Clinical Pediatrics

Schwartz, Richard H.; Cohen, Peter; Hoffmann, Norman G.; Meeks, John E.

doi: 10.1177/000992288902800801pmid: 2788059

Deliberate self-lacerations by rebellious or delinquent adolescent girls, known by them as "carving," may be erroneously diagnosed as a suicide gesture. Carving is an important physical sign suggesting possible drug and alcohol abuse during adolescence. Eighty-five adolescent female patients in a long-term outpatient, self-payment, therapeutic community-type of adolescent drug treatment program, participated in a descriptive survey of "carving" behaviors. Forty-one girls (48%) admitted to deliberate cutting of their own wrists, arms, or other body parts without suicidal intent. Fifteen of the 85 girls (18%) cut themselves six or more times. Many girls had scarified their bodies with their boyfriends' initials as a visible means of demonstrating their affection and loyalty. They also carved rock group symbols or a Christian cross. Large and disfiguring scars were noted on 14 patients. The girls explained the behavior as a method of dealing with depressed affect, anger, emotional pain, or emptiness.Suicide attempts, usually by purposeful overdose of medication, had been made by 24 (59%) of 41 girls who carved themselves. Multiple suicide attempts were associated with habitual carving. Epidemics of carving, led by one or more angry, depressed, or lonely adolescents, may occur in closed facilities such as correctional institutions and drug abuse treatment facilities.

Accardo, Pasquale; Whitman, Barbara

doi: 10.1177/000992288902800802pmid: 2474401

Toe walking unassociated with an autistic disorder or cerebral palsy generally has been considered a normal infant gait. The incidence of toe walking in various diagnostic subgroups of 799 developmentally disabled children presenting to a tertiary-level multidisciplinary assessment clinic was reviewed to investigate the authors' clinical impression that toe walking may be a marker for language dysfunction.Toe walking was found to be more frequent in those diagnostic subgroups with more severe language disorders. Toe walking also correlated with lower IQ scores (p < 0.0001). The sensitivities, specificities, predictive validities and odds ratios all supported the hypothesized association between toe walking and language disorders.Further prospective studies of the neurodevelopmental outcome of children with toe walking are needed to determine whether this behavior can identify children at risk for language disorders.

Squires, Robert H.

doi: 10.1177/000992288902800803pmid: 2758717

Vomiting is seen as a symptom in patients with brain tumors, but it rarely leads to the diagnosis in the absence of a recognized neurologic deficit. Five patients were referred to a pediatric gastroenterologist for outpatient evaluation of persistent vomiting and were subsequently found to have an intracranial mass lesion. The paucity of neurologic findings and the absence of headaches in most of these patients caused the referring physicians to focus on the gastrointestinal tract and not the central nervous system as the cause of the patients' vomiting. The pathophysiology of vomiting and evaluation of these patients is discussed; recognizable patterns of vomiting in these patients are described.

Caputo, Anthony R.; Wagner, Rudolph S.; Reynolds, David R.; Guo, Suqin; Goel, Ameet K.

doi: 10.1177/000992288902800804pmid: 2527102

A total of 187 medical records of Down syndrome individuals over a 10-year period were reviewed retrospectively for strabismus, myopia, hyperopia, astigmatism, nystagmus, cataract, glaucoma, and other significant eye findings. This study showed that a higher proportion of these individuals than reported in previous studies had strabismus (57%). Refractive errors of myopia (22.5%), hyperopia (20.9%) and astigmatism (22%) were common. The primary care physician needs to be aware of the specific eye problems of Down syndrome individuals so that he or she may initiate or refer the patient for appropriate ophthalmologic care, because most of the eye findings in Down syndrome are treatable. Significant visual loss, a usually avoidable event in Down syndrome, should occur rarely.

Hicks, Ralph A.; Cullen, John W.; Jackson, Mary Anne; Burry, V. Fred

doi: 10.1177/000992288902800805pmid: 2527103

A cost-benefit analysis of routine active immunization against hepatitis B virus (HBV) for 500 nursing personnel at The Children's Mercy Hospital in Kansas City, Missouri, is described. Based on outcomes of HBV infection, local charges for medical care and wages lost from illness, the authors calculate the average cost per case of HBV infection to be $1,990. Including the current system of postexposure prophylaxis and an annual attack rate of 1 percent the current annual cost of HBV infection in The Children's Mercy Hospital is $12,630.The HBV immunization program would have to continue for 15 years before its cumulative costs ($189,133) were exceeded by those of the current system ($189,450). Therefore routine immunization of nurses would not be cost effective in the near future. If, however, a subset of high-risk employees with a 2 percent attack rate is identified, or the cost of the HBV vaccine series fell from the current $103 to $27, then routine immunization would become cost beneficial within 6 years.

Schum, Timothy R.

doi: 10.1177/000992288902800806pmid: 2667835

Management of psychosocial issues associated with hospitalization are essential to the practice of pediatrics. The personal experience of our son's prolonged hospitalization due to osteomyelitis (23 days) was detailed by an ongoing diary. The impact of this hospitalization on our family is presented, including: 1) normal but bothersome behavioral changes in the patient and his sibling; 2) the effects of excessive parental stress; 3) the development of parental coping strategies ; and 4) stresses and coping strategies specific to a physician-father. Specific recommendations are presented to assist health professionals in addressing psychosocial issues.

Roach, E.S.; Sinal, Sara H.

doi: 10.1177/000992288902800807pmid: 2758718

Four infants with newly diagnosed cystic fibrosis developed a bulging anterior fontanel within days of starting enzyme replacement treatment. In the same time period, 41 hospitalized patients less than 1 year of age were diagnosed as having cystic fibrosis and treated, suggesting that increased intracranial pressure is common in this setting (9.7%).The clinical course of the four infants was similar: the bulging fontanel became apparent 1-6 days after initiation of pancreatic enzyme replacement and resolved within 1 week in three patients and within 4 months in the other patient. Two patients became mildly irritable. Computed cranial tomography and lumbar puncture were done in three patients, with completely normal findings except elevated cerebrospinal fluid pressure in two infants. There was no apparent difference in the treatment or clinical course before diagnosis between the four infants who developed a transient bulging fontanel compared with the overall group of cystic fibrosis patients.

Mandel, Scott H.; Magnusson, A. Roy; Burton, Brent T.; Swanson, J. Robert; LaFranchi, Stephen H.

doi: 10.1177/000992288902800808pmid: 2758719

The clinical course of a 29-month-old girl who was referred for evaluation after ingesting ninety 0.2-mg tablets of levothyroxine is reported. Despite an initial thyroxine (T4) level of 282 μg/dl and a triiodothyronine (T3) level of 1,837 ng/dl at 48 hours postingestion, her symptoms were mild and included irritability, vomiting, tremor, and tachycardia. Treatment was limited to activated charcoal and propranolol. Thyroid hormone levels fell to normal by 13 days postingestion. The child's clinical course was benign.Even after massive acute ingestions of levothyroxine, children's symptoms are usually mild and may be controlled with propranolol. This conservative approach should be considered before expensive and potentially dangerous therapies are undertaken.

Merine, Dimitri; Nussbaum, Anna R.; Fishman, Elliot K.; Sanders, Roger C.

doi: 10.1177/000992288902800809pmid: 2667836

The sonographic findings in a patient with typhlitis are presented. Sonography showed a solid mass with a "target" sign in the right lower quadrant, continuous with the ascending colon. In addition to suggesting the diagnosis, sonography was helpful in the follow-up examination of the patient because it was able to assess the gradual decrease in the thickness of the bowel wall and ultimate resolution of the inflammatory process.

Shannon, Michael; Graef, John W.

doi: 10.1177/000992288902800810pmid: 2758720

The lead found in drinking water can be a source of lead poisoning to young children, particularly those who consume large amounts of water. The authors describe a 13-month-old infant who was discovered to have plumbism during routine evaluation. The lead source was ultimately traced to the daily administration of powdered formula which was prepared with home tap water having a first-draw lead content of 130 parts per billion. This case suggests that whenever infants are fed powdered formula, consideration should be given to analysis of the home tap water for lead content.