Archive for the ‘Medical problems’ category

Bed sharing increases SIDS risk

June 3, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

The evidence has become quite clear: bed-sharing, or co-sleeping, increases the risk of Sudden Infant Death Syndrome (SIDS).

The latest study to reinforce the risk of bed sharing comes out of the UK (with contributions from New Zealand and Germany). Published in the British Medical Journal in May, 2013, Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies combined data from five separate case-control studies on SIDS, creating a data set of 1472 SIDS cases to compare with 4679 healthy babies—the largest data series on SIDS that has ever been collected. The authors were able to separate out the effects of bed sharing along with other SIDS risk and protective factors to determine the risks of SIDS for families who only bed-shared, versus those who combined bed sharing with breastfeeding, smoking, and alcohol use. Other factors like the baby’s age, birth weight, and sleep position were also included. Their results are statistically strong, and show large big effect sizes.

Infants who share a bed with their parents during the first 3 months of life increase their risk of SIDS by five times—even if parents don’t smoke, don’t use alcohol, and exclusively breastfeed. In other words, breastfeeding and other positive SIDS risk factors avoidance does not erase the increased risk of SIDS associated with bed sharing.

In the combined data, 22.2% of babies who died of SIDS versus 9.6% of controls shared beds with their parents. The risk was especially high when other risk factors were present: bed sharing among infants whose parents smoked led to a 65-fold increase in SIDS; if parents consumed alcohol, the risk increased 90-fold. The risk of SIDS was “inestimably large” for bed-sharing if the mother used illegal drugs. But, again, even if none of these other risks were present, there was still a very large increase in SIDS rates. Bed sharing, even among breast-fed babies with no other risk factors, increased the risk of SIDS by a 5-fold compared to babies who slept on their own surface in their parents’ room or in their own rooms.

The AmericanAcademy of Pediatrics has recommended against bed sharing since their 2011 recommendations for the safest sleep environment for babies. Their guidelines are comprehensive and well-referenced, including many specific recommendations:

  • Babies should be put down to sleep on their backs. (That doesn’t mean they must be kept on their backs. Once they can roll, let them roll. Do not use devices that force your baby to stay in one position. Baby sleep positioners kill.)
  • Infants should sleep in a crib or bassinet—on a firm flat surface that’s safety-approved for infant sleeping. Car seats and other devices that hold baby in a sitting or semi-sitting position are not for routine sleep. (Which means that Fisher-Price’s Rock –n- Play Sleeper is specifically contraindicated for sleeping.)
  • Room sharing without bed sharing is recommended.
  • Avoid pillows, quilts, comforters, sheepskins, and other soft surfaces under the infant or in their sleep environment.
  • Avoiding smoking, alcohol, and illicit drug use during and after pregnancy.
  • Breastfeed.
  • Consider offering a pacifier at sleep times.
  • Avoid overheating.
  • Immunize infants according to the established recommendations of the AAP and CDC (that is, don’t use one of the made-up schedules that have no scientific backing.)

Bed sharing is a choice that many families make. Some parents enjoy the closeness of baby, and feel more secure; some nursing moms feel that it makes nursing easier. But parents who choose to bed-share should have honest, well-researched information on both risks and benefits. Bed sharing, even with no other risk factors, dramatically increases the risk that your baby will die of SIDS.

Will cry-it-out hurt your baby?

May 16, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jess, like many parents, has been hearing conflicting information about what crying can do to your baby. She wrote: “So, my husband and I accidentally let our kiddo (5.5 months) cry it out. So of course, I’m spending all sorts of time on Google finding out that I’ve caused long-term damage to my son and he’ll be more likely to get ADHD and be dumber now that I’ve let him cry. I know the studies on cortisol show that some longer-term stress may be evident (at least for a few days), but are there any other real, scientific studies that show long-term damage due to cry it out? I’m pretty sure the other studies cited in the article above are irrelevant to this–am I right? I know you’ve written about cry it out before, but with all the hype, can you clarify?”

A friend of mine is working on a project called “Guilt Free Childbirth”, meant to dispel the guilt and hand-wringing that so many families seem to experience during and after childbirth. What if I need a c-section? What if I can’t do it “naturally”? What if I can’t “bond” instantly with my baby?

This cry-it-out worry—I think I could make an entirely new blog, “Guilt Free Parenting,” just to try to dispel this nonsense. Parents are so saturated with messages telling you that everything—I mean everything—we do is wrong, it’s a wonder we don’t all just curl up in a ball in the closet sucking our thumbs.

Wait, thumbsucking. That’s bad, too.

Anyway: the sky isn’t falling. We are not raising warped, worthless, sick, incompetent kids. There are always things parents could do better (including me!), but that doesn’t mean that if we don’t do everything “right”, our kids will suffer.

Back to cry-it-out: babies don’t always learn to sleep straight through the night on their own, and there are several competing “methods” to help nudge them towards independence. Some parents are very eager to help train, others take a more “easy-going” approach. How you tackle this depends on how parents feel about the importance of a good night’s sleep, and also on the temperament of the baby. I am not going to declare that any one method is perfect for everyone.

But if sleeping through the night is a priority, I have offered up one simple solution that works well for many families. Yes, there is crying. No, I don’t think there is any good evidence that shows any lasting ill effects from letting your baby cry some. There are certainly lots of web sites, pro and con, and lots of people with strong opinions—sometimes they’ll even comment in ALL CAPS for emphasis. But you are not damaging your child by letting tears fall without instant intervention.

Babies have been crying for many, many years. It is how they get our attention. If crying were so damaging, well, I don’t think any of us would have survived.

Jess included an example of reporting that stressed the damage done by cry-it-out sleep training, a list of 10 reasons it’s bad for babies. Most of the reasons were undocumented opinions from the author, who has clearly made up her mind on this issue. The references that were included are rife with methodologic issues—especially retrospective bias (of course parents with children who are thought of as problematic are going to report more sleep issues, in retrospect, when asked), or skim though the complex issue of cause-and-effect. That is, did the excessive crying cause the later problems, or are children who are temperamentally difficult more likely to resist sleep and more likely to later experience emotional problems? One thing may not cause the other, even if they are correlated.

Studies of levels of the cortisol rely on that hormone as a biomarker of stress, and cortisol does indeed increase with stress in humans and other animals. But is that bad? Didn’t human babies always have stress in their lives? Some studies point out that cortisol can change the way brains develop, or can perhaps contribute to the pruning of interconnections between neurons- but that is a normal process that occurs in the development of the human brain. Interfering with this process by avoiding undue “stress” may actually be harmful in the long run.

Or maybe not. I am not saying that babies need to cry to be healthy. Certainly I spent a lot of time holding and reassuring my babies (and even babies in my practice!) But these studies that some claim show cry-it-out = bad for babies, it’s a stretch. And it is not something that parents ought to be worrying about.

Though there aren’t a lot of great, long-term, clinical studies of the consequences of these different sleep approaches, one published last year was reassuring—a method that allowed more crying didn’t lead to scary consequences later.

Also: there are consequences to poor sleep, both for babies and for parents. Underslept babies are fussy and unhappy. Underslept parents are irritable and miserable, and may be more likely to get in car accidents, get divorced, or smack their child. It’s not unreasonable for parents to want to take an active role in pushing towards a good night’s sleep.

A great website with far more detail and insight into baby sleep issues is at www.troublesometots.com—including a detailed guide to one common-sense way to help babies learn to sleep better. Yes, there may be some crying. It’s OK.

What is and isn’t hypoglycemia in children

May 13, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

There’s a common “health entity” thing, often called “hypoglycemia.” Funny thing about that—children who have it are not hypoglycemic. But it is a real thing nonetheless, and there are steps parents can take to help deal with it.

Confused?

First: hypoglycemia means low blood sugar, and it can occur. In pediatrics we see it in tiny newborns and very sick children, or in little toddlers sometimes; it’s also seen in children with diabetes who get too much insulin. The main symptoms of hypoglycemia, real hypoglycemia, with real low blood sugars, are sweatiness, disorientation, unconsciousness, coma, and seizures. Real hypoglycemia is a big deal. Let’s call it HYPOGLYCEMIA, in all caps.

But what’s commonly called hypoglycemia in other situations isn’t really hypoglycemia. Here we mean a child (or adult) who gets cranky or headachy or irritable or just doesn’t feel right, especially several hours after a meal. If you check their blood sugars during an episode, it is normal. Their sugars are not low. Nonetheless, they feel better after a snack, especially a carb-snack with a jolt of tasty sugar. So they seem to be suffering from symptoms of hypoglycemia, even though they don’t have HYPOGLYCEMIA.

What’s going on here?

The symptoms of the lower-case hypoglycemia are real. They may not be caused by actual low blood sugar, but perhaps by a fall in the relative level of sugar from normal to lower-normal. Alternatively, it may be that other fuel sources in the blood (maybe an amino acid named alanine) have falled, though we don’t usually test for that.

So what should doctors and parents do when they have a child with the symptoms of HYPOGLYCEMIA—seizures and coma? Test sugar, and test everything else!

For the symptoms of hypoglycemia, no testing is needed. It’s going to be normal. Instead, families can learn to manage this problem on their own. The main therapy is to prevent these episodes of symptoms by providing frequent, healthy snacks—especially snacks that combine carbohydrate with fat or protein.

A quick biochemistry lesson: all carbs (including simple sugars and starches) provide a quick jolt of sugar, rapidly providing metabolic energy. But it may not be sustained—sugars are metabolized quickly. To provide sustained elevations in metabolic fuel, carb-rich snacks should be combined with foods rich in fat or protein, which are broken down slower.

A can of Coke, alone—that’s a terrible snack. As would be a glass of orange juice, or an apple. All of these are 100% carb. But smear that apple with peanut butter, or dunk carrot sticks in ranch dressing—those are snacks that will provide lasting food energy.

This kind of hypoglycemia (lower case) is sometimes referred to as “reactive hypoglycemia”, a term that’s just as misleading and even more abstruse. It tends to run in families, and in my experience affects skinny, active kids. If that sounds like your child, you don’t need a bunch of tests. You just need healthier snacking habits. Easy as pie… a la mode!

Kids are safer driving with Grandma

May 6, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD
Parents may be surprised to learn that their children may be safer riding in grandma’s car than their own.

A July, 2011 study published in Pediatrics looked at insurance claims data from crashes that occurred with a child in the car. About 12,000 accidents from 2003-2007 were reviewed. Based on telephone follow-up calls, a child was injured in 1% of the crashes. The surprising result: children were about 50% less likely to be injured in an accident if a grandparent were driving rather than a parent. This dramatic reduction in risk occurred despite the fact that grandparents were actually less likely to have been using child restraint seats correctly.

Does this really mean that grandparents are safer drivers?

Maybe. The study shows that if an accident occurred, a child was less likely to be injured with a grandparent driver. That doesn’t actually mean that grandparents get in fewer accidents– it just means that their accidents are less likely to be serious. Also, the average age of grandparents in the study was 58 (versus 36 for parents.) I’m not so sure that these results would be the same if researchers only looked at elderly grandparents.

Still, a fifty percent reduction in injury risk is a big difference. There may be lessons that parents can learn from grandparents about improving safety behind the wheel.

Though recent guidelines have stressed proper car seat use, the most important safety equipment in the car is the driver. Driving carefully, obeying traffic laws, and paying attention are crucial ways to avoid a crash, or at least make it less likely for a crash to result in an injury. Younger drivers are probably more likely to be distracted by mobile phones, text messages, and fiddling with the radio. If your eyes and your mind aren’t on the road, you’re asking for trouble.

In the developed world, motor vehicle accidents are among the most common cause of serious injury and death in children. If you want to keep your kids safe, take a lesson from grandma. Drive carefully.

Adapted from a blog post I wrote for WebMD in 2011. Yes, I’m reusing “classic material.” And by classic, I mean old.

Kids really do get migraine headaches

April 15, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

“My wife gets migraines—really bad ones—and now my daughter seems to be getting them too. She’s only 7! Is she just copying what her mom does? Can a child really start getting migraines?”

Oh, yes they can. Migraine is very much a childhood disorder. About 5% of adults have migraines, and half of them started having their migraines as kids.

As in adults, migraines in children can be severe and debilitating. However, there are some differences. Fewer children than adults report auras—those strange visual or other neurologic manifestations that often precede and accompany migraines. Also, children are more likely to have headaches that feel like they’re all over their head, or on both sides. Children may not report the “throbbing” nature as adults do, and their migraines may be quite a bit shorter.

The most characteristic features of migraines are the same in adults and children. Migraines will almost always be followed by deep sleep (which usually ends the headache). And in between migraines, there are no symptoms at all.

There are a couple of odd associations with pediatric migraine. Kids with migraines often have a history of getting carsick, and sometimes have a history of sleepwalking. Sometimes, when migraines start in early childhood, the attacks are not mainly headaches, but other sorts of symptoms like vomiting or abdominal pain or hallucinations or trouble with balance and walking. Later, many of these children will start to have more-ordinary, adult-like migraine headaches.

In most cases, migraine is diagnosed clinically, based on the history and a careful physical exam. No imaging by CT nor MRI is needed unless there are “red flags” that indicate a different diagnosis is likely.

Which children need to have advanced imaging? The most important clue is how the headaches are progressing. Headaches that are getting worse and worse indicate a need for rapid imaging, as opposed to headaches that have been episodic and have been going on for several months. Also, a sudden single very severe headache, sometimes called “The Worst Headache of My Life”, should prompt consideration of a brain scan (however, recurrent “Worst Headaches” that go away and come back later are not of as much concern—those are very likely migraines.) Other “red flags” that increase the need for imaging in a child include any persistent abnormalities on the neurologic exam, or headaches beginning in a child who for other health reasons is at risk for serious intracranial problems (like a child who has had brain surgery or has cancer.)

The most important part of treating childhood migraine is prevention. Many, but not all, kids with migraine will have identifiable triggers that can be avoided. These might include disrupted sleep or hunger, or bright light, or stress. Regular healthy lifestyle habits including good eating, sleep, exercise, and stress-reducing hobbies can go a long way towards preventing many migraines.

After prevention strategies, all migraine sufferers need an action plan: what to do when a migraine begins. Whatever treatment is chosen, it will work best if started soon, as soon as possible after a migraine begins, before the headache becomes severe. Some over-the-counter medicines work well, like ibuprofen. There are also prescription migraine-stoppers, some of which are FDA approved in children. Migraine treatment, after medicine, should also include encouraging the child to rest in a quiet, dark place.

It’s important that migraine-stopping medicines not be overused. Frequent use of any of these, including OTC products like ibuprofen or acetaminophen, will lead to rebound headaches that can get very bad, and can become a daily problem. Migraine stopping medicine shouldn’t be used more than two or three times a week.

There are also medical strategies to prevent migraines, including prescriptions that can be taken every single day. Some vitamins (like riboflavin) or herbs (butterburr), have been studied in adults and can be effective migraine preventers—but their use in children hasn’t been studied, and since these products are poorly regulated there are important questions about purity and dosing. Still, I often prescribe these alternatives. They may be worth trying prior to prescription medications.

It’s also important to be realistic when dealing with children who are having migraines. It may not be possible to prevent all of them, and treatment once a migraine begins may only be partially effective. Still, we can usually help children with migraine headaches feel better most of the time.

Can’t feel his poops

April 11, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Kathy wrote in about her son: “What can cause a nine year old boy to poop in his pants occasionally and not feel it? He was completely potty trained at age three. I have found dirty underwear, poop on the bathroom floor–and it just concerns me that he is unaware of it. It has been suggested at check ups that he may be constipated. My mother suggests he may simply not be paying attention until it’s too late and also if his bowel movements are soft (and they are) this might be part of the problem. I worry that there might be a congenital defect or the like and don’t want to overthink it, but also don’t want to ‘poo poo’ it.”

This is one of those problems that’s very, very common—as a pediatrician, I hear about this all the time—but parents don’t talk about it much among themselves. Parents sometimes think that their child is the only one who’s doing this. Believe me, he isn’t.

The name for what’s going in is encopresis, or fecal soiling. Kids with this leak soft stool, usually without noticing it at all. Very rarely, encopresis can be associated with an anatomic problem, like a serious anal malformation or spinal cord defect. But if your son is walking around and seems fine, and his pediatrician has looked at his spine and reflexes, there is no underlying anatomic or medical condition.

Encopresis is a complication of longstanding constipation. Kids hold their stool—often because it’s become hard and uncomfortable, or sometimes because they’re too busy to stop what they’re doing to have a good BM. Held-in stools become bigger and harder, and that reinforces the stool holding. Kids do not want to pass a painful stool! In time, they get so used to holding that they don’t even realize that they’re doing it. The distal colon becomes big and distended, and can hold an impressive amount of stool.

The poop, though, has to go somewhere. Eventually it will leak around the stool mass in the colon, and that’s when soiling occurs. The leaked stool is often soft—so parents may not believe us when we tell them there is constipation. Sometimes I’ll do a quick, one-view x-ray of the abdomen that shows the huge amount of stool that’s backed up.

Encopresis symptoms sometimes come and go. Some kids will eventually pass their huge backed up stool (often clogging the toilet), and then won’t leak for a few weeks. But the habits are still there, and they’ll usually get backed up again.

Treatment of encopresis begins with explaining to the parents what’s going on. Often there are some misconceptions and sometimes even some anger that that child is doing this willfully, or just doesn’t want to stop. Negative feelings and punishments never help kids with fecal soiling. If there is a lot of finger pointing, a referral to family therapy may be needed before much progress can occur to fix the encopresis.

Getting stool habits back to normal requires a comprehensive plan that everyone in the family must follow. There is no quick fix, and the longer the problem has been going on the longer it’s going to take to repair. Believe me, it is much better to face this head-on and fix it than to take halfhearted efforts that help for a little while, then back off and let the problem resurface again. The main components of therapy, in addition to family understanding, are:

  • A big clean out. Therapy will almost always start with relatively high dose stool softeners to get the old mass of stool out and let the colon return to a normal size. This is best done on the weekend!
  • Maintenance, ongoing, long term stool softeners. This is essential. Parents must keep their child’s stool soft and painless for many months or sometimes years to create a new habit. Backing off the stool softeners too early will inevitably lead to relapse and a more-difficult situation.
  • Reinforcing good stool habits. That means relaxed time on the pot, every day. Usually staying on the toilet for a set amount of time after a big meal is better than letting them go “until they’re done,” because at least at first these kids do not know when they’re done. Keep ‘em on the pot with a Game Boy or a new iPhone app. Those things are waterproof, right?

Dietary changes can also help, including more fluids and fiber. But changing diet alone will not fix the problem, and I don’t overly stress diet issues. Practically speaking, fighting with your child about bran rarely helps solve anything.

There are many good stool softeners out there that are not habit forming and can be safely taken long term. I try to stay away from enemas and suppositories unless they’re absolutely necessary. That’s a good rule of life: stay away from your child’s anus.

Encopresis can be fixed, but it takes time and consistency. Sometimes a referral to a pediatric gastroenterologist can help reinforce these instructions and help reassure parents. The most important thing: stick to the plan.

Who should change their toothbrush after an infection?

April 8, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Wendy wrote in, “My doctor has told me to change the toothbrush after a child has strep. Will it help after other infections, too?”

It may help the fine folks at Proctor and Gamble (makers of the Oral B line o’ tooth cleaning products) but it probably won’t help anyone in your family.

This business about changing toothbrushes after strep: I know it’s common wisdom, but I can’t find any support for it—no one officially recommends it, even the CDC. Their own “Use and Handling of Toothbrushes” page—yes, they have one—says “…no published research data documents that brushing with a contaminated toothbrush has led to re-contamination of a user’s mouth, oral infections, or other adverse health effects.” The American Dental Association says that tooth brush changing may be a good idea for those with immune-compromising conditions, or for patients or family members with a serious transmissible disease. (Family member? Look, if you’re sharing toothbrushes, ew. Of course change them. Or, better yet, get a different one for each family member. They even come in different colors now to help keep track.)

I did find one study that actually looked at this strep business, done in Sweden in 1998. They found 114 cases of strep, and randomized these families to get either hygiene education or, I think, a free couch from Ikea. The hygiene families were told to toss their toothbrushes, clean their linens, wash their toys, and go buy their own Dang couches*. At followup, 35% of the families had at least one recurrence of strep, but the rate was the same in the two groups. New toothbrushes (and new couches) made no difference.

There’s no studies, anywhere, about changing toothbrushes after common infections. But it doesn’t make a whole lot of sense to change the toothbrush. What you’re trying to prevent is the next cold, with the next new virus—reducing exposures to a virus that’s already made your child sick is like buying a new couch after the relatives have already gone home.

I know, enough with the couch jokes. Sorry.

Anyway: change your kids toothbrush when the bristles worn, or when they’re otherwise looking grody. If it makes you feel better to change them after strep, be my guest. But it’s not doing your family any good to buy a new one every time someone’s sick.

*-Dang is the name of an Ikea couch. I think they have others named Frood and Smoot-Hawley.


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