Drinking patterns and social consequences: a study of middle-class adolescents in two private pediatric practices.

One hundred sixty-two adolescents who were seen at two suburban private pediatric practices completed an anonymous, written questionnaire about drinking and drug habits. The respondents' ages ranged from 14 to 17 years; all were white and from middle- or upper middle-class families. The adolescents reported high self-esteem, good general health, and few psychologic problems. The majority (63%) reported having drunk alcohol at some time, and the proportion who professed never to drink alcohol became progressively smaller with age, to only 15% at age 17 years. Overall, one fifth claimed that they had to drink more than six beers before they "got a buzz," and this proportion increased to 43% by age 17 years. Among the 17-year-old respondents, 40% replied that their good friends had used alcohol more than 50 times. Twenty-four percent of respondents said that a good friend had received a citation for driving while intoxicated. Almost one fifth of respondents stated that someone in their family drinks alcohol every day, and that someone close to them has a drinking problem. Social acceptance of drinking, peer pressure, and the ready availability of alcohol have led to an epidemic of alcohol use among teenagers and to social, academic, and health problems in many frequent users. Pediatricians should play a more active role in the identification and management of alcohol abuse by their adolescent patients.

Vaccine storage practices in pediatric offices.

Fifty pediatric offices and clinics in the metropolitan Los Angeles area were visited to assess vaccine storage practices. Questionnaires were administered to the personnel responsible for vaccine storage and the vaccine refrigerators were inspected. Only 16% of vaccine storage coordinators could cite appropriate storage temperatures for vaccines and 18% were unaware that heat can harm certain vaccines. Refrigerator thermometers were checked at least weekly in only 20% of offices, and 22% of the refrigerators had inappropriately high temperatures. Vaccines were routinely stored outside of the refrigerator uninsulated during the practice day in 16% of the offices visited. It is concluded that vaccine storage errors occur in pediatric offices at an unacceptably high frequency. Pediatricians should familiarize themselves with the guidelines for optimal vaccine storage in order to minimize the potential for vaccine failure in primary care practice.

Current status of mumps and mumps vaccine in the United States.

Reported mumps in the United States has declined to all-time low levels following the increasingly widespread use of mumps-virus vaccine. Mumps vaccine has proven safe and effective. Its incorporation into combined live-virus vaccines, especially measles-mumps-rubella, has made mumps vaccination a practical and economically feasible component of routine immunization activities. Because of the favorable experience to date with mumps vaccine and the associated drop in mumps morbidity and mortality, mumps control programs likely will receive increasing public health attention in the coming years.

Structured guidelines for the use of influenza vaccine among children with chronic pulmonary disorders.

National committees recommend annual influenza vaccination for children > or = 6 months of age with chronic pulmonary diseases, but several studies have suggested that many high risk children do not receive the vaccine. The purpose of this pilot study was to determine whether the use of structured guidelines for which pulmonary disorders warrant influenza vaccination would increase agreement among physicians on whether specific children should be vaccinated. Hospital records of 73 children with an outpatient appointment during the previous month in the pulmonary, allergy or high risk neonatology clinics were reviewed independently by 4 pediatricians. Two reviewers used a set of specific guidelines in deciding whether influenza vaccination was indicated, whereas the other 2 used unspecified clinical judgment. Interrater agreement concerning the advisability of vaccination was higher between the reviewers using the guidelines (overall agreement, 0.89; kappa = 0.73) than between the reviewers using clinical judgment (overall agreement, 0.68; kappa = 0.31). Even among the 34 children for whom all 4 reviewers thought the vaccine advisable, only 13 (38%) had been vaccinated. Studies to define the risk of severe influenza among children with specific lung disorders are needed, but these guidelines can serve as a starting point for the identification of children who deserve individual consideration for annual influenza vaccination.

Comparison of three topical antimicrobials for acute bacterial conjunctivitis.

One hundred fifty-eight patients, 21 years of age or less, presenting with culture-positive (Haemophilus influenzae or Streptococcus pneumoniae) conjunctivitis were treated with trimethoprim-polymyxin B (TP), gentamicin sulfate (GS) or sodium sulfacetamide (SS) ophthalmic solution for 10 days. Clinical response at 3 to 6 days after start of therapy was similar for all test agents: 26 of 55 (47%) patients cured, 25 of 55 (45%) improved for TP; 28 of 57 (49%) cured, 26 of 57 (46%) improved for GS; and 19 of 46 (41%) cured, 22 of 46 (48%) improved for SS. Clinical response at 2 to 7 days after completion of therapy was also similar: 46 of 55 (84%) patients cured, 5 of 55 (9%) improved for TP; 50 of 57 (88%) cured, 5 of 57 (9%) improved for GS; and 41 of 46 (89%) cured, 2 of 46 (4%) improved for SS. Bacteriologic response at 2 to 7 days after completion of therapy was similar for all antimicrobials: 44 of 55 (83%) patients for TP; 39 of 57 (68%) for GS; and 33 of 46 (72%) for SS.

Rhinovirus inactivation by nasal tissues treated with virucide.

Rhinovirus colds may be transmitted by hand-to-hand contact followed by self-inoculation of nasal and/or conjunctival mucosa with virus contaminating the fingertips. The purpose of this study was to determine whether impregnation of nasal tissues with virucidal compounds could prevent rhinovirus from passing through the tissue and thus provide a means of preventing hand contamination during nose blowing. Paper tissues treated with a combination of citric acid, malic acid, and sodium laruryl sulfate were compared to placebo tissues containing sodium saccharin. Recovery of infectious virus was significantly reduced by passage of the virus-containing medium through virucidal versus placebo tissue (1/18 vs. 17/18 respectively, P less than 0.001, Fisher exact test). The virucidal effect of treated tissues was demonstrated for multiple rhinovirus serotypes suspended in either cell culture medium or nasal mucus. Virus contained in mucus from infected volunteers was also inactivated.

Explanation for false-positive urine cultures obtained by bag technique.

OBJECTIVE: To test whether a urine bag technique, previously shown in circumcised male infants 1 month to 1 year of age to yield no false-positive cultures, would give similar results in newborns (females and circumcised and uncircumcised males). DESIGN: Prospective study in which periurethral and urine specimens were obtained from healthy newborns. After the periurethral specimen was obtained, the perineum was washed and a urine bag applied. The urine bag was removed immediately after voiding and the urine was cultured. SETTING: Normal newborn nursery and pediatric hospital. SUBJECTS: Ninety-eight healthy full-term newborns (49 female and 49 male) admitted to the normal nursery during a 4-month period. MAIN RESULTS: Isolation of a pathogen from the bag urine reflected periurethral flora. In 20 (95%) of the 21 urine specimens from which a pathogen was isolated, the same pathogen was detected on the periurethra. Sixteen of the 21 urine cultures were falsely positive (> 10(4) colony-forming units of pathogen per milliliter). In 50 (98%) of the 52 urine samples that yielded no growth, the periurethral culture was also negative. In the remaining 25 urine samples in which nonpathogens were detected, the periurethra yielded nonpathogens or no growth. Thus, if a pathogen was isolated from a bag urine sample, the same pathogen was detected on the periurethra 95% of the time. Conversely, if the bag urine sample was negative for a pathogen, the periurethral culture was negative 100% of the time. The presence of a pathogen on the periurethra was more common in female than male neonates (16 of 49 vs four of 49; P = .004), and none of the 14 circumcised male neonates had a pathogen detected on their periurethra or in their urine. CONCLUSION: This study explains the finding of false-positive cultures with the bag technique. Pathogens detected in bag urine samples reflected pathogens on the periurethra. Until a bag collection technique that avoids contamination by periurethral flora can be developed, urethral catheterization and suprapubic aspiration remain the methods of choice for obtaining a urine specimen in female and uncircumcised male neonates.

Worldwide control of disease through immunization. Progress and prospects.

In summary, tremendous advances have been made over the past 15 years toward the development of effective national immunization programs throughout the world. Immunization levels among children in the developing world have risen dramatically, and in some instances, now equal or exceed levels in industrialized nations. There is no room for complacency, however, because millions of children remain incompletely immunized and many die each year from measles, pertussis, and neonatal tetanus. Immunization activities need to be intensified, accelerated, and sustained within the context of the primary health care system. Expansion of immunization programs to include additional vaccines and other simple health interventions will yield further benefits in the years ahead.

The bifid uvula: is it a marker for an otitis prone child?

All children seen by a pediatrician in a suburban practice during an 18-month interval were examined carefully for the presence of an abnormal uvula. Isolated bifid uvula, without overt cleft palate, was detected among 44 children who had been followed in the practice during the first three years of life. A chart review was performed to determine the frequency of acute otitis media (AOM) and of insertion of tympanostomy tubes among these study patients and among age-matched controls with normal uvulas. Compared to control children, a slightly higher proportion of children with bifid uvulas had experienced more than one episode of AOM (64% vs. 49%) and more than three episodes of AOM (16% vs. 8%) during the first year of life, but these differences were not statistically significant. By age 3 years, the incidences of AOM in the compared groups were more nearly equal. Insertion of tympanostomy tubes during the first three years of life for persistent middle ear effusion was slightly more common among the bifid uvula group than among the controls (14% vs. 10%), but this difference again was not statistically significant. Children with bifid uvula may be at slightly increased risk of middle ear problems during the first years of life, but the magnitude of this increase, if any, appears small.

Urinary cannabinoids in monitoring abstinence in a drug abuse treatment program.

Urine specimens from 162 adolescents entering a drug treatment program were tested for cannabinoids using a photometric immunoassay (EMITst) and thin-layer chromatography (TLC). The EMITst has a cutoff point of detection 25 ng/mL or less of 9-carboxy-tetrahydrocannabinol. When reported as positive, both tests appeared to be reliable. There were two false-positive EMITst results and three false-positive TLC results in the 67 urine specimens that did not contain cannabinoids. When reported as negative, however, the EMITst with its 100 ng/mL cutoff failed to detect almost 40% of all cannabinoid-positive specimens. Of the 65 chronic marijuana smokers in the present study who stated that they had smoked within two days of their admission into the treatment facility, 17 (26%) went undetected by the 100 ng/mL cutoff used by the EMITst method. In clinical settings such as drug treatment programs, tests for urinary cannabinoids should use a detection threshold at 20 ng/mL or less.

Antibiotic-seeking behavior in college students: what do they really expect?

Injudicious use of antibiotics contributes to increased bacterial resistance, and patient expectations encourage physicians to overuse antibiotics. The authors evaluated the level of ill college students' antibiotic-seeking behavior to determine if receiving an antibiotic prescription influenced patients' satisfaction with visits to a clinician. Of 129 students with upper respiratory complaints presenting to a university health center, 55% expected an antibiotic prescription. Antibiotic expectation was significantly more likely among students who thought they had a bacterial versus a viral infection (90% vs 40%; p < .01). A clear diagnosis, an explanation of the rationale for treatment, and an antibiotic prescription were significantly associated with patient satisfaction. Clinicians prescribed an antibiotic for 36% of the students; only 13% of these 46 had requested an antibiotic during the visit. At some previous time, one third of the students had taken an antibiotic prescribed for an earlier illness or for another person. Better patient education and improved clinician-patient communication can potentially help to reduce the injudicious use of antibiotics.

Acute suppurative otitis media in children. Diversity of clinical diagnostic criteria.

Practicing pediatricians were surveyed via mailed questionnaire and a review was made of the pertinent literature in an attempt to identify suitable criteria for making the clinical diagnosis of acute suppurative otitis media (ASOM) in children. Clinical diagnostic criteria were described in only 26 of the 43 studies reviewed; 18 different sets of criteria were used. Use of identical criteria in more than one study was usually the result of multiple publications by particular authors rather than agreement between two investigators. One hundred and sixty-five questionnaire respondents proposed 147 different sets of criteria. Only 11 criteria sets were proposed by more than one respondent, and no single set was listed by more than six respondents. Greater standardization of clinical diagnosis is desirable, but difficult to achieve and will require additional studies to correlate clinical findings with objective measures of diagnosis, such as tympanocentesis.

Baby powder use in infant skin care. Parental knowledge and determinants of powder usage.

One hundred parents of infants aged 2 weeks to 6 months were surveyed at the time of routine well-child visits to assess parental knowledge about baby powder and to determine whether hospital policy of providing a free powder sample to newly delivered mothers was unwittingly promoting powder usage. Most parents (69%) reported regular baby powder use as part of routine infant skin care. Powder-users were significantly more likely than nonusers to attribute to baby powder the ability to kill bacteria and yeast and to prevent diaper rash (p less than 0.01). Even among nonusers, fewer than half were aware that aspiration/ingestion of baby powder was a potential health hazard. Almost all parents reported receiving a free sample of baby powder while in the hospital as part of a complimentary gift pack provided by the manufacturers. Most powder-users were currently using a brand they had received as a sample, and eight parents cited the receipt of a sample as the major determinant for selecting a particular brand of powder. The short- and long-term effects of distributing sample packs to newly delivered parents deserve further study.

Nonparametric methods. Clinical applications.

In clinical research, "samples" are studied in order to get ideas about the characteristics of the larger populations from which the samples are taken. Population characteristics are called parameters (the population mean and standard deviation are examples). Parametric statistical methods are those that require estimates of parameters and assumptions about the source populations. Familiar examples of parametric methods are the t test, analysis of variance, and Pearson's correlation coefficient. Nonparametric (NP) methods do not require estimates of population parameters. These methods are sometimes called "distribution-free" because the samples of interest can be evaluated without concern for the shape (distribution) of the values in the populations providing the samples. NP methods also are called "ranking" or "ordering" tests, because the relative size or order of the observations may be evaluated, rather than requiring actual measurements. More than 30% of the research reports that appeared between July 1982 and June 1983, in four pediatric journals, employed at least one nonparametric method. The commonly used tests were chi-square, the Fisher exact test, and various "ranking" methods. An alphabetical list of common nonparametric tests is presented, with brief comments about each. Tables are presented, arranged by types of observations, so that the nature of the data guides the user to the method that might be used.

Children less than three-years-old with pharyngitis. Are group A streptococci really that uncommon?

During a 15-month period, 148 infants and children less than 3-years-old who presented with signs and/or symptoms of pharyngitis were monitored in a private pediatric practice. Clinical signs included fever (95 or 64%), tonsillar exudate (16 or 11%), and cervical adenopathy (5 or 3%). Beta-hemolytic streptococci (BHS) from group A were isolated from throat swabs in 37 (25%) instances. These isolations were more common among children 25-35 months old than among children less than 2 years old (35% vs. 19%, p less than 0.05), and were significantly more likely when overnight anaerobic culture techniques were used rather than conventional aerobic methods (23% vs. 11%, p less than 0.01). Group A BHS may be isolated relatively frequently from symptomatic children under 3-years-old. Whether these isolations reflect invasive infection or asymptomatic carriage is uncertain.

Use of an anaerobic culture jar in processing pediatric throat cultures.

Two hundred consecutive throat cultures from a Pediatric Walk-in Clinic were processed, using both aerobic and anaerobic culture techniques. The 35 aerobic isolates of group A beta-hemolytic streptococci (BHS) were all confirmed anaerobically as well, and there were two additional isolates detected only by the anaerobic technique. Of these 37 bacitracin-sensitive isolates, only 24 (65%) could be identified at 24 hours using the aerobic technique, compared to 29 (78%) using the anaerobic technique. In contrast to this relatively small effect upon the isolation of group A BHS, the yield of BHS from groups B, C, F, and G was more than doubled by the anaerobic technique. The confusion engendered by the improved detection of these bacitracin-resistant BHS using the anaerobic technique offset the small advantage in thoroughness and speed of detection of group A organisms. On this account, until more is known about the possible significance of isolating nongroup A BHS in the pharynx, the advisability of using an anaerobic culture jar to process pediatric throat cultures remains uncertain.

Providing free samples of baby items to newly delivered parents. An unintentional endorsement?

Recent studies have suggested that providing free sample packs of baby items to newly delivered parents may adversely influence parental health behavior. To determine the extent of this practice in Virginia, the head nurses of all 68 newborn nurseries and a random sample of 200 pediatricians were surveyed. Formula samples were being distributed at all hospitals. Formula packs were given to breast-feeding mothers at 65 (95%) hospitals although only 66 percent of the surveyed pediatricians approved of this practice. Samples of baby items other than formula (e.g., baby powder) were being distributed at 66 (97%) hospitals. Some physicians (18%) objected to the distribution of these nonformula samples, and others were not familiar with the content of these packs. In most instances, the hospital medical staff had not voted to approve the distribution of these packs. Parents were being informed only rarely about the source and intent of the packs. The provision of sample packs to newly delivered parents affects approximately 3,000,000 babies each year in the United States. The short- and long-term effects of providing these packs have been inadequately explored. Physicians should make an active decision whether to distribute sample packs. Those physicians choosing to dispense these samples may wish to review and edit the content of the packs and to enclose in the pack a brief note explaining that the provision of the products does not constitute a medical endorsement.

Kawasaki syndrome masquerading as bacterial lymphadenitis.

We present two case reports of older children who initially presented with cervical lymphadenitis and who were eventually diagnosed and treated for Kawasaki syndrome (KS). Both children presented with unilateral cervical lymphadenopathy and fever and later developed additional clinical features of KS, including cardiac aneurysms in one of the patients. Of the five KS clinical criteria which accompany fever for 5 days, cervical lymphadenopathy of > or = 1.5 cm is the least commonly found. Both patients were treated as having bacterial adenitis prior to the diagnosis of KS. We hope to illustrate that in the case of atypical cervical lymphadenitis, KS should be carefully considered in the differential diagnosis.

Parents' conception of their use of over-the-counter medicines.

To explore their hypothetical responses to management of fever or nasal congestion in their children, 109 patients were interviewed in a clinic waiting-room area. Most parents said they would medicate their children in these situations without first consulting a health professional. Parents were more willing to administer a drug product for fever than for nasal congestion, especially to children under 2 years of age. Although most parents selected appropriate medications for these situations, many were poorly informed about these drugs and falsely attributed germicidal and decongestant properties to aspirin and Tylenol. Younger, less educated, indigent parents in lower-status occupations were the least well informed. Pediatricians need to prepare parents for their role as health care providers.

Pertussis in primary care practice. Recent advances in diagnosis, treatment, and prevention.

Pertussis continues to be an important vaccine-preventable disease. The recent multiple outbreaks of pertussis have heightened interest in its diagnosis, treatment, and prevention. Diagnosis remains challenging, although new diagnostic tests, including enzyme-linked immunosorbent assay of sera and polymerase chain reaction of nasopharyngeal aspirates, offer the possibility of more rapid diagnosis. Erythromycin remains the preferred antimicrobial to reduce secondary transmission of pertussis. The recent approval of acellular pertussis vaccine for the primary series of immunizations ushers in an exciting new era of pertussis prevention.