Letters from our readers.
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As a general pediatrician who supervises pediatric residents, I was interested in the presentation in the October Pediatric Puzzler of the infant diagnosed with intussusception 24 hours after onset of symptoms. I note that the initial physical exam by the ER physician included a rectal examination reported as "negative with no stool in the rectal vault."
In my 45+ years as a general pediatrician, I have made the diagnosis of early intussusception in many infants with negative physical findings and brief histories of vomiting (less than 12 hours). It is essential that a digital rectal examination and Hemoccult be done. In spite of an empty rectal vault one can almost always get a minute amount of stool sufficient to do a Hemoccult test.
It is my teaching and practice that vomiting and a positive test for rectal occult blood necessitate the prompt ruling out of intussusception. I do not believe this is noted in pediatric texts or literature. Hematochezia or currant jelly stools are not seen at this early stage.
In the case presented, the diagnosis could have been made much earlier and reduction possibly could have been accomplished by nonsurgical means if a positive Hemoccult test had alerted the ER physician to the urgency of ruling out intussusception.
Samuel H. Gould, MD
The author replies: Dr. Gould makes an important point about completeness of a rectal examination. It is always important to check stool for occult blood, particularly in infants who are vomiting. The detection of occult blood should raise the suspicion of intussusception, as should, more certainly, the detection of the classic currant jelly stool. But currant jelly stools appear late. Dr. Moss did perform a test for occult blood on the smear of stool obtained on the initial rectal examination. The test was negative.
Ravitch, in the classic paper on intussusception, noted that blood, "at some time," was found on rectal examination in 91% of the 152 cases in the Johns Hopkins series (Ravitch MM: AMA J Dis Child 1952;84;17). He noted a difference in age of those with blood in the stools; 95% of patients under 2 years old vs. 65% of those over 2 years old had blood in the stools. He also noted that 60% of those who manifested blood in the stools did so in the first 12 hours after symptoms began and 37% in the first three hours. Others have reported less frequent positive stools. Bruce and colleagues noted (J Pediatr Gastroenterol Nutr 1987;6:663) that only 16% of the 583 patients in their series had detectable bleeding if symptoms were present for less than 12 hours.
The lack of blood on rectal examination should not be used as an intussusception "rule out." The presence of blood, even if occult, in the vomiting or lethargic child, should move the possibility of intussusception farther up on the diagnostic list. Dr. Gould's point is well taken.
Walter W. Tunnessen, Jr., MD
Dr. Gorski's response to a toddler who won't share toys discussed in Behavior: Ask the experts (October) gave several helpful suggestions regarding this common problem. An approach that I have used professionally and personally (with my three children when they were toddlers) is to allow the child, before the friend arrives, to put away any toys that he or she doesn't want to share that day. The child would usually choose a favorite security object as well as a few other toys. We would put those toys safely out of reach on a high shelf in the closet. This gave the child a sense of control over personal belongings, security in knowing the "special" toys were away and safe, and the understanding that the rest of the toys would be fair game for sharing. We were always very successful with this approach. Perhaps Dr. Waseem's patient would like to try this as well.
Diane Burgin, MD
The author replies: Dr. Burgin has a wonderful suggestion. This strategy upholds the child's personal dignity and natural territoriality while at the same time guiding her toward learning the rewards of sharing.
Another parent recently told me of a strategy she uses to ensure that all the children involved experience an equal opportunity to possess and to share toys. She invites the parents of the visiting children to bring along a favorite play object when they come to see her daughter. This way the young guests, as well as the young host, share in feeling the temptations, frustrations, and ultimately the rewards of playing together.
Peter A. Gorski, MD, MPA
I read, with great disappointment, "Nasal allergy: More than sneezing and a runny nose" (August). I simply can't fathom how one can review nasal allergens without mentioning second-hand tobacco smoke! Allergy shots in children for specific allergens will essentially be useless if parental smoking is a major contributor to the home environment. I'd like to point to an article that takes a different position (Semour BWP et al: J Immunol 1997;159:6169); it has a model in which serum IgE increases with tobacco smoke exposure. Shame on Dr. Solomon for not making this important issue part of the article.
Charles M. Goddard, MD
The author replies: While I respect the writer's capacity for righteous anger, this zeal may be misdirected. I agree that exposing growing children to sidestream smoke is unacceptable under any circumstances, just as, I'm sure, we would both inveigh against rodents, caustic liquids, or other dangers in the home. However, as in the latter examples, it is not allergic morbidity that is the issue, although these dangers could augment it, but more obvious adverse effects (infectious or toxic) on well-being.
Similarly, although a statistical increase in IgE seems to follow tobacco smoke exposure (before or after birth), there is little evidence that this change finds expression in worsened allergic symptoms; however, the "irritant" health effects of smoke, respiratory and otherwise, are increasingly clear. Probably because I feel that sidestream smoke is no more acceptable in the home than rats or loaded guns, I did not single it out from other widely recognized dangers to children and others.
William Solomon, MD
Thank you for the article on Internet safety (November). Allow me to add another option to the parents' toolbox. As pointed out in the parent guide that accompanied the article, filtering software is available, and some service providers offer parental controls.
Filtering is good, but limited. Some "good" sites will be blocked, and filters are not created fast enough to keep up with the growing number of bad sites. Most important, a youngster is not taught responsible decision making when filters are used.
A monitoring program such as Win Guardian may be more useful than a filter. These programs allow access anywhere, but keep track of all sites visited and every keystroke entered. Screenshots can be saved at predetermined intervals. I have found this to be a useful tool with my teenager since he has the power to make choices, but I have the power to review them with him.
As Dr. Lukefahr points out, nothing takes the place of parental supervision.
Don Seidman, MD
I thoroughly enjoyed your review of the Internet and its benefits and drawbacks as they pertain to children. Pediatricians must become aware that this medium will present as many challenges as television in making doubtful material available to children. We must become knowledgeable about the ins and outs of the Web and learn about ways to protect our children.
In response to exactly the concerns addressed in this article about access to inappropriate sites, my company has devised an Internet browser software package that automatically filters the content of a Web site before allowing the user to view the site. If the site contains inappropriate words, the browser simply refuses access to that site.
The best thing about our browser is that it is free, downloadable from our Web site by parents at any time at www.YourPediatrician.com.
Steven J. Halm, DO
The author replies: As Dr. Seidman so aptly notes in his letter, Web filtering programs have significant limitationsparticularly for use with teenagers, who may have bona fide reasons to explore topics dealing with sexuality, such as HIV. He presents an attractive alternative to filters: a program that helps monitor Internet activity without arbitrarily limiting it. This could be more practical and appealing for a lot of parents, particularly when combined with an opportunity for open communication with a teenager about the topic.
Filtering programs may be quite appropriate for use with younger children, though. I appreciate Dr. Halm's response, and I did visit the Web site he mentions (Dr. Halm is a co-owner and creator). Regrettably, I was unable to locate the downloadable browser and filter that he describes, and so I cannot comment on this particular product.
James L. Lukefahr, MD
In the December Pediatric Puzzler, an author's first name was misspelled. Her name is Deepika S. Darbari, MD.
Iris Rosendahl. Letters. Contemporary Pediatrics 2000;2:21.