AMERICAN ACADEMY OF PEI)IATRICS

Vol. 10 No. 5November 1988

Pediatrics Review andEducation Program

131 Exercise for Children Risser

I 4 1#{149}Health-Related Fitness asPreventive Medicine - Jopling

149#{149}Stimulation of Preterm Infants -

Field

I 55#{149}Adoption Haberkern

Answer Key: 1 .A; 2.D; 3.B; 4.B; 5.C; 6.D; 7.A; 8.E; 9.B; 1 0.B; 11 .E; 1 2.D; 1 3.E;14.B; 15.C.

Vol. 10, No.5, November 1988

Pediatricsin ReviewEDITORRobert J. HaggertyNew York Hospital-CornellMedical CenterNew York, NY

Editorial Office:.25 Sutton Place SouthApt mailbox 93New York, NY 10022

ASSOCIATE EDIITORR. James Mckay, Jr.Medical Center Hospital of VermontBurlington, VT 05401

ABSTRACTS EDITORRichard H. Rapkin, Newark. NJ

EVALUATION EDITORWiftiam H. Milburn, Longmont, CO

MANAGING EDITORJean Dow, Elk Grove Village, IL

ASSISTANT MANAGING EDITORJo A. Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan III, Philadelphia, PA

EDITORIAL BOARDRalph Cash, Detroit, MIDaniel D. Chapman, Ann Arbor, MIEven Chamey, Baltimore, MDRussell Chesney, Davis, CABarry Goldberg, Milford, CTAlan L. Goldbloom, Toronto, ONFernando A. Guerra, San Antonio, TXEdward A. Jacobs, Arcadia, CAJ. Stephen Latimer, Bethesda, MDMelvin D. Levine, Chapel Hill, NCMarie C. McCormick, Boston, MAKurt Metzl, Kansas City, MOLawrence F. Nazarian, Penfield, NYFrederick P. Rivera II, Seattle, WAWilliam 0. Robertson, Seattle, WARon Rosenfeld, Stanford, CARobert Schwartz, Providence, RILonnie K. Zeltzer, Los Angeles, CA

PUBLISHERAmerican Academy of Pediatrics

Penny Prettyman. Copy Editor

PEDIATRICS IN REVIEW(ISSN 0191-9601)15 owned andcontrolled by the American Academy of Pediatrics. ft ispublished ten times a year (July through April) by the Amer-can Academy of Pediatrics, 141 Northwest Point Blvd. Elk

Grove Village, IL 60009-0927.

Subscriptions will be accepted until December 31. 1988for the 1988-89 cycle. Subscription price per year Candi-date Fellow of the AAP $35.00; AAP Fellow $60.00; Non-member or InstItution $80.00. Current single issues $8.00.

Second-class postage paid at ELK GROVE VILLAGE,ILLINOIS 60009-0927 and at additional mailing offices.

C American Academy of PediatrIcs, 1988

Al Rights Reserved. Printed m U.S.A. No part may beduplicated or reproduced without permission of the Ameri-can Academy of Pediatrics.POSTMASTER: Send address changes to PEDIATRICS IN

REVIEW, American Academy of PedIatrics, 141 Northwest

Point Blvd. Elk Grove Village, IL 60009-0927

CONTENTS

ARTICLES

131 Exercise for Children

William L. Risser

141 Health-Related Fitness as Preventive Medicine

R. Joe Jopling

149 Stimulation of Preterm Infants

Tiffany Field

155 Adoption: New Tasks for the Pediatrician

Roy C. Haberkern

ABSTRACTS

140 Enzyme Multiplied Immunoassay Test

140 Mothering Abilities of Adolesc�ents

153 VATER Association

159 Children of Depressed Parents

Cover: Boy With Baseball, by George LukS (American artist of the Ash Canschool-i 867-1933). Son of a physician from Williamsport, PA, he studiedart in Philadelphia and Europe before settling in New York, where he worked

as a newspaper illustrator and cartoonist. Then he pursued a career as apainter. His work, like the other Ash Can artists, depicted life in the raw.Boy With Baseball, done in the early 20th century, is illustrative of his work.This appealing portrait of a street urchin, done in broad brush strokes, witha baseball, symbolizes the all-American game. This is an appropriate motiffor PREP 2-year 4, when sports medicme and physical fitness are special

topics for review.

‘� The printing and production of

D ______ Z Pediatrics in Review is made possibIe�

� ROB S R’ in part, by an educatIonal grant fromci Ross Laboratories.

.

.

.

PHYSICAL FITNESS

pediatrics in review #{149} vol. 10 no. 5 november 1988 PIR 139

more, they offer an advantage. Salt

S tablets are never needed and can bedangerous, producing hypernatre-mia. Athletes ordinarily do not needelectrolyte replacement during activ-ity. Their regular diet will replenishelectrolyte losses between exercisesessions.

SUMMARY

It is important for the pediatricianto have knowledge about the impactof acute and chronic disease onsports participation; knowledge ofup-to-date therapeutic and preven-tive strategies can help the clinicianachieve the goal of safe, successfulactivity for almost all children. Otherarticles this year in Pediatrics in Re-view will discuss the preparticipationexamination and physical fitness.These and the “Suggested Readings”are sources for further informationabout pediatric sports medicine.

ACKNOWLEDGMENTS

The author thanks the following for theirhelp with this manuscript: Drs Walter Anyan,Jr, Oded Bar-Or, Ignatius Di Stefano, DavidMcCormick, Jean Marcoux, and Ronald Port-man.

SUGGESTED READING

American Academy of Pediatrics, Committeeon Sports Medicine: Sports Medicine: HealthCare for Young Athletes. Evanston, IL, Amer-ican Academy of Pediatrics, 1983

American Academy of Pediatrics: Statementsof the Committee on Sports Medicine.(These and the firstreading can be orderedtoll-freeby calling the Academy at 1-800-433-9016. Several are cited inthe article.All

are listed in the back of the AAP FellowshipDirectory)

Bar-Or 0: Pediatric Sports Medicine for thePractitioner. New York, Springer-Verlag,1983

Micheli J: Pediatric and Adolescent SportsMedicine. Boston, Little, Brown, & Go, 1984

Smith NJ, and Stanitski CL: Sports Medicine,a Practical Guide. Philadelphia, WB Saun-ders, 1987

Strauss RH: Sports Medicine. Philadelphia, WBSaunders, 1984

The Physician and Sportsmedicine. (A journal,which is often free to physicians on request.Order from McGraw-Hill Inc, 4530 W 77thSt, Minneapolis, MN 55435)

Self-Evaluation Quiz

1. True statements pertaining to adoles-cents with arterial hypertension includeeach of the following, except:

A. An apparently healthy adolescent with ablood pressure at the 90th percentileshould not participate in any sports untilthoroughly evaluated.

B. Unless severe hypertension is present,dangerous acute elevations of bloodpressure usually do not occur duringweight training.

C. Aerobic (dynamic) exercise programs arerecommended for persons with persistenthypertension.

D. Graded exercise testing is not routinelyrecommended.

E. An individual with a systolic blood pres-sure at the 99th percentile and a diastolicat the 90th percentile should be treatedfor significant,but not severe, hyperten-sion.

2. Long-term restriction of an athlete, whohas suffered a concussion from collisionsports, would be least reasonable In whichof the following circumstances?

A. After three episodes of loss of conscious-ness.

B. After one episode if it leads to a perma-nent neurologic deficit.

C. After one episode if abnormalities arefound on a computed tomographic scanor magnetic resonance imaging scan.

D. After one episode of loss of conscious-ness lasting three to five minutes.

E. If a second concussion occurs during the

same season.

3. True statements about exercise-inducedbronchospasm include each of the follow-ing, except:

A. Many individuals with exercise-inducedbronchospasm are unaware of their prob-lem.

B. Exercised-induced bronchospasm israrely found in Olympic level athletes.

C. Running is the most common triggeringactivity.

D. With proper therapy, almost all childrenwith exercise-induced bronchospasm can

participate in active sports.E. An inhaled $-agonist is the initial treat-

ment of choice.

4. DurIng a vigorous workout on a hot day,a 17-year-old foothall player becomes weakand disoriented. He is moved to a cool shadyplace but does not improve. Appropriatemanagement at this time would Include eachof the following, except:

A. Remove equipment and clothes.

B. Measure oral temperature.C. Measure heart rate and blood pressure.D. Ensure 1 to 2 L of fluid intake within one

to two hours.E. If febrile, cool body by fanning and appli-

cation of ice water-soaked towels.

5. Which of the following is least importantin the prevention of heat illness In an ath-lete?

A. Gradual acclimatization to exercise in

heat.

B. Assess risk daily depending on the pre-vailing climate.

C. Use sugar/electrolyte-containing fluidsrather than water.

D. Enforce periodic drinking of specificamounts.

E. Identify athletes losing more than 3% of

body weight during activity.

Fitness

PIR 148 pediatrics in review #{149} vol. 10 no. 5 november 1988

used as a baseline for future refer-ence (just as is already done withheight, weight, and blood pressuredata) and can be used as the basisfor introducing the topic to the patientand the parents.

Office-based primary care physi-cians can collaborate with the localschool system to make a health-re-lated fitness profile for all of the chil-dren in a particular school system.The school systems can test thestudents in the areas of cardiovas-cular endurance capacity, muscularstrength and endurance, flexibility,and body composition. The laterthree areas tested could also be donein the physician’s office, if so desired.When a child’s test results areknown, the physician and the schoolcan work together to improve defi-cient areas.

No matter what method is usedand no matter what information isobtained, one cannot impart all of theinformation needed to start a newpersonal fitness or family fitness pro-gram in the 20 or 30 minutes that oneschedules for well-child visits andconsultations. The key is to person-ally introduce the topics of discus-sion, quickly go over the major pointsof a brochure or handout which thepatient or parent can take home, givesome specific suggestions to get thefamily started (write a daily log on thefamily calendar for each area you areworking on, ie, exercise, stress man-agement, and nutrition), and set up afollow-up visit for 1 to 4 weeks later.At the follow-up visit, the daily log canbe reviewed, repeat measurementscan be obtained, and the programcan be reinforced and clarified.

The beneficial changes achievedthrough any health-related fitnessprogram are not sustained if the pro-gram is discontinued. That is why theconcept of life-style changes is im-portant for the family to understand.

Pediatricians are frequently themain, if not the only, contact that

many young families have with themedical community. That is why theyshould attempt to counsel parentsabout the adult as well as pediatricbenefits of health-related fitness. Pe-diatricians should be encouraged tospeak to school boards about theirconcern regarding the type and theamount of health and fitness curricu-lum in the school systems. The effortthat is put into this educational proc-ess can help to maximize the healthpotential with which any one particu-lar child has been genetically en-dowed.

SUGGESTED READING

Anderson B: Stretching. Bolinas, CA, ShelterPublications Inc, Random House, 1980

Brownell KD, Nelson Steen 5: Modem meth-ods for weight control: The physiology andpsychology of dieting. Physician Sportsmed1987;1 5:122-137

cardiovascular risk factors from birth to 7years of age: The Bogalusa Heart Study.Pediatrics 1 987;80(suppl):767-81 6

Eisenman P, Johnson D: Coaches Guide toNutrition and Weight Loss. Champaign, IL,Human Kinetics Publishers, 1982

Geitmaker SL, Dietz WH: Increasing pediatricobesity in the United States. Am J Dis Child1987;1 41:535-359

Kraus H: Unfit kids: A call to action. ContempPediatr. 1988;5:1 8-30

Kwiterovich P0 Jr: Biochemical, ciinical, epi-demiologic, genetic, and pathologic data inthe pediatric age group relevant to thecholesterol hypothesis. Pediatrics 1986;78:349-362

Under �W, DuRant RH: Exercise, serum lipids,arid cardiovascular disease: Risk factors inchildren. Pediatr Ciln North Am 1982;29:1341-1354

Newman P, Halverson P: Anorexia Nervosaand Bulemia: A Handbook for Counselorsand Therapists. New York, Van NorstroudReinholt Co, 1983

Nora JJ: Identifying the child at risk for coro-nary disease as an adult: A strategy forprevention. J Pediatr 1980;97:706-714

Phelps JR: Physical activity and health main-tenance: Exactly what is known? West JMed 1987;146:200-206

Shepard RJ: Motivation: The key to fitnesscompliance. Physician Sportsmed 1985;13:88-101

Strong WB, Dennison BA: Pediatric preventive

cardiology: Atherosclerosis and coronaryheart disease. Pediatr Rev 1988;9:303-314

Strong WB, Wilmore JH: Unfit kids: An office-based approach to physical fitness. Con-temp Pediatr 1988;5:33-48

Suskind AM, Yarna AN: Assessment of thenutritional status of children. Pediatr Rev1984;5:1 95-202

Wilmore JH: Sensible Fitness. Champaign, IL,Leisure Press, Human Kinetics Publishers,1986

Self-Evaluation Quiz

6. The most prevalent risk factor for coro-nary artery disease Is:

A. Smoking.B. Hypertension.C. High serum cholesterol level.D. Physical inactivity.E. Obesity.

7. Each of the following is commonly in-cluded in the definition of health-related fit-ness, except:

A. Improved cognition.B. cardiorespiratory endurance.c. Flexibility.0. Appropriate percentage of body fat.E. Large-muscle strength.

8. Each of the following is a true statement,except:

A. Exercise to the point of pain should bediscouraged.

B. Walking is an aerobic activity that can bedone by almost everyone.

c. Flexibility helps to prevent musculoskel-etal injuries.

D. A body composition appraisal is a moreaccurate reflection of health-related fit-ness than is a weight to height ratio.

E. Ballistic, rather than static, stretching isrecommended.

9. Each of the f000wing is a true statementpertaining to diet, except:

A. In a proper diet, complex carbohydratesshould be the main source of calories.

B. Palm and coconut oils are recommended

sources of vegetable fats.C. Eating the largest meal of the day at

breakfast, rather than at night, helps peo-pIe lose weight.

D. Adolescents who follow unusual dietsshould be considered at risk for an eatingdisorder.

E. Crash diets lead to loss of muscle tissuewhile sparing fattissue.

Although most adoptees aretruly bonded to their adoptive

parents, they may need to“search” for their birth

parents.

.

Adoption

PIR 158 pediatrics in review #{149} vol. 10 no. 5 november 1988

is probably safest in following the rec-ommendations of the AmericanAcademy of Pediatrics’ (AAP) Com-mittee on Early Childhood, Adoption,and Dependent Care that, “place-ment must be made to provide thechild with an opportunity to grow upin a wholesome family setting that willoffer the affection, security, and un-derstanding needed for his best de-velopment.”9�147� It must be under-stood that these parameters cannotbe rigidly defined but must be deter-mined on a case-by-case basis. Thechild should be placed with familiesof similar racial and cultural back-ground, whenever possible, but nochild should be denied the opportu-nity to be adopted because a “per-fectly matched” family is not avail-able. The AAP endorses efforts toeducate members of minority groupsas part of the community as a wholeas to the needs of these children.

OPENNESS IN ADOPTION

The AAP supports the concept andpractice of openness in adoption.1#{176}The degree of openness in any adop-tion should be by the mutual consentof the birth parent(s), the adoptiveparents, and any intermediary thatmay be involved. The members of theadoption triad should be encouragedby pediatricians and others to provideregular, updated information to theagency or other mediating party toallow complete and factual responsesto inquiries concerning medical or so-cial developments. Laws regardingconfidentiality are changing in the di-rection of greater openness, and phy-sicians and agencies should assistmembers of the adoption triad whowish to establish contact with mem-bers of the biologic families, to theextent that the respective partiesmay so desire and legal conditionspermit.

Most adoptees have a warm, by-ing, and truly bonded relationship totheir adoptive parents. Regardless ofthis attachment, some adoptees havea compelling desire to learn of, andperhaps meet with, their birth par-ents.11 The latter may or may notshare this desire or need. Pediatri-cians should actively encourage thecollection of such information as maybe necessary to accomplish such a

search in a secure but accessiblemanner. The pediatrician who has acontinuing relationship with theadopted child can and should be pre-pared to assist the mature adopteein examining his or her feelings re-garding seeking information about, orperhaps locating and contacting, thebirth parents.

The adoptee should be reassuredthat feelings of a need to “search” tostabilize his or her sense of identityand connectedness are normal, asare the concomitant feelings of be-trayal of the adoptive parents, fear of

rejection by them, and anxiety aboutpossibly facing the fantasized causeof his or her rejection. The adoptiveparents must be reassured that theyare psychologically the “true” parentsand that feeling a need to search forone’s birth parents is common amongadolescent and adult adoptees. Withadequate preparation, the outcomeof such searches are usually positivefor all members of the adoptivetriad.12

FACING THE TASKS

The tasks faced by the adoptedchild, the birth parents, and the adop-tive parents are complex and de-manding. The large number of suc-cessful adoptions is testimony to theresourcefulness of these families.The tasks facing the pediatrician at-tempting to help them are similarlygreat, but with understanding and pa-tience the physician has much to offerin assisting all parties to achieve asatisfactory outcome.

REFERENCES

1 . Bachrach CA: Adoption plans, adoptedchildren, and adoptive mothers. J Mar-riage Family 1986;48:243-253

2. Millen L, Roll 5: Solomon’s mothers: Aspecial case of pathological bereavement.Am J Orthopsychiatry 1985;55:41 1-418

3. Schechter MD: About adoptive parents, inAnthony EJ, Bebedek T (eds): Parent-hood: It’s Psychology and Psychopathol-ogy. Boston, Little, Brown & Co, 1970

4. Sherry SN: Helping families adapt to adop-tion. Contemp Pediatr 1986;3:96-1 11

5. Kaunitz AM, Grimes DA, Kaunitz KK:physician’s guide to adoption. JAMA1987;258:3537-3541

6. Jerome L: Overrepresentation of adoptionattending children’s mental health center.Can J Psychiatry 1986;31 :526-531

7. Schwam JS, Tuskan MK: The adoptedchild, in Noshpitz JD (ed): The Basic Hand-book of Child Psychiatry. New York, BasicBooks, 1979, vol 1 , pp 342-348

8. Simon RJ, Altstein H: Transracia! Adop-tees and Their Families. New York, Prae-ger Publishers, 1987

9. American Academy of Pediatrics, Commit-tee on Adoption and Dependent Care:Transracial adoption. Pediatrics 1973;51:145-1 47

10. American Academy of Pediatrics, Commit-tee on Adoption and Dependent Care: Therole of the pediatrician in adoption withreference to “the right to know”: An up-date. Pediatrics 1981 ;67:305-306

1 1 . Sokoloff B: Adoption and foster care-The pediatrician’s role. Pediatr Rev1979;1 :57-61

I 2. Sorosky AD, Baran A, Pannor R: The ef-fects of the sealed record in adoption. AmJ Psychiatry 1976;1 33:900-904.

SUGGESTED READING

American Academy of Pediatrics: The pediatn-dan’s role in working with adoptive families.Pediatrics News and Comment 1983;34:10-11

American Academy of Pediatrics, Committeeon Adoption and Dependent Care: Identitydevelopment in adopted children. Pediatrics1971 ;47:948-949

American Academy of Pediatrics, Committeeon Adoption and Dependent Care: Adoptionof the hard-to-place child. Pediatrics1981 ;68:598-599

Enkson E: Childhood and Society. New York,ww Norton, 1950

Fisher F: The Search for Anna Fisher. NewYork, Arthur Field, 1973

Howard A, Royce DD, Skerl JA: Transracialadoption: The black community perspective.Social Work 1977;22:184-189

Kadushin A: Adopting Older Children. NewYork, Columbia University Press, 1970

Kim OS: Issues in transraciai and transculturaladoption. Soc Casework 1 978;59:477-486

Kirk HO: Shared Fate. New York, Free Press,1964

McRoy AG, Zurcher LA, Lauderdale ML, et al:The identity of transracial adoptees. SocCasework 1 984;65:34-39

Sorosky AS, Baran A, Pannor A: The AdoptionTriangle. Garden City, NY, Anchor Press-Doubleday, 1978

Self-Evaluation Quiz

13. Prior to adoption, the pediatrician’s re-sponsibilities include each of the followingexcept:

A. Interpretation of genetic information.B. Interpretation of potentially compromising

perinatal experiences.

EDUCATIONAL OBJECTIVE

42. The pediatrician should haveappropriate recognition of the ef-fact of major depressIon of parentsupon the development and behav-br of their children (Recent Ad-vances, 88/89).

SOCIAL PEDIATRICS

pediatrics in review #{149}vol 10 no. 5 november 1988 PIR 159

Assessment of the physical condition ofthe child.Apprise involved parties about any per-ceived special needs of the child.

E. Judge the advisability of the proposedadoption.

14. The number of children younger than 2years of age available for unrelated adop-tion has apparently decreased for each ofthe following reasons except:

A. Increased use of contraception.B. Decreased availability of abortion.

C. Changing attitudes toward single-parentfamilies.

0. Changing attitudes toward illegitimacy.E. Increased availability of day-care facilities.

15. True statements pertaining to adoption/adoptees include each of the following ex-cept:

A. It is important to obtain a complete historyof the child at the time of relinquishment.

B. Older children come to adoptive familieswith a sense of their own identity.

C. A need to search for his or her birthparents indicates that an adoptee has nottruly bonded to his adoptive parents.

0. Whenever reasonable, children should beplaced with families of similar racial andcultural backgrounds.

E. The degree of openness in an adoptionshould be determined by the mutual con-sent of the birth parent(s), adoptive par-ents, and involved intermediaries.

Children of Depressed Parents

Family Life Events, Maternal Depression, and Maternal and Teacher Descriptionsof Child Behavior. Fergusson DM, et al. Pediatrics 1985;75:30-35.Intelligence Quotient Scores of 4-Year-Old Children: Social-Environmental RiskFactors. Sameroff AJ, et al. Pediatrics 1987;79:343-350.Maternal Depression: A Concern for Pediatricians. Zuckerrnan BS, Beardslee WA.Pediatrics 1987;79:1 10-117.Children of Parents With Major Affective Disordec A Review. Beardslee WA, et al,Am J Psychiatry 1983;1 40:825-832.

Rates of diagnosed depression are known to be higher among women than men.Child rearing may increase the risk, with 12% of the mothers of young children havingdiagnosable depression and as many as 60% reporting depressive symptoms. Otherrisk factors indude marital discord and psychiatric disorder in the spouse, as well asenvironmental stress and limited personal and community resources to cope with thestress. Despite the long-standing recognition of the prevalence of the emotionaldistress especially among women, the elucidation of the relationship of such parentaldysfunction with child dysfunction is at a relatively early stage.

The major affective psychoses, such as schizophrenia, appear to cluster in familiesso that the child of a parent with such severe disability is at increased risk for similarproblems. For the more common affective disorders, mainly depression, the effect onthe child appears to be related to the developmental stage of the child. Maternaldepression during infancy and the early preschool period may be an antecedent ofcognitive delay as measured by 10 scores and nonorganic failure to thrive. In the laterpreschool and school-aged periods, maternal depression has been connected with avariety of behavior problems and school failure, as well as childhood injuries andpsychomatic complaints such as recurrent abdominal pain and headache. In laterschool-age and adolescence, behavioral problems may become more severe andsymptoms of emotional dysfunction, such as depression, more evident. Experiencediffers as to whether parental reports from an affected parent provide reliable indica-tions of child problems, probably as a function of both parental difficulties and variationin child behavior in different settings; thus, obtaining reports from alternative caregivers such as teachers is warranted when parental emotional problems are suspected.

Comment: The implications for intervention in the context of parental emotionaldysfunction are not clear. As the genetic component of the major psychoses andsubstance-dependence syndromes (eg, alcoholism) become clearer, it may be possibleto provide specific counseling to the offspring of affected parents. For the morecommonly encountered situations, the practitioner should consider the possibilitywhen faced with a child with otherwise unexplained failure to thnve, behavior or schoolproblems, or psychosomatic symptoms. The response must be tailored to the situationbut should combine encouragement for the parent to seek mental health services andsupport for the normal functioning and development of self-esteem of the child. (MarieC. McCormick, MD, PIR Editorial Board)