Lead poisoning, Breastfed baby starves; who's to blame? Educating parents about early brain development, Measuring children's well-being, Is there a nurse practitioner in your future? Pediatricians' salaries decline


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Lead poisoning

In the years since lead additives in gasoline, house paint, and plumbingfixtures were banned, blood lead levels for children from 1 to 5 years ofage have dropped precipitously. Nevertheless, some children in that agerange (6% overall, and 12.3% of children in poor families) continue to haveelevated lead levels that put them at developmental risk. How come?

Most authorities blame lead paint, flaking off old, delapidated housingin inner city neighborhoods. But according to Howard W. Mielke, who teachesat the College of Pharmacy of Xavier University in New Orleans, anotherculprit has been overlooked: lead particles from gasoline vapor that accumulatedin inner city soils in the decades before leaded gasoline was banned (AmericanScientist 1999;87[1]:62). What drew Professor Mielke's attention to thisoften overlooked hazard was his own daughter's elevated blood lead levels,which he traced to contaminated soil in the sandbox and playground of thepreschool she attended.

Professor Mielke suggests ameliorating the hazard by such simple measuresas covering playground surfaces with indoor/ outdoor carpeting. Researchersfrom Rutgers and Johns Hopkins also suggest thorough housecleaning, includingwet-mopping floors, sponging walls and horizontal surfaces, and vacuumingwith high-efficiency particle accumulating (HEPA) vacuum cleaners. Theyreport that elevated lead levels in a group of 46 urban children whose familiesreceived instruction and assistance with such housecleaning routines droppedby 17% on average over a nine to 15-month period (Pediatrics 1999; 103[3]:551).

Breastfed baby starves; who's to blame?

Last month in New York City, a 19-year-old welfare recipient went ontrial for recklessly causing the death of her 7-week-old, breastfed baby.The child died of starvation, the second case of this kind to be publicizedin the last year.

Who is to blame for this tragedy? Certainly this mother and child fellthrough the cracks in our imperfect health-care system; errors in processingthe baby's Medicaid application deprived him of checkups that could havedetected the weight loss and saved his life. But according to breastfeedingexpert Marianne Neifert, MD, at least some of the responsibility must beshared by health-care professionals who promote breastfeeding without makingsure that all new mothers have the supports they need to make successfulbreastfeeding possible. What's needed, Dr. Neifert believes, are creativesolutions to the problem of providing close follow-up for new mothers andbabies. Here are some of her suggestions:

  • Screening questionnaires for new mothers, filled out before discharge from the hospital, so that red flags for nursing problems--like the breast reduction surgery the mother in this case had undergone--are not ignored
  • A confirmed pediatric appointment no more than 48 hours after discharge, as a requirement before mother and baby can be released from the hospital
  • Special outpatient facilities like those Dr. Niefert is familiar with in several Denver-area hospitals, which provide maternal/new baby checkups within 48 hours of hospital discharge for a modest fee
  • Baby scales new mothers can rent, provided by hospitals just as some now provide car safety seats, for small, preterm, or other high-risk infants at the time of discharge.

Readers are encouraged to write to Contemporary Pediatrics with additionalsuggestions and to advocate for breastfeeding support programs at institutionswhere they are affiliated.

Educating parents about early brain development

Scheduled pediatric visits in the first year of life are largely devotedto giving immunizations and monitoring growth and development.But thosefrequent encounters are also an ideal time to educate parents about infants'emotional needs and to explain how loving interactions with caregivers areessential for healthy brain development.

To help you accomplish that task, you may want to turn to two new publicationswritten by the staff of the Ounce of Prevention Fund, a private/public partnershipestablished to promote the well-being of children, with advice and researchassistance from Zero to Three: The National Center for Infants, Toddlers,and Families. The first of these, Starting Smart, summarizes striking newresearch on how early experiences affect brain development and describessuccessful community programs that foster development. One example is theAbecedarian project at the University of North Carolina, which significantlyimproved IQ scores in low-income children with a full-time child-care andparent-education program starting in the first month of life. The secondbrochure, Ready to Succeed, emphasizes the importance of emotional nurturingin healthy development, cites research results and exemplary community programs,and recommends strategies health-care providers, parents, and child-careprograms can use to support children's emotional development.

Some 12,000 of these publications have already been mailed to federaland state policy makers, governors, professional organizations like theAmerican Academy of Pediatrics and the Children's Defense Fund, and themedia. Dissemination was underwritten by a grant from the Johnson& JohnsonPediatric Institute. Pediatricians can order copies by calling Zero to Threeat 800-899-4301. The price is $2 for a single copy or $1 per copy for ordersof 25 or more.

Measuring children's well-being

When pediatricians are wearing their advocate hats, lobbying school boardsor governors or members of Congress for policies favorable to children,they need all the information they can get. This month's editorial, on page9, cites some interesting findings on American families. Other questionsyou might want answered:

  • How many children are living in families with "food insecurity," worried about whether the week's income will stretch for enough food for the kids?
  • How many children live in neighborhoods where more than 40% of the population is poor?
  • How many mothers aren't getting the child-support payments they're legally entitled to?
  • How much time do parents spend interacting with their children? At meals? Over homework? Reading aloud?
  • How many children have AIDS, or elevated blood lead levels, or dental caries?
  • How many children carry weapons to school? Get enough sleep? Sniff glue? Live in a family where the adults don't speak English? Are recent immigrants? From where?

Pediatricians can find the answers to these and many more questions aboutthe lives of children in two new statistical compilations published by thefederal government: Trends in the Well-Being of America's Children and Youth,1998, from the Department of Health and Human Services, and America's Children:Key National Indicators of Well-Being, from the Federal Interagency Forumon Child and Family Statistics. Both are invaluable advocacy resources,and both are available free on the World Wide Web. To look up somethingin Trends, go to aspe.os.dhhs.gov, then click on Policy and Research topics,and on Trends. For information in Key Indicators, go tohttp://childstats.gov.

Is there a nurse practitioner in your future?

Very likely, says the 1998 Medical Economics Continuing Survey of office-basedphysicians in full-time practice. As the table at right indicates, pediatriciansare already among the top five specialties to employ mid-level practitioners,either physicians' assistants (24% of pediatricians) or pediatric nursepractitioners (38%).The other specialists who are particularly hospitableto these providers are cardiothoracic surgeons, orthopedic surgeons, familyphysicians, and internists. What's more interesting, however, are the factorsthat predict even more widespread use of these clinicians in the future.The survey shows that pediatricians who work with mid-level practitionerstend to be younger than colleagues who do not, and to be relatively new(five years or less) to pediatric practice. They are also more likely towork in large groups, participate in managed care, and be female. Soundslike a description of tomorrow's pediatrician, doesn't it?

Pediatricians' salaries decline

Income for physicians who work for groups did not keep pace with productivityin 1997, according to the Medical Group Management Association's most recentnational survey. While group physicians' productivity rose 2.6% in 1997,their median income increased less than 1%, to $135,791 for primary carephysicians.

Pediatricians actually experienced a loss, dropping 0.2% from a mediansalary of $132,039 in 1996 to $131,803 in 1997. Among primary care physicians,family practitioners did best, increasing their median income 2.7% to $136,002.Hospitalists, included in the MGMA survey for the first time, earned a medianincome of $139,000 in 1997. Survey results are based on responses from 1,675medical groups.


May 3­5, Childhood Obesity: Partnerships for Research and Prevention,Atlanta, GA. Contact program coordinator, International Life Sciences Institute,202-659-0074

May 14­16, Respiratory Illnesses in Children: Challenges for 2000.Cambridge, MA. For more information, E-mail Boston University School ofMedicine, cme@bu.edu

May 16­18, AAP Legislative Conference, Washington, DC. For more information,call the Washington office of the AAP, 800-336-5475

May 16­19, American Pediatric Surgery Association,Rancho Mirage,CA. For information, call 978-526-8330

May 27­30, National Rural Health Association Annual Conference, SanDiego, CA. Contact the NRHA at 816-756-3140, or E-mail them at mail@nrharural.org

May 30­June 3, American Society for Microbiology General Meeting,Chicago, IL. Contact the Society at 202-942-9356.

--Judith Asch-Goodkin

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