Posted On: November 30, 2012

Our Annual Hazardous Toy Review

For the last couple of years in advance of the holiday season, we have blogged about choosing safe toys here and here.

Last week, the U.S. Public Interest Research Group (USPIRG) released its 27th annual report, “Trouble in Toyland” in conjunction with the Consumer Product Safety Commission (CPSC). Here are some highlights to help you be a popular Santa’s helper while protecting the small fry from danger.

Some hazards never change: size (so small they present a risk for choking); toxins (lead, cadmium, phthalates); magnets (we recently blogged about their gastrointestinal danger.) Others are new: high volume of sound.

Among the more widely available toys deemed dangerous in “Trouble in Toyland” are plastic play food sold at Wal-Mart and Toys-R-Us (choking hazard) and Dora the Explorer guitar (hearing risk) sold at Target. For the full list, see the report.

In general, beware of toys posing these common hazards:

1. Choking. It’s the most common cause of toy-related deaths. According to the CPSC, from 2005-2009 at least 41 children choked to death on balloons, toys or toy parts.


  • Don’t buy small toys or toys with small parts for children younger than 3. If it can pass through a toilet paper tube, a toy or part is too small for toddlers and babies and any child who still puts things in his or her mouth.

  • Read and heed warning labels: Toys with small parts intended for children ages 3 to 6 are required to include an explicit choking hazard warning.

  • Never give young children small balls or balloons: They can block a child's airway. Balls for children younger than 6 must be larger than 1.75 inches in diameter. Never give latex balls to children younger than 8.


2. Lead and Other Toxic Chemicals. Some toys and children’s cosmetics may contain lead or other toxic chemicals, including phthalates. Most such chemicals are being phased out of toys, but older toys may still contain them.

Avoid toys made of PVC plastic, which can contain toxic phthalates; they pose developmental hazards. Choose unpainted wooden or cloth toys instead. High levels of lead paint have been found on toys, as well as in vinyl lunch boxes, bibs and in children's costume jewelry. All lead should be removed from a child's environment, especially lead jewelry and toys that can be swallowed. Use a home lead tester available at hardware stores to see if anything in your home presents this danger.

Read the labels of play cosmetics and avoid products with xylene, toluene or dibutyl phthalate.

3. Magnets. New, powerful small magnets used in most magnetic building toys, darts, magnetic jewelry and other items can fall out and look like shiny candy. If a child swallows more than one, they can cause life-threatening complications. If a child swallows even one magnet, seek immediate medical attention.

4. Watch or "Button" Batteries. Keep watch or "button" batteries away from children. If swallowed, the battery acid can cause fatal internal injuries.

5. Noise. Children's ears are sensitive. If a toy seems too loud to you, it’s probably too loud for a child. Remove the batteries from loud toys or cover the speakers with tape.

6. Strangulation. They include mobiles, cords and drawstrings. Keep them out of the reach of children in cribs and remove them before the baby is five months old or can push himself or herself up.

Remove knobs and beads from cords longer than one foot to prevent the cords from tangling into a dangerous loop. Don’t buy clothing with drawstrings on the hood—they can get caught on fixed objects like playground equipment and pose a strangulation hazard.

Tips for keeping kids safer:


  • Accessorize. Children should wear protective gear when riding bicycles, scooters, skateboards and inline skates. If your gift list includes them, also give a helmet, knee pads, elbow pads and wrist guards.

  • Stay informed of recalls. The CPSC recalls numerous toys and children's products each year. Find out what’s been recalled here. You can also sign up to receive email alerts of new recalls.

  • Visit this interactive website with tips for safe toy shopping. It also has recall information and is accessible via smartphone.


To report a dangerous toy, email the CPSC, file your comments on its website or call (800) 638-2772.

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Posted On: November 23, 2012

Study Supports Using the Toilet Training Method that Works for You

For a lot of parents, toilet training is an early focus of worry about inflicting psychological harm on a child. Everyone, it seems, has an opinion about how to accomplish human housebreaking, and all the things that can go wrong if you don’t do it their way. But relief is in sight: A recent study published in Clinical Pediatrics concludes that a kid’s urinary accidents are unrelated to the method his or her parents use for toilet training.

But they do recommend starting toilet training sooner rather than later.

“Our study,” the authors wrote, “showed that the method used for toilet training had no association with the development of dysfunctional voiding symptoms. This information may be helpful for parents of children with dysfunctional voiding who feel guilty for using the wrong training method. Further research should be conducted to [refine] the toilet training methods in order to find any significant difference, but as of now, parent-oriented and child-oriented toilet training should be considered equally effective.”

The researchers also concluded that earlier toilet training, between the ages of 24 and 32 months, is more important for reducing the risk of urinary concerns that whatever method parents use.

According to the study, children undergo toilet training at a later age now than in the past. In 1980, the average age was 25 to 27 months; in 2003, it was 36.8 months. Some studies have indicated that the later age has a negative impact, that late toilet training might be more difficult for parents because the child is more likely to resist their efforts to train. That can cause problems, such as constipation, daytime accidents (a “voiding dysfunction”) and infection.

One recent study showed that children with symptoms of voiding dysfunction (which also includes the frequent or urgent need to urinate) were toilet trained later than children who didn’t have these problems. But the delay can have a benefit—it produced the toilet training approach that follows a child’s readiness to participate rather than forced learning.

The study defines two broad categories of toilet training—parent-oriented and child-oriented. The former was more common before 1960; it supports early toilet training with firm parental direction, often using rewards to support the desired result and punishments or withdrawal of positive reinforcement to negatively reinforce accidents. The child-oriented approach is when a kid shows interest and willingness to learn to use the toilet, generally around 18 months of age or later. It praises success and avoids punishment. Both methods have myriad modifications, though, that might include rewards or the withdrawal of rewards to encourage kids to get with it.

The new study followed 215 children ages 4 to 12. Both genders were represented. Parental reports and medical examinations were included. The study compared the methods of training in two groups. The control group of 147 subjects had no urinary problems after training was completed. The other group of 58 subjects showed voiding dysfunction.

No association was found between the method used and urinary symptoms that may have followed training.

“Our study reveals that the decades of debate about the preferred method of training was not based on scientific evidence, but rather expert opinion,” said the lead researcher. “The evidence presented in our research should help ease parents’ concerns that if their child has urinary difficulties, it might be the result of incorrect training or the training method chosen. It isn’t.”

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Posted On: November 16, 2012

Sleep-Deprived Teen Athletes Suffer More Injuries

When you’re sleepy you’re more likely to make mistakes. And, it appears from research presented last month at a conference of the American Academy of Pediatrics, lack of sleep puts adolescent athletes at greater risk of injury.

Researchers studied middle- and high-school athletes in grades 7 to 12 for nearly two years. They found that those who slept eight or more hours every night were significantly less likely—68 percent—to be injured playing their sports than those who regularly slept less.

The study admittedly was small—it surveyed kids at only one California school. And it relied on students remembering and communicating accurately. But the premise, really, is a no-brainer: Insufficient sleep is not good for you, in many ways.

In addition to their sleep habits, students were asked about what sports they played, the time they spent playing sports either at school or in other programs, if they used a private coach, if they participated in strength training and how much they enjoyed their athletic endeavors. Split nearly evenly between boys and girls, 112 of the 160 students completed the survey, which was done in conjunction with Children’s Hospital Los Angeles.

The study’s author, Dr. Matthew Milewski, said, “While other studies have shown that lack of sleep can affect cognitive skills and fine motor skills, nobody has really looked at this subject in terms of the adolescent athletic population.”

In addition to hours of sleep per night being clearly associated with the incidence of injury, results showed that the higher the grade level of the athlete, the higher the likelihood of injury. Each additional grade level was associated with a 2.3 higher chance of getting hurt playing sports. No other element—gender, duration/hours of participation, number of sports played, strength training, private coaching or “fun” factor—showed a significant association with injury.
Milewski said that the association between higher grades/ages and increased chance of injury might reflect the cumulative effect of playing sports for several years as well as the fact that older kids are bigger, faster and stronger.

As reported on MedPage Today, the injuries involved multiple body parts. Most common, however, were injuries to the hand or wrist, knee, shoulder, ankle, back and head.

More than 38 million children participate in organized sports each year, according to MedPage Today. Approximately 1 in 10 is treated for a sports injury. Milewski said about half of all injuries probably are related to overuse, and half of those are probably preventable.

During the school study, nearly 6 in 10 athletes were injured; nearly 4 in 10 were hurt multiple times.

As MedPage reports, the Centers for Disease Control and Prevention and the National Sleep Foundation define insufficient sleep for high schoolers as fewer than eight hours per night. And the eight-hours threshold in this age group, Milewski said, is regularly missed—approximately 7 in 10 high schoolers don’t sleep that much. More than 3 in 4 four students involved in the survey said they slept fewer than eight hours. (See our post about how teenagers’ love of texting contributes to sleep deprivation.)

If parents needed another reason to nag their kids, the greater risk of getting hurt at play is a pretty good one: Tell your kid to log off of Facebook, turn off the smartphone and go to bed.

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Posted On: November 9, 2012

Older Kids Need to Use Booster Seats in Cars

Compelling evidence was presented last month at an American Academy of Pediatrics (AAP) conference that booster seats can save lives for kids in cars until they've reached close to adult stature (4 feet 9 inches tall).

As reported on MedPageToday, states that implemented booster seat laws recorded a decline in serious injuries from motor vehicle crashes for children 4 to 8 years old. States that lacked such regulations saw no changes in the same study period.

Although the study has not been published in a peer-reviewed journal, and therefore is considered preliminary, it’s hardly the first to confirm the wisdom of strapping children into booster seats. But it also supports the idea of using the seats for older children.

The AAP recommends that children be secured in a belt-positioning booster seat until they reach 4 feet, 9 inches in height. Usually, that’s between the ages of 8 and 12.

There is no federal effort to standardize booster-seat laws.

In the 10-year study, “Booster Seat Laws Reduce Motor Vehicle Fatalities and Injury,” there were 9,848 fatalities and incapacitating injuries in children ages 4 to 8. The rate of death and incapacitating injuries declined 20 percent for children 4 to 6 in states with booster seat laws, and 33 percent for kids 7 to 8. Children 4 to 6 with no or improper restraint were twice as likely to suffer death or an incapacitating injury, and members of the older group were four times as likely compared with properly boostered kids.

Children 4 to 6 who were restrained only by a lap/shoulder belt were 20 percent likelier to suffer death or an incapacitating injury, and 70 percent likelier if they were 7 or 8.

According to the Governors’ Highway Safety Association:


  • All 50 states, the District of Columbia, Guam, the Northern Mariana Islands and the Virgin Islands require child safety seats for infants and children fitting specific criteria.

  • Forty-eight states and the District of Columbia require booster seats or other appropriate devices for children who have outgrown their child safety seats but are still too small to use an adult seat belt safely.

  • The only states lacking booster seat laws are Florida and South Dakota.

  • Five states (California, Florida, Louisiana, New Jersey and New York) have seat belt requirements for school buses. Texas requires them on buses purchased after September 2010.


To find out more about the laws in your state, link here. For information about car seats and installation tips, visit the American Academy of Pediatrics site, and our post about rear-facing seats.

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Posted On: November 2, 2012

Off-Label Drugs Commonly Given to Intensive Care Patients

At the American Academy of Pediatrics conference last month, a researcher presented a paper that should give pause to anyone receiving or delivering treatment in a pediatric intensive care unit (PICU).

Susan Sorenson, who holds a doctorate in pharmacy, studied the use of 335 different drugs used in a PICU over a five-month period and found that 3 out of 4 were prescribed “off-label” at least once. “Off-label” is the practice of prescribing a drug for a condition or demographic other than the one for which it received FDA approval. Doctors have the right to so prescribe, and it’s often appropriate to do so, but the drug manufacturer may not promote a drug for any use other than what the FDA granted.

But as described in a report on MedPage Today, what appears to be a routine practice exposes patients to medications that may not have been adequately studied in children. Even if some compounds are suitable for pediatric use, if they haven’t been studied for that population it can be difficult to determine the proper dose and know the possible side effects and risks.

The study has not been published in a peer-reviewed journal, so it should be considered preliminary. The study group was limited to a single, 32-bed facility in Salt Lake where nearly all the patients (96 percent) were given a drug off-label at least once.

Drugs were considered to have been used off-label when prescribed for patients whose ages were not listed on the label, when no pharmacokinetic data (how drugs behave in the body over a period of time) were listed for the patient's age or when they were used for a disorder not approved by the FDA. The study involved 490 patients with ages ranging from 4 days to 17 years.

The most common medications prescribed off-label were morphine, ondansetron (Zofran, for the nausea and vomiting caused by chemotherapy and radiation treatments ), metoclopramide (Reglan, for heartburn and esophageal problems associated with gastroesophageal reflux disease), dopamine (for a wide variety of problems including shock, low blood pressure/heart attack, trauma and infections) and fentanyl (for breakthrough pain from cancer; that is, sudden pain that occurs despite other, ongoing analgesic treatment).

Recent legislation, including the the FDA Modernization Act (FDAMA) and the Best Pharmaceuticals for Children Act (BPCA), has addressed the issue of improved labeling for pediatric drugs. But, Sorenson told MedPage Today, “There’s still some work to do.”

We’ve written about the difficulty in researching and labeling drugs for pediatric applications and the fact that not even half of drug labels carry child-specific information.

Since passage of the BPCA in 2002, only 14 of 40 drugs with the highest number of off-label medication orders during the study have had labeling changes; 19 still lack safety and efficacy information for a pediatric population.

That seems like a roadmap of where to go next, but as Sorenson said, most of the drugs used in the study are off-patent, so it will be difficult to find funding to perform such expensive studies. If manufacturers cannot monetize new or additional research, they’re not motivated to conduct it.

There is some legislative relief: The BPCA extends patent protection for six months if a drug manufacturer agrees to perform pediatric studies. That can be added to the six months of market exclusivity granted by the FDAMA for performing studies in children.

If your child is in the PICU, closely monitor whatever drugs the doctors prescribe. Ask what they are, why they are being given, what is their intended effect and if they have been tested specifically for children or if they are being prescribed off-label. If the latter, ask if there are alternative therapies. And always ask what are the potential side effects and harms.

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