Archive for the ‘Medical problems’ category

Is your child’s head too big? Or just right?

April 6, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

“This chair is too big!” exclaimed Goldilocks. “And this chair is too small!”

“Just sit your rear down, missy!” said her mom, who had it up to here with her picky daughter. I mean, seriously?

Doctors and nurses and moms and dads, we all seem to like numbers. Unlike vague, untrustworthy adjectives (big? small?), they’re pointy and specific (23.5 centimeters!) I’ve even been known to crunch a number now and then. But when it comes to percentiles and measurements of growth, those pesky numbers sometimes cause more harm than good.

Tish wrote in, “I’m curious about head size, and when a parent should be concerned.  If a child is measuring well above the 97% line, but has no neurological symptoms and his growth curve mostly mimics that of other kids, is it likely just down to genetics?”

Too-short answer: Yes.

Too-long answer: Mostly, yes. But a head size that is too large—larger than expected for age and parents’ head size, or growing too quickly and shooting up off the chart—can actually be a serious and important thing, and can be an early sign of trouble.

Genetics plays a role, sure. The most common cause, by far, for a child to have a big head is “benign familial macrocephaly”. Mom and/or dad has a big noggin’, so Junior has a big noggin. As Tish says, as long as Junior is growing and thriving and otherwise well, a big headed kid with big headed parents needs to plan on buying big hats. But otherwise, there’s usually nothing to worry about.

How big should adult heads be? The data is pretty sparse. Seriously, if one of you wants to launch a survey site measuring normal adult heads to develop some good tables of normal values by gender/size/ethnicity, that would be really helpful. Maybe make it a Facebook page, “Measure your head!” or something like that. Until that’s done, we’re stuck with just a handful of published studies. The classic one is from 1992, and, yes, it’s still quoted in my pediatric textbook right here. All of the data comes from 354 white adults in Great Britain. We learn here that head circumference varies by height and sex. The 97%ile—a good “upper limit of normal” for an adult male of average height is 23 ½”; for a woman, the 97%ile is about 23”. Go check out your own size—see how it compares!—by wrapping a tape measure around your head.

The problem with that 1992 data is: I don’t actually believe it. I measure adult heads pretty frequently, and they’re often over 23-24 inches. There is some newer data out there—a Canadian study from 2012 recruited 280 all-male volunteers—that seems to show adult head circumferences are larger than they were in the 1992, but no one has done a very good, broad survey. So: even though we know big headed parents have big-headed kids, we don’t actually know how to define a big-headed parent. Maybe we should just ask about hat sizes, or ask Goldilocks what her opinion is (that head is too big!)

I did say this answer was the too-long version, didn’t I?

Big heads that we need to worry about fall into one of a few categories. Any head that’s quickly crossing percentiles upwards—going from, say, average, to Large, to HUGE over just a few months—is of Big Concern. A big head in a child who’s not meeting developmental milestones, or is losing milestones, is also a Big Red Flag. And big heads accompanied by obvious physical exam findings, like a bulging fontanelle, or a baby that’s hard to wake, or a baby that’s often fussy or irritable or vomiting—those need a Big Workup, pronto.

But for most kids with a big head, watchful waiting and a tape measure for mom and dad are all that’s needed.

Just-right answer: Frankly, I’m surprised you made it this far. I don’t really have anything else to say about big heads. Perhaps I didn’t think this Goldilocks motif through. Instead of another big head answer, I’ll send you to this short story I wrote. It has princesses and dragons and only a little bit of gore. Enjoy!

 

edit: The original title of this post was “Head too big? Too Small? Or just right?”– which was fine, until someone pointed out that I never actually got around to discussing small heads. So I changed the title. I can do that. 

Football helmets protect skulls. They don’t protect brains.

March 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A few weeks ago, I wrote about concussions—mild brain injuries caused by trauma. There’s increasing concern that repeated concussions—that is, repeated brain injuries—aren’t good. They can lead to depression, intellectual decline, movement disorders, and other kinds of symptoms that you’d expect from someone whose brain has been injured multiple times.

One tack that athletics departments are taking is to invest in more-expensive helmets. The idea has some appeal—wrap your head in something protective, and then you can bash it into things safely. But there’s a fundamental misunderstanding here. Helmets, the best helmets, can do a really good job at protecting your child’s skull from damage. But no helmet in the world has ever been shown to provide any protection for your child’s brain.

Think about it. The helmet protects the outside of your head, the hair, the skin, the eyes the cheekbones, all of those. People wearing helmets do not get lacerations of the scalp, and they don’t fracture their skulls, because the helmet protects these body parts from damage. But the brain, that is a very different story.

Your brain floats on the inside of your skull, enveloped in fluid. It gets injured not by directly smashing into someone else’s head, or into the ground, or into a windshield. The brain doesn’t strike your steering wheel and it doesn’t get hit by a hockey puck or a boxer’s gloved fist. What strikes your brain, and what causes the damage, is the inside of your own skull.

Picture this: you’re in a speeding car. You, your head, your skull, and your brain are all traveling 60 miles an hour when you swerve off the road into a concrete pole. Very quickly, you and your head stop moving—BAM, you’ve decelerated from 60 mph to zero in just a fraction of a second. If you’re lucky, your head is protected by snapping forward not into the windshield or your steering wheel, but into a relatively-soft air bag. Air bags do a great job to protect skulls and heads. But what happens to your brain? As smart as it might be, brains follow the laws of physics, too. It was just moving at 60 mph, and the thing carrying it, the skull, just stopped. The brain then slams into the front of the skull, from the inside, at 60 mph.

There is no airbag in there to protect the brain. In a car accident, the brain just slams into the inside of the skull. And in a football injury, the same thing happens—the helmet protects the scalp and the head, sure, but the brain still slams into the skull from the inside. Unless they figure out a way to implant a little helmet inside the head, between the brain and the skull, there’s nothing in there protecting the brain.

It’s worse, by the way. The really bad concussions—the most serious brain injuries—come from the brain slamming sideways into the side of the skull, or from rotational forces that shear the cortex, the top thinking part of the brain, away from the base (think of slapping a top from the side and watching it spin. Whee! Brain!) In any scenario, the physics are the same—forces act on the skull to change its motion, and the brain slams into the skull from the inside.

Good sports equipment is still essential for athletes, and I don’t mean to minimize what a good helmet can do. I don’t want poked out eyeballs or broken jaws or caved in skulls, either. But I’d also like to see a more-honest discussion of brain injury in sports, and what we can and cannot do to prevent and mitigate the effects of these injuries. We’re not getting honest info from the helmet manufacturers, that’s for sure.

Help fight childhood cancer, and help me get bald!

March 10, 2015

Heya fellow lovers of science and children! In a few days I’ll be getting my head shaved to help raise money to fight childhood cancer through St. Baldrick’s. It’s a great charity, and it’s a fun way to let the kids know we love them and would do anything to help.

As ya’ll know, I don’t take any advertisers, and I have no financial relationships or anything to disclose about drugs, medical products, or any of that lucrative endorsement stuff that could rake in the dough. I write and manage this blog just to ham it up, have a good time, and hopefully spread some solid info about children’s health. I don’t even accept donations to the blog (there is a “donate” link over there, but it’s just for show. As far as I know no one has ever clicked it.)

If you’ve ever felt that this blog is a useful resource and wanted to thank me by tossing over a few dollars, why not click this link and donate to St. Baldricks? You’ll help children with cancer, and you’ll get a glowy feeling inside. I’ll end up with less hair. It’s a win-win!

Get ready for spring! Allergy therapy update, 2015

March 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

In last year’s Pulitzer Prize winning* post, I reviewed the medications available for treating the symptoms of spring allergies—antihistamines, nasal sprays, prescription and non-prescription goodness. There’s some new information and changes this year, so it’s time for an update!

First, a study just published provides more reassurance about the use of topical nasal spray steroids and growth. About 220 kids aged 3-9 were randomized to receive placebo nasal spray or intranasal triamcinolone (sold OTC as “Nasacort”), and their growth was followed before, during, and after treatment. Growth when the medication started was very slightly slower (by about an eighth of an inch a year), but that difference was quickly erased by catch-up growth after the medication was stopped. In typical practice, these medicines aren’t used year-round anyway. Bottom line: if there is any effect on growth, it’s insignificant, and it’s temporary.

We’ve also got the first FDA-approved sublingual allergy immunotherapy tablet to come to market. Sold as “Grastek”, taken regularly this can help children and adults overcome allergy to one specific plant, Timothy Grass. Downside: it takes a long time to “kick in”, and it only protects against this one specific pollen—when usually, people with polen allergies are allergic to multiple things. So I’m not sure just how useful this is. Still, it’s an interesting foot-in-the-door for home immunotherapy without the shots. I’m sure we’ll be seeing more of this kind of thing.

Here’s the rundown on all of the other medications, updated for 2015:

Antihistamines are still 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. Most people use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheapo generics. They work taken as-needed or daily. There are still a few prescription antihistamines, but they have no advantage over these OTC products. Antihistamines don’t work at all to relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

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 he’s got in back.

Nasal cromolyn sodium (OTC Nasalcrom) works some, though not as strongly as prescription nasal sprays. Still, it’s safe and worth a try if you’d rather avoid a prescription.

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. The prescription nasal sprays, ironically, are much safer than OTC Afrin.

Nasal Steroid Sprays include OTCs Nasacort and now OTC Flonase. There are also many prescription products, like generic fluticasone, Rhinocort, Nasonex, Nasarel, Veramyst, and others. All of these are essentially the same (though some are scented, some are not; some use larger volumes of spray.) All of them 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.

Antihistamine nose sprays are topical versions of long-acting antihisamines, best for sniffling and sneezing and itching. They’re all prescription-only (though they’re super-safe). They’re marketed as either the Astelin/Astepro twins (Astepro came out later, when Astelin became available as a generic; it lasts longer) or Patanase.

Bonus! Eye allergy medications include the oral antihistamines, above; and the topical 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, which works about as well as rx Patanol, which they’re trying to replace with rx Pataday.

 

* That post didn’t win a Pulitzer. Does anyone read these footnotes?

Concussions are brain injuries

February 19, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Many parents (and even some teenagers) realize that kids are going to be using their brains at some point in their lives. I’m getting more and more questions about the effects of concussions—are they going to lead to trouble, down the road? How can they be prevented and treated?

First: let’s abandon the term “concussion.” It’s a weird word that waters down a much simpler term: traumatic brain injury. A concussion is a mild brain injury caused by trauma. So let’s just call it that, “mild traumatic brain injury.” Wordy, but those words say a lot more to parents and children than “concussion.”

How do you know a brain has been injured? Simply enough, it stops working right. A person who’s had a blow to the head followed by a period of brain-not-working has had a brain injury, a “concussion”. The symptoms could include, after the injury, a period of confusion or dizziness or a feeling that you’re “not all there.” Sometimes, but not usually, there’s a brief loss of consciousness. That worth saying again: people who’ve had a mild traumatic brain injury usually do not get knocked out. They just feel knocked around. Later, there are continued symptoms like headache, dizziness, a “fuzzy brain” feeling; sometimes there are also problems with moodiness or irritability, or trouble with sleep cycles. Again, remember, these are all symptoms of an injured brain.

People understand the concept of injuries. You injure your ankle, you expect to need to rest it. Everyone knows rest is the best way to prevent an injury from getting worse, and rest is the best way to prevent an even-worse re-injury. We instinctively know that during rehabilitation for an injured ankle, you’ll kind of walk and run funny—which puts you at risk for other injuries, too.

All of these concepts are exactly the same for concussion, and that’s easy to explain if you remember to think of a concussion as a “traumatic brain injury”. Rest is the key, to allow the brain to heal, to prevent worsening damage from continued trauma, to prevent re-injury of the brain, and to prevent injury of other body parts because you’re not performing well with an injured brain. See? Easy as an ankle to explain.

Of course, resting a brain isn’t exactly as simple as resting an ankle. We can’t use a sling or an ACE wrap (well, you can, but you’ll look weird and it won’t help.) Resting a brain means, well, brain rest: no intellectual work, no school, no physical exercise. Just like you’d rest an ankle until it felt better, resting a brain after it’s injured should continue until there are no symptoms of injury. No headaches, no sleep problems, no fuzzy brain, no dizziness, no trouble focusing. When all of these symptoms have abated, people with mild traumatic brain injuries should gradually advance to more-intense schooling and activities, step by step, until the patient is back up to full activity. If there’s a step backwards—if brain symptoms begin—do exactly what you’d do if your ankle starts to hurt again. Back off the activity and allow more time to heal.

There’s good evidence that allowing a period of time to rest and heal after a mild traumatic brain injury can help prevent re-injury and longstanding symptoms—but we don’t know exactly how long the rest should be. One recent study showed that to a point, too much rest for too long can actually worsen and extend symptoms. Once symptoms improve, it’s a good idea to start back on activities (start slow and advance step by step) rather than continue through a fixed number of days of rest. We have some work to do to fine tune and individualize the best concussion care advice.

While a single concussion, especially with appropriate treatment, is unlikely to lead to long term problems, there are some sobering concerns about people who’ve had multiple concussions. There’s an increased risk of long term cognitive decline, movement disorders, and depression. And we know many athletes under-report concussions. In one study, 30% of high school football players reported a history of concussion, but only half of those had reported the injury. There may be far more concussions injuring far more high school brains than we appreciate.

As I said, many of those brains are going to be used later. Maybe we ought to try to do a better job keeping them in good shape.

Vaccines: Children have rights, too

February 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Some people who argue against vaccinations claim that vaccine policies infringe on their “rights”—their rights, as parents, to make medical decisions for their children. It’s a scary, misleading, and chilling message. We need to be careful about where one person’s rights end and the next person’s rights begin. We need to remember that children (their children, and your children too) have rights of their own.

For example, Dr. Bob Sears says in all caps “FORCED VACCINATIONS FOR CALIFORNIANS ARE ON THEIR WAY.” No, Bob. California lawmakers have introduced a bill to eliminate “personal belief exemptions” for public school attendance. No one is going to force any vaccines on anyone, and there are no jackbooted thugs on the way. But if you want to send your child to public school, they’ve got to be vaccinated. There’s still a religious exemption (which is odd—no major religions are against vaccinating) and of course a medical exemption. But “personal belief exemptions” shouldn’t hold water, because personal beliefs don’t prevent disease. Vaccines do. You want your kids in public school, with my kids? Then my kids’ right to have a safe school overrides your rights to not vaccinate your child. Simple.

How far do rights go? Until they start to infringe on the rights of others.

Dr. Bob goes on to say that mandatory school vaccines violate “a parent’s right to make all health care decisions for their child.” He seems to agree with statements from a few politicians in the news lately. Rand Paul, an ophthalmologist and Kentucky Senator, says “The state doesn’t own your children. Parents own the children, and it’s an issue of freedom.”

No, Dr. Paul. Children are not things to be owned. They are not property. They are people, and they have rights too. Do what you want with your own children—anything short of abuse or egregious neglect, and the government won’t interfere. But as soon as your “rights” start to threaten the health of other children, and of our entire communities, that’s where your rights end. And the rights of the rest of us begin.

Can getting cold give you a cold? A win for Grandma!

January 29, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Grandma says, “Bundle up or you’ll catch cold!”

Research just published in the Proceedings of the National Academy of Sciences explains why Grandma may have been right.

A team from Yale University looked at rhinovirus–the most common of the common cold viruses—and the immune response in mice. They found some solid science:

Mouse airway cells infected with mouse-adapted rhinovirus 1B exhibited a striking enrichment in expression of antiviral defense response genes at 37 °C relative to 33 °C, which correlated with significantly higher expression levels of type I and type III IFN genes and IFN-stimulated genes (ISGs) at 37 °C.

In other words, when the nose is at the ordinary body temperature (37 C = 98.6 F), there is a more-robust immune response than when the nose is cold (33 C = 91.4 F). Cold temperatures allow the rhinovirus to replicate and spread more easily.

Does this mean you ought to put a muffler on your pet mouse this winter? Maybe so. And maybe your children, too!


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