Righting the Wrong

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772 COMMENTARIES

any beneficial effect on the clinical course.7 This has resulted in a decline in the use of ipecac as reported

in the massive data base reported yearly since 1983

by the American Association of Poison Control

Cen-ters. Ipecac use, for all types of ingestions, has gone

from 13.4% in 1983 to 6% in 1990.89 Since its use in

battery ingestions has no value and may be harmful,

it should not be used. One of the most disturbing

pieces of data in this study is the observation of use of salt, mustard, soapy water, etc, as emetic agents.

These agents have been contraindicated for more than

20 years. They are dangerous in all cases and must

never be used.1#{176}

While almost 10% of cases in this series had some

symptoms, most of these were not substantial and

only two patients had serious problems. Nonetheless,

proper and timely management should be provided

in all cases. There have been serious injuries reported including tracheoesophageal fistulas, perforation of

Meckel’s diverticulum, and esophageal burns.

Fortu-nately, these are not common; unfortunately, the

consequences can be devastating. Just as in ingestion

of corrosive drain cleaners, all ingestions MUST be

treated immediately with the view that serious

prob-lems may occur. An initial roentgenogram must be

performed as soon as a history of ingestion has been

obtained. The authors of the study have clearly

dem-onstrated that neither battery diameter nor symptoms were predictive of esophageal battery position.

We suggest that identification of the chemical

sys-tem and diameter is useful. This information can be

obtained by calling the local poison center or by

contacting the button battery hotline directly

(202-625-3333). If the battery is larger than 15 mm in

diameter, the chance of serious problems increases

both because of mechanical size and because mercury

may be contained in these larger cells.

If the battery has passed through the esophagus,

the risk of a serious problem is substantially reduced.

The study data suggest strongly that there is rarely a

need to attempt removal distal to the esophagus. The

exceptions to this are (1) the battery is larger than 15

mm in diameter in a child younger than 6 years old

that does not pass the pyborus in 48 hours and (2) the mercury-containing battery, which may fragment and

release mercury. In cases involving batteries other

than these exceptions, the stools can be observed and

neither frequent roentgenograms nor surgery is

usu-ably necessary.

Credit for this study must be shared by the battery

companies that funded this project. The authors

con-vinced this group to support the hotline and study.

This is an admirable response by industry

acknowl-edging a problem and responding appropriately, thus

benefiting all concerned including, most importantly, the patients.

CAROL M. Rucic MD

Dept of Radiology and Pediatrics University of Colorado Health Sciences

Center Denver

H. RUMACK, MD Dept of Pediatrics

Rocky Mountain Poison and Drug Center University of Colorado Health Sciences

Center

REFERENCES

I. Litovitz 1, Schmitz BF. Ingestion of cylindrical and button batteries: an analysis of 2382 cases. Pediatrics. 1992;89:747-757

2. Litovitz 1. Button battery ingestions: a review of 56 cases. JAMA.

1983;249:2495-2500

3. Studley JG, Linehan IP, Ogilvie AL, et al. Swallowed button batteries: is there a consensus on management? Gut. 1990;31:867-870

4. Berdon WE. Editorial comment. Pediatr Radiol. 1983;13:119 5. Rumack BH, Rumack CM. Diskbattery ingestion. JAMA.

1983;249:2509-2511

6. CampbellJB, Quattromani FL, Foley LC. Foley catheter removal of blunt esophageal foreign bodies: experience with 100 consecutive children.

Pediatr Radiol. 1983;13:116-118

7. Kulig KW, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of acutely poisoned patients without gastric emptying. Ann Emerg Med.

1985;14:562-567

8. Veltri JC, Utovitz U. 1983 annual report of the American Association

of Poison Control Centers National Data Collection System. Am IEmerg Med. 1984;2:420-443

9. Utovitz IL, Bailey KM. Schmitz BF, et al. 1990 annual report of the American Association of Poison Control Centers National Data Collec-tion System. Am IEmerg Med. 1991;9:461-509

10. Rumack BH, Spoerke DC, eds. POISINDEX Information System. Denver, CO: Micromedex mc; 1988-1991, through vol 71

Righting

the

Wrong

The evidence for the kinds of programs required to

meet children’s health needs has been frequently and

plainly demonstrated. The programs need to be

mul-tilayered, including welfare and educational aspects

in addition to health components. All Western

Euro-pean countries have such sociomedical plans in

op-eration. Not all are as well-organized or effective as

they might be, but in the Netherlands and

Scandi-navia, they are awesomely complete and effective.

Social measures augment and strengthen traditional

health services. Preventive measures are undertaken

across the board: nutrition enhancement in the

schools; home visits for immunization of very young

children; and after-school programs through the

school system to provide care, supervision, and beam-ing experiences. Medical care is part of a universal system. Specially trained nurses, home helpers, and school health attendants are part of the process.

American pediatricians and other children’s

advo-cates know this and most know about the European

experiences.’3 However, something in the American

credo seems to forbid a bold approach. In the recently

released Report from the National Commission on

Children, Beyond Rhetoric, the problems are presented frankly and fully, yet the recommendations are more

tentative.4 The Commission may be justified, in that

however minimal, the recommendations have been

Received for publication Nov 26, 1991; accepted Dec 2, 1991.

Reprint requests to (GAS.) Yale University School of Medicine, 590

Ell-sworth Aye, New Haven, CT 06511.

PEDIATRICS (ISSN 0031 4005). Copyright C 1992 by the American Acad-emy of Pediatrics.

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(2)

COMMENTARIES 773 met with only hesitant approval and discreet

indica-tions that not much is likely to happen.

A coherent, sociomedical plan to promote and

maintain child health is desperately needed: to meet

the scandalously high infant mortality rates in this

wealthy country, for one thing; to ensure preventive measures against clearly preventable diseases, for an-other; especially to offset the racially discriminatory patterns of health care delivery and the lack of access for poor, rural, and geographically isolated children;

and to offer organized approaches toward discovery

and treatment of neglected disabling and

handicap-ping conditions.

What prompts the most dedicated and concerned

advocates is American legislative history, the

his-tory of ‘incrementalism’ in social legislation.5’6 The excuse for introduction of small experimental pro-grams and limited approaches stems from belief in the basically incremental nature of social progress in

America. But in the past, incremental advances

fob-bowed on demands and popular pressure for much

broader and stronger measures. Adopting the small

increments as the goal frustrates progress toward any larger goal. Still, this is the decision of American social philosophers, child advocates, legislators: the pursuit

of a strategy of minimal effort-interim measures,

tinkering with the status quo, amending and correct-ing existing fragmented, inadequate authorizations, in an attempt to compensate for some part of obvious deficiencies.

‘Targeting!’ cannot be an effective answer when

the system itself is in chaos. Sincere reformers who

sponsor limited approaches may be stifling more

de-sirable restructuring. Unfortunately, with no clearly outlined goal toward which to strive, in the face of a

lack of strong and persuasive leadership for such a

goal and powerful opposition to any change, orderly

policy development is impossible.

One hopeful response has been to pursue

‘modebs’-demonstrations in a few modestly funded

programs to illustrate how infant mortality might be

reduced in a blasted slum, or a housing project, for

example-and the lessons learned diffused into the

larger society.7 Sometimes the effort is too narrowly focused, and the multifactorial elements are ignored. In focusing a program on ‘children bearing children,’

it should not be forgotten that condoms and sex

education and mothercrafting cannot compensate for

poor nutrition, miserable housing, or school

play-grounds that are syringe-littered wastelands where

drug dealers solicit sex for cocaine. The ‘culture of

poverty’ studies markedly resemble the studies of

tuberculosis prevalence 50 years ago, in their

La-marckian overtones of ‘nature’ versus ‘nurture.’

There are other defects in the modest approach,

particularly when the approach attempts to avoid, or disguise the reality of, hard questions. The hard ques-tion is how to guarantee all children the best of modern sociomedicab care. Shall proposals be

univer-sal or selective? For example, health programs

ad-dressed solely to the disadvantaged conceal the

in-adequacy of a child health system that fails all

chil-dren in some fashion. Shall a public program ignore

the needs of the better-off socioeconomic groups and

provide more for the poor than is available to those

groups whose taxes pay for the public program? Also,

targeting health programs on the ‘most in need’

depends on bong-term altruism, which ignores the

social maxim that long-term well-doing will weary even the best-intentioned.8

Incremental demands were not always the mode of

advocacy. In this century attitudes toward children’s health and welfare have ranged back and forth across the spectrum of concern and social action. Early social neglect of the poor and discrimination against minor-ities and immigrants were transformed by the current of Progressivism into public action on behalf of

chil-dren: child labor laws, the inauguration of White

House Conferences on Children, the establishment

of the Children’s Bureau, and the passage of the

Sheppard-Towner Act. Voluntary agencies kept in

step: there were settlement houses, clean-milk

cen-ters, clinics. The Depression accelerated activities on

behalf of children. In addition to the protection of

widows and orphans projected by the Social Security

Act, Title V especially, gave explicit evidence of sod-ety’s durable commitment to children’s health.

The fierce zealots of those times bearded the

Con-gress in its den, marched and wrote and orated on

behalf of children, seeking appropriate and complete

entry for their charges into better and healthier lives.

Sara Josephine Baker, Leona Baumgartner Martha

May Eliot, Annie Goodrich and Mary Putnam Jacobi, Florence Kelly and Julia Lathrop pushed and pressed

and harangued for the best and the most, never

sat-isfied that their accomplishments were enough.

Mar-tha Eliot’s ‘club’ of health program advocates that

met on the National Institutes of Health campus was

called ‘The Hundred Percenters.’

Thus the first steps toward comprehensive care for

children were taken. Some prejudicial preconceptions did remain, of course, so that not all the children

benefited to the same extent-many children in

mi-nority communities failed to benefit at all. Poverty still afflicted a significant number of families, and children in those families suffered the consequences

in a society dedicated to rationing of services by

income. Nevertheless, the children’s advocates had

dedicated themselves to accomplishing more, and

they sought to legislate broader and more inclusive programs and services for children.

Even in the dark days of the Depression, advances

in child health were made. After the 1930 White

House Conference on Children promulgating the

‘Children’s Charter,’ Title V of the Social Security

Act promised continuing vigorous steps toward a

comprehensive sociomedical program to guarantee

all

children a healthy start in life. The Depression stunted

the growth a bit, and World War II hampered

ad-vance, although the Emergency Maternity and

In-fancy Care program appeared as another step in that direction.

Following the war, when more comprehensive

ap-proaches to child health were considered, they were put off in expectation of a national health program, debated for the past half-century and always

antici-pated ‘imminently,’ so only modest and tentative

improvements were made. In the 1960s, after the

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774 COMMENTARIES

rebeffions of the poor, the blacks, and women, a

cornucopia of social legislation accompanied the

eco-nomic prosperity of that period, which did

signifi-cantly improve children’s situation. The number of impoverished families declined, and access to health services for children increased.

But this benign outpouring of public funds was

dissipated in the debts incurred as a result of the Vietnam War. The economic decline that followed, exacerbated by the stream of legislation favoring

mil-itary projects and benefiting the wealthy, turned the

clock back on all social legislation, and not just that

in behalf of children. The numbers of children

younger than 6 living in poverty has grown in 20

years from 3.4 million to 5.1 million. Not only is there

more poverty among children, there is more

home-lessness and less access to preventive services and

medical care. The Maternal and Child Health Block

Grant has gone from $457 million in 1981 to $587

million in 1991-a decline in view of inflation, and

ominous in terms of the added numbers of children in need.

The health professionals and children’s activists

who may be chastened and subdued by the long

years of declining legislative favor ought no longer

content themselves with nominal requests for

im-provement in services to children. The time has come

to challenge current values and reassert the primacy

of children’s needs, to demand soda! action of a

radically comprehensive kind. Those who speak for

the children will have to speak in a stronger voice.

No one knows better than those involved in creating

the National Commission on Children report that the

recommendations are basic demands, and not the

totality of what is required. To a nostalgic extent, the report echoes the ringing eloquence of Senator Walter

Mondale’s 1971 masterly address, ‘Justice for

Chil-dren.’9

It will be necessary to reorient the theoreticians and

strategists of political action, who see children as

minor players in the political struggle for legislative action. A reputable political scientist who has advised

a number of presidential candidates on health and

welfare matters over the years, in a public discourse

on the ‘imminent’ national health program, warns

his audience that children are not likely to benefit

from the development. To the audience of child care

workers, he proclaims, ‘You are just one more special interest group, and no more entitled to exceptional

consideration than others, who have more clout

any-how.’ (Theodore Marmon, personal communication)

It will be necessary to refresh the commitment of

the Department of Health and Human Services which

has not enunciated an overall child health policy, and press for such a policy statement from the President’s Domestic Council. This is a key objective for advocacy groups, because no national forum for the expression of children’s needs and rights exists. The White House

Conferences on Child Health, decennial meetings of

children’s advocates and public officials held between

1909 and 1970, are no longer available. Such

decen-nial conferences should be reinaugurated. The 1930

Conference produced the powerfully moving

‘Chil-dren’s Charter.’ President Hoover endorsed the

Charter and, in addition, subscribed to ‘A Child’s Bill of Rights.”#{176} President Bush’s pledge to the World

Summit on Children rings hollow in the light of the

actions of his administration. A renewed national

conference can reinvigorate congressional support. Perhaps the premier professional journal for pedia-tridans ought to reconsider its willingness to accept a

child health program that would place children in the

same precarious situation with regard to access and

cost inflation as Medicare does for the elderly.

Per-haps the most influential national advocacy group for

children would consider boldly lobbying for a

com-prehensive program rather than piecemeal

modifica-tion of Medicaid.

Children deserve much more than we ask for now,

and much more than the haphazard fragments of

legislation now being considered would offer. No

other industrially advanced or equally affluent coun-try is so niggardly with its expenditures for children. No European country lacks a maternity leave policy,

substantial day-care services, maternity and

chil-dren’s allowances, housing subsidies for families, or

a comprehensive health system accessible to all their

children. Those who cherish America’s children

should combine to design a rounded, comprehensive

social and health program, a true Children’s Health

Policy and Program, and establish a crusading orga-nization to achieve it.

GEORGE A. Snvn, MD

Yale University School of Medicine

New Haven, CT

REFERENCES

1. Kammerman SB. Maternity and parenting benefits: an international overview. In: Zigler E, Frank M. The Parental Leave Crisis. New Haven, CT: Yale University Press; 1988:235-244

2. Williams BC, Miller CA. Preventive Health Care for Young Children. New

York, NY: National Center for Clinical Infant Programs; 1991 3. Silver GA. Child Health: America’s Future. Germantown, MD: Aspen;

1978

4. National Commission on Children. Beyond Rhetoric. Washington, DC: Us Superintendent of Documents; 1991

5. Dahl RA, Lindbloom CE. Politics, Economics and Welfare. New York, NY:

Harper; 1953

6. Lindbloom CE. The science of ‘muddling through.’ Public Adm Rev.

1959;19:79-88

7. Schorr LB.Schorr D. Within OurReach. New York, NY: Anchor/Double-day; 1988

8. Sardell A. The US Experiment in Social Medicine. Pittsburgh, PA: Univer-sity of PittsbUrgh Press; 1988: chap 9

9. Mondale WF: Justice for children. Congressional Recorit December 9, 1970;116:197:420

10. ‘Children’s Charter’ and ‘Child’s Bill of Rights.’ In: Public Papers of the Presidents of the United States, Herbert Hoover, 1931. Washington, DC: US Government Printing Office; 1976:171-173. Document 124

The

Need

for Rational

Therapeutics

in the

Use

of Cough

and

Cold

Medicine

in Infants

Cough and cold medications (CCM) generally are

felt to be safe by both parents and health

(4)

1992;89;772

Pediatrics

GEORGE A. SILVER