bluuebunny/crossref_metadata_2025_split huggingface dataset:
Consultation with the specialist
Authors: Lovejoy Frederick H. 
Published: December 2021

Diagnosing poisoning by an unknown agent can be a difficult challenge. Five strategies of assessment may be used in logical sequence, however, to arrive at a diagnosis: (a) history, (b) physical examination, (c) rapid laboratory tests, (d) diagnostic trial, and (e) screening for toxins. This is illustrated by a case history, followed by discussion of a recommended approach and the utilization of these principles to arrive at a diagnosis in the case.
Initial Case History
A 41/2-year-old boy, with a history of onset of deep breathing following supper, is brought to your office by his mother. He had been alert and well all day, without fever, fully oriented, and without vomiting or diarrhea. He had been playing both in the house and garage in the morning and had spent the afternoon watching television. His temperature is 37.6°C, respiratory rate is 60 breaths per minute with deep inspiration and expiration, and pulse is 100 beats per minute and regular. He is without cyanosis. His pupils are midpoint, his lungs are clear, and his breath has no noticeable odor. What would you ask the mother in an effort to establish a diagnosis?
History
An unknown agent often can be suspected by history alone. The location of ingestion, if known, can offer clues.
The Pediatrician's Role in the Diagnosis and Treatment of Substance Abuse
Authors: Alderman Elizabeth Meller , Schonberg S. Kenneth , Cohen Michael I. 
Published: December 2021

Abuse of drugs and alcohol is pervasive in our society. The role of the pediatrician as a health-care provider from birth through young adulthood includes recognizing the stigmata in newborns of prenatally ingested drugs as well as being able to treat neonatal drug withdrawal syndromes. Questioning about drug use and other closely related topics should be incorporated into all health-care maintenance visits, starting at the age of 10 y, with parental participation and anticipatory guidance being offered. Physical examination and laboratory testing are not as helpful in confirming an impression of substance abuse as a comprehensive interview and a full appreciation of the warning signs of substance abuse.
Treatment of the problematic user with a multidisciplinary team that understands adolescent development and behavior as well as the problem of substance abuse is crucial. The decision to treat the teen in an ambulatory or inpatient setting is determined by the extent of abuse, underlying medical problems and psychopathology, and the degree of family dysfunction.
The pediatrician must not avoid addressing these issues with patients. If, however, upon identifying an adolescent or a newborn with a drug problem, the pediatrician feels uncomfortable or ill-prepared to manage the patient, appropriate professional referrals are warranted. Despite exercising the referral option for treatment, as advocate for child and family, the pediatrician remains professionally bound to track all drug abuse-related referrals while continuing to participate in the general ongoing care of the patient and family.
Sports Medicine
Authors: Risser William L. 
Published: December 2021

This article discusses several topics that are rather loosely related, including prevention of injury, disqualifying conditions, heat illness, proper nutrition in sports that have weight categories, anabolic steroids, and treatment of contusions. All but the last fit the theme of injury prevention.
Injury Prevention
CONDITIONING
Proper physical conditioning can prevent injury. The principles of preventing overuse injuries in distance runners discussed herein can be generalized to other sports.
At the beginning of the season, the coach must control the duration, intensity, and frequency of training carefully. Atheletes often develop overuse injuries when they do too much too soon. In addition, runners should warm up and stretch before exercise and cool down and stretch afterwards. If they are using strength training as part of their conditioning program, they should begin this slowly and carefully. In warm or humid climates, they need proper hydration and gradual acclimatization to avoid heat illness, particularly during the first 2 weeks of training.
Proper conditioning includes instruction in the correct biomechanics of running; errors can lead to injury. Malalignment in the lower extremities, such as leg length discrepancies or excessive pronation, may disturb normal biomechanics. Affected athletes may avoid overuse injuries by using heel pads or arch supports. Clinicians should identify malalignment during preparticipation sports examinations, before injury occurs.
Chronic Liver Disease in Children
Authors: Mews Catherine , Sinatra Frank 
Published: December 2021

Chronic liver disease encompasses a wide spectrum of disorders, including infectious, metabolic, genetic, drug-induced, idiopathic, structural, and autoimmune diseases. The clinical presentation and initial laboratory data in many of these diseases are similar, and a definitive diagnosis often relies on specialized laboratory investigation and histologic examination of liver tissue.
The aim of this article is to: 1) Define chronic hepatitis and cirrhosis; 2) Review briefly the clinical presentation, pathophysiology, diagnosis, and management of the more common pediatric causes of chronic liver disease; 3) Review the complications associated with chronic liver disease and discuss their appropriate management; and 4) Review the indications for hepatic transplantation.
Chronic Hepatitis
Chronic hepatitis is defined as ongoing inflammation within the liver that is capable of progression to cirrhosis, liver failure, and death. The presence of continued hepatic inflammation, as confirmed by clinical manifestations and laboratory studies, for a period of greater than 10 weeks usually excludes a self-limited hepatitis and implies chronicity. However, to fulfill the international criteria for chronic disease strictly, evidence of continued hepatic inflammatory activity needs to be present for a period of at least 6 months. Most pediatricians, however, allow 3 months for an acute liver insult to clear before undertaking specialized laboratory investigations and invasive studies.
Hallucinogens
Authors: Werner Mark J 
Published: December 2021

Substances that produce hallucinations have been used for thousands of years. It is said that the Oracle of Delphi inhaled carbon dioxide emanating from a rock fissure to alter consciousness. Cannabis and certain mushrooms were used at the time of the Vedas. Hallucinogenic drugs first captured the American public's attention and concern in the early to mid-1960s during the age of psychedelic experience and "flower children." Over the past 20 years the aura surrounding hallucinogens has changed so greatly that today they are sometimes considered to be just another class of drugs used inappropriately by adolescents. However, the use of hallucinogens by adolescents is much more widespread than many pediatricians may realize. Approximately 14% of adolescents have used hallucinogens. Annual surveys of high school seniors indicate that approximately 10% have used hallucinogens, with 2% to 3% having used them in the past month. Specifically, 1.8% have used lysergic acid diethylamide (LSD) and 1.4% have used phencyclidine (PCP) within the past 30 days. Studies suggest that PCP is the only drug for which use by adolescents has been increasing in recent years.
The purpose of this article is to review the major physiologic and behavioral consequences of hallucinogen abuse, the presentation and management of acute intoxication and withdrawal, and the association between maternal use of hallucinogens and fetal abnormalities or neonatal withdrawal syndromes.
Chronic Inflammatory Bowel Disease in Childhood
Authors: O'Gorman Molly , Lake Alan M. 
Published: December 2021

Definition
Chronic inflammatory bowel disease (IBD) of childhood is generally defined as either ulcerative colitis (UC) or Crohn disease (CD). The inflammation of UC is restricted to the mucosal lining of the colon, with the colonic involvement beginning universally in the rectum and extending proximally continuously. Although proctitis, persistent isolated involvement of the rectum, is common in adults (40%), it is rare in children (&lt;10%). In contrast, the enteric inflammation of CD is transmural and involves any level of the intestinal tract discontinuously. The intervals of relatively normal bowel are termed "skip areas." In CD, characteristic lesions range from oral ulcerations to perianal lesions, although the most frequently involved area is the terminal ileum of the small bowel, a process termed ileitis.
Recognition of these conditions by pediatricians is important because the peak incidence of IBD is in the second decade. Fewer than 5% of patients are diagnosed prior to age 5 years. In many children presenting with isolated colitis, the diagnosis of the chronic inflammation of IBD is established by biopsy before a clinical distinction between UC and CD can be established. These children carry the diagnosis of chronic nonspecific colitis or colitis type indeterminant. In our experience, the disease in approximately 50% of these children evolves within 5 years into more classic cases of UC or CD.
INDEX OF SUSPICION
Authors: Menna Vincent J. , Smith Summer , Liptak Gregory S. 
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 2-month-old breast-fed boy is brought to the office with a 2-day history of constipation, poor feeding, lethargy, wheezing, and a temperature of 101°F (38.3°C). In the office his temperature is recorded at 98.8°F (37.1°C) rectally. The infant does not appear lethargic, and the only significant physical finding is tearing of the left eye. Because of the history of fever, a complete blood count is obtained, which is normal. The infant is discharged home with a diagnosis of conjunctivitis and possible viremia. He returns within 48 hours and is found to be hypotonic with a poor gag reflex, weak suck, and weak cry. Despite his normal temperature a septic evaluation is initiated.
Case 2 Presentation
A 17-year-old boy complains of bilateral hip pain that has bothered him for the past year.
Near-Drowning
Authors: Fiser Debra H. 
Published: December 2021

Definition
Drowning is defined as death caused by submersion, whereas near-drowning connotes survival for some time period following submersion. The following remarks pertain to the near-drowning victim who presents for acute medical management.
Epidemiology
Because reporting of near-drowning incidents is incomplete, most of the available epidemiologic information focuses on drowning deaths, which number more than 6500 per year in the United States. Data from King County, Washington, however, suggest that near-drownings slightly out-number drownings. Drowning rates are highest for children under the age of 5 years and between the ages of 15 and 24 years. Males drown 4 times more frequently than females. African-Americans and low-income groups also are affected disproportionately, except for those drownings involving boats and residential swimming pools, which more often are owned by middle class groups.
Drownings peak during the summer months and are most common in the southern and western United States and Alaska. Forty to 45% of all drownings occur while the victim is swimming and 12% to 29% are boat-related. Alcohol plays a substantial role in these deaths.
Between one half and three quarters of all drownings occur in lakes, ponds, rivers, and the ocean. More than 40% of all submersions in these bodies of water involve older adolescents or young adults.
A Clinical Overview of Systemic Lupus Erythematosus in Childhood
Authors: Lang Bianca A. , Silverman Earl D. 
Published: December 2021

Systemic lupus erythematosus (SLE) is an autoimmune disorder resulting in inflammation of multiple organ systems. Although SLE is not common in children, it must be considered in the differential diagnosis of any child who has multisystem disease. The onset of SLE in children may be acute, with severe disease affecting one or more major organ systems, or it may be insidious, with intermittent symptoms of fever, malaise, rashes, arthritis, or pleuritis. SLE also must be considered if a child is found to have a positive antinuclear antibody (ANA) test result. Although almost all children who have SLE have a positive result, this laboratory test alone does not establish the diagnosis of SLE.
Classification Criteria
Eleven disease manifestations are included in the revised classification criteria for SLE established by the American College of Rheumatology (Table 1). These criteria were established as a classification tool to guide in selecting patients for clinical and laboratory studies rather than as a diagnostic system. Nevertheless, they have proven useful in the assessment of both pediatric and adult patients who may or may not have SLE.
Epidemiology
Childhood onset of SLE accounts for approximately 20% of all cases. The annual incidence in the United States is approximately 0.6 cases per 100 000 total population, with higher rates found in the African-American, Oriental, and Hispanic populations.
Otitis Media
Authors: Howie Virgil M. 
Published: December 2021

Definitions
When the diagnosis of otitis media has been made on the basis of skilled clinical observation and the tympanic membrane is intact, it is practical to assume that an effusion is present. However, this can be confirmed only by recovery of fluid from the middle ear on tympanocentesis or myringotomy. Several methods will confirm the diagnosis of effusion with the indicated accuracy, as generally reported in the literature (Table 1).
Acute Otitis Media
A common error in the diagnosis of otitis media with effusion (OME) is equating an "injected" or "red" eardrum with OME. Acute otitis media may present with an injected drum, but the critical factor is not drum color but the presence of fluid in the middle ear cavity. The drum frequently is suffused and red when an infant or toddler is crying from either fear or pain during the otoscopic examination. A bulging eardrum, on the other hand, usually is regarded as defining acute otitis media (also called suppurative or purulent otitis media) with or without symptoms (pain, sleeplessness, fever, irritability) of systemic illness.
Experienced clinicians try to avoid the "red ear" error with either tympanometry or acoustic reflectivity (Table 1) or by careful removal of all external ear contents to visualize fully the landmarks (eg, both ends of the malleolus) and their mobility with the pneumatic otoscope.
Physical Abuse of Children: An Update
Authors: Sirotnak Andrew P. , Krugman Richard D. 
Published: December 2021

Now, more than ever, physicians must be willing to suspect child abuse and report their concerns. New information from the past decade warns us that reports of violence against children continue to increase. We are learning that MRI imaging of the head may, in some cases, help date subdural hematomas, but long-term developmental follow-up studies of "shaken" infants are lacking. Intentional thoracic and abdominal injuries carry a high mortality. Finally, new information in the field of child abuse—in particular, physical abuse—is slow to come. Lack of funding for basic medical child abuse research and lack of trained researchers in the field are the two most important barriers.20
Preventive intervention at the community and family level needs to be supported by both the pediatrician and the local and national government leaders. As the U.S. Advisory Board on Child Abuse and Neglect says, "We need to make it as easy for parents to pick up the telephone and get help before they abuse their child as it is now for their neighbor or physician to pick up the telephone and report them after it has happened." Child health practitioners may be in the best position to implement such a policy.
INDEX OF SUSPICION
Authors: Friedman Elliott M. , Rotta Alexandre T. , Menna Vincent J. 
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 13-year-old girl comes to you because it is so painful for her to urinate that she has developed acute urinary retention. Over the past 6 months she has had recurrent mild abdominal cramps; exactly 1 month ago she experienced a similar episode of dysuria. At that time she was able to urinate and was diagnosed by positive culture as having a urinary tract infection, for which she was treated.
While preparing to catheterize her, you notice that this young woman is Tanner stage 5 in breast and pubic hair development, yet she states that she has never had a menstrual period. Her mother recalls her own menarche at age 11 years. Observations during the procedure allow you to determine the underlying cause of her problems.
Epstein-Barr Virus Infection
Authors: Durbin William A. , Sullivan John L. 
Published: December 2021

Introduction
Virtually all humans become infected with Epstein-Barr virus (EBV). The vast majority of these infections are inapparent, occur early in life, and are associated with lifelong latent infection and persistent shedding of virus.
Epidemiology
The prevalence of antibody to EBV has been determined in many age groups throughout the world. In developing and tropical areas, infection takes place early in life and is inapparent, with most children demonstrating antibody by age 6 years. Infection is believed to be related to hygiene and crowding as well as to cultural patterns that lead to exposure to saliva (eg, prechewing of food). In contrast, infection in Western Europe and the United States in childhood is less common, with only 35% to 50% of 5-year-olds demonstrating antibody.
Infectious mononucleosis (IM) emerges as a significant clinical entity only in populations where a sizable percentage of young adults lack immunity to EBV. Thus, IM is unknown among college freshman in Thailand or the Philippines, virtually all of whom have antibody to EBV at the time of admission. On the other hand, in schools in the USA and England, where the susceptibility percentage is in the range of 35% to 50%, infection is seen commonly. In such university settings, approximately 12% of susceptible students become infected with EBV during the freshman year.
Eating Disorders in Adolescence
Authors: Harper Gordon 
Published: December 2021

Eating disorders challenge the pediatrician in several ways. The treatment course can be long, and the patient's response may be frustrating. Patients find it hard to trust professionals (as they find it hard to trust themselves) and present their situation in provocative terms (eg, "I know what I need to eat; the only problem is that my parents are giving me a hard time.") that ignore the cultural, familial, developmental, and physiological roots of the disorders and minimize the patient's own confusion. The impression projected by the patient that she is "in control" can make it hard to view her sympathetically. Being "in control" of an emaciated body or of chaotic eating is part of the problem.
Unpleasant feelings, such as shame, blame, frustration, inadequacy, rage, and guilt, are felt routinely by patients, parents, and professionals. The risk of serious injury or death is great. The differential diagnosis includes many other serious disorders first presenting in adolescence. For all these reasons, the eating disorders are an important part of pediatric practice, and the pediatrician monitoring the patient's physical well-being and overall development is an indispensable part of the team.
The eating disorders are "model" disorders, whose management requires understanding the physical, physiological, psychological, familial, and cultural dimensions of a teenager's life.
INDEX OF SUSPICION
Authors: Falaki Najla N. , Shannon Michael , Policastro Anthony 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 with discussions.
Case 1 Presentation
A 7-month-old boy is brought to your office because of swelling in his neck. He has a history of recurrent ear infections and had tympanostomy tubes inserted 2 weeks ago. Some ear drainage has been noted in the last few days. The child has had a recurrent rash on his face and scalp as well as a stubborn diaper rash that has not responded to nystatin ointment. He has had no fever and has been active and feeding well.
On examination, the child appears healthy, and his temperature is 36.5°C (97.8°F) rectally. There is a seborrhealike maculopapular rash on his forehead and scalp, with some interspersed petechiae; inflamed skin is noted in the perineal area.
The Importance of Amy Lynn
Authors: Menna Vincent J. 
Published: December 2021

Recently I became a grandfather for the first time, certainly not an unusual event. However, the gestation and birth of this little girl made me more keenly aware of my responsibilities and role as a physician and specifically as a pediatrician. Preoccupation with the practice of medicine and life in general may have clouded the memory of my own children as infants.
In clinical residency, we often would distance ourselves emotionally from seriously ill patients by various defense mechanisms; it was difficult to experience children dying and their parents' grief. Too often, we would use terms or expressions that would be abhorrent to the lay public.