UPDATES

When terror struck

In the numbed days after terror came to America, the only possible subject with which to begin "Updates" is the massive attack on the World Trade Center in New York City and the Pentagon in the Virginia suburbs of Washington, D.C. The dead are still not fully counted, but Americans now understand that their number are surely, as New York City Mayor Rudolph Guiliani has said, "more than we can bear." We are all in shock, bereft from now on of a peculiarly American illusion that, whatever face Fortune turns toward people in faraway places like Bosnia and the Congo, God smiles on us.

Even as the foundations of our world-view shift under our feet, pediatricians and parents have an immediate and urgent task: to take care of the children in their care. How do we do that, now?

Surely, our priority is to help children deal with the trauma of having witnessed—for many, again and again on the endless, anesthetizing loop of TV—these extraordinary events of destruction and death. Perhaps, begin by looking at programs that pediatricians have designed to help inner-city children cope with the violence that surrounds them in daily life; such a program, in Boston, is described in "Silent Victims: Children who witness violence," Contemporary Pediatrics, August 1995.

Today, all children, all over America, are witnesses to these violent acts—they have become the silent victims. Some saw, or heard, the attack from classrooms in New York City close to the site, where the Twin Towers were a familiar part of the neighborhood. Some have lost parents, or must comfort friends who have; as days go by, more and more will discover connections that bound them and their families to the multitudinous dead. Almost all have witnessed the catastrophe as it unfolded on TV screens, read the screaming headlines in newspapers, or, in the telepathic manner of small children, simply picked up the emanations of horror of their teachers and parents.

(My 6-year-old grandson has alighted in the last category: Initially delighted to catch sight of his mother appearing at his morning recess, joy almost immediately gave way to panicky questioning: "Why are you here? What's wrong?" He listened to as much explaining as he could deal with and then—sensible child that he is—asked for time out: " I don't want to talk about this any more." Hours later, he looked up from the toy airplane that preoccupied him to ask sharply: "Was that daddy's building that blew up?" He heard his father say, "This isn't Star Wars—real people are dead," and stored that away, to help him in the difficult task of sorting reality from video epics. In weeks to come, he'll circle around the tragedy, measure what his friends are saying against what he learns from adults he trusts, and play out his feeling and fears with action figures or in drawings. His parents will keep telling him that they can keep him safe—even though they're not really sure of that.)

The American Academy of Pediatrics has offered advice on how to help children deal with the events of these terrible days:

Assure children they are safe and that their parents will keep them from harm.

Be alert for signs of distress in children and teenagers. In adolescents, these signs may include sleep disturbances, lack of pleasure in usual activities, and substance abuse.

Advise parents to watch television coverage of the tragedy with their child but to be wary of overexposure.

Encourage parents to discuss the disaster with their child and thereby help them reach an understanding of what has happened.

Pediatricians may find additional assistance in these documents:

How Pediatricians Can Respond to the Psychosocial Implications of Disasters—an AAP policy statement accessible on the World Wide Web at www.aap.org/policy/re9813.html

Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician—from the AAP and the US Center for Mental Health Services, at www.mentalhealth.org/publications/allpubs/SMA95-3002/SMA3022.htm

The Pediatrician's Role in Disaster Preparedness—also an AAP policy statement, at www.aap.org/policy/re9702.html

"Child Deaths Hit Communities Hard: Disasters Demand Psychological Triage"— an article from AAP News, at www.aap.org/advocacy/disarticle.htm

Helping Children After a Disaster—published by the American Academy of Child and Adolescent Psychiatry, at www.aacap.org/publications/factsfam/disaster.htm

Poison control

It's simple: Just dial 800-222-1222. That is the new toll-free number that gives parents, child-care givers, and pediatric providers anywhere in the country access to their local poison control center. The number should be posted in pediatricians' offices, circulated as part of parent education brochures, and publicized in schools. Call the number to obtain free telephone stickers to hand out to your patients.

Vaccine fears

Parents who read the fine print in package inserts know that diphtheria-tetanus-pertussis and measles-mumps-rubella vaccines can produce fever and even an occasional seizure in the days following vaccination. You can reassure parents who may be thinking of denying the protection of these vaccines to their children that their fears are unwarranted. An article in the August 30, 2001, issue of the New England Journal of Medicine reports on a massive study of data on 639,000 children as old as 7 years who received these vaccinations from 1991 to 1993—when they were infants. Those data show that, although some children did suffer fever and fever-related seizures, none were left with long-term neurologic or developmental effects (Barlow et al: The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. N Eng J Med 2001;345:661).

What parents don't know about chickenpox

According to the results of a survey conducted by Yankelovich Partners for the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP), 90% of parents of school-age children don't know that chickenpox can have deadly complications. Furthermore, approximately one half of parents would rather that their children catch the disease than have them vaccinated against it, and nearly one quarter either think varicella immunization isn't important or don't know that a varicella vaccine exists.

Given that state of parental mind, no wonder varicella vaccination coverage among school-age children is seriously incomplete. In response, NAPNAP is launching a publicity campaign urging parents to have older children vaccinated. Only 22 states require varicella vaccination for entry into day care or school.

Medications, environmental toxins, and human milk

In almost every case, medications prescribed for the nursing mother do not affect her supply of milk or her infant's well being. So says the American Academy of Pediatrics (AAP) in a new set of guidelines on the transfer of drugs and other chemicals into human milk (Pediatrics 2001;108[3]:776). The recommendations from the AAP's Committee on Drugs include detailed tables on the known effects of a variety of medications and environmental toxins on human milk. The guidelines update lists last published in 1994.

The most striking change in the current statement? Nicotine, listed in the 1994 report among "Drugs of abuse contraindicated during breastfeeding," has been eliminated from all tables of substances that pose a danger or concern.

"There is no evidence to document whether this amount of nicotine [present in breast milk in mothers who smoke] presents a health risk to the nursing infant," says the report. And for mothers addicted to cigarettes, the report continues, "it may be that breastfeeding and smoking is less detrimental to the child than bottle feeding and smoking."

Drugs cited in the tables are listed in alphabetical order by generic name; the report includes an extensive bibliography. Physicians who encounter adverse effects in infants who have been receiving drug-contaminated milk are urged to communicate their observations to the FDA ( www. fda.gov/medwatch/index.html ) and the AAP Committee on Drugs.

Secretin and autism, again

In the August issue of Contemporary Pediatrics, Updates reported a study from the May issue of Pediatrics showing that two doses of secretin had no more effect than placebo on measures of language, cognition, and autistic symptoms in a group of 64 children with diagnosed autism. In September, the Repligen Corporation announced that the Food and Drug Administration had given fast track status to their application to market secretin as a treatment for pediatric autism. According to Repligen, a statistically significant treatment effect was observed for secretin in a phase II clinical trial involving 126 children between the ages of 3 and 6 years of age. When patients receiving secretin in this study were compared with those getting a placebo, 64 of the secretin patients whose levels of digestive proteins calprotectin and chymotrypsin were normal showed improvement in social function, overall symptoms, and receptive language. According to Repligen, reports on the clinical trial will be presented at the annual meeting of the Society for Neuroscience (See Calendar, below) and submitted to peer-reviewed journals later this year.

Judith Asch-Goodkin
Contributing Editor

Eye On Washington

How to respond effectively to the terrorist threat is at the top of the government's agenda, and that preoccupation tends to crowd out any other conceivable activity. The impact on the federal budget of whatever protective and retaliatory policies Congress adopts is unknown, but health and social welfare programs are bound to feel a substantial impact. Whatever decisions are made, the mundane activities of government will continue to affect the lives of children and families. Actions with such significance last month include:

Bills in the hopper.

Two are worth watching:

• A bill sponsored by Senator Charles Schumer (D-N.Y.) and Representative Pete Stark (D-Calif.) would add the reduction of child poverty to the renewal of welfare reform as a stated goal of federal welfare policy

• The Act to Leave No Child Behind, sponsored by Senator Christopher Dodd (D-Conn.) and Representative George Miller (D-Calif.), would commit the federal government to lifting every child out of poverty by 2010, providing health insurance for every child and his or her parents, and full funding for quality Head Start, child care, and preschool programs.

Car safety. According to data gathered by the National Safety Council, air bags are killing fewer children than they did five years ago. Parents are, apparently, heeding advice to keep children under 12 years of age in the back seat.

Dietary supplements. A petition filed by the Public Citizen Health Research Group with the Food and Drug Administration asks the agency to ban dietary supplements that contain ephedra, which has been blamed for 1,398 adverse reactions between 1993 and 2001—including 81 deaths. Products that contain ephedra are touted as an appetite suppressant and energy producer.

Childhood diabetes. The Centers for Disease Control and Prevention has awarded a $3.2 million grant to study the growing incidence of diabetes in Hawaiian children. Researchers suspect that type 2 diabetes is becoming more prevalent in younger children as a consequence of obesity, which is the result of poor eating habits and lack of exercise.

Pediatric inpatients. The Department of Health and Human Services Agency for Healthcare Research and Quality has announced the launch of KID, an inpatient pediatric database that will allow researchers to obtain access to, and compare outcomes and hospital charges for, pediatric patients.

Stem-cell research. Nearly one month after President George W. Bush made his decision to allow federal funding for research using 60 existing stem-cell lines, Department of Health and Human Services Secretary Tommy Thompson disclosed to a Congressional committee that fewer than one half of the stem-cell colonies that the president had considered in his analysis of the matter were ready for use in research.

CALENDAR

November 5–7, Developmental Interventions in Neonatal Care, Washington, D.C. To register, fax Contemporary Forums at 900-320-9923.

November 9–11, Autism: Disorders of relating and communicating, Washington, D.C. To register, write to the Interdisciplinary Council on Developmental and Learning Disorders, 4938 Hampden Lane, Suite 800, Bethesda, MD 20814. For information, call 301-656-2667.

November 9–15, International Meeting for Autism Research, San Diego, Calif. For more information, go to the Web site of the Society for Neuroscience, www.sfn.org .

December 3–5, Mobilizing for a Safe USA: A leadership conference to reduce violence and injury in America, Atlanta, Ga. For conference information, go to www.cdc.gov/safeusa .

December 6–8, Second International Conference on Immunosuppression, San Diego. For information, e-mail kzavetz@pweg.com.

December 9–12, Institute for Healthcare Improvement, Orlando, Fla. For information, go to www.ihi.org .

Judith Asch-Goodkin
Contributing Editor

Updates.

Contemporary Pediatrics

2001;10:11.