bluuebunny/crossref_metadata_2025 huggingface dataset:
Eosinophilia-Myalgia Syndrome in a Child With Phenylketonuria
Authors: SPRINGER MICHAEL A. , BOCK HANS-GEORG O. , PHILEN ROSSANNE M. , HILL ROBERT H. , CRAWFORD LLOYD V.
Published: December 2021

Eosinophilia-myalgia syndrome (EMS) has been observed primarily among adults who take over-the-counter tryptophan preparations for a variety of common † We are saddened to report the untimely death of Dr Lloyd V. Crawford prior to the acceptance of this paper. We are grateful for his tremendous contributions and untiring efforts in Pediatrics, especially in the subspecialty ailments.1-5 EMS occasionally has been identified among children, including a neonate with persistent eosinophilia whose mother ingested tryptophan during pregnancy.6 However, no patients have been described as having EMS after ingesting infant formula containing contaminated tryptophan, nor have there been cases of EMS described among patients with phenylketonuria.
Patterned Abusive Bruises of the Buttocks and the Pinnae
Authors: FELDMAN KENNETH W.
Published: December 2021

Patterned bruises often result from abusive injuries. The bruise pattern commonly mimics the injuring object.1 With high-velocity injuries, like whippings or slaps, an unbruised negative image of the cord or hand may be outlined by a fine rim of petechae. At the margin of an injuring object, high-velocity impact stretches capillaries sufficiently to tear them. This may occur even when the force does not crush directly impacted vessels. Greater forces rupture directly impacted vessels creating in addition a positive image bruise of the object. If severe forces are applied more slowly, the elastic limit of the capillaries at the margins will not be exceeded.
Steroids, Chronic Lung Disease, and Retinopathy of Prematurity
Authors: EHRENKRANZ RICHARD A.
Published: December 2021

This issue of Pediatrics contains two conflicting, retrospective observational studies concerning the relation between steroid therapy for chronic lung disease (CLD) and the need for cryotherapy for severe retinopathy of prematurity (ROP). Batton et al1 noted that more infants treated with dexamethasone for CLD needed cryotherapy for ROP, whereas Sobel and Philip2 found that steroid therapy for CLD did not affect the number of infants who needed cryotherapy for ROP. In fact, Sobel and Philip suggest that prolonged (>24 days) treatment with steroids may actually reduce the likelihood that ROP will reach "threshold" criteria for cryotherapy. Are these reports really contradictory?
Lupus Nephritis Study—Questions
Authors: LEHMAN THOMAS J. A. , MCCURDY DEBORAH K.
Published: December 2021

In Reply.—

The comments on the statistical methodology are well thought out by Rabinovich et al. There are a large number of statistical models which can be created in evaluating any problem which may yield slightly different results. To quote a well-respected colleague in the field, "If I have to look at the footnotes to your table to see whether or not the finding was statistically significant, I'm not going to be impressed by your data no matter what the methodology you used.
Kernicterus in Preterm Newborns: Past, Present, and Future
Authors: Watchko Jon F. , Oski Frank A.
Published: December 2021

This historical overview of kernicterus in prematurity, from the 1950s to the present, provides a unique perspective on this clinical conundrum. Three separate periods of pediatric history are detailed in relationship to our understanding of kernicterus in the preterm newborn: (1) the pre-intensive care era (1950 to 1965); (2) the low bilirubin kernicterus era (1965 to 1982); and (3) the 1980s. Each period demonstrates selected insights regarding kernicterus in prematurity, and together with recent reports suggest that premature newborns are now at extremely low risk of developing kernicterus when managed using current standards of care. However, the current conservative empiric guidelines for preventing kernicterus are questioned, and it is suggested that additional study is needed to clarify this issue in the 1990s.
Validating Current Immunization Practice With Young Infants
Authors: LEWIS MICHAEL , RAMSAY DOUGLAS S. , SUOMI STEPHEN J.
Published: December 2021

A recent change in standard pediatric practice on immunization of young infants has involved the administration of two injections during the same office visit as opposed to one injection per office visit. In the past, infants received a single injection at 2, 4, and 6 months of age, to immunize against diphtheria, tetanus, and pertussis. Now, young infants also receive a second injection, to immunize against Haemophilus influenzae type b. This change in procedure raises the question whether two injections during the same visit might be too stressful for young infants. A clear demonstration that two injections are no more stressful than one could provide sufficient evidence to allow pediatricians to feel confident that this new procedure is appropriate.
The "Dose" Question
Authors: JONES R. A.K. , GRANT A. M. ,   the Collaborative Dexamethasone Trial Group
Published: December 2021

To the Editor.—

In our recent report of the collaborative trial of dexamethasone therapy for chronic neonatal lung disease1 we quoted a dosage schedule for dexamethasone of 0.6 mg/kg/d and omitted stating that the product used (Decadron, Merck, Sharp & Dohme) is supplied as dexamethasone sodium phosphate. After allowing for the sodium and phosphate, this is equivalent to a dose of 0.5 mg/Kg/d dexamethasone base.

Mammel and colleagues2 in the first published report of a controlled trial of dexamethasone for chronic neonatal lung disease, stated that they gave dexamethasone in a dose of 0.5 mg/kg/d.
Sleeping Positions
Authors: ORDWAY NELSON K.
Published: December 2021

To the Editor.—

Among the reasons for recommending that infants be placed in the prone position has been the assurance that symmetry of the head will be preserved—or even achieved. Many years ago Charles Chapple (inventor of the Chapple Incubator, the "Womb with a View"—later the Isolette) described the newborn's "position of comfort," ie, its previously intrauterine position. That position is not always symmetrical. A not infrequent asymmetry of the head and face occurs when the infant's head has been rotated to one side and flexed to the other.
Bronchopulmonary Dysplasia Criteria: A Mathematical Impossibility
Authors: SCHWARTZ Roy E. , STAYER STEPHEN A. , PASQUARIELLO CAROLINE A.
Published: December 2021

To the Editor.—

In the commentary "Bronchopulmonary Dysplasia: Twenty-five Years Later,"1 Dr Northway cited the diagnostic criteria for bronchopulmonary dysplasia. One of the criteria stated was a requirement for supplemental oxygen longer than 28 days of age to maintain a Pao2 above 500 mm Hg. Clearly, this was a misprint but it is important to realize why a Pao2 above 500 mm Hg in 21% oxygen at sea level is unachievable. The alveolar air equation is as follows:

Pao2 = (Pb - Ph2o)Fio2 - Paco2/.8
Pediatric Pain: Interacting Behavioral and Physical Factors
Authors: Zeltzer Lonnie K. , Barr Ronald G. , McGrath Patricia A. , Schechter Neil L.
Published: December 2021

Pain in infants, children, and adolescents warrants study from a developmental, behavioral, and physiological perspective because maturation of physical, emotional, and cognitive systems influences the way in which pain is experienced and expressed. Pediatric pain is an underdeveloped area ripe for study within the realm of developmental and behavioral pediatrics, as noted by documentation of its undertreatment in children. The focus of this paper is to present issues relevant to the study of pain in children, using the example of the recurrent abdominal pain syndrome to illustrate points regarding epidemiology, assessment, and intervention. It is the opinion of these authors that pediatric pain must be understood from a developmental perspective in both clinical and nonclinical populations of children. Multidisciplinary approaches to research in pain aids in understanding the development of nociceptive transmission and inhibitory systems, the development of pain expression, and the influence of context on pain experience and behavior. The goal of research in pediatric pain is to understand these systems within a developmental context so that preventive and therapeutic intervention strategies can be developed to reduce children's distress and pain-related disability.
Low-Level Lead Exposure, Intelligence and Academic Achievement: A Long-term Follow-up Study
Authors: Bellinger David C. , Stiles Karen M. , Needleman Herbert L.
Published: December 2021

The implications of low-level lead exposure for children's intellectual and academic performance at school age are uncertain. This issue was investigated in a prospective study of middle-class and upper-middle-class children with low lifetime exposures to lead. A battery of neuropsychological tests was administered at age 10 years to 148 children whose lead exposure and cognitive function had been previously assessed at ages 6, 12, 18, 24, and 57 months. Primary endpoints were Wechsler Intelligence Scale for Children-Revised (WISC-R) and the Kaufman Test of Educational Achievement (K-TEA). Higher levels of blood lead at age 24 months, but not at other ages, were significantly associated with lower global scores on both the WISC-R and the K-TEA after adjustment for potential confounders. Over the range of approximately 0 to 25 µg/dL, a 0.48-µmol/L (10 µg/dL) increase in blood lead at 24 months was associated with a 5.8-point decline in WISC-R Fullscale IQ (95% confidence interval: 1.7 to 9.9, P = .007) and an 8.9-point decline in K-TEA Battery Composite score (95% confidence interval: 4.2 to 13.6, P = .0003). Mean blood lead level at age 24 months was 0.31 µmol/L (6.5 µg/dL; SD: 4.9, 90% percentile: 12.5). Slightly elevated blood lead levels around the age of 24 months are associated with intellectual and academic performance deficits at age 10 years.
Relationship of Sudden Infant Death Syndrome to Maternal Smoking During and After Pregnancy
Authors: Schoendorf Kenneth C. , Kiely John L.
Published: December 2021

Sudden infant death syndrome (SIDS) is associated with maternal smoking during pregnancy. However, the relationship between tobacco exposure during infancy and SIDS is unknown. The examination of infants whose mothers smoked only after pregnancy will help determine the relationship between passive cigarette exposure during infancy and SIDS risk. This case-control analysis used data on normal birth weight (≥2500 g) infants included in the National Maternal and Infant Health Survey, a nationally representative sample of approximately 10 000 births and 6000 infant deaths. Infants were assigned to one of three exposure groups: maternal smoking during both pregnancy and infancy (combined exposure), maternal smoking only during infancy (passive exposure), and no maternal smoking. SIDS death was determined from death certificate coding. Logistic regression was used to adjust for potentially confounding variables. Infants who died of SIDS were more likely to be exposed to maternal cigarette smoke than were surviving infants. Among black infants the odds ratio was 2.4 for passive exposure and 2.9 for combined exposure. Among white infants the odds ratio was 2.2 for passive exposure and 4.1 for combined exposure. After adjustment for demographic risk factors, the odds ratio for SIDS among normal birth weight infants was approximately 2 for passive exposure and 3 for combined exposure for both races. These data suggest that both intrauterine and passive tobacco exposure are associated with an increased risk of SIDS and are further inducement to encourage smoking cessation among pregnant women and families with children.
Pediatric Submersions: Prehospital Predictors of Outcome
Authors: Quan Linda , Kinder Dennis
Published: December 2021

This retrospective cohort study was conducted to test prehospital prognostic indicators in pediatric submersion victims. The authors studied all less than 20 years old victims submerged in the non-icy waters of King County, WA who were treated by Seattle or King County Emergency Medical Services between 1985 and 1989 and were hospitalized or died. Seventy-seven victims were identified from emergency medical services incident logs, hospital discharge records, and medical examiner's registries. Outcome predictors were correlated with the victim's condition at hospital discharge. Of 29 victims in cardiac arrest, 13 had return of spontaneous circulation following field resuscitation. Of these, 6 (21%) survived, with mild (n = 2) and severe (n = 4) neurologic impairment at hospital discharge. The best outcome predictors were obtained in the field. These were, for death or severe neurologic impairment, submersion durations >10 minutes (6/6) and resuscitation durations >25 minutes (17/17), and for good outcome, sinus rhythm (37/37), reactive pupils (43/43), and neurologic responsiveness (40/40) at the scene. Field-determined factors were reproducibly good outcome predictors. Aggressive emergency medical services may save the lives of pediatric victims in cardiac arrest following short submersion durations. The data support pronouncing dead in the field those pediatric victims of non-icy submersions who do not respond to advanced life support within 25 minutes.
Efficacy of Adding Nebulized Ipratropium Bromide to Nebulized Albuterol Therapy in Acute Bronchiolitis
Authors: Schuh S. , Johnson D. , Canny G. , Reisman J. , Shields M. , Kovesi T. , Kerem E. , Bentur L. , Levison H. , Jaffe D.
Published: December 2021

Nebulized ipratropium bromide is thought to be synergistic with albuterol in therapy for acute childhood asthma. Because the efficacy of ipratropium in bronchiolitis is uncertain and some infants with bronchiolitis do not respond to nebulized albuterol alone, the following study was undertaken. In this double-blind, placebo-controlled trial, 69 infants between 6 weeks and 24 months of age who exhibited the first episode of acute bronchiolitis were randomly assigned to receive either nebulized albuterol (0.15 mg/kg per dose) and ipratropium bromide (250 µg per dose) (group A, n = 36) or nebulized albuterol and normal saline (placebo) (group B, n = 33) for two doses, 1 hour apart. The two groups were comparable at baseline. Both therapies resulted in clinically significant improvement. However, the addition of ipratropium resulted in no additional benefit with respect to decrease in the respiratory rate (mean ↓ 10.6/min vs ↓ 8.6/min, P = .86), accessory muscle score (range 0 through 3) (↓ 0.92 vs ↓ 0.82, z = –0.44), wheeze score (range 0 through 3) (↓, 0.94 vs 0.85, z –0.20), oxygen saturation (↑ 0.25% vs ↑ –0.33%, P = .86), or hospitalization rate (17 vs 10). The number of "nonresponders" and "clear responders" was also very similar in both groups. No toxicity was noted. The increase in heart rate was mild and similar in both groups (↑ 6.7 vs ↑ 11.1). The power of the study to detect a difference between the two treatment groups in the respiratory rate change ≥ 8/min is greater than 90%. It is concluded that the addition of nebulized ipratropium bromide appears to offer no further clinical benefit compared with albuterol alone in moderately severe acute bronchiolitis.
School Functioning of US Children With Asthma
Authors: Fowler Mary Glenn , Davenport Marsha G. , Garg Rekha
Published: December 2021

Data from the 1988 US National Health Interview Survey on Child Health, a nationally representative cross-sectional survey, were used to determine national estimates of school outcomes (grade failure, learning disabilities, and suspension/expulsion) and mean number of absences for children with asthma (CWA) compared to well children without current health conditions. Families indicated that 536 (4.9%) of the 10 362 survey children in grades 1 through 12 had had asthma in the previous 12 months. Families reported 18% of CWA vs 15% of well children had grade failure, 9% of CWA vs 5% of well children had learning disabilities, and 5% of CWA vs 6% of well children had been expelled or suspended. Children with asthma averaged 7.6 school days absent compared with 2.5 days for the well group. Multiple logistic regression was used to compare the odds of grade failure, learning disabilities, and suspension/expulsion among CWA and well children, overall and stratified by income. Similar methods were used to assess the role of health status among asthmatic children. After adjustment for demographic factors, CWA had similar risks of grade failure and suspension/expulsion, but 1.7 times the risk of learning disability compared with well children. Also, among families with incomes below $20 000, CWA had twice the odds of grade failure compared with well children. For asthmatic children, reported health status was an important predictor of learning disability. Ten percent of CWA were reported to be in fair-poor health. After adjustment for demographic factors, those in fair-poor health were twice as likely to have a reported learning disability compared with those in good-excellent health. These national data suggest a modestly increased risk of academic problems among children with asthma compared with well children.
Detection of IgM Rheumatoid Factors by Enzyme-Linked Immunosorbent Assay in Children with Juvenile Rheumatoid Arthritis: Correlation With Articular Disease and Laboratory Abnormalities
Authors: Jarvis James N. , Pousak Tracey , Krenz Margit
Published: December 2021

This study was undertaken to determine the clinical relevance of IgM rheumatoid factors (RFs) detected by enzyme-linked immunosorbent assay (ELISA) in children with juvenile rheumatoid arthritis (JRA) by examining their association with severity of acute articular disease. ELISAs for IgM-RF were performed on serum specimens from 65 children with JRA. Activity of articular disease was estimated by an arbitrary scoring system. Significant differences were seen in articular disease activity between the group of children with polyarticular disease who were IgM-RF-positive by ELISA compared with those who were IgM-RF-negative (P = .0003). When a small group of individual children with polyarticular disease were followed longitudinally, similar correlations were found between severity of acute disease and the presence of IgM-RFs detected by ELISA. In children with pauciarticular JRA, expression of IgM-RFs appeared to be a transient phenomenon with no correlation with either articular disease or laboratory abnormalities.
Salem Comes to the National Institutes of Health: Notes From Inside the Crucible of Scientific Integrity
Authors: Needleman Herbert L.
Published: December 2021

Many readers of Pediatrics may have only a dim idea of the combative arena in which environmental research is conducted. Probably, very few have had the experience of being investigated for scientific misconduct. My aim in reviewing these two topics is to provide a preventive road map to others and to reveal some inadequacies and inequities in the investigative process. It is necessary, to accomplish this, to be direct and specific. Tact is sacrificed here for the sake of clear instruction.

In 1972 I published 700 words in Nature reporting that Philadelphia inner-city children had higher dentine lead levels than suburban children.1 The paper suggested that the tooth might be a useful marker to estimate body lead burden after exposure had ended. I did not know then that I was taking the first step toward being investigated for scientific misconduct by my university and the National Institutes of Health (NIH) Office of Scientific Integrity.

The Environmental Protection Agency (EPA) asked me to present the 1972 tooth lead paper in Amsterdam at an international meeting on lead. I was unprepared by my past attendance at pediatric meetings for what I encountered there. This was no scholarly debate on the toxicology and epidemiology of lead; this was war. The speakers did not behave like academics hoping to embellish their reputations by parading the results of their last 6 months in the lab. These stakes were much higher.

Arrayed against each other were a small and defensive group of environmentalists and health scientists on one side, and on the other the representatives of the gasoline companies, including such formidable entities as EI DuPont, Associated Octel, Dutch Shell, and Ethyl Corporation of America.
Effects of Antiepileptic Drugs on Reaction Time, Attention, and Impulsivity in Children
Authors: Mitchell Wendy G. , Zhou Yi , Chavez John M. , Guzman Bianca L.
Published: December 2021

Simple, choice, and complex reaction times, attention (variability of responses and omission errors), and impulsivity (commission and wrong-hand errors on choice and complex reaction time) were repeatedly measured in 111 epileptic children, aged 5 to 13 years, tested a total of 232 times. Antiepileptic drugs (AEDs) were started, stopped, and adjusted throughout the study period, for a variety of clinical indications, and AED serum levels were monitored. The relationship of performance to AED serum level was examined. Overall the nonspecific effect of AEDs was minimal: higher total serum levels of AEDs correlated with more impulsive errors on complex reaction time testing only. In contrast, in 54 children receiving carbamazepine monotherapy, we found a dose-related beneficial effect upon reaction time, with higher serum levels associated with faster responses and fewer omission errors, particularly on complex reaction time. Phenobarbital caused minimal dose-related effects: only variability and impulsive errors increased with increasing serum levels, and only on one segment of the test (73 subjects).
Mythology of Lead Poisoning
Authors: BANNER WILLIAM , VUIGNIER BARBARA I. , PAPPAS JANNETTE B.
Published: December 2021

To the Editor.—

The commentary offered by Needleman and Jackson1 has raised some interesting points for discussion regarding the mythology surrounding the issue of lead poisoning and its treatment. Whereas the opening statement of the authors suggests that standards of practice are falling behind the scientific understanding of lead, the article under discussion by Glotzer and Bauchner makes it clear that both the science and standards of practice are very much lacking in the area of treatment for low level lead exposure.
SSI Benefits and Functional Assessment
Authors: BHUSHAN V.
Published: December 2021

To the Editor.—

Perrin and Stein1 have done a commendable job of informing the pediatric community about the recent changes in the adjudication of Supplemental Security Income (SSI) claims for children. The process of assessing disability in children has been streamlined further since the publication of this article. It now involves sequential analysis of medical impairments followed by analysis of functional limitations in five domains of development: cogntive, communicative, motor, personal-social, and behavioral. The later is called individual functional assessment (IFA), and involves comparing a child's function in various domains with an average child of that age.
Aural, Oral, or Rectal—Does It Make Any Real Difference?
Authors: ROSCELLI JOHN D.
Published: December 2021

To the Editor.—

I read with interest, the recent article by Freed et al1 in a recent issue of Pediatrics. This article was another in a seemingly endless series of articles which ask the interesting, but probably clinically irrelevant, question of whether there is a good correlation between aural temperatures and temperatures measured at other body sites, ie, rectal, oral, or axillary.2-8

The whole point of trying to determine if a patient has "an abnormal temperature," ie, fever (however that is defined), is that this fever hopefully would be a clue to the existence of some pathological process which is affecting the patient's thermoregulatory process.
New Recommendations Not Very Different from Current Practice
Authors: ALLEN RICHARD J.
Published: December 2021

To the Editor.—

In the "Evaluation and Treatment of Jaundice in the Term Newborn: A Kinder, Gentler Approach," Newman and Maisels1 focus on "unnecessary testing and treatment of many jaundiced term infants."1,p809 Although "routine screening with a more specific test" was suggested for galactosemia, none was mentioned in any of the five tables. In the follow-up commentaries only one other author mentioned galactosemia in the differential diagnosis of neonatal jaundice.2 After reading these several interesting papers it is still unclear to me whether reducing the frequency of tests for neonatal jaundice or excluding individual specific tests (ie, direct bilirubin) will benefit cost-effective analysis or be "a kinder, gentler approach" for babies.
Immunization of Preterm Infants
Authors: PETER GEORGES
Published: December 2021

To the Editor.—

In their paper published in the January 1992 Pediatrics, Langkamp and Langhough1 present their findings on the assessment of the knowledge of primary care providers about diphtheria-tetanus-pertussis (DTP) immunization recommendations for preterm infants. Their findings indicate the need for more explicit recommendations, specifically that birth weight is not a criterion for administration of DTP. In the 1991 edition of the Red Book, however (which was published after their manuscript was accepted), the recommendation on immunization of preterm infants was revised from the 1988 edition to include birth weight and is as follows: "Prematurely born infants should be immunized at the usual chronological age even if the infant was very small at birth" (indicates the change).
Overtreatment of Neonates
Authors: GARTNER LAWRENCE M.
Published: December 2021

To the Editor.—

Dr William Silverman's insightful commentary "Overtreatment of Neonates? A Personal Retrospective"1 correctly reminds us of how easily we slip into dangerous waters and find ourselves drowning either alone or with our colleagues, often without even realizing it. Dr Silverman raises many valid and extremely important questions about the "life at any cost" policy which has dominated neonatal intensive care for many years. He challenges us to "determine the extent to which an arbitrary, as opposed to a discretionary rescue policy is sensitive to a complex balance of interests" represented by the neonate, the family, and the community.
Deliberate Misrepresentations
Authors: ERNHART CLAIRE
Published: December 2021

Dr Herbert Needleman1 made numerous incorrect or misleading statements about his misconduct investigation, about my role in his misconduct hearing, and about research support by industry.

Misconduct. Dr Needleman stated that his Hearing Board "found no evidence of scientific misconduct." He did not go on to say that the Board found that he had engaged in deliberate misrepresentation, nor has he made the report public. The admission of the finding of misrepresentation is now publicly available because he made it in an amendment to his lawsuit against National Institutes of Health (NIH), his University, and officials thereof.2
Impact of Day Care on Parents and Family
Authors: Pawl Jeree H.
Published: December 2021

In addressing the impact of day care on parents and families, including the children who are in day care, one must first acknowledge the wide heterogeneity of the families who use day care. They include single parents who need to work to support themselves; single parents who are engaged in work-preparation programs in an effort to end their reliance on Aid to Families With Dependent Children (AFDC); single parents receiving AFDC who do not work and who, for various reasons, may have little hope of working, but where it is agreed that they need day care as respite or structure or as an educational or socioaffective experience for the child (a common but often vain intervention, given the quality of care such children are likely to receive); two-parent families who could not afford the most basic expenses without two incomes; two-parent families who could not afford the things they need and want without two incomes; two-parent families where both parents find great pleasure in working; two-parent families where neither really wants to be at home; two-parent families whose careers would suffer grievously if disrupted; and two-parent families where only one parent works but where the parents still choose to have their child in day care. There are certainly many more scenarios, but the point is that one must be careful when talking about the impact of day care because its quality, the reasons for which it is used, and by whom are key factors in determining what the impacts are.
Impact of Day Care on the Child
Authors: Caldwell Bettye M.
Published: December 2021

In the world of day-care research, the status of our knowledge is sufficiently shaky that we must continue to keep an open mind about the service. The knowledge base is growing rapidly, but the conceptual structure that supports it is flimsy and insubstantial. Fortunately, current research efforts are improving this situation.

Regardless of whether we like or dislike day care, it is, like the family, here to stay. That realization alone should strengthen our resolve not to compromise on the type of service we create. We have to continue to identify parameters of quality and become good matchmakers in terms of child care, family, and child characteristics. Through such efforts, a network of educare programs that will foster favorable development in children can become a national and global reality.
Care of the Ill Child in Day-Care Settings
Authors: Giebink G. Scott
Published: December 2021

Children experience many minor illnesses during the toddler and preschool years, and illness frequency is compounded by attendance in out-of-home child care programs. Although most of these illnesses are uncomplicated, some lead to complications that require medical evaluation and treatment. A majority of working parents of childbearing age have children in day care, and these illnesses have an impact on both the child's health and the parents' attendance at work. As a result, in-home and out-of-home sick-child care programs have emerged.

The common infectious diseases of children in child day care are also common among children not in out-of-home care. They can be identified as those primarily affecting the respiratory system, gastrointestinal system, and skin and those that may affect multiple organs. Respiratory infections predominate, followed by vomiting and diarrheal illnesses. Wald et al1 followed a cohort of children through the first 3 years of life; 97 received exclusive care at home, 23 received care in a group setting out of the home, and 33 attended day-care centers. During the first year of care, children in center care experienced significantly more infections than children in home care. Children in group care and center care were significantly more likely than children in home care to experience six or more infections and four or more severe illnesses. The majority (76% to 89%) of infections were respiratory, and otitis media complicated 28% to 44% of these respiratory infections.2 Children in nonparental home care experienced an average of 41 days of illness during the year; the average increased to 78 days in group care, and 96 days in center care.
Day-Care Standards: Need and Impact
Authors: Bredekamp Sue
Published: December 2021

Any discussion of standards, no matter how brief, must first acknowledge that there are different types of standards established for different purposes. As the director of the national voluntary accreditation system for child care centers and schools established by the National Association for the Education of Young Children (NAEYC), I am most familiar with the need and impact of accreditation standards, which are, by definition, standards for distinguishing high-quality programs established by a professional organization. In any case the implementation of a national accreditation system is heavily influenced by local and state licensing standards, which are mandatory government regulations that establish a baseline of protection. Accreditation and licensing standards are both influenced by model standards such as the health and safety standards of the American Academy of Pediatrics and the American Public Health Association.1 These standards establish a model, based on the best professional evidence, that serves as a reference for the other two systems but does not carry an enforcement system of its own.

This paper will discuss the need for and impact of all three types of standards from the point of view of my experience in operating NAEYC's accreditation system.2 Because our accreditation process is nationally administered, we have the opportunity to observe the impact of diverse licensing standards on quality. In order to maintain accessibility we have relatively few eligibility requirements, and because we do not require 100% compliance with our criteria, we also have the opportunity to observe the interrelationships among standards and other effects.

One caveat must be offered at the outset.
Adolescent Abortion: Views of the Membership of the American Academy of Pediatrics
Authors: Fleming Gretchen V. , O'Connor Karen G.
Published: December 2021

To identify the positions held by the American Academy of Pediatrics (AAP) membership on a number of issues that may be topics of legislation regarding abortion, the AAP carried out a survey based on a random sample of 1000 active US members. A total of 785 usable questionnaires were returned. The majority of members surveyed (56.7%) favored access to abortion for adolescents for all the reasons identified in the questionnaire; 35.4% believed abortion should clearly be restricted in some circumstances, and 7.0% believed adolescents should not have access to abortion under any circumstances. For each individual reason for abortion, at least 60% of the membership believed adolescents should have access to abortion services. In addition, most pediatricians supported legal positions that would facilitate access to abortion services for adolescents. Urban, female, and non—self-employed pediatricians were slightly more likely to support access to abortion by adolescents than comparison groups. Discussion focuses on the extent to which pediatricians' views reflect medical concerns, the extent to which their views are reflected in the current laws, and implications for practice and for AAP policy.
Pediatric Emergency Medicine: State of the Art
Authors: Isaacman Daniel J. , Davis Holly W.
Published: December 2021

To assess the current practice of pediatric emergency care in the United States, a questionnaire was mailed to the directors of all 240 emergency departments (EDs) affiliated with pediatric residency training programs in the United States. One hundred seventy-two programs (72%) returned completed surveys, which comprised 32 questions highlighting staffing patterns, ancillary services, clinical issues, and resident education. The mean annual ED census was 39 290; the mean number of visits for children 0 to 18 years of age was 17 473. Seven percent of pediatric visits were categorized as critical, 23% as urgent, and 70% as nonurgent. Eleven percent of patients were admitted to the hospital. During peak periods, patients whose visits were triaged as nonurgent waited an average of 1.5 hours to be seen by a physician. Twenty-eight percent of programs provided 24-hour onsite coverage by a pediatric attending physician or fellow. Of the remaining programs, the average daily on-site pediatric coverage was 8.6 ± 6.2 hours. Eighteen percent of programs used physician assistants or nurse practitioners in the ED. During their first, second, and third years of training, pediatric residents spent an average of 5.2, 5.8, and 3.5 weeks in the ED, respectively. The majority of EDs handled all levels of pediatric trauma (84%), had dedicated trauma teams (73%), employed social workers specifically assigned to the ED (62%), and had child abuse teams (72%). Ninety-one percent of EDs had radio communications with prehospital care vehicles and 67% provided medical command for incoming pediatric patients. Fifty-four percent of programs had a mechanism for ensuring telephone follow-up of worrisome patients, and 69% used a system for ensuring feedback to the referring physician. Ninety-five percent of programs had a system in place for contacting patients with positive cultures; in most cases this function was handled by physicians. Seventy-five percent of programs provided medical advice by telephone. These data highlight current practice patterns in EDs associated with pediatric training programs and may assist in the development of practice standards for pediatric emergency care.
From the Bedside to the Public Policy Arena: The Role of General Pediatric Research
Authors: Rivara Frederick P.
Published: December 2021

The Ambulatory Pediatric Association is an organization dedicated to improving teaching, patient care, and research in general pediatrics. This paper addresses the task of conducting successful research in general pediatrics, often a challenging task for fellows and junior faculty beginning their careers. However, I believe general academic pediatrics has almost a unique opportunity to translate what is seen at the bedside into a research question and from there to try to use the results to affect the health of children. There are three steps in this process: finding a good idea, conducting rigorous research, and doing something with the results.

PATIENT CARE AS A SOURCE OF RESEARCH IDEAS

How does one come up with the "right" research idea? Fellows and graduate students find this a difficult process. I believe the best way to select a research topic is from one's patient care experience. By listening to and learning from our patients, the most important research questions become obvious. Nearly all of us started our careers as pediatricians and most of us remain practicing physicians. This means seeing patients each week, listening to the concerns of their parents, dealing with the thorny issues that arise, and scratching our heads about the unknowns and the uncertainties we face as clinicians. From this constant experience, we learn what is important. We learn which are the problems most in need of prevention, which problems need further study of their etiology and which problems are the most vexing to manage because of our inadequate knowledge.
School-Based Crisis Intervention Services for Adolescents: Position Paper of the Committees on Adolescence and School Health, Connecticut Chapter of the American Academy of Pediatrics
Authors: SCHONFELD DAVID J.
Published: December 2021

The Connecticut State Chapter of the American Academy of Pediatrics, through its Committees on Adolescence and School Health, acknowledges that the need to respond effectively to crises involving adolescents within a school setting is confronting pediatricians and school systems with increasing frequency; although this paper will focus on the needs of adolescents, crises affect younger children as well. Concerted efforts between pediatricians and school personnel may serve as a first step in addressing this problem; this position paper is intended to stimulate both interest and action in this regard.

Schools provide a constant environment that can contribute positively to adolescents' psychological development.
Developmentally Disabled Children Recycle Car Seats: A Win-Win Program
Authors: BERGER LAWRENCE R. , BENALLY LORRAINE M. , ROBSON WILLIAM , OLSON LENORA M.
Published: December 2021

Injuries are the leading cause of death for Native Americans from age 1 to 44 years, accounting for 63% of all deaths in that age range.1 Motor vehicles are responsible for 55% of all Native American injury deaths.2 Among Native American children 1 to 14 years of age, the death rate from motor-vehicle occupant injuries (6.9/100 000 per year) is more than double that of white children in the United States (3.3/100 000 per year).3

To help reduce this toll, both the Indian Health Service (IHS) and individual tribes have initiated car seat loaner programs. Because of widespread poverty—the unemployment rate is as high as 80% in some Native American communities—no fees or deposits are collected in many of these programs.
Group Health Supervision Visits More Effective Than Individual Visits in Delivering Health Care Information
Authors: DODDS MARGARET , NICHOLSON LAURA , MUSE BRETT , OSBORN LUCY M.
Published: December 2021

Preventive health care consumes a substantial amount of pediatricians' time and has been promoted as one of the most important medical functions physicians perform.1-4 The American Academy of Pediatrics (AAP) has emphasized the need for preventive health care. To assist in the delivery of child health supervision, the AAP Committee on Psychosocial Aspects of Child and Family Health has recently published guidelines recommending specific topics to be covered at each of the routine health maintenance visits.5

Despite the acceptance of recommendations for preventive child health care, the efficacy of office-based prevention strategies has not yet been proven.6 However, assessment of the literature addressing the effectiveness and costs of strategies for promoting and maintaining child health has been noted to be "more remarkable for its limitations than its findings."6
Child Life Programs
Authors:   Committee on Hospital Care
Published: December 2021

Child life programs have become the standard in pediatric settings to address the psychosocial concerns that accompany hospitalization and medical care. Child life specialists facilitate coping and the adjustment of children and families by providing play experiences, presenting information about events and procedures, and establishing supportive relationships with children and parents to encourage family involvement in each child's medical care.

These activities are shared by other members of the health care team. The role of the child life specialist, however, is unique because it combines each of these services as the primary duty. The child life specialist focuses on the strengths and health of children.1 Most major hospitals for children have child life programs, and the number of these has doubled since 1965.

The patient-to-staff ratio should not exceed 15 patients to 1 child life specialist. Child life or similar services should be offered by all hospitals. Most child life specialists work in inpatient settings, but they are increasingly serving outpatient populations. Certification of child life specialists is available through the Child Life Certifying Commission, which was established in 1986.

PLAY

Play is the core of the child life program. Play activities are offered both in group settings and individual sessions. Play opportunities in health care settings communicate a respect for and understanding of children. Play helps eliminate the distinction between the comfortable and familiar setting outside the hospital and the foreign and intimidating hospital environment.

Play contributes to the child's adjustment in several important ways. By providing age-appropriate activities, the possibility that hospitalization may disrupt normal development is minimized.
Saving Young Arms and Batters' Heads
Authors: DORSEY J. KEVIN , BENTON RON
Published: December 2021

To the Editor.—

The local baseball commission of the boys' 8- to 10-year-old league recently implemented several changes in an attempt to increase safety and improve instruction. One of these was the use of a pitching machine for the first three innings of every six-inning game. A neutral adult served as a "pitching coach" for both teams and adjusted the height of the pitched ball to correspond to the strike zone of the batter. Pitch speed was regulated to approximate the speed of a ball thrown by an average to good pitcher in that age group.
Reactions of Pediatricians to a New Centers for Disease Control Recommendation for Universal Immunization of Infants With Hepatitis B Vaccine
Authors: Freed Gary L. , Bordley W. Clayton , Clark Sarah J. , Konrad Thomas R.
Published: December 2021

Despite immunization programs targeting high-risk groups, the incidence of hepatitis B has risen 37% over the last decade with 300000 new infections and 5000 related deaths now occurring annually in the United States. As a new strategy to control the spread of hepatitis B, the Advisory Committee on Immunization Practices of the Centers for Disease Control (CDC) recommended in November 1991 universal hepatitis B immunization of infants. Details were published in an addendum to Morbidity and Mortality Weekly Report. There was no other federal effort to disseminate this recommendation. On February 14, 1992, the American Academy of Pediatrics (AAP) issued a similar recommendation. The time between the CDC and AAP recommendations presented the opportunity to determine the singular effect on clinical practice of the CDC's dissemination effort. The purpose of this study was to assess (1) the effectiveness of the CDC in disseminating a new immunization recommendation, (2) the effect of the new recommendation on clinical practice, and (3) the degree to which noneconomic barriers may affect adoption of universal hepatitis B immunization. All 778 pediatricians in North Carolina were surveyed by mail 2 to 3 months after publication of the new CDC recommendation. Descriptive statistics, χ2 analysis, and logistic regression were used to assess the relationship of variables hypothesized to predict physician awareness of and/or agreement with the new recommendation. The response rate was 78%. Although 82% of pediatricians who administer immunizations were aware of the new recommendation, only 32% believed it was warranted in their practices. Twenty-six percent of respondents expect more than half of parents to refuse three injections at a single well-child visit, a possible result of adding this vaccine to the primary immunization series. Additionally, 29% expect nurses to resist giving three injections at one visit. It is concluded that current CDC efforts are insufficient to effect change in clinical practice. Practical concerns of physicians and their patients regarding multiple injections and other issues must be considered when formulating new immunization recommendations if their implementation is to be successful.
Human Immunodeficiency Virus-Infected Adolescents: The First 50 Patients in a New York City Program
Authors: Futterman Donna , Hein Karen , Reuben Nancy , Dell Ralph , Shaffer Nathan
Published: December 2021

To address the unique manifestations of human immunodeficiency virus (HIV) among adolescents aged 13 through 21 years, a comprehensive evaluation and treatment program for high-risk and HIV-positive adolescents was developed in New York City in 1987. Among HIV-infected youth, mean age of testing was 18.2 years. One third of the HIV-positive patients were female and four fifths were African-American or Hispanic. No significant differences were found between HIV-positive (n = 50) and HIV-negative (n = 43) patients for age at first intercourse, injecting or other illicit drug use, history of sexually transmitted diseases, or survival sex (exchange of sex for money or drugs). HIV-positive males were more likely than HIV-negative males to have engaged in anal intercourse and to report a history of sexual abuse. Among infected females, 82% acquired HIV through heterosexual intercourse. Almost half (48%) of HIV-positive adolescents had significant immune dysfunction at the time of their initial visit (CD4 <500/mm3) and were eligible for zidovudine. Many HIV-positive adolescents continued high-risk behaviors such as intercourse without condoms, particularly those with ongoing dependence on drugs or alcohol. With the epidemic of HIV infection increasing nationwide among adolescents, specialized, comprehensive programs are needed to counsel and treat HIV-infected adolescents and youth in high-risk situations.