Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media

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Exclusive

Breast-Feeding

for

at Least

4 Months

Protects

Against

Otitis

Media

Burns Duncan, MD; John Ey, MD; Catharine

J.

Holberg, MSc; Anne L. Wright, PhD;

Fernando D. Martinez, MD; and Lynn M. Taussig, MD

ABSTRACT. Objective. This study was designed to

assess the relation of exclusive breast-feeding, indepen-dent of recognized risk factors, to acute and recurrent

otitis media in the first 12 months of life.

Methods. Records of 1220 infants who used a health

maintenance organization and who were followed

dur-ing their first year of life as part of the Tucson Children’s Respiratory Study were reviewed. Detailed prospective

information about the duration and exclusiveness of

breast-feeding was obtained, as was information relative

to potential risk factors (socioeconomic status, gender,

number of siblings, use of day care, maternal smoking,

and family history of allergy). Acute otitis media and recurrent otitis media, defined as three or more episodes

of acute otitis media in a 6-month period or four episodes

in 12 months, were the outcome variables.

Results. Of the 1013 infants followed for their entire first year, 476 (47%) had at least one episode of otitis and 169 (17%) had recurrent otitis media. Infants exclusively

breast-fed for 4 or more months had half the mean

num-ber of acute otitis media episodes as did those not breast-fed at all and 40% less than those infants whose diets

were supplemented with other foods prior to 4 months.

The recurrent otitis media rate in infants exclusively

breast-fed for 6 months or more was 10% and was 20.5%

in those infants who breast-fed for less than 4 months.

This protection was independent of the risk factors

con-sidered.

Conclusion. These findings suggest that exclusive

breast-feeding of 4 or more months protected infants

from single and recurrent episodes of otitis media. Pediatrics 1993;91:867-872; breast-feeding, otitis media,

infant.

ABBREVIATIONS. AOM, acute otitis media; ROM, recurrent

oti-tis media; HMO, health maintenance organization; OR, odds ratio; CL, confidence limit.

Otitis media is one of the most common illnesses of

childhood. A large epidemiologic study of otitis me-dia reported that 62% of infants will have at least one episode and 17% will have at least three episodes of

acute otitis media (AOM) during their first year of

life.1 There is concern not only with the acute

mor-bidity from these episodes but also with potential

From the Department of Pediatrics, Steele Memorial Children’s Research Center, and The Respiratory Sciences Center of the University of Arizona

Health Sciences Center, Tucson.

Received for publication Jun 25, 1992; accepted Nov 24, 1992.

Reprint requests to (B.D.) Dept of Pediatrics, Steele Memorial Children’s Research Center, 1501 N Campbell Ave. Tucson, AZ 85724.

chronic adverse effects on hearing and subsequent

language development.

A number of risk factors have been identified that

predispose infants to one or more episodes of AOM,

and some infants seem predestined to have recurrent otitis media (ROM).2’3 Risk factors identified for

oti-tis include ethnicity (higher rates in Eskimos, for

ex-ample), male gender, orofacial abnormalities, feeding

in a supine position, passive smoke exposure, early

age of first episode (onset before 6 months has been

associated with an increased rate of ROM), nasal

al-lergies, the presence of older siblings in the same

household, use of day care, and family history of

recurrent otitis or allergies.

Breast-feeding has been found by some researchers

to protect infants from episodes of AOM as well as

from ROM.1’2’ Other reports, however, have not

found such a protective effect.3’0-13 These conflicting

results are probably due to the fact that few studies

have been large enough, some have not clearly

de-fined breast-feeding, and some have not controlled for many or most of the recognized risk factors. The

current study has sought to minimize these concerns

and addresses several questions: Is there a protective

relationship between breast-feeding and episodes of

AOM and/or the development of ROM? If so, is the

effect seen when breast-feeding is supplemented or

only when breast-feeding is exclusive? What

dura-tion of breast-feeding is required to have an effect? If breast-feeding does protect, is the protection inde-pendent of other recognized risk factors for otitis?

Population

SUBJECTS AND METHODS

Parents of healthy newborns enrolled in a large health mainte-nance organization (HMO) in Tucson, AZ, were invited to

partic-ipate in the Children’s Respiratory Study. The families were

gen-erally from the employed sector of Tucson and their characteristics

have been described elsewhere.14 Between May 1980 and October

1984, 1246 newborns were enrolled (78% of those eligible) and

followed prospectively for the first 3 years of life. Records for 1220 of these infants were available for review, of whom 1013 were

followed for their entire first year of life. The remaining 207 were

assigned a duration of care based on their last recorded health supervision visit as described previously and were included in the

survival analysis)5 Ten pediatricians and three pediatric nurse

practitioners in this HMO saw these infants for scheduled periodic

health supervision visits and for most of their intercurrent ill-nesses.

Outcome Variable: Otitis Media

The medical records of children in the study were reviewed for episodes of otitis media that had been diagnosed either during scheduled health supervision and sick-child visits in the

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cian’s office (86%) or during visits made at the HMO’s urgent care center (9%). The entire urgent care record had been incorporated into the child’s record and was also reviewed. An additional 3%

were diagnosed by physicians not in the same HMO, and in I %

the diagnostician was not recorded or the signature was illegible.

The date and type of each episode of otitis media were gathered by

registered nurses with considerable experience in pediatrics and

data collection; only episodes diagnosed as otitis media by the

providers were included. No specific criteria were established for the diagnosis of otitis media, as the Children’s Respiratory Study was not originally designed to look at this illness; however, all care

providers were experienced clinicians with an average of more

than 9 years (range 5 to 17 years) in pediatric practice. Recurrent otitis media for a subject was defined as at least three episodes of

acute otitis in a 6-month period or four episodes in 12 months,

with each episode separated by at least I month.’6 Subjects who

had one or more episodes of AOM otitis that did not meet these

criteria were classified as having non-ROM. In addition, the total

number of AOM episodes that occurred in the first and second 6

months of life and in the entire first year was determined for each

infant.

Feeding Information

As described in other reports from data on this population, the information concerning the duration and exclusiveness of

breast-feeding, the use of formula, and the introduction of supplemental

foods in the first year of life was derived from a combination of

data from two sources)7”8 The majority (74%) of the information

was obtained prospectively from health supervision visits at 2, 4,

6, 9, and 12 months. A smaller percentage (26%) of the information

was obtained retrospectively from questionnaires completed by

parents when enrollees were 12 to 15 months old. There was 90% concordance between the two sets of information and where there

was disagreement, priority was given to the prospective data.

Information relative to dietary intake and to the exclusiveness

of breast-feeding was obtained at the time of the health supervi-sion visits. The length and exclusiveness of breast-feeding was

then divided into five categories which corresponded to the timing for health supervision visits and questionnaire categories for the 1220 infants: (1) no breast-feeding (n = 169); (2) breast-feeding for

less than 4 months (n = 296); (3) breast-feeding for 4 months or

more but with supplemental formula or foods prior to 4 months (n = 200); (4) breast-feeding for 4 months or more with

supplemen-tation beginning between 4 and 6 months (n = 199); and (5) exclusive breast-feeding for 6 months or more (n = 154). The

remainder had missing or incomplete information.

Possible Confounding Variables

Questionnaires completed at the time of enrollment of the in-fants and at 12 to 15 months of age provided data on marital

status, socioeconomic status as defined by parental years of

edu-cation (equal to or less than 12 years or greater than 12 years),

physician-diagnosed family history of allergy, gender, number of siblings in the home, number of others sharing a bedroom with the

infant, use of day care for 9 or more hours per week, and maternal

smoking and the number of cigarettes she smoked each day. Not

all infants had complete sets of data on all variables considered.

Statistical Analysis

Evaluation of the mean number of AOM episodes by breast-feeding categories used analysis of variance, assessing the van-ance accounted for by the linear and nonlinear components. Since

the distribution of AOM episodes was positively skewed, a

Kruskal-Wallis nonparametric analysis of variance was also used to assess significant differences in the mean rank of cases by

feed-ing categories. Statistical significance of associations and trends

between categorical variables was determined using the x distni-bution.

For multivariate analysis, logistic regression models were used

to provide odds ratios (ORs) for having ROM or non-ROM, vs no

AOM, in relation to feeding practices while controlling for the

following set of potential risk factors for otitis media: parental history of allergy (defined in this study by physician-diagnosed hay fever), presence of one or more siblings, use of day care,

maternal smoking (defined in this study as 11 or more cigarettes per day), gender, ethnic group (Anglo vs other ethnic groups, mainly Hispanic), and maternal education of 12 years or less as a

measure of socioeconomic status. Initial models entered feeding

categories as dummy variables, with no breast-feeding as the

ref-erence category. Odds ratios for the breast-feeding category of less

than 4 months did not differ significantly from those of the refer-ence group, and these two groups were combined to form the new reference category of none to less than 4 months of breast-feeding. Since significant linear trends were identified in other analyses, final models entered feeding status as a single variable with ordi-nal categories. From none to less than 4 months of breast-feeding was given a value of I up to exclusive breast-feeding for 6 months or more, which was given a value of 4. For all logistic regression analyses, individual cases were aggregated into groups of cases for all possible combinations of risk factors to provide the appropriate degrees of freedom for the x goodness-of-fit test, rather than

proceeding on a case-by-case basis.

Survival analysis was used to examine the cumulative mci-dence of first otitis media episode by feeding status. The Lee-Desu statistic was used to assess the statistical significance of differences

in cumulative incidence in different feeding categories.19

All analyses, except the survival analysis, included only those

1013 subjects whose medical records were reviewed and who were

followed for the entire first year of life by the HMO pediatricians. Survival analysis included an additional 207 subjects who also had record reviews but with follow-up times of less than I year. An a level of <.05 (two-tailed) was considered statistically significant. This study was approved by the Human Subjects Committee of the University of Arizona Health Sciences Center.

RESULTS

There were 26 missing medical records among the

1246 infants originally enrolled in the study. Of the

remaining 1220 infants, 1013 were followed for their entire first 12 months of life. The diagnosis of AOM

was made 1950 times in the 1220 infants who had

medical record reviews. A total of 915 episodes were

experienced by the 181 infants who met the ROM

criteria and 1035 episodes were experienced by an

additional 538 infants in the non-ROM category. Of

the 1013 infants who were followed for the entire first

year of life, 476 (47%) were in the non-ROM group (at

least one episode of AOM) and 169 (17%) had ROM.

Table I compares a number of demographic and

other variables between the 1013 infants with

medi-cal record reviews who were followed for the entire

first year with the remainder whose data were in-complete. Mothers of infants with complete data sets

were significantly more likely to be married and to

have more than a high school education (P < .001)

compared with mothers of infants with incomplete

data.

With regard to breast-feeding status, there was no

significant difference in feeding patterns in relation

to gender (P = .75), the presence of one or more

siblings (P < .07), or physician-diagnosed parental

history of hay fever (P < .1). However, the duration

and exclusivity of breast-feeding was significantly (P

< .001) greater among infants of Anglo compared

with non-Anglo mothers, and significantly less

among infants who used day care and among those

whose mothers smoked 11 or more cigarettes per day.

Acute Otitis Media

Table 2 shows the relationship between the mean

number of episodes of AOM and breast-feeding

his-tory for the infants followed for the entire first year of

life. From both birth to 6 months of age and from 6

months to 12 months, the mean number of episodes

of AOM decreased significantly with increasing

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in-0.

0

(1 (S

w 0

a, > (S

E

0

Fig 1. Cumulative percent of infants by the age in months at

which they had their first episode of acute otitis media is shown in this line graph by feeding group.

any breast-feeding when considered irrespective of

the introduction of formula or foods. The percent

2 4 6 8 10 12 frequency of ROM decreased significantly with

in-Age (months) creasing duration of breast-feeding (trend P < .05).

The decreasing trend of ROM is more clearly defined

(P < .02) when both duration and exclusivity of

breast-feeding are considered (Fig 3). There was no

TABLE 1. Comparison of Infants With C

With Those Not Included in the Analysis*

omplete Records and Followed for the First Year of Life

Characteristic Complete Data

(N = 1013)

Incomplete Datat

(N = 233)

P

Anglo 82.8 73.4 <.001

Married 92.7 84.8 <.001

Maternal education 12 y 29.7 40.6 <.001

Gender (% males) 49.0 48.9 NS

Siblings (1 or more) 67.4 61 .6 NS

Room sharing (2 or more) 12.1 17.1 NS

Day-care use 47.6 41.6 NS

Maternal smoker 17.8 18.1 NS

Either parent with history of hay fever 58.9 52.5 NS * Values represent percentages.

t Includes infants for whom no records were found (n = 26) and those who left the practice in the first

year of life (n = 207).

1:NS, not significant.

TABLE 2. Mean Number of Episodes of Acute Oti

Infants Followed by Their Entire First Year

tis Media per Infant by Breast-Feeding S tatus for

Breast-Feeding Status 0-6 mo >6-12 mo 0-12 mo N

Mean SD Mean SD Mean SD

No breast 0.70 1.07

Breast <4 mo 0.59 0.98 Breast 4 mo, suppl <4 mo 0.59 1.07

Breast 4 mo, suppl 4-6 mo 0.34 0.68

Breast 6 mo 0.37 0.69

1.42 1.72

1 .37 1 .59 1.17 1.45

1 .18 1.55

1.11 1.59

2.13 2.19

1 .96 2.03

1.77 1.91

1.52 1 .83

1.48 1.95

154

271

189 185

138 937*

P Kruskal-Wallis .003

P Linearity .0001

.20

.03

.006

.0003

* Complete data were not available for the other 76 infants.

fants who were breast-fed for 4 or more months and

whose diets were not supplemented prior to 4

months had half the mean number of AOM episodes

as did those who were not breast-fed at all and 40%

less than those whose diets were supplemented prior

to 4 months.

Similar significant trends were seen considering duration of breast-feeding regardless of supplemen-tation, using the categories of no breast-feeding, less

than 4 months, 4 to 6 months, and greater than 6

months. The Kruskal-Wallis test for categories at >6 to 12 months of age was not statistically significant.

Figure 1 shows the cumulative incidence of the

first episode of AOM by the five feeding categories.

The vertical axis represents the cumulative percent of

infants in each feeding group who had an episode

of AOM up to the age in months depicted on the

horizontal axis. There was no significant difference

between the distribution of the three groups of

in-fants who received no breast-feeding or who, prior

to 4 months of age, received supplemental feedings

in addition to breast-feeding. Additionally, there

was no significant difference between the incidence

distribution for those who were breast-fed

exclu-sively for 4 months or for 6 months or more. The

cumulative incidence of AOM by 12 months of age

in those who were exclusively breast-fed for 4

months was 56.0% compared with 68.3% for those

infants who were not exclusively breast-fed up to 4

months of age (P < .0001). The mean age of the first

episode of otitis media for the entire group of

in-fants was 4.7 months, and there was no statistically significant difference in the age of first episode be-tween the feeding groups.

Recurrent Otitis Media

Of the 1013 infants followed for the entire first year

of life, 169 (16.7%) developed ROM within the first

year of life as defined in this study. Figure 2 shows

the incidence of ROM in relation to the duration of

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0

cx:

373 >6mos

0

N = 206 219 144

0 to <imo 1 to <4mos 4 to 6mos

Fig 2. Bars in this figure depict the percentof infants who had recurrent otitis media (ROM) but relate only to the duration of

breast-feeding regardless of supplementation with other foods or with formula.

N = 425 189 185 138

Breast 0 to<4mos Breast 4mos Breast 4mos Breast >6mos

Other 0 to <4mos Other <4mos Other 4 to 6mos Other >6mos

Fig 3. Bars in this figure depict the percent of infants who had

recurrent otitis media (ROM) relative to both the duration and the exclusivity of breast-feeding.

significant difference in the rates for those who were

not breast-fed (20.1 %) and for those breast-fed for

less than 4 months (20.7%), and these two groups

were combined. The ROM rates in infants exclusively

breast-fed for more than 6 months was 10%

com-pared with 20.5% in those who did not breast-feed or

who breast-fed less than 4 months.

Logistic regression (Table 3) was used to assess the

effect of breast-feeding for ROM and non-ROM vs no

otitis media while controlling for possible

confound-ing variables. The following were identified as

sig-nificant risk factors for ROM with the ORs and 95%

confidence limits (CLs) presented in parentheses: male gender (OR = 2.3, CL = 1.6 to 3.3); day care (OR = 2.2, CL = 1.6 to 3.4); one or more siblings at home

(OR = 2.1, CL = 1.4 to 3.2); exposure to maternal

smoking of more than one-half pack of cigarettes per day (OR = 1.8, CL = 1.1 to 2.9) (the effect of paternal

smoking on ROM was not evaluated); and

physician-diagnosed history of parental hay fever (OR = I .5,

CL = 1.1 to 2.3). The ORs show increased protection

against ROM and non-ROM with increased duration

and exclusivity of breast-feeding which was

inde-pendent of the other risk factors considered.

DISCUSSION

The results of this report are based on a large num-ber of infants who were closely followed by experi-enced clinicians for the first year of life and on whom

extensive clinical, social, detailed feeding, and acute

illness information was collected prospectively. The main findings of this study are as follows: (1) increas-ing duration and exclusivity of breast-feeding

signif-icantly decreased the total number of AOM episodes

in both the first and second 6 months of life; and (2) increasing duration and exclusivity of breast-feeding

was associated with decreased risk of ROM and

non-ROM in the first year of life, independent of the other

potential risk factors considered. Infants who were

breast-fed but received supplementation prior to 4

months had roughly three-fourths the risk of ROM,

compared with the reference group who were not

breast-fed at all or who were breast-fed for less than

4 months. Those infants who were breast-fed

exclu-sively for at least 4 months had one-half the risk, and

those infants who were breast-fed exclusively for 6

months or more had approximately one-third the

risk of developing ROM.

Reports on the protective influence of

breast-feed-ing have been conflicting. Saarinen4 followed 237

healthy infants prospectively for 3 years and

re-ported a protective effect from breast-feeding if it

continued for 6 months; however, there was no

con-trol for other risk factors. A number of studies have

reported a protective influence from breast-feeding, but breast-feeding was not clearly defined.1’2’5-7 0th-ers have reported no protection from breast-feeding, but the studies either do not clearly define

breast-TABLE 3. Odds Ratios for Recurrent Otitis Media (ROM) and Non-ROM Associated With

Breast-Feeding Status After Controlling for Other Factors Using Logistic Regression*

ROM vs No AOM Non-ROM vs No AOM

No breast and breast <4 mo 1.0 1.0

Breast 4 mo, suppl <4 mo 0.73 (0.60-0.90) 0.85 (0.74-0.97)

Breast 4 mo, suppl 4-6 mo 0.54 (0.35-0.81) 0.72 (0.54-0.95)

Breast 6 mo 0.39 (0.21-0.73) 0.61 (0.40-0.92)

x2for goodness of fit+ df85, P = .2 df95, P = .2

No. of infants ROM 143 Non-ROM 394

No AOM 297

N for totals 440 691

* A value of <1 is indicative of a protective effect.

t P values are not significant, indicating no significant differences between observed and expected

frequencies in the logistic regression models.

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feeding,3 or the numbers are small9’2 and, in one

study, the data were obtained from mailed,

parent-completed questionnaires.13

This report differs from many previous reports in

several respects. First, the infants were enrolled in an

HMO where there were little or no fiscal

disincen-tives for the infants to see their pediatrician. Second,

a large number of infants were followed by the same

primary health care providers. Third, a large amount

of information was obtained regarding possible risk

factors for otitis media, and multivariate techniques were used to adjust for these risk factors. Fourth, the

exclusivity of breast-feeding was well defined

pro-spectively.

Although criteria for the diagnosis of otitis media were not established prior to the onset of the study, we do not believe that this detracts from the conclu-sions. Since otitis media was not the original focus of

this study and feeding practices were only one of

numerous factors being considered for their

influ-ence on respiratory illnesses, there should have been no bias for or against the diagnosis of otitis media.

Feeding information was recorded at different times

and on forms separate from those on which the

di-agnosis of otitis media was recorded, further

mini-mi.zing bias. The incidence of otitis media in the cur-rent study (64%) was very similar to that reported in

the epidemiologic study from Boston (62%).1

Seven-teen percent of the infants in that study1 had three or more episodes in the first year of life, compared with

our study’s finding that 16.7% had three or more

episodes in a 6-month period or four or more in 12

months.

There was a decrease in the mean number of AOM

episodes with increasing breast-feeding, particularly if breast-feeding was not supplemented with formula or foods. If exclusive breast-feeding was continued for at least 4 months, there appeared to be a protec-tive effect that lasted beyond the first 6 months. Sim-ilarly, with breast-feeding durations of 4 to 6 months,

regardless of supplementation, a significant linear

decrease in the mean number of AOM episodes

be-yond 6 months was noted when compared with

those who breast-fed less, although the mean

num-ber of AOM episodes in each breast-feeding category

was not significantly different. These findings are

suggestive of a prolonged protective effect of

breast-feeding on AOM, but the evidence is not strong and

may simply reflect that if episodes of otitis media are

prevented early in life, subsequent episodes are less likely to occur.

The cumulative incidence of AOM depicted in Fig

1 shows a significant difference in the distribution of the first episode of AOM for those breast-fed

exclu-sively for 4 months or more compared with those

breast-fed for less than 4 months or not breast-fed at all. At 12 months, those infants who had been

exclu-sively breast-fed for 4 months or more had a

cumu-lative incidence of 56% compared with 68% in the

other groups. While increased duration of

breast-feeding beyond 4 months did not show further

de-dines in the cumulative incidence of AOM, the

per-cent frequency of ROM decreased significantly with

increased duration and exclusivity of breast-feeding.

The protective effect for ROM was independent of

the other risk factors considered (ie, gender, more

than one sibling in the household, use of day care,

maternal smoking of more than one-half pack of

cig-arettes per day, and physician-diagnosed hay fever in

the parents). A similar protective effect of decreased

magnitude was seen for non-ROM. The implication

of these results is that breast-feeding has the poten-tial to reduce the overall risk for ROM and non-ROM

independent of factors that may be affecting and

de-fining what has been termed the “otitis-prone”

child.2#{176}

There are several possible explanations why

breast-feeding has a protective effect against the

de-velopment of single or recurrent episodes of AOM.

The effect may be purely a mechanical one, since

infants being breast-fed are held in a different

posi-tion than those fed from a bottle. Unfortunately, we

did not collect data on feeding positions or on

whether breast milk was fed from the breast or from

a bottle after extraction from the breast. It may be

that the levels of secretory IgA found in breast milk

are protective. Hanson et al21 reported that

secre-tory IgA in human milk blocks the attachment of

Streptococcus pneumoniae and of Haemophilus

influ-enzae to retropharyngeal cells. Micronutrients in

breast milk may give protection. Backon advanced

the hypothesis that the high levels of prostaglandins

found in breast milk may be prophylactic against

otitis media. Prostaglandin E1 decreases the

inflam-matory response by inhibiting leukocytes from

releasing lysosomal enzymes and by reducing

vas-cular permeability induced by vasoactive

inflamma-tory mediators.23’24

Although the mechanism for a protective effect of

breast-feeding against otitis media is not clear, the results of this study clearly show that breast-feeding for the first 4 months of life protected the infants

against single and recurrent episodes of AOM. These

findings lend support to the American Academy of

Pediatrics recommendation that exclusive

breast-feeding should continue for 4 to 6 months.

ACKNOWLEDGMENTS

This work was supported by National Heart, Lung, and Blood

Institute Specialized Center of Research grant 14136.

We thank Marilyn Smith, RN, Kathy Van Hoesen, RN, and

Bruce Saul for their assistance.

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21. Hanson LA, Ahlstedt S. Andersson B, et al. Protective factors in milk and the development of the immune system. Pediatrics. 1985;75(suppl):

172-176

22. Backon J.Prolonged breast feeding as a prophylaxis for recurrent otitis media: relevance of prostaglandins. Med Hypotheses. 1984;13:161 23. Fantone JC, Kunkel SL, Ward PA, Zurier RB. Suppression by

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ADMINISTRATIVE

BLOAT

For most of this century, United States colleges and universities adhered to a

dogma that the best way to compete for students, faculty, and research dollars is to

expand. But this approach has led to large, complicated bureaucracies, according to

Barbara Bergmann, president of the American Association of University Professors

(AAUP). The net result of this, Bergmann says, is a debilitating malady called

“administrative bloat” ...

In a recent article in the AAUP journal Academe (77:12-16, 1991), Bergmann

writes: “On each campus that suffers from this disease, and most apparently do,

millions of dollars have been swallowed up. Huge amounts have been devoted to

funding administrative positions that a few years ago would have been thought

unnecessary” ...

“Sitting on top of every department is a whole apparatus of deans, associate

deans, and assistant deans,” Bergmann says. “And on top of them there is a

provost, assistant provost-and it goes on and on.” She says this adds superfluous

personnel to already menacing problems of rising expenses, red tape, and

paper-work.

Kaufman R. AAUP president claims campuses plagued with ‘administrative bloat.’ The Scientist. May 11,

1992:7.

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1993;91;867

Pediatrics

Lynn M. Taussig

Burris Duncan, John Ey, Catharine J. Holberg, Anne L. Wright, Fernando D. Martinez and