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CONTENTS

COMMENTARY

243 Editor and Editorial Office Move

Robert J. Haggerty

ARTICLES

245 Viral Hepatitis: A, B, C, D, and E-Prevention

Saul Krugman

248 Pediatric Neurodiagnostic Tests: A ModernPerspective

Peggy C. Feriy

257 Office Care of Wounds

John G. Lease

262 Care of the Normal Newborn

James W. Kendig

269 Index of Suspicion

Gregory S. Liptak, Thomas C. Bisett, James W. Sayre

273 Consultation with the Specialist: Diagnosis of the

Unknown Poison

Frederick H. Lovejoy, Jr

ABSTRACTS

243 Pediatric Poisoning by Organophosphate and

Carbamate-type Pesticides

244 Technical Tips: Mannequins for Enhancing Skills in

Pediatric Procedures

272 Chaperones During Examination of the Genitalia

275 Hematoma of the Nasal Septum

276 Bicycle Helmets

277 Listeria monocytogenes

278 Carbohydrate Metabolism in Cystic Fibrosis

279 Detection of Reflux Nephropathy in Infants

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 promote 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. C; 2. D; 3. B; 4. C; 5. A; 6. D; 7. A; 8. D; 9. C; 10. C; 11. D;12. E� 13. D; 14. D; 15. D; 16. D; 17. E; 18. D; 19. D; 20. B; 21. A

The printing and productionof Pediatrics in Review Ismade possible, in part, byan educational grant from

Ross Laboratories.

Pediatrics in Review

Vol 13 No 7

July 1992

EDifORRobert J. HaggertyUnwersity of RochesterSchool of Medicine and DentistryRochester, NY

Editorial Office:Department of PediatricsUniversity of RochesterSchool of Medicine and Dentistry601 Elmwood Aye, Box 777Rochester, NV 14642

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatric GroupRochester, NY

ABSTRACTS EDITORSteven P. Shelov, Bronx, NY

MANAGING EDITORJo Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan, III, Stanlbrd, CA

EDITORIAL BOARDMods A. Angulo, Mineola, NYRUSsell W. Chesney, Memphis, TNCatherine DeAngelis, Baltimore, MDPeggy C. Ferry, Tucson, AZRichard B. GoIdbIoom, Halifax, NSJohn L Green, Rochester, NYRobed L Johnson, Newark, MIAlan M. Lake, Glen Arm, MDFrederick H. Lovejoy, Jr, Boston, MAJohn T. McBride, Rochester, NYVincent J. Menna, Dcylestown, PALawrence C. Pakula. Timonium, MDRonald L Poland, Hershey, PAJames E. Rasmussen, Ann Arbor, MlJames S. Seidel, Torrance, CARichard H. Sills. Newark, MiLaurie J. Smith, Washington, DCWilliam B. Strong, Augusta, GAJon lingeiStad, GreerMIle, NCVernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CTTerry Yamauchi, Little Rock, ARMcritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANTSydney Sutherland

PUBUSHERAmerican Academy of PediatricsErrol R. j�Jden, Director,

Department of EducationJean Dow, Director

Division of PREP/PEDIATRICSDeborah Kuhlman, Copy Editor

PEDIATRICS IN REVIEW (ISSN 0191-9601) isowned and controlled by the M�erlcan Academyof Pediatrics. It is published monthly by theAmerican Academy of Pediatrics, 141 NorthwestPoant Blvd, P0 Box 927, Elk Grove Village, IL60009-0927.

Statements and opinions expressed rn Pectafricsin 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 1992: �AP Fellow $85;AAP Candidate Fellow $65; Allied Health orResident $65; Nonmember or Institution $115.Current single price is $10. Subscription claimswi� be honored up to 12 months from the publicationdate.

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

CAMERICAN ACADEMY OF PEDIATRICS,1992. All rights reserved. Printed in USA. No partmay be duplicated or reproduced withoutpermission of the American Academy of Pediatrics.POSTMASTER: Send address changes toPEDIATRICS IN REVIEW, American Academy ofPediatrics, P0 Box 927, Elk Grove Village, IL

60009-0927.

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Pediatrics in Review VoL 13 No. 7 July 1992 247

INFECTIOUS DISEASEHepatitis

UNIVERSAL IMMUNIZATION OF

INFANTS

Hepatitis B vaccine has been usedextensively throughout the worldsince its licensure in November1981 . Extensive experience involvingmany millions of vaccinees has con-firmed its safety and efficacy. Hepa-titis B vaccine currently is beingincorporated into the Expanded Pro-gram on Immunization of the WorldHealth Organization. The first doseof vaccine is given to all infants soonafter birth. Additional doses aregiven at subsequent routine visits.Universal immunization of all infantsin the United States is now recom-mended by the Advisory Committeeon Immunization Practices of theCenters for Disease Control and theCommittee on Infectious Diseases ofthe American Academy of Pediatrics.The preferred schedule is to give:1) the first dose of vaccine at birthbefore discharge from the hospital;2) the second dose at the first routinevisit 1 to 2 mo later; and 3) the thirddose at a routine visit between 6 and18 mo of age. An alternative sched-ule would include the first dose at2 mo of age, the second dose at 4mo of age, and the third dose at 6 to18 mo of age. It is anticipated that inthe future multiple antigen prepara-tions will include hepatitis B, diphth-eria-tetanus toxoids-pertussis, polio-virus, Haemophilus influenzae typeb, and hepatitis A.

TreatmentThere is no specific treatment forchildren who are infected with hepa-titis A, B, C, or D. The disease isgenerally so mild that bed rest is un-necessary after the acute stage. Thechild’s diet and return to activity usu-ally are gauged by the child’s desire.When anorexia is present, food is re-jected; broths and fruit juices shouldbe offered. A normal diet is recom-mended when appetite returns. Corti-costeroids and other drugs are notindicated for children who have un-complicated hepatitis.

The efficacy of alpha-interferon

therapy for chronic hepatitis B and Cinfections has been documented invarious controlled trials. About 30%to 40% of patients respond to ther-apy. However, 50% of patients mayrelapse when therapy is discontinued.Patients receiving therapy should bemonitored for the possibility of ad-verse psychological effects.

Suggested ReadingAlter MJ, Hadler SC, Margolis HS, Ct al. The

changing epidemiology of hepatitis B in theUnited States. Need for alternative vacci-nation strategies. JAMA. 1990;263:1218-1222

cente�s for Disease Control. Protection againstviral hepatitis: Recommendations of theImmunization Practices Advisory Committee(ACIP). MMWR. 1990;39:5-22

Centers for Disease Control. Hepatitis B virus:A comprehensive strategy for eliminatingtransmission in the United States throughuniversal childhood vaccination. Recom-mendations of the Immunization PracticesAdvisory Committee. MMWR. 1991;40:l-25

Choo Q-L, Kuo G, Weiner AJ, Overby LR,Bradley DW, Houghton M. Isolation of acDNA clone derived from a blood-bornenon-A, non-B hepatitis genome. Science.

1989;244:359-362Davis GL, Balart LA, Schiff ER, et al.

Treatment of chronic hepatitis C withrecombinant interferon alpha: A multicenterrandomized, controlled trial. N EngI J Med.

1989;321 :1501-1506

DiBisceglie AM, Martin P. Kassianides C, etal. Recombinant interferon alpha therapy forchronic hepatitis C: A randomized, double-blind, placebo-controlled trial. N EngI J

Med. 1989;321:1506-1510

Hilleman MR. Buynak EG, Roehm RR, TytellAA, Bertland AU, Lampson OP. Purifiedand inactivated hepatitis B vaccine. Am J

Med Sci. 1975;270:401-404Hoofnagle JH, DiBisceglie AM. Serologic

diagnosis of acute and chronic viralhepatitis. Semin LiverDis. 1991;11:73-83

Kuo 0, Choo Q-L, Alter Hi, et al. An assayfor circulating antibodies to a majoretiologic virus of human non-A, non-Bhepatitis. Science. 1989;244:362-364

McMahon BI, Rhoades ER, Heyward WL, etal. A comprehensive programme to reducethe incidence of hepatitis B virus infectionand its sequelae in Alaskan natives. Lance:.1987;2: 1134-1136

Rizzetto M. The delta agent. Hepatology.1983;3:729-737

Stevens CE, Taylor PE, Tong Mi, et al.Yeast-recombinant hepatitis B vaccine:Efficacy with hepatitis B immune globulinin prevention of perinatal hepatitis B virustransmission. JAMA. 1987;257:2612-2616

PIR QUIZ1 . Measures currently recommended

for prevention of transmission ofhepatitis A include each of thefollowing, e.vcep::A. Vigorous handwashing.B. Administration of standard

immune globulin.C. Avoiding raw shellfish from

polluted waters.D. Control of insect vectors.

2. Measures currently recommendedfor prevention of transmission ofhepatitis B include each of thefollowing, except:A. Use of clean needles by drug

abusers.B. Administration of a vaccine

using recombinant antigen.C. Testing of blood for hepatitis

B surface antigen prior totransfusion.

D. Administration of standardimmune globulin.

3. Each of the following statementsregarding the prevention of hepa-titis B in newborn infants of car-ncr mothers is true, except:A. An effective protocol for pre-

vention involves a combina-tion of immune globulin andhepatitis B vaccine.

B. Breast feeding is contraindi-cated.

C. The first dose of hepatitis Bvaccine is given at birth(before discharge from thehospital).

D. The United States PublicHealth Service has recom-mended routine testing ofpregnant women for hepatitisB surface antigen.

4. Each of the following statementsregarding treatment of viral hepa-titides is true, except:A. There is no specific therapy

for hepatitis A, B, C, or D.B. Alpha-interferon is helpful in

cases of chronic hepatitis dueto hepatitis B.

C. Corticosteroid administrationis advised to prevent compli-cations in children who havehepatitis.

D. Return of appetite is an appro-priate guide to reinstitutefeeding of a normal diet.

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PIR QUIZ

5. Diagnostic advantages of mag-netic resonance imaging in com-parison to computed tomographyinclude all of the following cen-tral nervous system problems,except:

A. Detection of calcification.B. Deposition of brain iron at

siteof prior infarction.C. Dysmyelination features of

carnitine deficiency.D. Posterior fossa tumors.

6. A 10-mo-old girl presents withthe clinical picture of delayedpsychomotor development, hy-potonia, grand mal seizures, andmicrocephaly. No dysmorphicfeatures are present. A diagnosisof neuronal migration dysplasiais suspected. The best test fordetection of this type of disorderis:A.

8. A 7-y-old girl presents with a1-y history of recurrent head-aches not typical of migraine.Physical examination, includingneurologic, is normal. The mostappropriate next step in manage-ment is:A. Obtain an electroencephalo-

gram both while awake andwhile sleeping.

B. Order skull roentgenograms.C. Request a cranial computed

tomographic study.D. Follow conservatively.E. Obtain a vestibular evoked

potential study.

10. A 2-y-old boy has a 6-wk his-tory of early morning emesis un-associated with nausea. Onexamination, he isafebrile andirritable but alert. Slight truncalataxia is present. On auscultationof the head with tapping of thecontralateral side, a “crackedpot” sound indicates separationof sutures. The next most appro-priate step in management is:A. Obtain a computed tomo-

graphic study.B. Perform a lumbar puncture

with studies for tuberculosis.C. Obtain a cranial magnetic

resonance imaging study.D. Order a positron emission

tomographic study.E. Request a brain electrical ac-

tivity mapping study.

11. Among the following, cranial ul-trasonography ismost useful instudies of:A. Benign hydrocephalus of

childhood.B. Acoustic neuroma.C. Herpetic meningoencepha-

litis.D. Neonatal periventricular

hemorrhage.E. Cerebral injury with child

abuse.

Cerebrospinal fluid electro-phoresis for abnormalprotein.

B. Cranial ultrasonography.C. Computed tomography.D. Magnetic resonance imaging.E. Positron emission

tomography.

9. A 14-y-old girl experienced theonset of a seizure disorder 6 moago. The seizures are character-ized by initial confusion andanxiety, followed by automa-tized repetitive lip-smacking andterminating in postictal confusionwith amnesia for the event. Thenext most appropriate step inmanagement is to:A. Obtain a computed tomo-

graphic study.B. Order a cranial roentgeno-

gram.C. Obtain a cranial magnetic

resonance study.D. Order a positron emission

study.E. Obtain a simultaneous dec.

troencephalographic andvideo monitoring study.

7. An 18-mo-old boy is seen forevaluation following his first fe-brile seizure. Past history andpresent physical examination arenormal. The most appropriatenext step in management is:A. Reassure parents regarding

benign prognosis.B. Obtain an electroencephalo-

gram while sleeping.C. Obtain a cranial computed

tomographic study.D. Order skull roentgenograms.E. Request urinary screen for

abnormal metabolites.

256 Pediatrics in Review VoL 13 No. 7 July 1992

NEUROLOGYDiagnostic Tests

REFERENCESDeitch EA. The management of burns. N EngI

J Med. 1990;323:1249-1253

Fitzgerald RH Jr. Cowan iDE. Puncturewound of the foot. Orthoped Clin N Amer.

1975;6:865-972Jacobs RF, Adelman L, Sack CM, Wilson

CB. Management of Pseudomonasosteochondritis complicating puncturewounds of the foot. Pediatrics.

1982;69:432-435Joseph WS, LeFrock JL. Infections

complicating puncture wounds of the foot.J Foot Surg. 1987;26:30-33

Krizek Ti, Robson MC. Evolution ofquantitative bacteriology in woundmanagement. Am J Stag. 1975;130:579-584

Mathes Si, Aboulijoud M. Wound healing. InDavis JH, ed. Clinical Surgery. St. Louis,MO: C.V. Mosby Co.; 1987

Reinherz RP, Hong DI, Tisa LM, et al.Management of puncture wounds in thefoot. J Foot Surg. 1985;24:288-292

Robson MC, Edstrom LE, Krizek RI, GroskinMG. The efficacy of systemic antibiotics inthe treatment of granulating wounds. J Surg

Res. 1974;16:299-306

Pediatrics in Review VoL 13 No. 7 July 1992 261

The extremity should be elevated andintravenous antibiotics instituted. Theinitial antibiotic of choice should bea penicillinase-resistant penicillin oran appropriate cephalosporin. Anti-biotic selection can be tailored to theinfecting organism once culture re-sults become available.

Osteomyelitis may develop within2 to 5 d of initial injury. Early casesare characterized by a paucity of sys-temic signs, but usually are markedby local signs of tenderness, edema,and erythema. Initially, there will beno changes seen on plain radio-graphs. Bone scan is useful duringthe first 2 wk to delineate the extentand location of infection. The factthat Pseudomonas aeruginosa is themost common pathogen should beconsidered when assigning antibioticcoverage. An aminoglycoside incombination with a synergistic peni-cillin is a good first choice. Estab-lished osteomyelitis requires aggres-sive surgical treatment, and all suchcases should be referred for inpatienthospital management.

Nonhealing wounds are not alwaysthe result of infection but can indi-cate the presence of a retained for-eign body. This possibility should beassessed carefully if wound healingdoes not follow the expected course.

PIR QUIZ12. Four hours ago, a 9-y-old girl

fell, cutting her right forearm ona piece of glass. On examina-(ion, you note in mid-forearm adirty wound on the dorsal sur-face, 4 cm long and 1 cm deep,with edges that can be apposedreadily. She previously had re-ceived 5 scheduled tetanus im-munizations, the last just beforeentering kindergarten. To pro-vide optimal care, you wouldperform each of the followingactions, except:

A. Assess tendon and neurovas-cular function.

B. Achieve analgesia and hemo-stasis by slowly infiltratingxylocaine with epinephrineusing a 30-gauge needle.

C. Irrigate the wound thor-oughly with saline using asyringe and 18-gaugeangiocath.

D. Perform a multilayered pri-mary closure.

E. Assure tetanus prophylaxisby administering adsorbedtoxoid.

13. Of the following patients withthermal bums, the one whichmay be treated simply and safelyby the pediatrician without hos-pitalization or consultation is:A. A 6-mo-old girl with an im-

mersion burn of both feet.B. A 1-y-old boy with a small

electrical burn on the cornerof his mouth.

C. A 5-y-old boy with a 3% su-perficial partial thicknessburn of the chest sustainedwhile trapped in a burninghouse.

D. A 2-y-old girl with a 6% su-perficial partial thicknesssplash burn of the shoulderand back.

E. A 9-y-old boy with a circum-ferential partial thicknessburn of the fingers of hisright hand.

14. An appropriately immunized2-y-old girl has a fresh 6% su-perficial partial thickness scaldburn on her chest. As optimalinitial care, you would carly outeach of the following, except:A. After assuring analgesia,

wash the burn with a dilutepovidone-iodine solution.

SURGERYWounds

B. Using aseptic technique, as-pirate all small bullae anddebride those larger than 2cm in diameter.

C. After cleansing and debride-ment, cover the burn with anocclusive sterile gauze andbacitracin ointment dressing.

D. Routinely prescribe broad-spectrum systemic antibioticsas prophylaxis against burnwound cellulitis.

E. Reexamine the burn within24 to 48 h.

15. A 6-y-old girl comes to your of-flee after suffering multiple shal-low facial abrasions in a fallfrom her bicycle. You can facili-tate prompt healing and the bestcosmetic result by performingeach of the following actions,except:A. Remove dried blood, serum,

and superficial debris bycopious irrigation with adilute povidone-iodinesolution.

B. Using local analgesia, re-move all embedded debriswith a surgical scrub brush.

C. Dress the clean wound witha combination of bacitracinointment and sterile gauze,which is changed at leastdaily.

D. Routinely prescribe oral anti-biotics to prevent secondaryinfection.

E. Suggest that an effective sun-screen be used regularly onthe injured area after healingfor a period of 6 to 12 mo.

16. A 9-y-old boy is brought to theemergency department after step-ping on an unknown sharp objectwhile playing barefooted in afield. On examination, you notean irregular 4-mm puncturewound of the right mid-foot.You should perform each of thefollowing actions, except:

A. Review tetanus immunizationhistory.

B. Obtain a plain radiograph toidentify an embedded radio-opaque foreign body.

C. Excise the wound marginand remove any obvious su-perficial foreign body.

D. Probe the wound for deepforeign bodies.

E. Irrigate the wound thoroughlywith saline using an 18-gaugeangiocath.

PIR QUIZ17. The first steps in resuscitation of

the newborn include all of thefollowing, except:A. Placing the infant under a ra-

diant warmer.B. Drying the infant to prevent

evaporation heat loss.C. Positioning to open the

airway.D. Gently suctioning the mouth

followed by suctioning thenares to prevent gaspaspiration.

E. Weighing the baby to assureaccurate drug dosages.

19.

E. The initial workup for neona-tal hyperbilirubinemia shouldinclude total and direct bili-robin levels, complete bloodcount, Coombs test, and test-ing of urine for reducingsubstance.

After the newborn infant is sta-biized, which of the followingp�duras is not indicated?A. O�W� � against

gonococcal disease andchlamydia.

B. Umbilical cord examination�d � �d � K

21.

D. The differential diagnosis forthe large-for-gestational ageinfant includes maternal dia-betes, maternal thyroid dis-ease, and maternal obesity.

E. Cycles of pauses of 5 to 10sec, followed by hyperpnea(eg, periodic breathing), is aprec��r to apnea andbrad�cardia.

Each of the following statementsis true, except:

A. Bilious vomiting in the new-born sometimes may be nor-mel and due to an active

18. Hyperbilirubinemia occurs fre-quently in the normal newborn.Each of the following is a truestatement, except:A. Exaggeration of the entero-

hepatic shunt may explainboth the early and late jaun-dice associated with breast-feeding.

B. The aggressive use of photo-therapy in healthy full-terminfants with nonhemolyticjaundice does not seem to beindicated when the total bill-rabin is < 20 mg/dL.

C. Sick premature infants whohave hyperbilirubinemia dueto hemolysis are at the high-est risk for developing bili-robin encephalitis.

D. Bacterial sepsis, syphilis,hypothyroidism, and earlygalactosemia may cause anelevated direct bilirubin

20.

injection.C. Review of the mother’s hep-

atitis status and serology.D. Maturational assessment

(Ballard scale), done be-tween 30 and 45 mm of age.

E. Facilitation of early parent-child interaction.

Each of the following statements� f�se, except:

A. Small-for-gestational age in-fants have a lower metabolicrate than those of the samewei�t who are appropriatefor gestational age.

B. Premature infants of lessthan 34#{189}weeks’ gestation� at increased risk for ap-nea and bradycardia.

C. i�te� infants are those ofless than 37 weeks’ gestationand a birthweight of< � g.

antiperistaltic reflex.B. Infants with confirmed sepsis

or meningitis should have abrainstem auditory evokedresponse examination.

C. Ninety-nine percent of nor-mat, full-term infants will ur-mate by 24 h of age.

D. All infantS of less than 35weeks’ gestation or whoweigh < 1800 g at birth andwho received oxygen therapyfor at least 6 h require anophthalmologic examinationfor retinopathy of prematur-

�Y at 4 to 8 wk of age.E. Hypoglycemia is a blood glu-

case measurement of < 40 to‘� mg/dL, regardless of ges-tational age.

level.

268 Pediatrics in Review VoL 13 No. 7 July 1992

NEONATOLOGY� Care of the Normal Newborn

be examined between 4 and 8 wk ofage by an ophthalmologist skilled inrecognizing retinopathy of prematur-ity are listed in Table 4. Profiles ofinfants who should have a brainstemauditory evoked response test forhearing evaluation are listed in Table5.

An infant’s feeding pattern,weight, and degree of jaundice mustbe evaluated before discharge. Theproper use of car seats must be re-viewed. A follow-up visit to the pe-diatnician’s office must be scheduledbefore the infant is discharged.

Some serious ductal-dependentcongenital cardiac defects, such ashypoplastic left heart and coarctationof the aorta, may not present untilafter 48 h of age. If an infant is dis-charged before then, the first visit tothe pediatrician’s office should bewithin 3 d. This visit also will helpwith early recognition of progressivejaundice and feeding failures. Infants

should then return to the pediatricianin 2 to 4 wk. By 2 wk of age, mostfull-term infants will have regainedtheir birth weight.

SUGGESTED READINGBerman L, Kienerman L. Ultrasound screening

for hip abnormalities: Preliminary findingsin 1001 neonates. BML 1986;293:719-722

Bloom RS, Cropley C. Textbook of Neonatal

Resuscitation. American Heart Associationand the American Academy of Pediatrics;1987

Constantine NA, Kraemer HC, Kendall-Tackett KA, Bennett FC, Tyson JE, GrossRT. Use of physical and neurologic observa-tions in assessment of gestational age in lowbirth weight infants. J Pediatr.

1987;1 10:921-928Druzin ML. Antepartum fetal heart rate

monitoring-State of the art. Chin Perinatol.1989;16:627-642

Lawrence RA. Breast feeding. Pediatr Rev.

1989;1 1:163-171MacEwen GD, Millet C. Congenital dis-

location of the hip. Pediatr Rev.1990;1 1:249-252

Menke JA, McClead RE. Perinatal grief andmourning. Adv Pediatr. 1990;37:261-283

Newman TB, Maisels Mi. Does hyperbili-rubinemia damage the brain of healthy full-term infants? Clin PerinatoL 1990;17:331-358

Poland RL. The question of routine neonatalcircumcision. N EngI J Med. 1990;322:1312-1315

Schoen El. The status of circumcision ofnewborns. N EngI J Med. 1990;1 1:1308-1312

Schwartz MZ, Shaul DB. Abdominal masses inthe newborn. Pediatr Rev. 1989;11:172-179

Sinkin RA, Davis JM. Cardiopulmonaiyresuscitation of the newborn. Pediatr Rev.

1990;12:136-141Stockman JA. The anemia of prematurity and

the decision when to transfuse. Adv Pediatr.

1983;30:191-219

Ward JC. Inborn errors of metabolism of acuteonset in infancy. Pediatr Rev. 1990;11:205-216

Ward KE, Pryor RW, Matson JR. Razook JD,Thompson WM, Elkins RC. Delayed detec-tion of coarctation in infancy: Implicationsfor timing of newborn follow-up. Pediatrics.

1990;86:972-976Guideline for Peri.natal Care. 2nd ed.

American Academy of Pediatrics and theAmerican College of Obstetricians andGynecologists; 1988