Updates

EYE ON WASHINGTON

A spoonful of sugar

Mary Poppins was right when she sang about a spoonful of sugar making the medicine go down; it's a truth that parents and manufacturers of children's medications are well aware of. But what the perfect nanny probably didn't realize is that sugary medications can also promote tooth decay--especially in children with chronic illnesses like epilepsy or asthma who take multiple doses over long periods of time. According to a study by Nancy Dougherty, DMD, and her pediatric dentistry colleagues Maureen Romer, DDS, and Rebekah Tannen, DDS, the sugar content of common liquid medications for children can be as high as 3.5 g of sugar for every 5 mL of solution. For comparison, the sugar content of Coca Cola--considered by many parents and pediatricians to be a dental hazard-- is 0.5 g/5 mL.

Patterns of medication administration, these researchers note, can increase the potential for dental decay. A child on liquid medication may receive three or four sugary doses a day, not necessarily at mealtimes--a practice that is "virtually the same" as eating sugary snacks between meals. Often, parents give a dose immediately before a nap or at bedtime. This is particularly hazardous because salivary flow--which cleanses the mouth and buffers oral pH during waking hours--is decreased during sleep.

How can pediatricians help reduce these risks? Dr. Dougherty has some suggestions:

• Press pharmaceutical manufacturers to list all ingredients, including grams of sugar per dose unit, on the labels of pediatric medications.

• Collaborate with dental and pharmaceutical organizations to compile lists of sugar-free medications and make them widely available to clinicians and parents.

• Inform parents that sugared medications have the potential to cause dental caries. Instruct them to have children brush their teeth immediately after taking medicine, and time doses to coincide with mealtimes, not bedtimes.

Healthy People 2000: A report

The Healthy People initiative, begun in 1979 by then Surgeon General (and renowned pediatrician) Julius Richmond, MD, is reformulated each decade. New goals for 2010 will be announced shortly, but first it's time to review the decade just ending. According to the Healthy People 2000 Review, 1989­1999, the record is cause for both rejoicing and dismay.

In the former category, the report notes that the targets have been met for 15% of the Healthy People objectives, in such diverse areas as nutrition, maternal and child health, heart disease, mental health, the reduction of outbreaks of food- and water-borne disease, and oral and breast cancer deaths. An additional 44% of the objectives are progressing on schedule, including those for child immunizations, breastfeeding, regular dental visits, mammography screening, and consumption of adequate amounts of fruit and vegetables.

On the down side, the report also shows that a fifth of the targets are farther away now than they were 10 years ago. These backward steps include numbers of overweight individuals, regular physical activity, and incidence, prevalence, and mortality from diabetes.

In the pediatric age group, the great triumph is in infant mortality; it has dropped steadily throughout the decade, to an overall rate of 7.1/100,000--almost at the goal of 7 for the year 2000. But the dreadful disparity between rates for white and black infants remains unchanged, with the black rate twice as high as the white. The death rate for children between the ages of 1 and 14 has dropped by 26% in this decade, and there has been substantial progress in reducing deaths in this age group from drowning, motor vehicle crashes, and fire. The bad news, for this age group, is an increase in rates of hospitalization for asthma.

Among adolescents and young adults (15­25 years of age), death rates have dropped 26% since 1979, to reach the year 2000 target of 85/100,000. In particular, alcohol-related motor vehicle crash deaths and suicides are down. Despite the recent outbreaks of adolescent violence in places like Littleton, the national statistics show that students are less likely now than they were 10 years ago to engage in fighting and less likely to bring knives and guns to school. National surveys also show, however, that heavy drinking is increasing among high school seniors and continues to be a serious problem among college students.

Quality child care

Six years ago, a consortium of psychologists and economists from the University of Colorado, the University of North Carolina, the University of California at Los Angeles, and Yale embarked on a study of the cost, quality, and outcomes in a large sample of public and private child-care centers in their home states (Updates, April 1995). The study's original findings showed a strong correlation between children's social and cognitive development and the quality of the child care they received. Unfortunately, the research also indicated that most children in the study were not receiving high-quality care--a standard that involved not only keeping children safe and well fed but surrounding them with caring adults who fostered development.

Now the children the researchers have been following are in second grade, and the quality of the child care they received as preschoolers continues to make a substantial difference in how they are doing in school. Specifically, the findings show:

• Children from high-quality child-care centers had better language and math skills in preschool and the first two years of elementary school, although the strength of this relationship diminished as the children progressed through school.

• Children who had close relationships with teachers in the child-care classrooms had better classroom social and thinking skills, language ability, and math skills in preschool and early elementary school.

• The relationship between quality child care and school performance was strongest for children whose mothers had less education.

• Children who attended higher quality child care had better cognitive and social skills in the second grade, even when kindergarten and second grade classroom experiences were taken into account.

• Children who experienced more positive classroom climates in child care had better relationships with peers in second grade.

Since quality counts for so much, these researchers recommend expanding federal and state funding programs that target quality care (so-called quality set asides); restructuring federal child-care tax credits to compensate parents for choosing high-quality care over lowest-cost care; upgrading state regulations for minimum levels of training for child-care teachers; development of a system for credentialing for child-care providers; federal support for teacher training in early childhood education; and an expansion of nationwide accreditation standards for child-care programs.

A copy of the report is available on the Web at www.fpg.unc.edu/.

AAP goes head to head with the generic drug industry--and wins

When the FDA Modernization Act was passed in 1997, it included provisions long sought by pediatricians to expand the number of pediatric drug studies. The carrot intended to induce pharmaceutical manufacturers to conduct these studies was an additional six months of market exclusivity, after the drug's original patent had expired. The provision has been effective; according to the Food and Drug Administration, 109 proposals for pediatric studies were received in the first nine months that the provision was in place. Pediatricians were delighted.

The generic drug industry, however, cried foul; why, they asked, should research-based companies get this unfair advantage, robbing the generic manufacturers of millions of dollars they might have earned during those extra six months. So two trade associations that represent the generic drug industry sued the FDA, requesting an injunction to block the application of the provision.

Now comes the American Academy of Pediatrics, feeling so strongly that the incentive for pediatric studies is vital to children's health that they requested permission from the court to join the FDA as defendants in the suit. Generic companies, charged Robert M. Ward, MD, chair of the AAP's Committee on Drugs, do not have the best interests of children at heart. "We want to help the federal government defend the law that can get medicines studied and labeled for use in children," Dr. Ward explained. "Our action sends the message that the AAP will do whatever is necessary to protect the pediatric drug policies we know will benefit thousands of children."

Lawyers for the AAP submitted a legal brief and presented oral arguments in the case in April. They must have made a persuasive case. On May 14, the generic drug companies gave up and withdrew their suit. "We are pleased," said AAP Executive Director Joe Sanders, Jr., MD, "that the FDA Modernization Act will be implemented in the way it was intended. The Academy will continue to support all efforts by the federal government to improve the way drugs are labeled for children."

Breastfeeding tragedy: The last act

"Who's to blame?" asked the headline on an April Updates item about a breastfed infant who died of starvation in New York City. According to Marianne Neifert, MD, a breastfeeding expert quoted in our article, the culprit was a health-care system that touts breastfeeding but fails to provide adequate support for breastfeeding mothers. Now the jury trying the baby's mother has arrived at its own answer: They found her not guilty of murder, as charged, but guilty of the lesser charge of criminally negligent homicide. Jurors who spoke to the press after the verdict were sympathetic, but felt the mother was criminally negligent for failing to perceive the seriousness of her son's condition.

Calendar

September 1­9, National Child Injury Prevention Week. For more information, write to Safety by Design, PO Box 4312, Great Neck, NY 11023

September 23­27, The Society for Developmental and Behavioral Pediatrics, Seattle, WA. For more information, call Noreen Spota at 215-248-9168, E-mail nmspota@aol.com

September 29­October 1, National Association of Children's Hospitals and Related Institutions (NACHRI) Annual Meeting, Detroit MI. To register, call 703-684-1355

October 7­9, Children and Adults with Attention Deficit Disorders Meeting, Washington, DC. Call 954-587-3700

October 9­13, American Academy of Pediatrics Annual Meeting, Washington, DC. To register, call the AAP at 708-228-5005

October 21­23, Pediatric Nursing 15th Annual Conference, Orlando, FL. For information, call 856-256-2300.

--Judith Asch-Goodkin

Summer heat seared Washington last month, and most members of Congress were delighted to get out of the broiling city for the Fourth of July recess. Debate on comprehensive federal standards for health insurance plans is scheduled to begin when they return. President Clinton outlined his proposals for Medicare reform, including a provision for prescription drug coverage, before he, too, left Washington to tour impoverished areas in Pine Ridge, SD, the Mississippi Delta, and East St. Louis, IL. Left behind in the heat, the civil servants who keep government agencies functioning went about their business, churning out regulations, issuing reports, and making legal decisions--many of which affect the welfare of children and pediatric clinicians. For example,

The Centers for Disease Control and Prevention, reacting to reports of a link between rotavirus vaccination and intussusception, has asked health-care providers to suspend vaccination at least until November, when additional data from a new CDC study will be available. If the link is not confirmed, vaccination could be resumed before the rotavirus season begins.

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention voted to recommend the use of inactivated polio vaccine (IVP) in all four doses on the immunization schedule. The new recommendation will take effect as of January 1, 2000.

The Second District Court of Appeals disallowed a prosecution for attempted homicide against a woman who drank heavily during her pregnancy. A fetus, the court held, is not a human being, and therefore charges of intentional homicide or reckless injury cannot be pressed against the mother.

The Food and Drug Administration finalized regulations for over-the-counter sun protection products, specifying three sun protection categories: minimum, for sun protection factor (SPF) of 2 to 11; moderate, for SPF 12 to 29; and high, for SPF 30 or greater. Unsupported, absolute, or misleading terms such as "sunblock," "waterproof," and "all-day protection" are banned, and tanning products that do not contain sunscreen must warn users the product does not protect against harmful effects of sun exposure.

The National Institute of Allergy and Infectious Diseases has posted an updated version of the Guidelines for the Use of Antiretroviral Agents in HIV­Infected Adults and Adolescents on the AIDS Treatment Information Service website, www.hivatis.org. The Guidelines will be updated at regular intervals.

Judith Asch-Goodkin. Updates. Contemporary Pediatrics 1999;8:11.