Archive for the ‘Pediatric Insider information’ category

Halloween: What should worry parents, what should not

October 24, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

 

Poisoned candy – not a worry!

There have been 5 deaths in the USA reported from poisoned Halloween candy. But: three were committed by family members (one using cyanide-laced Pixy Stix), one was by a child who ingested heroin (the family sprinkled more heroin on the candy afterwards to make it look like that was the source, but it turned out that the child had found and eaten his uncle’s stash) and one turned out to be related to an overwhelming strep infection – unrelated to the candy eaten the night before.

In 2000, several children in California found Snickers bars packed with marijuana. Funny story: a postal worker found a box of Snickers among the undeliverable mail, and brought them home to give to trick-or-treaters. It’s assumed that someone packed them with marijuana to sneak them through the US mail, but got the address wrong. There’s a lesson there. Anyway, no one ever found the culprit, and no one was hurt.

 

Metal objects in candy – not a worry!

 There have been about 80 reported cases of needles and razor blades and things in Halloween candy. But almost all of these were hoaxes that never actually happened. A few were true stories, but the objects were placed by family members (good old Uncle Bob, what a kidder.)

In 2000 there was a case in Minneapolis of a guy arrested after sticking needles into Snickers bars (What’s with the Snickers, anyway?) One teenager got stuck by a needle, but didn’t need medical attention. As far as I can find, this is the only documented case of a sicko randomly and deliberately handing out dangerously adulterated candy.

Some communities have had programs for x-raying candy – but I think these have been phased out. They’re expensive and unnecessary, and no one has ever spotted anything of concern on one of these.

 

Sexual assaults – not a worry!

 It’s been studied. Child sex crimes don’t increase on Halloween.

 

Getting your eye knocked out by a thrown egg – this is a thing, apparently

This report wasn’t about Halloween, but it did include several people with apparently severe eye injuries caused by assault by thrown raw eggs. So don’t do that. Raw eggs are for throwing at houses, not people. Wait, forget I even said that. Just leave the raw eggs at home. Make cookies or something.

 

Car accidents – the only serious possibility on this list

Now this is a real problem. Halloween is the #1 day of the year for pedestrian accidents among children, averaging 5.5 deaths per year in the US (that’s double the average for a typical day.) Be careful with your kids, and have them wear something light or (better yet) lit. Remind them to cross streets at crosswalks and corners, and not just dart around. If you’re driving, be very careful in residential neighborhoods, and don’t drink alcohol. Both drivers and pedestrians shouldn’t be messing with their phones. Pay attention, everybody.

 

Getting your brains sucked out by Alien Zombie Vampire Death Beings – rare?

As far as we know, this doesn’t happen. Much. Hardly ever. Really.

 

Tummy aches and weird nightmares from too much candy – yup, it happens

Don’t say I didn’t warn you!

 

More from Wikipedia, Snopes, Mental Floss, and Vince Guaraldi. Stay safe, have a good time, and remember: I like Almond Joys and Reese’s.

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Physician rating sites deserve their own “Black Box Warning”

September 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

When a drug is especially dangerous, or even potentially-maybe-especially dangerous, the FDA requires manufacturers to put a “Black Box Warning” on the product insert. (As it happens, many of these are misleading, inappropriate, or factually incorrect – but that’s a subject for another day.) A “Black Box Warning” is supposed to very explicitly say “BUYER BEWARE”, more than just the typical list of potential side effects mumbled by Mr. TalkFast at the end of a drug ad. The normal warnings look like “ThisDrugMayCauseDrowsinessTailGrowthAnalFlameDischargeAnUnpleasantMetallicTasteOrAnInexplicableInfatuationWithSenatorJonTester(D-Montana)”. It’s easy to ignore the wordy mumbling. The Black Box, that’s supposed to get your attention. It’s doesn’t mean the drug is a bad idea for everyone, but it does mean you’d better think before you take.

I’d like to see a Black Box warning on physician rating sites, too. They’re not always wrong, and they might just be useful once in a while. But you’d better think twice before taking them at face value, or using them to make decisions about whom to see for health care.

A few recent studies illustrate some of the problems. One looked at mortality rates for 614 heart surgeons scattered across 5 states, comparing those rates to their physician ratings on several well-known rating sites. There was no correlation at all. Physicians with high death rates often had great ratings; physicians with low death rates might have very good ratings. If your goal is to survive heart surgery, those physician rating sites tell you nothing. That should be in the Black Box warning.

Another study looked at physicians in California, comparing ratings on popular sites between 410 docs who had been put on disciplinary probation versus docs in those same Zip codes who hadn’t been sanctioned. Keep in mind that medical boards do not take probation lightly – docs who’ve been nailed by their board have probably done something fairly bad, and probably more than once (although there’s considerable variability, some luck, and politics involved. Good docs are sometimes trapped by their boards, too.) Although it varied by the reason for the probationary status, for many doctors disciplined for lack of professionalism, substance abuse, or sexual misconduct there was no correlation between ratings and probation status. Looking at the overall averages, docs on probation had an average score of 3.7, compared to 4.0 for docs who had behaved themselves. Very little difference, there.

There are several reasons that these doc rating sites not reflect genuine physician competence:

  • Only people who are motivated to write ratings do so. The vast majority of patients who have a reasonably positive experience do not bother to do rate their docs. I’ve called this property of internet postings “Exaggerating Freakiness”, and it pervades social media. The internet brings far more attention to the outliers than it does to ordinary stories, and that distorts the impression we get from just about every web site.
  • How people feel about the medical care they received doesn’t necessarily correlate with whether they got good care or not.
  • It’s pretty much impossible to tell if a public posting is true. There are many reasons people write both positive (friends, neighbors, well-wishers) and negative (competitors, those with specific agendas) reviews.

Some docs (and other businesses) are using litigation to aggressively fight back against negative reviews. But that’s not always fair, either. People are entitled to their opinions, and as long as they’re not just lying about what happened, I think it’s best if the lawyers stay out of this. Still, I get the frustration that business owners feel if they’ve been unfairly targeted.

Online rating sites are here to stay, and they’ll continue to rate doctors and hospitals, and people are going to continue to use them (Google just shoves the rating down your throat when you search. There’s no avoiding this.) Just remember the Black Box warning: physician rating sites may have some use, but they can have unintended side effects. They may mislead you into making a poor decision about your doctors, and that’s not good for your health.

Physician rating sites deserve their own “Black Box Warning”

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.

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.