Starting With Curious

We’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 4^th 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.

The 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.

@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.