Rabies, bats, and a tragedy in Florida. How to protect your kids.

Posted January 17, 2018 by Dr. Roy
Categories: In the news, Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

You’ve probably already seen the news: a 6 year old boy in Florida has died of rabies. He had handled a sick bat (some reports said he was trying to rescue the critter), and that was enough contact to transmit the virus. Once symptoms begin, rabies in almost always fatal – so the only way to prevent this from happening again is to avoid contact, and get rabies prophylaxis (a series of injections) if there’s an exposure.

 

Is rabies common?

Yes – in a way. In the US there are only a handful of human cases a year (43 cases from 2000 through 2013, the most recent statistics I could find.) But there are an estimated 60,000 deaths a year worldwide. So, travelers, be especially wary of animal exposures overseas. In fact, if you’re traveling to the developing world to an area with likely animal exposures and no access to medical care, it may be wise to get rabies immunizations beforehand.

 

How can people catch rabies?

It’s a zoonotic infection, meaning we catch it from animals. Only the saliva transmits rabies virus, so most infections come from bites (or sometimes scratches, since animals aren’t always so keen on washing their hands with soap and water.)

Any mammal could potentially become sick with and transmit rabies, but in the US almost all transmission is from a few carnivorous animals: bats (by far the most common source, accounting for all but 4 of those 43 cases), raccoons, skunks, foxes, coyotes, and bobcats. Small rodents (rats, mice, squirrels) and lagomorphs (rabbits, hares, and pikas) would very rarely be possible carriers. Animals with rabies may act sick, and may be especially aggressive or bitey, so always be wary of any sick mammal, especially bats.

Worldwide, the most common source of human rabies are domesticated and semi-domesticated dogs. A campaign to vaccinate pets and farm animals has virtually eliminated this kind of transmission in the US – so keep vaccinating your animals!

 

What are the symptoms of rabies?

The incubation period is typically 1-3 months, though it can be days or years after exposure before symptoms develop. It’s a quickly progressive illness that often begins with acute anxiety, pain and other sensory abnormalities, unstable blood pressure and pulse, and sometimes “hydrophobia”, an extreme fear of water. (Hydrophobia is a historic name for rabies.) These symptoms progress to coma and death.

There have been three reported survivors of rabies over the last 20 years, all teenage girls treated with a very aggressive protocol of intense medical support, including medical-induced coma and artificial ventilation. Despite this care, most patients will die.

 

What should I do to prevent rabies?

Make sure domestic animals are vaccinated, and take them to the vet if they’re sick.

Approach wild animals with respect, and teach this to your kids, too. Wild animals should not be approached, or trapped, or captured, or kept as pets. If you see an animal that’s acting sick, especially a mammal, stay away. If it’s the kind of mammal that’s likely to transmit rabies (a sick or wild dog, or a raccoon, skunk, fox, coyote, or bobcat), contact animal control or your county health department. Keep children away.

  

What if someone gets bitten or scratched by one of these animals?

First, clean the wound with soap and running water. Then go see your doctor, or go to the emergency department. Do not delay. If necessary, post-exposure injections can be given which will virtually guarantee that rabies won’t occur. These injections will not help once symptoms begin – they must be given before rabies develops. Public health people and other experts consider the circumstances of every case before deciding whether rabies prevention is needed – don’t rely on this post, or what you read on the internet, to decide if you need rabies shots. Go see a doctor right away if there’s been a potential exposure.

If it is possible to do it safely, trap or capture the biting animal. That will prevent other people from getting exposed, and will allow health authorities to test the animal for rabies.

In some circumstances, a biting animal can be observed in captivity for 10 days for signs of illness.

 

What about bats?

Bats are a special circumstance. They’re the most common rabies transmitter in the US. And small bats, especially, could potentially bite a sleeping person without anyone noticing. Young children may not be able to communicate exactly what happened during a bat incident. So if there’s a bat that’s been in a room with a sleeping child, or a child who’s been playing with a bat or near a bat for any reason, go see a doctor. (If you can capture the bat, or kill the bat and bring the carcass including the head, that can help – only if you can do this safely.)  Even if the risk of transmission is low, the consequences of not treating a rabies exposure are horrible.

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Use honey. Not Zarbees.

Posted December 26, 2017 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2017 Roy Benaroch, MD

What if there were something cheap and effective for cold symptoms – something you could buy at your grocery store. Heck, you probably already have it in your house. It’s undergone at least three solid studies showing that it helps alleviate cough more effectively than established cold medicines. And it’s safe for just about anyone age 12 months or older.

Cool, huh? It’s honey. Good old honey, the stuff beloved by Winnie the Pooh, made by bees, and especially tasty drizzled on a peanut butter sandwich. You shouldn’t give raw, unpasteurized honey to babies less than 12 months of age, but other than that it’s safe as can be. Try it next time you or your child has a cough. (** TIP ONLY FOR ADULTS: I’m told mixing equal parts of honey, lemon juice, and Canadian whiskey together makes a fine toddy that will make it feel like you aren’t even sick. Until you pass out. This is for parents, not children.)

And that should be the end of the story. But what if instead of honey, you mix it with some other ingredients, double the price, and sell it in the medicine aisle? Then you’ve got Zarbee’s, which (according to their website), is the #1 pediatrician-recommended cough medicine sold for children less than 6.

Keep in mind Zarbee’s wasn’t what was studied in those clinical trials. I can’t find any clinical trials of Zarbees. Even the company that makes it carefully tiptoes around that issue on their website, where they avoid claiming that there’s any evidence that their products effectively treat any symptoms. They “support immune systems” and “soothe”, but those are just weasel-phrases that can’t be tested. That’s why the packaging also says, in all-capitals, “THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THIS PRODUCT IS NOT INTENDED TO DIAGNOSE, TREAT, CURE, OR PREVENT ANY DISEASE.”

Though the Zarbee’s line started with just the cough syrup, they’ve now got a variety of products to treat symptoms, all based on “wholesome ingredients” – meaning, as far as I can tell, “things not tested for safety or effectiveness in children.” But I guess they expect a pass, because, you know, the bees and all.

Look, I know coughs and colds are frustrating and miserable. If there were anything that actually worked, whoever comes up with it will make a mint. Until then, we’ll continue to see the dizzying aisle of hundreds of competing medicines – and every few years, a new one will become popular. Remember the one “invented by a teacher”? Or that adorable mucus-monster that showed up a few years ago? Now we’ve got Zarbee’s. None of these products works any better than any of the others, and none work any better than typical home remedies. But no one will make any money selling chicken soup and honey, so I’m sure we’ll bee (ha!) seeing more products from the Zarbee’s line. Save your money.

Some reassurance about football and your child’s brain

Posted December 4, 2017 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2017 Roy Benaroch, MD

Concussions and football have come up before on this blog, and the news so far has been discouraging. We want kids to stay active, and football is one of the most popular boys’ sports out there. But we know that some prominent professional athletes have had serious, cumulative brain damage from years of football – sometimes brain damage that has destroyed their lives. What about high school football, or football starting even earlier? Are we encouraging a sport that’s a cause of serious, lifelong disability?

A recent publication gives at least some reassurance. From the August 2017 issue of JAMA Neurology comes a study titled “Association of Playing High School Football with Cognition and Mental Health Later in Life.” It’s not a perfect, definitive study, but it’s got some solid long term data.

Researchers have been studying a cohort of about 10,000 Wisconsin high school graduates – students who graduated in 1957, so they’re now about 78 years old. Of those, about 2700 have complete data, including formal testing of their mental condition at age 65 and 72. Tests were done of intelligence and brain functioning using several standard assessments, as well as testing for things like depression, anxiety, and alcoholism. They also went through the high school yearbooks to figure out which of these students played football (it turned out to be about 30%. Football was, and still is, big in Wisconsin.)

When the data was analyzed, it looks like football players were no more or less likely to have problems with dementia or mental illness 60+ years later; nor were they more likely to consume too much alcohol. What was different was that they were somewhat more likely to stay physically active (which may have protected them from memory problems as they became older.)

There are some shortcomings of a study like this. We don’t know which if any of the participants played football starting younger than high school, or which positions they played, or whether they had one or more concussions. And, I think even more significantly, it’s apparent that football now is played quite differently than in 1957. Players are bigger and stronger and faster, and collisions are more high-energy. It may be that there are more brain injuries happening now on high school football fields than there were back then.

Still, 60+ years is some great long-term follow-up. It’s good to know that at least one long term study shows that football in high school isn’t associated with later cognitive or mental health problems. We still need to minimize concussion risks and identify and treat them correctly, but this study should provide some reassurance that high school football might not be so bad for high school brains.

What causes dark circles under the eyes in children?

Posted November 6, 2017 by Dr. Roy
Categories: Guilt Free Parenting

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The Pediatric Insider

© 2017 Roy Benaroch, MD

Rachel wrote in a topic suggestion:

My 8 year old daughter has for years had dark circles under her eyes. What causes this? She is very healthy and hardly ever gets sick. I have ‘heard’ this can be caused by food allergies or liver problems, but I’ve been very skeptical about that.

Rachel, I see these in kids all the time. Most commonly, I think it’s just normal – especially in children with a fair complexion. It’s easier to notice these in kids with thin, light, milky sort of skin (often with light eyes and light or red hair, too.)

One medical issue that can contribute to darkness under the eyes is congestion in the veins lining the nose. This makes the blood vessels dilate and become more noticeable. You’ll see this in children with nasal allergies or “hay fever” to airborne allergens like pollen or dust or molds. That’s why these dark areas are sometimes called “allergic shiners.” If the nasal allergy symptoms are bothering the child, this can be treated by avoiding the triggers (not always easy), or nasal spray OTC allergy sprays like Nasacort or Flonase. Oral antihistamines like Zyrtec or Claritin will be less effective for nasal congestion.

I’ve also often heard that lack of sleep can cause dark circles – Google it, and there are plenty of people who say this. I couldn’t find any evidence that this is true in children, but it might be. And more sleep couldn’t hurt.

As for food allergies – you know, I wouldn’t have thought so, at least not in my experience. But this report showed that about 50% of kids who had classic GI symptoms of food allergy also had allergic shiners. So, yes, in a child who has GI symptoms of food allergies, they might get shiners too. But in a child with no GI symptoms, I don’t think allergic shiners would be a likely isolated finding of food allergy. And liver disease? No, I don’t think so. I couldn’t find any evidence for that at all, at least not in children.

So: pretty much benign, maybe related to allergies, and probably best ignored unless the allergic symptoms themselves are bothering the child. You can add “dark circles under eyes” to our ever-growing list of things parents really don’t need to worry about!

Halloween: What should worry parents, what should not

Posted October 24, 2017 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2017 Roy Benaroch, MD

 

Poisoned candy – not a worry!

There have been 5 deaths in the USA reported from poisoned Halloween candy. But: three were committed by family members (one using cyanide-laced Pixy Stix), one was by a child who ingested heroin (the family sprinkled more heroin on the candy afterwards to make it look like that was the source, but it turned out that the child had found and eaten his uncle’s stash) and one turned out to be related to an overwhelming strep infection – unrelated to the candy eaten the night before.

In 2000, several children in California found Snickers bars packed with marijuana. Funny story: a postal worker found a box of Snickers among the undeliverable mail, and brought them home to give to trick-or-treaters. It’s assumed that someone packed them with marijuana to sneak them through the US mail, but got the address wrong. There’s a lesson there. Anyway, no one ever found the culprit, and no one was hurt.

 

Metal objects in candy – not a worry!

 There have been about 80 reported cases of needles and razor blades and things in Halloween candy. But almost all of these were hoaxes that never actually happened. A few were true stories, but the objects were placed by family members (good old Uncle Bob, what a kidder.)

In 2000 there was a case in Minneapolis of a guy arrested after sticking needles into Snickers bars (What’s with the Snickers, anyway?) One teenager got stuck by a needle, but didn’t need medical attention. As far as I can find, this is the only documented case of a sicko randomly and deliberately handing out dangerously adulterated candy.

Some communities have had programs for x-raying candy – but I think these have been phased out. They’re expensive and unnecessary, and no one has ever spotted anything of concern on one of these.

 

Sexual assaults – not a worry!

 It’s been studied. Child sex crimes don’t increase on Halloween.

 

Getting your eye knocked out by a thrown egg – this is a thing, apparently

This report wasn’t about Halloween, but it did include several people with apparently severe eye injuries caused by assault by thrown raw eggs. So don’t do that. Raw eggs are for throwing at houses, not people. Wait, forget I even said that. Just leave the raw eggs at home. Make cookies or something.

 

Car accidents – the only serious possibility on this list

Now this is a real problem. Halloween is the #1 day of the year for pedestrian accidents among children, averaging 5.5 deaths per year in the US (that’s double the average for a typical day.) Be careful with your kids, and have them wear something light or (better yet) lit. Remind them to cross streets at crosswalks and corners, and not just dart around. If you’re driving, be very careful in residential neighborhoods, and don’t drink alcohol. Both drivers and pedestrians shouldn’t be messing with their phones. Pay attention, everybody.

 

Getting your brains sucked out by Alien Zombie Vampire Death Beings – rare?

As far as we know, this doesn’t happen. Much. Hardly ever. Really.

 

Tummy aches and weird nightmares from too much candy – yup, it happens

Don’t say I didn’t warn you!

 

More from Wikipedia, Snopes, Mental Floss, and Vince Guaraldi. Stay safe, have a good time, and remember: I like Almond Joys and Reese’s.

Physician rating sites deserve their own “Black Box Warning”

Posted September 26, 2017 by Dr. Roy
Categories: In the news, Pediatric Insider information

The Pediatric Insider

© 2017 Roy Benaroch, MD

When a drug is especially dangerous, or even potentially-maybe-especially dangerous, the FDA requires manufacturers to put a “Black Box Warning” on the product insert. (As it happens, many of these are misleading, inappropriate, or factually incorrect – but that’s a subject for another day.) A “Black Box Warning” is supposed to very explicitly say “BUYER BEWARE”, more than just the typical list of potential side effects mumbled by Mr. TalkFast at the end of a drug ad. The normal warnings look like “ThisDrugMayCauseDrowsinessTailGrowthAnalFlameDischargeAnUnpleasantMetallicTasteOrAnInexplicableInfatuationWithSenatorJonTester(D-Montana)”. It’s easy to ignore the wordy mumbling. The Black Box, that’s supposed to get your attention. It’s doesn’t mean the drug is a bad idea for everyone, but it does mean you’d better think before you take.

I’d like to see a Black Box warning on physician rating sites, too. They’re not always wrong, and they might just be useful once in a while. But you’d better think twice before taking them at face value, or using them to make decisions about whom to see for health care.

A few recent studies illustrate some of the problems. One looked at mortality rates for 614 heart surgeons scattered across 5 states, comparing those rates to their physician ratings on several well-known rating sites. There was no correlation at all. Physicians with high death rates often had great ratings; physicians with low death rates might have very good ratings. If your goal is to survive heart surgery, those physician rating sites tell you nothing. That should be in the Black Box warning.

Another study looked at physicians in California, comparing ratings on popular sites between 410 docs who had been put on disciplinary probation versus docs in those same Zip codes who hadn’t been sanctioned. Keep in mind that medical boards do not take probation lightly – docs who’ve been nailed by their board have probably done something fairly bad, and probably more than once (although there’s considerable variability, some luck, and politics involved. Good docs are sometimes trapped by their boards, too.) Although it varied by the reason for the probationary status, for many doctors disciplined for lack of professionalism, substance abuse, or sexual misconduct there was no correlation between ratings and probation status. Looking at the overall averages, docs on probation had an average score of 3.7, compared to 4.0 for docs who had behaved themselves. Very little difference, there.

There are several reasons that these doc rating sites not reflect genuine physician competence:

  • Only people who are motivated to write ratings do so. The vast majority of patients who have a reasonably positive experience do not bother to do rate their docs. I’ve called this property of internet postings “Exaggerating Freakiness”, and it pervades social media. The internet brings far more attention to the outliers than it does to ordinary stories, and that distorts the impression we get from just about every web site.
  • How people feel about the medical care they received doesn’t necessarily correlate with whether they got good care or not.
  • It’s pretty much impossible to tell if a public posting is true. There are many reasons people write both positive (friends, neighbors, well-wishers) and negative (competitors, those with specific agendas) reviews.

Some docs (and other businesses) are using litigation to aggressively fight back against negative reviews. But that’s not always fair, either. People are entitled to their opinions, and as long as they’re not just lying about what happened, I think it’s best if the lawyers stay out of this. Still, I get the frustration that business owners feel if they’ve been unfairly targeted.

Online rating sites are here to stay, and they’ll continue to rate doctors and hospitals, and people are going to continue to use them (Google just shoves the rating down your throat when you search. There’s no avoiding this.) Just remember the Black Box warning: physician rating sites may have some use, but they can have unintended side effects. They may mislead you into making a poor decision about your doctors, and that’s not good for your health.

Physician rating sites deserve their own “Black Box Warning”

Be wary of infant jewelry and lead poisoning

Posted September 5, 2017 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2017 Roy Benaroch, MD

A recent story reported by the CDC reminds us of a few important lessons about teething, lead, and the kind of jewelry you buy at craft shows. A mom had purchased a handmade “homeopathic magnetic hematite healing bracelet” from an artisan at a local craft show. Her 9 month old daughter wore it on her wrist, reportedly to help with teething symptoms, and occasionally chewed on it (as babies are known to do.) She was found on routine screening to have a blood lead level about 10 times the safe upper limit of safety.

Lessons to learn:

Babies really shouldn’t wear jewelry at all (they look good without it!) Some bling is probably OK (like small earrings), but you have to be sure they’re not made with lead. That’s because anything on a baby or near a baby will end up in the baby’s mouth. Seriously, everything.

This particular bracelet was triple-dangerous. Looking at the photo, it was made of little beads strung together, which apart from their poisonous lead content were a potential choking hazard. And: magnets are a very bad thing for kids to swallow, because they can glom onto each other in clusters, or even while pinching a piece of intestine. Magnets are less likely to make their own way out without causing big-time tissue damage. No lead, no beads, no magnets!

Babies should especially never wear any kind of jewelry around their necks. Even a small tug on a necklace can close off the airway and kill a baby. That includes those trendy amber teething necklaces, which are both a choking and strangulation hazard. There are media reports of deaths from those things. Look out for long cords or straps on pacifiers, or cords on window blinds or binoculars or anything else thin and round and shaped in a loop. Anything that could wrap around a neck can strangle a baby and needs to be cut to pieces or kept very far away.

And: teething. Most babies experience teething with no symptoms whatsoever – the only way you know, with most babies, is that you see teeth poking out. An occasional baby might have some fussiness with teething, and you can treat them with love and cuddling, maybe a teething ring, or some acetaminophen if needed. There is no great plague of terrible symptoms of teething that need constant treatment, especially not with dangerous things. Teething is just another thing most parents do not have to worry about.

Other dangerous teething “cures” have included “homeopathic teething tablets” which contained poison, and benzocaine-containing teething gels (now mostly off the market) that caused a potentially fatal blood disorder. The sad thing here is that none of these were ever really needed – they’re marketed based on fear of a normal, harmless condition. Don’t waste your money, or endanger your child’s health, on jewelry or potions to treat teething.