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.

School Refusal

What kid doesn’t like a snow day, or a chance to sleep in with a day off from school? For many children, getting to or staying at school all day can be nothing short of catastrophic.  Every morning they are lethargic and unable to get dressed or get going.  They have somatic complaints (headaches, abdominal pains) which can be persistent and severe; sometimes these complaints vary by the day.  Pushing the child along–forcing them to get ready for school–can elicit extremes of emotion, panic attacks, even violence towards property, self, or others.

Many of these children have school refusal.  An exact definition is tricky, but generally it entails severe, hysterical fear, anxiety, or panic regarding school attendance.  This is not truancy, which is more associated with faking illness to be out of school, while engaging in other(frequently anti-social) activities.  There can be some overlap–certainly some kids anxious about school can get into quite a bit of trouble while being absent.  Reports of occurrence vary from 5% to as high as 28%(if we include children who eventually, after great prompting, finally make it).  It peaks in 5-6 and 10-11 year olds.  Likely 25% have an associated psychiatric diagnosis–typically anxiety, depression, or OCD.

There can be many triggers.  Some children are just fearful of public bathrooms.  Sometimes there is justifiable fear for safety–physical safety from bullying or dangerous neighborhoods, or reputation safety from cyber-bullying or public shaming.  It can result from home difficulties–family illness or violence, financial disruption.  Note that children with real chronic medical conditions and legitimate physical complaints can develop school refusal from fears regarding worsening of their condition at school or just because they hate feeling “different.”

School refusal is a difficult problem requiring complex and nuanced management–no “one size fits all.”    Parents should maintain home routines:regular bedtime and wake up.  Homework should be completed; where possible, tests should be taken.  NO screen/phone time for a child while not in school due to anxiety.  Schools need to be flexible: allow the student to gradually increase school time or alternatives to in classroom attendance (any time in the building is positive).  Too severe a reaction–“my way or the highway” by administration is unhelpful.  But so is over-leniency: every complaint should not result in nurse discharging the student for the day.  School must be sensitive to reasonable concerns regarding personal security.  Developing positive reinforcements for attendance–by parents and schools–should be promoted.  Counseling, psychotherapy, and cognitive behavioral therapy can frequently be employed.  In selected situations, judicious use of psychoactive medications may be prescribed.

We should remember that generally these are good kids with a problem that requires our patience, understanding, and support.  Nobody is talking “indulgence” or “molly coddling.” But we must think these things through very carefully before we act.  If you have a child who is experiencing this type of difficulty please give me a call and let’s see what we can do.

Thanks for following.

Peanut Allergy

Peanut allergy management has made the news again this week.  That is because of the evolving recommendations for how to address the problem, which have essentially “done a 180” and are exactly the opposite of where we were with this topic as recently as just a decade ago.  Then, avoidance was the conventional wisdom.  And I have previously commented on the subject myself.  Note that peanut allergy has been a growing problem in the US, where it has increased from 0.7% to > 2% of children from 1999 to 2010.  While rare, peanut allergy causes by far the most mortality from food caused anaphylaxis.

The change grew out of a surprising observation by doctors in Britain who noted that the incidence of peanut allergy among British Jewish children was much higher than children in Israel.  And it was noted that many Israeli children enjoy a popular peanut based snack called Bamba.  So they studied peanut allergy prone children aged 4-11 months, introducing peanut based foods to half the kids and no early peanut introduction to the rest.  The findings were startling and definitive: peanut allergy developed in only 1.9% of the peanut fed group as opposed to 13.9% of those avoiding peanut.

Hence the new and very different guidelines–instead of avoidance, we now recommend earlier introduction.  For infants from non-allergic families or those kids with mild eczema only, introduce peanut after 6 months as before.  Never give a child under age 4 a whole peanut (or any small, hard food for that matter because of the risk of choking) and peanut based food should not be the first solid introduced.

For children from families with strong history of peanut or egg allergy, or for those kids with moderate to severe eczema, the approach is more involved.  Blood tests and skin testing performed by an allergist or dermatologist, to assess risk beforehand.  Then, for those who are deemed lower risk, introduction of small amounts of peanut food by 4-6 months old, preferably the initial ingestion in the doctor’s office.  This can be 6-7 gm of food divided in 3 meals.  A good way to do it is to mix a few tsp of peanut butter with an equal amount of warm water to make a slushy consistency.  As above, never give a child a whole peanut and the peanut food should not be the first solids introduced.

So after 31 years of clinical practice I’ve seen the recommendations go one way and now the other.  If I keep this up long enough maybe someday we’ll head back in the other direction again. But for now, this is the best available data so this is the way we should be doing it.

Please contact me with any questions or comments, and thanks for following.

Headphones and Hearing

A Happy or Merry Whatever to you all.  Let’s talk a bit about holiday presents.  Headphones are a frequent children’s holiday gift.  As with anything, we must exercise caution in considering these popular consumer items.  Studies indicate that children as young as 3 use  headphones, 1 /2 of 8-12 year olds and 2/3 of children 13+ use them frequently.

First , a bit of background.  The detrimental effects of noise on one’s ears is a function of both loudness and duration of exposure.  The unit range is not a linear phenomenon.  In other words, 80 decibels (dB) is 2x 70dB and 90 is 4x.  For a point of reference, 100 dB is the sound of a lawn mower and 15′ exposure is considered risky.  The National Institute of Occupational Safety and Health indicates that 85dB for 8 hours is the limit for safety in a work environment.

To be safe, headphones are supposed to max out at that 85dB level.  Unfortunately, many models can be cranked up as high as 97-107 dB, including brands that say they don’t.  Note that some MP3 players can reach 120dB–the sound of a rock concert stage; >5′ at that level is considered unsafe. I try to avoid endorsing any specific product brands on this blog, so keep those last facts in mind when choosing a model.  Sites like The Wirecutter and Consumer Reports can be helpful in assessing the accuracy of advertised claims.

As always, I advise parental involvement and supervision as your best strategy for safety.  Encourage your children to listen at 60% volume maximum and for no more than 1 hour.  Check the volume level your child uses yourself.  If you cannot clearly hear what’s being said to you from arm’s length distance then the volume is too high.  Take at least 10′ break for every hour of listening to rest your ears.

Symptoms of potential hearing loss include:

  • ringing, roaring, hissing, or buzzing in ears
  • difficulty understanding speech in noisy places
  • Ears feel muffled
  • Requiring progressively higher volume settings to listen

Please send along questions or comments.  Happy and Healthy New Year to all.