Posts Tagged ‘child’

Asthma News: Parents Underestimate Children’s Symptoms, Placebos Effective in Improving Patient’s Subjective Improvement but Not Objective Health

Monday, July 25th, 2011

image from consumerreports.org

A couple of months ago, one of my colleagues, Jon Stefanuca, wrote a post for Eye Opener entitled Four Tips For Getting the Medical Care You Need When You Are Having An Asthma Problem. In that article, he explained the importance of patients proactively knowing and explaining their asthma symptoms to healthcare providers. He focused on some of the key features of asthma and the unique symptoms that each individual may experience. If you have not already read that article, I highly recommend it as a great way to become a better advocate for yourself or someone in your life that suffers from asthma.

Over the last few months, I have been thinking about Jon’s advice in relation to some work I have been doing. It makes good sense and hopefully will help people receive better care when they are having exacerbations of their asthma. However, I was disheartened to read a recent article from Reuters about how frequently parents underestimate their children’s asthma symptoms.

Parents Underestimate Their Children’s Asthma Symptoms

I am always a little leery of studies that are drugmaker-funded, particularly when the study suggests that perhaps more medications are needed to combat a problem. However, taken at face value, this is a pretty frightening idea given how many children now suffer from asthma and how serious a condition it can be for those children and families. The article points to a disconnect between the parents’ description of their child’s asthma and whether the asthma was actually being adequately treated:

While more than seven out of every 10 parents interviewed described their child’s asthma as “mild” or “intermittent,” the disease was adequately treated in only six in 10 kids.

A doctor who was not involved in the study explained it this way:

“Parents are only aware of asthma when the child is more severely ill,” Dr. Gordon Bloomberg…

“Physicians cannot just ask the parent ‘how is your child doing?’ The physician will get a global answer that doesn’t reflect the child’s quality of life,” said Bloomberg, of Washington University in St. Louis.

Poor treatment may influence asthmatic children’s quality of life, as well as that of their families.

In the survey, more than four in 10 parents reported missing work because of their child’s asthma, and similar numbers of parents regularly lost sleep for the same reason.

Children are Better Reporters Than Their Parents of Symptoms

Interestingly, “[t]he study also found children tended to be better than their parents at determining how well their asthma was being treated.” So, clearly, doctors must take the time to discuss the asthma symptoms and treatments not only with parents but also in a sensitive and appropriate way with the children patients themselves in order to receive a better indication of the disease status. The doctors interviewed for the Reuter’s article had different opinions on what this means for asthma treatment:

According to a new report, this suggests parents need more education about asthma medications.

But one expert said more medication is not the be-all and end-all for children.

“The idea of total control…is not where we should be putting our energy,” Dr. Barbara Yawn from Olmstead Medical Center in Rochester, Minnesota, told Reuters Health in an email.

Instead of just giving children with stubborn breathing problems more medication, she said better communication is needed to determine how children’s lives are affected, and what it will take to prevent their symptoms.

New Study Shows Receiving Treatment, Even with Placebo, Important for Asthma Patients – But Does not Improve Objective Health

image from 123rf.com

In another recent study, reported in the New England Journal of Medicine, researchers looked at how asthma patients responded to a medication (bronchodilator), two different types of placebos (fake inhaler or fake acupuncture), or no intervention at all. An objective measure was taken of the patient’s ability to exhale after each intervention (or lack of intervention) and the patient’s own rating of improvement was noted. What was so interesting about this study were the different outcomes between the objective (spirometry) and subjective (patient’s self-reporting) measurements of improvement.

The bronchodilator provided markedly better objective treatment over the placebos or no treatment – a 20% improvement rather than 7% for the placebos or no treatment. However, the subjective measure of improvement found that patients were almost the same, 45-50% improvement, whether the patients received the actual bronchodilator (50%), the placebo inhaler (45%) or the sham acupuncture (46%).  All of which were higher than the 21% improvement reported by those who did not receive intervention.

An article about the study in medicalnewstoday.com explains the outcome this way:

Now a study of asthma patients examining the impact of two different placebo treatments versus standard medical treatment with an albuterol bronchodilator has reached two important conclusions: while placebos had no effect on lung function (one of the key objective measures that physicians depend on in treating asthma patients) when it came to patient-reported outcomes, placebos were equally as effective as albuterol in helping to relieve patients’ discomfort and their self-described asthma symptoms.

The study’s senior author, Ted Kaptchuk, Director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School explained it this way in the article:

“It’s clear that for the patient, the ritual of treatment can be very powerful…This study suggests that in addition to active therapies for fixing diseases, the idea of receiving care is a critical component of what patients value in health care. In a climate of patient dissatisfaction, this may be an important lesson.”

However, I wonder if it cannot also be understood another way – which is that patients are likely to feel like their symptoms have been improved after a visit to a doctor, even if objectively their airway is still compromised.

How Should this Impact Asthma Treatment?

So what can be done with this new information? I think that Jon’s advice about patient’s knowing their own symptoms and expressing them clearly to their doctors is critical. I also agree completely with his advice that patients should ask for an objective measure of their respiratory improvement before leaving a health care facility. These two steps seem key to making sure that patients objective health is being improved – not just their subjective opinion of improvement. Finally, I think that it is critical that parents act as the best advocates possible for their children – which may include making sure that the children are heard on their own symptoms since parents are not the most reliable reporters.

What do you think? Are there other tips for asthma patients and their parents out there? How do respond to these new studies?

Related Videos:

Videos about Asthma

Related Articles:

Four Tips For Getting the Medical Care You Need When You Are Having An Asthma Problem

Asthma – How to Protect Your Child When the Steroid Inhaler Fails

Use Of Acetaminophen In Pregnancy Associated With Increased Asthma Symptoms In Children

School’s Duty to Parents: Is Your Child at Risk?

Wednesday, May 11th, 2011

Image from tutoringmontana.com

Recently, I have been thinking quite a bit about schools. My son is going to start kindergarten in the fall and my daughter just started preschool last week. While both of my kids are still little, over the years children end up spending many of their waking hours each week at school. The school becomes as much a part of their lives as home for most kids. As parents, we put trust in the school that they will be keeping our children safe and healthy while we are not around to supervise. But do the schools recognize that trust and live up to it?

I was recently made aware of a situation involving a teenager who was having some health concerns. Her parents had first noticed that their daughter seemed to be altering her eating patterns. Since they were not certain if there was a problem forming and what was going on during the school day, they called the school and asked if the school thought that there was any reason to be concerned. This seemed to be a prudent action for any concerned parent. But what, if anything, is the school required to tell the parents? What if the parents had not noticed a problem, but the school knew that something was not right, would they have needed to call it to the parents’ attention?

Legally, it turns out that a school is considered to stand in loco parentis over the children in its care. This fancy legalese just means that the school stands in as substitute parents during the school day.  This is true of both public and private schools. The school holds a duty to protect and supervise students in its care. The courts have determined that this includes taking care to protect children from foreseeable harm, the way a reasonable parent would do if they were there.

So what does this all mean? Some of this is pretty straightforward. A school needs to protect your children from harm they could foresee. A school has to take reasonable precautions to protect children from getting hurt on the playground or from cars driving around the campus – to the same extent that a prudent parent would do so.  For public policy reasons, schools are often a place where the government often takes an even more active role in monitoring children’s health – for example in doing hearing and vision screenings.

But what about other types of harms? Most parents would want to know if their child was being bullied, was showing signs of developing an eating disorder or was considering hurting him or herself. Does a school have a duty to inform parents anytime there might be a chance of one of these harms?

The law does not seem to be settled in on this point.  Generally speaking, the school would need to take reasonable steps to protect a child if the school could foresee that the child was at risk of being harmed by another child in the school.  The law is not explicit about whether that includes informing the parents. When the risk is not of another child hurting your child but of your child hurting him or herself, the law is much less clear. In Maryland, it seems possible that a school might have a duty to warn a parent if they believe a child is suicidal. The school counselor may have a duty to warn the parent as part of a duty to take reasonable means to prevent the child’s suicide. However, the law is not explicit about when that duty arises.

What do you think? Does a school have a duty to inform parents if there is a reasonable chance that a child might be a danger to him or herself? What if your child is engaging in behaviors that might cause harm over time? Is this the role of a school?

4 Tips for Car Seat Safety

Wednesday, March 30th, 2011

Image from www.baby-safety-concerns.com

Most parents now know that car seats are essential for young children riding in cars. In today’s post, I am going to provide some updated information and lesser-known tips that might help keep your kids safer in their car seats. Does all of this matter? I think so. A recent article on healthychildren.org says that deaths in motor vehicle crashes are still the leading cause of death for young children:

While the rate of deaths in motor vehicle crashes in children under age 16 has decreased substantially – dropping 45 percent between 1997 and 2009 – it is still the leading cause of death for children ages 4 and older. Counting children and teens up to age 21, there are more than 5,000 deaths each year. Fatalities are just the tip of the iceberg; for every fatality, roughly 18 children are hospitalized and more than 400 are injured seriously enough to require medical treatment.

So how can you keep your children safer?

1. Keep Children Rear-Facing As Long As Possible

Parents often switch their toddlers into forward facing seats on or around their first birthdays. For many years, the AAP and others have recommended that children remain rear facing until they were at least 1 year old and 22 pounds. Many parents and caregivers thought that this meant that this was the appropriate age and weight to turn children around. I know plenty of parents who were elated to turn their children’s car seats around so that their kids could “see something” or so that their legs would not be cramped. Unfortunately, this is just not safe.

The new AAP recommendations, released last week, are grounded in safety research and the advice that many car seat advocates have emphasized for years. These recommendations call for children to remain rear facing as long as possible – at least until they are two years old and often beyond. A recent New York Times article explains that a 2007 study from the University of Virginia found “…that children under 2 are 75 percent less likely to suffer severe or fatal injuries in a crash if they are facing the rear.” That is a pretty compelling statistic.

I am excited about this new recommendation because I hope that it will encourage parents to consider keeping their children rear facing for much longer. I have kept both of my children rear facing far beyond their first birthdays.  In fact, my two year old is still happily rear facing. We have a car seat that allows rear facing until 45 pounds and my daughter is only about 23 pounds now. I doubt that she will stay rear facing until she is 45 pounds, but she will certainly stay that way for as long as possible.

My decisions were based on both safety and selfish reasons. First, the selfish reason: my first child was a kid who would sometimes fall asleep in the car on long trips. I realized that once we faced him forward his head would hang uncomfortably if he fell asleep and he would be much less likely to rest comfortably then rear facing when he was reclined enough to slumber with full support to his head and neck. Second, the safety reason is that we have relied on the assistance and expertise of Debbi Baer when installing our car seats for several years. Ms. Baer, “a labor and delivery nurse in Baltimore who has been a car safety advocate for children for more than 30 years,” is quoted extensively in the New York Times article (http://www.nytimes.com/2011/03/22/health/policy/22carseat.html), along with her daughter “Dr. Alisa Baer, a pediatrician at Morgan Stanley Children’s Hospital in New York.” Dr. Baer told the Times “she felt so strongly that if a parent wants to install a forward-facing seat for a child younger than 2, “I tell them, ‘If you really want to make a stupid decision for your child, you can do it, but I’m not going to help you.’ ”” Her mother’s attitude seems from our experience to be the same!

2. Don’t Rush Any of the Transitions – Car Seat to Booster to Seatbelt

In the The New York Times article , the AAP policy’s lead author says

“Our recommendations are meant to help parents move away from gospel-held notions that are based on a child’s age,” Dr. Durbin said. “We want them to recognize that with each transition they make, from rear-facing to forward-facing, to booster seats, there is a decline in the safety of their child. That’s why we are urging parents to delay these transitions for as long as possible.”

Therefore the same prudence should apply in making the transition from car seat to booster and ultimately to a regular seat.

The National Highway Traffic Safety Administration has created a nice flyer about the new recommendations.

The advice seems to boil down to a few key elements.

  • Keep kids rear facing as long as allowed by the seat.
  • Forward facing children should be in a 5-point harness as long as the seat allows
  • Only transition to a belt-positioning booster when children have outgrown the car seat with a harness
  • Keep kids in a belt-positioning booster until they are at least 4 feet 9 inches tall and 8-12 years old

3. Skip the Coats – Cover Kids Instead

Winter weather creates another potential danger about which many parents are unaware.  One of the keys to car seat safety is having straps that fit snuggly on the child. If kids are dressed in bulky winter clothing – particularly puffy type coats – those clothes can compress in an accident and leave the straps too loose for kids to be safety secured. To counter this dangerous possibility, most car seat experts recommend that parents always remove winter coats before strapping their children into a car seat. Instead, they recommend placing a coat or a blanket on top of the child after the child is safely and snuggly secured in the car seat. This way, the child stays warm without having any risk of the straps being too loose. If this seems to be a hassle, there is a whole group of both small and commercial companies and individuals out there who make poncho type coats that can be pulled up for the child to be strapped in safely. It is also a good idea to be in the habit of checking the snugness of the straps every time you strap your child.  For more details about winter coats in cars, check out this article.

4. Check the Installation!

All of the suggestions above are critical for safety, but none more so than making sure that your car seat is installed properly in the first place. If the car seat is not installed safely, having the child in the correct seat and having the child buckled properly will not be of nearly as much help. It is a commonly quoted statistic that 70% or more of children are not properly restrained. The good news is that help is available. At seatcheck.org you can find a listing of places near to you where you can get free or low cost assistance in properly installing your car seat. These experts can also check to make sure that the seats you have already installed are installed properly.

You may also want to watch this video from Dr. Alisa Baer, “the Car Seat Lady” -

httpv://www.youtube.com/watch?v=ULJ8Vx79Vv4&feature=player_embedded

Do you have other safety tips for car seats?  If so, share them with the rest of us!