Mixed messages: Where should babies sleep?

Posted June 12, 2017 by Dr. Roy
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© 2017 Roy Benaroch, MD

A new study about the best place for babies to sleep – in their own rooms, or sharing a room with their parents – contradicts current AAP guidelines. But hopefully, in the long run, it will help more parents and babies get a better night’s sleep overall.

The most recent “safe sleep” guidelines were published in 2016. They stressed evidence-based recommendations for the safest way for babies to sleep: put down on their backs for every sleep, and on a firm, flat surface. Since bed sharing is has been shown to increase the risk of SIDS (especially in younger babies), it was also recommended that babies sleep on their own surface, designed for infants. And babies were supposed to sleep in their parents’ bedroom for at least the first six months of life, and ideally for 12 months.

It’s that last recommendation that I’ve never been completely happy about. The recommendation is based on three studies from the 1990s, all from Europe (where almost all babies slept in parents’ rooms, and, at the time, on their tummies.) In the aggregate, these studies showed fewer SIDS cases in babies sharing a room with their parents. But: there were very few SIDS cases to compare, and the one study that separated out babies by age at death showed that babies less than 4 months were safer in their own rooms (and less than 4 months is the peak time for SIDS.)  So the evidence, then, wasn’t very strong – but it was the best evidence at the time, and the AAP decided the “share room with parents” idea deserved to be a recommendation.

I also think the Academy was swayed by room sharing’s making nursing easier, which is true. Breastfeeding is associated with a decreased SIDS risk.

The “ideally until 12 months” part of the recommendation was especially problematic. SIDS rates are very low past 6 months, making conclusions about the effect of sleeping location for older infants tenuous at best. 12 months is also peak time for separation anxiety, and a terrible time to first put your child alone to bed. The AAP decided to extend the “ideal time” in parents’ room to 12 months to be extra cautious, but I’m not sure they considered the overall burden this could place on many parents and children in terms of overall quality of life.

Now, a new study throws a wrench into this “same room” recommendation. Researchers tracked the sleep habits of babies who slept in their parents’ rooms, versus their own rooms, and the results aren’t terribly surprising. Room sharing at 4 and 9 months is associated with less sleep for babies, and fewer long stretches of sleep. Babies seem less able to “consolidate” or organize their sleep into longer stretches if they’re sharing a room with parents. And: room sharing makes it more likely that babies will end up in known unsafe sleep positions – like sleeping directly in their parents’ beds. But wasn’t room sharing supposed to be safer?

It’s a mixed message, but it reflects that the evidence for this room sharing recommendation has never been very strong. With this new study, parents should feel more comfortable, and less guilty, if they choose to put babies in their own rooms to sleep.

Nevus sebaceous – what we don’t know about their management

Posted June 5, 2017 by Dr. Roy
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© 2017 Roy Benaroch, MD

Trupti sent in a quick question, to which I’ve written an honest but worthless answer. Such is medicine, sometimes. But honestly is always the best policy, right?

“Hi Dr. Roy, can you please shed more light on nevus sebaceous and its management?”

Nevus sebaceous – also called “nevus sebaceous of Jadassohn” or “sebaceous nevus” – is a fairly common skin patch. And by fairly common, I’d say I see a new one of these on my patients maybe once a year. They’re usually found on the head or neck, often noted at or shortly after birth. I’ve also heard they can arise later, but I don’t think that’s too common. They look kind of waxy and bumpy, with a yellow-brown or yellow-pink color, and if they arise in the scalp they stand out a little more because they don’t grow hair.

Really, the only management decisions are whether to have the removed, and when. Do they have to be removed? The answer here is a clear and definite “maybe.”  Derm textbooks and many docs who trained in the past will tell you that many of these will turn into cancer, so they ought to be lopped off, excised, and fully extirpated with extreme prejudice. This is based on older studies that found cancer rates up to 10-30% — and, yes, if that were true I’d say get them off. But more-recent studies since the 1990s have found much lower rates of cancer, perhaps less than 1%. Those older studies had mis-classified pathology findings as basal cell carcinomas, when in retrospect they were benign. We honestly do not know exactly how many of these will develop into cancer over a child’s lifetime, though cancerous transformation certainly isn’t common when kids are young.

There still isn’t a consensus in the dermatology literature about this. Though some authors recommend prophylactic removal because of this cancer risk, others do not. Here’s a table from a 2012 review – note that newer recommendations tend to be less surgery-happy, but they’re still all over the place:

 

OK, so that’s clear now. Another reason to consider removal is cosmetic – and especially if one of these is on the face or the side of the neck, you’d probably want to consider removal for your child. That’s something to talk w/ a plastic surgeon or dermatologist about. Removal of one of these will always leave some kind of scar, and you want an honest assessment of what it will look like afterwards – there’s no such thing as a no-scar removal.

As for when to take them off, well, there’s no consensus about that either. In early childhood they’re smaller, so hypothetically easier to remove, but it’s harder to use safe local anesthesia in younger children. You could wait to see how it develops through adolescence, but if it gets much bigger a more extensive, possible multi-staged, procedure is going to be needed.

Bottom line: we don’t know if these should be taken off, or the best time to do the procedure. I know, clear as mud – aren’t you glad you asked, Trupti? You should talk with your child’s doc, and get the opinions of a few knowledgeable plastic surgeons to help make the best decision. Good luck!

Mosquito prevention and treatment: A quick guide for families

Posted May 19, 2017 by Dr. Roy
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© 2017 Roy Benaroch, MD

 

Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis and dengue fever can be spread by mosquito bites in the USA. Our newest worry, Zika virus, is especially dangerous to pregnant women and their unborn babies — and there will almost certainly be US cases this summer.  Itchy mosquito bites can be scratched open by children, leading to scabbing, scarring, and the skin infection impetigo. Prevention is the best strategy.

Try to keep your local mosquito population under control by making it more difficult for the insects to breed. Empty any containers of standing water, including tires, empty flowerpots, or birdbaths. Avoid allowing gutters or drainage pipes to hold water. Mosquitoes are “home-bodies”—they don’t typically wander far from their place of birth. So reducing the mosquito population in your own yard can really help.

Most biting mosquitoes are active at dusk, so that’s the most important time to be vigilant with your prevention techniques. Light colored clothing is less attractive to mosquitoes. Though kids won’t want to wear long pants in the summer, keep in mind that skin covered with clothing is protected from biting insects like mosquitoes and ticks. A T-shirt is better than a tank top, and a tank top is better than no shirt at all!

Use a good mosquito repellent. The best-studied and most commonly available active ingredient is DEET. This chemical has been used for decades as an insect repellant and is very safe. Though rare allergies are always possible with any product applied to the skin, almost all children do fine with DEET. Use a concentration of about 10%, which provides effective protection for about two hours. It should be reapplied after swimming. Children who have used DEET (or any other insect repellant) should take a bath or shower at the end of the day.

Other agents that are effective insect repellants are picaridin, oil of lemon eucalyptus, and IR3535 (also known as ethyl butylactylaminopropionate. Tasty!) These are probably not more effective than DEET, but some families prefer them because of their more pleasant smell and feel. Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all. The CDC has extensive info on these products here.

There are also yard sprayers or misters, devices that widely spray repellants or pesticides. I couldn’t find much in the way to independent assessments of these products, but there’s no reason to think they wouldn’t work. Still, I’m leery about the idea of spraying chemicals all over the place, when we know that DEET sprayed on your child is effective and safe for both child and environment.

About “Organic” or “Natural” insecticides or repellants – those are just  marketing words. Organic compounds are no more or less likely to be dangerous to people or the environment than non-organic compounds; likewise, “natural” in no way implies that something is safe or effective (or even “natural” in the sense that most people mean that term.) These words are tossed around as part of the typical salad of meaningless marketing-speak on labels. Ignore them.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Although I don’t have much independent confirmation that these work, they are probably environmentally friendly and safe.

Some children do seem more attractive to others to mosquitoes, and some children seem to have more exaggerated local reactions with big itchy warm welts. To minimize the reaction to a mosquito bites, follow these steps:

  1. Give an oral antihistamine like Zyrtec or Claritin, or old-school oral Benadryl (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.)
  2. Apply a topical steroid, like OTC hydrocortisone 1%. Your doctor can prescribe a stronger steroid if necessary.
  3. Apply ice or a cool wet washcloth.
  4. Reapply insect repellent so he doesn’t get bitten again.
  5. Have a Popsicle.
  6. Repeat all summer!

Updated and adapted from previous posts. Reduce reuse recycle!

Is 24% the correct goal for c-section rates?

Posted May 17, 2017 by Dr. Roy
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© 2017 Roy Benaroch, MD

Yesterday I wrote about a recent Consumer Reports article about c-sections and how to avoid them by choosing a hospital with a low c-section rate. I’m not convinced that’s the best way to choose a hospital.

In their piece, Consumer Reports quoted an overall “goal” for c-section rates of 23.9%, as determined by the US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (That’s right, the USDHHSODPHP. Yes there will be a quiz.) I was kind of flip in my dismissal of that number – I may have said something about it being “made up” or “pulled from the USDHHSODPHP’s nethers” – because to my knowledge there’s no data supporting an exact c-section rate that’s ideal for maternal and baby health.

In the spirit of pretending to be a journalist, I looked into that number a bit further. And it turns out I was right. It really was pulled out of USDHHSODPHP’s nethers.

Here’s where it comes from, see for yourself: MICH-7.1, a goal to “reduce cesarean births among low-risk women with no prior cesarean births.” They took the 2007 rate –estimated at 26.5% — and reduced it by a target of 10%. Not 11% or 5% or 15%, but 10%, because that’s a nice number. And that’s it. Our current official goal rate of 23.9% is exactly where we were, reduced by a nice round percentage.

The number has nothing to do with healthy babies or moms – they didn’t even try to figure out what c-section rate results in the best health outcomes. Or even the lowest cost, or the best patient satisfaction, or anything like that. It’s just an arbitrary number that could as easily been set higher or lower. I mean, if a 10% reduction is good, why not 15%? Or 41.5%?

Why this matters: women are trying to make good decisions for their own health and the health of their babies. Arbitrarily telling them that c-sections are bad and that hospitals that do fewer of them are good is, well, silly and paternalistic and insulting. We can admit that we really don’t know the perfect percentage for a c-section rate, which means it’s OK that it’s not the same at every hospital. Whether you get a c-section should depend on your health, your baby’s health, and a frank and honest discussion with your OB or midwife about the risks and benefits of a vaginal or c-section delivery. Let’s leave the USDGGSODPHP out of it.

Just “Reducing C-Sections” shouldn’t be a goal

Posted May 16, 2017 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

Consumer Reports today released a report critical of the c-section rates of many US hospitals. Titled “Your biggest c-section risk may be your hospital”, the article encourages parents to choose a hospital based on c-section rates. The lower, the better.

That’s misguided advice, and focuses attention on the wrong parameter. Parents should concentrate on improving their odds of a healthy and safe delivery for mom and baby. Knowing the overall c-section rate of a hospital doesn’t tell you anything at all about whether the babies born there are healthy.

In an ideal world, we would easily be able to tell exactly which mom-baby pairs need a c-section. Sometimes, it is easy to tell – mom’s past medical history, or something about the baby, makes a c-section very clearly necessary. But most of the time, c-sections are a decision made based on “risk reduction”. And that’s not an exact science. We know that some babies with a certain kind of fetal heart tracing may be headed for trouble – they’re at an “increased risk” of problems with delivery (and those problems can be devastating, leading to death or permanent neurologic disability.) But most of the time, even these “higher risk” babies can probably labor longer, and could probably be born vaginally and do fine. But what’s probably? What if you were told your baby had a 1 in 3 chance of severe complications? Or a 1 in 50 chance of having brain damage, and never being able to walk? Would 1 in 100 be a reasonable risk, or 1 in 500? We do c-sections to mitigate, or reduce, those risks. It’s up to midwives and moms and obstetricians to discuss these risks and decide on the best course of action for each individual mom in labor.

The article points out that over half of the hospitals surveyed – or “nearly 6 in 10” — have a c-section rate above the rate of 23.9% established as a goal by the US Department of Health and Human Services. But that means that close to half of the hospitals actually had a c-section rate somewhat less than the government target. But the CR headline doesn’t read “Nearly half of hospitals aren’t doing enough c-sections.”

By the way, I have no idea where that 23.9% goal comes from. I know of no data that explicitly determines the percentage of c-sections that is ideal for health. I don’t think any such data exist, or that there even could be “one number” that’s perfect for every community.

Although the survey did try to look at the reasons behind c-section variability at hospitals, those can be difficult numbers to quantify. We know older moms, and overweight moms, are more likely to need a c-section – so hospitals catering to those groups are being unfairly targeted for their high c-section rates. (One reason why c-section rates have crept up over the last few decades is the changing demographics of pregnancy in the US. There are more twins, too.) In fact, if I were a hospital administrator who wanted to brag about my low c-section rates, I’d just drop out of the business of seeing high-risk pregnancies, or catering to older or obese women. That hospital would “win” the low c-section sweepstakes! But is that the best way to take care of women – to neglect the ones that make our hospital numbers look bad?

Also – and I know I’m going to lose some of you with this – I’m not entirely comfortable with the overall message here that even elective, non-medical c-sections are bad and should be discouraged. Moms deserve honest, science-based advice on the pros and cons of both vaginal and c-section delivery, tailored to their own circumstances and health histories. If a mom, given good information, decides that even without a specific medical indication she’d prefer to get a c-section, is that wrong? Aren’t we past the point where doctors are supposed to tell their patients what to do? And aren’t we past the point where women should be told what to do by their man-doctors? (Parenthetically, all of the MDs interviewed for the CR story were men*. I’m sure that’s just a coincidence.)

C-section rates are one measure of a hospital – and for women who put a top priority on having a vaginal delivery, this Consumer Reports article gives some helpful information. But I don’t think most women ought to focus on that one parameter, or worry about taking steps to avoid a c-section. That’s my judgement, but you pregnant women should make up your own minds. I don’t think the “23.9 percenters” ought to try to take that decision away from you.

 

*Neel, Elliott, Aaron, Gilad, Robert – I’m assuming these are all male first names.

Expired Epipens are better than nothing

Posted May 15, 2017 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2017 Roy Benaroch, MD

A small study published this month showed that most Epipens retain their potency for at least 4 years after their expiration date. That’s no guarantee, of course. I’d still recommend as a “best practice” that families replace them as they expire. But it’s reassuring to know that they’ll usually be effective even when expired. And using an expired Epipen is almost certainly better than using nothing when there’s a life-threatening allergic reaction.

It’s a simple enough study. Over 2 weeks, families attending a clinic in California were asked to donate expired Epipens for analysis. They collected 40 devices that had expired up to 50 months before the study, and used state-of-the-art chemical analysis to determine the potency of the medication in the vials. None of them looked discolored or unsafe. All of the pens that had expired up to 2 and half years ago had at least 89% of their original potency, and even most of the older ones remained in the 85% range. Though overall the dose potency slowly deteriorated, all of these devices would have still been helpful to treat an anaphylactic reaction.

A few small previous studies reached similar conclusions in 2015 and 2000. Though these studies looked at the Epipen brand of auto-injectors, it’s likely that studies of similar or generic products would yield the same results.

The authors of the study aren’t recommending that families hoard Epipens, or delay replacing them – but they do point out that their findings support further studies to extend the labeled shelf life of these products. And if an expired Epipen is all you’ve got, it’s probably OK to use it as long as it’s not obviously broken or discolored.

To help keep your Epipens in good shape, store them somewhere relatively cool (not cold), and away from light, preferably in the original packaging. Do not leave them in your car in the summer. Epinephrine is a finicky sort of chemical, and light and heat will speed its deterioration. Although you can hold on to expired Epipens as a “backup”, it’s best to replace them so you’re 100% sure that you’ve got what you need when you need it.

 

Molluscum: Maybe best to leave them alone

Posted May 8, 2017 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

The Pediatric Insider

© 2017 Roy Benaroch, MD

Alina wrote in, “If Molluscum Contagiosum is limited to a few bumps, 10 or less, does it necessarily need treatment or will it pass on its own?”

Molluscum (plural, mollusca) will usually go away on its own. Eventually. Except when they don’t.

Some things I can say for certain: molluscum is one of the least-favorite things for pediatricians and dermatologists to deal with. There’s no great therapy, and they don’t always do what they’re supposed to do. Parents hate them, and whatever we try doesn’t work anyway. Stupid molluscum!

Molluscum contagiosum looks like little, waxy-looking, skin-colored bumps that usually affect children less than 10 or so. They sometimes show up in little clusters, or can be more widespread. They’re triggered by a viral infection – but the virus itself is ubiquitous and impossible to avoid, so pretty much all of us are exposed to it. We don’t know why some kids with this virus get bump, while many others never do. The good news is that this isn’t a serious issue, and doesn’t lead to any serious issues.

But the bumps can look ugly. And though most of the time they do go away entirely on their own, that process can take months or years. And sometimes they just insist on sticking around. So parents, understandably, want to find some way to get rid of them.

There are no FDA-approved medications that treat these, and no OTC or “natural” types of products that have ever been shown to be more effective than placebo. Dermatologists can scrape them off (ow!), or freeze them off (ow!), or dabble blistering agents on them (ow!). Though all of these methods work sometimes, they also sometimes lead to scarring or more lesions popping up nearby.

From my point of view, after about 20 years of fighting with these dang things on my patients, I usually encourage families to leave them alone. If they’re in a cosmetically important area or somewhere that’s hard to keep covered with clothes, I’ll sometimes try a gentle topical agent that seems to irritate them a bit, which hastens their destruction by the body’s immune system. But usually, if there aren’t a lot of them, and the family can just ignore them until they disappear, that’s the way to go.

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