The Wheezing Child

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The Wheezing

Child

Gary

S.

Rachelefsky, MD

From the Department of Pediatrics, Division of Allergy/Immunology, Universiy of California at Los Angeles, Allergy Research Foundation, Inc, Los Angeles

ABSTRACT. Asthma self-management is a new concept.

Asthma Care Training for Kids (A.C.T.) was developed

at the University of California at Los Angeles (UCLA);

its concepts have been incorporated into the daily

man-agement of the asthmatic child. The child is allowed to

be in the driver’s seat, to have some control of his or her

disease. Using the colors of the traffic signals-red, yel-low, and green-pediatricians teach children about their

symptoms, aggravators, and medications. The children

keep daily diaries, which result in better control of

dis-ease, along with increased compliance. Causes of asthma

are presented, pediatricians are advised to explain to their

patients and the parents the concept of hyperreactive

(“twitchy”) airways; that is, asthma can be caused or

aggravated by many things, including allergens, infection,

and exercise. Proper home management is detailed, in-cluding environmental control. The use of antiasthmatic medications is stressed, especially the side effects.

Pedi-atrics 1984;74(suppl):941-947; asthma self-management, Asthma Care Training for Kids, environmental contro4

bronchodilators, cromolyn sodium.

In this paper, I will present my educational ap-proach to the pediatric patient with asthma,

includ-ing the steps involved in teaching asthma

self-management, and I will provide answers to a

num-her of the questions about asthma that are com-monly asked by patients and their parents. The

emphasis is on the patient (especially the patient

more than 6 years of age) because in order to achieve optimal compliance and disease control, the physician must communicate with the individual who has the disease and must take the medication. Of course, the physician must communicate with the parents, but the child should be included in all

Part of this material has published (Lewis CE, Rachelefsky G, Lowis MA, et al: A randomized trail of A.C.T. (Asthma Care Training) for kids. Pediatrics 1984;74:478-486).

Read before the Symposium on Pediatric Patient Education: Challenge for the 80s, Dallas, Nov 29-30, 1983.

Reprint requests to (G.AR.) 11645 Wilshire Blvd. Suite 600, Los Angeles, CA 90025.

American Academy of Pediatrics.

discussions. Hopefully, this paper will provide

guidelines for pediatricians in communicating with (not speaking down to) patients and their parents.

ASThMA SELF-MANAGEMENT

Since 1978, I have been involved in the

develop-ment of a program to enhance and promote

chil-then’s self-management of asthma: Asthma Care training for Kids (A.C.T.). (Asthma Care Training for Kids was developed with the support of CIRID (Center for Interdisciplinary Research in

Immu-nologic Diseases) at UCLA, National Institute of

Allergy and Infectious Diseases, and the Allergy Research Foundation in conjunction with Charles

Lewis, MD, Mary Ann Lewis, RN, PhD, and Ann de la Sota, MA.) This program is based on the

following principles: The child must be an active

participant in preventing and controlling symp-toms. The child must be able to detect initial symp-toms and know the appropriate action to take in order for a therapeutic plan to be effective. Children

and parents should be treated as equal partners in the learning and caring process. Activities involving the child must result in the learning of skills that, when applied, increase his or her sense of mastery of the disease. Parents should be taught skills in nurturing and in creating a home environment in which children can practice decision making in caring for themselves.

The content of A.C.T. revolves around the theme “You’re in the driver’s seat,” which emphasizes that asthmatic children can take charge of their disease, rather than have it be in charge of them. To fadili-tate learning, an analogy is drawn between

main-taming health and maintaining and safely driving an automobile. A key concept in safe driving is

recognizing and obeying traffic signals-green for

go, yellow for caution, and red for stop. In the A.C.T. program, daily control of asthma symptoms means taking medications color-coded green, to

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symptoms develop, it is time to slow down and to take a more cautious approach, which involves tak-ing medication color-coded yellow. When more se-vere symptoms occur, it is time to take medication color-coded red, to stop the episode. In addition to using color-coded medication, children color-code their degree of sensitivity to various allergens and irritants.

I have incorporated the principles and methods of A.C.T. into the care of my asthmatic patients. They are taught the symptoms of nasal allergy and asthma, and the sequence of symptoms that leads to an attack (so that they will learn when to in-crease medication and/or take various actions to prevent its culmination). All medications are dis-cussed in terms of red, yellow, and green. The children are allowed (in most cases) to have control of their own medications. This is most important in single-parent families and in families in which both parents are employed. Environmental control

is stressed; telling the children and their parents

how bad cigarette smoke is or how difficult it is to control asthma when the children play with a cat makes such control a reality. This approach has

been more effective than just telling these things to parents or just providing a lot of dos and don’ts.

Essential to self-management is a form of daily monitoring of disease. The children accomplish this by keeping a daily diary and taking peak-flow

mea-surements. The diary uses the colors red, yellow,

and green to indicate severity. Red means a lot of

symptoms, yellow means moderate symptoms, and green means a perfect day. When two or three red

days occur in a row, it is time to call the doctor.

Peak flows should be performed two to three times a day, using an inexpensive peak-flow meter. This provides an objective measure of airway obstruction and serves as an early warning signal of worsening disease.

With this “nonmedical” management, I have found it much easier to communicate with, and control the disease of, my patients. It may take a little extra time, but it is worth it. For this approach to be successful, the child must be included in all facets of education and care.

COMMON QUESTIONS ASKED BY CHILDREN

WITH ASThMA

The following are some of the questions that children with asthma ask me. The answers are simplified and should be the way you communicate with your patients and their parents.

What Is Asthma?

Asthma is a disorder of the bronchial tubes

char-acterized by an abnormal “twitchiness” of the large and small airways to multiple stimuli, leading to widespread narrowing that may change in severity. It is a reversible obstructive disease.

What Are the Causes

of Asthma?

In answering this question, I again emphasize that asthma is reversible airway obstruction. The causes of such obstruction in children include al-lergy, viral respiratory infections, bacterial sinus-itis, irritants, changes in the weather, exercise, gas-troesophageal reflux, stress, and drugs.

Because these causes are important for patients and parents to understand, I often answer this question in considerable detail. The physician should continue to emphasize that allergens are not the only cause of asthma and that stress is rarely a factor.

Allergy. Allergic asthma is caused by an imme-diate-type hypersensitivity reaction to allergens that usually are inhaled but occasionally are in-gested. It is mediated primarily by immunoglobulin (IgE). The majority of asthmatic children more than age 5 years will have evidence of an allergic basis for their condition. Common inhaled allergens include pollens (grasses, weeds, trees), molds

(fungi), house dust (house dust mites), and house-hold pets. Foods are rarely a major cause of asthma, although they may contribute to it, especially in the infant less than 1 year of age.

Infection. Respiratory viral infections, in contrast to bacterial infections, commonly precipitate

at-tacks of asthma. Asthmatic or wheezing bronchitis

is a term used to designate single or recurrent

attacks of airways obstruction associated with these respiratory infections. Asthmatic attacks in chil-dren less than age 5 years (whether they are allergic or not) are most frequently due to these infections. In fact, many asthmatic patients in this age group are not allergic, although most come from families with allergic respiratory disease. The attack begins with a typical upper respiratory infection of one to two days’ duration followed by coughing and, within another 24 hours, overt wheezing. The temperature is usually elevated (greater than 38.3#{176}C(101#{176}F)).

The mechanism(s) by which viral respiratory in-fections trigger wheezing is unknown. Proposed mechanisms include enhanced sensitivity of the irritant receptors in the upper airways, increased

interferon production leading to mediator release from mast cells, production of IgE antibodies to the causative agent, and the development of cell-medi-ated reactivity to the viral antigen.

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airway obstruction truly “outgrow” their disease when their airways become larger, and they stop having frequent viral illnesses. Although up to 25% of these children may become allergic asthmatics, there is very little one can do to prevent this from occurring, except maybe to enforce strict environ-mental control, especially with regard to cigarette smoke and pets.

Sinusitis. A recently recognized aggravator or cause of asthma is inflammatory disease (usually bacterial infection) of the paranasal sinuses. It is mostly the maxillary sinus that is involved. Char-acteristically, these children have prolonged cough-ing (especially at night), persistent rhinorrhea, sore throat, and difficult-to-control wheezing. The

di-agnosis is best made by a Waters’s view roentgen-ogram of the paranasal sinuses. Treatment consists of 2 weeks of therapy with amoxicillin or trimeth-oprim/sulfamethoxazole and erythromycin. It

should be noted that there are children who wheeze only because they have sinusitis-if you treat the

sinusitis, the wheezing will be “cured.” The mech-anism(s) by which inflammatory disease of the sinuses causes lower airway obstruction is

un-known.

Exercise. Exercise-induced asthma occurs in 90% to 95% of children with asthma and 40% to 50% of children with allergic rhinitis. Characteristically, exercise-induced asthma starts five to six minutes into exercise and is manifested by cough, chest tightness, chest pain, and other symptoms that lead one to stop exercising. Within another two to five minutes, airway obstruction increases (manifested by wheezing, increased cough, and the like), which may resolve spontaneously in 20 minutes or may last for hours and even lead to status asthmaticus. Exercise-induced asthma is more severe when the air is polluted, dry, and cold; it is milder when it is warm and humid. Exercise-induced asthma is most commonly associated with free running; it is some-what associated with bicycling; and it is unusual with swimming.

Children with asthma should not avoid exercise (which they frequently do), and they should not be excused from physical education. Appropriate

phar-macologic management (an inhaled adrenergic agent and/or inhaled cromolyn sodium) should be instituted to allow the child with exercise-induced asthma to participate in normal activities.

Irritants and Changes in Weather. Because all asthmatics have hyperreactive (“twitchy”) airways, they should avoid irritants such as cigarette smoke, smog, hairsprays, insect repellants, and paint. One isn’t allergic to these irritants-they act as aggra-vators of the already abnormal airways. It is not uncommon for asthma to worsen with abrupt

tem-perature or barometric changes, with the onset or end of rain, or with windy days. Even entering or leaving an air-conditioned room can precipitate an attack.

Drugs. Aspirin-induced airway obstruction has been observed in 10% to 28% of children with chronic asthma, many of whom had never con-nected difficulty in breathing and other symptoms with their use of aspirin. Other nonsteroidal anti-inflammatory agents as well as tartrazine (Food and Drug Administration yellow food dye No. 5)

may also cause wheezing in the aspirin-intolerant

patient. Aspirin intolerance is sufficiently common in the asthmatic child to warrant avoidance unless it is needed to treat rheumatoid arthritis. Acet-aminophen appears to be a safe drug, although there have been a few cases in which aspirin-sensitive individuals also showed cross-reactivity to acet-aminophen. The mechanism of aspirin-induced asthma is not related to allergy but appears to be related to an adverse effect on endogenous prosta-glandin synthesis. Successful aspirin desensitiza-tion has been reported in some aspirin-sensitive adult asthmatics.

Gastroesophageal Reflux. Although a discussion of gastroesophageal reflux (GER) and asthma is beyond the scope of this paper, gastroesophageal reflux should be considered in cases of difficult-to-control asthma, especially if the disease is worse at night, if the patient is intolerant of theophylline, if the patient has frequent episodes of vomiting (es-pecially at night), or if the patient has repeated

bouts of atelectasis and/or pneumonia.

What Are the CIiniaI

Manifestations

of Asthma?

There is no one clinical picture that describes all children with asthma. An attack may be acute or insidious. Attacks associated with viral respiratory infections have a slow onset: one to two days of rhinorrhea, cough, and low-grade fever usually pre-cede overt wheezing. Although wheezing is gener-ally considered to be the sine qua non of asthma, in many children chronic or intermittent cough is the sole manifestation of their airway disease. They

usually complain of a dry cough that gets worse at

night, with exercise, and with temperature changes. During a severe attack, there is increased cough-ing, dyspnea, and wheezing, with associated prolon-gation of the expiratory phase of respiration. The child will be pale, apprehensive, sitting forward, perhaps visibly cyanotic. The use of accessory

mus-des (especially the sternocleidomastoids), the

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and the chest is held in an inspiratory position.

Complaints of a sore neck, throat, or shoulder could be an indication of the presence of subcutaneous air. This may be associated with pneumothorax or pneumomediastinum, conditions that can be

life-threatening. The physician should feel the neck

and the mediastinum of all children with acute

asthma to rule out the presence of extraneous air.

When Should the Physician Be Called?

This is a difficult question to answer. I tell my

patients and their parents to call me when they are concerned. Those who keep daily diaries call me when they are into their second red day. Patients (and their parents) should learn to recognize situ-ations that require being seen by the doctor (see Table).

What Medications Are Use to Treat or Prevent

Asthma?

This section is written the way I explain the use of medications to children and their parents. Parts may appear to be very simple. However, I have found that the message is understood; it works. Please refer to the general references for amplifi-cation regarding specific medication, doses, and side effects. The drug categories used are theoph-ylline, adrenergic agents, cromolyn sodium, corti-costeroids, and other medications.

Theophylline. Varius theophylline preparations

are available, in which the drug is the active and, in most cases, the only ingredient. There are quick-release preparations that must be given every six

hours, and there are sustained-release preparations that can be administered every eight to 12 hours. The exact interval needs to be determined by the physician. There appears to be little clinical differ-ence among the various theophylline preparations.

Blood levels of theophylline need to be obtained in all children receiving theophylline chronically in order to avoid toxicity, to allow safe increase of the dose if the patient’s condition is not clinically con-trolled, and to monitor compliance. In the treat-ment of asthma, theophylline is the only drug that can be measured in the blood. Even if the patient

is doing well, blood levels should be me4ery

3 mont ecause the clearance may chang#{232}Bl&l e s may increase (clearance decreased) when the child is given eriythromycin or cimetidine, has a viral illness, receives influenza vaccine, or has liver disease. Blood levels may decrease (clearance in-creased) with cigarette smoking and with a high-protein, low-carbohydrate diet.

The major side effects of theophyffine include insomnia, irritability, abdominal pain, vomiting, nausea, decreased appetite, and headaches (usually

intermittent). Palpitations and muscle cramping

may be observed. Seizures are rarely seen in chil-dren. In addition, I have observed a number of children receiving theophylline (even at low doses) who had problems with learning, memory, and/or concentration to the degree that it has interfered

with performance in school.

When prescribing theophylline, do not increase

the dose to high levels (>10 sg/mL) immediately;

increase the dose gradually. By doing this, imme-diate side effects will be avoided. When these occur, most parents are reluctant to use theophyffine again.

Adrenergic Agents. There are two groups of

bron-chodilators-theophylline and adrenergic agents.

Each appears to work differently, and they may be synergistic in their actions on the airways. Adre-nergic agents are available as syrups, tablets, in-jectable solutions, metered-dose inhalers, and so-lutions for inhalation therapy. There appears to be little therapeutic advantage to the three oral mod-ications (albuterol, metaproterenol, and terbuta-line) of relatively selective 32-adrenergic agents available in the United States. Only metaproterenol is approved for children less than age 12 years. Oral

adrenergic agents may be used regularly to control

asthma, or as needed to treat intermittent symp-toms. The metered-dose inhalers (metaproterenol, albuterol) are used to treat an acute attack at home or while camping, and can be used to prevent ex-ercise-induced asthma. A metered-dose inhaler should never be prescribed without showing the child how to use it and how often it should be used. Effectiveness may be increased by usin a spacer oiacliaiir. e every effort to prevent a

psy-TABLE. Symptoms or Situations That Require Visit to Pediatrician

1. Persistent coughing and/or wheezing that is unresponsive to oral medications 2. Vomiting that prevents administration of oral medications

3. Difficulty in sleeping because of wheezing, trouble breathing, or coughing

4. Difficulty in speaking because of respiratory distress 5. Fever

6. Chest, neck, or throat pain

7. In the child receiving theophylline: gastrointestinal side effects, loss of appetite,

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chological dependency on these inhalers. Nev .

dude a refill with the original inhaler, and

given.

The side effects of the adrenergic agents, espe-cially when administered orally, include hyperactiv-ity, tremors, headaches, nervousness, difficulty in sleeping, muscle cramps, and difficulty in concen-trating.

Cromolyn Sodium. Cromolyn sodium (Intal) is available as a powder (20-mg capsule) and as a 1% solution (containing 20 mg). This medication does not treat wheezing-it prevents it. The powder is inhaled with a special device called a Spinhaler.

Because a Spinhaler makes a noise when ume children do not want to use it in school; however, initially it should be used four times a day.

The solution is administered by a power-driven

nebulizer and is best suited to the young child who cannot use the Spinhaler properly. When taken as a soluti n with the nebulizer, cromolynmis

combin with an adrineic so1tiiiTovie preventive and a therapeutic agent.

and rarely produces systemic side effects. A small number of patients have developed hypersensitivity reactions. Sometimes the powder may cause coughing or some

throat irritation The major problem with cromolyn

sodium is compliance, which can be reinforced eas-ily. Frequently, I use cromolyn sodium as the sole preventive drug in the chronic asthmatic; it pro-duces fewer side effects than theophylline or the adrenergic agents. Cromolyn sodium appears to be as effective as theophylline. Through the use of the solution, there is enhanced ability to control the

toddler with chronic asthma, because such patients frequently cannot tolerate or will not take oral medication on a daily basis.

Corticosteroids (“Steroids”). Corticosteroids

should be reserved for treatment of asthma that has gone out of control; they allow bronchodilators to be more effective. Sometimes, only corticoste-roids can control a child’s asthma. In that case, it

should be used as a short-acting agent at the lowest dose necessary to control symptoms, and the dose should be administeredevery other mornin

Using steroids for three to we ys produces no significant side effects, but physicians should never allow their patients to control the use of steroids. All physicians should be aware of the side effects associated with the chronic use of corticosteroids.

Inhaled corticosteroids (beclomethasone dipro-pionate is the only one currently available in the

United States) are an adequate substitute for the oral form when chronic administration is indicated. It should be remembered that inhaled steroids are a prophylactic form of treatment: they do not stop

wheezing’, they prevent it. The major side effects of

roids when inhaled at the recommended dose cluded sore throat, hoarseness, and oral candidi-asis. Patients can prevent the last by rinsing the mouth after use.

Additionally, it should be remembered when pre-scribing corticosteroids that both theophyffine and an adrenergic agent should be used in conjunction, in maximally tolerated doses.

Other Medications. Antihistamines are used to

treat allergic nasal disease. They do not make asthma worse; there is no evidence that they dry lower respiratory tract secretions. In fact, antihis-tamines may help control the symptoms of the asthmatic child by decreasing the postnasal-drip-induced cough that will frequently lead to broncho-spasm.

lodides have never been shown to be effective

expectorants and have no place in the treatment of childhood asthma because of their potential side effects.

Fixed-dose bronchodilators, in the past the main-stay of therapy, have lost their usefulness. They

contain theophylline (a set dose), an adrenergic agent, and a “calming” agent or an expectorant. The set dose of theophylline allows for limited tailoring of therapy, and the adrenergic drug

(ephedrine) is relatively ineffective and has more side effects than the newer agents.

MANAGEMENT OF ASThMA

The scientific management of asthma consists of three approaches: avoidance of known precipitating factors (environmental control), immunotherapy (“allergy shots”), and pharmacologic therapy.

Environmental Control

It is essential that allergens or irritants deter-mined by the patient’s history and/or skin tests be eliminated or avoided. It is important to remain flexible and reasonable, always weighing the poten-tial benefit against any adverse psychological con-sequence. For example, it may be very difficult to recommend that a family not keep the household pet.

It is important that the bedroom, where the child spends much of his or her time, be kept dust-free. Vaporizers should not be used, as they may result in the formation of molds. Pillows, comforters, or

furniture that has down or feathers should be avoided. Water leaks should be repaired. There should be no cigarette smoking around the asth-matic child.

Immunotherapy

Immunotherapy is indicated in patients who are

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or eliminated from the child’s environment and in patients who have failed to respond to adequate pharmacologic therapy. Although there is evidence that this form of therapy is effective for allergic rhinitis, its use in the treatment of asthma is con-troversial. Immunotherapy involves the repeated injection of increasing amounts of the allergens to which the child is allergic. Although the optimal dose is arbitrary, patients receiving maximally to!-erated doses of allergens will (probably) achieve the greatest benefit. After the maximal dose is achieved, the interval between injections should be spaced out so that by 18 months so that injections are given every 6 weeks. It may take 12 to 18 months to realize the effectiveness of such therapy. Injec-tions should be continued for at least 3 to 5 years.

As discussed above, many nonimmunologic

fac-tors affect the airways, so that it is unlikely that immunotherapy will completely eliminate all symp-toms. This point must be made to all patients and their families before such therapy is started. There is no place for immunotherapy in the treatment of wheezing caused by viral illnesses. Bacterial vac-cines or food antigens should be avoided.

Pharmacologic Therapy

In the child who has occasional attacks of asthma, the cause is often an upper respiratory tract infection, exertion, or contact with a particu-lar allergen (such as a cat or dog). Mild wheezing can usually be controlled by oral theophylline or an adrenergic agent administered orally or by inhala-tion. The young child will tolerate ral adrener-gic agent better t an theophylline. In the older

child, or one with severe symptoms, the combina-tion of adr#{241}iic drug and theo hylline should be used. Cr yn so um may be helpful if used prior to an anticipated exposure to a known allergen or prior to exercise. Some parents can be taught to give epinephrine at home, with the clear under-standing that only two injections, 20 minutes apart, should be given for an acute attack. If there is no immediate improvement, the patient should be seen at the physician’s office or in an emergency room.

In the child who has chronic asthma, the goals of long-term drug management are to prevent re-current attacks or persistent symptoms and to achieve normal pulmonary function. The child must be able to function normally: not miss school, participate in sports, and sleep through the night.

The exact management of the child who needs to take medication daily is somewhat controversial.

Because of the frequent side effects noted with daily

high doses of theophylline, I prefer to use cromolyn sodium by itself or in conjunction with either low-dose oral theophylline, an oral adrenergic agent, or

an inhaled drug. The last is preferable with Intel. This combination is free of side effects.

When exacerbations occur in children with chronic asthma, short courses of oral prednisone (2

mg/kg/d for three to five days) are given. The oral

administration of corticosteroids in patients who are not hospitalized is avoided by many physicians, but such treatment is useful for short periods, en-abling easier control of the airways, facilitating the response to other agents, and frequently averting emergency room visits and hospitalization.

When the child with chronic wheezing is not relieved by the above agents, inhaled corticosteroids (beclomethasone dipropionate) should be consid-ered. Remember that use of the other antiasthmatic

drugs should not be discontinued when beclometh-asone is added to the therapeutic regimen.

EMERGENCY ROOM CARE

In the emergency room, initial care should be the

administration of epinephrine by injection or an

aerosolized adrenergic agent. The unpleasant side effects of epinephrine can be minimized if doses of no more than 0.2 to 0.3 mL are administered. A nebulized adrenergic agent appears to be more ef-fective.

The advantage of aerosol preparations is that substantially less drug is required; accordingly there are fewer side effects. Metaproterenol appears to be the most effective agent, with the fewest side ef-fects. A power-driven nebulizer is the method of choice; intermittent positive pressure devices are no more effective and occasionally may be hazard-ous by increasing airway resistance or because of their potential to induce or worsen pneumothorax or pneumomediastinum. If the patient responds to the initial epinephrine or aerosol therapy, an injec-tion of long acting epinephrine (Sus-Phrine) or terbutaline (in the child older than 12 years of age) may maintain bronchodilation until oral medica-tion (theophylline plus an adrenergic agent) be-comes effective.

If the wheezing is not relieved by the above measures, aminophylline and hydrocortisone are administered intravenously. If there is improve-ment during the next six hours, the child is sent home with around-the-clock medications, including oral corticosteroids. If there is no improvement, the child is admitted to the hospital.

EXERCISE-INDUCED ASTHMA

Exercise-induced asthma is best treated by the

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by using oral theophylline or an oral adrenergic agent.

SUMMARY

In my educational approach to the wheezing child and his or her parents, the concept of asthma self-management, along with a form of home monitor-ing, is central. The pediatric patients are taught about the medications they are using or will use in the treatment of their asthma.

SELECTED READINGS

1. Godfrey S: Childhood asthma, in Clark TJH, Godfrey S (eds): Asthma. London, Chapman and Hall Ltd. 1977, p 324

2. Pearlman DS, Bierman CW: Asthma, in Bierman CW,

Peariman DS (eds): Allergic Diseases of Infancy, Childhood and Adolescence. Philadelphia, WB Saunders Co, 1980, pp 581-604

3. Siegel SC, Katz RM, Rachelefsky GS: Asthma in infancy and childhood, in Middleton E Jr, Reed CE, Ellis EF (eds):

Allergy: Principles and Practice. St Louis, CV Mosby, 1978, pp 708-742

4. Siegel SC, Rachelefsky GS, Katz RM: Pharmacologic man-agement ofpediatric disorders. Curr PmblPediatr 1979;9:1-76

5. Self-management Educational Programs for ChildhOOd

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1984;74;941

Pediatrics

Gary S. Rachelefsky