Friday, May 17, 2013

Praise for Suffer the Children

Suffer the Children addresses the following themes:

* the shortcomings of how primary medical care is delivered
* how the expectations of parents affects the decision making of pediatricians
* the over-prescribing of antibiotics
* the lost art of obtaining a medical history and performing a physical diagnosis
* how laboratory studies are routinely misinterpreted and can subject your child to unnecessary treatments
* cognitive errors that lead physicians to mistaken diagnoses
* financial conflicts of interest in medical care
* suggestions for improving the quality of medical care.  We can and must do better!


Here's what readers have said of my book:

“a gem of a book...Its lessons are important and are not limited to pediatrics: every health care provider and every patient could benefit from reading this book.”
Harriet Hall M.D.
sciencebasedmedicine.org

“Dr. Palmieri has an admirably clear style and an enviable ability to explain scientific and medical concepts so that anyone can understand them… This is an excellent book that every parent and pediatrician should read and take to heart.”
Mama Mara,
“Science, medicine, and psychology for the discerning mommy”

"Suffer the Children is a comprehensive and accurate assessment of what needs to change in the practice of pediatrics. It should be read by the directors of every pediatric training program".
William Wilkoff, M.D.
Pediatrician and author, "Coping with a Picky Eater: A Guide for the Perplexed Parent"

"It's rare to see such an insider's view of his own profession, especially one that so eloquently and caustically exposes widespread systemic flaws. This isn't a book for the faint-of-heart, or for those who wish to blithely continue to obey the experts in whom they've trusted their children's care. It is a tome designed from the first page to open eyes and change thinking."
Roy Benaroch, M.D.
Pediatrician and author, "A Guide to Getting the Best Care for Your Child"

"Dr. Palmieri's book should be read by all medical students, residents and practitioners, regardless of their specialty. In today's age of evidence-based medicine (or better yet, science-based medicine), we cannot afford to constantly rely on folklore, logical fallacies and doctors who ignore science."
John J. Byrne, M.D.
Pediatrician

"Dr. Palmieri is correct, but what he describes equally applies to all medical professions."
Paul Prescott, M.D., F.A.A.P.
Pediatrician

Thursday, May 16, 2013

When Should I Pierce My Baby's Ears?



Parents of newborns often ask me what is the best time to pierce a baby’s ears.  My standard answer leaves many perplexed.  Before I reveal what that reply is, let’s briefly analyze the relevant issues surrounding ear piercing.
            Earrings have been used since biblical times and it seems that the practice of piercing infants’ ears dates back to that era. The most common reasons for ear piercing reported by parents are the following:
1.      It is traditional in our culture.
2.      It hurts less to have it done when they’re babies, or at least, they won’t remember the pain.
3.      They look cute.
4.      How else will people know that it’s a girl?
The arguments against early piercing revolve around the potential risks of complications and issues of safety.  There is the concern that babies have a higher risk for localized skin infections as well as for life-threatening generalized sepsis. The possibility of acquiring tetanus is quoted by those physicians who advocate waiting until six months of age (to complete three doses of tetanus vaccine) though it is hard to find any solid data on the actual incidence of this disease following ear piercing. Children are more likely to develop sensitivity to metals if exposed at an earlier age.  And when the child grows into a toddler, the risks of suffocation and injuries to the ear lobe increase as the child becomes more active.  Also, the studs of earrings have a propensity to become stuck or embedded under the skin on the back of the ear lobes of infants.
The weighing of risks and benefits in medicine incorporates two ethical prerogatives:  the principle of beneficence (the desire to provide aid and relief) and the principle of non-maleficence (the desire not to harm).  But, the issue of ear piercing should include yet another aspect of ethical consideration: the principle of autonomy – that an individual has the right to choose or refuse a treatment.  The individual, in this case, is the baby, and though we can’t ask her, there is no urgency that we can’t wait until she is able to express her opinion.
Some may scoff at this notion, pointing out that parents routinely make medical decisions for their children, but they do so in situations where there is a clear health benefit to their child, where it’s not feasible to wait a few years until the child is able to understand the choice and verbalize it.  No such benefit can be surmised with ear piercing. Still, most children wouldn’t make a big fuss about having had their ears pierced when they were infants, you may say.  But what about baby girls who have multiple ear piercings? How about boys that have had their ears pierced as infants?  Both of these are becoming more common trends.  Are they not entitled to make that choice for themselves?
So this is what I tell parents.  Jewelry is used in our society to connote social status (why else would someone drop thousands of dollars on a Rolex when they can use their cell phone to tell the time) and for cosmetic reasons.  Babies don’t care to flash Bling and they are adorable without jewelry (in fact, jewelry on babies is a tad gaudy – what’s next? Lipstick? High heels?).  If it is absolutely crucial to you that people know the gender of your child, use the old pink/blue color scheme, pick names that are not ambivalent as to sex, or just tell people, “She’s a girl!” or “He’s a boy!”
As far as the pain issue, it is clear that infants feel pain just as acutely as older children and adults do.  In fact, there is some evidence that early painful experiences might modulate the perception of pain later in life. If you think your child will not want to have her ears pierced when she’s older out of fear of pain, think again.  Teenagers hardly think twice about piercing their ears, noses, eye-brows, tongues, navels… and more sensitive parts.
What about the sense of culture and maintaining tradition? Traditions change.  When I was an infant no one used infant car seats and few buckled up their seat-belts, doctors smoked as they made hospital rounds and there was no talk of “health foods”.  Bucking tradition is one of the great joys of life, particularly when you are making a rational choice for your child.
So when is the best time to pierce your baby’s ears?  Answer: when she (or he) requests to have it done.  Now wasn’t that simple?

Tuesday, May 14, 2013

SLIM DOWN: A Healthy Approach to Preventing Childhood Obesity



Here’s an interesting fact: animals do not become overweight in their natural habitat. In the wild, cats are not fed Meow Morsels Select from a crystal bowl and must prowl and hunt for their meals. A fat cat makes a poor hunter. Even large animals, elephants and water buffalo, are not obese in the wild in the sense that they do not reach a weight that is physiologically detrimental to their health.  Bears fatten up before hibernating but this too is a normal physiologic mechanism that aids in their survival.
            Why do I bring this up? Because I’d like to make the point that humans no longer live in their natural habitat, and the explosion of obesity is a direct result of this fact.  Humans have not evolved in the last 100,000 years, yet we moved from our hunter-gatherer roots (our natural habitat) through the agrarian period, past the industrial revolution and into the information age.  But our physiology is still that of hunter-gatherers.
            Of course I’m not suggesting we all return to the forest to eat berries and trap squirrels. Yet we have to be mindful that we are living in an environment which is conducive to accumulating weight to a point that impairs our well-being. And we are raising our children in this challenging and unhealthy environment.
            So what can a parent do to try to buck the trend and help keep their children achieve a healthy weight? Over the years, as a board certified pediatrician, I’ve developed an acronym that I use as a mnemonic device in counseling my patients.  It captures a range of behaviors and habits that lead to healthier living. The goal, I always stress, is not to shoot for an arbitrary pre-selected weight, but to incorporate healthy habits.
            The acronym is SLIM DOWN, and I’ll go through each element briefly.

S = Sit at the table to eat
Perhaps as a result of the hustle and bustle of our lives, perhaps due to the pull of entertainment that attracts us like moths to a patio light, children nowadays eat in all sorts of unusual places: in the back seats of cars, in their bedrooms at their computer, on the sofa as they watch TV… I believe this is an unhealthy trend. First, kids are missing out on the significant social interaction of a family meal. Second, they are distracted when they are eating.  Distracted eaters have difficulty gauging satiety clues and tend to overeat.  Try to eat at least one meal a day as a family.  Your children can model their eating habits from you, you’ll be better able to monitor your child’s food choices, and there are countless other benefits stemming from the social interaction.

L = Limit screen time
From television to video games and computers, children are more sedentary than ever. Even reading a book burns more calories than sitting on the couch watching TV.  The best way to limit screen time is to give your children other options.  This may require going in the backyard to play catch with your child, or going to a park for a walk. Unfortunately, many children live in neighborhoods that are inherently unsafe which makes outdoor activity nearly unfeasible.

I = Include exercise as a daily routine
This doesn’t necessarily require participation in sports though certainly that is a good option for some children.  Riding a bike, playing in the park, walking the dog, just playing outdoors are all forms of exercise.  The key is to select an activity that is fun so that children look forward to it.

M = Motivate with rewards, not punishment
We can all use a pat on the back sometimes. Don’t use threats or demean your children when they resist incorporating new habits. Learn to use the carrot rather than the stick.  Set achievable goals and provide appropriate rewards to encourage your child.

D = Dine restaurant style, not buffet style
At a restaurant, you order an entrĂ©e and the waiter brings it to you (by the way, the size of dishes at many restaurants are way too big!).  If you finish everything that is on your plate, it is understood that the waiter will not bring you a second helping.  You ate what you ordered, that’s it! (Unless you order more food, which you probably shouldn’t.) At a buffet, on the other hand, if you like the fried chicken, you can go back in line and get some more, and why not pick up some more shrimp while you’re at it, to make sure you get your money’s worth?
            At home, the buffet setting happens whenever there is food available for second helpings; bowls on the table filled with delicacies within arm’s reach. Convert your home meals into a restaurant experience. Start by cooking less – it’ll save you money!  Plate appropriately sized portions. If your family members eat everything on the plate, guess what?  That’s it!  If you really misjudged the portion sizes, you can always bring a bowl of fruit to the table.

O = Offer fewer, better snacks
Grazing is the eating pattern of large mammals. When humans graze, they become large mammals.  Kids graze when they are constantly eating snacks.  Some children get the majority of their calories from snack foods (including drinks) rather than from their scheduled meals. Also realize that there is no Recommended Dietary Allowance for Flaming Hot Corn Chips. Your child can do without some food choices altogether.
            The best way to achieve this is to simply not buy massive amounts of food that require little or no preparation.  Your child might be able to quickly microwave some macaroni and cheese, but will not cook a chicken from scratch.  Food choices start at the grocery store, and if your purchases are strongly influenced by your child’s preferences (or tantrums), plan to go to the supermarket alone.

W = When in doubt, walk.
Many communities are designed in a way that discourages walking.  Distances to schools, stores and entertainment venues are prohibitively far or dangerous for pedestrians. Yet, by simply walking more, we can help burn a significant number of calories.  Park your car at the far end of parking lots.  This forces you to walk a little farther and your car will get fewer dents and dings. Take the stairs instead of the elevator if you need to go up or down less than three floors. Go for a walk at the local mall (leave your credit cards at home). Whenever the opportunity presents itself, walk.

N = Never talk the talk if you don’t walk the walk
The best way to teach your child is to be a role model.  They may not listen to everything you say (don’t be so sure) but they will notice everything you do.  Don’t expect your children to pick up any habit you are not willing to incorporate yourself, first.  And the key word is, “first”.  You want your child to exercise?  Start by getting into an exercising routine.  Then, invite your child to join you.  You want to wedge your child away from the computer?  Then get off the computer (but not until after you check out my book, Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care available for Kindle on amazon.com).
           
What if your child is doing all the things I’ve listed above and is still not losing weight?  That’s fine!  First off, many children who are at an unhealthy weight don’t need to lose weight – they just have to stop gaining weight.  So a prolonged period with no weight gain (as long as it is done through healthy habits) is a great outcome.  And either way, if your family adopts the strategies I’ve suggested, you will have picked up some healthy lifestyle choices.  Remember, it’s not a number you’re shooting for. Your goal is healthy habits.  Best of luck!

Peter Palmieri, M.D., M.B.A.

Monday, May 6, 2013

When A Diaper Rash Just Won't Go Away



Most diaper rashes are the result of sensitive skin irritated by moisture and friction and aggravated by exposure to urine and feces. In most cases, gentle cleansing and the use of any number of over the counter creams that create a protective barrier over the skin are enough to help the rash resolve. There are instances however, where a rash just doesn’t seem to want to go away. Rarely, a stubborn diaper rash may be the sign of a serious underlying illness.
1.      Fungal rash. When over the counter creams just don’t seem to work, the most frequent offender is yeast. The most common, Candida,  just loves the moist environment inside a diaper. This rash will often be more noticeable in the canyons of the skin folds rather than the over the mounds of flesh, at least when it’s first starting. It can cause a faint peeling, and there will often be tiny red spots surrounding the main area of rash which we call “satellite lesions”.  Your doctor will prescribe an an anti-fungal cream which may need to be used regularly for a couple of weeks.
2.      Scabies. This rash is generalized over the entire body, but it can have a predilection for the genitalia.  It is caused by a tiny mite that parasitizes the skin. The rash is very itchy, particularly at night when the mite tends to be more active. It is common for multiple family members to be affected at the same time. The typical treatment is a one-time application of Permethrin cream.
3.      Steroid diaper dermatitis. Steroid creams come in a range of potency. When a topical steroid is covered by a membrane such as plastic wrap or a diaper, the medicine is absorbed more readily and, as a result, the strength of the cream is augmented. Even creams of relatively weak potency become much more powerful, which is why we only use the weakest potency Hydrocortisone in a diaper area (if one is needed at all) for the shortest period of time.
Some doctors inappropriately prescribe a popular combination of an antifungal cream with a medium potency steroid to be applied to the diaper area (see my article on the Seven Medications Pediatricians Should Never Use But Still Do). The result can be severe irritation with the formation of skin ulcers. The treatment for this is to stop the steroid medication.
4.      Perianal Streptococcal Dermatitis. You’ve probably heard of strep throat, but you might not have known that children can get strep butt. The same bacteria that causes throat infections can cause an infection of the skin around the anus.  The affected area will look bright red. The child may be somewhat ill and run a fever. The diagnosis can be verified by obtaining a culture with a cotton- tipped applicator. The treatment is much like that of strep throat: a short course of an oral antibiotic.
5.      Hemangioma. This is not a rash at all but a benign skin growth composed of dilated blood vessels. Hemangiomas are very common in infancy and the majority will resolve by themselves though they often grown in size in the first nine months of life. The ones in the diaper area can be a bit more of a problem because they have a higher propensity for ulcerating and bleeding. A referral to dermatology is sometimes required.
6.      Psoriasis. This is a much rarer cause of diaper rash so it is often missed. Psoriasis in infants will often present with diaper rash and no other obvious signs and symptoms. Dermatologic evaluation is typically needed to verify the diagnosis and provide treatment.
7.      Zinc Deficiency. The deficiency of this mineral in the diet can cause a severe unremitting rash, often accompanied by a rash around the mouth and hair loss. The child may have an underlying condition that results in defective absorption of nutrients (such as cystic fibrosis) or may be malnourished. A rare genetic disease known as Acrodermatitis Enterohepathica is an inherited disorder of zinc metabolism. These children require expert consultation to address the underlying nutritional deficiencies.
8.      Langerhans Cell Histiocytosis. This is a poorly understood group of disorders that affect the cells that originate from the bone marrow as well as a specific type of skin cell known as the Langerhans cells. Children with this condition have a variety of symptoms, including chronically draining ears, a rash behind the ears, bone lesions and blood disorders in addition to severe diaper rashes that are generally unresponsive to common treatments.
Even with the most meticulous skin care, most infants will develop mild irritation in the diaper area from time to time. Most diaper rashes are transient and respond quickly to traditional treatments. The ones that don’t improve require evaluation by a physician. Rarely, a diaper rash can be a sign of a more serious malady.

Thursday, May 2, 2013

The Most Common Reasons for Unnecessary Pediatric ER Visits (And Why We Should All Care)



A large proportion of pediatric ER visits do not involve true emergencies. These children would better be served by their own physician in the office setting. But the number of children receiving part or all of their primary care in the hospital emergency room is growing. This should be a concern to all of us for several reasons. First, unnecessary visits clog up emergency departments, so if you or your family members have a true emergency there is the risk of delayed treatment, even when a good system of triage is maintained. Secondly, a majority of children receiving substantial care from ERs for trivial problems receive government sponsored insurance which is paid by all of us. Whereas an office visit might cost the taxpayer about fifty bucks, the same care in an ER usually saddles the tax payer with a bill for around $1,000. And perhaps most importantly, the ER is a poor place to receive primary pediatric care: the patient is seen by a different physician every time; the physician does not have access to important aspects of the child’s medical record; no follow-up or continuity of care can be provided.
            So why do so many families rely on Emergency departments for the medical care of their children? There are many reasons but these are by far the most common.
1.      A perceived emergency. We often deal with routine childhood illnesses that are not emergencies but are perceived as such by parents. This, in my view, is a perfectly appropriate reason to go to the ED but should be remedied by providing education and what is known as anticipatory guidance. The most important part of the education is to advise parents that, with the exception of trauma, poisonings, severe allergic reactions or respiratory distress they should phone their doctor’s office before going to the Emergency Room to receive advice and triage.
2.      Travel. For families on a trip away from home (particularly those who have government funded health insurance) the hospital ER is the only alternative to obtain care.
3.      Lack of insurance. In many cases this involves a lapse of Medicaid due to not complying with the renewal requirements. If you have no insurance and no independent financial means, you will not be seen in doctor’s offices or free-standing clinics, but the ER cannot refuse to provide care.
4.      Unavailability of primary care providers. This sounds ridiculous, but some physicians will close their offices for extended periods of time and not provide reasonable alternative coverage. Their coverage is the local ER. More frequently, the office is open but the doctor refuses to see a “sick” patient. The child has a high fever? Go to the ER. She has a tummy pain? Could be appendicitis. Go to the ER. Yes, it might be appendicitis, but you can’t possibly form a reasonable judgment unless you examine the child. And if it is, you might spare a wait in the ER and arrange for the child to be directly admitted to the hospital.
5.      Referrals from primary care provider. The emergency department has become a major destination for referrals in many cities. I have been referred patients for problems related to growth and even for dermatological problems. This is a waste of everyone’s time and an inappropriate use of resources. The thinking from the referring physician is that once the child is in the hospital, the ER doctor will make the proper referral, or a specialist will materialize in the ER out of thin air.
6.      Convenience. For families with working parents it is difficult to get to a doctor’s office if it does not have extended hours. The ER, on the other hand, is always open. It is disheartening to see how often families bring in three or four children at the same time. One child is ill, they explain, and they want to take the opportunity to just get the other kids checked out even though they’re feeling just fine.
7.      Second opinion. Many of the kids we see in Emergency Rooms have already seen one or more physicians for their child’s illness – often the very same day. They come to the ER to ask if the treatment provided by their own doctor is reasonable and appropriate, or because they haven’t noticed an improvement in their child’s ear infection after the first dose of antibiotic.
8.      Desire for specialty care. The family has already seen their physician who has reached a diagnosis and may or may not have instituted a plan of treatment but then the family decides they want a specialist to see the child. They register in the ED with the expectation that ENT, orthopedics, dermatology and endocrinology will see their child in the emergency room for a non-urgent problem. Not only will the specialist not see the child in the ER, the ER doctor may not be able to provide the desired referral because many health plans require the primary care doctor to submit this request for approval.
Children deserve to receive their medical care in a medical home; from a physician who knows the child and the family and is available to provide continuity of care. We all deserve Emergency Rooms that are not so bogged down in the management of trivial problems that when a true emergency happens our loved ones are able to receive immediate attention by professionals providing the care they were trained to provide.
            There is no simple fix to this problem, but certainly it must include a change in paradigm in the financing of care. Charging a small co-pay to Medicaid patients for ER visits is likely to assuage its use out of sheer convenience without discouraging appropriate visits. Altering payment patterns for physicians is also essential. Medicaid re-imbursement for sick visits is so low that it hardly is worth the effort to many pediatricians. It is imperative that patients, physicians and policy makers work together to find solutions or we will all suffer the consequences.