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What Does Nanny Case Reversal Say About Shaken Baby Syndrome?

In this July 30, 2015 photo, Aisling Brady McCarthy leaves court proceedings at Middlesex Superior Court in Woburn. Middlesex DA Marian Ryan announced Monday that the murder charge against the Irish nanny had been dropped. (Keith Bedford/The Boston Globe via AP)

In this July 30, 2015 photo, Aisling Brady McCarthy leaves court proceedings at Middlesex Superior Court in Woburn. Middlesex District Attorney Marian Ryan announced Monday that the murder charge against the Irish nanny had been dropped. (Keith Bedford/The Boston Globe/Pool)

You read about the striking reversal in the latest Boston nanny case and you wonder: How does this happen? How could a medical examiner first say a baby died of “complications from blunt force head injuries” and then, two years after the baby’s Irish nanny is accused of murder, decide that the cause of death is “undetermined”?

The medical examiner’s report has not been publicly released, but the Middlesex district attorney’s press release does cite a major review process that included “expert witness reports from the defense and prosecution, additional transcripts of police interviews, transcripts of grand jury testimony, additional medical records, DCF reports, and additional laboratory testing.”

On Radio Boston today, co-host Anthony Brooks spoke with Dr. Robert Sege, a member of the American Academy of Pediatrics’ committee on child abuse and neglect, and vice president at Health Resources in Action, a public health policy organization. Here’s an excerpt of that conversation, lightly edited:

Anthony Brooks: This is the second time in a year that the Massachusetts medical examiner has reversed its finding in a baby’s death, and we’ve been reading that in the United States, 16 convictions have been overturned since 2001, including three last year. So does this raise questions about the diagnosis of shaken baby syndrome? What are your thoughts on that?

Dr. Robert Sege: To me, it doesn’t raise the question at all. If you think about it, there are people who are falsely accused of murder, robberies, all kinds of things and the justice system is not perfect. So in a situation where we have hundreds and perhaps a thousand infants a year who experience shaken baby syndrome, the fact that 16 convictions over a multi-year period were overturned lets me know that the justice system worked, and that people get a fair shot at getting their story told…

I’m very happy that we live in a country with a judicial system that looks at things skeptically and tries to make sure that justice is done. It doesn’t change anything about whether or not shaken baby syndrome or abusive head trauma exists. Sadly, it does.

I want to read you one quote from Gregory Davis, the chief medical examiner in Birmingham, Alabama, and board chair of the National Association of Medical Examiners. He told the Washington Post:

“You can’t necessarily prove [shaken baby syndrome] one way or another … Neither side can point to compelling evidence and say, ‘We’re right and the other side is wrong.’ So instead, it goes to trial.”

Do you disagree with that?

I actually do, and I think part of the issue is that many cases of abusive head trauma never make it to trial, sometimes because the police and the prosecutors can’t figure out who the perpetrator was, but often — and I’ve certainly seen this — because someone confesses. It’s a very sad situation, but frequently a person just reaches the end of their rope. They’re frustrated, the infant won’t shut up, they don’t mean to cause harm or death but they just can’t stand it anymore. Continue reading

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I Never Expected To Love My Kids’ Sex Ed Course, But I Do

Oh boy... (Romana Klee/Flickr)

Oh boy… (Romana Klee/Flickr)

Truth is, I dreaded my children’s sexual education.

I’d read that parents can be a powerful force for smarts about sex, so I’d tried to script imaginary heart-to-hearts. But in my head, they all sounded like this: “Please don’t do these incredibly stupid things that I did when I was young.”

So I procrastinated, abetted by the younger generation’s point-blank refusal to let me even broach this most awkward of topics. Then, last year, word came home that middle-school health class would use a curriculum called “Get Real” that involved extensive family homework activities.

“Now I’m in for it,” I thought.

But in fact, I was in for a shockingly pleasant surprise — one that more and more parents may experience in the coming years if Get Real’s popularity continues to grow. As of this year, it has been adopted by 200 schools in seven states — 175 of them in Massachusetts. That’s up from 132 schools in 2012.

And in recent months, Get Real has scored two victories: An analysis by the Wellesley Centers for Women reported that students who go through Get Real do become likelier to delay sex, and the federal government put it on a list of “evidence-based” sex-ed programs.

No way is Get Real, which was created by the Planned Parenthood League of Massachusetts, for everybody. It strongly promotes abstinence as the healthiest choice for young people, but it’s not the sort of “abstinence-only” program that many parents and schools seek; it also includes teachings on birth control and preventing infection.

But perhaps more than any other curriculum out there, it pulls parents into the sex-ed endeavor, and here’s my pleasant surprise: It wasn’t awkward.

The Get Real homework prompted conversations about friendships, about feelings, about life lessons. I got to reminisce about my first crush, and talk about how important I think it is to stand up for yourself with a boyfriend or girlfriend. I even got to vent about how perniciously relationships are portrayed in that detestable high-school-girl series, “Pretty Little Liars.”

Sure, the course teaches intimate anatomy and the changes of puberty, but the body part it seemed to focus on most was the heart. It was teaching — well, love. Or rather, the skills that can make love better. Healthier. Skills like self-awareness and communication — useful in their own right, and also in service of sex-ed goals like preventing pregnancy and infections.

“We believe that if young people are able to develop healthy relationships in all aspects of their lives, they’re going to be that much better able to negotiate healthy sexual relationships,” says Jen Slonaker, vice president of education and training at the Planned Parenthood League of Massachusetts.

“The sad truth is that by the time young people get to college, it may be too late.”

– Nicole Cushman,
of sex-education organization Answer, on rape prevention

At this national moment of rising discussion about campus rape — from “Missoula” to this week’s New Hampshire prep school trial — the need for such skills has never seemed more urgent. And they take time to develop, says Nicole Cushman, executive director of Answer, a national sex-education organization based at Rutgers University.

“When people talk about sexual assault and rape prevention on college campuses,” she says, “the sad truth is that by the time young people get to college, it may be too late, because we haven’t really laid the groundwork by teaching them these basic concepts about communication and relationships from a younger age. So I really believe that comprehensive sex education is sexual assault prevention.”

‘Red Flags’

Ashley, a Boston high school senior who is on the Get Real Teen Council, went through the curriculum beginning in middle school but says she really started seeing its effects when she got to high school.

“I know that what I learned in Get Real classes made me see certain red flags in my friends’ relationships and my own relationships, and helped me solve what I need to do in order to get away from the red flags,” she says.

One friend who took the class with her drew on it to resist sexual pressure, Ashley says: “She didn’t know if she was ready to have sex, and she touched upon the consent part — she was like, ‘I don’t have to do this, necessarily. It’s like — consent. It’s not fair. I don’t have to engage.’ ” Continue reading

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New Moms Cite Lack Of Advice From Docs On Key Issues: Sleeping, Breastfeeding

A new study found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. (Mark Humphrey/AP)

A new study found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. (Mark Humphrey/AP)

After I gave birth to my kids, I was bombarded with advice from family, bestselling books and even strangers on topics ranging from how to lose the baby weight, when to have sex again and which infant toys boost IQ.

But according to a new, NIH-funded study, many sleep-deprived, hormone-addled new mothers may not be getting enough advice on critical issues from a most important source: doctors and other health care providers.

When it comes to breastfeeding, infant sleep position, immunization and pacifier use, many new moms report they get no advice at all from their children’s doctors — despite medical evidence on the benefits of certain practices, like breastfeeding and placing babies on their backs for sleep.

The new study — published in the journal Pediatrics and conducted by researchers at Boston Medical Center, Boston University and Yale University — found that about 20 percent of mothers said they didn’t receive advice from their baby’s doctors about breastfeeding or the current thinking on safe placement for sleeping newborns. And more than 50 percent of mothers told investigators that doctors did not offer guidance on where the babies should sleep.

(Of course the whole issue of where newborns should sleep is controversial. Official recommendations now say babies should “room share” with parents but not “bed share.”)

The study, part of a larger national effort called SAFE (Studies of Attitudes and Factors Effecting Infant Care Practices), surveyed more than 1,000 new mothers across the country, inquiring about infant care advice they received from different sources: doctors, nurses, family members and the media.

Dr. Staci Eisenberg, a pediatrician at Boston Medical Center and lead author of the new study, said in an interview that the number of moms who reported no advice from across the board is surprising.

“These findings say to me, ‘Hmm, this is a time to stop and think carefully about how we communicate, and are we communicating in a clear, specific enough way, and are we being heard, especially by new moms — new parents — who are often tired and likely overwhelmed?’ ” she said. “Amidst this sea of information, what are the messages that need to be highlighted and communicated clearly?” Continue reading

Boston Moms: Let’s Spend Olympics Savings On Gym And Recess For Kids

(Steven Depolo/Flickr)

(Steven Depolo/Flickr)

By Kate Lowenstein
 and Ramika Smith
Guest contributors

We have a suggestion for how to spend some of the billions of dollars that Boston will likely save by not hosting the Olympics: How about we invest even 1 percent of that into the bodies and brains of our children by ensuring they get ample physical education and recess time?

Instead of spending billions to have elite adult athletes playing sports in our city, we can at least give our own Boston Public Schools kids the chance to run and play here.

Most parents of kids in the city’s public schools assume their children get recess every day, as we did when we were kids, but the reality turns out to be quite different. While the CDC recommends that all children get at least 60 minutes of vigorous exercise every day, and at least 30 minutes of school-time physical activity, many of our schools allow for as little as 20 minutes, if that.

Over the past two decades, accelerated by No Child Left Behind’s focus on testing, the tendency has been to reduce or eliminate physical education and recess. And our school administrators and legislators look the other way without recognizing the overwhelming amount of evidence that shows the significant academic and mental health benefits of these physical activity breaks.

Recess and physical education are as integral to a long school day as are Math, Science, and English.

In January of 2009, the journal Pediatrics published a groundbreaking study of 11,000 third-graders, comparing those who had little or no daily recess with those that had more than 15 minutes of recess per day. The findings show that children who have more recess time behave better in the classroom and are likelier to learn more.

In January of this year, The Boston Foundation released a report: “Active Bodies, Active Minds: A Case Study on Physical Activity and Academic Success in Lawrence, Massachusetts.” The report found that only 15 to 20 percent of Massachusetts children are meeting the 60-minute daily recommendation for physical activity and only 10.2 percent were meeting the school-time recommendation of 30 minutes.

It also underscored what we already know from many other studies; that children in schools that provide an adequate amount of time and opportunity (and encouragement) for daily physical activity, in the form of recess, gym classes and movement breaks, have higher MCAS scores in both math and ELA. Continue reading

Mass. Has Paid Sick Leave, Now We Need To Change Culture Of Working While Ill

(Office for Emergency Management/Office of War Information/Domestic Operations Branch/Bureau of Special Services, via Wikimedia Commons)

(Office for Emergency Management/Office of War Information/Domestic Operations Branch/Bureau of Special Services, via Wikimedia Commons)

As of this month, we here in Massachusetts can proudly say that we enjoy the right to paid sick time. (Those of us who work for companies with 11 or more employees, anyway; workers for smaller companies can only get unpaid time.)

The law took effect July 1, and state Attorney General Maura Healey says that while it’s not the first such law in the country, “it is the most expansive.”

Yay, right? But here’s the next challenge: It’s not enough to have the law on the books; workers have to actually use it. And a new study of health care workers suggests that when it comes to calling in sick, we may often be our own worst enemies. (OK, yes, our bosses may also be our worst enemies.) It’s a sobering look: If even doctors and nurses don’t stay home when they should because of their workplace culture, what hope do the rest of us have?

The study in JAMA Pediatrics found that among more than 500 doctors and other staffers surveyed at a large children’s hospital in Philadelphia, 83 percent reported working while sick over the past year. Like, really sick: 30 percent had diarrhea, 16 percent had fever and more than half had “acute onset of significant respiratory symptoms,” which sounds to me like the kind of cough that can spread germs.

Why, oh why, would the staffers who understand best the risks of infection still come to work while possibly infectious? Solving that conundrum was the aim of the paper, titled “Reasons Why Physicians and Advanced Practice Clinicians Work While Sick.”

“Working while sick was regarded as a badge of courage, and ill physicians who stayed home were regarded as slackers.”

Among the reasons that respondents deemed important:

• 98.7 percent cited not wanting to let colleagues down

• 94.9 percent cited staffing concerns

• 92.5 percent cited not wanting to let patients down

• 64 percent cited fear of ostracism by colleagues

• 63.8 percent cited continuity of care

Other concerns that emerged from free-text responses: “extreme difficulty finding coverage (64.9 percent), a strong cultural norm to come to work unless remarkably ill (61.1 percent) and ambiguity about what constitutes ‘too sick to work’ (57 percent).” Continue reading

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An Uptick In Non-Jews Choosing Jewish Circumcision? Maybe

Reporter Jessica Alpert may have stumbled on a trend: non-Jews choosing to have their infant sons circumcised by traditional mohels, Jews trained to perform the ritual procedure, rather than doctors.

Alpert, a frequent CommonHealth contributor, writes in the current issue of Atlantic:

Finch isn’t the only non-Jew who has felt a connection to the religious elements of the procedure. Nationwide, circumcisions have decreased over the last few decades—from 64.5 percent of newborn boys in 1979 to 58.3 percent in 2010, according to Centers for Disease Control data—but among those opting to circumcise their sons, some non-Jews are forgoing the hospital or doctor’s office and requesting Jewish mohels for reasons both practical and religious. (Reliable statistics on religious circumcisions are hard to come by, but several mohels I talked to said they’ve noticed an uptick in their popularity in recent years.)

Whether or not the practice is taking off, Alpert suggests that this co-mingling of religious and non-religious realms may have “tricky implications for mohels performing non-Jewish circumcisions,” and raise thorny legal questions:

The right to perform brit milah is protected under the First Amendment, but when it’s no longer a religious ritual, mohels may run up against laws that forbid the practice of medicine without a license, explains Marci Hamilton, a church-state scholar and professor at the Cardozo School of Law at Yeshiva University. There is no legal gray area for mohels who are also health professionals—these mohels can perform the procedure on non-Jews as part of their medical practice, even if the primary purpose is religious rather than medical. But others, Hamilton says, may be subject to prosecution when they perform the procedure outside of its religious context.

When it’s a non-Jewish family using a mohel, “The mohel is not acting as a religious participant, and therefore his acts are not protected as free exercise,” she explains. Continue reading

When My Mother Died: A Story Of ‘Incomplete Mourning’

By Sarah Baker

I was 8 years old and the sky was black the day my mother died.

That morning, after a five-year struggle with a brain tumor, she’d passed away at Bethesda Naval Hospital, where she had been admitted a couple of days earlier. I hadn’t seen her since.

Grieving wasn’t an option in our house. We were a “chin up, shoulders back” group led by Dad, a rising star in the Navy. At my mother’s graveside in Arlington National Cemetery, my 10-year-old brother and I stood like little replicas of John F. Kennedy Jr. 12 years earlier when he saluted his father’s coffin. There were no tears, no signs of weakness. Long periods of mourning or sadness were not in our family culture — our grief was put on hold. There were bags to pack, and new ports of call. I was Soldiering On.

The Hardest Thing

According to the advocacy group SLAP’D (Surviving Life After a Parent Dies), 1 in 9 Americans loses a parent before age 20. Of those, nearly half said it was difficult to talk about their grief and only 7 percent said a guidance counselor helped. Six out of 10 adults interviewed, who lost a parent when they were children, said it’s the hardest thing they’ve had to deal with.

Sarah Baker at age 6, two years before her mother died (Courtesy)

Sarah Baker at age 6, two years before her mother died (Courtesy)

For us, the coping mechanism of Soldiering On worked splendidly for years, even decades. I survived all of the moves due to Dad’s deployments, even thrived, people might say. I went to college, graduate school, found great jobs, married a wonderful man, and had two beautiful children. All seemed well, at least on the surface.

But years of anxiety and disassociation gripped me. Recently, though, I felt all that emotional baggage was not sustainable. My external world appeared blissful (and it was!) but my internal world reeled. I had periods of blankness, inability to focus, sleeplessness, feelings of isolation when I was surrounded by loving people; despair, longing for something else, numbness, repeating negative loops in my mind, and sensations of being half dead. These feelings came in waves — days of it followed by lightness and connection. The longest darkness lasted three months — the world drained of its colors and none of my usual “reset,” or coping, tools seemed to work.

Necessary Grief

Importantly, coping is not grieving. “There is a kind of sanity to grief,” says Kay Jamison, a professor of psychiatry at the Johns Hopkins School of Medicine and author of “An Unquiet Mind.” “It provides a path — albeit a broken one — by which those who grieve can find their way. Grief is not a disease; it is a necessity.”

Funerals and other rituals bring people together and defend against loneliness. But if the grief lingers too long, is too severe, or unprocessed, it might begin to resemble depression. It’s a fine line indeed.

I now know I had never fully experienced the pain and sorrow of my grief. Continue reading

Just Sip It: More Than Half Of U.S. Kids Not Properly Hydrated

(sara_girl22/Flickr)

(sara_girl22/Flickr)

One statistic jumped out at me from this study by researchers at the Harvard School of Public Health about whether U.S. kids are drinking enough water: “Nearly a quarter of the children and adolescents in the study reported drinking no plain water at all.”

When you think about the kinds of serious health problems your kids might have, not drinking quite enough water may not top your list.

But it’s serious: beyond the physical problems related to insufficient water-drinking, there are cognitive implications as well, researchers report:

Inadequate hydration has implications for children’s health and school performance. Drinking water can improve children’s performance on cognitive tests. Two studies have found that children’s cognitive performance improved as their urine osmolality [a measure of urine concentration] decreased. Increasing drinking water access in schools may be a key strategy for reducing inadequate hydration and improving student health, because schools reach so many children and adolescents and that they typically provide free drinking water to students.

The study was published online in the American Journal of Public Health.

I asked Erica Kenney, a postdoctoral researcher and one of the study authors, a few questions about the work. Here, lightly edited, is what she said, via email.

RZ: What’s the takeaway here?

EK: We often take for granted that kids will keep themselves hydrated automatically and will drink when they’re thirsty, or that their schools, summer camps, afterschool programs, child care centers, etc. will be providing them with enough opportunities to drink water during the day. But our study indicates that this may not be the case — over half of all children and adolescents in the U.S. are estimated to be inadequately hydrated. We need to do a better job of getting safe, clean, appealing drinking water to kids (and by “we” I don’t just mean parents and families — I also mean the places where kids learn and play during the day) and keeping them hydrated so that they have the opportunity to be at their best in terms of well-being, cognitive functioning, and mood.

Where do we go from here? Continue reading

Why The Primary Care Problem (Lower Status, Pay) Matters

By Jeff Levin-Scherz, M.D., M.B.A.
Guest Contributor

Medscape just published its annual physician compensation survey. The survey includes almost 20,000 physicians and is given online, so it’s probably not entirely representative.

Also, the survey results are self-reported, and physicians generally under-report their income. But the comparative reported income among specialties is informative. This survey is among the largest available, and does not require an expensive paid subscription.

(Courtesy of Medscape)

(Courtesy of Medscape)

The results are no surprise. But they’re worth noting: Specialists make 45 percent more than primary care physicians, and orthopedists make 224 percent more than pediatricians.

The majority of respondent physicians were employed, and men consistently make more than women in the same specialty. Women have the largest representation in specialties with the lowest incomes.

Physician income was a bit lower in the Northeast but higher in the Northwest. Massachusetts’ physicians report that their income is 46th in the nation.

Internists are the least satisfied in their job (47 percent), and the least likely to choose their specialty if they could choose again (25 percent), but high in the rankings of specialties where the respondent would choose medicine again (71 percent).

(Courtesy of Medscape)

(Courtesy of Medscape)

Family physicians were only slightly more likely to choose the same specialty again as internists (31 percent), yet they were the most likely to say they would choose to go into medicine again (74 percent).

Pediatrician income is among the lowest of all specialties, yet they are twice as likely to say that they would choose the same specialty. Internists and family physicians would go into medicine again, but they would go into sub-specialties, and not do general primary care. The high cost of health care in the U.S. is in part due not to a shortage of primary care physicians, but also due to a surplus of specialists.

Why does all this matter?

The American College of Physicians reported on the impending “collapse” of primary care in 2006. There have been efforts to change this situation since, including “patient centered medical homes,” and short-term enhanced Medicaid primary care fee schedules built into the Affordable Care Act.

The continued relatively lower pay of primary care physicians and the lack of job satisfaction of general internists and family physicians means that our historic way of delivering primary care is about to change. Much future primary care is likely to be delivered by nurse practitioners or physician assistants, and some office-based primary care will be supplanted by telehealth or by apps with underlying algorithms.

The Medscape survey suggests that we will continue to face serious challenges to continue to deliver the highly personalized primary care which many of us value, and the highly coordinated care needed by the frail elderly and those with serious chronic illnesses.

Continue reading

One Doc’s Oreos-And-Batman Perspective: TV Doesn’t (Necessarily) Make Kids Fat

(Donnie Ray Jones/Flickr)

(Donnie Ray Jones/Flickr)

By Steve Schlozman, MD

Here are three recent headlines that got me thinking about kids and fat:

“Watching one hour of TV per day increases risk for obesity by 50%”

“Watching TV for Just an Hour a Day Can Make Children Obese”

“Study makes surprising link between TV time and childhood obesity”

Oversimplifications? Um, yes. Each of these headlines greatly simplifies (dare I say, incorrectly simplifies) a critical social and health issue. Personally, I don’t think TV is the sole evil culprit here. It’s far more complicated.

The medical community has long known that the amount of TV that a child watches correlates with obesity. We can even make some leaps from these data towards implicating causality. Unless your little ones happen to be doing aerobic exercises while they tune in to their cartoons, it’s easy to see how passive watching can equal active weight gain.

However, be wary of oversimplification and especially of the “one-size-fits-all” policy statements that these headlines often generate. The study authors here do, in fact, suggest further limiting TV exposure based on the existing American Academy of Pediatrics guidelines for young children as a means of controlling the rate of obesity in this country. (Currently, the AAP recommends limiting screen time to one to two hours or less for children over the age of 2, and discouraging screen time altogether for those who are younger.)

So, here’s the big question: Is the recommendation that TV time be further limited an entirely appropriate conclusion?

Beyond The Headlines

The answer, like many answers to social policy questions, is both yes and no.

What we know for certain is that we can’t really discern from the headlines what we ought to do, though there is ample reason to believe that most American rarely go beyond the headlines. Thus, we run the risk of jumping to more draconian conclusions than might be appropriate simply because we don’t have or take sufficient time to examine the flood of information.

How do we guard against this leap to oversimplification?

Here are a few key questions:

•Was there a large and diverse population studied?

There have been solid links between lower socioeconomic groups and some ethnic minorities and increased television time, as well as between lower socioeconomic groups and obesity.

The causes for both of these issues are of course multi-factorial. Fatty foods and higher calorie foods are cheaper. TV can function as a babysitter in households where parents are busy working and living paycheck to paycheck. However, the study in the headlines above, conducted by the Department of Education in conjunction with physicians at the University of Virginia, was indeed both large and diverse.

Over 12,000 children starting kindergarten were enrolled in the investigation, and a year later follow-up data was available for more than 10,000 of these children. These data included height and weight, as well as statistical analyses to account for differences in race, gender and socioeconomic effects. In other words, the numbers here are sufficiently large and diverse for us to feel comfortable drawing at least preliminary conclusions.

Causality, Really?

But beware, always beware, of flashy headlines. A Google search yielded all of the headlines above with equal weight, and yet one of the headlines clearly implicates causality. “Watching TV for just an hour a day can make a child obese.” (My italics.)

However, this study does not in any way suggest causality. There are a number of potentially unrelated factors that also happen everyday that might be associated with obesity, but not function as a cause of obesity. These could include behaviors like longer baths to cool down. We don’t know until we do the study whether longer baths would be associated with obesity. In other words, always be wary of blanket statements of causality with regard to the complexity of human behavior.

•What about the ample availability of screen-based material on demand? Perhaps the fact that children can often watch both what they want and when they want it affects their activity patterns in negative ways. We could ponder the fact that TV content, even for kids, has arguably (though not in all spheres) gotten better and of higher quality. There is even evidence that TV watching can improve behavior among kids, and this evidence also comes from the American Academy of Pediatrics. Does that mean we ought to make a policy statement advocating that TV should be less compelling?

Confessing My Bias

Things get even messier when we take the necessary step of examining our own personal biases. In my case, that examination includes a shameless confession regarding the ways my own penchants might complicate my interpretation of these data. Continue reading