What's realistic when giving fluids for dehydration?/Attachment therapy and adopted children: A caution/Questioning the science that underlies homeopathy
In "Heading off the dangers of acute gastroenteritis" (July 2003), the suggested mL/kg of fluids required for oral hydration were too precise. I can't imagine being able to get a child who has been ill with vomiting and diarrhea to take that much fluid in such a short time. If that is what the American Academy of Pediatrics considers "oral rehydration," I don't think I will be able to do it! I always try to give the child very small amounts of oral fluid to start, increasing the amount, and repeating the provision every 15 to 20 minutes or so. Comments?
Author reply: The fact that there is a difference between rehydration and hydration maintenance therapy may be responsible for Dr. Goldberg's very practical observation. The main determinant of a child's willingness to drink oral rehydration solution is the thirst driven by their dehydration. Therefore, a clear differentiation needs to be made between oral rehydration solution (ORS) used for rehydration as opposed to maintenance of hydration. Generally, children whose mental status is normal (not so dry as to be obtunded) can easily drink 50 mL/kg over four hours if they are dehydrated. Children on maintenance therapy may need only as little as 100 mL of extra ORS total in 24 hours. This latter group of children will clearly not be as interested in drinking a large amount of ORS. Providing the ORS in small aliquots makes sense in an ill child. Even a sip at a time would permit the delivery of 50 mL/kg over four hours.
A reference in the July 22, 2003 edition of the New York Times to "Promoting a healthy tomorrow here for children adopted from abroad" (February 2003, Contemporary Pediatrics) led me to read the article in your publication. I was shocked to see that the authors of the Contemporary Pediatrics article have been taken in by the claims of the former Attachment Center at Evergreen about the mental health of adopted children, taking a number of descriptive statements directly from that group's Web site, apparently without further investigation. This center, now operating under a different name, has promulgated the types of beliefs and practices that caused the death of Candace Newmaker in 2001 as well as the deaths of other children. My co-authors and I have carefully discussed this belief system in a recent book, Attachment Therapy On Trial (Praeger, 2003), and have shown its serious divergence from systematic evidence about early emotional development.
Pediatricians are rightly in the front lines of childhood mental health work, but they must be cautious about claims implying that diagnosis and treatment are simple matters. There is an evidentiary basis for mental health treatment as well as for physical health, and the practitioner should examine the evidence behind claims such as those of "attachment therapy." Otherwise, harm is bound to be done. I am afraid that the impact of this article will be harmful if your readers do not receive a warning about this material.
Author reply: We appreciate and share Dr. Mercer's concern for the mental health of adopted children, a concern stated in our article: "If a family is adopting a child who has been institutionalized [as many adopted children from abroad are], early referral to a child psychologist or other mental health professional with experience in adoption and attachment issues may be helpful."
Dr. Mercer voices concerns about the Attachment Center at Evergreen citation in our article. The citation relates to a list of potential symptoms that offers examples of the more technical symptom list found in other sources. For those who would rather not rely on the list of symptoms provided by the former Attachment Center at Evergreen, we have also given other citations for sources that address mental health concerns and attachment issues in adopted children.
We completely agree with Dr. Mercer's statement that "Pediatricians are rightly in the front lines of childhood mental health work, but they must be cautious about claims implying that diagnosis and treatment are simple matters." As the article makes clear, and as its conclusion repeats, "The entry of a child into a family, whether through birth or adoption, is a momentous and complex event. This is especially true with an internationally adopted child. Pediatricians may need to help the family sort through medical, developmental, psychosocial, and legal ramifications before, during, and after adoption."
The wonderful letter by Pierpaolo Palmieri, MD, in the July 2003 Readers' Forum ("Homeopathy: Good or bad science?") should be read by every one of my colleagues. It is important that each of us speak up whenever necessary. The Emperor's Clothes continues to stand as a most instructive lessonfor now and for the future.
Readers' Forum. Contemporary Pediatrics October 2003;20:20.