Archive for the ‘Medical problems’ category

Gluten and children’s health: The New Boogeyman?

July 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.

 

*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

Cootie Shots under fire

July 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Circle circle dot dot

Now I have a cootie shot

It’s a rite of passage for Kindergarteners, something we’ve all gotten used to accepting, without question. Now, an increasing number of concerned parent activists are raising concerns about Cootie Shots. They’re asking some uncomfortable questions. Are they even safe?

Last year, Ms. Emma Jane McGucket noticed her 5 year old son acting oddly. “He’s like a different boy,” she said. “His clothes no longer fit. And he smelled like grass.” Later that day, she says, she heard him say something that really started to make her wonder. “He said something about a Cootie Shot to his younger brother. It made my hair stand on end. What were these Cootie Shots? Have they been tested? Is this just another government plan to poison our children, like putting fluoride in the water or thiamine in the bread?”

After asking questions at her son’s school, Ms. McGucket still wasn’t satisfied. “It’s like they didn’t even know what was going on. They pretended these Cootie Shots are perfectly safe, even though they couldn’t list all of the ingredients.”

Ms. McGucket has formed a Facebook page, Families Against Cootie Shots (FACtS), and hopes to draw attention to what she considers “…the most important thing, ever, that everyone has to stop whatever they’re doing and worry about more than anything else.”

And she’s not alone. Her neighbor, whom Ms. McGucket refused to name, is also said to be worried. When we spoke with her though her closed door, she may have said something about toxins or GMOs used in their production.

“It’s not that I’m against Cootie Shots,” said Arlene Monger, president of the Calhoun County chapter of FACtS. “What we want, what our children deserve, are greener, safer Cootie Shots free of toxins and chemicals. We don’t need to give in to Big Cootie just to protect our children.”

“No one wants children safe from Cooties more than me,” she said. “But we have to read the product label and the government hazardous material sheets. These things are being injected directly in our children’s bloodstreams. They might even contain gluten.”

When contacted, Jamie Rosen of the 2nd grade’s Cootie Surveillance Section pointed out that Cootie Shots aren’t actually injected into anyone’s bloodstream. “They’re pretty much just touching the skin of the arm, you know, circle circle dot dot?”

“Those are the kinds of ‘facts’ we don’t need,” responded Ms. Monger. “A typical response from a typical official who’s been paid off. Like my son’s pediatrician. He said he wasn’t worried, which just proves it.”

Some activists are also concerns about the number of Cootie Shots being administered. On some playgrounds, they say, boys are giving themselves up to 6 or 7 doses in one recess. They say they need it to protect themselves from the girls, but parents are worried. “Too many, too soon!” says Ms. Monger. “They’re using a schedule that’s only been in use worldwide for what, 50 years? I’m supposed to be reassured by that?”

“I don’t need any studies,” Ms. Monger concluded. “I know what I know, and that’s enough for me to say no.”

cootie shots

 Osgood-Schlatter syndrome: A knee pain that will get better

June 4, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

 Betty asked, “My husband has this lump under his knee—he says it hurts when he kneels on it. And now, my 11 year old son is getting one of these too! I think it’s Osgood-Schlatter syndrome. What can I do about it?”

Osgood-Schlatter syndrome (or, sometimes, disease—I’ve seen it both ways) is a very characteristic knee problem that occurs in some growing children. Boys get it around 12-13 years, girls more like 10-12. Technically, the definition looks like this:

Osgood Schlatter syndrome (O-S) is a traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity.

(You may guess from that definition that neither Drs. Osgood nor Schlatter went out on a lot of dates.)

“Traction apophysitis” is pulling on a growth plate—and since only growing kids have these, pain from Osgood-Schlatter is only seen in children. After the growth plates fuse, the discomfort of O-S fades away. Sometimes, a bump stays under the knee in adults, and that can hurt with kneeling.

My hairy leg. I'm pointing to the tibial tubercle, where Osgood-Schlatter hurts, below the knee.

My hairy leg. I’m pointing to the tibial tubercle, where Osgood-Schlatter hurts, below the knee.

Why does it happen? Probably because there’s already some swelling at the growth plate, and the quadriceps tendon rubs right across there at the top of the lower leg.

The pain of O-S is typically not severe. It’s more of an achy sort of pain, mostly after exercise, especially after jumping or running. The area under the knee can also be tender, so if it’s banged up from falling or from being hit, that will hurt, too.

I don’t think there’s any great way to prevent O-S. Once it starts, ice or ibuprofen can help with the discomfort, and often that’s all that’s necessary. Continuing to play on it will not cause arthritis or knee damage—as long as the pain isn’t too bad, it’s reasonable to ice the area and keep playing. However, if it’s getting worse and worse a period of relative rest is a good idea, Maybe consider changing sports for a season.

You can also buy a little band like this one that goes right under the knee. It will provide a little padding to protect the tender area. Some people claim that these bands change the biomechanics of the tendon so it won’t rub—that’s not actually true, but hey, if it helps a kiddo feel better, wear it.

Another strategy is physical therapy, to strengthen and stabilize the quads and knee. It will also give Junior something active to do while sitting out of sports.

In time, after a year or so, O-S pain improves. Betty should take her son to his doctor to confirm the diagnosis and learn more about it. Usually, the history and physical exam are so characteristic that x-rays aren’t needed. Most kids can live with this until it gets better on its own.

Swings, slings, and car seats are not for sleeping

May 28, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

An April, 2015 report from the Journal of Pediatrics graphically illustrates the dangers of babies sleeping in gizmos not designed for sleep.

As I’ve written about before, the American Academy of Pediatrics has established specific guidelines on the safest ways for healthy babies to sleep. I last reviewed them in detail here. In summary, babies should always be put down on their backs to sleep on a firm, flat surface, like a crib or bassinet. Baby sleep positioners that hold an infant in place are a bad idea. Things that hold babies in an upright or semiupright position, like the Fisher-Price Rock ‘n Play Sleeper, are also a bad idea. Why?

They’re dangerous because little babies have big, heavy heads, and they lack the strength and muscle control to protect their little baby airways. If their heads fall forward, or their necks get entangled in a strap, they can die.

The new report (summarized here) points out that sleep-related deaths are the most common cause of death in infants from 1-12 months of age. The authors reviewed 47 deaths reported to the US government involving sitting or carrying devices, including car seats, slings, and bouncer-type devices.

I’m going to quote a few of the case histories, here. This material is cold and clinical and disturbing. Feel free to skip ahead a bit.

An 11-month-old boy was placed with a bottle in a car seat for a nap at a home day care center. He was covered with a fleece blanket. The chest buckles were secured, but the lower buckles were unsecured. One hour and 20 minutes later, the child care provider went into the room to check on the child. She saw that he had slipped down in his car seat, such that at least one strap was up against his neck, his color was pale, and he was gasping for breath. EMS was called and the victim was transported to a hospital, where he was declared dead.

A mother was attending a breastfeeding class with her 26-day-old son. She was wearing a cloth baby sling that was placed like a sash across her chest. The child was breastfeeding inside the sling. The child stopped nursing and was believed to have fallen asleep. Approximately 10 minutes, later the mother noticed that her son was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. The child was transported to a hospital and pronounced dead.

A 3-month-old boy was placed for sleep on his back in a bouncer. The father buckled the infant into the seat with the restraint belt and placed a blanket on him up to his waist. Ninety minutes later, the father found the victim face down and unresponsive, with his neck over the top of the bouncer. 911 was called and CPR started; the baby was pronounced dead at the scene. The detective related that the victim had apparently rolled over and pushed up to the top of the bouncer by pushing on the blankets.

An 8-month-old girl was sleeping unattended in a stroller at the mother’s workplace. The restraint belt was not fastened. The mother returned to the room after 5 minutes and found her partially hanging out of the stroller, her head wedged between the lower edge of the tray and the front edge of the seat. She was unconscious and not breathing, so CPR was initiated. She was resuscitated but was in a vegetative state, and life support was withdrawn 2 days later.

Some important lessons can be learned from the details of the report. Death can occur quite quickly—deaths in car seats and strollers were reported after a minimum of only 4 or 5 minutes. And they can occur at almost any age, from 10 days old in a sling to 2 years old in a car seat.

About half of the time, car seat deaths were caused by strangulation on unfastened straps. You might think that once a car seat is out of a moving vehicle, it would be safe to undo the straps—but those same straps that are so effective in keeping a child safe in a crash can strangle a baby. Many of the other deaths were caused either by positional asphyxia, with the head falling forward to close off the airway, or by a device tipping over and smothering the baby.

There’s some good news buried in this report, too. There were no deaths using a sling for breastfeeding—only when the babies were sleeping in a sling. And almost all of the car seat deaths were when using a car seat outside of a car. Based on this and other reports, the correct use of a car seat in a vehicle (baby strapped into the car seat correctly, and car seat strapped into the car correctly) is very safe. It’s the unintended use of car seats and other devices as sleeping devices in homes and daycares that’s dangerous. As the authors conclude, “It is possible that most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision.”

When I’ve written about safe sleeping before, I’ve gotten many colorful comments from people who say that their babies have unique health circumstances, and that their own pediatricians have made recommendations that differ from the usual guidelines. (That’s my translation of their comments, which are more-typically worded “You are an idiot.” or “How dare you question the advice of my pediatrician who has won a Nobel Prize and you are an idiot.”) The AAP sleep guidelines are for routine, healthy babies. If you think your babies need to sleep in a manner different from the typical guidelines, I suggest you speak their pediatricians about it, as soon as they return from Stockholm.

Delaying vaccines is not a good idea

May 21, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

I get asked, now and then, about delaying vaccines. What’s the harm?

#1: An increased risk of disease

There are many, many studies that have documented less disease in vaccinated individuals. Here’s one, just one recent one, from April 2015. Researchers in Israel looked at cases of pertussis in infants from 1998-2011, comparing the infants who had documented pertussis to a sample of infants who didn’t catch pertussis. Pertussis cases were more likely to be either unvaccinated or have fewer vaccines – a “delayed schedule” – than babies who got their vaccines on time.

#2: An increased risk of side effects

Several studies have shown this, too. Here’s an example: a 2014 study from several US centers showed that children who got their MMR vaccines late were about twice as likely to have seizures after vaccinations than those who got their MMR on time.

 

Let’s see. Increased disease, increased side effects. Still, we need to look at both the harms and the benefits to make an informed decision. So, for balance, what are the benefits of a delayed vaccine schedule?

There are none. Not one. Nada. It’s not safer, it’s not easier. It’s not better in any way. There are no benefits of delaying vaccinations.

So: delaying vaccines offers no benefits, and significant, objective risks. It should be an easy choice. Keep your children safe. Make sure they get their vaccines on time and on schedule.

 

Whooping cranes! Get it?

Guess what kind of birds these are

Other recent vaccine links:

An anti-vax mom learns a lesson when all 7 kids get pertussis

The benefits of measles vaccine are far more than preventing measles

 

 

Recurrent wheezing in preschoolers

May 18, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Maura wrote: “I’d appreciate a post on treating and understanding intermittent asthma (viral induced) in preschoolers. I’m currently very confused about whether the risks and benefits of treating with inhaled steroids are well established.  I’m also confused about what the literature means when they say ‘exacerbation’ of asthma.  Thank you!”

Hoo boy. This is one of those questions that would get different answers to if you asked a room full of pediatricians. Different answers, and arguing, and maybe a thrown chair or two.

Heck, we’re not even sure if we should call this asthma. So I’ll back up to what we all can agree on, first.

A “wheeze” is a specific physical exam finding. It’s a whistly, almost musical sort of chest noise, the noise you hear when air tubes are constricted. Most (but not all) wheezing is heard during expiration. Children who are wheezing almost always cough, and cough is the main symptom of most wheezy illness. It makes sense—the airways are constricted, so the body tries to “pop” them open with a forceful expiration. Coughing can open airways and at least temporarily relieve the airway constriction and wheeze.

Lots of health conditions cause wheezing, and at least 25% of children will wheeze at least once. Mostly typically, it’s caused by a viral infection. Whatever you do or don’t do to treat it, the noise will go away and Junior will stop coughing. But recurrent episodes of wheezing, that’s when things get interesting. And controversial.

In older children, school age and up, the most common—by far—cause of recurrent wheezing is asthma.  These kids usually have multiple triggers for their wheezing, including allergies, infections, cold air, and exercise (not all kids will have all of these triggers). Albuterol is the mainstay medicine to quickly stop wheezing and coughing once it starts. Inhaled steroids are the best medicine to use to prevent wheezing flare-ups (called “exacerbations”—that’s when kids with asthma have symptoms like coughing, wheezing, chest pain, and shortness of breath.) Inhaled steroids as preventive medicines work and they’re safe. Kids with asthma who use daily inhaled steroids have far fewer exacerbations, miss less school, and stay healthier.

But there’s another group of children in whom the usefulness of inhaled are less clear-cut. These are toddlers and preschoolers, little kids, who have recurrent wheezing episodes only triggered by one thing: viral infections. They get a cold, they start to wheeze. These kids seem to respond less robustly to both inhaled albuterol (which, especially in the youngest children, may not work at all), and less well to inhaled steroids, too.

Some people don’t even think we should label these little ones with recurrent wheeze as having asthma, because that can mislead us into using treatments that are less effective. A suggested label is to say these children have “WARI”, or Wheeze Associated with Respiratory Infections. Some docs say these kids have “RAD” or reactive airways disease, or “recurrent bronchitis”, or “viral pneumonia”, or recurrent “bronchiolitis”.

What makes this especially difficult is that we can never tell, from the first or second wheeze episode, if a child is going to end up with asthma (recurrent wheeze of many triggers) versus WARI (recurrent wheeze only triggered by infections.) Some suggest we look at family history, or whether the child has eczema or food allergies, but that history doesn’t reliably predict the future course of wheezing. What we really need is some kind of test or biomarker to predict who will really benefit from inhaled steroids. We don’t have any great way to know.

Inhaled steroids are safe, at least in ordinary low doses. In higher doses some growth suppression can occur, though that may disappear with long-term use. And we know out-of-control asthma, with frequent wheezing, will also stunt growth.

As always, risks and benefits have to be weighed. If a young child has infrequent flare-ups easily treated with albuterol I’m less likely to suggest a trial of an inhaled steroid; but if flare-ups are frequent or severe or land a child in the emergency department, daily inhaled steroids are worth a try. There’s some art here, and a lot we don’t know, and plenty of room for discussion between doc and parent about what’s best for each childs’ circumstances. The chair throwing, that’s optional.

I feel a song coming on!

I feel a song coming on!

Limes plus sun = burn

May 14, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

If life gives you lemons, make lemonade. But if life gives you limes, especially on a sunny day, what you might make is a big, uncomfortable burn.

Limes contain chemicals that can sensitize the skin to the ultraviolet spectrum of ordinary sunlight. It isn’t an allergic phenomenon, though it kind of looks like one. Areas of skin that have touched limes or lime juice and are then exposed to sunlight can react as if it has been burned. The visible reaction starts about 24 hours after the exposure, and is worsened by heat and sweat.

I’ll link to some photos, rather than paste them directly here. Some are icky. The skin reaction is often shaped like drips or a splash, and often affects the hands and upper arms.

The proper name for this reaction is phytophotodermatitis (plant-light-rash). I’ve also seen it called “lime disease” (get it?! And who said dermatologists weren’t funny!) or “margarita sunburn.” Other plants can cause the same reaction, including celery (mmm celery margarita) and several weeds.

If you’re chopping or cutting or squeezing limes, don’t do it in the sun. Do it in the kitchen, then wash your hands with soap and water before you go outside. Don’t let “lime disease” ruin your summer!

AT Sir Isaac Lime


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