Archive for the ‘In the news’ category

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

January 17, 2018

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.


Physician rating sites deserve their own “Black Box Warning”

September 26, 2017

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

September 5, 2017

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.


Just because a chemical is present doesn’t mean you have to worry about it

July 31, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Advocacy groups have been busy lately with their fancy-pants chemicalz detection science instruments, and their press releases have made it into the news. But is there news here, and are these chemicals something parents really need to worry about?

First it was a big lead from the New York Times called “The Chemicals in your Mac and Cheese.” The article started:

Potentially harmful chemicals that were banned from children’s teething rings and rubber duck toys a decade ago may still be present in high concentrations in your child’s favorite meal: macaroni and cheese mixes made with powdered cheese.

Oh noes, not high levels! The chemicals they’re talking about are from a family called “phthalates,” which sounds scary and difficult-to-pronounce. (Words shouldn’t start with four consonants. On this we should all agree.) Phthalates have been in wide use for over 80 years in plastics and other compounds. Though they’re not added to cheese, they’re on the coatings of tubes and platforms and whatever else is used in the machinery to make Magic Orange Cheese Powder. Foods with a high surface area (like a powder) are going to come in more contact with it, and a teeny bit of a trace of a few molecules are going to transfer over.

Important point: these chemicals have been in our food for many, many years. What’s changed is that we’ve now got fancy equipment to measure it. The Times story is quoting a kind of press release – not a medical study, or even anything published in the medical journal. It’s a “study” done by a consortium of food advocacy groups. It’s being promoted by an organization called “KleanUpKraft.Org” (Cutesy misspellings are at least as bad as starting words with four consonants, K?) And their “high levels” are in tiny parts per billion, at levels that are very low compared to amounts that cause adverse effects in animal studies.

Just because you can detect a chemical as present doesn’t mean there’s enough of it to hurt you. Mercury and arsenic are part of the natural world around us, and any food tested with equipment that’s sensitive enough will find at least traces of these and many other chemicals. It is not possible to get the values of phthalates or arsenic or many other chemicals down to zero in our foods.

Speaking of chemicals, this week another food advocacy organization announced that they’d found traces of an herbicide (glyphosate, found in Round-Up) in Ben & Jerry’s Ice Cream. And in every flavor tested, too, except Cherry Garcia, which is kind of nasty-tasting anyway (I’m sticking with Chunky Monkey, which wasn’t even tested.) But: their press release didn’t even reveal the levels that they found, only that they found it. Maybe it was one part in a zillion. Who knows? But: Do you think if the value were genuinely high they’d hide it like this? No way. It’s there in some kind of teeny amount, and they’re trying to scare you.

Don’t fall for all of this “The Sky is Falling, There’s Chemicals in My Food” hype. Just because something is hard to pronounce doesn’t make it dangerous, and just because something is present doesn’t mean it’s going to kill you. We’ve all got enough to worry about without being scared of Mac and Cheese and Ice Cream. In fact, a little comfort food in these troubled times would probably be good for all of us. Maybe even the grumps at

By the way, I don’t disagree with one thing – homemade Mac n Cheese is at least as good as that boxed orange stuff. Though sometimes, I won’t deny it, the orange stuff sure does hit the spot…


Vaxxed versus unvaxxed children: What a real study shows

July 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

You may have seen it on Facebook: A published study claiming to be “The First Ever” comparing vaccinated and unvaccinated children supposedly showed that vaccinated children are more likely to have a number of health problems. Let me promise you: there’s nothing to worry about here. The study is one of those garbage-in-garbage-out whackjobs that’s almost indescribably bad and unreliable. And: a much better study of the same thing – children who are vaccinated, versus children who are not vaccinated – shows that there are not any worrisome risks. The long-term health of vaccinated children is just fine, and even better than unvaccinated kids (because they don’t have to suffer through vaccine-preventable diseases.)

Let’s cover the good study, first. It was published in 2011, and tracked over 13,000 randomly selected children in Germany, tracking their health status and correlating that with their documented vaccine histories. The authors could find no examples of any increased risks of infectious or allergic diseases in the vaccinated children.

And now, this more-recent, execrable study. They didn’t use randomly selected children. What it actually compared were the 666 children of homeschoolers who chose to complete the survey (which was promoted on antivaccine websites), using their self-reports of vaccine histories and health status. Of these, 40% hadn’t been vaccinated, at least according to the surveys. No attempt was made to track who received the survey, what percentage of respondents completed it, and what kind of respondents completed it. Do you think it’s possible that a high proportion of vaccine-distrusting parents would complete a survey like this? Hint: if you did a survey of musical tastes at a Justin Bieber concert, you’re not going to find many Cab Calloway fans.

The “study” was really just a survey, and a biased one at that – a survey among people who were guaranteed to say exactly what the study authors wanted them to say. It had already been retracted, once previously (and, laughably, by a bottom-feeding journal that looks like it requires authors to pay to publish their studies. This isn’t the way legit journals work.)

Vaccines are safe, and they save lives. Make sure your kids are fully vaccinated. Don’t believe the Facebook rumors, or idiocy dressed up like science – what the real science shows is what parents should feel confident about. There’s no need to worry about vaccines.

A more detailed evaluation of this fakakta survey is here, and here’s more information about reliable vaxxed versus unvaxxed studies. Yes, they’ve been done before. Yes, they consistently show that vaccines are safe and that vaccinated children are healthy.



Expired Epipens are better than nothing

May 15, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A small study published this month showed that most Epipens retain their potency for at least 4 years after their expiration date. That’s no guarantee, of course. I’d still recommend as a “best practice” that families replace them as they expire. But it’s reassuring to know that they’ll usually be effective even when expired. And using an expired Epipen is almost certainly better than using nothing when there’s a life-threatening allergic reaction.

It’s a simple enough study. Over 2 weeks, families attending a clinic in California were asked to donate expired Epipens for analysis. They collected 40 devices that had expired up to 50 months before the study, and used state-of-the-art chemical analysis to determine the potency of the medication in the vials. None of them looked discolored or unsafe. All of the pens that had expired up to 2 and half years ago had at least 89% of their original potency, and even most of the older ones remained in the 85% range. Though overall the dose potency slowly deteriorated, all of these devices would have still been helpful to treat an anaphylactic reaction.

A few small previous studies reached similar conclusions in 2015 and 2000. Though these studies looked at the Epipen brand of auto-injectors, it’s likely that studies of similar or generic products would yield the same results.

The authors of the study aren’t recommending that families hoard Epipens, or delay replacing them – but they do point out that their findings support further studies to extend the labeled shelf life of these products. And if an expired Epipen is all you’ve got, it’s probably OK to use it as long as it’s not obviously broken or discolored.

To help keep your Epipens in good shape, store them somewhere relatively cool (not cold), and away from light, preferably in the original packaging. Do not leave them in your car in the summer. Epinephrine is a finicky sort of chemical, and light and heat will speed its deterioration. Although you can hold on to expired Epipens as a “backup”, it’s best to replace them so you’re 100% sure that you’ve got what you need when you need it.



Simplified CPR – without mouth-to-mouth – can save children’s lives

May 1, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Quick action is essential if someone has a sudden cardiac arrest. You might be in Target, or on a bus, or in a classroom when someone nearby just drops to the ground. Or maybe you’re boating, and you help pull a drowning victim out of the water. What do you do next?

CPR training is a great way to learn the steps, and I strongly encourage it for all parents and everyone else. But we know that many bystanders are unable to perform CPR when it’s needed. There’s panic and indecision and trying to remember what to do. To make it more possible for anyone to help, the old-school ABCs of CPR (Airway, Breathing,  Circulation) have been simplified. The current recommendations for CPR in most situations is just a few steps:

  1. Check if the victim is OK. Ask “Are you OK?” and give a little shake. If the person doesn’t respond, you need to act quickly.
  2. Call for help or call 911.
  3. Start pushing the middle of the chest down, over and over, fast and hard, until help arrives. If someone can bring over an automatic defibrillator, use it.

Those are all the steps. Rescue breathing has been deemphasized (it can still be used by trained people, if CPR is prolonged, or in some other situations.) Checking pulses and breathing isn’t necessary. It turns out that doing something (calling for help and starting chest compressions) is better than doing nothing.

However, there’s been some concern that compression-only CPR may not be as effective for children. Kids don’t have the same kind of arrests as adults (they’re much less likely to have a heart attack, for instance.) A new study from Japan shows that compression-only CPR is probably about as effective as traditional CPR in children – and it’s far better than doing nothing.

In Japan, all out-of-hospital arrests are recorded in a tracking database. Researchers looked at all of these events from 2011 to 2012 in children from age 1 to 18 (infants less than 1 were excluded.) This was at a time when compression-only CPR was being promoted for use by bystanders in Japan. Data had been collected regarding whether CPR was performed, and what kind; and the study authors tracked down all of the child victims to see how they were doing 1 month after their event. A good outcome was considered to be living with with normal or nearly normal neurologic function.

Overall, 2,157 children experienced a cardiac arrest over 2 years. The most common causes were from drowning and trauma. About ½ of the time, no CPR was performed; among the 1,150 who received CPR, 733 had compression-only CPR. The authors were then able to compare the outcomes.

The overall chance of a favorable outcome for all of these children was 10% (which is about what we’d expect for out-of-hospital cardiac arrests.) When the causes and severity of the arrests were controlled, conventional CPR provided a 18% good outcome, compression-only CPR 16%, and no CPR 4%.

So: doing anything was far better than doing nothing at all. It’s still unclear what the “best” CPR for children should be, and further studies will likely work that out. But we know now that simple, compression-only CPR is about as good as full-scale, mouth-to-mouth+compression CPR. If you’re not sure what to do, just push on that chest, fast and hard, until help arrives.

The best way to learn CPR is a hands-on, in-person course with a qualified instructor. There are some good alternatives if you’re in a hurry. The CPR anytime course can teach you the basics online in about 20 minutes. If you don’t have the time for that, watch this brief video about compression-only CPR. Remember, you don’t have to remember everything, and you don’t need to be perfect. Call for help, and then push – hard and fast. You can save a life.