November 28, 2014

Ground-Breaking Study of Kids' Health Could Be Grounded

Devised by Congress in 2000, the National Children’s Study (NCS) was designed to track the health of children from birth to adulthood in an effort to identify the best ways to prevent childhood disorders including asthma, autism and attention deficit disorder. But it’s in danger of being stopped before it even starts, thanks to cost, mismanagement and outdated research methods.

The study was supposed to begin this year, as explained by KaiserHealthNews.org (KHN), and was considered to be boldly ambitious. Advocates say it could influence a wide range of parental choices, from what to feed their kids to what household products to buy. They say its potential is endless for preventing illness that presents later in life, and probably will influence not only parents, but insurance coverage and public policy.

“We don’t have the evidence we need to truly improve children’s health in this country. We need this study. … The importance of the investment is clear,” Lisa Simpson told KHN. She’s president and CEO of AcademyHealth, a membership group of policy analysts and health services researchers.

The study is to follow 100,000 children for 21 years. But it’s expensive, and some people believe its scientific approach is antiquated. According to KHN, experts from the National Institutes of Health (NIH) are studying these concerns, and they’re due to make recommendations next month about the initiative’s future.

The impetus behind the study was a growing sense that children suffer disproportionately from the effects of social and environmental factors. In 2007, the Vanguard Study began a precursor to the NCS, sort of a smaller, beta version. It is underway in 40 sites testing how to recruit women who expect to be pregnant in the near future, and testing data systems.

But it’s been a rocky adventure, KHN reports, and in July, the Institute of Medicine, the nonprofit, independent organization that advises government and the public with unbiased and authoritative analysis, issued a report questioning whether the main study should proceed if it didn’t undergo major changes.

The Vanguard Study’s own researchers criticized its design and technological deficiencies.

Still, Jane Holl told KHN, “It could tell us so much about relationships — starting in the prenatal period through late childhood — and how those factors affect early adulthood.” Holl oversees 10 of the 40 pilot sites.

In 2013, federal funding for the research was put on hold for the main study after Congress appropriated $165 million per year for it — $30 million less than initially planned. It made that money contingent on the IOM evaluation, which focused the study’s advocates on the NIH recommendations, and how to make less money go farther.

It would be a shame if this truly novel idea disappeared into dust. Usually, research focuses on adult illnesses, so studying children until adulthood and figuring out how to prevent later problems would be a significant addition to the body of health science.

“If I’m a member of Congress,” James Perrin told KHN, “I’m more concerned about heart disease at 50 years old, and that’s where we’ve funded it more actively. We need to know what we can do in childhood,” said Perrin, who is president of the American Academy of Pediatrics.

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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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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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February 28, 2014

The Facts About Fever

Parents are wired to beware of fever in their children. But their fear often is misplaced.

According to Melissa Arca, a pediatrician writing on KevinMD.com, a moderately elevated temperature is not necessarily a bad thing; in fact, it can be beneficial. Lots of kid problems cause fever — the flu, colds, croup, ear infections…. The better you understand the reasons a child is feverish, and the purpose fever serves, the better you will be able to determine a minor problem from one that your doctor should address.

Arca offers four fever facts that should help you tell the difference between one that needs hot soup, and one that needs a doctor’s care.

1. Fever is a symptom, not a disease.

Fever is a reaction to illness. It’s a warning to rest and drink fluids. Treating your child’s fever won’t “cure” whatever infection he or she is fighting. “Think of it like disabling your car’s ‘oil change needed’ light,” Arca suggests. “Sure, you can turn off that light but it doesn’t negate the fact that your car’s oil still needs changing.”

Even if you suppress the fever — for example, with ibuprofen — the child still needs time to rest and recover from the infection.

2. Fever can wax and wane for three or four days.

Most fevers persist for a few days before they completely depart. So even if you treat it with acetaminophen or ibuprofen, expect it to recur after a few hours. That’s normal.

3. The number on the thermometer is not as important as how your child looks and feels.

Arca knows that most parents get a little panicked when their child’s temperature reaches 103 or 104. But that number does not communicate the seriousness of the illness. So resist the panic. Give the child a fever reducer for comfort and keep him or her well-hydrated. Fever makes the heart beat faster and increases the child’s insensible water loss (fluids lost through the skin and respiratory tract). Keep a bottle of water by the bed, and anywhere else your child is resting.

Remember, the goal is to help the child feel better, not to get rid of the fever.

4. A true fever is a temperature of 100.4°F (38°C) or higher.

Children’s temperatures naturally fluctuate throughout the day. So knowing what is a true fever is important.

In summary, resist the urge to treat a slight temperature elevation. Remember, says the National Institutes of Health, fever is an important part of the body's defense against infection because most bacteria and viruses that cause infections in people thrive at 98.6 °F. Many infants and children develop high fevers with minor viral illnesses, and although that’s a signal of the body waging battle, the fever is a weapon favoring the child. So unless you’re dealing with a temperature of 102°F or higher fever, let the fever run its course and provide comfort through fluids.

Brain damage from a fever generally doesn’t occur with fever less than 107.6 °F (42 °C). Untreated fevers caused by infection seldom exceed 105 °F unless the child is overdressed or trapped in a hot place.

Arca says these red flags demand a pediatrician’s intervention:


  • infants younger than 3 months with rectal temperatures of 100.4°F or higher;

  • fever that persists more than five days;

  • your child just doesn’t look well, is having difficulty breathing or has had a febrile seizure (one caused by fever);

  • your child’s fever is 105°F or higher. Although such a high temperature usually isn’t harmful, it merits a call to the pediatrician and the right dose of acetaminophen or ibuprofen.


Because acetaminophen, especially, can be harmful to youngsters, see our blog about proper dosages here.

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February 21, 2014

How to Avoid a Shopping Cart Injury

Parents with kids in tow welcome the use of shopping carts to contain the offspring as well as the merchandise. But as a recent report by NBC News notes, the convenience of a cart should come with a big dose of caution.

According to a study recently published in Clinical Pediatrics by Nationwide Children’s Hospital in Ohio, 66 children are hurt in shopping cart mishaps every day. “That’s one child injured badly enough every 22 minutes to go to the emergency room, or more than 24,000 children a year,” said NBC.

Voluntary safety standards for shopping carts were implemented in 2004, and they’ve had about as much effect as you would expect — none. In fact, it’s worse than none. The number of concussions each year resulting from shopping carts injuries to children younger than 15 jumped nearly 90% — almost double — according to data collected from 1990 to 2011 by Dr. Gary Smith, director of Nationwide’s Center for Injury Research and Policy.

“This is a setup for a major injury,” Smith told NBC. “The major group we are concerned about are children under 5.”

Newborns to 4-year-olds accounted for more than 8 in 10 injuries. More than 7 in 10 accidents were by falling out of the carts. Other common accidents were running into a cart, and carts tipping over.

It’s easy for a parent to focus on the shopping if he or she believes the child is secure, but a moment’s inattention can be tragic. “A wiggly baby in an infant seat or a toddler reaching for a bright box of cereal can easily cause a fall that results in serious injury,” NBC explained. “Children’s center of gravity is high, their heads are heavy and they don’t have enough arm strength to break a fall.”

Smith said the lack of stability standards for U.S. shopping carts that have been adopted in other countries is a contributing factor to the high incidence of injury. But that doesn’t means parents can’t improve the safety of a shopping trip. To be safe:


  • If possible, choose alternatives to placing your child in a shopping cart.

  • Always use using the shopping cart safety belts. Ensure that the child is snugly secured in the straps and that his or her legs are placed through the leg openings. If parts of the cart restraint system are missing or are not working, choose another cart.

  • Use a cart that has a child seat low to the ground, if one is available.

  • Make sure your child remains seated.

  • Stay with the cart and your child at all times.

  • Don’t place infant carriers on top of shopping carts. If the child isn’t old enough to sit upright in the shopping cart seat, use a front- or back-pack carrier, or a stroller.


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January 24, 2014

Sharing Is Good, Except for Germs

If there’s an echoing theme among parents with small children, it might be “Don’t put that in your mouth, you never know where it’s been.” As it turns out, according to a new study, bacteria are in a lot of places you don’t expect them to be, despite your best efforts.

As published in the journal Infection and Immunity and interpreted on AboutLawsuits.com, the study by researchers from the University of Buffalo suggests that cultures of certain bacteria can linger on cribs, toys, books and other children’s items long after scientists originally thought was possible, posing a potential risk of spreading common infections.

Researchers analyzed cultures, or biofilms, of Streptococcus pneumoniae and Streptococcus Pyogenes, and found that bacteria survived outside of the human body, the typical host necessary for growth, and they lasted for months as viable forms of infection.

S. Pyogenes is the culprit behind strep throat and skin infections. S. Pneumoniae attacks the respiratory tract, ears and other sites common among children and elderly people, and can cause death.

The researchers tested surfaces and items kids touch every day. There were high levels of both types of bacteria many hours after the surfaces had been cleaned; 4 in 5 stuffed toys tested positive for S. Pneumoniae and other surfaces yielded colonies of S. Pyogenes.

Because bacteria might survive in environments other than the human body, they have the potential to be continually infectious. The thinking used to be that their transmission required humans to breathe in infected bodily excretions from sneezing or blood exposure.

Rethinking cleaning procedures seems to be in order for day care facilities, schools, home nurseries and hospitals.

The best defense against this kind of bacterial exposure is what experts have preached forever: Wash hands often — yours and your kids — and use warm water and soap. Lather for at least 20 seconds.

Wash hands especially after touching particularly germy surfaces, such as toys, door handles, faucets, computer keyboards, touch screens and remote controls. Try not to touch your face after touching these surfaces.

Ask the people who look after your children — day care providers, baby sitters, teachers — what they do to prevent little ones from sharing the things they shouldn’t. Simply letting these folks know that you’re interested in hygiene can help them adhere to a healthful regimen.

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October 25, 2013

When Kids Get Headaches

Almost everyone gets the occasional headache, even children. Almost always, they’re insignificant in the grand scheme of health.

As described on KevinMD.com by Dr. Roy Benaroch, a pediatrician and author of “A Guide to Getting the Best Health Care for Your Child,” so-called “primary” headaches are those without a specific cause or association to a specific medical condition.

Often, he writes, headaches in children are are caused by a minor infection, dehydration, hunger or stress. “If they’re recurrent,” Benaroch says, “they’re likely to be one of the common primary headaches, like tension headaches or migraine or chronic daily headache. Headaches that are progressive (worsening), or associated with other prominent or worsening symptoms, need an urgent medical evaluation, but those are fortunately rare. More typically, headaches just need to be treated like, well, headaches.”

And what does that mean? As is often the case, it’s simple: a kiss to make it better, rest, a cool compress, something to help the kid relax. “In the long run,” Benaroch says, “those are probably better headache remed[ies] for children than any medication.”

Benaroch’s primer on primary headaches:

Migraine. This might be the most common of the more severe headaches. In children it’s often bilateral (not limited to one side of the head, as is common with adult migraines), and fairly brief. Sometimes it’s accompanied by vomiting, and gets worse with light or sound. Often the best treatment is to go to sleep. Migraines often run in families.

Tension. This creates a constricted feeling in the head, and isn’t usually severe. Kids of all ages get tense.

Chronic daily headache. This often occurs in addition to occasional more severe headaches, like migraines.

To treat chronic daily headache:


  • Avoid daily Advil or Tylenol. Using them more than three days a week perpetuates the headaches.

  • Follow a healthful lifestyle—good, regular sleep, sound diet without a lot of preservatives and chemicals, regular exercise.

  • Try not to miss school; it makes headaches worse.

  • Consider massage/yoga/relaxation therapy.

  • Address any depression/anxiety/mood issues. They often have a psychological component, either contributing to the headaches, or being caused by the headaches and missing school and activities.

  • Consider a daily medicine to control the headaches. Not painkillers, but meds that prevent headaches, which require a physician’s guidance.

CT scans are almost never necessary for chronic, ongoing, stable headaches, which come and go in a stable pattern. Imaging is useful only for acute, worse-in-a-lifetime headaches, those associated with other symptoms, such as seizures, or progressively worse headaches. CTs (or MRIs) are completely unnecessary in the workup of most children with headaches, and will sometimes give misleading results that lead to overtesting and misery. (See our blog, “CT Scans for All Kids with Head Injuries?”)

Most people who believe they have sinus headaches don’t. Truly recurrent sinus headaches are uncommon. When they do occur, they’re associated with persistent nasal congestion and cough that precede the headache. Migraines, which are far more common than recurrent headaches from sinusitis, can cause nasal or sinus symptoms that begin about the same time as the headache.

Another uncommon association with recurrent headaches in kids is vision problems. Some nearsighted people squint, and by the end of the day might develop pain from contracting the muscles of their face and scalp, but that, too, is uncommon.

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