22 Opinion P E D I AT R I C N E W S • M a rch 2 0 0 8 A D V I S E R ’ S V I E W P O I N T How to Discuss a Death With Children P You may be consulted regarding the icture this: It is a winter Monday afternoon and you are working your children’s participation in the wake, fuway through seeing all the children neral, burial, and other mourning rituals. who have become sick since your office The Smiths had made their decision, and closed on Saturday. You have a first-year on Saturday they brought the boys to the medical student observing you (through funeral but not to the burial. In my expethe clinical introduction course), and your rience, children are very honest and will nurse whispers that Mr. and Mrs. tell you to what extent they want to be in“Smith”—who are waiting with their chil- volved in the ceremonies that surround a dren in the next exam room—want to talk death. I would allow a child to go to the funeral if she wants to. But to you privately before you the child should be supergo in to see the children. vised by a less-involved When this was my Monadult, who can leave with day afternoon, I told the the child if the experience nurse to have one of the becomes too much for her. parents meet me briefly outOn the other hand, I would side the exam room, as I never force a child to attend. don’t like to conspicuously We certainly hope that, in leave the children alone the expected order of things, while they know we are talkour children will live to ating about them. What was tend our funerals without the problem? Dad’s brother, BY DEBORAH us there to take care of Uncle John—a police offiT O L C H I N , M . D. them. The experience they cer—died from a gunshot have with funerals of more from his own gun on Wednesday night, and they wanted me to distant connections can be considered a make sure that the children were doing all rehearsal: They learn what gets done, how people express themselves, and that right. What are the points you have to cover people do manage to get through the when dealing with a death in a child’s fam- mourning process. We need to see the experience through ily? Of course, you need to start the discus- the eyes of the child in order to know what sion by expressing your sympathy for the concerns each child might have; a child’s family’s loss, and when the child is present, experience may be very different from that of a grownup. Children of different specifically on his loss. You inquire about the relationship be- ages will certainly have different reactions. tween the child and the deceased. In this Young children may not act as if they case, he was a favorite uncle of “Joey” (9 take a death very seriously; they are used to playing “bang, bang, you’re dead,” and years old) and “Tom” (5 years old). You learn if the death was sudden or an- then getting up and playing another game. ticipated, and, if anticipated, how the chil- When an adult dies, both young and olddren were prepared for it. In this case, the er children need to be reassured that someuncle was in his room, his wife and moth- one will be there to take care of them. People from different backgrounds have er were elsewhere in the house, his gun went off, and he was found dead. The case different understandings about death. Ceris still under investigation. The Smiths are tainly parents will teach their children sure the death was accidental, not self-in- their own beliefs of what happens when flicted, and that is what the children have someone dies. But what I stress is the need to dwell on the existential aspect of been told. L E T T E R S Ensuring Continuity in Your Practice I am doing some research for a pediatrician and I noticed that Dr. Charles A. Scott has written numerous articles for PEDIATRIC NEWS. The pediatrician, who is 53 years old, is a bit concerned that his practice is shrinking as new parents select doctors who will be available for their children throughout their entire childhood. Does Dr. Scott have any suggestions? Bonnie Grosshans Memphis Dr. Scott replies: The pediatrician who is in his or her prime (by my standards) should first consider whether the practice can afford a younger colleague. That guarantees continuity when the senior physician retires. If there is not enough patient flow or revenue to support even a part-time younger pedia- trician, then the 53-year-old in this case has to assure his patients that a younger pediatrician will join the practice in a few years as he begins to wind down—but that he fully anticipates going for another 10 or 12 years and can see most patients through the throes of childhood. I am in the same boat. I have been telling my patients that I will be around for another 10 years (I’m 56) and I’m not thinking about slowing down anytime soon. Obviously, it is predicated upon my good health, which I hope will continue. Parents feel relieved that I will be able to care for their children for at least that many years. But I have younger associate doctors who will carry on after I retire. Dr. 53 needs to think about this as well. AAP Had Better Stick to Science The American Academy of Pediatrics’ stand on adolescent sexuality is unscientific the death, what we experience here and now: We know Uncle John is gone and is not coming back; we miss him and we feel sad because of that. We can think of all the nice things we did with Uncle John and remember what he was like. The boys tell me that Uncle John was a prankster, a comedian. Everyone enjoyed his company and liked him. We can even remember a couple of things that we did not like when Uncle John did them. We do not have to feel guilty about such thoughts; after all, he was a real person, and no human being is perfect. If we have a picture or some gift that Uncle John might have given us, we can keep it in a special place, as a reminder of him. We feel sad when someone we know and love has died. Even grownups, even fathers, may cry over the loss of someone they were close with. A parent who acts as if everything is fine after someone dies might convey a subliminal message to the child that the parent does not experience strong love, possibly giving the child the feeling that “it might not even upset them if I died.” In general, everyone processes a death at a different rate. I remember a young couple who lost a baby to crib death, years before the “back to sleep” campaign. When he wanted to go to the cemetery she was not ready to go, and when she wanted to go, he wouldn’t go with her. Fortunately, the marriage survived, and together they decided to have another child. Joey, the 9-year-old, was able to talk about good memories of his uncle and his joking around. He was overwhelmed by the constant crowd of people who came to pay their respects. We talked about his new worry: When his father is out, Joey frets about his father’s returning home safely. He expresses concern about his aunt. Tom, the 5-year-old, also was confused by so many people being around. He reported that the day before he had felt his heart beating (“going bump”). and impractical (“AAP Updates Policy on Adolescent Contraception,” December 2007, p. 6). Pontification is no way to address a biologic phenomenon governed by various hormones and neurotransmitters responsible for propagation and survival of the species. Twenty thousand years ago the average life expectancy of human beings was 20 years, and if they did not reproduce we wouldn’t be here. Times, values, requirements, societal structure, and ways to survive have changed over the millennia but biology has stayed the same. Abstinence as a recommended means of contraception is a religion-based value system with total disregard for biology. In addition, the sense of guilt associated with a breach of a religion-based value system is capable of causing conflicts and depression in young people. I am not sure we as professionals know what the adolescents understand of We concluded that—with all the visitors at the house and all the soda that was set out (and with nobody free to supervise how much he drank)—Tom had had a caffeine overdose and some PVCs (premature ventricular contractions); he was reassured when he learned that all he had to do was stop drinking soda and he would be fine. We ended the visit by agreeing that we would talk again as issues came up. The parents told me that the school was going to offer counseling to the children. Several weeks later, Ms. Smith was back in the office with both boys to deal with strep, and I took the opportunity to ask how things were going for the family. Mr. and Ms. Smith have good days and bad days, as do the children, more so the older boy. The boys have pictures of Uncle John. They are sad when they see any wedding picture, because they remember Uncle John’s wedding. Both are doing okay in school; the 9-year-old is into sports; the 5year-old likes to read and joke around. On Sundays after church, if the weather is good, the family goes to the cemetery, which is an emotional experience. They tidy up the grave; then the older boy reads from the Bible and the younger one recites a children’s prayer. I acknowledged that this was a meaningful thing for them to do, and further suggested that as time goes by, it would be normal to decrease the frequency of the visits and to go instead on special occasions and anniversaries. I asked the mother whether our discussion at the time of the death had been helpful to the family. She replied that it definitely was. She told me that the family had felt great relief afterwards. They recognized that they were together and they have someone to go to if they have a problem, and their overall reaction was “it’s going to be okay.” ■ DR. TOLCHIN is an attending physician at Montefiore Medical Center, New York. She is also a member of the PEDIATRIC NEWS Editorial Advisory Board. the emotional and physical consequences of sex. Preaching abstinence to such an organism will generate distrust, self-doubt, and guilt Contraception and sex education are the best scientific answers we have, and we must utilize them wisely. And the AAP as a scientific organization must follow rigorous scientific standards in its recommendations. Amar Dave, M.D. Ottawa, Ill. Agreed: MRSA Is a Superbug Dr. Christopher J. Harrison might be a bit too casual in his outlook regarding methicillin-resistant Staphylococcus aureus (“MRSA Panic Unwarranted,” ID Consult, November 2007, p. 16). First, the two most disturbing aspects of MRSA are its resistance to many (and sometimes all) of the standard antibiotics and its production of molecules which Continued on page 24 24 Opinion Continued from page 22 puncture and injure the immune cells trying to contain the infection. Regarding the second point, Michael Otto, Ph.D., of the National Institute of Allergy and Infectious Diseases, has shown that community-associated MRSA (CAMRSA) has a considerable amount of phenol-soluble modulin. This complex destroys neutrophils by forming pores on these white blood cells, greatly contributing to the organism’s deadly potential. Although Dr. Harrison hates the terminology, this trait of MRSA does make it a “superbug” with “flesh-eating” potential. Secondly, although many of the pharmaceutical giants are able to develop new antibiotics for these new strains of bacteria, costs are inhibitory. In 2000, a report in the Journal of Health Economics indicated a cost of more than $800 million to develop (and get Food and Drug Administration approval for) a novel drug with a new molecular structure. That figure has been revised, to adjust for inflation, to $1.3 billion. One must also add the probable legal costs, given the penchant by lawyers to initiate lawsuits, especially when dealing with virulent organisms. As the government pays more of the cost for pharmaceuticals, including innovative drugs, this issue of development of new antibiotics is woven into many aspects of health care policy. As with most national health issues, there is not a quick solution to CA-MRSA. Craig G. Burkhart, M.D. Sylvania, Ohio Dr. Harrison replies: I thank Dr. Burkhart for his comments, and I would stress that my outlook toward E DITORIAL A DVISORY BOARD LILLIAN M. BEARD, M.D., George Washington University, Washington LEE SAVIO BEERS, M.D., George Washington University, Washington SUZANNE C. BOULTER, M.D., Dartmouth Medical School, Hanover, N.H. KAREN E. BREACH, M.D., private practice, Charlotte, N.C. STUART A. COHEN, M.D., M.P.H., University of California, San Diego H. GARRY GARDNER, M.D., Northwestern University, Chicago THOMAS W. MAUSBACH, M.D., University of North Dakota, Fargo KEVIN T. POWELL, M.D., PH.D., pediatric hospitalist at St. Louis Children’s Hospital KEITH S. REISINGER, M.D., M.P.H., private practice and research at Primary Physicians Research Inc., Pittsburgh CHARLES A. SCOTT, M.D., private practice, Medford, N.J. JACK T. SWANSON, M.D., University of Iowa, Iowa City DEBORAH TOLCHIN, M.D., Albert Einstein College of Medicine, New York P E D I AT R I C N E W S • M a rch 2 0 0 8 MRSA is not casual. CA-MRSA has become an increasing problem in the office, clinic, and hospital. A recent report defines a USA300 lineage for most isolates of this strain of CAMRSA that seems to have appeared approximately 10 years ago. It has acquired multiple antibiotic resistance genes and multiple virulence genes. My column mentioned some such factors: “ ... most S. aureus can ‘eat flesh’ using coagulase and other enzymes.” Dr. Burkhart points out that phenol-soluble modulin (PSM) was reported by Dr. Otto’s group to be a candidate factor for increased virulence, suggesting it to be more important than Panton-Valentine leukocidin (PVL). However, Dr. Otto himself, commenting on the same report, did not claim that that PSM was the single virulence gene that determines the outcome of community-acquired MRSA infections. PSM is a pleiotropic factor with multiple effects. For example, PSM has long been noted to be a factor in producing biofilm associated with Staphylococcus epidermidis, not a highly virulent or aggressive pathogen. Biofilm, however, reduces penetration of even effective antibiotics to target bacteria. Biofilm also provides an environment that allows staphylococci of any species to adhere well to foreign bodies or even to human tissue. When a pathogen combines PSM with antibiotic resistance and other virulence factors, it can be more difficult to treat, particularly late in invasive disease. So PSM’s major impact may not relate only to the injury of the immune cells trying to contain the infection, as noted by Dr. Burkhart, but to other effects and their interaction with more than a dozen factors or enzymes which have accumulated in this MRSA strain. These include some that most clinicians may recognize, for example, staphylococ- Opinion M a r c h 2 0 0 8 • w w w. p e d i a t r i c n e w s . c o m cus protein A (a super antigen), leukocidins, and coagulase itself. Most of these same virulence factors also occur (with less frequency) in methicillin-susceptible S. aureus. So MRSA is not the only staphylococcus capable of producing severe or lethal disease. The USA300 CA-MRSA strain owes its potential for severe disease to a constellation of factors together with a universal resistance to current b-lactams, macrolides, an increasing resistance to quinolones, and occasional although potentially increasing resistance to clindamycin. This combination can, in selected hosts or with delayed/inadequate therapy, lead to serious outcomes. However, current data still indicate that the overwhelming majority of CA-MRSA infections are mild and can be treated on an outpatient basis with trimethoprimsulfamethoxazole or clindamycin. Most CA-MRSA strains are also susceptible to doxycycline and rifampin. Almost all are susceptible to linezolid and all have been susceptible to vancomycin. Our current tools to treat CA-MRSA are still adequate. Many new drugs aimed at resistant gram-positive pathogens including CAMRSA are in the pipeline. These include the fourth-generation cephalosporins, ceftobiprole, and cerexa, as well as the once weekly-dosed drug, dalbavancin. These drugs are more than halfway through the expensive regulatory and testing phases noted by Dr. Burkhart. We still need to be vigilant in detecting CA-MRSA in our patients and treat it appropriately before it produces severe outcomes. Our other role is to provide practical advice on measures to attempt prevention. Neither adding to the panic nor recommending excessive interventions will likely be useful. 25 LETTERS Letters in response to articles in PEDIATRIC NEWS and its supplements should include your name and address, affiliation, and conflicts of interest in regard to the topic discussed. Letters may be edited for space and clarity. Mail: Letters, PEDIATRIC NEWS, 5635 Fishers Lane, Suite 6000, Rockville, MD 20852 Fax: 240-221-4400 E-mail: [email protected]