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Pitfalls in General Pediatrics*
Pitfalls in General Pediatrics#
153. Inadequate isolation of children with infectious diseases. This includes children with viral, respiratory and intestinal disease. Widespread dissemination of infectious diseases occurs in many physicians' offices and clinics as well as in hospitals. Part of the reason for failure to isolate patients is the unavailability of isolation rooms. t
154. Hospitalization of too many patients with acute but not serious disease. Examples are bronchitis, otitis media, mild diarrhea. The combination of pitfalls 153 and 154 ( nonisolation and overadmission of patients with infection) suggests a solution: if fewer patients (only those sufficiently seriously ill) were admitted, the isolation (segregation) of patients with infection would be facilitated, since there would be sufficient isolation areas. 155. Failing to explain the essential role of the house staff to the parents during their child's hospitalization. This often leads to parental and house staff misunderstanding and resentment, and less than optimum patient care. Pitfalls numbers 153-161, 163, 165, 167, 169, 178, 180, 186, 197, 199, 201 and 202 were concurred in by both seminar and corresponding participants, and numbers 162, 166, 168, 170, 172-177, 179, 181-183, 185, 187-189, 191-196, 198, 200 and 203-207 by the seminar participants. 0
71
72
PITFALLS IN GENERAL PEDIATRICS
156.
Failing to recognize or to he sufficiently aware of possible emotional reactions to diagnostic procedures.
157.
Misinterpretation of the natural history of the clinical findings. This is the pitfall of giving a specific medication credit for tincture of time. In turn, this has the accompanying pitfall of giving medication for the wrong reason, even though the medicine might perfectly well be the correct one.
158.
Failing to take into adequate consideration the emotional effects of chronic disease when planning the management. This is especially true of congenital heart disease.
159.
Not being sufficiently concerned with the problem of the adolescent. For example, the preventive and therapeutic (from a physiologic or emotional point of view) aspects of acne, dysmenorrhea, gynecomastia and emotional problems.
160.
Placing heavy reliance for either diagnosis or treatment on any single finding of the history, physical examination or laboratory data. It is all too human to wish for an absolutely reliable guide to diagnosis or treatment, but in point of fact the only real safety lies in consideration of a number of findings weighed according to the physician's own
PITFALLS IN GENERAL PEDIATRICS
73
experience as to reliability. In the final analysis, rejection of certain data is often necessary to reach the definitive diagnosis or conclusion as to the best course of treatment. Although the statistical validity of this recommendation is easily obtained in classic textbooks on the subject, it can easily be shown that any single finding is quite fallible. For example, electrocardiograms of children are one of the more reliable tools in the diagnosis of cardiovascular disease, and yet no pattern is completely reliable or pathognomonic. Children with patterns of left ventricular hypertrophy may have the tetralogy of Fallot, and children with right ventricular hypertrophy who had tricuspid atresia have been seen. Even more dangerous is the very deep pitfall of excessive reliance on "gadgets," no matter how scientific their appearance or how complicated their mechanism.
161.
Failing to recognize that the complaint presented by the mother as the primary one may he of less concern to her than one which she fails to mention or does not emphasize. The latter includes sex-related phenomena, emotional disorders, developmental retardation, and symptoms which she feels might indicate serious disease, such as leukemia, and disorders which she feels might he caused by something she had done or had failed to do.
162.
Feeling that financial limitation plays a significant role when a patient needs medical help. For example, not performing laboratory studies which may be indicated. There was general agreement that all necessary data should be obtained, and that the costs will be adjusted in some way, sooner or later.
74
PITFALLS IN GENERAL PEDIATRICS
163. Not considering the possibility that maltreatment or abuse may be responsible for such conditions as sudden, unexplained death in infancy or for fractures, failure to thrive, burns, and so forth.
164.
Not appreciating that a simple change might be rewarding. For example, in the days of more widespread use of evaporated milk it was not unusual to have a baby on a Pet Milk formula, but fussing a bit. The mother would ask whether she might change to Carnation Milk because the baby next door receiving this formula was acting like a lamb. On the very same day another mother might want to change from Carnation to Pet Milk. Today, with the great use of ready-prepared formulas, the simple change from Similac, Enfamil or SMA to one of the other formulas frequently results in a perfect baby. Always remain master of the situation, but with ingenuity listen to the family's comments. Pay attention to the history. Many commented that changing formulas is a fairly harmless "placebo."
165. Believing that the "therapy" used cured the disease or symptoms. For example, antibiotics, nose drops, cough medicine, for simple, upper respiratory tract inflammatory disease. The need to placate the mother's (and the physician's) ego is often the chief reason for prescribing therapy. Furthermore, giving medicine is less time consuming than giving advice.
PITFALLS IN GENERAL PEDIATRICS
166.
75
Not using all available resources for diagnosing and treating seriously ill patients. Examples are as follows: Not calling the police to assist in getting information from those who might add to the history (poison cases particularly). Not calling neighboring hospitals or pharmaceutical firms, or even those far removed, to obtain rare biologics or drugs. Not telephoning knowledgeable medical colleagues for advice. Not referring difficult cases to the best institute, in the hope of keeping face or retaining prestige with your colleagues in your own institute.
167.
Ordering nonspecific heroic therapy for terminally ill pa· tients. "They shall not die without having received the 'benefits' of ( 1) a tracheotomy, ( 2) oxygen, ( 3) digitalis, ( 4) blood transfusion, ( 5) multiple antibiotics, etc., ( 6) fluids, ( 7) steroids, ( 8) cardiac massage." Such activity seems particularly inappropriate in patients with terminal neoplastic disease and neonatal respiratory distress syndrome.
168.
Believing that most parents give medications for the full, prescribed course. Even intelligent, highly motivated parents who have been given careful instructions sometimes fail to give the entire course.
76
PITFALLS IN GENERAL PEDIATRICS
169. Prescribing treatment which is more risky than that of the disorder itself. Examples are as follows: Using steroids to treat asymptomatic, idiopathic thrombocytopenic purpura, which is usually self-limited, particularly in newborns. Prescribing antibiotics for the management of viral respiratory infections. Performing tonsillectomy and adenoidectomy for "hypertrophied" tonsils (see pitfall number 11 [p. 11]) or repeated "sore throats." Performing exchange transfusion for asymptomatic hyperbilirubinemia of mild to moderate severity (see pitfall number 234 [p. 94]).
170. Failing to recognize allergy. Symptoms are repeated upper respiratory tract infections. Helpful points are sneezing, appearance of the nasal discharge, and eosinophils on nasal smear.
171. Failing to investigate the reason for a high water intake. Diabetes insipidus, diabetes mellitus and hyperthyroidism can be missed if this symptom is ignored.
172. Feeling that teething is a common cause of fever. Some felt that a child who is writhing in pain due to teething might well have a temperature of 101 o F. due to motor activity.
PITFALLS IN GENERAL PEDIATRICS
173.
77
Failing to maintain complete and detailed medical records. This is an important source of ignorance about the need for tonsillectomy and adenoidectomy. The time and characteristics of previous infections are frequently not recorded.
174.
Excessive referral of simple, mild cases. For example, the patient with minor allergies, mild orthopedic problem, and the like. Since the consultant usually feels that the referring physician has basic clinical knowledge and experience, he will often tend to conclude that simple examination or observation of the patient is not expected, but rather a definitive approach (e.g. desensitization), appliances, operation, and so on.
175.
Believing that there is such a thing as "growing pains." Most children with "growing pains" are active, often with evidence of bruising over the shins.
176.
Making an inappropriate diagnosis in relation to the age of the patient. Examples are dental abscess in a 19-month-old child, urticaria in a four-month-old infant (now dead of polyarteritis) or colic in an 11-month-old infant (now diagnosed as having infantile myoclonic seizures).
177.
Making "rash" diagnoses by telephone. Cases of meningococcemia . have been missed (admittedly rarely).
78
178.
PITFALLS IN GENERAL PEDIATRICS
Lack of adequate follow-up.
If adequate follow-up were practiced, physicians would not have to substitute antibiotics for good clinical judgment.
179.
Permitting parents to use high chairs with a narrow base for their infants. Their use is a common predisposing cause of head injury.
180.
Sending too many children with chronic illnesses to special institutions or camps. In fact, many chronic problems can be managed well at home by the family physician if he takes time to work on them. The physician must provide hope and optimism and counter pessimism.
181.
Giving antibiotics "prophylactically." Rheumatic fever and exposure to meningococcus are important exceptions to this pitfall.
182.
Failing to consider hepatitis in patients with fever of unknown etiology. Determination of the bilirubin and transaminase concentrations of plasma is sometimes very rewarding in patients with fever of unknown etiology.
PITFALLS IN GENERAL PEDIATRICS
79
183. Overdiagnosing "surgical abdomen" in patients with salmonella infection.
184. Failing to relate viral illnesses to specific viruses or group of viruses. Without definitive viral studies one may not be able to make an exact etiologic diagnosis. Nevertheless one may be able to do more than specify "virus which is going around" by keeping certain associations of viruses and clinical manifestations in mind, e.g. APC virus and conjunctivitis, Coxsackie viruses and palatal and/or pharyngeal ulcerations or nodules, herpesvirus and gingivitis, ECHO virus and exanthematous rashes.
185. Missing agammaglobulinemia. Possibly all children with a serious infection (pyogenic meningitis) as well as those with repeated serious infection should be evaluated, or at least those in whom lymphoid tissue is not apparent.
186. Not having an office incubator available to help diagnose streptococcal nasopharyngitis (tonsillitis) when there are no communal laboratory facilities immediately available.
187. Diagnosing "low-grade fever" too frequently. Temperatures up to 100.5° F. may be normal, particularly if the history indicates that this problem has occurred in other family members, or if the temperature rises rather high during minor respiratory infections. Crying and exercise for as little as one to two minutes may raise the rectal temperature 1 or more degrees.
80
PITFALLS IN GENERAL PEDIATRICS
In asymptomatic children with normal physical and laboratory findings (urinalysis, sedimentation test, tuberculin test, and so forth) the likelihood of an organic basis for fever is small. The case of an intelligent, malingering child who filled his mouth with hot water in order to have fever (for a psychologic reason) was mentioned.
188. Failing to appreciate that diarrhea in the first year of life may be due to (the result of or frequently associated with) otitis media. 0
189. Tending to ascribe all symptoms to tuberculosis when the tuberculin test result is positive.
190. Failing to use definitive therapy for treating staphylococcal infections, particularly pustules and boils which last more than a few days. One still sees children who have been given relatively ineffective therapy (compresses, local ointments, or penicillin) for weeks. Some physicians mistakenly believe that they have to save definitive agents for serious cases. Prostaphlin, oxacillin, Nafcillin, Cephalothin and erythromycin are a few of the many safe antimicrobial agents which are effectiveJor the majority of staphylococcal infections.
191. Discontinuing antibiotic therapy too soon in patients with otitis media. 0 Therapy should be continued for at least 10 days, and never less than seven days. All agreed that a shorter 0
See footnote on page 9.
PITFALLS IN GENERAL PEDIATRICS
81
course of antimicrobial therapy frequently may be sufficient, but the risk of a sudden recurrence with a chronic course is too great.
192.
Using expensive antibacterial solutions for normal infants to protect them from staphylococcal infections. Most infants do not acquire skin infections with or
without special cleansing solutions or soaps.
193.
Underdiagnosing encephalitis. The spinal fluid is normal in almost half of the patients with encephalitis. The diagnosis is made primarily on clinical grounds (lethargy, convulsions, and so forth).
194.
Underdiagnosing brain damage and schizophrenia. Many children with these conditions are considered "spoiled" or products of "difficult parents."
195.
Failing to recognize specific reading difficulty as a cause of poor school progress (grades). Although this phenomenon is well known to some physicians and school administrators, it is unfamiliar to other physicians, even pediatricians, and to many school teachers.
196.
Failing to hospitalize and to obtain a complete workup of patients with their first convulsion thought to be due to fever.
82
PITFALLS IN GENERAL PEDIATRICS
197. Failing to anticipate the possibility of a febrile convulsion in a young child with high fever.
If the family history indicates the occurrence of febrile convulsions, therapy should be given to prevent an attack.
198. Failing to examine carefully infants and children with "colic" for an inguinal hernia. Some suggest that it is unfortunate that more infants do not have colic.
199. Unnecessary surgical treatment of physiologic conditions. Notable examples: frenulum clipping, freeing labial adhesions, tonsillectomy and adenoidectomy, phimosis.
200. Failing to realize that a foreign body in the esophagus may remain there for a long time and, by pressure, cause symp· toms misdiagnosed as bronchial asthma.
201.
Labeling almost all skin eruptions in infants as eczema.
202. The overuse of many compounded dermatologic preparations. There is widespread failure to appreciate the ingredients in many such preparations, which are usually more expensive than simple basic medications.
PITFALLS IN GENERAL PEDIATRICS
203.
83
Permitting the use of plastic or rubber diaper covers, particularly overnight, especially in patients with gluteal dermatosis. This is one of the main causes of serious diaper rash.
204.
Mistaking seborrheic dermatitis for atopic dermatitis.
205.
Failing to realize that a seborrheic-like rash may accompany Letterer-Siwe disease and that atopic dermatitis is seen in children with phenylpyruvic oligophrenia.
206.
Using simplified "rule of thumb" methods for calculating drug ( or fluid) dosage. Serious toxicity and death have occurred when the following methods have been used for calculating drug dosage: Fried's rule, Child's rule, the method of milligram per kilogram (or milligram per pound) and the surface area (square meter) method. Possibly, more needless "iatrogenic" illnesses and death result from ignorance of the basic physiologic and clinical principles relative to drug dosage than from any other single cause. The section on Pediatric Drug Dosage considers this matter (see p. 131).
207.
Believing that Chlorox is a dangerous "corrosive" poison. In fact, asymptomatic children who have ingested
84
PITFALLS IN GENERAL PEDIATRICS
Chlorox do not require specific treatment or hospitalization. The conclusions reached by Landau and Saunders, 0 who have published a definitive paper on Chlorox, were as follows: 1. Liquid household chlorine bleach ( Chlorox) in amounts customarily ingested causes no serious or permanent injury to the esophagus. 2. Patients who ingest bleach require only symptomatic treatment. 3. Bleach, even in minimal amounts, is a powerful emetic.
" Arch. Otolaryngol., 80: 174, 1964.
153. Inadequate isolation of children with infectious diseases. This includes children with viral, respiratory and intestinal disease. Widespread dissemination of infectious diseases occurs in many physicians' offices and clinics as well as in hospitals. Part of the reason for failure to isolate patients is the unavailability of isolation rooms. t
154. Hospitalization of too many patients with acute but not serious disease. Examples are bronchitis, otitis media, mild diarrhea. The combination of pitfalls 153 and 154 ( nonisolation and overadmission of patients with infection) suggests a solution: if fewer patients (only those sufficiently seriously ill) were admitted, the isolation (segregation) of patients with infection would be facilitated, since there would be sufficient isolation areas. 155. Failing to explain the essential role of the house staff to the parents during their child's hospitalization. This often leads to parental and house staff misunderstanding and resentment, and less than optimum patient care. Pitfalls numbers 153-161, 163, 165, 167, 169, 178, 180, 186, 197, 199, 201 and 202 were concurred in by both seminar and corresponding participants, and numbers 162, 166, 168, 170, 172-177, 179, 181-183, 185, 187-189, 191-196, 198, 200 and 203-207 by the seminar participants. 0
71
72
PITFALLS IN GENERAL PEDIATRICS
156.
Failing to recognize or to he sufficiently aware of possible emotional reactions to diagnostic procedures.
157.
Misinterpretation of the natural history of the clinical findings. This is the pitfall of giving a specific medication credit for tincture of time. In turn, this has the accompanying pitfall of giving medication for the wrong reason, even though the medicine might perfectly well be the correct one.
158.
Failing to take into adequate consideration the emotional effects of chronic disease when planning the management. This is especially true of congenital heart disease.
159.
Not being sufficiently concerned with the problem of the adolescent. For example, the preventive and therapeutic (from a physiologic or emotional point of view) aspects of acne, dysmenorrhea, gynecomastia and emotional problems.
160.
Placing heavy reliance for either diagnosis or treatment on any single finding of the history, physical examination or laboratory data. It is all too human to wish for an absolutely reliable guide to diagnosis or treatment, but in point of fact the only real safety lies in consideration of a number of findings weighed according to the physician's own
PITFALLS IN GENERAL PEDIATRICS
73
experience as to reliability. In the final analysis, rejection of certain data is often necessary to reach the definitive diagnosis or conclusion as to the best course of treatment. Although the statistical validity of this recommendation is easily obtained in classic textbooks on the subject, it can easily be shown that any single finding is quite fallible. For example, electrocardiograms of children are one of the more reliable tools in the diagnosis of cardiovascular disease, and yet no pattern is completely reliable or pathognomonic. Children with patterns of left ventricular hypertrophy may have the tetralogy of Fallot, and children with right ventricular hypertrophy who had tricuspid atresia have been seen. Even more dangerous is the very deep pitfall of excessive reliance on "gadgets," no matter how scientific their appearance or how complicated their mechanism.
161.
Failing to recognize that the complaint presented by the mother as the primary one may he of less concern to her than one which she fails to mention or does not emphasize. The latter includes sex-related phenomena, emotional disorders, developmental retardation, and symptoms which she feels might indicate serious disease, such as leukemia, and disorders which she feels might he caused by something she had done or had failed to do.
162.
Feeling that financial limitation plays a significant role when a patient needs medical help. For example, not performing laboratory studies which may be indicated. There was general agreement that all necessary data should be obtained, and that the costs will be adjusted in some way, sooner or later.
74
PITFALLS IN GENERAL PEDIATRICS
163. Not considering the possibility that maltreatment or abuse may be responsible for such conditions as sudden, unexplained death in infancy or for fractures, failure to thrive, burns, and so forth.
164.
Not appreciating that a simple change might be rewarding. For example, in the days of more widespread use of evaporated milk it was not unusual to have a baby on a Pet Milk formula, but fussing a bit. The mother would ask whether she might change to Carnation Milk because the baby next door receiving this formula was acting like a lamb. On the very same day another mother might want to change from Carnation to Pet Milk. Today, with the great use of ready-prepared formulas, the simple change from Similac, Enfamil or SMA to one of the other formulas frequently results in a perfect baby. Always remain master of the situation, but with ingenuity listen to the family's comments. Pay attention to the history. Many commented that changing formulas is a fairly harmless "placebo."
165. Believing that the "therapy" used cured the disease or symptoms. For example, antibiotics, nose drops, cough medicine, for simple, upper respiratory tract inflammatory disease. The need to placate the mother's (and the physician's) ego is often the chief reason for prescribing therapy. Furthermore, giving medicine is less time consuming than giving advice.
PITFALLS IN GENERAL PEDIATRICS
166.
75
Not using all available resources for diagnosing and treating seriously ill patients. Examples are as follows: Not calling the police to assist in getting information from those who might add to the history (poison cases particularly). Not calling neighboring hospitals or pharmaceutical firms, or even those far removed, to obtain rare biologics or drugs. Not telephoning knowledgeable medical colleagues for advice. Not referring difficult cases to the best institute, in the hope of keeping face or retaining prestige with your colleagues in your own institute.
167.
Ordering nonspecific heroic therapy for terminally ill pa· tients. "They shall not die without having received the 'benefits' of ( 1) a tracheotomy, ( 2) oxygen, ( 3) digitalis, ( 4) blood transfusion, ( 5) multiple antibiotics, etc., ( 6) fluids, ( 7) steroids, ( 8) cardiac massage." Such activity seems particularly inappropriate in patients with terminal neoplastic disease and neonatal respiratory distress syndrome.
168.
Believing that most parents give medications for the full, prescribed course. Even intelligent, highly motivated parents who have been given careful instructions sometimes fail to give the entire course.
76
PITFALLS IN GENERAL PEDIATRICS
169. Prescribing treatment which is more risky than that of the disorder itself. Examples are as follows: Using steroids to treat asymptomatic, idiopathic thrombocytopenic purpura, which is usually self-limited, particularly in newborns. Prescribing antibiotics for the management of viral respiratory infections. Performing tonsillectomy and adenoidectomy for "hypertrophied" tonsils (see pitfall number 11 [p. 11]) or repeated "sore throats." Performing exchange transfusion for asymptomatic hyperbilirubinemia of mild to moderate severity (see pitfall number 234 [p. 94]).
170. Failing to recognize allergy. Symptoms are repeated upper respiratory tract infections. Helpful points are sneezing, appearance of the nasal discharge, and eosinophils on nasal smear.
171. Failing to investigate the reason for a high water intake. Diabetes insipidus, diabetes mellitus and hyperthyroidism can be missed if this symptom is ignored.
172. Feeling that teething is a common cause of fever. Some felt that a child who is writhing in pain due to teething might well have a temperature of 101 o F. due to motor activity.
PITFALLS IN GENERAL PEDIATRICS
173.
77
Failing to maintain complete and detailed medical records. This is an important source of ignorance about the need for tonsillectomy and adenoidectomy. The time and characteristics of previous infections are frequently not recorded.
174.
Excessive referral of simple, mild cases. For example, the patient with minor allergies, mild orthopedic problem, and the like. Since the consultant usually feels that the referring physician has basic clinical knowledge and experience, he will often tend to conclude that simple examination or observation of the patient is not expected, but rather a definitive approach (e.g. desensitization), appliances, operation, and so on.
175.
Believing that there is such a thing as "growing pains." Most children with "growing pains" are active, often with evidence of bruising over the shins.
176.
Making an inappropriate diagnosis in relation to the age of the patient. Examples are dental abscess in a 19-month-old child, urticaria in a four-month-old infant (now dead of polyarteritis) or colic in an 11-month-old infant (now diagnosed as having infantile myoclonic seizures).
177.
Making "rash" diagnoses by telephone. Cases of meningococcemia . have been missed (admittedly rarely).
78
178.
PITFALLS IN GENERAL PEDIATRICS
Lack of adequate follow-up.
If adequate follow-up were practiced, physicians would not have to substitute antibiotics for good clinical judgment.
179.
Permitting parents to use high chairs with a narrow base for their infants. Their use is a common predisposing cause of head injury.
180.
Sending too many children with chronic illnesses to special institutions or camps. In fact, many chronic problems can be managed well at home by the family physician if he takes time to work on them. The physician must provide hope and optimism and counter pessimism.
181.
Giving antibiotics "prophylactically." Rheumatic fever and exposure to meningococcus are important exceptions to this pitfall.
182.
Failing to consider hepatitis in patients with fever of unknown etiology. Determination of the bilirubin and transaminase concentrations of plasma is sometimes very rewarding in patients with fever of unknown etiology.
PITFALLS IN GENERAL PEDIATRICS
79
183. Overdiagnosing "surgical abdomen" in patients with salmonella infection.
184. Failing to relate viral illnesses to specific viruses or group of viruses. Without definitive viral studies one may not be able to make an exact etiologic diagnosis. Nevertheless one may be able to do more than specify "virus which is going around" by keeping certain associations of viruses and clinical manifestations in mind, e.g. APC virus and conjunctivitis, Coxsackie viruses and palatal and/or pharyngeal ulcerations or nodules, herpesvirus and gingivitis, ECHO virus and exanthematous rashes.
185. Missing agammaglobulinemia. Possibly all children with a serious infection (pyogenic meningitis) as well as those with repeated serious infection should be evaluated, or at least those in whom lymphoid tissue is not apparent.
186. Not having an office incubator available to help diagnose streptococcal nasopharyngitis (tonsillitis) when there are no communal laboratory facilities immediately available.
187. Diagnosing "low-grade fever" too frequently. Temperatures up to 100.5° F. may be normal, particularly if the history indicates that this problem has occurred in other family members, or if the temperature rises rather high during minor respiratory infections. Crying and exercise for as little as one to two minutes may raise the rectal temperature 1 or more degrees.
80
PITFALLS IN GENERAL PEDIATRICS
In asymptomatic children with normal physical and laboratory findings (urinalysis, sedimentation test, tuberculin test, and so forth) the likelihood of an organic basis for fever is small. The case of an intelligent, malingering child who filled his mouth with hot water in order to have fever (for a psychologic reason) was mentioned.
188. Failing to appreciate that diarrhea in the first year of life may be due to (the result of or frequently associated with) otitis media. 0
189. Tending to ascribe all symptoms to tuberculosis when the tuberculin test result is positive.
190. Failing to use definitive therapy for treating staphylococcal infections, particularly pustules and boils which last more than a few days. One still sees children who have been given relatively ineffective therapy (compresses, local ointments, or penicillin) for weeks. Some physicians mistakenly believe that they have to save definitive agents for serious cases. Prostaphlin, oxacillin, Nafcillin, Cephalothin and erythromycin are a few of the many safe antimicrobial agents which are effectiveJor the majority of staphylococcal infections.
191. Discontinuing antibiotic therapy too soon in patients with otitis media. 0 Therapy should be continued for at least 10 days, and never less than seven days. All agreed that a shorter 0
See footnote on page 9.
PITFALLS IN GENERAL PEDIATRICS
81
course of antimicrobial therapy frequently may be sufficient, but the risk of a sudden recurrence with a chronic course is too great.
192.
Using expensive antibacterial solutions for normal infants to protect them from staphylococcal infections. Most infants do not acquire skin infections with or
without special cleansing solutions or soaps.
193.
Underdiagnosing encephalitis. The spinal fluid is normal in almost half of the patients with encephalitis. The diagnosis is made primarily on clinical grounds (lethargy, convulsions, and so forth).
194.
Underdiagnosing brain damage and schizophrenia. Many children with these conditions are considered "spoiled" or products of "difficult parents."
195.
Failing to recognize specific reading difficulty as a cause of poor school progress (grades). Although this phenomenon is well known to some physicians and school administrators, it is unfamiliar to other physicians, even pediatricians, and to many school teachers.
196.
Failing to hospitalize and to obtain a complete workup of patients with their first convulsion thought to be due to fever.
82
PITFALLS IN GENERAL PEDIATRICS
197. Failing to anticipate the possibility of a febrile convulsion in a young child with high fever.
If the family history indicates the occurrence of febrile convulsions, therapy should be given to prevent an attack.
198. Failing to examine carefully infants and children with "colic" for an inguinal hernia. Some suggest that it is unfortunate that more infants do not have colic.
199. Unnecessary surgical treatment of physiologic conditions. Notable examples: frenulum clipping, freeing labial adhesions, tonsillectomy and adenoidectomy, phimosis.
200. Failing to realize that a foreign body in the esophagus may remain there for a long time and, by pressure, cause symp· toms misdiagnosed as bronchial asthma.
201.
Labeling almost all skin eruptions in infants as eczema.
202. The overuse of many compounded dermatologic preparations. There is widespread failure to appreciate the ingredients in many such preparations, which are usually more expensive than simple basic medications.
PITFALLS IN GENERAL PEDIATRICS
203.
83
Permitting the use of plastic or rubber diaper covers, particularly overnight, especially in patients with gluteal dermatosis. This is one of the main causes of serious diaper rash.
204.
Mistaking seborrheic dermatitis for atopic dermatitis.
205.
Failing to realize that a seborrheic-like rash may accompany Letterer-Siwe disease and that atopic dermatitis is seen in children with phenylpyruvic oligophrenia.
206.
Using simplified "rule of thumb" methods for calculating drug ( or fluid) dosage. Serious toxicity and death have occurred when the following methods have been used for calculating drug dosage: Fried's rule, Child's rule, the method of milligram per kilogram (or milligram per pound) and the surface area (square meter) method. Possibly, more needless "iatrogenic" illnesses and death result from ignorance of the basic physiologic and clinical principles relative to drug dosage than from any other single cause. The section on Pediatric Drug Dosage considers this matter (see p. 131).
207.
Believing that Chlorox is a dangerous "corrosive" poison. In fact, asymptomatic children who have ingested
84
PITFALLS IN GENERAL PEDIATRICS
Chlorox do not require specific treatment or hospitalization. The conclusions reached by Landau and Saunders, 0 who have published a definitive paper on Chlorox, were as follows: 1. Liquid household chlorine bleach ( Chlorox) in amounts customarily ingested causes no serious or permanent injury to the esophagus. 2. Patients who ingest bleach require only symptomatic treatment. 3. Bleach, even in minimal amounts, is a powerful emetic.
" Arch. Otolaryngol., 80: 174, 1964.