More on Cautious Use of Medicines

OK, back to one of my favorite themes: don’t over treat.  A recent study reviewed almost 800,000 infants receiving either antibiotics or antacids during the first 6 months of life.  They found a significant increased risk of allergic diseases in those children.  With respect to antacids, both “H2 blockers” like ranitidine (zantac) as well as “PPI’s” like omeprazole (prilosec) were associated with food allergies as well as chemical risk factors like elevated allergy antibodies (IgE) in the abdominal cavity.  There was a comparable increased risk with antibiotic treatment in this age group.  In that instance there was a 9-51% increase in problems like eczema, hives, contact dermatitis, drug allergies, anaphylaxis, and eye allergies.  The incidence of asthma increased > 2 fold and hay fever > 75%.

Significantly, this information corroborated the findings of other similar studies.  Numerous mechanisms have been proposed as the likely cause of such observed phenomena, all basically involve altering the natural bacteria colonization of the GI tract in some way specific to that particular drug.  In addition, animal models (mice) have been shown to produce similar outcomes.  So there is a large and growing body of evidence to support a more conservative approach to the use of these drugs in this age group, as I’ve discussed previously.

Now, a word of caution (as always). This shows an association, not necessarily a cause. Perhaps the symptoms that caused the infants to have the antacids prescribed were early and nonspecific demonstration of GI problems and allergies which was only clearly diagnosed later.  Likewise with antibiotic treatments in this age group: perhaps these infants were already more susceptible to respiratory infections requiring antibiotic treatment because of their allergies so they received prescriptions earlier and/or more frequently compared to children who did not go on to be diagnosed with those problems.  In other words, based on this data we have not clarified which is chicken and which is egg here, so to speak.  Did the medicine cause the problem or was it merely earlier evidence of which children were born with those conditions already?  There may be very good reasons why some of these children needed these medicines as infants.  But there are definitely risks with these drugs and in particular in this tender, delicate age group, so we must respect that and always act with caution.  I encourage my patients to call me so we can discuss proper use (and improper MISUSE) of these drugs in their babies (as well as in “children of all ages.”)

Thank you for following.


Adolescents and Social Media

When I first entered practice in 1985, the term “social media” wasn’t even a thing yet.  Now, of course, its a major issue in the lives of virtually everyone and in particular adolescents.  It is a frequent topic that I discuss with parents.

A recent study in a British public health journal demonstrated some very troubling patterns here.  They enrolled almost 10,000 children and followed them from ages 10-15 to > 16 years.  Initial surveys collected data on social media sites and amount of usage reported, then after several years standardized mental health questionnaires measuring both well being and negative emotions were completed by  the now young adult subjects.

In girls they found a clear and quite strong association of increasing media usage with more negative feelings and greater emotional difficulties in late adolescence.  Interestingly, they found no such correlation among boys.  Greater prevalence was demonstrated in homes of lower economic or parental educational achievement. Unsurprisingly, more social media usage increased sedentary lifestyle.  Racial differences were inconclusive.  Another non-factor was type of usage–“passive”(reading only) vs “active”(posting and responding)–girls did worse either way.

There may be several reasons for this observation.  Girls seemed to make a greater effort at online presence and often put greater emphasis comparing themselves to perceived online personality or situations.  “Likes’ and “hits” are viewed very directly as popularity in ways similar to public opinion polls.  Online, as opposed to in person, conversation is more “indirect,” allowing less emotional commitment to the relationship, less effort at properly expressing oneself, and no opportunity to learn to judge facial expression, voice inflection, or body language which may result in a person with more limited social development.  Needless to say, online interactions may increase risks of such negative interactions as stalking, bullying, or public shaming.

So–what’s a parent to do?  As always, I say “you are your child’s best teacher and best toy.”  Be a role model–don’t obsess with your phone and social media yourself.  Use only at specific times and situations.  Try not to walk into your home using the phone, no use of phone at meals or parent/child interactions interrupted(except true emergency, of course).  Endeavor to develop ongoing activities of interest for your adolescent and take an interest in their participation.  Spend time with them (a challenge–important part of adolescent development is to establish autonomy from parents, so don’t overdo it here; try to do things with them on their terms).  Also I believe it is fine–almost essential— to place concrete time limits on phone/social media use, particularly in the evening when it can most commonly be an impediment to a good night’s sleep. I always counsel that cellphones NOT be kept in the teen’s bedroom overnight but rather in some fairly distant location in the house to avoid that frequent problem.

Here are useful tools from the AAP that can help you manage your family’s social media in English and Spanish


Thanks for following.

More Thoughts on Child Obesity

We are all aware of the obesity epidemic throughout our population; as a pediatrician I focus on its presence in children.  In this month’s Pediatrics a study followed overweight children, who’s parents encouraged dieting for weight loss, for 15+ years into adulthood. They found  72%> binge eating, 79%> unhealthy weight control behaviors into adulthood.  The “adult kids” were 50%> pushing their kids to diet and 40%> having unhealthy family food communication (teasing)– important and wholly predictable information.

My advise is don’t initiate specific, direct dieting/weight loss discussion.  OK if your teen asks for dieting advise to be encouraging–“I think its a good idea.  You’ll feel better and better about yourself.  How can I help you?”–good, complete response(follow through, please).  Otherwise even pushing about “healthy eating”  is largely unhelpful–most teens are savvy enough to see “health” as a thinly veiled euphemism for “weight.”  Discussing “manners” and “etiquette” is fair game (see below)– kids are mostly unconcerned at the thought of being “unmannerly” rather than “unattractive.”  Mostly concentrate on environment(“under the radar”), so better food choices are obvious and made by them.   Suggestions:

  1. Limit fluid calories.  Lower fat milk, mostly water, seltzer (a squeeze of orange, lemon, or lime). Loaded with “empty” calories (fattening, not satisfying) and carbs.  Simply don’t have these in the house, period. Fruit juice is virtually identical (OK for breakfast).  Sugar causes pancreatic insulin release for absorption which also stimulates appetite.  The dissolved sugar in drinks causes faster and greater insulin release and appetite stimulus..
  2. More fiber–fresh fruit and especially low carb vegetables, some whole grain starches (bread or pasta).  Less fast food and prepared food from boxes or freezer.  The sugars in the fruit, unlike the juice, is INSIDE the cells.  Your body has to “break open” the cells to absorb it.  This slows down the process causing less and slower insulin release and less appetite stimulation.
  3. Eat slower and wait >15′ before “seconds” (especially desert/snacks).  Slows down the process as above and allows the “insulin rush” appetite stim from the first helping to dissipate.  Here’s where “etiquette” comes in.  Make conversation during mealtime.  Then you can say “stop talking while you are eating.  It’s impolite.”  They can perform table chores–clear used dishes, get ketchup out (“help your poor Mother–be polite.”)  NOT getting seconds–you do that (“Be polite–wait until everybody has had.” “I will serve seconds; you’ll spill and make a mess for me to clean.  Be polite.”)  Get it?
  4. OK to have some “fun food” snacks (pastry, ice cream)–modest amounts lasting a week.  If they finish off quickly, here’s your answer: “I don’t have all the time and money to go back to the supermarket repeatedly, so you’ll have to wait.  Next week pace yourself.  Be polite.” To stop one child from gorging  from siblings buy or cut into individual serving sizes and mark for each.  Taking others’ things is stealing and impolite.
  5. Exercise.  I say “throw the bums out”(weather permitting).  if they are outside with their friends they are more likely to engage in calorie burning play instead of staring at the computer. Exercise with them some.  Better for your health and  family bonding as well.

Above you have never mentioned weight, appearance, even health.  But you make the point.  Finally– delicately–be a role model.  It’s useless to forbid soda but bring it home to guzzle yourselves.  Kids hate hypocrisy and they’ll likely just steal and drink it themselves anyway.

Thanks for following.

Latest on Immunization during Pregnancy

We are all hopeful that this flu season may at last be winding down a bit.  Note that public health authorities recommend that, if you haven’t yet received a flu vaccine, it is still recommended to get one now.  I want to briefly mention vaccination for a particularly important and vulnerable population of people–pregnant women.  It’s relevant not only for this flu season but for those women who may become pregnant in the coming months and will be waiting to deliver as we enter flu season 2018-19.

A new study looked at over 400,000 infants born from 2004-14 who’s pregnant mothers were immunized against flu or with Tdap (against pertussis–“whooping cough”).  The study found no increased risk in those infants for hospitalization or death in the 1st 6 months of life.  The researchers reported that this is good news on top of previous similar reports that found Tdap or flu vaccine during pregnancy carried no increased risk to the baby for neonatal death, NICU admission, infections, respiratory, or neurologic complications, nor did it compromise infant growth out to 7 months and development out to 13 months.

They also noted significant benefits to the baby.  Maternal anti-flu antibodies crossed the placenta and provided good protection to the baby during the 1st 6 months.  Flu vaccine is not available <6 months, so this maternal transplacental transfer is all the antibody protection that these young babies can get.  They found that maternal Tdap during pregnancy lowered subsequent respiratory hospitalizations in those newborns during their first 6 months as well.  Of importance is that this data supports previous studies that drew similar conclusions regarding both flu vaccine and Tdap for pertussis.

The best time for a pregnant woman to receive Tdap is weeks 27-36.  Flu shots should be done any time that a woman is pregnant during flu season (check with your obstetrician).  Daddies get your shots too–its likely safer for you, your wife, and your baby (again, check with your doctor).

Flu mortality is up to 5x greater during pregnancy and of similarly greater risk for infants– in 2013-14 of 96 pediatric deaths 18 were in < 6 mo olds.  A word about the previous data: flu is a real public health problem and we should take it seriously.  Nevertheless, for healthy women of child bearing years and even for little infants, death from influenza in the US is rare.  As I always stress: caution–yes, panic– NO.

To summarize: flu and Tdap vaccination for pregnant women is beneficial to the women, safe for the child AND provides important protection during baby’s first months of life.  Ask me or your doctor for more information about it.

Thanks for following.

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.

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.