Archive for the ‘Pediatric Insider information’ category

Mosquito prevention and treatment: A quick guide for families

May 19, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

 

Mosquitoes are more than an itchy nuisance. Though uncommon, serious diseases such as West Nile Encephalitis and dengue fever can be spread by mosquito bites in the USA. Our newest worry, Zika virus, is especially dangerous to pregnant women and their unborn babies — and there will almost certainly be US cases this summer.  Itchy mosquito 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. Avoid allowing 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.

Most biting mosquitoes are 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 like mosquitoes and ticks. 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.

Other agents that are effective insect repellants are picaridin, oil of lemon eucalyptus, and IR3535 (also known as ethyl butylactylaminopropionate. Tasty!) These are probably not more effective than DEET, but some families prefer them because of their more pleasant smell and feel. Other products, including a variety of botanical ingredients, work for only a very short duration, or not at all. The CDC has extensive info on these products here.

There are also yard sprayers or misters, devices that widely spray repellants or pesticides. I couldn’t find much in the way to independent assessments of these products, but there’s no reason to think they wouldn’t work. Still, I’m leery about the idea of spraying chemicals all over the place, when we know that DEET sprayed on your child is effective and safe for both child and environment.

About “Organic” or “Natural” insecticides or repellants – those are just  marketing words. Organic compounds are no more or less likely to be dangerous to people or the environment than non-organic compounds; likewise, “natural” in no way implies that something is safe or effective (or even “natural” in the sense that most people mean that term.) These words are tossed around as part of the typical salad of meaningless marketing-speak on labels. Ignore them.

There are also devices that act as traps, using chemicals or gas to attract the mosquitoes from your yard. Although I don’t have much independent confirmation that these work, they are probably environmentally friendly and safe.

Some children do seem more attractive to others to mosquitoes, and some children seem to have more exaggerated local reactions with big itchy warm welts. To minimize the reaction to a mosquito bites, follow these steps:

  1. Give an oral antihistamine like Zyrtec or Claritin, or old-school oral Benadryl (do NOT use topical Benadryl. It doesn’t work, and can lead to sensitization and bigger reactions.)
  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!

Updated and adapted from previous posts. Reduce reuse recycle!

Is 24% the correct goal for c-section rates?

May 17, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Yesterday I wrote about a recent Consumer Reports article about c-sections and how to avoid them by choosing a hospital with a low c-section rate. I’m not convinced that’s the best way to choose a hospital.

In their piece, Consumer Reports quoted an overall “goal” for c-section rates of 23.9%, as determined by the US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (That’s right, the USDHHSODPHP. Yes there will be a quiz.) I was kind of flip in my dismissal of that number – I may have said something about it being “made up” or “pulled from the USDHHSODPHP’s nethers” – because to my knowledge there’s no data supporting an exact c-section rate that’s ideal for maternal and baby health.

In the spirit of pretending to be a journalist, I looked into that number a bit further. And it turns out I was right. It really was pulled out of USDHHSODPHP’s nethers.

Here’s where it comes from, see for yourself: MICH-7.1, a goal to “reduce cesarean births among low-risk women with no prior cesarean births.” They took the 2007 rate –estimated at 26.5% — and reduced it by a target of 10%. Not 11% or 5% or 15%, but 10%, because that’s a nice number. And that’s it. Our current official goal rate of 23.9% is exactly where we were, reduced by a nice round percentage.

The number has nothing to do with healthy babies or moms – they didn’t even try to figure out what c-section rate results in the best health outcomes. Or even the lowest cost, or the best patient satisfaction, or anything like that. It’s just an arbitrary number that could as easily been set higher or lower. I mean, if a 10% reduction is good, why not 15%? Or 41.5%?

Why this matters: women are trying to make good decisions for their own health and the health of their babies. Arbitrarily telling them that c-sections are bad and that hospitals that do fewer of them are good is, well, silly and paternalistic and insulting. We can admit that we really don’t know the perfect percentage for a c-section rate, which means it’s OK that it’s not the same at every hospital. Whether you get a c-section should depend on your health, your baby’s health, and a frank and honest discussion with your OB or midwife about the risks and benefits of a vaginal or c-section delivery. Let’s leave the USDGGSODPHP out of it.

Expired Epipens are better than nothing

May 15, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A small study published this month showed that most Epipens retain their potency for at least 4 years after their expiration date. That’s no guarantee, of course. I’d still recommend as a “best practice” that families replace them as they expire. But it’s reassuring to know that they’ll usually be effective even when expired. And using an expired Epipen is almost certainly better than using nothing when there’s a life-threatening allergic reaction.

It’s a simple enough study. Over 2 weeks, families attending a clinic in California were asked to donate expired Epipens for analysis. They collected 40 devices that had expired up to 50 months before the study, and used state-of-the-art chemical analysis to determine the potency of the medication in the vials. None of them looked discolored or unsafe. All of the pens that had expired up to 2 and half years ago had at least 89% of their original potency, and even most of the older ones remained in the 85% range. Though overall the dose potency slowly deteriorated, all of these devices would have still been helpful to treat an anaphylactic reaction.

A few small previous studies reached similar conclusions in 2015 and 2000. Though these studies looked at the Epipen brand of auto-injectors, it’s likely that studies of similar or generic products would yield the same results.

The authors of the study aren’t recommending that families hoard Epipens, or delay replacing them – but they do point out that their findings support further studies to extend the labeled shelf life of these products. And if an expired Epipen is all you’ve got, it’s probably OK to use it as long as it’s not obviously broken or discolored.

To help keep your Epipens in good shape, store them somewhere relatively cool (not cold), and away from light, preferably in the original packaging. Do not leave them in your car in the summer. Epinephrine is a finicky sort of chemical, and light and heat will speed its deterioration. Although you can hold on to expired Epipens as a “backup”, it’s best to replace them so you’re 100% sure that you’ve got what you need when you need it.

 

Molluscum: Maybe best to leave them alone

May 8, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Alina wrote in, “If Molluscum Contagiosum is limited to a few bumps, 10 or less, does it necessarily need treatment or will it pass on its own?”

Molluscum (plural, mollusca) will usually go away on its own. Eventually. Except when they don’t.

Some things I can say for certain: molluscum is one of the least-favorite things for pediatricians and dermatologists to deal with. There’s no great therapy, and they don’t always do what they’re supposed to do. Parents hate them, and whatever we try doesn’t work anyway. Stupid molluscum!

Molluscum contagiosum looks like little, waxy-looking, skin-colored bumps that usually affect children less than 10 or so. They sometimes show up in little clusters, or can be more widespread. They’re triggered by a viral infection – but the virus itself is ubiquitous and impossible to avoid, so pretty much all of us are exposed to it. We don’t know why some kids with this virus get bump, while many others never do. The good news is that this isn’t a serious issue, and doesn’t lead to any serious issues.

But the bumps can look ugly. And though most of the time they do go away entirely on their own, that process can take months or years. And sometimes they just insist on sticking around. So parents, understandably, want to find some way to get rid of them.

There are no FDA-approved medications that treat these, and no OTC or “natural” types of products that have ever been shown to be more effective than placebo. Dermatologists can scrape them off (ow!), or freeze them off (ow!), or dabble blistering agents on them (ow!). Though all of these methods work sometimes, they also sometimes lead to scarring or more lesions popping up nearby.

From my point of view, after about 20 years of fighting with these dang things on my patients, I usually encourage families to leave them alone. If they’re in a cosmetically important area or somewhere that’s hard to keep covered with clothes, I’ll sometimes try a gentle topical agent that seems to irritate them a bit, which hastens their destruction by the body’s immune system. But usually, if there aren’t a lot of them, and the family can just ignore them until they disappear, that’s the way to go.

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Obesity: It’s not just the sugar

April 18, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

For a while, fat was the culprit – eating too much fat was making us fat. We were swamped by low-fat products, like cheese and salad dressings and even low-fat potato chips. Briefly, Burger King even offered low-fat French fries (Those quickly disappeared from the menu. Don’t mess with the fries.) Yet, with or without the low-fat foods, obesity rates continued to climb.

More-recently, sugar has emerged as the “deadly villain” in the obesity epidemic. Forget the fat – it’s the sugar, or the refined high fructose corn syrup, that’s messing with our metabolism and expanding waistlines. Just cut back—or eliminate—added sugar, and our weight problems will be over.

But a recent study from Australia shows that maybe it’s not so simple as blaming the sugar, either. Researchers there found that, on a population level, reduced sugar consumption was associated with an increasing rate of obesity. It’s funny how real-world data seems to clash with our little pet theories sometimes.

The authors used data about food consumption from several different academic and government sources, creating graphs of overall per capita sugar consumption among Australian adults and children from 1980 and 2011. Although the exact numbers vary by demographic groups, there was a clear overall trend towards less sugar intake over those years. They then looked at obesity rates, based on national surveys.

The combined data is in the graph below. Sugar consumption is in blue, and though it goes up and down some years, the overall trend is downwards. In red you can see the Australian obesity rates. There’s more data in the paper about specific groups (men versus women, children versus adults), but overall the trend is clear: less sugar consumption is associated with more obesity.

The authors conclude, “There may be unintended consequences of a singular focus on refined sugars…”

So if it’s not the sugars, and it’s not the fat, what is it? I think it’s unlikely that there is a single boogeyman, or a “one thing” we can point our fingers at as the culprit. Obesity has many contributors, including decreasing physical activity, eating bigger portions, and eating more frequently. Low-quality “fast food” is quick and convenient, but it’s certainly not cheap in the long run. A ton of extra sugar can’t be good for your teeth, and is one source of extra calories you don’t need. But it’s not just the sugar that we’re eating too much.

Homemade slime isn’t hurting your child

March 20, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Another day, another internet scare. This time it’s about that homemade slime, and all the toxins and poisons in it – the ones that are pretty much killing our kids. Except there aren’t any toxins, and kids aren’t getting sick.

This rumor started with an article from the Daily Mail, a British “newspaper” that Wikipedia has deemed “generally unreliable.” In the fine tradition of crappy supermarket tabloids, the Daily Mail is on a par with the National Enquirer, the Star, the Sun, and Weekly World News – it’s a site that makes stuff up, or blows things crazy out of proportion to sell newspapers. Admit it – you were tempted to buy that cheap paper that proclaimed that Hillary was from Venus, or that there’s a Miracle Cream that Allows People to Grow a Sixth Toe. The story was amplified by a blog post at “This talk ain’t cheap”, where the author points out in the second sentence that she’s “not a doctor or a scientist or a chemist.”

As is the manner of clickbait about things hurting children, this one has been posted -n- reposted on Facebook and parenting blogs. In an effort to make sure the barn door is firmly bolted shut now that the horses are long gone, let me give you the quick version: there’s nothing in homemade slime that’s likely to hurt anyone, as long as it’s “used as directed.” Don’t eat the stuff, rub it in your eyes, or lie in a bathtub of it for an hour. Other than that, it’s safe.

We’ve still got an unopened box of borax and bottles of glue downstairs from my youngest’s “slime phase” last year. You mix up a bunch of chemicals (See! Chemicals! That’s your first warning, right there!!) to make a sort of gooey, hand-clinging, squishy mess. It even makes comical sounds when you squarsh it around between your hands. Harmless fun?

The Daily Mail article focuses on one ingredient in homemade slime, pointing out that boric acid (Borax) is labeled by the European Chemicals Agency as ‘toxic to reproduction’, and potentially irritating to eyes and lungs. The box in my basement says those things, too. Don’t eat it, and don’t rub it in your eyes, and don’t stick your face in the box and whiff it. If your children are too young to handle this on their own, they probably shouldn’t be making slime without supervision. Apart from the breathless and frightening tone, The Daily Mail’s critique of Borax is at least reasonably close to the truth. It’s conceivable that an unsupervised or particularly reckless child could get hurt by the stuff. It’s also possible that some kids could have more-sensitive skin, and could end up with a rash or the itchies (do I need to say: if your child gets irritated skin after playing with slime, he or she should stop playing with slime. The same is true if your child gets itchy skin after petting a cat or eating finger-fuls of cookie dough.)

But the blog post goes a step further, heading off the rails of the worry train. The blogger points out imaginary dangers of other ingredients, like glue. She says white glue – essentially, Elmer’s – can cause anxiety, convulsions, seizures (both convulsions AND seizures!), respiratory failure, and loss of appetite. Except none of this is true. In the manner of googlers-who-call-themselves-researchers everywhere, the author mistakes one kind of glue for another. Elmer’s white glue causes sticky hands, but is otherwise non toxic. What she’s quoting are side effects of huffing industrial glue or model cement, which is a different product entirely, and is not an ingredient in homemade slime.

There’s also shaving cream – which the blogger implies contains carcinogens and “very controversial” ingredients. I think of it as something people rub on their faces (men, typically), legs (often women), or all over the walls of the shower (children). If you’re afraid of your children touching shaving cream, I cannot help you.

By the way, homemade slime also contains water (AKA deadly dihydrogen monoxide) and often food coloring (I believe green is best, but mixing green and purple makes a hideous and wonderful color called “ocky” that has a certain charm.) A complete recipe is here. You can also make it with other, non-borax compounds like cornstarch or laundry detergent.

Parents, if your kids are taking a break from their iPhones to do something fun and icky with their hands, let them enjoy themselves. It may get messy, and you don’t want them (or the dog, or even the cat) eating their homemade slime. But it’s pretty much harmless fun. Today’s lesson: don’t let the internet scare you.

Fight the Fearmongers: MTHFR variants are nothing to worry about

March 13, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Another day, another scare. Honestly, if you take Facebook and The Interwebs seriously, we’d all be dead three times over already.  (By the way: Facebook and the Interwebs would make a good name for a 2000’s cover rock band.)

Here’s one that’s come up a few times at my office this month: parents worried about MTHFR “mutations” that are making themselves and their children sick and vulnerable to all kinds of diseases. It’s another example of alarmists taking advantage of a tiny speck of science to scare you and sell things. Don’t believe any of it.

Background: MTHFR stands for…. Ah, forget it. Who cares what it stands for. It’s a shorthand name for a gene that encodes a protein that does important things involving the metabolism of the vitamin folic acid.

It turns out that there are hundreds of variations in the MTHFR gene we all carry. Genes, actually, with an “s” – we all carry two copies. Some variations work more or less efficiently, and a few very rare ones don’t work well at all. But the important thing to remember is that these are examples of the normal variation of our species. Having a different MTHFR gene from your neighbor doesn’t make you strange or broken.

In fact, having these variations is very common – so common, that variation is the rule, not the exception. As we learn more about these variations, the percentage of people with “variants” continues to go up – maybe about 60% of us, now, have at least 1 copy of a “variant.” And since almost all of the variants work just fine, this doesn’t matter at all.

 Part of the problem comes from the language of genetics, and the way gene science is depicted in the media. Use the term “mutant” and you think Patrick Stewart lifting things with his mind. A mutant is changed gene – and in science, that term is used for one-time or rare events. These MTHFR things are NOT mutants, at least not in the way a genetic scientist would use the word. Having one of them will not give you a tail, allow you to change the weather, or make lasers shoot out of your eyes. It also won’t make you or your child more likely to get sick.

The correct, more-specific word for what I’ve been calling “variants” is “polymorphisms.” These are genes that are different in subtle ways, and have become fairly common in a population. Hint: if a polymorphism made you sick, people with it wouldn’t reproduce, and the polymorphism would become rarer. Polymorphisms that don’t change health (like these MTHFR polymorphisms) can spread and linger in a population, like blue eyes or the ability to taste a tiny speck of cilantro.

Nonetheless, there are scads of web sites out there pushing MTHFR testing, and trying to sell books and products to people with these polymorphisms (which, as I mentioned, are most of us.) This is called “fear-mongering” –creating fear of a non-existent disease to get attention and make money. I’m not going to link to any of these sites, but here’s a sampling of some of the headlines and what the sites are pushing:

  • The MTHFR Gene Mutation And How To Rewire Your Genetics – Note the use of the scare-word, mutation. And, of course, you cannot rewire your genetics. Nonetheless, this site pushes worthless genetic testing, suggests treating non-existent yeast infections, encourages the use of a dozen supplements you don’t need, and suggests “detoxing” with coconut charcoal. Absolute, bat-shit nonsense – all for a made-up health scare.
  • Someone calling themselves “Your Functional Medicine Expert ®” (followed by 16 letters – do not trust anyone who has more letters in their “degrees” than in their own name) has her own top ten list of things to do for what she calls your “mutation.” Some of these are perfectly healthy for all of us: get exercise, eat leafy greens, spend time in the sauna. But she goes off the rails, too, referring people to a “trained biologic dentist” and “dry skin brushing” to detox da chemicalz dat’ll killz ya.

There are also alt-med freakshow sites that somehow link MTHFR variants as a warning against (of course) vaccines. This is an absolute crock.

Bottom line: genuine medical geneticists do not recommend MTHFR testing. Just because something sounds sciency doesn’t mean it’s something that is going to kill you. Don’t worry about things because you read about them on the internet. Go hug your kids, enjoy some sunshine, and take a break from Facebook and the Interwebs. Their show is starting to get old, and you’ve got better and healthier things to do with your time.