bluuebunny/crossref_metadata_2025_split huggingface dataset:
Reader's Comments and Questions
Authors: H R. J. 
Published: December 2021

I treasure comments such as these which readers send with their self-assessment sheets, because it is one of the few ways we have of knowing how well we serve them. I will be grateful if even more of you will send in your responses. But let me answer a few of the questions raised by readers:
Are the articles in Pediatrics in Review too long, too short, too complicated, too simple? Such questions are not easy to answer. We seek to provide a mixture of articles. Abstracts, which some readers believe are too short and simple because they do not explain the complexities of most of modern medicine, are used to address specific educational objectives, usually developed as part of the Recent Advances objectives.
Diabetic Ketoacidosis in Children and the Role of Outpatient Management
Authors: Chase H. Peter , Garg Satish K. , Jelley David H. 
Published: December 2021

Diabetic ketoacidosis (DKA) is a common complication among children with diabetes, accounting for 14% to 31% of all diabetes-related hospital admissions.1,2 Extrapolation of data from the National Commission on Diabetes3 suggests that there are approximately 160 000 admissions to private hospitals each year in the United States for DKA. The cost of hospitalizations for DKA is over one billion dollars annually. Sixty-five percent of all patients admitted are less than 19 years of age. The incidence of DKA is believed to be declining. However, because the numbers of subjects with insulin-dependent diabetes mellitus is increasing, the absolute number of hospitalizations for DKA is still increasing. It is the single most common cause of death in diabetic patients under 24 years of age.2
The treatment of DKA has changed in recent years, particularly with the use of low-dose continuous intravenous insulin infusion and with the availability of blood pH levels. Severe DKA has been defined as "a state of ketoacidosis with serum bicarbonate decreased to 10 mmol/L or less," or more recently, as a "pH of 7.1 or less."4 The mortality from DKA has been reported to be in the range of 0.5 to 15.4%.3,5 Previous mortality figures were as high as 38%.2
Hypospadias
Authors: Duckett John W. 
Published: December 2021

Hypospadias results in various degrees of deficiency of the urethra, corpus spongiosum, and corpora cavernosa. The fibrous tissue that causes ventral curvature replaces Buck fascia and dartos fascia. The skin on the ventral surface may be thin; the prepuce is deficient ventrally and forms a dorsal hood over the glans.
As a rule, the location of the meatus does not cause significant obstructive urinary symptoms, although ventral deflection of the stream of urine commonly occurs. When the meatus is more proximal, the stream flows straight downward or backward, requiring the patients to urinate ad modum feminarum. Uncorrected, the curvature of the penis is likely to cause painful erections and result in severe psychologic consequences.
INCIDENCE/GENETICS
The incidence of hypospadias is about 1 in every 300 male children. If minor degrees of hypospadias are included, this incidence may be as high as 1 in 125 male births. If 1 848 500 male births occur in the United States, we should see 6200 hypospadias cases each year.
The risk of occurrence in an infant is 8% if his father has hypospadias and 14% if a sibling has the condition; if two members of the same family have hypospadias, the risk is about 21%.
The cause of hypospadias is still unknown.
Obesity in Childhood
Authors: Rosenbaum Michael , Leibel Rudolph L. 
Published: December 2021

It is estimated that as many as 25% of children and 30% of adults in the United States are obese. Clinicians need little reminding of the intractable nature of this disorder and the need for more effective and long-lasting therapies, Obesity in childhood may lay the foundation of the degenerative cardiovascular diseases that may or may not be grossly evident until adulthood. Obese children manifest many of the same disturbances (eg, hyperinsulism, hyperlipidemia, and hypertension) as obese adults. Tracking studies of obesity, hypertension, and serum lipid values from childhood to adulthood have indicated that these variables track well, ie, that the obese, hypertensive, hyperlipidemic child is likely to remain obese, hypertensive, and hyperlipidemic throughout many years. The observation that hyperlipidemia, obesity, and other factors associated with an increased risk of subsequent cardiovascular disease that are noted in childhood tend to persist into adulthood emphasizes the importance of screening in selected children to identify those at risk for subsequent morbidity. Pediatricians should recognize obesity as a significant disease entity with both immediate and long-term consequences.
DIAGNOSTIC CRITERIA FOR OBESITY IN CHILDREN
Obesity is a maladaptive increase in the amount of energy stored as fat. "Optimal" body fat stores for a given individual depend upon factors such as age, intercurrent health, genotype, and environment.
Biliary Atresia
Authors: Wanek Elizabeth A. , Karrer Frederick M. , Brandt Carlos T. , Lilly John R. 
Published: December 2021

Biliary atresia is a pathologic entity in which there is obliteration of some portion of the extrahepatic bile ducts. In the past, occlusion of the proximal ducts (at the liver hilus) was referred to as "noncorrectable" (Fig 1). If only the distal duct is occluded (and the proximal duct is patent), the lesion was referred to as "correctable." The distinction is academic because current treatment and prognosis are identical. The disease is panductular, ie, both extrahepatic and intrahepatic ducts are involved. Early in the disease, however, occlusion is complete only in the extrahepatic system. Without intervention, intrahepatic biliary obstruction and, subsequently, cirrhosis supervene.
In the past, except for a few cases of the correctable variant, surgical procedures were unsuccessful until Morio Kasai performed a hepatic portoenterostomy, which was first reported in English in 1968. Bile flow was effectively reestablished in both correctable and noncorrectable forms of biliary atresia. The operation was only successful when done before the patient was 4 months of age. Subsequent confirmation of Kasai's results were reported throughout the world.
ETIOLOGY/PATHOLOGY
Biliary atresia was originally thought to be a congenital malformation. Careful histopathologic examination of excised surgical specimens indicate that this is not the case; instead, the disease is a dynamic, progressive panductular sclerotic process that may continue in the intrahepatic ducts even after surgical relief of biliary obstruction.
Urinary Tract Infections in Infants and Children
Authors: Feld Leonard G. , Greenfield Saul P. , Ogra Pearay L. 
Published: December 2021

CASE HISTORY AND OFFICE DIAGNOSIS
A 7-month-old uncircumcised male infant had vomiting, diarrhea, and low grade fever (38.4°C) 2 days before coming to the pediatrician's office. One day before seeing the baby, the physician prescribed Pedialyte and acetaminophen elixir. The child appeared active to the pediatrician. Mucous membranes were slightly dry and tears were present. His blood pressure was 98/62 mm Hg, pulse rate 92 beats per minute, and temperature 38°C. Laboratory evaluation included an analysis and culture of catheterized urine sample: specific gravity, 1.025; pH, 6.0; protein, trace; blood, negative; sugar and ketones, negative; sediment—0 to 1 red blood cells per high-power field; 6 to 8 white blood cells per high-power-field and no bacteria. Based on the differential diagnosis of viral gastroenteritis vs urinary tract infection, the patient was sent home with a prescription for Pedialyte and acetaminophen and the parents were told to call the office in 24 hours for test results.
The urine culture was positive for greater than 100 000 colonies per milliliter of a single organism which was later identified as Escherichia coli and sensitive to all antibiotics. The child was started on a regimen of amoxicillin. Two weeks later, a repeat urine culture was negative for bacteria.
Evaluation of Hematuria in Children and Adolescents
Authors: Boineau Frank G. , Lewy John E. 
Published: December 2021

Hematuria is a frequent abnormal clinical finding in the genitourinary system, second only to urinary tract infection. The pediatrician needs to have an appropriate and organized approach to the examination of children with hematuria, to identify common causes or diseases and to identify those who need a more extensive evaluation of their problem and those who need urologic evaluation. The prevalence of microscopic hematuria among school-aged children ranges from 0.4% to 2.1%. Despite this frequency, it would appear that the presence of hematuria alone is rarely indicative of serious illness.
DEFINITIONS
The literature concerning hematuria is inconsistent in the various methods used to detect it and in the differing criteria for diagnosing hematuria. The most sensitive test for detecting the presence of blood in the urine is a reagent strip impregnated with orthotolodine-peroxide and enhanced with 6-methoxyquinolone. The commonly used dipsticks (Chemstrip-Boehringer Mannheim; Multistix or Labstix, Ames Division of Miles Laboratories) are sensitive. In the presence of hemoglobin (or another oxidizing agent), a blue coloration of the strip occurs. False-negative results are unusual but have been reported in the presence of high urinary concentrations of ascorbic acid. False-positive results (also unusual) are occasionally demonstrated in heavily infected urine where bacterial peroxidase is being liberated in high quantity.
Hypoglycemia in Children
Authors: Gruppuso Philip A. , Schwartz Robert 
Published: December 2021

Hypoglycemia, although rare in childhood beyond the newborn period, remains a vexing problem for the pediatrician. First, the symptoms may be vague and nonspecific, thus making diagnosis particularly dependent on a high index of suspicion. Second, the pathogenic mechanisms that result in hypoglycemia are as numerous and complicated as the physiologic mechanisms that maintain euglycemia. Finally, although most patients have no permanent sequelae, a catastrophic episode of hypoglycemia can cause neurologic deficit and mental retardation. In this brief review, the most common cause for hypoglycemia, namely, insulin-dependent type I diabetes mellitus, will not be considered. Instead, we will focus on those metabolic disorders that result directly in a loss of the ability to maintain normal serum glucose concentrations.
SYMPTOMS
In the older infant (older than 2 months), child, and adult, a rapid decrease in blood glucose to levels less than 40 mg/dL (2.2 mmol/L) may produce hunger and trigger an excessive release of epinephrine, causing weakness, anxiety, cold sweat, inward trembling and tachycardia. These adrenergic symptoms tend to occur in persons with postprandial hypoglycemia. In contrast, fasting hypoglycemia generally is progressive and gradual and produces neuroglycopenic symptoms which include headache, mental dullness, fatigue, confusion, abnormal behavior or psychosis, amnesia or other neurologic deficit, seizures, or frank coma.
Dehydration in Infancy: Hospital Treatment
Authors: Harrison Harold E. 
Published: December 2021

Dehydration of a degree severe enough to require intravenous replacement of water and electrolytes indicates (1) depletion of extracellular fluid sodium and water to such an extent that reduction of plasma volume results or (2) distortion of the composition of extracellular fluid with consequent disturbance of physiologic function. Such distortion may be marked hypernatremia, severe depletion of extracellular bicarbonate, or disturbances of potassium concentration resulting in either hyperkalemia or hypokalemia. In addition, hypocalcemia or hypomagnesemia may require specific replacement of these ions.
EXTRACELLULAR FLUID DEPLETION WITH HYPOVOLEMIA
The most important cause of extracellular fluid depletion in terms of frequency is loss of gastrointestinal secretions through either diarrhea or vomiting. In persons with lower intestinal obstruction, sequestration of gastrointestinal secretions in dilated loops of intestine may be sufficient to cause dehydration in the absence of vomiting. In infants with diarrhea, the onset of vomiting usually is an indication for intravenous replacement of electrolyte and water deficits. Oliguria is also an important item of information, indicating that dehydration is severe enough to require parenteral fluids. It has been estimated that hypovolemia and reduced glomerular filtration with oliguria results when about one third of extracellular fluid volume has been lost. In an infant, the normal extracellular fluid volume is 25% of body weight; therefore, a loss of 8% of body weight as extracellular fluid would result in the manifestation of severe dehydration with reduction of plasma volume.
Children of Divorce: Recent Findings Regarding Long-Term Effects and Recent Studies of Joint and Sole Custody
Authors: Wallerstein Judith S. , Johnston Janet R. 
Published: December 2021

The 10-year study revealed that the effects of divorce on children are often long lasting. Children are especially affected because divorce occurs within their formative years. What they see and experience during the failing marriage becomes a part of their view of themselves and of society. Although the findings from the study are, in some respects, dismaying, what emerges clearly is that a successfully reestablished family or a successful remarriage can improve the quality of life for both adults and children. The divorce may resolve the family conflict and allow the children to preserve a relationship with both parents. Divorce may also be useful in putting some distance between a child and a disturbed parent. Under these conditions, children may show accelerated maturity and independence. They may also bring to young adulthood a morality that places high value on sustaining relationships and on love, fidelity, and compassion.
The results of the longitudinal study, as well as those of the two joint custody studies, indicate that ongoing conflict between divorced parents has especially detrimental effects on the children and that children are particularly at risk when they have frequent and continuing access to both parents who are hostile and uncooperative with each other.
Odd Thoughts on Well-Child Care
Authors: Nazarian Lawrence F. 
Published: December 2021

It is good to take a hard look at longstanding habits. Well-child care is at the heart of pediatrics; yet, even this most sacred of commitments has been under scrutiny in recent years, and rightly so. But those of us who spend half of our time in well-child visits are frustrated by studies that fail to demonstrate any measurable benefits from our efforts, with the exception of immunization programs. Are researchers really looking at the right parameters? Are there too many variables to allow a truly scientific evaluation of these practices?
At least it is comforting to hear that parental satisfaction and confidence are acknowledged by-products of our work, and intuitively we believe that this effect is good for growing children.
Insulin-Dependent Diabetes Mellitus
Authors: Ginsberg-Fellner Fredda 
Published: December 2021

Insulin-dependent diabetes mellitus (IDDM), now usually called type I diabetes, is the most common endocrine disorder of childhood and adolescence, affecting at least 1 in 400 youngsters. In addition, the prevalence appears to be increasing, particularly as noted in Scandinavia, where registries for this disease are maintained. During the past 10 to 15 years, astounding advances have been made, both in the treatment of this disease and in understanding its etiology. However, perfect treatment, prevention, and cure of this disease and its long-term sequelae, which include cardiovascular disease, nephropathy requiring dialysis and renal transplantation, neuropathy, and retinopathy, are still lacking. During the next two decades, progress in these areas will surely be made, and the prognosis for children and adolescents with IDDM will continue to improve.
Until the discovery of insulin in 1921, virtually all children, adolescents, and young adults with IDDM died within 3 years of disease onset, often reduced to mere skeletons as their weight rapidly decreased secondary to low calorie diets. With the advent of insulin administration, mortality rapidly decreased and expectations increased that, as in other endocrine disorders requiring replacement therapy, diabetes would no longer be a problem after insulin was widely available. Indeed, the use of short-acting regular or crystalline insulin four times per day along with dietary restriction in the 1920s more closely parallels recommendations for control of the disease today than did the modes of therapy in vogue from the 1930s through the middle 1970s.
Congenital Dislocation of the Hip
Authors: MacEwen G. Dean , Millet Chad 
Published: December 2021

Early diagnosis and treatment are the keys to a successful result in infants with congenital dislocation of the hip. In the neonatal period, a majority of infants with hips that would later be found to be dislocated can be detected and effectively treated. With the use of ultrasonography to supplement clinical suspicion, the number of children with congenital dislocation of the hip diagnosed in the newborn period should be expected to increase. Repeated examination, especially during the first 6 months of life, can be expected to detect those additional children with congenital dislocation of the hip who were not detected in the nursery.
The Pavlik harness has been shown to obtain a successful result in most children younger than 6 months of age while holding the incidence of avascular necrosis to nearly zero. Even though these results are encouraging, the problem must be discovered early for the child with congenital dislocation of the hip to be treated optimally. Thus, it is of the utmost importance that the physician have an awareness of this problem. The primary physician must also continue to conscientiously examine the hips of patients on a regular basis even after the initial examination and, when necessary, use the added modalities available to him or her to accurately diagnose questionable hip conditions of patients.
Celiac Disease
Authors: Murphy M. Stephen , Walker W. Allan 
Published: December 2021

Celiac disease is a disorder characterized by a permanent sensitivity to gluten, such that its presence in the diet induces an enteropathy. Exposure of susceptible individuals to gluten-containing foods causes small intestinal mucosal injury associated with malabsorption of variable severity. The association between the occurrence of malabsorption and the presence of wheat or rye in the diet was first recognized by Dicke in 1950. Subsequently, barley was also shown to be toxic. The role of oats in producing disease remains controversial, but rice and maize are known not to cause disease.
EPIDEMIOLOGY
Celiac disease is one of the most frequent causes of malabsorption during childhood, with prevalence rates of between 1:500 and 1:3000 commonly quoted in the literature. Although the exact prevalence in any particular region is difficult to determine, marked geographical variations do appear to exist. A preyalence rate of 1:300 has been reported in western Ireland. Similarly, celiac disease is reported more frequently in patients from European countries than from North America. There is some evidence that the incidence may also be changing. Based on studies from the United Kingdom, it has been suggested that the incidence of childhood celiac disease may have been declining in recent years, following a peak in the early 1970s.
The Role of the Pediatrician in School Health
Authors: Sklaire Martin W. , McInerny Thomas K. 
Published: December 2021

Education and health are mutually dependent. If the child is not healthy, then he or she cannot be educated due to increased absenteeism. If the child is a failure in school, lack of self-esteem affects health and the relationship to the family and community. School health programs exist to support the education process. Most schools require that these programs be directed by a physician. Because of his or her training and interest in school children, the pediatrician thus takes on the responsibility of planning a school health program or acting as a liaison between the school, the child, and the family.1
SCHOOL HEALTH PROGRAM
Administration and Planning
Lower Gastrointestinal Bleeding
Authors: Silber Gary 
Published: December 2021

The differential diagnosis of lower gastrointestinal bleeding in children can be reduced markedly simply by taking into account the age of the child. The clinical condition of the patient can further help narrow the diagnostic possibilities. Newborns and infants who are clinically unstable are more likely to have diseases such as necrotizing enterocolitis, volvulus, Hirschprung disease, intussusception, or Meckel diverticulum. A baby who appears healthy should be examined for swallowed blood, allergic colitis, anal fissures, or lymphonodular hyperplasia. An older child of healthy appearance with bleeding is likely to have a juvenile polyp or infectious colitis, but a child who appears sick may have hemolytic uremic syndrome, Henoch-Schoenlein purpura, or inflammatory bowel disease. This information, along with that gleaned from the physical examination, can lead the pediatrician to determine the need for specific tests, such as abdominal radiographs, stool cultures, and an endoscopic evaluation.
We have come a long way in our ability to diagnose the causes of lower gastrointestinal bleeding. With the availability of newer radiographic and nuclear medicine modalities and the ability to visualize the colon endoscopically, the need for exploratory laparotomy for diagnosis is rarer. While surgery may still be the therapy of choice, new diagnostic modalities give the surgeon much more preoperative information.
Diagnosis and Management of Upper Gastrointestinal Tract Bleeding in the Pediatric Patient
Authors: Ament Marvin E. 
Published: December 2021

Gastrointestinal bleeding in patients at any age is frightening. The fear stems from the knowledge that bleeding, if severe enough and sustained for long intervals, may lead to shock and death. Fortunately, in both pediatric and adult patients, instances in which bleeding is so massive and uncontrollable that it leads to rapid demise are extremely rare. The approach to diagnosis and treatment of gastrointestinal hemorrhage by the physician should be calm, logical, and expeditious to help allay the fears of the patient and family, and to reduce the morbidity associated with the hemorrhage in the event its cause is found to be serious. Fortunately, the causes of gastrointestinal bleeding in the pediatric population are fewer than in adults; accordingly, the differential diagnosis is usually shorter, although not necessarily easier. In contrast to adults, the age of the pediatric patient may play a key role in determining the differential diagnosis.
MANIFESTATION OF BLEEDING (Table 1)
Before discussing the pathophysiology of bleeding, we will establish definitions of the words frequently associated with gastrointestinal bleeding.
Hematemesis is the vomiting of blood. The blood may be either bright red or "coffee ground" in appearance if it has been altered by gastric acid. Hematemesis implies that the site of bleeding is proximal to the ligament of Treitz.