We are such stuff
As dreams are made on; and our little life
Is rounded with a sleep.

Shakespeare, The Tempest Act IV, sc. 1, 156-158

I imagine a “rounded” sleep is a smooth and easy one, devoid of rough awakenings. It would be nice if my dreams were “rounded with a sleep,” but mine are jagged ones. And,  more often than not, they are about my work. It is the particularly stressful operating room cases I revisit again and again in recursive loops of dread late into the night.

I am an anesthesiologist practicing in San Francisco, providing care at several hospitals and surgery centers. It was at the old Children’s Hospital that this terrifying tale of a pediatric airway emergency took place.

New Dr. Salber‘s Review Notes appear at the end of the story.

To this day, I dream of this case even though it happened many years ago. The memory of it will startle me awake. It troubles my thoughts and makes my heart race. My breaths come sharp and quick until I calm myself and sink into my pillow. Then, I try to go back to sleep before the morning arrives far too early and far too soon.

The well-run operating room

The buzz of activity of a well-run operating room is a sight to behold. Wheeled carts laden with packs of instruments wrapped in sterile blue paper are delivered by attendants straight from the autoclave. Machines and monitors, X-Ray C-arms, and operating microscopes are ferried from one room to another.

Surgeons, nurses, and scrub techs walk briskly and purposefully down the corridors dressed in blue-green scrubs and cover-gowns in a coordinated and efficient dance. Patients come and go, shepherded safely from awake to asleep to awake again in precise fashion by the anesthesiologists at the head of each OR bed.

On this particularly busy day in the middle of the afternoon, the operating rooms were in full swing, filled with the usual variety of elective cases. In Room 1, there were urology cases. Rooms 6 and 7 were booked with orthopedics, and Room 9 held a long list of breast biopsies. I was in Room 2 doing pediatric ENT cases – ear tubes, adenoids, and tonsillectomies. In my dreams, I am transported back to that room…

The list of elective surgeries diminishes as one after another is completed and erased from the master schedule-board. It is a smooth human assembly line as patients walk over from Admitting and are ushered into the holding area. They wait, dressed only in their paper, ill-fitting Bair-Hugger gowns1, to be seen by the circulating nurses and the anesthesiologists before entering the OR.

The gowns are ugly but effective, and they are disposable. They are a distinct improvement over the traditional tied-in-the-back, thin cotton gowns. These are designed to allow hot air from an external blower to circulate throughout the gown in built-in baffles, enveloping the patient in warmth to ward off the cold exposure of the operating room.

A pediatric airway emergency is on the way 

Late in the afternoon, the smooth routine of my day is disrupted. A call comes from the
emergency room that immediately puts a hold on my next scheduled case. A one-year-old child is being rushed directly from the ambulance bay to the OR for a foreign body airway obstruction.

This is unusual – I typically go down to the emergency room to evaluate the children first, but I am told that I don’t have time, as this one is in severe distress and already on the elevator.

With a sinking feeling, I run back to my room to prepare for the case. Beyond what I have just heard, I know nothing else. I don’t know what the child may have swallowed or how long he has been in trouble.

Even though I have been well trained for this exact situation, my stomach twists, my chest tightens, and I breathe a little faster, fearful that this may end badly.

My greatest fear was my children choking

Pediatric airway obstructions are emergencies of the highest order. Ask any anesthesiologist who is also a parent to pick their greatest fear while raising their young children. Mine was choking.

Despite an outward appearance of being calm and efficiently competent in emergencies, I can be a fairly anxious individual, especially where my family is concerned. They have had to endure countless lectures from me on the “forbidden” foods of childhood.


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No raw carrots, peanuts, apples, hot dogs, steak, hard candy, and so forth, until the back molars are established, or the child has graduated from college, whatever comes last. And, definitely, no talking, laughing, singing, running, or walking around while eating.

Once at a birthday party for a friend of my eldest son, Henry, the other parents watched with both shock and embarrassment for me as I put a dramatic, hyperventilating, immediate end to a game of “Chubby Bunny.”2 If you have never heard of this game, consider yourself lucky. Chubby Bunny is a contest where the children compete to stuff as many marshmallows as possible in their mouth, one by one, and repeat the words “Chubby Bunny” three times.

To me, this game is tantamount to attempted child homicide. It is a prima facie example of gross parental neglect, justifying a call to Child Protective Services.

After startling all of the kids silent due to my sudden and very dramatic outburst, I made them immediately spit out the sticky gobs of marshmallow that were distending their cheeks like chipmunks.

I sarcastically and angrily asked the stunned host mother, “How about a game of
William Tell, or knife-throwing next? Do you have any Lawn Darts handy? Or let’s just tie up the kids and toss them in the pool to see which one can hold his breath the longest?” Obviously, it took a long time for me to be invited back to birthday parties after that.

Pediatric anesthesiology mantra: Airway, Airway, Airway

From day one of residency, anesthesiologists are taught a simple algorithm: “ABC – Airway, Breathing, Circulation.” In pediatric anesthesiology, we are taught an even more succinct
algorithm: “AAA – Airway, Airway, Airway.”

It doesn’t take long to suffocate when the airway is obstructed. An adult has about three to four minutes after cessation of breathing room air before suffering irreversible brain damage. A toddler may have even less time due to the nature of their more rapid metabolism and high demand of the developing brain for oxygen.

This is why the importance of maintaining a patent airway in order to breathe is drilled into us before we even get to touch our first patient. A great deal of our knowledge and equipment is tailored to achieve this goal.

We learn how to assess an airway preoperatively to judge the potential risk of losing it once an anesthetic begins and the patient is rendered unconscious and unable to breathe unaided.

We know how to manipulate the jaw to tighten the neck muscles to support the pharyngeal structures and facilitate breathing.

And we know many ways to re-establish an airway once it’s lost, including performing an emergency cricothyroidotomy,3 literally cutting a hole in the neck. Mostly, we know how to do these things in a logical sequence, as rapidly as possible. Time is of the utmost essence.

Treating airway obstruction

Treatment of an airway obstructed by a foreign body can range from a simple slap on the back to a Heimlich maneuver or even a manual extraction of the offending agent with a finger. The latter, however, can potentially make things worse by further pushing whatever is causing the blockage deeper into the larynx, cutting off the small amount of air that is getting through.

Sometimes anesthesiologists use a special type of curved grasper called a Magill Forceps4 to pluck an object from the back of the throat after using another instrument called a laryngoscope,5 a lighted retractor that holds down the tongue, thus allowing us an unobstructed view of the larynx and vocal cords. We use laryngoscopes to “intubate” patients – that is, passing a tube through the vocal cords into the trachea to establish a secure channel through which we deliver oxygen and anesthetic gases.

Face to face with a full-on emergency airway obstruction

As the elevator doors open, I see the huddle of doctors and nurses surrounding the crib of this small child being manually ventilated with oxygen, a clear plastic mask covering his mouth and nose. I can hear the awful high-pitched squeal and wheeze of the oxygen escaping around the edges of the mask rather than being delivered to the lungs. I am afraid that this will not be one of those quick and lucky situations.

The child is decidedly blue, pale around the mouth and eyes. His small, fragile body is slack, without muscle tone. We rush into the operating room and place him on the table. The anesthesia tech quickly transfers the cables from the transport monitor to my machine. Then, I take over the task of attempting ventilation.

I look up at the monitor that measures the percent oxygen saturation of circulating hemoglobin, the molecule that carries oxygen so efficiently to the rest of the body. I see a number alarmingly in the low twenties. It should be in the high nineties.

The lower the number, the lower the pitch the machine makes with each beat of the heart. This pitch portends doom. The heart rate is also steadily decreasing, an ominous sign that this child is about to have a full cardiac arrest.

The child is about to have a cardiac arrest

I inject atropine and then epinephrine into the IV already established by a skilled EMT on the way to the hospital. Then, I quickly look inside his mouth and throat with my laryngoscope and see nothing but mucus and blood. It appears that someone had looked before and stirred up a mess.

As the oximeter’s pitch drops even lower, I tell the nurse to begin chest compressions. And, I ask the surgeon to prepare to cut the neck to try and establish a surgical airway. This is difficult when the patient is an adult, but it is much harder when it is a small child. I force myself to breathe slowly and stop my hands from shaking.

–One more quick look

As a desperate last effort, I decided to take one more quick look inside the pharynx with my laryngoscope. This time I see something different. There’s a small glint, silver and shiny, reflected in the bright fiber-optic light from the tip of my laryngoscope blade. It is the thinnest visible edge of a dime.

The rest of it is buried in the swollen tissue, mucus, and blood obstructing the vocal
cords. It is wedged tightly by its serrated edge. I can understand why the paramedics and maybe the ER doctor missed it. Taking the pediatric Magill forceps in my free right hand, I fix my gaze on the tiny crescent moon of the edge of the dime. I don’t want to lose sight of it.

Above the background noise, I hear the pulse oximeter’s tone bottoming out, past the point where the numbers are even accurate. The child is purple and mottled. A full arrest is seconds away.

–A rush of stale air 

I’ve stopped shaking, and my hands are surprisingly steady. I aim for the small, barely perceptible glint and feel the solid metal between the jaws of the forceps. Gently and carefully, I pull it out. A rush of stale air follows.

The small coin had acted as a one-way valve, trapping the depleted air behind it. Now that it is gone, I can freely ventilate the lungs with pure oxygen.

After an agonizing number of seconds, I hear the oximeter’s pulse and pitch recover along with the oxygen saturation. The pallid limp child finally and mercifully becomes pink with life-giving, fully oxygenated blood. He begins to cry.

The memory of this pediatric airway emergency brings back feelings of dread

To this day, even awake, I cannot think about this case without feeling the familiar tightness in my chest, as well as a stomach-dropping sense of dread. Even though I know that this child made a miraculous full and symptom-free recovery, and even though I have had the opposite experience of having patients die in the operating room who were critically ill or traumatically injured and not expected to make it, this was the closest I have ever come to losing someone… a child, like this.

Working as we do in this environment, at the edge of the precipice, one never knows if the next elevator will be the one that opens to replay the nightmare over again.

My children are grown up now and no longer live with me. But, when they were younger and still in the safe embrace of my old house in their bedrooms down the hall, I couldn’t help myself. I would awaken, startled from my restless dreams in the deep hours of the night, sit up and listen intently, staring into the dark.

I’d swing my stiff legs out of bed and walk as quietly as I could down the hall to my daughter’s room. Pausing, I stand at her door for a moment, hovering, watching her uncertainly. Then softly, I go to sit on her bed and gently cup my hand near her mouth, reassured. Slowly, deliberately, I would count each warm breath as I stroked her precious face. One…two…three…four…

Other stories by this author:
An Anesthesiologist Learns the ‘Facts” about Epidurals in Childbirth Class
Perchance to Dream: A Suicidal Teen Shapes a Doctor’s Perception of Despair

***

Health Resources for Pediatric Airway Emergencies

References

  1. 3MTM, Science Applied to Life – Bair Hugger Patient Warming Gowns
  2. Wikipedia, Chubby bunny – httpss://en.wikipedia.org/wiki/Chubby_bunny
  3. John C Sakles, MD, Emergency cricothyrotomy, UpToDate, httpss://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy
  4. Wikipedia, Magill forceps – httpss://en.wikipedia.org/wiki/Magill_forceps
  5. Wikipedia, Laryngoscopy is endoscopy of the larynx – httpss://en.wikipedia.org/wiki/Laryngoscopy
  6. Stanford Children’s Health, How to Help a Choking Child – httpss://www.stanfordchildrens.org/en/topic/default?id=how-to-help-a-choking-child-1-197
  7. American Heart Association, CPR & First Aid Emergency Cardiovascular Care,AHA Pediatric Training for Healthcare Providers httpss://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/pediatric
  8. Performing the Heimlich Maneuver on a Child or Infant, YouTube Video – httpss://www.youtube.com/watch?v=aXaLc-AwX2g

  9. Health Resources and Service Center (HRSC), Poison Centers – httpss://poisonhelp.hrsa.gov/poison-centers

Medical Reviewer Notes by Dr. Salber

Dr. Swisher captures exactly the rapid transition from calm to terror that happens when even the most highly trained and experienced doctor is faced with a dire emergency, such as a pediatric airway emergency, that requires immediate intervention. I know because that was my life too when I practiced emergency medicine at a very busy ER in San Francisco.

One minute I could be joking with the nurses while moving from one routine case to another. Colds, flu, lacerations, sprains, infections…all things that could be dealt with without breaking into a sweat.

But the sudden arrival of a toddler in acute distress and my heart would race and my breathing quicken – just like it’s described in this story. In fact, when I first read this story, my pulse got fast, and I experienced a sense of foreboding. It was like being in the ER again. For those of you who haven’t had this experience, I can promise that this kind of work is exciting and rewarding. It is also the stuff of nightmares.

How many doctors do you see on a regular basis? Many of us probably go to the doctor for an annual physical. We also see specialists regularly as well. But what about an eye doctor? When was the last time you had an eye exam?

If you haven’t seen an eye care professional in the few years, perhaps you should put it on your “to do” list. Not only is a comprehensive eye exam essential to catch eye problems early, but it is also a good way to get a glimpse of your overall health. An eye doctor can look into your eyes and see the signs of chronic diseases. It’s not just about making sure you can see. It’s how you see and how you want to keep seeing.

How often should you have an eye exam?

Acknowledging that your eyes truly are a window to your overall health, adults should get a thorough eye exam every 1-2 years. During a routine exam, eye care professionals don’t just check to see if glasses or contact lenses are needed. They also check for eye diseases. 

And, they are often the first ones to spot a number of other chronic diseases, including

  • high blood pressure,
  • high cholesterol,
  • diabetes,
  • autoimmune disease
  • some types of thyroid disease
  • and even certain cancers.

A regular eye exam is especially important if you’re considered at risk for eye and vision problems.

At-risk people are usually those with diabetes and high blood pressure, or who have a family history of eye disease like glaucoma or macular degeneration. But you might be surprised to know that “at-risk” also includes contact lens wearers and people whose jobs are highly demanding visually. If you stare at a computer screen all day, you may also be considered at risk so you’ll want to be sure to get a thorough eye exam every year.

How do you know if you have an eye issue?

So how do you know if you’re experiencing an eye issue? You may not. Many eye diseases have no symptoms until the disease process is well advanced. Typically, vision issues manifest with blurred vision while driving or reading.

You may also find yourself squinting at the television, feeling visual fatigue by the end of the day, or getting frequent headaches. If it’s been more than 1-2 years since your last visit to your eye doctor, it’s possible your prescription may be out of date.

Are online eye exams good enough?

You may come across websites or smartphone apps that offer online eye exams. These services are definitely tempting. You can get your eyes checked from the comfort of your home instead of making an appointment with your eye care professional. However, you shouldn’t rely on an online test to give you a complete picture of your eye health. Here’s why:

  • An online exam can only show what vision correction you may need. In fact, the American Optometric Association has warned against online exams specifically because they aren’t thorough enough. For example, your phone or computer can’t do an eye pressure test to check for glaucoma, which means key indicators of potential health problems could be missed.

A comprehensive eye exam should include several different tests—many of which, today, have to be done face-to-face with the proper equipment.

Related Content: 

-Do You Know the 3 Main Causes of Blindness in the U.S.?
-Vision Correction: Risks and Benefit
-Dealing with a Rare Eye Disease in the Midst of COVID
-Thyroid Eye Disease: Who’s at Risk and Who’s on Call

What type of tests are included in comprehensive eye exams?

In addition to the routine eye pressure test, a comprehensive eye exam should include several different tests—many of which must be done face-to-face with the appropriate equipment. These include a slit lamp exam, which uses a unique microscope to review the structures of your eye. It often also includes pupil dilation, which can help detect conditions like retinal detachment, age-related macular degeneration (AMD), and glaucoma.

During your comprehensive exam, your doctor will also review your medical history to identify any risk factors for eye disease. He or she will then determine the appropriate tests for you. For instance, glaucoma, a group of eye diseases where damage to the optic nerve can cause blindness, is hereditary. So if you have a family member with glaucoma, chances are good your doctor will test you for it as well. If fact, many eye doctors include this test in all routine eye examinations.

Patients living with diabetes may develop retinopathy, a complication of diabetes that is a result of leakage from blood vessels. It can cause blindness. Diabetics may also be at higher risk of developing cataracts, a gradual clouding of the eye’s lens.

Older individuals may be at risk of experiencing AMD, an eye disease that causes damage to the macula, which is a tiny spot near the center of the eye that is responsible for seeing objects straight ahead.

During your exam, your eye doctor may test you for one or more of the following:

  • vision sharpness
  • color-blindness
  • eye movement
  • depth perception
  • a peripheral vision test

All of these tests are helpful in diagnosing potential vision issues and determining the best method to address them. Based on your results, your doctor might also suggest additional testing.

What should I know about children’s eye exams?

While you’re making your eye exam appointment, don’t forget about your kids. The American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus recommend that children receive at least 3 eye exams by age 6:

  • As a newborn
  • Between 6 and 12 months of age
  • About 3-3/12 years old

These exams can be done by an ophthalmologist or by other doctors with proper training.

Children’s eyes should also be screened for visual acuity at the time they enter school. because problems with visions can affect learning. After that, they should be examined every 1 to 2 years, depending on whether they need vision correction.

What are reasons for having a comprehensive eye exam in childhood?

Triggers for a comprehensive eye exam include the following: 

  • Failing or unable to perform a vision screening.
  • A school nurse or a pediatrician or family physician refers the child
  • The child has certain medical conditions that have a high risk for eye problems, such as
  • A family history of certain hereditary eye conditions, such as
    • strabismus
    • amblyopia
    • congenital cataracts 
    • congenital glaucoma 
    • retinoblastoma
  • The child has a learning disability, developmental delay, neuropsychological condition, or behavioral issue.
A child should also have a comprehensive eye examination if they have certain symptoms or behaviors, such as
  • Avoiding or disliking reading
  • Short attention span
  • Difficulty throwing or catching a ball, copying from a chalkboard, or tying their shoes
  • Pulling a book in close to their face or sitting too close to a TV
  • Lots of blinking or eye rubbing

Another reason to ensure your kids get regular eye exams is that nearly 80% of a child’s learning happens visually. Too often, a child who can’t see well is misdiagnosed with a totally unrelated behavioral problem like ADHD when they may only need a pair of glasses.

What should I tell my eye doctor during an eye exam?

Just like any other doctor’s appointment, an eye exam should include a robust dialogue with your doctor. It should include any current or past visual symptoms. There should be full transparency about the amount of time you spend staring at screens and tablets. It should also include a discussion of whether you follow guidelines for the proper use and cleaning of contact lenses and whether or not you sleep with your contact lenses in.

Sharing your lifestyle and habits with your eye doctor will allow him or her to provide guidance on optimal eye health for you. Some questions you may want to ask your eye doctor include:

  • Does my vision seem stable?
  • Are prescription sunglasses a good option for me?
  • How do I address tired eyes?
  • What kind of eye drops do you recommend, if any?

If it’s been a while since you or your kids had an eye exam, don’t put it off any longer. Make an appointment with an eye care professional today to help ensure good vision for life.

Related content: Do You Know the 3 Main Causes of Blindness in the U.S.?

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This article was first published on 8/26/2016. It was reviewed and updated on 5/24/20 for republication.

I fill the hours leading up to a novel experience by creating ridiculous stories about the person or place I’m about to see for the first time. After the occasion passes, I then take a few minutes to reflect on how my expectations lived up to reality. I’m sure it’s some sort of psychological defense mechanism evolutionarily adapted because it allays the most disconcerting of all human emotions, fear of the unknown.

If I imagine myself spewing wine all over my friend’s family’s Thanksgiving turkey after starting to laugh while taking a sip of chardonnay, the reality always seems much calmer and the experience a little, well, duller…unless, of course, my wildest imagination turns out to match the reality. This became the case for my first clinical instructor.

The pediatric hematology unit

Day One with Dr. R in a pediatric hematology unit. I had plenty of preconceived, wild notions in my head about this mysterious doctor. He was my ambulatory care preceptor, the only clinician with whom I would directly interact in a hospital setting during my first year in medical school.

The “clinical skills” part of my mind was essentially a blank slate for Dr. R to fill. After learning of my assignment, I needed to contact Dr. R to arrange my ambulatory care schedule with him. Simple? Not so.

After a few enthusiastic emails, calls to a phone number that wasn’t connected to a voicemail system, calls to his receptionist, and desperate last-ditch strategies discussed with the other student assigned to the same rotation, I finally received a two-word email from Dr. R in response to my elaborate plans for getting the most out of my shadowing experience.

“That’s fine.”

My imagination went wild

Visions began to dance in my head of this new character about to walk into my life, this “Dr. R”. A Google search yielded few clues—a photograph of a bald, smiling, middle-aged Indian man and a few PubMed articles.

My findings left plenty of room for imagination. Dr. R was a high-profile pediatrician and extremely hard to contact. He was in the process of making great strides in research involving debilitating diseases.

Related content: Osmosis: Revolutionizing Medical Education One Video at a Time

I envisioned myself regressing to “little girl” status with Dr. R as my disgruntled parent, dragging me along by the hand as he treated his patients. In my worst-case scenario, I accidentally broke a small child’s leg with a reflex hammer. Dr. R reported me to the appropriate authorities and I was sentenced to life imprisonment during which Dr. R visited weekly to laugh at me in jail.

The reality

When the first afternoon of my ambulatory care rotation finally arrived, I was confident I would exceed the low bar of my expectations. It was, after all, set at “not breaking a small child’s leg with a reflex hammer and dying in jail.”

How would my imaginary Dr. R compare to the living, breathing Dr. R? In his small office, I waited with a third-year medical student, twiddling my thumbs as we waited for him to return from lunch.

The other student spent the first ten minutes of the wait sharing tales of the third year’s horrors. I forgot her name so I mentally labeled her “Buzz Kill.” I zoned out as she droned on, letting my eyes wander around the cluttered desk and shelves. There were files holding pediatric patient information, a stack of papers for “stigma study” and a cabinet full of children’s books.

Hello everybody!,” Dr. R said as he burst into the room like a ray of sunshine. He radiated a level of warmth disproportionate to his diminutive size. He shook our hands and pushed through to his desk, shouldering two large bags. He emptied one of the bags on his desk and Asian pears tumbled out.

Can I pear pressure you to take a piece? They are very good, and fresh from the market!” Dr. R pulled out a pocketknife and began carving the large fruit in graceful strokes.

I was pear pressured for the first time

I was pear pressured for the first time that day. I held out my hand and caught the slice of Asian pear as it fell from the knife. I had never eaten an Asian pear and savored the crisp sweetness.

OK, I will be right back.”

Dr. R walked down the small hallway, poking his head into each patient’s room. He asked the children to hold out their hands to catch the succulent Asian pear pieces. I heard their mothers laughing as they, too, experienced pear pressure. I looked at Buzz Kill. She seemed happier.

Dr. R returned with one pear sliver, which he popped into his mouth. He had an unbelievable amount of food left on his desk that I now realized was not for him.

After we exchanged a sticky handshake, Dr. R launched into a long-winded and heartfelt explanation of his practice. Dr. R’s patients hailed from an underserved African-American community. Most were on Medicaid or had no medical insurance. He worked mainly with patients with sickle cell disease and those who were HIV positive.

Dr. R’s practice: An introduction to Empathy

Dr. R was leading a study about the stigma many communities attach to HIV patients. His relationships with these patients were longstanding. This was because these chronic conditions required multiple visits for blood work and check-ups.

He had been practicing and teaching at the hospital for a few decades. Some of his “pediatric” patients were currently in their late twenties and now brought their own babies to see him. None of them wanted to change doctors and he wouldn’t turn them away. I learned why.

Other stories by Medical Students:
The Privilege of Being a Third-Year Medical Student
How Phlebotomy Prepared Me for Medical School
A Mother’s Howl: A Medical Student’s Lesson on Giving Bad News

After our brief orientation, his work began. “Doctor’s work” doesn’t fully describe what I saw that afternoon. I saw “healing”.

Dr. R left each of his patients and their parents with smiles on their faces. Their stories were often moving, troubling, even frustrating. In addition to the obvious effects on children’s health, chronic diseases create great financial burdens for caregivers. Many of his patients’ parents lacked basic knowledge about good health practices.

Dr. R gave his patients all the time they needed, asking just the right questions to foster his relationship with them and steer them down the road to better health.

I saw a teen mom who had been kicked out of her parents’ home due to their strong religious beliefs against premarital sex. She was now living with an uncle, her baby’s father having long since vanished. I saw teens who were trying to get pregnant, which I questioned in my mind.

Dr. R’s good advice

Dr. R was a great listener. He was never judgmental. While we were waiting for more patients, he would give me what can only be described as “life tips”. Among them was the advice to never assume my own beliefs were shared by all people.

“It’s not ideal for a baby to be born to a young mother before she is married and has solidly established herself in the workforce. But some girls find their fulfillment in motherhood. Who am I to stop them from fulfilling the role they believe they were born to play? The baby will be loved. Our job is not to pass judgment, but to promote health and happiness.”

Dr. R explained with exquisite clarity the ramifications of sickle cell disease to a new mother whose baby was born with the condition. In the next room, he performed a well-child checkup on an albino girl with nystagmus, an eye disorder. Next door was a little boy with a rare fungal infection on his scalp.

Across the hall was a 4-year-old girl with sickle cell disease who knew she was there to have her blood drawn. Her mother told me her daughter wouldn’t cry. She never said a word when she came into the doctor’s office and saw white coats. 

Related Content: How Phlebotomy Prepared Me for Medical School

As she was explaining this silent treatment to me, Dr. R rushed by in the hallway. The four-year-old saw him through the open door and said softly and adoringly, “Dr. R!” She leapt off the examination table and ran into the hallway with open arms to hug him. The mother smiled and said Dr. R was her daughter’s exception.

I chatted with these patients as I took their medical histories, listened to their hearts, and palpated their spleens. I became more aware than ever of my ignorance. This was all the more ironic after the months I had spent in a library trying to make sense of the human body.

There was so, so much I needed to learn, which simultaneously frightened and excited me. Whenever I had a question, Dr. R was there to patiently answer it.

Real patient engagement

The day ended with a visit from a 4’10” 20-year-old woman recovering from HIV encephalopathy, a problem with her brain. Dr. R sent me down the hall to meet her while she was being triaged by the nurses, describing her as a “stand-up comedian”.

He was right. She had me laughing immediately as I watched her beg the nurse to add a few inches to her height measurement so she could hit the five-foot mark. We walked back to her room together.

We could have been in Dr. R’s living room. He asked her about the iPod he had given her for Christmas. He also asked if she needed money. When she nodded, he pulled out his wallet and gave her a twenty-dollar bill and a Metro ticket.

He knew from her blood test results she wasn’t regularly taking the antiviral drug cocktail she needed for her HIV. He gently probed to learn how often she was taking it.

So, how often do you take your medication? Once a month? Once a week?

I am taking my medicine.

Dr. R did not reprimand her, but softly continued the conversation about the importance of the medicine.

Hugs, kisses, and a slice of Asian pear

Dr. R loved to hug his patients and kiss babies and build the confidence of teenagers in the throes of their “awkward stage”. His distinctive and contagious laugh resonated down the hallway the entire afternoon. 

Every single patient that day received a hefty slice of Asian pear. All of the toddlers walked away with colorful children’s books from the stockpile he kept in his office. He had me personally autograph each book as if I were the author. I wrote little notes to the children above pictures of flowers and puppies.

When every patient had been healed, Dr. R and I walked through the hospital together on our way to the subway. Before we parted, he asked me to take some time that night to think about the people I had met that day.

The best and most crucial part of being a physician is learning from the patients’ stories. I can give medicines, but I think listening to the stories is much, much more important.

I never would have thought I could learn so much in a single afternoon. My hypothetical case could not compare to a pear-filled reality starring a doctor who placed all his patients on the pedestals the rest of society denied them. No wonder Dr. R had been difficult to contact.

He’s kinda busy.

More medical student essays: My First Patient, My First Death

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TDWI author, Margaret Cary, developed and taught the Narrative Medicine/Personal Essay course at Georgetown University School of Medicine. Her students’ essays, such as this one reflect their thoughts on being in medical school and becoming physicians. 

This essay was first published on August 24, 2010 with the title, Pear Pressure. It was republished on December 5, 2019.

As humans, we constantly form new epidermal cells. When these cells get closer to the surface of the skin, the cell slowly dies and the visual manifestation of this is flakes. This is a normal process that happens to everyone all the time. In some people, the rate of epidermal cell development is accelerated.

Dandruff and seborrheic dermatitis are conditions involving the increased rate of shedding of the topmost layer of the skin called the epidermis. The most common form of seborrheic dermatitis which only involves the scalp is dandruff.  Dandruff can be asymptomatic or cause mild flaking and itching. The best way to treat dandruff is to use over the counter (OTC) medicated shampoos like pyrithione zinc, ketoconazole, or selenium sulfide. These meds can be left on for a few minutes and then rinsed off. They can be used daily or 2-3 times per week until the symptoms are gone. Recurrence can be prevented by continuing to use one of these products 2-3 times per week.

With seborrheic dermatitis, there is a greater turnover rate of skin cells than in dandruff. The rest of this article focuses on seborrheic dermatitis

Seborrheic Dermatitis

The frequency of Seborrheic Dermatitis

As a pediatrician, I encounter seborrheic dermatitis at least 3 times a day on the infants I see. Many people know this condition as “cradle cap.” Seborrheic dermatitis is the scale on a 3-month-olds scalp, the flakes on their eyebrows, and the redness and moisture under the neck folds, behind the ears, in the armpits, and in the groin. About 1 in 3 infants are affected [1]. In pediatric offices in some countries, seborrheic dermatitis can account for 4.5% of problems seen in children younger than 6 years [1].

Seborrheic dermatitis is also found during puberty and in adulthood. It is thought that 1-3% of adults are affected. The peak prevalence in adults is during their 30s and 40s. The affected areas of the body that become red, itchy, flaky, and scaly are very similar to that which is found in infants: the face (especially below the hairline on the forehead, in and between the eyebrows, in the crease between the nose and the cheeks, and in the mustache and beard area in men with facial hair), upper chest, armpits, behind the ears and inguinal folds [2,3].

Of note, seborrheic dermatitis gets worse during cold and dry winter months and during times of stress and tends to improve in the summer possibly from sun exposure [3].

Financial Burden

The estimated financial burden of this disease is immense. “It is estimated that at least 50 million Americans suffer from dandruff, who spend $300 million annually on over-the-counter products to treat scalp itching and flaking.” [2] Outpatient office visits alone for seborrheic dermatitis (SD) cost $58 million in the United States in 2004, and $109 million was spent on prescription drugs [2].

“Together with over-the-counter products and hospital services, the total direct costs of SD were estimated to be $179 million, plus another $51 million indirect costs in the form of lost work days. In addition, because SD frequently occurs on the face and other visible areas, it has significant negative effects on patients’ quality of life (QOL) in the form of psychological distress or low self-esteem; the willingness to pay for relief of the symptoms was $1.2 billion.” [2].

What causes seborrheic dermatitis?

Most sources concur that a fungal species (yeast) called Malassezia is involved. This yeast metabolizes the oils produced by sebaceous glands producing a more irritating acid that starts the inflammatory cascade that causes the redness and leads to the overproduction of the topmost layer of skin cells (stratum corneum) causing the flaking and scaling.

With this overgrowth, the barrier function of the skin is disrupted and it loses moisture. Then you get more yeast and more inflammation and the cycle continues until the hormonal milieu (transitioning from infancy to childhood or childhood to puberty) changes sebaceous gland activity or we make a medical intervention.

The immune system and neurological system also play an unknown role in seborrheic dermatitis. People with an impaired immune system have an increased prevalence of seborrheic dermatitis and people with Parkinson disease have increased sebum production and when treated with L-dopa their seborrheic dermatitis improves [3].

Differential Diagnosis

What else shares similar signs or symptoms to those of seborrheic dermatitis? Other conditions doctors may need to consider are psoriasis, rosacea, allergic contact dermatitis, tinea versicolor, pityriasis rosea, tinea corporis, secondary syphilis, lupus erythematosus, and pemphigus foliaceous [3].

How does one treat seborrheic dermatitis?

Children:

In an informal study conducted in Houston, 7 out of 10 pediatricians recommended an adult OTC (Over The Counter) anti-dandruff shampoo with pyrithione zinc or selenium sulfide to treat seborrheic dermatitis, also called “cradle cap.” In refractory cases, pediatricians sometimes have to also add a topical steroid for a short duration.

Many families try coconut oil, baby oil, olive oil or petroleum jelly to loosen scales and then use regular shampoo. However, many infants do not improve with those treatments.

Adult anti-dandruff shampoos were suggested due to the lack of an OTC shampoo specifically designed for children of all ages. These shampoos work to address the issue, but they were designed for the skin of an adult and many times have strong fragrances or alcohols or dyes that are not suited to dry, irritated skin.

I have developed a new option for children of all ages (and adults) called Dr. Eddie’s Happy Cappy. It is the first OTC shampoo and body wash made specifically for children of all ages with an FDA approved active ingredient, pyrithione zinc. This shampoo is fragrance-free, dermatologist tested, dye free, alcohol free, paraben free and contains the natural ingredient Licorice Root Extract to help soothe redness behind ears, under armpits, and in neck folds.

Adults:

The most common treatment for adults is OTC anti-dandruff & anti-seborrheic dermatitis shampoos like pyrithione zinc, selenium sulfide, ketoconazole, salicylic acid or coal tar. Under the care of a physician, an adult may be prescribed topical antifungal medications like ketoconazole or for short duration they may receive topical steroids or calcineurin inhibitors (another category of topical medication). In Europe topically applied lithium sulfate or lithium gluconate is used to help seborrheic dermatitis in non-scalp areas.

“A 2015 systematic review and meta-analysis including 51 randomized trials with over 9000 participants found that in patients with seborrheic dermatitis of the face and scalp, topical ketoconazole 2% applied once or twice daily was more effective than placebo in improving erythema, pruritus {itching}, and scaling at four weeks.” [3]

Another 2014 study showed that use of topical calcineurin inhibitors (pimecrolimus or tacrolimus) or topical steroids or topical lithium applications all reduced the symptoms of seborrheic dermatitis about the same and did better than placebo. Side effects from these treatments include redness, burning, dryness, and itching [3].

Other topical remedies included in the UpToDate review article, include ones derived from sulfur—precipitated sulfur 3%, colloidal sulfur 3%, or sodium sulfacetamide 10% in cream or lotion base.  They comment that these are, “an old but effective remedy, although patients may object to its odor.” [3]

Oral antifungal agents have also been used for seborrheic dermatitis occupying multiple areas of the body or disease not adequately controlled with topical therapy; however, evidence supporting the use of oral therapies is limited [3].

  1. Foley P, Zuo Y, Plunkett A, Merlin K, Marks R. The frequency of common skin conditions in preschool-aged children in Australia: seborrheic dermatitis and pityriasis capitis (cradle cap) Arch Dermatol. 2003;139:318–322.
  2. Borda L, Wickramanayake, T. Seborrheic Dermatitis, and Dandruff: A Comprehensive Review J Clin Investig Dermatol. 2015 Dec; 3(2): 10.13188/2373-1044.1000019. Published online 2015 Dec 15. doi:  10.13188/2373-1044.1000019
  3. Sasseville, D., Fowler, J., (2018). Seborrheic dermatitis in adolescents and adults. In Corona, R., (Ed.), UpToDate. Retrieved July 20, 2018, from https://www.uptodate.com/contents/seborrheic-dermatitis-in-adolescents-and-adults

It was a bathmat that did it.

Leaning over my tiny daughter as I bathed her one night, I stared at the broken-in vinyl mat she was sitting on in the tub. For the first time, I wondered if it could be leaching into every night’s bathwater. And into her. When even Google couldn’t give me a clear answer, I knew I had work to do.

Turns out, there’s no clear, credible and concise site for consumers, no place where they can get actionable guidance about how to reduce their exposure to everyday toxic chemicals. Meanwhile, there’s a silent epidemic: A tidal wave of toxicity surrounding us. Most of us remain completely unaware of it – especially pregnant women who are responsible not only for their own health but also for the health of the whole next generation.

I started SafetyNEST to solve this problem.

We are surrounded by toxins

According to the EPA, there are more than 85,000 synthetic chemicals that surround us in everything from our living room couch to our cleaning products.1 Another way to slice it: 30,000 pounds of industrial chemicals are being produced for every single person in the United States, every year.2 Lead, mercury, phthalates, Bisphenol A, flame retardants, Teflon, and pesticides are among the chemicals of concern. Increasing evidence shows widespread exposure and adverse health outcomes as a result.

Here’s the glitch.

Most of us think that if it’s sold in the store, someone must have tested it for toxicity and safety…right?

Not so. Unlike pharmaceuticals, consumer product companies can constantly introduce chemicals into the environment with little to no proof of safety, due to a flawed approval system.3

These chemicals get into us through the air we breath, the food we eat, the water we drink and a host of products we routinely, blithely, benightedly use in our home and workplace. Us, by the way, includes pregnant women. Virtually every pregnant woman in the US, according to a UCSF study, has at least 43 toxic chemicals in her body. 4 These chemicals are also found in the breast milk of nursing mothers and the umbilical cord blood of newborns.

Toxins and pregnancy

We know for sure that exposure to toxic chemicals, even at very low levels, during vulnerable windows of development such as pregnancy and infancy can disrupt the delicate growth process, causing a lifetime of health havoc, even death.5 Prenatal exposure to toxic chemicals is linked to preterm birth, birth defects, childhood cancer, obesity, diabetes, asthma, and lasting harm to the brain.6

Toxic chemicals affect us all. But many toxic chemicals disproportionately impact vulnerable populations, leaving underserved women more susceptible to adverse impacts. These can be exacerbated by other factors, including stress, nutritional status, housing quality, and poverty. It’s notable that immigrant populations often work in occupations associated with hazardous workplace environments.

Related content: Fetal syndromes: Diagnosis, Treatment, and Outcomes

Research continues to prove that we are ignoring this issue – but shouldn’t be. In August 2017, UCSF released a study titled “Higher Exposure to Flame Retardants in Pregnant Women Leads to Lower IQ in Children.” The facts:

For every 10-fold increase in a mom’s levels of PBDE – the compounds used as flame retardants, which are found in couches, electronics, plastics and more – there’s a drop of 3.7 IQ points in her child.

The price tag for all this? In 2008, the price tag was $76 billion every year in the United States. This is for poor childhood health caused by environmental factors, such as air pollution and exposure to toxic chemicals.7 The Lancet published a 2016 study showing exposure to chemicals in pesticides, toys, makeup, food packaging and detergents costs the U.S. more than $340 billion annually, in health care costs and lost wages.8

How can this be something we are willing to ignore?

How can this be something we are willing to ignore? Maybe we’re not. Since SafetyNest started in 2016, a lot has happened:

  • There’s been an acknowledgment of the problem

In the US: The American College of Obstetricians and Gynecologists (ACOG) released a Committee Opinion in 2013 stating:

“The evidence that links exposure to toxic environmental agents and adverse reproductive and developmental health outcomes is sufficiently robust….Harmful chemicals can cross the placenta…ACOG and the American Society for Reproductive Medicine join leading scientists and other clinical practitioners in calling for timely action to identify and reduce toxic environmental agents while addressing the consequences of such exposure.” 9

There has been a call to action

FIGO, the International Federation of Gynecology and Obstetrics, released a call to action in 2015 that stated, categorically, that exposure to toxins before and after birth is a serious threat and

“Preventing exposure to environmental chemicals is a priority for reproductive health professionals everywhere.” 10

  • There has been legal reform

After 40 years of waiting, the Toxic Substances Control Act (TSCA) – our nation’s badly broken chemical safety law – was reformed in June 2016. It still leaves the majority of chemicals untested and only a very small fraction of new chemicals added to the list for assessment.11 But it is a step in the right direction.

SafetyNEST – a trusted source for pregnant women

We can’t just kick back and wait for strong policy to be enacted in the United States. We have to get smart, ourselves. This is why SafetyNEST’s mission is to become the most trusted source for every pregnant woman and her reproductive health provider to safeguard our babies’ health against toxic chemicals.

SafetyNEST transforms prenatal care by equipping both reproductive health providers and the pregnant women they serve with the most accurate, evidence-based, and personalized information about the effects of toxic chemicals on prenatal and early childhood health. Our goal is to reduce the incidence of preventable diseases linked to toxic chemical exposure.

Our priority is developing an engaging, digital health platform to educate women about how to reduce their exposure to toxic chemicals in their daily lives, particularly in their homes. Partners include UCSF Program on Reproductive Health and the Environment, Icahn School of Medicine at Mount Sinai and the American Medical Women’s Association.

Together we’re working to make sure no more mothers have that moment of panic I did, all those years ago, at bath time – or worse. It’s our job, and our mission, to give the next generation the best possible start.

References

1. Children and Environmental Toxins: What Everyone Needs to Know, Philip J. Landrigan and Mary M. Landrigan, Oxford University Press, 2018.
2. We’re Surrounded by Way More Chemicals Than We Thought, Mother Jones, October 2015.
3. Why the Toxic Substance Control Act Needs an Overhaul, and How to Strengthen Oversight of Chemicals in the Interim, SA Vogel and JA Roberts, Health Affairs, 30:898-905, 2011.
4. UCSF Study Identifies Chemicals in Pregnant Women, January 14, 2011.
5. Environmental Chemicals in Pregnant Women in the United States, Tracey Woodruff et al, Program on Reproductive Health and the Environment, Environmental Health Perspectives, June 2011.
6. The Role of Environmental Toxicants in Preterm Birth, National Academy of Sciences, 2007.
7. Environmental Illness In Children Costs $76.6 Billion Annually, Health Affairs, May 20111.
8. Exposure to Endocrine-Disrupting Chemicals in the USA: A Population-Based Disease Burden and Cost Analysis, The Lancet Diabetes and Endocrinology Journal, October 2016.
9. Committee Opinion Number 575, Exposure to Toxic Environmental Agents, ACOG Committee on Health Care for Underserved Women; American Society for Reproductive Medicine Practice Committee; UCSF Program on Reproductive Health and the Environment, October 2013.
10. Opinion on reproductive health impacts of exposure to toxic environmental chemicals, Di Renzo GC, et al, International Federation of Gynecology and Obstetrics, 2015.
11. Assessing and Managing Chemicals Under TSCA: The Frank R. Lautenberg Chemical Safety for the 21st Century Act, United States Environmental Protection Agency, June 2016.

It seems that a week does not go by where we are reading about another story related to obesity in America, or obesity trends globally. What I find even more concerning, are the increasing number of stories being published about childhood obesity. This is the real tragedy that is unfolding before our eyes. From my perspective, as a liver specialist, childhood obesity is public enemy number one.

The latest story was published in the Journal of Pediatrics, from Columbia University. What the researchers found is that childhood weight gain has a negative impact on the liver health in children as young as eight years of age. Larger waist circumference at age 3 raises the likelihood that by age 8, these young children will have early indicators of non-alcohol fatty liver disease (NAFLD).

This excess fat in the liver triggers inflammation in the liver, which in select patients, puts them at increased risk for advanced liver disease and cirrhosis (scarring of the liver). For those of us that are intimate with this topic and clinical scenario, this is an eye-opening report for parents, who need to seriously look at their children’s nutrition, what they are being fed, and the exposure to processed foods that are the norm in today’s culture.

 

Eating yourself sick

With over 25 years of experience in liver disease, I have written a book addressing these very concerns. Eating Yourself Sick: How To Stop Obesity, Fatty Liver, And Diabetes From Killing You And Your Family is the culmination of my years in practice, sharing my experience and suggestions on how to control this looming public health disaster.

According to the World Health Organization, obesity has more than doubled worldwide since 1980. In 2014, more than 1.9 billion adults were overweight, including 600 million considered to be obese. Those overweight comprised 39 percent of the adult population, one-third of all people age eighteen and over.

Some forty-two million children age four and under were also overweight or obese.3 Since 1980, the rates of obesity have tripled in youth, ages two to nineteen, while the numbers of obese six- to eleven-year-olds has doubled, and obese teenagers quadrupled from 5 to 20 percent. There are significant racial and ethnic inequalities in those numbers. Latinos and blacks, for example, become obese earlier, faster, and more frequently than whites and Asian.

Once thought of as a problem only affecting high-income countries, today obesity is on the rise in low- and middle-income areas of the world. In fact, the World Health Organization (WHO) reports that, worldwide, overweight and obesity now accounts for more deaths than underweight.

In addition to the current Journal of Pediatrics article, a recent New England Journal of Medicine article found childhood obesity to be a strong indicator of obesity at age thirty-five. Obese two-year-olds have a better than 50 percent chance of being obese at thirty-five, showing the powerful predictive value of obesity at a young age.

The discussion about obesity, as a result, needs to start even sooner, and is not just a problem of those adults over fifty years old. Research data further supports the revelation that because of obesity and fatty liver being seen in children, this generation of children will not live as long as their parents, a result of life-shortening complications of type-2 diabetes, liver disease, heart disease, and kidney disease.

Now, it’s true that the liver is capable of regenerating itself. In the very early stages of scarring, there is the potential to reverse some of the damage. But when it is subjected to a destructive, ongoing, vicious cycle of damage-regeneration-damage-regeneration, it begins to develop irreversible scar tissue. Ultimately, that leads to the develop­ment of cirrhosis.

Once cirrhosis has reached more advanced stages, there’s very little that can be done short of a transplant. Without a transplant, death is forthcoming.

 

 

Who is at risk for NAFLD?

NAFLD is more common in obese people, and as many as 7% of normal-weight people also have NAFLD. High-calorie diets that include consumption of excess saturated fats, refined carbohydrates, and high-fructose and sugar-sweetened foods and beverages have been associated with NAFLD.

Even without a current diagnosis of fatty liver, you may still fit into a high-risk category for fatty liver. Again, fatty liver is the liver mani­festation of metabolic syndrome. The other characters of metabolic syndrome—obesity, diabetes or insulin resistance, high cholesterol— increase the risk for fatty liver.

In studies of obese patients undergoing bariatric surgery, 90 percent have NAFLD, and around 5 to 8 percent of them already have cirrhosis. Type-2 diabetes also increases the prob­ability of having fatty liver. Studies have shown that 70 percent of people with type-2 diabetes who have gone in for an ultrasound were found to have fatty liver. And half of the people with high triglycerides and low HDL (bad cholesterol) are found to have fatty liver.

Since metabolic syndrome is an early warning of liver disease, the symptoms may not come from the liver itself but from one of the other characters: obesity, diabetes, or heart disease. If you have any of those comorbidities, those other metabolic syndrome characters, then you are at a higher risk for the development of more scar tissue and cirrhosis, which means you’re at risk for liver cancer, liver failure, and maybe, even the need for a liver transplant.

Related Content: Obesity in Men: It’s Not Just About How You Look

The silent killer

It has become popular with the lay public to refer to liver disease as the silent killer. While I have never truly liked this characterization, probably because not every liver issue will kill you, it does have some credence because all too many patients I have cared for over the past twenty-five years arrive too late to benefit from an early diagnosis and intervention.

But liver disease is called the silent killer because it often doesn’t reveal any real outward signs of problems until it’s too late. Unlike the gallblad­der, pancreas, and other abdominal organs, fatty liver really doesn’t cause pain or abdominal distress. It’s easy for people to ignore it and have a false sense of security that they’re well.

The first sign of a problem is often fatigue, something most people just tolerate by moping along. They make up excuses such as stress, a bad marriage, shift work, or other possible causes. But at age thirty, forty, or fifty, it’s not normal to be “just tolerating” fatigue. If you’re obese, fatigue may be a sign of sleep apnea. It may be related to acid reflux (GERD), which is causing an unrecognized disturbance in your sleeping pattern. Fatigue can also be an early symptom of diabetes, hormonal imbalances, anemia, or a yet-to-be-diagnosed cardiovascular disease or malignancy.

People also have a tendency to tolerate gradual weight gain. Obesity doesn’t usually happen as a fifty-pound gain over six months. It’s gradual, a pound or two every month adding up over several years. With so many extra pounds added on, people tend to overlook another symptom of liver problems: swelling of the legs and feet. Often, they’ll just chalk it up to being on their feet too long.

With cirrhosis, healthy, functioning, metabolically active liver cells are replaced with scar tissue, which, essentially, doesn’t work. Because of the scar tissue in the liver, circulation in the liver is altered and a condition known as portal hypertension develops. Complications of portal hypertension include ascites, which is a buildup of fluid in the abdomen.

By the time people come to me, many have advanced scarring and fibrosis. Once someone comes to me with fatty liver or a further progression of liver disease, we have a far more detailed conversation to put their situation into perspective.

When we are able to intervene earlier, when we identify that a patient is on the road to having metabolic syndrome by being overweight and having prediabetes or high blood pressure, we don’t fall back on the punch line, “Eat more fruits and vegetables.”

My staff and I know that simply snapping out some recommendations is an unrealistic way of turning things around. Instead, we guide patients through a detailed assessment that looks at eating patterns, snacking, family structure, barriers to exercise, barriers to eating right, and more. We ask questions such as,

  • Who is living at home with you?
  • Do you have little children?
  • Do you work shift work?
  • Are you a caretaker for someone with special needs?
  • How do the dynamics of your life positively or negatively impact your ability to shop, cook, eat, and prepare food?
  • What are the obstacles to going to the gym or going for a thirty-minute bike ride, four days a week?

For many people, turning around a lifestyle begins by learning what healthy food looks like.

The obesity epidemic is taking no prisoners.

Now, we need to be especially concerned about our children. Do you share my concern and outrage? You should.

In June 2017, a 4-year-old boy in Texas died under tragic and seemingly inexplicable circumstances. The boy, named Frankie Delgado, was playing in knee-deep water when a wave knocked him over, causing his head to dip below the water. Despite being monitored at the time, Delgado inhaled a small amount of water. After a brief coughing fit, he was able to calm down. The next night, he began to vomit and experience diarrhea. Later that week, he died suddenly. Because water was found in his lungs and around his heart, medical staff informed the parents that the boy died of “dry drowning”.

In 2017, news stories on cases of dry drowning spread across social media like wildfire, as did parenting blog articles providing some words of (sometimes ill-informed) wisdom in response to the hysteria. It has caused a phenomenon that some social commentators have dubbed parenting paranoia.

For any parent who read this story last year, the term “dry drowning” became ingrained in their mind. The idea that a child could inhale just a small amount of water during playtime and die days afterward is terrifying. The concept is so anxiety-inducing that it has caused some parents to live in fear, becoming the prototypical “helicopter parent”: closely monitoring their children, limiting what they can do, and reading misinformation about the phenomenon online.

Unfortunately, this unhealthy cycle of fear and overreaction is harmful to the parent-child relationship. According to Psychology Today, helicopter parenting can result in increased anxiety in children, and even stunt emotional and cognitive development. The resulting lack of self-efficacy can result in serious mental conditions such as depression. Kids raised in such conditions often grow up to be extremely dependent on others and may struggle to grow and learn.

What should you be aware of about dry drowning? How can you prevent it? Should you be terrified? Read on for more information on this issue:

 

What is dry drowning?

There is a good deal of confusion about what actually constitutes “dry drowning” or “secondary/delayed drowning”. However, there is a distinction between the two, and news stories often fail to differentiate.

  • Dry drowning: The above incident is not a true case of dry drowning. Dry drowning occurs when a person suffocates despite no water actually entering their lungs. This is an uncommon occurrence, and only a small percentage of all drowning fatalities can be classified as “dry drowning” accidents.

When a person suffers from dry drowning, water enters the mouth or nose and the person’s vocal cords spasm and close. The brain is essentially tricked into believing that it is in danger, and the resulting anxiety can result in a potentially fatal physiological response: It prevents breathing to such an extent that it can lead to suffocation. The lack of oxygen causes aerobic metabolism to stop, which can lead to cardiac arrest and a lack of blood circulation in the brain.

When a person is suffering from dry drowning, there are clear signs that something is amiss. While victims don’t typically thrash around or signal/call for help during a drowning, they will make a panicked effort to keep their head above the water, often rolling in the water. Lifeguards or parental guardians should be on the lookout for anyone who is swimming or bobbing in the water in an uncoordinated manner. This could be a sign that someone is in trouble.

  • Secondary/delayed drowning: Secondary drowning is also a rare occurrence. This occurs when an individual swallows water and gets it trapped in their lungs. While some symptoms (such as labored breathing) should be immediately apparent to the victim, the individual may go for hours or even days before the condition becomes debilitating or fatal.

Secondary drowning may cause inflammation and other severe complications. Pulmonary edema—a buildup of fluid in the lungs—can make it difficult to breathe. In a case of secondary drowning, this problem will worsen over time, typically becoming unbearable within 24 hours. Water in the lungs could also lead to potentially fatal infection.

A victim of this form of drowning may exhibit signs of difficulty breathing, begin vomiting, or experience coughing fits. Sufferers can also be mentally affected; they may experience extreme forgetfulness or sleepiness. A person who exhibits signs of secondary drowning should seek help immediately and be closely monitored. With quick medical intervention, the water can be safely removed from the lungs, and the victim can recover.

 

What should you do?

Practice swimming safety regularly and teach your children to follow these rules every time they enter the water. These rules include:

  • Only swim when a guardian or lifeguard is present
  • Swim with a buddy whenever possible
  • Avoid excessive horseplay; don’t get pressured into doing a stunt
  • Do not swim when you are sick or tired
  • Do not swim at night in areas without sufficient lighting
  • Do not eat or chew gum while swimming
  • Refrain from swimming during inclement weather
  • Obey all other posted swimming rules in the area

Parents and guardians should continue to monitor children during playtime—there is no reason to forsake trips to the pool or beach altogether. If a child shows signs of discomfort in the water, intervene; don’t assume that the lifeguard will be alert. The signs of drowning can be deceptive, and the instinctive drowning response can make it impossible for an individual to speak or signal for help.

If a child swallows any water, stay observant of their behavior over the course of the next few days. Secondary drowning complications escalate over time, with symptoms becoming apparent within a 24- to 48-hour timespan. Symptoms to be alert for include lethargy, labored breathing, vomiting, and incontinence. Some symptoms are commonly mistaken as symptoms of a cold or croup. Trust your gut—if something about your child’s demeanor seems “off”, consult a medical professional.

Don’t fall victim to the fear-inducing hype. While there are real risks to be aware of, being observant will eliminate nearly any risk. By following these best practices, parents can protect their children without imposing needless restrictions or limitations on their lives. Understand the risks of dry and secondary drowning, and act accordingly if you notice the symptoms.

For years, people have been talking about the microbiome, probiotics, and gut health. Yet, most parents (and even some doctors) are unaware of the critical role of the infant microbiome as a foundation for good health throughout a child’s life.

For example, here are several interesting facts about the infant microbiome:

  • Although children leave the sterile womb without any microbes, they eventually have more than 100 times more bacterial genes than human genes.
  • The development of a child’s gut microbiome can affect his or her ability to absorb nutrients, fight off infections, reduce pain and stress, and more.
  • Mothers can help their child create a healthy gut microbiome from the moment of birth, through early childhood, and beyond.
  • The good bacteria in a child’s gut can be fed by special prebiotics called human milk oligosaccharides (HMOs).* These are found in abundance in breast milk, where they play a very special role in supporting babies’ developing immune system. After more than a decade of research and development in this area, one infant formula in the U.S. has now added HMOs to its formulations**.

 

Why gut microbes matter

Although microbes are present everywhere in and on the body, the large intestine (or colon) contains the highest concentration and greatest diversity of microbes.

These trillions of microorganisms aren’t just along for the ride. We have a symbiotic relationship with them; in exchange for giving them a place to live, they help keep us alive.

For example, in addition to our digestive enzymes, microbes in the gut help to break down many of the proteins, lipids, and carbohydrates in our diet into nutrients that we can then absorb. They also have been shown to help to regulate the immune system’s responses to disease, control our weight, regulate our sleep, and alleviate stress.

 

Newborns are bacterial sponges

Before they’re one-year-old, babies are colonized by more than one thousand different species of bacteria. And their moms play an important role in building their gut microbiota. But, how so?

From the moment we’re born, our bodies begin to be colonized by trillions of microbes, with the first bacteria coming from our moms’ birth canals, gut, skin, and breast milk. The types of microbes will depend on where we were born, how we were delivered, and what we touch in our first hours and days of life.

Scientists have found that intestinal bacteria from the mother colonize the infant shortly after birth, indicating that mothers are a source of intestinal bacteria for vaginally-delivered infants. That’s why it’s important for moms to maintain a healthy diet during pregnancy.

It’s also beneficial for moms to have as much skin-to-skin contact as possible with their newborns, especially in the first 24 hours of life, which is a critical time for passing along immune-supporting bacteria.

 

HMOs in mother’s milk

There’s no doubt that breastfeeding is the best way to boost a baby’s immune system. But why is this true? What makes mothers’ milk unique and so potent?

One factor may be human milk oligosaccharides (HMOs), prebiotics that are the third most abundant solid component of breast milk after fat and carbohydrates (lactose). HMOs feed the good bacteria in baby’s gut which is where 70% of the cells of the immune systems reside, and they are thought to play multiple roles in helping to protect baby’s digestive and immune system.

Of the more than about 20 major types of oligosaccharides identified in human milk, 2’-fucosyllactose (2’-FL) is by far the most prevalent. Extensive preclinical research on 2’-FL throughout the last 15 years suggests that it may exert positive health benefits on the gut microbiome, infection and inflammation (infectious disease, immunity, and allergy), brain development and necrotizing enterocolitis (NEC)—during which portions of the bowel undergo tissue death.

Related Content:  What Parents Should Know About the New USDA Dietary Guidelines

Supporting gut health from pregnancy to early childhood

According to a 2016 CDC report, more than 8 in 10 mothers in the U.S. (81.1%) begin breastfeeding their babies at birth. It is the gold standard for infant nutrition. However, only about half of babies (51.8%) are still breastfeeding at 6 months of age.

But for all the parents who need or choose to use infant formula, there’s now a new way to give their children an immune-nourishing prebiotic previously only found at significant levels in breast milk. Backed by 15 years of HMO research, including 20 pre-clinical and clinical studies, Abbott’s Similac® with 2′-FL HMO* is the first and only infant formula in the U.S. to bring immune benefits of HMO to formula-fed babies. A 2016 Journal of Nutrition study shows that babies fed infant formula with a structurally identical version of 2’-FL HMO had an immune response more like breastfed babies.

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As parents introduce their children to solid foods, they can help diversify their babies’ microbiota by choosing foods that are unprocessed and gut-healthy such as vegetables, fruits, and grains. Encouraging a child to be active also can help build more than muscles, since research has shown that exercise may play a role in promoting a healthy gut microbiota.

At a time when some children spend countless hours interacting with digital screens, it’s become even more important for them to go outside and interact with the world around them. Research has shown that children may actually benefit from exposure to germs to develop protection from illnesses, allergies, and other autoimmune diseases. Studies show that children who grow up on farms, attend day care, or have pets are less likely to experience immune-related illnesses.

 

In summary

From the moment a child enters the world, the gut microbiome begins to develop. The first years of life are an especially critical time for growing trillions of bacteria to benefit the immune system and metabolic activity since a child’s microbiome stabilizes and begins to resemble an adult’s by the age of 3.

Pediatricians and parents play an important role in facilitating the development of the gut microbiome, which literally is a breeding ground for good health for the rest of a child’s life.

*not from human milk
**Similac with HMO was introduced in the U.S. in 2016, and will be introduced in several international markets throughout 2017 and 2018 – as the first infant formula with 2′-FL HMO, an immune-nourishing prebiotic that was previously only found at significant levels in breast milk. 

Editor’s note: Although this post has a commercial element, we felt the information valuable for our readers. We received no remuneration for posting this content.

All children play. Although you can provide them with toys, a sandbox, or figurines of their favorite cartoon characters, they really don’t need any of those things. They will play wherever they are and with whatever they have. Think, for instance, of all little kids you’ve seen stuck at an airport running around with “toys” such as an empty soda bottle or a plastic spoon. Who knew these things could be so entertaining? It turns out that this type of play, known as unstructured play, has science to support its importance in the brain development of children.

We all want to give our children the best opportunities to learn and to play. We try to make sure they have the best teachers and the best schools — if we have a choice in the matter. We enroll them in soccer, gymnastics, basketball, and other sports and try to teach them the rules and the fine points of the games. It’s only natural to try to guide them. And, that’s ok. But be sure to also allow them enough time to have playtime without guidance, rules, and structure.

The science of play

According to a scientific study, playing changes the neural connections in the front parts of children’s brains, called the prefrontal cortex. This part of the brain helps regulate emotions and aids in problem-solving and planning abilities.

This brain development is accomplished by free play, where children use their creativity and own ideas to come up with a desired game or type of play. Think back to the kid with the soda bottle. No one had to tell her how to play with it. It was the only offering the parents had, and she did all the rest.

Wrestling, making a fort, creating animals out of sticks, figuring out a game with a ball—all these activities help the brain build new circuits to aid in various social interactions and play. Children will find this type of play on their own if parents let them. Giving them the environment and opportunity is essential, but let them play on their own and in their own way.

A structure for unstructured play

Ironically, one of the best ways to induce unstructured play is the play structure. Don’t let the words mislead you. Commercial play structures provide a vehicle for creativity* but your children will do all the playing without instruction or any help from you.

Play can be a source of physical activity and development. Running, climbing, jumping, and other activities will develop strength, agility, and fine motor skills. Play structures offer attachments such as swings, slides, climbing ropes, and bridges. Usually, there is an inside of the structure that can serve as a fort or hideout conducive to social activity and development.

Children build self-confidence through play by meeting challenges from their peers or being able to traverse the horizontal ladder with only their arms or climbing the rope all the way to the top. Natural, unstructured learning will take place as games are created, modified, and played. Children will learn to share and take turns.

Socialization skills are fine-tuned as children learn to play well together, cooperate, and share. Remember some of the yard and playground games of your youth? The rules often changed to offer a new twist, or in some cases, to give scheming children a greater advantage. However, all these things need to be discussed, worked out, and implemented by the children involved.

Animals play, too

Animals are the same as children in their creative, unstructured play. Have you ever seen kittens stalk and jump on each other? Rats do the same thing: jump and pile on each other, chase one another around the cage, and wrestle for food. We often refer to our children as playing like puppies, so we know dogs offer many examples of unstructured play.

Dogs and puppies get in on whatever action there is. You may have had a good pair of shoes that served as an excellent play toy without your prior knowledge. Maybe the new pillows you bought are missing some stuffing from a past day’s play.

Play is much the same across many different species of animals. It is unstructured and looks that way, but they do follow some conventions if not rules. They don’t actually hurt each other on purpose, although it sometimes happens, just like with people. They take turns and usually involve everyone. In this way, play helps both animals and people develop social skills and create bonds among each other.

Play for success

Studies have shown children who play often are better students. An accurate prediction of academic success is how socially skilled children were in third grade. Those who played well with others and played often had a better chance to succeed academically later in school.

Traits like the ability to cooperate, to share, and to show empathy all were developed in the play environment and translated into academic success later in their schooling. Recess is being reconsidered as an educational tool now too, rather than just a break from learning.

Yes, we need balance. No one wants children playing all day, especially unsupervised. Certainly, they need to study, too, and to do their homework. Keep in mind, though, that when children play—especially in an unstructured environment—they are learning and developing many skills that will aid in their future success. Let them play, and let them tell you about how much fun they had and about the friends they have made.


*This is not a paid link, it was included because of the quality of the content.

Caleb Sears was a healthy 6-year-old boy who was looking forward to ice cream treats after his elective dental surgery. Before his dental extraction, Caleb’s parents were told that, despite being generally safe, intravenous anesthesia has a risk of serious complications, including brain damage and death. What they weren’t told was that anesthesia standards of practice vary in different settings. And, most importantly, that the risk goes up substantially when the oral surgeon is responsible for monitoring the effects of anesthesia at the same time that he is doing the operation.

To ensure the safety of children before, during, and after sedation for diagnostic and therapeutic procedures, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) guidelines state that there must be a clinician present other than the practitioner whose sole responsibility is to monitor the patient’s vital signs:

“The use of moderate sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures, if required…

During deep sedation, there must be 1 person whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration.”

Caleb Sears (286 x 365 px)

Caleb Sears (2008-2015)

The risks of not doing so may be serious injury or even death. The lack of an anesthesia-trained clinician, who is tasked with this responsibility, is tragically evidenced in the death of Caleb Sears, a child who received general anesthesia for a routine tooth extraction.

Caleb stopped breathing after receiving several different kinds of IV anesthetics, including the general anesthetic propofol and commonly used adjuncts of midazolam and fentanyl. The surgeon had to stop the surgical procedure and attend to the life-saving task of rescuing Caleb by administering 100% oxygen by mask, although, unsuccessfully. He then tried to place a breathing tube into Caleb’s trachea but was again unsuccessful. Precious minutes passed before the paramedics arrived at the oral surgeon’s office. Caleb was transported to the hospital, but too late. His brain had been without oxygen for too long and Caleb died. He was six years old.

 

Caleb’s Law

Determined that no other family should have to experience the devastation of losing a child due to dental anesthesia where the surgeon and the anesthesia provider are one in the same, Caleb’s family took the issue to the California Legislature. The result was Bill AB2235 (referred to as Caleb’s Law). The original proposed language of the bill would have required

“all oral surgeons and dentists performing heavy sedation or general anesthesia on minors in California have a licensed anesthesiologist or certified registered nurse anesthetist present during the procedure, whose sole role is to monitor the patient.”

This is consistent with the AAP/AAPD guidelines discussed above.

However, as often happens during the legislative process, the final language of the bill was watered down. According to the Mercury News, the California Dental Association (the lobby for dentists and oral surgeons) opposed Bill AB2235. In response to this legislative effort in support of patient safety, Alicia Malaby, spokeswoman for the California Dental Association, wrote in an email,

“There is no evidence that dental anesthesia under this model of care [operator-anesthesia] carries a greater risk than dental care with a second anesthesiologist present.”

In its current form, AB2235 requires the Dental Board of California to collect, study, and share data about deaths and injuries from dental anesthesia. Surprisingly, the reporting of adverse events due to dental anesthesia is woefully inadequate, not just in California, but nationwide. This is unconscionable as we have known for decades that systematically collected, high-quality data is an essential element of patient safety in healthcare. More astonishing is that regulatory agencies need data to prove that a practitioner trying to do two complex and risky procedures at the same time jeopardizes children’s safety. Drivers shouldn’t drive and text at the same time, so how can a dentist do dentistry and provide general anesthesia simultaneously?

The bill also requires dentists to inform parents or guardians that there are different ways of practicing anesthesia. And, depending on the patient’s age and health, the type of practitioner and their training, and the setting in which the anesthesia is required, the risks vary. It also encourages parents to explore all available options for their child and to consult with their dentist or pediatrician as needed about the anesthesia choices. It does not explicitly require disclosure of whether the operating dentist (or oral surgeon) and anesthesia provider are one and the same person.

 

The safety of general anesthetics in the outpatient settings

The deaths of Michael Jackson and more recently Prince have made the general public aware of the dangers of drugs like fentanyl and propofol—both of which depress respiratory drive. But there is an assumption that if those drugs are administered in a medical or dental setting appropriate precautions and safeguards are being followed.

The danger of propofol is so well known that the Federal Drug Administration (FDA) has the following warning on its label:

“For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion [the brand name of propofol] should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure [the emphasis is ours].”

When the American College of Gastroenterology (ACG), representing physicians who commonly employ an operator-anesthesia provider technique, petitioned to have the warning removed in 2005, the FDA reviewed the scientific and medical literature that had been submitted to support the request and denied the petition. They concluded the warning label was justified, stating,

“…the person administering propofol should not be otherwise involved in the conduct of the procedure…because adverse events associated with propofol can occur suddenly and must be addressed immediately.”

Continuous monitoring is difficult if not impossible to accomplish when the operator is immersed in performing the procedure, whether it is endoscopy, dentistry, or oral surgery.

 

Why object to improving patient safety?

The guidelines of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry have arguably set a standard of care against which clinicians will now be measured—a fact that will be noted by malpractice attorneys and risk managers.

Given what we know about general anesthesia with propofol, why wouldn’t the Dental Board of California (and Dental Boards everywhere)—or even the American Dental Association—jump at the chance to mandate that their members comply with recommendations consistent with these guidelines?

Perhaps, they believe that deaths due to dental anesthesia are relatively rare—although they can’t possibly know to what extent, given the current paucity of reporting data and lax regulations. Perhaps, there is resistance to change in an otherwise unregulated and profitable area of practice. And, maybe there is a reluctance to invite another licensed clinician into the somewhat isolated private practice settings of dentistry and oral surgery. The more important question, however, is why death due to pediatric dental anesthesia is not considered a “never event”—a tragic outcome that may be minimized or even eliminated when known preventive measures are implemented. Simply stated, we believe that no child should ever die of elective dental anesthesia.

 

Our recommendations

  1. Prior to a procedure involving moderate sedation or general anesthesia, patients and their families should ask their dentist or oral surgeon whether they will use a clinician with training in anesthesia—separate from the dentist doing the procedure—to administer and monitor the anesthesia consistent with recent pediatric guidelines.
  2. They should also ask what type of monitoring equipment (capnography, EKG, and continuous pulse oximetry) will be used during the procedure.
  3. Finally, they should inquire about the type of resuscitation equipment and emergency plan is available in the office where the procedure is being performed just in case there is an adverse event.

If the clinician does not answer those questions to your satisfaction, find another place to get the procedure done—your child’s life might depend on it.


Update: On September 23, 2016, Caleb’s Law was signed into law by Governor Brown. The law requires dentists administering general anesthesia to inform parents of the risks of operating and providing anesthesia simultaneously. The law also required the Dental Board of California to make a study of adverse outcomes and to review safety measures and make recommendations to reduce the potential for injury. We were unable to get a more powerful bill passed because of the opposition of the dental lobby. However, this week, rather to our surprise, the Dental Board of California met and recommended that all children under age 7 have a separate pediatric anesthesiologist when sedation is necessary. Since there were at least four pediatric deaths in 2015 we believe this law will save lives. Caleb would be pleased. Thanks to Annie Kaplan for leading this fight.