Archive for the ‘In the news’ category

Is the FDA’s antidepressant warning killing people?

October 27, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

In 2004, the FDA launched a program to “strengthen safeguards for children treated with antidepressant medication.” Among other steps, they started requiring manufacturers of several kinds of antidepressants to include a warning in their product labeling, a so-called “black box,” that explicitly and loudly proclaimed a risk for children taking these medications. The warning said that children taking these medications were at an increased risk of suicidal thoughts and behaviors. Later, the black box warning was expanded to include young adults. The warning was required to be added to the labeling of medications including Prozac, Zoloft, Celexa, Wellbutrin, and several other medications.

What prompted this action was an observation from studies of children taking these medications that in the weeks after starting them, there seemed to be increased thoughts of suicide. Not suicide attempts, and not deaths from suicide (there were actually no suicide deaths at all among the study groups), but self-reported thoughts about suicide.

Now, depression is a serious illness—and suicide is a very serious consequence of depression. People with major depression have about a 15% cumulative lifetime risk of death by suicide, so this is a very significant and serious problem not to be taken lightly. We know that people with depression often think of suicide, and are at grave risk for attempting suicide—is it possible that anti-depressant medications actually make this risk worse?

A June, 2014 study from The British Medical Journal has looked at the consequences of the FDA’s decision (and the ensuing broad media coverage.) Researchers examined data from a total of 2.5 million teens and young adults from 11 health care plans in the United States. After the warning, the use of these medications dropped by about 24-31% (depending on age grouping.) This was accompanied by an increase in the rate of suicide attempts, by 22-34%. The rate of deaths from suicide did not change at all—just the rate of attempted suicides.

So, no, the FDA’s warning, based on this study, didn’t increase actual deaths. But it did increase suicide attempts, which likely means it increased the rate and severity and consequences of depression. It certainly hasn’t done any good. The warning has scared many families and doctors away from one mode of therapy for depression. Antidepressant medications aren’t perfect—they do have important side effects, and they don’t always work, and they’re certainly not for everyone with symptoms of depression—but they can be one important part of the treatment of some depressed adolescents. It’s a shame that this misguided “black box warning” is doing more harm than good.

Defeating Ebola: Nigeria did it, so can we

October 21, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

In June, a man became very ill during a flight into Lagos, Nigeria. On the plane, he developed vomiting and diarrhea, and he collapsed in the very busy airport. Contacts on the plane and on the ground had no idea that he had Ebola—initially, he was treated for malaria—and many healthcare workers and bystanders on the plane and in the airport were exposed to his infectious body fluids. One of his close contacts, while ill, flew across the country to consult with a private physician.

A nightmare? Well, it wasn’t good. But health officials in Nigeria stepped up to the plate and dealt with it. Following protocols (yes, protocols) recommended by the WHO and CDC, and relying on a fairly meager public health infrastructure built to track polio cases, workers carefully tracked every single contact, and kept tabs on all potential cases. People who became sick were then isolated. In total, Nigeria experienced 19 cases of Ebola (including 7 deaths), all traceable to the single imported case.

Nigeria has not had any new diagnoses of Ebola disease in 42 days, twice the maximum incubation period of 21 days. The WHO has declared Nigeria Ebola-free.

No special medicines, no vaccine, no high-tech anything. Nigeria is Africa’s largest country, and the case was imported through a planeload of about 50 people, all potentially exposed to infectious material. All of these people then traveled through the country’s largest airport in its largest city. Yet there was no widespread illness—the outbreak was contained through the boring, tedious, essential work of screening and following. And it worked.

The media are in an absolute frenzy over Ebola in the US, pointing fingers and practically frothing at the mouth. I realize that in the noisy world of the internet, one has to shout to sell, and shout to be heard; I also realize that there’s an election coming up in just a few weeks, so anything that makes someone else look bad is going to be a tool that just has to be used. Politicians are doing what politicians do (grandstanding), and journalists and those-pretending-to-be-journalists aren’t far behind.

One example: everyone seems to clamoring for us to shut down flights from countries affected by the epidemic (Liberia, Sierra Leone, and Guinea). Politicians from both sides and pundits on the TV news are blasting the administration and public health authorities:

 “Of course we should ban all nonessential travel…” – Bret Stephens, Wall Street Journal

“…we should not be allowing these folks in. Period.” – Rep Fred Upton (Republican, MI)

“It starts with a travel ban for non-citizens coming to the US from affected areas…” – Sen. Mark Pryor (Democrat, AR)

But a widespread travel ban will do more harm than good. There already are no direct flights from any affected countries into the USA—anyone getting here will actually be coming from somewhere else. If a travel ban is in place, people who are potentially exposed will do what humans do: they’ll lie. And they’ll get here anyway, from Morocco or France or wherever. (The Liberian man who flew into Dallas, starting our only outbreak here, flew from Belgium). A travel ban will create a panic and a logistical nightmare. We won’t be able to know who is actually coming from where, and people who need to be tracked (maybe including people already sick with disease) may end up hiding from authorities. What happens then?

There are other reasons why a travel ban is a bad idea. It will prevent aid from getting where it’s needed (and the longer the epidemic brews in Africa, the longer we are at risk.) It will further destabilize struggling governments in the heart of the crisis. We should not take steps that will prolong the primary source of cases in West Africa. In fact, the most effective way to end this mess is to end it in Africa. We need to be there, helping with the fight.

None of that seems to matter—it’s all about the symbolism and messaging. Politicians want to look like they’re taking a Tough Stand to Protect America, and journalists want to sell their stories and newspapers. Shut the border! Meanwhile: there have been no further cases of Ebola from the small Texas outbreak. Though infection-control procedures needed to be tighter at first, it looks like health authorities have quickly adjusted their response to contain the spread, and it worked.

There will be more cases of Ebola appearing in the USA. We’re a big country, and we cannot practically just stop travel from an entire side of a continent. Despite what’s being screamed in the media, the CDC has done a good job at responding to this crisis. Future cases will be identified, and spread will almost certainly be limited to a handful of people genuinely at risk (not you, and not your kids.) There’s no need for panic. If Nigeria can do it, so can we.

Previously:

USA Ebola cases double. Media goes nuts, and still misses the point

Ebola and you

USA Ebola cases double. Media goes nuts, and still misses the point

October 13, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Technically, it’s true: the prevalence of Ebola infection just doubled in the USA, as news spread that a nurse in contact with the first case in Texas has come down with the disease. Technically, that’s not true. The first man died, which dropped the prevalence of Ebola to zero, then it went back up to one. But let’s not split hairs. The total cases just went from 1 to 2, which is a DOUBLING! Clearly, it is time for panic.

No, it is not. Ebola remains difficult to catch, requiring direct contact of either broken skin or mucus membranes (eyes, nose, mouth) with infectious fluid from a victim. And victims don’t become contagious until they’re sick, which explains why the planeload of passengers who accompanied Mr. Duncan from Liberia remain healthy. The people at the most risk aren’t you, or your children—unless they’re healthcare workers, and, really, unless they’re working in West Africa.

That’s where the tragedy is, and that’s where the international community needs to concentrate its resources. Until the epidemic is stopped in Sierra Leone, Guinea, and Liberia, a few cases are going to trickle out and potentially spread to a handful of people wherever they end up. The next case could be in Baltimore or Santiago or Moscow—but, as long as there’s a reasonable health infrastructure, cases can be identified and contained. It takes legwork and money and a grinding, relentless attention to detail, but it can be done. I doubt fancy-pants new vaccines or medicines are going to make much of a difference, here. This one’s got to be surrounded and defeated by old fashioned record keeping and case tracking and isolation by people right there where the action is.

Back to the unfortunate nurse in Texas: The CDC has blamed the spread on a “breach of protocol”. That’s an awkward, weird phrase—and it strikes me as odd that the director of the CDC, Dr. Tom Frieden, would so blithely blame the staff there. Dr. Frieden himself is an internist and infectious disease specialist, and he is no dummy. Any smart doctor knows you never toss your nurse under a bus. It may just be the jet lag talking, but I think there is more to this story, and more to this “breach”.

Stay tuned, though if you’re smart you’ll disregard the media blowhards. Ebola is a huge problem, and a huge human tragedy, but it’s still not something to panic about.

Infection Report 1: Why are infections such a problem again?

October 6, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Once again, infections are in the headlines.

Ironically, it wasn’t that long ago, around the 1950’s, that many people thought we had infections beat. Antibiotics could cure any infection, and the pace of new drug development was exploding. We were sure to outwit the stupid microbes. We’ve learned a lot since then:

1. Evolution by natural selection works. When the environment puts pressure on living things, the population best equipped to thrive under those conditions expands. In other words, the use of antibiotics encourages bacteria to become resistant. This is especially true when antibiotics are used indiscriminately, incorrectly, and inappropriately. And antibiotics can cause other side effects, too. In the long run, if our only weapon against infection is antibiotics, we are going to lose.

2. New viruses are guaranteed to appear, and are guaranteed to spread. The last 50 years has seen the rise of AIDS, SARS, MERS, and Ebola. There is no way to prevent the appearance of new viral infections.

3. The success of public health efforts to contain disease undermines public confidence in the need for public health efforts. I know, that sounds weird. But once disease XX becomes rare (typically through a whole lot of public health effort), people stop worrying about it. They even sometimes begin to distrust the system and the people whose work stopped the disease in the first place. Once strategies to contain disease are offhandedly dismissed, the diseases come back.

4. The world is big, and the world is interconnected. Diseases no longer lurk only in secluded areas or remote villages. Conditions in resource-poor parts of the world contribute to the development of new infections: living closely with animals, poor sanitation, lack of health education and resources, and ineffective government or public support for health maintenance and surveillance. Once new infections appear, they’re bound to spread—people routinely travel by planes across entire continents.

Sound grim? Maybe. Threats certainly loom, and they’re much closer than the horizon. What should you be doing to protect yourself and your family? This week’s daily posts will be about infections new and old, the ones in the news and the ones most likely to make your family sick. You might be surprised to learn that what you are worrying about and what you should be worrying about aren’t the same things, and that there are simple and safe things that you really should be doing to protect your family from real threats. The media is seething with news and worry—but I think, for the most part, they’re missing the point.

Next: Ebola and you

Protect your kids from the “new” respiratory virus

September 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Facebook and other social media sites are all a-twitter (ha!) about a “new” respiratory virus, sweeping the country and sickening thousands of kids. There is something new, or new-ish, out there, and it looks like the infection can get pretty bad. But now is not the time for panic. We’ll get through this, like we get through other spikes in viral infections. With some common-sense steps, your kids will be OK.

As reported officially by the CDC this week, in the last month hospitals in Illinois and Missouri reported an increase in emergency department visits and hospitalizations for respiratory symptoms. Since then, reports of similar illness are coming in from many other states, scattered across the country. Most (but not all) of the cases with more severe illness had pre-existing lung disease (like asthma).

The illness seems to be mostly affecting children. Most cases begin with ordinary, cold-like symptoms—and it’s likely that most cases actually never develop into anything more than that. The reported cases, so far, may well be a “tip of the iceberg” effect, where only the sickest children get tested and identified. These are the kids who develop trouble breathing and low oxygen levels, and often need intensive care. It’s quite likely that most children with this infection quickly recover after a cough, sniffles, and runny nose. Of the cases reported so far, only about 1 in 4 or 5 runs a fever. Probably, most children and adults who have this infection don’t seek medical care, and very few of them (so far) are even being tested for the likely viral cause.

Most of the reported cases are testing positive for a specific virus, called enterovirus D68. That virus was first identified in California and 1962, and until now had rarely been a reported cause of illness. The enterovirus group, as a whole, contains a lot of other viruses that cause a whole bunch of different symptoms—fevers, respiratory illnesses, GI problems, heart disease, rashes, and neurologic problems. Pediatricians and others who take care of kids are used to seeing tons of enterovirus, which usually strikes in the summer, most typically as hand-foot-and-mouth disease, or as a fever. So we’re used to these kinds of viruses, even though this specific one is a newly-recognized member of the family. We’re not 100% sure, yet, exactly how D68 is transmitted, but other enteroviruses spread though respiratory drops and in stool, and can remain infectious for a long time on contaminated surfaces.

As with many viral infections, prevention is the best strategy. Common sense things can really help: keep your kids home when they’re sick, and don’t send your kids off to play with sick children. Encourage your kids to wash their hands and use hand sanitizer frequently. Get a good night’s sleep and moderate exercise. Keep your child up-to-date on vaccines—though there is no specific vaccine for this enterovirus*, bacterial and viral coinfections with influenza and pneumonia can be prevented. If your child has asthma (or any other respiratory problems), make sure that you’re keeping up with all prescribed treatments, so things are less likely to spiral out of control when an infection strikes.

If your child does get sick with cough, look out for these symptoms:

  • Having trouble breathing. You may see individual ribs poking out with each breath, or the depression at the bottom of the neck sinking in, or bobbing up and down. Children with trouble breathing usually breathe fast, and sometimes breathe noisily.
  • Having trouble speaking. If you can’t get good breaths in, you can’t typically complete sentences and talk normally.
  • Seeming listless, with low energy. Children with serious respiratory compromise may not be getting enough oxygen to their brains. They can seem “foggy” or “out of it.”
  • Drinking poorly. Younger children and babies may have a hard time eating and (especially) drinking when they’re really ill.
  • Looking blue or pale.

If you’re seeing those kinds of symptoms, take your child to the doctor right away, or head to the emergency department. Even if things don’t seem quite that bad, if you’re worried, don’t hesitate to call for help.

Most children who are getting enterovirus D68 infection will do just fine. Some of you have probably already had children with this, and didn’t even know it. Every year, we see spikes of infections like this, caused by a variety of viruses like RSV, metapneumovirus, or influenza. Though there is no specific therapy for most of these, we’re pretty good at recognizing who needs extra help, and we can provide good supportive care when it’s needed. It sounds scary when you see news of a new, bad infection—but in truth, this isn’t very different from other infections we’re used to dealing with. We need to stay vigilant and keep our eyes on whatever’s out there making our children sick, but there’s no reason to get too worked up over this latest challenge.

*Fun trivia challenge: we routinely vaccinate against one other enterovirus, one that historically caused infections in the summertime. Guess!

This was adapted from a post I wrote for my practice website.

Dr. Bob Sears says skipping vaccines is not good for public health

September 9, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

This weekend, The Los Angeles Times reported on California pediatrician Dr. Bob Sears’ role as a favorite among vaccine-fearing parents. What he tells them is absolute nonsense that he has freely admitted he made up in a Reddit interview. Now he’s let a little more honesty shine through. He told the reporter:

“I do think the disease danger is low enough where I think you can safely raise an unvaccinated child in today’s society,” he said. “It may not be good for the public health. But … for your individual child, I think it is a safe enough choice.”

I had wondered: is it possible that a board-certified pediatrician, one from a family of influential and well-known children’s health experts including Dr. William “Attachment Parenting” Sears and Dr. Jim “The Doctors” Sears, could really believe the idiocy in his own book? Now we know. Dr. Bob Sears says screw public health, screw everyone else’s children, screw your neighbors and their families. It’s fine if you skip your child’s vaccines, because for your child the risk isn’t great. That may not be good for the public, Bob says, for all of those other idiots out there—we know if people start skipping vaccines the disease will surge back. But for your snowflake, well, it’s OK. You can even picture him winking when he says it.

This is just despicable. Mendacious, vile… I’m running out of adjectives, here. Dr. Bob thinks his own special pals, his patients, the suckers who buy his books, they don’t need their vaccines—they can just hide in the herd, as long as the rest of us get our kids vaccinated. His white, affluent, Orange County kids can’t be bothered with needles. Sure, it’s no good for public health, but public health isn’t something his parents need to think about.

Dr. Bob freely regurgitates long-disproved anti-vaccine canards throughout his laughably mis-named The Vaccine Book: Making the Right Decision for Your Child. The book has sold well. He’s telling people exactly what they think they want to hear, blaming all sorts of ills on vaccines, fueling fear and anxiety and a mistrust of every legitimate health authority on the planet. They’re all wrong, he says, the CDC and the IOM and every county health officer and every single country’s health ministries and all of the pediatricians, family medicine docs, infectious disease specialists, and everyone else who’s invested their careers in protecting the public health. We don’t need no stinkin’ evidence.

He’s making oodles of money off of your fear, while freely admitting that what he’s doing is no good for the public health. Don’t forget: the public is you, your children, your family. We’re all in this together, sharing our planet and sharing these infections. You can help keep your children and communities safe by making sure your kids are vaccinated. Or you can join the “me first, screw you” brigade led by Dr. Bob.

Breastfeeding and post-partum depression: A possible cure, a possible cause

September 3, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.


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