So, pretty please…with sugar on top. Stop prescribing codeine for children.
The safe and effective management of subjective symptoms in the pediatric population, in particular pain, has always been difficult. Young patients, even premature infants at the limit of viability, experience pain, a fact that sadly was not widely accepted until the late last century. But even with full recognition of pain as a potential concern in all pediatric patients, undertreatment of pain remains a system wide issue.
Pediatric pain management is especially challenging for a variety of reasons. Overall there are fewer pediatric friendly pharmaceutical options to choose from and limited data on available pain medications for children, leaving pediatric providers fitting square pegs in the round hole of adult medicine. Further complicating the situation is the fact that kids can have significantly different absorption and metabolism of drugs compared to adults. Finally, young children are more likely to be undertreated because of the reluctance to prescribe, or to consent to the use of, opioid medications by providers and caregivers respectively.
As if things weren’t difficult enough, the AAP Section on Anesthesiology and Pain Medicine has published a clinical report in the September Pediatrics that aims to remind providers that it is “time to say no” to one of the our most popular pain medications: codeine. Sadly, the authors are not raising new concerns. Instead, they are once again pointing out serious problems with this drug, problems we have known about for over a decade that have resulted in deaths and inadequately treated pain.
The patient doesn’t choose the Healing Life Wand. The Healing Life Wand chooses the patient.
If you wanted to design and market an ineffective treatment with the best chance of successfully fooling consumers, it would have to include a certain set of key components in order to maximize profit. A connection to nature is extremely important, the more emotional the better. Although trickier to pull off, your product would need to call upon ancient wisdom while also being associated with cutting edge science. But keep the association vague and let the consumers connect the dots. A hint of conspiracy, where the consumer believes that they are being let in on a secret or suppressed cure helps too.
The mechanism of action should be unclear in order to avoid easy refutation, and should preferably involve concepts such as removing toxins and balancing energy or hormones. Again, it’s important to combine science with your magic, so include things like lymphatic drainage or increased blood flow. The ailments your treatment would remedy need to be subjective and likely to respond to numerous placebo effects. And the treatment should be simple, even a bit fun, in both concept and execution. Finally, throw in a catchy slogan or two and you’ll be rolling around on a pile of hundreds in no time at all.
I had originally intended a focused discussion of a single topic, but life circumstances have conspired to prevent me from doing so. In the place of my intended post, please enjoy the following collection of hastily assembled pseudomedical odds and ends brought to my attention over the past few weeks. (more…)
Dr. Sidney Farber, shown here not believing in reiki or reflexology.
In June, an article in the Boston Globe covered yet another incursion of pseudoscience into a major academic medical center, this time at the Dana-Farber Cancer Institute. Dana-Farber, located just a couple of miles from the library where I’m writing this post, has provided world-class care for children and adults with cancer since 1947. It’s kind of a big deal.
Sidney Farber, already known as the “father” of pediatric pathology, was the first person to induce remission in pediatric acute lymphoblastic leukemia, which had a 100% mortality rate up to that point. He then went on to earn the title of “father” of modern chemotherapy by also curing Wilm’s tumor, a rare pediatric cancer of the kidneys. Farber, who was featured in the phenomenal book The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, would almost certainly be opposed the double standard being employed to justify quackery in the facility bearing his name (or anywhere else).
To Farber, a scientific approach to treating pediatric cancer patients was paramount, even to the point where he at first refused to initiate the combination therapy that would open the age of modern chemotherapy because he wanted to protect children from a potentially haphazard rush to cure them. He wanted strict scientific protocols in place and assurances that the evidence would be followed regardless of the outcome, so that the intense desire to find a cure for children that otherwise faced only suffering and death would not add to that suffering. (more…)
An infant with a left facial nerve palsy
There are numerous medical conditions that are seemingly designed to allow proponents of “irregular medicine” to proclaim their treatments to be effective. These conditions tend to be chronic and subjective in nature, or to have waxing and waning courses such that a parent or patient might easily be fooled into assigning a causal relationship between a bogus intervention and a clinical improvement. Brief, self-limited maladies are also quite convenient for people with nothing to offer but false information and false hope. After a recent encounter with a patient, I’ve added a new one to the list: idiopathic facial nerve palsy.
What is idiopathic facial nerve palsy?
Although not the first to do so, facial nerve dysfunction resulting in the sudden and unexplained weakness of all muscles on one side of the face was most famously described by Scottish neurophysiologist Sir Charles Bell in 1830. Hence it is commonly, if not always accurately, referred to as “Bell’s palsy.” Since then our understanding of the condition has progressed considerably, thanks to scientific investigation and improved diagnostic testing. In particular, we have learned that many cases are the result of infection, with ear infections, various human herpes viruses, and the spirochete responsible for Lyme disease being the most common culprits in children. (more…)
An acupuncturist and acupuncture anesthetist perform robotically-assisted acupuncture on a patient who has been feeling kind of tired lately
Developed over many thousands of years (or maybe a little less), what has come to be known as traditional Chinese acupuncture has proven capable of curing or at least ameliorating the symptoms of a variety of medical conditions. But one of its greatest strengths, the intimate connection between the practitioner and the acupuncture needle, is also one of its most significant weaknesses. Taking advantage of the robotic technology being used by surgeons to perform an increasing number of minimally-invasive procedures, cutting edge acupuncture providers are now able to provide relief for patients that were once felt to be either poor candidates or had failed to improve despite treatments with traditional acupuncture by hand. (more…)
During a particularly difficult shift early in my career, I spent the better part of two hours at the bedside with a patient’s family discussing the unexpected discovery of a large tumor in their child’s brain. The implications of the finding were grave, and the family was understandably devastated. I was just a few years out of residency and this was the first time I had made such a life altering diagnosis by myself, and it was by far the hardest news I had ever had to break to a family. Needless to say it was an experience that I will never forget, and one that has influenced my approach to medicine ever since.
The diagnosis was a surprise to everyone. There were of course red flags that appropriately led to the ordering of an MRI, but I really didn’t expect it to find anything. It wasn’t based on the fear of a lawsuit or the discomfort with uncertainty, influences that dictate the practice of medicine far too often, with the latter being considerably more of a problem (in my opinion). There was enough to support embarking on an encephalic expedition, but nothing so blatant as to really raise my suspicions. My guard was down and my emotional response to the situation was intense. Later, after care of the patient had been transferred to the pediatric oncology service, my introspective nature took over.
The sound of approaching hoofbeats
In medical school, there is an old adage often passed down to learners by seasoned physicians that serves to rein in an overly broad differential diagnosis, particularly when it includes increasingly unlikely etiologies. When one hears the sound of approaching hoofbeats, the inexperienced students are cautioned, one should expect to see horses rather than zebras. The world of medicine rarely mimics an episode of House, M.D. (more…)
While social media and news outlets were reacting, or in some cases overreacting, to a new rodent-based medical study on the unlikely link between cell phone use and brain cancer last month, two studies and an accompanying commentary were quietly published in Pediatrics that raised similar concerns. Rather than cell phone use, the proposed potential cause of pediatric cancer in these newly published papers was phototherapy, a common treatment for newborn jaundice that I use regularly and have written about before. My previous post has a full review of jaundice in the newborn, how it can potentially cause permanent brain damage, and why phototherapy is a safe and effective treatment in most cases.
But is phototherapy truly safe? Can exposure to a narrow spectrum of blue light increase the risk of cancer in young children? And if so, what type or types of cancer? This is exactly what the study authors set out to investigate using the power of “Big Data.” Time will eventually tell us if the authors’ conclusions are justified or if they will end up only serving as excellent future examples of the Texas Sharpshooter Fallacy. (more…)
An Australian chiropractor treating a baby kangaroo makes as much sense as treating a human child
Before I begin this brief update to my recent post on Australian baby chiropractor Ian Rossborough’s “crack heard round the world,” I want to give a quick thanks to Jann Bellamy for organizing our day of Science-Based Medicine at NECSS last week. It was an amazing experience sharing the stage with the SBM crew for my first public presentation, and finally getting to meet Scott, John, and Saul. I’ve given hundreds of lectures to residents and students, and even a grand rounds or two, but this was orders of magnitude more exciting and stressful. I may be biased, but I think we nailed it.
With NECSS prep taking up a significant percentage of my time and a rough current work week making up for days off, my post today is a little shorter than usual. My overall average word count still gives Gorski a run for his money however. Well, that’s not actually true. Gorski is in another league.
Rossborough provides an undertaking?
Chiropractor Ian Rossborough, who I recently discussed in a post on the backlash against pediatric chiropractic in Australia, has received the slap on the wrist I sadly expected. According to the Australian Health Practitioner Regulation Agency website, which has jurisdiction over the Chiropractic Board of Australia when it comes to “professional conduct, performance or health of registered health practitioners,” Rossborough has promised to leave them kids alone:
Chiropractor Ian Rossborough shown here mid-rationalization
In January, Melbourne chiropractor Ian Rossborough uploaded a video to YouTube of himself treating a 4-day-old premature infant. The video, one of many that can be found on his “Chiropractic Excellence” channel, is for educational purposes only, intended to teach the world about the miraculous benefits of chiropractic care for a wide variety of conditions. Although the cynical among us may proclaim that his videos are just more examples of chiropractic practice building shenanigans, Rossborough claims that he simply wants to “enable natural healthy living, without resorting to drugs or surgery.”
Australian physicians respond
Well, there are apparently a lot of angry and cynical Australians, particularly journalists and physicians. In late April, the video, which features Rossborough manipulating the newborn’s thoracic spine hard enough to cause a loud cracking sound and a cry of pain went viral after it was featured in a story on Australian Broadcasting Corporation Radio National. Rossborough, and the treatment of children by chiropractors, has since come under intense scrutiny.
According to the Australian press, “doctors have declared war on chiropractors” in response to the realization that newborns and young infants are undergoing unnecessary spinal manipulation for problems such as colic, acid reflux, and excessive crying as well as for nebulous benefits like boosting the immune system and improved growth and development. The Royal Australian College of General Practitioners, the largest medical college in Australia with a membership of over 30,000 rural and urban primary care physicians, has even requested that members refrain from referring patients to chiropractors. They want the federal government and private insurers to stop paying for nonsense such as infant chiropractic.
Frank Jones MD, president of the RACGP, has made the media rounds, describing infant and toddler adjustments as “seemingly almost cruel” and lacking any supporting evidence. He has also called for the Chiropractic Board of Australia to shape up in order to have any chance of being accepted as a legitimate scientific discipline. Jones thinks that chiropractors like Rossborough and his ilk don’t know what they are doing and are putting patients at risk. He reminds the public that a physician’s job is to advocate for patients and to try to reduce exposure to practices where the risk far exceeds any potential benefit. I like this guy.