COMMENTARIES
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
Management of Otitis Media and
Functional Outcomes Related to
Language, Behavior, and Attention:
Is It Time to Change Our Approach?
ABBREVIATIONS. OM, otitis media; OME, otitis media with ef-fusion; VT, ventilating tubes; AOM, acute otitis media; WW, watchful waiting; dB, decibel.
O
utcomes research assesses the end results of health care from the perspective of those who receive the care, those who provide it, and those who pay for it. The article by Karin Minter and her colleagues1 at the Frank Porter Graham Child Development Center in Chapel Hill, North Carolina, provides important new information related to the functional outcomes of otitis media (OM) in early childhood. Their study documenting the relationship of otitis media with effusion (OME) and hearing loss with functional measures of attention and behavior obtained from parents, teachers, and clinicians ap-pears in this issue ofPediatrics.1They conducted this prospective cohort study in 85 children whose mid-dle ear and hearing status had been closely moni-tored from 6 months to 4 years of age. The diagnosis of OME was based on both pneumatic otoscopy and tympanometry. Audiologists who were unaware of the middle ear findings performed hearing assess-ments. The validated measures used to assess out-comes included the behavior rating scale of the Bay-ley Scales of Infant Development, the Parenting Stress Index, the Social Skills rating system, and the Conners’ Teacher/Parent Rating Scale. Children’s at-tention and behavior were assessed during infancy, preschool, and first grade. Mother’s education, socio-economic status, child gender, child care quality, and a measure of the home environment (home screening questionnaire) were included as covariates in all analyses. When these covariates were considered, there were no significant correlations between OME or hearing loss with any of the measures of attention and behavior at any age during the first 6 years of life.In a previous publication, the investigators failed to document an association between otitis or hearing loss and the acquisition of language skills in this
population.2The availability of this new data as well as the recent publication of several prospective co-hort studies and a randomized clinical trial of venti-lating tubes (VT) inPediatricsshould lead to a reas-sessment of current guidelines for the medical and surgical management of OME.
The diagnosis and management of OM, the most common childhood bacterial infection, remains one of our most challenging and difficult clinical prob-lems. OM, or inflammation of the middle ear space, includes a continuum of conditions involving both acute otitis media (AOM) and OME.3AOM is com-monly defined as inflammation of the middle ear presenting with rapid onset of signs and symptoms such as otalgia, fever, irritability, anorexia, or vom-iting. OME is usually defined by the presence of an asymptomatic middle ear effusion, although it can be associated with a “plugged ear” feeling. Otoscopic findings of inflammation associated with AOM may include decreased tympanic membrane mobility with a bulging contour (recognized by impaired vis-ibility of the ossicular landmarks), a yellow and/or red color, exudate, or bullae. Findings that suggest OME include visualization of air fluid levels and diminished membrane mobility when the membrane is translucent. OME can also be associated with neg-ative middle ear pressure suggested by prominence of the lateral process, a more horizontal orientation of the malleus, and better mobility with negative pressure. Both AOM and OME can be associated with decreased tympanic membrane mobility, a flat type B tympanogram, and a mild to moderate con-ductive hearing loss. Bacterial pathogens can be iso-lated frequently from purulent, serous, and mucoid effusions regardless of the presence of membrane inflammation or clinical symptoms. The pathophys-iologic mechanisms of AOM and OME are quite complex and involve the interrelationships between viral and bacterial infection as well as other host and environmental factors, especially exposure to passive cigarette smoke. Although middle ear effusions can precede the development of AOM, they are also a common consequence of the inflammation associ-ated with AOM.
Proper diagnosis and management of OM is not a trivial financial concern to the health care system. The total cost for children 13 years of age and younger has been estimated at $5.3 billion, of which 12.1% is related to antibiotics, 56.3% to patient visits, and 31.6% to surgery.4Twenty-five to thirty-five per-cent of all otitis cases have been estimated to be OME,5and a substantial portion of the OM-related surgery is for the management of OME. High rates of antibiotic treatment of AOM and OME have been a major contributor to the rise in antimicrobial-resis-Received for publication Oct 3, 2000; accepted Oct 3, 2000.
tant bacterial strains causing disease.6 The use of more expensive antibiotics being used to cover resis-tant pathogens has added to the health care financial costs. However, this unintended consequence of oti-tis management has not been considered in most estimates of OM-related expenditures.
The rationale for aggressive medical and surgical approach to OME has been based on the theory that OM and hearing loss can delay the acquisition of language skills, alter behavior, and affect attention patterns. According to this theory children are more vulnerable to the effects of persistent or fluctuating conductive hearing loss during the first 2 to 3 years of life when a young child is experiencing the most rapid phases of receptive and expressive language development. Children with hearing loss early in life may not establish the normal response mechanisms to conversing and inappropriately learn to “tune out” certain types of stimuli. This may cause later attention and behavioral problems. Does the avail-able evidence support this theory? The 2 types of studies that best address this question are observa-tional cohort studies and randomized intervention trials. Observational cohort studies prospectively document middle ear status and hearing levels dur-ing early childhood and later assess language, behav-ior, and attention outcomes. Prospective studies are desirable because of the importance of carefully doc-umenting middle ear and hearing status during early childhood. Randomized trials of interventions such as VT that are likely to restore hearing allow for a comparison of functional outcomes. Regardless of the study design, it is important to analyze the out-comes according to varying otitis and hearing loss characteristics including the degree of hearing loss, type of loss (fluctuating or prolonged), unilateral or bilateral involvement, and the specific timing of the otitis in relation to the developmental phase. In ad-dition, the impact of OME and hearing loss varies according to population characteristics. Therefore, the interpretation of the findings also requires con-sideration of many confounding factors known to be strongly associated with language, behavior, and at-tention such as gender, family socioeconomic status, maternal age and education, quality of child care, and associated medical conditions. Unfortunately, it is not possible to adequately perform a meta-analysis of the many studies addressing these issues because the studies have used different measures of lan-guage, attention, and behavior and have used differ-ent observers. Given these considerations, it is not surprising that studies with small sample sizes with different populations, otitis characteristics, and out-come measures should report conflicting results.
In the clinical practice guideline published by the Agency for Health Care Policy and Research in 1994, the panel considered the then available evidence that OM and hearing loss affected language, behavior, and attention.5 Because of conflicting findings and methodologic inadequacies of studies available at that time, the report stated that insufficient evidence was available to support a causal relationship. The panel called for new studies that would overcome the methodologic deficiencies.
The findings of several of these new studies have recently been published. Many of the study design issues have been addressed in a prospective study conducted in Pittsburgh, Pennsylvania, which en-rolled ⬎2000 children from a racially and economi-cally diverse population.7,8 Children with known risk factors associated with developmental delay such as prematurity, serious illness, or neonatal as-phyxia were excluded, as were children who were at risk of developmental problems because of severe family dysfunction, or inadequate parenting related to maternal substance abuse or having an adolescent mother. This study reported a negligible association between the presence of unilateral or bilateral mid-dle ear effusion and parent-reported language devel-opmental skills during the first 2 years of life.7 An-other publication reporting data from this study found a negligible association between time with unilateral and or bilateral effusions and measures of attention and behavior assessed by the Parental Stress Index/short form at 1, 2, and 3 years of age and parent ratings of child behavior using the Child Behavior checklist at 2 and 3 years of age.8
Rovers and colleagues9 published findings of a randomized trial performed in the Netherlands that assessed the effect of VT on language development in young children 16 to 24 months old with OME. After adjusting for such factors as mother’s educa-tional level and the child’s IQ, the study found no relevant differences in language skills after 6 and 12 months between the 93 children treated with VT and the 94 managed with watchful waiting (WW). Im-provement in language skills was most strongly as-sociated with the educational levels of the mother. An important finding was the similarity in improved hearing levels after 6 and 12 months of follow-up in the 2 groups (6 months of follow-up: 10.2 decibels [dB] in the VT group vs 4.6 dB in the WW group; 12 months of follow-up: 13.1 dB in the VT group vs 8.5 dB in the WW group).
or attention. These children have a higher risk of being affected by a hearing loss and the greater chance of benefiting from an intervention that re-stores normal hearing. Until data are available for this population, it seems prudent to continue to treat OME more aggressively in this high-risk population. Were we naı¨ve to believe that medical and surgical interventions to cure OME and restore normal hear-ing would be a silver bullet to promote language development and prevent subsequent behavior and attention problems? The recently published studies all suggest that parenting is a much more powerful force than antibiotics and surgery in promoting lan-guage development. In their bookMeaningful Differ-ences in the Everyday Experience of Young American Children, Hart and Risley10 describe vocabulary dif-ferences in 3- and 6-year-olds from low-, medium-, and high-income families and the subsequent impact on school readiness and long-term learning. In their longitudinal study they determined that economi-cally advantaged children hear about 30 million words in the home setting before age 3. Low-income children hear ⬍10 million words. The ratio of en-couragement (affirmative sounds and gestures) to discouragement (prohibitions) is important. They found that encouragement is high among high-in-come families. Discouragement outweighs encour-agement in low-income families. Hart and Risley concluded that the amount of conversation and par-ent interaction (through play) coupled with the amount of encouragement a child receives by age 3 is the most meaningful difference across social strata affecting school readiness and later school perfor-mance. Would children be better served if we could transfer the expenditures that have been used to treat OME with antibiotics and surgery to community, child care, and physician-based programs that moti-vate parents and other caregivers to talk with and encourage young children? Should our pediatric re-search identify practice-based language and literacy promotion approaches11that will eliminate the word gap heard by children living in low-income com-pared with high-income families? This type of out-comes research and subsequent child health policy would make the most sense from the perspective of those who receive the care, those who provide it, and those who pay for it.
Steve Berman, MD Department of Pediatrics
University of Colorado School of Medicine Children’s Hospital
Denver, CO 80218
REFERENCES
1. Minter KR, Roberts JE, Hooper SR, Burchinal MR, Zeisel SA. Early childhood otitis media in relation to children’s attention-related behav-ior in the first six years of life.Pediatrics.2001;107:1037–1042 2. Roberts JE, Burchinal MR, Zeisel SA, et al. Otitis media, the caregiving
environment, and language and cognitive outcomes at 2 years. Pediat-rics. 1998;102:346 –354
3. Berman S. Current concepts: otitis media in children.N Engl J Med. 1995;332:1560 –1565
4. Bondy J, Berman S, Glazner J, Lezotte D. Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric Medicaid cohort. Pediatrics. 2000;105(6). URL: http://www.pediatrics.org/cgi/content/ full/105/6/e72
5. Otitis Media Guideline Panel.Otitis Media With Effusion in Young Chil-dren. Clinical Practice Guideline No. 12.Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; AHCPR Publ. No. 94-0622. 1994
6. Dowell SF, March SM, Phillips WR, Gerber MA, Schwartz B. Otitis media—principles of judicious use of antimicrobial agents.Pediatrics. 1998;101(suppl):165–171
7. Feldman HM, Dollaghan CA, Campbell TF, et al. Parent-reported lan-guage and communication skills at one and two years of age in relation to otitis media in the first two years of life.Pediatrics. 1999;104(4). URL: http://www.pediatrics.org/cgi/content/full/104/4/e52
8. Paradise JL, Feldman HM, Colborn K, et al. Parental stress and parent-rated child behavior in relation to otitis media in the first three years of life.Pediatrics. 1999;104:1264 –1273
9. Rovers MM, Straatman H, Ingels K, van der Wilt G-J, van den Broek P, Zielhus GA. The effect of ventilation tubes on language development in infants with otitis media with effusion: a randomized trial.Pediatrics. 2000;106(3). URL: http://www.pediatrics.org/cgi/content/full/106/ 3/e42
10. Hart B, Risley TR.Meaningful Differences in the Everyday Experience of Young American Children.Baltimore, MD: Paul H. Brookes Publishing Co; 1995
11. High PC, LaGasse L, Becker S, Ahlgren I, Gardner A. Literacy promo-tion in primary care pediatrics: can we make a difference?Pediatrics. 2000;105:927–934
What Happened to
Primum Non
Nocere?
ABBREVIATIONS. AAP, American Academy of Pediatrics; USPHS, US Public Health Service; HBV, hepatitis B vaccine; FDA, Food and Drug Administration; CDC, Centers for Disease Control and Prevention.
O
n July 7, 1999, the American Academy of Pediatrics (AAP) and the US Public Health Service (USPHS) jointly indicated that the first dose of hepatitis B vaccine (HBV), often given in the first days after birth, be deferred until infants are about 6 months of age in instances when the infant is born to a hepatitis B-seronegative mother.1,2The ra-tionale for this changed recommendation was con-cern about the safety of thimerosal, a preservative used in many vaccine preparations since 1930. More than 30 vaccines on the market today (10/00) contain thimerosal, an ethyl mercury compound with a mer-cury content of 49.6%. Although the Food and Drug Administration (FDA) had reviewed thimerosal safety in 1976 and concluded that there were no harmful effects, the FDA Modernization Act, passed by Congress in 1997, mandated testing and analyz-ing of mercury-containanalyz-ing products. After passage of the FDA Modernization Act, interaction between the FDA and vaccine manufacturers was underway with the aim of encouraging manufacturers to remove thimerosal from all licensed vaccines, as is evidencedReceived for publication Oct 17, 2000; accepted Oct 17, 2000.
Address correspondence to Robert S. Daum, MD, University of Chicago, Department of Pediatrics, Section of Pediatric Infectious Disease, MC 6054, 5841 S Maryland Ave, Chicago, IL 60637-1470. E-mail: rsd2@midway. uchicago.edu.
Reprints not available.
from the thorough assessment of the use of thimer-osal in vaccine preparations that appears concur-rently in this month’s issue ofPediatrics.3
To many, the statement issued by the AAP and the USPHS on July 7, 1999, seemed precipitous and caught the medical, scientific, industrial, and regula-tory communities by surprise. Although some stud-ies suggested that low-level, frequent exposure to another mercury salt, methyl mercury, might be harmful to the developing fetal central nervous sys-tem,4other research efforts provided conflicting data on this point5 and no data existed that implicated ethyl mercury, the mercury moiety found in thimer-osal. Certainly, it was known that a massive acute mercury ingestion could lead to severe nephropathy or death but no convincing data have implicated thimerosal, given in the course of a pediatric immu-nization regimen offered in the first 2 years of life, in any clinically important side effect with the excep-tion of infrequent hypersensitivity to this compound. The decision to recommend delay of the first dose of HBV was made in the presumption that if this dose were given later, the thimerosal content of the vaccine would constitute a smaller mercury expo-sure on a per kilo basis, and, therefore, be of lower theoretical toxicity. It had previously been deter-mined, for unrelated reasons, that small infants (those weighing ⬍2000 g) were excluded from im-munization until they were heavier.
Unfortunately, this change in the vaccine schedule had great potential for negative impact. At a recent workshop on thimerosal safety conducted at the Na-tional Institutes of Health in Bethesda, Maryland, in August 1999, it was evident that the recommenda-tion to delay the first dose of HBV had caused con-fusion in the practicing community. At one institu-tion, it was reported that 3 infants of hepatitis B-seropositive mothers had the initial neonatal dose of HBV deferred by individuals confused by the new AAP/USPHS guidelines.6Furthermore, delay in the receipt of the first HBV dose in the nursery has been associated with delay in the receipt of the complete HBV series7,8 and of other routine pediatric immu-nizations.7
At the time the AAP/USPHS recommendation was issued, the HBV was well-integrated into the immunization schedule. In inner-city Chicago be-tween 1991 and 1995, the percent of children com-pleting the 4:3:1 series who also completed the HBV series increased dramatically from 7% to 90%.7 Ad-ditionally, the importance of the birth dose was dem-onstrated in that children who received a first HBV dose at birth were more likely to receive their first diphtheria, tetanus, and pertussis vaccine dose on time (60.1% vs 36.4%; P ⬍ .001) and complete the 4:3:1 series by 19 months (49.8% vs 37.9%; P⬍ .05). This finding was corroborated by a recent analysis of data from the 1998 National Immunization Survey conducted by the Centers for Disease Control and Prevention (CDC) that also demonstrated a higher rate of HBV series completion among children who received the first dose at birth. The CDC investiga-tors found that children who received the first HBV dose within 7 days of birth were more likely to
complete the HBV series on time compared with those who received the first dose at 8 to 41 days of age, or at 42 to 91days of age (96.3% vs 91.7% vs 77.3% for 0 –7 days, 8 – 41 days, and 42–91 days;P⬍ .001; 0 –7 days vs either group). Thus, the AAP/ USPHS recommended delay probably diminished the potential benefits of the birth dose that are rele-vant not only to HBV series completion, but also possibly to on-time receipt of other childhood vac-cines.
It is also clear that withdrawal of thimerosal and other preservatives from pediatric vaccines will probably curtail all manufacture of multi-dose vac-cine vials and make single-dose vials the packaging modality of choice for vaccines in the United States. This will certainly increase the cost of preparation of many vaccines as well as the cost of additional stor-age facility. There is, therefore, a potential to create difficulties for vaccine programs in the United States and especially in developing countries.
In an interim report (September 1999), the AAP indicated that “when sufficient supplies of [a hepa-titis B vaccine that does not contain thimerosal] are available,” it will be appropriate to resume neonatal hepatitis B immunization.2 On September 13, 1999, one thimerosal-free preparation appropriate for birth dose became available and another preparation with thimerosal content decreased in excess of 96% has subsequently become available.9,10More directly, the AAP has recently appealed to its membership to resume HBV administration at birth.11 Unfortu-nately, many hospitals and clinicians have not re-sumed routine administration of HBV at birth. An August-September 2000 survey of all Chicago area hospitals that provide obstetric services indicated that a substantial number of hospitals that routinely administered the HBV at birth before the AAP/ USPHS recommendation have not resumed doing so since the thimerosal-free preparations became avail-able (unpublished data). Similar observations have been made by investigators at the CDC and the Uni-versity of Wisconsin Medical School.11 Thus, al-though the rapidity by which many discontinued the HBV birth dose was remarkable, these data suggest that resumption of the birth dose will apparently be much less rapid.
What happened toprimum non nocere? Hepatitis B remains a major health concern in the United States and throughout the world. An estimated 1 to 1.25 million Americans are infected with the hepatitis B virus and at least 18 000 children under 10 years of age were infected annually before the introduction of immunization.10Did the evidence on thimerosal ex-posure warrant such a cacophonous disruption in the HBV immunization schedule? The hastiness in promulgating the AAP/USPHS recommendation to suspend the birth dose did not even allow sufficient time for the CDC’s Advisory Committee on Immu-nization Practices to debate the prudence of the change.
eliminate mercury-containing preservatives from vaccine preparations as it becomes feasible in the near future.
However, it was probably unnecessary to recom-mend a delay in initiating the HBV series with such haste. A more reflective process would have in-cluded discussion of the pros and cons of postponing the routine birth dose. Ball et al3sum up 70 years of experience and correctly conclude that there was no evidence of harm caused by doses of thimerosal found in vaccines. The potential for serious and on-going impact of the AAP/USPHS recommendation on immunization rates and vaccination policies and practices raises the question of whether the principle of primum non nocere was disregarded in a rush to judgment. As a vaccine community, we must insist that vaccines, like all medical interventions, be as safe as they can possibly be. Just as important, our best delivery strategies for vaccines to all children ensure our best chance of diminishing the enormous burden of hepatitis B and all other vaccine-prevent-able diseases. In our haste, we must not forget that the agents causing these diseases constitute unac-ceptable threats to all our children.
John B. Seal, MA
Robert S. Daum, MD, CM University of Chicago Department of Pediatrics
Section of Pediatric Infectious Diseases Chicago, IL 60637-1470
REFERENCES
1. American Academy of Pediatrics. Joint statement of the American Academy of Pediatrics (AAP) and the United States Public Health Service (USPHS).Pediatrics. 1999;104:568 –569
2. American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Environmental Health. Thimerosal in vaccines—an interim report to clinicians.Pediatrics. 1999;104:570 –574
3. Ball LK, Ball R, Pratt RD. An assessment of thimerosal use in childhood vaccines.Pediatrics.2001;107:000 – 000
4. Grandjean P, Budtz-Jorgensen E, White RF, et al. Methylmercury expo-sure biomarkers as indicators of neurotoxicity in children aged 7 years. Am J Epidemiol. 1999;150:301–305
5. Davidson PW, Myers GJ, Cox C, et al. Effects of prenatal and postnatal ethylmercury exposure from fish consumption on neurodevelopment: outcomes at 66 months of age in the Seychelles child development study.JAMA. 1998;8:701–707
6. Watson B. Comment. In: Transcript of the National Vaccine Advisory Committee Workshop on Thimerosal in Vaccines; August 12, 1999; Bethesda, MD
7. Lauderdale DS, Oram RJ, Goldstein KP, Daum RS. Hepatitis B vacci-nation among children in inner-city public housing, 1991–1997.JAMA. 1999;282:1725–1730
8. Hussain YR, Daniels D, Smith P, Coronado V, Rodewald L. Association between administration of hepatitis B vaccine at birth and completion of the hepatitis B and 4:3:1:3 vaccine series.JAMA. 2000;284:978 –983 9. CDC. Notice to readers: availability of hepatitis B vaccine that does not
contain thimerosal as a preservative.MMWR Morb Mortal Wkly Rep. 1999;48:780 –782
10. CDC. Notice to readers: update: expanded availability of thimerosal preservative-free hepatitis B vaccine.MMWR Morb Mortal Wkly Rep. 1999;49:642
11. Pickering LK. Resume Hep B immunization at birth: AAP.AAP News. 2000(Jun);16:1
12. Margolis H. Be as sure as you can be!: give babies hepatitis B vaccine at birth.Needle TipsSpring/Summer 2000. Available from: URL: http:// www.immunize.org
The Future of Pediatric Education
(FOPE) II Report Summary and
Pediatric Subspecialists
ABBREVIATIONS. FOPE II, The Future of Pediatric Education II Report Summary; PSS, pediatric subspecialists.
T
he Future of Pediatric Education (FOPE) II re-port summary1 is a thoughtful, prudent plan for the future of the education of general pedi-atricians. Yet, the summary takes a pessimistic view of the future for pediatric subspecialists (PSS) and has few useful recommendations to immediately im-prove the education of PSS.We believe that PSS provide the best care for chil-dren with complex and advanced disease. Physicians who care for these special children on a part-time basis, without equivalent specialty training,will not usually be able to provide the same service, as sug-gested by parents’ lack of confidence in skill of gen-eralists in managing chronic illness (FOPE II sum-mary, page 187) FOPE II summary accurately documents the decreasing numbers of PSS and the subspecialty residents (FOPE II summary, pages 185–186) from 27% of pediatricians to 18% over the past decade. The report notes that “a shortage of subspecialists, therefore, has grave implications for the improvement of child health” (FOPE II summary, page 189). We believe that implementation of the FOPE II summary is more likely to exacerbate than ameliorate these problems.
FOPE II supports PSS training generalists and adult subspecialists to assume some of the responsi-bilities for care of children with complex, chronic disease. We agree that some training of generalists to help provide medical care for children with special needs in underserved areas is important and those linkage relationships between PSS and generalists and adult subspecialists are essential.
We believe, though, that care of these children by generalists and adult subspecialists over the long-term will not be as effective as that of PSS. We are confident that the need for PSS in all regions of the United States will increase, not decrease, in the de-manding, consumer-driven medical marketplace of the next few decades. Biotechnology is moving rap-idly into new areas of pediatrics. Full-time PSS must now work hard to stay current with these major changes, much less part-time PSS. If PSS are forced from the pediatric landscape by financial pressures and lack of support, they will be reinvented in the next few decades. It is likely that many generalists and adult subspecialists doing part-time subspe-cialty work will eventually evolve into full-time PSS. The FOPE II report’s suggestions to improve PSS
Received for publication Dec 27, 2000; accepted Feb 2, 2001.
Address correspondence to Charles H. Spencer, MD, La Rabida Children’s Hospital, E. 65th at Lake Michigan, Chicago, IL 60649. E-mail: cspence@ midway.uchicago.edu
education and meet the challenges of declining num-bers are ambitious long range goals but are not use-ful, realistic short-term goals. Increasing financial support should be sought aggressively from the Na-tional Institutes of Health for PSS fellowships, from Medicare for support of PSS training in all academic health centers (including freestanding childrens hos-pitals), and from philanthropy and industry. Yet, given the current political climate, these solutions can hardly be relied on. Similarly, the goals of limit-ing fellowships to centers of excellence, increaslimit-ing grant applications, and supporting pediatrician sci-entists are critical for improving pediatric research, but fail to address the clinical needs of the US pedi-atric population, especially children with special health care needs.
The FOPE II summary appears to favor training a limited number of research-trained PSS who support their salaries and section activities by research grants. The inference may be drawn that clinical PSS are less desirable, especially those unable to support themselves by clinical billings. Without these clinical PSS, it is not clear how pediatric faculty can properly educate medical students, residents, general pedia-tricians, and adult subspecialists. Even now, not all medical schools and pediatric residency programs have a full complement of PSS for necessary instruc-tion. It is also not clear how a limited number of PSS can maintain the regional and state systems of med-ical care for children with special health care needs. FOPE II falls short in specific recommendations for educating subspecialty residents. We believe that pe-diatric department chairman and program directors should move to eliminate the recent bias against pediatric subspecialty training in their effort to pro-mote primary care. Financial support of subspecialty training must be provided from departmental, insti-tutional, philanthropic, and governmental sources, especially in centers of excellence.
Pediatric faculty should also encourage residents to train in undermanned PSS and help them obtain skills that will improve their academic viability. Fast-tracking PSS training programs should be imple-mented that may appeal to pediatric and surgical residents with substantial debts and/or less re-search-oriented career goals (eg, reviving 2 years of PSS training for fellows interested in a clinical PSS
career and 4-year combined pediatric/subspecialty programs for certain PSS). Pediatric organizations should also strongly back PSS debt forgiveness pro-grams.
Although not within the scope of FOPE II, we wish to draw attention to the critically important role played by pediatric surgical subspecialists of all sur-gical disciplines. These PSS have skills needed by children, generalists, and other PSS. It is even less appropriate to suggest that adult surgical specialists can replace pediatric surgical specialists than in other PSS. We must continue to support the training of these individuals and publicly recognize that their surgical skills are unique and irreplaceable.
For PSS, the FOPE II summary was a missed op-portunity. It exhibits a lack of balance that is unfor-tunate. The report has a pessimistic outlook for PSS, especially clinical PSS, and suggests a low priority for improving their status. FOPE II should have been, and pediatric organizations should continue to be, equally supportive of generalists and subspecial-ists, both medical and surgical. This support should be clear and unequivocal and is especially important in the current health care marketplace where there is pressure on both medical and surgical subspecialists. Pediatric generalists and PSS need each other and children in the United States need both. Together generalists and PSS can provide the best care for all children.
Gerald Gilchrist, MD, Chairperson Walter Fierson, MD, Chairperson-elect Charles H. Spencer, MD, Medical Group 1
Representative
Kristan Outwater, MD, Medical Group 2 Representative
Edward Saltzman, MD, Multidisciplinary Representative
Arnold Coran, MD, Surgical Representative Patience White, MD, Ex-Officio
Council of Sections Management Committee American Academy of Pediatrics
REFERENCE
DOI: 10.1542/peds.107.5.1175
2001;107;1175
Pediatrics
Steve Berman
Behavior, and Attention: Is It Time to Change Our Approach?
Management of Otitis Media and Functional Outcomes Related to Language,
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DOI: 10.1542/peds.107.5.1175
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Steve Berman
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