The holiday un-gift guide: What not to buy this season

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ho ho ho! It’s time for my nearly-every-yearly, not-too-clickbaity, almost-useful holiday gift guide with a twist! Plenty of guides tell you stuff you should buy. We’re here to save you money, and maybe even save your child’s life. Here’s a bunch of things you really shouldn’t buy this holiday season.

 

Baby walkers

Gizmos like this are a terrible thing to buy for a baby or family. Walkers slow infant development by making it more difficult for your baby to learn to walk. And, bonus, they injure about 9,000 babies a year in the USA. The AAP has called for banning them. Please, just don’t buy one of these things, m’kay?

Instead, consider a push-behind device or something like a standing activity center. They’re fun, provide genuine help with motor skills, and won’t maim or kill your baby!

 

Tiny magnet toys

Even the manufacturers of these toys, consisting of dozens or hundreds of little magnets, know they’re unsafe. But they still send mixed messages on their product listings. This one says it’s for ages 14 and up – “Use under adult supervision only” – right underneath where it says “GREAT GIFT FOR YOUNG AND OLD.”

What’s the problem? Little kids love to swallow these. And clumps stick together in the gut, causing necrosis (dead gut tissue.) Kids who swallow these are rushed to the OR, pronto. Before and after photos, courtesy of my friend and pediatric GI specialist, Dr. Tejas Mehta:

 

Baby sleep positioners

These are completely unnecessary, and can kill your baby. Other than that, sure, they’re fine. No, seriously, do not use a gizmo to position your baby in sleep. Seriously. Death. Bad. Ok?

 

Toy Vacuum Cleaners

Everyone likes to vacuum, right? And it’s not that toy vacuums like this one ($43) are dangerous. But you can buy a REAL ONE for $35. You have a kid wants to vacuum? Get him a real vacuum and put him to work!

 

Baby Bum Brush

You can use this to spread diaper cream on your baby’s bottom. Or this. Or this. Or your fingers, like God intended.

 

Amber Teething Necklaces

These are both a choking hazard and a strangulation hazard – especially ones that proclaim “The screw clasp prevents your baby from taking the teething necklace off.” That also means if the necklace gets caught on something, rather than breaking at the clasp it can strangle your baby. Or, if they do break apart, each individual bead becomes a choking hazard. And, besides, there’s no evidence whatsoever that these things relieve any symptoms of teething at all.

 

Crib Bumpers and Pillows

Babies should sleep on a firm, flat surface, NOT near soft squishy things that can interfere with their safe sleep. Squashy soft pillowy things are not only unnecessary, they kill babies. The AAP has been calling for them to be banned for years. I can’t even look at that photo without cringing.

 

Food Sensitivity Tests

Give the gift of paranoia! IgG-based food sensitivity tests, widely advertised on platforms like Facebook, are absolutely worthless. They measure an antibody response that shows you’ve eaten the food, not that you’re allergic or sensitive to the food. These tests don’t predict allergy or sensitivity or anything else. They just make people worry and encourage eating disorders and orthorexia.

 

Measles

Just don’t. There’s a very safe and very effective vaccine that had stopped measles transmission almost entirely in the US, Europe, and many other areas of the world. Now, thanks to the lies and distortions from antivaccine groups and Russian trolls, it’s surging back. That so many wealthy and privileged people are “helping” bring measles back to both the US and to developing countries is despicable. Be safe. Protect your children, your family, and your neighborhoods – even those too ill or young to be vaccinated. Make sure you and your children are protected, safe, and immunized.

Goodbye, Benadryl – it is time for you to retire

This has become, by far, the most-discussed and most-hated post that I’ve ever written. In retrospect I should have been much more explicit: I’m talking here about using Benadryl as an antihistamine to treat allergic disease. A follow-up post includes about 10 links to well-supported, recent guidelines that support my contention that Benadryl is not a good choice to treat allergic disease. Newer agents are faster, more effective, and safer. 

 

The Pediatric Insider

© 2019 Roy Benaroch, MD

Sometimes, old ideas and time-tested treatments remain the best. Newer doesn’t always mean better. Except, in the case of tried-and-true Benadryl. It is time for that old drug to be retired, sent off to pasture, and never used again. Goodbye, Benadryl. Fare thee well, adieu, and don’t let the door hit you on the way out.

Benadryl (diphenhydramine) was introduced in 1946. The top single that year was Perry Como’s “Prisoner of Love,” and, with all due respect, neither has aged well. Back in 1946, medicines like Benadryl didn’t have to pass the stringent safety and efficacy standards now required. And there’s zero chance, today, it would every have been approved for over-the-counter sale – and even if it made it as a prescription medicine, it would be plastered with warning labels.

tl;dr: Newer & better alternatives to treating any allergic disease are cetirizine (Zyrtec), loratadine (Claritin), and fexofenadine (Allegra). These are all safer, faster, and more effective. There is no situation where Benadryl is a better choice as an oral medication. No one should be using Benadryl for anything.

 

Benadryl isn’t safe

Benadryl causes significant sedation. One study in a driving simulator showed an ordinary adult dose of Benadryl caused worse driving than a blood alcohol level of 0.1% (that’s fairly drunk, probably between buzzed-drunk and frat-party drunk). Ordinary doses of Benadryl can also commonly cause urinary retention, dizziness, trouble with coordination, dry mouth, blurry vision, and constipation.

But more importantly, in an overdose Benadryl becomes very dangerous. It has caused respiratory depression, coma, heart arrythmias, and death in children and adults, and in doses that aren’t super-high. This is not safe stuff to have in the house with an exploring toddler, or in a teenager who might help themselves to whatever is in the medicine cabinet.

 

Newer alternatives are much safer

In the 1980’s, newer-generation antihistamines were introduced. At first, they required a prescription and were crazy-expensive; now, the best of these are cheap, generic, and easily available OTC.

These medicines were developed to address the serious safety concerns of Benadryl and other older antihistamines. They do not cross the “blood brain barrier”, cause minimal if any sedation, and don’t cause nearly as many of the other side effects. And, bonus, they’re not very dangerous even in massive overdoses. A recent review quoted that there has never been a death even in instances of up to 30 times the recommended dosing.

 

Newer alternatives are more effective, act more quickly, and last longer

In a serious allergic reaction, we want a treatment that’s quick and effective. Keep in mind that in the case of anaphylaxis, the most serious allergic reaction, antihistamines are NOT the correct, first-line treatment. Anyone experiencing an anaphylactic reaction, which can include a loss of consciousness, trouble breathing, and widespread hives and flushing, should immediate and without hesitation be given epinephrine by injection. Epinephrine should never be delayed while looking for or preparing an antihistamine. Antihistamines do not save lives. Epinephrine does. Keep your eye on the ball.

But for more-mild allergic reactions, like simple hives, an antihistamine is a good idea. And some docs still prefer Benadryl, since it’s been around forever. But the newer drugs are much more effective. They begin working more quickly, they are more effective at controlling symptoms, and they last much longer – so symptoms are less likely to return. And, bonus, since side effects are minimal, doctors can safely prescribe regimens even up to four times the labeled doses for specific indications (this has been studied extensively). For routine use, follow the label instructions – talk to your doctor if that’s not working, or if you think a higher dose is needed.

 

Benadryl and its generics (diphenhydramine and many combo meds) are still very popular sellers, and many docs and nurses still recommended it. This is just out of habit and inertia – there is no good reason, under any circumstances, where Benadryl is the right choice when an oral antihistamine is needed. It’s not 1946. It’s time for Benadryl to be permanently taken off the market and relegated to the history books.

Chocolate best for cough? How to spot misleading headlines

The Pediatric Insider

© 2019 Roy Benaroch, MD

I’ve got a new course out – The Skeptic’s Guide to Health, Medicine, and the Media available in video from The Great Courses or audio from Audible. Both have trial offers, free returns, yada yada, check it out! I didn’t cover the chocolate-for-cough story below in the course, but if you find it interesting, or want to learn more about the best way to review health articles with a skeptic’s eye, this course is for you! Why not buy a copy for a friend, too? (Hey, never hurts to ask!)

Everyone loves chocolate, and nobody likes to cough. So when headlines like these appeared, it made a big media splash:

Apparently Chocolate Might Be Better for Treating Coughs than Honey and Lemon – from UK’s Metro

Chocolate Fights Coughs Better Than Codeine, Says Science – from allrecipes.com

Chocolate Is a Better Cough Suppressant than Medicine, Study Says – from The Atlanta Journal Constitution

Never Mind Honey and Lemon, the Best Cure for a Cough is CHOCOLATE: Leading Professor Busts Common Cough Myths… — from The Daily Mail

Looks good, huh? Chocolate for a cough – and the headlines say it’s better than medicine, based on Science! These are legit, big news organizations (well, maybe not allrecipes.com, but I threw that in there to illustrate just how pervasive these stories can get). You’d think they would have dug a little bit to see if their own headlines were true.

But they didn’t. If you want to know what The Science really says, you have to read past the headlines and past the media spin. The best way to do that is to look at the actual study – where the information, originally came from. If you review the articles above, many just point to each other, or quote experts. But with a little digging, I found the actual study that lead to these headlines here.

So what did the study actually show? They didn’t compare chocolate to codeine, or honey, or lemon – so any headline that made that comparison is false. And the study medicine itself wasn’t just chocolate, it was a mixture of three active medicines in a chocolate base. So any conclusion that it was the chocolate itself that made the difference is, well, silly and unjustified.

The study compared the chocolate-mixed medicines (a brand called “Unicough”) to another kind of cough medicine, called “simple linctus,” which contains a single ingredient not found in Unicough. If the authors wanted to look at the potential effect of the chocolate, they should have compared two identical products, one with and one without chocolate. But that’s not what was done.

And: the study itself was negative. That is, for the primary endpoint of the study, there was no difference in cough among people taking the chocolate-containing Unicough versus the “simple linctus.” There were some differences in what are called “secondary outcomes,” but that doesn’t mean the study showed that Unicough was superior. And: the study itself was funded by the manufacturer of Unicough, and one of the authors was a Unicough employee. Somehow that wasn’t mentioned in the fawning media stories.

The chocolate-for-cough study was misrepresented, and its conclusions reported incorrectly. Unfortunately, this is common in media portrayals of health news. There were some skeptical outlets that tried to present the other side of this story, but as so often happens the voice of reason was too little, too late. The story had already developed a life of its own. If you think chocolate might help your cough, go ahead and try it – but don’t be fooled by headlines like these.

Eager to learn more about interpreting media stories? Check out my new course! I cover many more examples of both good and bad reporting, and will teach you how to tell the difference. They’ve got it at Amazon too! What are you waiting for?! Go buy buy buy now!

Breastfeeding increases the risk of newborn readmission. Now what do we do?

The Pediatric Insider

© 2019 Roy Benaroch, MD

An August 2018 paper in Academic Pediatrics found an unsettling conclusion: breast-fed newborns have about double the risk of needing to be hospitalized in their first month of life, compared to babies who were formula-fed. The numbers are solid, and they jibe with the real-life experience of many pediatricians, including me. So what should we do about it?

The study itself looked at about 150,000 healthy, normal newborns born in Northern California hospitals from 2009 to 2013. The study authors were able to collect data on how these babies were fed in the few days following birth from hospital records (dividing them into groups of all-breast, all-formula, and a mixed group that did some of both.) They were then able to track these babies over the first month of their lives to see which ones ended up hospitalized for any reason. Most of the hospitalizations were related to dehydration and jaundice, which are closely linked to inadequate feeding.

The good news is that relatively few of these babies ended up back in the hospital – whether bottle-fed, breast-fed, or both, most babies did great. But babies who were breast-fed were much more likely than formula-feeders to end up underfed and hospitalized. Among vaginal deliveries, the risk of rehospitalization was 2.1% for bottle-fed babies versus 4.3% for breast-fed babies (the risk for mixed feeders was in between.) That’s about double the risk. Mathematically, the “number needed to harm” was 45. That is, for every 45 babies exclusively breast fed, one extra baby would end up in the hospital. Not good.

Among Caesarian births, the differential was less, with an increased risk of hospitalization of 2.1% (breast) versus 1.5% (formula). Both of these numbers are lower than the risk of rehospitalization for vaginal deliveries, probably because c-section babies already spend an extra day or two in the hospital. This provides more time for good feeding to be established (whether breast, bottle, or both.)

Does this mean we should discourage breast feeding? Of course not. Most breast-fed babies do great, and there are some health advantages of breastfeeding. But we need to be honest with ourselves, and honest with moms who are trying to do the best thing for their babies. Nursing isn’t perfect. It’s not a perfect food*, and it’s not a perfect method. There are pros and cons to both nursing and formula feeding, and parents (and babies) deserve an honest appraisal.

Nursing moms also need support. That includes “technical support” (ie “How to do it”) but also emotional and medical support – which should include time for rest, and an honest evaluation of how both moms and babies are doing. There is a role for formula, both for moms who choose to use it and for situations where babies aren’t getting enough to eat. Families, pediatricians, nurses, and lactation specialists all need to work together, without guilt or finger-pointing, to help keep babies and moms healthy.

*Human breast milk is an inadequate source of vitamin D from birth, and an inadequate source of iron by 4-6 months of life.

Allergy Myths – don’t be fooled!

The Pediatric Insider

© 2018 Roy Benaroch, MD

Allergy issues are a big problem – both food and environmental allergies cause quite a bit of misery, and sometimes serious health problems, too. But there are a lot of myths swirling around the world of allergy, too. It’s time for a pop-those-myths listicle!

#1 WRONG: Food allergies are common

Many people think they’re allergic to foods, but rigorous studies using the best, most reliable diagnostic tools find food allergies to be present in about 2-8% of the population. Most of these reactions are mild. True, life-threatening food allergies are quite rare—in the United States, about 150 people die each year from food allergies, which is only a little higher than the number of people struck by lightning.

But: food allergy rates are rising, and we don’t want to be too complacent. When allergies do occur, they can be serious. The best approach is good, science-based prevention, evaluation, and treatment.

 

#2 WRONG: Most reactions to food are allergies

An allergy refers to a specific kind of reaction, most commonly hives or wheezing. Other, more common reactions include lactose intolerance (an inability to digest milk sugar, leading to abdominal cramps and diarrhea) and gastroesophageal reflux related to spicy or acidic foods. The distinction is important because rare, very serious allergic reactions can occur. If the reaction was not allergic in nature, it will not be life-threatening if exposure occurs again.

 

#3 WRONG: Most reactions to medicines are allergies

The most common adverse reaction to a medication is a rash, but these are usually not caused by allergy (the only common truly allergic rash is hives, which are raised, itchy areas that move about the body.) Most people labeled as “allergic” to penicillin are not in fact allergic, and can safely use this medication. Only a careful history and exam can determine this—there is no accurate test to confirm or refute true drug allergies. If you or your child is thought of as drug allergic, review the exact circumstances with your physician to see if it is a good idea to try the medication again (do NOT do this on your own!)

 

#4 WRONG: People who are allergic to a medicine should never take it again

Certainly, if a life-threatening reaction occurred you need to be very careful. And be much, much more wary of medications given as a shot or intravenously (I’m not sure anyone has ever died as a result of an allergic reaction to oral penicillin.) But unless the reaction was a true allergic reaction, usually manifested by hives or wheezing, a medication can usually be given safely in the future (again, do NOT do this on your own!)

 

#5 WRONG: People with egg allergy shouldn’t get a flu or MMR vaccine

Flu vaccines are safe in people with egg allergy – great studies have proven this. People with egg allergies can get routine flu immunizations, and are not at elevated risk of reactions (this is reflected in current guidelines – if anyone tells you differently, they’re not keeping up with the science.)

And egg allergy was never a contraindication to MMR. That was a myth. MMRs can safely be given to anyone with egg allergies.

 

#6 WRONG: Allergy testing can tell you if a child is allergic to something

Hoo boy, doctors misunderstand this one, too. The way to know if a person is allergic is entirely in the history: do symptoms of allergy occur upon exposure? If they do, that’s allergy; if they don’t, that is not allergy. If the history is clear, the diagnosis is nailed, done, confirmed, and set. No tests are needed; in fact, tests are quite likely to confuse the picture.

Allergy tests are for when the history is not clear, to help separate exposures that are “likely” from “less likely”, so that further history can be explored and attempts at avoidance attempted to see what the response is. Allergy testing, either with blood tests or skin testing, is far too inaccurate to be used in any other way.

Be especially wary of web-based labs that promise extensive “sensitivity” testing to investigate vague symptoms like weight gain, abdominal pain, low energy, fatigue, and behavior problems. These symptoms are not caused by allergy, though fraudulent testing will inevitably lead to false positives and incitements to purchase detoxifying supplements. This is expensive quackery. Stay away!

 

#7 WRONG: Hives are usually caused by allergies to foods

In adults, this might be true; but in kids, hives are more often triggered by minor infections than by food exposures. Sure, if there are hives you ought to think about potential new foods, and if there is a correlation you ought to look into that. But in the majority of cases in pediatrics, isolated or even recurrent episodes of hives are not from food allergies.

 

#8 WRONG: Specific allergies run in families

“Don’t give him penicillin! Mom’s allergic!” While the predisposition to allergies, asthma, and hay fever run in families, it isn’t to the same specific trigger. Junior has a mom with shrimp allergies? That means that he might more likely have food allergies of his own, but not more likely to shrimp than to peanut or egg or anything else. Same for medication allergies.

 

#9: WRONG: The best way to avoid food allergies is to avoid or delay giving the food.

This is an old myth that won’t die – but it’s completely wrong. In fact, it’s backwards. One of the best ways to prevent the development of food allergies is to start complementary foods between 4-6 months of life, and to quickly give a wide variety of all foods (avoid honey and anything that’s a choking hazard.)

 

If your physician is telling you myths from the above list, it’s time to ask for a referral to an allergist to get the best information. If it’s an allergist tell you one of these myths, well, I’m stumped.

Adapted from an earlier post

Join the fight – learn how to help prevent suicide

The Pediatric Insider

© 2018 Roy Benaroch, MD

Suicide is among the most common causes of death of teens and young adults, and the rates are rising. Unfortunately, people at the most risk of suicide may not be able to get themselves the help and resources they need.

I’ve written and taped a short, 45 minute lecture series, A Practical Guide to Suicide Prevention, to help family and friends recognize the warning signs of suicide risk, and to help people learn the best steps to take when someone is in danger. It’s part of The Great Courses Plus streaming service, and you can watch or listen to the audio as part of a free trial.

If you do join The Great Courses Plus, please check out my other courses. I have three audio/visual series titled Medical School for Everyone. They’re all presented as medical mystery cases for laymen to figure out. While figuring out the mysteries, you’ll learn about medicine, physiology, therapeutics, and how doctors think through solving diagnostic mysteries yourself. The feedback has been great – I think you’ll enjoy the courses! You can watch them via the free trial on The Great Courses streaming service, or buy them individually (with a no-hassle money back guarantee) from The Great Courses. Links below!

Next year I have a new course coming out called A Skeptic’s Guide to Health, Medicine, and the Media. It’s going to be great – look out for it around February 2019.

My courses:

A Practical Guide to Suicide Prevention – via The Great Courses Plus

Medical School for Everyone: Grand Rounds Cases – medical mysteries for you to solve! From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Emergency Medicine – mystery cases from the Emergency Department. From The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Medical School For Everyone: Pediatric Grand Rounds – mystery cases from the world of pediatrics! The Great Courses Plus streaming, from The Great Courses to purchase, or from Amazon

Don’t waste your money on “food sensitivity” tests

The Pediatric Insider

© 2018 Roy Benaroch, MD

Ah Facebook. Where else could I stumble on a video of a baby hippo taking a bath, or Toto’s Africa performed on solo Harp? But among the shares and silliness and talent, there’s a dark side to Facebook. It’s become a fast way for quacks to push their scams and empty your wallet.

Just today in my feed I received a “promoted” post about a “Food Sensitivity Test”. I’m not going to link directly to the company – feel free to do a Google or Facebook Search, you can find them along with dozens of other companies that push a similar product. What they’re selling, they claim, is an easy, at-home test that will reveal your “food sensitivities”.  They say their test won’t diagnose allergies (which is absolutely true), but it will help you find out which foods might be causing things like “dry and itchy skin, other miscellaneous skin problems, food intolerance, feeling bloated after eating, fatigue, joint pain, migraines, headaches, gastrointestinal (GI) distress, and stomach pain.”

This is absolute nonsense. Their test can’t in any way determine if any of these symptoms are possibly related to food. What they’re testing for in your blood, they say, are IgG antibodies that react to each of 96 different foods in your body. But we know that these IgG antibodies are normal – all of us have some or most of these if we’ve ever eaten the food. IgG antibodies are a measure of exposure, not a measure of something that makes you sick or makes you feel ill. Having a positive IgG blood test for a food means that at some point you ate the food. That’s it. Nothing more.

This isn’t something that we just now discovered. IgG antibodies to food have been a known thing for many years. We know why they’re there and we know what they do. And we know testing them is in no way indicative of whether those foods are making you sick. Recommendations from the American Academy of Allergy Asthma & Immunology, The Asthma and Allergy Foundation of America, the American College of Allergy, Asthma, and Immunology, and the European Academy of Allergy and Clinical Immunology all unequivocally recommend against food IgG testing as a way to evaluate possible food sensitivities. The testing just doesn’t work to reveal if a food is making you sick.

But that doesn’t stop quacks from direct-marketing on Facebook. If you’re offered IgG-based food sensitivity testing, either through the mail, at a physician’s, or at a chiropractor or naturopath, I’ll tell you exactly what it means: Save your money and run the other way. Whoever is pushing the test is either deliberately deceiving you or doesn’t understand basic, medical-school level immunology. It’s a scam.

More details about the (lack of) science behind IgG food testing

Preventing prescription pitfalls – How to save money and hassle at the pharmacy

The Pediatric Insider

© 2018 Roy Benaroch, MD

Doc writes prescription, pharmacist fills prescription, insurance covers prescription. Simple, right? But that’s not the way it works anymore.

Some changes are good. Gone are the cryptic abbreviations and illegible handwriting–replaced by computer printed scripts, or better yet scripts magically transmitted via the ether. But along with fewer errors there’s even less transparency on pricing and coverage. Patients, who haven’t been to pharmacy school and couldn’t possibly decode the pages of exclusions and conditions in their insurance contract, get hosed. And doctors and pharmacists get blamed.

Remember this, if nothing else: it’s all gamed by the payer. Insurance company tricks are there to prevent them from spending money on your health care, while making your doctor and pharmacist look bad. Inscos are often abetted by Pharmacy Benefit Managers (PBMs) – middlemen who skim even more health care dollars off the top, adding another layer of screwage.

But you can fight back. Here are some tips to help you get the medications you need, affordably.

Ask for generics (from your doc and pharmacist). There are often generics available, though these days they’re not always cheaper than the brands. Ask anyway. Remember that newer, brand-only drugs are not more likely to be better or safer. Go with an older, established medication if you can.

Don’t assume your “insurance price” is the best price. You might think your insurance-negotiated rate is better than what you can get without insurance. That’s not necessarily so. Those PBMs mark up everything, and often drive the price of very inexpensive drugs higher for those with insurance. Ask for the retail price to compare. And check out pricing sites, too.

Visit NeedyMeds.org for drug-discount programs and other information. This is a great non-profit, non-commercial site that pulls together just about all of the information you need to save money on prescriptions. There’s a price look-up, lists of industry- and private-sponsored assistance programs, and tons more.

Try out other “pricing sites” to help compare. Two simple ones that work well are Goodrx.com and WellRx.com. They don’t have the depth of info that NeedyMeds offers, but they’re simple to use to find prices in your area. You’ll enter the name of your medication and your zip code, and get back the price (to the penny) available at local chains. This assumes you don’t use your insurance – so keep in mind buying meds this way won’t count against your deductible.

Look into “90 day” supplies of medications. If you’re on a stable dose, your doc may be happy to write for 90 days instead of 30. That often saves $$. But you won’t be able to refill your next supply until that 90 days is almost up, so pay attention to the calendar. If your doc sends the prescription in too soon, the pharmacist will hold it until your insco deems it time for you to be able to refill it. Not doc’s fault, not pharmacist’s fault.

Don’t assume mail-order pharmacies are cheaper than filling locally. This happened to me – the Aetna mail order 90 day supply price was twice what it cost to fill the same medication for 90 days at my local pharmacy. Unexpected. But I’ll take the less-expensive, less-hassle option of a local pharmacy for sure.

Not-in-stock doesn’t mean never-in-stock. If your medication is out of stock at your favorite pharmacy, they can usually order it in just a few days – just ask them, if you’re not in a huge hurry to get the meds. If you are in a hurry, call around to different chains (not just different locations of the same chain, which probably use the same warehouse to resupply them shelves.)

Avoid “prior authorization” medications when possible. A prior auth is a nightmare, designed to prevent you from getting medicine while making it look like your doctor’s fault. “Just tell them to do a prior auth,” you’ll be told – but doing a prior auth typically takes a tremendous amount of time and frustration, and unless you’ve met the “secret criteria” it’s not going to work.

If you do need a prior auth, figure out the “secret rules” first. As with any game, you won’t win if you don’t know the rules. If your insurance insists on a prior authorization, call them and get them to tell you exactly what is needed to happen for the prior auth to be approved. Do you need to try one or more medications first? Which medications? What are the criteria that they use to make their determination of coverage? If you can find that out and tell your doctor, it will save everyone a lot of hassle – and you might just get your meds covered.

Consider OTCs over prescriptions. There’s a mystique to prescription medications, and that makes it seem like they’re more powerful or more-likely to work. That’s just not true. For conditions like allergies and acne, OTC meds or combinations of OTCs and prescriptions are often just as effective, safer, and cheaper than prescriptions.

The deck may seem stacked against you – the insurance company has the resources, and they make the rules. But you’ve got your doctors, nurses, and pharmacists on your side. Work together to get the meds you need at a price you can afford.

Life lessons from fruit

The Pediatric Insider

© 2018 Roy Benaroch, MD

A Twitter argument about the relative merits of honeydew got me thinking. (What, that’s never happened to you?)

Some fruits are reliably good: apples, say, and bananas. Peel a banana, eat a banana, and it always tastes like a pretty-good banana. Unless it’s not ripe, in which case it tastes like sheetrock, but ignoring that issue, let’s say this: bananas are a reliable, low-risk, fairly-low-reward fruit.

Other fruits are a lot of work, and you don’t really know what you’re going to get at the end. Honeydew, for instance – a pain to prep and get the rindy bits off. And the white-stuff-near-the-rind part that tastes of despair, that’s got to go, too. Work work work. And what you’re left with might be sublime cubes that taste of warmth and that little tide of happiness when you unexpectedly see a friend. Or it might just be vaguely greenish chunks of meh.

Mangoes, too, the most high-reward, high-risk fruit of all. A lot of work, always (and don’t send me videos of all of those “best ways to slice a mango.” None are effective. Not even that clever one with the glass tumbler. It may look good in the video. IRL you get a handful of mango squish and broken glass on the floor.) But once you slice a really good mango, you get a taste of summer, and hope, and love. The kind of love that sparkles. Really. If you haven’t had a great mango yet, keep trying.

Some things are worth the effort.

Don’t waste your money on follow-up formulas and their ilk

The Pediatric Insider

© 2017 Roy Benaroch, MD

Leave it to marketers to find as many ways as possible for parents to waste their money.

A growing market is developing for what’s variously called “follow up formulas,” “toddler drink”, or “toddler milk.” Short version for those of you in a hurry: don’t bother buying these. You do not need to waste your money. Details below, after a (very) brief lesson on how to feed a baby.

 

How to feed a baby in the developed world, 21^st century edition

Like all mammals, our newborns depend on liquid nutrition (AKA “milk.”) Mother’s milk works great for most families; commercial infant formula is a great choice, too. Between 4-6 months, start introducing complementary foods, using whatever the family is eating, kind of mushed up into a puree. You can use commercial baby foods, too, or commercial baby cereals and things – they’re not necessary, but they’re handy and easy. As babies grow from 6 to 9 to 12 months, they should take more and more of their food from first a spoon, and then by feeding it to themselves when their motor skills are up to the task. Be prepared for mess. At 12 months, if you’re bottle feeding, switch from commercial formula to whole or 2% or skim milk; if you’re nursing, feel free to continue. Have family meals for the next 18 years or so, and later on make your kids take you out to dinner on their dime. Ha!

 

Notice: nowhere in there is any mention of “toddler milk” or “followup formula” – those products are not recommended by the American Academy of Pediatrics or the American Academy of Family Physicians. Honestly, they have no use at all for routine use in children. So what are they, where did they come from, and why are the formula companies selling them? It’s time for the details!

Traditional commercial baby formula is an option to replace breast feeding for the first 12 months of life. Babies younger than that shouldn’t be fed straight up cow’s milk (unless, of course, we’re talking about a baby cow.) Baby humans need a different blend and amount of (especially) protein, and have different nutritional needs that are best met by human milk or a commercial copy of human milk, AKA “baby formula.”

But: and here’s the key thing: by 12 months of life, baby humans can do fine with cow’s milk as part of their diet. Remember, by now they should also be eating a good variety of other foods, so they’re not depending on milk, alone, for their nutrition.

A gallon of milk costs about $3.00, less if you catch a sale at Kroger. A gallon of infant formula costs about $21.00 (that’s reconstituted from powder, using the prices I found at Walmart today.) Are you starting to figure out where the idea of “follow up formula” came from?

It’s ingenious – these products are packaged to look like baby formula. And they have clever names that imply parents should be moving to them from baby formula, using words like “transitions” or “next step.” Some are named in a way that implies they’re a special kind of milk – “toddler milk” – that’s somehow superior to ordinary milk. Hats off to the marketers – they’ve come up with a product that’s much more expensive than the alternative (milk), and that’s completely unnecessary. But it’s selling, so I guess they win.

Look, I’m glad the good people at Mead-Johnson, Ross, Gerber, and even those faceless generic companies are producing good quality baby formulas. But I’m not so glad they’re trying to extend their markets by creating the illusion that infants past 12 months need their products. Spend your money on what your children really need – a variety of foods, or books, or a slide for the backyard. Save for college, or a family vacation. But you really don’t need to keep spending money on special milk or formula past your baby’s first birthday. The formula companies already got plenty of your moolah – don’t feel bad about keeping a little more for yourself.

 

Just for fun: below is a comparison of macronutrient compositions of cow’s milk versus infant formula versus 2 kinds of followup formulas (Enfagrow, marketed for 9-18 months, and Similac Go & Grow, marketed for 12-24 months.) Compared to milk, the big nutritional difference with these followup formula is more calories, and especially more calories from carbohydrates. That is not what American children need.

 

	Kcal/8 oz	Fat, g	Protein, g	Carbs, g	cost, gallon
Whole milk	136	7	7	10	$3.00
2% milk	122	5	8	11	$3.00
skim milk	86	0	8	12	$3.00
Enfamil	168	9	3	18	$21.76
Enfagrow	160	8	4	17	$17.92
Similac	160	9	3	17	$21.40
Sim go & grow	150	8	4	16	$13.95