Pediatrics Review andEducation Program

CONTENTS

Printed in USA.

COMMENTARY

263 Extending the Boundaries of MedicineRobert J. Haggertv

ARTICLES

265 Strokes in ChildrenMichael J. Rivkin and Joseph J. Volpe

279 Separation or Synthesis: A Holistic Approach toTherapeuticsKat/ii J. Kemper

284 Developmental Learning Disorders: Clues to TheirDiagnosis and ManagementDonna M. C’apiii

291 Index of SuspicionJ. Peter Harris, Carol J. Buzzard, Liliana D. Gutierrez,

Franz E. Babi, Susan K. Ratzan

IN BRIEF

263 Pressures: Impact on Health of Adolescents

294 Rifampin

DEPARTMENT OF CORRECTIONS

264 Erratum

COVER

Each of our 1996 issues of Pediatrics in Review will feature a work of art

submitted to our cover art contest this past year. We received more than200 entries and have chosen 12 to appear on our covers-four from eachof three age groups: 5 to 7 years, 8 to 10 years, and 11 to 15 years. The

entrants were asked to submit a drawing of what they like to do best.Most entries will be displayed by the American Academy of Pediatrics at

various sites.

This month’s work, by 9/i-year-old Alexander Alemar, is of himswimming. Alexander lives in Las Vegas, NV; his pediatrician is Kim M.

LaMotte, MD.

ANSWER KEY

1. D; 2. B; 3. D; 4. B; 5. E; 6. D; 7. C; 8. D; 9. D; 10. A; 11. A; 12. B; 13. D; 14. A;

15.D

Pediatrics in ReviewVol.17 No.8

August 1996

EDITORRobert J. HaggertyUniversity of RochesterSchool of Medicine and DentistryRochester. NY

Editorial Office:Department of PediatricsUniversity of RochesterSchool of Medicine and Dentistry601 Elmwood Ave. Box 777Rochester, NY 14642

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatric GroupRochester, NY

CONSULTING EDITOREvan Charney, Worcester, MA

EDITOR, IN BRIEFHenry M. Adam, Bronx. NY

ASSOCIATE EDITOR, IN BRIEFTina L. Cheng, Washington, DC

MANAGING EDtTOR

Martha H. Sallzman, Elk Grove Village, IL

EDITORIAL CONSULTANT

Victor C. Vaughan, III, Stanford. CA

EDITORIAL BOARDHoover Adger, Jr. Baltimore, MDRussell W. Chesney, Memphis, TNPeggy Copple, Tucson, AZJames J. Corrigan, Jr. New Orleans, LABrahm Goldstein, Portland. ORJohn L. Green, Rochester, NYWalter Huurman, Omaha, NEJohn Kattwinkle, Charlottesville, VAKathi Kemper, Seattle, WAJohn T. McBride, Rochester, NYLawrence C. Pakula, Timonium, MDKenneth B. Roberts, Worcester, MABradley M. Rodgers, Charlottesville, VAAllen W. Root, Tampa, FLLawrence Schachner, Miami, FLGail G. Shapiro, Seattle, WAFrank R. Sinatra, Los Angeles, CAMartin T. Stein, LaJolla, CAJon Tingelstad, Greenville, NCTerry Yamauchi, Little Rock, AR

EDITORIAL ASSISTANTSydney Sutherland

PUBLISHERAmencan Academy of PediatricsOlle Jane Z. Sahler, MD, Director

Department of EducationJo A. Largent, Director

Division of Medical JournalsDeborah Kuhlman, Copy Editor

PEDIATRICS IN REVIEW(ISSN 0191-9601) is ownedand controlled by the Amencan Academy of Pediatrics.It is published monthly by the American Academy ofPediatrics, 141 Northwest Point Blvd. P0 Box 927, ElkGrove Village, IL 60009-0927.

Statements and opinions expressed in Pediatrics inReview are those of the authors and not necessarilythose of the American Academy of Pediatrics or itsCommittees. Recommendations included in this pub-lication do not indicate an exclusive course of treat-ment or serve as a standard of medical care.

Subscription price for 1996: AAP Fellow $110: AAPCandidate Fellow $85; AAFP $135; Allied Health orResident $85; Nonmember or Institution $145. Currentsingle price is $10. Subscription claims will be honoredup to 12 months from the publication date.

Second-class postage paid at ARLINGTONHEIGHTS, ILLINOIS 60009-0927 and at additionalmailing offices.

© AMERICAN ACADEMY OF PEDIATRICS, 1996.All rights reserved. Printed in USA. No part may beduplicated or reproduced without permission of theAmerican Academy of Pediatrics. POSTMASTER:Send address changes to PEDIATRICS IN REVIEW,American Academy of Pediatrics, P0 Box 927, ElkGrove Village, IL 60009-0927.

The printing and production of Pediatncs in Review ismade possible, in part, by an educational grant fromRoss Products Division, _____________Abbott Laboratories. r��i

IROSSII SUPPOR�NG II PEDiATRIC I1.EDUCAT1ONJ

278 Pediatrics iii Review Vol. 17 No. 8 August 1996

�:�c.‘ ; .:

with human immunodeficiency virus. Arch

PediatrAdolesc Med. 1994:148:965-970

‘�‘‘ ‘ � ‘‘‘ “ � ‘� �‘ “ � � �

Pihko H, Tyni T, Virkola K, et al. Transient PIR QUIZ A. Albuterol.

ischemic cerebral lesions during induction B. Aspirin.

chemotherapy for acute lymphoblastic I . The most common clinical mani- C. Nifedipine.

leukemia. J Pediatr 1993;l23:7l8-724 festation of stroke in a full-term D. Oral contraceptives.

Ravelli A, Martini A, Burgio 0. Antiphospho- newborn is: E. Theophylline.

lipid antibodies in paediatrics. EurJ A. Anisocoria.Pediatr 1994; 153:472-479

Rivkin M, Anderson M, Kaye E. Neonatal idio-B. Bulging fontanalle.

C. Decerebrate posturing.

4. Which one of the following disor-

ders of amino acid metabolism

pathic cerebral venous thrombosis: an unrec- D. Focal seizures. carries the greatest risk of cere-ognized cause of transient seizures or lethar-

gy. Amimi Neural. 1992:32:51-57

E. Hemiparesis. brovascular occlusion?

A. Hartnup disorder.

Scott M, Barnes P. Kupsky W, Adelman L. 2. Which one of the following thera- B. Homocystinuria.

Cavernous angiomas of the central nervous

system in children. J Neurosurg.

pies is most useful in the manage-

ment of cerebrovascular occlusion

C. Maple syrup urine disease.D. Phenylketonuria.

1992:76:38-46 in a child who has sickle cell dis- E. Tyrosinosis.Sigal L. The neurologic presentation of vas- ease?

culitic and rheumatologic syndromes.Medicine. l987;66: 157-180

Siegler R. Spectrum of extrarenal involvement

in postdiarrheal hemolytic-uremic syn-

drome. J Pediatr l994;125:Sll-5l8

Simioni P. Battistella P. Drigo P. et al.

Childhood stroke associated with familial

protein S deficiency. Brain Devel.

1994:16:241-245

Warach 5, Chien D, Li W, et al. Fast magnetic

resonance diffusion-weighted imaging of

acute human stroke. Neurolog�� ‘

1992:42:1717-1723

A. Co�ticosteroids.

B. Exchange transfusion.

c. Heparinization.D. Strepto�tinase infusion.

E. Surgical thrombectomy.

3. Which one of the following med-

ications is most likely to predis-

pose to cerebrovascular thrombo-sis

5. Deficiency of which of the follow-

ing is associated with an increased

risk of thrombotic/embolic cere-

brovascular disease?

A. Factor V.

B. Fibrinogen.

C. Plasminogen.D. Platelet activating factor.

E. Proteins C and S.

‘ ‘ � � . -� . � � . � � . � ‘ � � � ‘ � . .‘

Pm Quiz-CME CreditA short quiz can be found at theend of each article in Pediatrics in

Review. Use the Quiz Card (boundinto the January issue) to recordyour answers. Each question has a

SINGLE BEST ANSWER. Theanswers to the questions appear onthe inside front cover of each issue.Three AMA Category 1 continuingmedical education (CME) credits are

awarded per completed issue for ayearly total of 36 CME credits.

To obtain credit, record youranswers on the Pediatrics in Re-

view Quiz Card and send it to theAmerican Academy of Pediatrics,PREP Office, P0 Box 927, Elk

Grove Village, IL 60009-0927. Toreceive CME credit on the 1996annual credit transcript, Quiz Cardsmust be received by February 28,1997. Quiz Cards received after this

deadline will be recorded in the yearthey are received. Quiz Cards fromthe 1996 volume of Pediatrics in

Review will be accepted throughDecember 31, 1998. A special note

to PREP gmup subscribers: Youwill receive the PIR Quiz Card and

the Self-Assessment Credit ReplySheet under separate cover.

The American Academy of Pedi-attics (AAP) is accredited by the

Accreditation Council for Continu-ing Medical Education to sponsorcontinuing medical education forphysicians. The American Acad-emy of Pediatrics designates thePediatrics Review and Education

Program (PREP) for 56 credithours in Category 1 of the Physi-cian’s Recognition Award of theAmerican Medical Association.

PREP meets the criteria for 56hours of credit toward the AAPPREP Education Award.

PREP has been reviewed and isacceptable for 56 prescribed hoursby the American Academy ofFamily Physicians. (Term of ap-proval: beginning date January 1996.Enduring materials are approved for1 year with option to request renew-al.) For specific information, pleaseconsult the AAFP Office ofContinuing Medical Education.

PREP has been reviewed and isacceptable for 32 AOA Category2-B CME hours by the AmericanOsteopathic Association. For spe-cific information, please consult theAOA Department of Education.

PREP has been approved for 56NAPNAP contact hours. An individ-

ual requesting contact hours shouldsubmit proof of participation and

verification of PREP accreditation tothe NAPNAP National Office.

In addition, the Canadian Paedi-atric Society has approved PREP

as one method for pediatricians to

demonstrate maintenance of com-petence (MOCOMP). For specificinformation, please consult theCPS directly.

PREP EDUCATION AWARD:

The AAP PREP Education Awardrecognizes Academy Fellows andCandidate Fellows who earn a mm-imum of 150 AAP-approved CME

credits over 3 consecutive years.The Award will be mailed auto-

matically in July 1997 to all mdi-

viduals who qualify.To qualify for the PREP Educa-

tion Award, a Fellow or Candidate

Fellow must:

. Earn a minimum of 75 credithours through participation inPREP or PREP: The Course, and

. Earn the remaining credit hours(75 hours) through other Acade-my-sponsored or -approved CME

activities. This may include: AAPSpring Session or Annual Meet-ing; AAP CME courses; ACQIP;Pediatric UPDATE Audiocasseue

Tape Program; or other AAPapproved courses.

ThERAPEUTiCSHolistic Medicine

PIR QUIZ

6. Of the following conditions, the onethat can be treated most appropri-ately primarily by lifestyle therapyis:

A. Acute otitis media.B. Crohn disease

C. Pulmonary hypertension.D. Systemic hypertension.

E. Urolithiasis.

7. Of the following conditions, the one

that can be treated most effectively

with biomechanical therapy is:

A. Acne.

B. Autoimmune thyroiditis.

C. Depression

D. Primary enuresis.

E. Retinitis pigmentosa.

8. Of the following conditions, the one

that can be treated most effectivelywith bioenergetic therapy is:

A. Acne.B. Conduct disorder.

C. Inflammatory bowel disease.D. Migraine headache.

E. Schizophrenia.

9. Of the following conditions, the one

that can be treated most effectively

with biochemical therapy alone is:

A. Attention deficit hyperactivitydisorder.

B. Chronic recurrent abdominalpain.

C. Intussusception.

D. Streptococcal tonsillo-

pharyngitis.

E. Tension headache.

Pediatrics in Review Vol. 17 No. 8 August 1996 283

REFERENCES1 . Eisenberg DM, Kessler RC, Foster C, et al.

Unconventional medicine in the United

States. N Engl J Med. l993;328:246-252

2. Spigelblatt L, Laine-Ammara 0, Pless lB.

Guyver A. The use of alternative medicine

by children. Pediatrics. 1994:94:8 1 1-8 14

3. Stern RC, Canda ER, Doershuk CF. Use of

nonmedical treatment by cystic fibrosis

patients. JAdolesc Health. 1992:13:

612-6154. Weizman Z, Alkrinawai 5, Goldfarb D, et

al. Efficacy of herbal tea preparation in

infantile colic. JPediatr. 1993:122:

650-6525. Johnson ES, Kadam NP, Hylands DM, et

al. Efficacy of feverfew as prophylactic

treatment of migraine. Br Mcdi. 1985:

291:569-573

6. Lindahl 0, Lindwall L. Double-blind study

of a valerian preparation. Pharmacol

Biochem Behav. 1989:32:1065-10667. Berkowitz CD. Homeopathy: keeping an

open mind. Lancet. 1994:344:701-702

8. Rieder MJ. Prevention of neural tube

defects with periconceptional folic acid.

Clin Perinatol. 1994:21:483-503

9. Kleijnen J. Ter Riet G, Knipschild P.

Vitamin B6 in the treatment of premenstru-

al syndrome-a review. Br J Obstet

Gvnecol. 1990;97:847-852

10. Warshafsky 5, Kamer RS, Sivak SL. Effect

of garlic on total serum cholesterol. A

meta-analysis. Ann Intern Med. 1993:119:

599-60511. Nagarathna R, Nagendra HR. Yoga for

bronchial asthma: a controlled study. Br

MedJ. 1985:291:1077-1079

12. Spiegel D, Bloom J, Kraemer AC. Gottheil

E. Effect of psychosocial treatment on sur-

vival of patients with metastatic breast can-

cer. Lancet. 1989:2:888-891

13. Wheeden A, Scafidi FA, Field T, et al.

Massage effects on cocaine-exposed

preterm neonates. J Dev Behav Pediatr.

1993: 14:3 18-322

14. Field T, Morrow C, Valdeon C, et al.

Massage reduces anxiety in child and ado-

lescent psychiatric patients. J Am Acad

ChildAdolesc Psvchiatr. 1992:31:125-131

15. Lu DP, Lu OP. Acupuncture

anesthesia/analgesia for pain and anxiety

control in dental practice. Compendium.1993; 14:464-468, 470-472

16. Klide AM. Acupuncture analgesia. Vet Clin

North Am SmallAnim Pract. 1992:22:

374-37917. Hesse J. Mogelvang B, Simonsen H.

Acupuncture versus metoprolol in migraine

prophylaxis: a randomized trial of trigger

point inactivation. J Intern Med.

1994:235:451-45618. Bellumomini J, Litt RC, Lee KA, Katz M.

Acupressure for nausea and vomiting of

pregnancy: a randomized, blinded study.

Obstet Gvnecol. l994;84:245-248

19. Brewington V. Smith M, Lipton D.

Acupuncture as a detoxification treatment:

an analysis of controlled research. J Subst

Abuse Treat. 1994:11:289-307

20. Gagne D, Toye RC. The effects of thera-

peutic touch and relaxation therapy in

reducing anxiety. Arch Psychiatr Nurs.

l994;8: 184-189

21. Kramer NA. Comparison of therapeutic

touch and casual touch in stress reduction

in hospitalized children. Pediatr Nurs.

1990:16:483-485

22. Byrd RC. Positive therapeutic effects of

intercessory prayer in a coronary care unit

population. South MedJ. 1988:81:

826-82923. Dossey L. Healing Words: The Power of

Prayer and the Practice of Medicine. New

York, NY: Harper Collins; 1993

24. Reilly D, Taylor MA, Beattie NO. et at. Is

evidence for homeopathy reproducible?

Lancet. 1994:344:1601-160625. Jacobs J, Jimenez LM, Oloyd SS, et al.

Treatment of acute childhood diarrhea with

homeopathic medicine: a randomized clini-

cal trial in Nicaragua. Pediatrics.1994:93:719-725

290 Pediatrics in Review Vol. 17 No. 8 August 1996

DEVELOPMENTLearning Disorders

language therapists, neunopsycholo-gists, education specialists, and occu-pational therapists. This multidisci-

plinany approach will help prevent

the secondary conditions that causeso much acute distress and associatedmorbidity. Early diagnosis and inter-vention can have a momentous effecton some of the most significantaspects of a child’s life.

SUGGESTED READINGAmerican Psychiatric Association. Diagnostic

(hid Statistical Manual. 4th ed. Washington

DC: American Psychiatric Association:1994

Denckla MB. The child with developmental dis-

abilities grown up: adult residua of child-

hod disorders in behavioral neurology.

Neural Clin. 1993:11:105-125

Filipek PA. Neurobiologic correlates of devel-

opmental dyslexia: how do dyslexics� brains

differ from those of normal readers? J Child

Neurol. I 995: 10:S62-S69

Galahurda AM. The pathogenesis of childhood

dyslexia. In: Plus F. ed. Language

Comniunication an(l tilt’ Brain. New York.

NY: Raven Press: 1988:127-138

Interagency Committee on Learning

Disabilities. A Report to the US Congress.

Washington. DC: US Government Printing

Office: 1987

National Joint Committee on Learning

Disabilities (1990). Learning Disabilities:

Issues on Definition. A Position Paper of the

National Joint Co,n,nittee on Learning

Disabilities. Austin. Tex: Pro-ED: 1994

Osterrieth PA. Le test de copie d’une figure

complexe. Arc/i de Psvcho!ogie. 1944:30:

206-356Pennington BF. Diagnosing Learning

Disorders: A Neuropsvchological Frame-

work. New York. NY: Guilford Press: 1991

Rourke BP. ed. Syndrome of Non verbal

Learning Disabilities. New York. NY:

Guilford Press: 1995US Department of Education. Sixteenth Annual

Report to c’ongress 00 the Implementation

oft/ic Individual.s with Disabilities

Education Act. Washington, DC: 1994

PIR QUIZ

10. As currently defined, learning

disabilities comprise difficulties

in reading. writing, or arithmetic

that occur in children who have:

A. Otherwise normalintelligence.

B. Residual effects of central

nervous system trauma.C. Residual effects of fetal alco-

hol syndrome.

D. Residual effects of lead poi-

soning.

11. As currently defined, learning

disorders comprise each of the

following except:

A. Elective mutism.B. Specific mathematical

disability.

C. Specific reading disability.

D. Posttraumatic learning

disability.

12. In the evaluation of a child sus-

pected of having a learning dis-ability, the most helpful examina-

tion among the following is:

A. Electroencephalography.

B. History.

C. Metabolic studies.D. Magnetic resonance imaging.

E. Physical examination.

13. Which of the following disorders

is least likely to be comorbid

with a learning disability?

A. Anxiety disorder.B. Bipolar disorder.

C. Depression.

D. Psychosis.

E. Substance abuse.

14. For which of the following is

there least evidence of specific

location of function in the brain?A. Executive function.

B. Long-term memory.

C. Phonologic processing.

D. Social cognition.

15. Academically, the grade level atwhich the transition from learn-ing to read to reading to learntakes place is:A. Kindergarten.B. First grade.

C. Second grade.

D. Fourth grade.E. Sixth grade.