Read This—It's Important

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.

Toxic Effects of Indoor Molds

To the Editor.—

I have just read the AAP Committee on Environmental Health’s “Toxic Effects of Indoor Molds,” which appeared in the April 1998 issue of Pediatrics. Unfortunately, I do not find any mention of indoor use of vaporizers/humidifiers in this warning report. What should we pediatricians know or do in this regard—if anything?

Gary M. Gorlick, MD, MPH, FAAP

Los Angeles, CA 90048

In Reply.—

Many parents use cool mist humidifiers or vaporizers when children have colds or when the air is dry in the winter. Contam-inated humidifiers are a very common source of airborne mold spores in the home.1_{Acute pulmonary hemorrhage in infants has} been linked to toxins produced by molds such asStachybotrys atra

that grow in homes with severe water damage from flooding, roof leaks, or plumbing leaks.2_{However,S atrahas not been shown to} grow in cool mist humidifiers or vaporizers. This mold requires water-saturated, cellulose-based materials to grow, and cool mist humidifiers do not provide a source of cellulose.S atragrows and produces toxins in cellulose-containing respirator filters at ex-tremely humid conditions (84%–100% relative humidity).3

If the humidity in the home is adequate, the parents may wish to forgo using a humidifier or vaporizer. Indoor levels of humidity can be tested with a hygrometer (available at Radio Shack and other stores). To discourage mold growth, the indoor humidity should be kept below 40%. If parents wish to use a cool mist humidifier, it is necessary to keep the humidifier clean by chang-ing the water frequently and cleanchang-ing all the parts thoroughly as directed in the package instructions. The humidifier should be emptied, cleaned with soap and water, and dried when not in use.

Ruth A. Etzel, MD, PhD, Chairperson

AAP Committee on Environmental Health

REFERENCES

1. Solomon WR. Fungus aerosols arising from cold-mist vaporizers. J Allergy Clin Immunol.1974;54:222–228

2. Etzel RA, Montana E, Sorenson WG, Kullman GJ, Allan TM, Dearborn DG. Acute pulmonary hemorrhage in infants associated with exposure toStachybotrys atraand other fungi.Arch Pediatr Adolesc Med.1998;152: 757–762

3. Pasanen A-L, Nikulin M, Berg S, Hintikka E-L.Stachybotrys atracorda may produce mycotoxins in respirator filters in humid environments.

Am Ind Hyg Assoc J.1994;55:62– 65

When Is There Enough Evidence to Stop

Worrying About Pertussis Vaccine?

To the Editor.—

Government agencies in the United States continue to take the position that pertussis vaccine may, at times, produce permanent

brain damage. They continue to look for evidence that supports their position, and, as a result, an undercurrent of anxiety and uncertainty about the safety of the vaccine will be with us into the 21st century.

A conference on the hypotonic-hyporesponsive episode (HHE), reported to occur after pertussis immunization, was assembled by the Food and Drug Administration and the United States Public Health Service.1_{Although several investigations have not detected} any brain damage in the first 2 years of life after an HHE epi-sode,2– 4_{the conference has stated that there might be subtle} neu-rologic damage from the vaccine that might be found years later. The conference encouraged plans that look for possible brain damage after the episode when the children become 5 to 81_⁄2years of age.

The conference included a detailed study from the Netherlands of 101 cases of HHE.2_{All the children were followed into the} second year of life (mean age, 11_⁄2years).1_{At follow-up no} partic-ular anomalies of health or development were noted. In addition, 84 of these children were reimmunized with pertussis vaccine (236 doses of vaccine). A full 3 doses were given to 74 children. The conference noted a “low rate of recurrent collapse” (subsequent HHE) when, in fact, there werenorecurrences of HHE. One child who received no further vaccine developed severe pertussis.

A Swedish study of 100 infants with the diagnosis of HHE were later tested by medical personnel with respect to motor and cog-nitive development.3_{All showed normal development after the} episode at 18 months of age. In this study, the onset of HHE symptoms began 1 minute to 25 hours after vaccination (median, 5 hours). Seventy percent of the children had an onset of symp-toms between 3 and 5 hours after vaccination. The sympsymp-toms lasted from 1 minute to 4 hours (median, 30 minutes). A total of 33 children were hospitalized. Reporting this disorder were involved parents and persons who witnessed the event. All were contacted by telephone. It was not the responsibility of physicians to estab-lish the diagnosis. The working definition of HHE was loss of muscle tone and diminished or absent response to stimulation. Families in the vaccine program had been forewarned on parental consent forms about possible neurologic reactions to the pertussis vaccine. The form stated “neurological events with brain damage have very rarely been reported after whooping cough vaccine but have not been shown to be associated with the vaccine.” Extreme limpness or a very high-pitched cry were other adverse reactions included on the form.

It is worth noting that allergic reactions were considered to be a potentially serious adverse reaction to the vaccine in the study and were systematically searched for. Not one allergic reaction was reported by the follow-up personnel. It is also important to note that the parental consent form made no mention of allergic reactions.

It remains to be seen if the Swedish population can be con-vinced that pertussis vaccine causes no brain damage. Moreover, this same study that found no abnormalities of development after the HHE episode at 18 months of age did not find any cases of acute encephalitis or chronic encephalitis attributed to the vaccine in an area wide study of.240 000 injections of vaccine, acellular and whole-cell. On the other hand, among 17 607 children who did not participate in the vaccine program, there were 3 cases of encephalitis complicating pertussis infection.3

Samuel Sepkowitz, MD

Oklahoma City, OK 73112

REFERENCES

1. Braun MM, Terracciano G, Saliva ME, et al. Report of a US Public Health Service workshop on hypotonic-hyporesponsive episode (HHE) after pertussis immunization.Pediatrics. 1998;102(5). URL: http:// www.pediatrics.org/cgi/content/full/102/5/e52

2. Vermeer-de Bondt PE, Labadie J, Rumke HC. Rate of recurrent collapse after vaccination with whole cell pertussis vaccine: follow up study.Br Med J.1998;316:902–903

3. Olin P, Gustafsson L, Rasmussen F, Hallander H, Heijbel H, Gottfarb P.

Efficacy Trial of Acellular Pertussis Vaccines. Technical Report Trial II With Preplanned Analysis of Efficacy, Immunogenicity and Safety.Stockholm, Sweden: Swedish Institute for Infectious Disease Control; 1997 4. Gold R, Scheifele D, Halperin S. Hypotonic-hyporesponsive episodes in

children hospitalized at 10 pediatric tertiary-care centres, 1991–1994.

Can Comm Dis Rep.1997;23:73–77

5. Strom J. Further experience of reactions, especially of a cerebral nature, in conjunction with triple vaccination: a study based on vaccinations in Sweden 1959 – 65.Br Med J.1967;4:320 –323

6. Isacson J, Trollfors B, Taranger J, Zackrisson G, Lagergard T. How common is whooping cough in a nonvaccinating country?Pediatr Infect Dis J.1993;12:284 –288

Read This—It’s Important

To the Editor.—

The Current Procedural Terminology (CPT) Editorial Panel of the American Medical Association recently issued its 1999 revi-sions. This revised edition included the input of numerous med-ical specialties. The American Academy of Pediatrics (AAP) agreed previously with the use of the CPT codes and the Resource-Based Relative Value Scale (RBRVS) physician fee schedule, but emphasized a need to rectify the inequities of the CPT and RBRVS system.1_{The AAP also filed recently anamicus curiaebrief with the} US District Court for the northern district of Illinois against a suit to decrease reimbursements for pediatricians based on the RBRVS system.2 _{The RBRVS physician fee schedule was established to} recognize objective measures of physician work, while creating equity in reimbursement for all physician services across special-ties. The RBRVS system is based on uniform definitions of physi-cian work defined as relative value units (RVUs). An informal survey of pediatricians in our hospital revealed none with knowl-edge about specific inequities of RVUs, although most knew about the inequities of reimbursements. All were aware that RVUs are used to assess physician performance and productivity at Baylor College of Medicine and other institutions. A new billing software program, e.bill, developed by the authors allows comparisons of expected reimbursements and RVUs for all specialists. A demon-stration of the RVUs for procedure and nonprocedure specialties usually elicited shocking disbelief from the same pediatricians. For pediatricians without the time or means to pursue these inequities, we present several examples below:

CPT Code Medicare

Reimbursement RVU

99213—Outpatient visit, low, moderate severity, 15 minutes

$ 40.45 1.13

11301—Shaving, trunk, arms, legs, .6 to 1.0 cm

$ 57.06 1.58

11313—Shaving, face, ears, nose, over 2.0 cm

$118.47 3.26

CPT Code Medicare

Reimbursement RVU

71020—Radiographic examination, chest, two views

$ 35.63 .96

76020—Bone age $ 30.39 .82

44955—Appendectomy $532.04 14.6

99372—Telephone call, intermediate $ 0.00 .77

A surgeon shaving a 2.0 cm area of a patient’s facial hair in,1 minute (11313) earns almost three times the RVUs compared with a pediatrician evaluating a complex problem in 15 minutes (99213). A radiologist reading a child’s chest film in,2 minutes (71020) earns almost the same RVUs compared with a pediatrician compiling 12 glucose levels from 3 days and adjusting NPH and regular insulin administration in a diabetic child in a 15-minute telephone call. A surgeon shaving only a 1.0 cm area of a child’s leg in,1 minute (11301) earns almost twice the number of RVUs compared with the above pediatrician’s telephone call. Further-more, the radiologist and surgeon receive Medicare reimburse-ments while the pediatrician does not receive Medicaid reim-bursements.

These examples demonstrate the need for pediatricians to be-come involved and knowledgeable about the efforts to change the current standards and to support the AAP in its efforts to promote equity with procedure-oriented physicians. Pediatricians should refuse to accept passively the latest RVUs associated with the CPT codes. Telephone call, letters, e-mail, and political pressure should flood the offices of those promulgating this inequitable system.

Philip R. Beckett, PhD John L. Kirkland, MD

Endocrine and Metabolism Section Department of Pediatrics

Baylor College of Medicine Houston, TX 77030

REFERENCES

1. Resource-Based Relative Value Scale Project Advisory Committee. Is-sues in the application of the resource-based relative value scale system to pediatrics: a subject review. American Academy of Pediatrics. Pedi-atrics.1998;102:996 –998

2. Szabo J. Washington Watch: P-C doctors back HCFA in suit over practice expenses.Physicians Financial News.1999;17:17

Observer Bias in Acellular Pertussis Vaccine Trials

To the Editor.—

In an article in the October 1998 issue ofPediatrics,Cherry et al1 discuss the influence of observer bias on the estimated efficacy of an acellular pertussis vaccine they have tested.2 _{These authors} conclude that “observer bias can significantly inflate calculated vaccine efficacy.” They furthermore assume that “it is likely that all recently completed efficacy trials have been affected by this type of observer bias and (that) all vaccines have considerably less efficacy against mild disease than published data suggest.”

Having been responsible for a vaccine trial performed in Ger-many,3_{we do not share this view. We would like to document} why, depending on the design of the vaccine study, observer bias can be ruled out of our trial.

In the study cited by Cherry et al,2_{which was randomized for} vaccines containing pertussis antigens and had an open DT con-trol group, a two-step procedure for finding cases of pertussis was used: the study physicians monitored families in 2-week intervals. If coughing illness for 7 days or more was noted, the child under-went diagnostic procedures and was evaluated clinically. After 2 weeks, the study physician had to decide whether or not the child was still coughing strong enough to be referred to a central inves-tigator.

In contrast, we used a prospective household contact design for our study. A household was enrolled by the principal investigator on the presentation of a 7-day cough. Immediately, a prospective active surveillance of all eligible household members for any coughing illness was initiated. This was conducted by a “medical field supervisor,” a pediatrician, who worked independently of

LETTERS TO THE EDITOR 577

at Viet Nam:AAP Sponsored on August 30, 2020 www.aappublications.org/news

the primary investigator’s office. The medical field supervisor followed the clinical course of all coughing illnesses in the index case and its contacts by weekly standardized telephone calls, the results of which were immediately put into a computer system. Pertussis was confirmed according to World Health Organization (WHO) criteria. Index cases were not used for estimating vaccine efficacy. Thus, in contrast to the study cited by Cherry et al, the investigator had no influence on the clinical assessment of the study children; his only choice was to identify or not the potential index case.

All data about acellular pertussis vaccines suggest that the observed efficacy increases with severity of disease. As shown in Table 1 the efficacy of a three-component acellular vaccine dif-fered between a point estimate of 88.7%, when the WHO defini-tion (21 days or more of paroxysmal coughing) was used, and 61.1%, when any type of coughing for 1 day or more was ana-lyzed. This was observed not only for the acellular vaccine but also for the whole-cell pertussis vaccine (Table 2), although the cases in the whole-cell group were few.

The same vaccine that was used in our study has also been evaluated in another study using a double-blind, randomized, controlled trial design.4_{Although it is difficult to compare results} from studies differing in vaccination schedule, case-finding, sur-veillance, etc, both studies resulted in very similar point estimates of vaccine efficacy not only for severe disease (WHO definition), but also for milder pertussis cases.

The data from Cherry et al are an important warning that observer bias may be introduced into vaccine trials depending on details of the study design. However, we think that study design, as in our study, can also be used to rule out, as far as possible, any influence of the observer on estimates of vaccine efficacy.

C. H. Wirsing von Ko¨nig, MD

Institute for Hygiene and Laboratory Medicine Klinikum Krefeld

D47805 Krefeld, Germany

H. J. Schmitt

Pa¨diatrische Infektiologie Klinik fu¨r Allgemeine Pa¨diatrie Universita¨t Kiel

Kiel, Germany

A. Neiss

Institute for Medical Statistics and Epidemiology Technical University

Munich, Germany

REFERENCES

1. Cherry JD, Heininger U, Stehr K, Christenson P. The effect of investi-gator compliance (observer bias) on calculated efficacy in a pertussis vaccine trial.Pediatrics.1998;102:909 –912

2. Stehr K, Cherry JD, Heininger U, et al. A comparative efficacy trial in Germany in infants who received either the Lederle/Takeda acellular pertussis component DTP (DtaP) vaccine, the Lederle Whole-cell com-ponent DTP vaccine, or DT vaccine.Pediatrics.1998;101:1–11 3. Schmitt HJ, Wirsing von Ko¨nig CH, Neiss A, et al. Efficacy of acellular

pertussis vaccine in early childhood after household exposure.JAMA.

1996;275:37– 41

4. Greco D, Salmaso S, Mastrantonio P, et al. A controlled trial of two acellular vaccines and one whole-cell vaccine against pertussis.N Engl J Med.1996;334:341–348

Too Little Water Intake Causing Nephrolithiasis,

Revealed by Too Much Water!

To the Editor.—

In the western world children are generally spared from renal stone disease. However, metabolic diseases, such as primary cystinuria, hyperoxaluria, and renal tubular acidosis, are examples of rare causes of childhood nephrolithiasis seen worldwide. We wish to report an even rarer combination of factors leading to renal stones in a typical adolescent girl.

A 17-year-old Italian girl was followed in our pediatric ne-phrology outpatient clinic with corticosteroid sensitive minimal change nephrotic syndrome (NS) since 1990. The initial treatment consisted of predisolone in a daily dose of 2 mg/kg for approxi-mately 2 months. Six months later additional corticosteroid treat-ment was needed for a full-blown relapse of her NS. On remission she was kept for a prolonged period on an every-other-day dose (6 mg) of prednisone.

This good-looking young girl was obviously concerned about her physical appearance and the possible adverse influence of long-term corticosteroid treatment. As it turned out, she had no physical signs or symptoms of continuous alternate-day cortico-steroid treatment. Nevertheless, she reacted with what seems to be a healthy form of reduction in food intake (mild, “controlled” anorexia).

On a recent follow-up visit she complained of unexplained, vague abdominal pain, orthostatic hypotension, and admitted to not having had her menstrual period for approximately 4 months. She lost 3 kg in weight during the last months (height: 158 cm, percentile 10 –25); BW: 46 kg, percentile 3–10). Because the phys-ical examination was within normal limits, a gynecologic ultra-sonography examination was ordered. As usual with such an examination, she was asked to drink at least 1 liter of fluids to fill her bladder for better ultrasonographic contrast. Shortly after-wards she had a typical left-sided renal colic. No gynecologic abnormality was detected, but several stones were found in the lower part of the left ureter. They were later removed endoscop-ically because extracorporeal lithotripsy was unsuccessful. The stones consisted of calcium-oxalate. An intravenous urographic examination showed a normal urinary tract.

The cause of the renal stones was not immediately obvious. The urinary calcium/creatinine and uric acid/creatinine ratios were normal. In going over her past hospital chart, we, however, sud-denly realized (the famed retrospectoscope!) that we had over-looked the fact that for a long period of time she repeatedly had presented with maximally concentrated urines, as evidenced by the finding of urinary creatinine concentrations of 20 000 –30 000

mmol/L (226 –339 mg/dL), once even 31 060mmol/L (351 mg/dL) (normal: usually below 12 000mmol/L, 136 mg/dL) in the second morning urine specimen. Urinary creatinine had been measured to quantitate and standardize urinary protein excretion (U-pro-teine/creatinine) in the follow-up of NS. This was a case of self-induced chronic dehydration. It now turned out that ES had not only reduced her calorie but probably even more her fluid intake. It thus seemed that the nephrolithiasis was caused not by an abnormal urinary excretion of certain metabolites but by second-ary hypersaturation of those metabolites (calcium and oxalate).

The incidence of nephrolithiasis and nephrocalcinosis is known to be increased in NS though still extremely rare, certainly in childhood. Most often the nephrolithiasis in this setting is

attrib-TABLE 2. Point Estimates and Confidence Intervals (CI) on Efficacy of a Whole-cell Pertussis Vaccine in a Household Contact Study3

Clinical Case Definition % Vaccine Efficacy Point Estimate

95% CI

Spasmodic cough$21 days 97.6% 83.1/99.7 Spasmodic cough$14 days 95.6% 82.5/98.9 Spasmodic cough$7 days 93.6% 80.6/97.9 Any cough$21 days 91.7% 78.4/96.8 Any cough$14 days 89.8% 76.0/95.6 Any cough$7 days 87.5% 73.0/94.2 Any cough$1 day 87.4% 72.6/94.2

TABLE 1. Point Estimates and Confidence Intervals (CI) on Efficacy of a Three-Component Acellular Pertussis Vaccine in a Household Contact Study3

Clinical Case Definition % Vaccine Efficacy Point Estimate

95% CI

utable to hypercalciuria after corticosteroid administration. The latter can cause volume expansion, a rise in renal blood flow, and glomerular filtration with increased urinary excretion of sodium, calcium, and magnesium.1_{No evidence for this course of events} was found in our patient. Chronic dehydration sometimes leads to nephrolithiasis, especially uric acid stones.2_{This probably played} an important role in our case. Severe anorexia is known to alter calcium metabolism with decreased oral calcium intake, low es-trogene levels, altered vitamin D metabolism, and high levels of serum cortisol. This may lead to osteoporosis and/or fractures.3,4 Studies on urinary calcium excretion in anorexic patients are controversial.3,5_{Only two previous studies report nephrolithiasis} in women with eating disorders.5,6 _{This report is probably the} third.

The case mentioned above is instructive, be it only by drawing attention to the need to carefully follow urinary concentration indices (easily done and relatively cheap) in young girls with a tendency towards anorexia.

F. Cachat, MD J-P. Guignard, MD

Department of Pediatrics Pediatric Nephrology University Hospital 1011 Lausanne, Switzerland

REFERENCES

1. Rude RK, Singer FR. Adrenal glucocorticoids: interactions with kidney. In: Bronner F, Coburn JW, eds.Calcium Physiology, II.New York, NY: Academic Press; 1982;chap 9:485– 486

2. Borghi L, Meschi T, Amato F, Novarini A, Romanelli A, Cigala F. Hot occupation and nephrolithiasis.J Urol.1993;150:1757–1760

3. Abrams SA, Silber TJ, Esteban NV, et al. Mineral balance and bone turnover in adolescents with anorexia nervosa. J Pediatr. 1993;123: 326 –331

4. Brotman AW, Stern TA. Osteoporosis and pathologic fractures in an-orexia nervosa.Am J Psychiatry.1985;142:495– 496

5. Carmichael KA, Carmichael DH. Bone metabolism and osteopenia in eating disorders.Medicine.1995;74:254 –267

6. Silber TJ, Kass EJ. Anorexia nervosa and nephrolithiasis.J Adolesc Health Care.1984;5:50 –52

Myoclonic Movements in Very Low Birth Weight

Premature Infants Associated With Midazolam

Intravenous Bolus Administration

To the Editor.—

Midazolam, a relatively new sedative and muscle relaxant that belongs to the benzodiazepine family, has lately started to be part of the arsenal of drugs used in the neonatal intensive care units.

There are a few reports and studies related to the benefits and safety of its use in premature infants. Few side effects were re-ported as a 12% to 43% decrease in the midcerebral blood flow velocity after a transient drop in the systemic blood pressure, after administration to ventilated infants.1–3 _{Involuntary epileptiform} movements were observed as well after intravenous bolus injec-tion of 0.2 mg/kg midazolam.4

Three premature infants in our unit suffered from accentuated myoclonic jerks, resembling clonic seizures, within 5 minutes after they received a slow bolus administration of 0.1 mg/kg of mida-zolam for sedation. The babies were born at 24, 25, and 26 weeks’ gestation, with an average weight of 6716170 g. The drug was administrated to the first infant on day 28, to the second infant on day 32, and to the third infant on day 2. It was the first time this medication was administrated to each of the infants. Changes in oxygen saturation, respiratory rate, heart rate, skin color, or blood pressure were not observed. The abnormal movements resolved within 5 to 10 minutes after they started. Three other infants who received midazolam during the same period did not suffer from any evident side effects.

The actual mechanism of this effect is unclear. It could be related to the hemodynamic changes described in the cerebral blood flow, cortical inhibition, or changes induced in neurotrans-mitters or specific receptors stimulatory/inhibitory activity.

Although in the mentioned references midazolam is considered as relatively safe for use in the VLBW premature infant, more information about the pharmacology of this drug and effects on the developing brain are needed to consider its safe use in those infants.

Dan Waisman, MD Zalman Weintraub, MD Avi Rotschild, MD Yoram Bental, MD

Department of Neonatology

Carmel Medical Center—Technion—Israel Institute of Technology, School of Medicine

34362 Haifa, Israel

REFERENCES

1. Harte GJ, Gray PH, Lee TC, et al. Haemodynamic responses and pop-ulation pharmacokinetics of midazolam following administration to ventilated, preterm neonates.J Paediatr Child Health.1997;33(4):335–338 2. Jacqz-Aigrain E, Daoud P, Burtin P, et al. Placebo-controlled trial of midazolam sedation in mechanically ventilated newborn babies.Lancet.

1994;344(8923):646 – 650

3. Van Straaten HL, Rademaker CM, de Vries LS. Comparison of the effect of midazolam or vecuronium on blood pressure and cerebral blood flow velocity in the premature newborn.Dev Pharmacol Ther.1992;19:191–195 4. Van den Anker JN, Sauer PJJ. The use of midazolam in the preterm

neonate.Eur J Pediatr.1992;151:152

LETTERS TO THE EDITOR 579

at Viet Nam:AAP Sponsored on August 30, 2020 www.aappublications.org/news

DOI: 10.1542/peds.104.3.577

1999;104;577

Pediatrics

Philip R. Beckett and John L. Kirkland

It's Important

−−

Read This

Services

Updated Information &

http://pediatrics.aappublications.org/content/104/3/577.1

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/104/3/577.1#BIBL

This article cites 2 articles, 1 of which you can access for free at:

Subspecialty Collections

http://www.aappublications.org/cgi/collection/billing_-_coding_sub

Billing & Coding

_management_sub

http://www.aappublications.org/cgi/collection/administration:practice

Administration/Practice Management

following collection(s):

This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

in its entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.104.3.577

1999;104;577

Pediatrics

Philip R. Beckett and John L. Kirkland

It's Important

−−

Read This

http://pediatrics.aappublications.org/content/104/3/577.1

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1999

has been published continuously since 1948. Pediatrics is owned, published, and trademarked by

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

at Viet Nam:AAP Sponsored on August 30, 2020 www.aappublications.org/news