The AAP (American Academy of Pediatrics) is a broken, failed organization
by Vinay Prasad | Aug 27, 2022
The American Academy of Pediatrics (AAP) is a failed organization. For years, they have made mistakes, but the pandemic elevated their failings to catastrophic errors.
Pre-pandemic, the AAPs failures were due to overconfidence; making recommendations when the right action would be to express uncertainty and support efforts to collect better data. During the pandemic, this deficiency was paired with naked politics, and selling out scientific thinking to political allegiance. Ultimately, children were abandoned by the millions by the AAP.
My proposed solutions include dismantling the AAP and creating a new organization: resistant to political pressure, with the sole goal of promoting the well-being of children.
First, I will consider just one example of the AAPs pre-pandemic error, and then I will detail the AAPs repeated failures to support children during the pandemic.
The AAP gives the wrong advice on peanuts
In 2000, the AAP, based solely on opinion, issued guidance that mothers of children at high risk for food allergy avoid (a) eating nuts when pregnant, (b) eating nuts when breast feeding, and (c) delay peanut exposure for kids until they are 3 years old. (Pediatrics 2000)
In the years that followed the AAP’s “expert” advice, rates of peanut allergy doubled in the population.
Ultimately, in 2015 , a randomized trial was reported. The trial randomized high risk infants to early exposure to peanuts (4 -11 months) vs. delaying this exposure (per the AAP’s advice). The trial found that early exposure was far better for kids, “Among infants with high-risk atopic disease, sustained peanut consumption beginning in the first 11 months of life, as compared with peanut avoidance, resulted in a significantly smaller proportion of children with peanut allergy at the age of 60 months.”
In short, the AAP got it wrong.
Did they AAP need to issue their 2000 guidance at all? Some contend that the AAP had to say something. But this is false. They could have simply admitted: we don’t have data. They might have suggested a randomized studies with at least 3 randomizations (factorial design). Randomize woman to their advice (don’t eat peanuts or not) during pregnancy, during breastfeeding, and for introducing solid foods.
Had the AAP admitted uncertainty and suggested a trial in 2000, two things might have happened. Fewer peanut allergies over the next decade (as there would be less off-protocol use), and the trial might have launched and resulted sooner.
What’s the take home lesson? The lesson for the AAP, and one all doctors should heed: when you don’t have robust data, you should have humility. It’s ok to have hypotheses, but be honest about what you don’t know. You should always admit there is uncertainty, and you should point out studies that would help reduce it. Guidelines are great, but they are best issued AFTER you run the right study, not BEFORE it.
The AAP could have learned their lesson: be wise, be humble, but they did no such thing. As the AAP dealt with the pandemic, they would become a deranged organization, both incompetent and nakedly political.
The AAP sacrifices kids to prevent Trump from a Political win
Between June and July 2020, according to National Public Radio reporting, the AAP “Walk[ed] Back Support For In-Person School.”
The facts are simple. The AAP initially put forth the right decision, “recommending that education leaders and policymakers “should start with a goal of having students physically present in school” by fall of 2020.
Then Trump famously voiced his full-throated support for reopening schools 100% by the fall, and cited the AAP report as evidence he was correct. (For the record: Trump was correct about this one issue).
The AAP immediately began walking back support for children. The AAP president said, “local coronavirus infection rates and hot spots have to be taken into consideration to safely reopen schools.” But, this was inaccurate. European experience showed that reopening was possible irrespective of local infection rates; Kids could benefit from school, even in places with high spread, and schools could safely reopen even there.
In an NPR interview the AAP president, specifically criticized Florida, whose governor was Republican that its plan to aggressively reopen schools was against their recommendation.
Ultimately, the AAP issued a second statement that further eroded support for schools. This statement was cosigned by, “the two national teacher unions and AASA, the School Superintendents Association.” The statement said, “Public health agencies must make recommendations based on evidence, not politics.”
The irony was palpable. The AAP cautioned that science not politics should guide children’s schools decisions, while they themselves were engaging in politics and not science to sabotage schooling. Their flip flop occurred in response to actions taken by the Trump White House, and specifically singled out Republican Governor DeSantis.
Ultimately, these were not insignificant actions, they kept schools closed in Democratic cities for another year; and the harmful impact on millions of children has yet to be fully realized. I believe it will exceed even the most catastrophic predictions.
The AAP on masking kids
In contrast to the World Health Organization (WHO), UNICEF, and the European CDC, the US’s AAP decided that kids as young as 2 should wear masks. This recommendation was invented, and is not supported by any pre-pandemic evidence. I say that as an author of a systematic review on the topic.
The best studies on the topic exploit natural experiments. Two Finnish cities with different mask policies (kids aged 10-12), and a rule in Spain that only masked above 6 and up, and not 5 and below both failed to find benefit to masking kids in school, but let us be clear, the AAPs advice targeted a much younger age group. The AAP said that kids as young as 2 should mask— with the exception of 1-3 hours during which all kids would remove their masks, and sleep side by side in the same room for nap time.
Just think about that for a second. The AAPs own guidance had a prolonged period of unmasked time. Even the greatest mask proponent should recognize that this policy can not possibly work, unless the virus naps too. For folks interested in this topic, I have discussed the evidence here, here and here.
Instead, let me focus on the AAPs rhetoric over the last year. Facing mounting criticism that prolonged deprivation of faces might have deleterious effects on kids growing up, the AAP issued this tweet:
Babies and young children study faces, so you may worry that having masked caregivers would harm children’s language development. There are no studies to support this concern. Young children will use other clues like gestures and tone of voice. healthychildren.org/English/health…
But the statement revealed incompetence. Of course, no historical studies could document the impact on long term communication among kids deprived of seeing faces because no society on earth has ever embarked on such a deranged experiment. No society has deprived children of seeing faces on this scale and for this time for so long, so naturally robust evidence of harm cannot exist.
The burden in medicine and public health is to show evidence of benefit, and yet the AAP has never done that. The organization has never run a single cluster RCT to demonstrate masking kids works in any setting. This is despite the fact that it has continued to recommend masking for 2+ years.
The AAPs statement ran counter to European government advice. This is a video clip from Ireland
And here is the Singapore’s Prime Minister
Many nations like the United Kingdom never masked kids <12; and absolutely never masked kids <6; These nations also never masked day care providers for infants.
Meanwhile, by early 2022, nearly all US children had and recovered from COVID19. Estimates from Jan 2022 showed 75% of kids had prior covid. Given that these serological tests miss some kids, and given that we have had many more kids infected with Omicron since then, it is likely that currently upwards of 90% of kids have had COVID19. Yet, the AAP still promotes masking; doubling down in their rhetoric:
But this argument is even worse than the one before. Communication is more than sound, and of course, visually impaired children do not comprehend all the dimensions of communication that sighted kids do. They cannot for instance look at someones face, and without audible sound, determine their mood, temperament, or disposition of that person.
Dr. Michael Absoud, Pediatrician and academic at Kings College London had this to say:
Again the AAPs statements were again at odds with the European Union
“Wearing a mask when interacting with children appeared to be the most contentious issue, raising questions on the impact this could have on children, e.g. on their language and emotional development.” op.europa.eu/en/publication…
American Academy of Pediatrics@AmerAcadPeds
If caregivers are wearing masks, does that harm kids’ language development? No. There is no evidence of this. And we know even visually impaired children develop speech and language at the same rate as their peers.
What is wrong with the AAP?
Of course, I will concede that this is my guess from carefully studying the organization from outside. And full disclosure: I say this as a Democrat who is closely aligned with the economic policies of Sanders/ Warren.
The AAP has always been comprised of a group of physicians who were poor thinkers in the domain of evidence based medicine. They were always comfortable with making strong recommendations without adequate data, and have never fully understand the importance of randomization. That’s why even after the Peanut-saga, they continued to dump a steady stream of unsupported guidance.
But something has changed.
Over the last few years, the organization has been captured by increasingly vocal advocates on the political left. Thus, a lack of understanding of evidence has been paired with naked political advocacy. This is why the AAP flip flopped on schools. They chose to pair themselves with Teachers Unions and denounce DeSantis and Trump, even though this action meant the ruin of many children.
On masking, the AAP pursued toddler masking with a frenzied zealotry only after Donald Trump famously refused to wear a mask. Masking has become a religion on the political left, long after it made any sense. The AAP is fully ensnarled in this fervor. They demand masking at younger ages and for longer years, simply because this reveals greater devotion to the religion. Because the organization is so poor at thinking and evaluating medical evidence, they cannot re-evaluate their stance. They cannot course correct.
The AAP rhetoric about seeing faces is also uncoupled from common sense. This is pediatrician Alasdair Munro, a vaccine trialist from the UK.
There are other important issues that the AAP has put forth a deranged political stance, but I will save those for another day; We have enough evidence here to conclude: the AAP is a failed organization. Bad evidence paired with naked politics led to the abandonment of children.
What can we do?
COVID-19 has revealed that no organization in the USA defends the interests of kids. Kids don’t have lobbyists. But, it is vital that they do. I support the creation of a non-partisan federal agency whose sole task is to evaluate, in real time, the impact of policies on children. Just as the CBO scores legislation for fiscal impact, this group would score the balance of an intervention’s impact on kids.
The agency will also be tasked with issuing prospective guidance to promote the welfare of children. The agency can suggest and enforce policies to correct the deficiencies of the pandemic. If money is allocated to schools, and I support this, the agency can enforce that it be spent on kids, not teachers unions.
The fate of all societies depends on how we treat the next generation. The AAP was happy to sacrifice millions to score a pyrrhic victory against Trump. We must have a new group empowered to protect kids interests in the face of incompetence, irrationality and tribalism. The AAP is not fit for that task. A new group must be created.
If you want to hear more on this topic, watch this video:
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