Posted On: September 27, 2012

Getting Your Baby to Sleep

Earlier this year, our post about infants with breathing problems during sleep cautioned parents to monitor the quality of their baby’s slumber. But simply getting a baby to sleep and keeping him or her in a restful state can be one of the more bedeviling challenges of early parenthood.

A new study published in the journal Pediatrics might save some parents from constant worry if they’re getting bedtime routine right.

As reported on MedPage Today, certain behavioral techniques for getting babies to sleep by themselves, such as initially remaining in the child’s room, can be effective without any adverse emotional outcomes in the long term for either the kid or the parents.

The study followed up with 6-year-olds who had been studied as infants. Any problems with the youngsters were not significantly more common among those who had been “trained” to sleep alone versus those who hadn’t.

Many parents worry about long-term harm if they don’t respond immediately to a crying baby in a crib, having been influenced by older practices of letting a kid “cry it out” that causes harmful distress.

But the study showed that "camping out" to get kids to fall asleep and "controlled comforting" to help learn how to settle down on their own by gradually lengthening intervals at which parents respond to crying improved infants' sleep. It also reduced depression among mothers by 60 percent.

Among the 225 families followed through the child’s sixth birthday, there were no differences between the group that underwent behavioral training and the one that didn’t in outcomes for:

  • sleep habits;

  • parent-reported psychosocial functioning;

  • child-reported psychosocial functioning;

  • chronic stress as measured by cortisol (a hormone produced in response to stress) levels on a nonschool day;

  • child-parent closeness;
  • conflict between parent and child;

  • overall quality of the relationship between parent and child;

  • disinhibited attachment (emotionally and socially remote behavior);

  • depression, anxiety and stress scores in the mother;

  • authoritative parenting (deemed the optimal parenting style demonstrating warmth and control).

The researchers noted that their inability to follow up on about one-third of the families initially involved with infants meant the study couldn't rule out small harms or benefits long term. But, they concluded, “Nonetheless, the precision of the confidence intervals make clinically meaningful group differences unlikely."

“…[P]arent education programs that teach parents about normal infant sleep and the use of positive bedtime routines could effectively prevent later sleep problems," they concluded.

For more information, see “Getting Your Baby to Sleep” on the website of the American Academy of Pediatrics.

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Posted On: September 21, 2012

Does Your Kid Really Need Antipsychotic Drugs?

Whether it’s a marker of our “take a pill, solve a problem” mentality or a genuine effort to address a medical diagnosis with less than laserlike precision, a whole lot of kids are taking a whole lot of seriously psychotropic drugs for problems that don’t necessarily require them.

Psychotropic drugs alter perception, emotion and/or behavior. We’ve covered their misuse in general, but this study focused on children at doctors' offices. It followed a similar study last year that surmised that the increase of these powerful agents for youngsters was probably due to inpatient use.

As reported last month by Reuters, antipsychotic drugs are prescribed in nearly 1 in 3 of all visits by children and teens to psychiatrists in the U.S. That’s a significant increase from the 1990s, when it was about 1 in 11 such visits.

The study of this practice was published in the Archives of General Psychiatry. It concludes that the increase is the result of doctors prescribing the drugs for disruptive behaviors, such as attention deficit/hyperactivity disorder (ADHD), never mind that the FDA does not approve antipsychotics to treat those disorders in kids.

They are approved to treat schizophrenia, bipolar disorder and irritability with autism.

Use of them for other purposes is deemed “off-label,” which isn’t illegal, provided the drug manufacturers don’t promote them for such uses.

The study couldn’t say whether the prescriptions were unnecessary, but their effectiveness for disorders such as ADHD is uncertain. And, like all drugs, they carry the potential for side effects. Antipsychotic drugs can promote weight gain and have been linked to diabetes.

Last year, according to Reuters, a large study of children found that kids who took antipsychotic drugs were four times more likely to develop diabetes than their peers who weren’t taking them.

In September, an FDA advisory panel expressed concern about the drugs’ appropriateness for children, and urged the agency to monitor weight gain and metabolic diseases (diabetes) in children who take them.

Antipsychotic drug use is increasing across all demographic groups, but it’s most accelerated for children and teens. It’s difficult to cite exact numbers because the research concerns only prescriptions written during doctor office visits—clinics, community health centers or other facilities weren’t included. Another complication to being exact about antipsychotic drug use in children is that researchers don’t know how long each patient took the drug or if any prescription was written at a repeat visit by the same patient.

The new study’s lead author has his own prescription for parents whose children might be given an antipsychotic drug prescription at a doctor’s appointment. He advises them to ask more questions about the drugs—why is it being prescribed, what are the intended effects, how soon are they expected to appear, what are the side effects (see our blog, “Questions Patients Should Always Ask”)—and also if there are any alternative treatments.

He said psychosocial interventions (training for parents to manage the behavior from certain disorders) can reduce aggressive and disruptive behaviors in kids. But they take time, and they’re more expensive.

"Perhaps if they were more available, we wouldn't have as much use of these antipsychotic medications," he told Reuters.

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Posted On: September 14, 2012

Head Lice--An Icky Fact of Childhood, and What Parents Can Do

As autumn approaches, one of this season’s greetings is familiar to parents with younger school-age children: head lice. It’s one of the top five disorders for school-age children.

The little critters live on the scalp and feed on blood. Their eggs, or “nits,” attach to hair, most commonly on children ages 3 to 12. Their presence is completely democratic—anyone can be affected regardless of socio-economic status.

Lice don’t cause illness, but most people think they’re gross, and they’re annoying—there’s a lot of itching. Scratching an itch can break the skin and invite infection.

Lice can jump from one kid’s head to another nearby. That starts anew the egg-laying- itching cycle. An active lice infestation often prompts schools to send a child home to avoid spreading the creepy joy.

Lice must be removed and/or treated in some way. The insects jump and are elusive, but the nits attach firmly to strands of hair. A nit attached to the hair at scalp level is probably alive and must be treated or removed or it will hatch. If the nit has grown away from the scalp, the louse probably has hatched.

According to the Centers for Disease Control and Prevention (CDC), all members of a household where someone has head lice should be checked for the presence of an active infestation and treated if necessary. That involves removing lice and nits with a fine-toothed comb, and following up with medicine called “pediculicides.”

Combing can be tedious, but sometimes it’s sufficient to stop an infestation. Most often, though, a pediculicide is necessary. Some are available over the counter, others only by prescription. The first application kills active lice and must be repeated if all the lice don’t die. Additional treatment may be needed in seven to nine days to kill lice that have hatched from remaining nits.

Lice can develop resistance to certain chemicals, so if one pediculicide doesn’t work another might. If your child has lice, consult your pediatrician or the school nurse about the best treatments. The CDC site also provides guidance.

Because previous treatments haven’t worked or to avoid chemicals, some people try home remedies such as vinegar, isopropyl alcohol, mayonnaise and petroleum jelly. They seldom work.

Here are some lice-removal tips provided by the CDC:

  • Before applying treatment, remove clothing that can become wet or stained.

  • Apply pediculicide according to the instructions contained in the box or printed on the label. If the infested person has hair longer than shoulder length, a second bottle might be necessary. Pay special attention to instructions on the label or in the box regarding how long the medication should be left on the hair and how it should be washed out.

  • If a few live lice are still found 8 to 12 hours after treatment, but are moving more slowly than before, do not re-treat. The medicine may take longer to kill all the lice. Comb dead and any remaining live lice out of the hair using a fine-toothed nit comb. They’re often found in lice medicine packages, but many flea combs made for cats and dogs are also effective.

  • After each treatment, checking the hair and combing with a nit comb to remove nits and lice every couple of day might decrease the chance of self-reinfestation. Continue to check for two to three weeks to be sure all lice and nits are gone.

  • If you’re using the prescription drug malathion, re-treatment is recommended after seven to nine days ONLY if crawling bugs are found.

  • Do not use a combination shampoo/conditioner, or conditioner before using lice medicine. Do not wash the hair for a day or two after the lice medicine is removed.

Head lice can’t survive long if they cannot feed on someone’s scalp. So you needn’t spend a lot of time or money on housecleaning activities after treatment. To avoid re-infestation by lice that have fallen off the hair or crawled onto clothing or furniture:

1. Machine wash and dry clothing, bed linens and other items that the infested person wore or used during the two days before treatment using the hot water (130°F) laundry cycle and the high heat drying cycle. Clothing and items that are not washable can be dry-cleaned
sealed in a plastic bag and stored for two weeks.
2. Soak combs and brushes in hot water (at least 130°F) for 5 to 10 minutes.
3. Vacuum the floor and furniture, particularly where the infested person sat or lay even though the risk of getting infested by a louse that has fallen onto a rug or carpet or furniture is very small.
4. Do not use fumigant sprays; they can be toxic if inhaled or absorbed through the skin.

Some common treatments can cause skin or eye irritation. Call the poison center if a child swallows lice shampoo or medicine or if someone splashes these products into the eyes. The 24-hour number is (800) 222-1222.

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Posted On: September 7, 2012

When Should an Emergency Department Transfer a Child for Specialized Care?

Of the 27 million trips children make to U.S. emergency departments each year, about 7 million are at a rural ED or one that’s a considerable distance from a dedicated children’s hospital. For children critically ill with certain problems, of course, prompt transfer to a pediatric intensive care until improves the chances for positive outcomes.

In recent years, according to Christopher Johnson, a pediatric intensive care physician writing on, the medical establishment has begun to establish a system of transporting these sick kids to regional critical care centers. That’s good. Not so good, Johnson says, is an increasing tendency to routinely transfer children from an ED not dedicated to pediatric care to one that is. Such transfers aren’t always necessary from a medical point of view, and present unnecessary risks and costs.

This kid shuffle, Johnson warns, might be signaling an unwillingness of general purpose EDs to provide basic pediatric care. That’s unacceptable. Misfortune is an equal age-opportunity reality.

Johnson refers to a recent article published in the journal Pediatrics that studied what happened to children after they arrived at an emergency department. Researchers wanted to know how ED resources were being used in the younger demographic.

Of the children transferred from the facility where they presented to another that provided specialized care, nearly 1 in 4 was discharged directly from that ED, and 17 in 100 were admitted to the hospital for less than 24 hours.

Because a significant number of the transferred kids had been discharged to go home, they probably could have been treated appropriately at the ED that sent them someplace else.

Johnson says you shouldn’t overlook the fact that sometimes a pediatric subspecialist at the second facility (say, a pediatric cardiologist), simply has the expertise to make the call for discharge that a less qualified doctor doesn’t.

But, he adds, “I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.”

Johnson suggests that continuing to regionalize pediatric care is important in addressing the potential patient harm of such resource abuse. Regionalizing, he says, enables doctors in nonpediatric EDs to have easy access to specialists by phone or telemedicine links for remote consultation. This happens now, but only informally; codifying the process would improve care.

Medical emergencies are difficult enough without having to wonder if the care you get is sufficient or the advice to transfer is sound. But if you find yourself in a situation in which the emergency department wants to send your child to a facility that specializes in pediatric care, ask why. Find out what the doctors suspect is the problem and why they are unable to treat it. Ask about the availability of a remote consultation with a specialist.

Sometimes, that’s not possible and sometimes a transfer is the best medicine. But if it’s not, there’s no reason to assume unnecessary risk or cost.

To learn more about emergency medicine—what requires immediate, critical attention—see our backgrounder.

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