Letters
LETTERS
A shared responsibility?
I'm not sure about the shared responsibility in reducing crime or about the multiple variables that cause the kind of crimes committed by adolescents mentioned in Dr. McMillan's editorial, "A problem we share" (July).
I grew up in a ghetto where there were cockfights and bullfights at night, drunks were sleeping on the street, police were not around, and people settled scores on their own. Teachers were not responsible for children's behavior outside of school or for instructing them on tolerance.
The seven children in my family have become responsible, hardworking adults. Our father was always away from home, making a living, while my mother brought us up. There were many temptations around, but Mother kept a sharp eye on all of us. If any one of us was late returning from school, my mother would stand on the roof of the building we lived in and ask passersby if they had seen her kid. It was a disgrace in our family to come home late or to be found loitering on the street with other kids.
I agree with Dr. McMillan that, as parents, we do share responsibility with teachers and others in our community for what happens to children, but parents must bear most of the load. No one can influence the growing child the way a parent can. No one can do a better job than a parent of instilling a value system in young children and adolescents.
Amar Dave, MDOttawa, IL
Difficulties in forming relationships
Dr. Nathan Blum has some good suggestions for helping the girl who doesn't get along with peers in "Behavior: Ask the experts" (July). This patient should also be assessed for a possible nonverbal learning disability (NLD). Children with NLD often have difficulty initially in school with reading, but usually overcome this. They continue, however, to have substantial difficulties in mathematics and social skills, especially with peers. In contrast, they do quite well socially with much older children, much younger children, and adults. Standardized testing reveals a classic pattern on the WISC-III of a large differenceoften 30 points or morebetween the verbal and performance IQ; the verbal score is higher. On the other hand, the arithmetic subtest of the verbal IQ is often quite low. A combination of academic support and social skills training, as suggested by Dr. Blum, can be useful to children with nonverbal learning disabilities.
Deborah A. Sedberry, MDWalnut Creek, CA
The author replies: I appreciate Dr. Sedberry's recommendation. The child described has been in special education in the past and is still in a special education class for math. She should have been tested for a learning disability prior to this placement. If this hasn't been done, it's certainly appropriate. Learning disabilities in general are associated with problems in peer relationships. Nearly 75% of children with learning disabilities may be rejected or neglected by their peers. The identification of learning disability subtypes is relatively new and controversial, but the identification of a nonverbal subtype described by Dr. Sedberry seems promising. It highlights the importance of understanding and using nonverbal behaviors such as eye contact, facial expressions, body movements, and the timing of interactions in forming successful peer relationships. Problems with language, attention, activity level, poor self-esteem, differential treatment by teachers, parents, or other adults, and other factors may all contribute to the difficulties with peers experienced by children with learning disabilities.
Nathan J. Blum, MD
Philadelphia, PA
A better way to remove ear wax
In response to your Clinical Tip on ear wax (December 1998), I have a suggestion. When trying to remove moist cerumen from an ear canal, I have found simple ultrafine aluminum calcium alginate fiber-tipped sterile swabs superior to standard plastic and metal curettes. The swabs are sterile, less threatening, and gentler to the ear canal, and the moist wax adheres to them readily.
They do not work as well for dry, hard, impacted cerumen, which often needs softening or irrigation. However, for the vast majority of cerumen removals, these swabs are safer and more effective than plastic and metal curettes. I encourage my colleagues to give them a try.
Mike Dubik, MDNorfolk, VA
Managing seizures
I would appreciate it if Dr. Rivera and Dr. Laureta would clarify a few points in their timely article, "Emergency management of seizures: What fits for fits" (July). Some of the literature on this subject is confusing.
First, the authors suggest that the initial step in managing a child in status epilepticus is to implement the ABCs of life support, positioning the child's head with the head tiltchin lift maneuver to maintain an open airway. This involves placing the child on his back. In a new text, Current Management in Child Neurology, Dr. John Pellock suggests turning the child on his side to prevent choking and then gently tilting the head toward the chest. You suggest placing an oral or nasopharyngeal tube if necessary to maintain the airway but Dr. Pellock says, "Never place a spoon or other object in the mouth of the child having a seizure." These two views seem diametrically opposed.
Second, J. M. Chamberlain (Pediatr Emerg Care 1997;13(2):92) endorses midazolam (Versed, 0.2 mg/kg up to 7 mg) as a valuable drug for stopping seizures. One of the virtues of this drug is that it can be given intramuscularly. However, you do not mention the drug. Do you have any experience with midazolam? How does it compare with fosphenytoin (Cerebyx) as an IM anticonvulsant?
Stephen E. Landay, MDGainesville, FL
The authors reply: We appreciate Dr. Landay's comments and questions on the management of a child having a seizure. Regarding the use of anticonvulsant agents in situations where IV access cannot be established, rectal diazepam still has the fastest and most reliable absorption profile. This should be followed by intramuscular fosphenytoin when a longer acting agent is necessary. Although Dr. Chamberlain's study endorses IM midazolam as a useful option for the initial management of status epilepticus, particularly in the prehospital setting, midazolam has not been used extensively as a first-line anticonvulsant for the treatment of status epilepticus.
Regarding how to position a patient during a prolonged seizure, in our experience in the ED it is easier to have the patient supine with the head slightly elevated as this allows access to the extremities for IV placement. The patient usually has an intact gag reflex, which helps prevent aspiration. However, in the event that the patient vomits, the head may be turned to the side. Suction should be available at the patient's bedside at all times.
We agree with Dr. Pellock that during a seizure, a spoon or other object should not be placed in the patient's mouth as this may cause severe oral injury. However, if airway and oxygenation are impaired during a prolonged seizure, then an oral airway may be necessary to maintain airway patency
Ruby F. Rivera, MDEmma Laureta, MDBronx, NY
Advice on walkers
Even though rolling walkers are not recommended by safety experts, a lot of parents still buy them. When they do, I recommend that they tether the walker to a heavy piece of furniture (like a table) with a ribbon or tie. This keeps the child from wheeling his way into danger or down the steps. The tie should be at the base of the walker, and, of course, the child still should never be left unattended.
Vernessa D. Ekelem, MDJackson, TN
Choice of antibiotic for otitis
I have always enjoyed Contemporary Pediatricsespecially the mercifully short and almost always brilliant editorials. But I'm astounded at the September issue. The editorial states, "Antibiotics, however effective they may seem at first, can arm bacteria with powerful defensive weapons," but on page 69 is a Rocephin advertisement that says, "For acute otitis media 1 dose1 day100% compliance."
We pediatricians try not to prescribe antibiotics unless they are necessary. We start antibiotic therapy for otitis with amoxicillin and move on to other drugs like Augmentin or Zithromax if amoxicillin fails. We don't start out with the "super" drugs because we don't want the bugs to develop resistance. I can't imagine a pediatrician starting a child with otitis on Rocephin for that reason. If you treat a child with Rocephin for otitis in October, what will you treat him with in December if he has periorbital cellulitis?
I am surprised you ran that advertisement. I know you have First Amendment concerns about censorship, and you have financial needs for advertising revenue. But stillsomething's not right about all this. You wouldn't run a tobacco ad or one for the World Wrestling Federation, and I'm surprised you ran one for Rocephin for treating otitis media.
E. Noel Preston, MDNorcross, GA
The Editor-in-chief replies: I appreciate Dr. Preston's kind words about the editorials, and I suspect we have similar approaches to the treatment of otitis media. We cannot, however, exclude from our advertising pages claims that have been approved by the Food and Drug Administration. We will continue to advocate constrained use of antibiotics and hope that the products advertised in our pages will be used with appropriate concern for the medical context, expense, and potential adverse consequences.
Julia A. McMillan, MD Baltimore, MD
Correction
Table 2 in "When amoxicillin fails" (October) has an error. The third column under Pneumococcus should be labeled Penr, not Pens.
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We reserve the right to edit letters for clarity and length.
Iris Rosendahl. Letters. Contemporary Pediatrics 1999;12:18.
