bluuebunny/crossref_metadata_2025_split huggingface dataset:
Consultation with the Specialist
Authors: Warner Brad W. 
Published: December 2021

Wilms tumor is an important solid neoplasm in children that occurs with a frequency of 400 to 500 cases annually in the United States. It is important, therefore, for primary care physicians to be aware of the clinical presentation and associated symptoms and signs of Wilms tumor. Progress in management of this neoplasm has been outstanding, primarily because of cooperative efforts of the National Wilms Tumor Study Group. The significantly improved survival that has resulted from the Group's cooperative efforts serves as a paradigm for the management of all tumors.
Presentation
Wilms tumor most commonly presents as an asymptomatic abdominal mass. The average age of presentation is 3 to 4 years. This mass, which usually is located in the region of the flank, may be detected during a well-child routine physical examination. It also is not unusual for the mass to expand acutely due to hemorrhage within the tumor. This may account for discovery of the mass by the parents shortly after a recent thorough physical examination. The child also may present with abdominal pain associated with the mass due either to acute hemorrhage or to rupture of the tumor into the peritoneal cavity. Up to one third of children who have Wilms tumor may have microscopic hematuria, and in male patients, obstruction of the left spermatic vein can produce a left-sided varicocele.
Chronic Nonspecific Diarrhea
Authors: Judd Robert H. 
Published: December 2021

Case Presentation
A toddler is seen for his 2-year well child examination. His parents are concerned and have received complaints from his child care provider that he has three to four loose, watery bowel movements daily; each bowel movement requires a clean-up and change of clothes. This diarrhea has been present intermittently for at least 6 months. He has a very good appetite, no other abdominal symptoms, and no blood in his stools. His development appears normal. Physical examination is entirely normal, including a weight of 13 kg and height of 90 cm, both at the 75th percentile for age. What additional history is useful, what laboratory evaluation would you perform, and how would you advise his parents?
Introduction
Gastrointestinal disorders account for approximately 5% of pediatric office visits. Many of these visits are for acute diarrhea that usually is infectious in origin and resolves in fewer than 7 days. Diarrhea in the young child that persists for longer than 3 weeks is termed chronic and can be frustrating and anxiety provoking for both physicians and parents. Through careful clinical assessment, the clinician can separate the majority of patients who require only observation from those who require a limited number of simple tests or those who require extensive testing.
Definition
BACK TO BASICS
Authors: Jospe Nicholas , Forbes Gilbert 
Published: December 2021

Changes in volume and composition of body fluids due to disorders of fluid and electrolyte balance cause various common clinical illnesses. The rationale for reviewing the diagnosis and management of fluid and electrolyte disorders was eloquently denoted by Dr Altemeier, when he suggested that this knowledge belongs among the core concepts needed by the "keepers of the gates," that is, primary care pediatricians.1 In the body, homeostasis is maintained by the coordinated action of behavioral, hormonal, renal, and vascular adaptations to volume and osmotic changes. These core issues have been outlined in a previous article in this journal by Dr Hellerstein, and the current article proceeds from that discussion.2 Following introductory comments about body fluid volume and composition, we provide an overview of some of the etiologies of the disorders of volume, tonicity, and composition of body fluids and of the therapy to correct these disorders.
Sodium, Osmolality, and the Volume of Body Fluids
Total body water, which is 55% to 72% of body mass, varies with sex, age, and fat content and is distributed between the intracellular and extracellular spaces. The extracellular fluid (ECF), which comprises about one third of total body water, includes the intravascular plasma fluid and the extravascular interstitial fluid.
INDEX OF SUSPICION
Authors: Block Janice L. , Daisy Selina , Mostaque A K , Waler James A. 
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
An 11-month-old boy is brought to the emergency department because of 3 days of fever, "crossed eyes," and a discharge of bloody pus from his left ear. His mother also has noticed that he is less steady on his feet. His left ear has been infected for 6 months despite therapy with amoxicillin/clavulanate, cefpodoxime, clarithromycin, ceftriaxone, cefaclor, and antibiotic drops with hydrocortisone. The mother states that she has been fully compliant with the drug regimens.
On physical examination, the child's height and weight are in the 50th percentile. He tugs frequently at both ears but is afebrile and does not look ill. He is unable to move his left eye laterally past midline, giving him a cross-eyed appearance on left lateral gaze.
Separation or Synthesis: A Holistic Approach to Therapeutics
Authors: Kemper Kathi J. 
Published: December 2021

Over the past 50 years, health care has grown more complex and specialized. Health-care institutions now are staffed with an array of specialist physicians, social workers, psychologists, therapists, and nutritionists as well as general practitioners and nurses. The types of providers outside of the hospital are even more numerous and diverse: physicians; nurses; nurse practitioners; chiropractors; counselors; acupuncturists; herbalists; spiritual healers; and purveyors of nutritional supplements, aromatherapy, crystals, and more.
Intent on distinguishing their "products," providers focus on differences, polarizing into distinct camps such as "mainstream or traditional" versus "alternative or unconventional." Although these dichotomies are simple, they also can mislead. The definition of "alternative" is very dependent on the definition "mainstream"; acupuncture may be an alternative in one setting, but it clearly is traditional within Asian communities. Therapies that once were considered unconventional, such as hypnosis and meditation, have moved into many mainstream medical settings. (See Sugarman article "Hypnosis: Teaching Children Self-regulation" in the January 1996 issue of Pediatrics in Review.)
The public wants health care that is low-cost, safe, effective, and personalized. Practitioners of "natural" therapies often are viewed as more humanistic and less technological than busy physicians. According to one study, in 1990, alternative medical therapies were used by nearly one third of Americans.1
INDEX OF SUSPICION
Authors: Colson Eve R. , Herendeen Neil , Szilagyi Peter , Bush William , Pandit Sharad 
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 9-month-old African-American boy is brought to you in early April for a well child visit. Born after an uncomplicated pregnancy and delivery, he has been healthy at all previous visits and was noted to have normal growth and development when last seen at 6 months of age.
At this visit, the baby's length has dropped from the 50th to the 5th percentile, while his weight and head circumference remain at the 50th. He is breastfed and eats small amounts of chopped fruits and vegetables. His parents give him no foods that contain artificial ingredients, and he receives no supplemental vitamins. The baby's stools are normal in pattern and consistency, and he has had no recent illnesses.
Incest
Authors: Sarles Richard M. 
Published: December 2021

Incest, one facet of sexual abuse of children and adolescents, refers to sexual relations between persons too closely related to marry. These relations mean an overt action by one partner with a sexual intent ranging from physical fondling to genital contact and/or intercourse. Many legal codes extend the incest restrictions to adopted and/or stepchildren. This definition technically includes prepubertal sex play between siblings. However, curiosity appears to be the motivating factor in the prepubertal age group and clear evidence of the intent for sexual exploitation inappropriate for the children's age is usually lacking.
Father-daughter incest, including stepfather-stepdaughter incest, constitutes approximately 75% to 85% of the cases reported. Although brother-sister incest is thought to be the most common form of incestuous behavior, only 15% of the cases reported to the authorities are of this type. Most brother-sister incest represents exploitative sexual behavior rather than age-appropriate mutual curiosity and experimentation. Such sibling incestuous behavior does not cross generational lines and seems, therefore, to be less influenced by the guilt of the incest taboo. In mother-son incest, which is the most uncommon type, the taboo appears to be so strong that one or both of the partners are usually severely emotionally disturbed or psychotic.
Risk Factors for Coronary Artery Disease in Children: Recognition, Evaluation, and Therapy
Authors: Glueck C. J. , Mellies M. J. , Tsang R. C. , Morrison J. A. 
Published: December 2021

PEDIATRIC GENESIS OF ATHEROSCLEROSIS
Atherosclerosis results from a variety of pathophysiologic disturbances, some currently recognized, and many undoubtedly not yet recognized, which in aggregate are identified as risk factors. Genetic and environmental influences conjointly affect the incidence and the severity of these risk factors and, thus, coronary heart disease (CHD) risk. Prophylaxis should be designed to prevent or retard the development of arterial plaques. This suggests that diagnostic and preventive efforts should begin in childhood. Eating habits are also probably established in childhood, allowing their early modification.
The atherosclerotic plaque appears to have its genesis in childhood. The data from wartime autopsies confirm the presence of mature atherosclerotic lesions by the end of the second decade and emphasize the importance of primary atherosclerosis prevention beginning in the first and second decades.
While there are clearly genetic factors in CHD, variation in rates in differing geographic areas appears less likely to be related to genetic than to environmental differences. Marked differences in plasma cholesterol levels are found in children in different geographic areas, generally paralleling pediatric cholesterol and saturated fat intake and the incidence of adult coronary heart disease. The relationships of elevated total plasma cholesterol levels to the incidence of coronary heart disease are clearly established in adults.
Inborn Errors of Metabolism
Authors: Komrower George M. 
Published: December 2021

Around the turn of the century Garrard established the concept of an inborn error of metabolism using his study on alcaptonuria to exemplify his hypothesis that a considerable number of metabolic disorders with clearly defined clinical, pathologic, and biochemical abnormalities arise because an enzyme governing a single metabolic step is either reduced in activity or missing altogether. He pointed out the familial distribution of alcaptonuria and later showed that the inheritance could be explained on mendelian principles, ie, the affected individual was homozygous for the abnormal gene and that the inheritance was recessive, both parents being heterozygous for the disorder. He suggested that the accumulation of homogentisic acid in alcaptonuria was evidence that this substance is a normal metabolite in the degradation of tyrosine and attributed this accumulation to a failure of oxidation of homogentisic acid. In addition to alcaptonuria he described cystinunia, pentosuria, and albinism. This work was the forerunner of the classic studies of Beadle and Tatum on mutants of Neurospora crassa which led to the one gene-one enzyme concept.
DETECTION
Different groups require special attention: the family at risk because of previously affected individuals, those with unusual features suggestive of metabolic disorders, and sick newborns. Screening of normal newborns requires a different approach.
Editorial: Those Educational Objectives
Authors: H. R. J. 
Published: December 2021

The material Covered in PEDIATRICS IN REVIEW is, for the most part, based upon Educational Objectives developed by two Task Forces and accepted by the Coordinating Committee on Continuing Education and Recertification. Both Task Forces are made up of practicing pediatricians (at least 50%) and academicians, and are appointed by the American Academy of Pediatrics and the American Board of Pediatrics. The organization and respective responsibilities of the Task Forces are shown in the diagram. The activities of The Academy (PREP) and The Board are based upon these objectives.
The Topics Task Force develops some 25 to 35 Educational Objectives dealing with the Topics selected for review each year.
Febrile Seizures: Long-Term Management of Children with Fever-Associated Seizures
Authors:   Consensus Development Panel
Published: December 2021

A Consensus Development Conference on Febrile Seizures was held at the National Institutes of Health on May 19-21, 1980. The purpose of the Conference was to bring together practicing physicians, research scientists, consumers, and others in an effort to reach general agreement on the risks of sequelae in children with febrile seizures and to compare them with the potential risks and benefits of prophylaxis with anticonvulsants. This summary is the result of these deliberations.
1. What is a febrile seizure?
A febrile seizure (an abnormal, sudden, excessive electrical discharge of neurons (gray matter) which propagates down the neuronal processes [white matter] to affect an end organ in a clinically measurable fashion) is an event in infancy or childhood, usually occurring between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded. Febrile seizures are to be distinguished from epilepsy, which is characterized by recurrent nonfebrile seizures.
2. What are the risks facing the child who has a febrile seizure?
Children who suffer a febrile seizure generally enjoy normal health after the episode. They are, however, at some risk in several respects. Thirty percent to 40% of children who have one febrile seizure and who do not receive prophylactic therapy will experience a second.
Ankle Injuries in Children and Adolescents
Authors: Harvey Jack 
Published: December 2021

Every general pediatric practice has its share of minor orthopedic trauma, comprising approximately 5% of the average practice. In practices slanted toward the care of adolescents or athletes the percentage is higher. The vast majority of these injuries occur to the ankle and knee, however; this article will discuss ankle injuries exclusively. Whether you are dealing with athletes or with active children and adolescents, the proper diagnosis, treatment, and rehabilitation of common ankle injuries is an important aspect of general pediatric practice. Failure to treat a specific injury properly may not only prolong the discomfort and disability produced by the injury but may produce the end result of a chronically unstable ankle and possible degenerative joint disease.
ANATOMY AND BIOMECHANICS
Proper diagnosis of ankle injuries requires a knowledge of the anatomy of the bones and ligaments that make up the ankle joint (Fig 1). The distal ends of the fibula and tibia are held in close approximation by ligamentous structures to produce an ankle mortise lined with articular cartilage. This surface articulates with the cartilaginous surface of the dome of the talus. The anterior and posterior tibiofibular ligaments (syndesmosis) are responsible for holding the distal tibia and fibula together. The joint proper is stabilized medialy and laterally by the distal processus of these bones as well as attached ligaments.
Crohn's Disease in Children
Authors: Gryboski Joyce D. 
Published: December 2021

Once considered rare in children, Crohn's disease (CD) is being recognized with increasing frequency.1-3 This is due not only to physical awareness but to an alarming increase in the incidence of the disease in young people. Although early descriptions of CD localized the site of involvement to the terminal ileum, it is now recognized that all organs of the alimentary tract may be affected, and in some unfortunate patients involvement extends proximally as far as the stomach, esophagus, or oropharynx and distally, to involve even perianal tissue.
Unlike ulcerative colitis which is rather clear-cut in its presentation, CD is often insidious with solitary symptoms of anorexia, weight loss, short stature, or fever of unknown origin being its only manifestation. The presenting symptoms and longterm course vary with the site of disease, and although each patient must be evaluated and treated individually, some overall predictions may be offered as to the victim's future quality of life.4-6
Significant advances have been made during the last decade in understanding the pathophysiology of the disease and in methods of its treatment, although as yet the etiology remains to be defined. Although CD has many features in common with ulcerative colitis and the two are often combined in the terminology, "inflammatory bowel disease," the pathologic findings, course, and complications are distinctive enough that they should be considered as two distinct diseases.
Herpes Simplex Virus Encephalitis in Pediatrics
Authors: Nahmias André J. , Whitley Richard J. 
Published: December 2021

It is disturbing to note that since the advent of national reporting of acute encephalitis, no etiology has been established for the majority of cases diagnosed in the United States every year.1 This complacent approach to diagnosis probably stems from the apparent lack of specific therapy. Nevertheless, correct diagnosis has always been important for several reasons: for epidemiologic control of such entities as mosquito-borne encephalitis, for prognostic considerations, and so as not to miss known treatable conditions that may mimic encephalitis. In pediatrics particularly, we can illafford not to attempt to establish the specific diagnosis of encephalitis which is so prone to affect the quality of life of newborns and older children. There is even more reason today to improve our diagnostic acumen as newer methods are becoming available for the prevention and/or therapy of the second most devastating of the viral encephalitides—that due to herpes simplex viruses (HSV).
Less than a decade ago it was widely believed that HSV encephalitis in newborns and older children was an extremely rare occurrence, being a disease primarily of adults. This erroneous impression is again most likely a result of inadequate diagnosis, as well as the lack of adequate information. However, there have been many recent advances at all levels in this area.
Increased Intracranial Pressure
Authors: Griffith John F. , Brasfield Jimmy C. 
Published: December 2021

The infant or child with increasing pressure within the cranial cavity must be identified early and treated promptly in order to prevent serious complications or death. When the pressure elevation is gradual it is frequently well tolerated, and the patient may seem deceptively well. There is a critical point, however, beyond which any further increase in pressure leads to a catastrophic deterioration in the patient's condition.1 When this occurs, the outlook for quality survival is poor despite the best therapy. Unfortunately, this can occur when the underlying process is benign and would have been reversible if recognized and treated promptly. For prompt recognition and treatment, the physician must be familiar with the pathophysiology of raised intracranial pressure.
PATHOPHYSIOLOGY
The intracranial compartment contains blood vessels, cerebrospinal fluid (CSF), brain, and leptomeninges which include the rigid dural membranes forming the falx and tentorium. Whenever there is an increase in the volume of any one of these intracranial components (brain, CSF, blood) there must be a corresponding reduction in the size of the others in order for the intracranial pressure to remain normal. This type of compensation or buffering capacity is particularly important in the early stages of intracranial disease. As the pressure mounts from any type of mass lesion, the CSF is displaced caudally into the spinal subarachnoid space and there is a corresponding increase in the rate of absorption of CSF.2
Eczematous Eruptions in Childhood
Authors: Hurwitz Sidney 
Published: December 2021

Atopic dermatitis, one of the most common skin disorders seen in infants and children, is frequently a source of frustration to parents and presents a challenge to immunologists, pediatricians, and dermatologists alike. Affecting approximately 3% of the childhood population, atopic dermatitis frequently causes confusion because the terms eczema and dermatitis are often used synonymously and interchangeably.1 Eczema is a generic term that identifies an acute inflammatory cutaneous eruption characterized by itching, redness, papules, vesicles, edema, serous discharge, and crusting (Fig 1). Dermatitis without a qualifying adjective is less definitive and merely refers to an inflammation of the skin which may result in a spectrum of lesions varying from acute necrosis and ulceration to simple erythema.2 A modifying adjective therefore is frequently added to the general term in an effort to identify the specific eruption under consideration, hence the terms contact dermatitis, seborrheic dermatitis, nummular dermatitis, and atopic dermatitis.
PATHOGENESIS
Atopic dermatitis is the most common cause of eczema in children. Although its cause remains unknown, the disorder represents an eczematous disorder of characteristic distribution, a hereditary symptom complex in individuals with paradoxical physiologic responses to pharmacologic stimuli, a constitutional predisposition to develop dry skin and pruritus, and a personal or family history of allergy.