bluuebunny/crossref_metadata_2025_split huggingface dataset:
Practice Parameter: The Management of Acute Gastroenteritis in Young Children
Authors:   SUBCOMMITTEE ON ACUTE GASTROENTERITIS,   PROVISIONAL COMMITTEE ON QUALITY IMPROVEMENT
Published: December 2021

This practice parameter formulates recommendations for health care providers about the management of acute diarrhea in children ages 1 month to 5 years. It was developed through a comprehensive search and analysis of the medical literature. Expert consensus opinion was used to enhance or formulate recommendations where data were insufficient.
The Provisional Committee on Quality Improvement of the American Academy of Pediatrics (AAP) selected a subcommittee composed of pediatricians with expertise in the fields of gastroenterology, infectious diseases, pediatric practice, and epidemiology to develop the parameter. The subcommittee, the Provisional Committee on Quality Improvement, a review panel of practitioners, and other groups of experts within and outside the AAP reviewed and revised the parameter. Three specific management issues were considered: (1) methods of rehydration, (2) refeeding after rehydration, and (3) the use of antidiarrheal agents. Main outcomes considered were success or failure of rehydration, resolution of diarrhea, and adverse effects from various treatment options. A comprehensive bibliography of literature on gastroenteritis and diarrhea was compiled and reduced to articles amenable to analysis.
Oral rehydration therapy was studied in depth; inconsistency in the outcomes measured in the studies interfered with meta-analysis but allowed for formulation of strong conclusions. Oral rehydration was found to be as effective as intravenous therapy in rehydrating children with mild to moderate dehydration and is the therapy of first choice in these patients. Refeeding was supported by enough comparable studies to permit a valid meta-analysis. Early refeeding with milk or food after rehydration does not prolong diarrhea; there is evidence that it may reduce the duration of diarrhea by approximately half a day and is recommended to restore nutritional balance as soon as possible. Data on antidiarrheal agents were not sufficient to demonstrate efficacy; therefore, the routine use of antidiarrheal agents is not recommended, because many of these agents have potentially serious adverse effects in infants and young children.
This practice parameter is not intended as a sole source of guidance in the treatment of acute gastroenteritis in children. It is designed to assist pediatricians by providing an analytic framework for the evaluation and treatment of this condition. It is not intended to replace clinical judgment or to establish a protocol for all patients with this condition. It rarely will provide the only appropriate approach to the problem. A technical report describing the analyses used to prepare this parameter and a patient education brochure are available through the Publications Department of the AAP.
Fatal Dog Attacks, 1989-1994
Authors: Sacks Jeffrey J. , Lockwood Randall , Hornreicht Janet , Sattin Richard W. 
Published: December 2021

Objectives. To update data on fatal dog bites and see if past trends have continued.
Design. To merge data from vital records, the Humane Society of the United States, and searches of electronic news files.
Setting. United States.
Subjects. U.S. residents dying in the U.S. from 1989 through 1994 from dog bites.
Results. We identified 109 dog bite-related fatalities, of which 57% were less than 10 years of age. The death rate for neonates was two orders of magnitude higher than for adults and the rate for children one order of magnitude higher. Of classifiable deaths, 22% involved an unrestrained dog off the owner's property, 18% involved a restrained dog on the owner's property, and 59% involved an unrestrained dog on the owner's property. Eleven attacks involved a sleeping infant; 19 dogs involved in fatal attacks had a prior history of aggression; and 19 of 20 classifiable deaths involved an unneutered dog. Pit bulls, the most commonly reported breed, were involved in 24 deaths; the next most commonly reported breeds were rottweilers (16) and German shepherds (10).
Conclusions. The dog bite problem should be reconceptualized as a largely preventable epidemic. Breedspecific approaches to the control of dog bites do not address the issue that many breeds are involved in the problem and that most of the factors contributing to dog bites are related to the level of responsibility exercised by dog owners. To prevent dog bite-related deaths and injuries, we recommend public education about responsible dog ownership and dog bite prevention, stronger animal control laws, better resources for enforcement of these laws, and better reporting of bites. Anticipatory guidance by pediatric health care providers should address dog bite prevention.
Allergic Reactions in Rheumatic Fever Patients on Long-term Benzathine Penicillin G: The Role of Skin Testing for Penicillin Allergy
Authors: Markowitz Milton , Lue Hung-Chi 
Published: December 2021

An injection of 1.2 million U benzathine penicillin G (BPG) every 3 or 4 weeks has proven by far to be the most effective method to prevent recurrences of acute rheumatic fever.1-3 The efficacy of this method of prophylaxis was first demonstrated more than 40 years ago, and since its introduction, it has played a major role in reducing the morbidity and mortality from rheumatic fever.4
Rheumatic fever causes 25% to 40% of all cardiovascular diseases in developing countries.5 Because of the impact of this disease on public health, the World Health Organization (WHO) has helped establish programs for prevention of recurrent attacks of rheumatic fever in many developing countries.6 WHO recommends BPG as the prophylactic drug of choice. One of the problems encountered has been the high drop-out rates among patients enrolled in these programs. Among the reasons for discontinuing prophylaxis is the fear of an allergic reaction.7
The initial study using BPG for the prevention of recurrences of rheumatic fever in children and adolescents reported only 5 (1.2%) mild allergic reactions among 410 patients receiving monthly injections.1 Since then, although rheumatic fever prevention in the United States (U.S.) has consisted almost exclusively of using BPG, there been very few documented reports of serious allergic reactions in rheumatic fever patients on long-term prophylaxis. The only fatalities reported in the American literature occurred in four adults with advanced rheumatic heart disease.8,9
The salutary experience with BPG in the U.S. contrasts sharply with the numerous anecdotal reports of fatal allergic reactions to BPG in many developing countries.
Psychosocial Function During Treatment for Familial Hypercholesterolemia
Authors: Tonstad Serena , Nøvik Torunn Stene , Vandvik Inger Helene 
Published: December 2021

Objective. To determine whether children treated for familial hypercholesterolemia (FH) have greater psychosocial dysfunction compared with their peers.
Children. Children were 86 boys and 66 girls 7-16 years of age attending a lipid clinic. They were screened and instructed to follow a diet low in saturated fat and cholesterol 18 months to 9 years earlier (mean, 4 years), and their mean dietary intake, estimated by a quantitative food frequency questionnaire, was within recommended limits. One-fourth had lost a parent or had a parent who had had cardiovascular disease due to FH (parental disease group).
Methods. Results of the Child Behavior Checklist, Teacher's Report Form, and Youth Self-Report were compared with a population sample. A semistructured interview, the Child Assessment Schedule, was administered to the children with FH and a well-functioning comparison group from the population (epidemiologic cohort; n = 62).
Results. Psychosocial scores were similar in the children with FH and the population sample. The Child Assessment Schedule showed that, compared with the epidemiologic cohort, children with FH did not have increased symptoms in any area of function, and scores for family, mood, and expression of anger were lower (less symptomatic). The prevalence of psychiatric diagnoses was 10%, which was not greater than expected. Children from the parental disease group had higher symptom scores in the areas of school and expression of anger than the rest of the children with FH. Their mean Children's Global Assessment Score (CGAS, which gives average children scores of 70-79) was slightly lower (77 vs 79). Belonging to the parental disease group predicted a lower CGAS in multivariate regression analyses, as did male sex, parental divorce, and low parental educational level. These factors explained up to 19% (95% confidence interval, 9%-31%) of the variance in CGAS.
Conclusions. We found that the prevalence of psychosocial dysfunction was not greater than expected in children treated for FH. Psychosocial function within the group was associated with the usual demographic characteristics and with the loss or disease of a parent, beyond the period of bereavement or immediately after the event.
THE RELATIONSHIP BETWEEN PARENTAL AND CHILDREN'S SERUM IMMUNOGLOBULIN E (IgE) AND ASTHMA
Authors: Galant Stanley P. 
Published: December 2021

Purpose of the Study. To examine parental factors that influence bronchial asthma and immunoglobulin E (IgE) levels in their children.
Methods. The data in this study were derived from the Tucson Epidemiological Study of Airways Obstructive Diseases since 1972. Eleven evaluation periods have been performed since that time. Asthma histories were established by questionnaire. IgE levels were obtained in 738 children, 1043 fathers, and 1261 mothers. IgE levels were determined by paper radioimmunosorbent (PRIST) technique. IgE Z scores were established. An IgE Z score is the number of standard deviations IgE differs from matched age and sex-matched subjects and log corrected. Skin tests were performed by prick technique to house dust, mold, grass, tree and weed mix and appropriate controls.
Results. The percentage of children with bronchial asthma increased with the presence of asthma in parents so that 11.5% of children with asthma occurred in families with no parental asthma compared with 48.6% when both parents had asthma. The rate of childhood bronchial asthma was significantly related to parental IgE levels only when the mother and father had bronchial asthma (43% vs 20%) and much less so (22% vs 10%), when there was no parental asthma. In addition, asthma in the child proved to be a highly significant determinant of the child's IgE Z score, even after correcting for parental IgE Z score. The presence of atopy (ie, positive skin tests) was also not a significant determinant of IgE levels in asthmatic children.
Discussion. The authors conclude that the inheritance of IgE is only one factor related to the development of asthma, and is limited as a predictor.
Early Diagnosis of Coarctation of the Aorta in Children: A Continuing Dilemma
Authors: Ing Frank F. , Starc Thomas J. , Griffiths Sylvia P. , Gersony Welton M. 
Published: December 2021

Because late repair of coarctation of the aorta (COA) is associated with premature cardiovascular disease in adult life, early detection and treatment is important.
Objectives. To determine the timing of referral to see whether early detection of COA has improved in the past decade, to evaluate the pattern of and reasons for medical center referral, and to assess the clinical signs relating to the diagnosis of COA.
Methods. The records of 50 consecutive patients older than 1 year who had surgical repair of COA from 1980 to 1990 were reviewed. The age of referral, pattern of referral, and presence of standard clinical signs of COA were analyzed, and data were compared with those from the previous decade.
Results. The mean and median ages at referral were 8.4 and 5.8 years, respectively. Pediatricians accounted for 64% of the referrals. A specific diagnosis of COA was made in 2 (4%) of 50 patients before referral to a pediatric cardiologist. The most consistent clinical findings were a cardiac murmur and a systolic blood pressure gradient between the arms and legs of greater than 10 mm Hg, which were both present in all patients. Lower-extremity pulses were decreased in 37 (74%) and absent in 9 (18%). Forty-seven children (94%) had upper-extremity hypertension (&gt;95th percentile for age); 25 (50%) had systolic blood pressure higher than 140 mm Hg. COA would have been missed in 82% of children if absent lower-extremity pulses were required as a diagnostic feature. These findings were similar to those reported by our institution in the previous decade, suggesting that early detection has not improved.
Conclusions. The timing of, reasons for, and sources of referral for COA in this study, compared with data from the previous decade, indicate no improvement in early detection of COA by pediatricians. Screening all children for COA by routinely measuring upper- and lower-extremity blood pressures during at least one physical examination after the newborn period is mandatory.
Pediatric Locum Tenens Provided by an Academic Center
Authors: Poole Steven R. , Efird Deb , Wera Tom , Fox-Gliessman Deb , Hill Kathryn 
Published: December 2021

Background. Locum tenens, the use of a substitute physician to replace a physician who must be temporarily absent from his practice, is widely accepted in the United States. Locum tenens has not previously been described or studied in pediatric practice.
Objective. This article describes a locum tenens service for Colorado and Wyoming pediatricians provided by the Division of General Pediatrics and Pediatric Emergency Medicine at the University of Colorado School of Medicine and the Children's Hospital of Denver. An analysis and an evaluation of the program are presented, and implications are discussed.
Methods. All program data were prospectively collected and tabulated and later analyzed for the period from July 1, 1994, through June 30, 1995. A survey of all physicians using the Pediatric Locum Tenens Service was conducted within 2 months of service to evaluate the program and to refine the orientation, credentialing, and evaluation processes.
Results During the year, 35 pediatricians (14% of pediatricians in Colorado and Wyoming) made 97 requests for 398 days of locum tenens coverage. Coverage was used for vacation (85%), medical education (10%), medical leave (3%), and family matters (2%). Solo and rural pediatricians used the service at a higher rate than pediatricians in group or urban practices. Eighty-six percent had never used locum tenens coverage before because of either the expense (67%) or their unwillingness to trust their practices to physicians or services with whom or with which they were unfamiliar (50%). The majority (83%) were willing to pay an amount for locum tenens equal to the net income derived from the locum tenens coverage in the practice. None indicated a willingness to pay more than that. Referrals and admissions to the Children's Hospital from the pediatricians who used the service increased by 22% during the study period compared with the preceding year, whereas referrals and admissions increased by 9% among all other colorado and Wyoming pediatricians. All pediatricians completed surveys, and satisfaction with the locum tenens pediatricians, charges, and program administration was high. Their suggestions are described.
Discussion. The following topics are discussed: (1) the economics of pediatric locum tenens; (2) the use of a locum tenens service as a physician relations program by children's hospitals or academic departments of pediatrics; (3) guidelines for orientation of locum tenens pediatricians; and (4) a proposed evaluation and credentialing process for locum tenens physicians.
Apolipoprotein E Polymorphism and Serum Lipids in a Randomized, Prospective Trial of an Infant Diet With Reduced Saturated Fat and Cholesterol
Authors: Lapinleimu Helena , Viikari Jorma , Rönnemaa Tapani , Välimäki Ilkka , Tuominen Juhani , Marniemi Jukka , Ehnholm Christian , Jokinen Eero , Simell Olli 
Published: December 2021

Background. The inherited apolipoprotein E (apoE) phenotype may determine effectiveness of dietary atherosclerosis prevention. This study analyzes the effects of apoE phenotypes on changes in serum lipid concentrations in a 6-month prospective, randomized trial of a low-saturated-fat, low-cholesterol diet in infancy.
Patients and Methods. One thousand sixty-two healthy infants were randomized to intervention and control groups at the age of 7 months. Counseling was provided to the intervention families when the children's ages were 7, 8, and 10 months. Dietary goals were the child's intake of energy ad libitum, fat at 30% to 35% of energy, cholesterol at less than 200 mg/d, and saturated, monounsaturated, and polyunsaturated fatty acids at a 1:1:1 ratio. Control families consumed an unrestricted diet. The apoE phenotype of 846 of the infants was determined; serum lipid and lipoprotein concentrations were measured at 7 and 13 months of age; and nutrient intakes were analyzed using 3-day food records at 8 and 13 months of age.
Results. At 7 months of age, serum cholesterol concentration was higher in apoE4-positive infants (E2/E4, E3/E4, and homozygous E4) than in apoE4-negative infants (159 ± 31 mg/dL [4.10 ± 0.81 mmol/L] vs 150 ± 29 mg/dL [3.89 ± 0.74 mmol/L]). The high-density lipoprotein cholesterol concentration was slightly lower in apoE4-positive infants than in apoE4-negative infants (34 ± 8 mg/dL [0.88 ± 0.20 mmol/L] vs 35 ± 7 mg/dL [0.91 ± 0.19 mmol/L]). Between 7 and 13 months of age, the serum cholesterol concentration in infants in the intervention group was unchanged, apoB concentration increased slightly, and apoAl concentration decreased. In the control infants, serum cholesterol concentration increased 9 ± 25 mg/dL (0.24 ± 0.65 mmol/L), apoB concentration increased markedly, and apoAl concentration was stable. Changes in serum lipid and apo concentrations that resulted from the dietary intervention were independent of the apoE phenotype.
Conclusions. The apoE phenotype influenced serum cholesterol concentration markedly by 7 months of age. Between the ages of 7 and 13 months, a reduced saturated fat and cholesterol diet effectively prevented the ageassociated increases in serum cholesterol and non-highdensity cholesterol concentrations that were obvious in the control infants. The effects of the diet occurred in the infants independently of the apoE phenotype.
Idiopathic Disseminated Bacillus Calmette-Guérin Infection: A French National Retrospective Study
Authors: Casanova Jean-Laurent , Blanche Stéphane , Emile Jean-François , Jouanguy Emmanuelle , Lamhamedi Salma , Altare Frédéric , Stéphan Jean-Louis , Bernaudin Françoise , Bordigoni Pierre , Turck Dominique , Lachaux Alain , Albertini Marc , Bourrillon Antoine , Dommergues Jean-Paul , Pocidalo Marie-Anne , Le Deist Françoise , Gaillard Jean-Louis , Griscelli Claude , Fischer Alain 
Published: December 2021

Objective. Disseminated bacillus Calmette Guérin (BCG) infection after inoculation of live vaccine is considered to result from impaired immunity of the child. However, in half of the cases, regarded as idiopathic, no well-defined immunodeficiency condition can account for the infection. The objective of the present study is to report the prevalence, clinical features, associated infections, and outcomes of children with idiopathic disseminated BCG infection.
Design. National retrospective survey during the period from 1974 through 1994 in France.
Setting. All neonatology and pediatrics units in primary care and referral centers throughout France.
Patients. Data were collected from 595 (82%) of 721 units, 377 (93%) of 407 centers, and 320 (93%) of 345 cities. Selection criteria included BCG infection, dissemination to at least two areas beyond the inoculation site, and no well-defined immunodeficiency condition. Sixteen children (8 girls and 8 boys), born to families unrelated to each other but often consanguinous (5 of 16), satisfied the criteria; children were born in France (11 of 16) or abroad (5 of 16).
Results. The minimal prevalence rate was estimated at 0.59 cases per 1 million vaccinated children born in France. Clinical features included fever and cachexia, disseminated BCG infection to lymph nodes (15 of 16), skin (13 of 16), soft tissues (11 of 16), lungs (11 of 16), spleen (11 of 16), liver (11 of 16), and bones (9 of 16). Eight children had associated or subsequent severe opportunistic infection (50%), with either nontyphi Salmonella enterica serotypes (7 of 16) or Mycobacterium abscessus (1 of 16). The outcome was poor: 8 children (50%) died; the cause of death was BCG infection for most children (7 of 8); 8 survived until the last follow-up (50%).
Conclusions. Idiopathic disseminated BCG infection is a rare but severe complication of BCG vaccination. The infection probably results from an as yet unknown genetically determined immunodeficiency condition that affects the killing of intracellular bacteria such as BCG and Salmonella.
Spanking and Triage
Authors: Colvard Karen 
Published: December 2021

There is not much about corporal punishment in this article, but I understand that Dr Chamberlin argues, by omission, that spanking is only a bit player in the complex interplay of risks that threaten the future development of a child. A concerned society will do what it can broadly to increase the information and practical support available to families, which might prevent a variety of problems created or exacerbated by upbringing and experiences in childhood. One question for this meeting is: would the American Academy of Pediatrics be contributing to this broad mandate for prevention with a statement that focuses on spanking or other mild punishment, or does attention to a small problem draw attention from big problems that urgently need action?
I agree with Dr Chamberlin's argument for providing comprehensive services to all members of a community rather than targeting high-risk groups, except that I think his goals impractical given limitations on public funds for social services. How should we spend the small amount of public money available for the welfare of children?
Five to eight percent of all children have a temperamental problem with aggression; some 80% of boys growing up in poor, marginalized neighborhoods in US inner cities will be arrested for a violent crime before age 18. These data do not describe the same problem. We have heard several references in presentations here to the exceptional violence of US society and reports of studies that relate spanking to criminal violence in adulthood. Our cities do not have a patent on violence, and children everywhere deserve protection from abuse.