bluuebunny/crossref_metadata_2025 huggingface dataset:
INDEX OF SUSPICION
Authors: Sehgal Neeru
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 4-year-old boy is brought to the office because of bruising that his mother had noticed while bathing him 2 days previously. He has not had nosebleeds or noticeable blood in his stool or urine, and he has been well except for a bout of gastroenteritis 2 weeks earlier. His parents are separated, and his mother states that the youngster's father spanked and kicked him and his brother during a visit last weekend. An 11-year-old sister is present and says that the father grabbed the boy's arm and "kicked his rear with his boot."

On examination, the child has multiple bruises—some appearing fresh, some apparently several days old—on his back, anterior torso, arms, and anterior thighs.
Immunodeficiency Disorders
Authors: Iseki Mikiro , Heiner Douglas C.
Published: December 2021

Introduction

Immunodeficiency diseases are a group of disorders that increase susceptibility to infection, malignancy, and autoimmunity. Deficiencies of the immune system may be congenital or acquired. They may be secondary to a developmental anomaly or an enzymatic defect or be of unknown etiology. Recently it has become clear that immune responses are comprised of a large number of discrete steps, and there may be a breakdown at any point in this process. It is likely that hundreds of different lesions lead to immunodeficiency diseases. It is important to remember that it was from studies of patients who had abnormalities of the immune system that many of the functions and components of the normal immune system have been elucidated. There are two broad categories of immunodeficiencies: those that are primary and those that are secondary to another disorder.

Classification and Incidence

The immune system has four major components: 1) antibody-mediated (B cell) immunity, 2) cell-mediated (T cell) immunity, 3) phagocytosis (polymorphonuclear and mononuclear cells), and 4) the complement system. This division provides a practical way to classify the immunodeficiencies (Table 1). Common secondary immunodeficiencies are listed in Table 2. A more complete classification of primary immunodeficiencies is that of the 1986 WHO Scientific group (see Suggested Reading).
Assessment and Treatment of Childhood Obesity
Authors: Dietz William H. , Robinson Thomas N.
Published: December 2021

Childhood obesity is among the most difficult problems that confront pediatricians. Its rising prevalence and its increasingly recognized risk of morbidity heightens our concern and increases our frustration when families appear unmotivated or when treatment fails. Because childhood obesity is so difficult to treat and because obesity is viewed widely as a form of social deviancy, we are tempted to blame patients and families for our lack of successful therapy. In this review we consider the identification of childhood obesity, explore its potential etiologies and consequences, and outline an approach to therapy.

Identification

The identification of childhood obesity and its severity clarifies the degree of risk and represents the first step of therapy. The two indices used most commonly to determine the degree of adiposity in humans are the body mass index (BMI, weight in kg/height in m2) and the triceps skinfold thickness. Each has advantages and limitations.

The advantage of the BMI is that height and weight are measured easily and reliably in a variety of settings by personnel who have had minimal training. A BMI in excess of the 85th percentile has been used arbitrarily to define obesity. However, the BMI does not measure fatness directly. Variations in frame size as well as increases in fatness will increase the BMI.
Sinusitis
Authors: Wald Ellen R.
Published: December 2021

Upper respiratory infections (URIs) are the most common organic condition presenting to the primary practitioner who cares for children. It recently has been estimated that approximately 5% to 10% of URIs in early childhood are complicated by acute sinusitis. Because children average six to eight colds per year, sinusitis is a very common problem in clinical practice.

When considering a diagnosis of sinusitis in a child or an adult, the major problem is to distinguish simple URI or allergic inflammation from secondary bacterial infection of the paranasal sinuses. The diagnosis of URI or allergy may prompt consideration of symptomatic treatment, while patients who have sinusitis will benefit from specific antimicrobial therapy. Both URI and allergic inflammation are recognized risk factors for acute sinusitis, with URI being the more common.

Anatomy and Physiology

A brief review of the anatomy and physiology of the paranasal sinuses will help clarify certain clinical features of sinus infection. The Figure shows a coronal and two sagittal views demonstrating the relationship between the nose and the paranasal sinuses. The nose is divided in the midline by the nasal septum. From the lateral wall of the nose are projected three shelf-like structures designated according to their anatomic position as the inferior, middle and, seen best on the sagittal view, superior turbinates.
INDEX OF SUSPICION
Authors: Marino Elizabeth R. , Baker Robert B. , Devries Jeffrey M. , Amin Sanjiv B.
Published: December 2021

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

We invite readers to contribute case presentations and discussions.

Case 1 Presentation

You are seeing a 16-year-old male who has had nasal congestion that began a few months ago. The congestion was intermittent at first but has become constant. He denies sneezing, itchy eyes, or other respiratory difficulty. His mother is concerned because he often is awakened by his congestion. He frequently is irritable in the mornings, and she believes the sleep disturbance is responsible for the decline in his grades, which had been very good. Except for one uncle, no family members have complained of allergies.

He is a slim boy whose pulse is 90 beats/min, blood pressure is 136/80 mm Hg, and temperature is 98.8°F (37.1°C). Physical examination otherwise is normal except for mildly reddened, edematous nasal mucous membranes that have a small amount of thin white mucoid discharge.
Conflict Resolution
Authors: Deutsch Morton , Brickman Ellen
Published: December 2021

An Orientation to Conflict

Conflict is like sex: it is an important and pervasive aspect of life. It should be enjoyed and should occur with a reasonable degree of frequency, and after a conflict is over the people involved should feel better than they did before.

Some psychiatrists and social scientists have given conflict a bad reputation by linking it with psychopathology, social disorder, and war. Conflict can be dysfunctional, but it also can be productive. It has many positive functions, including preventing stagnation and stimulating interest and curiosity. It is the medium through which problems can be aired and solutions developed. It is the root of personal and social change. The practical and scientific issue is not how to eliminate or prevent conflict but rather how to have lively controversy rather than deadly quarrels.

A conflict exists whenever incompatible activities occur. The incompatible actions may originate in one person, group, or nation (intrapersonal, intragroup, or intranational) or they may reflect incompatible actions of two or more persons, groups, or nations (interpersonal, intergroup, or international). An action that is incompatible with another action prevents, obstructs, interferes, injures, or in some way makes the latter less likely or effective. A potential conflict exists when the parties involved perceive themselves to have incompatible values, interests, goals, needs, or beliefs.
Pregnancy During Adolescence
Authors: Jaskiewicz Julie A. , McAnarney Elizabeth R.
Published: December 2021

Adolescent pregnancy continues to be one of our most challenging public health issues. Prevention is the most important goal that can be sought. Pediatricians can play a major role with young people and their families in pursuit of this goal. Young women who become pregnant must be referred early to obstetric care so that either early prenatal care can be established or an abortion can be performed early so as to prevent morbidity by delaying the procedure. New contraceptive methods such as contraceptive implants provide hope that improved contraceptive technology will aid in decreasing the likelihood of adolescent pregnancy.
INDEX OF SUSPICION
Authors: McCarthy Dennis J. , Garcia Juan J. Jiménez , Swanson Holly
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

As you finish examining a 14-year, 11-month-old girl for an upper respiratory infection, she asks when she might expect to stop growing. When told that most girls stop growing after menarche, she explains that she has never had a menstrual period.

On examination, her height is 69 1/2 in (above the 95th percentile) and her weight is 119 lb (50th percentile). Her breast development is at Tanner stage IV, and she says that her breasts have remained at their present state of development for at least 3 years. She lacks both pubic and axillary hair. Her external genitalia are normal, as is the remainder of her physical examination.

Case 2 Presentation

A 9-year-old girl is brought to your office having a 1-week history of bilateral neck swelling.
Guess Who's Going to Medical School!
Authors: Scheiner Albert P. , Sahler Olle Jane Z.
Published: December 2021

Both Pediatrics in Review (PIR) and CompuPREP are rich resources that can be incorporated into the clinical curricula designed for medical students. Although both are geared to meet the needs of the practicing pediatrician, in our experience they have served as excellent adjuncts to self-study syllabi, lecture presentations, and small group discussions for students, as well.

Creative Use of PIR

At the University of Massachusetts, the review articles and their associated quizzes, the section entitled "Index of Suspicion," and the Guides for Record Review all have been used for a variety of instructional purposes. The review articles are especially adaptable to seminars using a problem-based or clinical problem-solving model.
Antimicrobial Prophylaxis
Authors: Schutze Gordon E. , Jacobs Richard F.
Published: December 2021

The issue of antimicrobial prophylaxis in preventing infections in infants and children is important in the practice of pediatrics. Children are especially prone to certain infections, and pathogens are amenable to prophylaxis. Chemoprophylaxis may be used to prevent primary disease (eg, ophthalmia neonatorum) or recurrent infections (eg, otitis media). Individuals exposed to certain micro-organisms (eg, Neisseria meningitidis) or immunosuppressed patients (eg, those who are asplenic) may benefit from prophylaxis in certain situations. The duration of chemoprophylaxis may be as short as two doses (eg, endocarditis prophylaxis) or may last a lifetime (eg, rheumatic fever prophylaxis).

Questions concerning the potential benefits of antimicrobial prophylaxis are quite common, and many of the answers are controversial. Because the list of specific pathogens and conditions for prophylaxis is quite long, this review will encompass only the more common conditions encountered in a busy general pediatric practice (Table 1).

Otitis Media

Acute otitis media is the most common diagnosis made in children when visits to the physician are prompted by illness. For every three children who have acute otitis media with effusion, one will suffer from recurrent acute otitis media: antimicrobial prophylaxis, tympanostomy tube placement, and adenoidectomy. Of these options, only chemoprophylaxis can be managed by the primary physician.
Fears and Phobias
Authors: Schowalter John E.
Published: December 2021

Definitions

Fears and phobias represent a major segment of the psychological distress experienced by children while growing up. It is important to distinguish between the two.

Fears are a normal part of life and usually are most vivid and ubiquitous during childhood. Fear is the emotional and physiologic response to an external danger. At their best, fears help keep one safe. The fear of being burned, being accosted by strangers, disappointing parents by doing poorly on an examination, or ending up in jail all can lead to a more healthy and productive life. One could speculate that heights and snakes are among the most common fears among adults because those ancestors who avoided snakes and high places were most likely to live long enough to ensconce these tendencies in the gene pool.

The differential diagnosis of fears and phobias is easier during adulthood than it is during childhood. This is because the child's physical and cognitive immaturity can confound reality testing on developmental and psychopathologic bases. The toddler who is so small, helpless, and unable to understand the forces of physical and human nature accurately often has many normal fears. These typically may include strangers, their parents' leaving, monsters, the dark, or going to sleep.
Consultation with the Specialist
Authors: Hardy Stephen C. , Walker Allan
Published: December 2021

Acetylcholine (ACh), a common neurotransmitter in the human, acts in the brain at the neuromuscular junction and throughout the autonomic nervous system. Cholinergic receptors have been separated into two main groups: nicotonic (present at the neuromuscular junction) and muscarinic (present at all ganglia of the autonomic nervous system and postsynaptically in the parasympathetic nervous system).

Anticholinergic medicines act at muscarinic sites. The first anticholinergic drugs were extracts of belladonna plants, which were used for centuries for their antimotility and antisecretory properties. These drugs generally are ineffective blockers of ACh at nicotinic receptors and cause neuromuscular blockade only at excessive doses.

Because antimuscarinic medications block the effect of the parasympathetic nervous system, they affect the gastrointestinal (GI) tract. In general, the parasympathetic nervous system stimulates the GI system. Cholinergic impulses cause increased tone and motility of the stomach and intestines and increased secretion of gastric and intestinal fluids. Exocrine pancreatic secretion and gallbladder contraction also are stimulated by cholinergic activity. Anticholinergics reverse these responses.

The prototypical anticholinergic, atropine, decreases output of gastric, intestinal, and pancreatic secretions; decreases motility and tone of the GI tract; and relaxes the gallbladder. Atropine not only interferes with cholinergic activity in the GI tract, it affects the entire body increasing heart rate, depressing salivary and bronchial secretion, decreasing sweating, dilating the pupils, inhibiting accommodation, inhibiting micturition, and causing constipation.
BACK TO BASICS
Authors: Woodin Kathleen A. , Morrison Susan H.
Published: December 2021

Introduction

Unlike physicians practicing in the 1940s, who had only sulfonamides and penicillin to treat infections, practitioners now choose from a broad (and sometimes overwhelming) number of antibiotics. However, trends in emerging antimicrobial resistance may force us to take a giant step backward to that frightening situation of the past of having bacteria that are essentially "untreatable" by any of our available antibiotics.

This article is an overview of some of the microbiology, pharmacology, and physiology critical to the rational use of antibiotics in today's practice. It summarizes the basic mechanisms of action of some commonly used antibiotics and briefly discusses the emergence of resistance to several common pathogens.

Structures of Bacteria Important to Antibiotic Action

The outermost component of most bacteria is the cell wall, a multilayered structure located external to the cytoplasmic membrane. The cell wall is composed of an inner layer of peptidoglycan, a complex interwoven lattice of linear sugars (glycan) that are cross-linked by peptide chains. Peptidoglycan provides the rigid support by which the cell maintains its characteristic shape.

Gram-positive and Gram-negative bacteria differ in their cell wall structures (Figure). In Gram-positive organisms, the peptidoglycan layer is a thick (15 to 80 nm) multilayer and may have a thin layer of teichoic acid outside the peptidoglycan.
The Changing Face of Anemia in Infancy
Authors: Graham Elinor A.
Published: December 2021

Introduction

The pattern of anemia in infancy is changing in North America. The major factors contributing to anemia include iron endowment at birth, adequacy of dietary iron, frequency of infection, and the genetic background of a child. The characteristics of all of these factors are changing in the pediatric population. As more premature infants survive, their inadequate birth endowment of iron results in iron deficiency at an earlier age. Because of widespread use of iron-fortified formulas or iron supplementation with breastfeeding, iron deficiency now causes less anemia in the first year of life. As iron nutrition of infants has improved, anemia associated with infection has been identified more frequently. Increased work force participation of mothers has resulted in more exposure to infections by infants in child care. An increase in the percentage of children who are of Asian and African genetic backgrounds has increased the prevalence of inherited hemoglobin disorders among children. Newborn screening for hemoglobinopathies has resulted in more frequent identification of these disorders.

Decline in the socioeconomic status of children in the United States adds to the complexity of this picture. More than one factor often produces anemia in an infant from a poor family, and the anemia may have a greater impact on the psychosocial development of a child from a low-income background.
Cystic Fibrosis
Authors: Colin Andrew A. , Wohl Mary Ellen B.
Published: December 2021

Cystic fibrosis (CF) is an autosomal recessive inherited disorder caused by mutations of both alleles of the CF gene. These mutations result in abnormalities in the production or function of the gene product, a protein known as the cystic fibrosis membrane conductance regulator (CFTR). The CF gene is large (250 000 base pairs) and located on chromosome 7. A deletion of three base pairs that results in the absence of phenylalanine at codon 508 is the most common defect (designated F 508) and accounts for about 70% of the mutant genes in North American populations. Other genotypes observed with some frequency (but <3%) are G542X, G551D, W1282X, W1303K, and R553X. The twelve most common CF gene mutations account for approximately 85% of cases in North America. Mutations other than F508 number more than 200 and account for the remaining cases. Most of these 200-odd mutations are "private," observed only in the affected kindred. Because the CF locus has so many DNA sequence changes associated with disease, precise genetic testing cannot replace clinical criteria for diagnosis, and the sweat test remains an important diagnostic test.

The CF gene is expressed in epithelial cells of the pancreas, sweat and salivary glands, intestine, and reproductive and respiratory tracts, particularly in the submucosal glands.
Craniosynostosis
Authors: Marion Robert W.
Published: December 2021

On the surface, premature closure of one or more sutures of the skull may appear to be a straightforward malformation that leads to a specific, recognizable pattern of symptoms and signs, an anomaly that can be corrected simply by a surgical procedure. But in fact, craniosynostosis, which occurs in approximately I in 2500 children, is a dynamic process, the external reflection of a series of complex conditions that may cause an underlying abnormality not only in the skull but in other systems.

In most cases, surgical repair of both the fused sutures and the resulting craniofacial asymmetry will resolve the primary problems caused by craniosynostosis, namely, compression of the brain because of lack of space, functional anomalies of the eye due to aberrant placement of the orbits, and sometimes, grotesque distortion of the facies.
Children Who Have Difficulty in School: A Primary Pediatrician's Approach
Authors: McInerny Thomas K.
Published: December 2021

"Doctor, I just had a conference with my son's teacher because my son seems to be doing poorly this year." Thus begins an increasingly common phone call to the pediatrician. Parents usually rely on their pediatrician, as a trusted professional of several years' duration, for advice and assistance when informed of their child's academic shortcomings. Although the first inclination may be to consider the problem as educational rather than medical, the pediatrician has an important role to play in caring for his or her patient by guiding the parents through the steps necessary to remediate the situation. Parents often are confused or intimidated by educators and turn to their pediatrician for strength and guidance in dealing with the educational "system." With some effort, most pediatricians can acquire the skills necessary to intervene successfully. In fact, they already possess many of those skills: a knowledge of child development, good rapport with the family, concern for the child's total well-being, and professional stature in the community. By taking the time to become familiar with the school programs in the area, to gain a passing knowledge of psychoeducational testing (also see article on page 338), and to determine appropriate referral sources for further assistance, the pediatrician can be the child's advocate in such situations.
Developmental Testing
Authors: Gilbride Kathleen E.
Published: December 2021

Many screening tools are available to the pediatrician; the ones described here are just a sample of some that are used commonly. Understanding the purpose and limitations of each screening measure, in terms of reliability, validity, sensitivity, specificity, and the population for which it was designed, will help the pediatrician use these tools effectively to identify children at risk for developmental delay. Most importantly, the pediatrician should view screening tests as one source of information to be used in an overall strategy of developmental surveillance that includes careful historical review, systematic clinical observations, and solicitation of parental concerns and attitudes.

Pediatricians play a central role in monitoring the development of infants and children during the course of providing well child care. Parents turn to pediatricians for help in determining whether their child has a temporary lag in development, a serious delay or disorder, or a significant behavior problem that should be addressed. With the passage of PL 99-457, pediatricians also play a key role in referring children at risk to early intervention services. By employing a strategy of developmental surveillance, with periodic developmental screening, the pediatrician can determine when a child should be referred for more extensive developmental or psychological testing, which will aid in the process of diagnosis and treatment of developmental disabilities and behavioral disturbances. Knowledge of the screening and testing measures used commonly, as well as their limitations, will result in more accurate interpretation of the data derived from such measures. Once delays are diagnosed and treatment is initiated, repeated assessments over time will serve to identify areas in need of continuing intervention while indicating gains made in specific areas of developmental functioning. Throughout this process, the pediatrician's role as advocate for the child and family serves as a bridge to other professionals and services, with the ultimate goal of facilitating the optimal development of the child.
INDEX OF SUSPICION
Authors: Amin Sanjiv B. , Devries Jeffrey M. , McQuilkin Patricia , Quion Nathalie , DeWitt Thomas G.
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 15-year-old girl comes to your office complaining that she has experienced intermittent, sudden episodes of chest pain, fatigue, palpitations, and sensations of difficulty breathing and lightheadedness for 2 months. These episodes occur several times daily and are unaccompanied by other symptoms such as syncope, wheezing, swelling of the extremities, or fever. She denies being worried, but reports that her parents are very frightened because a 16-year-old male cousin died recently while playing soccer, and two other relatives, a 27-year-old cousin and a 29-year-old uncle, died suddenly during exercise.

The physical examination reveals a somewhat anxious girl complaining of mild precordial chest pain. Her temperature is 36.9°C(98.4°F) orally, respiratory rate is 16 breaths/min, heart rate is 110 beats/min, and blood pressure is 100/60 mm Hg; weight and height are at the 75th percentile.
Babies Who Are Small for Gestational Age
Authors: Russell Barbara K.
Published: December 2021

Small for gestational age (SGA) is a term applied to a heterogeneous population of babies who do not meet the expected growth parameters for their gestational age. The definition of SGA is variable, but the clinical definition used most often is any baby who weighs less than 2500 g and falls below the 10th percentile on the growth chart for its gestational age. These infants are at increased risk for hypoglycemia, polycythemia, and temperature instability and suffer higher neonatal mortality rates.

Although they often are used interchangeably, the terms SGA and intrauterine growth retardation (IUGR) are not always synonymous. Approximately 60% of infants classified as SGA are constitutionally small babies who are small for gestational age but not growth retarded.
Leukocyte Disorders: Quantitative and Qualitative Disorders of the Neutrophil, Part 2
Authors: Boxer Laurence A. , Blackwood R. Alexander
Published: December 2021

The differential diagnosis for a patient presenting with recurrent infections is formidable, given the complexity of the immune system. The clinical presentation of a patient who has a qualitative neutrophil abnormality may be similar to that of one who has an antibody or complement disorder. In general, evaluation for phagocytic cell disorders (Table) should be initiated among those patients who have at least one of the following clinical features: 1) Two or more systemic bacterial infections; 2) Frequent, serious respiratory infections, such as pneumonia or sinusitis, or frequent bacterial infection, such as cellulitis, draining otitis media, or lymphadenitis; 3) Infections presenting at unusual sites (hepatic or brain abscess); and 4) Infections associated with unusual pathogens (ie, Aspergillus pneumonia, disseminated candidiasis, or infections with Serratia marcescens, Nocardia sp, and Pseudomonas cepacia).

Disorders of Neutrophil Function

HYPERIMMUNOGLOBULIN E SYNDROME (JOB SYNDROME)

Hyperimmunoglobulin E (hyper-IgE) syndrome is an autosomal dominant disorder with incomplete penetrance that is characterized by elevated levels of serum IgE and recurrent staphylococcal abscesses (Table). Neutrophils in these children exhibit impaired chemotaxis, although phagocytic function is normal. Clinically, hyper-IgE syndrome must be distinguished from severe atopic dermatitis. Both disorders are characterized by the development of severe dermatitis in the presence of elevated IgE levels.
BACK TO BASICS
Authors: Voter Karen Z. , McBride John T.
Published: December 2021

Objective measurements of a wide variety of aspects of respiratory function can be useful in the evaluation and management of children and adolescents who have respiratory symptoms or disorders. Many of the tests described in this article can be performed reasonably in the pediatrician's office. Pediatricians can be comfortable in measuring and interpreting pulse oximetry, blood gas analysis, spirometry, and peak flow. They also should be familiar with the indications for the less common tests of pulmonary function that now are widely available.
Consultation with the Specialist
Authors: Richards B. Stephens
Published: December 2021

Slipped capital femoral epiphysis is the most common orthopedic hip disorder occurring in adolescence. In this condition, the femoral head (epiphysis) displaces, or slips, on the femoral neck through the region of the growth plate. This may result from traumatic forces acting on a normal growth plate (physis) or from ordinary forces acting on a weakened growth plate. In the latter situation, resistance to shear-type forces within the physis is decreased. This leads to the growth plate giving way when exposed to modest forces, such as running, skipping, or twisting. The femoral head may displace abruptly, analogous to a fracture, and may be exquisitely painful to the patient. Or, the femoral head may displace gradually, maintaining a stable relationship between it and the femoral neck, and may present clinically only as an ache in the groin. Regardless of the clinical presentation, the proper management requires urgent surgical intervention in an effort to avoid further displacement. Thus, early diagnosis is of utmost importance in the management of slipped capital femoral epiphysis.

Epidemiology

The general incidence of this condition is 1 to 3 per 100 000, with a slightly higher incidence in African-American children. Males are affected twice as often as females. The children are obese (the weight being 2 standard deviations above the mean for the child's age) in 67% of cases.
Recurrent Abdominal Pain in Childhood
Authors: Barbero Giulio J.
Published: December 2021

Recurrent abdominal pain (RAP) in childhood is a common complaint that may be difficult to diagnose and manage. Apley has reported that 10% of children have three or more episodes severe enough to impair activity and function over at least a three-month period. RAP appears less often in preschool children and, when present at earlier ages, it usually occurs in brief episodes rather than the more frequent and intense pattern that is characteristic of the school-aged child. RAP is more frequent in girls and is particularly prominent as a symptom in early adolescence. Occasional abdominal pain is a universal symptom in childhood and its significance is often difficult to assess. A practical approach is to determine the frequency, severity, and limitations produced by the pain before further exploration of its cause.

DIAGNOSIS

Recurrent abdominal pain in childhood can be divided into disturbances of gastrointestinal functions and a variety of pathologic disease or organic categories. A combination of the disturbance of function and other organic disease can also be present as the basis for the pain. Fewer than 10% to 15% of referred children reported in various studies have been found to have pain of organic origin. It is important to recognize that many patients and their parents are fearful of the pain as a symptom and are not easily able to incorporate a concept of disorder of a gastrointestinal function at the onset.
Adolescent Health: Concerns for the Eighties
Authors: COHEN MICHAEL I.
Published: December 2021

More than a quarter of a century after Dr. J. Roswell Gallagher began the first formal adolescent medicine program, several significant issues surrounding care for teenagers continue to surface and form the basis for concern by pediatricians in the upcoming decade. The degree of serious health disability that exists in this age group is shown by the fact that this is the only age group for which the death rate is rising. Furthermore, once recognizing the extent of morbidity and mortality and its diverse characteristics and complexities, it seems clear that to a very significant degree, the mechanism for resolution resides in effective pediatric health care.
Practical Aspects of Pediatric Management of Families with Twins
Authors: Siegel Sheila J. , Siegel Michael M.
Published: December 2021

Tommy, a rather large 4 year old, invited his younger twin friends over to play. He expected to be the leader as he knew he was older and was certainly lots bigger. Although the twins included him, they joined together so as to dominate the interactions. By the end of the afternoon, looking totally overwhelmed and somewhat bemused, Tommy turned to his mother and said, "Next time only invite one of them, or get another Tommy." Parents, friends, teachers, doctors, any of us who spend time with twins find them fascinating, puzzling, and occasionally a little overwhelming. Twins and parents of twins bear the brunt of this curiosity in the barrage of questions that often assail them: "What is it like to have twins?" "Is it twice as hard to raise two as it is to raise one?" "What is it like to be a twin?" Perhaps the not uncommon wish to have been a twin or to have twins is behind this phenomenon, or perhaps it is the rarity with which twins occur that explains this curiosity. Such attention, however, aggravates major problems most common to twins.

Parents often seek pediatricians' advice about raising their children. In this article we will address childrearing issues but from the perspective of parents of twins.
An Ounce of Prevention Is Worth a Pound of Cure
Authors: WEINSTOCK IRVING
Published: December 2021

Continuing medical education is being conducted in many overseas sites. The physician who contemplates such trips should be prepared for the more common medical emergencies which may occur to him, his family, or other travelers on such trips. Dr Irving Weinstock, an experienced pediatrician and traveler on such educational programs, has provided a short list of items that he considers useful. Since this journal is dedicated to successful continuing pediatric education, being so prepared may help.

R.J.H.

In preparing for an overseas trip, I have found it useful to include the pharmaceuticals and medical supplies listed in the Table. The journey will be more enjoyable and pleasant, knowing that you are prepared for most contingencies.
Adolescent Sexuality
Authors: Duke Paula Maguire
Published: December 2021

The shaping of sexual beliefs, attitudes, and behavior begins at birth, continues throughout childhood, and is dramatically influenced by puberty. At this time, teenagers must incorporate their changing physical appearance into their self-image, ideally including knowledge and acceptance of their bodies. In addition, they must explore and learn ways of interacting with their peers, sexually and otherwise.

When thinking about how a pediatrician can best serve the needs of an adolescent, especially with regard to sexuality, it becomes clear that there is very little requirement for "treatment" in the traditional medical sense, ie, prescriptions, surgery, physical therapy, etc. Instead, the greatest contribution comes from eliciting and answering questions, providing information about the teenager's current physical and social environment, and bringing to his or her awareness changes and issues that might come to the fore in the near future. The process of taking the history and performing the physical examination provides numerous opportunities to gather and dispense information, as will be illustrated below.

Practice experience as well as research data indicate that issues of importance to the prepubertal or early pubertal child differ from those of the mid or late adolescent. This natural separation will form the framework for the following discussion, although it must be realized that some adolescents cannot be so neatly categorized.
Sunburn: Effects and Management
Authors: Leach James
Published: December 2021

The salutary benefits of basking in the sun have been sought by human beings since ancient times. Regarded in the past as a deity, the sun still confers its radiant benedictions on its modern devotees who have been persuaded by contemporary fashions that a dark brown tan is a sure sign of well-being, both physical and psychological. At some time, virtually all ardent sun-worshippers discover the unpleasant acute cutaneous reaction commonly called sunburn.

PHYSICAL PROPERTIES OF SOLAR RADIATION

Constituting a continuous spectrum, the electromagnetic radiation from the sun ranges from the highly energetic short wavelengths to the less energetic longer wavelengths. The wavelengths that impinge on the earth's surface are between 290 and 3,000 nm. On the basis of our visual physiology, they can be arbitrarily divided into visible, ultraviolet, and infrared waves.

The portion of solar radiation that elicits the sunburn reaction lies between 290 and 320 nm in the ultraviolet band and is traditionally designated ultraviolet B (UVB). The earth's stratosphere effectively absorbs the potentially more harmful shorter wavelengths. This filtering is accomplished by the thin ozone layer that continually absorbs ultraviolet radiation (UVR) from 200 to 320 nm, completely cutting out all radiation less than 290 nm. The longer ultraviolet wavelengths from 320 to 400 nm, designated ultraviolet A (UVA), are approximately one thousandth as effective as UVB in evoking erythema.
Care of the Foreskin
Authors: Boyce W. Thomas
Published: December 2021

The pediatrician inclined to read further in the extensive literature on neonatal circumcision may well be more impressed with the intensity of the arguments than with the finality of the conclusions. For many, circumcision (or its abolition) has become a cause, with all the attendant rhetoric and dogma. Yet one is struck by the high level of ambivalence with which most of us approach the issue, both as pediatricians and as parents.

One source of this ambivalence may be the uncertainty surrounding the proper role of the pediatrician in decisions regarding circumcision. Should we act simply as purveyors of medical information, leaving the decision entirely to parents? Or are we obligated to assume a position of advocacy, actively arguing for or against circumcision? At the very least, the pediatrician should be prepared to summarize for parents the evidence that may affect their decision and to provide the appropriate information and support to those who decide against the operation.
Infant Nutrition
Authors: Lawrence Ruth A.
Published: December 2021

NORMAL GROWTH IN BREASTFED INFANT

Appropriate growth in a breast-fed infant is comparable to appropriate growth in a bottle-fed infant. An infant who gains steadily is usually not of concern. However, a normal breast-fed infant may lose 5% to 8% of birth weight in the first few days of life and not begin to gain until the fifth to the seventh day, with birth weight being regained at 10 to 14 days. If weight gain is evaluated from the point of regaining birth weight, the curve is a steady one, with a total gain of two pounds in the next four weeks. Infants fed formula often lose only 1% to 2% of body weight and regain birth weight by the first week. A breast-fed infant whose mother is a primipara may lose more weight because the volume of milk does not increase until the fourth day post partum whereas a multipara's milk comes in sooner (in inverse relation to her multiparity).

Ideally, the breast-fed infant gains two pounds per month in the first three months, one pound per month in the second three months, and one-half pound per month for the next six months. The birth weight is doubled at four to five months and tripled at one year. Some available growth curves are based on formula-fed infants, a group that includes a greater number of obese infants.
Androgen Disorders in Children: Too Much, Too Early, Too Little, or Too Late
Authors: Rosenfield Robert L.
Published: December 2021

Pubarche, used here as synonymous with the onset of sexual hair (Tanner pubic hair stage III), usually follows the onset of true puberty by one to two years. The true status of puberty is best indicated by testicular size in boys and breast development in girls. Departure from this sequence of events, or dissociation of pubic hair from gonadal development are important clues to proper diagnosis when pubarche begins prematurely. Hirsutism or acne in adolescent girls, particularly when associated with menstrual irregularity or obesity, has a high probability of having an androgenic basis. Polycystic ovary syndrome is the most common cause of this situation in teenagers. The pattern of sex hormone levels can be an important clue to the diagnosis of hyperandrogenic disorders, particularly when coupled with a "low-dose," five-day dexamethasone suppression test. Delayed puberty is usually a "constitutional," familial variant of normal development, but can often be distinguished from true hypogonadism by the mid-teenage years using history, examination, steroid 1evels, and a gonadotropin-releasing hormone test.

ANDROGENS

Testosterone and dehydroepian-drosterone-sulfate (DHAS) are the most important androgens in blood (Fig 1). Testosterone is the major potent form of circulating androgen. DHAS is the most abundant circulating 17-ketosteroid. The normal plasma and urine levels of the androgens are shown in Table 1.
Burns in Children
Authors: GUZZETTA PHILIP C. , RANDOLPH JUDSON
Published: December 2021

One of our readers wrote concerning the article, "Burns in Children," (PIR 4:271, 1983): "There is a difference of opinion between experts regarding early use of colloid solution in treatment of second and third degree burns. Guzzetta and Randolph do not recommend colloid, whereas other experts do. What is the consensus of experts?"

In reply: The use of colloid solution as part of the fluid resuscitation formula in burned children is controversial. Baxter has shown that for the first 24 hours a "capillary leak" exists throughout the body and not just in the burned area. It is difficult to justify using a more expensive volume expander such as albumin, when the capillaries are equally permeable to both the colloid and Ringer's lactate.
Cholestasis of the Newborn (Obstructive Jaundice)
Authors: Gartner Lawrence M.
Published: December 2021

Obstructive jaundice of the newborn is a misnomer as fewer than half of all cases usually referred to as "obstructive jaundice" result from mechanical interference with the flow of bile. In the majority of cases, intrinsic liver disease is the cause of this type of jaundice. The term "cholestasis" more comprehensively describes the various disorders and the pathophysiology, which includes retention of direct-reacting (conjugated) bilirubin, bile acids, and other components of bile.

Direct-reacting hyperbilirubinemia is almost always the first definitive sign of hepatobiliary dysfunction, often appearing during the first weeks of life just as the normally occurring, indirect-reacting (unconjugated) hyperbilirubinemia of physiologic jaundice of the newborn is receding. Initially, there may be uncertainty as to the significance of the persisting or recurring jaundice, particularly whether the direct-reacting fraction is elevated.

As a general rule, when the direct-reacting portion exceeds 2.0 mg/dl and is more than 10% of the total serum bilirubin, it should be considered clinically significant. Although the direct-reacting fraction may occasionally account for 90% of total serum bilirubin, in most cases the direct-reacting portion will range only from 25% to 75%. The degree of variation has no diagnostic significance. As only water-soluble, direct-reacting bilirubin is excreted by the kidney, the presence of bilirubinuria may be used as confirmation of elevation of the direct-reacting fraction.
Scoliosis Screening
Authors: Berwick Donald M.
Published: December 2021

Scoliosis screening reduces the frequency of scoliosis surgery in a population, and probably leads, through early bracing, to a reduction in the degree of at least some serious curves. Its costs, however, are far from negligible. Even in the best of hands, a screening program induces costs and concerns in follow-up for many more children than it helps, and, if poorly administered, these induced costs can far outweigh the advantages to the screened population.

For the moment, until inexpensive and noninvasive follow-up methods are developed, it is probably advisable that children in the age range of 10 to 14 years be screened competently at least once, but with strict attention to the following principles:

1. Follow-up of those with positive results on screening should be suited to the age, sex, and risk factors for the individual child, and should minimize expense, roentgenogram ex-posure, and concern wherever possible.

2. Screening should be done by well-trained personnel who are fully aware of both the signs of significant curvature and of the costs and risk of inappropriate referral.

3. Screening programs should systematically assess the psychological morbidity of the labeling process in their target populations, and should modify their procedures accordingly if that morbidity is high.

4. Programs should be solidly linked to sound, prompt, and circumspect referral patterns—either primary care or specialty consultants. The mere "detection" of positive screening findings without assuring competent follow-up does not consitute effective screening.
Other Causes of Red Urine
Authors: HEFELFINGER D. C.
Published: December 2021

I am writing in reference to "Hematuria in Childhood" by Kaplan (PIR 5:99, 1983). In Table 1 are listed several causes for "red" urine. Under discolored urine, external pigments, drugs, I would like to suggest that rifampin be included. This is particularly important because many physicians are using this drug as prophylaxis in the treatment of Haemophilus influenzae type B carriers. This drug produces red urine in almost all who take the substance. I suspect that currently, at a national level, this single agent is presently more responsible for red urine than all of the other agents added together. Fortunately, this is a totally reversible process, despite possible other harmful side effects.