Vaccine reactions: How your “gut feelings” can fool you

Posted November 23, 2015 by Dr. Roy
Categories: Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

I’m struck, sometimes, by the vehement tone of some of the antivaccine comments you see out there. People who hate or distrust vaccines proudly proclaim that their Googling and life experiences have taught them that vaccines are bad. They don’t care what the science or the evidence shows. They know what they know.

Me? I’m not so much into vehemence and dogmatism. I’ll follow the evidence. Show me solid science that what I’m doing is wrong or harmful, and I’ll learn. I’ll let science—observations of the natural world—guide me, rather than what Facebook or Google or “my gut” says. Why? Because our guts can so easily be deceived.

A quick example: a baby gets vaccines, and five days later develops a health thing, like a life threatening allergy to peanuts, or a fever, or SIDS, or a rash, or a fussy night, or anything. The “logical” thing to do might well be to correlate one with the other. Baby got vaccine, a few days later something happened, so they’re related, right?

Wrong. Just because one thing follows another, one thing doesn’t cause another. In Latin, this is called the post hoc ergo propter hoc fallacy. An easy example:

My phone broke when I joined Netflix. So Netflix broke my phone. No, they’re probably unrelated. Phones break all the time, and people (used to) join Netflix all the time.

Babies in the first year of life have about 5 separate encounters for vaccines (it actually may be from 4-6, depending on timing and how the flu vaccine might be given, but we’ll just say “5”). So 5 of the 52 weeks of the first year of life – or about 1 in 10 — are, in fact, within a week following vaccines. Think about that. If anything bad happens in that week, and there isn’t another clear explanation, the bad thing may well be blamed on vaccines.

Statistically, about 1 in 10 babies who die of SIDS had a vaccine within the preceding week. That sounds scary, right? But in fact 1 in 10 ordinary, healthy babies from 0-12 months of age had a vaccine within the preceding week. There is no greater chance of dying of SIDS in the week following a vaccine than there is in any other week (in fact, vaccines are protective against SIDS—babies are less likely to die of SIDS if they’ve been vaccinated.)

Sometimes, a specific emotional story can frame a discussion. A friend of mine, a pediatrician, told me this story: his office was called at 4 in the afternoon by a mom who missed her baby’s 4 month well check appointment because their car broke down. No problem, she just rescheduled. But that night, her baby died of SIDS. That’s a terrible tragedy. What would the family had thought if that same baby had in fact gotten her vaccines that very day, and died that night? It was just a fluke that the car broke down. But you can imagine how the story might have played out on Facebook if the baby had been vaccinated that day.

And Facebook – we’re just beginning to realize how the expansion of social media is skewing our perception of the world around us. I’ve called this the “exaggerating freakiness” effect (I need to find a Latin phrase for that, or it will never catch on.) When an ordinary thing happens—and millions of ordinary things happen, every day—no one runs to the internet to post about it. But we love to post about the weird things, the unexpected things, and the one-in-a-million things. We don’t read about the millions of babies who get their immunizations without any problems. But we do read about babies who had issues after vaccines—whether or not the vaccines had anything to do with the problem. We can’t tell from Facebook posts whether one thing caused another, or even if the story is true. None of that matters. What we remember are stories that have emotional impact, regardless of what they mean about reality.

Parents do not need to worry about vaccines. They’re safe, they’re effective, and there is an extremely small risk of serious side effects—far outweighed by the good they’re doing keeping children and communities safe throughout the world. Don’t let headlines, click-bait, and emotional arguments trick you into worrying. Play it safe, protect your kids, and immunize.

What is “Natural”, anyway? FDA edition

Posted November 19, 2015 by Dr. Roy
Categories: In the news

Tags: ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

You frequently see the word “Natural” on food packaging, but what does it mean? Probably not what you think it does. And the FDA has decided it’s time—maybe—to legally define the term, and enforce rules about when food manufacturers can use the word. I agree that words have meanings, and that consumers ought to be able to know what they’re buying. But “Natural” is a slippery term, and more regulations about its use might not clarify much of anything.

Natural, one would think, means “from nature” or “occurring in nature.” But plenty of things you might think of as “unnatural” are very much from nature. Like ionizing radiation, which you’re being bathed in right now (from cosmic rays from above, and radioactive elements from below. Hello, radon!) Or toxins like those made by pufferfish or chrysanthemums (the active ingredient in many lice preparations). Living organisms like vegetables are loaded with toxic compounds including pesticides that are just as harmful as anything man-made.

Pyrethrin - natural!

Pyrethrin – natural!

Likewise, some things you might think of as “natural” are not, in fact, from nature at all. Homeopathy is touted as “natural”, when it in fact relies on a completely magical, imaginary mechanism of action that can’t be observed and isn’t in any way a part of the natural world. Diluting a chemical until it doesn’t exist any more doesn’t make it magically more powerful. Homeopathy is “supernatural”, meaning that it relies on magic, not nature.

The FDA has known that it would be difficult to pin down what’s meant by “natural”, and had previously said it has no interest in formally defining the term. Their current policy is that it’s OK to use the word on foods that don’t have any added color, synthetic substances, or synthetic flavors. Their policy doesn’t consider how a product is made—so synthetic pesticides are OK, as is irradiation, as are genetically modified organisms (GMOs.) Currently, these are all fair to label as “natural”.

Several citizen’s groups have petitioned the FDA to define “natural”, tightening up their policy to exclude more things. The FDA is now soliciting comments from the public on exactly how to do that, and based on the comments I’m reading this isn’t going to be easy. Here are the current top two comments:


“Natural should mean nothing in it but food grown without chemicals…”

That makes no sense. Water is a chemical, manure is loaded with chemicals, and, well, everything is a chemical. I think what this person meant was food grown without pesticides or fertilizers—but, again, plenty of those are natural too, and current regulations for organic farmers include long lists of scary, chemically-sounding compounds that they’re allowed to use because they’re “natural.” Food can’t be grown without chemicals, and life can’t occur without chemicals, and what the chemical names are (or how “scary” they look) have nothing to do with whether they’ll hurt you or not, or now “natural” they might be.


Natural should be an ingredient that has not been boiled, microwaved, or in anyway (sic) tampered by chemical process.”

 Cooking food (boiling, baking, using a George Foreman Grill) is a chemical process—you add heat to facilitate chemical reactions. That liberates more-accessible energy, and often makes food tasty. Humans have been cooking food, in nature, for thousands of years. Does it make any sense that a food is only natural until you cook it, or that cooking makes something un-natural? Really?


The FDA, I’m sure, would like to come up with a definition that’s clear and enforceable, but in common usage the word “natural” isn’t so easily pinned down. It’s reminiscent of the supreme court’s 1964 attempt to define pornography: “I can’t say what natural is, but I know it when I see it”. Meanwhile, food-scare opportunists are making a fortune selling a fear of “un-natural” foods.

Until we come up with a way to define the word “Natural” in a way that we can all understand, I suggest you ignore it on food labels. It doesn’t mean anything—not anything more than any other marketing words, like “fresh” or “delicious”. Buy a variety of foods that your family enjoys eating, especially fresh fruits and vegetables, and cook and eat together as a family. Forget the fear, and ignore the labels.

Spend more, save more! (Lawsuits, that is)

Posted November 16, 2015 by Dr. Roy
Categories: Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

A November, 2015 study shows that doctors who spend more money are less likely to get sued.

Researchers from Harvard, Stanford, and UCLA looked at data from admissions to Florida hospitals from 2000-2009, examining the rates of lawsuits filed against physicians versus the amount of money spent on the admission. Sure enough, in six of the seven specialties evaluated, there was a clear trend showing that at each step-up in spending, there was as step-down in the rate of lawsuits filed. For instance, in internal medicine the lowest fifth of spenders (~$20,000 for admission) had a 1.5% risk of a lawsuit; the highest fifth (~$40,000) had a risk of .3%. Double your spending, decrease your risk of a lawsuit by five times. Not a bad deal, really, for the doctors.

But was it a good deal for the patients? These investigators didn’t look at outcomes, but overall we know higher spending does not equal better care or healthier outcomes. More spending may seem to increase “patient satisfaction scores”, but high patient satisfaction negatively affects overall health. More tests often lead to the overdiagnosis of conditions that didn’t need to be treated, causing more worry and spending even more money.

So why do some docs spend more than others? This study reinforces the evidence for so-called defensive medicine: tests and procedures done only to ward off lawyers, the way garlic keeps away vampires. But garlic is cheap and harmless, and vampires are, well, imaginary. In the real world, docs are doing unnecessary tests and procedures, harming patients and flying through money, to stay out of the courtroom. Do I blame them? No. Is there a better way? I hope so.


Drug safety tip: Do not point nose spray upside down

Posted November 12, 2015 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD


Here’s a safety tip that makes sense—and it took a very simple study to show it. Nose sprays that are meant to be squirted with the bottle facing upwards shouldn’t be turned around to squirt medicine downwards.

Researchers from UCLA just published an eye-opening report on dosing of nasal spray medications. They studied oxymetazoline, a common OTC nasal decongestant spray marketed as “Afrin.” We know that 1-2 mL of this product (swallowed or sprayed into the nose) can lead to an overdose, including symptoms of slowed heart rate and breathing. We don’t worry about that, much, because the squirt bottle it’s packed in only delivers about 0.03 mL per squirt – you’d have to do over thirty squirts to reach a toxic dose. But that’s only if you use the squirt bottle correctly.

The investigators, instead, bought three different brands of oxymetazoline, and squirted it downwards, at a 45 degree angle, simulating what parents might do if they were squirting this into the nose of a child who is laying down. The volume delivered this way was between 0.6 and 0.9 mL for a single squirt—meaning, if both nostrils were hosed this way, you would almost certainly reach a potentially toxic dose.

With the help of my assistant, Blue Toad (who, ironically, doesn’t even have a nose), we’ve taken some helpful photos to demonstrate. Here, Blue Toad is getting a safe dose, using the bottle pointed upwards as designed:

Squirting up -- safe!

Squirting up — safe!

But here, Blue Toad is lying down, and the bottle is pointed down into his nose. Bad news for Blue Toad!

Squirting down? Bad idea!

Squirting down? Bad idea!

All medicines should be used carefully, following the directions—and the directions for this nose spray clearly say to hold the bottle upright. Still, I could imagine some parents trying to use this while their kids were lying down. Better to play it safe: make them sit up, and squirt up.

Homeopathy as good as antibiotics? No.

Posted November 9, 2015 by Dr. Roy
Categories: Medical problems, Pediatric Insider information, The Media Blows It Again

Tags: , , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

An August, 2015 study in Multidisciplinary Respiratory Medicine is being touted as evidence that homeopathy is as affective as antibiotics for respiratory infections in children. It doesn’t show that at all—in fact, it doesn’t show anything, except that crappy studies in crappy journals can nonetheless be used to manipulate opinion. Beware.

First, the study itself. Researchers in Italy looked at about 90 children with ordinary colds. All of them were given a homeopathic product that the authors claimed had already been shown to be effective for cough (that’s not actually true, but let’s let it slide for now.) All of the children did improve, as expected—colds go away, as we all know.

The “study” part was randomizing the children into two groups. One half of the study subjects only got the homeopathic product, the other half got both the homeopathic syrup PLUS amoxicillin-clavulanate, an antibiotic. You Insiders are already thinking—what, wait, what? You know that antibiotics have no role at all in the treatment of the common cold. Colds are caused by viruses, and antibiotics won’t make any difference. In fact, they’re very likely to cause harm, causing allergic reactions and gut problems and maybe triggering c diff colitis. It was entirely unethical for them to even give these antibiotics to the children, with not even an inkling of a reason to think they were a valid medical therapy. But they did it anyway.

The results are exactly what you’d expect. Both groups of children (the ones on homeopathy, and the ones on homeopathy plus antibiotics) did the same—their symptoms all improved over the weeks of the study. No surprise at all.

But the authors claimed “Our data confirm that the homeopathic treatment in question has potential benefits for cough in children…” The study didn’t show that all. They didn’t even look for that kind of effect—if they wanted to, they could have, by randomizing one group to receive homeopathy, and the other group to not receive homeopathy. But that kind of study wouldn’t show what they wanted it to show, so they didn’t do it.

You’re wondering, maybe, why did Multidisciplinary Respiratory Medicine even print this unethical, worthless study? The answer is here:

How much does it cost to publish?


Multidisciplinary Respiratory Medicine is what’s called a “predatory journal”, which charges high fees — $1,940 — to publish articles. These types of journals exist only to make money—there is minimal or no editorial oversight, and the whole point is to publish whatever someone will pay them to publish. The authors get their publication, and journalists and the public are fooled into thinking real science has occurred.

Another highlight – I’m not an investigative journalist, but looking at the full text of the article, I see under footnotes “The authors declare they have no competing interests.” Yet under acknowledgements, it also says “We thank Boiron SA, Messimy, France for a non-binding financial contribution.” Boiron is a huge producer and marketer of homeopathic products. And: when I Googled the lead author’s name + the word “Boiron,” I found this page, which features a video of him on Boiron’s site. No competing interests?

So, an unethical study comparing the wrong things claiming to show something it didn’t, published in a pay-to-play journal, paid for by a homeopathy company, written by a guy who is featured on said homeopathy company’s website. You still shouldn’t use antibiotics to treat a cold. And this study, like so many other homeopathy studies, shows only that homeopathy is a scam.

Insiders, we have a winner!

Posted November 5, 2015 by Dr. Roy
Categories: Pediatric Insider information

The winner of our “What should I call people who follow this blog” contest is Mindy E., who suggested “Insiders”. No, it’s not too obvious (I didn’t think of it, and I’ve been hacking away at this blog for 8 years). It’s perfect!

Mindy E. gets a copy of my new lecture series from The Great Courses, Medical School for Everyone: Emergency Medicine. Which, by the way, is on sale now for as low as $45 for the audio download. What a bargain!  The audio-only features my fine bosso voice, and you don’t even have to look at me. You’re all winners! (Though, more accurately speaking, only Mindy E. is a winner, because she gets it for free. The rest of you are expected to pony up.)

Thanks for playing and following, Insiders!

Phenylephrine: A placebo you don’t need

Posted November 2, 2015 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Doctors, myself included, are dismissive of placebos. “That doesn’t work,” we say, referring to countless therapies that have no benefit over fake therapies (placebos), including pediatric chiropractic, homeopathy, and acupuncture.

We need to be honest. We have our placebos, too—pushed by modern pharmaceutical companies and genuine medical doctors. Maybe we ought to spend more time cleaning up what we do rather than pointing fingers at them.

Case in point: phenylephrine, marketed as a nasal decongestant. To understand how phenylephrine (PE) became so popular, we’ll have to go backwards a bit, to 1994, when the FDA published a list of nasal decongestant products that it considered safe and effective. Anything on “the list” could be sold without further FDA review. Included on that list were two oral decongestants: phenylephrine and pseudoephedrine (commonly known by the brand name Sudafed), which was far more popular.

In the 2000’s, to combat the epidemic of methamphetamine abuse, Congress attached an amendment to the Patriot Act (yes, that Patriot Act), restricting the sale of pseudoephedrine-containing medications. You could still buy them, but in limited quantities, and you had to present your ID to the pharmacist so your purchases could be recorded and tracked. All pseudoephedrine-containing products were pulled from the shelves. And, predictably, sales suffered. People didn’t want the bother of confronting a pharmacist to buy Sudafed, and pharmacists frankly had better things to do with their time than check ID for $6 purchases.

The marketers, predictably, won: a whole slew of new products, containing PE instead of pseudoephedrine, hit the market, prominently displayed on store shelves. Names like “Sudafed PE” minimized the change in the active ingredients, relying on well-known brand names to sell the product. Within a few years, PE-containing products far outsold the hidden pseudoephedine products. And everyone was happy.

Well, almost everyone. If you had a stuffy nose, you were most certainly not happy. Because oral phenylephrine never actually worked. A 2007 review showed that the PE was no better than placebo, and the FDA considered removing it from the allowed-drugs monograph—but they were swayed by a different published analysis showing a small but positive effect of PE on one measure of nasal congestion. That study has been criticized on many grounds, including that it cherry-picked positive studies and ignored evidence that weighed against PE. Still, the FDA allowed PE to continue to be sold and advertised as effective—though they did request a solid, placebo-controlled study to settle the issue.

Now, finally, in 2015, a placebo-controlled study of PE has finally been published. It’s fairly large, using 539 adults, and it looked at multiple doses sizes of PE compared to placebo top treat seasonal allergic rhinitis. The results are unequivocal: PE, at every dose, works no better than placebo—meaning it doesn’t work at all. About 18% of study participants developed side effects, mostly headache (none were serious.)

I don’t know what the FDA is going to do with this information. They asked for it, and now they’ve got it. Perhaps they’ll pull PE from the shelves. Perhaps they’ll ask for more studies. Maybe they’ll say that the drug companies can no longer sell PE for allergies, but can continue to sell them for congestion caused by a common cold (there’s no evidence it works for that, either, but there are no big robust placebo controlled studies to cite.) For the time being, PE, the placebo, continues to be sold, and continues to be recommended by physicians. It’s hard to change habits.

If you’ve got a congested nose, there are some things that do work. Congestion can be relieved by saline washes or sprays or a steamy shower. If allergies are the culprit, a nasal steroid spray is very effective. Pseudoephedine (Sudafed) is still out there, though you have to ask for it. Topical nasal decongestant sprays (like Afrin) work, too, though should typically be used for only a few days.

Or, go with a placebo. If that’s your style, choose something safe, like a homeopathic product. It won’t relieve congestion any better than plain water, but at least it won’t hurt anything but your wallet. That’s more than I can say for phenylephrine and our other real-medicine-placebos.


Get every new post delivered to your Inbox.

Join 1,611 other followers