Pediatrics is full of uncertainty, not unlike the practice of parenthood

Recently I wrote a blog about how the American Academy of Pediatrics (AAP) thinks that otherwise healthy children with ear infections should wait a couple of days before starting antibiotics, because many will get better without them.

Now there are two articles in the New England Journal of Medicine (here and here) saying that children with ear infections who are given antibiotics are more likely to get better, and to get better quickly, than those who aren’t.

Awkward.

To be fair to the AAP, the studies don’t refute their policy as much as it might seem. In both of the studies, lots of children got better without antibiotics. And since the AAP doesn’t say that kids shouldn’t get antibiotics, just that they should wait, what these studies seem to say is that if parents truly need to do everything possible to get their kids better fast (e.g. the child missing school, or the parent missing work, is a real problem), giving antibiotics is the way to go.

All the concerns the AAP had about side effects (indeed, in both studies diarrhea was common in the kids who got antibiotics) and increasing resistance to antibiotics (interestingly, in both studies the antibiotic used was something stronger, and more likely to cause resistance, than the antibiotic recommended by the AAP) still remain. Both studies acknowledge that more studies need to be done.

But the studies do put me in the position of rethinking, and possibly changing, the advice I give parents—the advice I gave rather publicly just a couple of months ago.

Like I said: awkward.

This actually happens all the time. Doctors rely on scientific studies to tell us how to practice medicine. The thing is, scientific studies are much less clear than people realize. The way a study is designed affects everything, as does how many patients were in it (lots of patients is always better, but it’s not always easy to get lots of patients in a study), how long it lasted, and lots of other factors.

A study can seem to show clearly that X is the best treatment for a condition, so we all start doing X…only to have the next study show that Y is much better than X…only to have the next study show that neither is a good idea and that we need to go back to the drawing board.

When I started being a pediatrician a couple of decades ago, we were taught that if a baby was at least 9 months old and weighed at least 18 pounds, it was okay to switch from formula to cow’s milk. Now we know that starting cow’s milk before 12 months can lead to iron deficiency, and would never give that advice. Another example: We used to tell parents that it was a good idea to get their baby boys circumcised, because it lowered the risk of urinary tract infections and penile cancer. Then specialists studied the issue and decided that the risks of the circumcision itself (like bleeding or other complications) just about equaled the risks of infection and cancer. So the advice changed: we told parents to make the decision based on personal or religious preference, because there wasn’t a good medical argument either way. Now, with more and more evidence that circumcision may help prevent HIV infection, we may change our advice again.

Parents want their doctors to be authoritative, to tell them exactly what to do. For what it’s worth, we doctors want to be authoritative. It’s much more comfortable and comforting to have The Right Answer than it is try to explain that medicine is art and shades of gray, influenced by an understanding of science that is always evolving. But The Right Answer can be elusive sometimes.

So cut us doctors some slack the next time we hesitate, or waver, or even contradict what we said last year or last week. Understand that it’s not that we don’t know what we’re doing—it’s just that we are learning new things all the time. When we offer you options, understand that the reason we’re doing that is not to confuse you, or to get out of making a decision, but because there truly are different options and the science can’t tell us yet which is best.

The practice of pediatrics is not unlike the practice of parenthood: full of uncertainty, impossible to understand completely and done best when the child is more important than anything else. We’re coming at it from different places, but we’re in this together.

Claire McCarthy is a primary care physician and the medical director of Children’s Hospital Boston’s Martha Eliot Health Center.  She blogs at Thrive, the Children’s Hospital Boston blog.

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  • http://www.archerfriendly.com Archer

    I like how you pointed out how things aren’t always black and white in medicine. I think the general public doesn’t always get this. I think that was one of the biggest learning curves I had to make in med school. So true that medicine is art and shades of gray…

  • http://natickpediatrics.net Rob Lindeman

    Clare, please read the NEJM articles carefully and then see David Newman’s podcast on OM. A thorough take-down of the NEJM articles appears at the end.

    http://www.smartem.org/smartem.org/Blog/Entries/2011/2/18_Antibiotics_for_Otitis_Media__Feel_Better.html

    While you’re at it, check out Jerome Klein’s accompanying editorial. In it he trots out a statistic about how devastating was OM in the early part of the last century. In fact, the citation he brings shows just the opposite, that children were hospitalized for OM precisely because the entity was being overtreated. (Bakwin H, Jacobinzer H. Prevention of purulent otitis media in infants. J Pediatr 1939;14:730-736

    Bottom line, This SHOULD NOT be awkward.

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