Prics�’Review and

Education Program

213

218

;��I�RIC�N ACAIH�’IY OF PLI)I\TRICS

Vol. 12 No. 7January 1991

195 #{149}“I-800:Please Admit” - Menna

196 #{149}Abdominal Masses in Children -

Brodeur and Brodeur

208#{149}Clinical Disorders of Neutropenia- Roskos and Boxer

#{149}Recurrent Epistaxis - Mulbury

#{149}Conduct Disorders in Childrenand Adolescents - Gottlieb andFriedman

CONTENTS

COMMENTARIES

195 “1-800:Please Admit”

Vinc�ent J. Menna

ARTICLES

196 Abdominal Masses in Children: Neuroblastoma, Wilms

Tumor, and Other Considerations

Armand E. Brodeur and Garrett M. Brodeur

208 Clinical Disorders of Neutropenia

Rudolph R. Roskos and Laurenc�e A. Boxer

213 Recurrent EpistaxisPeter E. Mulbury

218 Conduct Disorders in Children and Adolescents

Susan E. Gottlieb and Stanford B. Friedman

ABSTRACTS

207 Screening for Illicit Drug Use

212 Hypoxia and Infant Care Seat

217 Sinusitis in Infants and Children

223 Comforters and Night Waking

Cover: Two Young Girls at the Piano, by Pierre August RENOIR (© 1989

The Metropolitan Museum of Art; Robert Lehman Collection, 1975.

(1 975.1 .201)). Two Young Girls at the Piano is one of at least five versionsof the same scene by Renoir, including a lovely pastel recently sold atauction. Renoir was 51 years of age at the time he did this work in 1892,and at the height of his popularity. This lovely presentation evokes a formerera when adolescents, at least those in favored economic status, spent theirleisure learning skills such as playing the piano and singing. One of themajor tasks of adolescence is to develop one’s identity and sense of

competence. Whether it is the charming skills so beautifully depicted in thispainting or others, the task of pediatricians is to assist young people indeveloping skills of which they can be proud.

The printing and production of

Pediatrics in Review is made possible,

______ in part, by an educational grant from

�. R D S S � Ross Laboratories.

‘7

Answer Key: lA; 2.A; 3.B; 4.D; 5.E; 6.B; 7.A; 8.E; 9.E; 1O.D; hG; 12.D; 13.D; 14.C;15.A; 16.B; 17.A; 18.E; 19.D; 20.E.

Vol. 12, No. 7, January 1991

Pediatricsin ReviewEDITORRobert J. HaggertyNew York Hospital-CornellMedical CenterNew York, NY

Editorial Office:The William T. Grant Foundation515 Madison Aye, 6th Floor,New York, NY 10022-5403

ASSOCIATE EDITORLawrence F. NazananPanorama Pediatric GroupRochester, NY

ABSTRACTS EDITORSteven P. Shelov, Bronx, NY

MANAGING EDITORJo A. Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan III, Stanford, CA

EDITORIAL BOARDMorris A. Angulo, Mineola, NYRalph Cash, Detroit, MIDaniel D. Chapman, Ann Arbor, MlEvan Chamey, Worcester, MARussell W. Chesney, Memphis, TNCathetine DeAngelis, Baltimore, MDPeggy Ferry, Tucson, AZAlan L Goldbloom, Toronto, ONRichard B. Goldbloom, Halifax, Nova ScotiaJohn L Green, Rochester, NYRobert L. Johnson, Newark, NJAlan M. Lake, Glen Arm, MDFrederick H. Lovejoy, Jr, Boston, MAJohn T. McBride, Rochester, NYMane C. McCormick, Boston, MAVincent J. Menna, Doylestown, PAKurt Metzel, Kansas City, MOLawrence C. Pakula, Timonium, MDPhilip A. Pizzo, Bethesda, MDRonald L Poland, Hershey, PAJames E. Rasmussen, Ann Arbor, MlRobert Rennebohm, Columbus, OHWilliam 0. Robertson, Seattle, WAJames S. Seidel, Torrance, CARichard Sills, Newark, NJLaurie Smith, Washington, DCWilliam B. Strong, Augusta, GAVernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CTW. Allan Walker, Boston, MATerry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTElizabeth A. Nelson

PUBLISHERAmerican Academy of Pediatrics

Errol R. Alden, Director, Department of EducationNancy Wachter, Copy Editor

PEDIATRICS IN REVIEW (ISSN 0191-9601) is owned andcontrolled by the American Academy of Pediatrics. It is publishedtwelve times a year (July through June) by the American Acad-emy of PediatrIcs, 141 Northwest Point BIvd, P0 Box 927, Elk

Grove Village, IL 60009-0927.Subscription price per year Candidate Fellow of the AAP $50;

AAP Fellow $75; Allied Health or Residents $50; Nonmember orInstitution $100. Current single Issues $8.

Second-class postage paid at ARUNGTON HEIGHTS, LU-NOIS 60009 and at additional mailing offIces.

C) American Academy of Pediatrics, 1991.All Rights Reserved. Printed in U.S.A. No part may be duplicated

or reproduced without permission of the American Academy ofPediatrics.POSTMASTER: Send address changes to PEDIATRICS IN RE-VIEW, American Academy of Pediatrics, 141 Northwest PointBlvd, P0 Box 927, Elk Grove Village, IL 60009-0927.

Cornrnentary“1 -800:Please Admit”

During my internship on medicinerotation I made daily rounds with aninternist. One of his female patientshad a different pain daily that radiatedto all parts of her body. I was im-pressed at how patiently he listenedto her symptoms and was amazedthat he was taking notes. One day Ilooked over his shoulder to discoverthat while she was complaining, hewas making a list of his inpatients.

That patient along with others whowere in the hospital for a “rest” justi-fiably would have a great deal of dif-ficulty being admitted in 1990. How-ever, I feel that the pendulum hasswung too far in the opposite direc-tion from the days of the lady withtotal body pain. Now we have to callthe insurance company’s toll-freenumber to ask for permission to ad-mit and give our plan of therapy, notto another physician, but to paramed-ical personnel. Most of our admis-sions are not elective, and the atmos-phere is usually hectic at the time,thus adding to the aggravation. If call-ing between the hours of 5 PM and 9AM, one does not even receive thecourtesy of talking to a human being,but only to an answering device. If itis that important to call, insurancecompany personnel should be avail-able. In the middle of the night I haveoften been tempted to leave a sca-thing message.

Once the patient is hospitalized,our charts are scrutinized daily bynurse administrators to insure that,

by their standards, hospitalization isjustified. After discharge, the diag-nosis must have a correspondingnumber or the medical records peo-pie have a major motor seizure. Ithoroughly enjoy making an unusualdiagnosis that has no correspondingnumber in the “big book.”

For most pediatricians, the hospitalis a last resort. Many of us have seenpatients daily or more than once dailyto avoid hospitalization. During ourtraining it was instilled in us to avoidhospitalization, but there are timeswhen it is necessary, even if the pa-tient does not fit into a listed diagnos-tic category or really need intrave-nous therapy, which seems to be oneof the “buzz” words. What do you doif parents have difficulty dealing withan illness or if admission is needed toprotect a child from suspectedabuse?

Recently, I treated a chronically ill-appearing 1 2-year-old girl who hadhad a fever for 12 days. There wereno obvious physical findings to ex-plain the fever, and basic laboratorystudies were normal. I elected to referher to an inpatient physician at an-other hospital. The physician finallyadmitted the child, but had to fabri-cate a diagnosis because the insur-ance company frowned on an admit-ting diagnosis of fever of unknownorigin.

The early discharge of newborns isanother problem. I wonder who willbe responsible for the infant who de-

velops sepsis on the third day or fi-nally manifests the symptoms of hy-poplastic left heart after leaving thehospital early. Recently, I received acall from the nursery in midafternoonthat a mother was just informed byher insurance company that she andher infant had to leave the hospitalafter 36 hours. This necessitated anextra trip by me back to the hospitalto discharge the infant.

I was amused by a bumper stickeronce that read “Become a Doctor-Support a Lawyer.” Now we also helpto subsidize a whole new group ofbureaucrats. Not only are we helpingto pay their salaries, but these sameindividuals are dictating how we prac-tice medicine.

I believe that there are courses ofaction we must take. First, pediatn-cians must continue to practice cost-effective medicine. Second, we mustbecome involved with the administra-tive boards of the insurance compa-nies. This obviously takes time, butis a necessity. Third, we must be-come active in our medical societiesat all levels to influence the third partypayers. Many pediatricians havebeen reluctant to join local and na-tional medical societies. With apolo-gies to Ben Franklin, we will hangtogether or we will hang separately.

Vincent J. Menna, MDDoylestown, Pennsylvania

Self-Evaluation Quiz--CME Credit

As an organization accredited for continuing medical education,the American Academy of Pediatrics certifies that completion of theself-evaluation quiz in this issue of Pediatrics in Review meets thecriteria for two hours of credit in category I of the Physician’sRecognition Award of the American Medical Association and 10%cyan PREP credit.

The questions for the self-evaluation quiz are located at the endof each artide in this issue. Each question has a SINGLE BEST

ANSWER. To obtain credit, record your answers on your quiz replycards (which you received under separate cover), and return thecards to the Academy. On each card is space to answer thequestions ui six issues of the journal: CARD 1 for the July throughDecember issues and CARD 2 for the January through June issues.To receive credit you must currently be enrolled in PREP or asubscriber to Pediatrics in Review-and we must receive both cardsby August 31, 1991.

Send your cards to: Pediatrics in Review, American Academy ofPediatrIcs, 141 Northwest Point Blvd, P0 Box 927, Elk Grove Village,IL 60009-0927.

The correct answers to the questions in this issue appear on theinside front cover.

Thie One -�_________

I�I�IIU�UI1�UHII�U�D�IIHlU� pediatrics in review #{149}vol. 12 no. 7 january 1991 PIR 195WP5H-�52 L-69QH

Abdominal Tumors

PIR 206 pediatrics in review #{149}vol. 12 no. 7 january 1991

moved in a delayed or “second-look”procedure.

Radiation Therapy. With the ad-vent of effective chemotherapeuticagents, radiation therapy has taken asecondary role in the treatment ofWilms tumor. Currently, it is not usedin the treatment of patients with stageI or II disease and favorable histology.Its role in stage Ill disease with favor-able histology is still being tested, butit appears that a dose of 1000 cGydelivered to the tumor bed is ade-quate to provide the beneficial effectsof radiation seen in this group of pa-tients. Radiation therapy to the lungswas evaluated in the past for patientswith pulmonary metastases, but it isnot current practice.

Chemotherapy. Vincristine and ac-tinomycin-D are the mainstays oftherapy for Wilrns tumor, althoughdoxorubicin is useful for patients withadvanced stages of disease. A seriesof studies have been undertaken bythe National Wilms Tumor Study, andthe current study is the fourth in thisseries. In this study, patients withstages I and II disease with favorablehistology are treated for 3 to 5months with vincristine and actino-mycin-D, and the major differences inthe treatment regimens consist of dif-ferences in the drug delivery sched-ule. Differences in drug deliveryschedule are also part of the treat-ment regimens for the more ad-vanced stages, although these regi-mens are more intensive than forlower stages and they involvethe useof doxorubicin.

Prognosis

The most impressive advancementin the treatment of any solid tumorhas been seen in the case of Wilmstumor. More than 85% of patientscan be cured (that is, have a 5-yeardisease-free survival, with minimalchance of recurrence) with currentapproaches. Thus, future ap-proaches are beginning to focus ondecreasing the toxicity of treatmentby eliminating doses of drugs, dura-tion of therapy, and the use of radia-tion. Currently, the 2-year survival ofchildren with favorable histology is98% for stage I,95% for stage II,90% for stage III, and 80% for stageIV. The prognosis for unfavorable his-

tology of any stage is a survival rateof about 80%.

Future Prospects

With the availability of effectivechemotherapeutic agents to treatmost patients with Wilms tumor, thefocus of future studies will be to de-crease toxicity. On the other hand,more effective approaches must bedeveloped for patients with advanceddisease and unfavorable histology.Recent progress in understandingthe development of Wilms tumor andmapping predisposition loci promisesto provide new approaches to identifyindividuals at increased risk for de-veloping this tumor. Although the ge-netic basis of Wilms tumor appearsto be more complex than that seenfor retinoblastoma, molecular geneticapproaches are likely to begin to haveclinical applications within the next 5to 10 years. Such approaches mayprovide insight into malignant trans-formation and provide ways to clas-sify tumors or predict prognosis moreobjectively. In addition, they mayidentify critical genetic pathways onwhich future therapeutic approachesmay be focused.

CONCLUSION

Any abdominal organ or tissue iscapable of developing into a mass.The spectrum of afflictionincludesdilatedhollow viscera, inflammatorymasses, and cystic or solid tumors(malignant or benign). The keys tothe most favorable outcome lie inprompt diagnosis and skillful man-agement with the choice of an appro-priate therapeutic regimen.

SUGGESTED READING

Neuroblastoma

Brodeur GM, Fong CT. Molecular biology andgenetics of human neuroblastoma. CancerGenet Cytogenet. 1989;41 :153-174

Brodeur GM, Seeger AC, and 24 other contrib-utors. International criteria for diagnosis,staging and response to treatment in pa-tients with neuroblastoma. J Clin Oncol.1988;6:1 874-1881

Brodeur GM. Neuroblastoma and other tumorsof the peripheral nervous system. In: Fern-bach DJ, Vietti TJ, eds. Clinical PediatricOncology. 4th ed. St Louis, MO: CV Mosby;1990. In press

Evans AE, D’Angio GJ, Propert K, AndersonJ, Hann HWL. Prognostic factors in neuro-blastoma. Cancer. 1 987;59:1 853-1859

Hayes FA, Smith El. Neuroblastoma. In: PizzoPA, Poplack DG, eds. Principles and Prac-tice in Pediatric Oncology. Philadelphia, PA:JB Lippincott; 1989:607-622

Knudson AG Jr, Meadows AT. Developmentalgenetics of neuroblastoma. J NatI CancerInst. 1976;57:675-682

Nishi M, Miyake H, Takeda T, et al. Effects ofthe mass screening of neuroblastoma inSapporo City. Cancer. 1 987;60:433-436

Pochedly C, ed. Neuroblastoma: Tumor Biol-ogy and Therapy. Boca Aaton, FL: CRCPress; 1990. In press

Wilma TumorBeckwith JB. Wilms tumor and other renal

tumors of childhood: a selective review fromthe National Wilms Tumor Study PathologyCenter. Hum Pathoi. 1983;14:481-492

D’Angio GJ, Beckwith JB, Breslow N, Finkle-stein J, Green DM, Kekakis P. Wilms tumor(nephroblastoma, renal embryoma). In: PizzoPA, Poplack DG, eds. Principles and Prac-tice of Pediatric Oncology. Philadelphia, PA:JB Lippincott; 1989: 583-606

D’Angio GJ, Evans A, Breslow N, et al. Thetreatment of Wilms tumor: results of thesecond National Wilms Tumor Study. Can-cer. 1 981 47:2302-2311

D’Angio GJ. Oncology seen through the prismof Wilms tumor. Med Pediatr Oncol.1985;1 3:53-58

Fembach DJ. Wilms tumor. In: Fembach DJ,Vietti TJ, eds. Clinical Pediatric Oncology.4th ed. St Louis, MO: CV Mosby; 1990. Inpress

Matsunaga E: Genetics of Wilms tumor. HumGenet. 1981 57:231-246

Pochedly C, Baum ES. Wilms Tumor: Clinicaland Biological Manifestations. New York,NY: Elsevier; 1984

Self-Evaluation Quiz

1. Among the following conditions produc-ing abdominal masses in infants, which isleast typical with respect to the age of thepa�ent?

A. Multicystic kidney in a newborn.

B. WiIms tumor in a 3-month-old infant.C. Neuroblastoma in a 1-year-old child.D. lntussusception in a 9-month-old infant.E. Posterior urethral valves in a 1 -month-old

infant.

2. Of the following, which finding is leastlikely to be associated with neuroblastoma?

A. Diarrhea.B. Opsoclonus.C. Hematuna.D. Abdominal calcification.E. Proptosis.

EDUCATIONAL OBJECTIVE

82. The pediatrician should havethe appropriate abllfty to recom-mend screening methods to detectillicit drug use. (Recent Advances,90/91)

ONCOLOGY

pediatrics in review #{149}vol. 12 no. 7 january 1991 PIR 207

3. Among the following, neuroblastoma is 4. Among the following, which is least likely most improvement in prognosis has beenleast likely to metastasize to: to be associated with Wilms tumor? achieved for

A. Lung. A. Beckwith-Wiedmann syndrome. A. Ewing sarcoma.B. Skin. B. Anindia. B. Neuroblastoma.C. Bone marrow. C. Homer syndrome. C. Wilms tumor.D. Regional nodes. D. Hemihypertrophy. D. Osteosarcoma.E. Liver. 5. Among the following malignancies, the E. Rhabdomyosarcoma.

Screening for Illicit Drug Use

The Clinical Utility and Evaluation of Drug Screening Techniques. MacKenzl AG,Cheng M, Haftel AJ. Pediatr Clin North Am. 1987;34:423.Moral and Legal Issues in Screening for Drug Use in Adolescents. King NM, CrossAW. J Pediatr. 1987;1 1:249.Adolescent Marijuana Use: Concordance Between Questionnaire and Immunoas-say for Cannaboid Metabolites. Silber TJ, Getson P, Ridley S, et al. J Pediatr.1987;111:299.

Sensitive and specific tests are now available for marijuana, cocaine, and a host ofother drugs. This availability makes the decision about when to use these tests acrucial issue in the care provided to adolescents. When to suspect drug abuse andacute intoxication, what to do with the drug test result, and whether or not to doroutine screening in schools or in the pediatrician’s office, especially if a drug test isspecially requested by a parent, are central. Screening of body fluids for drugs isrecommended for adolescents with mental state or performance changes, psychiatricsymptoms, or acute-onset behavior states. It also is recommended for those withrecurrent respiratory ailments and for high-risk adolescents (eg, runaways, delin-quents). Testing can also be used to monitor abstinence. Clearly, any comatoseadolescent should be screened for toxins in serum, urine, and gastric contents.

The enzyme immunoassay technique is now commonly used for assay of marijuanametabolites, benzodiazepines, phencyclidine, barbiturates, opioids, and cocaine me-tabolites in the urine and for benzodiazepine, phencyclidine, barbiturates, tncyclicantidepressants, and ethyl alcohol in the serum. Sensitivity and specificity are quitegood, although cross-reactivity with some substances may yield false positives. Theapproximate duration that drugs are detectable in the urine are: 1) alcohol, 12 hours;2) marijuana, 120 hours (single dose) to 240 hours (daily use); 3) cocaine, 18 to 27hours (single intranasal dose of 13 to 30 mg) to 96 to 144 hours (oral dose of 300mg, as metabolite); and 4) phencyclidine, 200 hours following an overdose.

The moral and legal issues in drug screening for adolescents are also complex. Thecurrent recommendation is not to include drug screening as part of routine adolescenthealth care. If a parent requests such testing, the pediatrician should ask permissionof the adolescent. Usually, the test will be negative if the adolescent assents. If theadolescent refuses, the index of suspicion is raised without the trust and respect ofthe patient being lost and the confidentiality of the medical relationship being violated.

Comment: When parents request drug testing of their adolescent, the criticalquestion of the pediatrician should be: “Why?” Attention should be given to parentalconcerns and parent-adolescent communication. This should prompt individual, privatediscussion with each parent and the adolescent, in addition to discussions in whichboth adolescent and parent(s) are included. (Lonnie Zeltzer, MD, Editorial Board)

Neutropenia

PIR 212 pediatrics in review #{149}vol. 12 no. 7 january 1991

the granulocyte colony-stimulatingfactor is an investigational agent, re-ferral to a tertiary care center is nec-essary to obtain its use. In 50% ofaffected patients who have sympto-matic immune neutropenia, success-ful therapy can be accomplished byuse of prednisone, 2 mg/kg givenorally for 1 month.

REFERENCES

1. Baehner, RL. Disorders of granulopoiesis.In: Miller D, Baehner R, McMillan C, MillerL, eds. Blood Disease of Infancy andChildhood. 5th ed. St Louis, MO: CV.Mosby Co; 1984:504

2. Alario AJ, O’Shea J. Risk of infectiouscomplications in well-appearing childrenwith transient neutropenia. AJDC.1989;143:973-976

3. Lalezan P, Khorshidi M, Petrosova M. Au-toimmune neutropenia of infancy. J Pe-diatr. 1 986;1 09:764-769

4. Conway LT, Clay ME, Kline WE, RamsayN, Krivit W, McCullough J. Natural historyof primary autoimmune neutropenia in in-fancy. Pediatrics. 1 987;79:728-733

5. Boxer LA, Greenberg MS, Boxer GJ, et al.Autoimmune neutropenia. N EngI J Med.1975;293:748-753

6. Bussel J, Lalezan P, Fikrig S. Intravenoustreatment with ‘y-globulin of autoimmuneneutropenia of infancy. J Pediatr.1988;1 12:298-301

7. Cumutte J, Boxer LA. Disorders of gran-ulopoiesis and granulocyte function. In:Nathan DG, Oski FA, eds. Hematology ofInfancy and Childhood. 3rd ed. Philadel-phia, PA: W. B. Saunders Company;1988:797-847

SUGGESTED READING

Hutchinson RJ, Boxer LA. Disorders of gran-ulocyte and monocyte production. In: BenzEJ Jr, Cohen HJ, Fune B, Hoffman R, ShattilSJ, eds. Hematology Basic Principles andPractice. New York: Churchill Uvingstone; inpress

Self-Evaluation Quiz

6. Neutropenia is associated with abnormalphysical findings in each of the followingconditions except:

A. Reticular dysgenesis.B. Cartilage-hair syndrome.C. Shwachman-Diamond syndrome.D. Dyskeratosis congenita.E. Fanconi syndrome.

7. Patients with neutropenia have a majorincrease in risk for infections due to:

A. Viruses.B. Bacteria.C. Fungi.D. Parasites.E. Protozoa.

8. Granulocyte colony-stimulating factorhas been shown to be beneficial in the ther-apy of each of the following except:

A. Severe congenital neutropenia.B. Neonatal isoimmune neutropenia.C. Acquired idiopathic symptomatic neutro-

penia.

D. Cyclic neutropenia.

9. Among the following, transient neutro-penia is least likely to be a manifestation of:

A. Viral infection.B. Bacterial infection.C. Maternal isoimmunization.D. Maternal autoimmunization.E. Hypersplenism.

10. Patients with neutropenia will leastlikely benefit from administration of:

A. Granulocyte colony-stimulating factor.B. Transfusions of white cells.C. Glucocorticoids.D. y-Globulin.E. Antibiotics.

Hypoxia and Infant Care Seat

Ventilatory Changes in Convalescent Infants Positioned in Car Seats. Willet LD,Leuschen MP, Nelson LS, Nelson AM. J Pediatr. 1 989;1 15:451-455.

Because premature infants have been shown to be at nsk for hypoxia and brady-cardia when positioned in standard car seats, this study was done to confirm thisfinding in a larger sample, to investigate convalescent full-term infants in the neonatalintensive care unit for respiratory compromise in car seats, and to determine thephysiologic mechanism or mechanisms responsible. Extensive multichannel polygraphrecordings were obtained, and pulmonary function tests were performed on 50convalescent infants from the neonatal intensive care unit before, during, and afterplacement in a car seat. Mean total dynamic compliance, total pulmonary resistance,and work of breathing improved in the car seat. Thirty percent of premature infantsexperienced hypoxia, bradycardia, or both in a car seat; in this group, tidal volumewas low. In 11 of 16 infants with abnormal findings, oxygen desaturation was relatedtemporally to episodes of short and mixed apnea. No full-term convalescent infantexperienced respiratory difficulty in a car seat regardless of primary diagnosis. Theseresearchers conclude that premature infants may have respiratory compromise of amultifactorial nature when in car seats. Further development of car seats is necessaryif such respiratory problems are to be avoided. (R.J.H.)

EDUCATIONAL OBJECTIVE

122. The pediatrician should havethe appropriate ability to recognizesinusitis in young children. (RecentAdvances, 90/91)

OTORHINOLARYNGOLOGY

pediatrics in review #{149}vol. 12 no. 7 january 1991 PIR 217

Self-Evaluation Quiz

11. Each of the following is a true statementabout epistaxis in children, except:

A. The majority of cases originate from the

anterior 2 to 3 cm of the nasal septum.B. Most cases are due to digital manipula-

tion.

C. Nasal polyps are a common cause.D. Rhinitis medicamentosa is not a common

cause.E. Any inflammatory disorder in the nose

may be a cause.

12. A 7-year-old boy has recurrent epistaxisthought to be due to a bleeding disorder.

The initial laboratory evaluation should in-clude each of the following, except:

A. Complete blood count with differentialand smear.

B. Total and direct serum bilirubin.C. Platelet count.D. Prothrombin and partial thromboplastin

times.

13. Which of the following is not true aboutjuvenile nasopharyngeal angiofibromas?

A. They are benign vascular neoplasms aris-ing in the lateral nasopharynx.

B. They occur only in pubescent males.C. Biopsy is a high-risk procedure.D. They are associated with recurrent pos-

tenor epistaxis.E. Radiation therapy is the treatment of

choice.

14. Each of the following is a valid associ-ation regarding the treatment of epistaxis,except:

A. Anterior bleeding site-Cautery or oint-ment.

B. Persistent anterior bleeding site-Ante-rior pack.

C. Nosebleeds during “nosebleed sea-son”-Buffered saline nasal spray.

0. Septal perforation-Foley catheter.E. Hereditary telangiectasis-Laser treat-

ment or surgery.

Sinusitis in Infants and Children

Management of Sinusitis in Infants and Children. Wald ER. Pediatr Infect Dis J.1 988;7:449-452.Comparative Effectiveness of Amoxicilhin and Amoxicilhin-Clavulanate Potassiumin Acute Paranasal Sinus Infections in Children: A Double-Blind, Placebo-Con-trolled Trial. Wald ER, Chiponis D, Ledesma-Medina J. Pediatrics. 1986;77:795-800.Sinusitis: Early Recognition, Aggressive Treatment. Goldenhersh MJ, RachelsfskyGS. Contemp Pediatr. 1 989;6:22.

Acute paranasal sinusitis complicates upper respiratory tract inflammation in chil-dren 1% to 5% of the time. Of the many causes, allergic or infectious upper respiratorytract infections are the most common. The most common manifestation of acuteparanasal sinusitis includes persistent nasal discharge of any color for more than 10days, cough, low-grade fever, and, occasionally, foul breath or nonpainful eye swelling.Headaches are uncommon in this group. Occasionally, high fever, purulent rhinorrhea,headache, and periorbital swelling occur as the upper respiratory tract infectionworsens.

Results of physical examination are often nonspecific. Direct observation of thenares may reveal purulent drainage from the middle meatal sinus. In children, themaxillary and ethmoid sinuses are involved most commonly. Sinus radiographs canbe normal or reveal opacification, air fluid levels in the child more than 5, or mucousmembrane swelling of 5 mm or greater. Mucous membrane swelling correlates wellwith bacterial sinus aspirates. The use of ultrasonography and transillumination iscontroversial and usually not beneficial in diagnosis.

Bacterial organisms responsible for acute paranasal sinusitis are Streptococcuspneumoniae (25% to 30%), Branhemella catarrhalis (1 5% to 20%), and nontypableHaemophilis influenzae (1 5% to 20%). Sterile aspirates occur 20% to 35% of the time.Amoxicillin is the drug of choice for treatment, given in 10- to 21 -day courses,depending on clinical response. Trimethoprim-sulfamethoxazole, cefaclor, or amoxi-cillin potassium clavulanate can be used for �3-lactomase-producing organisms or inthe case of clinical nonresponse. Sinus aspirates or hospitalization are sometimesrequired if clinical response is inappropriate. Oral decongestants, antihistamines, andnasal spray medications, although frequently used, have not been tested for efficacy.

Comment: Children with radiologically proven sinusitis require appropriate treatmentand follow-up. It is more difficult to evaluate the child with mild but persistent symptomssuggestive of sinusitis in the absence of radiologic confirmation. The treatment ofupper respiratory tract infections with antibiotics simply because sinusitis is suspectedestablishes inappropriate parental expectations for the treatment with each suchinfection. Because frequent sinus radiographs are also inappropriate for mildly illchildren, the pediatrician is required to use his or her best clinical judgment to evaluatechildren with suspected sinusitis. Sinusitis resolves spontaneously in about 40% ofcases, and many children with mild symptoms require only careful observation.Significant orbital and intracranial complications are the risks of inappropriately rec-ognized or managed sinusitis, providing yet another balancing act for pediatricians.(Daniel D. Chapman, MD, Editorial Board)

tensive investigation. Through thisapproach, factors identified as pro-moting a positive outcome might beincorporated into treatment strate-gies for the future.

BEHAVIORAL PEDIATRICS

pediatrics in review #{149}vol. 12 no. 7 january 1991 PIR 223

REFERENCES

1 . American Psychiatric Association. Diag-nostic and Statistical Manual of MentalDisorders. 3rd ed revised. Washington,DC: American Psychiatric Association;1987:53-56

2. Rutter M, Tizard J, Yule W, et al. Researchreport: Isle of Wight studies 1964-1974.Psychol Med. 1976;6:31 3-332

3. Quay Hc. conduct disorders. In: QuayHc, Werry JS, eds. Psychological Disor-ders of Childhood. 3rd ed. New York:Wiley & Sons; 1986:35-72

4. Stewart MA, Behar 0. Subtypes of ag-gressive conduct disorder. Acta PsychiatrScand. 1983:68:178-185

5. Walker JL, Lahey BB, Hynd GW, et al.Comparison of specific patterns of anti-social behavior in children with conductdisorder with or without coexisting hyper-activity. J Consult Clin Psychol.1987;5:91 0-912

6. Puig-Antich J, Rabinovich H. Major childand adolescent psychiatric disorders. In:Levine MD, Carey WB, Crocker AC, GrossRT, eds. Developmental-Behavioral Pedi-atrics. Philadelphia: W.B. Saunders Com-pany; 1983:884-886

7. Mednick SA, Hutchings B. Genetic andpsychophysiologic factors in asocial be-havior. J Am Acad Child Psychiatry.1978;1 7:209-223

8. Bohman M. The interaction of heredity andchildhood environment: some adoptionstudies. J Child Psychol Psychiatry.198122:195-200

9. Rutter M. The city and the child. Am JOrthopsychiatry. 198151 :610-625

10. Quay HC. A dimensional approach to be-havior disorder. School Psychol Rev.

1983;1 2:244-24911 . Goyette H, Conners CK, Ulrich RF. Nor-

mative data on the revised Conners Parentand Teacher Rating Scales. J AbnormChild Psychol. 1978;6:221 -236

1 2. Achenbach TM, Edelbrock CS. The ChildBehavioral Profile: II, boys aged 12-16,girls aged 6-1 1 and 1 2-1 6. J Consult ClinPsychol. 1979;47:223-233

13. Kulik JA, Stein KB, Sarbin TA. Dimensionsand patterns of adolescent behavior. JConsult Clin Psychol. 1 968;32:375-382

14. Kazdin AE, French NH, Unis AS. Child,mother and father evaluations of depres-sion in psychiatric inpatient children. J Ab-norm Child Psychol. 1 983;1 1:167-180

1 5. Conners CK. A teacher rating scale foruse in drug studies with children. Am JPsychiatry. 1969;1 26:884-888

16. Edelbrock C, Achenbach TM. The teacherversion of the Child Behavioral Profile: I,boys aged 6-1 1 . J Consult Clin Psychol.1984;52:207-21 7

17. Robins LN. Sturdy childhood predictors ofadult antisocial behavior: replications fromlongitudinal studies. Psychol Med.1978;8:611-612

18. Richman N, Stevenson J, Graham PJ. Pre-school to school: A behavioral study. Lon-don: Academic Press; 1982

SUGGESTED READING

Bodenhamer G. Back in Control: How to GetYour Children to Behave. New York: PrenticeHall Press; 1984

Forehand A, McMahon J. Helping the Noncom-pliant Child: A Clinician’s Guide to ParentTraining. New York: Guilford Press; 1981

Kazdin AE. Treatment of Antisocial Behavior inChildren and Adolescents. Homewood, IL:Dorsey Press; 1985

Patterson GA. Living with Children: New Meth-ods for Parents and Teachers. 3rd ed. Cham-paign, IL: Research Press; 1976

Quay HC, Werry JS, eds. Psychopathologic

Disorders of Childhood. 3rd ed. New York:Wiley and Sons; 1986

Self-Evaluation Quiz

15. As defined in the Diagnostic and Statis-tical Manual, revised 3rd edition, the mostprevalent psychophysiologic disorder ofchildren and adolescents is:

A. Autism.B. Depression.C. Latent schizophrenia.D. Gilles de Ia Tourette syndrome.E. Conduct disturbance.

16. Of the following possible factors con-tnbuting to conduct disturbances in childrenand adolescents, which is likely to be theleast important epidemiologically?

A. Specific genetic influences.B. Family discord.C. Occurrence of depression.D. Peer influences.E. Learning disabilities.

17. In assessing children suspected of con-duct disturbance, which of the following isleast likely to be helpful?

A. Wide Range Achievement Test (WRAT).B. Stanford-Binet Test.C. Child Behavioral Checklist.D. Conners Teacher Rating Scale.E. Conners Parent Rating Scale.

18. Among the following, the least helpfultreatment for a conduct disturbance is likelyto be:

A. Family therapy.B. Parent reeducation in child rearing.

C. Behavior therapy.D. Individually oriented psychoanalytic ther-

apy.E. Cognitive therapy with the child.

Comforters and Night Waking

Comforters and Night Waking. Morley R, Morley CJ, Lucas PF, Lucas A. Arch DisChild. 1 989;64;1 624.

Among 320 low birthweight infants seen at 9 months postterm, those using a softobject, thumb, or fingers as a comforter were significantly less likely to wake at night(9 of 96, 9%) than those with no comforter or using a dummy (66 of 224, 29%).Dummy users were as likelyto wake (27 of 93, 29%) as those without a comforter(39 of 131, 30%).

Comment: Everyone in Britain knows that dummies are pacifiers. However, in viewof the fact that they do not seem to pacify at night, perhaps dummy is a better term.(R.J.H.)