bluuebunny/crossref_metadata_2025 huggingface dataset:
CORRESPONDENCE
Authors: VEEDER BORDEN S.
Published: December 2021

As examiner in pediatrics for the National Board of Medical Examiners, I would like to bring to the attention of the pediatricians an important change in Part III of the examination, as it involves pediatrics. This is the oral examination given at the end of a year's internship by "subsidiary boards" in 29 medical centers throughout the country. The clinical nature of the examination provides an opportunity to determine the candidate's ability to apply the knowledge which he has previously demonstrated in the written examination of Parts I and II.

For many years the examination has included medicine, surgery, and obstetrics as major subjects, while pediatrics has been included in a group of specialties as being of minor importance.
SALMONELLA BREDENEY MENINGITIS
Authors: KANTOR HOWARD L.
Published: December 2021

A case of Salmonella bredeney meningitis with recovery in a 19 day old infant is reported. This is the youngest patient with Salmonella meningitis known to have recovered. This is the second known case of Salmonella meningitis with recovery in a patient less than one month of age. Treatment with multiple antibiotics and chemotherapy both parenterally and intrathecally produced rapid improvement. An equally effective supportive blood transfusion may have aided this recovery. The use of chloromycetin after discontinuance of all other antibiotics was effective in producing a clinical recovery without relapse. No sequelae were noted at the end of a three month observation period.

Attempts at discovering the carrier state of the infesting organism by careful examination of the family revealed no source of infection.
MAXIMUM BREATHING CAPACITY AND VITAL CAPACITY OF MALE CHILDREN AND ADOLESCENTS
Authors: FERRIS B. G. , WHITTENBERGER J. L. , GALLAGHER J. R.
Published: December 2021

Expected mean values and a range of normal values (plus or minus two standard deviations) are presented for the vital capacity and the maximum breathing capacity of male children and adolescents.

It is recommended that calculations of the above values be based upon four attributes (age, height, weight, and body surface area) rather than upon a prediction deriving from a single attribute (especially in the individual who does not have a standard height and weight for his age).
Sudden Infant Death Syndrome and Sleeping Position
Authors: HUNT CARL E. , SHANNON DANIEL C.
Published: December 2021

Do something, anything! is a universal cry at the onset of the pain and suffering of illness; healers have responded with imagination and boundless enthusiasm.

—Lewis Thomas (NY Rev Books. September 24, 1987)

We have learned, to our sorrow, that strong emotional interest in the force of speedy medical action when there is substantial uncertainty has led to recurring iatrogenic disasters.

—William Silverman1

The American Academy of Pediatrics Task Force on Infant Positioning and SIDS recently has reviewed the existing epidemiological data and concluded that (1) the weight of evidence implicates the prone position as a significant risk factor for sudden infant death syndrome (SIDS), and (2) for healthy and full-term infants, prone sleeping should be abandoned in favor of the supine or lateral position.2
A Role for Prostacyclin in Bruising Symptomatology
Authors: Gerrard Jon M. , Duta Elena , Nosek-Cenkowska Barbara , Singhroy Sandra , Cheang Mary , Kobrinsky Nathan L.
Published: December 2021

The relationship between bleeding and bruising and the production of prostacyclin and thromboxane was assessed in children who were to have a tonsillectomy and/or an adenoidectomy. Eicosanoids in the blood oozing from the bleeding time incision were measured and correlated with the reported frequency of bruising and epistaxis. A striking association (P .0003) between prostacyclin production and the frequency of bruising was found; children reporting bleeding at least biweekly had the highest prostacyclin synthesis. Successively lower levels of the prostacyclin metabolite, 6-keto-prostaglandin F1α, were found in children reporting less frequent bruising. Prostacyclin production in bleeding time blood was also correlated inversely with systolic blood pressure and hemoglobin level, although neither of these variables could explain the association between prostacyclin production and bruising. There was no correlation between thromboxane formation, systolic blood pressure, hemoglobin level, age, or bleeding time and the frequency of bruising. The ratio of thromboxane B2 to 6-keto-prostaglandin F1α was correlated inversely with the length of the bleeding time (P = .016). It is concluded that vascular prostacyclin production may have a role in bruising symptomatology. It is suggested that prostacyclin formed at the injured vessel surface collects within the first few seconds after injury inside the tissue space at the site of the bruise and, by influencing the formation of the platelet/fibrin plug and/or the leakage of blood from the vessels, plays a significant role in modifying the development of bruising.
Referral Patterns for Children with Chronic Diseases
Authors: Blancquaert Ingeborg R. , Zvagulis Inta , Gray-Donald Katherine , Pless I. Barry
Published: December 2021

A sample of 1377 physicians were surveyed by mailed questionnaire to study to what extent primary care physicians are involved in the long-term care of children with chronic disorders. The sample included all pediatricians practicing in the province of Quebec and a stratified random sample of general practitioners (10% sample in urban areas and 25% sample in rural areas). A response rate of 81% was achieved. Referral patterns were studied for asthma, congenital heart disease, and diabetes. Although pediatricians referred their patients less frequently than general practitioners, referral patterns depended mainly on the clinical condition. "No routine referral" was the most popular management strategy for asthma, whereas for congenital heart disease and diabetes more than 20% of physicians referred their patients for all aspects of care. Rural physicians tended to assume patient care to a greater extent than did urban physicians. Most pediatricians referred patients directly to subspecialists practicing in tertiary care centers, whereas general practitioners often sent patients to pediatricians practicing elsewhere, or to other specialists. These data suggest that the availability of medical resources in the community and accessibility to tertiary care centers also influence physicians' involvement in the long-term care of these children.
The Issues
Authors: JONES JAMES FLY
Published: December 2021

The recent FDA label warnings of severe varicella infection following corticosteroid therapy and therapeutic recommendations are provocative.1 On the one hand, the warnings appropriately raise the level of concern regarding the seriousness of varicella infection in healthy and immunosuppressed children. On the other hand, the blanket inclusion of corticosteroids of all administration modes without reference to dosage, proof of immunosuppression, and subsequent increased risk, is of concern.

A review of the literature regarding steroids and varicella supports high oral doses (≥1.0 mg/kg of prednisone) as being associated with rare fatalities.2
Variability and Self-regulation of Energy Intake in Young Children in Their Everyday Environment
Authors: Shea Steven , Stein Aryeh D. , Basch Charles E. , Contento Isobel R. , Zybert Patricia
Published: December 2021

Recent data from small numbers of children studied under controlled protocols indicate that intraindividual variation in energy consumption over 24 hours is smaller than variation from eating occasion to eating occasion, implying that children self-regulate their energy consumption. This hypothesis was tested children living in their everyday environment. Between 1986 and 1989, 24-hour recalls were administered on seven occasions (four times in 1986 through 1987 and three times in 1988 through 1989) to the mothers of 181 preschool children in New York City. Each 24-hour period was divided into six meals or snacks. The coefficient of variation (standard deviation divided by the mean) was calculated for each child for energy consumption at each eating occasion and for the day as a whole. Coefficients of variation for energy consumption at the six eating occasions ranged from 46.5% to 165.8%, compared with 30.3% for the whole day. This coefficient of variation for the observed whole-day energy consumption was significantly less (P < .001) than would be expected if no autoregulation of energy intake (no meal-to-meal correlation) occurred. These findings in children living in their everyday environment are consistent with observations under more controlled study conditions. These data suggest that children who eat less at one meal compensate at another, although the data do not address the issues of longer term energy self-regulation, overall energy balance, or diet quality.
Sleeping Through the Night: A Developmental Perspective
Authors: Anders Thomas F. , Halpern Leslie F. , Hua Jenny
Published: December 2021

This study examines falling asleep and night waking in human infants during the first 8 months of life. All-night time-lapse video recordings were obtained at 3 weeks and 3 months of age; a Sleep Habits Interview was completed at these ages and repeated at 8 months of age by telephone interview. At the 3-week and 3-month ages, self-report measures of maternal psychologic distress, depression, and self-esteem were also obtained. The data are examined from both cross-sectional (age group) and longitudnal (individual) perspectives. Parent-infant interactions at bedtime and during the middle of the night changed significantly with increasing age. At 3 weeks of age, most infants were put into their cribs for the night already asleep. When they awakened in the middle of the night, they were removed from their cribs. By the time they returned to their cribs, they were again asleep. By 3 months of age, infants who were put into the crib awake at bedtime and allowed to fall asleep on their own were more likely to return to sleep on their own after awakenings later in the night. In contrast, infants who were put into the crib already asleep at the beginning of the night were significantly more likely to be removed from the crib following a subsequent nighttime awakening. Thus, the pattern of bedtime sleep onset was related to sleep onset following an awakening in the middle of the night. This association was present at 8 months as well. Infants who used sleep aids were more likely to be put into their cribs awake at bedtime and were also more likely to return to sleep on their own after a nighttime awakening at both 3 and 8 months of age. At 8 months of age, 7 of the 21 infants were identified by their mothers as problem sleepers. All were male infants who were still put into their cribs asleep at the beginning of the night. These individuals could not be predicted from 3-week or 3-month observations of video-recorded sleep-wake state organization or mother-infant interaction. The authors speculate about the interplay between sleep-wake state regulation, nighttime interactions, problem sleep, temperament and maternal factors such as depression, self-esteem, and stress.
Biologic, Foster, and Adoptive Parents: Care Givers of Children Exposed Perinatally to Human Immunodeficiency Virus in the United States
Authors: Caldwell M. Blake , Mascola Laurene , Smith Walter , Thomas Pauline , Hsu Ho-Wen , Maldonado Yvonne , Parrott Robert , Byers Robert , Oxtoby Margaret ,   Pediatric Spectrum of Disease Clinical Consortium
Published: December 2021

Children born to human immunodeficiency virus (HIV)-infected mothers often do not live with a biologic parent because of drug use, illness, or death of the mother. Public health officials need to know the number and proportion of children who will require care by someone other than a biologic parent (alternative care giver). The Pediatric Spectrum of Disease project, conducted in six different geographic regions in the United States, assesses issues specific to HIV in children. Among the information being collected in this study are data regarding the primary care giver. Of 1683 children born to HIV-infected mothers and enrolled through 1990, 55% (937) were living with a biologic parent, 10% (169) with another relative, 28% (455) were in foster care, 3% (55) had been adopted, and 4% (67) lived in group settings or with other care givers. In all locations and for all racial/ethnic groups, children of mothers who used intravenous drugs were more likely to be living with an alternative care giver than were children of mothers who had not used intravenous drugs (odds ratio 4.15). However, there were striking variations by study location (odds ratio range 1.4 to 7.2). The data suggest that maternal drug use may be the most important factor determining whether a child lives with a biologic parent and that there are also regional differences in alternative care placement.
Near Fatal Fire Ant Envenomation of a Newborn
Authors: HARDWICK WILLUAM E. , ROYALL JAMES A. , PETITT BRUCE A. , TILDEN SAMUEL J.
Published: December 2021

Imported fire ants, Solenopsis richteri and Solenopsis invicta, are menacing health hazards for the 20 to 30 million people who live in the fire ant-infested regions of the southeastern and south central United States. In the early 1900s, fire ants were brought into the port city of Mobile, Alabama, on vegetation and produce from South America. Their aggressive behavior compared to native ants and the favorable climate throughout the southeast allowed extensive spread. In 1985 it was estimated that fire ants infested approximately 250 million acres in eleven southern states and Puerto Rico.1 In infested areas fire ants account for 90% of all ant populations and stings from fire ants are more frequent than stings from other hymenoptera, becoming the most common cause of insect venom hypersensitivity.
Cerebral Infarction Complicating Hemorrhagic Shock and Encephalopathy Syndrome
Authors: BRATTON SUSAN L. , JARDINE DAVID S.
Published: December 2021

Hemorrhagic shock and encephalopathy syndrome (HSES) is a severe, life-threatening illness affecting infants and young children. Patients stricken with this illness suffer high rates of neurological injury and mortality. We describe a child with HSES whose course was complicated by global cerebral infarction. This injury, although extensive and severe, was not appreciated during the initial examination of the child. Cerebral infarction during HSES may not be detected reliably unless imaging studies of the central nervous system are preformed after cerebral edema has resolved.

CASE REPORT

The patient was a 7-week-old girl born to a healthy 20-year-old woman. The infant had been healthy until 1 week prior to admission when she developed an upper respiratory tract infection.
Temperature Measurement
Authors: FREED GARY L. , FRALEY J. KENNARD
Published: December 2021

In Reply.—

We thank Alexander and Terndrup for their comments on our paper and appreciate the opportunity to respond to them.

Those performing FIRST temp measurements for our study were instructed to use both the appropriate mode and "offsets" for comparison. Although we did not independently verify the "offset" for each temperature determination, we have no reason to suspect it was not performed appropriately.

However, it is the misinterpretation by Alexander and Terndrup of the meaning of "mean differences" in Table 2 that is of greater concern.
Improved Survival Accounts for Most, but Not All, of the Increase in Bronchopulmonary Dysplasia
Authors: Parker Robert A. , Lindstrom Daniel P. , Cotton Robert B.
Published: December 2021

The incidence of bronchopulmonary dysplasia (BPD) increased from 10.6% in 1976 through 1980, to 21.7% (1981 through 1985), and to 32.9% (1986 through 1990) in very low birth weight neonates (1500 g or less) admitted to the Vanderbilt Neonatal Intensive Care Unit, while there was a concurrent decline in incidence of neonatal death (NEOD) during the same periods (26.4%, 18.3%, and 15.9%, respectively). Population changes in risk factors (birth weight, sex, race, location of birth, gestational age, diagnosis of hyaline membrane disease, and 5-minute Apgar score) over time do not account for this increase. To estimate the proportion of the increase in BPD attributable to the concurrent decline in NEOD during these periods, separate logistic regression models for NEOD and BPD were calculated from patients born during 1976 through 1985. These results were used to predict the expected number of cases of NEOD and BPD during 1986 through 1990, assuming that the adjusted incidence of NEOD and BPD remained constant from 1976 through 1985, to 1986 through 1990. The increase in the combined outcome, NEOD/BPD, over the three time periods (34.2%, 36.1%, and 43.5%) remained statistically significant after adjustment for the risk factors listed above. During 1986 through 1990, the predicted number of NEOD was 83 more than the number observed, while the predicted number with BPD was 115 less than the number observed. If all 83 averted cases of NEOD during 1986 through 1990 had developed BPD, then 83 (72%) of the 115 excess cases of BPD could be attributed to averted NEOD. The approximate 95% confidence interval for this estimate was 58% to 87%. These results indicate that while most of the excess cases of BPD in 1986 through 1990 could be explained by neonates who previously would have died, there were still additional cases of BPD that were not explained by the risk factors included in this analysis.
Recombinant Erythropoietin as Treatment for the Late Hyporegenerative Anemia of Rh Hemolytic Disease
Authors: Ohls Robin K. , Christensen Robert D. , Wirkus Paul E.
Published: December 2021

Infants with Rh hemolytic disease can develop a "late" anemia characterized by low serum concentrations of erythropoietin but erythroid progenitors that remain highly erythropoietin-responsive. Erythropoietin administration was evaluated in two patients as an alternative to transfusion. Reticulocyte counts increased after 5 days of treatment, and hematocrits increased after 10 days. Neither patient received erythrocyte transfusions following erythropoietin therapy.
Mental Disorders in Chronically Ill Children: Parent-Child Discrepancy and Physician Identification
Authors: Canning Emily Harris , Hanser Suzanne B. , Shade Kathryn A. , Boyce W. Thomas
Published: December 2021

Mental disorders affect 18% to 20% of children and adolescents. The rate in children with chronic illness is probably higher. This study of chronically ill children addresses the discrepancy between parent and child reports of child psychiatric disorders and the extent to which pediatricians agree with reports by children and parents regarding such problems. Eighty-three subjects, aged 9 to 18 (mean = 12.6), were recruited; they had the following diagnoses: cystic fibrosis, diabetes, inflammatory bowel disease, and cancer. Subjects and one parent were interviewed separately, using the Diagnostic Interview Schedule for Children (DISC-2.1). The subject's physician completed a questionnaire asking about the presence of a range of mental disorders. Forty-one (49%) subjects reached threshold criteria for a psychiatric diagnosis, using both parent and child as informants. Psychiatric disorders were identified in only 22 subjects (54%) by the child and in 28 (68%) by parent alone. Thus, reliance on one informant resulted in failure to identify one third to one half of psychiatric disorders. Physicians' ratings agreed significantly with children's reports but not with parental reports, suggesting that physicians are sensitive to children's concerns but may underestimate the value and importance of parents' reports. Clinical and research evaluations of chronically ill children, as well as clinician identification of mental health problems, will be influenced by the choice of informant.
Ethical Decisions in Neonatal Intensive Care Units: The Dutch Experience
Authors: Sauer Pieter J. J.
Published: December 2021

Modern technology makes it possible to keep more sick, extremely small, and vulnerable neonates alive. Many neonatologists in the Netherlands believe they should be concerned not only about the rate of survival of their patients, but also about the way the graduates of their care do, in fact, survive beyond the neonatal period. In most cases, we use all available methods to keep newborns alive. However, in some instances there is great concern about the quality of life, if the newborn should survive; here questions do arise about continuing or withholding treatment. In this commentary, I present my impression of the opinions held by a majority of practicing neonatologists in the Netherlands, as well as some personal thoughts and ideas.

Recently, a committee convened by the Ministers of Justice and Health in the Netherlands issued an official report regarding the practice of euthanasia and the rules of medical practice when treatment is withheld.1 In this report of more than 250 pages, only 2 pages focus on the newborn. The following conclusions were made in this small section of the report. In almost one half of the instances of a fatal outcome in a neonatal intensive care unit in the Netherlands, discussions about sustaining or withholding treatment did take place at some stage of the hospital stay. A consideration of the future quality of life was always included in the discussion. The committee agreed with doctors interviewed for the report that there are circumstances in which continuation of intensive care treatment is not necessarily in the best interest of a neonate.
Looking at the Child Care Landscape
Authors: Lombardi Joan
Published: December 2021

This introductory paper has a threefold purpose: (1) to provide an overview of the various types of child care, any or all of which may be found in an individual American community; (2) to present some terminology that may be used repeatedly in the papers of this supplement; and (3) to begin to discuss the role of the medical community in child care.

OVERVIEW OF CHILD CARE

This topic may best be explored by discussing the process new parents go through to select child care and by describing some of the obstacles they may face. For those readers who are from the child care community, and therefore familiar with this information, these are problems that can be shared with the medical community in your area.

Expectant parents may not begin to think about care until after their baby is born. It is often hard to anticipate the issues related to balancing work and family life until you are actually in the situation. Child care may not be included as a topic in childbirth classes, even though that is probably the first place that the options should be discussed.

Once the child is born, a decision may have to be made within the first few weeks after birth, because parental leave is, unfortunately, not guaranteed in the United States. Parents may turn to the pediatrician for advice, but most often they talk with neighbors and friends about child care options. A growing number of parents are beginning to use local Child Care Resource and Referral organizations, which provide consumer education and referral to parents, as well as support and resources to child care providers, policy makers, and the private sector.
Quality of Child Care as an Aspect of Family and Child Care Policy in the United States
Authors: Scarr Sandra , Phillips Deborah , McCartney Kathleen , Abbott-Shim Martha
Published: December 2021

The quality of child care services in the United States should be understood within a context of child care policy at the federal and state levels. Similarly, child care policy needs to be examined within the larger context of family-support policies that do or do not include parental leaves to care for infants (and other dependent family members) and family allowances that spread the financial burdens of parenthood.

Maynard and McGinnis1 presented a comprehensive look at the current and predictable policies that, at federal and state levels, affect working families and their children. They note the many problems in our "patchwork" system of child care—problems of insufficient attention to quality and insufficient supply for low-income families. Recent legislation is a step toward improving the ability of low-income families to pay for child care (by subsidizing that part of the cost of such care which exceeds 15% rather than 20% of the family income) and some steps toward training caregivers and improving regulations. They note the seeming political impasse over parental leaves, even unpaid leaves, and the impact of this lack of policy on the unmet need for early infant care.

We should step back from the current morass of family and child care policies in the United States and look at what other nations have done and continue to do for their working families. By comparison with other industrialized countries in the world, the United States neglects essential provisions that make it possible for parents in other countries to afford to rear children and to find and afford quality child care for their children.
Advising Parents to Stop Smoking: Pediatricians' and Parents' Attitudes
Authors: Frankowski Barbara L. , Weaver Sheila O. , Secker-Walker Roger H.
Published: December 2021

Pediatricians are in a unique position to address the issues of smoking cessation with parents. Vermont pediatricians and parents of their patients were surveyed to assess attitudes about giving and receiving smoking cessation advice. A questionnaire was mailed to all pediatricians in Vermont, and 72 valid responses were received, for a response rate of 91%. Forty percent of pediatricians routinely took a smoking history from parents and 11% recorded this information in the child's chart. Most pediatricians (94%) reported advising at least 60% of smoking parents to quit, and they spent an average of 4.4 minutes doing this. Barriers to giving advice were lack of time (42%), feeling that parents did not expect advice (25%), and feeling ill at ease giving the advice (25%). Only 8.5% of pediatricians had received training in how to give smoking cessation advice, but 87% were willing to learn methods to give advice briefly. Six hundred seventy-six parents from randomly selected pediatric practices were interviewed. The average parental age was 32, and 84% were women; 49% had never smoked, 30% were former smokers, and 21% were current mokers. Current smokers were less likely to agree with statements about the adverse effects of passive smoke on children. Most parents (56%) felt that pediatricians should give quit-smoking advice to parents, and 52% of smoking parents reported that they would welcome advice. Only 30% of current smokers said advice would bother them somewhat, and 15% had more negative reactions. Parents and pediatricians agreed on the best opportunities to give quit-smoking advice. Since 91% of parents said they intended to quit smoking sometime, and since pediatrician-delivered quit-smoking advice would be acceptable to them, it would be worthwhile for pediatricians to learn methods of delivering advice succinctly.
Comparison of Childhood Burns Associated With Use of Microwave Ovens and Conventional Stoves
Authors: Powell Elizabeth C. , Tanz Robert R.
Published: December 2021

To identify the incidence, type, and severity of burns associated with microwave oven (MW) use and to compare MW-associated burns with those associated with use of conventional stoves, we conducted a review of a national data base. Data were obtained from the US Consumer Product Safety Commission Injury Information Clearinghouse for 1986 through 1990 concerning burn injuries to children (0 to 19 years). There were an estimated 5160 burns associated with MW use. The mean age was 7.6 years (median, 6 years); 25% of burns were to children younger than 36 months old. Fifty-eight percent involved females. Most MW burns were scalds (95%); 16% of these scalds were from exploding eggs or other food. No MW burn involved a body surface area greater than 25% and no patient required hospital admission. Microwave oven burns were compared with stove burns. There were an estimated 41198 stove-associated burns to children. The mean age was 5.8 years; the median was 3 years. Forty-five percent of burns were to children younger than 36 months old; 55% were to males. Most stove burns (74%) were thermal; 7% involved a body surface area greater than 25%. Five percent of children with stove burns required hospital admission. We conclude that (1) burns to children associated with MW use are less frequent and less severe than stove burns; (2) MW burns predominantly affect females; and (3) burn prevention efforts should emphasize the hazards of stoves, which vastly exceed those of MWs.
Family Correlates of a 10-Year Pulmonary Health Trend in Cystic Fibrosis
Authors: Patterson Joan M. , Goetz Darryl , Budd Jeffrey , Warwick Warren J.
Published: December 2021

In this study, 33% of the variance in the 10-year trend of forced expiratory volume in 1 second (FEV1), used as an index of pulmonary health, was explained by differences in family characteristics at the start of the study. Balanced family coping, a family emphasis on personal growth, and compliance with treatment for 91 children with cystic fibrosis were assessed at the start of the study and the FEV1 was observed at every clinic visit over the next 10 years. When both parents' coping emphasized family integration, support for self, and medical consultation, the FEV1 trend was better. Compliance with daily chest physical therapy and with quarterly clinic visits was associated with a better FEV1 trend. Poorer FEV1 trend was associated with active social involvement of family members. Older patients and patients whose parents worked more hours outside the home had lower compliance. These findings support the importance of encouraging families to balance their resources between child's health needs and family needs.
Perianal Injuries Resulting From Sexual Abuse: A Longitudinal Study
Authors: McCann John , Voris Joan
Published: December 2021

Four children who incurred perianal injuries as a result of a sexual assault were followed on a longitudinal basis to document the anatomical changes that ensued. The subjects, whose ages ranged from 4 to 8 years, were followed from 1 week to 14 months. They were examined in both supine and prone knee-chest positions and a 35-mm camera mounted on a colposcope was used to record their injuries. At the time of the initial examination, there were a variety of findings including erythema of the tissues, edema of the skin folds, localized venous engorgement, dilation of the external anal sphincter, and lacerations of different depths. Superficial lacerations reepithelized within 1 to 11 days. The second-degree wounds in two of the children were healed by the 1- and 5-week return visits, leaving narrow bands of scar tissue. In the two subjects who were followed the longest, signs of both a second-degree laceration and a surgically repaired third-degree injury had virtually disappeared by 12 to 14 months after the assaults. The wounds in one subject, infected with a herpes simplex type 2 virus, remained erythematous for a longer period of time than did similar injuries in the other children. A skin tag created by the avulsion of the tissues in one subject persisted, although it became less obvious as it retracted into the redundant folds of the perianal tissues over time.
Neonatal Intensive Care and Birth Weight-Specific Perinatal Mortality in Michigan and Lorraine
Authors: Howell Embry Martin , Vert Paul
Published: December 2021

This study investigated the factors influencing use of neonatal intensive care and perinatal mortality in regions of the United States and France, two countries with similar health care systems but different approaches to health financing. The study employed birth certificates from Michigan and a birth registry from Lorraine in 1984. The study showed that geographic access and socioeconomic status were important in determining use of neonatal intensive care in both regions. Socioeconomic factors in perinatal mortality were also shown for both regions, after controlling for gestational age, birth weight, and neonatal intensive care use. In Michigan, infants of mothers with low education had higher mortality rates and in Lorraine residents of low income areas had higher mortality rates. A higher proportion of Michigan women delivered in hospitals with neonatal intensive care than in Lorraine, in all weight/gestation categories. Perinatal mortality rates were also lower in Michigan than in Lorraine, overall and within birth weight categories.
Injuries in Children of Adolescent Mothers: Home Safety Education Associated With Decreased Injury Risk
Authors: Jordan Elizabeth A. , Duggan Anne K. , Hardy Janet B.
Published: December 2021

The purpose of this study was to describe the epidemiology of injuries in children of adolescent mothers (<18 years old at delivery) in Baltimore, MD, and to explore the relationship between maternal receipt of home safety information and child injury. A random sample of 363 adolescent mothers and their children were followed longitudinally by home interview at 3 and 15 months postpartum. Receipt of home safety information and information source were assessed at the 3-month interview. Injuries requiring medical attention were assessed at the 15-month interview. Sixty-eight children sustained injuries during follow-up and 14% required hospitalization. Falls and burns predominated as the cause of injury, with burns much more common in girls. The children of mothers who received home safety information from family and community-based sources by 3 months postpartum had significantly lower risk of injury during follow-up than children of mothers who had not received home safety information. As the number of information sources increased, the injury rate decreased. Further work is needed to examine the most appropriate timing, repetition, format, and content of injury prevention education.
Wisconsin Cystic Fibrosis Chest Radiograph Scoring System
Authors: Weatherly Mark R. , Palmer Christina G.S. , Peters Mary Ellen , Green Christopher G. , Fryback Dennis , Langhough Rebecca , Farrell Philip M.
Published: December 2021

A new clinical scoring system for patients with cystic fibrosis is needed because of recent advances in diagnosis and treatment which have changed the course of this disease. Chest radiograph scoring is the best objective measure of pulmonary disease for longitudinal studies beginning with infants; however, based on pilot studies, previous scoring systems are not sensitive enough in discriminating between degrees of mild lung disease. Therefore, a new radiographic scoring system was developed with the goal of achieving both sensitivity and reproducibility. This objective was pursued by applying multiattribute utility theory, using a panel of interpreters with expertise in cystic fibrosis radiology, and employing mathematical modeling techniques to weight the various components. The system was developed and validated in three phases including comparison to the Brasfield method of quantitative radiology. The data demonstrate that the new system can be applied reliably and conveniently to generate reproducible scores of pulmonary disease severity. Evaluation of the scores by four independent raters using chest radiographs from 61 patients at an average age of 8.37 years revealed good agreement with a .714 Kendall coefficient of concordance. Assessment of serial changes over time was performed using a group of 176 chest radiographs from 25 patients ranging from 4 weeks to 6 years old; this showed that the Wisconsin system generates score differences that are greater in magnitude with disease progression compared with the Brasfield method. Therefore, the new method is more sensitive to progression of mild disease and should be superior to prior radiographic scoring systems for evaluating therapies designed to modify the early course of disease. The Wisconsin system is designed to be useful in longitudinal clinical studies involving young children with cystic fibrosis and is capable to detecting progression from normality to mild lung disease.
Childhood Lead Poisoning: Definitions and Priorities
Authors: Schoen Edgar J.
Published: December 2021

By using motor developmental status as the outcome measurement, Dietrich et al,1 in the current issue, have tried to lend objectivity to the controversial question of whether neurologic damage in childhood can be attributed to low lead (Pb) levels. Previous prospective studies have shown a lack of consistency between Pb exposure and many measurements of cognitive development and language skills. Children who have elevated blood Pb levels are frequently subject to other neurologic risk conditions, including poverty, disorganized family situations, low maternal intelligence (IQ) and education, and poor nutrition, particularly anemia. The problem is to separate the effect of Pb from the confounding variables.
Principles of Child Health Care Financing
Authors:   Committee on Child Health Financing
Published: December 2021

Inequitable financing mechanisms contribute to the current level of preventable mortality and morbidity today among American infants, children, and adolescents. Current financing systems must be improved to maximize access to and ensure the quality of comprehensive pediatric care.

The American Academy of Pediatrics (AAP) advocates universal and insured financial access to quality health care for all pregnant women and infants, children, and adolescents through age 21 years, here-inafter referred to as pregnant women and children. Such insurance should be a comprehensive benefit package which contains preventive care, including immunizations, and acute and chronic care services.

As the public and private sectors and the AAP continue to explore the structure of health care financing, the following principles will be used to evaluate proposed changes.

1. Children's Right to Access to the Health Care System.

• All pregnant women and children have a right to comprehensive health care.

• Financial barriers should not prevent pregnant women and children from receiving comprehensive health care.

• When families are not covered by insurance provided by an employer, purchase of a private plan, or personal means, pregnant women and children should be insured by public funding.

• Health care financing mechanisms should permit the patient and his/her family to choose a health care professional who provides quality pediatric care, particularly pediatricians whose offices will serve as the medical home and from which referrals would be made only as appropriate.

• Managed care plans should not restrict access to qualified pediatric primary care or appropriate referral to pediatric subspecialty and inpatient care.
Efficacy of Intranasal Midazolam in Facilitating Suturing of Lacerations in Preschool Children in the Emergency Department
Authors: Theroux Mary C. , West David W. , Corddry David H. , Hyde Patrice M. , Bachrach Steven J. , Cronan Kathleen M. , Kettrick Robert G.
Published: December 2021

Sedating children safely and effectively for minor laceration repair is a well-recognized clinical problem. A randomized, double-blind, and controlled study was conducted to evaluate the efficacy of intranasal midazolam for reducing stress during the suturing of lacerations in preschool children. Fifty-nine children with simple lacerations that required suturing were randomly assigned to one of three groups. Group 1 received intranasal midazolam, 0.4 mg/kg, prior to suturing. Group 2 received an equivalent volume of normal saline intranasally prior to suturing as a placebo. Group 3 was the control group and received no intervention prior to suturing. Heart rate, respiratory rate, blood pressure, and pulse oximetry were monitored at 5-minute intervals throughout the procedure. Subjective variables were also measured at 5-minute intervals and included a cry score, a motion score, and a struggle score. Parent satisfaction was measured via a short telephone interview the following day. There were no significant differences in outcome between the placebo group and the control group. Their results were pooled and compared with the results for the midazolam group. The midazolam group showed significant reductions for mean heart rate, maximum heart rate, and maximum systolic blood pressure when compared with the placebo/control group. Scores for two of the three subjective variables, cry and struggle, were significantly reduced for the midazolam group. The papoose board was considered unnecessary in retrospect for more than half of patients in the midazolam group compared with only one fifth of patients in the placebo/control group. Telephone follow-up revealed that parents in the midazolam group were twice as likely (68% vs 33%) to find the suture experience in the emergency department better than they had expected. No respiratory depression or any other significant adverse effects were noted in any of the three groups. It is concluded that infranasal midazolam was effective and safe in reducing anxiety and stress, which commonly accompany the suturing of lacerations in healthy preschool children.
Saddened Not Amused
Authors: HAMMER SANDRA JO
Published: December 2021

To the Editor.—

I am writing to express my outrage at your publication of the paper by D.S. Nelson (Pediatrics 1992;89:1089-1090) which I read with interest as the title was intriguing.

Although humor and good stress reducing mechanisms are vitally important to the healthy maintenance and well-being of staff in emergency departments, this paper described what is in effect a derision of patients and parents, first by the emergency department staff and then by the author's bold affectation of this as research and a "fertile source of medical humor."
Pelvic Examination—An Essential Skill
Authors: STAFFORD ELIZABETH M.
Published: December 2021

To the Editor.—

In "Technical Skills Required in General Pediatrics" the authors suggest that a basic list of 24 skills considered to be necessary by 95% of pediatricians surveyed serve as a guide for skills training in pediatric residency.1 As an educator in the field of adolescent medicine, I was alarmed to find that the pelvic examination was omitted. It was one of 72 skills to be ranked by general pediatric practitioners.

I suspect that an element of sampling bias effected the omission of the pelvic examination as nonessential.
Culture, Ethnicity, and Bicultural Competence: Implications for Children With Chronic Illness and Disability
Authors: Brookins Geraldine Kearse
Published: December 2021

The examination of culture and child and human development is not a new venture. There has been a fascination with how culture shapes human behavior over decades.1-4 Generally, whenever the terms "culture" and "child development" were invoked, they referred to work that was conducted in faraway places and compared to middle-class European-American children and families as the standard or norm.

For so long, studies of development focused on the generic human child—white and middle class. LeVine5 noted that many psychologists seemed to have a deep-seated metaphysical conviction that humans everywhere, all those that counted, at least, were the same in all respects. Cultural variations were merely external details not unlike malnutrition. Importantly, to the discipline's credit, views of child development have changed from the examination of development via a perspective that implied that the human organism existed in a vacuum without context, to the recognition that our understanding of the complexity of individual development is greatly enhanced by focusing on the child in context. Among developmental psychologists, there is a general consensus that a broad spectrum of maturational factors undergirds human development. Even so, human behavior manifests itself in differentiated arrays across cultural settings.

Rogoff6 suggests that variability is intrinsic to the developmental process and this variability is structured by those events and conditions within the ecological environs that serve to promote and constrain human endeavor. She notes that ". . . the inherent variations in development that occur with different groups and circumstances are ordered in their own terms, with progress toward developmental goals across the course of life."6(p30)
The Need for More Accurate and Timely Diagnosis in Fanconi Anemia: A Report From the International Fanconi Anemia Registry
Authors: Giampietro Philip F. , Davis Jessica G. , Adler-Brecher Barbara , Verlander Peter C. , Auerbach Arleen D. , Pavlakis Steven G.
Published: December 2021

Objective. The objective of this study was to address the need for early diagnosis of Fanconi anemia (FA), an autosomal recessive chromosomal instability syndrome characterized by a unique cellular hypersensitivity to DNA cross-linking agents, such as diepoxybutane, and by a high risk of malignancies.

Methods. We analyzed data from 370 FA patients enrolled in the American Registry of the International FA Registry. Of these individuals, 220 had congenital malformations; the rest were ascertained based on hematologic abnormalities only or on clinical evaluation and screening following the diagnosis of an affected family member. The probands noted to have congenital malformations at the time of diagnosis were classified into two groups on the basis of their clinical presentation: (1) patients manifesting both congenital malformations and hematologic abnormalities (159 individuals); (2) patients manifesting congenital malformations only (61 individuals).

Results. The mean age of diagnosis was 6.6 years and 1.1 years for Groups 1 and 2, respectively. Thus, the majority of FA patients with congenital malformations were not diagnosed until after the onset of hematologic abnormalities. We also report central nervous system, gastrointestinal, and skeletal malformations which previously have not been included as part of the FA phenotype. Our review of the patients enrolled in the International FA Registry indicates that the FA phenotype is more variable than recognized previously.

Conclusions. Testing for sensitivity to diepoxybutane to rule out a diagnosis of FA needs to be applied more widely in patients with congenital malformations. All siblings of affected probands also should have testing, because a lack of concordance of phenotype in affected siblings makes clinical diagnosis unreliable even within sibships. A more timely diagnosis of FA in the preanemic phase is needed to implement appropriate therapy and to enable parents to make informed reproductive decisions.