Archive for the ‘Medical problems’ category

Teenager hears herself too loud. Crazy? No.

September 29, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Amanda wrote in: “I know this sounds crazy, but my teenage daughter has been complaining that she hears herself talk very loudly. She’s self-conscious to begin with, so now she tries to talk very quietly, and no one can even hear her at all! She also says that she can hear her heart beating and her own breathing, and all of this is making her very anxious. We took her in for a hearing test, and it was OK, and I think the doctor thought she was making this up (she does have problems with anxiety, too.) Is this just all in her head?”

As a general sort of rule, I don’t usually answer specific medical questions about individual cases on my blog here. I can’t examine patients, and I can’t really get the kind of information I need to make a diagnosis; besides, I’m not your doctor. My advice for most people writing in for my help figuring out what’s wrong with your child is to go see your own doctor.

But Amanda’s question caught my attention. I hate that her daughter was “blown off” by her doc. I get it, she has anxiety issues, and that can lead to a lot of physical symptoms (typically headaches, belly aches, nausea, and dizziness.) But even while we’re thinking that psychological factors may be contributing to physical symptoms, doctors need to keep in mind that kids can have more than one thing going on. Yes, there’s anxiety. But guess what? I think Amanda’s daughter may also have a physical diagnosis. So I’m going to bend my own rule here, and toss out a possible diagnosis—and I hope Amanda’s mom takes her into a different doctor to get this checked out for real.

The symptoms described—hearing one’s own voice, breathing, and heartbeat excessively loudly, to the point where it’s annoying and distracting—can be caused by what’s called a “patulous eustacian tube” (another term, patulous auditory tube, is more correct, but people don’t really call it that.) To understand what’s going on, we’ll have to do a (brief) anatomy lesson.

Your middle ear is a small, air-filled space behind the eardrum. When you go up in a plane, the drop in air pressure around you allows that air in the middle ear to expand, so you feel a “pressure” in your head. A small tube connects the middle ear to the nasal cavity, which allows pressure to equalize—you hear or feel a little “pop”, and that funny sensation of fullness goes away. Something similar happens when you descend. Most of the time, that little tube (called a eustacian tube, or auditory tube) stays closed—it just pops open now and then to equalize the pressure on either side of your eardrum. Usually, it pops open for a moment when you swallow (which is why chewing gum is a good way to clear your ears after a flight).

With a patulous eustacian tube, the tube stays open all of the time. That allows sound waves from within your head to get directly to the middle and then inner ear, bypassing the dampening effect of the eardrum and middle ear structures. The bottom line: you hear the noises from your own body much louder than you ought to, and noises like your own voice, breathing, and heartbeat can even sound louder than noises from the outside world.

Ordinarily, the eustacian tube is kept closed by surrounding fat and other tissues. Being slender, or losing a lot of weight quickly, seems to be a risk factor for developing a patulous eustacian tube. It can also occur after certain kinds of ear surgery, or during pregnancy. Sometimes, there’s no apparent cause. The presence of a patulous eustacian tube can sometimes be confirmed during the physical exam, by looking at the eardrum while the patient breathes or talks. Sure enough, you can sometimes see the drum vibrate at those times if the eustacian tube is staying abnormally open all of the time.

There aren’t a lot of great treatment options for this—but I’ve found it’s very helpful to reassure the patient that while this is, in fact, all in their heads, it is not “all in their heads.” I found this news report of a new method being tried in England, sticking a bit of putty on the eardrum to dampen sounds. If that pans out as truly effective, it can bring some serious relief to a lot of people. But, as the news article says, do NOT try this at home!

More resources here

When a child refuses to poop

September 18, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Michelle wrote in: “We trained my 3 year old son approximately 3 months ago, and it’s been great. He’s been having virtually no accidents. The problem is that he’s terrified of making ‘dirty’ on the toilet. He does it in his pamper at night when he’s sleeping. He’s very verbal about it, and tells me that he’s scared to let the dirty come out. It’s really difficult to deal with because there are days when he holds it in all day, and misbehaves all day because he’s in pain. All of my friends tell me to give him laxatives to make him go, but my pediatrician recommended against it because he said he doesn’t want to mess with his muscles, and he’ll get over it eventually. I trust my pediatrician completely, but I wanted to hear your thoughts.”

Here are three parenting truisms: you can’t make kids eat, you can’t make kids sleep, and you can’t make kids poop. So issues around eating, sleeping, and the potty are often the biggest parenting challenges, a least for younger children. Parents wish they had a way to “fix” these issues, or “make” their child do what they know their child needs to do. It can be frustrating, but raising children doesn’t always work like that. Children really do have ultimate control over their own eating, sleeping, and pooping. Why do children sometimes hold their stool? Sigmund Freud felt that stool holding was part of the anal psychosexual stage, and that a children who rebelled against potty training would develop anal-retentive personalities. He also thought that boys in particular had a fear of castration, and that stool looked like a little penis, so boys didn’t want to even symbolically lose their little penises into a toilet. Fascinating stuff, Freud—though it’s worth remembering that his specific analytic theories were just about 100% wrong, even though he deserves credit for figuring out that experiences and subconscious thought affected our outward behavior. In other words, I doubt Michelle’s son is holding his stool because he’s afraid his penis is falling off, but I do believe that his fear could be related to other experiences he’s having a difficult time articulating.

Freud’s theories aside, I think the most common reasons for kids to hold their stool are more ordinary: (1) they like being in control; and (2) stools sometimes hurt. Whatever the initial cause, stool holding inevitably leads to larger, more-painful stools, which makes the child try even harder to hold the stool. I’ve called this the “constipation death spiral.” Fixing stool holding means interrupting the cycle of holding leading to pain leading to more holding.

One thing you can try that will not work: talking. I’m not saying you shouldn’t talk about this with your child, but honestly, once your child learns it hurts to poop, you’re not going to be able to talk him out of it. Sure, you’d love to crawl into his little brain and say “Relax, honey. If you let the poop out it will feel better and you’ll be OK.” Good luck with that. Instead, try all of these methods, all at the same time:

Don’t make passing stool any more uncomfortable than it already is. Don’t try to force it, and don’t punish any behavior that’s involved with stool. Don’t belittle the child or insult him. Avoid saying things like “don’t act like a baby” or “you’re making me mad.” Don’t show even with body language that you’re disappointed or upset, even after a stool accident—all of that just feels negative to the child, and will reinforce a holding habit.

Please, please don’t rely on enemas or suppositories. Maybe once every ten years I’ve suggested one of these, and I’ve usually regretted it afterwards. Almost all constipation and holding, no matter how bad, can be managed without sticking things into your child’s bottom. Believe me, once you start wresting with things down there, it will only get worse.

Make stools more comfortable by using an oral, daily stool softener. You can get exact doses and instructions from your pediatrician. The key here is to use a consistent daily dose to keep stools soft and painless, and to not stop using the stool softener until all memories of the painful stools have disappeared. This usually requires months of therapy. That may sound discouraging, but it’s much better than going on and off medications for years. The main medication you’ll use will be a softening agent only, though sometimes we have to add a laxative to get the bowel squeezing. Again, rely on your own child’s pediatrician for specific advice here.

Michelle mentioned a concern that medications might change the muscles of the bowel. While it’s true that with long term use some laxatives (including Exlax and Senokot) can cause changes in muscle functioning, the stool softeners (like Miralax) are not addictive in any way, and don’t permanently change anything. They just make stool softer. In fact, by relieving the pressure of a big retained mass of stool, softeners allow the muscle wall of the colon to return to normal. No one should be afraid of using these sorts of agents to help their child.

Encourage healthy eating, though don’t harp on it or make it a big deal. More fruits and vegetables, and drinking more water, can help. More dairy can make things worse. But, again, don’t harp on diet or punish your child because of food issues. That will lead to even bigger problems. You will not solve a holding habit by changing diet alone.

Set aside a “potty time” every day for Junior to go sit on the pot, to wait to see what happens. A good time for this is right after dinner. Don’t let Junior just sit there a few seconds and have a little tiny BM—encourage him to sit a long time, read a story, or play with your phone (I think some Samsung phones are water resistant!) Do whatever keeps him happy. This should not come across as a punishment. The idea here is to stop relying on whether Junior says he does or doesn’t have to “go”—just tell him it’s time to go, once a day. And don’t rush.

One final idea: add some fun with something called “The Poopy Party”. (Works best for boys over age 3)

By the way, as with many of my posts, all of this applies to ordinary, healthy, neurologically typical children. If your child has GI problems or developmental challenges, other approaches might be more appropriate. Please talk with the doctors who know your child best.

With time and patience, stool holding will stop. The approach needs to be gentle, non-judgmental, and consistent—and even with that, it takes time to develop new habits. Good luck, Michelle, and let us know how it goes!

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.

Back to school means back to backpack back pain

September 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

(Yes, I know, I need an editor to help me write better headlines for these stories. Send in your application to our human resources department.)

From researchers in Spain, a simple, brief study confirms what you would have guessed: kids’ huge backpacks are hurting their backs.

A team collected data from about 1400 students in lovely Galicia, Spain (where I have decided I want to go on vacation, despite the hordes of back-injured children. I won’t tell them I’m a doc.) Those carrying the heaviest backpacks had a 50% increased incidence of back pain. The risk was higher among girls.

There are a lot of pressures on kids these days. You’d think a huge backpack wouldn’t have to be one of them. There are some things parents might be able to do to mitigate this problem:

  • See if you can access textbooks online—and if so, encourage your child to just leave his books at school rather than lugging them back and forth.
  • If you can’t get online access, consider getting a second set of books to keep at home. You can probably buy them used on Ebay or Amazon, or maybe convince the school to give you a second set with a doctor’s note documenting back problems.
  • If allowed, try a rolling backpack. Many schools discourage these because they gum up the overcrowded hallways.
  • Use a backpack that fits right, with the straps tight enough to hold the weight high on the back. A high-quality backpack has wide, padded straps and is designed to keep the weight close to the body, not hanging down the back.
  • Discourage the slouchy, single-shoulder carry. A backpack with a significant amount of weight is best carried on straps across both shoulders—or even better yet, with a belt across the lower belly that supports some weight on the hips.

Contest Winners!

August 25, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Thanks for everyone for playing last week’s contest! The winners are all getting a copy of my Great Courses lecture series, Medical School for Everyone: Grand Rounds Cases!

First, the answers– What’s the name of the theme song of these TV shows?

Sanford and Son  – The Streetbeater, by Quincy Jones

Taxi  – Angela, by Bob James

M*A*S*H – Suicide is Painless, music by Johnny Mandel, lyrics by Mike Altman (the 14 year old son of the movie’s director, Robert Altman. It’s said that he made far more money by writing those lyrics than his father made from directing the film.)

The Benny Hill Show – Yakety Sax by Boots Randolph

The Dukes of Hazzard  — Gold Ol’ Boys by Waylon Jennings

 

Our winners are stuart, Sallie, Karen, Sheila, and Teresa! Woot! You all will be getting your courses in the mail soon, congrats!

If you didn’t win– please check out my lecture series over at The Great Courses. Feedback has been excellent! They have a 100% no-questions money back guarantee if you want to return your purchase, and the course is at special sale price right now!

 

 

 

Another win for dogs!

August 14, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Trying to decide whether to get a dog? Here’s more evidence that you should!

A 2012 Finnish study looked at about 400 babies from birth through the first year of life. Families kept diaries to track respiratory infections together with information about both dog and cat contacts.

Author and Misty, 1976

Children who lived with dogs had fewer colds and fewer ear infections; they were also prescribed fewer courses of antibiotics. The effects were dose-related, too—more time with dogs increased the health advantages. Cat exposures were much less beneficial.

Author and Lucky, 2014
Author and Lucky, 2014

Other research has shown that pet ownership decreases stress, increases life satisfaction, and may decrease the incidence of allergies. Dogs are also really fun to have around. Please consider a rescue pup from an organization like Furkids/SmallDog Rescue (they’re in Georgia—many other great non-profit rescues can be found all over the country. Look for your own local rescue via Google.) There are some great dogs out there who really need a home, and they’ll pay you back with love, companionship, and fun.

Cats are nice, too. I suppose.

Pregnant women should get influenza vaccines to protect their babies and themselves

August 4, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

The kids are heading back to school, and my zucchini vines are withered—that means summer’s almost over, and we’re heading back into flu season. This year, I’m going to try my best to convince as many of you as possible to get yourselves and your children vaccinated.

Why? Because I don’t like to see people suffer and die. We’ve got a good, safe, effective way to prevent influenza—and the more people vaccinated, the better it works. There are very few medical contraindications, and the CDC recommends that everyone aged 6 months and over get the vaccine each year. That helps protect us all.

Today I’m going to focus at the beginning of the life cycle, with pregnancy. We’ve known for a long time that pregnant women are especially prone to complications and death from influenza infection, and ACOG (The American Congress of Obstetricians and Gynecologists) has recommended since 2010 that women receive a dose of injected influenza vaccine during pregnancy. Uptake has been poor, in part because of lingering safety concerns.

There have been several recent studies that provide solid reassurance about the safety and effectiveness of influenza vaccines during pregnancy. In 2013, the New England Journal published a study from Norway that looked at 117,347 pregnancies—vaccinated moms were less likely to get influenza, and less likely to have their babies die. Another study, BMJ 2012, looked at about 55,000 pregnancies in Denmark, showing no increased risk of birth defects, preterm birth, or fetal growth problems after vaccination. That same Danish group published a second study from their data set showing no increased risk of fetal death. The Danish studies looked rigorously for adverse reactions, finding no support for any significant problems, though these studies were not designed to look at the effectiveness of the vaccines.

The effectiveness of these vaccines has already been demonstrated, both to protect mom and to protect baby. Pregnant women ought to make the safe choice: get vaccinated against influenza. It’s the right thing to do for you, and the right thing to do for your baby.


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