Pediatric legends: Debunking common myths
Medical myths generated and perpetuated by the public and by physicians continue to hamper the care and treatment of children. Are you doing enough to dispel those myths? Or are you one of the guilty?
Pediatric urban legends:
Debunking common myths
By Andrew J. Schuman, MD
Medical myths generated and perpetuated by the public and by physicians continue to hamper the care and treatment of children. Are you perpetuating the myths presented here? Are you doing enough to dispel them?
As pediatricians, many of our conversations with parents involve detailed discussions of "old wives' tales" that are passed from parent to parent and generation to generation. Caring, wise grandparents spread the word that children must dress warmly and don a hat to prevent colds, wait an hour after eating before going swimming to avoid cramps, and be introduced to yellow vegetables before green ones. In contrast, caring, wise contemporary pediatricians advise parents that respiratory infections are spread by viruses, waiting an hour between eating and swimming is unnecessary, and no particular sequence of introducing solids is superior to any other.
In fact, much of our "quality time" with parents, either in the office or on the phone, is spent allaying fears and debunking the many "facts" they've learned about fever, immunizations, medications, foods, and a variety of childhood illnesses. Nonetheless, the continued existence of these myths indicates that more debunking needs to be done.
It is ironic that pediatricians, while quick to acknowledge lay medical myths, continue to perpetuate a variety of "professional" ones (although some myths are held by both pediatricians and the lay public). We offer advice that has little or no scientific basis or, worse, has actually been proven to have no merit at all. It's not difficult to understand why. Only a fraction of what we consider core medical knowledge is based on solid scientific evidence; most of our practices are based on logical assumptions that stem from our understanding of anatomy and physiology. Pediatricians are also the products of the education they received in medical school and residency, and many of us accept the teachings of our professors as gospel. (See "From myth to reality: Confessions of an LMD" below.)
The introduction of practice guidelines by dozens of medical organizations and the interest in evidence-based medicine have alerted pediatricians to the fact that accepting clinical "truths" at face value is inappropriate. But old habits die hard. Studies have shown that a minority of physicians follow clinical guidelines. Physicians have criticized guidelines for lacking scientific evidence, not considering costs of recommended care, and not taking into account patient preferences.1,2 Likewise, while evidence-based medicine suggests that physicians should supplement their clinical expertise with literature searches, few physicians have the time, expertise, or resources to integrate best evidence into real world practice.
While it may not be prudent to be among the first adopters of new clinical tools or therapies, it is foolish to be among the last. In the trenches of pediatric care, many of us have found that experience is one of the best teachers, and we have adopted a basic, common sense approach to pediatrics that is embodied in Loeb's laws of medicine. These laws state simply: (1) If what you're doing is working continue to do it, and (2) If what you're doing is not working then stop doing it.
This article will review clinical practices that persist in the face of evidence that demonstrates they should be modified or abandonedthat is, professional myths. We will also discuss some lay myths we contend with every day. Both lay and professional myths can be considered "urban legends," mythology that has become so popular it is regarded as truth.
Infant care myths
Inexperienced parents are inundated with conflicting child-rearing advice from friends and relatives. The pediatrician's most convincing competitors when it comes to such advice are the infant's grandparents. Tread carefully when discussing grandparent-generated or grandparent-supported mythology, and be prepared for numerous follow-up phone calls!
Myth: Teething can produce fever and a wide variety of other symptoms, such as diarrhea and ear infections.
Type of myth: Lay and professional
In ancient times, teething was reported to cause seizures, colic, rashes, and even death. As we emerge from the 20th century, parents continue to blame a host of symptoms on teething, including high fever, fussiness, otitis media, and diarrhea.3 Pediatricians often don't do enough to correct these misbeliefs.
Surprisingly, the association of fever with teething was not examined until 1992, in a well-designed study performed by several pediatricians in Israel. Over a five-month period, mothers of 46 healthy infants took daily temperature measurements prior to the eruption of the first tooth. They examined their child's gums daily and kept a log of behaviors and any abnormal symptoms. The study showed that temperatures on the day of tooth eruption did not exceed 100.4° F and were not associated with an increased incidence of otitis media, diarrhea, or cold symptoms.4
Both parents and pediatricians need to be cautious when attributing symptoms to teethingthe diagnosis of more serious conditions may be delayed or missed as a result. Symptoms in a fussy, teething baby may be caused by a urinary tract infection, ear infection, or cardiac or gastrointestinal disorder, not just by teething. In addition, ascribing normal physiologic and behavioral changes to teething is an all-too-common method of avoiding discussions of developmental issues. Infants develop eczema and diaper dermatitis in the first few months of life, and sleeping patterns normally change at 6 to 9 months of age. Upper respiratory infections and otitis media are seen during early infancy as well, and their appearance frequently coincides with the eruption of deciduous teeth.
The only thing we are certain teething produces is, well, teeth!
Myth: All infant formula needs to be sterilized before feeding.
Type of myth: Lay and professional
In the early 20th century, refrigeration was not universally available in the United States and public water supplies were not all chemically purified. As late as 1961 the American Academy of Pediatrics (AAP) recommended that formula be sterilized to reduce or eliminate bacterial pathogens that could contaminate the water, bottle, and nipple used to administer the formula.5 "Terminal sterilization" was the recommended method: Bottled formula was immersed in boiling water for 25 minutes and the bottles were then stored in a refrigerator until used. In the 1960s and 1970s, pediatricians began to recommend the "clean method"of formula preparations: Washing bottles and nipples in hot soapy water and diluting powdered or concentrated infant formula with unsterilized tap water.6,7 Subsequent studies revealed no difference in the incidence of gastroenteritis in infants fed formula prepared with either method.8,9
Even though infant formula labels now advise parents to ask their physicians about the "best method" of formula preparation, many parents who bring their baby in for the first time tell me they've been told by friends and family to sterilize water for formula. When safe water is available, pediatricians should advise parents that they can save considerable time and effort by using the clean method of formula preparation.
Myth: Disposable diapers are more likely than cloth diapers to cause diaper rash.
Type of myth: Lay
This may have been true oncebefore the introduction and refinement of modern superabsorbent diapers containing absorbent gelling material. Studies have shown that infants wearing these diapers are much less likely to experience diaper rash compared with those wearing cloth diapers. Reasons include a more favorable pH, rapid removal of wetness from the layers of the diaper next to the skin, and reduced mixing of stool and urine.
Diaper technology has significantly reduced the incidence of diaper rash and parents should be made aware, if they are not already, that a trial of superabsorbent diapers is worth considering if their infant has recurrent episodes of diaper dermatitis.10
Myth: Dehydration is a common cause of fever in newborns.
Type of myth: Professional
Dehydration fever is a temperature elevation seen in the first few days of life in newborns who have had relatively poor fluid intake. Still described in some pediatric textbooks, but omitted from the major neonatology texts, the etiology of this phenomenon is theorized to be hypothalamic dysfunction due to poor central nervous system perfusion. While one can't prove that dehydration fever doesn't occur, the problem is that a pediatrician evaluating a young febrile infant may diagnose dehydration fever rather than consider the possibility of an infectious etiology.
Although many septic newborns present with hypothermia, young febrile infants still need to be assessed for perinatal risk factors (maternal illness prior to delivery, presence of premature rupture of membrane, exposure to group B streptococcus, use of prophylactic antibiotics, and so on). They also require a complete blood count and differential and, possibly, blood, urine, and cerebral spinal fluid cultures.
Food myths
Food myths abound. We need to debunk the more common misconceptions about food and its effect on infant and child physiology and behavior.
Myth: Iron-fortified formula produces diarrhea, constipation, or colic.
Type of myth: Professional
As young infants grow, they may experience loose stools, hard stools, and varying degrees of mild gastroesophageal reflux. Since lactose-based, iron-fortified formulas are recommended for nonbreastfed infants, they get blamed for innumerable symptoms. Pediatricians, as a result, are quick to suggest that parents switch to either a low-iron formula or a soy or protein hydrolysate formula. However, many excellent studies have shown convincingly that iron-fortified formulas produce few GI problems and, with the exception of green stools, are not associated with any of the symptoms we'd like to blame on them.11,12 (Similarly, the early introduction of solids has not been shown to be of benefit in getting infants to sleep through the night.13)
Myth: Chocolate and fried foods can cause acne.
Type of myth: Lay
Parents of teenagers with acne often admonish their children to lay off the chocolate and fried foods in the hope that a change in diet will lessen the severity of their teen's acne. It won't. Studies dating back to the 1950s have shown that french fries and chocolate bars are no more likely to produce pimples than whole milk and fresh fruit.14
Myth: Sugar consumption leads to hyperactivity.
Type of myth: Lay
Parents swear that they witness a "sugar rush" after their children eat candy, and they routinely avoid sugar challenges. But there is simply no proof that a "sugar rush" exists.15,16 Most pediatricians would, however, recommend a well-rounded diet that includes proteins, fats, and appropriate amounts of carbohydrates.
Myth: Food supplements are essential.
Type of myth: Lay
Parents are often concerned about the diet of their young infants and older children, who, despite appropriate growth, appear to be "picky" eaters. According to current recommendations from the AAP committee on nutrition, few food supplements are necessary. Formula and baby foods are replete with vitamins. And most older children, unless malnourished, require no vitamin supplements, although a daily chewable vitamin can do no harm.
Fluoride supplementation should, of course, begin at 6 months of age in places where fluoridated water is not available. Additionally, infants should receive iron supplements no later than 6 months of age, when placentally transmitted iron stores are becoming depleted. Iron supplements should be started sooner in premature infants who did not benefit from accumulating iron stores in the last trimester. The iron can be provided as iron-fortified solids or, in the case of infants who are not breastfed, as iron-fortified formula.17 Last year, the AAP formally recommended that low-iron formula be discontinued.18 Vitamin D and iron may need to be given before 6 months of age in certain groups of infants. For example, in light of increasing reports of rickets among infants who are exclusively breastfed, the 1998 AAP Nutrition Handbook recommends vitamin D supplementation for deeply pigmented breastfed infants, particularly if they are exposed to minimum amounts of sunlight.
Treatment myths
Few pediatricians have questioned the validity of traditional treatments and cures. Unfortunately, some of these remedies don't work, and they may even make things worse.
Myth: Fever is extremely dangerous and must be managed aggressively.
Type of myth: Lay and professional
One of the most enduring medical myths is that a child's fever must be treated with all haste. No doubt this myth stems from the years before modern medicine, when medical treatment was supportive. We all remember television shows showing febrile patients packed in ice. When the fever broke, the patient was miraculously cured.
Barton Schmitt created the term "fever phobia" in a 1980 article detailing the many misconceptions parents have about fever in children.19 He found that most parents considered fevers below 102° F to be high fevers, that a significant number believed that untreated fever could rise to 110° F, and that half of the surveyed parents feared that fever could result in permanent brain damage. Pediatricians admit to worrying about fever as well. In a 1992 survey of pediatricians, most said they believed that temperatures less than 104° F could be dangerous and most were very eager to treat fevers below 102° F with antipyretics.20
To combat fever phobia, we need to teach parents that fever is a symptom of an illness, nothing more, and that antipyretics help provide comfort, not a cure.
Myth: Fever should be treated by alternating between acetaminophen and ibuprofen.
Type of myth: Professional
A recent article described a survey of general pediatricians that examined their fever management recommendations. Half of those surveyed said they recommend alternating antipyretics (giving one dose of acetaminophen, one dose of ibuprofen, and so on). One quarter said they thought the AAP recommended this practice (it does not).21 As the article points out, there is no scientific evidence that this method is safe or reduces fever faster than using either acetaminophen or ibuprofen alone.
Myth: Clavicular fractures should be treated with a figure-of-eight splint.
Type of myth: Professional
It has long been tradition to place children with a clavicular fractureeither displaced or nondisplacedin a figure-of-eight splint. It is commonly assumed that such treatment, though uncomfortable, helps immobilize the fracture and accelerate healing. Studies have shown, however, that the splint is of no benefitit doesn't accelerate healing. A simple sling is just as effective and much more comfortable.22 (As an orthopedist friend of mine once said, "As long as the ends of a displaced clavicular fracture are in the same room, they will heal just fine.")
Myth: Steroids used to treat asthma in a child must be tapered.
Type of myth: Professional
It is not unusual for children with exacerbations of asthma to be treated with several days of oral steroids. It continues to be common practice to wean the steroids, rather than stop them abruptly, for fear of producing a relapse of symptoms. But studies have shown that steroids administered for 10 days or less can be stopped abruptly without causing a relapse, provided there has been significant clinical improvement and the patient has regained normal pulmonary function. Up to 10 days of oral steroid therapy will not produce adrenal suppression.23,24
Myth: Corneal abrasions must be treated with eye patching.
Type of myth: Professional
It's common practice to treat minor corneal abrasions with an ocular antibiotic and eye patch. The patch is supposed to reduce movement of the involved eye, thereby decreasing irritation and accelerating healing. In a review article published more than 10 years ago, it was shown that eye patching neither improves comfort nor accelerates healing.25 Many patients do, however, complain of increased eye discomfort while wearing the patch, in addition to loss of binocular vision.
Myth: Antibiotics are required to cure acute otitis media. Pressure-equalizing tubes are needed in cases of chronic or recurrent otitis media with effusion.
Type of myth: Professional
Most cases of acute otitis media (AOM) will resolve without intervention, and in many European countries AOM is treated symptomatically unless the infection persists or the patient appears ill. Antibiotics continue to be prescribed heavily for AOM in the United States, however.
With studies showing that antibiotic treatment increases cure rates by no more than about 14%, the focus in the US has now been placed on making an accurate diagnosis, rather than prescribing antibiotics. Similarly, it is now recommended that pressure-equalizing tubes be placed for chronic cases of otitis media with effusion only if OME is associated with persistent bilateral hearing loss.26
Myth: Needles need to be changed before inoculating blood culture bottles.
Type of myth: Professional
In a effort to reduce the rate of contaminated blood cultures, pediatricians have passed down the tradition of switching needles after drawing blood and before inoculating blood culture bottles. A 1990 study involving blood cultures obtained from 303 children found similar, small rates of contamination in study groups in which there was either no needle change following phlebotomy and the inoculation of a blood culture bottle, a single needle change (before inoculation into one culture bottle), or a double needle change (before inoculation into each of two culture bottles). The study showed that skin antisepsis is much more important to preventing contamination than changing needles is.27
Change is inevitable
Which of the "urban legends" detailed in this article will survive unchanged years from now? Which practices will be shown the proverbial exit door? It's hard to predict, but this much is certain: Through careful observation and clinical study, pediatricians will continue to challenge traditional diagnostic and therapeutic beliefs and strategies, and medical research will make discoveries that will lead to new practices. Because of change, and the controversy that often accompanies it, pediatrics will continue to be a fascinating and exciting avocation.
The author would like to thank Virginia A. Mason for her assistance in the preparation of this article.
REFERENCES
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2. Christakis DA, Rivara FP: Pediatricians' awareness of and attitudes about four clinical practice guidelines. Pediatrics 1998;101:825
3. Schuman AJ: The truth about teething. Contemporary Pediatrics 1992;9(10):75
4. Jaber L, Cohen IJ, Mor A: Fever associated with teething. Arch Dis Child 1992;67(2):233
5. American Academy of Pediatrics Committee on Fetus and Newborn: Sterilization of milk-mixture for infants. Pediatrics 1961;28:674
6. Gerber MA, Berliner BC, Karolus JJ: Sterilization of infant formula. Clin Pediatr 1983;22:344
7. Feder HM, Pugno PA: Sterilization of infant formula: Current practices and recommendations. J Fam Pract 1986;22:259
8. Kendall N, Vaughn VC, Kwakcioglu A: A study of the preparation of infant formulas. Am J Dis Child 1971;122:215
9. Fischer CC, Whitman MA: Simplified method of infant feeding: Bacteriologic and clinical study. J Pediatr 1959;55:116
10. Schuman AJ: Disposable diapersdefinitely. Contemporary Pediatrics 1997;14(11):131
11. Oski F: Iron-fortified formulas and gastrointestinal symptoms in infants: A controlled study. Pediatrics 1980;66:168
12. Nelsen SE, Ziegler EE, Copeland AM, et al: Lack of adverse reactions to iron-fortified formula. Pediatrics 1988;81:360
13. Macknin ML, Mendendorp S, Maier MC: Infant sleep and bedtime cereal. Am J Dis Child 1989;143:1066
14. Rasmussen JE, Smith SB: Patient concepts and misconceptions about acne. Arch Dermatol 1983;119(7):570
15. Wolraich ML: Diet and behavior: What the research shows. Contemporary Pediatrics 1996;13(12):29
16. Wolraich ML, Wilson DB, White JW: The effect of sugar on behavior or cognition in children: A meta-analysis. JAMA 1995;274:1617
17. Walter T, Dallman PR, Pizarro F, et al: Effectiveness of iron-fortified infant cereal in prevention of iron deficiency anemia. Pediatrics 1993;91:976
18. American Academy of Pediatrics: Committee on Nutrition. Iron Fortification of infant formulas. Pediatrics 1999;104:119
19. Schmitt BD: Fever phobia: Misconceptions of parents about fevers. Am J Dis Child 1980;134(2):176
20. May A, Bauchner H: Fever phobia: The pediatrician's contribution. Pediatric 1992;90:851
21. Mayoral CE, Marino RV, Rosenfeld W, et al: Alternating antipyretics: Is this an alternative? Pediatrics 2000;105:1009
22. Andersen K, Jensen PO, Lauritzen J: Treatment of clavicular fractures. Figure-of-eight bandage vs. a simple sling. Acta Orthop Scand 1987;58(1):71
23. Cydulka RK, Emerman CL: A pilot study of steroid therapy after emergency department treatment of acute asthma: Is a taper needed? J Emerg Med 1998;16(1):15
24. Hatton MQ, Vathenen AS, Allen MJ, et al: A comparison of 'abruptly stopping' with 'tailing off' oral corticosteroids in acute asthma Respir Med 1995;89(2):101
25. Flynn CA, D'Amico F, Smith G: Should we patch corneal abrasions? A meta-analysis. J Fam Pract 1988; 47:264
26. Combs JT, Schuman AJ: Three technologies for taming otitis media. Contemporary Pediatrics 1999;13(3):78
27. Isaacman DJ, Karasic RB: Lack of effect of changing needles on contamination of blood cultures. Pediatr Infect Dis J 1990;9:274
THE AUTHOR is Adjunct Assistant Professor of Pediatrics at Dartmouth Medical School, Lebanon, N.H., and practices pediatrics at Hampshire Pediatrics, Manchester, N.H. He is a Contributing Editor for Contemporary Pediatrics.
From myth to reality: Confessions of an LMD
It's been more than two decades since I began my pediatric residency under the tutelage of academic pediatricians. At the tertiary care center where I worked, we were often presented with complicated cases referred by community physicians, pediatricians we called LMDs, aka local medical doctors. The residents perceived the LMDs as having trouble keeping current with medical developments, more likely to prescribe antiquated medications, having great difficulty starting an IV or performing a spinal tap, and not as aggressive diagnostically as our professors at the medical center.
In our view, LMDs perpetuated the professional myths in pediatric practice, while the academicians championed the abandonment of dated medical practices. My fellow residents and I swore that we would never become LMDs. As fate would have it, my fellow residents became specialists. I became a general pediatrician. I now proudly proclaim myself an LMD.
As an LMD, I've learned just how challenging "real world" pediatric practice can be. Beyond the complexities imposed by government regulations, insurance companies, and managed care, I must diligently monitor the development and growth of thousands of patients, try to distinguish significant medical problems from minor ones, and try to keep current with the latest recommendations in our field. In my short career I've witnessed changes in many common practices as professional medical myths succumb to well-designed studies that support their abandonment. Such antiquated practices include:
- the administration of fractionated-dose immunizations to reduce the incidence of side effects
- the routine end-of-treatment spinal tap
- the use of surface and gastric aspirate cultures in the work-up of neonatal sepsis
- the aggressive treatment of neonatal jaundice, with the initiation of phototherapy in healthy term babies at levels far below those currently recommended
- the use of epinephrine and Sus-Phrine injections for asthma (because nebulized bronchodilators are equally effective and have fewer side effects)
- the use of silver nitrate for newborn eye prophylaxis and triple dye for newborn cord care (because better alternatives are now available)
- the use of aspirin for fever reduction (because of its association with Reye syndrome)
- the recommendation that newborns sleep on their stomachs (because of evidence that the supine sleep position reduces the incidence of sudden infant death syndrome).
While I may not be as good at starting an IV as I was in residency, resources like Pediatrics in Review from the AAP and Contemporary Pediatrics keep me current with the latest and greatest in our field. I've also learned the wisdom of not accepting all recommendations empirically but to question the reasoning and scientific proof responsible for changes in policies.
Andrew Schuman. Pediatric legends: Debunking common myths. Contemporary Pediatrics 2001;0:115.
