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REFERENCES

1. Griswold WR, Reznik V, Mendoza SA, et al: Accumulation

of aluminum in a nondialyzed uremic child receiving

alu-minum hydroxide. Pediatrics 1983;71:56

2. Hodsman AB, Sherrard DJ, Wong EGC, et a!: Vitamin-D resistant osteomalacia in hemodialysis patients lacking see-ondary hyperparathyroidism. Ann Intern Med 1981;94:629

phatemia

as the best

approach

to this

difficult

problem.

W. R. GRISWOLD, MD

VIVIAN M. REzNIK, MD

S. A. MENDOZA, MD Department of Pediatrics

University of California Medical Center San Diego

University Hospital

225 Dickinson St San Diego, CA 92103-9981

Hazards

of Battery

Ingestions

To the

Editor.-We found the report from Temple and McNeese’ on

the hazards of small flat disc batteries very timely. The

management of these ingestions has been controversial

and

in recent months, the pendulum of recommendations

for therapy has swung from nonintervention to very early endoscopic or surgical intervention.

The

Nassau

County

Medical

Center’s

Long

Island

Regional Poison Control Center has reviewed its battery ingestion experience and statistics for the past 16 months.2 Only 1/30 cases of small flat disc battery inges-tions required surgical intervention for removal of an intact battery. The decision for removal was made when the battery failed to move from the cecum for five days.

In response to the increasing frequency of these inges-tions and our experience we have adopted the following protocol: (1) locate the battery by roentgenogram; (2) remove battery if lodged in esophagus or if remains in

the stomach

for more than

24 hours; if lodged in Meckel’s

diverticulum; if there are signs of gastrointestinal irrita-tion or peritonitis; if there is evidence of leakage or a

similar battery shows evidence of corrosion in 1.5 pH

fluid; (3) if the previous conditions are not observed,

refrain from intervention unless there is no movement for several days.

The intention of the protocol is twofold: (1) to

mini-mize the harmful effects of small flat disc battery

inges-tions and (2) to limit the potential morbidity that can result from anesthesia and overzealous surgical

interven-tion.

As further experience is accumulated, the protocol may

require

modification.

HOWARD C. MOFENSON, MD

JOSEPH GREENSHER, MD

THOMAS R. CARAccI0, PHARMD Nassau County Medical Center

Long

Island

Regional

Poison

Control

Center

2201 Hempstead Turnpike

East Meadow, NY 11554

REFERENCES

1. Temple DM, McNeese MC: Hazards of battery ingestion. Pediatrics 1983;71:100

2. Mofenson HC, Greensher J, Caraccio TR, et a!: Ingestion of small flat disc batteries. Ann Emerg Med 1983;12:88

In

Reply.-The guidelines for management of battery ingestion

presented by Mofenson et al certainly exhibit compro-mise between those physicians who advocate immediate removal of all batteries”2 and those who essentially ad-vocate “cautious observation only”3 one the battery is to

the stomach. Since our article4 was submitted in July

1982, several additional case reports have come to our attention.3 Five of these cases involved a battery that

lodged in the eosphagus. All patients in this group

expe-rienced

significant

if not fatal

complications.

Of batteries

that passed to the stomach, 37 asymptomatic cases were managed by “cautious observation” and resulted in spon-taneous passage in 35 instances, perforation of small

bowel at site of Meckel’s diverticulum in one case, and nonfatal mercury poisoning in one case.

In spite of this expanded data base, the definitive

management of battery ingestion once in the stomach is

not known. If physicians were to adopt temporarily a middle of the road approach as recommended by

Mofen-son et

al, careful

data

collection

should

still be obtained

and

reported

to poison

centers.

These

data

should

not

only evaluate the corrosive aspects of battery

complica-tions, but also evaluate potential mercury toxicity

(amount

of mercury

in cell, evidence of whether leakage

occurred,

and evidence

of mercury

poisoning).

Once the true risks of severe sequelae are known, then

perhaps permanent management protocols can be estab-lished.

DAVID

M.

TEMPLE,

MD

MARGARET

C.

McNEESE, MD

Department of Pediatrics

The University of Texas Health Science Center P0

Box

20708

Houston, TX 77025

REFERENCES

1. Votteler TP: Warning: Ingested disc batteries. Tex Med

1981;77:7

2. Reilly DT: Mercury battery ingestion. Br Med J March 31,

1979;(6167):859

3. Litovitz TL: Button battery ingestions: A review of 56 cases. JAMA 1983;249:2495

4. Temple DM, McNeese MC: Hazards of battery ingestion.

Pediatrics 1983;71:100-103

Breast

or Bottle:

A Personal

Choice

To the

Editor.-Many women throughout the country have chosen not

to breast-feed or have been unable to do so. Their

(2)

suf-LETTERS

TO THE EDITOR 435

fered

while

they

have

tried

unsuccessfully

to satisfy

the

needs of the new baby. They have lost confidence in

themselves as mothers, and lack of sleep and routine have

brought about general chaos in their households. When they have considered bottle-feeding in the best interest ofbaby and family, they have been pressured by extremist groups into believing that breast-feeding is “vital” to the

survival of their babies, and have been urged to continue

by peers and medical professionals. It has been promoted

as the “perfect” way to feed a baby, yet some babies have

lost up to 3 lb in their first month, and many mothers cringe with pain each time their babies nurse. They feel guilty and inadequate, ashamed to admit that they do not

fit the ideal picture of the happy mother peacefully

nurs-ing the contented baby at her breast.

Babies can be equally loved, healthy, and well

nour-ished

with formula or breast-milk. A woman’s choice of

feeding method should not label her as a good or bad

mother. It is time for each new mother to be aware of the

myths, facts, and realities of both methods so that she can be free to use her own judgment, without condem-nation, in choosing the method that is right for her to meet the needs of the new baby, her own needs, and the needs of her family. The vulnerable young mother (not

the

pediatrician,

husband,

friend,

or expert)

nurses

all

night, listens to a dissatisfied baby cry all day, and watches her infant fail to thrive on her milk while trying

to cope

with

the

needs

of her husband,

children,

and,

in

many cases, a job outside the home as well. Many women

have to make the decision to stop breast-feeding weeks

or months

after

they

leave

the

hospital

without

infor-mation

about

formula

and

sometimes

without

any

sup-port or encouragement.

A random

sampling

of educated

middle-class

women

in

a university

neighborhood

reveals

startling

numbers

of women

who

have

had

difficulty

breast-feeding,

and

shows a great deal of misunderstanding of both methods, for example:

MYTH: Babies who are not breast-fed are more likely to die

from “crib death.”

FACT: Crib death (sudden infant death syndrome or SIDS)

has existed since biblical times and so it cannot result from

formula feeding! Most recent studies of crib death have focused

on newborn breathing abnormalities (apnea), abnormalities in

the nervous system, and enzyme deficiencies.

REALITY: A first-time mother was told incorrectly by a

pediatric nurse that her infant would be more likely to die of

SIDS if she did not breast-feed. Her baby cried day and night

for two months and gained no weight as she used hot packs and

nipple shields on her breasts every two hours trying desperately

to feed her baby. The infant began to thrive only when she,

against the wishes of her pediatrician, her husband, and her peers, changed to formula.

MYTH: Breast-fed babies are always healthier than bottle-fed babies.

FACT: Every baby acquires maternal antibodies in the uterus. The fetus itself begins to make its own antibodies prior to birth and continues for several years until its full immunity is reached.

Studies have found no significant difference between concentra-tions of these antibodies in breast-fed and formula-fed infants.

Some immunoglobulins may be transmitted through colostrum

and somewhat through breast milk, but some authorities have

pointed out that they are in protein form and probably digested;

therefore, it is still questionable how much immunity

breast-feeding can actually provide. Little information is available to

support the belief in the beneficial role of breast milk against

respiratory infections and intestinal viral infections. Recent reports have indicated, in fact, that there is a possibility that ingestion of human milk contaminated with group B -hemolytic Streptococcus may be associated with development of clinical

disease in the infant. Studies comparing incidence of disease are

hampered by the many differences in mothers and infants. REALITY: A mother was persuaded that her babies would be more healthy if she breast-fed. She nursed her second baby every three hours all night for 3 months while her husband and toddler were making poor adjustments to the new arrival. When the

infant became ill for the second time in 3 months, the mother

decided to formula feed. The baby not only thrived but imme-diately began sleeping through the night and the family adjusted to, and enjoyed the new baby. In another family, the first nursed

child had severe ear infections and tubes were placed in his ears

by 4 months of age; the second baby, also breast-fed, had tubes

in her ears by 2 months of age.

MYTH: Breast-fed babies will not have allergies.

FACT: Studies have shown that allergens such as eggs, choc-olate, oranges, and cow’s milk may enter breast milk and cause

allergic reactions in susceptible nursing infants, making a

con-trolled study difficult and the offending allergen difficult to

pinpoint. A breast-feeding mother would have to eliminate these

possible allergens from her diet if she has an allergic baby. All

breast-feeding mothers would also avoid the use of drugs,

medi-cines, caffeine, cigarettes, spicy or gas-producing foods, all of

which could cause toxic reactions or distress in the infant. When formula feeding, the only allergen is cow’s milk (formula base)

in the early months. Solids are then introduced one at a time,

and highly allergenic foods are not introduced at all in the first year. On occasion, an infant can develop an allergy to cow’s milk

protein in breast milk or cow’s-milk-based formula. The

availa-bility of formulas containing predigested proteins or soybean

protein base can help eliminate the problem for such a baby.

The processing of cow’s milk to make formula has altered casein

(milk protein), eliminating the main cause of cow’s milk

mdi-gestibility.

REALITY: A mother believed that her baby would not have

allergies if she breast-fed. The infant began showing signs of

severe allergic reactions, and after months of trying to pinpoint

something in her diet, it was found that the baby was reacting

to milk and milk products in her mother’s diet.

MYTH: Breast-fed babies are more well-nourished than for-mula-fed babies.

FACT: The single most common cause of failure-to-thrive is

inadequate nursing! When breast-milk production is adequate,

the nutritional value of breast milk is largely dependent upon

the health and diet of the mother. Formula must adhere to strict

Food and Drug Administration regulations and can be easily,

quickly, and properly prepared according to instructions on each

can. Formula and breast milk contain nearly equal amounts of

calcium, protein, carbohydrates, fats, minerals, and vitamins,

with the exception of vitamin D and fluoride which need to be

supplemented in the breast-fed baby’s diet. Unmodified cow’s

milk contains three times the amount of protein in formula or

breast milk and is not recommended for infants until at least 6

months of age.

REALITY: A nursing infant went from a birth weight of 8 lb

to a weight of 5 lb before baby and mother were hospitalized for

1week for tests. It was determined that something was “wrong”

with the mother’s milk, and only after she began to formula feed

did the baby begin to thrive.

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(3)

MYTH: Formula-fed babies must have iron-fortified formula

or they will become anemic.

FACT: According to the American Academy of Pediatrics, every infant possesses its own store of iron at birth, and the need for supplementary iron can be filled in the form of iron-fortified baby cereals, vitamin/mineral preparations, or iron-fortified formula, when the infant’s store of iron becomes de-pleted at 4 to 6 months of age.

REALITY: Many bottle-feeding mothers have found iron-fortified formula to be very upsetting to the newborn infant, causing severe cramping and constipation (sometimes misinter-preted as milk allergy).

MYTH: Breast-fed babies should not have solids until at least

6 months of age.

FACT: According to the American Academy of Pediatrics,

“Infants should be breast-fed solely through the first six months of life as long as they gain weight appropriately, are happy, and can sleep well between feeds and at night.” According to a registered dietition at Stanford Medical Center, weight gain of all infants should average approximately 2 lb/mo, and the infant

is ready for solids when birth weight has doubled, or the infant

is drinking more than one quart offormula per day. The dietitian

contends that NOT beginning the feeding of solids when the infant is ready can delay the development of normal feeding skills and the opportunity to experience new tastes and textures. Dr Myron Winick at Columbia states that the average mother produces only one pint of milk per day, increasing to 1#{189}pints per day by the sixth month.

REALITY A nursing mother brought her first 5-month-old baby to the hospital in desperation when she could no longer agree with her pediatrician that nothing was wrong with her

tiny, crying, vomiting baby. The infant was determined to have

“air pockets” in his intestines from months of crying. She was

told to feed him (formula, cereal, fruit) to “straighten him out.”

MYTH: Bottle-fed babies sleep through the night because they have residue in the bottom of their stomachs.

FACT: Babies will eat more frequently if they take a small amount at each feeding. If the infant finds enough available milk, the quantity of milk consumed at each feeding increases and the infant adjusts to a routine of daytime activity, sleeping for longer periods at night. The breast-fed baby’s total daily

intake is dependent upon the mother’s emotional state of mind,

physical capabilities, and constant sucking stimulus.

REALITY: A mother chose to formula-feed each of her three children. She found that in spite of differences in gender and

personality, each baby followed the same feeding pattern. Each

infant ate every four hours in the early weeks. Sucking time was regulated by size of nipple holes to suit each baby’s sucking ability. By two to four weeks of age, each infant “dropped” one night-time feeding, sleeping eight hours at night and taking more formula at each daytime feeding. At approximately 2 months of age, each refused a second night-time bottle, sleeping

for 12 hours, and soon began consuming approximately one

quart of formula per day in four feedings. Each enthusiastically welcomed solids and by 4 months of age, they fit easily into their

family’s three-meals-a-day routine. They were happy, healthy

babies weaned from bottle to cup by age 1 year.

MYTH: Bottle-fed babies will become fatter adults than

breast-fed babies.

FACT: In the early months, the bottle-fed baby’s weight gain

is greater than his length gain so that he appears to be heavier.

This balances out between ages 6 months to 1 year. Habits are

acquired at an early age, and if each time the baby cries the mother feeds it, some authorities feel that eating may become a

way the adult will later seek gratification, a major cause of

obesity in later life. Generally, if a baby cries soon after a

complete feeding, the reason is not hunger. The mother is then

confident that her baby is tired, bored, or uncomfortable, and

acts to remedy the situation. The breast-feeding mother who is

not confident that her baby has had enough may find it all too

easy to again offer the breast. Babies who habitually nurse at

any time ofthe day or night find it difficult to break this pattern. REALITY One breast-feeding mother showers with her 8-month-old in a backpack because if she leaves him he will scream until nursed. Another mother crawls across the floor so her baby

in a playpen will not see her and demand to be nursed. Still

another mother has bonded with her child by sleeping with her and nursing all night for 2 years; the child has never spent a

night in her own crib. (Displaced husbands are receiving

coun-seling to deal with nursing wives.)

MYTH: Breast-fed babies will become more secure and well-adjusted individuals than bottle-fed babies.

FACT: Personality development is far too complex to relate to feeding method. Data are not available at this time to relate clearly the role of breast-feeding in the long-term emotional development and social adaptability of the child in later life. Many mothers, however, feel that predictable eating and sleeping patterns provide a needed sense of security and contentment for the infant, confidence and control for the mother, and enable

the entire family to enjoy fully each exciting new stage of baby’s

development.

REALITY: A 2-year-old thwarted by a playmate climbs into

his mother’s lap to be nursed. A kindergarten child is being

nursed after school to help her “unwind.”

MYTH: Breast-feeding mothers have a closer relationship with their babies than bottle-feeding mothers.

FACT: Maternal-infant bonding takes place for all breast-feeding or bottle-feeding mothers who look forward to holding their babies at feeding time in a peaceful experience of sharing and enjoyment. An unsuccessful breast-feeding experience

ac-tually delays the bonding process for some mothers. Dr Reba

Michels Hill, in the latest pamphlet on breast-feeding published

by the American Academy of Pediatrics, states that “to

success-fully breast feed her infant the mother must have personal motivation and not be coerced into breast feeding by a friend, husband, or doctor. Women must not be made to feel guilty for

refusing to breast feed their infant.” Many nursing mothers

resent the constant demands of the hungry infant; some even

use Lamaze breathing techniques for painful nipples as they

nurse. Many look wistfully at happy and contented babies,

recalling the frustrations they experienced and feeling that they have missed out on what should have been a joyful experience.

REALITY: Breast-feeding is not for everyone! According to a 1982 update, breast-feeding failure is a common experience in

all parts of the world. At least 20% of first-time mothers may

have complete failure in breast-feeding and up to 50% of nursing mothers may show significant difficulties. On the other hand, countless numbers of normal, intelligent, and loving mothers have chosen to formula-feed their babies and have had successful and enjoyable experiences.

Breast milk and formula have nutritional advantages

and disadvantages.

The

emotional

needs

of mothers

and

their

babies

are satisfied

by the maternal-infant

bonding

that occurs through holding, cuddling, and nurturing,

regardless

of feeding

method.

It

is then

a matter

of

individual choice of the method that is best suited to

needs of mother, infant, and family. Every mother should

be supported by her peers as well as medical professionals

and respected

for her choice.

PATRICIA

J.

FISHER

1209 Westmoreland Ave

(4)

LETTERS TO THE EDITOR 437

BIBLIOGRAPHY

Brown W Jr: Child health-Some old and new rules about

infectious illness. Mother’s Manual, Sept-Oct 1980

Gerrard JW: Allergy in breast fed babies to ingredients in breast milk. Ann Allergy 1979;42:69-72

Hattner J: Expanding baby’s menu. Baby Talk, January 1982

Hill RM: Breast-Feeding. Evanston, IL, American Academy of

Pediatrics, 1981

Hyde RM, Platnode RA: Immunology. Reston, VA, Reston

Pub-lishing Co, 1978

Ogra PL, Greene HL: Human milk and breast feeding: An update

on the state of the art. Pediatr Res 1982;16:266-271

Sauls HS: Potential effect of demographic and other variables

in studies comparing morbidity of breast-fed and bottle-fed

infants. Pediatrics 1979;64:523-527

Vaughan VC III, McKay RJ Jr, Behrman RE (eds): Nelson

Textbook of Pediatrics, ed 11. Philadelphia, WE Saunders Co, 1979

Saarinen UM, Pelkonen P, Siimes MA: Serum immunoglobulin

A in healthy infants: An accelerated postnatal increase in

formula-fed compared to breast-fed infants. J Pediatr 1979;95:410-412

Campylobacter

Infection

To the

Editor.-Chamovitz et al’ recently reported the occurrence of

hemolytic-uremia syndrome with evidence of

Campylo-bacter jejuni infection in both a mother and daughter.

Although they indicated that there were no previous

reports of the association of this enteric pathogen with

hemolytic-uremic syndrome, we must point out the report

of Denneberg et al,’ who noted this association in 1982.

.

In addition,

we have

recently

treated

a 22-month-old

white girl with classic hemolytic-uremic syndrome who had bloody diarrhea as an early symptom. C jejuni was

isolated from her stool cultures. Thus, the association

between C jejuni infection and hemolytic-uremic

syn-drome has occurred at least four times, suggesting that this infectious agent may be much more commonly found in subjects with hemolytic-uremic syndrome than

here-tofore suspected.

REFERENCES

STANFORD T. SHULMAN, MD

DONALD MOEL, MD

Department of Pediatrics

Northwestern University Medical School

303 East Chicago Ave

Chicago, IL 60611

1. Chamovitz BN, Hartstein Al, Alexander SR, et al:

Campy-lobacter jejuni-associated hemolytic-uremic syndrome in a mother and daughter. Pediatrics 1983;71:253-256

2. Denneberg T, Friedberg M, Holmberg L, et a!: Combined

plasmapheresis and hemodialysis treatment for severe

he-molytic-uremic syndrome following campylobacter colitis.

Acta Paediatr Scand 1982;71:243-245

Prediction

of Child

Abuse-Does

It Work?

To the

Editor.-Rosenberg et al’ report on a prospective, “random”

study of 476 patients up to 2 years of age seen in an

emergency room. The paper is concerned with a problem

of importance to health care providers and of great

inter-est to parents and society. The paper reports statistically

significant differences in rates of observed or reported

child abuse between children grouped according to the

presence of certain abnormal features. Our concern is that the reported results may be easily misinterpreted and, therefore, may be misleading.

The recommendation in the last paragraph of the

article “that skilled social workers evaluate the home situation of children with unkempt appearance, abnormal

bruises, or combinations of unkempt appearance and abnormal parenting patterns” appears unwarranted es-pecially for office-based or clinic-based pediatricians and family physicians. The finding that certain factors, such as unkempt appearance, appear more frequently in abused children than in children who are not abused does

not necessarily mean that the factor is an appropriate

“screening test.” For example, we would not attempt to study all adults more than 6 ft tall for a rare condition

such as Marfan’s syndrome, although there is clearly a

statistically significant difference between the number of

adults with Marfan’s syndrome who are more than 6 ft

tall and those less than 6 ft tall.

Appropriate screening tests must fill a number of

gen-erally agreed upon criteria.2 For a test or characteristic

to be useful in screening it must have a high predictive

value, or likelihood of identifying individuals with a

se-rious condition. The predictive value, or ability of a test to predict directly individuals subsequently confirmed to have a disease or condition, is determined by the sensi-tivity of the test, the specificity of the test, and most

importantly, although least frequently recognized, by the prevalence of the condition in the population.

Further-more, the condition being screened for should have an accepted and proven efficacious treatment, and the cost of screening must be within acceptable limits.

Using the authors’ data we have calculated sensitivity

and specificity for different abnormal features as

predic-tors of child abuse (Table 1) and the positive predictive values for different incidence rates (Table 2). The authors

have not clearly distinguished between prevalence, the

frequency or total number of cases or episodes in the

population at a particular moment in time, and incidence,

the number of new cases in a given population in a certain

period of time. The distinction is important because the

likelihood of finding a “child abuser” on a particular

home visit would be far less than the 4.3% reported as

the yearly incidence in this study; and, in most practices the yearly incidence would be less than 4.3%. The au-thors’ recommendation would therefore, require

screen-ing a very large number of normal households. The dollar

cost to society for administration of the program, includ-ing salaries of social workers, and the psychosocial

con-sequences to families confronted falsely may outweigh

the potential benefits. In fact, we have little evidence that some of these children woud not be otherwise

iden-tified, or that the identification would result in a better

health outcome (less abuse). And, last, 85% of abusers would not be identified at all using the criteria (sensitivity

of 15%).

Child abuse is a disturbing medical and social problem.

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(5)

1983;72;434

Pediatrics

PATRICIA J. FISHER

Breast or Bottle: A Personal Choice

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including high resolution figures, can be found at:

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1983;72;434

Pediatrics

PATRICIA J. FISHER

Breast or Bottle: A Personal Choice

http://pediatrics.aappublications.org/content/72/3/434.3

the World Wide Web at:

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

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

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1983 by the

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

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

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References

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