bluuebunny/crossref_metadata_2025 huggingface dataset:
SOME OBSERVATIONS ON THE FEEDING OF PREMATURE INFANTS BASED ON TWENTY YEARS' EXPERIENCE AT THE NEW HAVEN HOSPITAL
Authors: POWERS GROVER F.
Published: December 2021

No new concepts of infant nutrition have been presented, but an old one is emphasized. It is that infants' dietaries can be understood intelligently only when analyzed in terms of the unit of metabolism—the calorie. When babies do not thrive on a given food, it should not be changed blindly, but with careful consideration of the clinical conduct of the individual child, of the relative proportions in terms of calories of the essential food elements and of the concentration, i.e. the water content. Qualitative characteristics of food essentials are important but are not discussed in the paper.

It is also pointed out that infants, particularly those who are feeble, premature, convalescent, malnourished, can be fed very successfully on a cooked cow's milk mixture lower in fat and higher in protein and carbohydrate content than human milk. Calcium and phosphorus are present in ample amounts, but vitamins must be added to the diet. Liver, or liver extract, is recommended for administration to feeble, sick and premature infants based on the concept that unrecognized deficiencies may thereby be supplied.

The evidence is against the ideal food for these infants' being human milk—nature's food, certainly—but for the mature, healthy infant. No one can regard nourishing infants with adulterated or "reinforced" human milk as breast milk feeding.
TICK PARALYSIS
Authors: MCCUE CAROLYN MOORE , STONE J. B. , SUTTON LEE E.
Published: December 2021

The three cases of tick paralysis occurring in Virginia in the last two years are presented. One of these cases required the respirator. In this case the tick was identified as Dermacentor variabilis Say.

Only ten other cases of tick paralysis have been reported in the eastern United States. A summary of the findings of these cases is charted. Three recent cases in the west, also charted, showed only one case needing a respirator. A brief review of the epidemiology, symptoms, signs and treatment of tick paralysis is given.

The seriousness of tick paralysis, if the tick is not found and removed, and the usual dramatic recovery after removal make it extremely important to consider this condition in any case showing such neurologic manifestations as those presented in this report. During an epidemic of poliomyelitis, tick paralysis should always be kept in mind as a possible alternative diagnosis.
CONCENTRATION OF URINE SOLUTES BY YOUNG INFANTS
Authors: PRATT EDWARD L. , BIENVENU BEATRIZ , WHYTE MURIEL M.
Published: December 2021

The water exchange of five infants, one to two months old, is described during the water restriction imposed by feeding food mixtures of undiluted evaporated milk.

It is shown that the urine solutes can be concentrated to the level of 1.2 osM/l. The high order of the concentrating ability by the kidneys of these young patients means that, in healthy infants one month old or older, over half of the water provided by the infant's usual food can be conserved to cover abnormal losses by other routes of water removal.

A chart is given for the estimation of the renal water requirement for infants at any given concentration of urine solutes on a variety of intakes.
THE DIAGNOSIS AND TREATMENT OF ATRESIA OF THE ESOPHAGUS AND TRACHEO-ESOPHAGEAL FISTULA
Authors: SWENSON ORVAR
Published: December 2021

DURING the past few years there have been an increasing number of reports on the successful operative correction of atresia of the esophagus and tracheo-esophageal fistula.

In the past eight years at the Children's Hospital in Boston, 113 such cases have been operated upon and 57 of the patients have survived.

There are certain facts about normal embryologic development which afford some explanation of these congenital malformations. In early fetal life, the esophagus and [SEE FIG. 1-a FIG. 1-b IN SOURCE PDF] trachea are one tube, which subsequently becomes divided into two structures by the lateral ingrowth of mesoderm. After this division, the lumen of the esophagus becomes obliterated by the proliferation and concrescence of its epithelial lining. Later, as this solid cord becomes vacuolated and coalescence of the vacuoles occurs, the lumen of the esophagus is re-established. It is probably in the period of separation of the single structure into esophagus and trachea that tracheo-esophageal fistulas develop. Esophageal atresia is probably related to incomplete coalescence of the vacuoles.

The anatomic variations of the anomaly can be divided into five groups. In the simplest form of the anomaly, the upper portion of the esophagus ends in a blind pouch in the upper portion of the chest and the lower esophageal segment begins again as a blind [SEE FIG. 2-b FIG. 2-a IN SOURCE PDF] pouch somewhat above the diaphragm (Fig. 1-a). About 3% of the cases are of this type. In the commonest form of the anomaly a tracheo-esophageal fistula is associated with the atresia, and in 94% of the cases communicates with the lower esophageal segment.
Child Health
Authors: MCCULLOCH HUGH
Published: December 2021

A series of 22 articles by individual authors, dealing with the major problems of ill health in childhood from the more positive attitude of the maintenance of health and describing the numerous health services available for the care of children. Most of the articles had been published previously. The editorial preface outlines the philosophy of the book as follows: "Preventive medicine as applied to children includes not only measures adopted for the protection of the completely healthy child (as in diphtheria prophylaxis) but also the important task of preventing minor maladies from becoming major illnesses.
The Physiology of Body Weight Regulation: Relevance to the Etiology of Obesity in Children
Authors: Rosenbaum Michael , Leibel Rudolph L.
Published: December 2021

The prevalence of obesity in children and adults in the United States has increased by more than 30% over the past decade. Recent studies of the physiology and molecular genetics of obesity in humans have provided evidence that body weight (fat) is regulated. Some of the genes encoding the molecular components of this regulatory system have been isolated from rodents. The increasing prevalence of obesity in the United States apparently represents the interaction of these genes with an environment that encourages a sedentary lifestyle and consumption of calories. The rapid increase in the prevalence of obesity emphasizes the role of environmental factors, because genetic changes could not occur at this rate. Thus, understanding of the relevant genes and how their effects are mediated by environment and development should lead to more effective prophylaxis and therapy of obesity. Although no clear environmental factors have been identified as causative of obesity, the rapid increases in the prevalence of obesity and the seeming voluntary immutability of adult body fatness can be taken as tacit evidence that the pediatric environment can be altered in a way that affects adult body weight.
Development of Physical Activity Behaviors Among Children and Adolescents
Authors: Kohl Harold W. , Hobbs Karen E.
Published: December 2021

Physical activity is a key component of energy balance and is promoted in children and adolescents as a lifelong positive health behavior. Understanding the potential behavioral determinants necessitates understanding influences from three fundamental areas: 1) physiologic and developmental factors, 2) environmental factors, and 3) psychological, social, and demographic factors. The literature to date has generally investigated potential predictors of physical activity in children and adolescents in each of these three general areas, although existing data rely largely on cross-sectional studies in which it is difficult to distinguish a determinant from a correlate. In all likelihood, aspects of each of these three areas interact in a multidimensional way to influence physical activity in youth. This article reviews evidence of potential determinants of physical activity in children and adolescents and provides recommendations for future work.
Treatment of Mixed Tumors of the Kidney in Childhood, by Robert E. Gross, MD, and Edward B. D. Neuhauser, MD,Pediatrics, 1950;6:843–852
Authors: Randolph Judson
Published: December 2021

This fundamental paper by a surgeon, Dr Gross, and a radiologist and radiotherapist, Dr Neuhauser, cleaned up the existing information and conflicting results of therapy for Wilms' tumor through 1947. There is a careful review of literature, comments about existing suggestions of preoperative radiation versus postoperative radiation versus radiation only and versus surgery without radiation. The authors then carefully analyze the experience at Boston Children's Hospital over the period from 1914 to 1947. This material is carefully broken down into three periods, 1914 to 1930, 1931 to 1939, and 1940 to 1947. During period I, 1914 to 1930, 27 cases of Wilms' tumor were seen and four cures were obtained for a survival rate of 14.9%. Beginning in 1931, under the able leadership of Dr William E. Ladd, a vigorous approach to the surgery for children with Wilms' tumor was undertaken. The program consisted of a wide transabdominal incision rather than the more classic approach to kidney surgery by a flank incision. This surgical exposure allowed prompt identification and control of the renal vessels and removal, in most cases, of the entire tumor and kidney mass without rupture of the encapsulated tumor. Additionally, Dr. Ladd insisted on careful fluid and blood replacement before and during surgery and a meticulous approach to the anesthestic management of the child undergoing surgery. In previous experience at Boston Children's and other reported centers, there had been a large number of intraoperative deaths. After 1932, there were no deaths from the surgery at Children's Hospital in Boston. In the 1931 to 1939 experience, 31 patients were operated on and ten cures were achieved for a survival rate of 32.2%.

Beginning in 1940, Dr Gross and Dr Neuhauser instituted a program of immediate surgery and postoperative radiation to the bed of the tumor. Thirty-eight children were so treated with a survival rate of 47.3%. This group of patients was subsequently followed for 2½ years so that cures, recurrences, and deaths could be accurately reported. This patient material also emphasized that babies in the first 12 months of life had a far better outlook than did older subjects. The authors also emphasized that if recurrences were to occur, they were usually evident within 9 months after operative removal and radiation therapy. Postoperative radiation therapy was given in daily doses of 200r alternately using three portals, anteriorly, laterally, and posteriorly over the tumor bed reaching a total of 4000 to 5000r using a 200KV machine.
The Exposure of Children to Lead, by J. Julian Chisholm and Harold E. Harrison, Pediatrics, 1956:18;943–958
Authors: Jackson Richard J.
Published: December 2021

During the years 1952 to 1954 in Baltimore, Maryland, 197 lead-exposed children were studied, including 89 with acute encephalopathy. Of those with acute encephalopathy, 4 children died and 23 had severe sequelae such as severe mental retardation, behavior disorder, or recurrent convulsions. These poisonings were caused by the ingestion of lead-based paint. Strikingly, even ingestion of very small quantities of paint flakes was associated with serious illness. Illness onset was most often in the summer season. Lead exposure in children who were originally used as unexposed control subjects was found to be significant as well, indicating that lead exposure as a child health problem is much more extensive than heretofore thought to exist. The only adequate protective measure is removal of lead from the child's environment.
The Alveolar Lining Layer: A Review of Studies on Its Role in Pulmonary Mechanics and in the Pathogenesis of Atelectasis, by Mary Ellen Avery, MD,Pediatrics, 1962:30:324–330
Authors: Jobe Alan H.
Published: December 2021

The alveoli of the normal lung are lined by a substance that exerts surface tension at the air–liquid interface. In the expanded lung, the tension is high and operates to increase the elastic recoil of the lung. In the lung at low volumes, the surface tension becomes extremely low. This confers stability on the air spaces and thus prevents atelectasis. This lining layer is a lipoprotein film, which is not found where alveoli still are lined by cuboidal epithelium. Its appearance coincides with the appearance of alveolar lining cells. Electron microscopic evidence of secretory activity in alveolar cells suggests that they may be the source of the surface-active film. The normal alveolar lining layer is not present in lungs of infants who die from profound atelectasis and hyaline membrane disease. Whether its absence is a failure of development or attributable to inactivation is not established.
Intrauterine Growth as Estimated From Liveborn Birth-Weight Data at 24 to 42 Weeks of Gestation, by Lula O. Lubchenco et al,Pediatrics, 1963;32:793–800
Authors: Greer Frank R.
Published: December 2021

Data on the birth weights of 5,635 live-born Caucasian infants at 24 to 42 weeks' gestation are presented. All infants were born from July 1948 to January 1961. Data from infants born at greater than 36 weeks' gestation after 1955 are excluded because of the large number of infants. The socioeconomic stratum represented by this population is defined as medically indigent or part-pay. The median weights of Colorado babies (3230 g) were found to be lower at 40 weeks' gestation that the national median (3340 g). Weight curves in the form of percentiles are generated from the data. These curves can be used as standards for determining the adequacy of weight gain of individual infants which may be done either at the time of birth, or after birth in relation to extrauterine environmental factors.
Responses of Children Immunized with Capsular Polysaccharide of Hemophilus influenzae Type b, by David H. Smith, MD, et al,Pediatrics, 1973;52:637–644; andHaemophilus influenzae Type b Capsular Polysaccharide Vaccine in Children: A Double-blind Field Study of 100 000 Vaccinees 3 Months to 5 Years of Age in Finland, by Heikki Peltola, MD et al,Pediatrics, 1977;60:730–737
Authors: Peter Georges
Published: December 2021

One hundred forty-one children of 5 to 59 months of age were immunized with a single intramuscular dose of 0.67, 3.3, 17, or 67 μg polyribophosphate (PRP), the capsular antigen ofHemophilus influenzae, type b. The immunizations were well tolerated, particularly at doses of .67 to 17 μg. Antibody activity was measured by radioactive antigen binding, using3H-labelled PRP. Doses of 3.3 and 17 μg produced significant antibody rises in nearly 90% of recipients; 0.67 and 67 μg in approximately half. The geometric mean titers were similar at three and six weeks after immunization and were greater with the middle doses.

The net antibody increase in responding children was strongly age dependent, but was not related to the preimmunization antibody concentration. Rises in serum bactericidal activity against H. influenzae type b generally accompanied rises in antibody concentration as measured by the antigen-binding assay.

A recently developed Haemophilus influenzae type b capsular polysaccharide vaccine was given to 48 977 children 3 months to 5 years of age; an equal number of children receiving group A meningococcal vaccine served as controls. The protection as well as serum antibody response was strongly age dependent. Among children who had received the H. influenzae type b vaccine when 18 months of age or older, there were no cases of bacteremic disease caused by H. influenzaetype b in the first year after vaccination. At the same time 11 such cases were seen in the control group of the same age, a highly significant difference. In the second year after vaccination two cases occurred in the H. influenzae type b-vaccinated group, five in the meningococcal-group A vaccinated group. No protection was seen among children who had been younger than 18 months when vaccinated, even if they received a booster dose of the vaccine.

The serum antibody response to the H. influenzae type b polysaccharide, measured by radioimmunoassay, was poor in children below 18 months of age and good in those above it. No effect of the vaccine could be seen on the nasopharyngeal carriage of H. influenzae type b, which was approximately 6% in this age group. Adverse effects of the vaccine were mild.
Tap Water Scald Burns in Children, by K. W. Feldman, R. T. Schaller, J. A. Feldman, and M. McMillon,Pediatrics, 1978;62:1–7
Authors: Rivara Frederick P.
Published: December 2021

Tap water scald burns account for 7% to 17% of all childhood scald burns that require hospitalization. Often the burns are severe and disabling. Toddlers and preschool children are the most frequent victims. In 45% of the injuries, the unsupervised victim or peer turned on the tap water; in 28% the cause was abuse. Eighty percent of the homes tested had unsafe bathtub water temperatures of 54°C (130°F) or higher, exposing the occupants to the risk of full-thickness scald with <30-second exposure to hot water. Such burns may be prevented passively by limiting household water temperatures to <52°C (125°F). New water heaters could be preset at this temperature, and families could be taught to turn down the temperature on existing units.
Apgar Scores as Predictors of Chronic Neurologic Disability, by Karin B. Nelson, MD, and Jonas H. Ellenberg, PhD,Pediatrics, 1981;68:36–44
Authors: Golden Gerald S.
Published: December 2021

Apgar scores were recorded at one and five minutes for ∼49 000 infants, and at 10, 15, and 20 minutes for babies who did not achieve a score of 8 or higher at five minutes. These children were followed to 7 years of age. Low Apgar scores were risk factors for cerebral palsy, but 55% of children with later cerebral palsy had Apgar scores of 7 to 10 at one minute, and 73% scored 7 to 10 at five minutes. Of 99 children who had Apgar scores of 0 to 3 at 10, 15, or 20 minutes and survived, 12 (12%) had later cerebral palsy; 11 of the 12 also were mentally retarded (in 10, IQ <50) and half had seizure disorders. Eight children who survived after having very low late Apgar scores and who did not have cerebral palsy had lesser but significant disabilities. Of the children who had Apgar scores of 0 to 3 at 10 minutes or later and survived, 80% were free of major handicap at early school age.
Growth and Normal Puberty
Authors: Abbassi Val
Published: December 2021

We reviewed the growth characteristics of American boys and girls from published studies, including age at takeoff, age at peak height velocity, peak height velocity, duration of puberty, and the magnitude of the pubertal contribution to adult height. Age at takeoff is highly variable and sex-dependent. The mean takeoff age in children growing at an average rate is ∼11 years in boys and 9 years in girls, and peak height velocity occurs at a mean age of 13.5 years and 11.5 years, respectively, in these children. Whole-year peak height velocity is 9.5 cm/y in boys and 8.3 cm/y in girls, with slight variations in the different studies. The contribution of pubertal growth to final height is ∼30 to 31 cm in boys, accounting for 17% to 18% of the final height, and 27.5 to 29 cm in girls, accounting for 17% of the final height. The magnitude of pubertal growth has a negative correlation with age at takeoff, but no correlation with final height. Age at takeoff, however, correlates highly with pubertal stage, but correlates negatively with duration of puberty.
Current Dosing of Growth Hormone in Children With Growth Hormone Deficiency: How Physiologic?
Authors: MacGillivray Margaret H. , Blethen Sandra L. , Buchlis John G. , Clopper Richard R. , Sandberg David E. , Conboy Thomas A.
Published: December 2021

The current doses of recombinant growth hormone (rGH) are two to three times those used in the pituitary growth hormone era. These rGH doses (0.025 to 0.043 mg/kg/d) are similar to or moderately greater than the physiologic requirements. Growth velocity and height gains have been shown to be greater with 0.05 mg/kg/d of rGH than with 0.025 mg/kg/d. Larger doses of GH and early initiation of treatment result in greater heights at the onset of puberty and greater adult heights. Earlier onset of puberty and more rapid maturation, as indicated by bone age, were not observed in children who were given 0.18 to 0.3 mg/kg/wk of rGH. The frequency of adverse events is very low, but diligent surveillance of all children who are treated with rGH is essential.
Mothers' Emotional Needs
Authors: Stern Daniel
Published: December 2021

In most families, mothers contribute substantially to the new infant's emotional environment and development. Because such mother–infant interaction is crucial, a mother's emotional context is very relevant to infant development. This article in New Perspectives in Early Emotional Development addresses the relationships that a mother requires to regulate her maternal or parental capacities, which enable the infant to develop appropriately.
Role of the Father
Authors: Pruett Kyle D.
Published: December 2021

Fathers make definite contributions to infant development and are now spending more time with their children than in many past decades. This article reviews the most compelling research on the developmental importance of fathers, including father–infant attachment and interaction, and differences between maternal and paternal interaction styles. Results of a long-term study of primary caregiving fathers also are presented.
Colic and Crying Syndromes in Infants
Authors: Barr Ronald G.
Published: December 2021

Colic or excessive crying is one of the most frequent problems presented to pediatricians by new parents. Organic disease accounts for <5% of infants presenting with colic syndrome. Colic may be best viewed as a clinical manifestation of normal emotional development, in which an infant has diminished capacity to regulate crying duration.
Talking With Parents About Emotional Development
Authors: Melmed Matthew E.
Published: December 2021

Parents play a central role in their children's emotional and overall development. To provide the most developmentally sound environment, professionals need to communicate the fine points of research and clinical studies effectively. This article details many strategies for reaching parents; perhaps the most important lessons are to be culturally sensitive, be positive, be relevant, and speak clearly.
The Effect of Price Information on Test-ordering Behavior and Patient Outcomes in a Pediatric Emergency Department
Authors: Hampers Louis C. , Cha Susie , Gutglass David J. , Krug Steven E. , Binns Helen J.
Published: December 2021

Objective.

We sought to determine whether information on hospital charges (prices) would affect test-ordering and quality of patient care in a pediatric emergency department (ED).

Design.

Prospective, nonblind, controlled trial of price information.

Setting.

Urban, university-affiliated pediatric ED.

Methods.

We prospectively assessed patients 2 months to 10 years of age with a presenting temperature ≥38.5°C or complaint of vomiting, diarrhea, or decreased oral intake. The assessments were done during three periods: September 1997 through December 1997 (control), January 1998 through March 1998 (intervention), and April 1998 (washout). In the control and washout periods, physicians noted tests ordered on a list attached to each chart. In the intervention period, physicians noted tests ordered on a similar list that included standard hospital charges for each test. Records of each visit were reviewed to determine clinical and demographic information as well as patient disposition. In the control and intervention periods, families of nonadmitted patients were interviewed by telephone 7 days after the visit.

Results.

When controlled for triage level, vital signs, and admission rates, in a multivariate model, charges for tests in the intervention period were 27% less than charges in the control period. The greatest decrease was seen among low-acuity, nonadmitted patients (43%). In telephone follow-up, patients in the intervention period were slightly more likely to have made an unscheduled follow-up visit to a health care provider (24.4% vs 17.8%), but did not differ on improved condition (86.7% vs 83.4%) or family satisfaction (93.8% vs 93.0%). Adjusted charges in the washout period were 15% lower than in the control period and 15% higher than in the intervention period.

Conclusion.

Providing price information was associated with a significant reduction in charges for tests ordered on pediatric ED patients with acute illness not requiring admission. This decrease was associated with a slightly higher rate of unscheduled follow-up, but no difference in subjective outcomes or family satisfaction.
Quality Improvement Methods in Clinical Medicine
Authors: Plsek Paul E.
Published: December 2021

This article surveys the methods and tools of quality improvement used today in health care. Specifically, we describe how clinicians can use these methods to impact the clinical practice of medicine. Improvement teams from a variety of health care organizations have reported the successful use of basic methods such as group work, flowcharting, data collection, and graphical data analysis. In addition to these incremental, problem-solving methods borrowed from the industrial practice of improvement, we have also seen the use of specific process design methods in health care applications such as care path development. The pace of change in health care has also led to the practical development of newer methods for rapid cycle improvement. We will review the basic approach behind these methods and illustrate key elements such as the ideas of change concepts and small-scale tests of change. Unfortunately, whereas these methods have been very successful and highly appealing to improvement practitioners, they may also have inadvertently widened a gulf between these practitioners and traditional health-services and clinical researchers. We offer an assessment of this issue and suggest ways to narrow the communication gap. Measurement has also traditionally been a part of the thinking about quality assurance and improvement in health care. We review the new philosophy of measurement that has emerged from recent improvement thinking and describe the use of control charts in clinical improvement. Benchmarking and multiorganizational collaboratives are more recent innovations in the ways we approach improvement in health care. These efforts go beyond simple measurement and explore the why and how associated with the widespread variation in performance in health care. We explore a variety of health care examples to illustrate these methods and the lessons learned in their use. We conclude the article with an overview of four habits that we believe are essential for health care organizations and individual clinicians to adopt to bring about real improvement in the clinical practice of medicine. These are the habits for: 1) viewing clinical practice as a process; 2) evidence-based practice; 3) collaborative learning; and 4) change.
Vital Records for Quality Improvement
Authors: Gould Jeffrey B.
Published: December 2021

The birth certificate and death certificate are important sources of population-based data for assessing the extent of risk and the quality of perinatal outcome. The birth certificate contains the hospital of birth and many items, such as birth weight and race, that can serve as important risk adjusters for neonatal mortality. To assess mortality a second vital record, the death certificate, must be linked to the birth certificate. If the analysis is to be stratified by level of neonatal care or other hospital characteristics, a third file providing these details must also be utilized. The exact vital record formats, recording protocols, and quality control efforts are determined by and differ across each state. Even with these differences, the quality and completeness of vital records and their linkage are reasonable for population-based analyses. Although the most important vital outcome from a neonatologist's perspective is neonatal mortality, vital records can also be used to assess fetal, perinatal, postneonatal, and infant mortality.

The analytic paradigm that is used in quality analysis performed on data derived from the vital record states that observed outcome is a function of risk, chance, and care. Risk is a characteristic or condition such as low birth weight or low 1-minute Apgar score that elevates the probability of an adverse outcome but is beyond the control of the agent responsible for the outcome. Using risk matrices or regression analysis one determines the expected mortality for a specific institution's case-mix. This expectation is usually based on the statewide analysis of infants with a similar risk profile. A standardized mortality ratio is calculated by dividing observed by expected mortality. A hospital with a high observed mortality (12 deaths per 1000) and an even higher expected mortality based on the risk characteristics of its neonates (24 per 1000) would have a standardized mortality ratio of 0.5. Once the effects of chance have been accounted for by statistical testing this finding could indicate that mortality in this hospital is 50% lower then expected.

Although initially intended for legal and broad-based public health purposes, vital records represent an important source of data to inform perinatal quality improvement activities. The optimal usefulness of information derived from vital records requires that clinicians take an active role in assuring that data entry is complete and accurately reflects risk status, clinical factors, and outcomes. However, even a superb database will be of limited usefulness unless it is linked to an initiative that actively involves clinicians committed to quality improvement.
The Neonatal “Sepsis Work-up”: Personal Reflections on the Development of an Evidence-Based Approach Toward Newborn Infections in a Managed Care Organization
Authors: Escobar Gabriel J.
Published: December 2021

“Rule out sepsis” may be the most common discharge diagnosis among infants admitted to the neonatal intensive care unit. Although the frequency of sepsis, meningitis, and other confirmed bacterial infections has remained constant (between 1 and 5/1000 live births) for many years, the number of infants evaluated and treated is much higher. Each year in the United States, as many as 600 000 infants experience at least one evaluation for suspected bacterial infection during the birth hospitalization. The number treated is estimated at 130 000 to 400 000 per year. Despite massive overtreatment, delayed diagnosis still occurs.

The Kaiser Permanente Medical Care Program (KPMCP) considers developing and implementing an evidence-based approach to “rule out sepsis,” a research and operational priority. To achieve these goals, it is essential to consider two key aspects of the problem. First, it is important to adopt a phenomenologic approach that takes clinicians' personal experience into account. This must include reflection on those aspects of experience often considered “irrational” or “subjective.” Second, incorporation of a phenomenologic approach needs to be tempered with sound epidemiologic methods.

If one considers these two aspects—physician experience and sound epidemiology—it is clear that much of the existing literature on “rule out sepsis” is of limited utility. Consequently, the KPMCP has conducted its own studies. These are aimed at characterizing the “sepsis work-up,” developing electronic datasets that would permit clinicians to simulate various strategies, and developing techniques for ongoing electronic monitoring.

This article summarizes the approach taken by the KPMCP Division of Research. It describes the results of a pilot study as well as the development and use of a dedicated neonatology outcomes database, the Kaiser Permanente Neonatal Minimum Data Set (NMDS). The NMDS database includes the Score for Neonatal Acute Physiology and permits ongoing monitoring of sepsis “work-ups” as well as confirmed cases of neonatal infection. The article also describes how the experience from the pilot as well as the NMDS was incorporated in the design of a much larger study on “rule out sepsis.” Finally, the article describes some important theoretic issues affecting decision rule development and the use of computer simulations in neonatology. These issues are 1) how one handles possible overanalysis of a dataset; 2) how one handles data points that are unstable (eg, the absolute neutrophil count, which can vary considerably depending on age and sampling conditions); and 3) the limitations of decision rules based on computer simulations.
A Block Rotation in Community Pediatrics
Authors: Shope Timothy R. , Bradley Beverly J. , Taras Howard L.
Published: December 2021

Objectives.

To develop, implement, and evaluate a 1-month block rotation in community pediatrics.

Interventions.

Faculty from University of California San Diego and Naval Medical Center San Diego developed a combined and integrated curriculum for second-year residents in community pediatrics. Resident activities included structured site visits to schools, day care centers, and community organizations that participate in child health promotion, advocacy, public health, and prevention activities. Resident school consultation and child advocacy projects were established and mentored during the block rotation.

Evaluation.

Formative evaluation of the program by residents was used to shape the program design. Residents' self-perceived competence in eight areas of community pediatrics was measured with questionnaires administered before and after completion of the rotation. Resident involvement in school consultation and child advocacy projects was assessed in a cross-sectional survey.

Results.

Twenty-three residents completed the rotation during the 1-year study period. Statistically significant improvements in self-perceived competence were noted in all eight areas of community pediatrics. Among residents who were at least 3 months beyond the rotation completion date, 55% (11/20) reported continued involvement with their school consultation or child advocacy project, and 25% (5/20) reported this involvement to be on a quarterly to monthly basis.

Conclusions.

Two institutions successfully implemented and integrated a block rotation in community pediatrics. Positive short-term improvements were noted in resident self-perceived competence in community pediatrics.
Black and White Middle Class Children Who Have Private Health Insurance in the United States
Authors: Weitzman Michael , Byrd Robert S. , Auinger Peggy
Published: December 2021

Objective.

To compare the health, behavior and school problems, and use of medical, mental health, and special education services of privately insured, middle class black and white children in the United States.

Design/Methods.

Analyses of the Child Health Supplement to the 1988 National Health Interview Survey, with a nationally representative sample of 17 110 children age 0–17 years.

Results.

Privately insured middle class black children had fewer chronic health conditions, but were less likely to be reported to be in excellent health (46.2% vs 57.3%) and more likely to have had asthma (8.5% vs 5.8%) or to have been of low birth weight (10.7% vs 5.6%). There were no differences in rates of having a usual source of routine care (92.2% vs 93.8%) or of being up to date with well-child care (79.3% vs 78.2%), but black children made fewer physician visits, were less likely to use physicians' offices, were more likely to lack continuity of care, and were twice as likely to use emergency departments. These differences in use of medical services persisted in multivariate analyses and analyses restricted to more affluent children. Despite similar rates of behavior problems, black children were more likely to repeat a grade (20.0% vs 12.3%) and to have been suspended from school (11.3% vs 5.0%). Although significantly fewer black middle class children received mental health or special education services in bivariate analyses, no differences in receipt of these services were noted in multivariate analyses. All differences reported were significant.

Conclusions.

Among middle class children in the United States, black and white children have similar rates of health and behavior problems, but black children experience substantially increased rates of asthma, low birth weight, and school difficulties. Although not differing in the receipt of mental health or special education services, middle class black children, even in the presence of private health insurance, have markedly different sources and patterns of use of medical services.
Patient Recruitment—European Perspective
Authors: Hoppu Kalle
Published: December 2021

A considerable number of patients have to be recruited in a clinical trial to obtain solid results. In pediatric studies, patient recruitment is frequently problematic. In the simple common childhood illnesses, the number of recruitable patients is certainly large, but they may be hard to reach, and the imbalance between potential benefit and inconvenience of participation may reduce motivation to enroll. In severe diseases, the balance may be right, but the available number of patients may be small. Good communication with the child and family, as well as the motivation of colleagues to admit, is another key element in success. Proper study design, including realistically identified sources of patients, reasonable inclusion, and exclusion criteria, also are required.
Does a Health Maintenance Curriculum for Pediatric Residents Improve Performance?
Authors: Lopreiato Joseph Onofrio , Foulds D. Michael , Littlefield John H.
Published: December 2021

Objective.

To assess the knowledge and skills of residents in health maintenance and to measure the effectiveness of a new curriculum.

Design.

Longitudinal cohort study of first- and second-year pediatric residents over 2 academic years (AY). Residents in AY 1995–1996 (n = 32) comprised a control group. Residents in AY 1996–1997 (n = 36) served as a study group who completed a structured 12-week program of reading materials, small group discussions, and case scenarios.

Methods.

A needs assessment identified 7 topic areas in health maintenance: health screening, immunizations, nutrition, development, behavior, injury prevention, and dental health. Control and study residents' cognitive knowledge, chart documentation, and clinical performance were assessed using a 50-item multiple choice examination, medical records audit, and standardized patient evaluations.

Results.

Mean examination scores, chart documentation, and clinical performance did not differ significantly between first- and second-year control residents. In the study group, mean examination scores of first-year residents were not significantly better than controls. Second-year residents significantly improved their knowledge about health screening, nutrition, and dental health compared with controls but showed no improvement in other areas. Medical record documentation increased significantly among study residents compared with control residents. Clinically, first-year residents significantly improved in the task of health screening (relative risk [RR] 6.33) and markedly improved (36.8% vs 66.7%) their injury prevention counseling compared with controls. Second-year residents showed significant increases in health screening (RR 6.09) and taking a nutritional history (RR 1.44) compared with controls. Assessment of the curriculum by residents showed a high degree of satisfaction with the program.

Conclusions.

Pediatric residents who had clinical experience and completed the curriculum demonstrated significant improvements in their medical record documentation and selective gains in knowledge and clinical performance of health maintenance compared with residents with clinical experience only. A structured curriculum in health maintenance and a multifaceted assessment system can identify and enhance the skills of pediatric residents.
Final Report of the FOPE II Financing of Pediatric Education Workgroup
Authors: Jones M. Douglas , Boat Thomas , Adler Robert , Gephart Harlan R. , Osborn Lucy M. , Chesney Russell W. , Mulvey Holly J. , Simon Jimmy L. , Alden Errol R.
Published: December 2021

Some of the challenges of financing pediatric medical education are shared with all medical education; others are specific to pediatrics. The general disadvantage that funding of graduate medical education (GME) is linked to reimbursement for clinical care has uniquely negative consequences for freestanding children's hospitals because they therefore receive little Medicare GME support. This represents both a competitive disadvantage for such hospitals and an aggregate federal underinvestment in children's health care that now amounts to billions of dollars. The need to subsidize medical student and subspecialty education with clinical practice revenue jeopardizes both activities in pediatric departments already burdened by inadequate reimbursement for children's health care and the extra costs of ambulatory care. The challenges of funding are complicated by rising costs as curriculum expands and clinical education moves to ambulatory settings. Controversies over prioritization of resources are inevitable. Solutions require specification of costs of education and a durable mechanism for building consensus within the pediatric community. Pediatrics2000;106(suppl):1256–1269; medical student education, continuing medical education, medical subspecialties, children, pediatrics, health maintenance organizations, managed care, hospital finances, children's hospitals.
ON THE NATURAL REGRESSION OF PULMONARY CYSTS DURING EARLY INFANCY
Authors: CAFFEY JOHN
Published: December 2021

The immediate and ultimate prognosis of pulmonary and pleural cysts, untreated surgically, is excellent, even during the early weeks of life.
RENAL WATER REQUIREMENT OF INFANTS FED EVAPORATED MILK WITH AND WITHOUT ADDED CARBOHYDRATE
Authors: PRATT EDWARD L. , SNYDERMAN SELMA E.
Published: December 2021

The renal water requirement of six rapidly growing small infants on a food mixture composed of solely evaporated milk and water has been compared with the renal water requirement in the same infants on isocaloric feedings of evaporated milk, added carbohydrate and water. The higher protein and mineral intake of the unmodified milk mixture resulted in an 85% increase in the renal solute load compared with the load from the modified mixture. Although this increase in renal load, and hence renal water requirement, may be of little significance under the usual conditions of water intake and expenditure, the margin of safety against dehydration has been decreased. At the same time, this larger renal solute load may be an important factor in compromising water balance and well being unless additional water is supplied whenever the usual intake is appreciably decreased, the extrarenal water expenditure is increased or there is impairment of the ability to produce a concentrated urine.

Thus the practical importance while planning infant feedings of considering properties in addition to purely nutritive factors is emphasized.
RICKETS, DEFICIENCY OF "ALKALINE" PHOSPHATASE ACTIVITY AND PREMATURE LOSS OF TEETH IN CHILDHOOD
Authors: SOBEL EDNA H. , CLARK LELAND C. , FOX R. PHYLLIS , ROBINOW MEINHARD
Published: December 2021

A child, studied between the ages of 1½ and 3½ years, presented an abnormally low plasma alkaline phosphatase activity (0.8-1.64 Bessey-Lowry u.), a deformed skeleton and the loss of most of her deciduous teeth. The serum Ca was normal; the serum inorganic phosphate remained at the normal relatively high levels of infancy as the child grew older Roentgenograms demonstrated deficient mineralization of the skeleton and teeth. Biopsies of the liver and the costochondral junction displayed a deficiency of tissue alkaline phosphatase activity. The architecture of the rib was consistent with rickets. There was no evidence for the presence of an inhibitor of alkaline phosphatase, such as beryllium, or for an excessive excretion of the enzyme. Treatment with purified growth hormone, ascorbic acid and thiamin chloride had no effect, while vitamin D 500 thousand u. caused little change in the enzyme activity in a 10 day period. The father had low plasma alkaline phosphatase activity and a number of similar patients are mentioned, for whom there was also evidence that the deficiency in alkaline phosphatase activity may be genetically determined.

While the precise role of alkaline phosphatase activity in the metabolism of bone is not clear, the findings in this patient suggest that growing bone may require the presence of alkaline phosphatase for normal calcification, and that the skeletal disorder, which could not be distinguished from rickets, may be related to a disturbance in the local factor.
EOSINOPHILIA-HEPATOMEGALY SYNDROME OF INFANTS AND YOUNG CHILDREN
Authors: MILBURN CONN L. , ERNST KENNETH F.
Published: December 2021

Attention is directed to the existence of a recently recognized syndrome in infants and young children with the prominent features of chronic eosinophilia, hepatomegaly, liver biopsy findings of eosinophilic infiltrative and granulomatous lesions, a benign course, and occasionally symptoms and signs of transient pneumonitis.

An analysis of 15 reported cases with the syndrome is presented, including the report of a case due to an unidentified nematode larva, but probably Toxocara canis, invading the liver.

Signs and symptoms, pathology, pathogenesis, etiology, course and prognosis, and treatment are discussed.

Evidence is preponderantly in favor of the etiology in all cases being nematode larvae invasions of the liver and other viscera.

These cases cause conjecture as to whether other diseases of chronic eosinophilia, such as Löffler's syndrome, tropical eosinophilia, familial eosinophilia and pseudoleukemic cosinophilia, may not also be due to visceral nematode larvae migrations. Further investigation is warranted in these diseases.
STAPHYLOCOCCAL PNEUMONIA AND EMPYEMA
Authors: KANOF ABRAM , EPSTEIN BERNARD , KRAMER BENJAMIN , MAUSS IRVING
Published: December 2021

Forty-one cases of staphylococcal pneumonia, treated with sulfonamides, sulfonamides plus penicillin, and with aureomycin plus penicillin are described. Since characteristic bacteriologic findings are now uncommon, diagnosis of this condition depends on the presence of a typical clinical and roentgenologic picture, herein described.

The mortality rate with sulfonamide treatment alone was 50%. The mortality rate in cases treated with sulfonamides and penicillin was 25%. With the introduction of aureomycin none of the 12 consecutive cases in this series died.

Empyema treated with sulfonamides and penicillin often cleared with repeated aspiration alone or aspiration followed by instillation of penicillin into the pleural cavity. Cases of empyema treated with aureomycin plus penicillin seldom required paracentesis.