Induced Labor, Preschool Injuries, Dog Allergy – PediaCast 112

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Topics

• Induced Labor
• Preschool Injuries
• Dog Allergy
• Introduction Of Whole Milk
• Nurse Practitioners

Links

• MythBusters
• Avoiding Induced Labor Is More Beneficial To Moms And Babies
• Labor Begins On Its Own
• Tips For Avoiding Induced Labor
• Lamaze International
• More Injuries Sustained By Preschool Children Who Have Insufficient Sleep
• PediaScribe: Saturday Photo Hunt — Wooden

Transcription

Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every child, for every reason.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from Birdhouse Studios, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome to PediaCast, a pediatric podcast for parents. This is Dr. Mike coming to you from Birdhouse Studio. And as always, I'd like to welcome everyone to the program. Today, we're going to talk about induced labor. See, we're carrying on with the pregnancy theme here, I realized and I promise to drop it soon.

0:01:04

But this was another thing that was in the news recently that I just had to tackle. And you know, labor involves babies. And this is a pediatric podcast so I think I'm still in the clear. We're also going to talk about dog allergies and nurse practitioners. I'm going to try not to get myself into trouble today. But you know how that usually works out.

Before we get started, I do have to mention a show that is on the Discovery Channel because I bring this up several times in the course of today's show. And so those of you who have no idea what Myth Busters is, I wanted to give you a little primer here.  

As I said, it's on the Discovery Channel. You'll find new episodes; I believe it's Wednesdays at 9:00 PM. Although I'll be honest, I don't usually watch it then. We have a DVR and we have a season pass or subscription or whatever your machine calls it. You know what I mean. So that basically an episode will be waiting for you when you are ready to watch it. Yeah, kind of like this show. It's the Cable TV's version of a feed.

0:02:12

So anyway, I think new shows are Wednesdays at 9:00. Although they do show past episodes frequently. And really, in many ways, Myth Busters should almost be required viewing for all PediaCast audience members because if you like what I do, you will love what they do.

I mean, basically these are two guys. They've had some special effects Hollywood experience. But basically, they take myths and then they set out to confirm them or bust them using the scientific method. Alright, sometimes it's a loose approach to the scientific method, I realized that. But that makes it more fun.

Just some examples of myths that they have tackled in the past. If you flush an airplane toilet while you're sitting on the seat, will the suction keep you there until the plane lands or does a rolling stone really gather no moss? Or will a cell phone actually cause an explosion while you're pumping gas?

0:03:15

And really, the list goes on and on. I mean it's really a critical thinkers' paradise. Plus, they're funny and entertaining to boot. So I mean if your kids are going to spend some time in front of the TV, you might as well make it something good. And Myth Busters is a good choice because you do learn a little bit of science. You learn to think critically and you know, I really, I think it's a great show. I can't say enough about it.

And this is not a paid advertisement. I've never had any contact with the people involved with the show. I really think you'd like it and the reason I'm putting so much effort into telling you about it is because as I was preparing the script for today's program, I do make some comparisons to Myth Busters because a lot of what I do here and in the office every day in pediatrics is busting myths.

0:04:12

Do kids get sick or why do they keep getting ear infections? Because water gets in their ear, because they go outside without a hat on, I mean those are just some of the simple ones but there's just so many myths out there and we're trying to teach people from a scientific basis what really is happening.

And I think I'm not getting myself into trouble with global warming, but there's a big argument out there. Is global warming really through or is it a myth and how can approach it with the scientific process. Same thing with has gone on, we're talking about MMR and autism, is that a myth or is it true? How can we use science to bust it or confirm it? So really, it's a lot of what we do in the pediatric room and they just do it on a much larger scale. Plus they like to blow things up which is always cool. You know as long as no one gets hurt.

0:05:01

Alright, don't forget if there's a topic that you would like us to discuss on PediaCast, it's really easy to get a hold of me. Just go to Pediacast.org, that's our home site on the Internet and use the Contact link. You can get to me that way. By the way, I did get an email recently from a gentleman in Japan who pointed out that I do a really poor job of answering comments in the comments section for each episode.

And the issue is I've got – just I'm just too busy. I mean I really have to sort of limit what I can do. And maybe in the summer when I'm not quite as busy in the office, I can get a chance to do that. But I just don't have the time. And now his comment was if you're not going to make comments, why even have the ability to make a comment. Well, you know, the way I look at is if you want to make a comment about a certain show, I'm going to read all the comments.

And that's – and a few of those is the place where parents have supported each other, if there's a topic that near and dear to your heart in a specific episode, you can make a comment, then someone else may have some supportive information for you.

0:06:11

But anyways, it's going to be a few and far between that I actually get a chance to write back because I just get so many emails during the day. I'm trying to get shows out. And I have this little thing called a full-time job and a family and so it's tough.

So that's one way you can get a hold of me is pediacast.org through the contact link or you can email pediacast@gmail.com or call the voice line at 347-404-KIDS.
The information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination. Also your use of this audio program is subject to the PediaCast Terms of Use agreement which you can find at pediacast.org. And with all that in mind, we will be back with the News Parents Can Use right after this short break.

0:07:08

[Music]

Our News Parents Can Use is brought to you in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.

Throughout pregnancy many women eagerly anticipate the day they finally will meet their new baby. This is especially true in the last few weeks of pregnancy when as a baby grows larger and expectant mother begins to feel increasingly uncomfortable and inpatient to finish out her pregnancy.

0:08:07

Despite the anticipation, research shows that allowing labor to start naturally rather than induced is more beneficial to both mom and baby. Labor induction or artificially initiating labor through the use of medicine is performed for a variety of reasons.

Today, one of the more common reasons for induction is convenience. Hospitals can staff extra nurses, physicians can scheduled birth for times that are most convenient for them and expectant parents can make work and family arrangements in advance according to their scheduled induction date.

At first glance, labor induction may seem more convenient. However, it's important to recognize that induction may lead to a longer labor and overall hospital stay, more medical interventions, higher costs, risk of potential for litigation and adverse outcome for mother or baby.

In the last few weeks of pregnancy, a woman's body and her baby perform crucial functions to prepare for birth. The baby's lungs mature and he or she develops a protective layer of fat.

0:09:10

In addition, the baby drops down into the pelvis. The cervix tilts forward and softens and irregular contractions help the cervix think and begin to dilate. In most cases, a woman's body goes into labor only when her body and her baby are ready.

"Research at the University of Texas Southwestern Medical School suggests that it is a signal from the baby that starts the process of labor," says Professor Debbie Amos and the best way for a mother to know that her baby is fully mature and ready to be born is to allow labor to begin on its own.

Lamaze International agrees with Professor Amos but points out exceptions are appropriate when there is a true medical reason to induce. However, if the only reason is convenience, mom and her doctor should think again because allowing labor to start on its own reduces the possibility of complications including a vacuum or forceps-assisted birth, fetal heart rate changes, babies with low birth weight or jaundice and caesarean surgery. In fact, studies consistent show that inducing labor almost doubles a woman's chance of having caesarean surgery.

0:10:17
Alright I have to post here because this new story was put out by Lamaze International. And don't get me wrong, I agree with their stands but this is an example of an organism using numbers for the benefit of their argument.

So they're saying studies consistently show that inducing labor almost doubles a woman's chance of having caesarean surgery. Now let's think about this. Because inductive labors have twice the risk of progressing to C-section, does not mean that the induction is the only variable.

If a baby has fetal distress, or a mom has preeclampsia, may prompt an induction and if that induction doesn't work, then a C-section is going to follow because the situation deteriorates, not because of the induction but because of the underlying condition.

0:11:16

So you have to watch how you present these statistics because we want to be honest here. A better statistic to site is how many inductions done solely for convenience lead to C-section. And I bet that number is much lower. That, of course, is a difficult number to quantify with the study. Why? Well if you did it as a retrospective study, how many doctors are going to admit that the decision to induce was solely for convenience after the fact especially if that induction ended up as a C-section and maybe there were complications. I mean what's the potential liability there?

Also you could try to do it as prospective study where you take one group and let them have natural birth and the other group you induct them for convenience and then you see how many of each group wind up with the caesarean section.

0:12:07

But that will be hard one — that'd be a hard one to get off the ground because you are putting moms and babies in the induce group at risk for caesarean section complications. And to borrow an example from my favorite TV show, Myth Busters, it's like testing cell phones in an airplane.

Instruments and wiring are heavily shielded to protect against RF radiation and it's extremely unlikely that a cell phone call is going to bring a plane down. But there is a slight risk for a catastrophic consequence if some machine in the plane is not properly shielded against RF radiation.

So why even take a chance? And in the same way, what we're talking about there is a slight risk for a catastrophic consequence resulting from a C-section. If there is any risk of induction being more likely to lead to a C-section, why chance it merely for convenience?

0:13:07

Now if you were doing a study of a disease, it will be different because then the experimental group is already in danger and you're trying to find out some way to help them. But in this case, the experimental group, the group that you would have them do C-sections only for convenience is a healthy group. So why chance a problem? And can you imagine the liability there? So Darla, your pregnancy is going great, can we induce you to see if we can create a problem? I mean, no. It's not going to happen and it shouldn't.

Alright that was a much longer pause than I had planned, back to the story. "By avoiding induction, women are less likely to encounter other medical interventions," says Lamaze International President, Allison J Walsh. Experiencing natural contractions and laboring without unnecessary medical interventions increase a woman's freedom to respond to contractions by moving and changing position, both of which facilitate the process of labor and birth.

0:14:02

Avoiding inductions also decreases the likelihood of a premature birth because neither doctors nor mothers can determine the baby's due date with 100% accuracy. Babies may be induced accidentally before they reach full term or at least 37 completed weeks.

A scheduled induction at 39 weeks could result in giving birth to pre-term baby who is only 36 weeks gestation. Preterm babies miss critical stages of development that take place during the last weeks of pregnancy and are at risk for several postnatal complications.

A study published in the Journal of the American Medical Association examined 4.5 million births in the United States and Canada and concluded that babies born only a few weeks early at 34 through 36 weeks gestation were nearly 3 times more likely to die in their first year of life than full-term infants.

When medically necessary, inducing labor can be a life-saving procedure, the American College of Obstetricians and Gynecologists states that labor may be induced if it is more risky for a woman's baby to remain inside her body than to be born. So note that does not make an exception for convenience.

0:15:10

Medical reasons for induction include a woman's water has broken and labor has not begun for several hours; her pregnancy is post term or more than 42 weeks; she has a pregnancy-induced high blood pressure or preeclampsia; she has health problems that could affect her baby like diabetes or there's an infection in her uterus or her baby is growing too slowly

First-time mothers are most vulnerable to the risks of inductions contrary to what many believe, suspecting a large baby is not a medical reason for induction. It is very difficult for a doctor or midwife to determine the size of a woman's baby before birth with accuracy even with the use of ultrasound. Studies consistently show that inducing for a suspected large baby increases, rather than decreases, the incidence of caesarean birth.

Lamaze International has developed a care practice paper entitled Labor Begins On Its Own which presents the research surrounding labor induction and presents tips for avoiding induced labor. Childbirth education classes such as Lamaze provide women with the tools and information they need to make educated choices during labor and birth and to find a Lamaze class in your area, visit lamaze.org.

0:16:19

OK, enough of the commercial. We will have links in the Show Notes at Pediacast.org to Lamaze International and the labor begins on its own paper and the tips for avoiding induced labor because I look through them and they're actually really good. And where will you find the Show Notes? Let's all say it together, pediacast.org.

Lack of adequate sleep can lead to increased injuries among preschool children, new research shows. This study, published in public health nursing, shows that the average number of injuries during the preschool years is two times higher for children who don't get enough sleep each day as described by their mothers. Each year, approximately 20% to 25% of all children in the United States sustained injuries that require medical attention. Childhood injuries, one of the 10 leading health indicators being tracked over the next 10 years by the US Public Health Service.

0:17:11

Dr. Christina Koulouglioti and colleagues, Dr. R. Cole and Dr. H. Kitzman of the University of Rochester School of Nursing, collected data from nearly 300 mothers and their preschool children over the course of two and a half years.

Mothers reported on their child sleep and data on injuries were collected through self-report and medical records. The study was funded by the National Center for Injury Prevention and Control. The study found a direct negative relationship between children's sleep and injuries. Children who get an adequate amount of sleep sustained fewer injuries. [Laughs]

I'll tell you why I'm laughing in a second. The National Sleep Foundation recommends that children three to six years of age get 11 hours or more of sleep a day. The increased risk of injuries associated with inadequate sleep was significant even after taking into account factors including maternal age, education and the child's temperament. Of course, they didn't take into account how much the child's awake. [Laughs]

0:18:10

See, you have to make a socioeconomic diversity of participant shows the relevancy of this issue across different backgrounds. The result of our study have significant implications for the prevention of injuries, Koulouglioti concludes. The findings provide additional support for the essential role of poor sleep as a risk factor for injuries among all preschool children.

So why am I laughing about this? They controlled for these variables, right? They controlled for mom's socioeconomic backgrounds, mom's level of education, the child's temperament. But how do you control for increased playtime? I mean if a toddler is not sleeping, what are they doing? They're moving, right? And if toddlers are moving more often, aren't they in a better position to injure themselves?

Now look, I'm not saying lack of sleep is OK. It's probably not. But the issues with the study like this is you have a variable that's difficult to control and this difficult to control variable is one that has a big, big effect on the outcome.

0:19:10

I mean you'd have to calculate how long the kids are awake on average in each group, subtract the difference and for that many hours a day, the kids in the experimental group have to be tied to a chair or flop in front of the TV with no wrestling, jumping or horseplay allows for several hours. That way, they're both awake and playing and able to injure themselves the same amount of time during the day. That way you'll know if the kids who gets less sleep really hurt themselves more or they just hurt themselves more because they're up more.
& Alright. I bet, actually, I bet kids who watch more TV sustained fewer injuries than kids who play. Right? Nevermind the obesity issues, they get hurt less often. Of course, kids who sleep more have fewer injuries. But you know, if sleep's really the issue, this study does not prove that sleep, lack of sleep leads to more injuries in kids. I'm sorry, I'm going to call this one busted. [Laughs]

0:20:08

By the way, Adam and Jamie on Myth Busters, they're my heroes, if you haven't figured that one out yet.

Alright, we're going to take a break and we will be back to answer your questions right after this.

[Music]

Marilyn:& This is Marilyn calling from Littleton Colorado, and I had a couple of questions for you. My son is almost 11 months old and lately when he's been playing with our little beagle, his eyes get red and he starts rubbing them and it seems like he might be allergic to her.  

0:21:05

And so I'm wondering if there's any merit to the idea that you should expose your children to the dogs early on so that they don't get allergic later – they don't become allergic to things such as dogs and cats. Or if I should just try to keep them away altogether?

And my second question is as I said he's 11 months old and I am currently breastfeeding but I'm not able to keep up with him recently. And I'm wondering at what age I can start giving him whole milk. I know the standard is usually 12 months. But I'm wondering if there's any leeway and starting at, let's say 11 months, if I can start supplementing him with whole milk in addition to the breast milk.

And I would like to say that I love your tangents and it's especially funny when you point them out. Thanks for your help. Bye.

0:22:03

Dr. Mike Patrick: Alright. Well thanks for your question, Marilyn. Really, there's two questions here and I'm going to break them up and deal with them separately. So question number one, Marilyn has an 11-month-old son. When he plays with the beagle, his eyes get red and he rubs them and she's wondering if he's allergic to the dog. And then wants to know if there's any merit to exposing children to dogs and cats early so they don't become allergic to them later on or should she just keep him away from the dog altogether.

Well first, this process by which you put someone in contact with what it is that's making them allergic and hopes that their body will stop reacting to it is called desensitization. And that's how allergy shots work. I mean the idea is, the more you're around something or become exposed to it, then your body will start to accept it and not react to it.

0:23:00

There are of course many kids who are allergic to dogs and cats, and particularly cats. Cats tend to be, for a lot of kids, more of an issue than dogs. And you do see a lot of kids who are OK with the cats living in their own house. But if you have them spend the night with a new cat, it's all over. Their eyes are watering, they're itchy, they're sneezing and they're a mess. And actually, my son, Nicholas is one of those kids.

Now is this proof that they have to become desensitized to their own cat? Well, maybe, but probably not. Remember cat allergy is usually an immune reaction to the Fel D1 protein which is found in cat's spit.

Now cats groom themselves and then that protein from their spit coats the skin cells during grooming. The skin cells slough off as they tend to do as you make new skin. The allergic person breathes these cells in which is coated with this protein and wham, there's your problem.

0:23:59

So if a child who does well with his or her own cat, but not with other cats, are they desensitized to their own cat or does their particular cat make less Fel D1 protein? Or does their cat groom less often or less regularly or thoroughly than other cats or does it slough off less cells or does mom vacuum more often, change the furnace filters, not let the cat in the child's room, et cetera. Or is it not the Fel D1 protein causing the problem for that child in the first place?

So it's hard to say and there's no real research out there on this. And even if there were, it would likely be hard to apply it to your specific situation because there's so many variables at play.

Personally, I don't think that these kids are becoming desensitized to their pet. Because for every kid I see in my office who's fine around their own cat, like my child and only their cat, I see tons, tons more who do poorly around any cat including their own. In fact, the reaction just keeps getting worse. They have the worst allergy symptoms and it becomes harder and harder to control without some sort of intervention.

0:25:09

So why? Why doesn't desensitization to pets work like allergy shots work? Well, it's because desensitization works best when the exposure is tiny amounts of intermittent antigen, which is what we call the protein or the chemical that you're allergic to. So you want an exposure of tiny amounts of it intermittently over a long period of time. And that is the process involved with allergy shots. Being blasted with antigen or what you're allergic to every day does not help so much. And if it did, then ragweed and dust mites and molds wouldn't be a problem for people, at least not for long because they've all of become desensitized to it.

So I think in this case, desensitization is out and it's probably not going to work. So what can you do? OK, well, here's the advice I give to people in my office in a similar situation. Like how I qualify that, this is not advice for you, Marilyn, this is advice for people in my office in a similar, but not exact situation. Now I got to love the lawyers.

0:26:10

OK. Number one, I would say you want to make sure that you aren't the one creating the problem. In other words, be sure it's the dog's fault. I mean are you using shampoos, flea control products or are there any chemicals that you might be using putting on the dog that your child is actually having the allergic reaction to and not the dog itself.

Next I would minimize exposure as much as you can. Vacuum, freshen up the house, open up the windows. Hopefully they're not allergic to environmental allergens that would come inside the house. Keep the dog off limits in the bedroom. Change or clean any air filters especially forest air furnaces. And you know could the dog become an outside dog? That's something else to consider.

The third thing you could do is drug the kid. You could use non-drowsy antihistamines like Claritin and Zyrtec to try to alleviate the symptoms. Now are they safe to use for an 11-month old? Well, that's between you and your doctor. Are there 11-month olds out there on Claritin and Zyrtec? Certainly, there are. Does that mean you should use it? You've got to ask your doctor.

0:27:16

The big question to ask is especially if you're considering medication for a pet allergy is this, does the benefit of having the pet outweigh the risk of the medicine? And that's always the question we ask here when we prescribe any drug.

And for an 11-month old who is the sole consideration in my mind, it's probably not worth the risk. I mean an 11-month old really doesn't care about the dog and here she – I mean they might, yeah, they like the dog. They think the dog's cool. But your baby's probably going to forget the dog ever existed two months after it's out of the house.

Now but what if you have an older child in the house who is attached to the dog or your child is older to begin with, you're not talking about 11-month old here, you're talking about a six-year-old. Or what if mom and dad are attached to the pet, what then?

0:28:08

Now does the benefit of having the pet outweigh the risk of medicine in an 11-month old in the same house. Again, that's up to you and your family and for your doctor to decide.

I will say medications like Claritin and Zyrtec have an excellent safety profile when taken as directed by your healthcare provider. They are approved as over-the-counter medicine now. They haven't been taken off the shelves like cough and cold medicines have. But still, talk to your doctor. I'm not telling you to give your 11-month old Claritin, that's not my place. But it doesn't hurt to ask your doctor about the possibility.

Now if the medication doesn't work and your child is miserable or you decide it's not worse… worth the slight risk of problems with the medication or the benefits of having a pet is not really all that great for your family, then the best option is to get rid of the dog. And in my opinion, that's probably the best option rather than hoping for desensitization which is unlikely to occur.

0:29:08

OK. And then Marilyn's second question. It's standard to introduce whole milk at age 12 months and is there any leeway on this; can she start to supplement breastfeeding with whole milk at 11 months?

The age to switch from formula or breast milk to a whole vitamin D whole cow's milk used to be like back in the '60s and early '70s, six months. And then it crept of to nine months and now it's 12 months. So really the question is why the change? Most babies are going to do well with whole milk at six months of age. OK, I just said that, most babies are going to do well with vitamin D whole milk, cow's milk, at six months of age, but there's a small number who will not.

The milk protein is going to cost inflammation in their gut. There's that pesky immune system again. That's going to result in microscopic blood loss which is unnoticed by mom or dad, but does come out in the poop and over time, over a few months time, that blood loss adds up and the child's becomes extremely anemic. And there is the potential for severe, even life-threatening anemia.

0:30:16

Now the problem is you can't tell which kids are going to have that problem if you switch them at six months of age. But if you wait until 12 months of age to switch them to vitamin D whole milk, then virtually, no kids is going to have that problem. I mean there may be one in hundreds of thousands. But it's not going to be very common at all.

Therefore, you tell everyone to wait until 12 months and that way, you protect those who would have been affected. And OK, the rest of everyone else is slightly inconvenienced, there's this little bit of an increased cost to those who wouldn't have been affected.

But remember, those who wouldn't have had any problem even switching over at six months are by far the largest group. So knowing this, what is the risk of switching any particular baby to whole milk a month early? It's low. It's really low.

0:31:06

What's the risk of switching them two months early? It's low, but a little higher, right? What's the risk of switching them three months early then? Well, higher and it's becoming a slippery slope now here, isn't it? Ultimately, you have to make the decision when to switch from breast milk or formula to vitamin D whole milk for yourself. There's no law that says you have to wait until 12 months.

The experts say 12 months is the safest. But you're the mom or the dad and you get to actually decide. OK, there's no law that you can't switch them sooner. I'm not suggesting you do at six months or nine months, 10 months, I wouldn't. 11 months, OK. I mean, what's the difference between 11 months and 12 months?

You know the facts here. I mean I've just explained it to you. You can make an informed decision for yourself. Is it OK to start slipping in some vitamin D whole milk at 11 months? What do you think?

0:32:06

See where all the litigation in this country gets us? I can't say, fine do it. Even though I want to. Or does that mean I just did?

Alright, let's move on. Amy in Chicago says, "Hi Dr. Mike. I just found your podcast and I love it. Please excuse me if you have already addressed this topic, but I haven't yet listened to all the past shows.

When I was making my daughter's two months well check-up appointment, they offered me the nurse practitioner. I must have given a funny look because she said, don't worry they have the same amount of schooling as a doctor.

My thought was then wouldn't they be a doctor? Anyway, could you please explain what this practitioner title means? Thanks again for a great show. My husband bought me a radio for my iPod so I listen to you while I go about my day."

Alright, thanks for the question, Amy. Thanks for your patience too because I received this question more than a month ago. And I have sat on it. I've wanted to address it and I've been sort of dreading addressing it as well.

0:33:10

I put it in a few shows as I was creating scripts and I always took it out at the last minute. But I'm leaving it in this time, doggone it. The simple answer to your question is no. Pediatric nurse practitioners do not have the same amount of schooling as a doctor. And to say they do, is misleading and it's wrong and shame on the office person who said that.

Now does that mean the care that you get from a pediatric nurse practitioner is inferior to the care you would get from a doctor and you should not see one? [Sigh] I go back and forth on this one which is why I've hesitated in answering it. But I've come to the conclusion that I should address it and discuss this and I'm going to get flacked either way. So here's my thinking on this.

0:34:00

Pediatric nurse practitioners are generally smart people, OK. You want that in a healthcare provider. They generally have a Masters degree in nursing or even PhD level training. They have to pass a national certifying exam. They are licensed by their state. Most states require continuing medical education that they have to go through to keep their national certification with that exam. They have to get recertified every 7 years.

I mean all of these are things that make one seem qualified to take care of your kids. But there are some important differences. And again, I'm not saying that pediatric nurse practitioners are bad or that you should avoid them. I'm just telling you the facts as I see them.

Number one, the route to doctorhood teaches critical thinking which is essential in practicing both the science and the art of medicine. While the content of organic chemistry and calculus and physics and hard-core science stuff and advanced microbiology don't help a doctor in their day-to-day contact with patients, they do teach one to think critically. And that sort of rigorous science training is missing in the education of most nurse practitioners.

0:35:21

So they may learn that symptoms X, Y and Z point to disease A which is treated with medicine C, but there's an underlying foundation of knowledge and critical thinking skills that are missing in their education. And at the end of the day, it's like trying to replace a doctor with a computer program and a drug-vending machine. I mean sure you can plug symptoms into some software, get a diagnosis and dispense the medicine called for in the program's algorithm. And you'll be right, a good percentage of the time.

But when you're wrong because you missed something subtle or you shrugged off a seemingly minor co-variables, the result of delayed diagnoses and inappropriate treatment can be tragic and life-altering.

0:36:06

And how about interpreting the medical literature? It does take a strong science background to critically evaluate what's out there so you can practice evidence-based medicine and not be swayed by the hoards of bad research that is out there.

So there's another example of the importance of learning to think critically and having a background of hard-core science and undergraduate school and then medical school to develop the ability to evaluate the literature and to think critically.

Are there nurse practitioners out there with strong science backgrounds? Sure. Are there doctors out there who don't give a lick about critically evaluating the current research? Sure.

But in general, most doctors are going to have better critical thinking skills in the science disciplines and I think that's important. Then again, I'm a doctor, so I may be a little biased. Number two, another issue is experience. Pediatric residency prepares you for primary care practice in a way no Master's level nursing program can. Especially if you train in a large, high-volume program. In the course of three years, you're exposed to everything in all disciplines of pediatrics.

0:37:17

And you do call upon that knowledge your entire career. I mean I am more than 10 years out from residency training and I still come across things in the office that cause my mind to raise back, oh yeah, I remember seeing a kid with that. Or we had to get this test or we had to consult that specialist.

And these tend to be rare and potentially deadly diseases that present with common symptoms and ends up being the right combinations of common symptoms that causes the alarm. Diseases like Kawasaki's disease, rheumatic fever, Stephen Johnson syndrome. Things you don't see very often and on the outside, the symptoms you get don't seem like a big deal but it's like a slot machine. The right combination line up and it's a problem and it's not going to be recognized by someone who's never been exposed to it.

0:38:08

And that's where the experience of three crazy years seeing thousands and thousands and thousands of kids in a large referral centers pays off. That experience counts and nurse practitioners don't have that experience.

Now to be fair, there is a place where I think nurse practitioners are fabulous. And OK, I know it's the wrong thing to say because I'm sure there are nurse practitioners and pediatric practices that are fabulous. I guess what I'm trying to say is they really make a lot of sense in specific environments.

For example, in the neonatal intensive care unit, in anesthesia departments, in diabetes management, there are nurse practitioners in those fields that have… they have been nurses in those fields for years.

Now the knowledge base is not as wide, OK. There's only a limited number of things that go wrong with babies in the NICU. There's only a limited number of things that go wrong with children under general anesthesia. There's a certain set of things that go wrong with kids with diabetes.

0:39:12

And so these nurses in the subspecialty areas know their stuff. And they are definitely in a position to lend a hand to the clinical practices that they're involved with.

In general pediatrics, it's more difficult because you are calling upon such a broad area that it's difficult in training for a pediatric nurse practitioners to come across all the things they need to know about.

Now but do they have a place seeing well checkups or simple sick visits? You know what I'm saying? OK, do you really need a strong science background at diagnosing your infection? Do you really needed to go through their growth chart and give them their shots and then if you have a problem referring them on to the pediatrician that they're working with? Although in some states, they can work on their own independent of a physician, which I think is crazy.

0:40:06

In my mind though, it's like inducing labor, OK. It's like starting whole milk early. The vast majority of kids who seen nurse practitioners are going to get good care, they're fine. They're going to be fine.

But there's a number out there who aren't fine. They have subtle issues and it's going to be something the nurse practitioner is going to miss and yet, something a trained pediatrician is going to pick up. In most cases, that something is going to be small and minor and not a big deal.

But for a small, small number of kids, seeing a pediatrician will make a difference and potentially, a life-changing difference. And since I want the absolute best for my kids, I would stick with the pediatrician over the nurse practitioner. But again, that's me. I'm a pediatrician. I might be a tad biased and I'll leave you to form your own conclusion.

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0:41:25

Alright, now that's all the pediatric nurse practitioners have unsubscribed from PediaCast, let me say thank you to Nationwide Children's Hospital for providing the bandwidth for our program. Also Medical News Today for helping us out with the news department. Vlad atVladstudio.com, our resident Russian artist who provides the wonderful artwork for the website and our feed. And of course, thanks to all of you for subscribing, tuning in, participating, writing reviews in iTunes and generally, being a great part of the program.

Please, if you're a pediatric nurse practitioner, don't write me hate mail. I don't hate you. I really don't. But you know there's a place, there's a place.

Alright, Saturday Photo Hunt across the blogosphere. Karen participated in that with a Pediascribe blog. This week's topic was Wooden. And as it turns out, Karen's dad is a woodworker of sorts. And she shows off his collection including pictures of our bedroom because he made our bed.

0:42:24

I don't know, there's something weird about that. Pictures of my bedroom on a blog for the world to see. But I have little editorial content over Pediascribe these days. So it's just good, except for the pictures of my bedroom.

But anyway, you can check it out for yourself at Pediascribe.com or go to the Show Notes at Pediacast.org and click on the link there.

Don't forget we have a Poster page at the website. If you go to Pediacast.org and click on the Poster page, they are PDF files that you can download, print out and hang on bulletin boards, take to your doctor and say, hey, this is really cool program, you got to check it out. And see if they'll post it in exam rooms. Of course word of mouth helps.

0:43:04

The ultimate goal here, OK let's just take a moment and say, what's the goal? I mean what am I aiming at? Why do I want you to tell people about this show? It's because I love doing this. You probably figured that out. I really love doing this. And it is tough to give this the attention that I would like to give it and practice full-time.

So eventually, I would like to be able to cut down on my practice a little bit. Now I can't stop practicing altogether. I mean I lose credibility doing a show like this if I don't see kids in the office.

But we are busy. We have a really, really, really busy practice. And I would like to be, to cut back a little bit. But to do that, I've got to actually start making money with this podcast. And I always wanted it to be free for you, the parent. I don't want any obstacles. Otherwise, we become just like what to expect when you're expecting blogs. I mean you got to pay it to get it.

I want this to be free information. But we need sponsorship. And to get good sponsorship, you got to have a big audience. So that's the goal. I'm just being honest with you. That's where we are with this.

0:44:12

We should have another show out before the week is up and I promise to try to throw in some school-aged kids and teenage topics into the hopper. I know we've been leaning heavily on pregnancy and babies the last few shows, so I'll try to get my act together and get some teen topics because there have been some questions that relate to school-aged kids and teenagers so we'll get to that.

And until next time, this is Dr. Mike saying, "Stay safe, stay healthy and stay involved with your kids…. So long, everybody.

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