Updates

UPDATES

Child safety seats

Parents who wouldn't dream of starting the car until the children are safely buckled in their seats feel confident they are protecting their children from harm. But according to the chairman of the National Transportation Safety Board, that confidence is often unwarranted; eight out of 10 child safety seats are improperly installed or the wrong size and do not provide the protection children need when an accident occurs.

To remedy that situation, the federal government has been urging automobile and safety seat manufacturers to produce uniform fastening devices that will make proper installation simpler. For the present, parents should have the installation of their children's safety seats checked by an expert. In February, the Daimler-Chrysler Corporation, in cooperation with safety seat manufacturer Fisher-Price and the National Safety Council, began to offer free inspections at dealerships around the country. Parents can use the service whether their car is made by Daimler Chrysler or some other manufacturer. Safety seat inspection is now available by appointment at almost 400 participating dealers, with a total of 650 trained inspectors. The program will expand to cover 1,000 dealers by year's end. To make an appointment, parents can call 877-fit-4-a-kid, or go on the Web at www.fitforakid.org. Not to be outdone, General Motors has put a fleet of minivans on the road that will provide safety seat checkups at dealerships, day-care centers, shopping malls, and other locations. One minivan will cruise each of the 50 states and the District of Columbia. Many local hospitals and community service agencies also provide free car seat safety checks. Pediatricians should urge parents to take advantage of these opportunities.

Do you know where your asthma patients are?

Childhood asthma is seriously underdiagnosed, according to many public health experts, and Raoul L. Wolf, MD, Associate Professor of Pediatrics at the University of Chicago School of Medicine has a very practical suggestion for improving the diagnostic batting average (Wolf RL, Berry CA, O'Connor T, et al: Validation of the brief pediatric asthma screen. Chest 1999;116:224S).

Whenever a family comes in, regardless of the reason for the visit, Dr. Wolf suggests that health-care providers ask them to fill out a questionnaire with five simple questions:

• Has your child ever been diagnosed by a doctor as having asthma?

• Has your child ever had episodes of wheezing (whistling in the chest) in the last 12 months?

• In the last 12 months, have you heard your child wheeze or cough during or after play?

• Other than a cold, in the last 12 months, has your child had a dry cough at night?

• In the last 12 months, has your child been to a doctor, an emergency room, or a hospital for wheezing?

In a trial of the screening instrument with a group of 81 children who had not received a previous asthma diagnosis (that is, parents answered No to the first question), 34 children with "possible asthma" were identified. These were children whose parents answered Yes to the last question or to any two of the symptom questions. Each of the 81 children was then evaluated by history, physical examination, and spirometry by an allergist and a nurse who were unaware of the screening results. When the evaluation results were compared with the responses to the screening questions, the screen showed a sensitivity of 75% and a specificity of 81.2% in identifying children with asthma.

Routine use of the questionnaire in pediatric waiting rooms, Dr. Wolfe and his colleagues believe, would alert providers and parents to the possibility of asthma, avoid inappropriate antibiotic treatment for asthmatic symptoms, and help institute timely asthma control regimens.

Conjugate pneumococcal vaccine approved

Now that the Food and Drug Administration has approved Prevnar, the new seven-valent conjugate pneumococcal vaccine from Wyeth Ayerst, pediatricians will be able for the first time to immunize children under 2 years of age against disease caused by the seven most common strains of Streptococcus pneumoniae. FDA approval was given for prevention of invasive disease only, specifically meningitis and bacteremia; the vaccine's effectiveness in preventing ear infections was not evaluated by the FDA.

Infants can be given the vaccine as a series of four inoculations, at 2, 4, 6, and 12 to 15 months of age. Prevnar immunization will be costly; the total for the four shot series is estimated at $232. For that reason, according to the New York Times, the Advisory Committee on Immunization Practices (ACIP) has recommended Prevnar's inclusion in the routine immunization schedule for babies born from now on, but did not recommend catch-up immunization for children over 2 years of age unless they are at high risk of pneumococcal disease. High-risk children were defined by ACIP as children who are black, Native American, or Alaskan Native, and those with HIV infection, sickle cell anemia, or other disorders that weaken the immune system. The ACIP also recommended that, in considering the use of Prevnar for children over 2, priority be given to children in group day care, those who are socially or economically disadvantaged, and those with frequent or recurrent otitis media.

Waiving bye-bye to some CLIA regulations

When the Clinical Laboratory Improvement Amendments (CLIA) were enacted in 1988, many pediatricians closed down their office laboratories. But in the years since, the number of tests for which CLIA regulations have been waived has grown steadily. It's worth keeping abreast of the changes, for some of these newly waived tests may be just what your office could use. Recent newcomers to the waived list include:

• Urine chemistry analyzers Chemstrip 101 Urine Analyzer/Chemstrip 10 UA ( Roche Diagnostics at 800-852-8766) and Clinitek 50 Urine Chemistry Analyzer/Multistix Reagent Strips (Bayer Diagnostics, 800-445-5901).

• Fecal occult blood tests dBest Sensitive Occult Blood Test (AmeriTek, Inc, 800-851-6762); ColoScreen-ES (Helena Laboratories, 800-231-5663); and Instant-View Fecal Occult Blood Test (Alfa Scientific Designs, 858-350-9798).

• Instant-View Pregnancy Urine Test (Alfa Scientific Designs).

• Group A streptococci tests, including Acceva Strep A Test (Biostar, 800-637-3717); ImmunoCard STAT Strep A Test (Meridian Diagnostics, 800-343-3858); Accustrip Strep A Test (Jant Pharmacal, 800-676-5565); QuickVue In-Line One-Step Strep A Test (Quidel Corp, 800-874-1517); and Contrast Strep A Test (Genzyme Diagnostics, 800-332-1042).

• Mononucleosis tests including CARDS O.S. Mono Test (Quidel) and Accutest Infectious Mononucleosis Whole Blood Test (Jant Pharmacal).

Judith Asch-GoodkinContributing Editor

EYE ON WASHINGTON

March comes in like a lamb in the District of Columbia, greeting members of Congress and bureaucrats alike with the bright yellow of daffodils and forsythia. The number of serious presidential contenders had been reduced to two and, with that distraction out of the way, Congress was free to concentrate on making a record to run on in November. At present, however, there hasn't been much movement on issues of concern to families and health-care providers. Action on bills to regulate gun sales and protect patients' rights vis-à-vis managed care organizations remain stalled in conference committees, and an increase in the minimum wage may founder on the tax cut provisions that have been attached to it.

As is usually true—except when Congress cuts off funding altogether—the President and the administrative agencies manage to operate whether or not Congress is being particularly productive. Some cases in point:

President Clinton, in the wake of the shooting of 6-year-old Kayla Rolland by a first grade classmate, continued to call for more stringent firearm safety regulations and exchange charges with the National Rifle Association over the seriousness of his gun control efforts.

The Agency for Healthcare Research and Quality (AHRQ) issued the first in a series of annual reports on access and use of health care by children and youth that provide baseline data for assessing the adequacy of pediatric health care. The 1999 report is available as a supplement to the January issue of Pediatrics. Reprints are available from AHRQ, publication number 00-R014. Also available from AHRQ are two evidence-based reports on the diagnosis and treatment of attention deficit hyperactivity disorder. Summaries of the reports are available on the agency's Web site, www.ahrq.gov.

The Centers for Disease Control and Prevention established a new telephone hotline to answer questions about safety. The number is 888-252-7751. The CDC promises a "live person" will answer any question about safety or refer you to someone who can.

The Consumer Product Safety Commission, after inspecting a national sample of motels and hotels around the country, concluded that eight of every 10 cribs these establishments provide for families are unsafe. Spot checks in 90 hotels located in 27 states found loose hardware, unsecured mattress supports, dangerously soft bedding, and too-large sheets—conditions that can cause strangulation or suffocation.

The National Library of Medicine opened a database on clinical trials where physicians and the public can find out what trials are being conducted throughout the country and what the requirements are for enrollment. The site can be accessed at http:// clinicaltrials.gov. The database currently contains 4,000 studies at 47,000 sites nationwide, most of them conducted by governmental institutions and universities. Trials by pharmaceutical manufacturers are expected to be included at a future date.

CALENDAR

May 12­16, Advancing Children's Health 2000, Boston, MA. To register, call Melissa Singleton at the American Academy of Pediatrics, 800-433-9016 or fax 847-228-5059

June 25­27, Association for Health Services Research Annual Meeting, Los Angeles, CA. For more information, call the Association for Health Services Research, 202-223-2477.

Judith Asch-Goodkin. Updates.

Contemporary Pediatrics

2000;4:13.