Archive for the ‘Medical problems’ category

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.

Headaches every single day

August 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jenny wrote in about her son, who has a lot of headaches: “My 12 year old son gets them pretty much every day, and this has been going on for six months. He missed a lot of school, and now is starting to get them again in the summer. The doctor ordered a CT scan which didn’t show anything. What can this be? Could it be sinuses?”

Headaches are common in children. They’re usually “primary” headaches—meaning they’re not caused by anything specific, and they’re not associated with any specific medical condition. They’re just headaches.

Kinds of “primary” headaches in children include:

Migraine – maybe the most common of the more-severe headaches. In children they’re often bilateral and fairly brief. Sometimes they’re accompanied by vomiting, or are worsened by lights or sound; often the best “cure” is to go to sleep. Migraines often run in families.

Tension – These create a band-like, or squeezy feeling in the head, and aren’t usually severe. Yes, kids of all ages get tense.

Chronic daily headache – This sounds like Jenny’s son. They often occur on top of occasional more-severe headaches, like migraines.

The general principles of chronic daily headache:

  • AVOID daily Advil or Tylenol– if you use those more than 3 days a week, you will perpetuate the headaches. I know this sounds odd, but I promise it is true.
  • Try to maximize healthy lifestyle things: good regular sleep, diet, avoiding a lot of preservatives and chemicals, getting regular exercise. Again, I know this sounds odd, but it does help.
  • Try NOT to missschool– that inevitably makes headaches worse.
  • Consider massage/yoga/relaxation therapy.
  • If there is an overlay of depression/anxiety/mood issues, deal with that. There is often a psychological component, either contributing to the headaches, or being caused by the headaches and missing school and activities.
  • Consider a daily medicine to control the headaches– not painkillers, but other kinds of medicines that prevent headaches. You will need a physician’s guidance if daily medication is needed.

About CT scans and headaches: they’re almost never necessary for chronic, ongoing, stable headaches (or headaches that come and go in a stable pattern.) Imaging is really only useful for acute, worse-in-a-lifetime headaches, headaches associated with other symptoms (like seizures or neurologic problems), or progressive headaches that are getting worse and worse. CTs (or MRIs) are completely unnecessary in the workup of most children with headaches, and will sometimes give misleading results that lead to wild goose chases and misery.

Another headache myth: Most people out there who think they’ve got sinus headaches have been misdiagnosed.  Recurrent “sinus” headaches are genuinely uncommon. When they do occur, they’re associated with persistent nasal congestion and cough that precede the headache. Migraines themselves, which are far more common than recurrent headaches from sinusitis, can cause nasal or sinus symptoms that begin about the same time as the headache. It’s unlikely that Jenny’s son has headaches from sinus disease without other obvious persistent sinus symptoms, especially with a normal CT scan.

Yet another headache myth to dispel: vision problems rarely cause recurrent headaches in kids. Some people who are nearsighted will squint, and by the end of the day will develop tension-like pain from tightening up the muscles of their face and scalp, but that really is uncommon.

Headaches in children are common, and most commonly are caused by a minor infection, dehydration, hunger, or stress. If they’re recurrent, they’re likely to be one of the common primary headaches, like tension headaches or migraine or chronic daily headache. Headaches that are progressive (worsening), or associated with other prominent or worsening symptoms, need an urgent medical evaluation, but those are fortunately rare. More typically, headaches just need to be treated like, well, headaches. Don’t forget the simple stuff: rest, a kiss on the forehead, a cool compress, something to help relax. In the long run, those are probably better headache remedy for children than any medication.

New guidelines provide all you ever wanted to know about ear tubes. And more!

July 22, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

The AmericanAcademy Otolaryngology – Head and Neck Surgery (AAO-HNS, often abbreviated “ENTs”) has come out with their official, evidence-based guide to one of the most common medical procedures in children: tympanostomy tubes, or “ear tubes”. It’s long, it’s detailed, and it’s well-referenced, and it ought to help guide ENTs, family docs, and pediatricians to help families make good decisions about who needs tubes, when they ought to be done, and how to take care of them.

The document includes solid background info on the health care burden of ear infections, and the risks and benefits of tubes. What I’m going to concentrate on here is the twelve “action” statements that they’ve come up with to guide health care decisions. All of these I’m paraphrasing from the statement—take a look there for references supporting these statements.

The first five statements are about children with what’s called “OME”, for “otitis media with effusion.” This is when there’s clear, uninfected fluid behind the eardrum. OME does not cause pain or fever or really other symptoms, though may be associated with some hearing loss. OME should not be treated with antibiotics—it is not an infection, and antibiotics will not help. It’s typically called “fluid in the ear” or “fluid behind the eardrum.”

1. Do not place tubes for uninfected fluid behind the eardrums (OME) of less than three months duration. Uninfected fluid just sits there and causes minimal symptoms (perhaps some blunted hearing), and it can be safely observed for at least 3 or more months before surgical intervention is even considered.

2. If fluid (OME) persists > 3 months, do a hearing test prior to surgery, or when surgery is considered. The reason to “fix” OME is to correct a possible hearing deficit; if there is no deficit, tubes are not generally needed. You have to check, first.

3. If there is fluid (OME) > 3 months plus hearing loss, consider placing tubes.

4. If there is fluid (OME) > 3 months plus other symptoms like school issues, balance problems, ear discomfort, or “reduced quality of life”, tubes can be considered as an option. This is not a recommendation—just an “option”, because there is very little evidence that tubes will fix these problems.

5. If fluid (OME) lasts > 3 months, it ought to be monitored at regular intervals to make sure hearing remains normal and that there are no other medical problems being caused by the fluid.


The next three statements are about “AOM”, or acute otitis media, defined by infected fluid behind the eardrum. It’s red, it’s bulging and distorted, and it causes ear pain and other symptoms. This is what’s commonly called an “ear infection”.

The statement defines “recurrent AOM” as 3 or more proven ear infections in the last 6 months, or 4 in the last 12 months (including at least 1 in the last 6 months.)

6. Clinicians should not place tubes for recurrent AOM if there is not fluid behind the ear at the time of the assessment. This is a little bit of a slap at pediatricians and the rest of us who diagnose ear infections—basically, it says that the ear specialist has to see for themselves that there is at least one infection before doing surgery. I agree with this. Ear infections can be tricky to see and are frequently over-diagnosed. If Junior isn’t really having ear infections, surgery is not going to help.

7. Ear tubes (in both ears) should be offered for recurrent AOM who have middle ear disease at the time of the evaluation. Note that “offer” is not a very strong recommendation—there is limited evidence that tubes help prevent AOM, and what evidence there is shows only a modest effect.

The next two statements refer to children who have special medical needs:

8. Clinicians ought to consider the big picture—including what children are at risk for further ear infections or developmental challenges related to hearing loss. Children with anatomic issues (eg, cleft lip), or baseline cognitive, developmental, or behavioral issues are at higher risk for complications from AOM, so may benefit from more-aggressive therapy.

9. In children “at risk” per statement 8, consider tubes when fluid lasts for three months or longer.

And, last, there are three miscellaneous statements:

10. Clinicians should teach families about tubes, especially about the expected duration of function, after-care, and potential for complications.

11. If there is drainage from tubes, it ought to be initially treated with eardrops instead of oral antibiotics.

12. Children with tubes should not be routinely discouraged from water sports, and need no routine ways to prevent water from getting into their ears. That means no earplugs, no headbands—just go swim and enjoy yourself.

So: a lot of information. The most important points are about fluid behind the eardrum. If it is uninfected, it can safely be monitored for at least three months before even considering tubes; even then, tubes really only should be pursued if there is hearing loss or a high probability of complications. If there is infected fluid behind the eardrums, tubes should only be considered if there are documented recurrent episodes, at least three in the last six months. And: ENTs and pediatricians ought to stop encouraging earplugs and water restrictions, because those measures do not help.

For those of you interested in the details, the full report is quite detailed and referenced—and can probably teach most physicians quite a bit about the best way to manage common ear problems. Tubes can help, sometimes, but they’re not always needed, and ought to be used only when they’re likely to help.

More about ears and infections:

The Earwax Manifesto

How many ear infections are too many?

How to prevent ear infections

The weekend ear pain action plan – what to do when your child’s ear hurts

Should we check blood pressures routinely in children?

July 15, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

National guidelines suggest that we check blood pressure at every well check starting at age three. But a recent study calls that wisdom into question. Do we really need to measure blood pressures routinely in children?

In a study published this month, researchers looked at records of over 72,000 children from age 3 through 17. About 8% (6108 children) had an elevated blood pressure during the study—and all of these, as a routine, were told to come in for a repeat measurement within a few weeks. Only 20% returned for a recheck—and of those, only 84 (1.4% of those with an elevated initial BP) actually had a persistently elevated blood pressure.

So: a great majority of elevated blood pressures weren’t even rechecked; and among those that were rechecked, very few remained elevated.  So what’s the point of all of the checking in the first place?

Children often have a mildly elevated BP at the doctor’s office—either from anxiety, or from the cuff size being wrong, or from the fact that kids get kind of worked up sometimes. But if we measure BPs, we really ought to make sure to follow-up on the “abnormal” ones. If we can’t make sure that there’s follow up, or if followup isn’t even necessary, then we shouldn’t be measuring the BP.

The problem as I see it is that the blood pressure tables are set too low in pediatrics. They’re designed, I guess, after the adult blood pressure tables—where a mildly increased blood pressure, over a lifetime, increases long-term disease risk. In pediatrics, we’re looking for a different entity: markedly increased blood pressures that indicate there’s heart or (more likely) kidney disease, right now.

Blood pressures a tad high can probably be ignored—unless there are other indications of long-term cardiovascular risk, like obesity or diabetes. It’s the blood pressures that are really high that really need follow-up. Most pediatricians probably know that, and are hopefully doing that already. But let’s not miss those very few genuinely elevated BPs in the forest of children just a few points high.

Acne: What really works

July 1, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Mark wrote in about acne: “What products are proven to work? And is it wise to start slathering on the benzoyl peroxide at the first sign of acne in order to *prevent* it from getting worse, or should you just wait until it gets bad before doing anything?”

There are plenty of products that work. The trick often isn’t in choosing which acne treatment—it’s in using whatever’s chosen correctly. We’ll get to that later. But first, the Insider Acne Treatment Roundup:

Topical Benzoyl Peroxide: The grand old man of acne therapy, benzoyl has been around a while, and it’s really the foundation of almost any acne plan. The OTC versions are as good as the prescriptions. For mild acne, Benzoyl works fine alone; for more severe acne, benzoyl is added to other things. Watch out, I’ll bleach your sheets.

Topical antibiotics: These work well for mild-to-moderate acne, and topicals are unlikely to lead to much resistance. Older versions are inexpensive. There seem to always be a few new ones out there, in crazy sorts of variations or vehicles (foam!) that supposedly justify brand-name prices. Don’t fall for that.

Topical retinoids: These are the first-line therapy recommended by dermatologists for all but the most mild acne. They do work, but they can take weeks or longer to make much difference. And many are irritating and drying. There are basically three retinoids out there: adapelene (Differin or generic)—the mildest and least effective; tretinoid (Retin-A and many generics); and tazarotene (Tazorac), the harshest and most effective.

Combo topicals: pick two of any of the above, and someone’s probably put together a combo in one tube. Some of these are really, really expensive—far more expensive than the two separately. Older combos often have affordable generics. Combos probably save a little time, and might help people actually use both products correctly.

Oral antibiotics: they work, but there are more potential side effects and concerns of encouraging antibiotic resistance. The dermatologists officially recommend using them only for the short-term, but then turn around and leave people on them for two years. Go figure.

Oral isotretinoin (Accutane used to be the brand name, a name that’s still used despite the withdrawl of the original product from the market.): Hoo boy this stuff can work, even on the worst scarring acne. But there are many, many potential side effects. Patients have to get repeated blood tests and women & girls have to take contraceptives to avoid the almost-certain occurrence of birth defects if pregnancy occurs on Accutane.

All sorts of washes/scrubs and other OTCs are sold, some under very well known brand names. They do very little to fight acne, and end up irritating the skin. Just wash with a nice mild soap.

And forget about diet. Acne isn’t caused by chocolate or oily food. It has nothing to do with what anyone eats. Or impure thoughts, or sex, or masturbation, or not cleaning your skin. Those are all myths.

Back to using medicines correctly. The crucial step is to use whatever you’re using every single day. Teenagers (and the rest of us, too, honestly) stop using their acne meds as soon as their skin clears up. It’s much more effective to stay on it, every day, to keep acne under control than to start and stop these meds.

And: acne topicals do not have to be used in bulk. Slathering is not encouraged. The best application method is to squeeze out a little pea-sized blob, then use that blob to make little dots on the affected areas of the face. Then spread it around with both hands.

Mark also wanted to know: should acne therapy start when acne is first noticed? That’s a matter of patient preference. Acne that bothers the patient should be treated; any acne that’s scarring or even near-scarring should be treated aggressively. Early treatment can get acne under control, but if your child really isn’t bothered by mild acne, I’m not sure it’s worth pestering her into taking care of it (she won’t use the medicine anyway.)

Effective acne therapy means coming up with a medicine or combination that will work, and convincing the patient to stick with the plan. It may take weeks to reach maximum effect. Sometimes the first regimen doesn’t work, and you have to try something else—there’s no one magic regimen that’s perfect for everyone. But a good pediatrician, family doc, or dermatologist should be able to teach you and your kiddo how to use these meds to keep those zits under control.

Lick the pacifier, prevent asthma?

June 17, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Those wacky, wacky Swedes. They’ve given us the Fyrkantig candle at Ikea. And the word “nomofob.” And now, a study of babies whose parents sucked pacifiers. Not their own, parental pacifiers—their babys’ pacifiers.

Researchers in Sweden published a study in the May, 2013 issue of Pediatrics. They  looked at a group of 184 babies, interviewing the parents about their pacifier cleaning techniques. At six months, there were 65 parents who were “suckers”—these are the ones who reported that they routinely cleaned their child’s pacifier in their own mouths. The rest of the families said that they used other kinds of cleaning techniques. Maybe they used a stranger’s mouth. Frankly, I don’t want to know.

Anyway: at 18 months and again 36 months of life, the babies were examined for findings of allergic disease. The researchers reported that at 18 months, “sucking” was associated with less asthma and less eczema; at 36 months, only eczema still seemed to show any difference in the two groups.

It’s an interesting study, but I don’t think it’s very conclusive. It’s interesting that the asthma “protection” seemed to disappear at three years (I wonder if the eczema “protection” waned later.) And the overall protective effects weren’t particularly large. In nerd-statistics language, the confidence intervals almost overlapped odds or hazard ratios of 1.

Also, studies like these don’t show that the intervention—parental pacifier sucking—was what caused less allergic disease. I imagine that these families who cleaned pacifiers in their mouths were otherwise somewhat less diligent about cleanliness. Perhaps that’s what accounts for the difference, not the pacifier habits themselves.

I also have some misgivings about suggesting that parents slurp away on their kids’ pacifiers. Many people carry bacteria in their mouths that contribute to tooth decay, and it would be unwise for those families to continually re-inoculate their babies. There are other mouth germs, too—strep, herpes, and who-knows-what-kind-of Swedish meatball germs (as featured in this documentary.)

I’m sure an occasional, in-a-hurry-and-just-want-it-clean-enough suck is harmless, but it really doesn’t make sense to go out of your way to put your child’s pacifier in your mouth. If you want one that badly, go buy your own.

Mosquito prevention and treatment, updated

June 13, 2013

The Pediatric Insider

© 2010 Roy Benaroch, MD

Jen wanted to know about mosquito sprayers and misters: “With all of this rain, we have a ton of mosquitoes out  Our neighbors really like the Mosquito Tuxedo misting system.   I’m not sure which is better or worse:  Misting chemicals (organic insecticide – whatever that means), spraying chemicals directly on the children’s bodies, or letting them get bitten by mosquitoes!”

I remember a trip to the Florida Everglades as a child with school—surrounded by mosquitoes, alligators, and miles of swamp. Our teachers told us that mosquitoes are a vital part of the food chain, and essential to the ecosystem. Blah blah blah.

I hate those bloodsuckers. The mosquitoes, I mean. Not the teachers.

Anyway: mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis and dengue 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. Avoid allowing 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.

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 (the active ingredient in Cutter Advance) and oil of lemon eucalyptus. These have no advantage over DEET, but some families prefer them because of their more pleasant smell and feel. Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all.

Jen asked about yard sprayers or misters. 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 we know that DEET sprayed on your child is effective and safe for both kid and environment.

About “Organic insecticides”—it’s just a marketing term. In the world of chemistry, the word “organic” means that the molecule contains carbon. Organic compounds are no more or less likely to be dangerous to people or the environment than non-organic compounds; likewise, “natural” in no way implies that something is safe or effective (or even “natural” in the sense that most people mean that term.) These words are tossed around as part of the typical salad of meaningless marketing-speak on labels. Ignore them.

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.

Some children do seem more attractive to others to mosquitoes, and some children seem to have more exaggerated local reactions with big itchy warm welts. To minimize the reaction to a mosquito bites, follow these steps:

  1. Give an oral antihisamine like Benadryl, Zyrtec, or Claritin (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.)
  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!

This is an update of an original post from June, 2010


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