Posted On: April 26, 2013

Nursing Shortages in NICUs Promote Infection in Babies

Any parent whose newborn has spent time in the neonatal intensive care unit (NICU) has felt helpless and frightened seeing their tiny baby swathed in more medical paraphernalia than you’d think he or she could withstand. They’ve probably also felt grateful and in awe of the medical army charged with nurturing delicate new life into viability.

Neonatal nurses are truly on the front lines of their babies’ survival. And a recent study published in JAMA Pediatrics concludes that the warriors fighting for your kid are under serious attack from a lack of numbers. Depleted staffs raise the risk of infection in critically ill babies.

The study, as interpreted on MedPageToday, shows that infection rates for very low birth weight infants were 40% higher in NICUs that were understaffed with nurses.

The problem seems to be widespread: The researchers found that hospitals understaffed nearly 1 in 3 of their NICU infants and more than 9 in 10 of their high-acuity NICU infants, relative to staffing guidelines. (“High-acuity” patients are seriously ill and require medical interventions of an emergency and/or specialized or complex nature.)

National guidelines spell out optimal nurse-to-patient ratios. They’re based on acuity. Staffing for low-acuity infants is supposed to be one nurse per three or four babies; levels for the highest-acuity patients are at least 1 to 1.

When these levels aren’t maintained, studies show, the patients have a higher rate of nosocomial infections, especially infants with very low birth weights. “Nosocomial” means the infection was contracted as a result of the hospital setting—from a treatment or other exposure.

The study examined data from 67 NICUs from the Vermont Oxford Network, a nonprofit collaboration of health-care professionals working in more than 900 NICUs around the world. Measured by the national guidelines, hospitals understaffed nearly 1 in 3 NICUs infants in 2009 and nearly 5 in 10 in 2008, but the levels varied by acuity. Hospitals understaffed more than 8 in 10 high-acuity infants in 2008 and more than 9 in 10 in 2009.

The study did have limitations—it might not represent all hospitals with a NICU or consider other factors that might be important in NICU staffing decisions, including non-nursing personnel.

But the researchers’ conclusion was unequivocal: The "most vulnerable hospitalized patients, unstable newborns requiring complex critical care, do not receive recommended levels of nursing care."

Usually, parents don’t choose the NICU in which their ailing babies are assigned. So if yours is a NICU patient, find out if your child is considered a low- or high-acuity patient, and let the staff know you’re aware of the staffing recommendation for each. If the facility is understaffed, be extra vigilant about monitoring its infection-control measures. Find out more on our blog, “Controlling Infections in Pediatric ICUs.”

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Posted On: April 19, 2013

Hospitals Show Progress in Clamping Down on Early Elective Deliveries

A few months ago, we recalled a case in which Patrick Malone represented a family who sued a group of obstetricians when their baby was delivered early and suffered brain damage. As we noted in that blog, except when there are real medical complications, the American College of Obstetricians and Gynecologists recommends against delivering babies or inducing labor before 39 weeks of gestation.

Earlier this month, a study published in the journal Obstetrics & Gynecology not only confirms the wisdom of waiting to full-term before delivering the baby, but shows that hospitals that promote full-term delivery can realize excellent results.

As described by KaiserHealthNews.org, the study profiled 25 hospitals in five states that were able to cut their rates of elective early deliveries from nearly 28 in 100 to fewer than 5 in 100 in one year.

Such efforts are critical to lowering the rates of deliveries, which can put babies at risk of serious health issues including feeding, breathing and developmental problems. The latter often turn out to be long-term problems—one study by researchers at Emory University found that babies born before 38 weeks had lower scores on standardized tests in first grade.

Because 10 to 15 of 100 U.S. babies are delivered early without a medical reason, the value of full-term gestation needs to have wider appreciation among both parents and doctors. It is not uncommon for either party to opt for early delivery not because it’s optimal for the wee ones, but simply because it’s more convenient. That is, too often early delivery is a matter of scheduling preference than medical need.

Hospitals are starting to accept that they are on the frontlines of preventing the long-term negative effects of early delivery, and so must the rest of us. As the lead author in the hospital survey said, “This quality improvement program demonstrates that we can create a change in medical culture to prevent unneeded early deliveries and give many more babies a healthy start in life.”

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Posted On: April 12, 2013

Boom in ADHD Diagnoses Can Lead to Overmedicating and Drug Abuse

The news last month from the Centers for Disease Control and Prevention (CDC) was widely reported: Nearly 1 in 5 high-school age U.S. boys and more than 1 in 10 of all school-age children have been diagnosed with attention deficit hyperactivity disorder (ADHD).

ADHD generally is thought to result from abnormal chemical levels in the brain that impair the ability to pay attention and compromise impulse control.

The New York Times was among the media outlets that reported the significant increase of the diagnosis, and the concern about overprescribing the drugs used to treat it. We, too, have questioned the practice.

More than 6 million children 4 to 17 have been diagnosed with ADHD; their numbers have increased 16 percent since 2007, and more than doubled in a decade. More than 2 in 3 currently diagnosed take Ritalin or Adderall, stimulants that certainly help the afflicted, but, according to the The Times, also can cause addiction, anxiety and even psychosis.

Sales of stimulants to treat ADHD, The Times says, have more than doubled to $9 billion in 2012 from $4 billion in 2007.

Some people legitimately need these drugs, but experts estimate that only 3 to 7 in 100 children suffer from ADHD, and that the meds are being given to people with mild symptoms who shouldn’t be taking them.

As The Times puts it, “While some doctors and patient advocates have welcomed rising diagnosis rates as evidence that the disorder is being better recognized and accepted, others said the new rates suggest that millions of children may be taking medication merely to calm behavior or to do better in school.”

Kids often share or sell their meds to classmates, so the boom in ADHD opens the door to drug abuse and its consequent health risks. CDC Director Thomas R. Frieden compared the rising rates of stimulant prescriptions among children to the overuse of pain medications and antibiotics in adults.

One heartbreaking illustration of this scenario was presented last week in a commentary in the New York Times. The writer, Ted Gup, told the story of his son David, who was diagnosed with ADHD as a first-grader and told by one psychiatrist that he wouldn’t even see the child until he was medicated.

Gup resisted, but after a year of David’s “rambunctious” behavior, he started taking Ritalin, then Adderall.

As a 21-year-old college senior, he was found on the floor of his room, dead from a fatal mix of alcohol and drugs. The date was Oct. 18, 2011.

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son … was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it. What he did cannot be excused, but it should be understood. What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

Stories like David’s are likely to repeat. As The Times points out, the American Psychiatric Association is planning to broaden the definition of ADHD in the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (see our blog, “Controversy Swirls as Psychiatry Manual Gets an Update.”)

That invites more people to be diagnosed and be medicated, possibly many for whom other treatments are more appropriate.

Pharmaceutical company marketing enables any parent seeking to help a kid who’s misbehaving and whose grades are falling. The Times noted that the brochure for Vyvanse, an ADHD drug, shows a parent looking at her son and saying, “I want to do all I can to help him succeed.”

Dr. Jerome Groopman, professor of medicine at Harvard Medical School, told The Times, “There’s a tremendous push where if the kid’s behavior is thought to be quote-unquote abnormal — if they’re not sitting quietly at their desk — that’s pathological, instead of just childhood.”

Diagnosing ADHD is a difficult judgment call. As The Times notes, there’s no definitive test for it—it’s determined only by extensive communication with patients, parents and teachers, and by ruling out other possible causes for its behavioral symptoms. The process is subjective and made more difficult when parents pressure doctors for a diagnosis. ADHD is a chronic condition that often endures in adulthood.

More than twice as many boys as girls have been diagnosed with ADHD—15 in 100 versus 7 in 100. The rates were highest among high-schoolers—1 in 10 girls, and nearly twice as many boys. About 1 in 10 high-school boys takes ADHD medication.

Before yours becomes one of them, find out if your kid truly is suffering from a mental disorder. Explore other treatment options, such as counseling, and causes for unacceptable behavior that might be social (bullying?) instead of chemical. Drugs can be lifesavers, but they also can harm.

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Posted On: April 5, 2013

More Proof that Vaccines Have Nothing to Do With Autism

A new, large study by the Centers for Disease Control and Prevention (CDC) should help redirect the concern of parents who still wonder if vaccines have a role in children developing autism.

The science-based medical establishment has not wavered from the position that children should be vaccinated against a variety of diseases (See our blog, “Feds Say Childhood Vaccine Schedule Is Safe and Effective”), but a campaign devoid of science and juiced by quackery keeps planting the seeds of skepticism about whether vaccines do more harm than good.

As reported last week on NPR, the answer, again, is a categorical “no.” The CDC study found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. And even though kids get more vaccines than they used to, they’re far less able to provoke an immune response than older versions.

That’s because newer vaccines have fewer antigens. Those substances cause the body to produce antibodies, which are proteins that fight infection. Our bodies are experienced antibody-producers because we’re routinely exposed to microbes, whether they’re the bacteria responsible for a sinus infection or a virus that results in a cold sore. In other words, antibody production is a natural, vital part of human life. To believe it’s responsible for causing a mental disorder is nonsensical.

The CDC study compared the vaccine histories of about 250 children diagnosed with autism spectrum disorder with the histories of 750 kids who weren’t. Researchers compared medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were clear.

"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," said lead author Frank DeStefano, director of the Immunization Safety Office of the CDC. Because kids, like everyone else, are constantly exposed to antigens from bacteria and viruses, "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he said.

The the number of vaccines a kid is supposed to get has increased, but the number of antigens in vaccines has decreased. A lot. In the late 1990s, vaccinations exposed children to several thousand antigens, the study said. By 2012, that number was 315.

That’s because the science of vaccination has improved; it’s more precise in how antibodies kick-start the immune system.

The problem with supporters of quack science is not only that they leave their children and others in their community vulnerable to the problems vaccines address, they also divert resources into worthless pursuits that otherwise would contribute to the body of science, not waste time trying to overcome it.

"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Ellen Wright Clayton told NPR. She’s a professor at Vanderbilt University who contributed to a report on vaccine safety for the Institute of Medicine. “That would let researchers pursue more important questions.

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she said. "It's not vaccines."

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