Archive for the ‘Medical problems’ category

Should a tongue-tie be clipped?

December 5, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Anita wrote in: “My little newborn has this bit of tissue under his tongue, so he can’t stick his tongue out. Should it be removed?”

I’m thinking Anita means, should the little bit of tissue be removed. Not the whole tongue. Probably.

That little bit of tissue is called a “lingual frenulum”, or a “sublingual frenulum.” What to do about these things is something that’s changed as years have gone by. When I was a baby, doctors would routinely just clip the things, right there in the nursery, as a matter of course. Probably without consent or any handwringing discussions.

Then, the pendulum swung away from clipping. By the 1990’s, the standard teaching was to leave the darn things alone. We figured that they didn’t do much harm, and seemed to go away on their own, so why mess with them?

Now, the pendulum may be swinging back towards at least considering clipping those frenula. Several small but good studies have shown that at least some mom-baby pairs have trouble nursing with a tight frenulum (sometimes called ankyloglossia, or a “tongue-tie.”) Clipping a tongue-tie in a baby who is nursing poorly can dramatically improve latching and milk transfer, and can really reduce the pain some women experience when trying to nurse a baby with a tight frenulum.

It’s less clear whether clipping has longer term benefits. Some feel that a tight frenulum can cause speech problems, or perhaps issues with eating or kissing.  Studies looking at the long-term effects of clipping on these issues haven’t been done.

Clipping one of these is a simple, safe, and quick procedure. However, few pediatricians who’ve been trained in the last 20 years have any experience with doing these. I did a CME training course that included videos and practicing on a dummy with a little pretend tongue, and it’s easy enough to learn. It is important that a good exam confirms that it’s a simple tongue-tie that can be easily clipped in the office. Some of these, if large or dense or located more towards the back of the tongue, would be better addressed by a surgeon in the operating room.

So, to answer Anita’s question: whether to clip a tongue-tie depends on what problems it’s causing. If there are nursing difficulties or pain, there’s very good evidence that clipping is a good idea. There’s not much evidence one way or the other to tell us if clipping should be done to prevent speech or language or other issues later in life. I try to judge that by how tight the frenulum appears, whether the tongue can be extended, and how much I think I can improve the tongue movement with a little snip, but that’s a call that has to be made individually for each baby.

If your pediatrician doesn’t have experience judging whether a tongue-tie needs to be clipped, ask for a referral to an ENT who can help decide if the procedure is needed, and how to do it safely.

The best treatment for warts? Leave them alone!

November 21, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

You have got to hand it to the Dutch—they know how to put together a good observational study. Want to know what really happens when children get warts? Our friends in the Netherlands have it figured out.

In a study published this month, researchers described what happened to children’s warts over a 15 month study period. They enrolled 1100 children, and examined them regularly for common warts. They also tracked which parents decided to treat the warts, and what factors seemed important in determining whether the warts resolved. What they found:

  • At study entry, 33% of children had at least one ordinary wart.
  • Half of all warts went away within a year, whether treated or not.
  • 90% of older warts—ones that were present at the start of the study—went away within a year.
  • About 40% of families chose to treat the warts, either with OTC or prescription products. Treated warts were less likely to resolve than warts that were simply observed without therapy.
  • Warts were more likely to resolve in younger children, and in non-Caucasian children (though neither of these factors was really very strong.) Whether or not warts resolved was not influenced by their size, quantity, or location.

Bonus: the author’s first acknowledgement wasn’t a drug company—instead, they said “We thank all the primary schoolchildren and their parents for their enthusiastic participation.” Now that’s a classy study!

I’ve written about common warts before, including a review of treatment options—and back then, my first listed treatment was “do nothing.” This study reinforces that advice. There seems to be no treatment that really makes much of a difference anyway.

Protecting your child from concussions

November 7, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

A concussion is a brain injury resulting from a blow to the head. Not the kind of injury you can see on a CT scan or MRI—there’s no broken bones and no squashed or visibly damaged brain. But nonetheless, the brain is damaged. Symptoms tell you immediately after a concussion that the brain has been affected. Sometimes, a person is knocked out cold, but a concussion can occur without unconsciousness. Milder symptoms can include disorientation, confusion, and problems with memory and balance. With time and rest, these symptoms will usually improve, especially after a first concussion.

But sometimes concussions can cause real, lasting brain damage. After a concussion, athletes (both professional and student) can suffer from poor attention, headaches, memory problems, and depression—symptoms that may or may not get better with time. Unfortunately, young athletes may be more at-risk than the pros. Young brains are still developing, and are more likely to be injured. There’s also some genetic variability—some people are more resilient than others to the effects of concussions. Repeated concussions can be dangerous to anyone, and a “second hit” after a concussion that hasn’t completely healed can be deadly.

As I tell the teenagers: “Protect your brain. You may need to use it later.”

What can parents and coaches do to help keep their kids safe?

  • Provide good training so young athletes know how to play safely. Support coaches who teach student athletes well, and take potential brain injuries seriously.
  • Make sure that athletes have good protective equipment, including helmets and mouth guards. These don’t prevent all (or even most) concussions, but using them consistently and correctly is still important.
  • School systems should have mandatory, science-based concussion management systems, developed in accordance with national guidelines.
  • Officials and referees need to call fouls, and discontinue play when it’s dangerous. Players who put themselves or others at risk should be sent off the field without hesitation.
  • Coaches on the sidelines need to look for even subtle signs of concussion in their players, and pull them out of the game if there are any signs at all. When in doubt, players should sit out.
  • Players themselves need to know that they should never tough it out—any “dinger” needs to be reported, even if that means they’ll be pulled from the game. Brains are far more important than scores.
  • If your child does have a concussion, be sure to follow the guidance of his physician. A gradual return to sports should not begin until all signs and symptoms of concussion have resolved. And if symptoms occur with activity, you must back off again.
  • If your child has had more than one concussion, or a concussion with prolonged symptoms, consider working with a neurologist to ensure that there’s no lasting damage.

Influenza is here

October 31, 2013

The leaves are changing, there’s a nip in the air, and I’m making plans to steal my kids’ Reese’s tonight. And to make Halloween just a little scarier: we’ve got our first case of influenza, right here in Atlanta!

I don’t know if this will be a mild, moderate, or severe flu season—but even in the mildest years, we’re going to see a lot of miserable kids and families in our office, and a handful of really sick, hospitalized children. While nothing can give you 100% protection, one of the best ways to help keep your kids, yourself, and your neighborhoods healthy is for all of us to get the flu vaccine. It’s not too late! Go, now, get vaccines for your family to protect yourselves. Do the safe thing.

If you do get the flu—the aches, the fever, the misery—stay home. The best treatment is rest and fluids and maybe acetaminophen or ibuprofen. Anti-viral medications like Tamiflu are expensive, nauseating, and not very effective. Still, for high-risk cases it’s the best we’ve got.

You know what they say: an ounce of prevention is worth a pound of Tamiflu. Or something like that. Go get your vaccine!


How to transmit influenza to your friends and enemies

Preventing and treating influenza

The CDC’s influenza page, including links to maps showing current influenza activity nationwide

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.


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.


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