just a procedure, it is a process that involves pretest counseling, history taking, physical examination, clinical procedures, labora-tory testing, and posttest counseling. Responsible and prudent practice requires at-risk families to be informed of prenatal diag-nosis options and to be provided avenues to their access. Some will decline and some will accept all or part of the services offered, based on the counseling provided to them, the specific medical, social, emotional, and spiritual circumstances of the family, and the nature of the risk. The suggestion that certain prenatal diag-nostic procedures should not be offered unless the family is will-ing to abort the pregnancy fails to recognize and acknowledge the many other important benefits that can be realized through know-ing whether the fetus is affected with disorders such as sickle cell anemia and Down syndrome, to use Dr Chilton’s examples. Knowledge of such diagnoses can help families prepare emotion-ally for the task of raising a child with a disability, because they will have time to educate themselves about the nature of the disorder and its possible medical, social, and educational compli-cations. They can explore support groups specific to that diagnosis and tap into a network of support and advocacy instead of ap-proaching these issues in the crisis atmosphere of a birth hospital. This knowledge also allows families to make appropriate deci-sions about insurance; for example, the primary earner may choose to remain in a particular job with broad health insurance benefits rather than change to another job with a less secure health insurance plan. If the child will have special education needs, the parents may choose to live in a locale that has a school district known to have superior special education programs; and if the child will have significant medical needs, they may choose to live near a tertiary medical center and the subspecialists who will be involved in their child’s care. To reduce the benefits of prenatal diagnosis to the narrow scope of pregnancy termination, fetal treatment, or emergent newborn treatment is to adopt a purely medical approach to a situation that reverberates with social, financial, educational, occupational, emotional, and familial issues that need to be recognized if one wishes to examine the utility of such a process in an informed and balanced manner.
It is unfortunate that Dr Chilton’s colleagues in the emergency department at Lovelace Medical Center often order tests that, in his opinion, are unnecessary. We share his concerns about this kind of practice and what it may mean for future health care costs. He goes on to suggest that this clinical report presents an analo-gous situation, one that does not reflect a responsible or judicious approach to genetic testing, and on this point we most wholeheart-edly disagree. For each prenatal diagnostic procedure that is pre-sented in this report, there is an appropriately detailed and refer-enced discussion of the associated advantages, disadvantages, and risks of the procedure. The major benefit is also well documented, namely to know whether the fetus is affected or unaffected. Al-though Dr Chilton has chosen to approach this issue from the calculus of a strict medical model, we believe that such a model fails to embrace the full spectrum of risks and benefits that need to be considered in any responsible, compassionate, and thorough analysis of the systems that provide care and support for children and their families.
Christopher Cunniff, MD
Department of Pediatrics
University of Arizona College of Medicine Tucson, AZ 85724-5073
REFERENCE
1. Cunniff C; American Academy of Pediatrics, Committee on Genetics. Prenatal screening and diagnosis for pediatricians.Pediatrics.2004;114: 889 – 894
doi:10.1542/peds.2004-2458
Height and Social Adjustment
To the Editor.—
There continues to be debate about whether short children suffer psychological stress from their short stature. Sandberg et al1 have reported that extremes of stature have minimally detectable impact on peer perceptions of social behavior, friendship, or ac-ceptance in a general population of school children. This research
was supported in part by a grant from the Human Growth Foun-dation, a nonprofit organization dedicated to research, education, advocacy, and support for people with growth disorders. We believe that this research is important, because most reported studies on the psychological effect of short stature have been conducted in the population of children who have been referred for medical evaluation of their short stature. We hope to be able to support similar studies in the future.
It is of interest that these observations differ from what is seen in patients referred to growth clinics or in terms of the concerns of parents who seek information and support from organizations such as the Human Growth Foundation. Stabler et al2reported that academic underachievement, behavior problems, and re-duced social competency are overrepresented in the population of short children (heights ⫺2.7 SD) who are being treated with growth hormone. As many as 40% had some form of psychosocial adjustment problem. It is probable that children referred for short stature represent a different population than those who are not referred for medical evaluation. In fact, it has been reported that those short children not referred for evaluation do not experience psychological problems.3,4 Lindsay et al5evaluated children in Salt Lake City (Utah) schools and reported that although⬃1 in 3500 children met the criteria for the diagnosis of growth hormone deficiency, only half of them were actually being evaluated or treated. Another striking difference between the children in the Sandberg article and the children we see in our clinics or at the Human Growth Foundation is the degree of short stature. Al-though Sandberg et al tried to evaluate children with heights
⬎2.25 SD below the mean, the number of subjects in this height range were too few for meaningful analysis. By contrast, the heights of patients who have been treated for idiopathic short stature or growth hormone deficiency followed by postmarketing studies have had average heights of⫺2.7 to⫺3.2 SD. An addi-tional issue is that Sandberg et al examined their study population with specific instruments with a limited number of endpoints. It is not clear that these instruments have been validated appropri-ately. There may be other instruments that would identify issues that have are not seen in this report.
Sandberg et al1suggest that children or parents of children concerned about psychological problems associated with short stature may be exhibiting a focusing illusion. Stabler et al6have shown that children with short stature treated for 3 years with growth hormone demonstrated improvement in behavior prob-lems (whether they had growth hormone deficiency or idiopathic short stature), suggesting that the behavior problems may not simply represent a focusing illusion and that treatment of the short stature, at least in some cases, seems to address the behav-ioral issues.
The study shows no significant drawbacks in socialization of the shorter (but normal-statured) children. However, it does not and cannot examine what it may have taken for the shorter chil-dren to develop their adaptive or coping strategies to allow them to fit in with their peers. In fact, the authors have some data contradicting their own conclusions. The shorter children were perceived as looking younger, which was correlated with small increases in emotional sensitivity, victimization and passive with-drawal, and small decreases in physical and verbal aggression and dominance. These findings are minimized by the authors but could nevertheless be relevant to the individual patients who present to the clinic and to the group of significantly shorter children not examined in the study. It is possible, as these authors suggest, that short stature may not cause psychological problems for all short children, and there may be many short children who may not benefit from growth hormone therapy. However, there is also a body of data indicating that very short children who seek medical attention for their short stature may be experiencing academic underachievement, behavior problems, and reduced so-cial competency. It would be a mistake to deny medical evaluation or growth hormone therapy (when appropriate) to these children.
Stephen F. Kemp, MD, PhD
Department of Pediatrics
University of Arkansas for Medical Sciences Arkansas Children’s Hospital
Little Rock, AR 72202
LETTERS TO THE EDITOR 515 at Viet Nam:AAP Sponsored on August 29, 2020
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REFERENCES
1. Sandberg DE, Bukowski WM, Fung CM, Noll RB. Height and social adjustment: are extremes a cause for concern and action? Pediatrics.
2004;114:744 –750
2. Stabler B, Clopper RR, Siegel PT, Stoppani C, Compton PG, Underwood LE. Academic achievement and psychological adjustment in short chil-dren.J Dev Behav Pediatr.1994;14:1– 6
3. Sandberg DE, Brook AE, Campos SP. Short stature: a psychosocial bur-den requiring growth hormone therapy?Pediatrics.1994;94:832– 840 4. Voss LD. Growth hormone therapy for the short normal child: who
needs it and who wants it? The case against growth hormone therapy.
J Pediatr.2000;136:103–106
5. Lindsay R, Feldkamp M, Harris D, Robertson J, Rallison M. Utah Growth Study: growth standards and the prevalence of growth hormone defi-ciency.J Pediatr.1994;125:29 –35
6. Stabler B, Siegel PT, Clopper RR, Stoppani CE, Compton PG, Underwood LE. Behavior change after growth hormone treatment of children with short stature.J Pediatr.1998;133:366 –373
doi:10.1542/peds.2004-2207
In Reply.—
Although we are grateful to Dr Kemp for his interest in our study,1we would like to respond to several issues raised in his letter. We assert that the industry-sponsored studies2,3cited to support Kemp’s view that patients with short stature exhibit ac-ademic underachievement, behavior problems, and reduced social competency relative to norms are limited by several fundamental problems. First, no evidence was provided that participants in either study were representative of the cohort referred to pediatric endocrinologists at the 27 recruiting centers of the Genentech-sponsored National Cooperative Growth Study. Without details regarding selection factors, prevalence estimates of adjustment problems are meaningless. Second, it was reported that IQs for the patient groups fell in the high-average range, whereas scholastic achievement was average.2The authors interpreted the disparity between the 2 as indicative of academic underachievement. A critical analysis of the methods selected suggests an alternative conclusion. The measure of IQ that was selected overestimates intelligence, whereas the measure of academic achievement un-derestimates performance. Thus, the relatively high rate of aca-demic “underachievement” is likely an artifact of the battery of psychoeducational tests selected.
Third, Kemp concludes from the second National Cooperative Growth Study report3that apparent improvements in behavioral adjustment associated with growth hormone treatment provides evidence of a preexisting disability and that treatment ameliorates these problems. Unfortunately, the research-design flaws of that study undermine any such conclusion. D.E.S. and W.M.B. (with others) have detailed these weaknesses elsewhere.4It is notable that Stabler et al3failed to demonstrate that increases in relative height were related to adjustment. This dissociation has been reported elsewhere.5,6Kemp also failed to cite epidemiologically oriented clinic-based studies, which do not detect clinically signif-icant problems of psychosocial adaptation or self-concept among youths or young adults with short stature.5,7–9 In the case of 1 study cited,8Kemp is mistaken when he refers to that sample as “not referred.” Most importantly, no research has shown clear linkages between giving growth hormone, changes in height, and subsequent changes in adjustment. If growth-promoting medical therapies are offered to improve the individual’s quality of life in the present or future, then it is incumbent on clinicians and clinical researchers to incorporate a comprehensive psychosocial assess-ment in the evaluation of patients. Although the parameters of such an evaluation have been outlined,10to the best of our knowl-edge they have not been adopted in the clinical decision-making algorithm, and no clinical research data support this model.
Kemp’s contention that population-based samples of short chil-dren include chilchil-dren who are insufficiently short to test hypoth-eses concerning height and psychosocial adjustment is not sup-ported by the evidence. A number of clinic-based studies have also failed to demonstrate that psychological adjustment declines with increasing severity of short stature.5,8,11In fact, 1 study found the opposite to be true: relatively taller children with short stature (ie,⬍5th percentile) exhibited significantly more behavior
prob-lems than relatively shorter youths (range: ⫺4.0 to⫺1.6 height SD).8
Although we recognize that the subsample of very short youths (ie, less than⫺2.25 SDs) in our study was not large (n⫽22), statistical power was sufficient in that design to detect effect sizes large enough to be interpreted as evidence of significant impair-ment in peer relations. Moreover, the height range of this group (⫺4.67 to ⫺2.25 SDs; mean:⫺2.68 SD) is comparable to that of patients involved in the referenced postmarketing studies.2,3
In contrast to Kemp, we believe that obtaining data from peers about peer relationships is the methodology of choice. The mea-sures used in our study have a long history of use in developmen-tal psychology and have the distinction of being stable over time and predictive of future psychological functioning across multiple domains.12We acknowledge that this type of research is challeng-ing to complete, but responses from peers on widely used mea-sures of social relationships are considered to be the methodolog-ical “gold standard.”
William M. Bukowski, PhD
Department of Psychology and Centre for Research in Human Development
Concordia University
Montreal, QC, Canada H4B 1R6
Robert B. Noll, PhD
Children’s Hospital of Pittsburgh Departments of Pediatrics, Psychiatry, and Psychology
University of Pittsburgh Pittsburgh, PA 15213
Caroline Fung, PA-C
Department of Psychiatry University at Buffalo
State University of New York Buffalo, NY 14222
David E. Sandberg, PhD
Departments of Psychiatry and Pediatrics University at Buffalo
State University of New York Buffalo, NY 14222
REFERENCES
1. Sandberg DE, Bukowski WM, Fung CM, Noll RB. Height and social adjustment: are extremes a cause for concern and action?Pediatrics.
2004;114:744 –750
2. Stabler B, Clopper RR, Siegel PT, Stoppani C, Compton PG, Underwood LE. Academic achievement and psychological adjustment in short chil-dren. The National Cooperative Growth Study.J Dev Behav Pediatr.
1994;15:1– 6
3. Stabler B, Siegel PT, Clopper RR, Stoppani CE, Compton PG, Under-wood LE. Behavior change after growth hormone treatment of children with short stature.J Pediatr.1998;133:366 –373
4. Sandberg DE, Kranzler J, Bukowski WM, Rosenbloom AL. Psychosocial aspects of short stature and growth hormone therapy.J Pediatr.1999; 135:133–134
5. Theunissen NC, Kamp GA, Koopman HM, Zwinderman KA, Vogels T, Wit JM. Quality of life and self-esteem in children treated for idiopathic short stature.J Pediatr.2002;140:507–515
6. Steinhausen HC, Dorr HG, Malin Z. Behavioral evaluation of GH treat-ment in short statured children and adolescents: findings from a pilot study.J Endocrinol Invest.2002;25:351–356
7. Zimet GD, Cutler M, Litvene M, Dahms W, Owens R, Cuttler L. Psy-chological adjustment of children evaluated for short stature: a prelim-inary report.J Dev Behav Pediatr.1995;16:264 –270
8. Sandberg DE, Brook AE, Campos SP. Short stature: a psychosocial burden requiring growth hormone therapy?Pediatrics.1994;94:832– 840 9. Rekers-Mombarg LT, Busschbach JJ, Massa GG, Dicke J, Wit JM. Quality of life of young adults with idiopathic short stature: effect of growth hormone treatment. Dutch Growth Hormone Working Group.Acta Paediatr.1998;87:865– 870
10. Noeker M, Haverkamp F. Adjustment in conditions with short stature: a conceptual framework.J Pediatr Endocrinol Metab.2000;13:1585–1594
11. Steinhausen HC, Dorr HG, Kannenberg R, Malin Z. The behavior pro-file of children and adolescents with short stature.J Dev Behav Pediatr.
2000;21:423– 428
12. Rubin KH, Bukowski WM, Parker JG. The peer system: interactions, relationships and groups. In: Eisenberg N, ed.The Handbook of Child Psychology. New York, NY: Wiley; 1998
doi:10.1542/peds.2004-2625
Epidemiology of Community-Acquired
Pneumonia in Children
To the Editor.—
We read the recent article by Michelow et al,1“Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in Hospitalized Children,” with great interest. One hundred fifty-four children were enrolled in this study, and blood or pleural fluid cultures, pneumolysin-based polymerase chain reaction as-says, and serologic tests were used to clarify the epidemiology. The study indicated that Streptococcus pneumoniae, Mycoplasma pneumoniae,Chlamydia pneumoniae, and respiratory viruses were the major pathogens involved in community-acquired pneumonia (CAP). Although these results are informative for pediatricians, it does not seem appropriate that Haemophilus influenzaewas not found to be a causative pathogen of CAP in this study. In the guidelines2published by the American Thoracic Society,H influ-enzae is recognized as an etiologic pathogen that causes CAP. There may be some discrepancy between adults and children over whetherH influenzae is a respiratory pathogen of CAP. As it is stated by the authors in their discussion, however, such a discrep-ancy in the epidemiology might be the result of a lack of specific tests for H influenzae (and Moraxella catarrhalis). Because most respiratory infections ofH influenzaeare caused by nontypeable strains, analysis by serologic methods should be improved to include antigens made by local strains ofH influenzae. We have been using a semiquantitative culture method of detection on washed sputum samples for a couple of decades and have found thatH influenzaeis one of the most frequent causative pathogens found in lower respiratory tract infections in children. This method is not difficult for pediatricians and is less invasive for children. Although expectorated sputum is difficult to obtain from younger children, it can be obtained successfully from children repeatedly by inducing cough. In this method, the sputum ob-tained is washed in sterile saline three times to reduce the effect of microorganisms from the upper respiratory tract that are usually present on the outside of the specimens. Using this method, Ue-hara3emphasized the significant etiologic role ofH influenzaein children with CAP, and our recent data also indicate that nearly 30% of lower respiratory infections in children are related toH influenzae(unpublished data). We would suggest that this semi-quantitative culture analysis of washed sputum be compared with an improved serologic method forH influenzaein the future.
Tsutomu Yamazaki, MD, PhD Kei Murayama, MD
Atsuko Ito, MD
Suzuko Uehara, MD, PhD Nozomu Sasaki, MD, PhD
Department of Pediatrics Saitama Medical School
Moroyama, Iruma, Saitama 350-0495, Japan
REFERENCES
1. Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical char-acteristics of community-acquired pneumonia in hospitalized children.
Pediatrics.2004;113:701–707
2. Niederman MS, Bass JB Jr, Campbell GD, et al. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American Tho-racic Society. Medical Section of the American Lung Association.Am Rev Respir Dis.1993;148:1418 –1426
3. Uehara S. A method of bacteriological examination of washed sputum in infants and children.Acta Paediatr Jpn.1988;30:253–260
doi:10.1542/peds.2004-2055
In Reply.—
The incidence ofHaemophilus influenzaeinfection was not spe-cifically studied in our recent publication.1Although non-type b and nontypeableH influenzaehave been confirmed as causes of pneumonia in children, the frequency of infection in the United States is poorly defined. Since the introduction of the conjugated polysaccharideH influenzaetype b vaccine in 1990, the incidence of invasive disease by that pathogen has declined dramatically. A limited number of publications have demonstrated lower frequen-cies of non-type b and nontypeableH influenzae pneumonia in children compared with adults and in developed countries com-pared with developing countries.2These strains have also been isolated from patients with underlying respiratory disorders in-cluding acute exacerbations of chronic bronchitis, bronchiectasis, and cystic fibrosis.3
H influenzaecommonly colonizes the upper respiratory tract of children. These commensal organisms can gain access to the lungs by contiguous spread or aspiration but are less likely to invade the blood stream thanH influenzaetype b. Therefore, to confirm in-fection with non-type b or nontypeable H influenzae, culture of percutaneous lung aspirates are necessary.4,5Because these inva-sive procedures are rarely undertaken in children, the incidence of pneumonia caused by these strains presumably is underestimated. Other diagnostic approaches have not been adequately vali-dated in children. Specifically, acute and convalescent serology may indicate acute infection withH influenzae, but serologic assays may also reflect a nonspecific anamnestic response to a previous infection or a response to colonizing organisms during a viral infection.6,7Sputum collection in young children is unreliable, and semiquantitative cultures of sputum samples to diagnose causes of pneumonia in children have not been adequately validated by other investigators. BecauseH influenzaefrequently colonizes the nasopharynx of children, there is a substantial risk of overestimat-ingH influenzaepneumonia based on nasopharyngeal cultures.5
Ian C. Michelow, MBBCh, DTM&H
Department of Pediatrics Massachusetts General Hospital Boston, MA 02114
George H. McCracken, Jr, MD
Department of Pediatrics
University of Texas Southwestern Medical Center Dallas, TX 75390
REFERENCES
1. Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical char-acteristics of community-acquired pneumonia in hospitalized children.
Pediatrics.2004;113:701–707
2. Heath PT, Booy R, Azzopardi HJ, et al. Non-type bHaemophilus influenzae
disease: clinical and epidemiologic characteristics in the Haemophilus influenzaetype b vaccine era.Pediatr Infect Dis J.2001;20:300 –305 3. Klein JO. Role of nontypeableHaemophilus influenzaein pediatric
respi-ratory tract infections.Pediatr Infect Dis J.1997;16:S5–S8
4. Liston TE, Foshee WS. Invasive disease due to nontypableHaemophilus influenzaein children.South Med J.1982;75:753–754
5. Shann F.Haemophilus influenzaepneumonia: type b or non-type b?Lancet.
1999;354:1488 –1490
6. Korppi M, Katila ML, Jaaskelainen J, Leinonen M. Role of non-capsulated
Haemophilus influenzaeas a respiratory pathogen in children.Acta Paedi-atr.1992;81:989 –992
7. Bradley JS. Management of community-acquired pediatric pneumonia in an era of increasing antibiotic resistance and conjugate vaccines.Pediatr Infect Dis J.2002;21:592–598; discussion 613– 614
doi:10.1542/peds.2004-2480
LETTERS TO THE EDITOR 517 at Viet Nam:AAP Sponsored on August 29, 2020
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DOI: 10.1542/peds.2004-2207
2005;115;515
Pediatrics
Stephen F. Kemp
Height and Social Adjustment
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