868 PEDIATRICS Vol. 88 No. 4 October 1991 and Child Health grants and the Healthy Mothers!
Healthy Babies Coalition. Federal support has
dwindled. But all these efforts pale before the media blitz of public advertising of infant formula by competitors, a blatant disregard for the World Health Organization code for infant formula distri-bution which prohibits public advertising. An even more insidious destructive advertising effort is seen in the mailing of samples of formula and free cou-pons for formula by certain manufacturers directly to the home of breast-feeding mothers shortly after hospital discharge and again when their infants are 1 month of age. In the state of New York, where
distribution of going-home formula packages to
breast-feeding mothers has been limited by hospital code since 1984, the arrival of the formula on the mother’s doorstep becomes the first demoralizing step in the failure of breast-feeding for the most vulnerable mothers, especially the young and un-dereducated.
While the authors8 suggest further intensive study of the uneven distribution of the decline in breast-feeding (well-educated, older women, espe-cially those living on the West Coast, have contin-ued to breast-feed at the rate of 75%), I would suggest that federal, state, and local efforts be launched to stem the tide that sweeps our most vulnerable mothers and their infants into the media whirlpool. This should serve to limit this formula publicity and home distribution campaign by
cer-tam
manufacturers and provide instead adequate resources supporting WIC and the Health Mothers! Healthy Babies Coalition to continue their work in supporting breast-feeding. The public advertising of infant formula not only usurps the woman’s right to an informed choice about feeding her infant but it totally circumvents the pediatrician as theguard-ian of the infant’s nutritional management at a
time when body growth and brain growth are most important. The trends in breast-feeding reported in this journal deserve serious action.
REFERENCES
RUTH A. LAWRENCE, MD
Dept of Pediatrics
University of Rochester Medical Center Rochester, NY
1. Report of the Surgeon Generals Workshop on Breastfeeding
and Human Lactation. 1984. Rockville, MD: US Dept of
Health and Human Services publication HRS-D-MC 84-2
2. Lawrence RA. Review of Surgeon General’s workshop on breastfeeding and human lactation. Presented at the Amer-ican Public Health Association meetings; November 1984;
San Diego CA
:3. Martinez GA, Krieger FW. 1984 Milk-feeding patterns in the United States.Pediatrics. 1985;76:1004-1008
4. Martinez GA, Nalezienski JP. The recent trend in
breast-feeding. Pediatrics. 1979;64:686-692
5. Martinez GA, Nalezienski JP. 1980 Update: the recent trend in breast-feeding. Pediatrics. 1981;67:260-263
6. Martinez GA, Dodd DA, Samartgedes JA. Milk-feeding pat-terns in the United States during the first 12 months of life.
Pediatrics. 1981;68:863-868
7. Martinez GA, Dodd DA. 1981 Milk-feeding patterns in the United States during the first 12 months of life. Pediatrics.
1983;71:166-170
8. Ryan AS, Rush D, Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984 through
1989. Pediatrics. 1991;88:719-727
9. Lawrence RA. Breastfeeding: A Guide for the Medical
Profes-sion. 3rd ed., St Louis, MO: CV Mosby; 1989
10. Rush D, Leighton J, Sloan NL, et al. The national WIC evaluation: evaluation of the Special Supplemental Food Program for Women, Infants and Children. IV: study of infants and children. Am J Clin Nutr. 1988;48:S484-S511
Frogger
“I see nobody on the road, “ said Alice.
“I only wish I had such eyes, “ the King remarked
in a fretful tone. “To be able to see Nobody! And at
that distance too!”
-Through the Looking-Glass
“Frogger,” the video game, is now a classic. The game is played from the frog’s point of view. Video frogs must cross the road, negotiating lanes of in-creasingly hostile traffic. Many frogs get squished.
When you
run
out of frogs, you push the resetbutton and play again.
Rivara,1 in this issue of Pediatrics, reports on an ambitious effort to educate early elementary school-age children on the rudiments of traffic safety.
Although he demonstrates behavior change, the
results are ultimately disappointing. Even after six lessons and involvement by parents, the older (and cognitively more able) students usually did not stop
at the curb, only looked for traffic half the time,
and usually did not continue looking for cars while crossing the street. We certainly do not want this group of “educated” children negotiating traffic by themselves. Rivara concludes that this modest ef-fect of education is a strong argument for a long-term commitment to better urban planning.
Two points are pertinent. First, our urban areas
were never designed with the child pedestrian in
Received for publication Feb 27, 1991; accepted Feb 27, 1991. Reprint requests to (M. D. W.) Department of Pediatrics, Penn-sylvania State University, MS Hershey Medical Center, P0 Box
850, Hershey, PA 17033.
PEDIATRICS (ISSN 0031 4005). Copyright 1991 by the American Academy of Pediatrics.
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COMMENTARIES 869 mind. In today’s city, there are not only thousands
of designated intersections, but also innumerable
potential intersections, of pedestrian traffic and
motor traffic. Perhaps if we could do it all over
again, we would design cities, towns, and
neighbor-hoods with sidewalks, fences, underpasses,
over-passes, parks, and playgrounds so that children
rarely were tempted and barely able to venture into
the path of a moving car. But urban design being what it is, for now, we are left with the “mid-block dart-out,” the “intersection dash,” and an epidemic
of childhood injuries.2 For the age group under
consideration, collision of the child with an
auto-mobile’s exterior (pedestrian injury) remains a
more likely cause of death than collision with an
automobile’s interior (occupant injury).3
Second, the pedestrian’s tasks are deceptively
complex and variable. It is like tying shoelaces. The tasks seem simple after they have been mastered, but when you try to teach them, the complexity becomes apparent. There are signaled intersections and unsignaled intersections. There can be multiple lanes, parked cars, and cars that are double-parked. Rush hour is different than noon, and not all roads are straight. Finally, recreational roadway exposure (being in the street incidental to play) is qualita-tively different from crossing the street on your way to school. In some small, but occasionally
signifi-cant way, nearly every pedestrian exposure is
unique.
Pedestrian safety problems are complicated by
our lack of insight into of how children perceive the
roadway and the task of negotiating traffic. How
does the task appear from the child’s point of view?
How much of the variability does the young
pedes-trian appreciate, and how much is he prepared to
deal with? With 500 children killed and 18 000
injured as pedestrians each year among those 5 to
9 years of age,4 it seems that we ought to have a
better understanding of the thinking of young
pe-destrians.
We need this insight because any near-term
pro-gress in reducing pedestrian injury will depend most
heavily on behavior, not engineering. There is just
too much to be engineered.5 We have to learn to
change behaviors effectively. Perhaps we were
spoiled by the easier applicability of engineering solutions to vehicle occupant injuries (roadside
haz-ard reduction, vehicle design, seat restraints, air
bags). Child pedestrian safety is different.
Due to the complexity of the subject and other
methodological problems, credible research into
pe-destrian safety education has lagged behind other
safety research.6 However, information to date sug-gests that traditional education can change
knowl-edge in young children far more readily than it can
change behavior.2’6 Classroom teaching away from
the real world is ineffective.7 Teaching must be
tailored to the cognitive abilities of the student, not
the apparent demands of the subject matter.
COGNITIVE DEVELOPMENT
We learn from study of cognitive development
(Piaget) that until 6 years of age or so, children are in their “preoperational period” of thinking.8 Here, children have limited ability to deal with multiple variables when problem-solving. Piaget’s classic ex-ample is of the 5-year-old who perceives a tall, skinny glass as holding more water than a short, fat glass, because the child is capable of considering only one dimension at a time. Asking such a child to negotiate traffic is like asking you or me to take a stint as an air traffic controller. Parents are likely
to forget (or to be unaware of) how limited their
5-or 6-year-old is in his ability to process complex
information.9 (You may wish to remind, or educate,
parents in this regard using Piaget’s example.)
Turn now to elementary school children beyond
the age of 6 years, children in Rivara’s “window of vulnerability.” These children are cognitively in
their period of “concrete operations.” Are they yet
prepared developmentally to master the concepts
of traffic safety and apply those concepts to specific situations? The answer is unclear.
Early elementary school-age children should be
able to learn and apply rules. Children aged 7 to 11
years should be able to make traffic decisions as long as each situation follows from specific exam-ples learned or encountered in the past, and as long as they are not distracted. Children older than 6 years of age can even deal with multiple variables
at once, perhaps recognizing simultaneously the
importance of an oncoming car’s distance and its
speed. Yet we must remember that these children will base their decisions on rules rather than info-vative application of safety concepts.
THE LAWS OF MOTION
Newton’s Laws of Motion (the only laws univer-sally obeyed by motor traffic and pedestrians alike) are not part of the elementary school curriculum; they are saved for secondary school. The laws of motion are not difficult to learn; they are difficult
to apply. Recitation of Newton’s three laws is far
less difficult than mastering a classification of di-nosaurs, a competence that many younger children
routinely use to astound their parents,
grandpar-ents, and teachers. Yet children must await a new
stage of cognitive development, the period of
“for-mal operations” (around age 12 years) to apply
general principles to novel situations.8 That raises two questions. First, is acquisition of traffic safety skills like classifying dinosaurs, or does it require
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870 PEDIATRICS Vol. 88 No. 4 October 1991 something more? Second, how can we best engage the child’s cognitive capabilities toward improving his traffic safety skills?
Until these questions are answered, we should
err on the side of caution. We should make parents
aware of the younger child’s difficulty in handling the nonroutine, the unfamiliar, the unpracticed,
and the more demanding traffic situations. We
should recognize our limitations in equipping younger children to deal well with unexpected var-iations on routine traffic themes: the erratic
mat-tentive driver, the delivery truck that stops and
goes, streets in unfamiliar neighborhoods, a heavy
fog.
EDUCATING BETTER
To educate better, we need a better
understand-ing of our students. What do they understand; how
do they decide? We need to see the road through
the eyes of the frog. Such a view will help define both the potential of education and its limits.
Developmentally based safety research should
supplement, not supplant, the work of epidemiolo-gists (identifying risk factors) and the work of traffic engineers (reducing hazards).1#{176} Having
de-fined the risks, we can find ways to redesign the
environment so that travel from school to home to corner store is free of traffic challenges beyond the young pedestrian’s capabilities. Simultaneously,
be-havioral research must proceed. The challenge is
multidisciplinary.6 What an opportunity for psy-chologist, planner, educator, epidemiologist, and pediatrician to share skills in what remains, for investigators, a largely untraveled road.
REFERENCES
MARK D. WIDOME, MD, MPH Department of Pediatrics
The Pennsylvania State University
College of Medicine Hershey
1. Rivara FP, Booth CL, Bergman AB, Rogers LW, Weiss J. Prevention of pedestrian injuries to children: effectiveness of a school training program. Pediatrics. 1991;88:770-775 2. Malek M, Guyer B, Leschohier I. The epidemiology and
prevention of child pedestrian injury. Accid Anal Prey.
1990;22:301-313
3. Division oflnjury Control, Center for Environmental Health and Injury Control, Centers for Disease Control. Childhood injuries in the United States. AJDC. 1990;144:627-646
4. Rivara FP. Child pedestrian injuries in the United States. Current status of the problem, potential interventions and future research needs. AJDC. 1990;144:692-696
5. Chang A, Griffith JG. Childhood pedestrian injuries.
Pedi-atrics. 1987;79:1055. Letters to the Editor
6. Tanz RR, Christoffel KK. Pedestrian injury: the next motor
vehicle injury challenge. AJDC. 1985;139:1187-1190
7. Michon JA. Traffic education for young pedestrians: an introduction. Accid Anal Prey. 1981;13:163-167
8. Pulaski MAS. Understanding Piaget: An Introduction to
Children ‘s Cognitive Development . New York: Harper &
Row; 1971
9. Rivara FP, Bergman AB, Drake C. Parental attitudes and practices toward children as pedestrians. Pediatrics.
1989;84:1017-1021
10. Scheidt PC. Behavioral research toward prevention of
child-hood injury: report of a workshop sponsored by the National
Institute of Child Health and Human Development, Sept 3-5, 1986. AJDC. 1988;142:612-617
What Happened
to the
Predicted
Glut of
Pediatricians?
In 1986 the Council on Graduate Medical
Edu-cation (COGME) was asked to advise the Congress
of the supply and distribution of physicians in the
United States, current and future shortages or
ex-cesses of physicians by specialty, issues relating to foreign medical graduates, and other matters relat-ing to the financing and structure of undergraduate
and graduate medical education. In 1988, the
COGME Subcommittee on Physician Manpower
stated to the Congress that “there appears to be an
impending oversupply of pediatricians at present,”
and the Subcommittee undertook-before making
its final report to the Congress-its own
independ-ent study on manpower needs for pediatrics and six
other specialties.
The Subcommittee’s consulting firm, Abt
Asso-ciates, was to answer this question: Are we
produc-ing the right number of pediatricians to satisfy
current and future child health needs, taking into
account the past decade’s changes in the needs of
children and adolescents and assuming that all
children have access to care for all medical needs?
Abt reported in January, 1990, that the surplus
of pediatricians projected for 1990 by the 1980
Graduate Medical Education National Advisory
Committee should have been 7289, not 4950, and
that the surplus would be 12 931 in 2000 and 18 462
in 2010.2 We thoroughly disagree with these projec-tions.
Received for publication Jun 26, 1991; accepted Jun 26, 1991.
Reprint requests to (APE.) American Academy of Pediatrics, 141 Northwest Point Blvd, P0 Box 927, Elk Grove Village, IL 60009-0927.
PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the American Academy of Pediatrics.
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1991;88;868
Pediatrics
MARK D. WIDOME
Frogger
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