Nicotine Dependence: Diagnosis, Chemistry, And

Nicotine Dependence: Diagnosis, Chemistry, and

Pharmacologic Treatments - Miller and (ocorcs

Giardiasis - Seidel

ii’ Pediatrics in Review

Vol 14 No 7 July 1993

EDITOR Robert J. Haggerty Univ&s14’ of Rochester School of Medicine and Dentistiy Rochester, NY

Editorial Office: Department of Pediatrics University of Rochester CONTENTS School of Medicine and Dentistr 601 Elmwood Aye, Box 777 Rochester, NY 14642 ASSOCIATE EDITOR ARTICLES Lawrence F. Nazanan Panorama Pediatric Group Rochester, NY

251 Is It Bacterial or Viral? Laboratory Differentiation ABSTRACTS EDITOR James C. Overall, Jr Steven P. Shelov, Bronx, NY MANAGING EDITOR 262 Consultation with the Specialist: Jo Largent, Elk Grove Village, IL Sepsis in the Newborn EDITORIAL CONSULTANT Victor C. Vaughan, III, Stanford, CA Ronald L. Poland and Kristi L. Watterberg EDITORIAL BOARD Moris A. Angulo, Mineola, NY 265 The Pediatrician’s Role in Infant Feeding Decision- Russell W. Chesney, Memphis, TN Making Cathenne DeAngelis, Baltimore, MD Peggy C. Ferry, Tucson, AZ Ruth A. Lawrence Richard B. Goldbloom, Halifax, NS John L Green, Rochester, NY 273 The Acute Management of Paroxysmal Robert L Johnson, Newark, NJ Jan M. Lake, Glen Arm, MD Supraventricular Tachycardia in Children Frederick H. Lovejoy, Jr, Boston, MA John T. McBnde, Rochester, NY Lars C. Erickcon and Mark W. Cocalis Vincent J. Menna, Doylestown, PA Lawrence C. Pakula, Timonium, MD 275 Nicotine Dependence: Diagnosis, Chemistry, and Ronald L Poland, Hershey, PA James E. Rasmussen, Mn Arbor, MI Pharmacologic Treatments James S. Seidel, Torrance, CA Norman S. Miller and James A. Cocores Richard H. Sills, Newark, NJ Laurie J. Smith, Washington, DC Wdliam B. Strong, Augusta, GA 281 Index of Suspicion Jon Tingelstad, Greenville, NC Bradley J. Bradford, Hany S. Miller, Walter L. Gilbert Vernon T.. Tolo, Los Angeles, CA Robert J. Touloukian, New Haven, CT 284 Giardiasis Terry Yamauchi, Little Rock, AR Moritz M. Ziegler, Cincinnati, OH James Seidel EDITORIAL ASSISTANT Sydney Sutherland

PUBUSHER ABSTRACTS American Academy of Pediatrics Errol R. Alden, Director, Department of Education Jean Dow, Director 263 Atypical Tuberculosis Division of PREP/PEDIATRICS Deborah Kuhlman, Copy Editor

264 Cough Medicines: When Should They Be Prescribed? PEDIATRICS IN REVIEW (ISSN 0191-9601) is owned and controlled by the American Academy 272 New Manifestations of Rheumatic Fever of Pediatrics. It is published monthly by the American Academy of Pediatrics, 141 Northwest Point BIvd, P0 Box 927, Elk Grove Village, IL 280 Rabies 60009-0927. Statements and opons expressed m Pediatrics 286 Infant Walkers in Review are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Recommendations included in this publication do not indicate an exdusive course of treatment or serve as a standard of medical care. Subscription price for 1993: AAP Fellow $95; COVER MP Candidate Fellow $70; MFP $115; Allied Health or Resident $70; Nonmember or Institution “Sara Handing a Toy to the Baby” was painted by Mary Cassatt (1845 - $125. Current single price is $10. Subscription 1925). Cassatt, an American artist, was the daughter of a wealthy daims will be honored up to 12 months from the Philadelphia businessman. She went to Pans to study and never returned. publication date. Second-class postage paid at ARLINGTON Most of her paintings are of mothers and children, although she herself HEIGHTS, IWNOIS 60009’0927 and at additional never married. This lovely painting shows an older sibling handing a toy to mailing offices. her younger brother. We all know that sibling relations are never this CAMERICAN ACADEMY OF PEDIATRICS, 1993. All rights reserved. Printed in USA. No part serene at all times, but we can always eiicourage the sharing and love so may be duplicated or reproduced without beautifully shown here. (This painting is reproduced with the permission of permission of the American Academy of Pediatrics. the Hill-Stead Museum, Farmington, CT). POSTMASTER: Send address changes to PEDIATRICS IN REVIEW, American Academy of Pediatrics, P0 Box 927, Elk Grove Village, IL ANSWER KEY 60009-0927. The printing and production 1. C; 2. D; 3. D; 4. C; 5. E; 6. D; 7. C; 8. E; 9. D; 10. B; 11. A; 12. E; of Pediatrics in Review is 13. A; 14. E; 15. E; 16. B; 17. D; 18. E; 19. D; 20. D; 21. B; 22. A; 23. C; made possible, in part, by iRO8Si 24. B an educational grant from T Ross Laboratories. ucATIoNj

Printed in the USA INFECTIOUS DISEASE Laboratory Diagnosis

Shulman ST. Streptococcal phaiyngitis: LIiII IIIIiIIiiIIIIIiIi iIIIIiiIEi clinical and epidemiologic factors. Pediatr Infect Dis J. 1989;8:816-819 RUBELLA HI TITERS (I9G) Todd JK. The sore throat: pharyngitis and SERUM MOTHER BABY MOTHER BABY epiglottitis. Inftct Dis Clin North Am. 1988;2:149-162 At exposure 128 - <8 - Turner RB, Lande AE, Chase P, Hilton N, At birth 128 256 1024 1024 Weinberg D. Pneumonia in pediatric 6 months 256 <8 1024 2048 outpatients:cause and clinical manifestations.J Pediatr. 1987;1 11:194- postpartum 200 Comment Passive transfer Congenital Wildin S, Chonmaitree T. The importance of the virology laboratory in the diagnosis and of antibody rubella management of viral meningitis. Am I Dis No congenital Child. 1987;141:454-457 rubella Yogev R. Advances in diagnosis and treatment of childhood meningitis. Pediatr Infect Dis I. 1985;4:321-325

PIR QUIZ

1 . A true statement regarding labora- 3. A tnie statement regarding the use C. Mycoplasma pneumoniae and tory techniques useful for diagnos- of antibody titers for viral diagnosis CIZIamydJa pneumoniae are the ing bacterial pneumonia is: is: two organisms most likely to be A. Accurate diagnosis of chlamy- A. Currently, there is no serologic the cause of a nonconsolidated dial infections requires that pu. test to diagnose parvovirus B19 right lower lobe infiltrate in an rulent material be obtained. infection. acutely ill 15-year-old boy. B. Chiamydia pnewnoniae infec- B. Given the sensitivity of current D. Testing for Chiamydia pneumo- tions are best diagnosed by rapid methods, serodiagnosis is no niae is essential for proper diag- antigen detection methods. longer fully dependent on the nosis of pneumonia in a 2- C. Rapid antigen detection methods immune competence of the host. month-old infant who does not for diagnosing Chlamydia tra- C. Specific Epstein Barr virus anti- have a fever. chomatis infections are at least body tests are most useful in E. Viral cultures are likely to alter as sensitive as culture. children less than 5 years of age. the therapy of a 2-month-old D. Serologic techniques are less re- D. The time required to diagnose child who has pneumonia with liable than culture for diagnosing arboviral infection makes the pleural effusion. Mycoplasma pnewnoniae infec- technique less valuable for the 5. A true statement regarding the diag- tion. individual patient, but may pro- nosis of perinatal infections is: E. Urine antigen detection tech. vide useful epidemiologic infor- A. An elevated cord blood level of niques for Haemophilus influen- mation. virus-specific serum IgO is diag- we are especially helpful E. A virus-specific immunoglobulin nostic of congenital infection. because of high specificity. o (IgO) test is more likely to in- B. For best results, specimens for fluence the diagnosis of acute in- 2. Of the following viruses, the one for viral culture should be frozen in fection than is a virus-specific which antibody titer is the preferred a regular freezer before trans- 1gM test. method of diagnosis is: port. A. Cytomegalovirus 4. A true statement regarding the diag- C. Human immunodeficiency virus B. Enterovirus nosis of pediatric pneumonia syn- infection characteristically mani- C. Herpes simplex virus dromes is: feats clinical findings shortly D. Human herpesvirus type 6 A. Bacterial culture of nasopharyn- after birth. E. Respiratory adenovirus geal secretions in a 2-year-old D. Immunoglobulin 0 (IgO) titers girl who has lobar consolidation are important for the rapid diag- is likely to provide useful diagnosis of acute perinatal viral nostic information. disease. B. Collection of nasophatyngeal se- E. In an acutely ill neonate who has cretions for viral antigen detec- both pneumonia and hepatitis, tion and culture is inappropriate the differential diagnosis should in a febrile 2-month-old infant include herpes simplex virus and who has pneumonia and severe enterovirus infection. respiratory distress.

Pediatrics in Review VoL 14 No. 7 July 1993 261 riiii. T11 ABSTRACT Serious symptoms of failure to New Manifestations of Rheumatic Fever thrive, with few stools and infrequent voidings, deserve a full evaluation. The Resurgence of Acute Rheumatic Fever 3) fever, 4) an elevated erythrocyte in the United States. Congeni BL. Pediatr sedimentation rate, 5) a positive C- SUGGESTED READING Ann. 1992;21:816-820 Committee on Drugs, American Academy of Acute Rheumatic Fever in Western reactive protein, 6) leukocytosis, and Pediatrics. Transfer of drugs and other Pennsylvania: A Persistent Problem into 7) a prolonged PR interval or other chemicals into human milk. Pediatrics. the 1990s. Zangwill KM. Wald ER, electrocardiographic changes. Either 1989;924-936 Londino AV Jr. JPediatr. 1991;118:501- two major criteria on one major and Huggins K. The Nursing Mother’s Companion. 503 two minor criteria are required to Revised Edition. Boston, MA: The Harvard A resurgence of acute rheumatic Common Press; 1990 make the diagnosis of ARF in the Lawrence RA. Breastfeeding: A Guide for the fever (ARF) occurred in the mid- presence of supporting evidence of a Medical Profession. 3rd ed. St. Louis, MO: 1980s, as evidenced by several preceding streptococcal infection (eg, CV Mosby; 1989 reports of outbreaks in various elevated titer of antistreptococcal regions of the United States. Around antibodies, positive throat culture for the same period, some reports GABHS, or recent scarlet fever). described a dramatic increase in the Canditis and arthritis remain the PIR QUIZ virulence of Group A Beta-hemolytic most commonly encountered clinical 6. One of the many special qualities Streptococcus (GABHS), resulting in manifestations, occurring in more of human milk when compared fulminant disease in both adults and than 50% of the recent outbreaks. with formula is: children. Although several strains of A. Increased methionine content Mitral insufficiency and aortic B. Increased phenylalanine content GABHS were implicated in these insufficiency are the most common C. Lower cysteine content outbreaks, the most common isolate murmurs associated with ARF. While D. Lower protein content identified was the mucoid group A the classic ARF was associated with E. Lower taurine content type 18 strain (M-18). a migratory polyarthritis, some recent 7. Strict vegetarian mothers are at risk In contrast to the pre-Wonld War II cases have exhibited arthritis of an for nutritionally inadequate breast classic ARF, which was described in milk, which is deficient in: additive nature. The appearance of a A. Antibodies overcrowded, indigent urban popu- new murmur of mitral insufficiency B. Vitamin A lations, the current outbreak was or aortic insufficiency is highly C. Vitamin B12 noted predominantly in suburban, suggestive of carditis. With the D. Vitamin C medium-sized, middle class families advent of echocandiography, the E. Vitamin E who had access to medical care. clinician’s ability to detect the 8. Which of the following statements Also, the patients affected by the presence of canditis has been regarding colostrum is correct? A. It is high in fat content. newer ARF reported either a mild enhanced greatly. B. It is low in lactose content. pharyngitis on no pharyngitis Therapy for ARF includes C. It is low in protein content. preceding the diagnosis. However, eradication of any persistent D. It is replaced by mature milk the clinical manifestations of ARF streptococcal pharyngitis and within 48 to 72 hours. did not change as substantially as the E. It provides enzymes to stimu- prophylaxis against recurrent late gut maturation. epidemiology of the disease. infections. Salicylates are still the The diagnosis of ARF is made on 9. Epidemiologic studies provide pro- cornerstone of therapy and usually vocative information regarding the basis of the Revised Jones produce a dramatic improvement in possible immunologic protection of Criteria (Major and Minor Mani- symptoms of arthritis within 24 to 36 breast feeding against each of the festations) plus supporting evidence hours. Many authoritiesrecommend following except: of streptococcal infection.The major the addition of an antiinflammatory A. Childhood onset diabetes manifestations include: 1) carditis, B. Celiac disease corticosteroidregimen in patients C. Crohn disease 2) polyarthnitis, 3) chorea, who have severe carditis. D. Juvenile rheumatoid arthritis 4) erythema margmnation, and E. Lymphoma 5) subcutaneous nodules. Minor Philip 0. Ozuah, MD 10. Which of the following would be a manifestations of the Jones Criteria Albert Einstein College of Medicine/ contraindication to breast feeding include: 1) previous ARF or Montefiore Medical Center in the United States? rheumatic heart disease, 2) anthralgia, Bronx; New York A. Allergic disease in the family B. HIV infection C. Infantile diarrhea D. Marijuana smoking E. Maternal use of ibuprofen 11. Which of the following is the most common cause of inadequate breast milk supply? A. Lack of proper instruction B. Maternal vegetarian diet C. Nursing on demand D. Sore nipples E. Substitute bottle feedings

272 Pediatrics in Review VoL 14 No. 7 July 1993 CARDIOLOGY Paroxysmal Tachycardlas few minutes up to a maximum of heart failure, hypotension, or shock. PIR QUIZ 300 mcg/kg until heart block is Following conversion to normal achieved. The usual effective dose is sinus rhythm, an ECG should be ob- 12. Paroxysmal supraventricular tachy- cardias in young children most 75 to 150 mcglkg. Most patients re- tamed and a physical examination commonly are due to: port a brief sensation of flushing, performed. If either is abnormal, a A. Atrial flutter dyspnea, or chest pain with the pediatric cardiologist should be con- B. Automatic ectopic foci administration of adenosine. Some sulted. A child who has electrocardi- C. Electrolyte disturbances patients experience extreme anxiety ographic evidence or a history of D. Medication E. Reentrant rhythms or nausea, and a few develop bron- Wolff-Parkinson-White syndrome chospasm. The effectiveness of aden- should not be treated with digoxin 13. A 2-month-old infant has been breathing more rapidly than usual osine may be attenuated in patients except under the care of a pediatric for the past several hours. Physical taking theophylline preparations, cardiologist. Otherwise, the child examination reveals: respiratory while it may be increased in patients should be started on a maintenance rate, 60/mm; heart rate, 260/mm; taking dipyridamole or who have re- oral dose of digoxin (0.01 mg/kg per blood pressure, 60/30 mm Hg; pal- br; poor perfusion; rapid, weak active airways disease. day up to a maximum of 0. 125 mg/ pulse; and an edge of liver 5 cm The major advantages of adenosine day). Follow-up with a pediatric car- below the right costal margin. A are the short duration of action and diologist for elective screening echo- consultant recommends electrical the lack of such side effects as the cardiography is important because a cardioversion, but the necessary myocardial suppression associated small fraction of children who have apparatus proves to be inoperative. The preferred management at this with beta blockers and verapamil. PSVT have associated cardiac lesions point would be: Because of its short duration of ac- (eg, Ebstein anomaly, corrected A. Administration of adenosine tion, however, it is not useful for transposition, etc.) B. Administration of digitalis preventing the recurrence of PSVT. In summary, the smooth and suc- C. Administration of verapamil D. Application of ocular pressure Patients in whom PSVT recurs fol- cessful management of SVT requires E. Induction of vomiting lowing conversion with adenosine a careful evaluation to confirm the 14. A 4-year-old boy has had two epi- may require the addition of a longer diagnosis and an understanding of the sodes of paroxysmal supraventricu- acting agent, such as digoxin, vera- underlying mechanism. In the hemo- las tachycardia within a 24-hour pamil, a beta blocker, or procaina- dynamically stable patient, vagal period. Both responded to vagal mide. stimulation maneuvers followed by stimulation. Heart rate is now If adenosine is not available, vera- digoxin usually are the only interven- 100/mm. He is hemodynamically stable, with no evidence of conges- pamil (0. 1 to 0.3 mg/kg IV over 2 to tions required. Adenosine has be- tive heart failure. Findings on elec- 3 minutes, not to exceed 5 mg) can come accepted as a safe, effective trocardiography are consistent with be used, for it has a well-established alternative to venapamil on cardiover- Wolf-Parkinson-White syndrome. role in the acute termination of sion in the initial management of this The most appropriate management PSVT. However, because verapamil disorder. at this time would be A. Administration of adenosine can be associated with hypotension B. Administration of digoxin and bradycardia, calcium chloride SUGGESTED READING C. Administration of verapamil D. Complete restriction of activity (20 mg/kg IV), isoproterenol, and Camm AJ, Garratt CJ. Adenosine and supra- E. Referral to a pediatric cardiolo- volume expanders must be available ventricular tachycardia. N EngI J Med. gist immediately at the time of its admin- 1991;325:1621-1629 istration. Calcium gluconate and cal- O’Connor BK, MacDonald D II. What every pediatrician should know about supra- cium glubionate cannot be substituted ventricular tachycardia. Pediatr Ann. for calcium chloride in this setting 1991;20:368-376 because the calcium ion in these Perry JC, Garson A. Supraventricular compounds is not immediately avail- tachycardia due to Wolff-Parkinson-White syndrome in children:early disappearance able. Verapamil is contraindicated in and late recurrence. JAm Coil CardioL children less than 12 months of age 1990;16:1215-1220 and in the presence of congestive

274 Pediatrics in Review VoL 14 No. 7 July 1993 SUBSTANCE ABUSE 1 Nicotino

covery program is becoming popular. served for the difficult-to-treat nico- Tobacco Smoke and Nicotine: A For this reason, physicians should be tine addict or for those who have had Neurobiological Approach. New York, NY: Plenum Press, 1987:178-199 aware of its contraindications and multiple relapses and is used only in Warburton DW. The puzzle of nicotine use. how it is being used to treat nicotine the short term. In: The Psychopharmacoloj’ of Addiction. addiction. New York, NY: Oxford University Press; The literature surrounding the use SUGGESTED READING 1988 of scopolamine as treatment for nico- American Psychiatric Association. Diagnostic tine addiction is scanty and has meth- and Statistical Manual of Mental Disorders. odologic deficiencies. In 1970, it was 3rd ed. Revised. Washington, DC: reported that mecamylamine and sco- American Psychiatric Association; 1987 PIR QUIZ Benowitz NL. The use of biologic fluid 15. Each of the following statements polamine reduced puffing in mon- samples in assessing tobacco smoke about the pharmacokinetics of ni- keys. A medical protocol using consumption. In: Grabowski J, Bell CS, cotine is true, except: scopolamine was developed later and eds. NIDA Research Monograph 48. 1983; 6-26 A. Nicotine is absorbed readily piloted in humans. Nicotine-depen- from the respiratory tract, buc- Cocores JA, Gold MS. Nicotine dependent dent patients are treated with one in- cal membranes, and skin. psychiatric patients. In: Cocores JA, ed. The B. Absorption from inhalation is jected dose of scopolamine, atnopine, Clinical Management of Nicotine much more rapid than from the and chlorpnomazine. The anticholi- Dependence. New York, NY: Springer- oral route. Verlag; 1991 nergic injection is supplemented with C. The half-life of nicotine is ap- Glassman AH, Stetner F, Walsh BT, et al. 2 weeks of an oral combination med- proximately 2 hours. Heavy smokers, smoking cessation and D. Nicotine is excreted in the milk ication containing an anticholinergic clonidine. JAMA. 1988;259:2863-2966 and a benzodiazepine. The pilot Henningfield JE. Pharmacological basis and of lactating women who smoke. study reported that 40% of the 500 treatment of cigarette smoking. J Clin E. The nicotine content of smok- Psychiatr. 1984;45:24-34 smokers treated with the anticholi- ing tobacco ranges from 0.5% Hoffman D, Hect SS. Nicotine-derived N- nergic protocol remained nicotine- nitrosamine and tobacco related cancer. to 35%. free at the end of 1 year. One corn- Cancer Res. 1985;453:935-944 16. Each of the following statements mercial smoking-cessation program Jaffe JH. Drug addiction and drug abuse. In: about the pharmacologic treatments has been using this anticholinergic Goodman LS, Gilman, AG, eds. The of nicotine dependence are true, protocol for more than 6 years and Pharmacological Basis of Therapeutics. 6th except: ed. New York, NY: Macmillan Publishing A. These treatments are relatively has treated thousands of patients in Company; 1985:532-581 new, and no treatment can be dozens of locations across America. Jarvik ME, Henningfield JE. Pharmacological said to be preferred over The anticholinergic protocol should treatment of tobacco dependence. another. not be administered by physicians in- Pharmacol Biochem Be/wv. 1988;301 :279- B. Correct pharmacologic treat- 294 experienced with the medicines on ment will prevent relapse after Malcolm R, Curry HS, Mitchell MA, Keil JE. an extended period of absti- the procedure. Silver acetate chewing gum as a smoking nence. A simplified version of the anti- deterrent. Chest. 1986;90:107-131 C. A specific regime must be cholinengic protocol outlined previ- National Institutes of Drug Abuse. National planned if nicotine gum is used ously has been tried and has revealed High School Suri’ey. Washington, DC: US in the withdrawal plan, lest ni- Government Printing Office; 1989 cotine polacrilex addiction that tnanscutaneous scopolamine Noland MP, Kryscio RJ, Riggs RS, Linville results. alone eliminates nicotine craving and LH, Perritt U, Tucker TC. Saliva cotinine D. Transcutaneous nicotine reduces withdrawal symptoms. One and thiocyanate: chemical indicators of patches are used with the study found 87% of 31 subjects smokeless tobacco and cigarette use in amount of nicotine decreasing adolescents. J Behav Med. 1988;11:423-433 during a 3-week period. treated with transdermal scopolamine Schneider N. How to Use Nicotine Gum & E. Transcutaneous scopolamine to remain nicotine-free at the end of Other Strategies to Quit Smoking. New patches are used to facilitate 6 months. Other uncontrolled studies York, NY: Pocket Books; 1988 withdrawal. Sees KL, Stalcup SA. Combining clonidine report a decrease in nicotine craving 17. Each of the following statements is and nicotine replacement for treatment of and withdrawal symptoms after the true, except: nicotine withdrawal. J Psychoact Dnigs. A. There are 12 million smokeless use of transcutaneous scopolamine. 1989;21:355-359 tobacco users in the United Patients who have been assessed Taylor P. Ganglionic stimulating and blocking States. agents. In: Gilman AG, Goodman LA, Rall medically and found appropriate for B. Eighty-five percent of alcohol- TW, Murad F, eds. The Pharmacological scopolamine treatment apply one ics smoke cigarettes. Basis of Therapeutics. 7th ed. New York, 1 .5-mg transcutaneous patch to the C. With inhalation, nicotine NY: Macmillan Publishing Company; reaches the brain within mastoid area for 3 additional days. 1985:345-382 7 seconds. Transcutaneous scopolamine is not U.S. Department of Health & Human D. It takes twice as long as it does Services. The Health Consequences of recommended for use beyond 6 days smoking cigarettes to achieve Smoking: Nicotine Addiction. A Report of and is contraindicated in patients who the same blood nicotine level the Surgeon General. Washington, DC: using smokeless tobacco. are hypersensitive to scopolamine on U.S. Government Printing Office; 1988 who have glaucoma. Scopolamine E. Smokeless tobacco increases U.S. Public Health Service. The Consequences the risk of oral and pharyngeal of Using Smokeless Tobacco. A Report of use should be avoided in patients cancer. who are recovering from alcohol or the Advisory Committee of the Swgeon drug addiction on have mental disor- General. DHEW Publications No. (PHS) 86-2874. Washington, DC: U.S. ders, cardiac problems, or intestinal Government Printing Office; 1986 problems. Scopolamine usually is ne- Warburton DM. The functions of smoking. In:

Pediatrics in Review VoL 14 No. 7 July 1993 279 ABSTRACT

PIR QUIZ Infant Walkers 18. The following statements are all true, except: Use of Infant Walkers. American Medical infants sustained skull fractures, and A. Giardia lamblia cysts are not Association Board of Trustees. Am I Dis killed by chlorination. Child. 1991;145:933-934 one patient required treatment for B. Campers and hikers are at risk Chronic Subdural Hematoma: Another posttraumatic meningitis. from waterborne, vertical trans- Babywalker-Stairs Related Injury. There is no evidence to support mission outbreaks. DiMario FJ. Clin Pediatr. 1990;29:405-408 parental beliefs in early ambulation Baby Walker Injuries. Fazen E, Felizberto C. Sexual transmission may occur. due to infant walkers. Infants use D. Giardia lamblia is the most P1. Pediatrics. 1982;70:106-109 common parasite isolated in Head Injury and Baby Walkers. Partington different sets of muscles for walkers stool specimens submitted to MD, Swanson IA. Ann Emerg Med. and for ambulation. Walkers actually laboratories in the United 1991;20:652-654 may delay walking in some children States. Many parents view infant walkers as who have cerebral palsy. E. The parasite reproduces by bi- nary fission and colonizes the being safe sources of infant stimulation The combination of decreased large intestine. and activity. The infants can explore supervision and increased mobility 19. All of the following statements are their environment independently and makes the infant walker a very true, except: are entertained for hours. Unfortu- dangerous device. Parents need to be A. Many Giardia lamblia infec- nately, walkers often substitute for cautioned about the likelihood of tions are asymptomatic. vigilant parental supervision. Parents walker-related injuries, especially B. Lactose intolerance may de- also believe that infant walkers among unsupervised infants in velop and persist for some time after the elimination of the stimulate early independent walking. walkers for long periods of time. parasite. However, mobility is increased greatly Education also should stress that C. Signs and symptoms of giardi- well before the infant reaches the walkers do not promote independent asis include abdominal bloat- normal developmental stages necessary walking and are not safe babysitters. ing, flatulence, and frequent Parents then can make informed foul-smelling diarrheal stools. for cruising in a walker, and this D. The immune response in the increased mobility places the infant in decisions about appropriate infant intestine is IgG-mediated. many perilous situations not antici- walker use. E. Damage to the mucosal surface pated by parents. More than 70% of of the intestine may lead to Susan Kahn, MD infants, mostly between 5 and 12 malabsorption and malnutrition. Albert Einstein College of Medicine/ months of age, use infant walkers. Bronx Municipal Hospital Center Match the statements in 20 through 23 Almost 50% of these children are with the tests (A through E) used in the Bro,u New York diagnosis of giardiasis: involved in a walker-related accident. 20. Monoclonal antibodies have been Common injuries include those Comment: “Unsafe at any speed” used to detect fecal organisms. from falls down stairs, tipping over, is what I tell my patients’ parents, 21. Introduced into the duodenum via a and finger entrapment. Most walker- gelatin capsule. and we actively discourage the use of related accidents occur with one or 22. Although highly specific and sensi- walkers in our practice. Given the both parents in the home. Fifty tive, does not replace microscopic significant doubts about their impact examination. percent of all falls down stairs occur on development (which I have felt 23. Single stool specimen may miss in homes that have stairwell gates. 10% to 50% of infections. for a long time) and the large number The probability of an accident A. ELISA test of associated injuries, it is not really increases with the amount of time B. String test surprising that the American Acad- spent in a walker. Falls occur in C. Microscopic stool examination emy of Pediatrics feels very strongly D. Immunofluorescence fewer than 30% of infants who spend about discouraging the use of infant E. Endoscopy with small bowel less than 2 hours a day in a walker biopsy or duodenal aspiration walkers. Caring for just one child and in 55% of those who spend who comes into the office or emer- 24. All of the following statements greater than 2 hours daily in a about the treatment of giardiasis gency room after having fallen down walker. Many of these injuries are are correct, except: a flight of stairs in a walker and sus- minor and not brought to medical A. Quinacrine HC1 is the drug of taming a significant head injury is choice for giardiasis. attention. enough to convince anyone that cx- B. Asymptomatic infected patients Infant walker-related accidents posing young babies to this risk sim- do not need to be treated. from falls down stairs can cause C. Metronidazole is effective in ply is not worth it. I do feel, severe injuries. In a retrospective the treatment of giardiasis, but however, that more vigilance must be is not approved by the FDA. review of children under 2 years of taken on the part of all organizations D. The cost of treatment with age seen in the Mayo Clinic for head involved with children and their envi- quinacrine is one tenth that of trauma, Partington found that infant metronidazole. ronment. These injuries are entirely walker use was the third most E. The problems with the use of preventable. furazolidone are side effects, common mechanism of injury after cost, and efficacy. falls from furniture and falls down Steven P. Shelov, MD stairs. A total of 47.4% of these Abstracts Editor

286 Pediatrics in Review VoL 14 No. 7 July 1993