Television, ADHD, and other bad things

The Pediatric Insider

© 2009 Roy Benaroch, MD

Steve wanted to know: “I have a 16 month old and I was wondering how much television watching is too much? Also I heard too much TV viewing can lead to ADHD. Is this possible?”

I’ve written about television a few times before—about its association with depression in teens, and why having TVs in bedrooms is a bad idea. Studies such as this one also seem to tie excessive TV watching to symptoms of Attention Deficit Hyperactivity Disorder (though other authors dispute those findings.) The association of TV with ADD seems especially strong if televisions are kept in children’s bedrooms. However, it’s not really clear that excessive television actually causes ADHD—it could be the other way around. A hyperactive, difficult-to-control child may be offered more “screen time” by exhausted parents. Or maybe the association is even less direct. We know that ADD and ADHD run in families, and we know that parents who watch a lot of TV tend to have children who watch a lot of TV, so maybe the excessive TV watching reported in children with ADD just reflects a family habit rather than anything that’s really causing anything else.

There are plenty of reasons to limit television time for children. Besides issues including teen depression and ADD, excessive television watching is also associated with a poor diet choices in preschoolers, more fast food consumption, and difficulty with sleep. Reducing TV time can also both prevent and treat obesity in children.

Need more reasons to turn off the set? How about delayed speech development (also here) in children who watch excessive TV, or an increased risk of psychological disease? Or a greater likelihood of unplanned teenage pregnancy and high blood pressure? I also found studies linking television with an increased risk for asthma and poor bone mineral content. I’m sure there are even more negative associations, but I’ve read enough to convince me many times over: television and especially young children are not a good mix.

Current guidelines from the American Academy of Pediatrics suggest no television at all for children less than 2 years of age, and not more than 1-2 hours per day of quality, non-commercial television entertainment for older kids. The current average screen time (adding television, video games, computer time, etc) for an American child is over six hours a day—more time, on average, than they spend in school. You can quibble over the exact amount that is “OK”, but clearly there is far too much TV now, and less of it would be a very good thing.

Besides, there isn’t anything good on, anyway.

Why why why

The Pediatric Insider

© 2009 Roy Benaroch, MD

Christy posted, “I have a 5-year-old daughter who has developed a bad habit of not responding to questions when asked by an adult. For example, ‘Why did you throw your milk cup on the floor?’ At home, she is either sent to time-out or her room. However, this is now occurring in her kindergarten class. It seems to be a power-struggle or step to independence. What suggestions do you have?”

“Why” questions are tough—especially when little kids are asked them right after they’ve done something wrong. In court, she’d have a constitutionally guaranteed right not to self-incriminate, but I doubt many five-year-olds have the wherewithal to come up with “I plead the fifth.” Instead, kids just look at their shoes.

For a child who doesn’t seem to want to answer adult’s questions, it’s important to step back and make the questions easier to answer, so the child can build confidence through success. A good rule that I apply to many areas of parenting: practice what works, and stop practicing what doesn’t work. If “Why” questions are tough, back off and practice easier ones, and work back up to harder ones.

Easier questions start with “What”—“What is your name?” or “What is your brother’s name?” or “What age are you? (Yes, I know, idiomatically the correct question is “How old are you?”, but How questions are harder than What questions, and I’m trying to make a point here.) Little kids also do pretty well with “Where,” unless the rest of the question is “did you put your shoes?”,  which is apparently a brain teaser that no child can answer. “When” gets a little trickier—“When are you supposed to bring in your share? When is the parent-teacher conference?”

“Why” questions are the toughest off all, and not in the least because parents so often ask them after a child has done something wrong. “Why did you hit your brother?”, or “Why did you cut your own hair?”—these are as difficult as any Zen Koan when you’re on the spot with the teacher or mom giving you a hairy eyeball.

If you’d like to help your child get better at “Why” questions, answer them often yourself, by using the word “because” a lot. “We need to go to the grocery because were out of food,” or “I got mad because that man ran over my foot with his cart. Then I felt better because I realized it wasn’t his fault.” You can also encourage your child to ask why questions—not the annoying, one-word “Why?”, which is just a time-waster, but a properly phrased “Why” question, like “Mommy, why did you talk to that lady so long?” (“Because,” you could say, “she is my friend and I hadn’t seen her in a while. Thank you for waiting. It’s hard to wait because waiting is boring.”) Be sure to ask your child “Why” questions when it’s not a challenging, tense situation—or better yet, when the answer is easy. “Why are you happy on your birthday?” or “Why should we bring an umbrella?”, or maybe something a touch more difficult, like “Why are your shoes getting too small?”

Another tip for kids who seem shy at “Whys” would be to have her help you put on puppet shows, where the puppets talk through answers with each other. Kids learn a lot through pretend games like these, and don’t seem to find them threatening.

Keep in mind that it’s not just the difficulty of the question, it’s the overall setting that sets the anxiety level. If a child feels threatened or upset, even an easy question might not get an answer. And some children are certainly more outgoing and talkative with adults than others. The more shy kids are going to need more gentle practice, and will have more setbacks.

By the way, if your child does something she knows she shouldn’t do—like throwing her milk cup on the floor—I don’t think it’s wise to waste time asking why. You won’t get a useful answer. A better response would be “Don’t throw your milk on the floor,” followed by taking her hand and making her clean it up. A habitual offense might need a time out before clean-up, but more talking won’t help. Tossing cups on the floor is an attention-getting behavior, and having a one-sided conversation about it afterwards will only encourage more milk to land where it’s not supposed to be.

Flu: To shot, or not

The Pediatric Insider © 2009 Roy Benaroch, MD

Good news: today, the FDA announced the approval of vaccines to prevent novel H1N1 influenza. It sounds like these immunizations will be available in the coming weeks, and studies in adults performed so far show excellent and rapid immune responses with minimal side effects. Studies looking at children are currently underway, and confirmation of the safety and effectiveness of these vaccines for all ages should be available by the time they’re distributed.

Phew.

My state has one of the highest rates of H1N1 influenza, probably thanks to our twisted, evil preoccupation with starting school too early (oddly, the school boards have not sought my opinion on this matter.) So we’ve been seeing dozens, maybe hundreds, of H1N1 cases in my office. The good news is that no one has been super-super-sick; the bad news is that many kids have been pretty-super-sick, and their parents and siblings are getting it too. Tamiflu can help some, if started early, but really hasn’t proven to be particularly effective. Probably better for most victims to just head to bed, and have chicken soup, tea with honey, and maybe a popsicle or two. Best case scenario: a 4 or 5 day illness, and hopefully no trips to the hospital for children or the parents when they get it.

Other parts of the country have barely started experiencing a spike in H1N1 cases, so the vaccine may indeed be able to avert a huge epidemic—if it’s distributed and used quickly. If a community can get a big chunk of its citizens vaccinated, especially the children, the spread of the virus can be halted.

That’s still a big if. It’s going to be logistically difficult to distribute enough doses of the vaccine quickly enough. Furthermore, some people seem reluctant to accept the vaccine.

Myth: This H1N1 vaccine is new, so it might not be safe.

Fact: Every year’s flu vaccine is “new,” in the sense that they’re made from different flu strains. But the technology and method to make them is identical from year to year, and has been identical for decades. Rates of adverse reactions, serious and non-serious, do not vary from year-to-year, and don’t seem to depend on the strains involved. Nonetheless, safety testing is an essential part of vaccine development, and the H1N1 vaccine has been tested both here and abroad in thousands of patients. Side effects are uncommon, and almost all of them have been very minor.

Myth: Some people “get the flu” from the vaccine.

Fact: The commonly used injected vaccine is not live, and cannot transmit influenza. A small percentage of people run a brief fever or feel a little achey after the flu shot, but that’s not nearly a full-blown case of the flu. The newer, nasal mist flu vaccine is a live vaccine, but the virus used has been adapted so it cannot survive at normal human body temperatures. It cannot transmit the flu.

Myth: Only people who are infirm or elderly get the flu; or only weak people die from the flu.

Fact: Though you’re more likely to die of flu if you have pre-existing illnesses like heart or lung disease, many healthy young adults get very seriously ill with influenza, especially in pandemic years like the one we’re having now.

The best ways to protect yourself and your children against the flu are to practice good hand washing and hygiene, to avoid sick people, and to get flu vaccinations. The flu vaccine not only protects the recipient, but also the whole family, and the community. Where uptake of flu vaccines has been good, there’s a dramatic drop in influenza cases for everyone—including very young babies, who can’t get vaccinated, yet are at very high risk of complications, and including the elderly, in whom vaccinations are ineffective.

It’s not clear now how much H1N1 vaccine can be distributed, or what risk groups will be targeted. It is clear that from a public health point of view, the most important vaccine recipients are school-aged children, because they serve as the reservoir and source of spread of infection for communities.

Right now, immunizations against other flu strains are available—though the injectable kind is running in short supply, as many manufacturers have focused their efforts on H1N1 vaccine. Please, if you have children, get a winter flu vaccine administered as soon as you can, and keep in touch with your pediatrician’s office to find out when H1N1 vaccine will be available in your community. We’re all in this together. Go get your shots.

Who has ADHD?

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kristin would like to know, “How do you actually ‘diagnose’ a nine year old boy with ADHD? Descriptions of ADHD are so vague. Most of what is described as ADHD symptoms seem like normal boy behavior to us. Can a child be a straight A student and still have ADHD?”

It’s a fair question. There is no objective test for any psychiatric or mental health disorder, including ADD (Attention Deficit Disorder; one subtype is ADHD, or Attention Deficit-Hyperactivity Disorder), depression, anxiety disorders, autism—none of these can in any way be “tested for” or diagnosed with the kind of precision expected of ordinary medical diagnoses. I’m convinced that in 100 years, doctors will look back at my generation of physicians and chuckle knowingly, saying things like “¡ssǝ1ǝn1ɔ ʍoɥ ’suɐıɹɐqɹɐq ǝsoɥʇ”. (Apparently, in the future, people speak upside down.)

In an effort to codify and standardize the language and diagnoses of psychiatry, the American Psychiatric Association first published the “Diagnostic and Statistical Manual of Mental Disorders” in 1952. The current version, last revised in 2000, is called the DSM-4-TR. It’s been criticized as “cookbooky”, relying on lists of symptoms to establish mental health diagnoses using checklists reminiscent of ordering a family meal at a Chinese Restaurant. Choose at least one from Column A (eg “inability to sit still”) and one from column B (“starting not older than seven years”), plus some qualifiers, and you’ve either got Mongolian Beef or Major Depression, maybe even both.

Though there are legitimate criticisms of the DSM, in fairness to psychiatry there are important caveats that are often overlooked. The book states explicitly that the diagnostic labels are mainly useful as “convenient shorthand for professionals,”  and that only well-trained professionals should interpret the standards and apply diagnostic criteria. So consider the DSM as a starting point for mental health diagnoses, not a straightjacket (sorry, poor time for a straightjacket joke).

DSM-IV Criteria for ADHD

I. Either A or B

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level.

Inattention

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level.

Hyperactivity

• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often “on the go” or often acts as if “driven by a motor.”
• Often talks excessively.

Impulsivity

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one’s turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

In summary: children with ADD have either inattention or impulsivity & hyperactivity, have these to a greater extent than expected for the developmental age, have these starting in early childhood, and have these as a more-or-less permanent part of their behavioral makeup. The symptoms must occur in multiple settings, and must occur to such an extent that they interfere with social, school, or occupational functioning. Part V is especially helpful—it says, essentially, that it’s ADD unless it is something else. Clearly, attorneys were involved in the preparation of this document.

To help “standardize” the diagnosis and hopefully make the assessment more objective, many clinicians rely on standardized testing instruments. Parents and teachers are asked a number of questions, like “How often does he fidget,” and answer something like always, sometimes, or never. The answers are decoded in a manner similar to the quizzes in Glamour Magazine (“What kind of guy is perfect for you?”), and the total score can be compared with thousands of other children who took the test. The “outliers”—the ones with the highest scores, above some set statistical set point—are said to have ADD.

Though these tests are helpful, it’s easy to see how parent or teacher preconceptions could color their answers. There are strong feelings about ADD and medication for ADD, and I’m not sure that making adults bubble in answers recalling a child’s behavior is likely to cut through their own feelings in a way that can reliably reveal what’s going on with a child. ADD “testing” has a role—in my mind, chiefly to rule out learning disorders and other problems that often go together with or appear very much like ADD—but a more reliable diagnosis I believe requires a thorough medical history and evaluation, as well as multiple observations over time by a skilled examiner. It’s not easy, and not quick, to do it right.

In answer to the final question, “Can a straight A student have ADHD?”—according to the DSM criteria, ADD characteristics like hyperactivity and inattention must occur to a degree to cause problems in school, home, or work. If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may  benefit from behavioral interventions to encourage better sustained attention—but that’s a subject for a future post!

Strep test horrors

The Pediatric Insider

© 2009 Roy Benaroch, MD

Sandy said, “Do you have a suggestion on how to handle a child who is hysterical at the thought of a strep test? Not just ‘I don’t want to’ but screaming and crying hysterically, running around the exam room to avoid the nurses.”

I’ve seen kids like this—scared out of their wits. I know a strep test isn’t the most pleasant thing in the world, but some children think they’re the most painful, horrible thing possible. Fighting and holding them down won’t help dispel their fears!

First, I hope that your pediatrician only wants to do a strep test if it’s really necessary. Most sore throats, even in the winter during strep season, are not caused by strep bacteria. Strep throat typically looks like this:

• Sudden onset
• Severe sore throat, with red and swollen tonsils
• Swollen, tender lymph nodes in the neck
• Usually fever
• Sometimes abdominal pain, nausea, or vomiting
• Sometimes headache
• Seldom cough or runny nose

Most viral sore throats are more like this:

• More gradual onset
• Milder sore throat, without swollen nodes, or with small non-tender nodes
• Often runny nose and cough
• Fever, if present, will only be there for the first day or so

Based on the symptoms and physical exam, you and your doc can make a pretty good guess whether it’s likely to be strep. If it seems far more likely to be viral, it’s unnecessary to do the test. In fact, it’s more than unnecessary—it’s a very bad idea. A strep test isn’t perfect; if the “pre-test probability” of strep is very low, even a positive test will probably be incorrect.

What if based on the symptoms and physical exam the possibility of strep is very high? In that case, it may also be a good idea to skip the test—your doctor is probably going to prescribe antibiotics anyway, so why do the test? Strep tests are most important in that grey zone, when it’s kind of hard to know for sure whether an infection is likely to really be strep.

Taking it a step further, what would happen if you and the doctor decided to just skip the test, and make a guess? One of these four scenarios would occur:

1. The child really has strep, and you’ve decided to give antibiotics. Well, that’s just peachy.
2. The child really has strep, but you’ve decided against giving antibiotics. In this case, Junior will most likely get better anyway—but it will take a few extra days, and in the meantime he might be infecting other people. There’s also a small, but real chance that the infection can spread into an abscess, and a very small risk that untreated strep could result in heart damage from rheumatic fever (this is often given as the main reason to do the strep test, to avoid untreated strep. But in fact rheumatic fever for reasons unknown has become very rare in the developed world, even without antibiotics being used.)
3. The child doesn’t have strep, but you put him on antibiotics anyway. We’d like to avoid doing this—unnecessary antibiotics contribute to bacterial resistance, and put your child at risk for allergies. Still, a single course of antibiotics is unlikely to make a huge difference in any significant way.
4. The child doesn’t have strep, and you’ve decided to withhold antibiotics. Perfect.

Though it sounds like sacrilege to say it, this Pediatric Insider thinks: none of these four scenarios is likely to end in disaster.

So think carefully, and ask for your pediatrician’s input: for a child truly terrified of a strep test, is it really necessary to do it? Under ordinary circumstances, I think a strep test should always be done prior to antibiotics—there are risks of antibiotic overuse that are a real problem—but in an individual case where a child is going to be traumatized, there really is wiggle room for compassion and judgment.

OK, you’ve decided: you need to do the test. There are ways to (hopefully) minimize the discomfort and anxiety of the child. Some of these tricks I’ve tried:

• Let the doctor do it instead of the nurse. I think some patients think I’m more gentle. I don’t know if that’s correct, but if makes Junior feel better, I’m game to try.
• Let the child do it himself. Really. Tell Junior to hold the stick, and stick it down there, and swoosh it around. I’ll look with a flashlight to make sure you did it right, and I’ll keep my hands behind my back—promise. This really has worked for me, more than once.
• If the child’s willing to work slowly with me, I’ll take the swab and just rest it on his tongue awhile. Let him get used to it. Keep talking, distracting, and inching it back. It sometimes might take a few false starts, but this can work.
• Spray benzocaine solution back there to numb things up, wait 10 minutes, then do the test. Honestly, I’m not sure if maybe the benzocaine spray might interfere with the test—but at least the child feels he’s overcome some fear, and you can build from this positive experience in the future.

One thing I would not recommend is brute force. It might work—once—but it reinforces the worst lessons and scariest feelings, leaving the child vulnerable and completely out of control. It also makes future interactions a nightmare. Whether a strep test is done is never a critical issue. This isn’t someone who might be having a heart attack, or who needs an essential test to see if he has cancer. Keep things in perspective, and have some compassion. He probably feels pretty bad already, and doesn’t need some big galoot holding him down!

A Pandemic Primer for Parents

The Pediatric Insider

© 2009 Roy Benaroch, MD

It’s here.

The “new flu”, officially known as “Novel-H1N1 influenza,” and often referred to as “swine flu,” is now widespread throughout the United States and the rest of the world. We’ve seen dozens of cases in my office, and will probably see hundreds more in the next few months. The World Health Organization has officially declared it an epidemic, and I’m officially declaring it a great big pain in the arse. For parents, kids, and pediatricians, it’s going to be a long, long winter.

The new flu first appeared in Mexico in the spring of 2009, and cases very started appearing in the United States soon after. Although early media reports focused on a very high mortality rate, hundreds of those early cases were later re-classified  by United Nations health officials as unrelated to, or at least not-definitely-caused-by, the new flu strain. Still, media reports have seemed to give the impression ever since then that this new flu was far deadlier than influenza infections we have seen before. While there is some fear that the new flu could become more virulent, right now the strain circulating here is not worse than any other flu. It’s more common, and it’s spreading faster, but in terms of how sick your child is likely to get the new flu is no worse than ordinary winter flu. Which is still pretty bad, don’t get me wrong, but the media is really pushing an unwarranted “killer flu” story that’s causing a lot of unnecessary anxiety.

Let’s set the record straight.

Why is the new flu special? Why are they making such a big deal about it?

This influenza strain, called “Novel H1N1,” truly is a new flu virus. No one has ever been exposed to it before, so almost none of us have any protective antibodies (about a third of elderly people have some antibody protection, presumably from flu strains that circulated long ago, but it’s unclear if that will help prevent them from getting sick.) It has quickly spread throughout the globe, and we’re seeing many cases of flu right now caused by this new strain well before the start of the usual winter flu season.

It is worse than regular flu?

Because no one is immune, the new flu will probably infect far more people this year than typically get the winter flu. Some health authorities estimate that ten percent of the American population will get it. With so many sick people, there could be a major impact on businesses and the economy, and on the ability of hospitals and clinics to help take care of sick people.

But at least so far, individuals who catch this new flu are no sicker than individuals who catch the ordinary winter flu. It makes people sick, sure, but the vast majority of us will recover fully with no medication needed.

Why is it called the swine flu, anyway?

The new H1N1 flu is genetically similar to an influenza virus that occurs in pigs, and may it is probably a mutated version. But you can’t catch swine flu from being around pigs or eating pork.

Good, I like bacon. If I can’t get it from pigs, where can I catch it?

People, especially sick people, and especially sick people who don’t wash their hands.

How can my family avoid it?

There are many strategies that can help. As a community, we need to encourage sick people to stay home from work, and sick children to stay home from school. People with flu need to avoid crowds for about a week, or at least 1 day past the time all symptoms improve. This creates difficulties with people feeling they need to get back to work—but we’re all in this together. Employers need to encourage people to stay home, and schools need to STOP penalizing children for missing days when they’re sick.

One of the most important strategies for avoiding the flu is to keep your hands clean. Flu virus must get into your body through the lining of your nose, or your mouth, or your eyes. It can’t get through your skin. Even if you just shook hands with The Captain of the Influenza Snot team, you won’t catch the flu until you touch your own face. Wash your hands frequently, or use hand sanitizer. Use a tissue if you’ve got an itchy nose rather than your bare hand, and throw that tissue away afterwards. And stop fiddling with your contact lenses, will ya?

Isn’t there a vaccine for the swine flu?

Yes, there is a vaccine in development—but the CDC is now saying they think it will be available in mid-October, and that’s probably optimistic. It’s not clear how it will be distributed, how many doses will be necessary, how many doses will be available, or for whom the vaccine will be recommended. You can follow the latest news about the vaccine and availability at the CDC’s novel H1N1 flu site.

Will the ordinary winter flu vaccine help?

You should definitely get the ordinary winter flu vaccine, which is available now. While it won’t specifically protect you against the new flu, soon the regular winter flu will also be circulating, and getting them both will be a miserable double-whammy. If fewer people catch the ordinary winter flu, may help prevent the new flu from becoming more virulent.

What are the symptoms of the flu?

Fever, body aches, headaches, runny or congested nose, and cough are the most frequent symptoms. Some people also have nausea, vomiting, or diarrhea. The symptoms last about five days. While some people use the word flu to describe any sort of bad cold, the symptoms really are quite different from and more severe than an ordinary upper respiratory infection.

If I think I have the flu, or my child has the flu, should I go to the doctor?

People are having severe symptoms should certainly see their doctor. This includes difficulty breathing or pain that isn’t relieved by over-the-counter medicine. People whose illness lasts longer than five days without improvement, or people who are at high risk for complications of the flu (babies, elderly people, or those with chronic health problems) should also strongly consider a doctor visit.

On the other hand, most people with influenza have relatively mild symptoms that are at least temporarily relieved by rest and over-the-counter medicine. These people really ought to stay home so they don’t unnecessarily expose more people to illness, and so they don’t overwhelm clinics and emergency rooms that will be needed for sicker patients.

What are the warning signs of severe flu—the signs that we need to see the doctor right away, or go to the emergency room?

• Fast breathing or trouble breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting
• Being so irritable that a child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

(from http://www.cdc.gov/h1n1flu/qa.htm)

What can relieve symptoms of the flu?

Rest and fluids are very important. Over the counter medicines like ibuprofen (Motrin or Advil) and acetaminophen (Tylenol) will help relieve the aches and fevers. Honey helps cough, nasal saline spray helps congestion, and a nice pot of chicken soup helps everything. I like ice cream and popsicles, too (I am a pediatrician, after all.) There are shelves full of “cold and flu” medications available at the local CV-Rite-greens, but by and large they don’t actually work.

There are a few medications that can be prescribed to fight the flu virus, but they’re not especially effective and shouldn’t commonly be used. The one that’s most widely known is Tamiflu. Ordinary winter flu has already become nearly 100% resistant to this drug, and the new flu is quickly becoming more resistant as well. To work, Tamiflu and other flu medications need to be started as soon as possible after infections; even then, they don’t confer a tremendous benefit. Currently, anti-flu medicines are recommended only for cases of severe flu and for people at high risk for complications from flu.

What’s the incubation period for flu? How long is a patient contagious?

The incubation period for ordinary flu is 1-4 days, usually 2. A person becomes contagious 1 day prior to the fever, and can continue to spread the virus at least until the fever is gone (5 more days), and probably for one further day. Although these characteristics aren’t as well studied for the new flu virus, they’re probably about the same.

What’s with the masks, anyway?

Media reports on the new flu from Mexico, and the Bird Flu of East Asia, invariably showed people wearing masks. Though flu virus can spread in coughs and sneezes, the main way that masks probably help is by preventing healthy people from reaching up to scratch their noses, or reaching into their own mouths. Likewise, eye protection will not only keep sneezed flu-laden mucus from reaching you, it’ll also keep your hands away from your own eyes. That’s a very good habit for this winter.

Wow, thanks unpaid physician author, I’ll sleep much better tonight! But what if I have more questions?

Stay away from the “It bleeds, it leads” local news, and instead check out these reliable resources:

• The CDC’s H1N1 page
• More info from the US Gov’t
• The international perspective from the WHO
• See what the big-brained folks at The New England Journal of Medicine have to say
• This has nothing to do with the flu, but it’s cool and kid friendly

Media scaremongering and Gardasil

The Pediatric Insider © 2009 Roy Benaroch, MD

Count on routine media outlets to mangle and misinterpret science news and information. The recent brouhaha over the Gardasil vaccine is a typical example of how science writers in big media are far more interested in making a splash than in conveying accurate, useful information.

On August 19, 2009, the Journal of the American Medical Association published “Postlicensure Safety Surveillance for Quadravelent Human Papillomavirus Recombinant Vaccine”, a study reviewing adverse events following administration of Gardasil. That’s Merck’s vaccine designed to prevent infections with the virus that causes genital warts and cervical cancer.

The article was pre-released 2 days early to news outlets, though not to physicians. As is typical, doctors don’t get to read these studies until after “the news” folds, spindles, and mutilates the story for a few days. By the time most physicians get to actually read the report, the news has moved on to some other crisis.

Some headlines, reflecting how the study was reported:

• From US News and World Report, Gardasil Side Effects Tough to Monitor.

• ABC news says Gardasil HPV Vaccine Faces Safety Questions.

• UPI (whose web site boasts “100 years of journalistic excellence,”) proclaimed Report Links Gardasil to Side Effects.

• Yahoo News, in a story from Time magazine, seems to have reached a different conclusion. Their headline reads HPV Vaccine: Study Suggests Gardasil is Safe.

Using the resources of my crack research team (I asked the librarian at Children’s Healthcare of Atlanta to send me a copy of the article, and I read it this past weekend), I can now reveal what the JAMA article actually said. As always, you can depend on me for true Pediatric Insider information.

But first, some required boring background information: infections with Human Papilloma Virus (HPV) are the root cause of genital warts and cervical cancer. This is by far the most common sexually transmitted disease, with almost 80% of US adult women having been infected at some point in their lives. Though most infections with HPV are successfully cleared by the immune system, some infections remain active for a long time, and can eventually lead to serious problems. The virus can also more rarely cause throat and oral cancers, anal problems, and nodules in the respiratory tract of babies that lead to serious, even fatal, respiratory problems.

In 2006 the FDA approved a vaccine called “Gardasil” that had been shown to prevent infections by 4 of the nearly 100 strains of HPV. These four were among the most common strains to cause cancer and warts, and probably account for about 70% of cases of cervical cancer in women.

The study reviewed all side effects reported to the Vaccine Adverse Event Reporting System, a passive government database. Anyone can report side effects to this database, including representatives from Merck (they reported more of the side effects than anyone else), medical personnel, or patients. Any sort of side effect can be reported at any time—the database is meant to cast as wide a net as possible, to collect any possible side effects.

About 23 million doses of Gardasil had been administered during the 2 ½ years of the study period. During that time, 12, 424 adverse events were reported, meaning one in 1850 doses. The most common reactions were fainting (14%), dizziness (14%), nausea (9%), and headache (8%). Of the 12,424 adverse events, 772 were considered “serious”—including allergic reactions, blood clots, and neurologic manifestations. That’s one in about 30,000 doses.

Press reports about this study invariably focused on deaths. The most widely quoted number was 32 deaths reported in the study; of those, 8 were second-hand reports that couldn’t be verified, and 4 didn’t include identifying information. There were 20 verified deaths reported to VAERS for which medical records could be reviewed. The cause of death among these 20 were:

• 4 – unexplained
• 2 – complications of diabetes mellitus*
• 1 – prescription drug overdose*
• 1 – amyotrophic lateral sclerosis (Lou Gehrig’s Disease)*
• 1- bacterial meningitis*
• 1 – influenza*
• 3 – pulmonary embolism; two of the cases were also taking contraceptive pills, a known risk factor for clotting. One of these was also a complication of diabetes mellitus (another cause of PE), but it’s unclear whether that person was also on contraceptives.*
• 6 – cardiac causes including arrhythmias
• 2 – seizures

(These total 21 because one reported case had 2 of these conditions.) I starred items that are clearly related to pre-existing or unrelated cases, though in some instances like the 2 with seizures, it’s not clear whether this was a preexisting problem or not. But liberally counting the ones that might have been caused by Gardasil, there were 12 deaths. Among 23 million doses. That’s one in about 2 million.

And it’s not at all clear that even these 12 deaths were in any way related to Gardasil. Though it seems heartless to say so, there are always some deaths among any group of people, even healthy young adults. I couldn’t find an exact expected death rate for women aged 9-26 (that’s the ages where Gardasil is licensed), but just for comparison I did find the death rate for teenagers 15-19—nationwide in the US, it’s 65 per 100,000 per four years. Assuming ~ 10 million different women got Gardasil over the 2 ½ year period of the study (each patient is supposed to get 3 doses, but most in fact get only 1 or 2), if the death rate of 9-26 year old women is the same as the death rate of 15-19 year old teens (or at least in that ballpark, which is reasonable to assume) then you’d expect (2 ½ * 65 * 10,000,000)/(100 000*4) deaths during the study period, or 4065 deaths. Even if you assume about ½ of these were from car accidents, homicide, and suicide (these are the leading causes of death at that age, though violent death is more common in males), that would still mean you’d expect about 2,000 deaths to be reported.

2,000 deaths expected. But only 32 were reported. This is good news, right? From a statistical point of view, the reported deaths were very much within the rate of deaths that’s expected—in fact, it was far, far lower.

Now, there are some reasonable criticisms of the study. It’s entirely possible that some deaths went unreported—this is a passive system, and someone has to take the time to report deaths. However, after such a dramatic and serious event as a death you’d think at least most families and physicians would make a report. But let’s even assume that only 1 in ten deaths was reported—even then, if there really were 320 deaths rather than 32, that’s still far less than the expected ballpark “background” death rate of 2,000.

Though press reports concentrated on the reported deaths, when you look at the study and the actual numbers the only reasonable conclusion is that there is no increased risk of death after vaccination with Gardasil. Oddly, few of the mass-media outlets reported the study that way.

Of the 772 reported serious reactions, many were self-limited, and many, like the deaths, were clearly not related to vaccination. Clearly, however, this are some true side effects; like any medical intervention, Gardasil has both risks and benefits. But it’s good to know that serious reactions are so rare.

Of the adverse events that did occur at relatively high rates, fainting is one that we ought to be watching out for. If a girl faints after a dose of vaccine, she can fall and hit her head or otherwise injure herself—in fact, that was the most common of the 772 “serious” side effects, an injury after a fall following fainting. For this reason, Gardasil should be administered while the patient is lying down, and afterwards it’s a good idea to stay lying down for about 5 minutes. Note that teenagers, male and female, are apt to faint after other vaccines, blood draws, and other medical procedures, so lying down after any sort of shot is probably a good idea.

There are some important questions about Gardasil that still need answers. It’s unclear how long protection will last, and it’s unclear how Gardasil immunization will effect rates of cervical cancer many years later—those studies just haven’t been done yet, because they take so much time. Reasonable families, given these unknowns, may have misgivings about immunizing now against a disease that shows up so much later. Gardasil vaccination is also very, very expensive—at least $400 for the three doses, and considering that cervical cancer is not common, and can be screened for with pap smears, there may be better uses for these health care dollars. Still, from a safety point of view, the recently published study is very reassuring, and very good news for families considering this vaccine. Too bad many in the press didn’t bother to get their facts straight to present the study in a truthful manner.

Stinky pits

The Pediatric Insider

© 2009 Roy Benaroch, MD

Rosa asked, “What can I do for my teenager’s stinky armpits? He uses an antiperspirant, but he still sweats a lot and smells bad. He doesn’t want to talk to the doctor about it, so he can’t get a prescription. Is there anything else I can do?”

Hope is on the way!

I know this sounds weird, but most people don’t use antiperspirants correctly. Antiperspirants will work much better if they’re put on at night, before going to sleep. That way they can soak into the sweat glands. If your son puts on his antiperspirant in the morning, he’s already sweating and diluting the effects.

You don’t believe me? Try it for a few nights—trust me. Put on antiperspirant right at bedtime. Even if you shower in the morning and don’t put more antiperspirant on, you’ll stay dryer than if you used your roll-on after the shower.

Another advantage: you won’t end up with those pit-stains on your clothes.

There are also a few “prescription strength” products now on the market, like “Degree Clinical Protection.” I don’t have any experience with these, but if they truly have a higher concentration of active ingredients then they may work better than the ordinary stuff. A doctor could also prescribe a high concentration antiperspirant, but honestly using the ordinary over-the-counter stuff at night seems to work well for almost everyone.

You could also look into deodorant soaps or other products that might mask the smell better.

I’d also like to reassure your son that he really could talk to his doctor about this, or anything else. There is very little we haven’t heard, and just about nothing is off-limits. Rarely, a true medical condition can cause excessive sweating, so if this issue is new or your son is losing weight or otherwise doesn’t feel well, he really ought to go talk to a doctor. I won’t complain, even if he’s stinky.

The Poopy Party

The Pediatric Insider

© 2009 Roy Benaroch, MD

Julie’s 3 year old son uses the potty great—at least for urine. For poop, well, he’d prefer to use a diaper. What she needs to know about is the poopy party, and how to create some fun and excitement to get her son to take that last step!

Keep in mind: there are three ironclad rules of parenting. You can’t make ‘em eat. You can’t make ‘em sleep. And you definitely can’t make ‘em poop. Kids will hold it and hold it, and will make themselves sick, if you try to force them to poop on the potty. Don’t try that. No forcing, no punishing, no humiliating, nothing at all negative is going to work if you want your child to be successful on the potty.

Fortunately, all kids inherently want to succeed and learn new things. As soon as they’re sure you’re not pushing, and they start to get an inkling that—hey, this is the way to go!—they’ll do it. For kids who are a little late to the party, here’s one way to jump-start the process.

“The Poopy Party”: A method to encourage using the potty for stool

This works best at age 3 and above, and seems more effective with boys than with girls. You’ll see why! It’s important to “ham it up” and really play with this to create a sense of fun and excitement about the potty. At no point should you be direct—never say “Don’t you want to use the potty now?” The point is to create excitement, but only to indirectly talk about what the potty is for.

You’ll need: a willing Daddy (this is manly stuff, and seems to work better mano-a-mano), two hardhats, two bright orange construction worker vests, and two big chunky flashlights. Feel free to add any other mechanical-plumber sort of equipment.

Dad puts on his outfit with hat and vest, and goes to get the child so he can put his set on. They’ve both got their own big flashlights. Dad says something like, “Something’s up with the toilet, we’ve got to get it fixed so the poop can go to The Poopy Party!”

Don’t talk more about The Poopy Party…yet. Let the excitement build!

Then go to the toilet and take it apart, or as much of it as Dad feels comfortable putting back together. Talk about the parts, the flusher, the bobber thing, the insides, and where the poop goes down. Then, if you can, go to the basement and pull down some tiles, and shine your light along the big drain pipe all the way outside the house. Go out to the street and pull off a manhole cover (or the utility cover over the water main, or just peer down a storm drain) and shine your lights down there. Then talk about The Poopy Party. Yep, that’s where the poop goes, down there. There’s dancing and singing, and it’s a great place for poop to go!

If you want to go a step further, take the child to the county wastewater treatment plant. You’ve got to keep the hardhat on. Explain there that you want to show your son where the poop goes. They’ve got big tanks and turbines and other manly things. Then go out for ice cream.

Afterwards, hang up the vest in the bathroom where he’ll see it, but – and this is very important – do NOT talk about this any more. You set the stage, make it exciting, but do not remind or suggest. Anything like that will further delay potty success.

And be prepared, once he’s using the potty, to bring the vest everywhere you go.

Acetaminophen safety alert

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kelly posted, “After the FDA’s recent announcement about the dangers of acetaminophen overdose, I now think twice before using it for me or my family.  What’s your take on whether the drug is safe in the prescribed dosages – particularly for kids?”

In June, 2009 the FDA released information from an advisory committee studying the safety of medications containing acetaminophen (most commonly known by the brand name Tylenol.) They pointed out that acetaminophen can cause acute and chronic liver injury, which can be fatal. Since then, the manufacturer has started an advertising campaign defending the safety of their product. So who to believe?

Acetaminophen is very, very safe—when taken correctly by people who are not already at risk for liver problems. But it turns out in practice that many, many people have been injured because they didn’t take the medicine right, or didn’t realize that acetaminophen isn’t always safe for everyone.

Who shouldn’t take acetaminophen? Anyone with chronic liver damage or liver disease. The main group are adults who consume too much alcohol. It turns out that not everyone tells their doctor about their alcohol habits, so doctors haven’t necessarily warned people about this. Other causes of chronic liver problems are obesity (so-called “fatty liver” has become the most common cause of liver disease in adolescents), the use of other medicines that affect the liver, and hepatitis. For most children (excluding overweight adolescents), the chance of having liver disease is very, very small.

How do you take acetaminophen correctly? Read the label. Use the included dosing device, and if you’re not sure how to use it, ask your doctor or pharmacist. Don’t combine multiple medications that contain acetaminophen, and make sure that if your child does take other medicines every day, you know if there are interactions between that and acetaminophen (or any other over-the-counter meds you might try.)

One specific recommendation from the FDA committee was to insist that all children’s and infant’s acetaminophen products be sold at the same concentration, simplifying dosing instructions. Right now there are several different strengths of liquids, chewables, and “Junior” tablets that are unnecessary and confusing.

Also, don’t use acetaminophen (or any other medicine) unless you really need to. Fever itself doesn’t necessarily need to be treated with medication (see here and here), but if your child feels lousy, you ought to try to help her feel better.

Alternatives to Tylenol include Motrin or Advil (both are brands of ibuprofen, see here for comparisons), or a non-medical approach like cool towels to reduce a fever, or a gentle heating pad to reduce ear pain.

If your child is in pain or has a fever, acetaminophen is a good safe medication to use. Just use it carefully and correctly, and check with your doctor or pharmacist if there’s any reason to think that your child has liver disease or is on any other chronic daily medication.