Showing papers in "Pediatric Annals in 1991"

Resilience in children's adaptation to negative life events and stressed environments.

Abstract: Functional adequacy (the maintenance of competent functioning despite an interfering emotionality) is a benchmark of resilient behavior under stress. While resilient adults can be identified as adults who once experienced a great deal of despair as children, I am not prepared to mark off the construct of resilience because such people may carry with them a realistic baggage of sadness and unhappiness. The very nature of despair that is present for children of the ghetto, the status of minority children in today's America, all have a reality that can neither be ignored or denied. Perhaps a portion of resilient behavior is the evaluative awareness of a difficult reality combined with a commitment to struggle, to conquer the obstacle, and to achieve one's goals despite the negative circumstances to which one has been exposed, which were and remain evocative of sadness.

Transcatheter ablation for pediatric tachyarrhythmias using radiofrequency electrical energy.

Abstract: Radiofrequency ablation is a promising therapeutic option for difficult tachycardias in patients of all ages. Conditions in the pediatric age group that appear most amenable to the technique include accessory pathways and ectopic focus tachycardias, but the list is likely to expand with further experience. Until all long-term risks have been better explored, our institutional policy is to restrict RF ablation to symptomatic children who have failed at least one through trial of pharmacologic control. When a choice must eventually be made between potent antiarrhythmic drugs with variable efficacy and side effects, or an involved and costly surgical procedure, transcatheter ablation would appear to be a reasonable, if not preferred, alternative.

Infectious mononucleosis in adolescents

Abstract: Infectious mononucleosis is a clinical manifestation of primary EBV infection in adolescents, characterized by a triad of clinical, laboratory, and serologic features. The classic signs and symptoms are not seen in every patient; rather, the presentations tend to fit into one of three clinical forms (pharyngeal, glandular, or febrile). Recognizing these syndromes provides a useful framework for anticipating the clinical course, complications, and differential diagnosis. Nonclassic presentations of IM include a wide variety of neurologic abnormalities, thrombocytopenic purpura, and splenic rupture. The laboratory features of IM include absolute lymphocytosis with a large percentage of atypical lymphocytes, and abnormal liver chemistries in 90% of patients. The diagnosis of IM is confirmed serologically, usually with the demonstration of heterophile antibodies; the test can conveniently be performed in office laboratories. If the heterophile antibody test is negative, EBV-specific serologic tests can identify whether the illness is due to primary EBV infection. Once the diagnosis of IM is made, appropriate guidelines for resumption of activity should be provided to patients, especially to those with evidence of splenomegaly. Medical management includes supportive therapy with adequate analgesia. Corticosteroids are indicated for patients with upper airway obstruction; they may be helpful in patients with neurologic, hematologic, or cardiac complications. Acyclovir may prove to be useful, but further studies are needed before its use can be recommended.

Siblings of chronically ill children: a question of vulnerability versus resilience.

Abstract: The study of siblings of chronically ill brothers or sisters would benefit from a change in perspective. Research in the last decade still framed studies from the perspective of vulnerability rather than resilience. Having benefited from these studies, the study questions need to be reframed. Because childhood chronicity is a given, identifying risk factors for both able-bodied brothers and sisters as well as disabled children can reduce negative outcomes for these children and their parents. Many children are living successfully with disabled siblings, and their success should be the focus of current research so that appropriate interventions can be initiated.

Evaluating the child with syncope.

Abstract: Syncope is a multifactorial disorder; however, most pediatric syncopal episodes result from vasodepressor syndrome or the simple faint. A very detailed history and physical examination should indicate the etiology in the majority of cases. Extensive diagnostic studies are rarely necessary. Tilt table testing is a reliable way of identifying individuals predisposed to vasodepressor syncope, and may provide a means of assessing the efficacy of therapeutic interventions in those who require treatment. Treatment for syncope from etiologies other than vasodepressor syndrome is directed at the underlying cause.

Risk of Enteric Infection Associated With Child Day Care

Abstract: Pediatricians may advise parents that diarrhea is a frequent occurrence among infants and toddlers in day care and that diarrhea is usually mild and self-limited. A child newly enrolled in a day-care facility is at a particularly high risk for developing a diarrheal illness within the first month after enrollment, but the risk has been found to decrease as children remain in the same setting. Children who have diarrhea, fever, or vomiting of infectious origin should be isolated from well children. Infants and toddlers may return to the day-care environment when their diarrhea subsides and they are feeling well. Transmission of enteric infection from the child attending day-care center to other members of the family is possible; therefore, family members should also routinely practice good hygiene. Child-care providers should enforce written guidelines that establish hygienic practices and outline the management of ill children. Parents should be encouraged to read these policies and observe practices within the child-care setting before deciding to enroll their child in any care setting. The National Standards for out-of-home child care scheduled for release in 1991 will be important reading and a comprehensive reference for pediatricians who choose to be a child health consultant to one or more day-care facilities.

Primary nocturnal enuresis: current concepts about an old problem.

Abstract: In summary, all children and families who present with nocturnal enuresis should be offered education, reassurance, and ongoing support as a premier component of any treatment regimen. At the same time, the family should be informed about all the treatment options that exist with a goal of tailoring the specific treatment to the individual patient. In most cases, this approach will lead to child, family, and physician satisfaction.

Substance abuse in pregnancy: teratogenesis.

Abstract: Substances of abuse include those that are legal (such as alcohol) and those that are illegal (street drugs). Many of these agents produce reproductive toxicity including intrauterine growth retardation. Teratogenesis is unproven with most of these agents. Alcohol is an exception, producing the fetal alcohol syndrome. Cocaine causes marked reproductive toxicity including decreased growth and morbidity. A number of birth defects have been associated with cocaine use including genitourinary, cardiac, and limb anomalies. The reproductive toxic and putative teratogenic effects of cocaine are probably associated with its well-known pharmacologic action causing vasoconstriction. From preliminary studies, it would appear that methamphetamine also produces reproductive toxic effects similar to those of cocaine.

Antibiotic Treatment Failures in Acute Otitis Media

Abstract: When the clinician is presented with apparent treatment failure, noncompliance must be considered first. If this is the problem, the medication should be reinstituted after the parents are counseled. Next, the possibility of a superimposed viral illness also must be considered. When satisfied that these are not the problems, the clinician must consider whether the MEE has created so much positive pressure that antimicrobials cannot completely penetrate the middle ear space. If positive pressure is considered the problem, the same or another antimicrobial should be continued for a second 10-day course, allowing the pressure to decrease with time permitting more complete antibiotic penetration into the MEE. Alternately, clinicians with appropriate training may elect to relieve the pressure by tympanocentesis or myringotomy. If the clinician decides that it is more likely that the patient has a pathogen resistant to the initial choice of an antimicrobial agent, a second course of a more potent second-line antimicrobial is appropriate. Patients who fail a second course of antimicrobials should receive an alternate second-line antimicrobial or undergo drainage of the middle ear abscess. Those who fail a third course of antimicrobials should be referred to an otolaryngologist for evaluation or surgical intervention. Antimicrobials should be continued until the consultation occurs. This article has outlined potential clinical presentations for treatment failures as well as choices for second-line antibiotics. The relation of anatomic, environmental, microbial, and antimicrobial factors in persistent AOM must be considered in order to determine if the clinician should do more than merely prescribe second-line antibiotics.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexually transmitted diseases in adolescents: update 1991.

Abstract: Clinicians caring for sexually active adolescents are likely to be called on to diagnose and treat many of the STDs discussed in this article. A variety of other STDs not covered here also may be observed, including lymphogranuloma venereum, granuloma inguinale, molluscum contagiosum, scabies, pediculosis, and hepatitis A, B, and C. Some of the special issues related to gay and lesbian youth are discussed in the article by Drs Bidwell and Deisher (see "Adolescent Sexuality: Current Issues," pp 293-302). Nonetheless, it should be mentioned that the same STDs occur in homosexual youths as in their heterosexual counterparts. However, the prevalence rates for many STDs differ between the two groups, and some STDs are rarely seen in heterosexual males. These discrepancies may be explained by a number of determinants including anatomic and physiologic factors (eg, lesbian women have lower rates of STDs), differences in sexual practices (eg, genital-anal and oral-anal contact), and numbers of sexual partners, although this last factor may be less important in adolescents as compared with adult gay men. Discovery of one STD should always prompt a search for others because multiple concurrent infections is the rule rather than the exception. A serologic test for syphilis and a discussion of the potential for HIV infection (possibly testing for HIV as well) should take place at each new encounter for an STD. Some patients, including those with multiple partners, have an increased chance for acquisition of an STD. However, the reality is that any adolescent who has had sexual intercourse could have an STD.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis and management of mastoiditis in children.

Abstract: Even though mastoiditis as a complication of AOM is uncommon, its recognition is imperative to institute timely therapy. Acute coalescent mastoiditis generally follows a severe bout of AOM. Intravenous antimicrobial therapy and myringotomy drainage are usually satisfactory measures. However, refractory cases may require a simple mastoidectomy. Chronic mastoiditis in children is treated initially with intravenous antimicrobial therapy and vigorous aural toilet, which is successful in most patients. Mastoidectomy may be required in selected patients. The clinician must be aware of the differential diagnosis of chronic otorrhea so that biopsies can be obtained whenever a neoplasm is suspected.

Obstetrical Issues in Substance Abuse

Abstract: Substance abuse complicates between 10% and 25% of pregnancies, and has been associated with increased perinatal morbidity and mortality. The mechanisms of action of certain drugs predispose to specific types of complications, but the explanations for obstetrical effects of other drugs are more obscure. It is often difficult to differentiate the effects of drugs from the socioeconomic issues surrounding the drug abuser. There is no doubt, however, that the infants of pregnant drug abusers suffer from increased risks of low birthweight, preterm delivery, possible teratogenic effects, fetal dependence and withdrawal, and possible neurobehavioral effects. Health-care providers must encourage these patients to seek prenatal care early and to continue care throughout pregnancy. With a coordinated system for antenatal monitoring and support, these risks hopefully can be decreased and the perinatal outcome improved.

Evaluation of children for epilepsy surgery.

Abstract: Surgical management of refractory epilepsy in childhood is a viable treatment option available for many children. Ideally, this treatment should be applied to appropriate candidates prior to adulthood to prevent them from becoming "psychosocial invalids." The pediatrician is instrumental in identifying potential candidates for epilepsy surgery and referring them to a tertiary-care epilepsy center. Few detrimental long-term cognitive or behavioral deficits occur if the surgery is uncomplicated. The cost of the presurgical evaluation and surgical treatment varies from $25,000 to $100,000, depending on the preoperative work-up required.