Tattoos and Piercings

I grew up in an age when tattoos were the stuff of drunken sailors and Marx Brothers movies.  Now, of course, they are nearly everywhere–among the kids and, not infrequently, the parents. I admit, I still don’t get it, but on the other hand, who cares about the style opinions of a crotchedy old geezer like me? So I’d like to discuss some safety issues with tattoos and piercings.  A recent article in my journal Pediatric News reviewed an excellent  presentation by Dr. Cora Breuner of Seattle Children’s Hospital which I will summarize.

Tattoos have been around for >4,000 years, body piercings since at least 700 AD. As above, the style has really taken off in popularity.  38% of 18-29 year olds have them (72% of tattoos are on non-visible body areas) and 23% have body piercings.  Tattoo recipients have increased by 20% from 2012-16 alone, it’s now a $1.65 billion industry. Most people (86%) like their choice–it makes them feel happy, attractive, sexy, rebellious, unique–even athletic or spiritual.  Who am I to argue?

The main risk of tattoos is skin infection. Given the nature of tattoos, those infections can get quite deep and pretty unpleasant. However, by all accounts, the incidence is fortunately low. Michigan is one of the few states that maintains accurate records of tattoo infection and found only 18 in 2010.  Hepatitis C is some concern as well; this is a more serious problem but more difficult to track, due to the relatively high incidence of tattoo recipients who may engage in risky behaviors like IV drug use and unprotected and more aggressive sex practices. Obviously, sticking with licensed shops compared to illegal operations is better.  In NJ, shops must be licensed by the Health Dept. and artists must be OSHA certified in handling blood born pathogens. <18 year olds need parental permission for tattoos or piercings.

With piercings the risks are more varied.  Bleeding is uncommon with ears and noses but more so with tongue, uvula, nipples, and genitalia as these areas take longer to heal (3-9 mo compared to a few weeks for ears). Dental complaints can occur with piercings in the mouth–bleeding, chipped teeth, receding gums.  This is more common with “barbell” piercings (47% had some tooth chipping after 4 years–people tend to bite down on them).  Hepatitis C appears to be a greater risk with piercings compared to tattoos.

Historically, tattoos and piercings were problematic as young people grew and entered the employment pool, but my general feeling now is that that concern is passe. I don’t think anybody pays too much attention anymore. At any rate, if the involved body part is hidden, nobody notices anyway.

I think it is reasonable for parents to review these risks with teens who express interest in tattoos and piercings.  Of course insist on patronizing only reputable establishments; I think it’s fair for parents who object to require the kids to pay for it themselves.  But don’t force your choice on them–their lives, their bodies, their decisions, Mom and Dad.

Send along questions or comments, and thanks for following.

Stuttering

I have had several families asking about stuttering recently so it seems a good time to address the topic.  Stutter/stammering is usually merely a mild developmental issue most frequently between the ages of 2-5 years, more commonly among boys.  It may become more noticeable in situations where the child becomes nervous, anxious, excited, angry or generally with greater emotions.  On occasion it may be associated with other problematic movements like blinking, twitching, trembling, or other involuntary tic like behaviors.

There are several types of stutter/stammer utterances you may notice:

• Repeating the first sound in a word (“w-w-w-water”).  Note that repeating a sound in the middle of the word (“wat-t-t-er”) may be of greater concern.
• Prolonged first sound ((“ssssister”). Again, note that that phenomenon in the middle of the word(“sisssster”) can be more of an issue
• Use of interjected sounds (“um”)
• Long pauses
• Frozen speech(mouth open, unable to get sound out
• Appearing out of breath while speaking

Mostly there isn’t too much you have to do in this situation (I resist calling it a “problem”) as it will usually just dissipate on its own.  So generally watchful waiting and try not to worry.  Keep these general principles in mind:

• Keep things calm and relaxed.
• Speak slowly and clearly to your child. Pay attention.  Look at them when you speak to them and when they speak to you.
• Do not criticize or tease; don’t rush or interrupt them.
• Don’t emphasize their stutter; don’t avoid it, either.
• Encourage them to talk about topics of interest to them.
• It’s ok to ignore mild stuttered words.
• If stuttering, you can look at your child and discretely, slowly repeat the troubling word with them.
• Make teachers and ancillary caregivers aware of the stutter and of the above strategies.
• It can be beneficial to practice difficult, problematic words. Use of poems or songs with the “problem” words may help.

While most stuttering is purely self limited and developmental only, there is stuttering that is neurogenic ( due to brain problems) or psychogenic (emotional/psychological trauma or mental health) related. If there is a family history of speech problems, if the condition lasts > 6 months or is associated with other speech difficulties, if your child’s school performance or social interactions deteriorate due to the stutter we should look into it more thoroughly.  Note that there are many healthy, intelligent, accomplished adults who deal with stuttering every day (including, unfortunately, facing up to the occasional ignorant or boorish remark).   

There are several specialists we may contact–speech pathologists, audiologists(hearing specialists), neurologists. I urge everyone to disregard most pitches about medicines, herbals/supplements, or on line fad pitches for miracle cures.  As in most situations, they are mostly a load of bunk.

Please let me suggest one of my late favorite movies where stuttering is an important part of the plot: “The King’s Speech” (Colin Firth, Geoffrey Rush, Helena Bonham Carter) 4 stars, inspiring(the pic above from the movie).  Find it “On Demand” I bet you’ll love it!

Send along questions and comments, and thanks for following.

Sleep and your Child

My own friends and family will attest to my personal fixation (not too strong a word) with sleep.  Yet, I’m not crazy (well, I am, but anyway)–adequate sleep is vital for your child’s good health.  Infants need 12-15 hrs, toddlers 10-14 hours, school age 9-11 hrs and teens 8-10 hours per night–note that that applies through teen years, so it includes high school seniors and college students as well . Additionally, continuous sleep is essential.   This enables the brain to go through the various physiologic cycles of normal sleep, including vital “REM”(rapid eye movement) sleep, so 6 hours at night and a 2 hour nap is simply NOT as restful, restorative, or beneficial to health.

Why is this important? There are almost too many ways to count.  Sleep is essential for brain development and plasticity (flexibility). Numerous animal models demonstrate proper sleep associated with more grey matter (brain tissue)  and better synapse (nerve cell connection) development.  Other studies show that children and adults with good sleep both perform better on memory tests compared to sleep deprived individuals.  A recent report in the journal Sleep found a higher rate of language and reading problems, as well as more ADHD symptoms in children who routinely got < 10 hours sleep/night before age 3.  I can tell you that my standard approach to ALL mental health evaluations–depression, anxiety, behavior/school discipline issues, ADHD, even headaches–includes a thorough and detailed review of the child’s present and historical sleep patterns.  It is not rare for me to discover a history of bad habits in that area in children coming in with those concerns, and, additionally, upon correcting those sleep problems many such complaints are improved if not outright resolved.

It goes beyond mental health, though.  A 2018 review conducted by British researchers of over 40 studies that included >75,000 children and adolescents, followed for 3 years, found poor sleep was a strong risk factor (as much as 58% greater) for obesity, cardiovascular disease, and Type II diabetes. Just getting poor sleep resulted in the kids gaining weight faster

In 2016-17, the National Survey of Children’s Health reported a review of almost 50,000 American youth that found only 63% of those aged 6-12 and 68% of 13-17 regularly got a proper night’s sleep.  This is a serious health problem.  What can a parent do?  There are lots of things, but  the simplest I recommend is summed up in 2 words ;  SHUT OFF.  I’m talking phones, computers, tablets, games.  Get your kids off of those things after a reasonable amount of time.  My advise is maximum use 1 hour/day weekdays, 2hr/day weekend/holiday (not including  school work) TOTAL; discontinue use >1/2-1 hour before bedtime, and DO NOT allow your child to store or charge those devises in their bedroom.  (You can BUY a real alarm clock!)

For more on sleep you can check out some articles from the American Academy of Pediatrics here. I have previously reported on public policy initiatives that can help with this problem here.

So please pay close attention to your child’s sleep habits throughout their growing years.  Contact me with any questions or concerns, and thanks for following.

Featured image courtesy of Alamy.

Antibiotics and allergy

A recent JAMA Pediatrics study has identified an association between antibiotic treatment 0-6 mo of age and risk of allergic diseases like food allergy, hay fever, eczema, and especially asthma.  The research looked at almost 800,000 infants from 2001-13 who subsequently received >160,000 prescriptions for antibiotics, finding the highest risk for penicillins and lower but significant risks for cephalosporins and sulfa drugs.  Asthma incidence increased by 47%, and multiple prescriptions–especially with different drugs– in that age group “upped the ante” on those risks.

Researchers and allergists speculate that use of antibiotics alters “the microbiome”which can disrupt the natural protective properties of those intestinal bacteria. Disrupting that balance, they postulate, interferes with normal body immune development which can explain the study’s findings.  I will stress that this study demonstrates an association.  In other words, it may be showing that taking antibiotics in infancy increases the risk of allergic disease, or that children with allergic diseases end up receiving antibiotics earlier and more frequently.  We don’t know which for sure, but it certainly is important to keep in mind when we are considering prescribing antibiotics, especially in these little kids.

One aspect of this story that I wish to note is the frequency of antibiotic prescription at so called urgent care centers.  Some studies report that 46% of patients received antibiotics for conditions that did not warrant their use; nationwide, 40% of all outpatient antibiotic prescriptions originate from urgent care encounters.  The CDC estimates that, nationwide, 23,000 people die each year from antibiotic resistant bacterial infections with names like MRSA, “c dif,”, VRE, CRE.  Many public health officials fear that, with antibiotic overuse, those numbers may explode into the millions in the decades to come.

To their credit, many urgent care center organizations are working diligently to improve their performance in that area by such initiatives as developing best practice protocols and partnering with organizations like the George Washington University Antibiotic Resistance Action Center to educate their providers about this issue.  However, as the patients and their histories are not well known to these caregivers–who are often nurse practitioners or physician assistants with less experience and clinical training than MD’s or DO’s–making progress with this is a great challenge for these facilities.

I recommend exercising caution in utilizing  urgent care centers for your children and in particular that age group–0-6 months.  Generally if you can get the fever down (even if it goes back up later), your child has an appetite for fluids and is holding them down, urinating at least 3-4x/24 hours, then the situation is likely stable and can wait for the regular doctor’s office to open.  Remember– fast does not necessarily equal good.  I stress the term “generally”–OF COURSE each situation must be judged based on the condition of that particular child at that particular time.

But before rushing off to the urgent care center or the ER keep the above in mind and give me a call before you go.  I’m here to  help you make the best decision for your child.

Image courtesy of Children’s Healthcare of Atlanta.  Thanks for following.

Carseat Installation Safety

Carseat/booster seat usage is now almost universal in the US. This has greatly reduced serious injury from auto accidents in children.  Nevertheless crashes remain a great hazard in children (25% of all accidental injury deaths) and the National Highway Safety Administration finds still that 72.6% of carseats are not installed properly.  Here are some things to remember.

For newborns and infants be sure you place the seat at the proper angle.  Too low may not provide sufficient protection.  Too upright too soon may result in serious head injury in a crash as the child could flop violently during impact.  Head control is an evolving process in infants and is usually not reliable until past the first birthday.  Also, being too upright too early can even risk some airway compromise.

Pay attention to positioning of chest clips and straps. The clip should be at chest level(too high, again, bad for airway, too low and the child can slip through). The shoulder straps should go through the slats BELOW the child’s shoulders in a rear facing carseat and in the slats ABOVE the shoulders when forward facing. Don’t forget the tether strap must be secured to the anchor at the base of the back of the seat.

Be careful with winter coats and other bulky outerwear. These can cause laxity and allow the child to slip through in a violent collision. Better to use a light jacket and then cover the restrained child with the coat or heavier blanket. When properly restrained, you should not be able to pinch any loose material of the engaged straps between your fingers.

Use seat belt clips ONLY from the one seat.  DON’T install the carseat in  the middle by using the outside belt restraint from the other seats ; if the middle does not have its own seatbelt then it’s better to secure the child in the seat at either side that does have one. Only use the middle seat if it has a seatbelt or anchors specifically for that seat.

Be sure to follow weight and height/length guidelines listed for that specific model.

The latest guidelines for forward facing carseat now is to delay turn around well past 2 years.  It’s more weight than age.  Most children will be comfortable rear facing until AT LEAST 35 lbs.

No rush to get a young child out of the booster seat. Most modern boosters are designed to accommodate a child to at least 65 lb (that’s an 8 year old, folks!). To check if your child is safe out of a booster seat, note the positioning of the 3 point harness contact points. The shoulder harness should contact the sternum and the lap belt should go across the hips.  If they contact the neck or the waist then then those soft areas can sustain serious injury from the belt itself in a collision.

Finally, all modern cars have front airbags.  These are designed to cushion impact by contacting the chest area of a person at least 90 lb and 58″. Smaller persons can be struck in the face, again, causing serious trauma during a collision from the bag itself. They should sit in the back.

Studies suggest that following these guidelines can lower your child’s risk of serious injury in a car accident by as much as 75%, so please keep them in mind.

Thanks for following. Image from Sunday Times Driving.

Carsickness

My little grandson, Otto, struggles with carsickness, so this topic has been on my mind of late.

Carsickness, of course, is a sensation of dizziness, fatigue, restlessness, confusion, nausea or actual vomiting associated with car rides or other movements.  The actual mechanism is a dissociation of visual from spatial sensory input.  In other words, the eyes misperceive where the inner ear says the body is going (or vice versa). It can occur 1-18 years of age but is most common in 4-13 years, peaking age 6-9,  usually dissipating thereafter. Perhaps 30% of children have some symptoms, 5% have severe/prolonged/frequent symptoms.  10% even report problems on swings and slides.

What can we do? Some suggestions:

1. Proper seat positioning–front facing is better than rear (but only if its safe–children should be rear facing until AT LEAST age 2, and sit in the back until > 90lb)
2. Plenty of fluids before/during the drive. Adequate hydration will mitigate symptoms.
3. Keep window down when feasible–fresh air also relieves some of the problem.
4. If possible, warm the car up during cold months so the child can sit in their seat without heavy outer clothing, increasing comfort and easing symptoms during the ride.
5. Distractions– as with seasickness better to look to the horizon, its best to focus out of the car.  ‘I spy” games are good; pointing out interesting sites like mountains, buildings, even road signs.  Anything requiring close looking is bad–movies/videos; video games are the worst(no surprise!). Nontechnical interactive games (“Madlibs”) can be a fun way to shift the child’s focus. Audio pass times, like singalongs, listening to music, audio books are another good strategy.
6. Snacks before or during the ride. Light, “neutral” foods like crackers, ice pops, non-acidic fruits are good; heavy, fatty, greasy foods, or very salty, spicy fair with strong odors–not so much.
7. Be aware of your child’s symptoms.  Poor color, change in demeanor, evidence of anxiety, and, of course, if your verbal child complains of symptoms–consider stop and take a brief walk for some fresh air.
8. Patience and humor–car sickness certainly has a clear psychological component. An easygoing, approach to your child’s difficulties–to limit anxiety or negative feelings on their part–is essential.  Junior vomited in the car? Gross, but relax: wash it out and the odor is gone, tomorrow you will forget it and in a few years it’ll be a humorous family anecdote!
9. If all else fails, try some anti-histamines. Dramimine for > age 2, benadryl can be used for younger kids.  These medicines may cause drowsiness which can be of benefit, if the child sleeps through some of the symptoms.  However, be aware of a “paradoxical reaction“–some children experience agitation, irritability, confusion, even transient hyperactivity from antihistamines which can be unpleasant or even worsen the underlying problem. So (as always!)  try everything else before considering drugs.

If your child struggles from car/motion sickness, please give me a call and let’s discuss it.  Thanks for following.

Kudos to the NY Times Parenting blog for some of the inspiration for this blog post.

Maternal Immunization

As we enter flu season , let’s review some important immunization information. Young parents, and in particular expectant mothers are an important population of citizens who should keep their immunization status current.  This involves in particular 2 shots–TdaP and, in this season, flu shots.  Children under 6 months old are ineligible to receive flu vaccine so their only protection comes from immunizing their contacts.  Under 2 months they also have not received whooping cough vaccine yet, so, again, prevention by keeping that infection out of their environment is essential to protect them.

But that protection goes even further.  Both vaccines provide antibodies that cross the placenta and provide good immunity to the baby from even before actual birth. As 80% of whooping cough infections occur before 2 months of age–before they have even received their first shot–and 70% of infant deaths occur in that age group, this early maternal conveyed immunity can be life saving.  In a typical year 20 infants < 2 months of age will die from pertussis. Studies demonstrate that hospitalization for pertussis in this age group is decreased 90% when mother’s receive prenatal TdaP. Therefore, it is recommended that women receive TdaP with each pregnancy between week 27-36.

Also note that infants <6 months of age are at greater risk for hospitalization from flu compared to older children, as well as many serious complications from that infection–pneumonia, secondary bacterial sepsis, or encephalopathy(brain swelling). If the baby has other health problems like prematurity, genetic or chromosome abnormalities like Down Syndrome, or heart disease, that merely ups the ante for this risk. Maternal prenatal immunization lowers infant hospitalization rates for influenza by 77.7%.

Influenza, of course, poses substantial risk for pregnant women themselves.  While approximately 9% of women age 15-44 are pregnant during flu season, 23-44% of women in that age group who require hospitalization are pregnant. Of additional concern is that influenza is an important risk factor for the pregnancy and is a frequent cause of complications like premature birth.  Studies indicate that maternal prenatal flu immunization lowers that risk by 40%.

Only 59% of pregnant women get flu shots and 55% get TdaP; only 35% get both. Both vaccines are recommended for all pregnant women (flu in season).  They are both safe and effective. The leading reason for not immunizing is not knowing the recommendation.

So I’m telling you now. Expectant Mom’s (and Dads!)–talk to your primary care physician (mothers to OB) about flu and TdaP vaccine.  Call me and let’s talk about it. It may very well save your baby’s life.

Thanks for following. Image credit from communications.wellsfargoadvisors.com.