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Separating Fact from Fiction in Pediatric Medicine: Infant Teething

Teething is one of the most common sources of parental concern in the world of pediatric medicine. All children go through it, typically starting at about 6 months of age, and the current list of signs and symptoms attributed to the eruption of teeth in infants is long and varied, with most if not all of them inaccurate if not highly suspect. And although teething as a concept may seem rather commonplace, it is an entity with an interesting history and a frequent impetus for exposing young children to ineffective and even risky treatments.

What is teething?

Simply put, teething occurs when a tooth nears completion of its journey into the oral cavity, a journey which begins early in fetal development. The tooth erupts though the gum, often preceded by a small lump. Occasionally there can be a larger eruption cyst, and the area may appear somewhat bluish and swollen from bleeding into the tissue, but this is uncommon. The most widely accepted duration of a bout of teething is a roughly 8 day period, with tooth emergence generally felt to occur on day 5. The whole process usually takes about two years, with an average of one tooth emerging each month until the full complement of 20 baby teeth are present. (more…)

Posted in: Science and Medicine

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Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Umbilical Cord Blood Banking

For those who can’t get enough of Clay Jones, he is now available in multimedia through the magic of podcasts! Dr. Jones was interviewed for The Prism blog last Monday, discussing the general topic of alternative medicine and pediatrics, followed by a dive into fluoride and cavities in kids. It is available for your listening pleasure at their website or on iTunes. Next step, a semi-hostile takeover of Mark Crislip’s multimedia empire – Ed

A family has many choices to make as the arrival of a new baby approaches. What will they name their child? Will they breast or bottle feed? Should they use cloth of disposable diapers? What about circumcision? Will they vaccinate or not? Some of these choices are relatively minor while some may significantly impact the health of their child for years to come. A fairly recent addition to the long list of choices that parents are burdened with, thanks to a push from reputable organizations like the American Academy of Pediatrics, as well as private companies looking to turn a profit, is what to do with the blood in their newborn infant’s umbilical cord.

Currently the most commonly-chosen option remains to simply leave it in there. In that case, it will be discarded along with the mother’s placenta or even occasionally eaten although that is a topic for another post perhaps. Another option is to have blood from the umbilical cord donated to a public cord blood bank. These have been popping up all over the place and public banking is currently recommended by the AAP whenever possible. The final option, which is by far the most controversial (and expensive), is paying to have the umbilical cord blood banked privately for personal use by the donating child or a family member. As I will explain, while not entirely without potential benefit, the private banking of cord blood is probably not a good idea and the thousands of dollars that it costs might be better spent elsewhere. Unfortunately, because of the fear of making a wrong choice, many parents are vulnerable to being persuaded by the calculated misinformation produced by these companies. (more…)

Posted in: Science and Medicine

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Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Pacifiers and Nipple Confusion

My first “real world” employment after completing residency was as a full-time newborn hospitalist in Houston. After spending 3 years in Space City, often rounding on as many as 30 newborn infants in the Level 1 and Level 2 units each day at the county hospital, I feel as if I’ve probably about seen it all when it comes to the nursery. I then left the babies behind while working as a pediatric hospitalist in Baton Rouge for four years, but now I’m back in the newborn business up here in Boston. While there have certainly been a few changes since 2009, many things remain exactly the same.

I help take care of a very vulnerable population in my current position: parents. Parents, in particular the young and first time variety, often approach parenting with a blank slate. Sure there is frequently a grandparent or four there for assistance, but the healthcare professionals working in the nursery are looked to for vital knowledge about how to care for the new arrival. Even some of the more experienced parents will still have questions, and most respect and follow the advice given during those first few days while at the hospital. These questions most commonly focus on topics such as feeding, vaccinations and vitamin supplementation, but I am regularly asked about a variety of routine parenting skills such as swaddling, and even baby “gear” like Angel monitors.

Parents love their children and want what is best for them, and they frequently express fear and anxiety over some of these topics. Love and fear are two powerful factors in the acceptance of pseudoscience and bad advice, which is why parents are set up to be fooled. Over the next few posts, I plan to cover some examples of newborn issues known to cause excessive parental anxiety and that sometimes lead to poor decisions, in large part because of bad information received from people who should know better.

First up is a concept that is well-known in the nursery, and strikes fear in the hearts of lactation consultants all over the world. I’m talking about nipple confusion. This is a concept that may seem silly to those unfamiliar with the world of parenting, but it is something that newborn doctors deal with daily and there is a great deal of controversy. Not “vaccines and autism” controversy unfortunately, but if after reading this post you find yourself feeling let down because I didn’t start with something sexier, take solace in the fact that winter is coming. (more…)

Posted in: Science and Medicine

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Chiropractic Vs. Conventional: Dueling Perspectives On Infant Colic…..

Infant colic, while not a deadly disease by any stretch of the imagination, is an extremely troubling entity. Not only can it be quite distressing to caregivers, it is also a well-established risk factor for neglect and abuse of the child. Excessive crying in general, whether diagnosed as infant colic or not, is a frequent impetus for seeking advice from medical professionals. How science-based providers approach the evaluation of babies with excessive crying, and the management of infant colic if diagnosed, can have a powerful impact on how families perceive the health of their child and on future interactions with the healthcare system.

Infant crying is about as bread and butter as it gets in pediatrics. It is a problem which we are constantly exposed to during our training. We discuss it with families in our continuity clinics, where we learn how to truly be primary care providers. We address it on the inpatient wards, where children often cry because of illness or pain, and during our months of service in the newborn nursery. We frequently are called upon to talk anxious parents through it while taking overnight phone calls, and we learn over time with variable success the seemingly preternatural ability to understand what babies are trying to tell us with their cry.

Crying happens for a variety of reasons in young infants, ranging from the benign and expected to the life threatening. Discussing excessive crying, regardless of why it occurs, requires effective communication skills. And the evaluation of unexplained excessive crying often tests the limits of our ability to practice non-defensive medicine, avoiding unnecessary laboratory testing and imaging. Because of all this, I believe that infant crying, and in particular the entity known as infant colic, serves as a useful entry point into a discussion of the differences between a science-based approach to medicine and one based on pseudoscience like chiropractic.

Readers of this blog should be well aware of the push by alternative medical practitioners for recognition as primary care providers, with the chiropractic community leading the charge. In this post I will compare and contrast the common understanding of the etiology and treatment of infant colic held by conventional medical doctors and doctors of chiropractic. You will see that in some ways they do not differ as much as we might expect, but have little in common where it truly matters. (more…)

Posted in: Chiropractic

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Chiropractic Practice Building: A Doctor’s Confession and the Report of Findings

“I’ve got to get this off my chest!”

Dear chiropractic practitioner,

Confessions are tough…Real tough. They are painful, awful things. But, sometimes a confession can set the record straight, and I want to give credit where credit is due. Before I talk about my confession though, let me say a few other things first. You may want to sit down.

You know, when I meet people in town they usually say, “Oh, yeah, I know you, you’re Dr. Jones. I’ve seen your posts with that picture of you and the two cute little girls.” Well, I’m the guy on the left. Aren’t they cute? Now do you feel like you can trust me?

Years ago, something happened to me that changed my life forever. And I would love to tell you all about it, but first I need to give you my report of findings.

I’ve correlated the findings of your examination, and I’ve put it into a package that I’m going to review and send home with you, so you’ll know what we found and what we’re going to do to help you. In the next 10 minutes or so I’m going to review what we found, explain what these findings mean, recommend a course of action and discuss the results you can expect in the future. Feel free to ask any questions as we go along.

First a quick review. You’ve come to our website suffering from an inability to recognize your complete lack of effectiveness in the treatment of headaches, ear infections, asthma, or any other condition with the possible exception of acute musculoskeletal pain involving the back. You have difficulty accepting that any treatment you offer which is effective is provided by physical therapists, minus all the ”baggage”, and that nothing you offer which is unique to chiropractic is effective. You are in denial over how the majority of your profession is woefully ignorant of, or exists in a state of denial of, so many of the advancements in modern medicine, like life-saving vaccines, made since chiropractic was invented by D.D. Palmer in 1895.
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Posted in: Chiropractic

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Improperly Performed Acupuncture Linked to Spontaneous Human Combustion

Experts in traditional Chinese medicine are warning patients to avoid unlicensed acupuncture practitioners after an apparent case of spontaneous human combustion.

Baton Rouge, LA-When investigators climbed from out of the smoldering debris that was the home of Hank Thomas, the looks on their faces told the gathering crowd what these hardened veterans of the Baton Rouge Fire Department couldn’t put into words. Thomas, a yoga instructor and avid fisherman who had lived in Baton Rouge his entire life, had exploded. And as the grisly details slowly emerge, people are asking questions about what might be to blame and how they can prevent being the next Baton Rougian to erupt into a massive fireball of body parts and Tony Chachere’s Creole Seasoning.

Some local medical professionals have proposed a controversial theory. Based on reports that Thomas has undergone acupuncture treatments for sciatica several times in the weeks preceding his untimely fulmination, a group of local experts are speaking out. They are warning the community to beware of discount acupuncture clinics.

“We aren’t saying that every incidence of spontaneous human combustion is linked to the incorrect placement of acupuncture needles,” Kuang Zhu LAC, Chief of Pragmatic Acupuncture in the Health and Wellness division of Vic’s Day Spa and Pet Grooming Center, explained during a recent press conference. “But in some cases, there is a relationship that is hard to explain otherwise.”
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Posted in: Acupuncture, Humor

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The Overuse of Antibiotics for Viral Infections in Children

“For every complex problem there is an answer that is clear, simple, and wrong.”

-H. L. Mencken

This approach is not endorsed by the American Academy of Pediatrics.

As I sit in an apartment full of unpacked boxes and grumpy children, only a few days removed from driving 1,600 miles to a 3rd floor walk-up and a better life just outside of Boston, I find the task of writing a post somewhat daunting. But I must admit that this new town is not without the potential for inspiring future musings. In fact, I find myself surrounded by irregular medicine of all shapes, sizes and dilutions.

Next door is a chiropractor who cures Tourette’s syndrome and, according to the pamphlet available outside the clinic entrance, only uses the in-house x-ray machine on select patients who truly need it. A few buildings down from me is an acupuncturist that treats athletic injuries with ear acupuncture and Kinesio-tape while liberally sprinkling references to his practice of “sports medicine” and “orthopedics” throughout the clinic’s promotional material. But at least I was reassured that acupuncture is completely harmless because it is a natural medicine. Finally, a block further down the road, completing my welcome committee of woo is a clinic that uses homeopathy to treat just about every real and fictional condition under the sun. I checked out their website and it’s a good thing that the walls are well insulated or my neighbors would have surely been forced to ignore the sound of my forehead pounding a wooden desk like a flagellant monk hoping for divine intervention.
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Posted in: Medical Ethics, Science and Medicine

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Human Sex Determination: Psychic Sperm and the Gambler’s Fallacy…..

Carl Sagan supposedly once said that randomness is clumpy. Those three words have become one of my favorite go-to quotes, particularly when teaching residents and medical students who are often overly impressed with improbable runs of similar diagnoses or exam findings. I love this quote because it is so simple and yet reveals so much about our experience with observing the natural world. Sagan’s ability to offer up insightful nuggets of rational thought, even if he didn’t actually produce this gem, was unmatched and his efforts to bring science and reason to the public have been sorely missed. If you haven’t read any of Sagan’s works, I highly recommend The Demon-Haunted World: Science as a Candle in the Dark.

If you have a coin, and a few hours to kill, record the results of a long run of flips and you’ll see what Sagan meant about the nature of randomness. You will inevitably observe clusters of heads or tails that might seem improbable, but eventually the outcomes will average out to about half of the flips being heads and half resulting in tails. The more trials that you perform, the closer the outcomes will approach 50% for each possible result, assuming you aren’t gaming the system by using a trick coin.

I don’t think that very many people would argue with the fact that on average a coin flip is random chance, although there are still people out there who think that the Earth is flat and that Justin Bieber is a reptilian humanoid. But because of a deeply rooted cognitive bias, the gambler’s fallacy, we frequently fail at recognizing that randomness is clumpy. We accept the established overall odds, but our acceptance wavers in the face of short runs that go against our expectations. This error in logic can lead to the belief, for instance, that after five heads in a row there is a higher than 50% chance that the next flip with land on tails as if to magically even things out.

In my line of work as a pediatric hospitalist, I frequently experience other healthcare professionals making this mistake in a variety of circumstances. There is a known likelihood of bacteremia when an infant less than 28 days of life is evaluated for fever, for example. Despite this, it is common for physicians and nurses to lament, upon seeing fever as the triage chief complaint, that they are due for this life threatening infection after a number of recent febrile neonates have had negative blood cultures. (more…)

Posted in: Basic Science, Critical Thinking, Obstetrics & gynecology

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Infant and Toddler Swimming Programs: Are They Safe and Effective?

It’s now officially summertime, but people have been hitting the pools and beaches for weeks in many parts of the nation. In fact it has been well into the 90’s for over two month here in Baton Rouge, which is what I blame for the early exit of LSU from the College World Series. Our boys just weren’t used to that cold and dry northern weather.

Not surprisingly, the media has already been busy reporting on some of the many tragic drowning incidents that have occurred thus far, and Facebook profiles have been full of commentary from worried parents. And, as usual, there are businesses offering infant and toddler swimming lessons costing hundreds and even thousands of dollars per course, some of which come with claims of decreasing the risk of drowning in the young participants.

At what age can a child begin swimming lessons? According to Jan Emler of Emler Swim School, teaching a child to swim can start “As soon as the umbilical cord falls off.” Emler, like more reputable proponents of infant and toddler swimming programs, doesn’t actually put newborns into swimming pools for lessons (I’ll leave water birthing enthusiasts out of this discussion). For the most part these programs only cover bath time activities to help younger babies grow comfortable being in the water. Truly teaching infants and toddlers behaviors aimed at reducing the likelihood of drowning in the event of falling into a body of water doesn’t usually start until 6 months of age. There are exceptions.

But when should these lessons start, are they safe and do they work? Or do they actually put children at risk of injury and the parent at risk of having a false sense of security? Until their updated 2010 policy statement on the prevention of drowning, the American Academy of Pediatrics came down firmly against initiating swimming lessons in children less than 4 years of age for a number of very good reasons. Why did they soften their stance and does their change of opinion support the claims that are being made by infant and toddler swimming programs?  First some background information.
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Posted in: Basic Science, Public Health

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The Sleep Bank

The following article is entirely made up. It’s satire. I am making fun of treatment modalities which are claimed by proponents to cure everything, from real medical ailments to fictional entities like “adrenal fatigue”. I am also poking fun at the state of medical reporting these days. If the concepts discussed seem similar to actual alternative medical practice, it is because a great deal of what goes on out there in the real world really isn’t distinguishable from purposefully outlandish fictional treatments made up by someone with a doctoral degree in Feng Shui from Thunderwood College. (more…)

Posted in: Humor, Science and the Media

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