I wrote here about the recent findings that driving while using a cell phone impairs driving ability as much as being legally drunk. It should come as no surprise, then, that not paying attention to what you’re doing, when what you’re doing requires concentration, can be dangerous if what you’re doing can be dangerous. It’s obvious; I’m surprised someone actually did this study, but they did. The study, in the journal Pediatrics, drove home the implications of this common-sense observation.

The study looked at children (preadolescents) in simulated street-crossing situations. To no one’s surprise, when a child was talking or text-messaging on a cell phone while doing this, they had a higher liklihood of being hit by a (simulated) car. The younger and more generally distractable the child, of course, the more likely this was to happen.

One of the four key principles of standard medical ethics is the principle of autonomy, which I’ve written about here. Autonomy means that patients are in control of their own bodies and make the key decisions about what sort of medical care they will (or will not) receive. For children, this principle means that the child’s parents make these decisions.

There are exceptions, as with all things in medicine. For example, if a child’s physicians believe that the parent’s choice will harm the child, the physician can ask a court to intervene. This is a very rare occurrence, but it happens sometimes. I have been involved in a few of those cases. But that’s not what I’m writing about now — I’m writing about nearly-adults, those children who are almost independent, but not quite.

The law generally defines the age of majority, the point at which a child is no longer a child and may decide these things for herself, at age eighteen, although there are variations between states. (The age is younger for so-called emancipated minors — those children who are entirely self-supporting or who are married.) What should we do when such a near-adult and her parents disagree about the treatment the child should get? There have been several recent examples of the variety of things that can happen then.

One case is that of Dennis Lindberg, a fourteen-year-old boy who died from leukemia in 2007. Dennis was a Jehovah’s Witness and, like others in his faith, rejected blood transfusions, even in life-saving situations. It is common for the courts to mandate transfusions in very small children over the objections of Jehovah’s Witness parents. The rationale for this is that a small child is too young to decide himself if he agrees with his parents. Dennis’s doctors went to court to get such an order.

But this case was different — Dennis was not a toddler or small child. He was an aware, articulate, young man who understood the meaning of both his illness and the consequences of not getting the transfusion. The court ruled that Dennis had the right to make his own choice, which he did.

His case dramatized a very grey area in medical ethics — when ought a young person be able to make these decisions on his own? In my own career I have had several occasions when an adolescent disagreed with the doctors, his parents, or both about what to do. In all those situations everyone eventually came to an understanding. That’s the best outcome, of course, but these will always be ambiguous situations because children mature at differing rates. Some thirteen-year-olds are wiser than seventeen-year-olds. For that matter, some young adolescents are wiser than others who have already attained the magic age beyond which we give them the right to make all these decisions.

If you are interested in these kinds of ethical questions as they relate to children, here is an excellent site where you can learn much more. And here is another example of a teen (with the support of his parents) going to court to assert his right to refuse standard therapy for cancer.

I’ve written before about traumatic brain injuries in children. These sorts of injuries are frustratingly common — I’ve just seen several new ones. Although we’ll never eliminate them, there are many ways to reduce both their number and the severity of those that do occur. These ways are well known and extremely low-tech. Since car accidents are the leading cause of them in children, that is where we can really have an effect.

A small child who is unrestrained by a car seat is particularly likely to have a severe brain injury if involved in an accident, and that accident need not be at highway speeds. These days more and more parents know how to use car seats for their infants and toddlers, and over the past decade I’ve seen fewer and fewer injuries to unrestrained small children.

What I continue to see, however, are teenagers who are out by themselves, away from their parents, and don’t use a seat belt. The result is they are ejected from the car after impact, and this raises enormously the risk of severe brain injury. I’ve just seen yet another such case.

The most severe injuries come from what we call diffuse axonal injury, or shear injury. This injury results from the brain being jarred suddenly inside the skull, often with a bit of rotational effect. We call it shear injury because the force of impact shears apart the delicate wiring bundles that connect the nerve cells to one another. Most children recover to some extent, but some degree of permanent damage is common.

If you are interested in learning more about traumatic brain injury, the Brain Trauma Foundation is an excellent place to start.

We have known for a long time poverty is associated with illness. Tiny Tim did not die at the end of Dickens’ Christmas Carol. The reason he lived was because, just in time, Scrooge had an epiphany and raised the Cratchit family’s standard of living. That Christmas goose brought more than good cheer to the Cratchits — it brought good health, too. Some historical studies, such as those of Thomas McKeown, have linked the long population rise of the past century to improved nutrition. Experts still debate if this is true or not, but either way it is old news.

It may be old news, but for today’s Tiny Tims it is very much still current news. The furious debates over what to do about health care reform are often about choice — what choices Americans should have selecting their health care, what choices doctors should have in providing it, and what choices society has in paying for it. I take care of children, so that is the lens through which I see the issue. And children have no choice at all in this matter, because the family they are randomly born into determines everything, even if they will live or die. Across America we have constructed what are, in effect, a series of laboratories to test the results of what happens when different sorts of children get severely ill. These laboratories are pediatric intensive care units.

Poor children are far more likely than affluent children to end up in a PICU. The simplest indication of this is to look at the proportion of children in PICUs who are on Medicaid: it is generally at least half, often more. Yet the proportion of children in the general population who are on Medicaid is roughly a third. Why is this? Why are poorer children more likely to become critically ill or injured?

One reason is that pregnant woman who are poor are more likely to deliver prematurely, and former premature infants have a high prevalence of residual medical problems, things which often lead to future PICU admissions. Thus more premature births equals more PICU admissions. Another reason is that, because of low reimbursement rates for providers, it is often hard for a child on Medicaid even to find a doctor. So children with chronic problems, such as asthma or diabetes, often cannot get the kind of good routine care that would keep them out of the PICU. These reasons are straightforward, ho-hum, so obvious we have become inured to their implications. (Though we should not be.)

If we dig deeper, though, we find other disturbing possibilities. For example, a study by Evans and Kim on the physiological effects of poverty found that poor children have chronically high levels of stress hormones that correlated with the length of time they were in poverty. Adolescents who were recently poor did not show these findings; what mattered most was the duration of poverty. We know childhood poverty is strongly associated with poor health as an adult, and this may be one of the reasons. Even if a poor child somehow later breaks through to affluence, the health effects linger on.

Thankfully, evidence shows that once children on Medicaid who need a PICU get there, they get the same level of care and have the same outcomes as children with private insurance. That is reassuring; poor kids on Medicaid do not get second-class care and have the same risk of mortality as the affluent ones. However, the research uncovered a very disturbing finding — children without any insurance at all were more likely to die. Why? Because they were sicker when they first arrived in the PICU, undoubtedly because their parents feared to bring them to the doctor. Because of our current dysfunctional non-system, the parents waited, and their children died as a result. Personal anecdotes are not research, but I have thirty years of them saying the same thing — uninsured kids are sicker when they get to the PICU. This is entirely predictable. Of course the prospect of a massive, bankruptcy-inducing medical bill makes even the best of parents equivocate and delay why they should not.

It is fair to debate how many adults without health insurance are in that situation owing to their own choices, although I think that argument is a straw man, as is the notion that many homeless adults choose to live in boxes under bridges. But it is not fair to inflict this debate on children, who are stuck with their birth situation. Childhood poverty carries life-long health care risks, but at least Medicaid generally gets the poorest children the care they need. Denying children health care insurance, however, kills them. I find this to be obscene.