Most natural remedies aren’t

Posted January 17, 2017 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2017 Roy Benaroch, MD

Rachel wrote:

My daughter and I were talking the other day and saying we would like to ask a doctor what his thoughts are about all these ‘natural’ remedies that are available. Recently a friend made the remark, ‘I do everything I can to avoid a doctor.’ I lean more toward the medical system and the knowledge they have acquired over the years rather than relying on these home remedies. What are your thoughts?

A great question, Rachel. It turns out that many of these “natural” remedies aren’t very natural at all. Something should be considered “natural” if it exists in the world around us – if it’s a part of the observable, real world we live in – and a part of our world that we didn’t create or imagine. Trees and rocks and wind are natural. Ghosts and voodoo curses are not (they only exist in our imagination). Bridges, ovens, clothing, and books are not (we made those things.)

When you think about it, a lot of what passes for “natural” remedies are not natural. Homeopathic remedies rely on an entirely imagined mechanism of chemistry invented by Samuel Hahnemann around 1796. He thought that by diluting and shaking substances, a vital essence of their properties could be captured, which upon further dilution could alleviate the symptoms that were caused by ingesting that same substance. Acupuncture relies on changing the flow of a life-energy, Qi, through channels in the body that do not, objectively, exist. Chiropractic (invented by DD Palmer in 1895) relies on identifying and treating “subluxations” that do not exist on x-rays or any other objective test. Modern chiropractors have acknowledged that their subluxations are more of an idea than a real thing, but most of them insist that treating these nonexisting things is helpful. (Not all chiropractors subscribe to this belief – a small group is trying to distance themselves from the dogmatic belief in Palmer’s subluxations. I wish them well.)

Many other kinds of healing supported by “naturopathic doctors” are not at all natural. Reiki, Ayurveda, “detoxification”, iridology, reflexology, kinesiology, and many other ideas are like homeopathy, chiropractic, and acupuncture. They all  “supernatural”, like ghosts and voodoo and magic.

What about herbal medicine? Herbs, themselves, are natural (and, often, tasty!) But what’s sold at drug and what used to be called “health food” stores is not. Many herbal supplements do not in fact contain the labeled herbs. The herbs are imaginary and un-natural. Even if the herbs are indeed contained in the supplement, by the time they’ve been processed and turned into capsules, are they any more natural than the “medications” on the shelf nearby?

I think the wisest way to think about Rachel’s question is to reject the false dichotomy between what’s “natural” and what’s not. There’s nothing inherently safer or better about natural things. Smallpox is natural, earthquakes are natural, heart attacks and strokes and cerebral palsy are all natural. Poisons from pufferfish and venoms from rattlesnakes are natural. On the other plenty of good and necessary things are “unnatural.” The food we eat has been grown with fertilizers and pesticides (including organic foods, which use all kinds of substances you wouldn’t consider “natural” at all), brought to stores by trucks on roads driven by people wearing wristwatches and clothes. None of these things are natural. And that’s OK.

 

Coming up next post: OK, fine, natural remedies aren’t natural. But do they work?

Who you gonna call?

Thanks, 3 million!

Posted January 12, 2017 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

Hey Insiders! It’s time for a quick thanks! About a month ago we passed 3 million views, which is pretty cool for a blog with no commercial partners. I don’t get any links or love from pay or industry sites – all of my traffic comes from you guys, sharing and posting and linking. Thanks!

For those who’ve found the site recently, let’s go over the rules: Feel free to share and post. Anything derogatory, threatening, or downright mean will be deleted. If you’ve got a topic to suggest, feel free to write in – but keep them brief and general. I will not respond to questions asking for specific or personal medical advice. If you’re my patient, contact me at my office with medical questions.

Thanks again, especially for the posts, comments, and shares!

Thanksgiving parade

Nosebleeds: A quick guide to prevention and treatment in children

Posted January 9, 2017 by Dr. Roy
Categories: Medical problems

Tags: , ,

The Pediatric Insider

© 2017 Roy Benaroch, MD

Frequent commenter wzrd wrote in, “Perhaps in the future, a timely article on epistaxis, specifically seasonal/winter related? I used to have the worst nosebleeds in the winter as a child, literally filling bath towels with blood. I’m sure that you’d have excellent insight into the worthiness of cautery in severe cases.”

Wzrd here is asking about epistaxis, usually called a “nosebleed” by most people. I have no idea why doctors need a separate word for everything. Hey! Were you curious about where that word, epistaxis, comes from? “Epi” shows up in a lot of medical words, like epidermis or epiglottis – it means “upon.” The “staxis” means to “to let fall in drops,” sharing the same root as “stalactite”. Which doesn’t necessarily mean nosebleeds are like stalactites hanging off your face. Isn’t language fun?

Winter nosebleeds are often caused by dry, hot air pouring out of the furnace. That dry air sucks the moisture out of the lining of the nose. Little cracks form, which are itchy and irritated. Junior rubs or picks his itchy nose, and nosebleeds start. Once a nosebleed begins, it will clot off—omnes sanguinem clausuris—but the clot is never as strong as the intact blood vessel. So children typically get a few nosebleeds in a row, over a few days, as they continue to rub their itchy dry nose.

Parents need to make sure there isn’t some other kind of issue going on. If a child has nosebleeds accompanied by other bleeding—like bleeding under the skin, or gum bleeding—or if there’s a strong family history of excessive bleeding, then a blood workup for a bleeding disorder is needed. Most of the time, though, nosebleeds are just nosebleeds.

Nosebleeds, as wzrd said, can sometimes bleed a lot, even soaking sheets or towels. (More medical lingo fun: in doctor-talk, we call that “bleeding like stink.” I don’t know the Latin roots of that phrase.) To treat a nosebleed, have your child sit up, maybe leaning forward a bit, and pinch the fleshy end of the nose shut. Be gentle—it doesn’t take a hard squeeze. Then resist the temptation to check too soon. Once you let go, if it’s still bleeding you should hold it even longer the next time. Start with a 5-minute hold, and if that doesn’t work 10 minutes, and if even that doesn’t work, try 10 minutes again on your way to the ER to get the nose packed. You can also try putting some ice (or a bag of frozen peas) on the bridge of the nose to decrease blood flow.

You may have heard that people with nosebleeds ought to lie down, or lie back. That’s not a great idea. More blood will be swallowed that way, and blood in the stomach can cause vomiting.

To prevent nosebleeds, keep the air as humid as possible. A vaporizer or humidifier can help, especially one that really pours out the mist. A good humidifier will use at least a gallon of water to humidify a child’s bedroom every night. Many nosebleeds are also caused by picking (or, as we say in Latin, “digital trauma.”) You may want to encourage Junior to keep his or her fingers out of there.

You can also moisturize your child’s nose by having him snort some saline nasal gel. Dab a blob of this gel—it has the consistency of toothpaste—on a fingertip, and have your child snort it up into his nose at bedtime. They also make swabs of saline gel, but the swabs themselves are stiff and can irritate the lining of the nose if used too aggressively.

If nosebleeds are frequent or problematic, and these simple steps haven’t helped, the next step would be to visit an ENT specialist (or an “otorhinolaryngologist” – you look up the Latin. What do I look like, Google?) They can peek up the nose with a little endoscope, and see if there’s an exposed blood vessel that can be chemically cauterized. The procedure is done with a little squirt of topical anesthetic, and is reasonably easy and painless to do once a child can sit still.

Drowsee

Why aren’t there any cough medicines that actually work?

Posted January 3, 2017 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

Coughing is one of the most common reasons parents bring their children to see me. And I can see why. Coughing is noisy and uncomfortable, and gets kids dirty looks in schools and subways. Even worse, coughing keeps kids and their parents awake. We’ve all been there, and no one likes to cough.

But: coughing is there, usually, for a reason. Almost all coughs are from upper respiratory infections (that’s fancy talk for common, ordinary colds caused by common, ordinary viruses.) People cough because viral infections cause excess mucus to form throughout your “respiratory tree” – from your nose, down your throat, down the airways deep into your lungs. And that mucus isn’t good. If it just sits there, that warm sticky mucus will attract bacteria like swimming pools attract children. Worse, once the bacteria are enjoying themselves in the sticky mucus, they’ll reproduce and make tons more bacteria, causing more inflammation and more sticky mucus.

Fortunately, we have a built-in, excellent way to get rid of that sticky mucus before it gets loaded with bacteria. It’s called “coughing”. Coughing brings the mucus up and out of the lungs and respiratory tract (it’s usually swallowed, which is harmless – respiratory bacteria cannot survive in your stomach.) Coughing also agitates the mucus, preventing bacteria from developing their defensive biofilm and creating a huge colony of pus-filled goo.

Coughing is good. It’s there for a reason. And: if we had a medicine that could genuinely stop a person from coughing, it would kill people. People taking that magic medicine would end up filled with infected mucus, and if they couldn’t cough it up, they’d die. There is no “medical” way to get out infected mucus. No medicine, no suction, no procedure we’ve ever come up with is nearly as effective as a good old fashioned, God-given cough.

There are dozens, maybe hundreds of medicines you can buy that allegedly help stop or reduce the cough. One brand of them has that adorable mucus-monster guy—which is ironic, because coughing is the only way to get rid of him. Why are there so many choices of cough and cold medications at the drug store? Because none of them work. Sure, some might make you sleepy, and a few might reduce nasal congestion for a little while. But none of them, zero, none, have ever been shown to reduce cough in any meaningful way.

How long should an ordinary cough last? Longer than you think. Only 50% of coughs with a common cold improve by day 10. Many last 2 or 3 weeks, and 1 in 10 children with ordinary coughs are still coughing well past that 3 week mark.

Not all coughing is medically benign. Many coughs are caused by asthma, which shrinks down the breathing tubes and causes them to collect even more mucus. Asthma-caused coughs need to be treated with asthma medicines (not with cough “suppressants” or any other alleged “cough medicines”.) Some coughs are triggered by post-nasal drip from allergies, and we do have effective strategies and medicines to treat those. Coughs can also be triggered by lots of other things, like a side effect of some medications, or by an inhaled foreign object, or by pneumonia (which in children is usually viral, but that’s another story for another day.) Though most coughing is ordinary and benign and viral, a bad or lasting or troublesome cough should be evaluated by a doctor to determine the cause.

So what to do with a child who’s coughing? Soothe the airway with extra liquids, maybe a popsicle or warm soup (either warmish or coolish liquids seem to help, whichever you or your child prefers.) Older kids can suck a cough drop. Some families swear by those vapor products, like Vicks, though evidence that they help is weak. Of all of the “medicines” that have ever been studied to help with cough in children, the one with the best-documented effectiveness is honey. Not honey-made-into-cough-medicine, just regular ordinary honey from the grocery store, which is safe to use from age 1 and up. Honey, of course, won’t stop the cough – nothing will, which is good – but it can be soothing and seems to help with the throat irritation.

Coughing has a purpose. It’s there to prevent an ordinary, mucousy cold from turning into something much worse. There’s no medicine that stops a cough, and that’s a good thing.

**Bonus! Didja know why it’s sometimes spelled mucus, and sometimes spelled mucous? Grammar can be fascinating and disgusting!


koffingicon_400x400

What can be learn from vending machines and casinos to stop childhood whining?

Posted December 19, 2016 by Dr. Roy
Categories: Guilt Free Parenting, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

Megan, like all parents, hates the whining and nagging:

It’s driving me crazy. My children whine and complain until they get what they want. I try not to give in, but sometimes it’s just impossible. What can I do?

(That’s an excerpt from a much longer message. You get the idea.)

Let’s look at whining from a classic behavioral approach. Stay with me, here – behavioral theory is a big part of why we do the things we do, children and adults alike. It’s worth understanding.

What we’re talking about here is called “operant conditioning.” Basically, whether people continue to do something depends on the consequences. If complimenting your spouse gets you a friendly smile or peck on the cheek, you’ll keep doing it (assuming you like smiles and kisses.) If your child’s whining means she gets what she wants, she’ll keep doing that, too. A related term is “positive reinforcement” – that’s a reward or benefit that comes after a behavior. Positive reinforcements (giving a child exactly what she wants) make it more likely that the behavior (whining) will happen again.

So: step one of dealing with whining (or many other undesirable behaviors) is to remove the positive reinforcement. But there’s a twist, here – it turns out that the schedule of the positive reinforcers can change how well it works. This might not be intuitive, but it turns out that regular, always-given, predictable positive reinforcements are not as lasting or powerful as irregular, unpredictable, changing positive reinforcers.

Think about vending machines and casinos. With a vending machine, you always get exactly what you ordered (assuming the stupid thing isn’t broken – there’s an interesting behavioral lesson about that situation, too, but we’ll save that for another time.) People who get things from vending machines are positively reinforced, but they don’t typically crave vending machines. And: when the positive reinforcement ends (say, for 1 or 2 times you don’t get your bag of Funyuns), you’ll quickly stop using the vending machine.

But at a casino, you don’t know what your reward will be, or even if you’ll get one. In fact, most of the time, you get nothing at all. But that kind of reinforcement, the “sometimes-surprise” schedule, reinforces the behavior even more effectively. Think about people pumping money into slot machines, only to get occasional, unpredictable rewards.

Let’s come back to whining. If you reinforce the whining sometimes, or in an unpredictable way (“Here! Just have the whole bag of lollopops!”), you’ll unintentionally be encouraging the behavior even more than if you always said “yes.” If Megan is serious about stopping the whining, she has to stop reinforcing it, and shouldn’t give in. Ever.

What about punishment to stop whining? A punishment is an action you take after the behavior, a consequence that’s designed to stop the behavior. It turns out that behavioral studies in animals, children, and adults show that punishment is typically only temporarily effective. Yelling at your child for whining, or restricting privileges, or some other punishment – none of these will work well. That’s like the vending machine giving you a bag of stale chips. You’ll be mad, and might avoid the vending machine for a few days, but you’ll be back. Or, imagine, if a casino sometimes just took your money away from you. That’s a valid punishment, but it doesn’t really change a behavior as well as completely stopping the positive reinforcements (in a casino, the occasional big payouts.) If the punishment of losing money at casinos actually worked, they’d all be out of business.

Sometimes, there’s more to whining than just behavior and consequences. I’d consider the child’s development and communication skills, and overall parenting style, expectations, mental health, resource scarcity — lots of things beyond behavioral theory. But a straight-up behavioral approach is sometimes the simplest, best way to get children to stop with the whining. And if it works, Megan owes me a trip to Vegas. Or at least a bag of Funyuns.

Red wine pouring into wine glass, close-up

Red wine pouring into wine glass, close-up

Preventing and treating pediatric migraines

Posted December 12, 2016 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents are sometimes surprised to find out that migraines are the most common cause of recurrent headaches in children. Yes, kids get migraines – and many adults who get them started getting them as children, even if they weren’t diagnosed correctly.

(And: many adults who get migraines are still not being diagnosed correctly. Do you get “sinus” headaches? They’re almost certainly migraines. Yes, I know you feel congested with them. Yes, I know you know they’re “sinus.” But they’re not. They’re migraines, and have nothing to do with your sinuses. But I’m getting off topic here, and I’m not your doctor, and feel free to just disregard this paragraph.)

Dealing with pediatric migraines starts with making the right diagnosis – which is usually easy, if you listen to the patient and ask a few of the right questions. A brief physical exam can confirm that there’s nothing else to worry about, and advanced imaging like CTs or MRIs is almost never needed. Once there’s a history of over a few months of recurrent headaches, a clinical exam will tell you everything you need to know.

Prevention is the key. Migraines are really uncomfortable and disruptive, and an ounce of prevention is worth much more than a pound of cure. Many pediatric migraines are triggered by things like hunger, lack of sleep, disrupted schedules, dehydration, and many other lifestyle habits. Stress is almost always another contributor. Remember: stress to a child includes not just worry, but even excitement and strong positive emotions. Stress isn’t just things a child doesn’t like. Families and kids can learn to identify and avoid some of their own triggers, leading to far fewer migraines.

In adults, daily medications are commonly used as preventives. A recent study from the New England Journal looked at two common migraine preventers in children – topiramate (AKA Topamax) and amitriptyline.  The good news is that both medications did decrease the frequency of headaches – but the bad news is, neither was any better than the placebo group. That’s right, whether the study participants (all children and teens) took either of the drugs or a placebo pill, they all reported a decrease in headaches. Score one for sugar pills! Both the amitriptyline and topiramate groups experienced side effects, so the study was stopped early.

There’s some evidence for the effectiveness of a few less-traditional agents to prevent migraines in adults. These might help in children, too. Vitamin B2, taken daily, seemed to work better than placebo, and at least small trials of a few other generally-safe agents like magnesium and butterbur show promise. Even if they’re not much better than placebo, they’re safer than most medications.

We do have very good “abortive” agents to treat migraines once they begin. These include non-steroidal OTC meds like ibuprofen or naproxen, or prescription medications called “triptans”. All of these work best if taken very soon after any migraine symptoms start. But all of these are also prone to causing “rebound headaches” if taken too frequently. So, again, prevention is better than cure. (Still, a cure is nice to have if you need one!) By the way, narcotic medications should never be used to treat migraines, especially in children—they increase the sensitivity of the pain system, and can increase pain episodes
after even short-term use.

If your child has recurrent headaches, start by keeping a log to track potential triggers and causes. Don’t discount the role of stress, even if your child “doesn’t seem stressed”. And try to encourage good, regular sleep and eating habits. Still having headaches? It’s time to see the doctor. Even if daily medications don’t show much promise, we’ve got other good options to both prevent and treat migraines in children.

How old is he now, anyway?

Parents can tell if an ear infection is getting better

Posted December 5, 2016 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

Good things come in small packages. A short, sweet letter to the editor in the November, 2016 edition of JAMA Pediatrics confirms that parents can tell whether their children are getting over an ear infection, with no doctor exam required.

The letter, from four Finnish physicians, is about a page long. It summarizes a small part of their data from a much larger study on the treatment of ear infections. In the letter, they’re only looking at 160 children, age 6 months to 3 years, who were initially treated for an ear infection without any antibiotics. Current guidelines from the US and many other countries do support treating less-severe ear infections with pain relievers only, waiting on antibiotics. But these guidelines suggest that if children with ear infections aren’t given antibiotics, they need to be followed closely and re-examined to make sure they’re really getting better. These authors asked, is that really necessary?

The 160 children were all reexamined for this study, and parents were also asked questions about whether they thought their children were improving, getting worse, or staying about the same. It turns out that among the children whose parents thought were getting better, only a very small number had worsening ear exams (less than 3%). Compare that with children thought to be getting worse – about 30% had worsening findings on their ear exams. Keep in mind that these were all children who did not receive any antibiotics. Presumably, if they had, even fewer of them would have gotten worse.

Parents, not surprisingly, were pretty good at judging whether their children were getting better. So good that based on these numbers, a repeat exam to make sure ear infections were clearing was probably unnecessary!

Caveats: I’d be a little more cautious with children at risk for prolonged ear infections or  persistent fluid behind the ears. Children with a history of difficult-to-treat ear infections should get a repeat exam, as should kids with hearing problems or developmental language delays—it’s crucial that those children get over their infections completely. But for the majority of children with ordinary ear infections that seem to be getting better, it may be reasonable to wait until their next check up to look at those ears again. Most of the time, parents’ judgment is just as good as a repeat ear exam.

Finalnd!