Archive for the ‘Medical problems’ category

When polio was wild

September 12, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

“Polio. I’ve seen polio.”

Last night, I was speaking with one of the most experienced pediatricians I’ve ever met, Dr. Jack Burstiner. I’ve known him for 50 years. I would have known him even longer if I had been born earlier. He lived in my neighborhood, two doors down. He was my pediatrician.

Jack is almost 90 years old. But he still looks like a pediatrician. He’s got a smile a child could trust, now hidden under a white mustache. His green eyes twinkle when he talks about his patients, the kids he’s seen. There are some things about a pediatrician that never change.

Though he stopped practicing in the 1980’s, Dr. Burstiner worked for 30 years in pediatrics, at a time when pediatricians did everything. Hospitals, emergency departments, newborn deliveries, everything. And in 1955, just starting his training, Dr. Burstiner was a pediatric intern at Kings County Hospital, Brooklyn. It was a busy hospital, sure, but it was especially busy in the summer. Polio season.

“That’s where they’d all come, the kids with polio. They didn’t look right. They’d be dragging a leg, or not moving right. Sometimes an arm wouldn’t move, but usually a leg. And all night, every third night, I admitted all of them. It was just me. I’d do the spinal tap, and I’d look in the microscope, and I’d count the cells. If they had a lot of cells, that was polio. Of course we knew it anyway, but we had to tap all of them to be sure. All night long.”

Polio is caused by specific virus, an enterovirus that circulates especially in the summer and fall. It’s spread by contaminated water, sometimes in swimming pools or from unsafe taps, or from household contamination via stool. Most kids with polio develop a fever and then recover, but many develop paralysis of their skeletal muscles. It doesn’t affect their thinking, or their ability to feel sensations or pain. But it can make it impossible to walk or use other muscle groups, and can sometimes shut down the muscles that keep them breathing.

“It’s funny,” Dr. Burstiner said. “It was a big hospital, and upstairs – up above the emergency department, and the wards, the rooms the patients – upstairs were some of the smartest people in the world. They had dedicated their whole lives to fighting polio, and they knew all about it. But we still couldn’t really do anything to treat it. I was there, this intern, and I could tap them and I’d admit them, and then hopefully they’d keep breathing.”

In 1955 there were about 29,000 cases of polio in the United States. Dr. Burstiner estimates he admitted about 100 of those, ten a night, on the every third overnight he worked at the Brooklyn Hospital for one month during that hot summer.

“100 cases, I think I admitted, just in that one month. And all of those smart people upstairs, what could they do? But you know what happened next? The vaccine came out, and everyone wanted it. And in just a few years, it wasn’t 100 a month in one hospital. There wasn’t any, there was no polio anymore. I saw more polio in that one month than there was in the entire country, just a few years later.”

The first polio vaccine was introduced in 1955. By the mid-sixties, there were fewer than 100 cases of polio per year in the United States. We beat it. There have been zero cases of polio transmitted in the US since 1979; the last imported case to reach our shores from overseas was in 1993. There are still pockets of polio transmission, but it’s very possible the disease will be wiped off the earth entirely in the coming years.

Dr. Burstiner and I talked a while more, trading war stories, talking about cases. I’ve never seen polio, but I have seen children die of pneumococcal meningitis, and I’ve seen complications of chicken pox that put children in the ICU for weeks. Those are some of the diseases I may have the pleasure of never seeing anymore. Maybe someday I’ll tell the next generation of pediatricians about how we knocked out rotavirus diarrhea, and HIB septicemia, and HPV-related cancer. Measles, diphtheria, hepatitis A and B, we’ve got the tools to beat these and other diseases. We just need the will to see the fight to the end.

There’s a lot that hasn’t changed. Parents still worry about their kids, and kids still get sick. But there are many diseases that parents just don’t have to worry about anymore. That’s incredibly good news for you and your family. Protect your children, protect your communities, and help be a part of making the world healthier for the future. Vaccinate.

Advertisements

ADHD meds don’t help students without ADHD

September 4, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

College students work hard, and many are looking for ways to improve their studying and learn more effectively. Getting more sleep and more exercise would probably help, but up to a third are trying ADHD medications to see if pills can give them that extra boost. A small, recent study shows that they’re not getting the effect they’re looking for.

We’re not talking, here, about teens who have ADHD. There’s robust evidence that medical and non-medical therapy helps people with ADHD stay focused, and medication can help them succeed. But what about the far-larger number of college students who don’t have ADHD. Can they benefit from the same medications?

Researchers at two universities in Rhode Island – a tiny state, but they’ve got 12 colleges overall – picked 13 healthy student volunteers to take tests of their cognitive ability, memory, and other academic measures. They took these tests in a random order on 2 different days. But on one day, they also took the commonly-used ADHD medication Adderall at a nice hefty dose of 30 mg. On the other day, they received placebo. The researchers were then able to compare the differences in their performance.

Some things did change. On Adderall, blood pressure and pulse were higher, as were self-reported positive emotions and energy. However, there were very small effects on actual cognitive or thinking ability, with some small positive and some small negative effects. Working memory – the ability to recall information – was much worse with the medication. Overall, Adderall did not help these college students study better or learn more.

This was a small study, with only 13 subjects. But the results are striking. On college campuses, medications like Adderall are being used both as study aids and as a way to stay up longer and party harder. But they’re not without risks, including depression, psychosis, weight loss, and addiction. These are serious medications, and while they can have a role in helping some people, they ought to be only used when necessary, under medical supervision.  They’re not for everyone, and especially not for most college students looking for a way to improve their grades.

Urgent care centers lead the way in unneeded antibiotic prescribing

July 23, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Urgent care centers are way ahead in prescribing unnecessary, potentially harmful antibiotics that are doing no one any good – at least no patients any good. The owners of the urgent care centers are the ones who are benefitting. And you and your family are being bilked, misled, and harmed.

A July, 2018 study published in JAMA Internal Medicine looked at the proportion of antibiotic prescriptions that were made for viral respiratory infections – things like the common cold and bronchitis. These are viral infections, caused by viruses (sorry if I’m hammering that too much – but obviously it bears repeating.) The researchers looked at over 150 million visits to emergency departments, urgent care centers, retail pharmacy clinics, and medical office visits to compare the rates of inappropriate prescribing between these settings.

Why is this important? Because antibiotics will not help anyone who has a viral infection. But they can lead to allergic reactions and serious complications like C. difficile colitis. They also contribute to antibiotic resistance, or the emergence of so-called “superbugs” that we can’t kill with any antibiotics. This is not just a theoretical problem – it’s a huge a growing nightmare occurring in hospitals all over the world. Some bacteria have figured out how to evade all of our antibiotics, and it’s entirely our fault.

Big differences were found in the rates of inappropriate antibiotic prescriptions. In ordinary medical offices, 17% of respiratory viral infections were treated with antibiotics. That’s way too high, and we need to work on that. But even worse: emergency departments prescribed antibiotics for about 25% of these viral infections. And topping the list was urgent care centers, where 46% of viral respiratory infections were treated with antibiotics. That’s about three times as bad as regular office visits.

The best prescribing habits – and they deserve credit for this – was found at the retail pharmacy clinics, at about 14%. They often use protocol-driven clinical pathways which leave little “wiggle room” for the nurse practitioners that usually are on staff. I’ve been critical of these quick-minute-clinics before, and I still don’t think they’re a good place for children to be seen, but give them credit for not throwing around antibiotics.

But those urgent care centers – why are they so quick to write for an unneeded and potentially harmful antibiotic? Though this study didn’t look at potential reasons, one potential driver may be profit. Urgent cares may be especially quick to write antibiotics because they make more money that way.

Some urgent care centers sell the antibiotics (and other medicines) that are prescribed, so there’s a direct profit there. But more commonly, antibiotics are prescribed because it’s a quick way to give patient what they want, to get them out the door so the next patient can be seen. It takes much more time to explain why an antibiotic isn’t needed than it takes to write the prescription. And writing that prescription seems to feed a cycle of dependence – now, the patient thinks every cough needs an antibiotic. Repeat business!

It’s not just antibiotics that fly off the shelves at urgent care centers. They make money from lab tests and x-rays, too. I spoke with one urgent care center physician who had this to say:

Our pay was a small base compensation and all the rest was a percentage of our billing. The more patients you saw, and the more lab, x-ray and meds you ordered, the more you got paid. Plain and simple. So not only was prescribing an antibiotic lucrative, not wasting time explaining why was also lucrative.

Now, many urgent care physicians are good doctors who genuinely want to help people. And it’s convenient to have them nearby for quick visits. But their employees may be under financial pressure to over-prescribe and over-test – and that can affect the care that you get.

How can you protect yourself?

  • Tell the physician, plainly, that you don’t want an antibiotic if it’s not needed. The doctor may be assuming incorrectly that everyone wants a prescription. Tell her that’s not the case.
  • Have reasonable expectations about ordinary illnesses. Coughs and cold symptoms rarely need antibiotics, even when they make you feel miserable. Most sore throats are caused by viral infections. We know you want to return to work and feel better, but an antibiotic isn’t going to help.
  • Use your primary care physician’s office as your main site of care. Get to know your doctors, and let them get to know you as someone who isn’t there just to get a prescription. If your own doctor is one of those that’s quick to prescribe, think about why that might be the case, and think about getting a new doctor.
  • Prevention is key! Wash your hands, stay away from sick people, get a good night’s sleep, and get all recommended vaccines. Remember, immunizations are the real immune boosters.

Earlier:

Keeping the world safe from antibiotics

Fighting back the superbugs

Essential oils – aroma OK, but not for ingestion

July 12, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Anjelika wrote in:

Hi there Dr. Benaroch, I would first just like to thank you for all of the valuable information you have provided over the years (and also the laughs) for so many of us – it means a lot! I was wondering if you had any opinions on essential oil diffusers around babies and toddlers since I have a 3 month old and a 29 month old. I’m only interested in making my house smell good (not looking for topical use or ingestion), but I want to be sure it’s not dangerous for them to be breathing it in.

Anjelika, not to worry. Hypothetically, I suppose a child might be allergic to the volatile aromatic molecules (technically, the “stinky bits”), or some might object to the odor if it’s strong. But smelling essential oils diffused in a room ought to be safe, as long as you’re not talking about gallons of the stuff sprayed about.

Be wary of the diffuser, though. You don’t want kids drinking the oil, or getting their hands on a warming element. Just keep whatever it is that spreads the smell, and its electric cord, up out of the reach of little ones.

Previously: Essential oils: When shady marketing and quackery meet

How to get your child to poop on the potty: The Poopy Party

May 29, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Julie’s 3 year old son uses the potty great—at least for urine. For poop, well, he’d prefer to use a diaper. What she needs to know about is the poopy party, and how to create some fun and excitement to get her child to take that last step!

Keep in mind: there are three ironclad rules of parenting. You can’t make ‘em eat. You can’t make ‘em sleep. And you definitely can’t make ‘em poop. Kids can hold their poop for a shockingly long time when they’re feeling stubborn, and you may end up with a very stubborn child if you try to force her to poop on the potty. So no forcing, no punishing, no humiliating, and nothing at all negative is going to work if you want your child to be successful on the potty.

Fortunately, all kids inherently want to succeed and learn new things. As soon as they’re sure you’re not pushing, and they start to get an inkling that—hey, this is the way to go!—they’ll do it. For kids who are a little late to the party, here’s one way to jump-start the process.

 

“The Poopy Party”: A method to encourage using the potty for stool

This works best at age 3 and above. It’s important to “ham it up” and really play with this to create a sense of fun and excitement about the potty. At no point should you be direct—never say “Don’t you want to use the potty now?” The point is to create excitement, but only to indirectly talk about what the potty is for.

You’ll need: a willing parent or caretaker, two hardhats, two bright orange construction worker vests, and two big chunky flashlights. Feel free to add in some kind of wrench looking thing, and a tape measure, and whatever other mechanical-plumber sort of equipment inspires you. If you want, you can involve your child in a trip to the tool store to load up on your equipment.

The parent puts on an outfit with hat and vest, then (while dressed up!) goes to get the child so she can put her set on. Child and parent have both got their own big flashlights, vests, tools, whatever. Dad or mom says something like, “Something’s up with the toilet, we’ve got to get it fixed so the poop can go to The Poopy Party!”

Don’t talk more about The Poopy Party…yet. Let the excitement build!

Then go to the toilet and take it apart, or as much of it as a parent feels comfortable putting back together. Talk about the parts, the flusher, the bobber thing, the insides, and where the poop goes down. Then, if you can, go to the basement and pull down some tiles, and shine your light along the big drain pipe all the way outside the house. Go out to the street and pull off a manhole cover (or the utility cover over the water main, or just peer down a storm drain) and shine your lights down there. Then talk about The Poopy Party. Yep, that’s where the poop goes, down there. There’s dancing and singing, and it’s a great place for poop to go!

If you want to go a step further, take the child to the county wastewater treatment plant. You’ve got to keep the hardhat and vest on. Explain there that you want to show your child where the poop goes. Then check out the big tanks and turbines and other fascinating things. Then go out for ice cream.

Afterwards, hang up the vest in the bathroom where the child will see it, but – and this is very important – do NOT talk about this any more. You set the stage, make it exciting, but do not remind or suggest. Anything like that will further delay potty success.

And be prepared, once she’s using the potty, to bring the vest everywhere you go.

 

Adapted from an earlier post

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

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.