Update: Medications and Side Effects

I recently read 2 medical articles regarding drugs and side effects; I have touched on that subject frequently. We are lucky in the modern world to have many treatments available to address all kinds of medical problems that our ancestors had to simply endure. However in reality each drug does have inherent risks; it’s imperative to use them in a cautious, thoughtful way. The 2 articles looked at 2 very commonly prescribed medications–antibiotics and steroids.

The 1st study found a significant correlation between antibiotic use with subsequent acute appendicitis. In 1.4 million children and 12,000 cases of appendicitis, the results were striking: a relative risk of 1.72–almost double — after one course of antibiotics. There were 3 other important findings: greater risk with “broad spectrum”(ie, more potent) antibiotics, a steadily increasing risk with each additional course of antibiotic treatment, as well as additional risk to children treated < 6 mo of age. The authors point out that this study only chronicles an “association”–they did not establish an exact “cause and effect” relationship, nor any specific mechanism to explain the association. But the data is clear, and troubling.

The second article looked at almost 2.5 million young, healthy adults receiving short courses of oral steroids and found a significant risk of GI bleeding, heart failure, and blood infections(sepsis) in those patients in the month after treatment compared to the 3 months prior. While not specifically looking at children, these young adults developed problems well known as risks of steroids, so “cause and effect” is well established here–what is new is the high risk of complications with even very short course of treatment.

Previously I’ve referenced articles noting the tendency of urgent care centers to overprescribe antibiotics. While that article did not mention steroids, my personal observation over the course of 35 years in practice is that unfortunate trend of too liberal prescribing holds for steroids as well. We should note that, with steroids, there are usually good, safer alternatives–including inhaled or topical forms, other safer non-steroidal drugs, and–not infrequently–no medicine at all.

In the world of covid, going to the ER or urgent care center must be measured carefully against the risk of exposure to serious infections there. My office now offers covid PCR testing (most insurance covers the cost) that has shown to be approximately 90% accurate. The turnover is usually +/-24 hours; those tests with faster turnover times tend to be less reliable. Usually, its safe to wait for regular office hours to assess your child’s condition and send the more accurate test from there. As we know, there is no specific treatment for covid anyway.

So give me a call if you are concerned about corona. We can address the issue together, decide if testing is appropriate, avoid unnecessary exposure (we usually do the testing right in the parking lot!), and, I am confident, avoid overprescribing for your child as well. Of course, in the event that the situation seems potentially more serious when we talk, I’ll help you there as well.

Thanks for following

Child Sleep Patterns

With the birth this week of beloved grandson #3–August Fels Geneslaw, 6 lb 5 oz–I’m thinking again of the new parents’ eternal lament: sleep disruption while their infant/young toddler establishes nighttime routines. Additionally, I spoke with a good friend, a former patient now grown, also a Mom and an ancillary healthcare professional herself, who was “heartbroken” for her friend going through just the above with her own new baby.

Frustration and fatigue are universally understandable. That fear, thankfully, is usually misplaced.

A recent study from the Journal Sleep Medicine of almost 6000 children followed over their first 2 years found significant variability in sleep patterns through much of that life phase. <6 mo many children took > 20 min to fall asleep. 40% of parents stated that their 8 mo old still had not established a consistent night routine; many still took > 45 min to fall asleep and/or had extended wakefulness in the “wee hours.” By 12 mo most toddlers will take < 45 minutes to fall asleep; 18 mo olds by 1/2 hr. Most 2 year olds had consistent night routines but STILL often with at least one late night awakening.

The important point is that these patterns are NORMAL. If your child’s growing along his curve, generally eating well, establishing regular eliminating patterns, that points towards good overall health. Appropriate developmental milestones are certainly important: young infant smiles, tracks, picks head off table when prone, brings hands together; older infants roll over, sit, babble, use hands; toddlers stand, cruise, feed self, begin simple words or gestures. If most of these things are happening on schedule(note: there is considerable variability here)then the sleep difficulties likely will work out eventually as well.

How to address problems depends on the particular child, age, the parents, and family dynamics. Certain basic principles do apply. A calm, consistent approach to bedtime and late awakening is essential: avoid becoming upset or angry. From very early, establish routines (do a, b, c) before bedtime: get into pajamas, lower ambient light, cool the room; avoid stimulating activity–quiet reading, singing is better; endeavor to learn even young infant’s cues of tiredness so you can initiate the sequence at the opportune time; in more difficult situations it is reasonable to let young children sleep NEXT TO parent(on the floor, in a day bed) but we pediatricians encourage parents to not bed share if at all avoidable.

When to give up/give in is tougher. Generally by 6 mo parents can regularly check a crying baby, allowing her to develop “self soothing” activities to drift off. But, again, variability is the rule. If your child cannot fall to sleep, nighttime awakening is increasing(especially older infants and toddlers), developmental milestones seem problematic and/or consistent elimination patterns are a struggle then there may be cause for some concern. NOTE: this applies to children in good health. “All bets are off” during or immediately after acute illnesses like the flu. Those disruptions should be temporary, however.

If you have concerns with the above, please give me a call so we can discuss. Thanks for following.

Vote for Kids

Today’s blog post, with < 40 days to the election, covers a topic that the American Academy of Pediatrics considers of vital concern for your child’s health–voting. It is your most basic right and responsibility as a citizen to have your voice heard on issues of public policy and how they impact your family’s well being.

To those who know me personally I am not the least hesitant to promote my preferred candidates but I certainly will NOT engage in that type of naked politicking here. Rather I will concentrate on 2 factors. Firstly, be sure to register and vote. NJ has pledged to mail ballots to all registered, active voters by Oct 5. READ IT CAREFULLY; fill it out properly. The rules are specific–postmarked by Nov 3, received by county clerk by 8pm Nov 10. If your ballot misses any requirements likely it will not be accepted and your vote not counted. If you are unsure of your registration status, go to vote.org where you can check, register or even apply for a mail in ballot. Please note that there is no early in person voting in NJ. More questions? Call NJ Secretary of State office at 1-609-292-3760.

Secondly, while I do not advocate for any candidate here, I fully support the AAP “Vote for Kids” initiative. To summarize some AAP positions on important policy questions as they impact the lives of children:

  1. Healthcare insurance–we favor expanded access to Medicaid and Children”s Health Insurance Program(CHIP) and generally oppose provisions that may interfere with access–block grants, asset tests, work requirements, drug screens. All “waiver” applications should at least “do no harm” –to limit access, coverage, eligibility, or the basic list of covered services established by the Affordable Care Act.
  2. Climate–We find that climate change is a legitimate public health crisis and the excessive burning of fossil fuels is a particular danger for children–from asthma and chronic lung diseases, to increases in low birth weight, premature infants; it contributes to IQ loss, attention, learning, and sleep disorders, and has numerous other neurotoxicities.
  3. Environmental toxins–From heavy metals like lead and mercury to insecticides like chlorpyriphos, we favor policies to limit these agents’ release into the air, water, and soil. This is a particular hazard to pregnant women and unborn babies. The American College of Obstetrics and Gynecology states that “reducing exposure to toxic environmental agents is a critical area of intervention for reproductive health professionals” and calls for “timely action to identify and reduce exposure to toxic environmental agents.”
  4. Guns- Every day 87 children are injured or killed by gun violence. AAP supports 2nd Amendment rights, but advocates for a vigorous scientific approach informed by research to keep children safe from gun violence. We support legislation for strong background checks, safe storage, assault weapon bans, and to prevent firearm trafficking, as well as $50 million to NIH and CDC for gun violence prevention research.
  5. LGBTQ–AAP policy is that these youngsters have a RIGHT to comprehensive, gender affirming, developmentally appropriate healthcare(including mental health), that insurance cover the specific health needs of these children; we advocate for schools and community groups to promote inclusive and accepting policies, prevent bullying, for laws that prevent discrimination and violence, as well as for equal employment opportunities for LGBTQ people.

Groucho Marx famously quipped, “these are my principles–if you don’t like them, I have others.” These are some of the policies that we at the AAP identify as the best way to insure healthy children receive the promises of our great country. So many brave Americans fought and died to secure that right–the vote– for all of us.

Honor their service–get out and “Vote for Kids.”

Flattened Infant Heads

SIDS research has raised awareness about the importance of proper sleep technique: no “co-sleeping”(baby sleeps in crib NEXT TO, not in bed with parents), NO smoking in the house (PERIOD), flat spare crib without fluffy pillows, covers, bumper pads, and baby sleeps on back. “Back to Sleep” principles have, since, 1994, decreased the incidence of sudden infant death syndrome by 40%.

As a result of sleeping supine, some parents will note a flattening or irregular shaping of the back of baby’s head. This is called positional brachiocephaly or plagiocephaly. Usually, the occiput (back of the head) will flatten symmetrically and can be seen best looking from the side. In some instances, the head shape will distort more on one side than the other, which can be seen best by noting asymmetrical ear positioning while looking down at the top of the baby’s head.

Flattened Head Syndrome or Positional Plagiocephaly -

Most typically, this is a completely benign situation and has no effect on brain development whatsoever. The “fontanelle”(soft spot) remains open, soft, flat, and nontender, which means there is plenty of room for the brain to grow. Most of the time, the problem will correct itself as the baby becomes more mobile and can reposition himself while asleep. so nothing MUST be done. Parents can take steps to correct or prevent brachi/plagiocephaly. Do “tummy time” play. Endeavor to carry your baby upright as opposed to in infant seat while you are out and about. Reposition her head from side to side periodically while very young infant is sleeping.

I do not recommend helmets as therapy. While they do seem to afford some head shape correction(especially if begun <6 mo old), most studies indicate that they have no real long term effects. In other words, whatever improvements achieved by the helmet were likely going to happen anyway; they would just take a few months longer. As such, in my experience, health insurance usually does not cover the cost as they consider it temporary and purely cosmetic. Given the evidence, its hard to disagree with them in this instance.

Craniosynostosis is an unusual, more serious (but treatable)problem, caused by a genetic defect that results in the fontanelle closing early before first year brain growth has completed. This can dangerously interfere with normal brain development. These children demonstrate early rapid head growth, often with more pathologically unusual head shapes. The best thing parents can do to address this problem is come in for well check up appointments, when your pediatrician will chart head circumference on a graph; we pediatricians are trained to differentiate the subtle differences between innocuous brachi/plagiocephaly and more alarming craniosynostosis.

Your baby’s check ups are more than shots and “green vs yellow veggies.” Be sure to keep up with them.

Send along questions and comments, and thanks for following.

Flu and Covid

With Labor Day approaching we should focus somewhat on influenza season/shots. I have previously commented on this regularly at this time of year. With covid now it’s critical for every eligible person to be vaccinated.

Last year approximately 34,000 US residents died from flu (169 children). This is better than in years past(2017-18: 61,000 fatalities),  likely due to yearly variation but also the effects of social distancing from covid which, recall, commenced in mid-March during the latter stages of 2019-20 flu season. New Jersey suffered approximately 1300 deaths.  There were perhaps 40-60 million US cases with almost 740,000 hospitalizations(78/100,000 population). Nationally immunization rates approximate 45% of total population but the rate in the essential 18-50 age cohort is unfortunately lower. About 58% of children are immunized annually, and, thankfully, 81% of healthcare workers get their flu shots.

Most people are eligible for flu immunization:

  • 6mo-9 years need a second  shot >30 days after their first if it’s their first year being immunized. In subsequent years only one shot is needed in that age group that year. < 6 mo are ineligible. Therefore, all household contacts and caregivers for <6mo infants should be immunized for baby’s protection. There are some reports of very small risk of febrile seizure in young children receiving DTaP and flu shot simultaneously, however, the data is inconsistent(some say yes, some no) and even among the positive reports there was no evidence of long term harm to any child in that affected group.
  • People with chronic illnesses like asthma, diabetes, heart disease, or neuromuscular disorders need their flu shot.
  • Immunosuppressed people, like cancer chemotherapy patients should definitely be immunized, although with “inactivated” vaccine only–NOT “Live, attenuated” vaccines.
  • Pregnant women should be immunized. Side effects are mild and infrequent, essentially the same as non-pregnant women; serious side effects are extremely rare. Hospitalization rates during pregnancy are lowered approximately 40% by immunization, and infants born to immunized mothers contract influenza 63% less in their first 6 months (recall, they are ineligible to be immunized at that young age)
  • Egg allergic patients can be immunized safely if they only had mild allergy reactions like hives as opposed to anaphylaxis.  In between reactions should consult an allergist first.

We all witnessed with horror as corona gripped the tristate area this past early spring and with similar dismay as it rolls across various states and regions now. I witnessed first hand how it devastated our local hospitals and, as the father of a NYC based ICU pediatrician, know from first hand reports how City hospitals were pressed to the breaking point and beyond with ER, inpatient, and ICU admissions for corona.  Most authorities predict increased covid activity as the weather chills, so it’s imperative that every eligible person gets his/her flu shot this year so that we don’t create a public health crisis, with hospitals overwhelmed by corona, flu, and combined cases. That scenario puts literally everyone at greater health risk.

Our flu shots are in, please call to schedule for your child. I urge everyone to get immunized: protect your community, your loved ones, and yourself.

Thanks for following.

 

Kids and Face Masks

I have previously blogged on the importance of face masks to enable our country to gain control of the covid pandemic.  No reason to use the word “controversy” or “debate” here.  There is none: it is settled science among all established authorities.  Currently, public mask wearing is the most effective way to stop the spread of covid, period. Doubt its effectiveness?  Try to blow out a candle wearing a good mask. Uncomfortable, inconvenient? Perhaps–A BIT. Hardly any major disruption of one’s normal routine. Threat to democracy?  CERTAINLY NOT.   It is simply good citizenship and good manners: you are showing concern for your fellow citizens and protecting potentially vulnerable neighbors.  What is “controversial” about that?

It does get to be a bit challenging with younger children– younger the kid, greater challenge.  Under age 2 or with special needs/incapable of removing a mask by herself—no mask. Older toddlers/young school age children should be encouraged–NOT FORCED–it’s cruel and counterproductive (a crying, resistant child, constantly pulling at the mask only INCREASES aerosol spread).

Some suggestions to improve cooperation for a more pleasant experience:

  • Talk it up. Explain what masks are, why they help.  Use simple terms. Answer questions honestly–if you don’t know, don’t make it up–look it up. Emphasize that they are being brave, grown up, and are helping others–Grandma, their teacher.
  • Demystify the process. Demonstrate mask use yourself: how to put it on, take off. Show them multiple times, have them practice those things on you. Have young children draw pictures of people wearing masks; put them on dolls for practice.
  • Personalize the mask. Buy or draw on action figures, super heroes, designs: planets, rainbows–whatever themes your child likes (Beatles masks for Dr. G?) She can add beads, studs/costume jewels if she likes (be sure secured to avoid breathing problems).
  • Acknowledge fears. Younger children read entire faces. Covering half can be confusing and frightening. Compare them to Halloween masks, have several “models”(parents, grandparents, older sibs) show what they look like in masks with different expressions. Do the same if the child has breathing fears. Multiple demonstrations, reviewed and reinforced over time, are helpful. Brief “practice periods” at home are beneficial.
  • Proper mask and fit. Snug but comfortable.  Triple layer is best. High tech “N-95’s” more expensive and probably not necessary.  Later study suggests that bandanas and “neck grinders” may not be effective. However, as above–cooperation is key, so generally get the mask your child likes best.

Mostly keep masks on for all indoor play, especially if high risk people are present in that dwelling(exceptions for cohabitants in the home and perhaps a very FEW close loved ones beyond that group–“a pod.”).  Typical outside play–with constant movement and not too much direct contact– usually does NOT require mask wearing; the aerosols quickly dissipate in cross breezes. Avoid kisses and hugs.

Remember it’s rare to know one is contagious in the early stages of infection(if at all!) so caution is always best. Again–these are small inconveniences for a much larger good.  This is hardly any threat to “freedom” and forgive an editorial comment–asserting one’s “rights” without accepting “responsibilities” is not “liberty.”

That is adolescence.

Thanks for following.

Covid and Your Grandchildren

Each of the past 2 weekends my married children and their families have joined Kim and me to relax by our pool.  I love that phrase–“and their families”, because it includes my adorable, delightful little grandsons. How to approach these family visits?

I have made some comments about socializing before. Stay outside as much as feasible. That is safest.  If indoors, wear masks as much as you can, especially if in close quarters (grandchild on your lap while you read them a story). Once in a while, I steal a kiss on the back of my grandson’s shoulder or foot(or tush!). Otherwise I have not kissed either one’s face or hands since March. It kills me, but it’s the safer thing to do.  Grandparents, wash your hands before and after any closer interaction with your grandchildren (like lap time above).

In October, we look forward with joy to meeting grandson #3. The above particularly applies to that more vulnerable age of baby.  Masks are imperative around infants. NO KISSING! If Grandma is planning to cohabit with the new baby to help Mom for those first few weeks, I strongly suggest that  both adults endeavor to self isolate for as close to 2 weeks before “the blessed event” as possible. More liberal interactions between Grandma and baby are probably ok after that.

Another question that this raises in the Geneslaw clan is nursery school: what to do with the toddler, especially if a new little sibling has arrived? The risk/rewards here are at least as great as older children and school. Toddlers derive great benefit from the social and educational stimulation of preschool, are typically safer from severe covid illness, but are more difficult to keep clean, limit exposure, and are therefore at risk to bring disease home to potentially vulnerable family members. Generally I favor putting your healthy toddler in nursery school.  The AAP has published sensible guidelines for safe practices.  Endeavor to be sure that your preschool follows as many of these practices as possible.

Finally, the CDC has updated guidelines(they stress these are not “rules”) for when previously ill individuals may return to normal activity.,  Retesting is not necessary. Rather, the person should be > 24 hours fever free(<100.2) without the use of anti-pyretics like acetaminophen, all symptoms of illness are resolved(chest pain, cough, shortness of breath, diarrhea), and are > 10 days since onset of being sick.

Unfortunately, the US is a laggard among developed nations in our response to the pandemic–with 4% of world population, we have >25% of cases and fatalities.  This is horrible and TOTALLY unacceptable. We simply MUST take this seriously to do better. Follow some of the above suggestions and previous posts. Listen to science and public health experts (not pundits or politicians). WEAR A MASK IN PUBLIC. It’s annoying and a bit inconvenient, but it’s really not that hard, is it?

We can still enjoy family and friends, and be safe.  And save lives–maybe your own.

Thanks for following.

Video Media and Your Child

This week, lets momentarily step away from covid (thank Gd!) and take a look at 2 recent studies about children and electronic media.

The first, from the University of Alberta (Canada), reports a strong correlation between increasing screen time ages 3-5 and subsequent diagnosis of ADHD. On average, they found, kids spend 1-4 hours per day in front of screens but that those with >2 hrs/d had a significantly increased likelihood of eventually being diagnosed with ADHD. Those children had a greater risk of both “externalized” mental health problems (“acting out”) and “internalized” difficulties(anxiety and depression) as well compared to children reporting <1/2 hr/d of screen exposure.   2 important related findings noted were a clear “dose related” response–the longer the screen time, the greater the problems reported, and children with > 2 hours active physical activity/day were relatively protected from the problem compared to baseline. Not really surprising, if you think about it.

That’s why AAP guidelines recommend maximum 1 hr/day screen time and for parents to maximize “co-viewing.”  Please note that there is no allowance for so-called “educational” videos.  Videos are videos–not too much! However, communication screen time (eg “FaceTime”) is not included in the limitation.  Given how much I love seeing my grandsons, I especially agree with that part!!

The second report, from The Lancet, found a significant association between increasing use of social media with mental health complaints in 13-16 year olds, in particular anxiety and depression.  Here, again, we note a “dose related”effect–more social media use meant greater severity of these problems. Notably, in girls the problems seemed to correlate  with sleep disturbances, decreased physical activity, and increased exposure to cyber-bullying, while in boys the problem seemed to be independent of those variables. We should also site that this was a report of “association”–the increased social media use and the mental health problems more commonly occurred in the same person. The study did not establish “causation” eg, that social media use CAUSED the problem in that person.  EDITORIAL COMMENT–surely, I have my suspicions!

Coming back to corona for a moment(and how can we escape?), we must realize that outside of school and summer camp, and with social distancing requirements, children frequently fall back on these modalities to escape feelings of loneliness and/or isolation (adults, too, of course).  So parents, I urge you to endeavor to help your children find safer, healthier, and even more productive pass times.  Best of all–whenever possible? Spend time with them! Read to/with them, play board games, outside play/sports (bike, walk, run, tennis–whatever).  It’s healthier (for both of you) and has the added benefit of being FUN!!

Send along questions and comments, and thanks for following.

Addendum to “opening up” 6/19

I wish to add a few brief thoughts that I neglected to include in my post of 6/19 regarding socializing during covid.  Firstly, keep your outdoor group social groups small, to allow for necessary social distance.  Secondly, with respect to hand hygiene, use disposable paper towelettes to dry hands after washing as opposed to reused terrycloth versions. Lastly, keep background music volume modest so everyone can converse at a modest volume.  Loud talking may lead  to virus spread.

I read a few good ideas regarding food: guests bring their own condiments to avoid mixing.  Serve individual served items like hamburgers, hot dogs, or chicken wings as opposed to steaks or items that must be cut and shared.

Enjoy.

 

Open the Schools

Now that we are in ACTUAL summer vacation, our thoughts turn to the upcoming academic year.  What now?  Last month the American Academy of Pediatrics strongly stated our position that we as a society must make every effort to get children physically back to school. There are several reasons for this.

Firstly, at best, distance learning is inconsistent. While children from high income areas seem to maintain academic achievement, studies show that middle income children lost 1/3 of math progress; low income kids lost 1/2. Overall, children fall behind by about 7 months on average; minority children, those with special needs, or in rural areas lose considerably more.

Secondly, for many families, school attendance is essential to parents earning a living.  This is difficult to measure and varies by region.  The Brookings Institute estimates that 4 weeks of closure cost Los Angeles $1.1 billion and NYC $1.5 billion. They estimate that if an additional 12 weeks are lost in the upcoming year it will cost the US $130-140 billion, with secondary losses caused by the particular disruption to the healthcare work force.

A third consideration are the nutritional/health effects on children’s lives. For many children of low income families, school provides the most nutritious meal of the day. Many districts tried to address this by distributing lunches to homes via idled school buses, a helpful but limited solution. Outside of school children gravitate towards unhealthy lifestyles with less exercise and more and less healthy snacking. The Journal of Sport and Health Science estimates that a school closure just through the end of 2020 will result in 1.3 million more cases of childhood obesity in the US.

The CDC has listed a detailed plan for school openings.  Here are some highlights:

  • Everyone in the building wear a mask.
  • Social distance–6 ft where feasible.
  • Outdoor classes where/when feasible.
  • Teachers travel between classrooms, children largely stay put.
  • Lunches eaten at desks.
  • Temperature checks, upon entry, periodically during the day.
  • Clean surfaces regularly.
  • Separate children’s belongings and limit use of shared items. Encourage stocking adequate supplies for individual use.
  • Modify layout of desk placement, hall traffic(all one way), tape markers on floor for spacing, physical barriers where appropriate.
  • Consider staggered scheduling, additional ancillary staffing to supervise children onsite but outside of classrooms/formal learning session to assist safe spacing.
  • Policies need to be IN PLACE for children or employees who test positive, in particular if those individuals have been inside the building–do you close classrooms, the building, which contacts are sent home and for how long? What accommodations need to be made for school employees at high risk(older, chronic health problems)?

1/3 of parents express concerns that school closures have negatively impacted their child’s mental health. This means we need to RAISE guidance/counseling personnel capabilities.

All of this is likely to cost money, folks, when most communities are facing significant tax revenue shortfalls. So we, as a society, are going to have to face that and figure it out. Sacrifice likely will be required from each of us for the well being of our children and the future of our communities.

Thank you for following.