Archive for the ‘Medical problems’ category

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.

Mosquito wars: Why do some kids get bitten more than others?

June 30, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

“I have three children. But it’s only the middle one who gets bitten by mosquitoes! We’re outside for 20 minutes, and he’s covered with big itchy welts. They never bite the rest of us. I’m beginning to wonder what is wrong with him?”

I’ve wondered this myself—why are some people more mosquito-attractive than others? I’ve got some theories:

  1.  Some kids play more in the shade where mosquitoes lurk.
  2. Some kids are less sensitive to mosquitoes on their skin, so they don’t slap them away before being bitten.
  3. Some kids have a bigger reaction than others, so bites are more noticeable. (The welts you see are an allergic reaction to, essentially, mosquito spit. Like any other allergy, some people are more sensitive to others. It’s possible some people get bitten and don’t react at all.)
  4. Some children are just plain tastier. Mmmm, say the mosquitoes.

So what can you do about it? For families who have one or more bite-attracting kids, you need a good mosquito bite prevention and treatment plan for the summer.

 Prevention

Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis, dengue fever, and now chikungunya fever can be spread by mosquito bites in the USA. The itchy bites can be scratched open by children, leading to scabbing, scarring, and the skin infection impetigo. Prevention is the best strategy.

Try to keep your local mosquito population under control by making it more difficult for the insects to breed. Empty any containers of standing water, including tires, empty flowerpots, or birdbaths. Don’t let gutters or drainage pipes to hold water. Mosquitoes are “home-bodies”—they don’t typically wander far from their place of birth. So reducing the mosquito population in your own yard can really help.

There are yard sprayers either applied professionally or as a home job to reduce the local mosquito population. I have no personal experience with these products, and couldn’t find much in the way to independent assessments on the web. There’s no reason to think they wouldn’t work—but I’m kind of leery about the idea of spraying chemicals all over the place when there are simpler options. Still, for very sensitive people or heavy infestations, this might be a good idea.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Again, I don’t have much independent confirmation that these work, but they ought to be environmentally friendly and safe. If any of you visitors have used either these traps or the yard/mister sprays, let us know how well they worked in the comments.

Biting mosquitoes are most active at dusk, so that’s the most important time to be vigilant with your prevention techniques. Light colored clothing is less attractive to mosquitoes. Though kids won’t want to wear long pants in the summer, keep in mind that skin covered with clothing is protected from biting insects. A T-shirt is better than a tank top, and a tank top is better than no shirt at all!

Use a good mosquito repellent. The best-studied and most commonly available active ingredient is DEET. This chemical has been used for decades as an insect repellant and is very safe. Though rare allergies are always possible with any product applied to the skin, almost all children do fine with DEET. Use a concentration of about 10%, which provides effective protection for about two hours. It should be reapplied after swimming. Children who have used DEET (or any other insect repellant) should take a bath or shower at the end of the day.

Two other agents that are effective insect repellants are picaridin and oil of lemon eucalyptus. These have no advantage over DEET, but some families prefer them because of their more pleasant smell and feel. (Picaridin, oddly, smells like Fritos.) Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all.

Treatment

No matter what you do, occasional bites are going to happen. To minimize the reaction to mosquito bites, follow these steps:

  1. Give an oral antihistamine like Benadryl, Zyrtec, or Claritin (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.) For kids who get bitten a lot, it makes sense to just give an oral antihistamine daily, before the bites.
  2. Apply a topical steroid, like OTC hydrocortisone 1%. Your doctor can prescribe a stronger steroid if necessary.
  3. Apply ice or a cool wet washcloth.
  4. Reapply insect repellent so he doesn’t get bitten again.
  5. Have a Popsicle
  6. Repeat all summer!

The many causes of sore throat: Diagnostic pearls

June 26, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Sallie wrote in about what to do when a common complaint is caused by an uncommon diagnosis. Her child was having a lot of sore throats, one after another, and saw a lot of doctors before the final diagnosis was reached. It’s a good question, and a golden opportunity to talk about keeping your mind open to new ideas, especially when things aren’t progressing as expected.

Pearl #1: Common diagnoses are common

Common things happen commonly—or, in other words, when someone is sick, it’s much more common for it to be a common illness than an uncommon illness. 90% of sick visits to pediatricians are for one of 5 diagnoses. Those rare things you read about on the internet? They don’t happen much. That’s why they’re called “rare.”

For people with a sore throat, the very common diagnosis is a viral infection that will get better. These infections begin with a sore throat, then turn into a stuffy nose and cough. There may be some fever and aches. We’ve all had this, multiple times. It’s an upper respiratory infection, and it’s the single most common driver of pediatric visits. And we still don’t have any effective treatment for it. Humbling.

One other common diagnosis that causes sore throat is a strep infection, or “strep throat.” (It’s never “strept throat.” I have no idea where that extra “t” comes from.) Strep is less common the a viral sore throat, but it’s still fairly common. So many people with sore throat (especially when accompanied by fever and red tonsils and enlarged lymph nodes) get a strep test to see if it’s viral or strep.

Sore throats can be caused by other common infections, too: influenza, mononucleosis, or laryngitis. These usually cause other symptoms that make the diagnosis easy (or easy-ish), but sometimes they don’t… which leads us to the next pearl:

Pearl #2: It is much more common for common diseases to present uncommonly, than for uncommon diseases to present at all

Most people with influenza will have fevers and aches, in addition to sore throat; most people with croup or laryngitis will have hoarse voices or a barky cough; most people (at least teenagers) with mono will have fevers and tiredness in addition to their sore throat. But, again, not always. And these common conditions will sometimes fool you by not causing every expected symptom.

Or: let’s say a child has frequent sore throats—but they don’t seem to be viral or bacterial. That is, they’re not accompanied by fevers or runny noses or cough, and strep tests come back negative. What’s likely to be going on? It could be a genuinely weird, uncommon diagnosis—or, more likely, it could be a common thing that’s presenting in an odd manner. For instance, GERD (reflux) is common, and usually presents with heartburn or spitting up or an obvious sensation of food coming up into the mouth. But sometimes, it can cause sore throats.

Pearl #3: Even though they’re rare, if you keep looking you’ll find uncommon diagnoses Pearls #1 and #2 pretty much discount rare diagnoses, because they’re rare. But: every once in a while, those rare things do happen. But if doctors stop looking for them, they’ll never find them. Nearly everyone has a common diagnosis—except those rare people who don’t. And no one comes into the office with a stamp on their forehead that says “Think! I have something rare!”

Chronic or recurrent sore throats can rarely be caused by, among other things, a mass or tumor in the throat; or by nerve damage that prevents the vocal cords from operating normally; or by irritation from a toothpaste or mouthwash. Or from yelling frequently, especially if you’re not yelling correctly (yes, there’s a right way to yell that will cause less damage to your throat. Some people don’t do it right.)

One quite-rare example of a cause of chronic or recurrent unexplained throat pain is Eosinophilic Esophagitis (EE). This is an inflammatory condition that usually causes mostly esophageal symptoms (symptoms similar to heartburn, or to a feeling of food getting “stuck.”) Rarely, this uncommon condition can present in a very uncommon way: with sore throat. Which is actually, after a prolonged diagnostic journey, what Sallie’s son turned out to have.

The only way to diagnose EE is with a biopsy—you have to look down there, in the throat, with a scope, and get some tissue. Not everyone with sore throats needs that kind of evaluation. But we need to keep in mind that at least some kids with common complaints might just have something genuinely rare going on. If we don’t look, we’ll never see.

Hey! If you liked thinking about this—the way doctors think about making diagnoses, about looking for needles in haystacks and thinking critically about clues and medical mysteries, you might enjoy my lecture series at The Great Courses! It’s called “Medical School For Everyone”, and it’s a series of 24 medical case studies for laymen to try to figure out. I’ll give you the clues! Check it out through that link, and let me know what you think!

Flat head? Helmets aren’t the answer

May 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

International campaigns to reduce the incidence of Sudden Infant Death Syndrome (SIDS) have been very successful, with reductions of 50% or more in just about every country that’s pursued public education campaigns. Putting babies “back to sleep” is now ingrained in the public psyche. It’s saving lives.

But an unintended consequence has been an increase in babies with flattened heads. Doctors, who need a different word for everything, call this “plagiocephaly”, and it’s almost always caused by prolonged periods of unequal pressure on the growing cranium. If Junior sleeps on his back with his head turned to his right, the back/left of his head will always be pressed down into the bed. Over time, that side will become flatter. Over more time, if steps aren’t taken to correct this, the left ear and the left side of the forehead will shift forward. Viewed from above, the head of a baby with this kind of “positional plagiocephaly” will look like a parallelogram.

This kind of plagiocephaly—caused by pressure on the head, in the shape of a parallelogram—does not cause any developmental or brain problems. The significance is entirely cosmetic. If severe, it can be quite noticeable, but mild to moderate plagiocephaly has minimal if any cosmetic impact and no health consequences whatsoever.

Still, moderate-to-sever plagiocephaly is noticeable, and parents and pediatricians have been eager to find ways to correct it. One treatment that’s become very common is the use of a custom-made, lightweight fiberglass “helmet” that’s worn throughout the day and night. As baby’s head continues to grow, the thinking goes, it will grow into the nice round shape of the inside of the helmet. Problem solved?

But what seems to work, or what you think is likely to work, might not really work. That’s what practicing medicine is all about. We have to test our therapies and ideas, studying them objectively and impassively. We want it to work, it seems like it works, it makes sense that it does work. But does it really make any difference?

Researchers from The Netherlands just published a randomized clinical study, “Helmet therapy in infants with positional skull deformation: randomised controlled trial”. 84 infants who were already enrolled in conservative programs to address moderate-to-severe skull deformity were randomized at 5 months of age to either get fitted with a molding helmet, or to just continue monitoring alone. Helmets were worn for 23 hours a day for six months, with the helmets being re-fashioned and adjusted as the children grew.

Some red flags popped up early on. 403 infants were deemed eligible for the study, but only 21% of their parents agreed to participate—most of the parents did not want to consider joining a study where there child could be randomized to not receiving a helmet. And as the study went on, 100% of the helmet children reported what were considered significant side effects, including skin irritation, pain, decreased cuddling, and unpleasant odors from the helmets.

Still, almost all of the families assigned helmets completed the study and were compliant with therapy, and almost all of them had a full reassessment at 24 months of age to compare helmeted children with those that were just watched. What was found was stark. Use of the helmet made no difference in any measure of head shape. Unbiased observers, who didn’t know which treatment group the children were in, found that measures of head asymmetry were identical. The helmets just didn’t make any difference. Among children who wore a helmet versus those who didn’t, the same degree of improvement was seen, though complete resolution of head asymmetry was seen in only about 24% of patients in both groups. Overall, parents from both groups were equally satisfied with the improvement in their childrens’ head shape.

So what really should be done to deal with positional plagiocephaly? First, a fear of plagiocephaly should not discourage parents from setting their babies down to sleep on their backs. Safe sleeping is preventing thousands of SIDS deaths. But are ways to encourage safe sleep that won’t increase your baby’s risk of a flat head. Rotate the position of sleep, by putting Junior’s head on alternating nights and naps first at one end, then the other end of the crib. Junior will turn his head to look into the room, at the interesting parts. If his head is always on top of the bed, he’ll be looking over the same shoulder all of the time. Sometimes, place him with his head at the bottom of the crib.

Don’t use any sleep positioners—they’re not needed, and make sleep more dangerous. Don’t routinely sleep your child in a car seat, bouncy seat, or sling-shaped positioner—these can all increase the risk of plagiocephaly, and are not safe. Encourage tummy time when infants are young, and upright/sitting play when they’re a little older and ready for it.

Some children with plagiocephaly have a physical problem with the muscles in their necks, which prevents equal rotation to either side. These babies sit with their heads cocked to one side, and sometimes have a thickening you can feel in the muscle along one side of the neck. This is called “torticollis,” and can usually be treated with physical therapy.

If you’re concerned about your child’s head shape, make sure to bring it up with your doctor. Rarely, head shape problems can be a sign of a medical problem that needs to be addressed. Usually, though, a few simple steps at sleep and play times can help head shapes improve—apparently, just as much as an expensive, sweaty, unpleasant head helmet. Sometimes less is more. You don’t have to have your child helmeted for six months to get a fine looking head. Nice to know, and one less thing to worry about!

Human babies should not be born underwater

April 21, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

You’d think, being land-based mammals, we’d all be able to agree on the basic fact that humans breathe air, and that newborn human babies ought to be born into the air.  You know, so they can breathe. That’s how human babies have always been born, and that’s how all other primates are born, and that’s how all other land mammals are born. (Hats off to our cetacean cousins for their sticking to their evolutionary guns on the water birth. Unlike humans, Flipper doesn’t do well in air.)

And yet, there’s always someone willing to wonder, “Could there be a better way?” Immersion in water during labor or birth is touted by some as beneficial to both mother and baby. What does the evidence show? I’m willing to suspend common sense, here—show me it’s safe, then, sure, let’s join the dolphins.

Except it isn’t safe. And the purported benefits? No so much.

In a joint statement from the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists, physicians have reviewed what we know and don’t know about water birth. What we do know, really, is very little—studies are of limited quality and small scope, and use varying methods and varying definitions of “water birth.” Many of the “studies” are not in scientifically reviewed journals, and are more like collections of cherry-picked stories than actual objective evidence. Most of these “studies” show zero objective benefit during labor, though some pooled studies combining case series show a reduced use of anesthesia and a reduced time of labor during immersion in water. However, no matter how the data are combined, there’s no difference in perineal trauma, tears, c-section rates, or a need for assisted delivery. And there are no individual trials or pooled collections that show any benefit to the newborn infant at all.

What there are, though, are several case reports and case series of babies suffering harm from water birth. Because the numbers of women undergoing labor or birth in a water bath aren’t known, we can’t estimate the rates of these complications. But the complications are real and can be devastating: umbilical cord tears leading to hemorrhage and shock,  hypothermia, drowning, seizures, brain damage, and death. Are these kinds of risks an acceptable trade-off for the meager, unproven benefits of water birth?

The ACOG and AAP point out that immersion in water during what’s called the first stage of labor—the early part, when there are regular contractions but the cervix isn’t fully dilated—may be appealing to some women, and may offer some potential benefit in terms of pain control. Even though there’s no evidence of benefit to the baby, as long as immersion doesn’t otherwise interfere with good care it’s not unreasonable. Rigorous protocols ought to be in place, though, to protect mom and baby—including maintenance and cleaning of the tubs, infection control and monitoring, and careful observation for signs that it’s time to move out of the tub. Before someone gets hurt.

However, immersion during the second stage of labor, when the cervix is dilated and Junior is making his way into the world we share—that’s of zero benefit, and can lead to great harm. Humans are not water creatures, and it’s not likely that our babies really ought to be born underwater.


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