Children aren’t professional athletes

Posted September 19, 2016 by Dr. Roy
Categories: Guilt Free Parenting, In the news

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Daniel K. wrote in a one-line topic suggestion: “The professionalization of Youth Sports and stress level in children”. It’s a big problem – younger and younger children are being expected to behave like professional athletes. They specialize in one sport, train almost as much as a full-time job, and are often expected to “tough it out”, or play through pain. Not only is this bad for kids’ bodies and minds, but it’s bad for their athletic futures. If you want your child to be a star athlete, early specialization and professionalization are not good ideas.

Gone are the days of pick-up games and Ultimate Frisbee on the street. Children and adolescents now play organized sports coached by parents, or sometimes professionals, who may or may not know what they’re doing, and may or may not have the same goals as their players. Kids, overall, want to have fun and compete and play. Coaches want to see their players shine and win. There’s increased pressure to play “for real” in a single-sport, sometimes year-round, and sometimes on multiple teams. That increases the risk of injuries (both serious and minor), and burnout. A kid who gets sick of playing is going to quit – as do 70% of children playing organized sports, by the time they’re 13.

The cold statistics: only 3-10% of high school athletes play at a college level; only 1% receive an athletic scholarship. About .03-.5% of high school athletes make it to the pros. The vast majority of youth sports are played by people who are in it to have fun, stay in shape, and work off stress.

Let’s say your child really does want to take it to the next level. What’s the best way to increase that slim chance of becoming a big-name athlete? It turns out that early specialization is exactly the wrong thing to do. Athletes competing in a wide variety of sports have fewer injuries and continue to play longer than those that specialize early, especially before puberty.

What about that “rule” you may have heard, that athletes need 10,000 hours in their sport to really get good at it? That’s a myth. The number was extrapolated from studies of chess players, and has no empiric evidence in any sport. Many excellent professional athletes start their main sport late, even in college; and most young people who play far more than 10,000 hours of a single sport don’t end up playing for college or the pros. By playing in a variety of sports, young athletes learn the basics of body movement, tracking, reflexes, and teamwork – all skills that can easily transfer to any specific sport, later.

Certain sports do seem to require early specialization for elite competition, probably because the nature of the competition favors bodies that aren’t mature. Figure skating, gymnastics, and diving have long favored young competitors. Still, that’s not necessarily a good thing – female competitors, especially, in these sports are at high risk of overuse injuries and the “female athlete triad” of bone loss, unhealthy energy metabolism, and delayed or absent menstruation. I’ve also been seeing an increasing number of young men with, essentially, eating disorders and related health problems related to similar sports situations.

Youth, as they say, is wasted on the young – but that doesn’t mean we ought to take it away from them. Let your kids be kids, and let them run and play and make up their own games. If they’d like to try organized sports, sign them up for a different sport each season, with a few months of breaks here and there. Later, if they want to, they can specialize and take it up a notch. Children shouldn’t be treated like professional athletes.

Tara Lipinski

USA’s Tara Lipinski performs her routine during the ladies free skating long program at the White Ring Arena on Friday, Feb. 20, 1998, in Nagano, Japan. (AP Photo/Doug Mills)

What do physicians do all day?

Posted September 12, 2016 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2016 Roy Benaroch, MD

The television doctors: striding purposefully through the ER, giving orders, surrounded by a gaggle of eager learners and a super-team of nurses and techs. Or spending hours operating, then sipping martinis while waiting for the next disaster. Maybe saving lives in between daydreams and liaisons with hot colleagues and nurses. All in a day’s work!

Maybe not. A new study looked at what doctors really do all day. In the real world, there’s precious little time for striding, martinis, or even a quick trip to the bathroom. In the real world, docs spend most of their time doing paperwork and data entry. That’s hardly sexy, and not even remotely fun, and –gasp—not really what we were trained to do.

From the Annals of Internal Medicine, September 2016, comes a downright depressing study: “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.” The researchers had medical students (hopefully they were paid) follow 57 US physicians in 4 different specialties in 4 different cities for a total of 430 observation hours. These physicians were all observed during their office hours (excluding time in the hospitals and operating rooms.) Observers used a technique called The Work Observation Method By Activity Timing – I mention this only because it’s abbreviated WOMBAT – to track exactly what the docs did all day. Categories included things like clinical time (either talking or interacting with patients, or talking with staff about matters directly related to a patient), desk work, time spent documenting on an electronic health record, and administrative time. They even recorded “personal time” including bathroom breaks and eating (many of the medical students, I think, were surprised that doctors are even allowed to use the bathroom. Ha!) Separately, they had a few dozen of the physician participants fill out diaries to see what they’re up to in the evenings.

The painful results: doctors, overall, spend about 33% of their net workday actually taking care of and interacting with patients. For every hour of direct patient care activity, two hours are spent on typing, data entry, and paperwork. Over the course of an entire workday, we spend only about half of our time in exam rooms, but even while in the exam rooms we’re focusing on and interacting with actual patients about half of that time. Just as much exam-room time is spent typing or dictating into our computers as spent talking with and examining patients.

And, after the work day is over, doctors spend an average of 1.5 hours working from home, spending most of this time on—you guessed it—more data entry into electronic medical records.

Old school: “Mommy, I want to be a doctor!”

Modern equivalent: “Mommy, I want to type and click boxes and fill out forms!”

I’m imagining medical school deans, with this study in mind, are hastily adjusting the curriculum. Gone is biochemistry – replaced with “Sports forms, basic and advanced.” Physiology can become “Navigating disability and FMLA paperwork”, perhaps with a “Disabled parking permit seminar”. The surgical clerkship can become “Type, click, backspace, repeat”, and all of obstetrics and gynecology can become “Prior authorization jujitsu.” This will surely prepare the next generation of medical students (nurses, too!) for what’s to come. If anyone still wants to do it. We’ll leave the light on when we leave, just in case.

Benjamin Franklin "Hawkeye" Pierce

Epipen alternatives – there are cheaper options

Posted August 30, 2016 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Epipens have gotten crazy expensive, yes — $600 for a two-pack. Here are some alternatives that might help you save a few bucks.

#1: Wait a few weeks, and see what Mylan does. Mylan, the company that makes the “Epipen” brand of epinehphrine auto-injector, has been under a lot of pressure lately to back off their unseemly price gouging. They’ve introduced a savings card that claims to lower your out-of-pocket expense to no more than $300 dollars, and say they’ve expanded eligibility for their patient assistance program for their less-wealthy-yet-still-allergic patients. Just yesterday, they accounced a new generic version of their own Epipen, claiming it will be identical to the genuine Epipen, but at half the price. Weird, yes, selling two things that are identical (other than the price), but I suppose stranger things have happened. Give Mylan a few more weeks, and they’ll probably start giving away Epipens in cereal boxes.

#2: Find out if you really need to have an Epipen available for your child. Epipens, until recently, weren’t prescribed for many children. A robust marketing program from Mylan (including appearances by Sarah Jessica Parker on daytime talk shows) along with an expanded FDA indication for people at any risk for allergic reactions turned a niche product into a billion-dollar moneymaker – and that was before they raised the prices through the roof. A reasonable question: are all of those Epipens really necessary? Certainly, those who’ve had a life-threatening allergic reaction to a food or bee sting in the past need one available. And high risk patients (for example, those allergic to peanuts who also have a history of asthma) clearly need them, too. But what about people allergic to other foods, who’ve had multiple reactions in the past, but never anaphylaxis? What about the many people who’ve tested positive for allergic sensitization, but have never actually had any reaction at all? Doctors are loathe to withdraw an Epipen recommendation (better safe than sorry!), but there are times when all of this money could be better spent in another way. If you’re not sure if or why your child needs an Epipen prescription, ask your doctor to review this with you before you refill it.

#3: Hold on to expired Epipens, at least for a little while. Epipens keep at least some potency beyond their expiration dates, especially if they’ve been stored in a cool place. Don’t discard your old Epipens until you’ve purchased new ones – it’s better to use an expired Epipen than to have no epinephrine available when needed.

#4: Consider the Other Brand, “Adrenaclick”. Epipens have pretty much flooded and dominated the market, but there is another epinephrine auto-injector out there, the “Adenaclick.” Instructions for using it are a little different, so if you get one make sure you’re familiar with it. A two-pack lists for $140 less than Epipen, and you can get that price even lower by using a coupon from GoodRx.com. Even better: there is a generic Adrenaclick out there, and it’s even cheaper if you can find it (supplies, I’m told, are limited.) To get an Adrenaclick or the generic version, you need a specific prescription from your doctor listing this by name. In most states, pharmacists cannot substitute Adrenaclick for an Epipen. You’ll want to check your insurance formulary, too – the list prices may not matter as much as what “tier” these products fall under for your plan.

Epinephrine (or adrenaline, if you prefer)

Expired Epipens – Safe to use?

Posted August 29, 2016 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

The sticker shock for Epipen purchases has some people wondering: Do I really have to buy a new one every year or so? Does it really matter if the drug has aged past its expiration date?

An Epipen is a device that automatically injects epinephrine. It is The Drug for potentially catastrophic allergic reactions to things like foods or bee stings. If someone’s having a bad reaction, epinephrine can save a life. In a medical situation, we’d typically draw up epinephrine from a little vial (which is way cheap, less than 5 bucks) and inject it into an available big muscle. Presto, you’re in the clear (it really can work super-quickly. Quite satisfying.) Since it’s awkward and perilous to draw up epinephrine into a syringe while you or your child is dying of an allergic reaction, for home use an automatically-injecting device is prescribed. Handy! Just remove a cap, press against the skin, and a little spring loaded mechanism fires off, poking out the needle and injecting the medicine in one E-Z step.

Those autoinjectors were first developed by the US military for treating nerve gas attacks. By the mid-1970’s a home version for allergies came out, and though the company that developed it has changed hands, merged, and moved on, the thing that’s currently sold uses pretty much the same technology. The medicine in there, epinephrine, is (and has been) dirt cheap for decades. What makes an Epipen expensive is the device used to inject it, which is currently protected by both patent law and an FDA that seems keen on making sure it’s the only widely available brand. Free from any competition, and with sales buoyed by aggressive marketing, by the manufacturer has been jacking the price through the roof.

Making this even more expensive: a newly purchased Epipen has a manufacturer’s expiration date, typically less than 2 years after purchase. So what happens after that date? Does the medicine really “go bad”?

There aren’t a lot of studies about this. I found two (thanks very much to the Simons, both F. Estelle and Keith, from Winnipeg, Canada – they’re authors on both papers!) In May, 2000, the Simons examined 34 donated Epipen injectors, administering them to 6 New Zealand White rabbits (not at the same time.) The out-of-date injectors delivered less epinephrine, and the drop was proportional to the age past expiration. The older the device, the more it lost its punch. Still, eyeballing their data in Figure 2, devices that were less than 24 months past expiration had between 60-90% of their drug intact, which isn’t terrible. They concluded that as long as the epinephrine wasn’t visibly discolored or damaged, it was better to use an expired Epipen than nothing at all.

Those same authors (with a few extra friends, minus the rabbits) looked at expired Epipens again in 2015, measuring potencies of 80-100% in devices up to three years past their expiration. Again, not too shabby.

Epinephrine is especially vulnerable to breaking down in heat. Epipens stored in car glove boxes aren’t going to last. And the auto-injecting mechanism, while robust, isn’t made for kickboxing practice or roller coaster festivals.

Still, for ordinary households who try to keep their Epipens in a cool, the devices  probably keep at least some potency somewhat past their printed expiration dates. It’s best if families replace them after they expire, to make sure they’re getting a full and reliable dose. But if someone needs a dose of epinephrine, and the only Epipen you’ve got is expired – use it.

And when you do buy a new one, make sure to ask the pharmacist to give you the new stuff, even if she has to reach way in the back. Since they’re so expensive, it might even be worth it to call around a few places, to see whose stock is the freshest.

More about drug expiration dates

I'm Gerald Ford, and you're not.

Epipen price gouging: Sowing, reaping, and a senator’s daughter

Posted August 25, 2016 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents, docs, and pundits are fuming. A life-saving, critical medication, used mostly in children, has become just about unaffordable for thousands of families. The Evil Drug Company Mylan has jacked up the price to over $500 over the last several years – this despite no increase in their costs. Congresspeeps, presidential candidates, and the ever-wise Facebook community all agree: Something must be done!

This isn’t the only example of weirdly-high prices for certain older drugs over the last few years. The system seems to be broken. To understand how best to fix it, it would be a good idea to go over just how the system was supposed to work.

After a drug is invented and tested, the company that developed it gets to sell it exclusively, under patent, for a set number of years. During that time the drug is only available as one “Brand Name”. The patent system is in place to reward the company for their innovation, allowing them to recoup their development costs, and make a profit. That encourages them to develop more new drugs, to make more money and to continue to bring new drugs into the marketplace. This part of the system certainly isn’t perfect – you can argue over just how many years drug companies should get exclusive rights to sell the drug they developed, and drug companies seem to be pouring more of their money into marketing and lobbying than into researching and developing new drugs. But the current problem really isn’t about new drugs or new patents.

What’s broken is the step that happens after the drug exclusivity patent expires. That’s when “generic” companies should be able to bring competing products to market. These are the same chemical, but packaged and sold by a different company. When multiple drug companies step in and produce generics, the market price of the drug falls precipitously. Many older drugs that now have multiple generic versions (including many antibiotics, statins, blood pressure, pain, and psychiatric meds) now have generics that are almost “free” – given away by grocery and pharmacy chains as loss-leaders. Yes, you can get a free supply of some antibiotics at Publix. That’s the marketplace at work. When it works, it works.

Except when it doesn’t. That price fall depends on generic companies being able to cheaply and easily bring the generic versions to market. Epinephrine, the medication in Epipen, has been around for decades, and it’s not under a patent. But regulatory issues have thwarted competitors from selling competing versions. One competitor, Auvi-Q, was recalled after a few dozen cases of wrong doses being dispensed by the device (to my knowledge no one was harmed by any of those errors.) In February, 2016 the FDA rejected Teva’s application for a generic epinephrine injector, and in June they delayed another company’s application, calling for expanded patient trials and more studies.

And it’s not just FDA regulations that gum up generic availability. Sometimes, drug manufacturers “pay off” generic makers to delay the introduction of generic medicines. These and other legal anti-competitive shenanigans create a marketplace that’s far from fair, preventing competition from driving down prices.

There is a very similar auto-injecting epinephrine device available, and it’s far cheaper: Adrenaclick. But the packaging and delivery system is different, so it’s not allowed to be freely generically substituted for an Epipen. If you want it, you have to have your prescriber specify that brand.

So: with no generic substitutions in sight, Mylan could freely increase their price. The same thing happens if there’s only one gas station in town, or only one health insurer in a local market. As we all learned from the board game, Monopolies are good for the monopoly, but bad for everyone else.

There’s more to the Epipen story. Mylan has been quietly jacking up the price for years, but no one really noticed until now. Until recently the list prices of medications were largely hidden from consumers. If you had health insurance, they paid the price, and you paid just a copay or whatever. Who cared what the “real” price was? Now that many of us have high deductible plans, those prices become important. Hiding the true cost of things from consumers, in the long run, doesn’t make for a fair or efficient marketplace.

And: you might imagine, with all of this price-gouging talk, you’d hear calls for someone’s head on a platter, in front of congress. Not this time. Mylan’s CEO is Heather Bresch, daughter of Senator Joe Manchin (D-West Virginia.)

The situation with the Epipen will wash out soon. The manufacturer has announced new cost-savings programs, and will almost certainly be lowering the list price shortly. But the regulatory framework that led to this disaster is still there, and until that’s addressed we’re going to be seeing more examples of crazy-priced drugs (and other medical services) soon.

Price Gouging

Is burping really necessary? Grandma versus science!

Posted August 22, 2016 by Dr. Roy
Categories: Guilt Free Parenting, Medical problems

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Ann wrote in: “My baby doesn’t burp easily – sometimes she doesn’t burp at all. Trying to make her burp makes her upset. Do babies really need to be burped after nursing?”

A fair question. Generations of parents have been burping their babies, and it seems like something we probably ought to do. I mean, it’s uncomfortable to have un-burped gas in your belly, right? And gas there probably causes fussiness, and maybe makes babies spit up, right? Not only does it make sense, but that’s what Grandma has been saying. Could Grandma possibly be wrong?

Let’s see what science says. There was a study of this exact question, published in 2014 in the journal Child: Care, Health and Development. A group including nursing and pediatric specialists from Chandigarh, India took on the Grandmas in their publication, “A randomized controlled trial of burping for the prevention of colic and regurgitation in healthy infants.” Their conclusion: “burping did not significantly lower colic events and there was significant increase in regurgitation episodes.” Yikes!

It was a simple study design, the kind I like best. 71 babies were randomly placed into two groups: an “intervention” group, where moms were taught burping techniques and told to burp their babies after meals; and a “control” group, where mom were taught other things about parenting, but were not taught about burping. The babies were all otherwise healthy, ordinary term infants, enrolled shortly after birth. They were followed for three months, with the families recording crying times and the number of spit-ups (regurgitation.)

The results: the amount of crying in each group was about the same. Burping did not prevent “colic”, or excessive crying. When comparing the episodes of spit-up, the “burping” group had approximately twice as many spit up episodes as the non-burped babies. So: burping had no effect on crying, and actually made spitting worse.

There are some important limitations. The study was done in India, and the conclusions might not be the same in babies from other parts of the world. Also, the intervention wasn’t “blinded” – for practical reasons, the parents knew if their babies were in the burping group. Still, the conclusions were statistically strong, and I think they’re probably correct.

Will this convince anyone to stop burping babies? Probably not. But I would say, for Ann, if burping makes your baby upset, there’s no reason to keep doing it. For the rest of you: you’ll have to settle this with Grandma, yourselves. I’m not getting in the middle of it!

Ogre belches are the worst

Die, rumor, die! Offgassing is not the cause of SIDS

Posted August 11, 2016 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Leah wrote in: “I was wondering if you could shed some light on mattress wrapping to prevent off gassing and the New Zealand SIDS statistics. If there anything to this?”

Like a zombie rising from the grave to eat your brain, the “offgassing” hypothesis of SIDS is one of those rumors that just won’t stay in its grave. We can thank the internet for its unique ability to keep obviously wrong ideas alive, forever and ever. Every once in a while, someone stumbles on hoary old posts and “news” stories, reposts them on Twitbook or Faceter, and the idea arises again. There has got to be something better for all of us to be doing with our time!

It all started in 1989 when someone claimed that he had figure out the cause of SIDS. It was chemicals (fire retardants) used in crib mattresses, interacting with a fungus that released toxic gases. I’m not linking the sites that claim this, because I have no wish to perpetuate the rumor– if you want to find out more, Dr. Google will be your willing ally for your adventures. You’ll see that there are several sites that all reference each other, rather than any substantial published studies; many sell special mattress wrappings to keep the Evil Gasses at bay. You’ll see claims that no baby ever dies on a specially-wrapped mattress, and that the government and doctors has been hiding these statistics (because, presumably, we’re all in the pocket of “big mattress” and “fire fighters”.) You’ll also see claims, on those same sites, that HIV doesn’t cause AIDS and other, shall we say, “colorful” health beliefs. Seriously, if you do end up Googling this, you’ll want to put on a fresh tin foil hat first.

The facts of the matter are summed up here, in a document from First Candle. They’re a non-profit dedicated to fighting SIDS and providing support for grieving families. They point out some simple facts: the rate of SIDS dropped after “The Chemicals” were added to mattresses to prevent fires;  the fungus claimed to be associated with SIDS is almost never actually present in any mattresses; wrapping mattresses has never been shown to prevent SIDS, babies have in fact died on wrapped mattresses; and SIDS occurs at a similar rate in countries that do and don’t use flame-retardant chemicals in mattresses. There’s more to it, including summaries of multiple, well-funded investigations into the theory, but you get the point: there’s just no evidence, whatsoever, that toxic gasses from unwrapped mattresses are killing babies. Those that support the theory are not telling the truth.

There’s been good progress fighting SIDS in the 25 years since the “offgassing hypothesis” appeared – we now understand a lot of ways families can protect their children, and SIDS rates have fallen dramatically. This idea wasn’t an unreasonable hypothesis when it was proposed, but studies haven’t backed it up. It’s time for the Toxic Gas idea to stay buried and forgotten.

Ironic