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Am Fam Physician. 2000;62(6):1439-1446

AAP Policy Statement on Childhood Bereavement

The Committee on Psychosocial Aspects of Child and Family Health of the American Academy of Pediatrics (AAP) has issued a policy statement on the role of the physician in childhood bereavement. The AAP policy statement appears in the February 2000 issue of Pediatrics.

According to the AAP committee, the death of an important person in a child's life is one of the most stressful events a child can experience. Because the family's physician is already familiar with the family interactions and individual coping skills, he or she is in a position to help evaluate and understand a child's reactions and to advise and assist the family in responding to the child's needs. Knowing the child's temperament and typical responses to stress can help the physician counsel the child and family. Cultural and religious background and circumstances of the death are important considerations in dealing with the bereaved family.

The AAP committee recommends that the child be told about a death honestly and in language that is developmentally appropriate. Children need to be reassured that they will be cared for and loved by a consistent adult who is sensitive to their needs. They must also be assured that they did not cause the death, could not have prevented it and cannot bring back the deceased. Parents should be encouraged to continue family routines and discipline.

For children, grief is a process that unfolds over time. The physician should be aware of the range of manifestations of childhood grief and be alert to prolonged or severe behavior change that signals the need for more intensive intervention. The AAP committee feels that referral to a mental health professional or clergy should be considered when progress is not being made or if the physician would feel more comfortable having someone else work with the family.

FDA Approval of Rivastigmine Tartrate

The U.S. Food and Drug Administration (FDA) has approved rivastigmine tartrate (Exelon) for the treatment of mild to moderate Alzheimer's disease. Rivastigmine has been found to improve a patient's daily functioning, behavior and cognition.

According to the manufacturer, rivastigmine is a cholinesterase inhibitor that blocks the breakdown of an important neurotransmitter called acetylcholine. Acetylcholine is believed to play an important role in memory and cognition; levels of this neurotransmitter seem to be dramatically lower in persons with Alzheimer's disease. Cholinesterase breaks down and inactivates acetylcholine. By inhibiting cholinesterase, more acetylcholine is available for normal memory-related and cognitive functioning.

In clinical trials, patients who used rivastigmine showed significant improvement in areas such as average total word recall and recognition, orientation and ability to speak when compared with patients treated with placebo. The patients treated with rivastigmine tartrate experienced fewer delusions than patients given placebo and engaged in less purpose-less activity (e.g., engaging in an activity for no particular reason, such as repeatedly opening and closing a door).

In patients who used rivastigmine, the most common side effects included nausea, vomiting, anorexia, dyspepsia and asthenia. These side effects were usually transient and mild to moderate in severity. Adverse reactions were generally less frequent later in the course of treatment. Patients with known hypersensitivity to rivastigmine, other carbamate derivatives or other components of the formulation should not use rivastigmine tartrate.

Use of Activella to Prevent Osteoporosis

The U.S. Food and Drug Administration (FDA) recently approved estradiol–norethindrone acetate tablets (Activella) for the prevention of postmenopausal osteoporosis. More than 28 million Americans have osteoporosis, 80 percent of whom are women. Bone fragility associated with the disease can lead to fractures of the hip, spine and wrist. Bone fractures are a major cause of morbidity and mortality associated with osteoporosis.

Estradiol–norethindrone acetate is a continuous-combined once-daily tablet that combines estrogen (1 mg of estradiol) and progestin (0.5 mg of norethindrone acetate). It was previously FDA-labeled for the treatment of moderate to severe vasomotor symptoms associated with menopause and for vulvar and vaginal atrophy associated with menopause. Only women with an intact uterus should use estradiol–norethindrone acetate.

In clinical studies, estradiol–norethindrone acetate was found to be effective in preventing bone loss in postmenopausal women when compared with placebo, based on measurement of various skeletal sites, including the lumbar spine and total hip.

Common side effects of estradiol–norethindrone acetate may include breast tenderness and pain, upper respiratory complaints, headache and postmenopausal bleeding. Persons who should not use estradiol–norethindrone acetate include women with known or suspected pregnancy, breast cancer, estrogen-dependent neoplasia, active deep venous thrombosis, thromboembolic disorders or stroke, undiagnosed genital bleeding, or liver dysfunction or disease. Anyone with a hypersensitivity to any of the components of estradiol–norethindrone acetate should not use it.

Personal Watercraft Use by Young Persons

The Committee on Injury and Poison Prevention of the American Academy of Pediatrics (AAP) has issued a statement on the use of personal water-crafts by children and adolescents. The statement appears in the February 2000 issue of Pediatrics.

According to the AAP committee, personal watercrafts allow one person to operate a small boat while standing up. Newer sit-down models allow up to three persons on board and can pull a water skier, reach speeds of 60 mph and have engines that range from 60 to 135 hp. In the past decade, the use of personal watercrafts has increased dramatically. As the use has increased, a simultaneous increase in injury and death related to the use of personal water-crafts has occurred.

Personal watercrafts are the only recreational boats for which the leading cause of death is not drowning, but blunt trauma. Most injuries appear to occur when personal watercrafts collide with other vessels or with fixed objects such as docks or tree stumps. Behavioral factors cited in several studies include operator inexperience, operator inattention, and excess speed or reckless operation. Operators who rent watercrafts seem to be at especially high risk.

The AAP committee makes the following recommendations for the use of personal watercrafts:

  • No one younger than 16 years should operate a personal watercraft.

  • The operator and all passengers should wear a U.S. Coast Guard-approved personal flotation device.

  • Alcohol and other drug use should be avoided before and during operation.

  • Participation in a safe boating course with specific information about personal watercrafts should be required before operation.

  • Safe operating practices, such as no operation between sunset and sunrise, no wake jumping, and observing posted speed limits or nowake zones, should be followed.

  • Personal watercrafts should not be operated near swimmers.

  • If a personal watercraft is towing another person on skis, kneeboards, tubes or other devices, a second person must face the rear to monitor the person being towed.

  • Protective equipment such as wet suits, gloves, boots, eyewear and helmets may be appropriate to wear.

The AAP committee also recommends the passing of legislation to support the previous recommendations and additional research into the safety of personal watercraft use.

Services for Children with Special Needs

The Committee on Children with Disabilities of the American Academy of Pediatrics (AAP) has issued a new policy statement on the provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. The policy statement appears in the February 2000 issue of Pediatrics.

According to the AAP committee, children and adolescents with chronic diseases and disabling conditions often need related services, such as speech therapy, occupational therapy, physical therapy and nursing care. When physicians assume the role of medical home professionals, they can assist children and their families with the complex local, state and federal laws, regulations and systems associated with these services.

To best serve children with disabilities and their families, physicians should be aware of the issues related to education services, their legal basis and the special education process and system, reports the AAP committee. The physician's role mandated by the Individuals with Disabilities Education Act as a related service is defined to include only the diagnosis and evaluation of the disability. In the context of primary care, the physician's role also includes the medical management, supervision and program planning for the children.

The AAP policy statement includes the following recommendations:

  • Physicians should be well informed about the medical or educational needs of children and adolescents with chronic diseases and disabling conditions. Learning opportunities should be developed and widely disseminated.

  • Physicians should help parents find advocates. Physicians can be advocates or can assist with establishing an appropriate balance between the recommendations made by the school team and the desires of the family.

  • When considering educational services, physicians should focus on the child's specific needs, not the relationship of services to the child's educational placement.

  • The physician's role in the care of children and adolescents with disabilities can be expanded to a more active role in the development and implementation of Individual Family Service Plans and Individual Education Plans.

FDA Approval of New Rapid-Acting Insulin

The U.S. Food and Drug Administration (FDA) recently approved a premixed insulin containing a rapid-acting insulin. Humalog Mix75/25 Pen (75 percent insulin lispro protamine suspension, 25 percent insulin lispro injection [rDNA origin]) will help patients with diabetes control blood glucose levels and manage challenges in taking their medication with regimented meal schedules.

The duration of action of Humalog Mix75/25 is similar to that of Humulin 70/30 (70 percent human insulin isophane suspension, 30 percent human insulin injection [rDNA origin]). Humalog is absorbed quickly by the body within 15 minutes of eating. The insulin lispro protamine suspension component was specially developed to be mixed with Humalog and the manufacturer does not plan to market it separately.

The insulin is available in a prefilled insulin pen, a pen-like device that helps patients increase dosing accuracy and convenience. The pen is meant to replace the traditional vial and syringe. With the pen, patients turn a dose knob to select the amount of insulin they need. The dose knob can be dialed forward or backward in single unit increments and emits an audible “click” with each unit dialed until the exact number of units appears in the magnifying dose window. The Humalog Mix75/25 pen contains 300 units of insulin and does not require refrigeration after the first use.

Potential side effects that are associated with the use of all insulins include hypoglycemia, weight gain, hypokalemia, lipodystrophy and hypersensitivity. Because the action of Humalog is different from other insulins, care should be used in patients in whom these conditions may be clinically relevant (e.g., those who are fasting, have autonomic neuropathy or renal impairment, are using potassium-lowering drugs or taking drugs sensitive to serum potassium levels). The manufacturer warns that patients should not mix Humalog Mix75/25 with another insulin, and that starting or changing insulin therapy should be done cautiously and only under medical supervision.

Surgeon General Report on Oral Health

In May, the Surgeon General issued “Oral Health in America: A Report of the Surgeon General,” which identifies the essential role of oral health in overall health and well being. The Notice to Readers regarding the Surgeon General's report was published in the June 30, 2000 issue of Morbidity and Mortality Weekly Report.

According to the report, oral health has improved since the 1950s, but many persons are still affected by disparities in oral health status and access to care. Those with low income and members of racial/ethnic minority groups are especially affected. The report also discusses the underutilization of safe and effective means of preventing oral disease, such as the use of fluoridated water or dental sealants.

In the report, the Surgeon General calls for the following actions:

  • Increasing awareness of the importance of oral health as part of general health.

  • Accelerating the building of the science base and applying it more effectively to improve oral health.

  • Strengthening the local, state and federal capacity to perform core public health functions.

  • Removing barriers between people and receipt of oral health services.

  • Using public-private partnerships to improve the oral health of those who still suffer disproportionately from oral diseases.

A copy of the report may be obtained on the Web at Additional information is also available on the Web at or by calling 887-232-2020.

New AHA Web Site to Improve Patient Compliance

When patients do not follow their physician's advice, it can delay recovery from illness, increase medical costs and raise the risk for certain conditions such as cardiovascular disease and stroke, reports the American Heart Association (AHA). Because the average office visit lasts 15 minutes or less, many physicians do not have the time or the tools to properly counsel patients on the importance of compliance. To help physicians and patients correct this problem, the AHA has created a new compliance Web site (

The new AHA Web site is divided into two sections: one for health care professionals and one for patients. The area for health care professionals provides tools for the health care team to use to help patients comply with treatment recommendations. The section includes the following: patient information sheets that are easy to understand and monitoring logs on topics specific to compliance, including smoking cessation, medications and weight management; patient brochures that can be downloaded and that provide patients with education and tips to help with compliance; and physician and patient compliance quizzes to help physicians determine if they and their patients are compliant.

The patient area offers information, tools and tips on better ways to follow appropriate professional advice about medications, diet, exercise and smoking cessation.

More information on appropriate medical advice can be obtained from the AHA by calling 800-AHA-USA1 (800–242–8721).

Guide for Newborn Hearing Screening Programs

Early intervention for newborns is essential in preventing hearing loss and the associated delays in language development. In response to this health care problem, the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA) has funded an implementation guide for newborn hearing screening programs. “Early Identification of Hearing Loss–Implementing Universal Newborn Hearing Screening Programs” is available free of charge to hospitals and birthing centers across the United States.

The guide is based on more than a decade of work in universal newborn hearing screening in hospitals nationwide. According to the guide, areas that should be considered when setting up this type of program include determining protocol in the participating hospital, choosing equipment, training, financing, managing data, and talking with parents, physicians and hospital staff.

HRSA reports that currently, approximately 35 percent of newborns are being screened for hearing loss before discharge and hundreds of hospitals operate screening programs. The manual describes four practical and cost-effective screening technologies used.

The guide is based on the experiences of staff of the National Center for Hearing Assessment and Management at Utah State University. For a free copy of the guide, call the National Maternal and Child Health Clearinghouse at 888-434-4624. The guide is also available on the Web at

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