Letters to the Editor
Breast-Feeding and Infant Oral Health
TO THE EDITOR: As I read the excellent article by Sanchez and Childers1 entitled "Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations," I was struck by two thoughts.
First, although there are studies in the dental literature that would seem to show an association between "prolonged" (more than 12 months' duration) and/or nighttime breast-feeding and the formation of dental caries, most of those studies are poorly controlled for the other cariogenic factors (e.g., high-sugar diet, poor dental hygiene, lack of early or routine dental examinations and positive family history). Other in vitro2 and in vivo studies3 have concluded that human breast milk and breast-feeding are not by themselves a cause of dental caries. Therefore, in view of the many benefits of breast-feeding, it would seem imprudent to recommend a specific age of weaning with respect to this conjectural concern.
Second, although an association between bottle feeding and malocclusion has been suggested, I was surprised that this aspect of dental health was not mentioned. Multiple studies have demonstrated that the shape of the hard palate in children who suck on a relatively harder artificial nipple is markedly different from that in breast-fed children and that this difference in shape contributes to malocclusion.4,5 One study even suggests a "dose-dependent" association, with each additional month of breast-feeding contributing to a decline in malocclusion index.5
The American Academy of Pediatrics was apparently aware of these facts when they formulated their most recent recommendation that children be breast-fed for "at least 12 months, and as long thereafter as mutually desired."6
REBECCA B. SAENZ, M.D., I.B.C.L.C.
University of Mississippi Medical Center
Jackson, MS 39216IN REPLY: We appreciate the comments of Dr. Saenz because they illustrate a point of confusion and controversy over the issue of breast-feeding and its potential relationship to early childhood caries. The term "prolonged," as used in our article,1 was intended to be associated with an excessive length of time during feedings rather than being associated with a specific age of weaning. We certainly appreciate the lack of consensus of the proper time for weaning and, although from a dental standpoint many dentists encourage parents to wean children from the bottle, the breast and the "sippy cup," we can understand and accept the potential benefit of human breast milk for an extended period (more than one year of age).
As Dr. Saenz's letter indicates, there is no clear evidence specifically linking human milk to caries. Although many studies have been conducted, the literature on the caries potential of breast-feeding is not decisive. The Academy of Pediatric Dentistry guidelines2 state that the group "recognizes the need for further scientific research on the oral effects of breast-feeding and the consumption of human milk." Nonetheless, circumstances of prolonged breast-feeding (e.g., nocturnal ad libitum breast- or bottle-feeding) are associated with early childhood caries.
Dental caries is a multifactorial infectious disease with many levels of complexity related to host and parasite factors, including diet (i.e., not simply one dietary factor such as breast milk), oral flora, salivary content (quality and quantity produced), and mineralization and morphology of dental structures (enamel and dentin). Therefore, obtaining the "last word" on the cariogenicity of dietary substances such as human milk is difficult.
We certainly did not mean to imply that there was any detrimental effect of breast-feeding on oral development. Alternatively, nonnutritive sucking habits are another area of much controversy. Factors such as frequency, duration and intensity are extremely important in determining the risk for adverse effects on oral development. However, most dental practitioners agree that this is not usually a serious problem before eruption of permanent teeth.
OLGA M. SANCHEZ, D.M.D., M.S.
NOEL K. CHILDERS, D.D.S., M.S., PH.D.
University of Alabama at Birmingham
School of Dentistry
Birmingham, AL 35294-0007REFERENCES
- Sanchez OM, Childers NK. Anticipatory guidance in infant oral health: rationale and recommendations. Am Fam Physician 2000;61:115-20,123-4.
- American Academy of Pediatric Dentistry, Reference Manual 1999-2000. Pediatric Dentistry 1999;21:19.
Neuropsychiatric Complications of Malaria InfectionTO THE EDITOR: Infection with the malaria parasite remains the most prevalent parasitic infection in the world and affects more than 400 million persons,1 with about 2.6 billion persons at risk of contracting the disease. Although malaria is primarily a disease of tropical and subtropical areas of the world, it can occur in any country because of increased global travel.2 This letter reports a case of malarial infection that illustrates the neuropsychiatric sequelae of acute and chronic malaria.
A 37-year-old man was admitted to the medicine unit of a teaching hospital after presenting with the sudden onset of fever, chills, headache, nausea, vomiting and dark urine with reduced output. In addition, he had been irritable and easily frustrated. The symptoms began seven days after he returned from a trip to West Africa.
Physical examination revealed a temperature of 38.9°C (102°F), pulse of 96 beats per minute, blood pressure of 110/71 mm Hg and respiration rate of 20 per minute. He had bilateral icterus with dry mucous membranes. Examination of the neck revealed no nuchal rigidity. The rest of the physical examination was unremarkable. The patient was cooperative but anxious, and the results of mental status examination were otherwise within normal limits.
A blood smear obtained during the emergency department examination revealed ring forms of malaria parasites consistent with Plasmodium falciparum malaria of 82,000 per µL. On admission, additional investigation revealed a white blood cell count of 8,200 per mm3 (8.2 3 109 per L), hemoglobin of 12.2 g per dL (122 g per L) and a platelet count of 18,000 per mm3 (18.0 3 109 per L). Blood urea nitrogen (BUN) was 93 mg per dL (33.0 mmol per L), and serum creatinine was 6.4 mg per dL (570 µmol per L). The lactate dehydrogenase (LDH) level was elevated at 1,624 U per L, and the aspartate aminotransferase (AST) level was 113 U per L. Total bilirubin was 13.5 mg per dL (230 µmol per L), with the direct portion being 11.2 mg per dL (192 µmol per L).
The admitting diagnosis was P. falciparum malaria complicated by acute renal failure. He was treated with intravenous doxycycline in a dosage of 100 mg twice daily and oral quinine in a dosage of 650 mg twice daily for three days. He was rehydrated with normal saline. The BUN and creatinine levels continued to fall steadily and were within normal limits two weeks after discharge from the hospital. Two weeks later, the patient noticed that he was apathetic and depressed. These feelings were accompanied by irritability, reduced appetite, insomnia, anhedonia and reduced energy. He was diagnosed as having adjustment disorder with depressed mood and was treated with brief psychotherapy.
Neurologic sequelae are well recognized with malarial infestation (especially cerebral malaria). Up to 12 percent of persons surviving cerebral malaria may have persistent neurologic abnormalities that include impaired consciousness, confusion and seizures.3 P. falciparum malaria has been associated with other self-limited neurologic deficits including cerebellar ataxia, generalized convulsions and fine postural tremors. Although the neurologic sequelae of cerebral malaria are well documented, its long-term neurocognitive effects are more controversial. The extent of central nervous system involvement may reflect the virulence of the parasite, host immune status, time of onset of symptoms to initiation of treatment or a combination of these factors.
Acute psychiatric complications that have been described in acute cerebral malaria include schizophrenic and manic syndromes, typical and atypical depression, acute anxiety attacks, acute confusional states, possession or trance-like states, delirium, amnesia, acute personality changes and twilight states.2 However, the exact causal relationship has not been fully investigated. There is no solid evidence that malaria psychosis exists.
Other psychiatric symptoms that have been described as sequelae to malaria infestation include irritability, violence, impaired memory, personality changes, anxiety and depression.1 The treatment of patients with psychiatric symptoms following malarial infestation should involve treating the acute infection aggressively. Patients with mild anxiety or depression may be treated with psychotherapy; pharmacotherapy may be required in patients with moderate and severe symptoms of depression.
ADEKOLA ALAO, M.D.
JENNIFER C. YOLLES, M.D.
WENDY A. ARMENTA, M.D.
State University of New York Health Science Center
750 East Adams St.
Syracuse, NY 13210REFERENCES
- Dugbartey AT, Dugbartey MT, Apedo MY. Delayed neuropsychiatric effects of malaria in Ghana. J Nerv Ment Dis 1998;186:183-6.
- Osuntokun BO. Malaria and the nervous system. Afr J Med Sci 1983;12:165-72.
- Gorbach SL, Bartlett JG, Blacklow NR, eds. Infectious disease. 2d ed. Philadelphia: Saunders, 1998.
CorrectionAn item in "Tips from Other Journals" (January 15, 2000, page 493), entitled "Diagnosis of Acute Meningitis in Adult Patients," contained an error. Near the end of the first paragraph of the right-hand column on page 493, the text mentions that the Brudzinski sign has a 97 percent sensitivity in the diagnosis of acute meningitis in adults. Neck stiffness has a pooled sensitivity of 70 percent. Although Brudzinski's original study (which included 42 patients, one half of whom had tuberculous meningitis) reported a sensitivity of 97 percent for the Brudzinski sign, there have been no subsequent studies evaluating this sign. The Kernig sign was found to have a sensitivity of 57 percent in the original study, but a later study reported a sensitivity of only 9 percent. The authors of the study reviewed in this Tip concluded that meningitis can be ruled out if a patient does not have fever, stiff neck or mental status changes. Fever is the most sensitive of the three signs, and neck stiffness is the next most sensitive. Kernig and Brudzinski signs, although poorly tested, seem to be specific for the diagnosis of meningitis. The authors do not believe that either sign is sensitive enough to be used for making the diagnosis of meningitis.
*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
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