I’ve written about this before, but it’s well worth doing it again. It’s once more cold season, bringing up the question parents commonly face: Should they buy one of those rows and rows of cough, sneeze, and runny nose medicines one finds in every drug store and supermarket? In a nushell, no — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a report some years ago by the Food and Drug Administration, one still worth reading. You can read about the details, as well as the history of how and why these cold remedies were regulated in the past, here.
There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spend millions of dollars marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.
In fact, they are not. Poison control centers receive thousands of calls about them every year, and The Centers for Disease Control found that many are seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.
The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.
The Food and Drug Administration has issued a public health advisory that they not be used at all in children less then two years of age. They left use in children older than two alone, but I wouldn’t use them for those children, either. They don’t help, and may harm.
If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple – don’t use them in small children.
So what can you use for a child with a bad cough? Some recent research, a good quality study, suggests that Grandma’s old folk remedy of honey actually helps. It not only can sooth the cough, but may have a specific cough-supressant effect.
Another thing to keep in mind is that persistent cough may actually represent a variant of bronchospasm or wheezing, particularly if your child has had wheezing troubles in the past. So it’s worth checking with your doctor if your child has a persistent cough because anti-wheezing medications, such as albuterol, can help that situation.
It is well known that more people today are overweight or obese than in the past. This has been a steady trend for decades, but there is some recent evidence this increase has stabilized. This is promising. Since many obese adults began as obese children, during the last decade physicians who care for children have devoted considerable effort to reversing the trend. This is important because obesity sets up the individual for a host of chronic disease problems later in life. How well are we doing? Are we getting anywhere? A recent study published in the journal Pediatrics gives us some answers about that question.
The study was a survey of adolescents during three time periods: 2001-2002, 2005-2006, and 2009-2010. The survey looked at several things. These included physical activity and screen time — time spent watching TV, playing video games, etc. It assessed several dietary issues, including number of portions per day of fruits and vegetables, sweetened beverage consumption, and chocolate and other sweet intake. The survey also measured how many days each week a child ate breakfast, since skipping breakfast has been associated with weight gain.
What did the investigators find? Well, there is both encouraging and discouraging news. First, the encouraging news: they found improvement in all the measures. On average, over the time period studied, kids exercised a bit more, ate more fruits and vegetables and drank less sugary drinks, and spent a bit less time in front of the TV. These encouraging trends happened across all age and socio-economic groups.
The discouraging news is that, first, although the average of these behaviors was in the right direction, the majority of adolescents still rank poorly in all these measures that are associated with obesity. More than that, obesity, as measured by the body mass index (BMI), continued to increase over the time period, rising from 10.3% of adolescents in 2001 to 12.7% in 2009. Yet there is a glimmer of hope: the increase occurred between 2001 and 2005. There was no change between 2005 and 2009. In addition, the number of kids classified as overweight but not obese dropped just a bit. The graph from the article lays out what is really the bottom line.
This study also brings up an issue we see a lot in clinical medical research: the contrast between process measures and actual outcome measures. For example, we assume that emphasizing hand washing decreases infection rates in hospitals. So we focus on the process measure of improving hand washing rates. Unfortunately, process measures, especially of complicated, multi-factorial problems like obesity, don’t always reflect the underlying problem we are studying.
The other issue that sometimes comes up is that the process measure we think improves the situation is actually just an association, not a cause and effect thing. If that’s the case improving the process measure may not have any effect on the basic problem.
Still, I am encouraged by these results and hope they persist over time.
A large number of pediatric practices these days use after-hours call centers for parents who have questions about a sick child. I’ve been looking around to find some data about how common this is, but my sense is that the majority of pediatricians use them. There is no question these call centers make live easier for the doctor; having somebody screen the calls, answer easy questions, and only call you for important issues is a great boon. But that boon comes at a cost: the people staffing the call centers are not doctors. They are often experienced nurses, but that is not the same thing. So deciding what is important and what can wait can be a problem.
The call centers generally use predetermined protocols drawn up by experts to help guide decision-making. This is a good way to ensure consistent, quality advice. But not every child fits the protocol, and a set of guidelines is not a substitute for actual clinical experience. Really, these days a savvy parent can get almost as much useful guidance from consulting Dr. Google (or my latest book). A study presented at the most recent meeting of the American Academy of Pediatrics examines another question: do these call centers send too many children to the emergency department?
My assumption would be that they do. After all, they are hard-wired to do so. If you call one, the person giving you advice not only is not a doctor, they do not know your child. Also, the decision-making protocols they use necessarily err on the safe side. So if there is any doubt about what to do they will advise you to take your child to the emergency department even though your child’s doctor often might not do that.
The study bears out this presumption. The investigators, from Children’s National Medical Center in Washington, D.C., examined the records of 220 children for whom the call center advised parents to take their child to the emergency department. They used a panel of evaluators to see if the visit to the ED was appropriate. They found that, for a third of the children, they could have safely stayed home.
After-hours call centers have made doctors’ lives less hectic, and I’m not suggesting we do away with them. They give thousands of parents useful advice. Plus, what we don’t know is if even more of those 220 children would have ended up in the ED if the call center didn’t exist: who knows, perhaps they steered a significant fraction of children away from an inconvenient and expensive ED visit. However, in my own anecdotal experience the call centers do increase ED use. I have had many parents tell me, after I’ve seen their child in the ED, that the only reason they came was that the call center told them t0 — that they were surprised by that advice and otherwise would have stayed home.
My own father was a small town pediatrician. He didn’t have an answering service. When parents wanted to ask about their sick child they just called him at our home. His phone number was in the directory just like everybody else’s. He didn’t have any sort of pager. If he wasn’t home, people called back or else called whatever number one of us kids or my mother told them to call to find him. Those were simpler times, and not necessarily better ones. Now we have call centers, and we need to figure out how best to use them.
I’d be interested in any experiences, good or bad, that parents have had with after-hours call centers. Were they helpful? Were they a problem?
Asthma is a common problem in children — nearly 10% now have it — and the number is increasing. Researchers are not sure of the reasons for this steady increase (more here), but decreased air quality, lower activity levels among children, and an increase childhood obesity have all been implicated. Whatever the cause, it means that millions of American children take medicine for asthma. A significant number of these children end up in the PICU for a severe asthma attack. As I speak to their parents, it is clear that more than a few parents have only vague ideas of how the different types of asthma medicines we use work in their child’s body. This is an important subject, since using the medicines correctly is the best way to keep your child out of breathing trouble, and to use them correctly it very much helps to understand how they work.
The first thing to understand is what is taking place inside the lung during an asthma attack. Once you know that, you can see how the different asthma medicines relieve the symptoms. Here is a schematic drawing of what a normal lung looks like:
You can think of the lungs as being composed of two parts. The first is a system of conducting tubes that begin at the nose and mouth, move through the trachea (windpipe), split into ever smaller tubes, called bronchi, and end with tiny tubes called bronchioles. The job of this system is to get the air to the business portion of the lungs, which are the alveolar sacs. This second part of the lung brings the air right next to tiny blood vessels, or lung capillaries. Entering capillary blood is depleted in oxygen and loaded with carbon dioxide, one of the waste products of the body’s metabolism. What happens next is gas exchange: as the blood moves through the capillaries, oxygen from the air we breathe in goes into the blood, and carbon dioxide leaves the blood and goes into the air we breathe out. The newly recharged blood then leaves the lungs in an ever enlarging system of pulmonary veins and then goes out to the body.
The main problem in asthma is that the conducting airway system gets blocked in several ways, so the oxygen can’t get in and the carbon dioxide can’t leave. Although both are a problem in a severe asthma attack, getting the air out is usually a bigger issue than getting it in because it is easier for us to generate more force sucking in air than blowing it out. So the hallmark of asthma is not getting the air out — called air trapping. Why does this happen? There are two principal reasons: for one, the small airways, the bronchioles, constrict, get smaller; for another, the walls of the airways swell and the airways themselves fill with excess mucous, blocking air flow. Here’s another schematic drawing of what that looks like.
Thus during an asthma attack these things happen, all of which act together to narrow the airways and reduce air flow:
- The smooth muscle bands around the tiny airways tighten
- The linings of the airways get inflamed and swell
- The mucous glands in the airways release too much mucous, filling the airways
The medicines that we use to treat asthma work by reducing (or even preventing) one or more of these things. But before we get to them, an obvious question is why are our lungs are constructed in this way, especially if it can cause trouble? Why are those smooth muscle bands there? Why does there need to be mucous in our airways?
The smooth muscle bands are there for a good reason. The lungs need a way to direct the air we breathe in to the best spots, which are those regions of the lung with the best blood flow, and that changes from minute to minute from such things as changes in our position — lying down to standing up, for example. Those muscle bands function like the head gates of an irrigation system, opening and closing to direct air to the best places. The mucous is important because it is one of the chief defenses our lungs have against harmful or irritating things we breathe in. The mucous traps debris and steadily moves it up and out of our lungs. In asthma, both of these natural systems become deranged. The so-called triggers for this derangement vary from person to person, but the results are similar. The medicines we use are similar, too, no matter what started the asthma attack.
One of the mainstays of asthma treatment is a member of a class of medicines we call selective beta agonists. The generic name for the one we use most commonly is albuterol. Common brand names for albuterol are Ventolin and Proventil. Albuterol comes as a liquid, which we blow into a mist either with a device called anebulizer or with what’s called a metered dose inhaler (“puffer”). The second of these is more convenient to carry around, but it can be more difficult to use with small children, although adding a special chamber to the device can help. The patient inhales the mist of albuterol. It works by soaking into the smooth muscle bands, making them relax, and in that way making the airway tubes bigger to allow more air flow. (There is also an oral form of albuterol, but for a variety of reasons it is not a good choice for children with asthma.) For many patients with asthma, inhaled albuterol alone is adequate treatment for their symptoms. A key thing to know about albuterol is that it goes to work right away, generally within minutes, so it is a good medicine for an acute asthma attack.
Another class of medicines long used in the treatment of asthma is corticosteroids, or steroids for short. These medicines work by being powerful blockers of inflammation. If you have ever had a poison ivy rash, for example, you are familiar with inflammation: redness, swelling, and seepage of fluid from the tissue (we can use steroids to treat poison ivy, too). A similar inflammation around the small airways is characteristic of asthma. It makes the linings of the airways swell, weep fluid, and increase mucous production. For a severe attack, we give steroids by mouth or intravenously (IV, directly into the bloodstream). They are very effective when given that way. But they do not go to work right away — several hours are needed at least. So although we may start them during an acute attack, we don’t expect them to help for a while.
Steroids are powerful drugs. When you take them by mouth they affect your entire body, not just your asthma, and that can cause problems. This is why we only use systemic steroids — those by vein or by mouth — for as short a time as possible, typically five days or so. We have other forms of steroids that are inhaled. This allows them to work directly on the airways without affecting the entire body. Common brand names of inhaled steroids are Pulmicort and Flovent. The inhaled steroids, like the systemic ones, don’t go to work right away. So they are intended primarily as a medicine to maintain control of the asthma. It is a common mistake for parents to give their child multiple doses of inhaled steroids when they have worsening breathing troubles — steroids are not intended to be used that way. The proper so-called “rescue medication” for worsening symptoms is albuterol or drugs like it.
These days we have hybrid medications that combine a long-acting albuterol type drug with an inhaled steroid. This combination is intended as something to be taken for chronic control of patients with moderate or worse asthma, and these agents are quite effective at doing that. Common brand names are Advair and Symbicort.
So albuterol (and beta-agonists like it) and steroids are mainstay medicines for treating asthma. In combination they make a good team because they attack the asthma via two different modes of action. We have some other medications that work by still other mechanisms. Montelukast (brand name Singulair) blocks airway inflammation by another mechanism than do steroids. Unlike systemic steroids, the action of montelukast is more selective and this medication is safe to take for prolonged periods. For some patients, montelukast and an occasional puff of albuterol is sufficient to keep them out of trouble. Finally, an inhaled drug called ipratropium (brand name Atrovent) blocks excessive mucous production by another method than blocking inflammation; it is often helpful as an adjunct to the other medicines. A couple of medications (brand names Combivent and DuoNeb) combine ipratropium and albuterol together so they can be inhaled at the same time.
So how do doctors decide what asthma medicines to use? One obvious principle is that it makes little sense to use more than one medication of the same category: combinations ought to work in different ways so they can work together. But beyond that obvious principle, how do we decide? The usual approach is to classify patients with asthma according to their severity and then add medicines in a logical, step-wise way until we get control of the symptoms. There are guidelines to help us do this. A good, recent summary is here, published by the National Institutes of Health. If you or your child has asthma it is a good place to find information. It is also useful to look at the actual decision tree doctors use to decide what medicines to use and in what order. You can find it here. One key principle is that we divide medicines into maintenance medications — those the child takes every day — and “rescue” medications, ones the child takes for worsening symptoms.
Asthma is common and is getting more common every year. Certainly speak with your child’s doctor about doing some good detective work to figure out what your child’s asthma triggers are. Then take steps to modify exposure to them or avoid them. Common sense tells us that if we can reduce symptoms by reducing exposure to common triggers, such as tobacco smoke, we should do everything we can to reduce the need for asthma medications. But for many children, this will not be enough; their parents should understand how these medicines work in order to make the best use of them.
Childhood vaccination remains controversial among some non-physicians, in spite of being nearly universally recommended by physicians. If you spend some time on Google you will discover a whole world of websites where the issue, long settled in the medical community, is vigorously debated among non-experts. Of course a large component of this controversy is fallout from the now thoroughly debunked claims by Andrew Wakefield that there was a link between vaccines and autism, but I have practiced long enough, and know enough medical history, to know that parental fear and misinformation about vaccines was present before Wakefield, and certainly long before the internet.
So physicians are not uncommonly faced with the task of trying to convince parents to vaccinate their children. The standard way to do this is to present the information about vaccines in a calm, non-confrontational way that both respects parental autonomy and does not belittle their concerns. That can be a tough thing to do. The American Academy of Pediatrics even offers advice about how best to do it. The bottom line is really quite simple. All medical procedures carry risk. We always the weigh the risk of doing the procedure against the risk of not doing the procedure. In the case of vaccines, the risk is infinitesimally small; the benefit is large. So that calculation favors vaccination.
What interests me is the interpersonal dynamic in which a physician is trying to convince a skeptical parent to vaccinate their child. And that led me to a fascinating post on a political blog called The Non Sequitur – here. (Also see here.) The issue is this: what happens when people with incorrect information are convinced they are correct, are then given the correct information, but then an argument ensues anyway. Of course we don’t want to argue in the examining room, but the principles are similar. Here’s the gist of it:
Research by Nyhan and Reifler on what they’ve termed the “backfire effect” also suggests that the more a piece of information lowers self-worth, the less likely it is to have the desired impact. Specifically, they have found that when people are presented with corrective information that runs counter to their ideology, those who most strongly identify with the ideology will intensify their incorrect beliefs.
It’s a form of digging in, I suppose. When we encounter this problem, what should we do about it? It’s a bad strategy just to say the same thing over and over again, and it’s certainly bad to do so in an increasingly louder and more disparaging voice. The approach that seems to work best is to dial things down a notch or two, something that skilled negotiators have always known. The author uses a couple of boxing metaphors, which again aren’t quite what we’re up to in the examining room with a child and her family, but they make good sense.
We argue like boxers wildly throwing powerful haymakers that have no chance of landing. What if instead we threw carefully planned jabs that were weaker but stood a good chance of connecting?
Sometimes what we think are the most obvious, overwhelming arguments in our favor are those that threaten the other side the most.
Constantly going for the knock out argument is a bad strategy primarily because it’s bad argumentation. Such moves are very likely to distort the views of the person you’re trying to convince and in so doing alienate them. What’s better is the slow accumulation of evidence and the careful demonstration of the truth or acceptability of your beliefs.
Looking at things this way makes a lot of sense to me, and would help make a parent a collaborator rather than an adversary. But how could that work in practice?
One approach that I’ve found useful is to talk about the concept of relative risk. Non-physicians don’t think about risk in the same way physicians do. Parents want no risk; physicians would like that, too, but realize there is no such thing.
The notion of risk is pretty abstract — it helps to think of specifics. According to the Centers for Disease Control, the overall risk for a serious side effect from two common vaccines, DaPT and MMR, is about 1 in a million at worst, more likely about 1 in 10 million. By comparison, the risk of being hit by lightning is, on average, about 1 in 700,000 per year, yielding a lifetime risk (if you live to be 80) of 1 in 3,000. Over the last 20 years on average around 50 people die each year from being hit by lightning.
Most parents would make sure their child was not out in a lightning storm, so perhaps a more relevant statistic is the risk of being killed in a car accident. Parents these days put their children in car seats, which has greatly improved safety, but they still head out onto the highway without thinking about the risk. And the risk is not trivial: anyone’s average lifetime risk of dying in a car accident is 1-2%, and car accidents are the leading cause of death in children ages 2-14.
If you spend a little time researching you can find mortality statistics for a host of everyday activities, things parents do with their children without even considering the risk. The object, of course, isn’t to scare parents; rather, it is to put vaccine risk in an understandable perspective. This approach is more likely to be a useful strategy to convince them than going for the heavy, “knockout punch.”
And, if you’re a parent skeptical about vaccines, I hope I’ve given you a different slant on the issue.
We know that drinking lots of sugary drinks is bad for school-age children. A recent research article in Pediatrics, the journal of the American Academy of Pediatrics, asks a related question: What do we know about these drinks and younger children?
The authors examined the correlation between consumption of sugar-sweetend beverages and body mass index (BMI) in 9,600 children ages 2-5. Children who drank sugar-sweetened beverages for meals and snacks had a higher risk of being obese. Further, two-year-old children who continued to consume these drinks over the next several years had a steadily increasing BMI on average.
There is a good accompanying editorial to the article that reviews what we can or should do about this disturbing trend. The authors conclude:
To date most SSB policy discussion has neglected the youngest children. Isn’t it time to effect meaningful policies and implementation strategies to curb SSB consumption in our youngest children?
We have been training physicians the same way for a century, ever since the famous Flexner Report of 1910. That report was commissioned by the Carnegie Foundation in an attempt to improve medical education. Up until then many medical schools were simply terrible. Many were proprietary schools, owned by doctors and run for profit rather than education. Many doctors met their first actual patient after they graduated.
During the decade following Flexner report these proprietary schools either closed or merged with universities, becoming the institution’s medical school. Within a fairly short time the model of medical school as a four year course divided into two preclinical years (studying basic medical science) and two clinical years (learning to treat patients) was the standard. We’ve been doing it that way ever since.
There have long been calls to change this. Various schemes have shortened the usual eight year process of four years of college followed by four years of medical school, usually by shortening the college part. A recent op-ed in the New England Journal of Medicine renews the call for shortening the process, this time by making medical school three years instead of four. A counter-point essay follows, arguing to keep medical school at four years.
What do I think? I think the arguments for shortening medical school are beside the point. Two of the main reasons the advocates give are to reduce student debt and lengthen the useful practice careers (by one year!) of doctors. The latter, they write, would improve the doctor shortage. But really, if the problem is student debt, there are many direct ways to address that. Likewise, if one thinks we need more doctors, then train more.
I think we should keep medical school at four years. There is already far more to learn than can be learned in that period, so shortening things would only make it worse. There is also the maturation factor; to function as a doctor you need how to think like one and act like one. That takes time — I’m still learning at age 61. Lopping a crucial year of the process is not the answer.
Most educators, and plenty of parents, think children these days spend too much time in front of a screen — computer screen, video game screen, or television screen. It is the last of these that has particularly interested physicians who care for children because increased TV time is associated with some health problems. For example, there is a correlation between time spent watching TV and the propensity to develop asthma. It’s not that TV causes asthma, but that children who spend hours each day watching it are more likely not to have less healthy lifestyles overall — like the kid in the picture.
Several things are associated with children spending more time in front of the tube. Not surprisingly, having a TV in a child’s bedroom is one. The American Academy of Pediatrics is particularly concerned about TV use in children under two years of age — here is their policy statement about that.
A new study, whose author one could easily call Captain Obvious, demonstrates that the highest correlation regarding how much TV a child watches is with how much his or her parents watch. Still, it’s helpful to have research confirm common sense.
So, if you want your child to watch less TV, watch less yourself.
Pain, in all its varieties and subtleties, is among the most complex of human symptoms. It has been described in uncounted ways by writers and portrayed by actors, but we read or view these characterizations through the lens of the pains we ourselves have had. Even though we all have felt pain, and in that sense have shared the experience with all other humans, it is also unique to us. Pain is both universal and profoundly personal. It’s a complicated subject.
Pain is not limited to humans, of course. All mammals certainly feel pain. Some aspects of the pain response reach far down below mammals in the animal kingdom to quite primitive creatures. How these creatures perceive it, if that is even the right word, is mysterious, but this observation tells us pain has been with us for many eons. That fact alone should tell us it must serve some important purpose.
All of us know that pain comes in many forms. There is the sharp pain from stepping on a tack. There is the vague, dull aching of a twisted knee, the cramping pain in the lower abdomen that comes with the flu, the pounding inside the skull of a migraine headache, the gnawing pain of a toothache. There is the restless pain that persists in spite of what positions you take, as well as the pain that only relents when you lie completely still. All of us could think of many more examples.
Pain is reported to the brain via a dense network of nerve fibers. Think of this network as an intricate grid of electrical wires, because that is what nerve signals are made of — electricity. These wires are of several kinds, but there are two principal ones. They differ in how well insulated they are. Instead of the plastic insulation that protects electrical wires, the body uses a substance called myelin to insulate the neural wiring. Some wires are more tightly wrapped with myelin than are others. Some nerve fibers have no myelin at all. The more wrapping, the faster the electrical signal travels, so myelinated fibers transmit signals faster than those without myelin.
The nervous system uses a series of switching stations to pass a signal from, for example, the end of your finger to your brain. The first of these are in the spinal cord. When you prick your finger, an electrical signal goes from a nerve fiber there, up your arm, and on to a relay station in the spinal cord in your neck. From there, it continues on up your spinal cord to your brain. What happens to it when it reaches your there is fascinating — and complicated.
Pain is a subjective feeling, meaning no one besides yourself can know precisely how you are feeling it. This means no two people will experience pain in the same way; the exact same finger prick may be perceived quite differently by two different people. An injured person can even be initially unaware of his injury because he does not feel it at first. Probably you have experienced the situation in which, distracted by something else, you did not feel a stubbed toe or a bug bite to the same extent you would have if your mind were not focused on something else.
This variability in how pain is perceived, of the discomfort it causes us, is because the simple electrical signal running up your finger from that needle prick gets modulated by a maze of other nerve cells in the spinal cord and in the brain. Some of these influences dampen down the signal, others ramp it up. The result is when it finally gets to your upper brain, where your consciousness lies, all sorts of things have affected the signal, things that are unique to you and your brain.
You have several kinds of nerve fibers in your finger. The ones that transmit the fastest signals, the heavily myelinated ones, mostly are concerned with light touch and position sense, which is knowing where your finger is in space. This makes sense, because these bits of information are things the brain needs to learn as rapidly as possible. If you want to demonstrate this for yourself, close your eyes, open your mouth, and rapidly stick your finger in your mouth. You can do this without poking yourself in the eye because your brain knows, every millisecond, just where your finger is in space in relation to your mouth. These nerves are also involved in the pain response, particularly in blocking some of its input in the spinal cord. When they do not work, the perceived pain from a pricked finger is worse.
The nerve fibers in your finger that transmit pain signals, the ones with less or no myelin insulation, can sense three kinds of things: mechanical forces like hard pressure, hot and cold, and chemical substances. If you pay attention when you whack your finger with a hammer, hard as that may be to do, you can distinguish between them in action. You first feel a very sharp, very localized pain. This is a signal from the insulated fibers, which gets to your brain first. An instant later you begin to feel a more diffuse, deeper pain that is less well localized to the precise spot. This is input from the slower fibers with no myelin.
Another way we experience the difference between fast and slow fibers is when we bark our shins on a piece of furniture when walking in the dark. We first feel our leg hit the furniture — those are the insulated touch and position sense fibers at work. After a perceptible lag, we feel like yowling in pain — those are the uninsulated pain fibers catching up with their messages.
We have two main approaches for treating pain: we can do things that reduce the pain signals coming from the spot that hurts, or we can use medications that confuse the brain into thinking the pain is either not there or is not so bad.
There are several simple things we can do to reduce the pain signals coming up the nerve fibers. A simple one has been known to parents for eons — simple rubbing of a painful spot. Stimulating one set of nerve fibers, particularly the fast, insulated ones, affects how our brain processes sensations. Every parent knows how to do this, although you probably did not know why it works. When your child comes running to you after falling down and bonking her head, what do you do? Generally you rub it, and it really does feel better. This is not just from parental love. Stimulating the touch fibers in the same place where the pain is coming from causes them to intervene and dampen back the pain signal coming from the other fibers. The same thing happens when we rub any body part after we hit it on something.
Cooling the area with an ice pack is another way to reduce the pain signals coming up the nerve network. Yet another is to put a medicine that interferes with how the nerves work right on the painful spot. Examples of this approach include ear drops that can numb the ear drum for a child with an infection or numbing sprays and ointments for a child with sunburn. A dentist injecting a painkiller around a sore tooth is using a more powerful version of these same methods.
The other way to treat pain is to use medications that act directly on the nervous system to alter how the brain reacts to the signals coming up from the painful place. They convince the brain to downplay or even ignore the information. This is how both acetaminophen (Tylenol and many other brands) and ibuprofen (Motrin and many other brands) work. Ibuprofen also relieves pain in another way that acetaminophen does not; ibuprofen can work directly at the site, such as the inflamed finger or ear, to block the production of some of those substances that cause the inflammation. We also have an injectable medication related to ibuprofen, only more potent, called ketorolac (brand-named Toradol).
More severe pain, such as from a broken arm, calls for medications more powerful than Tylenol or Motrin. Members of the opiate family, also called narcotics, are the standard. There are many members of this family, which vary in how they are given, their appropriate dose, and some of their side-effects, but they all work in the same way: they go to the brain and the spinal cord and alter a person’s perception of the pain. They also can alter mood and a person’s level of awareness to things around them.
Even though we give narcotic medications for severe pain, a fascinating thing about them is that they are not really foreign to the body at all. We have similar substances that occur naturally in our body, and presumably these natural narcotics, called endorphins and enkephalins, are performing some useful function inside us, most likely involving pain control. So when we give a child with more severe pain, such as a broken leg, a medication of this type we are really just reinforcing a normal pathway. The presence of these natural substances could explain why some persons, an Indian Yogi for example, can walk across a bed of hot coals without pain because he has learned how to alter his brain’s perception of what is painful.
Pain, uncomfortable as it is, does serve some useful purpose, and in that sense helps a child heal. Pain alerts us that something is wrong and tells us we should try to do something about it. If we cannot feel the pain, worse injury often results. A good example of this is what happens when a person lacks sensation in an arm or a leg. Because he cannot feel there, painful things, such as an ill-fitting shoe, can go unnoticed and lead to injury.
But pain can also interfere with healing. Mild or moderate pain does not seem to affect healing much, but more severe pain, if it persists, can interfere with it. This stems from the effects of what we call stress hormones, substances like adrenaline, which the body releases at times of stress. They are called “fight or flight” hormones because they probably helped our ancient ancestors deal with things like a wild animal attack. Although they can help in times of acute danger, prolonged high levels of these hormones, such as occurs with continuing severe pain, do inhibit proper healing. Researchers have studied this phenomenon in children who have had major surgery, and it is clear that using pain-killers does not just make the children feel better — it also makes them heal better.
Doctors once thought that children do not feel pain to the same degree adults do, and children were often under-medicated with pain drugs for things for which no adult would tolerate not receiving adequate medications. Now we know better. If your child is, for example, in the emergency department with a broken arm, make sure the doctors take care of her pain as well as fix the broken arm. Just because a child can’t tell us about the pain doesn’t mean it’s not there.
I’ve written about this before, but it’s always a good thing to remind ourselves of simple things in medicine. The severe-looking physician pictured above is Robert F. Loeb, long a professor at Columbia University Medical School. He reportedly could be a bit tyrannical to students and residents, but he is credited with formulating a simple way to cut through to the nub of things.
Sometimes we doctors are prone to do too much to our patients, especially in high-tech environments like the PICU. The bewildering array of all the tests and therapies we have can confuse us more than enlighten us. Dr. Loeb long ago offered a simple way to cut through all the confusion, offering what have come to be known as Loeb’s Laws. We all learned variants of them in medical school, but now and then we need to be reminded of them. Here is one formulation:
1. If what you are doing is doing good, keep doing it.
2. If what you are doing is not doing good, stop doing it.
3. If you do not know what to do, do nothing.
4. Never make the treatment worse than the disease.
Dr. Loeb was not a surgeon, so one occasionally hears a tongue-in-cheek substitution of his fourth law that goes something like this: “If at all possible, keep your patient out of the operating room.”
Seventy years later, Dr. Loeb’s wisdom is still often useful. All of us, doctors and patients, are tempted to do things just because we can do them, or because we’re curious. That’s never a good way to proceed.