Archive for the ‘Pediatric Insider information’ category

Ibuprofen or acetaminophen: Which is better for treating a kid’s fever?

January 30, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Ask babies with fever how they feel, and they’ll say… well, they probably won’t say anything, because they’re babies. But ask older kids, and they’ll look at you funny, and maybe say “Why are you asking me?” Kids these days, am I right?

Fevers make kids feel bad. Achy and miserable and bleh. So for comfort, I think it’s a good idea to treat fever in a child who’s uncomfortable. What’s important isn’t the number – how high the fever is – but how the child feels. Feeling bad? Let’s help you feel better.

(By the way, even though they make your child feel miserable, fevers will not harm your child in any way. Don’t be afraid of fevers.)

To treat a fever: first, offer extra fluids. Fevers are dehydrating, and a popsicle tastes good. Then reach for a fever reducing medicine, typically a brand of acetaminophen (like Tylenol) or ibuprofen (Advil or Motrin.) But which one’s better? A November, 2016 study in Clinical Pediatrics gives ibuprofen the edge, though not by much. Ibuprofen worked a little faster (peak effect in 90 minutes, versus 2 hours for acetaminophen), and lasted somewhat longer (by about an hour, though there was a lot of variability.) My usual advice is to use whichever one you’ve got at home and what’s seemed to work best in the past.Although serious side effects are rare, either medication can cause serious problems. Acetaminophen, especially in overdoses, is toxic to the liver (so be careful using this in a child who already has liver disease.) Ibuprofen, especially with prolonged use, can cause gastric irritation and bleeding, and rarely kidney problems. It’s important to use what you’re using correctly, at the correct dose and at the correct interval (both can safely be given every 6 hours.)

Which brings us to another idea: if either is good, can a combination of them be better? In an alternating strategy, one drug is alternated with the other, so something is given every three hours, and the same drug comes around for a dose every six. Several studies (summarized here) have shown that this can reduce fever somewhat better than either drug alone, but with a much greater chance of medication errors and overdoses. If you want to try this, write down what you’re giving and when, and make sure you (and your spouse) understand the schedule.

There are a lot of myths about fever. 98.6 F is not and has never been the “normal” temperature. Fevers, themselves, cause no harm. They also don’t help very much. In the modern world, fever is not a necessary or particularly useful part of your immune response. If a fever is making your child feel bad, treat it. With acetaminophen or ibuprofen, your choice.

Not feel good by Sophie

Most natural remedies aren’t

January 17, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Rachel wrote:

My daughter and I were talking the other day and saying we would like to ask a doctor what his thoughts are about all these ‘natural’ remedies that are available. Recently a friend made the remark, ‘I do everything I can to avoid a doctor.’ I lean more toward the medical system and the knowledge they have acquired over the years rather than relying on these home remedies. What are your thoughts?

A great question, Rachel. It turns out that many of these “natural” remedies aren’t very natural at all. Something should be considered “natural” if it exists in the world around us – if it’s a part of the observable, real world we live in – and a part of our world that we didn’t create or imagine. Trees and rocks and wind are natural. Ghosts and voodoo curses are not (they only exist in our imagination). Bridges, ovens, clothing, and books are not (we made those things.)

When you think about it, a lot of what passes for “natural” remedies are not natural. Homeopathic remedies rely on an entirely imagined mechanism of chemistry invented by Samuel Hahnemann around 1796. He thought that by diluting and shaking substances, a vital essence of their properties could be captured, which upon further dilution could alleviate the symptoms that were caused by ingesting that same substance. Acupuncture relies on changing the flow of a life-energy, Qi, through channels in the body that do not, objectively, exist. Chiropractic (invented by DD Palmer in 1895) relies on identifying and treating “subluxations” that do not exist on x-rays or any other objective test. Modern chiropractors have acknowledged that their subluxations are more of an idea than a real thing, but most of them insist that treating these nonexisting things is helpful. (Not all chiropractors subscribe to this belief – a small group is trying to distance themselves from the dogmatic belief in Palmer’s subluxations. I wish them well.)

Many other kinds of healing supported by “naturopathic doctors” are not at all natural. Reiki, Ayurveda, “detoxification”, iridology, reflexology, kinesiology, and many other ideas are like homeopathy, chiropractic, and acupuncture. They all  “supernatural”, like ghosts and voodoo and magic.

What about herbal medicine? Herbs, themselves, are natural (and, often, tasty!) But what’s sold at drug and what used to be called “health food” stores is not. Many herbal supplements do not in fact contain the labeled herbs. The herbs are imaginary and un-natural. Even if the herbs are indeed contained in the supplement, by the time they’ve been processed and turned into capsules, are they any more natural than the “medications” on the shelf nearby?

I think the wisest way to think about Rachel’s question is to reject the false dichotomy between what’s “natural” and what’s not. There’s nothing inherently safer or better about natural things. Smallpox is natural, earthquakes are natural, heart attacks and strokes and cerebral palsy are all natural. Poisons from pufferfish and venoms from rattlesnakes are natural. On the other plenty of good and necessary things are “unnatural.” The food we eat has been grown with fertilizers and pesticides (including organic foods, which use all kinds of substances you wouldn’t consider “natural” at all), brought to stores by trucks on roads driven by people wearing wristwatches and clothes. None of these things are natural. And that’s OK.

 

Coming up next post: OK, fine, natural remedies aren’t natural. But do they work?

Who you gonna call?

What can be learn from vending machines and casinos to stop childhood whining?

December 19, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Megan, like all parents, hates the whining and nagging:

It’s driving me crazy. My children whine and complain until they get what they want. I try not to give in, but sometimes it’s just impossible. What can I do?

(That’s an excerpt from a much longer message. You get the idea.)

Let’s look at whining from a classic behavioral approach. Stay with me, here – behavioral theory is a big part of why we do the things we do, children and adults alike. It’s worth understanding.

What we’re talking about here is called “operant conditioning.” Basically, whether people continue to do something depends on the consequences. If complimenting your spouse gets you a friendly smile or peck on the cheek, you’ll keep doing it (assuming you like smiles and kisses.) If your child’s whining means she gets what she wants, she’ll keep doing that, too. A related term is “positive reinforcement” – that’s a reward or benefit that comes after a behavior. Positive reinforcements (giving a child exactly what she wants) make it more likely that the behavior (whining) will happen again.

So: step one of dealing with whining (or many other undesirable behaviors) is to remove the positive reinforcement. But there’s a twist, here – it turns out that the schedule of the positive reinforcers can change how well it works. This might not be intuitive, but it turns out that regular, always-given, predictable positive reinforcements are not as lasting or powerful as irregular, unpredictable, changing positive reinforcers.

Think about vending machines and casinos. With a vending machine, you always get exactly what you ordered (assuming the stupid thing isn’t broken – there’s an interesting behavioral lesson about that situation, too, but we’ll save that for another time.) People who get things from vending machines are positively reinforced, but they don’t typically crave vending machines. And: when the positive reinforcement ends (say, for 1 or 2 times you don’t get your bag of Funyuns), you’ll quickly stop using the vending machine.

But at a casino, you don’t know what your reward will be, or even if you’ll get one. In fact, most of the time, you get nothing at all. But that kind of reinforcement, the “sometimes-surprise” schedule, reinforces the behavior even more effectively. Think about people pumping money into slot machines, only to get occasional, unpredictable rewards.

Let’s come back to whining. If you reinforce the whining sometimes, or in an unpredictable way (“Here! Just have the whole bag of lollopops!”), you’ll unintentionally be encouraging the behavior even more than if you always said “yes.” If Megan is serious about stopping the whining, she has to stop reinforcing it, and shouldn’t give in. Ever.

What about punishment to stop whining? A punishment is an action you take after the behavior, a consequence that’s designed to stop the behavior. It turns out that behavioral studies in animals, children, and adults show that punishment is typically only temporarily effective. Yelling at your child for whining, or restricting privileges, or some other punishment – none of these will work well. That’s like the vending machine giving you a bag of stale chips. You’ll be mad, and might avoid the vending machine for a few days, but you’ll be back. Or, imagine, if a casino sometimes just took your money away from you. That’s a valid punishment, but it doesn’t really change a behavior as well as completely stopping the positive reinforcements (in a casino, the occasional big payouts.) If the punishment of losing money at casinos actually worked, they’d all be out of business.

Sometimes, there’s more to whining than just behavior and consequences. I’d consider the child’s development and communication skills, and overall parenting style, expectations, mental health, resource scarcity — lots of things beyond behavioral theory. But a straight-up behavioral approach is sometimes the simplest, best way to get children to stop with the whining. And if it works, Megan owes me a trip to Vegas. Or at least a bag of Funyuns.

Red wine pouring into wine glass, close-up

Red wine pouring into wine glass, close-up

Preventing and treating pediatric migraines

December 12, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents are sometimes surprised to find out that migraines are the most common cause of recurrent headaches in children. Yes, kids get migraines – and many adults who get them started getting them as children, even if they weren’t diagnosed correctly.

(And: many adults who get migraines are still not being diagnosed correctly. Do you get “sinus” headaches? They’re almost certainly migraines. Yes, I know you feel congested with them. Yes, I know you know they’re “sinus.” But they’re not. They’re migraines, and have nothing to do with your sinuses. But I’m getting off topic here, and I’m not your doctor, and feel free to just disregard this paragraph.)

Dealing with pediatric migraines starts with making the right diagnosis – which is usually easy, if you listen to the patient and ask a few of the right questions. A brief physical exam can confirm that there’s nothing else to worry about, and advanced imaging like CTs or MRIs is almost never needed. Once there’s a history of over a few months of recurrent headaches, a clinical exam will tell you everything you need to know.

Prevention is the key. Migraines are really uncomfortable and disruptive, and an ounce of prevention is worth much more than a pound of cure. Many pediatric migraines are triggered by things like hunger, lack of sleep, disrupted schedules, dehydration, and many other lifestyle habits. Stress is almost always another contributor. Remember: stress to a child includes not just worry, but even excitement and strong positive emotions. Stress isn’t just things a child doesn’t like. Families and kids can learn to identify and avoid some of their own triggers, leading to far fewer migraines.

In adults, daily medications are commonly used as preventives. A recent study from the New England Journal looked at two common migraine preventers in children – topiramate (AKA Topamax) and amitriptyline.  The good news is that both medications did decrease the frequency of headaches – but the bad news is, neither was any better than the placebo group. That’s right, whether the study participants (all children and teens) took either of the drugs or a placebo pill, they all reported a decrease in headaches. Score one for sugar pills! Both the amitriptyline and topiramate groups experienced side effects, so the study was stopped early.

There’s some evidence for the effectiveness of a few less-traditional agents to prevent migraines in adults. These might help in children, too. Vitamin B2, taken daily, seemed to work better than placebo, and at least small trials of a few other generally-safe agents like magnesium and butterbur show promise. Even if they’re not much better than placebo, they’re safer than most medications.

We do have very good “abortive” agents to treat migraines once they begin. These include non-steroidal OTC meds like ibuprofen or naproxen, or prescription medications called “triptans”. All of these work best if taken very soon after any migraine symptoms start. But all of these are also prone to causing “rebound headaches” if taken too frequently. So, again, prevention is better than cure. (Still, a cure is nice to have if you need one!) By the way, narcotic medications should never be used to treat migraines, especially in children—they increase the sensitivity of the pain system, and can increase pain episodes
after even short-term use.

If your child has recurrent headaches, start by keeping a log to track potential triggers and causes. Don’t discount the role of stress, even if your child “doesn’t seem stressed”. And try to encourage good, regular sleep and eating habits. Still having headaches? It’s time to see the doctor. Even if daily medications don’t show much promise, we’ve got other good options to both prevent and treat migraines in children.

How old is he now, anyway?

Parents can tell if an ear infection is getting better

December 5, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Good things come in small packages. A short, sweet letter to the editor in the November, 2016 edition of JAMA Pediatrics confirms that parents can tell whether their children are getting over an ear infection, with no doctor exam required.

The letter, from four Finnish physicians, is about a page long. It summarizes a small part of their data from a much larger study on the treatment of ear infections. In the letter, they’re only looking at 160 children, age 6 months to 3 years, who were initially treated for an ear infection without any antibiotics. Current guidelines from the US and many other countries do support treating less-severe ear infections with pain relievers only, waiting on antibiotics. But these guidelines suggest that if children with ear infections aren’t given antibiotics, they need to be followed closely and re-examined to make sure they’re really getting better. These authors asked, is that really necessary?

The 160 children were all reexamined for this study, and parents were also asked questions about whether they thought their children were improving, getting worse, or staying about the same. It turns out that among the children whose parents thought were getting better, only a very small number had worsening ear exams (less than 3%). Compare that with children thought to be getting worse – about 30% had worsening findings on their ear exams. Keep in mind that these were all children who did not receive any antibiotics. Presumably, if they had, even fewer of them would have gotten worse.

Parents, not surprisingly, were pretty good at judging whether their children were getting better. So good that based on these numbers, a repeat exam to make sure ear infections were clearing was probably unnecessary!

Caveats: I’d be a little more cautious with children at risk for prolonged ear infections or  persistent fluid behind the ears. Children with a history of difficult-to-treat ear infections should get a repeat exam, as should kids with hearing problems or developmental language delays—it’s crucial that those children get over their infections completely. But for the majority of children with ordinary ear infections that seem to be getting better, it may be reasonable to wait until their next check up to look at those ears again. Most of the time, parents’ judgment is just as good as a repeat ear exam.

Finalnd!

 

Beware crappy telephone medicine

November 28, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Someday we may miss the quaint idea of going to see your own doctor for your medical concerns.

I realize taking your children to see their doc is a pain. So is taking your car in to the mechanic, or waiting for the cable guy, or going out for groceries. There are other things you’d rather be doing with your time. Can a quick phone call substitute for a doctor visit?

Apparently at least one huge insurance company thinks so. My own family’s health insurance comes from Aetna Healthcare (the letters of which can be rearranged to spell “At Heartache Lane”.) They’re really pushing me to try out “Teladoc” (which, ironically, can be rearranged to spell “late doc” or “eat clod” or “led taco.”) One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?”, it says, in big friendly letters. Holly, presumably the child’s mom, is quoted “One night my child was running a high fever. I called Teladoc & the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER.”

24/7 doctors! What could go wrong?!

What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history, and symptoms, it would have been appropriate to either: (1) stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor; or (2) if there was chance of a genuinely serious medical issue, to go get evaluated right away. The child could have had meningitis, pneumonia, or a viral infection, or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever means “call in a prescription”? That’s completely, utterly wrong.

So why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?

I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis and prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.

Though there are zero pediatric studies, I found one good study in adults,  reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses, and many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record.

I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just 2 copies of telemedine records in the last few years, and they’re frankly embarrassing. One was about an 8 year old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s what’s called the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone. The other telemedicine record I have was nearly identical, a 15 month old also diagnosed with strep , amoxicillin called in. More Krap Kare for Kids.)

There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be a great way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms.

But current available technology (like this Teladoc service) doesn’t allow a clinician to really examine a patient, look in their ears, or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick – and that, really, is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy. But it’s no substitute for genuine medical care.

Codeine is not for children

October 31, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Codeine is a terrible choice for treating children’s pain and cough, and we ought to just stop using it. It’s like an old yogurt container, way at the back of your fridge — sure, it was once tasty, and then for a while you held on to it for sentimental reasons. “Remember that yogurt?” you’d say to your spouse. But it’s well past time to throw that stinky stuff away.

For a long time, codeine was thought to be safer than other opiate-based pain medications. It’s a naturally occurring form of morphine with good oral bioavailability (that means you can swallow it in pill or liquid form.) But codeine, the molecule itself, has no biologic activity or drug effect on its own. It has to be converted, in the liver, to an active “metabolite” to have any effect on your body. And that’s the problem: the “activation” step. It turns out that different people have a huge variability in how quickly they activate codeine, which can lead to all kinds of problems.

Some people are “fast metabolizers” — meaning they very rapidly activate codeine. If you’re one of these people, the effects and side effects of codeine will be much higher than expected. There have been about 64 cases of severe respiratory depression reported in children taking “normal” doses of codeine, and many of these children died.

On the other hand, some people are “slow metabolizers”. They can take a dose of codeine, and their liver just sits there, twiddling its liver thumbs. Nothing happens. There’s no therapeutic effect of even very high codeine doses in these people, because their bodies don’t activate the drug.

A slew of international smart-guys has already begun to limit the use of codeine, especially in children. The US FDA slapped a black box warning against its use in post-op children, the Europeans issued a report suggesting that we stop using codeine entirely in children less than 12, and Health Canada even joined the fun, calling codeine “a big hoser of a mistake, eh?”

So, if not codeine, what else can we safely use to treat serious pain in children? Oxycodone (found in Percocet and other products), should have much less variability, though there will still be some added risk to fast metabolizers. The best option, really, might be to go back to using straight-up morphine, but there aren’t great studies looking at its absorption in children.

Non-opiate pain medicines work well, too — in many cases, as well as opiates, if used correctly. These medications, including acetaminophen and ibuprofen, can very effectively relieve even serious, post-op pain, if they’re given in advance and on schedule. Even if they can’t relieve pain completely, they can be used to reduce the doses of opiates needed. There are also IV preparations of acetaminophen and some NSAIDs.

We also need to be very careful about the kind of pain we’re treating. Acute serious pain, from surgery or a broken bone, can and should be safely treated with a combination approach that often includes opiates in the short run. But chronic or recurrent pain (including backaches and migraines) should not be treated with opiates. In the long run, these medicines actually increase the body’s sensitivity to pain, potentially leading to a cycle of dependence and addiction.

Sometimes, codeine is also used as a cough suppressant. The same risks for high- or low- metabolizers are there, and in fact there are no studies showing that codeine is even effective for cough in children. You’ve got all the risk for potentially zero benefit.

Codeine is an old medicine that’s way past its prime. We’ve got better drugs to choose from. If your doc offers a codeine prescription for your child, it’s time to say “no.”

Mmm codeine