Will cry-it-out hurt your baby?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jess, like many parents, has been hearing conflicting information about what crying can do to your baby. She wrote: “So, my husband and I accidentally let our kiddo (5.5 months) cry it out. So of course, I’m spending all sorts of time on Google finding out that I’ve caused long-term damage to my son and he’ll be more likely to get ADHD and be dumber now that I’ve let him cry. I know the studies on cortisol show that some longer-term stress may be evident (at least for a few days), but are there any other real, scientific studies that show long-term damage due to cry it out? I’m pretty sure the other studies cited in the article above are irrelevant to this–am I right? I know you’ve written about cry it out before, but with all the hype, can you clarify?”

A friend of mine is working on a project called “Guilt Free Childbirth”, meant to dispel the guilt and hand-wringing that so many families seem to experience during and after childbirth. What if I need a c-section? What if I can’t do it “naturally”? What if I can’t “bond” instantly with my baby?

This cry-it-out worry—I think I could make an entirely new blog, “Guilt Free Parenting,” just to try to dispel this nonsense. Parents are so saturated with messages telling you that everything—I mean everything—we do is wrong, it’s a wonder we don’t all just curl up in a ball in the closet sucking our thumbs.

Wait, thumbsucking. That’s bad, too.

Anyway: the sky isn’t falling. We are not raising warped, worthless, sick, incompetent kids. There are always things parents could do better (including me!), but that doesn’t mean that if we don’t do everything “right”, our kids will suffer.

Back to cry-it-out: babies don’t always learn to sleep straight through the night on their own, and there are several competing “methods” to help nudge them towards independence. Some parents are very eager to help train, others take a more “easy-going” approach. How you tackle this depends on how parents feel about the importance of a good night’s sleep, and also on the temperament of the baby. I am not going to declare that any one method is perfect for everyone.

But if sleeping through the night is a priority, I have offered up one simple solution that works well for many families. Yes, there is crying. No, I don’t think there is any good evidence that shows any lasting ill effects from letting your baby cry some. There are certainly lots of web sites, pro and con, and lots of people with strong opinions—sometimes they’ll even comment in ALL CAPS for emphasis. But you are not damaging your child by letting tears fall without instant intervention.

Babies have been crying for many, many years. It is how they get our attention. If crying were so damaging, well, I don’t think any of us would have survived.

Jess included an example of reporting that stressed the damage done by cry-it-out sleep training, a list of 10 reasons it’s bad for babies. Most of the reasons were undocumented opinions from the author, who has clearly made up her mind on this issue. The references that were included are rife with methodologic issues—especially retrospective bias (of course parents with children who are thought of as problematic are going to report more sleep issues, in retrospect, when asked), or skim though the complex issue of cause-and-effect. That is, did the excessive crying cause the later problems, or are children who are temperamentally difficult more likely to resist sleep and more likely to later experience emotional problems? One thing may not cause the other, even if they are correlated.

Studies of levels of the cortisol rely on that hormone as a biomarker of stress, and cortisol does indeed increase with stress in humans and other animals. But is that bad? Didn’t human babies always have stress in their lives? Some studies point out that cortisol can change the way brains develop, or can perhaps contribute to the pruning of interconnections between neurons- but that is a normal process that occurs in the development of the human brain. Interfering with this process by avoiding undue “stress” may actually be harmful in the long run.

Or maybe not. I am not saying that babies need to cry to be healthy. Certainly I spent a lot of time holding and reassuring my babies (and even babies in my practice!) But these studies that some claim show cry-it-out = bad for babies, it’s a stretch. And it is not something that parents ought to be worrying about.

Though there aren’t a lot of great, long-term, clinical studies of the consequences of these different sleep approaches, one published last year was reassuring—a method that allowed more crying didn’t lead to scary consequences later.

Also: there are consequences to poor sleep, both for babies and for parents. Underslept babies are fussy and unhappy. Underslept parents are irritable and miserable, and may be more likely to get in car accidents, get divorced, or smack their child. It’s not unreasonable for parents to want to take an active role in pushing towards a good night’s sleep.

A great website with far more detail and insight into baby sleep issues is at www.troublesometots.com—including a detailed guide to one common-sense way to help babies learn to sleep better. Yes, there may be some crying. It’s OK.

What is and isn’t hypoglycemia in children

The Pediatric Insider

© 2013 Roy Benaroch, MD

There’s a common “health entity” thing, often called “hypoglycemia.” Funny thing about that—children who have it are not hypoglycemic. But it is a real thing nonetheless, and there are steps parents can take to help deal with it.

Confused?

First: hypoglycemia means low blood sugar, and it can occur. In pediatrics we see it in tiny newborns and very sick children, or in little toddlers sometimes; it’s also seen in children with diabetes who get too much insulin. The main symptoms of hypoglycemia, real hypoglycemia, with real low blood sugars, are sweatiness, disorientation, unconsciousness, coma, and seizures. Real hypoglycemia is a big deal. Let’s call it HYPOGLYCEMIA, in all caps.

But what’s commonly called hypoglycemia in other situations isn’t really hypoglycemia. Here we mean a child (or adult) who gets cranky or headachy or irritable or just doesn’t feel right, especially several hours after a meal. If you check their blood sugars during an episode, it is normal. Their sugars are not low. Nonetheless, they feel better after a snack, especially a carb-snack with a jolt of tasty sugar. So they seem to be suffering from symptoms of hypoglycemia, even though they don’t have HYPOGLYCEMIA.

What’s going on here?

The symptoms of the lower-case hypoglycemia are real. They may not be caused by actual low blood sugar, but perhaps by a fall in the relative level of sugar from normal to lower-normal. Alternatively, it may be that other fuel sources in the blood (maybe an amino acid named alanine) have falled, though we don’t usually test for that.

So what should doctors and parents do when they have a child with the symptoms of HYPOGLYCEMIA—seizures and coma? Test sugar, and test everything else!

For the symptoms of hypoglycemia, no testing is needed. It’s going to be normal. Instead, families can learn to manage this problem on their own. The main therapy is to prevent these episodes of symptoms by providing frequent, healthy snacks—especially snacks that combine carbohydrate with fat or protein.

A quick biochemistry lesson: all carbs (including simple sugars and starches) provide a quick jolt of sugar, rapidly providing metabolic energy. But it may not be sustained—sugars are metabolized quickly. To provide sustained elevations in metabolic fuel, carb-rich snacks should be combined with foods rich in fat or protein, which are broken down slower.

A can of Coke, alone—that’s a terrible snack. As would be a glass of orange juice, or an apple. All of these are 100% carb. But smear that apple with peanut butter, or dunk carrot sticks in ranch dressing—those are snacks that will provide lasting food energy.

This kind of hypoglycemia (lower case) is sometimes referred to as “reactive hypoglycemia”, a term that’s just as misleading and even more abstruse. It tends to run in families, and in my experience affects skinny, active kids. If that sounds like your child, you don’t need a bunch of tests. You just need healthier snacking habits. Easy as pie… a la mode!

The best thermometer for measuring fever in a child is….

The Pediatric Insider

© 2013 Roy Benaroch, MD

There are lots of choices, so which one is best? Which kind of thermometer should parents buy and use?

Keep in mind that body temperature is one measurement—but it’s certainly not the only measurement, and it’s far from the most important way of knowing if your child is ill. Kids can be seriously sick without a fever; and almost all ordinary children with fever do not have a serious illness. There’s far too much “fever phobia” out there, and there’s already far too much preoccupation with whether Junior has a fever and how high the temperature is. Fever itself doesn’t hurt anyone. It doesn’t cause any damage, and won’t hurt your child. But fever can make your child feel sick, so it’s worthwhile to treat it. Safe medicines for fever can help your child feel more comfortable.

Also, any discussion of fever needs a caveat: all of this information is only for healthy, otherwise-well children with no immune-compromising condition. That means children who have NOT gotten all of their vaccines are NOT healthy and otherwise-well, and have a much greater risk of serious, even overwhelming infection. If your child isn’t up to date on vaccines, I offer no advice on how to measure or handle temperatures. Call your doctor. Better yet, unless there is a medical contraindication, get your child caught up on vaccines, pronto. You wouldn’t drive without your child in a safety seat, would you?

Another fun fever fact, before we get to the meaty stuff: if anyone has told you that 98.6 F is the “normal” temperature, they’re wrong. It’s not normal, it’s average. 98.6 is no more the normal than saying 5’10” is the normal male height. As with every other measurement in nature, temperatures vary among individuals, and temperatures vary throughout the day. 98.6 is the average, meaning that normal ranges from below this to above this. In most circumstances, most pediatricians consider anything measured at 100.4 or above to be a fever. Values measured below that threshold are not “low grade fevers”—they’re normal temperatures. And don’t start adding degrees, depending on how you measured the temp. That just confuses everyone.

So what are the choices for thermometers, and which should you choose? I’m going to include links here to Amazon products, just so you know what I’m talking about. (I have no financial relationship, and I don’t care if you buy through these links, etc.)

Mom or dad’s hands: These actually make a reasonably good thermometer, at least for “ruling out” fever. If you touch your children, and they do NOT feel warm, they almost certainly do not have a fever. The inverse of this, by the way, is not true: often your child will feel warm, and won’t actually have a fever—so touch can rule out fever, but cannot confirm or measure a fever. But it’s a start, and for busy people with older, healthy kids, using your hands alone is not an unreasonable way to check.

Rectal thermometer: These work, though they’re slow. They’re also the only method used in most studies of small babies less than 2-3 months of age, so typically that’s what pediatricians want you to use at that age. But please, no rectal temps in older kids, OK? It’s just creepy and unnecessary.

Axillary thermometer, AKA “The Chicken Wing”: These work, though they’re also kind of slow. Not bad for an estimate. Kids feel silly sitting there holding their arms still, but that’s the price they have to pay.

Oral thermometer: Those old, mercury-filled ones you have to shake back down have gone the way of the dinosaurs. They’re all digital now, and they read faster. And if you shake one down after reading it people will edge away from you and give you odd looks. These work about as well as the others in this list.

So far, rectal/axillary/oral, it’s all good, at least when they’re appropriate for the age. But they’re all old school. Isn’t there something newer that’s better?

Binky-temps (AKA: a digital thermometer built into a pacifier): Please. This measures, maybe, the temperature of the top of the tongue, wherever that’s been lately. Don’t waste your money.

Forehead tape thermometers: These have vague glowing numbers that indicate, well, where the vague glowing numbers are. Might as well make up a temperature rather than rely on these things.

Infrared thermometers: The ones marketed to parents are sometimes called “non-contact” thermometers, because these don’t actually touch your child. They’re also sold at hardware stores to measure the surface temps of things from quite a long way away, like industrial transformers or crème brulee. They are not suitable for people-use, because they only measure surface temperature. We want core temperature, or the temperature of the blood as it exits the chest. The temperature of the skin is NOT an acceptable or accurate way to measure core temps.

Forehead thermometers:  One company sells a digital version of what’s essentially your hand, touching your child’s forehead. Use your own appendages instead, they’ll be just as accurate, and they’re much more handy! (Get it? Handy?! Hahahahaha. Hem. Sorry.)

Ear thermometers: Supposedly these measure the temperature in the middle ear, where the monkeys live (or so I’ve been told.) Several years ago, a company that will remain nameless (hint: the name rhymes with mermo-flan) gave my practice a dozen or so of these, so we could try them out. I guess they figured we’d love them, and patients would see us using them, and they’d rush out and buy them too. Trouble is, the darn things were terrible—they missed high temps, they inflated no-temps, they gave children random fevers. So we threw them all away. If you’ve already bought one, maybe you can repurpose it as a chicken cutlet pounder or decorative paperweight.

Temporal artery thermometer: I’ve save the best for last! It’s quick, it’s easy, and a recent study showed that it’s pretty much as good as a rectal temp.

So: if your child feels warm, and you’d like to measure the temp, a temporal artery thermometer may be the best way to go. They’re more expensive than an ordinary digital thermometer for oral or axillary use, but they’re faster and I think they’re easier to use.

We have a winner!

More about fevers:

The fever action plan

Why do people get fevers?

Medicines for treating fever

Kids are safer driving with Grandma

The Pediatric Insider

© 2013 Roy Benaroch, MD
Parents may be surprised to learn that their children may be safer riding in grandma’s car than their own.

A July, 2011 study published in Pediatrics looked at insurance claims data from crashes that occurred with a child in the car. About 12,000 accidents from 2003-2007 were reviewed. Based on telephone follow-up calls, a child was injured in 1% of the crashes. The surprising result: children were about 50% less likely to be injured in an accident if a grandparent were driving rather than a parent. This dramatic reduction in risk occurred despite the fact that grandparents were actually less likely to have been using child restraint seats correctly.

Does this really mean that grandparents are safer drivers?

Maybe. The study shows that if an accident occurred, a child was less likely to be injured with a grandparent driver. That doesn’t actually mean that grandparents get in fewer accidents– it just means that their accidents are less likely to be serious. Also, the average age of grandparents in the study was 58 (versus 36 for parents.) I’m not so sure that these results would be the same if researchers only looked at elderly grandparents.

Still, a fifty percent reduction in injury risk is a big difference. There may be lessons that parents can learn from grandparents about improving safety behind the wheel.

Though recent guidelines have stressed proper car seat use, the most important safety equipment in the car is the driver. Driving carefully, obeying traffic laws, and paying attention are crucial ways to avoid a crash, or at least make it less likely for a crash to result in an injury. Younger drivers are probably more likely to be distracted by mobile phones, text messages, and fiddling with the radio. If your eyes and your mind aren’t on the road, you’re asking for trouble.

In the developed world, motor vehicle accidents are among the most common cause of serious injury and death in children. If you want to keep your kids safe, take a lesson from grandma. Drive carefully.

Adapted from a blog post I wrote for WebMD in 2011. Yes, I’m reusing “classic material.” And by classic, I mean old.

The best drug discount card

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve gotten loads of drug discount cards in the mail to give out to patients. They look almost too good to be true—they claim to have no costs, and to provide discounts on prescriptions of up to 75%! Wowza, can’t go wrong with that! Right?

When something looks too good to be true, it usually is.

I’ve gotten these from a few different organizations, but they look similar. One is from “The Healthcare Alliance”, which has a .org web address on their letterhead—that extension is traditionally used by non-profits, but when you look through their website, they don’t claim to be non-profit. And in fact the .org address actually forwards to a .com site.

I found an exposé of their pharmacy discount card from a local TV investigation. The good news is that it does work, at least some. The amount of discount varies widely. On average, their reporter got a 23% discount off retail prices. But the card doesn’t really help people with insurance—it won’t cut your copay, and insurance drug costs are already negotiated downwards. The biggest savings seem to be for people without insurance, and only for some of the most popular generics.

The bad news: companies like this collect your personal information, including your contact info and information about the medicine you purchase. They sell this info to marketers who will use it to try to sell you more stuff. Now, you may not mind this, but you ought to at least think twice before agreeing that all of this personal health info is being sold. Marketers will know if you have diabetes, or hemorrhoids, or if you’re on a birth control pill, or if you’ve taken morning-after contraception, or if you’re on medicine for anxiety or depression or genital warts. To me, that’s kind of creepy.

The good news is: there is a better way! A retired-doctor-friend of mine, Rich Sagall, has set up a real non-profit organization that offers comprehensive, reliable information on saving money on prescriptions—and his site has a downloadable drug discount card too. Best of all, the Needymeds privacy policy is right there for you to see, and they do not, ever, sell or use your private health information for marketing. They promise to keep your health info private, the way it should be.

So: forget about those too-good-to-be-true discount cards from for-profit companies. You can save money by using generics and by taking advantage of the Needymeds non-profit, 100% legit discount card. That one is NOT too good to be true. I guarantee!

The Fisher-Price Rock ‘n Play Sleeper is NOT for sleeping

The Pediatric Insider

© 2013 Roy Benaroch, MD

You might think a thing sold by a huge manufacturer of children’s toys and furniture as a “sleeper” would a safe, appropriate place for a baby to sleep. It is, after all, called a “sleeper.” But it is not a safe place for your baby to sleep.

The Fisher-Price Newborn Rock ‘n Play Sleeper is a sling-shaped baby holder sort of gizmo, fitted into a frame that allows it to rock back and forth. The baby is held kind of snuggled in a pouch, in a sitting-like position, tilted up maybe thirty degrees or so. The name implies that it’s for rocking (that seems right, though I don’t think they’re talking about this kind of rocking—give that man a towel) and for playing. The problem I’m worried about is that last word in the name, the “Sleeper”. This slingy soft thing is not a place to leave your baby to sleep.

Why? Because we know that to best prevent Sudden Infant Death Syndrome, and to best encourage normal physical and motor development, babies ought to be put down to sleep flat on their backs, on a firm, flat surface. The Rock ‘n Play Sleeper is not firm, and it’s not flat—so it is not a safe place to routinely sleep.

The AmericanAcademy of Pediatrics published detailed guidelines about safe sleeping environments for babies in October, 2011. The Rock ‘n Play Sleeper clearly doesn’t fulfill many of these evidence-based criteria. I contacted Fisher-Price in February, and spoke with a very nice person, the “Manager-Risk Management.” I’ve sent her a detailed e-mail with my concerns that she said she would forward to the Director of Safety Management. Since then, all I’ve heard from Fisher-Price is:

Thank you for your inquiry and comments. We did receive your email on February 7. 2013.  We have provided these comments to the appropriate people within Fisher-Price.

The Rock ‘n Play Sleeper complies with all applicable standards.  We encourage consumers who have questions or concerns about providing a safe sleeping environment for their babies to discuss these issues with their doctors or pediatricians.

We appreciate your taking the time to contact us.

OK, since they say they encourage consumers to discuss these issues with their pediatricians, let’s discuss it!

Below is what I had sent to Fisher-Price: the details of my concerns, based on the AAP’s recommendations in bold. The numbers refer to each recommendation in the AAP document.

1. To reduce the risk of SIDS, infants should be placed for sleep in a supine position (wholly on the back) for every sleep by every caregiver until 1 year of life.

The Newborn Rock ‘n Play Sleeper does not keep a baby wholly on the back, but rather in an inclined position. It is not a safe way for babies to sleep.

2. Use a firm sleep surface—A firm crib mattress, covered by a fitted sheet, is the recommended sleeping surface to reduce the risk of SIDS and suffocation.

The Newborn Rock ‘n Play Sleeper is not a firm crib mattress.

2e. Sitting devices, such as car safety seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep in the hospital or at home.

Though this sentence doesn’t specifically mention your product, the Newborn Rock ‘n Play Sleeper is shaped like the devices in this category, and is therefore not recommended for sleep.

2e. If an infant falls asleep in a sitting device, he or she should be removed from the product and moved to a crib or other appropriate flat surface as soon as is practical.

Again, babies should not be left to sleep in a device like your Rock ‘n Play Sleeper.

16. Media and manufacturers should follow safe-sleep guidelines in their messaging and advertising.

From your website describing this product, at http://www.fisher-price.com/en_US/products/51903, I quote: “The seat is also inclined, which makes napping more comfortable for babies who need their heads elevated.” This implies that babies need their heads elevated, or that perhaps some of them need their heads elevated for comfort for napping. This is incorrect and contradicts the AAP, and is inconsistent with the safe sleeping guidelines.

In short, the Fisher-Price Newborn Rock ‘n Play Sleeper does not meet the standards established by the AAP for safe sleep. Parents, do not leave your babies sleeping in this gizmo. Their safety is too important.

Warning: The medication may cause… anything

The Pediatric Insider

© 2013 Roy Benaroch, MD

Have you listened to the ending of a TV or radio ad for a new medication? “Side effects may include palpitations, chest pain, stoppage of the heart, sneezing, itchy scalp, limping, emotional upset, tiredness, wakefulness, getting an 80s song stuck in your head ….. do these lists ever end?

Regulations require that pharmaceutical ads and promotional materials include the information in the approved “Product Insert”, or “PI.” That’s the big sheet of tiny type, folded up into a little wad, that you’ll find in a new box of medicine from the pharmacy. It traditionally starts with a chemical description of the medication (just to be sure that no one reads any further), followed by a summary of research studies, and ending with dosing guidelines. In there somewhere will be paragraphs of information about any potential side effects—lists of any symptoms that occurred more often with the new drug than with placebo.

These lists end up so long that they’re almost useless. One study showed that new drug labels, on average, include 70 listed side effects—and some drugs included over 500. How could anyone, patient or doctor, slog through a list of 500 “potential” side effects to determine if any of them are relevant or worth worrying about?

The PI, like many other warning labels, seems to be more a tool to protect against lawsuits than a way to convey useful information. It’s like those food labels—“Made in a facility that also processes peanuts and shellfish and eggs.” What does that mean? People don’t get allergic reactions from eating food that was near something they’re allergic to. Just tell me what’s in the product, not what was in the building.

We need clear information about common, significant side effects and any early warning signs of rare but serious side effects that mean the drug should be stopped immediately. For almost any medicine I can think of, this list ought to be one short paragraph. A list of 500 side effects isn’t anything anyone will ever be able to use. Information overload is de rigueur, but it doesn’t help anyone avoid real risks.

Adapted from a WebMD post I wrote in 2011