Category Archives: Pediatrics

Suffering

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I was intrigued by the title “The Word That Shall Not Be Spoken” (NEJM 2013; 369; 177-78).

According to the author the word is “suffering.”  He notes that clinicians do not like to use this word. Some of the reasons:

  • It is not “actionable”..it is “too heterogeneous, too complicated”
  • It reminds us that we are “powerless against so many of our patients’ problems”
  • Because “the idea of taking responsibility for it overwhelms us as individuals –and we are already overwhelmed by our other duties and obligations

His conclusion: “in truth, I’m less interested in the words we use than in what we actually do, and what we organize ourselves to do. Collectively, we should not shy away from work that can never be completed.  For our organizations, relief of suffering does seem like the right goal, endless though the work might be.”

Probiotics for Colic

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Another study has shown the potential for probiotics to help colicy infants.  In an editorial, Carlos Lifschitz sums up the paper (The Journal of Pediatrics Volume 163, Issue 5 , Pages 1250-1252, November 2013); here is an excerpt (link from Kipp Ellsworth twitter feed —goo.gl/b3iMFu):

For reasons that are not clear, human infants are born with a well-developed capacity to cry.1 …Unexplained and severe crying affects 3%-28% of breastfed or formula-fed (otherwise-healthy) young infants.2 Although excessive, inconsolable crying and colic are considered to be a benign, self-resolving problem, they can be very distressing and lead to marital conflict and parental exhaustion.3 Infantile colic is defined as paroxysmal, excessive, inconsolable crying without an identifiable cause in an otherwise-healthy infant occurring in the first 3 months of life and lasting a minimum of 3 hours per day, 3 days per week, for 3 weeks…

Enter probiotics. Lactobacillus reuteri DSM 17 938 at a dose of 108 colony-forming units per day in breastfed infants improved symptoms of infantile colic,19 a finding that was further corroborated.20 Despite evidence that altering the microbiota may result in reduced crying, the physiopathology still remains unclear…

In this issue of The Journal, Pärtty et al22 attempt to prevent excessive crying in former premature infants….To determine whether excessive crying is preventable by manipulation of intestinal microbiota, 94 preterm infants, some breast- and formula-fed, with gestational ages ranging from 32 to 36 weeks and birth weights >1500 g, were randomized in the first 3 days of life in a double-blind study to receive for the following 2 months either a mixture of galacto-oligosaccharide and polydextrose (prebiotic group), Lactobacillus rhamnosus GG (probiotic group), or placebo…Follow-up consultations were conducted by the same study nurse at the age of 1, 2, 4, 6, and 12 months…

Significantly less frequent crying was observed in both the pre- and probiotic groups compared with the placebo group (19% vs 19% vs 47%, respectively; P = .02). At 1 month of age, the infants’ fecal microbiota were investigated. The proportion ofLactobacillus-Lactococcus-Enterococcus group to total bacterial count and the proportion of Clostridium histolyticum group to total bacterial count was greater in excessive criers than in contented infants in all 3 study groups (pre-, probiotics, and placebo). The authors concluded that early pre- and probiotic supplementation may alleviate symptoms associated with crying and fussing in preterm infants.

Although in the study the following associations did not reach statistical significance, they are of interest for future investigation: contented infants were more often exclusively breast-fed during the first 2 months (42% vs 22%, respectively, P= .09) and their mothers had received perinatal antibiotics less often (22% vs 41%, respectively, P = .07) than criers… Contrary to this hypothesis, however, is the finding that persistent criers were more often born by vaginal delivery as opposed to cesarean delivery (81% vs 63%, P = .07) than contented babies. This finding is surprising because birth by cesarean delivery and, therefore, lack of exposure to the microbiota of the vaginal canal and perineum, has been associated with abnormal development of intestinal microbiota and several diseases.

Related blog posts:

In a video, Dr. Sanjay Gupta and Dr. John Bachman say ‘we don’t know why babies have colic, but it will end and is not the parent’s fault:’ ow.ly/q4IsW 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

Additional references:

  • -Pediatrics 2010; 126: e526.  Double-blind randomized placebo-controlled trial of Lactobacillus reuteri.
  • -J Pediatr 2009; 155:823. Increased calprotectin in colicy infants. n=36. editorial pg 772.
  • -J Pediatr 2009; 154: 514-20. Colic and reflux. (Orenstein et al), & 475 (editorial -Putnam). PPIs (lansoprazole) do not help colicy Sx in infants c GERD. n=162. Increased resp infections in pts on PPIs. 44% response in Rx & control group.
  • -J Pediatr 2008; 152: 801. Probiotic helped reduce colic sx in 30 preterm infants, Lactobacillus reuteri
  • -Pediatrics 2007; 119; e124. Probiotics reduced colic in breastfed babies more than simethicone. n=83, lactobacillus reuteri, 10-8th power per day. Decreased crying 18 minutes per day at 1 week compared to simethicone & by 94 minutes/day at 4 weeks (95% response vs 7% of simethicone)
  • -Pediatrics 2005; 116: e709. Low-allergen maternal diet was helpful.
  • -Hochman JA, Simms C: “The role of small bowel bacterial overgrowth in infantile colic“J Pediatr 2005; 147: 410-411 (Letter to Editor).
  • -Arch Pediatr Adol Med 2002; 1183 &1172. lack of sequelae on maternal mental health.
  • -Arch Pediatr Adol Med 2002; 156: 1123-1128. colic 24% of infants, breastfeeding did not help.
  • -Pediatrics 2002; 109: 797-805. carbohydrate malabsorption with breath testing in colicy infants, n=30. 2 hour fasting period.

Casting a Wide Net: Whole-Exome Sequencing

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A recent study shows that whole-exome sequencing can be used to diagnose genetic defects in patients with a range of phenotypes (NEJM 2013; 369: 1502-11).

In this study, the first 250 patients who had whole-exome sequencing performed at Baylor College of Medicine were studied.  80% had neurological problems and all had undergone previous extensive evaluation.

Results:

  • The authors identified “86 mutated alleles that were highly likely to be causative in 62 patients (25%)”
  • 83% of the autosomal dominant mutant alleles (n=33) and 40% of the X-linked mutant alleles (n=9) occurred de novo.
  • In four patients, the authors identified multiple causative genes.  This may lead to a paradigm shift from Occam’s razor towards more cases of “multiple hits.”
  • The authors speculate that the yield of this type of testing will improve as databases grow since many mutations at this time are of uncertain clinical significance

Bottomline: While this approach was used mainly in individuals with unexplained neurological problems, the use of whole-exome sequencing has broad potential.  In GI/Liver, the uses could include unexplained diarrheal disorders, metabolic/cholestatic liver disease, failure to thrive, inflammatory bowel disease, and many other conditions.

Related blog links:

Being Short -Not Pathologic

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A recent retrospective review from Cincinnati Children’s showed a surprisingly low level of underlying disease in asymptomatic short children (J Pediatr 2013; 163: 1045-51).

The authors reviewed 1373 consecutive cases of short stature referrals (endocrinology) between 2008-2011.  In this cohort, there were 235 who met inclusion criteria as having height <3rd percentile and otherwise well.

Results:

  • “Nearly 99% of patients were diagnosed as possible variants of normal growth: 23% with familial short stature, 41% with constitutional delay…and 36% with idiopathic short stature”
  • New pathology: 1 patient with biopsy-proven celiac disease, 1 patient with unconfirmed celiac diease, and 1 patient with potential insulin-like growth factor I receptor defect.
  • Cost for each new diagnosis:  >$100,000

One important caveat from the study was the focus was not on those with growth failure –height velocity less than 5 cm/year; this study analyzed those with short stature only.  In all short (growth failure and isolated short stature) patients, previous studies have identified a much higher rate of organic pathology.  The authors also note that only 37% of their patients had appropriately maintained growth records forwarded (even after requests).  One other point that I found interesting: “Contrary to common belief, short stature has not been shown to result in impaired quality of life.”

Conclusions: “healthy short children do not warrant non directed, comprehensive screening.” The authors advocate for revision of pediatric endocrine guidelines for evaluation of these children. Reference: J Clin Endocrinol Metab 2008; 93: 4210-7.

These conclusions should be applied ONLY to those without symptoms and with normal exams (which should include a perianal examination).

Related blog posts:

Quality care = Work Satisfaction for Physicians

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From Atul Gawande’s twitter feed:

RAND study:

“Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” Full article: http://bit.ly/19vVAnK 

1) Best predictor of MD work satisfaction: how we rate system’s care quality.  Physicians who felt that they were working in an environment with high quality care had higher work satisfaction.

2) Bad EHRs are killing us.  (Related blog entry: Aptly titled “The Cost of Technology” | gutsandgrowth)

 

Why I blog

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I was asked to participate in a “Meet the Professor Breakfast Session” at the NASPGHAN Annual Meeting. This year’s meeting is taking place at the Chicago Hilton Downtown, October 9-11th. The proposed title of my session:

“Twitter/Facebook/Blog- Use of Technology in your practice”
Co-presenter: Eric Benchimol; time 7am (central) tomorrow morning (October 11)

My focus will be to discuss this blog and how it relates to my practice.  I started this blog shortly after the NASPGHAN meeting in 2011.  There were two main factors that contributed to starting this blog.

1. The death of the palm pilot and other PDAs.  After my fellowship, in 1997 I joined Mike Hart in Atlanta at Egleston Children’s Hospital.  He had started using a palm pilot and I began using one as well. I stored a lot of useful information on drugs and personal contacts.  By each local physician, in addition to their name, I kept the names of referred patients and their diagnoses.  I also decided that instead of tearing journals I would make entries in my Palm device and keep annotated references of journals that I was reading. When the support services disappeared for my Palm device, I transferred a lot of information to Notespark but was not as pleased with this site as I had been with my Palm.

2. NASPGHAN meeting. While at the NASPGHAN meeting, I listened to a talk by Bryan Vartabedian (33 Charts — medicine. health. (social) media).  Prior to that meeting, I had not considered starting a blog.  He made several points that I considered important.

  • Physicians need to provide a voice and balance in social media.  In many areas of medicine, like immunizations, the voices of extremists dominant the conversation.  “The solution to pollution is dilution.”  When physicians add their reasoned opinions to topics related to public health, this will steer the conversation towards sanity.
  • Taking part in social media allows a physician to modify their digital footprint.  Without our participation, what is placed on the internet is beyond our control (Physician Online Reputation Management – 2 Realities – 33 Charts).

His blog on social media and medicine has been present for many years and elaborates on these points and many others.

So I decided to start a blog.  This might sound difficult but it wasn’t.  I didn’t even need to ask my teenage sons for hardly any help.  Though, in retrospect, it may have been a good idea.  I found that wordpress.com provides tools for individuals to create their own blogs at no cost (alternative sites are noted in my slides -see link below).  Though, they definitely encourage an upgrade ($18 per year). Basically, I registered a name, picked a design type for the blog, and made a few choices about the formatting.

If you have time, you can look at some amazing blogs: photographers post pictures from all corners of the earth, professional chefs & domestic chefs provide recipes for anything you could think of eating, Nate Silver can tell you who is going to win the next presidential race, KevinMD has thoughtful posts from a huge number of health professionals, our hospital (like many others) has a blog, improvecarenow has a blog, there are blogs explaining the NEJM articles, my sister has a blog about what turning 50 means, and so many others.

What were my goals/Why I blog?

  • To create a site where I could archive the references of journal articles and have them accessible for easy searching.
  • To develop a relatively non-controversial digital footprint.  Truth be told, I would love to create a joke blog.  However, I think that anything you put out on the internet is available for public consumption and I am certain that some of my jokes would not be well-received in some circles.
  • To add my voice to topics like immunization policy, judicious use of antibiotics, and healthy nutrition choices.
  • To share some of my readings with my colleagues and mid-level providers.  I hoped that some of the information might help with more uniform adoption of best practices.  For example, with H pylori, we have an international expert in our group (Benjamin Gold who is speaking at this conference). Yet, the information that clarithromycin should not be a 1st line drug had not been brought up in any of our meetings.
  • To promote some aspects of our groups’ accomplishments.  When one of our physicians publishes an article, I definitely want to review that for my blog.
  • To remember journal articles with more clarity.

While many physicians might see the opportunity for patient education, I decided to target the blog to a medical professional audience.  Our office website (Children’s Center for Digestive Healthcare, LLC (GI care 4 kids) already has a great deal of patient-related information and links to numerous other useful sites.

When I first started the blog, I only notified a few people outside of our group.  This included my mentors in Cincinnati (including Mitchell Cohen, William Balistreri, and Jim Heubi) as well as my former boss Mike Hart.  All of these individuals, along with my other mentors in training (Colin Rudolph, Jorge Bezerra, Mike Farrell, and Jon Bucuvalas), could probably provide a great deal more insight.

After writing a few blogs, I decided I would send an email to authors of papers that I commented on.  This would allow them to provide additional insight as well if they chose.  After about a year of blogging, Mike Hart asked if I was OK with him sending an email out to the pediatric GI bulletin board listserv because he thought more people might enjoy the blog’s contents.  Also, now I usually will post a link on twitter so that individuals who follow me can access the blog as well.

Many physicians have avoided social media due to either time constraints or concerns of potential risk about putting out medical information.  I do put in time and try to be careful about what I write.  And, unlike medical journals, I do not have any editors.

At the same time, I have a lot of advantages.

  • I can provide links to media.  Some of these links are just for fun.  For example, in previous posts:  “dont go ninjin nobody that dont need ninjin” Kung Fu Hillbilly – Training Video – YouTube or “Everybody Poops” – a bad lip reading of the Black Eyed Peas ….  In addition, it is not difficult to place graphs or pictures.
  • I can provide links to newspaper articles and original publications.
  • I have the opportunity to provide more timely information.
  • The information on my blog is much easier to search.
  • Many other physicians forward me articles that they think would be of interest.
  • I can link previous related posts.  This is a lot easier than tracking down other types of references.
  • I can use twitter to leverage a great deal of information.  For example, Kipp Ellsworth has a twitter feed, @PedNutritionGuy, which cites a large number of relevant nutritional studies. Jeff Schwimmer has a twitter feed, @TheLiverPost, which highlights recent hepatology advances.
  • The blog site has a lot of tools, like widgets, which can help present useful information

Since my blog is mainly for health professionals, I have on occasion written patient-related information for our hospital blog: When a Child Swallows a Button Battery – Dedicated to All Better.  I’ve been told that this posting has had more than a thousand views.

Full presentation (powerpoint): WhyIBlogSlides

Related post:

Probiotics, Atopy, and Asthma

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Moving from theory to practice with probiotics has been problematic in many areas.  That is, theoretically probiotics by altering the microbiome should have numerous beneficial effects; however, demonstrating these positive effects in practice has been difficult for many conditions.  A recent study (thanks to Mike Hart for this reference) highlights this issue with regard to asthma:  Pediatrics 2013; 132: e666-76. Full article:

http://pediatrics.aappublications.org/content/132/3/e666.full.html

Background: Due to the immune modulating effects of probiotics and mindful of the hygiene hypothesis regarding the rise of atopic diseases, some have proposed the use of probiotics to reduce the risk of atopy and asthma in children.

Methods: In this study, the authors performed a meta-analysis of numerous randomized studies.  Out of a total of 1081 articles, 25 studies met predefined criteria, with a total of 4031 participants (see Table 1 in publication).  Numerous probiotics were administered.  The most common probiotic in these trials, Lactobacillus GG,  was used in 8 of the studies.

Results:

  • For serum immunoglobulin E (IgE) levels, 9 of the trials (n=1103) provided data.  Probiotics were associated with a -7.59 U/mL reduction in total IgE (P= .044).  The effect of probiotics was more pronounced with longer, follow-up periods.
  • Probiotics, in comparison to placebo, were associated with a reduced risk of atopic sensitization based on positive skin prick and/or elevated specific IgE to common allergens.  This was true whether the probiotic was administered prenatally (relative risk 0.88, P=.035) or postnatally (relative risk 0.86, P=.027)
  • Probiotics did not reduce the risk of asthma/wheeze (relative risk 0.96 [95% CI 0.85-1.07]

Study limitations: heterogeneity of clinical trials in meta-analysis, various probiotic strains, variable duration and timing of probiotic use.

Related blog posts:

Graphic Ads Motivate Smokers to Quit

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From NY Times (coverage of Lancet article), those graphic anti-smoking ads seem to be helping.
http://nyti.ms/18RT9Kq

An except:

For almost two decades, Lisha Hancock smoked between one and two packs of cigarettes a day…..

Then she saw a graphic television commercial featuring a former smoker, Terri Hall, who developed head and neck cancer. The widely seen advertisement shows Ms. Hall inserting a set of false teeth and placing a small speaker inside a hole in her neck.

“It scared me because I had always had problems with my throat,” said Ms. Hancock, 38, who lives in Kentucky. “When I saw that, it made me realize that there are other types of cancer besides lung cancer, and that really hit home for me.”

The ad prompted her to give up smoking about eight months ago, using a combination of an exercise and healthful eating regimen along with nicotine lozenges, and she has not had a cigarette since. But Ms. Hancock may be just one of thousands of Americans who quit smoking after seeing the commercial featuring Ms. Hall, which was part of a series of antismoking ads put out by the federal government last year. The campaign, called Tips From Former Smokers, was notable both for its raw images and because it marked the first time that the government directly attacked the tobacco industry in paid, nationwide advertisements.

According to a new study published on Monday in The Lancet, the ads may have prompted more than 100,000 Americans to give up smoking for good. (emphasis added by blog)

The study, led by a team at the Centers for Disease Control and Prevention, surveyed 5,300 Americans before and after the campaign, including 3,000 smokers. The paid ads ran for three months beginning in March, just after the New Year resolution season, when the percentage of smokers trying to quit is typically on the decline.

The researchers found that over all, four of five of smokers had seen the commercials, and the percentage who reported trying to quit rose by 12 percent. Of those who tried to quit, about 13 percent remained abstinent after the campaign had ended.

Using census data, the researchers estimated that as many as 1.6 million smokers nationwide attempted to quit as a result of the ad campaign. Most smokers require several attempts before they give up cigarettes for good, so only a fraction of those who were motivated by the campaign would have succeeded. The ads were expected to spur about 50,000 smokers to quit permanently, but the Lancet study estimated that twice that number were successful….

Historically, about half of the nation’s 45 million smokers try to quit every year, and yet cessation rates hover around 5 percent annually. Public health officials have long been telling smokers that cigarettes shave years off your life, contributing to more than 400,000 deaths every year.

The new campaign went in a different direction, focusing not on death but on quality of life. The creators of the campaign used focus groups and feedback from smokers to develop sobering ads showing real smokers with amputations, paralysis and disfigurement from heart and lung surgeries.

“I think the fact that you may die is not highly motivating to people,” Dr. Frieden said. “The fact that the remainder of your life may be very unpleasant is, and that’s what the data shows. Not only do smokers die about ten years younger than most people, but they feel about ten years older than their age.”

The campaign last year cost about $54 million and was paid for by the Affordable Care Act. …. Dr. Frieden said the money, which is only a fraction of the $8 billion the tobacco industry spends on marketing and promotion every year, was well spent.

“This is a campaign that has literally saved tens of thousands of lives,” he said. “We would like to be able to have hard-hitting campaigns like this on the air year round. The tobacco industry spends what we spent on this campaign in three days.”

Related blog posts:

Hospital-based Antimicrobial Stewardship

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While there has been growing recognition of antibiotic resistance, the efforts to implement strategies to preserve the effectiveness of our current antibiotics have not been embraced by enough stakeholders.  A recent review provides insight into the antibiotic stewardship (AS) programs that are being implemented by pediatric hospitals (JAMA Pediatrics; 2013; 167: 859-66).  Thanks to Ben Gold for sharing this reference.

AS goals are to “optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance.”  Five specific goals:

  • timely management of antimicrobial therapy -prompt initiation when indicated, avoid when not indicated (eg. viral illness)
  • appropriate antibiotic selection -minimize redundant antibiotic coverage
  • appropriate antibiotic administration and de-escalation of therapy -reassess after 48-72 hrs whether to discontinue antibiotics, monitor levels when needed
  • use of available expertise and resources at point of care
  • transparent monitoring of antimicrobial data usage

Adoption of AS programs has been accelerating in the past few years.  “A recent survey of 43 children’s hospitals showed that 16 institutions (37%) ..currently have an established AS  program supported by full-time equivalents for a pediatric infectious diseases physician and/or clinical pharmacist.”  Another 15 (35%) are in the preparatory stage of implementing an AS program.

Potential barriers for AS programs:

  • Lack of funding or time –these programs have been reported to yield cost savings
  • Lack of hospital leadership
  • Concerns about physician autonomy

Potential outcome variables to measure:

  • Reduction in adverse events
  • Improved (?) antibiotic resistance trends
  • Reduction (?) in C difficile rates

The authors note that on a national level that AS programs have not been mandated. However, multiple societies, including the Infectious Diseases Society and the Society for Healthcare Epidemiology of America, have recommended their widespread adoption.

Bottomline: Improving hospital antibiotic usage with the use of AS programs will help reduce antibiotic resistance, but it is the tip of the iceberg when it comes to addressing this issue (see related blog posts below).

Related blog entries: