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Wednesday, September 23, 2020

Post #52 Overkill: When Modern Medicine Goes Too Far by Paul Offit M.D.

Overkill: When Modern Medicine Goes Too Far by Paul Offit M.D.

I am admittedly a huge fanboy of Paul Offit, an infectious disease guru at Children's Hospital of Philadelphia, one of the preeminent pediatric hospitals in the world. 


His latest book Overall: When Modern Medicine Goes Too Far, is a collection of medical facts that are already known to the well-read individual, but fly in the face of wrongly-held, out-dated, commonly-believed medical concepts. 


The majority of the incorrect information was previously considered the standard of care, but newer and better science and studies have clearly demonstrated updated - often conflicting - medical truths.


I have summarized some of the more salient facts here as a quick read for the over-worked and under-rested parent, so that they can take better care of their precious little ones without having to read the whole book (although I highly recommend it). 



Chapter 1: Treating Fever Can Prolong or Worsen Illness


Fever-reducing medicines are found to prolong and worsen infections in experimental animals and people. Societies that use fever-reducing meds suffer a 5% increase in flu cases and deaths. Researchers have estimated that avoiding fever-reducers during a flu season would save about 700 lives in the USA and about 40,000 lives worldwide every year.


In my pediatric practice I only recommend fever-reducers for two reasons:


  1. If a fever is affecting a child’s activity level to the point they refuse to drink, fever-reducers may help perk a child up to encourage fluid intake to stay hydrated
  2. As a litmus test. The activity level of a child is a great way to assess how serious an infection truly is. If a child’s activity level is down, a fever-reducer can help perk them up (even if for just 30 minutes), which should reassure a parent that their fever source is very likely non-serious. If a child's activity level continues to be depressed despite taking a fever-reducer, it is a good idea to touch base with your pediatrician.


Chapter 2: Finishing the Antibiotic Course is Often Unnecessary


The thinking used to be that antibiotic courses needed to be fully completed per doctor’s order to prevent antibiotic resistance from occurring. Many health organization including the World Health Organization in 2016 used to ingrain this idea into doctor's and patient's heads alike. 


However, multiple studies for many different types of infections in both adults and children have shown that finishing the antibiotic course is unnecessary


Pediatric Urinary Tract Infections


In 2002, Australian investigators reviewed the results of ten studies of 650 children, and they found that for a bladder infection there was no difference between 2 to 4 or 7 to 14 days of antibiotics when measured by the elimination of bacteria from the urine and for resolution of clinical symptoms.


Other Pediatric Infections


Studies now show that for adults and as well for children old enough to describe their symptoms, the best advice for diseases such as bladder infections, kidney infections, pneumonia, sinus infections, skin infections, appendicitis, and ear infections is to stop the course of antibiotics when symptoms begin to improve. 


When the immune system, working synergistically with the antibiotics, has defeated the bacteria, the signs and symptoms of inflammation, such as fever and accompanying symptoms will abate and at this point the bacteria are no longer actively reproducing.



Chapter 3: Antibiotic Drops Don’t Treat Pinkeye


About 70% of people who develop conjunctivitis (pinkeye) will visit their doctor. Most will receive an antibiotic that costs the healthcare system between $377 and $857 million each year!


The most common cause of conjunctivitis is allergies - every year up to 40% of Americans suffer from allergic pinkeye. The second most common cause is viruses - about 8% of infectious pinkeyes are caused by viruses. The least common cause of pinkeye is bacterial.


A simple rule for differentiating the 3: allergic is itchy, viral is accompanied by other cold symptoms, and bacterial causes thick, purulent discharge. Unfortunately there is a lot of overlap. But even so, the studies show that antibiotics don’t treat bacterial conjunctivitis.


In 2012, researchers from the University of Edinburgh reviewed all of the existing studies on conjunctivitis and they found two high-quality studies, one of which was performed in children.


In July 2005, researchers from Oxfordshire in the U.K. divided 320 children into 2 groups. One group was given antibiotic drops every 2 hours for the first day and then 4 times a day until the infection resolved. The other group was given a placebo eye drop. Seven days later, 86% in the antibiotic group and 83% in the placebo group were cured - an insignificant difference.


The adult study from Switzerland and the Netherlands found the same result.


As a consequence of these studies, the American Academy of Ophthalmology now recommends watchful waiting for those suffering from acute pinkeye, whether it’s caused by bacteria or not.


Complications of using antibiotic eye drops include irritation, emergence of antibiotic resistant strains, and expense of the medication. In general, patients are probably better off using cheaper over-the-counter lubricating eye drops or cold compresses for comfort.


Unfortunately (and incorrectly), many work places and schools will not allow return until drops have been utilized for 24 hours.



Chapter 8: Embrace Allergenic Foods for Infants


In 2000, medical advisory boards in the United States put out recommendations to avoid peanut-containing foods early in life.  By 2008, overwhelming evidence proved that this recommendation was useless and not decreasing the incidence of peanut allergies.


In 2015, researchers from the U.K. published a groundbreaking study called the LEAP trial, for  “Learning Early About Peanut Allergies.”


Between 2006 to 2009, 640 infants between 4 and 11 months old who had eczema or egg allergies or both were divided into 2 groups. One group consumed 6 grams of peanut protein per week until age 5; the other group was instructed to completely avoid all peanut-containing foods. 


At the end of the study there was an 86% reduced risk of developing peanut allergies in the group that was fed peanuts early on. In other words, eating peanuts early in life decreased the risk of peanut allergies later in life.   



Chapter 10: Avoid Reflux Medicines for Fussy Babies


All babies cry and all babies spit up, but very few require treatment for gastroesophageal reflux disease (GERD). If they are gaining weight appropriately, there is low cause for concern.


Evidence clearly shows that reflux medicines do not work to treat fussy babies. In fact reflux medicines are known to cause several concerning side effects:


  1. Decreased stomach acid which increases the risk of bacterial infections such as pneumonia and necrotizing enterocolitis. Acid kills bacteria, so reducing it increases the risk of infection.
  2. Reflux medicines change the healthy bacteria living in our intestines (the microbiota)  which can have downstream effects on obesity, allergies, diabetes, and other medical problems.
  3. More recently, a study of 850,000 babies found that those who received reflux meds were at higher risk of bone fractures.


It is much safer to burp frequently, position upright after feeds, thicken feeds, and if breastfeeding avoid milk, eggs, coffee, and spicy foods - all of these things can be discussed in more detail with your pediatrician.



Chapter 18: Don’t Ice Sprains


The acronym RICE (rest, ice, compression, elevation) was originally developed by a Baylor College of Medicine doctor named Gabe Mirkin. Because of the easy-to-remember acronym, it was widely used as the standard of care for sprains. However, clear evidence since has demonstrably refuted the RICE method, leading to Dr. Mirkin himself no longer recommending to follow his original advice.


Multiple well-done studies from New Zealand, Ireland, Amsterdam, and Taiwan have shown that icing sprains delays healing.


The key to healing is inflammation, which recruits helpful immune cells to the damaged area by increasing blood flow. Increased blood flow also promotes the manufacturing of collagen, which is necessary to create new, healthy ligaments and muscles.


Therefore, anything reducing blood flow, such as rest, ice, compression, and elevation, actually stymies the healing process. Of course all or these things lessens the initial pain, so people are still tempted to employ these techniques. However, for faster healing, you are better off using warm compresses, stretching, and movement to promote blood flow to the injured area.



The remaining chapters are not quite as relevant to pediatrics (or the truth is better known - such as the teething chapter) but they are equally compelling. I have listed them below as the chapter titles themselves express the salient information which can be expounded upon by reading the actual book. The book itself is a quick read and well catalogued with studies that drive each point home. It is time well spent and the dividends will lead to better health for the whole family.


Modern medicine continues to progress at an exponential rate, but as Paul Offit clearly demonstrates, sometimes it is important to take a breath and make certain that in proactively treating things we are not causing more harm than good.



Chapter 4: Vitamin D Supplements Aren't a Cure-all


Chapter 5: Supplemental Antioxidants Increase the Risk of Cancer and Heart Disease


Chapter 6: Testosterone for "Low T" is Dangerous and Unnecessary


Chapter 7: Baby Aspirin Doesn't Prevent First Strokes or First Heart Attacks


Chapter 9: The False Security of Sunblock


Chapter 11: Prostate Screening Programs Do More Harm Than Good


Chapter 12: Thyroid Cancer Screening Programs Do More Harm Than Good


Chapter 13: Breast Cancer Screening Programs Aren't Exactly as Advertised


Chapter 14: Heart Stents Don't Prolong Lives


Chapter 15: Surgery For Knee Arthritis is Unnecessary


Chapter 16: Don't Remove Mercury Dental Fillings


Chapter 17: Vitamin C Doesn't Treat or Prevent Colds


Chapter 19: Teething Doesn't Cause Fever

Saturday, August 1, 2020

Post #51 Our Family’s School Decision Making Process

My boys do not want to wear pants.


A small factor, but part of the reason they campaigned for remote learning. My daughter, who generally prefers clothing, remained on the fence.


The remote vs. in-person learning decision has so many different factors it is very difficult as a pediatrician to give families a single clear answer.


As new data emerges, it further confounds a family’s decision that seemed crystal clear just 2 internet articles ago.


Several people have asked point blank, “What are you doing for your own kids?”

If I have left your text unanswered or have not replied to your email or Facebook comment, I apologize! A binary, “remote” or “in-person” response seemed too hasty and irresponsible.


While every family will have their own personal best answer, I hope sharing how my wife and I arrived at our decision will benefit the process for other parents.


To start off, some demographics are in order:


Our children are 12, 14, and 16 years of age – boy (7th grade), boy (9th grade), girl (11th grade) respectively. I am a pediatrician and my wife is a former elementary school teacher and now stay-at-home mom.


We are zoned to Cy-Fair Independent School District and the schools our children attend are Title 1 schools, with an eclectic mix of socio-economic backgrounds.


Children’s Health


The first and most important factor in making our decision was the health of our children. As of the writing of this blog, the overall risk to healthy children from COVID-19 is very small.


The CDC keeps a provisional death count by age, and as of August 1, 2020, there have been a total of 42 deaths in children younger that 15 years for the entire country. To put things in perspective there have been 185 deaths due to influenza in children younger than 18 for the 2019-20 season. Overall, children have fared extremely well with the pandemic in terms of deaths and medical complications.


If I were only factoring in the health risk to our children, I would feel safe sending them to school, given a few caveats that I will get to later in this blog.


Family’s Health


Our home is solely occupied by our nuclear family (no grandparents) and everyone is in relatively good health with no underlying health conditions.


If we had people over 60 living at home (the older the more concerning) or if someone at home had a serious underlying medical problem, I would be much more concerned about in-person learning.


The newest data from Chicago shows that, contrary to earlier studies, young children do get infected and do have high levels of virus.


Further, in a study from a Georgia sleep-away camp of all ages, of 344 campers and staff for whom tests were available, 260 tested positive after just a few days at camp.


The vast majority of kids may not get seriously ill, but it appears they can bring it home, and as such, an important part of the decision making process has to include the risk to family members.


Community Spread


The initial data from Europe, Asia, and Australia was quite comforting in terms of community spread risk from reopening schools. It is important to note that local COVID-19 caseload numbers were low and under control in the countries that reopened schools.


The recent data from Israel, South Korea, Georgia, and Chicago has rained on the parade.

Epidemiologists all agree that schools will contribute to spread in some fashion, but to what extent is still up for debate. The pendulum appears to be swinging towards children being as infectious as adults.


Ultimately, regardless of children’s infectiousness, the more important factor affecting community spread will be a school’s ability to follow certain protocols: masking, social distancing, and sanitizing. If these measures are rigorously followed, community spread should be minimal.


Additionally, it will be prudent to pay attention to local COVID-19 statistics. If caseloads are rising and hospital are overwhelmed, school closures may be necessitated.


Another important factor in community spread will be the population density at each school. As more families opt out of in-person learning, it will commensurately improve the risk for those who do attend, including the risk to our educators, many of whom will not have a choice but to be physically present.


For those who have the ability to do so, I encourage you to strongly consider remote learning to lessen the risk for those who cannot.


Educational Value


A child’s aptitude for learning remotely has to be a major factor. For some children, the value of in-person school is enormous.


Can they learn independently?


Can they focus for extended periods of time?


Will the lack of peer stimulation hamper their education?


Continuity


Attending in-person school may get interrupted from time-to-time should quarantine and isolation protocols be triggered by someone in the classroom testing positive for COVID-19.


This may force remote learning for periods of time, disrupting the continuity and flow of school.


For those kids who do not do well with change, remote learning may be the better option.


Family Decision


These were some of the variables that my wife and I contemplated as we arrived at our decision. We let our children voice their opinions as well, which we factored in.


So what did we decide?


I thought my wife said it perfectly, so with her permission, I have copied her words from her recent Facebook post.


“We are going online for the first grading period for the following reasons:


· Online instruction will be live and interactive (as opposed to the video lessons we did last spring).


· My kids are able to focus fairly well with the online learning.


· They actually are not going insane with the lack of peer interaction (they see some friends occasionally, with safety measures in place). I know this is a big deal for a lot of kids, and I totally get it.


· Our school community is around 70% low income. A lot of those families would benefit from in-person instruction, so we will be 3 less kids on campus to try to help with the numbers.


· If school has to shut down, we won’t have to transition from in-person to online instruction (I still can’t wrap my head around what this will look like).


· Masking for long periods of time is hard. So is wearing pants.


So this is our decision. We will do this for the first grading period and see how it goes. Stuff is constantly changing, so it’s hard to plan ahead this far in advance. We still have a lot of questions about how things will work, but we just have to wait and see.”


As my wife mentioned, this is a decision in flux that may change as new data or family issues emerge.


But at least for the first six weeks, my boys will be pants-less.

 

Thursday, July 23, 2020

Post #50 School Reopening during the COVID-19 Pandemic

There is probably not a more emotionally charged topic of discussion currently than that of school reopening this fall. And for good reason - nearly everyone has a stake in it.

Society is concerned because of the real risk of increased community spread.

Teachers are concerned because of the COVID-19 risk to themselves and how the logistics of school will directly affect their livelihood and stress level as they have to constantly adjust to the barrage of changes and duties. 

Families are concerned because of the COVID-19 risk to their children and to those living at home. Not to mention, many depend on school to allow for both parents to work. And what about the educational risks if everything is remote learning? And if kids stay home, will mom and dad working from home stay sane?

The number of different factors weighing in on the discussion is overwhelming. The implications affect the economy, family lives, the future of our country, and society as a whole. Superintendents, teachers, and those directly affecting school policy have their work cut out for them - thank you in advance for everything you are doing.

A good place to start the discussion is assessing the real risk to the different groups as listed above.

Students

A recent study of nearly 65,000 people in South Korea made an important distinction in children younger than 10 and those between the ages of 10 and 19, in that the younger group transmits the virus much less often than adults do. 

Ten years is not some magical demarcation as almost everything in medicine is a continuum with COVID-19 risk increasing commensurately as a child ages. For those seeking a technical explanation of this, it is likely related to the lower number of ACE2 receptors in the respiratory tract of children. 

Other possible factors that may contribute to children posing lower risk could stem from their smaller volume of breaths and the fact that they are short and thus their inhalation and exhalation is closer to the ground and not in the same plane as adults. Obviously, if they are in school and with their peers, the latter advantage becomes less relevant.

The take home message here is that younger children pose a substantially lower risk for COVID-19 spread than older children and adults. Elementary school is likely safe. Middle school and high school remain suspect. 

As for deaths in children, the CDC keeps a provisional death count by age, and as of July 22, 2020, there have been a total of 36 deaths in children younger that 15 years for the entire country. To put things in perspective there have been 185 deaths due to influenza in children younger than 18 for the 2019-20 season. Overall, children have fared extremely well with the pandemic in terms of deaths and medical complications.

Families

There is a real risk that students attending school will bring the virus home to their families. For those living with their grandparents or an immunocompromised individual or family members with underlying health issues, this poses a difficult conundrum. 

A recent systematic review of 700 scientific papers found that children are rarely the index case in outbreaks and were unlikely to impact the COVID-19 mortality in older people. While this data gives a great deal of reassurance, children still contribute to some level of spread, and as the South Korean data demonstrated, older kids are likely on par with adults in terms of risk.

Teachers

The best data on school spread comes from other continents where school reopenings have already taken place.

An excellent case study in Australia looked at 18 infected individuals (9 students and 9 staff) from 15 schools from March to mid-April of this year. 735 students and 128 staff were close contacts of these initial 18 cases. No teacher or staff member contracted COVID-19 from any of the initial school cases. However, one child from a primary school and one child from a high school may have contracted COVID-19 from the initial cases of their schools.

Another paper from the Journal of Pediatrics reviewed outbreaks in Switzerland, China, France, and Australia (cited above) and found that children are rarely drivers of COVID-19 transmission.

This is not to say that there is zero risk to teachers from students, but the data suggests it is minimal. And while children are unlikely to infect teachers, other staff and teachers pose a real risk to each other; adult to adult transmission is real and South Korea suggests students 10 and older are on par with adults.

Guidelines are Needed

If school reopening is to happen, detailed guidelines must be in place. The American Academy of Pediatrics (AAP) recently published excellent guidance for reopening schools.

A key phrase they used was that "policy makers should acknowledge that COVID-19 policies are intended to mitigate, not eliminate, risk." This is important to bear in mind. If we are attempting a zero risk solution, it will not happen.

AAP outlines key principles in consideration of reopening schools:
  1. School policies must be flexible and nimble.
  2. Strategies may need to be revised and adapted depending on the level of virus transmission in the school and community.
  3. Policies should be practical, feasible, and appropriate for the child's developmental stage.
  4. Special considerations should be made for the medically fragile, impoverished, and those with developmental challenges or special health care needs.
  5. Minimize exclusion.
  6. Policies should be guided by supporting the overall health and well-being of all involved.

Strategies recommended by the AAP include to cohort classrooms to minimize crossover, utilizing outdoor spaces when possible, limiting visitors, mandating face coverings, spacing desks 3 to 6 feet apart, eliminating lockers, having teachers rotate instead of students, and creating one-way hallways.

As states consider the different options before them, some are appropriately using local COVID-19 caseload numbers and hospitalization rates as a qualification to reopen schools. Especially for middle school and high school this seems prudent. The data from Australia, Europe, and Asia school reopenings came from countries where the pandemic was under far better control than it currently is within the United States. 

Moving forward, should COVID-19 numbers improve within the community at large and thresholds are met, school reopenings should merit serious consideration. But in states where the intensive care units are at capacity and caseloads are rising, prudence makes sense.

Of course, this poses a dilemma for working parents. This is where a novel idea such as Safe Centers for Online Learning (SCOLs) could come into play. Essentially, for those who cannot watch their children at home, students could do online learning and be cared for in large venues, such as convention centers, stadiums, performing art centers, and parks that are currently going unused. 

Whether it be SCOLs or some other concept, relief must be provided in some form to allow for parents to return back to work. This will be an essential component of moving our economy forward. 

Without question, for the upcoming school year, there will be a new normal. Each school district and family will be faced with a plethora of decisions as they weigh risks and benefits. Luckily, many countries have wrestled with these same questions ahead of us and provided helpful data. Ultimately, each family understands their needs and risk appetite best. 

Ideally, schools will have the ability and resources to offer multiple options to accommodate each family. Hopefully, the information provided here will empower parents as they navigate school reopenings during the pandemic.

One thing is and has always been true: children are the future - let's keep them safe and make sure we provide them the best education possible.









Saturday, June 13, 2020

Post #49 Church Small Group Meeting Guidance during COVID-19 Pandemic

Updated June 13, 2020

Disclaimer: COVID-19 is a pandemic in flux. As the number of active cases and hospital ICU occupancy changes and new research comes out, recommendations will change. Please check with your church, doctor, local health departments, and www.CDC.gov for the most up-to-date information and guidance on meeting in person.

As most people know by now, COVID-19 is mainly targeting the old, immunocompromised, and individuals with underlying health issues. But it bears reminding that normal, healthy young adults are also getting severely ill

Importantly, children of all ages have been afflicted by a condition now termed Multisystem Inflammatory Syndrome in Children (MIS-C), which has led to some deaths in normal, healthy kids with no underlying health issues. MIS-C and healthy young adults getting severely ill is a small risk, but it is a real risk. Please bear this in mind.

However, at some point we all take risk. Driving down the freeway could lead to a fatal accident but we do it everyday. Children attending school even when there is no pandemic could lead to meningitis, but we do it everyday.

The key is calculating risk and minimizing it without going overboard - which is a very tricky thing to do with a new virus such as COVID-19.

If you are older than 60 years, have serious health issues, or are immunocompromised - you should not join an in-person meeting of a small group until further notice from public health officials.

If you are living with anyone meeting any of these criteria, you should strongly consider not joining an in-person meeting of a small group as you are putting that individual at real risk.

If you do not meet either of the above two criteria, meeting in a small group may be reasonable with the following parameters:

1. Masks should be worn as much as possible and for the entirety of the meeting.

2. If cases of COVID-19 in your city are rising, it is probably better not to meet in person. A great resource for this in Houston is www.TMC.edu.

3. If you do meet, SINGING is one of the biggest risks. It is highly advisable not to sing indoors at all. Either do praise time outside (with masks ideally) or skip praise time altogether. Even with masks on, singing in a confined space is a serious risk for spread – many people do not wear snug fitting masks and mask quality is highly variable.

4. It is advisable for mealtime to be done outdoors as it necessitates removing your masks. If you do eat indoors, you should be 6 feet apart ideally. Talking to one another for 10-15 minutes in close proximity without masks is an easy way for COVID-19 to spread.

5. Whoever is handling food prep must be masked when serving food. Everyone should thoroughly wash hands prior to eating.

6. Word time, sharing time, and prayer time can be done indoors, but outdoors is still preferable when reasonable. Either way, try to remain 6 feet apart. If sitting indoors, good air circulation is very important: turn on the AC and ceiling fan and open windows when possible.

7. Do not hug or shake hands. Elbow bumps are ok.

8. Try to keep any indoor portion of the small group as short as possible. Consider moving rooms when feasible for each segment of the small group meeting to keep the surrounding air fresh and new. Open, airy rooms with good air circulation are the safest.

9. Should you meet in-person, especially if the meeting is indoors, the smaller the group the safer. At this time, 10 people (including children) would be a reasonable cap to your group size.

10. Anyone who is possibly sick should ABSOLUTELY NOT come.

11.Anyone who cannot afford a two week quarantine period should they later find out someone in the group tested positive, should NOT come.

12. Anyone who is or is living with someone who is awaiting a COVID-19 test* or has recently been diagnosed with COVID-19 or is displaying COVID-19 symptoms should NOT come. See scenarios below to help with timeframe on returning.

*For the purposes of this guidance and the information below, a COVID-19 test refers to the nasopharyngeal nucleic acid swab test and not the antibody test – there is a major difference between the two tests that is beyond the scope of this guidance.

· Close contact with COVID but No Test Pending

o Safe to return after 14 day quarantine at home AND no symptoms develop during that time.

· Asymptomatic and COVID Test Pending

o It is definitely safest to wait until the COVID test is back. However if the individual is completely symptom free AND wearing a mask the ENTIRE time, it is reasonable to partake but would not advise.

· Symptomatic and COVID Test Pending

o Do not join until the test result returns AND the individual meets the criteria in one of the following scenarios.

· Asymptomatic and Positive COVID Test

o Safe to return when either of below criteria met:

§ 10 days after the first test was performed and remains asymptomatic.

OR

§ 2 negative nasopharyngeal swab specimens collected at least 24 hours apart. Tests for clearance should be done a minimum of 5 days after the initial POSITIVE test was performed.

· Symptomatic and Positive COVID Test

o Safe to return when either of below criteria met:

§ It has been 10 days since the onset of symptoms AND no fever for 3 days AND significant improvement of symptoms (cough, runny nose, etc.).

OR

§ 2 negative nasopharyngeal swab specimens collected at least 24 hours apart. Tests for clearance should be done a minimum of 5 days after the initial POSITIVE test was performed.

· Symptomatic but Negative COVID Test

§ Safe to return when 24 hours without fever without the use of fever-reducing medication AND significant improvement of symptoms.

Some of these recommendations may seem over-the-top, but COVID-19 warrants a high level of vigilance. It is a very serious illness and there is a long way to go before the pandemic is over. 

The safest thing of course is to meet through video-conferencing. At the present moment, it is this author’s preference until the risk further decreases.

Remember when you get together, you are not only potentially sharing germs with the people in your small group, but you are also sharing germs with everyone they live with and everyone they live with may be sharing germs with you. The larger the group, the greater the risk to everyone at the meeting.

Hope this guidance helps as you do the Lord's work!