Archive for the ‘Medical problems’ category

A cold, the flu, or sinusitis? Part 3: Myths

October 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

You might not like to hear it, but the truth is….

 

Nothing really works well to treat these things

Colds, flus, and sinusitis all share some things in common—and the most important one is that just about all of us get these, and they make us miserable, and we want them to go away. Billions are spent on all sorts of things to treat these conditions, both from pharmaceutical companies and from companies that make supplements and other alternative-health nostrums. We’ll try just about anything. But if clinical studies reliably show that just about nothing really helps, why do we keep buying them?

I think the most important factor is simple human nature, and the way that symptoms change. If you have a cold, the symptoms get better and worse throughout the day—so if you take medicine or supplement XX when you feel really bad, the natural ups and downs average out, and you’ll feel better. But: you would have felt better anyway! Still, human nature, you took the magic beans (that you paid for), then you felt better, so there must be a connection, right?

That happens at the end of an illness, too. Let’s say you’ve had a cold for 6 days, and you go to the local get-me-some-drugs at the QuickieClinic. You get some antibiotics, and a few days later you start to feel better. Boom, QED, there’s all the proof you need. (BTW, docs are pretty much just as bad about giving out unnecessary antibiotics, too.) But: you were going to get better anyway.

Think about this, it’s really important: many symptoms occur like a mountain, with an up and a down. If you try therapy at the top, when you’re feeling bad, you will feel better. But that doesn’t mean that the therapy was why the mountain went downhill.

 

Flu shots work

The effectiveness of flu vaccines varies from year to year, but typically runs ~ 50-75% — that’s pretty good, really, for a health intervention (it’s much better than, say, the effectiveness of taking a cholesterol-lowering drug to prevent a heart attack. And some people take those every day for years.) It does mean, though, that in a family with say four people who’ve gotten flu vaccine, one child may not be well protected. That’s why it’s important for the whole family to get it.

Also: flu vaccines only prevent the flu. They don’t prevent colds. And they take 3 weeks or so to “kick in” – you don’t get instant protection.

 

Flu shots cannot cause the flu

MythsNo. They can’t, and they don’t. They can sometimes cause a little fever or achiness, but that is not the flu—and anyone who’s actually had the flu will tell you that these mild symptoms after a flu vaccine are pretty much nothing. Sometimes, right after a flu vaccine, someone does get the flu—that’s because we’re giving flu vaccines during flu season, and if you don’t get it in advance it can’t protect you. The vaccines take about 3 weeks to work. If you catch influenza right after getting the flu vaccine that’s called “bad luck” or “bad planning”, not “bad vaccine.”

 

Green snot means sinusitis

No, green snot means it’s been sitting around up your nose (you’ll often notice this overnight), and your white cells are busy fighting off the viral infection. Good for your white cells. Go blow your nose, and stop looking at the color—it doesn’t matter what shade it is.

 

Flu tests are needed to diagnose flu

Commercially available flu tests aren’t very good—they give a lot of false negatives (a negative test even in the setting of flu), and some false positives (a positive test in a person without flu.) Many health care facilities don’t even use them. A flu test can be helpful, sometimes, if I’m on the fence about a diagnosis, but they’re really just not very reliable to help make decisions about treatment.

 

Cold weather causes colds

Colds are caused by viruses, one of many from families called “rhinovirus” and “coronavirus” and others. They’re not caused by cold weather. BUT there is a germ of truth here: cold air in the nose can make it more likely that these viruses can be transmitted. Grandma may have been right!

 

I’m sure there are other myths, feel free to add your own in the comments!

 

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

A cold, the flu, or sinusitis? Part 2: Treatment  

October 12, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The previous post was about the symptoms of colds, the flu, and sinus infections—they’re not the same. This time, we’ll cover their treatment. And, surprise, it turns out that treating all of these is pretty much the same.

Style: "Neutral"

The most important part of treatment is rest and comfort. Get more sleep, and stay out of school or work until feeling better. That helps you and your children recover, and hopefully prevents the spread of illness. Drink more fluids, and have some soup.

To treat aches and pains, use acetaminophen or ibuprofen. It’s better to use these around-the-clock for a few days rather than just when symptoms become bad—these medicines are better at preventing pain and fever than treating pain and fever.

Treating nasal congestion is all about drainage. Use a humidifier and/or nasal saline spray. If your child is old enough, sometimes OTC decongestants given orally or as a nasal spray can help some, but they’re certainly not miracle drugs.

Coughs are annoying, but they’re there for a purpose: to get mucus up and out. If a cough is bothering your child, one of the best treatments is ordinary honey (for age 12 months and up.) Older children can sometimes benefit from OTC cough suppressants, but, again, they don’t work great. If your child has asthma, it’s probably a good idea to start up rescue medications during a cough.

There are a few more-specific treatments, depending on the diagnosis. If it’s influenza, a specific anti-viral medication (usually Tamiflu) can help some if started within the first 24-48 hours of symptoms. But the benefits of this medicine are modest at best. Tamiflu does not prevent serious complications, and only reduces symptoms by a little bit. Most people with influenza won’t notice any huge improvement with Tamiflu.

Sinusitis is typically treated with antibiotics, though even then the benefits of antibiotics are often over-stated. Studies looking at populations of both children and adults, comparing active antibiotics versus placebos, have shown really limited benefits to using antibiotics to treat sinusitis, at least ordinary, uncomplicated cases. And, of course, these same studies show that people taking antibiotics are much more likely to experience side effects and adverse reactions than those taking placebos.

The good news is that whatever you do, you’re going to get better. Whether it’s a cold, the flu, or sinusitis, symptoms will get better with or without treatment—though you’re going to be feeling sick for a while. If that’s the case, why does it seem like Tamiflu, antibiotics, OTC supplements, and all sorts of other things “work”? Next up, Part 3: Myths.

 

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

October 8, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

 

We’re heading back into colder weather again, and along with the change in the leaves comes more people with miserable, congested noses. Today’s post is all about telling the difference. Next time, I’ll tell you how to treat them.

 

The common cold

Captain ColdAlso called an “acute upper respiratory infection”, a “cold” is far and away the most common cause of congestion and cough. It usually starts with a vague ill feeling, followed by a sore throat and then a congested or drippy nose. Sometimes, there’s a fever at the start of the illness (that’s more common in babies and younger children.) A few days later, a cough begins. On average, the symptoms of a cold last about 10 days, though often the cough lingers for 2 or 3 weeks.

Notice: the symptoms grow or develop over several days, and the fever is really only at the beginning. By day 7-10 things are starting to improve.

 

Influenza

“The flu” is a specific viral infection, and it’s not just a bad cold. Symptoms including fever, sore throat, body aches, nasal congestion or drip, and cough all pretty much start all at the same time, or within a few hours. Sometimes there are also gastrointestinal symptoms like abdominal pain or vomiting. Fever and aches are usually the worst symptoms – you feel, pretty much, like you’ve been hit by a truck. The worst symptoms last five days, but the congestion and cough often linger for another week or so.

Notice: the symptoms are sudden and severe.

 

Sinusitis

Most common colds, of course, go away on their own, with or without any kind of treatment. But rarely a common cold can turn into a sinus infection. That occurs when the persistent mucus becomes infected with bacteria, leading to worsening symptoms 7-10 days into an ordinary cold, or persistent symptoms 2 weeks after a cold begins. Very rarely, sinusitis can start suddenly and severely, but much more typically there is first a cold that turns into a sinus infection.

Notice: a sinus infection is like a cold, but the symptoms worsen after 7-10 days. A congested nose for less than 7-10 days is unlikely to be a sinus infection, even if it feels really stuffy.

 

Next up: treating colds, the flu, and sinus infections.

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

 

Serious side effects of vaccines are rare. What does that mean?

October 1, 2015

The Pediatric Insider

© 2014 Roy Benaroch, MD

Since every second of my life, and then some, seems preoccupied with the transition to the New and Improved ICD-10 code set — I can’t imagine how I lived so long without being able to code for macaw attacks – I’ve had no time to write anything new. So today you get a refurbished, classic post. And by classic, I mean old. I put a new photo somewhere in the text to freshen it up, so I promise it’s worth a read. Enjoy!

“Serious side effects of vaccines are rare.”

Vaccines are not 100% safe. Like any medical intervention, there’s some risk (honestly, like anything at all, anything we do, there’s some risk. But let’s not get sidetracked here.) Side effects, including serious side effects, can happen after vaccines. What are these reactions, really? How often do they occur?

Here, I’m only talking about genuine, established side effects. Things are genuinely, scientifically, reliably linked to vaccines. Some things that had once been thought be a potential side effect of vaccines are now known to have been caused by other conditions (like seizures and encephalopathy after DTP, now known to be most-often caused by a rare genetic condition called Dravet Syndrome, that would have occurred whether the child was immunized or not.) There are also side effects reported that are clearly unrelated, like choking on a bean in the trachea or turning into the Incredible Hulk. We’ll ignore those, and concentrate on the real, serious, potentially deadly side effects that have been documented to be caused by vaccines. I’m going to list all of them, for every vaccine.

Any vaccine – Serious allergic reactions can occur. These do happen, though the rate of serious reactions depends on the vaccine. For most immunizations, the rate is less than 1 in 1 million; however, some very-rarely used vaccines can have a higher rate. The yellow fever vaccine, for instance, causes severe allergic reactions in about 1 in 55,000 people; anthrax vaccine is estimated to cause severe reactions in 1 in 100,000. Almost all severe allergic reactions occur within minutes of vaccination, and health care facilities who give vaccines should have people trained to treat rare reactions like these.

Influenza – The Pandemrix brand of influenza vaccine, which was never licensed or used in the United States, has been linked as a cause of narcolepsy in about 1 in 55,000 vaccine recipients in several countries in Europe. This product was only used during the 2009-2010 season. The CDC is currently sponsoring an international study to try to better understand this, and why that one formulation seemed to be a unique trigger for this rare condition.

In 1976, a different specific Swine Flu vaccine was linked to about 450 cases of Guillian-Barre Syndrome (GBS), a neurologic disorder that was estimated to occur in about 1 in 100,000 people who got that specific vaccine that year. The baseline rate of GBS is probably 1-2 per 100,000, so when 45 million doses of vaccine were given in 1976, some cases were going to occur coincidentally. Substantial studies have shown that other flu vaccines from more-recent years do not cause GBS. Ironically, influenza disease itself causes more GBS than even the 1976 Swine Flu vaccine is purported to have caused, and even if that association were true influenza vaccination would prevent far more GBS than it would trigger.

Japanese encephalitis – Rarely used in the United States, the Japanese Encephalitis vaccine has been linked to prolonged arm and shoulder pain among vaccine recipients. I could not find an exact rate, but this appears to be an uncommon reaction.

MMR — About 1 in 30,000 people given a dose of MMR will have a drop in their platelet count, which can predispose to bleeding. The rate of low platelets is much higher in real measles than after the vaccine, so, again, ironically MMR probably prevents more cases of low platelets than causes it. This condition is temporary and almost always requires no treatment at all.

Polio — The oral polio vaccine, no longer used in the United States, could trigger genuine, full-blown polio in some people—probably about 8 per year in the entire US, back when we used the oral version. We’ve been using only the injected polio since the mid-1990s, which carries zero risk of causing polio.

Rotavirus – Rotavirus vaccines carry a small risk of causing an intestinal blockage called “intussusception.” This condition is treatable, though it often requires a brief hospitalization. The risk was highest after the first doses of the original brand of vaccine, Rotashield, which was withdrawn from the market; the risk after current brands is probably in the range of 1-3 in 100,000. However, rotavirus itself, the real infection, is also a cause of intussusception. To put this in perspective: using the high end of the risk estimates, about 40-120 vaccinated infants may develop intussusception each year in the USA, compared to 65,000 infants who had been hospitalized for rotavirus illness each year prior to the vaccine becoming available.

Smallpox – Routine smallpox vaccinations stopped by 1970 in the US, but a smallpox vaccine is available for high-risk researchers and military people and others thought to be at risk of exposure. The vaccine can cause heart problems in 1 in 175 people, and there is a risk that the vaccine virus can spread on the skin of a vaccinated person or contacts, especially when the skin is damaged or there are immune problems.

Yellow fever – Used only in certain travelers, some kinds of typhoid vaccine can causes severe neurologic problems (about 1 in 125,000) or death, especially in elderly people (1 in 500,000).

That’s it—that’s the list. All of the serious, lasting, you-need-to-worry about side effects. You’ll notice that almost all of the really serious side effects occur only with vaccines that aren’t likely to be recommended for your children. Most of the routine childhood vaccines (DTaP, HIB, pneumococcal conjugate, hepatitis B, hepatitis A, chicken pox, meningococcal conjugate, human papilloma virus) only carry a very rare risk of allergic reactions, and even those are entirely treatable and temporary. In other words, science has failed to find any evidence for any real, lasting, serious vaccine reactions among any of the vaccines currently recommended for routine use in children in the United States.

When we say “serious side effects are rare,” we mean “serious side effects are very very very rare.”

This is an orcaWhat parents need to worry about are diseases, not vaccines. Don’t let the scaremongers and internet rumors sway you. The risk of a serious, lasting side effect from any routine childhood vaccine is just about zero. Make sure your children are safe and protected. Vaccinate!

The myth of iodine allergy

September 28, 2015

The Pediatric Insider

© 2013 Roy Benaroch, MD

 

Since every second of my life, and then some, seems preoccupied with the transition to the New and Improved ICD-10 code set — I can’t imagine how I lived so long without being able to code for macaw attacks – I’ve had no time to write anything new. So today you get a refurbished, classic post. And by classic, I mean old. I put a new photo somewhere in the text to freshen it up, so I promise it’s worth a read. Enjoy!

 

One of the goals of this site—along with soliciting donations and letting me write and publish goofy stuff—is to promote good, solid science-based medical information. If you’ve been around, you know I don’t go for made-up-stuff. And I especially don’t like it when it’s other doctors spreading the misinformation.

Have you had a reaction to intravenous contrast dye during a CT scan or other exam? Have you been told you’re allergic to iodine, and that you should avoid seafood?

Wrong wrong wrong. You’re not allergic to iodine. And you can almost certainly have seafood—you’re no more likely than anyone else with any allergy to be allergic to seafood, or salt, or dairy products, or anything else that contains natural or added iodine. The only thing you may need to avoid is that same kind of IV contrast dye in the future—though even then, it can probably be safely used with simple premedication.

Iodine is a natural element. It is essential for life—if you didn’t have any, your thyroid gland couldn’t work, and you’d get sick and die. Iodine is found especially in seafood, but also in some vegetables and dairy products (especially if the cows were grazing on land where the soil was rich in iodine.) In many countries, including the USA, salt is routinely fortified with iodine to prevent thyroid disease.

Allergies are almost always triggered by proteins—big, honking, complex molecules made of chains of amino acids—or other big molecules. Someone who’s had a reaction to IV contrast dye has not reacted to the iodine, but to the other constituents of the dye. People who’ve had these reactions may need to be premedicated or use a different, low-reaction type of dye is used in the future if they need further studies.

These are dangerous macawsIt may be that people who’ve had reactions to IV contrast might also have a food allergy, and that food allergy might even be to seafood. But there is no increased risk of seafood allergy than to allergy to any other foods. You might be allergic to seafood or milk or eggs or peanut or… nothing. But you’re not allergic to iodine.

Refs:

http://www.ncbi.nlm.nih.gov/pubmed/20045605

http://www.ncbi.nlm.nih.gov/pubmed/16541971

Want kids to see better? Send them outside

September 24, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

This month in JAMA, physicians from China reported a large, randomized trial – and it turns out that, at least in China, more outdoor time means fewer kids need glasses for nearsightedness.

About half of 1900 students from 12 schools were randomized to either get an extra 40 minutes of outdoor play each school day, or continue their usual routine. They were followed for three years and then assessed for nearsightedness, or myopia.

In the control group (with no extra outdoor time), 40% of the children were myopic by the end of the study; those who got extra outdoor time reduced their risk to 30%. The risk remained about the same when parents’ eyesight was factored in. And among children who were myopic at the start of the study, their vision worsened more quickly if they didn’t get the extra outdoor time.

It’s been observed that a lot of close-up work in young children seems to contribute to myopia. About 90% of young adults in the East Asian countries of China, Taiwan, and South Korea are myopic, compared to 20-30% in the UK. Rates have risen dramatically in these Asian countries as academic pursuits have begun to dominate their early educational experiences—and perhaps the close reading work, instead of playing outdoors, is to blame.

It’s not clear whether increased outdoor play would decrease myopia in the USA—but this is just one more potential plus for outdoor activities. Now stop reading and go outside!

Vision therapy for dyslexia and reading disorders

September 14, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Dyslexia is a specific learning disorder—a problem not with intelligence or a lack or trying, but with the ability of children to learn to read. It affects 3-20% of children (depending on the exact definition used). Because reading is essential to school success in almost every subject, problems with reading need to be addressed as early as possible.

One kind of therapy for dyslexia is based on the premise that reading problems are caused by vision problems—though the scientific community isn’t convinced that this is the case. The large, national professional bodies representing pediatricians, ophthalmologists, and optometrists recommend only routine vision screening for children having reading difficulties. Nonetheless, there’s a cottage industry of so-called developmental or behavioral optometrists who offer a variety of services commonly called “vision therapy” to help with reading problems and other developmental challenges. There is very little objective evidence that any of these therapies offer more than short-term improvement. Besides, they’re very expensive, and often not covered by medical or vision insurance. Parents need to know whether this kind of therapy is worth pursuing.

Researchers in the UK published a study in May, 2015, looking at a large number of children in a birth cohort from the early 1990’s. These children had all had thorough serial health assessments as they grew. For this specific study, they found that 3% (172 kids) in the birth cohort of 5822 children met objective criteria for reading impairment. All of these children had a very through vision evaluation, and most of those were completely normal; the small number of reading-disabled kids who weren’t 100% normal on their vision assessment had subtle abnormalities. The authors concluded “We found no evidence that vision-based treatments would be useful to help children with severe reading impairment.”

A strength of the study was that it was population-based—it didn’t just include children referred to a clinic because of problems. And the findings were objective and validated. However, the authors only looked at the most severe level of reading impairment. It’s possible they may have missed vision issues in less-affected children (though one would think, if vision were the root of reading problems, that the worst readers would have the most egregious and easily-identified vision problems.)

This study adds to the weight of evidence that “vision therapy” is unlikely to be useful for reading problems, and may be a waste of time and money.