Your Voice: Breast milk, immunizations, and iron

September 1, 2009

Letters to the editor about iron deficiency, encouraging vaccinating children in the hopsital, and more.

Why not immunize hospitalized children?

Regarding Dr. McMillan's editorial "Vaccine policy and health care reform," there is a window of opportunity for vaccinating our children every year against influenza that no one has really pushed forward on. When children are hospitalized during influenza season, shouldn't we address-or at least encourage on discharge-that they receive a flu vaccine? We have established this protocol of care for all adults admitted into a hospital, but few hospitals advocate the same standard for pediatrics. Many families have no primary care provider, or are lax about yearly flu vaccine: they could be approached during hospitalizations. Has the American Academy of Pediatrics even addressed this issue? I am a Pediatric Clinical Nurse Specialist in a community hospital with a big pediatric population, and hope to start a hospital-based pediatric flu immunization program.

Sincerely,
SUSAN HINDS, ARNP, MS, CPNP
Lakeland, Fla.

Many thanks to Ms. Hinds for her letter reminding us that children who are hospitalized should be offered influenza vaccine before discharge. Hospitalized children are likely to be among those at greatest risk for severe influenza infection, and hospitalization provides an opportunity to emphasize the importance of annual influenza immunization.

Ms. Hinds is correct that recommendations for immunization of pediatric patients have lagged behind those for adults. Standing orders for influenza immunization, particularly for elderly patients, have been the norm in many hospitals for at least a decade. One can imagine many reasons for reluctance to implement a routine policy for pediatric patients:

1) Depending on the time of year, many hospitalized children will have already received influenza vaccine for the relevant season; policy implementation would require verification with each child's primary pediatrician to avoid duplicate immunization.

2) Coordination with primary pediatricians for children who require two doses of influenza vaccine during the relevant season would also require careful communication and documentation to ensure correct timing of doses and to prevent duplication.

3) Availability of vaccine varies by time of year, so any protocol for routine immunization would be relevant only during the months vaccine is available, and will vary from year to year.

None of the above reasons justifies failure to ensure appropriate influenza immunization of children who require hospitalization. Perhaps, one day, we will have immunization registries in all communities, and documentation of receipt of immunization will be available to any provider from whom families seek care. Until then, direct communication between hospital-based providers and community physicians is the only means of assuring appropriate administration of influenza vaccine (and any other missed immunizations) to hospitalized pediatric patients.

–JULIA A. McMILLAN, MD

OME AND CHILD DEVELOPMENT

In the late 1960s, when still in private solo practice in a large suburban community, I was the only pediatrician who did not buy into the studies that otitis media with effusion (OME) caused children to have difficulty speaking or delayed their development. I did not agree with the AAP's recommendations for surgical intervention. All my pediatric peers, on their patients and their own children, gleefully practiced myringotomy and tympanostomy tube insertion. No one believed me when I refused to refer my own OME patients to otolaryngologists for this procedure, and did my very best to discourage all patients who came to me for a second opinion. My reasoning: If OME caused delayed speech and development, why did I not see this in any of the parents of my patients (and the general population I dealt with) who obviously had just as much OME in their youth, without the benefit of tympanostomy tubes?

I thought this reasoning was just common sense, obviously not realized by the academic institutions pushing for tympanostomy tube insertion and making the rules for us pediatricians "in the field." It was heartening to read the article in Contemporary Pediatrics by Feldman and Paradise, with their recommendations and AAP's new stance on this subject. I felt justified that I did do the right thing, did not harm my patients with what I considered a common-sense approach, and saved them from a surgical procedure they did not need. And saved them some money.

HORST D. WEINBERG, MD
Sacramento, Calif.

Dear Dr. Weinberg, Thank you for sharing your perspective on the issue of tympanostomy tubes for OME. It sounds from your letter that you were indeed prescient. However, even if we end up on the "right" side of a debate, all of us in medicine must guard against the temptation of drawing inferences from the relatively small samples we encounter in our own clinical practices. We are gratified that the evidence-based recommendations for management of OME, promulgated by several major professional organizations, now draw heavily from the studies we summarize in this article.

HEIDI M. FELDMAN, MD, PHDJACK L. PARADISE, MD

THE BREAST VS COW'S MILK

I agree with both Dr. Voit and Dr. Weintraub about breatsfeeding (Your Voice, July 2009). We need to start being more proactive, especially as pediatricians. Our biggest role is to promote prevention by encouraging healthy eating from the beginning at birth.

I am a full-time pediatrician at a very busy practice. I breastfed my son until fifteen months of age. This was hard, as I spent two to three short breaks a day pumping. Learning the breastfeeding and pumping process was extremely difficult and painful. I think it is our health care professions' responsibility to mandate assistance to all new moms to make certain this imperative process is successful. We all know the short-term and long-term benefits. I will admit that until I breastfed my son, I had no idea how difficult a task it was, and how little support there was out there. It can and needs to be done.

It does absolutely impact the iron deficiency anemia problem we face. As kids become cow's milk drinkers they pay the price not only with this problem, but with many others: GERD, poor feeding, constipation, chronic abdominal pain, eczema, allergies, reactive airways disease, tonsillar and adenoidal hypertrophy with subsequent snoring and potential sleep apnea, poor sleeping, attention issues, etc.

The recommendation of 24 ounces of cow's milk, especially whole milk at one year of age, needs to be reexamined. What are we doing to our kids? We need to encourage more breastfeeding and encourage a limit on cow's milk consumption. Kids get plenty of calories from solids, and that is where the majority should come from. Back off the juice recommendation, too. Maybe then we could combat iron deficiency anemia, childhood and adult obesity, and decrease ER and doctor's visits for illness related to the diseases listed above.

Sincerely,
KRISTIN STRUBLE, MD
Phoenix