Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

I have often noted in these columns that I came from an era before the discovery of antibiotics. We were, I believe, very skillful at diagnosis but woefully lacking in treatment. As interns and residents, we were taught how to lance retropharyngeal abscesses, holding the children upside down to prevent inhalation of pus. We practicing pediatricians carried myringotomy knives in our bags and used them frequently. We were capable of diagnosing scarlatina - many children developed nephritis and occasionally a child would die of this disease. I remember diagnosing a case of "black measles" and sending the child to the Rockefeller Institute where in spite of all their efforts, the boy died. I could go on and on - there is so much to remember during that age of medical helplessness.

In the late 1930s, a new drug, sulfonilamide was formulated and the world of chemotherapy was opened. Suddenly, almost overnight, our hands were untied in the treatment of bacterial infections. Every modern pediatrician knows the rest of this story. Now almost all bacterial infections have been conquered even though we still have certain viral infections to overcome.

Accurate diagnosis and effective treatment of any disease or abnormality is only part of any scientific approach to a medical problem. Of greatest importance is prevention, and this is most vital in the case of infection.

The close relationship between malnutrition and infection has been demonstrated in many areas of the world where protein calorie starvation is prevalent. Malnutrition is only one, but a most important, factor in breaking down the body's barriers against infection; and infection, in turn, further damages the nutritional state.

The human body has many defenses against infection, including the skin and mucous membranes, cell mediated and humoral immunity, the complement system and phagocytic activity.

A careful review of the effect of malnutrition on the various body defenses is presented in the first article in this symposium. "Nutrition, Infection and Immunity" studies each of the body's defenses when malnutrition affects the human being.

The authors are all from the Nutrition-Infectious Disease Unit, Division of Pediatrie Infectious Diseases and Nutrition Pathology of the Boston University School of Medicine. They are Dr. Jose Ignacio Santos, Assistant Professor of Pediatrics and Pathology; Dr. Jose Louis Arredondo, Fellow in Pediatrie Infectious Disease and Nutrition Pathology; and Dr. Joseph J. Vitale, Professor of Pathology and Associate Dean for International Health.

It seems simplistic, but it is nevertheless true that if we were, in the future, able to overcome malnutrition we would radically cut down the mortality and morbidity due to infections throughout the world.

This is conceivable if the countries of the world work together. Other problems, such as neonatal sepsis, acute bacterial pharyngitis, and otitis media, do not seem as easy to solve. But I remind myself that I am living in a time when smallpox, a deadly and frequent disease, has been overcome, and when tuberculosis has been largely vanquished.

Neonatal sepsis is a difficult condition to forecast, although once diagnosed it can be treated fairly successfully. I can foresee that someday we will be able to treat or vaccinate preterm mothers against the most common infectious agents - streptococcus Group A and Escherichia coli.

A few years ago on the island of Haiti the native women gave birth to their babies following the customs of ancestors. The women would squat out in the open when giving birth while their "midwives" and older women aided. When the baby was born those attending the mother would get two rocks from the side of the road and sever the cord by grinding the…

I have often noted in these columns that I came from an era before the discovery of antibiotics. We were, I believe, very skillful at diagnosis but woefully lacking in treatment. As interns and residents, we were taught how to lance retropharyngeal abscesses, holding the children upside down to prevent inhalation of pus. We practicing pediatricians carried myringotomy knives in our bags and used them frequently. We were capable of diagnosing scarlatina - many children developed nephritis and occasionally a child would die of this disease. I remember diagnosing a case of "black measles" and sending the child to the Rockefeller Institute where in spite of all their efforts, the boy died. I could go on and on - there is so much to remember during that age of medical helplessness.

In the late 1930s, a new drug, sulfonilamide was formulated and the world of chemotherapy was opened. Suddenly, almost overnight, our hands were untied in the treatment of bacterial infections. Every modern pediatrician knows the rest of this story. Now almost all bacterial infections have been conquered even though we still have certain viral infections to overcome.

Accurate diagnosis and effective treatment of any disease or abnormality is only part of any scientific approach to a medical problem. Of greatest importance is prevention, and this is most vital in the case of infection.

The close relationship between malnutrition and infection has been demonstrated in many areas of the world where protein calorie starvation is prevalent. Malnutrition is only one, but a most important, factor in breaking down the body's barriers against infection; and infection, in turn, further damages the nutritional state.

The human body has many defenses against infection, including the skin and mucous membranes, cell mediated and humoral immunity, the complement system and phagocytic activity.

A careful review of the effect of malnutrition on the various body defenses is presented in the first article in this symposium. "Nutrition, Infection and Immunity" studies each of the body's defenses when malnutrition affects the human being.

The authors are all from the Nutrition-Infectious Disease Unit, Division of Pediatrie Infectious Diseases and Nutrition Pathology of the Boston University School of Medicine. They are Dr. Jose Ignacio Santos, Assistant Professor of Pediatrics and Pathology; Dr. Jose Louis Arredondo, Fellow in Pediatrie Infectious Disease and Nutrition Pathology; and Dr. Joseph J. Vitale, Professor of Pathology and Associate Dean for International Health.

It seems simplistic, but it is nevertheless true that if we were, in the future, able to overcome malnutrition we would radically cut down the mortality and morbidity due to infections throughout the world.

This is conceivable if the countries of the world work together. Other problems, such as neonatal sepsis, acute bacterial pharyngitis, and otitis media, do not seem as easy to solve. But I remind myself that I am living in a time when smallpox, a deadly and frequent disease, has been overcome, and when tuberculosis has been largely vanquished.

Neonatal sepsis is a difficult condition to forecast, although once diagnosed it can be treated fairly successfully. I can foresee that someday we will be able to treat or vaccinate preterm mothers against the most common infectious agents - streptococcus Group A and Escherichia coli.

A few years ago on the island of Haiti the native women gave birth to their babies following the customs of ancestors. The women would squat out in the open when giving birth while their "midwives" and older women aided. When the baby was born those attending the mother would get two rocks from the side of the road and sever the cord by grinding the rocks together with the cord between them. Then they would tie the cord with a piece of nearby grass and dry the cut end of cord with soil.

Many of the newborns developed tetanus and died from this practice.

Attempts by physicians to change these tribal habits failed. Then they gave the mothers tetanus toxoid p rena ta Uy, and this prevented the onset of the disease among the newborns.

Perhaps the future will hold something of this nature for the unborn child, protecting it from specific bacterial infections.

The second paper in this symposium is on the "Management of Neonatal Sepsis and Meningitis." It is written by Dr. Jerome O. Klein and Dr. Hanspeter G nehm. Dr. Klein, one of the nation's outstanding authorities on infectious diseases, is Professor of Pediatrics at the Boston University School of Medicine and Director of the Maxwell Finland Laboratory for Infectious Diseases of the Boston City Hospital. He is the Guest Editor of this issue of Pediatrie Annals.

Dr. Gnehm has been a Research Fellow in Pediatrics at the Maxwell Finland Laboratory, and is now Assistant Director of the University Children's Hospital in Zurich, Switzerland.

The authors point out the high mortality of neonatal sepsis, especially if meningitis ensues. They divide the condition into two areas; early onset, and late onset disease, the mortality rate being higher in the former. The microbiology is described as well as the methods of diagnosing the infection.

The remainder of the article is given to an excellent and complete discussion of therapy. This includes the initial treatment, the determination of dosage schedules, and the duration of therapy.

This authoritative paper should be carefully read and filed for reference by all pediatricians who treat newborns.

The third paper deals with modern concepts in diagnosis and treatment of otitis media. It is authored by Dr. Stephen I. Pelton, Associate Professor of Pediatrics, and Dr. Patricia Whitley, Assistant Professor of Pediatrics, both of the Maxwell Finland Laboratory for Infectious Diseases of the Boston University School of Medicine,

This article covers a condition very frequently encountered by all pediatricians. It considers and answers most of the questions faced. Most pediatricians treat acute otitis media with antibiotics and decongestants or antihistamines. But what do we know about the value of the decongestants and antihistamines, and can you treat the condition effectively with antibiotics without knowing the infecting organism?

Many of us have worried that if an ear effusion lasts for weeks it could permanently damage hearing. A great many ear specialists have been advising myringotomy with tube insertion to relieve the effusion. Is this a necessary procedure? Should adenoidectomy be prescribed? These are among the many questions asked and answered in this very informative article.

The next two articles in the symposium deal with changes in the infectious environment of infants and children due to social and political changes.

The rising tide of feminism has brought many young women into business and professional life. Whether they have their children before 30 years of age or between 30 and 40 years the majority of these mothers will continue to work after their children are born. The young children are placed in day nurseries where at an early age they are exposed to and endure frequent intercurrent infections.

This subject of communicable diseases in day care centers is discussed in the next paper written by Dr. Cynthia E. Trumpp, Assistant Professor of Pediatrics of the Boston University School of Medicine, and Medical Director, Community Infectious Disease Epidemiology of the Department of Health and Hospitals of the City of Boston. Her co-author is Dr. Raymond Karasic, Research Fellow in Pediatrie Infectious Diseases at the Boston City Hospital.

The authors describe why these young children are especially susceptible and discuss the most frequent infectious organisms and communicable diseases to which the children are exposed.

Many pediatricians are involved in the care of infants and young children attending day care centers. A problem which frequently confronts them is when these children should be excluded from attending the facility. The authors specify which children with upper respiratory infections may be permitted to attend. I find it interesting and somewhat questionable that on the basis of their studies they permit afebrile children with upper respiratory infections to attend and that, in their opinion, fever alone is not a contraindication to attendance.

The organisms most responsible for upper respiratory infections are considered, with the most effective antimicrobial agents. Diarrheal illness is also discussed as are outbreaks of hepatitis A.

The authors emphasize that the epidemiology in a day care center differs considerably from that of nursery schools and kindergartens.

The final paper in this symposium is political in origin and is causing a new awareness by pediatricians in many areas of the country. It relates to "Infectious Disease Problems in Indochinese Refugees" and has been written by Dr. Barry Dashefsky, Assistant Professor of Pediatrics at the Boston University School of Medicine, and Dr. David W. Teele, Associate Professor of Pediatrics at the Boston University School of Medicine, both of the Maxwell Finland Laboratory for Infectious Diseases.

The authors point out, at the outset of their article, that 500,000 Indochine se refugees have settled in the United States since 1975, and that the government has committed itself to absorb 168,000 Indochinese refugees annually.

These new immigrants are checked by the US Public Health Service and their reports have been reassuring. The refugees are generally healthy, and free of any unusual or exotic diseases, and no outbreaks of infectious diseases have been attributable to them.

There are, however, certain infectious disease problems that may be found among these immigrants, diseases with which American pediatricians have had little experience. Such conditions include tuberculosis, infections with parasites or protozoans, malaria and venereal diseases. There are also less common conditions such as tapeworms, trichinosis and filariasis. Many children and adults have been incompletely immunized.

Most modern pediatricians have an understanding of the routine treatment of tuberculosis. However, as pointed out in this article, one-third of the cases of tuberculosis in Indochinese refugees were found to be resistant to one or more of the standard drugs used in treatment of the disease. Guidelines for anti-tuberculosis therapy among the refugees are presented.

The frequency of intestinal parasites is also reported - with 80% of the refugees having at least one parasite, and 55% having more than one. Many of these parasites may cause no symptoms in the individual harboring them; but they may produce some adverse effect on the community. This is especially true of giardia and E. histolytica.

One by one Dr. Dashefsky and Dr. Tecle review the various parasites which may be found, with brief diagnostic features and therapy.

The subject of malaria is fully covered since its incidence has recently been rising in the United States. This should not be overlooked when examining any Southeast Asian child with unexplained fever and who may have one or more of the following symptoms: splenomegaly, anemia, chills, headache and malaise. Treatment of this disease is reviewed.

Acute and chronic hepatitis B virus infections are next considered since these frequently occur among the refugees who, though often asymptomatic, may be carriers. An interesting portion of the article discusses neonates bora to mothers with either acute or chronic hepatitis B. How should one treat such babies? May they be breast-fed? The authors state that present studies will suggest immunization of such neonates with hepatitis B vaccine.

The lack of adequate immunization is also noted. Although primary vaccinations and immunizations were started in Asian transit camps many are still incomplete and must be followed through by American physicians.

The article concludes by advising an anticipatory and sympathetic approach to both the emotional and the physical problems of these people uprooted from their homelands.

10.3928/0090-4481-19830301-01

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