ACL injuries in girls

As we move to warmer weather we can now really begin to enjoy the outdoors, which means lots of youth sports.  I say great–but I also will take a moment to discuss concerns about the absolute epidemic of anterior cruciate ligament (ACL) injuries in adolescent female athletes.  Over the past generation we’ve seen increasingly frequent ACL injuries by up to 900% due largely to the explosive growth of girls sports since Title IX; anywhere from 20,000-80,000 occurrences yearly.  Soccer, basketball, and gymnastics cause the most injuries; girls are up to 8x greater risk compared to boys.

Some background: the ACL is inside the knee and keeps the tibia (shin) from sliding forward relative to the femur (thigh) during ambulation.  >70% of injuries result from no contact with other players but rather from some sudden, awkward movement.  One example: a girl plants her right foot with extended knee and then tries to quickly cut right.  With sudden deceleration her weight is back with leg straightened moving under her upper body as her torso turns right and out and her thigh rotates inward(counterclockwise) and POP!! (there is often a loud snap that everyone close to the injured girl will hear when the tear occurs).  This is a common mechanism of injury.

There are many physiologic factors contributing to girls’ ACL risks:

  • Hormones–testosterone surge in boys makes for greater muscle development allowing boys to control movement more with muscle strength; girls tend to rely more on bones and ligaments.
  • Menstruation-the ACL actually gets slightly longer and more lax mid-cycle creating greater risk
  • Neuromuscular factors–quadriceps (front thigh):hamstring (back thigh) muscle strength ratio is greater in girls compared to boys.  This puts greater strain on the ACL.  Girls also tend to have one leg stronger than the other compared to boys more symmetrically distributed leg strength which creates more problems in the weaker leg.
  • Girls tend to run and land relatively flat footed.  Boys are up on their forefoot more which is a better shock absorber.
  • Girls have relatively less core body strength.
  • Wider pelvis makes for more uneven landing

Note that for both boys and girls being overweight increases risk.

There are many steps we can take to avoid ACL tears.  Proper fitting quality footwear for their sport is a nice start.  Core strengthening is key–lots of sit-ups and planks.  Neuromuscular training is a very important component.  Here is an excellent program.  A variation on that program is demonstrated here.  So besides dribbling, passing, shooting and SCORING, make these exercises a regular part of your daughter’s training routine, especially off and pre-season.

Chance of ACL injury does not at all mean that your daughter should shrink from enthusiastic participation and aggressive competition.  Like all risk it must be balanced by advantages and can largely be controlled by proper lifestyle.  Sports will help make her more confident, stronger, healthier and so often happier.  And most importantly–IT’S FUN!!  So get out there and play.

Send along questions and comments, and thanks for following.


Drug addiction–medicine disposal

Most of us have become aware of the terrible scourge of drug abuse that grips our nation.  Here in Ocean County, heroin kills one person every 48 hours.  Statewide we have seen a 214% increase in drug use since 2010 with approximately 128,000 New Jerseyans struggling with addiction at last count.  As a community, Toms River ranks 8th statewide in the rate of heroin addiction and overall Ocean County ranks 2nd in that sad list with 157 heroin deaths in 2015.

The problem is not just heroin, of course, but also prescriptions pain killers as well–including frequently used drugs like oxycontin, hydrocodone, and fentanyl(note–available as a dermal patch).  Many may have these drugs in their medicine cabinets left over from ailments like dental work, back pains, or surgical procedures.

What can we do with these medications when the problem is resolved but there are pills left over?  It’s NOT as simple as one might think.  The risks here are obvious–adolescents are impulsive and can be foolish: parents should never be too confident and should NEVER take anything for granted here.  And we must note that other youngsters visit and that just adds another variable to that safety equation:

  • Do NOT discard medicines in the trash
  • Be careful about flushing medications down the toilet
  • Best to discard at a reputable center
  • When in doubt, check with your pharmacist
  • When disposing pill bottles, be sure to scratch off all identifying information
  • Do not crush pills, but you can break them into halves or quarter
  • If you are going to discard pills, mix them with undesirable substances like dirt, kitty litter, or coffee grounds and discard in trash in sealed plastic bags

One last suggestion:  ask me about keeping a prescription  for naloxone (narcan)–available as a nasal spray–for your home.  Naloxone is an absolute antidote for opioids, is easy and VERY safe to administer.  Because “you never can tell,”

Please send along questions and comments, and thanks for following.


Probiotics can often be a good natural remedy for simple–if annoying– gastrointestinal complaints.  They are defined as ” live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.” These products have been tried in a variety of situations.  The medical literature is actually quite extensive but, at the same time, conclusions are rather spotty.  Nevertheless I think they are useful in the right setting and, in particular, (“naturally”) I favor their use over most medicines in many instances.

Historically, probiotics have been among the top 3 non-vitamin, non-mineral supplements given to children ages 4-17.  They seem to be most helpful in 2 clinical situations: acute gastroenteritis (AGE) and in the prevention of post-antibiotic diarrhea.  For these conditions the data is quite strong.  For instance, in the latter, probiotic use in one study of over 3,000 children showed a 52% reduction in the risk of diarrhea.  The efficacy of the treatment seems most tied to 2 things.  Firstly is the organism used and the second parameter is the dose of treatment.  The most extensively studied organisms–and those with the best “track record” –are Lactobacillus rhamnosus GG and Saccharomyces boulardii.  For both, 5 billion CFU (“colony forming units”) once or twice daily for 2-4 days seems to be enough to be helpful.  Both of these treatments are available as commercial products in either chewable or packet form and can be purchased in pharmacies or health food stores (I do not list brand names of products in my blog posts).

People have also tried probiotics for a number of other medical conditions like community acquired infections, colic, eczema, and even more severe medical problems like Clostridium dificile (“C dif”) infections and inflammatory bowel diseases like Crohn’s or ulcerative colitis.  Here there is considerably less evidence to support their use so I do not recommend that you rely on probiotics for those problems.  Additionally, many brands of yogurt are touted as a useful source of probiotics.  However, recent studies have not shown significant benefit of yogurt as a probiotic in any of the above medical conditions.  Food experts postulate that there probably aren’t enough “CFU” organisms in yogurt to be effective.

Lastly, we should recall that this treatment utilizes living organisms.  Therefore, use in infants or immunocompromised children–those with HIV, cancer, or receiving other immunosuppressive treatments or with other immune compromised conditions–is not recommended and could even be quite dangerous.

Much of the above information is summarized from a very useful article I found in a professional journal “Infectious Diseases in Children” written by Edward Bell, PharmD at Drake University, Des Moines, Iowa.  So a “shout out” to Dr. Bell for his help here.

Please send along questions and comments, and thanks for following.

Novel Psychoactive Substances

Many conscientious parents are aware of the terrible scourge of drug addiction that grips many in our nation and in particular locally here in Ocean County.  I wish t0 make you all aware of another danger that exists somewhat under the radar–“novel psychoactive substances” (NPS).  These products are usually not specifically illegal to sell or possess in the US but have various intoxicating effects.  Needless to say, as they are not meant for human consumption they can also often cause serious harm.

There are basically 4 categories of NPS:

  • Stimulants–drugs similar in action to cocaine, amphetamines, and MDMA(“ecstasy”).  The most commonly used agent here is mephredone which is sold in the US as a garden fertilizer.  Street names are drone, M-CAT, white magic, or meow-meow.  Taken orally (“bombing”) snorted, injected, even anally.  Toxic effects include agitation, psychosis, hypertension or even heart attack, elevated body temperature, seizures.  If mixed with certain standard prescription or OTC drugs can also cause potentially life threatening serotonin syndrome.
  • Cannabinoids–marijuana like substances.  There are a variety of “herbal essence” products that are often used in vape devices.  Brand names include K-2, Spice, Black Mamba, Bliss, Bombay Blue, Genie, Zohai.  Side effects include sleepiness confusion, excessive sweating.  Rarely can cause cardiac toxicity(hypertension or heart attack) kidney, lung, or neurologic damage( seizure or stroke).
  • Hallucinogens–there are 2 classes:
  1. Dissociative–the primary agent is methoxetamine (“mexxy”) It is not specifically illegal in NJ and can be purchased online.  It produces a sensation of weightlessness and “out of body” experience.  Side effects include nausea and vomiting, cramping, cardiovascular problems.  Injury and death from accidents caused by impulsive or careless behavior is not uncommon.
  2. Psychedelics–LSD like effects.  Most common example is NBOMe.  This class os substance is currently on a “temporary” Class I status so cannot legally be obtained in the US.


  • Depressants–also 2 classes
  1. benzodiazepine like–common agents are diclazepam or flubromazepam.  They also are available online.  They cause confusion, somnolence.  These drugs’ effects last longer than commonly used variants like valium or xanax–sometimes > 1 day.
  2. Opioids–morphine or heroine like effects of calm, sleepiness but can progress to coma, respiratory depression.  They do respond to antidote naloxone (“narcan”).  Common agents AH-7921 was made Class I illegal as of May 2016, however MT-45 is a lower level variant which is still available legally online in the US.  While nominally somewhat milder, it can be deadly if combined with alcohol or other drugs with sedating effects.

My advise to concerned parents, of course, is vigilance.  Pay attention to your teen’s social environment.  Monitor computer and smart phone use.  Be very aware of online purchases (if you permit them) and if you do not recognize a product purchased or in their possession be sure to look into it very carefully.

And, certainly, call me with questions, and thanks for following.

Reflux redux

Let’s circle back to review a common problem which I have referenced previously–colic and reflux (GER) in infants.  A recent journal article looked at the use of medication in preterm infants with this condition.  I think the results are also useful to consider for full termers.  The study found that up to 40% of “premies” are treated with various medications to address reflux and 3/4 of those patients are started as outpatients: in other words based only on empiric examination without more specific evaluation and testing. This trend is very troubling.  These are not benign medicines.  The study states that “although there remains a role for these medications in documented reflux diseases, empirical treatment of infants is not recommended.”  Complications like pneumonia, gastroenteritis, clostridium dificile (serious GI) infection, alteration in gut microflora, and fractures (due to impaired digestion) are documented.

And what are meds accomplishing?  Not too much, according to NASPGHAN, the pediatric gastroenterology society:

  • Crying–“The available evidence does not support any empiric trial of acid suppression in infants with unexplained crying, irritability, or sleep disturbance.”
  • Apnea/SIDS–“The available evidence suggests that in the vast majority of infants, GER is not related to pathologic apnea.  Pharmacotherapy has not been shown to be effective.  The occurrence diminishes significantly  with age and without therapy in most cases, suggesting that no anti-reflux therapy is needed.”
  • Asthma/wheezing–“There is no strong evidence to support empiric therapy in unselected patients with wheezing and asthma.”
  • Poor growth–the guidelines suggest that rather than empiric trial of acid reflux medication, careful evaluation for other chronic causes of growth failure, and then close outpatient monitoring of calorie intake and weight gain; trial non-milk and then specialized hypoallergenic formulas, and for severe and persistent cases inpatient observation and testing, and tube feeding may be indicated.

So what CAN we do for that crying, barfing baby?

  1. Avoid tobacco smoke exposure.
  2. Thickened feeding–1 tsp cereal:2 oz formula.  Perhaps adjust nipple hole size/tightness of nipple on bottle for adequate milk flow/swallowing.
  3. Smaller volume/more frequent feeding with frequent burping.
  4. Formula change: a trial of milk free or hypoallergenic formulas is often wise.  I recommend a trial of minimum 3-4 days(unless a violent reaction).  Only striking change, I feel, is meaningful. “Slight” improvement is usually “observer bias”–science talk for “wishful thinking.”
  5. Positioning–lying on child’s back is bad, even with head elevated.  After feeding keep baby upright for 1/2 hour or lie on right side x 1 hour then on left side afterward.
  6. To the extent that medications may be tried, NASPGHAN guidelines suggest a short 2 week trial only to break the cycle.  In the recent premie study, 43% of infants started before age 6 mo were still on medications after their 1st birthday (not if I can help it!)

The above conservative therapy shows significant improvement in >3/4 of patients and  complete resolution in 1/4.  As previously stated, in most infants it normally resolves within a few months anyway.  So, as in so many other situations, for me here mostly “just say no” to drugs.

Send along questions/suggestions.  Thanks for following.

Another word about lead

Lead exposure for our children has been in and out of the news for a few years–now back in, unfortunately.  I have written about this previously.  21 school districts statewide have recently reported elevated lead levels; several of these are local.  Overall, approximately 800 locations are covered by updated regulations adopted last summer by the state Department of Education for testing of school drinking water.  In Toms River, Pine Beach, South Toms River, West Dover, and Washington Street Elementary schools all had a few locations within their buildings with unacceptable lead levels.  Fortunately in each of those places, no contaminated areas involved student drinking fountains but rather only cleaning and janitorial stations.  Unfortunately, previously in Brick Drum Point, Emma Havens, and Herbertsville Schools also had these problems with the first 2 including some drinking locations.

In all of the above instances, school authorities have been quick to note the problem and commit to prompt correction.  In the short term this involved isolating the contaminated fixtures and avoiding the use of water from them; long term requires replacing old pipes and plumbing fixtures.  And the state has added an additional $10 million  (on top of a like amount appropriated last year) to fund those capital improvements.

So–reason to remain vigilant and concerned.  No cause for alarm.

I’d like to close with 2 additional points.  Presently elected officials on the national level have committed to comprehensive review of government regulations affecting so much of business and public life.  I say–great.  New sets of eyes can bring fresh perspective; things change, information is updated, and often we can find new, better, and maybe even less expensive ways to do these things.  But we must be careful to not –literally–“throw out the baby with the bath water.”  Lead exposure illustrates that there are often very solid reasons behind plenty of these rules, and many people–in particular vulnerable children–are protected by those regulations being on the books.  In life it has been my experience that some people– who’s financial interests may be adversely affected by those guidelines and mandates– at times, shall we say, may have difficulty fully appreciating those virtues.  As a pediatrician who has dedicated over half of my life to children’s health, I, for one, am grateful that people both at the state Department of Environmental Protection AND at the federal Environmental Protection Agency are there to help look out for those kids.

And one more thing.  Nationally we have become more aware of the issue of lead toxicity since the events in Flint, Michigan in 2015.  There, the problem was uncovered thanks to the dogged persistence of a local pediatrician, Dr. Mona Hanna-Attisha–an Iraqi immigrant–on behalf of her patients.  Dr. Hanna-Attisha is a credit to the medical profession and our nation owes her a debt of gratitude.

Please send along questions and comments, and thanks for following.

Osgood-Schlatter, Sever’s Apophysitis

Children’s skeletal growth occurs at the growth plate or apophysis.Typically, the apophysis remains “open” and growth continues for girls until age 13-15 and boys 16-18.  For a year or 2 before growth plate “closure” that child will experience maximal growth velocity.  2 large tendons–the patellar tendon in the knee and the Achilles tendon in the heel–insert into the growth plates of the respective bones below that joint (tibia for knee and calcaneus for heel).

During that period of maximal skeletal growth those tendons are actually sliding along the bone at the site of the growth plate over time as it lengthens. This is necessary so that the tendon remains in proper anatomic position as the bone elongates.  Specifically, as the tibia grows longer at the top, the patellar tendon slides upwards and as the foot grows longer at the calcaneus(heel) the Achilles tendon will slide backwards. Microscopically, this occurs as the fibers on one side of the tendon tear free and new ones grow and attach on the other side so that the tendon grows/moves in the same direction as bone growth.  This process at the growth plate (apophysis) during accelerated growth in adolescents can cause inflammation and pain at the site called apophysitis.  Knee pain apophysitis is called Osgood Schlatter’s disease and at the heel it is called Sever’s disease (I’m still not sure if “Sever” should be pronounced as rhyming with “weaver” or “weather,”, but anyway).  The pre-teen or teen will complain of chronic pain that is worsened by running, jumping, or climbing stairs.  The only finding in OS may be  a painful red lump below the kneecap, affects about 20% of athletes, and in about 25% will be bilateral.  In Sever’s the child will have tenderness on the inside and outside of the heel, has a 2-3:1 male;female ratio and may be bilateral up to 60% of the time.

Both conditions are usually self limited in that they will resolve when the child achieves adult height and the growth plates close.  For both conditions, usual treatment consists of proper stretching before activity and ice the affected area afterwards.  Ibuprofen is good for pain avoid caffeinated beverages on ibuprofen); padded knee pad for OS and cushioned shoe soul inserts for Sever–either “off the rack” or custom made orthotics by a podiatrist are often helpful as well.

Many children can “play through the pain.”  Some may choose a period of rest, or changing sports to relieve pain (swimmers don’t have these problems).  Both of these conditions tend to be mild, uncomfortable inconveniences as opposed to more serious threats to a child’s wellbeing, but either can rarely be more serious requiring specialists management(orthopedist or podiatrist).  Of course, not all knee or heel pain is apophysitis.  So, if your child is experiencing these problems, give me a call and we can check it out together.

Send along questions and comments and thanks for following.