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In 1978 the Committee on Children with Disabilities of the Northern California Chapter I of the American Academy of Pediatrics published a report titled 'Medical and Health Care in State [...]

• The impact of providing home care for ventilator-dependent children was studied in a cross-sectional survey of 18 northern California families. Through the use of a confidential structured interview and the Impact on Family Scale, we obtained information on family demographics; the childrens' medical conditions; financial, social, and personal impact on the family; and parental coping-mastery of the care of a ventilator-dependent child at home. Analysis of scores from the Impact on Family Scale showed no differences in the perceived family impact between primary caretakers and their spouses. Primary caretakers in the sample, however, showed significantly reduced Coping subscale scores with a longer duration of home ventilatory care. This finding, if confirmed in future studies, has policy implications for physicians and other health professionals working with ventilator-dependent children and their families, especially those who care for children over long periods.(AJDC. 1990;144:1238-1241)

• We found substantial dysplasia of fingernails and toenails in each of four siblings demonstrating other features consistent with a diagnosis of fetal alcohol syndrome (FAS). This aspect of examination Is frequently overlooked in routine physical assessments. All four affected teenagers of this heteropaternal sibship demonstrated common features of FAS, including moderate mental retardation, maxillary hypoplasia, an elongated philtrum, and narrow palpebral fissures, as well as absence or dysplasia of two or more nails. Although nail hypoplasia has been previously reported as a minor finding in FAS, a literature review confirmed that nail dysplasia is found in more than 20% of individuals with FAS.(Am J Dis Child 1983;137:1069-1072)

Sir.—Dr Heifer's editorial "Primary Care: Does It Belong in Pediatrics?"1 was indeed thought provoking and very much to the point. As a faculty member of a university division of general pediatrics (pediatric generalist with subspecialty in developmental pediatrics), I can readily agree with Dr Helfer on most of his points.However, I all too often am privy to the confessions of pediatric residents who explain their decisions to pursue one of the more lucrative tertiary subspecialties because they have decided they "simply cannot afford to practice primary care." I believe Dr Helfer was in error when he compared the pediatrician's otoscope to the plumber's roto-rooter. Recently, I was grateful when the plumber's assistant relieved the impaction in our bathtub drain with the help of his "hi-tech gimmick," but my gratitude was somewhat short of ecstatic when this young high school dropout presented me with a bill for $60