John L. Ey

Recurrent Group C Streptococcal Tonsillitis in an Adolescent Male Requiring Tonsillectomy

A 15-year-old boy had repeated episodes of tonsillitis with group C strepto cocci over a four-month period. The tonsillitis cleared with antibiotic therapy but was followed by a recurrence within a few days. Tonsillectomy resulted in a permanent cure and group C streptococcus was found in the tonsils. A literature search has failed to reveal similar cases and a brief review of the existing literature is given.

The influence of preschool pertussis immunization on an epidemic of pertussis

Between 1988 and 1989 there were 896 reported cases of pertussis in Arizona. Of the 781 investigated cases 55 were identified in children younger than 5 years of age. Thirty-five percent of children between 6 months and 5 years of age were not fully immunized; 3 infants died. Approximately 50% of infected children between 5 and 14 years of age had not received 5 doses of pertussis vaccine. Of the 413 physician respondents to a questionnaire, fully 10% do not administer pertussis vaccine to preschool children because of parental, personal or other reasons. We hypothesize that the reservoir of pertussis-susceptible older children and young adults is augmented by this omission of the fifth diphtheria-tetanus toxoids-pertussis vaccine. Newer educational and vaccine strategies are necessary to prevent epidemics of pertussis.

Pediatric emergency training: An alternative teaching-patient care model

We describe a cost-effective alternative to the pediatric and general emergency department (ED), the emergent/urgent care clinic (EUC). The vast majority of pediatric Medicaid-eligible patients are rerouted from the ED to the EUC, where they receive care from pediatric residents and faculty. A retrospective analysis of patient encounter forms from two EUCs was performed. The type and distribution of diagnoses at the EUCs were comparable with published data from pediatric and general EDs. The cost of care in the EUC is significantly less than that in the ED, although the educational opportunities for house staff and patients are superior to those obtained in the traditional ED setting. A patient population that historically seeks episodic care in EDs is provided with continuity of care and disease prevention through screening, guidance, and up-to-date immunizations.

Lactose Deficiency in Infants

to milk protein. Cow’s milk protein in the mother’s diet does end up in breast milk in sufficient amounts to cause symptoms in an intolerant baby. Babies being fed regular formulas, which are made from cow’s milk, are receiving large amounts of cow’s milk protein. It is believed that about 2% to 7% of infants have this problem, which, unlike lactose intolerance, tends to go away. (Many babies outgrow cow’s milk intolerance by the age of 6 months, even more by 1 year of age, and nearly all by the time they are 2.) Many, but not all, babies who are intolerant to cow’s milk are also intolerant to soy—approximately 20% to 30%. This means, though, that the majority of babies with this problem do just fine when there is no longer any cow’s milk protein in their mother’s milk or, in the case of formula-fed infants, when they are switched to a soy formula. For those who react to soy, other, more specialized (and more expensive) formulas are available. Actual allergy to cow’s milk protein is less com

Office laboratory procedures, office economics, patient and parent education, and urinary tract infection

This section updates the reader on four important areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infections. Dr. Michael Aldous reviews the recent literature about office laboratory procedures, including the continued impact of the Clinical Laboratory Improvement Ammendments, what is new in the diagnosis of streptococcal pharyngitis, urinalysis improvements, the diagnosis of anemia, and which patients should undergo cholesterol screening. Dr. Rickey Williams discusses the literature on office economics, including new technology for billing and charting, whether pediatricians should bill for telephone calls, and the latest information on health care policy and the changes offices are facing with the growing managed care market. Dr. Burris Duncan reviews patient and parent education, including new apporaches to infant colic, sleep positioning for the prevention of sudden infant death, the need for the hepatitis B vaccine (which has been slowly implemented), and finally ways that pediatricians can help with parenting. Dr. John Ey discusses the recent literature on urinary tract infections in children, including better ways of making the diagnosis, whether there are any new treatment approaches for urinary tract infections, useful investigational studies for evaluating the urinary system, and how best to follow up children with infected urinary tracts. We hope that this review will help the practicing pediatrician to better care for patients and provide each of you with a greater satisfaction in delivering health care in an office setting.

Office laboratory procedures, economics of practice, patient and parent education, and urinary tract infection.

This review highlights recent advances in four major areas that are relevant to office practice: office laboratory procedures, economics of practice, adolescent risk-taking behavior in terms of sexually transmitted diseases, and urinary tract infections. Who should be screened for diseases and where these screening tests should be done are addressed, keeping the practicing pediatrician in mind. Next we review current office economics, including whether professional courtesy should be continued, how our practices are going to be increasingly influenced by guidelines developed by the American Academy of Pediatrics, the Clinical Laboratory Improvement Amendments, and the new Clinton Health Plan if it survives Congress, and finally how all of these issues will affect our expected income in the years ahead. As pediatricians strive to retain adolescent patients in their practices, they will need to find appropriate ways of counseling these patients concerning risk behaviors that could result in sexually transmitted diseases or HIV infections. Should we leave the comfortable confines of our offices to participate in these counseling programs for adolescents, and are there lessons from existing successful International Health Programs that we can use? Finally, urinary tract infections (UTIs) continue to be a common cause of childhood infections with possible serious long-term sequelae. Can we do a better job of diagnosing UTIs, has improved treatment become available, and is prevention of recurrences possible? Once the diagnosis has been made, how can we best evaluate these children with UTIs for underlying urologic abnormalities? It is our hope that the practicing pediatrician will be better prepared to face these issues having read this review.

Protect Yourself and Your Baby From Whooping Cough

dehydration because the sick child loses interest in food and drink. Although whooping cough is no picnic at any age, young infants are the most at risk from this disease. In addition to dehydration and weight loss, infants can develop seizures, swelling of the brain, or pneumonia as complications of pertussis. Prolonged coughing spells can deprive them of adequate oxygen. Death can occur in infants, as well. In 2004, there were 24 deaths from pertussis in babies less than 3 months of age (and 3 in children older than 3 months). In 2005, there were 32 deaths in young infants (and 7 in those older than 3 months). Adolescents and adults with pertussis generally miss school or work. They can develop pneumonia or can crack a rib from coughing, even without a complicating bacterial infection. They can be sick for 2 or 3 weeks, or their illness may linger for 3 or 4 months (the Chinese call whooping cough the “hundred-day cough.”) Adolescents and adults are the primary source of infection for young babies because the immunity obtained from the preschool series of pertussis vaccinations only lasts for about 6 years. Even the immunity acquired from the natural infection wanes after about 6 years. Once someone is diagnosed with pertussis, they are asked to avoid contact with other people and especially with young infants, but a diagnosis of pertussis is not even considered until symptoms begin getting worse instead of better at about 2 weeks into the illness. The infection is most contagious in the entire first 2 to 3 weeks. It is wise to keep people with mild cold symptoms away from your young infant even if a cold is all you think they have. But what if the person with mild cold symptoms is you . . . or his/her father . . . or his/her siblings? (Studies have suggested that mothers are responsible for nearly one-third of pertussis cases in their babies.) Dear Dr Sue:

Ask Dr. Sue: Fluoride Supplementation

and makes them more resistant to tooth decay. Topical fluoride is available in many toothpastes, in certain mouth rinses, and in applications that your dentist can apply himself. When fluoride is taken by mouth, it can actually become part of teeth that are still forming. Also, when taken internally, fluoride is present in your child’s saliva, which continually bathes the teeth and provides constant topical application. Fluoride, like all dietary supplements, should be taken only in recommended amounts. Too much fluoride can cause fluorosis, a condition in which the teeth have a mottled appearance. This condition is not felt to be dangerous to your child, but severe cases can be very unappealing. (Mild fluorosis usually causes tiny white specks or streaks, but severe fluorosis can cause the teeth to be pitted, rough, and hard to keep clean.) Severe fluorosis usually occurs in a child who is using fluoridated toothpastes and possibly swallowing a fair amount in addition to drinking fluoridated water and being given a supplement. If in doubt, you should confirm that there is no fluoride in your child’s drinking water before you give him a fluoride supplement. You should also supervise your young child’s use of fluoridated products. Children younger than age 3 should not use toothpaste with added fluoride; special toothpastes are available for their use. Once children reach the age of 3, they are usually better at spitting and not swallowing the paste. Even then, though, they should use only a pea-sized amount on their brush (not the large swirl they may see in the commercials). Children younger than age 6 should not use the special anticavity mouth rinses that contain fluoride. They can be helpful for older children, however. Ask your dentist if your child would benefit from one of these. Certainly, a large overdose of fluoride can occur if your child swallows the contents of an entire bottle Dear Dr. Sue:

Office pediatrics: Office laboratory procedures, Office economics, Patient and parent education, and Urinary tract infection

&NA; This section updates the reader on four important areas of office practice: office laboratory procedures, office economics, patient and parent education, and urinary tract infections. Dr. Micheal Aldous reviews the recent literature about office laboratory procedures, including the continued impact of the Clinical Laboratory Improvement Ammendments, what is new in the diagnosis of streptococcal pharyngitis, urinalysis improvements, the diagnosis of anemia, and which patients should undergo cholesterol screening. Dr. Rickey Williams discusses the literature on office economics, including new technology for billing and charting, whether pediatricians should bill for telephone calls, and the latest information on health care policy and the changes offices are facing with the growing managed care market. Dr. Burris Duncan reviews patient and parent education, including new apporaches to infant colic, sleep positioning for the prevention of sudden infant death, the need for the hepatitis B vaccine (which has been slowly implemented), and finally ways that pediatricians can help with parenting. Dr. John Ey discusses the recent literature on urinary tract infections in children, including better ways of making the diagnosis, whether there are any new treatment approaches for urinary tract infections, useful investigational studies for evaluating the urinary system, and how best to follow up children with infected urinary tracts. We hope that this review will help the practicing pediatrician to better care for patients and provide each of you with a greater satisfaction in delivering health care in an office setting.

Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media

OBJECTIVE This study was designed to assess the relation of exclusive breast-feeding, independent of recognized risk factors, to acute and recurrent otitis media in the first 12 months of life. METHODS Records of 1220 infants who used a health maintenance organization and who were followed during their first year of life as part of the Tucson Childrens Respiratory Study were reviewed. Detailed prospective information about the duration and exclusiveness of breast-feeding was obtained, as was information relative to potential risk factors (socioeconomic status, gender, number of siblings, use of day care, maternal smoking, and family history of allergy). Acute otitis media and recurrent otitis media, defined as three or more episodes of acute otitis media in a 6-month period or four episodes in 12 months, were the outcome variables. RESULTS Of the 1013 infants followed for their entire first year, 476 (47%) had at least one episode of otitis and 169 (17%) had recurrent otitis media. Infants exclusively breast-fed for 4 or more months had half the mean number of acute otitis media episodes as did those not breastfed at all and 40% less than those infants whose diets were supplemented with other foods prior to 4 months. The recurrent otitis media rate in infants exclusively breast-fed for 6 months or more was 10% and was 20.5% in those infants who breast-fed for less than 4 months. This protection was independent of the risk factors considered. CONCLUSION These findings suggest that exclusive breast-feeding of 4 or more months protected infants from single and recurrent episodes of otitis media.