bluuebunny/crossref_metadata_2025 huggingface dataset:
Lupus Nephritis: Prognostic Factors in Children
Authors: McCurdy Deborah K. , Lehman Thomas J. A. , Bernstein Bram , Hanson Virgil , King Karen K. , Nadorra Rosario , Landing Benjamin H.
Published: December 2021

As newer treatment modalities become available for patients with severe lupus nephritis, it becomes increasingly important to identify patients at risk for renal failure. In this study, the records of 90 children presenting with systemic lupus erythematosus over a 13-year period were reviewed. Nineteen were lost to follow-up prior to completion of the study. Of the 71 remaining children, 16 (22%) progressed to chronic renal failure. Persistent hypertension lasting greater than 4 months, anemia, abnormalities of the urinalysis, and elevated serum creatinine level were significantly associated with progression to renal failure. Sex, race, age, abnormalities of creatinine clearance, and 24-hour urine protein collection were not associated with progression to renal failure. Renal biopsies were obtained in 45 children. Biopsies were initially classified according to World Health Organization criteria. Diffuse proliferative glomerulonephritis was significantly associated with progression to renal failure. The 45 biopsies available were reviewed by one of the authors and categorized by activity and chronicity indices. Both the active lesions of fibrinoid necrosis, synechiae, tubular casts, and vasculitic lesions and the chronic lesion of glomerular sclerosis correlated with progression to renal failure. Of the 16 children who progressed to renal failure, 2 had cadaver kidney transplants and are well 5 years posttransplant; 4 had fulminant lupus and died within 1 month of commencing dialysis; 10 began chronic dialysis. Five of the 10 children on chronic dialysis died from sepsis. These data suggest that children with systemic lupus erythematosus who undergo dialysis do poorly. This alters the risk-to-benefit ratio of newer, more aggressive treatment protocols which should be considered in children whose clinical, laboratory, and renal biopsy findings suggest eventual progression to renal failure.
The Commercialization of Children's Television
Authors:   Committee on Communications
Published: December 2021

The principal goal of commercial children's television is to sell products to children. Advertisers use two approaches to sell their products. The traditional method intersperses commercials in programs that are attractive to children to promote products unrelated to the program. Foods and toys constitute the two most frequently advertised product categories. The second approach, instituted in 1982, features toy action figures as the main characters of a program. Because these programs promote specific toys and are often developed by the marketing divisions of toy companies, they are known more appropriately as "program-length commercials."

Young children are unable to distinguish between programs and commercials and do not understand that commercials are designed to sell products.1,2 This observation suggests that any advertising directed at young children is inherently unfair. Program-length commercials make distinctions between programs and commercials even more difficult.

In the past, broadcasters followed the commercial time limits developed by the National Association of Broadcasters. In 1984, the Federal Communications Commission (FCC) declared that commercial time would be regulated by the marketplace. Subsequently, commercial time during children's programs increased dramatically. In addition, voluntary guidelines established by the toy industry suggesting that characters or products associated with a program should not appear in advertising within or adjacent to a program3 have been stretched.

The use of commercials and programs to sell products now forms a tight ring of commercialism around children's television from which young viewers cannot escape. Television programs promote toys. The same toys are used to promote cereals and other foods.
The Other View of Disposable Diapers
Authors: CAMPBELL ROBERT L.
Published: December 2021

To The Editor.—

I'm writing to you to express my extreme disappointment at the publication of the commentary titled "Baby Bottoms and Environmental Conundrums: Disposable Diapers and the Pediatrician" that appeared in the August 1991 issue of Pediatrics.1

Public Health Issue About Diaper Disposal. The authors have treated briefly the issue of public health and diaper disposal.1,p387 The reader is left with a perception that discarded diapers pose public health hazards. While the issue of public health and the disposal of diapers and other solid wastes is important, it is treated neither adequately nor fairly in this commentary.
Mental Retardation and ADHD!
Authors: HANDEN BENJAMIN L. , FELDMAN HEIDI
Published: December 2021

In Reply.—

We wholeheartedly agree with the cautions cited by Drs Voigt, Johnson, and Brown. Practitioners must be especially cautious in considering the diagnosis of ADHD among individuals who are mentally retarded, as deficits in attention, impulsivity, and activity level may be inappropriate for chronological age but appropriate for developmental level. Additionally, the need for nonpharmacologic treatment interventions to address social skill and learning deficits also must be considered carefully. Children with mental retardation may be at greater risk than nonretarded children for the inappropriate use of stimulant medication.
More on Dog-Bite Injuries
Authors: LACKMANN G. -M. , TÖLLNER U.
Published: December 2021

To the Editor.—

With great interest we have read the article by Avner and Baker1 about dog bites in urban children. We would like to add some results of our own investigations.

In childhood, the face is the most frequent site of dog-bite injuries. Gonnering2 described a "central target region," consisting of nose, mouth, and periorbital region, which is afflicted in up to 78% of all children suffering dog bites. In 1990, we studied the clinical course and follow-up of 16 children aged 18 months to 14 years who were treated surgically at our hospital because of facial dog-bite injuries.3
Very Low Birth Weight Outcomes
Authors: HARRISON HELEN
Published: December 2021

To the Editor.—

The authors of the National Institute of Child Health and Human Development report on neonatal care1 found "important" variations among neonatal intensive care units in philosophies of treatment, methods of treatment, and short-term outcomes. In a recent meta-analysis of follow-up studies,2 researchers document a similarly haphazard approach to the long-term evaluation of very low birth weight survivors. Until randomized controlled clinical trials validate the safety and efficacy of neonatal therapies, and until long-term outcomes are assessed accurately, the treatment of very low birth weight infants should be declared experimental.
Very Low Birth Weight Outcomes
Authors: HACK MAUREEN
Published: December 2021

In Reply.—

The National Institutes of Health have recognized the need for randomized controlled clinical trials to validate the safety and efficacy of neonatal therapies, and it was specifically for this purpose that the National Institute of Child Health and Human Development initiated a Neonatal Intensive Care Network to conduct multicenter studies of therapeutic interventions. The Generic Database reported in our publication was developed specifically to provide baseline information for planning randomized clinical trials for very low birth weight infants, as noted in our publication.1,p588
Hyperbilirubinemia in Low Birth Weight Infants and Outcome at 5 Years of Age
Authors: van de Bor Margot , Ens-Dokkum Martina , Schreuder Anneke M. , Veen Sylvia , Brand Ronald , Verloove-Vanhorick S. Pauline
Published: December 2021

The collaborative national survey on morbidity and mortality in preterm and small for gestational age infants in the Netherlands enrolled initially 1338 infants born in 1983. The relationship between maximal serum total bilirubin concentration in the neonatal period and neurodevelopmental outcome in the survivors of this cohort was studied. This relationship at the corrected age of 2 years was previously reported. A dose-response relationship between maximal serum total bilirubin concentration and risk of adverse outcome was observed in the 831 surviving children. The present study reassessed the relationship at the age of 5 years in 814 children. There was no significant difference in mean maximal serum total bilirubin concentration between the children with and without a handicap. This was confirmed by logistic regression analysis. After correction for seven suspected confounding factors (gestational age, birth weight, intracranial hemorrhage, ventriculomegaly, seizures, bronchopulmonary dysplasia, and socioeconomic status) the estimated odds ratio was 1.2 (confidence interval 0.89, 1.43) per 50 µmol/l increase of total bilirubin. However, in this analysis an interaction between bilirubin and intracranial hemorrhage was observed. Therefore, the cohort was divided into two groups according to the absence or presence of an intracranial hemorrhage. Logistic regression analysis including four suspected confounding factors (gestational age, ventriculomegaly. seizures, and socioeconomic status) was then again applied. In children who had suffered from an intracranial hemorrhage in the neonatal period the estimated odds ratio was 1.84 (confidence interval 1.08, 3.15) per 50 µmol/l increase of bilirubin. Similar results were obtained treating bilirubin as a categorized exposure. The odds ratio in children without a hemorrhage was 1.05 (confidence interval 0.80, 1.38), probably because of the small number of surviving handicapped children.
Appearance of the Hymen in Prepubertal Girls
Authors: Berenson Abbey B. , Hayes Jean M. , Bailey Rahn K. , Heger Astrid H. , Emans S. Jean
Published: December 2021

The recent increase in requests for genital examinations in girls who may have been sexually abused has necessitated detailed information not previously available on normal anatomy of the prepubertal girl. This study was undertaken to document the genital anatomy of 211 girls between the ages of 1 month and 7 years who presented for well child care or nongynecologic complaints and who had no history of sexual abuse. Each child's genitalia was examined and photographed, with findings reported reflecting those observed photographically. The study population consisted of 36% blacks, 33.6% white non-Hispanics, 29.9% Hispanics, and 0.5% Asians. Subjects had a mean age of 21 ± 20.6 (SD) months. Extensive labial agglutination sufficient to obscure the hymen was noted in 5% (10/211) and partial agglutination in an additional 17% (35/211). A significant difference was noted in hymenal configuration by age, with a fimbriated hymen the most common type (46%) in infants aged 12 months or younger and a crescentic hymen the most common (51%) in girls older than 24 months (P ≤ .001). No significant difference was noted in hymen configuration by race. Hymenal bumps (mounds) were observed in 7%, hymenal tags in 3%, vestibular bands in 98%, longitudinal intravaginal ridges in 25%, and external ridges in 15% of subjects in whom the anatomy under study could be visualized. Hymenal notches (clefts) occurred superiorly and laterally on the hymenal rim but none were found inferiorly on the lower half of the hymen. A narrow rounded hymenal ring with a transection was observed in only 1 (0.5%) of 201 subjects and was not considered a normal finding. Transverse hymenal openings measured only in annular and crescentic hymens had a mean which ranged from 2.5 ± 0.8 to 3.6 ± 1.2 mm and varied significantly with age (P = .003). Normal hymenal findings must be recognized by medical professionals so that posttraumatic findings can be diagnosed appropriately.
Self-administered Questionnaire for Structured Psychosocial Screening in Pediatrics
Authors: Kemper Kathi J.
Published: December 2021

Screening for psychosocial risk factors has been limited by lack of a structured approach. The purpose of this study was to assess the utility of a self-administered questionnaire compared with routine history as recorded in the medical record in screening for risk factors for dysfunctional parenting in an urban pediatric clinic. English-speaking parents were offered questionnaires in the waiting room. In addition to routine demographic and medical questions, the questionnaries contained standard screening instruments for substance abuse, depression, self-esteem, and social support, as well as questions about domestic violence, homelessness, and parental history of abuse as a child. Medical records were reviewed separately. Of the 114 mothers who returned questionnaires, the response rate for sensitive questions such as income was ≥85%. Compared with the medical record, the questionnaire identified significantly more mothers with possible substance abuse, depression, low self-esteem, and/or history of abuse as a child (P < .01 for each). Compared with what is usually recorded in the medical record, self-administered questionnaires yield substantial additional information regarding psychosocial risk factors for dysfunctional parenting. Such questionnaires should be considered for routine psychosocial screening in clinics serving high-risk populations.
Prolonged Periodic Breathing: Significance in Sleep Studies
Authors: Finer Neil N. , Barrington Keith J. , Hayes Barbara
Published: December 2021

Periodic breathing (PB) is a pattern of breathing that is frequently recognized in infants being studied for possible sleep apnea. Infants presenting to a sleep laboratory over a 3½-year period who had evidence on their initial study of prolonged (>15% of total sleep time) PB were prospectively studied in an effort to determine the significance of this pattern of breathing. Of the 331 infants studied, 40 demonstrated prolonged PB. Sixteen of these infants, who were of 37 weeks's gestation or greater at birth and did not receive pharmacologic therapy, were studied on at least two occasions (group 1). Of the remaining 24 infants, 11 were treated with methylxanthines by their attending physician (group 2), and 13 did not return for sequential studies (group 3). All infants who were of less than 37 weeks' gestation at birth were separately evaluated (group 4). For group 1, who were studied at a mean age of 5 postnatal weeks, there was a mean of 36.4% periodicity which decreased on the second study to 18.0%. By the fourth study, this had decreased to 9.2%. In group 2, there was a mean of 41.3% periodicity during the first study which decreased to 6.4% on the second study. Infants of group 3 had a mean of 31.4% PB on their initial study and the premature infants, group 4, had 30.1% PB. All infants showed a decrease in PB with sequential studies and no infant was known to have died of sudden infant death syndrome or any other disorder in the first year of life. For the majority of infants, the abnormal duration of PB was the only abnormality noted on the sleep recording. The results suggest that excess PB as an isolated abnormality on a sleep recording is not an indicator of subsequent risk. Additional longitudinal evaluations of this respiratory pattern are needed.
Maternal Type A Behavior During Pregnancy, Neonatal Crying, and Early Infant Temperament: Do Type A Women Have Type A Babies?
Authors: Parker Steven J. , Barrett David E.
Published: December 2021

It was hypothesized that type A behavior in pregnant women would be associated with increased neonatal crying and differential reports of infant temperament at 3 months. Type A behaviors during pregnancy were measured in a self-selected cohort of 72 healthy, primiparous, middle-class women. Their newborns were assessed at 48 hours of age and the women completed an infant temperament questionnaire at 3 months. Women who were classified as type A on the Job Involvement scale of the Jenkins Activity Survey had infants who cried more during a standardized neurobehavioral assessment compared with infants of women who were type B on the same scale. Women who were type A for Job Involvement rated their 3-month-old infants as more intense and less predictable in their responses to the environment. They were also more likely to be breast-feeding their infants at 3 months. This is the first study to examine the prevalence and nature of maternal type A behaviors during pregnancy and to show their relationship to neonatal crying behavior, to maternal report of early infant temperament, and to maternal breast-feeding.
Weight and Menstrual Function in Patients with Eating Disorders and Cystic Fibrosis
Authors: HERGENROEDER ALBERT C.
Published: December 2021

To the Editor.—

This letter is in response to the article entitled "Weight and Menstrual Function in Patients with Eating Disorders and Cystic Fibrosis."1

Under "Methods," the authors describe a method for calculating percent ideal body weight by plotting the patient's height on standard growth curves derived from the data of Hamill et al,2 and the ideal body weight being the weight at the same percentile for age. Using the tables of Hamill to calculate percentages of height and weight for females older than 10 years and males older than 11½ years should be done cautiously.
Midazolam Versus Fentanyl as Premedication for Painful Procedures in Children with Cancer
Authors: Sandler Eric S. , Weyman Christine , Conner Kathy , Reilly Kathleen , Dickson Nancy , Luzins Jan , McGorray Susan
Published: December 2021

Premedication for painful procedures in children with cancer is not routinely used. Many medications used are only intermittently effective or require special equipment or anesthesia support. In a randomized,double-blind, crossover study, the safety and efficacy of midazolam, a short-acting benzodiazepine, were compared with the safety and efficacy of fentanyl, a short-acting narcotic analgesic. In 25 children studied, 100% of children and their parents preferred study drugs to any previous premedication. Seventy-two percent preferred midazolam to fentanyl. Preprocedural anxiety, adverse behavioral symptoms, and visual analog scales all improved and side effects were minimal. It is concluded that premedication for painful procedures should be used routinely in children with cancer. With proper monitoring, fentanyl and midazolam can be used safely in the outpatient clinic setting. Midazolam was found to be the drug of preference for the majority of patients.
Severe Protein S Deficiency in a Newborn
Authors: PEGELOW CHARLES H. , LEDFORD MARUIES , YOUNG JONELL , ZILLERUELO GASTON
Published: December 2021

Protein S is a vitamin K-dependent glycoprotein which acts as a cofactor for the anticoagulant activity of protein C.1,2 With production under autosomal control, heterozygotes produce half-normal levels and thrombotic disease may develop.3-6 Although thromboses occur primarily in adults, there are isolated reports of their occurrence in affected children.7-13

Severe protein C deficiency results in a syndrome in which affected children develop multiple thromboses in the newborn period.14 A recent report described a child with homozygous protein S deficiency who presented with neonatal purpura fulminans and other thromboses similar to those found in protein C deficiency.15,16 In this report, we
Guidelines for Human Immunodeficiency Virus (HIV)-Infected Children and Their Foster Families
Authors:   Task Force on Pediatric AIDS
Published: December 2021

STATEMENT OF THE PROBLEM

At the end of 1990, approximately 2786 cases of acquired immunodeficiency syndrome (AIDS) in children younger than 13 years of age had been reported to the Centers for Disease Control. Many more children are infected with the human immunodeficiency virus (HIV) but have milder or no apparent disease. The majority of young children have acquired their infection through perinatal transmission from HIV-infected mothers. A small minority have acquired their infection through blood transfusions received before 1985 when routine screening of the blood supply for HIV was initiated. Although many infants with perinatally acquired HIV infection will become symptomatic in the first year of life, a significant, but unknown, number of HIV-infected children are affected mildly or show minimal signs of infection for periods of up to 5 to 10 years.1,2 There is evidence to suggest that antiretroviral treatment with Zidovudine prolongs survival, and it is hoped that early treatment will increase the interval between development of infection and symptoms and reduce the severity of symptoms.3 Thus, children with HIV infection increasingly should be able to benefit from preschool and out-of-home child care programs. The social circumstances that may accompany HIV infection include (1) parents who have died or are too ill to care for their children; or (2) parents who are unable or unwilling to care for their children, most often as the result of continuing drug abuse. These situations frequently lead to the need for foster care or adoptive placement.

This statement makes recommendations regarding
Therapeutic Orphans
Authors: WEISMAN STEVEN J. , SCHECHTER NEIL L.
Published: December 2021

To the Editor.—

The report by Yaster et al, “Midazolam-Fentanyl Intravenous Sedation in Children: Case Report of Respiratory Arrest,”1 is the first we are aware of in the pediatric literature which reviews and promotes the use of this method of sedation and analgesia for children. Unfortunately,the title of the article and some of its emphasis may have the unfortunate consequence of delaying acceptance of this generally safe technique which is clearly not the intent
Therapeutic Orphans
Authors: DARLING HALINA S. , LAMBERT GEORGE H.
Published: December 2021

To the Editor.—

The case report by Yaster et al1 demonstrated the problems that can be encountered with conscious sedation, and it reconfirms the need to provide to children receiving sedative agents a certain level of care as detailed in the 1985 statement2 from the American Academy of Pediatrics (presently under revision).

The safety and efficacy of midazolam and fentanyl in combination for conscious sedation in children, to our knowledge, has not been established. In
HIV and Day Care
Authors: MORROW ARDYTHE L. , PICKERING LARRY K.
Published: December 2021

In Reply.—

We appreciate Dr Fenster's letter, especially since it underscores issues raised by the possibility of having human immunodeficiency virus(HIV)-infected children in day care centers. There are three issues raised by the letter: (1) the question of parent rights; (2) the role of physicians and public health institutions to assess health risks posed by individuals for the population as a whole; and (3) the content of the educational message that should be provided
Preoperative History and Coagulation Screening in Children Undergoing Tonsillectomy
Authors: Burk Carol D. , Cohen Alan R. , Miller Linda , Handler Steven D.
Published: December 2021

To evaluate the usefulness of preoperative screening for coagulation disorders in children, we prospectively studied laboratory and bleeding histories in 1603 children undergoing tonsillectomy. All patients had preoperative laboratory screening with a complete blood count, prothrombin time, activated partial thromboplastin time, and bleeding time. Persistent abnormalities on repeat testing 1 week later were investigated further by a standardized schema. A subset of 129 patients, including all those who bled perioperatively or had laboratory abnormalities, completed a standard historical questionnaire. Thirteen patients had persistent laboratory abnormalities diagnostic of lupus inhibitor (5), non-lupus inhibitor (6), mild hemophilia A (1), and vonWillebrand disease (1). Two patients had persistently prolonged activated partial thromboplastin times of undefined cause. Fourteen patients (10.8%) interviewed reported positive bleeding histories. Of these, five, including the patient with vonWillebrand disease, had persistent laboratory abnormalities. History alone failed to detect the patient with hemophilia A. For patients with inhibitors or prolonged activated partial thromboplastin times of unknown cause, surgery was delayed until the coagulation abnormalities resolved, and there was no perioperative bleeding. The patient with vonWillebrand disease had severe postoperative bleeding despite treatment with cryoprecipitate. In predicting perioperative bleeding, history and laboratory screening had a high specificity but a very low positive predictive value due to poor sensitivity and a low prevalence of bleeding. Some children with bleeding disorders may be identified first during routine preoperative coagulation testing, and replacement therapy or delay or cancellation of surgery may reduce or prevent perioperative hemorrhage. However, the large number of false positive laboratory tests and bleeding histories, coupled with the relative rarity of inherited and acquired coagulopathies, raises doubts about the overall value of routine screening.
An Endemic Strain of Staphylococcus haemolyticus Colonizing and Causing Bacteremia in Neonatal Intensive Care Unit Patients
Authors: Low Donald E. , Schmidt Barbara K. , Kirpalani Haresh M. , Moodie Rosemary , Ford-Jones Elizabeth L. , Kreiswirth Barry , Matlow Anne
Published: December 2021

Coagulase-negative staphylococci are now the major cause of bacteremia in neonatal intensive care units. To date, coagulase-negative staphylococci causing neonatal infections have been found to be distinct when typed by standard techniques. To determine whether or not an endemic strain could be identified using more discriminatory techniques, we characterized coagulase-negative staphylococci isolates obtained from a prospective study of coagulase-negative staphylococci bacteremia in a neonatal intensive care unit during 1984 through 1985, by standard techniques supplemented with DNA-DNA hybridization and restriction endonuclease analysis. We typed 58 strains that were isolated from 52 episodes of bacteremia in 38 neonates. There were 46 isolates of Staphylococcus epidermidis. Three pairs of strains were identical, and each strain was from a different patient. There were 12 isolates of Staphylococcus haemolyticus. Ten were identical, referred to as strain TOR-35, and had been isolated from eight different infants. Characterization of strains obtained in 1986 from a prospective study of coagulase-negative staphylococci-colonizing neonates admitted to the same neonatal intensive care unit found the TOR-35 strain had colonized 6 of 17 neonates by day seven. A point prevalence survey of all neonates in the same neonatal intensive care unit in 1990 found 5 of 30 neonates to be colonized with the TOR-35 strain. Therefore, we were able to identify an endemic strain of S haemolyticus that caused multiple episodes of bacteremia during a 6-month period and remained present in the same environment for a 5-year period.
Telephone Triage by Primary Care Physicians
Authors: Yanovski Susan Zelitch , Brown Richard L. , Balaban Donald J. , Yanovski Jack A. , Malley James D.
Published: December 2021

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening.

Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions.

In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.
Demography of Sexual Orientation in Adolescents
Authors: Remafedi Gary , Resnick Michael , Blum Robert , Harris Linda
Published: December 2021

This study was undertaken to explore patterns of sexual orientation in a representative sample of Minnesota junior and senior high school students. The sample included 34 706 students (grades 7 through 12) from diverse ethnic, geographic, and socioeconomic strata. Five Items pertaining to sexual attraction, fantasy, behavior, and affiliation were embedded in a self-administered survey of adolescent health. Overall, 10.7% of students were "unsure" of their sexual orientation; 88.2% described themselves as predominantly heterosexual and 1.1% described themselves as bisexual or predominantly homosexual. The reported prevalence of homosexual attractions (4.5%) exceeded homosexual fantasies (2.6%), sexual behavior (1%), or affiliation (0.4%). Gender differences were minor; but responses to Individual sexual orientation items varied with age, religiosity, ethnicity, and socioeconomic status. Uncertainty about sexual orientation diminished in successively older age groups, with corresponding increases in heterosexual and homosexual affiliation. The findings suggest an unfolding of sexual identity during adolescence, influenced by sexual experience and demographic factors.
Is It Practical to Screen for Familial Vesicoureteral Reflux Within a Private Pediatric Practice?
Authors: Peeden J. N. , Noe H. Norman
Published: December 2021

A prospective study was established within a private pediatric practice to identify the incidence and severity of vesicoureteral reflux in the siblings of patients known to have reflux. Twenty-four siblings of 18 children with reflux were studied. Eleven of these siblings were found to have reflux for an incidence of 46%. The risk of reflux in siblings of known children with reflux is thus significant and, at least in this study, compares with the risk of reflux after urinary tract infection. The outcome of the sibling group is discussed, along with our thoughts on the possible modes of inheritance of this disorder.
Prepayment with Office-Based Physicians in Publicly Funded Programs: Results from the Children's Medicaid Program
Authors: Davidson Stephen M. , Manheim Larry M. , Hohlen Mina M. , Werner Stephen M. , Yudkowsky Beth K. , Fleming Gretchen V.
Published: December 2021

This paper is a report of the results of a demonstration designed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program: (1) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and (2) capitation and financial risk-sharing along with the same physician agreement to manage utilization. Participating physicians were assigned randomly to either of the two payment groups. Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program(fee-for-service, low fees). Results showed no adverse effect of capitation payments on primary care visits to office-based physicians. Capitation physician referrals to specialists decreased relative to all other groups studied, consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists.
Cerebellar Symptoms as the Presenting Manifestations of Bilirubin Encephalopathy in Children with Crigler-Najjar Type I Disease
Authors: LABRUNE P. H. , ODIÈVRE M. , MYARA A. , TRIVIN F. , FRANCOUAL J.
Published: December 2021

Crigler-Najjar (CN) disease is a rare metabolic disorder characterized by a permanent deficiency in hepatic bilirubin UDPglucuronate β-d-glucuronosyl-transferase (UDPG-T, EC 2.1.4.17) activity. Since 1969, patients affected by this disease have been classified in two groups: in the first group (CN type I), the serum bilirubin concentration does not decrease under treatment with phenobarbital although it does so dramatically in the second group (CN type II).1,2 Despite the use of phototherapy and cholestyramine to avoid bilirubin neurotoxicity, patients affected by CN type I disease are at permanent risk of developing kernicterus with severe neurologic sequelae. The classic symptoms of kernicterus in the neonate, with or without CN disease, do not comprise prominent cerebellar manifestations, and, in most cases, the infants die or develop choreoathetosis, hearing loss, and severe mental retardation.3,4
Righting the Wrong
Authors: SILVER GEORGE A.
Published: December 2021

The evidence for the kinds of programs required to meet children's health needs has been frequently and plainly demonstrated. The programs need to be multilayered, including welfare and educational aspects in addition to health components. All Western European countries have such sociomedical plans in operation. Not all are as well-organized or effective as they might be, but in the Netherlands and Scandinavia, they are awesomely complete and effective. Social measures augment and strengthen traditional health services. Preventive measures are undertaken across the board: nutrition enhancement in the schools; home visits for immunization of very young children; and after-school programs through the school system to provide care, supervision, and learning experiences.
The Need for Rational Therapeutics in the Use of Cough and Cold Medicine in Infants
Authors: GADOMSKI ANNE , HORTON LISA
Published: December 2021

Cough and cold medications (CCM) generally are felt to be safe by both parents and health professionals. Widespread possession of CCM in the household and the common perception that CCM are efficacious1 reflect the influence of the marketing and promotion of drugs. In 1987, more than 1.9 billion dollars was spent on CCM nationwide.2 However, two recently published controlled trials have demonstreated little efficacy of CCM in children younger than 5 years old. One study demonstrated no significant improvement in the symptoms of upper respiratory tract infections among children 6 months to 5 years old treated with an antihistamine-decongestant, placebo, or no treatment.3
Hypercholesterolemia Screening Questioned
Authors: SHEPS SAM
Published: December 2021

To the Editor.—

The allure of screening has reached epic proportions in a medical world that apparently has difficulty finding enough to keep itself intellectually and gainfully occupied. A case in point, is the recent article by Steiner et al,1 entitled "Hypercholesterolemia in Adolescence: Effectiveness of Screening Strategies based on Risk Factors." Despite the fact that the authors clearly demonstrate that high-risk status as defined by either the 1985 or 1989 American Academy of Pediatrics (AAP) criteria (or both) is not predictive of high cholesterol levels in adolescents (Table 3 notes positive predictive values ranging from .09 to .11), the authors conclude with the startling statement that "Until all the related controversies surrounding cholesterol testing are more clearly understood, all adolescents must be screened to adequately identify those with hypercholesterolemia."
The Overdiagnosis of Erythema Multiforme
Authors: WESTON JANET A. , WESTON WILLIAM L.
Published: December 2021

To the Editor.—

Erythema multiforme (EM) is an acute, self-limited mucocutaneous eruption characterized by the abrupt onset of symmetrical, fixed, red papules, some of which evolve into target lesions, the hallmark of EM.1 Since the original description by Ferdinand von Hebra in 1860, there has been confusion regarding the diagnosis.2 From children referred for a National Institutes of Health-sponsored research study of EM, we noted that a large majority of the children did not meet the criteria for EM.1
Chronic Fatigue Immune Dysfunction Syndrome: An Epidemic?
Authors: SMITH MARK SCOTT
Published: December 2021

In Reply.—

The chronic fatigue syndrome (CFS) remains an enigma. A recent Australian study estimated the point prevalence at 37.1/100 000 (5.5 of age 0 to 9 years; 47.9 for 10 to 19 years).1 Since the diagnostic criteria of the study were less stringent than those proposed by Centers for Disease Control (CDC),2 this is probably an overestimate. All the 15 adolescents in our report had profound chronic fatigue, multiple somatic complaints, and marked functional disability, but only six met CDC CFS criteria.
Evaluation and Treatment of Jaundice in the Term Newborn: A Kinder, Gentler Approach
Authors: Newman Thomas B. , Maisels M. Jeffrey
Published: December 2021

Standard recommendations for evaluating and treating jaundice in term babies include following all babies closely for jaundice, obtaining several laboratory tests in those with early jaundice or bilirubin levels more than 12 to 13 mg/dL (205 to 222 µmol/L), using phototherapy to try to keep bilirubin levels below 20 mg/dL (342 µmol/L), and doing exchange transfusions if phototherapy fails, regardless of the cause of the jaundice. These recommendations are likely to lead to unnecessary testing and treatment of many jaundiced term infants. Because most jaundiced infants have no underlying illness, and the generally recommended laboratory tests lack sensitivity and specificity, they are seldom useful. In most babies, the only blood tests needed to evaluate jaundice are the blood type and group (of baby and mother) and a direct Coombs' test. A determination of direct bilirubin level should be added if jaundice is prolonged (>2 to 4 weeks) or the baby has other signs of illness. Bilirubin toxicity is rare in term babies without hemolysis. In this low-risk group, the risks and cost of identifying and treating high bilirubin levels may exceed the benefits. Such infants need not be closely followed for jaundice. If significant jaundice is nonetheless found, treatment should be deferred to relatively high levels of serum bilirubin, with a goal of keeping bilirubin levels below 400 to 500 µmol/L (23.4 to 29.2 mg/dL). Babies with hemolytic disease should be followed more closely, and their bilirubin levels kept below 300 to 400 µmol/L (17.5 to 23.4 mg/dL). These recommendations should be reevaluated as new data become available. In the meantime, currently available data justify an approach to the jaundiced term infant that is less aggressive than previously recommended.
Bilirubin Recommendations Present Problems: New Guidelines Simplistic and Untested
Authors: WENNBERG RICHARD P.
Published: December 2021

Newman and Maisels1 raise strong arguments to change our approach to neonatal jaundice in the wellbaby nursery. The plea for a more gentle approach to the jaundiced newborn is long overdue, but what do we then do? Newman and Maisels not only identify the problem, but they offer a detailed solution which would significantly alter standards of practice for neonates.

While one might bicker about their selection of evaluation tests to be conducted in the nursery, the proposed guidelines present two more fundamental problems: (1) the recommendation for intervention (total bilirubin concentration 25 to 29 mg/dL) sustains the myth that the total unconjugated bilirubin is the best clinical predictor of kernicterus and ignores known and proposed pathochemical processes involved in bilirubin encephalopathy, and (2) no mechanism is proposed to evaluate the safety and efficacy of their proposal.
Yet Another Expert Opinion on Bilirubin Toxicity!
Authors: JOHNSON LOIS
Published: December 2021

Drs Newman and Maisels1 have provided valuable new guidelines for management of jaundice in the term newborn which take into account age at discharge from the hospital and some of the factors altering the general risk of bilirubin toxicity. They note that much of the information needed to identify the individual at risk is still unavailable and remind their readers that their "recommendations should be reevaluated periodically as new data become available."

I have serious concerns, however, with the second half of their paper which almost completely downplays the toxic potential of bilirubin, its often erratic expression, and its ability to cause a spectrum of damage ranging from frank kernicterus to insults that are so minor as to be compensated for completely over time.2-4
Response to Commentaries Re: Evaluation and Treatment of Jaundice in the Term Newborn: A Kinder, Gentler Approach
Authors: NEWMAN THOMAS B. , MAISELS M. JEFFREY
Published: December 2021

We thank Dr Lucey for soliciting expert commentaries on our manuscript and for providing us the opportunity to respond to them. Although we do not have space to respond to each of the commentaries in depth, we will address the major points brought up by more than one author and selected points from the individual commentaries.

Drs Poland and Wennberg emphasize that neurotoxicity due to bilirubin is a complicated process, with many determinants besides the serum bilirubin level; Dr Cashore's four example cases illustrate this point. We agree. A bilirubin level that may be toxic in one infant may not be hazardous in another.
Preschool Vision Screening in Pediatric Practice: A Study From the Pediatric Research in Office Settings (PROS) Network
Authors: Wasserman Richard C. , Croft Candace A. , Brotherton Sarah E.
Published: December 2021

In this cross-sectional study, the vision-screening process is described for 8417 children aged 3 to 5 seen for health supervision in a group of 102 pediatric practices in 23 states and Puerto Rico. Three hundred forty children who failed screening (63% of those who failed) were followed up 2 months after initial screening. The sample was 52% male, 86% white, 9% black, 3% Hispanic, and 1% Asian. Vision screening was attempted on 66% of children overall. Pediatricians' reasons for not screening were "not routine" (44%), "too young" (40%), and "screening done previously" (17%). Younger children were less likely to be screened than older children (39% of those aged 3), and Hispanics were less likely to be screened than other ethnic groups (P < .001). Thirty-three percent of children received no screening for latent strabismus. Two months later, 50% of parents whose child had failed a vision test were unaware of this fact on questionnaire follow-up. Eighty-five percent of children referred to an eye specialist had made or kept an appointment. It is concluded that pediatricians need to increase vision screening among younger preschool children and communicate more effectively to parents the results of screening failure.
Controlled Study of Linear Growth in Asthmatic Children During Treatment With Inhaled Glucocorticosteroids
Authors: Wolthers Ole D. , Pedersen Søren
Published: December 2021

Linear growth was investigated with weekly knemometry in a population of 43 schoolchildren with mild asthma treated with inhaled budesonide. The design was a randomized, double-blind, parallel group study with three dose groups of 200, 400, and 800 µg of budesonide per day. Each dose group received budesonide for 8 consecutive weeks. Placebo was given for either 4 weeks before or after budesonide treatment. Twelve children in the 200-µg group, 14 in the 400-µg group, and 12 in the 800-µg group completed the 12-week study period. There was no significant difference in mean growth velocity among the three dose groups during placebo treatment. Compared with placebo (growth velocity: 0.39 mm/wk), mean lower leg growth velocity was reduced with 0.26 mm/wk (P < .001, t = 5.0, df = 11; 95% confidence interval 0.14 to 0.37 mm/wk) in children treated with 800 µg of budesonide. There was no statistically significant difference in growth velocity between 200- or 400-µg budesonide treatments and placebo. These data indicate that inhaled budesonide can be safely used in doses up to 400 µg/d in schoolchildren with asthma.
Sudden Infant Death Syndrome (SIDS) in Denmark: Evaluation of the Increasing Incidence of Registered SIDS in the Period 1972 to 1983 and Results of a Prospective Study in 1987 through 1988
Authors: Helweg-Larsen Karin , Knudsen Lisbeth B. , Gregersen Markil , Simonsen Jørn
Published: December 2021

To investigate a reported increase, from 0.4 to 1.3 per thousand live births, in the Danish incidence of sudden infant death syndrome (SIDS), a retrospective analysis of SIDS in Denmark from 1972 to 1983 was carried out. Based on data registered with the National Board of Health, a notable regional difference in SIDS rate between the western and eastern parts of Denmark was found. This difference did not correlate with the overall postneonatal mortality by region. Danish law requires medicolegal investigation in all cases of sudden unexpected death. Medicolegal autopsies are performed only in the three forensic institutes which cover all of Denmark. Despite the law and a uniform organization of the forensic medical services, differing application of postmortem examinations and individual interpretation of the history and autopsy in cases of sudden infant death existed. Differences in reporting of respiratory infections, suffocation, and cardiac malformation were found to contribute to the increase and to regional disparities in SIDS incidence. The three Danish forensic institutes examined all cases of sudden infant deaths in Denmark 1987 and 1988. These cases were classified as explained cause of death, pure SIDS, and atypical SIDS; atypical cases were evaluated by consensus. The SIDS incidence (the number of classic SIDS and atypical SIDS per thousand live births) was 1.9 in 1987 and 1.3 in 1988, and it was identical in the eastern and western part of Denmark; however, a higher incidence both of overall postneonatal and SIDS mortality was found in the middle region of Denmark. The analysis stresses the importance of high autopsy rate and expert investigation in all cases of infant death in order to obtain reliable data for epidemiological studies. A prospective joint study of all postneonatal infant deaths in Finland, Iceland, Norway, Sweden, and Denmark will be carried out to analyze the reliability and the possible cause of reported differences in SIDS incidence in the five Nordic countries.