I often read Contemporary Pediatrics and, like many other pediatricians, find so much of the information it contains helpful and pragmatic. I am truly perplexed, however, by the glaring omission of the option of abstinence in "Helping adolescents prevent unintended pregnancy" (May). I do not understand how the authors could overlook this as an option to prevent both pregnancy and every sexually transmitted disease.
The oversight is an unfortunate reflection of both children and the physicians who care for them. Sexuality and sexual development are certainly a part of being human, but we must also educate children that sex is not merely a physical act with physical consequences; we must help our patients consider the emotional impact that sexual activity can have as well. We cannot shy away from our responsibilities as pediatricians and as responsible and influential adults.
Even if the most extreme physical consequences, such as pregnancy or HIV, were the only consideration, abstinence would still be the only 100% preventative measure. If we as pediatricians do not consider abstinence a prevention to pregnancy, why should adolescents?
The author replies: I concur with Dr. Green about the need to include abstinence counseling in the encounter with adolescents. In fact, the original draft of the article opened with the statements: "Adolescents who engage in sexual activity are at risk for sexually transmitted diseases and early unintended pregnancy. They should be encouraged to postpone sexual involvement. However, the adolescent females and males who are already involved should be offered confidential contraceptive counseling and services." The point about postponing sexual involvement was probably edited out to focus the article on helping the physician who is counseling patients who have already chosen the option of contraception, and the content of the article is meant to address that need.
I co-authored an article in Contemporary Pediatrics in June 1995 ("Keeping adolescents healthy") that clearly states the role of the physician in counseling continued abstinence in the adolescent who is not sexually active. Although abstinence can certainly be reemphasized to adolescents who have already begun to have sex, in my experience there are very few times I can rely on that method to be successful.
I read with interest the letter regarding the deaf toddler who is not toilet trained (Behavior: Ask the experts, June). While I agree with Dr. Hall's concern for other possible developmental issues, I am even more concerned with the communication issues raised. The physician states that "the child is deaf and signs very little." My first question is whether the child was placed in an appropriate early intervention program upon diagnosis of the deafness. My next question is whether the family has learned sign language.
Of the 90% of deaf children born into hearing families, only about 5% of the families learn sign language. This barrier to communication in the home begins early and only becomes greater as the child ages and becomes more fluent in sign. While much of the medical focus is often placed on rehabilitating the child (be it augmented hearing, speech therapy, or cochlear implants), we often fail to address the needs of the family. To have a healthy, productive deaf child, we need to bring language into the home.
Having the child able to communicate with other deaf children is wonderful, but there will be a lot more problems than toilet training if language barriers persist within the family.
The author replies: I agree that issues of communication are a concern. Since, however, it is not evident that toilet training among deaf children is a unique problem, given that the vast majority (90%) are born to hearing parents with no prior knowledge of sign language, it is not clear in this particular case whether delay is due to developmental issues, to normal variation, or to lack of communication in the home.
In summary, one cannot conclude that delayed toilet training is indicative of language problems, developmental problems, or any pathological medical condition. The delay may, however, raise some suspicion that there may be an underlying problem.
I wish to offer the following comments on the excellent article by Drs. Hafeez and Vuguin, "Managing diabetic ketoacidosisa delicate balance" (June). Though as many as one in five insulin-dependent diabetics have thyroid antibodies in their serum, only a small proportion of these insulin-dependent diabetics develop clinical hypothyroidism, with the interval between diagnosis of diabetes and thyroid disease being five years on average (Kaplan S: Clinical Pediatric Endocrinology, WB Saunders, 1990, p 157). Therefore, while I would not disagree with obtaining a baseline serum free T4 or TSH at the time of diagnosis of new onset insulin dependent diabetes mellitus (IDDM), the likelihood of obtaining a clinically significant free T4 or TSH abnormality at the time of diagnosis of new onset IDDM is considerably less likely than after having IDDM for many years. So, the importance of doing a screening for free T4/TSH becomes potentially more clinically relevant the longer one has IDDM.
Regarding the differential diagnosis of new onset IDDM/diabetic ketoacidosis (DKA), one should note that a persistent Candida diaper rash or vulvovaginitis not responding to conventional treatments may be a sign of new-onset IDDM. Therefore, if there is a delay in screening such a patient for IDDM, the patient may present later with life-threatening DKA instead of hyperglycemia without ketoacidosis.
Lastly, to maintain a blood sugar of 150-250 mg/dL while on the low dose continuous insulin infusion/dextrose solution, one alternative approach is to calculate the hourly IV glucose need at 2-4 g of glucose per unit of insulin/hour (usually 2.5-3 g of glucose/unit of insulin/hr) with a corresponding minimal regular insulin drip rate of 0.05 units/kg/hr, along with frequent blood sugar checks.
The authors reply: We would like to thank Dr. DiNicola for his comments and practice suggestions. In patients with type 1 diabetes mellitus (T1 DM) the frequency of thyroid antibodies is 7% to 40% in different studies, with a higher frequency in adolescent girls (Lorini R et al: J Pediatr Endocrinol Metab 1996;9:89). Although the majority of these patients were euthyroid, 3.9-11% had subclinical hypothyroidism, 3% had overt hypothyroidism, 3% had subclinical hyperthyroidism, and 6% had overt hyperthyroidism (Roldan MB et al: Diabetes Nutr Metab 1999;12:27; Smithson MJ: Diabet Med 1998;15:148). Since there is a greater prevalence of undiagnosed thyroid disease in T1 DM, we continue to screen for it.
We agree with the observation that persistent Candida vaginitis or dermatitis is a presenting sign of diabetes mellitus, although our intent was to discuss the differential diagnosis of DKA.
The key to maintaining glycemic control in DKA is close monitoring. We usually titrate the insulin drip according to the blood sugar, pH, and bicarbonate level, especially in DKA where insulin sensitivity is not known (new onset, puberty, obesity, and other insulin resistance states).
While I appreciated the helpful hints in "Bringing a formidable opponent down to size" (May), I have some questions for the authors. I wonder if they could clarify their use of BMI in defining obesity. As they use it, a child is overweight if his or her BMI is above the 80th percentile and obese if above the 95th percentile for age. When the article states that "22% to 23% of American children ages 6 to 17 are above the 85th percentile for BMI for age and 10.9% are above the 95th percentile," it appears to me that something is wrong with the whole concept! That is, by definition, only 15% can be above the 85th percentile and only 5% can be above the 95th.
Indeed, since we are seeing an increasing number of overweight children, defining obesity in terms of BMI percentile for age will result in underdiagnosing the problem as charts of BMI for age are revised upwards. To avoid this problem, is there a difficulty with using a BMI of 30 as the cut-off for obesity? Or a BMI of 25 to 27 for overweight?
When discussing the physical examination, the authors could be more specific when they say "remember to correct for sexual maturity rating." My own take on the puberty factor is that when I see a 5-year-old girl with obesity, I am more concerned than if she were a boy, or younger. I know that we have a limited time to help her with her overweight before she is likely to be triggered into early puberty, which can be an emotional and social disaster (breasts in 2nd grade!) and a mighty exacerbation of the weight problem.
With that in mind, I am baffled by the observation that a 2-year-old who is overweight but has thin parents and no risk factors for cardiovascular disease does not need intervention. It takes a year and a half of no weight gain whatsoever for a prepubertal child to grow into every extra 20% of weight. That is, a child who is 40% overweight (say, a girl age 7 of average height who weighs 77 pounds) will need three years of no weight gain at all to return to a normal weight for height (Bandini, Dietz: Pediatric Annals 1992;21647). How many 7-year-olds can handle that challenge, especially since, in the case of a girl, the extra weight she already has may induce puberty before she reaches age 10?
Surely, then, the issue of overweight should be addressed as soon as a child is identified as being at risk. My own rule is that I intervene when a child deviates upward from the 50th to the 75th percentile or over on the weight-for-height chart, no matter what the age of the child. Most times, the deviation is explained by parental misunderstanding of normal eating patterns, by a caretaker who encourages snacks, TV, and naps, or by a preschooler's preference for sedentary rather than active pursuits. This is much more easily tackled when it first occurs than it is when habits are fully established. The chubbier the child, the more averse to physical exercise; the less physical exercise, the greater the tendency to gain weight.
Moreover, studies that prognosticate childhood risk of obesity are likely to be falsely reassuring. We won't know for 18 to 20 years whether today's 2-year-olds develop into obese adults. Our society, as the article states, is not stable but increasingly obesogenic. Why not intervene, gently but promptly, when children are still young enough to have their lifestyle directed by their parents and other caretakers and are not so much at the mercy of the media and their peers?
I take exception to the idea that it is easy to tell whether a child is of normal weight, chubby, or obese. The reference for this study, in which a nurse practitioner diagnosed obesity by a visual appraisal, is not given in the article. Most of the overweight and even obese children I see in a very busy, highly educated, affluent practice have not been identified as such by their parents. Indeed, most of them fool even our medical students! It takes proper use of the weight-for-height (not weight-for-age) chart, or the use of BMI (weight in pounds divided by inches squared times 705) to determine the degree of overweight. I believe this is because, as the proportion of chubby children in society as a whole has grown and as their portrayal in the media has increased, our perceptions have become skewed. To many adults, a normal-weight prepubertal child looks skinny, a chubby one normal, and an obese one pleasantly plump. Does anyone remember the article by Jerome Knittle et al (Journal of Clinical Investigation, Vol. 63, Feb. 1979) that showed that between ages 2 and 10, normal-weight children do not gain a significant amount of weight as fat? Their weight gain comes almost entirely from muscle, bone mass, and organ growth. No wonder a normal-weight 7-year-old (at the 50th percentile of weight for height) looks "all skin and bones"!
Finally, the article makes no reference to the program SHAPEDOWN, which has a proven track record of helping older children and adolescents manage weight problems. Have the authors found it to be of any assistance?
"Bringing a formidable opponent down to size" is an excellent, timely, and useful article. One thing I would like to have seen, however, is some discussion of physician coding and reimbursement for medical visits related to obesity.
I was wondering if the authors want to comment on the fact that, among patients with bulimia or anorexia, being labeled obese and being told to lose weight by their pediatrician is a not uncommon history.
The authors reply: We thank Dr. Nathanson for her comments. Regarding her questions on BMI, Troiano et al (Arch Pediatr Adolesc Med 1995;149:1085) compared BMI of children in the latest National Health and Nutrition Examination Survey (NHANES III) with the BMI percentiles from the 1970s survey (NHANES I), which used the same methods. Therefore, 22% of 6- to 17-year-olds in the 1990s have BMI above the 85th percentile based on the standards used in the 1970s. Secondly, to prevent the underdiagnosing that Dr. Nathanson has rightly pointed out is a concern, the revised growth charts now available from the CDC continue to utilize earlier data and did not "revise upward" (Kuczmarski RJ et al: "CDC Growth Charts: United States," Advance Data 2000;314:1).
Regarding intervention for the chubby 2-year-old of thin parents, we are referring to the 20-year follow-up by Whitaker et al, which showed a low risk of adult obesity if the only childhood risk factor is a high weight/ height percentile in infancy (N Engl J Med 1997;337:869).
The "visual test" for obesity is a frequently quoted finding that obviously needs repeating using modern data. SHAPEDOWN is a widely used program that seems well designed but for which there is little data to support or refute its efficacy or to let us know for which patients it is most effective.
We thank Dr. Fine for her important comment about reimbursement. It is currently difficult for patients to be reimbursed for obesity treatment. In fact, a recent study by Tershakovec et al (J Pediatr 1999;134:573) reports a reimbursement rate of only 11% at their obesity referral program, and most of the funds came from their Medicaid patients. Many adolescents with obesity have other treatable problems related to their conditions; for example, hypertension, hyperlipidemia, genu varum, or sleep apnea. Since it is poor practice to wait until one of these complications develops to intervene, it is important for all practitioners to advocate for improved reimbursement for this major health problem.
Regarding Dr. Ammerman's observation, while it is true that patients sometimes take our nutritional suggestions to unhealthy extremes, it is important to remember that the morbidity and mortality is as significant for obesity as it is for eating disorders, and the prevalence of obesity is many times greater. Therefore, we do not believe that fear of triggering an eating disorder should prevent us from addressing the problem of adolescent obesity. Rather, to minimize the risk for developing an eating disorder, obesity should be approached in sensitive and nonpejorative terms and with time set aside to understand the patient's and parents' perspective. Close follow-up to see the effect of any diet advice on this vulnerable age group is also essential. We also believe that, whenever practical, recommending weight maintenance, and not weight loss, early in the illness will help prevent extreme solutions by the patient and family.
Julia McMillan. Letters. Contemporary Pediatrics 2001;1:16.