Letters of special interest to pediatricians from our readers.



Too old to breastfeed?

Dr. Barbara Howard's answer to Dr. Mario Sangillo's questions about a mother who is tandem nursing a newborn and a 4-year-old (Behavior: Ask the experts, October) implied that there was something abnormal about a 4-year-old child nursing when, in fact, it is quite normal and natural. The worldwide weaning age is 2 to 4 years, but breastfeeding until the child is 4 to 6 years is not unusual. Most mammals nurse their young until the permanent teeth begin to erupt—and in humans this would be about age 4 to 6 years. Our western society has shortened the normal nursing period to one year.

Plenty of studies in the medical literature demonstrate that children benefit from the immune protection of human milk as long as they are breastfed. Breastfeeding a toddler/preschooler provides needed nurturing, not dependence, as well as immune protection.

The mother is doing what is best for both her children by not rushing the weaning of the older child. She should be commended and encouraged. More American mothers should emulate her!

Linda L. Shaw, MDAltoona, PA

Evidence-based medicine

I was a bit perplexed by the article on evidence-based medicine, "Medicine for the millennium: Demystifying EBM" (December). Although we did not necessarily call it EBM, my residency training was, for the most part, based on providing treatment for patients that was supported by scientific evidence and fit into the patient's sociocultural environment. I have always assumed that was the point of modern medicine. Otherwise, we might as well be selling snake oil (or treating green rhinorrhea with amoxicillin). I was surprised to find that there is a system to help people do what I thought we were already supposed to be doing.

Kurtis L. Sauder, MDStaunton, VA

The authors reply: The principles behind EBM are certainly not new. We all strive to bring external clinical evidence into practice (by subscribing to journals and attending CME courses, for instance), but the wide variations in how individual physicians practice and the inconsistencies in the care patients receive suggest we are not always successful. For example, the likelihood that children will receive anti-inflammatory therapy for their asthma can vary threefold based on which city they live in. Practices such as the use of antenatal steroids for women in preterm labor and endorsement of the supine infant sleep position have been delayed despite good evidence supporting them.

With a 7% annual increase in an already astronomical number of biomedical publications, it is inconceivable that any of us can keep up-to-date with reading journals and the latest textbooks. Fortunately, the now ubiquitous desktop computer can give us ready access to electronic databases and enable us to obtain information in a systematic fashion that is both comprehensive and current. As Dr. Sauder suggests, EBM is a system (a paradigm) that stresses critical thinking about daily decisions and provides the tools to inform that process.

Lloyd N. Werk, MD, MPHOrlando, FL

Howard Bauchner, MD
Boston, MA

John B. Chessare, MD, MPHBoston, MA

Another opinion about the NRA

I have enjoyed your journal tremendously, but I was surprised and dismayed by the Letter to the Editor from Joseph R. Asiaf, MD (November). With his touting of a National Rifle Association program and a book that claims to change a person's sexual identity, his is clearly a conservative/right-wing agenda which I find offensive. The reason I write, however, is actually far more important. I am concerned that the advice he urges readers to follow derives from political propaganda (the NRA) and an anecdotal account (the book by two former homosexuals) rather than scientific data.

What has the field of pediatrics come to when we read in one of its most informative journals a recommendation to use a gun safety program developed by the organization that has repeatedly thwarted legislation that would keep kids safer from gun violence? And next time, I would rather see a reference to a study than a reference to the ABC news program that reviewed a study claiming that the NRA program works. Pediatrics works best when it listens to evidence, not propaganda, especially from a political organization that has a track record of far more harm than help to kids.

I would also like to know why a journal that has done such a good job of promoting acceptance of homosexuals should print a letter referring to a book that presumably teaches our teens to change who they are. It's alarming that there's a physician out there who would take the anecdotal advice of "two former homosexuals" and a fundamentalist organization, Focus on the Family, rather than the reasoned expertise of Drs. Jellinek and Rodgers. Let's hope he has not persuaded others to do the same.

Eliana M. Perrin, MDStanford, CA

The Editor-in-chief replies: The concern expressed by Dr. Perrin is likely shared by many of our readers. I suspect, however, that Dr. Asiaf is not alone in his opinion, either. Letters to the editor provide a means for readers to react to the content of this publication. We do not censor those opinions, and we hope that readers will ultimately benefit from the exchange of ideas the letters provide.

Julia A. McMillan, MD Baltimore, MD

Treatment of otitis media

"When amoxicillin fails," by Richard Linsk, MD, PhD, Janet Gilsdorf, MD, and Marci Lesperance, MD (October), is very informative and discusses the latest recommendations for the treatment of otitis media. I do have one concern that needs clarification. The data in Table 2 imply that cefpodoxime and cefuroxime axetil both provide excellent coverage against Haemophilus influenzae and Moraxella catarrhalis. However, it appears that cefpodoxime has a slight edge over cefuroxime axetil against penicillin-resistant Streptococcus pneumoniae. The article states that cefuroxime appears to be the best oral cephalosporin for treating otitis media caused by PNSSP. This viewpoint seems to parallel the Centers for Disease Control and Prevention recommendations regarding cefuroxime axetil as a good second-line agent. I am curious if Dr. Linsk's research grant from Glaxo Wellcome contributed to the authors' favoring cefuroxime axetil over cefpodoxime.

Robert J. Gadawski, MDNiagara Falls, NY

The authors reply: The conclusions of the CDC working group were based on the best information available at the time of publication. Their recommendation of oral cefuroxime rather than oral cefpodoxime was based largely on the relative lack of documentation that the recommended dose of cefpodoxime attains therapeutic middle ear concentrations in patients. The data shown in Table 2 are adapted from in vitro measurements of minimum inhibitory concentrations, and, as stated in the footnote, should not be interpreted as predictive of clinical outcomes. The major intention of the table was to point out the theoretical advantage of high-dose amoxicillin over any oral cephalosporin for the treatment of resistant pneumococcus.

For practical purposes, cefuroxime, cefpodoxime, and the new oral third-generation cephalosporin, cefdinir, are clinically equivalent. We do not believe that we favored either cefuroxime or cefpodoxime in our recommendations (in contrast to the CDC guidelines). Any of these agents would be a good choice in a patient with a history of amoxicillin-unresponsive otitis media or in a child with a history of amoxicillin/clavulanic acid intolerance or "amoxicillin allergy" (not amoxicillin-induced anaphylaxis).

The main point of the article, however, is that antibiotic choice has a limited impact on the outcome of empirically treated acute otitis media, and that patience, realistic expectations, and ibuprofen are often the best medicine.

Richard Linsk, MD, PhDJanet Gilsdorf, MDMarci Lesperance, MDAnn Arbor, MI


Iris Rosendahl. Letters. Contemporary Pediatrics 2000;3:23.

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