bluuebunny/crossref_metadata_2025 huggingface dataset:
Orbital and Periorbital Cellulitis
Authors: Powell Keith R.
Published: December 2021

The acute onset of eyelid redness and swelling in a child usually results in a quick visit to the doctor's office or an emergency room. The differential diagnosis for these signs ranges from relatively innocuous problems, such as allergy or an insect sting, to potentially vision-affecting or even life-threatening diseases, such as orbital cellulitis or cavernous vein thrombosis. The orbital contents often are protected from an inflammatory process by the orbital septum, a continuation of the periosteum of the bony orbit to the margins of both the upper and lower eyelids (Figure 1). An inflammatory process occurring in the structures superficial to the orbital septum is defined as preseptal or periorbital cellulitis; an inflammatory process in structures deep to the orbital septum is defined as orbital cellulitis of a specific complication thereof. Bacterial infection can cause both periorbital and orbital cellulitis.

Another anatomic feature of importance is that the skin of the eyelid is the thinnest skin of the body. The subcutaneous tissue of the eyelid is composed of musculofibrous tissue and no fat. This combination of thin skin and loose subcutaneous tissues makes it possible for the eyelid to swell dramatically as it fills with edematous fluid.

Epidemiology and Pathogenesis of Periorbital Cellulitis
Autism and the Pervasive Developmental Disorders: Part 2
Authors: Bauer Stephen
Published: December 2021

Differential Diagnosis

The differential diagnosis of autism includes many other conditions and will depend on the age of the child at the time of evaluation, the child's developmental level, and the type of symptom that is most prominent.

For a child found to fall within the spectrum of autism, the category most applicable along that spectrum is an additional differential diagnostic issue. The lines of division are not clear, although DSM-IV provides some help. In general, the term pervasive developmental disorder (PDD) is more likely to be used when cognitive, communicative, and social skills are high relative to other children who are autistic. Some studies have shown that the clinical criterion most useful in separating the two categories is the degree of socialization and relatedness shown by the child. Children who display an active social interest, a degree of empathy, and a better ability to sustain interactions tend to be placed in the PDD category. If they have particularly strong language skills along with the milder socialization difficulties, Asperger disorder is likely to be diagnosed.

For the child who has significant developmental delays in all areas, the primary differential diagnosis will be mental retardation without autism. Many children who are severely mentally retarded exhibit some of the behaviors seen in autism, such as stereotyped behaviors and perseveration, emotional lability, and self-injurious behavior.
Sports-related Injuries Among Adolescents: When Do They Occur, and How Can We Prevent Them?
Authors: Rome Ellen S.
Published: December 2021

Sports injuries, as causes of frequent morbidity but infrequent mortality among teens, receive less attention than do more dramatic motor vehicle accidents, homicides, and suicides. Injury to adolescents caused by both organized and informal athletics occurs commonly, yet the precise frequency, severity, and predisposing risk factors of such injuries have not been defined well. Unlike mortality data, which can be obtained readily from death certificates or through the National Center for Health Statistics, nonfatal sports injuries often go unrecognized among injury statistics because adolescents frequently do not seek health care or tell a coach or family member about the injury. Moreover, data on injuries can exist in a variety of places outside of physicians' offices, including emergency department or hospital records, school-based health centers, or trainers' logs. Different studies also have defined injury differently, with little standardization between studies and variances in sources used for data collection. Hospital or emergency department data may differ in the degree of severity of the injury from office-based data or data on those injuries treated solely by a coach or athletic trainer. Despite these difficulties, a plethora of data exists on the topic of sports injuries and their prevention.

Common Causes of Sports Injury

In a Massachusetts study by Gallagher and colleagues in the 1980s, sports injuries were found to be the most common cause of injury and, overall, the second leading cause of emergency department visits and hospital admissions in the 13- to 19- year-old age group.
Management of Urinary Tract Infections: Children Are Different
Authors: Todd James K.
Published: December 2021

Urinary tract infection (UTI) is a common problem in infants and children and may have serious consequences leading to chronic renal failure. In spite of its frequency and potential severity, UTI often is felt to be a simple problem. Nothing could be further from the truth; there are many dynamic issues related to its proper diagnosis and appropriate treatment. Especially important are the differences in UTI between adults and children that emphasize that children are not "little adults."

Epidemiology

The prevalence of UTI varies by age and sex. In the newborn period, approximately 1% to 2% of both girls and boys (usually uncircumcised) have UTIs. In infancy and childhood, UTI is more common in girls than in boys; approximately 1% of school-age girls develop symptomatic infection each year. This incidence increases even further when adolescent girls become sexually active. Risk factors for UTI in females include sexual intercourse, sexual abuse, use of bubble bath, constipation, pinworms, and infrequent or incomplete voiding. In either sex, risk factors include ureteric reflux in a sibling, urologic abnormalities, indwelling urethral catheterization, and neurogenic bladder.

Pathogenesis

Although cystitis may be caused by adenovirus, UTI usually is caused by bacteria that commonly are found on the perineum and ascend up the urethra into the bladder.
Consultation with the specialist
Authors: Johnson Robert L.
Published: December 2021

The wide array of therapeutic responses to substance use/abuse suggests that there is not one best approach to solve the problems of any one adolescent or young adult. Indeed, most young people require a variety of therapeutic interventions, which may include inpatient treatment, ambulatory therapeutic groups, and individual counseling, as well as self-help groups.

In choosing a therapeutic program, the physician must be circumspect when interpreting the reported success or "cure" rates of any of these modalities. Such citations often are misleading because frequently they fail to reflect accurately the therapeutic influence of several important patient population variables that distinguish the programs. For example, an outpatient program may report better "cure" rates than an inpatient program because the ambulatory program may have enrolled clients who have more limited substance use patterns and who are more committed to abstinence. Furthermore, there is no standard methodology for reporting "rates of success." Some programs simply report a compliance rate for clients who attend meetings or scheduled therapeutic sessions, some report the numbers of clients who complete the program without any reference to recidivism, and some report the numbers of clients who are "drug-free" after 1 year.

Given these caveats, the experience of most clinicians suggests that many adolescents who experiment with the traditional "gateway" drugs (eg, tobacco, alcohol, marijuana) respond well to outpatient group and individual therapy, those adolescents committed to a substance use/abuse pattern respond best to inpatient or residential programs, and adolescents who have a psychiatric/behavioral problem complicated by substance use/abuse require formal psychiatric treatment. Single-drug programs such as methadone maintenance or Alcoholics Anonymous have limited applicability for treatment of most adolescents who suffer from substance abuse.
Common Respiratory Disorders of the Newborn
Authors: Kopelman Arthur E. , Mathew Oommen P.
Published: December 2021

Respiratory distress is a frequently encountered problem in the first few days of life. The general pediatrician must assess the infant's condition, make a tentative diagnosis, institute appropriate care, and decide whether to transfer the infant to a neonatal intensive care unit. The decision to transfer an infant should be based on the interest and training of the physician as well as on readily available resources for optimal management. In general, any infant who needs mechanical ventilation for more than a few hours should be transferred to a regional intensive care nursery.

An infant who is in respiratory distress of any cause may present with tachypnea, nasal flaring, sternal and intercostal retractions, cyanosis, and even apnea. The differential diagnosis of respiratory disorders in the newborn is extensive and includes disorders of the major airways, diseases of the pulmonary parenchyma, and rib cage abnormalities. Review of the history of pregnancy, labor, delivery, and resuscitation; careful physical examination; analysis of laboratory tests such as blood gases, hematocrit, and blood glucose; and evaluation of a chest radiograph usually permit a tentative diagnosis. Additional challenges arise when an infant who has chronic lung disease is returned to the community hospital for continuing care.

This review covers three of the most common forms of neonatal respiratory distress: transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), and bronchopulmonary dysplasia (BPD).
INDEX OF SUSPICION
Authors: McCarthy Dennis J. , Tuite Robert J. , Conners Gregory P.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 5-year-old girl is brought to your office because she has been unable to walk since awakening this morning. Last night her family returned from a 4-day summer camping trip during which she was active and healthy. Her past medical history is unremarkable and she is fully immunized. There is no evidence of infectious, drug, or toxic exposures.

On examination, the child is alert and cooperative but unable to stand or walk, although she denies pain. Deep tendon reflexes cannot be elicited in her lower extremities. Hercranial nerve function is normal, as are her vital signs and the rest of her physical examination.

Case 2 Presentation

A 4-year-old girl is brought to the office because of a swollen, tender 3.0-cm mass under her left mandible that has been present for 2 weeks.
Consultation with the Specialist
Authors: Sills Richard H.
Published: December 2021

The indications for bone marrow examination in children are varied and complex. In children who have isolated anemia, marrow examination usually is limited to those who have severe or persistent normocytic anemia in the absence of blood loss or hemolysis. Bone marrow studies are not necessary in children who have reactive lymphocytes; in most children who have leukopenia, leukocytosis, or thrombocytosis; and in many who have ITP. Marrow examination always is indicated when leukemia is suspected, in children who have pancytopenia of unknown etiology, and when metastatic involvement of the marrow is suspected. If one believes that examination of the bone marrow may be indicated, consultation with a pediatric hematologist/oncologist is recommended. The consultant can verify the need for the examination, decide what specific marrow studies should be performed, and suggest what other laboratory studies could be helpful.
PERIPHERAL BRAIN
Authors: Baren Jill M. , Seidel James S.
Published: December 2021

This section of Pediatrics in Review is designed to be clipped or duplicated and filed in a handy place in the office, clinic, or emergency department, providing a convenient and concise reference.

All offices in which children are examined should have pediatric emergency equipment, supplies, drugs, policies, and procedures. The equipment, supplies, and drugs kept in the office will depend on the spectrum of ill or injured children seen in the practice. However, a source of oxygen, basic resuscitation drugs (suited to the patient population and experience of the health-care providers), and a dosage chart or weight-based dosing tape (Figure 1) should be available in all offices. The following list of drugs is fairly comprehensive and is organized according to sign or symptom needing treatment. Health-care providers should become familiar with the information regarding specific drugs that they use commonly, eg, choose a short-acting benzodiazepine such as diazepam or lorazepam for treating status epilepticus.

The intraosseous (IO) route of drug administration can be used for the majority of emergency drugs listed in the chart that suggest administration by the intramuscular (IM) or intravenous (IV) routes. The IO route is appropriate for children age 6 years and younger and should be reserved for those circumstances where failure to achieve vascular access might result in loss of life or limb (ie, anaphylaxis, cardiopulmonary arrest).
Peptic Ulcer Disease in Children
Authors: Mezoff Adam G , Balistreri William F
Published: December 2021

The term peptic ulcer disease describes a group of disorders, rather than a single pathologic process. It is recognized increasingly in children, often with long-term ramifications. In the past decade, management of patients who have peptic ulcer disease has changed dramatically. Antacid therapy has given way to treatment with histamine (H2) receptor antagonists, a new class of pharmacologic agents that has fostered a billion dollar industry. Other modalities of treatment have been developed as well, such as cytoprotective agents (sucralfate) and proton pump inhibitors (omeprazole), which are based on research into the pathophysiology of gastric acid disorders. In addition, the discovery of an infectious agent (Helicobacter pylori) that contributes to the formation of peptic ulcers has led to a reevaluation of the traditional approach to diagnosis and treatment of abdominal pain in children.

Duodenal ulcers are defined as mucosal defects penetrating the mucosa, submucosa, and muscularis mucosa of the duodenum. Gastric ulcers are defined as mucosal defects that penetrate the muscularis mucosa of the stomach. Primary ulcers are those that have no known underlying cause. Secondary ulcers are associated with a known ulcerogenic event such as stress, burns, or ingestion of nonsteroidal anti-inflammatory medications. A discussion of peptic inflammation that typically does not cause ulceration, such as esophagitis, is beyond the scope of this review.
Special Considerations in the Use of Glucocorticoids in Children
Authors: Spahn Joseph D. , Kamada Alan K.
Published: December 2021

GCs are used commonly for the treatment of various inflammatory and autoimmune diseases. Although potent and generally effective, they are not without risks for producing serious adverse effects, especially when used in high doses for prolonged periods of time. Thus, the clinician must balance the therapeutic effects of GCs with their risks for adverse effects; using the lowest possible effective GC doses as well as maximizing other therapeutic modalities are means by which this goal can be achieved. Early recognition and appropriate management are other methods to minimize GC-induced adverse effects. Maximization of therapy, early recognition, and appropriate management of adverse effects can minimize the potential severe complications of GC therapy.
Another Year, Another Volume!
Authors: H R J
Published: December 2021

Link to Recertification Examination

From the first issue in 1978, Pediatrics in Review has been tied closely to the American Board of Pediatrics' program of recertification. Since 1988, this program has been called the Program for Renewal of Certification in Pediatrics (PRCP), and it requires that each pediatrician who has been Board-certified since that date participate in this program to be recertified.

The American Board of Pediatrics has developed a list of more than 4000 core content statements prepared by practitioners and academicians in all phases of pediatrics as the basis of the examination. Each year the Board selects some 900 of these as the basis for the recertification examination the next year.
Anemia in Preterm Infants
Authors: Roth Philip
Published: December 2021

During fetal life, hemoglobin concentration increases from a level of 9 g/dL at l0 weeks' to 14 to 15 g/dL at 22 to 24 weeks' gestation. By the middle of the third trimester, concentrations close to those observed at birth (16 to 17 g/dL) are reached, and little additional change occurs. As a result, cord hemoglobin concentrations in term and preterm newborns are very similar, with the possible exception of the most extremely preterm infants. Immediately after birth, the hemoglobin concentration begins to rise from the combined effects of placental transfusion and the postnatal readjustment of plasma volume. At approximately 8 to 12 hours of life, the hemoglobin plateaus at levels 1 to 2 g/dL above those observed at birth (about 18 g/dL).
Reactions to Iodinated Contrast Media
Authors: Farkas Jeffrey , Liebling Melissa S. , Pritzker Henry A.
Published: December 2021

The exact mechanism responsible for adverse reactions to iodinated contrast administered intravenously during radiologic evaluation is not known. However, through work that has been performed both in the laboratory and in clinical trials, we do know that the types of reactions are variable and the underlying etiologies multifactorial. Moreover, reactions can be prevented in many cases through careful choice of contrast agent and pretreatment with corticosteroids and antihistamines.

Adverse contrast reactions can be separated into two broad categories: chemotoxic and anaphylactoid. Chemotoxic reactions are dose-dependent and related to direct chemical effects of the contrast medium. Pain at the injection site and flushing belong in this category; a combination of hypertonicity and calcium binding results in vasodilatation.
Herpes Simplex Virus Infections
Authors: Annunziato Paula W.
Published: December 2021

Case Report

A term female developed fever and tachypnea and had a transient episode of poor color and tone on the third day of life. She was delivered by cesarean section 5 hours after rupture of membranes to a 19-year-old, gravida 4, para 0 mother whose serology was negative for syphilis, human immunodeficiency virus (HIV), and hepatitis B surface antigen. The mother had no history of sexually transmitted diseases. Apgar scores were 8 at 1 minute and 9 at 10 minutes. When the infant was admitted to the nursery, scalp abrasions were noticed by the nurse. On the third day of life, a sepsis evaluation was initiated, and the infant received ampicillin and gentamicin intravenously: no bacterial infection was found. On the fifth day of life, vesicular lesions were noticed on her scalp. Bilateral interstitial infiltrates were present On chest radiograph and laboratory studies revealed mild elevations in liver function tests. There were no cerebrospinal fluid (CSF) abnormalities. She was started on intravenous acyclovir, and herpes simplex virus (HSV)-2 subsequently was isolated from both her pharynx and scalp lesions. After receiving intravenous acyclovir for 3 weeks, she was discharged with no evidence of residual sequelae. Four days after acyclovir was discontinued, new scalp vesicles appeared and the infant developed a temperature of 38.8°C (102°F).
Serologic Tests: Utility in Clinical Pediatric Practice
Authors: Krilov Leonard R.
Published: December 2021

Despite clinical microbiologic advances in the isolation and/or detection of bacterial pathogens, determination of infection with a number of clinically important bacteria relies on serologic testing. When a reliable specific immunoglobulin (Ig) M test is available or when a significant (ie,≥4 fold) change in titer is obtained in acute and convalescent serologies, these tests can be used to make a definitive diagnosis. A single elevated titer in the face of a compatible clinical scenario also may help support a given diagnosis.

Infection with a number of infrequently encountered bacteria, when suspected, can be documented well by serologic testing. Examples include the primarily zoonotic organisms Brucella, Leptospira, and Francisella tularensis.
Gifted and Talented Children: Issues for Pediatricians
Authors: Robinson Nancy M. , Olszewski-Kubilius Paula M.
Published: December 2021

Giftedness is both similar to and different from other exceptionalities in its implications for the lives of children and families. Unlike other exceptionalities, the prognosis for giftedness is, of course, considerably more positive. Like the others, however, this kind of differentness makes demands on family and community resources and carries risks of psychosocial stress, social isolation, and nonfulfillment of potential. Given society's other pressing needs, those of this group often are brushed aside, even resented; both the life quality of the children and their families and the contribution the children might make in years to come, therefore, can be eroded. All children deserve to love school and to have the opportunity to make the best of their possibilities. Informed and sympathetic pediatricians who are sensitive to the issues involved can play critical roles in promoting healthy development.

Definitions and Prevalence

Reasoning from the apparent symmetry of the normal curve, professionals sometimes tend to regard giftedness as the mirror image of mental retardation, but this is not a useful model. There is much greater diversity among the highly capable than among the less capable. Indeed, advanced ability is neither restrictive nor defining; gifted children (and their families) are probably more diverse than any other group in our society.
IN MINIMAL ACCESS SURGERY
Authors: Lobe Thom E
Published: December 2021

The pediatrician must be cognizant of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide either outpatient surgery or short-stay surgery appears to be cost-effective and appropriate state-of-the-art medical care. As the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will become increasingly available.
Almost Extinct Diseases: Measles, Mumps, Rubella, and Pertussis
Authors: Gold Eli
Published: December 2021

Introduction

The availability of effective vaccines led to a dramatic decrease in the number of cases of measles, mumps, rubella, and pertussis reported each year. However, several years after their introduction, small but significant outbreaks began to appear in urban settings among clusters of children, adolescents, and young adults. Some of those who became ill were members of families that did not accept vaccine for religious reasons or because of fear of adverse reactions. Others were "vaccine failures," the 5% to 10% who did not respond to injected antigens or responded with only transient low levels of protective antibody. However, the majority of children who are infected during community outbreaks of contagious disease are those younger than school age who never received the vaccine. The requirement for immunization before school attendance and the new practice of administering a second dose of measles, mumps, rubella (MMR) vaccine to children of school age has resulted in relatively good levels of immunity among those 5 years of age and older, but more vigorous efforts are needed to protect a higher proportion of those not yet in school. Estimates for the year 1993, based on the National Health Interview Survey (NHIS), revealed that 67.7% of children ages 19 to 35 months had received the series of vaccines recommended routinely: four doses of diphtheria and tetanus toxoids and whole-cell pertussis (DTP) vaccine, three doses of polio vaccine, and one dose of MMR.
Lipoprotein Disorders
Authors: Belamarich Peter F.
Published: December 2021

Although symptomatic lipoproteinemias are rare in childhood, early detection often can prevent severe complications.

Abetalipoproteinemia is characterized by severe hypolipidemia, fat malabsorption, failure to thrive, unusual spiculated erythrocytes known as acanthocytes, and progressive neuromuscular and retinal pigmentary degeneration believed to be related to vitamin E deficiency. Plasma triglyceride concentrations are so low as to be frequently undetectable, and cholesterol concentrations typically are less than 50% of normal. This disorder results from an inability of both enterocytes and hepatocytes to secrete their apoprotein B-containing lipoproteins. Consequently, chylomicrons, very low-density lipoprotein are absent from plasma.

A related disorder, homozygous familial hypobetalipoproteinemia, mimics the signs and symptoms and the characteristic lipid levels of abetalipoproteinemia, but is believed to involve a different mutation.
Kawasaki Syndrome
Authors: Melish Marian E.
Published: December 2021

Kawasaki syndrome (KS) is an acute, febrile, self-limited, multisystem vasculitis that almost exclusively affects young children. First described in 1967 by Dr. Tomisaku Kawasaki of Tokyo, Japan, it now has been recognized as occurring in all regions of the world among children of multiple and diverse ethnic groups. Its occurrence is common enough in all parts of North America that primary physicians should be familiar with its diagnosis and treatment. Originally thought to be a benign febrile exanthem, it soon was recognized that fever could be prolonged and that significant adverse cardiac effects were common, especially the development of coronary aneurysms that could lead to myocardial infarction and sudden death.

Fatal KS is a multisystem vasculitis indistinguishable from infantile periarteritis nodosa (IPN); until the discovery of KS, IPN had been a condition diagnosed only at autopsy. Dr. Kawasaki's enduring contribution is the recognition and description of the major clinical features of this unique disease, which only rarely causes death. The clinical criteria he described remain the basis of all clinical and epidemiologic descriptions in use today.

Although effective therapy has been discovered, the etiology of the disease remains unknown. The acute, febrile, self-limited nature of the disease and its clinical features of fever; rash; and menigeal, joint, hepatic, and mucous membrane inflammation strongly suggest that the etiologic agent is microbial.
Acute Otitis Media
Authors: Maxson Suzanne , Yamauchi Terry
Published: December 2021

Definitions

Acute otitis media with effusion (AOME) is a clinically identifiable, suppurative infection of the middle ear. The infection has a relatively sudden onset and short duration. It denotes inflammation of the mucoperiosteal lining of the middle ear. The inflamed tympanic membrane (TM) is bulging, opacified, or both.

The condition chronic otitis media is poorly defined, but it may be categorized into two clinical entities for simplification: chronic otitis media with effusion (COME) and chronic suppurative otitis media (CSOM). COME, also known as serous or non-suppurative otitis media, is characterized by the presence of a middle ear effusion (MEE) behind an intact TM that persists for more than 2 to 3 months. It may be asymptomatic except for hearing loss. There generally are no acute clinical signs or symptoms, and the TM is not red or bulging. CSOM is characterized by chronic perforation of the TM, with purulent discharge, for a prolonged period of time, usually more than 6 weeks. There generally is an insidious clinical onset. Either COME or CSOM may follow AOME.

Epidemiology

Otitis media is one of the most frequent causes for physician visits by children. Approximately 25% of such visits during the first year of life are for middle ear disease; this increases to 40% for children 4 to 5 years of age.
INDEX OF SUSPICION
Authors: Nield Linda S. , Keri Jonette E. , Fisher Randall G. , Khanfar Nasha't M.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

A 10-year-old boy is brought to your office in late spring because of an erythematous rash on his arms and legs that has been present for 4 days and because he is having joint pains. The rash first appeared after the boy had been playing outdoors for several hours in the sun. He did have a new commercial sunblock lotion applied to his skin before going outdoors. His father is concerned because even though the rash is less pronounced, his son has been experiencing stiff and painful knees and ankles upon awakening for the past 2 days. The joint discomfort improves with movement during the day. The boy has had no other symptoms and has been free of fever.
Advances in the Management of Acute Asthma in Children
Authors: Murphy Shirley J. , Kelly H. William
Published: December 2021

In 1991, the National Heart, Lung and Blood Institute's National Asthma Education Program (NAEP) published "Guidelines for the Diagnosis and Management of Asthma" recommended by an expert panel. This was followed in 1992 by the publication of the "Internal Consensus Report on Diagnosis and Management of Asthma" (ICR). These reports reviewed the current state of knowledge and established the goals of therapy for both chronic asthma and acute exacerbations. This article will provide an update on the research that has been published since those recommendations.

The first NAEP guidelines established three goals for the treatment of acute asthma: Rapid reversal of airflow obstruction, correction of significant hypoxemia, and reduction of the rate of recurrent severe asthma symptoms. The ICR added two additional goals: Restoration of lung function to normal as soon as possible and development of a written plan of action in case of a further exacerbation.

Both reports concluded that these goals could be accomplished best by aggressive use of inhaled selective beta2-agonists and early introduction of systemic corticosteroids (in certain patients at home). The liberal use of low-flow oxygen was considered safe; it often easily corrects the hypoxemia produced by the alveolar hypoventilation and the mismatch in ventilation/perfusion (V/Q) that frequently accompanies acute asthma exacerbations.
Pressures: Impact on Health of Adolescents
Authors: Neal Wendy , Alderman Elizabeth
Published: December 2021

Adolescents experience a variety of daily pressures from various facets in their social environment. Their ability to deal with these pressures and the resulting stress depends on individual coping mechanisms. Stress that is induced by pressures can manifest itself as participation in risk-taking behaviors and development of poor self-concept, leading to an overall poor self-assessment of health and somatic complaints. Recent data evaluating the impact of stress on adolescents have focused on the influence of the adolescent's social environment, specifically peer and family relationships.

Metzler et al studied risky sexual behavior in a group of adolescents as a consequence of associations with peers engaging in risk-taking behaviors.
Developmental Learning Disorders: Clues to Their Diagnosis and Management
Authors: Capin Donna M.
Published: December 2021

Introduction

The observant physician can make a truly life-enhancing difference with the timely diagnosis of a learning disorder. Approximately 6% to 7% of all school-aged children are identified as "learning disabled" and receive special educational services. In the 1992 to 1993 school year, 4,633,674 students ages 6 to 21 years received services under Federal formula grant programs. In medical settings, roughly twice as many boys as girls are diagnosed formally, a ratio that most likely is biased by the different phenotypes of learning problems among boys and girls. High-profile disorders that cause disruption in classroom and family functioning are the earliest to be identified and often are referred for help as early as the preschool years. More subtle or nearly "invisible" disorders (such as isolated attention deficit without hyperactivity) are masked by unexceptional or even "good" (passive) behavior and can persist undetected into adulthood, becoming symptomatic in college or graduate school. Long-term follow-up studies and evaluations of the parents of children who have learning disorders have taught two lessons: 1) learning disorders are not "outgrown" and 2) they can be extremely subtle and well hidden, especially among adolescents, who are more likely able to compensate (albeit at a price) through most of their formal schooling.
INDEX OF SUSPICION
Authors: Harris J. Peter , Buzzard Carol J. , Gutierrez Liliana D. , Babl Franz E. , Ratzan Susan K
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

While driving to work, a 17-year-old female high school senior who has been in good health has an abrupt syncopal episode resulting in a headon collision at 40 miles per hour. She is alert and oriented right after the accident, but complains of sternal pain as well as pain in her left chest, left shoulder, and the right side of her jaw. Evaluation in the emergency department reveals slight tachypnea of 26 breaths/min, blood pressure of 90/60 mm Hg, a midsternal abrasion, a left pneumothorax, and nondisplaced fractures of the left clavicle and right mandible. Results of her neurologic examination, including mental status, are normal.

She denies the use of any medication, street drugs, or alcohol, but she does report a 9-month history of brief spells of lightheadedness, diaphoresis, nausea, and visual blackouts, with one previous episode proceeding to complete syncope.
Lifestyle and Practice Style: Making Choices
Authors: Haggerty Robert J.
Published: December 2021

Although pediatricians are knowledgeable in many areas of the human condition, most will admit to an incomplete understanding of homosexuality, an aspect of life that is poorly understood by most of society. At the same time, the overwhelming majority of pediatricians are dedicated to providing each patient with complete and appropriate care, regardless of where that individual fits into the societal mosaic. Consequently, all of us are indebted to Perrin for providing a clear and useful guide to understanding gay and lesbian youth, many of whom currently are in our care, whether or not we know it.

Defining sexual orientation, gender identity, and gender role is the important first step that Perrin takes in educating the reader.
Pneumonia
Authors: Schidlow Daniel V. , Callahan Charles W.
Published: December 2021

Introduction

One in three children can be anticipated to develop a lower respiratory tract infection (LRI) in the first year of life. Denny and Clyde reported 6000 cases of LRI in an outpatient practice in North Carolina. Of this group, 15% had croup, 34% had tracheobronchitis, 29% had bronchiolitis, and 29% had pneumonia. The overall attack rate for pneumonia in all ages was four to six cases per hundred children per year.

An LRI is defined as any respiratory tract infection involving the larynx or structures distal to it. Four clinical syndromes have been described: croup, tracheobronchitis, bronchiolitis, and pneumonia. Croup is characterized by hoarseness, cough with inspiratory stridor, and laryngeal obstruction. Tracheobronchitis leads to cough with rhonchi, but without laryngeal obstruction. Croup and acute tracheobronchitis primarily are the result of extension of viral upper respiratory infections. They generally are self-limited and require no more than symptomatic treatment. Neither will be discussed further.

Bronchiolitis is an acute infectious inflammation of the lower airways. The classic syndrome is defined as the first episode of wheezing in a child younger than 2 years of age. Viral infection of the airways, most often respiratory syncytial virus (RSV), is the most common etiology of bronchiolitis. However, other viral agents and chronic inflammatory diseases, including cystic fibrosis, ciliary dyskinesia, and recurrent aspiration, also can be associated with bronchiolitis.
Consultation with the Specialist
Authors: Leslie Laurel K. , Boyce W. Thomas
Published: December 2021

Historical Perspective

In 1964, Green and Solnit first described a constellation of clinical features comprising a "vulnerable child syndrome" based on a cohort of 25 families. Each of the families had a child who had suffered a life-threatening illness in infancy. The authors observed that the parents, particularly the mothers, shared a continuing and unfounded anxiety concerning their children's health. Green and Solnit hypothesized that the parents persisted in fearing that their child was destined to die in childhood.

The parents' perception of their child as uniquely vulnerable led to myriad maladaptive behaviors and difficulties in parent-child interactions (Tables 1 and 2). The parents overprotected the child, were unable to set age-appropriate limits, and displayed excessive concerns in medical settings about their children's health. The children, responding to their parents' expectations of vulnerability, evidenced exaggerated separation anxiety, out-of-control behavior, school underachievement, and distorted perceptions of their own health. Interestingly, these behaviors were not noted in the parents' interaction with their other children.

As clinicians began to identify families that had this constellation of clinical features, additional details about the vulnerable child syndrome were elucidated. Parental perception of their child as medically vulnerable was not a universal legacy of severe illness in infancy, but more likely a reflection of how an individual family responded to an illness in their child.
Fever and Host Responses
Authors: Shelov Steven P.
Published: December 2021

Even though fever, as part of the inflammatory response, is only a sign of an underlying pathologic stress, we seem to have the need to treat it with a drug or a sponge, as if it were the noxious culprit itself. In contrast to hyperthermia, fever rarely poses any threat to a child's well-being; in fact, it has been argued that as an energy-expensive process, it is not likely to have weathered evolution without conferring some survival benefit. Because fever is the most frequent signal of illness in children, serving as the chief complaint for as many as one third of all pediatric office visits, we do well to understand fever as a phenomenon distinct from the illnesses that cause it.
Editorial: The First Birthday
Authors: H. R. J.
Published: December 2021

With this issue of PEDIATRICS IN REVIEW we start our second year of publication. In the spirit of the second year theme of PREP, "Child Development," I feel that during this first year we have developed a considerable amount of trust and support from our readers' acceptance of the journal and, at times, from their stern guidance; we have also learned some things that should improve the Journal during the second year.

EDUCATIONAL OBJECTIVES

I had originally hoped to address, in the course of a year, the majority of the educational objectives developed by the two task forces, but the task force on Recent Advances produces some 150 objectives per year and the one on Topics produces 35.
Editorial: Feedback
Authors: H. R. J.
Published: December 2021

During the 1980/81 year the self-assessment examinations at the end of each issue of PEDIATRICS IN REVIEW were dropped in response to the large number of criticisms of the questions. In their place the computer cards required readers to check whether the articles were relevant and accurate. In addition, we asked readers to add comments on the back of cards. The feedback has been very useful.

Dropping the self-assessment examinations has been overwhelmingly condemned. Many wrote that, while they had written protesting the quizzes last year, they now had changed their minds and wanted them back. The Chapter Chairmen, overwhelmingly, voted to have them reinstated.
Tics
Authors: Schowalter John E.
Published: December 2021

Tics can be classified as transient (under one year's duration), chronic motor (lasting longer than one year), Tourette's disorder (motor plus verbal—especially explosive foul language—coprolalia), and atypical disorders. Initial management of transient tics should help child and family ignore the tic and support and reassure the family. At least 40% of those suffering from Tourette's disorder can be helped with haloperidol but side effects (drowsiness, extrapyramidal signs, and blunted cognition) limit its use. Clonodine is helpful in some patients who are resistant to haloperidol.
Fetal Drug Syndromes
Authors: HILL REBA MICHELS , SMITH DAVID W.
Published: December 2021

1. The antiepileptic drug syndrome does occur, but 80% to 90% of the babies born to mothers on antiepileptic drugs are normal.

2. The minor malformations are not physically handicapping to the child.

3. The majority of major anomalies are medically or surgically correctable. Some, such as the VSD, correct spontaneously.

4. Exposure of the fetus to phenobarbital alone may result in a similar yndrome, so the term "hydantion syndrome" is a misnomer.

5. Infants with lQ >120 may be born to mothers on phenytoin or phenobarbital.

6. There appears to be an increased number of malformations and lowering of IQ from multiple drug exposure rather than single drug exposure.

7. The physical appearance of the child may be reasonable and not grotesque.

8. Infants exposed to alcohol, phenobarbital, or phenytoin have been reported to have malignancy, but the incidence must be compared to the general population to see whether it is significant.

9. Vitamin K3 must be given immediately after birth and a clotting profile checked to see whether additional vitamin K3 is needed, or whether frozen plasma is indicated, because hemorrhage may result in a 33% mortality.

10. Multiple deficiency states occur in patients on chronic drug therapy, and these deficiency states may contribute to the neurologic and physical disability. Vitamin supplements for pregnant epileptic patients may be indicated.

11. Seizures do not increase in the epileptic patients who are given supplementary folic acid as believed by neurologists.

12. A comparison was made between the morbidity in the infant of the epileptic and that of the infant of the diabetic. Since 1950, there have been no recommendations to abort diabetic patients. Their infants have morbidity similar to that of infants of epileptics. Physicians learned what contributed to the morbidity and treated it.

13. Physicians should not administer trimethadione or paramethadione to women of childbearing-age since by the time a pregnancy is diagnosed fetal injury may have already occurred.
Kawasaki Syndrome (Mucocutaneous Lymph Node Syndrome)
Authors: Melish Marian E.
Published: December 2021

Kawasaki syndrome or the mucocutaneous lymph node syndrome (MCLS, MLNS) is an acute febrile exanthematous illness of children, first recognized in Japan by Kawasaki in 1967.1 In 1970, the Research Committee of MCLS, supported by the Ministry of Health and Welfare of the Japanese government, organized a case registry to elucidate the clinical, pathologic, epidemiologic, and etiologic features. By 1974, the committee had collected approximately 5,000 cases from all over Japan.1,2 The illness has continued to be recognized in Japan with more than 10,000 cases registered by 1979.

The disease was recognized independently in the United States by Melish et al with 12 cases encountered between 1971 and 1974.3,4 Although these American workers had no knowledge of the Japanese experience they independently identified the same diagnostic criteria. Later consultations with Japanese MCLS researchers have established that the cases in Hawaii and the cases in Japan were indistinguishable in their presenting manifestations and their clinical course.

Since 1974, Kawasaki syndrome has been recognized worldwide. Outside Japan, the illness appears to be most prevalent in Hawaii which has the largest published series3; the largest proportion of cases in the United States reported to the Center for Disease Control come from this state. The experience at the Kapiolani-Children's Medical Center now includes more than 100 cases from various parts of Hawaii.
Pediatric Understanding of Child Abuse and Neglect
Authors: Bittner Stephen , Newberger Eli H.
Published: December 2021

When C. Henry Kempe and his colleagues coined the term "battered child syndrome" in 1961, the attention of the American medical community was focused on one of the most dramatic manifestations of family violence. Since then family violence has been perceived as a major social problem, and the eyes of pediatricians have been opened to familial causes of morbidity and mortality.

In this paper the term "child abuse" is used to encompass all the symptom indicators of maltreatment of children, including physical injury, physical neglect, sexual abuse, and some ingestions of harmful substances. We address these problems not as discrete illness entities or syndromes, but as symptoms of different issues and risks for particular children in individual families.

Kempe noted that notwithstanding a long history of concern with child welfare, the pediatric community ignored the implications of injury and neglect of children because of a "process of denial that was unequal to anything ... previously seen in pediatrics." This denial continues today in spite of an increasing and visible literature on child abuse.

The task of this paper is to summarize current knowledge about the causes, differential diagnoses, and management of child abuse in a fashion accessible to pediatricians and members of the colleague disciplines.
Febrile Seizures: A Consensus of Their Significance, Evaluation, and Treatment
Authors: Freeman John M.
Published: December 2021

The National Institutes of Health recently convened experts from this country and abroad to present current knowledge about febrile seizures and their consequences, and about the risks and benefits of therapy. This information was presented to a panel under the chairmanship of Dr Edwin Kendig, former president of the American Academy of Pediatrics. The panel consisted of both academicians and practitioners. The preceding statement represents the consensus of that panel.

The statement bears reading in its entirety, for it should influence the way that pediatricians think about the child who has had a seizure with fever, how he evaluates and treats that child, and what he tells the parents.