Paediatric Grand Rounds 1:19

Whether we've taken an elegaic turn because it's approaching the end of year, or there is a general zeitgeist, the paediatric blogosphere offers many thoughtful posts. We have sex, drugs, issues of life, death, morality; ethical dilemmas that reflect religious and cultural values as well as the challenges posed by advances in medicine. Because this is PGR, we also have snot, magical thinking and the general weirdness of contact with children.

Machiavelli famously claimed that statecraft involves fortifying the banks against the rivers of misfortune. We're not all the way there, but most of us are fortunate enough to live in societies where we have fortified the banks of paediatric health against the erosive forces of disease, morbidity and mortality. We live in good housing, we have clean water, standards for air quality, good nutrition, safety standards, improvements in medical science and public health measures such as vaccination. Most of us can be confident that children will survive through to adulthood.

Reading Dr. Flea's series of posts on vaccination has been like a tour through recent social history with some remarkable social changes and a recrudescence of familiar objections to vaccinations. You've probably already read through these posts but if you have a blog, please think about putting up a link to them to improve their search engine ratings. I had a nasty shock recently when I was looking up vaccination on Google and the first few pages of results were dominated by anti-vax entries: it is important to address this imbalance in information. The significance of this was brought home with great force by an email that Dr. Flea received from a mother who thanked him for quieting her anxiety about the risks of immunisation that she had developed from her awareness of media sources and her excursions into parts of the internet.

• A Very Great Fright (smallpox vaccination)
• On My Left Shoulder (smallpox vaccination)
• The Can From Hell (polio vaccination)
• Go Home and Die (Haemophilus influenzae type b vaccination)
• Strangling Angel (diphtheria)
• Risus Sardonicus (tetanus vaccination)
• The Cough of One Hundred Days (pertussis or whooping cough vaccination)
• Dew Drops on Rose Petals (chickenpox vaccination)
• Yellow Alert (Hepatitis B virus vaccination)

It is sobering to recall what a comparatively recent privilege it is that children survive through to adulthood. The London Bills of Mortality up to 1830 had documented a significant improvement in death-rates for the under-fives: from 1730-79 66.2 percent of the children died; from 1780-1829 there was a substantial drop to 37.8 percent. Dickens commented on this in the outraged voice of an anxious father in The Uncommercial Traveller:

I learn from the statistical tables that one child in five dies within the first year of its life; and one child in three, within the fifth. That don't look as if we could never improve in these particulars, I think!

Those who did survive childhood endured the helplessness of watching parents, siblings, and their own offspring killed by disease or the aftermath of it. Compilations of statistics can be dry and roundly abused but in the 1851 Census the covering commentary made a desolate cry against the widespread individual loss: "[U]ntimely death is a great evil. What is so bitter as the premature death of a wife, -- a child, -- a father?".

The novels of Dickens, the Bronte Sisters and Mrs Gaskell (amongst others) are full of sickly children or children who succumb to an untimely death. Despite this grim reality, there was opposition to the government introduction of new Public Health measures such as clean water and vaccination. Vaccines were intrinsically linked to civil liberties and accusations of abuse of governmental powers. In 1853 the UK Government imposed an act that made vaccination compulsory. Gibbs countered by setting up an anti-vaccination society of people opposed to the idea of "medical spies forcing their way into the family circle". In 1854 there was a leader in The Times that summed up this attitude with brutal clarity:

The British nation abhors absolute power. We prefer to take our chances with cholera and the rest than be bullied into good health.

Some of the comments on Dr. Flea's posts have been modern echoes of these viewpoints. Anthony Cox of Black Triangle wonders whether his proposal that there should be greater parental awareness of the safety systems used to monitor vaccine safety would reduce concerns about vaccination.

Social changes and collective action have led to startling improvements such that today, even with the comparatively high level of prematurity, and the survival of very ill children, the mortality rate for children is less than 1 in 100 in the UK. Even so, Dr. Sam Blackman of Blog MD still needs to hold The Most Difficult Conversation. Just how do you discuss end of life issues with a young patient and their family? I'm resisting the urge to quote swathes of this powerful writing, apart from:

The ‘C’ word tends to turn off rational thought and turn on the “white noise of emotion” machine at 110 decibels...The ‘C’ word conjures up images of very small coffins.

Dr. Clark Bartram of Unintelligent Design tells us about another difficult conversation that is grounded in dilemmas that have been created by advances in medical technology. Is it at all feasible to expect children to make informed, adult decisions about matters in their future? Is it right or proper to compel a twelve-year old to bank his sperm for future use?

Neonatal Doc has been contemplating his own difficult conversations: Honesty. As with Sam
Blackman, sometimes the emotional white noise makes it very hard for relatives to follow the details.

Kal of Trauma Queen reminds us of another reason why infant mortality rates have been improving: we know how to restore the airways of choking babies (scroll down for this heartstopping account of a call to a one month old).

Pink, wriggly babies are what we look for, pink and floppy is indicative of being well on the way to blue and floppy which is well on the way to, well, you get the idea.

Sometimes, you can be thankful for a biting, crying child. Control Room Despatcher Mark of Nee Naw is grateful for the detailed protocol that helped him to talk a parent through unblocking the airway of a choking toddler for whom neither backslaps nor the Heimlich manoeuvre had worked.

I sometimes feel annoyed with parents who seem to be so caught up in the complexities of their own lives that they ignore their responsibilities to their children and their contribution to their wellbeing. Dr. Signout gives us her account of admitting a one week-old baby whose mother did not know that she was pregnant until she give birth: The Story of Ignorance. The story shouts more than usual chaotic circumstances yet there are surprising and touching actions from the adults concerned. Nonetheless, Signout poses the stark questions:

Is it not possible to be too stupid to raise children? And if the story of ignorance is an invention, what are the odds that it is covering up something more benign?

It may be groundless optimism, but I have to hope for a better outcome than she anticipates.

On a seasonal note, Dream Mom tells us that sometimes, when the diagnosis is unknown, the prescription is Santa. Moreena of The Wait and the Wonder is prompted to seasonal speculation about the nature of unhappy families. However, she also provides a lively insight into how experienced parents distinguish between a change in mental status that might presage a deterioration in health in a severely ill child, and the run-of-the-mill weirdness of children's logic and conversations: happy like little snowflakes. Dr. Jest of Dr. Jest's Caseblog describes his own recent experience of a child's logic when a little boy tries to avoid a physical exam by clamping his hands over his eyes: Interview with the...ostritch.

Despite the holidays, Madeline, the self-styled Whitterer on Autism is only too aware that an autistic child's need for consistency demands that there should be minimal disruption to routines: read her Holiday Survival Guide.

If the parents permit the days to become holidays, either for their own benefit or that of their children, you can pretty quickly find that they regress a few months...

Seven months to acquire two new foods and a blink of an eye to lose them again.

On the topic of autism, Dad of Cameron disputes that there is sound evidence to support the autism epidemic that is much bruited in the media. He links to an interesting presentation: It's Not JUST Better Diagnosis.

After the sturm and drang of some of the above threads, I return to the usual mundanities of a common paediatric problem when I offer a guide to using nasal irrigation to shift your child's mucosal gunk. Dr. Alex reminds us of the rather charmingly-named slapped cheeks disease and discusses the persistent issue of intoe-ing.

Dr. Bryan Vartabedian of Parenting Solved gives us a surprising modern twist to the traditional problem of young children swallowing anything that they can get their hands on. We learn why small magnets pose new risks for toddlers.

On the theme of oddities, Awesome Mom describes Strange Things. We learn how odd it can be to adjust to a child who has the full working use of two arms where his elder sibling has one:

I still dress Harry like I am compensating for a gimpy left hand. I just can't break the habit.

In Fogel’s The Escape from Hunger and Premature Death, 1700-2100, he argues that until comparatively recently, most people were battling a series of infections almost all the time, and that people (particularly children) expended a substantial amount of their calorie intake on fighting infection. It is a relatively recent development that we are so secure in our access to adequate calories that we can now concern ourselves with details of our diet. We are bombarded with advice about how we should feed children. Sandy Szwarc of Junk Food Science gives us a fine discussion of the paucity of evidence behind the claims that we should reduce children's intake of salt. She tells us that a meta-analysis that was much-hyped in the media "offered no clinically meaningful evidence, only speculations". She rightly questions how the researchers can acknowledge that the "physiological need for salt intake in children has not been studied,” yet still conclude that

current salt intake in children is unnecessarily high and is very likely to predispose children to develop hypertension later.

Scalpel or Sword tells us something about the changing nature of paediatrics that it is not unusual for a trip to the ER to be more about emergency parenting assistance rather than a health emergency. Neonatal Doc relates the story of a very young mother who was Waiting and seemed in need of parenting assistance for herself, as well as her children.

I wish I knew what to do with people like her. Spending all day in a hospital waiting room with a three day old baby and a toddler? That's almost mind boggling.

Leaving aside the issue of inadequate parenting, as the historical threats to children's health diminish for most of us, what are the new frontiers in paediatric medicine? Dr. Sam Blackman wonders whether it is a modern phenomenon that when parents learn of a diagnosis they almost always ask,

“Was there something in my genes that caused this? Is it hereditary?”. ...[I]t is fascinating to ponder the reasons why people ask this question, and whether or not they would have asked it 25, 50 or 100 years ago.

Darwin's daughter Annie, died when she was 10 years old. Influenced by Lamarckism, and his own theories, Darwin tormented himself with thoughts that he had contributed to Annie's death by passing on the sickly characteristics that he'd acquired during his lifetime. Darwin also contemplated what it meant for there to be a divine influence; Annie's death caused him to ask hard questions about his faith. Ultimately, he lost his Christian faith and died a self-described Agnostic.

Abel Pharmboy of Terra Sigillata discusses the clash between medicine and religion when parents' religious or cultural beliefs lead them to reject paediatric healthcare treatment. Do parents have the right to martyr their children to their own beliefs? Abel wants input on this question from those who care for children and paediatric patients.

Parental guilt, concern and adequacy seem to be common threads in children's health throughout history but as some of the above links highlight, so is the delight of caring for children and watching them develop.

Thank you for joining us on Paediatric Grand Rounds. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

The next Paediatric Grand Rounds is scheduled for January 13, 2007 and your host is Dr. Bryan Vartabedian of Parenting Solved. Email your contributions to him at fox42 AT mac dot com

I'd like to thank all of the contributors who have so generously shared their posts with me. I look forward to seeing you in future editions of Paediatric Grand Rounds.

The illustration reflects the idea that the scale of something is no indication of its sophistication or complexity: like much of paediatric care. Credits for the photos are as follows or courtesy of the Family Bartram. 1. abby, 2. armonk, 3. red dot, 4. Hermit Crab, 5. drops of yellow petals, 6. Caught me hiding, 7. P, 8. snake hand (20040329), 9. G, 10. Tiny frog, 11. Magical Colours, 12. Tiny Frog, 13. R

Created with fd's Flickr Toys Mosaic tool.