#{163}��II:RI(;;�N ;�(�I)I�’�lY OF Pl:I)IVIRI(:s

Vol. 12 No. IJuly 1990

3#{149}PREP 2-Year 6- Hag�jerty

Review andEducation Program 4l�1

5#{149}The Pediatrician and ChildrenWith Mali�jnancy - Ha�j�jerty

5. Cancer and the Pediatrician -

Pizzo

6#{149}The Child With Cancer - Sahier

11 The Case of Donnie J - Bur�j

15#{149}Peptic Ulcer Disease - (ryboski

25#{149}Alopecia - Atton and Tunnessen

3 PREP 2-Year 6: An End and a New Beginning

Robert J. Haggerty

5 The Pediatrician and the Care of Children WithMalignancy

Robert J. Haggerty

5 Cancer and the Pediatrician: An Evolving Partnership

Philip A. Pizzo

6 Caring for the Child With Cancer and the Family:Lessons Learned From Children With Acute Leukemia

Olle Jane Z. Sahler

ARTICLES

11 The Case of Donnie JFredric D. Burg

15 Peptic Ulcer Disease in Children

Joyce D. Gryboski

25 Alopecia in Children: The Most Common Causes

Andrew V. Atton and Walter W. Tunnessen Jr

8

910

1314

21

22

23

24

3031

The printing and production of

4,

Pediatrics in Review is made possible,m - � in part, by an educational grant from� R OS S /� Ross Laboratories.

Answer Key: iD; 2.D; 3.A; 4.6; 5.A; 6.D; 7.E; 8.A; 9.C; 10.A; liD; 12.A; 13.E.

Vol. 12, No. 1, July 1990

Pediatricsin ReviewEDITORRobertJ. HaggertyNew York Hospital-CornellMedical CenterNew York, NY

Editorial Office:The William T. Grant Foundation515 Madison Ave. 6th Floor,New York, NY 10022-5403

ASSOCIATE EDITORLawrence F. NazarianPanorama Pediatric GroupRochester, NY

Mailing Address:29 Surrey PlacePenfield, NY 14526

EVALUATION EDITORWilliam H. Milbum, Lyons, CO

MANAGING EDITORJo A. Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan III, Stanford, CA

EDITORIAL BOARDRalph Cash, Detroit, MlDaniel D. Chapman, Ann Arbor, MlEven Chamey, Worcester, MAAlan L Goldbloom, Toronto, ONMane C. McCormick, Boston, MAKurt Metzl, Kansas City, MOPhilip A. Pizzo, Bethesda, MDRobert Rennebohm, Columbus, OHWilliam 0. Robertson, Seattle, WARobert J. Touloukian, New Haven, CTW. Allen Walker, Boston, MA

EDITORIAL ASSISTANTElizabeth A. Nelson

PUBLISHERAmerican Academy of PediatricsNancy Wachter, Copy Edftor

PEDIATRICS IN REVIEW(ISSN 0191-9601)is owned and

controlled by the American Academy of Pediatrics. It ispublished twelve times a year (July through June) by theAmerican Academy of Pediatrics, 141 Northwest Point Blvd.

P0 Box 927, E5 Grove Village, IL 60009-0927.

Subscriptions will be accepted until December 31. 1990for the 1990-91 cycle. Subscription price per year: Candi-date Fellow of the AAP $50; AAP Fellow $75; Allied Health

or Residents $50; Nonmember or Institution $100. Currentsingle issues $8.

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

C American Academy of PedIatrics, 1990All Rights Reserved. Printed in U.S.A. No part may be

duplicated or reproduced without permission of the Ameri-can Academy of Pediatrics.POSTMASTER: Send address changes to PEDIATRICS IN

REVIEW, American Academy of PediatrIcs, 141 NorthwestPoint Blvd. P0 Box 927, Elk Grove Village, IL 60009-0927

CONTENTS

COMMENTARIES

ABSTRACTS

Department of Corrections

Head InjuriesReactive Arthritis

Antigen Detection Test for Streptococcal PharyngitisFetal Lead Poisoning

Department of Corrections

Unproven and Controversial Techniques in AllergyPulmonary Reactions to Nitrofurantoin

Cerebral Cavernous MalformationsDepartment of Corrections

The Use of Lorazepam in the Management of Seizures

Cover: Two Young Girls at the Piano, by Pierre August RENOIR (© 1989The Metropolitan Museum of Art; Robert Lehman Collection, 1975.(1975.1.201)). Two Young Girls at the Piano is one of at least five Versionsof the same scene by Renoir, including a lovely pastel recently sold at

auction. Renoir was 51 years of age at the time he did this work in 1892,and at the height of his popularity. This lovely presentation evokes a formerera when adolescents, at least those in favored economic status, spent theirleisure learning skills such as playing the piano and singing. One of themajor tasks of adolescence is to develop one’s identity and sense of

competence. Whether it is the charming skills so beautifully depicted in thispainting or others, the task of pediatricians is to assist young people indeveloping skills of which they can be proud.

PEDIATRICS REVIEW AND EDUCATION PROGRAM

Pecli#{228}tricsin R#{246}��li#{233}�W.

American Academy of Pediatrics

VOLUME 12

1990-1991

In this volume we have brought together all twelve issues of the twelfth year ofpublication of Pediatrics in Review. This includes three Guides for Record Review,published by the American Board of Pediatrics, which served as supplements to thejournal. The articles and abstracts were developed to help readers achieve educationalobjectives set for the continuing education program of the American Academy ofPediatrics. We believe that they contain material of use to a wider readership thanmembers of the Academy who subscribe to the Pediatrics Review and EducationProgram (PREP) such as residents, nurses, family physicians, and other clinicians.We hope that you find them useful.

Robert J. Haggerty, MDEditor

EDITOR

ISBN 0-910761-30-2.

Robert J. HaggertyNew York Hospital-Cornell Medical Center, New York, NY

ASSOCIATE EDITOR

Lawrence F. NazarianPanorama Pediatric Group, Rochester, NY

ABSTRACTS EDITOR

Steven P. ShelovBronx, NY

MANAGING EDITOR

Jo A. LargentElk Grove Village, IL

EDITORIAL CONSULTANT

Victor C. Vaughan Ill

Stanford, CA

EDITORIAL ASSISTANT

Elizabeth A. NelsonNew York, NY

EDITORIAL BOARD

Morris A. Angulo, Mineola, NYRalph Cash, Detroit, MlDaniel 0. Chapman, Ann Arbor, MIEvan Charney, Worcester, MARussell W. Chesney, Memphis, TNCatherine DeAngelis, Baltimore, MDPeggy C. Ferry, Tucson, AZAlan L. Goldbloom, Toronto, ONRichard B. Goldbloom, Halifax, NSJohn L. Green, Rochester, NYRobert L. Johnson, Newark, NJAlan M. Lake, Glen Arm, MDFrederick H. Lovejoy, Jr., Boston, MAJohn T. McBride, Rochester, NYMarie C. McCormick, Boston, MAVincent J. Menna, Doylestown, PA

Kurt Metzl, Kansas City, MOLawrence D. Pakula, Timonium, MDPhilip A. Pizzo, Bethesda, MDRonald L. Poland, Hershey, PAJames E. Rasmussen, Ann Arbor, MIRobert Rennebohm, Columbus, OHWilliam 0. Robertson, Seattle, WAJames S. Seidel, Torrance, CARichard H. Sills, Newark, NJLaurie J. Smith, Washington, DCWilliam B. Strong, Augusta, GAVernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CTW. Allan Walker, Boston, MATerry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

PUBLISHER: American Academy of Pediatrics, Jean Dow, Director, Division of PREP/Pediatrics, Nancy Wachter, Copy Editor.© American Academy of Pediatrics, 1991. All Rights Reserved. Printed in U.S.A. No part may be duplicated or reproduced without permissionthe American Academy of Pediatrics.Guides for Record Review ©1991. Published by The American Board of Pediatrics.� All Rights Reserved.

S elf-Evaluation Quiz- ANSWER. To obtain credit, record your answers on your quiz replycards (which you received under separate cover), and retum theC ME Credit cards to the Academy. On each card is space to answer the

questions in six issues of the journal: CARD 1 for the July throughDecember issues and CARD 2 for the January through June issues.

As an organization accredited for continuing medical education, To receive credit you must currently be enrolled in PREP or athe American Academy of Pediatrics certifies that completion of the subscriber to Pediatrics in Review-and we must receive both cardsself-evaluation quiz in this issue of Pediatrics in Review meets the by August 31 , 1991.criteria for two hours of credit in Category I of the Physician’s Send your cards to: Pediatrics in Review, American Academy ofRecognition Award of the American MediCal Association and two Pediatrics, I 41 Northwest Point BIvd, P0 Box 927, Elk Grove Village,hours of PREP credit. IL 60009-0927.

The questions for the self-evaluation quiz are located at the end The correct answers to the questions in this issue appear on theof each article in this issue. Each question has a SINGLE BEST inside front cover.

pediatrics in review #{149} vol. 12 no. 1 july 1990 PIR 3

CommentaryPREP 2 - YEAR 6: An End and a New Beginning

It does not seem possible that 12years have passed since the launch-ing of PREP. The first issue of Pedi-atrics in Review appeared in July1 979, preceded by several years ofplanning. The exact origin of the jointefforts of the American Academy ofPediatrics and the American Board ofPediatrics to develop a continuing ed-ucation program tied to recertificationis not clear to me today. Suffice tosay that Dr Olmstead (then Directorof the Academy’s Department of Ed-ucation), Dr Fraser (the Executive Di-rector of the Academy), and DrBrownlee of the Board worked to-gether to form a Coordinating Com-mittee made of representatives fromboth organizations and from pediatricpractice and academia. Committeeswere formed to develop two sets ofeducational objectives each year.One set was devoted to 25 to 35particular content areas or “Topics”within four or five subspecialty areas.For instance, hematology/oncologyand gastroenterology are among thetopics in 1990 to 1991. The secondset of objectives was composed ofsome 125 to 150 items and based on“Recent Advances” within the field.Recent Advances objectives encom-passed the entire field of pediatricsbut were limited to new informationfrom the previous 7 years. (Informa-tion on “Topics” objectives had notime limit.) Working from these objec-tives, separate groups of pediatri-cians developed questions for the re-certification examination of the Boardand the self-assessment questions ofthe Academy. With the able assist-

ance of the Editorial Board of Pedi-atrics in Review, I recruited the arti-des and abstracts for the journalbased upon the educational objec-tives.

I do not believe that the continuingeducation program of any medicalspecialty has been developed morerationally. Although the recertificationaspect of the program was greetedwith a good deal of hostility, cooper-ation between the Board and theAcademy has continued unhamperedthroughout the 1 2 years. I have al-ways believed that the recertificationportion is an important and integralpart of the whole program, both toincrease motivation for education andto ensure public confidence in pedia-tricians’ competence. But) also agreewith those who oppose recertificationthat there is more to being a goodpediatrician than passing a paper-and-pencil cognitive examination.However, it is hard to conceive thatone can be a good pediatrician with-out a specific knowledge base. Thedevelopment of an educational pro-gram to address what was consid-ered by both practitioners and aca-demicians to be important knowl-edge, not esoterica, has been theprimary goal of PREP. The PREPprocess has ensured that the infor-mation provided through the programand the knowledge base required topass the Board’s examination is rel-evant to practice. In Pediatrics in Re-view, I have attempted to publish ar-ticles and abstracts to provide up-to-

date information pertinent to the ob-jectives. Pediatrics in Review has

been well accepted as a reliablesource of continuing education infor-mation for pediatricians. This 1 990 to1 991 PREP 2 - Year 6, which beginswith the July 1990 issue, marks theend of this phase. I have enjoyed theprocess of editing the journal be-cause, for me as well as for our read-ers, it has been a wonderful continu-ing education process.

THE NEW BEGINNING

The next phase of PREP presentsan exciting challenge. Those pediatri-cians who became certified by theAmerican Board of Pediatrics in 1988now have a time-limited certificationand will be required to participate inthe Program for Renewal of Certifi-cation in Pediatrics (PRCP) if theywish to remain certified. There will befour parts to this program: 1 ) an ex-amination drawn from a comprehen-sive list of “core content” statementsof knowledge; 2) a record review; 3)an examination to assess diagnosticprocesses; and 4) an examination toassess skills in the management ofclinical problems. Pediatrics in Re-view will concentrate on providing pe-diatricians with information relating tothe core content and record review.

THE CORE CONTENT

Task forces similar to those whichdeveloped the educational objectivesfor PREPs I and II have begun todevelop hundreds (eventually thou-sands) of core content statements

EDUCATIONAL OBJECTIVE

30. The pediatrician should have

appropriate knowledge of the limi-tations of antigen detection testsfor streptococcal pharyngitis. (Re-cent Advances, 90/91)

HEALTH SUPERVISION

pediatrics in review #{149}vol. 12 no. 1 july 1990 PIR 13

of preschool children predict injuries ofschool-aged children? Pediatrics.

1 988;82:707-71 23. McCormick MC. Accidental injury in pri-

mary care pediatrics. Principles and Prac-

tice of Clinical Pediatrics. Chicago, IL:Yearbook Medical Publishers lnc;1988:112-116

4. Henderson D, Gerberding JL. ProphylacticZidovudine after occupational exposure tothe human immunodeficiency virus: An in-terim analysis. J Infect Dis.

1989;1 60:321-327

Self-Evaluation Quiz

1. A 7-year-old new patient recentlyarrived

from Southeast Asia has an uncertain his-

tory of immunization. It would appear appro-priate at this time to administer each of thefollowing except:

A. Oral poliovirus vaccine.B. Measles-mumps-rubella vaccine.C. Tetanus and diphtheria toxoids.D. Haemophilus influenzae type b vaccine.

2. A 4-year-old new patient recently arrivedfrom Southeast Asia has an uncertain his-tory of immunization. It would appear appro-priate at this time to administer each of thefollowing except:

A. Oral poliovirus vaccine.

B. Diphtheria and tetanus toxoids plus per-tussis vaccine.

C. Measles-mumps-rubella vaccine.D. Hepatitis B vaccine.

3. A 4-year-old new patient recently arrivedfrom Southeast Asia has an uncertain his-tory of immunization. It would appear appro-priate at this time to administer each of thefollowing as a prophylactic measure except:.

A. PPD.B. H influenzae type b vaccine.C. Diphtheria and tetanus toxoids plus per-

tussis vaccine.D. Oral poliovirus vaccine.

Antigen Detection Test for Streptococcal Pharyngitis

Current Problems in Managing Streptococcal Pharyngitis. Denny FW. J Pediatr.1 987;lll:797-806.Antigen Detection Test for Streptococcal Pharyngitis: Evaluation of SensitivityWith Respect to True Infections. Gerber MA et al. J Pediatr. 1 986;1 08:654-658.Comparison of a Latex Agglutination Test and Four Culture Methods for Identifi-cation of Group A Streptococci in a Pediatric Office Laboratory. Roddey OF et al.J Pediatr. 1986;108:347-351.Performance of an Enzyme Immunoassay Test and Anaerobic Culture for Detec-tion of a Group A Streptococci in a Pediatric Practice Versus a Hospital Laboratory.Kellog JA et al. J Pediatr. 1987;llI:1 8-21.Identification of Streptococcal Pharyngitis in the Office Laboratory: Reassess-ment of New Technology. Radefsky M et al. Pediatr Infect Dis J. 1987;6:556-563.Streptococcal Pharyngitis in the 1980’s. Dillon HC. Pediatr Infect Dis J. 1987;6:1 23-130.Resurgence of Acute Rheumatic Fever in the Intermountain Area of the UnitedStates. Veasy LG et al. N EngI J Med. 1987;31 6:421-427.

Since 1954, the use of office throat cultures has been the gold standard in thedetection of Group A �3-hemoIytic streptococcal pharyngitis. In recent years, rapiddiagnostic tests based on detection of bacterial antigen or other microbial constituentshave become available. These tests have a positive test correlation with positivecultures in more than 90% of cases. False negatives occur if there is sparse growthon culture (fewer than 10 colonies), and there is considerable test-to-test variability.The advantages of these rapid diagnostic tests include symptomatic benefit of earlytreatment, the possible earlier return of the child to day care or school, reducedtransmission to family and close contacts, and the decreased use of unnecessaryantibiotics. The disadvantages are the bacteriological inaccuracy, the effect on office-laboratory routine, and the increased cost. These rapid diagnostic tests are an optionaladjunct to throat cultures. A positive test result is generally reliable and justifiesantimicrobial therapy. A negative test result does not exclude the possibility of groupA streptococcal pharyngitis, and a concomitant throat culture should be obtainedwhen clinical findings suggest streptococcal infection. With the resurgence of acuterheumatic fever in some areas of the United States, the importance of properbacteriologic diagnosis of pharyngitis has been reiterated. In this diagnostic regime,rapid diagnostic tests have a role. However, their limitations must be recognized, andthe physician must remember that the throat culture remains the standard by whichall other means of diagnosis should be measured.

Comment: In our office practice, the value of the rapId diagnostic test has been indetermining whether immediate treatment of the child is indicated, thus decreasingthe use of unnecessary antibiotics and increasing parental compliance with treatmentregimen. (Kurt Metzl, MD, Editorial Board)

GASTROINTESTINAL DISEASE

pediatrics in review #{149}vol. 12 no. 1 july 1990 PIR 21

quired for specific antibacterial ther-apy.

REFERENCES

1 . Drumm B, Rhoads JM, Stringer DA, et al.Peptic ulcer disease in children: etiology,clinical findings, and clinical course. Pedi-atnics. 1988;82:41 0-414

2. Murphy MS, Eastham EJ, Jiminez M, Nel-son R, Jackson RH. Duodenal ulceration:review of 1 1 0 cases. Arch Dis Child.1987;1 2:554-558

3. Collins JSA, Glasgow JFT, Trouton TG, etal. Twenty-year review of duodenal ulcer.Arch Dis Child. 1 986;61 :407-408

4. Nord K. Peptic ulcer disease in the pedi-atnc population. Pediatn Ciln N Am.1988;35:1 17-1 38

5. Wolfe MM, SoIl A. The physiology of gas-tric secretion. N Engl J Med.1 988;31 9:1707-1715

6. Euler AR, Byrne WJ, Cousins LM, et al.Increased serum gastnn concentrationsand gastric hyposecretion in the immedi-ate newborn period. Gastroenterology.1 977;72:1 271-1273

7. Euler AR, Byrne WJ, Meis PJ, et al. Basaland pentagastnn-stimulated gastric secre-tion in newborn infants. Pediatr Res.1979;1 3:36-37

8. Miller V, Doig CM. Upper gastrointestinaltract endoscopy. Arch Dis Child.1984;59:1 100-1102

9. Euler AR, Byrne WJ, Campbell MF. Basaland pentagastnn-stimulated gastric acidsecretory rates in normal children and inthose with peptic ulcer disease. J Pediatr.1983;1 03:766-768

10. Christie DL, Ament ME. Gastric acid hy-persecretion in children with duodenal ul-cer. Gastroentenology. 1976;71 :242-244

11. Agunod M, Yagamuchi N, Lopez R, et al.Correlative study of hydrochloric acid,pepsin and intrinsic factor secretion innewborns and infants. Am J Dig Dis.1969;14:400-41 4

12. Pun P, Boyd E, Blake N, Guiney EJ. Duo-denal ulcer disease in childhood: a contin-uing disease in adult life. J Pediatr Sung.1978;1 3:525-526

13. White A, Carachi R, Young DG. Duodenalulceration presenting in childhood: long-term follow-up. J Pediatr Sung. 1984;1 9:6-8

14. Gryboski JD. Pain and peptic ulcer diseasein children. J Clin Gastnoentenol.1 980;2:277-279

1 5. Tam P. Hypergastrinemia in children: duo-denal ulcer. J Pediatn Sung. 1988;23:331 -

33416. Langman MJS. Epidemiologic evidence

and the association between peptic ulcer-ation and antiinflammatory drug use. Gas-troentenology. 1989;96:640S-646S

1 7. Graham DY. Prevention of gastroduodenalinjury by chronic non-steroidal antiinflam-matory drug therapy. Gastroenterology.1989;96:675S-681 S

1 8. Tedesco FJ, Goldstein PD, Gleason WA,et al. Upper gastrointestinal endoscopy inthe pediatric patient. Gastnoenterology.1976;70:492-494

19. Ament ME, Christie DL. Upper gastroin-testinal fiberoptic endoscopy in pediatricpatients. Gastroentenology. 1 977;72:244-248

20. Chiang BL, Chang MH, Lin Ml, et al.Chronic duodenal ulcer in children: clinicalobservation and response to treatment. JPediatn Gastroenterol Nutr. 1 989;8:1 61-165

21 . Czinn S, Speck WT. Campylobacter pylon:a new pathogen. J Pediatn.1989;1 14:670-672

22. Graham DY. Campylobacter pylon andpeptic ulcer disease. Gastroentenology.1989;96:61 5S-625S

23. Marshall BJ, McGechie DB, Roberts PA,et al. Pyloric Campylobacter infection andgastroduodenal disease. Med J Aust.1985;1 42:439-444

Self-Evaluation Quiz

4. The major factor in causing stress-re-lated ulcer is:

A. Increased gastric acid secretion.

B. lschemia.C. Fever.D. Inhibition of prostaglandin synthase.E. Decreased bicarbonate production.

5. Which of the following is more frequentin primary than secondary peptic ulcer dis-ease?

A. Abdominal pain.B. Melena.

C. Hematemesis.D. Perforation.E. Death.

6. Each of the following is true about non-steroidal anti-inflammatory drugs (NSAIDs)and peptic ulcer disease, except:

A. They are associated with the develop-ment of both gastric and duodenal ulcers.

B. Most have been implicated as a cause ofpeptic ulcers.

C. A personal or family history of ulcers isapparently a risk factor for NSAID-in-

duced ulcers.D. Even with antacid or Hrreceptor antago-

nist treatment, a NSAID-induced pepticulcer will not heal unless the drug is dis-continued.

E. They act as both local and systemic rn-tants to the gastric mucosa.

7. Which of the following is least likely to bea true statement pertaining to primary pepticulcer disease in children?

A. Initial symptoms in young children ofteninclude feeding problems or vomiting.

B. Gastric ulcers are more common thanduodenal ulcers in children less than 6years of age.

C. After 10 years of age, the majority ofulcers are found in boys and are duo-denal.

D. Pain in young children often has no as-

sociation with meals.E. Children with duodenal ulcers rarely have

pain at night.

8. The most accurate test(s) for establish-ing the diagnosis of peptic ulcer diseaseassociated with Helicobacter pylon or Cam-pyiobacter pylon is (are):

A. Special stain and/or culture of biopsiedgastric tissue.

B. Culture of gastric juice.C. Qualitative identification of ammonium ion

in agar-incubated tissue.D. Cl 4 urea breath test.E. Observation of motile organisms in fresh

tissue specimen.

DEPARTMENT OF CORRECTIONS

In the article by Ginsberg-Fellner in the February 1 990 issue of Ped!atr!csin Review, “Insulin-Dependent Diabetes Mellitus,” the blood concentration atwhich the kidneys excrete glucose was stated incorrectly. On page 242, the22nd line of the section on the management of children and adolescents withdiabetes should indicate that this occurs only when the blood glucoseconcentration is greater than 180 mg/dL.

Alopecia

PIR 30 pediatrics in review #{149}vol. 12 no. 1 july 1990

spection of the surface of the scalpor palpation of it may give the nec-essary clues to the correct diagnosis.

LOOSE ANAGEN SYNDROME

This syndrome is included in thediscussion of disorders with alopeciafor two reasons: (1 ) it was only de-scribed recently, and (2) it may bemuch more common than recognizedpreviously. Prominent areas of alo-pecia do not seem to be a character-istic feature, although areas ofmarked scalp hair loss may be pres-ent. The primary complaint concernseasy pulling out of hair without pain.The disorder is most commonly de-scnibed in children, particularly blondegirls. On inspection of the hair that iseasily epilated, the bulbs appear tobe anagen in nature, although theyare commonly misshapened and lackan outer root sheath. Parents maynote that their children’s hair doesnot grow or grows very slowly, andalmost never requires cutting. Thecause of this disorder is not known.Although no treatment is available,the parents can be comforted toknow that the appearance of the hairimproves with time.

SUMMARY

The differential diagnosis of alope-cia in the pediatric age group is sim-plified by the fact that 90% to 95%of the cases are caused by four majorentities: alopecia areata, telogen ef-fluvium, tinea capitis, and trichotillo-

mania. Careful examination of thescalp, hair, and historical pattern ofthe loss will usually be rewarded bythe correct diagnosis.

REFERENCES

1 . Milgraum SS, Mitchell AJ, Bacon GE, etal. Alopecia areata, endocrine function,and autoantibodies in patients 16 years ofage or younger. J Am Acad Dermatol.1987;l 7:57-61

2. Thiers BH. In: Esterly NB, ed. AlopeciaAreata Symposium. Pediatn Dermatol.1987:4:137-158

SUGGESTED READING

Datloff J, Esterly NB. A system for sorting outpediatric alopecia. Contemp Pediatr.1986;3:53-72

Guzzo C, Rabinowitz LG, Honig PJ. A head-to-toe guide to common fungal infections.Contemp Pediatr. 1 986;3:53-78

Oranji AP, Peereboom-Wynia JDR, De Raey-maecker DMJ. Trichotillomania in childhood.J Am Acad Dermatol. 1986;15:614-619

Price VH, Gunmer CL. Loose anagen syn-drome. J Am Acad Dermatol. 1989;20:249-256

Rasmussen JE. Hair loss in children. PediatnRev. 1981 3:85-90

Stroud JD. Hair loss in children. Pediatr Clin NAm. 1983;30:641 -658

Self-Evaluation Quiz

9. The four disorders responsible for 90%

to 95% of alopecia in children include eachof the following except:

A. Tinea capitis.B. Alopecia areata.C. Seborrheic dermatitis.

D. Trichotillomania.E. Telogen effluvium.

10. A 7-year-old epileptic boy on valproicacid develops diffuse thinning of his hair.His scalp appears normal, but plucked hairsshow an increased telogen count. The mostlikely diagnosis is:A. Telogen effluvium.

B. Alopecia areata.C. Tinea capitis.D. Trichotillomania.E. Loose anagen syndrome.

1 1. Each of the following is a true statementabout kerions except:

A. They are caused by a hypersensitivityreaction to a dermatophyte.

B. They form a boggy, inflammatory mass

on the scalp.C. They are associated with cervical lymph-

adenopathy.

0. Their presence indicates a need for mci-sion and drainage.

E. The recommended therapy is oral gnse-ofulvin.

12. An 11-year-old girl has scaling of herscalp, patchy hair loss, and broken hairs. Afungal infection is suggested by a KOHmount, but examination with Wood lightshows no fluorescence. The most likely di-agnosis is:

A. Tinea capitis.B. Trichotillomania.C. Traumatic alopecia.D. Telogen effluvium.E. Alopecia areata.

13. Typical findings in the loose anagensyndrome include each of the following ex-cept:

A. Hair pullsout easily.

B. Epilation is not painful.C. No prominent areas of alopecia are found.0. Hair does not grow or grows slowly.E. The appearance of the hair worsens with

time without treatment.

DEPARTMENT OF CORRECTIONS

In the article on “Hemangiomas and Spitz Nevi” published in the March1990 issue of Ped!atn!cs !n Rev!ew, the authors’ titles were reversed. DrRasmussen is a Professor of Dermatology and Pediatrics in the Departmentof Dermatology at The University of Michigan-Ann Arbor, and Dr Hartley is aprivate practitioner.