bluuebunny/crossref_metadata_2025 huggingface dataset:
Odd Thoughts on Well-Child Care
Authors: Nazarian Lawrence F.
Published: December 2021

It is good to take a hard look at longstanding habits. Well-child care is at the heart of pediatrics; yet, even this most sacred of commitments has been under scrutiny in recent years, and rightly so. But those of us who spend half of our time in well-child visits are frustrated by studies that fail to demonstrate any measurable benefits from our efforts, with the exception of immunization programs. Are researchers really looking at the right parameters? Are there too many variables to allow a truly scientific evaluation of these practices?

At least it is comforting to hear that parental satisfaction and confidence are acknowledged by-products of our work, and intuitively we believe that this effect is good for growing children.
Insulin-Dependent Diabetes Mellitus
Authors: Ginsberg-Fellner Fredda
Published: December 2021

Insulin-dependent diabetes mellitus (IDDM), now usually called type I diabetes, is the most common endocrine disorder of childhood and adolescence, affecting at least 1 in 400 youngsters. In addition, the prevalence appears to be increasing, particularly as noted in Scandinavia, where registries for this disease are maintained. During the past 10 to 15 years, astounding advances have been made, both in the treatment of this disease and in understanding its etiology. However, perfect treatment, prevention, and cure of this disease and its long-term sequelae, which include cardiovascular disease, nephropathy requiring dialysis and renal transplantation, neuropathy, and retinopathy, are still lacking. During the next two decades, progress in these areas will surely be made, and the prognosis for children and adolescents with IDDM will continue to improve.

Until the discovery of insulin in 1921, virtually all children, adolescents, and young adults with IDDM died within 3 years of disease onset, often reduced to mere skeletons as their weight rapidly decreased secondary to low calorie diets. With the advent of insulin administration, mortality rapidly decreased and expectations increased that, as in other endocrine disorders requiring replacement therapy, diabetes would no longer be a problem after insulin was widely available. Indeed, the use of short-acting regular or crystalline insulin four times per day along with dietary restriction in the 1920s more closely parallels recommendations for control of the disease today than did the modes of therapy in vogue from the 1930s through the middle 1970s.
Congenital Dislocation of the Hip
Authors: MacEwen G. Dean , Millet Chad
Published: December 2021

Early diagnosis and treatment are the keys to a successful result in infants with congenital dislocation of the hip. In the neonatal period, a majority of infants with hips that would later be found to be dislocated can be detected and effectively treated. With the use of ultrasonography to supplement clinical suspicion, the number of children with congenital dislocation of the hip diagnosed in the newborn period should be expected to increase. Repeated examination, especially during the first 6 months of life, can be expected to detect those additional children with congenital dislocation of the hip who were not detected in the nursery.

The Pavlik harness has been shown to obtain a successful result in most children younger than 6 months of age while holding the incidence of avascular necrosis to nearly zero. Even though these results are encouraging, the problem must be discovered early for the child with congenital dislocation of the hip to be treated optimally. Thus, it is of the utmost importance that the physician have an awareness of this problem. The primary physician must also continue to conscientiously examine the hips of patients on a regular basis even after the initial examination and, when necessary, use the added modalities available to him or her to accurately diagnose questionable hip conditions of patients.
Peptic Ulcer Disease in Children
Authors: Gryboski Joyce D.
Published: December 2021

Chronic gastroduodenal ulceration is the end product of an imbalance between acid levels, peptic hostile factors, and mucosal defenses. This condition differs significantly from stress ulceration, in which the primary factor is decreased mucosal blood flow, and from nonsteroidal anti-inflammatory drug-induced injury, in which there is local vascular injury and inhibition of prostaglandin synthesis. The identification of H pylori as a cause of chronic gastritis, duodenitis, and peptic ulcer is required for specific antibacterial therapy.
Cancer and the Pediatrician: An Evolving Partnership
Authors: Pizzo Philip A.
Published: December 2021

Although cancer is among the leading causes of death in children, only approximately 6550 new cases are diagnosed each year in children less than 15 years of age in the United States. Thus, most pediatricians are unlikely to diagnose cancer in a child in their clinical practice. At the same time, major progress in the treatment of children with cancer has been made in the last decades. Indeed, more than 50% to 60% of children diagnosed with cancer are likely to become prolonged survivors, and most will be cured of their malignancy. Accordingly, it has been estimated that in 1990, 1 of every 1000 young adults reaching the age of 20 will be a survivor of childhood cancer.
Celiac Disease
Authors: Murphy M. Stephen , Walker W. Allan
Published: December 2021

Celiac disease is a disorder characterized by a permanent sensitivity to gluten, such that its presence in the diet induces an enteropathy. Exposure of susceptible individuals to gluten-containing foods causes small intestinal mucosal injury associated with malabsorption of variable severity. The association between the occurrence of malabsorption and the presence of wheat or rye in the diet was first recognized by Dicke in 1950. Subsequently, barley was also shown to be toxic. The role of oats in producing disease remains controversial, but rice and maize are known not to cause disease.

EPIDEMIOLOGY

Celiac disease is one of the most frequent causes of malabsorption during childhood, with prevalence rates of between 1:500 and 1:3000 commonly quoted in the literature. Although the exact prevalence in any particular region is difficult to determine, marked geographical variations do appear to exist. A preyalence rate of 1:300 has been reported in western Ireland. Similarly, celiac disease is reported more frequently in patients from European countries than from North America. There is some evidence that the incidence may also be changing. Based on studies from the United Kingdom, it has been suggested that the incidence of childhood celiac disease may have been declining in recent years, following a peak in the early 1970s.
Special Infant Formulas
Authors: Klish William J.
Published: December 2021

Breast-feeding is still the optimal mode of feeding for the normal full-term infant. At the present time, no infant formula has been developed that can reproduce the immunologic properties, digestibility, and trophic effects of human milk. The nutritional content of infant formulas has come a long way since 1849 when Baron Justus van Liebig stated that all living tissue, including food, was composed of different proportions of carbohydrate, fat, and protein. This resulted in the first commercially available human milk substitute, Baron von Liebig's Soluble Food, which was available in the United States by 1869.1 In 1884 Dr A.V. Meigs of Philadelphia published the chemical analysis of human and cow's milk that has served as the basis for modern infant formulas.2 The stimulus for this early research for a substitute for human milk was based upon the recognition that not all infants have access to human milk. Infants fed with substitute foods did not thrive well, so attention was turned to the nutritional content of infant feeding mixtures. This emphasis remains to the present time, even though technology has developed in this past decade so that investigators are beginning to understand the importance to the growing infant of other factors such as the immunologic and trophic components of milk.
The Role of the Pediatrician in School Health
Authors: Sklaire Martin W. , McInerny Thomas K.
Published: December 2021

Education and health are mutually dependent. If the child is not healthy, then he or she cannot be educated due to increased absenteeism. If the child is a failure in school, lack of self-esteem affects health and the relationship to the family and community. School health programs exist to support the education process. Most schools require that these programs be directed by a physician. Because of his or her training and interest in school children, the pediatrician thus takes on the responsibility of planning a school health program or acting as a liaison between the school, the child, and the family.1

SCHOOL HEALTH PROGRAM

Administration and Planning
Lower Gastrointestinal Bleeding
Authors: Silber Gary
Published: December 2021

The differential diagnosis of lower gastrointestinal bleeding in children can be reduced markedly simply by taking into account the age of the child. The clinical condition of the patient can further help narrow the diagnostic possibilities. Newborns and infants who are clinically unstable are more likely to have diseases such as necrotizing enterocolitis, volvulus, Hirschprung disease, intussusception, or Meckel diverticulum. A baby who appears healthy should be examined for swallowed blood, allergic colitis, anal fissures, or lymphonodular hyperplasia. An older child of healthy appearance with bleeding is likely to have a juvenile polyp or infectious colitis, but a child who appears sick may have hemolytic uremic syndrome, Henoch-Schoenlein purpura, or inflammatory bowel disease. This information, along with that gleaned from the physical examination, can lead the pediatrician to determine the need for specific tests, such as abdominal radiographs, stool cultures, and an endoscopic evaluation.

We have come a long way in our ability to diagnose the causes of lower gastrointestinal bleeding. With the availability of newer radiographic and nuclear medicine modalities and the ability to visualize the colon endoscopically, the need for exploratory laparotomy for diagnosis is rarer. While surgery may still be the therapy of choice, new diagnostic modalities give the surgeon much more preoperative information.
Diagnosis and Management of Upper Gastrointestinal Tract Bleeding in the Pediatric Patient
Authors: Ament Marvin E.
Published: December 2021

Gastrointestinal bleeding in patients at any age is frightening. The fear stems from the knowledge that bleeding, if severe enough and sustained for long intervals, may lead to shock and death. Fortunately, in both pediatric and adult patients, instances in which bleeding is so massive and uncontrollable that it leads to rapid demise are extremely rare. The approach to diagnosis and treatment of gastrointestinal hemorrhage by the physician should be calm, logical, and expeditious to help allay the fears of the patient and family, and to reduce the morbidity associated with the hemorrhage in the event its cause is found to be serious. Fortunately, the causes of gastrointestinal bleeding in the pediatric population are fewer than in adults; accordingly, the differential diagnosis is usually shorter, although not necessarily easier. In contrast to adults, the age of the pediatric patient may play a key role in determining the differential diagnosis.

MANIFESTATION OF BLEEDING (Table 1)

Before discussing the pathophysiology of bleeding, we will establish definitions of the words frequently associated with gastrointestinal bleeding.

Hematemesis is the vomiting of blood. The blood may be either bright red or "coffee ground" in appearance if it has been altered by gastric acid. Hematemesis implies that the site of bleeding is proximal to the ligament of Treitz.
Juvenile Dermatomyositis: A Clinical Overview
Authors: Pachman Lauren M.
Published: December 2021

The child who develops the symptoms of the specific rash, proximal muscle weakness, and fatigue should seek medical care promptly. With the advances in physical and medical therapy, many of the consequences of the disease can now be ameliorated. There are suggestive data that JDMS and PM may each have a different pathophysiology, but more evidence is needed. The next few years should be exciting as there is increased effort to determine if there is, in fact, a causal relationship between Coxsackievirus B or other enterovirus and genetic factors that alter the susceptibility to or severity of the course of the disease—JDMS.
Cardiopulmonary Resuscitation of the Newborn
Authors: Sinkin Robert A. , Davis Jonathan M.
Published: December 2021

Approximately 3.5 million babies are born each year in approximately 5000 hospitals in the United States. Only 15% of these hospitals have neonatal intensive care facilities. Six percent of all newborns require life support in the delivery room or nursery, and this need for resuscitation rises to 80% in neonates weighing less than 1500 g at birth.

Personnel who are skilled in neonatal resuscitation and capable of functioning as a team and an appropriately equipped delivery room must always be readily available. At least one person skilled in neonatal resuscitation should be in attendance at every delivery. Currently, a joint effort by the American Academy of Pediatrics and the American Heart Association has resulted in the development of a comprehensive course to train appropriate personnel in neonatal resuscitation throughout the United States. Neonatal resuscitation is also taught as part of a Pediatric Advanced Life Support course offered by the American Heart Association. In concert with the goals of the American Academy of Pediatrics and the American Heart Association, we strongly urge all personnel responsible for care of the newborn in the delivery room to become certified in neonatal resuscitation.

The practical approach to neonatal resuscitation is the focus of this article.
Inpatient Care: The General Pediatrician's Future
Authors: Menna Vincent J.
Published: December 2021

In my 22 years as a general pediatrician, I have practiced at an isolated military post as well as in a wealthy suburb, a rural area, and a combination small town-suburb. In addition, I trained in a major urban area. As a result of these travels, I feel that I have some insight into the problems of pediatricians in different areas and the future we face.

A significant problem facing present-day pediatricians is how to care for sick inpatients as well as maintain a busy office practice. Although many of our medically interesting and challenging problems are inpatients, most of a general pediatrician's income is generated from his or her outpatient practice.
Enuresis: The Difference Between Night and Day
Authors: Hurley R. Morrison
Published: December 2021

The differentiation between night and day wetting allows the application of practical developmental and behavioral approaches to the diagnosis, evaluation, and therapy of each problem. Wetting the bed is mainly a developmental issue, and wetting the pants is a behavioral one.
Recurrent Epistaxis
Authors: Mulbury Peter E.
Published: December 2021

Epistaxis in the pediatric patient is a relatively common, and usually easily controlled, event. The practitioner should be aware of the anatomy, potential causes, and methods of control available for this condition.
Surfactant Replacement Therapy
Authors: Soll Roger F. , Lucey Jerold F.
Published: December 2021

Despite medical and technological advances, respiratory distress syndrome (RDS) remains a major cause of morbidity and mortality in premature infants. Thirty years have passed since Avery and Mead demonstrated that infants dying of RDS were deficient in pulmonary surfactant. In those three decades, advances in our understanding of the composition, function, and metabolism of pulmonary surfactant have finally led to clinical trials of surfactant replacement therapy in thousands of premature infants. This article reviews the current status of surfactant replacement therapy.

BACKGROUND

Pulmonary surfactant is essential for normal lung function. Surfactant forms a film at the alveolar surface, which prevents the lung from collapsing at the end of expiration. Surfactant may have other functions as well, including the prevention of pulmonary edema, the prevention of infection, and the prevention of lung injury from toxic substances, such as oxygen (Table 1)

CHEMICAL MAKEUP

The chemical makeup of pulmonary surfactant has been well defined (Table 2). Lipids are the major component, comprising up to 80% to 90% of surfactant by weight. The majority of the lipids in pulmonary surfactant are highly polar phospholipids, predominantly phosphatidylcholine. Three proteins associated with surfactant have been these surfactant proteins may play a critical role in surfactant function by improving the adsorption of surfactant at the alveolar surface and by aiding in surfactant re-uptake and metabolism.
Consultation with the Specialist
Authors: Healy Gerald B.
Published: December 2021

Otitis media with effusion (OME) offers the primary care physician both a diagnostic and a therapeutic challenge. The tympanic membrane of a child frequently is difficult to assess, especially in the uncooperative patient whose ear canal is partially occluded by cerumen. However, if the ear canal can be cleared to allow an unobscured view of the tympanic membrane, then pneumatic otoscopy and tympanometry can be extremely valuable in both the diagnosis and follow-up after initiation of treatment.

Patient Groups

The pediatrician usually is faced with two groups of patients in this disease process. The first group includes the young child who has recurrent episodes of acute otitis media. Frequently, affected patients can be subdivided into those who clear their middle ear space of fluid between episodes and those who do not. The second group consists of children who have asymptomatic chronic effusion, usually leading to persistent hearing loss. These children tend to be slightly older but are no less troublesome for the clinician.

Treatment

Controlled clinical trials have been extremely important in providing information about both of these groups. These studies have shown that chemoprophylaxis is extremely useful in managing the patient who has recurring acute suppurative episodes not complicated by persistent effusion during the interval periods.
Lumps and Bumps in Children
Authors: Putnam Thomas C.
Published: December 2021

Many lesions involving the skin or subcutaneous tissues alarm parents and, often fearing cancer, they bring their child to a physician. Most lesions are benign and rarely life-threatening. The physician faces the problem of determining which characteristics suggest only observation of a lesion and which make biopsy necessary.

Because many lesions have a predilection for certain areas of the body, this is a useful form of categorization (Table 1). On first inspection of a superficial lesion, several questions must be asked, including the known duration, change in size, presence of pain or other signs of inflammation, and any noted multiplicity. The examination includes an accurate measurement of the size and, most importantly, a determination of the level of the lesion. This will help establish the diagnosis and help to determine whether the possibility of malignancy exists.

Essentially all lesions originating in the skin of children are benign. Some are obvious, such as a wart, while others may not be so clear-cut, especially if the epidermis is not altered in appearance. Upon palpation of a cutaneous mass, the skin does not move over the surface and puckers when the adjacent skin and tissues are compressed and elevated. If the skin moves freely over the mass, the nature of the lesion is not so readily apparent.
INDEX OF SUSPICION
Authors: Berera Geeta , Dixon Robert H. , Koenig Willaim J.
Published: December 2021

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

We invite readers to contribute case presentations with discussions.

Case 1 Presentation

A 24-mo-old boy is seen with a 2-d history of cough and fever. His past medical history includes recurrent vomiting and poor weight gain since 3 mo of age, and he has been hospitalized five times for dehydration. The child sat independently at 7 mo of age but is not yet walking.

On examination, he appears to be small and thin and is irritable. His temperature is 39.5°C(103.1°F), pulse is 150 beats/mm, and respiratory rate is 35 breaths/mm. The child's height, weight, and head circumference are all below the 5th percentile, but proportional. Except for nasal congestion and mild dehydration, the remainder of his examination is normal. Serum sodium is 140 mEq/L, potassium 3.5 mEq/L, chloride 117 mEq/L, and bicarbonate 11 mEq/L.
Childhood Asthma: Update
Authors: Shapiro Gail G.
Published: December 2021

Definition and Pathophysiology

Asthma is a reversible airways disease characterized by both smooth muscle hyperreactivity and airway inflammation. During the 1970s and early 1980s the focus was on smooth muscle constriction, and it was believed that better bronchodilators would greatly diminish our difficulties in controlling this condition. This, unfortunately, was not the case. The emphasis of therapy today has turned to airway inflammation. Lung biopsies from patients who have asthma show destruction of respiratory epithelium, basement membrane thickening, and inflammatory cellular infiltrate. Among the infiltrating cells are eosinophils, macrophages, and neutrophils that are called to the site of inflammation by the chemotactic products released by activated mast cells. Upon their arrival, these cells release their own products of inflammation, which amplify this immunologic response. A variety of neuropeptides also play a role, some serving to stabilize and others to destabilize the airway. One result of this airway inflammation is airways reactivity, also known as bronchial hyperresponsiveness.

A common example of this scenario is the child who has allergic asthma and encounters a problematic allergen. This child has immunoglobulin E (IgE) to this allergen bound to mast cells in his or her airway. Upon exposure to the allergen, the binding of IgE and antigen triggers mast cell mediator release within minutes.
Pediatric Pharmacokinetics and Therapeutic Drug Monitoring
Authors: McLeod Howard L. , Evans William E.
Published: December 2021

Recent advances in pediatric clinical pharmacology have provided a more rational approach to using several medications in children. An increased understanding of the effect of human development, concurrent medications, organ function, and disease states on the absorption, distribution, metabolism, and excretion of drugs has provided a stronger scientific basis for determining drug dosages in children. By measuring drug concentrations and utilizing pharmacokinetic and pharmacodynamic principles, the probability of therapeutic response can be enhanced for a number of medications. Likewise, therapeutic drug monitoring can minimize the risk of adverse effects from many drugs used in children. However, it must be recognized that toxicity can occur in some patients even though plasma drug concentrations are in the therapeutic range; similarly, some patients may not experience a therapeutic effect when plasma drug concentrations are in the same target range. Therefore, achieving the desired plasma concentration of a drug can enhance both the probability of a therapeutic response and diminish the probability of a toxic response. Therapeutic ranges, however, are only intermediate endpoints that must be used in the context of additional criteria to assess the clinical efficacy of any given drug therapy.
Pediatric Ocular Injuries
Authors: Klein Betty R. , Sears Marvin L.
Published: December 2021

Although an ophthalmologist should be consulted for virtually all eye injuries, the first person to see the patient or talk to the parents can be of enormous value in preventing or limiting the sequelae of the injury and subsequent visual loss. This article provides a practical guide to the management of pediatric ocular injuries resulting from trauma and addresses the incidence of ocular trauma in children and the potential for preventing these injuries.

Potential Injuries

The eye is an anatomically and physiologically complex system that is easily disrupted by sharp or blunt trauma. For this reason, subtle signs of external trauma may indicate serious intraocular injury. The cornea and vitreous are avascular and can be the sites of fulminant infection by even the most indolent of organisms introduced by injury. The crystalline lens is readily dislocated or may opacify after blunt or penetrating trauma. The diaphanous retina is attached to the inner surface of the eye by hydrostatic and osmotic forces. The smallest perforation can lead to total retinal detachment. The highly vascular uvea, which lies beneath the retina, can undergo massive hemorrhage after sharp or blunt trauma. The retinal arteries may occlude after sudden increases in intraocular pressure, which sometimes accompany intraocular or intraorbital hemorrhage.
INDEX OF SUSPICION
Authors: Green John L. , Tejeda David M.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

You are seeing an 8-year-old boy with the complaint of left knee pain and limp during the previous week. His mother reports that at times he plays well and seems fine, and at other times he limps noticeably on his left side and walks stiff-begged with his left knee aching. He has had a low temperature of 100°F to 101°F (37.7°C to 38.3°C) intermittently over the last few days, but generally has slept and eaten well.

On examination, he is cooperative, pleasant, and comfortable at rest, but looks noticeably pale. He does walk rather stiff-legged on the left side, with a mild limp both on walking and running. His knees are symmetrical al and equal in circumference, with full range of motion.
The Pediatric Hospital Consultant
Authors: Drutz Jan E.
Published: December 2021

Most pediatricians have been asked at one time or another to be a consultant or have been the primary care physician asking for a consultation. We or our consultant colleagues, however, often fail to appreciate the subleties inherent in our respective roles.

Although communication among physicians, both written and verbal, is essential for optimal patient care, communication between individual physician, parent, and patient not only extends common courtesy but also remains crucial in our present medicolegal climate. How often have we failed to tell a parent that we have asked for a consultant's opinion or, more embarrassingly, been asked to be the consultant and then walked in on the patient only to discover that no member of the family had ever been told by the patient's physician who we were or why we were there?
Consultation with the Specialist
Authors: Klein Betty R. , Sears Marvin L.
Published: December 2021

Optimal management of eye trauma requires a careful history, a controlled examination, protective measures to limit the damage and prevent infection, and swift triage to an ophthalmologist. Personnel in the emergency department or office can accomplish these goals and save the patient permanent visual disability.

How Does One Evaluate Trauma to the Eye?

A systematic approach emphasizing history, visual acuity, and external examination are essential in the evaluation of eye injuries.

The history should be detailed and should note the mechanism of injury, the events following the injury, preexisting eye disorders, systemic disorders, drug allergies, contraindications to anesthesia, when the patient last ate, and prior tetanus immunization. If ocular perforation, laceration, or intraocular foreign body is suspected, treat the patient as if preoperatively, allowing nothing by mouth, and consider intravenous antibiotics to protect against exogenous endophthalmitis.

Visual acuity examination must be performed in every case. Measure the visual acuity in each eye separately with corrective lenses in place. A near card may be used for examination at bedside. Picture cards and charts are available for measuring acuity in children age 3 to 6 years. Preverbal children can be tested grossly by allowing them to reach for a small toy with one or the other eye covered.
Henoch-Schoenlein Purpura
Authors: Lanzkowsky Shelley , Lanzkowsky Leora , Lanzkowsky Philip
Published: December 2021

The distinctive syndrome of Henoch-Schoenlein purpura (HSP) was first described by Heberden before 1800, and in 1808 English physician Robert Willan described a patient who had swollen, painful joints and a rash.

The syndrome owes its name to two German physicians. In 1837, Johan Schoenlein described several cases of purpura associated with arthritis, which he termed "peliosis rheumatica." In 1868, Edouard Henoch pointed out that the term "peliosis rheumatica" was inappropriate and restrictive because patients who had urticarial purpura and acute arthritis also manifested gastrointestinal symptoms, such as vomiting, colicky abdominal pain, and melena. He described four children who had purpura, colicky abdominal pain, gastrointestinal hemorrhage, and joint pain as well as renal involvement.1 Since these first descriptions, HSP also has been referred to as anaphylactoid, allergic, or rheumatoid purpura; leukocytoclastic vasculitis; and allergic vasculitis.1,2

Epidemiology

Seventy-five percent of all cases of HSP occur in children between 2 and 11 years of age, with younger children rarely affected. Children younger than 2 y experience a milder course of illness, with less frequent renal and gastrointestinal manifestations.3 HSP is exceedingly rare in adults, among whom other causes of vasculitis should be considered more likely.

The incidence of HSP is greater in males, with a male-to-female ratio of 1.5 to 2.0:1.
Children, Adolescents, and Television
Authors: Strasburger Victor C.
Published: December 2021

No parents in their right minds would invite a stranger into their home to teach their children for 3 to 5 hours per day; yet the television set is doing precisely that.1 Television is a powerful teacher of children. Children and adolescents spend more time watching television than in any other activity except sleeping, and more time from age 2 to 18 in front of the television set (15 000 to 18 000 h) than in the classroom (12 000 h).2 By the time today's children reach age 70, they will have spent a total of 7 y of their lives watching television. During an average year, an American youngster will be exposed to:3,4

• More than 14 000 sexual references, innuendos, and jokes—yet <175 will deal with birth control, self-control, abstinence, or sexually transmitted disease;

• Between 1000 and 2000 beer and wine commercials;

• More than 1000 murders, rapes, assaults, and armed robberies, and

• Nearly 20 000 commercials.

These figures notwithstanding, many parents and pediatricians underestimate the power of television to influence attitudes and behavior. Television is an equal opportunity teacher, capable of conveying prosocial messages just as easily as harmful ones. Because television is such a pervasive and influential medium that can affect a variety of health-related behaviors, pediatricians should familiarize themselves with its effects on children and adolescents.
INDEX OF SUSPICION
Authors: Goldbloom Richard B. , Bracikowski Andrea C. , Goldbloom Richard B.
Published: December 2021

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

We invite readers to contribute case presentations with discussions.

Case 1 Presentation

A 3-mo-old girl is admitted to the hospital for investigation of generalized swelling of 1 week's duration. The swelling involves her face and extremities. Her 2-y-old sister is healthy and her parents are not related.

The baby was born at term following an uncomplicated pregnancy and delivery and was breast fed during the first month of life. She fed eagerly but cried a lot, usually beginning 30 to 60 min after each feeding. Suspecting that she was not providing sufficient milk, her mother weaned her to a standard prepared infant formula at 1 mo of age. Although she took the formula well, the baby continued to cry excessively and had loose, foul-smelling stools. On the advice of her physician, she was changed to a soy-based formula, which she again took eagerly.
Vitamin Update
Authors: Udall John N. , Greene Harry L.
Published: December 2021

Pediatricians should be aware of the recommended daily allowances (RDAs) for vitamins. They also should have knowledge of the symptoms and signs of vitamin deficiencies and excesses so as to be able to institute treatment before severe and permanent functional impairment of vital organs occurs. In this article, the RDAs for vitamins will be discussed, followed by an update of fatsoluble and water-soluble vitamins.

Recommended Daily Allowances (Table 1)

In principle, the RDAs are based on various kinds of evidence: 1) nutrient intakes of fully breast-fed infants and of apparently healthy people from their food supply; 2) studies of subjects maintained on diets containing low or deficient levels of a nutrient, followed by correction of the deficit with measured amounts of the nutrient; 3) nutrient balance studies that measure nutrient status in relation to intake; 4) biochemical measurements of tissue saturation or adequacy of molecular function in relation to nutrient intake; 5) epidemiologic observations of nutrient status in populations in relation to intake; and 6) in some cases, extrapolation of data from animal experiments. In practice, there are limited data on which to base the RDAs.1 It should be recognized that all RDAs are somewhat arbitrary and generally on the high side.
Developmental Dyslexia: An Update
Authors: Nass Ruth
Published: December 2021

Definitions

Developmental dyslexia, also known as specific reading disability, is an unexpected difficulty in learning to read that occurs in the otherwise normal child. Rudel1 suggests it be defined by both exclusionary and inclusionary criteria. Her strict definition requires that five criteria be met: 1) The child must have no major neurologic abnormalities, such as overt cerebral palsy. Affected children may and often do have "soft" signs on neurologic examination, however. 2) The major sensory functions must be normal; the child cannot be blind or deaf. Practically speaking, children who are blind or deaf or who have cerebral palsy may be dyslexic if they have reading difficulties disproportionate to their other academic and intellectual abilities. 3) The child should have no major psychiatric problems. Problems with self-esteem are often, however, a reactive secondary issue in the child who has a learning disability. 4) Normal intelligence is required, using either a verbal or nonverbal measure. Children who have dyslexia often also have language problems. Hence, verbal intelligence scores may not reflect overall intellectual abilities accurately. 5) Finally, the dyslexic child must have been in a social and educational environment conducive to learning to read. Several studies of inner-city school children have demonstrated that enrichment programs help some nonreaders become readers, demonstrating the importance of teaching techniques.
Editor and Editorial Office Move
Authors: H. R. J.
Published: December 2021

A friend once said to me that three moves equal one fire to get rid of excess baggage. If so, I sense I have little baggage left. Some of my friends have kidded me that I cannot hold a job for long. In fact, I have moved at least every 12 years during my 43-year career in pediatrics. Once again, I am on the move, but this time it is due to my retirement from the Presidency of The William T. Grant Foundation in New York City. I have moved back to The University of Rochester, New York, where the Editorial Office will be located in the Department of Pediatrics.
Viral Hepatitis: A, B, C, D, and E—Prevention
Authors: Krugman Saul
Published: December 2021

The article in the June 1992 issue of Pediatrics in Review included a detailed discussion of the etiology, pathogenesis, clinical manifestations, course, complications, epidemiology, and prognosis of hepatitis A, B, C, D, and E. This second section reviews prevention and treatment of these infections.

Prevention of Hepatitis A

GENERAL MEASURES

Procedures designed to prevent fecaloral spread of hepatitis A virus should be used for control. These include scrupulous handwashing, proper sterilization of food utensils, fly abatement, and exclusion of potentially infectious food handlers. Although close contact is the most common mode of transmission, common source epidemics stemming from contaminated food, milk, and water supplies may occur.

PASSIVE IMMUNIZATION

Postexposure prophylaxis with standard immune globulin is recommended for all individuals who have had intimate exposure to a person with the disease. Immune globulin also is indicated for persons living in the same household because they are likely to have contact with the virus. However, routine use of immune globulin in schools, offices, and factories is not warranted; disease spread is unlikely under the conditions existing in these open facilities. The recommended 0.02-mL/kg dose of immune globulin should be given within 48 h, if possible, but not later than 1 wk after exposure.

Preexposure prophylaxis with standard immune globulin is recommended for persons traveling to or working in areas where type A hepatitis is highly endemic.
Consultation with the specialist
Authors: Lovejoy Frederick H.
Published: December 2021

Diagnosing poisoning by an unknown agent can be a difficult challenge. Five strategies of assessment may be used in logical sequence, however, to arrive at a diagnosis: (a) history, (b) physical examination, (c) rapid laboratory tests, (d) diagnostic trial, and (e) screening for toxins. This is illustrated by a case history, followed by discussion of a recommended approach and the utilization of these principles to arrive at a diagnosis in the case.

Initial Case History

A 41/2-year-old boy, with a history of onset of deep breathing following supper, is brought to your office by his mother. He had been alert and well all day, without fever, fully oriented, and without vomiting or diarrhea. He had been playing both in the house and garage in the morning and had spent the afternoon watching television. His temperature is 37.6°C, respiratory rate is 60 breaths per minute with deep inspiration and expiration, and pulse is 100 beats per minute and regular. He is without cyanosis. His pupils are midpoint, his lungs are clear, and his breath has no noticeable odor. What would you ask the mother in an effort to establish a diagnosis?

History

An unknown agent often can be suspected by history alone. The location of ingestion, if known, can offer clues.
Transmission of Infectious Diseases in Children
Authors: Goldmann Donald A.
Published: December 2021

A rational approach to the control of pediatric infectious diseases requires an appreciation of their epidemiology and mechanisms of transmission. The setting in which the exposure occurs may have a major influence on the risk of infection. Unfortunately, the epidemiology of many important pediatric pathogens is complex and incompletely understood. Recent advances in diagnostic microbiology and molecular epidemiology may help to solve some of the remaining riddles.
The Pediatrician's Role in the Diagnosis and Treatment of Substance Abuse
Authors: Alderman Elizabeth Meller , Schonberg S. Kenneth , Cohen Michael I.
Published: December 2021

Abuse of drugs and alcohol is pervasive in our society. The role of the pediatrician as a health-care provider from birth through young adulthood includes recognizing the stigmata in newborns of prenatally ingested drugs as well as being able to treat neonatal drug withdrawal syndromes. Questioning about drug use and other closely related topics should be incorporated into all health-care maintenance visits, starting at the age of 10 y, with parental participation and anticipatory guidance being offered. Physical examination and laboratory testing are not as helpful in confirming an impression of substance abuse as a comprehensive interview and a full appreciation of the warning signs of substance abuse.

Treatment of the problematic user with a multidisciplinary team that understands adolescent development and behavior as well as the problem of substance abuse is crucial. The decision to treat the teen in an ambulatory or inpatient setting is determined by the extent of abuse, underlying medical problems and psychopathology, and the degree of family dysfunction.

The pediatrician must not avoid addressing these issues with patients. If, however, upon identifying an adolescent or a newborn with a drug problem, the pediatrician feels uncomfortable or ill-prepared to manage the patient, appropriate professional referrals are warranted. Despite exercising the referral option for treatment, as advocate for child and family, the pediatrician remains professionally bound to track all drug abuse-related referrals while continuing to participate in the general ongoing care of the patient and family.
Sports Medicine
Authors: Risser William L.
Published: December 2021

This article discusses several topics that are rather loosely related, including prevention of injury, disqualifying conditions, heat illness, proper nutrition in sports that have weight categories, anabolic steroids, and treatment of contusions. All but the last fit the theme of injury prevention.

Injury Prevention

CONDITIONING

Proper physical conditioning can prevent injury. The principles of preventing overuse injuries in distance runners discussed herein can be generalized to other sports.

At the beginning of the season, the coach must control the duration, intensity, and frequency of training carefully. Atheletes often develop overuse injuries when they do too much too soon. In addition, runners should warm up and stretch before exercise and cool down and stretch afterwards. If they are using strength training as part of their conditioning program, they should begin this slowly and carefully. In warm or humid climates, they need proper hydration and gradual acclimatization to avoid heat illness, particularly during the first 2 weeks of training.

Proper conditioning includes instruction in the correct biomechanics of running; errors can lead to injury. Malalignment in the lower extremities, such as leg length discrepancies or excessive pronation, may disturb normal biomechanics. Affected athletes may avoid overuse injuries by using heel pads or arch supports. Clinicians should identify malalignment during preparticipation sports examinations, before injury occurs.
Chronic Liver Disease in Children
Authors: Mews Catherine , Sinatra Frank
Published: December 2021

Chronic liver disease encompasses a wide spectrum of disorders, including infectious, metabolic, genetic, drug-induced, idiopathic, structural, and autoimmune diseases. The clinical presentation and initial laboratory data in many of these diseases are similar, and a definitive diagnosis often relies on specialized laboratory investigation and histologic examination of liver tissue.

The aim of this article is to: 1) Define chronic hepatitis and cirrhosis; 2) Review briefly the clinical presentation, pathophysiology, diagnosis, and management of the more common pediatric causes of chronic liver disease; 3) Review the complications associated with chronic liver disease and discuss their appropriate management; and 4) Review the indications for hepatic transplantation.

Chronic Hepatitis

Chronic hepatitis is defined as ongoing inflammation within the liver that is capable of progression to cirrhosis, liver failure, and death. The presence of continued hepatic inflammation, as confirmed by clinical manifestations and laboratory studies, for a period of greater than 10 weeks usually excludes a self-limited hepatitis and implies chronicity. However, to fulfill the international criteria for chronic disease strictly, evidence of continued hepatic inflammatory activity needs to be present for a period of at least 6 months. Most pediatricians, however, allow 3 months for an acute liver insult to clear before undertaking specialized laboratory investigations and invasive studies.
New Concepts in the Management of Encopresis
Authors: Nolan Terry , Oberklaid Frank
Published: December 2021

Persistent fecal incontinence without anatomic abnormality, otherwise known as soiling or encopresis, frequently brings ridicule and shame to the affected child. The disability that it imposes is accentuated by the parental anger, guilt, and helplessness it engenders; by the peer hostility and rejection it promotes; and by the disgust with which it may be greeted by teachers. Home-based pediatric therapy is safe, generally very effective, and rewarding to patient, family, and physician. However, it requires a comprehensive understanding of both the underlying pathophysiology and the integrated therapeutic program of counseling, pharmacotherapy, and behavior modification.
Hallucinogens
Authors: Werner Mark J
Published: December 2021

Substances that produce hallucinations have been used for thousands of years. It is said that the Oracle of Delphi inhaled carbon dioxide emanating from a rock fissure to alter consciousness. Cannabis and certain mushrooms were used at the time of the Vedas. Hallucinogenic drugs first captured the American public's attention and concern in the early to mid-1960s during the age of psychedelic experience and "flower children." Over the past 20 years the aura surrounding hallucinogens has changed so greatly that today they are sometimes considered to be just another class of drugs used inappropriately by adolescents. However, the use of hallucinogens by adolescents is much more widespread than many pediatricians may realize. Approximately 14% of adolescents have used hallucinogens. Annual surveys of high school seniors indicate that approximately 10% have used hallucinogens, with 2% to 3% having used them in the past month. Specifically, 1.8% have used lysergic acid diethylamide (LSD) and 1.4% have used phencyclidine (PCP) within the past 30 days. Studies suggest that PCP is the only drug for which use by adolescents has been increasing in recent years.

The purpose of this article is to review the major physiologic and behavioral consequences of hallucinogen abuse, the presentation and management of acute intoxication and withdrawal, and the association between maternal use of hallucinogens and fetal abnormalities or neonatal withdrawal syndromes.