Saturday, February 23, 2008

stating the obvious

just got a "news flash" from some pediatric journal: caregivers should not "pre-chew" the food for a child because they could get aids from it. wow, glad they told me that one. i'm going to have to put up a sign or something to make sure my patients aren't doing this. forget that food grinder, that blender, do it the "natural" way and chew it for them! oh, and you shouldn't do it especially if you have any open sores in your mouth. please! i've heard many stupid things that parents have done, but this takes the cake. at least there's a reason not to do it now, besides the fact that it's disgusting and i can't even imagine being on either end of that activity! sorry, just had to share that with you.
seems there needs to be a statement to tell people not to do stupid stuff, like the coffee may be hot, and don't put this plastic bag over your head, or don't stick this knife in your eye, or don't swallow this little bag of sand in your medicine bottle, and on and on. one hopes that people who can actually read the warning labels (or can interpret the symbols on the warnings that are supposed to tell people who can't read not to do the stupid stuff) should have the common sense not to do those things, and that the warnings would be unnecessary, but no. sort of like the statement on the airline safety handouts that say "if you can't read this, ask someone to read it to you"...well, if you can't read, how do you know to ask?
i tell parents not to tell the older siblings of a new baby not to do something they haven't already done, like "you can't carry the baby", and things like that, because to do so might give the child the idea. so, if attorneys are responsible for these warnings, and we are a society of idiots, as it seems, is it better to tell us not to do these stupid things or should they not mention them in hopes we won't think of them ourselves? time will tell.

Sunday, February 17, 2008

letters vs. words

We have become increasingly comfortable in recent years in the area of assigning acronyms to diseases and disorders or viruses and bacteria. This makes them easier to refer to and maybe less scary. Or are they less scary? Is something we can't pronounce or understand more or less scary than the letters that represent it? Is the IRS more or less scary because we have relegated it to the status of acronym? I should actually change the word from acronym to initialism. Acronyms are supposed to actually spell a word that can be pronounced, like NOW for the National Organization of Women, etc., whereas initialisms are things like IRS which take some or all of the initials of something and make it a common phrase or almost a word. I looked that up, are you impressed?
What's funny is now that I know that, the whole MRSA thing has really got me going! What do you call an initialism (MRSA) that people, usually on the news, have begun to pronounce as a word, like MeRSA, or MaRSA, when the 'e' or 'a' is nonexistent, not just silent? You call it an attention-getter, a catch phrase, a buzz word, a lead-in, a hype...One would conclude from watching the news (another acronym, by the by) that if you don't die from the flu this year you're bound to succumb to MeRSA or RSV or AIDS. The FDA is making a new PI for the old AD's and NSAID's because of AE's noted in RS's of UD. I made most of that up, but it's jargon for the fact that the FDA is "re-looking" at old drugs based on retrospective studies of usage data. The news talking head doesn't know that, he or she just knows the initials and leaves the rest to you to decipher.
So, is methicillin resistant staphylococcus aureus more or less scary than MRSA? Would Kelly Ogle be able to repeatedly say the "non-initialism" and therefore it would be the problem that it is vs. the BREAKING NEWS STORY it has become?
The lay (nonmedical) public's understanding of microbiology is pretty minimal, and if I wasn't a doctor, mine would be, too, I'm sure. But THE FLU is a virus (not, "I hope it's just a virus and not THE FLU."). RSV, initialized from respiratory syncytial virus, is also a virus, obviously, hence the name and the 'v' on the end of the initialism. Viruses are myriad - there's a gazillion of them, more or less. From the common cold (rhinovirus most often) to the stomach "flu" (another misconception - "I thought he had the flu, but he wasn't throwing up", the real live influenza virus isn't known for causing vomiting as much as high fever, body aches, sore throat, cough, so stomach "flu" is a misnomer, but the most famous in kids is rotavirus, another, famous on cruise ships, is the Norwalk virus), some are petty and to be endured until they go away, while others, like herpes simplex, to quote Eddie Murphy, you keep "like luggage". Then there are the scary viruses, like HIV, an initialism for human immunodeficiency virus, which causes AIDS, an acronym for acquired immunodeficiency syndrome. It can kill you. Some are more in the middle, like hepatitis A, which you get and get over, not to be confused with hepatitis B, which again is like luggage, and even like HIV, can kill. 
One must not only differentiate between viruses and bacteria, but between diseases and their causes. AIDS is the disease caused by HIV. Hepatitis is a liver disease caused by a few different viruses, typically, but can be caused by drugs and other toxins that are not infectious agents. Pneumonia is a lung infection and can be caused by viruses or bacteria. We typically think of it as a bacterial infection and in this case the public lack of knowledge is fed by the medical community's consistent use of antibiotics for pneumonia and bronchitis while studies continue to show that most cases are caused by viruses and no antibiotic treatment is needed. I'm guilty here, too, but hey, how do we know? To find out specific causes takes a lot of time and a decent amount of money, and the public hears pneumonia and has an expectation of at least an antibiotic, hopefully a shot, and if grandma hears about it, she thinks it means hospitals and possible death.
So, pneumonia isn't one thing, nor is hepatitis. RSV is one thing, a virus, but it causes several other things, like bronchiolitis, bronchitis, pneumonia, pneumonitis, ear infections, etc. MRSA is technically one thing, or a group of similar things. 
To further clarify (?), viruses are viruses, and bacteria are bacteria. There don't seem to be as many famous bacteria as viruses lately, but MRSA is an exception. Maybe E. coli is another. There are bunches of bacteria, too, but some of them are good and play a part in our health, whereas viruses are pretty much always a nuisance if not a problem, though most of us have had exposure to way more viruses than we know. Point: there aren't any "good" viruses, only ones that don't cause problems, where there are some "good" bacteria, like probiotics, which actually help us. I may get corrected for saying there are no good viruses, maybe I just can't think of any.
Bacteria are things like streptococcus, which causes strep throat, but others with that first name can cause pneumonia, meningitis, flesh-eating diseases, etc. Staphylococcus is a bacterial first name, and here's a place for another clarification. Germs, viruses and bacteria, often have a first and last name, and some even have some letters and numbers after that. The strep of strep throat is different from the strep of meningitis and pneumonia, the first names are the same but the last name is different. Sort of the opposite of the way we are named here in the US and elsewhere. Strep is more like Smith or Jones, and the word after it tells which Smith or Jones you're talking about. 
Bacteria are killed by antibiotics, or antimicrobials, to be exact, because guns could be said to be antibiotics, since it means to be against living things. When we use antibiotics for a while, the bacteria get smart and some get resistant to that antibiotic. When a bacteria gets resistant, we switch to a different antibiotic, and on and on, until something like MRSA shows up, or some strains of tuberculosis, which are "multiple drug resistant", meaning they are not killed by the usual antibiotics, and we have to pick specific ones, and then...nothing works. Or so it seems, but God didn't create us to be wiped out by a bacteria so He made our immune systems so that we can kill most bacteria on our own given time and a decent immune system, but boy oh boy, having antibiotics to help sure has made things better for the most part, or so it seems. 
Viruses are not killed by antibiotics, in fact, they laugh at them. By using antibiotics in a viral infection, we have selected resistant bacteria to cause secondary infections, so that's why the first antibiotic your kid took for his "cold" didn't work and now you're on to the $100 one. 
Secondary bacterial infections, ones that occur on the tail end of a viral infection, are the problem which we, as physicians, face daily. "Yes, today my child has a "cold", but I know that tomorrow it will be an ear infection, can't we just put him on something now to keep that from happening?" I'd love to be able to do that, but the timing is of the essence. If I put him on an antibiotic before a bacteria has decided it wants to cause a secondary infection, then the antibiotic will kill all the bacteria it can, leaving perhaps, and increasingly commonly, one or more that aren't killed by that antibiotic. So, I've guaranteed that the first drug won't work. How do we know when to treat with an antibiotic? We don't, always. However, a good rule of thumb is that it is better to be a little late than a little early with an antibiotic. Let one settle in a bit, and let it get rid of its rival bacteria, then go in and kill it with an antibiotic.  It seems to be increasingly less common for a child to actually have a bacterial infection in the office. Moms are acutely aware of the early warning signs and perceive themselves as bad mothers if they are unable to anticipate an ear infection or strep throat and the child actually gets sick. This is a challenge daily. 
Viruses, at least some of them, can be treated, but they aren't really killed like some bacteria are killed by antibiotics, they are just kept from replicating or reproducing. So you've got whatever symptoms you've got for however long that particular viral generation lasts, then you get over it. Tamiflu, for instance, works that way with influenza A and B. If you've already got the flu virus, you can start it but you won't get well in a day, it will take a couple or more to let the virus die off and since it can't replicate, it's over at that point. You can also take tamiflu to keep from getting the flu if you've been exposed. Viral resistance to drugs happens, too, and they shift pretty quickly, making the little boogers hard to hit sometimes, hence the flu shot only working on 40% of the flu virus present in the US this year. 
To finish, don't be scared of bugs with initials. They are no more scary than when they had long names that were hard to pronounce. Conversely, they aren't tamed when they've been initialized either. Learn the difference between a virus and a bacteria, an initial infection and a secondary infection, and then you can make better choices as to when to take your child or yourself to the doctor and when and if an antibiotic is indicated. Antibiotics aren't all bad or all good, they are tools, and when used properly, work pretty well. When they become overused, whether by the physician or based on the demands of a patient (sometimes it's hard to separate the two, but healthcare is a consumer driven business to a great extent, and the customer has to leave satisfied...), bad things can happen. Remember, better to wait an extra day or so on an antibiotic than to start too early. There are few bacterial infections out there that are exceptions, like meningococcal meningitis, but 99.9% of the time, this caveat holds true.
Wow, I started off on acronyms and ended up with a microbiology lesson. Sorry. LOL (I don't even know for sure what that initialism means!) but it's a pretty common one in the text business. Have you seen the commercial where the mom, grandma, and daughter are playing Scrabble and they're using initialisms from texting for words? PFF (pretty fricking funny).

Sunday, February 10, 2008

obesity in children

Just finished reading an article that even an optimist like me can't find too many things good to say about. It reviews the literature on the role of the mother in a child's eating and the role of the child in eating and then the combination of the two. You can pretty much guess how it turned out. If it was all the mom, she could change, maybe. If it was all the kid, the kid could change or be changed. If it was all genetic, we're getting there. If it was all psychological, well...but it's all those things and more. It's the mom, it's the kid, it's the two of them together, it's the genes and the environment and whether the mother was overweight and whether they're poor or of low socioeconomic status. It's the grandma, surprise, and where she came from and whether she had plenty of food or not enough. It's the culture, it's where you grow up and the sizes of the kids around you. It's whether your kid tends to eat in the absence of hunger, something they've coined EAH, which I find amusing in our world of 3 and 4 letter confusion. I have EAH. Please forgive my obesity. I can't help it. I really do. I eat because it's time to eat more than because I'm hungry. I eat because there's food there to eat, often without regard to whether or not I'm hungry. My wife on the other hand forgets to eat. What's that? NEPH? Not eating in the presence of hunger? Maybe ADD of hunger? I just didn't pay attention to my hunger. That's never happened to me. 
My advice for parents for many years, learned from experts and observation, is that if you have healthy food around the house, present it at regular times and in measured quantities (another paper I just read says that kids don't want more of a snack if it's presented in a small quantity and they can't see the whole sack of cookies, etc. ) and don't get too wrapped up in whether or not your child ate or didn't eat, you will be less likely to have an overweight child. Or an underweight child. Detach from your child's eating except as it is your job to provide it. There are two good articles to read: one from Contemporary Pediatrics on "Mother Knows Best", vol. 25, no. 1, and one from Wondertime magazine, 3/08, on "natural selection", and no, it's not by Charles Darwin, it's by Catherine Newman. The "heady" one from Contemporary Peds is the more depressing of the two, basically coming to the conclusion that it's all a crapshoot and we have no answers for you, and the other is very funny and well-written and I think speaks to most moms who either are naturally relaxed and have some common sense and faith or who take their xanax regularly, saying that you know what's healthy and just because it's organic doesn't mean you can eat more of it and don't fall prey to the "green" advertising ploys out there that make you think there's a healthy ice cream or potato chip! Good reading. 
These, and many other, articles continue to make me aware that the more we know the less we understand, and I go back to Genesis where the tree of the knowledge of good and evil was the one we weren't supposed to take a bite of, but who in today's world wouldn't have done what Eve did way back then? I know I would have, at least if I'd gotten my lazy overweight butt over to it and the fruit wasn't too high up or too hard to pick or clean or cook or...


OK, random thought while opening a package recently: most of life is packing "peanuts" and they are there to protect the real product inside. Many, if not most, of life's experiences are packing nuts. Newspaper. Those new air bladders that I suspect are cheaper since they keep showing up more and more. Actually, the air bladders pretty much make the metaphor more nebulous and unfortunately more realistic. Most of life is just air, a la Solomon in Ecclesiastes. Our package, our life, has but one precious content, our Savior, our faith in God, our worship of Him, and all the other stuff is just packing - nuts, newspaper, air, bubbles - either protecting that precious cargo or just obscuring it from view. The more room the actual contents of the package takes up, the less packing material is needed, right? Are we the kind of package I saw at Christmas this year where one keeps opening another and another box until the tiny box is finally opened at the end? Or are we open packages, showing the contents for the world to see our God and the faith we have in a way that they can touch and feel and not just hear and wonder if it's the real thing?
OK, that's my random thought of the day. Radical, maybe. Do I do it the way I've suggested? Probably not. I'm pretty much a big old air bladder with just that tiny nugget of faith inside, hidden from all but the most curious of observers, but it's there, trust me, it's there.

Saturday, February 9, 2008

who are "they"?

"They say you're not supposed to let a baby sleep on his belly". "They say that you're supposed to keep a baby on formula until a year of age". "They say that kids need to be socialized earlier than school age".
Who are "they"?
They most often are people with an agenda. With the 2nd and 3rd ones above, the agenda is a fairly simple and straightforward marketing one. They want you to buy more formula, maybe you're even duped into buying a "toddler" formula. They want you to sign your kid up to go to daycare, preschool, mother's day out, or some other form of high cost babysitting and feel you're doing the right thing, and people who aren't doing it are very wrong.
The belly sleeping thing is a harder nut to crack. I can't find an agenda there. Sure, the studies show a 50% decrease in SIDS when babies sleep on their backs. They have gone so far as to say that if you really want to prevent SIDS, the baby should sleep in his crib, on his back, with a pacifier, in your room. Now who sleeps? No one. But at least you don't die of SIDS. Don't get me wrong. SIDS is a scary thing. It's the ultimate "what if". If I'm wrong on an ACL tear or pneumonia your kid's not going to die as a result. 
One of my friends is fond of saying "to the best of the current knowledge" as the answer to the changes we accept as the norm in our lives today. Meaning: don't get too used to doing things a certain way, they're going to change the advice soon. Sort of like the weather, if you don't like it right now, just wait. That's the point with the back sleep thing. When I was raising kids we weren't supposed to let them sleep on their backs because they'd spit up, choke, and die. Seriously, that was pretty much the "current" thinking. Until 15 years ago when they ("they" in this case were some docs in Seattle) showed that SIDS occurred in about 12 kids out of a thousand if they slept on their bellies or sides, and only 6 or so out of a thousand if they were on their backs. Big deal if you're one of the 6 whose life was saved, but statistics have been used very cunningly in this "back to sleep" push, saying, rightfully so, that there is a 50% decrease in 
SIDS if your kid sleeps on his back. But looking at it from a reverse angle, that means a kid is not likely to die of SIDS on his belly 99.988% of the time vs. 99.994% of the time if he's on his back. Does it impress you as much? I didn't think so. It's like those Lysol cans that say "kills 99.99% of germs". Well, since there are billions and billions of germs, that leaves plenty of germs around to do harm if they want. It's all in how you use statistics and the point you want to make. 
Trust me, I don't want even 1 child in a billion to die of SIDS. If I came up with a cure for it, I'd be touting it, too. But we have to look at the bigger picture and consider the ramifications of a change in something. Remember the movie "The Jerk" with Steve Martin? Everybody loved his invention until they all started going crosseyed as a result of it. Actions have consequences. Nobody wants to admit that back sleeping has had bad consequences, but it has. Are they as bad as death? Doubtful. Are there many more "morbidities" (harmful outcomes short of deaths) from back sleeping than "mortalities" (deaths) from sleeping on the belly? When death is in the equation, as a parent, you don't want to take the risk. So you take out the bumper pads and you buy a positioner and you watch the news to make sure there's not something else "they" found that could kill your kid since yesterday's Oprah.
So, who are "they"? They are the nebulous "experts" that purport things on the TV or the internet or in old wives' tales and get enough exposure through the grapevine that their word becomes gospel and who are you to question "them".  Well, look hard at them before you buy their line of bs. Sometimes it's just that. Sure, sometimes it's real and dangerous and if you keep doing this or don't start doing that you will be endangering your child, but the existence of people out there without scruples who will spout nonsense just to see if someone is listening makes me cynical about "them" and "they". To listen to all the stuff that's out on "health watch" and other tv news fillers one should really be surprised that people still are alive and kicking on the earth given all the dangers. We tend to forget that we were created, "fearfully and wonderfully made" I think it says, and that until God decides to put His foot down, the myriad "theys" out there are for the most part just noisemakers in a party they're trying to crash. So, go with your heart, not "theirs". There's no set of absolute rules of sleeping position, no sleep police, no formula police (though formula reps would love pediatricians to espouse their notions and some do, as well as for sleep), no preK hit squad going door to door to make sure your child is being socialized in the (currently and politically) "correct" fashion. You do what seems right and reasonable to you given your experience and gut. Remember, you can find someone on the internet to tell you that everything you are doing is wrong or right at any given time. Forget Oprah. Maybe a little Dr. Phil is OK. But quit worrying about "them" and what "they" say. You're the only "they" your kids really care about, their parents. Look for the hidden agenda in fad thinking about childrearing. 

what if...?

OK, I've dealt with tmi (too much information) as a subject before, but I have to return. Now it's the "what if" factor. Parents can find out so many things on the internet. They get way more information than they are ready to digest, but they don't often know that. They have no filters.
So, "what if" is a common question. One I didn't used to get 15-20 years ago, and one I bet my dad never got. What if it's pneumonia? What if it's cancer? Leukemia? Broken? Rotator cuff? Autism? So many my head swims some days. Not that the questions are always unwarranted, but they sort of take me off my "groove". I have a sort of script in my head sometimes for a visit and how I'd like it to go and when I'd like to share information about "ruling out" certain things. It really has more to do with me than with the patient, so I guess I shouldn't be so conscious of the rhythm or the tone of the visit if I answer the questions and help solve the problems to the best of my ability and to the patient's satisfaction. But the "what if's" are sort of scary in a way. What if I don't have an answer? What if it is meningitis and I didn't consider that? It is entirely possible that I haven't considered every single possibility. 
When I get a "what if" it's a challenge to me and my professional demeanor and expertise, whether the patient knows it or not. Maybe I have considered this or that diagnosis, but haven't mentioned it because it is so unlikely or I'm waiting to go down my list of "what I think it is" before I get to that one and the reasons I don't think it's that. Maybe I don't even want to mention my own complete list of things I'm "ruling out" (see blog of similar name previously) to try not to scare the parents or make them think of something more ominous than they are currently thinking. Aside: we get this in screening tests in newborns fairly often. A positive screen for cystic fibrosis with a nice comment on the bottom of the sheet from the health department that though this screen was positive, it's probably nothing. Then why did you report it to me? And what am I supposed to do about it? Like the heart murmurs so often heard in newborns; if I tell the parents about it, the kid's got it forever! "What if" it's his heart? Remember he had a murmur!? How much information should one share? I'm trying not to be a facilitator of the info overload, but in this day of webmd and google, it's not like parents are blissfully ignorant unless they really want to be, and even then, they have some friend or relative who surfs the web and shares her findings with them, often using a bludgeon rather than a pillow to posit her own theories on what's wrong based on her exhaustive, though completely uneducated, research. Sorry for the sidebar. And, sexist that I must be, I did say the friend or relative who researched everything and shared it with no thought of the effect was a "she" and I did that partly by eenie meenie minie moe and partly by design, since it seems that, from well-meaning aunts and grandmothers to the lady you've never seen before in walmart, it's rarely, rarely, a man who does this. Why? I don't know. Maybe guys don't care enough to search the very best. Have you ever heard of a grandfather causing a ruckus in a family due to his opinions if he was not suffering from dementia in some form? 'Nuff said. Oh, one more. If a dad who isn't the primary caretaker of the child brings a boy, infant or otherwise, to see me, I can bet the problem is about the penis. That's pretty much what we care about! This observation has held true for many years. 
More people want more tests these days to cover for the "what ifs" and there are vultures out there willing to suck you dry to allegedly make you feel better because now you know it is or isn't a torn ACL or a brain tumor or it's just that he isn't talking yet and it's not autism. Sure, I could do lots of tests on lots of patients, and I'd probably get some information I didn't have before the test, but in my experience, most tests lead to more tests rather than more answers. If all a doctor did was order tests, which it seems is occurring  more and more, then why do you need the doctor? You could go to Google, type in your list of symptoms, get the tests to figure out which thing it is, then order your treatment from the online pharmacy without a prescription. I'd best not give Hillary any ideas, so I'll quit this line of thinking, but suffice it to say, we physicians have allowed ourselves to be test-orderers and pill-prescribers instead of diagnosticians and allies in health, and it's our loss and yours.
So, what if things were different? If insurance companies weren't our biggest source of income and we listened to and treated patients the way we wanted and they needed instead of the way the insurance companies and pharmaceutical companies say we should? If you didn't know about ED and Viagra unless you went to the doctor and told him your problem? If you hadn't heard of ADD and if it didn't seem to be such a convenient explanation for Billy's problems at school and what was the name of that new medicine on the back cover of Newsweek? 
What if? What if we ate better and lived better, rather than longer, lives? What if we rested on the Sabbath rather than cram all our activity outside of work into that day? What if we just did nothing sometimes and didn't feel guilty? What if we let our batteries recharge and paid less attention to the crazies on Oprah and at walmart and if we trusted our Creator to know what's going on and to have a plan for us and that we don't always have to know all the answers though science/medicine is doing its best to convince us they (we?) know everything but they/we change it every once in a while to keep you guessing and to keep our profit margin healthy with a new drug or treatment? What if?
Sorry, I know it rambled, but hey... 

Saturday, February 2, 2008

be amused

A mom the other day used a phrase that got me thinking about parenting in general. She was in with her second child, a 3 year old girl, and when I asked about how she was doing, she said "I'm amused by her sometimes".
To be amused is a good thing. It can be a bad thing if one is amused by worthless endeavors like TV, video games, and other activities that further no cause other than to take up time. In fact, "amuse" comes from the greek word muse, which means to think, and the a is added up front to make it a negative, or to not think. So, in digression and to end said digression, sometimes amuse isn't a good thing, or is at least a thing that should be done with care and with limits. However, in this case, amuse is a good thing in my opinion. 
To be amused, we are usually watching something or someone, though sometimes we are participating, but that takes it to enjoy vs. amuse, so for my point, I would use amuse as a spectating word. I like to tell parents that they need to detach from their kids every once in a while, in certain situations. Step back. Look from afar. Spectate. Not on a soccer field or basketball court or baseball diamond or gym floor or any number of places where you go and expect to watch, though watching seems far from many parents' minds in these situations as they yell and scream at players and refs and kids while making fools of themselves for others to spectate.
Distance is a good thing in some cases. It allows us to appreciate things in perspective. Sometimes we have trouble seeing the forest for the trees if we're in the middle of a situation that some distance would clarify. This is not an easy thing to do, however. We are sometimes said to be "too close" to a situation, so I guess some distance or detachment is a good thing. Sure, we can get too far away, uninvolved to any extent. If I haven't blogged about it before, it's all about balance. This is one of those situations. You can be too close or too far away. Only you can decide the right distance or closeness for a given circumstance.
There is a great article by Brett Paesel in Wondertime magazine (March 2008) called in praise of lazy parenting, and it summarizes the amusement/detachment issue succinctly and humorously and is in agreement with my own laissez faire attitude to parenting toddlers and up.
So...go be amused by your kids. Enjoy them for who and what they are. Don't spend all your time trying to make them who you think they should be. If you're not amused by your 2 and 3 year olds, you are really going to hate the teenage years.