Monthly Archives: March 2016

This milk tastes sour: cows’ milk allergy and industry-sponsored disease creep

jcJonny Coates is one of the First5 GPs that’s not in Australia.  He works in Newcastle upon Tyne.

Hospitals are awash with Pharma freebies. CCU is littered with the logo of the latest statin, the psychiatrist’s pen bears the name of the latest modified-release SNRI, and the chest clinic post-it notes are adorned with inhaler brands.

The paediatric ward is slightly different though. Just as the rest of the hospital is branded by Big Pharma, the paeds ward is branded by ‘Big Formula’. The logos on the pens and lanyards of the paediatricians, and the adverts filling their journals, are all for formula milk brands.

And the formula companies are now hungrily eyeing up primary care.  At a recent CCG educational event, our local paediatric immunologist gave a talk on cows’ milk allergy (CMA) in children.   We were handed glossy, branded copies of the MAP (Milk Allergy in Primary Care) Guideline.  We were offered “free” courses to study for a diploma, courtesy of the ever-beneficent formula companies.

According to the guideline, a diagnosis of CMA should be considered if a child has “one, or often more than one” of the following symptoms:

  1. Colic.
  2. Vomiting, ‘reflux’, GORD.
  3. Food refusal or aversion.
  4. Loose or frequent stools.
  5. Perianal redness.
  6. Constipation.
  7. Abdominal discomfort.
  8. Blood/mucus in stools of an otherwise well infant.
  9. Pruritis/erythema. Significant atopic eczema.
  10. ‘Catarrhal’ upper airways symptoms.

Remember: “One, or often more than one” of these.

I had my third child 10 months ago. She has had many of these symptoms fairly frequently. As did both of my other children. In fact, I would find it extremely hard to find any child who doesn’t have “one, or more than one” among the many children I see each day in surgery. They are all extremely common symptoms in infancy.

Most of these children with mild symptoms don’t ever come onto our radar as clinicians, as parents correctly realise that they are part of normal childhood. However, since the companies are now marketing their products directly to patients through websites (, TV adverts (here) and newspaper articles (more GP-bashing from the Daily Mail), I suspect we will be seeing much more of it. We are at great risk of medicalising normal infancy.

Financial links to a variety of milk manufacturers, including Mead Johnson Nutrition and Danone, have been disclosed by authors, as outlined in a 2013 BMJ article. Mead Johnson Nutrition are the very people behind my glossy handout, and the website and TV ads outlined above. This has echoes of the recent scandal around dementia screening, when campaigns to increase diagnosis turned out to have been funded by a drug company with a new product to sell (discussed here by Margaret McCartney).

I do not doubt for a moment that CMA exists, and I do not doubt that it makes some infants very ill. I do not doubt that specialised formula milk is an excellent treatment for these children.  I have seen and treated cases myself (both during my paediatric jobs and as a GP): of babies becoming very unwell due to CMA, and making a remarkable improvement with the correct milk.

I do however, have significant concerns about GPs being asked to diagnose and treat CMA on the basis of this low-threshold diagnostic guideline, which is promoted by milk manufacturers, and whose authors are paid by those very same companies.

Worst of all, these companies are marketing directly to patients to drum up business.

This is industry-sponsored disease creep, and we should be questioning it much further before accepting it.


This article is crossposted from Jonny’s own blog:

Update 30th March. In response to feedback this blog was edited to remove a reference to the MAP guideline being funded by milk manufacturers. This was an error: the guideline itself was not funded by industry.

GP Journal Club – March 2016

The March GP Journal Club is now on Storify.

The paper discussed was: Holt TA, Fletcher E, Warren F, et al. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. Br J Gen Pract Mar 2016, 66 (644) e214-e218.

The next GP Journal Club will be in April – you can follow @GPjournalclub and #gpjc. Click here for the GP Journal club blogposts.

GP Journal Club – Sunday 20th March 2016 at 20:00 GMT

The next GP Journal Club will be discussing the BJGP paper:

Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial by Holt et al. 

You can download it here.

Suggested questions include:

1) What do you think of the selection of consultation duration as the outcome?
2) Any thoughts on the study design?
3) Does the fact that only same-day consultations are triaged change the results?
4) Are the data collection methods reliable?
5) Has this paper changed your views on phone triage?

Feel free to suggest questions – via Twitter or leave them in the comments box below.

Trainee notes: Life school

IMG_3788Aisha Yahaya is a GP ST2 with Imperial VTS who has an interest in effective communication with patients, writing and a yearly resolution to save her guitar from the dusty corner in which it sits.

Increasingly, I learn more about the way of the world by looking through the eyes of my patients.  As I reflect on my time spent in a large urban GP surgery, I share my feelings and what I learnt from the patient narrative.

Bravery, active listening and understanding. Very often, a patient will come with a problem that has troubled them for a while and their appointment with me is the first time they have mustered enough courage to seek help.  I was faced with this scenario when a patient told me they were uncomfortable with their identity and wanted to change this. In this case I learnt about bravery.  Patients take steps to help themselves by asking me for help or guidance. This is a sign of strength and it gives me a chance to empower them to take control of their health, wellbeing and happiness. I often expect patients to trust me easily and follow my advice, which makes me question why they would do so and how willing I would be to do the same if in their shoes.

I am aware of how perceptive patients can be of their doctor’s mood and a balance must be struck when navigating my feelings and theirs.  The difference between a successful or disastrous consultation could be the blank gaze I give a patient if my mind is elsewhere, compared with a simple nod of acknowledgement or the offer of a tissue when they are crying.  In a room with just the patient and me, there is nowhere to hide and this allows vulnerability to thrive.  In order to gain a patient’s trust I have found that putting them at ease and inviting open dialogue goes a long way. There is a reason why patient satisfaction questionnaires that are mostly aimed at a doctor’s attitude towards a patient rather than their breadth of knowledge, which of course goes without saying.

Bigger is not always better. I am sometimes disheartened when I feel I have not made a difference to my patient’s problem.  Despite this, I learnt that whatever the patient describes as a positive effect could be more important than what I think is significant or obvious. For example this could be the case of a simple lifestyle change in a patient with low mood or chronic disease. My GP trainer picked up on a management plan from my entry in a patient’s medical notes during a follow up appointment and asked the patient about it.  The plan was a single goal that the patient and I were confident they could achieve.  My trainer told me that the documentation and acknowledgement of this plan made the patient feel as though they had been listened to and taken seriously.  I find this encouraging and hopefully the patient felt as though they had genuine support from me and the other doctors.

My job as a GP trainee often doubles up as a life school where sometimes the most important lessons are learnt.  As always, I look forward to the next one.