Pediatric Grand Rounds: Volume 1, Issue 24

©2003 Derek Dudek

Welcome to Pediatric Grand Rounds, Volume 1, Issue 24!

It seems that many of the pediatricians are swamped with patient care duties. It could be the tail-end of RSV season, the onset of rotavirus season (depending on where you are), or the ongoing norovirus outbreaks. Whatever the case, this week’s call for grand round submission resulted in more entries from the recipients of pediatric care than from the providers. As always, because the purpose of grand rounds is to broaden one’s perspective, I’ve included equal number of both and also purposefully created the artificial divide of physicians and patients to allow one to compare and contrast the perspectives.

Pediatricians

I’ve come to expect discussions regarding immunization to come from my friend Flea. However this week it seems that Dr. Rob at Musings of a Distractible Mind is going to carry that particular torch. In his entry, “I Hate Immunizations” he discusses the non-medical aspects of this fundamental work done by our specialty. His inclusion of the very busy 2007 Recommended Immunization Schedule reminds me of the challenges faced by pediatricians who have so much important work to fit into a 15 minute office visit.

The ever-entertaining Flea offers us “More Notes from the Lunatic Fringe”. Flea must have some special radar for finding people with odd credentials weighing in on subjects such as immunization and shaken-baby syndrome because he manages to bring us the story of Viera Scheibner, a retired micropaleontologist from Bratislava, Slovakia, who fancies herself an expert on vaccines despite the fact that she’s neither a pediatrician, a physician, an immunologist, nor even a biologist. After reading his post and the Wikipedia entry on “Dr.” Scheibner, I think that I agree with Flea’s description of her occupying a place far out on the fringe. I am wondering if Flea’s subscription to the New Yorker is up-to-date. If so, he must have loved the story in this week’s issue on HIV and AIDS deniers and the devastating impact they’re having on the lives of HIV-infected people in South Africa.

In a similar vein, Orac’s post, “The Depths of Antivaccination Lunacy” goes into greater detail about people on the fringes of reality trying to link vaccinations to shaken baby syndrome. Orac’s blog, Respectful Insolence has long been one of my favorites, both for the quality of his writing, the depth of the content, and the “prickliness” with which he takes on the pseudoscience frauds who prey on the fears of others.

The always-resourceful Shinga has introduced to me the pediatrician blogger David Blake, who writes the interestingly-named Mavistown 3.0. Shinga volunteered David’s accounting of a parental malapropism for this week’s grand rounds. Happy that I pulled the correct grammatical term out of some dusty 6th-grade synapse, I googled ‘medical malapropism’ to see what else I could find and came up with a couple of cute cartoons courtesy of Twosheep, a knitting blog. Of note, Twosheep is clearly a science nerd. Intrigued, I dug a little deeper and found a bona fide article from The Journal of Family Practice, entitled (appropriately) “Children’s medical malapropisms”. You can get the radiologists (markedly less funny) perspective on medical malapropisms here (note: links to .pdf file).

Sandy, at Junkfood Science, submitted a number of entries, from which I’ve selected her essay on the safety of cow’s milk and the occasional hysteria around recombinant bovine growth hormone (rBGH). While I’m likely to agree with Sandy on the safety of milk, and her assertion, “… that milk is … a perfectly safe, wholesome and nutritious food for growing children and those who choose to enjoy it,” I am, of late, less convinced that cow’s milk is the best food, or even necessary, for human children, as I’ve detailed in my post, “Not Milk?“. This short piece was inspired by new genetic evidence showing that the lactase gene is the egg, and not the chicken (how’s that for mixed metaphors!) when it comes to digesting lactose.

On the NICU front, Neonatal Doc elicited a whopping 38 comments on his post entitled, “Village” where he discusses one of the core dilemmas in neonatology: who does, or should, shoulder the work of caring for the severely impaired children that are the product of our resuscitating younger and younger pre-term infants? In doing so, he raises important and difficult questions about the ethics of “saving” these remarkably premature newborns.

Clearly, though, there are miraculous saves that take place in the NICU. A couple of weeks ago the major news outlets trumpeted the survival of a 22 week old preemie. Laura, at Adventures in Juggling celebrates the healthy checkup of her ex-24-weeker (and the child’s vaccination experience) in her post entitled, “Doing Shots Mean Mommy Style”.

Shinga sent me well over a dozen different selections this week, and I was a little worried that she had failed to include her own entry. Sure enough, tucked at the bottom of a long e-mail I found a link to her post entitled, “Vaccination versus Faith in Vitamins” Touching, But Insufficient Evidence“. It seems like she’s taken her lumps in the fight that we pediatricians wage to prevent illness in children:

This week, I was told that my stance on vaccinations is proof that I am a fool and a pharma shill which is par for the course. I was informed that it has been proved both that healthy children don’t get childhood illnesses and that if they do, those illnesses strengthen their immune systems.

I’m surprised that she didn’t mention the recent JAMA paper which last week provided additional evidence to support the assertion that the multi-billion dollar vitamin and dietary supplement industry is a drain on world-wide healthcare resources. It never ceases to amaze me how people will gulp down expensive handfuls of vitamins and anti-oxidants for which there is little scientific proof but balk at vaccines for which there is both extensive high-quality scientific evidence and decades of experience. In fact, as this analysis states, there seems to be evidence that consumption of certain anti-oxidant vitamins may actually increase mortality!

On the child advocacy front, Lourdes de Asis, over at Allergy and Asthma Source, takes a break from allergies and asthma to bring us a detailed public service message on household poisons.

Signout, who is three-quarters of the way through her internship year (hang in there, Signout!), hasn’t seen a pediatric patient in a while, but shares with us an experience from a couple of months ago on the pediatric oncology service in her post entitled, “The New Black“. She makes an interesting observation:

Talking about death and dying is the new black–it’s all over medical school curricula, residency program workshops, and newspaper science sections.

I agree – it seems that we are now, finally, talking more about death and dying, and as hard as it is to do so with children, I heartily endorse it. Her use of the phrase “[phenomenon] is the new black” reminds me to share with you an interesting project that documents every instance of the phrase ‘is the new’ encountered from various sources in 2005 (courtesy of MetaFilter).

A pediatric grand rounds wouldn’t be the same without some mention of poop. Thankfully, Clark Bartram, who writes Unintelligent Design, shares with us a Code Brown, and a case of Hirschprung disease in a newborn in his post entitled, “The Not So Normal Newborn Nursery: Poop There It Is …“.

And finally, from the housestaff front comes Vitamin K, MD and her blog, Peds. Not Just for Those With a Foot Fetish. Her entry, “… how do I handle this …?” details her reaching the point in her training where she’s learned enough medicine and science to realize that there are too many instances where things are done to patients despite the evidence. Vitamin K – we feel your pain (for which, the evidence now shows, you should use ibuprofen instead of acetaminophen, courtesy of Medpundit).

Parents

This episode of Pediatric Grand Rounds also brings a host of emotions from parents: disappointment, frustration, hopelesslessness. Hmm. Sounds like things have been a lot harder for the parents this week than for the pediatricians.

On the parent side, frustration is the theme for Purple Kangaroo who grapples out loud with the differences between food allergy and dietary intolerance and provides a real-world example of the aphorism, “Ask 12 specialists, get 13 different opinions.” Her heartfelt essay highlights an important phenomena in medicine: the disconnect between physicians, who are experienced in dealing with not-well-understood phenomena, and parents, who find such phenomena disconcerting when they happen to their children.

Moreena, at The Wait and Wonder, highlights the sense of helplessness that parents of critically ill children experience. She does a wonderful job of showing me an entirely different perspective on the advice that I’ve often given to the parents of my patients. I have told the parents of children who have successfully completed their cancer therapy, and who are consumed with worry about relapse, that it is not possible to predict or control relapse. I tell them, from my relatively safe position, that life is full of unknowns. I tell them that I cross the street between the building with my lab and the hospital a half-dozen times a day and never think about the fact that on any one of those occasions, I could be run over by the hospital shuttle. It’s certainly possible, but I’m not going to stop crossing the street just because of the possiblity.

Moreena points out a perspective that I’d not considered:

People with the best intentions have pointed out to me that something bad could happen to any of us, at any time. The idea is that we never know, and usually have no control over bad stuff happening, anyway, so therefore I should just let go of all my constant worrying … Honestly, there is just no way that is ever going to happen …We just don’t worry as much about theoretical dangers. But once we can name the danger; once we know what it looks like, once it takes up space in our lives as a realistic and constantly present concern, then it’s hard not to let the worry take over and taint everything we do.

Thanks, Moreena, for the terrific post and the valuable perspective. You are, without a doubt, my pick for the best of the entries this rounds. Your essay reminded me to also share with everyone a post that I came across from the mother of a young boy with neuroblastoma who writes the blog How Can I Keep From Singing. Her post, “Untitled“, was one of the most heart-wrenching and thoughtful pieces written by a parent I’ve read in a long time. These two posts highlight for me the value of medical blogs – both physician- and patient-authored. What I’ve learned from Moreena and Susan reading these will surely help me to better understand my patient’s parents, and that’s a pretty valuable gift to receive, especially from disembodied words on the internet.

The industrious Shinga forwarded me an entry entitled, “Early days 3” from Whitterer on Autism. Mcewen writes 3 different blogs and in this entry discusses the disappointment of having realized that there were no magic therapies for her child’s speech delay.

On a lighter note, Jen, who writes Unique But Not Alone, a blog that discusses her experience with her daughters’ alpha-1 antitrypsin deficiency, shares some “kid logic” in her post entitled “Ginormous”. This reminded me to share with you an episode of the wonderful radio program This American Life also entitled, “Kid Logic” (note: links to .mp3 file).

Also on a somewhat lighter note (at least I hope it was meant as light), Awesome Mom’s son, in anticipation of getting a shot, decided to induce his own respiratory arrest in the physician’s office. She managed to capture on of her son’s breath holding spells an shares it with us in a post entitled, “How to Surprise Your Pediatrician“. Having done the respiratory arrest thing one this week in the ED, I thank Awesome Mom for pushing my post-traumatic stress button.

Ami Chopine responded to my essay on co-sleeping with her thoughts in favor of co-sleeping.

When I first read Do’C’s post from his blog Autism Street, I truly thought he was a physician or scientist (no offense, Do’C). He writes with the same degree of skepticism and critical thinking that I attribute to Orac and Flea. His entry, “A Hot Cup of Jack Squat” written with fellow blogger Not Mercury dissects yet another pseudoscience essay purporting to link mercury to autism written by an author who is a chemist at the Wisconsin State Laboratory of Hygiene and just so happens to have an autistic child.

Well, that just about wraps up another episode of Pediatric Grand Rounds. I want to thank everyone for their contributions, including those whose couldn’t fit into the current issue. I learned great deal from putting this issue together, and I hope that everyone takes at least one or two pearls away with them. The next issue of Pediatric Grand Rounds is being hosted by Rob over at Musings of a Distractible Mind two weeks from now.

And if you enjoyed this issue of PGR, please return on March 20th as I attempt to take on the original blog Grand Rounds.

Finally, be sure to take a moment and let your fellow bloggers know that the current issue of PGR has been posted so that everyone’s hard work and thoughtful comments can be disseminated along the Internets!