California
Chapter 1
May 1997 News Update
Managed Care Initiative
By Anthony T. Hirsch, MD and Burton F. Willis, MD
Co-Chairs, Managed Care Task Force
With the initial data collection process almost complete (except for an additional focus group – discussed below), the task force has developed a work plan to best present to our different audiences-employer groups, health plans, consumers and pediatricians.
Editorial campaign: We will initiate an editorial campaign in local newspapers focusing on child health issues and pediatricians. This campaign will identify issues that have some media currency and translate these issues into editorial commentary. The purpose of the editorial campaign is to position pediatricians as the best child’s advocate on pressing public and private health concerns. We have accomplished a fair amount since the initiative began almost two years ago but we still have a long way to go to communicate our concerns. As always if you have questions or concerns please feel free to contact us.
The President’s Column
By Lucy Crain, MD
It’s been reassuring to note the various media features this week addressing the importance of early child development and of reading to young children. From statements by the President and the First Lady to television, magazines, and national and local newspapers; special programs, articles, and discussions have highlighted this too often taken for granted and all too frequently neglected essential phase of human development. Wouldn’t it be great if parents and grandparents and aunts and uncles and babysitters would actually take the time to read to and sing to their infants and young children, and to gently encourage them to follow some of the simple truths of getting along in the world. Knowing right from wrong is a basic. It’s been repeatedly shown that if the the basics of differentiating right from wrong are established early on, individuals can better deal with subsequent questions and challenges to their moral integrity.
Television often is the target of critics of our society and what’s happening to our children, not to mention life in general in the U.S. and around the world. True, there is far too much violence and explicit sexual behavior depicted on television to permit these boxes to take the place of moral and parental leaders for the young child’s crucial development. No V chips or other sophisticated electronic limits on the sets in homes will suffice to correct this observation. (For one thing, children today can decode and recode such limiting devices more quickly than most adults can set them.) Limits on what’s appropriate and inappropriate viewing in terms of program content as well as time expended should be internalized from parental teaching. Some parents (including some pediatrician-parents) have decided to exclude television sets from their homes in order to emphasize their disdain for undesireable program content and the time factor. It’s been my impression that children from these homes read more, are better conversationalists, and perhaps better grounded in reality than are children with unlimited television access. However, the argument can be made that these same children are less well informed on current affairs and miss the benefits of occasional exceptional educational programs enjoyed by the classmates with televisions. The inroads made in the more innocent years of childrens’ television with Sesame Street and those great songs like “Now I Know My ABCs” and “It's Not Easy Being Green" and gentle, reassuring Mr. Rogers have enriched the early childhood experiences of several generations of children. In major part, these have been recently overshadowed by purple dinosaurs, flying ninjas, and all those programs in which Saturday morning cartoon programs specialize: frenetic activity, danger, action, and violence.
There is a logical middle ground: keeping the television set with parental guidance and example as to when, what, and how much viewing is acceptable.
The way to Sesame Street is still open. (Limited access advised!) Not coincidentally, federal hearings on the V chip, content of childrens’ television programming, and a variety of other media issues are in progress. Arguments about “freedom of speech”, censorship, and denial of media rights will undoubtedly continue until/unless the media and parents and babysitters and health care providers all shoulder their responsible shares of guidance for appropriate uses of television, the Internet, and other educational vehicles for children.
Pediatricians are active participants in the child rearing process. (Many parents actually listen to us.) We should remember to inquire in all of our well child visits about time spent reading to the child and time spent viewing television, surfing the ‘Net, or playing computer games. There is a readily evident difference in parental roles usually employed in those two activities: active (reading to) and passive (parking the child in front of the tube or CPU). Remind parents to read to and to talk with their children! Consider dispensing age appropriate book lists as well as television program lists for your patients. (Send copies of your lists to Mark Simonian and Mika Hiramatsu for inclusion in our Chapter Newsletter.)
This is my last column as president of California Chapter I, and I am grateful for your support of that office,as well as for those of you who have read my contributions to the newsletter. In deliberating what topic to choose, I considered the vast array of legislative issues. (I spent yesterday lobbying on behalf of pediatricians and children in Sacramento with our new AAP District lobbyist, Erin Aaberg – formerly of California Childrens’ Lobby and a great new asset to our organization—as well as with Kris Calvin, District IX Administrator, Dr. Arlene Downing from San Diego's Chapter III, and Dr. Jan Young, from our own Chapter I Committee on Children with Disabilities.) I also considered the continued downsizing and anticipated eventual closure of the State Developmental Centers, about which our group met yesterday morning with the Department of Developmental Services. I considered re-addressing issues of welfare reform and/or health care or market reform. Somehow, those issues paled in the wake of my current lameduckhood as chapter president, in comparison to the issues of early child development and the vast opportunities and privileges we all have to mold the upbringing of the future legislators, parents, lobbyists, administrators, plastic surgeons and ballerinas (the joint career goal of one of my 5 year old patients this week!), and pediatricians...whose potential is inherent in children. My hope (in addition to your reading at least parts of my last long winded column) is that it will provoke some letters to the editor and some thoughts about ways to improve on these crucial opportunities.
Vice President’s Column
Wake Up Calls
By Tom Long, MD
Wake up calls come at strange hours and at odd times in our lives. I received such a call about ten days ago. My mother called to tell me that my Dad had suffered another stroke. I traveled to Toronto to spend a few days with my family and to be with my father as he began another rehabilitation program. Caring for the elderly is much like what we do as pediatricians or parents of newborns — feeding, clothing, changing, all in the context of loving.
My journey took me back to the roots of my training, to the hospital of my internship and some memories and associations of which I am very fond. My Dad’s physician was my Chief Resident when I was an intern. Then on the verge of becoming a Fellow of the Royal College of Physicians, Peter Koplin’s leadership was characterized by diligence and compassion. Today some 30 years later he is clearly an active listener and still has a wonderful sparkle in his eye. His bedside manner that allows such dignity for his patients is even more genuine.
My Dad was visited by many old friends. One reminded me of a conversation we had about 35 years ago while sitting out on the porch of my family’s home. He was a large man whose voice and presence dominated any gathering. He was then a young successful surgeon and I was an aspiring medical student wondering if the long road through medical school was the right thing for me. He shared with me some words of his own satisfaction and assured me that with some hard work and perseverance I too would find such satisfaction. Today he is retired. In the hospital room his presence is still dominating. We mused about our different paths and noted the similar problems of medicine here in the United States with managed care versus the Ontario Health System, i.e. the downward financial squeeze. With that same twinkle in his eye he challenged that there is a need for change and in fact some things will be better for it. After all, we are imperfect creatures in an imperfect world and we all seek to leave this world better than we found it. But along the way the cost is not really the issue; rather, the challenge is to prevent the waste of time and human lives. These are the real resources.
At the hospital I encountered another fondly-remembered mentor, a gastroenterologist who remains very active and who resists retirement despite having had a heart valve replacement and 30 years of kidney disease for which he recently began a dialysis program. We chatted and discussed the satisfaction that still comes from the laying on of hands. Today he is as warm and friendly as when we walked the halls together. Together we pondered the reality of time that has so quickly passed. Not surprisingly his appointment calendar is still full.
So what do this family stuff and past acquaintances have to do with pediatrics today? I might also add that my reading during these travels was Bob Greene’s recent book, The 50 Year Dash. Now that I am closer to one hundred than I am to my birthday it takes on more meaning – time spent on a geriatric ward is very thought-provoking. By contrast time spent in the nursery and with our own children, that helpless new baby stirs thoughts of hope and wonder and dreams for the future. At the other end of life helplessness requires care that is given with appreciation. We children will provide this care for far less time than our parents ever provided for our needs. But what gives some people their sparkle and zest for life? Why in others does the fire go out, sometimes too soon? It would seem that involvement is the key. We cannot dwell in the past but must be part of the change which is ever going on about us.
What lights your fire? What will keep your embers glowing? Dr. Hannemann in a recent AAP publication encouraged pediatricians to be involved in their communities. This kind of active community involvement in these days of health care transition gives us another forum in which we can speak to the added value of pediatricians and demonstrate it. Using our pediatric skills outside of the office makes us visible role models for young people and further promotes the good image which pediatricians enjoy as physicians. Volunteerism is such an important part of the American way that some large corporations such as A T & T have instituted a Volunteer Day as a paid benefit.
Our Chapter has many needs, commitments and goals. Our Chapter committees help us to accomplish our tasks in conjunction with our national organization. The Council on Child Health is concerned with behavioral pediatrics, children with disabilities, early childhood and adoption, injury and poison prevention, school health, etc. The Council on Pediatric Practice serves the needs of you and me. We have a Child Health Finance Committee, and a Medical Education Committee, to name but a few. Every committee needs another member. What can you do for kids, for each other?
Wake up! The fun and satisfaction are in being part of the evolution and taking care of the children entrusted to us. Time is fleeting.
Collaborative Office Rounds in Psychosocial and Behavioral Pediatrics
In 1997 the Division of Behavioral and Developmental Pediatrics at UCSF will be offering a 4th year of monthly seminars for Bay Area pediatric practitioners who are interested in expanding their skills and knowledge in the psychosocial and developmental aspects of pediatric care. The Collaborative Office Rounds (COR Program), sponsored by the Division under the auspices of the Maternal and Child Health Bureau, provide pediatricians an opportunity to review behavioral and developmental cases and concerns in an informal, ongoing, group seminar format. Participants meet one evening per month to discuss issues of interest and specific cases of concern from their own practice experiences.
Faculty leaders are Eugene Shatkin, MD, Clinical Professor of Child Psychiatry and Pediatrics at Langley Porter, and Lane Tanner, MD, Associate Clinical Professor of Pediatrics, Division of Behavioral and Developmental Pediatrics at UCSF. Meetings are held every 3 weeks, Tuesday evenings, between 7 PM and 9 PM, usually at UCSF. Eight to ten participating pediatricians are involved each year. Hour for hour Category 1 CME credits are offered. A fee of $120.00 is charged per annum.
For additional inquiries, call Lane Tanner, MD, at (415) 353-7772.
Community and Public Health Committee
At the start of the meeting, J. Takayama asked that everyone think about what the goals and tasks of this committee should be. As discussed previously, this committee is currently responsible for C.C.S., CHDP, Community Health and Public Health. M. Miller suggested that the C.C.S. portion be delegated to the Disabilities Committee as their focus is in line with C.C.S. issues. This discussion will be continued at our next meeting.
Dr. Sophia Chang Medical Director of the San Francisco Health Plan, described the history, structure, and current status of the health plan. In California, several counties are undergoing a transition of Medi-Cal fee for service into managed care using a two-plan model. San Francisco and Alameda Counties are examples, while Medi-Cal in San Mateo County operates under one plan.
Regarding this transition, services have been carved out and enrollment has been designated as either mandatory or optional for several groups. C.C.S. services are carved out and the elderly and disabled and subgroups of foster children are not mandated to enroll in the managed care portion of Medi-Cal.
The intent was to initially exclude people with special care needs until Medi-Cal managed care was running smoothly. However, in response to the state mistakenly distributing enrollment packets to groups of people who were not mandated to enroll, a significant proportion with special care and high cost needs in fact have enrolled in Medi-Cal Managed Care. As a result, the S.F. Health Plan has had to shift much of its financial resources to the reimbursement of care for such individuals. The impact on the majority of enrollees for whom managed care was intended, women and children, is not yet known.
Although C.C.S. services are carved out, the CCS-eligible children’s primary care services are provided through the SF Health Plan. An ironic outcome is that successful primary care prevention may result in a decrease in C.C.S. services but any savings would not be passed on to SF Health Plan. Unless there is good communication between the SF Health Plan and C.C.S., primary care providers will not necessarily see the effect of quality preventive services.
Several individuals mentioned that San Francisco has many services for people with different special care needs but that there is a general lack of coordination of services resulting in much inefficiency. The separation of C.C.S. and managed care services may be an example of such a piecemeal approach.
Finally, Dr. Chang discussed one critical logistical problem faced by the SFHP and its enrollees. Because of the cumbersome nature of choosing one of the two health plans (paperwork difficult for anyone to understand that is distributed by the state) over 70% in San Francisco are not exercising choice but are defaulting. During the first month of default, however, members can change immediately their primary care provider assignment; after that time, changes are implemented at the beginning of the following month (if made before the 20th of the month). A handbook of SFHP primary care providers have been distributed but with errors. A revised handbook will be redistributed.
Although there are many problems with the SFHP, under Dr. Chang’s direction, it has achieved one important goal, the placement of responsibility for the authorization process at the local level, e.g., the medical group level. Dr. Crain mentioned that the Brown & Toland authorization procedure is much more complicated than the SFHP. The SFHP, however, will be reviewing utilization to identify practice that is very different from the norm (e.g., type of therapy, volume of utilization). Pediatricians can play an important role by staying informed and advocating on behalf of patients whenever possible. All new systems have kinks that need to be straightened out and that can only be done through timely feedback. Although much of this and public discussion has been on eligibility, logistics and structure, more thought and inquiry must be directed towards quality – coming up with both process and outcome measures that truly reflect the quality of health care. Although not discussed, eventually C.C.S. services will be “carved- in” and children in foster care will be mandated to enroll in Medi-Cal managed care.
John Takayama, MD
CoChair
From the Public Relations Chair
By Mika Hiramatsu, M.D.
Available now for Chapter 1 members for school, community, and other presentations is a Speaker’s Kit on child safety. Included in the kit is a set of 18 slides along with suggested accompanying dialogue. The talk addresses such issues as: fire safety, burn and poisoning prevention, medicine safety, cribs and walkers, unintentional firearm injury, drowning prevention, pool safety equipment, bicycle, pedestrian, passenger safety, and toy safety.
The kit is part of All Kids Safe, an alliance of Allstate Insurance Company and the AAP, supported by a grant from the Allstate Foundation. If you are interested in borrowing the kit for a local presentation, please contact Beverly Busher at (415) 459-4775 or Mika Hiramatsu at (510) 581-1446.
AAP Committee on Children with Disabilities
Phil Ziring, MD, Chair
The Supplemental Security Income (SSI) program for children regulations were published February 11 in the Federal Register (www.ssa.gov/odhome, click on “childhood disability”) and go into effect April 14, 1997. All children who apply for SSI benefits beginning August 22, 1996, will be evaluated under the new rules. In accordance with the law, 263,000 children currently receiving SSI will be redetermined under the new regulations, and it is estimated that only half of these children will continue to receive benefits. The redetermination deadline is August 22, 1997; for those children found ineligible, benefits will not stop before July 1, 1997.
Pediatricians can play an important role by:
The AAP encourages all pediatricians to contact your state Social Security Medical Relations officer to receive the most detailed information available about changes to the SSI program.
Phyllis Scaduto, regional professional relations coordinator: (415) 744-4513/-4504 (fax)
Social Security Administration, Center for Disability, 74 Hawthorne St., 3rd floor, San Francisco, CA 94105
Professional Relations Specialists:
Joyce Bullivant (916) 774-4183/-4162 (fax)
John Davis (510) 286-1549/-4237
Celeste Fox (209) 440-5377/800-869-0195
Luis Garcia (recruitment specialist) (916) 323-8660/327-5536
Cindy Henley (209) 440-5371/800-869-0195
June Masuyama (510) 286-1552/-4237
Diane Milstead (916) 263-5024/-5310
Committee on Medical Liability
By Jeffrey Berman, MD
The American Academy of Pediatrics Committee on Medical Liability met in Denver March 15-16, 1997. It was a long but very interesting meeting. Here are some items that I believe the Chapter members might be interested in.
National Vaccine Injury Compensation Program
This program has been reasonably successful. The program now includes DTaP, the Varicella vaccine, and the Inactivated Polio vaccine. In addition, the tax on the vaccine that the manufacturer is paying will drop from $4.44 for MMR and $4.58 for the department to $0.51 per disease prevented, basically, $0.51 per vaccine. The program has well over 1 billion dollars in it and that is why people are cutting back and no longer see the need for taxing the company as much per dose.
Malpractice Claims on the Internet
In six states, including California, companies have launched a profile of physicians over the Internet. The profiles include basic biographical information, the status of the practitioner’s license, the date the license was first granted, the provider’s education, the specialty, and any disciplinary action. In Massachusetts people can phone an 800 number and get what kind of disciplinary action has been taken against the physician. This could be a very dangerous precedent. Many physicians get sued. Most of these suits are dropped and yet they would be on the Internet. In addition, in some of these States, information that comes to the medical board can be published. In California, if a lawsuit is settled for more than $30,000 it is reported to the Medical Board of California. This information may be available on the Internet.
Washington Report
At the present time there is no major push in Congress for any bills, as Congress is just getting started. Many medical organizations such as the AAP and AMA will push again for medical liability reform similar to what we have in California. Senator Orin Hatch of Utah and Ted Kennedy of Massachusetts are two of the backers of a National Children’s Health Care bill. Their approach is pay for this bill through an increase in the Tobacco Tax. As of yet there are no attachments to this bill but this is something the AAP will watch closely.
Denver Telephone Triage System
Doctor Barton Schmidt, one of the developers of their program and the pediatric protocols used, was in attendance at the meeting. Currently, most of the State of Colorado is under the coverage of the Denver program. Most of the Denver pediatricians sign out at 5 o’clock and their calls are covered until morning. If the physician elects not to attend a patient in the night or admit new patients, there is additional pediatric on-call coverage contracted through the Denver program. Twenty percent of the calls results in a clinic or Emergency Room visit. Only one percent of the calls results in a hospitalization. Wouldn’t we all like to have a system like this? I understand that Stanford University and other universities are using the Denver Protocols. I would be very interested to hear from those of you who are using this protocol through a university system and how much it costs.
[Editor’s Note: $75.00 for the manual. In the August News Update Dr. Simonian will write about his experience as Medical Director of the Advice Line Service at Fresno Valley Children’s Hospital and writing protocols for that program.]
Practice Parameters
The Committee on Medical Liability has been discussing practice parameters. We have asked that a disclaimer be placed at the bottom of each one saying that these are for educational purposes only. It may be said that disclaimers are of no real value and that these parameters will become a standard of care across the country. As we know, patients are all individuals, and individual things happen that are not always covered by the protocol.
Telemedicine
We spent a great deal of time discussing this topic. Telemedicine in the future will be a major component of medical practice. If you receive advice from a physician in another state, follow that advice, something goes wrong, and there is a law suit, the question arises regarding who is responsible. Some states like Kansas require that anyone practicing their state must have a Kansas license. I am not sure if this is going to solve the problem. In addition, if there is a law suit on a patient that you have given advice that is out of state, or if you have asked for advice and it was wrong, in what state does the law suit take place?
Finally, we spent some time discussing the expert witnesses issue. The Academy has made a previous statement. This is a complicated issue and needs further discussion. If you have any comments about this or any of the above topics and would like to share your experiences, feel free to contact me.
Committee on Careers and Opportunities
By Bob Kamei, MD
The Committee on Careers and Opportunities is currently in transition, trying to identify new leadership and develop a working agenda. We will be trying to involve resident fellows in more of our activities, organize the region’s teaching sites (for both medical student and residents), and look at opportunities for collaborative teaching programs and career development projects.
Legislative Agenda
From Action Report of the Medical Board of California (April 1997)
“The Medical Board is once again sponsoring legislation (SB 324, Rosenthal) to clarify that those who make decisions for managed care companies about patient tests and treatment in this state are requiured to be licensed California physicians. This legislation, when introduced last year, was ground breaking and caused a great deal of controversy. The Medical Borad has expended much effort in explaining its need since then and a measure of success in that endevor is that five bills have been introduced in this session of the Legislature which address this subject.”
Congressional Schedule
Pediatricians should use congressional recess time to visit senators and representatives. They are usually in their home districts during that time.
Senate
January 21 – First full working day
Senate Recess
May 24-June 1
June 28-July 6
August 2-September 1
October 11-19
House
February 3 First full working day
May 22-June 2
June 27-July 7
August 2-September 2
October 2
October 13
AAP Calls for Ban on Tobacco Advertising
The AAP calls on Congress and the Federal Trade Commission to ban all tobacco advertising in all media, sponsor counter advertisements about the dangers of tobacco, strengthen health warnings on cigarette labels and increase the federal excise tax on tobacco products in a new policy in April’s Pediatrics.
A recent national survey revealed that 43 percent of children 2 months to 11 years of age live in homes with at least one smoker, with nearly 48 million adults smoking cigarettes nationwide. Secondhand smoke is associated with increased illnesses in children, including lower respiratory illness, ear infections, asthma, and sudden infant death syndrome. Secondhand smoke is composed of more than 3,800 different chemical compounds.
PROS Studies Onset of Puberty
American girls are entering puberty sooner than expected, according to a study by 225 practicing pediatricians in PROS (Pediatric Research in Office Settings, the practice-based research network of the AAP). In studying more than 17,000 girls between ages 3 and 12, 14.7 percent of white girls and 48.3 percent of African American girls showed secondary sexual characteristics (pubarche or thelarche) between their eighth and ninth birthday. In fact, 6.7 percent of white girls and 27.2 percent of African American girls had begun puberty between their seventh and eighth birthdays. The current commonly used figure is that only one percent of girls under age 8 have started puberty. At the same time, average age of menarche (12.5 years) has not changed significantly over the past 40 years. (April, 1997 Pediatrics)
One in Five Toddlers Refuse to Poop in Potty, Study Reveals
The first large-scale study in 30 years on toilet training has shown that one in five toddlers use a potty-chair or toilet to urinate but not for bowel movements. A researcher at the University of Pennsylvania School of Medicine, Philadelphia, studied 482 healthy toddlers between 18 and 30 months of age, questioning parents every 6 months until their child was trained. Of those studied, 106 children used the toilet to urinate but not to defecate for at least one month, and 29 of the 106 requested pediatrician help because of stool withholding or inability to train by 3.5 years of age. Interrupting toilet training and having 28 of these children return to diapers resulted in 25 using the toilet for bowel movements within 3 months.
Other study findings:
Four percent of the children were potty trained by age 2, 22 percent by 2.5, 60 percent by 3, 88 percent by 3.5, and 2 percent were still not trained at 4 years old.
Forty-eight percent of boys compared to 30 percent of girls were not trained until after 3 years old.
Fifty-nine percent of boys were at least 2 years old when introduced to toilet training, compared to 41 percent of girls.
The age at which a child was toilet trained was not associated with the child’s behavior score, whether he or she attended day care, had siblings or a mother who worked.
In a related study, researchers from University of Pennsylvania School of Medicine and Children’s Hospital of Philadelphia found children refusing to move their bowels in a potty chair or toilet do not have more behavior problems than children who are toilet trained. (January, 1997, Pediatrics)
Surgery Unnecessary for Most Flat Heads
The vast majority of children with flattened backs or sides of heads can be treated effectively by nonsurgical means, such as a helmet, and by alternating infant head position during sleep. The study, from Children’s Hospital in Pittsburgh, Pa., found that of 71 children with posterior plagiocephaly, 69 were from molding from too much time lying on that part of the head. The other two infants had true synostosis. (February, 1997, Pediatrics)
From The Pediatrics electronic pages
Breastfeeding Regains Popularity
Breastfeeding initiation has reached its highest level (59.7 percent) since 1982 (61.9 percent) according to the Ross Laboratories Mothers’ Survey, a large national mail survey of new moms. There was a 14 percent increase in initiating breastfeeding and a 19.3 percent increase in breastfeeding at 6 months of age in 1995 compared to 1989. Breastfeeding at 6 months of age also nearly doubled among those least likely to breastfeed, including black women, women less than 20 years old, full-time workers and women participating in WIC.
Physicians Favor Payment For Telephone Advice
A study from Albany Medical College of 55 pediatricians and 479 other private physicians revealed that 69.9 percent favor compensation for after-hours telephone calls. However, after adjusting for liability concerns, negative sentiments about after-hours calls and call duration, pediatricians and surgeons were less likely to favor compensation than the group as a whole.
LP’S in Term Newborns with Sepsis Risk
Lumbar puncture is unnecessary in asymptomatic full-term newborns, according to a study from the Department of Pediatrics at Case Western Reserve. The study of approximately 24,452 full-term births between 1987 and 1993 also found that empiric use of Gentamicin only improved coverage of ampicillin alone from 90 percent to 93 percent of pathogens, while exposing more than 5000 infants to the side effects of Gentamicin. The authors also found that the presence of leukopenia (WBC/mm3) is highly predictive of bacteremia.
Children No Strangers to Family Violence
A study of family violence has found that children are often injured during fights between parents, extended family members and even family friends. The average injured child was 5 years old, and 48 percent of children were under 2 in the study from the University of Pennsylvania School of Medicine. Most children were injured by being hit directly (36 percent), but of those under 2 years, 59 percent were injured while being held by a parent. Thirty-nine percent of children were injured trying to intervene in fights. Most injuries were to the head (25 percent), face (19 percent) and eyes (18 percent), and of 91 percent discharged from emergency rooms, 73 percent returned home. It is estimated that more than 3.3 million American children between 3 and 17 years of age are at risk of parental violence each year.
Also, check out our Chapter 1 authors Ann Petru, MD and Diane Wara, MD in April’s issue of Pediarics electronic pages at http://www.pediatrics.org/cgi/content/
Full/99/4/e4.
On the Funnier Side of Things
Excuses actually received by teachers at school by means of notes from home:
Dear School: Please accuse John from being absent on January 28, 29, 30, 31, 32, and 33
Please excuse Dianne from being absent yesterday. She was in bed with gramps.
I had to keep Billie home because she ad to go Christmas shopping because I didn’t know what size she ware.
Please excuse Johnny for being. It was his father’s fault.
AAP Supported TV Turnoff Week
During the last week of April 1997, thousands of families, schools, libraries, and community organizations joined together to encourage people to leave their televisions off for 1 week. The American Academy of Pediatrics is one of 40 national organizations that supported the third annual National TV Turnoff Week.
The huge success of the previous TV Turnoffs (more than 4 million people have participated) shows that a solid one week recess from TV helps establish conditions that allow for more family interaction, reading, volunteering, exercising, enjoyment of nature, playing of sports, traking part in community affairs, thinking, creating, and doing. The hope is that after TV Turnoff week has ended, people will continue to spend more time on such activities.
The PIAA top ten reasons that Pediatricians are sued
From George Thomasson, MD
Copics most expensive claims
From a February 1997 issue of State Health Watch The Newsletter on State Health Care Reform
Six states join forces to offer doctor profiles that include malpractice claims on the Internet
Arizona, California, Iowa, North Carolina, Texas, and Vermont plan in April 1997 to present “DocFinder” - a centralized database on the World Wide Web.
“Basically, what we want to be able to do is have people be as close as possible to their homes and to look up and print out as many profiles as they want for free,” says Barbara Neuman, vice president of Administrators in Medicine, the national association for directors of state licensing and disciplinary boards. The service would also be useful for physicians, hospitals, and licensing boards, she says.
Administrators in Medicine plans to bring out “DocFinder” officially at its annual meeting in California in April. The site is already accessible on the Internet at http://206.67.216.45. Profiles include basic biographical information as well as the status of the practitioner’s license, the date the license was first granted, the license expiration date, the provider’s education and specialties, and disciplinary action.
Parents’ Religious Objections to Care Addressed
A new AAP policy states that no child should be denied access to medical care based on a parent’s religious beliefs. “Pediatricians should seek to make collaborative decisions with families whenever possible and should take great care when considering seeking authority to override parental preferences,” the policy states, but when parental practices have potentially harmful consequences for the child, the pediatrician may need to intervene on the child’s behalf.
“Constitutional guarantees of freedom of religion do not permit children to be harmed through religious practices, nor do they allow religion to be a defense when an individual harms or neglects a child,” the AAP states.
Currently 46 states have religious exemption clauses within child abuse and neglect laws, which protect parents from civil or criminal action when denying medical treatment to their children based on religious beliefs. The policy reaffirms the AAP stance calling to repeal the religious exemption statutes, which has been done in Hawaii, Maryland, Massachusetts and South Dakota.
AAP Requests Labeling of Inactive Pharmaceutical Ingredients
The AAP has recommended mandatory labeling of inactive ingredients on prescription and over-the-counter pharmaceutical products. More than 773 chemical agents have been approved by the FDA as inactive ingredients, including sweeteners, dyes and coloring agents, and preservatives, some of which may cause negative reactions. Drugs taken orally are not required to have inactive ingredients disclosed on the label. The most common pediatric reactions to inactive ingredients include seizures, headaches, bronchospasm and diarrhea.
In My Opinion
Teething
“My child has had a fever of 104° for two days, but I was not worried because I knew he was teething!” How often have you heard this story from mothers of infants? I am constantly amazed at the variety of symptoms and complaints that are blamed on purely physiological process of teething, e.g.: fevers, vomiting, diarrhea, rashes, to mention a few. Unfortunately, the medical profession not infrequently reinforces this concept of teething maladies. I am constantly telling mothers and grandmothers that teething causes teeth and nothing else.
An article in Lancet (Vol. 384, page 1710, 12/2/96), The Lancet and the Gum Lancet : 400 years of teething babies, discusses teething particularly from the point of view of lancing of the gums which was apparently introduced by the French physician, Ambrose Pare’ (1510-90) and which remained as an accepted procedure even into this century although gum lancets are no longer regarded as a necessary instrument for the practicing physician.
In my opinion, there is one bona fide situation where teething can become, at least, an annoying symptom. This is when a two year molar is erupting through the gum and where the tooth capsule has not broken but filled with blood. This is easily recognized by the purple swelling over the erupting tooth and can be instantly relieved by firm pressure on the capsule with the thumb or a blunt instrument to rupture the capsule.
I welcome hearing your views on teething.
Joseph Davis, MD
40 Anderson Way
Menlo Park, CA 94025
Fax: (415) 853-6051
[Past editor of the News Update AAP Newsletter]
Letters to the Editor
Samuel A. Tiu
Professional Sales Representative, McNeil
17 Stanford Height Ave.
San Francisco, CA 94127
Dear Sam,
This letter is a follow-up to our recent conversation regarding Tylenol Cold medicine.
As you know, a large part of a pediatrician’s effort is aimed at educating parents and patients regarding prevention and treatment issues. Education take time – both the physicians’ and parents’ time – a commodity which is limited and should be used wisely and efficiently. The more time we spend on one area, the less time that is available for other issues.
I have recently found myself spending time dealing with several parents who have purchased Tylenol Cold medication for their child who had a “cold.” This is a combination fever and “cold symptom” medication which I personally feel is rarely indicated in children.
The following are some concerns:
Medications should be as symptom specific as possible. A medication with four plus active ingredients provides a [unnecessary] shotgun approach to treatment.
Fever phobia
Pediatricians have spent a great deal of effort in getting parents not to treat fevers unnecessarily. Giving Tylenol Cold medicine to a child with a URI but no or little fever allows the child to get acetaminophen unnecessarily.
Fever treatment.
Combination medications make it difficult to titer the dose of acetaminophen appropriately to give the recommended 10-15 mg/kg dosing for a fever that should be treated. Giving 15 mg/kg of acetaminophen might also give the child an unnecessary amount of antihistamine or decongestant.
Labeling and perceptions
Tylenol is a well recognized and trusted medication. I have found that some parents interchangeably use Tylenol and Tylenol Cold medication.
As a practicing pediatrician for almost 20 years, I have been impressed with Tylenol’s sound marketing efforts in the past that made very good sense both clinically and in the area of safety. The efforts ranged from safety packaging, taste efforts, standardization of concentrations for drops, liquids, and chewable tablets, to clearly labeled measuring devices.
I was thus disappointed at the marketing of Tylenol Cold medication. I appreciate the opportunity to share with you my concerns and look forward to your response.
Sincerely,
Gary D. Gin, MD, MPH
Chief, Division of Pediatric Primary Care
California Pacific Medical Center
Editors’ Notes:
The article featuring Dr. Marvin Auerbach in the last Chapter I News Update originally appeared in The Bulletin, the official publication of the San Mateo County Medical Association, November 1996, Vol. XLV, No. 10.
Monterey Conference
Come to Monterey!
May 24-26, 1997
Speakers will be:
Bradley Chipps,
MD
Allergy and Pulmonary Consultant
Private Practice
Sacramento
Gabriel Escobar,
MD
Investigator, Division of Research
Kaiser Permanente
Oakland
Lewis First, MD
Chair, Department of Pediatrics
College of Medicine
University of Vermont
Burlington
Alfred Lane, MD
Professor of Dermatology and Pediatrics
Chairman, Department of Dermatology
Stanford University School of Medicine
Stanford
Stephen Ludwig,
MD
Professors of Pediatrics
University of Pennsylvannia School of Medicine
Associate Chairman for Medical Education
Children’s Hospital of Philadelphia
Philadelphia
Peggy Weintraub,
MD
Clinical Professor of Pediatrics
University of California School of Medicine, San Francisco
Department of Pediatrics
San Francisco
11 Hours of CME
Credit
Call for Brochure at:
(415) 459-4775
Topics include:
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