mean ± SD). Interindividual coefficient of variation of plasma to saliva theophylline concentrations ratios was 12.4%; mean intraindividual coefficient of variation was 5.3%. The use of citric acid for saliva stimulation is easily applicable to infants and young children. Compared with blood drawing, stimulation of saliva secretion by citric acid is painless and noninvasive, is more readily accepted to patients, is at least as clinically relevant for theophylline determination, and allows frequent measurements of drug levels for individualization of the dosage with samples taken at home. The therapeutic concentrations range of theophylline in saliva is estimated to be between 5.6 and 11.2 µg/mL (equivalent to plasma concentrations of 10 to 20 µg/mL) in our laboratory.
Treatment Failure in Celiac Disease Due to Coexistent Exocrine Pancreatic Insufficiency
Authors: Weizman Z. , Hamilton J. R. , Kopelman H. R. , Cleghorn G. , Dune P. R.
Published: December 2021

A 17-year-old white adolescent had a history of chronic diarrhea, delayed puberty, and growth failure. Investigations excluded cystic fibrosis, Shwachman syndrome, and endocrine causes of growth failure. Severe steatorrhea was diagnosed from fecal fat studies, and a jejunal suction biopsy showed total villus atrophy, consistent with a diagnosis of celiac disease. Following introduction of a gluten-free diet, his appetite and growth improved, but he continued to have abdominal discomfort and loose offensive bowel motions. One year later, severe steatorrhea was present. A repeat jejunal biopsy showed partial recovery of villus architecture. Serum immunoreactive trypsinogen level was low, which was highly suggestive of exocrine pancreatic failure. Results of quantitative pancreatic stimulation test confirmed the presence of primary pancreatic insufficiency. After introduction of oral pancreatic enzyme supplements with meals, his gastrointestinal symptoms resolved and growth velocity accelerated. Previously, primary pancreatic insufficiency has only been described in elderly patients with long-standing untreated celiac disease. This case, however, emphasizes that pancreatic failure can occur with celiac disease at any age. Determination of a serum immunoreactive trypsinogen level should be considered a useful screening tool for pancreatic insufficiency in patients with celiac disease who have not responded to a gluten-free diet.
Immunoglobulin Subclass Antibodies to Varicefla-Zoster Virus
Authors: Asano Yoshizo , Hiroishi Yuichi , Itakura Naoko , Hirose Shigeyuki , Kajita Yuji , Nagai Takao , Yazaki Takehiko , Takahashi Michiaki
Published: December 2021

Commercially available mouse monoclonal antibodies to human IgG subclass (IgG1 to IgG4) were applied to an enzyme-linked immunosorbent assay to measure IgG subclass-specific antibodies to varicellazoster virus in children naturally infected with varicellazoster virus and in varicella vaccine recipients. In children naturally infected with varicella-zoster virus, IgG 1 antibody was detected 2 weeks after onset of the disease in all cases, its activity increased at 1 month after onset, and almost equal antibody value was maintained 10 years after infection. This pattern of antibody response was similar to that of total IgG antibody to varicella-zoster virus after natural infection. On the other hand, low antibody activity was found in IgG2 only at 1 month of the disease. The highest antibody level of IgG3 was shown 2 weeks after onset of the disease; then, it gradually decreased, and no antibody activity was detected 10 years later. IgG4 antibody was first detected 1 month after onset and an almost equal level of antibody was shown 10 years after the disease. After inoculation of children with a live varicella vaccine, in contrast, IgG subclass antibody responses to vaccine recipients were almost equal to those after natural infection.
Hypoglycemia Pathogenesis in Children With Dumping Syndrome
Authors: Rivkees Scott A. , Crawford John D.
Published: December 2021

Three children with severe hypoglycemic reactions secondary to dumping syndrome were studied to discern the mechanism by which hypoglycemia occurred. Symptoms in patient 1 developed after fundoplication, generalized autonomic dysfunction occurred in patient 2, and dumping syndrome developed in patient 3 after malplacement of a feeding gastrostomy tube. Average blood glucose levels studied during and after two to seven meals in each child were 375 ± 97 mg/dL (mean ± SD) 30 minutes postprandially and 35 ± 10 mg/dL >120 minutes later. Swings in glucose values were proportional to the volume of meals. Insulin and glucagon levels were followed during a single meal challenge test in each patient; the average glucose concentration increased to 356 ± 59 mg/dL 30 minutes postprandially and decreased to 32 ± 11 mg/dL at 150 ± 30 minutes. Hormonal analyses indicated (1) inappropriate early release of glucagon (300 pg/mL at 15 minutes) in patient 1, (2) exuberant early release of insulin (maximum 190 ± 15 µU/mL) resulting in rapid decrease in glucose concentration in all patients, (3) development and/or persistence of hypoglycemia after the decline in circulating insulin to undetectable levels, and (4) inadequate glucagon response to hypoglycemia resulting in sustained hypoglycemia. These data indicate that gross disturbances of the insulin-glucagon axis attend childhood dumping syndrome.
Financing Health Care for the Medically Indigent Child
Authors:   Committee on Child Health Financing
Published: December 2021

Children should not be denied access to the health care system because of financial barriers or preexisting medical conditions, and yet evidence suggests that for millions of children this is the case. The American Academy of Pediatrics (AAP) in its 1986 "Medicaid Policy Statement" and its 1983 "Principles of Child Health Financing" espoused the belief that all children have a right to receive comprehensive and quality health care.

Regrettably, no national policy exists which addresses medical indigency among children and their families. Although most state legislatures have considered the indigent care issue, they have focused primarily on hospitals1 uncompensated care burdens and not on ambulatory care needs. Moreover, because of budget implications and the lack of federal revenues, these state initiatives appear to be limited measures and are not intended to support comprehensive, long-range health care plans for the medically indigent.

Data show that lack of ambulatory care, is a significant problem for medically indigent children. Comparisons of average numbers of visits to physicians for uninsured and insured children point to measurable service gaps.1 In particular, medically indigent children are not receiving the primary preventive care promulgated by the AAP and its "Recommendations for Preventive Pediatric Health Care."

The AAP believes that equitable financing solutions for the medically indigent child must be developed immediately. The purpose of this statement is to inform AAP Fellows and health policymakers of the growing numbers of underserved children and to recommend remedial action by the federal, state, and local governments, as well as the private sector.
Teach Pediatrics in Private Offices
Authors: CROOK WILLIAM G.
Published: December 2021

To the Editor.—

I liked the commentary by the late Joseph W. St Geme, Jr, MD (Pediatrics 1987;79:287-288), and his recommendation for more clinic-side teaching. He pointed out that the offsite conference room is not the best place to teach. Instead, he said that "bright energetic young men and women ... will find their pediatric adventure where the children are."

During the 1960s, I served on the Council on Pediatric Practice of the American Academy of Pediatrics.
Transcutaneous Oxygen Monitoring and Retinopathy of Prematurity
Authors: GRYLACK LAWRENCE J.
Published: December 2021

To the Editor.—

In response to the article by Bancalari et al (Pediatrics 1987;79:663-669) on transcutaneous oxygen monitoring

[See table in the PDF file]

and retinopathy of prematurity, I would like to share information on this subject from our nursery population. The incidence of retinopathy was evaluated retrospectively in a group of 288 preterm newborns during a 7-year period (1975 to 1982) in relationship to birth weight and transcutaneous oxygen monitoring. Of 57 babies with birth weights <1,000 g, 3.5% had cicatricial retinopathy of prematurity and 15% had proliferative disease.
Bioavailability of a Slow-Release Theophylline Capsule Given Twice Daily to Preschool Children With Chronic Asthma: Comparison With Liquid Theophylline
Authors: Sallent Jorge , Hill Malcolm , Stecenko Arlene , McKenzie Michael , Hendeles Leslie
Published: December 2021

The reliability of slow-release theophylline products in young children has been questioned. Therefore, we studied the bioavailability of a commonly prescribed slow-release theophylline formulation (Slo-Bid Gyrocaps), administered twice daily by sprinkling the beads on applesauce. Serial measurements of serum theophylline concentrations were obtained during steady state in eight children (ages 1.6 to 5 years) after receiving a reference liquid theophylline product every six hours and also while receiving the slow-release product every 12 hours. The morning dose of slow-release theophylline was given before the child had eaten, and the evening dose was given two hours after supper. The extent of absorption of the slow-release product was 98.3 ± 20.2% (mean ± SD) relative to the liquid reference. The serum concentration fluctuations, expressed as percentage of the measured trough, did not differ between the two products: 108 ± 59% v 129 ± 97% (P > .05) for reference and slow-release products, respectively. Three of the eight patients had unacceptably large fluctuations (> 100%) while receiving the slow-release regimen, and two of these three had unacceptable fluctuations while receiving the liquid reference. The rate of absorption was slower after the evening dose of slow-release product (postprandial), resulting in significantly smaller fluctuations, and lower peak concentrations. Time to peak concentration while receiving the slow-release regimen varied from two to four hours after the evening dose and from two to eight hours after the morning dose. However, the average difference between the peak concentration and the fourhour measurement after the morning dose was only 0.3 µg/mL (range 0 to 2.6 µg/mL). We conclude that Slo-Bid can achieve acceptably stable concentrations for about 60% of asthmatic children when administered every 12 hours. Those with persistent bronchodilator-responsive asthmatic symptoms associated with large fluctuations may benefit from the same total daily dose given in divided doses every eight hours.
Syndrome of Erythroderma, Failure to Thrive, and Diarrhea in Infancy: A Manifestation of Immunodeficiency
Authors: Glover M. T. , Atherton D. J. , Levinsky R. J.
Published: December 2021

Five infants with a triad of symptoms comprising generalized erythroderma, failure to thrive, and diarrhea are presented. All of these children demonstrated significant immunologic abnormalities. This is a recognizable clinical syndrome that reflects immunodeficiency; however, the responsible immunodeficiencies do not appear to be the same in every case. Early investigation and appropriate therapy may considerably reduce morbidity, and mortality in children with this syndrome.
Early and Late Surfactant Treatments in Baboon Model of Hyaline Membrane Disease
Authors: Maeta Haruo , Vidyasagar Dharmapuri , Raju Tonse N. K. , Bhat Rama , Matsuda Hiroo
Published: December 2021

Because the issue of optimal time for artificial surfactant therapy for hyaline membrane disease has not been established, the effects of treatment with a reconstituted bovine surfactant (surfactant TA) were compared at two time periods in a hyaline membrane disease model in a premature baboon. The baboons were delivered by cesarian section at 75% of gestation (139.5 ± 1.5 days, mean ± SD). One group was treated with surfactant TA within ten minutes after birth (ultraearly), another group was treated at two hours of age (late) and a third (comparison group) did not receive the surfactant. Both treatment groups had significantly higher compliance and ratio of arterial to alveolar Po2 ratio and lower mean airway pressure and oxygen requirement (Fio2) than the comparison group. At autopsy, the largest residual volume and hysteresis in pulmonary pressure-volume curves were noted in the ultraearly group, intermediate values were found in the late group, and least values were found in the comparison group. These data indicate that early surfactant therapy for hyaline membrane disease results in greater improvement in lung mechanics than delaying treatment, even for two hours. Delivery room treatment with surfactant of infants at risk for hyaline membrane disease is perhaps better than therapy for established hyaline membrane disease.
Right to Refuse Life-Sustaining Treatment
Authors: GUSTAITIS RASA
Published: December 2021

Recent judicial actions expanding individual rights to refuse life-prolonging medical intervention serve to call attention to the absence of similar development regarding severely damaged, critically ill newborns. Whereas courts have provided guidelines that will allow adults to choose death when hope for meaningful life is lost, hopelessly ill infants continue to be treated aggressively, even in violation of their physicians' reasonable judgment and parental choice.

Significant rulings that allow adults to refuse life-supporting treatment grow from the same perception as gives rise to the ethical dilemmas posed by severely damaged newborns: that it is inhumane, indeed morally indefensible, to prolong life when "the burden of maintaining a corporeal existence degrades the very humanity it was meant to serve" (The New York Times, Sept 12, 1986, p A10).
Anesthesia and Intraventricular Hemorrhage
Authors: COLAVITA RICHARD D.
Published: December 2021

To the Editor.—

The study by Goddard-Finegold and Armstrong1 demonstrated a decreased incidence in intraventricular hemorrhage in hypertensive beagle puppies pretreated with phenobarbital. However, there was no discussion of the possible effects of the anesthetic agent, ketamine, on their results.

Dawson et al2 demonstrated an 80% increase in cerebral blood flow in dogs after receiving ketamine, 2 mg/kg, IV. Blood flow returned to baseline levels after 30 minutes. This effect of ketamine on cerebral blood flow was blocked by prior treatment with thiopental.
Bacteremia: Occult or Nonoccult?
Authors: MAURO ROBERT D.
Published: December 2021

To the Editor.—

For those many pediatricians who have wondered whether antigen detection would provide a superior means for screening febrile children for bacteremia, Rubin and Carmody (Pediatrics 1987;80:92-96) have provided a thoughtful and needed study. Unfortunately, their results lead one to the conclusion that current technique is not sufficiently discriminating, when applied to all infants at risk for occult bacteremia, to be clinically valuable.

I am concerned, however, whether their study did in fact address the question of occult bacteremia, and I request a clarification of the authors' methods.
Vaginal Discharge of `Beads' and the New Diapers
Authors: RIMSZA MARY ELLEN , CHUN JAMES J.
Published: December 2021

To the Editor.—

We report on a "new morbidity" associated with "supra-absorbent" paper diapers, which we term "beaded" vaginal discharge.

A 4-month-old girl was referred to Maricopa Medical Pediatric Gynecology Clinic because of "discharging clear beads" from her vagina. This discharge had been a daily occurrance. The beads were described by the mother as being approximately 1 mm in diameter, clear, colorless, firm, but compressible.

The child had been in good health since birth. Growth and development were normal.
Respiratory Origin of Fluctuations in Arterial Blood Pressure in Premature Infants With Respiratory Distress Syndrome
Authors: Perlman Jeffrey , Thach Bradley
Published: December 2021

A variable fluctuating pattern of arterial BP often precedes intraventricular hemorrhage in mechanically ventilated preterm infants. To learn more about the origin of this pattern, arterial BP and respiratory muscle activity were studied in five intubated premature infants who were at high risk for intraventricular hemorrhage. We monitored esophageal pressure, gastric pressure, and arterial BP. Consistent findings were: (1) arterial BP fluctuations have the same frequency and direction of change as esophageal and gastric pressure changes associated with spontaneous breathing (R ranged from .93 to .98, P < .001); (2) spontaneous apneic pauses were accompanied by sudden and complete cessation of arterial BP fluctuations; (3) large "cough-like" fluctuations in esophageal and gastric pressures, seen in all infants, were associated with the largest fluctuations in arterial BP; (4) cutaneous stimulation had negligible effect on fluctuation in arterial BP provided no change in esophageal and gastric pressures occurred; (5) the effects of change in esophageal and gastric pressures on arterial BP were nearly simultaneous (0.05 to 0.25 second latency); (6) respirator pressure fluctuations had negligible effects on the fluctuations in arterial BP. These data suggest that the fluctuations in arterial BP are directly related to respiratory muscle activity and are most consistent with the familiar pulsus paradoxus that occurs in various other cardiorespiratory diseases.
Urine Output Determination From Superabsorbent and Regular Diapers Under Radiant Heat
Authors: Hermansen Marcus C. , Buches Mary
Published: December 2021

The rate of water evaporation from diapers was determined by sequential weights of open and closed regular diapers and of open superabsorbent diapers in three different environments—radiant heater at 100% heater output, radiant heater at 50% heater output, and room air. In all three environments, evaporation was greatest with open regular diapers, less with open superabsorbent diapers, and least with closed regular diapers. Evaporation was greatest under the radiant heater with 100% heater output, less under the radiant heater with 50% heater output, and least in room air. An open, regular diaper under 100% heater output lost 45% of its water after one hour and 85% had evaporated after two hours. Smaller volumes of water demonstrated a larger percentage of evaporation than larger volumes. Recommendations are made for the use of(1) either open, superabsorbent diapers or closed, regular diapers, (2) prompt weights after urination, and (3) accurate and precise scales.
Renal Injury in Sick Newborn Infants: A Prospective Evaluation Using Urinary β2-Microglobulin Concentrations
Authors: Tack Eric D. , Perlman Jeffrey M. , Robson Alan M. , Hausel Cathy , Chang Charles C. T.
Published: December 2021

Urinary concentrations of β2-microglobulin and creatinine were measured serially in 140 sick infants, of whom 109 were asphyxiated, and in 35 healthy preterm and term infants. First voided urines and samples from days 3 and 7 postpartum were studied. Urinary β2-microglobulin concentrations in healthy infants averaged 1.34 ± 1.34 mg/L (mean ± SD) in first voided specimens and 1.32 ± 0.98 mg/L in day 3 samples; the calculated upper limit of normal (95% confidence limit) was 4.00 mg/L. Elevated values (those exceeding the 95% confidence limit) occurred most often in the sick asphyxiated patients (56%); the first voided sample value in these patients was 10.0 ± 10.4 mg/L. The equivalent value in the sick nonasphyxiated infants was 8.32 ± 7.27 mg/L. Values were significantly and persistently elevated in the sick infants on days 3 and 7. Factoring β2-microglobulin levels by urinary creatinine concentration did not affect the significance of the findings. The increased urinary β2-microglobulin levels were not (1) related to gestational age; low β2-microglobulin values occurred at all gestational ages for both healthy and sick infants; (2) a consequence of urine flow rate; urinary β2-microglobulin did not correlate with urinary creatinine concentration or with urine to plasma creatinine ratio; and (3) a consequence of increased production of β2-microglobulin; urinary and serum β2-microglobulin values did not correlate (r = .03). Thus, we propose that the elevated levels of urinary β2-microglobulin in the sick infants were the consequence of tubular injury. This was associated with hematuria but not with a high incidence of azotemia or oliguria. In the most premature infants (<32 weeks), elevated urinary β2-microglobulin concentrations were associated with significantly increased urinary concentrations of sodium and potassium. These data suggest a higher prevalence of acute tubular injury in sick newborn infants than has been reported in previous studies in which more traditional indices of renal injury were used.
Overt Glucocorticoid Excess Due to Inhaled Corticosteroid Therapy
Authors: Hollman Gregory A. , Allen David B.
Published: December 2021

Inhaled corticosteroids have become an important therapeutic option in the treatment of childhood asthma. The preparations currently available for pediatric use (beclomethasone dipropionate and triamcinolone acetonide) do not, in general, cause significant hypothalamic-pituitary-adrenal axis suppression and physical signs of glucocorticoid excess have not been described with their use. We report an 8-year-old girl with asthma in whom obesity, hirsutism, and growth retardation developed during treatment with inhaled triamcinolone acetonide alone. Laboratory studies showed suppression of endogenous cortisol production but did not demonstrate suppression of the hypothalamic-pituitary-adrenal axis. Cessation of inhaled triamcinolone acetonide therapy resulted in resolution of obesity and hirsutism, resumption of normal growth, and a return to normal of serum cortisol levels and urinary 17-hydroxycorticosteroid excretion. Careful monitoring of growth velocity and (if clinically indicated) morning serum cortisol levels in asthmatic children using inhaled corticorsteroids will detect the rare instance of glucocorticoid excess resulting from systemic absorption of these drugs.
Psychologic Aspects of Childhood Reflex Neurovascular Dystrophy
Authors: Sherry David D. , Weisman Robin
Published: December 2021

Psychosocial factors in 21 families with children affected by reflex neurovascular dystrophy were studied. Each family was interviewed and given a battery of standardized psychologic tests. Two distinct types of families were identified. Fifteen families showed high internal cohesion, expressiveness, and organization and low levels of conflict. Six families showed high overt conflict with low levels of family cohesion, expressiveness, and organization. In all families parental enmeshment with the patient was present. Marital discord was present in 12 families. Thirteen patients had significant school problems (ten had learning disabilities). Although most of the children were described as especially bright, only four had above average intelligence test scores. Four had a history of sexual abuse. The patients and their mothers perceived the health problem as significantly worse than did children with arthritis from whom similar scores had been obtained. Possible role models with similar symptoms were reported by ten patients. These data support the concept that childhood reflex neurovascular dystrophy is frequently a stress-related disease; the therapeutic approach to treating these children and their families must take these psychosocial factors into account.
Inflammatory Bowel Disease in a Patient With Nephropathic Cystinosis
Authors: TREEM WILLIAM R. , RUSNACK EILEEN J. , RAGSDALE BRUCE D. , SEIKALY MOUIN G. , DIPALMA JOAN S.
Published: December 2021

Cystinosis is an inherited metabolic disorder characterized by the accumulation of free cystine within lysosomes resulting in cystine crystal deposition in multiple organs and tissues. Although the most affected organ is the kidney and renal failure develops at approximately 10 years of age, other nonrenal manifestations have been increasingly recognized.1,2 As a result of successful renal transplantation, patients are living beyond the first decade and hypothyroidism, photophobia, decreased visual acuity, corneal ulcerations, hepatomegaly, and splenomegaly are becoming more prominent. We report a 6-year-old boy with cystinosis in whom ulcerative colitis developed. This is the first such report of the occurrence of these two uncommon diseases in the same patient.
Palpable Lymph Nodes
Authors: EMBREE JOANNE , MURIITHI JANET , BRADDICK MICHAEL , PLUMMER FRANCIS A.
Published: December 2021

To the Editor.—

We read with interest the article by Bamji et al (Pediatrics 1986;78:573-575) concerning the presence of palpable lymph nodes in 24% of healthy newborns. Information of this nature is valuable in the assessment of the likelihood that congenital infections are present in neonates if lymph nodes are palpable during the first days of life. We have also conducted a survey of palpable lymph nodes in healthy young term infants. Sixty-five neonates born at the Pumwani Maternity Hospital in Nairobi, Kenya, were examined for the presence of palpable axillary and inguinal lymph nodes within 24 hours of birth.
Lack of Evidence of Retroviral Involvement in Kawasaki Disease
Authors: OKAMOTO TAKASHI , KUWABARA HIROYO , SHIMOTOHNO KUNITADA , SUGIMURA TAKASHI , YANASE YOSHIO , KAWASAKI TOMISAKU
Published: December 2021

To the Editor.—

Microbes have long been suspected to be a causative agent of Kawasaki disease since the original report by Kawasaki.1 Yanagawa et al2 described an epidemic wave of Kawasaki disease spread from central Japan to the entire nation in 6 months. This strongly suggests that an infectious agent might be involved. Furthermore, recent studies by Shulman and Rowley3 and Burnes et al4 have independently demonstrated retrovirus-specific reverse transcriptase activities in the culture supernatants of peripheral mononuclear cells from US patients with Kawasaki disease.
Chlamydia and Suspected Sexual Abuse
Authors: NEINSTEIN LAWRENCE S. , FUSTER C. DANIEL
Published: December 2021

In Reply.—

We thank Dr Hammerschlag for her thoughtful comments. We wholeheartedly agree with her about the use of cultures in the setting of suspected sexual abuse. As other studies have indicated, the sensitivity and specificity of the direct fluorescent antibody test are too low in a population with low prevalence rates such as a population with suspected child abuse.

We also agree with Dr Hammerschlag about the possibility of perinatal infection in a young child.
Clinical Spectrum of Mucolipidosis Type IV
Authors: AMIR NAOMI , ZLOTOGORA JOEL , BACH GIDEON
Published: December 2021

In Reply.—

Drs Weitz and Kohn refer to a 15-month-old boy with moderate generalized hypotonia and elevated muscle enzyme levels in which the opportunistic finding of corneal opacities led to the diagnosis of mucolipidosis type IV. Although they provided no information about the visual behavior or psychosocial developmental level of the patient, they conclude that clinical evidence of muscle disease may be the presenting sign of mucolipidosis type IV. They refer to the article by Zlotogora et al (Neuropediatrics 1983;14:104-105) who reported a child whose profound global retardation began to be evident in infancy and the muscle disorder was clearly part of an extensive CNS disease.
Diagnosis of Meningitis
Authors: EGUIGUREN LUIS , CHERNOW BART , TODRES I. DAVID
Published: December 2021

To the Editor.—

In reviewing the medical literature about meningitis in infants, we found the review article by the Academy's Task Force on Diagnosis and Management of Meningitis1 to be helpful. However, we noted two important errors in Tabe 2: (1) The table (which is adapted from another article2) should be properly entitled, "Cerebrospinal Fluid Findings in Infants Without Meningitis" or "CSF Findings in Normal Infants." (2) The fifth age category in the table should be >12 months instead of 7-12 months.
Diagnosis of Meningitis
Authors: KLINE JEROME O.
Published: December 2021

In Reply.—

Drs Eguiguren, Chernow, and Todres are correct on both counts. The table title should have identified CSF findings in infants without meningitis and the last age category is >12 months.
Multiple Cutaneous Hemangiomas and Coarctation of the Aorta With Right Aortic Arch
Authors: VAILLANT LOÏC , LORETTE GÉRARD , CHANTEPIE ALAIN , MARCHAND MICHEL , ALISON DANIEL , VAILLANT MARIE-CATHERINE , LAUGIER JEAN
Published: December 2021

Strawberry hemangiomas are the most common congenital vascular malformation seen in infants. Usually, they appear as a raised bright or purplish red lobulated tumor with well-defined borders and capillaries protruding from its surface. They are not present at birth. They develop during the first weeks of life, grow rapidly during the first 6 months, remain stationary for awhile, and then undergo complete or partial involution and resolution without treatment. Usually, these hemangiomas are solitary or in small number1 and are not associated with congenital anomalies.

We report a case of strawberry hemangiomas that is unusual because of the multiplicity and extension associated with laryngeal hemangioma and coarctation with right aortic arch.
Child Life
Authors: BRAZELTON T. BERRY , THOMPSON RICHARD H.
Published: December 2021

This past May more than 250 members of the Child Life Council gathered in Halifax, Nova Scotia, Canada, for their annual conference and celebrated the fifth anniversary of the organization. Established in 1982 under the auspices of the Association for the Care of Children's Health, this young organization has grown steadily and now numbers nearly 700 members. In another indication of the development of the profession of child life, more than 300 individuals were granted certification as child life specialists in 1986/1987, the first year in which certification was available.

As the Child Life Council enters its second half-decade, and because the profession shows additional signs of maturation, it would be wise to reflect on the contributions made by this relatively new member of the pediatric health care team.
First Aid for the Choking Child, 1988
Authors:   Committee on Accident and Poison Prevention
Published: December 2021

Aspiration of a foreign body is a common hazard in infancy and childhood. In the last 6 years, there has been a great effort to educate the public concerning the prevention of choking due to accidental aspiration of foods or small objects by children. Concomitantly, there has been a campaign to teach the first aid measures essential for evaluation and treatment of choking.

HISTORIC OVERVIEW

Much of the existing data regarding treatment of the choking child is anecdotal. In 1981, the Committee on Accident and Poison Prevention of the American Academy of Pediatrics1 reviewed the available literature. The committee recommended that a foreign body in the upper airway be considered an immediate threat to life and that such a foreign body required urgent removal. In addition, the committee recognized the effectiveness of natural coughing and recommended that, if a choking child could breath and was able to speak and/or cough, all maneuvers were unnecessary and potentially dangerous. If the choking child could not breathe, cough, or make a sound, a series of back blows and chest thrusts was recommended. The committee recommendations resulted in a spirited controversy concerning the most effective management of the choking child.2-6

At the July 1985 National Conference on Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, the American Heart Association, American College of Cardiology, and the American Red Cross convened a panel on Management of Foreign Body Airway Obstruction to review and revise the past recommendations.
Benign Epilepsy of Childhood and Gowers's Statements
Authors: BOUMA P. A.D. , PETERS A. C.B.
Published: December 2021

To the Editor.—

Is there a group of children whose seizures have an excellent prognosis without any treatment whatsoever? The recent article by Freeman et al1 clearly favors a positive answer. They suggest that children who are likely to remain seizure free when medication is discontinued after 2 years without seizures2 might be good candidates for withholding any treatment.

Our findings3 may support this suggestion. Anticonvulsant medication was stopped in a prospective study in 116 children with epilepsy (defined as two afebrile seizures or more) who had had no seizures for 2 years.
Substantiation of Sexual Abuse Charges When Parents Dispute Custody or Visitation
Authors: Paradise Jan E. , Rostain Anthony L. , Nathanson Madelaine
Published: December 2021

Recent news reports have implied that charges of sexual child abuse during parental separation or divorce are often deliberately falsified. Such a conclusion could be harmful if it biased practitioners faced with such allegations in clinical practice. To investigate this concern, sexual abuse cases in a hospital-based consecutive series and in one author's clinical practice were reviewed. Abuse allegations with and without a concomitant custody or visitation dispute were compared. A custody or visitation dispute occurred in 12 (39%) of 31 sexual abuse complaints lodged against a parent. Allegedly abused children whose parents contested custody or visitation were significantly younger than those for whom custody or visitation was not an issue (5.4 v 7.8 years, P = .02). Sexual abuse allegations were substantiated less frequently when there was concomitant parental conflict (67% v 95%, nonsignificant) but were nevertheless substantiated more than half of the time.
Reduced Hemoglobin Values in Children and Young Adults With Hemophilia
Authors: Buchanan George R. , Holtkamp Christine A.
Published: December 2021

Mild leukopenia and thrombocytopenia are common in multitransfused hemophiliacs. Because little attention has previously been directed to measurements of erythropoiesis in these patients, we prospectively examined hemoglobin concentration and RBC indices in 94 children and young adults with hemophilia during comprehensive clinic visits. Additional studies performed in many included serum transferrin saturation, ferritin, haptoglobin, and free erythrocyte protoporphyrin measurements. Hemoglobin concentrations were recorded as age-related percentile values. Hemophiliacs of all ages and degrees of severity often had lower than average values for hemoglobin; 31% had values less than the third percentile, 46% less than the tenth percentile, and 83% less than the mean value. Reduced hemoglobin percentile values were unrelated to age, severity of disease, or human immunodeficiency virus antibody status. Only five patients had an obvious cause for anemia. Serum ferritin, transferrin saturation, and erythrocyte protoporphyrin values were usually normal, indicating that iron deficiency and anemia of chronic disease were uncommon. Although serum haptoglobin was reduced in 44% of the patients, reticulocyte count was infrequently increased. We conclude that hemoglobin values are frequently less than the mean normal values for age in hemophiliacs. Although frank anemia is common, it is usually mild and without obvious cause. Hemophiliac individuals with slightly reduced hemoglobin values probably do not routinely require detailed investigation for occult blood loss, iron deficiency, or inflammation.
Peritonitis in Children With Nephrotic Syndrome
Authors: Gorensek Margaret J. , Lebel Marc H. , Nelson John D.
Published: December 2021

In a retrospective review of 214 children with nephrotic syndrome seen at Children's Medical Center and Parkland Memorial Hospital in Dallas throughout the 20-year period from 1967 to 1986, 62 cases of primary peritonitis were identified in 37 patients (17.3% rate). Streptococcus pneumoniae was the major pathogen, accounting for 38% of the cases. An additional 27% of patients had negative culture results but were clinically responsive to penicillin. Gram-negative organisms were cultured from only 3% of patients; 5% were caused by α-streptococci and 2% each by enterococcus and anaerobes. In 23% of cases the cause was unknown. Our findings differ from the recent trend in the literature in which Gram-negative organisms associated with these infections are increasingly implicated. The incidence and bacteriology of peritonitis do not appear to have changed significantly during the 20-year period. Clinically, peritonitis was characterized by abdominal pain (98%), fever (95%), rebound tenderness (85%), and nausea and vomiting (71%). A total of 79% of patients were either in relapse or receiving steroid therapy at the time peritonitis was diagnosed; 13% had infiltrates visible on their chest radiographs. Based on our data, it seems reasonable to initiate antimicrobial therapy in nephrotic children with suspected peritonitis using a combination of penicillin plus either an aminoglycoside or a cephalosporin. This regimen should continue until culture results are available, unless Gram-positive diplococci are identified in a Gram-stained specimen of peritoneal fluid, in which case penicillin alone should suffice.
Fetal Therapy: Ethical Considerations
Authors:   Committee on Bioethics
Published: December 2021

The practice of caring for a pregnant woman and her fetus has always had the dual goal of good outcome for both parties. Furthermore, the pregnant woman has always had to consider undergoing risks or discomforts for the sake of her fetus. With recent advances in perinatal medicine, the pregnant woman and her fetus are increasingly viewed as two treatable patients.1 The fetus is less surrounded in mystery and is more accessible to diagnostic procedures and treatment in utero. The area of fetal evaluation and therapy has created a variety of ethical questions.

Decisions concerning fetal therapy have several important aspects. The field of fetal medical and surgical treatment is new and evolving at such a rapid rate that most techniques involving fetal intervention are clouded in more uncertainty than is the case for many other therapeutic decisions. Some fetal therapeutic interventions, such as intrauterine transfusion or cesarean delivery for placenta previa, are standard practices of proven efficacy. Other interventions, such as cesarean delivery for fetal distress, are routine practices but have a more ambiguous data base upon which to make decisions. Still other fetal interventions, such as shunt diversions for hydrocephalus or obstructive uropathy, are considered research procedures and are not standard medical practices. An international registry has been established to record experience with these experimental surgical interventions.2

Although decisions concerning a fetus require surrogate decision makers, as in the case of infants and children, decisions by pregnant women concerning their fetuses involve more than considerations of the best interests of their offspring.
Emergency Drug Dosage Guides
Authors: OKSTEIN CHARLES J. , ODAL MARCIA , KELLY RONALD W.
Published: December 2021

Successful cardiopulmonary resuscitation of pediatric patients is complicated by the fact that physicians perform such therapy infrequently, and resuscitative efforts resulting in death or serious disability are common. For example, in one study of 91 children who were treated in an emergency department for cardiopulmonary arrest, only two survived without neurologic handicaps or death.1 These statistics are particularly discouraging when it is noted that 14 of those children had their arrests in the emergency department itself.

One factor complicating resuscitation of pediatric patients is that dosages of emergency medications must be adjusted accurately and quickly for each patient's body weight.
Directory of Overseas Service Opportunities for Pediatricians
Authors: Ledbetter Edgar O.
Published: December 2021

The following directory contains more than 80 organizations that recruit US pediatricians for both long- and short-term service opportunities overseas. This list was compiled by the staff of the Task Force on International Child Health of the American Academy of Pediatrics. Facts concerning each program were obtained through correspondence and telephone interviews with organization representatives. We have tried to make the list as complete and current as possible.

Anyone knowing of a service organization that has been omitted is encouraged to supply the necessary information to:
School Bus Seat Belts?
Authors: WIDOME MARK DAVID
Published: December 2021

In Reply.—

Dr Laws has a good idea. Sound public health concepts often gain wide acceptance because they appeal to different constituencies for different reasons. In fact, the demonstration that passenger restraint systems improve behavior of preschool children has been used successfully in the promotion of car safety seat use.1 No doubt, the perennial concern regarding student behavior might be used to advantage by those of us convinced that seat belts offer crash protection. Although there have been occasional intervention studies addressing deportment on the school bus,2 I am unaware of any in which the effect of seat belts has been looked at specifically.
Brain Swelling in the Asphyxiated Term Newborn: Pathogenesis and Outcome
Authors: Lupton Brian A. , Hill Alan , Roland Elke H. , Whitfield Michael F. , Flodmark Olof
Published: December 2021

The role of brain swelling following acute hypoxic-ischemic insult in the genesis of brain injury in the term newborn is controversial. Recent experimental animal studies suggest that it may result from prior irreversible cerebral necrosis and therefore represents a consequence as opposed to a cause of major brain injury. In this study, 32 asphyxiated term newborns were studied during the first week of life with serial intracranial pressure measurements. A total of 26 infants had scans during the first five days of life. Seven patients had two CT scans within this period. These investigations were correlated with outcome at 18 months of age. Seven infants had increased intracranial pressure (> 10 mm Hg) that reached a maximum between 36 and 72 hours of age. Cerebral perfusion pressures remained normal, which makes ongoing ischemic injury unlikely as a cause. The seven patients with increased intracranial pressure had decreased attenuation on CT that was generalized in six infants and patchy in one infant. Of the infants with increased intracranial pressure and severe CT abnormalities, three died and four had severe neurologic sequelae. In seven infants, a second CT scan at three to four days of life demonstrated progression of the decrease in tissue attenuation. Most of the infants with normal intracranial pressure (23/25) had no or had only minor neurologic abnormalities at follow-up. These data suggest that brain swelling is relatively uncommon in the asphyxiated term newborn. The temporal profile of increased intracranial pressure and CT abnormalities, with maximum abnormalities at 36 to 72 hours of age, is most consistent with cerebral necrosis as a cause that, in turn, implies a poor prognosis.