Archive for the ‘Medical problems’ category

Parents can tell if an ear infection is getting better

December 5, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

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

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

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

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

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

Finalnd!

 

Acute Flaccid Myelitis: A reassuring primer for parents

November 14, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

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

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

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

 

What’s AFM, anyway?

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

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

 

What causes it?

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

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

 

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

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

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

 

Who is catching this? How serious is it?

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

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

 

What should parents do?

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

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

More about AFM from the CDC

keep calm

Codeine is not for children

October 31, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

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

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

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

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

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

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

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

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

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

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

Mmm codeine

Is there a link between birth control pills and depression?

October 10, 2016

© 2016 Roy Benaroch, MD

A provocative new study from Denmark supports a link between hormonal contraceptive methods (like birth control pills) and depression. And the association seems to be strongest for adolescent girls.

Huge studies like this are based on huge datasets – in this case, relying the Danish medical system’s longstanding penchant for meticulous and integrated medical records. You just couldn’t do this kind of research in the USA, where medical records systems can’t talk to each other or combine their data in a coherent way.

The researchers started by reviewing the medical records of Danish women, age 15-34, from 2000 through 2013 (excluding women with a preexisting diagnosis of depression or related disorders.) To determine when women took hormonal contraceptives, they relied on a National Prescription Register, which included all prescriptions made and filled for combination contraceptives (these are the ones most commonly used) as well as other medicines and devices (like implants and injected progestin) that rely on hormones to prevent pregnancy. For the purpose of the study, women were considered to be on prescribed hormones for the period of time they filled these prescriptions, plus six months. Over a million women made up the final dataset, followed for an average of 6.4 years each. At any given time, 55% of the women were taking these kinds of contraceptive medications.

The researchers then figured out when all of these women had depression, relying on either their filling a prescription for an antidepressant medication, or when any medical facility made a diagnosis of depression. Overall, during the study period, a total of 133, 178 prescriptions for antidepressants were filled for about 23,000 diagnoses of depression (many of the patients with depression filled more than one prescription.)

Using the data including the timing of contraception usage and depression diagnoses, the study authors could then compare whether depression was diagnosed while the women were either taking or not taking these contraceptives. And it turned out the depression was more common during the on-contraceptive periods. Overall, the increased risk of depression during contraceptive use was about 20% for all women in the study. The increased risk rose to 80% when only adolescent young women from age 15-19 were evaluated. The elevated risks were seen among all the different kinds of hormonal contraceptives examined.

This doesn’t necessarily mean that the contraceptives caused depression. Observational cohorts like these only show a temporal association. It’s possible that women taking contraceptives are more likely to become depressed for reasons unrelated to the medication itself – perhaps relation to the kinds of relationships they were in. Contraceptives are prescribed for many reasons other than contraception, too – to improve menstrual symptoms, or to help with acne. It’s also true that antidepressant medications are prescribed for things other than depression, like anxiety disorders or some chronic pain syndromes.

Still – over a million women in the study, and the effect size (especially among adolescents) was significant. While this study does not mean that women shouldn’t take contraceptives, it does mean that prescribers and their patients should keep depression in mind as a possible side effect, and that women at risk for depression may wish to consider other, non-hormonal means of contraception.

OCPs

 

 

Fisher-Price: Stop selling your unsafe Rock-n-Play Sleeper

October 3, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

The Rock-n-Play Sleeper, made by Fisher-Price, is marketed and sold as a “sleeper”. You can tell, because the word “sleeper” is in the name of the product. One might think that it’s a good, safe place for a baby to sleep. But it’s not. It’s long past time for Fisher-Price to stop selling it, or at least change its name and marketing.

I first wrote about the RnP in 2013, in one of my most-read and most-pingbacked posts. I closed the comments last year, mostly because everything that needed to be said had already been said. My favorite comment began “You sit are an idiot.” I was also accused of having a vendetta against the Rock-n-Play, a charge that I gladly accepted. I am, admittedly, against things that are spelled in an unnecessarily cutesy way, especially when they kill babies. I’ve since written related posts critical of Fisher-Price for selling a gizmo making it easy for newborns to use an iPad, and another post reviewing a study of 47 deaths among babies who were died while sleeping in unsafe devices.

Since the first post was published, I’ve heard from several people who have been actively pressuring Fisher-Price to change their ways. The most chilling calls have come from an attorney who’s representing a family whose child died in a Rock-n-Play. The autopsy report was heartbreaking – because the baby was sleeping on the curved, soft surface of the Rock-n-Play, his neck was bent forward, closing his airway. No airway, no breathing, dead baby. This same attorney has heard from several families who’ve had near-death experiences with their babies in a Rock-n-Play. One even documented that their baby’s breathing stopped several times a night while in the sleeper (and was normal when slept correctly, flat on his back, on a firm flat surface.)

I’m not always a fan of lawyers and litigation, but this is a case where legal action might be the only way to compel Fisher-Price to adhere to the well-established guidelines for a safe sleep environment for babies. For now, they’re apparently still selling tons of these things, but a few big-money lawsuits may just open some eyes over at Fisher-Price, Inc. I hope so, before more families are misled into thinking the Rock-n-Play is a safe place for babies to sleep.

RnP

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.

Ironic