Child Health ALERT

Volume 16 A Survey of Current Developments Affecting Child Health Care September 1997

Yes-Head Lice Can Be Resistant To Treatment!

When parents find out that their children have lice, their first reaction may be surprise or shock. Then they become anxious about how to eliminate this problem so their children can return to school or child care. In years ears past parents could reasonably expect that standard treatment which included pesiticide-containing shampoo and removing nits (lice eggs) - would eliminate the head lice. However, in more recent years, parents and health care professionals have been frustrated by their inability to control head lice epidemics through standard treatment; a number of people have suspected that head lice might have become resistant to these treatments. and it's now clear that resistance Is a real problem that may occur often.

Just as bacteria are becoming resistant to many of the antibiotics we commonly use, there also appears to be a growing problem of head lice becoming resistant to some of the agents (called pediculicides) that have been the mainstays of managing outbreaks. At this time, it's hard to know how widespread the problem is, but approaches that are used to control and treat head lice should take into account this possibility.

When a child needs to be treated for head lice with a pediculicide, parents should be sure to accurately follow the instructions that come with the product. It's important to understand that following these instructions is critical if the treatment is to be effective. However, because some lice may be resistant to one or another pediculicide, following instructions may no longer guarantee that the treatment will work.

The problem of resistant head lice has focused new attention off the importance of preventing head lice outbreaks in the first place. The National Pediculosis Association (NPA) is stressing the need for continuous and aggressive efforts aimed at early detection, and is challenging communities to go all out by following these points:

- Educate child care providers and parents in advance of outbreaks
- Know how to properly diagnose head lice
- Encourage routine lice screenings
- Promote early detection
- Institute a "No Nit" policy that stresses getting lice and their nits (eggs) completely out of children's hair
- Recognize that lice-killing products are pesticides
- Discourage use of environmental lice sprays and lindane-containing products
- Comb regularly as a part of routine hygiene (the NPA has introduced a new comb for this purpose. called the "Lice Meister")

Though some of these guidelines might seem burdensome and time consuming, they will pay off by reducing the risk of lice epidemics and unnecessary exposure to pesticides as well as by allowing parents and child care professionals to take control of a very disrupting and frustrating situation. The NPA offers the Lice Meister comb for $ 14.95 & S&H. and have a toll-free number available for orders only: 1-888-Lice Meister

RESOURCE

Resource: Making Smarter TV Watchers

Parents are frequently advised to carefully supervise their children's TV watching, but it's difficult to find guidelines that help in this important effort. A short new video, called "Taking Charge of Your TV", offers just that kind of guidance. Narrated by Rosie O'Donnell, it is designed to teach parents critical viewing skills and help them teach their children to be smarter TV watchers. The video was developed by the National PTA and the National Cable Television Association, and it has been endorsed by the American Academy of Pediatrics. "Taking Charge of Your TV" points out the fact that most programs are supported by advertisers who encourage children to buy their products; that most programs are pretend, not real; and that TV violence can have a negative impact on young children. The video is free, and can be obtained by calling 1-800 452-6351.

DIET & NUTRITION

Sorbitol And Diarrhea In Young Children

Sorbitol is a kind of sugar that occurs naturally in fruit, but it is also used in many "sugar-free" products such as chewing gums and candies. The reason sorbitol products are called "sugar-free" is because the sugar isn't absorbed from the intestine and therefore doesn't provide calories; however, because sorbitol isn't absorbed, large amounts can cause gas, bloating, cramps, and diarrhea. These effects are more severe as the dose of sorbitol increases. It's been estimated that diarrhea in a 3 year old child could be caused by about 4 pieces of sugar-free gum or breath mints, or 1 and 1/2 sugar-free lollipops. To determine just how frequently sorbitol might cause diarrhea in young children researchers first identified the amounts of sorbitol in sugar-free gums, mints, and dietetic candies, and found that gums and breath mints ranged from 1. 1 to about 2 grams of sorbitol per piece, and candy ranged from 1. 1 to 5.5 grams per piece.

Researchers asked parents of children in preschool child-care centers in Indiana and Michigan to complete a questionnaire about how often their children consumed sugar-free products and how often they had diarrhea without fever (the kind that might be caused by sorbitol). The study found a striking increase in sorbitol intake as children became older, from 9% among 1-year olds to 81 % among 5 year olds. They also found that in many children, diarrhea was related to the amount of sorbitol they ate.

They conclude that even the medical community may not be aware of how many episodes of diarrhea might be due to sugar-free products consumed by preschoolers. (Payne ML et al. Journal of the American Dietetic Association, May, 1997, pp. 532-534)

COMMENT: There's little question that sorbitol can cause diarrhea and other abdominal problems "'I young children. What surprised us was the large proportion of preschoolers, at least in these samples from Indiana and Michigan, who consume sorbitol products . If these findings are typical of other preschoolers, then half or more of 2and 3-year olds, and the large majority of A- and Midyear olds, are getting at least some sorbitol from sugar-free products. Add to this sorbitol from fruit and fruit juices (and even medications), and it becomes clear that a large number of young children are at risk for diarrhea and abdominal pains caused by this nonabsorbed sugar.

PARENT/CHILD

Is The World Wide Web A Reliable Place To Find Health Information?

The rapid growth of computer based electronic communication and the shift toward giving patients more responsibility for their health care decisions has led parents to look to the internet as a source of child health information. However. little had been done to check the quality of this medical information. In one recent study, researchers from Italy searched for parent--oriented web pages relating to home management of feverish children (using the Yahoo and Excite search engines and the keywords "fever management" and "child" and "parent information").

Of the 41 web pages they found, 32 were developed by commercial ventures and 9 by individual practitioners, clinics, academic institutions, or other educational organizations. Most (3 1) of the web pages were created by centers in the U.S., and English was used in 38 of the 41 pages.

When these researchers compared information provided on the web about fever management in children, they found that only four sites closely followed what the authors considered to be proper advice, and there were wide variations in the advice offered by the various web sites.

The authors conclude that "variability in both content and quality of medical information to the public" is not a problem limited to the internet, but this review "suggests that there is an urgent need to check public oriented health care information on the internet for accuracy, completeness, and consistency". (Impicciatore P et al: British Medical Journal, June 28, 199 7, pp. 1875-1881)

COMMENT: Having seen some of the medical information offered to parents on the internet, we've been waiting for someone to conduct this sort of analysis. The printed word, whether on a computer screen or on a page, appears to have special authority. However, when it comes to presenting medical advice to parents, no one needs a license. In theory. misinformation can come as easily from the printed word as from the web. In reality, however (or perhaps in virtual reality ). anyone who can set up a web page can also offer medical advice; on the other hand, the complicated process of publishing reduces the risk of incorrect medical advice appearing in print.

As parents increasingly use and rely on the internet, they will increasingly become potential victims of misinformation regarding their children's health. We would encourage those who do surf the web for child health information to focus on that which is provided by major academic medical centers.

ENVIRONMENT

Power Lines And Childhood Leukemia: Is The Issue At Last Resolved?

Almost two decades ago, it was first suggested that electromagnetic fields near homes may be linked to childhood leukemia. but results of studies conducted since then have been inconsistent A major problem has been how researchers have measured exposure to power lines. In an attempt to resolve that and other problems in this area of research, investigators from the National Cancer Institute (a branch of the National Institutes of Health) studied 638 children with acute lymphoblastic leukemia and a similar number of children who did not have leukemia. They took direct measurements of magnetic fields in the subjects' cur-rent and former homes, including the children's bedrooms and other sites.

The authors considered a number of situations where children might have been exposed to electromagnetic fields, including exposure in the homes where their mothers lived when they were pregnant with these study children, but they found that the risk of leukemia was not linked number of residential magnetic field levels. (Linet MS et al: New England Journal of Medicine, July 3, 1997, pp. 1-7)

... An Editorial View

An accompanying editorial reviews the 18-year history of this controversy, and points out that when something as widespread and misunderstood as these electromagnetic fields is accused of causing cancer in children, "people's reactions may be driven more by passion than by reason". The author argues that we should not overlook one important fact-that the electric energy we worry so much about is actually hundreds of times weaker than the energy produced by the Earth's magnetic field. The writer concludes that "in recent years, several commissions and expert panels have concluded that there is no convincing evidence that high-voltage power lines are a health hazard or a cause of cancer. And the weight of the better epidemiologic studies, including that by Linet et al., now supports the same conclusion." (Campion EW: New England Journal of Medicine, July 3, 1997, pp. 44-46)

COMMENT: This study is certainly considered one of the largest and best ever conducted on the subject, even by some who believe the link between power lines and cancer may be real. Further, the better studies, conducted more recently, have tended to be reassuring.

But will this end the debate? Not likely. At the same time this report was published, another journal was publishing a study from Sweden which again linked magnetic field exposure (among electrical workers) to leukemia. Though the Swedish study had lots of limitations, the fact that positive studies continue to appear means that the issue is far from dead.

What are anxious parents to believe? As we've noted before, when some studies identify relatively small risks and others (particularly the better ones) find none, it's reasonable to conclude that if there is indeed a risk, it is so small as to be almost immeasurable. What that means. in our view, is that rather than worrying about power lines and electromagnetic fields, parents would be better advised to concentrate factors their concerns on factors such-as immunizations and bike helmets) that we know will influence the health and safety of their children, both in the short and long term.

CHILDCARE ISSUES

Mary Ucci:
Back To School: A Challenge For Young Children, Parents And Teachers

The first days of school are filled with a mixture of high excitement and some anxiety for young children and their parents. As these initial few days pass, what should child-care providers know about children's ongoing adjustment to school?

Transitions from the fun and free schedules of summer to the structure of the school world are part of the human experience. Providers and parents need to view this important process as a valuable learning and growth opportunity. What should we expect at this time?

* Separation is a process, not an event. Children who seem to have successfully separated from their parents and seem to be fully involved in school activity are still dealing with separation issues. Children need transitional support for the first month or more. Give it time.

* Support and comfort can be physical, verbal, and environmental. Holding a baud and quietly reassuring children that you are going to care for them are obvious and basic supports. Equally comforting, though, are establishing clear routines and building classrooms that are organized, predictable, and developmentally appropriate. Offer comfort even if they look OK.

* Children need to trust that they are safe. It takes time to build a sense of trust in a new situation. Make sure that children know that there are fair rules for sharing and that you will help them learn to control their impulses. Children can relax, play, and learn only when they know they'll be safe. Make sure they know the rules and feel protected.

- Children need to understand the connection between school and home. Young children need to know that home and parents exist even though they cannot see them. They also trust a provider more quickly if that person shows some knowledge of their out of school life. A home visit of a few stories shared from parents can ease rough separations. A reference to children's summer camp, family pet, or even a new night light can let them see that you know them and like them. Make a connection to home.

- Separation anxiety can recur weeks after school begins. Young children sometimes regress in their development. Some have gotten past the first excitement and now really understand for the first time that they are actually coming to school every day-it's not like a weekend at Grammy's house. For others, something may have happened at home, like the birth of a new sibling, that causes them to return to the feelings of anxiety at being separated from parents at school. Watch for regression.

* Children show their anxiety in many different ways. Typically, they might cling to a parent, cry, show disinterest in playing, or ask frequently for their parents. Others might regress in their toilet training, experience eating problems. be more subdued or less active, or express more anger. Try to balance your enthusiasm over the beginning of school with some acknowledgement to the children that it may be hard to them. Watch for each child to respond differently to newness.

* The transition to school is not just about separation, it's about getting used to something new. All new experiences challenge children in many different ways-physically,. socially. emotionally, and cognitively. Parents and providers need to let children know that they have faith in the children's ability to cope with new situations. Coping is one of life's most valuable assets. Show that you value and respect coping with things that are new and different.

(Mary Ucci, who is Educational Director of the Child Study Center of Wellesley College, writes this periodic column on early childhood development; she welcomes questions from readers, which she will answer as space permits. Questions should be sent to her c/o CHILD HEALTH ALERT P.O. Box 610228, Newton Highlands, MA 02461.)

PRODUCT RECALLS

Recalls: Fisher-Price Toy Police Cars...

Fisher-Price, Inc., of East Aurora, NY, is recalling about 17,000 toy police cars that were sold since February, 1997. The back of some cars could crack and break apart, presenting a potential choking hazard to young children. The toy is part of a the Little People Roadside Rescue vehicle set, which includes one white and blue police car, one yellow tow truck, one red passenger car, three figures (an auto mechanic, police officer, and a driver), two orange traffic cones, one red stop sign, and one yellow yield sign. The police car is the only toy in the set that is involved in the recall.

The set is packaged in a cardboard box labeled, in part, "FisherPrice Little People Roadside Rescue... Ages 11/2-5 years... 72394". It was sold in major stores and mass merchandise outlets nationwide for about $8. Consumers should call Fisher-Price toll-free at 1-888 407-6479 to receive a replacement vehicle free of charge.

... Pacifier Pencils ...

Papel Freelance, Inc., of Cranbury, NJ, is recalling about 28,000 pencils that have miniature pacifiers where erasers are normally found. These pacifiers detach very easily from the pencil, posing a choking risk to young children. The wooden pencils, 7 inches long, are made in pink and blue, with the words "Papel/Freelance" printed on the side. The pacifiers, 1 1/2 inches wide, are mostly cream in color. They were sold in various retail stores nationwide, including Winn Dixie and Hallmark, from September, 1996 through April. 1997 for about $2.

Consumers should return the pencils to the store where they were purchased for a full refund. For more information, call Papel Freelance, Inc., at 1-800 634-8384.

... And Gymboree Children's Umbrellas

Gymboree Corp., of Burlingame, CA, is recalling about 6,500 children's umbrellas that have surface coating decorations with high levels of lead. About 700 similarly decorated beach and golf umbrellas are also being recalled. The umbrellas are multi-colored with polka-dot stripe and checkered square panels alternating with solid color panels. The kid-sized compact umbrella has a clown on the purple panel. Model numbers don't appear on the umbrellas, but are on the price tag. The child's model is no. 27000033, the golf model is 27000025, and the beach model is 27000041. Gymboree stores sold them nationwide from September, 1996 through May, 1997 for about $12 to $30, depending on the model. Consumers should return the recalled umbrellas to any Gymboree store for a full refund. For more information, call Gymboree at 1-800 558-9885 between 9 AM and 5 PM PDT Monday through Friday. (AM notices were provided by the U.S. Consumer Product Safety Commission, Washington, D.C.)