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Clinical facts and curios
Clinical Facts and Curios 1.
a. Surfactant is obviously effective in the prevention of the respiratory distress syndrome. As menboned in prior C/mfca/ Facts and Curios, It has a/so been suggested to be helpful in the management of the pulmonary comphcations related to drownmgs. Can you name a third potentral beneficial usage of surfactant?
A. There IS another benefit to surfactant, depending on whether you are a gerbil. If you are not aware, gerbils are an excellent model for study of the pathophysiology of otitis media. For example, if you inject Streptococcus pneumoniae into the middle ear of a gerbil, you will find within a relatively short period of time that infection markedly increases the surface tension of the fluids limng the eustachian tube. The higher the surface tension, the greater the force in the lumen of the eustachian tube needed to maintain patency. Also, the force required is greatest for tubes of small radius. With this principle in mind and understanding that the presence of a substance that lowers surface tension would be predicted to decrease the required opening pressure of the eustachian tube, a couple of investigators from Hershey, Pennsylvania, and Portsmouth, Virginia, took a few gerbils and studied whether surfactant would, if blown into the eustachian tube, help to keep the eustachian tube open. Indeed it does (Fornadley JA, et al. Otolatyngol Head Neck Surg 1994;llO:llO). The addition of surfactant dramatically reduced the pressure necessary to keep the eustachian tube open, indeed, to a level markedly below that seen in normal ears, much less infected ears. So now we know that the next time you have plugged-up ears, don’t reach for the antihistamine, take some surfactant nose drops. Even the lowly gerbil can teach us a thing or two when it comes to things otolaryngolic. 2.
Q. There are a// sorts of dimfnut!ve forms of sporting actintres. for example, if you don’t like tackle football, you can play touch football. If you don’t like wrestimg, you can arm wrestle. The question IS, what IS even a more diminutive form of wrestlmg and what complication might you expect occasionally from it?
A. An even lesser form of wrestling than arm wrestling is “finger” wrestling. Whereas arm wrestling is a well-recognized sport, finger wrestling is hardly an official sporting activity, yet it is a common activity among teenagers wishing to prove their strength. In finger wrestling, the proximal interphalangeal joint of the third and strongest finger is flexed to 90 degrees (corresponding to the elbow in arm wrestling), and the distal interphalangeal joints are flexed to allow the fingertips of the two wrestlers to interlock. The aim of each wrestler is to rotate the hand of the opponent into full supination. Try finger wrestling with a friend and you’ll soon learn what the potential problem could be. The only force applied to cause pronatlon of your opponent’s hand is a torsional force The potential complication is obvious and has now been reported twice. When a bone IS loaded in torsion, a small crack may occur that first forms in the neutral axis from sheer and propagates along the plane of maximal tenslle stress to cause a spiral fracture that would invanably be expected to CuPIn pnosi PEDIATR1994;24:249-55. Copyright 0 1994 by Mosby-Year Book, 0045.9380!94/$4.00 + .I 0 5311157546
Inc.
Current
Problems in Pediatrics
/ August
1994
249
Clinical Facts and Curios
be of the third metacarpal bone (Peiser J, et al. Contemp Orthop 1993;27 459). Some fun. Treatment consists of a closed reduction and splinting of the third and second fingers to one another for a 2- to 3-week period followed by a l-month physical therapy program during which there can be no more finger wrestling, or any other activity of the digit affected. 3.
Q. The prior question had to do with what happens to the bones of those who finger wrestle What happens to the bones of weight Irfters? A. There’s been much concern in recent times about ways to prevent bone loss. particularly as one ages. Cne of the best ways tc minimize the Impact of the kinds of bone loss that we all experience as we age is to start into mature adulthood with the greatest amount of calcium in our bones that is possible. By now you’ve read that those who have a later-onset puberty are at highest risk of having the least amount of “hard bone.” To maximize the density of the bones of the teenage population for whom you provide care, you might advise them to become involved with competitive weight lifting. A study of 25 elite junior weight lifters whose average age was 17 showed that if you measure bone density by energy x-ray absorptiometry, you will find that the bones of the spine and legs, particularly the femurs, are substantially higher in calcium than the bones of non-weight lifting teenagers and remarkably higher than middle-aged adult men (Conroy BP, et al. Med Sci Sports Exert 1993;4:1103). As you might suspect, you have to be quite a serious weight lifter to make your bones hard. If a teenage girl didn’t mind being a little muscle-bound, she might serve herself very well by following the lead of the elite junior male weight lifter
4.
Q. What happens to teenagers as they get a little bit older with respect to their risk behaviors for HIV infection? A. You might think that this would be a hard question to answer with any degree of validity, given the difficult methodology that would be involved to do a precise study on this topic. Fear not, such a study is under way and IS yielding valuable new information about what happens to our teenagers in terms of their risk behaviors for HIV infection and sexually transmitted diseases. Investigators at The Urban Institute in Washington and the Wellesley College Center for Research on Women started the “National Survey of Adolescent Males” in 1988 as a study of representative never-married, noninstitutionalized males 15 through 19 years of age living in households throughout the United States. These same teenagers have now been followed for several years and data comparison between 1988 and 1991 is possible. By 1991, the group that started in 1988 ranged in age from 17 to 22 years. For those boys who had engaged in intercourse in the previous 12 months in each of the 2 study years, the mean number of acts of intercourse in the preceding 12 months increased from 23.3 to 62.5. There was a doubling (from 4.4 to 10.4) in the 3-year period in the percentage of individuals who had sex with five or more female partners in the preceding 12-month period. Not only were there no significant increases in condom use between 1988 and 1991, just the opposite occurred. The consistency of condom use during the 3-year period dropped (in blacks it fell from 61.4% of times used to 50.3%, In whites it fell from 54.4% to 44.7%, and in Hispanics from 51 .l% to 42.6%). If it were possible to quantitate the risk that these boys had, given the decreased
250
Current Problems in Pediatrics
1 August
1994
Clinical Facts and Curios
use of condoms and the marked increase in their sexual activrty, and diversity of that activity, you can see that it would be far safer to remain a 17-year-old. When HIV first became an apparent problem, many thought that there was an undue amount of paranoia about the disease. A wise man once said that paranoia, by definition, is nothing more than a heightened awareness of reality. In this case, that wise individual was right on the money. 5.
Q. You are seeing a child who, for the fourth time, has a dislocation of her kneecap. She is short, has a webbed and short neck, a low hairline, a high narrow pa/ate, a shieldlike chest, cubitus valgus, and a short fourth metacarpal. Name her syndrome and give a differential diagnosis of the causes of recurrent dislocation of the pate/la.
A. No star for your forehead for naming the syndrome-it’s obviously Turner’s syndrome. Four stars for your forehead if you named all of the predisposing conditions to recurrent dislocation of the patella. These predisposing factors include genu valgum, patella alta, hypoplasia of the lateral femoral condyle, laterally located tibia1 tubercle, vastus medialis insufficiency, abnormal attachment of the iliotibial tract, and several of the syndromes characterized by generalized ligamentous laxity, which include Down syndrome, Ehlers-Danlos syndrome, and Marfan syndrome. Recently a few cases of Turner’s syndrome popped up and that disorder must now be added to those predisposing factors associated with recurrent dislocation of the kneecaps (Mizuta H, et al. J Pediatr Orthopaed 1994; 14:74). 6.
Q. For a// the information that we learned as medical students and residents about normative linear growth in infants, toddlers, and older age group children and adolescents, most of us learned little or nothing about how quick/y kids’ feet grow in a normative fashion. All that we as parents recall is buying a lot of shoes. The quest/on IS, does foot length parallel change In linear height? A. No. As complicated growth velocity curves are for height, the foot is much more simple. The foot grows extremely fast up to 3 years of age. After that age, there is an almost constant growth rate that is exactly the same in both sexes until about age 12, when girls’ feet stop growing. Boys’ feet continue to grow for approximately 3 more years (Volpon JB. J Pediatr Orthopaed 1994;14:83). Sorry to say, there is no such thing as a growth spurt when it comes to the objects upon which we walk. No footsying around about it.
7.
Q. A traditional Chinese family has moved into your area from Hong Kong. You will be providing care for the children in the family. What are some important understandings you should have about how a Chinese family may view medical care by a pediatrician?
A. There are lots of things you should know. Among these are the following: l
l
l
Chinese families usually do not bring children to physicrans unless they are sick. However, they understand the importance of immunizations. It is customary for a Chinese child to be called 1 year old at birth and to be called 2 years old after the date of the first Chinese New Year. Thus it is theoretically possible to ask the mother of a l-month-old the age of the infant and hear that the baby is 2 years old, depending on the timing of the birth and the occurrence of the Chinese New Year. Recall that most Chinese children born in Asian cities have received bacille
Current
Problems in Pediatrics
i August
1994
251
Clinical Facts and Curios
Calmette-Guerin (BCG) vaccine. In Hong Kong, BCG vaccine is repeated every 5 years until the child has a positive tuberculosis skin test. l Pay a little extra attention during certain parts of your physical examination. For example, traditional Chinese medical practice emphasizes the quality of the pulse. Careful examinations of the pulse, it is believed, can tell the physician what is wrong with the patient. Therefore it is a major part of the examination. Thus a Chinese physlcian would spend a great deal of time pausing over the examination of the pulse, whereas Western pediatric medical practitioners usually find that the pulse is no more important than other parts of the examination, such as listening to the heart and chest. A Chinese parent not only will be much impressed by your lingering over the pulse part of the examination but more importantly will develop a greater confidence in you because of this. l If you want to be precise about it, don’t use standard growth curves, which were developed for Iowa children. You may want to see the “Standards of Height and Weight of Southern Chinese Children” as published in the Far East Medical Journal (pp. 101-109, 1965). l If a Chinese family brings their child to you because the child has what otherwise seems to be a simple cough, what they may be concerned about is tuberculosis. They also believe that a long scarf wrapped snugly around the neck will provide protection or relief from colds. l When encouraging extra fluids for a child who has an upper respiratory Infection, prescribe extra warm tea or warm cola with lemon or ginger. Although you may believe that orange juice is useful for the management of common colds, Chinese families think that orange juice is harmful when a child has a cough. l For a child with a cold, don’t encourage chicken soup. Chinese families believe that chicken should be avoided when you have a cold and that greasy foods should be avoided when there is a fever. Potatoes and rice porridge are thought to be especially helpful when you are sick. l Finally, the Chinese believe you have only a certain amount of blood available in your body. Therefore they believe that blood is very precious. They will be quite suspicious of you when you order any blood tests. Blood is so precious to the Chinese that they will think that you may be selling even the small amount of samples drawn for laboratory tests. The above are only a few snippets of information about how to relate to traditional Chinese families. If you want to read more about this, try to obtain a copy of a wonderful little pamphlet entitled, “Common Childhood Medical Problems: A Bilingual Guide to Improve Communication Between Chinese Parents and Western Doctors” prepared by Dr. Marc Weissbluth in 1979. Dr. Weissbluth is a practicing pediatrician in Chicago.
a.
Q. You practice in a small relatively poor community without many resources. In 7983 the government closed a lead smelter in your town because it exceeded ambient lead air standards. Unfortunately, no cleanup was done even though the smelter was declared a Superfund site and listed’on the Environmental Protection Agency Priority List. Knowing that even low amounts of lead exposure can produce problems for children, you decide to screen a group of 500 children aged 6 to 71 months who live in the area. You find that 76% have blood leads 270 pgldl. What is likely to happen to these blood lead /eve/s over time?
A. This is a real saga. Kimbrough et al. (Kimbrough RD, et al. Pediatrics 1994; 93:188) were faced with this very dilemma. Specifically, there was no money to
252
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Problems in Pediatrics
/ August
1994
Clinical Facts and Curios
invest in anything except follow-up for these children. It was possible to instruct the parents or guardians of the children on the prevention of lead poisoning and on behavloral factors that increased the potential for lead exposures. Parents were told to wash their children’s hands before eating and before putting them to bed, to keep their children’s fingernails clipped short, and to offer a wellbalanced diet. Where indicated, suggestions were made to carefully remove peeling paint or to make sources of lead inaccessible in the home by installing barriers. No formal “de-leading” of the homes was possible. The parents were given detailed instructions on the safe removal of paint, however, and advice on good housekeeping. The children with elevated blood lead levels and their siblings were instructed not to put their hands and nonfood items into their mouths and to wash their hands before eating. The counseling sessions were conducted with the entire family present. Each session was approximately 30 to 45 minutes. The children were tested again 4 months later and, when possible, 1 year later to determine their blood lead levels. The results showed that a little education can go a long way. The mean blood lead level 4 months afterward showed a decrease from 15 pgidl to 7.8 bg/dL. One year later the blood leads were approximately the same as at 4 months.
9.
Q. There’s only one pediatric neurologist in your town and he is off on a we//deserved vacation. You agree to cover his calls. What would you do about the following? You are asked to see a 2ih-year-old gid who had recent/y been discharged from the hospital after open heart surgery for definitive repair of a tetralogy of Fallot. The child had undergone an unremarkable open heart surgery and was recuperating very nicely at home when generalized chorea that would cease on/y during sleep developed. A review of the operative procedure showed that there were no difficulties with the surgery. The pump time was 2% hours during which time the heart was stopped for about 1 hour under deep hypothermia. The parents want to know why this has happened, what you are going to do about it, and what the outcome will be.
A. In addition to having second thoughts about volunteering to cover your neurologist friend, if you can’t figure out what is going on, you better research the literature. There you will find an important report by Medlock et al. (Medlock MD, et al. Ann Neurol 1993;34:820), which showed that during a IO-year period among 668 children who underwent open heart surgery, post-pump chorea (PPC) developed in 1.2%. PPC generally occurred some days after surgery, at times when the child is already home. No one really knows why PPC occurs, but with positron emission tomographic scanning abnormal areas of brain metabolism can be found. Patients with PPC generally have somewhat longer pump times at temperatures ~36” C and are more likely to have had an iatrogenic circulatory arrest. The bad news is that PPC doesn’t resolve in most cases. Its prognosis is extremely guarded, and virtually all children have significant developmental deficits.
10.
Q. We all know that the United States has a higher infant death rate than Japan, Canada, or Great Britain. Was this always so, and if not, when did things begin to go wrong?
A. For the answer to this question, see the “Annual Summary of Vital Statistics1992,” a report of M E. Wegman (Wegman ME. Pediatrics 1993;92:743). In 1930,
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Clinical Facts and Curios
of these four countries, Japan easily led the pack with the highest infant death rate. The United States was the lowest, with Canada and Great Britain in between. Things changed in 1955 when Great Britain began to better the United States figures. By 1964 Japan beat us out, and in 1966 Canada did as well. It’s been no contest ever since, particularly given the dramatlc improvements that continue for the Japanese population.
11.
Q. You are elected to your local school board. You are attending your hrst meeting. It seems only natural that you will be asked your opinion regarding the frrst item on the agenda. The issue has to do with the best material to use to surface the school playground. You must deode whether the surface should be made of wood chips, sand, grass, gravel, or commercial rubber mats. Wood chips are the least expensive and rubber mats the most expensive materials. but which is safer? What would you advise?
A. Sometimes going on the cheap is Ihe best advice you can give. In this case it would have been the correct choice. With playground injuries accounting for more than 170,000 emergency department visits annually in the United States, this is no minor issue. For such recreational areas what you want is the most shock-absorbing substance. The Consumer Product Safety Commission has conducted studies to determine the shock-absorbing properties of several types of surfacing materials for playgrounds utilizing a test method that involves dropping an instrumented metal head form onto a playground surface and measuring the peak deceleration in G forces and the duration of impact in milliseconds When comparing wood chips, sand, gravel, grass, and commercial rubber mats on dry, wet, and frozen surfaces, wood chips absorb the shock of impact significantly more than does gravel in either the dry or frozen state. It was hands-down better than grass, synthetic mats, or sand (Lewis LM, et al. J Trauma 1993;35:932). There’s one other thing you might learn from the preceding report, at least by implication. If you can’t afford a car with an air bag, you might just fill a plastic trash bag with some wood chips and place it in front of you as you’re tooling down the highway. Except for the splinters, you might be protected from significant injury. 12.
Q. You and a group of other pediatricians are invited to tour pediatric facilities in China. While visiting the Beijing Children’s Hospital you are struck by the fact that many children seem to be receiving antibiotics for relatively trivia/ illnesses. What is the chance that your child would be given antibiotics for the treatment of the common co/d if you brought your child to that particular hospital?
A. There IS a 98% probability that a child with a common cold will be given a prescription for an antibiotic to treat the common cold if that child were seen in the outpatient department of Beijing Children’s Hospital. Yang et al. (Yang Y-H, et al. Pediatr Infect Dis J 1993;12:986) describe the severity of abuse of antibiotics among Chinese pediatricians and the impact of such antibiotic use on the potential interference in the ability to determine the cause of serious bacterial diseases. For example, bacteria were shown to be recovered significantly less often from samples such as cerebral spinal fluid if the cerebral spinal fluid already had antibacterial activity before the administration of antibiotics to treat meningitis. Indeed, 70% of blood samples and 43% of cerebrospinal fluid samples from patients with bacterial meningitis were shown to have antibacterial
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1994
Clinical Facts and Curios
activity before the first dose of intravenous antibiotlc was given, so common is the widespread use of antibiotics in China. James A Stockman Ill. MD President, American Board of Pediatrics Professor of Clinical Pediatrics, University of North Carolina School of Medicine Consultant Professor, Duke University Medtcal School
Current
Problems in Pediatrics
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1994
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a. Surfactant is obviously effective in the prevention of the respiratory distress syndrome. As menboned in prior C/mfca/ Facts and Curios, It has a/so been suggested to be helpful in the management of the pulmonary comphcations related to drownmgs. Can you name a third potentral beneficial usage of surfactant?
A. There IS another benefit to surfactant, depending on whether you are a gerbil. If you are not aware, gerbils are an excellent model for study of the pathophysiology of otitis media. For example, if you inject Streptococcus pneumoniae into the middle ear of a gerbil, you will find within a relatively short period of time that infection markedly increases the surface tension of the fluids limng the eustachian tube. The higher the surface tension, the greater the force in the lumen of the eustachian tube needed to maintain patency. Also, the force required is greatest for tubes of small radius. With this principle in mind and understanding that the presence of a substance that lowers surface tension would be predicted to decrease the required opening pressure of the eustachian tube, a couple of investigators from Hershey, Pennsylvania, and Portsmouth, Virginia, took a few gerbils and studied whether surfactant would, if blown into the eustachian tube, help to keep the eustachian tube open. Indeed it does (Fornadley JA, et al. Otolatyngol Head Neck Surg 1994;llO:llO). The addition of surfactant dramatically reduced the pressure necessary to keep the eustachian tube open, indeed, to a level markedly below that seen in normal ears, much less infected ears. So now we know that the next time you have plugged-up ears, don’t reach for the antihistamine, take some surfactant nose drops. Even the lowly gerbil can teach us a thing or two when it comes to things otolaryngolic. 2.
Q. There are a// sorts of dimfnut!ve forms of sporting actintres. for example, if you don’t like tackle football, you can play touch football. If you don’t like wrestimg, you can arm wrestle. The question IS, what IS even a more diminutive form of wrestlmg and what complication might you expect occasionally from it?
A. An even lesser form of wrestling than arm wrestling is “finger” wrestling. Whereas arm wrestling is a well-recognized sport, finger wrestling is hardly an official sporting activity, yet it is a common activity among teenagers wishing to prove their strength. In finger wrestling, the proximal interphalangeal joint of the third and strongest finger is flexed to 90 degrees (corresponding to the elbow in arm wrestling), and the distal interphalangeal joints are flexed to allow the fingertips of the two wrestlers to interlock. The aim of each wrestler is to rotate the hand of the opponent into full supination. Try finger wrestling with a friend and you’ll soon learn what the potential problem could be. The only force applied to cause pronatlon of your opponent’s hand is a torsional force The potential complication is obvious and has now been reported twice. When a bone IS loaded in torsion, a small crack may occur that first forms in the neutral axis from sheer and propagates along the plane of maximal tenslle stress to cause a spiral fracture that would invanably be expected to CuPIn pnosi PEDIATR1994;24:249-55. Copyright 0 1994 by Mosby-Year Book, 0045.9380!94/$4.00 + .I 0 5311157546
Inc.
Current
Problems in Pediatrics
/ August
1994
249
Clinical Facts and Curios
be of the third metacarpal bone (Peiser J, et al. Contemp Orthop 1993;27 459). Some fun. Treatment consists of a closed reduction and splinting of the third and second fingers to one another for a 2- to 3-week period followed by a l-month physical therapy program during which there can be no more finger wrestling, or any other activity of the digit affected. 3.
Q. The prior question had to do with what happens to the bones of those who finger wrestle What happens to the bones of weight Irfters? A. There’s been much concern in recent times about ways to prevent bone loss. particularly as one ages. Cne of the best ways tc minimize the Impact of the kinds of bone loss that we all experience as we age is to start into mature adulthood with the greatest amount of calcium in our bones that is possible. By now you’ve read that those who have a later-onset puberty are at highest risk of having the least amount of “hard bone.” To maximize the density of the bones of the teenage population for whom you provide care, you might advise them to become involved with competitive weight lifting. A study of 25 elite junior weight lifters whose average age was 17 showed that if you measure bone density by energy x-ray absorptiometry, you will find that the bones of the spine and legs, particularly the femurs, are substantially higher in calcium than the bones of non-weight lifting teenagers and remarkably higher than middle-aged adult men (Conroy BP, et al. Med Sci Sports Exert 1993;4:1103). As you might suspect, you have to be quite a serious weight lifter to make your bones hard. If a teenage girl didn’t mind being a little muscle-bound, she might serve herself very well by following the lead of the elite junior male weight lifter
4.
Q. What happens to teenagers as they get a little bit older with respect to their risk behaviors for HIV infection? A. You might think that this would be a hard question to answer with any degree of validity, given the difficult methodology that would be involved to do a precise study on this topic. Fear not, such a study is under way and IS yielding valuable new information about what happens to our teenagers in terms of their risk behaviors for HIV infection and sexually transmitted diseases. Investigators at The Urban Institute in Washington and the Wellesley College Center for Research on Women started the “National Survey of Adolescent Males” in 1988 as a study of representative never-married, noninstitutionalized males 15 through 19 years of age living in households throughout the United States. These same teenagers have now been followed for several years and data comparison between 1988 and 1991 is possible. By 1991, the group that started in 1988 ranged in age from 17 to 22 years. For those boys who had engaged in intercourse in the previous 12 months in each of the 2 study years, the mean number of acts of intercourse in the preceding 12 months increased from 23.3 to 62.5. There was a doubling (from 4.4 to 10.4) in the 3-year period in the percentage of individuals who had sex with five or more female partners in the preceding 12-month period. Not only were there no significant increases in condom use between 1988 and 1991, just the opposite occurred. The consistency of condom use during the 3-year period dropped (in blacks it fell from 61.4% of times used to 50.3%, In whites it fell from 54.4% to 44.7%, and in Hispanics from 51 .l% to 42.6%). If it were possible to quantitate the risk that these boys had, given the decreased
250
Current Problems in Pediatrics
1 August
1994
Clinical Facts and Curios
use of condoms and the marked increase in their sexual activrty, and diversity of that activity, you can see that it would be far safer to remain a 17-year-old. When HIV first became an apparent problem, many thought that there was an undue amount of paranoia about the disease. A wise man once said that paranoia, by definition, is nothing more than a heightened awareness of reality. In this case, that wise individual was right on the money. 5.
Q. You are seeing a child who, for the fourth time, has a dislocation of her kneecap. She is short, has a webbed and short neck, a low hairline, a high narrow pa/ate, a shieldlike chest, cubitus valgus, and a short fourth metacarpal. Name her syndrome and give a differential diagnosis of the causes of recurrent dislocation of the pate/la.
A. No star for your forehead for naming the syndrome-it’s obviously Turner’s syndrome. Four stars for your forehead if you named all of the predisposing conditions to recurrent dislocation of the patella. These predisposing factors include genu valgum, patella alta, hypoplasia of the lateral femoral condyle, laterally located tibia1 tubercle, vastus medialis insufficiency, abnormal attachment of the iliotibial tract, and several of the syndromes characterized by generalized ligamentous laxity, which include Down syndrome, Ehlers-Danlos syndrome, and Marfan syndrome. Recently a few cases of Turner’s syndrome popped up and that disorder must now be added to those predisposing factors associated with recurrent dislocation of the kneecaps (Mizuta H, et al. J Pediatr Orthopaed 1994; 14:74). 6.
Q. For a// the information that we learned as medical students and residents about normative linear growth in infants, toddlers, and older age group children and adolescents, most of us learned little or nothing about how quick/y kids’ feet grow in a normative fashion. All that we as parents recall is buying a lot of shoes. The quest/on IS, does foot length parallel change In linear height? A. No. As complicated growth velocity curves are for height, the foot is much more simple. The foot grows extremely fast up to 3 years of age. After that age, there is an almost constant growth rate that is exactly the same in both sexes until about age 12, when girls’ feet stop growing. Boys’ feet continue to grow for approximately 3 more years (Volpon JB. J Pediatr Orthopaed 1994;14:83). Sorry to say, there is no such thing as a growth spurt when it comes to the objects upon which we walk. No footsying around about it.
7.
Q. A traditional Chinese family has moved into your area from Hong Kong. You will be providing care for the children in the family. What are some important understandings you should have about how a Chinese family may view medical care by a pediatrician?
A. There are lots of things you should know. Among these are the following: l
l
l
Chinese families usually do not bring children to physicrans unless they are sick. However, they understand the importance of immunizations. It is customary for a Chinese child to be called 1 year old at birth and to be called 2 years old after the date of the first Chinese New Year. Thus it is theoretically possible to ask the mother of a l-month-old the age of the infant and hear that the baby is 2 years old, depending on the timing of the birth and the occurrence of the Chinese New Year. Recall that most Chinese children born in Asian cities have received bacille
Current
Problems in Pediatrics
i August
1994
251
Clinical Facts and Curios
Calmette-Guerin (BCG) vaccine. In Hong Kong, BCG vaccine is repeated every 5 years until the child has a positive tuberculosis skin test. l Pay a little extra attention during certain parts of your physical examination. For example, traditional Chinese medical practice emphasizes the quality of the pulse. Careful examinations of the pulse, it is believed, can tell the physician what is wrong with the patient. Therefore it is a major part of the examination. Thus a Chinese physlcian would spend a great deal of time pausing over the examination of the pulse, whereas Western pediatric medical practitioners usually find that the pulse is no more important than other parts of the examination, such as listening to the heart and chest. A Chinese parent not only will be much impressed by your lingering over the pulse part of the examination but more importantly will develop a greater confidence in you because of this. l If you want to be precise about it, don’t use standard growth curves, which were developed for Iowa children. You may want to see the “Standards of Height and Weight of Southern Chinese Children” as published in the Far East Medical Journal (pp. 101-109, 1965). l If a Chinese family brings their child to you because the child has what otherwise seems to be a simple cough, what they may be concerned about is tuberculosis. They also believe that a long scarf wrapped snugly around the neck will provide protection or relief from colds. l When encouraging extra fluids for a child who has an upper respiratory Infection, prescribe extra warm tea or warm cola with lemon or ginger. Although you may believe that orange juice is useful for the management of common colds, Chinese families think that orange juice is harmful when a child has a cough. l For a child with a cold, don’t encourage chicken soup. Chinese families believe that chicken should be avoided when you have a cold and that greasy foods should be avoided when there is a fever. Potatoes and rice porridge are thought to be especially helpful when you are sick. l Finally, the Chinese believe you have only a certain amount of blood available in your body. Therefore they believe that blood is very precious. They will be quite suspicious of you when you order any blood tests. Blood is so precious to the Chinese that they will think that you may be selling even the small amount of samples drawn for laboratory tests. The above are only a few snippets of information about how to relate to traditional Chinese families. If you want to read more about this, try to obtain a copy of a wonderful little pamphlet entitled, “Common Childhood Medical Problems: A Bilingual Guide to Improve Communication Between Chinese Parents and Western Doctors” prepared by Dr. Marc Weissbluth in 1979. Dr. Weissbluth is a practicing pediatrician in Chicago.
a.
Q. You practice in a small relatively poor community without many resources. In 7983 the government closed a lead smelter in your town because it exceeded ambient lead air standards. Unfortunately, no cleanup was done even though the smelter was declared a Superfund site and listed’on the Environmental Protection Agency Priority List. Knowing that even low amounts of lead exposure can produce problems for children, you decide to screen a group of 500 children aged 6 to 71 months who live in the area. You find that 76% have blood leads 270 pgldl. What is likely to happen to these blood lead /eve/s over time?
A. This is a real saga. Kimbrough et al. (Kimbrough RD, et al. Pediatrics 1994; 93:188) were faced with this very dilemma. Specifically, there was no money to
252
Current
Problems in Pediatrics
/ August
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invest in anything except follow-up for these children. It was possible to instruct the parents or guardians of the children on the prevention of lead poisoning and on behavloral factors that increased the potential for lead exposures. Parents were told to wash their children’s hands before eating and before putting them to bed, to keep their children’s fingernails clipped short, and to offer a wellbalanced diet. Where indicated, suggestions were made to carefully remove peeling paint or to make sources of lead inaccessible in the home by installing barriers. No formal “de-leading” of the homes was possible. The parents were given detailed instructions on the safe removal of paint, however, and advice on good housekeeping. The children with elevated blood lead levels and their siblings were instructed not to put their hands and nonfood items into their mouths and to wash their hands before eating. The counseling sessions were conducted with the entire family present. Each session was approximately 30 to 45 minutes. The children were tested again 4 months later and, when possible, 1 year later to determine their blood lead levels. The results showed that a little education can go a long way. The mean blood lead level 4 months afterward showed a decrease from 15 pgidl to 7.8 bg/dL. One year later the blood leads were approximately the same as at 4 months.
9.
Q. There’s only one pediatric neurologist in your town and he is off on a we//deserved vacation. You agree to cover his calls. What would you do about the following? You are asked to see a 2ih-year-old gid who had recent/y been discharged from the hospital after open heart surgery for definitive repair of a tetralogy of Fallot. The child had undergone an unremarkable open heart surgery and was recuperating very nicely at home when generalized chorea that would cease on/y during sleep developed. A review of the operative procedure showed that there were no difficulties with the surgery. The pump time was 2% hours during which time the heart was stopped for about 1 hour under deep hypothermia. The parents want to know why this has happened, what you are going to do about it, and what the outcome will be.
A. In addition to having second thoughts about volunteering to cover your neurologist friend, if you can’t figure out what is going on, you better research the literature. There you will find an important report by Medlock et al. (Medlock MD, et al. Ann Neurol 1993;34:820), which showed that during a IO-year period among 668 children who underwent open heart surgery, post-pump chorea (PPC) developed in 1.2%. PPC generally occurred some days after surgery, at times when the child is already home. No one really knows why PPC occurs, but with positron emission tomographic scanning abnormal areas of brain metabolism can be found. Patients with PPC generally have somewhat longer pump times at temperatures ~36” C and are more likely to have had an iatrogenic circulatory arrest. The bad news is that PPC doesn’t resolve in most cases. Its prognosis is extremely guarded, and virtually all children have significant developmental deficits.
10.
Q. We all know that the United States has a higher infant death rate than Japan, Canada, or Great Britain. Was this always so, and if not, when did things begin to go wrong?
A. For the answer to this question, see the “Annual Summary of Vital Statistics1992,” a report of M E. Wegman (Wegman ME. Pediatrics 1993;92:743). In 1930,
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of these four countries, Japan easily led the pack with the highest infant death rate. The United States was the lowest, with Canada and Great Britain in between. Things changed in 1955 when Great Britain began to better the United States figures. By 1964 Japan beat us out, and in 1966 Canada did as well. It’s been no contest ever since, particularly given the dramatlc improvements that continue for the Japanese population.
11.
Q. You are elected to your local school board. You are attending your hrst meeting. It seems only natural that you will be asked your opinion regarding the frrst item on the agenda. The issue has to do with the best material to use to surface the school playground. You must deode whether the surface should be made of wood chips, sand, grass, gravel, or commercial rubber mats. Wood chips are the least expensive and rubber mats the most expensive materials. but which is safer? What would you advise?
A. Sometimes going on the cheap is Ihe best advice you can give. In this case it would have been the correct choice. With playground injuries accounting for more than 170,000 emergency department visits annually in the United States, this is no minor issue. For such recreational areas what you want is the most shock-absorbing substance. The Consumer Product Safety Commission has conducted studies to determine the shock-absorbing properties of several types of surfacing materials for playgrounds utilizing a test method that involves dropping an instrumented metal head form onto a playground surface and measuring the peak deceleration in G forces and the duration of impact in milliseconds When comparing wood chips, sand, gravel, grass, and commercial rubber mats on dry, wet, and frozen surfaces, wood chips absorb the shock of impact significantly more than does gravel in either the dry or frozen state. It was hands-down better than grass, synthetic mats, or sand (Lewis LM, et al. J Trauma 1993;35:932). There’s one other thing you might learn from the preceding report, at least by implication. If you can’t afford a car with an air bag, you might just fill a plastic trash bag with some wood chips and place it in front of you as you’re tooling down the highway. Except for the splinters, you might be protected from significant injury. 12.
Q. You and a group of other pediatricians are invited to tour pediatric facilities in China. While visiting the Beijing Children’s Hospital you are struck by the fact that many children seem to be receiving antibiotics for relatively trivia/ illnesses. What is the chance that your child would be given antibiotics for the treatment of the common co/d if you brought your child to that particular hospital?
A. There IS a 98% probability that a child with a common cold will be given a prescription for an antibiotic to treat the common cold if that child were seen in the outpatient department of Beijing Children’s Hospital. Yang et al. (Yang Y-H, et al. Pediatr Infect Dis J 1993;12:986) describe the severity of abuse of antibiotics among Chinese pediatricians and the impact of such antibiotic use on the potential interference in the ability to determine the cause of serious bacterial diseases. For example, bacteria were shown to be recovered significantly less often from samples such as cerebral spinal fluid if the cerebral spinal fluid already had antibacterial activity before the administration of antibiotics to treat meningitis. Indeed, 70% of blood samples and 43% of cerebrospinal fluid samples from patients with bacterial meningitis were shown to have antibacterial
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activity before the first dose of intravenous antibiotlc was given, so common is the widespread use of antibiotics in China. James A Stockman Ill. MD President, American Board of Pediatrics Professor of Clinical Pediatrics, University of North Carolina School of Medicine Consultant Professor, Duke University Medtcal School
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