OBJECTIVE:To examine whether a protein-sparing modified fast diet and a hypocaloric balanced diet are safe and effective for children in an outpatient weight reduction program.DESIGN:Randomization of two groups to either diet, with follow-up at 14.5 months.SETTING:Physician or parent referral to outpatient program at Children's Hospital of New Orleans, La.PARTICIPANTS:Nineteen children, ranging in age from 7.5 to 16.9 years, weighing 45% to 131% more than the mean weight for age, sex, and height.INTERVENTION:During the first 10 weeks, 10 children were placed on a protein-sparing modified fast diet (2520 to 3360 J), and nine children and adolescents were placed on a hypocaloric balanced diet (3360 to 4200 J). Subsequently, all participants were placed on a hypocaloric diet; calories were increased from 4200 to 5040 J in a 3-month period and maintained for 1 year.SELECTION PROCEDURES:Children were assigned to one of two diets for the first 10 weeks according to their time of enrollment.MEASUREMENTS/MAIN RESULTS:Both diets produced significant weight loss during the first 6 months. However, the protein-sparing modified fast diet produced significantly greater changes in the percentage of overweight at 10 weeks (-30% vs -14%) and at 6 months (-32% vs -18%). At 10 weeks, a significant loss of adipose tissue with preservation of lean body mass occurred in the protein-sparing modified fast group. A transient slowing of growth velocity was noted at 6 months in both dietary groups compared with values at 14.5 months. Growth velocity approached normal levels at 14.5 months compared with standards for North American children. When dietary groups were combined, the initial mean blood pressure decreased significantly at all points in the study. The initial mean serum cholesterol value also decreased significantly at 10 weeks. No biochemical or clinical complications were observed.CONCLUSIONS:These hypocaloric diets appear to be safe and effective in the short-term management of pediatric obesity. However, these diets should not be used without close medical supervision.
Sir.—I would like to commend Rupp et al1on a splendid study of the incidence of exercise-induced asthma in treadmill exercise among largely black inner-city athletes in Georgia undergoing preparticipation physical examinations. The authors allude to the importance of screening adolescents before they reach competitive collegiate or Olympic levels. The authors' work is based on the results of screening spirometries. We have recently completed a study of almost 900 children, with a mean age of 12 years, in a private allergy and pediatric practice setting. We used results of free running tests and spirometry to compare peak expiratory flow. This comparison of free running test results and peak flow may be more practical in a primary care or private practice setting. Our population was largely an unselected general pediatric one, although high school students requiring preparticipation examinations and even patients with allergies were included for comparison purposes.
Primary immunodeficiency diseases are inherited disorders that affect human adaptive and innate immunity. In most cases, affected individuals experience recurrent infections, but they may also suffer from autoimmune diseases and malignancies. This chapter focuses on X-Linked Lymphoproliferative Diseases,including the historic and scientific background, clinical presentations, immunologic characteristics, and the molecular/genetic underpinnings. Where appropriate, diagnostic tools and therapeutic options are outlined -- from prophylactic anti-infective measures to hematopoietic stem cell transplantation and gene therapy.
In November 1991, the United Nations declared and celebrated the success of its universal childhood immunization campaign. Seventeen years after the Expanded Program on Immunization began by capitalizing on investments in the global smallpox eradication campaign, the United Nations Children's Fund (UNICEF) and World Health Organization (WHO) achieved their goal. Over 80% of children born in the world in 1990 received the six standard vaccines (against tuberculosis, diphtheria, pertussis, tetanus, polio, and measles). The United Nations Children's Fund estimates that over 3.2 million children's lives are saved annually.1Yet infectious diseases continue to kill children in developing countries. We are not getting the full benefits of the six Expanded Program on Immunization vaccines. Measles account for the death of almost 1 million children each year. There are 500 000 neonatal deaths related to tetanus each year and 400 000 to pertussis according to UNICEF. In Africa, Latin America, and
Sir.—We would like to report an additional case of benign neonatal sleep myoclonus1recently seen when the patient was 5 days of age. On day 3 the child developed the typical features of jerking when asleep; this lasted a few seconds with no associated features. Results of examination that included electroencephalogram when the patient was awake were normal, and no abnormality appeared on biochemical, hematologic, or infection screens. Of interest was the presence of pronounced stimulus-induced myoclonus when the patient was asleep. He was being nursed in a clear cot; when the cot was tapped, several myoclonic jerks were evident in the arms. These did not disappear with holding of the limbs. Recent pediatric neurology textbooks2,3have referred to this condition as benign neonatal myoclonus, but the paucity of information in these sources demonstrates the difficulty of keeping up with the broad expanse of knowledge in our
ObJective.-To assess the height outcome of newborns born small for gestational age.Design.-A historical prospective study.Setting.-A cohort of 1758 newborns born at a single university hospital maternity ward and subsequently examined at the military draft medical board at age 17 years.Participants.-Newborns whose weight at birth was below the third percentile were defined as small for gestational age. Their body measurements at age 17 years were compared with those of their peers who were appropriate for gestational age.Measurements/Main Results.-The adjusted mean+/-SEM height for boys born small for gestational age vs peers born appropriate for gestational age was 169.9+/-1.5 vs 175.4+/-0.8 cm (P<.0001); and for girls, 159.4+/-1.3 vs 163.1+/-0.8 cm (P<.0005). In addition, the risk for height attainment below the 10th percentile was significantly increased for newborns born small for gestational age. The adjusted odds ratio was 4.13 for boys (95% confidence interval, 1.66 to 10.25; P<.0006) and 3.32 for girls (95% confidence interval, 1.38 to 8.05; P<.0005).Conclusion.-Infants born small for gestational age may be at increased risk for short stature in late adolescence.
To describe birth-weight-specific differences in mortality risks between white and black Illinois infants by age at death and leading cause of death.Population-based birth cohort study.State of Illinois.All Illinois infants who were born from 1980 through 1989 and reported to the Illinois Department of Public Health. The death certificates of these infants were matched to corresponding birth certificates using a computerized linkage algorithm.None.The high black infant mortality rate is attributable to higher mortality risks in the neonatal period for black, normal birth-weight infants and in the postneonatal period for all black infants, regardless of birth weight.Efforts to narrow the black-white gap in infant mortality and to reduce black mortality should not be limited to reduction of low birth weight and premature birth in black infants but should also include efforts to reduce risk factors associated with mortality among normal birthweight black infants.
Any discussion concerning the possible approaches toward improving health care provision to neonates naturally encompasses the improvement of health care provision to their mothers, both before and after delivery. In a larger sense, it encompasses solving the deficiencies in health care provision to the entire population, as babies and their mothers are only two of the overlapping circles in this large Venn diagram. Thirty-seven million Americans are without health insurance, and therefore frequently without access to necessary care. Simultaneously, we devote a larger portion of our gross domestic product to health care than any other industrialized country, yet we rank 15th in male life expectancy, seventh in female life expectancy, and 19th in infant mortality. There is a national realization, by politicians and the public alike, that health care costs are not only excessively high, but that health care resources are unwisely and inequitably distributed. 1 A change in perception
JAMA and all of the American Medical Association's family of journals, including AJDC , will dedicate all or most of one of their fall 1993 issues to manuscripts devoted to the theme of genetics. This initiative is in recognition of the significant and fast-paced changes that have occurred in our understanding of the molecular basis of heredity and all that stems from that understanding. Forty years ago, James D. Watson and Francis H. C. Crick published their reports unraveling the structure of DNA and revealing it as a double helix. In the intervening decades, sometimes at a dizzying pace, the molecular basis of heredity and developmental biology has been similarly unraveling. It is difficult to believe that today humans are receiving gene therapy in experimental situations with the prospect of reversing genetic defects once thought immutable. In both a tribute to these advances and in prospect of the significant changes in
The increasing complexity of primary pediatric care is focusing renewed attention on the relationship between the pediatrician and emergency department (ED) physician. Primary-care pediatricians and emergency physicians (EP) are colleagues in the provision of coordinated care to pediatric patients. Whether referral is made to an ED specializing in pediatric emergency medicine or to an ED serving primarily adults, pediatricians and EPs must communicate effectively to provide the best possible patient care. In this article, we discuss the general process of referral, and present the example of Children's National Medical Center (CNMC), Washington, DC, as a successful system for processing referrals in the ED. We review the necessary information for the smooth transition of care from the physician's office to the ED. Potential problem areas and solutions are discussed. Checklists with potential value for both pediatricians and EPs are presented. WHY PEDIATRICIANS REFER TO EDs The reasons for referral generally fall
• Objective. —To provide an approach toward the diagnosis of children with human immunodeficiency virus (HIV) infection in the acute care setting. Design. —Patient reports and review of recent literature. Setting. —Emergency departments or acute care clinics. Selection Procedures.—Analysis of important recent clinical publications. Interventions. —None. Results and Conclusions. —The clinical and historical findings associated with pediatric HIV infection are occasionally subtle and differ from those findings in adults. In this article, we have divided the first presentation of HIV in the acute care setting into five categories: recurrent bacterial infections, failure to thrive, unexplained organomegaly, adolescents with HIV, and late presentation of perinatally acquired HIV. Each category is illustrated by a patient treated in the acute care setting. Recognition of these categories of presentation will hopefully assist acute care physicians in the early diagnosis of HIV infection. (AJDC. 1993;147:1104-1108)
Sir .—Typically, the infant with meconium aspiration syndrome (MAS) is a term or postterm neonate with a birth weight exceeding 2500 g. In a series of 88 meconium-stained infants, Gregory et al 1 found a mean birth weight of 2911 g and a mean gestation of 290 days or 10 days after the expected delivery date. 1 After reviewing 125 cases of meconium-stained infants, Ting and Brady 2 reported similar results. In utero meconium passage occurs in only 3% of infants of gestational age younger than 36 weeks. 3 In the past, meconium aspiration has been regarded entirely as a postnatal event. We report an unusual case of intrauterine meconium aspiration in a premature infant. Patient Report .—A 610-g white male neonate was born to a 24-year-old gravida 2, para 0010 mother at 27 weeks' gestation by dates and examination. The pregnancy was complicated by maternal diethylstilbestrol exposure, hyperemesis, and
OBJECTIVE:To describe birth-weight-specific differences in mortality risks between white and black Illinois infants by age at death and leading cause of death. DESIGN:Population-based birth cohort study. SETTING:State of Illinois. PATIENTS:All Illinois infants who were born from 1980 through 1989 and reported to the Illinois Department of Public Health. The death certificates of these infants were matched to corresponding birth certificates using a computerized linkage algorithm. INTERVENTIONS:None. RESULTS:The high black infant mortality rate is attributable to higher mortality risks in the neonatal period for black, normal birth-weight infants and in the postneonatal period for all black infants, regardless of birth weight. CONCLUSION:Efforts to narrow the black-white gap in infant mortality and to reduce black mortality should not be limited to reduction of low birth weight and premature birth in black infants but should also include efforts to reduce risk factors associated with mortality among normal birthweight black infants.
Sir .—Despite the known value of vaccinations, the national goal of achieving a 90% rate among 2-year-old children by 1990 was not met. 1 This suggests the need to develop new strategies to vaccinate preschool children. At high risk for undervaccination are the impoverished, the uninsured, and toddlers. 2 Many of these children receive care in an emergency department (ED) at some time during the vaccination window of their lives. 3 In fact, children seen in the ED are more likely to be undervaccinated than their age-matched peers from the same primary-care practice. 4 Tifft and Lederman 5 conducted a study in Baltimore, Md, on the documentation of status of hospitalized preschool-aged patients. The admitting physician documented parental report of status as being up-to-date in 36 (35%) of the 102 charts reviewed, specific age-appropriate vaccine documentation was available in 30 (29%), a deficiency was documented in 19
