Archives of Pediatrics and Adolescent Medicine

IN 2001, a team of artists, historians, and grade-school students met to create a public exhibit on the history of disability. There were historical presentations, parent discussion groups, art sessions with children, and a school forum linking children from an honors English class with children from a "varying exceptionalities" classroom. Led by renowned artist Xavier Cortada, the team created some artwork, a Web site, and a timeline of disability scrawled across the art gallery's wall. Out of this interaction also came this brief essay on what it means to be different, written as an introduction to the art exhibit.

It is encouraging to see the financing aspects of health care for young adults with chronic health conditions and disabilities becoming a focus of health services research, and study findings are providing new perspectives on the cost and benefits of moving children with special health care needs from pediatric to adult-oriented medical systems. Nonetheless, transitioning young adults to adult-oriented medicine, or for that matter any transition in medicine,1,2 is a complex phenomenon and financial measures alone cannot adequately reflect short- and long-term consequences at the patient, health care professional, and health system levels.

The review article by Tobian and colleagues¹ differs from most review articles. Review articles typically give an overview of the literature, but Tobian and colleagues present evidence to support their hypothesis while ignoring contradictory evidence. This includes studies of herpes simplex virus type 2 seroconversion,² human papillomavirus infection,³ human immunodeficiency virus (HIV) infection,⁴,5 cervical cancer in female partners,⁶ and infections in female partners.

A FEMALE INFANT, the product of a normal pregnancy and delivery, presented with an 8× 8-cm soft scalp mass in the right parietal region. The mass grew larger when the right jugular vein was compressed or when she cried. The appearance resembled fluctuant, bulging veins that were easily compressed (Figure 1 ), and the lesion was covered by red and ulcerated skin, with associated areas of alopecia. Under the veins, osseous grooves were palpable. No thrill or bruit was present. Results of the physical and neurological examination and routine laboratory studies were otherwise normal. Skull roentgenograms, a cranial computed tomographic scan (Figure 2), and a selective internal angiogram of the carotid sinus (Figure 3) were obtained.Denouement and Discussion Sinus Pericranii Sinus pericranii is an abnormal communication between the extracranial and intracranial venous systems, usually involving the superior sagittal or transverse sinus. In this malformation, a network of thin-walled veins adhere

AN 18-YEAR-OLD white man with neurofibromatosis (NF) presented with intermittent hypertension. His medical history included a plexiform neurofibroma of the left eye and spinal fusion for xyphoscoliosis. His physical examination revealed a blood pressure of 170/110 mm Hg, facial asymmetry with proptosis of the left eye, Lisch nodules in the right eye, normal cardiopulmonary function, and a soft abdomen without hepatosplenomegaly or masses. No bruits were present. His skin showed multiple café au lait spots, axillary freckling, and a neurofibroma on his left ankle. Results of a laboratory evaluation, including complete blood cell count, routine blood chemistry studies, and urinalysis, were normal. A 24-hour evaluation of a urine specimen for vanillylmandelic acid and catecholamine levels yielded normal results. A renal nucleotide scan and flow with captopril showed slightly decreased perfusion to the right kidney with decreased excretion and radionuclide retention in the calyx of the upper pole. Postcaptopril renin levels

Last month's release of the second child health scorecard by the Commonwealth Fund reminded us of the enduring challenge of suboptimal care for too many children in this country.¹ This is just the most recent example of the growing literature documenting the many shortfalls in quality in every aspect of pediatric care. This evidence base has already contributed to significant new federal investments in strategies to measure and improve pediatric quality through the reauthorization of the Child Health Insurance Program Reauthorization Act in 2009 and the national quality strategy called for in the Accountable Care Act.² Eighteen states are now working to develop and test new ways to improve quality of care for children, and 7 Centers of Excellence in pediatric quality measures have been recently established to improve existing measures and develop new measures for the numerous gaps that currently exist.³ This issue's articles on quality of care are an important contribution to this field, first in helping us understand the challenges and begin to address them, but also in reminding us of the current limitations in the methods used in many quality-related studies.

A 4-YEAR-OLD girl with a pink birthmark covering the right side of her face (Figure 1 and Figure 2) developed recurrent seizures. A plain roentgenogram of the skull (Figure 3) was obtained to support the suspected diagnosis.Denouement and Discussion Sturge-Weber Syndrome The most common vascular lesion associated with the Sturge-Weber syndrome is a port-wine stain or nevus flammeus, a vascular malformation present at birth and consisting of ectatic capillary to venular-sized blood vessels in the dermis. The port-wine stain does not resolve over time, unlike capillary hemangiomas. There may be associated blood vessel abnormalities involving the eye on the same side of the face, which may subsequently lead to the development of glaucoma. Leptomeningeal angiomatosis on the ipsilateral surface of the cerebral hemisphere is the other major component of the Sturge-Weber syndrome, and this malformation is responsible for the development of seizures and

An infant delivered at 29 weeks' gestation with a birth weight of 1.06 kg was noted to have large, coalescent patches of hypopigmentation that were most prominent on the back (Figure 1). Routine cranial ultrasonography revealed extensive multicystic encephalomalacia (Figure 2). Bilateral chorioretinal scarring and optic atrophy were present on ophthalmologic examination (Figure 3). Results of an electroencephalogram and testing of acoustic and visual evoked reflexes were markedly abnormal.Denouement and Discussion Intrauterine Herpes Simplex Virus Infection DISCUSSION The estimated incidence of neonatal herpes simplex virus (HSV) infection varies from 1 in 2000 to 1 in 5000 live births in the United States per year.1 Neonatal HSV disease may involve either the type 1 or 2 virus, with the latter accounting for approximately 75% of the isolates from infected neonates.2 The HSV may be transmitted to the fetus or newborn in utero, at the intrapartum stage, or postnatally. Although

To examine the neurosensory and cognitive status of extremely low-birth-weight (ELBW; < 1,000 g) children born from January 1, 1992, through December 31, 1995, and to identify the significant predictors of outcome. An inception cohort of ELBW infants admitted to the neonatal intensive care unit (NICU) and observed to 20 months' corrected age. A tertiary level urban NICU and follow-up clinic at a university hospital. Of 333 ELBW infants without major congenital malformations admitted to the NICU, 241 (72%) survived to 20 months' corrected age. We studied 221 children (92%) at a mean of 20 months' corrected age. The mean birth weight was 813 g; mean gestational age, 26.4 weeks. Assessments of cognitive and neurosensory development. Major neurosensory abnormality was present in 54 children (24%), including 33 (15%) with cerebral palsy, 20 (9%) with deafness, and 2 (1%) with blindness. The mean (+/- SD) Bayley-Mental Developmental Index (MDI) score was 74.7 +/- 17. Ninety-two children (42%) had a subnormal MDI score (<70). Neurodevelopmental impairment (neurosensory abnormality and/or MDI score <70) was present in 105 children (48%). Multiple stepwise logistic regression analysis that considered sex, social risk, birth weight, and neonatal risk factors revealed significant predictors of a subnormal MDI score to be male sex (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.52-4.92), social risk (OR, 1.48; 95% CI, 1.09-2.00), and chronic lung disease (OR, 2.18; 95% CI, 1.20-3.94). Predictors of neurologic abnormality were a severely abnormal finding on cerebral ultrasound (OR, 8.09; 95% CI, 3.69-17.71) and chronic lung disease (OR, 2.46; 95% CI, 1.12-5.40); predictors of deafness were male sex (OR, 2.79; 95% CI, 1.02-7.62), sepsis (OR, 3.15; 95% CI, 1.05-9.48), and jaundice (maximal bilirubin level, >171 micromol/L [>10 mg/dL]) (OR, 4.80; 95% CI, 1.46-15.73). There is an urgent need for research into the etiology and prevention of neonatal morbidity.

To compare outcomes in premature infants with respiratory distress syndrome who received surfactant replacement therapy and were treated with either high-frequency or conventional mechanical ventilation. Retrospective chart review of patient series. Tertiary academic medical center. One hundred fourteen extremely low-birth-weight infants (< 1000 g) with respiratory distress syndrome treated with surfactant replacement therapy, consecutively admitted to the neonatal intensive care unit between September 1989 and August 1992. Treatment with either high-frequency ventilation (n = 46) or conventional mechanical ventilation (n = 68) after surfactant replacement therapy. Intraventricular hemorrhage and neurodevelopmental status. Infants who received high-frequency ventilation had significantly lower birth weights and were more premature than infants receiving conventional mechanical ventilation. Despite this, patients ventilated with high frequency had similar incidences of intraventricular hemorrhage and impaired neurodevelopmental outcomes when compared with the conventionally ventilated patients. As expected, the smaller and more premature infants receiving high-frequency ventilation required a longer duration of respiratory support (mechanical ventilation and nasopharyngeal continuous positive airway pressure). Additionally, multiple logistic regression analysis to control for differences in birth weight and gestational age between the two groups revealed a significant association between the combined use of high-frequency ventilation and antenatal corticosteroids and the absence of either intraventricular hemorrhage or pneumothorax. We conclude that high-frequency ventilation combined with surfactant therapy is as safe as conventional mechanical ventilation combined with surfactant therapy for treating respiratory distress syndrome in extremely low-birth-weight infants (< 1000 g) and does not increase the risk of either intraventricular hemorrhage or abnormal neurodevelopmental outcome.

To determine the efficacy of nicotine patch therapy in adolescents who want to stop smoking and to assess biochemical markers of smoking and nicotine intake. Nonrandomized, open-label trial using a 15 mg/16 h patch. Two midwestern cities. One hundred one adolescents aged 13 through 17 years smoking at least 10 cigarettes per day (cpd). Six weeks of nicotine patch therapy and follow-up visits at 12 weeks and 6 months. Self-reported smoking abstinence verified by expired-air carbon monoxide (CO) level of no more than 8 ppm, nicotine withdrawal symptoms, and plasma cotinine level. Forty-one participants were female (mean [+/- SD] age, 16.5 [+/- 1.1] years). Median baseline smoking rate was 20.0 cpd (range, 10-40 cpd). Biochemically confirmed point prevalence smoking abstinence was 10.9% (11/101) at 6 weeks and 5.0% (5/101) at 6 months. The mean (+/- SD) plasma cotinine level at baseline was 1510.9 +/- 732.7 nmol/L; for nonsmoking subjects at weeks 3 and 6, 607.8 +/- 386.2 and 710.0 +/- 772.5 nmol/L, respectively. Plasma cotinine levels were correlated with CO levels at baseline (r = 0.27; P = .006), week 3 (r = 0.34; P = .004), and week 6 (r = 0.26; P = .03) and with mean cigarettes smoked per day during weeks 3 (r = 0.24; P = .04) and 6 (r = 0.30; P = .02). Mean smoking rates decreased significantly during the study, an effect that lessened at 12 weeks and 6 months. Nicotine patch therapy plus minimal behavioral intervention does not appear to be effective for treatment of adolescent smokers. Plasma cotinine and CO levels appear to be valid measures of smoking rates during the cessation process, but not at baseline. Smoking rates were reduced throughout the study. Additional pharmacological and behavioral treatments should be considered in adolescent smokers.

To better understand the motivation for adolescent smoking and drinking and to identify the underlying risk and protective factors associated with these behaviors among adolescents. Cross-sectional, school-based survey of students in grades 5 through 12. A nationally representative sample of 2574 boys and 2939 girls in grades 7 through 12 from 297 public, private, and parochial schools across the United States who participated in The Commonwealth Fund Survey of the Health of Adolescent Girls and Boys in 1997. Sex-specific adjusted relative risks (RRs) and 95% confidence intervals (CIs) comparing self-reported regular smokers and regular drinkers by risk and protective factors with adolescents reporting none of these behaviors. Adolescent boys and girls were equally likely to be regular smokers (11.2%). The prevalence rate of regular drinking was only slightly higher for boys (22.4%) than it was for girls (19.3%). The rates of both health-risk behaviors were significantly higher for those reporting risk factors, and the strengths of associations varied by sex. Sex differences also emerged in motivation for engaging in these behaviors. When we adjusted for demographic characteristics, exposure to childhood abuse (RR, 4.1; 95% CI, 2.4-7.0) and stressful life events (RR, 2.4; 95% CI, 1.1-5.4) were strongly associated with increased risk for boys' regular smoking. Similar associations were found for regular drinking. For girls, a history of abuse (RR, 1.8; 95% CI, 1.1-2.8), violence within the family (RR, 2.2; 95% CI, 1.6-3.2), depressive symptoms (RR, 1.6; 95% CI, 1.0-2.4), and stressful life events (RR, 3.1; 95% CI, 1.8-5.6) were significantly associated with increased risk for regular smoking. Similar associations were again found for regular drinking. Parental support was protective against both health-risk behaviors for both sexes. Participation in extracurricular activities was associated with lower risk for regular smoking for boys (RR, 0.4; 95% CI, 0.2-0.7) and for girls (RR, 0.3; 95% CI, 0.2-0.5); however, there was no significant association between drinking behavior and participation in activities. The increased risk for regular smoking and regular drinking among adolescents with a history of abuse, family violence, depressive symptoms, and stressful life events suggests that routine screening for abuse, violence, and other family experiences should be an essential component of adolescent health care visits. Effective prevention programs to reduce smoking and drinking among adolescents should recognize that health-risk behaviors may be associated with other negative life experiences and that the strength of these associations differs by sex.

The prevalence of iron-deficiency anemia in children has decreased owing to the provision of iron-containing infant formula and cereal and food vouchers to children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). To determine the prevalence of anemia and changes in anemia status in children receiving WIC supplementation. Retrospective cross-sectional and longitudinal analysis of information on WIC participants. Two definitions of anemia were considered separately: Anemia1 and Anemia2, the latter using a more stringent definition of anemia to avoid misclassification. Consecutive cohort of 7053 infants and children aged 6 to 59 months. Prevalence of anemia by age and race or ethnicity and relationship between anemia and sex, birth weight, and weight-for-height z score. Infants aged 6 to 8 months were 3.3 times more likely to be anemic than children aged 36 to 59 months. There was no association between anemia and race, birth weight, sex, or weight-for-height z score. Anemia rates were approximately halved in the more stringently defined Anemia2 group. Among children seen for at least 3 visits (n = 2926), 8.5% developed anemia and 19.1% of initially anemic children remained anemic; an additional 6.6% developed anemia at a third visit after having had 2 normal hemoglobin measurements. Anemia was common in WIC participants, with infants at highest risk. The diagnosis of anemia in black children depends on the cutoff value used. Despite ongoing receipt of WIC benefits, many children develop anemia or remain anemic. Implementation of mandatory follow-up of all anemic infants by WIC or health care providers may be warranted.

The increasing use of varicella vaccine in children attending day care has rapidly decreased the incidence of wild-type varicella disease. The herd immunity noted is significant and will have an effect on the epidemiology of natural varicella. To monitor the change in varicella incidence in day-care attendees after the licensure of varicella vaccine. A prospective observational cohort study design. Eleven private day-care centers and preschools in North Carolina participated in the study from January 1, 1995, through December 31, 1999. All children in the 11 centers were eligible for participation. Some participated more actively, supplying information on a regular basis. Others participated passively. Day-care personnel provided information about all cases of varicella. None. The change in the incidence of varicella disease was documented as the use of varicella vaccine increased. Varicella vaccine coverage increased substantially from 4.4% in 1995 to 63.1% in December 1999. The vaccination rate accelerated dramatically in 1996 and 1997, leveled off in 1998, and rose again in 1999. Cumulative varicella incidence decreased from 16.74 cases per 1000 person-months in July 1996 to 1.53 cases per 1000 person-months in December 1999 in unvaccinated children. The varicella vaccination rate continued to increase slowly in the day-care population after an initial rapid uptake. The decrease in varicella disease is greater than the increase in varicella vaccination. This herd effect is welcome and even apparent in the unvaccinated children younger than 1 year.

To determine if limited ability to delay gratification (ATDG) at age 4 years is independently associated with an increased risk of being overweight at age 11 years and to assess confounding or moderation by child body mass index z score at 4 years, self-reported maternal expectation of child ATDG for food, and maternal weight status. Longitudinal prospective study. Ten US sites. Participants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main Exposure Ability to delay gratification at 4 years, measured as pass or fail on a validated task. Overweight at 11 years, defined as a body mass index greater than or equal to the 85th percentile based on measured weight and height. Of 805 children, 47% failed the ATDG task. Using multiple logistic regression, children who failed the ATDG task were more likely to be overweight at 11 years (relative risk, 1.29; 95% confidence interval, 1.06-1.58), independent of income to needs ratio. Body mass index z score at 4 years and maternal expectation of child ATDG for food did not alter the association, but maternal weight status reduced the association significantly. Children with limited ATDG at age 4 years were more likely to be overweight at age 11 years, but the association was at least partially explained by maternal weight status. Further understanding of the association between the child's ATDG and maternal and child weight status may lead to more effective obesity intervention and prevention programs.

Studies indicate that children use media (television, video, and computer) more than the recommended limit of 2 h/d, but little is known about parents' role in mediating their children's media use. Office-based survey. Data were collected on demographics, reported media behaviors, parental awareness about media effects, television in the bedroom, and parental concern. We developed logistic regression models to examine factors associated with the following 3 mediation approaches: restrictive, instructive, and unlimited. Pediatric Research in Office Settings practices. Parents with children aged 2 to 11 years (n = 1831) presenting for a well-child visit. Almost half of parents reported a single mediation approach, including restrictive for 23%, instructive for 11%, and unlimited for 7%, with 59% reporting the use of multiple strategies. Restrictive (odds ratio [OR], 1.16; P<.001) and instructive (OR, 1.06; P = .02) approaches were associated with increased awareness about negative media effects, whereas a decreased awareness existed for those who used an unlimited approach (OR, 0.87; P<.001). A restrictive strategy also occurred with increased parental concern (OR, 1.77; P<.001) and 2 adults in the home (OR, 1.64; P<.01). The only strategy associated with the child's age was instructive mediation, noted more often with younger children (OR, 1.41; P<.001). Allowing unlimited media use occurred when parents permitted a television in the child's bedroom (OR, 2.13; P<.001) and were Latino (OR, 2.03; P<.01) or African American (OR, 2.20; P<.001). Mother as primary decision maker and maternal education were not statistically significant. Pediatric health care providers should identify parental practices and reinforce active media mediation strategies.

To determine the prevalence of obesity among sixth- and seventh-grade students in a school-based setting, and to identify lifestyle parameters associated with obesity. Sixth- and seventh-grade students (n = 385, 186 boys and 199 girls) from 3 schools participated in a school-based screening study, and 319 completed a short questionnaire. Height and weight were measured, and body fat as a percentage of body weight was obtained using a Tanita bioelectrical impedance scale. Overall, 35.3% of students had a body mass index (BMI; calculated as the weight in kilograms divided by the height in meters squared) at or above the 85th percentile, and half these students (17.4%) had a BMI at or above the 95th percentile. Rates were higher among Latino and lower among Asian than non-Hispanic white students. Significant associations were found between BMI and hours of television watched per evening and daily soft drink consumption. The mean (SE) BMI z score for those watching less than 2 hours per night (0.34 [0.09]) was lower than for those watching 2 or more hours per night (0.82 [0.08]; P<.001). The mean (SE) BMI z score for those consuming less than 3 soft drinks per day (0.51 [0.07]) was lower than for those consuming 3 or more soft drinks per day (1.02 [0.13]; P =.003). Latino students watched more television (2.4 hours per night) than did non-Hispanic white or Asian students (1.3 hours per night; P<.001 for each) and consumed more soft drinks (1.6 per day) than non-Hispanic white students (1.1 per day; P =.004) or Asian students (0.7 per day; P<.001). Time spent watching television and the number of soft drinks consumed were significantly associated with obesity. Latinos spent more time watching television and consumed more soft drinks than did non-Hispanic white or Asian students. These findings will be beneficial in developing preventive measures for these children.

Early malnutrition is linked to poor cognition, but long-term effects have not been extensively examined and psychosocial confounds have not always been controlled. To test the hypothesis that malnutrition at age 3 years will be associated with poorer cognitive ability at age 11 years independent of psychosocial confounds. A prospective, longitudinal study of a birth cohort of 1559 children originally assessed at age 3 years for malnutrition (low hemoglobin level, angular stomatitis, kwashiorkor, and sparse, thin hair) and followed up to age 11 years. A community sample of 1559 children (51.4% boys and 48.6% girls) born between September 1, 1969, and August 31, 1970, in 2 towns in the island of Mauritius, with 68.7% Indians and 25.7% Creoles (African origin). Verbal and spatial ability measured at ages 3 and 11 years and reading, scholastic ability, and neuropsychologic performance measured at age 11 years. Malnourished children had poorer cognition at both ages. Deficits were stable across time, applied to all sex and ethnic groups, and remained after controlling for multiple measures of psychosocial adversity. Children with 3 indicators of malnutrition had a 15.3-point deficit in IQ at age 11 years. Malnutrition at age 3 years is associated with poor cognition at age 11 years independent of psychosocial adversity. Promoting early childhood nutrition could enhance long-term cognitive development and school performance, especially in children with multiple nutritional deficits.

Wave III of the National Longitudinal Study of Adolescent Health provides opportunities to describe the reactions of young adults to September 11, 2001, and to increase understanding of the reactions among those who do not directly witness disasters. To compare the feelings, perceptions, and behaviors of respondents interviewed before with those of respondents interviewed within 9 weeks after September 11; and to test the influence of time and distance from terrorist sites on pre-post comparisons. Cross-sectional study, with comparison groups before and after September 11. In-home interviews. Seven thousand ninety-five respondents aged 18 to 26 years. Sadness, psychological distress, closeness to parents, importance of religion and spirituality, trust in government, and substance use. Male (adjusted odds ratio [aOR], 1.33; 95% confidence interval [CI], 1.08-1.65) and female (aOR, 1.44; 95% CI, 1.22-1.71) respondents interviewed after September 11 were more likely to report sadness and increased trust in government (aOR range, 2.11-3.30) than those interviewed before September 11. Proportions reporting sadness returned to baseline in 4 to 6 weeks; increased political trust persisted for the 9-week study period. Male respondents interviewed the second week afterwards were more likely to report religious faith (aOR, 2.06; 95% CI, 1.40-3.00) and spiritual life (aOR, 1.75; 95% CI, 1.18-2.60) as important than were those interviewed before the event. Female respondents interviewed afterwards were more likely to report higher levels of psychological distress (aOR, 1.40; 95% CI, 1.08-1.83) and closeness to fathers (aOR, 1.36; 95% CI, 1.08-1.72). There were no pre-post differences in substance use. Respondents closest to terrorist sites were most affected. Young adults who did not directly witness the events of September 11 experienced reactions that were multifaceted and transient--except for persisting trust in government.

To determine vaccination coverage at selected ages and by birth cohort and to assess whether all indicated vaccines were administered during vaccination visits. Population-based cross-sectional study. National Immunization Survey-Teen 2009 telephone interview. United States adolescents aged 13 to 17 years with provider-reported vaccination histories (N = 20 066). Among all adolescents and by birth cohort: coverage estimates for 3 childhood vaccines (measles-containing, hepatitis B, and varicella) and 3 adolescent vaccines (tetanus-diphtheria and/or tetanus-diphtheria-acellular pertussis, meningococcal-containing, and human papillomavirus for girls) at selected ages. By age 11 years, most adolescents had obtained the childhood vaccines. Receipt of a tetanus-diphtheria and/or tetanus-diphtheria-acellular pertussis vaccine at ages 11 to 12 years increased significantly from the 1991 to 1996 birth cohort (33.8% vs 68.2%, P < .001); receipt of meningococcal-containing vaccine at ages 11 to 12 years increased significantly from the 1993 to 1996 birth cohort (8.4% vs 50.0%, P < .001). Among girls, receipt of human papillomavirus vaccine at ages 11 to 12 years increased significantly from the 1994 to 1996 birth cohort (11.1% vs 30.5%, P < .001). Overall, 54.9% of adolescents received at least 1 vaccination visit at ages 11 to 12 years. Among adolescents who made a vaccination visit at ages 11 to 12 years and were eligible for vaccination, 19.5% did not receive tetanus-diphtheria and/or tetanus-diphtheria-acellular pertussis, 60.9% did not receive meningococcal-containing, and 62.4% did not receive human papillomavirus vaccines. Receipt of vaccines at the recommended ages of 11 to 12 years appears to be increasing; however, providers often do not administer all indicated vaccines during a vaccination visit.

Objectives: To investigate how the pediatric clerkship affected student attitudes toward pediatrics, and to determine if correlations existed between changes in attitudes toward pediatrics and in ratings of certain aspects of the clerkship with an increased interest in a pediatric career. A one-page survey measuring interest in a career in pediatrics and agreement or disagreement with seven statements about pediatrics was administered at the beginning and end of the pediatric clerkship at 11 medical schools for the 1992-1993 academic year. The proportion of students with a strong interest in a pediatric career increased from 6.7% before the clerkship to 15.2% after the clerkship (for women, 11% to 22%; for men, 4% to 11%). Attitudes toward pediatrics were more favorable at the end vs the beginning of the clerkship. The change that correlated best with change in interest in a pediatrics career was agreement that children are enjoyable to work with. Of the eight aspects of the clerkship rated, the patients worked with on the ward received the most positive mean score. The item that correlated best with increased career interest was a positive feeling toward the ward residents. The recent trend for women to have a greater interest in careers in pediatrics than men is continuing. Finding ways to make students more comfortable when they interact with children and improving the teaching skills of residents could improve recruitment of medical students into pediatrics.

To investigate the associations between 4 categories of daily 100% juice consumption (0 fl oz, > 0 to < or = 6 fl oz; > 6 to < 12 fl oz; and > or = 12 fl oz) and nutrient and food group intake and weight in children. Cross-sectional study. Secondary analysis of the 1999-2002 National Health and Nutrition Examination Survey data. Children 2 to 11 years of age (N = 3618). Juice consumption. The association between juice consumption, nutrient intake, food group consumption, and weight status was determined as was the likelihood of overweight with juice consumption. Mean daily juice consumption was 4.1 fl oz, which contributed a mean intake of 58 kcal (3.3% of total energy intake). Compared with nonconsumers, the overall nutritional profile of those consuming 100% juice had significantly higher intakes of energy, carbohydrates, vitamins C and B(6), potassium, riboflavin, magnesium, iron, and folate and significantly lower intakes of total fat, saturated fatty acids, discretionary fat, and added sugar. Children consuming 100% juice also consumed significantly more servings of total whole fruit than nonconsumers. No significant differences were found in weight status and the amounts of 100% juice consumed. There was no difference in the likelihood of being overweight between juice consumers and nonconsumers. On average, children consumed less than the maximum amounts of 100% juice recommended by the American Academy of Pediatrics. One hundred percent juice consumption was associated with better nutrient intake than in the nonconsumption group and was not associated with weight status or the likelihood of being overweight in children 2 to 11 years of age.

Charles Rosenberg, in The Care of Strangers: the Rise of America's Hospital System, wrote that hospitals have “reproduced in microcosm the history of a larger society.”1(p4) Candace O’Connor reinforces this insight in her engaging history of St Louis Children's Hospital. O’Connor takes readers through the founding years of the hospital to the present and, along the way, through changes in the broader context of the professions of pediatrics and nursing and developments in medical technology and national health care. Hope and Healing was written for and published by St Louis Children's Hospital, and it is not primarily an academic study. It is nevertheless a pleasure to read, filled with gorgeous period photographs and sidebars featuring recollections from members of the nursing and clinical staff. This volume also provides a compelling story of women in American medicine within the context of a single institution, merely by paying balanced attention to the formative forces and personalities involved in the history of St Louis Children's Hospital. That alone is reason enough to buy and read this book.

This volume is the result of an international effort to create a comprehensive approach to the management of visual disabilities in children. The expertise of contributors from Great Britain, Europe, the United States, and Canada is used. The editors have recognized that children with visual impairments present one of the greatest challenges to health and education professionals, as well as to the family and its interaction with society. Current educational issues and technical innovations are lucidly discussed, as is the need for the management of children with visual impairments by a team requiring cooperation between health professionals, teachers, social workers, and the family.Each chapter includes a bibliography with pertinent references. Specific case studies that give a more personal view of the many problems children with visual disabilities face are presented throughout the book. Recommendations for handling specific problems are enumerated.Because two thirds of children with visual impairments also.

To describe trends in the occurrence of the common cold during the first 13 years of life among children who attended different childcare settings early in life. The Tucson Children's Respiratory Study involves 1246 children enrolled at birth and followed up prospectively since May 1980 through October 1984. Children with data regarding day care use during the first 3 years of life were included in this investigation (n = 991). Parents reported the occurrence of frequent (> or = 4) colds during the past year by questionnaire when each child was 2, 3, 6, 8, 11, and 13 years of age. Child care at home (no unrelated children), at small day care (1-5 unrelated children), or at large day care (> or = 6 unrelated children) was reported retrospectively by parental questionnaire when the children were approximately 6 years old. After adjusting for potential confounding variables, compared with children at home those in large day care had more frequent colds at year 2 (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.0-3.4; P =.04), less frequent colds at years 6 (OR, 0.3, 95% CI, 0.1-0.9; P =.02) through 11 (OR, 0.4, 95% CI, 0.1-1.2; P =.09), and the same odds of frequent colds at year 13 (OR,1.0, 95% CI, 0.3-3.8; P =.95). In addition, compared with children in large day care for 1 year or less those attending large day care for more than 2 years had more frequent colds at year 2 (OR, 1.7, 95% CI, 1.0-3.0; P =.04), less frequent colds at years 6 (OR, 0.5, 95% CI, 0.2-1.1; P =.08), 8 (OR, 0.2, 95% CI, 0.1-1.0; P =.04), and 11 (OR, 0.3, 95% CI, 0.1-1.0; P =.05); and the same odds of frequent colds at year 13 (OR, 0.9, 95% CI, 0.3-2.9; P =.80). Attendance at large day care was associated with more common colds during the preschool years. However, it was found to protect against the common cold during the early school years, presumably through acquired immunity. This protection waned by 13 years of age.

To compare the body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and the prevalence of BMI at or above the 85th centile and 95th centile (overweight) in adolescents. Cross-sectional, nationally representative school-based surveys in 1997-1998 by means of identical data collection methods. Austria, Czech Republic, Denmark, Flemish Belgium, Finland, France, Germany, Greece, Lithuania, Ireland, Israel, Portugal, Slovakia, Sweden, and the United States. A total of 29 242 boys and girls, aged 13 and 15 years. The BMI, BMI at or above the 85th centile, and BMI at or above the 95th centile (overweight) from self-reported height and weight. The highest prevalence of overweight was found in the United States and the lowest in Lithuania. On the basis of the study reference standard, the prevalence of overweight (percentage) in the United States was 12.6% in 13-year-old boys, 10.8% in 13-year-old girls, 13.9% in 15-year-old boys, and 15.1% in 15-year-old girls, all significantly increased. Prevalence of overweight in Lithuania was significantly below the expected 5%, with 1.8% in 13-year-old boys, 2.6% in 13-year-old girls, 0.8% in 15-year-old boys, and 2.1% in 15-year-old girls. Relative rankings among countries were similar for BMI at or above the 85th centile, although there were less dramatic differences at this level. The highest prevalences of overweight were found in the United States, Ireland, Greece, and Portugal.

A meningococcal (groups A, C, Y, and W-135) polysaccharide diphtheria toxoid conjugate vaccine (MCV-4; Menactra; Sanofi Pasteur Inc, Swiftwater, Pa) was developed to improve the profile of currently licensed products. The objective of this study was to compare the tolerability, immunogenicity, and immune memory of MCV-4 with those of a quadrivalent polysaccharide vaccine (PSV-4; Menomune A/C/Y/W-135; Sanofi Pasteur Inc). A randomized, double-blind trial was performed at 11 clinical centers in the United States. The vaccine MCV-4 or PSV-4 was administered to 881 healthy 11- to 18-year-olds. Sera were collected prevaccination and 28 days postvaccination. Three-year follow-up and booster vaccination with MCV-4 were performed in a participant subset from each group and a control group. Proportion of participants with a 4-fold or greater increase in serum bactericidal antibody against each serogroup 28 days after initial vaccination, geometric mean serum bactericidal antibody titers, and safety assessments. Both vaccines were well tolerated; most reactions were mild. More MCV-4 recipients reported solicited local reactions (68.9%) than PSV-4 recipients (30.2%). Both MCV-4 and PSV-4 were highly immunogenic; similar proportions of participants had 4-fold or greater increases in serum bactericidal antibody (range, 80.1%-96.7%) to the 4 serogroups. Three-year follow-up showed persistence of serum bactericidal antibody and booster responses to MCV-4 consistent with immune memory in participants previously vaccinated with MCV-4, but not in those who had previously received PSV-4. The vaccine MCV-4 was well tolerated and highly immunogenic. Persistence of bactericidal activity with MCV-4, but not PSV-4, was evident 3 years after the initial immunization. Booster response was demonstrated after a second vaccination with MCV-4.

While many previous reports describe injuries to adolescents in the workplace, few focus on toxic substance exposures among such injuries. Yet low-skill, entry-level jobs pose a particular hazard of toxic exposure owing to the frequent use of cleaning agents, solvents, and/or other chemicals in carrying out assigned tasks. To analyze the types and severity of adolescent occupational toxic exposures. Secondary analysis of calls to a single regional poison control center (PCC). Massachusetts PCC poisoning consultations between 1991 and 1996. Children aged 19 years or younger reporting toxic exposures occurring in the workplace. Of 7024 occupational toxic exposures recorded by the PCC in the 6 years of study, 269 incidents (3.8%) involved adolescents aged 14 to 19 years (median age, 18 years; 124 aged 14-17 years and 145 aged 18-19 years; 65% were male). The most frequently involved agents were cleaning compounds (27.8%); paints, solvents, and glues (9.0%); caustics (8.7%); hydrocarbons (8.7%); and bleaches (7.3%). Of 88 cases (32.7%) in which a worksite was identified, food services (30.7%), automotive services (14.8%), and general retail stores (12.5%) were the most common locations. One hundred fifty-six patients (58.0%) were triaged to an emergency department; 7 were hospitalized. Forty-three subjects (16.0%), 18 who were between the ages of 14 and 17 years and 25 who were aged 18 or 19 years, were judged to have moderate to severe injuries. There were no deaths. This study confirmed the usefulness of PCC surveillance as a source of information about adolescent toxic exposures occurring in the workplace. The occupational toxic exposures reported here most commonly involved cleaning agents, solvents, paints, caustics, and bleach used in those entry-level jobs most frequently filled by adolescents. We conclude that occupational toxic exposures are an underrecognized adolescent injury, and that PCC experience can be used to fill a gap in the surveillance of such workplace-associated events.

To classify features of effective violence prevention programs for 7- to 14-year-olds according to children's risk groups and targeted behaviors. Articles published between 1980 and 1999 were identified via electronic databases (MEDLINE, ERIC, PsychINFO) using the key words violence, violence prevention, youth violence, or aggressive behavior. Reference lists were hand-searched for additional publications. One hundred fifty-three articles were reviewed with a modified scale by one of the principal investigators/authors (W.O.C. or M.L.) and a research assistant (K.F.); the other principal investigator resolved any discrepancies. Articles were included if they reported prevention efforts in 7- to 14-year-olds and compared outcome measures, met requirements for scientific rigor, and reported significant improvements (effect size, >0.1 or P< or =.05). Sixty-seven percent (n = 102) did not meet the inclusion criteria. Of the remaining 51 articles (33%), 38 met requirements for scientific rigor, and 32 articles describing 25 programs reported significant improvements in at least 1 area. Twenty-five programs indicated significant improvements in attitudes, knowledge, or intentions (n = 10) and/or reduction in delinquency rates and violent and/or aggressive behavior (n = 11); significant changes in both types of outcomes were indicated in 4 programs. Most programs (n = 13) targeted older children (aged 11-14 years) and focused on fighting (n = 13) and conflict management (n = 14). Classroom teaching was the most common process (n = 18) used. Few programs (n = 7) involved family intervention. Although limited in number, effective youth violence prevention programs were identified from current literature. Study findings were compiled into a database outlining effective processes for specific sociodemographic and risk behavior groups that will be helpful to future program planning.

FOR ALMOST 6 centuries, visitors to the Brancacci Chapel in Florence, Italy, have been charmed by the toddler shown here clinging to his mother, his little rounded rump dangling over her arm. Masaccio (1401-1428), St Peter Distributing Alms to the Poor (ca 1425), Italian. Fresco. Reproduced with permission from Scala Fine Arts/Art Resource, New York, NY. The frescoes that cover the chapel walls show scenes from the life of St Peter, one of Christ's 12 disciples. In this panel, Peter has traveled to a town in Palestine to spread the gospel and to do good works following Christ's resurrection. A community of believers have sold their personal property and pooled their funds, to be distributed according to need. Peter is shown putting money into the hand of the child's indigent mother. At their feet lies a man named Ananias, who secretly withheld part of the proceeds from selling his property and who fell dead when his deception was exposed.

The sleeping princess pictured on this month's cover could be Sleeping Beauty, waiting for a charming prince to awaken her with a kiss and end her slumber of 100 years. Or she could be the princess from the story of the princess and the pea, who had such delicate skin that her sleep was disturbed by a pea buried beneath 20 mattresses and featherbeds. Instead, she is Princess Ursula, daughter of good King Norus of Brittany in the 5th century AD. According to legend,¹ Ursula was famous far and wide for her beauty, virtue, and wisdom, and she had many suitors. One day the king of Anglia sent his ambassadors to ask for Ursula's hand in marriage to his only son. Ursula did not want to say no, because it was a worthy offer; and besides, the king of Anglia was powerful and might not take rejection lightly. On the other hand, she did not want to say yes, because she was a good Christian girl and did not want to betray her faith by marrying a heathen prince. So, the clever princess agreed to marry the Prince of Anglia only after a waiting period of 3 years, during which he would be baptized and tutored in Christianity.

Previously we reported the rapid emergence and exponential increase of community-acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) infections in South Texas children. To assess whether changes have occurred in the frequency, types, susceptibility, and treatment of CAMRSA infections at Driscoll Children's Hospital. Data from 1990 through 2001 were collected during 2 previous studies. Data from 2002 through 2003 were collected and compared with data from 1990 through 2001. All S aureus isolates were identified by a computer-assisted search of culture results, and the medical records were reviewed for all patients with MRSA infections. A total of 1002 MRSA cases were identified from 1990 through 2003 of which 928 (93%) were community-acquired. The number of CAMRSA cases ranged from 0 to 9 per year from 1990 through 1999 and then increased exponentially from 36 in 2000 to 459 in 2003. The most common type of CAMRSA infection in children without (94%) and with (72%) risk factors was cellulitis and abscess. A higher percentage of children with risk factors had invasive CAMRSA infections (26% vs 3%; P<.001). From 2002 through 2003, there was a significant difference in clindamycin susceptibility between CAMRSA isolates from children without and with risk factors and nosocomial isolates (97% and 86% vs 62%; P<.005). A higher percentage of patients admitted for treatment of CAMRSA infections received an empirical intravenous antibiotic to which the organism was susceptible when comparing 2002-2003 with 1990-2000 (96% vs 15%; P<.001). During this 14-year study, all patients recovered, including those with life-threatening CAMRSA infections. The rapid emergence of CAMRSA as a cause of noninvasive and invasive infections in children, which started occurring in the 1990s, has reached epidemic proportions.

To examine whether sociodemographic factors and health risk and problem behaviors explain the prevalence of cigarette smoking among US adolescents. Probability survey. A nationally representative sample of US adolescents. Weighted prevalence, adjusted odds ratio (OR), and 95% confidence intervals (CIs) for current smoking status by health risk and problem behaviors. The prevalence of smoking was highest among adolescents who were white, older, and who had a high school education or lived in the Northeast. When we adjusted for sociodemographic factors and health risk and problem behaviors, smoking was associated with marijuana use (OR, 3.7; 95% CI, 2.7-5.1), binge drinking (OR, 2.1; 95% CI, 1.6-2.8), and fighting (OR, 1.4; 95% CI, 1.1-1.7) among white adolescent males. Similar associations between each of these 3 behaviors and cigarette smoking were found among white adolescent females and African American and Hispanic adolescent males and females. Cigarette smoking was also associated with using smokeless tobacco, having multiple sexual partners, and not using bicycle helmets among white adolescent males and females, having multiple sexual partners among Hispanic adolescent females, and carrying weapons among Hispanic adolescent males. Marijuana use, binge drinking, and fighting are correlates of cigarette smoking among US adolescents. These associations, which vary by sex and race or ethnicity, suggest clustering to form a risk behavior syndrome.

IN THE LARGER PAINTING ENTITLED CHILDREN'S Games (Figure 1), from which the 5 details on this month's cover are drawn, more than 230 children have taken over the streets of a 16th-century Flemish village. They are playing at more than 85 different pastimes in all. If paintings came with soundtracks, Children's Games might require turning down the volume. Pieter Bruegel the Elder (1525/1530–1569), Children's Games (1560), Flemish. Oil on wood. Copyright Kunsthistorisches Museum, Vienna, Austria.

To determine the incidence of autism among children in Olmsted County, Minnesota. Through the Rochester Epidemiology Project, all inpatient and outpatient diagnoses are indexed for computerized retrieval. This computerized diagnostic index was used to identify children with any developmental disorder. A glossary of symptoms of autism was used to review medical and school records of these children for symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for autistic disorder. Olmsted County, Minnesota. Subjects All residents of Olmsted County 21 years or younger between 1976 and 1997. Main Outcome Measure The incidence of research-identified autism based on DSM-IV criteria for autistic disorder. The age-adjusted incidence of research-identified autism was 5.5 (95% confidence interval, 1.4-9.5) per 100 000 children from 1980 to 1983 and 44.9 (95% confidence interval, 32.9-56.9) from 1995 to 1997 (8.2-fold increase). This increase was confined to children younger than 10 years who were born after 1987. The incidence of research-identified autism increased in Olmsted County from 1976 to 1997, with the increase occurring among young children after the introduction of broader, more precise diagnostic criteria, increased availability of services, and increased awareness of autism. Although it is possible that unidentified environmental factors have contributed to an increase in autism, the timing of the increase suggests that it may be due to improved awareness, changes in diagnostic criteria, and availability of services, leading to identification of previously unrecognized young children with autism.

To assess the association between vigorous physical activity, participation on sport teams and in exercise programs, television watching, family environment, and weight status in youth. Cross-sectional data from the Third National Health and Nutrition Examination Survey. A group of 2791 youth between the ages of 8 and 16 years who were enrolled in the Third National Health and Nutrition Examination Survey. Overweight was defined using age- and sex-specific 85th percentile of body mass index using Center for Disease Control and Prevention growth charts. Both males and females who had an overweight mother and or father were more likely to be overweight compared with youth who did not have an overweight parent. Females who watched 4 or more hours of television were more likely to be overweight than those who watched less than 4 hours. Males and 14- to 16-year-old females who participated in sport team and exercise programs were less likely to be overweight than their counterparts who did not participate. Also, females with larger families and males from families with higher family incomes were less likely to be overweight. These results suggest that family environment is associated with overweight in youth and that sport and exercise program participants are less like to be overweight and that, for females, increased television watching is related to overweight.

To evaluate renal function in a population-based cohort with urographic renal scarring after childhood urinary tract infection (UTI). Follow-up investigation 16 to 26 years after the first recognized UTI. Outpatient university clinic for children with UTI serving the local area. From the original cohort of 1221 consecutive children with first UTI diagnosed during 1970 to 1979, 57 (41 females and 16 males; mean age, 24.5 years) of 68 with nonobstructive renal scarring participated as well as 51 (38 females and 13 males; mean age, 24.9 years) matched subjects without scarring. Glomerular filtration rate (GFR) measured by chromium 51-EDTA clearance, expressed as milliliters per minute per 1.73 square meters. Median GFR was 99 in both those with and without renal scarring. In patients with unilateral scarring, the total GFR remained unchanged over the years whereas the individual GFR of the scarred kidneys declined significantly from 46 to 39. In 7 patients with bilateral scarring, the GFR declined from 94 to 84 (P = .14); compared with those with unilateral scarring, the GFR was significantly lower at follow-up (P = .007). Median urinary albumin-creatinine ratio was 1.2 and 0.6 mg/mmol in those with scarring and those without, respectively (P = .30). The GFR 2 decades after the first recognized UTI in childhood was well preserved. However, a significant reduction of individual renal GFR in the unilaterally scarred kidneys indicates that further follow-up is required. Although there were few patients with bilateral scarring, a more serious prognosis can be expected among them.

Each year, boys and girls all over Holland look forward to December 5 with eager anticipation. It is the night called Sinterklaas, named after the patron saint of children and sailors, a venerated figure in this seafaring land. St Nicholas arrives from the sea wearing an embroidered, jewel-studded robe and bishop’s miter, riding a white horse, carrying a crooked staff, and accompanied by his faithful servant, Black Piet. On the night of December 5, they scamper about the rooftops of Holland, dropping gifts and goodies down the chimney into shoes and stockings left near the fireplace. Often, children leave carrots or hay in their shoes as a snack for the bishop’s horse. With a little help from their parents, wise old St Nick knows which boys and girls have been good and which have been naughty or lazy during the year, and he gives what he thinks each child deserves.

To determine whether an interactive curriculum that integrates dating violence prevention with lessons on healthy relationships, sexual health, and substance use reduces physical dating violence (PDV). Cluster randomized trial with 2.5-year follow-up; prespecified subgroup analyses by sex. Grade 9 health classes. A total of 1722 students aged 14-15 from 20 public schools (52.8% girls). Intervention A 21-lesson curriculum delivered during 28 hours by teachers with additional training in the dynamics of dating violence and healthy relationships. Dating violence prevention was integrated with core lessons about healthy relationships, sexual health, and substance use prevention using interactive exercises. Relationship skills to promote safer decision making with peers and dating partners were emphasized. Control schools targeted similar objectives without training or materials. The primary outcome at 2.5 years was self-reported PDV during the previous year. Secondary outcomes were physical peer violence, substance use, and condom use. Analysis was by intention-to-treat. The PDV was greater in control vs intervention students (9.8% vs 7.4%; adjusted odds ratio, 2.42; 95% confidence interval, 1.00-6.02; P = .05). A significant group x sex interaction effect indicated that the intervention effect was greater in boys (PDV: 7.1% in controls vs 2.7% in intervention students) than in girls (12.1% vs 11.9%). Main effects for secondary outcomes were not statistically significant; however, sex x group analyses showed a significant difference in condom use in sexually active boys who received the intervention (114 of 168; 67.9%) vs controls (65 of 111 [58.6%]) (P < .01). The cost of training and materials averaged CA$16 per student. The teaching of youths about healthy relationships as part of their required health curriculum reduced PDV and increased condom use 2.5 years later at a low per-student cost.

To determine whether sequential laboratory and clinical evaluations during the first 3 days of postnatal life can be used to safely limit the duration of antibiotic therapy for term neonates whose mothers received intrapartum antibiotic treatment for intra-amniotic infection (ie, chorioamnionitis). Since postpartum neonatal body fluid cultures can be falsely negative because of transplacental passage of maternal antibiotics, we prospectively followed up 6620 pregnancies for 28 months (December 1991 through March 1994) for the occurrence and treatment of chorioamnionitis. Neonatal antibiotic therapy was initiated and limited to 3 days or continued for 7 days or more in neonates with abnormal laboratory values or clinical signs that were consistent with sepsis on day 3 of postnatal age. Both groups were observed in the hospital for 24 to 48 hours after antibiotics were discontinued. Of the 6620 pregnancies, 158 infants (2.4%) born to 155 mothers received intrapartum antibiotics for chorioamnionitis; 10 additional neonates diagnosed as having chorioamnionitis were transported from other hospitals (N = 168). Because of the absence of signs and negative cultures, 82% (137/168) were treated with antibiotics for 3 days, while 18% (31/168) received 7 days or more of therapy. In 84% of the 3-day group, discharge was accomplished by postnatal day 4 or 5, whereas all of the 7-day or more group were discharged after day 8. Follow-up calls placed 1 month after discharge disclosed no adverse outcomes or hospital readmissions in any of the infants in this survey. Neonates with infection who are born to mothers pretreated with antibiotics for intra-amniotic infection can be reliably identified less than 72 hours after birth and treated appropriately. As 82% of at-risk patients are asymptomatic and have a negative body fluid culture, our data support the position that a full course of antibiotic therapy can be restricted to only those patients with clinical or laboratory signs of sepsis (18%). This will effective reduce the average length of hospital stay for intrapartum-treated neonates by a minimum of 3 to 4 days compared with a commonly used empiric therapy approach of continuing medication for 7 days or more. Perhaps hospital discharge can be further shortened if a 1- to 2-day posttreatment observation period is eliminated for all patients except those with a positive body fluid culture.

When I was an intern, the Harriet Lane Handbook was my security blanket—I carried it everywhere. My new white coat soon bore the rectangular imprint of my constant companion, an imprint that proudly announced my growing status as a seasoned intern. I used the Handbook with almost every admission to the hospital, to write orders, check medication dosing, and confirm my differential diagnoses and management plans. When I became a junior resident, my relationship with Harriet Lane changed. The Handbook became less like my security blanket and more like a trustworthy friend. Although I didn't always need to have the Handbook with me, I did consult it for every major decision—checking medications, confirming formulas, or consulting tables and algorithms. And like any good friend, the Harriet Lane Handbook was a source upon which I could steadfastly rely.

The association of psychiatric disorders (PDs) with other PDs and medical disorders (MDs) has been insufficiently explored in children and adolescents. To estimate medical and psychiatric comorbidity present in children with PDs and to determine the medical service usage of children with PDs. We use administrative health care data to describe the health care provided for study children. Psychiatric disorders were classified into the following 3 categories: psychosis, emotion, and behavior. We used logistic regression to assess medical comorbidity for each category. Psychiatric comorbidity was determined using chi(2) test analysis. Health care use was determined by comparing the frequency of visits for MDs and PDs between children with PDs and children without PDs. We studied 406,640 children (50.6% male) between 6 and 17 years old, living in Alberta, Canada, during the fiscal year April 1, 1995, through March 31, 1996. A PD was diagnosed in 32,214 (60.3% male) children. Psychiatric comorbidity was present in 13.6% of the children; comorbidity existed in all 3 psychiatric groups and peaked in postpubertal children. More girls than boys had significant medical comorbidity. Significant odds ratios (ORs) for girls varied from 1.2 (behavior and sinusitis, bronchitis, and chronic disorders; psychosis, and menstrual problems) to 15.3 (behavior and developmental delay). Among boys, the highest OR was seen with the combination of behavior and developmental delay (OR, 8.3) and psychosis and poisoning (OR, 8.2). With ORs ranging from 4.6 to 15.3, developmental delay consistently had high ORs for both sexes and all 3 types of PDs. Poisoning also had high ORs (3.3-14.1) with all 3 PDs and both sexes. Among girls, disorders associated with pregnancy and the genitourinary system had modest associations (OR, 1.9-2.2, for behavior) to moderate (OR, 2.5-4.0, for emotion). Children with PDs had significantly greater medical service usage than did children without PDs. Girls had greater medical health care usage than boys. Psychiatric service usage was similar for both sexes. Medical and psychiatric comorbidity exist in children with PDs. Girls are more commonly affected. Health care usage is higher in children with PDs.

To investigate associations of mental disorders and physical illnesses during adolescence with quality of life (QOL) 17 years later. The Children in the Community Study, a prospective longitudinal investigation. Upstate New York. A community-based sample of mothers and their offspring were interviewed. Axis I disorders and Axis II personality disorders and physical illnesses were assessed by self-report and mother report in 1985-1986. Outcome indicators of QOL were assessed in 2001-2004. Compared with participants without adolescent illness or disorder, those with a history of physical illness reported poorer physical health (mean difference [MD], -4.8); those with a history of an Axis I disorder reported poorer physical health (MD, -8.0) and more problematic social relationships (MD, -4.5); and those with a history of personality disorder reported poorer physical health (MD, -8.2), more problematic social relationships (MD, -5.0), lower psychological well-being (MD, -3.6), and more adversity within their environmental context (MD, -4.6) in adulthood. Comorbid physical illness and mental disorder were associated with all 5 QOL domains (MD, -3.1 to -11.9). After adjusting for all demographic variables and comorbidity, associations remained between physical illness and poor physical health (effect size [ES], -0.33); an Axis I disorder and problematic social relationships (ES, -0.37); and personality disorder and problematic social relationships (ES, -0.36), low psychological well-being (ES, -0.23), impaired role function (ES, -0.24), and an adverse environmental context (ES, -0.50). Mental disorders may have more adverse long-term associations with QOL than do physical illnesses. Adolescent personality disorders may have a more adverse impact on adult QOL than do adolescent Axis I disorders.

Parents communicate their aspirations for their children in various ways. Charles Willson Peale was not subtle; he named 6 of his 17 children Raphaelle, Rembrandt, Rubens, Titian, Angelica Kauffmann, and Sophonisba Angusciola. The strategy worked. Three of them grew up to be professional artists, including Rembrandt Peale, who painted this affectionate portrait of his 17-year-old brother Rubens when the artist was 23.Rembrandt Peale (1778-1860), Rubens Peale with a Geranium, 1801. Oil on canvas, 71.4 × 61 cm. From the Patrons’ Permanent Fund, © 2005 Board of Trustees, National Gallery of Art, Washington, DC.

To determine (1) patterns of secure vs insecure attachment relationships in infants of adolescent and nonadolescent mothers and (2) if these patterns are mediated by parenting characteristics, including depression, self-esteem, parenting stress, child abuse potential, psychological distress, rating of infant temperament, and the caregiving environment. Fifty-one adolescent mothers and their 18-month-old infants were compared with 76 nonadolescent mothers and their 18-month-old infants. Infant attachment classifications were assessed via the Ainsworth Strange Situation. Maternal and infant characteristics were obtained through self-report measures. There were no differences in attachment classification between infants of adolescent mothers and nonadolescent mothers. Secure attachment classification was found in 67% of the infants of adolescent mothers and 62% of the infants of nonadolescent mothers. There were significant differences in the self-reported maternal characteristics. Adolescent mothers reported lower self-esteem (P<.05), more parenting stress (P<.05), more child abuse potential (P<.05), and provided a lower quality of home environment (P<.05) than nonadolescent mothers. Adolescent mothers also rated their infants as having a higher activity level (P<.05) than infants born to nonadolescent mothers. In multivariate analysis, none of these variables or social classes were found to affect attachment classification. Infants of adolescent and nonadolescent mothers show similar patterns of attachment. Adolescent and nonadolescent mothers show substantial differences in parenting characteristics and in how they rate their infants' temperaments. However, these differences do not seem to impair the infant-mother attachment relationship.

To assess the effect of loss to follow-up rates at 18 to 24 months on neurodevelopmental outcome statistics for infants of less than 1000 g birth weight or less than 28 weeks' gestational age. MEDLINE, EMBASE, PubMed, and Cochrane Library databases (January 1, 2000, to June 30, 2010). We searched for studies reporting outcomes of infants of less than 1000 g birth weight or less than 28 weeks' gestational age who were born after 1990. Eligible articles had to report the primary outcome and follow-up rates at 18 to 24 months. Our primary composite outcome of neurodevelopmental impairment (NDI) was any of a mental developmental quotient 2 SDs below the mean, using the Bayley Scales of Infant Development II; cerebral palsy; visual impairment; or significant hearing impairment. Of 43 publications describing outcomes at 18 to 24 months, 20 provided rates of follow-up, describing a total of 34,185 infants. The NDI rates ranged between 12.4% and 57.5%. Follow-up rates ranged between 71.6% and 100%. Higher rates of NDI were significantly correlated with greater loss to follow-up (r(2) = 0.38, P = .007). Higher rates of both NDI and loss to follow-up were seen in the United States compared with Canada, the United Kingdom, Finland, Denmark, Austria, Germany, and Australia (r(2) = 0.70, P = .001). Ascertainment bias may overestimate NDI in extremely low-birth-weight or extremely low-gestational-age survivors at 18 to 24 months. Alternatively, the characteristics of different populations and health systems may contribute to higher rates of attrition and higher rates of NDI.