bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Yellow Flag is Still Up
Authors: Krugman Richard 
Published: December 2021

Several years ago, I wrote an editorial entitled "It's Time to Wave the Yellow Flag."1 The metaphor was to automobile racing, where a yellow flag is waved following a crash. Drivers are "cautioned," hold their places, but keep moving. The impetus for that editorial was the increasing criticism the child protection system was coming under for both failing to protect children who were being "killed" with "open cases" and for being too intrusive and violating family rights on the basis of "false reports."
I was reminded of that editorial recently, when Pediatrics in Review published the Carol Berkowitz review on "Child Sexual Abuse."2
Consultation with the Specialist
Authors: Harris J. Peter 
Published: December 2021

Introduction
As many as 90% of children will have an audible heart murmur at some point in time. However, the prevalence of nontrivial heart disease in this age group is less than 4 per 1000. The practitioner's task is to distinguish the ubiquitous innocent or normal murmur from the murmur indicating heart disease. Normal murmurs include vibratory and pulmonary flow murmurs, venous hums, carotid bruits, and the murmur of physiologic branch pulmonary artery stenosis. Mislabeling of a normal murmur as pathologic may have adverse psychological effects on the family and the child, including unwarranted exercise restrictions and problems later with insurability and employment. Alternatively, failure to identify a pathologic murmur may delay appropriate intervention, especially in early infancy. Recent well-publicized sudden cardiac deaths of professional athletes have augmented the anxiety caused by the specter of heart disease in the young.
Because less than 5% of heart murmurs in children denote cardiac pathology and because each practitioner is likely to see no more than five patients per year who have important heart disease, distinguishing normal from organic murmurs is not always simple. Nevertheless, given the high prevalence of murmurs in the young and because nearly 50% of the patients who have murmurs referred to pediatric cardiologists do have underlying heart disease of variable severity, most clinicians can recognize normal murmurs.
Migraine Headaches in Children
Authors: Singer Harvey S. 
Published: December 2021

Headache, especially migraine, is a common medical complaint that has confounded physicians since ancient times. Hippocrates, about 500 BC, is credited with describing symptoms we now associate with migraine. Galen, a Greek physician in the second century AD, recognized the unilateral feature of these headaches and coined the term "hemicrania." Migraine is a French word that was derived from the Latin term for hemicrania.
In the US it is estimated that 8.7 million females and 2.6 million males suffer from disabling migraine. The occurrence of migraine is greatest in adulthood, but this disorder is one of the most common causes of headache in children as well. In a 14-year longitudinal study of more than 9000 school children, Billie reported that 5% had had migraine attacks by 15 years of age. A recent population-based study in Olmsted County, Minnesota, suggests an even greater incidence in this age range. For example, the highest incidence of newly diagnosed migraine headaches appearing in males, 246 per 100 000 person-years, occurred in those aged 10 to 14 years.
This review is directed toward the identification, classification, pathophysiology, and management of migraine in children and adolescents. Readers are referred to several recent articles for more general discussions of chronic recurrent headaches in childhood (see Suggested Reading).
Insulin-dependent Diabetes Mellitus
Authors: Plotnick Leslie 
Published: December 2021

Insulin-dependent diabetes mellitus (IDDM) is a chronic, serious disease in children and adolescents. Its diagnosis is straightforward and rarely subtle. The major challenges of this disease for the child, family, and health-care team involve long-term management of medical and metabolic factors as well as psychological and behavioral concerns. While developments in the past 10 to 15 years have made metabolic control technically possible, psychological stresses and behavioral problems often interfere with metabolic goals. There are few, if any, other diseases that require such intensive and extensive self-care skills.
Definitions
Diabetes generally is classified in two types. Type I, or IDDM, is seen mostly in younger people (children and adolescents). It previously was called juvenile onset or ketosisprone. Insulin deficiency characterizes IDDM, and patients need exogenous insulin for survival. Type II, or non-IDDM (NIDDM), previously called adult or maturity onset, is the type seen most commonly in older people and in obesity and is not discussed in this review.
To make a diagnosis of diabetes, a child must have either classic symptoms with a random plasma glucose above 200 mg/dL or specific plasma glucose levels before and after a standard glucose load if asymptomatic. The diagnosis of IDDM usually is clear-cut.
Consultation with the Specialist
Authors: Seidel James 
Published: December 2021

Achieving vascular access in infants and children is often a challenge for emergency medical technicians, nurses, and physicians. It is a vital intervention in the critically ill or injured child and is necessary for infusing medications and fluids and obtaining blood samples for laboratory analysis. It often takes more than 10 minutes to achieve venous access during pediatric resuscitation. The presence of subcutaneous fat, the small size of peripheral vessels, vasoconstriction, and the behavior of anxious and frightened infants and children often are barriers to successful intravenous line placement. Other factors that may affect success include: 1) the skill of the person performing the procedure, 2) immobilization of the patient and/or extremity, 3) the availability of small over-the-needle catheters, 4) the availability of all materials necessary to secure the line, and 5) the site of catheter placement.
Critically ill or injured pediatric patients need rapid vascular access. Health-care providers, therefore, must understand the priorities for obtaining access to a vein. Peripheral venous access is a satisfactory route for infusions, but no more than 1 to 2 minutes should be spent attempting to establish peripheral intravenous access in ill or injured patients. A reasonable approach to vascular access in these patients is as follows: 1) Attempt peripheral access for 1 to 2 minutes
Head Trauma in Children
Authors: Goldstein Brahm , Powers Karen S. 
Published: December 2021

Head injury, either alone or in association with multiple other injuries, is extremely common. The initial assessment and management of children who have a head injury is an important topic for all pediatricians.
Epidemiology
Table 1 lists definitions of minor, moderate, and severe head injuries as determined by the initial neurologic presentation. The most common method to assess a child's neurologic status initially is to assign a score based on the Glasgow Coma Scale (GCS). The GCS is determined by eye opening and best verbal and motor responses (Tables 2 and 3). Mild-to-moderate head injuries are far more common than severe injuries in the pediatric population. More than 90% of children requiring admission to a hospital following head injury have a GCS score of 13 to 15; severe head injury (GCS≤ 8) accounts for approximately 5% of admissions.
Motor vehicle accidents, bicycle accidents, falls, sporting accidents, assaults, and child abuse are the most common causes of pediatric head injury. Despite a significant reduction in the number of pediatric fatalities due to implementation of the 55 mile/hour speed limit, motor vehicle accidents still result in a large number of hospital admissions and deaths each year. Many of these accidents are associated with drug or alcohol abuse.
Hypothyroidism
Authors: Fisher Delbert A. 
Published: December 2021

Thyroid Development
THYROID HORMONE SYNTHESIS AND CONTROL
Thyroid hormones (TH) are critical for normal growth, development, and metabolism during infancy and childhood. They are synthesized by the thyroid gland follicular cells, the function of which is to concentrate iodide from the blood and return it to peripheral tissues in a hormonally active form. The thyroid cell iodide-concentrating mechanism, often referred to as the iodide pump, confers on the gland its ability to concentrate iodide to many times its level in plasma. The steps involved in synthesis and release of TH include: 1) iodide trapping by the thyroid gland; 2) synthesis of thyroglobulin; 3) organification of trapped iodide as iodotyrosines (monoiodotyrosine, MIT, and diiodotyrosine, DIT); 4) coupling of the iodotyrosines to form the iodothyronines thyroxine (T4) and triiodothyronine (T3) and storage in follicular colloid; 5) endocytosis of colloid droplets and hydrolysis of thyroglobulin to release MIT, DIT, T4, and T3; and 6) deiodination of MIT and DIT with intrathyroidal recycling of the iodine.
The concentration of iodide in plasma under normal circumstances is less than 0.2 µg/dL. The iodide is removed from plasma almost entirely by the kidney and the thyroid gland. Transport of iodide across the thyroid cell membrane is the first and ratelimiting step in TH biosynthesis.
Hemangiomas
Authors: Wahrman Julie E. , Honig Paul 
Published: December 2021

The lack of standardized terminology has been a significant obstacle to a clear understanding of vascular lesions. Although the classic hemangioma undergoes involution with time, the term hemangioma has been used generically to include various vascular lesions, such as port-wine stains or venous malformations. Hemangiomas differ significantly from these other vascular lesions with regard to their clinical and histologic characteristics as well as long-term prognosis.
In 1982, Mulliken and Glowacki published a classification scheme that simplified the nomenclature of vascular anomalies. It is based on the cellular biology and natural history of these lesions. The authors divide vascular birthmarks into two groups: hemangiomas and vascular malformations.
Definitions
HEMANGIOMAS
Hemangiomas are defined as benign neoplasms composed of proliferative and hyperplastic vascular endothelium. They are dynamic lesions that demonstrate rapid postnatal growth followed by slow involution. Resolution is associated with diminished cellularity and fibrosis.
Hemangiomas are subdivided into three types: superficial, deep, and mixed. Superficial hemangiomas, otherwise referred to as capillary or strawberry hemangiomas, lie in the papillary (upper) dermis. Deep lesions, also called cavernous, hypodermal, or subcutaneous hemangiomas, lie in the reticular (lower) dermis, fat, and muscle. Hemangiomas also may be mixed, having both superficial and deep components. Whether capillary hemangiomas differ histologically from cavernous lesions is controversial.
Atopic Dermatitis
Authors: Lapidus Candace S. , Honig Paul J. 
Published: December 2021

Introduction
Atopic dermatitis, also referred to as atopic eczema, infantile eczema, allergic eczema, disseminated neurodermatitis, and prurigo Besnier, is a common and important cause of morbidity in children of all ages. A total of 22% of patients seen in pediatric dermatology clinics have atopic dermatitis. In 1969, Wingert et al reported that 4% of pediatric emergency room visits at the Los Angeles County General Hospital were due to atopic dermatitis, and this did not include patients seen for impetigo, a common complication of atopic dermatitis. The prevalence of atopic dermatitis in the pediatric population has increased over the past 3 decades from 3% to 10%, and it appears to be even higher in heavily populated urban areas. Pediatricians, therefore, must understand its pathogenesis and management.
Epidemiology
Sixty percent of children who have atopic dermatitis manifest their disease in the first year of life; 90% do so by age 5 years. A genetically prone individual may not manifest the disease until exposed to a particular environmental situation. Onset has been associated with relocation from a rural to an urban location or from a region of high to low humidity.
The course of adopic dermatitis is difficult to predict, although one 15-year longitudinal study revealed that the disease persisted in 60% of cases.
Consultation with the Specialist
Authors: Pakula Lawrence C. 
Published: December 2021

A variety of children's behaviors are distressing to parents and often very difficult to manage. These can include biting, temper tantrums, breath-holding spells, and hitting.
Biting
Biting often is the first behavior that provokes major concern and a demand for solutions. The same child who might be excused for hitting may well end up isolated from peers and at risk of being barred from child care for biting. The situation is aggravated by increased parental fears of infection (acquired immunodeficiency syndrome, hepatitis, tetanus, rabies).
The initial biting episode often occurs when the child is teething, with parents being the first bitten; they mistakenly may think it is a cute game. A typical scenario is when one child wants the toy of another and bites in frustration. Many parents do not respond until the possibility of penalties that affect them arise. All adults must be encouraged to have a rule that interrupts the behavior with a strong "No, we never bite people because it hurts them," which can be extended to include pets and stuffed animals. With children in this age group, longer, more complex explanations only provide additional attention and reward behavior that you are trying to stop. Interruption and prevention before the biting occurs is important.
Conversion and Somatization in Pediatrics
Authors: Hodgman Christopher H. 
Published: December 2021

Although conversion disorder rarely is diagnosed formally in ordinary pediatric practice, busy pediatricians often do encounter the phenomenon of conversion. Conversion is the experiencing of unacceptable emotional conflicts as symptoms, usually but not always physical, rather than as mental events. Conversion is commonplace, affecting almost all body systems. It must be recognized and managed appropriately early in its course, lest inappropriate evaluations and treatments occur; in addition to their other costs, such unnecessary procedures may introduce the child inadvertently to such symptomatization as a life-long pattern of behavior. More than a century ago, Briquet recognized that at least 50% of adult "professional patients" begin their symptomatic careers before puberty; thus, inappropriate care of the young patient who has conversion symptoms may have serious, long-lasting consequences.
Problems in Diagnosing Conversion
The traditional diagnostic elements of conversion often are difficult to demonstrate in pediatric practice. Almost all are either not specific to conversion or hard to confirm in young patients for reasons of developmental immaturity. These "standard" elements include the following:
• Stress or conflict preceding symptoms (true of many illnesses)
• Unconscious symptom production outside the patient's awareness (thus often inaccessible to the pediatrician)
• A model for the symptom (either unverifiable or prone to observer bias)
• Primary gain or relief of underlying conflict (again, difficult to confirm)
Therapeutic Uses of Intravenous Immunoglobulin (IVIG) in Children
Authors: Ramesh Sujatha , Schwartz Stanley A. 
Published: December 2021

Introduction
HISTORY
Immunologists have been aware of the existence of protective humoral substances in the serum of patients after an infectious episode for a long time. Serum harvested from large animals after their immunization with specific pathogens was injected into humans for the prophylaxis and treatment of serious infections. The concept of immunoglobulin (also called gamma globulin) therapy originated from these early experiments. Subsequently, Paul Ehrlich produced antitoxin to diphtheria in 1897. To avoid complications such as serum sickness with the use of animal serums, attempts were made to concentrate the antibody-containing fractions of human serum. In 1936, placental immunoglobulin samples were used for prophylaxis of measles. In 1952, Bruton recognized that an 8-year-old child who had serious recurrent infections despite conventional therapy was incapable of making significant quantities of immunoglobulin. This was the first time primary immunodeficiency was diagnosed and treated successfully with intramuscular immunoglobulin. Since then, and until 1981, intramuscular gamma globulin or, alternatively, fresh frozen plasma has been the mainstay of treatment of hypogammaglobulinemia and other primary immune deficiencies. In 1981, intravenous immunoglobulin (IVIG) became available commercially in the United States.
The advantages of IVIG over intramuscular gamma globulin are: 1) administration is relatively painless; 2) higher doses can be given, resulting in rapid achievement of therapeutic levels, because volume is not a limitation: 3) its absorption is good: 4) it does not undergo local degradation during infusion; and 5) it does not aggregate and activate complement.
Consultation with the Specialist
Authors: Lovejoy Frederick H. , Woolf Alan D. 
Published: December 2021

Two particularly relevant questions frequently asked by pediatricians about caustic ingestions by children are: 1) What signs and symptoms are common with a caustic ingestion, and can esophageal injury occur in the absence of mouth burns? and 2) When should the patient be referred to the surgeon for endoscopy to confirm a corrosive ingestion?
Signs and Symptoms
Approximately 53 000 corrosive exposures occur yearly in the United States. The Federal Hazardous Substances Act and the Poison Prevention Packaging Act of 1970 requires that corrosive agents that have concentrations of active ingredients greater than 10% be sold in child-resistant containers. This has done much to reduce the frequency and severity of signs and symptoms of corrosive ingestions. The child may lick or take only several swallows of a corrosive liquid compared with an adolescent purposefully ingesting a corrosive, who may consume a larger amount. The lips, oral mucosa, tongue, pharynx, esophagus, and stomach all may be affected. Other areas, such as the eyes, larynx, and/or respiratory tract, also may be exposed to the corrosive agent.
Many infants and children who have a history of ingesting a corrosive recently are without signs and symptoms. However, others have clear signs of injury, including pain on swallowing, drooling, excessive salivation, and inability or refusal to drink. Examination of the mouth shows edema, inflammation, or whitish areas.
Erythema Infectiosum (Fifth Disease)
Authors: Stiefel Laurence 
Published: December 2021

Erythema infectiosum (EI), also known as fifth disease, is one of the most common childhood exanthems. The condition first was described by Tschamer in 1889 and initially was thought to be a manifestation of rubella. It is seen most often in children ages 4 to 15 years and has peak incidences in winter and spring. It can present in focal outbreaks or in community-wide epidemics, which can last from 3 to 6 months. Infection rates of 20% to 50% have been noted in families and classrooms.
The condition was termed fifth disease because of the numerical designation it originally was given (following measles, scarlet fever, rubella, and Filatov-Dukes disease, now regarded as a mild atypical form of scarlet fever).
Autism and the Pervasive Developmental Disorders: Part 1
Authors: Bauer Stephen 
Published: December 2021

Introduction
It has been just 50 years since the syndrome of autism was named and described by Leo Kanner. In 1943, he wrote about a small group of children in his child psychiatric practice who shared clinical characteristics of extreme social isolation, severe language abnormalities, and unusual responses to their environment. Since that time, many earlier concepts have given way to a newer, biologically based understanding of autism as a developmental disability that has an underlying neurologic basis. An expanding body of research has revealed insights into the broad clinical range of autism, the possible nature of the underlying defects, and useful approaches to helping children who have the disorder.
Autism also has become part of the public consciousness. Television talk shows frequently feature autism-related topics, and autobiographies by adults who have autism have become best sellers (see Grandin and Williams on the Resources list). Perhaps the event that most solidified autism as a subject of popular interest was Dustin Hoffman's portrayal of Raymond Babbitt, a young adult who had high functioning autism, in Barry Levinson's 1988 film Rain Man.
Once considered to be encountered only rarely in practice, autism now is thought to be part of a spectrum of related conditions that are much more common than previously thought.
INDEX OF SUSPICION
Authors: Dover Arthur S. , Love Barry A. , Khanfar Nasha't M. 
Published: December 2021

This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page.
We invite readers to contribute case presentations and discussions.
Case 1 Presentation
A 7-year-old girl is admitted to the hospital because of 9 days of gastrointestinal illness with fever. Her illness began with watery green diarrhea that has persisted. She has had several stools each day: no pus, blood, or mucus has appeared in the stool. She has been vomiting up to six times a day, with bile noted in the vomitus at times. Abdominal pain has been present almost constantly from the onset. The pain has been generalized except for intermittent periods of right-sided lower abdominal, groin, and leg discomfort. Fever in a daily spiking pattern and chills have occurred since shortly after her illness began. She has complained of a frontal headache and has had a mild cough.
Pneumococcal Vaccine
Authors: Peter Georges , Klein Jerome O. 
Published: December 2021

Streptococcus pneumoniae, commonly termed the pneumococcus, is a major pediatric pathogen both in developed and developing countries. Despite the availability of multiple antimicrobials to which this organism is susceptible, it continues to cause significant morbidity and mortality. Recognition of the limitations of antimicrobial therapy in controlling the consequences of infection, particularly among high-risk persons such as those who have underlying pulmonary or cardiovascular disease and the elderly, led to the introduction in the 1970s of a polyvalent, polysaccharide pneumococcal vaccine. As a result, the current indications for vaccination of both children and adults are based on risk factors for severe, potentially life-threatening pneumococcal infections and, in the case of children, the age-related immunogenicity of the polysaccharide antigens of this vaccine. Appropriate use of this vaccine is facilitated by knowledge of the pathogenicity of S pneumoniae, epidemiology of the infections it causes, and the immunogenicity and efficacy of the vaccine.
The limitations of the current pneumococcal vaccine not only affect management of vaccinated patients but also have prompted development of investigational vaccines for use among infants and young children. Polysaccharide-protein conjugate pneumococcal vaccines that have increased immunogenicity in infants are in clinical trials and will be discussed only briefly in this review.