Sunday, November 9, 2014

The AAP's Don'ts and Don'ts of Bronchiolitis, Explained

A lot of clinicians are confused about the new American Academy of Pediatrics guidelines on treating bronchiolitis, released just in time for the wheezin’ season (see “wheezing” doesn’t really rhyme with “season,” but if you adopt a faux rural accent you can kind of make it work). To help, I’ve translated the technical language of the guidelines into plain English, using words like “wheezin’”. You’re welcome.


1a) Clinicians should definitely diagnose bronchiolitis. That way it looks like we know what we’re doing. This diagnosis should be made by taking a history, examining the child, then standing back and saying, “Looks like bronchiolitis.” Then go on to explain that this is not the same as the “bronchitis” that grandpa just got treated for with Zithromax at urgent care.

1b) Clinicians should get a worried look on their faces if the disease looks bad and say something like, “This looks pretty bad.”

1c) Whatever they do, clinicians should resist the urge to order chest x-rays or labs. You already know it’s bronchiolitis. What, are you going to act all surprised when the result comes back “Suspect bronchiolitis?”. Remember, no matter what you see in comic books, no amount of radiation will give the child superpowers.


2) Once you have diagnosed bronchiolitis, run and get your office’s nebulizer. Take it to the parking lot and dash it to the concrete until it’s irreparably broken. What were you thinking, considering giving that kid albuterol? Now you won’t be tempted.

3) Go back in the office, open your code cart, and find the epinephrine. Look at it sternly and say, “I’m saving you for croup and anaphylaxis.” Close the code cart, and give the key to someone you trust to hide it from you until the patient leaves.

4a) Break into the ED late at night and steal all their hypertonic saline nebs to use for brining turkeys (I recommend a minimum of 3 liters for a 16 lb bird). It does not help bronchiolitis, but if they have it, they’ll use it.

4b) If the child is admitted to the floor, and the hospitalist uses nebulized hypertonic saline, do not be insulting about it. The data are still unclear, and besides, you already have your turkey brine for this Thanksgiving.

5) Do not give steroids to children with bronchiolitis. They will grow unusually large muscles and be elected governor of California, where their unfortunate personal decisions will cloud their legacies.

6a) Don’t bother giving oxygen unless the patient’s oxygen saturation is under 90%. To do otherwise will make you look like a big wimp who’s frightened of a little old O2 monitor.

6b) Don’t use continuous pulse oximetry in the first place. You have eyes and a stethoscope, right? When children are really hypoxic, many of them will take on a bluish tint, like in the movie Avatar.

7) Do not use chest physiotherapy for infants with bronchiolitis. Do you really think that beating a kid like a drum with a cupped hand does something other than provide full employment for respiratory therapists? That said, sometimes the rhythm is pleasing and helps soothe you to sleep.

8) Step away from the antibiotics. Bronchiolitis is a virus, you know that, right? It causes a fever and rales, right? So dude, unless pus is streaming from the ear, why do you want to also invite diarrhea into this picture? 

9) If bronchiolitis is interfering with a child’s hydration, put in an IV or an NG tube and help the kid out. Congratulations, finally you have an intervention! Pat yourself on the back, you did good.


10a) Pavilizumab is a total racket, okay? We don’t care how many lunches the reps brought your staff, if the infant in question was born after 29 weeks gestation and didn’t have chronic lung disease or heart disease, leave it. Expect your local detail person to cry a little, but remember, he’s not thinking about the wellbeing of your patients. He’s remembering a puppy he lost when he was 7.

10b) For infants born before 32 weeks and who have lung and heart disease, go ahead and give the pavilizumab. That detail person has a family to feed.

10c) Give it 5 times in the first year of life. You can’t stand to see your drug rep cry, and he also has a boat payment to make.

11a) If you’ve touched a patient with bronchiolitis, wash your friggin’ hands! You were wearing gloves? So what? Is a little soap gonna kill you? Make sure you wash adequately by singing all of Wagner’s Ring Cycle.

11b) Alcohol hand sanitizer works, too, especially for those who can’t sing in German.

12a) Ask about tobacco smoke exposure when you see a kid with bronchiolitis. If you get a positive answer, gently shake your head from side to side and sigh heavily.

12b) Explain why you are so very disappointed about 12a.

13) Encourage moms to breastfeed exclusively for the first 6 months of an infant’s life by saying, “You wouldn’t want your baby to get bronchiolitis, now would you?” Nothing builds a therapeutic relationship like fear and guilt.

14) When diagnosing bronchiolitis, give parents and caregivers a handout to read. People love handouts, and they meet Meaningful Use guidelines. Make sure you get a new handout that explains why you’re doing nothing about the bronchiolitis. Then, get to the next room quickly. Remember, it’s the wheezin' season!

Saturday, November 8, 2014

You Don't Say!

Researchers using sophisticated microphones and computers reported in this month's Pediatrics that dads talk to their infants about 1/3 as much as moms between birth and age 7 months. Reaction from outraged fathers was swift. Dan Rogers of Akron, Ohio, father of 3, said, "Whoa." LaShawn Coleman of Memphis, Tennessee took to Twitter to proclaim, "#Hmmm." Dr. Johann Schlemmer, tenured professor of linguistics and child development at Harvard was quoted opining, "Well..." Clearly this research has opened a floodgate of paternal opinion, and we will continue to follow the debate until the groundswell of conversation finally ebbs.

Thursday, November 6, 2014

Welcome to Likelihood Ratio

When the editor of Pediatric News asked me to start the Needles blog in 2011, no one had ever succeeded in making pediatrics hilarious on a regular basis. Many of my loyal readers agree that, after 126 Needles columns, they’re still waiting. Now I’m starting “Likelihood Ratio,” where I hope that one of the commenters will finally pull it off.

Those of you with medical or statistical training will recognize a likelihood ratio as that formula you had to write on the palm of your hand right before the test so you wouldn’t flunk. In case you’ve since washed your hands, it’s a calculation that tells you whether the sensitivity and specificity of a test makes it even worth doing or whether the test will just make you and the lab more money while simultaneously giving the appearance that you’re a smart and caring clinician. 

Like “Needles,” this blog will be a place to explore developments in the pediatric literature and to ask ourselves, “Should I even care?”. If all goes well, we’ll laugh together, we’ll learn together, and I’ll get offered lucrative speaking engagements in attractive destinations. Don’t worry, I’ll post photos. Welcome, then, to Likelihood Ratio. I hope you’ll like it.