Flu and tamiflu

The ONLY medical story anyone is discussing currently is influenza, so let’s review quickly.  Influenza is an RNA virus(genetic material RNA not DNA) that is identified by 2 “antigens”–outer coat proteins –called hemagglutinin (H) and neuraminidase (N).  There are a dozen+ variations of both H and N found on different “strains” of the virus which mutate via 2 pathways: “antigenic drift”–small changes of only a few molecules on the protein render it unfamiliar to the immune system’s defenses; and “antigenic shift”–a more dramatic change in the chemical makeup of H, N, or both.  When that happens we may get pandemics–more extensive, serious infections. This happens periodically–1959, ’68, 2009, and the granddaddy of all flu seasons, 1919, when, worldwide, millions died.  That event remains the worst flu pandemic in modern history –still the stuff of public health workers’ nightmares.

Given the large number of different H’s and N’s, there are literally hundreds of possible flu combinations. Practically, however, we really only have a few that cause most problems–H1N1, H2N2, H3N2, H5N1, H1N2, and a few others.  These are the strains that infect humans, pigs, and domestic poultry(chickens, ducks).  It is the interplay of influenza infecting these various host species that enables these buggers to change so subtly but effectively to make us sick every year.

Vaccine is produced by growing virus in egg culture in “the off season” and then noting how the H’s and N’s change, predicting and producing  shots based on those observations. However, the virus mutates at variable and unpredictable rates, so it can still change at least a bit after vaccine is manufactured.  Most of these “escape mutations” are meaningless as they usually render the virus LESS transmissible.  But when it goes the other way the vaccine becomes less effective as it may “miss the target.”  While that occurrence is relatively infrequent, given the speed and frequency that flu mutates it still is not rare–including this year, when estimates for vaccine effectiveness are only 10-30%.

We hear a lot about tamiflu (oseltamivir), which blocks production of N.  Without N the virus cannot break out of infected cells to attack other cells, curtailing infection.  The idea is to start early enough to block virus spread across your body and shorten illness duration.  Later in the course,  “virus load” is much higher–treating after 48 hours is literally “shutting the barn door after the horse escapes.”

The evidence for tamiflu is somewhat mixed.  Lancet reported strong effect, but that was mostly on mortality in seriously ill, hospitalized people with flu.  The Cochrane Collaboration study found more limited benefit–<24 hrs symptom relief.  Side effects were infrequent–<5% GI (diarrhea, nausea, pain) and <1% psychiatric (confusion or lethargy.)  More severe psychiatric  problems were only anecdotal.

My own experience is that tamiflu is mild and safe, but also of only limited benefit.  So I feel it’s useful–especially if started <48 hours–but no miracle and certainly not essential.  Best to focus on fever control, rest, and lots of fluids.  So give me a call to discuss.

Thanks for following.

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Oral Steroids

In keeping with a regular theme of this blog, let’s review patterns of use/overuse of oral steroids. (OS).  “Glucocorticosteroids” have been in use since the 1940’s; most common forms are prednisone, prednisolone, methylprednisolone, and dexamethasone.  Note that these are not “anabolic” steroids–drugs that cause muscle development and are sometimes abused by unscrupulous athletes and coaches.  Rather these steroids reduce the body’s inflammatory response, relieving a variety of medical conditions (at least in theory) like respiratory problems (croup, bronchitis, even common cold) allergic (hives, hay fever), skin (eczema, psoriasis, seborrhea), overuse orthopedic ailments (tennis elbow, back pain).

Now, for SOME of the above, with more severe exacerbations, OS can be very helpful.  But there are pitfalls that we should keep in mind. Firstly, the evidence for efficacy in several of the above is at best questionable if not actually disproven (for example, bronchiolitis in babies and back pain in all ages).  Secondly, these are powerful drugs with significant side effects so they are best used sparingly and judiciously.  Here again, 2 more points.  #1, as I say, “the punishment should fit the crime,” by which I mean that I try to limit OS use to patients who are quite sick and/or very uncomfortable. #2 given #1 there are often milder interventions (e.g, inhaled steroids for respiratory illnesses, anti-histamines or cool bathes for hives)that can address the problem at hand at lesser risk so they should be used first whenever possible.

What are some side effects of short term (< 1 wk) OS use? (long term OS use has many serious risks and are used only for chronic or potentially life threatening illnesses)  Most common are vomiting, sleep disturbance, and mild behavior change like irritability or overactivity.  Short term immune suppression with increased risk of infection is a concern.  Less common, transient, but still unsettling are weight gain, fluid retention, slight facial swelling, and elevations of BP or blood sugar.  Growth compromise and bone thinning have not been definitively established but with repeated usage are a real concern among researchers and clinicians.  Suppression of natural steroid production has sometimes been demonstrated with even short term use.   This is actually a quite alarming development, but thankfully so far it is only a short term and biochemical phenomenon and has never been shown to cause any adverse clinical event in a patient in reality.

I keep all of that close in mind when I consider using OS.  It concerns me greatly, given all of the above, to find too many instances when my patients are treated in emergency rooms or urgent care centers where I strongly feel that the providers in those locations are too quick and easy to jump to the use of OS for milder and even clinically questionable circumstances.  If your child is treated at one of these places I urge you to carry a healthy skepticism if  prescribed OS and, if you feel it is safe, please subsequently call me or even come in so we can discuss if it is the best approach for that situation.

Thanks for following.

The Latest on Colic

We’ve spoken about colic before.  Anyone who’s raised an infant has at least some experience here.  By definition we are referring to children ❤ mo old who cry for >3 hr/day for >3day/wk.  Officially about 20% of infants fit the definition; in reality many babies will experience at least some colicky periods.  Now, there have been almost as many remedies suggested as there are doctors treating the condition: non-medical interventions are always good–swaddling, holding, gently walking with baby; heating pads to baby’s belly, specially prepared colic relieving “gentle” formulas or nursing mother dietary changes, even extra warm baby booties; crib vibrating devices.  There have been a variety of medicines tried–“gas drops” like simethicone or “gripe water”, antacids, up to powerful narcotics like paregoric.

The truth is that all of the above have proponents and all have had some level of at least anecdotal success.  With most of the medicines used there have been credible reports of some side effects–in some instances quite serious ones.  So I generally try and stay away from drugs as we are dealing with the littlest and most vulnerable people and a problem that, while upsetting and frustrating, is otherwise benign and self limited(usually by the time the baby is 3 mo old).  So, greatest caution should be the order of the day, I think.

Into the mix we can now add probiotics, specifically those containing a bacteria called Lactobacillus reuterii.  Probiotics have actually been used in Europe with good success for quite some time now.  Several new studies, as recently as last year, compared L. reuterii to placebo and found significant improvement, at least in breast fed babies.  They were 2-3x more likely to to see improvement for an average of 46 minutes per day and spit up 2-3x less frequently.  Unfortunately, there was no significant improvement demonstrated in formula fed babies.  Dosage is important–about 1,000,000 cells/dose appears to be about right.  There are numerous preparations and brands available (I avoid naming or endorsing specific products in this blog).  Very few untoward effects have ever been reported; however I should note that some gastroenterologists express  reservations about administering doses of microorganisms to young infants.  Therefore it is best if we discuss using probiotics for your fussy baby, so give me a call and let’s talk.

And thanks for following.

Siblings of Autistic Children

Managing life with autistic children often tests the abilities of even the heartiest of people.  Daily schedules taken for granted by the rest of us requires persistence, patience, and planning by them.  Let’s touch briefly on issues facing siblings of autistic children.

Firstly, there are medical and mental health considerations.  While specific molecular causes of “non-syndromic” autism( i.e, not associated with some described medical/genetic condition) is uncommon, siblings have approximately 20x greater likelihood of having autism themselves (for identical twins almost 50/50).  Curiously, an older autistic sister appears a greater association than brothers.  Also note that autism is associated with “co-morbidities” like ADHD, anxiety, learning disorders and intellectual impairment, all having a tendency towards familial association.  So siblings themselves should be carefully monitored.  Considering the above, by far still the most common occurrence between 2 siblings is for one to be affected and the other unaffected.  So please keep that in mind.

The other aspect to touch upon are coping skills for the sibling.  The autistic child is  going to require more attention and effort by the parent; there is no way around that.  Its so important to not allow others to be “lost in the mix.”  This is a complex situation depending on many parameters like the degree of disability in the involved child, sibling number and birth order, temperament of all living in the home, marital status and nuclear and extended family dynamics, community and school types, and parental physical and mental health(studies suggest greater influence from the mother’s status here).

There are a variety of difficulties for children living with an autistic sibling: anger, resentment, fear, embarrassment, loss, isolation.  Normal childhood play and sibling rivalry can become troubled.  Siblings can struggle with interpersonal relationships, school functioning, and use of leisure time, as well as perceived or real expectations to assume more adult caretaker roles not typically assigned to youth of their age.

Happily, as is often the case, there can be an “up side.” Many of these kids can develop greater empathy, earlier and deeper maturity, and stronger coping skills from their home experience. Children who have a greater understanding of their sibling’s disability and receive positive reinforcement from parents and peers in their interactions with their siblings can do very well.  This can be aided by honest, open, age appropriate communication, endeavoring to develop and maintain “normal” family life activities (restaurants, sports, vacations), providing individual and undivided parental attention(“quality time”) and “safe space” for the sibling(including toys and possessions), as well as helping that child through periods of loneliness or isolation and developing strategies to address questions and comments from peers. Counseling can be beneficial with the last 2.  As always, these can all become more fraught during adolescence .

Being proactive about siblings’ physical and mental health is a foundation for all of the above, so please give me a call.  I’m here to help.

Some of the information presented here was detailed in Pediatric News by Dr. Jeremiah Dickerson of University of Vermont and from Indiana University’s Resource Center for Autism.  I am grateful to those sources.

 

Arsenic in baby food

There have been numerous reports regarding arsenic levels in a variety of foods, with particular concern for rice and rice based infant cereals.  The rice plant tends to take up soil arsenic at a higher rate compared to other grain plants.  As a result, there are arsenic levels reported at 0.1mcg/serving in cereals to 7.2mcg/serving in brown rice.  Now, arsenic is a naturally occurring metal which exists in a variety of sources, mostly in the non-toxic organic form (for example, seafood).  Inorganic arsenic–the toxic type–can be found in minute amounts in drinking water (the Institute of Medicine sets safe level as 10 parts per billion) Inorganic arsenic was banned from use in home products by the EPA in 1991 but remains in use in agricultural and industrial agents.  As a result, there are routes for toxic arsenic to find its way into the water we drink and the soil growing our food and under our feet. There can be numerous serious health effects in children from chronic arsenic poisoning–from intellectual disability, damage to lung and kidney, and skin cancer.

The good news is that, while there are no specific arsenic levels established as “safe” in food, most toxicologists still feel that the levels found in foods, including rice based, are not generally of great concern for most people.  So no cause for alarm.  However, there are steps that parents can take to further limit exposure risk.  For one, be sure to offer your child a varied diet.  I follow current AAP guidelines and recommend infants start vegetables first(yellow, then green) followed by meat, THEN cereal and fruit.  Use more non-rice cereals like barley, buckwheat, oatmeal, or quinoa.  When preparing rice dishes, boil in 1:10 ratio to water and drain all excess out before eating.

Finally, advocacy:its no secret that the current political trends are focusing more attention on the outlook of industry with respect to the use of chemicals as aids to our economy as opposed to the effects on our environment.  Certainly, we should seek balance between those two legitimate needs.  However, we should all try to remember that these rules as they apply to the regulation and de-regulation of chemicals like arsenic can cause real and permanent harm to real children.  Let’s keep that in mind going forward.

Send along questions and comments, and thanks for following.

Concussion Update

Concussion is an ongoing concern to healthcare professionals and people in all areas of sports and at levels from the pro’s to pee-wee leagues.  A large and fraught subject that evolves constantly is impossible to address fully here, so I wish only to review a few updated developments.  One reason the subject is so challenging is that a fully accepted definition still eludes us: a blow to the head followed by loss of consciousness; or is it followed merely by “change in mental status?” And “followed by” in what time frame?

Nowadays we are beginning to recognize various concussion “subtypes:”

  1. Vestibular (dizziness)
  2. Oculomotor (vision and balance)
  3. Post traumatic migraine
  4. Cervical (neck) symptoms
  5. Anxiety/mood
  6. Cognitive (concentration/confusion/fatigue)

Obviously, there is a veritable smorgasbord of overlap and combinations of the above.

A recent symposium of concussion experts noted that there are about 4 million concussions annually.  Ages 14-18 tend to have the longest course and recovery time for girls > boys.  Those with eye muscle problems (lazy eye, misalignment), motion sickness, or migraines are at greater risk for concussion.  The TEAM (Targeted Evaluation Active Management) group developed a 16 point statement of agreement generally stating that concussions are characterized by adverse symptoms, impairments, and evolving clinical profiles; recovery rates vary by injury severity, modifying factors, and treatments; and additional research is essential.

Notably they concluded that the “absolute rest” approach is no longer accepted as beneficial.  Medical literature and experience indicate that it is typically unhelpful and even sometimes detrimental to recovery.  Taking that approach conveys a sense of “punishment” to many children who then tend to sneak around or disregard recommendations out of a sense of defiance to that conclusion which can delay improvement; can increase anxiety and worry which often will itself exacerbate symptoms and hurt recovery; can of itself prolong or worsen vision or balance symptoms due to lack of use; and lead to de-conditioning which can cause re-injury when the athlete returns to competition (particularly if he/she is cleared to make it back just in time for “the big game”).

Therefore the “graded approach” now appears better.  I try and have the injured child begin homework and reading for at least short periods promptly and return to school by day 3-4 for at least part time attendance.  Light training first with cautious and step wise increase back to full sports participation, particularly for contact sports.  “If it hurts or causes symptoms, stop” is my motto.  Part time jobs later, and “blue light” entertainment(computer, cellphone, video games LAST (as always).

Of course we are just scratching the surface here.  If you have questions or concerns regarding head injury and your child please give me a call, and thanks for following.

Pain and Opiates

Anyone following news even occasionally is likely aware of the terrible scourge of opiate addiction sweeping our nation.  Many consider Ocean county to be an epicenter of the problem.  Both the origins and the treating factors are multifactorial–economic, social, educational, legal, technologic, even religious.  And medical–certainly physician prescribing practices contribute.  I think we doctors simply must endeavor to be more cautious and aware when faced with the challenge of treating pain.

There are several studies published currently that look at the use of opiate vs. non-opiates for post-operative pain management for common uncomplicated surgical situations.  Recently the Canadian Medical Journal compared ibuprofen to morphine after simple orthopedic procedures like fracture reduction.  154 children were enrolled from 2013-16 for either medicine.  Pain control was similar for both drugs after the first dose and after multiple treatments.  Not surprisingly, side effects were more common with morphine compared to ibuprofen: nausea (30% vs. 13%), vomiting (12% vs. 3%), drowsiness (31% vs. 15%), dizziness (20% vs. 4%), constipation (9% vs 3%) or “any” (45% vs 26%).

The results of this study were similar to one from 2015 in Pediatrics comparing the same drugs post-tonsillectomy.  There 91 children were observed and the ibuprofen group actually reported better pain relief (68% vs 14%) with fewer incidents of respiratory depression and no difference in post operative bleeding.

So where does that leave us? In each analysis there is very good evidence that the simpler, milder, non-addictive agent is at least as good as the “stronger” opiate painkiller.  Now, while there currently aren’t studies for every clinical situation, I think it is not unreasonable to extrapolate to comparable common surgical/trauma/pain issues like dental procedures and oral surgery, suturing, moderate burns, or outpatient abscess drainage: likely at least as effective to use the milder OTC analgesics like ibuprofen or acetaminophen.  And certainly safer for the child and for the larger community to stay away from the addictive stuff.  Please keep this in mind should your child require such interventions.

For questions about pain management or any other conditions, please don’t hesitate to call, and thanks for following.