Archive for the ‘Medical problems’ category

Drug safety tip: Do not point nose spray upside down

November 12, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD


Here’s a safety tip that makes sense—and it took a very simple study to show it. Nose sprays that are meant to be squirted with the bottle facing upwards shouldn’t be turned around to squirt medicine downwards.

Researchers from UCLA just published an eye-opening report on dosing of nasal spray medications. They studied oxymetazoline, a common OTC nasal decongestant spray marketed as “Afrin.” We know that 1-2 mL of this product (swallowed or sprayed into the nose) can lead to an overdose, including symptoms of slowed heart rate and breathing. We don’t worry about that, much, because the squirt bottle it’s packed in only delivers about 0.03 mL per squirt – you’d have to do over thirty squirts to reach a toxic dose. But that’s only if you use the squirt bottle correctly.

The investigators, instead, bought three different brands of oxymetazoline, and squirted it downwards, at a 45 degree angle, simulating what parents might do if they were squirting this into the nose of a child who is laying down. The volume delivered this way was between 0.6 and 0.9 mL for a single squirt—meaning, if both nostrils were hosed this way, you would almost certainly reach a potentially toxic dose.

With the help of my assistant, Blue Toad (who, ironically, doesn’t even have a nose), we’ve taken some helpful photos to demonstrate. Here, Blue Toad is getting a safe dose, using the bottle pointed upwards as designed:

Squirting up -- safe!

Squirting up — safe!

But here, Blue Toad is lying down, and the bottle is pointed down into his nose. Bad news for Blue Toad!

Squirting down? Bad idea!

Squirting down? Bad idea!

All medicines should be used carefully, following the directions—and the directions for this nose spray clearly say to hold the bottle upright. Still, I could imagine some parents trying to use this while their kids were lying down. Better to play it safe: make them sit up, and squirt up.

Homeopathy as good as antibiotics? No.

November 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

An August, 2015 study in Multidisciplinary Respiratory Medicine is being touted as evidence that homeopathy is as affective as antibiotics for respiratory infections in children. It doesn’t show that at all—in fact, it doesn’t show anything, except that crappy studies in crappy journals can nonetheless be used to manipulate opinion. Beware.

First, the study itself. Researchers in Italy looked at about 90 children with ordinary colds. All of them were given a homeopathic product that the authors claimed had already been shown to be effective for cough (that’s not actually true, but let’s let it slide for now.) All of the children did improve, as expected—colds go away, as we all know.

The “study” part was randomizing the children into two groups. One half of the study subjects only got the homeopathic product, the other half got both the homeopathic syrup PLUS amoxicillin-clavulanate, an antibiotic. You Insiders are already thinking—what, wait, what? You know that antibiotics have no role at all in the treatment of the common cold. Colds are caused by viruses, and antibiotics won’t make any difference. In fact, they’re very likely to cause harm, causing allergic reactions and gut problems and maybe triggering c diff colitis. It was entirely unethical for them to even give these antibiotics to the children, with not even an inkling of a reason to think they were a valid medical therapy. But they did it anyway.

The results are exactly what you’d expect. Both groups of children (the ones on homeopathy, and the ones on homeopathy plus antibiotics) did the same—their symptoms all improved over the weeks of the study. No surprise at all.

But the authors claimed “Our data confirm that the homeopathic treatment in question has potential benefits for cough in children…” The study didn’t show that all. They didn’t even look for that kind of effect—if they wanted to, they could have, by randomizing one group to receive homeopathy, and the other group to not receive homeopathy. But that kind of study wouldn’t show what they wanted it to show, so they didn’t do it.

You’re wondering, maybe, why did Multidisciplinary Respiratory Medicine even print this unethical, worthless study? The answer is here:

How much does it cost to publish?


Multidisciplinary Respiratory Medicine is what’s called a “predatory journal”, which charges high fees — $1,940 — to publish articles. These types of journals exist only to make money—there is minimal or no editorial oversight, and the whole point is to publish whatever someone will pay them to publish. The authors get their publication, and journalists and the public are fooled into thinking real science has occurred.

Another highlight – I’m not an investigative journalist, but looking at the full text of the article, I see under footnotes “The authors declare they have no competing interests.” Yet under acknowledgements, it also says “We thank Boiron SA, Messimy, France for a non-binding financial contribution.” Boiron is a huge producer and marketer of homeopathic products. And: when I Googled the lead author’s name + the word “Boiron,” I found this page, which features a video of him on Boiron’s site. No competing interests?

So, an unethical study comparing the wrong things claiming to show something it didn’t, published in a pay-to-play journal, paid for by a homeopathy company, written by a guy who is featured on said homeopathy company’s website. You still shouldn’t use antibiotics to treat a cold. And this study, like so many other homeopathy studies, shows only that homeopathy is a scam.

Phenylephrine: A placebo you don’t need

November 2, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Doctors, myself included, are dismissive of placebos. “That doesn’t work,” we say, referring to countless therapies that have no benefit over fake therapies (placebos), including pediatric chiropractic, homeopathy, and acupuncture.

We need to be honest. We have our placebos, too—pushed by modern pharmaceutical companies and genuine medical doctors. Maybe we ought to spend more time cleaning up what we do rather than pointing fingers at them.

Case in point: phenylephrine, marketed as a nasal decongestant. To understand how phenylephrine (PE) became so popular, we’ll have to go backwards a bit, to 1994, when the FDA published a list of nasal decongestant products that it considered safe and effective. Anything on “the list” could be sold without further FDA review. Included on that list were two oral decongestants: phenylephrine and pseudoephedrine (commonly known by the brand name Sudafed), which was far more popular.

In the 2000’s, to combat the epidemic of methamphetamine abuse, Congress attached an amendment to the Patriot Act (yes, that Patriot Act), restricting the sale of pseudoephedrine-containing medications. You could still buy them, but in limited quantities, and you had to present your ID to the pharmacist so your purchases could be recorded and tracked. All pseudoephedrine-containing products were pulled from the shelves. And, predictably, sales suffered. People didn’t want the bother of confronting a pharmacist to buy Sudafed, and pharmacists frankly had better things to do with their time than check ID for $6 purchases.

The marketers, predictably, won: a whole slew of new products, containing PE instead of pseudoephedrine, hit the market, prominently displayed on store shelves. Names like “Sudafed PE” minimized the change in the active ingredients, relying on well-known brand names to sell the product. Within a few years, PE-containing products far outsold the hidden pseudoephedine products. And everyone was happy.

Well, almost everyone. If you had a stuffy nose, you were most certainly not happy. Because oral phenylephrine never actually worked. A 2007 review showed that the PE was no better than placebo, and the FDA considered removing it from the allowed-drugs monograph—but they were swayed by a different published analysis showing a small but positive effect of PE on one measure of nasal congestion. That study has been criticized on many grounds, including that it cherry-picked positive studies and ignored evidence that weighed against PE. Still, the FDA allowed PE to continue to be sold and advertised as effective—though they did request a solid, placebo-controlled study to settle the issue.

Now, finally, in 2015, a placebo-controlled study of PE has finally been published. It’s fairly large, using 539 adults, and it looked at multiple doses sizes of PE compared to placebo top treat seasonal allergic rhinitis. The results are unequivocal: PE, at every dose, works no better than placebo—meaning it doesn’t work at all. About 18% of study participants developed side effects, mostly headache (none were serious.)

I don’t know what the FDA is going to do with this information. They asked for it, and now they’ve got it. Perhaps they’ll pull PE from the shelves. Perhaps they’ll ask for more studies. Maybe they’ll say that the drug companies can no longer sell PE for allergies, but can continue to sell them for congestion caused by a common cold (there’s no evidence it works for that, either, but there are no big robust placebo controlled studies to cite.) For the time being, PE, the placebo, continues to be sold, and continues to be recommended by physicians. It’s hard to change habits.

If you’ve got a congested nose, there are some things that do work. Congestion can be relieved by saline washes or sprays or a steamy shower. If allergies are the culprit, a nasal steroid spray is very effective. Pseudoephedine (Sudafed) is still out there, though you have to ask for it. Topical nasal decongestant sprays (like Afrin) work, too, though should typically be used for only a few days.

Or, go with a placebo. If that’s your style, choose something safe, like a homeopathic product. It won’t relieve congestion any better than plain water, but at least it won’t hurt anything but your wallet. That’s more than I can say for phenylephrine and our other real-medicine-placebos.

Tea tree oil for lice (and many other things?)

October 19, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alana wrote in:

My boy/girl twins will be 3 in December, and have just begun nursery school. It seems like reports of head lice are everywhere these days, and adding tea tree oil to shampoo (or using it as a spray on the hair) seems to be a popular recommendation for prevention. I thought that might be worth trying, thinking the worst thing that could happen is that it wouldn’t do anything and I’d be out a few bucks. But I did a little Googling, and it looks like there are some studies linking the use of tea tree oil to gynecomastia in boys.

Tea tree oil is one of those “natural” things that sounds like it has a use for everything, but I’m wondering if you know of any evidence that would suggest it should or shouldn’t be used? And if not, any other suggestions on lice prevention?

As Alana says, tea tree oil is indeed one of those things that seems to have use for almost everything—or at least that’s what you can find on Google. I quickly found sites suggesting it be used to freshening carpets, cleaning cuts and scrapes, treating fleas on your dog, making your breath fresh, taming asthma, and treating almost any skin condition from psoriasis to insect bites to body odor. And lice, too—preventing and treating lice both on you and your dog, apparently (yes, dogs can get lice, but not the same lice as humans. Lice are persnickety about whom they infest.)

Can one magic potion do all of that?

Tea tree oil is extracted from the leaves of the Melaleuca plant from Australia. It’s sometimes called a “tea tree”, but it’s a different plant from the one that drinking tea comes from. There’s also tea oil out there, which is meant for seasoning and cooking—that’s different stuff, too. Tea tree oil has become especially popular as one of many so-called “essential oils” often sold via multilevel marketing schemes. That term itself, essential oil, seems to be rooted in the alchemy of the middle ages, though it’s been newly popularized as a catch all for oil-based essences of plant fragrances and other compounds.

The best reference I could find summarizing what’s known about tea tree oil comes from the US National Library of Medicine’s Medline Plus database.  Some studies have shown it’s possibly effective when used topically for athlete’s foot, toenail fungus, and acne. There’s insufficient evidence to make a reasonable judgement about its use in any other health conditions.

Ice ice babyFor lice specifically, I looked through the Medline database for all relevant studies. There are a few, but the results aren’t really impressive. A 2007 study looked at tea tree oil along with other botanical and synthetic substances to prevent lice—including DEET, a commonly used insect repellant. Though tea tree oil did repel lice, it was only to a small degree, and the authors concluded that none of the tested products were effective at preventing lice.

In 2011, a blinded and randomized trial took hair clippings with attached lice eggs, exposing them to different essential oils (tea tree, lavender, eucalyptus) versus a standard “suffocation” type of product. Rounding off, the suffocation chemical killed 70% of eggs, and tea tree oil 45% — not great, though better than nothing.

A more-promising study from 2012 combined tea tree oil with the chemical nerolidol, and found good effectiveness against both lice and their eggs, at least in a laboratory setting (tea tree oil alone wasn’t as effective, especially against unhatched eggs.)

Net: no chemical treatment, whether based on botanical essential oils or any other chemical, seems effective at preventing lice. There’s some promise that tea tree oil might be part of a treatment regimen, but at least so far synthetic “traditional” lice treatment strategies are far more effective.

Tea tree oil is generally safe when used topically, other than occasional local irritation or a local allergic reaction. There was a report that continuous, high-surface-area skin exposure could cause estrogen-like effects (specifically, gynecomastia, the growth of breast tissue in boys), though it’s unlikely that short-term, limited use of this product would cause the same effect. Tea tree oil is poisonous and should not be ingested or used near the mouth.

Alana asked about preventing lice. What can work is trying to discourage children from wrestling, playing close, or sharing hair accessories. If lice do appear, stay cool. Remember that even though they’re icky, human lice do not spread any disease and are not a sign that your children are unclean or uncared for. There are a number of OTC and prescription products that can effectively kill lice (be sure to follow the directions, and repeat the process as directed.) Intense efforts to rid your child’s bed or your entire house are not necessary—the only lice that spread from child to child are the ones on heads. Lice that fall off are dead or dying, and are not spreading to other people.

More lice news: a 2014 study found that at least some louse eggs hatch as late as 13 days after they’re laid—which means that repeating lice treatment in 7-10 days may be inadequate (that is, it may leave some viable eggs ready to hatch.) Since most lice treatments don’t effectively kill the eggs, the timing of re-treatment needs to be both early enough so that newly hatched lice aren’t mature enough to lay new eggs, but late enough so that all eggs have hatched. If this 2014 report is correct, the best strategy may be to repeat the lice treatment twice—at 8 days and again at 15 days. It’s more complicated, but would effectively knock out all lice and eggs. Of course, no strategy will overcome the potential that your child will get lice back from another child at school—but, again, they’re still just lice, and we need to keep that in perspective. Itchy, yes. Icky, sure. But really, still, not something to get too worried about.

Related post: Don’t banish kids with lice

A cold, the flu, or sinusitis? Part 3: Myths

October 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

You might not like to hear it, but the truth is….


Nothing really works well to treat these things

Colds, flus, and sinusitis all share some things in common—and the most important one is that just about all of us get these, and they make us miserable, and we want them to go away. Billions are spent on all sorts of things to treat these conditions, both from pharmaceutical companies and from companies that make supplements and other alternative-health nostrums. We’ll try just about anything. But if clinical studies reliably show that just about nothing really helps, why do we keep buying them?

I think the most important factor is simple human nature, and the way that symptoms change. If you have a cold, the symptoms get better and worse throughout the day—so if you take medicine or supplement XX when you feel really bad, the natural ups and downs average out, and you’ll feel better. But: you would have felt better anyway! Still, human nature, you took the magic beans (that you paid for), then you felt better, so there must be a connection, right?

That happens at the end of an illness, too. Let’s say you’ve had a cold for 6 days, and you go to the local get-me-some-drugs at the QuickieClinic. You get some antibiotics, and a few days later you start to feel better. Boom, QED, there’s all the proof you need. (BTW, docs are pretty much just as bad about giving out unnecessary antibiotics, too.) But: you were going to get better anyway.

Think about this, it’s really important: many symptoms occur like a mountain, with an up and a down. If you try therapy at the top, when you’re feeling bad, you will feel better. But that doesn’t mean that the therapy was why the mountain went downhill.


Flu shots work

The effectiveness of flu vaccines varies from year to year, but typically runs ~ 50-75% — that’s pretty good, really, for a health intervention (it’s much better than, say, the effectiveness of taking a cholesterol-lowering drug to prevent a heart attack. And some people take those every day for years.) It does mean, though, that in a family with say four people who’ve gotten flu vaccine, one child may not be well protected. That’s why it’s important for the whole family to get it.

Also: flu vaccines only prevent the flu. They don’t prevent colds. And they take 3 weeks or so to “kick in” – you don’t get instant protection.


Flu shots cannot cause the flu

MythsNo. They can’t, and they don’t. They can sometimes cause a little fever or achiness, but that is not the flu—and anyone who’s actually had the flu will tell you that these mild symptoms after a flu vaccine are pretty much nothing. Sometimes, right after a flu vaccine, someone does get the flu—that’s because we’re giving flu vaccines during flu season, and if you don’t get it in advance it can’t protect you. The vaccines take about 3 weeks to work. If you catch influenza right after getting the flu vaccine that’s called “bad luck” or “bad planning”, not “bad vaccine.”


Green snot means sinusitis

No, green snot means it’s been sitting around up your nose (you’ll often notice this overnight), and your white cells are busy fighting off the viral infection. Good for your white cells. Go blow your nose, and stop looking at the color—it doesn’t matter what shade it is.


Flu tests are needed to diagnose flu

Commercially available flu tests aren’t very good—they give a lot of false negatives (a negative test even in the setting of flu), and some false positives (a positive test in a person without flu.) Many health care facilities don’t even use them. A flu test can be helpful, sometimes, if I’m on the fence about a diagnosis, but they’re really just not very reliable to help make decisions about treatment.


Cold weather causes colds

Colds are caused by viruses, one of many from families called “rhinovirus” and “coronavirus” and others. They’re not caused by cold weather. BUT there is a germ of truth here: cold air in the nose can make it more likely that these viruses can be transmitted. Grandma may have been right!


I’m sure there are other myths, feel free to add your own in the comments!


The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

A cold, the flu, or sinusitis? Part 2: Treatment  

October 12, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The previous post was about the symptoms of colds, the flu, and sinus infections—they’re not the same. This time, we’ll cover their treatment. And, surprise, it turns out that treating all of these is pretty much the same.

Style: "Neutral"

The most important part of treatment is rest and comfort. Get more sleep, and stay out of school or work until feeling better. That helps you and your children recover, and hopefully prevents the spread of illness. Drink more fluids, and have some soup.

To treat aches and pains, use acetaminophen or ibuprofen. It’s better to use these around-the-clock for a few days rather than just when symptoms become bad—these medicines are better at preventing pain and fever than treating pain and fever.

Treating nasal congestion is all about drainage. Use a humidifier and/or nasal saline spray. If your child is old enough, sometimes OTC decongestants given orally or as a nasal spray can help some, but they’re certainly not miracle drugs.

Coughs are annoying, but they’re there for a purpose: to get mucus up and out. If a cough is bothering your child, one of the best treatments is ordinary honey (for age 12 months and up.) Older children can sometimes benefit from OTC cough suppressants, but, again, they don’t work great. If your child has asthma, it’s probably a good idea to start up rescue medications during a cough.

There are a few more-specific treatments, depending on the diagnosis. If it’s influenza, a specific anti-viral medication (usually Tamiflu) can help some if started within the first 24-48 hours of symptoms. But the benefits of this medicine are modest at best. Tamiflu does not prevent serious complications, and only reduces symptoms by a little bit. Most people with influenza won’t notice any huge improvement with Tamiflu.

Sinusitis is typically treated with antibiotics, though even then the benefits of antibiotics are often over-stated. Studies looking at populations of both children and adults, comparing active antibiotics versus placebos, have shown really limited benefits to using antibiotics to treat sinusitis, at least ordinary, uncomplicated cases. And, of course, these same studies show that people taking antibiotics are much more likely to experience side effects and adverse reactions than those taking placebos.

The good news is that whatever you do, you’re going to get better. Whether it’s a cold, the flu, or sinusitis, symptoms will get better with or without treatment—though you’re going to be feeling sick for a while. If that’s the case, why does it seem like Tamiflu, antibiotics, OTC supplements, and all sorts of other things “work”? Next up, Part 3: Myths.


The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

October 8, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD


We’re heading back into colder weather again, and along with the change in the leaves comes more people with miserable, congested noses. Today’s post is all about telling the difference. Next time, I’ll tell you how to treat them.


The common cold

Captain ColdAlso called an “acute upper respiratory infection”, a “cold” is far and away the most common cause of congestion and cough. It usually starts with a vague ill feeling, followed by a sore throat and then a congested or drippy nose. Sometimes, there’s a fever at the start of the illness (that’s more common in babies and younger children.) A few days later, a cough begins. On average, the symptoms of a cold last about 10 days, though often the cough lingers for 2 or 3 weeks.

Notice: the symptoms grow or develop over several days, and the fever is really only at the beginning. By day 7-10 things are starting to improve.



“The flu” is a specific viral infection, and it’s not just a bad cold. Symptoms including fever, sore throat, body aches, nasal congestion or drip, and cough all pretty much start all at the same time, or within a few hours. Sometimes there are also gastrointestinal symptoms like abdominal pain or vomiting. Fever and aches are usually the worst symptoms – you feel, pretty much, like you’ve been hit by a truck. The worst symptoms last five days, but the congestion and cough often linger for another week or so.

Notice: the symptoms are sudden and severe.



Most common colds, of course, go away on their own, with or without any kind of treatment. But rarely a common cold can turn into a sinus infection. That occurs when the persistent mucus becomes infected with bacteria, leading to worsening symptoms 7-10 days into an ordinary cold, or persistent symptoms 2 weeks after a cold begins. Very rarely, sinusitis can start suddenly and severely, but much more typically there is first a cold that turns into a sinus infection.

Notice: a sinus infection is like a cold, but the symptoms worsen after 7-10 days. A congested nose for less than 7-10 days is unlikely to be a sinus infection, even if it feels really stuffy.


Next up: treating colds, the flu, and sinus infections.

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths



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