Comprehensive. Comiuiinity-ide Approaches 1()Prevention ... · Pediatrics inReview VoL13 No.2 February 1992 63 HEMATOLOGY Thalassemla PIRQUIZ 12.Youareasked toserve asa consultant

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Medical Record Documentation of Seizures - Xazariaii

CONTENTS

ARTICLES

43 Menstrual Disorders in the Adolescent: Amenorrhea

Margaret M. Polaneczky and Gail B. Slap

50 Malformations of the Gut

Lynn F. Duffy

55 Update on Thalassemia

P.J. Giardina and M. W. Hilgartner

64 Preventing Low Birth Weight, Child Abuse, and

School Failure: The Need for Comprehensive,

Community-wide Approaches

Robert W. Chamberlin

72 Consultation with the Specialist: Sibling Rivalry

Lawrence C. Pakula

75 Medical Record Review:

Lessons to Learn From the Treatment of Children

Who Have Seizures

Lawrence Nazarian

76 Medical Record Documentation of Seizures

ABSTRACTS

49 Relation of Chronic Cough to Atopy and Defects in

Host Defense

49 Acute Appendicitis in Children

73 Causes of Decreased Height and Weight in

Individuals Who Have Cystic Fibrosis

74 Peritonsillar Abscess

77 Brachial Plexus Injuries

78 Breast Self-Examination

COVER

“The Knitting Lesson” (Ca 1860) by Jean Francois Millet (1814-1875).

Renowned for his peasant paintings, Millet in this painting illustrates thecycles of life and the passing on of skills from one generation to another.

One of the major tasks of pediatricians is to teach parents and childrenskills to prpmote health. May we do it as gently and lovingly as thismother teaches her daughter knitting. (From the Museum of Fine Arts,

Boston, Massachusetts.)

ANSWER KEY

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

11. C; 12. D; 13. B; 14. A; 15. A; 16. C; 17. D; 18. D;19. A; 20.E; 21. C; 22. B; 23. C; 24. D; 25. B; 26. E; 27. C;

28. D; 29. C

Pediatrics in Review

Vol 13 No 2

February 1992

EDITORRobert J. HaggertyNew York Hospital-CornellMedical CenterNew York, NY

Editorial Office:�( The William T. Grant Foundation5 15 Madison Aye, 6th FloorNew York, NY 10022-5403

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatric GroupRochester, NY

ABSTRACTS EDITORSteven P. Shelov, Bronx, NY

MANAGING EDITORJo 1st-gent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan, III, Stanford, CA

EDITORIAL BOARDMoms A. Angulo, Mineola, NYRussell W. Chesney, Memphis, TNCatherine DeAngelis, Baltimore, MDPeggy C. Ferry, Tucson, AZRichard B. Goldbloom, Halifax, NSJohn L Green, Rochester, NYRobert L Johnson, Newark, NJfrJan M. Lake, G/en 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, GAVernon T. ToIo, Los Angeles, CARobert J. Touloukian, New Haven, CTTerry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTElizabeth A. Nelson

PUBLISHERAmerican Academy of PediatricsErrol A. 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 Village, IL60009-0927.

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LMenstrual Disorders in theAdolescent: AmenorrheaMargaret M. Polaneczky, MD* and Gail B. Slap, MDt

This is the first of a two-pan article about menstrual disorders in the

adolescent. The second part, on dysmenorrhea and dysfunctional uterinebleeding, will appear in the March 1992 issue of Pediatrics in Review.R.J.H.

FOCUS QUESTIONS1. What is the difference between

primary and secondary

amenorrhea?

2. What are the symptoms ofhypothalamic amenorrhea andhow are they treated?

3. What is the appropriate

laboratory evaluation of secondary

amenorrhea?

4. What is the diagnostic approach to

patients who have primaryamenorrhea?

PIR Quiz-CME CreditThe American Academy of Prescribed hours per issue by rate cover.) To receive CMEPediatrics is accredited by the the American Academy of credit on the 1992 annual creditAccreditation Council for Con- Family Physicians. (Terms of summary, you must be enrolledtinuing Medical Education to approval: Beginning date Jan- in PREP or subscribe to Pediat-

sponsor continuing medical ed- aury 1992. Enduring Materials rics in Review and return theucation for physicians. As an are approved for 1 year, with PIR Quiz Card by February 28,organization accredited for con- option to request renewal. For 1993. PIR Quiz Cards receivedtinuing medical education, specific information, please after this deadline will be re-completion of the PIR Quiz consult the AAFP Office of corded in the year it is re-meets the criteria for 2 hours of Continuing Medical Education.) ceived; with cards from thecredit, per issue, of the Amen- The questions for the PIR 1992 PIR journals, acceptedcan Academy of Pediatrics’ quiz are located at the end of through December 31, 1994.PREP Education Award. each article in this issue. Each The PIR quiz card is bound

The American Academy of question has a SINGLE BEST into the January issue. Corn-Pediatrics designates this contin- ANSWER. To obtain credit, plete the quizzes in each issueuing medical education activity record your answers on the PIR and send it to: American Acad-for 2 credit hours, per issue, in Quiz Card found in the January erny of Pediatrics, PREP Of-Categoiy 1 of the Physician’s issue, and return the card to the fice, P0 Box 927, Elk GroveRecognition Award of the Amer- Academy. (PREP group partici- Village, IL 60009-0927.ican Medical Association. pants will receive the PIR Quiz The correct answers to the

This program has been re- Card and Self-Assessment questions in this issue appearviewed and is acceptable for 2 Credit Reply Sheet under sepa- on the inside front cover.

Pediatrics iii Review Vol. 13 No. 2 Februa,y 1992 43

The menstrual history is an integralpart of the evaluation of the adoles.cent female. Abnormal menstrualflow or timing may be the first signof systemic illness or sexually trans-mitted disease. Amenorrhea may sig-nal an endocrine or genetic disorderor may suggest structural abnormali-

ties of the genital tract. Most impor.tantly, any abnormality in menstru-ation should alert the clinician to thepossibility of pregnancy.

Normal Menstrual CycleThe average age of menarche in the

United States is 12.8 years andranges from 9 to 16 years. Menarcheusually occurs 2 to 2.5 years afterbreast budding and 1 year after thegrowth spurt. Consequently, the ab-sence of menarche at 15 years of agemay be normal in an adolescent whojust passed her growth spurt but ab-normal in an adolescent who com-pleted puberty 2 years earlier. Mostearly menstrual cycles are anovula.tory. As a result, menses in theyoung adolescent often are irregularand may be prolonged or heavy.Dysmenorrhea and premenstrual

ARTICLE

symptoms tend to accompany ovula-tory cycles and, therefore, are morecommon in the older adolescent.

Regular ovulatory cycles usuallyare established within 1 to 2 years ofmenarche. Although normal cyclelength ranges from 21 to 45 days, thelength for a given individual is fairlyconstant. Normal menstrual flowlasts 2 to 7 days and usually is heavi-est on the first and second days. Theaverage blood loss during a normalmenstrual period is 30 to 40 mL.

Primary Amenorrhea

Primary amenorrhea, or delayedmenarche, is defined as any one ofthe following: 1) the absence of men-arche by 16 years of age in the pres-ence of normal pubertal growth anddevelopment; 2) the absence of men-arche by 14 years of age in the ab-

sence of normal pubertal growth anddevelopment; or 3) the absence ofmenarche 2 years after completedsexual maturation.

INITIAL EVALUATION

A complete history and physical ex-amination is the most important stepin evaluating the adolescent who hasprimary amenorrhea. Particular atten-tion should be focused on pubertalmilestones. The history should in-elude questioning about maternal age

ABSTRACT � -�

Relation of Chronic Cough to Atopy and Defectsin Host Defense

Acute Appendicitis in Children

Pediatricsin Review VoL 13 No. 2 February 1992 49

r-� �:--PIR QUIZ1. Each of the following statements

defining primary amenorrhea is trueexcept:A. The absence of menarche by 16

years of age despite the presence

of nonnal physical signs ofpuberty.

B. The absence of menarche by 14years of age despite the presenceof normal physical signs ofpuberty.

C. The absence of menarche 2years after completed sexual

maturation.D. The absence of menstruation

more than 18 months aftermenarche.

2. Each of the following is a truestatementregarding amenorrheaexcept:A. Exercise-induced amenorrhea is

due to a complex interplay ofdecreased body fatand stress.

B. Athletes who have body fatbelow the 25th percentile for ageare likely todevelopamenorrhea.

C. High energy output and stressmay act independently of bodyfat in the case of exercise-induced amenorrhea.

D. The hypothalamic amenorrheasof anorexia nervosa andexercise-induced amenorrheahave similar mechanisms: lowbody fat, stress, and beta-endorphin release.

Using the diagnostic approach topatients who have primary amenorrhea,match items in the following columns:

3. Follicle-stimulatinghormone.

4. XY karotype.5. Testosterone/kaiyotype.6. Cyclic pain.

A. Breast(+)Uterus (-)

B. Breast(+)Uterus (+)

C. Breast (-)Uterus (+)

D. Breast(-)Uterus (-)

Chronic Cough in a Hospital Population: ItsRelationship to Atopy and Defects in HostDefence. Lewis HM, Haeney M, Jeacock J,Thomas H. Arch Dis Childhood.1989;64:1593-1598

The background and etiology ofchronic cough were investigated bycomparing three groups of childrenunder 6 years of age, 60 of whomhad simple cough, 60 of whom hadasthma, and 60 of whom were usedas controls. Both cough and asthmawere more common in boys andassociated with a history of eczema,chest deformity, and skin reactivityto inhaled allergens, but thesefindings were more prevalent inconjunction with asthma than withcough. House dust mite sensitivity

ABSTRACT �

Acute Appendicitis in Children: Evaluationwith Ultrasound. Vignault F, Filiatrault D,Brandt ML, Garel L, Grignon A, Ouimet A.Radiology. 1990;176:501-504

Ultrasonography in the Management ofPossible Appendicitis in Childhood. RubinSZ, Martin Di. J Pediatr Surg.

1990;25:737-740

Vignault et al evaluated 70 children

suspected of having appendicitisusing ultrasonography. Thirty-fivehad a noncompressible appendix withan external diameter of >7 mm.Thirty-one of 25 had appendicitis. Of35 children for whom the results ofultrasonography were negative, 33did not have appendicitis, but twodid. The authors conclude that theuse of ultrasonography in clinicallyambiguous cases will enable earlier

diagnosis and reduce complications.In the study by Rubin et al, 134

children suspected of havingappendicitis were evaluated usingultrasonography. Of 45 patients whohad appendicitis, ultrasonographywas diagnostic in 40 cases (and

was found in 34 (57%) of thechildren who had simple cough, 45(75%) of those who had asthma, and6 (10%) of the control subjects. Testsof immunologic function showedsome high concentrations of 1gM ingroups with both cough and asthma.IgG1 and IgG2 concentrations wereelevated in some children with coughor asthma, but the only low subclassconcentrations were of IgG3 observedin the group with cough. Childrenwho had simple cough represented aheterogeneous population, but manyshowed evidence of atopy. Majordefects of immunity were notobserved.

ItJ. H.

falsely negative in five cases). Of 65

patients who did not have appendi-

citis, false-positive results onultrasonography were obtained in fivecases and negative results were

obtained in 60 cases. “We recom-mend that in acute abdominal painwhenever the surgical clinicaldiagnosis of appendicitis is in doubt,

ultrasonography should be

considered.. .real time ultraso-nography of the abdomen in childrenrequires experience.”

Comment: These two studiessuggest the addition of ultraso-nography to our diagnosticarmamentarium for appendicitis. It iscertainly not a perfect tool, but whenused carefully by capable and

diligent people, it can add precisionin diagnosing appendicitis.

Richard H. Hopkins, MD and

Shyan C. Sun, MD

Children’s Hospital of New JerseyNewark� NJ

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54 Pediatrics in Review VoL 13 No. 2 February 1992

GASTROINTESTINAL DISORDERSMalformatIons

2% to 3% of individuals. It is the re-suit of a failure of the fetal gut toseparate completely from the yolksac. The diverticulum is located on

the antimesenteric border of theileum 40 to 100 cm proximal to theileocecal valve. It is lined by ilealmucosa and contains ectopic gastricor pancreatic tissue in 30% of cases.

Patients who have symptomaticMeckel diverticulum present mostcommonly with either bleeding orobstruction. Bleeding results in caseswhere ectopic gastric mucosa is pres-ent in the diverticulum. Secretion ofacid and pepsin within the diverticu-lum causes ulceration of the mucosa,resulting in hemorrhage. Painless rec-tal bleeding with bright red or ma-roon-colored stools is the classicinitial sign. This usually occurs inpatients younger than 2 years of age.

Blood loss may vary from minimal,without hemodynamic changes, tomassive, resulting in shock. Pain willbe present if there is inflammation ofthe diverticulum. Obstruction second-ary to Meckel diverticulum occurswith intussusception, where the di-verticulum acts as the leading edge;herniation; kinking; or volvulus. Theintussusception of Meckel diverticu-lum is ileo-ileal. When obstruction ispresent, the patient may present with

abdominal pain, vomiting, and a

palpable abdominal mass.Diagnosis of Meckel diverticulum,

where ectopic gastric mucosa is pres-

ent, is made by 99m technetium per-technetate scintigraphy. Wheninjected intravenously, the radioiso-

tope is taken up by gastric mucosaand pools in the diverticulum. Incases of intussusception, a bariumenema is useful, not only to confirmits presence, but also as a therapeuticmeasure for reduction. If the intus-

susception cannot be reduced, or ifbarium does not flow freely into theterminal ileum, then exploration ofthe abdomen is necessary.

Diverticulotomy is the treatment of

choice. Because of its site at the anti-mesenteric border, resection of adja-cent intestine is necessary only incases where ulceration of the diver-ticulum is extensive or where bowelhas been compromised from obstruc-tion. Because only a small segmentof bowel is involved, prognosis isexcellent.

Summary

Although there are many differentmalformations of the intestine, clini-cally they can present similarly. Inaddition, even conditions that are notcongenital may be difficult to differ-entiate. An approach that employs a

detailed history, physical examina-tion, and use of appropriate radio-logic studies is important. Somemalformations can have life-threaten-ing consequences if diagnosis is de-layed; therefore, expediency isimperative.

SUGGESTED READINGAndrassy Ri, Mahour GH. Mairotation of the

midgut in infants and children. Arch Surg.

1981;1 16:158-160Hocking M, Young DO. Duplications of the

alimentary tract. BrJ Surg. 1981;68:92-96Spitz L, Kiely E, Brereton RJ. Esophageal

atresia: Five year experience with 148 cases.J Ped Suig. 1987;22:103-108

Vane DW, West KW, Grosfeld JL. Vitelline

duct anomalies: Experience with 217childhood cases. Arch Surg. 1987;122:542-547

Walker WA, Dune PR, Hamilton JR. Walker-

Smith JA, Watkins JB, eds. Pediatric

Gastrointestinal Disease. Philadelphia, PA:

BC Decker; 1991

Welch KJ, Randolph JO, Ravitch MM,

O’Neill JA Jr, Rowe MI, eds. Pediatric

Surgery. 4th ed. Chicago, IL: Year BookMedical Publishers; 1986

PIR QUIZ

7. The most common type ofesophageal atresia is:A. Esophageal atresia with

associated distaltracheoesophageal fistula.

B. Esophageal atresia withouta tracheoesophageal fistula.

C. H-type tracheoesophagealfistula.

D. Esophageal atresia withassociated proximal anddistal tracheoesophagealfistula.

8. The radiologic “doublebubble” sign is associatedwith which of the followingconditions?A. Esophageal atresia.B. Duodenal atresia.C. Jejunal atresia.D. Ileal atresia.E. Colonic atresia.

9. Abdominal cysts occur leastcommonly in the:A. Duodenum.B. Jejunum.C. Ileum.D. Colon.

10. The recommended therapy formalrotation of the intestine inthe asymptomatic patient:A. Is surgery at the time of

diagnosis.B. Is surgery during

adolescence.C. Is delay of surgery until

symptoms appear.D. Does not include surgery

because this condition isbenign.

11. The most common presentingsign of Hirschsprung diseaseis:A. Vomiting.B. Abdominal distention.C. Delayed passage of

meconium (longer than48 h).

D. Protein-losing enteropathy.E. Enterocolitis.

Pediatrics in Review VoL 13 No. 2 February 1992 63

HEMATOLOGYThalassemla

PIR QUIZ

12. You are asked to serve as a

consultant in the case of anotherwise well 9-month-oldboy who has a mild microcyticanemia. The beta thalassemiatrait would be least likely asan explanation if the parentswere natives of:A. Greece.B. Syria.C. Nigeria.D. Sweden.E. Vietnam.

Match each of the following beta

thalassemia disorders with the most

compatible clinical presentation:

13. Heterozygous silent betathalassemia.

14. Heterozygous classic betathalassemia trait.

15. Heterozygous delta-betathalassemia trait.

16. Homozygous beta�thalassemia.

17. Homozygous beta#{176}thalassemia.

A. Usually asymptomatic;usually either not anemicor only mildly so; risk ofsignificant anemia duringpregnancy.

B. Always asymptomatic; noanemia.

C. Usually symptomatic after1 year of age; thalassemicfacies; most oftenmoderately anemic, butrequires blood transfusiononly occasionally.

D. Usually symptomaticbefore 1 year of age;thalassemic facies; severe,transfusion-dependentanemia.

Match each of the following betathalassemia disorders with the mostappropriate hemoglobinelectrophoresis:

18. Heterozygous classic betathalassemia trait (withoutconcomitant irondeficiency).

19. Heterozygous silent betathalassemia.

20. Heterozygous delta-betathalassemia trait.

21. Homozygous beta�

thalassemia.22. Homozygous beta#{176}

thalassemia.A. Hb A (96%), Hb A2

(2.5%), Hb F (1.5%).B. HbA2(10%),HbF

(90%).

C. Hb A (15%), Hb A2 (6%),Hb F (79%).

D. Hb A (90%), Hb A2 (6%),Hb F (4%).

E. Fib A (90%), Hb A2 (2%),Hb F (8%).

23. You just have diagnosed

thalassemia major in a 7-month-old girl who recentlymoved to the United Stateswith her parents fromBombay, India. In planningher future therapy to optimizebenefits and minimizecomplications, you would doeach of the following except:A. Ensure that the patient is

immunized effectivelyagainst hepatitis B(assuming she has notalready acquired the virusduring the perinatalperiod).

B. Attempt to maintain apretransfusion hemoglobinlevel of approximately11 g/dL.

C. Assure that the patientreceives at least 12 to16 mL/kg of packed redblood cells with eachtransfusion to maintain aninterval of at least 1 monthbetween visits.

D. Use leukocyte-poor packedred blood cells to avoidurticarial and febriletransfusion reactions.

E. Initiate regular chelationtherapy withdesferrioxamine at 4 to 5years of age.

24. A 7-year-old boy who hasthalassemia major hasdeveloped significanthypersplenism and will requiresplenectomy soon. Forappropriate management, youwill do each of the followingexcept:A. Assure immunization

before splenectomy againstStreptococcus pnewnoniaeand Haemophilus

inJluenzae type B.

B. Maintain the patient aftersplenectomy on daily oralantimicrobial prophylaxis.

C. Immediately examine thesplenectomized patient ifhe or she develops a fever.

D. After examination,continue the febrilesplenectomized patient onprophylactic oralantibiotics (assuming thatfocal signs of infection areabsent and that appropriatedeep cultures have been

obtained).E. After examination,

promptly treat the febrilesplenectomized patient forpresumed sepsis withbroad-spectrum parenteralantibiotics (assuming thatfocal signs of infection areabsent and that appropriatedeep cultures wereobtained before initiatingtherapy).

PIR QUIZB. Intensive family support

programs including homevisits.

C. Respite programs forfamilies with difficult-to-rear children.

D. School-based health andparent education programs.

E. Opportunities to participatein littleleague sports

programs.

25. Community risk factors thatincrease the likelihood ofadverse child health anddevelopmental outcomesinclude each of the followingexcept:

A. Exposure of families tounhealthy living situations.

B. Exposure to mass mediathat deal principally withmethods of prevention.

C. Unwillingness of local andstate governments to fundprevention programs ofproven value.

D. Lack of opportunity toearn a reasonable income.

E. Feelings of local residentsthat they live in an

uncaring environment thatlacks any sense ofcommunity.

28. Which of the followingstatements about a community-wide preventive approach isnot true?A. It is complicated to

implement.B. It requires expenditure of

public funds.C. It strives tp increase self-

esteem.D. It provides positive short-

term results.E. It serves as a focal point to

coordinate state and localagencies.

27. In some areas, pediatricianshave added each of thefollowing family supportcomponents to their primarypractice base, except:

A. An early interventionprogram.

B. A parent drop-in center to- serve a catchment area for

a population of 10 000.C. Service as ombudsman for

parents dealing with stateand national organizations.

D. A lending library of bookson child development andparenting topics.

E. Advocacy groups forchildren.

26. Data show that we can reducethe number of individual riskswhen we increase access tocaring services, which includeeach of the following except:A. Better access to quality

prenatal care for low-income residents.

29. The component least likely tobe essential to theestablishment of community-wide programs is:A. Research to define a

satisfactory geographiccatchment area.

B. Development of a broad-based local coalition.

C. Having a large governmentgrant to initiate action.

D. Accumulation of records tobuild a data base.

E. Formation of a localadvocacy group.

Pediatrics in Review Vol. 13 No. 2 February 1992 71

ready have reached a high-risk status.

The best results can be obtainedwhen all levels of government andthe private sector work together. In

this partnership, the best outcomes

appear to result when the state andfederal governments, private corpora-tions, or both provide technical as-sistance, additional funding as

needed, and help in setting programstandards, and when the communitymaintains local control over estab-lishing priorities and implementation

strategies. However, to reach thesegoals and to maintain program sup-port over the long time periodsneeded to show positive results (4 to8 years), it is necessary to becomeskilled in social marketing techniquesto turn program need into demand

and to develop a strong local andstatewide advocacy group to facilitate

passage of needed legislation andprevent funding cutbacks.

Pediatricians can modify theirpractices to make them more suppor-

tive to families and can work withother community leaders to bringabout the changes in attitudes and

about the changes in attitudes andfunding priorities at the state andcommunity levels that will be neces-sary to develop more effective pre-ventive programs.

REFERENCES1. Schorr L. Within Our Reach: Breaking the

Cycle of Disadvantage. New York, NY:Anchor Press, Doubleday; 1990

2. Dunn A. Bringing families andcommunities together. Family Resource

Coalition Report. No. 3. Chicago, IL:Family Resource Coalition; 1988:9

3. Rubin G, Koota I. Parents andpediatricians, partners in care. . Family

Resource Coalition Report. No. 2.Chicago, IL: Family Resource Coalition;1985:12-13

SUGGESTED READINGBronfenbrenner U, Weiss HB. Beyond policies

without people: An ecologicalperspectiveon child and family policy. In: Ziegler E,Kagan S. Kiugman E, eds. Children,

Family, and Government: Perspectives on

American Social Policy. New York, NY:Cambridge University Press; 1983

Chamberlin R, ed. Conference Proceedings:

Beyond Individual Risk Assessment:

Community Wide Approaches to Promoting

the Health and Development of Families and

Children. Washington, DC: The National

CHILD HEALThCommunity Services

Center for Education in Maternal ChildHealth; 1988

Committee for Economic Development.Children in Need: Investment Strategies for

the Educationally Disadvantaged. NewYork, NY: Committee for EconomicDevelopment; 1988

Kagan S, Powell D, Weissbourd B, Zigler E.America ‘s Family Support Programs. NewHaven, CT: Yale University Press; 1987

Rosen G. Sick individuals and sickpopulations. mt J EpidemioL 1985;1 14;32-38

Schorr L. Within Our Reach: Breaking the

Cycle of Disadvantage. New York, NY:Anchor Press, Doubleday; 1990

Tsouros A, ed. World Health Organization

Healthy Cities Project: A Project Becomes aMovement - Review of Progress, 198710

1990. Copenhagen, Denmark: FADLPublishers; 1990

I wish to acknowledge the help of Cheryl

Mitchell, Co-Director of the Addison CountyParent Child Center, and her staff, and Steven

Bauer, MD, a Co-Founder of the Child Health

Center of Norway, Maine, for providing

infonnazion about their programs. The other

pediatric practice described is that of Dr Ivan

Koota and his associates in upstate New York.

I also wish to thank Drs I. Bar,y Pless and

Arden Miller for their helpful comments and

suggestions for improving the manuscript.