Archive for the ‘Science-Based Medicine’ Category

Reader Feedback #1: I’m a Closed-Minded Denialist

I recently received the following response on the “About Red Stick Skeptic” section of my blog:

“I totally understand the need for skeptism and critical thinking in this day and age. We have become much more focused on the almighty $ than anything else. However, to lump all alternative medicine practioners/practices into the category of pseudoscience is not only shortsighted but misleading. Some of these therapies have been around longer than medicine and have stood the test of time.

I know that we are all essentially wired the same, however, how we respond to certain things can be completely different. So just because one person does not respond favorably to a particular therapy does not mean the next person won’t.

Skepticism is healthy, denial is not. Millions of people have been helped in some way, shape, or form from alternative therapies. Have an open mind and ask questions, but try things for yourself and let your body determine what’s right for you.”

This may seem like a reasonable criticism at first glance. Skepticism, the commentor remarks, is healthy while denial(ism) is not. That is probably very true, although I have a feeling that we disagree on just what defines these terms. I doubt that the commentor understands the practice of skepticism, which is more than just having and open mind and asking questions, although both are important. He is a pseudoskeptic. Like the pseudoscientist who makes use of the trappings of science to give the appearance that legitimate investigation is taking place, he uses skeptical terminology and professes his appreciation for critical thinking. He knows some of the lingo, but this is merely subterfuge.

Psuedoskepticism is sometimes an intentional act employed to fool others by giving claims an air of undeserved legitimacy. “Hey, I’m a skeptic and I really believe in this stuff!” Many people intuitively know to be wary of obvious salesman, although they do tend to leave this inherent skepticism at home when they seek relief for what ails them.  Or it occurs as a mechanism to avoid cognitive dissonance, to better convince oneself that the bunk they are spouting is the real deal.  I suspect that the commentor falls into the latter category and is himself denying the robust evidence that exists refuting the personal belief in alternative medicine that he is so invested in emotionally, and likely economically. But I’m an optimist.

Skepticism calls for the provisional acceptance of claims based on scientific evidence and plausibility. The greater the evidence, the less plausible a claim must be to be accepted. Some seemingly outlandish hypotheses have come to be accepted because the evidence is clear and powerful. (An expanding universe? My ancestors were apes? What the heck?) The greater the plausibility, the less robust the evidence needs to be for the skeptic to tentatively accept the claim.  But there must still be evidence, however, and that evidence must still be scientifically sound. 

We place greater or lesser importance on evidence based upon its type. Trying things for oneself and letting one’s body determine what is right, as was recommended in the above comment, is anecdotal and subject to being impacted by countless biases and confounding factors. Not suprisingly, it is the weakest form of evidence when it comes to figuring out whether or not a treatment works. Calling for me or my readers to base acceptance on this is a huge red flag indicating that we are dealing with a believer rather than a skeptic. Regardless, there is always the risk of improperly including individuals or practices in one classification if you overgeneralize or make straw man arguments. We should always remain open-minded to new ideas. We shouldn’t ignore evidence because of an idealistic or dogmatic set of beliefs. All of these are valid points, all true sentiments. And all are clearly empty words when read in the context of the entire comment.

It is implied that I am unfairly claiming that all alternative medicine modalities are pseudoscience and their practitioners frauds. He claims this is shortsighted because some of these therapies have been around for hundreds of years and have stood up to the test of time. Millions of people, he reveals, have been helped in “some way, shape, or form” by alternative therapies. That is rather nebulous but that many people can’t be wrong. Right? Well, how have they been helped exactly? Make a specific claim and I’ll address it. There are many examples throughout history of lots of people being fooled and the bottom line can be summed up with the well worn skeptical axiom, “The plural of anecdote is anecdotes, not evidence.”

It is ironic, and just plain wrong, for a skeptic to use an argument from antiquity or an argument from popularity as support for my being shortsighted. These supposedly ancient therapies, acupuncture often coming up in this context, have had centuries or longer to prove themselves and continued existence is a poor marker for true efficacy. Physicians and other healers bled patients for more than a thousand years, all claiming just as vehemently that the benefit was clear. They did so in pre-scientific times and thus have somewhat of an excuse for killing their patients in an earnest attempt to save their lives. But times have changed and the age of science has brought a better understanding of the natural world. Bloodletting was a casuality of this advanced ability to lift the veil of ignorance, along with the humoral system of medicine that birthed it.

A healing therapy can survive and manitain popularity for a variety of reasons, even when it is ineffective. The only way to root out therapies that work from the countless examples of those that at best serve as placebos, or at worst cause harm, is the scientific method properly applied. Good science has been used to investigate these therapies and the verdict is in: There are no alternative medical therapies that have proven benefit for any human ailment beyond that of placebo. A great deal of bad science has unfortunately been used to propel these modalities further into public awareness and even into hallowed halls of many academic institutions. This is a trend that has worsened over the past few years and shows no signs of slowing down. It is quite accurate to refer to therapies as pseudoscientific that are bolstered with bogus and meaningless scientific jargon (human energy fields, cellular vibrational frequencies, etc) and badly designed studies (no placebo control, anomaly hunting, etc).

It would be quite unfair, however, for me to lump all practitioners of pseudoscientific therapies into the category of fraudulent hucksters and snake-oil salesman. I don’t know what is truly in the hearts of these folk. I have no doubt that some of them are dishonest and know that they are selling lies but I am equally sure that some honestly believe in their practice or product. It is easy to be fooled into thinking that something works when it doesn’t. I don’t attack the person, I focus on the idea, and in the world of alternative medicine the idea is rotten and needs to be thrown out with yesterday’s copy of Fortean Times.

There is good science taking place every day that focuses on areas considered, wrongly, to be alternative medicine, and there have been many great successes. Many of the effective components of our pharmaceutical armamentarium originated from the plant world, for instance. Study in this area continues and will likely yield future advances in medicine. Proponents of alternative medicine are quick to hold these successes up as evidence for the worth of alternative medicine in general but this is absurd and highlights the risk inherent in having a category of medicine which includes modalities as disparate as medicinal herbs and reiki. Imagine if I decided to treat a patient’s abdominal pain with an antihypertensive agent because penicillin is an effective treatment for strep throat. It is equally ridiculous to imply that because aspirin was derived from the willow that iridology is a legitimate modality for diagnosing lung cancer, or that echinacea is effective in treating the common cold. But this kind of reasoning takes place every day and my critic’s comment is saturated with it.  Using the sucess of one treatment labeled as alternative medicine, especially when it shouldn’t even be included in the group, to give legitimacy to another may be effective if your objective is widespread acceptance, but it is a dangerous double standard. 

Herbs, even if touted as safe and natural alternatives to conventional medicines, are merely drugs. Crude, unrefined and sloppy drugs. Of course there are likely to be herbs that have the ability to effect the physiology of the human body, and the low hanging fruit have been collected over the past couple of hundred years. The overwhelming majority of what is left over will have no effect, or will have a deleterious one. But there may be a supplement on a GNC store shelf somewhere that might hlep with a particular condition. The reality is that those who take that supplement are just as subject to the potential risk as they would be taking amoxicillin for an ear infection. Ephedra comes to mind quite easily. Without proper scientific investigation, it is a roll of the dice and that is assuming the contents actually match what is on the label. Many supplements have been found to contain pharmaceuticals. Viagra in male enhancers, for instance. There is nothing alternative about studying the natural world scientifically for possible benefit to mankind. It is alternative, however, when herbs or supplements are touted as natural and risk free cures when evidence is lacking or, as in many cases, after scientific evidence is clearly unsupportive.

The commentor agrees with me, and others who are decidedly smarter than me, that humans share some hardwiring. I don’t think he quite understands what we mean, however, but he certainly provides a fantastic example of it. When I say that the human brain is hardwired to respond to certain situations in fairly reproducible ways, I am talking about mental behaviors. We all employ certain heuristics, or rules of thumb applied to thinking, that help us efficiently make sense of our environment. This is an advantage in many instances, and helps set us apart from the rest of the animal kingdom, but it has its downside. We often sacrifice accuracy for efficiency. We jump to conclusions when we apply these mental shortcuts too broadly or place more importance on our gut conclusions than on scientific evidence. Logical fallacies, such as the appeal to antiquity and the argument from popularity, are examples of hardwiring that hinders our ability to correctly assign cause and effect relationships.

We are also similarly hardwired, although I don’t typically use that term in this setting, in the sense that we share a physiology that responds in a very predictable pattern to changes in our environment, to injury and illness and to foreign substances such as toxins or medications. This is one of the foundations upon which the scientific investigation of medical therapies relies upon to determine safety and efficacy. It all comes down to the basics of our physiology, which we have an impressive, although admittedly incomplete, grasp of. One of the findings of proper scientific inquiry into the treatment of human illness is that the more we treat every patient the same, the better the outcomes tend to be. 

Naturally we must take into account a number of psychosocial factors in addition to the biological ones, and there are ranges of variable response to our interventions. But much of this is due to factors that we have discovered and understand through the use of science. To claim that humans respond to treatments completely differently, however, is misleading. And to use that claim as impetus to seek out implausible and unproven remedies is risky. Where does one draw the line? How do we measure response and decide if it is favorable? How would we decide that any one treatment is not effective? If science is to be ignored, how would we decide what treatments should be attempted first, or which are too dangerous? Pseudoskeptics tend to avoid following this kind of thinking out to its logical conclusion, an approach to healthcare which would be a nightmare for patients and would quickly fail because of enormous expense and increases in morbidity and mortality.

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The Truth Behind Herbs and Supplements…..

For a few years during my high school and college days, I was into supplements. I was also into country music, but nobody is perfect. I took vitamin C to ward off colds, B vitamins for increased energy and ephedrine for weight loss to name just a few. My excuse? Like the ancient Chinese who supposedly used acupuncture 5,000 years ago*, or the 18th century American physicians who bled their patients to remove excess bodily humors, I was prescientific.

In contrast to those dark days, as a result of my discovery of the work of James Randi and the modern skeptical movement I spent the early years of my pediatric residency developing an interest in so-called alternative medicine. My eyes were opened as I learned about the reality behind the substances I ingested with the fearlessness of ignorance and I became embarrassingly aware of the simple fact that science just doesn’t support the near entirety of claims made by the manufacturers of herbs and supplements**. Despite this, these products can be found on the shelves of thousands of stores across this country and they rake in billions of dollars annually. Unfortunately, consumers are generally unaware of the science, or rather the lack of it, behind these products, and of the risk that they take each time they head down to the GNC or Rite-Aid. 

If I were to walk out my back door and take a random sampling of the available plant life, place those clippings of various flowers, weeds and grasses in my blender, and press liquefy, the end result would have the potential to make me a very rich man. To the untrained eye it would appear to be merely a glass full of grass juice, and to the naive mind a nasty and useless concoction. But to an individual initiated in the unethical reality of herbs and supplements, it might just be a gold mine. You see, all it would take to turn green grass into green cash is the current state of regulation of herbs and supplements in the United States and a vague structure/function claim. 

Here’s how it works. Since the early 90’s, 1994 to be exact, with the passage of the Dietary Supplement Health and Education Act, the supplement industry has essentially existed as if stuck in the days of the American Old West. The Law of the day, much like our current Food and Drug Administration, served as a means of maintaining a somewhat controlled chaos. Try this excerpt on for size, podnuh. 

“Under the Dietary Supplement Health and Education Act of 1994 (DSHEA), the dietary supplement manufacturer is responsible for ensuring that a dietary supplement is safe before it is marketed. FDA is responsible for taking action against any unsafe dietary supplement product after it reaches the market. Generally, manufacturers do not need to register their products with FDA nor get FDA approval before producing or selling dietary supplements.” 

Now just let that sink in for a moment. Wait for it. Wait for it. Has it hit yet? Has that feeling of emptiness and despair that I experience on a near daily basis during my frequent adventures in the Land O’Woo settled in yet? Allow me to break this down for you. Since 1994, when the FDA was sent outside to fetch its own switch so that Congress could more effectively tan its hide, manufacturers have had no oversight whatsoever when it comes to determining whether or not their herb or supplement is safe. My fictional grass juice, which I’ll have you know has been used by Native Americans to cure teeth itch and hair pain for thousands of years, could contain iocane powder*** and kill several consumers before the FDA would be able shut down my operation. In fact, as I am writing this there are herbs and supplements sitting on store shelves which contain toxic levels of heavy metals such as lead or mercury and which are adulterated with pharmaceuticals****. When enough people are harmed by an herb or supplement, such as in the infamous case of ephedrine a few years ago, the FDA investigates and the product is pulled. There are thousands of new supplements that go on the market each year and the emergence of the next Ephedra is only a matter of time. 

But what about effectiveness? Unfortunately, DSHEA rains on that parade as well. There is no requirement under the law for an herb or supplement to be proven effective by the company selling it as long as the claims made fit certain criteria. If claims of positive impact on a specific disease are made, then the FDA has the power to make sure that the evidence supports those claims. If vague claims involving support of structures or bodily functions are made, then the FDA is impotent. So if I attempted to market my backyard grass juice to cure epilepsy, I wouldn’t get very far. But if my infomercial talks about supporting brain health (wink wink, nudge nudge) or improving neurological function, I’ll be opening my Swiss bank account in no time. 

The dangers of DSHEA and the herb and supplement racket actually go much deeper than this brief discussion goes into. I’ll devote additional posts to these issues but I encourage my readers to take the next step and investigate for themselves. A great place to start, as it is with any healthfraud or alternative medicine related topic, is Science-Based Medicine

*The Chinese weren’t using acupuncture 5,000 years ago despite what numerous news reports and press releases claim. What is known today as acupuncture has only existed for the past several decades and has failed the test of science. 

**These manufacturers are typically subsidiaries of the mammoth pharmaceutical companies so reviled by the alt med crowd. Awareness of this fact has forced many a believer to erect additional impenetrable walls of cerebral compartmentalization to avoid the coma inducing cognitive dissonance. 

***Iocane powder is a deadly poison that is odorless, tasteless and highly soluble. It is only available in powder form and was once popular for use during battles of wits when death was on the line, particularly with Sicilians. Although it takes a few years, determined individuals are capable of developing immunity to the poison. 

****Actual Viagra has been found in supplements bearing claims of male enhancement!

Fever Phobia #2: The High or Unresponsive Fever…..

**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**

Fever phobia is everywhere. In preparation for writing this post I took just a few minutes to peruse the internet and, not surprisingly, found a seemingly never-ending supply of flawed information. A great deal of this misinformation can be found in places where I would expect it, such as on chiropractic websites and parenting message boards. But much of it is put out by what would seem to most people to be legitimate sources, including the websites of pediatric practices.

A number of studies looking into fever phobia have consistently found that two of the most common concerns expressed by parents and medical professionals are the risk of health problems related to highly elevated temperatures and to fever that does not respond to antipyretic medication such as acetaminophen and ibuprofen. This concern seems to be based on a number of misconceptions, in particular the unfounded belief that the height of a fever positively correlates with the severity of the infection and that fever over 104-105 degrees can cause brain damage, seizures, hearing loss, or even death. As I will shortly explain, both of these concerns are unwarranted.

Fever due to infection, rather than hyperthermia due to being left in a hot car on a Louisiana Summer day, is a homeostatic process. When the body is exposed to infectious organisms such as viruses and bacteria, a number of so-called pyrogens are produced as part of the inflammatory response. These pyrogens can then act to raise the core body temperature set point, which is regulated in the brain by the hypothalamus. The body then undergoes a variety of physiological and behavioral changes in order to increase our core body temperature to match this new set point.  These changes include the clamping down of blood vessels in the skin in order to decrease heat loss, shivering to produce heat, and raising the ambient temperature with blankets and heaters.

At a certain core temperature, depending on the age of the person, the type of infection, the intake of antipyretic medications and certainly a number of currently unknown feedback mechanisms, the body will put into play measures to lower the temperature set point. Our peripheral blood vessels dilate, we become flushed and break into a sweat, and we crank up the AC. This will occur 100% of the time, even if no medications are given to assist the process. It is physiologically impossible, in the setting of infection alone, for our core body temperature to be raised higher than 106-107 degrees without inappropriate exposure to an external heat source.

Even at that extreme of possible core body temperature mentioned above, there is no direct link between fever and brain damage, hearing loss, or death. The height of fever is an independent risk factor for febrile seizures, but treatment does not prevent their occurrence. I covered febrile seizures in an earlier post. There is an indirect association, and this is likely why the fear emerged initially, between fever and poor neurological outcomes however. An infection, in particular a severe bacterial infection involving the blood and/or brain, which has led to a febrile response may, unfortunately, ultimately lead to these dreaded complications. But it is the underlying infection to blame, not the fever. Treating fever in these instances does not improve the outcome.

In addition, the height of fever has not been reliably linked to the severity of the infection that has caused it, especially in the post-vaccine era. A patient can have a life-threatening case of Haemophilus or Staphylococcal meningitis with no appreciable fever just as a child with a minor viral upper respiratory infection can spike to 105. Many protocols in use today still base treatment decisions on the height of fever, but they are not based on current evidence and they lead to increased practitioner/parental anxiety and overuse of testing and imaging modalities. Similarly, a fever that does not come down after administration of an antipyretic is not more likely to be caused by a severe infection. It just doesn’t work that way. What is more important is how the child looks, regardless of what their temperature does with Tylenol on board. A lethargic toddler with a stiff neck, or an infant that refuses to feed, needs to be evaluated while a playful 4 year-old with draining snot and a temperature of 103 degrees can probably just be watched in most cases.

At the heart of fever phobias such as these, is the general misunderstanding of fever as a disease in and of itself. It is more helpful to think of fever as a symptom in the same way we might regard heartburn. There is something that leads to the development of fever, typically an infection, and it is likely that there is a good reason for the febrile response to be so prevalent in the animal world. Although it hasn’t been replicated in humans, studies have shown decreased mortality in a variety of other species related to mounting a fever in response to an infection. There are hypotheses as to why fever may be beneficial. Perhaps pathogens are unable to replicate as efficiently, or perhaps our immune system is more effective, when core body temperatures are elevated. It is a fascinating area of study.

Thinking of fever as a symptom rather than as a disease helps to put it into perspective. Many people, when their head begins to ache after a long day at work, reach for an analgesic medication such as Ibuprofen or Naproxen while others prefer to see if it will progress before attacking that childproof lid. Some will even tough it out until the pain is excruciating or forego treatment alltogether. Almost all headaches will eventually resolve on their own. The overwhelming majority of headache sufferers do not treat their headache because they are worried that the headache itself will lead to a bad outcome, such as a brain tumor or stroke. They treat the headache because it makes them uncomfortable and they will only seek medical attention in certain instances. With fever, parents absolutely should treat with antipyretics when their child is uncomfortable. Helping a sick kid feel better, in my opinion, is more important than preserving the possible minor benefit gained from a febrile response to infection. And parents absolutely should seek medical attention when the fever occurs in the context of other risk factors for serious infection, such as age less than 28 days or a very ill appearance, to single out just a couple. When in doubt, I always recommend that a caregiver call their child’s pediatrician or family doctor. In general though, if you have a healthy older child who doesn’t seem to be bothered by the fever it is okay to not give antipyretics, and it is okay to not even recheck the temperature. Just focus on their appearance and behavior.

A 2001 study in Pediatrics revealed that almost 75% of parents sponge their children in the setting of fever, with many doing so at temperatures of less than 100 degrees. This is problematic for two reasons, the most important of which is that sponging doesn’t work. And if you are one of the two-thirds of parents that use improper technique, then you may be making your child more uncomfortable and putting their health at risk. The proper technique, or at least the technique least likely to add insult to injury, is the use of a sponge or rag soaked in tepid water to dampen a febrile child’s head and neck. While this might lead to some subjective improvement, perhaps secondary more to the loving attention of the child’s caregiver than to any specific effect, it will not lower core body temperature. Unfortunately many caregivers use cool or cold water to sponge with, submersion in cool or cold water, application of ice packs and even topical rubbing alcohol in an attempt to treat fever. These techniques are ineffective and potentially dangerous in the case of rubbing alcohol. Use of cool or cold water leads to constriction of skin blood vessels and impairs the child’s ability to lose heat which can cause intense shivering. This is uncomfortable and actually raises body temperature. Rubbing alcohol can be absorbed through the skin and result in lethal toxicity.

Some have described fever as our friend, typically as a means of getting across the message that it might actually have a beneficial purpose during an infection. Some friend. Fever can make a child feel absolutely lousy and I don’t blame parents for not wanting it to come over and play after school. Although the evidence is not clear that fever plays a significant positive role during some illnesses rather than the traditional part of the Snidely Whiplash, it is clear that fever phobia is counterproductive and potentially harmful. The same studies that delved into parental and medical professionals’ fears regarding fever also showed us that concerning numbers of parents give doses of antipyretics that are higher and more frequent than recommended. They also showed that a majority of parents will give, and medical professionals will recommend, alternating Tylenol and Motrin despite the lack of evidence for safety and efficacy of the practice. The AAP specifically recommends against it.

The final fever myth I’ll discuss is the belief that medications, like Tylenol and Motrin, are safe because they are over-the-counter. The truth is that they are both pretty darn safe, especially acetaminophen, but there are reasons to be cautious. First and foremost, if there is no benefit from the administration of a medication, any risk is unacceptable. Giving antipyretics to comfortable children with fever falls into that category most of the time. Tylenol, when overdosed, can cause irreparable liver damage. Motrin, even when dosed appropriately, can cause kidney and gastrointestinal damage, especially in the context of dehydration and it should not be given to children under 6-months. During the first several years of life for most children, there will occur numerous febrile episodes. During many if not most of them, there will be a legitimate need for antipyretic medication. But it is impossible to make rational decisions regarding the care of a child without the proper information to base those decisions on. Acting out of fear, and on misinformation, should be avoided at all costs.

Fever Phobia #1: Febrile Seizures…..

I’ve been asked to speak at a upcoming city-wide nursing conference, and it took all of about three seconds to think of a topic: fever. Across the board, and that includes physicians as well as nurses and parents, an understanding of the pathophysiology of fever due to infection is lacking, and the approach to its treatment is problematic. The number of blatant misconceptions regarding childhood fever truly is staggering. Since the early 1980’s, when the seminal paper on the subject of fever phobia was published in the Journal of the American Medical Association, there have been several additional studies confirming and cataloging the causative factors and potentially dangerous resulting behaviors.

Fever is one of the most common reasons for parents to seek medical care for their children as well as a frequent impetus for late night phone calls to sleepy hospitalists. Elevated body temperature also serves as a source of unnecessary laboratory tests and imaging time and time again, which further reinforces parental fever phobia. These tests, along with the inappropriate monitoring and treatment of fever, lead to significant amounts of discomfort for children and even puts their health at risk.

My goal for the next few posts is to discuss a number of the most commonly held myths regarding childhood fever and to provide some evidence-based recommendations on what to do when the mercury, as well as the anxiety level, is rising.

**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**

First up, febrile seizures.

One of the most common reasons stated by parents, as well as medical professionals, for their concern regarding the onset of fever in a child is the specter of febrile seizures. While it is true that there is an association, and likely a causal one, between fever and seizure activity in some children, the terror I often see in the eyes of caregivers is very often unwarranted albeit understandable, as is the use of antipyretic medications like acetaminophen ibuprofen (Tylenol and Motrin for most readers). Confused? I realize that it seems counterintuitive to not give medication that reduces fever to a child in order to prevent seizures most probably caused by fever, but allow me to explain.

When addressing the subject of fever and febrile seizures, it is important to ask two questions: Are febrile seizures worthy of the dread they instill in caregivers and does the routine use of antipyretic medications and non-pharmaceutical measures to reduce fever prevent their occurrence. The answer to both questions is, with rare exception, no. But before I go any further, I must differentiate between classic febrile seizures and children with underlying neurological conditions that predispose them to seizures.

This discussion is about the former. If your child has a seizure disorder or a condition that puts them at risk of having seizures, see the above disclaimer. In fact, everyone just see the above disclaimer. In addition, there is a difference between febrile seizures and seizures that can occur in the setting of fever. A child with a bacterial meningitis can, in severe presentations, seize. This is not a febrile seizure. A child can have fever from an ear infection and have a seizure after getting kicked in the head by a mule. This is also not a febrile seizure. So what is a febrile seizure?

Simple febrile seizures occur in roughly 2-4% of children (this means 96-98% of children will never ever have one) between the age of 3 months and five years during a febrile response to an infection, usually viral in nature. They are seen in this age group most probably because of some immaturity in the developing brain, the higher incidence of febrile illnesses, and the typically higher febrile response as compared to older children and adults. In otherwise healthy children, which is the overwhelming majority of children who have an occurrence of a febrile seizure, it is a benign process that typically lasts seconds to few minutes. The seizures are almost always generalized, meaning they cause abnormal movements from head to toe rather in just one limb for instance. There is a much less common entity known as the complex febrile seizures, but these are rare and do not typically result in any immediate harm either (The long term prognosis is different and beyond the scope of this post.)

So children recover from these very well. Naturally they are a scary thing for an uninitiated parent to experience, and I certainly do not intend to belittle anyone’s emotional response. My intention is to reassure, and hopefully to decrease potentially risky behaviors that result from fever phobia in the future.

Febrile seizures, in the majority of instances, will only happen once to any given child. In about a third of children who have a febrile seizure there is recurrence, but each subsequent seizure is equally benign. And the long term risk of seizures, such as with epilepsy, beyond the febrile seizure age is slightly increased. Which children are at risk? Well, they can occur in any child but they tend to occur in families. It is clear that there is a genetic predisposition in some children, but where that defect lies is as unknown as the particular physiological changes that lead to the seizure activity. The leading theory involves the lowering of the seizure threshold by cytokines, chemicals released in response to infections that, among many other end results, lead to fever. But we don’t understand why seizures only occur in certain children and not others, or why they recur only in some children.

So simple febrile seizures, the most common form of seizures in childhood, do not cause any harm in almost all cases. But they do lead to parental and practitioner anxiety, and they do lead to ambulance rides, ER evaluations, and a large amount of wasted resources in the form of testing and hospital admissions. So shouldn’t we use the wonders of modern medicine to prevent them by lowering a child’s temperature into the normal range? What the normal core body temperature is exactly is fodder for another post (hint, it ain’t 98.6 degrees), but regardless of what a temperature should or should not be, simply throwing an antipyretic or two at it does not prevent febrile seizures. This fact is fairly clear even in children we know tend to get febrile seizures recurrently.

So febrile seizures are pretty much harmless and you can’t prevent them with medication or other measures such as sponging or cold water submersion. Plus, they don’t occur after about age five. Medications such as Tylenol and Motrin are safe, but they are not risk free, and non-pharmaceutical methods do not work to lower fever anyway. There are multiple studies revealing that high percentages of parents dose these medications too high and too frequently, often because of fever phobias such as these. Taking these facts into account, there is no reason to reach for the Tylenol or Motrin, or for a rag soaked in cold water, to treat a fever if your concern is preventing a seizure. The risk clearly outweighs the benefit. There are perfectly good reasons to treat a fever though, and I will discuss them in an upcoming post.

Science-Based Medicine and the M&M Conference…..

Last week I attended a Morbidity and Mortality conference, or M&M,  held by the group of hospitalist physicians I recently joined. For those of you unaware of  the concept of the M&M, these recurring conferences serve as one of the cornerstones of science-based medicine and have been vital to improving patient care since first proposed a hundred ears ago by Dr. Ernest Codman at Massachusetts General Hospital. And though typically associated with academic medical centers and community hospitals, most large medical and surgical practices engage in similar group discussions as well.

Much like the peer-review process which is so integral in the publication of new studies in medical journals, the M&M allows for critique of how a particular patient’s medical or surgical case was handled. Cases selected for review usually are those in which some kind of complication or medical error took place. Those involved in the patient’s care discuss the particulars, not with the intent to ridicule or shame into compliance, but with a focus on discovering how to avoid these problems in the future. Not every presentation involves issues with medical decision-making, however. Many are useful in uncovering problems with the system itself, such as miscommunication between doctors and nurses or between the floor and the pharmacy. A host of potential stumbling blocks to providing the best care possible for patients can be rooted out and dealt with.

Because of repeated and invaluable efforts like the M&M conference, which was initially rejected by colleagues of Dr. Codman, science-based physicians have become increasingly aware of the importance of laying out medical errors for all to see and to learn from. Medicine based on the principles of science, such as the importance of taking into account just how easily we can fool ourselves into thinking a particular therapy is effective, or how personal biases can lead to the dismissal of poor outcomes, is the best approach to patient care. It is also the best approach to the education of future generations of physicians, which is why accredited residency programs are required to hold M&M conferences.

Of course, not every physician takes part in such a review process. Many, who are a part of small group or single doctor practices simply don’t have the opportunity. With the widespread incorporation of computers and the internet into physician offices and homes over the past decade, there are resources for self-education available at all times for motivated physicians. These don’t require a thorough scouring of the current literature and an answer can be found sometimes in minutes. But not every physician takes the time to avail themselves of up-to-date recommendations based on the best evidence available. There are thousands of doctors across the full spectrum of legitimate medical specialties that fall heavily into the practice of what I like to call experience-based medicine.

As Mark Crislip, a frequent contributor to Science-Based Medicine, likes to point out, the three most dangerous words in medicine are “In my experience,…..”. Doctors who subscribe to the principles of experience-based medicine are significantly more open to being effected adversely by myriad well-described and inherent weaknesses in the way the human brain interprets the natural world. And those who claim the title of alternative medical practitioner, or promote therapies which fall under that umbrella term, base their worldview entirely on them. 

More to come.