Archive for the ‘Medical problems’ category

Infection Report 5: What you really should be worried about

October 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

This week’s posts have all been about infections, new and old—infections newly found, and infections sneaking back. On the one hand, the media is agog with news of Ebola and the mysterious paralysis virus; on the other hand, threats that are far more likely to kill us are being largely ignored.

One infection is on the verge of sneaking back, which is a shame. We had it beaten, and now we’re allowing it to gain a foothold. We’ve got a great way to eradicate measles, but fear and misinformation have led to pro-disease, anti-vaccine sentiment, especially among those white, elite, and wealthy. As we’ve seen, we’re all in this together—so those anti-vaccine enclaves are going to affect all of us.

Measles, itself, is just about the most contagious disease out there. You don’t need to have infected fluid splashed on you (Ebola), and you don’t need to actually even touch a contaminated surface (influenza). All it takes to catch measles is to breathe the same air as someone with the disease. The measles case doesn’t even still have to be in the same room—particles of infectious measles can float around long after the patient has left. Measles can also be transmitted from contaminated surfaces (and even if person A who touches the surface is immune, he can spread it later on to person B.) Measles is so transmissible that 90% of non-immune people who come near someone with measles will themselves get it. To make matters worse: a person with measles starts spreading virus 4 days before they get sick (compare that to Ebola, which has no transmission until symptoms appear.)

And it’s serious, too. Measles is far more than spots. In the USA, about 1 in 20 people with measles require hospitalization for pneumonia; about 1 in 1000 get brain swelling, which can lead to permanent disability. Measles still kills close to 200,000 people, worldwide, every year (about 1 in 4 people with measles die in the developing world.)

While no vaccine is 100% effective, the measles vaccine is pretty darn close. About 95%-100% of people develop lifelong protective antibodies after the two-dose series. Unfortunately, not everyone can be vaccinated—the vaccine isn’t routinely used less than 12 months, and some people with certain health conditions and immune problems can’t safely be vaccinated. Still, when vaccine uptake rates were strong throughout the developed world in the 1990s, there was very little transmission of measles in the United States, just a handful of cases each year.

And now, it’s back. 2014 is going to have by far the most measles cases in 20 years. Though overall rates of vaccination remain strong, some neighborhoods have immunization rates poorer than third-world countries. And cases that begin or are imported into those areas become outbreaks that public health officials struggle to contain.

Think about this: in west Africa, thousands of people are dying of Ebola, for the lack of rubber gloves and other ways to isolate cases. Here, we do have a safe and effective vaccine against a disease that’s far more transmissible—and some people choose not to get it. There, they battle a lack of basic health resources. Here, our enemy is fear and misinformation. That’s what American families really need to worry about.

This week’s posts about infections new and old were meant to contrast the kinds of challenges faced here, versus the challenges faced in most of the rest of the world. We’re so safe and rich that we can afford to be afraid of things that really shouldn’t scare us (vaccines), while the media becomes preoccupied with things that aren’t likely to become a threat here (Ebola.) We don’t get our flu vaccines because “I heard the flu vaccine can give you the flu” – an utter falsehood that is probably contributing to thousands of deaths. At the same time, we guzzle unnecessary antibiotics for viral infections that do us far more harm than good.

Preventing infections is always the best strategy. Wash your hands, stay away from sick people, keep your kids home when they’re ill, and listen to what every legitimate health authority on the planet says: get yourself and your kids vaccinated. As long as we get them, vaccines are one thing you do not have to worry about.

This week’s posts: The Infection Report

Why are infections such a problem again?

Ebola and you

The single biggest infectious health risk is preventable

Two newcomers and the importance of paying attention

What you really should be worried about

Infection Report 4: Two newcomers and the importance of paying attention

October 9, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

While Ebola makes the headlines and influenza prepares its yearly visit, two other “new” infections have been brewing this summer. We’re still got a lot to learn about “the new respiratory virus,” AKA enterovirus D68, and whatever seems to be causing cases of paralysis in 9 kids in Colorado. It’s even possible that these two infections are the same. These infections are coming to light because hospitals and public health officials stay on the lookout for new patterns of disease and infections. It’s not complicated, and it’s really not rocket science. It’s all about paying attention.

Earlier this year, hospitals first in Illinois and Missouri reported an unusual spike in ER visits and hospitalizations for respiratory symptoms, including cough, wheezing, and difficulty breathing. Often, children with this infection became very sick very rapidly, requiring hospital or ICU-level care very shortly after the onset of symptoms. Most, but not all, affected individuals had pre-existing lung problems, mostly asthma. Though routine testing for a specific agent still isn’t widely available, laboratories were able to identify a specific viral cause, an “enterovirus” named D68. That virus has been around since at least 1962, but until this year hadn’t caused widespread infections. It’s probably spread throughout the United States, and continues to contribute to many hospitalizations.

Many children (and adults) with this infection probably have mild symptoms, indistinguishable for any other viral “cold”, but some go one to become seriously ill. By the way, that’s true for almost all ordinary cold viruses—though most people sail through those infections just fine, every once in a while an ordinary cold virus makes someone very, very ill. This new enterovirus isn’t really that different from many other respiratory viruses, but it’s newly widespread and seems to have a disproportionately high rate of complications.

Or maybe it is kind of different, after all. We’re also hearing reports out of Colorado of a new kind of illness, one that looks like an infection, that’s caused flaccid paralysis in at least 9 children (actually the CDC is investigating about 23 reports, though it’s not yet clear if all of these are the same condition.) Many of those children seem to have had a respiratory illness about 2 weeks prior to the onset of the paralysis. MRI scanning is showing changes in the part of the spinal cord that controls motor functioning, and in some ways the clinical presentation and MRI findings look similar to an old infection, poliomyelitis. But specific tests for polio virus have been negative.

Here’s an theory: this respiratory virus D68 and polio virus are related—they’re both from a large, diverse family of viruses called “enterovirus.” These viruses typically cause summer infections, and different kinds of enterovirus can cause disease of the gut, lungs, liver, nerves, skin—all sorts of things.  About half of the Colorado 9 children have tested positive for D68. That’s not definitive—that doesn’t mean D68 is causing the paralysis—but it’s certainly suggestive and interesting. It is possible that these two new things, the respiratory virus and the paralysis, are actually being caused by the same infection.

We’ll be learning more about these infections in the coming months. For now, the best steps available to protect your family are common sense things: wash hands, stay away from sick people, don’t touch your face, and beware of signs of bad respiratory disease. Though there are no vaccines for these new infections yet, you can prevent the return of polio and the widespread sickness of influenza with current, safe, effective immunizations. Hospitals, doctors, and staff at hospitals in the midwest did a great job in identifying these new problems and alerting public health officials to begin their investigation. Our health depends on all of us, together, paying attention to and confronting health threats like these.

Next: What you really need to worry about

Infection Report 3: The single biggest infectious health risk is preventable

October 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here’s what people are dying of in the United States, in order: heart disease, cancer, chronic lung disease (mostly COPD, usually among smokers), stroke, accidents, Alzheimer disease, diabetes. And at number 8, the first infectious cause of death on the list: influenza and pneumonia, about 54,000 deaths a year.

(By the way, at least some cancers are infectious diseases, and two of those we can prevent with vaccinations. But let’s focus on influenza and pneumonia here.)

The most common fatal complication of influenza is pneumonia, so it can be difficult to tease out how many of those 54,000 “pneumonia and influenza” deaths were caused by influenza. Influenza also contributes to death by many of the other causes (it is the final straw in many patients with COPD or other health problems.) It’s likely that influenza viral infections are the proximal cause of about 36,000 deaths a year in the United States.

Unlike Ebola, influenza spreads rapidly in a community. Influenza virus can be spread by sneezing or coughing, or even better by mucus left on surfaces and doorknobs. Also, unlike Ebola, people with influenza become infectious a day or so before they’re obviously sick.

There are simple steps you can take to prevent contracting and spreading influenza. Most importantly, people with influenza symptoms shouldn’t go to school or work. Keep your mucus to yourself, as much as you can, by sneezing into tissues and using hand sanitizer to clean your hands. Remember, influenza virus gets from place to place on hands—once deposited somewhere, it doesn’t jump up and fly around. You have to touch it, then touch your own face, to get sick from influenza virus.

One more step that we all need to take: make sure you and your family get influenza vaccinations! The vaccine is terrifically safe, and it works well most of the time to  reduce the transmission, rate, and severity of influenza. Taken as part of an overall influenza prevention scheme, vaccination is an essential step.

The CDC recommends influenza vaccinations for all of us, everyone over six months of age. That’s because the more people get the vaccine, the more all of us are protected. It doesn’t work 100% of the time, and young babies and people with some health conditions can’t be vaccinated—so it’s up to the rest of us to keep vaccination rates high, to protect everyone. One lesson is clear from the current media hysteria over Ebola, Enterovirus D68, and other new infections: we’re all in this together. Influenza is one infection that we’ve got the tools to beat.

Tomorrow: more new infections that are making the headlines.

More info:

Flu myths

CDC comprehensive flu info

Infection Report 2: Ebola and you

October 7, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Ebola isn’t actually a new infection, but it’s pretty close: the first cases were reported in the 1970’s, in central Africa. Since then there have been several, relatively small outbreaks, typically beginning in communities with close contact with animals, sometimes with infections appearing in chimps or other primates before appearing in people. The infection itself rapidly causes severe disease, and has been associated with a fatality rate in the 50-70% range.

Symptoms begin 2-21 days after exposure, and typically include high fevers, aches and pains, diarrhea, and vomiting. More severe cases develop “hemorrhagic fever,” with bleeding under the skin and in the gut, followed by shock, cardiovascular collapse, and death. This infection is fast, and it is bad news.

But here’s the thing: unlike horrible epidemics portrayed in movies and novels, Ebola is not actually that easy to catch. A person with Ebola cannot spread the virus before symptoms appear—there is no “silent carriage.” You can ride in a planeload of people who have contracted Ebola, but until one of them actually has symptoms, they’re not contagious, and you’re not at risk. And since the symptoms themselves are not subtle, it is unlikely that someone with Ebola is quietly sitting next to you on a bus. Those people are going to head to the hospital, pronto.

And, even if that person is sitting next to you on the bus is sick with Ebola, you cannot catch Ebola unless you come in direct contact with body fluids: blood, bloody diarrhea, or vomit. Staying away from blood, bloody diarrhea, and vomit is a good idea, whether or not there’s any Ebola around.

Though there’s media panic brewing, containing Ebola in the United States is something we’re equipped to do. We’ve got a good public health infrastructure in place, and we’ve got hospitals equipped to handle infectious material from sick people. What we need to do most, here, is to stay aware of the possibility of Ebola in people who’ve recently been in west Africa, where Ebola cases have truly become epidemic (mostly Sierra Leone, Liberia, and Guinea.) If people who’ve lived or traveled to those areas become ill with fevers and other Ebola symptoms, they need to be treated, isolated, and tracked.

The problem, honestly, isn’t here. The problem is in west Africa, where there is no public health infrastructure, and no hospitals, and no way to protect families and communities from contact with Ebola. When someone gets sick, they stay home with their families, and they are spreading infectious fluids. It’s nearly impossible to clean up those homes or protect people. No gloves, no disposable sheets, no autoclaves, not even enough plastic body bags. It is truly a health disaster, and we need world governments to step up to help the people there—or this is going to spread throughout the developing world. And, of course, the more cases there, the more the risk here, as it becomes more difficult to identify people exposed to cases that might spread to an ever-widening area. Helping the people of west Africa overcome this epidemic is both a moral and public health imperative.

Unlike Ebola, which can’t spread in the air and is only being contracted by people in a limited area, there are far-more-common infections right here, right now, and one of those will end up sickening far more of us in the United States. Yet many of us won’t even bother to take one simple, safe step to prevent it. Want to do something that can really help keep your family safe this winter? Tune in tomorrow!

More about Ebola from the CDC, and my Ebola podcast from The Great Courses.

Next: an infection that kills thousands in the USA… and can be prevented.

Stretch marks in teens

October 2, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

MJ sent me a photo of her teenage son’s back, and asked “Could these be stretch marks from growing so fast?”

Striae

That’s exactly what I think they are, MJ. I see shallow, linear, parallel marks that lie across the back, perpendicular to the long axis of growth. The doctor-word for this is “striae atrophicae”, or just striae or stria. Everyone else calls them stretch marks.

Women who’ve been pregnant know all about stretch marks, but other people get them too. Teenagers who are growing taller rapidly often get them, as can anyone who gains excessive weight (especially if the weight comes on quickly.) We most commonly see normal striae on the shoulders, abdomen, hips, buttocks, thighs, and breasts.  In time, these striae in teenagers gradually fade, and lose their reddish or purplish color.

There are some other health conditions that can cause a lot of striae, often appearing in unexpected places where there isn’t much stretching of the skin. People with Marfan Syndrome sometimes have quite a bit of stretch marks (they’re also usually tall and lean and gangly, with long arms and flexible joints.) Using oral or high potency topical steroids can predispose to striae, as can Cushing Syndrome (excessive adrenal steroids—very rare in kids, but when you see it they’ve got a round face and stop growing taller.) Children who’ve undergone chemotherapy or who’ve experienced other major illnesses sometimes develop striae. Most striae, though, are just a normal part of growing up.

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!


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