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I just read the Updates item"Breastfed baby starves; who is to blame?" (April 1999) This item is of particular interest to me because I was an expert witness who testified in this case. I do not refute Dr. Neifert's suggestions and comments about breastfeeding and the possible complications stemming from breastfeeding failure and consequent starvation.
In this particular case, however, the autopsy material and pathological sections, which I examined, provided unequivocal evidence of extreme hypoplasia of the adrenal glands, resulting in adrenal insufficiency and Addison's disease. This disease was the cause of extreme wasting, bronzing of the skin, particularly in the genital region, and death at 2 months of age. The medical examiner who performed the autopsy failed to recognize the actual cause of this infant's demise and attributed the death to homicide by starvation.
This case and many others in which I have testified attest to the paramount importance of a thorough pathological examination by an expert in pediatric pathology to avoid a potential wrongful conviction and the possibility of lifetime imprisonment.
Dr. Casale does a fine job of reviewing the management of diurnal enuresis in "Daytime wetting: Getting to the bottom of the issue" (February), but I think he addresses the treatment of constipation almost as an afterthought. In my experience, when constipation coexists with enuresis, as it often does, the constipation must be treated before there is any hope of correcting the urinary incontinence. In many of the cases that Dr. Casale has termed "dysfunctional elimination syndrome," correction of the chronic constipation will result in spontaneous resolution of the urinary incontinence.
When treating daytime wetting, the following should be emphasized: First, new onset enuresis requires a more urgent and complete evaluation than primary failure to develop urinary continence. Second, parents must understand that "lazy bladder syndrome" is just that and not "lazy child syndrome"; if one accomplishes nothing else at the first visit, educating parents that they are not dealing with a simple case of a "bad habit" is crucial. Last, parents need to understand that there is no instant cure. Resolution of the problem frequently takes months, and without persistent vigilance relapses are common.
David H. Austein, MDOlney, MD
The author replies: I did not intend to diminish the role of constipation in urinary incontinence. In fact, the article repeatedly stresses that relationship. I cited studies by Loening-Bauke and others to support the contention that correction of functional constipation leads to resolution of urinary incontinence in many children. Although constipation is a key element in the etiology of incontinence in children it is not the only one and my position, as the article states, is that the physician should identify and treat all contributing causes.
As to the distinction between new onset incontinence and primary failure to develop continence, the importance of this distinction depends on the age of the child at presentation and other factors such as overall development and neurologic findings. I believe that daytime incontinence is never normal past the age that toilet training is appropriate for the individual child. The article states that transitional incontinence around the time of toilet training is not an indication for detailed evaluation.
I agree with Dr. Austein that the physician should ensure that parents do not think the type of childhood incontinence termed "lazy bladder syndrome" has anything to do with their child's laziness. I disagree, however, that habits do not play a role in this problem. By definition, habits are repeated patterns of behavior. Dysfunctional voiding and functional constipation are clinical problems whose cause lies in a complex mixture of abnormal behavior and physiology. We usually attribute the child's failure to void appropriately to poor or immature decision making; this problem is corrected with classic behavioral modification. Medication improves the bladder and bowel physiology that facilitates this modification. I agree that changing this behavior is usually a long process and relapses are common.
As a pediatric dentist, I have a few comments on "Fluorides: Getting the benefits, avoiding the risks" (February), which includes some excellent information. The authors note that while consumption of fluoridated water during the first three years of life is not likely to cause fluorosis, fluorosis will result "if consumption of fluoridated water is combined with fluoride supplements or if the child swallows toothpaste during brushing." The quoted statement applies to water with optimal fluoride levels. If the water has suboptimal fluoride levels, however, fluorosis will not result. What counts is the total net amount of fluoride that is consumed.
With regard to testing well water for fluoride content, parents should be warned not to use a glass container to collect the water sample to be tested. The glass will chelate the fluoride ion, leading to a false reading.
Finally, before considering fluoride supplementation for a particular child, the pediatrician should make an early referral to a pediatric dentist (or general dentist who treats young children), if possible. By working together, these two professionals can achieve a balance between too little and too much fluoride.
Doron Kochman, DDSPittsford, NY
Where and how can parents get their drinking waterhome supply and bottled watertested for fluoride content?
Kyung Murphy, MDHampton, VA
The authors reply: Dr. Kochman makes some excellent points. The bottom line on initial fluoride assessment is the total net amount of baseline fluoride intake. All sources of fluoride should be considered to make this determination. We were unable to verify the chelation of fluoride by glass containers; the 20th edition of Standard Methods for the Examination of Water and Wastewater recommends using plastic collection containers for fluoride determinations, however.
As to Dr. Murphy's question, since fluoride is regulated by the Environmental Protection Agency, all states should have an established way to test local water supplies. The local health department may be able to supply test kits, which should include a collection bottle and instructions. Tell parents in your practice not to fill the bottle to the top to keep down postage costs.
Kevin J. Hale, DDSBrighton, MI
On page 77 of "The toxic toddler: Drugs that can kill in small doses" (March), the term "ß-adrenergic agent" at the bottom of the second column should have read "
-adrenergic agent." On page 78 at the bottom of the third column, the term "ß-agonist" should have read "
Julia McMillan. Letters. Contemporary Pediatrics 2000;6:16.