Archive for the ‘Medical problems’ category

Swings, slings, and car seats are not for sleeping

May 28, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

An April, 2015 report from the Journal of Pediatrics graphically illustrates the dangers of babies sleeping in gizmos not designed for sleep.

As I’ve written about before, the American Academy of Pediatrics has established specific guidelines on the safest ways for healthy babies to sleep. I last reviewed them in detail here. In summary, babies should always be put down on their backs to sleep on a firm, flat surface, like a crib or bassinet. Baby sleep positioners that hold an infant in place are a bad idea. Things that hold babies in an upright or semiupright position, like the Fisher-Price Rock ‘n Play Sleeper, are also a bad idea. Why?

They’re dangerous because little babies have big, heavy heads, and they lack the strength and muscle control to protect their little baby airways. If their heads fall forward, or their necks get entangled in a strap, they can die.

The new report (summarized here) points out that sleep-related deaths are the most common cause of death in infants from 1-12 months of age. The authors reviewed 47 deaths reported to the US government involving sitting or carrying devices, including car seats, slings, and bouncer-type devices.

I’m going to quote a few of the case histories, here. This material is cold and clinical and disturbing. Feel free to skip ahead a bit.

An 11-month-old boy was placed with a bottle in a car seat for a nap at a home day care center. He was covered with a fleece blanket. The chest buckles were secured, but the lower buckles were unsecured. One hour and 20 minutes later, the child care provider went into the room to check on the child. She saw that he had slipped down in his car seat, such that at least one strap was up against his neck, his color was pale, and he was gasping for breath. EMS was called and the victim was transported to a hospital, where he was declared dead.

A mother was attending a breastfeeding class with her 26-day-old son. She was wearing a cloth baby sling that was placed like a sash across her chest. The child was breastfeeding inside the sling. The child stopped nursing and was believed to have fallen asleep. Approximately 10 minutes, later the mother noticed that her son was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. The child was transported to a hospital and pronounced dead.

A 3-month-old boy was placed for sleep on his back in a bouncer. The father buckled the infant into the seat with the restraint belt and placed a blanket on him up to his waist. Ninety minutes later, the father found the victim face down and unresponsive, with his neck over the top of the bouncer. 911 was called and CPR started; the baby was pronounced dead at the scene. The detective related that the victim had apparently rolled over and pushed up to the top of the bouncer by pushing on the blankets.

An 8-month-old girl was sleeping unattended in a stroller at the mother’s workplace. The restraint belt was not fastened. The mother returned to the room after 5 minutes and found her partially hanging out of the stroller, her head wedged between the lower edge of the tray and the front edge of the seat. She was unconscious and not breathing, so CPR was initiated. She was resuscitated but was in a vegetative state, and life support was withdrawn 2 days later.

Some important lessons can be learned from the details of the report. Death can occur quite quickly—deaths in car seats and strollers were reported after a minimum of only 4 or 5 minutes. And they can occur at almost any age, from 10 days old in a sling to 2 years old in a car seat.

About half of the time, car seat deaths were caused by strangulation on unfastened straps. You might think that once a car seat is out of a moving vehicle, it would be safe to undo the straps—but those same straps that are so effective in keeping a child safe in a crash can strangle a baby. Many of the other deaths were caused either by positional asphyxia, with the head falling forward to close off the airway, or by a device tipping over and smothering the baby.

There’s some good news buried in this report, too. There were no deaths using a sling for breastfeeding—only when the babies were sleeping in a sling. And almost all of the car seat deaths were when using a car seat outside of a car. Based on this and other reports, the correct use of a car seat in a vehicle (baby strapped into the car seat correctly, and car seat strapped into the car correctly) is very safe. It’s the unintended use of car seats and other devices as sleeping devices in homes and daycares that’s dangerous. As the authors conclude, “It is possible that most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision.”

When I’ve written about safe sleeping before, I’ve gotten many colorful comments from people who say that their babies have unique health circumstances, and that their own pediatricians have made recommendations that differ from the usual guidelines. (That’s my translation of their comments, which are more-typically worded “You are an idiot.” or “How dare you question the advice of my pediatrician who has won a Nobel Prize and you are an idiot.”) The AAP sleep guidelines are for routine, healthy babies. If you think your babies need to sleep in a manner different from the typical guidelines, I suggest you speak their pediatricians about it, as soon as they return from Stockholm.

Delaying vaccines is not a good idea

May 21, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

I get asked, now and then, about delaying vaccines. What’s the harm?

#1: An increased risk of disease

There are many, many studies that have documented less disease in vaccinated individuals. Here’s one, just one recent one, from April 2015. Researchers in Israel looked at cases of pertussis in infants from 1998-2011, comparing the infants who had documented pertussis to a sample of infants who didn’t catch pertussis. Pertussis cases were more likely to be either unvaccinated or have fewer vaccines – a “delayed schedule” – than babies who got their vaccines on time.

#2: An increased risk of side effects

Several studies have shown this, too. Here’s an example: a 2014 study from several US centers showed that children who got their MMR vaccines late were about twice as likely to have seizures after vaccinations than those who got their MMR on time.

 

Let’s see. Increased disease, increased side effects. Still, we need to look at both the harms and the benefits to make an informed decision. So, for balance, what are the benefits of a delayed vaccine schedule?

There are none. Not one. Nada. It’s not safer, it’s not easier. It’s not better in any way. There are no benefits of delaying vaccinations.

So: delaying vaccines offers no benefits, and significant, objective risks. It should be an easy choice. Keep your children safe. Make sure they get their vaccines on time and on schedule.

 

Whooping cranes! Get it?

Guess what kind of birds these are

Other recent vaccine links:

An anti-vax mom learns a lesson when all 7 kids get pertussis

The benefits of measles vaccine are far more than preventing measles

 

 

Recurrent wheezing in preschoolers

May 18, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Maura wrote: “I’d appreciate a post on treating and understanding intermittent asthma (viral induced) in preschoolers. I’m currently very confused about whether the risks and benefits of treating with inhaled steroids are well established.  I’m also confused about what the literature means when they say ‘exacerbation’ of asthma.  Thank you!”

Hoo boy. This is one of those questions that would get different answers to if you asked a room full of pediatricians. Different answers, and arguing, and maybe a thrown chair or two.

Heck, we’re not even sure if we should call this asthma. So I’ll back up to what we all can agree on, first.

A “wheeze” is a specific physical exam finding. It’s a whistly, almost musical sort of chest noise, the noise you hear when air tubes are constricted. Most (but not all) wheezing is heard during expiration. Children who are wheezing almost always cough, and cough is the main symptom of most wheezy illness. It makes sense—the airways are constricted, so the body tries to “pop” them open with a forceful expiration. Coughing can open airways and at least temporarily relieve the airway constriction and wheeze.

Lots of health conditions cause wheezing, and at least 25% of children will wheeze at least once. Mostly typically, it’s caused by a viral infection. Whatever you do or don’t do to treat it, the noise will go away and Junior will stop coughing. But recurrent episodes of wheezing, that’s when things get interesting. And controversial.

In older children, school age and up, the most common—by far—cause of recurrent wheezing is asthma.  These kids usually have multiple triggers for their wheezing, including allergies, infections, cold air, and exercise (not all kids will have all of these triggers). Albuterol is the mainstay medicine to quickly stop wheezing and coughing once it starts. Inhaled steroids are the best medicine to use to prevent wheezing flare-ups (called “exacerbations”—that’s when kids with asthma have symptoms like coughing, wheezing, chest pain, and shortness of breath.) Inhaled steroids as preventive medicines work and they’re safe. Kids with asthma who use daily inhaled steroids have far fewer exacerbations, miss less school, and stay healthier.

But there’s another group of children in whom the usefulness of inhaled are less clear-cut. These are toddlers and preschoolers, little kids, who have recurrent wheezing episodes only triggered by one thing: viral infections. They get a cold, they start to wheeze. These kids seem to respond less robustly to both inhaled albuterol (which, especially in the youngest children, may not work at all), and less well to inhaled steroids, too.

Some people don’t even think we should label these little ones with recurrent wheeze as having asthma, because that can mislead us into using treatments that are less effective. A suggested label is to say these children have “WARI”, or Wheeze Associated with Respiratory Infections. Some docs say these kids have “RAD” or reactive airways disease, or “recurrent bronchitis”, or “viral pneumonia”, or recurrent “bronchiolitis”.

What makes this especially difficult is that we can never tell, from the first or second wheeze episode, if a child is going to end up with asthma (recurrent wheeze of many triggers) versus WARI (recurrent wheeze only triggered by infections.) Some suggest we look at family history, or whether the child has eczema or food allergies, but that history doesn’t reliably predict the future course of wheezing. What we really need is some kind of test or biomarker to predict who will really benefit from inhaled steroids. We don’t have any great way to know.

Inhaled steroids are safe, at least in ordinary low doses. In higher doses some growth suppression can occur, though that may disappear with long-term use. And we know out-of-control asthma, with frequent wheezing, will also stunt growth.

As always, risks and benefits have to be weighed. If a young child has infrequent flare-ups easily treated with albuterol I’m less likely to suggest a trial of an inhaled steroid; but if flare-ups are frequent or severe or land a child in the emergency department, daily inhaled steroids are worth a try. There’s some art here, and a lot we don’t know, and plenty of room for discussion between doc and parent about what’s best for each childs’ circumstances. The chair throwing, that’s optional.

I feel a song coming on!

I feel a song coming on!

Limes plus sun = burn

May 14, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

If life gives you lemons, make lemonade. But if life gives you limes, especially on a sunny day, what you might make is a big, uncomfortable burn.

Limes contain chemicals that can sensitize the skin to the ultraviolet spectrum of ordinary sunlight. It isn’t an allergic phenomenon, though it kind of looks like one. Areas of skin that have touched limes or lime juice and are then exposed to sunlight can react as if it has been burned. The visible reaction starts about 24 hours after the exposure, and is worsened by heat and sweat.

I’ll link to some photos, rather than paste them directly here. Some are icky. The skin reaction is often shaped like drips or a splash, and often affects the hands and upper arms.

The proper name for this reaction is phytophotodermatitis (plant-light-rash). I’ve also seen it called “lime disease” (get it?! And who said dermatologists weren’t funny!) or “margarita sunburn.” Other plants can cause the same reaction, including celery (mmm celery margarita) and several weeds.

If you’re chopping or cutting or squeezing limes, don’t do it in the sun. Do it in the kitchen, then wash your hands with soap and water before you go outside. Don’t let “lime disease” ruin your summer!

AT Sir Isaac Lime

Don’t banish kids with lice

May 11, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A new clinical report from the American Academy of Pediatrics is a rare beacon of coherent thought about lice and children.

Rather than humiliating children and driving them away like lepers, the AAP recommends common-sense steps to identify and treat lice. Some facts really shouldn’t be in dispute:

  • Lice is not a serious illness or a significant hazard to health. They don’t make anyone sick, and they do not spread any disease.
  • Lice is not a sign of poor hygiene or parental failure.
  • Lice cannot jump or fly from person to person—they’re only transmitted by close and prolonged personal contact.
  • Transmission via objects—combs, hats, and pillowcases—is uncommon.
  • Most lice transmission occurs in neighborhoods and households, not in schools.

Nonetheless, a case of lice in a school seems to cause hysteria and panic. Children are marched through the “nurse’s office”, examined by a (sometimes) poorly trained parent, and sent home—usually because of a few flecks of dandruff or debris. Most kids sent home because of lice don’t even have them. Parents miss work, kids are humiliated, and households are turned upside down with washing and spraying and vacuuming and combing and worrying. There are whole industries, now, of people who can comb your child’s hair or use special treatments guaranteed to rid them of the pesky varmints.  To treat what is, at most, an itchy scalp.

Here’s what parents should keep in mind when they suspect their child has lice:

  • Lice are not difficult to diagnose. They run around the scalp. Look. If they’re there, you’ll see them. You can also “catch” them on a comb.
  • Lice are not little fluffy bits of fuzz or little flakes of nothing.
  • Lice eggs (nits) look like sesame seeds, and they’re literally glued to individual hairs, down near the scalp. The live ones, ones that will hatch, are within ½ inch of the scalp. Any nits further out are dead or already-hatched.
  • OTC lice treatments (like “Nix”) work very well when used as directed. Repeat the treatment in 9 days to kill newly-hatched eggs before the little ones have a chance to mature and lay more eggs.
  • Most treatment failures are from improper use, failure to repeat treatment, or from re-infestation. True resistance to OTC products does occur, but it is not common. The people yelling about resistance are usually the same people who are trying to sell you something.
  • Combing can help treatment work (by dislodging viable eggs and removing live lice.)
  • Nit removal is not necessary for effective treatment, but some misguided schools insist that a child be nit-free before returning. That’s stupid, and it’s not recommended by legitimate health authorities. But, hey, I don’t make the rules.
  • It’s prudent to change and wash pillowcases—though even that is probably not necessary, as only 4% of pillowcases harbor live lice, even when someone with lice sleeps in the bed. Live lice cannot live off of a warm body for very long.
  • Consider washing items that have recently (within 2 days) come in contact with a child’s head, like hat or hair accessories, but exhaustive and widespread cleaning and vacuuming efforts are not needed. Widespread use of chemical sprays in the house is dangerous and unnecessary.

Most importantly, as the AAP says, it doesn’t make any sense to exclude children with lice or nits from school. That doesn’t decrease transmission, and it doesn’t prevent any important illness. Children with lice should be (correctly) identified and (correctly) treated, but they don’t need to be embarrassed, excluded, or humiliated.

Lice can make you or your child itch, and that’s not pleasant. But, really, they’re just another thing that you shouldn’t worry about. Safe treatment isn’t very difficult, and it usually works. It’s only our own sense of ick that’s turned lice and lice-removal into a Big Deal.

Now, excuse me while I scratch my head…writing this has made me itchy.

Full report from AAP on head lice

A tired traveling two-year-old, exercise and weight loss, and a big-tonsilled tooth grinder

May 6, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

I’ve been writing a follow-up course to my first video lecture series, and falling behind on blogging. Never fear! Once this baby is taped I’ll be back here, full time. Or nearly full time—I have a job, too, you know. For today, I’ll post a bunch of brief answers to questions that have been sent in lately. Keep the questions coming, I’ll get to them eventually!

 

“Graham is 2 ½, and every time we travel and he sleeps somewhere other than his crib, he goes crazy. Even if we do his same routine at home (and have even tried packing up his crib to bring with us!), he takes hours to go to sleep, and usually wakes up in the middle of the night screaming and nothing will calm him down. My husband usually ends up driving around with him in the car all night. I keep thinking he will outgrow it, but at almost 3, it is still happening. Any ideas of what we could do to help him sleep so we can still travel?”

Graham sounds like he likes his routines. And I’m not so sure you’ll be able to perfectly recreate his home setting and routine when you’re on the road.

Instead, it might help to start the process even before you travel. Have him start sleeping in his travel crib or pack n play a week or so before the trip, or mix things up in other ways—maybe move his crib to another part of the room, or even into a different room. Try to make it a fun adventure! Let him choose what “crazy place” to sleep at night. Maybe then the broken routine when you travel won’t seem as jarring.

 

“I’ve seen reported in the media recently that exercise doesn’t help with weight loss so there’s no point in even trying.”

 Whether or not exercise helps with weight loss, it’s still a good thing to do. People who exercise improve their cardiac and metabolic risks—think less diabetes and fewer heart attacks– whether or not they lose weight. Exercise helps sleep, prevents depression, decreases stress, and has turned me into the glistening man-hunk that I am (OK, I may have exaggerated that last point a bit.)

And: exercise can help you lose weight, too. You just have to not eat more when you do it.

 

“My 10 year son has been a super nighttime teeth grinder for as long as I can remember.  He also has very (naturally) large tonsils.  The dentist today said that the grinding is likely because his airway is partially obstructed when he sleeps and he’s trying to get air, and referred me to an ENT to have his tonsils removed.”

 There does seem to be an association between sleep-disordered breathing—loud snoring and pauses caused by upper airway obstruction—and teeth grinding (AKA “bruxism”). In a 2004 study from Brazil, about half of 69 children referred to an ENT group for adenotonsillectomy had bruxism; after surgery, the percentage dropped to 12%. If your child has large tonsils and sleep-disordered breathing, tonsillectomy may improve the teeth grinding. An ENT eval is a good idea.

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. 


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