Archive for the ‘Medical problems’ category

Is Tummy Time really essential?

March 17, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Fiona has had it with “Tummy Time”! She wrote: “Doctors, prenatal classes, books, other Mums all stress that it’s vital for preventing a flat head and strengthening muscles.  But my little monkey screams blue murder the second I put her on her tummy.  What’s the evidence behind this (fairly recent?) exhortation to put babies on their tummies for a few minutes every day? Have people always done it, and if not, were kids in times gone by somehow delayed in their motor development? My instinct says no, but the call for tummy time seems to be so ubiquitous. And if it’s so important, how do we convince the babies who resist? Mine spends much of her awake hours sitting upright in a sling so I guess she gets a neck workout that way and isn’t lying on her back all the time risking flat-headedness, but it’d be nice to be reassured!”

Tummy time isn’t supposed to be “torture time.” If your baby absolutely hates it, pick her up. There’s no great evidence that it’s necessary at all.

The growing enthusiasm for tummy time began with recommendations in the 1990s that babies be put down to sleep on their backs, rather than their tummies. This led to a dramatic drop in deaths from SIDS, but an increase in what’s formally known as “positional plagiocephaly”, or flat little heads. It turns out that when Junior sleeps on her back, especially with her head turned to the same side all the time, that side gets kind of flatter. There’s no significant medical issue here—heads flattened in this manner don’t cause brain damage or developmental problems—but in severe cases it can be noticeable.

There are good ways to prevent flat heads. The AAP recommends alternating head positions from night to night, and periodically changing around the positioning of the crib so interesting things aren’t always in the same position (you can accomplish the same things by alternating which end of the crib is “up”, or which end the head and feet point to.) And, yes, as part of the anti-flat-head routine, the AAP recommends “a certain amount” of supervised “tummy time” when Junior is awake. They acknowledge that there’s no evidence that this helps, and no studies have shown how much tummy time is ideal, or at what ages it’s needed. It’s more of a common-sense thing. More time on tummy means less time on back, which should not only prevent flat heads but also facilitate motor development by giving Junior a chance to work on her push-ups. So for the many babies who don’t mind some tummy time, I think it’s probably a good idea.

If you’ve got a baby who’s starting to look a little flat in the head department, talk with your pediatrician. Re-orient the crib to encourage Junior to look the other way, and try to alternate head positions and increase tummy time. Your pediatrician should also check for torticollis, a muscular condition that makes in difficult for babies to turn their heads in both directions. Rarely, a molding helmet can be used to help heads grow more round in shape, but beware that companies are marketing these directly to parents, and many babies with mild asymmetry really don’t need anything special, just some repositioning and time to grow and develop.

But for babies like Fiona’s, who absolutely hate tummy time, there’s no reason to think it’s critical. I’d try to make tummy time more fun, if possible, by lying down with the baby so she could see me. But bottom line: if she’s hysterical, pick her up. This issue is not worth any misery.

Chikungunya fever: A new infection, coming your way soon

March 13, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

I first heard about chikungunya about ten years ago, when outbreaks of this mosquito-borne illness were becoming common among travelers to India. It hasn’t taken long to spread to the Caribbean, and soon enough it’s likely to become widespread in the United States.

Sometimes called “Chikungunya Fever,” the illness causes fever and severe joint pain that can be debilitating, and can last for weeks. Fatalities are rare, and there is no specific treatment and no vaccine. Unlike West Nile Virus, the virus that causes Chikungunya triggers symptoms in almost everyone who is exposed.

The chikungunya virus is spread by the bite of one of two species of mosquitoes—species that are widespread in especially the southern USA. Those same mosquitoes can also transmit dengue, which has already started appearing in Florida and Texas.

We live in a big, interconnected world, with plenty of travelers and plenty of ways for new infections to cross continents and seas. In addition to new strains of influenza and the spread of resistant microorganisms, in the last ten years we’ve seen the emergence of new serious respiratory infections like MERS and SARS. Old infections, like tuberculosis, are back. And once-defeated vaccine-preventable diseases have returned to many communities, especially where vaccine uptake has fallen.

Germs have been around far longer than we have, and they will patiently wait for us to drop our defenses. We will not win this battle anytime soon. But we can still fight back:

  • Prevent mosquito-borne infections by preventing mosquito bites. Keep them off of your skin and out of your yard.
  • Continue to fund a strong public health infrastructure to track and identify health risks. We need to continue to pay attention, not just here, but throughout the world.
  • Advocate for universal vaccination of all children. It is always better to prevent infections than treat them. Vaccines need to be a public health priority, and no child should be denied vaccines because of financial reasons. Parents who are scared of vaccines because of misinformation need to hear the truth from friends, relatives, and their doctors.

Fixing peanut allergy by eating peanuts

February 20, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Peanut allergy can be a big deal. And most children who are allergic to peanuts will not outgrow their allergies. Avoidance has been the main way to treat peanut-allergic people, but that doesn’t always work. Peanuts can sneak into foods, especially with young children who may not be able to monitor their intake closely. What if there were an easy way to “cure” peanut allergy?

Researchers in the UK published a study last week looking at the safety and effectiveness of oral desensitization. They enrolled 99 children from age 7-16, all of whom with documented real peanut allergy by prior oral challenge (ie, they had all had serious, immediate reactions to peanut under controlled conditions in the past.) They were randomized into two groups. The control group was told to continue avoiding peanuts. The kids in the intervention group were given a daily dose of oral peanut flour, starting with a tiny dose of 2 mg, and working up every two weeks to a maximum dose of about 5 peanuts worth of protein.  Of the 49 children randomized into the intervention group, 6 withdrew from the study—four of whom because of reactions to the peanut. One child required one dose of epinephrine during the study because of a serious reaction. After the study period, all of the remaining participants in both groups had a double-blind, placebo controlled peanut ingestion to see if an ordinary dose of about 10 peanuts could be safely tolerated without a reaction.

Of the children in the control group, who had been told to just continue to avoid eating peanuts, none could then tolerate a peanut ingestion (46 of the 46 who were still participating at that time reacted.) In the exposure arm, about 85% of the participants who completed the oral desensitization scheme were able to tolerate eating peanuts. After the study period, most of the children who had been randomized into the control arm were offered oral desensitization, and they ended up doing about as well.

Though oral desensitization worked most of the time, some questions remain. It’s not known how long these children will remain desensitized—they may need to continue oral exposures daily to prevent relapse back into clinical allergy. And about 20% of the original intervention group didn’t complete the study for a variety of reasons, some of whom because they couldn’t tolerate the treatment itself. But for most of the children who could complete the therapy, oral desensitization seems very promising.

It makes sense, too—we know that early oral exposures to foods seems to prevent at least some kinds of allergies, and that policies that encouraged delaying foods (especially past six months of age) probably led to increased allergy.

However: this is still an area of active research. Please do NOT try this on your own. The research groups had specific protocols using purified proteins, and though it’s likely that widespread use of this technique will lead to a simple, home-based regimen, we’re not quite there yet. If your child has peanut allergy and you’re interested in pursuing oral desensitization, speak with a board-certified allergist about enrolling in a trial or learning more about this before you give your child any peanut.

edit 2/21/2014 — fixed broken link to study

Who needs a tetanus shot?

January 30, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Rich asked, “After a cut, how do I know if my child needs a tetanus shot?”

When in doubt, get one. Tetanus is way-bad news, and prevention is much better than trying to treat it. Keep your child up-to-date and fully vaccinated so you don’t have to worry about this; but if you’re not sure, or you’ve let immunizations lapse, just get the booster.

Tetanus is a deadly illness caused by contamination of a wound with the bacteria Clostridium tetani. The bacteria itself lives in soil all over the world, and can also happily colonize your intestine without making anyone sick. So it’s impossible to eradicate the bacteria itself, and no amount of good hygiene or clean living can eliminate the risk of tetanus. Still, good wound care does decrease the risk. In the developed world, tetanus often develops from contamination of the umbilical cord after delivery, when the cord is cut with dirty instruments. Without intensive care, most of these babies will die.

Photo from CDC

Photo from CDC

When a wound is contaminated, the tetanus bacteria produces a potent neurotoxin that causes severe muscle spasms, including spasms of the face and jaw muscles, causing “lockjaw”. The spasms are aggravated by any external stimulus—light or sound or movement—and can be so severe that swallowing and breathing become impossible. The spasms are so rigid and unremitting they look more like a seizure, though unlike a seizure they’re very painful and can last for weeks. Treatment with immune globulin and antibiotics can help, but it’s not very effective. People with tetanus may need complete sedation and mechanical ventilation for several weeks to survive.

Photo from CDC

Photo from CDC

Tetanus vaccinations have been available since the 1930s, and since then the burden of tetanus has all but disappeared. In the United States, only about 40 cases occur each year, almost all of these in people who have not been properly vaccinated. One recent report reviewed two cases of tetanus in Oklahoma, both in homeschooled, unvaccinated children. One of them was in the ICU on mechanical ventilation for over two weeks. Both families reported that they didn’t realize tetanus was so serious.

The usual vaccine series for tetanus starts with DTaP, which includes components to protects against diphtheria, tetanus, and pertussis. Five doses of this are given by age five (usually at ages 2 months, 4 months, 6 months, 18 months, and 4 or 5 years.) After that, a dose of Tdap is given at age 11 or 12, followed by a Td tetanus booster every five to ten years. If a child is up-to-date on vaccinations, no extra booster of tetanus is typically needed after a cut or wound, unless it’s very large and very contaminated. However, if you’re not sure your child is up-to-date, check with your child’s doctor. It is much more effective—and safer—to stay up on tetanus vaccines rather than get one after a wound.

It’s also important to clean cuts, burns, and other wounds thoroughly, with plenty of running water. The most high-risk wounds for tetanus and other infections are ones that are deep and difficult to clean, or ones with a lot of crushed or damaged tissue nearby. Even with a complete tetanus series, other kinds of wound infections can occur. If a wound is deep or hard to clean, or if the area starts to ooze, turns red, or has increasing pain, see your doctor.

Sleep aids for children

January 13, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

J-Mom wrote: “My 10 year old son often has trouble falling or staying asleep, mostly due to anxiety.  My son has not had any help from melatonin in the past.  We do several things to help him fall asleep, back scratch, singing softly, white noise machine, but some days are just impossible for him to sleep.  His doctor mentioned using a magnesium supplement as a natural sleep aid.  Do you have any experience with trying magnesium in kids?  Some cursory research I did suggests that it’s effective in cases of a Mg deficiency. Do some people use it even if no deficiency is found? Do you have to test them first? Any thoughts on this?  Thanks!”

The best ways to help a child relax and sleep are simple steps that J-Mom is probably already doing:

Have a set, relaxing bedtime routine.

Avoid screens for 1-2 hours before bedtime.

Set a consistent time for bed and waking.

Get plenty of exercise (though not in the few hours before bedtime)

Make the bedroom comfortable and happy.

Still, some kids even with great routines can still have trouble falling asleep or staying asleep. That can be especially so for children who are anxious—sometimes worries become magnified at night. Anxiety that causes significant day or night symptoms really should be discussed with a child’s pediatrician, and may need to be treated to help overcome its effect on sleep.

But to answer J-Mom’s question, what other kinds of sleep aids are there for children?

Melatonin is probably the most popular. What’s widely sold is a synthetic version of a natural human hormone that seems important in regulating sleep cycles and setting our “biologic clock” for the day. We know that children with damage to the part of the brain that makes melatonin have problems with sleep cycles, so why not give a little extra to help everyone sleep better?

In general, melatonin seems pretty safe for most people. It can have interactions with some medications, and there is some evidence that in at least some children it might increase the risk of seizures (though that is not seen commonly). There also isn’t great long-term data on daily melatonin use in kids. So I’d treat melatonin with respect, like any other medication: use it only if necessary, at a minimum dose, for a minimum amount of time.

J-Mom also asked about magnesium supplementation. Deficiencies of both magnesium and calcium have been linked to poor sleep in animal and observational studies, and magnesium supplementation in at least one study did seem to help elderly people sleep better. However, I couldn’t find any good evidence that magnesium supplements will help children sleep. An ordinary-dose magnesium supplement is unlikely to be harmful, so trying one isn’t unreasonable. Blood tests for magnesium levels can be deceptive—a one-time test may miss some people who are truly deficient, so testing children for blood magnesium levels is unlikely to be useful.

Chamomille and valerian are two herbs that have some evidence as sleep aids in adults, though again, studies in children are lacking. They’re both probably safe. One “natural product” that had once been touted as a sleep aid is Kava (sometimes called Kava-Kava), which has been linked to liver toxicity and many drug interactions, and should be avoided.

If a child is having significant sleep concerns, this ought to be discussed with a doctor. In addition to anxiety, medical things including asthma, allergies, sleep apnea, and restless leg syndrome can interfere with sleep. Though sedatives and sleep drugs are rarely used in pediatrics, there are often lifestyle changes and simple steps that can make a big difference. Though some natural sleep remedies are probably safe enough to try, they’re not the best way to help most children sleep better.

Does the influenza vaccine work? A small observational study

December 30, 2013

The Pediatric Insider

© 2014 Roy Benaroch, MD

Flu season is in full swing here, and I’m seeing dozens of feverish, miserable kids a week. Since it started early this year, maybe that means influenza will burn out and be over soon—but maybe not. Some years we get a “double dip” as a second strain of flu moves through town.

Influenza does a very good job of working its way through our communities each year. The symptoms of flu, including runny nose and cough, make transmission of infected mucus almost guaranteed.  And the virus itself, already very contagious, changes over time– so neither natural infection nor immunizations provide reliable lasting protection.

Though far from perfect, influenza vaccinations should be an important part of your family’s flu prevention strategy. Their effectiveness varies from year to year, but is probably overall in the range of 50-70%. Not great, but if even half of the cases of flu could be prevented, that’s a whole lot less misery, and far fewer people continuing to spread infection. Remember: for every case of influenza prevented, that’s fewer exposures for the rest of us.

I get asked a lot: how’s this year’s vaccine doing? Does it work? So a few days ago I collected data from my practice. I copied out the log book we keep of flu tests from 12-18-2013 to 12-24-2013—this is a list of all of the rapid flu tests we did in one of my two offices, the names of the patients and the results of the tests. Then I went back through their charts to see if they had been fully vaccinated against influenza this year.

Here’s the data, raw, in a “2×2 contingency table”:

Vaccine Yes Vaccine No total
Flu test POS 2 14 16
Flu test NEG 9 9 18
Totals 11 23 34

I’m not going to go into big-time statistics with this—I’m not pretending that this was a full-scale, professional study. This was just a convenience sample of kids who had flu tests done in my office over a few days in December. But what it does show is striking:

  • If you had a flu vaccine, your chance of testing positive for influenza was about 20%.
  • If you didn’t have a flu vaccine, your chance of testing positive for flu was 60%– three times the risk.

For you statistics types, I did plug these numbers into a web-based statistics package, and based on the Chi-Square calculation for a 2×2 contingency table the difference was statistically significant with p<0.05. However: I’m not 100% sure I did that right. I’m not swearing by my statistical chops here. Anyone out there with a good statistics background: if you want to chew on the data, please do, and post in the comments what you’ve determined.

Now, to be honest, there are some big-time caveats to this “study.” We didn’t systematically test people based on certain criteria. Each doc decided who to test, and it’s possible that some of my docs would be more or less likely to test people depending on whether they had had a flu vaccine. The test itself isn’t perfect—though a positive test is quite reliable, it’s possible that a negative flu test misses up to even 50% of true flu cases. The study wasn’t a randomized clinical trial- whether or not each child was vaccinated was up to the parents, and could have been influenced by their individual child’s risks of influenza exposure. And I didn’t look at the timing of the vaccines that were given—it’s possible that some kids in the “Vaccine YES” column received their vaccines too late in the season to be effective, and should have been counted as “Vaccine NO.” Furthermore: I only had access to my own records. Some of the “Vaccine NO” children could have gotten flu vaccines elsewhere.

Still: from this small sample, it looks like flu vaccines were strongly effective at preventing influenza in children at my practice.

More on preventing and treating influenza

Holding children back: Can it “prevent” ADHD?

December 19, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’ve been skeptical of the trend of “holding back” children with late birthdays. These are kids, usually born in the summer, who are just a few months short of the next grade cut-off. Some parents wonder whether it would be wise to hold them back a few months, so they end up one of the oldest (rather than youngest) kids in their class. This might seem to confer an advantage in terms of maturity, academic ability, and physical size, strength and coordination. Since children usually continue tracking up yearly, without later switching grades, kids “held back” in kindergarten will end up perhaps bigger and stronger and faster when trying out for teams in high school. A good idea?

Recent research has shown some stark differences in children who end up as the youngest versus the oldest kids in a classroom, which gives support to the idea of re-considering firm birthday-based rules for choosing when to start kids in school.

One good study was performed by researchers collaborating in Boston and Iceland. They looked at a nationwide cohort of Icelandic children, about 12000 kids, specifically grouping them by both birthdate and grade in school. Some findings from the study:

  • Mean test scores were lowest among the youngest children, especially in early grades. This gap lessened by middle school, but was still significant.
  • Children in the youngest third of a class were about 50% more likely to be prescribed medication for ADHD than kids in the oldest third of the class.

Similar findings have been reported by other researchers—this seems to be a real effect. Lumping children together by age creates a disparity in abilities within a classroom, with the youngest children being put at a relative disadvantage. That seems to create a greater likelihood of medical diagnoses and treatment for attention deficit disorder. It’s not known if holding back these younger kids with ADHD would allow them to become better students without fulfilling an ADHD diagnosis.

I’m not certain what the best approach is, here. Some kind of division between grades is inevitable, and some kids in any group are going to be the youngest. Perhaps smaller classes with a smaller age-range of children would help; or, perhaps an individualized approach to determining which kids will do best to start sooner versus later would address this disparity. In the held-back year, children who weren’t ready for school could get extra help with their attention abilities and other skills that will help them advance. However, this could lead to other problems later on, when kids of greatly varying age (and therefore physical and sexual maturity) are mixed together.

I don’t have a solution, but it seems like this is a genuine problem. We’d better figure out a way to work this out that doesn’t depend on more medications for the youngest kids in a grade.


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