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Letters and comments from readers
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Regarding the April 2003 Clinical Tip advocating the use of glue on a plastic-handled cotton swab to remove a foreign body from the external auditory canal: I've seen bad results in two cases using this approach. In one case, the swab became glued into the external auditory canal (a possibility mentioned by the authors of the tip). In the second, the swab came out but the glue sealed the foreign object into the external auditory canal.
The safest way to remove a bead in a cooperative child is to slide a small, blunt, right-angled pick past the bead and then pull it and the bead out. This is not painful. Even if the bead appears to be occluding the external auditory canal, the cartilaginous canal has enough give to allow the pick past.
If the child is uncooperative or manipulation of the object is painful, then it is less traumatic for patient, parents, and doctor to have the object removed in the operating room or with the aid of a short-acting anesthetic.
I agree with the advice given in "Sleep problemIs it more than it seems?" (Behavior: Ask the Experts, April 2003) but ask for specifics on how to get this child to fall asleep on his own and stay in his own bed through the night. Also, I believe that not all children respond to behavioral management. In my practice, behavioral techniques (allowing the child to cry himself to sleep, gating the door, and so on) have not been 100% successful. It becomes evident years later that the child has a condition that may have prevented the behavioral techniques from working. Such conditions include attention deficit hyperactivity disorder (ADHD), anxiety disorder, and bipolar disorder. Is there a connection? I hypothesize that there is.
One case, for example, involved a child with restless sleep (moaning, crying out, inability to sleep without someone nearby). After Depakote for seizures was started, these symptoms abated. (They recurred when Depakote was stopped, as did the seizures, and abated again when Depakote was restarted.) The parent has ADHD.
Author reply: Thank you to Dr. Lubischer for his comments. My original published reply was premised on the absence of evidence of a neurodevelopmental or metabolic disorder. Certainly, any clinically directed suspicions from the family history, developmental history, or direct examination in these areas should be formally assessed. As for specific behavioral interventions, there is no magic here, just theoretically-based and evidence-based tried and true approaches.
One-year-olds are able to follow simple verbal communication and can certainly understand parents' affective signals of body language and emotional tone of voice. Strategies mostly start and end with calm, willing parents who feel confident about the benefits of the intervention and feel supported by adult family and friends. Infants sense when caregivers are nervous about the situationthey imagine, therefore, that there must be good reason to feel anxious themselves.
Most successful interventions involve pleasant bedtime rituals (storytelling, reading aloud, singing, etc.) followed by a very brief goodnight farewell and withdrawal from the child's room. If the child continues to fuss urgently, parents can return every 10 to 15 minutes as needed, staying as briefly as one to two minutes to calm the infant using minimal social interaction, and each time calmly withdrawing from the room. Most infants will protest this new effort by increasing their fussing for the first two or three nights, so parents should be forewarned. If parents continue with the intervention, the infant quickly learns to accept and, ultimately, enjoy mastering his or her sleep state.
The American Heart Association has issued guidelines for the prevention, beginning in childhood, of atherosclerotic cardiovascular disease. The guidelines offer strategies for promoting cardiovascular health in all children and adolescents and for identifying those at high risk of cardiovascular disease. In addition, interventions for those identified as being at risk are reviewed. See Kavey RW et al: Circulation 2003;107:1562 ( www.circ.ahajournals.org ).
Readers' Forum. Contemporary Pediatrics June 2003;20:19.