Archive for the ‘Medical problems’ category

Thanks, 3 million!

January 12, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Hey Insiders! It’s time for a quick thanks! About a month ago we passed 3 million views, which is pretty cool for a blog with no commercial partners. I don’t get any links or love from pay or industry sites – all of my traffic comes from you guys, sharing and posting and linking. Thanks!

For those who’ve found the site recently, let’s go over the rules: Feel free to share and post. Anything derogatory, threatening, or downright mean will be deleted. If you’ve got a topic to suggest, feel free to write in – but keep them brief and general. I will not respond to questions asking for specific or personal medical advice. If you’re my patient, contact me at my office with medical questions.

Thanks again, especially for the posts, comments, and shares!

Thanksgiving parade

Nosebleeds: A quick guide to prevention and treatment in children

January 9, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Frequent commenter wzrd wrote in, “Perhaps in the future, a timely article on epistaxis, specifically seasonal/winter related? I used to have the worst nosebleeds in the winter as a child, literally filling bath towels with blood. I’m sure that you’d have excellent insight into the worthiness of cautery in severe cases.”

Wzrd here is asking about epistaxis, usually called a “nosebleed” by most people. I have no idea why doctors need a separate word for everything. Hey! Were you curious about where that word, epistaxis, comes from? “Epi” shows up in a lot of medical words, like epidermis or epiglottis – it means “upon.” The “staxis” means to “to let fall in drops,” sharing the same root as “stalactite”. Which doesn’t necessarily mean nosebleeds are like stalactites hanging off your face. Isn’t language fun?

Winter nosebleeds are often caused by dry, hot air pouring out of the furnace. That dry air sucks the moisture out of the lining of the nose. Little cracks form, which are itchy and irritated. Junior rubs or picks his itchy nose, and nosebleeds start. Once a nosebleed begins, it will clot off—omnes sanguinem clausuris—but the clot is never as strong as the intact blood vessel. So children typically get a few nosebleeds in a row, over a few days, as they continue to rub their itchy dry nose.

Parents need to make sure there isn’t some other kind of issue going on. If a child has nosebleeds accompanied by other bleeding—like bleeding under the skin, or gum bleeding—or if there’s a strong family history of excessive bleeding, then a blood workup for a bleeding disorder is needed. Most of the time, though, nosebleeds are just nosebleeds.

Nosebleeds, as wzrd said, can sometimes bleed a lot, even soaking sheets or towels. (More medical lingo fun: in doctor-talk, we call that “bleeding like stink.” I don’t know the Latin roots of that phrase.) To treat a nosebleed, have your child sit up, maybe leaning forward a bit, and pinch the fleshy end of the nose shut. Be gentle—it doesn’t take a hard squeeze. Then resist the temptation to check too soon. Once you let go, if it’s still bleeding you should hold it even longer the next time. Start with a 5-minute hold, and if that doesn’t work 10 minutes, and if even that doesn’t work, try 10 minutes again on your way to the ER to get the nose packed. You can also try putting some ice (or a bag of frozen peas) on the bridge of the nose to decrease blood flow.

You may have heard that people with nosebleeds ought to lie down, or lie back. That’s not a great idea. More blood will be swallowed that way, and blood in the stomach can cause vomiting.

To prevent nosebleeds, keep the air as humid as possible. A vaporizer or humidifier can help, especially one that really pours out the mist. A good humidifier will use at least a gallon of water to humidify a child’s bedroom every night. Many nosebleeds are also caused by picking (or, as we say in Latin, “digital trauma.”) You may want to encourage Junior to keep his or her fingers out of there.

You can also moisturize your child’s nose by having him snort some saline nasal gel. Dab a blob of this gel—it has the consistency of toothpaste—on a fingertip, and have your child snort it up into his nose at bedtime. They also make swabs of saline gel, but the swabs themselves are stiff and can irritate the lining of the nose if used too aggressively.

If nosebleeds are frequent or problematic, and these simple steps haven’t helped, the next step would be to visit an ENT specialist (or an “otorhinolaryngologist” – you look up the Latin. What do I look like, Google?) They can peek up the nose with a little endoscope, and see if there’s an exposed blood vessel that can be chemically cauterized. The procedure is done with a little squirt of topical anesthetic, and is reasonably easy and painless to do once a child can sit still.

Drowsee

Why aren’t there any cough medicines that actually work?

January 3, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Coughing is one of the most common reasons parents bring their children to see me. And I can see why. Coughing is noisy and uncomfortable, and gets kids dirty looks in schools and subways. Even worse, coughing keeps kids and their parents awake. We’ve all been there, and no one likes to cough.

But: coughing is there, usually, for a reason. Almost all coughs are from upper respiratory infections (that’s fancy talk for common, ordinary colds caused by common, ordinary viruses.) People cough because viral infections cause excess mucus to form throughout your “respiratory tree” – from your nose, down your throat, down the airways deep into your lungs. And that mucus isn’t good. If it just sits there, that warm sticky mucus will attract bacteria like swimming pools attract children. Worse, once the bacteria are enjoying themselves in the sticky mucus, they’ll reproduce and make tons more bacteria, causing more inflammation and more sticky mucus.

Fortunately, we have a built-in, excellent way to get rid of that sticky mucus before it gets loaded with bacteria. It’s called “coughing”. Coughing brings the mucus up and out of the lungs and respiratory tract (it’s usually swallowed, which is harmless – respiratory bacteria cannot survive in your stomach.) Coughing also agitates the mucus, preventing bacteria from developing their defensive biofilm and creating a huge colony of pus-filled goo.

Coughing is good. It’s there for a reason. And: if we had a medicine that could genuinely stop a person from coughing, it would kill people. People taking that magic medicine would end up filled with infected mucus, and if they couldn’t cough it up, they’d die. There is no “medical” way to get out infected mucus. No medicine, no suction, no procedure we’ve ever come up with is nearly as effective as a good old fashioned, God-given cough.

There are dozens, maybe hundreds of medicines you can buy that allegedly help stop or reduce the cough. One brand of them has that adorable mucus-monster guy—which is ironic, because coughing is the only way to get rid of him. Why are there so many choices of cough and cold medications at the drug store? Because none of them work. Sure, some might make you sleepy, and a few might reduce nasal congestion for a little while. But none of them, zero, none, have ever been shown to reduce cough in any meaningful way.

How long should an ordinary cough last? Longer than you think. Only 50% of coughs with a common cold improve by day 10. Many last 2 or 3 weeks, and 1 in 10 children with ordinary coughs are still coughing well past that 3 week mark.

Not all coughing is medically benign. Many coughs are caused by asthma, which shrinks down the breathing tubes and causes them to collect even more mucus. Asthma-caused coughs need to be treated with asthma medicines (not with cough “suppressants” or any other alleged “cough medicines”.) Some coughs are triggered by post-nasal drip from allergies, and we do have effective strategies and medicines to treat those. Coughs can also be triggered by lots of other things, like a side effect of some medications, or by an inhaled foreign object, or by pneumonia (which in children is usually viral, but that’s another story for another day.) Though most coughing is ordinary and benign and viral, a bad or lasting or troublesome cough should be evaluated by a doctor to determine the cause.

So what to do with a child who’s coughing? Soothe the airway with extra liquids, maybe a popsicle or warm soup (either warmish or coolish liquids seem to help, whichever you or your child prefers.) Older kids can suck a cough drop. Some families swear by those vapor products, like Vicks, though evidence that they help is weak. Of all of the “medicines” that have ever been studied to help with cough in children, the one with the best-documented effectiveness is honey. Not honey-made-into-cough-medicine, just regular ordinary honey from the grocery store, which is safe to use from age 1 and up. Honey, of course, won’t stop the cough – nothing will, which is good – but it can be soothing and seems to help with the throat irritation.

Coughing has a purpose. It’s there to prevent an ordinary, mucousy cold from turning into something much worse. There’s no medicine that stops a cough, and that’s a good thing.

**Bonus! Didja know why it’s sometimes spelled mucus, and sometimes spelled mucous? Grammar can be fascinating and disgusting!


koffingicon_400x400

Preventing and treating pediatric migraines

December 12, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents are sometimes surprised to find out that migraines are the most common cause of recurrent headaches in children. Yes, kids get migraines – and many adults who get them started getting them as children, even if they weren’t diagnosed correctly.

(And: many adults who get migraines are still not being diagnosed correctly. Do you get “sinus” headaches? They’re almost certainly migraines. Yes, I know you feel congested with them. Yes, I know you know they’re “sinus.” But they’re not. They’re migraines, and have nothing to do with your sinuses. But I’m getting off topic here, and I’m not your doctor, and feel free to just disregard this paragraph.)

Dealing with pediatric migraines starts with making the right diagnosis – which is usually easy, if you listen to the patient and ask a few of the right questions. A brief physical exam can confirm that there’s nothing else to worry about, and advanced imaging like CTs or MRIs is almost never needed. Once there’s a history of over a few months of recurrent headaches, a clinical exam will tell you everything you need to know.

Prevention is the key. Migraines are really uncomfortable and disruptive, and an ounce of prevention is worth much more than a pound of cure. Many pediatric migraines are triggered by things like hunger, lack of sleep, disrupted schedules, dehydration, and many other lifestyle habits. Stress is almost always another contributor. Remember: stress to a child includes not just worry, but even excitement and strong positive emotions. Stress isn’t just things a child doesn’t like. Families and kids can learn to identify and avoid some of their own triggers, leading to far fewer migraines.

In adults, daily medications are commonly used as preventives. A recent study from the New England Journal looked at two common migraine preventers in children – topiramate (AKA Topamax) and amitriptyline.  The good news is that both medications did decrease the frequency of headaches – but the bad news is, neither was any better than the placebo group. That’s right, whether the study participants (all children and teens) took either of the drugs or a placebo pill, they all reported a decrease in headaches. Score one for sugar pills! Both the amitriptyline and topiramate groups experienced side effects, so the study was stopped early.

There’s some evidence for the effectiveness of a few less-traditional agents to prevent migraines in adults. These might help in children, too. Vitamin B2, taken daily, seemed to work better than placebo, and at least small trials of a few other generally-safe agents like magnesium and butterbur show promise. Even if they’re not much better than placebo, they’re safer than most medications.

We do have very good “abortive” agents to treat migraines once they begin. These include non-steroidal OTC meds like ibuprofen or naproxen, or prescription medications called “triptans”. All of these work best if taken very soon after any migraine symptoms start. But all of these are also prone to causing “rebound headaches” if taken too frequently. So, again, prevention is better than cure. (Still, a cure is nice to have if you need one!) By the way, narcotic medications should never be used to treat migraines, especially in children—they increase the sensitivity of the pain system, and can increase pain episodes
after even short-term use.

If your child has recurrent headaches, start by keeping a log to track potential triggers and causes. Don’t discount the role of stress, even if your child “doesn’t seem stressed”. And try to encourage good, regular sleep and eating habits. Still having headaches? It’s time to see the doctor. Even if daily medications don’t show much promise, we’ve got other good options to both prevent and treat migraines in children.

How old is he now, anyway?

Parents can tell if an ear infection is getting better

December 5, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Good things come in small packages. A short, sweet letter to the editor in the November, 2016 edition of JAMA Pediatrics confirms that parents can tell whether their children are getting over an ear infection, with no doctor exam required.

The letter, from four Finnish physicians, is about a page long. It summarizes a small part of their data from a much larger study on the treatment of ear infections. In the letter, they’re only looking at 160 children, age 6 months to 3 years, who were initially treated for an ear infection without any antibiotics. Current guidelines from the US and many other countries do support treating less-severe ear infections with pain relievers only, waiting on antibiotics. But these guidelines suggest that if children with ear infections aren’t given antibiotics, they need to be followed closely and re-examined to make sure they’re really getting better. These authors asked, is that really necessary?

The 160 children were all reexamined for this study, and parents were also asked questions about whether they thought their children were improving, getting worse, or staying about the same. It turns out that among the children whose parents thought were getting better, only a very small number had worsening ear exams (less than 3%). Compare that with children thought to be getting worse – about 30% had worsening findings on their ear exams. Keep in mind that these were all children who did not receive any antibiotics. Presumably, if they had, even fewer of them would have gotten worse.

Parents, not surprisingly, were pretty good at judging whether their children were getting better. So good that based on these numbers, a repeat exam to make sure ear infections were clearing was probably unnecessary!

Caveats: I’d be a little more cautious with children at risk for prolonged ear infections or  persistent fluid behind the ears. Children with a history of difficult-to-treat ear infections should get a repeat exam, as should kids with hearing problems or developmental language delays—it’s crucial that those children get over their infections completely. But for the majority of children with ordinary ear infections that seem to be getting better, it may be reasonable to wait until their next check up to look at those ears again. Most of the time, parents’ judgment is just as good as a repeat ear exam.

Finalnd!

 

Acute Flaccid Myelitis: A reassuring primer for parents

November 14, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Nina wrote in: “Hi Dr. Roy. There has been a lot of discussion in the media lately around acute flaccid myelitis (AFM). This I am sure as it is for many parents is terrifying, especially when you are a card carrying vaccination parent (which doesn’t matter in this case from what I understand)! Any insight you can provide here would be so much appreciated.”

AFM has been in the news a lot lately, typically with breathless click-bait headlines.  The Washington Post, never stingy with words, came up with “A mysterious polio-like illness that paralyzes people may be surging this year.”  Huffpo’s headline was more direct: “A mysterious neurological condition is paralyzing children” The antivaccine sites (to which I will not provide links), predictably, blame it on vaccines, because they blame everything on vaccines. Which is ironic, because we’ve been able to prevent almost all historical cases of this condition with vaccination. It’s a funny world, sometimes.

Anyway: there’s no need to panic. While there’s more to learn about AFM, it’s not as mysterious as these headlines would lead you to believe – and it’s really rare.

 

What’s AFM, anyway?

AFM (Acute Flaccid Myelitis) is a disease of the nervous system. Inflammation causes damage to one section of the spinal cord, leading to weakness of one or more extremities. Sometimes, the weakness affects muscles in the head or neck. There’s typically no changes in sensation like numbness or tingling. The brain is not affected, so there aren’t symptoms like fuzzy thinking, seizures, or coma.

The words in the name AFM describe its key features: it’s Acute, meaning it starts suddenly; it’s Flaccid, meaning muscles are weak or floppy; and it’s a Myelitis, meaning there’s inflammation of the spinal cord.

 

What causes it?

Historically, almost all cases were caused by polio. 60 years ago, poliovirus infected about 60,000 children per year – thousands of whom became paralyzed. Polio has been entirely eradicated in the US and in most of the rest of the world. But until it’s 100% gone, we need to stay vigilant and keep vaccinating. We know that interruptions in vaccine programs have led to the return of polio to areas of Africa and Asia – and polio could come back here, too.

Though polio itself is not causing any of these AFM cases in the United States now, poliovirus has cousins – other viruses in the enterovirus family. One that seems to be associated with many cases of AFM is a relatively new enterovirus, called D68. Other new or “newish” viruses can cause AFM, too, like West Nile Virus. And some cases seem to be associated with other well-known or common viruses, like adenovirus.

 

That sounds kind of weaselly. How can one disease be caused by different viruses? And what’s with the “seems to” and “associated with” stuff? I just want a straight answer!

Medicine is messy sometimes, and often there are multiple causes for similar conditions. The common cold can be causes by dozens of different viruses (rhinovirus, coronavirus, human metapneumovirus, and many others), and pneumonia can be causes by a whole slew of viruses, bacteria, or even fungal infections. It would be simpler if we said that there was one cause of AFM, but it wouldn’t be true.

And those “seems to” kinds of phrases – that’s what happens when we’re accurate. Some cases of AFM will occur in children who have a definite viral diagnosis, but sometimes the tests are done too late to know for sure what the cause was. That doesn’t mean we’re completely in the dark, or that this is a huge mystery illness.

 

Who is catching this? How serious is it?

Children, mostly. So far in 2016, 89 people have been reported with AFM nationwide, mostly in the western states, and most cases have occurred in kids (average age, about 7.)

The best long term data we have on the outcome of AFM are from a case series from 2014. Though there we no deaths, many of the children did not have a return to normal muscle functioning. Supportive care has helped prevent complications, but so far no specific therapy has seemed to help these children recover.

 

What should parents do?

Don’t panic. Take a break from media and Facebook, and spend some time playing with your kids instead of reading about the Next Big Danger.

Though AFM remains rare, there are ways to prevent at least some cases. Make sure your child is fully vaccinated (that eliminates not only the risk of polio, but greatly reduces the risk of many other neurologic illnesses, including meningitis and encephalitis associated with influenza, mumps, and other causes). Try to avoid mosquito bites (which rarely can spread West Nile Virus and other causes of encephalitis). Wash hands, use hand sanitizer, try not to be around sick people, keep your children home when they’re sick, and get into the habit of not touching your face with your fingers. I know, that stuff sounds simple, but those are the best ways to keep your children healthy.

More about AFM from the CDC

keep calm

Codeine is not for children

October 31, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Codeine is a terrible choice for treating children’s pain and cough, and we ought to just stop using it. It’s like an old yogurt container, way at the back of your fridge — sure, it was once tasty, and then for a while you held on to it for sentimental reasons. “Remember that yogurt?” you’d say to your spouse. But it’s well past time to throw that stinky stuff away.

For a long time, codeine was thought to be safer than other opiate-based pain medications. It’s a naturally occurring form of morphine with good oral bioavailability (that means you can swallow it in pill or liquid form.) But codeine, the molecule itself, has no biologic activity or drug effect on its own. It has to be converted, in the liver, to an active “metabolite” to have any effect on your body. And that’s the problem: the “activation” step. It turns out that different people have a huge variability in how quickly they activate codeine, which can lead to all kinds of problems.

Some people are “fast metabolizers” — meaning they very rapidly activate codeine. If you’re one of these people, the effects and side effects of codeine will be much higher than expected. There have been about 64 cases of severe respiratory depression reported in children taking “normal” doses of codeine, and many of these children died.

On the other hand, some people are “slow metabolizers”. They can take a dose of codeine, and their liver just sits there, twiddling its liver thumbs. Nothing happens. There’s no therapeutic effect of even very high codeine doses in these people, because their bodies don’t activate the drug.

A slew of international smart-guys has already begun to limit the use of codeine, especially in children. The US FDA slapped a black box warning against its use in post-op children, the Europeans issued a report suggesting that we stop using codeine entirely in children less than 12, and Health Canada even joined the fun, calling codeine “a big hoser of a mistake, eh?”

So, if not codeine, what else can we safely use to treat serious pain in children? Oxycodone (found in Percocet and other products), should have much less variability, though there will still be some added risk to fast metabolizers. The best option, really, might be to go back to using straight-up morphine, but there aren’t great studies looking at its absorption in children.

Non-opiate pain medicines work well, too — in many cases, as well as opiates, if used correctly. These medications, including acetaminophen and ibuprofen, can very effectively relieve even serious, post-op pain, if they’re given in advance and on schedule. Even if they can’t relieve pain completely, they can be used to reduce the doses of opiates needed. There are also IV preparations of acetaminophen and some NSAIDs.

We also need to be very careful about the kind of pain we’re treating. Acute serious pain, from surgery or a broken bone, can and should be safely treated with a combination approach that often includes opiates in the short run. But chronic or recurrent pain (including backaches and migraines) should not be treated with opiates. In the long run, these medicines actually increase the body’s sensitivity to pain, potentially leading to a cycle of dependence and addiction.

Sometimes, codeine is also used as a cough suppressant. The same risks for high- or low- metabolizers are there, and in fact there are no studies showing that codeine is even effective for cough in children. You’ve got all the risk for potentially zero benefit.

Codeine is an old medicine that’s way past its prime. We’ve got better drugs to choose from. If your doc offers a codeine prescription for your child, it’s time to say “no.”

Mmm codeine