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Newborn Phototherapy and Cancer: Cutting Edge Research or “Big Data” Failure?

intensive-phototherapy

Photo by Mike Blyth

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…)

Posted in: Science and Medicine

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The Crack Heard Round the World

Chiropractor Ian Rossborough mid-rationalization

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.

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Posted in: Chiropractic, Science and Medicine

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Parents Convicted in Death of Toddler

Stephans

David and Collet Stephan, parents to the now-deceased Ezekiel Stephan.

This is a very sad and tragic case, and I have great sympathy for the extended family of Ezekiel Stephan, the 19-month-old who died of meningitis four years ago. In my opinion, there are many victims in this case.

The jury, apparently, agreed. Yesterday they returned a guilty verdict for Ezekiel’s parents, David and Collet Stephan, who now face sentencing for failing to provide the basic necessities of life to their son. It is reported that many of the jurors were crying when the verdict was given – clearly this was a difficult and emotional case.

Just the facts

As is often the case, there are different narratives of what happened, depending on your perspective. It is likely the jury had access to more facts than the public, and so their verdict, which was clearly difficult, needs to be taken seriously. Here are the basic facts as being reported:

In March of 2012 Ezekiel became ill with flu-like symptoms. His parents report that they thought this was a normal childhood illness and would pass. His mother reported to police that she thought he had croup. They treated him with natural remedies, mostly supplements. (more…)

Posted in: Ethics, Herbs & Supplements, Naturopathy

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Audio Therapy for Postoperative Pediatric Pain: Randomized Controlled Nonsense

For 10/10 pain I recommend two Rihannas and a Captain and Tennille!

For 10/10 pain, I recommend two Rihannas and a Captain and Tennille

In January of 2015, a study on “the effect of audio therapy to treat postoperative pain in children” performed at Lurie Children’s Hospital and published in Pediatric Surgery International made the media rounds. It was the typical story where numerous news outlets further exaggerated already exaggerated claims made in a university press release, in this case Northwestern University in Chicago. Some of the reporting was quite silly.

The study authors, the chair of pediatric anesthesiology at the hospital and his daughter, a biomedical engineering student at Northwestern who is now a fourth year medical student at Johns Hopkins, make some reasonable points in the introduction. Fear of opioid-related side effects, in particular respiratory suppression, does often result in poorly managed postoperative pain in kids. And there isn’t great data on the safety and efficacy of non-opioid medications for this purpose. (more…)

Posted in: Science and Medicine

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Confusing overdiagnosis for an “epidemic” of thyroid cancer in Japan after Fukushima

A Japanese girl being screen for thyroid cancer.

A Japanese girl being screen for thyroid cancer.

One of my favorite topics to blog about for SBM is the topic of overdiagnosis and overtreatment. These are two interrelated phenomena that most people are blissfully unaware of. Unfortunately, I’d also say that the majority of physicians are only marginally more aware than the public about these confounders of screening programs, if even that.

Overdiagnosis has long been appreciated to be a major impediment to translating programs to screen for disease into better outcomes in a number of diseases but has only recently really seeped into the public consciousness, beginning in particular in 2009 when the United States Preventative Services Task Force (USPSTF) issued mammography recommendations that pushed back the recommended age to start screening to 50. Certainly, the concept of overdiagnosis is counterintuitive. After all, why do we screen for disease in asymptomatic people? The reason is simple—and maddeningly intuitive. We screen for disease based on the belief that catching potentially deadly diseases like cancer early, before they produce clinical symptoms, will allow earlier intervention and save lives. It seems blindingly obvious that this should be the case, doesn’t it? Unfortunately, real life biology and pathophysiology aren’t quite so neat and tidy, and the relationship between early detection and improved survival is muddied by phenomena such as lead time bias and the Will Rogers effect, in addition to overdiagnosis.

What is overdiagnosis? In brief, it is the detection of pathology or disease that, if left untreated, would never endanger the life of a patient or even harm him. Note that overdiagnosis is not the same thing as a false positive. A false positive occurs when a test detects disease that isn’t really there; in contrast with overdiagnosis there is definite pathology. The disease being screened for is there, at least in an early form. It’s just that, at the very early stage detected, it’s either not progressive or so indolent that the patient will grow old and die of something else before it would ever cause a problem. Indeed, it’s been estimated that as many as one in three breast cancers detected by mammography in asymptomatic women might be overdiagnosed and that one in five might spontaneously regress. However, because we don’t know which ones are unlikely to cause harm and haven’t worked out a safe method of observing them and intervening if they look as though they are progressing, we are obligated to treat them all when discovered. The problem of overdiagnosis has led to multiple alterations in what once were considered definitive recommendations for screening mammography, first by the USPSTF and most recently by the American Cancer Society.
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Posted in: Cancer, Epidemiology

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Subluxation Correction: A Chiropractic Treatment for Babies

baby
My article “Pediatric Chiropractic Care: The Subluxation Question and Referral Risk” was published in the 2016 February issue of the journal Bioethics. The abstract summarizes the message of the article:

Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a “vertebral subluxation” or a “vertebral subluxation complex” alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations─the International Chiropractic Association and the American Chiropractic Association─support chiropractic care for children, care that includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.1

The first objection to my article came in a January 30 Facebook posting by Milehighchiro, a subluxation-based group: (more…)

Posted in: Chiropractic, Science and Medicine

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Kangaroo Mother Care, Skin-To-Skin Contact, and the Risk of Sudden Unexpected Postnatal Collapse

Skin to skin sleeping baby
In January, a study published in Pediatrics, the American Academy of Pediatrics’ flagship peer-reviewed journal, presented evidence in support of Kangaroo Mother Care (KMC) and its primary intervention: prolonged skin-to-skin contact (SSC) between a mother and her newborn child. I was originally asked to discuss this report at the time by the editors of The Scientific Parent, which is a great resource by the way, but I wanted to expand on my initial thoughts after letting them simmer for a bit over the past few weeks. Please check out the great work done by Leslie and Julia over at TSP after you finish this post.
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Posted in: Science and the Media

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Baby Translating Technology: Revolutionary Parenting Tool or Confirmation Bias Bonanza

stupidbaby
Caring for a young infant, although a potentially rewarding means of producing a labor force for chores and minor home repairs, can be a trying ordeal for both new and experienced parents. The peaks and valleys of parental experience can leave a caregiver both exhilarated and agonizingly frustrated during a single hour of childcare, let alone the first few months. It is not an uncommon experience for a parent to rapidly alternate between extreme states of emotional arousal, one minute gazing down at their sleeping baby with seemingly limitless feelings of joy and love, and the next panicking at the perception that it has been too long since their baby’s last breath.

Babies, especially stupid ones, require near constant attention during the first several weeks of life, and that’s if it is going well. There is no user manual for the care of the newborn human that could possibly describe every situation and how to effectively respond to it in each individual child. A trial and error approach is always necessary to some degree, and it tends to result in a lot of sleepless nights, with many parents finding themselves more exhausted than they ever dreamed possible. So it shouldn’t be surprising that parents are a particularly vulnerable population when it comes to the marketing claims of bogus technology aimed at making their lives even the slightest bit easier. (more…)

Posted in: Science and Medicine

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Separating Fact from Fiction in Pediatric Medicine: Ear Infections

chiroears

Please don’t try chiropractic first, or at all, for any pediatric condition

As discussed numerous times on the pages of Science-Based Medicine, children are increasingly a target of chiropractors, with some even pushing for recognition as primary care practitioners. Despite a thoroughly inadequate training, and a lack of experience with ill pediatric patients, they believe that they have what it takes to recognize and manage common pediatric conditions or refer to an actual pediatric medical professional when they deem it appropriate. While a significant percentage of pediatric illness is self-limited, and thus might appear to respond to chiropractic manipulation, I have seen many deteriorate quickly and with little warning. The idea of an ill child suffering at the hands of a charlatan is terrifying.

Many chiropractors are of course more than happy to see pediatric patients without acting as their PCP. They love to claim that children are at risk of developing misalignment of the bones of the skull and spine, chiropractic subluxations, and numerous other conditions unique to alternative medical reality, particularly during the first few years of life. They tell caregivers that these insults can be subtle, or even silent for years, and that regular maintenance care is required to prevent severe problems, even going so far as to blame SIDS and “shaken baby syndrome” on these fictional entities.

Many chiropractors are also quick to claim that they can prevent or cure some of the most common conditions seen by pediatricians and family healthcare providers, such as viral infections of the upper respiratory tract, asthma, bedwetting, and ear infections to name just a few. By simply improving the function of the nervous system, chiropractors believe that they can “boost” the immune system’s ability to fight infections, improve control over bladder function, and even reduce airway inflammation and bronchoconstriction. If you think that sounds like nonsense, you’re right!

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Posted in: Science and Medicine

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Acupuncture/TCPM Crapfest

Acupuncture needling

Look Ma! No gloves!

As I get older I get more grumpy. Issues that at one time I was rather sanguine about, now irritate the hell out of me. It is not like it was when I started practice. Information was hard to come by. Going through the Index Medicus, with the world’s tiniest font, wandering the stacks looking for papers, sending off for reprints, getting a precious Xerox (or even a mimeograph) of a classic paper from an attending.

You understood the value of eminence-based medicine, as it took a career to acquire and master the literature. You relied on the wisdom of old geezers like me who had decades of experience and reading.

That was then. Now? The world’s information is available almost instantaneously. You may not be able to master a new topic spending a day on Google and Pubmed, but you can acquire a reasonable understanding, especially of you have some background.

Because of Google and Pubmed, the only reasons for ignorance of your area of expertise in medicine are time, laziness, or stupidity. As a specialist, only time is an excuse. It is my job to keep up with infectious diseases, although with over 10,000 articles a year in ID, it is impossible to read everything. But if I have a question concerning patient care, I need to look it up. I have another blog whose raison d’être is looking up answers to the daily questions that arise in practice.

On the characteristics of a useful clinical trial

So the characteristics of a useful clinical trial are not hard to determine: Randomized, double blind, placebo controlled, adequately powered. Because you want to avoid spending time and money on a study only to end up with no useful conclusions. This is especially important with acupuncture where it not does matter what kind of acupuncture is used, if needles are used, where the needles are placed or even if you mime acupuncture or perform acupuncture on a rubber hand. The key features for success in acupuncture are belief that the patient is receiving acupuncture and that the patient believes the acupuncture will be effective. And the stronger the belief, the better the subjective response. (more…)

Posted in: Acupuncture, Clinical Trials, Traditional Chinese Medicine

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