Archive for the ‘Medical problems’ category

Bedwetting in a pre-teen

August 3, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Josh wrote in about his 12 year old daughter – they’ve tried everything, specialists and medications, and she still wets the bed every night:

We have done everything. Waking her, withholding fluids, buzzer. She has taken the highest dosage of desmopressin allowed, to no avail. She has been to an endocrinologist and tested thoroughly, seen her pediatrician many times, had abdominal X-rays and ultrasounds, and been examined for psychological issues. Nothing. The next step our doctor suggests is a urologist. She currently wears a diaper to bed, and we are very straightforward and sympathetic with her. Only positive reinforcement, but she is frustrated with herself at this point.

Josh, about 3% of 12 year olds still wet the bed, at least sometimes (though most of those are boys). It’s not crazy-uncommon for your daughter to be doing this, but I know she wants to stop. Trouble is: bedwetting happens when you’re asleep, and what you want or don’t want doesn’t really matter. Positive reinforcement won’t hurt, but it probably won’t help much, either. What might hurt is encouraging her to “try harder” – this is something that isn’t about trying or practice or rewards. It’s about neurologic maturity.

What supposed to happen: past a certain age, even while we’re asleep we can still pay attention to signals from our bladders. When it’s full, or getting full, we tighten up our pelvic muscles to hold in the urine, without waking up. A good trick, that is, and babies can’t do it, and young children can’t do it. People who are heavier sleepers find it harder to do this, too – and that makes sense. Sleeping like a rock means it’s more likely that you’ll wake up like a, well, wet rock. And there’s not much you can do to “lighten” someone’s sleep cycle.

What *might* work – and I know Josh’s daughter has already tried some of these, but just for completeness:

Drinking more in the morning I know, the usual advice is to drink less at night – but it turns out that’s really difficult to do. If you’re thirsty, you’re thirsty, and not drinking when you’re thirsty is nigh impossible. Instead: stay well hydrated the rest of the day, especially the morning, so you don’t feel like drinking in the evening.

Don’t hold urine during the day I know, some people suggest “bladder stretching” by day to hold more at night. But the problem isn’t a small bladder – it’s that the sleeping child doesn’t notice that their bladder is full. It turns out that holding by day gets the brain “used to” the feeling of a full bladder. It dampens (sorry) the nerve signals, so you don’t get as strong a feeling of a full bladder. This is exactly what you do not want. Frequent, relaxed daytime emptying can help a child stay dry at night.

Treat constipation Constipation leads to holding which leads to less awareness of a full bladder; it also inadvertently strengthens muscles you don’t want strengthened, making it difficult to empty the bladder. At 12, if bedwetting is an issue, I suggest treating constipation even if you don’t think your child is constipated. Just try it. It might work.

Consider medication Two meds have wide use to help with bedwetting: desmopressin and imipramine. Either or both are worth a try, especially if the child is concerned about this.

Don’t make this about trying or not trying I said this before, but let me repeat it: kids don’t wet the bed because they want to wet, and don’t stop wetting the bed because they want to stop. Josh mentioned looking into psychological contributors, which may be a good idea, but don’t create a bigger problem by blaming or by implying that kids can solve this problem by trying harder. That’s not fair and won’t be helpful.

See a urologist At some point, I think it’s a good idea – to rule out very rare anatomical issues, and make sure all medical contributors have been addressed.

And, finally: Focus on the positive. I agree, Josh’s daughter has every right to be upset about this and to want it to stop. And it will stop. I’d pursue some (or all) of the ideas above, while at the same time keeping the conversation positive, non-blamey, and focused on things she does well.

Republican and democratic lawmakers: Grow up and do your jobs

July 20, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Health – /helTH/ – The state of being free from illness or injury

Care – /ker/ – The provision of what is necessary for the health, welfare, and protection of someone or something.

System – /’sistəm/ – A set of things working together as parts of a mechanism or an interconnecting network.

It’s not keeping us Healthy, it doesn’t seem to Care, and it’s certainly no kind of System. What we’re got is more about hostile parties protecting their turf and income than a system that’s working together. The docs fight the insurance companies to get things covered; the patients fight the hospitals over inflated, inscrutable bills; the insurance companies fight the pharmaceutical companies over the eye-popping prices of new drugs. The people least suited to fight end up losing the most – that’d be the “patients.”

Meanwhile: the peeps we’ve hired to fix this mess are too busy trying to make each other look bad – which, by the way, is like shootin’ fish in a barrel these days, amirite? – to pass some kind of legislation to even begin to help fix this fine mess. Ever get hired to do a job that you don’t do for 2 or 4 or 8 or 20 years? Didja keep that job? Mind: boggled.

OK, in the spirit of angering everyone involved, so I can bask in the flames of democrats and republicans alike, I will now specifically criticize the approach of both parties. Those of you with strong loyalties may want to skip the next (democratic) or following (republican) paragraphs, lest you be exposed to a worldview that’s not aligned with your own. But for the few of you left who are still capable of seeing two sides of an issue, start here:

Democrats: Obamacare has problems. The insurance marketplaces in many places are collapsing, and premiums are going thru the roof. Even people who have “insurance” often have huge deductibles that they can’t afford. In short: just having “insurance” isn’t the same as “having access to health care.” Obamacare didn’t do a thing to rein in the biggest problem: health care costs too much, and too many people (sorry, “market stakeholders”) are chewing up huge slices of the pie without contributing anything useful to helping patients. I know you’re feeling hurt that you lost the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

Republicans: The free market, alone, cannot save health care. The barriers to entry are too huge (it’s hard to become a doctor, harder to open up a company to manufacture medicines, and even harder to open up a hospital) – which means competition is artificially stunted, and won’t pop up automatically to reduce prices. Also, Emergency Departments are required, by law, to offer care to people who cannot pay – that’s morally the right thing, and don’t even think about removing this safety net. Health care choices are also difficult and fraught, and often made under the duress of pain and worry. People cannot be expected to call around to different ambulance companies to check their prices when they’re experiencing crushing chest pain. You have to admit: health care is unique, and you can’t depend on free market principles, alone, to fix it. The solution is going to include regulations and guidelines and (gasp) some guarantees of coverage, and might even require ways to rein in insco, hospital, doctor, and pharmaceutical profits. I know you’re feeling giddy that you won the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

It’s not easy, I know – but at this point, it’s clear that members of both parties aren’t keeping their eyes on the ball. Your job isn’t about re-election, and payback, and “If you play with Susie than you can’t be my friend anymore.” This isn’t kindergarten, and we don’t really care who plays with Susie – we just want Susie and her family to have access to affordable, good health care. Congresspeople, it’s time to grow up and do your jobs.

Vaccines: We’re all in this together

July 17, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

When we work together, great things can happen.

Polio has been around since ancient times – there are depictions of it in art thousands of years old. Improved sanitation helped, but it was vaccines that have nearly eradicated polio from the world. This is a disease that paralyzed over 21,000 people in the US in 1952. There are still plenty of people around living with deformities and chronic pain from polio they suffered through years ago. Our children will never have to face this, because our parents and grandparents were sure to get us vaccinated.

Smallpox – gone.

Rinderpest – gone, too, though you may not have known what it was. It’s a neat story. Rinderpest was also known as cattle plague or steppe murrain, and may have been one of the biblical plagues. Our livestock no longer have to worry about it (I’m not sure they ever did, really. That’s livestock for you. But for farmers & pastoral nomads, rinderpest was a big deal.)

Measles – another ancient disease, and a serious one that continues to kill people – was almost eradicated from the western world. It’s no longer endemic (constantly circulating) in the USA, though pockets of certain populations can still support local outbreaks. And that exactly what happens, when vaccine rates fall. Measles cases rapidly return. It’s happening in Europe, and it’s happening in communities in Minnesota who’ve fallen for the lies of the antivaccine propagandists.

Have you or your kids had tetanus, lately? Diphtheria? No. And it’s not because you’re lucky. It’s, again, because our parents and grandparents got us vaccinated, and almost all of us continue to vaccinate our children.

Most parents get it, that vaccines protect not only our children, but everyone else’s children – especially babies too young to get their immunizations, or children who have cancer or other immune problems. Elderly people, adults on medicine for their psoriasis or rheumatoid arthritis, or in chemotherapy – all of us, in every community, benefit when parents vaccinate their children.

And when parents don’t vaccinate, bad things quickly happen. The diseases will wait, patiently, until we let our guard down and invite them back into our homes. They’re not busy. They’re waiting.

There’s a choice, here. Live in fear – fake fear, made-up fear, fear based on lies and propaganda and the same stuff that tries to fool you into e-mailing your bank routing number to a Nigerian prince. You’re not getting that $26 million (or $43 million), and your doctors and the CDC and governments all over the world are not trying to poison your children. Honestly. Let us protect your kids. Great things can happen when we all vaccinate. Protect your children, your community, and yourself.

Bonus! Another example – great things can happen when we all work together. Or, in this case, sing together. Listen, it’ll give you goosebumps.

Most kids with penicillin allergies aren’t actually allergic

July 6, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

It’s a common problem: an infant or child has a rash or another symptom while taking antibiotic, so he’s considered “allergic.” The chart is so marked, and the child isn’t allowed to take that antibiotic anymore. But a new study adds to growing evidence that many children thought to be allergic actually aren’t. They could take that same drug again, and they’d do fine.

This isn’t a minor issue. Second like drugs used when there’s a reported allergy tend to be less effective or more broad-spectrum, leading to more side effects. And some kinds end up with a whole lot of alleged allergies, making it difficult to treat them with anything.

In the current study, the authors looked at children (age 4 to 18) showing up to an Emergency Department with a history of any penicillin allergy (this includes amoxicillin, Augmentin, and other penicillins.) Parents were asked to fill out a questionnaire about their child’s previous reactions, and most of the common reactions reported were considered “low risk” for true allergy – symptoms like any rash (hives or not hives, any rash), itching, diarrhea, comiting, runny nose, nausea, cough, headache, dizziness, or allergy suspected based only on a family member being allergic. If a child’s symptoms were one or more of these items, they were considered “low risk” to be truly allergic. When 100 of these “low risk” patients had formal allergy testing, ALL of them tested negative. Not one of them was allergic to penicillin.

Reported “high risk” symptoms included facial or lip swelling, difficulty breathing, wheezing, throat swelling, skin blisters or peeling, or a drop in blood pressure. These children were not tested for penicillin allergy, and were presumed to be really allergic.

This was a small sample – despite their “100% not allergic” finding, I don’t think anyone’s prepared to say that all amoxicillin rashes can be disregarded as non allergic. But it’s clear that most children (and adults) labeled as penicillin or amoxicillin allergic are not allergic, and could safely try the medication again. If you or your child is thought to be allergic, talk with your doctor about the exact reaction, and see if either a rechallenge or a referral to an allergist would be a good idea.

 

 

Just “Reducing C-Sections” shouldn’t be a goal

May 16, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Consumer Reports today released a report critical of the c-section rates of many US hospitals. Titled “Your biggest c-section risk may be your hospital”, the article encourages parents to choose a hospital based on c-section rates. The lower, the better.

That’s misguided advice, and focuses attention on the wrong parameter. Parents should concentrate on improving their odds of a healthy and safe delivery for mom and baby. Knowing the overall c-section rate of a hospital doesn’t tell you anything at all about whether the babies born there are healthy.

In an ideal world, we would easily be able to tell exactly which mom-baby pairs need a c-section. Sometimes, it is easy to tell – mom’s past medical history, or something about the baby, makes a c-section very clearly necessary. But most of the time, c-sections are a decision made based on “risk reduction”. And that’s not an exact science. We know that some babies with a certain kind of fetal heart tracing may be headed for trouble – they’re at an “increased risk” of problems with delivery (and those problems can be devastating, leading to death or permanent neurologic disability.) But most of the time, even these “higher risk” babies can probably labor longer, and could probably be born vaginally and do fine. But what’s probably? What if you were told your baby had a 1 in 3 chance of severe complications? Or a 1 in 50 chance of having brain damage, and never being able to walk? Would 1 in 100 be a reasonable risk, or 1 in 500? We do c-sections to mitigate, or reduce, those risks. It’s up to midwives and moms and obstetricians to discuss these risks and decide on the best course of action for each individual mom in labor.

The article points out that over half of the hospitals surveyed – or “nearly 6 in 10” — have a c-section rate above the rate of 23.9% established as a goal by the US Department of Health and Human Services. But that means that close to half of the hospitals actually had a c-section rate somewhat less than the government target. But the CR headline doesn’t read “Nearly half of hospitals aren’t doing enough c-sections.”

By the way, I have no idea where that 23.9% goal comes from. I know of no data that explicitly determines the percentage of c-sections that is ideal for health. I don’t think any such data exist, or that there even could be “one number” that’s perfect for every community.

Although the survey did try to look at the reasons behind c-section variability at hospitals, those can be difficult numbers to quantify. We know older moms, and overweight moms, are more likely to need a c-section – so hospitals catering to those groups are being unfairly targeted for their high c-section rates. (One reason why c-section rates have crept up over the last few decades is the changing demographics of pregnancy in the US. There are more twins, too.) In fact, if I were a hospital administrator who wanted to brag about my low c-section rates, I’d just drop out of the business of seeing high-risk pregnancies, or catering to older or obese women. That hospital would “win” the low c-section sweepstakes! But is that the best way to take care of women – to neglect the ones that make our hospital numbers look bad?

Also – and I know I’m going to lose some of you with this – I’m not entirely comfortable with the overall message here that even elective, non-medical c-sections are bad and should be discouraged. Moms deserve honest, science-based advice on the pros and cons of both vaginal and c-section delivery, tailored to their own circumstances and health histories. If a mom, given good information, decides that even without a specific medical indication she’d prefer to get a c-section, is that wrong? Aren’t we past the point where doctors are supposed to tell their patients what to do? And aren’t we past the point where women should be told what to do by their man-doctors? (Parenthetically, all of the MDs interviewed for the CR story were men*. I’m sure that’s just a coincidence.)

C-section rates are one measure of a hospital – and for women who put a top priority on having a vaginal delivery, this Consumer Reports article gives some helpful information. But I don’t think most women ought to focus on that one parameter, or worry about taking steps to avoid a c-section. That’s my judgement, but you pregnant women should make up your own minds. I don’t think the “23.9 percenters” ought to try to take that decision away from you.

 

*Neel, Elliott, Aaron, Gilad, Robert – I’m assuming these are all male first names.

Molluscum: Maybe best to leave them alone

May 8, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Alina wrote in, “If Molluscum Contagiosum is limited to a few bumps, 10 or less, does it necessarily need treatment or will it pass on its own?”

Molluscum (plural, mollusca) will usually go away on its own. Eventually. Except when they don’t.

Some things I can say for certain: molluscum is one of the least-favorite things for pediatricians and dermatologists to deal with. There’s no great therapy, and they don’t always do what they’re supposed to do. Parents hate them, and whatever we try doesn’t work anyway. Stupid molluscum!

Molluscum contagiosum looks like little, waxy-looking, skin-colored bumps that usually affect children less than 10 or so. They sometimes show up in little clusters, or can be more widespread. They’re triggered by a viral infection – but the virus itself is ubiquitous and impossible to avoid, so pretty much all of us are exposed to it. We don’t know why some kids with this virus get bump, while many others never do. The good news is that this isn’t a serious issue, and doesn’t lead to any serious issues.

But the bumps can look ugly. And though most of the time they do go away entirely on their own, that process can take months or years. And sometimes they just insist on sticking around. So parents, understandably, want to find some way to get rid of them.

There are no FDA-approved medications that treat these, and no OTC or “natural” types of products that have ever been shown to be more effective than placebo. Dermatologists can scrape them off (ow!), or freeze them off (ow!), or dabble blistering agents on them (ow!). Though all of these methods work sometimes, they also sometimes lead to scarring or more lesions popping up nearby.

From my point of view, after about 20 years of fighting with these dang things on my patients, I usually encourage families to leave them alone. If they’re in a cosmetically important area or somewhere that’s hard to keep covered with clothes, I’ll sometimes try a gentle topical agent that seems to irritate them a bit, which hastens their destruction by the body’s immune system. But usually, if there aren’t a lot of them, and the family can just ignore them until they disappear, that’s the way to go.

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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.