Archive for the ‘Medical problems’ category

Human babies should not be born underwater

April 21, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

You’d think, being land-based mammals, we’d all be able to agree on the basic fact that humans breathe air, and that newborn human babies ought to be born into the air.  You know, so they can breathe. That’s how human babies have always been born, and that’s how all other primates are born, and that’s how all other land mammals are born. (Hats off to our cetacean cousins for their sticking to their evolutionary guns on the water birth. Unlike humans, Flipper doesn’t do well in air.)

And yet, there’s always someone willing to wonder, “Could there be a better way?” Immersion in water during labor or birth is touted by some as beneficial to both mother and baby. What does the evidence show? I’m willing to suspend common sense, here—show me it’s safe, then, sure, let’s join the dolphins.

Except it isn’t safe. And the purported benefits? No so much.

In a joint statement from the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists, physicians have reviewed what we know and don’t know about water birth. What we do know, really, is very little—studies are of limited quality and small scope, and use varying methods and varying definitions of “water birth.” Many of the “studies” are not in scientifically reviewed journals, and are more like collections of cherry-picked stories than actual objective evidence. Most of these “studies” show zero objective benefit during labor, though some pooled studies combining case series show a reduced use of anesthesia and a reduced time of labor during immersion in water. However, no matter how the data are combined, there’s no difference in perineal trauma, tears, c-section rates, or a need for assisted delivery. And there are no individual trials or pooled collections that show any benefit to the newborn infant at all.

What there are, though, are several case reports and case series of babies suffering harm from water birth. Because the numbers of women undergoing labor or birth in a water bath aren’t known, we can’t estimate the rates of these complications. But the complications are real and can be devastating: umbilical cord tears leading to hemorrhage and shock,  hypothermia, drowning, seizures, brain damage, and death. Are these kinds of risks an acceptable trade-off for the meager, unproven benefits of water birth?

The ACOG and AAP point out that immersion in water during what’s called the first stage of labor—the early part, when there are regular contractions but the cervix isn’t fully dilated—may be appealing to some women, and may offer some potential benefit in terms of pain control. Even though there’s no evidence of benefit to the baby, as long as immersion doesn’t otherwise interfere with good care it’s not unreasonable. Rigorous protocols ought to be in place, though, to protect mom and baby—including maintenance and cleaning of the tubs, infection control and monitoring, and careful observation for signs that it’s time to move out of the tub. Before someone gets hurt.

However, immersion during the second stage of labor, when the cervix is dilated and Junior is making his way into the world we share—that’s of zero benefit, and can lead to great harm. Humans are not water creatures, and it’s not likely that our babies really ought to be born underwater.

The Insider’s guide to allergy medications

April 7, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Ah, spring is here. Time to plant my little seedings. Time to wash the yellow pollen off my car. And time to sniffle, sneeze, and snork. Confused by all of the choices of allergy meds? Look no further than this short, no-nonsense Pediatric Insider guide to allergy medications.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which still works well—but it’s sedating and only lasts six hours. Most people 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 daily. There are a few prescription antihistamines, but they have no advantage over these OTC products.

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 genertics 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 he’s got in back.

Nasal cromolyn sodium (OTC Nasalcrom) works some, though not as strongly as rx nasal sprays. Still, it’s safe and worth a try if you’d rather avoid a prescription.

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. The prescription nasal sprays, ironically, are much safer than OTC Afrin.

Nasal Steroid Sprays include OTC Nasacort, and Rx Flonase (or generic fluticasone), Rhinocort, Nasonex, Nasarel, Veramyst, and others. All of these are essentially the same (though some are scented, some are not; some use larger volumes of spray.) All of them 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.

Antihistamine nose sprays are topical versions of long-acting antihisamines, best for sniffling and sneezing and itching. They’re all prescription-only (though they’re super-safe). They’re marketed as either the Astelin/Astepro twins (Astepro came out later, when Astelin became available as a generic; it lasts longer) or Patanase.

Bonus! 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, which works about as well as rx Patanol, which they’re trying to replace with rx Pataday.

Does acetaminophen in pregnancy cause ADHD?

March 20, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Kelly and a few other readers contacted me about a recent study that links acetaminophen use in pregnancy to the later development of ADHD in children. Is Tylenol yet another thing pregnant women need to avoid?

The study, titled “Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders” was published this month in JAMA Pediatrics. Dutch researchers looked at about 60,000 children born from 1996-2002. Their parents have been filling out questionnaires and completing phone interviews from pregnancy onward about medication use, illnesses, and many environmental exposures. This study looked specifically at reports of whether mom took acetaminophen during pregnancy, based on multiple phone interviews during pregnancy and six months after each child was born. They also asked about mom’s health during the pregnancy, and about a possible family history of mental disorders. Then, the researches used multiple ways to determine whether these children had ADHD or ADHD-like symptoms at age 7. Parents completed a structured developmental screening tool, and ADHD diagnoses were further collaborated by mining the Danish Psychiatric Central Registry. They also looked at which children had ever filled prescription for a medicine typically used to treat ADHD.

They found that acetaminophen use during pregnancy was correlated with an increased risk all of their ADHD measures—not only the actual diagnosis of ADHD, but ADHD-like behaviors on rating scales and Ritalin prescriptions, too. The risk was increased by 15-40%, depending on the measure; and the risk increased with increasing acetaminophen exposure. Even when the authors factored out the influences of fevers and infections during pregnancy and mom’s mental health, the association remained strong.

So what does this mean? It’s too early to say if acetaminophen caused ADHD. It may be that there was some other factor that drove women to take acetaminophen, such as reduced coping skills or family support. But clearly, there is something going on here, and it is possible that acetaminophen really is the culprit. In this study, 56% of pregnant moms reported taking acetaminophen. Even if the causal factor only increased ADHD risk by a small amount, the net effect would be substantial, given how common acetaminophen use seems to be.

Previous studies have looked at other exposures for pregnant women that might be linked to later ADHD. A 2012 study from New England showed that fish consumption was correlated with a lower risk, and industrial mercury exposure with a higher risk of later ADHD. This study, like the current one, could not prove that these influences were causal, or only associations. But they were statistically valid, and raise important questions about prenatal influences on later mental illness, school, and behavior problems.

If you’re pregnant, I’d think twice about taking any medication, including acetaminophen. While there are times when the risk: benefit ratio of a medicine is clearly justified, medicines should only be taken when there isn’t a more-safe option. Headaches could perhaps first be treated with massage and relaxation time (which I suspect every pregnant woman deserves anyway.) If medicines are used, patients should strive to use the lowest effective dose for the shortest amount of time.

And don’t forget to eat more fish—preferably the kind without any mercury.

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.


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