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CONTENTS

ARTICLES

291 IgG Subclasses: Importance in Pediatric Practice

Penelope G. Shackelford

297 Consultation with the Specialist:Screening for Scoliosis

James S. Marsh

299 Medical Record Review: When Parents Become

Critical Observers: Caring for the Child Who Has a

Head Injury

300 Medical Record Documentation of Head Injury

302 Abdominal Pain Unrelated to Trauma

Richard .1. Stevenson and Moritz M. Ziegler

313 Recurrent Abdominal Pain During Childhood

Tim F. Oberlander and Leonard A. Rappaport

320 Otitis Media

Virgil M. Howie

324 Point-Counterpoint: Sexual Abuse - The Yellow

Flag is Still Up

Carol Berkowitz and Richard Krugman

ABSTRACTS �

312 Intraluminal Nutrition

326 Familial Aspects of Tall Stature

COVER

“Sara Handing a Toy to the Baby” was painted by Mary Cassatt (1845 -

1925). Cassatt, an American artist, was the daughter of a wealthy

Philadelphia businessman. She went to Paris to study and never returned.

Most of her paintings are of mothers and children, although she herself

never married. This lovely painting shows an older sibling handing a toy to

her younger brother. We all know that sibling relations are never thisserene at all times, but we can always encourage the sharing and love sobeautifully shown here. (This painting is reproduced with the permission of

the Hill.Stead Museum, Farmington, CT).

ANSWER KEY

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

13. A; 14. B; 15. C; 16. D; 17. E; 18. E; 19. D

The printing and productionof Pediatrics in Review ismade possible, in part, byan educational grant fromRoss Laboratoriss.

1

#{149}� IROBB ISUPt�ORTING IPEDIATRIC IE OUc�NJ

Printed in the USA

Pediatrics in Review

Vol 14 No 8

August 1993

EDITORRobed J. Hagge�yUnWers�� of RochesterSchool of Medicine and Dentist,yRochester, NY

Edttor�aI Office:Department of PediatricsUniverstr�’ of RochesterSchool of Medicine and Dentistiy601 Elmwood Ave. Box 777Rochester, NY 14642

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatec GroupRochester, NY

ABSTRACTS EDITOR

Steven P. Shelov, Bronx, NY

MANAGING EDITOR

Jo Largent, Elk Grove Village, IL

EDITORIAL CONSULTANT

Victor C. Vaughan, III, Stanford, CA

EDITORIAL BOARDMoris A. Angulo, Mineola, NYRussell W. Chesney, Memphis, TNCatherine DeAngelis, Baltimore, MDPeggy C. Feny, Tucson, AZRichard B. Goldbloom, Halifax, NSJohn L Green, Rochester, NYRobeit L Johnson, Newark, NJAlan M. Lake, Glen Arm, MDFrederick H. Lovejoy, Jr. Boston, MAJohn T. McBride, Rochester, NYVincent J. Menna, Doylestown, PALawrence C. Pakula, Timonium, MDRonald L Poland, Hershey, PAJames E. Rasmussen, Ann Arbor, MIJames S. Seidel, Torrance, CARichard H. Sills, Newark, NJLaurie J. Smith, Washington, DCWilliam B. Strong, Augusta, GAJon Thgelstad, Greenville, NCVernon T. Tolo, Los Angeles, CARobeil J. Touloukian, New Haven, CTTerry Yamauchi, Little Rock, ARMorltz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTSydney Sutherland

PUBUSHERAmerican Academy of PediatricsErrol R. Alden, Director,

Department of EducationJean Dow, Director

Division of PREP/PEDIATRICSDeborah Kuhlman, Copy Editor

PEDIATRICS IN REViEW (ISSN 0191-9601) isowned and controlled by the American Academyof Pediatrics. It is published monthly by theAmerican Academy of PedIatrics, 141 NorthwestPoint BIvd, P0 Box 927, Elk Grove Viliage, IL60009-0927.

Statements and opinions expressed in ec*abfosin Review are those of the authors and notnecessarily those of the American Academy ofPediatrics or its Committees. Recommendationsinduded in this publication do not Indicate anexclusive course of treatment or serve as a standardof medical care.

Subscription price for 1993: AAP Fellow $95;AAP Candidate Fellow $70; AAFP $115; AlliedHealth or Resident $70; Nonmember or Institution$125. Current single price is $10. Subscriptionclaims will be honored up to 12 months from thepublication date.

Second-class postage paid at ARLINGTONHEIGHTS, IWNOIS 600090927 and at additionalmailing offices.

#{149}AMERICAN ACADEMY OF PEDIATRICS,1993. All rights reserved. Printed in USA. No partmay be duplicated or reproduced withoutpermission of the American Academy of Pedlatiics.POSTMASTER: Send address changes toPEDIATRICS IN REViEW, American Academy ofPediatrics, P0 Box 927, Elk Grove Village, IL60009-0927.

PIR QUIZ

1. By history, an immune deficiency ismost likely to be present in:A. A 4.month��ld female who has

recurrent oral candidiasis.B. An 18-month-old boy who has

recurrent otitis media and bilat-eral perforations.

C. A 2.year-old girl who has mal-absorption.

D. A 5-year-old girl who has recur-rent urinary tract infections.

E. A 10-year-old boy who haschronic suppurative adenitis incervical and inguinal sites.

3. Among the following tests,the mostlikely resultto be associatedwith animmune deficiency is:A. A positive wheal and flare

response to pokeweed mitogen.B. Absence of anti-A antibodies in

an individual who has bloodtype B.

C. Absence of measurable 1gM inrespiratory secretions.

D. Development of high titer anti-body to pneumococcal vaccine.

E. Positive delayed hypersensitivityto Candida albicans antigen.

2. An 8-year-old girl has had threebouts of bronchopneumonia-two inthe right lower lobe and one in theleft lower lobe. The WBC and dif-ferential count are normal. Onradiographic study, the right mmdl-lary sinus is completely opacifiedand the left maxillary sinus has anair-fluid level. The total serum IgGlevel isin the normal range. Of thefollowing, the study most likely tobe useful is:A. Antibody titer response to polio

vaccine booster.B. Lymphocyte proliferation

response to concanavalin A.C. Measurement of the concentra-

tions of the IgG subclasses.D. Measurement of the titer of

hemolytic complement.E. Nitroblue tetrazolium test of

leukocyte function.

4. The most correct statement regard-ing IgG subclasses is:A. Antibodies to diphtheria protein

antigen are primarily of the IgG1subclass.

B. Combined deficiency of IgG2and IgG4 is associated with au-toimmune thrombocytopenia.

C. IgG2 deficiency is associatedwith repeated viral respiratoryillnesses.

D. lgG3 subclass contains the ma-jority of antibodies to pneumo-coccal polysaccharide antigen.

E. IgG4 activates the classical path-way of complement.

296 Pediatrics in Review VoL 14 No. 8 August 1993

IMMUNOLOGYGamma Globulins

3. Weinberg GA, Granoff DM, Nahm MH,Shackelford PG. Functional activity ofdifferent IgG subclass antibodies againsttype b capsular polysaccharide ofHaemophilus influenzae. I Immunol.

1986; 136:4232-42364. Shackelford PG. Granoff DM, Nelson Si,

Scott MG, Smith DS, Nahm MH. Sub-class distribution of human antibodies toHaemophilus influenzae type b capsularpolysaccharide. J Immunol. 1987;138:587-592

5. Shackelford PG. Granoff DM, PolmarSH, et al. Subnormal serum concen-trations of IgG2 in children with frequentinfections associated with varied patternsof immunologic dysfunction. I Pediatr.

1990116:529-5386. Jeffries R, Kumararatne DS. Selective IgG

subclass deficiency: Quantification andclinical relevance. Clin Erp Immunol.

1990;81:357-3677. Meissner C, Reimer CB, Black C, et al.

Interpretation of IgG subclass values: Acomparison of two assays. J Pediatr.1990;1 17:726-731

8. Carbonara AO, Demarchi M. Ig isotypesdeficiency caused by gene deletions.Monogr Allergy. 1986;20:13-17

9. Oxelius V-A. Chronic infections in afamily with hereditary deficiency of lgG2and IgG4. Clin Esp Immunol. 1974;17:19-27

10. Oxelius V-A, Laurell A-B, Lindquist B,et al. IgG subclasses in selective IgAdeficiency. NEnglJMed. 1981;304:1476-1477

11 . BjOrkander J, Bake B, Oxelius V-A,Hanson LA. Impaired lung function inpatients with IgA deficiency and lowlevels of IgG2 or IgG3. N EngI I Med.

1985;313:720-72412. Lane P, MacLennan I. Impaired lung

function in patients with IgA deficiencyand low levels of IgG2 or IgG3. N Engll

Med. 1986;314:924-92613. Umetsu DT, Ambrosino DM, Quinti I,

Siber GR, Geha RS. Recurrent sino-pulmonary infection and impairedantibody response to bacterial capsularpolysaccharide antigen in children withselective IgG-subclass deficiency. N EngI

I Med. 1985;313:1247-125114. Smith TF, Morris EC, Bain RP. IgG

subclassesin nonallergicchildrenwithchronic chest symptoms. I Pediatr.

1984; 105:896-90015. Inset RA, Anderson PW. Response to

oligosaccharide-protein conjugate vaccineagainst Haemophilus inJluenzae b in twopatients with IgG2 deficiency unrespons-ive to capsular polysaccharide vaccine. N

EngI J Med. 1986;315:499-50316. Shackelford PG, Granoff DM, Madassery

JV, Scott MG, Nahm MH. Clinical andimmunologic characteristics of healthy

children with subnormal serum concen-trations of IgG2. Pediatr Res. 1990;27:16-21

17. Holmes SA, Lucas AH, Osterhoim MT.Froeschle JE, Granoff DM. Immuno-globulin deficiency and idiotypeexpression in children developingHaemophilus influenzae type b diseaseafter vaccination with conjugate vaccine.JAMA 1991;266:1960-1965

18. Geha RS. IgG antibody response to poly-saccharides in children with recurrentinfections. Monogr Allergy. 1988;23:97-102

19. Ambrosino DM, Siber GR, ChilmonczykBA, Jernberg JB, Finberg RW. Animmunodeficiency characterized byimpaired antibody responses to poly-saccharides. N Engl I Med.

1987;316:790-793

SUGGESTED READINGBerger M. Immunoglobulin G subclass

determination in diagnosis and managementof antibody deficiency syndromes. IPediatr. 1987;! 10:325-328

Lyall EGH, Eden OB, Dixon R, Sutherland R,Thomson A. Assessment of a clinicalscoring system for detection of immuno-deficiency in children with recurrentinfections. Pediatr Infect Dis I. 1991;10:673-676

Morell A. IgG subclass deficiency: A personalviewpoint. Pediatr Infect Dis I. 1990;9:S4-S8

Ochs HD, Wedgwood Ri. IgG subclassdeficiencies. Ann Rev Med. 1987;38:325-340

Wood RA, Sampson HA. The child withfrequent infections. Curr Probl Pediatr.

1989;19:229-284

CARING FOR THE CHILD WHO HAS A HEAD INJURY

1 . The most important thing to watch is how alert and responsiveyour child is. If he talks well, plays, and is interested in what is goingon, those are good signs. If he is confused, hard to keep awake, talkingin a funny way, or just acting peculiarly, those are bad signs and youshould call. You may let him sleep, but wake him about every 2 hoursto make sure he can respond normally.

2. Some headache is not unusual. Severe headache or headache that doesnot improve or gets worse is a reason to call. Acetaminophen-not aspi-rin-may be given for headache, and a cold pack can be applied to anybruises.

3. Vomiting shortly after the injury is not unusual. Vomiting later on, es-pecially repeated vomiting, should be reported. Liquids only should begiven at first. Light foods can be given later.

4. If the child has trouble with coordination, such as stumbling or havingunusual muscle movements, or if there are vision complaints, unusualeye movements, or dizziness, call. If you are not sure about a certaincomplaint or behavior, call to talk it over.

From 8:00 AM to 5:00 PM, call 277-3252; after hours, 277-8876.

Pediatrics in Review VoL 14 No. 8 August 1993 301

IIMPRESSION: No signs of serioushead injury; dietary indiscretion.

PLAN: Continued observation; callin morning-sooner as needed.

PS, MDThursday, June 10, 199311AMTelephoneFeeling much better.Headache gone;up and around. Eating without nau-sea. Wants to go out and play.School tomorrow. Parents to discussplayground safety with Roger. Briefvisitnext week; call sooner ifneeded.

PS, MD

FIGURE: Example of an instruction sheet for caregivers of children who have a head inju,y.

Emphasis is on those signs that require a call for advice.

Pediatrics in Review VoL 14 No. 8 August 1993 311

GASTROENTEROLOGYAbdomInal Pain

nias and hyperlipidemias; 4) infec-tions such as mumps; and 5) con-genital on acquired anatomicabnormalities, including pancreasdivisum, duplications, common ductstones, adjacent masses, and ductalatnesias and stenoses. Pancreatitisalso may be associated with end-stage renal disease and any prolongedsevere illness.

Mid-epigastnic abdominal pain isthe primary presenting symptom,usually without radiation. More se-vere cases may be associated withnausea and vomiting, jaundice, andacholic stools. The physical examina-tion reveals epigastnic tenderness;frequently the abdomen will be dis-tended, and there may be decreasedbowel sounds. An epigastnic massmay be found. The mainstay formaking the diagnosis remains an ele-vated serum amylase level or serumlipase level. A urinary amylase clear-ance test is more specific, with avalue greaten than 5 suggesting pan-creatitis. An abdominal radiographmay show an epigastnic sentinel loopon pancreatic calcifications. US isvery sensitive and will show an en-larged, hypoechoic pancreas, possi-bly a pseudocyst, or even anenlarged pancreatic duct.

SUGGESTED READING

Abbott J, Emmans LS, Lowenstein SR.Ectopic pregnancy: ten common pitfallsindiagnosis. Am J Emerg Med. 1990;8:515-522

Bailey PV, Connors RH, Tracy TF, et al.Changing spectrum of cholelithiasis andcholecystitis in infants and children. Am J

Surg. 1989;158:585-588Bonadio WA. Clinicalfeaturesof abdominal

painfulcrisisin sicklecellanemia. I Pediatr

Surg. 1990;25:301-302

Brandt ML, O’Regan 5, Rousseau E, YazbeckS. Surgical complications of the hemolytic-uremic syndrome. I Pediatr Surg.1990;25:1109-1112

Cromer BA, Brandstaetter LA, Fischer RA, etal. Tubo-ovarian abscess in adolescents.Adolesc Ped Gynecol. 1990;3:21-24

Cull DL, Rosario V. Lally KP, Ratner IJ,Mahour GH. Surgical implications ofHenoch-Schonlein purpura. I Pediatr Suig.

1990;25:741-743Fa EM, Cronan JJ. Compression

ultrasonography as an aid in the differentialdiagnosis of appendicitis. Surg Gynecol

Obstet. 1989;169:290-298Graff L, Radford Mi, Werne C. Proba-

bility of appendicitis before and afterobservation. Ann Emerg Med. 1991;20:503-507

Ichida F, Fatica NS, O’Loughlin JE, KleinAA, Snyder MS. Levin AR. Epidemiologicaspects of Kawasaki disease in a Manhattanhospital. Pediatrics. 1989;84:235-241

Jinzhe Z, Yenxia W, Linchi W. Rectalinflation reduction of intussusception ininfants.I Pediatr Surg. 1986;21:30-32

Joseph VT. Surgical techniques and long-termresults in the treatment of choledochal cyst.I Pediatr Surg. 1990;25:782-787

Martinez-Frontanilla LA, Silverman L,Meagher DP. Intussusception in HenochSchonlein purpura: diagnosis withultrasound. I Pediatr Surg. 1988;23:375-376

Rothrock 5G. Skeoch G, Rush JJ, JohnsonNE. Clinical features of misdiag-nosed appendicitis in children. Ann Emerg

Med. 1991;20:45-50Spigland N, Ducharme J-C, Yazbeck S.

Adnexal torsion in children. I Pediatr Surg.

1989;24:974-976Spigland N, Brandt ML, Yazbeck S.

Malrotation presenting beyond the neonatalperiod.I Pediatr Surg. 1990;25:1 139-1142

St. Vil D, Brandt ML, Panic 5, BensoussanAL, Blanchard H. Meckel’s diverticulum inchildren: A 20-year review. I Pediatr Surg.

1991;26:1289-1292Tsang T-M, Saing H, Yeung C-K. Peptic ulcer

disease in children. I Pediatr Surg.

1990;25:744-748West KW, Stephens B, Rescorla FJ.

Postoperative intussusception: experiencewith 36 cases in children. Surgery.

1988; 104:781-787

PIR QUIZ

5. A true statement about abdominalpain in children is:A. Colicky pain generally reflects

conditions involving a solidorgan, such as the liver.

B. Pain of inflammatory origin inthe stomach or duodenum willbe referred to the shoulder.

C. Patients suffering from pain ofacute inflammatory origin usu-ally prefer to remain quiet andmotionless.

D. Sudden onset pain generally isof acute inflammatory origin.

E. Vomiting that occurs with pain-ful abdominal conditions usuallyprecedes the onset of pain.

6. Among the following, the least

helpful tool in the evaluation ofacute abdominal pain in children is

A. Complete blood countB. Plain abdominal radiographC. Temperature measurementD. Ultrasound examinationE. Urinalysis

7. A true statement about appendicitisin children is:A. A plain radiograph of the abdo-

men can aid diagnosis.B. Adolescents are affected more

commonly than younger chil-dren.

C. Fever is an essential sign inyoung children.

D. Hunger argues against the diag-nosis in toddlers.

E. Perforation occurs rarely ininfants.

8. Among the following, the findingthat is most suggestive of intussus-ception is:A. Currant jelly stoolsB. HematemesisC. Normal temperatureD. Stabbing subdiaphragmatic painE. Tea-colored urine

9. A true statement about variouscauses of acute abdominal pain inpediatric patients is:A. Gallbladder disease can develop

without cholelithiasis.B. Intussusception arising as a corn-

plication of abdominal surgeryusually occurs more than Imonth after the procedure.

C. Testicular torsion first occursduring puberty.

D. The incidence of ectopic preg-nancies in adolescents isdecreasing.

E. Volvulus typically presents withnonbilious vomiting.

PIR QUIZ

10. A 9-year-old boy has been broughtto you because of the complaint ofabdominal pain. You suspect hemay have recurrent abdominalpain. Your diagnosis is supportedby the finding that his attacks ofpain are characterized by:A. Bloody stoolsB. Occurring after mealsC. FatigueD. Short durationE. Weight loss

13. A 12.year-old African-Americanboy complains frequently of bloat�ing, cramping, and recurrent lowerabdominal pain following meals.You tentatively diagnose lactoseintolerance.Your diagnosis ismost

readily made by:A. A breath hydrogen testB. Elimination dietC. Gastric lavage with enzyme

studiesD. Serum electrophoresisE. Stool analysis1 1. In taking a thorough history of a

child who has abdominal pain, cer-tam “red flags” may lead you tosuspect a specific illness other thanrecurrent abdominal pain. Thefinding most likely to support adiagnosis of recurrent abdominalpain would be:A. Changes in bowel habitsB. Interference with daily routinesC. Onset later than 15 years of ageD. Pain that awakens the child at

nightE. Pain well localized away from

the umbilicus

14. There is much confusion betweenirritable bowel syndrome (IBS) andrecurrent abdominal pain (RAP).Of the following statements, thetrue statement regarding lBS is:A. Age incidence of lBS bears no

relation to RAP.B. Gastrointestinal motility dys-

function is not an organic causeof lBS.

C. Guaiac-positive stools arecommon.

D. lBS may account for 25% ofRAP.

E. The bowel appears macroscopi-cally distorted.

12. In performing a thorough physicalexamination, certain “red flags”may lead you to suspect a specificillness other than recurrent abdomi.nal pain. The physical finding most

likely to support the diagnosis ofrecurrent abdominal pain would be:A. An anal fissureB. Associated joint tendernessC. Left lower quadrant tendernessD. Occult blood in the stoolE. Organomegaly

15. A tentative diagnosis of recurrentabdominal pain has been made fol-lowing a thorough examination ofa 12-year-old girl. In developing atherapeutic plan for her, it is es-sential that:A. Anticholinergic medication be

started.B. Diet be supplemented with 10 g

of corn fiber daily.C. Normal school activitiesbe

continued.D. Psychiatric consultation be

obtained.E. Serious underlying disorder be

ruled out.

Pediatrics in Review VoL 14 No. 8 August 1993 319

GASTROENTEROLOGYJ_ _____ Recurrent Abdominal Pain

Levine MD, Rappaport LA. Recurrentabdominal pain in school children. Pediatr

Clin North Am. 1984;31 :969-991Pineiro-Carrero VM, Andres JM, Davis RH,

Mathias JR. Abnormal gastroduodenalmotility in children and adolescents withrecurrentfunctionalabdominal pain.IPediatr. 1988;1 13:820-825

Rubin KS, Barbero Ci, Sibingar MS. Pupillaryreactivity of children with recurrent abdom-inalpain. Psychosom Med. 1967;29:119-120

Strauss RG. Cholelithiasis in childhood. Am I

Dis Child. 1979;117:689-692Walker LS, Green 1W. Children with recurrent

abdominal pain and their parents: Moresomatic complaints, anxiety, and depressionthan other patient families? I Pediatr

Psycho!. 1989; 14:231-243Walker L, Green 1. Negative life events and

symptom resolution in pediatric abdominalpain patients. Pediatr Psycho!. 1991;16:39-57

PIR QUIZ

16. Which of the following methodsmost accurately aids diagnosis ofotitis media with effusion?A. AudiometiyB. Nonpneumatic otoscopyC. Pneumatic otoscopyD. TympanocentesisE. Tympanometuy

17. Among the following, the most

common complication of chronicotitis media with perforation is:A. CholesteatomaB. LabyrinthitisC. MastoiditisD. PetrositisE. Recurrent acute otitis media

18. A recent report that up to 50% ofcases of otitis media in infants andyoung children are asymptomaticcan best be confirmed by:A. Cross-sectional studies in

institutionsB. Cross-sectional studies in

medical settingsC. Cross-sectional studies in the

homeD. Longitudinal studies in medical

settingsE. Longitudinal studies in the

home

19. Among the following, the bacterialorganism most likely to cause otitismedia with effusion is:A. Escherichia coliB. Moraxella catarrha!is

C. Staphylococcus aureus

D. Streptococcus pneumoniae

E. Streptococcus pyogenes

324 Pediatrics in Review VoL 14 No. 8 August 1993

L POINT-COUNTERPOINT

Sexual AbuseA number of readers were concernedabout the following points raised byDr Berkowitz in her article in theDecember 1992 issue of Pediatrics in

Review (1992;13:443-452).Several photographs were thought

to be normal (Figures 9, 10, and 12)rather than documenting sexualabuse. The readers were concernedthat if these particular photographsare used to diagnose sexual abuse,overdiagnosis of such a devastatingpsychosocial problem could have se-rious and long-lasting consequences.Another reader also noted, “theredoes not seem to be any consensusamong experts. ..as to which terms touse (notched, cleft, transection, con-cave hymenal variations, V- or U-shaped indentations) for genital analfindings. Finally, the quality of thecolor pictures was very poor, andthree were either upside down (Fig-ures 3 and 6) or sideways (Figure8). “ (The Editor apologizes for theseerrors.)

Dr. Berkowitz replies:“The article was written more than

2 years ago, and within these 2years, new studies have been pub-lished that have shed light on our un-derstanding of the physical findingsin sexually abused children.

“I chose photos of cases in whichthere was not only a credible disclo-sure, but also a confession or convic-tion. I then reviewed those photoswith my colleagues at Harbor Gen-eral Hospital, and we as a groupreached consensus. I agree that thephotos appear quite dark and thatthey are not of the best quality. Theywere published directly from the col-poscopic slides, and the publisher didnot do any modification. Let mecomment on our areas of disagree-ment vis a vis the figures. Figure 9:Review of my records showed thatthe entire left side of the hymen wasthickened and adherent. I will grantyou that this is not readily apparentin the photos. I believe that Figures10 and 12 are consistent with the his-tory of penetration because of thefindings noted in each figure.”

In response to another letter, DrBerkowitz notes, “Your letter mis-states what is stated in the article;specifically, your statement, ‘She in-cludes mounds, bumps, localized

areas of thickening, and reduced hy-menal remnants, penianal venouspooling, altered penianal rugae pat-tern as signs of abuse trauma....’What the article actually states is,‘mounds, bumps, or localized areasof thickening . . . are noted more fre-quently in abused girls. ‘ I believethat alteration in the rugae patterndoes occur with repeated penetration.Certainly Hobbs and Wynne notethis. I specifically commented on thecontroversy vis a vis venous pooling:‘McCann et al, however, observedsuch pooling in the majority of non-abused children who are maintainedin a prone knee-chest position for 5

minutes.”Finally, in response to a writer

who questioned her expertise, DrBerkowitz notes, “I am consideredan expert nationally in the area ofchild sexual abuse. . . have been ex-amining sexually abused children for10 years; have personally evaluatedabout 2500 children; and am on the730 panel of the Superior Court ofCalifornia and serve as an expert forthe federal government, the military(Naval investigations), the County ofLos Angeles and of San Diego, theCenter for Child Protection, and thePublic Defender’s Office of Los An-geles, Santa Barbara, San Diego, andSan Bernardino Counties.”

The Yellow Flag is StillUpSeveral years ago, I wrote an edito-rial entitled “It’s Time to Wave theYellow Flag.” The metaphor was toautomobile racing, where a yellowflag is waved following a crash.Drivers are “cautioned,” hold theirplaces, but keep moving. The impe-tus for that editorial was the increas-ing criticism the child protectionsystem was coming under for bothfailing to protect children who werebeing “killed” with “open cases”and for being too intrusive and vio-lating family nights on the basis of“false reports.”

I was reminded of that editorial re-cently, when Pediatrics in Reviewpublished the Carol Berkowitz reviewon “Child Sexual Abuse.”2 That ar-ticle, which included colposcopicphotographs (some apparently misla-

PIR Quiz-CME Credit

Elk Grove Village, IL 60009-0927.

PREP EDUCATION AWARD:

The PREP Education Award pro-vides recognition and support forthose Academy Fellows and Candi-date Fellows who participate inPREP. Individuals who qualify for

the PREP Education Award willreceive their award automatically.To be eligible for this award, aFellow or Candidate Fellow of theAmerican Academy of Pediatricsmust receive, over a 3-year period,150 hours of Category 1 CMEcredits from the following sources:

The American Academy ofPediatrics is accredited by the Ac-creditation Council for ContinuingMedical Education to sponsor con-tinuing medical education for phy-sicians.

The American Academy of Pedi-atrics designates this continuingmedical education activity for 40credit hours in Category 1 of thePhysician’s Recognition Award ofthe American Medical Association.

As an organization accredited forcontinuing medical education(CME), completion of the PREPprogram meets the criteria for 40hours of credit toward the AAPPREP Education Award.

This program has been reviewedand is acceptable for 40 Prescribedhours by the American Academyof Family Physicians. (Term of ap-proval: beginning date January1993. Enduring materials are ap-proved for 1 year, with option torequest renewal.) For specific in-formation, please consult with theAAFP Office of Continuing Medi-cal Education.

This program has been reviewedand is acceptable for 28 AOA Cat-egory 2-B CME hours by theAmerican Osteopathic Association.For specific information, pleaseconsult with the AOA Department

of Education.In addition, this course has

been approved for 40 NAPNAPcontact hours. An individual re-questing contact hours shouldsubmit proof of participation andverification of PREP accreditationto the NAPNAP National Office.

The questions for the PIR quizare located at the end of each arti-dc in this issue. Each question hasa SINGLE BEST ANSWER. Toobtain credit, record your answerson the PIR Quiz Card found in theJanuary issue, and return the cardto the Academy. (PREP group par-ticipants will receive the PIR QuizCard and Self-Assessment CreditReply Sheet under separate cover.)To receive CME credit on the 1993annual credit summary, you mustbe enrolled in PREP or subscribeto Pediatrics in Review and returnthe PIR Quiz Card by February 28,1994. PIR Quiz Cards receivedafter this deadline will be recordedin the year they are received, with

cards from the 1993 PIR journalsaccepted through December 31,1995.

The PIR Quiz card is bound intothe January issue. Complete thequizzes in each issue and send itto: American Academy of Pediat-rics, PREP Office, P0 Box 927,

. 75 hours must be obtained fromparticipation in PREP (the Self-

Assessment Exercise and/or

Pediatrics in Review) or PREP:The Course.

. The balance (75 hours) of the150 CME credits may be ob-tamed through other programssponsored or approved by theAcademy. This includes: theAAP Spring Session or AnnualMeeting, CME courses, Acad-emy-approved courses, or thePediatric UPDATE audiocassettetape program.

The correct answers to the ques-tions in this issue appear on the in-

side front cover.

This One

Pediatrics in Review VoL 14 No. 8 August 1993 327

girls. Before embarking on suchtherapy, it is essential that the adultheight be predicted as accurately aspossible based on x-rays of the handand wrist. Therapy only should beundertaken after known potential sideeffects of therapy, with high-dose

estrogen (testosterone in boys) havebeen discussed with the parents. Mostmethods proposed for prediction ofadult height are accurate but arelimited in that the prediction generallyis within ± 4 cm (1.5 inches) of thefinal actual height (Table).

Paul Saenger, MD

Professor of Pediatrics

Head, Division of PediatricEndocrinology,

Albert Einstein College

of Medicine!Montefiore Medical Center