Saturday, October 20, 2012

Tradition vs Evidence

Tradition vs Evidence
Tyler d'Hulst, PA-C, MPAS

As a medical professional working in an area of low socioeconomic status I constantly find myself educating patients and their families about a variety of subjects, but none so prevalent as the subject of tradition verses evidence. Many of us have a plethora of traditions tightly woven into the fabrics of our every day lives. Some of these traditions are beneficial and fun (like shoving someone's face into a birthday cake, or jumping naked off of a houseboat at Lake Powell) while others can put ourselves or those we love at increased risks of physical or emotional damage. Being able to differentiate between these traditions and the risks/benefits they pose is essential to living productive and healthy lives. The problem arises when our beloved traditions conflict with established evidence based science.

I work in family medicine and have patients that fall anywhere between pediatrics and geriatrics. At both ends of this spectrum usually the person involved in a patient's care typically is a parent or child of the patient. Parents bring in their children constantly for routine medical exams and acute problems. One thing I have found very common among my patients is the tradition of supplementing infant feeding with free water (i.e. baby feeds on 4 oz of formula every 2-3 hours plus gets an additional 2-3 oz of pure water once or twice a day). The infant normally will feed on breast milk or formula based milk but many parents will also supplement this with many ounces of free water on a daily basis. This has been going on for years and is very popular, especially among patients of Latin American heritage. Supplementing an infant's nutrition with free water increase the risk for neonatal hyponatremia which can lead to lethargy, seizures, coma and even death. The neonate is at increased risk for hyponatremia already because of limited sources of nutrition and immature kidneys which currently is not efficient in retaining sodium or flushing excess fluids from the system. Their is no evidence that suggest an infant needs supplemental fluids (note 1) besides breast milk or formula. When discussing this with patients (and unfortunately many family members) the reaction is typically the same, "my parents fed us water when we were young and nothing happened to us and their parents did the same thing."  The belief is that because someone else did it and no one was injured then it must not be dangerous to me.

I also speak with parents about accidental suffocation in infants, typically due to having an infant sleep in the same bed as the parent and not in their crib and on their back. Again, the argument is "my other kids slept in my bed when they were young and nothing happened to them."

The fallacy lies in the patient's misunderstanding of the risks. Not every case of supplementing nutrition with water or an infant sleeping in the parent's bed leads to hyponatremia or suffocation but these practices increase the risks. These risks have been studied extensively through out the years and are well known in the medical community. My recommendations to these parents are not anecdotal in nature but are based on evidenced backed studies.

Unfortunately many patients still tend to doubt recommendations from health care professions because it conflicts with traditions and anecdotal experiences.

Note 1
There is currently a product out their being marketed as "infant water." It's intended use is for formula fed infants and is to substitute tap water for mixing formula. It is not intended to be an additional water supplementation.