Updates

UPDATES

Happy, happy shall I be When I've learned my ABC

The evidence grows more persuasive all the time: high-quality education starting in early childhood has solid, lasting benefits for poor children. That finding holds up for children in 111 poor African-American families in Chapel Hill, NC, who were enrolled in the Abecedarian project in infancy and followed till the age of 21. These were children who were medically healthy but—in terms of family income, mother's age and education, inner city residence—at risk for school failure. Half the children in the study were randomly assigned to full-time day care from infancy until 5 years of age; the others received nutritional and social work interventions, but did not attend the project's day-care program. Both groups attended comparable public schools from kindergarten on.

Children in the program progressed through a series of carefully designed educational games, ranging from simple visual stimulation for infants to scavenger hunts and mazes for older toddlers. Games were informal, happening whenever children and adults interacted, at meals, during diapering, or on the playground, and the activities were interspersed throughout what project members describe as "a high-stimulus day" of art projects and playground visits. Staff members were well-trained professionals, turnover was minimal, and adult-to-child ratios ranged from 1:3 for infants to no more than 1:7 for older children. The project was based at the Frank Porter Graham Child Development Center in Chapel Hill.

Differences between the two groups of children were striking. Children in the program outperformed controls on cognitive and academic tests in the early grades, and the differences persisted into adolescence. While test scores were below average for both groups and dropped over time, children who had been in the program kept an edge of about five percentage points through age 21. By age 15, twice as many of the control children were in special education classes. At age 21, twice as many of the program graduates were still in school; 65% either had a good job or were in college, compared to 40% of the controls. The program also helped the children's parents, with teenage mothers far more likely to have completed high school after their babies received the intervention.

If funding holds out, the researchers intend to continue tracking these children until the age of 28 or 29, but the import of their study seems clear enough at this point: high-quality early childhood education can make a difference. To get an advance look at the findings, prior to print publication, go to the project's Web site: www.fpg.unc.edu/~abc.

More ado about vaccines

The big news is that Prevenar, the trade name for the seven-valent conjugate pneumococcal vaccine from Wyeth Lederle Vaccines, is well on its way to licensure. The new vaccine was recommended for inclusion in the routine immunization schedule by the Advisory Commission on Immunization Practices (ACIP) in late October, and found "safe and effective in preventing invasive pneumococcal disease in young children" by the Food and Drug Administration's Vaccines and Related Biologicals Advisory Committee on November 5. A priority review by the FDA is currently underway.

Other vaccines also made the headlines last month:

• Routine rotavirus vaccination, suspended while a suspected link to intussusception was investigated, is no longer recommended by the ACIP. The Centers for Disease Control and Prevention reported studies showing the vaccine appears to cause the condition in about one of 5,000 children who received the vaccine. American Home Products, the manufacturer, has withdrawn the vaccine from the market.

• Routine immunization against hepatitis A in 11 states where the infection is endemic has been officially endorsed by the CDC. The states are AZ, AK, CA, ID, NV, NM, OK, OR, SD, UT, and WA. Consideration of routine immunization was also recommended for MO, TX, CO, AR, MT, and WY.

• The ACIP now recommends inactivated poliovirus vaccine (IPV) for routine use, with the oral vaccine being reserved for special circumstances. The AAP's Committee on Infectious Diseases is expected to make the same recommendation in a report published in this month's issue of Pediatrics. The rationale behind the new recommendation is that IPV decreases the risk of vaccine-associated paralytic polio.

• Meningococcal vaccination for college freshmen who live in dormitories was recommended by ACIP as the best means of preventing outbreaks of meningococcal meningitis in the college age group. In recent years, infection rates have been rising among young adults, and studies have shown that college freshmen are particularly vulnerable.

• Varicella immunization recommendations have been updated. ACIP now says that all states should require vaccination or evidence of immunity for all children entering child-care facilities and elementary schools; that susceptible patients should be vaccinated after exposure; that teens and adults who live with young children are a high-risk group and should be vaccinated; and that the vaccine may be given to children with asymptomatic or mildly symptomatic HIV infection.

For more on vaccines, watch for our special report on the vaccine schedule for 2000, coming next month.

The electronic pediatrician

It was only a matter of time until the American Academy of Pediatrics took off into cyberspace, claiming a share in the booming business of providing health information to consumers and customized home pages for physicians. The new venture is called Medem.com, and it is being launched by a consortium of physicians' associations that also includes the American Medical Association, The American College of Obstetricians and Gynecologists, the American Academy of Ophthalmology, the American College of Allergy, Asthma, and Immunology, the American Psychiatric Association, and the American Society of Plastic and Reconstructive Surgeons.

Medem, which stands for "medical empowerment," is a two-tiered organization consisting of a for-profit company owned by the participating associations and a nonprofit corporation. The for-profit company is responsible for the design, development, delivery, and management of the Internet services provided for consumers and physicians. The nonprofit entity controls editorial standards for independence, appropriateness, and integrity of the content.

Initial funding for the project came from contributions from the seven founding medical societies. Ongoing funding will be derived from advertising and corporate sponsorship. Pediatricians who open a home page will be charged a monthly fee or can choose to accept corporate "sponsorship" for the page. According to Joe M. Sanders, Jr., MD, AAP Executive Director, ads and sponsors will be vetted for appropriateness and accuracy; unhealthy or unsafe products (cigarettes or home trampolines, for example) would be off limits.

Pediatric information dispensed on the site will be drawn from content already published by the AAP, in the Academy's journals, patient education brochures, and parenting books. When necessary, the material will be rewritten by Medem staffers to be accessible to consumers. Parents can access information directly from the Medem Web page or via their own pediatrician's home page. Home pages also allow for e-mail communication between patients and the pediatrician's office and, as Dr. Sanders says, "put physicians back in the loop" when internet-savvy parents go looking for answers to their children's health-care needs.

We're a winner!

The editorial staff of Contemporary Pediatrics was delighted to learn recently that the magazine had been chosen to receive a 1999 Editorial Excellence Award from Folio magazine, a publication with a 10-year tradition of honoring magazine editors. At a gala awards dinner at Manhattan's New York Hilton last month, we were given a gold award in the medicine and health category.

Folio's Editorial Excellence Awards are unusual in that entries are judged on how well they fulfill their own mission statements rather than against other entries. Our mission statement emphasizes our educational aims and the diversity of pediatricians' needs, and we entered our November 1998 issue. It included Joan Chesney and Ian Burgess's cover story on lice; other feature articles on strep throat, the hip, inborn errors of metabolism, gay and lesbian teens, and cleft lip and palate; a profile of a school principal in Rochester, NY; and our usual complement of departments. What a line-up! What fun to win!

Psychotropic drugs for kids

Pediatricians and family physicians are not hesitating to prescribe selective serotonin reuptake inhibitors (SSRIs) for children and adolescents—despite the paucity of data on safety and efficacy in the pediatric age group. When researchers from the University of North Carolina at Chapel Hill asked 600 physicians whether they had ever prescribed an SSRI for a patient younger than 18, 72% said Yes. Mild or moderate depression was the most common reason for the prescription, cited by 67% of respondents. More than half (57%) had also prescribed an SSRI for a diagnosis other than depression, including attention deficit/ hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), aggression/conduct disorder, and enuresis. Despite this widespread use, only 8% of respondents felt they had received adequate training in the management of childhood depression, and only 16% said they felt comfortable with the care of depressed children.

According to Jerry L. Rushton, MD, a pediatrician and Robert Wood Johnson Clinical Scholar at Chapel Hill, the findings show that SSRIs are being incorporated into primary care practice. Dr. Rushton believes that treating childhood depression with SSRIs is "reasonable," and advises clinicians that the drugs should be used with caution and the children who take them be monitored closely. "SSRIs should not be used," he says, "for transient symptoms, school problems, or nebulous behavior problems." He urged primary care physicians to work with psychiatrists and to include psychotherapy or counseling in their patients' treatment plans. Multimodal approaches to depression such as counseling, family intervention, and behavioral therapy have been shown to be effective in adults and adolescents.

EYE ON WASHINGTON

In the nation's capital last month, campaign fever was in the air. Presidential candidates from both parties put forth policy position on issues like education, health care, and tax cuts, and made frequent visits to New Hampshire in hopes of corralling votes in the upcoming presidential primary. The Congressional leadership and the Administration battled publicly over appropriations bills, while privately trying to negotiate compromises that would keep the government running and allow Congress to adjourn by Thanksgiving. Members of the House were particularly anxious to be free to attend to their reelection campaigns; according to a New York Times/CBS poll, 45% of voters nationwide say they will vote for a Democratic candidate, 38% for a Republican. If that seven percentage point advantage were to hold through all 435 districts, Democrats would regain control of the House of Representatives.

In actions of particular interest to physicians last month:

President Clinton announced new federal regulations governing the confidentiality of electronic medical records and printouts from such records. Patients would have the right to review, copy, supplement, and suggest corrections to their records. Under the proposed rules, physicians, hospitals, and managed care organizations would be required to notify patients of their privacy rights but not to require consent before records are shared for the purpose of medical treatment or the payment of claims. The federal rules would not preempt more stringent state regulations where they exist. The public will have an opportunity to comment on the proposed rules, which will be issued in final form by February 21^st of next year.

The CDC reported four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in MN and ND. The four children, none of whom had established risk factors for MRSA, were a 7-year-old girl, a 16-month- old girl, a 13-year-old girl, and a 1-year-old boy. The CDC advises clinicians to consider MRSA in cases of severe pediatric pneumonia or sepsis syndromes in areas where community MRSA infections have been reported.

The Consumer Product Safety Commission outraged some pediatricians and parents who favor co-sleeping with a pronouncement that letting children under 2 years of age sleep in the parental bed was unsafe. The Commission's warning was based on a study of 515 deaths of children under 2 years of age recorded in death certificates and newspaper accounts over an eight-year period. In 121 of these deaths, a parent, sibling, or other adult had overlain the child; in the remaining 394, the children had died after becoming trapped in the bed structure (wedged between mattress and headboard, for example) or suffocated when lying face down on a waterbed.

The National Center for Complementary and Alternative Medicine (NCCAM) has a new director: Stephen E. Straus, MD. Dr. Straus has served since 1991 as Chief for the Laboratory of Clinical Investigation at the National Institute for Allergy and Infectious Disease and is a recognized expert on chronic fatigue syndrome, Lyme disease, AIDS, and chronic post-herpetic pain—all conditions for which alternative remedies are in use.

The Agency for Health Care Policy and Research has named pediatrician Donald M. Berwick, MD, chair of the National Advisory Council for Health Care Policy, Research, and Evaluation. The agency, along with the David and Lucile Packard Foundation and the Health Resources and Services Administration (HRSA), has allocated $9.1 million over a three-year period to fund research into improving quality and access to care for low-income children. It has also opened a Web site (www.guideline.gov) where physicians can access clinical practice guidelines gathered by the National Guideline Clearinghouse.

—Judith Asch-Goodkin
Contributing editor

Judith Asch-Goodkin. Updates. Contemporary Pediatrics 1999;12:8.