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Dr. Prober's "Managing the febrile infant: No rules are golden" (June) is an excellent review of the current knowledge about this subject. However, the article contained a misinterpretation of epidemiologic data. If a WBC less than 15,000/mL has a negative predictive value higher than 98% for bacteremia, as stated by the author, then one can conclude that less than 2% of children with a WBC less than 15,000/mL will have bacteremia. One would not conclude that less than 2% of children with bacteremia would have a WBC less than 15,000/mL.
Jonathan R. Fox, MD
Dr. Prober's article offers a rational and balanced approach to managing the feverish infant. Although there may be individual differences in handling this problem by practitioners, the administration of an antimicrobial agent (typically intramuscular ceftriaxone) without obtaining appropriate cultures first is not a good plan. The error of this method is implied in the article, as all management strategies discussed include (1) whether to perform cultures or not, and (2) if cultures have been obtained, whether to treat empirically with antibiotics or not.
However, it should be made clear that the use of an antimicrobial agent is rarely justified without first obtaining cultures (blood, urine, and/or cerebrospinal fluid, depending on the situation) in a child who has fever without localizing signs. From a patient-care perspective, such indiscriminate use of antibiotics dramatically decreases the chances of making the correct etiologic diagnosis in a child with a serious bacterial infection. From a public health perspective, it contributes to the emergence of antimicrobial-resistant pathogens in the community.
Thomas G. Boyce, MD
The author replies: I appreciate the kind words of Dr. Fox and Dr. Boyce regarding my article. I also gratefully acknowledge the issues raised in each of their letters. Dr. Fox astutely corrects my statement regarding the interpretation of the negative predictive value of a WBC less than 15,000/mL for bacteremia. If the WBC is less than 15,000/mL, the likelihood that an infant is bacteremic is less than 2%.
Dr. Boyce is correct in interpreting what I meant to imply regarding the use of empiric antibiotics in febrile infants. If, after careful consideration, the practitioner decides to prescribe antibiotics empirically, cultures should be obtained before administering the first dose. Failure to perform appropriate cultures may obscure the correct etiologic diagnosis, and excessive use of antibiotics certainly will contribute to the continued increase in antimicrobial resistance.
I am in favor of relieving pain and effecting cures in children afflicted with infectious agents. I am concerned, however, about using acyclovir in otherwise healthy children with herpes simplex virus (HSV) and varicella-zoster virus (VZV), as advocated in "Routine acyclovir therapy: Isn't it time?" (April). The article notes that there is no evidence of acyclovir-resistant strains of HSV and VZV (perhaps because most pediatricians are not consistently prescribing acyclovir). Yet I wonder if these strains will develop over time if enough physicians start prescribing acyclovir routinely, just as multiantibiotic-resistant bacterial strains have emerged because of overuse of broad-spectrum antibiotics. Use of acyclovir seems valid for treating children who have a severe case of HSV gingivostomatitisif only I had a crystal ball that told me which children with mild stomatitis would develop severe necrotizing disease.
Dennis Boardman, MD
I enjoy articles that challenge current thinking, such as the one on acyclovir therapy. In this age of resistance to antimicrobial therapy, however, I wish that the authors had approached their subject more carefully. It is irresponsible to use antimicrobials for minor, self-limited infections without considering the impact of this use on the future efficacy of the medication. I was very disappointed that the article failed to address how increased use of acyclovir might affect development of resistance to the medication. Will treating herpetic whitlow with acyclovir today mean that we will be unable to treat herpes meningitis with this medication in the future? I am not willing to make that trade-off.
Thomas Huffer, MD
Green Bay, WI
The authors reply: We waited 17 years (the duration of the acyclovir patent) before writing the article on the expanded use of acyclovir. During those 17 years, more pathogenic resistant strains of herpes simplex virus types 1 or 2 or varicella-zoster virus have not emerged in otherwise healthy individuals treated with acyclovir. The patients include many young adults with recurrent genital herpes infections who have received suppressive treatment for a decade or more. Despite the fact that acyclovir is prescribed more frequently in some European countries than in the US, virulent resistant strains have not emerged there. Appropriate references to this important issue were included in our bibliography. In summary, two university physicians based the opinions expressed in the article on a collective 34 years of experience with acyclovir. In addition, we contacted numerous community pediatricians to see if they had reached the same conclusions we did. As described in our article, we were particularly impressed by the account of one physician who used acyclovir to prevent outbreaks of herpes gladiatorum among the athletes in a highly ranked varsity wrestling program in Iowa. Unlike some, however, we do not advocate the over-the-counter sale of acyclovir.
Although I concur with Dr. Green's recommendations for handling talk of suicide in "Behavior: Ask the experts" (May), I would suggest an additional consideration before concluding that the statements of both young boys warrant a referral to a specialist. I do not mean to make light of a child's expressions of a death wish, or of a parent's concern about it. On the other hand, children, especially young children, "try on" ideas. They frequently lack an appreciation for the significance of a comment they've expressed. When a child makes what, to an adult, sounds like a dangerous statement, a valuable first response is to explore what the child means, rather than to react as if it came from the mouth of an adult.
"Trying on" an idea may result in a normal expression of longing and sorrow masquerading as a death wish. Understanding the significance of a child's statement can spare a family the additional anxiety that referral to a specialist entails.
The two scenarios presented strike me as warranting different levels of concern. The 5-year-old who wanted to "see his grandfather again"could just be expressing a natural longing to reconnect with his grandfather. It is important for his parents to know that such expressions of sorrow may be normal. Parents can learn to give children permission to feel their feelings without giving permission to act on those feeling.
A low-key, inquiring, empathic, and value-laden statement, made by a physician or a family member, may accomplish more than upping the ante with referrals. A response such as: "You miss Grandpa, don't you. We all do. But people should not kill themselves. It's not right. Dying is something that happens because it can't be helped. If you ever killed yourself, it wouldn't make Grandpa happy; it would make him terribly unhappy. And I would miss you too much to bear it. Maybe we can write a letter to Grandpa to say what you want to say to him." Follow-up by parent and physician could ascertain whether this reaction was adequate to allow the child to move forward in his ability to process his grandfather's death.
The second child, the 4-year-old who lost his father unexpectedly and has already been through a year of grief counseling but is still talking about killing himself, not just to "see" his father but to "be with him," arouses greater concern for me. On the basis of the limited facts provided, I would not hesitate to refer this child. This does not preclude helping the parent respond to the child's feelings without validating the suicidal component.
Ruth Frank, MD
The author replies: I wish to thank Dr. Frank for her thoughtful letter concerning the pediatrician's role in helping children master the impact of the death of a parent, grandparent, other family member or friend. In the developmental surveillance of a bereaved child, the pediatrician, guided by the subsequent adaptation of the child to this major stressor, is prepared to intervene constructively when one of the "red flags"of maladaptation enumerated in my response are reported. These include, of course, more than talk of suicide. The psychologic availability and perceptible competence of the pediatrician who submitted the question, Dr. Stewart Barbera, permitted these mothers to share their concerns. Those qualities, and the sensitivity evident in Dr. Frank's letter, help explain why parents, as well as children, develop a very special and supportive relationship with their pediatricians.
"Bang, bang. You're dead" (Updates, July) discusses children and gun safety and concludes that the education program being reviewed is not effective. The National Rifle Association's Eddie Eagle program works very well, teaching children never to handle guns that they might find in their homes. The ABC News broadcast of April 6, 1998 (ABC transcript 8228) reviewed a study performed with a one-way mirror, real disabled guns, and play guns. The children who participated in the Eddie Eagle program tried to alert an adult about the guns while the untrained children played with all of the guns. Anyone interested in the program should contact the NRA at 230-828-6000.
In the same issue, Behavior: Ask the Experts, included a discussion of cross-dressing and homosexuality. Drs. Jellinek and Rodgers feel that trying to change a person's sexual orientation from homosexual to heterosexual may be futile, cause "shame and guilt," and "damage the child's self-esteem." I refer readers to a book entitled Coming Out of Homosexuality by two former homosexuals, Robert Davies and Lori Rentzel, Westmont, IL, InterVarsity Press, 1993. Other information may be obtained from Focus on the Family, an organization with headquarters in Colorado Springs, CO 80995.
I have a simpler cure for cradle cap than Cetaphil cleansermentioned by Dr. Paula Schreck in her Clinical Tip. Combing small amounts of olive oil (light to extra virgin) through a child's hair at night is a good solution. This cure, which is cheap and safe, will rid the child of this nuisance.
Emilio Del Valle, MD
Fort Myers, FL
Iris Rosendahl. Letters. Contemporary Pediatrics 1999;11:19.