Archive for the ‘Medical problems’ category

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.

Strep throats can usually return to school the next day

September 10, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A simple study published in August, 2015 has shown that starting antibiotics for strep throat in the afternoon means that your child can safely return to school the next day.

Physicians in Virginia recruited 111 children with strep throat, proven by rapid testing and culture. All received a single routine dose of amoxicillin. The next morning, about 90% of them had a negative strep culture—they had already cleared the bacteria. The authors conclude that children who begin treatment for strep throat by 5:00 PM may safely go back to school the next day, without fear of infecting classmates, as long as they feel better and have no fever.

(I’m honestly not sure why they threw in the lack of fever as a criteria. But I think most kids with fever probably still feel pretty bad, and ought to take another day off—so I don’t disagree with their conclusions.)

Though the study didn’t address this, parents still need to complete the full course of antibiotics. We know from many older studies that less than a full course of antibiotics increases the risks of complications from strep.

Simple, quick, and a straightforward and well-informed answer. Science!

The latest in autism research

August 31, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Science: it may not always be the fastest, coolest, or sleekest way to get from one place to another. And it certainly is prone to dead ends and tangents. But if you want to really understand what something is all about, real science and real research are your best tools. Some great examples come from a few studies that came out this year about autism.

A British study from May, 2015 (summarized nicely here) looked at sets of twins, looking not only at diagnosed autism but at autistic behavior traits. Bottom line: autism is very largely genetic, as demonstrated by the higher association of autistic traits in identical twins. Since sets of twins largely share the same environmental and family influences, looking at identical (ie sharing the same genes) versus fraternal (sharing genes only as siblings) is a well-established way to separate out genetic and environmental influences. Using Fancy Math, the authors conclude that autism’s roots are found in one’s biologic make-up at least 74% of the time, and perhaps much higher than that. Studies like this will help future researchers concentrate on the most likely candidates for autism’s cause.

Another cool study, this one from the University of North Carolina, took the role of genes even further. We know that about 1,000 genes have been linked to autism—meaning that certain variations are more likely to occur in individuals with autism. What these researchers did is take that further, finding the exact functioning of one of these candidate genes. They found that the gene encoded for an altered protein that incorrectly flags other proteins in a cell for destruction. This causes the appearance of what are called ‘spines’ on cells in the brain—and, sure enough, we already knew that these spines were more common in kids with autism. It’s like connecting a circle—you start by figuring out which genes are present in autism, then figure out what they do, then confirm that the result of having these genes is present in children with autism. That’s how we go from understanding why autism occurs (a change in a gene) to how it occurs. And once we know how it occurs, we can start working on reversing or stopping the process, to preventing the altered gene from causing problems.

Studio 54The internet is a noisy disco of flashy memes, slogans, and catchphrases. And, of course, ubiquitous Google searches ironically misunderstood as “research.” But those sorts of things don’t help anyone really understand what’s going on. Want to understand and help families with autism? Support the science, not the noise.

“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.