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 entrée 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.

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.

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.

Munchausen's by Doctor: A Previously Unrecognized Entity

One of the most important jobs of a pediatrician is to imbue parents with self-confidence. Instead, we often confuse them, scare them and fill them with self-doubt. This can have a long-term detrimental effect on the parent-child relationship. Parents whose child experienced an illness early in life can fall prey to the Vulnerable Child Syndrome, where they perceive that their now healthy child is still somehow medically fragile and prone to illness. This not only can result in unnecessary medical interventions; it can lead to behavioral and developmental problems in the child.

Why do doctors create the belief that children are ill when they are not? For starters, with the exception of checkups, every encounter a child has with his physician results in a diagnosis. This is obligatory, as physician visits are compensated by insurance companies based on diagnostic codes that are catalogued in a constantly updated publication known as the International Classification of Disease Manual or ICDM. There is no code for "healthy child" or "normal", though there is code V65.5: "Person with feared complaint in whom no diagnosis was made" or "worried well". But physicians who use this code run the risk of not getting paid for the visit. Insurance companies view such encounters as superfluous. No, it's safer, from a financial standpoint, to report that the child was sick.

So most children are assigned an ersatz diagnosis to justify a medical visit. From the doctor's perspective, the diagnosis is tentative and plays more of a bookkeeping function than a medical one. There is danger in this. Diagnostic labels tend to stick. What was a provisional diagnosis, long discarded by the treating physician, becomes a permanent part of the medical record. And the diagnosis remains cemented in the parent's mind. That perfect little baby is no longer perfect. He has "Reflux". He is sick. He is vulnerable.

The tendency to diagnose illness in healthy children is also driven by the failure of many pediatricians to recognize the wide range of normal when it comes to children's behavior, development, growth, and pattern of expulsion of bodily contents from various orifices. Differences in doctors' confidence in their clinical skills, variations in comfort in dealing with uncertainty, and unique personality traits of the physician all lead to wide discrepancies in how symptoms are interpreted. I have met many a neurotic pediatrician who instinctively sees a tempest when a lonely cloud drifts across a blue sky. These doctors tend to have practices full of high strung parents.

In some instances doctors jump at the chance of making an "interesting diagnosis" to relieve the drudgery of seeing an endless parade of runny noses. In the television coverage of a recent devastating earthquake, I was surprised to learn that in order to keep search and rescue dogs from becoming discouraged, human volunteers hide in the rubble from time to time so that they can be "found". This is essential to keep the dogs keen and it has a salubrious effect on their psychological well-being. I believe doctors have the same need. If a "good find" is not available, a doctor will sometimes just make one up.

I once attended a drug company sponsored lecture featuring a distinguished visiting allergist at a restaurant with gaudy Victorian décor. Having arrived early, I was invited to dine with the scheduled speaker and a local family practitioner who had also come early for the talk. The family doctor, a kindly gentleman whose long face was exaggerated by his bald pate, started describing a very interesting case he had seen some weeks earlier.

A middle aged man presented to his office with a hacking cough. Further discussion brought to light that the patient owned a parrot. The family doctor paused for effect, smiled, leaned forward as if revealing a secret and said, "The gentleman had Psittacosis".

Psittacosis, also known as "parrot fever", is an infection caused by the bacteria Chlamydiophila Psittacci, which can be inhaled from bird droppings. The diagnosis is suspected based on history and physical and is confirmed by one of several blood tests.

"How interesting", said the allergist. "How did you make the diagnosis?"

The smile vanished from the family doctor's face. He straightened his spine and said, "Sir, he had a parrot!"

The gentleman may have had Psittacosis, but the family doctor fell a little short of proving the diagnosis. And he was offended by the allergist's query which in effect questioned the validity of his diagnosis. The family doctor was proud of having made the diagnosis of psittacosis. To suggest that the diagnosis was wrong was like finding a live person in the rubble of an earthquake, only to be told he is a stooge.

What I am suggesting is that doctors get an emotional high from doctoring. Medical students experience this when they successfully insert their first I.V. Residents are overjoyed when they succeed in performing a spinal tap on an infant on their first try. And many doctors in practice like to boast that they have a high proportion of ill children on their patient panel.

There is nothing wrong in deriving pleasure from helping your fellow man, after all it is a common motivator for pursuing a career in medicine. But we must be sure that the procedure we are doing is in the interest of the patient rather than for our own mental well-being. Along these lines, I believe there is a previously unrecognized phenomenon that I have dubbed "Munchausen's syndrome by doctor".

Munchausen's syndrome, named after Baron Karl Friedrich von Munchausen, an eighteenth century German nobleman with a penchant for telling fantastic tales of his implausible feats and unbelievable exploits, is a condition in which an individual fabricates symptoms in order to receive medical care. It must be distinguished from malingering, which is the feigning of illness in order to gain a surreptitious objective (such as skipping work or defrauding an insurance company) in that the entire goal is to be a patient and assume the role of the infirm. It is also distinct from conversion disorder, an involuntary condition with psychological underpinnings in which an individual perceives symptoms consistent with a morbid condition even when the condition is not present.
Munchausen syndrome by proxy is a form of child abuse in which an adult (usually a parent) fabricates symptoms or induces illness in a child so as to get attention and fulfill a pathologic psychological need. Some parent groups argue that there is no such thing as Munchausen's by proxy, that it is a diagnosis invented by a callous medical establishment that is unsympathetic to the plight of parents whose children have true medical needs. Yet there is ample documentation, including the use of covert video surveillance in the hospital setting, that shows parents suffocating, poisoning and producing fractures in their own children.

I believe that there is a Munchausen Syndrome by doctor, where a perfectly healthy child is diagnosed with, and treated as having a disease for the pure psychological need of the treating physician. The parent becomes an unwitting accomplice, becoming thoroughly convinced that their child is terribly ill, always on the brink of a medical catastrophe, requiring multiple daily medications to allay a crisis. These children tend to be labeled with several diagnoses from a limited pool, most frequently asthma, gastro-esophageal reflux, gluten insensitivity, recurrent infections (bronchitis, sinusitis and ear infections), and allergies to multiple foods and medications. The child frequently presents to the Emergency Room with a shopping bag full of medications, often including Metoclopramide, Lansoprazole, Fluticasone, Montelukast, Levalbuterol, Tacrolimus, antihistamines and the ubiquitous antibiotic. And the child looks completely well despite the parents' and referring doctor's anxiety. And stopping the pharmaceuticals results in no ill effect.

I believe that Munchausen's syndrome by doctor is far more common than Munchausen by proxy, which has been estimated to affect 2 out of 100,000 children. As in Munchausen by proxy, there are, in my opinion, certain personality traits that are more common in those doctors that perpetrate Munchausen syndrome by doctor. These individuals are basically insecure, and try to compensate by interpreting every symptom in its most malicious form, falling victim to a neurotic paranoia which can be kept at bay only through the incessant ordering of laboratory studies and the prescription of treatment upon treatment. The offices of these doctors are almost always full, seeing as each patient requires frequent visits. And they attract ever more individuals who, in their state of anxiety, are oddly reassured by being told that their child is ill; but at least they are in the hands of a doctor that will see them over and over, and who will provide the most aggressive treatments (whereas the other doctor just kept telling them there was nothing wrong with their child).

Convincing a parent that her child is ill is a treacherous threshold to cross. The perception that one's child is ill always alters the way the parent views and treats her child. It can undermine the confidence and sabotage the effectiveness of a parent. Again, one of the most important jobs a pediatrician has is to reassure parents so they can be more effective and self-confident, yet we frequently do the opposite, either as a result of our own insecurity, out of sheer ignorance and, on occasion, because of a pathologic impulse to feel needed, appreciated and valuable.

Dr. Palmieri is a board-certified pediatrician and the author of "Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care".

http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_3?ie=UTF8&qid=1308158437&sr=8-3

Article Source: http://EzineArticles.com/6354347

Article Source: http://EzineArticles.com/6354347

7 Medications Pediatricians Should Never Prescribe...But Still Do

Almost every visit to the pediatrician results in the prescription of one or more medications. As a parent, you'd like to trust that the medications your doctor prescribes for your child are selected based on careful reflection, and are not only effective, but safe. Unfortunately that's not always the case. As a board-certified pediatrician of sixteen years I regret to confess that many of the treatments we provide are ineffective, while others can cause grave harm. Too often, we doctors stray from accepted standards of care as a matter of expediency, the result of habit, or to satisfy perceived parental expectations. Nowhere is this so apparent as when a pediatrician prescribes a medication that experts agree should never be used by primary care doctors.

A medication that is shunned by pediatricians typically possesses one or more of the following features: it is not safe; it is not effective; its use has been supplanted by newer, better choices; pediatricians do not have the expertise required to prescribe the drug. Using these criteria, let us examine 7 medications that your pediatrician should never prescribe under any circumstance.

Promethazine:

Pediatricians commonly use this medication for the treatment of nausea and vomiting that often accompany viral intestinal infections. Unfortunately, it doesn't work very well and it frequently produces drowsiness, dizziness and confusion: symptoms we'd like to avoid in a child whose mental status must be monitored as an indicator of dehydration. The intra-venous use of this medication has resulted in tragic events requiring the amputation of limbs due to the caustic nature of the drug, and is now prohibited in many hospitals. Fortunately, we have a much more effective medication at our disposal with a far better safety profile; which makes one wonder why some doctors still cling to Promethazine.

Cough suppressants:

The common cold is the most common ailment in childhood. It is natural to want to provide some relief to a child whose cough is keeping her from sleeping. Unfortunately, the cough medications we have at our disposal have not been shown to be effective in children and may cause unacceptable side-effects. Over the counter cough medicines almost universally include the active ingredient, Dextromethorphan (DM), whereas prescription versions may employ Codeine. Both these drugs are derivatives of opiates. Respiratory depression and behavioral problems have been observed in children taking these products, and in infants, overdoses have resulted in deaths.

In October 2007, the American Academy of Pediatrics proposed to the Food and Drug Administration that the following warning be included on the labeling of cough medications:
"This product has been shown to be ineffective in the treatment of cough and cold in children under six years of age. Serious adverse reactions, including but not limited to death have been reported with the use, misuse and abuse of this product." Inexplicably, many pediatricians continue to routinely prescribe these medications even to infants.

Dexamethasone eye drops:

This is an example of a medication that can be extremely efficacious, but which pediatricians should not prescribe because they lack the requisite expertise to use it safely. Dexamethasone is a steroid that is utilized for its anti-inflammatory properties. These eye drops are a powerful tool for a variety of conditions but require a careful eye exam by an ophthalmologist prior to their use. If applied in the midst of some eye infections, Dexamethasone-containing drops can exacerbate the infection and lead to irreparable eye injury. This medication is best left to the eye specialists.

Nystatin with Triamcinolone Combination Cream:

Sometimes the sum of the parts is less than the individual parts. Nystatin is a useful topical antifungal, routinely used to treat diaper rashes that have an overgrowth of yeast. Triamcinolone is a potent steroid cream that is effective in treating a variety of inflammatory conditions of the skin, including eczema. The problem arises when these two medications are combined. Doctors, wanting to add some anti-inflammatory effect in the treatment of a yeast rash, or uncertain as to whether the rash is the result of a fungal infection or due to plain inflammation, mistakenly instruct parents to use this product in the diaper area. The potency of all steroid creams is multiplied when applied to skin that is occluded by dressings, plastic wraps, or diapers. When applied under cover of a diaper, Triamcinolone can lead to ulcerations of the skin, which often intensify as a well-meaning parent continues to apply ever more cream in a frantic but futile attempt to alleviate the worsening rash. Only thin applications of far weaker steroid creams might be applied to this extremely delicate area of the body, and only after the careful consideration of potential risks and benefits.

Cefaclor:

A few decades ago, Cefaclor was one of the only oral preparations of a family of antibiotics known as the Cephalosporins, which are commonly used to treat a variety of childhood infections. This particular medication, however, has a much higher rate of allergic reactions compared to other drugs in its class, including a particularly severe complication known as Serum Sickness-Like Reaction, in which children develop rash, fever, swollen, painful joints, and other troubling symptoms. Furthermore, many bacteria have become resistant to this drug. In a large study published in 2003, out of 19 antibiotics tested, Cefaclor was the least likely to kill the most common bacterium implicated in ear infections, sinus infections and pneumonia. Academic medical centers have stopped using this medication some 20 years ago, but some doctors in the community just can't break the habit.

Albuterol Oral Syrup:

Albuterol by inhalation, either in an aerosol or inhaler form, remains the most important rescue medicine for the treatment of asthma attacks. When the medication is inhaled, it travels directly to receptors located on the walls of the respiratory airways, signaling muscle fibers to relax, thereby reducing bronchial constriction and improving the flow of air in and out of the lungs. The inhaled route maximizes the amount of medication delivered to its intended target and mitigates common side-effects, such as jitteriness and an accelerated heart rate, that are produced when the drug enters the bloodstream. When the oral formulation is used, the medication must first be absorbed from the intestinal tract into the circulation, by which it then travels throughout the body, with just a fraction of the ingested dose eventually finding its way onto the receptors of the airways. This is a highly ineffective delivery system that magnifies the side-effects while minimizing effectiveness. Albuterol oral syrup is often used not for asthma, but as a type of ersatz cough medicine; a practice that is a relic of the past.

Anti-Diarrhea Compounds:

Diarrhea is a common occurrence in childhood, most often the result of a viral gastroenteritis; what is commonly referred to as the "stomach flu". At times, it can be the result of bacterial dysentery. The key to the treatment of this usually self-limited but bothersome condition is to provide hydration and nutrition. Guidelines from the American Academy of Pediatrics and the Center for Disease Control and Prevention discourage the use of anti-diarrhea compounds due to their lack of efficacy and the potential for serious side-effects, including severe cramping, and temporary paralysis of the gut, which can lead to a concentration of bacteria and their toxins in the setting of dysentery. Unfortunately, many pediatricians are either unaware of, or choose to ignore these recommendations.

At its best, the practice of pediatrics incorporates scientific evidence, critical thinking, best practices, and accepted standards of care, while embracing humility and a deep compassion; ever cognizant of each child's unique constitution and the cultural values of his family. Too often, we doctors fall far short of this objective, particularly when we are rushed, when we don't take the time to listen patiently or examine carefully, or when we fall into the ruts of habit, not questioning what we think we know.

Sir William Osler, a renowned 19th century physician who practiced at a time where many of the treatments were ineffective and fraught with hazards, wrote, "One of the first duties of the physician is to educate the masses not to take medicine": an admonition that retains a clear ring of truth even in the 21st century. All medications have potential side-effects and, particularly in children, a wise philosophy is to use the fewest medications with the most favorable safety profile for the least amount of time.

Many childhood illnesses are self-resolving conditions that doctors should manage by providing comfort to the child and by counseling parents, rather than blithely dispensing prescriptions designed to subdue symptoms without a conscientious attempt at identifying the true nature of the underlying condition. We doctors must do better. The best parents can do is to become informed consumers of health-care, and never hesitate to question their doctor.

Dr. Palmieri is a board certified pediatrician and the author of Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. His interests include patient safety and how cognitive errors lead to errors in diagnosis and treatment.

http://www.amazon.com/Suffer-Children-Fallacies-Shortcomings-ebook/dp/B004R1QBCY/ref=sr_1_2?ie=UTF8&qid=1306890395&sr=8-2