Archive for the ‘Medical problems’ category

Getting care quickly improves concussion recovery

January 28, 2020

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

What do current guidelines say about treating allergies with Benadryl?

November 24, 2019

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.

Safe sleep for baby is flat — not inclined

October 22, 2019

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!

Measles update: Which adults need a dose of MMR vaccine?

May 9, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

While the vast majority of measles cases in the US and worldwide are occurring in unvaccinated children, a fair percentage is also occurring in adults.  With more-widespread transmission of measles, it’s becoming more important for all of us – yes, that includes parents – to make sure we’re well-protected.

Measles is probably the single most contagious infection that humans face. The key to preventing the return of widespread measles is in keeping vaccination rates high, so even if there is a case it cannot spread or cause an outbreak. Once there’s a neighborhood, school, or community with a concentration of unvaccinated individuals, it’s only a matter of time before measles returns and spreads widely.

Though we’re used to our children getting vaccinated on well-established schedules that ensure vaccines are safe and effective, many adults have fallen through the cracks.

People born before 1957 are presumed to be immune, because measles was so widespread in the past that almost all children contracted the infection.

Adults considered at “high risk” include healthcare workers, international travelers, those who are living in communities with outbreaks, and university students (I would also include all adults who teach and work in universities, though that’s not part of the official CDC high risk group). If you’re in these groups, you should have had TWO doses of MMR to ensure immunity. If you’ve only had one, get another; if you’re not sure if you’ve had any, get two doses. The second dose should be 4 weeks or more after the first.

Other adults (those born after 1957 and who do not live in a community with measles transmission) are considered immune and protected if they’ve had one dose of MMR.

For people born between 1957 and 1968, there’s a catch. Some of the measles vaccine used then was an inactivated vaccine that didn’t confer good immunity. If you have documentation that your vaccine was the “live” vaccine, that’s the good one. If you’re not sure which you received, get one dose of the current MMR to make sure you’re protected.

An alternative to receiving the vaccine, if you’re unsure of your vaccine status, is a blood test for measles titers (IgG antibodies.) If your titers are high, you’re protected; if they’re low, you need another dose of MMR.

The MMR vaccine shouldn’t be given to people with compromised immune systems or pregnant women, though it is fine for nursing moms.

Bottom line: if you’re an adult and you’re not sure if you’re adequately protected, you should receive at least one dose of MMR.

 

From the CDC:

Current outbreaks

More info about measles

 

What’s the best timing for my child’s measles vaccine doses? Should we give them early?

May 7, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

As the US endures its largest measles outbreak in 25 years – one that’s almost certainly going to get worse before it gets better – we’re getting a lot of calls and questions at my office. What’s measles, what’s the best way to prevent it, when should the vaccine be given to adults and children? I’m going to do a series of mini-posts, just focusing on one question at a time. We’ll see how this format works out – let me know if you like it!

The measles vaccine is given as “MMR”, which teaches the immune system to fight off measles, mumps, and rubella. It’s a very effective vaccine that confers lifelong immunity. A single dose is about 93% effective, and two doses get that up to 97%. There aren’t many other preventive interventions in medicine that are even close to that good.

The first dose should be given between 12 and 15 months of age, though at this point I’d say 12 months is better. Why wait until 12 months? Earlier than that, babies may still have enough antibodies from their mother to partially block the effectiveness of the vaccine.

But in some circumstances, you should get that first dose early, as early as six months. If there’s a high risk of exposure, an early dose (though imperfect) will give at least some protection. That dose should then be repeated at 12 months. Who’s at high risk of exposure? Anyone who’s living in a community with cases of measles – that includes, as I’m writing this, areas of New York, Michigan, and California. Plus the Philippines, Israel, and Ukraine. And, really, most of Europe. If you’re traveling with your baby under 12 months out of the US (or even within the US), you should look at the news and talk with your child’s doctor about getting an early dose of MMR.

The second dose of MMR is traditionally given at age 4-6 years, prior to school entry. But that timing was chosen for purely administrative reasons –kids almost always come in for a preschool physical, and they also need doses of polio and DTaP vaccines, which must be given after the fourth birthday. But that second dose of MMR can be given much earlier. It will be just as safe and effective if given any time 4 weeks or more after the first dose. So if the first dose is given right at 12 months, the second dose could be given at 13 months (or, more likely, at 15 months, since that’s when the next check-up age falls.)

Again, if you’re living in or traveling to an area experiencing a measles outbreak, you should get that second dose early. There is no downside. Honestly, there’s no reason why any of our young babies should wait until age 4 to get it – it’s just a bit of history and convenience that placed the second dose at age 4. If your children do get the second dose early, keep in mind that they do not ALSO need a dose at age 4 (though a third dose will not be harmful, it’s just not necessary.)

 

More info:

The nitty gritty details about the history of the MMR vaccine and its timing

Measles from the CDC

Recurrent vomiting in a baby – could it be FPIES?

March 8, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Not every diagnosis is easy, and not every diagnosis can be made correctly from a first impression. FPIES is one of those tricky ones, and parents and docs can get it right by paying attention to clues and keeping an open mind. Let’s start with a story, and then we’ll talk about FPIES (hint: these are not the kind of PIES you want to eat!)

5 month old Sally has had two trips to the emergency department and one to her pediatrician for vomiting episodes. Each time, she has a sudden onset of vomiting, diarrhea, and lethargy, and gets sick quickly – twice she ended up needing IV fluids. She recovers in a few days and seems to feel better. Overall she’s usually a happy baby, but her weight has been concerning. She’s not growing as fast as she should. Sally attends day care and has two older siblings.

What do you think? Vomiting illnesses are very common, and they’re usually caused by viruses (like Norovirus, especially this time of year.) If there had been one or two episodes like this, and Sally otherwise seemed OK, the story wouldn’t necessarily seem unusual. After all, she’s in day care, and probably is exposed to a lot of yuck.

But, still, there are some clues that there’s more to this story. Most vomiting illnesses do not require IV fluids – Sally’s needed that twice. And overall her weight isn’t great. Could there be a connection?

Making a medical diagnosis is like detective work. First collect the clues (which are almost always in the story), then find a diagnosis that fits. But keep in mind that every diagnosis is a “work in progress” that may have to change as new facts come it. Sally seemed like she had a viral gastroenteritis (a “tummy bug”), until the story continued to unfold. I warn medical students and residents: don’t lock yourself into a diagnosis. Stay curious!

Sally’s “mystery” diagnosis turned out to be “FPIES”, or “Food Protein Induced Enterocolitis Syndrome.” It’s a rare-ish allergic condition usually affecting young babies and toddlers, who react to certain foods with episodes of intense vomiting, often with diarrhea. Sometimes FPIES can be more of a chronic presentation, including lower-grade, ongoing symptoms like poor growth. Common triggers include cow’s milk and soy, but also grains like oats and rice. There’s no test for FPIES – ordinary ‘allergy testing’ is often misleading – so the diagnosis rests on the story.

The prognosis for PFIES is very good. Children usually outgrow it. The trick is making the diagnosis early, so parents can avoid the trigger food(s). And the key to making the diagnosis is paying attention to the clues your patients and their parents are trying to tell you.  I tell my medical students and residents: stay curious and pay attention!

More about FPIES

Interested in learning more about how doctors think, and how the best diagnosticians work through the clues to figure out the answer? I’ve made three courses about this, available from The Great Courses, in audio or video formats. They can be watched or listened to in any order. You can buy ‘em (money back guarantee!), or stream them from TheGreatCoursesPlus.

Help fight childhood cancer!

March 6, 2019

Hey hey! My teenage daughter and I will be getting our heads shaved on Saturday to help raise money to fight childhood cancer! Please donate to me, my daughter, or our team! (Since it is in fact my birthday today, you should probably donate to me. But any donations are appreciated!)

Pediatric cancer is more common than you might think. Every year in the US about 16,000 kids (birth through 19 years) get cancer — that means 1 in 285 people will be diagnosed with cancer during their childhood. That’s a lot of children and families affected.

In some ways, the statistics are encouraging. The rates of these cancers, overall, hasn’t changed much over the last 40-50 years — but the survival rates have improved dramatically. Overall there’s an 80% five year survival. But there’s a lot of variability in types of cancer, with some cancers making very little progress. Many types of childhood cancer still have a poor prognosis.

And sometimes the treatment itself can be very difficult. The goal of treating most pediatric cancers is a cure, which means that the treatment itself — surgery, radiation, chemo — is often more aggressive than the treatment for adult cancer. Two-thirds of childhood cancer survivors struggle with health problems related to their cancer or the treatment. There’s still a lot of progress to be made.

The funding for pediatric cancer research is far less than what we might expect. The NIH budget for adult cancer research was 5.6 billion in 2009; for pediatric-specific cancer research, it’s probably in the range of 30 million dollars a year.

Pediatric cancer research needs better funding. We’ve already shown that better treatment leads to dramatically better outcomes, but we need to keep making progress. And public awareness can support both charitable giving by individuals and better support for pediatric cancer among foundations, endowments, and large national cancer organizations.

That’s my why daughter and I will be shaving our heads with the St. Baldrick’s charity. It might seem like a silly sort of stunt — and in a way, it is — but it draws attention to the problem of pediatric cancer in a uniquely pediatric way. We’ll have fun with it, and we’ll have fun with the kids, but in a serious way we hope to raise more money and improve more lives. Please give if you can.