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Language delay and birth orderI greatly appreciated the article by Dr. Marilyn Agin, "The 'late talker'-when silence isn't golden" (November 2004). As a general pediatrician in practice for 16 years, I have seen, empirically, that "subsequent" children (second born, third born, etc.) acquire expressive language later than most first-born children. I have attributed this to a number of factors, including: other siblings speaking for the child; parents knowing what the child wants and providing it before the child has an opportunity or need to speak; and less time spent on language-developing tasks because more children are in the home. Is there literature looking at acquisition of expressive language by birth order? And assuming there is a difference in language acquisition based on birth order, should we have a different "standard" for first-born children vs. those born later when assessing speech?

Michael Weiss, MDRancho Santa Margarita, Calif.

Author reply: Dr. Weiss's observation that first-born toddlers tend to talk earlier (and usually have more varied vocabularies) than later-born siblings has been confirmed in multiple studies.1,2 First-born children usually have their parents' undivided attention, and they learn to speak using an adult as a model rather than another child in the family, who may be learning language himself and not yet be proficient. A second- or third-born child may also be required to follow multiple-person conversations that may not be directed at him. The good news is that most second- and third-born children catch up by about 3 years of age, and their later-born status does not place them at greater risk of persistent speech delay.

Marilyn C. Agin, MD

Remove a tick completely? Or let it be?Regarding "Removing ticks without trauma" (Clinical Tip, August 2004): I consider a punch biopsy much more traumatic than observation. Why does an embedded tick head have to be removed? I have always advocated no therapy but have yet to see a complication. Is there evidence that removing the head decreases the risk of infection? My understanding of the transmission of Lyme disease is that it occurs when the tick regurgitates. Can a decapitated tick do that? Has anyone seen data on this?

Gail Schonfeld, MD East Hampton, N.Y.

Contemporary Pediatrics board member Steven M. Selbst, MD, replies: Not much scientific evidence exists for complete removal of ticks from the skin. Henretig and King's Textbook of Pediatric Emergency Procedures (Williams and Wilkins, 1997) recommends complete removal using an 18-gauge needle to excise remaining parts (like removing a splinter). The authors do not specify why they make this recommendation. My textbook, Illustrated Textbook of Pediatric Emergency and Critical Care Procedures (Dieckmann, Feiser, Selbst [eds], Mosby, 1997), also recommends complete removal, but does not cite a source for that recommendation.

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