bluuebunny/crossref_metadata_2025 huggingface dataset:
Lead Study Results Questioned
Authors: Landrigan Philip J.
Published: December 2021

Ernhart et al1 have reported the results of developmental follow-up evaluation of black urban schoolchildren with increased exposure to lead. Perino and Ernhart2 had assessed the development of this same group of children five years previously. In the earlier evaluation, Perino and Ernhart divided the children into low lead (blood lead level, 10 to 30 µg/100 ml) and moderate lead (40 to 70 µg/100 ml) exposure groups; no child in either group had clinical manifestations of lead poisoning.
Aspirin Fatalities—The New Taxonomy
Authors: McIntire Matilda S. , Angle Carol R.
Published: December 2021

For many years aspirin and aspirin-related products were the leading cause of accidental poisoning in children less than 5 years of age. In the mid 1950s 51% of all accidents in young children were due to accidental poisoning and aspirin was the leading offender. Aspirin ingestions accounted for 19% of total ingestions in 1958 and increased to 26% by 1965. In 1966-67, baby aspirin was limited to 36 per package and child-resistant closures were introduced by two major pharmaceutical companies on a voluntary basis.
New Evidence on Diet in Hyperkinesis
Authors: Arnold L. Eugene , Nemzer Elaine
Published: December 2021

We wish to draw the attention of practicing pediatricians to two recent studies that converge on some important clinical implications for management of attention deficit disorder (ADD, hyperkinesis, MBD).

Prinz and associates1 found in a sample of hyperkinetic and normal children that destructive-aggressive and restless behavior significantly correlated with the amount of sugar consumed by a child, with the ratio of sugar products to other foods, and perhaps most importantly, with the ratio of carbohydrate to protein in the diet.
PLANNING
Authors: von Braun Werner
Published: December 2021

Crash programs fail because they are based on the theory that, with nine women pregnant, you can get a baby a month.
Effects of Central Apneas on Transcutaneous Po2 in Control Subjects, Siblings of Victims of Sudden Infant Death Syndrome, and Near Miss Infants
Authors: Kahn A. , Blum D. , Engelman E. , Waterschoot P.
Published: December 2021

A total of 75 polysomnograms recorded during night sessions in 25 control subjects, 25 siblings of sudden infant death syndrome victims, and 25 near miss infants were studied in order to correlate the duration of central apnea to the decrease in transcutaneous oxygen pressure (tcPo2). A total of 1,650 central apneas were recorded. The three groups of infants presented the same tendency for a lower tcPo2 in indeterminate and active sleep as in quiet sleep (P > .10). The apneas were not preceded by a decrease in tcPo2, but were followed by a decrease in tcPo2, directly proportional to the duration of apnea. The correlation was measured in each infant individually, and proved to be significant in all cases, and comparable in the three groups. The longest apneas (greater than ten seconds) were followed by the greatest decrease in tcPo2, and were restricted to the near miss group. Apart from this observation, the near miss and sibling infants did not show lower tcPo2 than the control subjects, at any time, during sleep.
THE DREADFUL OUTCOME OF EXPOSING CHILDREN TO DANCING AND MUSIC, AS VIEWED IN 1583
Authors: C. T. E.
Published: December 2021

Philip Stubbes (fl. 1583-1591), and English Puritan pamphleteer, in his The Anatomie of Abuses (1583), denounced the evil consequences of teaching dancing and music to children as follows:

If you would have your son soft, womanish, unclean, smooth-mouth, affected to bawdry, scurrility, filthy rimes, and unseemly talking; briefly if you would have him, as it were, transnatured into a woman or worse, and inclined to all kinds of whoredom and abomination, set him to dancing school and to learn music, and then you shall not fail of your purpose. And if you would have your daughter riggish, bawdry and unclean, and a filthy speaker, and suchlike, bring her up in music and dancing and my life for yours, you have won the goal.1
Echocardiography in Aspergillus Endocarditis
Authors: Kleiman Martin B.
Published: December 2021

In the letter "Echocardiography in Aspergillus Endocarditis" (Pediatrics 69: 252, 1982) the authors' names are as follows: Martin B. Kleiman, MD, Randall Caldwell, MD, Donald Girod, MD, and Roger Hurwitz, MD.
PURULENT OPHTHALMIA IN THE CHILDREN'S ASYLUM OF THE PHILADELPHIA ALMSHOUSE IN 1836
Authors: C. T. E.
Published: December 2021

Alfred Stillé (1813-1900), professor of the theory and practice of medicine at the University of Pennsylvania from 1864 to 1883, vividly described his experiences as a young intern in 1836 when he lived for six months in the children's asylum of the Philadelphia Almshouse.

It was a very interesting field for me from a humanitarian as well as a medical point of view. A hundred or more children [Stillé was the only house officer] were sheltered there on their way to the early grave to which most of them were destined. Illegitimate and other outcasts formed the majority, and ophthalmia, that curse of children's asylums, made of them a blear-eyed, puny crowd, most pitiable to see. I soon became convinced of the causes that produced the crippling and mortality of these outcasts and waifs. I pointed out to the committee of the board how the disease was disseminated by the children washing in the same basins and using the same towels, and how it was maintained by their having no shaded placed for exercise in the open air, and also by the insufficient food permitted them; for if the soup which they received one day was nutritious, the meat of which the soup had been made, and which formed their dinner on the following day, must necessarily be nearly devoid of nutriment. But of course, the committee on the children's asylum and the guardians knew better than I, and at the time, at least, nothing was done to correct this wrong.1
Cross-Cultural Perspectives in Child Abuse
Authors: Kempe C. Henry
Published: December 2021

Cross-cultural perspectives in the field of child abuse and neglect are largely lacking. In many countries, not much is published about child rearing and about possible child abuse and neglect. One or two official statistics are not adequate to show a low incidence of these conditions. Thirty years ago child abuse in the industrial world was thought to be uncommon. Only active public and professional concern led to the emergence of a truer picture of all forms of child abuse: physical abuse, sexual abuse, and emotional and nutritional failure to thrive owing to maternal deprivation.

Child rearing is the essential element in the transmission of culture in any group or society.
Aplastic Anemia and Down's Syndrome
Authors: McWilliams Nancy B. , Dunn Nancy L.
Published: December 2021

The first case report of aplastic anemia in Down's syndrome (Weinblatt ME, Higgins G, Ortega JA: Aplastic anemia in Down's syndrome. Pediatrics 67:896, 1981) may stir up a flurry of other such case reports.

We are studying a 27-month-old black girl with a 47,XX + 21 karyotype who had been doing well following repair of an endocardial cushion defect at age 10 months, until she was seen with petechiae and purpura at age 19 months.
Saving Money and Saving Lives
Authors: Margolis Lewis H.
Published: December 2021

Although Chilton's desire to reduce prescription costs is admirable (Chilton L: Strategies for reducing prescription costs. Pediatrics 68:713, 1981), potential toxicity dictates that care must be taken in recommending large quantities or high concentrations. The decline in salicylism which resulted from limitations on the per-bottle quantities of baby aspirin is evidence of the health value in restricting quantities. Large bottles of medicine—no matter how well secured by the most vigilant of parents— represent a preventable health risk.
Symptomatic Sinus Node Dysfunction in Children Without Structural Heart Disease
Authors: Yabek Steven M. , Dillon Terrence , Berman William , Niland Colleen J.
Published: December 2021

Symptomatic sinus node dysfunction rarely occurs in children with structurally normal hearts. Three children with syncope and bradycardia are described. Noninvasive and invasive testing revealed isolated sinus node dysfunction and normal cardiac anatomy. Electrophysiologic evaluation showed abnormalities of sinus node automaticity and sinoatrial conduction. All three patients were treated with permanent ventricular pacemakers and have remained asymptomatic. Sinus node dysfunction should be considered in the differential diagnosis whenever a child is seen with unexplained dizziness or syncope.
Takayasu's Disease with Aneurysm of Right Common Iliac Artery and Iliocaval Fistula in a Young Infant: Case Report and Review of the Literature
Authors: Gronemeyer Pamella S. , deMello Daphne E.
Published: December 2021

Takayasu's arteritis or nonspecific arteritis is a term used to designate a primary arteritis of unknown etiology involving the aorta and its major branches at any level. Generally, the lesions are obliterative; however, aneurysms and saccular dilations have also been described. The arteritis was originally believed to be limited to the aortic arch; however, involvement of the descending thoracic and abdominal aorta has been reported. In fact, the majority of cases of Takayasu's disease in children involve the descending thoracic and abdominal aorta. A case of Takayasu's disease in a 7-month-old black male infant involving the right common iliac artery with development of a large aneurysm and an iliocaval fistula is reported. This child is the youngest to be affected by the disease as reported in the literature. Although Takayasu's disease is rare, it should be considered in the differential diagnosis of children with an abdominal mass.
Persistent Anterior Fontanel in a Normal Child: Case Report
Authors: Davidson Robin I. , Klineman P.
Published: December 2021

Persistence of the anterior fontanel has been described in a variety of congenital and metabolic disorders, but to our knowledge there is no recorded discussion of failure of closure of this structure in an otherwise normal child. We recently encountered a 3½-year-old patient whose anterior fontanel was widely patent without evidence of abnormal membranous bone formation, underlying cortical dysgenetic problems, or failure of normal physical and intellectual development.

CASE REPORT

This 3½-year-old white girl, the product of a normal gestation, was referred for continued patency of the anterior fontanel. The child was totally asymptomatic. On examination, a pulsatile irregular 5x6-cm anterior fontanel was noted.
Letters to the Editor
Authors: Chilton Lance
Published: December 2021

I appreciate the comments on my recent article on reducing prescription costs. In revising and shortening the paper prior to publication I removed many of the caveats to the use of "quantity discounting." Snodgrass has pointed them out: fear of abuse of a large quantity of medication and pricing the medication out of an immediately affordable range even if the total cost over time is reduced.

It is clear that chronically used medications are more likely to be amenable to "quantity discounting"—for them, savings can occasionally be considerable, as noted in the example given in the paper.
Nutritional Balance Studies in Very Low-Birth-Weight Infants: Role of Soy Formula
Authors: Prinsloo J. G.
Published: December 2021

Shenai et al1 are mainly concerned about the relative hypophosphatemia of the soy group, although the phosphorus retention values of the soy- and milk-based groups were similar (49 and 51 mg/kg/day, respectively). This reflects again one of the difficulties of short-term balance studies. We also found significantly lower phosphorus values after 32 to 35 days in our soy-fed patients in comparison with a milk-fed group.2 In addition, weight gain was inferior in the soy-fed group and their serum albumin levels were significantly lower than in the milk-fed group at the end of our trial (32 to 35 days).
Diagnosis, Management, and Long-Term Results of Patients with Congenital Complete Atrioventricular Block
Authors: Pinsky William W. , Gillette Paul C. , Garson Arthur , McNamara Dan G.
Published: December 2021

Sixty-five patients with congenital complete atrioventricular block have been studied. The median age at time of diagnosis was 7 months with 26 infants being diagnosed prior to 1 month of age. Anatomic heart disease was present in 25/65 (39%) infants, with ventricular inversion/L-transposition of great arteries complex occurring in 20/25 infants (80%). The site of block was above the bundle of His in 11 of 18 (61%) patients studied, in the bundle of His in three of 18 (17%), and below the bundle of His in two of 18 (11%). Permanent pacemakers were implanted in 17 (26%). Ten patients (15%) have died. The highest risk was in patients with anatomic heart disease and patients diagnosed early in life.
Marital Stability and Congenital Heart Disease
Authors: Silbert Annette R. , Newburger Jane W. , Fyler Donald C.
Published: December 2021

The incidence of divorce or legal separation was studied in 438 families of children born with heart disease who entered the New England Regional Infant Cardiac Program between 1968 and 1973. The parents were interviewed when the children were 5½ years old. The rate of divorce in 438 families of children with critical congenital heart disease was not significantly different from the rate in two comparison groups: (1) 25 families of children whose cardiac defect was spontaneously cured, and (2) 26 families of children catheterized in infancy for suspected cardiac defect but who were found to be free of heart disease. Rates of divorce or legal separation for the three groups were: critical congenital heart disease, 12.1%, spontaneously cured, 4.2% free of heart disease, 11.5% these rates were not significantly different. The average national divorce rate was 20.3% for the same period.
Climatic Heat Stress and the Exercising Child
Authors:   Committee on Sports Medicine, Shaffer Thomas E. , Flynn Thomas G. , Coryllos Elizabeth , Dyment Paul G. , Kennell John H. , Luckstead Eugene F. , McLeod Robert N. , Smith Nathan J. , Strong William B. , Thornton Melvin L. , Van Rooy Clemens W. , Murray John
Published: December 2021

Heat-induced ifiness is preventable. Physicians, teachers, coaches, and parents must be made aware of the potential hazards of high-intensity exercise in hot climates and of the measures needed to prevent heat-related illness in preadolescents.

Because of the following morphologic and functional differences, exercising children do not adapt to extremes of temperature as effectively as adults when exposed to a high-climatic heat stress.1

1. Children have a greater surface area-mass ratio than adults, which induces a greater heat transfer between the environment and the body.

2. Children produce more metabolic heat per mass unit than adults when walking or running.2

3. Sweating capacity is not as great in children as in adults.3,4

4. The capacity to convey heat by blood from the body core to the skin is reduced in the exercising child.4,5

The foregoing characteristics do not interfere with the ability of the exercising child to dissipate heat effectively in a neutral or mildly warm climate. However, when air temperature exceeds skin temperature, children have less tolerance to exercise than do adults. The greater the temperature gradient between the air and the skin, the greater the effect on the child.4,6,7

Upon transition to a warmer climate, any exercising individual must allow time for conditioning for heat (acclimatization). Intense and prolonged exercise undertaken before acclimatization may be detrimental to health and might even lead to fatal heat stroke.8 Although children can acclimatize to exercise in the heat,6,9 the rate of their acclimatization is slower than that of adults.1 Therefore, a child will need more exposures to the new climate to sufficiently acclimatize.
Lactose Breath Hydrogen Test
Authors: Sheps Sam
Published: December 2021

The recent article by Barr et al, "Mucosal Function and Breath Hydrogen Excretion: Comparative Studies in the Clinical Evaluation of Children with Nonspecific Abdominal Complaints" (Pediatrics 68:526, 1981), provided some useful data on the utility of the lactose breath hydrogen test (LBHT) for the diagnosis of lactase deficiency in children with nonspecific abdominal complaints. However, two comments are in order.

1. Because new diagnostic tests must be compared to a "gold standard" test for evaluative purposes, the meat of this article resides in table 3, in which a LBHT is compared with lactase activity demonstrated on biopsy material.
In Reply: Testing and Stuffing Cotton Balls in Your Ears
Authors: Paradise Jack L.
Published: December 2021

Desch and Laskowski make an important point in reminding us that developmental test results may not be valid if, at the time of testing, the subject's hearing is sufficiently impaired to interfere with comprehension of test instructions. This point is germane to the class of studies termed group A in my review,1 and does raise questions about the linguistic and cognitive impairments described among subjects in those studies.

However, the principal focus of my review was the group of studies termed group B, which involved children whose hearing acuity presumably had been impaired early in life, but was no longer appreciably impaired at the time of developmental testing.
Optic Atrophy Induced by Vincristine
Authors: Shurin Susan B. , Rekate Harold L. , Annable William
Published: December 2021

Bilateral optic atrophy developed in a 15-year-old patient receiving concomitant neuraxis radiation therapy and weekly vincristine sulfate for medulloblastoma. Other neurologic manifestations that have been associated with vincristine therapy, including inappropriate secretion of antidiuretic hormone, hypertension, confusion, and a severe peripheral neuropathy, were also observed. Neither increased intracranial pressure nor active tumor was identified. Recovery of visual function followed discontinuation of vincristine. Other neurotoxicities also reversed with drug withdrawal. Visual loss occurring in a patient receiving vincristine should alert the physician to the possibility that the process is drug related. This complication may be more likely in patients receiving concomitant or previous cranial radiation therapy. Other central neurotoxicities of vincristine may also be accentuated by neuraxis radiation. It is recommended that vincristine be discontinued in this situation if an aggressive search for a structural anatomic lesion in the optic mechanism is unrevealing, as the prognosis for recovery of visual function appears excellent.
Leg Burns from Mopeds
Authors: Bantz Eric , Auerbach Julian
Published: December 2021

Accidents are responsible for more than 50% of childhood fatalities, and therefore, they represent a major pediatric problem in the United States today.1 Mishaps result in countless children being severely injured every day. Even as our society attempts to prevent injuries from previously proven hazards, children are presented with new means of incurring bodily injury. Indeed, the growing popularity of the moped has resulted in the increasingly clear understanding of its danger to children. We report two patients who came to our clinic within a period of six days; their injuries illustrate what we feel is yet another danger of this vehicle.
Subgaleal Hemorrhage in Infants with Hemophilia: Report of Two Cases and Review of the Literature
Authors: Rohyans Jo Ann , Miser Angela W. , Miser James S.
Published: December 2021

Hemorrhage in the newborn period in infants with hemophilia is rarely seen except in those children undergoing circumcision.1 Although reported in only five infants since 1960, scalp hemorrhage in newborn infants with hemophilia may be life-threatening.2-5 We have recently seen two infants with severe hemophilia A; each had a life-threatening subgaleal hematoma in the newborn period. Consumptive coagulopathy complicated the clinical and diagnostic evaluation in one case.

CASE REPORTS

Case 1

K. J. was a 3,370-gm infant born at 42 weeks' gestation by a forceps delivery after a prolonged labor with oxytocin (Pitocin) augmentation. In the first hours of life, a hematoma was noted over the right parietal area.
Epidemic Hysteria in a Montreal Train Station
Authors: Moffatt M. E. K.
Published: December 2021

Epidemic hysteria is a fascinating condition that primarily affects girls between the ages of 9 and 20 years who are together in a group for one reason or another. Sirois1 in a landmark review summarizes the important reported outbreaks since the Middle Ages; there have now been approximately 100. The manifestations are myriad, but in recent years the most common are fainting, abdominal pain, nausea, headache, and weakness. Only three of the reports are in the pediatric literature.2-4 Inasmuch as pediatricians are very likely to see the victims, it was felt worthwhile to describe an episode that occurred in Montreal.
The Environmental Consequences of Tobacco Smoking: Implications for Public Policies That Affect the Health of Children
Authors: Finberg Laurence , Garfunkel Joseph M. , Gehlbach Stephen H. , Graef John W. , Hanson James W. , Heavenrich Robert M. , Mauss Irving H. , Stevenson John L.
Published: December 2021

The human health consequences of cigarette smoking have been more thoroughly studied than those of any other environment exposure. According to the 1979 publication, Smoking and Health: A Report of the Surgeon General,1 and the 1982 Surgeon General's Report on the Health Consequences of Smoking,2 specific mortality ratios are directly proportional to the years of cigarette smoking, and they are higher for those who initiated smoking at younger ages. Smoking contributes to mortality from lung cancer, cardiovascular disease, and non-neoplastic bronchopulmonary disease; and it increases the risk of cancer from exposure to other carcinogens, such as asbestos. Birth weight and fetal growth may also be adversely affected by smoking during pregnancy. Despite their efforts to educate young patients about the dangers of smoking, it is alarming to pediatricians that the incidence of daily smoking among high school seniors is still 20%.2

Although the direct effects of cigarette smoking on the smoker are generally accepted, and less attention has been paid to the environmental hazard created by smokers for the nonsmoker, these effects also are addressed in the Surgeon General's report. Tobacco and tobacco smoke act as antigens and sensitize T lymphocytes. The lighted cigarette generates approximately 4,000 compounds, including gases and particulate phases. Cigarette smoking in enclosed areas can produce concentrations of carbon monoxide well above the ambient air quality standard, even when ventilation is otherwise adequate. In comparison with children of nonsmokers, children of parents who smoke have more bronchitis and pneumonia and reduced pulmonary function. Nonsmokers who are chronially exposed to tobacco smoke have reduced function of small airways comparable to that found in light smokers.
Hairy Ears
Authors: Woods David L. , Malan Attis F.
Published: December 2021

We read with interest the recent paper by Rafaat1 describing hypertrichosis pinnae in infants born to diabetic women. We have noted the association for many years and have illustrated the observation in an article relating the adequacy of maternal diabetic control to patterns of fetal growth.2 Although the degree of hirsutism increases with poor diabetic control, even infants born to well controlled diabetics commonly have hairy ears.

Not all infants with excessive hair growth on their pinnae are born to diabetic women, however; hairy ears may be an inherited trait3 and they are common in Asians.4
Phenobarbital and Cognitive Function
Authors: Schain Richard J. , Dreisbach Melanie
Published: December 2021

The article by Wolf et al1 describes the performance of children on a battery of psychometric tasks. The study is an important one since it attempts to evaluate the effects of phenobarbital on cognitive abilities of preschool aged children. This topic has been neglected even though phenobarbital has been freely administered to children for prophylaxis against febrile seizures.

The authors state that no impairment of cognitive function was observed in children who received daily phenobarbital for a period of years.
Letter to the Editor
Authors: Diamond Harriet , Forsythe Alan , Friedman Robert , Stunden Alastair , Wolf Sheldon
Published: December 2021

Much anxiety has been engendered in clinicians and parents by reports of serious brain damage due to phenobarbital given to young rodents in doses far higher than those clinically used for children.1,2 Our study, and that of Camfield et al3 better enables parents and pediatricians to evaluate the degree of risk to cognitive development with continuous phenobarbital at conventionally used dosage. We would welcome the publication of any of Schain's data, using whichever tests he prefers, which might give further information about the effect of both phenobarbital and febrile seizures on intellectual development in children.
Rapid Elimination of Quinidine in Pediatric Patients
Authors: Szefler Stanley J. , Pieroni Daniel R. , Gingell Robert L. , Shen Danny D.
Published: December 2021

The oral absorption and elimination of quinidine in pediatric patients was studied. Single oral doses of quinidine sulfate were administered to 13 patients ranging in age from 4 to 22 years of age. Serum quinidine concentration reached a peak within 30 minutes to two hours after drug administration. The serum half-life of quinidine varied from 2.5 to 6.7 hours and was, on the average, shorter than the reported estimates for adult volunteers and cardiac patients (means ranging from 4.9 to 7.3 hours). Hence, more frequent dosing or the use of slow-release preparations may be necessary in some pediatric patients in order to avoid excessive fluctuation in serum drug concentrations over a dosage interval. The oral dose clearance of quinidine (ie, oral dose divided by the area under the serum concentration time curve) varied over a threefold range, from 0.151 to 0.570 liter/hr/kg, and was found to correlate inversely with age (r = .80). In comparison with mean clearance estimates that have been reported for normal adult volunteers (0.293 ± 0.078 liter/hr/kg), children less than 12 years of age (0.461 ± 0.117 liter/hr/kg) were found to have significantly higher clearances, whereas no difference was observed between older children (0.287 ± 0.101 liter/hr/kg) and adults. Inasmuch as the average steady-state serum drug concentration for a given daily maintenance dose is directly related to clearance rate, children less than 12 years of age may require a higher dosage of quinidine on a per kilogram of body weight basis. Proper selection of quinidine dosage, careful adjustment of dosage according to age, and regular monitoring of drug response and serum drug concentration are essential steps to a rational management of quinidine therapy in children.
Echocardiographically Assisted Balloon Atrial Septostomy
Authors: Perry Lowell W. , Ruckman Roger N. , Galioto Frank M. , Shapiro Stephen R. , Potter Barry M. , Scott Lewis P.
Published: December 2021

Balloon atrial septostomy is an accepted method for palliation of certain types of congenital heart disease. However, malposition of the balloon may lead to cardiac perforation, avulsion of an atrioventricular valve, or laceration of the systemic or pulmonary veins. Inasmuch as single-plane fluoroscopy may not identify balloon position correctly and as biplane fluoroscopy adds significant radiation exposure, two-dimensional echocardiography has been used to assist in balloon atrial septostomy in ten infants. The catheter is advanced from the inferior vena cava to the right atrium across the foramen ovale to the left atrium with the echo transducer in the subxiphoid position. The balloon is inflated and its position within the left atrium is confirmed by echo. The catheter is withdrawn according to the technique of Rashkind. Withdrawal is halted when the balloon traverses the atrial septum. Adequate septostomy is indicated on echo by a defect at least 5 mm in diameter and by flapping of the inferior rim of the atrial septum. There were no complications using this technique and a clinically adequate septostomy was achieved in each patient. Two-dimensional echocardiography-assisted balloon atrial septostomy minimizes risk of complications and decreases exposure to ionizing radiation.
Antibody Therapy of Digoxin Intoxication
Authors: Cohen Sanford N.
Published: December 2021

The potential toxicity of digitalis preparations has been recognized since Withering's original report of the medicinal uses of foxglove in 1785. Over the years, physicians have developed clinical practices to maintain most patients who require digitalis preparations on dosage regimens that maximize clinical efficacy while minimizing the potential for serious toxicity. However, in some instances therapeutic administration still leads to clinical toxicity and may cause the death of a patient. Examples of such "iatrogenic" induction of digitalis intoxication are well known to anyone who deals with pediatric patients who are seriously ill with heart disease. Two other all-too-common phenomena are the accidental ingestion of digitalis preparations by young children and the intentional ingestion of this potent drug with suicidal intent.
Letter to the Editor
Authors: Shapiro Gail G. , Koup Jeffrey R.
Published: December 2021

In response to the letter by Kirshenbaum and Frick, we have the following comments:

First, calculation of the upper and lower limits of the dosage requirement (mg/kg/day) as stated in our paper was correct. One need only be aware that 10 µg/ml equals 10 mg/liter and that there are only 1,000 µg/mg not 1,000,000 as suggested by Kirshenbaum and Frick. Thus, the dosage limits are 7.5 to 54 mg/kg/day.

Second, the doses shown in the table were prescribed on the basis of "nearest fit" timed-release preparation available at the time of the study.
Water-Soluble Vitamin D in Human Milk: A Myth
Authors: Little Joseph A.
Published: December 2021

I was happy to read the report from Greer et al.1 This biochemically confirms the clinical observation that the majority of children who develop clinical rickets are breast-fed. During the ten years, 1970-1979, I have seen six cases of clinical rickets. All of these infants were breast-fed.2 The only exception has been the rickets of prematurity.

I should like to commend, again, the report from the Department of Pediatrics and Biochemistry of the University of Wisconsin.
Tuberculosis Returns
Authors: Leggiadro Robert J. , Laaly Farah Olga
Published: December 2021

We read with interest "Apparent Resurgence of Tuberculosis in Urban Children" by Inselman et al.1 The authors emphasized the continued need for routine tuberculin skin testing in children, especially those in high-risk areas. We agree and wish to underscore further aspects of tuberculosis control.

Our recent experience at a suburban county hospital serves to remind the clinician that aggressive identification and appropriate management of close contacts of patients with active tuberculosis remain critically important in terms of individual morbidity and mortality and optimal control of the disease.2
Neonatal Hospice Program
Authors: Whitfield Jonathan M. , Glicken Anita , Harmon Robert , Siegel Roberta , Butterfield L. Joseph
Published: December 2021

We wish to comment on the editorial by Silverman (A hospice setting for humane neonatal death, Pediatrics 69:239, 1982), which we find both insightful and timely. We feel we must take issue with some of Silverman's statements. Over the last 3½ years we have actively incorporated hospice concepts into our neonatal program at Denver Children's Hospital, creating a so-called Neonatal Hospice Program.

1. We agree that health care professionals involved in neonatal intensive care tend to be oriented to "rescue" care; however, in our own experience we have found that with adequate training not only are the staff members open, but often they are very willing to switch from a rescue to palliative mode of treatment in the appropriate circumstances.
Letter to the Editor
Authors: Ginsburg Charles M. , McCracken George H.
Published: December 2021

Boxerbaum has implied that we have questioned the concept of penicillin prophylaxis for patients with rheumatic fever. We did not! Rather, we provided pharmacologic data demonstrating that the concentrations of penicillin in serum may be inadequate to prevent colonization or disease with group A streptococci or pneumococci 18 days or longer after administration of the doses of benzathine penicillin G that are recommended by the American Heart Association. In fact, Boxerbaum's data support our contention—group A streptococci were isolated from 8% of his patients who had received intramuscular benzathine penicillin.
Treatment of Obese Children With and Without Their Mothers: Changes in Weight and Blood Pressure
Authors: Brownell Kelly D. , Kelman Jane H. , Stunkard Albert J.
Published: December 2021

Weight and blood pressure changes were evaluated in a 16-month controlled trial comparing three methods of involving mothers in the treatment of their obese adolescents (aged 12 to 16 years). The treatments were: (1) Mother-Child Separately—children and mothers attended separate groups; (2) Mother-Child Together—the children and mothers met together in the same group; and (3) Child Alone—the children met in groups and mothers were not involved. The program consisted of behavior modification, social support, nutrition, and exercise. The Mother-Child Separately group lost more weight (8.4 kg) during treatment than did the other two groups (5.3 and 3.3 kg). Differences between the groups increased at the 1-year follow-up: compared to pretreatment weight, the Mother-Child Separately group lost 7.7 kg compared with gains of approximately 3 kg in the other two groups. Blood pressures of children with the highest initial pressures decreased by 16/9 mm Hg at the end of treatment and by 16/5 mm Hg at the 1-year follow-up. These results suggest that a program of behavior modification and parent involvement can lead to significant weight losses in obese children, and that the nature of parent involvement may be important.
Decline in Neonatal Mortality, 1968 to 1977: Better Babies or Better Care?
Authors: David Richard J. , Siegel Earl
Published: December 2021

A state's declining neonatal mortality rate was studied over the decade 1968 to 1977 to determine how much of the decrease resulted from improved risk characteristics in the newborn population. A shift was found over time, mostly among white births, toward higher birth weights and longer gestations. Overall, there was a 19% reduction in the low-birth-weight rate. Considerable improvement in birth weight-specific mortality was also found, especially in babies weighing 1,000 to 2,500 g during the last 5 years of the study. A neonatal risk matrix model was applied to the changes over time to separate the improvement due to shifts in population risk characteristics from that due to better care of the newborn. Thirty-four percent of the decade's decrease in NMR was attributable to changes in the birth weight and gestational age makeup of the newborn population. This "better babies" component was more prominent early in the decade and among the white population.
Incidence, Severity, and Timing of Subependymal and Intraventricular Hemorrhages in Preterm Infants Born in a Perinatal Unit as Detected by Serial Real-Time Ultrasound
Authors: Dolfin Tzipora , Skidmore Martin B. , Fong Katherine W. , Hoskins Elizabeth M. , Shennan Andrew T.
Published: December 2021

Real-time ultrasound scans were performed on 66 low-birth-weight infants within the first six hours of life (mean, two hours), and then at 12, 24, 48, and 72 hours, and thereafter at weekly intervals. All of the infants were born in a perinatal unit. The incidence of intraventricular hemorrhage and subependymal hemorrhage was 31%. Eight of 20 infants had small hemorrhages (Papile, grades I and II); seven infants sustained grade III hemorrhages, and five infants sustained grade Iv hemorrhages. All hemorrhages occurred in the first 72 hours of life; 25% were diagnosed with the first scan (ie, within the first six hours of life). The infants especially at risk were those less than 29 weeks's gestation. Five infants developed progressive posthemorrhagic ventriculomegaly that subsided spontaneously by age 8 weeks. The mortality in the study group was only 4.5%.
Cutaneous Amebiasis
Authors: Rimsza Mary Ellen , Berg Robert A.
Published: December 2021

An infant with cutaneous amebiasis of the vulva and amebic liver abscess is described. Epidemiologic investigations and serologic studies were crucial in establishing the diagnosis. The vulvar amebic ulcers responded dramatically to metronidazole therapy. Cutaneous amebiasis is a rare complication of Entamoeba histolytica infection which should be considered in the differential diagnosis of perineovulvar or penile ulcers. Cutaneous amebiasis may also occur on the abdominal wall surrounding a draining hepatic abscess, colostomy site, or laparotomy incision.
Body Shape in Young Children with Homozygous Sickle Cell Disease
Authors: Stevens Michael C. G. , Hayes Richard J. , Serjeant Graham R.
Published: December 2021

Body shape, defined by detailed anthropometric measurement, was compared in 64 children with homozygous sickle cell (SS) disease, and in 123 children with a normal hemoglobin (AA) genotype, aged 4 to 6 years. Children with homozygous sickle cell disease showed an average reduction in weight, height, sitting height, limb length, interacromial and intercristal diameters, and skinfold thickness. They showed increased anteroposterior chest diameters with an increased anteroposterior-lateral chest diameter ratio. This report establishes that the effect of homozygous sickle cell disease on growth patterns in childhood is apparent before the age of 6 years. The relationship to changes in body shape, seen during adolescence and in affected adults, and their possible determinants, are discussed.
Pharyngeal Gonorrhea
Authors: EMANS S. JEAN
Published: December 2021

To the Editor.—

The article "Screening for Pharyngeal Gonorrhea in the Urban Teenager"1 is clearly of value to pediatricians. However, I believe the final conclusion of the paper, which advocates routine culture for pharyngeal gonorrhea "whenever genital cultures are collected," is premature. As a single culture for gonorrhea is currently $18 in our laboratory, triplicate screening cultures of the pharynx, rectum, and cervix would be a financial burden to most asymptomatic adolescents in a low-risk setting (asymptomatic rate 1% to 2%).
Peritonitis in Children Undergoing Continuous Ambulatory Peritoneal Dialysis
Authors: Fine Richard N. , Salusky Isidro B. , Hall Teresa , Lucullo Liliana , Jordan Stanley C. , Ettenger Robert B.
Published: December 2021

The incidence of peritonitis in 29 children undergoing continuous ambulatory peritoneal dialysis during a 20-month period was one episode every 12.5 patient-months. Of the 20 episodes of peritonitis, seven (35%) were treated on an ambulatory basis, and 13 required patient hospitalization. The annualized hospitalization rate for the 29 patients during 252 patient-months was 3.8 days per patient. All patients recovered from peritonitis; the only complication was the need to replace two peritoneal catheters. These data would seem to indicate that the potential threat of peritonitis should not curtail continued utilization of continuous ambulatory peritoneal dialysis in children.
Tracheal Atresia, Proximal Esophageal Atresia, and Distal Tracheoesophageal Fistula: Report of Two Cases and Review of Literature
Authors: Sankaran K. , Bhagirath C. P. , Bingham W. T. , Hjertaas R. , Haight K.
Published: December 2021

Two cases with unusual primitive foregut anomalies are described. Both children, born within 24 hours of each other, had complete tracheal atresia, proximal esophageal atresia, and distal tracheoesophageal fistula along with some minor anomalies; both needed immediate tracheostomy for adequate ventilation. At 15 months of age, both patients are thriving and developing normally with the exception of their speech. A review of the literature revealed no other survivers with this condition. Diagnosis of tracheal atresia should be kept in mind when a newborn infant exhibits respiratory distress without an audible cry associated with failure to advance the endotracheal tube beyond the vocal cords. An immediate tracheostomy can be lifesaving in these children.
Extended Contact After Birth: Time-Controlled or Self-Regulatory?
Authors: ANDERSON GENE CRANSTON
Published: December 2021

To the Editor.—

Lamb has written a thought-provoking article in which he reviewed the research on early contact and maternalinfant bonding.1 He concluded that the methodologies were impoverished and the conclusions were based on equivocal findings. Although his critique merits consideration, it is important to realize that the contact opportunities were self-regulatory in only one of the many studies he reviewed.2 In the context of birth, self-regulatory means that the mother and infant remain together after birth in the same bed, or at least adjacent ones, and are allowed to interact with each other on cue and to satiety.
Extended Contact After Birth: Time-Controlled or Self-Regulatory?
Authors: LAMB MICHAEL E.
Published: December 2021

In Reply.—

Anderson may indeed be correct in arguing that the opportunity for self-regulatory extended contact positively affects the process of mother-neonate bonding. However, the only relevant study1 cited contains a methodologic flaw, which makes the results uninterpretable.2 Confounds like this cannot simply be ignored just because we like the tenor of the results. Thus the issue remains open—neither proven nor disproven. It should also be noted that the direct effects of self-regulatory extended contact, if they exist, are likely to be temporary.
Central Venous Catheter Complications
Authors: DOLCOURT JACK L. , BOSE CARL L.
Published: December 2021

In Reply.—

We thank Hoelzer and L'Hommedieu for their comments and for pointing out that subclavian catheters are capable of lasting as long as the percutaneously placed central Silastic catheter (PCSC).1,2 The median duration for PCSC usage in our series3 was 21 days.

For us, the diagnosis of superior vena cava syndrome is only suspected in the presence of differential upper body edema. The diagnosis of right atrial thrombosis is not likely to be made by us without clinical signs of venous obstruction as echocardiograms are not routinely performed.
Flaws in Study of Management of Children with Febrile Illness
Authors: LEDUC D. G. , PLESS I. BARRY
Published: December 2021

In Reply.—

In general, we agree with the criticism raised by Soman and by the Journal Club in Minneapolis. The "bottom line" of our paper is that there were no significant differences between the outcomes in the two groups. However, whenever a study involves relatively small samples the possibility of a type II error, due to lack of statistical power, must always be considered. The differences to which we called the readers' attention would have been statistically significant (with β set at .5) if the samples were as large as 375.
Aminophylline Confusion
Authors: WEINBERGER MILES
Published: December 2021

In Reply.—

Patano has identified an inconsistency in our position paper on the treatment of asthma in that the term aminophylline was used in place of theophylline. unfortunately, this is one more example of the confusion created by continuing to use the antiquated terminology for some traditional theophylline formulations that have been marketed as so-called "salts." The active ingredient in the formulation identified as "aminophylline" is theophylline, which makes up approximately 80% of the labeled aminophylline content.
Back Blows and Choking
Authors: MONTGOMERY WILLIAM H.
Published: December 2021

To the Editor.—

The special commentary by Heiemlich on first aid for choking children1 is filled with inaccuracies, is a gross distortion of real issues, and cannot go unanswered by the American Heart Association (AHA).

It was most appropriate to publish Day's scientific article on choking.2 It is studies such as this that assist the AHA is making recommendations for standards and guidelines in cardiopulmonary resuscitation (CPR) for the professional and lay communities.

Contrary to Heimlich's statements, back blows are not death blows! Medical literature contains articles regarding their successful application,3 and there are literally hundreds of successful anecdotal cases.4
Back Blows and Choking
Authors: HEIMLICH HENRY J.
Published: December 2021

In Reply.—

Day and colleagues1 at tye Yale University School of Medicine reported studies proving that back blows propel a foreign body downward and backward into the throat or larynx in a direction toward the lung at a force of 3 g. Day et attributed this finding to Newton's Third Law of Motion: "To every action there is always opposed an equal reaction." They conclude that, in a choking person, "in the case of a partial obstruction, a back blow could transform the situation into one of compleete blockage."
Environment, Genes, and Alcohol
Authors: CASEY PATRICK H.
Published: December 2021

To the Editor.—

The recent article by Golden et al1 on fetal alcohol syndrome (FAS) and infant development purpots to be a controlled study which suggests that infants with fetal alcohol effects can be classified at birth and that their developmental outcome can be accurately predicted. Although there are several problems in the interpretation of their data and conclusions, I would like to address a major methodologic flaw in this report which persists throughout the literature on FAS.
The Irresponsible Expert Witness
Authors: TURETSKY ROCHELLE A.
Published: December 2021

To the Editor.—

Congratulations are in order to Robert L. Brent for calling attention to the ethical and scientific problems of the expert witness (Brent RL: The irresponsible expert witness: A failure of biomedical graduate education and professional accountability. Pediatrics 1982;70:754-762). That the recent American Academy of PEdiatrics meetings in New York devoted a Round Table session to this issue, points up the concern with which health care professionals view the interface of law and medicine.

Two points alluded to by Brent deserve to be clearly restated.
BCG Vaccine and Isoniazid Prophylaxis
Authors: BRUNELL PHILIP A.
Published: December 2021

In Reply.—

The Committee on Infectious Diseases, after carefully considering the advice of its consultants and reviewing the available data, recommends that isoniazid (INH) should not be used concurrently with bacillus Calmette-Guerin (BCG). As indicated in the most recent report of the Committee,1 there is concern about the protection conferred by BCG,2,3 even when it is given without INH. To administer a drug that inhibits the replication of BCG, therefore, appears to be imprudent.

That INH inhiits the replication of BCG is generally acknowledged.