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

Posted September 20, 2018 by Dr. Roy
Categories: Guilt Free Parenting, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

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

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

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

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

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

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

Advertisements

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

Posted September 17, 2018 by Dr. Roy
Categories: Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When polio was wild

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

Tags: ,

The Pediatric Insider

© 2018 Roy Benaroch, MD

“Polio. I’ve seen polio.”

Last night, I was speaking with one of the most experienced pediatricians I’ve ever met, Dr. Jack Burstiner. I’ve known him for 50 years. I would have known him even longer if I had been born earlier. He lived in my neighborhood, two doors down. He was my pediatrician.

Jack is almost 90 years old. But he still looks like a pediatrician. He’s got a smile a child could trust, now hidden under a white mustache. His green eyes twinkle when he talks about his patients, the kids he’s seen. There are some things about a pediatrician that never change.

Though he stopped practicing in the 1980’s, Dr. Burstiner worked for 30 years in pediatrics, at a time when pediatricians did everything. Hospitals, emergency departments, newborn deliveries, everything. And in 1955, just starting his training, Dr. Burstiner was a pediatric intern at Kings County Hospital, Brooklyn. It was a busy hospital, sure, but it was especially busy in the summer. Polio season.

“That’s where they’d all come, the kids with polio. They didn’t look right. They’d be dragging a leg, or not moving right. Sometimes an arm wouldn’t move, but usually a leg. And all night, every third night, I admitted all of them. It was just me. I’d do the spinal tap, and I’d look in the microscope, and I’d count the cells. If they had a lot of cells, that was polio. Of course we knew it anyway, but we had to tap all of them to be sure. All night long.”

Polio is caused by specific virus, an enterovirus that circulates especially in the summer and fall. It’s spread by contaminated water, sometimes in swimming pools or from unsafe taps, or from household contamination via stool. Most kids with polio develop a fever and then recover, but many develop paralysis of their skeletal muscles. It doesn’t affect their thinking, or their ability to feel sensations or pain. But it can make it impossible to walk or use other muscle groups, and can sometimes shut down the muscles that keep them breathing.

“It’s funny,” Dr. Burstiner said. “It was a big hospital, and upstairs – up above the emergency department, and the wards, the rooms the patients – upstairs were some of the smartest people in the world. They had dedicated their whole lives to fighting polio, and they knew all about it. But we still couldn’t really do anything to treat it. I was there, this intern, and I could tap them and I’d admit them, and then hopefully they’d keep breathing.”

In 1955 there were about 29,000 cases of polio in the United States. Dr. Burstiner estimates he admitted about 100 of those, ten a night, on the every third overnight he worked at the Brooklyn Hospital for one month during that hot summer.

“100 cases, I think I admitted, just in that one month. And all of those smart people upstairs, what could they do? But you know what happened next? The vaccine came out, and everyone wanted it. And in just a few years, it wasn’t 100 a month in one hospital. There wasn’t any, there was no polio anymore. I saw more polio in that one month than there was in the entire country, just a few years later.”

The first polio vaccine was introduced in 1955. By the mid-sixties, there were fewer than 100 cases of polio per year in the United States. We beat it. There have been zero cases of polio transmitted in the US since 1979; the last imported case to reach our shores from overseas was in 1993. There are still pockets of polio transmission, but it’s very possible the disease will be wiped off the earth entirely in the coming years.

Dr. Burstiner and I talked a while more, trading war stories, talking about cases. I’ve never seen polio, but I have seen children die of pneumococcal meningitis, and I’ve seen complications of chicken pox that put children in the ICU for weeks. Those are some of the diseases I may have the pleasure of never seeing anymore. Maybe someday I’ll tell the next generation of pediatricians about how we knocked out rotavirus diarrhea, and HIB septicemia, and HPV-related cancer. Measles, diphtheria, hepatitis A and B, we’ve got the tools to beat these and other diseases. We just need the will to see the fight to the end.

There’s a lot that hasn’t changed. Parents still worry about their kids, and kids still get sick. But there are many diseases that parents just don’t have to worry about anymore. That’s incredibly good news for you and your family. Protect your children, protect your communities, and help be a part of making the world healthier for the future. Vaccinate.

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.

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