Archive for the ‘Pediatric Insider information’ category

Be wary of infant jewelry and lead poisoning

September 5, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A recent story reported by the CDC reminds us of a few important lessons about teething, lead, and the kind of jewelry you buy at craft shows. A mom had purchased a handmade “homeopathic magnetic hematite healing bracelet” from an artisan at a local craft show. Her 9 month old daughter wore it on her wrist, reportedly to help with teething symptoms, and occasionally chewed on it (as babies are known to do.) She was found on routine screening to have a blood lead level about 10 times the safe upper limit of safety.

Lessons to learn:

Babies really shouldn’t wear jewelry at all (they look good without it!) Some bling is probably OK (like small earrings), but you have to be sure they’re not made with lead. That’s because anything on a baby or near a baby will end up in the baby’s mouth. Seriously, everything.

This particular bracelet was triple-dangerous. Looking at the photo, it was made of little beads strung together, which apart from their poisonous lead content were a potential choking hazard. And: magnets are a very bad thing for kids to swallow, because they can glom onto each other in clusters, or even while pinching a piece of intestine. Magnets are less likely to make their own way out without causing big-time tissue damage. No lead, no beads, no magnets!

Babies should especially never wear any kind of jewelry around their necks. Even a small tug on a necklace can close off the airway and kill a baby. That includes those trendy amber teething necklaces, which are both a choking and strangulation hazard. There are media reports of deaths from those things. Look out for long cords or straps on pacifiers, or cords on window blinds or binoculars or anything else thin and round and shaped in a loop. Anything that could wrap around a neck can strangle a baby and needs to be cut to pieces or kept very far away.

And: teething. Most babies experience teething with no symptoms whatsoever – the only way you know, with most babies, is that you see teeth poking out. An occasional baby might have some fussiness with teething, and you can treat them with love and cuddling, maybe a teething ring, or some acetaminophen if needed. There is no great plague of terrible symptoms of teething that need constant treatment, especially not with dangerous things. Teething is just another thing most parents do not have to worry about.

Other dangerous teething “cures” have included “homeopathic teething tablets” which contained poison, and benzocaine-containing teething gels (now mostly off the market) that caused a potentially fatal blood disorder. The sad thing here is that none of these were ever really needed – they’re marketed based on fear of a normal, harmless condition. Don’t waste your money, or endanger your child’s health, on jewelry or potions to treat teething.

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What happened to those pain-killing ear drops?

August 14, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

MJ wrote in about her daughter. In the past, she used to use a prescription drop called Auralgan (benzocaine plus antipyrine) for ear pain, but it’s been taken off the market. What happened to it? Was it unsafe? Can she start buying it from Canada? What other options are there?

The FDA got tough on Auralgan and several other similar ear drops – AB Otic, Aurodex, Auroto, and other brands – in 2015. To my knowledge, there wasn’t any specific incident or allegation that these products caused any problems. But they’ve never been shown to be safe, and they’ve never been shown to be effective.

For many years these and other older “grandfathered” drugs were cheerfully sold alongside other prescriptions. But all new drug applications submitted to the FDA must include proof of both safety and effectiveness – that’s been the law since 1938, though what’s passed for “proof” has varied. Many older drugs, like these ear drops, slipped though when things were less stringent. But the FDA has always had the right to ask for more proof from the manufacturers.

I don’t really know why these drops got the FDA’s attention. It is true that there’s never been any proof of effectiveness. A German study cited in the non-discontinued products’ insert showed that children given Auralgan for earache did improve – but they didn’t compare the responses with a placebo, and we know that ear aches get better on their own, anyway. There was also a study from Pittsburgh in 1997 – the authors say they showed that topical Auralgan was “likely to provide additional relief” when given along with acetaminophen. But their study showed no statistical difference in pain scores at 3 of the 4 time periods, meaning that Auralgan was equivalent to their placebo (olive oil drops.)

There’s also no science reason to even think these drops would work. The two ingredients, benzocaine and antipyrine, are not effective when applied to the skin – they only work when injected or swallowed. Benzocaine has some activity when rubbed onto a mucus membrane, like on your tongue or gums, but that’s not what’s inside your ears. And: it makes absolutely no sense to use these to treat middle ear pain (like an ear infection, or the pain you get in an airplane), because drops in your ear canal don’t get into your middle ear. That’s like treating stomach pain by pulling on a finger. OK, bad example (ref: grandpa). Anyway, you get the idea.

Real Drugs are only supposed to be marketed in the USA with FDA approval, which requires proof of safety, effectiveness, and quality control manufacturing standards. For ear pain, if you want to stick with a Real Drug, acetaminophen is a pretty good choice. MJ asked about buying Auralgan from Canada – it looks like it’s still on the market up there. I found one place selling it for $142. That’s one expensive placebo.

Or, MJ could wander outside of the realm of Real Drugs. The 1997 study used olive oil as a placebo, and that’s safe – and you could use the leftovers in a salad. Or you could look in the alt-med, “alternative medicine” section of the drug store – there are ear drops there, but they’re not FDA regulated, so purveyors can sell whatever they’d like. You don’t know what you’re getting in those bottles, and there’s no reason to think they’d work any better than olive oil, pickle brine, or ranch dressing.

 

Competition can’t reduce health care costs if the prices are a secret

August 8, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Competition often works. Competing dry cleaners or donut shops must either improve the quality of their product or keep their prices low, or customers will go somewhere else for their cruller fix. In time, the better businesses – the ones that provide tastier pastries at a lower price, – will thrive, and less-good, more-expensive businesses will go away. In the long run, all customers benefit from competition between businesses.

That’s how it’s supposed to be in the American marketplace. But the reality in health care is that it’s not a free market, and it can’t be a free market, and we cannot rely on competition to keep prices down. One big reason: health care prices are a secret.

 You know how much a donut costs. If it’s too much, you’ll take your business elsewhere. Or eat a croissant, or (God forbid) a gluten-free muffin. But can you shop around to find  better health care costs?

A quick story: I use a CPAP machine at night. (Apparently, if I don’t, I stop breathing. I’m told that’s bad.) I get billed $140 a month from the CPAP company, which is magically transformed into $42 a month on the insurance statement, which I pay towards my deductible. I called today to find out from the CPAP company what the total cost will be (it’s a rent-to-own deal, and eventually the machine will be paid off.) They wouldn’t tell me the total, but suggested I call my insurance company. Who also wouldn’t tell me the total, but assured me that if the CPAP company went over their “contractual rate”, the insurance company would stop paying. (How this helps me, I don’t know, but isn’t it nice to know that my insurance company won’t overpay? I might get hosed, but thankfully the good people at Aetna are protected from CPAP price gouging.) That “contractual rate”? It’s a secret (their computer knows, I was assured, but they can’t tell me.)

Even if I wanted to shop around for a less-expensive CPAP device, I couldn’t, because no one will tell me the price. Not that I would shop around, honestly – after those two phone calls, I’d rather poke a fork in my eye, or just stop breathing at night and let my wife shake me awake (which has always worked before. Maybe I need to start paying her that $42 a month.) Secret pricing and means that competition and comparison shopping just aren’t possible for many medical services.

There are other reasons that health care doesn’t abide by free-market principles:

Hospitals and emergency departments have to provide care to everyone, even if they can’t pay. Imagine running a grocery store where sometimes you had to give the food away. To stay in business, you’d have to jack up the prices on the paying customers to cover the non-payers. Now: emergency departments are not grocery stores, and I agree that it is morally unacceptable to turn sick people away. But someone has to pay for this. Emergency departments cannot be run like an ordinary competitive business.

The “barriers to entry” are too high to ensure competition. If a donut shop offers crappy, expensive donuts, another shop can open up across the street. But opening up a hospital is very expensive – and requires government clearance for a “certificate of need” and all sorts of other hoops. Pharmaceutical companies, device manufacturers – these are also very, very expensive companies to start up, and that stifles competition. Legal wrangling also gets in the way. There is no fair playing field to even out or control prices for the biggest-ticket medical expenses.

On the other hand, it’s relatively inexpensive to open up another walk-in or urgent care center – that’s why there’s one on every corner. At least in wealthy neighborhoods. You’d think that would create competition and lower prices – but that won’t happen, not unless their customers can comparison shop for price and quality. (By the way: judging the quality of medical care is also fraught.)

Many people don’t pay their own health care bills. We’ve come to expect health care to be covered by insurance (though that’s changing, with more high-deducible plans and cost-sharing). Many of us don’t even think to comparison shop. But if no one cares about the prices charged, “competition” doesn’t work.

Health care is often “purchased” under duress. When you’ve got crushing chest pain, you don’t call your insurance company to find an “in-network” hospital or ambulance service. And you shouldn’t have to.

The biggest problem with health care is that it costs too dang much. Providing better access to insurance and doctors is morally the right thing to do, but – and this is important, here – better access does not control costs. Competition, alone, won’t work. We’d better come up with some better ways to get costs under control, or there won’t be any money left over for those tasty donuts.

Most kids with penicillin allergies aren’t actually allergic

July 6, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

It’s a common problem: an infant or child has a rash or another symptom while taking antibiotic, so he’s considered “allergic.” The chart is so marked, and the child isn’t allowed to take that antibiotic anymore. But a new study adds to growing evidence that many children thought to be allergic actually aren’t. They could take that same drug again, and they’d do fine.

This isn’t a minor issue. Second like drugs used when there’s a reported allergy tend to be less effective or more broad-spectrum, leading to more side effects. And some kinds end up with a whole lot of alleged allergies, making it difficult to treat them with anything.

In the current study, the authors looked at children (age 4 to 18) showing up to an Emergency Department with a history of any penicillin allergy (this includes amoxicillin, Augmentin, and other penicillins.) Parents were asked to fill out a questionnaire about their child’s previous reactions, and most of the common reactions reported were considered “low risk” for true allergy – symptoms like any rash (hives or not hives, any rash), itching, diarrhea, comiting, runny nose, nausea, cough, headache, dizziness, or allergy suspected based only on a family member being allergic. If a child’s symptoms were one or more of these items, they were considered “low risk” to be truly allergic. When 100 of these “low risk” patients had formal allergy testing, ALL of them tested negative. Not one of them was allergic to penicillin.

Reported “high risk” symptoms included facial or lip swelling, difficulty breathing, wheezing, throat swelling, skin blisters or peeling, or a drop in blood pressure. These children were not tested for penicillin allergy, and were presumed to be really allergic.

This was a small sample – despite their “100% not allergic” finding, I don’t think anyone’s prepared to say that all amoxicillin rashes can be disregarded as non allergic. But it’s clear that most children (and adults) labeled as penicillin or amoxicillin allergic are not allergic, and could safely try the medication again. If you or your child is thought to be allergic, talk with your doctor about the exact reaction, and see if either a rechallenge or a referral to an allergist would be a good idea.

 

 

Mixed messages: Where should babies sleep?

June 12, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A new study about the best place for babies to sleep – in their own rooms, or sharing a room with their parents – contradicts current AAP guidelines. But hopefully, in the long run, it will help more parents and babies get a better night’s sleep overall.

The most recent “safe sleep” guidelines were published in 2016. They stressed evidence-based recommendations for the safest way for babies to sleep: put down on their backs for every sleep, and on a firm, flat surface. Since bed sharing is has been shown to increase the risk of SIDS (especially in younger babies), it was also recommended that babies sleep on their own surface, designed for infants. And babies were supposed to sleep in their parents’ bedroom for at least the first six months of life, and ideally for 12 months.

It’s that last recommendation that I’ve never been completely happy about. The recommendation is based on three studies from the 1990s, all from Europe (where almost all babies slept in parents’ rooms, and, at the time, on their tummies.) In the aggregate, these studies showed fewer SIDS cases in babies sharing a room with their parents. But: there were very few SIDS cases to compare, and the one study that separated out babies by age at death showed that babies less than 4 months were safer in their own rooms (and less than 4 months is the peak time for SIDS.)  So the evidence, then, wasn’t very strong – but it was the best evidence at the time, and the AAP decided the “share room with parents” idea deserved to be a recommendation.

I also think the Academy was swayed by room sharing’s making nursing easier, which is true. Breastfeeding is associated with a decreased SIDS risk.

The “ideally until 12 months” part of the recommendation was especially problematic. SIDS rates are very low past 6 months, making conclusions about the effect of sleeping location for older infants tenuous at best. 12 months is also peak time for separation anxiety, and a terrible time to first put your child alone to bed. The AAP decided to extend the “ideal time” in parents’ room to 12 months to be extra cautious, but I’m not sure they considered the overall burden this could place on many parents and children in terms of overall quality of life.

Now, a new study throws a wrench into this “same room” recommendation. Researchers tracked the sleep habits of babies who slept in their parents’ rooms, versus their own rooms, and the results aren’t terribly surprising. Room sharing at 4 and 9 months is associated with less sleep for babies, and fewer long stretches of sleep. Babies seem less able to “consolidate” or organize their sleep into longer stretches if they’re sharing a room with parents. And: room sharing makes it more likely that babies will end up in known unsafe sleep positions – like sleeping directly in their parents’ beds. But wasn’t room sharing supposed to be safer?

It’s a mixed message, but it reflects that the evidence for this room sharing recommendation has never been very strong. With this new study, parents should feel more comfortable, and less guilty, if they choose to put babies in their own rooms to sleep.

Nevus sebaceous – what we don’t know about their management

June 5, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Trupti sent in a quick question, to which I’ve written an honest but worthless answer. Such is medicine, sometimes. But honestly is always the best policy, right?

“Hi Dr. Roy, can you please shed more light on nevus sebaceous and its management?”

Nevus sebaceous – also called “nevus sebaceous of Jadassohn” or “sebaceous nevus” – is a fairly common skin patch. And by fairly common, I’d say I see a new one of these on my patients maybe once a year. They’re usually found on the head or neck, often noted at or shortly after birth. I’ve also heard they can arise later, but I don’t think that’s too common. They look kind of waxy and bumpy, with a yellow-brown or yellow-pink color, and if they arise in the scalp they stand out a little more because they don’t grow hair.

Really, the only management decisions are whether to have the removed, and when. Do they have to be removed? The answer here is a clear and definite “maybe.”  Derm textbooks and many docs who trained in the past will tell you that many of these will turn into cancer, so they ought to be lopped off, excised, and fully extirpated with extreme prejudice. This is based on older studies that found cancer rates up to 10-30% — and, yes, if that were true I’d say get them off. But more-recent studies since the 1990s have found much lower rates of cancer, perhaps less than 1%. Those older studies had mis-classified pathology findings as basal cell carcinomas, when in retrospect they were benign. We honestly do not know exactly how many of these will develop into cancer over a child’s lifetime, though cancerous transformation certainly isn’t common when kids are young.

There still isn’t a consensus in the dermatology literature about this. Though some authors recommend prophylactic removal because of this cancer risk, others do not. Here’s a table from a 2012 review – note that newer recommendations tend to be less surgery-happy, but they’re still all over the place:

 

OK, so that’s clear now. Another reason to consider removal is cosmetic – and especially if one of these is on the face or the side of the neck, you’d probably want to consider removal for your child. That’s something to talk w/ a plastic surgeon or dermatologist about. Removal of one of these will always leave some kind of scar, and you want an honest assessment of what it will look like afterwards – there’s no such thing as a no-scar removal.

As for when to take them off, well, there’s no consensus about that either. In early childhood they’re smaller, so hypothetically easier to remove, but it’s harder to use safe local anesthesia in younger children. You could wait to see how it develops through adolescence, but if it gets much bigger a more extensive, possible multi-staged, procedure is going to be needed.

Bottom line: we don’t know if these should be taken off, or the best time to do the procedure. I know, clear as mud – aren’t you glad you asked, Trupti? You should talk with your child’s doc, and get the opinions of a few knowledgeable plastic surgeons to help make the best decision. Good luck!

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!