Letters from Maine

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.

One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.

Lunchtime for me meant an hour of physical activity outside. In the early years, it was spent trying to keep up with my preschool children in the backyard. Most often my activity was a bicycle ride over the hilly terrain between Brunswick and Freeport. If it was raining, I would go for a run or a walk. In the winter you might find me skating on a flooded mall at the center of downtown or skiing some loops around the Bowdoin College athletic fields.

The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.

A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.

The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.

You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.

One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.

Lunchtime for me meant an hour of physical activity outside. In the early years, it was spent trying to keep up with my preschool children in the backyard. Most often my activity was a bicycle ride over the hilly terrain between Brunswick and Freeport. If it was raining, I would go for a run or a walk. In the winter you might find me skating on a flooded mall at the center of downtown or skiing some loops around the Bowdoin College athletic fields.

The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.

A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.

The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.

You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.

One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.

Lunchtime for me meant an hour of physical activity outside. In the early years, it was spent trying to keep up with my preschool children in the backyard. Most often my activity was a bicycle ride over the hilly terrain between Brunswick and Freeport. If it was raining, I would go for a run or a walk. In the winter you might find me skating on a flooded mall at the center of downtown or skiing some loops around the Bowdoin College athletic fields.

The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.

A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.

The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.

You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

A study published in Pediatrics by Kao-Ping Chua, MD, and associates entitled “Use of Low-Value Pediatric Services Among the Commercially Insured,” (2016 Dec doi: 10.1542/peds.2016-1809) doesn’t address the question of where pediatricians sit in the rogue’s gallery of health care dollar wasters. But it does provide a chilling glimpse at the size of our contribution to the problem.

Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.

I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?

The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.

As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.

But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

A study published in Pediatrics by Kao-Ping Chua, MD, and associates entitled “Use of Low-Value Pediatric Services Among the Commercially Insured,” (2016 Dec doi: 10.1542/peds.2016-1809) doesn’t address the question of where pediatricians sit in the rogue’s gallery of health care dollar wasters. But it does provide a chilling glimpse at the size of our contribution to the problem.

Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.

I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?

The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.

As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.

But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307[14]:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?

A study published in Pediatrics by Kao-Ping Chua, MD, and associates entitled “Use of Low-Value Pediatric Services Among the Commercially Insured,” (2016 Dec doi: 10.1542/peds.2016-1809) doesn’t address the question of where pediatricians sit in the rogue’s gallery of health care dollar wasters. But it does provide a chilling glimpse at the size of our contribution to the problem.

Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.

I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?

The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.

As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.

But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.

At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.

When it comes to breastfeeding, interpreting the wordless communications of an infant can be very difficult. Crying notoriously lacks specificity. Is it hunger? Sleep deprivation? Pain? Insecurity? As a baby gets older, interpreting his behavior gets a bit easier, and some parents get reasonably skillful at sorting out one kind of cry from another. On the other hand, I fear that too many parents are overly influenced by their own biases, and miss their children’s true messages.

For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.

Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.

When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.

I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.

In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.

At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.

When it comes to breastfeeding, interpreting the wordless communications of an infant can be very difficult. Crying notoriously lacks specificity. Is it hunger? Sleep deprivation? Pain? Insecurity? As a baby gets older, interpreting his behavior gets a bit easier, and some parents get reasonably skillful at sorting out one kind of cry from another. On the other hand, I fear that too many parents are overly influenced by their own biases, and miss their children’s true messages.

For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.

Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.

When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.

I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.

In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

With a moistened index finger pointing skyward, I always have tried to remain alert to where the winds of change are blowing. But every now and then I miss a trend in child care, and that is the case with something known as “baby-led weaning.” Influenced by the questionable notion that there is a “natural” way of doing almost everything, the concept hinges on the belief that an infant will “tell” his mother when it is time to stop nursing and begin solids, aka complementary feeding.

At face value, the concept of allowing the baby to lead is a good one simply because of universality of biologic variation. Just as with the question of how much sleep a baby needs, I don’t think anyone (let alone clinicians) can give with assurance an answer that can easily be applied to all infants. There are just too many variables.

When it comes to breastfeeding, interpreting the wordless communications of an infant can be very difficult. Crying notoriously lacks specificity. Is it hunger? Sleep deprivation? Pain? Insecurity? As a baby gets older, interpreting his behavior gets a bit easier, and some parents get reasonably skillful at sorting out one kind of cry from another. On the other hand, I fear that too many parents are overly influenced by their own biases, and miss their children’s true messages.

For most dyads, breastfeeding is more than just passing calories from one individual to another. Nursing can offer a sense of security and calming both for infants and their mothers. In many cases, the breast unfortunately has become a critical ingredient in the infant’s ritual for falling to sleep. For some mothers, success at breastfeeding becomes an important validation of her feelings of confidence and self-worth that in the past may have been battered by a male-dominated environment. If breastfeeding has been an unpleasant experience, a mother may be more likely to interpret her infant’s behavior as a message that it is time to wean. The bottom line is that a mother’s perception of her baby’s messages about weaning often reflects her own feelings about nursing.

Of course, we clinicians can influence a mother’s perception of her baby’s messages by introducing our own biases about what we believe is the safest, most nutritionally sound way to introduce complementary feeding. And let’s be honest and acknowledge that those are biases mostly unsupported by good scientific study. In many cases, they are more of a reflection of the cultures in which we have grown up.

When asked by parents how they will know when their infant is ready for complementary feeding, I suggest that it’s time when the infant is not only curious about what the adults around him are eating, but obviously is upset that he isn’t being offered a taste. I add that exactly what that food should be is a matter of debate and common sense.

I also encourage parents to allow the child to do as much self-feeding as possible and not worry about the mess. An old shower curtain floor and plenty of sponges and paper towels are a must.

In most cases, I think we can trust babies to take the lead in weaning. But I also believe that as clinicians we must remain alert to the few situations when extended nursing is not in the best interest for the baby who is not growing well or for the mother for whom the nursing is taking an unreasonable toll on her physical and mental health.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.

Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.

In general, parents accept the reality that they can’t be home 24/7/365, but most of them wonder if certain times of the day are more critical to their young child’s emotional health and development. Their instincts tell them that meal times and bedtimes are probably events that should be given the highest priority if they have some flexibility in their schedules.

Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).

Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.

I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.

The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.

Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.

In general, parents accept the reality that they can’t be home 24/7/365, but most of them wonder if certain times of the day are more critical to their young child’s emotional health and development. Their instincts tell them that meal times and bedtimes are probably events that should be given the highest priority if they have some flexibility in their schedules.

Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).

Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.

I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.

The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

A few years ago I audited a college course on leadership taught by Angus King (I-ME), former governor and now independent Senator from Maine. He emphasized that an important characteristic of effective leaders is that they show up for work. They are there, present, on the scene. Attempting to lead in absentia is seldom successful. Knowledge gathered firsthand can be critical when it’s decision-making time. And the connectedness fostered by the leader’s physical presence can bolster morale in a crisis.

Being a parent is more complex than simply being a leader, but showing up is just as important to being a good parent as it is to being an effective leader. Most parents already believe that “being there” is important, and feel guilty when they have obligations that prevent them from maintaining a perfect attendance record.

In general, parents accept the reality that they can’t be home 24/7/365, but most of them wonder if certain times of the day are more critical to their young child’s emotional health and development. Their instincts tell them that meal times and bedtimes are probably events that should be given the highest priority if they have some flexibility in their schedules.

Common sense also may suggest to parents that their presence is less important as their children get older. Certainly, the behavior of most teenagers would suggest that adolescents couldn’t care less whether their parents were at home or vacationing in the Bahamas. However, this is one of those situations where appearances may be deceiving. The author of an opinion piece in the New York Times presents some compelling evidence that in fact, adolescents place a higher value on their parents’ presence than the common stereotype of teenage behavior would suggest (”What Do Teenagers Want? Potted Plants Parents,” By Lisa Damour, Dec. 14, 2016).

Citing her own experience as a psychologist in private practice in Ohio and several recent studies from the psychology literature, the author observes that “sheer proximity confers a benefit [to the adolescent’s psychological health] over and above feeling of closeness or connectedness between parent and child.” At present there is no explanation for this benefit of just being there for your teenage child. But it may be that a parental presence, even if it is silent, provides a stable base and comfort zone that the adolescent can return to as he or she tests the ability to function independently in the world outside of the family.

I suspect that most of you have observed this counter-intuitive phenomenon in which teenagers who give every outward appearance of wanting nothing to do with their parents actually would like to have at least one parent be at home. They just don’t want to be hovered over. Ninety-nine percent of the time the parent will receive no positive feedback for just being there like a “potted plant” to use Ms. Damour’s analogy.

The problem is how to get this message to parents early enough in their parenting trajectory that they can adjust work schedules and priorities to be home with their adolescents. It was not unusual for new parents to ask for my thoughts as they were considering various day care and work schedule options for their infants. If I thought they were really going to take my advice seriously I would add, “You know you should also be thinking ahead when she is a teen. She won’t ask, but she probably would like it if you were home in the afternoon when she gets home from school.”
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.

Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.

As a result of these unpleasant side effects or in many cases simply because they didn’t feel the need to take the prescribed medication, most of my friends have accumulated a significant stash of unused opioids. With a quick calculation on a cocktail napkin, I once calculated that a dozen of my friends could keep the addicted population of a small town happy for a week or two with the painkillers they have in their medicine cabinets and sock drawers.

These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.

It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.

In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.

The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.

So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.

The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.

The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

 

When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.

Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.

As a result of these unpleasant side effects or in many cases simply because they didn’t feel the need to take the prescribed medication, most of my friends have accumulated a significant stash of unused opioids. With a quick calculation on a cocktail napkin, I once calculated that a dozen of my friends could keep the addicted population of a small town happy for a week or two with the painkillers they have in their medicine cabinets and sock drawers.

These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.

It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.

In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.

The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.

So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.

The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.

The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

 

When your peer group is dominated by folks in their early 70s, conversations at dinner parties and lobster bakes invariably morph into storytelling competitions between the survivors of recent hospitalizations and medical procedures. I try to redirect this tedious and repetitive chatter with a topic from my standard collection of conversation re-starters that includes “How about those Red Sox?” and “How’s your granddaughter’s soccer season going?” But sadly I am not always successful.

Often embedded in these tales of medical misadventure are stories of unfortunate experiences with pain medications. Sometimes the story includes a description of how prescribed pain medication created symptoms that were far worse than the pain it was intended to treat. Vomiting, constipation, and “feeling goofy” are high on the list of complaints.

As a result of these unpleasant side effects or in many cases simply because they didn’t feel the need to take the prescribed medication, most of my friends have accumulated a significant stash of unused opioids. With a quick calculation on a cocktail napkin, I once calculated that a dozen of my friends could keep the addicted population of a small town happy for a week or two with the painkillers they have in their medicine cabinets and sock drawers.

These caches of unused opioids, many of which were never needed in the first place, are evidence of why our health care has become so expensive, and also represent the seeds from which the addiction epidemic has grown. Ironically, they also are collateral damage from an unsuccessful and sometimes misguided war on pain.

It isn’t clear exactly when or where the war on pain began, but I’m sure those who fired the first shots were understandably concerned that many patients with incurable and terminal conditions were suffering needlessly because their pain was being under-treated. Coincidently came the realization that the sooner we could get postoperative patients on their feet and taking deep breaths, the fewer complications we would see. And the more adequately we treated their pain, the sooner we could get those patients moving and breathing optimally.

In a good faith effort to be more “scientific” about pain management, patients were asked to rate their pain and smiley face charts appeared. Unfortunately, somewhere along the line came the mantra that not only should no patient’s pain go unmeasured, but no patient’s pain should go unmedicated.

The federal government entered the war when the Centers for Medicare & Medicaid Services issued the directive that hospitals ask patients who were being discharged if their pain had been well controlled and how often did the hospital staff do what they could to ease their pain? The answers to these questions, along with others, was collected and used in assessing a hospital’s quality of care and determining its level of reimbursement.

So far, there is insufficient data to determine how frequently this directive on pain management induced hospitals to over-prescribe medication, but it certainly hasn’t been associated with a decline in opioid abuse. It is reasonable to suspect that this salvo by the government has resulted in some collateral damage as it encouraged a steady flow of unused and unnecessary prescription narcotics out of the hospital and on to the streets.

The good news is that there has been enough concern voiced about the unintended effect of these pain management questions that the CMS has decided to eliminate financial pressure clinicians might feel to over-prescribe medications by withdrawing the questions from the patient discharge questionnaire.

The bad news is that we continue to fight the war on pain with a limited arsenal. As long as clinicians simply believe that no pain should go unmedicated, they will continue to miss opportunities to use other modalities such as counseling, physical therapy, and education that can be effective without the risk of collateral damage. Instead of asking the patient (who may not know the answer), we should be asking ourselves if we have been doing everything we could to help the patient deal with his pain. The answer is often not written on prescription pads.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

 

No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.

It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.

I have a less than modest proposal, based to some extent on the last several years that I practiced office pediatrics. How about we put ourselves on a screen diet? Don’t you think that you could see most of the patients without referring to a computer in the examining room?

It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.

Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.

At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.

I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.

If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .

 

No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.

It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.

I have a less than modest proposal, based to some extent on the last several years that I practiced office pediatrics. How about we put ourselves on a screen diet? Don’t you think that you could see most of the patients without referring to a computer in the examining room?

It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.

Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.

At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.

I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.

If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .

 

No, this isn’t a test, this is an admonishment. For years, I have been using these letters to vent my frustration with the federal government and practice administrators who have foisted several generations of user-unfriendly electronic health records on us. Maybe it’s time to accept the ugly fact that, for the near future, clunky and time-gobbling EHRs are the reality, and we need to think of strategies to make the best of a bad situation.

It’s not only physicians who are complaining about EHRs. Listen to your friends and relatives at cookouts and in the line at the grocery story. You’ve heard what they are saying about us. “He always has his eyes on the computer screen. Never looks at me, and I’m not sure he’s listening.” “She asks me the same questions the nurse and that other woman already asked me. Hasn’t she already looked at my chart?” If you haven’t heard those complaints, make an appointment to see a doctor and experience the distortion of the doctor-patient interaction that the computer has created.

I have a less than modest proposal, based to some extent on the last several years that I practiced office pediatrics. How about we put ourselves on a screen diet? Don’t you think that you could see most of the patients without referring to a computer in the examining room?

It might take some reordering of how you do things. Take a look at the patient’s chart before you go in to see the patient. Many of you may do this already. It’s the courteous thing to do. In the few cases you don’t think you can trust your memory on the trip between your office computer and the exam room, scribble a few notes on a scrap of paper.

Ask the patient to repeat his chief complaint; it may have a completely different ring to it than the one the nurse/receptionist entered in the computer. Apologize to the patient for asking the history again. Or even better, why not be the first and only person to take the history? Scribble a few more notes and a few more after the physical exam if necessary.

At the end of the visit, return to your office to order any lab work and prescriptions the visit required. Take a few minutes to look at the next patient’s medical record and then repeat, repeat. I have found that, in a general pediatric practice, when I was busy, I could batch three, rarely four, patients together before returning to my desk for a more lengthy sit down to finalize the charts, sometimes using my few scribbled notes to jog my memory.

I am confident that most of you are capable of the same mental gymnastics. You’ve passed the MCAT, graduated from medical school, passed the state board, and probably your specialty boards. You should be the master of retention. If a skilled wait person at a good restaurant can keep four patrons’ orders in his/her head, you should be able to retain the basic clinical information on a couple of patients with the help of a pencil and paper. The reward for your mental effort will be dramatically improved doctor-patient interaction. The patients will be impressed that you are looking at and listening to them, and not a computer screen. You will get more and better information from them, and this will make for more accurate diagnoses and better targeted therapies.

If you can’t imagine this working because your office system demands that a diagnosis and billing code be entered before that patient checks out, it may be time to demand a scribe.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected] .

By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.

Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.

However, when I step away from who I am, I can accept the reality that most young people are not as risk averse as my wife and I are. I also realize that not everyone who takes the risk and tries cocaine or heroin becomes addicted. I have always wondered if there was some personality profile that could identify those at risk, especially when they were young enough to be rescued by an intervention.

A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.

The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.

With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.

While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.

Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.

Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.

However, when I step away from who I am, I can accept the reality that most young people are not as risk averse as my wife and I are. I also realize that not everyone who takes the risk and tries cocaine or heroin becomes addicted. I have always wondered if there was some personality profile that could identify those at risk, especially when they were young enough to be rescued by an intervention.

A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.

The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.

With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.

While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.

Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

By nature, my wife and I are risk-averse people. Our investment strategy is just a few baby steps short of hiding our money under the mattress. We have never tried marijuana, though to some extent this is because we were out of college and already married when its popularity surged across this country’s campuses. We do drink alcohol, which was so ubiquitous when we were teenagers that it seemed innocuous.

Given my personality, you can understand why I have trouble understanding why anyone would ever try heroin or any opiate. I realize that many of the young addicts don’t follow the news closely enough to realize the risks. But the epidemic of addiction is so entrenched here in rural Maine that they must have known someone who has died of an overdose.

However, when I step away from who I am, I can accept the reality that most young people are not as risk averse as my wife and I are. I also realize that not everyone who takes the risk and tries cocaine or heroin becomes addicted. I have always wondered if there was some personality profile that could identify those at risk, especially when they were young enough to be rescued by an intervention.

A recent op-ed piece in the New York Times describes a program that attempts to do just that (“The 4 Traits That Put Kids at Risk for Addiction,” by Maia Szalavitz, Sept. 29, 2016). The program is called Preventure and is the result of some work by Patricia Conrod, a psychiatry professor at the University of Montreal. It has been tried in Britain, Canada, Australia, and the Netherlands with some success in reducing binge drinking. In other studies, it reduced symptoms of depression, panic attacks, and impulsive behavior.

The program begins with testing middle school students and focuses on the traits of hopelessness, sensation-seeking, impulsiveness, and anxiety sensitivity. Hopeless is not a surprising choice given that many of the areas of this country with highest rates of opiate addiction are economically depressed. And it is easy to see why impulsivity and sensation-seeking are related to addiction potential. Anxiety-sensitivity is a less intuitive choice.

With the results of this testing in hand, the program administrators wait several months before approaching the outliers. The next step offers two 90-minute workshops to the entire school with the stated goal of showing how the students can channel their personalities toward success. Although the workshops are advertised as being open to everyone but limited in number of attendees, only the students identified as being at the highest risk are actually selected. It is hoped that this deception will avoid having the participants feel that they have been labeled. However, if a student asks about the selection process, he is given an honest answer. The workshops are targeted to the students’ specific emotional and behavioral vulnerabilities, and teaches cognitive behavioral techniques on how they can be managed.

While I think the deceptive selection process is a clever to wrinkle to avoid labeling, I wonder how long the ruse will survive should the program become more universally adopted. With increased popularity and publicity, every parent and most of the children in a school will realize why the test is being administered and what being selected for the workshop means. There is the threat that being identified as at risk for addiction will become a self-fulfilling prophecy and a trigger for depression.

Preventure sounds like a program worth watching. If larger series and long-term outcomes continue to be favorable, it will remain to be seen whether labeling is a hazard worth worrying about.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

The American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.

Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).

In another frequently referenced paper from England, Blair et al. suggest that “further research is required to investigate whether room sharing is protective in itself or merely a matter of hidden confounders not measured in this study” (BMJ. 1999 Dec 4; 319[7223]:1457-62). While it may be that room sharing has some positive effect, do we have any sense of its magnitude? And, is that effect large enough to make the recommendation that infants share a bedroom with their parents for the first 6 months?

For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?

Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.

For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.

As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).

I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.

On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

The American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.

Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).

In another frequently referenced paper from England, Blair et al. suggest that “further research is required to investigate whether room sharing is protective in itself or merely a matter of hidden confounders not measured in this study” (BMJ. 1999 Dec 4; 319[7223]:1457-62). While it may be that room sharing has some positive effect, do we have any sense of its magnitude? And, is that effect large enough to make the recommendation that infants share a bedroom with their parents for the first 6 months?

For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?

Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.

For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.

As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).

I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.

On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

The American Academy of Pediatrics has recently released a new policy for parents on safe sleep practices that in addition to the previous warnings about bed sharing and positioning includes the recommendation that an infant sleep in the same room as her parent for at least the first 6 months (Pediatrics. 2016 Oct;138[5]:e20162938). Apparently what prompted this new set of recommendations is the observation that deaths from sudden unexpected infant deaths (SUIDS) and sudden infant deaths (SIDS) has plateaued since the dramatic decline we witnessed in the 1990s following the Back-to-Sleep campaign.

Although the policy statement refers to “new research” that has become available since the last policy statement was released in 2011, I have had trouble finding convincing evidence in the references I reviewed to support the room sharing recommendation. In some studies, room sharing was the cultural norm, making it difficult to establish a control group. In one of the most frequently cited papers from New Zealand, the authors could not sort out the effects of prone sleeping and sleeping alone, and wonder whether both factors may be affecting risk “through a common mechanism” (Lancet. 1996 Jan 6;347[8993]:7-12).

In another frequently referenced paper from England, Blair et al. suggest that “further research is required to investigate whether room sharing is protective in itself or merely a matter of hidden confounders not measured in this study” (BMJ. 1999 Dec 4; 319[7223]:1457-62). While it may be that room sharing has some positive effect, do we have any sense of its magnitude? And, is that effect large enough to make the recommendation that infants share a bedroom with their parents for the first 6 months?

For some, parents attempting to follow this recommendation may not be without its negative consequences. Sleeping like a baby is not the same as sleeping quietly. Infants often breathe in a pattern that includes long, anxiety-provoking pauses. The implication of this policy recommendation is that parents can prevent crib death by being more vigilant at night. Do we have enough evidence that this is indeed the case?

Most parents are already anxious, and none of them are getting enough sleep. I can envision that trying to follow this recommendation could aggravate both conditions for some parents. Sleep-deprived parents often are not as capable parents as they could be. And they certainly aren’t as happy as they could be. Postpartum depression compounded by sleep deprivation continues to be an underreported and inadequately managed condition that can have negative effects for the health of the child.

For some parents, room sharing is something they gravitate toward naturally, and it can help them deal with the anxiety of new parenthood. They may sleep better with their infant close by. But for others, the better solution to their own sleep deprivation lies in sleep training, a strategy that is very difficult, if not impossible, for parents who are sharing their bedroom with their infant.

As the authors of one of the most frequently quoted papers that supports room sharing have written, “the traditional habit of labeling one sleep arrangement as being superior to another without awareness of the family context is not only wrong but potentially harmful” (Paediatric Resp Review. 2005, Jun;6[2]:134-52).

I think the academy has gone too far or at least moved prematurely with its room sharing recommendation. For some families, room sharing is a better arrangement, for others it is not. It may well be that the plateau in crib deaths is telling us that we have reached the limits of our abilities to effect any further decline with our recommendations about sleep environments. But more research needs to be done.

On a more positive note, the new recommendation may force parents to reevaluate their habit of having a television in their bedroom. Will it be baby or TV in the bedroom? Unfortunately, I fear too many will opt to have both.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

What are your options? You can reexamine the infant and hope that her tympanic membranes that looked so normal 20 minutes ago have now become red, opaque, and bulging. Or maybe you will hear a few crackles in her chest that you didn’t hear on first listen. Any hint of a diagnosis other than a urinary tract infection could make the results of a urine sample moot.

But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.

If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.

But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.

The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.

You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.

It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

What are your options? You can reexamine the infant and hope that her tympanic membranes that looked so normal 20 minutes ago have now become red, opaque, and bulging. Or maybe you will hear a few crackles in her chest that you didn’t hear on first listen. Any hint of a diagnosis other than a urinary tract infection could make the results of a urine sample moot.

But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.

If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.

But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.

The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.

You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.

It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Is it more difficult to get blood from a stone or urine from a 3-month-old infant with a fever for which there is no apparent cause? Silly question? Not if you’re a pediatrician, and it’s 4:30 on a Friday afternoon before a 3-day holiday weekend.

You would probably prefer your chances with the stone. You have been there before. You have been peed on more than once by a 3-month-old baby you were examining. But you know from experience that when you really need just a milliliter or two of urine from a sick infant to rule out a diagnosis, those few drops of golden liquid will be hard to come by.

What are your options? You can reexamine the infant and hope that her tympanic membranes that looked so normal 20 minutes ago have now become red, opaque, and bulging. Or maybe you will hear a few crackles in her chest that you didn’t hear on first listen. Any hint of a diagnosis other than a urinary tract infection could make the results of a urine sample moot.

But of course the child’s exam hasn’t changed, and you can’t convince yourself that your training can be ignored. You must have that urine. Can you bring yourself to launch an invasive attack on the child with a catheter? Despite your reassurances and explanations and your confidence with the technique, catheterization isn’t easy with the child’s parents watching. You wonder again, “Do I really need that urine?” You have done one or two needle bladder aspirations during your training years ago, but that prospect has even less appeal than the catheterization. Of course, there is always the urine bag and its significant risk of providing you with a contaminated sample or leaking even if it has been properly applied.

If only the patient were old enough to follow directions and give you a clean catch midstream sample. But you have chosen to be a pediatrician, and with that comes the reality that most of your sick young patients with unexplained fevers aren’t going to be able to comply by producing a urine sample. Sometimes you get lucky, and as the child is being prepped for catheterization or application of the collecting bag, she will surprise you by squirting out a small arc of urine that can be caught in midair – that is, if you or your assistant is prepared with an open sterile (or even just clean) cup and quick hands. After several missed opportunities over the first several years in practice, I have tried to remember to always have my assistants ready with an open container. And remind them to keep their eyes on the exposed perineum of any infant from whom we might need a clean urine sample.

But there is another option, and you can find it in this September’s Pediatrics (Evaluation of a New Strategy for Clean-Catch Urine in Infants, Labrosse et al. 2016 Sept;138[3]). The Canadian investigators describe a technique in which the infant is stimulated to void. After giving the child 20 minutes to drink and gently cleaning the perineum, the child is held vertically, the girls with their hips flexed. The physician or nurse then taps the suprapubic area at a rate of 100 taps per minute for 30 seconds and then gently massages the lumbar paravertebral area for 30 seconds. The two stimulation maneuvers are then alternated until the child voids. The investigators recommend stopping if no urine is obtained in 300 seconds, or 5 minutes.

The results are very encouraging with a success rate of 49% on a series of 126 infants. The investigators report a contamination rate of 16% that is not statistically different from collections using an invasive technique. Median time to success was 45 seconds.

You can look at the photos for yourself, but it looks like you would need at least one assistant in addition to a parent who is holding the child. I suspect that it also helps to have quick hands once the voiding starts.

It certainly sounds like a technique worth trying. The authors claim that when used as the first attempt at collection, the number of catheterizations could be cut by a third. I suspect that just like with any technique, some folks on your staff will emerge as the ones with the magic hands and might have a success rate well above that reported in this article. Groom and treasure those in-house experts at collecting those little yellow drops. They are worth their weight in gold.
 

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].