This has been a controversial topic in pediatrics for many decades. In my forty year experience one of the most common determining factors in whether or not a child gets tympanostomy tubes (ear tubes) is whether or not they’ve been seen by an ENT physician (ear, nose, and throat surgeon). In fairness to my ENT colleagues, of whom I have many excellent ones, I find this not surprising. Any specialist physician is naturally inclined to do what they are trained to do. I suppose it’s also a version of the ancient saying I learned during my surgery rotations: “A chance to cut is a chance to cure.” So generally if your child’s physician refers you to an ENT specialist for recurrent acute ear infections, the recommendation will be for ear tubes. On the other hand, if the referral goes to a pediatric infectious disease specialist, the recommendation may well be for recurrent antibiotics as needed. So what’s the latest on which of these approaches is best? Before we get to that, I should provide some quick background on the cause of acute middle ear infections. If you want a deep dive into that question, you can find more information here.

Ear infections are extremely common in children, particularly toddlers. Estimates are that a quarter of children will have at least one by their first birthday and half will by the age of three. The cause is pretty well known. You can think of an ear infection as a complication of a viral cold, and toddlers get a lot of colds. Inflammation in the back of the nasopharynx blocks drainage from the Eustachian tube that connects the middle ear to the back of the nose. Bacteria normally living in the nose take advantage of this disruption to crawl into the middle ear and multiply, leading to infection. Toddlers are more susceptible because in them this tube is short and straight; as children age it lengthens and develops a kink, making it more inaccessible to bacterial invasion. This process is illustrated in the image below.

Antibiotics are used to kill the bacteria, which generally, but not always, works. But recurrences are common, often leading to multiple rounds of antibiotic treatment. The idea of tympanostomy tubes is to put a plastic ventilation device across the eardrum so that the middle ear has another way to get ventilated if the Eustachian tube gets blocked. After a year or two the tubes usually fall out, but by then the child is often at lower risk owing to age. There are pros and cons to both approaches: antibiotics are cheaper, but recurrent bouts of otitis can add up, and frequent courses of antibiotics carry problems; ear tubes are more expensive up front and they carry the risk of any surgical procedure. So which way is best? We have some useful new information to help parents choose.

The group at the University of Pittsburgh have been doing research on otitis media for a long time — Dr. Jack Paradise has been leading this effort for decades. That group recently published a randomized study in the prestigious New England Journal of Medicine: “Tympanostomy tubes or medical management for recurrent acute otitis media.” Although the study was randomized, meaning assignment of the children to the antibiotic group or the ear tube group was random, of course it couldn’t be blinded, since it’s obvious which group the child is in. Still, it is an excellently designed study. The article is accompanied by a useful editorial on what it all means. If you don’t read the article, I at least recommend the short editorial, even though the editorialist’s final conclusion reads a bit mealy-mouthed to me. So what did they find? The answer is both satisfying and not satisfying, depending upon your perspective, I suppose.

Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management.

To me, that’s kind of an odd way to put it, although I suppose the question they were getting at is if ear tubes are better, which their study shows they aren’t; the two approaches gave equivalent outcomes. Although the two approaches gave the same benefits, there are some differences between them in risks, and that’s where parental choice plays an important role. Recurrent courses of antibiotics carry with them risks of developing allergic reactions to them. There is also the issue of the relatively unclear risks of causing derangements in the normal bacteria living in our gut, since oral antibiotics indiscriminately slaughter masses of “friendly” bacteria. Certainly diarrhea is a common side effect. We are also always concerned about how excessive antibiotic use can lead to development of resistant strains of bacteria. On the other hand, any surgical procedure, even a relatively minor one like ear tubes, carries a slight anesthetic risk. I have also seen complications of ear tubes, such as persistent holes in the eardrum that won’t heal. Tubes can also fall out too soon and need replacement, meaning another surgical procedure.

An important point to understand is that this study is about recurrent bouts of ACUTE ear infections, not CHRONIC, persistent ear problems. Using ear tubes in chronic ear problems is an entirely different issue. If you’re interested in that debate, or if your child has that problem, you can read more about it here. But with recurrent acute ear infections, the editorialist correctly points out:

Thus, management decisions can be made jointly with a high degree of parental satisfaction.

A recent article in Pediatrics, the journal of the American Academy of Pediatrics, studies a particular aspect of a disturbing disparity many of us have known about or suspected for many years: a newborn’s chance of dying varies quite a bit with where it is born and who its mother is. It’s well known infant mortality varies 230% between states, with Mississippi having the highest rate at 8.3 deaths per 1,000 live births. Overall the deep South has the worst rates. It’s also well known infant mortality varies with socioeconomic status, with infants born to poorer mothers suffering a higher risk of death. A previous study identified rural location and low socioeconomic status with a higher infant mortality rate, but those two variables were bound together in that rural mothers tended to be poorer. A key issue is that rural counties have more limited access to healthcare and this would tend to drive up the infant mortality rate irrespective of socioeconomic status of the mother. This study tried to tease out those two factors.

The authors studied an enormous group — all births in the United States between 2014 and 2016 and linked them to infant death records at the county level. They used a somewhat complicated but easily understandable algorithm to adjust death rates independently for access to hospitals and socioeconomic status of the mothers. Their conclusions:

Higher infant mortality rates in rural counties are best explained by their greater socioeconomic disadvantage than more-limited access to health care or the greater prevalence of mothers’ individual health risks.

There is an additional interesting article on a related topic in the same issue of Pediatrics. It studies the effects of overall state and local expenditures on services not related to healthcare, what one might call quality of life things, and the effect on infant mortality. Previous evidence has suggested expenditures on non–healthcare services can reduce infant mortality, but it is unclear what types of spending have the greatest impact among groups at highest risk. Their conclusions:

Increased expenditures in public health, housing, parks and recreation, and solid waste management were associated with the greatest reduction in overall infant mortality rate. Investment in non–health care services was associated with lower infant mortality rates among certain high-risk populations. Continued investments into improved social and environmental services hold promise for further reducing infant mortality disparities.

Each incremental increase in overall state and local spending was associated with what one could call a dose-related improvement in infant mortality. That is a powerful finding. Their conclusion may offer some insight into why the deep South, where spending on these things is notoriously lower than other places in the country, has worse infant mortality rates even beyond the socioeconomic status of the mother. Correlation is not causation, of course, but I think these findings are quite intriguing. If we make life more civil and rewarding, we appear also to increase the chances of an infant living to enjoy it.

As I’ve written before, I have to confess I’ve never been a huge fan of pathways and protocols. They often struck me as rigid and insensitive to the the nuances of differences between patients. There also are times when they are just absurd, times when physicians, and especially mid-level providers, implement them when analysis of the clinical situation clearly shows them to be inappropriate. I suppose part of me feels rigid protocols and pathways diminish the art of medicine, especially for physicians like me who have been practicing for decades. But more and more evidence is emerging that these things help patient care by ensuring nothing falls through the cracks. I find myself noticing as I enter protocol-driven orders that they can remind me of how to proceed. In the electronic medical record I can always uncheck a pre-filled order box if it is inappropriate for a particular patient.

Now we have more data about the topic. The clinical situation that has been extensively studied with protocols is sepsis, which is a series of life-threatening systemic events that can be provoked by various things, but most commonly a serious infection. A key reason for sepsis being highly appropriate for protocols and pathways is that outcome, odds of survival, is highly influenced by early recognition and treatment. Moreover, the immediate treatment is simple, relatively safe, and available in any hospital. This is why virtually all hospitals now have what are called “sepsis bundles.” These are measures taken for suspected sepsis early in the course, before the diagnosis is confirmed. Because it’s common, researchers have looked at how implementing sepsis bundles has affected outcomes. Bear in mind these comparisons are generally not randomized trials because the ethics of that would be questionable. Historical controls, what happened before implementing the bundle, are often used. This approach carries the possibility of a Hawthorne Effect: the phenomenon that can happen when people know they are being observed and change their behavior.

Of the many investigations reporting an improvement in sepsis outcomes, this one and this one are representative. The latter is part of the Surviving Sepsis program, and initiative of the Society of Critical Care Medicine. The bottom line is that such bundles of strongly recommended actions improve outcomes. Sepsis is a bit of an unusual case, though, because in sepsis early and immediate action is important, something not the case in many other conditions in which we have time to ponder things. New York state offers an interesting test cast of bundle effectiveness since it has a state law that mandates them. The above studies were in adults. There have been several recent studies of sepsis bundles in children, such as here and here, and they also show benefit. New York provided the comparison, before and after the implementation of the mandate (“Rory’s Regulations).

I still believe slavish, unthinking adherence to pathways and protocols is bad because they can get in the way of clear thinking. And we don’t need protocols for everything. Yet with more and more acute care being delivered by mid-level, non-physician providers, people who do not have extensive training in the pathophysiology of disease, these things provide a safety net of care. I’ve become cautiously reconciled to them, especially things like sepsis and stroke, in which early and prompt action matters a great deal.

I’m being sarcastic, of course, but that’s often how it feels some days. And, since I posted on this subject a few years ago, not much has changed. If anything it’s worse, with more and more clicks needed on the screen to find what I want to find. Those are days when I’ve been busy at patients’ bedsides all day and then struggle to get my documentation done later, typically many hours later. I jot notes to myself as I go along, but it can be hard to recall at 5 PM just what I did and why at 8 AM. This is a particular problem in critical care because some of our billing codes are time-based and we’re supposed to remember exactly, to the minute, how much time we spend on each patient.

It used to be very different, and that wasn’t always a good thing either. Years ago I spent months going through patient charts from the era of 1920-1950. They were all paper, of course, and the hospital charts were remarkably thin, even for complicated patients. I recall one chart in particular. It was for a young child who was clearly deathly ill. The physician progress notes for her already prolonged stay in the hospital consisted of maybe 2 sheets of paper. Most of the daily notes were a single line. I could tell from the graphs of the child’s vital signs — temperature, pulse, breathing rates, and blood pressure — that one night in particular was nearly fatal. The note the next morning was written by a very famous and distinguished physician. I knew him in his retirement and he was a very loquacious man in person. His note after the child’s bad night was this: “mustard plaster did not work.” If I were caring for a patient like that today there would be just for that day and night multiple entries probably totaling several pages on the computer screen.

Patient charts are burdened with several purposes that don’t always work together. The modern medical record as we know it was invented by Dr. Henry Plummer of the Mayo Clinic in the first decade of the twentieth century. Up until that time each physician kept his (only rarely her) case notes really as notes to themselves. When the multi-specialty group appeared, and Mayo was among the first, the notion of each physician having separate records for the same patient made no sense; it was far more logical to have a single record that traveled from physician to physician with the patient. That concept meant the medical record was a means for one physician to communicate with another. So progress notes were sort of letters to your colleagues. You needed to explain what you were thinking and why. Even today’s electronic medical records are intended to do this, although they do it less and less well.

Now, however, the record is also the principal way physicians document what they did so they can get paid for it. Patient care is not at all part of that consideration. The record is also the main source for defending what you did, say in court, if you are challenged or sued. The result is that documentation, doctors entering things in the record, has eaten more and more of our time. Patients and families know this well and the chorus of complaints over it is rising. Doctors may only rarely make eye contact these days as they stare at a computer screen and type or click boxes. But we don’t have much choice if we are to get the crucial documentation done. That’s how we (and our hospitals) are paid and payers are demanding more and more complex and arcane documentation. I don’t know what the answer is, but I do think we are approaching a breaking point. We are supposed to see as many patients as we can. But the rate-limiting step is documentation.

To some extent we brought this on ourselves. In our fee-for-service system physicians once more or less said to payers: “We did this — trust us, we did it — now pay us for it.” I can’t think of a formula more guaranteed to cause over-utilization or even rare cases of outright fraud. But there is only so much time in the day. In my world an ever smaller proportion of it is spent actually with the patient.

The demand for ever more detailed documentation is not the fault of the electronic medical record. One thing that helps in pediatric critical care is the notion of bundled care. This applies for all children up to age 5 — there are categories for 0-29 days of age, 29 days to 2 years, and 2 years to 5 years. The patient is charged a flat rate for the initial day of care, then a flat rate for each subsequent day of critical care. For anyone older than 5 you are supposed to keep track of the specific minutes you spend on them. My colleagues in hospital medicine bill according to the complexity of care, called evaluation and management or E&M codes, which on the face of things seems reasonable. What can become unreasonable is that there are all manner of odd and picky criteria, constantly changing, requiring the use of special magic language, to fulfill the requirements of the several different categories. For pediatric critical care (for those under 5) one only really needs to document how the child is critically ill and what you did about it. After that the daily global charge kicks in.

For myself, I only ask for a system in which the time we spend with patients is more than the time we spend with their medical record. Surely such a thing is possible?

Regular readers of the blog know I have written before about the potential effects of screen time on brain development. I think it’s an important issue and represents a kind of ongoing experiment in our children for which we don’t know the results. But what we do know is that excessive screen time is bad for development. The problem is we don’t know what “excessive” means in this situation. This new study brings further information to the question. The somewhat ominous title is: “Associations between screen-based media use and brain white matter integrity in preschool-aged children.”

The authors used MRI scanning, a way of imaging the brain in detail, to assess the fine details of brain structure in children who were chronically exposed to more screen time than that recommended by the American Academy of Pediatrics. (You can find the AAP recommendations here.) They studied 47 children ages 3 to 5 years. That’s not a huge number, but it’s still quite a few, considering the cost and difficulties in doing MRIs on young children. You don’t need to be a developmental neurologist to understand the implications of the findings:

In this cross-sectional study of 47 healthy prekindergarten children, screen use greater than that recommended by the American Academy of Pediatrics guidelines was associated with (1) lower measures of microstructural organization and myelination of brain white matter tracts that support language and emergent literacy skills and (2) corresponding cognitive assessments.

Although this is a small study, the take-home message to me is to take seriously the recommendations of the AAP regarding screen time for small children, certainly until we know more about what this vast, uncontrolled experiment in our children — the proliferation of screens in our daily lives — represents.