Archive for the ‘Medical problems’ category

School morning belly aches: Are they “real”?

December 14, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Dave’s story: “I have a six year old who gets a lot of belly aches. She’s seen her ped and a GI, and all the tests say nothing. Her belly aches really only happen in the morning before school. I think it might be psychological, and have told her about the boy who cries wolf, but she insists that her tummy hurts. What should we do?”

We need to settle one thing up front. These belly aches are in every sense “real”, even if they’re related to psychological factors on school days. The pain is real, because the pain hurts. Telling her that it doesn’t hurt, or talking with her about boys and wolves, is unlikely to help her feel better.

There’s this weird, false dichotomy in medicine between “real” and “not real” in the way we talk about medical problems—as if psychiatric or psychological issues are less important in some way. Sometimes words like “organic” are used for “real” pathology, as opposed to “inorganic”, whatever that means. You’ll also see references to “functional” pain, somehow implying that this kind of pain is somehow less real. But it still hurts!

There’s even a specific name for “GI pain where no pathology can be seen through a microscope and no lab tests are abnormal but nonetheless it hurts and ow I wish it would feel better.” It’s called irritable bowel syndrome, and it affects millions. Again: it hurts.

Dave’s already taken an important step: by keeping track of the symptoms, he’s narrowed this down to a school-morning phenomenon. That’s very important information, because it tells us that we don’t need more invasive tests or procedures. Instead, we ought to be focusing on ways to help the child feel better. Is there a specific stressor (like a bully) at school? Can we reduce overall stress in other ways? Can we think of ways to make school mornings a little less dread-inducing? Perhaps, in addition to reducing stress, we can also start to teach the child new ways of dealing with stress—like a special lovey to hug, or a punching bag to whale on (you can see, the approach may depend on the child!) Things like a hot water bottle, extra time on the toilet, or waking up early enough so the family doesn’t have to rush can all help.

The bottom line: belly aches that only happen on school day mornings are real. Parents won’t be able to talk their child out of it. Instead, we ought to be working with our children to see how we can help them feel better.

Vitamin B12 quackery

December 6, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Here at The Pediatric Insider, we’re about science. Medicines and other treatments need to be tested. We want reliable proof that something works and is safe before we recommend it. We don’t like the false dichotomy of “alternative medicine”. If there is good evidence that it works, it’s medicine. If it doesn’t work, it’s quackery.

It doesn’t matter who’s doing the quacking. A quack is a quack, even if there’s a medical diploma on the wall.

The story: a woman brings in her teenage daughter, complaining that the girl is tired a lot. It turns out that mom herself has had some blood tests that showed a low vitamin B12 level, so her doctor is giving her regular B12 injections. Can her daughter get some, too?

I realize that B12 injections are common. Many docs administer these, and many adults get these—probably some of you reading this. So what’s the science behind this practice?

Vitamin B12 deficiency is a real thing. It can occur because of a poor diet, or because some medications (like acid blockers) interfere with absorption. Or it can occur because of a specific autoimmune disorder called “Pernicious Anemia.” Whatever the cause, the health consequences of vitamin B12 deficiency can include anemia, neuropathy, irritability, and depression.

There is a simple blood test to measure vitamin B12 levels, though the levels in the blood don’t always correlate with whether there is enough B12 levels in the cells themselves. We can test for this, too, indirectly, through other blood tests including methylmalonic acid and homocysteine levels. So we can, in fact, know if a person is truly deficient. These confirmatory tests are rarely done.

Instead, many adults are told that their vague symptoms of tiredness or fatigue are caused by B12 deficiency, instead of actually trying to address genuine issues like insufficient sleep, sleep apnea, overreliance on caffeine, and depression (to name a few of the many genuine causes of fatigue.)

It gets worse. The treatment of B12 deficiency, as has been established from studies done in the 1960s, is ORAL B12. That’s right. Pills. Injections of B12 are not necessary—oral supplements work well, even in pernicious anemia. They’re cheap and they work. I suppose a very rare patient, say one who has surgically lost most of their gut, could require injections. But the vast majority of people with genuine B12 deficiency can get all of the B12 they need through eating foods or swallowing supplements. No needles needed.

So why this fetish with injections? From the patient’s point of view, shots feel more like something important is going on. Placebos need rituals—with acupuncture, for instance, the elaborate ritual creates an illusion of effectiveness. And from the doctor’s point of view, injections reinforce dependence on the physician, creating visits and cash flow.

So: people seem to think they feel better with injections, and the doctor makes a little cash, and everyone’s happy. So what’s the harm in that?

I think it’s wrong to knowingly dispense placebos, even harmless ones. We doctors like to criticize the chiropractors and homeopaths. We point fingers. They’re the quacks. We’d better take a close look at what we’re doing, first. Our placebos are sometimes far more dangerous than theirs.

More importantly, people should be able to expect more from physicians. Patients come to us for genuine answers—if they wanted a witch doctor, they would have found one. I think we need to hold ourselves to a higher standard than a huckster at the carnival. We’re not here to promise that we’ve got all the answers. We are here to be honest, and to use the best knowledge that science has to offer, using  genuine compassion and thought. Let’s leave the quacking to the quacks. We’ll stick with real medicine.

Breast Cancer versus HIV screening: Always a good idea?

November 30, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Screening tests to looking for disease early may not always be a good thing.

On one side: The Unites States Preventative Services Task Force– or USPSTF– now recommends universal screening for HIV infection among all adults aged 15-65. Their draft statement, released this week, now agrees with the CDC’s 2008 recommendation, which essentially said the same thing in 2006.

Contrast this with a study of screening mammography published in the New England Journal of Medicine a few days ago. Looking at over 30 years of data, researchers found  that up to a third of tumors identified by screening mammography were likely diagnosed incorrectly. They were in fact harmless. That’s a lot of women undergoing biopsies, surgery, radiation, and chemotherapy. The authors say that their study supports the 2009 USPSTF recommendation that most women in their 40′s not undergo routine mammograms.

So why the difference?

Whether to screen or not depends on the answers to some tricky questions:

How accurate is the screen? In the case of HIV testing, it’s very accurate. Mammography? Many false positives, and some false negatives too.

What happens after a positive screen? HIV screening tests lead to a few more blood tests to confirm the diagnosis. A positive mammo leads to biopsies and surgery and maybe more.

What happens if we miss a diagnosis? HIV positive individuals spread infection. Earlier diagnosis of HIV can not only lead to effective treatment, but also to an overall reduced risk to the population. Breast cancer isn’t contagious, and it’s unclear that earlier treatment is always better—some small tumors may regress without any treatment at all.

We have a lot more to learn about the answers to these questions, and recommendations for screening should always be based on the best available science. What strategy keeps the most people healthy, does the least harm, and is the most effective way to spend health care dollars? These answers aren’t always obvious, and new studies sometimes lead to new perspectives.  But it is clear that not every screening test is a good idea for everyone.

Baby sleep positioners kill

November 26, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

The AAP has been warning against these things for years, and finally the FDA and CPSC have weighed in: Infant sleep positioners don’t prevent SIDS, and don’t save lives. But they can kill your baby.

These things are wedge-shaped or U-shaped gizmos that are supposed to keep your baby in a certain position while sleeping, supposedly to prevent SIDS and other alleged problems. But the “back to sleep” anti-SIDS campaign, which has reduced deaths by over 50%, never suggested to have to keep your baby on his back. The message from the back to sleep campaign has always been to put your baby down on his or her back, then to go away. Once your baby can move or roll to a different position, that’s fine.

The SIDS prevention guidelines are pretty straightforward, but that hasn’t stopped companies from capitalizing on fear to sell devices that they claim will reduce SIDS. Special monitors, mattresses, pillows, bumpers, and infant positioners have all claimed to protect babies, yet the FDA (nor the AAP, nor anyone else who knows what they’re talking about) has ever endorsed or approved any such device.

Want to prevent Sudden Infant Death Syndrome? Here are some proven methods. These are from the AAP’s Details and references are all in the AAP’s 2011 policy statement on preventing SIDS and other sleep-related infant deaths, which includes more details and references for all of these recommendations.

  • Breastfeed.
  • Immunize – follow the established schedule, which reduces SIDS by about 50%.
  • ALWAYS put your baby down to sleep on his or her back.
  • Don’t use bumper pads or other padded fluffy things in the crib.
  • Always use a firm, flat sleep surface. Babies should not routinely sleep in carriers, car seats, or bouncy seats.
  • Place your baby on a separate sleeping surface, not your bed (Bed sharing is discouraged.) Babies can sleep in their parents room, but should not sleep in their parent’s bed.
  • Wedges and sleep positioners should never be used.
  • Don’t smoke during or after pregnancy.
  • Offer a pacifier at sleep and naptimes.
  • Avoid covering baby’s head.
  • Avoid overheating.
  • Practice supervised, awake tummy time to help motor development and avoid flattened heads.
  • Ensure that pregnant women and babies receive good regular care.

The AAP’s recommendations not only address specific, known, modifiable risk factors for SIDS, but also help reduce the risk of death from suffocation and other causes. They are the best way to help keep your baby safe. Forget the hype and expense and unfounded promises from manufacturers—you can best keep your baby safe without buying anything.

Antibiotics may do more harm than good

November 19, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Add to the growing list of reasons antibiotics might not be good for you and your children: a recent study showing a statistical link between early ear infections and inflammatory bowel disease (IBD).

Researchers in the UK analyzed data from about a million children, looking specifically at the 750 who developed IBD (Crohn Disease and ulcerative colitis, mostly.) They then compared the kids with IBD to children without that diagnosis, and looked back at the frequency of prior ear infections. Ear infections are the most common diagnosis leading to the use of antibiotics in young children, so it was figured that more ear infection diagnoses were a good marker for more antibiotics.

Their analysis found that early ear infections increased the risk of IDB substantially, probably by about 80%. The highest risk was among children with the most ear infections, and among children with the earliest diagnoses. So more antibiotics, and earlier antibiotics, seem to be predictive of the later development of IBD.

IBD is a complex illness. It seems to be related to altered immune regulation in the gut and other tissues. It’s been speculated that the normal bacteria in the gut help with the early formation and control of the immune system.  Early antibiotics could indeed interfere with that process, and are a plausible trigger for IBD, at least in people who are genetically predisposed. There are probably other factors at work, too.

Indiscriminate antibiotic use is bad news. It contributes to the development of resistant superbugs, and may play a role in the development of obesity, allergic disease, and asthma. Insidious forces can sometimes encourage the perceived “quick fix” of an antibiotic prescription—including rushed doctors, exasperated parents, and a health care system that rewards “satisfaction” over health. If you want to protect your child from unnecessary antibiotics, you have to ask a few questions:

  • Is this antibiotic really necessary?
  • Are there other options?
  • Is it safe to wait?
  • If we do need an antibiotic, what’s the safest one to use?

And, of course, remember that prevention is always better than cure. Keeping your child up to date on vaccines—including influenza vaccination—prevents both bacterial infections and some viral infections that predispose to ear infections and other antibiotic temptations. Nursing, avoiding group care, avoiding second-hand smoke, and not bottle-propping—all of these can help prevent at least some ear and other infections.

There will be times when an antibiotic is a good idea—I don’t want parents to be afraid of them when they really are necessary. But parents and doctors both need to take an active, thoughtful role in deciding when antibiotics are really a good idea.

Maternal illness and autism

November 15, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

This week’s autism headline: Flu, fever during pregnancy linked to autism risk.

Researchers in Denmark reviewed health information from a group of about 100,000 children born between 1997 and 2003. The mothers had been interviewed during and shortly after their pregnancies to determine who had had infections, fevers, or other health issues during pregnancy. Now that the children had grown to 8-14 years of age, the study looked backwards to see if the children developed autism had mothers who reported more infections or fevers during pregnancy.

The good news: for many minor infections, including common colds or short-lived fevers, there was no significant association with autism. However, mothers who had recalled having the flu had about double the risk of autism in their children, and mothers who reported a fever lasting over a week had triple the risk.

The authors themselves stress that these are preliminary findings, and that their complicated mathematics could have exaggerated trends that aren’t really significant. Still, there is animal data that shows inflammation from infection during pregnancy can indeed influence fetal brain development. These findings about flu and fever are plausible.

This study adds to the growing evidence that at least in many cases, the causes of autism begin well before a baby is born. Previous research has shown in increased risk of autism with older fathers, maternal obesity, and closely spaced pregnancies. It is very likely that there are numerous, overlapping causes of autism that include genetic, prenatal, and environmental factors. We’re learning more and more, but we’ve still got far to go.

Back to the current study: the overall risk of having a child with autism following influenza is still low—there is no need for panic or extensive watchfulness. However, this study provides yet more evidence that pregnant (or expecting-to-get-pregnant) moms need to protect themselves from infection. Eat right, sleep right, wash your hands, avoid sick people. And please, get yourself and your children influenza vaccines. Want to avoid autism? Vaccinate!

Fear the diseases, not the vaccines

October 30, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

About 3 million children’s lives are saved each year by vaccination. In the United States alone, 20 million cases of serious illness are prevented every single year, because of the power of immunizations. That’s why immunizations are among the greatest public health achievements of all time.

With vaccine-preventable illnesses at historic lows, some parents are becoming more fearful of vaccines than of the diseases themselves. That’s a tragedy. Vaccines are the most intensely studied and researched health interventions we have, and there is a tremendous amount of data supporting their safety. Yet, rumors and internet sites have contributed to a mistrust of not only vaccines, but to the doctors who recommend them, the governments who supply them, the scientists who invent them, and the companies that manufacture them. Somehow, the diseases themselves are no longer the bad guy.

Vaccine-refusers expose their children to a 23-fold increased risk of pertussis, a 35-fold increased risk of measles, and a 9-fold increased risk of chicken pox. You get the idea. These vaccines work. They prevent illness, and prevent death.

Refusing vaccines hurts your children and your community. There are always people in a community who are at high risk for disease. This includes the very young and old, and people who for health reasons have poor immunity or who can’t be vaccinated. It also includes some people who were vaccinated, but who didn’t develop good immunity. Though vaccines work very well, they’re not perfect, and some people don’t develop protection from their vaccinations. If almost everyone in a community is vaccinated, it helps protect the most vulnerable among us. And once enough families refuse vaccines, this protective effect will evaporate. Not vaccinating doesn’t only affect your own children. It can affect mine, and your neighbors’, and the people in the nursing home. It affects us all.

Fear of vaccines has led some parents to want to “space them out”—the exact wrong thing to do, if you want to keep your children and your community safe. One idiot doctor even made up an alternative schedule, and he’s sold a lot of books about it. But why would anyone think his made-up schedule is safer than the one recommended by every important health authority in the world? Why is that one guy more trustworthy than your own pediatrician? Think about this: if vaccines were in some way unsafe, why is making more separate visits so your child gets more days with shots better than bunching them up and getting them over with? There is no evidence, and no plausible scientific reason, to think that the stretched out schedule is safer. It just leaves your child more vulnerable, longer. Fear drives the use of this weirdball schedule—a misguided fear of vaccines, instead of a fear of disease. There are different reasons why some parents refuse vaccines, but the common thread is fear.

The media hasn’t always done a great job presenting the science of vaccines, preferring sometimes to stick with sensationalism over useful information. And the internet, by its very nature, tends to exaggerate freaky new stories over context and followup, leaving parents reeling. Parents want to keep their kids safe and healthy. But with “all those stories on the internet”, who can they believe?

I’ll tell you who to believe. Believe the doctors and scientists around the world who’ve dedicated their lives to keeping children safe. Believe the parents, the millions of them, whose children have been saved by vaccines. Believe your own pediatrician, not celebrities and fear-mongerers on the web. Believe the science that continues to study and monitor and improve vaccines. Don’t give in to an irrational, unnecessary, and harmful fears. Protect your kids and mine. Vaccinate.

Bleach baths can help—just do them right

October 15, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

“My doctor recommended that my child soak in a bleach bath to prevent staph. Can that be right?”

Whoa, wait just a minute here. Kids should NOT soak in undiluted bleach—no way, no how. I think there may have been a misunderstanding here. Diluted bleach baths can be a way to help prevent staph infections, but you need to do them correctly.

  1. Put about 10-12 inches of water in an ordinary-sized tub. If you’ve got one of those big garden tubs, that’ll be more water, so you’ll need to add more bleach in the next step.
  2. Add ¼ to ½ cup or ordinary household bleach. Not the ultra-concentrated stuff, the cheap ordinary stuff mama used to use.
  3. Add the child. Naked. Encourage him to scoot and move around, but let’s keep the splashing to a minimum. Ideally the water should come up to his chin. The most important body part to get under the water and move around is the butt and genitals.
  4. Soak for 5-10 minutes.
  5. Afterwards, drain the tub. Junior can take a regular shower if he wants, or just dry off and get dressed.

That amount of bleach adds a chlorine concentration similar to what’s in a swimming pool, and won’t hurt or bleach skin. It also won’t hurt if a little bit gets in the mouth.

Bleach baths can be done every day for a week or so to help treat an acute staph infection, and can then be continued about once a week to prevent recurrences. They’re also helpful to control eczema, which often flares up when skin is colonized with staph. They’re safe, they help, and they’re a good idea—just do ‘em right!

The renegade pediatrician

October 11, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Mark wants to know: “How often do you have a dissenting view of a recommendation by the AAP?  When a pediatrician doesn’t agree, are there any implications or difficulties for his practice?”

We’re talking about the AAP here—The American Academy of Pediatrics. I’m a “fellow”, as is just about every genuine pediatrician in the US. To give you an idea of what a bunch of tough-guy enforcers we are: at last year’s big AAP convention, the keynote speaker was Caroll Spinney. That’s right, Big Bird himself.  And if you don’t follow the AAP’s recommendations, he shows up and lays an egg on your head.

No, the AAP really doesn’t have any kind of enforcement. They don’t take your membership card away if you tick them off, or kick you out of the exclusive kiddie pool. Still, I think most practicing pediatricians probably follow at least most of their recommendations. Because, in fact, they’re our recommendations.

The AAP leadership is all pediatricians, from the national level to each state and local chapter. The “recommendations” endorsed by the AAP are written by pediatricians who are recognized as knowledgeable doctors and good, experienced thinkers. They work with specialty organizations, the CDC, and other big-brained types to come up with recommendations that really are based on solid science.

That’s not to say that I never disagree with their recommendations. For instance, until recently it was recommended that all young children get a study called a “VCUG” after even one urinary tract infection. However, good studies published after that recommendation showed that the VCUG may not be necessary, and may not even help; meanwhile, many of us became more concerned about the amount of radiation that we were using. No one wants to irradiate ‘lil ovaries unless it’s really necessary. The AAP’s recommendation, based on older studies, became outdated and flawed, and many of us practiced differently, counter to the recommendations, until it was updated.

I suppose one theoretical implication of practicing counter to recommendations is that you’d be more exposed in a malpractice lawsuit. But as long as what you’re doing meets the reasonable standard of care for your community, you’d probably be OK.

Most of the time, AAP recommendations make sense, and I follow them. They’re not a straightjacket, and they certainly don’t exhaustively address the peculiarities of every situation. I think if a pediatrician is going to practice counter to the recommendations, he or she ought to be able to explain why. As long as what we’re doing makes sense and is guided by the art and science of medicine, it’s all good.

Snoring isn’t good for children

October 1, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

In children, snoring may be more of a problem than we thought.

A September, 2012 prospective study of 249 preschool children looked at parent-reported rates of persistent, loud snoring. About 10% of the 2-3 year old children in this sample had persistent, loud snoring—and these kids were much more likely to have significant behavior problems including hyperactivity, inattention, and symptoms of depression. Higher rates of snoring were found in homes with smokers, households with lower socioeconomic status, and among children who weren’t breast-fed—but even after controlling for these factors, snoring itself seemed to be associated with these behavior problems.

Previous studies have already documented that snoring is associated with poor school performance in older children, as well as decreased attention in adults. We also know that in its more severe form, snoring is associated with sleep apnea, which can cause heart and lung problems in adults if untreated.

Parents can look out for these signs of possible sleep apnea in their children:

  • Frequent snoring (> 2 – 3 times per week)
  • Labored breathing during sleep
  • Gasps/snorting during sleep
  • Prolonged bedwetting
  • Sleeping in a sitting position
  • Sleeping with the neck hyperextended (in a “looking up” position)
  • Headaches upon awakening
  • Daytime sleepiness
  • Attention-deficit disorder or learning problems

In addition, the physical examination of children with sleep apnea can include overweight or underweight, big tonsils, poor growth, and high blood pressure. However, even without any of these findings, this recent study suggests that persistent loud snoring alone may have important consequences.

If your child is a loud snorer, look for the symptoms above and talk with the pediatrician. To know for sure if there are problems with breathing during sleep, a sleep study may be needed. Alternatively, some pediatricians may prefer to refer to a specialist like an ENT (ear-nose-throat) doctor for further evaluation.

Treatment can include a trial of medications. Though none are specifically FDA approved to treat snoring or sleep apnea, there is good evidence that inhaled nasal steroids may help, and a very recent study showed that a common asthma/allergy medicine called montelukast may also be worth a try. If medicines don’t work, or if symptoms are quite significant, the most definitive treatment is surgical removal of the tonsils and/or adenoids.

Snoring isn’t just a problem for Wilma Flintstone. If your child has significant, loud, persistent snoring it might be causing some real problems. Go get it checked out.


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