Unsafe playtime activity?
During my first clinical rotation in medical school, I found myself at the pediatric nurse station one afternoon waiting for a patient to arrive from the emergency department. An adorable older infant was there sitting in a bouncy chair, smiling and drooling as babies tend to do, and looking rather well for an inpatient. The nurse watching her explained that she had come a long way since first being transported to the facility by ambulance after being admittedly shaken (and almost certainly also beaten) by her mother’s new boyfriend one evening when she wouldn’t stop crying.
Now, cortically blind and facing a lifetime of disability, the child was awaiting placement by social services. I had experienced my first exposure to child abuse, a scourge of pediatric medicine that I hadn’t thought of at that point despite having decided on a career in pediatrics well before being accepted into medical school. I’ve since had many more opportunities to care for abused children, some of which involved considerably more visually disturbing findings and a couple that resulted in a child’s death. But I will never forget her and the feeling of utter revulsion I felt that day.
Child abuse is common and it comes in many forms that can involve physical abuse as well as neglect. Children under the age of 4 years are the most frequently affected, but children under a year tend to suffer the most severe manifestations. Head injuries make up the bulk of physical abuse in this age group, and they are often fatal. Roughly 40% of child abuse-related deaths occur in the first year of life and there is frequently both a history of abuse prior to the fatal event as well as missed opportunities for medical professionals to have intervened.
The head injuries that children suffer at the hands of abusive caregivers, if not fatal, are frequently still devastating. It is not uncommon for these children to suffer permanent neurologic injury which can include persistently altered mental status, cognitive impairment, cerebral palsy, blindness and recurring seizures. In addition to the child’s injuries, the psychosocial impact on the family can also be quite severe. I’ve seen families torn apart because of guilt and anger. (more…)
In August of this year, a new policy statement from the American Academy of Pediatrics was published which tackled the widespread problem of insufficient sleep in our adolescent population. They even went so far as to label insufficient sleep as “one of the most common, important, and potentially remediable health risks in children.” The statement, which gave a number of recommendations on how to address the problem, made the news rounds primarily because of the call for schools to delay start times until at least 8:30 AM.
I wrote about pediatric sleep in March for a post on the potential link between some sleep disorders in children, specifically nightmares and night terrors, and the development of psychosis. Those claims are suspect but please read that post for a review of what sleep is, why we need it, and what can go wrong with it in children of all ages. For this post, my focus will be on adolescent sleep specifically, and on the role of delaying school start times in improving a variety of health parameters.
What are the common adolescent sleep challenges?
The typical modern teenager faces a variety of challenges to consistently obtaining a full night’s sleep, which is considered by most sleep experts to be in the 8.5 to 9.5 hours per night range. This doesn’t mean that every teenager will fall apart if they only get 7 hours of sleep each night, but sub-optimal sleep can adversely affect school performance in many, and even lead to long-term health problems in some children who establish such a pattern during these pivotal years. Hold that thought for now, however.
One obvious reason for insufficient sleep in teenagers, at least it is likely obvious if you have one of your own or have ever spent more than two minutes near one, is technology. Most older children have electronic media in their rooms, if not attached to their bodies in the form of a smart phone. 24-7 access to the internet and social media is a commonly-cited impediment to sleep onset. The increasing availability and popularity of energy drinks containing absurd amounts of caffeine among adolescents likely also plays a role as both a coping strategy for daytime fatigue resulting from insufficient sleep, and as a cause of it. In fact, I think I’ve just come up with the topic for my next post.
Foolproof cure for hiccups?
nOne of the most common questions I get in the newborn nursery, especially from first time parents, involves hiccups. Babies hiccup in the womb and most, if not all of them, will have periodic bouts of hiccups in the neonatal period. But many new parents are surprised by their baby’s first spasmodic contractions of the diaphragm. When brought up, it is often to simply acknowledge that their baby had a run of a few hiccups, usually associated with a feed, with some parents expressing surprise and others nervousness. Regardless of their assumed motivation, I always provide reassurance that hiccups are a normal experience for babies, as they are across the entire spectrum of age.
The medical term for hiccups, which I admit I only learned while researching this topic, is “singultus.” We doctors like to use our own peculiar language as much as possible in order to maintain a sense of superiority when dealing with today’s internet savvy customers, I mean patients, and their families. The rumbling of your stomach, that’s actually borborygmus. You don’t have a unibrow above your nose, that’s a synophrys. It isn’t abdominal or pelvic discomfort associated with ovulation that keeps annoying you midway through your menstrual cycle, it’s mittelschmerz. But since this is a forum meant for general public consumption, I’ll use the rather pedestrian and philistine “hiccup” for the duration of the post. (more…)
A significant part of my job as a pediatric hospitalist involves caring for newborns. It is arguably the best thing that I get to do as a physician, even if I do at times prefer the increased intellectual stimulation of the ill hospitalized child. While seeing newborns, I am almost always surrounded by happy and appreciative parents, grandparents and whoever else is invited to meet and greet the new arrival because the babies are almost always healthy. In fact, and not that I really care (sniff, sniff), the parents of newborns are with rare exception the only caregivers that ever thank me at discharge.
Unfortunately, sometimes I am called upon to assist babies that are having difficulty transitioning into the outside world for a variety of reasons. These reasons can range from the fairly minor and transient to the catastrophic. And despite our advances in the understanding of neonatal pathophysiology and in medical technology, there remain newborn infants that cannot be saved or who have severe lifelong deficits caused by their illness or injury. This will likely always be the case, especially if unqualified professionals continue to involve themselves in either the delivery or the care of babies.
Over the course of 11 years of practice, and after having seen thousands of both perfectly healthy and severely ill newborns, I have acquired a skill set which allows for the recognition of a baby in trouble and the ability to respond appropriately. All pediatricians and family doctors strive to develop this, particularly if they see patients in the newborn nursery, although I imagine none, including myself, would claim to have perfected this “art”. Newborn medicine can be very challenging for many reasons, not the least of which is the significant overlap of the presenting signs and symptoms of many serious conditions, with even normal baby behavior sometimes mimicking potentially life-threatening pathology. (more…)
There is no role of chiropractic in treating childhood bedwetting
In pediatrics, very few things are completely black and white. This is an aspect of conventional medicine in general that tends to separate the approach of science-based practitioners from that of proponents of the many forms of irregular medicine commonly discussed on SBM. They appear to experience no shame in claiming absolute certainty while doling out all manner of implausible remedies for ailments ranging from the well-established to the fictional.
While we do face questions from patients and their caregivers regarding largely invented diagnoses in pediatrics, with chronic Lyme disease and non-celiac gluten sensitivity being just two of many increasingly encountered concerns, my experience has been that alternative medical providers tend to focus their efforts on the same real problems that pediatricians and family practitioners deal with on a daily basis. And I don’t believe that it is mere coincidence that these conditions are largely self-limited in nature, a fact often not shared. Parental and patient buy-in is often more easily obtained with certainty rather than nuance.
Chiropractors, for example, seem to pride themselves on their ability to cure ear infections. Of course in greater than 80% of children with acute ear infections, symptoms will resolve without any intervention whatsoever. This is why the AAP has been trying for years to decrease the rates of antibiotic prescriptions for ear infections, unfortunately with little in the way of success thus far. And when the infections don’t resolve on their own, there is no good evidence that anything a chiropractor has to offer can help. The same can be said for their claims regarding colic and gastroesophageal reflux, which I’ve written about before.
Another condition frequently mentioned by chiropractors as being particularly in their wheelhouse is nighttime bedwetting, the medical term for this being nocturnal enuresis. Rarely have I seen a chiropractic website with a section on the benefits for children that does not mention their success in curing bedwetting. Fred Clary, DC, even claims on his website to be able to cure bedwetting in the newborn baby. And to think I’ve just been ignoring the problem as a newborn hospitalist. Is it because the thought of a newborn infant gaining continence is absurd, or am I just a shill for Big Pampers?
“Ummm, I probably shouldn’t be telling you this.”
The July issue of Pediatrics, the official journal of the American Academy of Pediatrics, contains an extremely thought provoking article discussing the risks and benefits of disclosing an incidental finding of nonparentage during pediatric genetic testing. Nonparentage occurs when one, or very rarely both, of the social parents did not serve as source code for a child’s genetic programming, so to speak. Naturally, we aren’t talking about known adoptions but rather when the nonbiological parent is unaware of the fact that they did not contribute an egg or sperm.
Authors Marissa Palmor and Autumn Fiester, both bioethicists at the University of Pennsylvania’s Perelman School of Medicine, take the position of universal nondisclosure when nonparentage is discovered. They acknowledge the pro-disclosure arguments and, in my opinion, successfully rebut them. They go on to make a compelling recommendation for the incorporation of a universal nondisclosure clause into consent forms which states clearly that parental status will not be discussed. (more…)
I’ve written about the management of acute pain in children in the past, and unfortunately my feelings haven’t changed in the interim. Acute pain, particularly pain related to procedures such as venipuncture for blood sampling and intravenous access, and intramuscular administration of medications such as antibiotics and vaccines, is commonly undertreated, downplayed and even ignored altogether by medical professionals and even caregivers. So when I was made aware of a device being used in pediatric clinics and emergency departments (and even available for home use) with apparent success in preventing or reducing procedural pain in children, I was intrigued and more than a bit hopeful. (more…)
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
The practice of medicine is an art, based on science.
-Sir William Osler, AEQUANIMITAS
The truth is that many of us have some kind of “extraordinary gift.” For a few of us, that gift is the ability to throw a ball at 90 miles per hour and hit a catcher’s glove. For others, that gift is a form of extraordinary perception. Medical intuitives “see” things that others don’t. Wendy Marks has been described as a “human CT scan.” What no one has been able to diagnose by conventional methods is often seen when Wendy scans a body.
–Boston Women’s Journal April/May 2002
The concept of an art to the practice of medicine comes up frequently and in a variety of contexts. Early on in our medical education, we are exposed to the phrase and what it supposedly means, which I will discuss in more detail shortly. But the art of medicine is always painted (pun intended) in a positive light. I will admit that I have a strong opinion, perhaps biased by my involvement with the science-based medicine movement and an equally early exposure during my medical training to champions of evidence-based practice and the use of critical thinking in the approach to patient care.
By now, regular SBM readers should be aware of the Choosing Wisely initiative. Just in case, Choosing Wisely is a campaign developed by the ABIM Foundation to bring together experts from a variety of medical specialties in order to identify common practices that should be questioned by patients and providers, if not outright discontinued. Their ultimate goal was not to establish treatment guidelines or dictate care, but to foster discussion. As I’ve written about in a prior post on the overuse of antibiotics in pediatrics, it doesn’t appear to have caught on. I routinely ask colleagues, residents and students if they are aware of it, and am frequently disappointed by their response.
The American Academy of Pediatrics issued a list of five questionable practices back in February of 2013 and I loved it. All five are important:
- Stop treating viruses with antibiotics
- Stop prescribing and recommending cough and cold medicines for young children
- Stop routine use of CT scans for minor head injuries
- Stop routine use of neuroimaging for simple febrile seizures
- Stop routine use of CT scans for abdominal pain