More Recess @AmerAcadPeds @ChildHealthUSA @childhealthwi

January 29, 2016

CHW LogoWe’ve all heard the adage “All work and no play makes Jack a dull boy.”  It turns out that it also makes him obese, interferes with his learning, increases his cardiovascular risk, and ruins his vision.  Yet American children continue to face pressures to work more and play less.

American children have the 4th highest number of classroom hours in the world, yet some of the shortest recess.  Moreover, with the increased focus on standardized testing and “accountability,” the school year has gotten longer and recreational time has decreased. The pressure on so-called failing schools to improve their test scores has led to socioeconomic disparities as well.  In Seattle, for example, schools in higher income neighborhoods averaged 16 minutes per day of recess time than those in low income areas.

All this despite the mounting evidence of the benefits of unstructured play time, especially outdoors, for children of all ages.  Here are a few examples:

  • A study in the Journal of Pediatrics showing that adolescents with higher levels of moderate-to-vigorous physical activity had higher attention capacity; 60 minutes per day or more of activity correlated with the best attention capacity
  • A 2005 systematic review of 850 studies showing benefits in a variety of health and behavioral outcomes associated with 60 or more minutes a day of at least moderate physical activity
  • A recent study of teenage girls showing that even short periods (3 hours) of sustained sitting produce adverse effects on the cardiovascular system; these effects were averted with brief interludes of modest activity
  • A study from Asia showing a strong correlation between fewer hours of outdoor activity and the incidence of myopia (nearsightedness) in children

In addition to these and other observational studies, a randomized trial of a school-based physical activity intervention program in low income children showed an increase in learning readiness and a decrease in bullying.  The evidence is sufficiently strong that the American Academy of Pediatrics has issued a policy statement calling recess “crucial” to children’s well-being and recommending at last 60 minutes per day of physical activity for school children.

So why do children in American schools continue to face declining opportunities to get up, get out, and get around?  One factor may be that parents are kidding themselves about how inactive their kids are; a study in the International Journal of Pediatrics showed that parents frequently misperceive both their children’s weight status and their activity levels.  But the other is the mistaken belief that if we only keep kids at their desks longer, and keep them away from frivolous activities like recess, it will make them smarter.  We need to learn a lesson from Finland, which has some of the shortest school hours, longest recess, and highest test scores in the world.  No Child Left Behind has become No Child Allowed Up Off His Behind, much to the detriment of our kids.


Physicians United

January 15, 2016

CHW LogoThe US Supreme Court has ruled money is equivalent to speech.  It now appears that money is also equivalent to a medical education and training.

In an op-ed in the Milwaukee Journal Sentinel last fall, I wrote about the importance of experience and transparency in providing specialized pediatric care.  I cited the example of St. Mary’s Hospital in Florida, where an unusually high number of infants died following cardiac surgery; investigation revealed they were performing far fewer than the recommended minimum number of cases to maintain the necessary skills and competency.  After an outcry from professionals and the public, the hospital – owned by the global for-profit Tenet Healthcare – shut down its pediatric cardiac surgery program.

End of story?  Not really.  CNN reports that the following month, the state of Florida decided to repeal its standards for cardiac surgery, which had been in place since 1977.  Why the change?  It may just be coincidence, but as reported by CNN, Tenet Healthcare has donated $100,000 to Florida Governor Rick Scott’s PAC, and another $100,000 to the Florida Republican Party, in 2013-14. I looked at the contribution disclosures from Tenet, and while they are bipartisan in their giving, which is extensive, their contributions to both Gov. Scott (himself a former for-profit healthcare executive) and the Florida party are substantially higher than the next highest contributions.

In addition to repealing the state standards in August 2015, a year earlier a negative review of the St. Mary’s pediatric heart surgery program by the Florida Cardiac Technical Advisory Panel was suppressed at the request of the state surgeon general.  The physicians on the panel are, needless to say, irate, and are considering a legal challenge to the state’s moves, which they believe are politically motivated.  Officials at both Tenet and the governor’s office deny there was any discussion between them about the cardiac surgery standards or the case of St. Mary’s Hospital.  (Naturally.)  It would be almost impossible to prove a specific quid pro quo; it always is.  But the timing and details in this case are, to say the least, suspicious.

Transparency about outcomes is important in helping parents choose the best and safest care for their children, but it came too late to save the at least eight babies who died at St. Mary’s.  There is a critical role for standards and oversight to ensure safety in the healthcare system.  When political contributions – regardless of party – are allowed to overrule clinical expertise in setting those standards, that’s more than corruption.  It’s conspiracy to commit murder.


Less Is More

January 8, 2016

CHW Logo@AmerAcad Peds @childhealthUSA

My favorite piece of camping equipment is a BioLite stove.   Using only the kind of tiny twigs that would barely serve as kindling for a fire, it not only produces enough heat to boil a pot of water in less than 5 minutes, it also generates electricity for charging a phone.  Designed for poor countries where access to electricity and fuel is a challenge, it happens to be far better than the large majority of “high tech” stoves I’ve seen.  It’s a great example of so-called reverse technology transfer: more “primitive” technology is adopted by a more “advanced” culture.  (Sorry for all the “quotes.”)

Another great example is known as kangaroo mother care.  Developed in the 1970’s in Bogotá, Colombia, as an alternative to expensive and unavailable incubators for the care of premature infants, it involves, according to the World Health Organization, early, continuous, and prolonged skin-to-skin contact between the newborn and mother; exclusive breastfeeding; early discharge from the health facility; and close follow-up at home.  It doesn’t get more low tech than basically holding and nursing the baby.  Seems like a reasonable alternative to fancy equipment like a neonatal incubator.

Except it isn’t.  It’s better.  A recent review of 124 studies of kangaroo care, published in Pediatrics, demonstrated that for babies under 2000 grams (4 pounds 4 ounces), infants receiving kangaroo care had 36% lower mortality and sharply reduced rates of a number of serious complications compared with those receiving conventional care.  Because of the large number of studies included, the authors could look for important differences between them to test the robustness of the findings.  Of note, one third of the studies were performed in high income countries like the US (where conventional care is high tech), and the advantages of kangaroo care were similar.  We provide kangaroo mother care for eligible infants in the neonatal ICU at Children’s Hospital of Wisconsin.  While it may seem incongruous in one of the most sophisticated NICUs in the world, the evidence shows that it is better and cheaper.  That’s the definition of value.  And parents love it!

Oral rehydration therapy is another example of reverse technology transfer – a third-world technology that is equally or more effective than the more expensive, resource intensive , first-world alternative.  I wonder how many more such value-laden options are on the horizon, especially as we become increasingly aware of the hidden costs (e.g., carbon footprint) of much of our technology.  Agriculture may become a prime example; many of the techniques of sustainable agriculture, which is growing exponentially in the US and Europe, started as alternatives to the modern miracles of fertilizer and pesticides in resource-poor settings.

At a recent conference on innovation in pediatrics, there was a good deal of discussion about “design thinking.” This is a method of innovation in which the first steps are to truly understand and define the actual need, not just the stated or perceived need.  It is tempting, especially in the industrialized world, to define the problem in terms of technology.  But technology is not an ends, it’s merely a means.  The question isn’t necessarily how to build a better mousetrap, it’s what are other ways of getting rid of mice.   If Dr. Sanabria had defined his problem as “how do I make a less expensive incubator?” he would have come up with something different.  His insight was to see that the actual problem was “how do I provide appropriate womb-like conditions for preterm infant outside the womb?”  In the US, that meant an incubator.  But in Colombia, that became kangaroo care.

As we seek to provide better value in healthcare, we have to continue to look everywhere to find it, even in the most unusual places, like the pouch of a marsupial.


December 14, 2015

CHW LogoToday I watched a boy bleed to death.

I watched as a dozen doctors and nurses poked him, ventilated him, poured blood into his veins, sliced open his grotesquely swollen limbs to prevent gangrene.  I watched as, despite their efforts, despite two operations in a few hours, his teenage body continued to hemorrhage beyond repair.  I watched his parents standing outside the room, anxious and tearful. I watched his extended family gathered outside the hospital, holding one another, waiting for word.

This is what guns do.

Yesterday he was just another teenager worrying about all the usual adolescent things.  This morning he got in an argument with another teenager over a phone.  We all know how stupid teenagers can be, and we’ve all done something like that at some point in our lives.  But this time one of them had a gun, and one body lies cold and blue in the morgue, while another is in detention. Two lives destroyed, two families shattered.

This is what guns do.

I am not here to make a political argument, because this isn’t a political problem.  It’s a public health problem: a public health crisis.  If that boy, and the tens of thousands of others that meet a similar fate every year in this country, had bled to death from Ebola no one would hesitate to acknowledge that.  It’s made out to be a political problem because a few truly evil people (I’m talking to you, NRA leader Wayne LaPierre), cynically manipulate genuine concerns about the balance between public well being and constitutional rights.  But facing public health threats always requires such a balance.  Tobacco, automobile crashes, polio – all of these were addressed by reasonable, common sense restrictions on rights, in the form of requirements (you must wear a seat belt, you must get immunized) and prohibitions (you may not buy cigarettes if you are under 16, you may not drive above the speed limit), which have been readily accepted by the public.

We will continue to see thousands of people die by murder or suicide, and many thousands more wounded, until gun violence is seen as a health crisis.  More people need to see what I did this morning.  We need to stop letting Wayne LaPierre set the agenda.  Instead, we need a Mamie Till.

When Mamie’s son Emmett was brutally tortured and lynched in Mississippi in 1955, she insisted that the world needed to see what she saw.  His battered corpse was on view in an open casket funeral attended by hundreds and shown in newspapers around the world.  Racial violence was no longer an abstraction that could be glossed over.  It was a raw, ugly reality not only to its victims, but to the entire public.  It was a key moment in spurring the civil rights movement.

Sadly, the death I watched didn’t even make the news.  After all, there isn’t enough room in the papers to report on every person felled by a gun.  But crime still sells, and there are plenty of media items about gun violence.  In the wake of recent mass shootings, the New York Times ran its first front page editorial in almost a century.  That won’t do it.  People don’t need to be convinced, they need to be shocked out of complacency.  We need to stop showing photos of the perpetrators, or grainy high school yearbook pictures of the victims.  We need to show graphic, gruesome images.  Family survivors need to do what Mamie Till did – make everyone share your horror and grief.  Everyone needs to see what guns really do.


Public Enemy?

December 4, 2015

CHW LogoIn 1882, Norwegian playwright Henrik Ibsen wrote An Enemy of the People.  It tells the story of a doctor who becomes concerned about contamination of the water supply for his town.  When he speaks out publicly, he is condemned by the political and business leaders – who know about and profit from the tainted water – and eventually run out of town.  He, rather than those who are poisoning the water, is branded an enemy of the people.  Abandoned by family and friends, the doctor stays true to his principles and refuses to back down.

It sounds (and in fact is) a bit melodramatic; Ibsen himself wasn’t sure whether to label it a tragedy or a comedy.  Either way, it is fiction. Or is it?  Fast forward to 21st century America and you can find a similar, and true, story.  In October 2015, the water supply in Flint, Michigan was determined unfit to drink and a public health emergency was declared.  While the ending is happier for the public than in Ibsen’s play, it followed vigorous denials by the authorities.  As in the play, it was a physician – a Flint pediatrician – who first raised the concerns and was dismissed and criticized.

Dr. Mona Hanna-Attisha had been hearing complaints about the smell and taste of the Flint water since 2014, when the supply was changed from Lake Huron to the Flint River.  Many of her patients’ families suspected the water was making their children ill.  After learning of a similar problem in Washington DC in the early 2000s that resulted in high levels of lead toxicity, Dr. Hanna-Attisha reviewed the results of lead testing in Flint and found that the rate of lead poisoning had more than doubled after the change in water supply. Working with an environmental toxicologist from Virginia Tech, who had discovered the lead problem in DC, she learned that the new water supply was more caustic, allowing lead to leach out of the aging pipes in Flint’s water distribution system.

State officials responded with criticism, calling the findings “unfortunate” and accusing Dr. Hanna-Attisha of “near hysteria.”  Like the doctor in Ibsen’s play, she refused to back down.  She convinced the state to re-analyze their data, which demonstrated that the rate of lead poisoning had in fact increased.  At that point, the state conceded and declared the water emergency.  The Flint water supply has now reverted to Lake Huron, with anticorrosion measures in place to prevent the lead leaching.

It’s a thin line between advocacy and subversion.  Pediatricians and other pediatric professionals, as advocates for children, are often skating along that line.  Lead in the water in DC or Flint, injuries and deaths from gun incidents both intentional and accidental, climate change that threatens the health of this next generation and the ones that follow: all of these and many others are issue on which we must, and do, stick out our necks.  At times, that means being an enemy of the powerful.


Good Germs

November 6, 2015

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I’m looking out my window at a gorgeous fall day, the kind of day that makes you notice the variety of trees and plants in their different stages of seasonal metamorphosis.  The kind of day that makes you wish you were outside, where things are fresh and alive, instead of in the hermetically sealed sterility of the great indoors.

Except it’s not sterile.  The indoor environment, where the vast majority of modern humans spend the vast majority of their time, is in many ways as lush as the woods on the Milwaukee County Grounds on which I am gazing.  Researchers are beginning to catalog the richness of the indoor microenvironment – the bacteria, fungi, and other microorganisms living on all the surfaces of our homes, schools, offices, hospitals, etc. – with an eye toward understanding how it affects us and vice versa.  Among the findings coming from The Wild Life of Our Homes:

  • The average person sheds about 37 million bacteria per minute into the interior environment; homes and even rooms (including hospital rooms) develop unique microbial identities from their inhabitants
  • Over 40,000 species of fungi have been identified inside homes – this is more than the total number of named fungal species in North America
  • The composition of the indoor microbial community can affect the risk of allergic and immune diseases such as asthma, inflammatory bowel disease, and diabetes
  • The presence of pets alters the indoor microbiome, in ways that may be healthier for the human inhabitants

There has been a huge advance in the past decade of our understanding of the human microbiome.  Health and disease rely in large part on the complex interplay between our genes, the micro-organisms inhabiting our skin and respiratory and GI tracts, and other environmental factors such as diet, exercise, and air- and water-borne contaminants.  The implications range from understanding how antibiotic resistance can spread through a community due to antibiotics use in concentrated animal feeding operations, also known as CAFOs or “factory farms” (farm workers become colonized with resistant bacteria and spread them for days); to the use of fecal transplants for treatment of a variety of conditions including C.difficile colitis.  But now we are also developing a better comprehension of how our immediate surroundings influence the microbial world within our bodies.

It starts early in life.  Babies born by Caesarean section develop a different intestinal microbiome, one in which skin flora predominates, than those born vaginally, and these differences can last for years.  This appears to explain some of the findings of a variety of diseases that are more common among babies born via C-section.  Some of the relationships, though, are more complicated than believed.  For example, scientists had hypothesized that homes in rural environments had richer microbial profiles than those in urban areas, which would go along with the observed lower rates of allergic diseases in rural areas (supporting the hygiene hypothesis, which posits that early exposure to microbes elicits healthy immune responses and protects against such diseases).  However, maps from the Wild Life of Our Homes project show such a relationship between rural setting and microbial diversity for fungi, but an opposite one for bacteria.  Also, a study showed that buildings, including hospitals, with recirculating air systems have less microbial diversity, and more pathogens, than those with more exposure to outside air.  As I said, it’s complicated.

So why do I bring this up?  In part because I think it’s really cool.  But also to raise awareness that microbes are necessary and usually good, and require appropriate care.  We can support efforts to reduce unnecessary antibiotic use in the food chain and in clinical care Avoid overuse of antibacterial soaps and sanitizers, which are no better than conventional cleaners and disrupt bacterial ecology of a community when they enter the water supply.  Open the windows.  Get a dog.


Hug a Pharmacist

October 22, 2015

CHW LogoA couple of years ago I visited what is purported to be the oldest pharmacy in Europe, in the tiny town of Llivia on the border between France and Spain.  Filled with Latin-labeled jars of various plant materials and other exotic ingredients reminiscent of a Potions class at Hogwarts, it reminded me how far medicine in general, and pharmacy in particular, has come.  And the pace of change is accelerating.  The large majority of medications in current use – entire classes of them – didn’t exist when I was in medical school 30 years ago.  Keeping up with that kind of transformation is a challenge.  Thank goodness for pharmacists!

I want to offer a shout out to my pharmacy colleagues during National Hospital Pharmacy Week.  The range of skills and the many ways pharmacists allow us to provide safe, effective, and efficient care is quite impressive.  At Children’s Hospital of Wisconsin, we have pharmacists working in the main pharmacy and satellite pharmacies for the intensive care units, operating room, and oncology units.  They do far more than oversee the dispensing of medications by the team of pharmacy technicians.  Pharmacists are an integral part of the care team: participating in rounds; providing advice on medication selection, drug interactions, dosing, and adverse effects; leading efforts around antibiotic stewardship and rational formulary development; assisting in medication reconciliation and patient education; and ensuring compliance with the myriad regulations around medications.  Hardly a shift in the emergency department goes by where I don’t have an interaction with the pharmacists in which I am both helped and enlightened!

As you might expect, the role requires a substantial amount of education and training.  Pharmacists typically receive an undergraduate degree and then pursue a four-year doctor of pharmacy program.  While retail pharmacists often stop their training there, hospital pharmacists most often pursue additional training, especially to practice in a specialized area like pediatrics.  Our hospital offers a highly competitive two-year pharmacy residency that prepares people for the rigors of the role of a hospital pharmacist in the modern era of team medicine.

Pharmacy today bears as little resemblance to the mixing of obscure powders in medieval Llivia as surgery does to the barbershop purveyors of the same era.  For my colleagues who are masters of modern pharmacy, I offer my gratitude and appreciation.


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