September 12, 2014

Weight Gain Makes Kids More Vulnerable to Asthma

Asthma and obesity are common problems among U.S. children, and a new report in the Annals of Allergy, Asthma & Immunology ponders how obesity contributes to childhood asthma.

Nearly 7 million U.S. children have asthma, and more 12 million kids from 2 to 9 years old are obese. According to the American College of Allergy, Asthma and Immunology (ACAAI), obese children have an increased risk of developing asthma. An ACAAI news release accompanying the journal report acknowledges link between childhood obesity and asthma, but said research hadn’t determined which condition generally occurs first, or whether one causes the other.

This study suggests that being overweight comes first, although the connection is complex and many factors have yet to be examined.

The report showed that rapid growth in body mass index (BMI) during the first 2 years of life increased the risk of asthma until kids were 6 years old. Previous studies showed that the onset and duration of obesity and the ratio of lean tissue to excess fat can affect lung function. (See our blog, “Fast Food Diet Shows Link to Breathing Problems.”)

But practitioners often don’t know if the constricted airways characteristic of asthma makes kids unwilling to exercise, and therefore gain unhealthy amounts of weight, or if being overweight narrows airways, prompting the development of asthma.

“Most kids who suffer from asthma also have allergies,” Michael Foggs, MD, and president of ACAAI, said in the news release. “These allergic responses in the lung can lead to symptoms of allergy. Coughing, wheezing and shortness of breath are all symptoms that make exercise harder.”

The ACAAI says that children with asthma and other allergic diseases should be able to participate in any sport they want to as long as their condition is monitored and controlled. If they show symptoms of asthma during or immediately following exercise, it’s an indication that their condition is not being properly controlled.

In other words, asthma shouldn’t be so severe that it restricts a kid from being active; it’s a condition that can be managed and accommodated.

For advice from allergists about dealing with your child’s asthma, link here. To learn more generally about asthma and allergic conditions, and to locate an allergist in your area, link here. For information about hospital treatment of children with asthma, see our blog, “Assessing the Quality of Hospital Care for Children with Asthma.”

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September 5, 2014

Schools Start Early, but Teens Need to Sleep Later

Although plenty of studies show that the natural sleep cycle of teenagers skews late, school hours start early. In addition to health problems, sleep deprivation can cause lower academic performance and increased risk of accidents.

The American Academy of Pediatrics (AAP) recently issued a new policy statement supporting the idea of a later start time for middle and high school. The academy recommends starting no earlier than 8:30 a.m., it says, to “align school schedules to the biological sleep rhythms of adolescents, whose sleep-wake cycles begin to shift up to two hours later at the start of puberty.”

The September issue of the journal Pediatrics published the statement, “Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences,” which referred to research showing that adolescents who get enough sleep enough lower their risk of being overweight, suffering depression and being in an automobile accidents. They also get better grades and report a better quality of life, according to Dr. Judith Owens, a pediatrician and lead author of the policy statement.

“Chronic sleep loss in children and adolescents is one of the most common – and easily fixable – public health issues in the U.S. today,” she said.

Mark Fischetti, a senior editor at Scientific American, voiced strong support for the movement toward later school hours.

“Ask any groggy teenager waiting for a bus or yawning in ‘home room,’” he wrote, “and he or she will tell you that it’s just too darn early in the morning to learn chemistry equations or analyze a narrative by some Russian novelist.

“Are they just lazy? No. Scientific studies of teen sleep patterns say they’re right. So do results from numerous schools across the country that have delayed start times: The later classes begin, the more academic performance improves. Bonus points: attendance goes up, teen depression goes down, and fewer student drivers get into car crashes.”

It’s all about circadian rhythms, the biological clock that makes you feel awful when you travel across several time zones (jet lag) and can disrupt workers whose shifts change from day to night to day.

Circadian rhythms, Fishchetti noted, shift during the teen years. Starting around age 13 or 14, the kids naturally stay up later and sleep later, a pattern that peaks between 17 and 19. Adolescents also need more sleep than an adult.

One study of 9,000 high school students in three states showed that grades in science, math, English and social studies rose when school began at 8:35 or later. Experiments at two North Carolina high schools and at the U.S. Air Force Academy also showed that academic performance improved when start times were later.

School districts might be reluctant to revise what they’ve always done, but Fischetti reported that their concerns about starting school later aren’t fulfilled — kids still can hold an after-school job, and participate in after-school programs.

“The issue is not the start time. It’s that the students are overly busy,” said Kyla Wahlstrom, one of Fischetti’s sources. “There is too much pressure to cram it all in just to have a good resume to get into college.”

Wahlstrom is director of the Center for Applied Research and Educational Improvement at the University of Minnesota. She said students, parents and school advisors should ratchet back the activities, and emphasize certain ones they enjoy or do well at, rather than participate in order to impress colleges. She said students should get eight, and preferably nine, hours of sleep every night.

Other countries seem to be learning this lesson. Studies in Brazil, Italy and Israel associate later start times with improved learning, and high-school level students in Europe seldom start before 9:00 a.m.

Even if it’s not about academics, it’s about safety. Fischetti referred to a high school in Wyoming that moved the start time from 7:35 a.m. to 8:55 a.m. and saw a 70% reduction in car crashes among drivers ages 16 to 18.

University of Kentucky researchers studied the issue and found that crash rates of teen drivers fell 16.5% in the two years after start times were delayed one hour, while the teen crash rate where they remained the same rose 7.8% in the same time period. The students in each of those groups, respectively, slept different amounts. In the reduced-crash group, those who got at least eight hours of sleep during weeknights rose from 36% to 50% percent, and those who got at least nine hours rose from 6% to 11%.

Your teen probably isn’t willing to go to bed earlier, and if he or she does, might not be able to fall asleep. But almost all of them would be willing to sleep later.

It’s time for school districts to wake up and smell the coffee.

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August 29, 2014

Worrisome Trend: Sunscreen Use Declines Among Teens

Although the rate of some cancers has declined in recent years, melanoma — the most serious form of skin cancer — is not among them. The situation is more troubling with the news of a new study that fewer teenagers are using sunscreen than they used to.

Because sun damage is cumulative — that is, like X-rays and other forms of radiation, the more exposure you have and the longer you have it, the greater the risk of developing cancer — the news is particularly unsettling. The earlier in life you develop the habit of reducing sun exposure, and of using sunscreen when you are outside, the greater your chances of minimizing the risk.

The study about teens was part of the Youth Risk Behavior Surveillance System, an initiative of the Centers for Disease Control and Prevention (CDC). It reviewed use of sunscreen and indoor tanning devices among high-school students across the U.S. between 2001 and 2011. Even though teens generally practice fewer skin-protection habits than adults, this study, as reported on, showed a decline sunscreen use and an increase in indoor tanning use even from previous reviews.

The number of teens who use sunscreen dropped by more than 1 in 10 from 2009 to 2011. The lowest rate of sunscreen use was in 2005, when only 5 in 100 teens applied it. The rate teens used indoor tanning devices varied less in that period, from 15 in 100 in 2009 to 13 in 100 in 2011, but it still declined.

Although as adults, more women than men wear sunscreen, the CDC study showed that girls used indoor tanning devices more than boys. In 2009, 1 in 4 girls tanned indoor regularly compared with 6 in 100 boys. And their use of tanning beds increased as they got older. Sunscreen use was fairly consistent across all grade levels.

A few years ago, we blogged about the dangers of kids and tanning beds, “Youth and Tanning Beds: Do Not Mix,” but it appears American youth — and their parents — aren’t getting the message.

According to the American Cancer Society, melanoma is diagnosed in about 69,000 Americans each year, and about 8,650 die from it. The CDC says that rates of melanoma rose 1.6% among men and 1.4% among women every year from 2001 to 2010.

Other forms of skin cancer are less lethal than melanoma, but are still problematic and require treatment. AboutLawsuits refers to a study from a few months ago that showed that teenagers who use tanning beds are more likely to develop basal cell carcinoma, one of those forms, and that they were more likely to be diagnosed at a much earlier age.

However you get harmful radiation, and wherever it shows up on your body, it’s not good. And, often, it’s preventable. Adults should make sure they minimize exposure to the sun, and should spurn the use of tanning beds, and they should make sure their kids do, too. It’s an investment in future health.

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August 22, 2014

Why “Go Out and Play” Is Good Advice to Build Healthy Brains

As families start to wind down summer activities and gear up for the return to school, new research may help parents realize that recess can be as important to a child’s brain development as time in the classroom.

Studies discussed in the book “The Development of Social Engagement: Neurobiological Perspectives,” show that the experience of play alters neurons in a certain part of the brain for a benefit that doesn’t otherwise occur.

Changes in the prefrontal cortex during childhood, said researcher Sergio Pellis in an interview on NPR, help wire the brain's executive control center, which is critical in regulating emotions, making plans and solving problems. So play, Pellis said, prepares a young brain for life, love and even school.

But not just any kind of play. It has to be the kind that kids seem to get less of these days — free-form, uncoached, spontaneous play. No coaches, no umpires, no rules.

"Whether it's rough-and-tumble play or two kids deciding to build a sand castle together, the kids themselves have to negotiate, well, what are we going to do in this game? What are the rules we are going to follow?" Pellis said in the interview. Because these playful interactions actually are fairly complicated social relationships, the brain builds new circuits to navigate them.

A couple of years ago, we discussed another aspect of spontaneous play that involves risk-taking; see “Risky Play on Playgrounds Isn’t Always Wrong.”

These are lessons scientists have learned from animals.

Species including cats, dogs, most mammals and some birds engage in social play. Observers used to think that rough-and-tumble animal play might be how they develop survival skills. But studies have suggested otherwise. Even if adult cats were deprived of play as kittens, for example, they’re still good at killing a mouse.

So researchers began to see the value of play for different reasons. One, Jack Panksepp, studied rats, who horse around a lot, and emit a sound he dubbed "rat laughter." His studies showed that about 1 in 3 of the genes they looked at were significantly changed after a half-hour of play.

Of course, a rat brain isn’t a human brain, but there’s also a reason rats are common scientific test subjects. As Pellis noted, play behavior is similar across species. Rats, monkeys and children all seem to follow similar rules: Participants take turns, play fair and don’t inflict pain.

So play helps people and animals socialize.

In people, Pellis said, the skills associated with play can boost academic performance. One study showed that the best predictor of academic performance in eighth grade was a child's social skills in third grade.

As Pellis observed, "[C]ountries where they actually have more recess tend to have higher academic performance than countries where recess is less."

It’s good exercise and good discipline for kids to participate in organized sports. But it’s not the only form of physical activity that’s good for them. And, possibly, not even the most important.

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August 15, 2014

All-Terrain Vehicles Are Not Toys

Here’s a “Say what?” statistic that should give parents pause: More than half of all teens who have driven an all-terrain vehicle (ATV) have been involved in an accident.

So says research recently published in the Annals of Family Medicine. The report also shows a propensity for teens to engage in several kinds of risky behavior when they ride on an ATV.

As explained on, researchers from the University of Iowa Carver College of Medicine found that 3 in 4 teenagers in the state of Iowa have driven an ATV and that kids 15 and younger represented 1 in 5 ATV-related deaths.

The findings about the number of teens who had been in crashes were similar to previous studies from other states.

The conclusions were based on a survey of 4,684 youngsters between 11 and 16 taken over 2½ years at 30 different schools throughout Iowa. More than 1 in 3 of the kids who said they’d ridden an ATV reported doing so every day or every week. More than half of the ATV riders said they’d been in at least one accident, and nearly all of them acknowledged having engaged in risky behavior, which was defined as:

  • riding with a passenger (9 in 10 reported doing this);

  • riding on public roads (8 in 10);

  • riding without a helmet (more than 6 in 10).

Six in 10 respondents reported having engaged in all three dangerous behaviors at some point. A scant 2 in 100 said they had engaged in none of them.

According to the ATV Safety Information Center, an initiative of the U.S. Consumer Product Safety Commission, of about 100,000 ATV injuries in 2012, one-quarter were kids younger than 16, and of the 353 ATV fatalities that year, 54 were from that group.

Even for people who are careful, ATVs are dangerous — they’re powerful and can be unstable, especially if they have more riders than they’re built to accommodate.

The most fearsome accidents, of course, involve brain injuries, which, according to the new study, “are among the leading cause of death and disability from ATV crashes. They are more likely to occur on the roadway than off road, even when controlling for helmet use. Helmets are estimated to reduce the risk of fatal ATV-related head injuries by 40% and of nonfatal head injuries by 60% or more.”

To learn more about brain injuries, see our backgrounder.

If you and your family enjoy riding all-terrain vehicles, make sure you follow the safety guidelines provided by the CPSC:

  • Do not drive ATVs on paved roads.

  • Do not allow a child under 16 to drive or ride an adult ATV.

  • Do not drive ATVs with a passenger or ride as a passenger.

  • Always wear a helmet and other protective gear such as eye protection, boots, gloves, long pants and a long-sleeved shirt.

  • Take a hands-on safety training course.

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August 8, 2014

Emergency Surgery on the Weekend Is Riskier

If your child needs emergency surgery, here’s hoping it’s not on a weekend. A study published last month in The Journal of Pediatric Surgery suggests that kids undergoing emergency surgery on the weekend have more complications and deaths than if they’d had similar treatment during the week.

Researchers used a large national database, according to the New York Times, to compare 112,064 weekend surgeries on children younger than 18 with 327,393 such procedures on weekdays. All were coded as “emergencies,” and included appendectomies, brain shunts, hernias, bone fractures and abscess drainage.

Only about 1 in 100 had complications, and fewer than 1 in 1,000 died. But patients undergoing their surgeries on the weekend were:

  • 40% likelier to have an accidental puncture or cut;

  • 14% percent likelier to receive a transfusion; and

  • 63% likelier to die.

The lead author said that although mortality was low, over 20 years the number of weekend deaths would be about 50 more.

What can parents do about it? Obviously, you can't schedule when an accident is going to happen that requires surgery. But being aware that weekends carry higher complication rates can help make parents more alert to staffing issues and the need for vigilance by family members following an operation on a loved one. If something doesn't seem right, say so!

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August 1, 2014

Vaccine Film Prompts Adults to Teach Children the Wrong Life Lesson

When parents and teachers at a Southern California high school withheld a student-made film about vaccination out of concern for the social blowback, they voted for ignorance at the expense of science.

Carlsbad High has an award-winning broadcast journalist program that produced “Invisible Threat,” a documentary about “the science of disease and the risks facing a society that is under-vaccinated.” As the students and their advisors put the final touches on the film and prepared to release it, according the Los Angeles Times, “they found themselves cast as foot soldiers in a long-running immunization war between a small group of activists who argue that vaccines cause autism and the vast majority of physicians and scientists who say they don't.”

Readers of this blog will be familiar with the ongoing effort to protect public health in the face of vocal, and often prominent, people who have no scientific basis for their ridiculous ideas, and who, by not vaccinating their children, put everyone at risk. (See our blog, “More Proof that Vaccines Have Nothing to Do With Autism.”

In Carlsbad, the anti-vaccine lobby charged that the students had been duped by deceitful advisors who had been paid off by the pharmaceutical companies that make vaccines, and the criticism delayed the launch of the movie for months. In May, the parent-teacher association canceled an on-campus screening not because they didn’t believe it was a worthy film, but because they were afraid that anti-vaccine activists would show up.

In other words, they taught their kids that, even if you’re doing something right and righteous, if there’s a chance it will cause trouble, it’s best to relinquish your principles and sit quietly with your hands folded.

Nice lesson, eh?

The kids, to their credit, objected. "We're an extracurricular film club," Mark Huckaby told The Times. He narrated the film. "It's just not cool."

The filmmakers denied being pawns of anyone. And they had done some great journalism. Their area's historically high vaccination rate was starting to slip, and they knew there was a story there.

According to the California Department of Public Health, says The Times, the percentage of new kindergartners in San Diego County who seek exemptions from immunizations has increased from about 1 in 100 15 years ago to 4.5 in 100 last school year.

Measles and whooping cough, which had been in decline, were emerging anew, as in many other areas of the U.S.

The students read studies, interviewed medical experts who praised vaccines as well as parents who distrusted them and a local osteopath who treats autistic children.

Even Dr. Melinda Wharton, director of the U.S. Centers for Disease Control and Prevention (CDC) immunization services division said they did a good job interpreting the scientific material.

Some of the students initially believed vaccines and autism were linked, they said, but they changed their minds as they researched. "It was all social controversy. There was no science controversy," said Allison DeGour, another of the students involved.

The final version of "Invisible Threat" took a strong pro-vaccine position. And although it still hasn’t been seen by the large numbers it deserves, the parent advisor who served as the film’s producer announced that the movie would go on the Web on Aug. 1, in conjunction with National Immunization Awareness Month.

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July 25, 2014

Spray-On Sunscreen Is Not for Small Fry

Except for the youngest infants, using sunscreen is a good idea for anyone hoping to avoid the cancer and cosmetic risks of too much sun exposure. But one form of protection is not recommended for children: spray-on sunscreen.

Infants younger than 6 months should not use sunscreen; the best protection for them is to keep them out of the sun. That’s because their skin is immature and they have a higher surface-area-to-body-weight ratio compared with older children and adults. Those two characteristics make an infant’s exposure to the chemicals in sunscreens much greater, increasing their risk of side effects.

As explained by Consumer Reports, aerosol applications of sunscreen present the risk of inhaling ingredients that irritate the lungs. Earlier this summer, according to the magazine, the FDA said it was investigating these potential risks. Also, spray products are flammable, so don’t use them near a grill or fire, and don’t let even older kids fool around with them near an open flame.

No one of any age should inhale this stuff, but children are at greater risk because they’re more likely to move around while they’re being sprayed and accidentally get a dose where it doesn’t belong.

The safe use of sunscreen, says Consumer Reports, includes these practices:

  • Don’t use sprays on children, unless you have no other product available. In that case, spray the sunscreen onto your hands and rub it on. As with all sunscreens, be especially careful on the face, taking care to avoid the eyes and mouth.

  • Adults can use sprays, but don’t spray your face. Spray your hands and rub it on your face, making sure to avoid your eyes and mouth. Avoid inhaling it.

  • Make sure you apply enough. The magazine’s tests have found that sprays can work well when used properly, but it’s more difficult to gauge if you apply enough, especially when it’s windy. Spray as much as can be evenly applied, and then repeat the application, just to be safe. On windy days, spray the sunscreen on your hands and rub it on, or go with a lotion instead.

To see the FDA’s sunscreen recommendations, link here. For the agency’s sun safety tips for infants, link here. For Consumer Report’s recommendations for sunscreens for kids and babies, link here. To see what Consumer Reports has to say about sunscreens generally, and to review its list of recommended products, link here (some pages are subscription only).

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July 18, 2014

Kids and CT Scans: Not So Fast, Parents

Responsible doctors are worried that children can get way too much radiation exposure when they are tested for common problems in the emergency room. X-rays can have great benefit in diagnosing what's wrong, but they can also pose serious long-term risks of cancer from accumulated unnecessary testing.

The main culprit is the CT scanner. Parents need to know that CT scans send out X-ray beams. The typical CT study doses a patient with the equivalent of many dozen chest X-rays.

Ultrasound, by contrast, uses sound waves, so there's no exposure to potentially harmful radiation.

Smart parents sometimes mistakenly push for a CT scan because it's the fanciest and therefore "best" technology. But that's not always true. Ultrasound has now replaced CT as the first-line choice for imaging the abdomen to see if a kid with severe pain might have an inflamed appendix.

A group of doctors just published an article they titled An Appeal for Safe and Appropriate Imaging of Children, in the Journal of Patient Safety. They used as a case study a true story of an 11-year-old girl with abdominal pain who wound up getting two CT scans and scaring her parents to death, all because of a benign nodule found as an "incidental finding" in the lung. She should have received an ultrasound and no CT.

They wrote:

This child has already received an estimated ~20 mSv, which carries with it an increased cancer risk of approximately 1 in 500. Stories like this likely occur every day in the United States.

This unfortunate sequence of patient harm, waste, and needless anxiety could have been completely avoided with the Ultrasound First policy being used at many centers.

We've written before about how doctors are worried about overuse and misuse of radiation imaging. Parents need to know about the issue and work with medical professionals to get their sick and injured children the right imaging test and not necessarily the most high-tech one.

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July 11, 2014

24-Hour Pharmacists Make for a Safer ER for Kids

Medication errors are far too common among hospital patients, but one pediatric hospital is taking measures to reduce them and the sometimes life-threatening harm they can cause.

Making fewer medication mistakes, which, according to a story on, contribute to more than 7,000 U.S. deaths every year, is a matter of more professionals remaining on the job for a longer period of time — specifically, hospital pharmacists. In the emergency department at Children's Medical Center in Dallas, pharmacists who specialize in emergency medicine review each prescription to ensure it's the correct one in the correct dose.

Children’s has 10 full-time emergency pharmacists, more than anywhere else in the country, and they’re on call 24 hours a day.

"Every single order I put in," Dr. Rustin Morse told NPR, "is reviewed in real time by a pharmacist in the emergency department prior to dispensing and administering the medication." Rustin is chief quality office and a pediatric ER doc.

That quality-control seems like a no-brainer, but especially in a busy ER, doctors treat fast and move on to the next patient. Writing down the name and quantity of a drug quickly invites mistakes. But in this ER, if that happens, it’s more likely a pharmacist will catch it.

Medication errors, as NPR notes, can be the result of poor handwriting, confusion between drugs with similar names, poor packaging design or confusion between metric or other dosing units. Often, more than one factor is involved.

That’s particularly dangerous for children because medication errors are three times more likely to occur with youngsters than adults. They absorb drugs at a different rate from adults.

So, for the nearly 20,000 drug orders processed at Children’s in a given week, pharmacists review all pertinent information — the child's weight, allergies, medications and health insurance coverage.

The electronic medical record system also automatically checks orders to prevent errors. You need both reviews, because neither human nor machine is infallible.

Dr. James Svenson, associate professor of emergency medicine at the University of Wisconsin, co-authored a study in the Annals of Emergency Medicine that found that even with an electronic medical record, 1 in 4 children's prescriptions had errors; 1 in 10 adult prescriptions also was wrong. So now, there’s a 24-hour ER pharmacist at Svenson’s hospital.

The reason most hospitals don’t embrace this practice is the usual one: money. "If you're in a small ER, it's hard enough just to have adequate staffing for your patients in terms of nursing and techs,” Svenson said, “let alone to have a pharmacist sitting down. If the volume isn't there, it's hard to justify."

But the investment has been proved to work. Researchers for the Journal of Pediatric Pharmacology and Therapeutics showed that prescription review can reduce the number of hospital readmissions. That not only saves money, but also lives.

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July 4, 2014

Warning of Suicide Risk with Antidepressants Had Unintended Consequences

Remember several years ago, when the FDA issued warnings about the risk of suicide for children and adolescents who were taking antidepressants? Well, stand by for an attitude adjustment. A study published last month in BMJ showed that the effort to save children probably harmed them instead.

The researchers tracked an increase in suicide attempts that seem to have been the result of depressed youngsters failing to seek treatment at all. They said the study shows how public health warnings that were intended to do good sometimes can backfire, especially if the subject is sensitive and gets a lot of media attention.

As the Washington Post recalled, the FDA issued warnings in 2003 and 2004 of an increase in suicidal thoughts among some children and adolescents who were taking a certain class of antidepressants (selective serotonin reuptake inhibitors, or SSRIs); you might recognize some of their brand names — Paxil and Zoloft.

So dire was the potential for harm that the FDA required manufacturers of the drugs to include a “black box” warning on the label. Such warnings denote the highest level of concern about side effects, including death. The warnings specified that the drugs presented an increased risk of suicidal thoughts and behaviors in youths who take them.

The media were all over this story, and the study’s researchers said the coverage focused more on the tiny percentage of patients with those thoughts than on the vastly larger number of youths who benefited from antidepressants.

After the warning, antidepressant prescriptions declined sharply among kids 10 to 17 years old, and among young adults from 18 to 29. Coincidentally, the researchers found, the number of suicide attempts rose by more than 1 in 5 among the younger group, and by more than 1 in 3 among the older group.

Of course the media’s lapel-grabbing headlines — “FDA links drugs to being suicidal” (New York Times), and “FDA confirms antidepressants raise children’s suicide risk” (The Washington Post) — “became frightening alarms to clinicians, parents and young people,” the researchers wrote. But consumers bore some responsibility as well.

“There was a sort of overreaction by the media, but also an excessive caution on the part of patients,” Christine Lu, a Harvard Medical School researcher and co-author of the BMJ study, told The Post. “Lots of people who needed treatment steered clear because of the fear factor. … For any drug, there are risks, for sure. But there’s also the risk of leaving the underlying condition untreated.”

Her team plotted the rise in suicide attempts by studying reports of nonfatal poisonings involving psychiatric medicines, which is a common indicator of attempted suicides. They thought the likely number of suicide attempts probably was much higher, because they didn’t track other suicide methods and poisonings that went unreported.

As The Post noted, the BMJ findings dovetail with a 2007 study in the American Journal of Psychiatry that showed a steep decline in antidepressant prescriptions after the feds issued the warnings.

That study didn’t prove that suicides rose as a direct result of fewer such prescriptions, but experts said there weren’t a lot of other explanations.

Despite their conclusion, the BMJ researchers don’t believe that the FDA was wrong in issuing the warning 10 years ago. But “FDA advisories and boxed warnings can be crude and inadequate ways to communicate new and sometimes frightening scientific information to the public,” they wrote.

And the researchers point out that media attention can raise awareness of medical situations people should know about, like the risk of Reye’s syndrome in children who are given aspirin. But, they said, sometimes “the information may be oversimplified and distorted when communicated in the media.”

Not every scientific mind agreed that advisories were too bold. In Discover magazine, an article by The Neuroskeptic titled “The FDA’s Antidepressant Warning Didn’t Really ‘Backfire,” took issue with the study’s conclusions:

“And while the authors never outright state that the FDA’s warning caused the extra suicide attempts,” it said, “they strongly imply that, using phrases such as ‘It is disturbing that after the health advisories, warnings, and media reports [...] we found substantial reductions in antidepressant treatment and simultaneous, small but meaningful increases in suicide attempts.’ “Are they right to be disturbed? By my reading – no. Their data just don’t support a causal effect.”
Neuroskeptic’s argument is interesting and rather geeky, and deserves consideration. The lesson here is that both regulators and the people who watch them must not be alarmists when communicating drug risks. And the lesson for parents with children who are depressed is to discuss frankly and fully the risks and benefits of all treatments. Like all drugs, antidepressants might be exactly what some people need, and not the best option for others.

It’s a matter of the degree of illness and managing its risk.

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June 27, 2014

New Rules Should Protect Quality of Baby Formula

Earlier this month, the FDA finalized new guidelines for manufacturers of infant formula in order to better protect babies from contaminated products. The move is a response to several prominent nationwide recalls of different formula products in the last several years.

As reported by, in 2010, 5 million containers of Similac were recalled by Abbott Laboratories because they might have been contaminated by insect parts. In 2011, powdered versions of Enfamil, made by Mead Johnson Nutrition, were yanked from store shelves over concerns of contamination, which later proved unfounded.

Still, the red flag was raised, and now companies that make baby formula will be required to test for the presence of two kinds of bacteria, salmonella and cronobacter, that pose serious health risks to wee ones. They’ll also have to monitor their products for a longer period.

Salmonella can cause diarrhea and fever, sometimes to a life-threatening degree; cronobacter, which prefers dry environments such as powdered formula, can cause swelling of the brain — meningitis — in infants.

Most public health officials and medical professionals say breast milk is best for babies, but for various reasons of both necessity and convenience, many mothers don’t breast feed. So, many infants get all or part of their nutrition from formula.

Baby formula is not subject to FDA approval prior to sale. But all formula sold in the U.S. must meet federal nutrient requirements, and they do not change with the new regs. Infant formula manufacturers are required to register with FDA, and notify the agency before they market a new formula.

The FDA conducts yearly inspections of all facilities that manufacture infant formula. It collects and analyzes product samples, and inspects new facilities. If the feds determine that a formula presents a risk to human health, its manufacturer must conduct a recall.

The new requirements, according to the FDA, are meant to establish the "good manufacturing practices" that many companies voluntarily follow. These regulations establish federally enforceable standards for safety and quality.

They apply to formula sold "for use by healthy infants without unusual medical or dietary problems," said the FDA.

Under the new rules, companies must test their products' nutrient content and prove that the formulas can "support normal physical growth," the agency said. They must test the nutrient content in the final product stage, before entering the market and at the end of the products’ shelf life.

According to FDA, about 1 million U.S. infants are fed formula from birth; by the time they are three months old, about 2.7 million rely on formula for at least part of their nutrition.

Infant formula comes in three forms:

  • powder — the least expensive of the infant formulas, it must be mixed with water before feeding;

  • liquid concentrate — must be mixed with an equal amount of water;

  • ready-to-feed — the most expensive form of formula that requires no mixing.

The protein source varies among the different types of formula. The FDA’s nutrient specifications are set to meet the nutritional needs of average, healthy infants. Manufacturers use nutrient levels that usually exceed the FDA minimum. So babies fed infant formulas don’t need added nutrients unless they are fed a low-iron formula.

The formulas currently available in the U.S are either “iron-fortified” — with about 12 milligrams of iron per liter — or “low iron” — with about 2 milligrams of iron per liter. The American Academy of Pediatrics (AAP) recommends that formula-fed infants be fed iron-fortified formula to help reduce the prevalence of iron-deficiency anemia.

To learn more about safety and infant formula, such as proper storage, visit the FDA website. To learn more about childhood nutrition, see our blogs on the topic.

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