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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June 20, 2014

CDC Says Parents Who Opt Out of Vaccinations Are Spreading Measles

A disturbing number of parents refuse vaccinations for their children because they believe immunization poses a risk of autism. They don’t believe the science proving not only the wisdom of being immunized, but the folly of the autism claim. And the consequences of their actions are beginning to emerge. In the first five months of this year, 288 cases of measles were reported to the Centers for Disease Control and Prevention (CDC).

That’s the highest year-to-date total in 20 years.

The CDC report was clear that the reason for measles’ renewed vigor in the U.S. was because more people are rejecting vaccination — 200 of the 288 cases occurred in unvaccinated people. And in 1 of 5 of the rest, vaccination status couldn’t be determined, so the 200 figure could well be low.

Measles is not just an inconvenient episode of itchy, red skin bumps. It can lead to pneumonia, encephalitis and even death, especially for children and infants.

Loyola University Health System in Chicago is renowned for its work in infection control and prevention. In a statement last month, Dr. Jorge Parada, its medical director for infectious disease, said, “People who consciously opt out of vaccines are depending on herd immunity — that enough other people will get vaccinated so as to prevent infection — which seriously undermines the herd immunity they depend on for safety. It's a numbers game, and America is losing ground in the fight against preventable disease.”

People in the anti-vaccination movement generally are affluent, educated and privileged. They have no excuse for choosing to be ignorant. They are vocal, but why anyone grants them a bully pulpit is mystifying. That question was plumbed by a recent episode on TV’s satiric “Daily Show," which was at once hilarious and painful.

We’ve regularly expressed our astonishment that people are so eager to accept bunk; that they are not, in fact, protecting their children from autism by withholding vaccinations, but instead are increasing their risk — and that of other people — of measles, polio and whooping cough. (See our blogs, “Feds Say Childhood Vaccine Schedule Is Safe and Effective” and “More Proof That Vaccines Have Nothing to Do With Autism.”)

The CDC noted that the three largest outbreaks of measles so far this year “occurred after introduction of measles into communities with pockets of persons who were unvaccinated because of philosophical or religious beliefs.”

“Religious, philosophical or personal reasons are not medical reasons for not getting vaccinated,” Parada said. And although that’s a harsh judgment, it’s based on concern for society at large.

Sometimes, the individual must sacrifice for the greater good, but in this case, it’s not even about sacrifice — when the reasons behind the anti-vaccination movement have been proved to be bogus, the only thing you’re sacrificing by doing the responsible thing is willful ignorance.

Some people have legitimate medical reasons for not being immunized — they might be allergic, or pregnant, for example. (See the CDC’s guide to who should not get vaccinated here.) These are the people most vulnerable to contracting disease when others opt not to protect themselves.

People who shun vaccination play the odds that they won’t get sick, but do they have the right to play with other peoples’ odds?

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June 13, 2014

Turning Normal "Spitting Up" Into a Disease

When does typical baby behavior become medically treatable baby behavior? When misguided doctors and scared parents promote it from what is normal to something that sounds ominous and urgent.

An essay published in the New York Times by Dr. Aaron E. Carroll says that calling an ordinary health problem a disease leads to bigger problems, and a primary example of it is brought to you by way too many people who care for babies.

Babies spit up. A lot. About half of all healthy infants, Carroll says, spit up more than twice a day. More than 9 in 10 completely stop this behavior without treatment. “When a majority of infants have (and have always had) a set of symptoms that go away on their own, it isn’t a disease — it’s a variation of normal,” Carroll writes.

Infants vomit more often than older people because their diet is all liquid, because they eat frequently and because their developing esophagus isn’t quite closed off from their small stomachs. Milk leaks back into the esophagus, producing symptoms of gastroesophageal reflux, one of which is regurgitation.

Gastroesophageal reflux disease (GERD) is different from this common baby behavior. Children with GERD are truly ill, but they are rare. “But over time,” Carroll says, “more and more babies with reflux were labeled as having a ‘disease.’ The incidence of a diagnosis of GERD in infants tripled from 2000 to 2005.”

We have a term for that, and readers of our patient safety blog will recognize it: disease-mongering. As defined by the journal PLoS Medicine it’s “the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments.”

Carroll is familiar with the phenomenon. “When I was a pediatrics resident,” he writes, “my hospital constructed foam wedges for infants to sleep on. The thinking was that infants who were sleeping at an angle would be less likely to have milk come back up.

“The wedges cost about $150. They didn’t work.”

Carroll’s pediatric colleagues have tried other ways to control infant regurgitation — special infant seats; thickened food; special formulas. “None of these things really work,” he concludes. “An incredible amount of time and money has been wasted.

“The bigger problem, though, is that the vast majority of these infants weren’t ‘sick.’ We just gave them an official diagnosis. This labeling of patients with a ‘disease’ can have significant consequences, for both people’s health and the nation’s health-care budget.”

Drugs, of course, play a large role in disease-mongering. Infants may be treated with a group of drugs called proton pump inhibitors (PPIs). You might recognize some of their brand names — Nexium, Prilosec, Prevacid and Protonix. Between 1999 and 2004, the use of one liquid PPI increased more than 16-fold, Carroll reports, never mind that PPIs have not been approved by the FDA for the treatment of GERD in infants.

In 2009, a randomized, controlled trial whose results were published in The Journal of Pediatrics examined how well a PPI worked for infants with symptoms of GERD. It found that the drug had no more of an effect than a placebo, or fake, inert pill. But — and here’s the harm of disease-mongering — the children who took the PPI had significantly more serious adverse events, including respiratory tract infections.

Another study Carroll recalls was published last year in the journal Pediatrics. The researchers randomly chose parents who were told either that their baby’s reflux was GERD or was, instead, “a problem.” Half of each of group also was told that medications were ineffective.

Parents who were told that their kid had GERD were far more interested in having their child take medication, even when they were told that it was ineffective. Parents of babies who were not labeled with GERD weren’t interested in medication when they were told it didn’t work.

“Words matter,” Carroll says. “Studies have shown that once people with high blood pressure are labeled ‘hypertensive,’ they are significantly more likely to be absent from work, regardless of whether treatment was begun. Many diseases have become so much broader in definition that they now encompass huge swaths of the public.”

But medicalizing normal variations in physiology so that they become “treatable conditions” leads to unintended — and unwelcome — consequences. Needless worry. Treatments with unpleasant and possibly dangerous side effects. Unnecessary costs.

As one of Carroll’s colleagues puts it, “Our job as doctors is to make sick patients healthy, not to make healthy patients sick.”

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June 6, 2014

Dangerous Flame Retardant Chemicals Are Everywhere

Parents of small children know that day care centers and preschools are notorious providers of germs the whole family can share, but what they might not be aware of is that they also pose a danger because their furnishings often are treated with flame retardants.

The chemicals in flame retardants, polybrominated diphenyl ethers (PBDEs) and tris phosphate compounds, have been linked to hormone disruption and lower IQs in children. According to a study published in the journal Chemosphere, they were found in 100% of the dust samples collected from 40 child care centers serving more than 1,760 children in Northern California.

As reported by the San Francisco Chronicle, the study was conducted by researchers from the University of California, Berkeley’s Center for Environmental Research and Children’s Health. They said that the results were representative of what's found in many homes and other environments because the chemicals have been widely used for decades in the polyurethane foam inside upholstered furniture.

In the early 1970s, California imposed requirements that upholstered furniture be manufactured with flame retardant chemicals. Those measures became standard elsewhere as well. But they were changed to enable flammability standards to be met without the use of the chemicals. As we noted earlier this week in our Patient Safety blog, “Burn Surgeon’s Testimony Tainted by Conflict of Interest,” chemical industry interests have tried to promote these dangerous substances using unsavory and misleading means.

Although PBDEs have been banned in California for almost a decade, they’re still found in older furniture and other products. And in many cases, their replacement was chlorinated tris, never mind that it had been removed from children's pajamas in 1977, according to The Chronicle, after it was found to mutate the DNA of people exposed to it. In California, it’s considered a carcinogen, or cancer-causing substance.

The Chemosphere study found levels of PBDEs in the child-care facilities to be somewhat lower than what previous studies found in residences. But the amounts of chlorinated tris were similar or higher than household levels found in other reports.

The authors said that the higher tris levels probably were found in the mats children use for napping, as well as in furniture. Of the facilities studied, 29 had upholstered furniture and 17 had napping mats made of foam.

To minimize your child’s exposure to these chemicals:

  • Choose natural fiber wall coverings instead of paint.

  • Use cleaning supplies without harsh chemicals.

  • Maintain a low level of dust.

  • Cover childrens' mats with cotton sheets.

And don’t despair: Despite the study's results, Asa Bradman, its lead author and an environmental health scientist, told The Chronicle, "People shouldn't panic and feel like child care is toxic for children."

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