ADHD meds don’t help students without ADHD

Posted September 4, 2018 by Dr. Roy
Categories: Medical problems

Tags: , , ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

College students work hard, and many are looking for ways to improve their studying and learn more effectively. Getting more sleep and more exercise would probably help, but up to a third are trying ADHD medications to see if pills can give them that extra boost. A small, recent study shows that they’re not getting the effect they’re looking for.

We’re not talking, here, about teens who have ADHD. There’s robust evidence that medical and non-medical therapy helps people with ADHD stay focused, and medication can help them succeed. But what about the far-larger number of college students who don’t have ADHD. Can they benefit from the same medications?

Researchers at two universities in Rhode Island – a tiny state, but they’ve got 12 colleges overall – picked 13 healthy student volunteers to take tests of their cognitive ability, memory, and other academic measures. They took these tests in a random order on 2 different days. But on one day, they also took the commonly-used ADHD medication Adderall at a nice hefty dose of 30 mg. On the other day, they received placebo. The researchers were then able to compare the differences in their performance.

Some things did change. On Adderall, blood pressure and pulse were higher, as were self-reported positive emotions and energy. However, there were very small effects on actual cognitive or thinking ability, with some small positive and some small negative effects. Working memory – the ability to recall information – was much worse with the medication. Overall, Adderall did not help these college students study better or learn more.

This was a small study, with only 13 subjects. But the results are striking. On college campuses, medications like Adderall are being used both as study aids and as a way to stay up longer and party harder. But they’re not without risks, including depression, psychosis, weight loss, and addiction. These are serious medications, and while they can have a role in helping some people, they ought to be only used when necessary, under medical supervision.  They’re not for everyone, and especially not for most college students looking for a way to improve their grades.

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Life lessons from fruit

Posted July 30, 2018 by Dr. Roy
Categories: Pediatric Insider information

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.

Urgent care centers lead the way in unneeded antibiotic prescribing

Posted July 23, 2018 by Dr. Roy
Categories: Medical problems

Tags: , , , , ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

Urgent care centers are way ahead in prescribing unnecessary, potentially harmful antibiotics that are doing no one any good – at least no patients any good. The owners of the urgent care centers are the ones who are benefitting. And you and your family are being bilked, misled, and harmed.

A July, 2018 study published in JAMA Internal Medicine looked at the proportion of antibiotic prescriptions that were made for viral respiratory infections – things like the common cold and bronchitis. These are viral infections, caused by viruses (sorry if I’m hammering that too much – but obviously it bears repeating.) The researchers looked at over 150 million visits to emergency departments, urgent care centers, retail pharmacy clinics, and medical office visits to compare the rates of inappropriate prescribing between these settings.

Why is this important? Because antibiotics will not help anyone who has a viral infection. But they can lead to allergic reactions and serious complications like C. difficile colitis. They also contribute to antibiotic resistance, or the emergence of so-called “superbugs” that we can’t kill with any antibiotics. This is not just a theoretical problem – it’s a huge a growing nightmare occurring in hospitals all over the world. Some bacteria have figured out how to evade all of our antibiotics, and it’s entirely our fault.

Big differences were found in the rates of inappropriate antibiotic prescriptions. In ordinary medical offices, 17% of respiratory viral infections were treated with antibiotics. That’s way too high, and we need to work on that. But even worse: emergency departments prescribed antibiotics for about 25% of these viral infections. And topping the list was urgent care centers, where 46% of viral respiratory infections were treated with antibiotics. That’s about three times as bad as regular office visits.

The best prescribing habits – and they deserve credit for this – was found at the retail pharmacy clinics, at about 14%. They often use protocol-driven clinical pathways which leave little “wiggle room” for the nurse practitioners that usually are on staff. I’ve been critical of these quick-minute-clinics before, and I still don’t think they’re a good place for children to be seen, but give them credit for not throwing around antibiotics.

But those urgent care centers – why are they so quick to write for an unneeded and potentially harmful antibiotic? Though this study didn’t look at potential reasons, one potential driver may be profit. Urgent cares may be especially quick to write antibiotics because they make more money that way.

Some urgent care centers sell the antibiotics (and other medicines) that are prescribed, so there’s a direct profit there. But more commonly, antibiotics are prescribed because it’s a quick way to give patient what they want, to get them out the door so the next patient can be seen. It takes much more time to explain why an antibiotic isn’t needed than it takes to write the prescription. And writing that prescription seems to feed a cycle of dependence – now, the patient thinks every cough needs an antibiotic. Repeat business!

It’s not just antibiotics that fly off the shelves at urgent care centers. They make money from lab tests and x-rays, too. I spoke with one urgent care center physician who had this to say:

Our pay was a small base compensation and all the rest was a percentage of our billing. The more patients you saw, and the more lab, x-ray and meds you ordered, the more you got paid. Plain and simple. So not only was prescribing an antibiotic lucrative, not wasting time explaining why was also lucrative.

Now, many urgent care physicians are good doctors who genuinely want to help people. And it’s convenient to have them nearby for quick visits. But their employees may be under financial pressure to over-prescribe and over-test – and that can affect the care that you get.

How can you protect yourself?

  • Tell the physician, plainly, that you don’t want an antibiotic if it’s not needed. The doctor may be assuming incorrectly that everyone wants a prescription. Tell her that’s not the case.
  • Have reasonable expectations about ordinary illnesses. Coughs and cold symptoms rarely need antibiotics, even when they make you feel miserable. Most sore throats are caused by viral infections. We know you want to return to work and feel better, but an antibiotic isn’t going to help.
  • Use your primary care physician’s office as your main site of care. Get to know your doctors, and let them get to know you as someone who isn’t there just to get a prescription. If your own doctor is one of those that’s quick to prescribe, think about why that might be the case, and think about getting a new doctor.
  • Prevention is key! Wash your hands, stay away from sick people, get a good night’s sleep, and get all recommended vaccines. Remember, immunizations are the real immune boosters.

Earlier:

Keeping the world safe from antibiotics

Fighting back the superbugs

Early solids, better sleep

Posted July 16, 2018 by Dr. Roy
Categories: Nutrition

The Pediatric Insider

© 2018 Roy Benaroch, MD

Current American and UK guidelines call for exclusive breastfeeding of all infants until six months. That’s not especially realistic, and relatively few parents do it, but it’s an “aspirational” sort of recommendation that’s been around a while.

Earlier solids now seem to be gaining some traction. Early peanut introduction (in a 4 to 6 month window) can help prevent peanut allergy. Though the evidence that this is true for other foods is less clear, we know earlier foods won’t make allergies more common or worse.

And now, there’s good evidence for another reason why waiting until 6 months might not be the best choice: babies who start solids earlier might just sleep better.

A British study published in July, 2018 looked at about 1300 breastfed infants from Great Britain and Wales, randomized at three months of age to either begin solids right away, or wait until about six months of age. Questionnaires were completed every one to three months, tracking their health, sleep habits, and other factors until age three. The results seem to back up some conventional wisdom many grandmas have been saying for years: feeding babies earlier than six months helps them sleep better.

Parents weren’t forced to start solids exactly at a certain age, but on average most of the babies in the early group started by 4 months, and most of the babies in the late group started between 5 and 6 months. While the differences in sleep weren’t huge, they were significant:

  • Early-fed babies slept, on average, 7 minutes more per night; the peak of the difference was at 6 months of age, when early-fed babies slept over 16 minutes longer.
  • Early-fed babies were less likely to wake at night, averaging 2 fewer awakenings per week.
  • Later-fed babies were twice as likely to be reported to have “serious sleep problems” by their parents.

Bonus: the early-fed babies were just as likely to continue breastfeeding. Often, exclusive breastfeeding has been recommended to continue for six months; but it turns out that introducing solids early did not lead to early cessation of nursing. Moms can do both.

There’s been some concern that early introduction of solids may increase obesity risk, but the evidence for this is not conclusive, either. So: early solids seem associated with less food allergy, better sleep, no impact on breastfeeding, and (probably) no effect on obesity. It’s looking like the “wait until six months” recommendation, so widely ignored, might not be a reasonable recommendation after all.

So when should you start? Babies need to reach certain motor and cognitive milestones, so they can take a mouthful off of a spoon. The four-to-six month window seems very reasonable to me. Sit together, eat as a family, share your foods, and enjoy the mess!

More about introducing solids to babies:

What’s the exact, best age to start solids for your baby?

Introducing solids to baby: Which ones, and when?

What should a seven-month-old baby eat?

Fixing peanut allergy by eating peanuts

Want to avoid celiac? Don’t delay wheat past six months

Essential oils – aroma OK, but not for ingestion

Posted July 12, 2018 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2018 Roy Benaroch, MD

Anjelika wrote in:

Hi there Dr. Benaroch, I would first just like to thank you for all of the valuable information you have provided over the years (and also the laughs) for so many of us – it means a lot! I was wondering if you had any opinions on essential oil diffusers around babies and toddlers since I have a 3 month old and a 29 month old. I’m only interested in making my house smell good (not looking for topical use or ingestion), but I want to be sure it’s not dangerous for them to be breathing it in.

Anjelika, not to worry. Hypothetically, I suppose a child might be allergic to the volatile aromatic molecules (technically, the “stinky bits”), or some might object to the odor if it’s strong. But smelling essential oils diffused in a room ought to be safe, as long as you’re not talking about gallons of the stuff sprayed about.

Be wary of the diffuser, though. You don’t want kids drinking the oil, or getting their hands on a warming element. Just keep whatever it is that spreads the smell, and its electric cord, up out of the reach of little ones.

Previously: Essential oils: When shady marketing and quackery meet

How to get your child to poop on the potty: The Poopy Party

Posted May 29, 2018 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2018 Roy Benaroch, MD

Julie’s 3 year old son uses the potty great—at least for urine. For poop, well, he’d prefer to use a diaper. What she needs to know about is the poopy party, and how to create some fun and excitement to get her child to take that last step!

Keep in mind: there are three ironclad rules of parenting. You can’t make ‘em eat. You can’t make ‘em sleep. And you definitely can’t make ‘em poop. Kids can hold their poop for a shockingly long time when they’re feeling stubborn, and you may end up with a very stubborn child if you try to force her to poop on the potty. So no forcing, no punishing, no humiliating, and nothing at all negative is going to work if you want your child to be successful on the potty.

Fortunately, all kids inherently want to succeed and learn new things. As soon as they’re sure you’re not pushing, and they start to get an inkling that—hey, this is the way to go!—they’ll do it. For kids who are a little late to the party, here’s one way to jump-start the process.

 

“The Poopy Party”: A method to encourage using the potty for stool

This works best at age 3 and above. It’s important to “ham it up” and really play with this to create a sense of fun and excitement about the potty. At no point should you be direct—never say “Don’t you want to use the potty now?” The point is to create excitement, but only to indirectly talk about what the potty is for.

You’ll need: a willing parent or caretaker, two hardhats, two bright orange construction worker vests, and two big chunky flashlights. Feel free to add in some kind of wrench looking thing, and a tape measure, and whatever other mechanical-plumber sort of equipment inspires you. If you want, you can involve your child in a trip to the tool store to load up on your equipment.

The parent puts on an outfit with hat and vest, then (while dressed up!) goes to get the child so she can put her set on. Child and parent have both got their own big flashlights, vests, tools, whatever. Dad or mom says something like, “Something’s up with the toilet, we’ve got to get it fixed so the poop can go to The Poopy Party!”

Don’t talk more about The Poopy Party…yet. Let the excitement build!

Then go to the toilet and take it apart, or as much of it as a parent feels comfortable putting back together. Talk about the parts, the flusher, the bobber thing, the insides, and where the poop goes down. Then, if you can, go to the basement and pull down some tiles, and shine your light along the big drain pipe all the way outside the house. Go out to the street and pull off a manhole cover (or the utility cover over the water main, or just peer down a storm drain) and shine your lights down there. Then talk about The Poopy Party. Yep, that’s where the poop goes, down there. There’s dancing and singing, and it’s a great place for poop to go!

If you want to go a step further, take the child to the county wastewater treatment plant. You’ve got to keep the hardhat and vest on. Explain there that you want to show your child where the poop goes. Then check out the big tanks and turbines and other fascinating things. Then go out for ice cream.

Afterwards, hang up the vest in the bathroom where the child will see it, but – and this is very important – do NOT talk about this any more. You set the stage, make it exciting, but do not remind or suggest. Anything like that will further delay potty success.

And be prepared, once she’s using the potty, to bring the vest everywhere you go.

 

Adapted from an earlier post

Your children deserve better than telephone medicine

Posted May 23, 2018 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2018 Roy Benaroch, MD

Someday we may miss the quaint idea of our children having their own doctors – doctors who actually get to know their patients and families. We keep all of your records, we know how many ear infections your child has had, we make sure they’re protected with vaccines and we monitor their growth and development – you know, the important, big picture things. The things you just can’t get with a quick phone call to an anonymous telephone doc. Can a phone call substitute for an in-person visit with a doctor who knows your child?

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

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

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

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

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

I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just a handful of telemedine records in the last few years, and they’re frankly embarrassing. One was about an 8 year old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. I’ve also got records from kids treated with three days of antibiotics for a sinus infection, and urinary tract infections being treated without any testing of the urine (again, these examples completely contradict evidence-based care guidelines) If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone.

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

But current available technology (like this Teladoc service) doesn’t allow a clinician to really examine a patient, look in their ears, or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick – and that, really, is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy – and that’s why this kind of care is being pushed by insurance companies. But it’s no substitute for genuine medical care from your own child’s doctor. Your children deserve better care than pretend medicine over the phone.

 

Adapted from an earlier post