Archive for the ‘Medical problems’ category

“The Science of Mom” – a great new book for parents

August 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

New parents have access to plenty of information. Websites, Facebook pages, blogs, tons of stuff, all ready to answer any question. The problem is that many answers are just plain wrong. Not just “your-opinion, my-opinion” wrong, but flat out stinking lies of wrongness, repeated over and over, until one has to figure, hey, I saw that somewhere. I guess it’s true.

You don’t have to guess. If you want reliable and honest information, let me suggest a new resource: a book by Alice Callahan, PhD, called The Science of Mom: A Research-based Guide to Your Baby’s First Year. Dr. Callahan’s blog has been a favorite of mine, with solid, well-referenced, and very readable articles on parenting topics.

Her new book is organized into chapters covering many “hot topics” concerning a baby’s first year. There’s an introductory chapter that concisely explains how science can turn you into a better parent, and how to tell good science from bad. Other chapters cover topics both expected (vaccines, breastfeeding, sleep training) and unique (how newborns learn and interact with the world.) The breastfeeding chapter did a particularly good job presenting this nuanced subject – in fact, the science says more than just “breast is best.” Her chapters on sleep training and sleep safety were also very good, though I would have been even more direct about SIDS prevention. Still, that’s a style thing—she’s got the science down, solid.

Dr. Callahan isn’t bossy, and isn’t out to tell you what she thinks. Her book tells you what the science says, and explains how we know what we know, and what things we still need to learn more about. There’s humility and warmth, here, which I think parents of newborns will find reassuring. There are many “controversies” that you really don’t need to worry about.

This book is great for parents of newborns and babies, and I think it would make a very good gift for expecting couples. In the spirit of full disclosure, I got my copy for free (thanks!), though I’m planning to donate it tomorrow to my local little free library. Stop by Womack near ChamDun to grab my copy, or get it from Amazon or whatever. It’s good.

Is general anesthesia safe for children?

August 24, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Meghan wrote in:

My 10 month old son (a twin) has a mild hypospadias and chordee. The recommendation from our pediatric urologist was surgery at 6 months. Another specialist said that we could wait a few months, which may even lead to better outcomes (due to difference in size) but that we would absolutely need to operate before he was walking and reached ‘genital awareness.’

This surgery requires general anesthesia, and there have been a number of studies published recently (i.e. NEJM and Pediatrics) that suggest that this poses serious risks (learning disabilities, etc.) Of course for life threatening conditions, you would need to operate, but for a non-life threatening condition (mild hypospadias) I wonder if the pros outweigh the potential cons?

I would greatly appreciate your thoughts. The specialists whom I have tried to engage (urologists and anesthesiologists) have been unfortunately, very dismissive to entering into discussions around this issue. Even guidance on who to approach for their thoughts would be so appreciated!

First: hypospadias, if mild, probably doesn’t have to be repaired at all. But that chordee—if that’s present, Junior would appreciate it if you’d get that fixed for him before he has painful erections that don’t (for lack of a better term) work.

What Meghan really wanted to know about was the potential risks of anesthesia, especially in light of recent publications that have brought up questions about anesthesia’s long term affect on children’s brains. Some of these studies have been on animals (both rodents and primates), showing “anesthetic neurotoxicity”—the death of brain cells with exposure to anesthetic agents. But rats and monkeys aren’t people, and we know that brain cells (especially cells in brains of children in intellectually stimulating environments) can regrow and regain function. In fact, it may well be that younger children could conceivably recover from this kind of damage better than adults.

Other studies have been observational, retrospective studies—looking at groups of children who did and did not have exposure to anesthesia. One from a few months ago did show that kids who had anesthesia before age four did have slightly lower IQ scores (tho IQ remained in the normal range for both groups, it was 5-6 points higher in the children who had not had anesthesia.) But these kinds of studies aren’t very reliable. It’s difficult to know, for instance, if the difference is from the anesthesia itself, or from the health condition that necessitated the surgery. That is, kids who require surgery and kids who don’t require surgery aren’t equal in many ways. The ones who need surgery are more likely to have health problems, and maybe that’s why their measured IQ at age four could be lower. Besides, does the IQ at four even matter? What if it’s recovered to the same by school age?

Meghan might think that for what’s going on with her son, which is a genital concern, there wouldn’t be any expected difference in brain strength. But statistically, that’s not true. We know babies born prematurely are more likely to have hypospadias; and we know that babies born prematurely are more likely to have intellectual deficits, ADHD, autism, and cerebral palsy. Statistically speaking, having a hypospadias means you’re more likely to have these other things, too. We also know that the most effect on development and IQ is seen in children who’ve had multiple surgeries (who are also the children most likely to have the most complicated medical histories, like heart disease or brain malformations.) So was is it the anesthesia that’s the risk?

Chicken, meet egg.

The best studies to tease this out haven’t been completed yet, but they’re underway. Children with the same health conditions (for example, a group of boys with hypospadias) need to be randomized so some have surgery now, and some wait a few years. Then they can be followed with periodic neuropsychiatric testing to see how they do. This kind of randomized, prospective study is the best way to isolate a variable (in this case, anesthesia) and establish whether that’s really a risk.

Since those studies haven’t been done yet, for now I’d say: if general anesthesia isn’t required – if the procedure is entirely cosmetic, or can safely be put off until a child is older – it makes sense to wait. But in some cases, there’s a medical benefit to doing surgery earlier. Cleft lip repair early allows for better language development and feeding; a shunt to treat hydrocephalus prevents brain damage when done young; eye muscle surgery allows the development of sharp vision. The potential risk of general anesthesia has to be balanced against the risk of waiting, and there’s no “general rule” that you can apply that could account for all circumstances.

The most troubling part of Meghan’s question was her last comment—that the surgeons and anesthesiologists were dismissive of her concerns. Those are the people she ought to be able to depend on to follow the literature closely and be able to discuss this. If they’re unwilling to take these questions seriously, it’s probably best to Meghan to find some new doctors.

Dumb, dangerous things in your home

August 3, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Little kids are curious by nature. They like to get into things, and they like to put things in their mouths. Manufacturers of many dangerous things take all kids of steps to prevent that from happening. For instance, children’s liquid acetaminophen is packaged in bottles that are relatively small—even if a bottle of liquid is swallowed, it’s less likely to cause toxicity. And those Gummi-style vitamins never contain iron, because iron is the one “vitamin and mineral” that’s really, really toxic in overdoses. I’m still not so sure it’s a great idea to make multivitamins into Gummi candy, but at least the people who make them are trying to keep them safe.

A few products seem to have missed the boat on this whole “safety for children” thing.

First, here’s a pocket or purse sized container of ibuprofen from a prominent national brand (don’t try to guess which one—I’ve cleverly covered the label with my thumb.) The child-proof cap is a joke—you can’t really screw it back closed, so it’s really easy to open.

Ibuprofen tablets

Worse, the tablets themselves look pretty much exactly like candy M&Ms. They melt in your mouth, not in your hand:

IMG_3275

And, worst of all, the little tablets are coated in sucrose. Lick ‘em, and they’re sweet and tasty. So: packaged so they’re easy to open, and designed so they look and taste like candy. Far be it from me to disparage a national brand, but one might come to the conclusion that these people hate toddlers and want to kill them. Of course, I wouldn’t say that on my blog, because I’m allergic to lawyers.

Next on the “Products that seem to have been designed for maximum toddler maiming potential” are laundry pods. These are those little prepackaged things that cleverly save us the trouble of measuring out laundry detergent with a scoop. (What are we, cavemen?) They’re colorful and cool and – guess what!?—toddlers like to put them in their mouths. Ingestion of these things is very dangerous. Worse, manufacturers don’t have to tell anyone what’s inside, making it difficult for doctors and poison centers to manage ingestions. They’re looking into adding bitter substances to laundry pods, making them less likely to be eaten. (I can see it now, pods flavored like brussels sprouts.) But still: if they look cool and are easy to break open or swallow, someone little is going to get hurt.

Laundry-detergent-pods-jpg

You can’t rely on product manufacturers to protect your kids. Use common sense. Dangerous things—like medicines, cleaning supplies, oven cleaners, pesticides, and laundry detergents should be kept way out of sight and unreachable by curious kids. Keep the phone # of the poison center (1-800-222-1222) handy, and call them immediately if there’s been an ingestion. And just say “no” to laundry pods and medicines that look and taste like candy.

Gluten and children’s health: The New Boogeyman?

July 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.

 

*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

Cootie Shots under fire

July 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Circle circle dot dot

Now I have a cootie shot

It’s a rite of passage for Kindergarteners, something we’ve all gotten used to accepting, without question. Now, an increasing number of concerned parent activists are raising concerns about Cootie Shots. They’re asking some uncomfortable questions. Are they even safe?

Last year, Ms. Emma Jane McGucket noticed her 5 year old son acting oddly. “He’s like a different boy,” she said. “His clothes no longer fit. And he smelled like grass.” Later that day, she says, she heard him say something that really started to make her wonder. “He said something about a Cootie Shot to his younger brother. It made my hair stand on end. What were these Cootie Shots? Have they been tested? Is this just another government plan to poison our children, like putting fluoride in the water or thiamine in the bread?”

After asking questions at her son’s school, Ms. McGucket still wasn’t satisfied. “It’s like they didn’t even know what was going on. They pretended these Cootie Shots are perfectly safe, even though they couldn’t list all of the ingredients.”

Ms. McGucket has formed a Facebook page, Families Against Cootie Shots (FACtS), and hopes to draw attention to what she considers “…the most important thing, ever, that everyone has to stop whatever they’re doing and worry about more than anything else.”

And she’s not alone. Her neighbor, whom Ms. McGucket refused to name, is also said to be worried. When we spoke with her though her closed door, she may have said something about toxins or GMOs used in their production.

“It’s not that I’m against Cootie Shots,” said Arlene Monger, president of the Calhoun County chapter of FACtS. “What we want, what our children deserve, are greener, safer Cootie Shots free of toxins and chemicals. We don’t need to give in to Big Cootie just to protect our children.”

“No one wants children safe from Cooties more than me,” she said. “But we have to read the product label and the government hazardous material sheets. These things are being injected directly in our children’s bloodstreams. They might even contain gluten.”

When contacted, Jamie Rosen of the 2nd grade’s Cootie Surveillance Section pointed out that Cootie Shots aren’t actually injected into anyone’s bloodstream. “They’re pretty much just touching the skin of the arm, you know, circle circle dot dot?”

“Those are the kinds of ‘facts’ we don’t need,” responded Ms. Monger. “A typical response from a typical official who’s been paid off. Like my son’s pediatrician. He said he wasn’t worried, which just proves it.”

Some activists are also concerns about the number of Cootie Shots being administered. On some playgrounds, they say, boys are giving themselves up to 6 or 7 doses in one recess. They say they need it to protect themselves from the girls, but parents are worried. “Too many, too soon!” says Ms. Monger. “They’re using a schedule that’s only been in use worldwide for what, 50 years? I’m supposed to be reassured by that?”

“I don’t need any studies,” Ms. Monger concluded. “I know what I know, and that’s enough for me to say no.”

cootie shots

 Osgood-Schlatter syndrome: A knee pain that will get better

June 4, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

 Betty asked, “My husband has this lump under his knee—he says it hurts when he kneels on it. And now, my 11 year old son is getting one of these too! I think it’s Osgood-Schlatter syndrome. What can I do about it?”

Osgood-Schlatter syndrome (or, sometimes, disease—I’ve seen it both ways) is a very characteristic knee problem that occurs in some growing children. Boys get it around 12-13 years, girls more like 10-12. Technically, the definition looks like this:

Osgood Schlatter syndrome (O-S) is a traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity.

(You may guess from that definition that neither Drs. Osgood nor Schlatter went out on a lot of dates.)

“Traction apophysitis” is pulling on a growth plate—and since only growing kids have these, pain from Osgood-Schlatter is only seen in children. After the growth plates fuse, the discomfort of O-S fades away. Sometimes, a bump stays under the knee in adults, and that can hurt with kneeling.

My hairy leg. I'm pointing to the tibial tubercle, where Osgood-Schlatter hurts, below the knee.

My hairy leg. I’m pointing to the tibial tubercle, where Osgood-Schlatter hurts, below the knee.

Why does it happen? Probably because there’s already some swelling at the growth plate, and the quadriceps tendon rubs right across there at the top of the lower leg.

The pain of O-S is typically not severe. It’s more of an achy sort of pain, mostly after exercise, especially after jumping or running. The area under the knee can also be tender, so if it’s banged up from falling or from being hit, that will hurt, too.

I don’t think there’s any great way to prevent O-S. Once it starts, ice or ibuprofen can help with the discomfort, and often that’s all that’s necessary. Continuing to play on it will not cause arthritis or knee damage—as long as the pain isn’t too bad, it’s reasonable to ice the area and keep playing. However, if it’s getting worse and worse a period of relative rest is a good idea, Maybe consider changing sports for a season.

You can also buy a little band like this one that goes right under the knee. It will provide a little padding to protect the tender area. Some people claim that these bands change the biomechanics of the tendon so it won’t rub—that’s not actually true, but hey, if it helps a kiddo feel better, wear it.

Another strategy is physical therapy, to strengthen and stabilize the quads and knee. It will also give Junior something active to do while sitting out of sports.

In time, after a year or so, O-S pain improves. Betty should take her son to his doctor to confirm the diagnosis and learn more about it. Usually, the history and physical exam are so characteristic that x-rays aren’t needed. Most kids can live with this until it gets better on its own.

Swings, slings, and car seats are not for sleeping

May 28, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

An April, 2015 report from the Journal of Pediatrics graphically illustrates the dangers of babies sleeping in gizmos not designed for sleep.

As I’ve written about before, the American Academy of Pediatrics has established specific guidelines on the safest ways for healthy babies to sleep. I last reviewed them in detail here. In summary, babies should always be put down on their backs to sleep on a firm, flat surface, like a crib or bassinet. Baby sleep positioners that hold an infant in place are a bad idea. Things that hold babies in an upright or semiupright position, like the Fisher-Price Rock ‘n Play Sleeper, are also a bad idea. Why?

They’re dangerous because little babies have big, heavy heads, and they lack the strength and muscle control to protect their little baby airways. If their heads fall forward, or their necks get entangled in a strap, they can die.

The new report (summarized here) points out that sleep-related deaths are the most common cause of death in infants from 1-12 months of age. The authors reviewed 47 deaths reported to the US government involving sitting or carrying devices, including car seats, slings, and bouncer-type devices.

I’m going to quote a few of the case histories, here. This material is cold and clinical and disturbing. Feel free to skip ahead a bit.

An 11-month-old boy was placed with a bottle in a car seat for a nap at a home day care center. He was covered with a fleece blanket. The chest buckles were secured, but the lower buckles were unsecured. One hour and 20 minutes later, the child care provider went into the room to check on the child. She saw that he had slipped down in his car seat, such that at least one strap was up against his neck, his color was pale, and he was gasping for breath. EMS was called and the victim was transported to a hospital, where he was declared dead.

A mother was attending a breastfeeding class with her 26-day-old son. She was wearing a cloth baby sling that was placed like a sash across her chest. The child was breastfeeding inside the sling. The child stopped nursing and was believed to have fallen asleep. Approximately 10 minutes, later the mother noticed that her son was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. The child was transported to a hospital and pronounced dead.

A 3-month-old boy was placed for sleep on his back in a bouncer. The father buckled the infant into the seat with the restraint belt and placed a blanket on him up to his waist. Ninety minutes later, the father found the victim face down and unresponsive, with his neck over the top of the bouncer. 911 was called and CPR started; the baby was pronounced dead at the scene. The detective related that the victim had apparently rolled over and pushed up to the top of the bouncer by pushing on the blankets.

An 8-month-old girl was sleeping unattended in a stroller at the mother’s workplace. The restraint belt was not fastened. The mother returned to the room after 5 minutes and found her partially hanging out of the stroller, her head wedged between the lower edge of the tray and the front edge of the seat. She was unconscious and not breathing, so CPR was initiated. She was resuscitated but was in a vegetative state, and life support was withdrawn 2 days later.

Some important lessons can be learned from the details of the report. Death can occur quite quickly—deaths in car seats and strollers were reported after a minimum of only 4 or 5 minutes. And they can occur at almost any age, from 10 days old in a sling to 2 years old in a car seat.

About half of the time, car seat deaths were caused by strangulation on unfastened straps. You might think that once a car seat is out of a moving vehicle, it would be safe to undo the straps—but those same straps that are so effective in keeping a child safe in a crash can strangle a baby. Many of the other deaths were caused either by positional asphyxia, with the head falling forward to close off the airway, or by a device tipping over and smothering the baby.

There’s some good news buried in this report, too. There were no deaths using a sling for breastfeeding—only when the babies were sleeping in a sling. And almost all of the car seat deaths were when using a car seat outside of a car. Based on this and other reports, the correct use of a car seat in a vehicle (baby strapped into the car seat correctly, and car seat strapped into the car correctly) is very safe. It’s the unintended use of car seats and other devices as sleeping devices in homes and daycares that’s dangerous. As the authors conclude, “It is possible that most, if not all, of these deaths might have been prevented had the device been used properly and/or had there been adequate supervision.”

When I’ve written about safe sleeping before, I’ve gotten many colorful comments from people who say that their babies have unique health circumstances, and that their own pediatricians have made recommendations that differ from the usual guidelines. (That’s my translation of their comments, which are more-typically worded “You are an idiot.” or “How dare you question the advice of my pediatrician who has won a Nobel Prize and you are an idiot.”) The AAP sleep guidelines are for routine, healthy babies. If you think your babies need to sleep in a manner different from the typical guidelines, I suggest you speak their pediatricians about it, as soon as they return from Stockholm.

 

edit 4/12/2016: A reader sent me this link, about a baby who died in a car seat. An entirely preventable, tragic death: http://www.popsugar.com/moms/Baby-Died-From-Sleeping-His-Car-Seat-40838059.


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