The issue of food allergies is a complex one, probably because the food we eat is complex stuff. Many parents observe that particular foods don’t agree with their child. Pain, bloating, and diarrhea are all symptoms that can be evidence of this. Often such parents will say that their child is “allergic” to a particular food that they see causing those sorts of symptoms.

A broader term for this is food intolerance, the observation that particular foods upset the child’s digestive system. There are many examples of this kind of thing. One of the most common is a deficiency along the intestinal wall lining of lactase, the enzyme that digests the sugar lactose. This is not an allergy — it means that the person is intolerant of lactose, the sugar in many milk products. This lactase deficiency may be inherited or acquired later. (You can read more about this problem here.)

To a physician, the word “allergy” has a very specific meaning: it means that parts of the child’s immune system are reacting to components of the food. A common offender is peanuts (about 1% of all children), but there are many others. The symptoms of these true allergies can be much more severe, and typically cause problems outside the digestive system. Hives and difficulty breathing, either from wheezing or from swelling in the throat, are not uncommon. We occasionally see children in the PICU who have these more severe reactions to food. Parents of such children often need to have an injectable medication, epinephrine, handy at all times if this happens.

How common are food allergies and intolerance? A recent study in the journal Pediatrics gives us some answers. The authors found that in 2007, 4% of children under 18 had some form of problem with food. This was an increase of 18% over the previous decade, although it was unclear if this was a real increase or simply reflected increased awareness among parents and physicians. This particular survey, although broad, did not distinguish between allergy and intolerance. However, the authors noted that it correlated with other, smaller studies in which true allergy was documented with specific tests. So it seems like a real phenomenon

Here is a recent article of mine published by Smartman Daily.

Most dads with a toddler have experienced the ear drum game. For the minority who haven’t, it goes something like this. Your child has a cold for a few days, but otherwise seems fine. Suddenly she spikes a high fever and clearly hurts somewhere. You take her to the doctor. He takes a very quick look–only seconds, it seems–at her ears and pronounces that she has an ear infection. By the age of three, eighty percent of all children will have had one, and half will have had more than one. Here are answers to six important questions about this common condition.

#1: How can a doctor be sure your child has one?
Here’s a trade secret–frequently we aren’t. If you ask five pediatricians to look in a child’s ear, you may well get five different opinions. This is why medical students call it the ear drum game–it seems whatever they say about a child’s ear, their instructor will say the opposite. Sometimes the diagnosis is obvious. The ear drum is inflamed and bulges outward from the pressure behind it. That pressure comes from infected fluid clogging up the normally air-filled middle ear cavity. Those are the easy ones. The tougher ones are ear drums that are somewhat red, a bit distorted in their shape, perhaps a little less mobile than usual. In those children doctors are often swayed by other things–fever, if the child seems to be pulling at her ears, if she has had past ear infections. These cases are judgment calls, but doctors often follow our old saying that “common things are common,” so we tend toward diagnosing ear infection if it is a borderline case.

#2: Where do ear infections come from?
The middle ear, the place where sound waves bouncing off the ear drum get passed along to the brain so a child can hear, is normally free of germs. There is a tube connecting the middle ear to the back of the nose, there to let air in and out. You can feel this happening when your ears pop going up and down in an airplane. The nose is normally thick with germs. The connecting tube has ways of keeping the germs out of the middle ear, but when those defenses break down the germs pounce on the opportunity, crawl up the tube, and cause an ear infection. The most common cause of tube malfunction is a viral respiratory infection, which is why an ear infection so frequently follows a cold. The tendency for the tube to malfunction also runs in families, which is why frequent ear infections do the same.

#3: Why do we treat ear infections with antibiotics?
An ear infection means germs in the middle ear, but often a child’s body can handle the germs without help. After all, children have been getting ear infections for eons and antibiotics have only been around for a half-century or so. Sometimes these germs aren’t even bacteria, so antibiotics would be of no use anyway. The practice among most American physicians over the past decades has been to treat all ear infections with antibiotics. The reason was to reduce the chances of a child getting one of the uncommon complications that can happen, and the number of these complications has dropped significantly in the antibiotic era.

#4: Okay, but do ear infections always need antibiotics?
For children over six months, the answer is no. The antibiotics-for-all approach has always been questioned by some doctors, especially for children older than two. These doctors reserve antibiotics for children whose symptoms last more than a day or so. This is a decision that should involve parents. Most want antibiotics, and there is nothing wrong with that–it is standard practice. But if you don’t want them, at least right away, another acceptable approach is to get a prescription for the antibiotic, but not fill it unless your child’s symptoms persist. More and more physicians and families are opting for this. Antibiotics are not risk-free. Either way, it’s a good idea to treat the ear pain and fever with medicines like ibuprofen (Motrin) or acetaminophen (Tylenol).

#5: What about prevention?
We know some things are associated with ear infections, and they share the property of contributing to malfunction of the tube between the middle ear and the nose. Exposure to tobacco smoke is one, because it irritates the lining of the nose. Another is putting a child to bed with a bottle, because every time a child swallows the tube opens wider. If the child is lying on her back, the nose bacteria have an easier time of reaching the middle ear.
Sometimes doctors prescribe a low dose of a daily antibiotic for a child who has had many infections. The more controversial kind of prevention is placing a plastic tube through the ear drum to connect the middle ear directly with the outside world. These so-called pressure equalization tubes work by helping keep the middle ear free of the fluid that gives bacteria a hospitable place to grow. If your child has a lot of ear infections, your doctor may recommend these. Besides talking to your doctor, you can learn more about the generally accepted reasons for placing tubes at several authoritative sites, such as here.

#6: Why do ear infections generally go away when a child gets older?
By the time a child gets to school-age, ear infections are uncommon. This is because, as the skull grows, the connecting tube gets longer and less straight, putting a useful mechanical obstacle in the way of germs trying to get up the tube to reach the ear. Additionally, older children get fewer colds than toddlers. So, if your child has a lot of ear troubles, take heart in the fact things will certainly get better over time.

Often children in the PICU need a mechanical ventilator — a breathing machine — so parents are confronted with this machine. When do we use them and how do they work?

There are three main reasons for using a ventilator: 1.) the child’s lungs are not working well, not getting needed oxygen into the body and carbon dioxide waste out (severe pneumonia is a good example); 2.) the child is not awake and aware enough to breathe and cough properly on his own (a head injury is an example); 3.) the child’s lungs and level of awareness are fine, but he is too weak to breath properly (various muscle problems are examples).

There are many different kinds of ventilators made by different companies, and superficially they may look very different from one another. They have an array of dials and flashing indicators on them, and most draw complicated graphs on a screen as the ventilator works. But in spite of this variability, at root all common ventilators are alike (there are exceptions — special machines we use in special situations). They give a child a breath of air down through a breathing tube, called an endotracheal tube, which we place through a child’s mouth or nose. That air nearly always has extra oxygen in it. We express this additional oxygen as a percent — ordinary room air is 21% oxygen (most of the rest is nitrogen) and pure oxygen is 100%.

We use all the knobs on the machine to set what kind of breaths we want — how big and how often. We also tell the machine what to do if the child takes a breath on her own, usually telling it to help the child in one of several ways with her spontaneous breathing attempts. Finally, we tell the machine what to do between breaths, typically to maintain some air pressure in the system (called PEEP, for positive end-expiratory pressure).

The whole point of using a ventilator is to take over the job of breathing from the child. The machine can do it all, or it can assist the child while she does some of the work. A mechanical ventilator is not an all or nothing device. After the child has healed and no longer needs the ventilator, we can progressively turn down the settings on the machine, in this way asking the child to take over her own breathing more and more. When she can do all the work herself, we pull out the breathing tube.

These principles are straightforward. But if your child, or one you know, needs a ventilator machine, you should know that managing a ventilator is a fine art — it can’t be done by cookbook. We have general guidelines we follow, but most pediatric intensivists have their own personal wrinkles in how they apply the guidelines, using what has worked for them over the years. Most importantly, each child is different and reacts to the ventilator differently, so its use needs to be tailored to each child.

Mechanical ventilators in the PICU are an excellent example of something that appears, on the surface, to be high-tech modern medicine in action. Using one successfully, though, takes some low-tech skills of the sort good physicians have used for generations.

The PICU is a very high-tech place — full of machinery that helps sick children breathe better, assists their hearts to beat better, and helps their kidneys do their job. The PICU room of a sick child can be stuffed with machines that flash, beep, and bing. We also have an array of monitoring devices that tell us how a child’s organs are doing. They alert us to when there are problems. They also give us evidence of when things are improving.

The interesting thing, though, is that often the first signs of improvement do not come from any of the machinery. Often an experienced eye — especially a parent’s eye — can sense that things are just better. The child simply looks better. There is no monitoring device that can replace that experienced eye.

I’ve written before about what we call Evidence-Based Medicine. The idea is that doctors shouldn’t do things for which we lack good evidence that it works. That seems like a silly notion — don’t doctors know what they’re doing? In fact, a good portion of medical practice rests upon tradition or fairly weak anecdotal evidence. This matters a lot when we’re talking about high-risk things — nobody should be subjected to risk without potential benefit. It also matters a lot when we’re talking about expensive things. Good estimates are that about a third of what doctors do helps little, if at all.

The state of Washington pays for the healthcare of about 700,000 people, and has taken the lead in trying to do transparent, out-in-the-open evaluation of some expensive medical interventions. If they don’t work, they won’t be covered. No exceptions. Most of the decisions taken thus far are for expensive surgical procedures, things that are fairly easy to assess. You can read about it here. It will be much more difficult to do this for the vast majority of situations, in which the data are more murky.

As a nation, I think we must do something like this. We certainly shouldn’t do things that don’t work. More than that, we can’t afford to keep doing so.

A child’s growth over time is a key part of pediatric care. This is true for all pediatricians, including those of us in the PICU. The most important concept is that a child keep “following the curve,” not shifting too much up or down. We use growth charts to track this, something most parents understand. Most parents also want to see their child’s chart, and many parents keep their own at home.

Thus it is important for parents to understand what the chart shows. A recent study in the journal Pediatrics, a survey of 1000 parents, showed that around half of parents misunderstood how to use them. There are some nice pictures of growth charts in the above link, but a simpler explanation is here. It’s something worth knowing about for all parents.

The new flu, the so-called H1N1 strain, has certainly landed with a bang. My own experience with it thus far is that it doesn’t appear to be much worse for the individual child than “usual” seasonal flu — every year we have severe cases in the PICU — but the degree to which disease from this strain is compressed in time is remarkable. That is, it is causing a huge number of infections in a very brief time period. This probably is because the pool of susceptible people includes pretty much all of us because this strain is so new.

Still, we have had several cases already in the PICU and I expect to see more. Nationally, 11 children died last week from flu; there have been 95 such deaths since last April. The very best place to get updated news of the epidemic is from the Centers for Disease Control in Atlanta. Their influenza monitoring site is here.

Last week there was a notice in my mailbox from the pharmacy telling me that an antibiotic intensivists use frequently, vancomycin, was in extremely short supply. We still have some, but we were instructed to watch carefully how we use it until the shortage abated. How long would that be? It shouldn’t be too long — just a couple of weeks. Actually this sort of thing happens all the time. Brief (usually), unanticipated shortages of drugs are common.

The causes of the shortages are typically some problem at the facilities that manufacture them, and often there are only a few of these. Sometimes the cause is a sudden huge spike in demand, such as we saw for the antibiotic ciprofloxacin (Cipro) a few years ago during the anthrax scare and are now seeing with oseltamivir (Tamiflu) with the current influenza outbreak, but usually the cause is just some glitch in the manufacture of the drugs. Sometimes only a single facility is making a drug. This is particularly the case if the drug is a cheap generic, one for which the manufacturer doesn’t stand to make much money. Further, there generally are no stockpiles in case of emergencies like this.

If you are interested in learning which drugs are currently in short supply (and why), the American Society of Health-System Pharmacists keeps an ongoing list here

Here’s a recent piece I wrote for an excellent site aimed at fathers — Smartman Daily.

Fifty years ago it was nearly always mothers who brought children to the doctor. Things are different now. A child’s father is as likely to be the one to make the trip (and put up with those long spells in the waiting room). Whichever parent brings the child in, chances are the visit requires taking time off from work. Insurance co-pays continue their relentless increase, but one of the biggest costs to families is a hidden one–your time. So here are five ways you can make the trip to the pediatrician more efficient and useful to you and your child. One or more of these might annoy your pediatrician, but don’t be dissuaded. You’re not being a pest–you’re being a good dad.

1. Ask the doctor to explain exactly what he is doing during the examination. If you’ve watched carefully as a doctor examines your child, you’ve probably noticed it’s not a random process. There is a method to it. We’re looking for specific things when we shine a light down the throat, feel the front of the neck, or push on sore bellies. These things are often not mysterious, and parents can learn about them, too. No, you shouldn’t be using a stethoscope to listen to your child’s chest or an otoscope to look into his ears, but there is a lot of practical information you can glean from understanding how a doctor’s physical examination proceeds and why. So don’t be afraid to ask the doctor to show you what he’s up to. If you do, you’ll get much better at describing your child’s problems. That will help speed things up at the next visit to the pediatrician-and reduce the risk that the doctor will overlook something important.

2. Insist that the doctor gives a precise and understandable explanation of his conclusions. Making a medical diagnosis is a mixture of science-based decisions, educated guesses, and occasionally just speculation. When the doctor tells you what she thinks, ask her why–and how solid her conclusion is. Pin her down. If you don’t understand what she is saying–if her answer is full of jargon, for example–ask her again. Have her draw a picture or two, if necessary. Ask the doctor to think out loud for you about her decision-making. If you do that over the course of several visits, and pay attention to the process, you can actually learn yourself how to make some simple medical decisions. I’m not suggesting you try to practice medicine on your child. But the more you know about how doctors decide things, the more productive your doctor visits will be. You might even avoid a visit or two in the future.

3. Take notes during the visit, and review them with your doctor. We doctors take notes when we talk to parents, so why shouldn’t you take notes when you talk to them? It’s the best way to avoid misunderstanding. In particular, make sure you have the correct spelling of whatever condition or disorder the doctor describes to you. If he uses anatomical terms, make him spell those, too. You can then use this information to do a little research yourself afterward.

4. Tell the doctor you’re going to do some research of your own. Some doctors get annoyed when parents come to the appointment with a packet of information they found on the Internet. It’s true that there is a lot of misinformation out there-and this is precisely why a savvy parent should quiz the doctor about what Internet resources she recommends. Many doctors these days have handouts for parents suggesting where to look, but many also do not. So ask, then go yourself and learn. Sites maintained by children’s hospitals or organizations, such as the American Academy of Pediatrics or the American Academy of Family Physicians are examples of reliable sites.

5. Ask the doctor about e-mailing one another. Many doctors have embraced the benefits of electronic medicine. E-mail can be a huge time-saver both for you and for your doctor. From my perspective, e-mail is better than getting constant telephone calls that interrupt whatever I’m doing. If your doctor seems resistant to emailing with you, press him a little. You probably can save yourself the time and expense of a few office visits.

Doing any or all of these things may annoy your pediatrician. Yet medical practice in general needs some new ways of doing things, since at least part of the reason we are in the middle of so much health care turmoil stems from the traditional ways medicine is practiced. The way to think of your visit to the doctor is a team meeting of equal partners in your child’s care. Acting on these suggestions means that you are doing your part to educate your fellow team member, your doctor. Good doctors learn from parents all the time!

Opponents of the current proposals in Congress for reforming healthcare have asserted that nearly all physicians are in opposition to these measures. I’ve even read claims that physicians will leave practice in droves if any of these bills pass, leaving America short of doctors. The highly respected Robert Wood Johnson Foundation recently surveyed physicians to see how we actually felt about reform. You can read the summary of their findings here. The bottom line — a large majority of physicians favor reform.

The survey found that 63% of physicians supported a public option — a system in which there was a government-funded alternative to private insurance. More radical than that, 10% supported a straight-up single payer system, such as Canada has. In sum, this is three-quarters of America’s doctors. In addition, a majority (58%) supported lowering Medicare eligibility to include 55-year-olds.

The survey does not address reasons doctors think this way. I think a majority of them, like me, realize our current non-system is unsustainable financially. I also think it is immoral socially, but I may be in the minority on that one.