Some reassurance about football and your child’s brain

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

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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.

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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.

Breath holding spells —  Super Scary for parents, not a big deal for kids

Posted August 28, 2017 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

Lemelon wrote a topic suggestion: “Breath holding spells. My toddler had a cyanotic breath holding spell after a bad fall where he struck his head on concrete from a height of about 4-5 feet. I didn’t know about breath holding spells and was pretty sure he was going to die. Thought maybe other parents would like to learn about them and their prevalence. Thanks!”

Near the top of a list of super-scary things for parents to see are breath holding spells. Your kiddo, typically a toddler, bonks his head or gets really mad about something. Then he stops breathing, turns white, and collapses on the floor. And looks dead. Really. Dead. It’s quite dramatic. I can say this, calmly now, because the child of mine that used to have them hasn’t had one in over 10 years. I’m a doctor, but with your own kid breath holding spells are freaky and scary.

But they aren’t freaky and scary to the children. After a few moments, they start to breathe again, and they might be a little tearful or clingy for a few minutes, and then they’re fine. Mom and dad need a long lie-down and a few glasses of Chablis, but the kiddos, I promise, they’re fine.

So what are breath holding spells? They’re kind-of-sort-of like a faint. They usually happen in toddlers, say from 6 to 18 months of age, and usually start with either a painful stimulus or less-often a very frustrating or fearful sort of event. The child might then gasp, and stop breathing, and almost immediately turn very pale or sometimes blue. Here’s a weird thing: even though their skin can look blue, there’s still plenty of oxygen in their blood. This happens way too fast to drop blood oxygenation. They look like they’re blue and dying, but they’re not. And: breath holding spells are entirely, 100%, involuntary. These are not kids who decide to hold their breath until they pass out.

During this period, what’s basically happening is that the autonomic nervous system – that’s the involuntary, behind-the-scenes part of the nervous system that you don’t think about much – slows down the heart, and clamps down the blood vessels, and, well, shuts off the brain. The kids go limp, and collapse breathless on the floor. Sometimes, there can be just a few little muscle jerks or spasms right there at the end, too, to further freak you out.

But just a few seconds later, everything resets. The heart resumes normal beating, circulation returns, and Junior wakes up. Crazy, I know, but leave it to kids to come up with something like this. Look mom, I’m dying! Just kidding!

(If the child doesn’t wake up and start breathing within 3 minutes, start CPR and call 911. I’ve not seen or heard of that happening, and I don’t think any parent would even wait that long, but I don’t want parents to not call 911 if they’re worried!)

Breath holding spells are fairly common – they happen in 4-5% of children, maybe a little more commonly in girls. Though they typically start at 6-18 months, some babies will start younger. They usually stop by age 4 years or so, though some kids go on to have more-ordinary fainting spells from there.

Bottom line: as scary as they are, breath holding spells are harmless. The main thing is to diagnose them correctly (which is 100% entirely by the history, there are no tests or scans or anything) and to avoid a huge, expensive, painful, and misleading diagnostic odyssey. These kids do not need a bunch of tests. If the diagnosis isn’t clear from the history (say, the events are unwitnessed or atypical), sometimes a few tests can rule out other things.

There are a few off-label medicines that are rarely prescribed to prevent breath holding spells, especially if they’re happening very frequently. There’s some evidence, not great, that iron supplementation may sometimes be helpful. But that’s it in terms of medical therapy. (That, and the Chablis)

With breath holding spells, the doc’s job is to listen and get the diagnosis right, without unnecessary tests; the parents’ job is to leave the kiddo alone until he wakes up, and try not to freak out; and the child’s job is to outgrow them before Daddy has a heart attack, OK?

What happened to those pain-killing ear drops?

Posted August 14, 2017 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2017 Roy Benaroch, MD

MJ wrote in about her daughter. In the past, she used to use a prescription drop called Auralgan (benzocaine plus antipyrine) for ear pain, but it’s been taken off the market. What happened to it? Was it unsafe? Can she start buying it from Canada? What other options are there?

The FDA got tough on Auralgan and several other similar ear drops – AB Otic, Aurodex, Auroto, and other brands – in 2015. To my knowledge, there wasn’t any specific incident or allegation that these products caused any problems. But they’ve never been shown to be safe, and they’ve never been shown to be effective.

For many years these and other older “grandfathered” drugs were cheerfully sold alongside other prescriptions. But all new drug applications submitted to the FDA must include proof of both safety and effectiveness – that’s been the law since 1938, though what’s passed for “proof” has varied. Many older drugs, like these ear drops, slipped though when things were less stringent. But the FDA has always had the right to ask for more proof from the manufacturers.

I don’t really know why these drops got the FDA’s attention. It is true that there’s never been any proof of effectiveness. A German study cited in the non-discontinued products’ insert showed that children given Auralgan for earache did improve – but they didn’t compare the responses with a placebo, and we know that ear aches get better on their own, anyway. There was also a study from Pittsburgh in 1997 – the authors say they showed that topical Auralgan was “likely to provide additional relief” when given along with acetaminophen. But their study showed no statistical difference in pain scores at 3 of the 4 time periods, meaning that Auralgan was equivalent to their placebo (olive oil drops.)

There’s also no science reason to even think these drops would work. The two ingredients, benzocaine and antipyrine, are not effective when applied to the skin – they only work when injected or swallowed. Benzocaine has some activity when rubbed onto a mucus membrane, like on your tongue or gums, but that’s not what’s inside your ears. And: it makes absolutely no sense to use these to treat middle ear pain (like an ear infection, or the pain you get in an airplane), because drops in your ear canal don’t get into your middle ear. That’s like treating stomach pain by pulling on a finger. OK, bad example (ref: grandpa). Anyway, you get the idea.

Real Drugs are only supposed to be marketed in the USA with FDA approval, which requires proof of safety, effectiveness, and quality control manufacturing standards. For ear pain, if you want to stick with a Real Drug, acetaminophen is a pretty good choice. MJ asked about buying Auralgan from Canada – it looks like it’s still on the market up there. I found one place selling it for $142. That’s one expensive placebo.

Or, MJ could wander outside of the realm of Real Drugs. The 1997 study used olive oil as a placebo, and that’s safe – and you could use the leftovers in a salad. Or you could look in the alt-med, “alternative medicine” section of the drug store – there are ear drops there, but they’re not FDA regulated, so purveyors can sell whatever they’d like. You don’t know what you’re getting in those bottles, and there’s no reason to think they’d work any better than olive oil, pickle brine, or ranch dressing.