Nurturing your children at home: Tips for sheltering in place

Posted March 31, 2020 by Dr. Roy
Categories: Guilt Free Parenting

The Pediatric Insider

© 2020 Roy Benaroch, MD

These are difficult times, and there’s a lot of uncertainty about what will happen next. When will our kids go back to school, and when will parents be able to return to their routines? There’s a lot we don’t know, But there are things you can do now to help you and your children stay well while staying at home.

Stay with a routine. Get up and go to bed at reasonable times, and block out time for school, play, and meals.

Get outside. We all need to avoid crowds, but that doesn’t mean you and your kids must stay indoors. Go for a bike ride. Draw a colossal, life-sized squid on the cul-de-sac. Take your dog for a walk. Everyone needs movement and exercise, every day. It doesn’t have to be in a gym.

Play with your kids. Foosball, Super Mario World on an old SNES, ping pong, Gin Rummy. Or make a game – create an obstacle course, or use paper towel rolls taped to the wall to create a ball-maze. Draw and dance and create together.

Connect with friends and relatives with Zoom, Facetime, or whatever. We’re supposed to be physically distant, but we’ve got the technology to stay socially together. Not ideal, but better than nothing!

Be gentle, and be kind – with yourself, with your kids, and with everyone else you meet. We’re stressed and life is strange, and that doesn’t always bring out the best in ourselves or our neighbors. Pay back negativity with kindness; or if that doesn’t work, ignore it. We all need more humor and positive vibes these days. If you or your kids aren’t getting that from certain friends, it’s time to “mute” them. (The friends, not your kids.)

Lower your expectations. You probably didn’t sign up to home-school your kids, and you’re maybe not going to be able to sustain the kind of job you wished you could do. (Hey, maybe we’ll all learn to appreciate our kids’ teachers more!) You may be discouraged that there’s a pile of laundry, or that you’re not getting enough stuff done every day. This is a whole new ball game, and failing at your expectations probably means your expectations were off-base – not that you’re a failure.

Help people. You’ll feel better (and you’ll set a great example for your kids) if you do simple things to help your neighbors. Send post cards. Deliver cookies (leave them at my door!) Offer to pick up someone’s medicine, or make a huge batch of chili to share. Look out for examples of people helping people – there are thousands of these stories on social media every day, though sometimes they’re lost in the clutter.

Speaking of social media: it’s a great way to connect and get news, but you’ve got to turn in off sometimes. There’s too much bad news, incorrect news, and hysteria to stomach for long. Consider putting guard rails up for yourself and your children – only, say, 1 hour of Facebook, once a day, then you are done. When you do post and share, post reliable things from credible sources. Even better, share silly things that will make your kids and your friends laugh.

Things will get better. In the meantime, we can make the best of our shut-in time. And, by the way, my favorite cookies are chocolate chip.

Getting care quickly improves concussion recovery

Posted January 28, 2020 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2020 Roy Benaroch, MD

Concussions are a mild traumatic brain injury. Mild means you can’t see any damage on a CT or MRI scan – but’s still an injury, and injured brains take time to recover. Symptoms like headache, brain fog, and trouble with mood, memory, and balance last on average 3 weeks in sports-injured teens. Three weeks is bad enough, but we know some teens have symptoms that linger far longer.

A new study from JAMA Neurology found an important predictor of a longer recovery: just how long did it take for a teenager with a concussion to get a medical evaluation and treatment? About 250 teens and young adults, aged 12-22, who had a sport-related concussion were tracked to see how long their symptoms lasted. The researchers looked back on many factors to see what best predicted longer symptoms. Many things you might think would be predictive were not, like measures of concussion severity or the findings of neurocognitive testing. These didn’t seem to matter.

The best predictor was a simple measure of how long it took to get in for an evaluation. If that first clinic visit took more than seven days, there was a six-fold increase in the chance of having symptoms lasting more than a month.

The treatment of concussion is actually pretty simple, but it is important. The first, most-important rule is to get people with suspected concussions off the field. They should absolutely not continue play. After the initial evaluation, they’ll need to reduce sports and academics, and slowly ramp back up to full activity as symptoms improve. Patients with concussions should not avoid all activity, though – some light exercise is ok, and can help recovery if done carefully. That’s why that initial medical evaluation is important, and should be done quickly. Patients and families need clear guidance on what to do, and what to expect from their recovery.

 

More about concussions:

What is a concussion?

What to do when your child has a concussion

Football helmets do not protect your child’s brain

The holiday un-gift guide: What not to buy this season

Posted November 29, 2019 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ho ho ho! It’s time for my nearly-every-yearly, not-too-clickbaity, almost-useful holiday gift guide with a twist! Plenty of guides tell you stuff you should buy. We’re here to save you money, and maybe even save your child’s life. Here’s a bunch of things you really shouldn’t buy this holiday season.

 

Baby walkers

Gizmos like this are a terrible thing to buy for a baby or family. Walkers slow infant development by making it more difficult for your baby to learn to walk. And, bonus, they injure about 9,000 babies a year in the USA. The AAP has called for banning them. Please, just don’t buy one of these things, m’kay?

Instead, consider a push-behind device or something like a standing activity center. They’re fun, provide genuine help with motor skills, and won’t maim or kill your baby!

 

Tiny magnet toys

Even the manufacturers of these toys, consisting of dozens or hundreds of little magnets, know they’re unsafe. But they still send mixed messages on their product listings. This one says it’s for ages 14 and up – “Use under adult supervision only” – right underneath where it says “GREAT GIFT FOR YOUNG AND OLD.”

What’s the problem? Little kids love to swallow these. And clumps stick together in the gut, causing necrosis (dead gut tissue.) Kids who swallow these are rushed to the OR, pronto. Before and after photos, courtesy of my friend and pediatric GI specialist, Dr. Tejas Mehta:

 

Baby sleep positioners

These are completely unnecessary, and can kill your baby. Other than that, sure, they’re fine. No, seriously, do not use a gizmo to position your baby in sleep. Seriously. Death. Bad. Ok?

 

Toy Vacuum Cleaners

Everyone likes to vacuum, right? And it’s not that toy vacuums like this one ($43) are dangerous. But you can buy a REAL ONE for $35. You have a kid wants to vacuum? Get him a real vacuum and put him to work!

 

Baby Bum Brush

You can use this to spread diaper cream on your baby’s bottom. Or this. Or this. Or your fingers, like God intended.

 

Amber Teething Necklaces

These are both a choking hazard and a strangulation hazard – especially ones that proclaim “The screw clasp prevents your baby from taking the teething necklace off.” That also means if the necklace gets caught on something, rather than breaking at the clasp it can strangle your baby. Or, if they do break apart, each individual bead becomes a choking hazard. And, besides, there’s no evidence whatsoever that these things relieve any symptoms of teething at all.

 

Crib Bumpers and Pillows

Babies should sleep on a firm, flat surface, NOT near soft squishy things that can interfere with their safe sleep. Squashy soft pillowy things are not only unnecessary, they kill babies. The AAP has been calling for them to be banned for years. I can’t even look at that photo without cringing.

 

Food Sensitivity Tests

Give the gift of paranoia! IgG-based food sensitivity tests, widely advertised on platforms like Facebook, are absolutely worthless. They measure an antibody response that shows you’ve eaten the food, not that you’re allergic or sensitive to the food. These tests don’t predict allergy or sensitivity or anything else. They just make people worry and encourage eating disorders and orthorexia.

 

Measles

Just don’t. There’s a very safe and very effective vaccine that had stopped measles transmission almost entirely in the US, Europe, and many other areas of the world. Now, thanks to the lies and distortions from antivaccine groups and Russian trolls, it’s surging back. That so many wealthy and privileged people are “helping” bring measles back to both the US and to developing countries is despicable. Be safe. Protect your children, your family, and your neighborhoods – even those too ill or young to be vaccinated. Make sure you and your children are protected, safe, and immunized.

What do current guidelines say about treating allergies with Benadryl?

Posted November 24, 2019 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

Last week, I published an essay titled Goodbye, Benadryl – It is time for you to retire. It generated, to use a precise term, a butt-ton of comments, almost all of which vehemently disagreed with my assertion that Benadryl is neither the safest nor most effective choice for most allergic symptoms. Here, I’ve revised the topic, looking at the most-recent published guidelines on the topic of allergies and their treatment.

Executive summary (tl; dr)

A large number of well-documented, authoritative guidelines on the treatment of allergic rhinitis and urticaria call for the use of newer antihistamines for the first line treatment of these common manifestations of allergic disease. Benadryl (diphenhydramine) is no longer recommended as first-line treatment because it works more slowly, is less effective, and is less safe. Benadryl may be useful for other conditions, but it should not be considered the first line therapy for most common allergic diseases.

 

Introduction

A Pubmed search was undertaken to find current guidelines from national or international health organizations on the treatment of allergic rhinitis and urticaria. These two diseases were chosen because they are by far the most common allergic indications for the use of diphenhydramine. I included guidelines I could find that focused on children and/or adults, mostly from 2015 and later.

The most definitive statement on the recommended use of antihistamines from these guidelines will be reported. Interested parties are encouraged to review the links for supporting documentation – these guidelines often have hundreds of references, and I’m not going to reproduce them here. Some passages will be bolded for emphasis.

In these reports, “second-generation” and “newer, non-sedating” antihistamines typically include cetirizine, loratadine, and fexofenadine; they may also include other agents that are less widely used here. “Older”, “first-generation”, or similar terms typically refer to diphenhydramine, chlorpheniramine, and other products.

 

Guidelines for the treatment of allergic rhinitis (“hay fever”)

From Clinical Practice Guideline: Allergic Rhinitis from Otolaryngology-Head and Neck Surgery (2015): “The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching.”

From International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (2018): “The AAO‐HNS concluded, based upon RCTs and a preponderance of benefit over harm, a “strong recommendation” for the use of newer‐generation oral H1 antihistamines for patients with AR….a favorable risk‐benefit ratio was determined for using newer‐generation oral H1 antihistamines over first‐generation oral antihistamines.1170 The evidence was further strengthened with several meta‐analyses of the current data, where accurate and robust effect estimations can be derived from a large population1171.

From Allergic Rhinitis, published as part of a series “Practical guide for allergy and immunology in Canada 2018”: “Second-generation oral antihistamines and intranasal corticosteroids are the mainstay of treatment.”

From Treatment of Seasonal Allergic Rhinitis: An evidence-based focused 2017 guideline update: “Antihistamines are available as oral (first- and second-generation) and intranasal preparations. First-generation antihistamines (eg, diphenhydramine, chlorpheniramine, and hydroxyzine) cross the blood-brain barrier easily and bind central H1-receptors abundantly, which can cause sedation. They also lack specificity because cross-binding also occurs with cholinergic, a-adrenergic, and serotonergic receptors, which can cause dry mouth, dry eyes, urinary retention, constipation, and tachycardia.18 Cumulative use of first-generation antihistamines with strong anticholinergic properties has been associated with higher risk of dementia.19 In contrast, second generation antihistamines (eg, fexofenadine, cetirizine, levocetirizine, loratadine, desloratadine, ebastine, epinastine, and bilastine) are more specific for peripheral H1-receptors and have limited penetration of the blood-brain barrier, thus reducing sedation.”

From Allergic Rhinitis, a clinical guideline from the American Academy of Family Physicians (2015): “Oral second-generation/less sedating antihistamines should be prescribed for patients with AR and primary complaints of sneezing and itching.”

It is clear that every major guideline for the treatment of AR prefers newer antihistamines over diphenhydramine. None of these agents, though, are as effective as other agents such as inhaled corticosteroids.

 

Guidelines for the treatment of urticaria (hives)

From BSACI guideline for the management of chronic urticaria and angioedema (2015): “Pharmacological treatment should be started with a standard dose of a non‐sedating H1‐antihistamine (grade of recommendation = A).”

From Clinical practice guideline for diagnosis and management of urticaria (2016) “With regard to side effects, EAACI/GA2LEN/DEF/WAO Guideline 2013 recommends the use of first-generation (sedating) -antihistamines only when second-generation non-sedating antihistamines are not available.”

From Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults – Brazilian Society of Dermatology (2019): “Oral antihistamines are key drugs in the treatment of chronic urticaria, especially nonsedating and low-sedating agents… According to the Urticaria International Guideline, as second-line of treatment, use of up to fourfold doses of second-generation antihistamines is indicated, whenever licensed dose failed to control the disease. , The use of these drugs at maximum doses, such as desloratadine 20 mg/day, levocetirizine 20 mg/day, loratadine 40 mg/day, and cetirizine 40 mg/day, is not yet approved in Brazil, despite published international scientific literature.”

From Management of chronic urticaria in children: a clinical guideline, Italian Journal of Pediatrics (2019): “Question 20. What is the drug of choice for CU? Recommendation. Second-generation H1-antihistamines are the first-choice treatment for CU (Level of evidence I. Strength of recommendation B).”

The overwhelming consensus from multiple international guidelines supports the use of newer antihistamines over older agents.

 

Guidelines on the use of antihistamines

From CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria (2019): “The Canadian Society of Allergy Clinical Immunology (CSACI) recommends that newer generation AHs should be preferred over first-generation AHs for the treatment of allergic rhino-conjunctivitis and urticaria.” This article summarized in a media account, here.

In addition, an extensive review from 2010 concluded, “This review raises the issue of better consumer protection by recommending that older first‐generation H1‐antihistamines should no longer be available over‐the‐counter as prescription‐free drugs for self‐medication of allergic and other diseases now that newer second‐ generation nonsedating H1‐antihistamines with superior risk/benefit ratios are widely available at competitive prices.”

 

Conclusion

Benadryl (diphenhydramine) and other older or first-generation antihistamines should not be considered first line therapy for urticaria or allergic rhinitis.

 

Caveats

There are certainly other uses of diphenhydramine, as an agent to treat extrapyramidal side effects and perhaps as a mild sedative. It can also be used to treat motion sickness and nausea. Evidence for its usefulness for nonspecific cough and cold symptoms is lacking, though it’s often included in multi-symptom “cold relief” medications. These should not be used under age 4, and should have a limited role in reducing symptoms in older children and adults as well.

Diphenhydramine is among the only antihistamines available for parenteral use, which can be uniquely advantageous in limited circumstances where use of an oral agent is not possible.

Though often used in a setting of serious allergic reactions, anaphylaxis should always be treated with epinephrine, not an antihistamine. Antihistamines can be considered adjunctive therapy for these reactions, but epinephrine should never be delayed while giving an antihistamine or awaiting a response to an antihistamine.

Goodbye, Benadryl – it is time for you to retire

Posted November 18, 2019 by Dr. Roy
Categories: Pediatric Insider information

Tags:

This has become, by far, the most-discussed and most-hated post that I’ve ever written. In retrospect I should have been much more explicit: I’m talking here about using Benadryl as an antihistamine to treat allergic disease. A follow-up post includes about 10 links to well-supported, recent guidelines that support my contention that Benadryl is not a good choice to treat allergic disease. Newer agents are faster, more effective, and safer. 

 

The Pediatric Insider

© 2019 Roy Benaroch, MD

Sometimes, old ideas and time-tested treatments remain the best. Newer doesn’t always mean better. Except, in the case of tried-and-true Benadryl. It is time for that old drug to be retired, sent off to pasture, and never used again. Goodbye, Benadryl. Fare thee well, adieu, and don’t let the door hit you on the way out.

Benadryl (diphenhydramine) was introduced in 1946. The top single that year was Perry Como’s “Prisoner of Love,” and, with all due respect, neither has aged well. Back in 1946, medicines like Benadryl didn’t have to pass the stringent safety and efficacy standards now required. And there’s zero chance, today, it would every have been approved for over-the-counter sale – and even if it made it as a prescription medicine, it would be plastered with warning labels.

tl;dr: Newer & better alternatives to treating any allergic disease are cetirizine (Zyrtec), loratadine (Claritin), and fexofenadine (Allegra). These are all safer, faster, and more effective. There is no situation where Benadryl is a better choice as an oral medication. No one should be using Benadryl for anything.

 

Benadryl isn’t safe

Benadryl causes significant sedation. One study in a driving simulator showed an ordinary adult dose of Benadryl caused worse driving than a blood alcohol level of 0.1% (that’s fairly drunk, probably between buzzed-drunk and frat-party drunk). Ordinary doses of Benadryl can also commonly cause urinary retention, dizziness, trouble with coordination, dry mouth, blurry vision, and constipation.

But more importantly, in an overdose Benadryl becomes very dangerous. It has caused respiratory depression, coma, heart arrythmias, and death in children and adults, and in doses that aren’t super-high. This is not safe stuff to have in the house with an exploring toddler, or in a teenager who might help themselves to whatever is in the medicine cabinet.

 

Newer alternatives are much safer

In the 1980’s, newer-generation antihistamines were introduced. At first, they required a prescription and were crazy-expensive; now, the best of these are cheap, generic, and easily available OTC.

These medicines were developed to address the serious safety concerns of Benadryl and other older antihistamines. They do not cross the “blood brain barrier”, cause minimal if any sedation, and don’t cause nearly as many of the other side effects. And, bonus, they’re not very dangerous even in massive overdoses. A recent review quoted that there has never been a death even in instances of up to 30 times the recommended dosing.

 

Newer alternatives are more effective, act more quickly, and last longer

In a serious allergic reaction, we want a treatment that’s quick and effective. Keep in mind that in the case of anaphylaxis, the most serious allergic reaction, antihistamines are NOT the correct, first-line treatment. Anyone experiencing an anaphylactic reaction, which can include a loss of consciousness, trouble breathing, and widespread hives and flushing, should immediate and without hesitation be given epinephrine by injection. Epinephrine should never be delayed while looking for or preparing an antihistamine. Antihistamines do not save lives. Epinephrine does. Keep your eye on the ball.

But for more-mild allergic reactions, like simple hives, an antihistamine is a good idea. And some docs still prefer Benadryl, since it’s been around forever. But the newer drugs are much more effective. They begin working more quickly, they are more effective at controlling symptoms, and they last much longer – so symptoms are less likely to return. And, bonus, since side effects are minimal, doctors can safely prescribe regimens even up to four times the labeled doses for specific indications (this has been studied extensively). For routine use, follow the label instructions – talk to your doctor if that’s not working, or if you think a higher dose is needed.

 

Benadryl and its generics (diphenhydramine and many combo meds) are still very popular sellers, and many docs and nurses still recommended it. This is just out of habit and inertia – there is no good reason, under any circumstances, where Benadryl is the right choice when an oral antihistamine is needed. It’s not 1946. It’s time for Benadryl to be permanently taken off the market and relegated to the history books.

Safe sleep for baby is flat — not inclined

Posted October 22, 2019 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2019 Roy Benaroch, MD

In June, 2019, Fisher-Price recalled almost 5 million of their “Rock ‘n Play Sleepers”, after publicity surrounding dozens of deaths. Pediatricians and other advocates had been saying these things were unsafe for years – at least one blogger even tried to warn the company directly, six years before the recall — but a lack of oversight and formal safety testing kept them on the market for far too long.

It was clear that the device prevented parents from being able to put their babies to sleep in a safe way, following the guidelines of the AAP. Babies, for safest sleep, should always be put down flat on their backs on a firm, flat surface.

Now, a new study (summarized here, details here under “Tab B”) has added even more weight to the evidence. It turns out that even a small inclined angle, raising the head even slightly, dramatically changes the way a baby can breathe, potentially causing death. The bottom line: these researchers showed that an incline of greater than 10 degrees makes sleeping less safe. So what’s ten degrees? Less than you’d think.

I’ll use an ordinary cookbook and my fingers to demonstrate. Here’s a firm, flat surface, at zero degrees – completely flat, which is the recommended way for babies to be put down to sleep:

If I put one finger under the edge, the book is at 5 degrees. This is just a tiny little angle, and the new study shows this slight incline is probably still safe:

But just two fingers reaches 12 degrees, above the unsafe threshold:

Three fingers gets you to 17 degrees:

And if I stick my whole hand under one edge, the book is at 30 degrees – the angle the recalled Rock n Play sleeper was designed for:

From the photos you can see that anything beyond the slightest angle is unsafe. And these “inclined sleepers”, like the recalled Rock n Play, went way beyond that. They were unsafe for other reasons, too – their sleep surfaces were not firm, and they surrounded the baby with soft cushy material. No wonder babies died.

Please, put your babies down to sleep on a firm, flat, not-inclined surface. If you’ve still got an “inclined sleeper”, return it or destroy it (don’t give it away or donate it!) Be safe!

Cell phones are not causing teens to grow horns: WaPo blows it

Posted June 22, 2019 by Dr. Roy
Categories: The Media Blows It Again

Tags: ,

The Pediatric Insider

© 2019 Roy Benaroch, MD

Last week the Washington Post (“Democracy Dies in Darkness”) ran this headline: “’Horns’ are growing on young people’s skulls. Phone use is to blame, research suggests.”

The headline is entirely correct except for a few minor points:

  • They’re not horns, which point up from the forehead. They’re more like little ½ inch nubs protruding downwards from the back of the skull.
  • They’re not new. There’s no comparison group to show that these are more or less common than they used to be.
  • They’re not “growing” on people’s skulls. There was no follow-up to show that they’re getting larger. They’re just “there”, and may always have been there.
  • Phone use isn’t to blame. Phone use habits weren’t even recorded, and no comparison between phone users and non-users was possible.
  • No research has suggested that any of the headline is accurate.

The article stems from two studies performed in 2018 by a chiropractor and a specialist in biomechanics, both from Australia. One study was on four teenagers whose parents brought them into a chiropractor to address their poor posture. Lumps were noted on their skull x-rays (Why were skull x-rays are needed to assess posture? Who knows. At least there wasn’t something important like a brain being irradiated for no reason. But I digress.) The authors speculated that perhaps the bony lumps appeared as a result of biomechanical stress from the teens’ leaning forward to look at their phones. It’s not an entirely outlandish idea – bones can and do remodel in response to mechanical stress. But it was only an idea, and an entirely untested idea at that. No one had asked the teens if they had used cell phones, or for how many hours; and there was no mention of any symptoms or problems the teens had (other than that their posture was upsetting to their parents.) And there was no comparison between phone users and non-users to help establish that phone use could be correlated with those bone lumps.

Later in 2018, the same authors reviewed 1200 x-rays from patients seen at chiropractic clinics. They found that 33% had these prominent boney lumps on the back of their heads—prominent meaning more than 10 mm, or about ½ an inch. There was no mention of cell phone use; there was no comparison group; and there was no correlation with any symptoms whatsoever. And certainly – I can’t stress this enough – the boney lump nub things did not look like horns.

I think the WaPo editor just like the idea of a headline including the words Horns, Growing, Skulls, Phone, and Blame. That’s a magical combination. Really: put those words in any order, and it’s a winner. But that doesn’t make it an accurate headline.

Don’t get me wrong: when you look around, you do see people hunching forward, clutching their phones. That can’t be good for posture. And I could see that contributing to neck and back pain. But to go from there to “Phones are to blame for head horns” is, well, ridiculous. WaPo, you really should have done better.

Hey! D’ya looking critically at media stories of health issues, maybe poking a little fun, and sometimes finding real gems of good reporting? Learn how to read studies and media reports with a skeptic’s eye, and how to find good, reliable health info in the news. Check out my 5-star course, A Skeptic’s Guide to Health, Medicine, and the Media. You can buy it or stream it, or get the audio-only from Audible. It’s fabulous!

BONUS mix -n- match headline section! Combine the words Horns, Growing, Skulls, Phone, and Blame to make your own Washington Post Style Headline! Put your favorites in the comments! I’ll start:

  • Blame Phone Skulls for Horn Growing
  • Horny Teen Blames Growing Phone Skull
  • Skull Growing? Blame Phone Horn