Revisiting neonatal jaundice, Pros and cons of juice, Baby not crawling? Not to worry! Eye on Washington



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Revisiting neonatal jaundice

Opinion seesaws in pediatrics on whether jaundice in the newborn requires aggressive treatment or benign neglect. During some periods, the faintest tinge of yellow sends newborns under the lights, while at other times a little jaundice has been accepted as a normal newborn phenomenon.

The pendulum may be about to swing again. The authors of a study at Children's Hospital of Philadelphia (CHOP) report that a small fraction of jaundiced newborns may require aggressive intervention to avoid long-term neurologic injury following development of kernicterus, a condition with severe neural symptoms that is associated with high levels of bilirubin.

Cases of kernicterus have been on the rise in the last decade and may be associated with the trend toward early hospital discharge of newborns. On May 2, the Joint Commission on Accreditation of Healthcare Organizations issued a special alert to hospitals, reminding them of existing guidelines for identifying and following newborns with a high bilirubin level.

The CHOP team performed a retrospective chart review for all term and near-term infants admitted between 1993 and 1996 with a bilirubin level higher than 25 mg/dL during the first week of life. Six of these infants (all breastfed) were identified, five of whom had neurologic symptoms. After aggressive treatment with IV fluids, phototherapy, and blood transfusions, all but one had a normal neurologic examination at follow-up. In addition, abnormalities of the brain that were identifiable on magnetic resonance imaging reverted to normal.

Pros and cons of juice

Do children drink too much fruit juice? Probably, according to the Committee on Nutrition of the American Academy of Pediatrics. The committee has issued a new set of guidelines, "The Use and Misuse of Fruit Juice in Pediatrics," to deal with the problem.

To begin with, the subject is fruit juice—not fruit drink, fruit beverage, or fruit cocktail. The federal government has standards for this kind of nomenclature, and a drink labeled "juice" must be exactly and totally that—no dilution or additions allowed. But even a drink that is 100% juice, the committee points out, is mostly water and contains a substantial amount of such carbohydrates as fructose, sucrose, glucose, and sorbitol. Granted, juice has no fat or cholesterol and some vitamins, but it also has no fiber, less nutrient value than milk, and only as much fluoride as the water used to reconstitute it.

The committee recommends going easy on juice. Infants shouldn't be given bottles or sippy cups of juice, and total intake should be limited to 4 to 6 ounces a day for children 1 to 6 years of age. To meet the daily requirements for fruit intake, the committee recommends eating whole fruits. Providers evaluating children with chronic diarrhea, excessive flatulence, abdominal pain, and bloating should ask parents how much juice the child is drinking.

On the other hand, a four-year study of 72 children funded by Gerber Products refutes the assertion, made by some health-care professionals, that juice is associated with overweight or short stature in children. The juice drinkers in this study were no fatter and no shorter than controls. In an additional finding of interest, researchers noted that as the children in the study grew older, they drank less juice and more carbonated drinks. The implication is that they'd be better off if they continued drinking juice (J American Dietetic Assn 2001;101:432).

Baby not crawling? Not to worry!

A parent in your practice greets you in the examining room with this complaint: "Doctor, Bobby's a year old and he isn't crawling yet. I looked it up in Caring for Your Baby and Young Child—you know, that book by the American Academy of Pediatrics? And it said crawling was a developmental milestone that he should have reached by this time. Should I be worried?"

What should you say? The right answer, as pediatricians who are up on the developmental literature know, is "No"; the baby books just haven't caught up with the times. In fact, lots of babies are skipping the crawling milestone these days; they don't even roll over when the books say they should (3 to 6 months). The reason for this change? According to a 1998 study, parents are following the AAP's advice and putting babies to sleep on their backs. [For more about risk factors for sudden infant death syndrome, see "Are you talking to parents about SIDS?" our March 2001 cover story.]

A baby lying on his back can see the world; he has no incentive to turn over. So the developmental progression from lying on the belly to getting up on hands and knees to crawling just doesn't happen. The Davis study made the reassuring finding, however, that in the long run it makes no difference when babies crawl. Of 351 infants in the study, those who slept on their belly rolled over sooner, crawled sooner, and pulled to stand sooner than those who slept on their back. But whatever the sleep position, all babies walked at about the same age.

The take-home message is, first, keep telling parents to put infants to sleep on their backs, because the change in sleep position makes a huge difference in babies' risk of SIDS, and, second, tell them not to worry about when—if at all—their baby starts to crawl. In fact, crawling is probably one milestone we can forget about.

Eye On Washington

Members of Congress usually spend the Memorial Day recess marching in hometown parades and glad-handing constituents. But this year, those peaceful pursuits were interrupted by a shocking announcement: Senator James Jeffords of Vermont, who has spent a long political career as a Republican, announced he was about to leave his long-time political home, become an Independent, and vote with the Democrats to reorganize the Senate. As long as the Senate was evenly split between 50 Republicans and 50 Democrats, Vice President Cheney's tie-breaking vote gave the Republicans control. Without Jeffords, the Republicans become the minority party. The Senate that reconvened after the Memorial Day recess was in the hands of the Democrats, who took over the chairmanship of committees that deal with issues like funding for special education and Head Start, health-care reform, and patients' rights. It's a whole new ball game.

While public attention was concentrated on the extraordinary turn of events, agencies of the federal government concerned with the welfare of children and families went about their business:

The Food and Drug Administration announced approval of Gleevec (imatinib mysylate, also known as STI-571) as an oral treatment for patients with chronic myeloid leukemia. The marketing application was approved in less than three months under FDA's accelerated approval regulations. Gleevec falls under the orphan drug program, which provides financial incentives for drugs developed to treat rare diseases.

The National Center for Injury Prevention and Control published the report of the American Veterinary Association's Task Force on Canine Aggression and Human-Canine Interactions. The report declares dog bites a serious public health problem and presents a community approach to prevention. The report can be downloaded from www.avma.org/press/dogbite .

The Supreme Court ruled that federal law does not allow a state to use the "medical necessity" exception to federal prohibition of the distribution of marijuana. According to the court, marijuana's listing as a Schedule I drug under the Controlled Substances Act means that it "has no currently accepted medical use."

The National Institute of Allergy and Infectious Disease announced completion of the sequencing of the genome of Streptococcus pyogenes (aka group A strep, or GAS), the bacterium that can lead to pharyngitis, scarlet fever, impetigo, pneumonia, toxic shock syndrome, rheumatic heart disease, and necrotizing fasciitis. According to Anthony Fauci, MD, Director of NIAID, mapping the genome of this organism promises better treatment and prevention strategies.

The Bureau of the Census, which announced tabulations from the recently completed national head count, discovered that married couples with children now account for fewer than a quarter of households. The number of households with children that are headed by Mother alone has increased nearly five times faster in the last decade than the number of married couples with children. The number of single-parent households with Father in charge is also rising rapidly, increasing by 62% in the past 10 years.

US Marine Corps officials are looking for families whose children were conceived while they were living in Marine Corps housing at Camp Lejeune, N.C., between 1968 and 1985. The Agency for Toxic Substances and Disease Registry is conducting a health survey of these children, focusing on adverse health effects that may be associated with dry cleaning and degreasing compounds found in the camp's water distribution system those years. To participate, call the National Opinion Research Center at 800-639-4270, or send an e-mail message to 4827-lejeune@norcmail. uchicago.edu.


August 24-26, Sports Medicine and Hockey: A Summit for the NHC and Beyond, Toronto, Ontario, Canada. For more information, go to the Web site of the American Orthopaedic Society for Sports Medicine, www.sportsmed.org .

September 8, Every Child Deserves a Medical Home Training Program, Cincinnati. For more information, go to the AAP Web site, www.aap.org .

September 9-12, American Academy of Otolaryngology Annual Meeting, Denver. To register, e-mail ksatterf@entnet.org.

September 29-October 1, Gay and Lesbian Medical Association Annual Conference: Commitment, Caring, Advocacy, New Orleans. For more information, e-mail info@glma.org.

September 30-October 3, American Neurological Association Annual Meeting, New Orleans. For more information, go to the ANA Web site, www.aneuroa.org .

October 20-24, American Academy of Pediatrics National Conference and Exhibition, San Francisco. For registration information, go to the AAP Web site, www.aap.org .

October 21-25, American Osteopathic Association Annual Convention, San Diego. For more information, go to the AOA Web site, www.aoa-net.org .

October 23-28, American Academy of Child and Adolescent Psychiatry Annual Meeting, Honolulu. For more information, go to the Academy's Web site, www.aacap.org/meeting .

October 27-30, International Meeting on Antimicrobial Chemotherapy in Clinical Practice, Portofino, Italy. For more information, e-mail Matteo Bassetti, mattba@tin.it.

November 16-20, Allergy, Asthma, and Immunology, Orlando, Fla. For more information, write to the American College of Allergy, Asthma, and Immunology, 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005.


Updates. Contemporary Pediatrics 2001;7:13.

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