Archive for the ‘Medical problems’ category

Dentists gone wild! Cavities in baby teeth may not need fillings

May 23, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Clara wrote in:

“My six year old has being seeing a dentist for three years, and has never had any problems. At the last visit, his dentist identified three cavities on x-rays, and recommends capping the teeth with stainless steel caps. He’s not having any pain or problems. This seems like a lot of expense and a big deal for baby teeth. Is the dentist just trying to make more money?”

Well, I’m not a dentist, and I haven’t examined your child. But the story does sound fishy to me.

Some background: dental cavities (or “caries”) have become much less common in the developed world, from both improved hygiene and the widespread use of water fluoridation. Not only are cavities relatively rare, but small cavities can often reverse themselves, or at least stay small, with good oral hygiene. It wasn’t like that before fluoridation. Until the 1970’s, once a cavity started, it was going to get bigger and worse. Dentists had to be more aggressive back then.

There are some groups of children who are still at risk for extensive dental disease, and those kids really need more-aggressive care. These include children with poor oral habits (like sleeping with a bottle of milk or a sippy cup of juice), or children with serious developmental challenges that make good hygiene and exams difficult. Some of these kids may have a hard time communicating that their teeth hurt, so we need to be extra careful. Severe crowding or other oral health problems can also contribute to extensive tooth decay.

But most of our children have very few (if any) cavities, and the ones they do get remain small and don’t cause any problems. Small cavities can be safely monitored at dental visits, to make sure they don’t get worse. They don’t need to be filled, and the teeth that get them don’t need to be capped. Junior does need to make sure that she’s brushing well and staying away from soda and sticky candy.

Cavities that are more likely to need fillings or caps are those that continue to grow, especially if they erode near the center of the tooth. Pain or temperature sensitivity can be signs of a significant cavity or other oral problem that needs dental attention. Sometimes, cavities form in a way that weakens the tooth, or might allow decay to spread to other teeth. A dentist can help decide which cavities are the ones to worry about.

I suggest Clara (or any other parent who’s concerned about overly-aggressive recommendations for dental care in baby teeth) seek a second opinion from a qualified, experienced pediatric dentist. Most cavities in baby teeth don’t need intervention, but some do, and you need a good dentist to help figure that out.

Disclaimer: I’m not a dentist, I did write a chapter in a pediatric textbook on dental health, so I’m reasonably tooth-savvy. I also called my kids’ own pediatric dentist this morning to make sure I was giving reasonable advice here. Thanks Dr. Mac, you da best!

Dr Teeth

Toxic mold? No, toxic scam

May 10, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Props to a local reporter here in Atlanta for uncovering quackery – not just quackery, but outright fraud. Randy Travis (not the other Randy Travis) with Fox5 has investigated an unlicensed non-doctor, Michael Pugliese, who operates the National Treatment Centers for Environmental Disease right near my practice in Alpharetta, GA.

Though his victims are told to call him doctor, it’s unclear what (if any) medical training Mr. Pugliese has had. What is clear is that worried people from around the country have gone to his clinics for treatment for all sorts of ailments. After a $3,300 up-front fee, all of them, based on his testing, are told that they’re suffering from the ill-effects of mold. And all of them are sold a variety of supplements and nose-sprays, some of which are made in his laundry room. Adding insult to injury, they’re told to eat canned chicken three times a day. That’s just weird.

Read more details of the investigation here and here.

The whole “toxic mold” thing is another money-draining, predatory quackfest. It’s not clear at all that mold causes any of the neurologic symptoms or other Big Problems it’s being blamed for – but that hasn’t stopped lawyers from suing, and scamsters from setting up fake labs and giving themselves fake credentials.

Mold can be an eyesore, and sometimes makes houses smell musty. Some people are allergic to indoor molds, which can then trigger symptoms like itchy eyes or noses, or worsening asthma symptoms. These symptoms can be prevented and treated by talking with a primary care doc or allergist.

But beware: there are a whole lot of scammers out there looking to take advantage of people. These are people who are hurting, and who have genuine concerns, and they’re looking for answers. It’s sad how many of these alt-health fraudsters are so eager to suck their bank accounts dry, preventing them from getting the real help they need.

 

Grunting Baby Syndrome – A whole lot of show for very little poop

April 21, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Lemelon wrote in:

“Grunting Baby Syndrome. Is this really a thing? My 6 week old son grunts, strains and writhes from ~approximately 3-6am every night. Most of the time he sleeps through it. My GP suspects reflux but ranitidine has not helped. Also, he’s very happy/calm all day rarely fusses or cries. My google searching came across Grunting Baby Syndrome. Is that a real thing? When do babies grow out of it on average?”

One of the fun things about writing this blog are good questions, or questions about things I had never heard of before. And, yes, Grunting Baby Syndrome is a real “thing”, and something I’ve talked with parents about for years. I’d just never heard this name for it. I think the name is mostly used in the UK (most of the sites I found referring to it come from across the pond), but it seems to be catching on here. Whatever you call it, it’s one of those things that makes sense with a little explanation.

Anyone who’s had a newborn knows that poop doesn’t always come easily. There’s often a big show, with grunting and a red face, and sometimes crying (this is the baby we’re talking about, here. Not dad. I think.) But the poo itself isn’t hard or even firm – it’s normal, ordinary baby poo, soft as applesauce or weird yellow pudding. So why the big show? Why all the grunting?

Two reasons, I think. One is that it’s genuinely difficult to have a bowel movement while lying on your back. Go ahead, try it yourself. We’ll wait here.

See? With nothing to push your feet against, it just doesn’t work. I’ll bet you were pushing and grunting and your face turned red too. Perhaps your behavior was puzzling to your spouse, who chased you out of the bedroom with a broom. You should probably go back and explain, later.

But there’s a second reason for the grunting. Have you ever thought about the steps you’re taking to poop? You need to tighten up your abdominal muscles to push, while simultaneously relaxing your pelvic floor and anus. Tricky! It’s like patting your head while rubbing your stomach – another trick that newborns can’t do well. Tightening one set of muscles while relaxing another isn’t easy. You can tell a baby’s having trouble coordinating this if you pat their bottoms while they’re grunting. Their little buns are squeezed together, all tense. It’s no wonder the poop can’t come out! And it’s no wonder that when it eventually does, it’s a noisy explosion that startles Junior and parents alike.

So: what should parents do? Relax. Don’t get anxious – that will not help your baby get through this. Gently bicycle his little legs, and hold him, and help him relax. When gas passes, and it will, make a little joke. “You sound like Daddy!” would be appropriate, or “Here comes Grandma!” if she’s not in the room. A bad thing to do is to get wrapped up in the drama, and add more worry. If it’s at night, and the grunting is keeping you awake, turn down the baby monitor. The poop will come, I promise.

This isn’t constipation, which requires hard stools. Giving a stool softener won’t work, and neither will changing formulas (though it will get you off the phone with your pediatrician’s office. I probably shouldn’t have told you that.) Rectal stimulation with a thermometer will work, but only in the short run—that won’t help Junior figure this out himself, which is the only long term solution.

If you’re worried that your child just cannot pass stools, talk with your child’s doc. There are some rare conditions that prevent poopage. But the vast majority of grunting, red-faced babies have this “Grunting Baby Syndrome”, which is another thing you don’t have to worry about.

Monica Seles

Serious allergic reactions to vaccines: Something else not to worry about

April 18, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A huge study of over 25 million doses of vaccines has shown that serious allergic reactions are super-rare, and even when they do occur they’re typically easy to treat.

Published in the October, 2015 edition of The Journal of Allergy and Clinical Immunology, the study looked at a huge database of 17,606,500 visits for a total of 25,173,965 vaccines. This is seriously Big Data, people. After all of these vaccines, only 33 cases of a severe allergic reaction occurred. Even among those 33, only one child required hospitalization, and none died.

More reassurance: there were zero serious reactions among children less than four years of age. And most of the 33 reactions (85%) occurred in children who had a history of other allergic diseases.

Despite its rarity, anaphylaxis is a potentially serious reaction. If your child experiences a widespread rash, trouble breathing, severe GI symptoms, or fainting after a vaccine, it might be an allergic reaction – a medical evaluation is needed. Most of these reactions won’t turn out to be serious or life-threatening, but they do need attention. Almost all teenagers who faint after vaccines have just fainted, and will be fine, but they need to be watched and their blood pressure checked. If further evaluation shows it’s an allergic reaction, medical therapy given quickly can help stop the reaction.

But: we need to keep these reactions in perspective. They’re really phenomenally rare. 33 out of 25 million vaccines means that your children have a higher chance of being hurt in a car accident on the way to their appointment than of having a serious allergic reaction to a vaccine. Other, non-allergic but serious reactions are really very rare, too. The internet has made otherwise well-adjusted people into parents worried stiff over vaccines. Don’t let it happen to you. Don’t live in fear and worry. Immunizations save lives, they’re safe, and they’re something you don’t need to worry about.

Wemberly Worried

Zika update!

April 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

I last wrote about Zika in January*, and there’s a whole lot more we now know about this mosquito-borne virus. And still a lot we don’t know. Time for a Q&A-styled** update!

 

Give it to me straight, doc. Does Zika really cause birth defects?

Yes. As is typical for scientist-written press releases, early reports this winter were equivocal—you’d see phrases like “is associated with” or “likely caused by”. That’s because unlike pushers of GMO-free foods, real scientists try to respect the intelligence of their audience. Back then, it was clear that there was both a big spike in cases of Zika-associated illness during pregnancies (mostly in South America), and a big spike in cases of microcephaly and other neurologic birth defects. But did one cause the other?

More-recent reports have included evidence of Zika in the brain tissue of affected fetal brains, and also in the brain and nerve tissues of children and adults suffering from neurologic symptoms during Zika infections. It’s clear that Zika is a neurotropic virus – it likes to invade neurologic tissue.

We also know more about the structure of Zika. At the molecular level, we know it has a structure that interacts with brain cells. That is completely cool—we know exactly what the virus looks like and how its molecules are arranged. That’s one step away from designing a vaccine. All of this research was done in just a few months. Science!

 

Is Zika coming to America?

It’s already in America, dummy. South America, which (last time I looked) was part of America. Oh, you mean North America? Which includes Mexico? Which is also part of America? Maybe you should just start over.

 

Is Zika coming to the United States?

It’s already here. Zika-virus associated infections have been reported in almost every US State, though at least so far the only locally-acquired cases have been transmitted through sex. (No, not sex with mosquitoes, you sicko.)

 

OK, so that means as long as I don’t have sex with anyone who’s been traveling, I’m protected, right?

Maybe for now, but not for long. Over 300 cases of Zika have occurred in the continental US, and even more in our Caribbean territories. And the mosquitos that transmit ZIka, by mid-summer, will be found in a wide swath of the US, across the entire souther border, reaching up into Ohio and Missouri. It is only a matter of time before local mosquitos stare biting people with Zika infection, and then spreading it to other people.

 

 Yikes. I’m glad I’m not a pregnant woman!

So are we. We’ve seen the quality of your questions here, and frankly it would be better if you didn’t reproduce.

 

I meant I’m glad only pregnant women need to worry about infections. Right?

Nope. Pregnant women, and their unborn babies, are clearly at the highest risk. It looks like about 25% of the time, infection during pregnancy results in fetal damage—though that’s an estimate based on preliminary data.

We do know that most infections in otherwise-healthy children and adults result in no symptoms whatsoever. Probably only 1 in 4 or 5 people with Zika develop symptoms, which include fever, joint aches, and rash. But a small number of people also go on to develop serious complications, which can include brain inflammation or Guillain-Barre Syndrome. Though these conditions after Zika infection are rare, we really don’t know exactly what the risk is, or who’s likely to progress to serious Zika-related illness.

 

What should I do if I think I have a Zika virus infection?

Testing is available through public health agencies, and is routinely recommended for pregnant women living in or traveling to areas with active transmission. For the rest of us, health-care providers can help decide whether testing is needed. Go see your doctor.

 

What’s the best way to prevent infection?

Right now, there’s no vaccine, though one is actively being developed. The best way to prevent infection is to avoid mosquito bites and travel to areas with high rates of infection. You can find maps and other resources through the CDC Zika Prevention site.

The bottom line with mosquitoes: wear long sleeves and long pants, keep mosquitos out of homes with nets, screens, doors, and air conditioning, and use a mosquito repellant that actually works. Those typically contain the active ingredients DEET, picaridin, or “oil of lemon eucalyptus.” Of these, DEET is the standard—it’s been around since 1957, and it works, and as long as you don’t drink the stuff it’s safe.

 

*I wrote about it weeks before the story was picked up by the so-called “mainstream media.” Yet, still, no Pulitzer. Am I bitter? Of course not.

**Some “journalists” say slapping together a blog post in Q&A format shows laziness and a lack of creativity. Those people should go stick their journalistic heads in buckets of icy cold water. It’s Saturday morning, it’s beautiful outside, and you guys are getting get what you pay for. Srsly.

 

Coming to America

Spring is here! Allergy therapy update, 2016

March 24, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Ah, spring. The birds are tweeting, the flowers are blooming… and there’s a layer of yellow dust all over my car. And a whole lot of sneezing and stuffy noses! 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. So many choices! 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 still very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. 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 cheapo 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.

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 OTCs Nasacort, Flonase, Rhinocort, and generic fluticasone (essentially identical to Flonase.) There are also many prescription versions of these, like Nasonex and Veramyst. All of these 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.

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, ironically, are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor.

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.

Spring!

Help fight childhood cancer!

March 7, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

On March 13, I’m getting my head shaved to help raise money to support children with cancer through the St. Baldrick’s foundation. I’d really appreciate any donations you’d like to give. It’s a great charity, and these are wonderful kids who can really use your help.

To donate or learn more about St. Baldricks, click here. Thanks!!


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