Monday, January 31, 2011

Listen to this

IF YOU'RE A PARENT, does the following scenario sound at all familiar? Your 18-month-old child catches a cold and after a few days of seemingly harmless sniffles, she morphs from a happy and inquisitive toddler into a dreadful beast — fragile, volatile and screaming when she should be sleeping.

Once a water baby, she's now deathly afraid of the bath; not wanting water within an American Girl's reach of her head. Already a picky eater, all of a sudden the only food she'll accept is dried fruit and the resulting "runs" obliterate the family's diaper reserves. Acetaminophen calms the situation, but a couple hours later it's back to hysteria-hood.

Not ringing any bells? Consider yourself fortunate (and warned) because this exact metamorphosis happened to my daughter several years ago. Of course, like any parent, I attempted to diagnosis the situation. After considering some possibilities (such as personality inception and possession by the devil), I settled on the most likely malady — otitis media, aka an ear infection.

Ear infections are quite common in children younger than 3, primarily because the anatomy of the young ear (specifically that of the Eustachian tube between the middle ear and back of the throat) doesn't allow for effective clearance of fluids. In youngsters with the sniffles, middle ear fluid often bottlenecks, allowing bacteria from the nose and throat to migrate into the ear.

So, suspecting an ear infection, I decided to do ... nothing. I thought I was being astute, as I was following the advice of the American Academy of Pediatrics. I was in "watchful waiting" mode, considered a viable alternative to antibiotics for many children with ear infections because the majority of these infections get better on their own.

Unfortunately, after 48 hours, watchful waiting had turned into witchful watching, and even though my daughter had not developed a fever, it was time to stop playing doctor with my own family. The pediatrician who examined her ears observed that they looked "extremely painful" and asked, "Wow, does she scream all night long?" Yes, I replied, she sure does!

Hayley took her first dose of antibiotics that afternoon and by the next morning the beast was gone, replaced by a (mostly) happy and inquisitive toddler. I was shocked with how quickly her symptoms improved and suddenly appreciated the words of dozens of parents who had sworn to me that antibiotics did help with otitis media. With this experience in mind, I can't say I was particularly surprised by the recent study that provided, for the first time, solid evidence that some children with ear infections do, in fact, get better faster with antibiotics.

The study, published in the New England Journal of Medicine, was led by Dr. Alejandro Hoberman from Children's Hospital of Pittsburgh. In it, the researchers examined the symptoms of 291 children (age 6 to 23 months) with ear infections who either did or did not receive an antibiotic (amoxicillin clavulanate, also known as Augmentin) for 10 days. They found, across several measures (including the composite Acute Otitis Media Severity of Symptoms [AOM-SOS] scale) that the group receiving antibiotics fared better in the short-term, with a faster time to symptom improvement and significantly lower rate of persistent infection. On the other hand, the kids receiving antibiotics suffered a 25 percent rate of diarrhea, versus 15 percent with the placebo group and there was no significant difference between two groups in the amount of painkiller used.

The authors summed up their study:

"(A)mong children 6 to 23 months of age with acute otitis media, treatment with amoxicillin clavulanate for 10 days affords a measurable short-term benefit ... (that) must be weighed against concern not only about the side effects ... but also the contribution of antimicrobial treatment to the emergence of bacterial resistance. These considerations underscore the need to restrict treatment to children whose illness is diagnosed with the use of stringent criteria."

It is with these stringent criteria that the issue gets tricky. The investigators in Hoberman's study were specially trained in examining the middle ear and, in some cases, their diagnoses were assisted with otoscopic photographs. In the normal clinical setting, such ideal circumstances do not always exist and children often require protracted wrestling and/or earwax removal before a doctor can even get a glimpse of the middle ear. Thus, decisions about antibiotic treatment must sometimes be made with imperfect information.

Also, there is the part about bacterial resistance; a major concern in general and especially with broad-spectrum antibiotics (ones are effective against a wide range of bacteria) like Augmentin. Typically, and in the case of my daughter, initial treatment for otitis media is with a more-targeted antibiotic such as amoxicillin, with Augmentin reserved for children who do not improve. To use Augmentin in all children with ear pain would eventually lead to a major resistance problem.

So, where does this lead us regarding antibiotics for ear infections? I asked Dr. Cindy Chung, chief of pediatrics at San Rafael Kaiser and she recommends the following guidelines for parents: "60 percent to 75 percent of ear infections get better by themselves and so it's not wrong to 'watch and wait,' but this approach is best reserved for kids older than age 2 because of higher complication rate in younger kids and the fact that children are harder to interpret when they can't speak."

From experience, I have learned that there are ways that young children communicate — such as persistent screaming — that indicate a certain treatment plan loud and clear.

Monday, January 17, 2011

To Trust To Your Intuition?

When you read the word “intuition,” what comes to mind?

1) A convenient excuse for acting on impulse
2) A skill molded by experience
3) The Somatic Marker Hypothesis
4) Jamie Foxx’s best-selling album about how to impress women

IF you answered “all of the above,” you are not only a student of the neural basis of cognition AND Jamie Foxx’s musical career, but also absolutely correct. Intuition is everywhere. It motivates a person to do something “because it feels right,” allows people to “follow their hearts,” and gives justification to those who, like a certain former President, tend to “trust their gut feelings.” Each day, whether you realize it or not, you make many choices that are intuitive, ones that just seem to pop into your consciousness – effortless decision-making. But, what is the scientific explanation for intuition, and should intuition be trusted? The answer to the former question involves involuntary bodily responses (such as heart rate) linked to a series of brain connections called the X system. The answer to the latter question has been much debated by neuroscientists. Interestingly enough, neither explanation references Jamie Foxx’s thesis from the single Intuition Interlude…”Oh, since I was a young player talking to the ladies…I just know…It's just my intuition.”

Intuition is indeed multi-faceted and certainly involves multiple areas and pathways of the brain, with romantic impulse processed differently than geometric guessestimation. Nonetheless, scientists are starting to identify distinct areas of the brain involved in intuitive knowledge. For example, functional MRI studies of self-knowledge demonstrate completely different areas of brain activation when someone speaks about something he or she has great experience with (e.g, a soccer player discussing soccer) versus a topic that he or she has only superficial knowledge of (e.g, a soccer player talking about acting). Furthermore, the areas of the brain triggered by experiential knowledge, which have been named the X system (for the ‘x’ in reflexive), also involve the mechanisms for affective cognition, known to most of us as “feelings.” Feelings often manifest themselves in bodily feedback – such as changes in heart rate and sweating. This brings us to an area of debate called the Somatic Marker Hypothesis (stay with me here – it sounds a lot more complicated than it actually is). The Somatic Marker Hypothesis proposes that people often “feel” intuitive knowledge through bodily changes before they are consciously aware of it. Strangely, the focus of the debate regarding this hypothesis has revolved around gambling.

In a recent study published in the journal Psychological Science, Barnaby Dunn of the Medical Research Council Cognition and Brain Services Unit (CBSU) in Cambridge, U.K., and colleagues attempted to determine whether the generation and perception of involuntary bodily responses influenced people’s decisions. The skill of perceiving bodily feedback is called interoception, and it’s quite variable from person to person. (Quick, without feeling your pulse, try and determine if your heart rate is at its normal speed). What is also variable, according to Dunn, is how helpful the interoceptive skill is in assisting with decision-making. For example, his study recreated an experiment called the Iowa Gambling Task (which previously provided the basis for the Somatic Marker Hypothesis). In the task, volunteers wearing heart and sweat monitors chose between four decks of cards with their choices having either positive or negative monetary value. Unbeknownst to the volunteers, two of the decks were profitable (60% payout rate) and two were not (40% payout rate). The researchers tracked decision-making success (picking from profitable decks) over time as well as changes in heart rate and sweating (bodily feedback) and subjects perception of such changes (interoception). Subjects who performed well went home with cash, albeit hamstrung by a un-Vegas-like maximum of $7/person.

The study confirmed previous observations that bodily responses signal new knowledge (such as the identity of a profitable deck of cards) before someone is consciously aware of it. But the study also showed tremendous variability among individuals – both in the ability to perceive bodily signals and in the accuracy of those signals. Thus, as it turns out, intuition, like blond hair or artistic ability, is not equally distributed across the population. This means that people who seem to be lucky and whose hunches pay off, may not really be simply lucky after all. They have a skill like any other. For them, an appropriate mantra may just be “Intuit? Then just do it.”

I imagine the next area of investigation will be on how to cultivate the skill of intuition. Clearly, experience helps a great deal – professionals with years of experience make better reflexive decisions than those just learning a craft. But what about meditation, biofeedback therapy and other methods used to access the innate and identify the subliminal? Is there a Rosetta Stone equivalent for intuition? Not that I am aware of. For the time being, try a daily dose of Jamie Foxx….” I know if it possess you…I know what you feel, you can’t even fight it…It's just my intuition.”