Archive for the ‘Medical problems’ category

Want to avoid celiac? Don’t delay wheat past six months

October 14, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Current recommendations suggest the introduction of complementary, solid foods between 4-6 months of life. Starting foods like grains, legumes, and probably eggs and cow’s milk later than six months seems to lead to an increased risk of food allergy.

And maybe other adverse reactions, too. Celiac disease isn’t an allergy—it’s an autoimmune disorder triggered in susceptible people by exposure to gluten, a protein found naturally in wheat, barley, and rye. It affects probably 1 in 100 people, and those people should not ever eat foods containing gluten. Norwegian researchers just published a study looking at when babies started eating wheat—and found that introduction earlier than 4 months, or later than  6 months, led to the highest later rates of celiac disease.

It’s a pretty nifty study, too. They followed a cohort of 107,000 babies, tracking their feeding habits and later diagnoses of celiac disease. The effect size wasn’t huge, but after controlling for other factors like mom’s celiac status, the risk of celiac for babies who first ate wheat after six months was increased by about 25%.

A surprising, second finding: babies nursed for longer than 12 months also seemed to have a modestly increased risk of celiac disease.

So: again, forget about all of that delayed solids business, once thought to help prevent allergy. Between 4-6 months of life, start adding solids to Junior’s diet—and it doesn’t just have to be traditional “baby food.” Anything puree-able is good. Little jars are fine for convenience, but the best way to get a good mix of food is to mash up whatever you’re eating.

Yum!

Top infection risks are all our fault

October 10, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Well, this isn’t good news.

The CDC has compiled an extensive report of the top US health risks from infections. Called “Threat Report 2013”, their evaluation shows that the three most worrisome risks have all been created by our own indiscriminant overuse of antibiotics. The biggest baddies:

Carbapenem-resistant Enterobacteriaceae – the carbenapenem antibiotics were first developed in the 1970s and grew into wide use in the late 1980s. They had been the biggest, baddest antibiotics, ever—capable of killing just about anything. Not any more. Many gram negative bacteria have become resistant to all carbenapenems, leaving essentially no other medications available for treatment. If you’ve got a carbenapenem-resistant bug, you are in very serious trouble. They cause pneumonias, other invasive infections, and death, especially in people in hospitals.

Clostridium difficile is a tiny bacteria that can live peacefully in your gut. But if the balance of C diff versus other bacteria is disturbed, C diff can grow out of control, releasing toxins and causing a life-threatening colitis that can be very difficult to treat (One potential treatment is a transplant of stool from a healthy volunteer through a tube down your nose. Quite the ick factor, but it can work.) Why does C diff get out of control? When antibiotics suppress other gut bacteria. And it may not take much—a simple, ordinary course of amoxicillin can cause fatal C diff colitis. It’s happening, and it’s happening more and more.

Drug-resistant Neisseria gonorrhoeae. Gonorrhea? Srsly? This was a bug that used to die quickly if it even smelled penicillin nearby. Not any more. Resistance is rapidly spreading worldwide, and antibiotics that were reliably effective a few years ago are now worthless. Untreated gonorrhea can lead to infertility, pelvic inflammatory disease, septic abortion, blindness, and other bad things you don’t even want to think about.

We used to think we had won: we found the drugs, the drugs killed the bugs, and we could relax. Not any more. The bugs have been around a long time, and they’re patient, and evolutionary pressure from antibiotics means that antibiotic-resistant strains push out the wimps. Can we keep making new drugs fast enough to kill the bugs as quickly as they learn to fight back? That’s a maybe.

A better plan is to do what we can to prevent bacteria from becoming resistant:

Preventing infections is always better than treating infections. Wash your hands, stay away from sick people, and get those vaccines you and your family need to stay healthy!

Avoid using any antibiotics unless they’re really necessary. Sinus infections? Bronchitis? Sore throat? Fever? Most of these are caused by a virus, not a bacteria. Ask the doctor: do I really need to take this antibiotic? For routine, non-emergency symptoms, avoid urgent cares and ERs—just about everyone leaves those places with an antibiotic prescription. Don’t go to the doctor at all for the symptoms of a minor cold, cough, or sore throat. If your own primary care doc is Dr. Quick-Draw McZithromax, change to someone else.

If you do need to take an antibiotic, make sure your doctor chooses the “narrow spectrum” ones—ones that are like a laser beam, killing only the bacteria you want to kill. You don’t need a shotgun or a nuclear weapon to kill an ordinary infection. Save those big guns for when they’re really needed.

Do not hoard antibiotics, and don’t take them on your own “just in case.” Complete every antibiotic prescription the way it was written. Never take someone else’s antibiotics, and don’t push doctors to prescribe them.

On a society level, we need to stop pumping antibiotics into healthy animals to increase farming yields. Of course, vets need to use antibiotics to treat sick animals—but in today’s agricultural world, almost all of the antibiotics used are “preventive” or “supplementary.” That’s ridiculous and needs to stop. Yes, the antibiotic resistant germs in animals make their way to humans. You think they care if they’re infecting a cow or your child?

Finally, doctors. We all know it’s quicker to just prescribe than explain; and we all know that Press Ganey satisfaction scores might just be better if we shut up and write the damn antibiotic prescription. Still. If we stick together and do the right thing, we might be able to change perceptions and get this barge moving in the right direction. We started this mess. We need to fix it.

Non-vaccinaters hurt their own kids. And yours.

October 7, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

It goes without saying that unvaccinated kids get more vaccine-preventable illnesses. For instance a 2010 study from Kaiser Permanente showed that children who hadn’t received pertussis vaccine were 23 times more likely than vaccinated children to get pertussis.

But there’s another consequence of not getting vaccines. It hurts your child, sure. But it also can hurt other people in your community.

Vaccines are not perfect. Not everyone who receives a vaccine gets 100% protection; and some people in a community are too young to be vaccinated, or have health conditions that prevent vaccination. Those that aren’t immune depend on what’s called “herd immunity” for protection. If just about everyone else is immune, then the diseases don’t circulate, and even those who are not immune are unlikely to come in contact with the disease.

This kind of protection—the herd effect—only works if just about everyone is immune. As soon as the herd fails to maintain a high percentage of immunity, more disease circulates, and more people get sick. Not only do those who chose not to vaccinate get vaccinated get sick, but also those who couldn’t get vaccinated, or those in whom the vaccine didn’t work.

This was just illustrated in a study reported this month in Pediatrics, looking at non-medical vaccine exemptions in California. Researchers looked at geographic areas where there were clusters to non-vaccinated families, and compared that to geographic areas with clusters of pertussis cases—and as expected, the two overlapped. If you live in an area with a higher proportion of non-vaccinated people, you’ve got a higher risk of picking up pertussis. This risk is increase even if you and your own family are vaccinated.

Though the vast majority of children nationwide receive their vaccines, a small number of vocal pro-disease, anti-vaccine propagandists has managed to scare many parents into becoming hesitant about vaccinations. And the diseases are coming back. Don’t fall for it. Protect your kids, protect yourself, protect your community. Get those vaccines, on time and on schedule.

Kids with nosebleeds

October 3, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Isaac asked, “What’s the best way to deal with a nosebleed? What if your child gets a lot of them?”

A single nosebleed, or even a few of them in a row, is rarely anything to worry about. Have your child sit up, maybe leaning forward a bit, and pinch the fleshy end of the nose shut. Be gentle—it doesn’t take a hard squeeze. Then resist the temptation to check too soon. Once you let go, if it’s still bleeding you have to hold it even longer the next time. So start with a 5-minute hold, and if that doesn’t work 10 minutes, and if even that doesn’t work, try 10 minutes again on your way to the ER to get the nose packed. You can also try putting some ice (or a bag of frozen peas) on the bridge of the nose to decrease blood flow.

You may have heard that people with nosebleeds ought to lie down, or lie back. That’s not a great idea. More blood will be swallowed that way, and blood in the stomach can cause vomiting.

Nosebleeds often happen in a little group, one after the other for a few days, until the clot gets strong. After one nosebleed, even a little bit of nose trauma, a rub or a blow, can lead to more bleeding for a few days.

Most nosebleeds are caused by picking (or, as we say, “digital trauma.”) So encourage Junior to keep his or her fingers out of there. Nosebleeds also happen when the lining of the nose is dry and cracked. In the winter, a humidifier or nasal saline gel can help keep the lining of the nose from drying out. Anyone with an irritated nose, say from second hand smoke or allergies, is going to rub their nose a lot, which can lead to nosebleeds, too. Oral allergy medications, like Zyrtec or Claritin, can help relieve the itchy feeling that accompanies allergies, so those might help prevent rubbing and nosebleeds, too. The prescription allergy medications that are sprayed up the nose might make nosebleeds better, but might actually make them worse by thinning the tissue inside the nose.

If nosebleeds are accompanied by signs of other bleeding, like gum bleeding or easy or unexplained bruising, your child needs to be evaluated for a bleeding disorder. Sometimes these run in families. Siblings might have easy bruising or heavy menstrual periods, or a family member might have had excessive bleeding after a tooth extraction. Any family history that suggests a bleeding disorder should be discussed with your child’s doctor.

If a bleeding disorder isn’t suspected, the next step for children with frequent nosebleeds is an evaluation by an ENT (ear, nose, and throat specialist.) Often, there’s an exposed blood vessel that can be chemically cauterized in an office procedure to prevent further re-bleeding.

Preventing cold sores in babies

September 26, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Eileen wrote in: “I’ve been cursed with cold sores since I was little, and I’m having yet another outbreak. However, I now have a baby to worry about, and I desperately want to avoid passing this on to my little girl. Do those over-the-counter cold sore remedies do anything? Would going to my doctor for a prescription help?”

Cold sores are those annoying sores near the mouth, most often right on the border of the lip and face. They’re caused by herpes simplex virus, and like other herpes family infections this virus becomes dormant in the body after the first infection. In some people, herpes simplex likes to pop back out every once in a while, causing recurrent sores. We don’t know why some people get frequent recurrences, while most other people never get any recurrences.

What we do know is that almost all of us, by the time we’re adults, are infected with the kind of herpes simplex that usually causes these oral sores. And many of us shed the virus intermittently—meaning we’re contagious and spreading the virus around—even when we don’t have any symptoms or sores at all. So it’s nearly impossible to avoid exposure to this virus.

Recurring outbreaks are somewhat less contagious than the first outbreak, at least in people with normal immune systems. Treatment options include topical medicines, either OTC or prescription—these are highly effective in making the sores look shiny, but pretty much ineffective at making them go away or making them less contagious. Oral anti-viral medicines (these are all prescriptions) can make the outbreak shorter and can decrease viral shedding and contagiousness, especially if they’re begun right at the start of the outbreak (or even better, before the sore even appears. Some people can tell they’re going to get a sore even before they can see it.) For people who have frequent outbreaks, taking anti-viral medications every single day can help suppress the next outbreak, too.

But again: people with herpes simplex can shed virus even when they have no symptoms or sores at all! So, again, it’s very difficult to prevent the spread of this virus.

If mom has had recurrent herpes simplex sores for years, her baby will probably be born with high concentrations of anti-herpes antibodies that will protect the baby from infection for the first six months of life. After that, those antibodies fade away, opening the window for infection. A worse scenario for baby is when mom has her first outbreak of herpes (oral herpes or genital herpes) right near the end of pregnancy—that means mom has no antibodies to share across the placenta with baby, and that baby can get a widespread, potentially catastrophic herpes infection during or right after birth.

For Eileen: especially as you get closer to your baby’s six month birthday, it would be a good idea for you to talk with your doctor about the pros and cons of an anti-viral medicine, either to take continuously or to take as a burst dose at the first sign of an outbreak. Most of these medicines are safe with nursing. There’s no guarantee that they’ll prevent transmission, but they may help delay or prevent your baby from picking up the virus.

Vitamin K can save your newborn’s brain. Get it.

September 23, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Some topics I enjoy writing about. Some give me no satisfaction whatsoever. Still: I never want to read about another baby going through a completely avoidable catastrophe again. So pay attention, especially those of you about to have a baby, or those of you who might someday have a baby, or those of you who ever talk to couples who are having a baby. Just all of you, pay attention here.

Hemorrhagic disease of the newborn is a real thing. Newborns aren’t born with good stores of Vitamin K, so they can’t make their own clotting factors well. Sometimes—rarely, but it does happen—they develop spontaneous bleeding. It might be from their umbilical cord, or in their gut, or in their brain. If the bleeding isn’t treated quickly, the baby will bleed to death or suffer brain damage.

Hemorrhagic disease of the newborn, you say? You’ve never heard of that? You’ve never heard of it because it’s rare to begin with, about .24-1.7 cases per 1000 live births, and because there is a nearly 100% effective way to prevent it. The AAP has recommended that all babies receive vitamin K shortly after birth since 1961, and multiple studies have confirmed that this is completely safe and just about 100% effective in preventing hemorrhagic disease.

There is no other way to prevent hemorrhagic disease of the newborn. It doesn’t matter how much vitamin K mom has—it doesn’t cross the placenta. It doesn’t matter whether baby nurses—vitamin K is not present in human milk. Commercial formulas do contain vitamin K, but not enough to “fill up the tank” when babies are born.

The best, most effective, and safest way to give vitamin K to a newborn is by injection. Though oral vitamin K is used in some countries, oral vitamin K fails to prevent all hemorrhagic disease, leading to about 1.2-1.8 cases per 100,000 births, versus zero cases after injected vitamin K.

There are no known side effects of vitamin K. There are no downsides to any baby getting this injection, which prevents death and brain damage.

Still, some parents choose to NOT allow their babies to get this injection. Their worry is based on completely unfounded internet hoopla, but that’s the way it is. Random internet stupidity trumps science, pediatricians, and the recommendations of public health agencies worldwide. Apparently it’s becoming trendy to skip the vitamin K injection.

The internet, as usual, exaggerates the freaky and uncomfirmable stories, and fails to tell the boring stories about the millions of babies who do great after receiving good routine care. Parents are tricked into worrying about the wrong things. Instead of protecting their babies, they place them in harms way. That’s a tragedy we all need to fight.

Shifting science: The New urinary tract infection guidelines

September 9, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Marie wanted to know about urinary tract infections (UTIs) in children. Are they associated with kidney damage? What kind of workup and treatment are now recommended?

This is one of those examples of how changes in our understanding lead to big changes in the way medicine is practiced. It’s part of the power of science—it self-corrects, and through the testing of hypotheses we improve our knowledge of health and medicine. On the other hand, it’s a good example also of how science can frustrate parents and patients. We used to do things one way, then we figured out that the way we were doing it was wrong. Sorry about that. Science lurches on!

In the old days, especially after a 1999 AAP practice parameter, an extensive workup was recommended after even the first UTI in children. The thinking was that at least some UTIs are associated with problems in the urinary tract that could predispose to more UTIs, and even permanent kidney damage that could require dialysis or transplantation. Bad news! The main “predisposing factor” we looked for was vesicoureteral reflux (VUR) which is when urine pushes backwards up the ureters to the kidneys. That “back pressure” was thought to cause kidney scarring.

So, for a decade or so, babies and young children after UTIs underwent kidney ultrasounds and a “VCUG” study involving catheterizing the bladder. Many were diagnosed with VUR and kept on prolonged courses of antibiotics. Some with more serious VUR underwent surgical procedures. Meanwhile, several groups collected data about how these children were doing.

Over the years after that 1999 parameter, several studies showed that the guidance was, well, misguided. Mild-to-moderate VUR usually got better on its own, without causing kidney problems; more-severe VUR could be identified on an ultrasound alone; and prolonged antibiotics didn’t actually prevent infections.

So in 2011 the AAP came out with a new set of guidelines. Gone are the VCUG after the first UTI, and out went the routine use of prophylactic antibiotics. Not everyone agrees with the new guidelines (just like not everyone agreed with the 1999 guidelines), but from what I’ve seen, fewer and fewer pediatricians are ordering those tests.

What certainly hasn’t changed is the need to correctly identify and treat children with UTIs. We do need to look for these infections, especially in young girls with unexplained fevers (or uncircumcised boys less than 6-12 months of age.) When they’re found, they need to be correctly evaluated with a urine specimen and treated with antibiotics; and current thinking suggests that a kidney/bladder ultrasound be done to look for anatomic issues (the ultrasound is painless and doesn’t involve any ionizing radiation, so I have no problem with doing those.)

Science isn’t just a collection of facts or a body of knowledge—it’s a method of figuring things out, and confirming what we suspect. By its nature, science will have false leads and misdirected paths. But in the long run it’s the best way we know of to figure out hw bodies work and how to improve and maintain health. That we blew it on the UTI thing isn’t an indictment of the method, but an illustration of its strength. Give it time, and we’ll make progress. Science*!

* Looks like they pulled the official video of the Thomas Dolby song from Youtube. A tragedy.


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