I recently reread an article that I thought poignantly summarized how food allergies should be approached by a clinician. Although the article was written in 2010, the information is scientifically sound and current. I bolded the recommendations as written by the author and added some commentary where appropriate. Parents can use this information to assess whether their doctor is appropriately advising them on how to approach the work-up of their child's food allergies (or lack thereof).
From Medscape Allergy & Immunology,
Food Allergy: What You Need to Know by Stephanie A. Leonard, MD, Posted: 11/15/2010.
1. Delaying of potentially allergenic foods until 1, 2, or 3 years of age has not been shown to prevent food allergies. In 2008, the American Academy of Pediatrics amended their earlier position and no longer recommends avoidance of such foods as a preventive measure.
There was an excellent study done in the Journal of Clinical Immunology in 2008 showing that early consumption of peanuts in infancy is associated with a lower prevalence of peanut allergy. Essentially, the study looked at the prevalence of peanut allergies in Jewish children in the UK (where peanuts are avoided in infancy) vs Jewish children in Israel (where peanuts are fed in infancy). The UK had a 10 fold higher prevalence in peanut allergies.
2. Food allergic patients, especially those with a new diagnosis, should be seen by an allergist for complete work-up, education, and management. Children can outgrow their food allergies, and yearly monitoring is warranted.
A complete work-up should include a thorough history and possibly skin testing and/or blood work. The skin tests and blood work are NOT highly accurate when used as a stand-alone test. They must be analyzed in conjunction with a good history and exam to achieve the most accurate diagnosis. Testing by itself will lead to 50% false positives.
3. Specific food IgE levels can be measured after careful history-taking identifies potential allergens. The focus should be on foods ingested within 2 hours leading up to an acute reaction or foods that appear to consistently exacerbate eczema.
IgE levels are the most common blood tests done to help identify food allergies. Common names for the IgE blood test are the RAST (RadioAllergoSorbent Test) or the ImmunoCAP test.
4. Specific food IgE testing panels are not recommended because of the occurrence of false positives and the potential for foods that an individual has been tolerating to be unnecessarily removed from their diet.
Removing healthy foods that a child has been tolerating well, simply because a test shows a possible allergy can make a family's life unnecessarily difficult and possibly hurt the overall nutritional value of a child's diet. Again, a thorough history and exam with the guidance of an experienced allergist should help prevent unnecessary diet modifications.
5. Removing a previously tolerated food from a patient's diet solely on the basis of an elevated specific IgE can put the patient at risk for developing an actual clinical allergy to that food.
Not only could you make your life more difficult than necessary, you may actually create a true food allergy when there was not one to begin with.
6. An undetectable specific food IgE level is not a guarantee that an individual is not allergic. If the history is suggestive, skin testing should be performed (and possibly an oral food challenge as well) before the food is ingested again.
In addition to false positives, the blood tests may also show FALSE NEGATIVES - meaning even though the blood test was negative, a true food allergy may exist. Again, a thorough history and exam with an allergist is important.
7. Specific food IgE levels help to predict the likelihood of reactivity but not the type or severity of reaction. The significance of the levels varies among foods, so they are not comparable.
The level of IgE is often misinterpreted as the higher it is, the more allergic the individual is to that certain food. Many of the "levels" are extrapolated from other foods and have not actually been individually calibrated; therefore the severity of allergy CANNOT be accurately measured by a blood test.
8. Food allergic individuals should carry 2 self-injectable epinephrine devices and antihistamine at all times in case of emergency. Self-injectable epinephrine devices should be renewed once a year.
The newer epipen injection devices are now coming in two-packs. They should NOT be split up. The two-packs are necessary because in 20% of anaphylactic reactions there will be a SECOND phase to the reaction necessitating a second epipen injection. Children should be monitored for 4-6 hours after the first injection to ensure another dose in not needed. Ideally, you will already have sought medical care in an appropriate setting by the time a second reaction occurs, but it is prudent to be prepared.
9. Epinephrine given for an allergic reaction is most effective when administered intramuscularly into the thigh muscle. Corticosteroids are not useful in the acute management of an allergic reaction because of slow onset, but they might prevent biphasic or protracted reactions.
Corticosteroids are oral steroids that can be given by injection or orally (as a liquid or pill).
10. Adolescents and patients with a history of asthma are at higher risk for fatal anaphylaxis and require additional education. Delay of epinephrine is also a risk factor for fatal anaphylaxis.
Teenagers are at highest risk because they are most likely not to have their epipen when needed or they fail to understand how dangerous a food allergy truly can be.
11. Food allergies have a profound effect on quality of life, and support groups and Websites of food allergy organizations (such as the Food Allergy and Anaphylaxis Network, or FAAN) can be useful.
Food allergies can be a big deal and when they have been appropriately diagnosed by an experienced allergist, the child must be seen regularly and proper precautions must be taken. However, improper use of blood tests and skin tests can lead to restrictive lifestlyes and possibly create a food allergy when there was not one to begin with. As always, judicious use of tests at the appropriate time will lead to the best results and healthiest child.
Friday, May 25, 2012
Friday, March 2, 2012
Post #29 Mom and Dad are on antibiotics, why not the kid?
Let's start with the kid.
Fact: Bacterial illnesses typically need antibiotics. Viral illnesses do not.
Antivirals help in certain rare cases - but for the purposes of this blog I will assume a typical viral illness encountered in a primary care physician's (PCP) office.
Your average child per the Centers for Disease Control and Prevention (CDC) will encounter 6-12 viral illnesses a year (typically colds and stomach bugs) and most of these will be concentrated during the wintertime when viruses tend to spread more easily due to humidity and temperature factors.
What this means is your child will be sick a lot - especially during the winter; and antibiotics will not help any of these viral illnesses. Of course should your child have a bacterial illness (often preceded by a viral illness) they should be prescribed antibiotics. The typical bacterial illnesses encountered in a PCP's office include: ear infections, pneumonia, sinus infections, and skin infections.
The majority of the sick children that I see on a daily basis have a fever or symptoms from a virus. I educate the parents on what a virus is, why antibiotics will not help, and what to look for in case the viral illness progresses to become a bacterial illness - in which case they will need to return to be placed on antibiotics. Overtime, my parents become adept at distinguishing the child who appears viral and the child who seems to have something a bit more serious. This in turn saves them visits to my office and decreases their overall expenditure of time and money - not too mention a significant reduction in frustration.
But every so often, a parent mentions that their adult PCP prescribed them some antibiotics for their recent illness and they wonder out loud why I am not following suit.
It is a fair question. Most of the time from my cursory visual exam of a parent I think to myself it is unlikely the mom/dad needs to be on antibiotics and thus ensues a dance to explain why I don't recommend antibiotics for colds, but perhaps the adult has something more serious - but in truth I suspect most of the time they have the exact same cold as their kid.
So why the discrepancy?
Let's move on to the adult.
The most common reason that an adult is prescribed antibiotics is for bronchitis or sinusitis.
The following information on bronchitis and sinusitis is straight from Up To Date, a website that most doctors trust and pay a hefty annual sum to access.
Bronchitis
Acute bronchitis is one of the most common conditions encountered in clinical practice. Acute bronchitis is a self-limited inflammation of the bronchi due to upper airway infection. Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production.
Acute bronchitis is one of the most common conditions associated with antibiotic misuse. This respiratory condition is generally caused by a virus. However, reports indicate that more than 60 to 90 percent of patients with acute bronchitis who seek care are given antibiotics.
Guidelines from the American College of Physicians and the Centers for Disease Control and Prevention (CDC) are intended to dissuade clinicians from prescribing antibiotics for acute bronchitis. Both guidelines state unequivocally that pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis. However, the frequency of prescriptions for antibiotics for acute bronchitis has decreased only modestly, from approximately 75 to 60 percent in the past decade. Additionally, the choice of antibiotics prescribed for the treatment of acute bronchitis has changed substantially during the same time span. Prior to 1990 approximately 20 percent of antibiotics prescribed for the treatment of acute bronchitis were broad spectrum; more recently approximately 60 percent of all prescriptions written for this condition were for broad-spectrum agents.
MICROBIOLOGY — The usual causes of acute bronchitis are viral infections of the upper airways including influenza A and B, parainfluenza, coronavirus (types 1-3), rhinovirus, respiratory syncytial virus, and human metapneumovirus.
Although it has been suggested that the bacterial pathogens that cause pneumonia (eg, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, or even gram-negative bacilli) can also cause acute bronchitis, there is no convincing evidence to support the concept of "acute bacterial bronchitis" caused by these pathogens in adults. An exception is in patients with airway violations such as tracheostomy or endotracheal intubation, or those with exacerbations of chronic bronchitis.
Sinusitis
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa.
Acute rhinosinusitis is further specified as acute bacterial rhinosinusitis (ABRS) or acute viral rhinosinusitis (AVRS).
The most common etiology of ARS is a viral infection associated with the common cold. Viral rhinosinusitis is complicated by acute bacterial infection in only 0.5 to 2.0 percent of episodes. Uncomplicated AVRS typically resolves in 7 to 10 days. ABRS also is most commonly a self-limited disease, with 75 percent of cases resolving without treatment in one month.
Distinguishing AVRS of colds and influenza-like illnesses from bacterial infection is a frequent challenge to the primary care clinician. Antibiotics may be indicated for ABRS, but are ineffective and not recommended for AVRS. Despite the overwhelming prevalence of a viral etiology, however, 92 percent of patients in the United Kingdom and 85 to 98 percent of patients in the United States (US) are prescribed an antibiotic when seen for an upper respiratory or sinus infection.
As you can see, for both bronchitis and sinusitis antibiotics are rarely needed in the adult patient. Bronchitis, unless caused by pertussis (uncommon), does not need antibiotics and less than 2% of sinusitis cases are caused by a bacteria.
However, the statistics repeatedly show a high prescription rate of antibiotics for both conditions.
Why?
1. Adults in general are more willing to try medications because they are less concerned about side effects. With their kids they are more scrupulous with what they feed them.
2. Even if the success rate is low, adults feel more pressure to return to work and are willing to get any advantage they can in feeling better sooner.
3. Past success with antibiotics makes adults assume future illnesses continue to require them.
4. Adult doctors know this is what patients expect and they do not want to lose business.
5. Some adult doctors are not aware of the Up To Date information posted above.
6. Educating a patient about the difference between a virus and a bacteria and the statistics on bronchitis and sinusitis can be time consuming.
7. Some doctors feel safer treating all patients with antibiotics so that they do not risk missing the 2% of sinusitis cases that are actually caused by bacteria.
8. Placebo effect.
Over the years, I have convinced many of my close friends and parents of patients of the above information. This has saved them trips to their doctors, co-pays, trips to the pharmacy, money spent on antibiotics, and unnecessary side effects incurred.
Of course, this is not to say that antibiotics are never needed. But just as my patient's parents have become astute with when their kids have something greater going on than a typical cold, adults too can become more in tune with their own body's illnesses.
Overtime, this will lead to better health and less frustration. Antibiotics are one of the greatest advances of modern medicine, but they are powerful tools that need to be utilized judiciously.
And often if your pediatrician is not recommending an antibiotic for your child, chances are you don't need one either.
Fact: Bacterial illnesses typically need antibiotics. Viral illnesses do not.
Antivirals help in certain rare cases - but for the purposes of this blog I will assume a typical viral illness encountered in a primary care physician's (PCP) office.
Your average child per the Centers for Disease Control and Prevention (CDC) will encounter 6-12 viral illnesses a year (typically colds and stomach bugs) and most of these will be concentrated during the wintertime when viruses tend to spread more easily due to humidity and temperature factors.
What this means is your child will be sick a lot - especially during the winter; and antibiotics will not help any of these viral illnesses. Of course should your child have a bacterial illness (often preceded by a viral illness) they should be prescribed antibiotics. The typical bacterial illnesses encountered in a PCP's office include: ear infections, pneumonia, sinus infections, and skin infections.
The majority of the sick children that I see on a daily basis have a fever or symptoms from a virus. I educate the parents on what a virus is, why antibiotics will not help, and what to look for in case the viral illness progresses to become a bacterial illness - in which case they will need to return to be placed on antibiotics. Overtime, my parents become adept at distinguishing the child who appears viral and the child who seems to have something a bit more serious. This in turn saves them visits to my office and decreases their overall expenditure of time and money - not too mention a significant reduction in frustration.
But every so often, a parent mentions that their adult PCP prescribed them some antibiotics for their recent illness and they wonder out loud why I am not following suit.
It is a fair question. Most of the time from my cursory visual exam of a parent I think to myself it is unlikely the mom/dad needs to be on antibiotics and thus ensues a dance to explain why I don't recommend antibiotics for colds, but perhaps the adult has something more serious - but in truth I suspect most of the time they have the exact same cold as their kid.
So why the discrepancy?
Let's move on to the adult.
The most common reason that an adult is prescribed antibiotics is for bronchitis or sinusitis.
The following information on bronchitis and sinusitis is straight from Up To Date, a website that most doctors trust and pay a hefty annual sum to access.
Bronchitis
Acute bronchitis is one of the most common conditions encountered in clinical practice. Acute bronchitis is a self-limited inflammation of the bronchi due to upper airway infection. Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production.
Acute bronchitis is one of the most common conditions associated with antibiotic misuse. This respiratory condition is generally caused by a virus. However, reports indicate that more than 60 to 90 percent of patients with acute bronchitis who seek care are given antibiotics.
Guidelines from the American College of Physicians and the Centers for Disease Control and Prevention (CDC) are intended to dissuade clinicians from prescribing antibiotics for acute bronchitis. Both guidelines state unequivocally that pertussis is the only indication for antibacterial agents in the treatment of acute bronchitis. However, the frequency of prescriptions for antibiotics for acute bronchitis has decreased only modestly, from approximately 75 to 60 percent in the past decade. Additionally, the choice of antibiotics prescribed for the treatment of acute bronchitis has changed substantially during the same time span. Prior to 1990 approximately 20 percent of antibiotics prescribed for the treatment of acute bronchitis were broad spectrum; more recently approximately 60 percent of all prescriptions written for this condition were for broad-spectrum agents.
MICROBIOLOGY — The usual causes of acute bronchitis are viral infections of the upper airways including influenza A and B, parainfluenza, coronavirus (types 1-3), rhinovirus, respiratory syncytial virus, and human metapneumovirus.
Although it has been suggested that the bacterial pathogens that cause pneumonia (eg, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, or even gram-negative bacilli) can also cause acute bronchitis, there is no convincing evidence to support the concept of "acute bacterial bronchitis" caused by these pathogens in adults. An exception is in patients with airway violations such as tracheostomy or endotracheal intubation, or those with exacerbations of chronic bronchitis.
Sinusitis
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa.
Acute rhinosinusitis is further specified as acute bacterial rhinosinusitis (ABRS) or acute viral rhinosinusitis (AVRS).
The most common etiology of ARS is a viral infection associated with the common cold. Viral rhinosinusitis is complicated by acute bacterial infection in only 0.5 to 2.0 percent of episodes. Uncomplicated AVRS typically resolves in 7 to 10 days. ABRS also is most commonly a self-limited disease, with 75 percent of cases resolving without treatment in one month.
Distinguishing AVRS of colds and influenza-like illnesses from bacterial infection is a frequent challenge to the primary care clinician. Antibiotics may be indicated for ABRS, but are ineffective and not recommended for AVRS. Despite the overwhelming prevalence of a viral etiology, however, 92 percent of patients in the United Kingdom and 85 to 98 percent of patients in the United States (US) are prescribed an antibiotic when seen for an upper respiratory or sinus infection.
As you can see, for both bronchitis and sinusitis antibiotics are rarely needed in the adult patient. Bronchitis, unless caused by pertussis (uncommon), does not need antibiotics and less than 2% of sinusitis cases are caused by a bacteria.
However, the statistics repeatedly show a high prescription rate of antibiotics for both conditions.
Why?
1. Adults in general are more willing to try medications because they are less concerned about side effects. With their kids they are more scrupulous with what they feed them.
2. Even if the success rate is low, adults feel more pressure to return to work and are willing to get any advantage they can in feeling better sooner.
3. Past success with antibiotics makes adults assume future illnesses continue to require them.
4. Adult doctors know this is what patients expect and they do not want to lose business.
5. Some adult doctors are not aware of the Up To Date information posted above.
6. Educating a patient about the difference between a virus and a bacteria and the statistics on bronchitis and sinusitis can be time consuming.
7. Some doctors feel safer treating all patients with antibiotics so that they do not risk missing the 2% of sinusitis cases that are actually caused by bacteria.
8. Placebo effect.
Over the years, I have convinced many of my close friends and parents of patients of the above information. This has saved them trips to their doctors, co-pays, trips to the pharmacy, money spent on antibiotics, and unnecessary side effects incurred.
Of course, this is not to say that antibiotics are never needed. But just as my patient's parents have become astute with when their kids have something greater going on than a typical cold, adults too can become more in tune with their own body's illnesses.
Overtime, this will lead to better health and less frustration. Antibiotics are one of the greatest advances of modern medicine, but they are powerful tools that need to be utilized judiciously.
And often if your pediatrician is not recommending an antibiotic for your child, chances are you don't need one either.
Saturday, January 28, 2012
Post #28 Respiratory Syncytial Virus (RSV) - Dispelling Some Myths
One of the common fear-inducing germs that moms ask me about during the wintertime is the Respiratory Syncytial Virus more simply known as RSV. Most moms correctly recognize the germ as a potentially devastating illness, however there are some common misconceptions about the germ that I would like to clarify.
Probably the most common misconception is that RSV is always dangerous; while RSV can be dangerous it typically is not. RSV is one of many known viruses which causes the common cold (there are over 200). The majority of people who acquire RSV will go on to have typical cold symptoms including cough, runny nose, and possibly fever. Most people will recover within a few weeks without any long term complications.
However, the very first time a human being catches RSV, there is a higher probability of lung involvement leading to either bronchiolitis (inflammation of the small airways) or pneumonia (inflammation of the lungs involving the air sacs); as such the younger you are the more likely you will have lung involvement with an RSV infection. Additionally, there is greater risk of severe disease in children who were born premature (especially less than 35 weeks gestation).
So if your child is younger than 6 months of age and in particular if they were under 35 weeks gestational age when born, there is greater risk of serious illness from an RSV infection.
The older your child becomes three things will favor them against serious complications:
1. There immune systems will mature.
2. They will become physically larger (as will their airways).
3. They will encounter the RSV germ repeatedly giving them greater antibody protection with each subsequent illness.
It should be noted that the elderly are also affected more significantly by RSV than a healthy young adult, however as a pediatrician I do not have any expertise in this population.
The second common misconception is that RSV can be avoided - it cannot. Almost every child will become infected with RSV at least once by their second birthday and reinfection is common.
RSV, like other cold viruses, is spread through respiratory droplets (i.e. sneezes and coughs) but more commonly it is spread via direct contact with other infected children and the surfaces they touch. It really is a matter of WHEN and not IF your child will catch RSV. As stated above, children's bodies handle RSV better as they get older.
Thus if your child is a preemie and/or they are under 6 months of age, it makes sense to take some precautions to delay the initial onset of the inevitable first acquisition of RSV. Typical hygienic habits are what serve you best: washing hands, portable hand cleanser, and covering sneezes appropriately (elbow method is best).
The last misconception is not as common and is not really a true misconception. As a pediatrician, I am often asked whether RSV lung infection will increase the risk of asthma in the future. The short answer is - it's complicated.
A good way to think about this is the chicken or egg analogy.
Do kids that are more prone to asthma genetically have a greater propensity of having lung involvement with their very first RSV infection?
Maybe.
Or does an early infection with RSV increase the chances of having asthma later in life?
Maybe.
One of those statements is likely true and possibly both. The research has not definitively answered either question adequately and we will likely never know for sure. What we do know is that RSV infection in the lungs (everyone eventually gets it but not everyone gets involvement of the lungs) has some correlation with recurrent wheezing. But we also know that long-term there are no permanent changes found in the lungs of these same children - at least not as a result of RSV.
The bottom line is that your child will catch RSV at some point in their life and it will likely manifest itself as nothing worse than the common cold. However if your child is under 6 months of age and particularly if they were born premature, healthy hygiene may prevent lung involvement and thus reduce the risk of serious illness. Finally, should your child have lung involvement with their RSV illness, they have a greater risk for recurrent wheezing, however the RSV germ should not cause long-term changes in their lungs.
Probably the most common misconception is that RSV is always dangerous; while RSV can be dangerous it typically is not. RSV is one of many known viruses which causes the common cold (there are over 200). The majority of people who acquire RSV will go on to have typical cold symptoms including cough, runny nose, and possibly fever. Most people will recover within a few weeks without any long term complications.
However, the very first time a human being catches RSV, there is a higher probability of lung involvement leading to either bronchiolitis (inflammation of the small airways) or pneumonia (inflammation of the lungs involving the air sacs); as such the younger you are the more likely you will have lung involvement with an RSV infection. Additionally, there is greater risk of severe disease in children who were born premature (especially less than 35 weeks gestation).
So if your child is younger than 6 months of age and in particular if they were under 35 weeks gestational age when born, there is greater risk of serious illness from an RSV infection.
The older your child becomes three things will favor them against serious complications:
1. There immune systems will mature.
2. They will become physically larger (as will their airways).
3. They will encounter the RSV germ repeatedly giving them greater antibody protection with each subsequent illness.
It should be noted that the elderly are also affected more significantly by RSV than a healthy young adult, however as a pediatrician I do not have any expertise in this population.
The second common misconception is that RSV can be avoided - it cannot. Almost every child will become infected with RSV at least once by their second birthday and reinfection is common.
RSV, like other cold viruses, is spread through respiratory droplets (i.e. sneezes and coughs) but more commonly it is spread via direct contact with other infected children and the surfaces they touch. It really is a matter of WHEN and not IF your child will catch RSV. As stated above, children's bodies handle RSV better as they get older.
Thus if your child is a preemie and/or they are under 6 months of age, it makes sense to take some precautions to delay the initial onset of the inevitable first acquisition of RSV. Typical hygienic habits are what serve you best: washing hands, portable hand cleanser, and covering sneezes appropriately (elbow method is best).
The last misconception is not as common and is not really a true misconception. As a pediatrician, I am often asked whether RSV lung infection will increase the risk of asthma in the future. The short answer is - it's complicated.
A good way to think about this is the chicken or egg analogy.
Do kids that are more prone to asthma genetically have a greater propensity of having lung involvement with their very first RSV infection?
Maybe.
Or does an early infection with RSV increase the chances of having asthma later in life?
Maybe.
One of those statements is likely true and possibly both. The research has not definitively answered either question adequately and we will likely never know for sure. What we do know is that RSV infection in the lungs (everyone eventually gets it but not everyone gets involvement of the lungs) has some correlation with recurrent wheezing. But we also know that long-term there are no permanent changes found in the lungs of these same children - at least not as a result of RSV.
The bottom line is that your child will catch RSV at some point in their life and it will likely manifest itself as nothing worse than the common cold. However if your child is under 6 months of age and particularly if they were born premature, healthy hygiene may prevent lung involvement and thus reduce the risk of serious illness. Finally, should your child have lung involvement with their RSV illness, they have a greater risk for recurrent wheezing, however the RSV germ should not cause long-term changes in their lungs.
Wednesday, October 19, 2011
Post #27 Proper Swaddling of Babies to Prevent Hip Dysplasia
In ten years of pediatrics I have only had a handful of cases of hip dysplasia. Hip dysplasia is when the hip joint (a ball and socket joint) does not develop appropriately and can lead to dislocation and improper development which in turn can lead to mobility issues in the future. Mostly, I have seen this occur in breech babies (legs are in funny positions in the womb), females (hip anatomy makes it have a higher propensity for issues than males), first born babies (the womb is tightest in the first pregnancy leaving less room for the baby and his/her hips), and low amniotic fluid (less room in the womb).
Recent evidence indicates that improper swaddling may contribute to hip dysplasia. Like other parts of the baby, the hip continues to develop and mature even after the baby is born. Proper assessment of the above risk factors and routine physical exams by your pediatrician can catch infants who have hip dysplasia. Parents can do their part in minimizing risks by using proper swaddling techniques which will allow for proper maturation of the hip joints.
The below information is from the International Hip Dysplasia Institute. There is a link embedded in the text that takes you to their web page where 3 different techniques for proper swaddling are demonstrated in a YouTube video. Although the risks with most current swaddling techniques are minimal, this intervention carries no side effects, incurs no costs, and is easy to do - so there is no reason not to try it!
Hip-Healthy Swaddling
Are you swaddling your baby properly?
Improper swaddling may lead to hip dysplasia or developmental dysplasia of the hip. When in the womb the baby's legs are in a fetal position with the legs bent up and across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.
Many parents find that swaddling can provide comfort for fussy babies, reduce crying, and develop more settled sleep patterns. When babies are swaddled, care should be taken to swaddle properly so the baby is safe and healthy.
There are many ways to swaddle babies by using blankets or commercial products designed for swaddling. In order for swaddling to allow healthy hip development, the legs should be able to bend up and out at the hips. This position allows for natural development of the hip joints.
The baby’s legs should not be tightly wrapped straight down and pressed together. Swaddling infants with the hips and knees in an extended position may increase the risk of hip dysplasia and dislocation.
Instructions on how to swaddle properly
Watch the video at this link to learn three, hip-healthy methods to swaddle your baby:
If you can't view the above video, here is one of the methods described in text:
1. If using a square cloth, fold back one corner creating a straight edge.
2. Place the baby on the cloth so that the top of the fabric is at shoulder level. If using a rectangular cloth, the baby's shoulders will be placed at the top of the long side.
3. Bring the left arm down. Wrap the cloth over the arm and chest. Tuck under the right side of the baby.
4. Bring the right arm down and wrap the cloth over the baby's arm and chest.
5. Tuck the cloth under the left side of the baby. The weight of the baby will hold the cloth firmly in place.
6. Twist or fold the bottom end of the cloth and tuck behind the baby, ensuring that both legs are bent up and out.
It is important to leave room for the hips to move.
What about sleepsacks and commercial products?
Some parents choose to wrap their babies in sleepsacks specifically designed for swaddling, instead of using a simple cloth or blanket. Commercial products for swaddling should have a loose pouch or sack for the baby’s legs and feet, allowing plenty of hip movement. However, even some of these commercial products can confine the legs if they are tightened around the thighs.
It's especially important to allow the hips to spread apart and bend up. In the womb the legs are in a fetal position with the legs bent up across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.
Final Thoughts
When put down to sleep, a swaddled baby should be placed on his or her back, face up.
If the baby can roll onto his or her stomach this may increase the risk of suffocation. Seek the advice of your child’s healthcare provider if swaddling an older or more active baby.
Recent evidence indicates that improper swaddling may contribute to hip dysplasia. Like other parts of the baby, the hip continues to develop and mature even after the baby is born. Proper assessment of the above risk factors and routine physical exams by your pediatrician can catch infants who have hip dysplasia. Parents can do their part in minimizing risks by using proper swaddling techniques which will allow for proper maturation of the hip joints.
The below information is from the International Hip Dysplasia Institute. There is a link embedded in the text that takes you to their web page where 3 different techniques for proper swaddling are demonstrated in a YouTube video. Although the risks with most current swaddling techniques are minimal, this intervention carries no side effects, incurs no costs, and is easy to do - so there is no reason not to try it!
Hip-Healthy Swaddling
Are you swaddling your baby properly?
Improper swaddling may lead to hip dysplasia or developmental dysplasia of the hip. When in the womb the baby's legs are in a fetal position with the legs bent up and across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.
Many parents find that swaddling can provide comfort for fussy babies, reduce crying, and develop more settled sleep patterns. When babies are swaddled, care should be taken to swaddle properly so the baby is safe and healthy.
There are many ways to swaddle babies by using blankets or commercial products designed for swaddling. In order for swaddling to allow healthy hip development, the legs should be able to bend up and out at the hips. This position allows for natural development of the hip joints.
The baby’s legs should not be tightly wrapped straight down and pressed together. Swaddling infants with the hips and knees in an extended position may increase the risk of hip dysplasia and dislocation.
Instructions on how to swaddle properly
Watch the video at this link to learn three, hip-healthy methods to swaddle your baby:
If you can't view the above video, here is one of the methods described in text:
1. If using a square cloth, fold back one corner creating a straight edge.
2. Place the baby on the cloth so that the top of the fabric is at shoulder level. If using a rectangular cloth, the baby's shoulders will be placed at the top of the long side.
3. Bring the left arm down. Wrap the cloth over the arm and chest. Tuck under the right side of the baby.
4. Bring the right arm down and wrap the cloth over the baby's arm and chest.
5. Tuck the cloth under the left side of the baby. The weight of the baby will hold the cloth firmly in place.
6. Twist or fold the bottom end of the cloth and tuck behind the baby, ensuring that both legs are bent up and out.
It is important to leave room for the hips to move.
What about sleepsacks and commercial products?
Some parents choose to wrap their babies in sleepsacks specifically designed for swaddling, instead of using a simple cloth or blanket. Commercial products for swaddling should have a loose pouch or sack for the baby’s legs and feet, allowing plenty of hip movement. However, even some of these commercial products can confine the legs if they are tightened around the thighs.
It's especially important to allow the hips to spread apart and bend up. In the womb the legs are in a fetal position with the legs bent up across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.
Final Thoughts
When put down to sleep, a swaddled baby should be placed on his or her back, face up.
If the baby can roll onto his or her stomach this may increase the risk of suffocation. Seek the advice of your child’s healthcare provider if swaddling an older or more active baby.
Saturday, September 3, 2011
Post #26 Flu Shot Update 2011
Flu viruses are always changing. Each year, experts study thousands of flu virus samples from around the world to figure out which viruses are making people sick and how these viruses are changing. With this information, they forecast which three viruses are most likely to make the most people sick during the next flu season. These strains are then used to make the flu vaccine for the next flu season.
This year’s three flu strains included in the vaccine remain the same as last year’s vaccine:
* A/California/7/2009 (H1N1)-like virus
* A/Perth/16/2009 (H3N2)-like virus
* B/Brisbane/60/2008-like virus)
As noted above, this year's seasonal flu vaccine will again include the Novel 2009 H1N1 flu strand (A.K.A. A/California/7/2009 (H1N1)-like virus) which was used during the global pandemic and which was also included in last year's flu vaccine. This means your child will only need to get vaccinated with one type of flu immunization this year.
However, if your child is under 9 years of age AND did not receive the seasonal flu vaccine last year (the 2010-2011 flu vaccine), they will need to get 2 immunizations this year. This rule applies to both the nasal flumist and the injectable vaccine.
Flu shots given prior to the 2010-2011 flu vaccine (including the single strand Novel 2009 H1N1 vaccine) do not factor into this year's decision making tree. Please note that this is a different policy from previous years.
Here is a decision tree to help you know how many flu vaccines your child needs this year (you must answer both questions in the order shown):
Is your child 9 years or older?
Yes: Only one immunization is needed this year.
No: Go to the next question -->
Did your child receive at least one 2010-2011 seasonal flu vaccine?
Yes: Only one immunization is needed this year.
No: Two immunizations are needed this year.
If your child needs 2 flu vaccines this year, they should be spaced apart by a minimum of 4 weeks. There is no deadline by which the 2nd flu vaccine needs to be completed, but once the minimum 4 weeks has passed, the sooner the better.
Yearly flu vaccination should begin in September or as soon as the vaccine is available and continue throughout the influenza season, as late as March or beyond. The timing and duration of influenza seasons vary.
While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in February or later. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.
In general, it is best to get your flu shot a.s.a.p. because you never know when the flu season will start!
For more information on the flu vaccine from the CDC click on this link.
This year’s three flu strains included in the vaccine remain the same as last year’s vaccine:
* A/California/7/2009 (H1N1)-like virus
* A/Perth/16/2009 (H3N2)-like virus
* B/Brisbane/60/2008-like virus)
As noted above, this year's seasonal flu vaccine will again include the Novel 2009 H1N1 flu strand (A.K.A. A/California/7/2009 (H1N1)-like virus) which was used during the global pandemic and which was also included in last year's flu vaccine. This means your child will only need to get vaccinated with one type of flu immunization this year.
However, if your child is under 9 years of age AND did not receive the seasonal flu vaccine last year (the 2010-2011 flu vaccine), they will need to get 2 immunizations this year. This rule applies to both the nasal flumist and the injectable vaccine.
Flu shots given prior to the 2010-2011 flu vaccine (including the single strand Novel 2009 H1N1 vaccine) do not factor into this year's decision making tree. Please note that this is a different policy from previous years.
Here is a decision tree to help you know how many flu vaccines your child needs this year (you must answer both questions in the order shown):
Is your child 9 years or older?
Yes: Only one immunization is needed this year.
No: Go to the next question -->
Did your child receive at least one 2010-2011 seasonal flu vaccine?
Yes: Only one immunization is needed this year.
No: Two immunizations are needed this year.
If your child needs 2 flu vaccines this year, they should be spaced apart by a minimum of 4 weeks. There is no deadline by which the 2nd flu vaccine needs to be completed, but once the minimum 4 weeks has passed, the sooner the better.
Yearly flu vaccination should begin in September or as soon as the vaccine is available and continue throughout the influenza season, as late as March or beyond. The timing and duration of influenza seasons vary.
While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in February or later. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.
In general, it is best to get your flu shot a.s.a.p. because you never know when the flu season will start!
For more information on the flu vaccine from the CDC click on this link.
Sunday, June 26, 2011
Post #25 Pediatrics is Priceless
An extra blue scrub top is tucked away in the lower right cabinet of the nurse's station. Every so often, after being sprayed with bodily fluid, I have to make a midday swap of my work clothes. However, it's a small price to pay to be a part of children's lives; one day the baby who spits up on your shoulder will be the same kid who runs down the hall screaming your name and clings to your leg with the dexterity of a koala. What makes pediatrics so rewarding is the long-term relationships that you build with children and their families who every day make you feel like a small hero.
Practicing general pediatrics often feels like searching for a needle in a haystack. Hidden in a sea of upper respiratory infections, reflux, eczema, and diaper rashes is a cystic fibrosis diagnosis, for example, that the astute clinician must not overlook. There are enough challenging cases to keep you on your toes to make everyday clinic interesting, but they don't overwhelm you. As a result, you'll have plenty of time each day to build new relationships and foster old ones. These relationships create the backbone of a successful pediatrician's practice.
To finish reading click here.
Practicing general pediatrics often feels like searching for a needle in a haystack. Hidden in a sea of upper respiratory infections, reflux, eczema, and diaper rashes is a cystic fibrosis diagnosis, for example, that the astute clinician must not overlook. There are enough challenging cases to keep you on your toes to make everyday clinic interesting, but they don't overwhelm you. As a result, you'll have plenty of time each day to build new relationships and foster old ones. These relationships create the backbone of a successful pediatrician's practice.
To finish reading click here.
Friday, April 15, 2011
Post #24 A Follow-up to the Risks of Cell Phones
I think employing the precautionary principle with cellphones is a reasonable idea depending on the circumstances. If it starts to impair your quality of life, I would argue the current safety profile of cellphones justifies a fairly liberal approach to their usage.
For example, as a pediatrician I get a lot of calls and I try to use my cellphone to return calls during downtime moments of my life so that when I get home I can maximize my time with my kids. I use my cellphone a lot (rather than waiting to arrive home and use my landline) and would not change this facet of my life as the risk of a brain tumor to me seems so remote and the time with my kids is tangible and valuable.
However with my kids, I will likely employ a stricter application of the precautionary principle. My children's skull bones are thinner secondary to physical immaturity and their brains are more plastic and still developing. Furthermore, their lifestyles will not dictate a heavy need for constant connectivity (at least not early on in life). Perhaps a cellphone that will only connect to my phone and my wife's phone? I doubt that this would be over-utilized!
I realize that this sounds contradictory to my previous blog where I concluded that I felt comfortable sending my kids to a school where a new cell phone tower is being built. My wife and I remain comfortable with that decision. As written previously, we are happy with our neighborhood elementary school and the good certainly outweighs any risk I might ascribe to radiaton from a cell phone tower (risk that I still believe is very low as further supported by a NYT article from April 13, 2011 - snippets of which I have posted below).
However, when it comes to the weighing of pros and cons in regards to my child carrying a cell phone and using it habitually, not many pros come to mind. Of course safety and better communication are a few positives, but I hope to achieve that with other means and I would not be opposed to a cell phone programmed to only communicate with a set directory. Of course, as my child matures - both physically and emotionally - I will likely liberalize their phone usage.
Even if there were no health concerns, there are other issues at stake - sexting, distractions at school, driving and dialing, and over-usage to name a few. The bottom line is that the health risks seem small and possibly zero. However, there are many reasons to limit the habitual use of a cell phone in a young child and the precautionary principle adds one more reason to the list, but it likely is just that - a precaution.
From the April 13, 2011 NYT. . . here are some excerpts from an excellent article titled "Do Cellphones Cause Brain Cancer" written by Siddhartha Mukherjee who is an assistant professor of medicine in the division of medical oncology at Columbia University. He is the author of “Emperor of All Maladies: A Biography of Cancer.”
The most exquisite — and arguably the most sensitive — means to identify a carcinogen is to study the effects of the substance not on humans or animals but on cells. In the 1970s, a Berkeley biochemist named Bruce Ames devised a cellular test to do just that. Ames’s test is based on a series of simple principles. Normal cells in the body grow through cell division, or mitosis, which is carefully regulated by genes. Certain genes accelerate growth, while other genes dampen or stop it. Cancer originates when the “accelerator” genes are permanently activated or when the “brake” genes are permanently damaged. Since genes are encoded by DNA, chemicals that mutate DNA — mutagens — can alter the growth-controlling genes and thereby cause cancer. Ames devised a special strain of bacterial cells that act as a “sensor” for mutations and therefore can also detect mutagenic chemicals. Chemical mutagens are so commonly carcinogenic that versions of the Ames test represent the gold standard by which most carcinogens are found.
Cellphone radiation is not a chemical, of course, but the rules about mutagenicity still apply (X-rays, for instance, are known to cause cancer and are detectable by Ames’s test). Laboratory experiments that link phone radiation to DNA mutation using a version of the Ames test have been largely contradictory. In 2005, a panel of experts, including a biomedical engineer, an epidemiologist, a genetic toxicologist and a radiation biologist, published a review of nearly 1,700 scientific papers on the cellular effects of radiation emitted by phones. In the review of more than 50 experiments linking phone radiation to DNA damage in animal or bacterial cells, evidence of damage has been negative in more than two-thirds of the studies. Since nonionizing radiation cannot directly affect the structure of DNA, experiments linking phone radiation to DNA damage are generally unconvincing. The most striking study linking cellular phone radiation to DNA damage, published in 2005 by researchers from the Medical University of Vienna, has recently been embroiled in even deeper scientific controversy: researchers studying the data intensively have argued that the original study is fraudulent.
But it is possible for something to be a carcinogen without directly damaging DNA. Some chemicals might activate growth pathways or survival pathways in cancer cells (eventually damaging DNA and mutating genes — but indirectly). Exogenous estrogen, for instance, activates growth pathways in breast cells and can cause breast cancer but doesn’t damage DNA. Others may provoke inflammation, creating a physiological milieu in the body that allows malignant cells to grow and survive. Yet others — the class of substances that we know least about — might not damage DNA directly but chemically modify genes so that their regulation is changed. These substances are like the dark matter of the carcinogenic world: they are barely visible to our current tests for carcinogens and thus lie at the boundaries of the knowable universe. Cellphones and their radiation have been tested for many of these properties — for instance, their ability to chemically modify DNA without causing mutations — but evidence linking this form of radiation to such cellular changes remains largely negative.
This section is about animal studies. . .
Nonetheless, biologists have exposed mice and rats to chronic nonionizing radiation (comparable to that emitted by phones) to determine whether it causes cancer. In rats prone to developing breast cancer, there was no acceleration of breast cancer. In another experiment, rats were treated with a chemical carcinogen in utero (to “prime” them to develop brain tumors) and then exposed to radiant energy comparable to cellphone radiation for two hours per day, four days a week, for 22 months. The experiment revealed no increased incidence of brain tumors in rats. Nor was there any accelerated growth in previously established brain tumors. From 1997 to 2004, six independent experiments on mice and rats studied the effects of chronic radiation on brain cancer. No experiment revealed an increased risk of brain cancer.
An excellent article and if you would like to read it in full here is the link.
For example, as a pediatrician I get a lot of calls and I try to use my cellphone to return calls during downtime moments of my life so that when I get home I can maximize my time with my kids. I use my cellphone a lot (rather than waiting to arrive home and use my landline) and would not change this facet of my life as the risk of a brain tumor to me seems so remote and the time with my kids is tangible and valuable.
However with my kids, I will likely employ a stricter application of the precautionary principle. My children's skull bones are thinner secondary to physical immaturity and their brains are more plastic and still developing. Furthermore, their lifestyles will not dictate a heavy need for constant connectivity (at least not early on in life). Perhaps a cellphone that will only connect to my phone and my wife's phone? I doubt that this would be over-utilized!
I realize that this sounds contradictory to my previous blog where I concluded that I felt comfortable sending my kids to a school where a new cell phone tower is being built. My wife and I remain comfortable with that decision. As written previously, we are happy with our neighborhood elementary school and the good certainly outweighs any risk I might ascribe to radiaton from a cell phone tower (risk that I still believe is very low as further supported by a NYT article from April 13, 2011 - snippets of which I have posted below).
However, when it comes to the weighing of pros and cons in regards to my child carrying a cell phone and using it habitually, not many pros come to mind. Of course safety and better communication are a few positives, but I hope to achieve that with other means and I would not be opposed to a cell phone programmed to only communicate with a set directory. Of course, as my child matures - both physically and emotionally - I will likely liberalize their phone usage.
Even if there were no health concerns, there are other issues at stake - sexting, distractions at school, driving and dialing, and over-usage to name a few. The bottom line is that the health risks seem small and possibly zero. However, there are many reasons to limit the habitual use of a cell phone in a young child and the precautionary principle adds one more reason to the list, but it likely is just that - a precaution.
From the April 13, 2011 NYT. . . here are some excerpts from an excellent article titled "Do Cellphones Cause Brain Cancer" written by Siddhartha Mukherjee who is an assistant professor of medicine in the division of medical oncology at Columbia University. He is the author of “Emperor of All Maladies: A Biography of Cancer.”
The most exquisite — and arguably the most sensitive — means to identify a carcinogen is to study the effects of the substance not on humans or animals but on cells. In the 1970s, a Berkeley biochemist named Bruce Ames devised a cellular test to do just that. Ames’s test is based on a series of simple principles. Normal cells in the body grow through cell division, or mitosis, which is carefully regulated by genes. Certain genes accelerate growth, while other genes dampen or stop it. Cancer originates when the “accelerator” genes are permanently activated or when the “brake” genes are permanently damaged. Since genes are encoded by DNA, chemicals that mutate DNA — mutagens — can alter the growth-controlling genes and thereby cause cancer. Ames devised a special strain of bacterial cells that act as a “sensor” for mutations and therefore can also detect mutagenic chemicals. Chemical mutagens are so commonly carcinogenic that versions of the Ames test represent the gold standard by which most carcinogens are found.
Cellphone radiation is not a chemical, of course, but the rules about mutagenicity still apply (X-rays, for instance, are known to cause cancer and are detectable by Ames’s test). Laboratory experiments that link phone radiation to DNA mutation using a version of the Ames test have been largely contradictory. In 2005, a panel of experts, including a biomedical engineer, an epidemiologist, a genetic toxicologist and a radiation biologist, published a review of nearly 1,700 scientific papers on the cellular effects of radiation emitted by phones. In the review of more than 50 experiments linking phone radiation to DNA damage in animal or bacterial cells, evidence of damage has been negative in more than two-thirds of the studies. Since nonionizing radiation cannot directly affect the structure of DNA, experiments linking phone radiation to DNA damage are generally unconvincing. The most striking study linking cellular phone radiation to DNA damage, published in 2005 by researchers from the Medical University of Vienna, has recently been embroiled in even deeper scientific controversy: researchers studying the data intensively have argued that the original study is fraudulent.
But it is possible for something to be a carcinogen without directly damaging DNA. Some chemicals might activate growth pathways or survival pathways in cancer cells (eventually damaging DNA and mutating genes — but indirectly). Exogenous estrogen, for instance, activates growth pathways in breast cells and can cause breast cancer but doesn’t damage DNA. Others may provoke inflammation, creating a physiological milieu in the body that allows malignant cells to grow and survive. Yet others — the class of substances that we know least about — might not damage DNA directly but chemically modify genes so that their regulation is changed. These substances are like the dark matter of the carcinogenic world: they are barely visible to our current tests for carcinogens and thus lie at the boundaries of the knowable universe. Cellphones and their radiation have been tested for many of these properties — for instance, their ability to chemically modify DNA without causing mutations — but evidence linking this form of radiation to such cellular changes remains largely negative.
This section is about animal studies. . .
Nonetheless, biologists have exposed mice and rats to chronic nonionizing radiation (comparable to that emitted by phones) to determine whether it causes cancer. In rats prone to developing breast cancer, there was no acceleration of breast cancer. In another experiment, rats were treated with a chemical carcinogen in utero (to “prime” them to develop brain tumors) and then exposed to radiant energy comparable to cellphone radiation for two hours per day, four days a week, for 22 months. The experiment revealed no increased incidence of brain tumors in rats. Nor was there any accelerated growth in previously established brain tumors. From 1997 to 2004, six independent experiments on mice and rats studied the effects of chronic radiation on brain cancer. No experiment revealed an increased risk of brain cancer.
An excellent article and if you would like to read it in full here is the link.
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