Likelihood Ratio


Likelihood Ratio is a topical blog that Dr. Hill has created, bringing common sense and wit together about current state of Media & Pediatrics. Continuing from the roots of his book “Dad to Dad”, Dr. Hill writes from the unique perspective of Doctor/Dad to help readers navigate the sometimes murky and confusing waters of being a caregiver for a child.

One of the experiences I anticipated most as a new parent was watching my kids learn to love some of my favorite things. After all, they were mine to mold, so how could they not come to embrace my enthusiasm for Santana, Star Trek and snorkeling? Right. If you’re a parent, you already know how that turned out. More like Harry Styles, Better Call Saul and Super Mario Brothers. But take heart, new parents, there’s still hope. For me perhaps the best example is seafood.


I’ve always loved fish, even when I was growing up in the 1970’s in landlocked Memphis, Tennessee. There, “seafood” mostly meant crispy fried catfish and the go-to sandwich of my youth: tuna salad made with albacore, yellow mustard, mayonnaise and pickle relish. On Friday nights, one grandmother treated me to shrimp cocktails and fried bay scallops, then it was off to the other grandmother’s house Saturdays for a dinner of stream-caught trout, followed by a breakfast of pickled herring or smoked salmon. I was hooked long before my young adult years, when I’d make the pilgrimage up the Gulf of Mexico from Houston to New Orleans to meet my parents and gorge on fresh red snapper, soft shelled crab and crawfish tails.


I moved to coastal Wilmington, North Carolina, in part because I imagined our family dinner table groaning under the weight of fresh locally-caught seafood, eager children seated quietly with their napkins in their laps making polite conversation before being allowed to dig in and then thanking me afterwards for treating them to such a priceless experience. It didn’t go down quite that way.


As a pediatrician, of course I needed no convincing about the importance of seafood in a healthy diet for my kids. Seafood provides the only naturally occurring source of dietary vitamin D (dairy products are fortified with it), and their high contents of omega-3 fatty acids give seafood a crucial role in promoting eye and brain development. Considering that seafood is also a vital source of healthy proteins, it’s no wonder that the 2015-2020 Dietary Guidelines encourage all Americans to eat at least 2 servings (8 ounces) of seafood a week and advise pregnant and breastfeeding women to quadruple their current seafood intake.


So what happened at my dinner table? Any parent (or pediatrician) will tell you two truths. First, each child is different. Second, it takes time. Was there a point at which we told my youngest that battered flounder was fried chicken so he’d try it? Maybe. Was I secretly thrilled when my pickiest eater stole all his sister’s shrimp off her plate at a restaurant while she was away at the bathroom? I’m not saying, but we did order more shrimp. Can a camping trip turn a young teen who never eats fish into one who won’t stop talking about cooking fresh bass over a wood fire? It would appear so.


Thankfully, modern shipping and packaging technology has brought the bounty that we enjoy here on the coast to my hometown of Memphis and beyond. Whether it’s canned or pouched tuna on the shelf or delicate calamari on ice at your favorite grocery store, cowboys in Oklahoma can enjoy the same oceanic flavors as foodies from Miami to Maui.


So what about that son who carefully studied his “chicken,” before gingerly putting a bite in his mouth? Check out this video to see what happened and to pick up a few of my favorite recipes. You can listen to Santana while you make them, but that Harry Stiles kid isn’t half bad.



Dr. Hill has been engaged by the National Fisheries Institute to provide his honest professional perspective on the health benefits of eating seafood.

Posted: August 7, 2017, 5:32 pm
I really wouldn’t be doing my job as a parent if I hadn’t downloaded Pokémon Go and started racing my kids around town to various PokéStops. It helps that I have a patient and indulgent wife, who complains only a little after being left in a running car in the middle of a strip mall parking lot while I follow my phone into a drainage ditch. 

I’m as excited as anyone that a mobile video game finally has kids staring endlessly at their phones…outdoors! An obvious next step would be for developers at Nintendo and Niantic to add a few new creatures to the Pokédex that appeal to, um, more senior players like me. I’m offering the following ideas for free:



  • Charminder (12 combat points). This adorable little guy is a Fire creature with the power to make sure you move those steaks from the grill flame to the infrared zone before they burn. His evolved form, Charmaster (26 combat points) can baste ribs for up to three hours. He is most vulnerable to the memory-diminishing attack of the Beerbasaur (6, 12, or 24 combat points).
  • Gyrtle (32 combat points). A creature from the Water weight environment, this Pokémon dwells discretely under the trainer’s clothing, where it makes unsightly bulges invisible. Given enough candy it evolves into a Spanx (260 combat points) with enhanced compression powers. Warning to would-be trainers: if you eat the candy yourself, your Gyrtle may explode.
  • Ivylauyer (520 combat points). Really by far the most important Pokémon to have in any battle, this fearsome Grass/Poison creature hurls powerful Soots, Injunkshuns, and Moshuns, for enough stardust or candy, payable in advance. In the unlikely event that your Ivylauyer appears to be losing a battle, it can offer the attacker a Seddlement, saving you precious points. The evolved form, the Pardnersaur (1000 combat points), benefits from the victories of its allies and gains candy even when its trainer loses.
  • Peakedachu (27 combat points). This worn-looking Pokémon saw his best days during high school, or maybe that one semester he played baseball in college. Looking at him gives the trainer a certain satisfaction that while he seemed pretty intimidating back then, he’s really downright average now, so how do you like them apples? His evolved form, the Hazzbin (3 combat points), can provide the trainer a transient mood boost through its powers of Shoddenfroyd.
Posted: July 17, 2016, 4:58 pm
When you were a kid, did you ever get the sense that the grownups in your life weren’t telling you, like, really important stuff? I think back on so many unanswered questions: “But how does Santa Clause get to all those houses in one night? Why would you ever want to go on vacation without me? Are martinis really the only way that Daddy can eat his olives?”

A new study in the journal Obesity proves that withholding the truth from children may be the key to addressing the childhood weight crisis. According to the authors, a restaurant chain called the Silver Diner (first sign of deception: not a one of their restaurants is made of actual precious metal) launched a new kids’ menu in 2012 that conveniently forgot to make any mention of “french fries,” replacing them with “strawberries” and “mixed vegetables.” It’s not that kids couldn’t order fries, they just had no way to know they were an option unless their parents slipped up and said something, presumably after having a few too many olives.

Here’s the thing: the kids were happy. They ate a measurably healthier diet, and revenues went up at Silver Diner as parents flocked to the chain to enjoy snickering behind their menus as their children snarfed "mixed vegetables." 


As a parent, not only do I wish that we had a Silver Diner around here, but I am just beginning to realize the power we might have if we all bond together in giant conspiracies: “I’m sorry, but Apple will not sell an iPhone to anyone under age 18.” “No, fighting with your brother is not on the menu, but I see here that they have hugging, playing soccer, and reading together.” “There are certain critical vitamins that dads can only obtain through olives. Now go eat your strawberries.”
Posted: May 14, 2015, 2:36 am
Are you as conflicted as I am about all the good news regarding alcohol, cigarette use, and drugs emerging from the world of adolescent health? Parenting four teens, I’m really relieved, but then I fear that we’re going to have to edit some of the classic teen movies for this new, more responsible generation. Here are some screenplays I’m currently working on (private message me for my agent’s contact information):

The Healthy Breakfast Club: A geek, a cool girl, a rebel, a jock, and a stoner learn to transcend stereotypes when they join forces on a Saturday morning to take over the school cafeteria and concoct an all-paleo meal, cleverly evading the eye of their carb-loving principle.

Porky’s, the Vegan Years: A ragtag band of high school boys have you-know-what on their minds - that’s right, shower safety. They sneak into the girls’ locker room and apply non-slip surfaces to the tile, pausing only to caulk up a hole in the wall, thereby reducing the school’s carbon footprint.

American Pie Presents: SAT Prep: Let’s face it, no one ever got into Stanford by going to Band Camp. Five high school friends are determined to gain early admission to highly selective universities before prom night ends. Over the course of this 16-hour film, viewers master the subtleties of English vocabulary and composition as well as advanced algebra. Tickets are $1200 and include the cost of workbooks and pencils. The movie’s most talked-about scene includes one boy being caught baking pies for Meals On Wheels because he has heard the experience would make a great essay topic.

I really hope that at least one of these ideas gets optioned, if only so that my own teenagers can learn to share my love of quality cinema. (Please, someone send this link to Molly Ringwald.)
Posted: December 21, 2014, 2:21 pm
A lot of clinicians are confused about the new American Academy of Pediatrics guidelines on treating bronchiolitis, released just in time for the wheezin’ season (see “wheezing” doesn’t really rhyme with “season,” but if you adopt a faux rural accent you can kind of make it work). To help, I’ve translated the technical language of the guidelines into plain English, using words like “wheezin’”. You’re welcome.

DIAGNOSIS

1a) Clinicians should definitely diagnose bronchiolitis. That way it looks like we know what we’re doing. This diagnosis should be made by taking a history, examining the child, then standing back and saying, “Looks like bronchiolitis.” Then go on to explain that this is not the same as the “bronchitis” that grandpa just got treated for with Zithromax at urgent care.

1b) Clinicians should get a worried look on their faces if the disease looks bad and say something like, “This looks pretty bad.”

1c) Whatever they do, clinicians should resist the urge to order chest x-rays or labs. You already know it’s bronchiolitis. What, are you going to act all surprised when the result comes back “Suspect bronchiolitis?”. Remember, no matter what you see in comic books, no amount of radiation will give the child superpowers.

TREATMENT

2) Once you have diagnosed bronchiolitis, run and get your office’s nebulizer. Take it to the parking lot and dash it to the concrete until it’s irreparably broken. What were you thinking, considering giving that kid albuterol? Now you won’t be tempted.

3) Go back in the office, open your code cart, and find the epinephrine. Look at it sternly and say, “I’m saving you for croup and anaphylaxis.” Close the code cart, and give the key to someone you trust to hide it from you until the patient leaves.

4a) Break into the ED late at night and steal all their hypertonic saline nebs to use for brining turkeys (I recommend a minimum of 3 liters for a 16 lb bird). It does not help bronchiolitis, but if they have it, they’ll use it.

4b) If the child is admitted to the floor, and the hospitalist uses nebulized hypertonic saline, do not be insulting about it. The data are still unclear, and besides, you already have your turkey brine for this Thanksgiving.

5) Do not give steroids to children with bronchiolitis. They will grow unusually large muscles and be elected governor of California, where their unfortunate personal decisions will cloud their legacies.

6a) Don’t bother giving oxygen unless the patient’s oxygen saturation is under 90%. To do otherwise will make you look like a big wimp who’s frightened of a little old O2 monitor.

6b) Don’t use continuous pulse oximetry in the first place. You have eyes and a stethoscope, right? When children are really hypoxic, many of them will take on a bluish tint, like in the movie Avatar.

7) Do not use chest physiotherapy for infants with bronchiolitis. Do you really think that beating a kid like a drum with a cupped hand does something other than provide full employment for respiratory therapists? That said, sometimes the rhythm is pleasing and helps soothe you to sleep.

8) Step away from the antibiotics. Bronchiolitis is a virus, you know that, right? It causes a fever and rales, right? So dude, unless pus is streaming from the ear, why do you want to also invite diarrhea into this picture? 

9) If bronchiolitis is interfering with a child’s hydration, put in an IV or an NG tube and help the kid out. Congratulations, finally you have an intervention! Pat yourself on the back, you did good.

PREVENTION

10a) Pavilizumab is a total racket, okay? We don’t care how many lunches the reps brought your staff, if the infant in question was born after 29 weeks gestation and didn’t have chronic lung disease or heart disease, leave it. Expect your local detail person to cry a little, but remember, he’s not thinking about the wellbeing of your patients. He’s remembering a puppy he lost when he was 7.

10b) For infants born before 32 weeks and who have lung and heart disease, go ahead and give the pavilizumab. That detail person has a family to feed.

10c) Give it 5 times in the first year of life. You can’t stand to see your drug rep cry, and he also has a boat payment to make.

11a) If you’ve touched a patient with bronchiolitis, wash your friggin’ hands! You were wearing gloves? So what? Is a little soap gonna kill you? Make sure you wash adequately by singing all of Wagner’s Ring Cycle.

11b) Alcohol hand sanitizer works, too, especially for those who can’t sing in German.

12a) Ask about tobacco smoke exposure when you see a kid with bronchiolitis. If you get a positive answer, gently shake your head from side to side and sigh heavily.

12b) Explain why you are so very disappointed about 12a.

13) Encourage moms to breastfeed exclusively for the first 6 months of an infant’s life by saying, “You wouldn’t want your baby to get bronchiolitis, now would you?” Nothing builds a therapeutic relationship like fear and guilt.

14) When diagnosing bronchiolitis, give parents and caregivers a handout to read. People love handouts, and they meet Meaningful Use guidelines. Make sure you get a new handout that explains why you’re doing nothing about the bronchiolitis. Then, get to the next room quickly. Remember, it’s the wheezin' season!



Posted: November 9, 2014, 2:43 pm

Researchers using sophisticated microphones and computers reported in this month's Pediatrics that dads talk to their infants about 1/3 as much as moms between birth and age 7 months. Reaction from outraged fathers was swift. Dan Rogers of Akron, Ohio, father of 3, said, "Whoa." LaShawn Coleman of Memphis, Tennessee took to Twitter to proclaim, "#Hmmm." Dr. Johann Schlemmer, tenured professor of linguistics and child development at Harvard was quoted opining, "Well..." Clearly this research has opened a floodgate of paternal opinion, and we will continue to follow the debate until the groundswell of conversation finally ebbs.
Posted: November 8, 2014, 11:26 pm
When the editor of Pediatric News asked me to start the Needles blog in 2011, no one had ever succeeded in making pediatrics hilarious on a regular basis. Many of my loyal readers agree that, after 126 Needles columns, they’re still waiting. Now I’m starting “Likelihood Ratio,” where I hope that one of the commenters will finally pull it off.

Those of you with medical or statistical training will recognize a likelihood ratio as that formula you had to write on the palm of your hand right before the test so you wouldn’t flunk. In case you’ve since washed your hands, it’s a calculation that tells you whether the sensitivity and specificity of a test makes it even worth doing or whether the test will just make you and the lab more money while simultaneously giving the appearance that you’re a smart and caring clinician. 


Like “Needles,” this blog will be a place to explore developments in the pediatric literature and to ask ourselves, “Should I even care?”. If all goes well, we’ll laugh together, we’ll learn together, and I’ll get offered lucrative speaking engagements in attractive destinations. Don’t worry, I’ll post photos. Welcome, then, to Likelihood Ratio. I hope you’ll like it.

Posted: November 7, 2014, 2:27 am

 

 



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