Archive for the ‘Medical problems’ category

Your children deserve better than telephone medicine

May 23, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Someday we may miss the quaint idea of our children having their own doctors – doctors who actually get to know their patients and families. We keep all of your records, we know how many ear infections your child has had, we make sure they’re protected with vaccines and we monitor their growth and development – you know, the important, big picture things. The things you just can’t get with a quick phone call to an anonymous telephone doc. Can a phone call substitute for an in-person visit with a doctor who knows your child?

Apparently at least one huge insurance company thinks so. My own family’s health insurance comes from Aetna Healthcare (the letters of which can be rearranged to spell “At Heartache Lane”.) They’re really pushing me to try out “Teladoc” (which, ironically, can be rearranged to spell “late doc” or “eat clod” or “del taco.”) One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?”, it says, in big friendly letters. Holly, presumably the child’s mom, is quoted “One night my child was running a high fever. I called Teladoc & the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER.”

What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history, and symptoms, it would have been appropriate to either: (1) stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor; or (2) if there was chance of a genuinely serious medical issue, to go get evaluated right away. The child could have had meningitis, pneumonia, or a viral infection, or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever does not mean someone should “call in a prescription”? That’s completely, utterly, and despicably wrong.

Why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?

I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis or the outcomes of prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.

Though there are zero pediatric studies, I found one good study in adults,  reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses, and many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record.

I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just a handful of telemedine records in the last few years, and they’re frankly embarrassing. One was about an 8 year old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. I’ve also got records from kids treated with three days of antibiotics for a sinus infection, and urinary tract infections being treated without any testing of the urine (again, these examples completely contradict evidence-based care guidelines) If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone.

There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be a great way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms.

But current available technology (like this Teladoc service) doesn’t allow a clinician to really examine a patient, look in their ears, or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick – and that, really, is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy – and that’s why this kind of care is being pushed by insurance companies. But it’s no substitute for genuine medical care from your own child’s doctor. Your children deserve better care than pretend medicine over the phone.

 

Adapted from an earlier post

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Spring is here! Allergy therapy update, 2018

March 13, 2018

The Pediatric Insider

© 2016 Roy Benaroch, MD

Ah, spring. Birds are tweeting, the flowers are blooming, there’s a layer of yellow dust all over my car, and just about everyone is sneezing and stuffy. Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheap generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray (see below) is far superior.

There are a just a few differences between the modern OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day. A 2017 study showed that Zyrtec is marginally more effective than Claritin, so I’ve been recommending that one first.

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff hidden in back.

Nasal Steroid Sprays include a huge and dizzying array of choices now. OTC Nasacort, Flonase, Rhinocort, Clarispray, Sensimist, and many generics are available. Many of the brands contain the identical ingredient, sold under different names for marketing purposes. All of these products are essentially the same. They all work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others. My personal favorite is Nasacort.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work—they actually work great—but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. Steroid nasal sprays are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical nasal spray steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor.

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

This is an updated version of previous posts.

 

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

January 17, 2018

The Pediatric Insider

© 2017 Roy Benaroch, MD

You’ve probably already seen the news: a 6 year old boy in Florida has died of rabies. He had handled a sick bat (some reports said he was trying to rescue the critter), and that was enough contact to transmit the virus. Once symptoms begin, rabies in almost always fatal – so the only way to prevent this from happening again is to avoid contact, and get rabies prophylaxis (a series of injections) if there’s an exposure.

 

Is rabies common?

Yes – in a way. In the US there are only a handful of human cases a year (43 cases from 2000 through 2013, the most recent statistics I could find.) But there are an estimated 60,000 deaths a year worldwide. So, travelers, be especially wary of animal exposures overseas. In fact, if you’re traveling to the developing world to an area with likely animal exposures and no access to medical care, it may be wise to get rabies immunizations beforehand.

 

How can people catch rabies?

It’s a zoonotic infection, meaning we catch it from animals. Only the saliva transmits rabies virus, so most infections come from bites (or sometimes scratches, since animals aren’t always so keen on washing their hands with soap and water.)

Any mammal could potentially become sick with and transmit rabies, but in the US almost all transmission is from a few carnivorous animals: bats (by far the most common source, accounting for all but 4 of those 43 cases), raccoons, skunks, foxes, coyotes, and bobcats. Small rodents (rats, mice, squirrels) and lagomorphs (rabbits, hares, and pikas) would very rarely be possible carriers. Animals with rabies may act sick, and may be especially aggressive or bitey, so always be wary of any sick mammal, especially bats.

Worldwide, the most common source of human rabies are domesticated and semi-domesticated dogs. A campaign to vaccinate pets and farm animals has virtually eliminated this kind of transmission in the US – so keep vaccinating your animals!

 

What are the symptoms of rabies?

The incubation period is typically 1-3 months, though it can be days or years after exposure before symptoms develop. It’s a quickly progressive illness that often begins with acute anxiety, pain and other sensory abnormalities, unstable blood pressure and pulse, and sometimes “hydrophobia”, an extreme fear of water. (Hydrophobia is a historic name for rabies.) These symptoms progress to coma and death.

There have been three reported survivors of rabies over the last 20 years, all teenage girls treated with a very aggressive protocol of intense medical support, including medical-induced coma and artificial ventilation. Despite this care, most patients will die.

 

What should I do to prevent rabies?

Make sure domestic animals are vaccinated, and take them to the vet if they’re sick.

Approach wild animals with respect, and teach this to your kids, too. Wild animals should not be approached, or trapped, or captured, or kept as pets. If you see an animal that’s acting sick, especially a mammal, stay away. If it’s the kind of mammal that’s likely to transmit rabies (a sick or wild dog, or a raccoon, skunk, fox, coyote, or bobcat), contact animal control or your county health department. Keep children away.

  

What if someone gets bitten or scratched by one of these animals?

First, clean the wound with soap and running water. Then go see your doctor, or go to the emergency department. Do not delay. If necessary, post-exposure injections can be given which will virtually guarantee that rabies won’t occur. These injections will not help once symptoms begin – they must be given before rabies develops. Public health people and other experts consider the circumstances of every case before deciding whether rabies prevention is needed – don’t rely on this post, or what you read on the internet, to decide if you need rabies shots. Go see a doctor right away if there’s been a potential exposure.

If it is possible to do it safely, trap or capture the biting animal. That will prevent other people from getting exposed, and will allow health authorities to test the animal for rabies.

In some circumstances, a biting animal can be observed in captivity for 10 days for signs of illness.

 

What about bats?

Bats are a special circumstance. They’re the most common rabies transmitter in the US. And small bats, especially, could potentially bite a sleeping person without anyone noticing. Young children may not be able to communicate exactly what happened during a bat incident. So if there’s a bat that’s been in a room with a sleeping child, or a child who’s been playing with a bat or near a bat for any reason, go see a doctor. (If you can capture the bat, or kill the bat and bring the carcass including the head, that can help – only if you can do this safely.)  Even if the risk of transmission is low, the consequences of not treating a rabies exposure are horrible.

Use honey. Not Zarbees.

December 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

What if there were something cheap and effective for cold symptoms – something you could buy at your grocery store. Heck, you probably already have it in your house. It’s undergone at least three solid studies showing that it helps alleviate cough more effectively than established cold medicines. And it’s safe for just about anyone age 12 months or older.

Cool, huh? It’s honey. Good old honey, the stuff beloved by Winnie the Pooh, made by bees, and especially tasty drizzled on a peanut butter sandwich. You shouldn’t give raw, unpasteurized honey to babies less than 12 months of age, but other than that it’s safe as can be. Try it next time you or your child has a cough. (** TIP ONLY FOR ADULTS: I’m told mixing equal parts of honey, lemon juice, and Canadian whiskey together makes a fine toddy that will make it feel like you aren’t even sick. Until you pass out. This is for parents, not children.)

And that should be the end of the story. But what if instead of honey, you mix it with some other ingredients, double the price, and sell it in the medicine aisle? Then you’ve got Zarbee’s, which (according to their website), is the #1 pediatrician-recommended cough medicine sold for children less than 6.

Keep in mind Zarbee’s wasn’t what was studied in those clinical trials. I can’t find any clinical trials of Zarbees. Even the company that makes it carefully tiptoes around that issue on their website, where they avoid claiming that there’s any evidence that their products effectively treat any symptoms. They “support immune systems” and “soothe”, but those are just weasel-phrases that can’t be tested. That’s why the packaging also says, in all-capitals, “THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THIS PRODUCT IS NOT INTENDED TO DIAGNOSE, TREAT, CURE, OR PREVENT ANY DISEASE.”

Though the Zarbee’s line started with just the cough syrup, they’ve now got a variety of products to treat symptoms, all based on “wholesome ingredients” – meaning, as far as I can tell, “things not tested for safety or effectiveness in children.” But I guess they expect a pass, because, you know, the bees and all.

Look, I know coughs and colds are frustrating and miserable. If there were anything that actually worked, whoever comes up with it will make a mint. Until then, we’ll continue to see the dizzying aisle of hundreds of competing medicines – and every few years, a new one will become popular. Remember the one “invented by a teacher”? Or that adorable mucus-monster that showed up a few years ago? Now we’ve got Zarbee’s. None of these products works any better than any of the others, and none work any better than typical home remedies. But no one will make any money selling chicken soup and honey, so I’m sure we’ll bee (ha!) seeing more products from the Zarbee’s line. Save your money.

Some reassurance about football and your child’s brain

December 4, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Concussions and football have come up before on this blog, and the news so far has been discouraging. We want kids to stay active, and football is one of the most popular boys’ sports out there. But we know that some prominent professional athletes have had serious, cumulative brain damage from years of football – sometimes brain damage that has destroyed their lives. What about high school football, or football starting even earlier? Are we encouraging a sport that’s a cause of serious, lifelong disability?

A recent publication gives at least some reassurance. From the August 2017 issue of JAMA Neurology comes a study titled “Association of Playing High School Football with Cognition and Mental Health Later in Life.” It’s not a perfect, definitive study, but it’s got some solid long term data.

Researchers have been studying a cohort of about 10,000 Wisconsin high school graduates – students who graduated in 1957, so they’re now about 78 years old. Of those, about 2700 have complete data, including formal testing of their mental condition at age 65 and 72. Tests were done of intelligence and brain functioning using several standard assessments, as well as testing for things like depression, anxiety, and alcoholism. They also went through the high school yearbooks to figure out which of these students played football (it turned out to be about 30%. Football was, and still is, big in Wisconsin.)

When the data was analyzed, it looks like football players were no more or less likely to have problems with dementia or mental illness 60+ years later; nor were they more likely to consume too much alcohol. What was different was that they were somewhat more likely to stay physically active (which may have protected them from memory problems as they became older.)

There are some shortcomings of a study like this. We don’t know which if any of the participants played football starting younger than high school, or which positions they played, or whether they had one or more concussions. And, I think even more significantly, it’s apparent that football now is played quite differently than in 1957. Players are bigger and stronger and faster, and collisions are more high-energy. It may be that there are more brain injuries happening now on high school football fields than there were back then.

Still, 60+ years is some great long-term follow-up. It’s good to know that at least one long term study shows that football in high school isn’t associated with later cognitive or mental health problems. We still need to minimize concussion risks and identify and treat them correctly, but this study should provide some reassurance that high school football might not be so bad for high school brains.

Breath holding spells —  Super Scary for parents, not a big deal for kids

August 28, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Lemelon wrote a topic suggestion: “Breath holding spells. My toddler had a cyanotic breath holding spell after a bad fall where he struck his head on concrete from a height of about 4-5 feet. I didn’t know about breath holding spells and was pretty sure he was going to die. Thought maybe other parents would like to learn about them and their prevalence. Thanks!”

Near the top of a list of super-scary things for parents to see are breath holding spells. Your kiddo, typically a toddler, bonks his head or gets really mad about something. Then he stops breathing, turns white, and collapses on the floor. And looks dead. Really. Dead. It’s quite dramatic. I can say this, calmly now, because the child of mine that used to have them hasn’t had one in over 10 years. I’m a doctor, but with your own kid breath holding spells are freaky and scary.

But they aren’t freaky and scary to the children. After a few moments, they start to breathe again, and they might be a little tearful or clingy for a few minutes, and then they’re fine. Mom and dad need a long lie-down and a few glasses of Chablis, but the kiddos, I promise, they’re fine.

So what are breath holding spells? They’re kind-of-sort-of like a faint. They usually happen in toddlers, say from 6 to 18 months of age, and usually start with either a painful stimulus or less-often a very frustrating or fearful sort of event. The child might then gasp, and stop breathing, and almost immediately turn very pale or sometimes blue. Here’s a weird thing: even though their skin can look blue, there’s still plenty of oxygen in their blood. This happens way too fast to drop blood oxygenation. They look like they’re blue and dying, but they’re not. And: breath holding spells are entirely, 100%, involuntary. These are not kids who decide to hold their breath until they pass out.

During this period, what’s basically happening is that the autonomic nervous system – that’s the involuntary, behind-the-scenes part of the nervous system that you don’t think about much – slows down the heart, and clamps down the blood vessels, and, well, shuts off the brain. The kids go limp, and collapse breathless on the floor. Sometimes, there can be just a few little muscle jerks or spasms right there at the end, too, to further freak you out.

But just a few seconds later, everything resets. The heart resumes normal beating, circulation returns, and Junior wakes up. Crazy, I know, but leave it to kids to come up with something like this. Look mom, I’m dying! Just kidding!

(If the child doesn’t wake up and start breathing within 3 minutes, start CPR and call 911. I’ve not seen or heard of that happening, and I don’t think any parent would even wait that long, but I don’t want parents to not call 911 if they’re worried!)

Breath holding spells are fairly common – they happen in 4-5% of children, maybe a little more commonly in girls. Though they typically start at 6-18 months, some babies will start younger. They usually stop by age 4 years or so, though some kids go on to have more-ordinary fainting spells from there.

Bottom line: as scary as they are, breath holding spells are harmless. The main thing is to diagnose them correctly (which is 100% entirely by the history, there are no tests or scans or anything) and to avoid a huge, expensive, painful, and misleading diagnostic odyssey. These kids do not need a bunch of tests. If the diagnosis isn’t clear from the history (say, the events are unwitnessed or atypical), sometimes a few tests can rule out other things.

There are a few off-label medicines that are rarely prescribed to prevent breath holding spells, especially if they’re happening very frequently. There’s some evidence, not great, that iron supplementation may sometimes be helpful. But that’s it in terms of medical therapy. (That, and the Chablis)

With breath holding spells, the doc’s job is to listen and get the diagnosis right, without unnecessary tests; the parents’ job is to leave the kiddo alone until he wakes up, and try not to freak out; and the child’s job is to outgrow them before Daddy has a heart attack, OK?

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.