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Pitfalls in Therapy
Pitfalls in Therapy
571.
Failing to note on the first page of each child's history the medications to which he is allergic.
572.
Indulging in "rationalized therapeutics." Many clinicians rationalize away the practicality of specific diagnostic procedures such as throat cultures for acute pharyngitis. Subsequently they rationalize the need to provide the patient with material evidence of the physician's presence by prescribing medication, often an antihistaminic expectorant or cough suppressant, and make a nondescript diagnosis. Summarily, this pitfall is a conjugate of underdiagnosis and overtreatment.
573.
Failing to relate the child's symptoms to disturbances in relations between the mother and other members of the family, with the unfortunate recourse to extensive, expensive laboratory studies. Feeding problems are possibly the most frequent examples of this pitfall in pediatrics.
574.
The overuse of parenterally administered medications (penicillin in particular).
281
282
PITF ALLS IN THERAPY
The incidence of adverse reactions is higher with parenteral than with oral administration. Parenteral administration is also more painful. Dr. Robert High reported that he has never seen a child without an adequate blood penicillin level within a few minutes after oral administration of penicillin, provided the patient did not vomit. Therefore using the intramuscular route to obtain a blood level rapidly is rarely justified. Ironically, hospitalized patients are usually not given their first injection for many minutes, or even hours, after the order has been written (the nurse is busy processing the admission, or the timing of the injection must be integrated with the ward routine). Had the dose been given orally when the need for therapy was identified (see below), a therapeutic blood level would have been achieved more rapidly. . The following procedure was recommended for children who are acutely but not critically ill, not vomiting, who require antimicrobial therapy: As soon as the physical findings indicate a definite need for antimicrobial therapy, obtain the necessary cultures and ascertain whether there has been a previous reaction to the antibiotic to be given. Give the medication orally, even before writing up the case. If the child refuses to take the medication orally, or vomits, the medication can then be ordered to be given parenterally. It is unusual when antibiotics cannot be given orally under these circumstances.
575.
Following blindly the edicts of certain health departments. In some areas all children bitten by a dog should, according to the law, receive at least five days of antirabies vaccine.
PITFALLS IN THERAl'Y
283
576. Failing to ascertain how much aspirin has been administered to a febrile child with an increased respiratory rate. Aspirin intoxication may be the underlying cause for the tachypnea.
577. Failing to recognize that the serious, life-threatening phase of aspirin poisoning may occur many hours after admission to the hospital, even as the blood salicylate concentration is declining.
578. Overusing drug mixtures. Many physicians do not know the ingredients of the mixtures they use. As a result, overdosage sometimes occurs because one of the ingredients in the mixture is given in another mixture or as a single agent. Some indicated that they almost never use drug mixtures.
579. Starting treatment in patients who are not critically ill before diagnostic studies have been obtained. For example, the administration of antibiotics before appropriate specimens for bacteriologic study have been collected, particularly in those conditions in which a bacteriologic diagnosis is important and cannot be made once drugs have been started.
580. Failing to direct diagnostic studies and therapy in seriously ill patients to all possible treatable conditions.
284
PITF ALLS IN THERAPY
Failing to obtain adequate consultations is the most common cause.
581.
Incorrect drug dosage. For example, ordering medications to be given three or four times a day may result in inadequate levels in the early morning.
Gross overdosage tends to occur when the dose method of milligrams per kilogram is used for a large child (deaths were mentioned). Gross underdosage tends to occur when the average adult dose is used and corrected for body weight. For a discussion of pediatric dosage, see the article on Pediatric Drug Dosage. #
582.
Failing to label certain parents as inadequate, and in some cases frankly irresponsible, and to provide for adequate supervision of their children through follow-up visits (by a physician, public health nurse, social service worker, and the like). The handling of potentially irresponsible parents is important for the adequacy of drug administration, particularly in patients with otitis media, rheumatic fever, cervical adenitis and pyelonephritis, and in infants with severe iron deficiency anemia. (For anemia, see pitfall number 629 [po 296]).
583.
Misplacing the decimal point in ordering digitalis and other potentially toxic drugs . .. Page 133 of the February number of the Pediatric Clinics.
PITFALLS IN THERAPY
285
It was suggested that fractions should be used as much as possible.
584. Failing to give certain medications intravenously to critically ill patients. Examples: digitalis for severe heart failure, antibiotics for meningitis. The argument for giving medications intravenously to seriously ill patients is sound, since they may have poor circulation, which may result in a relatively poor rate of absorption after oral and even after subcutaneous (? intramuscular) administration. But if one cannot enter a vein promptly, the intramuscular route should be used.
585.
Assuming that clinical improvement is due to the drug being given, rather than to the natural evolution of the disease. For example, the medications used for uncomplicated colds (particularly antibiotics), and antidiarrheal agents for (viral) gastroenteritis. "I have never used an antidiarrheal agent in 18 years of practice, all cases responding to specific medication or tincture of time."
586.
Counseling parents by the presentation of facts without considering the emotional impact of the facts. Emotional support is needed when giving genetic counseling, when pronouncing a grave prognosis for life or subsequent intellectual development, and so forth. Un-
PITFALLS IN THERAPY
286
der these circumstances one should provide prompt preventive psychotherapy.
587. Failing to appreciate that some children who are given pills feign swallowing the pills and later spit them out. The use of liquid medication minimizes this risk and should be considered if resistance to pill swallowing is pronounced.
588. Failing to treat symptoms. For example, a patient with otitis is given an antibiotic, but no analgesic. A case reported by Dr. Ziegra is illustrative. A boy entered the physician's office holding his ear (earache). He was later seen leaving the office holding both his ear and his backside: he had just received a penicillin injection, but no analgesic! The patient with fever and pneumonia who is given an antibiotic, but no sedation to facilitate sleep or an analgesic for pain, was cited. This pitfall is more common in those in training or among those who are "academic."
589. Failing to indicate when orders are to be carried out immediately (stat), and failing to see to it that such orders are carried out immediately. "Stat" orders are written so frequently that nurses sometimes cannot give the medicine immediately.
PITFALLS IN THERAPY
590.
287
Treating conditions for which the proper course consists in continuing observation.
Examples are asymptomatic thrombocytopenia (including neonatal thrombocytopenia), colds (nasal, coryza, cough) and many cases of enuresis (particularly in ages three to four years).
591.
Using Dilantin in a suspension. It is hard to redisperse Dilantin in suspension, even with vigorous shaking.
592.
Overuse of steroids for minor conditions, particularly allergic symptoms, including minor asthmatic attacks. Steroids are excellent for asthma when all other forms of medication have failed (psychotherapy, bronchodilators, desensitization).
593.
Treating repeated allergic symptoms symptomatically and failing to give consideration to specific allergic management.
594.
Giving sedatives to patients with respiratory tract obstruction.
595.
Using (hot) steam for croup associated with fever. If humidity is to be used for croup, it was suggested that cold moisture be used if the patient has a fever.
288
596.
PITI'ALLS IN THERAPY
Overusing digitalis. For example, the administration of digitalis to patients who are seriously ill, but without evidence of heart failure (as in patients with bronchiolitis, respiratory distress syndrome, and similar conditions).
597.
Using milk of magnesia, or other "safe" laxatives, in patients with abdominal pain. Simple constipation being suspected, the "safe" laxative is prescribed, sometimes with disastrous results.
598.
Overdosage with epinephrine (1: 1000 dilution). One tenth of a milliliter is usually enough in children weighing from 10 to 30 kg. One twentieth of a milliliter is probably enough at least for the initial dose in infants under 10 kg. A dose greater than 0.3 ml. is rarely needed. Deaths after the use of 0.5 ml. in young children were mentioned.
599.
Using expensive oral iron preparations. There is no reason to use any but the least expensive oral iron preparation, making sure, however, that an excessively large amount is not given at anyone time. Rarely is more than 10 mg. per kilogram per day indicated.
600. Failing to use fluoride supplementation when the communal
PITFALLS IN THERAPY
289
waters are not fluoridated; or using fluorides when the waters are fluoridated.
601.
The overuse of steroids for croup and eczema.
602.
Inducing aminophylline toxicity. There is failure to appreciate that the rectal administration of this drug must be precise. Five to 6 mg. per kilogram, no more often than every eight hours, is the average therapeutic dose. Some fail to remember that a cumulative effect may occur if the drug is given by several routes (intravenously and rectally).
603.
Giving too small a dose of sedative drugs. Infants and children who are acutely ill require relatively large amounts to facilitate sleep.
604.
Overdosage and misuse of tranquilizers. Failure to use far less expensive drugs, particularly ordinary sedatives, was repeatedly cited in this regard.
605.
Giving atropine or atropine-like medications for diarrhea in children under two years of age. The incidence of toxicity (and even death) is appreciable in young children. The risks may outweigh the
PITFALLS IN THERAPY
290
possible benefits. The use of paregoric in infants under one year of age was also felt to be far more hazardous than the possible benefits merited.
606.
Improper dosage of digitalis. Many patients receive either too large or too small a dose. Digitalis dosage must be suited to individual needs.
607.
The use of nose drops for otitis media. All agreed that they are often useless, of extremely limited value. Several mentioned that they had seen serious toxic reactions to Tyzine and condemned its use in infants and children. As little as 4 drops of the 0.1 per cent solution has resulted in collapse. (The use of Tyzine in infants under two years of age is not recommended, according to the commercial producer).
608.
Failing to· appreciate that most "summer colds" are pollinosis and do not require antimicrobial therapy.
609.
Using long-acting sul£onamides. These were, in general, considered to be unnecessarily hazardous in children because of possible overdosage.
610.
The vast overuse of ear drops. Ear drops treat the parents more than the child. Drops
PI'I'FALLS IN THERAPY
291
for topical analgesia are of negligible value, certainly not worth the risk of toxic reactions. If the ear is draining, antibiotics should be given systemically, not locally (except possibly for proved pseudomonas).
611.
Overuse of mixtures of antibiotics, particularly those containing antimonilial agents.
612. Failing to give adequate therapy, once the decision to use an antibiotic has been reached. This is frequently due to the misuse of the method of calculating drug dosage per kilogram (or per pound). See Pediatric Drug Dosage. 0
613.
Using two antibiotics concurrently in patients with a respiratory disease (not otitis media). One must remember that this doubles the risk of toxicity, increases the price and only slightly increases the probability of controlling the infection if the main antibiotic used is the appropriate one.
614.
Using dihydrostreptomycin. This drug has no further usefulness.
615.
Believing the results of bacterial disk data, and discontinuing ., Page 133 in the February number of the Pediatric Clinics.
292
PITFALLS IN THERAPY
antimicrobial medication which already seemed to have an effect in controlling infection.
616.
Using antibiotics for too long or short a period. For example, most patients with mild, purulent rhinitis, sinusitis (nonstreptococcal) and bronchitis require only five to nine days of therapy, whereas those with otitis media and cervical adenitis usually should be treated for 10 to 14 days.
617.
Failing to appreciate that penicillin is usually the best antibiotic (when one is indicated) for acute respiratory infections and is much less expensive than most other antibiotics.
618.
Using the more expensive forms of penicillins. There is up to a tenfold increase in cost of any single type of penicillin. The physician should ascertain which is the least expensive form manufactured by a reliable concern.
619.
Failing to obtain conclusive evidence that children with rheumatic fever are receiving penicillin daily. We apparently are not willing to assume a detective role and prove that the penicillin is being given regularly.
PITFALLS IN THERAPY
620.
293
Using streptomycin. No one supported the further use of streptomycin except for the initial treatment of tuberculous meningitis. Equally efficacious and safer drugs are now available for almost all bacterial infections. Specifically, streptomycin was felt to be improper for H. in/luenzae infections, in neonates (see pitfall number 327 [po 198]) and for the prevention of postoperative infections. According to adult experience, however, subacute bacterial endocarditis due to Streptococcus viridans may be an exception, as would the patient in whom sensitivity studies have demonstrated that streptomycin is the safest, most efficacious drug.
621.
Exposing children to procedures or treatment which carries a greater risk than the disease or condition which is being treated. For example, desensitization for mild allergy, exchange transfusion for mild hyperbilirubinemia (see pitfall number 234#), or having parents and child come to the office from a distance for an elective immunization or minor complaint. The automobile accident rate is sufficiently high that one should consider the risk of death (one per 10 to 20 million miles) or injury (one per 5000 to 50,000 miles) resulting from automobile travel as an important variable. The possibility of contracting symptomatic (nonfatal) poliomyelitis is now probably less than 1: 1,000,000 in areas where. there has been a community live poliomyelitis program. A child who must travel 20 miles (round trip) to receive a poliomyelitis immunization therefore would have a far greater risk of being injured or killed by an automobile injury than of contracting clinically significant poliomyelitis. #
Page 94 of the February number of the Pediatric Clinics.
294
PITFALLS IN THERAPY
622. Failing to follow up patients who have ingested corrosive agents. The consequences of esophageal stricture are so grave that the physician must be aggressive in obtaining an adequate follow-up, using community resources if needed.
623.
Inducing vomiting after the ingestion of kerosene, hydrocarbons, Thorazine and other antiemetics, and in patients who have swallowed corrosive agents. Such patients should not be made to vomit.
571.
Failing to note on the first page of each child's history the medications to which he is allergic.
572.
Indulging in "rationalized therapeutics." Many clinicians rationalize away the practicality of specific diagnostic procedures such as throat cultures for acute pharyngitis. Subsequently they rationalize the need to provide the patient with material evidence of the physician's presence by prescribing medication, often an antihistaminic expectorant or cough suppressant, and make a nondescript diagnosis. Summarily, this pitfall is a conjugate of underdiagnosis and overtreatment.
573.
Failing to relate the child's symptoms to disturbances in relations between the mother and other members of the family, with the unfortunate recourse to extensive, expensive laboratory studies. Feeding problems are possibly the most frequent examples of this pitfall in pediatrics.
574.
The overuse of parenterally administered medications (penicillin in particular).
281
282
PITF ALLS IN THERAPY
The incidence of adverse reactions is higher with parenteral than with oral administration. Parenteral administration is also more painful. Dr. Robert High reported that he has never seen a child without an adequate blood penicillin level within a few minutes after oral administration of penicillin, provided the patient did not vomit. Therefore using the intramuscular route to obtain a blood level rapidly is rarely justified. Ironically, hospitalized patients are usually not given their first injection for many minutes, or even hours, after the order has been written (the nurse is busy processing the admission, or the timing of the injection must be integrated with the ward routine). Had the dose been given orally when the need for therapy was identified (see below), a therapeutic blood level would have been achieved more rapidly. . The following procedure was recommended for children who are acutely but not critically ill, not vomiting, who require antimicrobial therapy: As soon as the physical findings indicate a definite need for antimicrobial therapy, obtain the necessary cultures and ascertain whether there has been a previous reaction to the antibiotic to be given. Give the medication orally, even before writing up the case. If the child refuses to take the medication orally, or vomits, the medication can then be ordered to be given parenterally. It is unusual when antibiotics cannot be given orally under these circumstances.
575.
Following blindly the edicts of certain health departments. In some areas all children bitten by a dog should, according to the law, receive at least five days of antirabies vaccine.
PITFALLS IN THERAl'Y
283
576. Failing to ascertain how much aspirin has been administered to a febrile child with an increased respiratory rate. Aspirin intoxication may be the underlying cause for the tachypnea.
577. Failing to recognize that the serious, life-threatening phase of aspirin poisoning may occur many hours after admission to the hospital, even as the blood salicylate concentration is declining.
578. Overusing drug mixtures. Many physicians do not know the ingredients of the mixtures they use. As a result, overdosage sometimes occurs because one of the ingredients in the mixture is given in another mixture or as a single agent. Some indicated that they almost never use drug mixtures.
579. Starting treatment in patients who are not critically ill before diagnostic studies have been obtained. For example, the administration of antibiotics before appropriate specimens for bacteriologic study have been collected, particularly in those conditions in which a bacteriologic diagnosis is important and cannot be made once drugs have been started.
580. Failing to direct diagnostic studies and therapy in seriously ill patients to all possible treatable conditions.
284
PITF ALLS IN THERAPY
Failing to obtain adequate consultations is the most common cause.
581.
Incorrect drug dosage. For example, ordering medications to be given three or four times a day may result in inadequate levels in the early morning.
Gross overdosage tends to occur when the dose method of milligrams per kilogram is used for a large child (deaths were mentioned). Gross underdosage tends to occur when the average adult dose is used and corrected for body weight. For a discussion of pediatric dosage, see the article on Pediatric Drug Dosage. #
582.
Failing to label certain parents as inadequate, and in some cases frankly irresponsible, and to provide for adequate supervision of their children through follow-up visits (by a physician, public health nurse, social service worker, and the like). The handling of potentially irresponsible parents is important for the adequacy of drug administration, particularly in patients with otitis media, rheumatic fever, cervical adenitis and pyelonephritis, and in infants with severe iron deficiency anemia. (For anemia, see pitfall number 629 [po 296]).
583.
Misplacing the decimal point in ordering digitalis and other potentially toxic drugs . .. Page 133 of the February number of the Pediatric Clinics.
PITFALLS IN THERAPY
285
It was suggested that fractions should be used as much as possible.
584. Failing to give certain medications intravenously to critically ill patients. Examples: digitalis for severe heart failure, antibiotics for meningitis. The argument for giving medications intravenously to seriously ill patients is sound, since they may have poor circulation, which may result in a relatively poor rate of absorption after oral and even after subcutaneous (? intramuscular) administration. But if one cannot enter a vein promptly, the intramuscular route should be used.
585.
Assuming that clinical improvement is due to the drug being given, rather than to the natural evolution of the disease. For example, the medications used for uncomplicated colds (particularly antibiotics), and antidiarrheal agents for (viral) gastroenteritis. "I have never used an antidiarrheal agent in 18 years of practice, all cases responding to specific medication or tincture of time."
586.
Counseling parents by the presentation of facts without considering the emotional impact of the facts. Emotional support is needed when giving genetic counseling, when pronouncing a grave prognosis for life or subsequent intellectual development, and so forth. Un-
PITFALLS IN THERAPY
286
der these circumstances one should provide prompt preventive psychotherapy.
587. Failing to appreciate that some children who are given pills feign swallowing the pills and later spit them out. The use of liquid medication minimizes this risk and should be considered if resistance to pill swallowing is pronounced.
588. Failing to treat symptoms. For example, a patient with otitis is given an antibiotic, but no analgesic. A case reported by Dr. Ziegra is illustrative. A boy entered the physician's office holding his ear (earache). He was later seen leaving the office holding both his ear and his backside: he had just received a penicillin injection, but no analgesic! The patient with fever and pneumonia who is given an antibiotic, but no sedation to facilitate sleep or an analgesic for pain, was cited. This pitfall is more common in those in training or among those who are "academic."
589. Failing to indicate when orders are to be carried out immediately (stat), and failing to see to it that such orders are carried out immediately. "Stat" orders are written so frequently that nurses sometimes cannot give the medicine immediately.
PITFALLS IN THERAPY
590.
287
Treating conditions for which the proper course consists in continuing observation.
Examples are asymptomatic thrombocytopenia (including neonatal thrombocytopenia), colds (nasal, coryza, cough) and many cases of enuresis (particularly in ages three to four years).
591.
Using Dilantin in a suspension. It is hard to redisperse Dilantin in suspension, even with vigorous shaking.
592.
Overuse of steroids for minor conditions, particularly allergic symptoms, including minor asthmatic attacks. Steroids are excellent for asthma when all other forms of medication have failed (psychotherapy, bronchodilators, desensitization).
593.
Treating repeated allergic symptoms symptomatically and failing to give consideration to specific allergic management.
594.
Giving sedatives to patients with respiratory tract obstruction.
595.
Using (hot) steam for croup associated with fever. If humidity is to be used for croup, it was suggested that cold moisture be used if the patient has a fever.
288
596.
PITI'ALLS IN THERAPY
Overusing digitalis. For example, the administration of digitalis to patients who are seriously ill, but without evidence of heart failure (as in patients with bronchiolitis, respiratory distress syndrome, and similar conditions).
597.
Using milk of magnesia, or other "safe" laxatives, in patients with abdominal pain. Simple constipation being suspected, the "safe" laxative is prescribed, sometimes with disastrous results.
598.
Overdosage with epinephrine (1: 1000 dilution). One tenth of a milliliter is usually enough in children weighing from 10 to 30 kg. One twentieth of a milliliter is probably enough at least for the initial dose in infants under 10 kg. A dose greater than 0.3 ml. is rarely needed. Deaths after the use of 0.5 ml. in young children were mentioned.
599.
Using expensive oral iron preparations. There is no reason to use any but the least expensive oral iron preparation, making sure, however, that an excessively large amount is not given at anyone time. Rarely is more than 10 mg. per kilogram per day indicated.
600. Failing to use fluoride supplementation when the communal
PITFALLS IN THERAPY
289
waters are not fluoridated; or using fluorides when the waters are fluoridated.
601.
The overuse of steroids for croup and eczema.
602.
Inducing aminophylline toxicity. There is failure to appreciate that the rectal administration of this drug must be precise. Five to 6 mg. per kilogram, no more often than every eight hours, is the average therapeutic dose. Some fail to remember that a cumulative effect may occur if the drug is given by several routes (intravenously and rectally).
603.
Giving too small a dose of sedative drugs. Infants and children who are acutely ill require relatively large amounts to facilitate sleep.
604.
Overdosage and misuse of tranquilizers. Failure to use far less expensive drugs, particularly ordinary sedatives, was repeatedly cited in this regard.
605.
Giving atropine or atropine-like medications for diarrhea in children under two years of age. The incidence of toxicity (and even death) is appreciable in young children. The risks may outweigh the
PITFALLS IN THERAPY
290
possible benefits. The use of paregoric in infants under one year of age was also felt to be far more hazardous than the possible benefits merited.
606.
Improper dosage of digitalis. Many patients receive either too large or too small a dose. Digitalis dosage must be suited to individual needs.
607.
The use of nose drops for otitis media. All agreed that they are often useless, of extremely limited value. Several mentioned that they had seen serious toxic reactions to Tyzine and condemned its use in infants and children. As little as 4 drops of the 0.1 per cent solution has resulted in collapse. (The use of Tyzine in infants under two years of age is not recommended, according to the commercial producer).
608.
Failing to· appreciate that most "summer colds" are pollinosis and do not require antimicrobial therapy.
609.
Using long-acting sul£onamides. These were, in general, considered to be unnecessarily hazardous in children because of possible overdosage.
610.
The vast overuse of ear drops. Ear drops treat the parents more than the child. Drops
PI'I'FALLS IN THERAPY
291
for topical analgesia are of negligible value, certainly not worth the risk of toxic reactions. If the ear is draining, antibiotics should be given systemically, not locally (except possibly for proved pseudomonas).
611.
Overuse of mixtures of antibiotics, particularly those containing antimonilial agents.
612. Failing to give adequate therapy, once the decision to use an antibiotic has been reached. This is frequently due to the misuse of the method of calculating drug dosage per kilogram (or per pound). See Pediatric Drug Dosage. 0
613.
Using two antibiotics concurrently in patients with a respiratory disease (not otitis media). One must remember that this doubles the risk of toxicity, increases the price and only slightly increases the probability of controlling the infection if the main antibiotic used is the appropriate one.
614.
Using dihydrostreptomycin. This drug has no further usefulness.
615.
Believing the results of bacterial disk data, and discontinuing ., Page 133 in the February number of the Pediatric Clinics.
292
PITFALLS IN THERAPY
antimicrobial medication which already seemed to have an effect in controlling infection.
616.
Using antibiotics for too long or short a period. For example, most patients with mild, purulent rhinitis, sinusitis (nonstreptococcal) and bronchitis require only five to nine days of therapy, whereas those with otitis media and cervical adenitis usually should be treated for 10 to 14 days.
617.
Failing to appreciate that penicillin is usually the best antibiotic (when one is indicated) for acute respiratory infections and is much less expensive than most other antibiotics.
618.
Using the more expensive forms of penicillins. There is up to a tenfold increase in cost of any single type of penicillin. The physician should ascertain which is the least expensive form manufactured by a reliable concern.
619.
Failing to obtain conclusive evidence that children with rheumatic fever are receiving penicillin daily. We apparently are not willing to assume a detective role and prove that the penicillin is being given regularly.
PITFALLS IN THERAPY
620.
293
Using streptomycin. No one supported the further use of streptomycin except for the initial treatment of tuberculous meningitis. Equally efficacious and safer drugs are now available for almost all bacterial infections. Specifically, streptomycin was felt to be improper for H. in/luenzae infections, in neonates (see pitfall number 327 [po 198]) and for the prevention of postoperative infections. According to adult experience, however, subacute bacterial endocarditis due to Streptococcus viridans may be an exception, as would the patient in whom sensitivity studies have demonstrated that streptomycin is the safest, most efficacious drug.
621.
Exposing children to procedures or treatment which carries a greater risk than the disease or condition which is being treated. For example, desensitization for mild allergy, exchange transfusion for mild hyperbilirubinemia (see pitfall number 234#), or having parents and child come to the office from a distance for an elective immunization or minor complaint. The automobile accident rate is sufficiently high that one should consider the risk of death (one per 10 to 20 million miles) or injury (one per 5000 to 50,000 miles) resulting from automobile travel as an important variable. The possibility of contracting symptomatic (nonfatal) poliomyelitis is now probably less than 1: 1,000,000 in areas where. there has been a community live poliomyelitis program. A child who must travel 20 miles (round trip) to receive a poliomyelitis immunization therefore would have a far greater risk of being injured or killed by an automobile injury than of contracting clinically significant poliomyelitis. #
Page 94 of the February number of the Pediatric Clinics.
294
PITFALLS IN THERAPY
622. Failing to follow up patients who have ingested corrosive agents. The consequences of esophageal stricture are so grave that the physician must be aggressive in obtaining an adequate follow-up, using community resources if needed.
623.
Inducing vomiting after the ingestion of kerosene, hydrocarbons, Thorazine and other antiemetics, and in patients who have swallowed corrosive agents. Such patients should not be made to vomit.