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Battling suicide

Thank you, Dr. McMillan, for your editorial ("Suicide, statistics, and a search for meaning," May 2002) calling our attention to the increasing impact of suicide on young Americans. As you point out, the shock of these sudden deaths is partly because parents, teachers, and friends so often don't suspect the possibility. And yes, we don't yet fully understand this disease and who is at risk.

Still, statistics can help. When cholera was killing people seemingly at random in 19th century London, John Snow used statistics to make sense out of the epidemic and interrupt it. However, just as Pasteur and later Dubos, when old, confessed to wishing that they had spent a bit less time on germs and more on hosts, so we need to move beyond alienation, overdoses, and guns and develop better epidemiology to determine who is susceptible to mental illness and why.

Statistics, properly gathered, help us sort out the genetic, intergenerational traumatic, early childhood protective and inimical factors, and adolescent adjustments that predispose to, or protect children from, suicide. Such data will also help us understand and prevent homicide and the far more common (as you point out) chronic mental health conditions such as depression and addiction. Some of the energy needed to make sense out of these tragedies can come from those bereaved by adolescent suicide, and will help promote healing for them and for us.

Nicholas Cunningham, MD, DrPH
New York, N.Y.

Dr. McMillan's informative and sensitive editorial about adolescent suicide is greatly appreciated. Although the statistics indicate that each pediatrician will have to deal with the issue professionally many times in a long career, I believe that many pediatricians are ill prepared to do so. This, in spite of the fact that the pediatrician often is in the best position to help.

Every pediatrician practices anticipatory guidance to make the home safe for a toddler. Make the home safe for an adolescent, too! A teenager who has attempted suicide may try again. You cannot rid the home of all kitchen knives, ropes, and plastic bags, but one can ask about the presence of guns in the house. Guns are unforgiving. In one case I know of, failure to advise against keeping a gun in the home of a depressed teenager who had been unsuccessful at committing suicide with pills resulted in his tragic "success" with the rifle, which had been a birthday present from Dad.

One can also clear the medicine cabinet of dangerous pills. The family liquor cabinet should be locked or otherwise unavailable.

Talk to the parents and tell them not to blame or find fault with the adolescent, each other, or any friend or family. Placing blame and finding fault is not productive and tends to push people apart. It is important to hang tough together.

Last, don't ignore the religious convictions of the family. Many times, mental health-care professionals ignore or belittle religious beliefs. If there is a more sincere or objective way than prayer for a person to prove that she or he has hope, I would like to know what it is. The depressed teenager may feel hopeless, but the family shouldn't. "Thank God that I didn't do it," is a common thought after an unsuccessful attempt.

One of the great rewards of a long career as a pediatrician is being able to help families through the pain of attempted suicide. I am caring for the beautiful children of several parents whom I cared for, and about, when they were wrestling as adolescents with the tragic impulse of suicide.

Jerome T. Combs, MD
Guilford, Conn.

Promoting breastfeeding

I was pleased to read the two-part series "Challenges in breastfeeding" (May 2002). In addition to the American Academy of Pediatrics' support of breastfeeding, Healthy People 2010 specifically identifies increases in the percentage of mothers who breastfeed their babies as one of its targeted goals.

Absent from either article, however, was any mention of the father's role in the decision to breastfeed the newborn and in the success of breastfeeding. Research in this area clearly shows that the father:

  • plays an important role in infant feeding decisions

  • is an important source of support for the breastfeeding mother

  • often has a more favorable attitude toward breastfeeding than the mother predicts

  • is often misinformed and has misconceptions regarding breastfeeding, and, like many mothers, needs education. (Bar-Yam NB et al: J Hum Lact 1997;13:45; Jordan PL et al: Birth 1990;17:210; Littman H et al: Clin Pediatr 1994;33:214; Freed GL et al: J Fam Pract 1993;37:148; Freed GL et al: Am J Perinatol 1993;10:300; Freed GL et al: Pediatrics 1992; 90[2 Pt 1]:224; Sharma M et al: J Am Diet Assoc 1997;97:1311)

The involvement of fathers clearly is among the important factors determining breastfeeding initiation, continuation, and success. Health-care professionals who work with parents of newborns would do well to include fathers in their approach to breastfeeding. In this way, we can move closer to increased and more successful breastfeeding of newborns.

Craig Garfield, MD
Chicago, Ill.

While I greatly enjoyed "Challenges in breastfeeding: Maternal considerations," I take exception to the emphasis on electric breast pumps as an aid to lactation for mothers whose infants are too ill to nurse. I would be the first to agree that the traditional "bicycle horn" style manual pump is of limited effectiveness. However, recent studies, both in the United States and in Great Britain, have shown that a manual breast pump is as effective in promoting lactation and at considerably lower cost (Fewtrell MS et al: Pediatrics 2001;107[6]:1291). The Avent ISIS breast pump is one such type that is well known and readily available. Regrettably, many neonatologists and pediatricians were trained at a time when only old-style pumps were available and are not familiar with newer types of manual pumps. For short-term use, certainly, a modern manual pump is an inexpensive alternative.

Robert B. Baker, MD
Monroeville, Pa.

"Challenges in breastfeeding: Maternal considerations" was timely, well written, and full of wonderful clinical tips and facts. I add one small word of caution about fenugreek, which is listed in the table on common galactogogues. The authors list several important adverse effects of this herb, which is commonly used around the world. I want to mention the case of a 5-week-old Egyptian baby who drank a tea containing fenugreek seeds and lapsed into a 10-minute period of unconsciousness (Sewell AC et al: New Engl J Med 1999; 341:769). The baby's body and urine emitted the aroma of Maggi (a flavoring) reminiscent of the sweet odor of maple syrup urine disease. Multidimensional gas chromatography and mass spectrometry analysis of the urine and the tea yielded positive results for the presence of sotolone, which is the compound responsible for the peculiar aroma in maple syrup urine disease.

Although the seeds of fenugreek have been used for both medical and culinary purposes since antiquity in Eastern Indian and Southeastern European cooking, patients and their physicians need full and reliable information before making a decision to prescribe or use this, or any, herbal medication. "Natural" is not always safe.

Gerald Ente, MD
Westbury, N.Y.

Complementary medicine: Ignored, at a price

Complementary modalities, such as those described in "Otitis media: When parents don't want antibiotics or tubes" (April 2002), range from ancient therapies to cutting edge approaches. Although volumes of information about these therapies exist, nothing about complementary medicine was ever taught to me in my four years of medical school or during my three years of residency. I suspect that many other physicians were not exposed to the possibilities of complementary medicine during their education or training.

My exposure to the world of complementary therapies was the result of a quest to help my 4-year-old son, Phillip, who has spastic diplegia cerebral palsy. Born at 28 weeks' gestation, he suffered an intraventricular hemorrhage and hydrocephalus requiring a ventriculoperitoneal shunt. We provided him with the early intervention program and many hours of physical therapy (PT), occupational therapy (OT), and speech therapy (ST). We tried botox and alcohol injections, which undoubtedly improved, albeit temporarily, the spasticity in Phillip's legs. However, the formation of antibodies from botox, the tissue destruction from the alcohol, and the need to undergo general anesthesia for the alcohol block led me to seek a more gentle, painless, longer lasting, less invasive therapy. After some trial and error we came upon a myofacial release massage therapy, which has helped Phillip and is used as an adjunct to his PT, OT, ST, and karate classes.

During my search I was thrilled—and somewhat overwhelmed—to discover a world of herbs, vitamins, minerals, homeopathics, bodywork, acupuncture, nutritional strategies, and a great many other modalities that have, I believe, so much to offer both the sick and the healthy patient. Why would medicine ignore such potentially beneficial modalities, some of which clearly are safe, simple, and effective?

We can argue endlessly about what "natural" means and whether it is better. And we must acknowledge that the safety and efficacy of complementary therapies are still being investigated. But with the trend toward using evidence-based medicine such as the Cochrane Library, thousands of years of anecdotal ancient therapies can be explored by mainstream professionals. We must keep an open mind about modalities we are not familiar with, no matter how absurd they initially seem. We must question if that which we think is beneficial really is. Just in my short time as a medical student and resident we have, for example, changed from putting babies to sleep on their stomach to putting them to sleep on their back, and from treating all cases of otitis media with antibiotics to not always prescribing antibiotics. The "truths" of allopathic medicine change from day to day.

Julia Bramwell, MD
Newark, N.J.


Readers' Forum. Contemporary Pediatrics 2002;8:19.

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