Category Archives: General Health

This Makes Me Mad…Immigration Policy

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When our government takes actions on behalf of our country, this reflects on all of our values.  So, earlier this year I was disgusted and angry when I learned that as part of a ‘zero tolerance’ rule, young children were separated from their parents and placed in something akin to cages.  For me, this is a stain on our country’s history that could be compared to other atrocities like the Tuskegee experiments and Japanese internment during WWII.  While this policy was more short-lived, there are still children separated from their parents and for the children involved the consequences could be life-long.  Sadly, our entire country is responsible because we elected this administration which adopted these policies.

Now, this administration which seems incapable of any shame, is planning more steps that should make decent persons upset. Additional threats to lawful immigrants are being devised (KM Perreira et al. NEJM 2018; 379: 901-3).

“Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States” and in some cases deported.  Public-charge guidelines aim to keep immigrants from relying on public charges (eg. cash-assistance programs like welfare) for the first 5 years after admission to the U.S.

“The Trump administration is proposing sweeping changes to these [public-charge] guidelines.”  One of these proposed expansions of public-charge determination is including enrollment for Obamacare, which is legally mandated and which can include subsidies.  Another target is the Children’s Health Insurance Program.  As a consequence of these guideline changes, instead of ~3% of lawful immigrants being considered as receiving a public charge, if adopted, this would increase to a range from 32% to 47%.

If these policies are adopted, this is likely to have a lot of adverse health consequences.  Immigrants, including U.S.-born children, will be less likely to receive health care and more likely to be food insecure; 25% of U.S.-born children of immigrants currently receive SNAP (supplemental nutrition assistance program) benefits. Health consequences will affect millions and include an increase in low birth infants, increased infant mortality, and increased maternal morbidity.

For health care providers and institutions, implementation of these policies is likely to result in higher costs from uncompensated care.

In related commentaries (BL Grace et al. NEJM 2018; 379: 904-5, M Martin. NEJM 2018; 379: 906-7), the authors note the following points:

  • “Current immigration policies are undermining trust in U.S institutions…and changing the way immigrants and refugees seek health care.”  Many are worried that seeking health care could lead directly or indirectly (after providing information) to deportation
  • “Even naturalized citizens fear that their status is no longer secure.”
  • “I feel sad that my colleague’s 6-year-old patient has nightmares and urinary incontinence because she is terrified her parents will be deported.  Sad that my patients fear coming to the hospital despite grave illness out of panic that someone will ask about their immigration status.”

My take: We are all accomplices (many unwitting) in the roll out of these detrimental policies that are now affecting lawful immigrants..

Related blog posts:

Pain in Children with Severe Neurologic Impairment

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A recent commentary (JM Hauer JAMA Pediatrics; 2018. doi: 10.1001/jamapediatrics.2018.1531) addresses a common misconception regarding children with severe neurologic impairment (SNI):

“we don’t think she experiences pain”

She notes that literature since 2002 has challenged this assumption and that this is addressed in a new AAP clinical report as well (Hauer J, Houtrow AJ. Pediatrics 2017; 139: e20171002).

Key points:

  • Children with SNI may have moaning, grimacing, changes in tone/body position in reaction to pain and treatment can make them comfortable.
  • “We can never prove that such a child does not feel pain…When parents of children with hydranencephaly were asked whether their child felt pain, 96% indicated yes.”
  • Pain can trigger changes in catecholamines, cortisol and stress hormones.  “These considerations suggest that untreated chronic pain is more harmful to the well-being of children with SNI than is treatment used for pain.”
  • Sometimes no source for pain is identified.  This may be related to a CNS etiology (alteration of CNS) and may benefit from treatment.
  • “It is time to do away with the question of whether these children feel pain and focus on how we as individuals” identify/consider pain

My take: Reframing this issue is important; pain can occur in children with SNI.  At the same time, we have to be careful that some “palliative” measures could paradoxically prolong suffering in some children.

Related blog post: Suffering

 

Sitting Better (like a dog) to Fix Back Problems

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On the way to work, I heard this NPR story:  To Fix That Pain In Your Back, You Might Have To Change The Way You Sit

An excerpt:

“Most of us do not sit well, and we’ve certainly been putting a lot more stress on our spines,” says Khan, who operates on spines at Sutters Health’s Palo Alto Medical Foundation.

If we change the way we sit, Khan says, it will help to decrease back problems.

“We should sit less, and we should sit better,” he says.

Over the past century or so, many Americans have lost the art of sitting, he says. Most people in the U.S. — even children — are sitting in one particular way that’s stressing their backs. You might not realize you’re doing it. But it’s super easy to see in other people.

Here’s how: Take a look at people who are sitting down – not face-on but rather from the side, in profile, so you can see the shape of their spine.

There’s a high probability their back is curving like the letter C — or some version of C. Or it might make you think of a cashew nut, sitting in the chair. There are two telltale signs: Their shoulders curve over and their butts curve under. That posture is hurting their backs, Khan says…

To figure out how to shift your pelvis into a healthier position, Sherer says to imagine for a minute you have a tail. If we were designed like dogs, the tail would be right at the base of your spine…

To straighten out the C shape, Sherer says, “we need to position the pelvis in a way that this tail could wag.”

My take -disclosure: I am not a back expert –so I am not sure about the expertise of some of this advice.  Also, this article is in sync with a previous NPR segment —Back Pain May Be the Result of Bending Over at the Waist (Lost Art of Bending Over: How Other Cultures Spare Their Spines)

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Exercise and Income/Race/Gender in U.S.

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Thanks again to Ben Gold for another good read: S Armstrong et al. JAMA Pediatr 2018; 172(8): 732-40.

This study provides a great deal of information on the physical activity of adolescents and young adults (age group 12-29) from 2007-2016 using NHANES data from 9472 participants.  The relationship of physical activity compared with income, race and gender is explored.

Background:

  • The current recommendation is for adolescents to engage in a minimum of 60 minutes of moderate to vigorous activity per day.  At age 20, adult guidelines recommend 150 minutes of moderate activity, 75 minutes of vigorous activity  or an equivalent combination of moderate and vigorous activity per week.
  • In previous studies, one-third of adults do not meet the recommended amount of physical activity

Key findings:

  • Percentage of individuals reporting any moderate or vigorous activity: 87.9% for age 12-17 y, 72.6% for age 18-24 y, and 70.7% for age 25-29 y.
  • Mean time for moderate or vigorous activity: For males: 71.1 min or age 12-17 y, 64.3 min for age 18-24 y, and 50.3 min for age 25-29 y. For females: 56.0 min or age 12-17 y, 44.9 min for age 18-24 y, and 39.2 min for age 25-29 y.
  • Younger age, white race, and higher income were associated with greater physical activity.  The breakdown on the specifics are listed in the five Tables.

The limitations of this study include that the data are cross-sectional and do not prove causality.  In addition, the data are self-reported and some groups may over- or under-report activity.

My take: This study shows that a lot of young individuals are not physically-active whihc increases the risk of some chronic diseases.  Examining the groups that have higher and lower physical activity may help understand ways towards improvement.

During a recent trip to Charlottesville, I came across this article. Someone is identifying dog poops with Nicholas Cage’s face –to highlight the problem?  Funny stuff.

Food Additives and Child Health

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For the next several days, this blog is going to highlight articles that Ben Gold (one of my partners at GI Care for Kids) has recently sent me.  For what it is worth, I am not sure that Ben Gold actually sleeps.  He seems tireless.  He shares articles with lots of individuals in our group on a wide range of subjects.  In addition to his loaded clinic schedule, he is busy giving lectures, engaged in NASPGHAN committees, provides guidance for our research projects, participates in hospital meetings, and is active with family pursuits (super-proud Dad).

Ben is also in the running to be the next NASPGHAN president & I think he is very well-suited for this role.  He has  been a Division Chief with a distinguished career both at the CDC and Emory, and has been in a busy private practice. Between these roles, he has acquired practical knowledge with regard to negotiating with hospitals, universities, insurers and industry. This combined academic-private practice experience would benefit NASPGHAN and its members, particularly at a time when the roles of physicians and hospitals are changing so rapidly.

A recent AAP policy statement and technical report (Trasande L, Shaffer RM, Sathyanarayana; Pediatrics 2018; 142 (2): e20181408 & technical report: Pediatrics 2018; 142 (2): e20181410) highlights child health concerns and food additives.

Food additives include the following:

  • Direct additives: colorings, flavorings, and chemicals added during processing. This policy statement notes that there are 10,000 direct food additives which are allowed in the U.S.
  • Indirect additives: food contact materials including adhesives, plastics, paper which can contaminate food as part of packaging and distribution
  • Other contaminants like pesticides are not addressed in this policy statement

Key points:

  • Regulation and oversight of many food additives is inadequate.  This is due to key problems with the Federal Food, Drug, and Cosmetic Act.  Current requirements allow for a “generally recognized as safe” (GRAS) designation. The GRAS process was intended to used in limited situations, but “has become the process by which virtually all new food additives enter the market.”
  • Yet the FDA does not have adequate authority to acquire data on chemicals and data about health effects of food additives on infants and children are limited or absent.
  • Furthermore, FDA regulation does not regularly consider issues of cumulative dosing and synergistic effects of food additives.

Specific examples:

  • Bisphenols, which are used in the lining of metal cans, could result in disruption of  endocrine pathways
  • Phthalates, which are used in adhesives, lubricants, and plasticizers during the manufacturing process, can also  in disruption of  endocrine pathways
  • Perfluoroalkyl chemicals (PFCs), which are used in grease-proof paper and packaging, may result in obsesogenic activity, decreased birth weight, and disruption of endocrine pathways
  • Nitrates and nitrites, which are added as preservatives and color enhancer especially with meats, may contribute to carcinogenicity and thyroid hormone disruption
  • Artificial food colors may be associated with exacerbation of attention-deficit/hyperactivity disorder symptoms

Conflict of interest with GRAS evaluations:

  • Among GRAS evaluations, 22.4% were made by an employee of manufacturer, 13.3% were made by a consulting firm selected by manufacturer, and 64.3% were made by an expert panel selected by manufacturer or manufacturer’s consulting firm

Given the potential safety concerns of numerous additives, the policy statement makes the following recommendations for pediatricians:

  • Prioritize consumption of fresh or frozen fruits and vegetables
  • Avoid processed meats, especially during pregnancy
  • Avoid microwaving food or beverages
  • Avoid placing plastics in dishwasher
  • Recycling labeling often offers clues to the type of plastic with concern for the following codes: 3 often indicating phthalates, 6 for styrene, and 7 for bisphenols –unless labeled as “biobased” or “greenware.”

The policy statement encourages further regulatory steps for government/FDA as well.

My take: These articles sound the alarm that food additives may be making us sick.  This area is ripe for further investigations.

Bow River, Banff

 

Ethics Test for Neonatal Care Providers

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An interesting study ( CL Cummings et al. J Pediatr 2018; 199: 57-64) examined performance levels on a reliable ethics knowledge questionnaire (TEK-Neo). They found that  out of 36 questions:

  • Medical students answered 25.9 correctly
  • Neonatal nurses/practitioners answered 27.7 correctly
  • Neonatal attendings answered 28.8 correctly
  • Neonatal fellows answered 29.8 correctly
  • Clinical ethicists answered 33.0 correctly

While the overall take-home from this study is that the TEK-Neo provides a reliable gauge of neonatal ethic knowledge, I was more interested in some of the specific questions.  Here are three true-or-false questions:

  • #20. “Medically provided fluids and nutrition constitute a medical intervention that may be withheld or withdrawn for the same reasons that justify the medical withholding of other medical treatments.”
  • #21. “Parents of a critically ill 3-day old infant in the NICU born at 26 weeks on noninvasive positive pressure ventilation decline reintubation in the setting of respiratory failure and new grade 3 IVH B/L. Their informed decision to refuse further life-sustaining medical treatment ought to be respected.”
  • #24. “A 14 day-old full-term boy has sustained severe anoxia perinatally and has severe hypoxic-ischemic encephalopathy confirmed on continuous electroencephalogram by persistently low -voltage isoelectric activity. He is unresponsive to his environment. In this situation, the patient’s enteral nutrition (administered via oral gavage tube) may be ethically withdrawn.”

Though the correct answer to these three questions is true, my experience is that parents rarely are interested in withholding or withdrawing care in these type of scenarios.