Your Voice

READERS' FORUM

This product is no longer used for fever

"Fever: Measuring and managing a sizzling symptom" (May) identifies PediaCare products as antipyretics that contain ibuprofen. PediaCare products currently do not contain fever-reducing medications such as ibuprofen and acetaminophen. PediaCare products are indicated to treat a child's cough and cold symptoms—not fever. Shipments of the two PediaCare products indicated for fever relief were discontinued last year (these products may still be on store shelves and in parents' medicine cabinets).

Barbara H. Korberly, PharmD
Pharmacia Consumer Healthcare
Peapack, N.J.

Getting to the root of digit sucking

As a board-certified pediatric dentist, I found the extensive review of digit sucking interesting ("Why we can't afford to ignore prolonged digit sucking," June). But why did the author only mention—in a parenthetical note near the end of the article—that dentists treat this common oral problem with appliances? I believe that parents should consult a dentist first to manage this oral habit and any associated oral sequelae.

Doron Kochman, DDS
Pittsford, N.Y.

Rosemarie Van Norman's behavioral approach to the problem of prolonged digit sucking is accurate and important for pediatricians to recognize. Dentists have been attempting to treat this behavior with intraoral appliances for many years. In my opinion—as a dentist, orthodontist, and speech and language pathologist who has treated such problems for 35 years—such appliances are almost always more of a detriment than an aid. These devices are invasive, difficult to manage, uncomfortable, often punitive, and address only the symptom of the behavior.

Van Norman does an excellent job of not only describing the causes of prolonged digit sucking but also presenting a comprehensive and clear therapeutic approach that addresses all aspects of the behavior. Fortunately, dental schools are increasingly aware of the behavioral basis of digit sucking and now stress behavioral approaches to remediation over appliances.

Robert M. Mason, DMD, PhD
Durham, N.C.

I was gladdened by Van Norman's call for an investigation into the effectiveness of fixed intraoral habit appliances ("oral cribs," "habit appliances") used by dentists and orthodontists to treat digit sucking. I am a librarian researching the literature of fixed intraoral habit appliances with a view to tracing the communication and flow of ideas in a specific branch of dentistry. I have researched the literature of these appliances beginning with the patent for the hayrake (a painful, spiked appliance still used) in 1936 to the present day. I have turned up references that give considerable cause for concern over the incidence of serious injuries to children from these appliances and their relative effectiveness when compared with the noninvasive therapies advocated by Van Norman. I will send, by e-mail, my complete list of references to fixed intraoral habit appliances beginning in the 1930s to any interested reader.

Nicholas L. Moore
West Sussex, England
nick.moore1@btinternet.com

The author replies: Many of my referrals come from orthodontists, pediatric dentists, and general dentists. I suspect that the clinician making the referral is reluctant to use habit appliances and that that reluctance is related to several factors:

• Invasive appliances with spurs— such as the hayrake mentioned by Mr. Moore—are punitive and can cause wounds to the tongue and digit. Children in whom this appliance is used, as well as those who have other palatal cribs or reminder devices, often experience difficulty with speech, eating, and hygiene. Noncompliant children often mutilate or displace the apparatus to facilitate continued sucking, causing it to become imbedded in palatal tissues; this leads to infection, discomfort, increased anxiety, and bilateral mesial tipping of the molars, to which the appliance is cemented. This is a frustrating experience for child, parents, and dentist.

• Many parents are not receptive to the concept of mechanical, invasive, or punitive methods to eliminate their child's sucking activity, and they want other options.

Prolonged digit sucking is a behavioral problem. Habit appliances treat only a symptom of the behavior and do not address its biologic, physiologic, or psychological elements. The least invasive approach to the management of issues affecting health and well-being is always the treatment of choice.

Positive behavior modification based on thorough understanding of the whole behavior and utilized by a well-trained and skilled clinician is very successful and does not require the use of invasive, intra-oral appliances. The child is highly motivated to discontinue the behavior and he or she does so quickly and without coercion. Children embrace this concept, and parents are not required to enforce compliance. Their role is simply that of a well-informed, empathic, and positive support system, which enhances the parent-child relationship.

Rosemarie A. Van Norman, COM
Omaha, Neb.

As health professionals, how do we measure (up)?

In "Understanding growth patterns in short stature" (June), the authors do an excellent job pointing out the importance of proper utilization of the new growth charts and increasing our understanding of when short stature calls for investigation. I want to add a caveat about the actual taking and interpretation of growth measurements. Although information gleaned from growth charts is vital to continually monitoring growth patterns, it is just as important to periodically assess the equipment utilized to measure growth and the techniques employed by clinic staff.

Human error is a major cause of discrepancies in measurement. In a recent randomized, controlled study conducted by the Pediatric Endocrinology Nursing Society, researchers concluded that children were measured with inaccurate equipment and incorrect technique at primary care practice study sites (Hench K et al: Linear growth measurement practices among US primary care providers: Findings from the first PENS Multicenter Study; abstract presented at the 14th Annual Conference of the Pediatric Endocrinology Nursing Society, San Diego, Calif., April 2001). This study illustrates that each source of measurement error can lead to a delayed or missed diagnosis—as Drs. Samuels and Cohen point out in the Contemporary Pediatrics article.

When our equipment is poor and measuring techniques improper, our assessment of patients' height is incorrectly reported, putting their health at risk; correcting for such errors would help in our continued assessment of infants' and children's growth. After all, the display of information on a growth chart is only as good as the accuracy of the measurer and the auxological equipment.

Terri Benyi, MSN, CPNP, CEN
Galveston, Texas

The authors reply: We wholeheartedly agree with Ms. Benyi. As we noted in the article, measurement errors and inaccurate plotting of measurements need to be ruled out first. (In fact, we considered reviewing proper techniques of measurement and making recommendations about appropriate measuring equipment in our manuscript, but then chose to focus instead on the patterns of growth. We're thrilled that someone has brought up some of what we left out.) In addition to proper equipment and technique, proper use of the information is important. Problems are caused by inappropriately plotting a standing "height" measurement on a recumbent "length" chart, for example, or by plotting on the wrong sex chart.

Ronald C. Samuels, MD, MPH
Laurie E. Cohen, MD
Boston, Mass.

CLINICAL TIP
A game plan for pneumatic otoscopy

Before I examine the ears of an apprehensive small child, I tell her that we are going to play a game. This approach works well with children around 2 years old. After a brief practice session, I put the speculum inside the ear, count to three and say "Ready—squeeze," then let the child squeeze the bulb of the insufflator. I do this at least two times in each ear. This technique helps me maintain the position of the otoscope and see the back-and-forth movement of the tympanic membrane better. Most children enjoy the "game," and so do I because it helps me perform the exam.

Nerissa V. Kongthong, MD
Cleveland, Ohio

Tape tips

Here are two techniques I've found helpful when applying bandages and dressings to young children. First, if you know you will need to apply an adhesive bandage immediately following a procedure, such as an injection, you can keep the bandage at hand, ready to use by unwrapping it, removing the protective paper strip from one side and lightly affixing that side to the face of your wristwatch.

Second, a toddler who needs a bulky dressing on the hand will more likely accept the addition if you draw a smiling face on the tape that holds it in place. The face turns the dressing into a doll or a playmate in the child's eyes, so it is much more apt to stay on.

Jerome T. Combs, MD
Wallingford, Conn.

Do you have a Clinical Tip to share with colleagues? Let us know; we'll pay $50 for each item accepted for publication. Tips sent by mail should be addressed to Molly Frederick, Clinical Tips Editor, Contemporary Pediatrics, 5 Paragon Drive, Montvale, NJ 07645-1742. If you submit by e-mail (Molly.Frederick@medec.com), please include your mailing address.

 

Readers' Forum. Contemporary Pediatrics 2001;10:129.