LETTERS

LETTERS

A clinical dilemma

I read "Perinatal GBS: Guidelines worth following" (January)with great interest. I would appreciate a comment on the following clinicaldilemma I repeatedly encounter. A full-term infant is born to a mother whois Group B streptococcal (GBS) positive. The mother has not previously deliveredan infant with invasive GBS disease, did not have GBS bacteriuria duringthis pregnancy, and did not have an intrapartum fever, and her membranesruptured within 18 hours before delivery. She received only one dose ofintrapartum penicillin prophylaxis before delivery.

The infant appears well after delivery with no signs or symptoms of sepsis.A complete blood count (CBC) with differential and blood culture is obtained.The baby will be observed for at least 48 hours before being discharged.What are the recommendations for interpreting the CBC with differentialas to antibiotic treatment for this baby?

Richard Sarkin, MD
Buffalo, NY

The author replies: The clinical scenario Dr. Sarkin describesis indeed common. A full-term infant appears healthy at birth, but has beendelivered to a woman who received insufficient prophylaxis for preventionof early-onset GBS infection. Empiric antibiotic therapy should not be initiatedin this infant unless signs of sepsis develop during the observation periodor the results of the limited evaluation suggest infection.

Dr. Sarkin appropriately questions how the CBC might dictate empiricantibiotics. The expert committees who recommended a CBC in these patientssuggest by implication that an abnormal result would prompt empiric therapy,but the definition of "abnormal" as it relates to suspicion forinfection is not precise.

The literature contains normal ranges in white blood cell count as wellas number of mature and immature neutrophilic forms. For a term infant,a white blood cell count of less than 5,000/mL or an immature-to-total-neutrophilratio exceeding 0.15would be considered abnormal during the first 24 hoursof life. The negative predictive value of these tests is high, but theyare insufficiently sensitive to predict infection accurately. This is afeature of the GBS prevention guidelines that needs additional study tojustify or refute the usefulness of this laboratory test in the managementof such infants.

Carol J. Baker, MD
Houston, TX

Wrong "take-home message"

The recommendations for hepatitis A vaccination for specific populationsoutlined in "A progress report on hepatitis A vaccination" (December)indicate that travelers and children in communities that have high ratesof hepatitis A "should" be vaccinated for hepatitis A, while menwho have sex with men are to be "considered" for vaccine.

In Seattle, WA, close to 50% of new hepatitis A cases are diagnosed inmen who have sex with men, in contrast to the 4% the article cites. Casesare occurring in younger men, many of whom obtain care from pediatricians.The Centers for Disease Control Committee on Immunization Practices andthe Committee on Infectious Diseases of the American Academy of Pediatricsare unequivocal in their recommendation for vaccination of this group alongwith the other groups mentioned in the article (MMWR 1996;45:1 and 1997Red Book). Neither statement mentions that vaccine should be "considered"for this population. The recommendations apply to all men who have sex withmen, whether or not they identify themselves as homosexual or bisexual.

Given the current epidemiology of hepatitis A and the recommendationsof both the CDC and the AAP, a "take-home message" of the articleshould have been the importance of identifying patients at risk via a nonjudgmentaland thorough sexual history, and immunizing all men who have sex with men.

Ted A. Eytan, MD, MPH
Seattle, WA

The authors reply: We concur with Dr. Eytan's comments. In fact,in the manuscript we submitted, the passage under discussion was wordedas follows: "In a pediatric practice, a history of homosexual relationsin an adolescent male should support vaccination." We agree that theeditors should not have used the word "consider" and that allpatients who give a history of homosexual male relations ought to receivethe vaccine or be tested for previous seroconversion.

Neil Harris
Kathryn Edwards, MD
Nashville, TN

Are metal curettes really a good idea?

Dr. Martin Herman's Clinical Tip (December) was unsettling to me. Dr.Herman was exasperated by the tendency of his metal cerumen curette to slipout of his pocket when he bent over to examine a patient. He discoveredthat the problem could be solved by wrapping a rubber band around the baseof the handle.

The practice of using a nondisposable ear curette may pose an unnecessaryrisk of transmitting blood-borne pathogens between patients. Even if theuser's technique is flawless and the patient's external canal epidermisnever is scratched, it is always possible that the patient's integumentis inflamed or broken. The risk, albeit small, is not worth taking. I wouldurge all physicians to use a new disposable plastic curette when removingcerumen from a patient's ear canal. Forget the rubber band.

Mary Ann Carmack, MD, PhD
Palo Alto, CA

I have two concerns about the efficacy of this Clinical Tip. First, inthis age of vigilance concerning cross contamination, why use a metal curette?Second, if the device is sterilized doesn't the attached rubber band becomebrittle or degraded? Maybe if the device is sterilized in an appropriatesleeve it would be more secure in the pocket and parents would not haveto worry that the device had been used on someone else.

Fred Malkin, MD
La Habra, CA

The author replies: While I can understand the concerns of Dr.Malkin and Dr. Carmack about using a metal cerumen curette, I do not sharethem.

First, since the auditory canal is external, rubbing it with the curetteamounts to nothing more than rubbing any patient's intact skin with a bluntmetal object, as when checking for a Babinski's reflex with a reflex hammer.Do these doctors suggest using a disposable reflex hammer when performingthat test? I should think not. Second, when I find purulent material ina patient's external ear, there is no need to clean the ear and I don'tuse the curette since I will be instituting therapy anyway.

I do not like the way the plastic disposable curettes perform. And mostdoctors I know who purchase them use each curette many times, mitigatingthe advantage of their disposability.

The possibility of HIV transmission is worth considering, but the risksare extremely low.

Martin Herman, MD
Cordova, TN

Why the eosinophilia?

With regard to the February Pediatric Puzzler "Stomach pain in a3-year-old: Abdominal or abominable?" I would like to know how theauthor explains the striking total eosinophilia present in both the initialand repeat CBCs.

Spencer J. Brody, MD
Laconia, NH

The authors reply: Dr. Brody is correct; the eosinophil countis high. The cause of the elevation was not pursued during the child's hospitalization.The family had a history of atopy, which may account for the eosinophilia.The degree of eosinophilia is not directly correlated with symptoms of atopicindividuals. The child had not received medications, so a drug reactionis not likely. Another cause of eosinophilia is infection, particularlyscarlet fever, tuberculosis, and histoplasmosis. It is possible that theepidural abscess may have resulted in this response.

Rani Gereige, MD
St. Petersburg, FL
Walter W. Tunnessen, Jr., MD
Chapel Hill, NC

For help with stuttering

I read with interest the question about stuttering in "Behavior:Ask the experts" (January) and Dr. Edward R. Christophersen's effortsto shed some light on this complex disorder affecting more than 3 millionAmericans. Your readers also should know how to contact an excellent nonprofitsource of help: the Stuttering Foundation of America. We make available,free of charge to pediatricians, a book entitled The Child Who Stutters:To the Pediatrician. The book includes a physician's checklist for referral,a list of questions that the pediatrician might ask parents, and suggestionsfor parents of children who stutter. For more information, readers may contactus at PO Box 11749, Memphis, TN 38111-0749. Our E-mail address is stuttersfa@aol.com and our website http://www.stutterSFA.org. Finally, physicianscan call our toll-free hotline at 800-992-9392.

Jane Fraser
Memphis, TN

More about transsexuality

As a pediatrician who answers a help line for PFLAG (Parents, Families,and Friends of Lesbians and Gays) I was interested in the exchange abouta boy who wants to be a girlin "Behavior: Ask the experts" (February).

The pediatrician has much to draw on to assure the parents of childrenwho are gay that the lives of their offspring can be happy and productive.But an individual who feels he or she must change genders has a rough roadahead. I gained the most understanding from a book chapter written by atransgendered woman. She tells of growing up as a boy but never feelingthat she was intended to be one. She later began to live as a woman andeventually found happiness after having sex-change surgery. Her story isone of 49 in From Wounded Hearts--Faith Stories of Lesbian, Gay, Bisexualand Transgendered People and Those Who Love them. The book is publishedby ChiRho Press, Gaithersburg, MD, and is available from Amazon.com.

Helen H. Rawson, MD
Lansdale, PA

CORRECTION

The telephone numbers for the Emergency Contraception Hotline given in"Providing emergency contraception in the office" (March) wereincorrect. The correct numbers are 888-NOT-2-LATE and 00-584-9911.