Posts Tagged ‘US’

Pediatric Newsletter #15: Food Allergies, Gluten, and Pizza

March 29, 2015  |  General  |  No Comments

Welcome to the latest edition of my newsletter for parents about pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health I think will interest parents. In this particular issue I tell you about a couple of new findings about allergies in children, as well as some new information about gluten sensitivity. I have over 30 years of experience practicing pediatrics, pediatric critical care (intensive care), and pediatric emergency room care. So sometimes I’ll use examples from that experience to make a point I think is worth talking about. If you would like to subscribe, there is a sign-up form on the home page.

Big News About Peanut Allergies

This one made a big splash both in the medical news sites and in the general media. Peanut allergy is common. It has doubled in the past decade, now affecting between 1 and 3% of all children. And it can be a big deal for children who have it, even life-threatening. For years we recommended that children not be given peanut products early in life, especially if they are at risk (based on their other medical issues) for developing allergy. Unfortunately, avoiding peanuts in the first year of life doesn’t make a child less likely to develop the allergy. So what, if anything, can?

This recent, very well done study published in the prestigious New England Journal of Medicine is really ground-breaking. It took 4 to 11-month-old children at high risk for developing peanut allergy and divided them into 2 groups. One group got the “standard” approach — being told to avoid peanut exposure. The other group was fed peanuts 3 times per week. It was done in the form of either a peanut snack or peanut butter.

At age 5 years (the long follow-up time is a particularly strong feature of the study) the children who had been fed the peanuts had nearly a 90% reduction in the development of peanut allergy. This is a huge difference.

The study also was able to provide a scientific explanation for the difference. The children fed the peanuts developed protective antibodies that cancel out the ones that provoke the allergic response.

Washing Dishes by Hand May Reduce the Risk of Food Allergies

This report comes from Pediatrics, the journal of the American Academy of Pediatrics. There has been a long-standing theory about how allergies develop in children called the “hygiene hypothesis.”

The notion is that children, particularly in Western countries, are more prone to allergies (and asthma) because their exposure to microbes is delayed by our more sanitized environment.

In this study from Sweden, children in households that washed dishes by hand rather than using a dishwasher experienced a lower risk of subsequent allergies. The authors speculated that there was a causal association. They couldn’t prove that, but they also noted that early exposure to fermented foods and if the family bought food directly from farms also correlated with less allergies. I’m not totally convinced, but it is an interesting study worth thinking about. I expect to see more on the topic.

Does the Age at Which You Introduce Gluten Into Your Child’s Diet Affect Future Risk of Gluten Sensitivity?

Gluten sensitivity is in the news, with signs everywhere advertising “gluten free” as if this is always a good thing. I hear a lot of misconceptions about gluten sensitivity. Gluten is a protein found in grains such as wheat and barley. There is a condition, called celiac disease or sprue, in which a person can develop moderate or severe intestinal symptoms triggered by gluten. It is one of the eighty or so autoimmune diseases. The incidence of celiac disease in the US is about 0.7%. The risk of developing celiac disease is closely linked to a genetic predisposition to getting it. Importantly, if you don’t have the disorder, there is no benefit to eliminating gluten from your diet. In fact, the great majority of people who think they have sensitivity to gluten . . . don’t.

But for those children who do have a higher risk for developing celiac disease because of their genetic makeup it has long been a question if delaying gluten exposure will affect their chances of actually getting the disease. A good recent study gives an answer to that question, and the answer is no. There is no correlation.

If you think your child (or you) have problems with gluten there is a useful blood test that looks for a specific antibody. However, many people who have the antibody never get symptoms of celiac disease. The ultimate test is an intestinal biopsy.

My take-away conclusion is that all this gluten-free stuff you see in, for example, restaurants, is just the latest dietary fad. For over 99% of us there is no health benefit to avoiding gluten.

So How Much Pizza Do Teenagers Eat?

This is kind of a quirky item. If nothing else, it demonstrates how weird the medical literature can be sometimes. Every parent knows kids, teenagers in particular, mostly love pizza. A recent article in Pediatrics, a fairly respected journal, used food surveys to find how much pizza kids eat and the percentage of their daily calories they get on average from pizza.

The answer? The authors claim that in 2010 21% of kids ages 12-19 reported eating pizza sometime in the past 24 hours. That number is actually down from a similar survey in 2003. What about calories? For those kids who reported eating pizza, it accounted for about 25% of their daily calories, and that hasn’t changed. The authors primly suggest that we should make pizza more nutritious. I wish them luck with that. And I’m 63 years old and still like pizza.

Meet the norovirus, now the most common cause of “stomach flu” in children

January 16, 2014  |  General  |  No Comments

Gastroenteritis, often called “stomach flu,” is common in children. It has nothing to do with influenza, the “true flu,” which is caused by a respiratory virus. Gastroenteritis is caused by a different set of viruses. These viruses are generally transmitted by what physicians call the fecal-oral route, which sounds kind of gross. What we mean by that term is that the bug is in our intestinal tract and gets on our fingers. When we touch things without washing our hands properly we can pass it on to other people who touch the same thing and then touch their mouths. Of course toddlers don’t wash their hands, so the illness is particularly common in them. Gastroenteritis can cause severe vomiting and diarrhea, which can lead to dehydration and a trip to the doctor, but usually it passes within a few days.

For many years rotavirus was a very common cause of gastroenteritis in small children, but now a vaccine has reduced its incidence. Nature being nature, a new virus is taking its place and is emerging as the most common cause for gastroenteritis, accounting for 20% of cases. It’s called norovirus, and it’s a pretty amazing beast. In particular, it’s astonishingly infectious, making transmission quick and easy for it to accomplish. A recent report in the New England Journal of Medicine gives us some information about how it behaves.

The most amazing thing is how few viruses a child (or you) needs to get into their system in order to cause illness. Most micro-organisms need thousands of individual bugs to cause disease. Norovirus needs just 10 to 100. Considering how small a virus is that is quite astonishing, making norovirus one of the most efficient pathogens I’ve ever heard of. It is possible to contract the infection just by walking by someone with it because, unlike rotavirus, norovirus can also spread through the air. In one outbreak, 300 people were infected in a concert hall when they walked through a lobby where an ill person had vomited on the floor. It’s a huge problem in the food industry: in one outbreak a single infected food worker contaminated 76 liters of icing that went on baked products, causing disease in 3,000 people over the course of 4 days. Norovirus is responsible for about half of all cases of food-borne illness in the US.

To put some perspective on how common it is, by the age of 5 years, the authors of the New England Journal article calculate that norovirus will have caused 1 in 6 children to see a doctor in the office and 1 in 14 children will have visited the emergency room because of it. One in 278 will have been hospitalized, usually for dehydration. That’s pretty common. The peak incidence is 6 to 18 months of age.

For a parent, the key to taking care of your child with gastroenteritis is to keep them from becoming dehydrated. Here are some details about how to do that. At this point there is no simple test for norovirus. Knowing it’s there doesn’t affect therapy. But my recent reading about it has given me new respect for it.

Do ads for drugs affect physician prescribing behavior?

January 22, 2012  |  General  |  No Comments

Open most any medical journal, including the most prestigious of them, such as the New England Journal of Medicine, and you will see page upon page of glossy advertisements from drug companies for their products. This has been going on for many decades. Do these ads affect physician behavior? Are we more likely to prescribe ones we read about in ads rather than in scientific reports?

There has always been a concern that advertising, not science, can affect doctors’ prescribing practices. Surely the drug companies think so, or they wouldn’t spend all the money on the ads. They’re not stupid. Now one medical journal, Emergency Medicine Australasia, has taken a stand against the practice; they’ve banned drug company advertising from their pages. In an editorial, they explained why.

This followed extensive debate on the growing evidence about the detrimental effects of the drug industry in medicine. Among the issues discussed were that the industry, one of the most profitable in the world, distorts research findings, such that drug company sponsored research is approximately four times as likely to be favourable to its product than independently funded research; authors of company-sponsored research are far more likely to recommend a company’s drug than independent researchers, and researchers with industry connections are more likely to publish data favourable to a company’s product than those without; selective reporting of results by industry is likely to inflate our views of the efficacy of company products; the drug industry has been shown to engage in dubious and unethical publishing practices, including guest and ghost authorship, and to apply pressure to academics to withhold negative findings; and the industry spends enormous amounts of money on advertising, which has been shown to change the prescribing practices of doctors, increasing sales in a dose-related manner to the volume of advertising.

Doctors, for their part, generally claim that such advertising has no effect at all on their prescribing practices. I know I would deny it. But really, how would I know? Advertisers put enormous effort into sending subliminal messages that work beneath the surface of our conscious radar. I could be manipulated as much as the next physician.

Drug companies value drug advertising in medical journals because it works. It is regarded as highly effective by pharmaceutical marketers, generating at least US $2-5 in revenue per dollar spent, with returns growing in the long term.

Not taking drug company ads has large financial consequences for journals, especially the second and third-rank ones; they more or less run on advertising revenue. The top ranking journals can depend upon high subscription fees; the lesser ones can’t. There are also many journals sent out to doctors that are actually free. We call them “throw-aways.” Trash cans next to the mailboxes in doctors’ lounges are stuffed with them. These can have a useful bit of information in them here and there, but mostly they are massive advertisements for the pharmaceutical industry. Doctors recognize this. But I think we’re less aware of the huge number of ads that appear in highly-ranked journals.

Emergency Medicine Australasia is a foreign journal, based in Australia, and has small impact on American physicians. But the principle they are arguing may well become a trend. I think the internet will help this, since the high costs of printing and mailing medical journals could be dramatically reduced by having the journals online only. Only a small paid editorial staff would be required, since the folks who review and decide on publication are nearly all unpaid as it is. (I used to do that a lot; you get an annual thank-you note — and maybe a calendar —  for your efforts.)

I think it’s something to watch closely.

Telemedicine and a “virtual PICU”

December 27, 2011  |  General  |  No Comments

There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?

I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.

Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practices.

How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.

Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.

Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.

The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.

Do drug ads in medical journals affect physician practice?

February 18, 2011  |  General  |  No Comments

Open any medical journal, including the most prestigious of them, such as the New England Journal of Medicine, and you will see page upon page of glossy advertisements from drug companies for their products. This has been going on for many decades. Do these ads affect physician behavior? Are we more likely to prescribe ones we read about?

There has always been a concern that advertising, not science, can affect doctors’ prescribing practices. Surely the drug companies think so, or they wouldn’t spend all the money on the ads. Now one medical journal, Emergency Medicine Australasia, has taken a stand against the practice; they’ve banned drug company advertising from their pages. In a recent editorial, they explained why.

This followed extensive debate on the growing evidence about the detrimental effects of the drug industry in medicine. Among the issues discussed were that the industry, one of the most profitable in the world, distorts research findings, such that drug company sponsored research is approximately four times as likely to be favourable to its product than independently funded research; authors of company-sponsored research are far more likely to recommend a company’s drug than independent researchers, and researchers with industry connections are more likely to publish data favourable to a company’s product than those without; selective reporting of results by industry is likely to inflate our views of the efficacy of company products; the drug industry has been shown to engage in dubious and unethical publishing practices, including guest and ghost authorship, and to apply pressure to academics to withhold negative findings; and the industry spends enormous amounts of money on advertising, which has been shown to change the prescribing practices of doctors, increasing sales in a dose-related manner to the volume of advertising.

Doctors, for their part, claim that such advertising has no effect at all on their prescribing practices. I know I would deny it. But really, how would I know? Advertisers put enormous effort into sending subliminal messages that work beneath the surface of our conscious radar. I could be manipulated as much as the next physician.

Drug companies value drug advertising in medical journals because it works. It is regarded as highly effective by pharmaceutical marketers, generating at least US$2-5 in revenue per dollar spent, with returns growing in the long term.

Not taking drug company ads has large financial consequences for journals, especially the second and third-rank ones; they more or less run on advertising revenue. The top ranking journals can depend upon high subscription fees; the lesser ones can’t. There are also many journals sent out to doctors that are actually free. We call them “throw-aways.” Trash cans next to the mailboxes in doctors’ lounges are stuffed with them. These can have a useful bit of information in them here and there, but mostly they are massive advertisements for the pharmaceutical industry. Doctors recognize this. But I think we’re less aware of the huge number of ads that appear in highly-ranked journals.

Emergency Medicine Australasia is a foreign journal, based in Australia, and has small impact on American physicians. But the principle they are arguing may well become a trend. I think the internet will help this, since the high costs of printing and mailing medical journals could be dramatically reduced by having the journals online only. Only a small paid editorial staff would be required, since the folks who review and decide on publication are nearly all unpaid as it is. (I used to do that a lot; you get an annual thank-you note for your efforts.)

I think it’s something to watch closely.

US health care stacks up poorly with other countries. Again.

December 24, 2010  |  General  |  1 Comment

A recent study by the Commonwealth Fund highlights what Americans experience in what passes for our healthcare “system” — higher costs, higher risks, and more stress. You can read about it on Chris Fleming’s excellent Health Affairs blog here, or else see the full study published here, in the journal Health Affairs.

The study surveyed eleven countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Survey samples sizes per country ranged from 1,000 to more than 3,500. From Chris Fleming’s blog, here’s a taste of a few things the survey showed.

• Twenty percent of US adults surveyed said they had had serious problems paying medical bills in the previous year. Responses to the same question from the other ten countries were all in the single digits. US respondents were also significantly more likely than adults in other countries to have gone without care because of cost.

• Thirty-five percent of US adults had out-of-pocket medical spending of $1,000 during the previous year, a far higher percentage than in any other country.

• Nearly one third of US adults (31 percent) reported either denial of payments by insurers or time-consuming interactions with insurers, a higher rate than in all other countries. Twenty-five percent of US respondents reported that their insurance company denied payment or did not pay as much as expected; 17 percent said they spent a lot of time on paperwork or disputes for medical bills or insurance — the highest rates in the survey.

• The United States had the widest and most pervasive differences in access and affordability by income of the eleven countries. The United Kingdom had the least.

We didn’t finish last in everything, at least — patients in Canada, Norway, and Sweden reported longer waits on average to see the doctor. But the key point to me is that America spends far, far more per capita on healthcare than any other country. For what we’re paying, we should get the best. We’re not. And those costs just have to come down — they’re unsustainable.

A virtual pediatric intensive care unit?

April 17, 2010  |  General  |  2 Comments

There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?

I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.

Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practice; here is an example of what it means.

How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.

Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.

Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.

The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.

How many children seen in emergency rooms don’t have emergencies?

March 20, 2010  |  General  |  No Comments

Everybody knows, especially those who work in emergency rooms, that a sizable proportion of patients there don’t have an emergency. This is true for children as well as adults. The reasons they are in the ER and not somewhere else are also pretty well known:

1.) A lot of children don’t have a regular doctor, so the ER, by default, serves as their doctor.

2.) Even if a child has a regular doctor, often appointments are hard to get and are days or even weeks in advance, something that doesn’t help very much if your child has an acute illness.

3.) Many doctors’ offices aren’t set up to have much capacity to handle walk-ins.

There is a growing number of free-standing ambulatory walk-in clinics, called by some a “doc-in-a-box,” that respond to this need, but a lot of parents end up taking their child to the ER. Of course this tends to clog up the ER, but many parents simply have no other choice. The question is, what proportion of the children being seen in America’s ERs don’t need to be there?

A recent study in Pediatrics, the journal of the American Academy of Pediatrics, tried to answer this important question. (The link is only to the abstract — unfortunately, you need a subscription to get the whole thing. If anybody wants one, let me know.) The study surveyed a national sample of 5,512 ER visits. The demographics of the group — age, sex, race, economic status — were broadly representative of the whole US population. The investigators counted the number of times the children used the ER and for what. Importantly, and a weakness in the data, is that they didn’t have access to the actual patient encounter charts, so the true severity of the children’s problems couldn’t be assessed; all they knew was what the final diagnosis was.

What they found was that yes, many children who, for one reason or another are brought to the ER, don’t need to be there. But the number of such visits — 1671, or 30% — was less than I expected. Like many pediatricians who have worked in ERs, as I did extensively for 5 years, it often seems like well over half the kids don’t really need to be there. But that’s not what the study found. Of course, 30% is still too many, because it diverts the attention of the ER staff from the sickest children and clogs the system. I think if you gave the parents of these children other options they wouldn’t use the ER. I say this because, in my experience, most parents really are excellent judges of how sick their children are.

Age also mattered; children older than two were more likely to be in the ER inappropriately than were younger children. This actually was a good thing. Infants get seriously ill faster, and with potentially worse consequences, than do older children. Those are the ones we want in the ER more frequently.

The data on socioeconomic status were the most interesting to me. Contrary to what you might think, low-income children, especially minority children, were less likely to use the ER inappropriately. Insurance status wasn’t a factor, although children with insurance had higher overall costs. This is likely an artifact of how we pay for medical care in America.

This study was a national average, and I’m sure the numbers would differ among inner-city urban, suburban, and rural hospitals.

Overuse of the ER is definitely something we need to fix if we ever are to bring down the cost of medical care. Because the overhead costs of ERs are so high (they must be constantly ready for anything), the cost of seeing common illnesses there is several times higher than the cost of the exact same thing seen in a doctor’s office or clinic.

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