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• Past work identifying "accident-prone" children with disproportionate rates of injury has been based on clinical data gathered in office, clinic, or emergency department settings. To avoid the biases inherent in such designs, we studied recurrent injuries in a school district population, utilizing a prospective surveillance system to identify injuries meeting standardized criteria. During three school years we observed 54 874 students, ranging in age from 6 to 18 years, for recurrent injuries, which were defined as those occurring in a year in which two or more injuries were reported for the child. Five hundred seventy-three recurrently injured children (1% of the school district population) sustained 1405 injuries (17% of the overall injury experience), a proportion significantly but only slightly greater than that expected on the basis of chance alone (14%). Most recurrently injured children were injured in only a single year, with only 15 children sustaining injuries in all three study years. Age, sex, and type of school were significant correlates of recurrent injury rates, with junior high school students, boys, and students attending schools with alternative educational programs having the highest rates of injury recurrence. The findings indicate that (1) a small group of schoolchildren sustain a disproportionate share of the overall injury experience, (2) the majority of recurrently injured children experience only transient periods of enhanced injury risk, and (3) preventive strategies may benefit from investigation of developmental and social environmental factors that alter such risk.(AJDC 1989;143:338-342)

• Are children in self-care more obese, do they miss more school days, and do they make more visits to the school health office than children not in self-care? We undertook a cross-sectional survey of students in ten public elementary schools in Tucson over a two-year period in an attempt to answer these questions. The sample included 503 fifth-grade students, 137 in self-care and 366 not in self-care. Demographic information and data on school absences were obtained from school records. Physical examinations were performed at school. Obesity was assessed using the body mass index calculation, in which body mass index = (body weight in kilograms)/(height in meters)2. Every visit to the school health office during the 1985-1986 and 1986-1987 school years was recorded for each child. There were no differences in age between those in the self-care and adult-care groups. Boys were more likely to be in self-care, as were non-Hispanic children. There were no differences in weight, body mass index, school days missed, or visits to the school health office between children in self-care and those in adult care. Our findings suggest that, by the criteria used in this study, 11-year-old children in self-care do not suffer more ill health than their counterparts in adult care.(AJDC 1989;143:112-115)

• The impact of providing home care for ventilator-dependent children was studied in a cross-sectional survey of 18 northern California families. Through the use of a confidential structured interview and the Impact on Family Scale, we obtained information on family demographics; the childrens' medical conditions; financial, social, and personal impact on the family; and parental coping-mastery of the care of a ventilator-dependent child at home. Analysis of scores from the Impact on Family Scale showed no differences in the perceived family impact between primary caretakers and their spouses. Primary caretakers in the sample, however, showed significantly reduced Coping subscale scores with a longer duration of home ventilatory care. This finding, if confirmed in future studies, has policy implications for physicians and other health professionals working with ventilator-dependent children and their families, especially those who care for children over long periods.(AJDC. 1990;144:1238-1241)

• Chlamydia trachomatis is known to cause infant pneumonitis and conjunctivitis and is a suspected cause of otitis media and gastroenteritis. To identify infections associated with exposure to C trachomatis, infant illnesses were studied through a "blinded" review of medical records of 244 infants born to women cultured antenatally for cervical C trachomatis, 25% of whom had C trachomatis–positive cultures. Compared with unexposed infants, infants exposed to C trachomatis had twice the rate of both pneumonitis and recurrent otitis media in the first six months. Infants who were exposed to C trachomatis and who had pneumonitis had higher subsequent rates of gastroenteritis than either unexposed infants or exposed infants without pneumonitis. These results suggest that appreciable outpatient infant morbidity may be associated with maternal infection with C trachomatis, and that it may either cause or promote the occurrence of early, recurrent otitis media and gastroenteritis.(AJDC 1985;139:127-133)

• Serum samples from 184 Infants and children whose blood was drawn during a clinic visit were tested for antibody to Chlamydia trachomatis, Epstein-Barr virus, and cytomegalovirus. Lifetime illness history was obtained from clinic records. Fifteen percent had anti–C trachomatis IgM antibody. Anti–C trachomatis IgM without IgG was significantly associated with upper respiratory tract syndromes within the 14 days prior to phlebotomy in 6- to 10-year-old patients. This association was not due to polyclonal activation from Epstein-Barr virus infection. A definitive study of chlamydial illness in children rather than infants appears to be indicated.(AJDC 1986;140:1068-1071)

• During the seven-year period from 1976 through 1982, 2133 cervical spine radiographs were obtained for children less than 18 years of age at two hospitals in Tucson. Twenty-five children (1.2%) had x-ray evidence of a cervical spine injury, with a male to female ratio of 4:1. Vehicular accidents accounted for 36% of cervical spine radiographic abnormalities, and sports or playground accidents accounted for an additional 36%. in an attempt to find clinical predictors that might identity x-ray abnormalities, we reviewed the medical records of these 25 children with abnormalities and 713 randomly selected children without x-ray evidence of cervical spine injuries for the following: (1) method of injury, (2) presenting complaints, (3) physical examination findings, (4) therapy, and (5) complications. No single clinical predictor had a sensitivity of 100% when considered in isolation, but clinical assessment consisting of EITHER a complaint of neck pain OR involvement in a vehicular accident with head trauma would have correctly identified all 25 cases of cervical spine injury. If this information had been used prospectively, the number of cervical spine radiographs ordered would have been reduced by 32%. We conclude that the use of this clinical "marker" would have positively identified all children with cervical spine injuries and would have reduced by one third the cost and radiation exposure associated with cervical spine radiographs. Because of the serious consequences of missing a cervical spine injury, we suggest that other studies confirm these results before this information is accepted as a recommendation.(AJDC 1987;141:199-201)

I appreciate the opportunity to reflect on an issue that I believe has become critical to professional life, particularly a life in medicine. My plan for this editorial is to share a collection of thoughts on the problem of setting priorities and to examine the way in which conventional approaches to the problem have been driven by a set of tacit (and possibly misleading) assumptions.One's approach to the issue of priority setting is necessarily idiosyncratic and highly personal. Mine is based primarily on the individual experience of Tom Boyce and has little objective validity beyond the criterion of seeming true to me most of the time. Readers are therefore encouraged to view all that is set forth herein through the interpretive lenses of their own worldviews. I am no expert in the field of setting priorities, and I have struggled with these issues as long and hard as anyone

In Reply.—We greatly appreciate the letter by Binns and colleagues. We would concur that if our two-variable clinical assessment model missed even one child with roentgenographically proven cervical spine injuries, then the two-variable model should not be used to determine the necessity of obtaining cervical spine films. In our assessment, we did not distinguish between neck pain and neck tenderness, but after talking with Dr Jaffe we fully understand their reasoning in making this distinction; Dr Jaffe pointed out that there is an important distinction between neck pain and neck tenderness, as tenderness implies that the neck immobilization collar was removed so that tenderness might be elicited. Dr Binns informed us that of the eight patients in their series who would have been missed if our criteria had been used, four did not have documentation of pain or tenderness, one had neck pain but not neck tenderness, and three

• We explored the history in two children who had bizarre, hyperpigmented skin lesions suggestive of child abuse. A final diagnosis of phytophotodermatitis was established. The lesions resulted from inadvertent application of squeezed lime juice to the children's skin by their parents during the routine preparation of drinks, followed by sun exposure, which activated the applied plant psoralens (furocoumarins). Phytophotodermatitis can be induced by a number of plants, and, when unrecognized, may lead to inappropriate investigation of child abuse.(AJDC 1985;139:239-240)

In Reply.—We appreciate McMillan and Weiner's concerns about misclassification of"exposed" and "unexposed" infants and the possible consequences for the results of our study.1 We would like to take the opportunity provided by their letter to comment further on these issues, since the effects of potential misclassification may not be widely appreciated.McMillan and Weiner's first point concerns the possibility that infants born to women who received antibiotics that are effective against C trachomatis were misclassified as exposed to C trachomatis. As noted in our discussion of the results, we did not have information on the use of antibiotic therapies during the pregnancies of this group of women. However, misclassification of infants who were actually unexposed (because their mothers received antibiotics effective against C trachomatis) would exert a conservative bias on the results—that is, the associations we reported between exposure to C trachomatis and rates of pneumonitis and recurrent

Roche and Malina have compiled a truly encyclopedic collection of physical and functional status measurements in children. Their work is a three-set, two-volume series that draws from and summarizes an expansive literature on anthropometric measures and measurements of functional status in children. The first volume (1A and 1B) addresses measurements of both the body as a whole and specific body parts, and the second volume presents complementary data dealing with functional measurements, body composition, organ dimensions, physiologic data, and physical performance.In most of the measurements reported, a distribution is summarized with the use of means and SDs drawn from the original work. In addition, an excellent list of annotated references is provided for the reader who is interested in a more exhaustive version of the data. Many tables consider representative samples of US or Canadian children, whereas others provide information on childhood populations from more narrowly defined geographic locations.