Doctors are NOT God, even though sometimes they act like it. Everyone deserves a second chance - even you!

Wow, these are crazy stories. Guess I'm with an excellent pediatrician and group. Haven't had any problems yet, and the diagnosis has always been correct.

Lisa, I can relate. My husband and I were trying for a baby for almost 5 years, and I was just about to start fertility treatments when I got pregnant at 34 with our now 11 yr old perfectly healthy son. My ob-gyn was being very insistent about doing an amnio & I was equally insistent that I was not going to allow it. The risk of a miscarriage was too high & there was simply no way I was willing to risk the safety of my baby. If he had heard me & stopped pushing I might have stayed with him. But he just couldn't understand why I would be willing to take such a chance & was treating me like I was being stupid for not going along with it. I fired him, found a new doctor, and I'm still with her today. Love her.

That's a bit selfish of you to ignorn medical research, putting your child and other children at risk of these horrible diseases, becuase you think you are "the end all be all."

I understand your concern about the MMR vaccine but remember that the ONLY reason you are talking about this with your doctor is because ONE researcher LIED about his irresponsible and unscientific studies. Why would you believe the lies perpetrated by one dishonest researcher, and not believe the thousands of studies that have come after? I know your instincts are to protect your child and err on the side of caution, but considering the rise in measles deaths in the last few years you really need to consider the reality more dispassionately. Fact: autism strikes more boys than girls. Obviously more boys than girls are not getting the MMR vaccine, so something else is at play. Fact: autism is inherited. If a close family member has autism (sibling, twin) then the child is much more likely to develop autism (30-90%).

I support your right as a parent to make decisions for your child's care, but your pediatrician would have been right to try and provide you with knowledge. Though not force his will on you!

There are risks with vaccinations but the argument saying Autism is a legitimate risk doesn't make it so. The one study published that did suggest a vaccination relationship has been rescinded, because it was a bad study for a number of reasons.

I think the doctor shouldn't have forced his will on you either. Being that your son is 3 at the youngest, I think some of these posters need to back off of their criticism about your autism fears.

I personally was never afraid of the MMR, but with your son's age, you were right in the middle of the "vaccine=autism" argument. You had no idea that a researcher lied, and your fears were valid and mainstream at the time. You were not selfish, you were protecting your child with medical research that was considered valid by some AT THE TIME. Now we are aware that the researcher lied, but at the time you were making your decision, no one knew.

If your doctor would've come at you differently, who knows what you would've decided to do. But, he is YOUR son and you were doing what you thought was best for him. You were not the first or only mother to deny the vaccine at the time. I am glad that your son was eventually vaccinated, but I will not vilify you for making your decision when you son was an infant.

my daughter fired her doctor after her 3 month old son experienced repeated seizures after his first MMR vaccine. the doctor refused to refer her to a pediatric neurologist, but we found one on our own. when the neurologist asked for the baby's medical records, my daughter found that the pediatrician had removed all traces of the baby's vaccines from the records before sending copies. the only way she could prove that he had the shots was from the insurance company's claims department records. then she fired him.

ScienceChick, actually, you have your facts wrong about autism "striking" more boys than girls. Autism is a spectrum disorder and they are finding that because girls exhibit autistic traits differently (ie; girls are generally more verbal and autistic girls tend to be on the more verbal side, as one example), they are most likely missing diagnosing girls, especially the higher functioning ones. Researchers tend to look for male behavior when diagnosing autism but are now realizing that there are major differences in the sexes. I say this as an autistic woman and the mother of two autistic children.

My wife and I own a pediatric practice and while we don't force any parent to vaccinate their children, we do have them sign a waiver if they choose not to vaccinate. The physician who started the MMR controversy has been shown to be a liar and a fraud. It wouldn't be so bad if he weren't a "trusted" physician, much as Madoff was a "trusted" financial advisor. While I'm happy that your child is healthy, the world is seeing a rise in diseases such as Mumps, Measles and others that were all but eradicated because of responsible vaccination programs. This is a crime!! Our nation in particular has been blessed because most of our generation hasn't had to live through an epidemic like polio, as did our grand parents, so we make decisions based upon "light reading" via the internet, as opposed to decades of sickness, death and scientific research.

This doctor should be tried for murder in my opionion. Not only did he put the children at risk who's parents listened to him, but other children who may have not been current in their vaccinations were put at risk too. Its one thing to not want to vaccinate your child, but quite another if your child carries disease and infects another child. We are all connected and we are all responsible for one another.

I'm attaching the Reuters article showing that Dr. Andrew Wakefield, the liar and fraud who started the controversy for fame and fortune, has been disavowed and proven to be a fraud. His so called "study" wasn't a study at all. Read for your self dear lady. Once again, this isn't a put down to you or your family, but it amazes me how a lie will be half way around the world while the truth is still putting on its shoes.

http://uk.reuters.com/article/2011/01/06/us-autism-vaccines-idUKTRE7050J420110106

So you're putting my child at risk because you fail to look it up and realize that it was just one guy that was lying about the vaccine?

@Grandma o'7: no 3 m/o should be getting the MMR vaccine. If a pediatrician did give the vaccine at that age, they were wrong to do so. It's indicated for children aged 12 mo and older. Febrile seizures do indeed sometimes occur with or without vaccination. Occurrence of more than one would probably warrant referral to a neurologist. Never be afraid to seek a second opinion, but please don't blame vaccination for the problem.

This doctor should be tried for murder in my opionion. Not only did he put the children at risk who's parents listened to him, but other children who may have not been current in their vaccinations were put at risk too.

More people died from measles in the 10 year period BEFORE Wakefield's paper than in the 10 years after.

So who exactly do you think he killed? And there are legitimate reasons to not get the MMR vaccines. It is known to cause convulsive febrile seizures. According to another doctor on this website that will get you a ticket for an unnecessary lumbar puncture spinal tap which results in unnecessary severe headaches for weeks in up to 40% of children. The MMR vaccine is not benign.

I see distortion is your forte Robert. The first dose of MMR is recommended to be given 12 months of age or later. Again, Mr. Distortion that's where the good history and physical comes in. I guess you missed that during med school--oh, wait...

Like I've said three or four times before, nobody suggested performing LP's willy-nilly without a good reason. A febrile 12-month old who is having tonic clonic seizure activity, with a good story on history and physical meningitis is a candidate for an LP. If the kid recently had the MMR vaccination within 14 days, one might consider an adverse reaction to the vaccine.

But if it makes you feel good to pass along bad info, be my guest.

My baby had awful diaper rash and a doctor gave us a cream to put on it. Two days later, the rash looked even worse and she was running a fever, so we took her to the ER because it was a Sunday. I recall a nurse telling us that diaper rash was not an emergency and that we should go to our regular clinic on Monday.

However, a nice young Navy corpsman looked at my baby's bottom and saw how awful it was. He went back and told the doctor that my baby should be seen, despite what the nurse had said.

The doctor determined that yes indeed, my daughter's diaper rash had developed a staph infection (causing the fever), and that she needed antibiotics (oral and topical) immediately. I am grateful that the corpsman stuck up for us despite the nurse blowing us off.

I hear you about that one! Likewise, some are better at treating only those that are very ill. My pregnancy was high risk because of my health issues, and it became more complicated when the baby (who turned out to be my now-32 y.o. son) was not developing properly. We interviewed and engaged a pediatrician before my son was born so we could have someone standing by in case some of the feared outcomes came to pass; this pediatrician had been chief resident in the NICU. Fortunately, my son was born healthy so we didn't need the dr's specialized NICU experience.

But when my son became ill when he was 10 months old, the pediatrician failed to recognize the seriousness of the issues my son was having. Since my son was born healthy, the pediatrician mentally catalogued him as a "healthy baby," and decided I was just an hysterical new mother. But that wasn't the case.

My son finally had to be hospitalized (dehydration from near constant vomiting and diarrhea), so I stayed in his hospital room and took the opportunity to get input from the interns and residents. Had a number of battles with the pediatrician to get him to listen to me and took actions I thought needed to be taken. When the symptoms reappeared a few days after my son was discharged from the hospital, we went right back to the pediatrician's office without waiting for an apppointment. Our pediatrican wasn't there, so I had the chance to speak to another Dr within the practice who didn't have the pre-conceived notion that my son was "healthy" and that his problems were all in my head. After speaking with me and examining my son, this Dr said yes, my son was definitely having problems. We fired our old pediatrician right then and there, and switched to his colleague.

Numerous tests, trial and error sessions, and weeks later, we learned that my son had numerous severe food allergies, plus celiac disease and resultant failure to thrive -- at 15 months old, he weighed only 17 pounds -- and his immune system was compromised because of everything his body was undergoing because of food that was literally poisoning him.

I learned that you have to be your child's advocate and insist that you be heard, if your gut tells you something is wrong. Don't stop until you get the answers, no matter what anyone with an M.D. after his name tells you.

Robert,

Not to rock the boat. I'd have to calculate the NNT from a meta analysis and it would take a little while, but really the NNT is irrelevant. Not performing a lumbar puncture on a 3-36 month old with suspected bacterial meningitis is malpractice, and many doctors in this country perform defensive medicine, particularly those in busy ERs. We don't actually know the entire circumstance behind the incident, so there very well might have been an indication for LP. It was unnecessary in this instance because the child luckily did not have bacterial meningitis.

However, you are correct. Children with simple febrile seizures and no meningeal signs generally do not need LP. A study of 410 patients (link below) indicated that children with bacterial meningitis always presented with some other neurological or meningeal sign, most frequently stiff neck (60-80%), so a savvy ER doc would monitor or look for other occult causes of fever (UTI, pneumonia, etc) before performing an LP.

In conclusion, NNT or not, febrile seizures can be managed defensively and appropriately with LP. If the doctor had not suggested it, and the child died of BM, and the parents sued, they would easily have won. I agree with MarineDoc in saying the mother should be fired over joking about their dog in a situation where the doctor needed more information to make a appropriate assessment and instead chose to be uncooperative, hostile, and probably made the physician practice even more defensive medicine.

Your child had a fever as high as 105 degrees Fahrenheit, and was convulsing, and you thought making a stupid joke about a goddamn dog was appropriate at the time?

You should have been fired as a parent.

The pediatrician was absolutely correct in wanting to perform a lumbar puncture (spinal tap), because your kid could have had meningitis or encephalitis!! It has a mortality rate of as high as 30% depending on age, and etiology.

This isn't a story you should be sharing....if anything you should keep it to yourself, and never tell anyone your father-in-law suggested otherwise--for his sake. It realy makes you sound stupid and reckless.

Seymour - MarineDoc is right. I would have let him do the spinal tap. You were very lucky your child didn't have meningitis.

Marine Doc, the invasive painful spinal tap was unnecessary. That was the fact. You can say what if and play CYA medicine all day.

Robert,

And you know it was unnecessary how? From the "excellent" history the patients parent gave about the Poodle? Pain is temporary, death is permanent--and painless.

I guess the new trend is if a child has a fever with convulsion then they get a mandatory spinal tap.

What's the NNT on that one Doc?

MarineDoc, you know damn well that febrile seizures in a child that young is extremely common. And if the child didn't have any of the other symptoms of meningitis (photophobia, vomiting, headache or the baby was altered) why would you put a baby through a painful tap? Fever spikes in kids that age are very, very common. Tapping them for it is a very unnecessary procedure that has serious risks involved. I think you owe that mom an apology.

The problem is you never know. Where the pediatrician was covering all bases another may have decided to wait and see. When you take your child to a hospital they tend to start the tests to rule almost everything reasonably out vs. a pediatrician's office will often go somewhat more conservatively (although less so these days). The two pediatricians may perform similar tasks but function in different modes of treatment. The hospital by nature is much more aggressive/crisis oriented.

Had it been meningitis or something else and the spinal tap not been offered most parents would have been screaming about how the incompetent pediatrician didn't catch it and sued.

Robert,

A LP puncture for a 12 month-old child was a reasonable suggestion to rule out meningitis. But please...don't take my word for it.

http://pediatrics.aappublications.org/content/127/2/389.full.pdf+html

Why would I put a child through an LP? Because I think it's better than being in the ICU with meningitis.

And you know it was unnecessary how? From the "excellent" history the patients parent gave about the Poodle?

The child didn't have have encephalitis. The lumbar puncture was unnecessary.

Pain is temporary, death is permanent--and painless.

Enough with the rhetoric.

What is the NNT for lumbar punctures to prevent encephalitis base on the symptoms of fever and convulsion?

Yes, enough with the rhetoric, "Dr. Robert". What would you have done?

12 month old child comes into the ED febrile to 105F with a parental report of seizure activity. Parent is not cooperative and is instead giving the medical history of her mothers @!$%#ing dog.

LP is a reasonable diagnostic test.

What is the number needed to treat using lumbar puncture to prevent ONE case of encephaltis complications?

As a doctor you should know this number. It's called evidence based medicine.

You are going to try to talk about EBM? Tell me what the best test is for meningitis in that age group?

If a child gets the MMR vaccine and goes into a convulsive febrile seizure do you automatically perform a Lumbar puncture or do you down play the seizure and fever?

So, when a 12-month old unvaccinated child arrives with fever to 105, having seizures (same symptoms as the kid above, but unbeknownst to YOU, she has a pretty severe case of bacterial meningitis). What test are you going to order? How long are you going to wait?

What's the natural history of bacterial meningitis?

Nothing is automatic Robert. Don't try to confuse the issue, answer the question.

Hello? Robert?

Do you understand what NNT means?

If you you were to perform spinal taps on every convulsive febrile child(what you would call a patient) how many would you have to perform to prevent one death from encephalitis/meningitis?

How come you don't know this? Are you an evidence based doctor?

I guess you neglected to follow the link to the American Academy of Pediatrics Recommendations on Febrile Seizures. Nobody has suggested performing lumbar puncture on EVERY child with a febrile seizure. Children 12 months and younger aren't able to describe their symptoms very well. Her child was 12 months old.

Robert, let me ask you again. What is the best test for meningitis in a 12-month old? What test would you order to rule out bacterial meningitis in a 12-month old? What happens to a child with untreated bacterial meningitis?

The practice of medicine is not merely quoting statistics. I hate to break it to you, but physicians aren't repositories for every bit of statistical minutia in the literature. If I want to know the NNT of anything, I would go look it up. Getting a good history, physical examination, and using clinical judgement is what's important.

Now, I've demonstrated that from this story, the pediatrician's course of action was appropriate. If the child did have bacterial meningitis and the parent refused care, we would have been reading a post about how a pediatrician let her baby die.

You've been perseverating on NNT, so if you'd like to have a discussion on levels of evidence, I'm all for it. However, you've failed to prove that doing nothing is the appropriate course of action. Again, answer my question from #12.14 or move along.

I posted my reply in the wrong section, its above, but here is the article I forgot to attach, if anyone is interested.

I guess you neglected to follow the link to the American Academy of Pediatrics Recommendations on Febrile Seizures.

No, I read it. There was no data in it. Just policy recommendations.

However, you've failed to prove that doing nothing is the appropriate course of action

Not doing a spinal tap on a little baby IS the appropriate course for almost all causes of febrile seizures.

I take it that you don't exactly know what the evidence is.

Getting a good history, physical examination, and using clinical judgement is what's important.

True. And this should lead to very littlle use of spinal tap for fevers . But clinical judgement is clouded by a policy that calls for spinal taps in little infants.

If you perform 1000 unnecessary spinal taps and cause 500 excruciating headaches on a little baby that doesn't have meningitis what happens to you? Nothing.

What happens if you miss one case of RARE meningitis? you get sued.

Do you think this type of personal risk benefit analysis plays into your clinical judgment. Harm 500 to prevent one case of encephalitis.

Good point. Although, I don't necessarily think it's "defensive". It's the right test, and won't delay proper treatment. I see a small child who is sick and unable to communicate with me, with a small, but significant chance of mortality. Of course nobody should rush to perform an invasive procedure without a good reason. As the treating physician is not here to tell us what his history and physical examination revealed, I like to believe a well trained pediatrician would order the appropriate test. I don't know anyone who jumps at the chance to perform an LP on a squirming, sick, 1-year old.

And then there's the small possibility of the organism being Neisseria meningitis...

So...you would do nothing in the case that I presented? So, you would let a small child die of a treatable disease, because you don't want to numb a child's back and poke him with a 22-gauge needle? And what are you talking about giving every patient an LP? We've been over this. You are worried about giving a kid a headache, when I'm thinking about keeping a kid from dying, and treating the right disease.

You know what Robert, when you have the responsibility making the right choice in a potentially life or death situation, give me a buzz eh?

EBM does not mean punching information into a computer algorithm and waiting for an answer. And unfortunately patients are not mass produced widgets with identical working parts. There are variables that require clinical judgement. Having said that, if you are interested in the statistics I invite you to summarize the 23 references at the end.

Agreed. I'm a pediatrician, and frankly the therapeutic relationship works much better if you feel I'm doing the right thing. If you disagree with your doc, or your child's doc, say so. Have an open dialogue. I'll be the first to admit that I'm not always right; no doctor is. However, understand also that just because you read something on the internet does not give you a medical degree.

Generally if a parent wants to try something or thinks the diagnosis is something other than what I say, I'm willing to entertain the possibility unless I think it's going to be harmful to a child.

Children can be wonderful patients, and the satisfaction of watching well children grow into adults over the years must be rewarding. Having dealt with the occasional overbearing parent who studied medicine at the University of Google...I wouldn't wish on my enemies. Thank you for having what seems like endless patience. I couldn't do it...especially when the discussion turns to vaccinations.

William, I agree with the fact that managed care is seriously impacting the quality of the health care that people receive. Over the years, I have seen the quality of care deteriorate at the practice we use - and I firmly believe it is due to the fact that they have to schedule so many patients every day to squeeze out a profit, that they can barely keep their patients straight any longer.

I agree if you're uncomfortable seek a second opinion or switch docs.

However, I can tell you I see a lot of kids who have colds and the parents want antibiotics. I wish I would make the kids better, but there is no 'aggressive treatment' that's going to work. I don't benefit from not treating children, but I also don't have a magical antiviral that makes colds go away. If I had a cure for the common cold I'd have a nobel prize and be able to retire. If I could make stomach flu go away I'd give out free samples for Christmas.

At that age, your child probably did have reactive airway disease (likely what was meant by "pre-asthma"), and the inhalers were probably appropriate.

http://emedicine.medscape.com/article/800119-overview#a0104

As children get older, they usually grow out of it. The great thing is most kids who wheeze at that age won't progress to having asthma. The inhalers help the child to breath.

Chronic lack of oxygen isn't very good for the child's development...so not filling the prescriptions aren't going to hurt you, but your child might suffer.

http://www.pediatricsdigest.mobi/content/114/3/805.full

You do not even have the whole health history but in every post you make you defend the doctor and his treatment as if he or she could not possibly have failed this family. Doctors are not without fault and do make misstakes, continuing to insist makes you look like a doctor that believes it impossible for the patient to be in the right. You are not doing your profession any favours. One of the first things mentioned in a lot of medical books for pediatric patients is that you should always pay attention to the mothers "instincts" (she knows her child) Unless that changed in the recent med books. Married to an old doctor without god complex

He did the same thing with the febrile child. He agreed to ordering a spinal tap on a child with a fever because he had a visceral response to the parent. The child was fine. The test would have been unnecessary. He attacked the parent and defended the doctor based. This showedd bias. He tried to justify his emotional response as "clinical judgement" but yet couldn't give the evidence of the NNT.

I'm afraid this happens too often. Overtesting means overtreatment and overHARM.

j smith,

So...let's review.

1. This woman complained that two chest x-rays were "always negative". CXR aren't simply positive or negative. They give all sorts of information. But for "asthma" (which really can't be reliably diagnosed until after about 3 years of age), a chest x-ray isn't very useful as a initial diagnostic tool, but rather it's used to look for complications, or other reasons the patient is having difficulty breathing.

2. The infant was prescribe "asthma" medications. These medications such as salmeterol, albuterol etc. relieve acute bronchospasm by relaxing smooth muscle in the airway...helping the child to breath. Prescribing them does not mean the child has asthma. Medications like ipratroprium (Atrovent) helps decrease secretions, and decreases the muscle tone in the small airways.--helping the child to move air more easily--also does not mean the child has asthma. There are others like cromolyn that stabilizes mast cells that have been sensitized to allergens. Corticosteroids, leukotriene inhibitors and many others.

Mom didn't even try any of these. So mom says the kid had allergies...which made me chuckle a bit. Why? The pathophysiology of pediatric airway disease:

Pathophysiology (from http://emedicine.medscape.com/article/800119-overview#a0104)

Numerous environmental stimuli induce an allergen-antibody interaction, causing a release of mediators that create airway inflammation. Airway inflammation is the primary factor responsible for smooth muscle hyperresponsiveness, edema, and increased mucous production, resulting in increased work of breathing. A complex interaction occurs between inflammatory cells and airway epithelium. Mediators released from mast cells induce edema, mucous secretion, and bronchospasm. These mediators include histamine, tryptase, heparin, leukotrienes, platelet-activating factor, cytokines, interleukins, and tumor necrosis factor. The other inflammatory cells (ie, eosinophils, lymphocytes) also release mediators and create a toxic environment to respiratory epithelial cells.

In infants and children younger than 3 years, the intrapulmonary airways are so small that any lower airway infection results in diminished airway function. Other anatomical factors, such as poor collateral ventilation, decreased elastic recoil pressure, and a partially developed diaphragm, may predispose the very young child to respiratory compromise.

Speculation exists that all infants are born with highly responsive airways. Increased immunoglobulin E (IgE) levels have been found in those younger than 2 years. A decrease in airway responsiveness may be associated with environmental allergens, viral respiratory diseases, and hereditary factors.

Rhinovirus infections are an important contributor to asthma exacerbations in children. Hence, therapies against rhinovirus might reduce the risk of severe exacerbations.^[3]

Fever and bronchospasm are not associated with a more severe clinical course. In fact, fever as a response to infection may have a beneficial effect and can be seen as a good prognostic indicator.^[4]

Hygiene hypothesis suggests that early exposure to infections and allergens might protect children from developing asthma later in life because of improved immune system.^[4]

Breastfeeding might protect children younger than 24 months of age against recurrent wheezing. The cytokine, TGF-B1, in human milk may have both suppression and enhancement functions in the immune reaction.

Exposure to maternal environmental tobacco smoke during pregnancy or the first year appears to predispose children to reactive airway disease.

But, like I said many children grow out this disease--my own son included. The difference is I actually LIKE oxygen rich blood to get to the brains of developing children.

Paying attention to mothers "instincts" are fine. Blindly following "gut feelings" and "instincts" isn't medicine. If understanding the pathophysiology of a disease is having a god-complex...then please I prefer to be called Dr. Odinn.

Robert LOL..."emotional response"...don't you have some backs to crack?

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