Child abuse in an infant presenting as unexplained acute systemic hypertension.

Hypertension in the infant is uncommon and is usually associated with renal vascular or parenchymal disease, coarctation or thrombosis of the aorta, or chronic lung disease. A 3-month-old infant who presented with unexplained acute systemic hypertension was subsequently discovered to have an undiagnosed femoral fracture secondary to child abuse. Undiagnosed fractures, which are often associated with child abuse, should be considered in the differential diagnosis of an infant presenting with unexplained systemic hypertension.

Magnesium, zinc and copper in plasma and blood cellular components in children with IDDM.

The levels of magnesium (Mg), zinc (Zn) and copper (Cu) in the plasma, erythrocytes (RBC) and polymorphonuclear (PMN) and lymphocyte (L), leukocytes (WBC) of 45 diabetic children were compared to those of 12 normal children and were related to the diabetic control via HbA1 and fasting blood sugar (FBS) assessments. Mineral levels were determined via Zeeman-effect atomic absorption spectrophotometry following separation of plasma, RBC, and WBC fractions (PMN vs. M). ANOVA (four-way, blood components, by two-way, diabetic vs. normal children) was significant for Mg only (F = 4.60, P < 0.004). Plasma Mg and M-WBC Mg were significantly lower in children with diabetes (780 +/- 16 vs. 860 +/- 29 mumol/l and 519 +/- 33 vs. 866 +/- 86 micrograms/10(10) cells, respectively). RBC Zn was significantly lower in diabetic youngsters by t-test (0.48 +/- 0.012 vs. 0.57 +/- 0.046 per mumol/g Hgb, t = 2.79, P < 0.004), but the ANOVA for Zn was not significant. Cu level differences were not significant. HbA1 was predicted only by PMN-WBC Mg (F = 8.78, P < 0.04) and FBS by none. In conclusion, the mineral status of these diabetic children was altered in regard to Mg, but was mainly independent of diabetic control.

Osteoporosis as the presenting sign of leukemic relapse in an adolescent: case report and literature review.

Osteoporosis in adolescence is rare and usually secondary to an underlying disease process whose diagnosis may be difficult to detect. Osteoporotic vertebral collapse is an uncommon presenting sign of acute lymphoblastic leukemia (ALL). We describe a 13-year-old boy with osteoporotic vertebral collapse secondary to relapse of ALL whose blood count and blood morphology were normal but whose 1,25 = (OH2) = vitamin D level was deficient. A combination of chemotherapy, calcitriol and calcitonin therapy was successful in reversing the process. His case is presented to describe the diagnostic and therapeutic issues involved.

Comparative heights of mothers and fathers whose children are short.

This study was designed to investigate and compare the heights of mothers and fathers whose children had various forms of short stature. The heights of parents of a total of 341 children were grouped by their children's diagnoses into three groups: group 1, genetic short stature; group 2, a constitutional delay of growth; and group 3, normal "short" stature (children in the fifth to 25th percentile). Analysis indicated that the data were gaussian in distribution and that no significant skewing or kurtosis was noted in any group for either maternal or paternal heights. The mean height of mothers in group 1 (mean +/- SD, 157.7 +/- 6.8 cm) was less than (F = 14.36) the mean height of mothers in either group 2 (mean +/- SD, 161.1 +/- 6.9 cm) or group 3 (mean +/- SD, 162.5 +/- 6.6 cm). In contrast, the mean heights of fathers were not significantly different (F = 2.13) among the three groups (mean +/- SD, 173.3 +/- 7.5, 173.8 +/- 8.3, and 176.0 +/- 9.6 cm). Thus, a significant shift to greater shortness in mothers' heights than in fathers' heights for the parents of children with genetic short stature was noted. Such a differential shortness was not detected in the parents of children with a constitutional delay of growth.

Nipple (papilla) development in girls: III. The effects of pregnancy.

Previous cross-sectional and longitudinal studies of girls have documented that they have a significant growth in nipple size during Tanner stages pubic hair (PH)4 and PH5 or breast (B)4 and B5. This study assesses whether there is any effect of pregnancy on nipple development in adolescent girls. Thirty-three pregnant girls were compared to a previously reported group of 390 girls who were not pregnant. Of the 33 girls, ten were followed longitudinally for a period of nine to 79 months, during which time they became pregnant. In each girl, nipple diameter was measured and the Tanner stage assessed. A markedly significant increment in nipple size was noted in the girls who were pregnant (pregnancy nipple size 12.6 mm vs. PH5 9.7 mm and B5 9.9 mm). Comparison of ten girls prior to and during pregnancy revealed a significant increment as well (10.2 mm vs. 12.8 mm, respectively). Pregnancy provides a further stimulus for nipple development in girls beyond that which occurs during normal puberty.

Nipple (papilla) development in puberty: longitudinal observations in girls.

The purpose of this study was to determine the manner of breast nipple (papilla) development occurring during puberty in girls on a longitudinal basis and to compare this development to the established criteria of sexual maturation. Forty-six girls (19 white and 27 black) were followed for periods of 2 to 5 years (mean 2.67 years). In each, the nipple diameter was measured and the Tanner stage assessed. Minimal nipple development occurred from stages PH1 to PH3 (3.24 to 4.44 mm) and B1 to B3 (3.00 to 4.72 mm) or more than 1 year prior to menarche (3.75 mm). Significant growth occurred beyond stages PH3 (PH4 6.54 mm, PH5 8.98 mm) and B3 (B4 7.25 mm, B5 9.41 mm) and from less than 1 year prior to menarche to more than 1 year after menarche (5.92 mm for girls less than 1 year premenarche, 7.88 mm for girls in their first year after menarche, and 9.05 mm for girls more than 1 year beyond menarche). A more objective definition for breast stages B4 and B5, based upon nipple diameter, is now feasible. Thus, these data enhance the precision with which physiologic events occurring toward the close of puberty in girls can be studied.

Papilla (nipple) development in puberty. The adolescent male.

Papilla (nipple) development was studied in 230 males (119 black, 111 white) aged 3-29 years to compare this development to the established criteria for sexual maturation. Comparison was also made with a previous study of female nipple development to determine whether or when any differences between male and female nipple development occurred. Our male subjects were further assessed to determine if nipple size differed in the presence or absence of gynecomastia. Significant nipple development occurred between pubic hair stages PH1 (diameter 2.8 mm), PH4 (4.4 mm), and PH5 (5.4 mm). Similarly, there was significant incremental growth between genital stages G1 (3.0 mm), G3 (4.6 mm), and G5 (5.5 mm). Nipple development was similar in both sexes through stage PH3, but significantly diverged at stage PH4 (p less than 0.000001) because of a marked increase in female nipple diameter. Boys with gynecomastia had a significantly larger nipple size than boys who had none (p less than 0.001). Differences in nipple diameter between the sexes and between boys with and without gynecomastia probably result from differences in estrogen levels. Perhaps in the future, it will be possible on the basis of nipple diameter to predict which adolescent boys will have persistent gynecomastia.

Benign galactorrhea/breast discharge in adolescent males probably due to breast self-manipulation.

Three adolescent males presented with nipple discharge. In two boys, the expressed secretion was clinically consistent with galactorrhea. Galactorrhea/breast discharge is a rare complaint in males of any age. Although galactorrhea is commonly associated with a neuroendocrine disorder or drug ingestion, the work-up in each, including basal prolactin level, was normal. Reluctantly, each by admitted to breast self-manipulation to reduce gynecomastia. When the behavior was discontinued, the galactorrhea/breast secretion ceased. Clinicians should be aware of this heretofore undescribed and apparently benign phenomenon. If basal hyperprolactinemia is absent in a male with a breast discharge and a history of breast manipulation, then an extensive work-up is not usually indicated.

Familial third-fourth pharyngeal pouch syndrome with apparent autosomal dominant transmission.

A family is presented in which both siblings and their father had evidence of third-fourth pharyngeal pouch syndrome (DiGeorge syndrome). All three individuals had hypocalcemia and unusual facies. Both infants had truncus arteriosus. One infant had evidence of impaired cell-mediated immunity; the father had a relatively decreased number of T-lymphocytes. The syndrome is uncommon, most cases being isolated, and familial presentations are even rarer. Two recent reports described several affected individuals who also had partial deletions of chromosome 22. Chromosome banding studies in our family were normal. Thus our family demonstrates an autosomal dominant pattern of inheritance, although it cannot be proved that this is a single gene defect. We propose that inasmuch as the presentation of the syndrome is quite varied, thorough family investigation including high-resolution cytogenetic analysis is necessary. Familial cases may be more common and require genetic counseling.

Galactorrhea in the adolescent.

Inappropriate lactation--that which occurs beyond the usual postpartum or breast-feeding period or in the male--has been of medical interest for centuries. There is a suggestion that the first recorded case occurred in the Bible in the Book of Esther wherein Mordecai may have breast-fed his niece Esther [1,2]. The Talmud describes a man who nursed his infant after his wife's death during childbirth [3]. Lactation in virgin women was noted by the early Greeks [4], and Aristotle observed lactation in men [5]. The phenomenon of "witch's milk," seen in the newborn, was described as early as 1684 by Bonetus [6]. The first alleged pediatric case of nonpuerperal lactation was of an 8-year-old girl who was able to suckle her baby brother as reported in the 18th Century by Baudelocque [7]. Subsequently, many other cases of abnormal lactation were described in the 19th and early 20th centuries [7-10]. In the past 15 years, there has been a vast proliferation of cases and studies concerning galactorrhea of both sexes [11]. The advent of the prolactin radioimmunoassay was the single most important factor behind the profusion of these investigations [11-14]. Most recently, attention has focused on the high incidence of pituitary tumors--specifically the prolactinoma--in women and to some degree in men [13,15]. The occurrence of such tumors in children and adolescents is also receiving more attention [16,17]. The purpose of this review is to update the reader on galactorrhea with a specific emphasis on: 1) outlining the various causes of galactorrhea that may be seen in adolescent patients; 2) describing the work-up and management of both the male and female adolescent patient with galactorrhea; and 3) describing what is known about the natural history of galactorrhea. A brief description of the physiology of the hypothalamic-pituitary-breast axis and lactation is also presented.

Short stature and dysmorphism in the child and adolescent female. Diagnostic dilemmas.

The clinician often encounters girls with varying combinations of short stature and subtle dysmorphic features that are compatible with either Turner or Noonan syndrome. A classic case of either syndrome with extensive unmistakable traits is the exception rather than the rule. Six cases are presented to help describe some of the difficulties in differential diagnosis and provide strategies to avert them.

Somatomedin activity before and after chelation therapy in lead-intoxicated children.

Somatomedin activity was measured in 21 lead-intoxicated children to determine whether plumbism interferes with the processes of statural (bone) growth. Somatomedin activity was measured both by the rabbit coastal cartilage bioassay and by radioimmunoassay of somatomedin-C. Compared to values in normal children, both the bioassay and radioimmunoassay somatomedin activity was increased. The degree of body lead burden was so extensive that the 21 study children required chelation therapy. Following EDTA or BAL + EDTA chelation therapy, the overall somatomedin activity of these children with plumbism further increased significantly. In contrast, measures of body lead burden--including blood lead levels--decreased after treatment in all lead-intoxicated youngsters. We conclude that plumbism is associated with increased somatomedin activity. Hence the increased somatomedin activity may explain why clinical experience fails to find any long-term deleterious effect of saturnism on statural (bone) growth. Possible mechanisms underlying the increased somatomedin activity in the lead-intoxicated children remain to be defined.

Papilla (nipple) development during female puberty.

The purpose of this study was do compare breast papilla (nipple) development to the established criteria of secondary sexual maturation. One hundred and sixty-eight girls (100 black and 68 white) ranging in age from 2-21 years had their papilla diameter measured and their Tanner stage assessed. Minimal nipple development occurred from stages PH1-PH3 (2.91-4.08 mm) and B1-B3 (2.75-3.96 mm) or premenstrually (3.61 mm). Significant growth occurred beyond stages PH3, B3 (PH4-7.22 mm, Ph5-9.36 mm, B4-7.74 mm, B5-9.47 mm) and near or after menarche (7.82 mm for girls 0-2 years post-menarche, 9.23 mm for girls 2-4 years post-menarche and 9.65 mm for girls more than four years after menarche). A more objective definition for breast stages B4 and B5, based on nipple diameter, may now be feasible, thus enhancing the precision with which physiologic events occurring toward the close of puberty can be studied.

Neck pain due to acute suppurative thyroiditis and thyroglossal duct abscess.

One case of acute suppurative thyroiditis and one case of thyroglossal duct abscess are presented and discussed. Although they may often present similar symptoms and signs, they need to be differentiated from each other and from other causes of painful thyroid-related neck masses to ensure appropriate therapeutic intervention. Techniques and new developments helpful in differential evaluation, including thyroid radioscintigraphy and ultrasonography, are discussed.

Adolescents who attempt suicide.

A suicide prevention program for teen-agers was established and at the completion of the first two years a review of the data was undertaken. A group of 65 adolescents who attempted suicide were identified in that time period. The median age group was 16 years, and 75% were girls. Ingestion was the predominant method used in these suicidal attempts. The major characteristics of these youngsters included long-term family disruption, social isolation, and academic difficulties. A subgroup of 25 adolescents received psychologic tests. When compared to a matched control group there was a significantly higher rate of minimal brain dysfunction for those adolescents who attempted suicide.