bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of Denver Developmental Screening Test
Authors: VANDERVOORT ROBERT L. , LEE EVON BATEY
Published: December 2021

To the Editor.—

Allan et al1 presented the developmental outcome of children with periventricular and intraventricular hemorrhage. They defined developmental delay as a "delay of 6 months or greater" as noted on the Denver Developmental Screening Test (DDST). The DDST is a screening test, not a diagnostic instrument, and as such, it is capable of determining children who are at increased risk of developmental delay. It does not indicate that a child is functioning at a particular age level.
Necrotizing Enterocolitis and Neuraminidase-Producing Bacteria: A Challenge for Future Investigations
Authors: DUC G.
Published: December 2021

To the Editor.—

The importance of intestinal bacteria as primary causal agents or as secondary invaders in necrotizing enterocolitis has been debated widely.1 Epidemic outbreaks of necrotizing enterocolitis have been found to be associated with the presence of Pseudomonas, Salmonella, Klebsiella, Escherichia coli, Coxsackie 2, and clostridia in the stools of affected babies. However, these same organisms are commonly found in nonaffected infants in neonatal intensive care. Thus, the causal relationship remains doubtful. Simultaneous detection of bacteria (such as Clostridium difficile) and toxin in babies with necrotizing enterocolitis,2 suggests that under some conditions, commensals may become pathogenic and play a primary role in the outbreak of epidemics.
Meat Tenderizer and Bee Stings
Authors: CARDONI ALEX A. , ROSENBERG PHILIP , AGOSTINUCCI WILLIAM
Published: December 2021

To the Editor.—

We recently came across Lanier's letter, "Meat Tenderizer and Stings,"1 and we were interested in his comments about potential lack of efficacy of meat tenderizer products to treat Hymenoptera stings. Each year the Connecticut Poison Center receives approximately 300 calls related to insect stings and bites, and we have been aware of the many first-aid measures recommended to treat reactions secondary to these stings. Ice, baking soda paste, topical corticosteroids, topical antihistamines, and meat tenderizer pastes have all been recommended.
Central Hypoventilation Syndrome in Pyruvate Dehydrogenase Complex Deficiency
Authors: Johnston Kay , Newth Christopher J. L. , Sheu Kwan-Fu Rex , Patel Mulchand S. , Heldt Gregory P. , Schmidt Kathleen A. , Packman Seymour
Published: December 2021

The presentation and treatment of a central hypoventilation syndrome in a boy with pyruvate dehydrogenase complex (PDHC) deficiency are reported. Dephosphorylated PDHC was assayed in disrupted fibroblasts after pretreatment with dichloroacetate, a pyruvate dehydrogenase kinase inhibitor. Maximal specific activity of activated patient PDHC was 10% to 30% of control values. Patient PDHC activity was not increased by alterations in concentrations of pyruvate or cofactors (thiamine pyrophosphate [TPP], coenzyme A [CoA], oxidized form of nicotinamide adenine dinucleotide [NAD+]). Clinically, normalization of plasma lactate by a high-lipid diet did not prevent slowly progressive neurologic decline. The patient manifested intermittent ataxia, episodic profound weakness, moderate psychomotor retardation, ophthalmoplegia, and retinal pigment epithelial changes. A true central hypoventilation syndrome was documented on the basis of rigorous radiologic, electrophysiologic, and pulmonary function criteria. Theophylline, progesterone, and ritalin neither altered ventilatory response to CO2 nor permitted weaning from the ventilator. In contrast, peripheral chemoreceptor stimulants (intravenous doxapram; oral almitrine) effected an acute doubling of minute ventilation with appropriate decreases in PaCO2. However, a positive response to long-term therapy with almitrine could not be unequivocally shown. It was concluded that measurement of disrupted fibroblast PDHC following dichloroacetate activation constitutes an accurate assay for PDHC deficiency. PDHC deficiency must be considered in the differential diagnosis of the central hypoventilation syndrome; this appears to be the first report of such an association. Finally, a therapeutic trial of a peripheral chemoreceptor agonist is warranted in the management of central hypoventilation syndrome.
Value of Systolic Time Intervals in the Diagnosis of Large Patent Ductus Arteriosus in Fluid-Restricted and Mechanically Ventilated Preterm Infants
Authors: Heitz François , Fouron Jean-Claude , van Doesburg Nicolaas H. , Bard Harry , Teasdale François , Chessex Philippe , Davignon André , Houde Louis
Published: December 2021

M-mode echocardiographic features suggesting a patent ductus arteriosus are based on two groups of indirect criteria: dilation of the left cardiac cavities and changes of systolic time intervals. The reliability of the first group of criteria has been questioned in fluidlimited, mechanically ventilated preterm infants. The sensitivity of the systolic time intervals in the same circumstances is investigated. Twenty-three patients with a large patent ductus arteriosus were selected. Review of their echocardiograms shows that the sensitivity of the various criteria (expressed as percentage of positivity) was as follows: inversion of the ratio of left ventricular preejection period to right ventricular preejection period, 91.3%; left ventricular preejection period to left ventricular ejection time over right ventricular preejection period to right ventricular ejection time < 1, 83%; left atrium dilation, 74%; shortening of left ventricular preejection period, 70%; dilation of left ventricular internal dimensions in diastole, 65%; increase in left atrium/aorta, 52%; and decrease of left ventricular preejection period to left ventricular ejection time, 48%. Three criteria involving time intervals (left ventricular preejection period to right ventricular preejection period, left ventricular preejection period, and left ventricular preejection period to left ventricular ejection time) had 100% specificity. The lowest specificity was found with criteria involving the left atrium (left atrial to aortic root ratio 75% and left atrium 63%). It is concluded that study of systolic time intervals is a reliable means of detecting preterm infants with hemodynamically significant left-to-right shunt through a patent ductus arteriosus even if the infants are mechanically ventilated and fluid restricted.
Research and Practice in the Treatment of Insulin-Dependent Diabetes: A Survey of 53 Pediatric Diabetologists
Authors: Kaye Robert
Published: December 2021

New techniques are available for the treatment of children with insulin-dependent diabetes mellitus. These include more intensive methods of insulin delivery by multiple daily injections or continuous subcutaneous infusion by portable pumps combined with patient self-monitoring of blood glucose. Long-term diabetic control can be evaluated by measurement of glycosylated hemoglobin, HbA1 or HbA1c. Pediatric practitioners may be in doubt as to the extent to which these techniques should be incorporated into their own practices. In order to provide some guidance in this quandry, the treatment practices as of June 1982, of 53 physicians with a special interest in the treatment of diabetic children were surveyed by questionnaire. The respondents estimated that they cared for 12,350 diabetic patients less than 19 years of age. Among their patients, 72% received twice-daily injections of insulin, 3% received three or more injections daily, and only 195 patients (2.7% of the total) were treated with insulin pumps. Among patients older than 10 years of age, 50% performed self-monitoring of blood glucose four times daily on one or more days per week and 32% of these patients did so daily. Two thirds of the patients utilized glucose oxidase-impregnated strips for blood glucose estimation and the remainder used reflectance meters. Essentially all respondents utilized glycosylated hemoglobin to evaluate quality of control. The mean number of determinations was 3.8 per year. Reasons for introducing pump therapy or discontinuing its use, glycemic targets for pump patients, and experience with utilization of the pump are described. Recommendations for the management of juvenile diabetes include: periodic determinations of glycosylated hemoglobin to evaluate quality of control; initiation, in children beyond the toddler age, of self-monitoring of blood glucose to guide insulin dosage for the purpose of achieving near-normal levels of blood glucose; and treatment of most patients with two daily injections of a combination of rapid and intermediate-acting insulins. For patients not responding to the above measures, initiation of pump therapy is an option provided that the patient is highly motivated and emotionally sound, and an experienced treatment team is available for supervision.
Knowledge of Testicular Cancer Risk and Need for Self-Examination in College Students: A Call for Equal Time for Men in Teaching of Early Cancer Detection Techniques
Authors: Goldenring John M. , Purtell Elizabeth
Published: December 2021

College athletes were surveyed about their knowledge and practice of early cancer detection techniques. Males were almost completely unaware of their risk for testicular cancer (87%). Only 9.6% had been taught testicular self-examination and only half of these by their physician. Six percent actually examined themselves regularly. In comparison, more than 60% of women had been taught breast self-examination (75% by a physician) and about one third were doing regular examinations. More than 90% of the young men and women had been seen by physicians for a physical examination within the past 3 years. Physicians need to begin educating males about testicular cancer and its early detection.
Pediatricians, Antibiotics, and Office Practice
Authors: DISNEY FRANK A.
Published: December 2021

To the Editor.—

I recently participated in a telephone conference call sponsored by an unidentified drug house on the subject of detailmen as seen by the private pediatric practitioner. There were seven of us (plus a nonphysician discussion leader); we were all from different states throughout the country and all of us were practicing pediatricians, except for one neonatologist. All were Board certified and all had been in private practice for a period of 10 to 25 years.
Self-Induced Urinary Tract Infection in Boys
Authors: LABBÉ JEAN
Published: December 2021

To the Editor.—

It is well recognized that urinary tract infection (UTI) is relatively uncommon in boys after the first months of life. Most authors also agree that, especially in children less than 10 years of age, boys with UTI are more likely than girls to have a urinary tract malformation and a secondary renal damage.1-5 Therefore, radiologic investigation is recommended at a first UTI in boys.6 On the other hand, ureteral instrumentation (like catheterization) can cause UTI in a normal urinary tract.
Noninvasive Monitoring of Cerebral Oxygenation in Preterm Infants: Preliminary Observations
Authors: Brazy Jane E. , Lewis Darrell V. , Mitnick Michael H. , vander Vliet Frans F. Jöbsis
Published: December 2021

A noninvasive optical method for bedside monitoring of cerebral oxygenation in small preterm infants was evaluated. Through differential absorbance of near infrared light, changes in the oxidation-reduction level of cytochrome aa3, in the oxygenation state of hemoglobin and in tissue blood volume were assessed in the transilluminated anterior cerebral field. Overall, cerebral oxygenated hemoglobin correlated significantly with transcutaneous oxygen, r = .44 p < .0001; however, correlation was best in the absence of cardiorespiratory disease. Hypoxia with or without bradycardia led to hemoglobin deoxygenation and a shift in cytochrome aa3 to a more reduced state. When hypoxic episodes came in series or were prolonged, aa3 reduction occurred simultaneous with hemoglobin deoxygenation but its recovery to base-line values sometimes lagged behind the return of hemoglobin oxygenation. In one infant with a large patent ductus arteriosus, even brief episodes of mild bradycardia caused precipitous reduction of cytochrome aa3 before any shift to greater hemoglobin deoxygenation. This response disappeared after ductal ligation. In general, the antecedent state of cerebral oxygenation, the severity and duration of deoxygenation, and the presence or absence of circulatory abnormalities all influenced the aa3 response to hypoxia. Continuous noninvasive near infrared monitoring of cerebral oxygenation can be performed on sick preterm infants at the bedside.
National Reye Syndrome Surveillance, 1982
Authors: Rogers Martha F. , Schonberger Lawrence B. , Hurwitz Eugene S. , Rowley Diane L.
Published: December 2021

Despite the fact that influenza B was the primary influenza virus strain during the winter of 1981-1982, only 213 cases of Reye syndrome were reported to the Centers for Disease Control (CDC) between Dec 1, 1981 and Nov 30, 1982. This national reported incidence of 0.33 cases per 100,000 children less than 18 years of age is the lowest reported incidence since the Centers for Disease Control began surveillance in 1973. This relatively low incidence probably reflected, at least in part, the fact the influenza B activity was spotty and the illness relatively mild the winter of 1981-1982. The 213 cases were reported from 43 states; and in 56% of the patients, Reye syndrome occurred following a respiratory illness. The mean age of the children was 7.0 years; there were equal numbers of girls and boys; and 93% were white. Of the ten black patients, 80% were less than 1 year of age compared with 9% of the white patients. Of the 208 patients with reported admission stage, 45% were admitted in stage I or 0, a slightly lower proportion than that observed in the previous 2 years. Salicylate levels were obtained in 55% of the patients and were reported as "detectable" in 81% compared with 96% in 1981 (P = .003, χ2). Of the 200 patients with known outcome, 70 patients died (a case fatality ratio of 35%).
Use of Noninvasive Tests to Predict Significant Jaundice in Full-Term Infants: Preliminary Studies
Authors: SMITH DAVID W. , INGUILLO DOROTHY , MARTIN DARREL , VREMAN HENDRIK J. , COHEN RONALD S. , STEVENSON DAVID K.
Published: December 2021

Hyperbilirubinemia continues to be a common problem of the neonate. A major factor contributing to the occurrence of significant neonatal jaundice is increased bilirubin production, and in hemolytic diseases the production may exceed the normal neonatal mean by up to tenfold.1-3 However, impaired elimination of bilirubin from the body, eg, decreased conjugation or increased intestinal reabsorption, is also an important contributing factor.4

In full-term infants, the concentration of bilirubin in serum is greatest at approximately 72 hours of age,4 and significant hyperbilirubinemia occurs in approximately 5% of these neonates.5 Motivated by hospital costs and by parental requests, many pediatricians are discharging infants from the hospital before 48 hours of age.
Parent-Specific Adjustments for Evaluation of Recumbent Length and Stature of Children
Authors: Himes John H. , Roche Alex F. , Thissen David , Moore William M.
Published: December 2021

A clinical "parent-specific" method for evaluating recumbent length and stature of children, allowing for the stature of parents, is presented. This method uses midparent stature and allows adjustment of recumbent length (birth to 3 years) and stature (3 to 18 years) of US children relative to National Center for Health Statistics growth charts. The method is based on parent-child relationships for 586 midparent-child pairs participating in the Fels Longitudinal Study, and on more than 16,000 serial measurements of recumbent length and stature. The method provides a clinical tool to separate the normal genetic contribution of parental stature to stature of children from other factors that affect stature such as malnutrition or disease.
Use of Oral Fluid Therapy and Posttreatment Feeding Following Enteritis in Children in a Developed Country
Authors:   Committee on Nutrition
Published: December 2021

The 1982-1983 report by the United Nations Children's Fund (UNICEF) on the State of the World's Children recommended widespread implementation of oral rehydration as one of the four strategies projected to save the lives of 20,000 children each day.1 In the developing countries, oral rehydration has been shown to be an effective, simple, and inexpensive therapy for dehydration caused by severe enteritis in infants.2-8 The modern concepts of oral fluid therapy for diarrheal diseases evolved in part from the clinical observation that orally administered glucose-electrolyte solutions can replace diarrheal fluid losses in cholera. Previous laboratory investigation had demonstrated the presence of a cotransport system of sodium with glucose or other actively transported small organic molecules in the small intestine in animals and in man. Clinical studies suggest that this sodium-glucose cotransport system remains intact not only when the pathophysiologic agent is an enterotoxin, such as that elaborated by Vibrio cholerae or enterotoxigenic strains of Escherichia coli, but also with inflammatioion such as that associated with rotavirus, Campylobacter jejuni, E coli, and Yersinia enterocolitica.4-8 These observations have provided a physiologic rationale for an appropriately efficient ratio of sodium to glucose in formulating solutions to be used in the developing countries for oral therapy in the treatment of infants with life-threatening diarrheal dehydration.

The question we address in this commentary is that of the appropriate implementation of oral hydration therapy in a developed country. Pediatricians and others concerned with the health of children in this country are not usually confronted with the problem of obtaining uncontaminated water nor with the management of large numbers of severely malnourished young infants with multiple health problems.
Prevention of Hepatitis B Virus Infections
Authors:   Committee on Infectious Diseases
Published: December 2021

Infants born to mothers who are hepatitis B surface antigen (HBsAg) positive are frequently infected with hepatitis B virus (HBV). Many of these newborns will become chronic carriers of HBV and will subsequently develop chronic liver disease. Recent studies have demonstrated that perinatal transmission can be prevented by immunization of the newborn. Recommendations for the management of infants at risk are presented.

PERINATAL TRANSMISSION OF HBV INFECTIONS

Perinatal infection of infants by mothers who are HBsAg positive is most likely to occur if mothers are also hepatitis Be antigen positive. About 90% of infants whose mothers are positive for both markers will become infected and most will become permanent carriers.1 Infants whose mothers are HBeAg negative or who have antibody to HBeAg are at lesser risk, but can still be infected.2

Infected infants usually will not become HBsAg positive until several weeks after birth. Although clinical jaundice or acute hepatitis are rare in infected infants, elevations in transaminase levels are frequent.3 It is estimated that about one in four infants who become chronic carriers following perinatal infection will develop cirrhosis or hepatocellular carcinoma later in life. As they are persistent carriers, later in life they may transmit infection to other family members, to sexual contacts, or to others by transfusions or inoculation of their blood. Infection of female infants may eventually result in transmission of HBV to their own infants. Indeed, transmission from mother to infant is a major method of perpetuation of this virus in hyperendemic areas, eg, the Far East.
Relationship Between Hospital-Based and Private Practice Physicians
Authors:   Committee on Hospital Care
Published: December 2021

For a number of reasons, hospitals appoint full-time and part-time physicians to practice medicine within the hospital or its outlying divisions. Such physicians provide a wide variety of primary, specialty, and subspecialty services. Among other advantages for hospitals are a potentially tighter reinon quality control and an increased bed occupancy and revenue at a time when financial issues have become increasingly important.

Physicians engaged solely in administration or research rarely pose a problem in the relationship between the hospital and private practice physicians. However, it is more likely that friction (which might adversely affect patient care) may occur when there is overlapping of services provided by the private practice physicains and the hospital-based physicians, whether they are salaried by the hospital or on a fee-for-service basis. Therefore, the Committee on Hospital Care of the American Academy of Pediatrics offers the following guidelines concerning this interface.

ROLE OF HOSPITAL-BASED PHYSICIANS

The Committee on Hospital care believes that many appropriate roles exist for hospital-based physicians. Certain specialties may advantageously be hospital based, or regional hospital units are involved. Such specialists might include (among others) those involved in burn care, spinal cord injuries, dialysis, cardiac surgery, emergency medicine, pediatric and neonatal intensive care, medical education, radiology, pathology, and anesthesiology. Certain hospital units benefit from continual organization and supervision which may best be provided by hospital-based physicians.

The Committee believes that research and teaching (including primary care teaching) must be maintained in certain hospitals. Commonly, these programs are centered around hospital-based physicians, although private practice physicians have participated productively in most programs.
Vitamin K Deficiency
Authors: ABALLI ARTURO J.
Published: December 2021

To the Editor.—

The article by Payne and Hasegawa1 on vitamin K deficiency of the newborn correctly stresses the existence of differences between vitamin K deficiency and Coumadin effect. This has been somewhat forgotten in important studies on the mode of action of prothrombin.2-4 Modern techniques as the Echis time5 and certain sophisticated electrophoretic6 methods confirm the suspected differences between these two disorders. However, many years ago it was shown7-9 that microgram doses of any vitamin K rapidly corrected the coagulation defect in deficiency.
Efficacy of Phototherapy in Prevention and Management of Neonatal Hyperbilirubinemia
Authors: Brown Audrey K. , Kim Mae Hee , Wu Paul Y. K. , Bryla Dolores A.
Published: December 2021

This report concerns the efficacy of phototherapy in preventing hyperbilirubinemia in infants with birth weight less than 2,000 g and in controlling already established hyperbilirubinemia in infants weighing more than 2,000 g in the National Institute of Child Health and Human Development (NICHHD, also called NICHD) phototherapy study initiated in 1974.

The details of the protocol have been reported by Bryla.18

STUDY POPULATION

The study included 1,339 infants from the six participating institutions: 672 were randomly assigned to the phototherapy group and 667 to the control group. As described previously, these infants were studied according to specific protocols in three birth weight groups.18

In infants weighing less than 2,000 g at birth (group A), the efficacy of phototherapy begun at 24 ± 12 hours of age in preventing hyperbilirubinemia was examined. In the other two birth weight groups infants with birth weight 2,000 to 2,499 g [group B] and infants with birth weight 2,500 g or more [group C], the effect of phototherapy on already-established hyperbilirubinemia was examined.

MODE OF USE OF PHOTOTHERAPY

Phototherapy using Westinghouse daylight fluorescent bulbs in an Air Shields unit was administered continuously. Duration of phototherapy was 96 hours for all treated infants.

In each study group, an attempt was made to apply phototherapy in a manner that mimicked common usage, except that control subjects were used. Further, because no infant was to be exposed to bilirubin levels considered "unsafe," maximum bilirubin levels were established for each weight group and exchange transfusions were performed in both phototherapy-treated and control infants when these levels were reached.
Phototherapy for Hyperbilirubinemia of Hemolytic Disease of the Newborn
Authors: Maurer Harold M. , Kirkpatrick Barry V. , McWilliams Nancy B. , Draper David A. , Bryla Dolores A.
Published: December 2021

Although phototherapy has proven effective in lowering the serum bilirubin concentration of fullterm and premature infants with physiologic or idiopathic hyperbilirubinemia, its effect on serum bilirubin concentration in hemolytic disease due to ABO blood group incompatibility remains uncertain. Sisson and associates91 have reported a marked effect of phototherapy on serum bilirubin levels and exchange transfusion rates in premature and full-term infants with ABO incompatibility. Others have reported similar findings, but studies were retrospective49 or uncontrolled.80 On the other hand, Patel and associates79 found no significant clinical response to phototherapy in five infants (four with birth weight >2,500 g) with ABO and one infant (birth weight 2,660 g) with Rh incompatibility.

A total of 1,339 infants were randomly selected for study between May 1974 and June 1976. Of the 1,339 infants, 79.4% weighed less than 2,500 g and 276 (20.6%) were 2,500 g or more at birth. Of the 1,063 infants who weighed less than 2,500 g, 17 had positive findings on Coombs tests, 14 due to ABO incompatibility and three due to Rh incompatibility. As phototherapy was administered early and prophylactically in infants weighing less than 2,000 g and late and therapeutically in infants weighing between 2,000 and 2,499 g, a combined analysis of the infants weighing less than 2,500 g and who had positive results on Coombs test was not possible.

Of the 276 infants whose birth weight was 2,500 g or more, 64 (23.1%) had positive findings on Coombs tests, 58 due to ABO incompatibility and six to Rh incompatibility.
Comparison of Phototherapy Results in Small-for-Gestational-Age and Appropriate-for-Gestational-Age Infants Weighing Less Than 2,000 Grams
Authors: Hodgman Joan E. , Wu Paul Y. K. , White Nathaniel B. , Bryla Dolores A.
Published: December 2021

The infant who is small for gestational age (SGA) is more mature at birth than similar weight infants who are appropriate for gestational age (AGA). Whether the SGA infant behaves as does the larger gestationally equivalent infant, or whether there are specific changes related to intrauterine growth retardation is a matter of some interest in the understanding of the special needs of these infants. The National Institute of Child Health and Human Development (NICHD) phototherapy study provided a large newborn population for whom birth weight, gestational age at birth, and, thereby, intrauterine growth were carefully assessed. Infants who weighed 2,000 g or more at birth were included in the study only when they became jaundiced, whereas infants who weighed less than 2,000 g at birth were routinely entered into the study. Consequently, this report will be limited to the lowbirth-weight population selected by birth weight. Too few SGA babies were present in the groups with greater birth weight to allow meaningful comparisons.

PATIENT SELECTIQN

All infants whose birth weight was less than 2,000 g were entered into the study at 24 ± 12 hours. Those excluded from the study were: (1) infants who died before 24 hours, (2) infants with serious congenital defects, and (3) infants whose mothers refused consent for study. The study population consisted of 922 infants surviving at 24 hours. Gestational age was calculated from the first day of the last menstrual period obtained from maternal history and also by the evaluation techniques of Dubowitz.25 Intrauterine growth was determined by plotting birth weight and gestational age on the Denver Intrauterine Growth Curves8; infants below the 10th percentile were considered SGA.
Epidemiology of Trauma in a Population of Incarcerated Youth
Authors: Woolf Alan , Funk Sandra G.
Published: December 2021

This study assessed the types, circumstances, frequency, and health consequences of trauma suffered by juvenile delinquents at a secure residential training school. A review of 369 medical records of 387 teenagers, aged 10 to 17 years, admitted to one such facility between 1978 and 1982 was made. Of the 369 students, 191 students (52%) suffered 391 separate trauma incidents serious enough to require a health care provider's attention. Circumstances surrounding the injuries included sports (36%), fights (20%), self-inflicted injuries (13%), suicide attempts (9%), incidents related to vocational studies (8%), and horseplay (3%). The most common types of injuries were musculoskeletal trauma, scratches, bruises and lacerations, and fractures. The usual sites of injury were the extremities, head, or neck. More than 50% of trauma incidents required a physician's attention initially or in follow-up; 28% of the injured were referred to an off-campus facility; 21% necessitated radiologic or laboratory studies; 4% required hospitalization; and one student died. The average trauma rate for teenagers in this setting was 1.2 injuries per person per year; the average rate of hospitalizations for trauma was 0.04 hospitalizations per person per year. These data call for further studies of trauma morbidity among adolescents in this and other settings and for innovative trauma prevention strategies.
Normal Cerebrospinal Fluid Values in Children: Another Look
Authors: Portnoy Jay M. , Olson Lloyd C.
Published: December 2021

Cerebrospinal fluid samples sterile for virus and bacteria from 371 patients who had no evidence of CNS pathology were examined. The patients were divided into five age categories. The white blood cell polymor-phonuclear, and mononuclear cell counts were evaluated. The frequency distributions for these cell counts were markedly skewed, so values were calculated as percentiles for each age group. WBC values were highest for CSF obtained from patients in younger age categories, but 25% of patients from all age categories had two or three WBCs in their CSF. Patients from all but the 3- to 6-month category had three polymorphonuclear cells in their CSF 5% of the time. There was no significant difference in CSF WBC count between patients who had seizures and those who did not. Knowledge of normal values in different age groups is needed for the interpretation of CSF findings, but it should be used in conjunction with other clinical and laboratory findings.
Does Indomethacin Cause Extension of Intracranial Hemorrhages: A Preliminary Study
Authors: Maher Patrick , Lane Bart , Ballard Roberta , Piecuch Robert , Clyman Ronald I.
Published: December 2021

Thirty-six infants who had an intracranial hemorrhage (diagnosed by cranial ultrasound) within four days after delivery (mean age 2.4 ± 0.9 [SD] days), were reexamined at three- to seven-day intervals for extension of their intracranial hemorrhage. Seventeen infants had a patent ductus arteriosus and were treated with indomethacin after the initial intracranial hemorrhage was diagnosed. The age for starting indomethacin was 3.8 ± 1.1 days. Nineteen infants did not have a patent ductus arteriosus and did not receive indomethacin. Both the indomethacin-treated and nontreated groups were similar in birth weight, gestational age, Apgar scores, gender, incidence of respiratory distress, as well as the location and the degree of hemorrhage in the initial scans. Only one of 17 (6%) infants who received indomethacin v two of 19 (11%) infants who did not receive it, had extension of their initial intracranial hemorrhage. orrhage. Although indomethacin may alter platelet function, it does not appear to cause extension of a preexisting intracranial hemorrhage.
Munchausen Syndrome by Proxy: A New Complication of Central Venous Catheterization
Authors: Malatack J. Jeffrey , Wiener Eugene S. , Gartner J. Carlton , Zitelli Basil J. , Brunetti Elizabeth
Published: December 2021

A recent case of supposed gastrointestinal (GI) bleeding in a small child underscored the difficulty inherent in making the diagnosis of Munchausen syndrome by proxy. In this case, an indwelling Broviac central venous catheter was used by the mother to withdraw blood which was then arranged to feign blood loss from her son's upper and lower GI tract. Despite the mother/perpetrator's displaying the classic personality traits of Munchausen syndrome by proxy, diagnosis was not made for many weeks.
Preschool Performance of Children with Normal Intelligence Who Were Very Low-Birth-Weight Infants
Authors: Klein Nancy , Hack Maureen , Gallagher John , Fanaroff Avroy A.
Published: December 2021

Children who were very low-birth-weight infants (< 1,500 g), beneficiaries of modern neonatal intensive care, are now of school age. To evaluate their school performance 80 children born in 1976 who had very low-birth-weight (mean birth weight 1.2 kg, mean gestational age 30 weeks) were examined at age 5 years. Sixty-five children were neurologically intact and had normal IQ (≥85) on the Stanford-Binet; five children were neurologically abnormal and ten had IQ below 85. Of the 65 children with normal intelligence and no neurologic impairments, 46 were single births and enrolled in preschool. These 46 children were matched by race, sex, and family background with classmate control children who had been born at full term. Outcome measurements included the Slosson Intelligence Test, the Woodcock-Johnson Psycho-Educational Battery (including subscales of Picture Vocabulary, Spatial Relations, Memory for Sentences, Visual Auditory Learning, Quantitative Concepts, and Blending) and the Beery Developmental Test of Visual-Motor Integration. No significant differences in IQ were found between children who were very low-birth-weight infants and control children; however, children who were very low-birth-weight infants performed significantly less well on the Spatial Relations subtest of the Woodcock-Johnson and on the Visual-Motor Integration test. Similar results were found for nine sets of twins and their control children. Recognition of these perceptual and visual-motor problems may permit appropriate early remedial intervention and prevent the compounding of these difficulties.
Foster Care for Child Maltreatment: Impact on Delinquent Behavior
Authors: Runyan Desmond K. , Gould Carolyn L.
Published: December 2021

Previous reports of child maltreatment Sequelae have not systematically examined the effects of societal intervention. A historical cohort study has been undertaken to examine the impact of one intervention, foster care, on the subsequent development of juvenile delinquency among child victims. One hundred fourteen foster children, aged 11 to 18 years, in foster care for three or more years, and who were in foster care as a result of maltreatment were studied. A comparison cohort was composed of 106 victims of maltreatment who were left in their family home; these children were similar to the children in foster care with regard to age, race, sex, and year of diagnosis. Cohort differences in maternal education, type of abuse, history of prior maltreatment, sex, and race were controlled in the analysis. Foster children committed 0.050 crimes per person-year after age 11 years; home care children committed 0.059 crimes per person-year after age 11 years (P > .2). Foster children were more likely to have committed criminal assault. Among foster children, increased number of foster home placements correlated with increased number of delinquency convictions. Overall, there appears to be no support for the idea that foster care is responsible for a significant portion of later problems encountered by victims of maltreatment.
Involuntary Smoking and Incidence of Respiratory Illness During the First Year of Life
Authors: Pedreira Frank A. , Guandolo Vincent L. , Feroli Edward J. , Mella Gordon W. , Weiss Ira P. , Marva Susan , DeFayette Helen
Published: December 2021

A prospective study of 1,144 infants and their families was performed. Smoking and family histories were evaluated with respect to the incidence of lower respiratory disease during the first year of life. It was found that (1) tracheitis and bronchitis occurred significantly more frequently in infants exposed to cigarette smoke in the home, (2) maternal smoking imposed greater risks upon the infant than paternal smoking, (3) occurrence of neither tracheitis nor bronchitis showed a consistent relationship to the number of cigarettes smoked, (4) a family history that was positive for respiratory illness (chronic cough or bronchitis) significantly influenced the incidence of bronchitis, (5) too few cases of laryngitis and pneumonia were seen to warrant any opinions regarding the adverse influence of either smoking or a family history that was positive for respiratory illness, and (6) occurrence of bronchiolitis was not affected by the presence of a smoker nor influenced by a family history that was positive for respiratory illness. It is concluded that passive smoking is dangerous to the health of infants and that infants born to families with a history that is positive for respiratory illness (chronic cough or bronchitis) are at risk of developing bronchitis.
Balloons as a Cause of Suffocation
Authors: BROOK ITZHAK
Published: December 2021

To the Editor.—

Accidents are the major cause of mortality in young children.1 I would like to highlight the danger of aspiration of a foreign body and suffocation that can occur in infants and toddlers following rupture of a balloon.

It was recently necessary to resuscitate a 2-year-old infant who suffocated after he had aspirated the distal portion of a balloon (Figure). The child bit the balloon and the force of the rupture blew the distal part of the balloon into the rear of his mouth.
Pertussis Vaccine and Neurologic Disease
Authors: KUMAR MARY L. , MORTIMER EDWARD A.
Published: December 2021

To the Editor.—

The revised recommendations of the Committee on Infectious Diseases concerning the use of pertussis vaccine in infants with proven or suspected neurologic disease1 warrant comment. Such modified recommendations are needed because of confusion about the causation of coincident or preexisting neurologic disease that appears or is first recognized in temporal association with the administration of diphtheria, tetanus, pertussis, (DTP), which confusion has resulted in extensive litigation over alleged personal injury. Although most authorities believe that pertussis vaccine does on rare occasions produce permanent neurologic damage, it is clear that the vast majority of these alleged injuries are of other etiology.
Breast-Feeding and Hyperbilirubinemia in Full-Term Newborn Infants
Authors: CORCHIA CARLO , RUIU MARIA , ORZALESI MARCELLO
Published: December 2021

To the Editor.—

Osborn et al1 have reported a positive association between breast-feeding and neonatal hyperbilirubinemia in full-term infants. To give further support to the findings of Osborn et al, we wish to report the results of two similar studies that have been completed in two different hospitals.

The first study was carried out in the nursery of the Second School of Medicine of Naples.2 Rooming-in was practiced from 9 am to 12 pm, and during the day, breastfed babies were only offered a supplement of 5% dextrose in water when appropriate.
Home Phototherapy
Authors:   Committee on Fetus and Newborn
Published: December 2021

Equipment designed for delivering phototherapy in the home has become available in several parts of the United States in the past few years. Home phototherapy for neonatal hyperbilirubinemia has been suggested as an alternative means of providing care for selected infants while saving much of the cost of continued or added hospitalization. Not enough information is available presently, however, on the safety or efficacy of home phototherapy as compared with alternatives to warrant an endorsement of this form of therapy.

This statement provides preliminary guidelines for physicians who might choose home phototherapy for their patients. No attempt is made here to address the pros and cons of phototherapy per se or to define types of equipment.

A physician who considers the use of home phototherapy should limit its use to infants with the following characteristics: (1) term infants, older than 48 hours, otherwise healthy; (2) serum bilirubin concentration greater than 14 mg/dL but less than 18 mg/dL; (3) no elevation in direct-reacting bilirubin concentration; and (4) diagnostic evaluation (described below) negative.

Prior to therapy, a diagnostic evaluation should include: (1) history and physical examination; (2) hemoglobin concentration or hematocrit; (3) WBC count and differential count; (4) blood smear for red cell morphology platelets; (5) reticulocyte count; (6) total and direct-reacting bilirubin concentration; (7) maternal and infant blood typing and Coombs test; and (8) urinalysis including a test for reducing substances.

The physician should estimate the rate of rise of the serum bilirubin concentration with laboratory determinations at least four hours apart before home phototherapy is initiated.
An AAP-Women Gap
Authors: SILVERMAN WILLIAM A.
Published: December 2021

To the Editor.—

Appellate Judge Bork recently1 pointed out that a fundamental requirement of the law in this country is one of democratic legitimacy. The disturbing lack of that characteristic in the recently passed "Baby Doe Amendment" is evident in the results of a survey2 conducted by Wellesley College Center for Research on Women. Sixty-four percent of nearly 120,000 women opposed laws that would require treatment of severely defective infants.

Why did the American Academy of Pediatrics distance itself so from the wishes of the majority of women by supporting passage of a measure that mandates actions that would be considered cruel and inhumane by many.
Epilepsy and Swimming
Authors: GREENSHER JOSEPH
Published: December 2021

In Reply.—

If all swimming were limited to pools that were always supervised by a lifeguard or competent adult, we would not have approximately 1,500 children drowning each year.

The risk of drowning or near-drowning for a child with epilepsy is four times that of other children. The risks to children who have been seizure-free for 1 year are only minimally greater than for the general population if they have stable therapeutic anticonvulsant levels, are mentally normal, and are well supervised in the water.1
E-Ferol
Authors: BOWEN FRANK W. , JOHNSON LOIS
Published: December 2021

To the Editor.—

Phelps' commentary, "E-Ferol: What Happened and What Now?"1 is an important reminder of the danger of using untested drugs. We feel, however, some points of clarification are needed.

First, Phelps cited Myers et al2 as using 1.1 mg/kg/d of E-acetate IV and raising serum E levels to 6 mg/dL in preterm infants. This is misquoted. Myers et al used 10 mg/kg of vitamin E over one hour (dl-α-tocopherol [Hoffman LaRoche] not E-acetate) and achieved levels of 0.6 mg/dL not 6 mg/dL at the end of the infusion.
Creatine Kinase Brain Isoenzyme: Relationship of Cerebrospinal Fluid Concentration to the Neurologic Condition of Newborns and Cellular Localization in the Human Brain
Authors: Worley Gordon , Lipman Brian , Gewolb Ira H. , Green James A. , Schmechel Donald E. , Roe Charles R. , Gross Steven J.
Published: December 2021

Immunocytochemical study of human brain showed creatine kinase brain isoenzyme (CKBB) present in both neurons and astrocytes. Because creatine kinase brain isoenzyme is an intracellular enzyme that might be released with brain injury, its concentration in the CSF of newborns was measured using a radioimmunoassay. Infants who suffered a documented neurologic insult (a cerebroventricular hemorrhage or a CNS infection) were found to have a greater mean CSF creatine kinase brain isoenzyme concentration than those without a history of neurologic insult. Infants with a high concentration had a poor short-term outcome (death or neurologic abnormality when discharged) more frequently than did those with a lower concentration. Infants with a grade 3 or 4 cerebroventricular hemorrhage had a higher mean concentration than did those with a grade 1 or 2 hemorrhage. These data are consistent with the hypothesis that CSF creatine kinase brain isoenzyme is a metabolic indicator of brain damage in newborns.
Economic Analysis of Regionalized Neonatal Care for Very Low-Birth-Weight Infants in the State of Rhode Island
Authors: Walker Donna-Jean B. , Vohr Betty R. , Oh William
Published: December 2021

Cost-benefit analysis was utilized to evaluate the economic outcome of regionalized neonatal care in the state of Rhode Island, with specific reference to newborns weighing less than 1,500 g at birth. Two time periods consisting of two calendar years each, were analyzed: 1974 to 1975 (initiation of perinatal regionalization) and 1979 to 1980 (regionalization established). The neonatal mortality for infants weighing between 501 and 1,500 g decreased significantly between the two time periods. Neurodevelopmental morbidity was unchanged. The costs per survivor (hospital charges plus estimated costs of long-term care of handicapped survivors) were consistent over the time periods studied. The estimated benefits per survivor increased between the time periods, although this increase was not statistically significant. Benefits outweighed costs in both study periods. When one compares the economic data of 1974 to 1975 with that of 1979 to 1980, the increase ìn the absolute number of normal survivors since the establishment of regionalized neonatal care has resulted in benefits surpassing costs by $2 million (a greater than twofold increase). Regionalized neonatal care in the state of Rhode Island has had a positive economic outcome.
Magnetic Resonance Imaging of Lesions of the Posterior Fossa and Upper Cervical Cord in Childhood
Authors: Packer Roger J. , Zimmerman Robert A. , Bilanuik Larissa T. , Leurssen Thomas G. , Sutton Leslie N. , Bruce Derek A. , Schut Luis
Published: December 2021

Magnetic resonance imaging (MRI) promises to be an effective, nonivasive means of visualizing intracranial pathology. It should be especially useful in the evaluation of posterior fossa and cervical spinal cord disease of childhood; computed tomographic (CT) evaluation is frequently suboptimal in this region. MRI results are reported for 46 consecutively seen children with posterior fossa and/or cervical spinal cord disease (28 had brain malignancies; seven had congenital anomalies; three had cerebrovascular accidents). MRI was performed primarily by the partial saturation on a .12 Tesla resistive proton unit. All patients underwent concurrent CT evaluation. demonstrated abnormalities in 96% of scans in patients with structural CNS disease (48 of 50). CNS malignancies were visualized in 100% (28 of 28) of children studied. MRI was especially useful in demonstrating the full extent of infiltrating gliomas and the anatomic location of other mass lesions. MRI frequently demonstrated disease to be more extensive than seen on CT. MRI was more sensitive than CT in documenting reponse to treatment and disease relapse in patients with infiltrating tumors. Cystic regions within tumors were poorly seen on MRI. Congenital anomalies were demonstrated in all patients evaluated and were better delineated using MRI than CT. MRI is sensitive in the evaluation of posterior fossa and cervical spinal cord disease of childhood and it has obvious advantages over CT; however, its specificity in such evaluations has yet to be proven.