Posted On: July 27, 2012

Must-Ask Questions Before Your Kid Undergoes Dental Anesthesia

Regular readers of this blog and our companion blog on patient safety are familiar with our concern about medical providers that are as interested in beefing up their receivables as they are in delivering high-quality care. Doctors with financial interests in medical testing equipment, for example, and pharmaceutical companies that promote their drugs for uses beyond that which the FDA has approved deserve our disdain.

Now, pediatric dentistry has come under the scrutiny of ABC News, and parents should be aware of the stories it’s telling.

Some inadequately trained dentists seeking to enhance profits, the network reports, sedate their young patients inappropriately for treatments as simple as teeth cleaning. More than a dozen children have died after being sedated by dentists, according to the Raven Maria Blanco Foundation, an organization founded by the parents of an 8-year-old who died after a routine dental appointment. The foundation’s mission is to alert parents to the potential dangers of the increasingly widespread use of oral sedatives on patients as young as 18 months.

Dental oversight is disjointed – there is no standard certification for the administration of oral sedatives, and state regulations vary. Some states require only a weekend course for dentists to be certified. There is no national registry of dental deaths, and many deaths may go unreported or not attributed to dental sedation.

Raven Blanco died after her dentist, Dr. Michael Hechtkopf, gave her "three times the average range" of sedatives, according to the Virginia Board of Dentistry. Five-year-old Diamond Brownridge died after being sedated before having cavities filled and teeth capped. Her dentist, Dr. Hicham Riba, administered an excessive dose of sedatives and demonstrated no understanding of conscious sedation, according to the Illinois Board of Dentistry.

Parents, of course, want to spare their children the discomfort of medical procedures if they can. Dental professionals say sedation for routine procedures can make it safer to work on young, anxious patients who make it difficult or dangerous to use high speed drills and other equipment. The well-meaning combination can spell danger.

Extensive training is required to learn how to administer sedation safely and be prepared to deal with emergencies. Dr. Norbert Kaminski told ABC "This is something that is being presented to the practitioners, the dental community, as a very easy thing to do, and nothing could be further from the truth." Kaminski is a dental anesthesiologist who has sought tougher standards for dentists who use sedation on patients.

In the last five years, the news network said, more than 18,000 dentists across the country have taken weekend courses in oral sedation in local hotel ballrooms that promise to add tens of thousands of dollars to the bottom line. That isn’t what Kaminski has in mind.

"Pain-free dentistry can mean tens of thousands of dollars of extra income in your pocket annually, and as much as half a million extra in your pocket at retirement," wrote Dr. Michael Silverman, a dentist and entrepreneur whose company offers the weekend seminars. American Academy of Pediatric Dentistry spokesperson Dr. Indru Punwani told ABC that a weekend course is "inadequate" for preparing dentists to deal with emergencies that can arise through the use of oral sedatives.

To protect your child against careless, ill-informed or greedy dentists, ask these questions provided by the American Dental Association (ADA) about sedation or anesthesia for children.

Before the procedure:

  • Who will provide the pre-operative evaluation of my child including past medical history such as allergies, current prescription medications and previous illnesses and hospitalizations?

  • How long should my child should be without food or drink before the procedure? Are there exceptions for certain medications?

  • Will any sedation medication be given to my child at home before the appointment and, if so, how the child be monitored?

  • What training and experience does the sedation/anesthesia professional have in providing the level of sedation or anesthesia that is planned for the procedure? Does this training and experience meet all of the standards of the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists?

  • Does the assisting staff have current training in emergency resuscitation procedures, such as Basic Life Support for Healthcare Providers and other advanced resuscitation courses as recommended by the ADA guidelines? How often is the training regularly renewed?

  • Does the state dental board require a special sedation/anesthesia permit or license to administer the sedation/anesthesia you plan to use?

  • In addition to the use of local anesthesia (numbing), what level of sedation or general anesthesia will be given to my child? Is it minimal sedation (relaxed and awake), moderate sedation (sleepy but awake), deep sedation (barely awake) or general anesthesia (unconscious)?

  • How will my child be monitored before, during and after the procedure until the child is released to go home? Are the appropriate emergency medications and equipment immediately available? Does the office have a written emergency response plan for managing medical emergencies?

After the procedure:

  • What are the instructions and emergency contact information if I have concerns or complications after returning home?

If the answers are incomplete or unacceptable, find another dentist.
Link here for information provided by the Raven Maria Blanco Foundation, and here for our recent story about good oral health for infants.

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Posted On: July 20, 2012

Antibiotics and ADHD Drug Use in Kids

A recent study conducted by the FDA presented a good-news/huh?-news scenario about what drugs are given to children. As reported by Reuters Health, in the last decade, the number of drugs prescribed for minors in the U.S. has declined. That contrasts with the increase in drugs prescribed for adults.

Although antibiotics use fell significantly, the use of drugs to treat attention deficit hyperactivity disorder (ADHD) rose. The good news relates to antibiotics, whose decline, one hopes, indicates an increasing awareness that these drugs are regularly overused, a practice that encourages the growth of drug resistant microbes.

The huh? news concerns ADHD. The stimulants prescribed to treat it, such as Ritalin (methylphenidate), lead the pack for children’s drug use. From 2002 to 2010, the use of these meds grew by nearly half, which adds up to about 800,000 prescriptions per year. More than 4 million Ritalin prescriptions were filled in 2010.

One professional camp sees this growth as positive. Dr. Scott Benson, a child and adolescent psychiatrist and spokesman for the American Psychiatric Association, told Reuters that the study results suggest “reduction in the stigma. It used to be, ‘You're a bad parent if you can't get your child to behave, and you're a doubly bad parent if you put them on medicine.'"

But Dr. Lawrence Diller, a behavioral pediatrician, saw things differently. Pointing out that the U.S. is the clear world leader in the use of these drugs, he said, “You have to look at how our society handles school children's problems. It's clear that we rely much, much more on a pharmacological answer than other societies do. The medicine is overprescribed primarily, but under-prescribed for certain inner-city groups of children."

As we reported a few years ago, there have been questions about ADHD drugs for a long time, and the medical establishment’s prescribing habits for them.

The new study showed that, overall, 263 million prescriptions for minors were filled in 2010, down by 7 percent since 2002. Adult prescriptions in the same period increased by 11 percent. In addition to the decline in antibiotic prescriptions for children, there were notable decreases in prescriptions for allergy medicines, cough and cold drugs, painkillers and antidepressants. In addition to ADHD drugs, other increases were tallied for asthma medicine and birth control pills.

As Reuters noted, the FDA couldn’t explain the reasons behind the changes.

A new resource for parents interested in ADHD research and treatment options is available here from the U.S. Department of Health and Human Services.

As always, when your doctor prescribes a drug for your child, ask:

  • Why is this drug being prescribed?

  • What are the potential side effects and risks?

  • How long should it take to see results?

  • What do you expect to happen if the child does not take the drug?

  • Are there alternative treatments?

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Posted On: July 13, 2012

Trade Group Tantrum Undermines Play Yard Standards

In 1998, a 17-month-old boy confined in a folding Playskool Travel-Lite play yard at his day-care provider’s home died when the side rails collapsed around his neck. The play yard had been recalled, but the caregiver was unaware.

Last year, a 3-month-old girl was snoozing in a bassinet that was snapped onto the side of her play yard. Because the assembly was not proper, the bassinet somehow detached, tilted and pushed her face into the mesh side of the play yard. She suffocated.

We’ve written about injuries associated with cribs and playpens, and the tragedies noted above were remembered, according to a story in the Washington Post, when the Consumer Product Safety Commission’s (CPSC) mandated new safety standards for folding play yards last month. The problems that caused the first accident were addressed; the problems that caused the second were not.

The CPSC ensures the safety of approximately 15,000 consumer products. At least 19 deaths have been tied to the side rail defect that killed the little boy, and about 1.5 million portable cribs with the defect have been recalled. them. Deaths declined as the industry embraced stricter standards, but some of the pre-standard models remain unaccounted for, according to Kids in Danger, an organization founded by the parents of the little boy who died.

Since 1985, according to The Post, there have been 20 recalls of play yards—also known as pack-and-plays—representing numerous deaths. The play yard safety standards approved last month require that portable cribs be tested to ensure such serious hazards have been addressed, but in certain quarters, the bassinet accessory dangers aren’t considered serious enough.

“It’s disheartening that we couldn’t get this taken care of,” Nancy Cowles, executive director of Kids in Danger, told The Post.

Congress approved a bill in 2008 that added muscle to the CPSC. One element requires the agency to strengthen some voluntary standards. The play-yard standards were among them, and regulators had been working with the industry to effect the necessary product changes.

Shortly after the CPSC heard about the baby girl’s death, the relationship between the guards and the guarded deteriorated. The CPSC added language making it more difficult to assemble a play yard with missing parts, which contributed to the baby’s death last year. One proposal required manufacturers to stitch all the parts together so that none could go missing.

In May, the Juvenile Products Manufacturers Association (the industry’s trade group) requested that the provision take effect later than originally intended. The CPSC agreed. In June, however, half an hour before the commission held a briefing on the standards, it received a letter from the JPMA accusing the CPSC of violating the law because it hadn’t solicited public comment on that provision.

The commission now plans to deal with this issue separately, and in a statement after the decision, the JPMA said it is pleased with that outcome. It also promoted itself as a guardian of kid safety:

“Each year, JPMA sponsors Baby Safety Month in September to educate parents and caregivers on the importance of the safe use and selection of juvenile products. Baby Safety Month 2012 is dedicated to helping educate parents and caregivers on the importance of safely using second hand, hand-me-down, and heirloom baby gear.”

This expressed concern for child safety would have more credibility if those articulating it would do the right thing instead of standing on ceremony.

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Posted On: July 6, 2012

Detergent Packs a Poison for Curious Kids

Packaging is a key part of consumer appeal, but a certain attractively designed laundry product can be far more problematic than a resistant ketchup stain.

As widely reported, including on NPR, the small, brightly colored single-use packets of laundry detergent—sometimes called detergent pods—can look like candy to a toddler or small child. When a kid bites into one, a burst of concentrated, corrosive detergent is released. Several hundred cases of illness have been reported this year. In California alone, 82 cases were reported through May.

According to the American Association of Poison Control Centers, youngsters who swallow the packets can become ill enough to require hospitalization. Some get the product in their eyes, resulting in significant irritation. Among the reports of children biting into a packet:

  • A 20-month-old child vomited profusely, wheezed and gasped, then became unresponsive to even painful stimuli.

  • A 15-month-old vomited profusely and had to be put on a ventilator at a hospital.

  • A 17-month-old rapidly developed drowsiness, vomited, breathed the product into the lungs and had to be put on a ventilator.

After sampling the detergent, kids can get sick in a hurry. They can grow excessively fatigued, lethargic and develop breathing difficulties. Symptoms of ingestion are worse than those seen from ingesting other types of detergent. Medical professionals aren’t certain why, but it might have to do with a constituent of the packets acting as a strong, short-acting sedative.

The good news is that symptoms generally resolve within a few hours, and the prognosis for full recovery is good, provided that the children get prompt care to support their breathing difficulties.

No deaths have been reported, and data from poison control centers is developing—the specific hazards of ingesting detergent packets were recognized only in the last couple of months.

A review in California found that the two most common single-dose detergent brands that children have consumed are Tide Pods Detergent and Purex Ultra Packs. But many other brands are marketed, and all should be considered as dangerous to children. Tide Pods is redesigning its packaging to make it more difficult to breach.

Parents and caregivers should ensure that detergent packets are treated like medication—they should not be accessible to children. If you suspect a child has had dangerous contact with a detergent packet, contact the poison control center at (800) 222-1222. If breathing difficulties develop, seek immediate care.

Apart from the new concern over detergent packets, there is good news from the harms department of household cleaning products: Injuries are declining. From 1990 to 2006, such misadventures declined from 22,000 to 12,000. Wee ones from 1 to 3 years old remain the most vulnerable to these accidents, representing nearly 3 in 4 incidents.

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