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UPDATES

High-quality child care not harmful, study shows

In the US today, stay-at-home parents are rare and many babies--eventhose who are very young--are cared for at least part of the time by others.Opinion about the impact of this trend on child development is sharply divided,and often impassioned. So the gathering of solid data on the subject shouldbe welcome.

The National Institute of Child Health and Human Development, in collaborationwith researchers at 14 universities around the country, has been gatheringsuch data since 1991. Their study has enrolled some 1,300 families and theirchildren at 10 different locations throughout the US. The children havebeen followed through their first-grade year.

Already published data has been, on the whole, reassuring. Researchershave found no differences in maternal-infant attachment between infantscared for only by their mothers and infants cared for part of the time bysomeone else. Further, findings released in 1997 indicated that high-qualitychild care had some real advantages for the development of cognitive andlinguistic skills. Additional findings released this year show childrenin quality care display greater social competence and less problem behaviorat 2 and 3 years of age than stay-at-home children, and that out-of-homecare still had no discernible influence on the security of attachment atage 3.

The problem, and it's a very serious one, is that most US child careisn't high quality. According to the research results, it's only "fair."To improve the picture, researchers say, child care centers must have smallergroups, a better ratio of teachers to students, better educated teachers,and more continuity of care.

Bite of bat--and other creatures

The Advisory Committee on Immunization Practices (ACIP) has recentlyrevised its recommendations for rabies prevention, and pediatricians shouldtake heed. For while this fatal infection is extremely rare in the US, thewidespread presence of the virus in wild animals--especially raccoons, skunks,and bats--continues to present a real danger (MMWR 1999;48[RR-1]).

According to the ACIP recommendations, the essential aspects of prophylaxisfor children exposed to a rabid animal are infiltrating bite wounds withrabies immune globulin and administering both rabies immune globulin andrabies vaccine. The problem is that exposure to a rabid animal is not alwaysobvious--especially when the animal is a bat whose tiny teeth may not leaveany marks or cause any sensation of being bitten.

So what's a pediatrician to do? According to Paul Arguin, MD, epidemiologyintelligence service officer in the CDC rabies section, the best adviceis to keep the possibility of rabies on your mental horizon whenever ananimal bite occurs--especially from a wild or stray animal. With regardto bats, be suspicious:

• whenever a child has been in direct contact with a bat, whether a bite is reported or not, or
• the child has been in a setting in which an unrecognized contact is a reasonable possibility--asleep in one part of the house when a bat was seen in another room, for example.

In situations like that, advise parents to keep the animal, dead or alive,for observation and testing, and call your local health department for adviceon what course to pursue. Remember, of the 21 cases of human rabies in whichabat-variant virus has beenidentified since 1980, a bat bite was reportedin only two.

Medical editors react to Lundberg's ouster

Jerome P. Kassirer, MD, editor of the New England Journal of Medicine,called it "an irrational decision and an ominous precedent." RichardHorton, in The Lancet, said it "needlessly wounded ...editorial independence."The editors, staff, and editorial board of the Journal of the American MedicalAssociation and the AMA's archive journals condemned it and published areaffirmation of JAMA's commitment to editorial independence.

"It" was the summary dismissal of George Lundberg, MD, fromhis position as editor of JAMA. Dr. Lundberg was fired by AMA ExecutiveVice President E. Ratcliffe Anderson, MD, for interjecting the journal intoa political debate by publishing a survey on whether oral sex constituted"having sex" at a time when that very question was part of thedebate on presidential impeachment (JAMA 1999;281[3]:275).

James A. Stockman III, MD, member of the Contemporary Pediatrics editorialboard and President of the American Board of Pediatrics, says Dr. Lundbergwas "between a rock and a hard place" when he had to decide whetherto publish a peer-reviewed, scientifically adequate but politically sensitivereport. But, Dr. Stockman continues, "a rock and a hard place is alsothe spot where journalistic integrity will quickly reside when editorialpolicy is no longer immune from the politics of parentmedical societies."And guaranteeing editorial independence, says Contemporary Pediatrics Editor-in-chiefJulia McMillan, MD, is what matters most: "Without such guarantees,the prestige of JAMA, developed during the 17 years of Dr. Lundberg's tenure,will be sorely compromised."

JAMA's loss is Medscape's gain. Dr. Lundberg was named Editor-in-chiefof the medical website in late February.

Surfing the web

Pediatricians struggling to keep their heads above the rising informationwaters can use some guidance
on websites worth consulting. Try these:

• www.pdr.net, for access toarticles from Medical Economics publications (including this one), the Physicians' Desk Reference, abstracts in the MEDSLINE,AIDSLINE, and CANCERLIT data bases, patient education, news, and stock quotes.
• www.brightfutures.org, to download health supervision encounter forms in English and Spanish, practice guidelines, and the Bright Futures newsletter.
• www.nhlbi.nih.gov, for up-to-date information on asthma diagnosis and treatment. The site, maintained by the National Heart, Lung, and Blood Institute, contains almost all the scientific literature on chronic asthma ever published.
• www.plasticsurgery.org, to help families find a board-certified plastic surgeon and learn how to fight insurance denials for reconstructive surgery for congenital deformities
• www.babycenter.com, for information on how to get a free web page for yourself on a site where parents shop for everything from car seats to pediatricians. The site is a joint venture of BabyCenter, Inc and Procter & Gamble's Pampers Parenting Institute. If you're interested, call 888-397-5544, extension 168.
• www.nal.usda.gov/fnic/IBIDS, for access to the International Bibliographic Information on Dietary Supplements (IBIDS), a database compiled by the NIH Office of Dietary Supplements and the Department of Agriculture.
• www.ldonline.org, for parent-education materials on learning disabilities. The materials are part of the Coordinated Campaign for Learning Disabilities, a collaborative public awareness effort sponsored by the Learning Disabilities Association of America with support from the Emily Hall Tremaine Foundation.

Dental association condemns tongue piercing

Of all the teenage fads that have come down the pike, the sight of aminiature barbell in a patient's tongue or a safety pin through the lipis probably one of the most disturbing. What's more, says the American DentalAssociation, this fad is downright dangerous to teenagers' health, whichis why the ADA passed a resolution condemning oral piercing at their recentannual meeting in San Francisco. "Our chief concern is beyond whetherit's crazy or not," says Dr. Timothy Rose, President of the ADA. "We'reworried about the risk of disease, which has to be immense when someonesticks a needle, clean or dirty, through a vascular part of your body."

Doron Kochman, DDS, a clinical reactor forContemporary Pediatrics, hasseen patients with "a lot of swelling and pain" after piercing,and he worries about the lack of sterility when untrained and unregulated"piercers" perform these operations. This is a free society, Dr.Kochman says somewhat ruefully, so teens have to be permitted to choosethis form of adornment if they like. But he'd like to see piercers regulated,to assure that their training is adequate and that all essential medicalprecautions are followed. Until that happens, the best you can do is discourageadolescents who ask about oral piercing and hope the fashion plays itselfout fairly soon.

New drugs

If you want to prescribe a third generation oral cephalosporin for youryoungest patients, cefdinir is now available as a suspension (Omnicef oralsuspension, Parke Davis) for patients 6 months of age and older. The strawberry-flavoredliquid contains no alcohol and for most indications is taken only once aday, without regard for meals.

Another cephalosporin, cefpodoxime proxetil (Vantin, Pharmacia and Upjohn)has been approved by the FDA as tablets and suspension for the treatmentof mild-to-moderate maxillary sinusitis; the suspension is also approvedfor five-day treatment of mild-to-moderate otitis media for patients 2 monthsto 12 years of age.

And for little kids who weren't happy with chewable acetaminophen tablets(Children's Tylenol), McNeil is introducing a Soft Chew dosage form in bubblegum, grape, and other fruit flavors.

In other drug news, Merck's 2.5 mg dose of hepatitis B vaccine (RecombivaxHB) has been replaced by a 5.0 mg dose recommended by ACIP for childrenaged 0 to 19 years of age, and the FDA now requires labels on inhaled andintranasal corticosteroids warning about possible growth rate reductionin children who use these products.

Calendar

April 7­10, Building for theFuture: Caring for Children, San Antonio,TX. Contact the National Association of Pediatric Nurse Associates and Practitioners(NAPNAP) conference office, 609-256-2300

April 12­13, Building Bridges Research Conference, Chicago, IL, sponsoredby the American Association of Health Plans, the Agency for Health CarePolicy Research, and the CDC. Contact Jill Arent, conference coordinator,at 202-778-3234 or Jarent@aahp.org

April 17­20, AAP spring session, Chicago,IL. For more information,call the AAP at 800-433-9016, extension 6338

April 25­29, The Child with Special Needs, Washington, DC. ContactProgram coordinator, Contemporary Forums, at 925-828-7100

April 29­30, Across the Spectrum: Learning Disabilites, ADHD, andAsperger's Disorder, Plantation, FL. For more information, call the NationalAssociation for Continuing Education, 954-723-0057

April 30­May 3, Asthma '99: Theory to Treatment, Honolulu, HI. Contactthe American Academy of Allergy, Asthma and Immunology at 414-272-6071.

--Judith Asch-Goodkin

EYE ON WASHINGTON

January's State of the Union speech was packed with goodies for childrenand families, but the continued presence of the President who deliveredthe speech was in some doubt. Now that the impeachment trial has ended inan acquittal, pediatricians can judge how successful this Administrationcan be in turning that agenda into a reality. According to the AmericanAcademy of Pediatrics, issues to watch when Congress returns from theirpost-impeachment week off include:

• expanded health-care coverage for children and adolescents
• tobacco control legislation
• bans on cigarette and alcohol advertising
• continued funding for firearms research by the National Center for Injury Prevention of the CDC
• continued funding for the Title X Family Planning Program
• stronger gun control legislation
• amendments to CLIA regulations that hamper pediatricians from performing basic lab tests in their offices.

Until Congress gets going, the action is in the agencies and the courts.

The National Center for Health Statistics is updating its growth charts,using data derived from the Third National Health and Nutrition ExaminationSurvey (NHANES 3). The new charts will use body mass index (BMI) as thebasic measurement. To find out when the new charts will be available, checkthe Center's website: www.cdc.gov/nchswww.

Health and Human Services General Counsel has concluded that the Congressionalprohibition on federal funds for human embryo research does not precludefunding for research using human pluripotent stem cells derived from early-stageembryos donated by people undergoing treatment at an in vitro fertilizationclinic. The ruling was immediately challenged by 70 members of the Houseof Representatives, who have asked that it be rescinded.

The Food and Drug Administration has lost a round in its battle to regulatecertain dietary supplements. A federal court has ordered the FDA to liftits ban on the importation of Chinese red rice powder, used in the manufactureof a dietary supplement called Cholestin. The FDA says Cholestin is a drugbecause it contains a natural form of lovastatin, the key ingredient inMevacor, Merck's cholesterol-lowering drug. The judge says it's a supplement,and therefore the FDA has no jurisdiction to ban imports.

The Department of Agriculture has approved the irradiation of red meatto control harmful bacteria--a possibility of particular interest in thewake of an outbreak of listeriosis that has prompted three recent recallsof meat and poultry products.