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technical tip

Technical Tip
Corneal Abrasions
Ann U. Stout, MD* sues of the body, so discomfort may external. The upper lid can be everted
range from mild to severe, depending over a cotton-tip applicator or a finger-
on the size of the defect. Symptoms tip to examine the tarsus. Abrasions
include photophobia, tearing, and in- that involve the entire cornea, such as
termittent sharp pain due to ciliary after chemical exposure, may be over-
Author Disclosure
body spasm. Physical findings include looked because no normal epithelium
Dr Stout did not disclose any irritability, blurry vision, conjunctival remains for comparison.
financial relationships relevant to injection, blepharospasm, irregular red Corneal abrasions heal rapidly, often
this tip. reflex, dulled corneal light reflex, and within 24 hours, although larger de-
fluorescein staining of the epithelial fects may take longer. Antibiotic oint-
defect. ment may help lubricate the surface
The father of a healthy 16-month-old Examination is facilitated by the use until healing occurs, but aminoglyco-
boy brings him in to check his eye. The of topical anesthetics (proparacaine or sides should be avoided because they
evening before, which had been rather tetracaine), which provide temporary may delay epithelial regrowth. The
windy, he had taken the child for a walk pain relief. Fluorescein helps define the chance of secondary infection is low,
in the stroller. During the walk, the boy size of the defect, although large de- unless foreign matter is retained.
began fussing and rubbing one eye. The fects may be seen without any dye. Therefore, a course of topical antibiot-
father noticed that the eye was watery Fluorescein strips can be moistened and ics is not requisite. Tight patching with
and red but could not see anything in touched to the lower fornix to apply two eye pads may help with comfort by
the eye. He gave the boy some acet- the stain or combination anesthetic/ blocking light and preventing the irri-
aminophen, and he slept well. Today, fluorescein drops can be used. The dye tation of repetitive blinking. The patch
however, the eye is still teary and stains the exposed corneal stroma, but must be tight enough to prevent inad-
irritated, and the boy is fussy. You washes off of intact epithelium. The vertent lid opening under the patch,
inspect the eye and find no foreign yellow dye is visible with regular white which could result in subsequent addi-
body. light, although blue or ultraviolet light tional abrasions from the patch mate-
Fluorescein staining viewed with a (Wood lamp) may make it more visible rial. Patching is not believed to speed
Wood lamp shows a 2-mm corneal and be better tolerated by a child who healing unless the defect encompasses
abrasion and fine linear vertical streak has photophobia. more than 75% of the corneal surface
defects. You suspect a hidden foreign The conjunctival cul de sac and area. Most younger children dislike the
body because the abrasion probably upper tarsus should be examined to rule patch, so it can be applied in the office
occurred yesterday and should have out retained foreign bodies, which may
healed overnight. Upon eversion of the cause persistent abrasions, unless the
upper lid, you see a small black particle cause of the abrasion is known to be
stuck to the tarsus that is removed
easily with a cotton swab (Fig. 1). You
prescribe analgesics as needed, topical
antibiotic ointment, and reassurance.
The next day, the father reports that his
sons eye is back to normal.
Corneal abrasions (Fig. 2) occur of-
ten in children of all ages. The cornea is
one of the most richly innervated tis-

*Casey Eye Institute, Oregon Health & Science


University, Portland, Ore. Figure 1. Foreign body in the eye. Figure 2. Corneal abrasion.

Pediatrics in Review Vol.27 No.11 November 2006 433


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in brief

and removed by the family if it is poorly Topical nonsteroidal drops (ketorolac) tial healing. During the night, the lid
tolerated. The family should not reapply may provide additional relief, but may sticks to the new epithelial cells and
it because it might be too tight or not delay healing. Topical anesthetics pulls them loose upon awakening.
tight enough. NEVER should be dispensed because These small abrasions are symptomatic
Over-the-counter analgesics or co- they not only retard healing but can upon awakening and often improve
deine may be used for pain manage- lead to corneal melting and perforation. throughout the day. Nightly lubrication
ment if needed. The pain of an abrasion Most small abrasions heal overnight. with ointment sometimes can break
should not be underestimated, and The patient can be seen the next day as this cycle. Patients who have nonheal-
treatment should be tailored to the needed or feasible. If symptoms and ing abrasions should be referred
childs comfort level. Pupillary dilation signs have resolved, it can be assumed promptly for additional evaluation be-
with a cycloplegic agent (tropicamide that the abrasion has healed. A small cause such abrasions can be due to
1% or cyclopentolate 1%) may help to group of patients are at risk of devel- secondary infections, occult foreign
block ciliary spasm and relieve pain. oping recurrent erosions from poor ini- bodies, or lacerations.

In Brief
Ampicillin and Amoxicillin
Zainab A. Malik, MD cians. Pediatrics. 2004;113: do not produce beta-lactamase. These
Nathan Litman, MD 14511465 agents are not active against Pseudo-
Childrens Hospital at Montefiore Management of Sinusitis. Subcommit- monas sp and are hydrolyzed by beta-
tee on Management of Sinusitis and
Bronx, NY lactamases, making them ineffective
Committee on Quality Improvement.
American Academy of Pediatrics. against beta-lactamase-producing strains
Pediatrics. 2001;108:798 808 of bacteria.
Author Disclosure
Ampicillin is effective in treating
Drs Malik, Litman, and Adam did not upper and lower respiratory tract infec-
disclose any financial relationships Ampicillin and amoxicillin are amino-
tions caused by Streptococcus pneu-
penicillins derived from the penicillin
relevant to this In Brief. moniae, beta-hemolytic streptococci, and
nucleus. Their basic structure consists
nonbeta-lactamase-producing strains of
of the beta-lactam ring and a side
Haemophilus influenzae. It also is ef-
The Use of Antibiotics. Kucers A. In: chain. The ring structure confers anti-
fective in the treatment of meningitis
Crowe KS, Grayson ML, Hoy J, eds. microbial activity, and the side chain
determines the antibacterial spectrum caused by group B streptococci, Listeria
The Use of Antibiotics: A Clinical
and pharmacologic properties. The an- monocytogenes, N meningitidis, and all
Review of Antibacterial, Antifungal
and Antiviral Drugs. 5th ed. Oxford, tibacterial activity of aminopenicillins except highly resistant strains of S
United Kingdom: Butterworth-Heine- is similar to that of other penicillins via pneumoniae. Ampicillin previously was
mann Publishing; 1997:108 143, inhibition of bacterial cell wall synthe- a first-line agent for treating urinary
192208 sis. Penicillin-sensitive reactions in tract infections (UTIs) caused by Esch-
Penicillins. Chambers HF. In: Mandell bacterial cell wall synthesis are cata- erichia coli and gastroenteritis caused
GL, Bennett JE, Dolin R, eds. Princi- lyzed by a class of proteins called by Salmonella enterica or Shigella sp.
ples and Practice of Infectious Dis- penicillin-binding proteins (PBPs), However, due to the rising prevalence
eases. Vol 1. 6th ed. Philadelphia, Pa: of beta-lactamase-producing strains of
which are inhibited by beta-lactam
Elsevier Churchill Livingstone; 2005:
antibiotics. these organisms, ampicillin no longer is
281293
The antibacterial spectrum of amino- the agent of choice for UTIs unless
Diagnosis and Management of Acute
Otitis Media. Subcommittee on penicillins includes nonbeta-lactamase- susceptibility has been documented.
Management of Acute Otitis Media. producing gram-positive cocci, anaer- The in vitro activity of amoxicillin is
American Academy of Pediatrics and obes, and gram-negative cocci, including similar to that of ampicillin. Ampicillin
American Academy of Family Physi- Neisseria and Enterobacteriacae that usually is given intravenously (IV) or

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in brief

intramuscularly (IM), whereas amoxicil- joint effusions, ascitic fluid, and para- and food does not alter its absorption.
lin is the preferred oral agent because it pneumonic effusions. Very low concen- Almost 60% of an oral dose of amoxi-
is less likely to cause diarrhea and can trations of ampicillin can be detected in cillin is excreted unchanged in urine
be administered less frequently than normal cerebrospinal fluid, but higher within the first 6 hours. It has a tissue
oral ampicillin. Amoxicillin is indicated levels are achieved in patients who distribution similar to that of ampicil-
in the treatment of otitis media, sinus- have bacterial meningitis due to ongo- lin, and tissue levels are 40% of serum
itis, pneumonia, and susceptible UTIs. ing meningeal inflammation. levels. Because amoxicillin achieves
Among the oral penicillins and ceph- The serum half-life of ampicillin de- high levels in the gastric mucosa, it is a
alosporins, amoxicillin can achieve clines with increasing postnatal age. In good antibiotic for treating Helicobac-
therapeutic minimum inhibitory con- neonates 2 to 7 days old, the serum ter pylori infections in combination
centrations in body tissues for nonmen- half-life is 4 hours; in 8- to 14-day-old with other agents. Oral amoxicillin is
ingeal infections caused by penicillin- neonates, it is 2.8 hours; and in 15- to not indicated for treating central ner-
resistant pneumococci, except highly 30-day-old neonates, it is 1.7 hours. In vous system infections.
resistant strains. Amoxicillin is not use- older children and adults, ampicillin has Amoxicillin is relatively nontoxic
ful in the treatment of shigellosis be- a serum half-life of 1 hour. After par- and may be given in the usual recom-
cause it is well absorbed in the small enteral administration, 75% of the dose mended dose to patients who have mild
intestine. Oral ampicillin is indicated for is excreted in the urine and 0.1% of the renal failure. The dose should be re-
this purpose; its poor intestinal absorp- dose is excreted unchanged in bile. duced for patients whose renal failure
tion allows significant levels of the Because high concentrations of ampi- is moderate to severe. Amoxicillin is the
antibiotic to reach the site of infection cillin are excreted in the urine, it was an drug of choice for treating acute bac-
in the large intestine. agent of choice for UTIs prior to the terial sinusitis and acute otitis media.
Ampicillin can be given IV or IM in emergence of microbial resistance. Factors that justify its use as a first-line
the form of its sodium salt. For neo- The major adverse effects associated agent include its narrow antimicrobial
nates weighing more than 2,000 g and with ampicillin use are rashes, which spectrum, pleasant taste, low cost, ac-
younger than 7 days old, a dose of tend to occur more commonly than tivity against susceptible and interme-
25 mg/kg every 8 hours is recom- with other penicillins (7.7% versus diately resistant pneumococci, and ac-
mended for mild-to-moderate infec- 2.75%). Ampicillin rashes may be urti- ceptable safety profile in children.
tions. With serious infections such as carial or macular, resembling measles There is a high prevalence of beta-
meningitis, the dose should be in- or rubella. The macular rashes usually lactamase-producing strains of H influ-
creased to 50 mg/kg every 8 hours. appear 4 to 5 days after therapy has enzae and Moraxella catarrhalis in up-
Neonates older than 7 days and weigh- begun, without any other associated per respiratory tract isolates in the
ing more than 2,000 g who have mild signs of allergy, and often subside with United States, making them resistant to
infections can receive a dose of ongoing treatment. The nonurticarial amoxicillin. Of the S pneumoniae iso-
25 mg/kg every 6 hours; for meningitis, rashes do not indicate true ampicillin lates from the upper respiratory tract,
the dose should be increased to hypersensitivity. Parenteral ampicillin an average of 30% are resistant to
200 mg/kg per day divided every therapy also can cause nausea and penicillin. Some 50% of these organ-
6 hours. For older infants and children, diarrhea, which are more common in isms are highly resistant, reflected in
doses of 100 to 400 mg/kg per day, younger children. Ampicillin and their lack of response to standard-dose
divided every 4 to 6 hours, are recom- amoxicillin can both be responsible for amoxicillin therapy. Penicillin resis-
mended. Because ampicillin is relatively Clostridia difficile-associated pseudo- tance among S pneumoniae results not
nontoxic, dose adjustment is not imper- membranous colitis. Very large doses from the production of an enzyme, but
ative in mild-to-moderate renal failure, that achieve serum levels of 800 mcg/mL from an alteration in PBPs on the bac-
although it may be required for patients may cause central nervous system toxic- terial cell wall, which confers resistance
who have severe renal dysfunction. ity, resulting in convulsions. to penicillins and cephalosporins.
Ampicillin is well distributed Amoxicillin is available in the trihy- Conventional doses of amoxicillin
throughout the body. Although the drate preparation for oral use. The stan- (45 mg/kg per day) are effective against
peak interstitial tissue concentrations dard dose is 45 mg/kg per day in two all susceptible strains of S pneumoniae
are lower than those achieved in serum, divided doses or 80 to 90 mg/kg per day and most strains that are intermediate
the drug persists in the interstitium for in two divided doses for indications in resistance to penicillin. Highly resis-
a longer period of time. It achieves that require high-dose amoxicillin. It is tant strains are not susceptible to con-
therapeutic concentrations in septic well absorbed after oral administration, ventional doses of amoxicillin. High-

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in brief

dose amoxicillin (80 to 90 mg/kg per otics in the preceding 3 months, partic- cause nausea and diarrhea, although
day) achieves high middle ear and sinus ularly among children younger than 2 less commonly than ampicillin.
fluid levels, making it effective against years of age.
all intermediately resistant strains and Amoxicillin and ampicillin are cross-
some, but not all, highly resistant allergenic with other penicillins and are Comment: Despite newer and newer
strains. In practice, the response rate to contraindicated in penicillin-allergic (and more expensive) antimicrobial
high-dose amoxicillin among children patients. Amoxicillin generally is well agents, amoxicillin remains the drug of
who have acute otitis media is approx- tolerated, although it has a propensity choice for both otitis media and sinus-
imately 80%. to cause rashes and results in a morbil- itis in most children. Its nice when
Risk factors for the presence of in- liform rash if given to a patient acutely oldies are still goodies.
termediate or highly resistant S pneu- infected with Epstein-Barr virus. The
moniae necessitating the use of high- maculopapular eruptions produced by
dose amoxicillin include child care amoxicillin are similar to those seen Henry M. Adam, MD
attendance and having received antibi- with ampicillin. Amoxicillin also may Editor, In Brief

In Brief
Cocaine
Christine Rizkalla, MD TOX-ACLS: Toxicologic-oriented ease hunger and thirst, and to improve
Young-Jin Sue, MD Advanced Cardiac Life Support. the stamina required for daily labors
Childrens Hospital at Montefiore Albertson T, Dawson A, de Latorre F, and life at great altitudes. Spanish col-
et al. Ann Emerg Med. 2001;
Bronx, NY onists of the region introduced the leaf
37(4 suppl):S78 S90
Cocaine, Amphetamines and Other to Europe, and the pure and far more
Sympathomimetics. Rao R, Hoffman potent chemical, cocaine, ultimately
Author Disclosure
R. In: Marx JA, Hockberger RS, Walls was extracted. The mid-1800s saw the
Drs Rizkalla, Sue, and Adam did not RM, eds. Rosens Emergency Medi- production of coca-infused wines and
disclose any financial relationships cine: Concepts and Clinical Practice. tonics. Early surgeons discovered its
relevant to this In Brief. 5th ed. St. Louis, Mo: Mosby; 2002: utility for local anesthesia. Sigmund
2386 2392
Freud praised the drug for its multiple
Body Packing: The Internal Conceal-
ment of Drugs. Traub S, Hoffman R, medicinal uses. In 1886, Dr John Pem-
History of Cocaine. Petersen RC. NIDA berton produced a new beverage
Res Monogr. 1977;13:1734 Nelson L. N Engl J Med. 2003;349:
2519 2526 named Coca Cola, combining coca and
Cocaine: History, Use, Abuse. Karch S.
caffeine from the African kola nut
J R Soc Med. 1999;92:393398
Cocaine Use: 20022003. The NSDUH According to one legend, before it was plant, touting it as tonic for multiple
Report. 2005. Available at: http:// a plant, coca was a beautiful woman, ailments and nervous disorders, partic-
www.oas.samhsa.gov/2k5/cocaine/ executed for adultery. Evidence of hu- ularly for the elderly. Gradually, more
cocaine.htm mans consuming Erythroxylon coca, a products contained greater amounts,
Intersecting EpidemicsCrack Cocaine South American shrub from which co- and consumption increased. Sir Arthur
Use and HIV Infection among Inner- caine (benzoylmethylecgonine) is de- Conan Doyle described his celebrated
city Young Adults. Edlin BR, Irwin fictional detective Sherlock Holmes us-
rived, dates to more than 1,000 years
KL, Faruque S, et al. Multicenter
ago. Regarded as divine in the northern ing cocaine when occupied by boring
Crack Cocaine and HIV Infection
Andes of Peru and Bolivia, cocaine cases. By the advent of the 20th cen-
Study Team. N Engl J Med. 1994;
331:14221427 played a role in religious ceremonies tury, increasing prevalence and nonme-
Cocaine and the Critical Care Chal- and inspired colorful mythology regard- dicinal use of pure cocaine brought
lenge. Shanti C, Lucas C. Crit Care ing its origin. Chewing coca leaves was with it the awareness of its toxic and
Med. 2003;31:18511859 promoted for its healing powers, to addictive potential. Beginning with the

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in brief

Harrison Act of 1914, the United States seizure, pulmonary hemorrhage, gastro- such complications. Potentially life-
government passed legislation to at- intestinal ischemia, rhabdomyolysis, threatening hyperthermia results from
tempt to control its availability, but and renal failure. Use in pregnancy may agitation, increased motor tone, and
public demand remained. lead to placental abruption or fetal vasoconstriction, interrupting the
Far from myth and legend, cocaine demise. Behavioral manifestations of bodys cooling mechanisms. Once iden-
now is popularly known as bazooka, this sympathetic overstimulation in- tified, hyperthermia must be addressed
white lady, Charlie, snow, tornado, clude euphoria, confidence, agitation, emergently with: benzodiazepines to
kryptonite, dust, bones, sugar, and aggression, and hallucinations (coke decrease agitation; paralysis and airway
blow, among other names. Estimates in bugs). stabilization if indicated; IV access for
both 2002 and 2003 were that more Cocaine blocks sodium transport aggressive fluid management; and rapid
than 5.9 million people in the United across cell membranes, slowing nerve cooling with ice.
States older than age 12 years (2.5% of impulses, which accounts both for its The clinician also must monitor lev-
the population) had used cocaine anesthetic properties and for its poten- els of creatine kinase, electrolytes, cre-
within the past 12 months, primarily tial to induce fatal ventricular arrhyth- atinine, coagulation parameters, and
within the 18- to 25-year-old group. mias and cardiac arrest. IV use carries urine myoglobin because rhabdomyoly-
Cocaine is abused by several routes. the additional risks of local infection, sis may be an associated complication.
Water-soluble cocaine hydrochloride is sepsis, and endocarditis. Human immu- A direct-acting alpha-adrenergic an-
snorted as a powder or injected as an nodeficiency virus transmission is an tagonist such as phentolamine and a
aqueous solution. Alkaloid preparations additional risk of IV drug use, both from vasodilator, usually nitroprusside, are
are smoked as free-base or as the needle-sharing and because high-risk used to treat critical hypertension. Beta
precipitated crystal form known as sexual encounters are associated with blockers should be avoided because re-
crack. As a base, cocaine is highly drug-seeking behavior. sultant unopposed alpha-adrenergic
purified, heat-stable, and lipid-soluble, Chronic use of cocaine is associated stimulation may exacerbate the hyper-
thereby readily crossing the blood-brain with cachexia, poor nutrition, and tension. Computed tomography (CT)
barrier and yielding an intense and crack dancing (choreoathetotic move- scanning of the brain and lumbar punc-
immediate high. Both smoking and ments from decreased dopamine ture should be strongly considered for
intravenous (IV) injection produce a stores). Upregulation of dopaminergic patients who have persistent headache
high within seconds to minutes that receptors exacerbates tolerance as well or altered mental status.
lasts 15 to 30 minutes unless repeated as the drug craving and dysphoria that Evaluation of chest pain in associa-
hits are delivered. The effects of insuf- follow each high. With greater intake tion with cocaine use requires radio-
flated cocaine peak at 20 to 30 minutes needed to achieve the same effects, graphs of the chest (for pneumothorax,
(due to local vasoconstriction, which cocaine users increase their potential widened mediastinum, and pneumonia),
slows its absorption) and last approxi- for morbidity and mortality. electrocardiography (ECG), measure-
mately 1 hour. Cocaine may be adulter- Cocaine users may not be forthcom- ment of cardiac enzymes and electro-
ated to augment its mass (eg, with ing about their drug taking. Urine lytes, a complete blood count, and
sugars or talc) or to enhance its effects screening is widely available, employing blood cultures. Acute coronary syndromes
(eg, with heroin known as a a highly specific immunoassay for the due to cocaine should be managed ini-
speedballphencyclidine, lidocaine, metabolite benzoylecgonine, which is tially with nitrates and benzodiazepines,
or strychnine). Use with alcohol pro- excreted for 24 to 48 hours. However, with use of alpha-adrenergic antagonists
duces the metabolite cocaethylene, depending on the chronicity of use, considered in refractory cases. Sodium
which may augment its toxicity. urine may remain positive for several bicarbonate is appropriate for treating
The physiologic effects of cocaine days. the sodium channel blockade that re-
result from the release of norepineph- As with all medical emergencies, sults in ventricular dysrhythmias, man-
rine from adrenergic nerve terminals individuals who present with symptoms ifested as a widened QRS interval on
and from inhibited reuptake of dopamine, of toxicity should be evaluated for air- ECG. Class 1A and 1C antidysrhythmic
epinephrine, serotonin and norepineph- way stability. The most rapidly fatal agents generally are contraindicated in
rine. Sympathetic overstimulation man- complications in cocaine use are re- such situations because exacerbation of
ifests as mydriasis, diaphoresis, tachy- lated to hyperthermia, hypertension, sodium channel blockade may ensue.
cardia, hypertension, and hyperthermia. and cardiac dysrhythmias. Benzodiaz- A unique set of problems arises with
This may be followed by the complica- epines and aggressive external cooling individuals who have ingested densely
tions of myocardial infarction, stroke, are the foundation of management of contained, well-sealed packets of the

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in brief

drug for transport (body packers) or bodies surrounded by gas. Bowel perfo- exposures, cocaine continues to present
who have hastily swallowed poorly ration is an additional concern. Because a complex and sometimes fatal public
sealed aliquots to conceal them from of the potential for lethal overdosing, a health challenge that includes the pe-
law enforcement officers (body positive urine assay accompanied by diatric population. Familiarity with the
stuffers). Body packers may harbor up symptoms of cocaine toxicity in such manifestations and management of co-
to 100 packages, each containing a individuals should prompt rapid surgi- caine intoxication is imperative for
lethal quantity of the drug. Body cal decontamination, with treatment of practitioners who work with children
stuffers, while concealing a lesser associated toxicity as described previ- and adolescents.
amount of drug, may be at greater risk ously. Stable individuals should be
for toxicity from rupture of poorly se- managed with whole bowel irrigation, Comment: So, at least initially,
cured packets. Plain radiographs may using polyethylene glycol to facilitate there really was a difference between
reveal air trapped between the wrap- gut emptying, and observation until Coke and Pepsi!
pers (often condoms) used for packag- passage of all packages.
ing (double-condom sign), and con- With considerable numbers of ado- Henry M. Adam, MD
trast CT scans may demonstrate foreign lescent users and accidental toddler Editor, In Brief

Correction
For question #11 on page 345 in the September 2006 issue of Pediatrics in Review,
the answer should be D rather than E.

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Pediatrics in Review Vol.27 No.11 November 2006 439
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Ampicillin and Amoxicillin
Zainab A. Malik and Nathan Litman
Pediatrics in Review 2006;27;434
DOI: 10.1542/pir.27-11-434

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/27/11/434
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Ampicillin and Amoxicillin
Zainab A. Malik and Nathan Litman
Pediatrics in Review 2006;27;434
DOI: 10.1542/pir.27-11-434

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/27/11/434

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2006 by the American Academy of
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