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Booster seats: Not just for young kids

Thank you for publishing the informative article "Airbags and children: A mixed blessing" (April). This is great information for both injury prevention and post-injury care.

I would like to point out a concern I had with the sidebar, "Using child safety and booster seats". The National Highway Traffic Safety Administration in fact says that most children need a booster seat until they weigh at least 80 pounds (not just 60) and are 4 feet, 9 inches tall. The size and position of the child are more important than the age range.

The American Academy of Pediatrics says that, to ride safely using an adult lap-shoulder belt, a child should be able to sit with the buttocks all the way back in the bend of the seat, with the knees bent 90º over the edge and feet preferably touching the floor. (Also, as the article states, the lap and shoulder portions of the belt must each be positioned correctly.) Most children who weigh only 60 pounds can't do this in most vehicles. Some children may be safer in a booster seat even if they weigh more than 80 pounds. In fact, models are available that can be used for children who weigh as much as 100 pounds.

To show parents why a booster seat is so important, I get up on the exam table and pretend I am their child, first sitting correctly and then scooting forward and slouching to get my knees over the edge of the table. I show them where the seat belt winds up and tell them what can happen to the child in a crash, including spinal and abdominal injuries and submarining and ejection. I often see their eyes widen, and several have told me that they started using a booster seat after our discussion.

Pippa C. Abston, MD, PhD
Madison, Ala.

The authors reply: We appreciate Dr. Abston's comments regarding our article. We agree: The size of the child is more important than the age range into which he or she falls. Most children require adult assistance in applying the lap and shoulder portions of the belt, and very short children benefit from a booster seat, even at a weight over 80 pounds. We are strong proponents of booster seats—even for short stature adults!

We compliment Dr. Abston on her initiative in communicating the importance of booster seats to her patients and families. Coming from a pediatrician, such advice will be respected and result in a much higher rate of compliance by both child and family.

Merv Letts, MD
Ken Kontio, MD
Ottawa, Ont., Canada

Weighing in on fever

At the risk of being sacrilegious at the "altar of fever," I want to offer an opinion that goes against the age-old wisdom of taking a child's temperature ("Fever: Measuring and managing a sizzling symptom," May). I practiced pediatrics for 20 years. My first night on-call in private practice, I received back-to-back telephone calls: One about a child with a fever of 105.5°, the other about an afebrile youngster who "just wasn't acting right." As I was going to see the febrile child anyway, I told the parents of the other youngster to meet me as well. The febrile child turned out to have a viral illness and was running around. The afebrile child had lobar pneumonia.

After that experience, the only time I asked for a temperature, the child had no fever but died 20 minutes later of sickle cell pneumococcal bacteremia. I never asked for a temperature again.

For the rest of my career, no one was ever harmed by my decision to not take a temperature. If a child appeared ill, I would see him, night or day. That is how to ensure a good outcome. Taking a temperature may frighten a child and may provoke false fear or give false assurance to parents. My own children never had their temperature taken and my new grandson won't either. My son knows how to observe his child; if all parents did, then the issue of temperature-taking would be moot.

Joel P. Sussman, MD
Columbia, S.C.

"Fever: Measuring and managing a sizzling symptom" contains outdated information in table 3. Feverall Sprinkle Caps were discontinued years ago. Feverall suppositories remain on the market.

Holly Wyrostek
Alpharma USPD
Baltimore, Md.

Day-care controversy

"The day-care wars" (UPDATES, June) reported seemingly negative news based on a recent presentation of findings from an ongoing longitudinal 10-site study on child care, sponsored by the National Institute of Child Health and Human Development (NICHD). Regrettably, that presentation did not tell the full story and may thereby fuel what we see as the prevailing bias of pediatric clinicians and the guilt of families who use out-of-home child care.

The full story makes three key points:

  • The quality of parental and nonparental child care matters. Quality care contributes to a child's school readiness and social development.

  • Children in center-based care have better cognitive outcomes than children in home-based care do.

  • The quantity of parental and nonparental child care also matters. The researchers reported that spending more hours per week in nonparental child care over the first four and a half years of life was related to more aggressive behavior at 4.5 years of age and in kindergarten.

There is so much more in this report than this last, more negative—and much publicized—finding. The reported aggressive behaviors were undesirable but not clinically pathologic. Furthermore, the percentage of child-care children reported to have shown somewhat elevated aggressive behaviors was the same as would be expected in the general population. Some of the reported behaviors were observed only in a group setting (fighting, bullying, teasing) and some involved noncompliance with adult authority (arguing, disobedience). Last, the study found that the effects of long hours in care could be partially alleviated by higher quality child care and more responsive parenting.

Whereas children with fewer hours in nonparental care showed fewer undesirable aggressive behaviors, only time will reveal whether their acquisition of these undesirable behaviors is merely postponed until they have more group experiences. As with infectious disease, perhaps protection lasts only until exposure stimulates response.

The work of the NICHD research team reminds us that placing infants and young children in child care challenges deeply held beliefs and scientific theories that stress the importance of exclusive maternal care. We hold that the role of the clinician is to support families who use nonparental care to supplement their child-care arrangements.

Nearly 80% of children have had nonparental child-care experience by 3 years of age, with almost 40% spending 39 hours a week or longer in such care (Capizzano J et al: Child care arrangements for children under five: Variation across states. New Federalism: National survey of American's families, Series B (No. B-7). Washington, D.C., The Urban Institute, 2000). The findings of the NICHD study should motivate all of us to improve parental and nonparental early child-care experiences. Parents need to have quality child-care options and make choices that work for their family.

Susan S. Aronson, MD
Philadelphia, Pa.

Marsha Weinraub, PhD
(member of the NICHD study team)
Philadelphia, Pa.

Kathy Hirsh-Pasek, PhD
(member of the NICHD study team)
Philadelphia, Pa.

The art of auscultation

"Emesis and a new murmur in an adolescent: Getting to the heart of the problem" (May, Pediatric Puzzler) highlights the importance of clinical auscultation, and thereby provides an incentive for those of us on the front line to review and perhaps improve our auscultation skills. Too often, the tendency is to write: "NSR w/o M." Ho-hum.

A brief description of the systematic process learned from Alexander Nadas, MD, pioneer in pediatric cardiology, follows. His method doesn't take long, yet it helps one better determine the presence or absence of normal and abnormal heart sounds. Over the years, this approach has enabled me to teach students and residents how to pick up a cardiac abnormality even in a crying newborn or while working in a noisy clinic.

Dr. Nadas taught that, having conducted inspection, palpation, and percussion at the outset (point of maximum impulse, heaves, rubs or thrills, cardiac rate and rhythm, and so on), and having warmed the stethoscope head and identified where on the precordium to place it (whether for atria, ventricles, aortic root, etc.), we should listen to S1, S2, systole, and diastole—but in a particular way. First, listen only to the space in systole between the first and second sounds. Focus on that space—the timing and qualitative characteristics of the noise(s) if any are detected—and describe them. Are they holosystolic or pansystolic? Ejection-type or crescendo-decrescendo? Rumble? Flow? Harsh? Soft? Squeaky? Whistle? Pay no attention to anything else—not S1, S2, diastole, breath sounds, or crying. Include outflow tracts, such as the neck and upper posterior thorax.

Second, move your auditory attention to the second "space," diastole; apply the same focused attention and do the same analysis.

Third, go to the first heart sound—usually the opening snap of the aortic and pulmonic valves—and listen for normal and abnormal or extra sounds (click?) in that same repetitive space of time, only in the course of the first sound. Finally, repeat the process with the second heart sound. Do the heart sounds seem normal overall but diminished in intensity, less distinct than usual, or even "mushy"? Myocarditis? Cardiomyopathy? Pericardial effusion? You might observe it in any child, whether infant or teenager.

With descriptions from the cardiac exam noted carefully, you can refer to textbooks or the medical literature for subsequent diagnostic identification of a particular murmur, extraneous sound, or otherwise abnormal auscultation. (Examples include the murmur manuscripts by Sapin [Pediatrics 1997;99:616] and Etchells [JAMA 1997;277:564].) The result of taking this systematic approach? Better auscultation skills, possibly even good enough to pick up pathology before it becomes symptomatic. Gaskin and colleagues (Pediatrics 2000;105;1184) observed that such "improved training in physical diagnosis should reduce the number of unnecessary referrals and may even enhance the accuracy of specific cardiac diagnosis."

Jonathan B. Rosefsky, MD
Haverford, Pa.


In "Preparing children and families to travel overseas" (June), the final dose for DTaP was inadvertently omitted from Table 2. The schedule for routine administration for DTaP is: 2, 4, 6, and 15–18 mo, age 4–6 yr.


Readers' Forum. Contemporary Pediatrics 2001;8:137.

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