The why and the how of stinky feet

Posted October 24, 2016 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Ever nibble on a baby’s toes? I sure have. It’s one of the perks of being a parent – and a pediatrician. Nom nom nom, nibble them, count them, baby toes are about as adorable as anything can be. So why do feet sometimes turn on us? The 10 cute piggies and sweet little feets, in a few years, sometimes become, well, foul and nasty.

Teenager: “Do I need to take my sneakers off for my sports physical?”

Me: “No no no no no no no!!”

Honestly, most feet don’t smell too bad. Sweat barely smells at all. But the combination of sweat, warmth, trapped air, and what we’ll call “cellular debris” (ie, bits of foot skin) create, at least in some people, a tasty salad for the overgrowth of stink-producing bacteria. These include Bacillus subtilis, Kytococcus sedentarius, and brevibacteria, which is also responsible for the smell of Limburger cheese. There’s some cocktail party trivia for you! The bacteria eat up the foot debris, releasing “evil stink molecules” of  organic acids and sulfur compounds. And it’s those compounds, the stuff made by hungry microorganisms, that create what Frank Zappa famously called Stinkfoot. The science name for this – more cocktail party trivia! — is “bromhidrosis.”

So what can kids do about the stinkfoot? Try to keep them (the feet) clean. Wash them, every day, with soap and water and a washcloth. Letting soapy water kind of dribble across feet in the shower doesn’t count. Use a washcloth or pouf or whatever, and don’t forget in between the toes. Afterwards, dry ‘em, and stay barefoot for a while. Bacteria love moist and dark and enclosed. Open, dry, cool air will help.

The choice of footwear matters. Natural fibers allow more air circulation, and plastic things are the worst. All-cotton socks are a good, too, though there are also sports-sweat-wicking socks that may work even better. Whatever socks and shoes you wear, once they’re wet with sweat, take them off and put on another pair. You might need 2 or 3 pairs to wear on different days, to make sure they completely dry out between wearings.

Sneakers can be run through a washing machine every few weeks, or at least their insoles. There are odor-neutralizing sprays, some of which have disinfectants, which can help too. Spray the shoes or spray your feet, whatever it says on the label. Powders can be used to trap sweat, but you need to clean up the gunky powder rather than let it accumulate and turn to concrete.

For ultra-stinkfoot that doesn’t improve with simple measures, a trip to a doc may be needed. Sometimes there’s a yeast or bacterial infection that can be treated. We can also use medicines or other things to decrease sweating (that’s not a quick-fix, though—clean foot hygiene will still be necessary.) As a last resort, I suppose you could try this. But remember, whatever you do, you can’t run away from your own feet.



How much media use is too much? The AAP weighs in

Posted October 21, 2016 by Dr. Roy
Categories: In the news

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Today, the American Academy of Pediatrics released two new policy statements outlining their official recommendations for media use in children and adolescents. Media, here, means television, video games, tablets, apps – pretty much anything with a screen. We know this kind of entertainment has become a huge part of our lives. How much is too much, and how do we ensure that media is being used wisely and safely? The policy and accompanying technical report rely on hundreds of solid references, providing the best answers based on the best science we know about how children learn and interact with the world of media.

Younger children, less than 2, need exploration and social interactions to learn best. They cannot learn from traditional “media”, at least not on their own. Some learning via electronics can begin by age 15 months, but only via caretakers participating with their children and reteaching the content in an interactive way. By 2 years, we know children can learn word skills by live video-chatting with a responsive adult, or by using apps that reward the child for choosing the right answers.

Preschoolers, aged 3 to 5, can boost their literacy and cognitive skills by watching well-designed TV programs (like Sesame Street.) However, higher-order thinking skills like task persistence, impulse control, and flexible thinking are still best learned during truly social, interactive play – and that’s just not something media can provide.

There are some specific medical concerns raised by media use in young children. Heavy media use increases the risk of obesity, by filling time with sedentary activity and exposing children to unhealthful food advertising. And increased media use directly corresponds to less sleep for children (this is especially true for evening exposures, before bedtime, which interfere with sleep onset, sleep quality, and sleep duration.)

Excessive media use in early childhood is also associated with cognitive, language, and social delays. Some of these associations depend on exactly what’s being watched — switching from violent to pro-social content has been shown to improve preschool behavior, especially in boys. There’s also concern that excessive media use by parents can interfere with other family activities, and may model and reinforce media excess in their children.

With all of this in mind, the AAP has made these specific recommendations for young children and media use:

  • Under 18 months, discourage all media use (other than video chatting with family. Facetime and Skype are OK.)
  • From 2-5 years, limit all media, combined, to a total of less than 1 hour per day of high quality shows. These should be shared together between parents and children.
  • No screens at all during meals and for 1 hour before bedtime.
  • Parents should keep bedrooms, mealtimes, and parent-child playtime screen free.

The AAP had a second policy statement about media use in school aged children and adolescents. There’s good evidence for some benefits of media use at this age, including exposures to new ideas and information, and opportunities for community engagement and collaboration. Social media can help children access support networks, which may be especially valuable for kids with ongoing illnesses or disabilities. Media can provide good opportunities to learn about healthy behaviors, like smoking cessation and balanced nutrition.

But: there’s a down side, too. There are risks for obesity and sleep problems with excessive or untimely media use. Children who overuse online media are at risk problematic, addiction-like media usage, sometimes characterized by a decreased interest in real-life relationships, unsuccessful attempts to cut back, and withdrawal symptoms.

Many teens use media at the same time they’re engaged in other tasks, like homework. They may think they’re learning, but good objective data shows that no one can truly multitask like that. And, of course, though media can deliver positive, healthful information, parents need to be wary of some of the misinformation that’s out there. Information about nutrition, vaccines, and exercise is often misleading or flat-out wrong. Kids can easily find material actually promoting risky health behaviors like eating disorders, sexual promiscuity, and self-mutilation.

There are also significant risks from cyberbullying, sexting, and online solicitation – issues that are especially problematic because the perpetrators may be anonymous. The internet has created some horrifying opportunities for the exploitation of children.

Bottom line, here’s what the AAP recommends for these school aged children and adolescents:

  • Families are encouraged to create their own Media Use Plan. This addresses how media is accessed, both how much and what kind. Consistent limits and a clear and explicit understanding of expectations is crucial. Families should work on these plans together.
  • Children should not sleep with their devices in their bedrooms (parents shouldn’t either.)
  • Media shouldn’t be used during schoolwork, family meals, or other family-designated “media free times.”
  • Parents should engage in selecting and co-viewing media with their kids.
  • There needs to be ongoing discussions of online citizenship and safety.

The AAP’s new policy doesn’t include a specific amount or number of hours of media time is recommended for children and teens. But media use should be limited, so there’s time for exercise, adequate sleep, and other activities. How much media is too much? For teens, when it prevents them from participating in other activities they ought to be doing. Media has become a huge part of all of our lives, but there needs to be time for other things, too.

My hero

Obamacare: Is it working or not?

Posted October 17, 2016 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

‘Tis a season, fraught and shrill. Volume has replaced thoughtful discourse. I realize many of us have long-ago made up our minds about the Affordable Care Act – and if you already know whether it’s good or it’s bad, this really isn’t the post for you. But if you’re one of the people in the eerie, quiet middle, curious for some context and facts, here’s one doc’s take on the status of what’s typically called “Obamacare.”


What are the problems?

There are two big ones, the way I see it. First, the whole program is not sustainable with the current model. When the ACA kicked in, the whole idea was to provide uninsured people with a way to purchase insurance plans, similar to the ones offered by employers. This looked like a big bumper crop of new customers for insurance companies, who initially lined up with all sorts of plans at affordable rates. The costs for consumers, at first, looked especially appealing, because government subsidies made premiums pretty cheap. At first.

But: insurance companies ended up taking a bath on those ACA insurance products. The people who signed up for them turned out to need more health care – to spend more money – than expected. The “young invincibles” who don’t need much health care spending aren’t signing up for these plans, despite having to pay a penalty. (The penalty is still cheaper than the premiums, and they can always sign up later if they develop a health problem. They’re young and invincible, but they’re not stupid.) Insurance companies have had to raise their rates, this year by an average of 10%, and in some areas as much as 55%. Many have exited this part of the insurance market entirely. It’s estimated that when enrollment starts in November, about 20% of people looking for individual plans in the ACA insurance exchanges will have only one plan from which to “choose.” And, of course, areas with fewer plans are seeing the highest rate increases.

Insurance companies would like to hold down rates, but so far their solutions have been both unsuccessful and unpalatable. Smaller “in-network” groups of physicians, hospitals, imaging centers, and labs do reduce costs. But inevitably that means clients – I mean, patients – have to wait longer for services, or travel farther, or navigate endless administrative roadblocks. Another idea to contain insco costs: increased deductibles and copays, which share more of the health care costs with patients.

Which brings us to the second Big Problem: many people are finding that their ACA-compliant plan is costing them, big time, to actually use. Just having health insurance doesn’t guarantee access to affordable health care if you’ve got huge deductibles and out-of-pocket expenses.


Have any parts of Obamacare worked?

Yes. The ACA has brought insurance to about 20 million Americans who lacked it, including about 9 million via expansion of state Medicaid programs to low-income families (that number could be much higher, if some states hadn’t refused to participate.) The uninsured rate has fallen from about 16% to 9%. Though deductibles can be high on some plans, people with insurance are at least protected against truly catastrophic costs from a serious hospitalization or chronic illness, like cancer or a heart attack.

Though premiums on the exchanges are rising, they’re actually about $600 a year below what was projected for 2016. And, overall, the rise in national health care costs has been reduced to record-lows, in part from ACA-required hospital cost-control and quality improvement mandates. Overall, federal government spending on health care in 2015 was $2.6 trillion less than it was expected to be – and that’s even with the 20 million more covered people in the system.


You’re full of sh*t. Obamacare is (the greatest thing ever)/(a complete disaster for everyone) <–ß you choose!

Yeah, well, see, I was hoping to weed out the partisans with that flowery introductory paragraph. People on either side of this issue seem to have a hard time seeing this from the other point of view. The very idea that “the other side” may have something worth saying and listening to doesn’t seem to jibe with the world of Facebook, Twitter, and the current election cycle. Democracy can be hard, but (I think) it’s the best system out there. Let’s give it a try!


OK, Hippie, we’ll try it your way. What do you suggest?

More young people need to sign up. This can be encouraged by increasing subsidies and/or increasing the penalty for non-insurance. Though forbidding insurance from excluding pre-existing conditions is a common-sense provision that needs to be retained, the rules can be tightened. People shouldn’t be allowed to take advantage of this by dropping insurance when they’re well and restarting it only when they get sick.

More flexibility will allow more competition, so people have a choice and premiums can be kept in check. Insurance companies should be allowed to offer products in any state, and regulations requiring certain kinds of coverage for all plans can be relaxed. People should be allowed to choose the kind of coverage they’re willing to pay for.

There are other good suggestions to improve the Affordable Care Act, but it will take a bipartisan congress of adults actually listening to each other to get it done. Their focus needs to be on making quality health care accessible, rather than protecting the profits of the insurance industry.


You’ve made some good points! Will you be our next Surgeon General?

I’ll consider it, but I certainly wouldn’t accept that nomination if <REDACTED> wins.

Balance is possible

Birth control pills for non-gynecologists

Posted October 13, 2016 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

 Note: Almost everything I write on this blog is for parents and lay-peeps. But every once in a while I write something kind of picky and technical for my medical audience. I’m not saying the rest of you shouldn’t read this, if you’re interested in this kind of thing, but today’s post isn’t the most riveting material for those of you who don’t prescribe oral contraceptive pills. But if you do prescribe ‘em, and you’d like to know what the differences are between the dozens of brands out there, this is the post you’ve been waiting for!


Oral contraceptive pills (OCPs) are fairly good at preventing pregnancy, though maybe not as good as we’d hope. Quoted failure rates in tightly-monitored clinical trials are often < 1% a year, but in more-typical use about 9 or 10 out of 100 women who rely on OCPs become pregnant. In pediatrics, OCPs are often prescribed for their non-contraceptive benefits, including reducing symptoms associated with menses and controlling acne. Most of us choose a few brands we become familiar with – probably the ones our attendings used in residency – and honestly, that’s probably good enough most of the time. But there are differences among OCPs. Curious? Read on.

Most OCPs are a combination of an estrogen – almost always ethinyl estradiol – and a progestin. The estrogen component is there to suppress the midcycle LH surge, preventing ovulation (this had once been thought to be the main way these pills work; but it turns out there are multiple, overlapping mechanisms). Estrogens also stabilize the endometrium and prevent bleeding. Old-school OCPs used to contain 80 or 100 mcg/day of estrogen, and these caused a lot of nausea, breast tenderness, edema, headaches, and weight gain. OCPs now contain 50 mcg or less; the lowest-dose pills contain 20 mcg, and one pill has 10. Lower estrogen doses are preferred for teens, but may not be as effective at decreasing breakthrough bleeding. There’s no evidence that higher or lower estrogen doses are more of less effective at contraception.

Another estrogen side effect is an increased risk of clotting, including deep vein thrombosis. This is especially a worry if there are other risk factors, like obesity or smoking. The clotting risk of birth control pills is also partially determined by the kind of progestin that’s used in the combination.

There are no “pure” progestin compounds available pharmaceutically – all of the progestins have a varying effect on testosterone receptors, too. Nogesterel and levonorgestrel have the most androgen effect, and a somewhat lower risk of clotting than newer agents. Some progestins have a slight anti-androgen effect, like drospirenone. These are associated with a higher risk of clots. Though some of these low- or anti-androgen OCPs are specifically FDA approved for the treatment of acne (Yaz and its generics), in clinical studies it appears that all of the combination OCPs have equal, modest effectiveness for this condition. Likewise, the “low-androgen” progestins may be favored to treat other hyperandrogen states, like PCOS, but the clinical differences between them appear to be minor.

So-called “minipills” are progestin-only contraceptives. They are safer for women with a clotting risk to take, but can worsen acne. Minipills do not regulate periods and may not reduce bleeding. They’re often thought of a second-line, less-effective contraception than combined OCPs, but objective data shows they’re about equally reliable.

Some pills are in bi-phasic or even tri-phasic dosing regimens, where the amount of estrogen and progestin varies over the month. There’s no great evidence that these work better or cause fewer side effects.

OCPs can also be used as continuous dosing or in an extended cycle, allowing for longer gaps between periods, or preventing menses altogether. Any combination OCP can work like this, if the placebo pills are skipped. The FDA has approved several brands (Seasonale and generic versions) specifically packaged in 90 day or longer cycles. One brand, Lybrel, can be taken every day with no placebo phase at all.



Most of the contraindications for taking combination OCPs are related to their known effect on increasing clot risk. People at a baseline high risk of clots or complications of clots should not take combination OCPs:

  • Age > 35 years and smoking > 15 cigarettes a day
  • History of venous thromboembolism or stroke
  • Those with a known clotting disorder
  • Existing multiple risk factors for cardiovascular disease (diabetes, age, hypertension) or known ischemic heart disease
  • Complicated valvular heart disease
  • Migraine with aura (that’s a marker for an increased risk of embolic stroke)
  • Lupus (with or without antiphospholipid antibodies), cirrhosis, breast cancer or liver cancer


Practical tips

Most OCPs come in packs of 21 “real” pills, then 7 placebos. They’ll sometimes have a “21” in their names (like “Loestrin 21”.) Some extend the “real” pills to 24 days, meaning they’ll be fewer placebo pills and fewer days of menstrual flow. These often have a “24” in the name (like “Minastrin 24”.)

Some OCPs replace true placebo pills with ones that contain iron, usually as ferrous sulfate. They’ll often have a FE in their names (“Junel Fe 24”)

Some OCPs come in varying strengths, usually expressed as the progestin/estrogen. For example, Junel 1.5/30 has norethindrone 1.5 mg + ethinyl estradiol 30 mcg.

For estrogen component: choose lower dose for less nausea, headache, edema; choose a higher dose for more-effective control of bleeding.

For progestin: there’s no solid evidence that the choice matters, but if side effects occur, choose a different one. Avoid some (eg, Yaz) if especially worried about clots.


Inexpensive options

Many OCPs have one or more generics that should contain the same active ingredients. Some practitioners feel that the purported increased variability of generics may cause more side effects such as spotting or nausea. Certainly, for most women at least, generic products seem to work well. Here are some good, cheap choices — in parentheses I’ve explained how each one is different from the previous:

  • Junel 1/20 (norethindrone 1 mg + estrogen 20 mcg)
    • Similar to brand Loestrin
  • Junel 1.5/30 (little higher estrogen & progestin dose)
  • Cryselle (also 30 of estrogen, but with different progestin [norgesterel])
    • Similar to Lo/Ovral
  • Sprintec (same norgesterel, 35 mg of estrogen)
    • Similar to Orthocyclen
  • Zarah (different progestin, only 20 mcg of estrogen, specifically FDA approved for acne)
    • Similar to Yaz

For a much more exhaustive list, search for “OCP” in the Epocrates app, then look at their “therapeutic equivalent” table. The ones listed as “no therapeutic equivalent” are often, but not always, more expensive.


The villian


edit: I added the contraindications section 10/17/2016


Is there a link between birth control pills and depression?

Posted October 10, 2016 by Dr. Roy
Categories: In the news, Medical problems

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© 2016 Roy Benaroch, MD

A provocative new study from Denmark supports a link between hormonal contraceptive methods (like birth control pills) and depression. And the association seems to be strongest for adolescent girls.

Huge studies like this are based on huge datasets – in this case, relying the Danish medical system’s longstanding penchant for meticulous and integrated medical records. You just couldn’t do this kind of research in the USA, where medical records systems can’t talk to each other or combine their data in a coherent way.

The researchers started by reviewing the medical records of Danish women, age 15-34, from 2000 through 2013 (excluding women with a preexisting diagnosis of depression or related disorders.) To determine when women took hormonal contraceptives, they relied on a National Prescription Register, which included all prescriptions made and filled for combination contraceptives (these are the ones most commonly used) as well as other medicines and devices (like implants and injected progestin) that rely on hormones to prevent pregnancy. For the purpose of the study, women were considered to be on prescribed hormones for the period of time they filled these prescriptions, plus six months. Over a million women made up the final dataset, followed for an average of 6.4 years each. At any given time, 55% of the women were taking these kinds of contraceptive medications.

The researchers then figured out when all of these women had depression, relying on either their filling a prescription for an antidepressant medication, or when any medical facility made a diagnosis of depression. Overall, during the study period, a total of 133, 178 prescriptions for antidepressants were filled for about 23,000 diagnoses of depression (many of the patients with depression filled more than one prescription.)

Using the data including the timing of contraception usage and depression diagnoses, the study authors could then compare whether depression was diagnosed while the women were either taking or not taking these contraceptives. And it turned out the depression was more common during the on-contraceptive periods. Overall, the increased risk of depression during contraceptive use was about 20% for all women in the study. The increased risk rose to 80% when only adolescent young women from age 15-19 were evaluated. The elevated risks were seen among all the different kinds of hormonal contraceptives examined.

This doesn’t necessarily mean that the contraceptives caused depression. Observational cohorts like these only show a temporal association. It’s possible that women taking contraceptives are more likely to become depressed for reasons unrelated to the medication itself – perhaps relation to the kinds of relationships they were in. Contraceptives are prescribed for many reasons other than contraception, too – to improve menstrual symptoms, or to help with acne. It’s also true that antidepressant medications are prescribed for things other than depression, like anxiety disorders or some chronic pain syndromes.

Still – over a million women in the study, and the effect size (especially among adolescents) was significant. While this study does not mean that women shouldn’t take contraceptives, it does mean that prescribers and their patients should keep depression in mind as a possible side effect, and that women at risk for depression may wish to consider other, non-hormonal means of contraception.




Great news about cancer prevention!

Posted October 6, 2016 by Dr. Roy
Categories: In the news

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The Pediatric Insider

© 2016 Roy Benaroch, MD

The first large, population-based study of real-world changes in cervical cancer screening in the era of HPV vaccination has delivered some great news: the HPV vaccine not only works, but it’s working better than expected.

Researchers looked at rates of CIN, the growth of abnormal cells in the cervix detected by Pap smears, among young women in New Mexico. Even though fewer than 40% of eligible women had received all three doses of the HPV vaccine, rates of these pre-cancerous lesions dropped by over 50%. That’s a huge impact. A safe intervention has cut the incidence of a common cancer by 50%, even in a community where HPV vaccine uptake wasn’t very good. It’s great news, and it hints at even greater news: if we can get more people vaccinated, this cancer-preventer can work even better.

Why did the vaccine work better than expected? There’s a herd effect, where vaccinated individuals help protect everybody by preventing spread of the virus. Plus, the vaccine seems to offer at least some protection against related strains. And it turns out that even women who receive less than the recommended three doses get at least some helpful immunity.

The most-used HPV vaccine in the United States goes by the brand name Gardasil-9, and it protects not only women, but men, too—especially from many cancers of the mouth and throat. Since there’s nothing analogous to a Pap smear for men, it will take longer to see these kinds of cancer-beating effects in the male population, but initial studies relying on rates of infection look very promising.

The HPV vaccine is very safe, and it’s already having a big positive effect in communities. Unfortunately, some parents have been scared away from this vaccine by irresponsible and often flagrantly false internet rumors. Don’t believe the scaremongers. Protect your kids from cancer by making sure they get their HPV vaccines.

Here’s a detailed and well-referenced post from The Skeptical Raptor explaining far more about the Gardasil vaccine, and debunking many of the myths being used to scare parents.

 Q&A from the CDC about HPV and HPV vaccinations


MERCK - Merck's HPV Vaccine, GARDASIL®9, now available in Canada

Homeopathic teething pills: Still poisonous

Posted October 4, 2016 by Dr. Roy
Categories: Guilt Free Parenting, In the news

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The Pediatric Insider

© 2016 Roy Benaroch, MD

In 2010, I wrote about the FDA’s recall of Hyland’s Teething Tablets. It turned out that the tiny little pills, sold to allegedly help babies with teething symptoms, had measurable and potentially toxic amounts of a poisonous plant extract, belladonna. See, they were supposed to not actually have any of that, because homeopathic products aren’t supposed to have any of anything.

One principle of homeopathy works like this: by ultra-super diluting a poison, you get a cure for the poison, or at least relief of the symptoms that the poison would have caused if you ingested it. Which, of course, you shouldn’t do (ingesting the actual poison is discouraged, until it’s ultra-super diluted and isn’t there anymore. That’s what you’re paying for.) Those Hyland’s Tablets turned out to contain the poison that wasn’t supposed to be in there. Oops.

By the way, it’s called “belladonna” from the Italian roots for “beautiful woman”. Belladonna comes from the nightshade plant, and this “natural” chemical will make your pupils dilate (that’s the beautiful part.) It can also cause excessive sleepiness, muscle weakness, difficulty breathing, agitation, and seizures. Those parts are less beautiful.

Last week, on September 30, the FDA updated their 2010 release, warning consumers against using any homeopathic teething tablets or gels. This includes not just Hyland’s products, but those sold at CVS and other retail and online stores.

The bottom line: if they’re manufactured correctly, homeopathic products don’t contain any active ingredients at all. There is nothing in there that could possibly help with teething or any other condition. Oh, sure, there may be other things added to homeopathic products to make you drunk, but that’s not the point. Homeopathic products should be as safe as drinking a little water or swallowing a tiny little sugar pill—because that’s exactly what they’re supposed to be, a little vial of water or a tiny little placebo pill.

That’s if they’re made the way they’re supposed to be made. But homeopathic products, like all of the other alt-med goodies sold next to the real medications, aren’t regulated. There’s no guarantee of purity, and no guarantee that what’s on the label is on the bottle. You’re paying for what you hope is a bottle of literally nothing, but you might accidentally get something that can hurt you.

Funny world, isn’t it? Can you imagine someone complaining to the manufacturer that their placebo was contaminated with a biologically active substance that might actually have an effect on their body? Hey, I paid good money for absolutely nothing, and that’s exactly what I wanted!

Anyway: if your baby seems to be having teething symptoms, try hugs and love or a dose or two of acetaminophen. If that doesn’t help, go see your doctor (it may not be teething at all—those little babies can’t talk yet, and it’s hard to know exactly what’s on their minds. Maybe they got a glimpse of that presidential debate, and they’re understandably worried about the future.) “Homeopathic Teething Tablets” certainly aren’t going to help, and might just make your baby sick.