Your Voice

READERS' FORUM

Addendum: March 2002 issue

Soren Pedersen, MD, one of the authors of "Inhaled corticosteroids and growth: How big a dose of caution?" (March), is a consultant for AstraZeneca. He does studies with, is a speaker for, and occasionally serves on advisory boards for GlaxoSmithKline, Schering-Plough, and Aventis.

Words of tribute to Walter W. Tunnessen, MD

I came to know Dr. Tunnessen through Pediatric Puzzler when I sent him my first-ever case report submission in 1985. Entitled "A curious yellow," it was based on my pursuit of mild jaundice in a young man that ultimately led to a diagnosis of Gilbert's disease. Bingo, overnight Dr. Tunnessen transformed a rural pediatrician into a somewhat academic one! I was thrilled. He edited several more cases I submitted for Puzzler after that. And, when I wrote to him about impressive blue sclera that was pictured in another publication, he took the time to write back and explain that it was the photographic effect and not the real blue sclera seen in Albright's disease.

I offer my tribute to the mentor and teacher I never met. His encouragement led me to continue to pursue writing for various journals, despite setbacks and rejections, and eventually led to published work and poster presentations. He has had a great impact on my professional life, bringing me tremendous joy and fulfillment. Although he will be missed by all who had the opportunity to work with him, he will continue to be an inspiration and guiding beacon for decades to come.

Amar Dave, MD
Ottawa, Ill.

The role of toilet training in constipation

"Managing constipation: Evidence put to practice" (December 2001) entirely overlooked the most common cause of the problem—toilet training—as well as the relative ease of its treatment: mineral oil. If asked, most parents will relate the onset of constipation to the time of attempted toilet training, however gentle. Even though most children are (actively) successfully trained, many end up with very delayed training or functional constipation. Most children hold back stool at least a little during the process. Holding back leads to infrequent, large, and painful stools. Pain leads to more pain, and the vicious cycle begins. Affected children are often pictured as having stools behind drapes or in other hidden locations.

Parents already know about dietary changes, which rarely help (except for reducing excessive milk intake). They also know about laxatives and stool softeners, which rarely help. In fact, laxatives often make the situation worse by increasing the urge to have a bowel movement, which forces the child to work even harder to hold back stool. The problem is in the child's head (fear of pain), not in the gut.

Mineral oil works, and since it is just a lubricant it does not increase urge. Although it is hard to administer, this can always be done with flavoring and encouragement. Start with two tablespoons twice daily. Increase by one tablespoon twice daily and do not stop until the child passes a large, oily but painless stool. Stay at this dosage for several days (during which time the stretched out and weakened walls of the rectum return to normal caliber and regain strength). Then, go back down the ladder, reducing the dosage by one tablespoon twice a day. This approach works; the rare recurrence would be treated in the same manner.

After this learning experience, most parents let any other children they have self-toilet train, even though they have been advised that this does not happen until about 3 years of age. Of interest, self-trained children rarely have "accidents." Training happens when children's heads are ready, not just when their sphincters are ready or when children of their parents' friends have trained. Toilet training happens naturally, just like walking.

Reuben H. Reiman, MD
Scottsdale, Ariz.

The work of the generalist still has lure

There will always be a need for the "general pediatric specialist" ("Whither the general pediatrician?" Readers' Forum, February). I have taken care of jaundice that turned out to be carotenemia, cyanosis in a newborn that was actually dye from a blue blanket, paralysis that turned out to be juvenile rheumatoid arthritis, gastroenteritis that turned out to be malrotation of the small bowel, bronchitis that was asthma, chronic organic recurrent abdominal pain that turned out to be school phobia, and rash treated with steroid that turned out to be scabies. The list goes on.

For those of us who prefer being a general pediatrician to being a so-called specialist, there is much to learn and explore. The delivery room has been a major area of ongoing learning and inquiry. I came up with the idea of "cry score," where no cry equaled 0, a weak cry equaled 1, and a lusty cry equaled 2. The cry score compared so well with the Apgar score that I was allowed to present the idea as a poster presentation at an international meeting of neonatologists. I was the only general pediatrician from rural America presenting! I had fun. Anybody who does not attend deliveries won't have fun and won't learn. Whether we do or don't learn is up to us—nobody can make us.

We also have a role to play in reducing health-care costs: When parents of some children in my practice found out the cost of going to the emergency department for treatment of constipation or an earache, they turned around and came to my office. I take every opportunity to tell such parents the difference in cost between an office visit and a trip to the ED. I still get agitated when hearing that evaluation of a benign vasovagal syncopal episode in a perfectly healthy child requires CT scan in the emergency room, not only making a $400 visit a $2,500 one but exposing the child to unnecessary radiation and anesthesia! A good clinician—one who makes good clinical diagnoses and uses diagnostic modalities only to confirm difficult cases—is the only hope for keeping health-care costs under control. Part of his (or her) role is to let the third-party payer and the patient know that it is in their best interest, economically and medically, not to have a test done if a clinical exam and history reveal that everything is okay. Astute clinicians ought to be rewarded by the nation and organized medicine. I hope that third-party payers figure out ways to recognize abuse of medical technology by incompetent physicians in the name of "rule out" diagnoses or for the purpose of covering themselves. Not a day goes by when I don't witness an unnecessary CT scan, emergency upper GI series, or lab test. Just cutting down on these tests will reduce heath-care costs tremendously. We have to work toward this goal.

Amar Dave, MD
Ottawa, Ill.

Readers' Forum.

Contemporary Pediatrics

2002;4:19.