CHAIRMAN’S NEWSLETTER
FEBRUARY 2011
Some Things Do Remain the Same (sort of – for now)
In the lead article in the New England Journal of Medicine on January 13th, Jack Paradise and his colleagues at the Children’s Hospital of Pittsburgh reported on the treatment of acute otitis media (AOM) in children under two. In the article, he demonstrated that among children between 6-23 months of age with AOM, those treated with amoxicillin/clavulinic acid (Augmentin®) had better short term outcomes than those treated with placebo. While at first blush this may seem like the obvious outcome, research in the past decade on otitis media has shown that a strategy of watchful waiting in AOM shows high rates of spontaneous improvement.
Current guidelines on the treatment of acute otitis media vary. The most recent American Academy of Pediatrics policy statement (2004) reviews the concerns about the need to be more judicious with the use of antibiotics in AOM. The statement reviews the data that most children (75%) will improve by day seven without antibiotics and that seven to 20 children need to be treated for one child to derive benefit. Despite the concern about the overuse of antibiotics and the resultant emergence of resistant bacteria, the policy waffles and states that observation without antibiotics is an option rather than a recommendation, and that if the decision is to treat, then amoxicillin at 80-90 mg/kg/day is the drug of choice. Other guidelines (such as Cincinnati Children’s Hospital) are more concerned about the emergence of killer bacteria and recommend withholding antibiotics in otherwise healthy children older than two years of age with uncomplicated AOM as a first-line strategy.
The term “safety net antibiotic prescription (SNAP)” was coined in 2004 and provides a good label for the strategy of waiting on initiating antibiotics for 24-48 hours after pneumatic otoscopic diagnosis of AOM. This is the strategy that I have employed periodically over the past seven years.
When I first read the article by Paradise, I was guiltily relieved that I could go ahead and treat the infants and toddlers with antibiotics, as I had in the past, without the need for an accompanying symposium to the parents on the relationship of widespread use of antibiotics and the development of resistant bacteria. I could just write the prescription and vamoose. But then I realized that while the NEJM study showed a statistically significant improvement between the antibiotic group and the placebo group, the placebo group, as in other studies, did quite well without antibiotics. On Day 7, 80% of the treated children had resolution of symptoms but fully 74% of placebo patients also had resolution of symptoms.
So we are still left with the question, is it worth treating so many children unnecessarily in order to treat the uncommon child who will not improve without antibiotics? We can still treat with safety-net antibiotics if there is no improvement after 24-48 hours. I will probably waffle myself and treat the infants bolstered by this study, but the symposia on overuse of antibiotics must go on.
Computerized Provider Order Entry (CPOE)
Computerized Provider Order Entry will go live in Pediatrics on April 26th. Training sessions are available on April 12, 13 and 14. For those pediatricians who admit and follow their own pediatric patients, CPOE training is required. Please contact Melissa Sparrow if you would like more information or if you would like to sign up for a training session send to msparrow@gbmc.org.
Timothy F. Doran, M.D.Chairman, Department of Pediatrics
CHAIRMAN’S NEWSLETTER
JANUARY 2011
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Crib Deaths in 2011
A couple came to my office two weeks ago to cancel their first-born son’s two-month appointment. When they were asked about the reason for the cancellation, the mother replied that that a week ago, the baby had died. Unfortunately, neither the hospital nor the coroner’s office had called me. In subsequent discussions with the parents, I learned that they had found their baby face down in his crib, despite his having been put in the crib in a supine position by his mother. Both parents described their baby as preternaturally advanced in his gross motor skills, and this was, apparently, the first time that he had rolled over in his crib. The coroner’s office found no gross abnormalities. This tragic event prompted me to review the literature on Sudden Unexpected Infant Death (SUID). While this baby most likely died of Sudden Infant Death Syndrome (SIDS), SIDS can only be diagnosed after a complete autopsy, a death scene investigation, and a review of the clinical history. In the U.S., there are approximately 4500 unexpected infant deaths a year; half of these are due to SIDS. Examples of unexpected deaths in infants that are not SIDS include deaths due to child abuse, from accidental suffocation or overheating, and deaths due to metabolic or genetic disorders. A fatal arrhythmia from prolonged QT Syndrome would be an example of a SUID that is not a case of SIDS.
The rate of SIDS is now about 1 in 2000, a 50% reduction since the efforts to encourage back-sleeping began. There are well recognized strategies to reduce the risk of SIDS - well known to most of you - but here is a quick review:
1. Back sleeping2. Use of a firm mattress3. No soft materials (quilts, pillows, etc.) in crib4. Avoiding overheating5. Infants sleeping in their own crib or a bassinette in the mother’s bedroom6. Avoiding devices to keep baby in a supine position7. No smoking in the home8. Use of pacifier (see below)
SIDS peaks at 2-3 months of age and over the last ten years has shifted to younger ages. It is rare after six months of age, less common in Asian-Americans, and more common in prematures, boy babies, and babies from poorer homes. The risk of SIDS from co-sleeping is controversial, but the incidence of SIDS is clearly higher when bed-sharing involves maternal alcohol use, the presence of other children in the bed, or co-sleeping on soft surfaces such as a couch. On the other hand, there are benefits to co-sleeping, including increased breastfeeding rates, improved bonding, and fewer sleep problems. Recent studies show a protective effect of sharing a bedroom if not a bed, so reasonable advice is to have the mother keep the bassinet next to her bed so she can breastfeed readily but then put the baby back in a bassinet .
There are also recent data to suggest that the brains of babies who die of SIDS are different from those of control babies in that they produce lower than normal levels of serotonin, a critical messenger in autonomic regulation. This finding supports the “triple-risk” model of SIDS causation, which postulates that there is an underlying vulnerability in the baby that is triggered by an external event at a biologically critical time.
A couple of final notes: home monitors do not prevent SIDS. Studies over the past ten years have failed to show a relationship between SIDS and apnea. There is no proven benefit to cardio-respiratory monitoring of babies with ALTEs. Contraptions to keep babies on their backs are also unproven. Discourage their use.
Finally, let’s hear it for the “binky.” Pacifier use was found to decrease the incidence of SIDS in a meta-analysis of seven studies. So once breastfeeding is well established, offering a pacifier during sleep may be a prudent strategy.Let us hope we continue to learn more about preventing SIDS. While we have made great progress in reducing the number of babies who have died from SIDS, we still have miles to go before we can sleep.
Timothy F. Doran, M.D.
A couple came to my office two weeks ago to cancel their first-born son’s two-month appointment. When they were asked about the reason for the cancellation, the mother replied that that a week ago, the baby had died. Unfortunately, neither the hospital nor the coroner’s office had called me. In subsequent discussions with the parents, I learned that they had found their baby face down in his crib, despite his having been put in the crib in a supine position by his mother. Both parents described their baby as preternaturally advanced in his gross motor skills, and this was, apparently, the first time that he had rolled over in his crib. The coroner’s office found no gross abnormalities.
DECEMBER 2010
Season’s Greetings
The Department of Pediatrics extends its best wishes for Happy Holidays and a happy and healthy New Year. May all your dreams come true!
The Department of Pediatrics extends its best wishes for Happy Holidays and a happy and healthy New Year. May all your dreams come true!
Accountable Care Organizations: Déjà vu all over again?
The recently passed Affordable Care Act (ACA) contains many good things for children and pediatricians. The law will cover millions more children, strengthen pediatric primary and secondary care, ban pre-existing conditions as exclusions to obtain insurance, eliminate co-pays for routine health maintenance visits, eliminate annual and lifetime caps on coverage and bring parity to Medicaid and Medicare payments for primary care docs.
One of the other provisions of the ACA is the encouragement of Accountable Care Organizations. These are organizations that can be made up of physicians in group practices or networks of practices, hospitals and their employed physicians, physician networks, or hospital/physician partnerships. These entities must have a formal legal structure, sufficient numbers of assigned beneficiaries (5,000), have a structure that includes clinical and administrative systems, and have a process to assess, promote and coordinate evidence-based medicine. While this sounds like the HMOs of the 80’s or the MCOs of the 90’s, this time around it is the federal government and not private industry driving the attempt to deliver better care at a reduced cost. The specifics are still unclear, and with a change in Congress, things may get murkier. One thing that all agree on, however, is that we cannot sustain the current rate of growth of health care costs.
The good news is that primary care is one of the keys to reducing costs. Studies show that high quality primary care is associated with lower costs, better care and better health. We all know this intuitively when patients leak from our practice and have a non-existent otitis diagnosed at a “convenience” clinic.
GBMC is committed to improving the relationship of the medical staff and the hospital. The new president of GBMC, Dr. John Chessare, understands the need to forge close relationships with the medical staff. The hospital is doing the groundwork to promote collaborative practices between the hospital and physicians. The bulk of the activity will be around adult patients initially, but I will keep you informed of any pediatric activity.
Finally, the Patient Centered Medical Home (PCMH) is not in the future, but now. Carefirst will be reimbursing primary care physicians an additional 12% on all CPT codes beginning January 1. I am available to help answer questions on the PCMH.
Timothy F. Doran, M.D.
Chairman, Department of Pediatrics
