bluuebunny/crossref_metadata_2025 huggingface dataset:
Feeding the Very Low-Birth-Weight Infant
Authors: Romero Rene , Kleinman Ronald E.
Published: December 2021

Unfortunately, premature birth occurs commonly in the United States. Improving the survival of very low-birth-weight (VLBW) infants depends in large part upon understanding the physiologic capabilities of their immature organ systems and providing appropriate support as they mature. Advances in the nutritional support of these infants have contributed to the better outcomes we have come to expect today, even for the smallest infants. In this review, we will discuss the limitations of gastrointestinal function and the unique nutritional requirements of very low-birth-weight infants and describe the current methods of enteral and parenteral nutrition support used to meet these requirements.

Developmental Physiology

By 24 to 26 weeks of gestation, the fetal gastrointestinal tract is morphologically similar to that of the full-term infant; however, functional development is far from complete. Maturation of gastrointestinal motility, digestion, and absorption continues through much of the first year of life, even in full-term infants, as a result of an interplay between the preprogrammed "biological clock" and environmental influences. The decision to feed the VLBW infant must take into account the developmental limitations as well as the potential for enhancing intestinal maturation at each stage of development (Table 1).

Fetal swallowing is evident at the beginning of the second trimester.
Bronchiolitis
Authors: Welliver Josephine R. , Welliver Robert C.
Published: December 2021

Bronchiolitis is an acute respiratory illness precipitated by a viral infection and resulting in obstruction of the small airways. While mortality due to bronchiolitis is low in developed countries, it remains an important illness because of the frequency with which infants require hospitalization and because of the potential association with asthma during later life.

Definition

An enduring definition of bronchiolitis has been the first episode during infancy of an illness beginning as an upper respiratory infection that progresses to the development of wheezing. This definition is inadequate for a number of reasons. First, infants who have obstructive airway disease do not always wheeze audibly. Second, many infants have two or more episodes of viral bronchiolitis within an interval of only a few months. The recurrent wheezing episodes are clinically quite similar to the first episode. Finally, some children may have their first episode of virus-induced wheezing during the second year of life, with the age of onset being the only feature that is different from a typical episode of bronchiolitis.

It has been suggested that clinicians use the response of the wheezing infant to a single subcutaneous dose of epinephrine to distinguish bronchiolitis from asthma. This is inappropriate because a small number of infants who have true bronchiolitis respond to the first course of beta-adrenergic agents while many patients with status asthmaticus do not.
INDEX OF SUSPICION
Authors: Bradford Bradley J. , Miller Harry S. , Gilbert Walter L.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations with discussions.

Case 1 Presentation

A 19-year-old girl comes to the university health service with complaints of difficulty swallowing and fever. The illness began 2 days ago with a minor sore throat. Although she has been able to take in sufficient fluids, she has had progressively more difficulty swallowing and has became febrile. There has been no known exposure to other illnesses, nor does she have any specific complaints of a chronic nature. Her last menstrual period was 3 weeks ago; she denies sexual activity.

Physical examination reveals a febrile young woman in no acute distress but complaining of throat discomfort. Pertinent findings include a markedly swollen oropharynx with erythema of the uvula and marked cervical adenopathy. The remainder of the examination is normal.
Recurrent Abdominal Pain During Childhood
Authors: Oberlander Tim F. , Rappaport Leonard A.
Published: December 2021

RAP offers a complex and often confusing array of symptoms and diagnostic possibilities. This may be due to its unique age of presentation, its inherent somatic and cognitive developmental issues, or the physiology of abdominal pain itself. A careful examination of the historic and physical findings should produce a therapeutic plan that addresses somatic, psychological, and environmental aspects of the child. This process will avoid overly simplistic and premature misdiagnosis or potentially unnecessary investigations that convey a sense of disinterest, haste, and disbelief in the problem. The successful management of RAP lies in the recognition that serious underlying disease frequently is not present and that time usually is on our side. It is the process of continued and thoughtful evaluation and reassurance over time that counts.
Hematuria
Authors: Fitzwater Douglas S. , Wyatt Robert J.
Published: December 2021

Hematunia occurs in approximately 1.5% of children. It is important in evaluating the patient who has hematuna to make sure that a positive dipstick test is accompanied by RBCs on the microscopic examination. Hematunia is defined by several parameters, the most common of which are 6 cells/cc of urine in a counting chamber or 2 cells per high-power field in a urinary sediment. Although the differential diagnosis for hematuria is extensive, the most important differentiating feature is the presence or absence of proteinuria. Those who have significant proteinunia deserve a rapid evaluation and early referral to a nephrologist. Those who do not have proteinunia should be followed and a step-wise evaluation performed. Finally, most patients who have asymptomatic microscopic hematunia do not have clinically significant glomenular pathology.
Then and Now
Authors: Menna Vincent J.
Published: December 2021

Dr. Nick, a family practitioner, has been a resident of Heaven for about 20 years. Although content in most respects, he began to miss the practice of medicine. Dr. Nick approached St. Peter, the archetypical gatekeeper, about the possibility of getting a glimpse of medicine in the 1990s, and the following conversation ensued:

Dr. Nick: I miss my office. I was alone and king of my castle. I had no staff and my office was in my home. The expenses were negligible.

St. Peter: Today most doctors have offices away from their homes and practice in groups. Their office staffs resemble General Motors, and overhead approaches 50%.
INDEX OF SUSPICION
Authors: Nield Linda S. , Tejeda David M. , Garfunkel Lynn C.
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A mother is concerned because her 2-year-old son is "not as sure on his feet as he used to be." In the past 2 weeks she has noticed that he seems clumsy and is falling more than usual when playing or walking. His babysitter also has noticed this change in abilities, heightening the mother's concern. No other neurologic impairment is noted, and his play does not seem disrupted.

The boy's medical history is unremarkable. Recently, he had a persistent middle ear infection that finally resolved after 1 month of treatment with three different antibiotics. He also has been having 6 to 12 loose stools a day. Clostridium difficile toxin has been isolated from his stool.
Juvenile Delinquency: Considerations for Pediatricians
Authors: Yancy W. Sam
Published: December 2021

Society long has been concerned about the behavior of its youth. Today, because of the easy accessibility of more dangerous drugs, more lethal weapons, and automotive transportation, this concern is greater. In 1989 there were 1 744 818 arrests among those under 18 years and 585 521 arrests in the age group under 15 years. Although the overall arrest rate for males has increased only 5% over the past 10 years, violent crimes such as murder and rape have increased significantly (>60% and >27%, respectively). Further, motor vehicle thefts have increased even more (72%). The overall arrest rate for females under 18 years of age has increased 13%, with aggravated assault and motor vehicle theft (>69% and 54%, respectively) chiefly responsible for the increase. These figures would be even more staggering if they included youth who commit delinquent acts but do not come into contact with legal authorities. Not only do pediatricians, because of their relationship with youth and their families, have an opportunity to affect those factors that may lead to delinquent behavior, but they have an obligation to provide for the medical and mental health needs of these youth.

Legal Considerations

Legally, a youth is considered a delinquent if he or she commits an act that violates the law and if the violation comes to the attention of the police or the court system.
Vesicoureteral Reflux
Authors: Sheldon Curtis A. , Wacksman Jeffrey
Published: December 2021

Vesicoureteral reflux describes a pathologic event in which urine progresses in a retrograde fashion from the bladder to the ureter and in many cases into the intrarenal collecting system. This pathologic event cannot be treated successfully in isolation. Appropriate care requires meticulous attention to the treatment and prevention of urinary tract infection; correction of any associated voiding dysfunction; and careful attention to such adjuvant care as perineal hygiene, hydration, and treatment of defecation disorders.

Vesicoureteral reflux is classified according to the International grading system demonstrated in Figure 1. Grade I reflux represents retrograde flow into a nondilated ureter only. Grade II reflux refers to the filling of a nondilated ureter and a nondilated renal pelvis. With Grade III reflux, one begins to see a dilatation of the collecting system, but the fornices remain sharp. With Grade IV reflux, the fornices become blunted. Grade V reflux refers to associated massive dilatation and tortuosity of the collecting system.

It is very important to classify ureteral reflux as primary or secondary in its etiology. Primary vesicoureteral reflux refers to a congenital deficiency of the ureteral insertion that results in an ineffective valve mechanism. Secondary vesicoureteral reflux refers to reflux that is caused by either bladder dysfunction or previous surgical intervention.
Neck Injury
Authors: Avner Jeffrey R.
Published: December 2021

Although rare in pediatrics, cervical spine injuries still are associated with serious morbidity, disability, and mortality. Many of these injuries are exacerbated by inadequate neck immobilization or improper manipulation. Thus, the physician should be aware of which children are at risk for cervical spine injury and how to assess these patients properly.

To find clinical markers that identify children who actually have cervical spine injuries, Rachesky et al reviewed 2133 cervical spine radiographs obtained in pediatric patients during a 7-year period. Of these children, 25 (1.2%) had abnormalities confirmed on radiographs. The incidence of injury increased with age; only four of the children who had cervical spine injuries were less than 8 years old.
Hirschsprung Disease
Authors: Rudolph Colin , Benaroch Lee
Published: December 2021

In 1886, Harald Hirschsprung first described a disorder in newborns of severe constipation with dilatation and hypertrophy of the colon. No mechanical obstruction could be demonstrated, but there appeared to be an area of spasm that prevented the movement of lumen contents through the sigmoid or rectum. This disorder, termed Hirschsprung disease, later was recognized to be due to an absence of the intramural neural ganglia in the rectum, and provided the first example of an abnormality of intestinal innervation associated with a disorder of gastrointestinal movement. Recent insights into the development of the gastrointestinal neural plexus that provide new clues to the pathogenesis of Hirschsprung disease are discussed in the first section of this review.

Despite continued uncertainty about the pathogenesis of Hirschsprung disease, surgical treatment approaches have evolved over the past 50 years, and after removal of the abnormal bowel, most affected children lead normal, productive lives. Unfortunately, children who have Hirschsprung disease can develop life-threatening bowel obstruction with perforation or severe diarrhea and sepsis before surgery. Early diagnosis and surgical treatment are crucial to preventing these complications, which remain the major cause of serious morbidity and mortality. To assure early diagnosis, this article reviews the clinical presentations of Hirschsprung disease and provides an approach to the differential diagnosis of constipation among infants and children.
Eating Disorders Among Children and Adolescents
Authors: Kreipe Richard E.
Published: December 2021

Anorexia nervosa and bulimia nervosa represent extreme manifestations of weight control patterns in adolescents. When they occur in children, they often are associated with more severe psychiatric or family dysfunction. However, rather than framing these conditions as purely psychiatric problems, it is more useful to approach them in terms of development. Then, the pediatrician can be positioned to address the various biologic, psychological, and social issues presenting in the individual. Furthermore, the pediatrician already is familiar with the principles of managing chronic illnesses, and eating disorders frequently require months to years of treatment. Finally, for each patient in a pediatrician's practice who has an eating disorder, several other patients will develop unhealthy habits with respect to eating, food choices, and weight control. By being familiar with the larger issues associated with weight loss, rather than the more narrow topic of eating disorders, the pediatrician will be able to help all patients remain healthy in a culture of thinness, regardless of their diagnosis.
Diagnosis of Allergic Disorders
Authors: Fireman Philip
Published: December 2021

Although some pediatricians may trivialize allergic illnesses as "just allergy," most clinicians now realize the significant impact that allergic diseases have on children's health and quality of life. Allergic diseases, including asthma, are among the major causes of chronic illnesses in the United States, affecting approximately 50 million patients or as many as one in five children. The economic impact is enormous; asthma alone is estimated to cost more than 6.2 billion dollars of health care expenditures annually. Of all the chronic illnesses, allergic respiratory problems, including allergic asthma, is the most common cause of school absenteeism. Even though allergic disease usually is not fatal, death can result as a consequence of allergic anaphylaxis related to medication, food, or insect venom allergy or from a complication of asthma. Therefore, the pediatrician must be capable of diagnosing allergic disease so as to institute appropriate management. This review will emphasize those clinical diagnostic features ascertained by history and physical examination as well as the appropriate laboratory studies useful in the diagnosis of respiratory (inhalant) and gastrointestinal (food) allergy.

General Features of Allergic Diseases

Allergic diseases are immunoglobulin E (IgE)-mediated immunologic illnesses that can affect any of the body's major organ systems either individually or collectively.
Management of Chronic Pain In Children
Authors: Kain Zeev N. , Rimar Stephen
Published: December 2021

Pain relief has received considerable attention in recent years, but pain in neonates and children has been underreported, undertreated, and misunderstood. Several reviews have dealt with the recognition and treatment of acute pain, but much less has been written about chronic pain in children. Here we will address general considerations of pain management in children and specific chronic and recurrent pain syndromes of childhood.

Developmental Considerations

The perception of pain includes both a sensory component, involving neural pathway activation in response to noxious stimuli, and an affective/cognitive response, involving several behavioral aspects.

Cutaneous sensory perception has been reported in the perioral area of human fetuses as early as the seventh week of gestation and spreads to include cutaneous and mucosal surfaces by the twentieth week. Incomplete myelinization of nerve fibers and immature synaptic connections have been thought to indicate a lack of maturity in the neonatal nervous system, but this phenomenon merely implies a slower conduction velocity, with much shorter traveling distance in newborns.

Development of the fetal neocortex begins during the eighth week of gestation; by 20 weeks, each cortex has a full complement of neurons. Sensory pathways required for pain transmission can be traced from receptors in the skin to sensory areas in the cerebral cortex of infants. Functional development of the cerebral cortex is suggested by specific features of both the fetal and the neonatal electroencephalogram.
Pubertal and Psychosocial Development: Implications for Pediatricians
Authors: Litt Iris F.
Published: December 2021

The endocrinology and somatic events of puberty have been well described, and their assessment is incorporated routinely into the evaluation of the adolescent patient. Because of the increasing collaboration between behavioral scientists and physicians who share an interest in the developing adolescent, understanding of the interactions between the physical, cognitive, and psychological experiences of this age group has grown. Examining the contextual and possible predictive implications of variations in pubertal events and their timing will help the pediatrician to guide and counsel adolescents and their parents.

Findings from recent research have highlighted the salience of gender differences in the experience of puberty and in the timing of its onset and tempo as well as the importance of being earlier in maturation rather than synchronous or later than one's peers. In this article, we will consider the findings in four major domains: 1) the effect of adolescent development on family homeostasis; 2) the implications for cognitive development; 3) the implications for personality (psychological) development; and 4) the recognition of risk factors or markers for problem behavior.

Pubertal Development and Family Homeostasis

One of the earliest tasks of adolescence is to separate from the family emotionally in preparation for developing independence.

For girls, pubertal development may be the signal to their fathers to be less physically affectionate.
Pinworms
Authors: Sonnenblick Howard
Published: December 2021

Enterobius vermicularis, more commonly known as pinworm, is the most common intestinal nematode in the United States, affecting 5% to 15% of the population. Although infection may appear in all age groups and socioeconomic levels, it is most prevalent in preschool and school-age children.

Typically, embryonated eggs are ingested and migrate to the duodenum where they hatch and undergo sexual maturation before reaching the cecum. Adult pinworms reside in the cecum, emerge at night through the anus, and migrate to the perianal region where gravid females deposit their eggs and die. The eggs cause anal pruritis, which leads to scratching and accumulation under the fingernails, thereby promoting auto-infection and spread to close contacts.
Consultation with the Specialist
Authors: Strong William B.
Published: December 2021

J.D. is a 3-year-old boy who has tetralogy of Fallot. His definitive correction has been deferred because of the parents' desire for bloodless surgery. Until 4 days prior to being seen in the office, he was in his usual state of health. He always has been reasonably active, and his oxygen saturation by transcutaneous pulsed oximetry has been in the mid-80% range. His last hemoglobin level, obtained 3 months ago, was 16.5 g/dL; his red blood cell indices were normal.

Four days prior to coming to the office he complained of a mild headache, and his mother thought he felt warm to the touch. He seemed to respond to acetaminophen therapy. Three days later, he again complained of headache, felt warm to the touch, and was not his usual active self. His mother stated that she thought he was coming down with the same virus from which his preschool brother had just recovered. He has not improved with acetaminophen, and he now appears more cyanotic and lethargic and complains of a severe left-sided headache.

Your examination reveals a sick-appearing child who is quite cyanotic and only moderately responsive to commands. His temperature is 38.8°C, pulse is 120 beats/min, respirations are 28/min and unlabored, and blood pressure is 96/58 mm Hg.
Control of Infections in Schools
Authors: McMillan Julia A.
Published: December 2021

School staff members, public health officials, and parents often look to pediatricians to provide recommendations for dealing with exposure in school to a variety of infectious diseases (Table 1). It is extremely important to provide accurate, consistent, and sufficient information to allow parents to make individual decisions regarding their children without unnecessary fear. Schools should take appropriate precautions to assure that students are not put at unnecessary risk of serious infection, but they also have a responsibility to protect the privacy of any children whose infection poses little or no risk to their classmates.

In considering appropriate recommendations for exposures to specific infections in schools, it is important to review the available information about the mechanism(s) by which the infection is spread from person to person as well as the likelihood of spread. It also is important to recognize the extent to which contacts would be expected to be immune, either by virtue of previous infection or through immunization. The availability of methods for prevention of infection in susceptible contacts (passive or active immunization, antimicrobial therapy) should be reviewed, and recommendations for implementation made based on the risk of infection and the severity of the disease.

Varicella Exposure

Varicella generally is a mild illness of childhood; 90% of cases occur in children 14 years of age or younger, and most cases in the United States occur in children between the ages of 5 and 10 years (Table 2).
Hemophilia: An Updated Review
Authors: Bell Beverly , Canty David , Audet Michelle
Published: December 2021

Introduction

Hemophilia is a genetic disorder that results in either an inactive or inadequate supply of a plasma protein needed for normal blood clotting. The two most common forms are hemophilia A and B, caused by a defect or deficiency in clotting factors VIII and IX, respectively. Both types are X-linked recessive disorders characterized by prolonged bleeding and hemorrhages, typically into joints and soft tissues. Hemophilia C is an autosomal recessive defect that results in a deficiency of factor XI. Marked by bleeding in mucous membranes, hemophilia C exhibits a somewhat different clinical pattern of hemorrhaging than hemophilia A or B but similar to that in von Willebrand disease. This review will focus on hemophilia A and B.

Hemophilia has served as a model for the treatment of chronic illness through the comprehensive approach to care. If a child who has hemophilia is managed appropriately with early factor replacement therapy and attempts to avoid the long-term consequences of bleeding, the prospects for a long, full, and healthy life are very good.

Epidemiology/Genetic Transmission

The incidence of hemophilia A and B is about 15 to 20 per 100 000 males born worldwide and occurs in all races and socioeconomic groups. Hemophilia A, also known as "classical hemophilia," accounts for about 80% of cases of hemophilia, occurs in one of 10 000 male births, and affects about 17 500 individuals in North America.
Divorce: Consequences for Children
Authors: Emery Robert E. , Coiro Mary Jo
Published: December 2021

An extensive body of research exists on the consequences of divorce for children. The conclusions of this research are captured by the concept of resilience, children's ability to "bounce back" in the face of stress. Most children from divorced families cannot be distinguished from children from married families on objective measures of psychological functioning, including assessments of conduct, depression, anxiety, and school performance. Nevertheless, it is clear that divorce often creates many dramatic stressors for children, including involvement in their parents' conflicts, decreased contact with one parent, strained relationships with the other parent, and economic problems. Coping with these substantial changes can tax children's emotional resources and may leave them with lingering feelings of hurt, resentment, and longing for a parental reconciliation. The concept of resilience highlights both children's ability to cope with change and some of the painful consequences of coping with unwanted changes in family life.

Definition

Despite its familiarity, several considerations should be noted about the definition of divorce. First, divorce is a developmental process that unfolds over time. Changes in family life typically begin long before the physical separation and continue long after the legal divorce. Second, because divorce reaches into many areas of people's lives, theorists often talk about the "legal divorce," the "emotional divorce," the "emotional divorce," the "economic divorce," and the "social divorce."
Hemoptysis in Children
Authors: Pianosi Paul , Al-sadoon Hammad
Published: December 2021

Definition

Hemoptysis is defined as coughing up of blood or the presence of blood in sputum. It is not a common symptom in children and although not usually life-threatening, it can become so. Massive hemoptysis is defined as bleeding that exceeds 8 mL/kg per 24 hours. Because children younger than 6 years of age tend to swallow their sputum, they rarely present with hemoptysis, unless the bleeding is substantial.

Epidemiology and Etiology

Causes of hemoptysis in children are listed in Table 1. Acute lower respiratory tract infection is the single most common cause, accounting for approximately 40% of cases. Hemoptysis that ranges from blood-tinged sputum to massive quantities of blood in the sputum is relatively common among those who have cystic fibrosis (CF). Massive hemoptysis is estimated to occur in 5% of CF patients, but approximately 1% will have mild hemoptysis every year, most commonly among those who are older than 18 years. In bronchiectasis due to causes other than CF, the incidence of hemoptysis is approximately 10% to 15%. Foreign body aspiration remains a leading cause of hemoptysis in children, with the majority of cases occurring in those younger than 4 years of age. Hemoptysis seldom is encountered in those who have primary pulmonary tuberculosis; it is estimated to occur in fewer than 1% of cases.
Infantile Spasms: Current Therapy and Progress
Authors: Wolf Steven M. , Ballaban-Gil Karen
Published: December 2021

Infantile spasms represent an age-dependent epileptic syndrome that usually begins between 4 and 6 months of life; onset is before the age of 12 months in about 90% of cases. The spasms are characterized by symmetric, bilateral, brief, and sudden contractions of the flexor or extensor muscle groups. The seizures may be resistant to treatment, and the syndrome frequently is associated with mental retardation.

In 14% to 38% of cases, infantile spasms are "cryptogenic," without identifiable underlying cause. However, the majority of patients have so-called "symptomatic" infantile spasms, with some identifiable pre-, peri-, or postnatal factor that underlies the syndrome: hypoxemiaischemia, intrauterine infection, a cerebral malformation or degenerative disorder, tuberous sclerosis, a genetic abnormality, an inborn error of metabolism, an intracranial hemorrhage, traumatic delivery, head injury, or a central nervous system infection.
Clindamycin
Authors: Rosenberg Michael G.
Published: December 2021

Clindamycin (CM) is a chemically synthesized derivative of lincomycin, which originally was isolated from the soil actinomycete Streptomyces lincolnesis in 1962. CM essentially has replaced lincomycin therapeutically because of its broader antimicrobial spectrum and enhanced gastrointestinal absorption.

CM inhibits bacterial protein synthesis by binding to the 50S subunit of the bacterial ribosome, thereby blocking peptide chain initiation and elongation. CM functions as a bacteriostatic agent; however, in certain clinical situations, it can be considered bactericidal. Interestingly, the ribosomal binding sites of macrolide antibiotics (erythromycin, clarithromycin, etc) and chloramphenicol appear to overlap, leading to the theoretic concern of drug antagonism should these medications be used in combination.
Congenital Muscular Torticollis
Authors: Robin Nathaniel H.
Published: December 2021

Congenital muscular torticollis (CMT) refers to unilateral contracture of the sternocleidomastoid (SCM) muscle that restricts the infant's range of motion at the neck, with the head tilted toward the shortened SCM and the chin rotated to point away from the affected side. Although a mass often is palpable in the inferior part of the affected SCM, in many cases this is not appreciated in the immediate newborn period; the condition may be recognized only as the infant develops better head control over the first few weeks of life, making the head tilt more obvious. Potential complications of CMT include facial asymmetry and plagiocephaly from the uneven tension produced by the contracted SCM as well as cervical scoliosis, with a compensatory thoracic scoliosis.
Consultation with the Specialist
Authors: Rosenfeld Ron G.
Published: December 2021

Multiple hormones participate in the endocrine regulation of growth, including thyroid hormone, androgens, and estrogens. Growth hormone (GH), the major hormone involved in postnatal skeletal growth, is a protein having an approximate molecular weight of 21 000 d and produced by the anterior pituitary.

Interestingly, GH appears to play little part in fetal growth. An infant who has congenital GH deficiency typically has a normal birth length and weight. Congenital hypoplasia of the anterior pituitary is suggested more commonly by the presence of neonatal hypoglycemia or microphallus in the male. An abnormal growth pattern in children who have congenital GH deficiency becomes apparent, however, by 3 to 6 months of age.

Although congenital GH deficiency results from hypoplasia of the hypothalamus or anterior pituitary, acquired GH deficiency may be the first clinical manifestation of a variety of clinically significant disorders. Central nervous system tumors, most classically craniopharyngiomas and histiocytosis X, may cause GH (and other pituitary) deficiency. Other etiologies include cranial trauma, infiltrative disorders, and cranial irradiation. Sometimes, congenital disorders causing partial GH deficiency may not become apparent until late childhood and will present as if they are "acquired" disorders. Familial forms of GH deficiency and septo-optic dysplasia (absence of the septum pelucidum, hypoplasia of the optic chiasm, and pituitary insufficiency) are congenital disorders that may become evident clinically beyond the neonatal period.
Evaluation of Renal Function During Childhood
Authors: Atiyeh Bassam A. , Dabbagh Shermine S. , Gruskin Alan B.
Published: December 2021

There are several methods to evaluate renal function during childhood. The use of serum creatinine, either alone or in combination with the Schwartz formula, is reliable and quick, but requires knowledge of conceptual age. A plasma creatinine concentration of 88.4 µmol/L (1.0 mg/dL), for example, represents normal renal function in an adolescent but more than 50% loss of renal function in a 5-year-old child. A timed urine collection for creatinine clearance is another evaluative method, but the adequacy of the urine collection always should be determined first. Urea clearance rarely is used to measure GFR because of the complex factors that influence urea excreation. Measurement of the disappearance of radioactive-labeled substances in plasma can be used to determine GFR. Radionuclide renal scans also can be used and offer the advantage of estimating the GFR of each kidney.

Although infants and newborns have an intact urine diluting ability, their concentrating ability is impaired. The maximal urinary concentration in the neonatal period is less than 700 mOsm/kg, but reaches adult values of 1200 mOsm/kg by 6 to 12 months of life. Similarly, the infant kidney has a limited capacity for salt regulation, predisposing the infant to salt disturbances.
Gastroesophageal Reflux in Infants and Children Who Have Neurodevelopmental Disabilities
Authors: Roberts Kenneth B.
Published: December 2021

Infants and children who have neurodevelopmental disabilities are at risk of additional compromise due to malnutrition. Poor nutrition may result from motor difficulties, which makes those affected difficult to feed. Oropharyngeal abnormalities may predispose to recurrent aspiration pneumonia. Gastroesophageal reflux (GER) is present in the majority of those who are affected severely and adds to malnutrition by limiting intake and, if chronic esophagitis develops, by expending energy in painful movements and by creating a catabolic state.

Although most of the attention to GER has centered on the control of vomiting and esophagitis, nutrition also must be a major consideration. Indeed, recent evidence suggests that GER may resolve if normal nutrition is attained.
Ambiguous Genitalia
Authors: Anhalt Henry , Neely E. Kirk , Hintz Raymond L.
Published: December 2021

The newborn whose genitalia are ambiguous presents a challenge to the pediatrician and the family. A clear understanding of the basis of sex differentiation and timely consultation with a pediatric endocrinologist is critical in the evaluation and determination of sex of rearing in a newborn who has ambiguous genitalia. Sex karyotype and a 17-OHP level may suffice in the initial evaluation of female pseudohermaphroditism because most patients will have virilizing CAH. If male pseudohermaphroditism is suspected on the basis of palpable gonads, we routinely obtain a karyotype, basal adrenal steroid levels, and levels of hCG-stimulated serum testosterone and DHT, then consider a testosterone treatment trial. Physicians who care for children who have ambiguous genitalia must appreciate the family's cultural, religious, and psychological needs and avoid determining sex of rearing before accurate diagnosis is reached.
Child Sexual Abuse
Authors: Hymel Kent P. , Jenny Carole
Published: December 2021

Multiple obstacles can hinder the medical evaluation of suspected child sexual abuse in pediatric primary care. The need for diagnostic accuracy is high. Knowledge of sexual abuse risk factors, an understanding of the victimization process, and awareness of the varied clinical presentations of sexual abuse can be of assistance.

Open-ended questioning of the suspected victim is the most critical component of the evaluation. Skillful medical interviewing requires time, training, patience, and practice. Pediatricians lacking any of these four requirements should defer interviewing in sexual abuse cases to other professionals.

Abnormal physical findings from sexual abuse are uncommon. Colposcopy has assisted pediatricians greatly in reaching consensus regarding diagnostic physical findings. Cases of acute sexual assault require familiarity with the forensic rape examination, STD screening and prophylaxis, and pregnancy prevention. Victimization from sexual abuse continues long after the abusive acts end, often requiring long-term therapeutic intervention.

An emerging standard of care for medical evaluations of suspected child sexual abuse recognizes the requirement for patience and compassion while retaining objectivity. The pediatrician's primary concern must be for the child's physical and emotional well-being.
Strokes in Children
Authors: Rivkin Michael J. , Volpe Joseph J.
Published: December 2021

Stroke denotes the sudden onset of a focal neurologic deficit and most often includes the abrupt appearance of weakness. Interruption of blood flow to a part of the central nervous system (CNS) usually underlies the resultant weakness. Because most strokes in children are related to focal cerebral involvement, the most common clinical manifestation is the abrupt appearance of hemiparesis. Less frequently, the cause of stroke involves the brain stem, cerebellum, or spinal cord. The functional consequences always reflect the neuroanatomic features of the affected CNS region.

Epidemiology

Childhood stroke occurs with an annual incidence of 2.5 cases per 100,000 population and has been reported in all racial and ethnic groups. The sequelae are not trivial. In addition to lasting lateralized weakness, cognitive deficits, disturbances of language, visual deficits, and seizures may persist long after the acute event has concluded.

The causes of stroke in children differ from those in adults. Stroke in adults is associated largely with hypertension or atherosclerosis and their respective hemorrhagic and ischemic consequences. Stroke in children more commonly is caused by or related to congenital heart disease, infection, metabolic disorders, hematologic diatheses, and vasculitic disorders, frequently due to autoimmune processes (Table 1). Nonetheless, despite the most thorough of evaluations, etiology escapes detection in approximately 30% of the pediatric patients in whom stroke occurs.
Pediatricians and Gay and Lesbian Youth
Authors: Perrin Ellen C.
Published: December 2021

The Epidemiology of Adolescent Homosexuality

PREVALENCE

Sexual orientation refers to an individual's pattern of physical and emotional arousal toward other persons. It is not synonymous with gender identity (the knowledge of being male or female) or gender role (outward expression of maleness or femaleness). Gender identity and gender role generally are defined by anatomic and chromosomal gender in both heterosexual and homosexual individuals. Sexual orientation also is not synonymous with sexual activity; many homosexual individuals, especially during adolescence, participate in heterosexual behavior and relationships,1,2 and many adults who identify themselves as heterosexual report homosexual activity during adolescence.3-5

It is difficult to know with certainty the number of people who identify themselves as exclusively or predominantly homosexual. It is more difficult still to estimate the number who have questions about their sexual orientation during adolescence because of the well-known fluidity and complexity of sexual attractions and activities during this period. The original Kinsey study of sexuality reported that from puberty to age 20, 28% of boys and 17% of girls had one or more homosexual experiences. The same survey reported that 37% of adults have had homosexual experiences and that 10% consider themselves to be predominantly homosexual.3,4 In a somewhat more recent cross-sectional study of 13- to 19-year-olds, 11% of boys and 6% of girls reported at least one homosexual experience, with 17% of boys aged 16 to 19 reporting such activities.6
Use of Nephrosonography in Evaluation of Renal Disease in Infants
Authors: Kelsch Robert C. , Oliver William J.
Published: December 2021

Indications and contraindications for nephrosonography in infants include:

1. Nephrosonography should be the initial procedure used in evaluating renal structure in infants with renal failure.

2. Nephrosonography may be the initial procedure used in evaluating an abdominal mass or urinary tract infection in infants under 2 weeks of age. Intravenous urography can follow at the appropriate time if indicated.

3. Intravenous urography should be the initial procedure in evaluating abdominal masses or urinary tract infection in infants more than 2 weeks of age.

4. Nephrosonography is a suitable screening procedure when the presence of certain congenital anomalies suggests the possibility of abnormal development of upper urinary tracts. Abnormalities found may require resolution by intravenous urograms.

5. Nephrosonography offers decreased risk in terms of hypersensitivity reactions and radiation exposure in the follow-up evaluation of certain diagnoses and treatment.
The Pediatrician and Psychometric Testing
Authors: Rosenberger Peter B.
Published: December 2021

Because of the importance of developmental disabilities in today's pediatric practice, familiarity with psychometric testing is essential to the modern pediatrician. It is unfortunate that pediatric training programs include so little instruction in this area. However, the subject is largely relevant to outpatient practice, and perhaps better taught at the postgraduate level.

Psychometric tests are essentially observations of behavior, a proper part of the clinical examination. The pediatrician should develop a repertoire of office tests of intellectual aptitude and achievement, using simple materials and readily available developmental norms.

Indications for formal psychometric testing have been discussed. Representative tests in each major category were reviewed briefly with a comparison of relative strengths and weaknesses, and the proper uses of psychometric test results as laboratory data in the diagnostic workup have been presented.
Inborn Errors of Metabolism
Authors: H. R. J.
Published: December 2021

In the December issue of PIR (2:175, 1980) under "Galactosemia, Treatment" (p 180), it was stated that the infant should be given vitamin K, 1 mg intramuscularly twice a day. This should read 1 mg intramuscularly two times. Vitamin K should not be given for more than one day or it may increase jaundice.
Genetic Counseling and Congenital Anomalies
Authors: Feingold Murray
Published: December 2021

As the role of the pediatrician changes, less time will be devoted to routine care and more time will be spent in other areas such as genetics and birth defects. Approximately 5% of all newborn babies have a significant birth defect requiring the care of a pediatrician. Structural abnormalities such as meningomyelocele, cleft palate, limb abnormalities, and other obvious defects usually do not present any diagnostic problems. However, there may be difficulty in diagnosis of the child who has nonspecific findings such as an unusual facial appearance and/or minor congenital anomalies. In this situation, the pediatnician must first decide whether the child is normal or abnormal; at times this may be difficult. If abnormal, then the correct diagnosis must be ascertained in order to provide the family with genetic counseling, a prognosis, and treatment when available.

Complicated medical gadgetry may be helpful in making a diagnosis, but a thorough history and physical examination remain the clinician's key to unlocking a diagnostic dilemma. A family pedigree should be constructed listing any significant illnesses, birth defects, chromosomal abnormalities, consanguinity, and mental retardation. A complete pregnancy history should always be obtained; what took place during the mother's pregnancy also affected the boarding fetus. Queries should be made concerning exposure to drugs, alcohol, infections, environmental contaminants, and radiation.
Dental Health and Pediatrics
Authors: Jolley H. M. , Pless I. B.
Published: December 2021

Dental problems continue to rank as the most common health problem of children today. Caries is remarkably prevalent and about half of school-aged children have some form of malocclusion or gingival disease. The situation is particularly pressing for the poor, among whom it is estimated that 97% of children require dental care. Not only is there a need for the treatment of caries but also for the institution of measures to prevent progressive periodontal disease in later life. Most oral diseases are preventable through adequate dental care and the establishment of preventive practices in the home. The pediatrician is in an excellent position to assist in the attainment of this goal by reinforcing these measures. Although the pediatrician can do little about increasing access to medical care, especially for the poor, he can play a more active role in the early identification of problems and facilitating appropriate referrals. The challenges and opportunities are great; with the enhanced knowledge of the nature of dental health problems provided here the pediatrician should be able to make a significant contribution to diminishing this large category of unmet health needs.
Hair Loss in Children
Authors: Rasmussen James E.
Published: December 2021

PHYSIOLOGY OF NORMAL HAIR1,2

Unlike the hair of most animals, human hair usually follows a random pattern of growth, rest, and shedding, followed by the growth and emergence of a new hair from the follicle. This cycle is related to histologic changes in the follicle: The anagen phase involves active growth (long follicle); the telogen phase is resting (short follicle); and the catagen phase is a transition between anagen and telogen.

The duration of the growing phase (anagen) determines the ultimate length of the hair: normally longest on the scalp, followed in descending order of length by the hairs of the beard, pubis, axillae, body, eyebrows, and eyelid margins. Longer hair is associated with a higher ratio (10:1) of anagen to telogen follicles. Hair plucking is the most rapid, convenient path to examine this relationship: anagen hairs have a glistening, cylindrical proximal sheath, approximately 3 mm long (Fig 1) whereas the telogen follicle yields a hair with a short, 1-mm knob, appropriately called a club (Fig 2).

The shape and color of hair are usually determined genetically. Straight hair is round in cross section, with curly and kinky (spiral) varieties becoming progressively more ellipsoid. Hair color may normally darken and shape change for the first five to ten years of life; this tendency is most commonly seen in the transformation of a curly haired blond child into a tow-headed or brunette adolescent.
The Pediatrician and Psychological Problems
Authors: KORSCH BARBARA
Published: December 2021

A reader, Dr Selter of Newton, MA., raised two points about the philosophy expressed in our articles on psychological problems. First, "There seems to be a consistent theme in your programs' handling of psychosocial issues: namely, the delay of psychological intervention until organic disease is effectively cluded." The writer went on to indicate "... the reserving of psychiatric input until `the end' denigrates its value.... " "I prefer a multidisciplinary ciplinary approach using both the physical and...." The second psychosocial tools concurrently...." The second point raised by the writer was that "... there is an idealistically undue reliance on the general pediatrician's ability, both timewise and interestwise, to deal with many of these problems.