The mathematics and politics of allocation of organs for transplant

January 13, 2015  |  General  |  No Comments

We have a problem in this country with how precious organs for transplant are allocated. The problem has been brewing for years, and is well recognized in the transplant community, the physicians and institutions that perform them. Two recent opinion pieces review the issue well — here and here. Since PICUs such as mine are closely involved in the practice of organ transplant, both from the donor and the recipient sides, pediatric intensivists like me have a great interest in the process. Above all else, we want it to be fair, because the supply of organs always falls short of the need. Many patients die on the waiting list.

The way the system works now is “locals first.” The country is divided into 58 geographical zones called donation service areas, which are in turn grouped into 11 regions. When an organ becomes available, the system called the United Network for Organ Sharing (UNOS) first tries to match the organ with the most needy person in first the service area and then the zone. Transplanted organs need to match the recipient in several key ways or they will be rejected. If there is no patient match in either of these, the organ can be listed nationally for a match. If there is one, we have a sophisticated system in place to scramble the team at the distant facility to fly to the place where the donor is to pick up the organ and get it back in time to transplant it, although there are some constraints to timing depending upon the particular organ.

The boundaries of these zones and regions were drawn decades ago. The problem is that some geographic areas have longer lists of patients waiting for organs than do others, and different places also vary in how many organs for transplant they produce. So, even though there is a “sickest first” priority system, a less sick patient in a region with a shorter list and for whom an organ matches may get that organ ahead of a much sicker patient in a less fortunate region. Patients can also choose to be listed in a region where they don’t live, as long as they can be at the hospital within several hours. Steve Jobs, for example, chose to be listed for a liver transplant in Tennessee rather than where he lived in Northern California, which has an average waiting time 6 years, because he was more likely to get a new liver in Memphis, which has an average waiting time of 3 months. When the call came, he chartered a jet to fly him there in time.

This doesn’t seem fair. But there are strong political reasons for the debate going on in the transplant community over the issue. If the system is changed, some smaller transplant centers might close down and some regions could become net exporters of organs. For example, the head of the transplant program at the University of Kansas estimates that his institution would lose 30-40% of its transplant practice.

There are some ethical issues to consider, too. For one, an individual physician is responsible for the care of his or her patient. It’s personal. How can a surgeon say to one them that, although there is a match for an organ in the same city, that organ is going to go half-way across the country to a recipient to whom the surgeon has no medical duty other than the abstract social principle of fairness? (To be fair, though, justice is one of the four principles of medical ethics.)

From the ongoing debate it seems clear that the system will be revised. For institutions, there will be winners and losers. But for patients, which is after all why we do transplants, it will be fairer. From one of the essays:

One way or another, I believe, the U.S. organ-transplantation system needs to change. The availability of the benefits of organ transplantation should depend neither on a patient’s ability to charter a private jet nor on whether he or she is lucky enough to live near a hospital that, thanks to our “local first” system, has a relatively short waiting list. When it comes to lifesaving transplants, geography should not be destiny.

Some clues why exercise helps depression

Some clues why exercise helps depression

January 5, 2015  |  General  |  No Comments

Researchers have known for many years that regular exercise helps relieve some of the symptoms of depression, but there has been little cellular or biochemical data on why that might be so, other than the generalization that exercising just makes us feel better about ourselves. There are some new and interesting findings that shed some light on what may be happening. The graphic above, from this article, illustrates the details.

Tryptophan is an amino acid, one of the building blocks of proteins. It is normally metabolized, broken down, in the tissues, including muscle. The system that does this is called the kynurenine pathway because the product of this process is called kynurenine. This substance penetrates the brain, is itself broken down, yielding some molecules that have been implicated in several brain disorders, including depression. This is shown on the left side of the graphic.

On the right side of the graphic you see what happens with exercise. Muscle that is being actively exercised produces enzymes called KATs that take the kynurenine and, before it can penetrate into the brain, change into a similar substance called kynurenic acid. The latter substance does not go into the brain and activate depression-causing pathways.

I think this is quite interesting. It is always fascinating when we find biochemical and cellular explanations for something we’ve observed before but for which we had no explanation.

The promises and pitfalls of healthcare quality performance measures

December 29, 2014  |  General  |  No Comments

The quality-measurement enterprise in U.S. health care is troubled. Physicians, hospitals, and health plans view measurement as burdensome, expensive, inaccurate, and indifferent to the complexity of care delivery. Patients and their caregivers believe that performance reporting misses what matters most to them and fails to deliver the information they need to make good decisions.

Thus begins a recent editorial in the New England Journal of Medicine. It was accompanied by another entitled “Getting More Performance from Performance Measurement.” These represent the rumblings of discontent with the status of current efforts to measure the quality of healthcare patients are getting.

Everyone wants high-quality healthcare. It’s obvious in the abstract. But how do we know what that is? It’s well known that healthcare delivery varies widely across the country. This was shown many years ago by the Dartmouth Atlas of Healthcare, which documented astonishing differences in how medicine was practiced, and of course therefore how much it cost, even between places right next door to each other. These variations persist today. Why? The diseases and disorders being treated don’t vary like that. It turns out, unsurprisingly, that local medical culture and traditions play a huge role. When a new physician comes to the area, he or she tends to fall in line with how things are done there. The obvious goal here should be to deliver the best and most effective healthcare — not skimping on useful care but not overdoing things and adding risk to the patient in the bargain. How can we do that? These days everybody is trying to figure that out, and our current efforts, as discussed in the above articles, aren’t doing as well as they could.

A key distinction to understand is the difference between process measures and outcome measures. A process measure is something that keeps track of a particular activity that we know or assume will lead to better outcomes. A good example is washing our hands. Documenting that we did that is a process measure. We know, however, that it will decrease the number of hospital-acquired infections, an outcome measure. Marking the surgical site before surgery is a process measure; eliminating wrong-site surgeries is an outcome measure. Unfortunately, very quickly things get more complicated than these simple examples. One chronic complaint from physicians is that we are held responsible for outcomes over which we have no power to influence the results. Another complaint is that, as with medical credentialing (I wrote about that swamp here), there are a host of players involved in performance measures and many have their own metrics that differ from each other. From the second essay:

The current measurement paradigm, however, does not live up to its potential. Many observers fear that a proliferation of measures is leading to measurement fatigue without commensurate results. An analysis of 48 state and regional measure sets found that they included more than 500 different measures, only 20% of which were used by more than one program. Similarly, a study of 29 private health plans identified approximately 550 distinct measures, which overlapped little with the measures used by public programs.

A mess like that is a prescription for cynicism among hospitals and physicians — and failure. We need a much smaller, much more manageable set of measurements that everybody agrees are real indicators of good medical care. I think this means, among other things, that we can’t have every payer concocting their own scheme. That is asking for chaos.

We have had some successes in linking a process measure to an outcome measure. A good example is planned delivery of infants who were almost, but not quite, at term. Sometimes there is a good medical reason for doing this. But in the past this was often done for the convenience of the doctor or the parents. Sometimes that meant a baby was delivered too early and had to spend time in a neonatal intensive care unit. As a result of close monitoring of early deliveries, of making sure they were really medically necessary, the rate of early delivery has fallen to a quarter of what it was several years ago. That’s real progress, and it came from performance improvement projects. The author is optimistic:

The science and practice of performance measurement have advanced substantially in the past decade, and increased transparency regarding results means that we know more quickly what works and what doesn’t. Furthermore, all stakeholder groups are now invested in getting more performance out of measurement, which should ultimately drive the care improvement that patients need and deserve.

Maybe. I know this is all inevitable and good for patients in the long run. But I think we will have many more growing pains — false leads, useless measurements — before we get there.


New recommendations for the treatment of bronchiolitis: we should do less because it doesn’t help

December 2, 2014  |  General  |  No Comments

Every fall I write about bronchiolitis because it is one of the most common respiratory ailments affecting infants and children under about two years of age. It is the most common reason infants end up in the hospital during the winter and early spring months. Every year we get severe cases in the PICU. Pediatricians have struggled for decades to figure out how to treat bronchiolitis but we don’t have any specific therapies that work very well. (We have some promising treatments on the horizon, though, as I wrote about here.) Recognizing this, the American Academy of Pediatrics has significantly revised its recommendations of what we should and should not do for children with bronchiolitis. Before I describe these new recommendations, however, I should review what bronchiolitis is and why it can make small children, particularly infants, so sick.

Bronchiolitis is caused by a viral infection of the small airways, the bronchioles. By far the most common virus to do this is one we call respiratory syncytial virus, or RSV. To scientists, RSV is a fascinating virus with several unique properties. One of these is its behavior in the population. When it’s present, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It’s the only virus that consistently and reliably causes an epidemic every year, although it often alternates more severe with milder visitations. RSV epidemics often have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.

Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first few years of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.

RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics. Every year a new crop of susceptible infants enters the population.

So what is bronchiolitis? What does it look like? In medical terminology, adding the ending “itis” to a word means that whatever comes before is inflamed. Thus tonsillitis is an inflammation of the tonsils and appendicitis means an inflamed appendix. So bronchiolitis is an inflammation of the bronchioles, the final part of the system of air-conducting tubes that connect the lungs with the outside world. Beyond the bronchioles are the aveoli, the grape-like clusters of air sacs where the business of the lungs — getting oxygen into our bodies and carbon dioxide out — takes place.

Bronchiolitis is a disorder of blocked small airways. This prevents air from getting in and out normally, primarily out.  The principal source of the blockage is that the bronchiole tubes are blocked from swelling of the walls and from debris caused by the RSV infection — bits of broken airway cells and mucous plugs. This picture shows what it looks like:

Infants are the ones who have the most trouble breathing with bronchiolitis. There are several reasons for this, but a key one is the construction of an infant’s chest. When small airways get blocked, we use our chest muscles — tightening them — to force air in and out of our lungs. We are helped in doing this by the fact that our lungs are encased in a fairly rigid rib cage; when we use our muscles to squeeze or expand our chest the system works like a bellows. Infants can’t do this well because the ribs across the entire front half of their chest are not yet solid bone — they are still soft cartilage.  So when a small infant tries to move air against anything that is restricting airflow, like clogged bronchioles, his chest tends to sink inwards, causing what we call retractions. These are easiest to see just below the last ribs. They especially have trouble forcing air out, so their chests become hyperexpanded with air, making it look as if their chests are puffed out a little. The other reason infants have so much trouble handling debris in their bronchioles is that these tubes are already much smaller to start with, so they get more easily clogged up than do the larger airways of older children.

How does a child with bronchiolitis look? Typically they are breathing faster than the normal respiratory rate of 25-35; often they are puffing along at 60-70 breaths per minute. They also will show those chest retractions and have a cough. Fever is uncommon. They may look a bit dusky from not having enough oxygen in the blood. They often have trouble feeding because they are breathing so fast. The fast breathing, along with the poor feeding, often makes them become dehydrated. Our breath is completely humidified, so when we breathe fast we lose more water.

What can we do to treat bronchiolitis? You read above that we have no specific medicine that will kill the virus. What we have to offer is what we call supportive care: treating the symptoms until the infection clears. Some of that supportive care has been based on how we treat asthma, another condition where air has trouble getting into and out of the lungs. Some years ago we learned that these asthma treatments, such as albuterol breathing treatments and steroids, helped very few children. Even though we knew that fact, a common thing was to try the asthma drugs and see if they helped an individual child, then continue them if it appeared they did.

The new recommendations come down strongly on the side of not even trying these asthma drugs because compelling research argues against it. More than that, the new recommendations say not to take a chest x-ray because it doesn’t help the child and may cause more risk; taking a chest x-ray often leads to physicians over-diagnosing pneumonia and giving antibiotics when they aren’t called for. The new recommendations even suggest we stop testing for the RSV virus, which has been commonly done, because it doesn’t affect anything we do. One thing the recommendations continue from the past is providing good hydration, as well as oxygen if the child needs it — some do, but many do not.

One important point to make, especially for me as a pediatric intensivist, is that these recommendations only apply to children with milder disease. Some children with bronchiolitis become extremely ill and require help with their breathing, either with soft plastic prongs in their nose that deliver oxygen and air pressure or with a mechanical breathing machine. For those children we do what it takes to keep their blood oxygen levels in the safe range.

Old ways die hard, and it will be interesting to see if physicians follow these new recommendations. My guess is that, over time, we will. More and more we are learning that therapies that add risk and cost, without adding any benefit, are not the way to go.

Pediatric Newsletter #12: genetic vs environmental causes for autism and more

November 23, 2014  |  General  |  No Comments

Here is the latest of my more or less monthly newsletter on pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health that I think will interest parents. If you want to subscribe to it and get it in the form of an email each month there is a sign-up form at the very bottom of my home page.

How much of autism is caused by genetic factors and how much by environmental ones?

Autism is always very much in the news. There is intense controversy about its cause, although the bottom line is that we don’t know. It also appears to be increasing, although we don’t know how much of this is what we call ascertainment bias — finding something more when we look for it more. A big part of the controversy is the relative contributions of genetic vs environmental factors.

recent study from Sweden offers useful information about this. The study was immense, over two million children, far larger than any previous ones.

The bottom line is there appears to be more or less a 50/50 split in the relative contributions of nature and nurture. That is, genetics contributes 50% of the causative factors, environment 50%. This is an important finding. Overall, a child with a sibling with autism has a 10-fold higher chance for getting the disorder than does a child without such a family history. The middle part of the article is dense, but the first part and the conclusions are understandable by non-physicians.

Those laundry detergent pods can be quite dangerous for your toddler

recent study examined how common poisoning or other injuries are from those convenient laundry detergent pods. I have seen one severe case myself, causing breathing problems bad enough to land the child on a mechanical ventilator. This study surveyed poison control centers to find out the extent of the problem. It is not trivial.

Between 2012 and 2013 there were over 17,000 exposures to these things, a 600% increase from the previous year, indicating how popular they have become. I can see why they are popular — I use them myself. It’s a lot easier to toss one of them into the wash than pour out detergent from a bottle.

But that convenience comes at a potential risk. Toddlers put anything and everything into their mouths, and the alluring, brightly colored pods quickly dissolve when wet. The survey revealed that there were over a hundred children who required emergency placement of a breathing tube and one death.

So if you use those convenient items, make extra sure your toddler can’t get at them.

Finally we have vaccines for all strains of the deadly meningococcus

Infections from a bacteria called Neisseria meningitides (aka meningococcus) are horrible and often fatal. I have seen probably 20 children die in my career from this, and at least as many suffer terrible complications, such as loss of arms or legs.  This is the bacteria you have probably read stories in the paper about because it can cause lethal mini-epidemics in schools and any place children and adolescents come together in close contact. The infections come in a couple of varieties: meningitis alone, meningitis with septicemia, or septicemia alone. Of the three, the last is generally the worst, with a high mortality rate and serious aftereffects in survivors.

There are five strains of meningococcus that cause disease. We have had a vaccine for four of them for many years. But one of them, group B, has been difficult to develop an effective vaccine for, and this strain is a common cause of disease. The big news, and it is big, is that we now have a vaccine for group B. Meningococcal vaccine is recommended for adolescents — see your doctor about getting it for your child.

All about caffeine: what is it, where is it, and how does it work?

This one is more for you parents than it is for your children. I ran across an excellent and readable summary of what we know about caffeine. First of all, the stuff is everywhere. It is a brain stimulant that is found in many food and drink products, although the most common sources are coffee, tea, and now energy drinks like Red Bull. Here are some fun facts about it.

  1. 68 million Americans drink 3 cups of coffee per day
  2. 21 million Americans drink more than 6 cups per day
  3. 50% of caffeine users experience unpleasant symptoms when they stop, typically headaches, which can last for a week
  4. 5 grams of it can be fatal, but that is 30-40 cups of coffee
Risk of autism: how much is inherited and how much is from environmental causes?

Risk of autism: how much is inherited and how much is from environmental causes?

November 19, 2014  |  General  |  No Comments

Autism was first reported in the medical literature 70 years ago. In 1943 a child psychologist named Leo Kanner described a child with social difficulties and repetitive, stereotypic movements; the following year Hans Asperger described four such children. Since then we have gradually learned more about what we now call autism spectrum disorders (ASD), although we still do not know what causes it. From early on it was apparent that the risk for developing autism was higher among children who had other family members with the disorder. But how much higher? Twice as high? Ten times as high? Recently a very good study from Sweden has given us solid information about genetic risk for ASD. The study’s title is “The Familial Risk of Autism“.

Sweden has a very centralized and complete health care and medical record system. This allows tracking of relatives beyond the immediate family — cousins and grandparents — as well as siblings and half-siblings. One thing to note, however, is that Swedish society is much more homogeneous than ours, something that we should keep in mind when we interpret the results. The researchers also made no attempt to understand what environmental factors could be playing a role in ASD. The power of the study is that the authors asked a simple question: What is the risk for an individual child for having ASD and how is that risk affected by having other family members with the disorder?

The authors studied just over two million Swedish children born between 1982 and 2006. That is a huge study group, much higher than earlier ASD studies. What they measured was the relative recurrence risk for autism. This is the risk for the disorder among children with family members who have it compared to the risk for children with no family members with ASD. If the risk is the same for both groups, there is no genetic component. The extent to which the risk is greater for children who have affected family members is the contribution of genetic factors. This risk should get higher the closer the relationship — a sibling should cause a higher risk than, say, a first cousin. There is an important caveat to keep in mind here. Close family members often share the same environment as well as the same genes. A standard way to get around this problem is to study closely related individuals, especially identical twins, raised in separate environments. The authors weren’t able to do that, but it is still a very powerful and compelling study simply because of its huge size.

So what did they find? The risk for ASD in a given child was 10-fold higher if there was an affected full sibling, 3-fold higher if there was an affected half-sibling, and 2-fold higher if there was an affected first cousin. Plugging these numbers into a series of calculations, the authors determined that, overall, the contribution of genetic factors to ASD was 50%; that of environmental factors was 50%. So, half and half.

Autism is a complicated disorder. Like other neurological problems with both genetic and environmental components, such as schizophrenia, it is most likely a complex interplay of environmental influences on a genetically susceptible brain. There is an enormous amount of ongoing research to identify what is happening and what we can do about it, and I fully expect useful answers and treatments within the next few years. Studies such as this one are crucial to figuring it out.

The credentialing process for physicians has become a cumbersome, chaotic, and unholy mess

November 12, 2014  |  General  |  No Comments

Everyone wants to be sure their physician is competent and appropriately trained. The way this is done is through credentialing. A new applicant for privileges to practice at a hospital or other healthcare facility fills out an application and submits a curriculum vitae that details when and where a physician trained and the certifications obtained, such as specialty boards, and a work history (if any). Copies of key documents — medical degrees, residency certificates, and the like — accompany the application. The applicant also provides the names of professional references who can attest to competency. Also required are declarations that the applicant has never been fired (or asked to resign) from a medical job for competency issues. The applicant also must also swear to a long list of other things. These include not being a drug addict (who would answer yes to that?), a convicted felon, or to have been disciplined for questionable or illegal activity. A committee then reviews the application and grants (or not) privileges to practice medicine at that facility.

Before the committee grants privileges, however, all the information gets verified. This makes perfect sense because, regrettably, there are more than a few documented instances of people embellishing or even outright lying on their applications. I have been on enough selection committees to know that folks occasionally stretch the truth. Flagrant examples of this occasionally make the news. The job of credentialing departments is to check up on all this. Interestingly, in the example I just linked to, the guy hoodwinked all the verifiers; it was only picked up later by accident.

It gets more complicated because not just hospitals and healthcare facilities want their practitioners credentialed. All of the people who pay the bills, such as insurance companies and the government — Medicare, Medicaid — want to make sure they are paying legitimate costs to legitimate practitioners. So they have their own credentialing departments, all different in how they do things. A typical physician has to be credentialed by every single one of the payers covering every single one of his or her patients. That can mean a dozen payers or more. So, for example, besides having privileges at the hospitals at which I practice, my background is verified by all the people who pay the bills for my patients. And believe me, the requirements of all these entities are not the same and all have their own sheaf of forms to fill out and supporting documents to submit.

This situation cries out for a central clearing house for credentialing information. Some examples of this exist, such as this one, if nothing else because collecting all this information is tedious and expensive. Credentialing departments at many facilities are getting larger all the time. Credentialing is also a major industry, with overwhelmed facility credentialing staffs farming out the process to outside contractors. The problem is that, in our disorganized healthcare “system,” no facility or entity wants to surrender the right to collect their own data in their own way. Attempts to institute a more global process, at least in my experience, have simply added another layer of bureaucracy to slog through. The convenience, or even the sanity, of the physicians wrestling with this unholy mess is not their concern. For physicians like me, who practice at several hospitals in different parts of the country with little overlap in who the regional payers are, the expense and hassle of it all are large. And even when you think you’re done, you’re not: many entities require frequent updates, often meaning a whole new application. One that I deal with demands this every three months.

Okay — rant over. But what prompted this was my agreeing recently to help out some people for a few weeks at a new hospital. I’m now four months into the credentialing “process.” During that time I’ve dealt with three separate organizations, none of which communicate with each other. I’ve worn out my fax machine submitting extraneous document after document. Nearly every day my email inbox has strident demands for still something else IMMEDIATELY! If I hadn’t promised my time to people I like, I think at this point I would just say: no, I’m done — good luck.

I’ve been practicing medicine for over 35 years. For my first job I just showed up for work. People checked that I had graduated from medical school, done a residency, and passed my exams, but that was about it. I realize physicians have to some extent brought all this on ourselves by a few of us scamming the system over the years or just lying. I recall a case some years ago of a physician lying about a five year gap in his work history, a gap that turned out to be because he was serving time in prison for third-degree murder. (I looked for a link to this incident but couldn’t find one — it most likely was pre-Google.)

Anyway, I think this credentialing mess has got to get better organized somehow. We need a central authority of some sort, accepted by all. The current trajectory is unsustainable. Healthcare is expensive enough, and all this adds many millions to the total costs for little benefit.


Most new parents don’t know how to use a car seat correctly, vitamin D, and more: Pediatric Newsletter #11

October 27, 2014  |  General  |  No Comments

Here is the latest of my more or less monthly newsletter on pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health that I think will interest parents. If you want to subscribe to it and get it in the form of an email each month there is a sign-up form at the very bottom of my home page.

About those physician rating sites: do parents use them to find a physician for their child?

There are now a multitude of web sites on the internet that allow consumers, that is patients and their families, to rate physicians. And why not? There are rating sites for many other products and services. But these sites can strike fear into the hearts of doctors because, when you look at them, the number of ratings for a particular physician is usually quite low. In my own case, for example, a popular rating site only lists one for me even though I’ve been practicing for 30 years. So there is the fear that one disgruntled patient can tank your rating. But these sites are here to stay, I think. A big question is if parents use them to find a doctor for their child: or, if they haven’t used them, would they? A recent survey asked that question and found that parents are beginning to use the information on the sites. My concern is that, if this is the future, they be run a little better. For example, Angie’s List, a popular one, has contacted me several times to ask me to rate myself. I assume it was a computer glitch, but the potential to cook the books is always a concern with anonymous rating sites.

Long term treatment of ADHD with stimulant medications does not affect growth

Pediatricians are always concerned that long term treatment with any medication could affect a child’s growth. This is true for any medication, but it is a particular concern for attention deficit/hyperactivity disorder (ADHD) because there are so many children taking these medications and they often take them for many years. A recent study in the journal Pediatrics is reassuring on that point. The authors studied a large group of children through childhood and on into adulthood and found no effect on growth.

A related, and important point, is how common is ADHD? A recent report from the Centers for Disease Control (the CDC) used surveys of parents to assess that issue. What they found is that 11% of all children between the ages of 4 and 17 had at one time or another been given the diagnosis of ADHD, and 83% of those still carried that label. And 69% of the total were currently taking ADHD medication. That represents a whopping 43% increase over the past decade. For myself, I find it hard to believe ADHD is increasing at that rate; it’s more likely increased awareness of the condition, but there also may be a component of you find what you look for.

What is my advice to parents about this? I’m not an ADHD expert, I’m a critical care pediatrician, but it seems to me to be a stretch to categorize 11% of all children as abnormal — that even defies the definition of what the word normal means. If your child’s teacher wants you to get ADHD medications for your child, I would first carefully look into the details of the concerning behavior. How troublesome is it really? Could there be other explanations? Could more structure help? Then see a physician or psychologist with experience with ADHD. If the recommendation is for medication, for myself I’d seek another opinion and see if they agree. This is an area in which parents should be the ones driving the bus.

Most parents don’t know how to use a car seat when they leave the hospital with their newborn infants

There is no question that car seats save lives. Since their use has been mandated by law, the death and injury rates of children involved in motor vehicle accidents have fallen dramatically (40-50%). But the seats need to be used correctly. A recent report suggests that new parents need more help in figuring out how to install and use them. In fact, 93% of new parents made at least 1 critical error in using the seat. So if you’re not entirely sure if you’re doing it right, have someone check. Our hospital, like all hospitals delivering babies, has specially trained nurses that can look at your seat, your car, and make sure the seat is installed right. There are also quite a few good online sites (like this one) telling you about different kinds of seats, which children need which ones, and how to install them.

Lower vitamin D levels found in children who drink non-cow’s milk

Many children do not drink cow’s milk. This may be because of a sensitivity to cow’s milk protein, a common condition, or because of parental preference. Parents of children in this situation should know that this brings a risk of reduced vitamin D levels in the blood. Commercial cow’s milk is fortified with vitamin D, as are infant formulas that don’t contain cow’s milk. A recent studymeasured vitamin D levels in children who don’t drink commercial cow’s milk and found that many of these children had low vitamin D levels.

Vitamin D has long been known to be crucial for bone growth. Rickets, a once common bone disease in children caused by low vitamin D, is now extremely rare since milk has been fortified with the vitamin. We also know now that vitamin D has many other functions, such as in cardiovascular health. Our body can make vitamin D if exposed to sufficient sunshine, but this is not a reliable source. Of note, the above study comes from Toronto, and rickets was once much more common in climates where children get less sunshine exposure.

The bottom line is that if your child does not drink fortified cow’s milk he or she is at risk for low vitamin D. Your child’s doctor can help you with identifying the best way to supplement this key nutrient.

The ultimate challenge in controlling healthcare costs: reducing needless care

October 8, 2014  |  General  |  No Comments

Efforts to reduce overuse of health care services run counter to the dominant financial incentives in our fee-for-service system, challenge the cultural assumption that more is better, and raise concerns about stinting on necessary care.

That quotation is from a recent editorial in the New England Journal of Medicine. It points out the often quoted estimate that 25-35% of all medical care either doesn’t do any good or is actually potentially harmful, what the editorialist calls low-value care. That is a huge problem, one that will prove very difficult to solve.

The fundamental issue as I see it is that, although founded on science, medicine is very imperfect as a science. It’s a mixture of science, near-science, intuition, guesswork, and blind luck. Depending upon the disease or condition, the more uncertain portions of medical practice figure much more prominently than the certain ones. Over the past several decades we have tried more and more to use evidence-based medicine, that is, doing only things and using only treatments that hard evidence has shown to be beneficial. Unfortunately, rigorous studies of what works and what doesn’t work are difficult and expensive to do. More than that, a great deal of what we do doesn’t even lend itself to that kind of research. We’re often stuck with what committees of experts recommend based upon weaker studies or just opinions.

The other huge problem is with how fee-for-service medical practice works: doctors are generally paid  much more for doing things than for not doing things. Low benefit or even useless treatments represent somebody’s revenue stream; limiting or even eliminating them takes money out of practitioners’ pockets, creating a strong impetus to keep going as we are. But the enormous cost may finally be convincing the public that something has to change:

Public acceptance of a role for policy in reducing the use of low-value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs.

I have no doubt that ultimately physicians will be told what they can and cannot do, most likely through the mechanism of what insurance payers will pay for. We’ve been seeing various forms of that kind of limitation for years and the process will accelerate. The mechanism of high co-pays was hoped to help by giving patients a financial incentive to avoid needless medical care. But there is a problem with that, too.

Demand-side interventions — targeting patients — principally include financial incentives and education. Increasing patient cost sharing is a blunt instrument: research shows that it can reduce use of both low- and high-value care, which suggests that patients do not have the information or skill required to differentiate between the two.

Many people outside the medical field think that applying simple market principles would help. If things cost so much, why not just increase the number of physicians and let them compete with each other on cost. Surely the result would be, as with other supply and demand commodities, that costs will come down. It doesn’t happen that way. In medical care, supply drives demand rather than the other way around. Adding more physicians who do things results in more things being done, something known for 50 years.

I don’t know what will happen with all this, but something will. But this will be the general direction:

To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value.

A smartphone app for jaundice, effects of digital media on children’s brains and more: Pediatric Newsletter #10

September 30, 2014  |  General  |  No Comments

Here is the latest of my more or less monthly newsletter on pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health that I think will interest parents. If you want to subscribe to it and get it in the form of an email each month there is a sign-up form at the very bottom of my home page.

Coming soon: A smartphone app to see if your baby is too jaundiced

This bit of news is pretty interesting, although the product is still in development. These days babies typically go home from the hospital when they’re a day old or even less.Newborn jaundice is very common, especially in breast-fed babies. Nearly all the time it means nothing and passes without treatment. Once in a while, though, the blood bilirubin, which causes the jaundice, gets dangerously high. We treat it with phototherapy. It takes a blood test to measure the blood level, although we’ve used devices for years in the hospital that estimate it from the skin color, identifying those babies that need the blood test. Now it looks as if there will be a way to screen your baby at home using your cell phone and then sending the results to you doctor. I think it’s a cool concept.

Let them sleep in more: American Academy of Pediatrics recommends delaying school start for adolescents

Every parent with a teenager knows they like to sleep more. To no one’s surprise, this is because they need more sleep to be healthy and sharp for school. Research has shown real benefits for mental and physical health. Starting school at 7:30 in the morning, or even earlier, is particularly hard for adolescents. Recognizing this, the AAP has come out with new recommendations for middle and high school start times, suggesting 8:30 am as more appropriate.

Who knows if this will go anywhere because the logistics of getting kids to school and parents to work on time can make it tough to change things. After school activities, such as sports, would also be affected if practice times are pushed back. But it seems pretty clear that a later start would be better for teenagers.

Children who use digital media a lot may be less able to read actual human emotions

This one is interesting. All of us, especially children, are spending a lot more time staring at digital screens — computers, smart phones, video games. A research report coming out next month suggests this may not be a good thing for emotional development. Children, who have not yet fully developed human interaction skills, may be less able to read emotions on actual human faces if they spend a large amount of time with screens.

The researchers found that children whose access to electronic devices was limited were better able to read other people’s emotions. The authors concluded: “Decreased sensitivity to emotional cues – losing the ability to understand the emotions of other people – is one of the costs. The displacement of in-person social interaction by screen interaction seems to be reducing social skills.

“I’m not surprised by this, really, and I find it concerning. It’s one of several reasons my wife and I monitor and limit our son’s computer and smart phone time.

High levels of physical activity linked to early academic achievement

Every parent knows that physical activity is good for children. Among other things, being active and not parking in front of the TV is linked to a lower level of obesity. A new study from Finland suggests that a higher than average level of physical activity is also linked to improved academic performance in elementary students, particularly among boys.

The authors observed 186 children during recess for the first 3 years of schooling and also collected other information on physical activity, such as riding a bike to school: “The improvements in academic attainment were most striking in male participants, especially with reading skills. Boys with higher levers of physical activity, and in particular walking or cycling to school, had better reading skills than the less active boys.

“I was interested to see this research but it seems to me to be confirming common sense. What it is really saying is that if you encourage children, especially boys, to run around a lot and work out their energy, they concentrate better in the classroom. It reminds us that old-fashioned recess is getting rarer and rarer. A half-hour of unstructured play time used to be common; it no longer is.