Posts Tagged ‘respiratory infections’
Welcome to my more or less monthly newsletter for parents about pediatric topics. In it I highlight and comment on new research, news stories, or anything else about children’s health I think will interest parents. I have 30 years of experience practicing pediatrics, pediatric critical care (intensive care), and pediatric emergency room care. So sometimes I’ll use examples from that experience to make a point I think is worth talking about. If you want to get the newsletter regularly you can sign up for it here, on my home page (down at the bottom).
The bad effects of bullying are cumulative
We’ve known for eons that bullying can be hard on children. Not surprisingly, bullying is also hard on children’s health. A new longitudinal study over time is useful in showing this. It studied over 4,000 children serially (that is, the same kids) when they were in the 5th, 7th, and 10th grades. The authors found that bullied children were far more likely to have poorer health overall; both chronic and current bullying are associated with substantially worse health. They conclude: “Clinicians who recognize bullying when it first starts could intervene to reverse the downward health trajectory experienced by youth who are repeated targets.”
One caveat is that children with chronic health problems are more likely to be bullied, so the cause and effect relationship is not totally straightforward. Still, it’s a useful study to have: bullying isn’t just mean.
Should you use retail clinics for your children?
The American Academy of Pediatrics has recently put out a policy statement about retail clinics — those free-standing places sometimes called “doc in a box.” Should you bring your child to one? In a nutshell, the AAP doesn’t like them. Of course you should not be surprised by that because in some ways they represent the competition. But the policy statement makes some good points that you should consider if you are thinking about taking your child with something simple like a sore throat or an ear ache to one.
These places won’t know your child; all they will know about her past medical history is what you tell them. Sometimes that matters, sometimes not, but it is a reality.
I’ve had some experience seeing children who have been to a retail clinic, and my experience tells me the training and skill sets of the providers working there are pretty uneven. Many seem to have poor pediatric knowledge and less than standard practice habits. It seems to me that the default for many of them is that the patient should leave with something, generally a prescription. So in my experience they over-diagnosis ear infections, strep infections, and urinary tract infections. This makes for a lot of overprescription of oral antibiotics. They also tend to give antibiotics for what are clearly viral upper respiratory infections, a big no-no.
I’m not saying never use them if your child has an ear ache in the evening. But bear in mind the care you get may well be less than optimal. As I wrote above — sometimes that matters a lot, sometimes not so much.
Old foe, old remedy
We have a lot of antibiotics to choose from when treating children with pneumonia. There is always the temptation to use the newest and fanciest of them, but that can cause problems. For one thing, using the latest antibiotic on an uncomplicated case of what we call community-acquired pneumonia (that is, not caught while already in the hospital) leads to the scourge of developing bacteria resistant to most antibiotics; so when we really need the fancy ones they may not be effective. The newest ones are also typically the most expensive.
Recently the Pediatric Infectious Diseases Society has put out a recommendation that the older, cheaper, and more “narrow spectrum” antibiotics are preferred in ordinary pediatric pneumonia. So if your child has pneumonia, it would be entirely appropriate for you to bring this up with your doctor if he is ready to prescribe $150.00 worth of antibiotics.
Those noise machines to make your baby sleep may loud enough to affect their hearing
I’ve raised a couple of kids of my own so I know how frustrating it can be when they just won’t go to sleep. Like many parents, I found that for several months my daughter just wouldn’t go to sleep unless I drove her around in the car. Then she was such a heavy sleeper I could bring her into the house and put her in her bed. These baby noise machines work on that principle.
These machines make various sounds — gurgling water, a heart beat, or just “white noise.” That’s all fine, but be aware that a recent study suggested that some of them make noises loud enough to affect a baby’s hearing, which is quite delicate.
The authors measured sound levels in 14 machines at various distances from a child’s ear. They found that all of the machines were capable of producing levels of sound hazardous to hearing. The authors don’t specify the brands, but my reading of the study is that all of them can be too loud even when used according to the directions.
My take home on this is that if you use one of these machine, use the lowest settings. Nobody has the sophisticated equipment that the authors of the study used to measure the sound intensity to make sure things are safe.
I’ve written about this before, but it’s well worth doing it again. It’s once more cold season, bringing up the question parents commonly face: Should they buy one of those rows and rows of cough, sneeze, and runny nose medicines one finds in every drug store and supermarket? In a nushell, no — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a report some years ago by the Food and Drug Administration, one still worth reading. You can read about the details, as well as the history of how and why these cold remedies were regulated in the past, here.
There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spend millions of dollars marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.
In fact, they are not. Poison control centers receive thousands of calls about them every year, and The Centers for Disease Control found that many are seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.
The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.
The Food and Drug Administration has issued a public health advisory that they not be used at all in children less then two years of age. They left use in children older than two alone, but I wouldn’t use them for those children, either. They don’t help, and may harm.
If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple — don’t use them in small children.
So what can you use for a child with a bad cough? Some recent research, a good quality study, suggests that Grandma’s old folk remedy of honey actually helps. It not only can sooth the cough, but may have a specific cough-supressant effect.
Another thing to keep in mind is that persistent cough may actually represent a variant of bronchospasm or wheezing, particularly if your child has had wheezing troubles in the past. So it’s worth checking with your doctor if your child has a persistent cough because anti-wheezing medications, such as albuterol, can help that situation.
I’ve written about this before, but it’s well worth doing it again. It’s once more cold season, bringing up the question parents commonly face: Should they buy one of those rows and rows of cough, sneeze, and runny nose medicines one finds in every drug store and supermarket? In a nushell, no — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a report some years ago by the Food and Drug Administration, one still worth reading. You can read about the details, as well as the history of how and why these cold remedies were regulated in the past, here.
There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spend millions of dollars marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.
In fact, they are not. Poison control centers receive thousands of calls about them every year, and The Centers for Disease Control found that many are seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.
The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.
The Food and Drug Administration has issued a public health advisory that they not be used at all in children less then two years of age. They left use in children older than two alone, but I wouldn’t use them for those children, either. They don’t help, and may harm.
If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple — don’t use them in small children.
The rates of prescribing oral antibiotics in children have been declining steadily since the early 1990s. A principle reason for this is the increased awareness, both among doctors and the general public, of the problem of producing antibiotic-resistant bacteria. These superbugs are created when we expose the whole population of bacteria in our bodies, most of which are friendly and cause no disease, to antibiotics. The friendly ones get killed, the nasty ones can acquire resistance to antibiotics. This is not a good thing for the patient or for the rest of us. We don’t want critters like this loose:
The best way to reduce this risk is to use antibiotics only when they’re really needed. A couple of decades ago it was common to give out antibiotics for upper respiratory infections that were clearly caused by viruses, which antibiotics have no effect against, “just in case.” Doing that subjects the patient to risk without benefit, something doctors should not do.
I think a change in public expectations has helped this trend, too. Patients once expected an antibiotic prescription for any respiratory ailment and were upset if they didn’t get one. Now most people are wiser, I think, especially if the doctor is willing to explain the situation. Of course that takes time. Doctors can be tempted just to give the prescription and get on to the next patient.
A recent article in Pediatrics, the journal of the American Academy of Pediatrics, adds an interesting new wrinkle to the issue. For pediatricians and family doctors, by far the most common reason for prescribing antibiotics is for middle ear infections, or otitis media. This article documents, at least in Massachusetts, a decline in the rate of diagnosis of ear infections. What is that about? Are ear infections really less common? I doubt it.
Examining the eardrums of an uncooperative toddler is a challenge, as most parents and all pediatricians and family doctors know. It can be really, really hard to get a good view of the eardrum in the couple of seconds you have to glimpse it. There is a huge temptation to glance at the ears of a toddler with a fever and pronounce that infection is present — parents accept it, even expect it, and it gives an excuse to prescribe an antibiotic. But not all cases of ear infection even need antibiotic therapy, and parents are increasingly likely to accept a watch-and-wait strategy for a day or so. Physicians are as susceptible to people’s expectations as anybody else, and I think part of the decline in ear infection diagnoses is a change in parent’s expectations of what needs to be done about them. (You can find a great review of diagnosis and treatment of ear infections here.)
My child is sick all the time. If you are a parent of a preschool child, have you ever thought that? And, if you have, did you worry all those frequent illnesses meant there was something seriously wrong, some significant, underlying illness? Pediatricians and family doctors often hear this worry from parents.
Preschool children have a lot of infections, especially upper respiratory ones, called URIs. Children under three average five to six URIs per year, although the range of normal is quite broad — as many as ten in a year is not necessarily abnormal. One large survey from the Centers for Disease Control polled nearly three thousand households and asked the parents if their children had experienced URI symptoms during the preceding two weeks — a third of children under three had, as did a quarter of children three to five years old.
Where children are during the day matters in determining how many URIs they get, and the youngest preschoolers spending their day with six or more other children of similar age, such as in a daycare setting, get the most. In the CDC sample, for example, about half the children spent time in daycare, and those children had, on average, a fifty percent higher rate of infection. Considering how toddlers share hugs, toys, and crackers with each other, this is not surprising. But for a parent whose child is in daycare, does this increased number of infections mean anything? Is it worse for your child?
Various studies help answer this key question, and the answer is reassuring. In fact, although children under three attending daycare have more URIs than do their stay-at-home compatriots, there is evidence they have less URIs later on, during their early grade-school years. So things appear to even out; the children who are not exposed to as many respiratory viruses as preschoolers meet those viruses later.
Can all these URIs lead to further problems? The answer is generally no, but once in a while they are a problem for certain children, especially those under two. The principal complication of a URI is a middle ear infection, termed otitis media. The inflammation from the URI blocks the normal function of the eustachian tube, the connection between the back of the nasal passages and the middle ear, allowing bacteria normally present in the area to infect the ear. Children vary in their propensity for this to happen. However, the younger they are when they have their first ear infection, the more likely they are to have more of them. Susceptibility to ear infections also runs in families. Another complication of URIs among some children is wheezing whenever they get one. If your child has problems with repeated bouts of either otitis or wheezing, reducing the number of URIs by reducing exposure to sick children is a good way to help control the situation.
Even though experiencing many URIs is common among preschoolers, there are times when a doctor worries about the situation. For example, if the child is having recurrent high fevers, severe rashes, or diarrhea, this could mean there are problems with the immune system. A key red flag is if the child is not thriving — failing to gain weight or even losing weight, or is not keeping up with normal developmental milestones.
If you are concerned your child is too sick too often, discuss the situation with your child’s doctor. But for nearly all preschoolers, having lots of URIs is just part of growing up.
This time of year I’m closely exposed to dozens of children with viral respiratory infections. I don’t want to get what they’ve got, both because it would be unpleasant for me and because my unhappy colleagues would be forced to cover whatever time away from the PICU an infection caused me. So I do whatever I can to stay well. This may sound like simple grandmotherly advice, but really the best way to keep from spreading respiratory viruses is to wash your hands a lot.
The reason is simple. Although viruses do fly through the air to some extent when coughed or sneezed, a more important way of spread is by touch. After infected persons blow their noses, for example, there inevitably is virus on their hands. The way to get rid of the virus? Wash those hands. Hospitals use a variety of special foams and gels for doctors and nurses to disinfect their hands as they go from patient to patient, and some of these are available in stores for you to buy, but plain soap and water is as good as anything.
You can read more about handwashing here, at the official web site of the Centers for Disease Control. The bulletin has some interesting historical observations about when doctors realized infections spread this way, and it is six years old itself. It still applies, though, especially during cold season.
In a nutshell — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a recent report by the Food and Drug Administration. You can read about the details of the decision, as well as the history of how and why these cold remedies were regulated in the past, here.
There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spent over 50 million dollars last year marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.
In fact, they are not. Poison control centers have received 750,000 calls about them since 2000, and The Centers for Disease Control found that over 1500 children under two were seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.
The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.
If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple — don’t use them in small children.
Sachin on 