bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing the Causal Effect of Childhood Corporal Punishment on Adult Violent Behavior: Methodological Challenges
Authors: Bauman Laurie J.
Published: December 2021

Professor Straus' article addresses a key scientific question in the debate over the use of corporal punishment: whether the practice has harmful consequences to society. In my discussion I have three goals. First, I want to discuss briefly some of the methodological challenges in testing the hypothesis that child corporal punishment causes societal violence. Second, I would like to set Straus' work into a larger framework so we understand its contribution to the debate about corporal punishment, and how the evidence he provides could be used to help settle the question. Last, I will suggest a scientific approach to the study of corporal punishment that would provide a set of decision rules concerning whether accept or reject corporal punishment of children.

METHODOLOGICAL CHALLENGES

The issue of potential short- and long-term harm from corporal punishment is a major theme in the literature, and many studies have been conducted to address this issue. In his article, Straus uses two kinds of evidence: data from studies of societies; and studies comparing children who were spanked and children who were not on rates of violent behavior in adolescence or adulthood. There are several difficulties in using these scientific approaches.

Societal Level Studies

Straus references societal-level data from Montague1 on eight nonviolent societies, all of which raise children without use of corporal punishment, and anthropological studies of over 300 societies archived in the Human Resources Area File. He uses these data to examine whether corporal punishment is associated with violence such as assault, homicide, or wife-beating.
Periconceptional Multivitamin Use and the Occurrence of Conotruncal Heart Defects: Results From a Population-based, Case-Control Study
Authors: Botto Lorenzo D. , Khoury Muin J. , Mulinare Joseph , Erickson J. David
Published: December 2021

Objective. The preventive efficacy of the periconceptional use of multivitamins is well established for neural tube defects, much less so for other birth defects. We conducted a population-based, case-control study to assess the effects of multivitamin use on the risk for conotruncal defects, a group of severe heart defects that includes transposition of the great arteries, tetralogy of Fallot, and truncus arteriosus.

Methods. From the population-based Atlanta Birth Defects Case-Control Study, we identified 158 case infants with conotruncal defects and 3026 unaffected, randomly chosen control infants, born from 1968 through 1980 to mothers residing in metropolitan Atlanta. Periconceptional multivitamin use was defined as reported regular use from 3 months before conception through the third month of pregnancy. We present the results of the crude analysis, because the multivariate model yielded essentially identical results.

Results. Mothers who reported periconceptional multivitamin use had a 43% lower risk of having infants with conotruncal defects (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.33 to 1.00) than did mothers who reported no use. The estimated relative risk was lowest for isolated conotruncal defects (OR, 0.41; 95% CI, 0.20 to 0.84) compared with those associated with noncardiac defects (OR, 0.91; 95% CI, 0.33 to 2.52) or a recognized syndrome (OR, 1.82; 95% CI, 0.31 to 10.67). Among anatomic subgroups of defects, transposition of the great arteries showed the greatest reduction in risk (OR, 0.36; 95% CI, 0.15 to 089).

Conclusions. Periconceptional multivitamin use is associated with a reduced risk for conotruncal defects. These findings could have major implications for the prevention of these birth defects.
GET REAL!
Authors: L. J. F.
Published: December 2021

Recent Bulletins from the language wars:

There are no more girdles left in the world-they are all "shapewear."

Nudists have virtually disappeared, though there are many practitioners of clothing-optional lifestyle.

At Stanford University, nobody ever fails a course. Instead, a dedicated campus underachiever gets an NP—no pass.

To the amazement of all, pedophiles and some sex researchers now refer to adult sex with children as "intergenerational intimacy."

Perhaps necrophilia would emerge as "post-terminal intimacy."
Intraventricular Hemorrhage and Hig-frequency Ventilation: A Meta-analysis of Prospective Clinical Trials
Authors: Clark Reese H. , Dykes Francine D. , Bachman Thomas E. , Ashurst James T.
Published: December 2021

Objective. The association between high-frequency ventilation (HFV) and intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) has been debated.

Purpose. To determine if premature neonates treated with HFV are at greater risk for developing IVH and/or PVL than neonates treated with conventional ventilation, we completed a meta-analysis of all prospective randomized control trials comparing HFV and conventional ventilation in the management of respiratory distress syndrome.

Methods. The meta-analysis included nine studies comparing HFV and conventional ventilation in the management of preterm neonates. To summarize the data, we calculated the difference in absolute risk for IVH and PVL between neonates treated with HFV and those treated with standard ventilation. These differences were combined to determine an overall difference in the absolute risk and its confidence interval. We examined the effect of estimated gestational age, birth weight, surfactant, and age at study entry on the results. Because one trial (HIFI study) was much larger than the other studies, it dominated the analysis, so we evaluated the data with and without including data from the HIFI trial.

Results. The occurrences of IVH and PVL ranged from 14% to 47% and 5% to 16%, respectively. This variation may be explained by the difference in the populations of neonates treated. The meta-analysis showed that use of HFV was associated with an increased risk of PVL (odds ratio = 1.7 with a confidence interval of 1.06 to 2.74), but not IVH or severe (≥grade 3) IVH. When the results of the HIFI study were excluded, there were no differences between HFV and conventional ventilation in the occurrence of IVH or PVL.

Conclusions. The association between HFV and adverse neurologic outcomes is primarily influenced by the results of the HIFI trial. Meta-analysis of more recent studies does not confirm the findings of the HIFI trial and suggests that HFV is not associated with increased occurrence of NH or PVL.
The Role of the Physical and Traffic Environment in Child Pedestrian Injuries
Authors: Agran Phyllis F. , Winn Diane G. , Anderson Craig L. , Tran Cecile , Del Valle Celeste P.
Published: December 2021

Objective. To identify environmental risk factors on residential streets for pediatric pedestrian injuries.

Method. The sample consisted of 39 Latino children 0 to 14 years of age injured as pedestrians on a street in the same block as their home and 62 randomly selected neighborhood control subjects matched to the case by city, age or year of birth, ethnicity, and gender. The cases were identified from a population-based hospital and coroner's office surveillance system established in north-central Orange County, CA. Neighborhood assessments were performed from 3:45 PM to 5 PM, a fairly active time for young pedestrians. The cases were compared with the controls using conditional logistic regressions; in this study design, the odds ratios were interpreted as estimates of the incidence rate ratios.

Results. Children living in a multifamily residence had an incidence of injury greater than that of children living in single-family residence on a single lot (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.3-7.6). The ORs in the highest category were several times those in the lowest category for both parked vehicles (OR 9.6, 95% CI 2.6-36) and total number of pedestrians observed (OR 4.7, 95% CI 1.4-16). Vehicle parking, total pedestrians, vehicular traffic volume, and speed were examined in a multivariate model. The association of vehicles parked on the street with pedestrian injury risk remained significant. Unlike the crude results, progressively greater vehicular speed was associated with a marked increase in risk. Progressively higher vehicular traffic volume was associated with a progressively lower adjusted OR.

Conclusion. The results of this analysis would indicate that residential streets with a high proportion of multifamily residences, over 50% of the curb occupied with parked vehicles, and a large number of pedestrians observed in unenclosed areas should receive high priority for intervention programs to reduce pediatric pedestrian injuries. The analysis suggests that on these streets, measures to reduce the amount of street parking (thus increasing visibility) and reductions in vehicular speed should be considered to decrease pedestrian injuries.
TECHNOLOGY'S REVENGE
Authors: Student
Published: December 2021

Technology designed to solve one problem ends up creating another or undoing its own solution. For every technological action, one might say, there is an equal and opposite reaction: technology's revenge.
Effect of Zinc Supplementation on Observed Activity in Low Socioeconomic Indian Preschool Children
Authors: Sazawal Sunil , Bentley Margaret , Black Robert E. , Dhingra Pratibha , George Sherly , Bhan Maharaj K.
Published: December 2021

Objectives. To investigate whether supplementation of zinc in preschool children is associated with improvement in observed activity levels.

Methods. On 2 consecutive days, we performed 5-hour observations with momentary time sampling (instant activity every 10 minutes) in children selected from an ongoing double-blind, randomized trial of zinc supplementation. The study was conducted in Kalkaji, a low-socioeconomic urban population of New Delhi with high diarrheal incidence and rates of malnutrition. A total of 93 children (48 zinc and 45 control) 12 to 23 months of age from an ongoing community-based, randomized, controlled trial received supplements for at least 1 month before study; 71% had received supplementation for more than 120 days. Zinc gluconate (10 mg of elemental zinc) was given daily, with both zinc and control groups receiving vitamins A, B1, B2, B6, D3, and E and niacinamide in addition.

Results. Outcomes were percentages of time spent in each of five activity levels and two groups representing high and low movement and overall rating by two activity scores. Children in the zinc group spent 72% more time performing activities in the high-movement group. Among the zinc-supplemented children, the activity rating by the children's activity rating score was 12% higher and by the energy expenditure score was 8.3% higher than in the control group.

Conclusions. In conclusion, zinc supplementation, given along with selected vitamins, was associated with significantly greater activity levels in children. The relationship between the activity increase and locomotor development needs to be investigated, as do the long-term implications of zinc supplementation in terms of developmental status and school performance.
Use of Diet History in the Screening of Iron Deficiency
Authors: Boutry Mireille , Needlman Robert
Published: December 2021

Objective. To determine the relationship between diet history and microcytic anemia, a proxy for iron deficiency, and the utility of a brief dietary history in screening for microcytic anemia.

Design. Cross-sectional study based on review of clinical records.

Setting. Urban academic primary care clinic.

Subjects. A total of 305 healthy, African-American inner-city children, presenting for well child care at 15 to 60 months of age. Children with recent minor illness or medicinal iron intake, hemoglobinopathies, chronic illnesses, failure to thrive, or elevated lead levels were excluded.

Method. A brief dietary history was taken in the course of primary care visits. Dietary deficiency was defined as: (1) less than five servings each of meat, grains, vegetables, and fruit per week; (2) more than 16 oz of milk per day; or (3) daily intake of fatty snacks, sweets, or more than 16 oz of soft drink. Hematologic indices were obtained.

Results. The prevalence of microcytic anemia (hemoglobin, < 11 g/dL; mean corpuscular volume, <73 fL) was 8% (24 of 305). The prevalence of low hemoglobin (<11 g/dL) with or without microcytosis was 12% (38 of 305). Dietary deficiency was associated with microcytic anemia (x2 = 26.8). As a screening test for microcytic anemia, dietary deficiency had a sensitivity of 71% (17 of 24), specificity of 79% (222 of 281), and negative predictive value of 97% (222 of 229).

Conclusion. Microcytic anemia was associated with a deficient diet among low-income African-American children. A brief dietary history correctly identified children at low risk for microcytic anemia 97% of the time.
Serial Assessment of Ductus Arteriosus Hemodynamics in Hyaline Membrane Disease
Authors: Phillipos Ernest Z. , Robertson Murray A. , Byrne Paul J.
Published: December 2021

Objectives. To assess the efficacy of Doppler echocardiography (DE) in the quantification of patent ductus arteriosus (PDA) shunt volume and to correlate PDA shunt volume with clinical outcome in infants with hyaline membrane disease.

Methods. Ninety-eight DE studies were performed in 30 preterm ventilated infants with hyaline membrane disease within the first 24 hours of age and then at 48-hour intervals to a maximum of three studies while ventilated with a final study after extubation. Right and left ventricular outputs (QRV and QLV, respectively) and PDA flow were calculated using cross-sectional area and flow velocity integrals. Left atrial-to-aortic root diameter measurements were also taken. Clinical outcomes were correlated with the shunt fraction (QLV/QRV).

Results. QLV/QRV demonstrated a linear relationship with the left atrial-to-aortic root diameter ratio (n = 92; r = .79). In the absence of a PDA (n = 33 studies), QRV versus QLV demonstrated a linear relationship (r = .88). In the presence of a PDA (n = 64 studies) the mean QLV (334 ± 133 ml/kg per minute) was significantly greater than the mean QRV (237 ± 84 ml/kg per minute). There was a linear relationship between QLV - QRV (PDA shunt volume) and PDA flow (n = 60; r = .84). In studies with exclusive left-to-right shunting at the PDA (n = 48), the mean QLV - QRV (112 ± 83 ml/kg per minute) was significantly higher than in those with bidirectional shunting (n = 16; mean QLV - QRV = 50 ± 27 ml/kg per minute). Two infants with severe intraventricular hemorrhage (IVH grade 3) and two infants with periventricular leukomalacia (PVL) had significantly higher QLV/QRV (2.09 ± 0.36 and 1.67 ± 0.02 respectively) than those with no IVH (n = 6; QLV/QRV = 1.31 ± 0.18) or those with IVH grades 1 and 2 (n = 8; QLV/QRV = 1.48 ± 0.27). There was no difference in QLV/QRV in infants with or without bronchopulmonary dysplasia retinopathy of prematurity. Necrotizing enterocolitis did not develop in any of the 30 infants.

Conclusion. PDA shunt volume can be quantified by DE. Larger studies are needed to correlate clinical outcome with QLV/QRV.
Cognitive and Neurologic Development of the Premature, Small for Gestational Age Infant Through Age 6: Comparison by Birth Weight and Gestational Age
Authors: McCarton Cecelia M. , Wallace Ina F. , Divon Michael , Vaughan Herbert G.
Published: December 2021

Objective. To compare the neurologic and cognitive outcomes of 129 premature small for gestational age (SGA) infants with 300 premature appropriate for gestational age (AGA) infants through 6 years of age.

Design. Infants born at ≤37 weeks gestational age and ≤2500 g with birth weight 2 standard deviations or more below the mean birth weight for gestational age were categorized as SGA. Cognitive and neurologic outcomes of SGA and AGA prematures at 1, 2, 3, and 5 and/or 6 years of age were compared when the infants were stratified by gestational age in 2-week intervals or by birth weight in 500-g intervals. The association between SGA/AGA and neurologic status on cognitive outcomes at each age was also examined.

Results. SGA infants had significantly poorer cognitive scores at each age when compared with AGA infants of similar gestational ages. Normal neurologic status was more likely at all assessments for the AGA than for SGA infants of comparable gestational age. There were no differences between SGA and AGA children in cognitive or neurologic outcomes at any age when grouped by birth weight. Cognitive impairment was closely associated with neurologic abnormality in both SGA and AGA groups. There was, nevertheless, a significant effect of SGA on cognitive outcome independent of neurologic status at all ages except 3 years.

Conclusions. Irrespective of degree of prematurity, SGA infants are at greater risk for neurodevelopmental impairment than are equally premature AGA infants. The cognitive impairment can be largely, but not entirely, attributed to a higher incidence of neurologic abnormalities in the SGA infants at each gestational age.
WHO IS KIDDING WHOM ABOUT RESEARCH?
Authors: Student
Published: December 2021

In the competition for funds, medical research has an advantage over many other fields in claiming that its goal is...to prevent human suffering and premature death from disease. We like to think this is our goal, but if this were the real intention of researchers, they would be better advised to divert the funds to the easily curable health care needs of the Third World, or even the inner cities of the First. In fact, most researchers have no real goal beyond what may be termed an unquenchable desire to understand. It is the need for money to reach the goals that drives the rhetoric of "saving humankind." The increasing commercialization of research is responsible not only for making secrecy more common, but also for the misleading inflation of the end results of medical research.
The Pediatrician's Role—Shrinking and Shrinking!
Authors: BURKE BRYAN L.
Published: December 2021

The article entitled "Physician Experience With Pediatric Inpatient Care in Washington State" that appeared in the January 1996 issue of Pediatrics disturbs me. The trend toward the deemphasis of the primary care pediatrician in the care of hospitalized children is one with which I disagree for the following reasons.

First, as the article acknowledges, pediatricians who practice in a rural setting need to know how to care for a critically ill child. If we elect to teach pediatric residents only the skills necessary for outpatient care, we will either be sending incompletely trained pediatricians to rural areas, or we will be worsening the trend toward pediatrician and physician geographical maldistribution by training pediatricians who will not feel comfortable practicing in rural areas, thereby virtually ensuring their choice of an urban area in which to practice.
Does Adenosine Infusion Improve Oxygenation in Term Infants With Respiratory Failure?
Authors: LEBLANC MICHAEL H.
Published: December 2021

I read with interest the article by Dr. Konduri et al in the March 1996 issue of Pediatrics entitled "Adenosine Infusion Improves Oxygenation in Term Infants With Respiratory Failure."

This article demonstrated that at 50 µg/kg/min adenosine infusion improved the oxygenation of term infants with persistent pulmonary hypertension. My concern is whether this dose of adenosine is, in fact, safe. A dose of 50 µg/kg/min of adenosine amounts to 72 mg/kg/day.

Neonates typically excrete only about 5 mg/kg/day of uric acid, which corresponds to approximately 8 mg/kg/day of adenosine.
Techniques for Evaluating Residents and Residency Programs
Authors: Quattlebaum Thomas G.
Published: December 2021

A comprehensive, functioning evaluation system is an important component of a residency program. It should focus on the residency program as well as on the residents and should provide feedback to the residents, their teachers, and the program director. Such a system allows residents and their faculty advisors to receive timely, ongoing, formative feedback concerning resident progress. Likewise, it can help the faculty recognize the strengths and weaknesses of the training program by providing data that can lead to the curriculum changes needed to improve resident experiences. Additionally, it can alert the residency program director to residents whose performance is significantly below that of their peers, allowing intensive faculty and advisor help for these individuals. The practical aspects of providing feedback and implementing an evaluation system apply no less to community-based educational experiences than they do to inpatient and outpatient training areas.
Comments of a Reactor Panel
Authors: Applebaum Michael
Published: December 2021

First, let me just say that managed care means different things to different people. I want to give you my personal perspective on pediatric residency training in community settings based on my own experiences in a nonprofit, physician-directed managed care system, Kaiser Permanente Health Care Plan, that has a 50-year history. My experience is, therefore, probably somewhat unusual and different from that of many other physicians throughout the country.

As I wandered back and forth among the various workshops during this conference, managed care was a prominent theme in most. I am going to restrict my comments to three areas: recruitment, evaluation, and financing.

With regard to recruitment, managed care systems are likely to have a strong interest in developing strategic alliances with academic teaching centers, but this interest is based on a reciprocity of needs. These kinds of alliances can only flourish when there is mutual trust that emerges after a variety of discussions at several levels.

Managed care systems can be encouraged, then, to participate actively in teaching programs, and they may be significant sources for recruiting teaching faculty. Some managed care systems can provide stable, multicultural patient populations that are derived from the communities in which they practice. Continuity experiences provided to residents focus on health and prevention issues as opposed to disease orientation. Managed care systems can be rich resources for population research in which residents can participate.

Another issue has not been raised here to any major extent, as far as I know. Teaching residents in a community setting can also involve inpatient care in a community hospital.
Editorial 2 Pediatrics in Review
Authors: Kendig Edwin L.
Published: December 2021

With this first issue of PEDIATRICS IN REVIEW the American Academy of Pediatrics' sponsored pediatric review and education program (PREP) has been launched. The program is multifaceted and will be coordinated with the American Board of Pediatrics program for recertification in pediatrics. Medical education (continuing education) has always been the Academy's highest priority and PREP is the most recent and most comprehensive of all Academy education programs.

Maintaining professional competence is a responsibility of every pediatrician and PREP is a coordinated program of continuing education designed to help pediatricians maintain and assess their own competency. The objectives for PREP (and for the American Board of Pediatrics recertification program) are: (1) To help pediatricians acquire new abilities in the management of acute and chronic illness in infants, children and adolescents; these abilities include attitudes (work habits), knowledge and clinical judgment, interpersonal (communication) skills, and technical skills; (2) To help pediatricians, through a program of self-assessment procedures, set their own priorities for professional advancement and to determine when their goals have been met.
Fluid and Electrolyte Therapy in Low Birth Weight Infants
Authors: Oh William
Published: December 2021

Infants with respiratory distress syndrome (RDS) often require parenteral fluid therapy during the course of acute respiratory illness due to difficulty giving oral feedings. Errors in prescribing the fluid treatment may lead to either dehydration or fluid overload, partly due to the limitations in renal compensatory mechanism in these infants. Therefore, inappropriate fluid and electrolyte management in infants with RDS may lead to metabolic complications, dehydration, poor nutritional support, and additional cardiopulmonary complications because of the fluid overload. This article provides a brief review on the principles of fluid and electrolyte management in infants with RDS with the aim of minimizing the complications of such therapy.

MAINTENANCE FLUID REQUIREMENT

The maintenance fluid requirement should consist of allowances for (1) insensible water loss, (2) water for urine formation, (3) water loss through the stool, and (4) in a growing infant, water required for tissue growth. In low birth weight infants, insensible water loss is higher than in term infants.1,2 The water required for urine formation is dependent on solute excretion which in turn is dependent on the amount of solute given exogenously (primarily electrolytes and protein) and those endogenously derived from normal body metabolism. The amount of water excreted through the stool is minimal in the first days of life particularly in low birth weight infants simply because of smaller amounts of stool in these subjects during the first week of life.
Cardiac Failure
Authors: Fowler Richard E. L.
Published: December 2021

Congestive heart failure is an altered state of circulatory dynamics resulting from an imbalance between the demands by the body for blood flow to meet its metabolic needs and the ability of the heart to meet those demands. The imbalance may be created in several different ways (Fig 1). The demand for cardiac output may be greatly increased in situations such as large intracardiac or extracardiac left-to-right shunts, valvular insufficiencies, hypermetabolic states, or fluid overload (Table 1). A demand for abnormally high pressure generation may be imposed by obstructive lesions of the outflow tracks of the left or right ventricles or by elevated resistance to blood flow in their attached blood vessels. An unbalanced state may also be produced by inability of the myocardium to meet normal demands when the myocardium has been damaged by inflammation (myocarditis), metabolic abnormalities (cardiac glycogenosis), fatigue or dysrhythmias (tachyarrhythmias, heart block), nutritional deficiencies (beri-beri, starvation), or toxins (diphtheria, alcohol). Still other causes of inadequate myocardial contractility are electrolyte disturbances (hyper- or hypokalemia), drugs (doxorubicin [Adriamycin]), muscular degeneration (muscular dystrophy), or coronary artery disease (congenital abnormalities, Kawasaki's disease). In each instance, the physician's task is to restore the needed equilibrium by reducing the demands upon the heart or by improving the myocardium's ability to respond.
The Febrile Infant
Authors: SMITH ARNOLD L.
Published: December 2021

Sorting out the child at risk, from those with illness that is not a threat to their health, is a fundamental goal of pediatrics. One of the most common complaints, which prompts us to initiate the sorting process, is fever. In the article by McCarthy (p 51), guidelines to aid in the sorting process are suggested.

Fever, an abnormal increase in core body temperature, results primarily from a decrease in heat loss; decreased trunk and extremity skin blood flow decreases the surface area available for convection and body heat loss decreases—mom feels the forehead or the face for increased temperature, areas less affected by thermoregulatory vasoconstriction.
Adolescent Pregnancy—A Multifaceted Problem
Authors: McAnarney Elizabeth R. , Greydanus Donald E.
Published: December 2021

Adolescent pregnancy is a major child health problem in the United States. Nearly one million adolescents became pregnant in 1977. Adolescent pregnancies result from earlier biologic maturity and sexual activity.

The average age of menarche in the United States is approximately 12.6 years and has declined four months during each decade in the last century. Boys also mature earlier than their peers of previous generations. As a result of better nutrition, the minimum age of biologic maturity has probably been attained. More young people are sexually active now than they were 25 years ago. In the late 1940s, 20% of unmarried women between 16 and 20 years of age reported having had intercourse. In 1971, 46% of unmarried women aged 19 years reported having had intercourse at least once and in 1976, 55%.1 In 1975, 69% of a sample of adolescent males were sexually experienced with black and Hispanic youth having had their first coital experience at the earliest ages.2

Of the approximately one million adolescents who became pregnant, 570,622 delivered children and approximately 370,000 had abortions. Birth rates to adolescents decreased between 1965 and 1975 for all ages, except for blacks and whites under 15 years and whites 15 to 17 years of age.
Lessons Learned from Patients: Two Cases
Authors: STRAIN JAMES E.
Published: December 2021

A 4-year-old white girl was entirely well until Jan 8, 1979, when her temperature was 104 F. Other symptoms included nasal congestion, slight cough, and pain in the right ear. On physical examination her right ear drum was moderately inflamed and bulging. Her tonsils were large and red, but no exudate was present. Tender anterior cervical lymph nodes, 2 x 2 cm, were palpable bilaterally. Her chest was clear. There was a grade 1/6 systolic murmur along the left sternal border (LSB) which had been heard on previous examinations and was thought to be innocent in nature. Her spleen was not palpable.
Epiglottitis: Diagnosis and Treatment
Authors: Bates Jonathan R.
Published: December 2021

Epiglottitis is a rapid and potentially fatal infection of the supraglottic larynx that causes death by upper airway obstruction and Gram-negative bacteremia with Haemophilus influenzae type B (HIB). The majority of patients (80%) are less than 5 years of age, and the remaining 20% are scattered over the remaining life span. Although sporadically recognized since the early 16th century, the disease has only become well-described since the late 1940s. Initial mortality rates approaching 100% have steadily declined to about 2% with the use of artificial airways and antibiotics.

The key to obtaining a good outcome with available effective therapy in this disease is prompt recognition and rapid initiation of therapy. Delays of even a few minutes can be disastrous. Advanced planning for the handling of such patients in the office, clinic, or emergency room has been effective in avoiding death from such delays. Decisive action can make the difference between death or anoxic damage as an outcome, and complete recovery without sequelae.

CLINICAL PICTURE

The disease typically begins abruptly with the onset of fever greater than 102° F (rectal) and sore throat or difficulty swallowing. These two features of epiglottic inflammation signal the onset of this illness and occur simultaneously or within a few hours of each other.
Interstitial and Hypersensitivity Pneumonitis and Their Variants
Authors: Hilman Bettina C.
Published: December 2021

INTRODUCTION, DEFINITION, INCIDENCE, AND CLASSIFICATION

Interstitial pneumonitis (IP) in children is now being recognized earlier and with increased frequency as a cause of chronic respiratory symptoms. Confirmation of the diagnosis, histologic classification, and management depend on studies of tissues obtained from lung biopsy. Since physicians are reluctant to utilize invasive procedures such as lung biopsy in children, the exact incidence of this entity is not accurately known. There are no pathognomonic clinical or laboratory features of interstitial pneumonitis other than histologic findings on lung biopsy. Since therapy depends upon accurate diagnosis this procedure is justified when symptoms and findings suggest this diagnosis. The timing of the biopsy must be individualized depending on the severity and progression of the clinical and/or roentgenographic findings. The diagnosis of IP in the immunocompromised host calls for a prompt aggressive approach to differentiate infectious causes from drug-induced pulmonary disease. Recently a rapid and safe technique, thoracoscopy, has been reported to provide accurate histologic and bacteriologic diagnosis in immunosuppressed children (Rodgers et al).

IP is a broad, inclusive term used to describe tissue response which takes place predominately in the supporting structures (interstitium) of the lung rather than within the alveoli. Multiple etiologies may result in similar clinical, histologic, and roentgenographic manifestations.
Recent Advances in the Care of Patients with Juvenile Diabetes Mellitus
Authors: Spack Norman P.
Published: December 2021

GENETICS AND ETIOLOGY: IMPLICATIONS FOR COUNSELING

Until recently, diabetics were classified into juvenile- or maturity-onset categories on the basis of the age at onset of disease. We now consider diabetes to be a syndrome in which various factors, diminished or absent beta cell secretory capacity, increased levels of gluconeogenic hormones, or altered insulin receptor binding, can produce the common denominator of hyperglycemia.

Although a rare form of mild diabetes has been characterized in children and appears to be inherited in autosomal dominant fashion (termed MODY-Maturity Onset Diabetes of the Young)1, the overwhelming majority of diabetic children and adolescents develop the insulin-dependent variety of the disease. Recent studies in Michigan define the prevalence of the latter form to be 1.89 cases per 1000 school-aged children (ages 5 to 18 years), with an annual incidence of 1.6 cases per 100,000 children (ages 5 to 18 years). Whereas increased risk has long been observed in relatives of insulin-dependent diabetics, several factors have confounded the geneticists: patients sharing the same genetic blueprint do not share equal likelihood for developing the disease. When one member of a monozygotic twinship develops diabetes under age 45, his twin has but a 50% chance of becoming diabetic. On the other hand, if a twin develops the disease over the age of 45, the risk to the other twin approaches 100%.
Changes in 1988/1989
Authors: H. R. J.
Published: December 2021

Relatively few changes will occur in the format for Pediatrics in Review in 1988/1989, its tenth year of publication. Dr Alden's commentary preceeding this expresses the very exciting and challenging tasks that lie ahead to make PIR most useful in the continuing education of pediatricians, especially for those who will receive a time-limited certification in 1988 and the future.

You will note questions at the beginning of each article, with the question and multiple choice answers at the end of each article. Answers remain on the inside front cover. The reason for this change is to help focus the reader's attention on what the author and our question writers believe to be most important points in the article.
Near Drowning
Authors: Brooks John G.
Published: December 2021

Drowning is the third most common cause of death for children between the ages of 1 and 14 years. Despite increasing understanding of the pathophysiology of drowning and continuing advances in cardiopulmonary resuscitation and support, efforts at cerebral resuscitation have been less successful, and it is estimated that only about half of the children who are apparently lifeless when removed from the water will survive. Prevention, effective on-scene resuscitation, and optimal inpatient care are the keys to reducing the morbidity and mortality of submersion accidents.

EPIDEMIOLOGY

Approximately 8,000 deaths due to drowning occur each year in the United States, and approximately 40% of the victims are less than 4 years of age. Drowning is second only to motor vehicle accidents as a cause of accidental death in children. Within the pediatricage range there are three particularly high-risk groups: toddlers, teenage boys, and children with seizure disorders. Special efforts should be devoted to educating parents of these children and to the older children themselves regarding water safety and their own particular risks. Parents of ambulatory infants and young children must be reminded that continuous, responsible supervision is absolutely essential around water or when the young child might wander away to a nearby body of water.
Athletic Injuries
Authors: Dyment Paul G.
Published: December 2021

Sports medicine was for many years considered to be the preserve of the orthopedic surgeon, and it consisted primarily of the management of musculoskeletal injuries. With the recognition that primary care physicians can adequately care for more than 80% of athletic soft tissue injuries, there has been a corresponding increase in the number of pediatricians incorporating sports medicine into their practices, and many are actively pursuing further training in this field by attending continuing medical education courses. Many pediatric residencies offer at least an elective experience in sports medicine.

The number of children and adolescents taking part in sports programs in the United States is enormous: 30 million in nonschool-organized athletics and more than 3 million in interscholastic sports. Therefore, it is not surprising that athletic injuries occur frequently in our patients. One study at a health maintenance organization indicated that more than 2% of all visits to that pediatric clinic were for recreational injuries.1 Another study of school-aged children found that each year 6% sustained an athletic injury requiring at least first aid.2 Pediatricians, because of their interest in preventive and behavioral medicine, can not only care for most injuries but, more important, can play a role in the prevention of injuries by becoming team physicians.
Insurability of the Pediatric Patient With Cardiac Disease
Authors: Talner Norman S.
Published: December 2021

This paper provides the pediatrician with suitable guidelines to counsel parents and their children when applying for life insurance. Knowledge of the natural and unnatural history, as influenced by surgical intervention of cardiovascular disorders in the child, has increased to the point where each condition for the most part can be critically defined as to severity and survival characteristics. This should lead to more uniform standards of insurability for this group of patients. The procurement of health insurance for individuals or small groups represents a continuing problem which will require new policies by the insurance industry or federal and/or state support.
Cardiac Transplantation in Children
Authors: Parness Ira A. , Nadas Alexander S.
Published: December 2021

HISTORICAL OVERVIEW

In 1967, Dr Christian Barnard1 captured the imagination of the world's lay and medical communities when he performed the first human orthotopic cardiac allotransplant. Although the recipient survived for only 17 days, even this limited success spurred many centers around the world to attempt heart transplantation in the late 1960s and early 1970s. Interestingly, Dr Adrian Kantrowitz2 in Brooklyn, NY, had attempted a human neonatal cardiac transplantation nearly coincidentally with Dr Barnard's historic operation; the neonate survived only a few hours. Because of poor results secondary to rejection, infection, and donor shortage, most centers had abandoned their heart transplantation programs by the middle 1970s. Experience at the few centers that persisted with heart transplantation, Stanford University being the most notable, led to improved candidate selection and improved immunosuppression. The introduction of endomyocardial biopsy in 19733 for the diagnosis of rejection also contributed substantially to improved understanding and management of this complication.

In the late 1970s, encouraging results from Stanford prompted renewed interest in the procedure. However, pediatric experience, even at Stanford, was limited to a small number of adolescents during the 1970s. In 1980, the introduction of a new maintenance immunosuppressive drug, cyclosporine A, led to improved survival because of less infection and better management of the rejection process.
Health-Related Fitness as Preventive Medicine
Authors: Jopling R. Joe
Published: December 2021

The decline of health-related fitness among children in the United States has brought about an interest in the topic by both professionals and the general public. The problem is pervasive and has seemed refractory to change.

In a recent survey, fewer than half the children taking the fitness test of the President's Council on Physical Fitness and Sports passed. In 1984, only 2% of all children taking the "President's Challenge" could qualify for the award that required them to uniformly do well in performing chin-ups, sit-ups, a 1 mi run/walk, and a shuttle run. Only 60% of boys aged 6 to 12 years and only 30% of girls aged 6 to 12 years and only 30% of girls aged 6 to 17 years could do more than one chin-up. Similarly, only 64% of boys aged 6 to 12 years and only 50% of girls aged 6 to 12 years could run/walk 1 mi in less than ten minutes.

Declining fitness can result in an increase in cardiovascular risk factors such as obesity, hypertension, elevated serum cholesterol level, and physical inactivity. In a recent Centers for Disease Control epidemiologic study, physical inactivity was shown to be as strong a risk factor for coronary heart disease as the traditional risk factors of smoking, hypertension, and a high serum cholesterol level, and physical inactivity was three to six times more prevalent than the other risk factors.
An Adolescent Fearful of AIDS: A `New' Disease Presents Some Old Clinical Problems
Authors: Taube Oscar
Published: December 2021

I recently received a phone call from an anxious 18-year-old first-year college student. She had become sexually intimate with a male partner: specifically, she had engaged in oralgenital sex. The "chief complaint" of the phone call was her fear that she would contract the acquired immunodeficiency syndrome (AIDS). A few more medical details were obtained. The patient had not previously had similar sexual experiences, nor had she ever had intercourse. The patient felt certain that her partner had not had many sexual partners, including high-risk partners, (eg, prostitutes). Neither the patient nor her partner had engaged in any other high-risk activities for AIDS, such as intravenous drug abuse.
Inguinal Hernia and the Acute Scrotum in Infants and Children
Authors: Nakayama Don K. , Rowe Marc I.
Published: December 2021

INGUINAL HERNIA AND OTHER INGUINAL SCROTAL PROBLEMS

Inguinal Hernia

Inguinal hernia and hydrocele develop because the processus vaginalis remains open after birth. When fluid passes distal to the internal ring, a hydrocele forms. An intraabdominal structure entering the processus produces a hernia. The processus, first seen during the third month of gestation at a time when the developing testis lies within the abdomen, extends into the scrotum by the seventh month. As the testis completes its descent, the processus begins to obliterate, a process that continues after birth. Data from autopsy studies reveal that most infants have an open processus for several months after birth. The incidence in the newborn period is 80% to 94% and decreases to 57% in the 4- to 12-month age group. A patent processus persists in 20% of adults without clinically apparent hernias. These rates far exceed the incidence of hernia or hydrocele; therefore, a patent processus may persist undetected throughout life. Excess fluid within the peritoneal cavity, typically from ventriculoperitoneal shunts and peritoneal dialysis, tends to maintain patency of the processus.

Inguinal hernia is one of the most common surgical conditions in infancy, with an incidence of 0.8% to 4.4% that varies with gestational age and birth weight.
Congenital Cardiovascular Defects in Infants With Down Syndrome
Authors: Clark Edward B.
Published: December 2021

Editor's note: In response to a reader's question about cardiac evaluation of patients with Down syndrome, we asked Dr Clark for a review and recommendation for workup by the general pediatrician. RJH

Infants with Down syndrome are at 50% risk for congenital cardiovascular malformations1 compared with a 0.3% (3 of 1000) risk for infants with normal chromosomes.2 These data confirm the original estimates of Rowe and Uchida3; other estimates have ranged from 20% to 70%.

The types of heart defects found in persons with Down syndrome are severe: complete atrioventricular canal, ventricular septal defect, partial atrioventricular canal, atrial septal defect, tetralogy of Fallot, and patent ductus arteriosus.4
Editorial Board Response
Authors: Nazarian Lawrence F.
Published: December 2021

Dr Menna makes several important points. If a partner anticipates reduction of his or her workload, plans should be worked out in advance for equitable payment, recognizing that those activities that generate the most income are not always the ones that impose the greatest stress. His scheme is a good one, although his statement that relative values of different shifts will vary from practice to practice must be emphasized. For some, a night on call involves constant activity and interrupted sleep; for others, there is minimal disruption of routine. In some practices, an additional adjustment for overhead considerations may be necessary.
Progress in Understanding the Pathophysiology of Otitis Media
Authors: Giebink G. Scott
Published: December 2021

Otitis media is one of the most common diseases of infants and young children, and its complications and sequelae may persist into adult years. The disease affects at least 7 of every 10 children, with one third of those affected having repeated episodes, and chronic middle ear disease, commonly called otitis media with effusion, developing in 5% to 10% of them.

The management of childhood otitis media has changed considerably during the past five decades. Before the introduction of antimicrobial drugs, myringotomy was, and in some countries remains today, the treatment of choice. The introduction of sulfonamides and penicillin four decades ago and their widespread use in treating acute otitis media led to a great reduction in the incidence of suppurative complications. Of the new orally administered antibiotics, many have been found to be efficacious in treating acute otitis media. Sophisticated methods of measuring treatment outcome suggest, however, that there are differences in rates of bacteriologic response to these drugs. Moreover, adjunctive therapies such as decongestants, antihistamines, steroidal and nonsteroidal anti-inflammatory drugs, and topical drugs, in addition to myringotomy and adenoidectomy, have been advocated by some in treating acute and recurrent otitis media. These newer therapeutic interventions have led to controversies regarding management of the disease.
PREP and Time-Limited Certification
Authors: Alden Errol R. , Dow Jean
Published: December 2021

The following statement was developed by the Advisory Group of the Pediatrics Review and Education Program (PREP) as part of an effort to inform the Academy membership about plans currently underway for the future of the program.

Although planning is still in the early stages, the Department of Education is enthusiastic about the projected changes, including the publication of 12 (instead of 10) issues per year of Pediatrics in Review starting in July 1990, the expansion of the journal to 40 (from 32) pages in 1992, the development of a new section in the journal devoted to practice management, and the availability of computerized diagnosis and management problems in addition to the Self-Assessment exam.