Archive for the ‘Medical problems’ category

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!!

Resistant “superlice” cause outbreak of poor journalism

February 29, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

You’ve seen it on Facebook, Drudge, Yahoo News, and just about everywhere else—headlines like “Superlice outbreak hits 25 states” or “Super lice spreading across the US.” Makes you itchy just thinking about it, right?

But “the news” has gotten it wrong. They’re relying on an advertising piece written on behalf of a company that – guess what? – treats lice. Web sites are just regurgitating the same “story”, as if it’s news.

So what’s the story, really? The original spate of headlines began in August, 2015, right about the time when school started. The root of those stories, then, was a press release from the American Chemical Society, “Lice in at least 25 states show resistance to common treatments.” Researchers had collected lice from all over the country, and examined them for genetic changes that are linked to resistance to one of the most common over-the-counter lice treatments (pyrethrins, the active ingredient in “Rid”.) Sure enough, many of the samples included lice with one or more resistance factors. But there were some important caveats:

  • It’s not clear just how resistant the lice were, in practice. Knowing the genetics doesn’t predict what happens in real life.
  • Pyrethrin isn’t the only OTC lice treatment, just one of them.
  • The study itself hadn’t been published yet, and (as far as I can tell) is still not actually published.
  • The study was funded by Sanofi, a company that makes a prescription product that kills lice.

The excitement over that press release, and the dozens of news stories published in August about it, seemed to settle down until last week. Then, a fresh round of headlines appeared. These stories (for instance, here and here and here) all use very similar language, and segue in the second paragraph to talk about one specific alternative treatment for lice, highlighting the name of the product and place that sells it.

Is there any actual new news about this, since August? No. But a tag at the bottom of one of those stories gives us a clue – copyright “Frankly Media”, which is a public relations firm. These news stories, reappearing in dozens or maybe hundreds of places, are almost all word-for-word copies of what was a press release by an advertising agency for a specific product. The story, here, isn’t a new one. It’s just that someone wants to use unpublished research to scare you into buying something.

Lice themselves are a nuisance, yes, but keep in mind that they don’t spread disease, and don’t cause any symptoms other than an itchy scalp. There are several reasons why treatment of lice might not work:

  1. The child doesn’t actually have lice. This is very common. We know that many children who are diagnosed by school nurses or parents don’t actually have lice. If their scalps are itching for some other reason, lice therapy won’t “work.”
  1. Treatments aren’t used correctly, or aren’t repeated correctly. Some lice treatments need to be left on overnight, or applied to dry hair; almost all of them must be repeated in about 9 days. If the directions aren’t followed, lice treatments won’t be effective.
  1. Children get re-infested. Even after successful treatment, if a child returns to play with another kid with lice, the infestation will recur.
  1. Some lice really are resistant. We don’t know the exact percentage, but some lice aren’t responding as well to time-honored medications. We’ve known about this for at least 20 years. It’s not news. And there are both OTC and prescription alternatives, as well as non-medication based treatments that work very well.

All of this talk of “superlice” is overblown. Resistant lice don’t cause worse or “super” cases, and are easily treated with alternative approaches. Most lice can still be treated with any of a number of inexpensive OTC products, if used correctly. The only thing that’s spreading quickly are industries eager to make money off worried parents, and lazy websites re-publishing advertising copy in place of actual journalism.

toby determined

It’s time to rethink pertussis prevention

February 8, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A large, sobering study published in the March, 2016 edition of Pediatrics illustrates just how far we still need to go to effectively control pertussis.

Pertussis, also known as ‘whooping cough’, is a serious illness. Older children and adults get to enjoy a horrible cough for about three months—a cough that sometimes makes people vomit, break ribs, or pass out. Seriously. You haven’t seen a “bad cough” until you’ve seen the cough of pertussis. Worse: in little babies pertussis can cause breathing problems, seizures, and death. Though its caused by a bacteria, antibiotics (unless given very early) are ineffective at reducing the length or severity of pertussis. Prevention, in this case, is worth far more than a pound of cure.

Up until the mid-1990s, infants and children routinely received the whole-cell DTP vaccine (DTP = diphtheria, tetanus, pertussis.) It worked at preventing all three of these diseases, but had a relatively high rate of side effects, mostly fevers. Many of the suspected more-serious side effects (like encephalopathy and seizures) are now known to have been caused by genetic conditions, not the vaccine, but nonetheless parents and doctors alike welcomed a newer vaccine, the acellular DTaP. This newer vaccine, which replaced DTP in the United States by around 1998, caused fewer fevers, and was thought to cause fewer serious reactions, too.

The problem is that it just doesn’t work as well. And as the first generation of infants to get an all-DTaP series starts to go through adolescence, we’re starting to see the unintended consequence of that vaccine change.

In the current study, researchers used a huge database of information from the Kaiser Permanente system of Northern California. We’re talking solid, big-data research, here, the kind of study that requires consistent and reliable data across a huge set of patients. In this case, about 3.5 million patients across 55 medical clinics and 20 hospitals, using centralized labs and an integrated medical records system. If health things happen to this population, Kaiser knows it.

In 2010 and again in 2014, California experienced large epidemics of pertussis. A total of 1207 cases were among Kaiser teenagers, all with complete records of their pertussis vaccination status. And the results aren’t anything to be happy about. In the first year after an adolescent pertussis (Tdap) booster, the vaccine was about 70% effective in protecting against pertussis. Not great, but not terrible, either – until you look a few days down the road. The vaccine effectiveness drops off dramatically, year after year, down to only about 9% by four years after receipt of the vaccine.

Why does Tdap seem to provide such poor protection—much worse than was seen in the original licensing studies? It’s a generational change, and it goes back to the shift from DTP to DTaP in the mid-1990s. By now, these teens in California are old enough to have received DTaP, not DTP, as infants. The authors looked at the specific ages of pertussis cases during the 2010 and 2014 outbreaks, and the trends support the conclusion that teens who received DTP as infants get good, lasting protection from Tdap; teens who got DTaP do not.

Now what? Clearly, we need a more-effective vaccine, perhaps even resuming the use of whole-cell pertussis vaccine, at least for the earlier doses. But in the meantime, we have to do the best we can with what we have. Vaccinating pregnant women with Tdap does effectively prevent pertussis in their babies, especially when they’re the youngest and most-vulnerable. And adults (who got DTP as children) should get Tdap boosters too, to protect the children around them. Another idea (floated by the study authors) is to use Tdap in teens not as a routine booster, but as a strategy to control local outbreaks, taking advantage of the higher effectiveness seen for the first year after vaccination.

I don’t have the answers. I’m not happy to see studies like these, but examining and re-examining vaccine safety and effectiveness is something we need to continue doing, with an open mind, relying on solid evidence. Bottom line: with pertussis, we need to do better.

Whooping crane

Which doctors get sued the most?

February 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A study published this week in the New England Journal of Medicine can teach us a few things about doctors and lawsuits. While many docs will go their entire careers without a single malpractice suit, a small proportion seem to attract a whole lot of litigation. There might be a lesson there.

It’s a big-data study, to say the least. Professors from both the Stanford, CA medical and law schools put their huge-brained heads together, along with collaborators from Australia and the US Department of Health and Human Services. They used the National Practitioner Data Bank (NPDB), a “confidential” depository of all paid lawsuits in the US, along with American Medical Association data on every single doctor, MD and DO. 10 years of data, from 2005 through 2014, were examined, including information on 66,426 malpractice suits from 915,564 physicians. The NPDB only includes information on “paid claims”—meaning a verdict or settlement that results in money going to a plaintiff. Lawsuits that were dismissed or dropped could not be included in this study.

Some interesting findings:

  • Only 6% of physicians, overall, had a paid claim in the 10 year study period. In other words, the vast majority of docs don’t settle or lose lawsuits.
  • Only about 30% of filed claims result in any payments at all—most lawsuits are just dropped without money changing hands (this was not from the data of the current study, but from a reference in the ‘discussion’ section.)
  • Only 3% of paid claims went to satisfy court verdicts. When malpractice suits end with money changing hands, it’s nearly always as a settlement, not as a verdict. These things, it turns out, rarely “go to court.”
  • The mean claim payment was $371,000; the median was $204,000. If you wish to learn more about the difference between mean and median, go back to middle school.
  • Though most physicians had zero claims, a disproportionate number accounted for multiple claims. Approximately 1% of all physicians owned 32% of all monies paid to plaintiffs, and just 0.2% accounted for 12%.
  • A physician’s risk of future claims – of being successfully sued ‘again’ – increased by more and more as the number of previous lawsuits accumulated. Compared with physicians who had been sued once previously, physicians who had been sued twice had twice the risk of a subsequent lawsuit; physicians with three previous claims had three times the risk of another recurrence. It goes up even more from there.
  • Male physicians had about a 38% higher risk of a subsequent lawsuit, and younger physicians had a lower risk than older docs.

What can we learn from all of this? Though malpractice litigation and a “fear of lawsuits” is a frequent topic of discussion among physicians, most of us don’t get sued, most suits don’t get paid, and even suits that do get paid are usually in settlements, not at the end of court dramas. And a relatively small number of docs seems to account for a disproportionately large percentage of legal action.

The authors of this study didn’t speculate on why some docs are sued more frequently than others. An overly-simple answer is that some docs just aren’t very good—but that misses some important truths. The risk of a lawsuit is only partially related to bad medicine and bad outcomes. A lot of the risk, really, comes down to poor communication, and sometimes bad luck. It’s also likely that some of these “frequent targets” are docs who serve the riskiest, sickest patients that no one else will touch. Those very fragile patients likely have the worst chance of a good outcome, even though thy might be under the care of the most talented and smartest docs. No good deed goes unpunished, you know. Still, if you learn that your doc has been sued 7 times, it might be time to go looking for another physician. You don’t want to end up on the plaintiff’s side of the table.

I fell asleep.

Vitamin D for winter eczema – Try it

January 28, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Eczema is a chronic, itchy skin condition seen in about 1 in 3 children. The skin is dry and scaly, and often red and inflamed. Eczema often seems to get worse in winter, in part because hot dry air from the furnace further dries out the skin.

Or, maybe, there’s another reason. Researchers in Ulaanbaatar, Mongolia (which, by the way, looks lovely) postulated that another reason for eczema to worsen in winter was decreased vitamin D levels. Most of us get our vitamin D from sunshine, and in the cold winters people spend less time outside. Less outside, less sunshine, less vitamin D. So what happens if you supplement children with eczema, and have them take a drop of extra vitamin D in the winter?

107 children were enrolled in the study, which was published in 2014. The average age was 9, and almost all of the children had what the authors characterized as “moderate” eczema. Half of the children were randomized to receive a vitamin D supplement (1000 IU once a day), and the other half a placebo drop; all of them were instructed to continue their typical eczema care, which usually consistent of skin moisturizers. A simple, clean study.

A month later, data were collected. There were no significant (or even mild) side effects in either group. 64% of the children who received extra vitamin D had improved skin, versus 43% in the control (placebo) group. Not a huge difference, but with an intervention that’s safe and cheap, that’s an important result that can potentially help a lot of children.

Some criticisms of the study: the authors didn’t check vitamin D levels before or after the intervention—so we don’t know if the children were actually vitamin D deficient, or if vitamin D supplementation was more likely to work in children with low levels. And the study didn’t involve many younger children (who are more likely to have eczema), and didn’t include any children less than 2 years of age.

Still: many children, we know, are vitamin D deficient, especially in the winter; and many children suffer from itchy eczema. At usual doses (like 1000 IU a day), vitamin D supplements are virtually free of risk. Worth a try, if your child has winter eczema? You bet.

Mongolia

Parents are tired

January 27, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

This just in, from the CDC: many adults wake up not feeling well-rested, especially those with children, and especially-especially those with young children. Here’s the graph:

I need a nap

See? Of adults surveyed, aged 18-64, about 35% said that they often wake up unrested. That increases to about 40% if they’ve got school-aged children, and 50% if they have children in the house less than 3. Women in every category feel less well-rested than men.

Glad that’s settled.