Air Quality and Child Safety

Let’s review 2 recent medical studies that can offer guidance on an important public policy issue.  The Lancet, a respected international medical journal, reported that worldwide >4 million children develop asthma annually from exposure to air pollution.  This represents 13% of new asthma diagnoses across the globe; the US was 3rd WORST in air quality (traffic fumes) caused asthma in this study.  Specifically nitrogen dioxide (NO2) concentration was the main culprit, but the study notes a strong correlation between NO2 and CO2 levels.

The occurrence, needless to say, was greater in urban compared to more rural areas, with the worst US cities being NYC, Los Angeles, Chicago, Las Vegas, and Milwaukee. Quoting the last sentence of the article–“Traffic emissions should be a target for exposure mitigations strategies.”

The second study, in the journal Environmental Research and conducted by the University of California, Merced and the National Institute of Health, analyzed data that calculated proximity to major roads and then compared parents’ reports of child development over their first 3 years. The investigators reported that being near major roads increased exposure to particulate matter (“PM2.5”)  and ozone, both prenatally and for those young children, was associated with developmental delay and impaired communication skills;  the incidence of these problems may double as a result of exposure to environmental hazards, the study suggests.  Again, the concluding sentence–“efforts to minimize air pollution exposure during critical development windows may be warranted.”

Consider this information in light of the present Administration’s proposal to freeze fuel emission standards in the year 2021 (as opposed to the present schedule to mandate greater efficiency standards through 2035). Their stated reason is that increasing those standards, as has been the policy for the past decade, compromises safety and increases fatalities.  However, these claims are contradicted by some of the government’s own data, by nonpartisan groups like Securing America’s Future Energy, industry groups like the Aluminum Association Transportation Group (which, please note, DOES have a vested interest in the subject) and even by officials presently serving in the government themselves. Many automakers oppose the idea as inefficient for them and expensive for consumers

Now, we hear arguments on either side of the climate change debate.  One can choose to accept that pollution causes climate change or not (and the comprehensive scientific conclusion is that it DOES).  As some skeptics like to say, “I am not a scientist”, therefore I cannot speak with any special authority about climate data.  But I am a pediatrician for 34 years, so I believe I am well qualified to address the pediatric medical literature. The above is only some of the information in my field telling us that pollution is bad for the wellbeing of the next generation, whatever you accept or reject about its effect on climate.  I say we ignore this at our children’s and grandchildren’s peril.

Please keep the above in mind as the debate–and political/election contests that are impacted by it–come before you this year, next year, and beyond.

Happy Easter and Passover to all and thanks for following.

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Consumer warning–Fisher-Price Rock n Play

I just want to place a quick note up for all about an important alert.  The Consumer Product Safety Commission has issued a warning about the Fisher Price Rock n Play infant seat/sleeper.  This warning has been published in numerous media outlets and I just wanted to place one more notice myself to do everything I can to alert parents to the risk presented here.

This product is used as  seat/rest for younger infants, but, since 2015, there have been 10 reported DEATHS in infants who rolled over in the seat, became entangled, and suffocated. All of the babies were > 3 months old.  With a look at the design of this product we can see where the danger resides (see above).

Recommendations from the manufacturer–Fisher Price–suggest that parents stop using this device by 3 months of age or when your baby begins to show ability to roll over.  My recommendation, with apologies to our friends at Fisher Price, is to forget the whole thing and find a different product.  Who wants to be guessing at this?

When using infant seats generally, be sure to always supervise your infant in these devises.  Best to keep them on lower surfaces–middle of your bed, or better yet, the floor.  Hard to get lower than the floor, right? Keeping your infant in an infant seat on your kitchen counter, say, assumes that she will not be able to roll/pitch herself over or forward and fall out, potentially all the way to ground.  Are you that sure that that cannot happen? All of us believe that our babies are the most beautiful and the smartest–and all of us are right!! Then let’s assume that this smart little person that makes you so (justifiably) proud is going to be able to figure that out faster than you imagined.  SAFETY FIRST!!

Send along questions and comments, and thanks for following

Pesticides and Autism

Those who know me well will tell you that I am certainly NOT a person without opinions on policy or politics.  Here I endeavor to stick with the facts of my specific expertise as a pediatrician and I want to continue that approach today.  However, in this month’s medical journal BMJ a large, well designed study from the UCLA School of Public Health described troubling findings regarding pesticides and autism.  Let’s discuss.

Covering 38,000 people and almost 3,000 autistic children, the study identified areas of greater risk–pregnant women living within 2 km(approximately 1 1/4 miles) of a “highly sprayed” area–10-16% more autism, and 30% more risk for autism AND intellectual impairment. Children living in that area for the first year of life had a 50% increased risk for those problems.

The study was thorough in its efforts to eliminate outside influences like pollution, family history, or demographics to confuse the conclusions; the authors pointed out that its data probably held up for children born or living an additional 500 meters(almost 3/4 mile) further out.  It showed a slightly greater association for boys than girls, but that was mostly due to numbers of boys compared to girls and how that affected the math in the statistical calculations.

A wide variety of chemical agents were identified–organophosphates, diazinon, malathion, pyrenthroids, glyphosphates, avermectin, methyl bromides, and chlorpyrifos. The Trump Administration has been outspoken in opposing government regulations generally and has actively worked to liberalize the rules controlling the use of these products, most recently focusing on chlorpyrifos.  It is their position that these rules create economic drag–raising prices to consumers and placing barriers to hiring and job creation.  I will refrain from commenting on any of those claims.

But let’s be clear: this study demonstrates that there are serious consequences to innocent children from these chemicals, and the more and greater use, the more and greater risk.  This study takes place in California, and we can try and look away–telling ourselves that this does not involve us or our families–but agriculture is a big part of the economy in the Garden State and Ocean County specifically, to say nothing that we and our children are all eating this stuff.  So next time we hear talk of “big government,” “government over-reach,” “administrative red tape,’ or other such complaints of government regulations, please keep this study in mind.  Overdoing it?  At times, most likely.  But often, there are good reasons for many of these rules, and often enforcing those rules mean protecting children’s lives or well being.

There are newer economic models estimating SOME of the costs of this diagnosis on our society.  With that in mind, and if one adds in the heart ache to families and the tragedy of lives disrupted and dreams unrealized by autism, one must ask: is it worth it?

Send along questions and comments, and thanks for following.

 

Update on Research Studies

Ah, Denmark this time of year–ice skating, The Little Mermaid, tulips, windmills.  Well, the tulips and windmills are Holland, I think–but both have friendly blond people, great chocolate, beer, and cheese. And Denmark has produced some important recent medical research; let’s discuss.

One study followed children from 1995-2015 (>1.7 million children) and found a strong association between antibiotic use < 1 year and celiac disease.  The author’s postulate that changes in intestinal bacteria types and amounts, altered by the antibiotic, causes physiologic changes not yet explained that leads to this serious digestive problem.  And it makes sense.   Nature intends for bacteria to colonize our intestines(that’s why they are there), and, of course, antibiotics will change that. Disrupt that natural order and all kinds of unexpected outcomes–some serious– can occur. It’s foolish to think we can completely isolate the good from the bad  with this approach.

For example, the competition of bacteria in and on our bodies is one of nature’s ways to PREVENT infection. They compete with each other for nutrients produced by our bodies; that competition helps keep any one bug from causing infection.  Think of it like this: lions and leopards compete with each other to eat antelopes on the plains of Africa.  Kill the leopards and the lions eat more antelopes and make more babies.  Their population goes up.  Same with bacteria: take an antibiotic and the bacteria that are sensitive to it die allowing the resistant bugs to grow faster (no antibiotic kills everything). Those heartier bugs then are MORE able to cause infection(and those bacteria tend to be more dangerous species like MRSA or “C dif.” ) That’s why we need to use antibiotics cautiously and with clear indications.  Please keep the above in mind if you find yourself in an urgent care center, where studies show 40% of children with respiratory illness are prescribed antibiotics despite good medical studies showing that < 5% of respiratory illnesses in children are caused by bacteria. Better yet, please allow me to suggest that you try and wait until regular office hours so we can look at these situations carefully.

The other study involved–you guessed it–MMR and autism.  Danish researchers studied > 600,000 children from 1999-2010 and found NO correlation between the 2. This study followed up another study from 1991-98 of >500,000 children with the same result.  Let’s recall that, up until even 1980’s, measles killed millions across the globe but by 2016 we were down to about 100,000. Now, of course, measles is spreading again.  In the last 2 years there have been almost 8,000 new cases and 12 deaths in Italy.  ITALY!!  And, of course, we are seeing outbreaks across the US–in New York City, Rockland County as well as 30 cases right here in Ocean County.

Seriously–this should shock the conscious of any responsible person. I must ask–if 20 years and > 1 million patients followed is not sufficient data to convince one of the reality that no correlation between MMR and autism exists, then what will? In the face of this mountain of evidence (and there is more) when does this inquiry leave the realm of reasonable, legitimate concern and become merely a stubborn mentality closed to facts and reality?

So kudos to our Great Dane colleagues for this valuable information, and thanks for following.

 

Febrile Seizures

A very common and frightening condition of young childhood is benign febrile seizures (BFS), defined as a seizure episode associated with febrile illness not involving the brain.  This condition effects 2-5% of children ages 6 mo-6 years, predominantly those under 18 months.  They are more typically of short duration(< 10 minutes) and “generalized,” meaning the child will briefly loose consciousness and the entire body will shake.

Febrile seizures are usually simple–lasting no more than 15 minutes (usually no more than a minute or 2) and subsequently the child will wake up and be fairly alert. “Complex” febrile seizures are longer, may be multiple during one illness, and/or display “focality”–predominantly one limb or one side shakes. The most important word in the above diagnosis name is BENIGN. They do not seem to have risks of serious neurologic disorders compared to others-problems like ADHD, hearing deficits, learning problems or developmental delay.  2-10% will develop epilepsy, about the same as the general population. Those with “complex” febrile seizures, those with developmental delay or underlying neurologic problems like cerebral palsy do, unfortunately, have a somewhat greater risk here.  In these instances, the seizure episode is felt to be more a marker as a tendency towards epilepsy as opposed to merely an isolated event.

Most children with BFS will only experience a seizure episode a very few times–only 1/3 will have more than 1, and fewer than 10% have more than 3.   Children who are less than 15 mo old, have frequent fevers, family history of epilepsy or febrile seizures, short time between onset of fever and seizure, or seizure with lower level of fever make up the cohort at risk for more frequent occurrences.

Children with BFS should receive more aggressive fever control during acute illnesses.  Keep ibuprofen available, as well as acetaminophen for both oral and rectal administration –in case the child will not or cannot take medicine orally(say, during a seizure).  Tepid baths, cool liquids to drink, appropriate light clothing are all helpful.  Acute use of anti-seizure medicine is occasionally employed but mostly we try to avoid that route, at least for those in the “simple” benign febrile seizure category.  The incidence of complications from these medicines, while quite low, is still higher for most BFS children, and, as we doctors say, “the cure should never be worse than the disease.”  Use of these medicines daily to control the problem is reserved for those with complex febrile seizures under the care of a child neurologist.

Though certainly terrifying to witness, parents should try and keep in mind that in the very large majority of children with BFS this disorder will just go away in time and their child will grow up healthy and normal.  If you have questions or concerns about benign febrile seizures and your child be sure to contact me, and thanks for following.

The Over Achiever

Typical parent’s frustration: aimless, lazy child. Doesn’t want to go to school or do homework, avoids or procrastinates with chores, whiles away hours aimlessly on video games or social media. “The idle mind is the devil’s playground.”

As with everything, too much of a good thing is problematic as well.   The other end of the spectrum: the intense, hyper-focused child who has to take every AP and ace EVERY test, play every sport(often simultaneously) and ALWAYS finish first, works long hours in after school jobs to buy a new car that an adult professional might envy.  We know that type as well.

As parents and (for me) the pediatrician, we must be on guard for that troubled lifestyle as well. It is essential to teach children as they grow into adolescents and young adulthood the value of ambition and the pitfalls of perfectionism. The latter causes internalized stress and disruption of normal life functions like rest, relaxation, unstructured recreation, fulfilling family and peer relationships.  Their aspirations(and at times there isn’t even anything specific identified) can become totemic goals that may or may not be attainable but ultimately are largely besides the point.  One need not have all the highest grades to get into a good college and achieve career success.  Athletic scholarships are nice but uncommon, and the vast majority will pay at best a modest portion of college costs.  Over the years I’ve seen many more overuse injuries from hyper-training end young athletic careers than scholarships attainted.

And let’s not forget another fraught psychological component: we as the adults cannot and must not seek to redo our own missed opportunities, disappointments, or failures(or successes!) through them.  We’ve had our youth–its a fool’s errand to try and live their’s.

So what to do?  A few simple suggestions:

  1. Failure is fine.  Always try your best, but people fail. It happens, it’s a good teacher and a great way to learn fortitude as well as strategies for success next time.
  2. Perspective–have self awareness.  As an example: there are few D1 NCAA basketball players at 5’7″ and NOBODY in the NBA like that now.  So your slick ball handler should try hard but remember those realities. I say: play D3, start a business, make millions and BUY the NBA franchise. Therefore:
  3. Varied interests–play different sports, pursue different interests( music, volunteer). A well balanced life. I hate to admit this, but lighthearted, unfocused entertainment–video games with friends–is OK (moderation!)
  4. Rest–adolescents need > 8 hours sleep nightly. If her day is so crammed that she isn’t sleeping that much MOST NIGHTS she is over-scheduled.  Time to step in and:
  5. Be Parents!!  Teach them specifically the above. Enforce rules that promote those principles as you would to prevent laziness or disrespectfulness. Engage with them and be involved–and NOT only with that (perhaps over) focused sport.
  6. Watch out for warning signs: sleeplessness, fatigue, social withdrawal or isolation,   prolonged bouts of irritability, negativity, or hopelessness, panic attacks, weight loss (especially girls).

I tell my very ambitious teens: don’t go looking too hard for adult responsibilities–they will find you soon enough anyway.  Be a kid: when you are older you’ll want to be one again.

If you have concerns about these tendencies in your children please give me a call.  Thanks for following

Penicillin Allergy (yes and no)

Obviously, penicillin is a very important and useful drug.  Most studies cite 10% of Americans identify as being penicillin allergic (pcnA).  However, later studies now suggest that this number is likely grossly overstated.  The actual number is likely around 1%, and 95% of pcnA diagnoses are inaccurate.

How does this happen?  Not infrequently, people self report their child as pcnA because one parent is so diagnosed.  However, most evidence indicates only a slight increase in risk–2 or 3%– with one parent allergic.  There is a somewhat greater risk if both parents are pcnA; however even in this instance guidelines do not recommend assuming allergy or avoiding use of penicillin, but rather test for accurate diagnosis.

A second problem is symptoms.  pcnA is caused by developing specific antibodies (“IgE”)to the penicillin molecule, causing hives, blisters, wheezing, joint inflammation, and, more ominously, swelling of lips, tongue, or throat.  The danger here–besides their own problems– is the risk that subsequent exposure can result in life threatening anaphlyaxis (shock, collapse).  Other symptoms often associated with use of penicillin(as for most antibiotics)–headache, nausea, abdominal pain, diarrhea–while upsetting and uncomfortable –are not caused by IgE, are not “allergic”,  and carry no risk of anaphylaxis.  But people may tend to conflate those other unpleasant but less dangerous side effects and will report that experience as “allergy.” So we doctors must look at these reports carefully.

Another cause can be timing.  Most URI’s–at least 95%–are viral. Recent studies find that urgent care centers  prescribe antibiotics for up to 40% of children treated there for these conditions.  Now, many of these viruses progress over 3-5 days and will then resolve with the breakout of a rash (for example, roseola–but there are lots of others).  So many of these kids can be seen at urgent care on, say, day 2 of the roseola like viral illness, diagnosed (over diagnosed?) with bacterial infections like otitis media, and then subsequently break out in the typical illness ending rash on day 4 or 5–the next thing you know, 2+2=3 and we have an (erroneous) diagnosis of pcnA.  This is just one more example of how temporal association does not establish causality, and, I say, another reason to access these establishments with caution.

This is not a trivial matter.  pcnA patients treated with alternate drugs after surgery tend to have more complications and poorer outcomes than those treated with penicillin.  pcnA patients have to take other, more “broad spectrum” type antibiotics which place them at greater risk for serious–sometimes life threatening–secondary infections like MRSA, clostridium dificile (“Cdif”), or “VRE”–vancomycin resistant enterococci.  Moreover, recent data indicate that up to 80% of people with actual IgE mediated pcnA will lose their sensitivity over time, enabling them to take penicillin again safely.  I will note here that, given the risks, this must be evaluated carefully beforehand to assure patient safety.

So if you have concerns about pcnA in your child let me know.  We can discuss it, test or refer to clarify this important issue.  Thanks for following.