Archive for the ‘Medical problems’ category

Is burping really necessary? Grandma versus science!

August 22, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Ann wrote in: “My baby doesn’t burp easily – sometimes she doesn’t burp at all. Trying to make her burp makes her upset. Do babies really need to be burped after nursing?”

A fair question. Generations of parents have been burping their babies, and it seems like something we probably ought to do. I mean, it’s uncomfortable to have un-burped gas in your belly, right? And gas there probably causes fussiness, and maybe makes babies spit up, right? Not only does it make sense, but that’s what Grandma has been saying. Could Grandma possibly be wrong?

Let’s see what science says. There was a study of this exact question, published in 2014 in the journal Child: Care, Health and Development. A group including nursing and pediatric specialists from Chandigarh, India took on the Grandmas in their publication, “A randomized controlled trial of burping for the prevention of colic and regurgitation in healthy infants.” Their conclusion: “burping did not significantly lower colic events and there was significant increase in regurgitation episodes.” Yikes!

It was a simple study design, the kind I like best. 71 babies were randomly placed into two groups: an “intervention” group, where moms were taught burping techniques and told to burp their babies after meals; and a “control” group, where mom were taught other things about parenting, but were not taught about burping. The babies were all otherwise healthy, ordinary term infants, enrolled shortly after birth. They were followed for three months, with the families recording crying times and the number of spit-ups (regurgitation.)

The results: the amount of crying in each group was about the same. Burping did not prevent “colic”, or excessive crying. When comparing the episodes of spit-up, the “burping” group had approximately twice as many spit up episodes as the non-burped babies. So: burping had no effect on crying, and actually made spitting worse.

There are some important limitations. The study was done in India, and the conclusions might not be the same in babies from other parts of the world. Also, the intervention wasn’t “blinded” – for practical reasons, the parents knew if their babies were in the burping group. Still, the conclusions were statistically strong, and I think they’re probably correct.

Will this convince anyone to stop burping babies? Probably not. But I would say, for Ann, if burping makes your baby upset, there’s no reason to keep doing it. For the rest of you: you’ll have to settle this with Grandma, yourselves. I’m not getting in the middle of it!

Ogre belches are the worst

Die, rumor, die! Offgassing is not the cause of SIDS

August 11, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Leah wrote in: “I was wondering if you could shed some light on mattress wrapping to prevent off gassing and the New Zealand SIDS statistics. If there anything to this?”

Like a zombie rising from the grave to eat your brain, the “offgassing” hypothesis of SIDS is one of those rumors that just won’t stay in its grave. We can thank the internet for its unique ability to keep obviously wrong ideas alive, forever and ever. Every once in a while, someone stumbles on hoary old posts and “news” stories, reposts them on Twitbook or Faceter, and the idea arises again. There has got to be something better for all of us to be doing with our time!

It all started in 1989 when someone claimed that he had figure out the cause of SIDS. It was chemicals (fire retardants) used in crib mattresses, interacting with a fungus that released toxic gases. I’m not linking the sites that claim this, because I have no wish to perpetuate the rumor– if you want to find out more, Dr. Google will be your willing ally for your adventures. You’ll see that there are several sites that all reference each other, rather than any substantial published studies; many sell special mattress wrappings to keep the Evil Gasses at bay. You’ll see claims that no baby ever dies on a specially-wrapped mattress, and that the government and doctors has been hiding these statistics (because, presumably, we’re all in the pocket of “big mattress” and “fire fighters”.) You’ll also see claims, on those same sites, that HIV doesn’t cause AIDS and other, shall we say, “colorful” health beliefs. Seriously, if you do end up Googling this, you’ll want to put on a fresh tin foil hat first.

The facts of the matter are summed up here, in a document from First Candle. They’re a non-profit dedicated to fighting SIDS and providing support for grieving families. They point out some simple facts: the rate of SIDS dropped after “The Chemicals” were added to mattresses to prevent fires;  the fungus claimed to be associated with SIDS is almost never actually present in any mattresses; wrapping mattresses has never been shown to prevent SIDS, babies have in fact died on wrapped mattresses; and SIDS occurs at a similar rate in countries that do and don’t use flame-retardant chemicals in mattresses. There’s more to it, including summaries of multiple, well-funded investigations into the theory, but you get the point: there’s just no evidence, whatsoever, that toxic gasses from unwrapped mattresses are killing babies. Those that support the theory are not telling the truth.

There’s been good progress fighting SIDS in the 25 years since the “offgassing hypothesis” appeared – we now understand a lot of ways families can protect their children, and SIDS rates have fallen dramatically. This idea wasn’t an unreasonable hypothesis when it was proposed, but studies haven’t backed it up. It’s time for the Toxic Gas idea to stay buried and forgotten.


Olympic health update: Zika, a broken leg, and bruised athletes swimming in poo

August 8, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

In case you missed it: in between commercials, NBC has been showing snippets of American athletes kicking butt in Rio. I believe there are other countries competing – I saw them on opening night, warming up for the all-important Taking Selfies event – but multiple health scares have apparently sent many Olympians from non-NBC-watching countries into hiding. And who can blame them? Rio may not be the safest place for anyone right now.

There’s Zika, of course, a virus spread by both mosquitoes and sex. Brazil’s got plenty of both. Gisele looked stunning in her prolonged demonstration of a slinky mosquito-repellent dress.

The swimmers have their own problems to face, especially Michael Phelps (who may be the only swimmer there, as far as we can tell.) Many are covered with round bruises from “cupping”, a skill discovered by countless preschoolers who’ve sucked cups onto their own faces to make funny snouts. Or maybe the marks are from TV producers beating them away from Michael Phelps so they don’t get in the way of the cameramen. Either way, with Michael Phelps on the team, they’re sure to win the men’s relay, sweep the dressage events, and maybe get featured in the next Hardee’s commercial as a burger topping.

There are added challenges for the outdoor swimmers in their featured “sewage” events. Athletes have been told to swim “as fast as possible, without breathing much, clenching shut your mouth and any other possible openings. Including that one.” Fortunately, Michael Phelps has been able to evolve a blowhole.

At the gymnastics arena, the world winced, looked away, and then watched repeated replays of French vaulter Samir Ait Said’s leg bend in a way that a leg should never bend. Is it possible that athletes are being pushed beyond the limits of what a human body can do? Or is it just a lack of enough kinesiology tape and Swarovski crystals? And what does Michael Phelps say about it?

Dotted Phelps

Garlic for ear infections? Think again.

August 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Supermouse wanted to know:

One of my sons recently developed an ear infection, and various people have suggested sticking a clove of garlic in his ear, or garlic ear drops. Of course, we took him to the doctor who prescribed Amoxicillin, which worked quickly and well.

I have a hard time believing that garlic is a natural antibiotic that could be substituted for actual antibiotics. I could believe that garlic has antibiotic properties, but that shoving garlic in your ear (besides just being a bad idea to stick things in one’s ear) would be a poor way to access them.

So…does garlic have an antibiotic properties? Could it be used (in some form, drops into/onto the infection or eating it) to cure an infection?

First: does garlic have antibiotic properties? Can it kill or suppress the growth of bacteria? It makes sense that it would. Vegetables and other things that live and grow have evolved elaborate mechanisms to fight back against anything that wants to kill them. Armadillos have those hard shells, poison dart frogs have poison, and manatees have – well, I don’t know what they have, but considering that their natural predator is the speedboat, what they probably need is some kind of rocket harpoon. Plants, too, have elaborate defenses, like spikes on cactuses, or toxic chemicals that prevent them from getting eaten or infected with parasites and bacteria. Yes, your vegetables are literally loaded with toxins, including antibiotics. Elaborate chemical studies that have confirmed this – multiple substances in garlic do fight bacteria.

But does that mean garlic, placed in the ear, can help fight off an ear infection? Nope, it can’t. It’s a simple matter of anatomy. An “ear infection” – more properly called an “otitis media” – is an infection in the middle ear cavity, behind your eardrum. Unless you poke a garlic clove in far enough to pop the drum and push on through (do NOT do that), garlic placed in the ear cannot get to the site of the infection. Putting garlic in your ear to combat an ear infection is like putting oil next to your car engine for lubrication, or putting food near your mouth to eat it. To fight an infection, an antibiotic needs to be where the bacteria are. And an ear infection is internal, on the other side of your eardrum, where garlic or garlic oil pushed into the ear cannot reach.

But, and here’s the rub: if you put garlic in your child’s ear during an ear infection, will he get better? Probably yes. That’s because most ear infections get better on their own, without any antibiotic at all. You can stick garlic in the ear, or margarine, or a banana, or skinny Aunt Lulu – any of those might seem to work, but none of them will make any difference at all. Still, you’ll see it all over The Internets: I put garlic in an ear, and the infection got better, so yeah. Sorry. That doesn’t prove anything.

Side note: there’s another cause of ear pain, called a swimmer’s ear (or “otitis externa”). This is an infection of the ear canal itself, outside of the eardrum. Hypothetically garlic placed in the ear could reach that surface. But I wouldn’t recommend it. Swimmer’s ears hurt, and hurt bad, and pressing a garlic clove in there may make it hurt more.

Garlic steeped in olive oil sounds like a great spread for crostini, and it might keep vampires away. But it’s not going to help anyone with an ear infection.

The weekend ear pain action plan

Count Chocula

Prenatal screens: Beware misleading results

July 18, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A few years ago, I met a lovely couple at a prenatal visit. Although we usually do these visits in groups, this time we had arranged to get together privately, alone, when the office was closed, when there wouldn’t be other families and children around. I wanted to meet the family, but I didn’t want to be cruel. This wasn’t a typical visit, and I didn’t think they were going to be comfortable sitting in a room full of pregnant women, or a room with children running around. This couple expected their baby to die.

Prenatal screening, the parents told me, had shown that their baby had Trisomy 13. This is a genetic condition involving an extra copy of one chromosome. Most babies who have this do not survive long enough to leave the hospital; the few that do are severely ill, and have multiple health complications. The family had been offered an abortion, but had decided to proceed with the pregnancy. They were well-educated, and certainly realistic – though they had hope, they knew that there was very little chance that their baby would do well. Still, that was the chance they wanted to take. They had heard that I had some experience taking care of children with this condition, and wanted me on board if by some miracle their baby was able to survive, even briefly.

A few months later, Sally was born. And she was normal. She didn’t have Trisomy 13, or really anything else wrong with her, and she was able to leave the hospital in a few days. She’s about 18 months old now, and she’s a great little kid, with red hair, a picky appetite, and a little bit of a temper. Imagine what the parents went through, expecting her to die; and imagine how many parents, told of the grim news, would have elected to abort what would have been a healthy baby.

So what happened? Was the test just wrong? No – the test was done correctly, and the result of the test was, technically, correct. But it was misunderstood, by both the doctors and the parents.

The fundamental misunderstanding was that screening tests are not diagnostic tests. This comes up again and again in medicine, and every week I have to explain to parents why their screening tests for allergies do not necessarily mean that their child is allergic, or that the vision screening test doesn’t mean their child needs glasses. An abnormal mammogram does not mean a woman has breast cancer, and an abnormal prostate antigen blood test doesn’t mean that grandpa has prostate cancer. These are only screening tests, meant to estimate risk—they do not, ever, diagnose disease.

Let me go back to the test done on mom during her pregnancy. It’s called a “cell free DNA” (cfDNA) test, done on blood drawn from mom. During pregnancy, a few cells from the placenta burst, releasing their DNA into mom’s circulation. It’s a tiny amount of DNA, and it’s quickly broken down and cleared, but with some very clever genetic tools that miniscule fraction of fetal DNA can be isolated in mom’s blood, and measured. And it’s that DNA that’s tested to provide the results of the test. The cfDNA can detect conditions where the as-yet-unborn baby has an incorrect number of chromosomes, including Down Syndrome (that’s an extra chromosome 21), Trisomy 13 (an extra 13), other trisomies, or conditions involving the sex chromosomes. These conditions have tremendous implications for a baby’s health, so advance screening is desirable. cfDNA screening can be done easily and painlessly, on a small sample of mom’s blood, with no risk to the baby. Pretty slick.

But that’s the key word, screening. Though it’s testing genetic material from the baby, cfDNA is still a screening test. To really understand why, we’re going to have to do some math (feel free to skip this and the next paragraph if you want to just take my word for it.) The accuracy of a test is expressed by two terms: sensitivity (the number of positive tests divided by the number of people who truly have disease), and the specificity (the proportion of negative tests among a group of people without disease). The sensitivity and specificity of cfDNA testing is excellent – over 99%, which is the “accuracy” figure often quoted in marketing literature about these tests.

But in real life, what we really want to know isn’t the specificity or sensitivity of a screening test. What we need to know is its positive predictive value – that is, in a woman with a positive cfDNA test, what is the chance that her baby will truly have one of these health conditions? To figure that out, you need to apply Bayes Theorem, which requires not only the figures for the accuracy of the test, but the “pre-test probability”. In a screening population with an overall low risk of disease, even a very accurate test is going to have plenty of false positives. If you don’t believe me, follow that link and do some math examples.

Bottom line: for cfDNA testing in a 38 year old woman, the positive predictive value of a “high risk” screen for Trisomy 13 is 37%. (The pre-test probability depends on mom’s age – older moms have an increased risk of babies with chromosomal disorders. You can calculate both the positive and negative predictive values for cfDNA based on the age of mom here.) In other words, even with an abnormal cfDNA screen, the chance of this mom having a baby with Trisomy 13 was 37% — with a 63% chance of the baby being fine.

What should have happened after the abnormal screening test is what should always happen after an abnormal screening test – or, better yet, before the test is even done. Patients need to understand that a positive screen means the condition is “at risk.” Better yet, if there’s solid data, the actual risk percentage should be shared (37%, in this case.) Then the family could decide what to do next. After an abnormal cfDNA test, what should usually be recommended is a diagnostic test, to get a genuine sample of fetal DNA (typically though amniocentesis or chorionic villus sampling.) These diagnostic tests are very, very accurate – and in Sally’s case, if these were done, they would have shown that she did not have Trisomy 13.

But the amnio wasn’t done, in part because the doctors told mom, incorrectly, that the cfDNA was like an amnio, and that the result was conclusive. The doctors fully expected this baby to have Trisomy 13 and even made plans to not do a c-section if the baby ended up in distress. After all, she was going to die, anyway.

The results of screening tests should never be described as “positive” or “negative.” The best way to express the result is “high risk” or “low risk”. The language, here, is really important – and using the right language helps both doctors and patients understand what test results mean. One of the reasons I’m skeptical of patient-ordered tests is that patients may not understand what the results mean (though, admittedly, in this case her doctors didn’t seem to understand the results, either.)

Prenatal screening is a good idea, and cfDNA testing is a good tool. If you’re having these kinds of tests done, make sure you understand what the results mean, and make sure that you have a confirmatory, diagnostic test before you make any decisions that can’t be changed later.

Sally’s story is completely true (other than her name). Thanks to her parents for giving me permission to share it. 


Watson crick franklin


Protect yourself from mosquitoes and Zika

July 5, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

I remember a trip to the Florida Everglades in about 1978. Surrounded by mosquitoes, alligators, and miles of swamp, our teachers told us that every creature was a vital part of the food chain, and essential to the ecosystem.

I hate those bloodsuckers. The mosquitoes, I mean. Not the teachers.

Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis and dengue fever can be spread by mosquito bites in the USA. Our newest worry, Zika virus, is especially dangerous to pregnant women and their unborn babies. Though it’s not yet been spread by mosquitoes in the continental USA, Zika will be here soon. Itchy mosquito bites can be scratched open by children, leading to scabbing, scarring, and the skin infection impetigo. Prevention is the best strategy.

Try to keep your local mosquito population under control by making it more difficult for the insects to breed. Empty any containers of standing water, including tires, empty flowerpots, or birdbaths. Avoid allowing gutters or drainage pipes to hold water. Mosquitoes are “home-bodies”—they don’t typically wander far from their place of birth. So reducing the mosquito population in your own yard can really help.

Biting mosquitoes are most active at dusk, so that’s the most important time to be vigilant with your prevention techniques. Light colored clothing is less attractive to mosquitoes. Though kids won’t want to wear long pants in the summer, keep in mind that skin covered with clothing is protected from biting insects like mosquitoes and ticks. A T-shirt is better than a tank top, and a tank top is better than no shirt at all!

Use a good mosquito repellent. The best-studied and most commonly available active ingredient is DEET. This chemical has been used for decades as an insect repellant and is very safe. Though rare allergies are always possible with any product applied to the skin, almost all children do fine with DEET. Use a concentration of about 10%, which provides effective protection for about two hours. It should be reapplied after swimming. Children who have used DEET (or any other insect repellant) should take a bath or shower at the end of the day.

Other agents that are effective insect repellants are picaridin, oil of lemon eucalyptus, and IR3535 (also known as ethyl butylactylaminopropionate. Tasty!) These are probably not more effective than DEET, but some families prefer them because of their more pleasant smell and feel. Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all. The CDC has extensive info on these products here.

There are also yard sprayers or misters, devices that widely spray repellants or pesticides. I couldn’t find much in the way to independent assessments of these products, but there’s no reason to think they wouldn’t work. Still, I’m leery about the idea of spraying chemicals all over the place, when we know that DEET sprayed on your child is effective and safe for both kid and environment.

About “Organic” or “Natural” insecticides or repellants – those are just  marketing words. In the world of chemistry, the word “organic” means that the molecule contains carbon. Organic compounds are no more or less likely to be dangerous to people or the environment than non-organic compounds; likewise, “natural” in no way implies that something is safe or effective (or even “natural” in the sense that most people mean that term.) These words are tossed around as part of the typical salad of meaningless marketing-speak on labels. Ignore them.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Although I don’t have much independent confirmation that these work, they are probably environmentally friendly and safe.

Some children do seem more attractive to others to mosquitoes, and some children seem to have more exaggerated local reactions with big itchy warm welts. To minimize the reaction to a mosquito bites, follow these steps:

  1. Give an oral antihisamine like Benadryl, Zyrtec, or Claritin (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.)
  2. Apply a topical steroid, like OTC hydrocortisone 1%. Your doctor can prescribe a stronger steroid if necessary.
  3. Apply ice or a cool wet washcloth.
  4. Reapply insect repellent so he doesn’t get bitten again.
  5. Have a Popsicle
  6. Repeat all summer!

Updated and adapted from a post in 2013

There you will learn from Yoda

Antibiotic overuse: Still a lot of room for improvement

June 22, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

We’ve heard it before: antibiotics just don’t work for viral infections. Docs know this, and I think most patients know this, but it’s an addiction we’ve had a hard time shaking.

Docs overprescribe because it’s fast, it’s easy, and it (might) increase patient satisfaction and return visits. That’s led to a cycle of reinforcing expectations from patients – who, after all, keep feeling better after the antibiotics. Of course they do. The minor viral infections that have been treated would have gotten better anyway. Still, it’s hard to shake that impression that it was the drug that made the illness go away. So next time, the patient expects and antibiotic, and doc is even quicker to prescribe it.

What’s the harm? Briefly: we’re encouraging the emergence of super-resistant super-bugs that, to put it bluntly, might just kill us all.

A study from 2015 illustrates some of the craziness and superstition that still guides a whole lot of antibiotic use:

The most-popular, most-prescribed antibiotic in the USA is “azithromycin”, known commonly as Zithromax. This top antibiotic is not recommended, first-line for ANY common infection—it’s not a good choice for ear infections, strep throat, or sinusitis. Not recommended for the top 3 reasons for antibiotic use, yet it’s still the top antibiotic*. Crazy.

Antibiotic prescribing varies tremendously by state. In Alaska, 348 scripts per 1000 patients per year; in Kentucky, it’s about four times that. Do they get four times as many bacterial infections in Kentucky? I don’t think so. Antibiotics, overall, are much more commonly prescribed in the southern states.

Another factor: counties with the most doctors – or the highest “per capita” number of people licensed to prescribe meds – have the highest rate of prescriptions. More docs doesn’t mean more preventive care, more access to good medical information, or better health. It does mean more prescriptions for antibiotics. (Why? I’d guess because it makes a practice more competitive and increases repeat business to write a lot of scripts.)

Current data shows that about 58% of antibiotic prescriptions handed out to human patients are for viral respiratory infections, including common colds or “upper respiratory infections”, viral sore throats, or ordinary “bronchitis”. None of these benefit from antibiotics in any way. Perhaps now’s a good time to revive the “Just say no” campaign.

There is some good news. There’s been about a 25% drop in antibiotic use since the 1990s, and I’m hearing from more and more patients who say right up front “we don’t want an antibiotic if we don’t need it.” That’s a very powerful message, and it’s something you ought to think about saying to your own doctor. You might think we’d only prescribe antibiotics if we genuinely thought they’d help… but the question is, who are they really helping? Probably not you.

*If you’re curious – why is Zithromax so popular, even though it doesn’t work well for any common infection? I think it’s because it can be prescribed with a very quick wave of the hand as a “Z Pak take as directed”. It’s so quick to write! So easy! Other meds need milligrams and instructions and things like “once a day” – who’s got time for that?! It also has a cool name. ZITH. Ro. Max! You may think I’m joking, but I’m not.