Archive for the ‘Medical problems’ category

Protect your kids from the “new” respiratory virus

September 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Facebook and other social media sites are all a-twitter (ha!) about a “new” respiratory virus, sweeping the country and sickening thousands of kids. There is something new, or new-ish, out there, and it looks like the infection can get pretty bad. But now is not the time for panic. We’ll get through this, like we get through other spikes in viral infections. With some common-sense steps, your kids will be OK.

As reported officially by the CDC this week, in the last month hospitals in Illinois and Missouri reported an increase in emergency department visits and hospitalizations for respiratory symptoms. Since then, reports of similar illness are coming in from many other states, scattered across the country. Most (but not all) of the cases with more severe illness had pre-existing lung disease (like asthma).

The illness seems to be mostly affecting children. Most cases begin with ordinary, cold-like symptoms—and it’s likely that most cases actually never develop into anything more than that. The reported cases, so far, may well be a “tip of the iceberg” effect, where only the sickest children get tested and identified. These are the kids who develop trouble breathing and low oxygen levels, and often need intensive care. It’s quite likely that most children with this infection quickly recover after a cough, sniffles, and runny nose. Of the cases reported so far, only about 1 in 4 or 5 runs a fever. Probably, most children and adults who have this infection don’t seek medical care, and very few of them (so far) are even being tested for the likely viral cause.

Most of the reported cases are testing positive for a specific virus, called enterovirus D68. That virus was first identified in California and 1962, and until now had rarely been a reported cause of illness. The enterovirus group, as a whole, contains a lot of other viruses that cause a whole bunch of different symptoms—fevers, respiratory illnesses, GI problems, heart disease, rashes, and neurologic problems. Pediatricians and others who take care of kids are used to seeing tons of enterovirus, which usually strikes in the summer, most typically as hand-foot-and-mouth disease, or as a fever. So we’re used to these kinds of viruses, even though this specific one is a newly-recognized member of the family. We’re not 100% sure, yet, exactly how D68 is transmitted, but other enteroviruses spread though respiratory drops and in stool, and can remain infectious for a long time on contaminated surfaces.

As with many viral infections, prevention is the best strategy. Common sense things can really help: keep your kids home when they’re sick, and don’t send your kids off to play with sick children. Encourage your kids to wash their hands and use hand sanitizer frequently. Get a good night’s sleep and moderate exercise. Keep your child up-to-date on vaccines—though there is no specific vaccine for this enterovirus*, bacterial and viral coinfections with influenza and pneumonia can be prevented. If your child has asthma (or any other respiratory problems), make sure that you’re keeping up with all prescribed treatments, so things are less likely to spiral out of control when an infection strikes.

If your child does get sick with cough, look out for these symptoms:

  • Having trouble breathing. You may see individual ribs poking out with each breath, or the depression at the bottom of the neck sinking in, or bobbing up and down. Children with trouble breathing usually breathe fast, and sometimes breathe noisily.
  • Having trouble speaking. If you can’t get good breaths in, you can’t typically complete sentences and talk normally.
  • Seeming listless, with low energy. Children with serious respiratory compromise may not be getting enough oxygen to their brains. They can seem “foggy” or “out of it.”
  • Drinking poorly. Younger children and babies may have a hard time eating and (especially) drinking when they’re really ill.
  • Looking blue or pale.

If you’re seeing those kinds of symptoms, take your child to the doctor right away, or head to the emergency department. Even if things don’t seem quite that bad, if you’re worried, don’t hesitate to call for help.

Most children who are getting enterovirus D68 infection will do just fine. Some of you have probably already had children with this, and didn’t even know it. Every year, we see spikes of infections like this, caused by a variety of viruses like RSV, metapneumovirus, or influenza. Though there is no specific therapy for most of these, we’re pretty good at recognizing who needs extra help, and we can provide good supportive care when it’s needed. It sounds scary when you see news of a new, bad infection—but in truth, this isn’t very different from other infections we’re used to dealing with. We need to stay vigilant and keep our eyes on whatever’s out there making our children sick, but there’s no reason to get too worked up over this latest challenge.

*Fun trivia challenge: we routinely vaccinate against one other enterovirus, one that historically caused infections in the summertime. Guess!

This was adapted from a post I wrote for my practice website.

Back to school means back to backpack back pain

September 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

(Yes, I know, I need an editor to help me write better headlines for these stories. Send in your application to our human resources department.)

From researchers in Spain, a simple, brief study confirms what you would have guessed: kids’ huge backpacks are hurting their backs.

A team collected data from about 1400 students in lovely Galicia, Spain (where I have decided I want to go on vacation, despite the hordes of back-injured children. I won’t tell them I’m a doc.) Those carrying the heaviest backpacks had a 50% increased incidence of back pain. The risk was higher among girls.

There are a lot of pressures on kids these days. You’d think a huge backpack wouldn’t have to be one of them. There are some things parents might be able to do to mitigate this problem:

  • See if you can access textbooks online—and if so, encourage your child to just leave his books at school rather than lugging them back and forth.
  • If you can’t get online access, consider getting a second set of books to keep at home. You can probably buy them used on Ebay or Amazon, or maybe convince the school to give you a second set with a doctor’s note documenting back problems.
  • If allowed, try a rolling backpack. Many schools discourage these because they gum up the overcrowded hallways.
  • Use a backpack that fits right, with the straps tight enough to hold the weight high on the back. A high-quality backpack has wide, padded straps and is designed to keep the weight close to the body, not hanging down the back.
  • Discourage the slouchy, single-shoulder carry. A backpack with a significant amount of weight is best carried on straps across both shoulders—or even better yet, with a belt across the lower belly that supports some weight on the hips.

Contest Winners!

August 25, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Thanks for everyone for playing last week’s contest! The winners are all getting a copy of my Great Courses lecture series, Medical School for Everyone: Grand Rounds Cases!

First, the answers– What’s the name of the theme song of these TV shows?

Sanford and Son  – The Streetbeater, by Quincy Jones

Taxi  – Angela, by Bob James

M*A*S*H – Suicide is Painless, music by Johnny Mandel, lyrics by Mike Altman (the 14 year old son of the movie’s director, Robert Altman. It’s said that he made far more money by writing those lyrics than his father made from directing the film.)

The Benny Hill Show – Yakety Sax by Boots Randolph

The Dukes of Hazzard  — Gold Ol’ Boys by Waylon Jennings


Our winners are stuart, Sallie, Karen, Sheila, and Teresa! Woot! You all will be getting your courses in the mail soon, congrats!

If you didn’t win– please check out my lecture series over at The Great Courses. Feedback has been excellent! They have a 100% no-questions money back guarantee if you want to return your purchase, and the course is at special sale price right now!




Another win for dogs!

August 14, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Trying to decide whether to get a dog? Here’s more evidence that you should!

A 2012 Finnish study looked at about 400 babies from birth through the first year of life. Families kept diaries to track respiratory infections together with information about both dog and cat contacts.

Author and Misty, 1976

Children who lived with dogs had fewer colds and fewer ear infections; they were also prescribed fewer courses of antibiotics. The effects were dose-related, too—more time with dogs increased the health advantages. Cat exposures were much less beneficial.

Author and Lucky, 2014
Author and Lucky, 2014

Other research has shown that pet ownership decreases stress, increases life satisfaction, and may decrease the incidence of allergies. Dogs are also really fun to have around. Please consider a rescue pup from an organization like Furkids/SmallDog Rescue (they’re in Georgia—many other great non-profit rescues can be found all over the country. Look for your own local rescue via Google.) There are some great dogs out there who really need a home, and they’ll pay you back with love, companionship, and fun.

Cats are nice, too. I suppose.

Pregnant women should get influenza vaccines to protect their babies and themselves

August 4, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

The kids are heading back to school, and my zucchini vines are withered—that means summer’s almost over, and we’re heading back into flu season. This year, I’m going to try my best to convince as many of you as possible to get yourselves and your children vaccinated.

Why? Because I don’t like to see people suffer and die. We’ve got a good, safe, effective way to prevent influenza—and the more people vaccinated, the better it works. There are very few medical contraindications, and the CDC recommends that everyone aged 6 months and over get the vaccine each year. That helps protect us all.

Today I’m going to focus at the beginning of the life cycle, with pregnancy. We’ve known for a long time that pregnant women are especially prone to complications and death from influenza infection, and ACOG (The American Congress of Obstetricians and Gynecologists) has recommended since 2010 that women receive a dose of injected influenza vaccine during pregnancy. Uptake has been poor, in part because of lingering safety concerns.

There have been several recent studies that provide solid reassurance about the safety and effectiveness of influenza vaccines during pregnancy. In 2013, the New England Journal published a study from Norway that looked at 117,347 pregnancies—vaccinated moms were less likely to get influenza, and less likely to have their babies die. Another study, BMJ 2012, looked at about 55,000 pregnancies in Denmark, showing no increased risk of birth defects, preterm birth, or fetal growth problems after vaccination. That same Danish group published a second study from their data set showing no increased risk of fetal death. The Danish studies looked rigorously for adverse reactions, finding no support for any significant problems, though these studies were not designed to look at the effectiveness of the vaccines.

The effectiveness of these vaccines has already been demonstrated, both to protect mom and to protect baby. Pregnant women ought to make the safe choice: get vaccinated against influenza. It’s the right thing to do for you, and the right thing to do for your baby.

Mosquito wars: Why do some kids get bitten more than others?

June 30, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

“I have three children. But it’s only the middle one who gets bitten by mosquitoes! We’re outside for 20 minutes, and he’s covered with big itchy welts. They never bite the rest of us. I’m beginning to wonder what is wrong with him?”

I’ve wondered this myself—why are some people more mosquito-attractive than others? I’ve got some theories:

  1.  Some kids play more in the shade where mosquitoes lurk.
  2. Some kids are less sensitive to mosquitoes on their skin, so they don’t slap them away before being bitten.
  3. Some kids have a bigger reaction than others, so bites are more noticeable. (The welts you see are an allergic reaction to, essentially, mosquito spit. Like any other allergy, some people are more sensitive to others. It’s possible some people get bitten and don’t react at all.)
  4. Some children are just plain tastier. Mmmm, say the mosquitoes.

So what can you do about it? For families who have one or more bite-attracting kids, you need a good mosquito bite prevention and treatment plan for the summer.


Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis, dengue fever, and now chikungunya fever can be spread by mosquito bites in the USA. The itchy bites can be scratched open by children, leading to scabbing, scarring, and the skin infection impetigo. Prevention is the best strategy.

Try to keep your local mosquito population under control by making it more difficult for the insects to breed. Empty any containers of standing water, including tires, empty flowerpots, or birdbaths. Don’t let gutters or drainage pipes to hold water. Mosquitoes are “home-bodies”—they don’t typically wander far from their place of birth. So reducing the mosquito population in your own yard can really help.

There are yard sprayers either applied professionally or as a home job to reduce the local mosquito population. I have no personal experience with these products, and couldn’t find much in the way to independent assessments on the web. There’s no reason to think they wouldn’t work—but I’m kind of leery about the idea of spraying chemicals all over the place when there are simpler options. Still, for very sensitive people or heavy infestations, this might be a good idea.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Again, I don’t have much independent confirmation that these work, but they ought to be environmentally friendly and safe. If any of you visitors have used either these traps or the yard/mister sprays, let us know how well they worked in the comments.

Biting mosquitoes are most active at dusk, so that’s the most important time to be vigilant with your prevention techniques. Light colored clothing is less attractive to mosquitoes. Though kids won’t want to wear long pants in the summer, keep in mind that skin covered with clothing is protected from biting insects. A T-shirt is better than a tank top, and a tank top is better than no shirt at all!

Use a good mosquito repellent. The best-studied and most commonly available active ingredient is DEET. This chemical has been used for decades as an insect repellant and is very safe. Though rare allergies are always possible with any product applied to the skin, almost all children do fine with DEET. Use a concentration of about 10%, which provides effective protection for about two hours. It should be reapplied after swimming. Children who have used DEET (or any other insect repellant) should take a bath or shower at the end of the day.

Two other agents that are effective insect repellants are picaridin and oil of lemon eucalyptus. These have no advantage over DEET, but some families prefer them because of their more pleasant smell and feel. (Picaridin, oddly, smells like Fritos.) Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all.


No matter what you do, occasional bites are going to happen. To minimize the reaction to mosquito bites, follow these steps:

  1. Give an oral antihistamine like Benadryl, Zyrtec, or Claritin (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.) For kids who get bitten a lot, it makes sense to just give an oral antihistamine daily, before the bites.
  2. Apply a topical steroid, like OTC hydrocortisone 1%. Your doctor can prescribe a stronger steroid if necessary.
  3. Apply ice or a cool wet washcloth.
  4. Reapply insect repellent so he doesn’t get bitten again.
  5. Have a Popsicle
  6. Repeat all summer!

The many causes of sore throat: Diagnostic pearls

June 26, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Sallie wrote in about what to do when a common complaint is caused by an uncommon diagnosis. Her child was having a lot of sore throats, one after another, and saw a lot of doctors before the final diagnosis was reached. It’s a good question, and a golden opportunity to talk about keeping your mind open to new ideas, especially when things aren’t progressing as expected.

Pearl #1: Common diagnoses are common

Common things happen commonly—or, in other words, when someone is sick, it’s much more common for it to be a common illness than an uncommon illness. 90% of sick visits to pediatricians are for one of 5 diagnoses. Those rare things you read about on the internet? They don’t happen much. That’s why they’re called “rare.”

For people with a sore throat, the very common diagnosis is a viral infection that will get better. These infections begin with a sore throat, then turn into a stuffy nose and cough. There may be some fever and aches. We’ve all had this, multiple times. It’s an upper respiratory infection, and it’s the single most common driver of pediatric visits. And we still don’t have any effective treatment for it. Humbling.

One other common diagnosis that causes sore throat is a strep infection, or “strep throat.” (It’s never “strept throat.” I have no idea where that extra “t” comes from.) Strep is less common a viral sore throat, but it’s still fairly common. So many people with sore throat (especially when accompanied by fever and red tonsils and enlarged lymph nodes) get a strep test to see if it’s viral or strep.

Sore throats can be caused by other common infections, too: influenza, mononucleosis, or laryngitis. These usually cause other symptoms that make the diagnosis easy (or easy-ish), but sometimes they don’t… which leads us to the next pearl:

Pearl #2: It is much more common for common diseases to present uncommonly, than for uncommon diseases to present at all

Most people with influenza will have fevers and aches, in addition to sore throat; most people with croup or laryngitis will have hoarse voices or a barky cough; most people (at least teenagers) with mono will have fevers and tiredness in addition to their sore throat. But, again, not always. And these common conditions will sometimes fool you by not causing every expected symptom.

Or: let’s say a child has frequent sore throats—but they don’t seem to be viral or bacterial. That is, they’re not accompanied by fevers or runny noses or cough, and strep tests come back negative. What’s likely to be going on? It could be a genuinely weird, uncommon diagnosis—or, more likely, it could be a common thing that’s presenting in an odd manner. For instance, GERD (reflux) is common, and usually presents with heartburn or spitting up or an obvious sensation of food coming up into the mouth. But sometimes, it can cause sore throats.

Pearl #3: Even though they’re rare, if you keep looking you’ll find uncommon diagnoses Pearls #1 and #2 pretty much discount rare diagnoses, because they’re rare. But: every once in a while, those rare things do happen. But if doctors stop looking for them, they’ll never find them. Nearly everyone has a common diagnosis—except those rare people who don’t. And no one comes into the office with a stamp on their forehead that says “Think! I have something rare!”

Chronic or recurrent sore throats can rarely be caused by, among other things, a mass or tumor in the throat; or by nerve damage that prevents the vocal cords from operating normally; or by irritation from a toothpaste or mouthwash. Or from yelling frequently, especially if you’re not yelling correctly (yes, there’s a right way to yell that will cause less damage to your throat. Some people don’t do it right.)

One quite-rare example of a cause of chronic or recurrent unexplained throat pain is Eosinophilic Esophagitis (EE). This is an inflammatory condition that usually causes mostly esophageal symptoms (symptoms similar to heartburn, or to a feeling of food getting “stuck.”) Rarely, this uncommon condition can present in a very uncommon way: with sore throat. Which is actually, after a prolonged diagnostic journey, what Sallie’s son turned out to have.

The only way to diagnose EE is with a biopsy—you have to look down there, in the throat, with a scope, and get some tissue. Not everyone with sore throats needs that kind of evaluation. But we need to keep in mind that at least some kids with common complaints might just have something genuinely rare going on. If we don’t look, we’ll never see.

Hey! If you liked thinking about this—the way doctors think about making diagnoses, about looking for needles in haystacks and thinking critically about clues and medical mysteries, you might enjoy my lecture series at The Great Courses! It’s called “Medical School For Everyone”, and it’s a series of 24 medical case studies for laymen to try to figure out. I’ll give you the clues! Check it out through that link, and let me know what you think!


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