LETTER FROM THE PRESIDENT
'Rul ofTrees' points up traged in chlIhealt bureauc:,,racy
Two infants, not one, die of malnutrition while
being breastfed! Two mothers, not one, are prosecuted for manslaughter, and the NewYork Times pub lishes two editorials, not one, expressing rage because
two infants, not one, are denied Medicaid despite
their eligibility. According to the rule of threes, there
enl | _ ~will be a third.
of the rule ofthrees
l .]x |1 1 ~~Ifirst heard
residency. Simply stated,
the rule. The rule was presented to me by an astute
attending as a clinical pearl and it made for remarkable teaching and discussion. Of course, I do not
remember the times when the rule didn't work.
I reported in an earlier column (AA4P News,
February) of the death of a nursing infant who was
denied medical care when the hospital turned
mother and infant away because the mother had
neither a Medicaid card, nor $25. The mother was
tried for manslaughter, but the charges were dismissed when pediatricians testified of the substantial risk to a breastfeeding infant who is not examined, weighed and appropriately monitored. When I
initially heard of a second case, my reaction was confusion with the first case. I could not believe there
could possibly be another such catastrophe so soon.
Then I remembered the rule of threes. The second
mother had made repeated attempts to enroll her
infant in Medicaid and was denied a card for her
infant because of computer errors and bureaucratic
confusion. She received in the mail two Medicaid
cards the week after the infant's death.
Now I'm waiting for the third tragedy. There will be
more tragedies so long as we, as a nation, fail to provide health insurance, as a right, to children and
ultimately all Americans. The bureaucratic rules we
|during
l n ~~when a child presents with an
| ~~~uncommon disease, or a com-
1 ;-3-_ mon disease presents in an
uncommon way, the rule says to
^_ ~~expect, within a short time, two
_
~~~similar events. To this day, I
remember when the rule worked.
Dr. Alpert
I was alerted by one unusual
ingestion to two others that followed. I remember
three children who were diagnosed with osteomyelitis, and three children who were admitted to the
hospital with malignancies with unusual presentations. All of these "threes" occurred within a period of
weeks.
Some clustering can be explained epidemiologically, as would be the case where there is an infectious
etiology. Obviously, there is no clear scientific basis for
create through means testing and limited eligibility
almost guarantee similar failures.
In today's political and economic climate, we must
demand that our nation protect not only Medicare
and Social Security, but also remove for children the
financial barrier to care by providing them with universal insurance. And universal insurance must provide coverage for comprehensive services as spelled
out in our AAP Health Supervision guidelines. The
tragedy oftwo infant deaths (every preventable death
is a tragedy) adds a human face to the statistic that 43
million Americans, 11.6 million of whom are children, lack health insurance. These two infants, and
infants to come, cry out that there must be no financial barrier when medical care is needed!
Now is the time to educate candidates of both
major parties who are competing for national office
in the year 2000 of the need for truly comprehensive
health insurance for all. It is time for action!
t .~~
-
Jo
Joel J. Alpert, M.D., FAAP
President, American Academy ofPediatrics
D enta l Contin ued from page I1provide pediatric dentists a home with health care
providers who are focused on the same population,"
are like a sponge, he said.
They absorb everything
and do what the doctor tells them to do.
Physicians can tap into that
_>_ ~~eagerness and pass along information such as the importance
_
_
~~~~ofcleaning an infant's teeth reg_
- ~~~ularly with a soft cloth and
_
s ~~~using bottles only at mealtimes
; _
n ~~~and switching children to a cup
_
_
~~~atabout I year to avoid baby
_
_
~~~bottle caries and swallowing
Dr. Simonsen
problems.
Other issues the section plans to address include
access to dental care for all children, early intervention and nutrition counseling.
Only 50 percent of children see a dentist once a
year, according to Dr. Simonsen. The Academy can
change that through public education. "A child needs
to be seen on a regular basis, preferably by a pediatric
dentist," he said.
said Gerald Gilchrist, M.D., FAAP, chair of the AAP
Council on Sections.
Since the Academy offered pediatric dentists associate membership in June 1997, their ranks have
grown to more than 200. The section plans to recruit
additional members through the American Academy
of Pediatric Dentistry and the American Dental
Association, said Provisional Section Chair Chris
Simonsen, D.D.S.
Educating both pediatric dentists and pediatricians
will be a major focus of the section, according to Dr.
Simonsen. The section hopes to provide information
on the Academy's Web site, through information in
AAP News and by producing a brochure that pediatricians could give to patients' parents.
Pediatricians can play a key role in reducing oral
health problems by educating parents, especially
first-time mothers, Dr. Simonsen said. New moms
Erra a:. Pern tlLGui Eintes .;
If a problem such as a malocclusion is spotted early,
intervention can prevent or minimize the need for
orthodontic treatment, Dr. Simonsen added.
Finally, more needs to be done to educate patients
and parents on good nutrition.
"So many of our youths are ingesting empty calories," Dr. Simonsen said. "They'll start school out with
a doughnut and a Coke," and continue bathing their
teeth in sugar, which leads to decay.
The section's executive committee is meeting in
May to put together a program for a future presentation to pediatricians that will address these types of
issues. Committee members include Martha Ann
Keels, D.D. S, Ph. D., Paul A. Weiss, D.D. S., Ray Stewart
D.M.D., Benjamin J. Cumbus, D.M.D., F.A.C.D. and
John Nathan, D.D.S., M.D.Sc.
"It's a great opportunity having pediatricians and
pediatric dentists in the same organization," Dr.
Simonsen said. "It gives us the opportunity to have a
unified voice for the total health of children."
Policies in Pediatrics
The following AAP policy statements were published in the May Pediatrics:
'Me following erratato GudlhmfoCrPerinallgawreed uponbytheAAP
Committee on Fetu and Newomornd theMiefc)POlg fbstetriciansAl
Fetal Therapy: Ethical Considerations
;000::00:
Gynecolog'ists' Committee on Obst*kPractice. 00
-Committee on Bioethics
The guidelinles shouldread as follows:4,
0fV0
-0V0
0000
0;0:
Measles Immunization in HIV-Infected Children
-Committee on Infectious Diseases and Committee on Pediatric AIDS
ff00000
f0
Hepatitis BSreigof P regnantWomeA:n0
Combination
teMaterS:::Infection)::
0 Vaccines for Childhood Immunization: A Subject Review
Pages 209-210(undder
Because historical infonrnation about n'sk factors idenltifiesfwe than half of
-CDCAdvisory Committee on Immunization Practices and the Academy
chromic carriers, serologic testing for HBsAg is Dreconunended as part of teroThe full text of AAP policy statements can be accessed on the Pediatrics Web site:
tine battery of prenat-al tests for pregnlant women. Sif
0~ t:
www. pediatrics. org.
CarSeat Adaptations for
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Page 171 (second sentencefrom top).
. .. Proper infant safety, includmtg car seat Ootations for inans wihing less
than 2,500 gand recommn ed sleeping o00ns fv premature infantsX
Coffection
Ophthialmologic Assessment of ghRisf-k Neonates:
In the "Managed Care Q & A" column that appeared in the April 1999 AA4P News,
4f
0
Pagel 71 (second bullet poi'nt):
Jerald L. Zarin, M.D., M.B.A., FAAP, should have been identified as a member of
Ophthalmologic assessrnent of neonates bmatless: tha28 weeks of gestational
the executive committee of the AAP Section on Administration and Practic'e
age or weighing less than or equal to 1,P500 g at birth (as determu'ed byhospital polManagement.
icy) has been performed, and a foUow-up appointment has bein scheduled.;
,
High-Risk Nonatest0
6
;L;0
4<; ;
00
May 1999
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Managed Care Q & A
Jerald L. Zarin
AAP News 1999;15;6
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Managed Care Q & A
Jerald L. Zarin
AAP News 1999;15;6
The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://aapnews.aappublications.org/content/15/5/6.4
AAP News is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. AAP News is
owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
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