bluuebunny/crossref_metadata_2025 huggingface dataset:
Spectrum and Frequency of Pediatric Illness Presenting to a General Community Hospital Emergency Department
Authors: Nelson Douglas S. , Walsh Kevin , Fleisher Gary R.
Published: December 2021

Knowledge of the range of pediatric illness presenting to a general emergency department (ED) is needed to optimize the quality of care delivered there. It was hypothesized that the pediatric population treated at a general ED exhibited a broad range of medical complaints, while differing significantly from children seen in a pediatric ED. General ED records from 1 week each season were reviewed, and patient age, chief complaint, diagnosis, time of arrival, season, and disposition were recorded. Data on 874 patients were analyzed and compared with pediatric ED data. General ED patient age affected chief complaint, diagnosis, and admission rate (9.5% ≤1 year admitted vs 2.6% >1 year, P < .001). General ED patients were older (7.9 vs 6.0 years, P < .001) and admitted less frequently (3.8% vs 11%, P 001). Admission rates varied by arrival time only at the general ED, where minor trauma was more common (41% vs 22%, P < .001). It is concluded that a wide range of pediatric illness is treated in a general ED, supporting the decision to have pediatric emergency physicians on staff, and that significant differences exist in the spectrum and frequency of pediatric illness seen in a general ED and pediatric ED.
Are Poor Families Satisfied With the Medical Care Their Children Receive?
Authors: Wood David L. , Corey Chris , Freeman Howard E. , Shapiro Martin F.
Published: December 2021

While access to care has been shown to be worse for poor populations, few studies have examined the quality of care received by the poor vs the nonpoor. Furthermore, serious concerns have been raised about the impact of cost-containment efforts on the quality of health care for both the poor and nonpoor. The authors examine the interpersonal quality of medical care received by children from poor and nonpoor families by assessing parental satisfaction with physician-patient communication in a telephone survey of a nationally representative sample of households containing 2182 children and adolescents 17 years or younger. The majority of parents were satisfied with many aspects of their interactions with physicians. However, poor families were more likely to be not completely satisfied with the medical care their children received at their last health visit than nonpoor families (27% vs 12%, P < .001). With regard to specific aspects of the physician-patient communication, poor families were more likely to be not satisfied with the physician's provision of information about the illness (40% vs 21%, P > .001); the physician's discussion of examination findings (21% vs 9%, P < .001); and the opportunity provided by the physician to express their concerns (12% vs 6%, P < .001). Logistic regression demonstrated that poor patients were approximately twice as likely to be not satisfied with the medical encounter and with various aspects of their communication with the physician. It is concluded that the parents of poor children are less satisfied with their care. Both policy and educational interventions may be needed to address this problem.
Neuroendocrine Effects of Toxic and Low Blood Lead Levels in Children
Authors: Huseman Carol A. , Varma Madan M. , Angle Carol R.
Published: December 2021

From 3 million to 4 million children In America have lead poisoning. This environmental toxin affects 1 in every 6 children younger than 6 years of age in the United States. The marked effects of lead toxicity on the central nervous system are well known, ie, lowering IQ and impairing memory, reaction time, and the ability to concentrate. Children are at greatest risk for the central nervous system effects of lead because the central nervous system is at its peak in development during the first few years of life. The negative correlation of stature and blood lead level (bPb) found in the National Health and Nutrition Examination Survey directed the authors to evaluate the possible neuroendocrine effects of this toxin in children. Twelve children were studied during toxic(≥40 µg/dL) and low bPb (<40 µg/dL). Classic provocative stimuli, l-dopa (15 mg/kg by mouth) and insulin (0.1 U/kg given intravenously), were used to determine human growth hormone (hGH) responses during toxic bPb and after chelation therapy in six of the subjects. An additional four subjects were studied during low bPb. In two patients LGH levels were determined every 20 minutes for 24 hours during toxic bPb. Thyroid-stimulating hormone and prolactin responses to thyrotropin-releasing hormone were also determined. All children studied showed growth retardation during toxic bPb. Mean peak hGH responses to provocative stimuli were lower during toxic bPb, but the responses were all within normal limits. The mean 24-hour hGH values were low in the two patients (0.8 ± 0.2 [SE] ng/mL and 2.0 ± 0.8 ng/mL) studied compared with normal control patients (6.4 ± 0.3 ng/mL). Insulin-like growth factor I values showed an inverse correlation with toxic blood bPb, up to 40 µg/dL. Basal thyroid-stimulating hormone, prolactin, thyroxine, and triiodothyronine concentrations were not affected by bPb. In addition, thyrold-stimulating hormone and prolactin responses to thyrotropin-releasing hormone were not affected by toxic or low bPb. Cortisol responses to insulin-induced hypoglycemia were normal (P ≤ .05). These observations, taken together, confirm the inadequacy of acute hGH responses to secretagogue as a reliable indicator of hGH secretion and indicate that lead-induced short stature may be due to diminished hGH secretion, which in turn results in reduced insulin-like growth factor I secretion, or that Pb may also directly inhibit insulin-like growth factor I formation.
Palliative Treatment of Hyperinsulinism With Cyproheptadine and Diazoxide
Authors: Rotenstein Deborah , Serbin Scott , Welsh Terra
Published: December 2021

Treatment for hyperinsulinism in infants and children can be difficult and has included numerous treatment modalities. This paper reports 16 months of palliative treatment with cyproheptadine and diazoxide in a child with hyperinsulinism initially diagnosed at 6 months of age (her insulin level was 80 µU/mL while her glucose level was 38 mg/dL). She continued to have episodes of staring and alteration in level of consciousness while receiving her usual doses of diazoxide (12 mg/kg) alone. Mean nocturnal glucose values, which were quite low during treatment with diazoxide alone, improved significantly with the addition of cyproheptadine to her therapeutic regimen. Fasted C-peptide values, elevated during diazoxide alone, returned to the normal range with combination treatment for 16 months. Cyproheptadine and diazoxide in combination may be useful for treatment of hyperinsulinism that presents after the neonatal period.
Passive Smoking and Middle Ear Effusion Among Children in Day Care
Authors: Etzel Ruth A. , Pattishall Edward N. , Haley Nancy J. , Fletcher Robert H. , Henderson Frederick W.
Published: December 2021

One hundred thirty-two children who attended a research day-care center were studied to determine whether passive tobacco smoke exposure was associated with an increased rate of otitis media with effusion or with an increased number of days with otitis media with effusion during the first 3 years of life. Based on preliminary studies, a serum cotinine concentration of ≥2.5 ng/mL was considered indicative of exposure to tobacco smoke. Otitis media with effusion was diagnosed using pneumatic otoscopy by nurse practitioners and pediatricians who reviewed the children's health status each weekday. The 87 children with serum cotinine concentrations ≥2.5 ng/mL had a 38% higher rate of new episodes of otitis media with effusion during the first 3 years of life than the 45 children with lower or undetectable serum cotinine concentrations (incidence density ratio = 1.38, 95% confidence interval 1.21 to 1.56). The average duration of an episode of otitis media with effusion was 28 days in the children with elevated cotinine concentrations and 19 days in the children with lower cotinine concentrations (P < .01). It is estimated that 8% of the cases of otitis media with effusion in this population and 17.6% of the days with otitis media with effusion may be attributable to exposure to tobacco smoke.
Effect of Discharge Samples on Duration of Breast-Feeding
Authors: Dungy Claibourne I. , Christensen-Szalanski Jay , Losch Mary , Russell Daniel
Published: December 2021

The breast-feeding patterns of 146 women who initiated breast-feeding during their hospital stay were evaluated to determine whether those women who received a hospital discharge package containing a manual breast pump breast-fed their infants for a longer period of time than did women who received a discharge package containing an infant formula. Women were randomly assigned to receive either a specially prepared pack containing a manual breast pump but no infant formula or a commercially available infant formula package. The women were interviewed in the hospital and by computer-assisted telephone interviews at 2, 4, 6, and 8 weeks postdischarge. Information obtained included infant-feeding practices, sociodemographic characteristics, and attitudinal data. Follow-up interviews were completed for nearly 85% of eligible women at each time period. Women who received a discharge pack containing a breast pump but no infant formula continued exclusive breast-feeding for a greater number of weeks (mean = 4.18 weeks) than did women receiving infant formula in their discharge package (mean = 2.78 weeks) (P < .05). Also, women who indicated that ease of nighttime feeding was an important consideration were more likely to breast-feed over the entire 8-week period if they received the breast pump rather than infant formula (P < .05). The conclusion is that an easily implemented, low-cost intervention, the inclusion of a breast pump in discharge packages, may increase the duration of breast-feeding.
Maternal Employment and the Quality of Young Children's Diets: Empirical Evidence Based on the 1987-1988 Nationwide Food Consumption Survey
Authors: Johnson Rachel K. , Smiciklas-Wright Helen , Crouter Ann C. , Willits Fern K.
Published: December 2021

Data from 442 children, aged 2 to 5, who were participants in the 1987-1988 Nationwide Food Consumption Survey, were examined to determine the effect of maternal employment on the quality of their diets. Diet quality was assessed by examining nutrient adequacy and nutrient overconsumption using the 3-day average of one 24-hour recall and 2 days of written diet records. To assess dietary adequacy, a mean adequacy ratio of the four nutrients (zinc, vitamin E, iron, and calcium) for which 30% or more of the children fell below 77% of the Recommended Dietary Allowances was constructed. Percent calories from fat and saturated fat, and intake of cholesterol and sodium were examined to assess overconsumption. Multiple correlation regression analysis was used to control for household income, maternal education and age, child's age, race, number of siblings aged 5 or younger, presence of male head of household, and number of meals eaten away from home. Maternal employment did not contribute significantly to the variation in any of the dietary variables. Although a number of dietary problems existed among the sample children, the variation in intakes of these nutrients was not directly related to maternal employment status.
Pediatric Dermatology Update
Authors: Krowchuk Daniel P. , Tunnessen Walter W. , Hurwitz Sidney
Published: December 2021

The Society for Pediatric Dermatology conducted its 15th Annual Meeting in San Diego, CA, August 8 to 11, 1990, and the Section on Dermatology of the American Academy of Pediatrics met during the Academy's Annual Fall Meeting in Boston, MA, October 7, 1990. Topics presented at these meetings that are of interest to pediatricians are presented in summary form below.

MEETING OF THE SOCIETY FOR PEDIATRIC DERMATOLOGY

Advances in the Treatment of Infestations

Head lice and scabies are common infestations affecting infants and children. Until recently, the preferred treatment for these conditions was the application of 1% lindane (Kwell) to the scalp in cases of pediculosis capitis, and to the body in cases of scabies. However, questions about lindane's safety and efficacy have been raised. First, neurotoxicity may occur as the result of systemic absorption of lindane during the treatment of scabies, though such adverse reactions have been reported only rarely and, in nearly all instances, were associated with excessive use of the product.1 Second, recent reports of lindanetolerant infestations have questioned the product's efficacy. As a result, considerable effort has been devoted to the development of newer treatments that offer enhanced safety and efficacy.

David Taplin, Professor of Dermatology and Cutaneous Surgery, Epidemiology and Public Health of the University of Miami School of Medicine, reviewed cutaneous infestations in children and emphasized the therapeutic advantages offered by permethrin. Permethrin is a synthetic pyrethroid, an agent related to pyrethrins, naturally occurring insecticides found in flowers of the genus Chrysanthemum.2 In the United States, two new permethrin formulations are being marketed, Nix Creme Rinse (1 % permethrin) for use in treatment of head lice and Elimite cream (5% permethrin) for use in scabies.
Medical Education in Transition: The Report of The Robert Wood Johnson Commission on Medical Education: The Sciences of Medical Practice
Authors: HAGGERTY ROBERT J. , BURG FREDRIC D.
Published: December 2021

Since the beginning of the 1980s, criticism of medical education in the United States has increased. At the same time, while biomedical science has undergone a revolution, medical education has been all too often mired in the same post-Flexnerian mode. Even today, basic sciences are often taught with no connection to clinical practice and with little connection among the basic sciences. Social and behavioral sciences, and the newer disciplines of clinical epidemiology and information sciences, may not be taught at all or only in a token manner. Criticism of the current curriculum has been increasing, and at least 11 national commissions in the past 40 years have made observations like "Medical education has kept only fitful pace with changes in biomedical science and health care needs."1
Serum Enzyme Monitoring in Asthma Patients
Authors: COLAN STEVEN D. , MAGUIRE JAMES F.
Published: December 2021

In Reply.—

Dr Choi has raised the very important issue of interpretation of electrocardiographic and serum enzyme changes. We agree entirely that these findings are not definitive, that is, diagnostic of ischemia. As we carefully stated, they are "consistent with" myocardial ischemia. Interpretation of these results, as with virtually any laboratory result, depends on the clinical setting and the probability of the various possibilities. As noted, elevation of creatine kinase (CK) activity can occur in a number of situations including vigorous exercise.
Physicians' Interactions with Pharmaceutical Companies
Authors: MARGOLIS LEWIS H.
Published: December 2021

In Reply.—

In my essay1 I suggested that the acceptance of gifts from pharmaceutical companies violates a duty of justice because gifts represent resources inappropriately taken from patients through the added costs of the drugs that they buy. Dr Procopio raises the larger question of how other types of promotional activities increase the cost of drugs in particular and medical care in general. His letter makes clear, however, that the contribution of an activity such as the distribution of samples to the cost of care is difficult to determine because several different purposes are served.
Recognizing the Identifiers of Child Abuse as a Syndrome
Authors: SILVERMAN FREDERIC N.
Published: December 2021

In Reply.—

The letter of Drs Renzuilli and Cardi is appropriate to call attention to two of their compatriots who published an excellent report on the subject of child abuse at the time the landmark paper "The Battered Child" appeared 30 years ago,1 but whose publication apparently has not been recognized in current bibliographies on the subject. Their letter also explains why this oversight occurred as the journal in which it was published was a nonindexed one.
Chest Pain in Otherwise Healthy Children and Adolescents Is Frequently Caused by Exercise-Induced Asthma
Authors: Wiens Lynn , Portnoy Jay , Sabath Richard , Ewing Lesley , Gowdamarajan R. , Scagliotti Daniel
Published: December 2021

Chest pain in children and adolescents, unlike in adults, is rarely of cardiac origin and its etiology is frequently unknown. In this age group, chest pain can limit normal activity and sports participation. The reported incidence of exercise-induced asthma in children with chest pain is less than 20%. For this study, 88 otherwise healthy children and adolescents with chest pain followed a treadmill protocol without a warm-up period designed to obtain a target heart rate of 180 or greater during the first several minutes of exercise. Patients maintained this workload for 6 to 8 minutes. Pulmonary function tests performed prior to exercise and at 2, 5, 10, 15, 20, and 25 minutes revealed a decrease in forced expiratory volume in 1 second or peak expiratory flow rate of ≥15% in 64 (72.7%) children. Inhaled albuterol resulted in subjective improvement in 97% (35/36) and objective improvement in 70% (25/36) of patients. In otherwise healthy children and adolescents with chest pain, the incidence of exercise-induced asthma seems greater than previously reported. Treatment with chodilators may help these patients lead a more active life-style.
Iron Status in Exclusively Breast-Fed Infants
Authors: Calvo Elvira B. , Galindo Ana C. , Aspres Norma B.
Published: December 2021

The aim of this study is to evaluate the iron nutritional status of infants breast-fed exclusively and for a prolonged period in relation to their growth rate and dietary changes. Forty subjects (25 breast-fed; 15 formula-fed) were studied from 0 to 9 months of age. Milk (human or formula) was the only source of food during the first 6 months. From the sixth month onward mothers were instructed to use iron- and ascorbic acid-rich foods to supplement breast-feeding. At the ninth month, prevalence of anemia was 27.8% in the breast-fed group and 7.1% in the formula-fed group. Storage iron was absent in 27.8% of the breast-fed infants vs none of the formula-fed infants. These findings reinforce the recommendation that breast-fed infants be given supplemental iron from the fourth month of life.
Brush-Culture Method for Diagnosing Tinea Capitis
Authors: Hubbard Thomas W. , de Triquet John M.
Published: December 2021

Using traditional methods to verify the existence of a fungal infection in children with suspected tinea capitis is a cumbersome process. Scraping scale and pulling hairs for culture or microscopic examination can be time-consuming and uncomfortable for the child. This study is the first comparison of this method with an alternate brush-culture method for diagnosing tinea capitis. In 70 children with symptoms suggestive of tinea capitis, there was strong agreement between methods in detecting disease or lack thereof (McNemar's test, P < .2). In the 51 paired positive cultures, those obtained by brush culture turned positive significantly faster (t test, P < .01) than samples obtained by the traditional method. The brush method is a reliable, painless, and more expedient way to obtain cultures from children with suspected tinea capitis.
Meconium and Tracheal Aspiration
Authors: WISWELL THOMAS E.
Published: December 2021

In Reply.—

Doctors Bull et al, Denk, and Reynolds all bring out an important aspect of our investigation...meconium-stained newborns whose tracheae were not intubated and suctioned were significantly more likely subsequently to develop the meconium aspiration syndrome (MAS).

I disagree with Dr Reynolds' contention that intratracheal suctioning of newborns is uniformly unnecessary among neonates born through thin meconium. Although babies born through "thin" meconium are less likely to develop MAS, as many as 38% to 41%1,2 of neonates with the disorder are born through thin-consistency fluid.
Lead Toxicity in the 21st Century: Will We Still Be Treating It?
Authors: SCHOEN EDGER J.
Published: December 2021

To the Editor.—

In the April 1992 issue of Pediatrics, Needleman and Jackson1 claimed that asymptomatic blood lead levels—those ≥10 µg/dL—represent a serious health problem, affecting three to four million children in the United States, and referred to lead contamination in children as a "man-made epidemic" as well as "a blunter of children's cognition and silent thief of their futures."1, p680 These authors recommended that all infants and young children be screened for blood lead, arguing that infants are screened routinely for conditions such as phenylketonuria which are much less common.
Mechanical Ventilation in Preterm Infants: Neurosonographic and Developmental Studies
Authors: Graziani Leonard J. , Spitzer Alan R. , Mitchell Donald G. , Merton Daniel A. , Stanley Christian , Robinson Nancy , McKee Linda
Published: December 2021

Surviving preterm infants of less than 34 weeks' gestation who were selected on the basis of serial cranial ultrasonographic findings during their nursery course had repeated neurologic and developmental examinations during late infancy and early childhood that established the presence (n = 46) or absence (n = 205) of spastic forms of cerebral palsy. Of the 205 infants without cerebral palsy, 22 scored abnormally low on standardized developmental testing during early childhood. The need for mechanical ventilation beginning on the first day of life (n = 92) was significantly related to gestational age, birth weight, Apgar scores, patent ductus arteriosus, grade III/IV intracranial hemorrhage, large periventricular cysts, and the development of cerebral palsy. In the 192 mechanically ventilated infants, vaginal bleeding during the third trimester, low Apgar scores, and maximally low Pco2 values during the first 3 days of life were significantly related to large periventricular cysts (n = 41) and cerebral palsy (n = 43), but not to developmental delay in the absence of cerebral palsy (n = 18). The severity of intracranial hemorrhage in mechanically ventilated infants was significantly associated with gestational age and maximally low measurements of Pco2 and pH, but not with Apgar scores or maximally low measurements of Po2. Logistic regression analyses controlling for possible confounding variables disclosed that Pco2 values of less than 17 mm Hg during the first 3 days of life in mechanically ventilated infants were associated with a significantly increased risk of moderate to severe periventricular echodensity, large periventricular cysts, grade III/IV intracranial hemorrhage, and cerebral palsy. Neurosonographic abnormalities were highly predictive of cerebral palsy independent of Pco2 measurements. However, neither hypocarbia nor neurosonographic abnormalities were associated with a significantly increased risk of developmental delay in the absence of cerebral palsy. In this preterm infant population, therefore, the risk factors for developmental delay differed from those predictive of spastic forms of cerebral palsy. Of the 57 ventilated preterm infants who were exposed to a maximally low Pco2 of less than 20 mm Hg at least once during the first 3 days of life, 21 developed large periventricular cysts or cerebral palsy or both. Those results suggest that prenatal and neonatal factors including the need for mechanical ventilation beginning on the first day of life and marked hypocarbia during the first 3 postnatal days are associated with an increased risk of damage to the periventricular white matter of some preterm infants. However, a causal relationship between hypocarbia and brain damage in preterm infants remains unproven.
Severe Retinopathy of Prematurity and Steroid Exposure
Authors: Batton Daniel G. , Roberts Connie , Trese Michael , Maisels M. Jeffrey
Published: December 2021

During a 3-year period (1988 through 1990) an increase was observed in the number of infants born at 23- to 26-weeks' gestation who required cryotherapy for severe retinopathy of prematurity (0/20, 1988; 3/14, 1989; 6/18, 1990; P = .015). Inasmuch as this was not related to improved survival, a retrospective case-control study was conducted to try to explain this observation. Of 52 surviving infants who had been born at 23 to 26 weeks' gestation, 9 required cryotherapy and the other 43 served as control subjects. There were no differences between groups in birthweight, gestational age, or the number of infants with hyaline membrane disease, intraventricular hemorrhage, or hydrocephalus. Factors related to the need for cryotherapy included patent ductus arteriosus (P = .046), mechanical ventilation for more than 21 days (P = .045), and the use of steroids for lung disease (P < .001). In this neonatal intensive care unit, steroids are administered according to the attending neonatologist's preference. Inasmuch as steroids are considered only for infants still ventilator dependent at 21 days, this group was analyzed separately (n = 36). Of the 21 factors examined, only the use of steroids for lung disease was associated with the need for cryotherapy (P < .001).
Dietary Intake of Healthy Children With Cystic Fibrosis Compared With Normal Control Children
Authors: Tomezsko Jean L. , Stallings Virginia A. , Scanlin Thomas F.
Published: December 2021

Because a low calorie intake may result in growth failure and malnutrition in patients with cystic fibrosis (CF), the dietary and energy intakes of 22 children CF who had mild lung disease and excellent Shwachman scores were examined and compared with those of 23 normal control subjects similar in age (5 to 10 years), gender, and weight. The children with CF consumed ficantly more calories than the controjectsl Calorie intake was 111 ± 19.9% (mean ± SD) of estimated requirements (World Health Organization recommendations) for the CF group and 97 ± 18.7% for the control group (P = .014). Calories consumed per kilogram of body weight were 117% of World Health Organization (CF) vs 97% (control) (P = .009). Calorie intake compared to the 1989 Recommended Dietary Allowance was 106 ± 20.6% for the CF group vs 93 ± 19.1% for the control group. Fat consumed as a percent of total calories was similar: 33.5% (CF) vs 32.2% (control). All children with CF had pancreatic insufficiency and, on average, consumed a large number of pancreatic enzyme supplements, resulting in dietary fat absorption of 86 ± 12%. It is concluded that these children with CF were able to maintain normal growth and energy stores on a diet that was relatively high in calories compared to control subjects and moderate in percent fat, along with an aggressive pancreatic enzyme supplement regimen.
Contribution of the 13C-Urea Breath Test to the Detection of Helicobacter pylori Gastritis in Children
Authors: Vandenplas Y. , Blecker U. , Devreker T. , Keppens E. , Nijs J. , Cadranel S. , Pipeleers-Marichal M. , Goossens A. , Lauwers S.
Published: December 2021

Serology, 13C-urea breath test, histology, Campylobacter-like organism testing, and culture were performed in 95 consecutive children to evaluate the contribution of these tests to the detection of Helicobacter pylori infection. In analyses considering any combination of three positive tests as "gold standard" for diagnosing H pylori infection, 26 children were Helicobacter positive (27%), which is only one patient more than the number of children with only a positive culture. The accuracy of culture was excellent when "any combination of three positive tests" was used as the gold standard (sensitivity 96%, specificity 100%, positive predictive value 100% [false positivity 0%], negative predictive value 99% [false-negative results 1%]). The results of invasive and noninvasive tests were comparable. When culture was considered as "gold standard," the sensitivity of serology and 13C-urea breath test was 96%; the specificity was 96% and 93%, respectively; the positive predictive value was 89% and 83% (false-positive results in 11% and 17%); and the negative predictive value for both was 99% (false-negative results in 1%). It is concluded that culture can be used as gold standard, but that noninvasive tests such as serology and/or 13C-urea breath test can be used to diagnose H pylori infection in children, since each has at least 95% sensitivity and 92% specificity.
Risk Factors for the Central Nervous System Manifestations of Gastroenteritis-Associated Hemolytic-Uremic Syndrome
Authors: Cimolai Nevio , Morrison Brenda J. , Carter James E.
Published: December 2021

Hemolytic-uremic syndrome is usually a consequence of enteric verotoxigenic Escherichia coli infection, and a prevailing hypothesis contends that systemically absorbed verotoxins are responsible for the multiple organ involvement. In an attempt to determine whether the central nervous system (CNS) manifestations could occur owing to factors that reflect a toxin insult, the authors studied the association of clinical and laboratory variables with the development of neurological disease. Ninety-one patients with hemolytic-uremic syndrome from 1982 through 1990 were included. Twenty-seven (18 female, 9 male) had a CNS disorder; 17 of these had seizures and there were two deaths. Multivariate analyses led to the following observations: female gender (odds ratio [OR] 8.50; 95% confidence interval [CI] 2.08 to 50.0), prolonged use of an antimotility pharmacological agent (OR 8.50; 95% CI 1.69 to 42.81), and an increased hemoglobin level (OR 1.11; 95% CI 1.05 to 1.17) were associated with an increased risk for developing a neurological manifestation. Prior administration of a blood product was associated with a decreased risk (OR 0.12; 95% CI 0.02 to 0.52). The findings suggest that other mechanisms for CNS disease may exist in addition to direct toxin insult.
Underestimation of the Incidence of Mental Retardation
Authors: CUNNINGHAM ROBERT D.
Published: December 2021

To the Editor.—

As pointed out by Yeargin-Allsopp et al,1 the prevalence of mental retardation differs with the population studied and the definition of retardation used. But it may also differ with the amount of effort put out in the attempt to identify individuals with mental retardation.

In this current study, children who were found by the school systems in metropolitan Atlanta to have an IQ of 70 or less on psychometric tests were defined as mentally retarded.
Double Versus Single Phototherapy in Low Birth Weight Newborns
Authors: Holtrop Paul C. , Ruedisueli Kathleen , Maisels M. Jeffrey
Published: December 2021

Conventional phototherapy systems that simultaneously irradiate the front and the back of the baby lower the serum bilirubin level more rapidly than one-sided systems, but they are impractical. Fiberoptic phototherapy makes it easy to administer conventional phototherapy from above while the infant lies on a fiberoptic phototherapy blanket. Newborns with birth weights less than 2500 g were randomly assigned to receive either single (n = 37) or double (n = 33) phototherapy. The groups were similar in clinical and laboratory characteristics. After 18 hours of therapy the serum bilirubin concentration declined by 31 ± 11% in the double and 16 ± 15% in the single phototherapy group (2.9 ± 1.1 vs 1.6 ± 1.4 mg/dL), and the difference in the total serum bilirubin levels after 18 hours of therapy was significant (double phototherapy group 7.1 ± 2.7 mg/dL vs single phototherapy group 8.2 ± 2.6 mg/dL). After 18 hours of treatment the serum bilirubin level was less than the phototherapy threshold level in 26 of 37 single phototherapy patients vs 32 of 33 double phototherapy patients. Double phototherapy was well tolerated. It is concluded that this type of double phototherapy is more effective than single phototherapy in low birth weight newborns. Double phototherapy may be useful when it is necessary to reduce an elevated serum bilirubin level as rapidly as possible or when the bilirubin level is rising with single phototherapy.
Wheezing in Infants with Cystic Fibrosis: Clinical Course, Pulmonary Function, and Survival Analysis
Authors: Reisman Joseph , Corey Mary , Canny Gerard , Levison Henry , Kerem Eitan , Bentur Lea
Published: December 2021

Wheezing is a common finding in infants with cystic fibrosis (CF). This study was undertaken to determine the prevalence of wheezing in infants with CF and to compare the clinical outcome of those who wheezed in infancy with that of those who did not. The study cohort included 229 CF patients born between 1965 and 1979 with CF diagnosed before 2 years of age. Fifty-seven (25%) had physician-documented wheezing during the first 2 years of life. Wheezing had resolved by the age of 2 years in 50% of the patients and by the age of 4 years in 75%. Although wheezing seemed to be linked to a family history of allergy and asthma, the frequency of the ΔF508 mutation was similar to that of the non-wheezers. There was no significant difference in survival at the age of 13 years between the two groups. At the age of 7 years, patients who had wheezed had significantly lower forced expiratory flow rate at mid-expiratory phase (85 ± 34% predicted) compared with those with no wheezing history (101 ± 34% predicted). At the age of 13 years, forced expiratory volume in 1 second values was lower in the wheezing group (69 ± 24% predicted vs 78 ± 21% predicted), as was forced expiratory flow rate at mid-expiratory phase (56 ± 33% predicted vs 69 ± 30% predicted). In conclusion, although wheezing in infants with CF seems to have diminished with age, pulmonary function abnormalities were more evident at 7 and 13 years of age in the group that wheezed than in the group that did not.
European Surfactant Trial: Questions About the Protocol
Authors: DEICHSEL GUNTRAM , GMBH KARL THOMAE , VON SEEFELD FRAU DR
Published: December 2021

To the Editor.—

The paper by Speer et al in the January 1992 issue of Pediatrics1 gives an impressive insight into current European surfactant research. What I missed, however, is a remark on the loopholes which inevitably occur during the conduct of a trial with intensive care patients.

A note on protocol violations certainly would explain the following discrepancy: 65% of the patients in the multiple-dose group required more than one dose, where an additional dose is to be given if there is need for supplementary oxygen (FIO2 > 0.21) after 12 or 24 hours (cf, middle of right column on pages 14 and 15).
Behavioral Consequences of Illness: Childhood Asthma as a Model
Authors: Creer Thomas L. , Stein Ruth E.K. , Rappaport Leonard , Lewis Charles
Published: December 2021

Several areas of research on childhood asthma are discussed within a transactional model of asthma. The model emphasizes the multidirectional influences that affect the severity of asthma and associated behavioral disability. The initial focus is on how the clinical presentation and morbidity of asthma are affected both by somatic predisposition and by interactions with multiple internal and external elements. Specific elements include emotional factors, neuroimmunology, temperament, and medication side effects. Second, the impact of asthma on the child, his or her family, and segments of the community are described, as are consequences of the disorder on quality of life. Third, there is a synopsis of preventative interventions for reducing the medical and behavioral impact of childhood asthma. The motif is that the interaction of medical and behavioral procedures can improve the management of asthma while consequences of the disorder are mollified. Finally, as examples of a transactional model of asthma, selfmanagement programs for teaching children to become partners with their physicians in establishing and maintaining control over the disorder are described. A representative of self-management—the ACT (Asthma Care Training) program—is described, along with the impact such programs have on children, their families, and institutions. The conclusion emphasizes that asthma is a complicated and unpredictable disorder that puzzles physicians, behavioral scientists, and patients. Although new treatments may be over the horizon, controlling childhood asthma and its consequences currently rests on the cooperation and increased interaction of medical and behavioral scientists
Money Alone Won't Do It
Authors: COPELAND DAVID
Published: December 2021

To the Editor.—

After reading the supplement, "Preventive Health Care for Young Children" (Pediatrics. 1992;89:983-998),1 I was left with the conclusion that the authors believe more money together with improved tracking and delivery will raise US standards to the level of other industrialized countries. It seems more probable, however, that the current rate of production of welfare babies has the capacity to stay ahead of any system we are likely to fund. Further, this burgeoning dependent subculture is a problem which similarly burdens no other country with whom we are being compared.
Progressive Hearing Loss in Infants With Asymptomatic Congenital Cytomegalovirus Infection
Authors: Williamson W. Daniel , Demmler Gail J. , Percy Alan K. , Catlin Francis I.
Published: December 2021

Congenital cytomegalovirus (CMV) infection is a major public health problem because 30 000 to 40 000 neonates with the infection are born each year in the United States. Although 90% of the congenitally infected infants are asymptomatic at birth, evidence is accumulating that these infants are at risk for audiologic, neurologic, and developmental sequelae. The current study describes the audiologic outcome of 59 infants with asymptomatic congenital CMV infection compared with 26 control infants. Eight of 59 infected infants had congenital sensorineural hearing loss (SNHL) but none of the control subjects did. Longitudinal audiologic assessments revealed that 5 of the 8 infants had further deterioration of their SNHL; a ninth infant with initially normal hearing experienced a unilateral SNHL during the first year of life, with further deterioration subseguently. The frequency of SNHL was similar for infected infants born to mothers with recurrent CMV infections during pregnancy (2 of 9) and for those born to mothers who experienced primary CMV infections (5 of 26). There was a significant difference between the occurrence of hearing loss in infected infants with normal computed tomographic scans (2 of 40) compared with those with either periventricular radiolucencies (4 of 13) or calcifications (1 of 3). Children with SNHL often have no identified cause of the loss; thus, it is likely that many of these children had asymptomatic congenital CMV infection. Given the progressive nature of SNHL associated with asymptomatic congenital CMV infection, longitudinal audiologic assessments are mandatory.
Serum Bilirubin Levels, Intracranial Hemorrhage, and the Risk of Developmental Problems in Very Low Birth Weight Neonates
Authors: O'Shea T. Michael , Dillard Robert G. , Klinepeter Kurt L. , Goldstein Donald J.
Published: December 2021

To study whether elevated levels of bilirubin in the neonatal period increase the risk of developmental problems for very low birth weight neonates, the investigators used data from a geographically based sample of 495 very low birth weight neonates, born January 1, 1985, to December 31, 1989, who survived to 1 year of adjusted age. Maximum neonatal bilirubin levels were found in medical records. A developmental problem was defined as either cerebral palsy or a Bayley Mental Developmental Index of less than 68 at 1 year adjusted age. Potentially confounding factors were controlled using logistic regression. To control for the effects of intracranial abnormalities (eg, intraventricular hemorrhage), separate logistic regression analyses were carried out for three strata, defined according to the results of cranial ultrasonography. In these analyses, the following odds ratios (with 95% confidence limits) were found for the association of maximum neonatal bilirubin concentration and developmental problems: for subjects without intracranial abnormalities, 0.9 (0.7, 1.9); for subjects with uncomplicated intracranial hemorrhage, 1.5 (0.8, 2.5); for subjects with complicated intracranial hemorrhage or intraparenchymal echodensities, 1.2 (0.4, 3.6). In summary, in analyses controlled for confounding factors, maximum neonatal bilirubin level was not consistently associated with the risk of developmental problems identifiable at 1 year.
Cystic Fibrosis Manifested as Undescended Testis and Absence of Vas Deferens
Authors: GOSHEN RAN , KEREM EITAN , SHOSHANI TZIPORA , KEREM BAT-SHEVA , FEIGIN ELAD , ZAMIR ODED , YAHAV YAAKOV
Published: December 2021

Cystic fibrosis (CF) is the most common autosomal recessive inherited disease in whites. Among whites of European ancestry, approximately 1 in 2000 live births are affected, implying a carrier frequency of 1:25.1 The disease is characterized by chronic lung disease, which usually leads to the patient's death. Furthermore, patients with CF suffer from pancreatic insufficiency and other less common manifestations, such as meconium ileus, hepatobiliary abnormalities, diabetes mellitus, and musculoskeletal problems.1 Almost all males with CF are infertile. Absence of the vas deferens has been reported in 70% to more than 90% of male patients affected by CF.2

Although 4% of full-term male neonates have un-descended testes at birth, 0.8% to 1.0% of 1-year-old boys have cryptorchism and may be subjected to a later surgical intervention.3
Longitudinal Follow-up of Malignant Osteopetrosis by Skeletal Radiographs and Restriction Fragment Length Polymorphism Analysis After Bone Marrow Transplantation
Authors: SCHROEDER ROBERT E. , JOHNSON F. LEONARD , SILBERSTEIN MICHAEL J. , NEUMAN WILMA L. , HOAG JEANNE M. , FARBER ROSANN A. , NOGUCHI AKIHIKO
Published: December 2021

Infantile malignant osteopetrosis is a rare autosomal recessive disorder characterized by presentation in the first months of life with manifestations related to an underlying defect in osteoclast function. Abnormal osteoclast activity paired with normal bone formation by osteoblasts leads to development of densely sclerotic fragile bones. Encroachment on the marrow cavities by hyperostotic bone results in profound anemia and thrombocytopenia, with extramedullary ullary hematopoiesis and hypersplenism. Deficits in immune function can lead to presentation with overwhelming sepsis in the newborn period. Narrowing of the optic and auditory foramina can lead to progressive blindness and hearing loss. Until recently, the prognosis for this disorder had been uniformly dismal with death usually occurring within a few months.l-3
How Much Resuscitation Is Enough Resuscitation?
Authors: ORLOWSKI JAMES P.
Published: December 2021

One of the problems facing all of us when we perform cardiopulmonary resuscitation on children is deciding when enough is enough, and when it is perhaps too much. We want to give any child experiencing a sudden, unexpected catastrophe with cardiopulmonary arrest the fullest benefit of our skills and techniques, but if we persist too long, we risk resuscitating the heart but not the brain and creating a fate worse than death: the neurologically devastated or persistently vegetative state. I am as guilty as others of losing track of time and have found myself trying to resuscitate a patient for more than an hour.
Pediatrics and the Patient Self-Determination Act
Authors: SAHLER OLLE JANE Z. , GREENLAW JANE
Published: December 2021

On December 1, 1991, the requirements of a new federal law, the Patient Self-determination Act (PSDA), went into effect.1 The PSDA requires hospitals, nursing home facilities, hospices, home health care programs, and health maintenance organizations to give adults (in most states, individuals 18 years of age or older) information about their rights under the laws of their state to accept or refuse medical treatment; to prepare an advance directive such as a living will which states the individual's preferences for medical treatment under certain circumstances that might occur in the future, at a time when the patient is no longer able to make decisions; and to appoint a health care agent or proxy, someone to make health care decisions on behalf of the individual if he or she is no longer able to make decisions.
Treatment of Attachment Disorder of Infancy in a Neonatal Intensive Care Unit
Authors: GOODFRIEND MARLENE S.
Published: December 2021

As a psychiatric consultant in an inner-city level III neonatal intensive care unit (NICU), I have seen several cases involving premature infants who did not have a caring, consistent adult in their lives. This neglect appeared to contribute to the development of behavior problems (eg, irritability) or feeding problems (eg, failure to thrive), and sometimes an infant failed to progress medically or experienced an exacerbation of medical problems. These infants were assigned the diagnosis of reactive attachment disorder of infancy. This is a recognized psychiatric entity that is defined, as follows, in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed, revised):
The Senior Pediatrician and Day Care
Authors: GRAYSON ROBERT
Published: December 2021

Accompanying this issue of Pediatrics is a supplement entitled "Pediatrics and Child Care." The papers in this supplement repeatedly emphasize the need and desire of day-care centers for more involvement with pediatricians. They also emphasize the pressing need to keep costs down so that day care of high quality can be accessible to more children. At about the same time in 1991 that the symposium which led to the supplement was held, an Interim Forum for Senior Members of the American Academy of Pediatrics (AAP) was formed, open to Fellows of the Academy older than 55 years of age. With the initial invitation to membership, approximately 1000 Fellows enrolled.
Home Phototherapy: Not Seeing the Light
Authors: POLAND RONALD L.
Published: December 2021

In this issue of Pediatrics, Meropol and her associates1 report an interesting survey of the opinions and practices of urban pediatricians regarding home phototherapy. They report that fewer than a third of pediatricians in their survey used home phototherapy in their practices. A variety of reasons for nonuse were elicited, mostly related to difficulties in getting phototherapy done at home. A minority of nonusers were concerned about potential complications, such as dehydration. On the other hand, many of the reasons given by nonusers were not experienced as actual problems by the pediatricians who reported using home phototherapy. In their conclusions, the authors suggest that until more is known, the American Academy of Pediatrics guidelines for home phototherapy should be followed and that we should strive to improve the benefit-risk ratio for the treatment of neonatal hyperbilirubinemia.
Group B Streptococcal Infections: An Obstetrical Viewpoint
Authors: LARSEN JOHN W. , DOOLEY SHARON L.
Published: December 2021

Group B Streptococcus (GBS) was first identified as a cause of puerperal sepsis during the late 1930s. However, concern regarding GBS was diminished in part by the greater pathogenicity of the group A Streptococcus, which was described in the same studies. Clinical research regarding GBS infections resumed during the 1960s. Data regarding the perinatal transmission of GBS have now accumulated to an extent that education of all obstetric and pediatric care providers is imperative.

During the past 2 years, committees of both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have considered the issues of perinatal transmission of GBS. Each group had input from the other by a series of meetings and document exchanges.