Letters to the Editor
Statements appearing here are those of the writers and do not represent the official position of the American Academy of Pediatrics, Inc. or its Committees. Comments on any topic, including the contents ofPediatrics,are invited from all members of the profession: those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.
• • •
Letters should be submitted in duplicate in double-spaced typing on plain white paper with name and address of sender(s) on the letter. Send them to Jerold F. Lucey, MD, Editor, Pediatrics Editorial Office, Fletcher Allen Health Care, Burlington, VT 05401.
Costs of Otitis Media?
To the Editor.—
In a recent publication, Carabin and colleagues attempted to estimate the direct and indirect costs of infectious diseases attrib-utable to day care attendance among Canadian toddlers.1
Al-though the researchers provided a thorough analysis of the ex-penses incurred by the parents of sick children, their estimates are ultimately limited by one major omission. Otitis media (OM) is a common illness among Canadian children, and the incidence of the disease is on the rise.2OM is also a common reason for visits
to physicians’ offices, the consumption of antibiotics and over-the-counter medicines, as well as minor surgical interventions such as myringotomy with tympanotomy tube placement. Annual treat-ment expenditures for OM have been estimated to exceed $600 million in Canada.3Furthermore, numerous studies have
demon-strated that day care attendance is a major risk factor for OM.4 –7
It is difficult to understand why the authors failed to include OM in their analysis of the costs of day care-related illness, con-sidering the fact that 50 (18.3%) children in their study suffered from chronic OM (see Table 1A, page 559). The average costs of treating an initial episode of OM exceed $100.8In cases of chronic
OM, treatment costs range from several hundred to more than $1000 dollars, depending on the method of management.9 By
failing to consider expenditures for OM, the researchers ignored an important contribution to the economic burden of day care-related illness.
Matthew D. Curry, RN
Greenville, NC 27858
REFERENCES
1. Carabin HC, Gyorkos TW, Soto JC, Penrod J, Joseph L, Collet, J-P. Estimation of direct and indirect costs because of common infections in toddlers attending day care centers.Pediatrics.1999;103:556 –564 2. Crouteau N, Vu H, Pless B, Infante-Rivard C. Trends in medical visits
and surgery for otitis media among children.Am J Dis Child.1990;144: 535–538
3. Elden LM, Coyte PC. Socioeconomic impact of otitis media in North America.J Otolaryngol.1998;27(suppl):9 –16
4. Froom J, Culpepper L. Otitis media in day-care children: A report from the International Primary Care Network.J Fam Prac.1991;32:289 –294 5. Hardy AM, Fowler MG. Child care arrangements and repeated ear
infections in young children.Am J Public Health.1993;83:1321–1325 6. Marx J, Osguthorpe D, Parsons G. Day care and the incidence of otitis
media in young children.Otolaryngology-Head and Neck Surgery.1995; 112:695– 699
7. Uhari M, Ma¨ntysaari K, Niemela¨ M. A meta-analytic review of the risk factors for acute otitis media.Clin Infect Dis.1996;22:1079 –1083 8. Kaplan B, Wandstrat TL, Cunningham JR. Overall cost in the treatment
of otitis media.Pediat Infect Dis J.1997;16(suppl):9 –11
9. Berman S, Roark R, Luckey D. Theoretical cost effectiveness of man-agement options for children with persisting middle ear effusions.
Pediatrics.1994;93:353–363
In Reply.—
We included direct costs related to OM and other specific diseases of preschool-aged children attending day care in the calculation of direct costs under both medication and visit to a physician.All prescription drugs and over-the-counter drugs pur-chased by the parent over the first 6 months of the study for episodes of colds, diarrhea and/or vomiting— caused by any ill-ness—would have been indicated on the daily calendar from which we estimated costs. Our definition of colds included OM— or at least its first symptoms. Therefore, most of the costs associated with OM were included. Instances of visits to physi-cians in a hospital setting would be captured in the section onvisit to a physician.Although, in Quebec, fees associated with visits to a physician and hospitalization are not directly paid by parents, we used, in our estimation of direct costs, a weighted average of the costs for a visit to a physician based on information (eg, type of physician, type of setting) provided by parents in the baseline questionnaire, which included data over the previous 4 weeks. Because it was not feasible to obtain all cost data for the hospital-izations (eg, duration, medication use during the hospitalization), we included only costs for visits to a physician and acknowledged that we are underestimating the true costs. It was not possible for us to estimate the magnitude of this underestimation, but readers might be able to appreciate it in their own public or private health care settings. Expenditures for children in our study, who attend daycare and who suffered from OM, would have been included in our cost estimates. The general issue of including hospitalization data is correctly identified by Mr. Curry as being an important component of this type of analysis.
He´le`ne Carabin, DVM, PhD
University of Oxford
The Wellcome Forest Centre for the Epidemiology of Infectious Disease
Oxford, England OX1 3PS
Evaluation of Vaginal Infections in Adolescent
Women: Can It Be Done Without a Speculum?
To the Editor.—
I appreciated the study published by Blake et al.1I agree with
the authors’ motivation for early detection and treatment of sex-ually transmitted diseases among young women. An initial or unexpected pelvic examination for most young women can result in anxiety for the patient, the parent, and possibly the primary caregiver. It also requires more time for the clinician, and may slow down patient flow in a busy practice. However, any delays in diagnosis of significant pelvic infections can have long-lasting complications.
The authors suggest that fear of pain during a speculum exam-ination may force young women to refrain from seeking care early. I take issue with this hypothesis. Millstein et al2reported
delay in seeking medical attention were personal neglect, misin-formation about the need for care or birth control, and fear of family members having knowledge of their sexual behavior. Al-though fear of the examination was listed as a deterrent, it was not foremost in preventing such care. However, the most common reason for ultimately seeking care was fear of pregnancy.
Pediatricians have been surveyed regarding their attitudes and practices on obtaining sexual history and performing breast and vaginal examinations. Although the overwhelming majority felt that these were important, only 75% completed breast examina-tion and,50% performed vaginal examinations.4,5
As pediatricians we have a responsibility beyond the diagnosis and treatment of sexually transmitted diseases. Without visualiza-tion we miss the opportunity to diagnose genital warts, vulvar ulcers, vaginal cysts, foreign bodies, anomalies, and possible sex-ual abuse.6We also miss an opportunity to counsel these
devel-oping adults regarding appropriate and safe sexual behavior. I would suggest that the nonspeculum evaluation be reserved for follow-up visits after treatment and for patients so uncooper-ative that they could suffer physical trauma during the proce-dure.7More data from large, controlled clinical trials is needed so
that practicing clinicians can feel confident about choosing this method over the traditional pelvic examination.
Iris D. Buchanan, MD
Morehouse School of Medicine Department of Pediatrics Atlanta, GA 30310
REFERENCES
1. Blake DR, Duggan A, Quinn T, et al. Evaluation of vaginal infections in adolescent women: can it be done without a speculum?Pediatrics.
1998;102:939 –944
2. Millstein SG, Adler NE, Irwin CE. Sources of anxiety about pelvic examinations among adolescent females.J Adolesc Health Care.1984;5: 105–111
3. Zabin LS, Clark SD Jr. Why they delay: a study of teenage family planning clinic patients.Fam Plann Perspect.1981;13:205–217 4. Nussbaum MP, Shenker R, Feldman JG. Attitudes versus performance
in providing gynecologic care to adolescents by pediatricians.J Adolesc Health Care.1989;10:203–208
5. Beatty ME, Lewis J. Adolescent contraceptive counseling and gynecology: a deficiency in pediatric office-based care.Conn Med.1994; 58:71–78
6. Perlman SE, Kahn JA, Emans J. Should pelvic examinations and Papa-nicolaou cervical screening be part of preventive health care for sexually active adolescent girls?J Adolesc Health.1998;23:62– 67
7. Shafer MB. Annual pelvic examination in the sexually active adolescent female: what are we doing and why are we doing it?J Adolesc Health.
1998;23:68 –73
In Reply.—
We appreciate Dr Buchanan’s comments regarding the appli-cation of our work to daily practice. Whenever an alternative approach to standard of care is presented, it is important to consider potential pitfalls of the approach thoughtfully. We agree that an annual pelvic examination with Pap smear is still recom-mended. Most of the findings that Dr Buchanan fears will be missed if a pelvic examination is omitted, would therefore be noted either during an annual gynecologic examination with Pap smear (intravaginal or cervical wart, cervical dysplasia, vaginal cysts, and congenital anomalies) or on external inspection of the genitalia at the time of the acute care visit (external genital warts and vulvar ulcers). If external genital warts are noted, then a speculum examination is indicated to look for concomitant vagi-nal or cervical warts; however, visible vagivagi-nal or cervical warts occurring in the absence of external warts are not common.1,2In an
adolescent, the possibility of a vaginal foreign body should be apparent from a careful history, as would the possibility of sexual abuse. Similarly, a careful history plus examination of the abdo-men should also identify those young woabdo-men who may have more than an uncomplicated lower genital tract infection. If either abdominal pain or tenderness is present, again a pelvic examina-tion is indicated. Although we agree that there are times when one must perform a pelvic examination, we believe that the medical history can guide these decisions.
Dr. Buchanan’s interpretation of the articles we had cited in support of the possibility that pelvic examinations may serve as an obstacle to prompt diagnosis of infection differs from our inter-pretation. Millstein et al3reported that the second most frequently
cited concern that teenagers had about the pelvic examination was fear of pain. This concern was reported by 65.5% of the respon-dents. Furthermore, most patients (74.1%) reported that they had experienced pain during their pelvic examination. Additionally, fear of pain was the variable most highly associated with anxiety about having a pelvic examination. Although Zabin and Clark4
found that fear of the pelvic examination was only the fourth most common concern among a list of 18 choices, it was cited by 25% of respondents as a contributing factor for delaying a visit to a family planning clinic. If it were possible to bring even some of these teenagers into the health care system sooner by eliminating this fear, many infections might be detected and treated more promptly.
As Dr Buchanan notes, many pediatricians do not perform pelvic examinations.5,6 We agree that physicians who care for
adolescent patients should make every effort to develop their pelvic examination skills. Nevertheless, it seems logical that a physician who does not feel comfortable performing a pelvic examination might be more likely to screen for sexually transmit-ted diseases if a pelvic examination were not required. We do not think that selectively forgoing the pelvic examination interferes with our responsibility to counsel patients about safer sexual practices and behavior; to the contrary, it may actually enhance our ability to do so. Less time spent performing the examination would result in more time to discuss safer sexual behaviors and effective methods of contraception.
In closing, we would like to reemphasize that we are not suggesting that pediatricians stop performing pelvic examina-tions. Sexually experienced adolescent females will still require an annual pelvic examination with Pap smear, although this too is being debated.7,8Any time that a patient’s history suggests the
need for a pelvic examination or her symptoms suggest that she may have something other than an uncomplicated genitourinary infection, a pelvic examination should be performed. However, we have demonstrated that pelvic examinations are not necessary to diagnose vaginal infections. This finding, combined with the recent availability of urine-based screening for cervical infections, now provides health care professionals with a noninvasive alter-native to the standard pelvic examination.
Diane R. Blake, MD* Anne Duggan, ScD* Thomas Quinn, MD‡ Jonathan Zenilman, MD‡ Alain Joffe, MD, MPH*
Departments of *Pediatrics and ‡Medicine Johns Hopkins University School of Medicine Baltimore, MD
REFERENCES
1. Koutsky LA, Kiviat NB. Genital human papillomavirus. In: Holmes KK, Sparling PF, Mardh PA, et al, eds.Sexually Transmitted Diseases.3rd ed. New York, NY: McGraw-Hill, Inc.; 1999:347–359
2. Blake DR, Duggan A, Quinn T, Zenilman J, Joffe A. Evaluation of vaginal infections in adolescent women: can it be done without a speculum?Pediatrics.1998;102:939 –944
3. Millstein SG, Adler NE, Irwin CE Jr. Sources of anxiety about pelvic examinations among adolescent females.J Adolesc Health Care.1984;5: 105–111
4. Zabin LS, Clark SD Jr. Why they delay: a study of teenage family planning clinic patients.Fam Plann Perspect.1981;13:205–217 5. Beatty ME, Lewis J. Adolescent contraceptive counseling and
gynecology: a deficiency in pediatric office-based care.Conn Med.1994; 58:71–78
6. Nussbaum MP, Shenker IR, Feldman JG. Attitudes versus performance in providing gynecologic care to adolescents by pediatricians.J Adolesc Health Care.1989;10:203–208
7. Shafer MA. Annual pelvic examination in the sexually active adolescent female: what are we doing and why are we doing it?J Adolesc Health.
1998;23:68 –73
Cancer in Children: Is the Sample Biased?
To the Editor.—
I read with interest the article by Noll et al1that appeared in the
January 1999 issue ofPediatrics.As an Instructor in Pediatrics and Psychiatry, in charge of the Pediatric and Adolescent Psychiatry Consultation Service at Memorial Sloan-Kettering Cancer Center, I feel compelled to share some concerns.
First, Dr Noll states in the “Methods” section that children were eligible if they were currently undergoing chemotherapy for a malignancy not primarily involving the central nervous system. Why this exclusion? According toNelson’s Textbook of Pediatrics, brain tumors rank second only to leukemia as the most prevalent malignancy in childhood and account for the most common solid tumors in this age group.2Furthermore, evidence from the
litera-ture supports the fact that children with neurologic dysfunction are at increased risk for psychological disorders than either the general child population3or children with other physical
disor-ders not involving the brain.4 The exclusion of this group of
children from the study seems to introduce substantial bias. Sim-ilarly, it is not clear if children who were receiving intrathecal chemotherapy for leukemia were included in this study. If not, I feel it is incumbent on the authors to state so and to explain why not.
Second, Dr Noll states that the children were enrolled in the study at an average of 11.1 months (standard deviation 2.9) after diagnosis and all were in their first remission. Why so long a wait? In our experience at Memorial, one third of our consultations are for adjustment disorders, which can cause substantial psychoso-cial morbidity within the first few months of diagnosis. Although the majority of these children will gradually adjust to their illness, enrolling children so late in the study ignores the initial emotional and social impact that diagnosis places on them. Similarly, why evaluate only those children in first remission? Although a sub-stantial number of children undergoing treatment will achieve first remission and cure, a similarly substantial number will re-lapse, and experience a more chronic course to their illness. Chronic health conditions such as these have been associated with an increased rate of psychological symptoms5and higher rates of
grade repetition and placement in special education.6It is
inter-esting to note that children placed in full-time special education were also excluded from this study.
It is my opinion that the conclusions drawn by Dr Noll are based on a seriously biased sample of children selected for an optimal psychological outcome. Perhaps a more accurate title for this article would be “Social, Emotional, and Behavioral Function-ing of Children Not in Full-Time Special Education, Approxi-mately 11 Months Status Postdiagnosis, Who Are in First Remis-sion and on Chemotherapy for Non-CNS Primary Cancer.”
Joseph P. Damore, Jr, MD
Department of Pediatrics and Psychiatry Memorial Sloan-Kettering Cancer Center New York, NY 10021
REFERENCES
1. Noll RB, Gartstein MA, Vannatta K, Correll J, Bukowski WM, Davies WH. Social, emotional, and behavioral functioning of children with cancer.Pediatrics.1999;103:71–78
2. Behrman RE, Kliegman RM, Nelson WE, Vaughn VC, eds. Nelson’s Textbook of Pediatrics. 14th ed. Philadelphia, PA: WB Saunders Company; 1992:1531
3. Kindlon D, Sollee N, Yando R. Specificity of behavior problems among children with neurological dysfunctions.J Pediatr Psychol.1988;13:39 – 40 4. Breslau N. Psychiatric disorder in children with physical disabilities.
J Am Acad Child Psychiatry.1985;24:87
5. American Academy of Pediatrics, Committee on Children With Disabil-ities and Committee on Psychosocial Aspects of Child and Family Health. Psychosocial risks of chronic health conditions in childhood and adolescence.Pediatrics.1993;92:876
6. Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic condi-tions, socioeconomic risks, and behavioral problems in children and adolescents.Pediatrics.1990;85:273
In Reply.—
It is with some interest that we read the letter to the editor from Dr Damore regarding our work examining the psychological func-tioning of children with cancer. Dr Damore raises several issues relevant to the external validity of our data.
Why did we exclude children with brain tumors? This group of tumors has not been excluded from our research activities. We initially wrote our manuscript1including children surviving brain
tumors. The manuscript was rejected from the first journal where it was submitted. All of the reviewers cited sample heterogeneity as a major limitation. Much of the work studying the psycholog-ical functioning of children with cancer has also been criticized for this reason. These data were split into 2 manuscripts. The data about children with cancer not primarily involving the central nervous system (CNS) were published in Pediatrics. The data about children with brain tumors2were published in theJournal of
Pediatric Psychology.We found that children surviving brain tu-mors who returned to regular classrooms (roughly one third of all patients diagnosed with brain tumors at our center, because one third had died and one third were in full-time special education) were perceived by peers, teachers, and self-report as being sensi-tive and isolated. Additionally, brain tumor survivors were less socially accepted by peers. We concluded that children with brain tumors were at high risk for unremitting psychological problems. Dr Damore also wondered if we included children who were receiving intrathecal chemotherapy. These children constituted more than 50% of our sample. Although we agree that consider-able evidence from the literature links neurologic dysfunction with increased risk for psychological difficulties, recent data from the Children’s Cancer Group linking contemporary intrathecal therapies to subsequent social, emotional, or behavioral difficul-ties was not impressive,3so these children were included.
Why did we wait 11 months to collect data on the functioning of children diagnosed with cancer? There are several reasons. First, we needed to wait until children returned to school after diagnosis. Commonly children with cancer miss several weeks or months of school at diagnosis. Even when they are attending school initially, attendance is spotty. We wanted to collect data when children were regularly attending school so peers would have opportunities to interact with these children while they were receiving chemotherapy. Second, collection of data from schools is extremely labor-intensive. The majority of this research was not supported by external funding; it was all completed by students enrolled in a 3-term course focusing on research methodology. The course begins in the fall and we take approximately 10 weeks to train students about data collection in schools. While the stu-dents are training, we go to the local cancer registry and identify every child between 8 and 15 years old who is on chemotherapy and will remain on treatment until June of the current academic year. Families are contacted in the fall to obtain permission to contact their child’s school. Beginning in January we give our students the names of the children with cancer and the name of their school. Because each child attends a different school, often in a different district, we must obtain permission from principals, school boards, and superintendents. This takes weeks to months for each school. We estimate that collection of data from each classroom requires about 60 hours of labor. We were willing to put in this much effort to obtain data from peers using standardized instruments because of the reliability and predictive validity of these measures.
Finally, the question was raised, why not study children who have relapsed? Studying the peer relationships of children after relapse while they are receiving treatment is a very difficult task. These children are commonly very sick and do not attend school regularly. Additionally, this is a relatively small percentage of all patients because approximately 70% of all children diagnosed with cancer remain in first remission. We have reported data regarding the peer relationships of children subsequent to receiv-ing a bone marrow transplant (BMT),4as many of these children
Dr Damore overstates the limits to the external validity of our data. We question the external validity of data focusing on mood, behavior, or social functioning during outpatient visits or hospi-talizations and encourage more work done in schools and homes when children are not especially physically sick and parents are less burdened. Appropriate controls with clear information about recruitment rates are also essential. We cited our earlier work about children with brain tumors and BMT survivors in our manuscript1to highlight the groups of children with cancer we
have identified as high-risk for psychological problems. We also cited work by our research group and others trying to define the broader parameters associated with increased risk for psycholog-ical problems in children with chronic illness.
Robert B. Noll, PhD Kathryn Vannatta, PhD
Division of Hematology/Oncology Children’s Hospital Medical Center Cincinnati, OH 45229
REFERENCES
1. Noll RB, Gartstein MA, Vannatta K, Correll J, Bukowski WM, Davies WH. Social, emotional, and behavioral functioning of children with cancer.Pediatrics.1999;103:71–78
2. Vannatta K, Gartstein MA, Short A, Noll RB. A controlled study of peer relationships of children surviving brain tumors: teacher, peer, and self ratings.J Pediatr Psychol.1998;23:279 –288
3. Noll RB, MacLean WE, Whitt JK, et al. Behavioral adjustment and social competence of long term survivors of childhood leukemia: parent and teacher reports.J Pediatr Psychol.1997;22:827– 841
4. Vannatta K, Zeller M, Noll RB, Koontz K. Social functioning of children surviving bone marrow transplantation.J Pediatr Psychol. 1998;23: 169 –178
Antibiotic Use and Parental Home Otoscopy
To the Editor.—
Bauchner et al1and others2have called attention to injudicious
antibiotic use, prompting calls for physician, as well as parent, reeducation. Confronted with an unhappy child who may have acute otitis media (AOM) and facing exhausted parents, physi-cians may find themselves under pressure to prescribe.3,4
Exces-sive prescriptions for antibiotics increase costs, engender toxicity, and promote relative and absolute resistance to antimicrobials. More stringent diagnostic criteria, shorter courses of medication, and specified clinical parameters have been proposed to reduce unnecessary antibiotic use.1–5However, the impact of such
mea-sures may be hard to assess, and desired changes may be slow in coming. Moreover, these strategies offer no mechanism for reas-sessing what is going on in the middle ear other than repeated visits to the doctor.
A different approach aims to reduce physician intervention by training parents in rudimentary home otoscopy. This approach is based on the recognition that most uncomplicated AOM is self-resolving.3,6 The goal of home otoscopy is to teach parents to
recognize a normal tympanic membrane. An instrument designed for home use, the EarCheck (MDI Instruments, Woburn, MA), uses acoustic reflectometry to detect middle ear fluid (OME), but cannot distinguish between AOM and OME.7,8In our practice, we
have used a less expensive, portable pediatric otoscope, the Ear-scope (Notoco, Ferndale, CA), which allows properly trained par-ents to visualize the light reflex and erythema of the tympanic membrane, but is less useful in detecting middle ear fluid. Both instruments are appropriate for children over the age of 1 year, provided the external canal is not occluded by cerumen and the child is reasonably cooperative. When children exhibit subtle symptoms of AOM, home otoscopy can eliminate the need for physician contact if there is no middle ear fluid9and the tympanic
membrane appears normal. Furthermore, home otoscopy can pro-vide serial examinations during treatment or observation periods without requiring repeated visits to the doctor.6 This permits
evaluation beyond that provided by vague changes in symptom-atology. The physician choosing to withhold antibiotics must pro-vide adequate analgesia during the observation period and retain appropriate parental contact to ensure safe management of the
patient.3It cannot be overemphasized that ongoing, parental
in-struction and supervision are paramount if home otoscopy is to be successful.
F. Ralph Berberich, MD Katherine Johnston, BA The Pediatric Medical Group Berkeley, CA 94705
REFERENCES
1. Bauchner H, Pelton SI, Klein JO. Parents, physicians, and antibiotic use.
Pediatrics.1999;103:395–398
2. Dowell SF, Marcy SM, Phillips WR, et al. Otitis media—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(suppl): 165–171
3. Hirschmann JV. Methods for decreasing antibiotic use in otitis media.
Lancet.1998;352:672
4. Abramson JS, Givner LB. Bacterial resistance due to antimicrobial drug addiction among physicians.Arch Fam Med.1999;8:79 – 80
5. Leggiadro RJ. Antibiotic therapy for otitis media.Semin Pediatr Infect Dis.1998;4:310 –313
6. Culpepper L, Froom J. Routine antimicrobial treatment of acute otitis media: is it necessary?JAMA.1997;278:1643–1645
7. Kimball S. Acoustic reflectometry: spectral gradient analysis for im-proved detection of middle ear effusion in children.Pediatr Infect Dis J.
1998;17:552–555
8. Barnett ED, Klein JO, et al. Comparison of spectral gradient acoustic reflectometry and other diagnostic techniques for detection of middle ear effusion in children with middle ear disease.Pediatr Infect Dis J.
1998;17:556 –559
9. Block SL, Mandel E, McLinn S, et al. Spectral gradient acoustic reflec-tometry for the detection of middle ear effusion by pediatricians and parents.Pediatr Infect Dis J.1998;17:560 –564
In Reply.—
I appreciate the opportunity to respond to the letter from Dr Berberich and Ms Johnston.
Involving parents in the care of their children should be a goal for every pediatrician. If parents are actively involved in medical decisions, they will feel more satisfied with the care their children receive and the quality of care is likely to be better than if they are not involved.
What should the role of the parent be with respect to the early diagnosis of otitis media (OM)? Clearly, some parents can be taught to use some of the new home technology for detecting middle ear fluid. However, for parents with young children who are ill, the lack of any middle ear fluid should not be reassuring that their child is well: rather, it is how the child is interacting with his or her environment that is the critical issue. Of note is that the vast majority of children who receive antibiotics for otitis media are,3 years old.
With respect to the decision to dispense antibiotics for the treatment of AOM, that remains a controversial subject, particu-larly in the United States. In general, most leading infectious disease experts have continued to endorse antimicrobial therapy for all children with AOM, certainly young children. I believe that some generalist practitioners have been more willing to consider withholding therapy. My own experience suggests that the tide is turning; parents have become aware of the consequences of the overuse of oral antibiotics and are more comfortable with the “no treatment” option for colds, coughs, runny noses, and sore throats (before the results of the throat culture are known). I have yet to encounter many parents who are willing or want to withhold antibiotic therapy when their child has AOM.
I firmly believe that the critical issue around inappropriate oral antibiotic use is not the treatment options for OM. Rather, we must be far more careful in making the diagnosis appropriately. I be-lieve that a substantial number of the 25 million to 30 million diagnoses of AOM that will be made this year will be inaccurate. In addition, we must not prescribe antibiotics for uncomplicated coughs, colds, and runny noses. Mangione-Smith et al1recently
If we communicate better with parents, practice some restraint, and improve our diagnostic skills, much of inappropriate oral antibiotic use will disappear.
Howard Bauchner, MD
Division of General Pediatrics
Boston University School of Medicine/Boston Medical Center
Boston, MA 02118-2393
REFERENCE
1. Mangione-Smith R, McGlynn EA, Eilliot MN, Krogstad P, Brook RH. The relationships between perceived parental expectations and pedia-trician antimicrobial prescribing behavior.Pediatrics.1999;103:711–718
Health Care for Children in Afghanistan
To the Editor.—
I read with interest the special article by Sogan et al1entitled
“21st Century Health Care for Children in Afghanistan.” As ex-pected, in the context of the prevalent political situation, the health care facilities are dismal in the capital of Afghanistan and nonex-istent in the rest of the country. I closely watched the MCH health care services and disease profile of children in Afghanistan during my 4-year tenure as the Director of the Institute of Child Health, Kabal, Afghanistan, during 1979 –1983. I was on deputation from the All India Institute of Medical Sciences, New Delhi, under the International Technical and Economic Cooperation (ITEC) Pro-gram of the government of India.
We have witnessed the unfortunate gradual destruction and disintegration of the beautiful country inhabited by simple, good-hearted Afghan people. Despite the invasion of Afghanistan by the Russian troops on December 26, 1979, life in Afghanistan was tolerable in those days. The Institute of Child Health at Kabul provided a good quantity of level II type of health care facilities to children in various disciplines of pediatric medicine and surgical specialties. A large number of Afghan pediatricians, pediatric surgeons, and nurses working at the Institute of Child Health in Kabul have had their postgraduate training from the All India Institute of Medical Sciences, New Delhi, under the ITEC Pro-gram. We were running a very successful postgraduate training program of Diploma in Child Health and several other diplomas in surgical subspecialities, especially in anesthesia, orthopedics, and ear, nose, and throat. We have published a large number of articles on the health status of children and common and peculiar
diseases in Afghanistan in peer-reviewed journals2–9 to which
Sogan et al have not made any mention in their article.
The country has gone from bad to worse from the days of the Russian siege to the Taliban takeover. The country where women are mostly illiterate and have no status or say in society has gone down to the abysmal depths of despondency during the religious fundamentalistic regime of the Talibans. There is no hope for the country or its people in the near future unless the political situa-tion improves and the rulers show some concern and commitment towards the welfare of their people rather than nursing their narrow political interest. I am sure that many countries and people like Sogan et al are willing to provide support with money, materials, and manpower to the caretakers of Afghanistan if only they show the willingness to seek and accept such things. Small steps are unlikely to provide any meaningful dividends, and concerted or dedicated efforts of pediatricians cannot be har-nessed to provide integrated child care services unless the chaotic situation is corrected by creating some semblance of livable law and order in Afghanistan—the bleeding and (slowly but surely) dying country!
Meharban Singh, MD
A-47, Sector 31 Noida-201301 India
REFERENCES
1. Sogan D, Bridel J, Shepherd C, Arzomend M, Southall DP. 21st Century Health Care for Children in Afghanistan.Pediatrics.1998;102:1193–1198 2. Singh M. Health status of children in Afghanistan.Indian Pediatr.1983;
20:317–323
3. Singh M, Qureshi MA, Aram GN et al. Morbidity and mortality in childhood in Afghanistan: a study of 40 492 consecutive admissions to the Institute of Child Health, Kabul.Ann Trop Pediatr.1983;3:25–30 4. Singh M, Saidali A, Bakhtiar A, Arya LS. Diphtheria in Afghanistan: a
review of 155 cases.J Trop Med Hyg.1985;88:373–376
5. Singh M, Arya LS, Aram GN. Visceral leishmaniasis in Afghanistan.
Indian Pediatr.1981;18:593
6. Singh M, Arya LS, Aram GN, et al. Kala-azar in Afghanistan.J Trop Med Hyg.1982;85:201–204
7. Singh M, Jawadi MH, Arya LS, Rahim F. Congenital malformations at birth among live-born infants in Afghanistan—a prospective study.
Indian J Pediatr.1983;50:139 –143
8. Singh M, Jawadi MH, Arya LS, Rahim F. Intrauterine growth of Afghan babies.Indian Pediatr.1983;50:139 –143
