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CONTENTS

COMMENTARIES

297 Taking the Record Review Section of the Pediatric

Recertification Examination

Lawrence F. Nazarian

298 Then and Now

Vincent J. Menna

ARTICLES

299 Medical Record Review:

Anemia and Other “Laboratory-Intensive”

Disorders:

Staying Afloat in a Flood of Data

Lawrence F. Nazarian

301 Prevention of Allergic Disorders

William R. Solomon

311 Pediatric Dental Update

Stephen Shusterman

321 Nutrition Update

Lewis A. Barness

327 Atopic Dermatitis

Candace S. Lapidus and Paul J. Honig

ABSTRACTS

319 Newborn: First Stool and Urine

320 Munchausen Syndrome by Proxy

DEPARTMENT OF CORRECTIONS

310 Erratum

COVER

� Gourmet,” painted in 1901 by Picasso (1881-1973) during his “BluePeriod,” demonstrates the natural appetite of the small child, who appears

well nourished and even is eating standing up. Eating problems in childrenare not inherent in their stage of development but are their response to

adverse environments. The blue color, however, suggests a threat to thishealthy state. Child health professionals must balance this innate healthy

aspect of childhood against the environmental threats to their well-beingand be advocates for the healthy development of children. (This painting is

from the National Gallery of Art’s Chester Dale collection and is

reproduced with permission.)

ANSWER KEY

1. D; 2. D; 3. B; 4. A; 5. B; 6. A; 7. A 8. D; 9. D; 10. D; 11. B;12. E; 13. B; 14. C; 15. B; 16. C; 17. D; 18. D; 19. C

#{149}#{149}�RO8BSUPRORTPr\JGRE DIATRICEOUCAT�DN

Printed in the USA

Pediatrics in Review

Vol 15 No 8

August 1994EDITORRobert J. HaggertyUnivers� of RochesterSchool of Med,cine and Dentistry,Rochester, NY

Editorial Office:Department of PediatricsUniversity of RochesterSchool of Medicine and Denti�st,y601 Elmwood Aye, Box 777

Rochester, NY 14642

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatric GroupRochester, NY

CONSULTING EDITOREvan Charney, Worcester, MA

ABSTRACTS EDITORSteven P. Shelov, Bronx, NY

MANAGING EDITORJo Largent, Elk Grove Wlage, IL

EDITORIAL CONSULTANTVictor C. Vaughan. III, Stanford, CA

EDITORIAL BOARDMoris A. Angulo. MineOIa, NYRussell W. Chesney, Memphis, TN

Peggy Copple, Tucson, AZRichard B. Goldbloom, Halifax, NS

John L Green. Rochester. NY

Robert L Johnson. Newark, MIKathi Kemper, Seattle, WAAlan M. Lake, Glen Atm, MDFrederick H. Loveioy. Jr. Boston, MAJohn T. McBride. Rochester. NYVincent J. Manna. Doylestown, PALawrence C. Paku�. lirnonsum. MDJohn M. Pascoe, Madison, WIRonald L Poland, Hershey, PAJames E. Rasmussen, Mn Arbor, MIKenneth B. ROberts, Worcester, MAJames S. Seidel. Torrance. CARichard H. Sills, Newark, NJLaurie J. Smith, Washington, DCWilliam B. Strong. Augusta. GAJon flngelstad, Greerwille, NCVernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CTTerry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTSydney Sutherland

PUBUSHERAmerican Academy of PediatricsErrol R. AJden, Director

Department of EducationJean Dow, Director

Division of PREP/PEDIATRICSDeborah Kuhlman, Copy Editor

PEDIATRICS IN REV1EW(ISSN 0191-9601) iaownedand controlled by the American Academy ofPediatrics. It is published monthly by the AmericanAcademy of Pediatrics, 141 Northwest POint Blvd.P0 Box 927, Elk Grove Village, IL 60009-0927.

Statements and opinions expressed in PediatricsU, Review ere those � the authots and ncit necesswilythose of the American Academy of Pediatrics or itsCommittees. Recommendations included in thispublication do not indicate an exclusive course oftreatment or serve as a standard of medical care.

Subsaiption price � 1994: AAP Fellow $100; MPCandidate Fellow $75; MFP $125; Allied Health orResident $70; Nonmember or Institution $130. Currentsingle price is $10. Subacription calms �u be honoredup to 12 months from the publication date.

Second-class postage paid at ARLINGTONHEIGHTS, IWNOIS 60009-0927 and at additionalmailing offices.

�frJ,4ERICAN ACADEMY OF PEDIATRICS, 1994.

All rights reserved. Printed in USA. No part may beduplicated or reproduced without permission of theAmerican Academy of Pediatrics. POSTMASTER:Send address changes lo PEDIATRICS IN REVIEW,American Academy of Pediatrics, P0 Box 927, ElkGrove Village, IL 60009-0927. _____________

The printing arid productionof Pediatrics in Review ismade possible, in part, byan educational grant fromRoss Products Division,Ab� Laboratories. ___

PIR QUIZ

1. Mrs. Smith is a healthy, 26-year-oldfemale who is in the first trimesterof her pregnancy. Her obstetricianhas referred her to you for a “getacquainted” visit. Mrs. Smith tellsyou that two of her close friendshave babies who developed atopicdermatitis. She believes her husbandhad eczema in infancy. She wondersif there are precautions she shouldtake with her baby. You advise herthat the most important course forher to take would be to:A. Add meats, vegetables, and non-

citrus juice to the child’s diet atmonthly intervals starting at 12months of age.

B. Add rice and wheat cereals tothe child’s diet at 6 months of

2. Kenny B is a 2-year-old male whohas rhinitis frequently and has hadoccasional ear infections. He wasbreastfed until 6 months of age andthen was placed on homogenizedmilk. He eats cereal, egg, somemeats, vegetables, and fruits. Hisparents feel his appetite is normalfor his age. He has his own bed-room. Both of his parents have ahistory of allergic rhinitis. Theywonder if there are things they cando to relieve or avoid a similarproblem for their son. You advisethem that the most helpful actionthey can take is to:A. Begin prophylactic antibiotic

therapy.B. Change his milk to a soy-based

product.C. Delay plans for child care.D. Make his bedroom dust- and

mold-free.E. Restrict egg, wheat, orange

juice, and peanuts in his diet.

3. Karen is a 6-year-old African-Amer-ican girl who has been having in-creasingly frequent bouts of mildwheezing without fever. Her motherfeels Karen’s appetite and diet arenormal for her age. Karen seems tohave little trouble while playing outof doors. Her mother feels that herwheezing began at about the timeshe started first grade. In taking fur-ther history, you especially wouldbe interested in knowing about:A. Any family history of similar

symptoms.B. Any family pets.C. Karen’s school problems.D. The mother’s health during

pregnancy.E. The relationship of ingestion of

specific foods to symptoms.age.C. Avoid cow milk, soy products,

egg, and wheat in her diet dur-ing the remainder of her preg-nancy.

D. Breastfeed her baby for at least6 months.

E. Supplement her baby’s diet withsoy-based milk at 6 months ofage.

4. The factor most clearly predictive ofan increased risk of atopic disease inthe newborn is:A. Bilateral atopic parentage.B. Formula feeding rather than

breastfeeding.C. Mother’s dietary history during

pregnancy.D. Presence of indoor pets.E. Status of bedroom environment.

310 Pediatrics in Review VoL 15 No. 8 August 1994

ALLERGY/IMMUNOLOGYNl.rglc Dlsord#{149}rs

DEPARTMENT OF CORRECTIONS ..

Erratum

There is an incorrect dosage in the articleCervical Adenopathy that appeared in the July1994 issue. In Table 10 on page 283, thecorrect treatment for documented group Bstreptococcal disease in infants having usualassociated bacteremia is Aqueous penicillin G200 000 lU/kg/day IV, if sensitive.

I

Newborn: First Stool and Urine

ABSTRACT

Pediatrics in Review VoL 15 No. 8 August 1994 319

PIR QUIZ

5. A true statement about abnormalitiesin the formation and eruption of theprimary and secondary dentition is:A. Dental hypoplasia results solely

from prenatal influences ontooth formation.

B. Failure of any primary teeth toerupt by 17 months of age re-quires evaluation.

C. Hypothyroidism typically causesprecocious eruption.

D. Natal teeth should be removedroutinely.

E. Supernumerary teeth are pathog-nomonic of ectodermal dyspla-sia.

6. A true statement regarding cario-genesis and its consequences is:A. A child who has caries involving

the pulp space may experienceno pain.

B. Breastfeeding protects infantsfrom developing nursing caries.

C. During childhood, most cariesoccur on the smooth surfaces ofthe anterior teeth.

D. Nursing caries typically affectthe primary mandibular incisorsand canines first.

E. Odontogenic periorbital cellulitismost commonly arises from in-fection of the mandibular mo-lars.

7. A true statement about gingivitisand periodontitis is:A. Areas of mild-to-moderate gin-

givitis are evident in mostschool-age children.

B. Eruption hematomas are besttreated by incision and drainage.

C. Fluoridation of water has vir-tually eliminated gingivitisamong adolescents.

D. Juvenile periodontitis usually iscaused by common aerobic oralflora.

E. Routine management of labialfrena consists of surgical re-moval during early infancy.

8. Of the following, the most appropri-ate management of dental injury is:A. An avulsed permanent tooth

should be scrubbed thoroughlyprior to reimplantation.

B. An avulsed tooth should bereimplanted 3 days after theinjury.

C. Any avulsed primary teethshould be reimplanted.

D. Bonding techniques should beused to stabilize and eventuallyrestore traumatized teeth.

E. Transport of an avulsed perma-nent tooth is best in sterilesaline.

Time of First Void and First Stool in 500Newborns. Clark DA. Pediatrics.

1977;60:457-459

Time of First Stool in Extremely LowBirthweight (� 1000 g) Infants. Verma A,Dhanireddy R. J Pediatr. 1993;122:626-629

Heat and Water Balance. Neonatal Decision

Making. Korones JB, ed. St. Louis, Mo:Mosby Yearbook; 1993:46

Passage of the first stool and urine in

full-term neonates within the first 24hours of life usually is a sign ofwell-being. After birth, 60% ofhealthy full-term neonates “stool”for the first time by 8 hours of life,91% by 16 hours, 98.5% by 24

hours, and virtually all by 48 hours.Delay in the passage of the first stoolin term neonates may be associatedwith lower intestinal obstruction, thatis, meconium plug syndrome,Hirschsprung disease, and imperfor-

ate anus. More generalized problemssuch as sepsis or hypothyroidismshould be considered and thematernal history should be reviewedcarefully for an unanticipatedcomplication of magnesium sulfateadministration or narcotic use.

Physical examination and simpleabdominal radiographs are theessential first steps in the evaluationof delayed passage of meconium. Ifanatomic abnormalities are suspected,consultation with a pediatric surgeonshould be considered.

Gut motility is decreased inpreterm infants. Several studiescorroborate the findings of a delay inthe passage of the first stool in theseinfants.

Nearly all neonates (full-term,preterm, and postterm) void by 24hours; approximately 92% do so by24 hours and 99% by 48 hours. It isrecommended that any infant whohas not voided by 24 hours beevaluated.

A wide variety of disorders mayresult in failure to void within the

first day of life. It is important toconsider prerenal, renal, or urinarytract etiologies for the anunia. The

outcome of some of these disorders,especially those of prerenal origin,will be better when treated early. If

no urine is seen by 24 hours, thematernal history should be reviewed

carefully for oligohydraminos;asphyxia; familial renal disorder;

drugs given to mothers, such as

vasodilatons (eg, beta agonists),

pancuronium bromide, onphenobanbital; and risk factors forinfections.

The physical examination shoulddetermine the state of hydration and

the presence of congenital heartdisease and hypotension (decreasedrenal perfusion) or hypertension(associated with renal disease). The

finding of an abdominal mass orspine abnormalities suggest renal andbladder disorders.

An ultrasonogram that is nonin-vasive and reliable for detectinganatomic abnormalities should be

performed early in the evaluation ofthese neonates. Urinary catheter-ization will help determine if thebladder outlet is obstructed (withadequate urine production andexcretion to the bladder-fullbladder), if urine production isdecreased, on if there is a higherobstruction to urine flow (emptybladder).

Laboratory evaluation may help

determine the etiology of anunia.Serum and urine electrolyte levels,creatinine, osmolality, and ureanitrogen can help differentiateprenenab, renal, and postrenab causes.A fractional excretion of sodium(FENa = UNJUCr X �CflNa X

100) of less than 1 suggests prerenalfailure; a FENa of more than 3supports the diagnosis of intrinsicrenal disease. Urine osmolality that istwice that found in the serum, inassociation with decreased serumsodium concentration, suggests thesyndrome of inappropriate anti-diuretic hormone secretion, perhapscaused by asphyxia. Hematunia withred blood cell casts indicates renal

panenchymal injury or disease.If prerenal failure is suspected by

clinical and laboratory evaluation, afluid challenge with 20 cc/kg ofintravenous normal saline over 1 to 2hours followed by 1 to 2 mg/kg ofintravenous furosemide is indicated.This should result in urine output ifdecreased renal perfusion secondaryto maternal drug ingestion, asphyxia,dehydration, or hypotension isconsidered a prenenab etiology.

Intrinsic renal causes such as renalagenesis, hypoplasia, cystic kidneydisease, or acquired acute tubular on

NUTRITIONNutrition j

FIGURE i. USDA Food Guide Pyramid.

energy or insufficient essential nu-

trients.

326 Pediatrics in Review VoL 15 No. 8 August 1994

and food intake will help determinenutritional status. Although wastingand obesity usually are obvious, each

child’s height, weight, and head cir-cumference should be plotted ongrowth charts. For those who deviatefrom their percentiles, measurementsof skinfolds and laboratory determi-nations, including blood hemoglobin,red cell index, and serum proteins,may be necessary. Failure to thrivemay have multiple secondary etiolo-gies; the proximal cause, however,

always is consumption of insufficient

SUGGESTED READINGAmerican Academy of Pediatrics. Pediatric

Nutrition Handbook, 3rd ed. Elk GroveVillage,Ill;1992

Lozoff B, Jimenez E, Wolff AW. Long-termdevelopmental outcome of infants with irondeficiency. NEngllMed. 1991;325:687-691

National Cholesterol Education Program.Report of the expert panel on bloodcholesterol levels in children andadolescents. Pediatrics. 1992;89:525-584

PIR QUIZ

9. Breast-fed infants are most likelyto require dietary supplementationwith:A. IronB. Vitamin AC. Vitamin CD. Vitamin DE. Zinc

10. Among the following, which ismost likely to be associated with avegetarian diet?A. Atherosclerotic heart disease.B. Cancer.C. Cholelithiasis.D. Growth failure.E. Obesity.

1 1 . A true statement regarding ironsupplementation is:A. Bottle-fed infants do not

require iron supplementationuntil weaning occurs.

B. Breast-fed infants should re-ceive iron supplementation be-ginning at 6 months of age.

C. Iron supplementation causesincreased stool problems.

D. Soy formulas contain supple-mental iron.

E. Unlimited consumption ofwhole cow milk avoids theneed for iron supplementation.

12. Milk, when included in the diet ofa nursing mother who is vegetar-ian, is most useful in protectingagainst deficiency of:A. Casein.B. Immune factors.C. Iron.D. Long-chain fatty acids.E. Vitamin B,2.

13. Among the following, which bestdescribes goat milk formulas?A. Adequately supplied with iron.B. Deficient in folicacid.C. Deficient in protein.D. Less allergenic than cow milk.E. Less costly than evaporated

milk.

14. Among the following, the least ef-fective measure to avoid obesity isto:A. Eat only when hungry.B. Exercise daily.C. Increase vitamin supplementa-

tion.D. Limit TV viewing.E. Snack on fruits.