Students wishing to go to medical school — premedical students — have gone through pretty much the same process for nearly a century. The requirements have some variability according to the whims of particular medical schools, but in general a person wishing to go to medical school needs a four year collage degree, during which he or she has completed two years of chemistry (including organic chemistry), a year of physics, a year of mathematics, and a year of biology. They also have to take a standardized test, the Medical College Admission Test (MCAT), which is intended to introduce some measure of comparability between what students from various colleges and universities know in common. (There are a few exception to this pathway: a few institutions have programs that combine undergraduate teaching and medical school training, producing a physician in six or seven, instead of eight years.)
Like premedical students, medical students have had pretty much the same training program for a century. Our current way of doing things dates back to the shakeup caused by the Flexner Report in 1910. This was a detailed survey of all American medical schools, and it showed how bad many of them were. As a result, many closed, and many others either merged with stronger schools or upgraded their teaching to what leaders of the time considered to be the gold standard: two years of basic science training followed by two years of practical, hands-on experience seeing patients. Although we have tinkered around the edges since then, little has fundamentally changed.
Here’s how things looked back then:
However, the world has changed. For one thing, medical science has exploded, yet we still train physicians for the same eight years we always have. Nobody wants to extend the duration of medical training; after all, with a typical residency added on after medical school it takes eleven years to produce a physician, often longer.
Now things look more like this — more diverse students, computers everywhere:
The heavily science-influenced training also raises another issue: GPA in science courses and MCAT scores predict well what a student’s academic performance will be in medical school (which is a bit tautological in itself), but they do not predict how good a physician he or she will be. Several medical schools have grappled with this by using what they term “holistic review” of prospective medical students, including objective measures (well, as objective as can be) of things like curiosity, interpersonal skills, empathy, and capacity for growth. An interesting recent article from Boston University School of Medicine assesses how successful these efforts have been.
The first, and to me unsurprising, result is that using this broader evaluation tool resulted in medical school classes that are more diverse in age, experience, race, and cultural background. Yet the average entering GPA and MCAT scores did not change, and student academic performance was just as high. Faculty at Boston University did note a couple of changes, though, including this key one:
The general sense of the faculty, particularly those who teach our small-group problem seminars, is that the students are more collegial, more supportive of one another, more engaged in the curriculum, and more open to new ideas and to perspectives different from their own. Some of these observations are subjective and difficult to quantify, but there is a striking, and uncoached, consensus among the experienced faculty members.
What about premedical training? What about the stereotypic hyper-competitive, obnoxious, fanatical premed, determined to get into medical school at any cost? Should we do something to change that culture? Or is it the best way to develop our future doctors? My own view is that these aspects of premedical training drive away many good students; they could be fine physicians, just lousy premeds. They never even consider the career. Another essay in the same issue of the New England Journal of Medicine describes Mount Sinai School of Medicine’s experience with that issue.
The Mount Sinai program, called Humanities and Medicine Program, provisionally admits, while still in college, students to medical school who are not premeds — they study whatever they want to. They don’t take the MCAT. They get their needed science background for medical training via a series of special summer boot camps. The most interesting thing to me is that for twenty-five years Mount Sinai has admitted half their class through the traditional pathway and half through the Humanities and Medicine Program: the academic performance, traditionally measured, of both groups in medical school has been the same. Here is what they have to say about its goals:
By eliminating MCAT use, outdated requirements, and “premed syndrome,” we aim to select students on the basis of a more holistic review of their accomplishments, seeking those who risk taking academically challenging courses; are more self-directed than traditional medical students; pursue more scientifically, clinically, and socially relevant courses; and pursue independent scholarship.
For myself, I applaud these efforts. Twenty years ago I spent four years on the admissions committee of Mayo Medical School, a highly selective medical school. I was discouraged over how committee members often mouthed the words of wanting more diverse, humanistic (whatever that means) students. But when it came time to vote on candidates, MCAT scores and GPA trumped all.
I also have a personal bias. I took the bare minimum of science courses in college, choosing a double major in history and religion. Even back then (1973) I was admitted to several medical schools. I never felt underprepared; you learn what you need to know when you need to know it. And I think that undergraduate experience made me a better doctor.
So I’d like to see more of this.
There is a large body of medical literature about the positive effects of music in a wide variety of situations: it has demonstrable calming effects. There is one group of very vulnerable patients for whom we have long done this, but in whom it is a bit hard to determine the effects — premature infants. An interesting recent study gives us some information about it.
The investigators, who work at one of 11 different neonatal intensive care units, studied for a two week period 272 premature babies with one of several common problems that babies of that age are prone to develop, including respiratory distress and infections. The music therapy was administered, and the results recorded, by trained music therapists. They noted the infants’ feeding behavior, heart rate, and respiratory function before, during, and after music sessions that lasted several hours each.
The results showed lowered heart rate (a sign of decreased anxiety and stress), lowered respiratory rate (another sign of decreased anxiety) and improved sucking behavior with feeding during the music time. Babies fed better and took in more calories when the music was playing.
The investigators used several kinds of music, coupled with other soothing sounds. It was provided live at the bedside, which is pretty amazing but probably not feasible for many places. The therapist sang lullabies or used a small instrument called a gato box, which produces a rhythm meant to simulate human heartbeat. Prerecorded ocean sounds were also used. Not surprisingly, parents observing all this reported they perceived their infants to respond by becoming calmer. The paretns probably became calmer themselves.
All three modalities improved sleep patterns. This figure shows this pretty clearly: control infants (those without the music therapy) has worse sleeping patterns. This effect was sustained over the whole study period, even the the therapy sessions themselves were only a couple of hours each three times each week.
Anybody interested in this should take a look at the article for details. To me the results are really an example of verifying and quantifying common sense: after all, parents have sung to their infants for as long as humans have been around. There’s a reason for that — it works, and is therapeutic both for parent and infant.
This is a topic that comes up from time to time for often spirited discussion. The most recent example comes in a a couple of articles in the New England Journal of Medicine. One was a research paper; the other was a pro and con discussion.
The research paper studied cardiac arrests that happened outside the hospital. The authors tested the premise that allowing families to watch the efforts of the medical team reduce their psychic distress later. One group of patients received usual care, which meant keeping the families away from what was going on. Families of patients in the other group were asked if they would like to observe the resuscitation up close: 79% chose to watch. A medical team member was assigned to be with them and explain everything that was going on. The researchers then followed up with the families 90 days later to determine how many had symptoms of anxiety, depression, or actual post-traumatic stress disorder.
The investigators found a significant reduction in psychological symptoms among family members who had watched the CPR. Also important is that there was no problem with family members interfering with the medical team.
Now comes the controversy. Family observation of CPR is a hot topic among critical care and emergency physicians, and opinions are strong both for and against. This is shown in the next article. It is short — a case scenario of a cardiac arrest, and is well worth reading if you don’t know what we actually do in those situations. Two experts then wrote brief pro and con statements about allowing families to watch. But it is in the comments where things really heated up. Here are some examples:
Being present is more harm to the family
A genie that should not have been let out of the bottle
No family presence for me!
Absolutely no — apart from the chaotic scenes of CPR, I don’t want to be accused by the family bystander that I killed their loved one, do you?
Don’t deny families who choose to be present –support them
Being present far more important for all.
Yes, I support family presence at the bedside during a code situation
And so on, for nearly a hundred comments. Scanning them over, they seem pretty equally divided. I assume the commenters were talking about adults, but this issue always comes up when we have a CPR event in the PICU. For pediatric intensivists, the question of parents observing is I think less devisive. I always ask families if they wish to leave or would like to stay with their child. Nearly all choose to stay. I have heard many times afterwards that they were glad they had the opportunity to participate in some small way. Nearly all the pediatric intensivists I know feel the same way.
I have never had a problem with parents interfering with care in any way. But the demeanor of the team members, especially the physician directing the resuscitation, is key. Resuscitations are stressful — and messy, too. But shouting never helps anything. A calm, firm demeanor is what parents need to see, especially in the doctor. So do the other team members. I’ve been doing this for 30 years and have seen my share of chaos. The way to control that is practice, practice, practice: mock codes keep everybody sharp.
It is crucial, however, that someone be delegated to stay right by the parents and explain what is happening. Usually I designate an experienced PICU nurse, who needs to be ready to support the parents emotionally — physically, too, which means finding chairs or stools as needed. Every parent I have ever dealt with in this way has been grateful afterwards for being allowed to stay.
Maybe adult patients are different; I have no experience with that. But I think parents of a child should always be given the option. It the resuscitation is unsuccessful, it is a good way to assure them that everything possible was done to save their child.
If you’re interested in this issue at all, I highly recommend you read the pro and con piece linked above, especially the comments.
Forty years ago I had a wonderful history professor at Haverford College, Roger Lane, who would begin the courses he taught by giving us “Lane’s Rules of History.” The first one was: “things are complicated.” Others included “things change,” which had a corollary: “and nobody knows how they will turn out.” What he meant, of course, is that generally the closer you study something involving human behavior, the more complicated it becomes. And predictions about the future are always problematical. Professor Lane has always had a healthy and amusing respect for the vagaries of human behavior, as you can see in the above picture of his often-smiling face.
Now we are finding that Professor Lane’s rules apply to medicine, too. This should not be surprising, since medicine is practiced by people on other people. Many years ago the Dartmouth Atlas of Health Care, a still ongoing project, noted there were astonishing differences in the cost of heath care across geographic regions of the country. Some of these differences were between places quite nearby to each other, and correcting for such things as differing costs of living and doing business did not affect the results. Most importantly, high cost regions did not deliver better health care — it just cost more overall.
What appears to be the most important difference between high and low cost areas is medical culture, mostly physician culture, in “the way we do things here.” Patterns of practice, of how doctors evaluate and treat the same condition, vary quite a bit. In places where doctors do more, costs are higher, but with no discernible improvements in patient outcomes. As a case study, Atul Gawande wrote a fascinating essay about the inexplicably high costs in McAllen, Texas — the most expensive medical market in the country. But people are no healthier there.
These disparities have not gone unnoticed by those who pay the bills, primarily Medicare. A recent editorial in the New England Journal of Medicine describes the results of a government study that tried to figure out what was going on. What they found is Lane’s First Rule of History in action — things are indeed complicated.
The Dartmouth Atlas divides the country into 306 hospital referral regions, among which there were these major differences in costs. That’s a lot of regions, so you would think it slices up the country into fairly small bits. But it is even more complicated, because the variations within some hospital referral regions were just as great as between them. Even more complicated was the finding that extensive (and expensive) use of treatments for one condition did not translate to others; regions were high cost in some things but low cost in others.
Some have argued the variation is primarily patient-related. That is, regions vary in the health of their respective citizens, so it’s not just doctors and hospitals in one place being more inherently aggressive than those in others. Some places, the theory goes, have sicker inhabitants than others. I’m sure there are examples of that. But refuting this theory is the finding that in many cases people who move from a high cost region to a low cost one, and vice-versa, immediately experience whatever the costs are in their new region. It seems unlikely they got sicker or healthier just from moving.
What conclusions did the blue-ribbon committee come to? What should be done? Anything? They did offer this:
In sum, the committee found that most of the variation among geographic areas is attributable to variation in the use of post–acute care and inpatient [hospital] services. Moreover, within any area, provider behavior varies substantially, so increasing reimbursement for all providers in an area would unfairly reward poorly performing providers, and reducing reimbursement for all providers in an area would unfairly penalize high-performing providers.
My conclusion is that sociology is at work here. I don’t think physicians and hospitals in one place are especially more venal than they are in another place. I think physician behavior varies according to the local physician culture. I have observed physician routines in multiple places around the country — Minnesota, Colorado, South Carolina, Kansas, Missouri, Arizona — and I have seen rather large differences in the nitty-gritty at least in how my branch of medicine is practiced.
We certainly can improve things with “best practices” research and training physicians to use them accordingly. Yet that approach only applies to some of what we do. Medicine resists standardization because it remains in some irreducible ways a black art — a mishmash of science, near-science, intuition, guesswork, and blind luck.
Things are complicated.
There is a fair body of research looking at the amount of television children watch. On a typical day, a child in America between the ages of infancy and 6 years watches about an hour and a half of TV. The effects of this on the child appear to be content-based. In particular, violence and other content inappropriate for children are associated with negative outcomes. In contrast, “pro-social” and certain varieties of educational content are associated with positive outcomes.
Very little, however, is known about the effects of background TV, those times when the television is on and in the room but nobody is really watching it. There is some research suggesting that increased background TV is associated with lower sustained attention during playtime, which is concerning, but which has not been verified with further research. A key question is just how much background TV children are exposed to. If kids spend an hour and a half watching TV each day, how many hours are they exposed to of background TV? A recent study in the journal Pediatrics gives some data about this question. The article also has references at the end if you want to track down the medical literature about the effects on children of watching different kinds of TV. (The full article is behind a paywall — if anybody wants the full version let me know.)
The study was a survey of about 1,500 households using daily diaries. The mix of families was a pretty close match to a cross-section of the population in racial and socio-economic characteristics, such as income and educational level. The results showed that the average child is exposed to 232 minutes of background TV — nearly four hours. This is a pretty startling number. Not surprisingly, having a TV in the child’s bedroom really jumped the exposure number. I think a TV in the bedroom of a young child is a really bad idea, just on general principles, but this is another reason not to have one.
The effects of this background TV exposure are still unclear, but I doubt they can be good.
Shortages of a long list of medications have been a problem for some time now. Many, many important drugs are in short supply. The FDA even keeps a list of them. The reasons for this are fairly well known. All of the drugs in short supply are generics, meaning they are off patent. This means the profit margins to be had for any company making them are very slim. The shortages mostly affect injectable drugs, not pills or tablets, because injectables are more expensive to manufacture. Often a particular generic injectable drug is made by only a few, or even a single, company. If there is a problem at the manufacturing plant, the supply can dry up quickly. The pharmaceutical industry does not really make drugs based upon what people need; they look at potential profits. So a drug for a rare condition does not have much chance.
One family of drugs long affected by shortages is that of injectable anti-cancer drugs. When that happens, cancer specialists sometimes can find other ways to treat the cancer. But often there is no equivalent medicine. A recent, disturbing article in the New England Journal of Medicine documents what can happen then. Faced with a shortage of a standard anti-cancer drug, called mechlorethamine, doctors had to devise an alternative treatment program for children with a cancer called Hodgkin’s lymphoma. As cancers go, this is a very curable one. Yet the children with the alternative program, without the mechlorethamine, did worse — much worse.
The authors’ conclusion is clearly correct:
Almost 80% of children and adolescents with cancer can be cured with current therapy. Most of the curative treatment regimens are based on chemotherapeutic agents that have been available for decades, but some of these have recently been in short supply. These shortages are likely to have devastating effects on patients with cancer and must be prevented.
We simply must find another way of ending these chronic generic drug shortages. This is not a problem a market-based, profit-driven pharmaceutical industry will fix on its own. They must be given some incentive, some reason to make these drugs. We are talking life and death here. The authors of the article rightly call this . . .
”an intolerable situation for young people with curable diseases.”
Imagine this scenario. Your two-year-old son has had a runny nose for a day or two and an occasional cough, but seemed no worse to you that everyone else in his preschool class. Two hours after you put him to bed you hear him coughing, only this cough is like none you have ever heard from him before. It sounds like a barking seal at the circus–a brassy, honking noise. In between coughs he his making a strange crowing-like noise. When you snap on the light you see him sitting up in his crib, leaning forward, and coughing that strange cough. You also notice the part of his chest below his ribcage is sinking inwards with each breath, backwards from the way it should go. Your little boy has a scared look in his eyes, and you are more than a little scared yourself. He has croup.
What is croup?
Croup is a disorder caused by inflammation of the trachea, the main breathing tube in the neck, just below the vocal cords, in an area called the subglottic region. Some say it gets its name for the old Anglo-Saxon word kropan, which means to croak or cry out. If true, such venerable terminology tells us this common childhood ailment has been recognized as a distinct entity by parents for a very long time. Physicians sometimes give it a much fancier name, laryngotracheobronchitis. This learned construction merely describes what croup is: inflammation (hence the “itis”) of the breathing tubes extending from the vocal cords (the larynx), through the trachea, and often down to the lower breathing tubes (the bronchi). Even though the inflammation can stretch up and down the airway, it is in the subglottic region where the symptoms happen. Why this is so is because of a simple law of physics–that is where the airway of a toddler is at its narrowest. The symptoms of croup come from blockage of airflow.
The inflammation of the subglottic region makes the lining of the trachea swell. Since the trachea is more or less round, this swelling makes the diameter of the airway smaller. Sometimes the swelling of the tissues gets so bad the size of the child’s airway is narrowed to that of a small straw. What happens next is simple physics, and is analogous to what happens in cold water pipes if they have their diameter narrowed by mineral deposits in them: flow through a tube is proportional to the fourth power of the radius of the tube. This may sound esoteric, but the principle has important practical implications for small children with croup.
Imagine an adult whose airway has a diameter of twelve millimeters. Then imagine the lining of this tube develops one millimeter of swelling all around its lining, thereby reducing its diameter to ten millimeters. If one does the calculations, this slight reduction in size reduces airflow by about half. Now consider a toddler with a five millimeter airway who has the same one millimeter of swelling all the way around it, reducing it to three millimeters in diameter. The adult in this example loses about half the airflow, something easily compensated for by just breathing a little harder. In contrast, the toddler has his airflow reduced to only thirteen percent of what it was. This reduction is too much to compensate for, although the child tries. His trying causes the symptoms of croup.
It is air rushing turbulently through a newly tiny airway that causes the crowing sound characteristic of the breathing of a child with croup. It is called stridor, and an experienced person can often make the diagnosis of croup based upon that sound alone, even over the telephone. Additionally, the front portion of a toddler’s ribcage is not yet solid bone–it is still partly cartilage. This means that, since a child’s chest is not yet firm in the scaffolding of the ribs, the increased effort of breathing makes the chest cave in the wrong way with each breath. These are called retractions. They are not specific to croup, but happen in a child with respiratory distress from a variety of causes. The final characteristic finding of croup, the seal-like barking cough, is from irritation of the vocal cords.
One of the characteristic attributes of croup is how sudden the onset of the stridor, the sign of upper airway, often is. For some reason croup tends to be worse at night; most visits to emergency departments for croup occur between ten in the evening and four in the morning. A typical story is that parents put their child to bed with just a mild cough only to awaken in the middle of the night to the sound of severe stridor. This is a predictable result of the place where the inflammation is happening. Since airflow is dependent upon the fourth power of the radius of the child’s trachea, he may not have much distress during the early stages of the illness. But as the airway gets smaller, subsequent reduction in size becomes critical. The analogy to water pipes is a good one: loss of half the space inside the pipe from mineral deposits causes only slight reduction in water flow when one turns on the tap, but just a little more blockage severely cuts down flow.
How common is croup and what causes it?
Croup is an extremely common childhood illness. Estimates vary, but studies suggest as many as fifteen percent of all children have croup at least once, and five percent have it more than once. Some have estimated croup accounts for fifteen percent of all respiratory tract disease seen in pediatric practice. The peak time for croup is fall and early winter, but it can occur any time of year, even summer. The peak risk age for children to get croup is eighteen months, and boys are one-and-one-half times more likely to get it than are girls.
Croup is caused by infection with a respiratory virus. Although there are a few ailments that resemble croup and are caused by something else (more on them below), standard croup symptoms are brought on by viral infection. There are multiple viruses that can do it, but nearly three-quarters of all cases stem from infection from a single family of three closely-related viruses–the parainfluenza viruses, which are cousins of true influenza. Less commonly croup is caused by the true influenza virus, respiratory syncytial virus (RSV), or a few others.
All these viruses are spread from child to child in the manner of most respiratory viruses–tiny droplets of infected mucous or saliva. These droplets can fly through the air after a cough or sneeze and be inhaled by someone nearby. Alternatively, virus-laden mucous gets deposited on a child’s hands when she puts them in her mouth or nose and the virus then moves on to someone else when the child touches them.
Either way, the first step is for the virus to infect the back of the throat, causing cold-like symptoms of nasal congestion, cough, and low-grade fever. For reasons we do not understand, some children get no more than that. Often, however, and especially with the parainfluenza viruses, the infection moves to the subglottic area of the trachea. There it causes the local irritation and inflammation that leads to the airway swelling and subsequent symptoms of obstructed airflow.
How is croup diagnosed?
Croup is entirely a clinical diagnosis; there is no specific test for it. This means the doctor decides it is croup based upon a typical story (cough, congestion, stridor, and mild fever). Sometimes, though, a doctor will get an x-ray of the child’s neck, which often shows some narrowing of the airway. The figure below is an example of this. Air on an x-ray appears black, bones are white, and tissue is grey. The central black column of this child’s trachea is narrowed abnormally at the point of the arrowhead. (The bones stacked like coins in the neck are part of the spinal column.) Doctors do not always get such an x-ray, especially if everything points to croup. If the story is atypical, a common reason for getting the x-ray is to make sure the child’s symptoms are not from something else. Those other possibilities are divided into infectious ones and non-infectious ones.
There are other infections besides viral ones that can infect a child’s airway and block airflow. Serious bacterial infection can do this also. The principal one of these is epiglottitis, a severe and rapid swelling of the epiglottis, a structure that sits just above the opening of the trachea at the back of the throat. The epiglottis is what keeps food from going into the trachea during swallowing. When it becomes severely swollen, which is what happens with epiglottitis, it can completely block the airway and cause a life-threatening emergency. Another infection that can mimic croup is bacterial tracheitis, a severe infection of the entire trachea that causes so much infected pus that a child’s airway can become obstructed. It, too, can be life-threatening.
Fortunately, both epiglottis and bacterial tracheitis are extremely rare. Epiglottis was once not uncommon, but near universal vaccination of children against the bacterium Hemophilus influenzae, the main causative organism, has dramatically reduced the incidence of the disorder. Both these serious conditions usually behave quite differently from croup. The main difference is that both cause high fever (croup’s fever is nearly always low-grade) and the children appear quite ill. The key distinction between croup and epiglottis is that the latter not only makes breathing difficult but also makes swallowing painful or even impossible for the child. Thus a child with epiglottis will not only have stridor, but will sit hunched forward and drool, unable to swallow.
An x-ray of the neck can help distinguish croup from these more serious infections. However, if the doctor thinks epiglottis is possible the standard way to proceed is for the child to be given a sedative and have his airway directly inspected using a procedure called laryngoscopy. If this is necessary, it is usually done by an airway specialist, such as an otolaryngologist, commonly called an ENT specialist.
There also are non-infectious things that can cause upper airway obstruction and stridor, since anything blocking the airway gives the same symptoms. Overall, what distinguishes these non-infectious causes of upper airway obstruction from the infectious ones is the lack of any other evidence of infection, such as nasal congestion, fever, or malaise.
If the onset of a child’s breathing problems is quite sudden, the doctor might consider the possibility of a foreign body stuck in the airway. Toddlers put anything into their mouths–toys and bits of food are frequent offenders when this happens. On the other hand, if the progression of a child’s symptoms is progressive over days or weeks, the doctor might think about several kinds of tissue growths that can occur within the airway. If either of these possibilities is likely, the child usually needs laryngoscopy or bronchoscopy, inspection of the trachea and lower airway, for diagnosis.
A few children have recurrent, sudden episodes of croup symptoms without any other evidence of viral infection. These attacks from what is called spasmodic croup also generally happen at night. The cause is unknown, but it may be related to allergies. It is generally treated the same way as viral croup (see below).
The walls of the trachea are stiffened with bands of cartilage; this is what holds them open and keeps them that way. Some children have an airway that is intrinsically less stiffened with cartilage than most, causing it to collapse a bit when the child breathes, causing stridor that can sound like croup. In this condition, called tracheomalacia, the symptoms are chronic and are often worse when the child is lying on his back because the weight of the tissue in the neck compresses the airway more. It requires bronchoscopy to diagnose for certain.
Croup ranges in severity from quite mild to the rare case of near total obstruction of the airway. To help categorize this severity doctors have devised various scoring systems to rate the child’s symptoms. One commonly used of these “croup scores” is the Westley scale. The scale assigns points for various symptoms and groups children into “mild,” (less than three points), “moderate,” (three to six points), and “severe” (more than six points). It uses five criteria to do this: severity of retractions, degree of stridor, how well the air is getting into the child’s lungs as assessed with the examiner’s stethoscope, if the child is dusky-colored from insufficient air, and if the child is becoming poorly responsive from lack of oxygen. Generally mild croup can be treated at home; moderate and severe croup require medical attention, and usually the more ill children will be admitted to the hospital.
How is croup treated?
Once a doctor decides a child has croup, it is fairly well-accepted how to treat it. Therapy is directed at two things: making the child feel better and reducing the airway inflammation to improve airflow. Mist has been a mainstay of treatment for mild croup for many years.
Most physicians believe steam often gives a child significant relief from the pain and raspy, dry feeling in the throat, although whether it actually helps reduce the inflammation of the airway itself and improves air flow is doubtful. Mist may also help loosen airway mucous and allow the child to cough it up easier. Throat pain and fever are helped by treatment with acetaminophen or ibuprofen.
The traditional home remedy for mild croup is to close the bathroom door and run a tap until the room is completely steamy, then turn it off and sit with the child in the mist. A parent needs to be careful with this, of course; children have been burned from scalding water. Exposure to cool night air (since croup happens mostly at night) is also a traditional remedy. Although widely practiced and certainly benign, it, too, has never been validated.
Doctors typically use one or both of two ways to reduce the inflammation and swelling in the child’s airway. Direct application of the drug epinephrine (adrenaline) to the swollen tissues shrinks them by constricting the tiny blood vessels under their surface; it is the virus-induced engorgement of these vessels and leakage of fluid out of them that causes the swelling in the first place. The drug is given by nebulization, blowing high-flow air or a mixture of air and oxygen through the liquid epinephrine and thereby dispersing it into a fine mist, which the child then breathes to carry the drug to the subglottic area. Epinephrine works within minutes and usually gives a child prompt relief from the stridor and retractions. Unfortunately the effects of epinephrine only last a few hours at most. It can then be repeated, although dose after dose of epinephrine can rarely lead to worse swelling when the drug wears off.
The subglottic swelling of croup is from inflammation in the area, so standard treatment of moderate or severe croup also consists of using a drug to reduce the inflammation–a steroid. Steroids are also being used increasingly for mild croup, both to make the child feel better and to interrupt in its early stages progression of the swelling. Steroids can be given orally, by intramuscular injection, or even nebulization like the epinephrine. A commonly used steroid for croup is dexamethasone (Decadron), a single dose of which is usually sufficient to reduce the inflammation. Unfortunately, steroids do not act immediately like inhaled epinephrine–they take four to six hours at least to work.
A typical treatment scenario for a child coming to the emergency department with croup would be to have him breathe some cool mist, followed by a nebulized epinephrine treatment. Usually the best way to do this is to have the child sit in a parent’s lap, since he is most comfortable there and agitation makes the stridor and retractions worse. Then the child receives a dose of steroids. Often by then the child’s symptoms are much better, but it is important to keep the child in the emergency department for at least an hour or two more to make sure the symptoms do not recur after the epinephrine wears off and the child needs more treatment. A child who has continues to have symptoms after epinephrine or who needs repeated doses of epinephrine needs admission to the hospital. What doctors particularly look for is continued stridor when the child is completely calm; called “stridor at rest,” it is a standard indication for hospital admission.
A child with severe croup needs more complicated management, although this is very uncommon. If the child is clearly not getting enough air to stay alert and keep his blood oxygen levels up he needs immediate placement of a breathing tube, called an endotracheal tube. It is placed by a procedure known as intubation. A child with less severe croup, but who remains in significant distress and begins to tire from the effort of breathing also needs intubation.
What is the typical course of a child with croup?
Croup usually runs its course in five to seven days, typically with one day of worst symptoms and several more of cough and hoarseness. Since the symptoms characteristically get better in the day, it is common during the middle of the illness for a child to have minimal symptoms during the day but several nights of worse cough.
What is the risk of a child getting croup again and are there any long-lasting effects?
There is no clear-cut evidence that children who have one episode of croup are more likely to get it again. There is some evidence children who have group are more at risk later to develop reactive airways disease–asthma–than children who never have croup. However, if true, this may not be a cause-and-effect association; the propensity for a child to get croup when infected by a respiratory virus may reflect the same innate tendency to develop asthma. They may be different manifestations of the same thing. There are no long-term after-effects of typical viral croup.
Jerome Groopman, Harvard professor and staff writer for The New Yorker, has written a book called How Doctors Think. It’s been on various best-seller lists, and deservedly so, since its publication. His point is that, among other things, the way doctors make decisions is filtered through our past experiences, what we have seen lately, and what we already know the most about. Heuristics, the formal discipline of problem-solving, is not taught to medical students, at least not widely. Most of us learn, as I did, by the apprenticeship system – watching more experienced doctors and how they operate. This can lead to problems. It is a hit-and-miss process in many ways.
One bias I’ve seen, and tried to hold in check in my own decision-making, is being overly influenced by what we have just seen. It is easy to understand how that happens because what we’ve encountered lately is fresh in our mind. Another variant of that to guard against, especially in PICU practice, is reacting to a recent complication or bad outcome in one of our patients. Children in the PICU are sick, and all of our therapies carry some risk. In practice we weigh the risk of doing a particular thing against the risk of not doing it. Since the risk is never zero, every once and a while an unfortunate thing will happen. But, if it does, that does not affect the risk of it happening next time. Yet it’s human nature to consider a recent random event when evaluating the risk of it happening again. If you flip a coin and get ten heads in a row, the chance of the eleventh flip being heads is still fifty percent.
One particular problem Groopman points out is that diagnostic decisions have a kind of momentum; once a child is placed in a particular disease category, a diagnostic box, we filter everything through our assumption the diagnosis is correct. I see this happen now and then. We are tempted to ignore any data that contradicts what we “know” to be the diagnosis. Doctors even have a saying to justify this: when something seems strange, we are taught “it’s more likely to be an uncommon manifestation of a common thing than it is to be an uncommon thing.” Perhaps so, but uncommon things still happen.
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.
The last decade has seen an attempt to bring more scientific rigor into medical practice. The movement is called Evidence Based Medicine. The notion seems simple, one few could argue with: take a critical look at all the research that’s been done about a particular medical treatment and see if, on balance, the treatment works. The process has several important principles, among which are to establish in advance how much credance we should place on various research studies, especially when they conflict with one another. To do this we assign a hierarchy of reliability of the evidence. The weakest evidence is expert opinion alone — after all, experts can be wrong. The strongest evidence is the randomized, placebo-controlled trial.
These trials compare the results between two groups of patients: those who got the treatment and those who didn’t. One key to this is the placebo part: neither group knows until the trial is over who got the treatment and who got the “placebo,” the sugar pill. A second key is patients are randomly assigned to the treatment or the placebo groups. A final crucial element is that the doctors caring for the patients don’t know themselves who’s getting the treatment and who’s getting the placebo until after the trial is done. Then the investigators look at the data and see if the treatment works, if it’s better than the placebo.
Sounds simple. It isn’t, though, especially as it applies to the Holy Grail of evidence based medicine. For one thing, for some things there isn’t a good placebo — a major operation, for example. For another, physicians have only studied a tiny fraction of all medical conditions, typically those which affect a lot of people, are controversial for one reason or another, or which look financially promising to drug companies. There is no way we ever will have controlled trials on everything we do.
So how do I and my colleagues decide what to do? We use hard evidence if there is any. (It’s amazing how often we have only low-grade evidence to go on, such as expert opinion.) We do what makes sense in light of what we do know about the condition or other conditions like it. We tend to do what we have been taught, and we respect the opinions of our medical forebearers. Sometimes we have no idea what to do, in which case it is usually better to do nothing. In short, medical practice still relies to a large extent extent on experience, intuition, guesswork, and blind luck. For myself, I actually would like things to stay at least a little bit that way. The human body is not a machine, and is often mysterious.
If you want to learn more about evidence based medicine, the guiding organization is the Cochrane Collaboration, a huge group of valiant volunteers who scour the medical literature to collect information about specific ailments and write reviews about what the data show. The Cochrane site is here.
