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Daily Dose

New Concussion Guidelines

1:30 to read

A really interesting study was published in Pediatrics online entitled “Benefits of Strict Rest After Acute Concussion”.  The guidelines for treating a concussion continue to be debated and that is what makes this study thought provoking.  

This was a “randomized controlled study”  which followed 88 patients between the ages of 11 and 22 years who had been diagnosed with a concussion.  45 of the patients were given instructions for 5 days of strict rest at home with no school, no work and no physical activity.  They were then allowed to have a “stepwise return to activity”.  The other 43 patients were told to “rest” for 1-2 days after which time they could  return to school also follow a “stepwise return to activity”.

Interestingly, there was no clinically significant difference in the  neurocognitive or balance outcomes between the two groups.  In fact the group that was “advised to rest for 5 days” reported more daily post concussive symptoms and slower resolution of symptoms than those who were told to rest for 1-2 days.  

This was a small study and does not mean that everyone should be treated the same way. In fact, when seeing a patient who has sustained a concussion each person seems to be a bit different.....as one could expect when discussing a “brain injury”.  No two brains are exactly alike...at least for the time being...who knows what will happen one day with genetics

In my own limited practice I have found that “very few” tweens and teens subscribe to the complete rest theory...that is no school, but also no TV, no computer and no videos or smart phones....WHAT??? No social media for 5 days?  You would have to put most of them on an isolated “post concussion island” to ensure they disconnect.  

The study authors also wondered if patients reported more symptoms after having strict rest recommended.  It seems plausible that I too might notice a few more symptoms when just sitting there wondering if my head hurts or if I seem to be more fatigued.

Subjective symptoms are always difficult to quantify...which makes treating a concussion more problematic.  I think erring on the conservative side and restricting “return to play” for a longer period seems to be of more importance than any other recommendation, including “5 days of strict rest”. In the meantime this is an interesting study....with more data to surely follow. 

 

Your Teen

Acne Gel Linked to Rare Side Effect

1:45

Nearly all teens will get acne at one time or another. For those that get severe acne, it can be devastating to their self-esteem. While acne isn’t a serious health problem, it’s not something that is easy to hide.

For a lot of teens, over-the–counter face washes and drying agents help keep acne under control. For more serious acne, families often turn to a dermatologist for prescription medicine.

In certain people, Aczone- the skin gel version of the drug Dapzone -may lead to a rare blood disorder called methemoglobinemia according to a new study.

That’s what a 19 year-old female in Pittsburgh was using to treat her acne before she entered the emergency room with a headache, shortness of breath, and blue lips and fingers. At first, her doctors were at a loss as to what was causing her condition.

The patient had been using a “pea-size” amount of Aczone on her face twice daily during the previous week and didn’t think to tell the doctors about it when questioned about any medications she was taking.

"We went over all her meds and herbal supplements," said Dr. Greg Swartzentruber, a medical toxicology fellow at the University of Pittsburgh Medical Center. "And we couldn't come up with a cause, even after interviewing her and her family. Aczone was just never mentioned."

Topical medicines can have systemic adverse effects on people, but many patients don’t think about topical creams or gels when asked about medications they are on by their doctor.

The study authors noted that prior research has shown that Dapsone pills, in very rare instances, can trigger methemoglobinemia, the abnormal production of a red blood cell protein that delivers oxygen throughout the body.

But the current case appears to be the first time that this condition has been associated with Aczone, the skin gel version of Dapsone, they said.

Dapzone pills have been available for decades and were once used to treat leprosy. In 2005, the FDA approved Aczone - the 5 percent topical cream – for acne treatment use. Dapzone and Aczone have been very effective for treating acne.

However, if someone has the rare genetic defect that makes it impossible to properly metabolize the drugs, it can cause serious health problems.

"The blood cells blow up, basically," said Dr. Darrell Rigel, a clinical professor of dermatology with New York University Medical Center in New York City. Rigel added. "The prevalence of this deficiency is very low. Maybe it affects less than 1 percent of the population, but those that have it can end up with serious problems."

Doctors were finally able to diagnose the young woman’s illness through a urine test. She was successfully treated and released from the hospital after two days.

Rigel noted that dermatologists who prescribe Aczone have a responsibility to always screen patients for this issue. "And patients have to know that when they're asked to give their drug history they can't forget their topicals," he said.

The young woman’s case was described in a letter published in the New England Journal of Medicine.

Source: Alan Mozes, http://www.webmd.com/skin-problems-and-treatments/acne/news/20150129/acne-gel-linked-to-rare-side-effect-doctors-warn

Your Teen

Teens Drive Better With More Sleep

1.45 to read

The study, published in Journal of Clinical Sleep Medicine, compared school start times and automobile crash rates for students aged 16 to 18 years in Virginia Beach, Va., where high school classes began between 7:20 a.m. and 7:25 a.m., to students at schools in adjacent Chesapeake, Va., where classes started between 8:40 a.m. and 8:45 a.m. A new study suggests that getting an extra hour of sleep at night could help your teen drive safer.

The study, published in Journal of Clinical Sleep Medicine, compared school start times and automobile crash rates for students aged 16 to 18 years in Virginia Beach, Va., where high school classes began between 7:20 a.m. and 7:25 a.m., to students at schools in adjacent Chesapeake, Va., where classes started between 8:40 a.m. and 8:45 a.m. What they discovered was that the earlier risers may not be very alert while behind the wheel and were more prone to sleep loss and daytime sleepiness. The study's lead author, Dr. Robert Vorona, said that starting high school later in the morning might make young drivers more alert simply because they get more sleep. There were 65.8 automobile crashes for every 1,000 teen drivers in Virginia Beach, and 46.6 crashes for every 1,000 teen drivers in Chesapeake. The comparisons were made in 2008 and were similar to results in 2007. "We believe that high schools should take a close look at having later start times to align with circadian rhythms in teens and to allow for longer sleep times," said Vorona who is an associate professor of internal medicine at Eastern Virginia Medical School. "Too many teens in this country obtain insufficient sleep. Increasingly, the literature suggests that this may lead to problematic consequences including mood disorders, academic difficulties and behavioral issues." An extra hour of sleep could also improve attention levels, reduce mistakes and performance according to another study in the April edition of the Journal of Clinical Sleep Medicine. The Israeli study of 14-year-old, eighth-grade students found those teens that slept 55 minutes longer each night performed better on tests that require attention. So just one more hour of sleep can make a big difference in how teens drive, and perform in school. Instead of the 7 or 8 hours of sleep recommended for adults, teens should think in terms of about 9 hours per night. With school schedules and other activities it can be a challenge to set aside that much time. It is also a good idea to get this amount of sleep on a daily basis and not skimp during the week and then try to make it up on the weekend.

Your Child

Super-Lice Resistant to OTC Treatment

1:45

Well, this certainly isn’t good news.

The American Chemical Society recently reported a new study shows that certain lice in at least 25 states are now resistant to over-the-counter (OTC) treatments.

Study author Kyong S. Yoon, PhD, assistant professor in the Biological Sciences and Environmental Sciences Program at Southern Illinois University, has been researching lice since 2000. His research is still ongoing, but what he’s found so far in 109 samples from 30 states is startling: the vast majority of lice now carry genes that are super-resistant to the OTC treatment used against them.

Permethrin, part of the pyrethroid class of insecticides, is the active ingredient in some OTC treatments. Certain lice have developed a trio of mutations that make it resistant to the pyrethroids. What happens is you end up with a new kind of super-lice that doesn’t respond to typical treatment any longer.

“It’s a really, really serious problem right now in the U.S.,” Yoon says.

Six million to 12 million U.S. children are infested with head lice every year, "with parents spending about $350 million dollars annually on permethrin-laced over-the-counter and prescription treatments," Yoon said. Lice infestations occur in rich neighborhoods as well as poor ones.

Currently, there are 25 states, including Arizona, California, the Carolinas, Connecticut, Florida, Georgia, Illinois, Maine, Massachusetts, Texas and Virginia where lice have what Yoon calls "knock-down resistant mutations". This involves a triple whammy of genetic alterations that render them immune to OTC permethrin treatments.

Lice in four states, New Jersey, New Mexico, New York and Oregon, have developed partial resistance, the researchers found.

Michigan's lice have no resistance as yet. Why that is remains unclear.

Fortunately, there are prescription medications that still work in treating lice. They are more expensive than over-the-counter formulas and do not contain permethrin. These prescriptions may contain benzyl alcohol, ivermectin, malathion and spinosad; all powerful agents or insecticides. Lindane shampoo is another alternative for difficult-to-treat cases.

If your child has head lice and OTC medicines haven’t worked, you can check with your pediatrician or family doctor for a prescription treatment. 

Sources: Mandy Oaklander, http://time.com/4000857/lice-treatment/

Alan Mozes, http://health.usnews.com/health-news/articles/2015/08/18/head-lice-now-resistant-to-common-meds-in-25-states

 

Your Child

Another Study Finds No Vaccine –Autism Connection

2:00

A new study, using insurance records for nearly 96,000 U.S. children, found no link between the measles - mumps – rubella (MMR) vaccine and autism – even among children who are at an increased genetic risk.

Experts are hoping that this study, along with several other studies on the risks of autism and the MMR vaccine, will reassure parents that the vaccine is safe.

While the original 1998 study associating the vaccine with autism has been found fraudulent, many parents continue to worry that the vaccine could be a trigger for autism; particularly parents that already have a child with autism.

"Research has shown that parents of kids with autism spectrum disorders are more likely to delay vaccinating their younger children," said Dr. Bryan King, an autism researcher at the University of Washington, in Seattle.

"Basically, they wait until the developmental dust has settled, and it looks like their child will be unaffected (by autism)," said King, who wrote an editorial published with the study.

Health officials are concerned that children who do not receive the MMR vaccine are putting other children at risk for serious diseases. They point to the recent measles outbreaks as one example. So far this year, 162 people have been sickened across 16 states and Washington D.C. according to the U.S. Centers for Disease Control and Prevention (CDC).

Scientists are working hard to find out why there has been an increase in autism over the last decade.  It's known that genes make certain children more vulnerable to autism -- that's why kids with an affected older sibling are at higher-than-average risk. But environmental factors also have to play a role, experts believe.

Based on years of research, the MMR vaccine is not that trigger, according to health experts. "Every study that's looked at this, through every strategy they've used, has found no signal," King said.

According to King, it's natural for parents with a child who has autism to want to reduce their younger kids' risk.

"Everyone believes there have to be environmental factors contributing to the exponential rise we've seen in ASDs," he said. "But we don't understand what those factors are yet."

Researchers are finding clues, though. And more and more, they suspect that prenatal brain development is the critical period, King said.

The new findings are based on insurance records for nearly 96,000 U.S. children with an older brother or sister; 2 percent had an older sibling with an autism spectrum disorder.

Of the children with an affected sibling, 7 percent had an autism spectrum disorder themselves, compared to just under 1 percent of other kids. There was no evidence, though, that the MMR vaccination raised the risk of autism in either group of children, Jain said.

Among kids with an affected sibling, those who'd received one MMR dose by age 2 were actually one-quarter less likely to be diagnosed with an autism spectrum disorder, the study found. The odds were even lower among those who'd received two doses by age 5.

The study did not reveal any evidence that the MMR vaccine offered any protective influence over autism, only that it was not associated with an increase of risk for autism.

More studies are in the works to find the source of autism. Environmental factors are playing a key role in many of those studies as well as genetic links.

It’s understandable that parents would worry about vaccinations of any kind having a negative effect on their child, but more and more studies confirm that the MMR vaccine is one that parents can eliminate from their list of concerns.

This study was reported in the April 21 issue of the Journal of the American Medical Association.

Source: Amy Norton, http://consumer.healthday.com/cognitive-health-information-26/autism-news-51/another-study-finds-no-vaccine-autism-link-698635.html

Your Baby

Preventing Peanut Allergies in High-Risk Children

2:00

New research suggests that, under clinical supervision, children that are at a high risk for developing a peanut allergy can build a lasting tolerance to the legume.

Children that participated in the new study were fed peanuts for years as part of a supervised clinical trial. Now, the researchers are reporting that those youngsters maintained their tolerance for at least a year, even if they didn't keep eating peanuts.

"The therapy persisted, and after 12 months of avoidance there was no increase in the rates of peanut allergy. They maintained their ability to tolerate peanuts, even though they hadn't been eating it," said Dr. Sherry Farzan, an allergist with Northwell Health in Great Neck, N.Y. Farzan wasn't involved in the research.

This suggests that the immune system "learns" that peanut is not a threat to the body, and kids won't have to keep eating peanuts for the rest of their lives to maintain their tolerance, said Dr. Scott Sicherer. He's a pediatric allergy specialist at Mount Sinai Hospital in New York City. Sicherer also wasn't part of the current study.

This study is an extension of the groundbreaking LEAP (Learning Early about Peanut Allergy) clinical trial. Last year, that trial found that feeding peanuts to at-risk babies for 60 months reduced their risk of developing a peanut allergy. The study determined an infant's risk of peanut allergy using an allergy skin test.

Before the original LEAP study results, physicians told parents to avoid exposing their child to allergic foods until they were older and their immune system were more developed.

But the LEAP trial found that exposing at-risk kids to peanuts regularly beginning in infancy actually prevented peanut allergies by the time they reached age 5, Sicherer said. Eating peanuts lowered the rate of peanut allergy by 80 percent in the now-preschoolers, according to the study authors.

"For this high-risk group, waiting longer and longer to eat peanut isn't good," Sicherer said. "It's better to get it into your diet as soon as possible."

Both Farzan and Sicherer warned that this type of preventive strategy should only be given under a doctor’s supervision.

And, this prevention therapy is only for kids at risk of peanut allergy, not for kids who already have developed the allergy, Sicherer warned.

"If you have someone who already had a peanut allergy and gave them peanuts, then they'd get sick and maybe end up in an emergency room," he said.

After the initial study, researchers wanted to know if the children who were successful at building a tolerance to peanuts would have to eat them regularly for the rest of their lives.

To answer this question, the researchers followed more than 500 of the original 640 children for a one-year period of peanut avoidance. Half of this group included previous peanut consumers. The other half had always avoided peanuts.

 

After 12 months of peanut avoidance, only 5 percent of the original peanut consumers were found to be allergic, compared to 19 percent of the original peanut avoiders, the findings showed.

"This study offers reassurance that eating peanut-containing foods as part of a normal diet -- with occasional periods of time without peanut -- will be a safe practice for most children following successful tolerance therapy," said Dr. Gerald Nepom. He is director of the Immune Tolerance Network (ITN), the consortium behind the LEAP trial.

"The immune system appears to remember and sustain its tolerant state, even without continuous regular exposure to peanuts," he added in an ITN news release.

Farzan said there appears to be a "critical period" between 4 and 11 months where "we can push the immune system around a little."

Farzan and Sicherer both said that by the time kids reach age 5, the immune system appears to have accepted that peanuts aren't a danger to the body.

"After following this pattern, it may not be that important anymore, at least after age 5, to worry if someone isn't keeping up," Sicherer said. "It may not be necessary to keep up with such consistent ingestion."

According to the John Hopkins Bloomberg School of Public health, food allergies affect between 2 and 10 percent of U.S. children. Peanut allergy is considered the most fatal food allergy. 

The LEAP study, and now with the results from its extended research, may offer a new generation of children a chance at preventing this problematic allergy altogether.

Story source: HealthDay reporter Dennis Thompson, http://www.webmd.com/allergies/news/20160304/supervised-exposure-therapy-for-peanut-allergy-lasts-study-finds

 

Your Baby

Eating Fish During Pregnancy Benefits Baby’s Brain Development

2:00

Can eating more fish during pregnancy help babies’ brains function better as they grow older? Yes, according to a new study from Spain. The researchers say that mothers who eat three substantial servings of fish – each week- during pregnancy may be giving their children an advantage as they mature.

Researchers followed nearly 2,000 mother-child pairs from the first trimester of pregnancy through the child’s fifth birthday and found improved brain function in the kids whose mothers ate the most fish while pregnant, compared to children of mothers who ate the least.

Even when women averaged 600 grams, or 21 ounces, of fish weekly during pregnancy, there was no sign that mercury or other pollutants associated with fish were having a negative effect that offset the apparent benefits.

“Seafood is known to be an important source of essential nutrients for brain development, but at the same time accumulates mercury from the environment, which is known to be neurotoxic,” lead author Jordi Julvez, of the Center for Research in Environmental Epidemiology in Barcelona, said in an email to Reuters Health.

This important health concern prompted the U.S. Food and Drug Administration (FDA) to come up with a guideline for pregnant women in 2014. It encourages women to eat more fish during pregnancy, but limit the intake to no more than 12 ounces per week.

For this study, researchers analyzed data from the Spanish Childhood and Environment Project, a large population study that recruited women in their first trimester of pregnancy, in four provinces of Spain, between 2004 and 2008.

Julvez and colleagues focused on records of the women’s consumption of large fatty fish such as swordfish and albacore tuna, smaller fatty fish such as mackerel, sardines, anchovies or salmon, and lean fish such as hake or sole, as well as shellfish and other seafood.

Women were tested for blood levels of vitamin D and iodine, and cord blood was tested after delivery to measure fetal exposure to mercury and PCB pollutants. At ages 14 months and five years, the children underwent tests of their cognitive abilities and Asperger Syndrome traits to assess their neuropsychological development.

On average, the women had consumed about 500 g, or three servings, of seafood per week while pregnant. But with every additional 10 g per week above that amount, children’s test scores improved, up to about 600 g. The link between higher maternal consumption and better brain development in children was especially apparent when kids were five.

The researchers also saw a consistent reduction in autism-spectrum traits with increased maternal fish consumption.

Mothers’ consumption of lean fish and large fatty fish appeared most strongly tied to children’s scores, and fish intake during the first trimester, compared to later in pregnancy, also had the strongest associations.

“I think that in general people should follow the current recommendations,” Julvez said. “Nevertheless this study pointed out that maybe some of them, particularly the American ones, should be less stringent.”

Julvez noted that there didn’t appear to be any additional benefit when women ate more than 21 ounces (about 595 g) of fish per week.

“I think it's really interesting, and it shed a lot more light on the benefits of eating fish during pregnancy,” said Dr. Ashley Roman, director of Maternal Fetal Medicine at NYU Langone Medical Center in New York.

“I think what's interesting about this study compared to some data previously is that they better quantify the relationship between how much fish is consumed in a diet and then the benefits for the fetus and ultimately the child,” said Roman, who was not involved in the study.

Roman also noted that pregnant women should avoid certain fish such as tilefish, shark, swordfish and giant mackerel. These are larger fish with longer life spans that may accumulate more mercury in their tissue.

While fish may be a great source of protein and benefit brain development in utero, most experts agree that women should consult their obstetrician about what fish are safer to eat and how much they should eat during pregnancy.

The study was published online in the January edition of the American Journal of Epidemiology

Source: Shereen Lehman, http://www.reuters.com/article/us-health-pregnancy-fish-idUSKCN0UW1S4

 

 

 

Your Child

Antibiotics Often Prescribed When Not Needed

2.00 to read

By now, most parents understand that antibiotics are not effective for viral infections, only for illnesses caused by bacteria.

However, that hasn’t deterred many physicians from over-prescribing antibiotics for children with ear and throat infections.

More than 11 million antibiotic prescriptions written each year for children and teens may be unnecessary, according to researchers from University of Washington and Seattle Children's Hospital. This excess antibiotic use not only fails to eradicate children's viral illnesses, researchers said, but also supports the dangerous evolution of bacteria toward antibiotic resistance.

"I think it's well-known that we prescribers overprescribe antibiotics, and our intent was to put a number on how often we're doing that," said study author Dr. Matthew Kronman, an assistant professor of infectious diseases at Seattle Children's Hospital.

"But as we found out, there's really been no change in this [situation] over the last decade," added Kronman. "And we don't have easily available tools in the real-world setting to discriminate between infections caused by bacteria or viruses."

 Doctors have limited resources when it comes to differentiating between bacterial or viral infections. Physicians can use the rapid step test to determine if the streptococcus bacteria is the cause of a child’s sore throat, but that is about it for immediate diagnostic tools.

Most colds are virus related and one of the first symptoms will be a sore or scratchy throat. It will typically go away after the first day or so and other cold symptoms will continue. Strep throat is often more severe and persistent.

A virus often causes ear infection as well. Many doctors treat ear infections as though they are bacterial to be on the safe side and avoid serious middle ear infections.

To determine antibiotic prescribing rates, Kronman and his colleagues analyzed a group of English-language studies published between 2000 and 2011 and data on children 18 and younger who were examined in outpatient clinics.

Based on the prevalence of bacteria in ear and throat infections and the introduction of a pneumococcal vaccine that prevents many bacterial infections, the researchers estimated that about 27 percent of U.S. children with infections of the ear, sinus area, throat or upper respiratory tract had illnesses caused by bacteria.

But antibiotics were prescribed for nearly 57 percent of doctors' visits for these infections, the study found.

Kronan hopes that the study’s results will encourage the development of more diagnostic tools and will spur doctors to think more critically about prescribing antibiotics unless clearly needed.

Previous research has shown that parents often pressure their doctor to prescribe an antibiotic to treat their child’s ear or sore throat symptoms. However, when parents are given other suggestions on how to alleviate the symptoms they have been much more receptive than when their doctor just flat out says he won’t prescribe antibiotics.

Many physicians and researchers are concerned that the amount of antibiotics being prescribed these days is setting us all up for future problems when dealing with bacterial infections. Bacteria are adaptable and mutate over time becoming less responsive to antibiotics. When possible, it’s much healthier in the long run to treat your child’s symptoms with simpler therapies. Ask your physican ways you can make your little one more comfortable until the symptoms pass. 

The study was published online in the journal Pediatrics.

Source: Maureen Salamon, http://consumer.healthday.com/infectious-disease-information-21/antibiotics-news-30/antibiotics-prescribed-twice-as-often-as-needed-in-children-study-says-691686.html

Your Child

Concussions May Last Longer in Girls

2.00 to read

New research suggests that girls who suffer a concussion may have more severe symptoms that last longer compared to boys.

No one seems to know why there is a difference, but other studies have come to the same conclusion.

"There have been several studies suggesting there are differences between boys and girls as far as [concussion] symptom reporting and the duration of symptoms," said Dr. Shayne Fehr, a pediatric sports medicine specialist at Children's Hospital of Wisconsin.

In his new study, Fehr also found those differences. He tracked 549 patients, including 235 girls, who sought treatment at a pediatric concussion clinic.

Compared to the boys, the girls reported more severe symptoms and took nearly 22 more days to recover, said Fehr, also an assistant professor of pediatric orthopedics at the Medical College of Wisconsin.

In the new study, Fehr tracked patients from 10 to 18 years old. All were treated between early 2010 and mid-2012. Each patient reported on their symptoms, how severe they were and how long it took from the time of the injury until they were symptom-free.

Girls reported more severe symptoms and took an average of 56 days to be symptom-free. In comparison, the boys took 34 days. Overall, the time to recovery was 44 days when boys and girls were pooled.

The length of time it took for patients to fully recover from concussion is quite a bit longer than people usually think.

"Commonly you hear that seven to 10 days [for recovery] is average," Fehr said.

The patient’s who were part of this study went to concussion clinics, so their injuries may have been more acute.

Fehr did not find age to be linked with severity of symptoms. Most of the injuries -- 76 percent -- were sports-related, with football accounting for 22 percent of the concussions.

The top five reported symptoms were headache, trouble concentrating, sensitivity to light, sensitivity to sound and dizziness. Boys and girls, in general, reported the same types of symptoms, Fehr said, but the girls reported more severity and for a longer time period.

Fehr will present the findings at the American Medical Society for Sports Medicine this week. Studies presented at medical meetings are typically viewed as preliminary until published in a peer-reviewed journal.

Whether it’s a boy or a girl that suffers a concussion, it's important to be seen by a doctor and not return to play prematurely, which can be dangerous or even fatal, according to the American Academy of Pediatrics.

Anyone with a history of concussion is also at higher risk for another injury.

Source: Kathleen Doheny, http://www.webmd.com/brain/news/20140410/girls-suffer-worse-concussions-study-suggests

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DR SUE'S DAILY DOSE

If your child snores, is this a sign of something more serious?

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