Cold Medicines

I have previously discussed appropriate non-medicine treatments for common cold symptoms.  The data–or lack thereof– regarding so called cough and cold preparations (“C/C”) continues to grow.  Let’s review it here.

In a recent edition of the journal Infectious Diseases in Children, Edward Bell, PharmD offered an excellent summary of the subject. His most important summary is direct–“evidence supporting the efficacy of commonly available orally administered C/C product ingredients (e.g. cough suppressants, mucolytics, anti-histamines, decongestants) in children does not exist.” This statement is based on research from 2002-15 involving > 3 BILLION pediatric visits and 95 million C/C prescriptions.  Randomized, controlled trials conducted in 1991 and 1997 compared drugs like diphenhydramine (benadryl) and dextromethorphan (the “DM” in most cough medicine) to placebo for treatment of nocturnal cough and found no difference between the 2 treatments (“fake” medicine did just as much).  A 2015 comprehensive review of > 4000 subjects(212 kids) evaluated anti-histamines for common cold symptoms demonstrated similar results–no difference, and Congressional testimony from respected university educators and researchers concurred that there is no scientific evidence  for efficacy of anti-histamines for treatment of common cold symptoms.

It is also important to note the evidence of no benefit with the well documented list of common and sometimes serious side effects of these drugs.  Besides sedation, they can cause dry mouth, urinary retention, increased heart rate and appetite.  Please note that these occurrences are NOT rare.  Perhaps of even greater concern are the secondary effects from the well known problem with drowsiness–cognitive impairment with adverse effects on learning(school) and DRIVING (teens!), even hallucinations.

In 2017 the Food and Drug Administration labelled codeine as of no use for cough suppression in children under age 12 and then followed that up with warnings against its use up through age 18 as well.  Side effects here also include even more serious problems with drowsiness along with constipation, abdominal pain, agitation, sometimes even respiratory compromise and /or drug dependency.

Claims regarding so called “second generation” antihistamines, like loratidine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) being “non-sedating” are at least somewhat disputed by considerable published literature.  Those studies suggest that mostly the above problems still occur with these more recently developed products, only to a lesser degree than the older stuff.

So, please, parents, I urge you to stay away from this CRAP and concentrate on what works–fluids, vaporizer, nasal saline, OTC analgesics. And try and be patient: George Harrison of the Beatles sang “All Things Must Pass” (couldn’t resist the reference) and mostly nature will run its course and in a bit of time all will be well again.  Too often, trying to rush things along like with the above does little of benefit and can cause harm. (A lesson in life, perhaps?)

Certainly for more severe episodes with significant fever, pain, sleep or activity disruption, or prolonged disruptive symptoms more thorough evaluation and often treatments may be indicated.  Give me a call to discuss it, and thanks for following.

Nursery School Absences

A fair number of patient encounters for any pediatrician involves toddlers excluded from nursery school/day care for medical problems these places determine are a potential hazard to the other classmates and/or require some treatment for safe return.  Truthfully, it is a fair source of business for us.  Now, while it is impossible to totally ignore the economic realities of maintaining one’s business, it has always been my practice (and, in my experience, for all of my colleague pediatricians that I personally know) to look to the medicine side of things and, as for the other, if not “run itself”, merely let good business flow from good care.

So many of those daycare mandated encounters are simply less than necessary from a treatment or safety standpoint for anyone in that particular center.  As most of these establishments have their exclusion protocols, in reality they are usually drawn up by teachers, administrators, or the business proprietors themselves–in other words, people without formal medical expertise.  They mostly are not based on research or scientific data.

For example, most require antibiotic drops for conjunctivitis with drainage and allow return after 24 hours of treatment.  However, virtually all medical studies indicate that drops have little effect on infection course and do not end contagiousness within 24 hours. >50% of centers require antibiotics to treat diarrhea; as these drugs frequently CAUSE diarrhea that is too often exactly the WRONG approach.

It turns out that the American Academy of Pediatrics, in conjunction with several other medical professional societies, has published a detailed manual for policies and procedures for these childcare facilities.  At almost 600 pages, it covers virtually every non-business/financial issue of those establishments’ daily working routine.  Summarizing , our guidelines do not recommend exclusion for (you intrepid readers can reference page 132 in the link):

  • Common colds irrespective of any nasal discharge
  • cough without fever
  • Pink eye regardless of discharge, unless 2 unrelated students have it at the same time
  • Fever<102 if unaccompanied by any other symptoms of illness
  • Rash without fever or behavior change, including molluscum contagiosum,                ringworm thrush, “Fifth disease” or even MRSA.
  • Lice or nits–only excluded at the end of the day

Recommendations for exclusion include cases where the child is too ill to participate in daily routines; requires care that would be beyond the ability of staff to administer without potentially compromising other children; diarrhea 2x/d greater frequency than the child’s normal stooling pattern or that is not contained in the diaper with blood or mucous, or a demonstrated bacterial cause of that infection; vomiting > 2/24 hours, abdominal pain with fever or > 2 hours; rash with behavior change or fever, mouth sores in drooling child.  Certain diagnosed infections (impetigo, varicella, TB, measles) have recommendations specific to that illness.

I believe it’s a fair question how any childcare center can exceed our scientifically determined recommendations, exclude a child based on their arbitrary decision, AND be justified to keep all of the money for that day’s care.

For what it’s worth, any parent making that point to their daycare facility has my support, even though it likely means fewer office visits for me.  That seems only fair in my mind.  Send along questions and comments, and thanks for following

Immunization update

Let’s review some recent data reported on the unfortunate and ongoing attempts to create controversy regarding immunizations.

Firstly, Danish researchers have summarized 2 large studies. One followed > 530,000 children from 1991-98. Approximately 440,000 were immunized with measles, the rest were not. 738 were diagnosed with either autism or autism spectrum disorder(ASD).  No difference in the incidence of those conditions were discovered between immunized vs  non immunized children either short or long term. Subsequently a second study did the same thing 1999-2010 with > 650,000 children; again, no difference in autism or ASD in children immunized vs those not, despite sorting the data by age, sex, birth cohort, family history of autism, or other immunizations.  Let us note that these 2 studies take place over almost 2 decades and observed over a million people without identifying any association of measles to autism .  I hope all concerned parents will consider that enormous amount of data very carefully.

Another report reviewed injury claims filed and paid by the National Vaccine Compensation Program. The NVCP was developed as a “no fault” system to compensate people for vaccine related injury claims in an effort to help people AND protect the source of life saving vaccine production from destructive litigation.  It is “user friendly”–its default position is that the vaccine is “guilty unless proven innocent” to enable people to receive needed compensation for serious problems (whether there is proof of association or not) and it goes so far as to pay claimants costs for legal representation and witness time irrespective of whether a claim is ultimately paid or not. About 70% of claims received compensation from 2006-17. 3.4 billion vaccine doses were given in that time, and the claim rate was 2/million doses.  A large portion of the claims were localized shoulder injuries when the vaccine was inadvertently injected into joint space causing arthritic changes as opposed to any systemic medical reaction.  For all the heat generated by claims of vaccine risk in the lay press and social media, one must wonder, where are all the actual injury claims?

As of this past Tuesday, New York City has declared the local measles outbreak is over.  Keeping the above in mind, let’s assess the damage: 654 people were diagnosed; 52 hospitalized and 16 required ICU care.  The City spent an additional $6 million to send 500 health workers out to identify and vaccinate recalcitrant citizens.

Unfortunately, here in New Jersey, the infection marches on.  In fact, the Asbury Park Press reports a 53% increase in “religious exemption” claims in schools for measles since 2013-14 (1641 to 2516).  In Ocean County, the absolute number of exemptions has jumped from 145 to 363 students–an increase of 1.8-4.2% of students enrolled. This may sound like small potatoes, but public health studies indicate that we need 95% immunization coverage to achieve “herd immunity.” Less than that and vulnerable people–the old, young, and chronically ill–are at much greater risk of exposure to measles, a disease that historically hospitalizes 25% of its sufferers and kills 2 of every 1,000 who become infected. How is that right, smart, or fair?

Send along questions or comments, and thanks for following.

Stye

A common problem in the office of primary care doctors and ophthalmologists is a stye.  These red, painful lumps form at the lid margin(the edge of the eyelid) and come in 2 basic forms:

  • Chalazion–from the Greek “hailstone” a non-infected lump
  • Hordeolum–from the Latin for “barley,” also a lump, but with more generalized redness and pain due to secondary infection. These can be further divided into internal or external  lid problems.

With both problems the cause is blocked glands within the lid itself; if on the inside surface a “Meibomian” gland, on the outside surface a “Zeiss” gland. In both instances, the purpose of these glands is to secrete lubricating mucous onto the lid as it slides over the eye; the gland’s duct becomes blocked and the mucous is unable to be pushed out.  So in some ways, it’s similar to acne–a pimple on your eyelid.

Risk factors for styes (either type) include blepharitis or conjunctivitis (either infectious or allergic), eyelid skin conditions like eczema, excessive sweating after play or workout, eye makeup, or unclean objects held against the face.

Given the above, the best approach is prevention–mainly, keep the eyelid clean.  Wash the child’s face well, launder blankets/stuffed animals and bedding regularly,  modest use of eye make up (editorial comment–isn’t that mostly better anyway?), use antibiotic (for BACTERIAL infection) or allergy drops where appropriate.

Generally, treatment for stye is conservative and supportive–OTC analgesics; moist, warm heat–teabag or washcloth against the eye for 5 minutes several times daily; do not use eye makeup or contact lenses until the problem has resolved.  Oral antibiotics are occasionally needed for more extensive infection, and surgical intervention with incision and drainage is even less frequently indicated.

In some instances, styes may be recurring.  Redouble efforts at keeping eyes clean from makeup, sunscreen, detergents, lotions, and other topical agents.  There is anecdotal, but good, data suggesting that regular supplementation with oral omega-3 oils can help prevent styes from recurring as well.

If you have questions about stye/chalazion/hordeolum  in your child please give me a call, and thanks for following.

Thanks to Eye Physicians of Northampton for featured image.

Tongue Tie

“Tongue Tie” (ankyloglossia) is a common condition in infants; it involves prominence– in length, thickness, or both–of the band of tissue that tacks the tongue to the floor of the mouth, as well as the similar tissue connecting the inner upper lip to the area above the upper teeth.  The exact frequency is unclear, but generally considered around 4-5%,  predominantly male.

I have avoided calling it a “disorder” or “abnormality” as ankyloglossia mostly appears to be an observation in search of a problem.  Some claim an association with poor dental hygiene, orthodontia, or bad breath, but tongue tie infants  don’t appear to grow up and require braces much more than the general population.  Another concern is speech problems; “dysarthria”(problems with enunciation) as opposed to problems of speech acquisition or comprehension–with tongue to teeth sounds of most concern (t, d, th, s, z, r, l).  However the little academic literature available on the subject suggests that the human tongue is a very agile muscle and mostly learns to adapt to the situation; children with prominent frenulums tend to speak at the normal time and ultimately clearly and normally without professional intervention.  Some worry over such activities as licking food, playing wind instruments, even “sexual expression” growing up or as adults, but, to my mind, none of these things should warrant aggressive intervention by parents for an infant(especially the latter one!).

The most immediate concern for ankyloglossia is breast feeding problems.  Here there is ample evidence that tongue tie babies may at least initially have some difficulties in latching causing frustration for both mother and baby, as well as variable nipple discomfort for Mom.  Even here, though, “problem” may be a stretch.  Most infants seem to gradually adjust and by 6 weeks are nursing well without disruptive discomfort for Mother.

So what to do?  Surgical repair is simple and straightforward–a mere “snip” of the frenulum with a scissors, scalpel, or laser, performed in a doctor’s office.  Complications are rare–post operative infections are very uncommon and the babies seem to tolerate the procedure well without significant increase in crying or fussiness afterwards.  The frequency that this procedure is utilized has dramatically increased recently and I’m not so sure that’s such a good thing.  However, as a man, far be it from me to tell a breast feeding woman to just “grin and bear it.”  6 weeks may seem a short time to me, but to a post partum woman, exhausted, nursing at 2am, may consider the experience very differently.

So context is important here.  My best advise to a nursing mother is that if you are mostly comfortable applying lanolin to nipples and using OTC pain meds, and your baby is feeding, voiding, and stooling well, then that conservative approach is always best.  Less is more–even for “minor” surgery. (I think most people legitimately feel that NO surgery is “minor” for one’s own baby–right?).

If that strategy is not working out, then come on in and let’s talk about it.

Thanks for following.

Image courtesy southlakeent.com

Nursemaid’s Elbow

Another in our recent orthopedic themed posts: a common toddler injury called “dislocated radial head.” I call it my favorite diagnosis, because  here a child walks into my office sick (elbow pain) and walks out cured (pain resolved).

A quick anatomy lesson illustrates what happens and how this disorder received its common nickname. As illustrated, the forearm consists of 2 bones–the ulna (pinky side) and the radius (thumb side). The elbow end of the radius is shaped like a knob which allows that bone to rotate over the ulna at the elbow, allowing you to turn your palm down or up (pronate or supinate); a U shaped sling like ligament holds that knob end against the ulna so the radius can rotate and turn the palm over.  In toddlers that ligament and the surrounding muscles are not as strong making the joint more injury prone.

That’s where the funny name from the title comes in: classically, the caregiver (nursemaid) gives a strong tug by the hand to the dawdling child to “keep up,” causing that knob end of the radius(at elbow) to get pulled under and past the U shaped ligament “dislocating” it.  Basically any vigorous pull at the hand from a considerably stronger individual can cause it: pulling the child up from or to avoid a fall, too vigorous play/pulling arm by an older sibling.

The child will often cry out in pain and then hold the injured arm flexed 90 degrees at the elbow against their trunk. Any attempt to move the arm is very painful and will be strongly resisted.  Noticeable swelling or discoloration at the joint is uncommon. The diagnosis is generally straightforward given the history of a pull at the child’s hand followed by pain and resistance against any movement thereafter.  It’s usually pretty easy to fix with a simple maneuver in the office.  (I encourage the “DIY”ers among you to leave that treatment to trained professionals–its your kid, not some kitchen appliance!) X rays aren’t required unless history isn’t clear, in which case, ruling out a fracture may be necessary. Curiously, it is not rare for the x ray tech to inadvertently reduce the injury while manipulating the arm to  get optimal views for the radiologist. That’s ok, too.

After the dislocation is reduced, I frequently find that the child will continue to resist moving the elbow out of fear of more pain: I hold the uninjured arm and offer a lollipop; after a while they can’t resist, take the candy with the cured arm and realize that now it’s ok again. Follow up care is ice for swelling and ibuprofen for pain.  Once the injury has occurred, the ligament is looser and more prone to re-injury.  It is best to avoid pulling any young child hard by the hand, ever.  In rare instances of multiple recurrences of this injury, orthopedic intervention to tighten the lax ligament can relieve that problem.

Please give me a call with questions and comments, and thanks for following. Featured image from: https://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/

Patellofemoral Syndrome

Having previously discussed Osgood Schlatter, let’s stick with this theme and turn to another very common knee problem, patellofemoral syndrome (PS).  PS is actually THE most common cause of knee pain from non-acute trauma in adolescents, in either athletes or those not engaged in organized physically competitive endeavors.

The hallmark of PS (sometimes called “chondromalacia of the patella which is actually only one form of PS) is pain in the knee just behind the kneecap (patella).  PS is also often called “runner’s” or “jumper’s” knee, because the problem is closely associated with, and exacerbated by, those activities/movements.  Kids with PS also commonly complain of worsening pain after sitting still for extended periods.  Some PS sufferers will note a popping or crackling sensation in the knee, especially upon climbing stairs.

No one knows the exact cause and in fact it likely has several contributing and compounding issues. The most common factor is wearing/thinning of the cartilage BEHIND the patella (NOT “meniscus”). The soft, smooth cartilage behind the kneecap and covering the lower end of the thighbone(“femur”) is a much more lubricated joint surface for movement than rough, hard bone. When/if that cartilage wears down it causes inflammation and pain.

The condition is usually brought on by some aspect of sub-optimal exercise/training routine: too much training, a sudden increase in training intensity, improper training technique,  using improper equipment(or proper equipment improperly) including footwear, bad or sudden change in training surface.

One common factor is quadriceps asymmetry.  The quadriceps is the main thigh muscle, responsible for straightening the leg at the knee by pulling the shin (“tibia”) forward at the knee joint.  As its name implies, the muscle has 4 parts, and if some sections are stronger/weaker than others the patella is not pulled straight through that cartilage lined groove at the bottom of the bone but rather will shimmy and bounce through it, causing the surface to wear down over time, leading to PS.

Thus a mainstay of treatment for PS is a good quadriceps strengthening program.  Also along those lines, I encourage athletes to avoid full “squats” generally and in particular if you have PS.  Half squats are usually ok. if they don’t cause pain.  If you must do full squats with weights, I encourage flexing the knee < 90 degrees and only use machines/apparatus where the weight is placed past the feet and pushed away from the body as opposed to the weight on the shoulders to be lifted.  A period of rest before return to sports is optimal or at least a modified training program limiting running/jumping outside of actual competition(substitute bike, low impact aerobic machines like elliptical trainer, swimming, water running). Heat before, ice after all vigorous activity. Wear a neoprene knee brace open at the patella for support during exercise. Anti-inflammatory medications like ibuprofen are often beneficial but not essential. 

Of course, if the pain is more disruptive or persistent then please come on in and let’s take a closer look together.  Thanks for following.