Ai�IERICAN ACADE1�1Y OF PEI)IATRICS

Vol. 10 No. 9March 1989

�22Pediatrics Review andEducation Program

259 #{149}Childhood Asthma: Management -

Goldenhersh and Rachelefsky

269 #{149}Suicide and Suicidal Behavior inChildren and Adolescents - Brent

277#{149}Child Care and the Pediatrician -

Aronson

Answer Key: 1.B; 2.D; 3.E; 4.A; 5.C; 6.C; 7.B; 8.C; 9.D; 1O.A; 11.D; 12.A;13.C.

Vol. 10, No.9, March 1989CONTENTS

Pediatricsin Review ARTICLES

.

EDITORRObert J. HaggertyNew York Hospital-CornellMedical CenterNew York, NY

Edftorlal Office:The William T. Grant Foundation515 Madison Ave. 6th Floor,New York, NY 10022-5403

ASSOCIATE EDITORR. James Mckay. JrMedical Center Hospitalof VermontBurllngton, VT 05401

ABSTRACTS EDITORRichard H. Rapkin, Newark, NJ

EVALUATiON EDITORWdIiam H. Milbum, Longmont, CO

MANAGING EDiTORJean Dow, Elk Grove Village, IL

ASSISTANT MANAGING EDITORJo A. Largent, Elk Grove Village, IL

EDITORIAL CONSULTANTVictor C. Vaughan III, Phlladelphia, PA

EDITORIAL BOARDRalph Cash, Detroit, MIDaniel D. Chapman, Mn Arbor, MIEven Chamey, Baltimore, MDRussell Chesney, Davis, CABarry Goldberg, Milford, CTAlan L. Goldbloorn, Toronto, ONFernando A. Guerra, San Antonio, TXEdward A. Jacobs, Arcadia, CAJ. Stephen Latimer, Bethesda, MDMelvin D. Levine, Chapel Hill, NCMarie C. MCCOrTTtiCk, Boston, MAKurt Metzl, Kansas City, MOLawrence F. Nazanan, Penfield, NYFrederick P. Rivara II, Seattle, WAWIlliam 0. Robertson, Seattle, WARon Rosenfeld, Stanford, CARobert Schwartz, Providence, RILonnie K. Zeltzer, Los Mgeles, CA

PUBLISHERAmerican Academy of PediatricsPenny Prettyman, Copy Editor

PEDIATRICS IN REVIEW(ISSN 0191-9601)is owned and

controlled by the American Academy of Pediatrics. It ispublished ten times a year (July through April) by the Amer-can Academy of Pediatrics, 141 Northwest Point Blvd. Elk

Grove Village, IL 60009-0927.Subscriptions will be accepted until December 31, 1988

for the 1988-89 cycle. Subscription price per year: Candi-date Fellow of the AAP $35.00; AAP Follow $60.00; Non-member or Institution $80.00. Current single issues $8.00.

Second-class postage paid at ELK GROVE VILLAGE,ILLINOIS 60009.0927 and at additional mailing offices.

© American Academy of Pediatrics, 1989All Rights Reserved. Printed in U.S.A. No part may be

duplicated or reproduced without permission of the Ameri-can Academy of Pediatrics.POSTMASTER: Send address changes to PEDIATRICS IN

REVIEW, American Academy of Pediatrics, 141 NorthwestPoint BIvd, Elk Grove Village, IL 60009-0927

259 Childhood Asthma: ManagementM. J. Goldenhersh and Gary S. RaChelefsky

269 Suicide and Suicidal Behavior in Children and

Adolescents

David A. Brent

277 Child Care and the Pediatrician

Susan S. Aronson

ABSTRACTS

268 Insulin-Dependent Diabetes Mellitus and Cognitive

Abilities

276 lgG Subclass Deficiency

287 Natural History of Nasolacnmal Duct Obstruction

275 Departments of Corrections

Cover: Boy With Baseball, by George Luks (American artist of the Ash Canschool-i 867-1933). Son of a physician from Williarnsport, PA, he studiedart in Philadelphia and Europe before settling in New York, where he worked

as a newspaper illustrator and cartoonist. Then he pursued a career as apainter. His work, like the other Ash Can artists, depiCted life in the raw.Boy With Baseball, done in the early 20th century, is illustrative of his work.This appealing portrait of a street urchin, done in broad brush strokes, witha baseball, symbolizes the all-American game. This is an appropriate motiffor PREP 2-year 4, when sports medicine and physical fitness are special

topics for review.

4’ � The printing and production of

______ Z Pediatrics in Review is made possible,

�. R os s ,� in part, by an educational grant fromj’ Ross Laboratories.

I

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The questions below should helpfocus the reading of this article.

1. What are the four major groups ofantiasthmatic medications?

2. What is the role of nebulized med-ications in the treatment of an acuteepisode of asthma?

3. What diseases or drugs tend toincrease serum theophylline levels?

4. What is the role of cromolyn so-dium in the treatment of chronicasthma?

5. When are corticosteroids indi-cated for childhood asthma?

EDUCATIONAL OBJECTiVES

Asthma is the most commonchronic illness in children. The foureducational objectives for 1988/89address only a small part of theknowledge that pediatricians needto diagnose asthma and managethese children affectively. This isthe second part of a two-part arti-cle, the first part of which appearedin last month’s issue of Pediatricsin Review. R.J.H.

The pediatrician should have:108. Appropriate familiarity withthe use of aerosol treatment ofacute asthma (Recent Advances,88/89).1 10. Appropriate understanding ofthe use of cromolyn sodium in thetreatment of chronic asthma (Re-cent Advances, 88/89).111. Appropriate appreciation ofthe advantages and disadvan-tages of the RAST test in manage-ment of allergic children (RecentAdvances, 88/89).112. Appropriate appreciation ofthe advantages and disadvan-tages of skin testing in manage-ment of allergic children (RecentAdvances, 88/89).

S e’f-Evaluat�on Quz- ANSWER. To obtain credit, record your answers on your quiz replyI U U cards (which you received under separate cover), and return theC ME Credit cards to the Academy. On each card is space to answer the

questions in five issues of the journal: CARD 1 for the July throughNovember issues and CARD 2 for the December through April

As an organization accredited for continuing medical education, issues. To receive credit you must currently be enrolled in PREP or� the American Academy of Pediatrics certifies that completion of the a subscriber to Pediatrics in Review-and we must receive both

self-evaluation quiz in this issue of Pediatrics in Review meets the cards by June 30, 1989.criteria for two hours of credit in Category I of the Physician’s Send your cards to: Pediatrics in Review, American Academy of

� Recognition Award of the American Medical Association and two Pediatrics, 141 Northwest Point Blvd, P0 Box 927, Elk Grove Village,hours of PREP credit. IL 60009-0927.

The questions for the self-evaluation quiz are located at the end The correct answers to the questions in this issue appear on theof each article in this issue. Each question has a SINGLE BEST inside front cover.

pediatrics in review #{149}vol. 10 no. 9 march 1989 PIR 259

Childhood Asthma: ManagementM. J. Goldenhersh, MD,* and Gary S. Rachelefsky, MDt

TREATMENT

The goals of childhood asthmatreatment are straightforward: facili-tation of parent/patient understand-ing and acceptance of the diseaseand prevention of patient physicaland emotional disability. Patient/fam-ily education should be instituted at

the time diagnosis is made, such thatthe patient and involved family mem-bers are familiarized with the short-

Part of this material was published previouslyin Siege/SC, Rachelefsky GS: Asthma in infantsand children, parts / and II. J Allergy Clinlmmunol 1985;76:1-14 and 1985;409-425.* Clinical Instructor of Pediatrics, Departmentof Pediatrics, Division of Allergy and Immunol-ogy, University of California, Los Angeles; Di-rector of Allergy Research Foundation, Inc, LosAngeles.t Clinical Professor of Pediatrics, Departmentof Pediatrics, Division of Allergy and Immunol-ogy, University of California, Los Angeles; Di-rector of Allergy Research Foundation, Inc.

term and long-term care that will benecessary. Setting realistic goals forasthmatic children that allow for anormal life-style (regular school at-tendance, participation in physical ac-tivities, etc) is helpful.

Successful management of child-hood asthma requires knowledge,experience, and time. The demandson the physician can be tremendous.Patient management will be dictatedby the age of the patient, the severityof the disease, and the social andfinancial resources of the involvedfamily. The pediatrician with extra ef-fort can provide appropriate care forthe child with mild asthma. The mod-erate to severe asthmatic child (par-ticularly those with evidence ofchronic obstruction) are probablybest managed by a team approach.Referral to a subspecialist who hasthe experience, updated knowledge,and time to institute both an educa-tional and treatment program willbenefit the patient with moderate tosevere asthma (Table 1). The subspe-cialist assists in appropriate alterationof treatment plans in accordance withpatient progress and may serve as auseful advisor to the pediatrician. Pa-tient compliance and commitment arevital to the successful attainment oftreatment goals. Generally, the asth-matic child, if well managed, will beable to participate in school and phys-ical activities without restriction.

General Measures

The specific therapy for asthmaconsists of four major treatment mo-dalities: (1) avoidance of or decreased

exposure to known asthma aggra-vators (environmental control, non-specific irritants), (2) pharmacologicmanagement, (3) specific immuno-therapy (hyposensitization), and (4)self-management. As stated before,

ALLERGY

pediatrics in review #{149}vol. 10 no. 9 march 1989 PIR 267

agement/educational programs areavailable in many communities. TheS pediatrician must make his or her pa-tients aware of them and encouragetheir participation.

Physical Exercise. Many yearsago, the asthmatic child was rele-gated to the role of “bench warmer”in active sports. This is no longerbelieved to be necessary; in fact,physical training should be encour-aged. Studies have shown that im-proved aerobic fitness, while not sub-stantially altering the forced vital ca-pacity, forced expiration volume in 1second, and midexpiratory flow rate,may lead to better exercise toleranceand less exercise-induced asthma.Theoretically, decreased hyperventi-lation associated with increasedaerobic fitness results in less airwaycooling, less change in osmolarity,and thereby less bronchial constric-tion. Benefits of physical training notonly include physical fitness but“emotional fitness” as well. Childrenmay achieve more social acceptanceand psychologic strength throughteam-related interactions.

Although the asthmatic child mayS freely select any sport, certain athleticactivities are known to cause lessbronchial reactivity. Swimming, sprintor short burst-type exercises, and in-termittent athletic activities (baseball,wrestling, etc) are said to be lessasthmagenic. Generally, asthmaticchildren should begin with a warm-upperiod (15 to 20 minutes with slowincrease in exercise intensity) beforestarting intense or prolonged athleticactivity.

Formal breathing exercises havebeen shown to benefit some adultswith asthma. Relaxation training(slow, full excursion diaphragmaticbreathing) may be of help in calmingthe asthmatic child who panics whenfeeling slightly hungry for air.

REFERENCES

i . Murray AB, Ferguson AC: Dust-free bed-rooms in the treatment of asthmatic chil-dren with house dust or house dust miteallergy: A controlled trial. Pediatrics1983;7i :4i 8-423

2. Lawlor GJ Jr, Tashkin DP: Asthma, inLawlor GJ Jr, Fischer TJ (eds): Manual ofAllergy and Immunology, ed 2. Boston,Little, Brown & Co, i988

3. Greenberger PA: Asthma management, inPatterson R (ed): Allergic Diseases, ed 3.Philadelphia, JB Uppincott, i985, pp 304-357

4. Weinberger M: The pharmacology andtherapeutic use of theophylline. J AllergyClin Immunol i984;73:525-540

5. Eitches RW, Rachelefsky GS, Katz RM,et al: Methylprednisolone and troleando-mycin in the treatment of steroid-depend-ent asthmatic children. Am J Dis Childi985;i 39:264-268

6. Haas A, Stiehm ER, Rachelefsky GS, etal: Status asthmaticus-A housestaffmanual. J Pediat Asthma Allergy Immunoli987;i :231 -239

7. Rachelefsky GS: Workshop on asthmaself-management. J Allergy Clin lmmunoli 987;80:487-5i 4

SUGGESTED READING

Mansmann HC Jr, Bierman CW, Peariman DS:Treatment of acute asthma in children, inBierman CW, Peariman DS (eds): AllergicDiseases From Infancy to Adulthood, ed 2.Philadelphia, WB Saunders Co, 1 988, chap42

Rachelefsky GS, Siegel SC: Asthma in infantsand children, part II. J Allergy Clin Immunoli985;76:409-425

Siegel SC, Rachelefsky GS: Asthma in infantsand children, part I. J Allergy Clin Immunoli985;76:i -i4

Tinkeiman DG, Falliers CF, Naspitz CK (eds):Childhood asthma pathophysiology andtreatment, New York, Marcel Dekker, i987

Self-Evaluation Quiz

1. Each of the following is included in thefour major groups of antiasthmatic medica-tions, except:

A. fl-agonists.B. Calcium channel blockers.

C. Cromolyn sodium.D. Theophylline.E. Corticosteroids.

2. True statements about nebulization ther-apy for acute asthma include each of thefollowing, except:

A. It is adaptable to all age groups.B. Nebulized i�-agonists are as efficacious

as subcutaneously administered adrena-lin.

C. Continuous nebulization of a fl-agonist issometimes appropriate for patients withstatus asthmaticus.

D. Inhaled corticosteroids are beneficial mi-tial management.

E. Aerosolized anticholmnergic agents aresometimes helpful when there is a poor

response to fl-agonmsts.

3. Each of the following tends to increaseserum theophylline levels, except:

A. Febrile viral infections.B. Reduced liver function.C. Congestive heart failure.D. Erythromycin.E. Phenytomn (Dilantin).

4. Each of the following is a true statementpertaining to cromolyn sodium, except:

A. It works only for asthma due to allergies.B. It is equally as effective as theophylline in

the management of chronic mild asthma.C. It may be nebulized simultaneously with

a /3-agonist.D. It is particularly useful in the prophylactic

treatment of asthmatic infants.E. It inhibits both the early and late phase

asthmatic responses.

5. Which of the following would be leastlikely to be an indication for corticosteroidtherapy in childhood asthma?

A. Severe asthma.B. Prevention of adrenal insufficiency in a

physiologically stressed child who has re-ceived steroids in the recent past.

C. Mild intermittent asthma.D. Improving asthma control prior to sur-

gery.E. Diagnostic fixed obstruction unrespon-

sive to bronchodilators.

BEHAVIORAL PEDIATRICS

pediatrics in review #{149}vol. 10 no. 9 march 1989 PIR 275

1 1 . Brent DA, Crumnne PK, Varma RR, et al:Phenobarbital treatment and major do-

S pressive disorder in children with epilepsy.Pediatrics 1987;89:909-91 712. Salk L, Lipsitt LP, Stumer WQ, et al: Re-

lationship of maternal and perinatal con-ditions to eventual adolescent suicide.Lancet 1 985;1 :624-627

13. Robins LN: SuicideAttempts in Teen-AgedMedical Patients. Proceedings of the Na-tional Institute of Mental Health/Centersfor Disease Control Conference in YouthSuicide. Washington, DC, Public HealthService, in press, 1989

14. Garflnkel B, Froese A, Hood J: Suicideattempts in children and adolescents. AmJ Psychiatry 1982;139:1257-1261

15. Rosenthal PA, Rosenthal 5, Doherty MB,et al: Suicidal thoughts and behaviors indepressed hospitalized preschoolers. AmJ Psychotherapy 1986;40:201-212

1 6. Pfeffer CR: The Suicidal Child. New York,The Guilford Press, 1986

1 7. Hibbard RA, Brack CJ, Rauch 5, et al:Abuse, feelings, and health behaviors in astudent population. Am J Dis Child1 988;1 42:326-330

18. Otto V: Suicidal acts by children and ado-lescents: A follow-up study. Acta Psy-chiatr Scand 1 972, vol 233 (suppl)

19. WeIner A, WeIner Z, Fishman R: Psychi-atric adolescent inpatients: Eight to ten-

year follow-up. Arch Gen Psychiatry1979;36:689-700

20. Rotheram MJ: Evaluation of imminent dan-ger for suicide. Am J Orthopsychiatry1 987;57:1 02-110

Self-Evaluation Quiz

6. During the past three decades, the mostmarked increase in suicide rate has oc-curred among:

A. Preadolescents.B. 1 0- to 1 4-year-old boys and girls.

C. 1 5- to 1 9-year-old boys.

D. 1 5- to 1 9-year-old girls.

7. In the United States, the most commonmethod for suicide among adolescents is:

A. Use of poison.B. Use of firearms.C. Hanging.D. Jumping from a height.E. Inhalation of carbon monoxide.

8. In adolescents, suicide is most often as-sociated with:

A. Schizophrenia.B. Bipolar depression.C. Unipolar depression.

0. Impulsivity in a previously well child.

E. Sexual abuse.

9. Of the following, the medical conditionhaving the closest association with suicidein children and adolescents is:

A. Cystic fibrosis.B. AIDS.C. Cerebral palsy.D. Epilepsy.

10. A 15-year-old girl, following a quarrelwith her mother, notified her mother that shehad swallowed ten adult aspirin tablets andwants to die. Her mother calls you In greatdistress and asks for advice. It is I 1 � Themost appropriate procedure would be to ad-vise:

A. That the girl be taken immediately to the

emergency room, where you will examineher.

B. That the amount taken is not likely to beharmful and that she need not be seen

before morning.C. That ipecac be given immediately, and

the mother should report the contents ofthe vomitus.

D. The mother to be bring the girl to youroffice immediately, where you will meetthem.

Department of Corrections

In the article by Risser in the November 1 988 issue of Pediatrics in Review, (vol 10,No 5), “Exercise for Children,” the sentence on page 1 32 should read: “The AAP isagainst trampoline use in all athletics.”

TABLE 6. Health Concerns forChild Care Programs

Routine child health care, screen-ing, medical evaluation, andtreatment

Care for children with special healthproblems

Care of ill children in the child careprogram

Dental health and hygieneHealth records for children, staff,

and volunteersHealth education for children, staff,

volunteers, and parentsStaff health and mental healthFirst aidEmergency, evacuation, and dis-

aster plansEnvironmental quality (heating,

lighting, ventilation, humidity)Safety (hazard surveillance and

staff procedures for the childcare facility, playground, andtransportation)

SanitationNutrition and food serviceHealth policies and proceduresLinkages with community re-

sources for health care andhealth advice

Child Care

PIR 286 pediatrics in review #{149}vol. 10 no. 9 march 1989

child care program policy is involved,if these differences cannot be recon-ciled by discussion among the differ-ing pediatricians, a pediatrician con-sultant to the program may need tomediate, decide for the program, orask the public health authority for an“official” view.

Advocate for Improved Child Carein the Community

At the community level, pediatni-cians can help alert parents and com-munity leaders about inadequatechild care program-licensing stand-ards, inadequate inspection routines,and underground child care opera-tions that need to be investigated bythe authorities. If caregiver training isnot readily available, a pediatricianmight offer an evening session for

local child care providers to gather atthe pediatrician’s office or anotherconvenient spot to talk about healthconcerns. Health concerns in childcare programs can cover a broadrange of topics (Table 6). This specialinterest and attention from a pediatni-cian will not go unnoticed by childcare personnel who frequently adviseparents about good sources for childhealth care.

SUMMARY

Working parents and child careprograms are here to stay. The pe-diatnician has many opportunities toadvocate for children concerningchild care, both in encounters withparents in the office and in rolesplayed in the community. By focusingattention on the determinants of thequality of child care, the pediatriciancan minimize the risks and enhancethe potential benefits of child careprogram participation.

SUGGESTED READING

American Academy of Pediatrics, Committeeon Early Childhood, Adoption, and Depend-ent Care: Health in Day Care: A Manual forHealth Professionals. Elk Grove Village, IL,American Academy of Pediatrics, 1987

American Academy of Pediatrics, Committeeon Infectious Diseases: Report of the Corn-rnittee on Infectious Diseases, Redbook. ElkGrove Village, IL, American Academy of Pe-diatncs, pt 2 (pp 61 -68), pt 3, 1988

Aronson 5, Gilsdorf J: Prevent and manage-ment of infectious diseases in day care. Pe-diatr Rev 1986;7:259-268

Guttentag RE: From another perspective. Zeroto Three 1987;8:21

Infant Day Care: A Continuing Dialogue. Zeroto Three, $4 from the National Center forClinical Infant Programs, 733 1 5th Street,NW, suite 91 2, Washington, DC 20005,1987

Whose Hands? A Demographic Fact Sheet onChild Care Providers. Washington, DC, Na-tional Association for the Education ofYoung Children, publication No. 760, 1985

Phillips D: Quality in Child Care: What DoesResearch Teil Us? Washington, DC, NationalAssociation for the Education of Young Chil-dren, Research Monographs, vol 1 , 1987

Scan’ 5, Phillips D, McCartney K: Facts, Fan-tasies, and the Future of Child Care in Arner-ica, manuscript available from Sandra Scarr,PhD, Department of Psychology, University

of Virginia, Charlottesville, VA 22903, 1988Who’s Minding the Kids? Child Care Arrange-

ments: Winter 1984-85, US Bureau ofCensus, Current Population Reports, senP-70, No 9. Government Printing Office,1987

Wilier B: The Growing Crisis in Child Care:Quality, Cornpensation, and Affordability inEarly ChildhoodPrograrns. Washington, DC,National Association for the Education ofYoung Children, June 1987

Self-Evaluation Quiz

1 1. True statements pertaining to child careinclude each of the following, except:

A. Most of the increase in early childhoodprogram attendees is related to increasedmaternal employment.

B. Pediatricians should provide informationto parents about how to look for good

child care.C. infants in child care have more infections

than those cared for only at home.D. All states require every day-care home to

be licensed and routinely inspected.E. Dual income families and single working

parents are now in the majority.

12. True statements about the benefits ofchild care programs include each of thefollowing, except:

A. The incidence of reported child abuse byan unrelated caregiver is greater thanabuse by family members.

B. Child care programs are helpful in thprevention and treatment of child abuse.

C. Good programs provide parenting infor-mation and support for inexperienced par-ents.

D. Children who attend licensed programsare better immunized than children whodo not attend child day care.

E. Parents with satisfactory child care ar-rangements are more loyal and produc-tive employees.

13. True statements about injuries in childcare programs include each of the following,except:

A. More than one half occur on the play-ground.

B. Most severe injuries are associated withfalls.

C. Injury rates are higher than those of chil-dren in general.

D. Toddlers have the highest frequency ofinjury.

E. The majority of injuries are the combinedresult of unrecognized hazards and gapsin supervision.