Bedwetting in a pre-teen

Posted August 3, 2017 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2017 Roy Benaroch, MD

Josh wrote in about his 12 year old daughter – they’ve tried everything, specialists and medications, and she still wets the bed every night:

We have done everything. Waking her, withholding fluids, buzzer. She has taken the highest dosage of desmopressin allowed, to no avail. She has been to an endocrinologist and tested thoroughly, seen her pediatrician many times, had abdominal X-rays and ultrasounds, and been examined for psychological issues. Nothing. The next step our doctor suggests is a urologist. She currently wears a diaper to bed, and we are very straightforward and sympathetic with her. Only positive reinforcement, but she is frustrated with herself at this point.

Josh, about 3% of 12 year olds still wet the bed, at least sometimes (though most of those are boys). It’s not crazy-uncommon for your daughter to be doing this, but I know she wants to stop. Trouble is: bedwetting happens when you’re asleep, and what you want or don’t want doesn’t really matter. Positive reinforcement won’t hurt, but it probably won’t help much, either. What might hurt is encouraging her to “try harder” – this is something that isn’t about trying or practice or rewards. It’s about neurologic maturity.

What supposed to happen: past a certain age, even while we’re asleep we can still pay attention to signals from our bladders. When it’s full, or getting full, we tighten up our pelvic muscles to hold in the urine, without waking up. A good trick, that is, and babies can’t do it, and young children can’t do it. People who are heavier sleepers find it harder to do this, too – and that makes sense. Sleeping like a rock means it’s more likely that you’ll wake up like a, well, wet rock. And there’s not much you can do to “lighten” someone’s sleep cycle.

What *might* work – and I know Josh’s daughter has already tried some of these, but just for completeness:

Drinking more in the morning I know, the usual advice is to drink less at night – but it turns out that’s really difficult to do. If you’re thirsty, you’re thirsty, and not drinking when you’re thirsty is nigh impossible. Instead: stay well hydrated the rest of the day, especially the morning, so you don’t feel like drinking in the evening.

Don’t hold urine during the day I know, some people suggest “bladder stretching” by day to hold more at night. But the problem isn’t a small bladder – it’s that the sleeping child doesn’t notice that their bladder is full. It turns out that holding by day gets the brain “used to” the feeling of a full bladder. It dampens (sorry) the nerve signals, so you don’t get as strong a feeling of a full bladder. This is exactly what you do not want. Frequent, relaxed daytime emptying can help a child stay dry at night.

Treat constipation Constipation leads to holding which leads to less awareness of a full bladder; it also inadvertently strengthens muscles you don’t want strengthened, making it difficult to empty the bladder. At 12, if bedwetting is an issue, I suggest treating constipation even if you don’t think your child is constipated. Just try it. It might work.

Consider medication Two meds have wide use to help with bedwetting: desmopressin and imipramine. Either or both are worth a try, especially if the child is concerned about this.

Don’t make this about trying or not trying I said this before, but let me repeat it: kids don’t wet the bed because they want to wet, and don’t stop wetting the bed because they want to stop. Josh mentioned looking into psychological contributors, which may be a good idea, but don’t create a bigger problem by blaming or by implying that kids can solve this problem by trying harder. That’s not fair and won’t be helpful.

See a urologist At some point, I think it’s a good idea – to rule out very rare anatomical issues, and make sure all medical contributors have been addressed.

And, finally: Focus on the positive. I agree, Josh’s daughter has every right to be upset about this and to want it to stop. And it will stop. I’d pursue some (or all) of the ideas above, while at the same time keeping the conversation positive, non-blamey, and focused on things she does well.

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Just because a chemical is present doesn’t mean you have to worry about it

Posted July 31, 2017 by Dr. Roy
Categories: Guilt Free Parenting, In the news, The Media Blows It Again

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The Pediatric Insider

© 2017 Roy Benaroch, MD

Advocacy groups have been busy lately with their fancy-pants chemicalz detection science instruments, and their press releases have made it into the news. But is there news here, and are these chemicals something parents really need to worry about?

First it was a big lead from the New York Times called “The Chemicals in your Mac and Cheese.” The article started:

Potentially harmful chemicals that were banned from children’s teething rings and rubber duck toys a decade ago may still be present in high concentrations in your child’s favorite meal: macaroni and cheese mixes made with powdered cheese.

Oh noes, not high levels! The chemicals they’re talking about are from a family called “phthalates,” which sounds scary and difficult-to-pronounce. (Words shouldn’t start with four consonants. On this we should all agree.) Phthalates have been in wide use for over 80 years in plastics and other compounds. Though they’re not added to cheese, they’re on the coatings of tubes and platforms and whatever else is used in the machinery to make Magic Orange Cheese Powder. Foods with a high surface area (like a powder) are going to come in more contact with it, and a teeny bit of a trace of a few molecules are going to transfer over.

Important point: these chemicals have been in our food for many, many years. What’s changed is that we’ve now got fancy equipment to measure it. The Times story is quoting a kind of press release – not a medical study, or even anything published in the medical journal. It’s a “study” done by a consortium of food advocacy groups. It’s being promoted by an organization called “KleanUpKraft.Org” (Cutesy misspellings are at least as bad as starting words with four consonants, K?) And their “high levels” are in tiny parts per billion, at levels that are very low compared to amounts that cause adverse effects in animal studies.

Just because you can detect a chemical as present doesn’t mean there’s enough of it to hurt you. Mercury and arsenic are part of the natural world around us, and any food tested with equipment that’s sensitive enough will find at least traces of these and many other chemicals. It is not possible to get the values of phthalates or arsenic or many other chemicals down to zero in our foods.

Speaking of chemicals, this week another food advocacy organization announced that they’d found traces of an herbicide (glyphosate, found in Round-Up) in Ben & Jerry’s Ice Cream. And in every flavor tested, too, except Cherry Garcia, which is kind of nasty-tasting anyway (I’m sticking with Chunky Monkey, which wasn’t even tested.) But: their press release didn’t even reveal the levels that they found, only that they found it. Maybe it was one part in a zillion. Who knows? But: Do you think if the value were genuinely high they’d hide it like this? No way. It’s there in some kind of teeny amount, and they’re trying to scare you.

Don’t fall for all of this “The Sky is Falling, There’s Chemicals in My Food” hype. Just because something is hard to pronounce doesn’t make it dangerous, and just because something is present doesn’t mean it’s going to kill you. We’ve all got enough to worry about without being scared of Mac and Cheese and Ice Cream. In fact, a little comfort food in these troubled times would probably be good for all of us. Maybe even the grumps at KleanUpKraft.org.

By the way, I don’t disagree with one thing – homemade Mac n Cheese is at least as good as that boxed orange stuff. Though sometimes, I won’t deny it, the orange stuff sure does hit the spot…

Vaxxed versus unvaxxed children: What a real study shows

Posted July 26, 2017 by Dr. Roy
Categories: Guilt Free Parenting, In the news

Tags: ,

The Pediatric Insider

© 2017 Roy Benaroch, MD

You may have seen it on Facebook: A published study claiming to be “The First Ever” comparing vaccinated and unvaccinated children supposedly showed that vaccinated children are more likely to have a number of health problems. Let me promise you: there’s nothing to worry about here. The study is one of those garbage-in-garbage-out whackjobs that’s almost indescribably bad and unreliable. And: a much better study of the same thing – children who are vaccinated, versus children who are not vaccinated – shows that there are not any worrisome risks. The long-term health of vaccinated children is just fine, and even better than unvaccinated kids (because they don’t have to suffer through vaccine-preventable diseases.)

Let’s cover the good study, first. It was published in 2011, and tracked over 13,000 randomly selected children in Germany, tracking their health status and correlating that with their documented vaccine histories. The authors could find no examples of any increased risks of infectious or allergic diseases in the vaccinated children.

And now, this more-recent, execrable study. They didn’t use randomly selected children. What it actually compared were the 666 children of homeschoolers who chose to complete the survey (which was promoted on antivaccine websites), using their self-reports of vaccine histories and health status. Of these, 40% hadn’t been vaccinated, at least according to the surveys. No attempt was made to track who received the survey, what percentage of respondents completed it, and what kind of respondents completed it. Do you think it’s possible that a high proportion of vaccine-distrusting parents would complete a survey like this? Hint: if you did a survey of musical tastes at a Justin Bieber concert, you’re not going to find many Cab Calloway fans.

The “study” was really just a survey, and a biased one at that – a survey among people who were guaranteed to say exactly what the study authors wanted them to say. It had already been retracted, once previously (and, laughably, by a bottom-feeding journal that looks like it requires authors to pay to publish their studies. This isn’t the way legit journals work.)

Vaccines are safe, and they save lives. Make sure your kids are fully vaccinated. Don’t believe the Facebook rumors, or idiocy dressed up like science – what the real science shows is what parents should feel confident about. There’s no need to worry about vaccines.

A more detailed evaluation of this fakakta survey is here, and here’s more information about reliable vaxxed versus unvaxxed studies. Yes, they’ve been done before. Yes, they consistently show that vaccines are safe and that vaccinated children are healthy.

26

Republican and democratic lawmakers: Grow up and do your jobs

Posted July 20, 2017 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2017 Roy Benaroch, MD

Health – /helTH/ – The state of being free from illness or injury

Care – /ker/ – The provision of what is necessary for the health, welfare, and protection of someone or something.

System – /’sistəm/ – A set of things working together as parts of a mechanism or an interconnecting network.

It’s not keeping us Healthy, it doesn’t seem to Care, and it’s certainly no kind of System. What we’re got is more about hostile parties protecting their turf and income than a system that’s working together. The docs fight the insurance companies to get things covered; the patients fight the hospitals over inflated, inscrutable bills; the insurance companies fight the pharmaceutical companies over the eye-popping prices of new drugs. The people least suited to fight end up losing the most – that’d be the “patients.”

Meanwhile: the peeps we’ve hired to fix this mess are too busy trying to make each other look bad – which, by the way, is like shootin’ fish in a barrel these days, amirite? – to pass some kind of legislation to even begin to help fix this fine mess. Ever get hired to do a job that you don’t do for 2 or 4 or 8 or 20 years? Didja keep that job? Mind: boggled.

OK, in the spirit of angering everyone involved, so I can bask in the flames of democrats and republicans alike, I will now specifically criticize the approach of both parties. Those of you with strong loyalties may want to skip the next (democratic) or following (republican) paragraphs, lest you be exposed to a worldview that’s not aligned with your own. But for the few of you left who are still capable of seeing two sides of an issue, start here:

Democrats: Obamacare has problems. The insurance marketplaces in many places are collapsing, and premiums are going thru the roof. Even people who have “insurance” often have huge deductibles that they can’t afford. In short: just having “insurance” isn’t the same as “having access to health care.” Obamacare didn’t do a thing to rein in the biggest problem: health care costs too much, and too many people (sorry, “market stakeholders”) are chewing up huge slices of the pie without contributing anything useful to helping patients. I know you’re feeling hurt that you lost the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

Republicans: The free market, alone, cannot save health care. The barriers to entry are too huge (it’s hard to become a doctor, harder to open up a company to manufacture medicines, and even harder to open up a hospital) – which means competition is artificially stunted, and won’t pop up automatically to reduce prices. Also, Emergency Departments are required, by law, to offer care to people who cannot pay – that’s morally the right thing, and don’t even think about removing this safety net. Health care choices are also difficult and fraught, and often made under the duress of pain and worry. People cannot be expected to call around to different ambulance companies to check their prices when they’re experiencing crushing chest pain. You have to admit: health care is unique, and you can’t depend on free market principles, alone, to fix it. The solution is going to include regulations and guidelines and (gasp) some guarantees of coverage, and might even require ways to rein in insco, hospital, doctor, and pharmaceutical profits. I know you’re feeling giddy that you won the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

It’s not easy, I know – but at this point, it’s clear that members of both parties aren’t keeping their eyes on the ball. Your job isn’t about re-election, and payback, and “If you play with Susie than you can’t be my friend anymore.” This isn’t kindergarten, and we don’t really care who plays with Susie – we just want Susie and her family to have access to affordable, good health care. Congresspeople, it’s time to grow up and do your jobs.

Vaccines: We’re all in this together

Posted July 17, 2017 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2017 Roy Benaroch, MD

When we work together, great things can happen.

Polio has been around since ancient times – there are depictions of it in art thousands of years old. Improved sanitation helped, but it was vaccines that have nearly eradicated polio from the world. This is a disease that paralyzed over 21,000 people in the US in 1952. There are still plenty of people around living with deformities and chronic pain from polio they suffered through years ago. Our children will never have to face this, because our parents and grandparents were sure to get us vaccinated.

Smallpox – gone.

Rinderpest – gone, too, though you may not have known what it was. It’s a neat story. Rinderpest was also known as cattle plague or steppe murrain, and may have been one of the biblical plagues. Our livestock no longer have to worry about it (I’m not sure they ever did, really. That’s livestock for you. But for farmers & pastoral nomads, rinderpest was a big deal.)

Measles – another ancient disease, and a serious one that continues to kill people – was almost eradicated from the western world. It’s no longer endemic (constantly circulating) in the USA, though pockets of certain populations can still support local outbreaks. And that exactly what happens, when vaccine rates fall. Measles cases rapidly return. It’s happening in Europe, and it’s happening in communities in Minnesota who’ve fallen for the lies of the antivaccine propagandists.

Have you or your kids had tetanus, lately? Diphtheria? No. And it’s not because you’re lucky. It’s, again, because our parents and grandparents got us vaccinated, and almost all of us continue to vaccinate our children.

Most parents get it, that vaccines protect not only our children, but everyone else’s children – especially babies too young to get their immunizations, or children who have cancer or other immune problems. Elderly people, adults on medicine for their psoriasis or rheumatoid arthritis, or in chemotherapy – all of us, in every community, benefit when parents vaccinate their children.

And when parents don’t vaccinate, bad things quickly happen. The diseases will wait, patiently, until we let our guard down and invite them back into our homes. They’re not busy. They’re waiting.

There’s a choice, here. Live in fear – fake fear, made-up fear, fear based on lies and propaganda and the same stuff that tries to fool you into e-mailing your bank routing number to a Nigerian prince. You’re not getting that $26 million (or $43 million), and your doctors and the CDC and governments all over the world are not trying to poison your children. Honestly. Let us protect your kids. Great things can happen when we all vaccinate. Protect your children, your community, and yourself.

Bonus! Another example – great things can happen when we all work together. Or, in this case, sing together. Listen, it’ll give you goosebumps.

Most kids with penicillin allergies aren’t actually allergic

Posted July 6, 2017 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: ,

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?

Posted June 12, 2017 by Dr. Roy
Categories: Pediatric Insider information

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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.