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.
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
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.
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
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
Objective.-To describe the mode of presentation and natural history of hereditary pyropoikilocytosis to promote earlier diagnosis and improve treatment of this disorder.Design.-Retrospective case analysis.Setting.-Tertiary care pediatric medical center.Participants.-Eight children referred for examination.Interventions.-Treatment of symptomatic anemia and complications.Measurements/Main Results.-Hereditary pyropoikilocytosis was responsible for a very characteristic perinatal course in our patient cohort. All patients had hyperbilirubinemia requiring either exchange transfusions or phototherapy. Peripheral blood smears at birth revealed nucleated red blood cells, marked poikilocytosis, microcytosis, and reticulocytosis. All other pertinent laboratory studies (eg, immune hemolysis, sepsis, hereditary spherocytosis, etc) were noncontributory. Specific red blood cell membrane analysis clearly identified these patients as having hereditary pyropoikilocytosis. Follow-up evaluation of these patients (in one instance spanning 12 years) determined that this disorder is associated with a clinically apparent anemia but an excellent prognosis.Conclusions.-Red blood cell membrane analysis should be performed in neonates with a hemolytic anemia requiring therapy in which no identifiable cause can be ascertained with a conventional diagnostic examination.
OBJECTIVE:To determine normative data on age-related probabilities of children with severe disabilities acquiring mobility or self-feeding skills, or dying during a 5-year follow-up period.RESEARCH DESIGN:A 5-year follow-up study of three mutually exclusive subgroups formed on the basis of severe, profound, or suspected levels of retardation and incontinence and the following combinations of feeding and mobility skills.PARTICIPANTS:The sample was made up of 7836 children and adults distributed among the three subgroups being served in California between January 1981 and December 1985.MEASUREMENTS/MAIN RESULTS:Subjects who were tube-fed and immobile showed very little likelihood of becoming mobile or feeding themselves and had a high probability of death. Individuals who had some mobility experienced a better outcome.CONCLUSIONS:After age 6 years, the most probable outcome for children who are immobile and cannot feed themselves is death or no improvement in self-help skills.
There is a story about a monk who announced that he was leaving monastery after 25 years. Is it food, Brother John? his superior asked him. No, he replied, the food is bad, but I would not leave because of that. Is it illumination? Are you concerned about your eyesight? he was asked. No, he replied, The work is tedious, but I would not leave for that reason. Is it celibacy? he was asked. No, he replied, like others, I am lonely, but I took vows with a full awareness of what I was sacrificing, and I would not leave because of that. Then what is it, why are you leaving? his exasperated superior wanted to know. It's just whole damn thing, Brother John explained. So it is with new genetic technologies. They raise no new ethical questions for physicians or patients. There
OBJECTIVE:To assess the efficacy of late active immunization against hepatitis B concomitant with diphtheria, pertussis, tetanus, and polio vaccine in high-risk infants receiving hepatitis B immune globulin at birth.DESIGN:Randomized study of infants born to mothers positive for hepatitis B surface antigen (HBsAg) and hepatitis Be antigen (HBeAg).SETTING:Three large city hospitals and one rural area providing prenatal care and obstetric services.SUBJECTS:Eighty neonates of HBsAg- and HBeAg-positive carrier mothers received 0.5 mL/kg of body weight hepatitis B immune globulin within 2 hours of birth and hepatitis B vaccine (10 micrograms) at 0, 1, 2, and 11 months of age (group A) or at 3, 4, 5, and 11 months of age concomitant with diphtheria, pertussis, tetanus, and polio immunization (group B). A second dose of hepatitis B immune globulin was given to infants on schedule B at 3 months.MAIN OUTCOME MEASURES:Blood samples were collected at 0, 3, 6, 11, and 12 months of age and tested for antibodies against hepatitis B core antigen and HBsAg. Follow-up visits were scheduled annually up to 5 years of age.RESULTS:Eight infants were excluded from analysis. During the study period, six children became HBsAg carriers, three in each group, which corresponds to a 5-year incidence of infection of 9% and 8% for groups A (three of 35) and B (three of 37), respectively. Subclinical infections (persistent anti-HBc positivity beyond month 12 or appearance of anti-HBc) were encountered in another eight infants (four in each group).CONCLUSION:Late active immunization starting at 3 months of age appears to provide similar protective efficacy as active immunization starting at birth when combined with hepatitis B immune globulin at 0 and 3 months of age.
In 1991, pointing out the benefits of a more decentralized and integrated service system for children and families in this country, we wrote, Perhaps it is idealistic to expect the country can create a new and vital service system during the next 10 to 20 years.1 We nevertheless expressed the hope that there would be bold and systemic change in the way services are provided. The 2 years since our piece was written constitute a fifth of the minimum amount of time that we allotted for our hope of genuine change to come to fruition. It also happens that those 2 years have witnessed fiscal constraints at all levels of government that have been significantly more severe than the ones that formed the backdrop to our piece in 1991. To a degree fiscal necessities create incentives for agencies and systems to work collaboratively, but as we also wrote, changing service
OBJECTIVE:To examine the behavioral adaptation to human immunodeficiency virus (HIV)-seropositive status, as defined by parental report, in children and adolescents with hemophilia.RESEARCH DESIGN:A clinical descriptive study of two groups of patients as part of a longitudinal design.SETTING:A university-based comprehensive hemophilia center and department of neurology acquired immunodeficiency syndrome dementia center.PATIENTS:Forty-six male children with hemophilia divided into two groups based on HIV-seropositive (n = 18) or -seronegative (n = 28) status. None of the patients were symptomatic for acquired immunodeficiency syndrome.SELECTION PROCEDURES:All pediatric patients with documented factor VII or IX deficiency aged between 4 and 19 years at study onset and their families were eligible to participate. All subjects were recruited without regard to human immunodeficiency virus status.INTERVENTIONS:None.MEASUREMENTS AND RESULTS:Profiles of behavioral adjustment were obtained from parents' reports on the Child Behavior Checklist for the HIV-seropositive and HIV-seronegative groups. The two groups did not differ on any of the major indexes of the Child Behavior Checklist, even after adjusting for maternal education and severity of hemophilia. There also was no difference between the groups when individual cases were examined for the number of child behavior checklist scales falling within a clinically significant range.CONCLUSIONS:The current findings fail to confirm any clear evidence of behavioral problems in an asymptomatic group of HIV-seropositive children and adolescents with hemophilia.
