pediatrics

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Calls For Better Pain Relief Measures For Newborns, Premature Infants

In this file photo, an infant is seen in the neonatal intensive care unit of the Swedish Medical Center in Seattle. (Paul Joseph Brown/AP)

In this file photo, an infant is seen in the neonatal intensive care unit of the Swedish Medical Center in Seattle. (Paul Joseph Brown/AP)

What could be more heartbreaking than witnessing some of the smallest, sickest babies undergoing painful medical procedures?

Yet that’s precisely the population subject to some of the most intrusive prodding and pricking, the “greatest number of painful stimuli” in the neonatal intensive care unit, or NICU.

Now the American Association of Pediatricians is calling for better, more comprehensive pain relief measures for newborns, including those born prematurely — both with medications and through alternative, non-drug measures — and for more research on effective treatments.

The AAP’s updated policy statement, published in the journal Pediatrics, asserts that “although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures.”

The AAP calls for new measures, specifically:

Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

If you’ve ever been in a NICU, you may have seen these types of procedures take place: suctioning of various secretions from the nose and throat; blood draws from veins, arteries, feet or heels; IVs being placed; adhesive tape — used to keep all those tubes and IVs in place — removed.

A landmark 2008 study from France found that the vast majority of newborns in the NICU didn’t get pain relief; researchers found only about 21 percent of infants were given either pain medication or non-drug pain relief before undergoing a painful procedure.

Why is this important? Continue reading

Study: Maternal Obesity And Diabetes Bring ‘Multiple Hits,’ May Raise Autism Risk In Children

A provocative new study finds that children born to mothers with a combination of obesity and diabetes before and during pregnancy may have up to four times the risk of developing autism spectrum disorder.

On their own, obesity as well as pre-pregnancy diabetes or gestational diabetes increase the risk of autism slightly, researchers report. But the study suggests that co-occurring obesity and diabetes may bring “multiple hits” to the developing fetal brain, conferring an even higher risk of autism in the offspring than either condition on its own.

According to the U.S. Centers for Disease Control and Prevention, about 1 in 68 children has autism spectrum disorder, which also includes Asperger syndrome and other pervasive developmental disorders.

This new study — led by researchers at the Johns Hopkins Bloomberg School of Public Health and published in the journal Pediatrics — was based on analyzing the medical records of 2,734 children who have been followed from birth at the Boston Medical Center between 1998 and 2014. (Of that group, 102 of the children had a diagnosis of an autism spectrum disorder. )

So what might be leading to this increased autism risk? Researchers don’t really know, but they raise several theories in the paper. In general, the possible mechanisms relate to immune and metabolic system disturbances associated with maternal obesity and diabetes that might cause inflammation and other problems for the developing fetus.

One of the study authors, Daniele Fallin, an epidemiologist and chair of the Department of Mental Health at Hopkins’ public health school, said in an interview: “We know that both diabetes and obesity create stress on the body, generally, and a lot of that stress manifests in disruption of immune processes and inflammation. Once you have the disruption in the mom, that may lead to inflammation problems in the developing fetus, and inflammation during neurodevelopment can create problems that manifest as autism.” Continue reading

More Evidence That Growing Up Poor May Alter Key Brain Structures

Allan Ajifo/flickr

(Allan Ajifo/Flickr)

Poverty is bad for your brain.

That’s the basic takeaway from an emerging body of research suggesting that the distress associated with growing up poor can negatively influence brain development in many ways, and in certain cases might also lead to emotional and mental health problems, like depression.

The latest study, led by researchers at Washington University School of Medicine in St. Louis, found that poverty in early childhood may influence the development of important connections between parts of the brain that are critical for effective regulation of emotions.

The study, published in the Journal of American Psychiatry, adds “to the growing awareness of the immense public health crisis represented by the huge number of children growing up in poverty and the likely long-lasting impact this experience has on brain development and on negative mood and depression,” researchers report.

Continue reading

Opinion: ‘Lactivism’ Has Trump-Like Appeal For Breastfeeding Backlash, But Science Is Off

A baby sleeps in the arms of his mother after breastfeeding. (Nikolas Giakoumidis/AP)

A baby sleeps in the arms of his mother after breastfeeding. (Nikolas Giakoumidis/AP)

By Melissa Bartick, M.D.

Judging from the hype around Courtney Jung’s new book “Lactivism,” breastfeeding backlash is alive and kicking. In fact, if Donald Trump suddenly jumped into the breastfeeding fray, he might sound a bit like Jung: In her world, breastfeeding advocates are nearly always “lactivists,” self-righteous extremists preying on innocent mothers in the name of science and good parenting.

Jung, a professor in the Department of Political Science at University of Toronto, conjures a villain (or villains) everyone can rally against, as evidenced in the book’s subtitle: “How Feminists and Fundamentalists, Hippies and Yuppies, and Physicians and Politicians Made Breastfeeding Big Business and Bad Policy.”

If only some of the glowing book reviews mentioned Jung’s sloppy reading of the scientific literature, her absurd claims about the breastfeeding industrial complex and her misplaced theories of breastfeeding class warfare.

Let’s be clear: There is no place for shaming any mother about how she feeds her infant. There are indeed people out there who deserve our ire, who shame and pressure women instead of listening and educating. But Jung lumps nearly all breastfeeding advocates into this camp, stoking hatred of an entire group where only some are guilty.

Perhaps the book is popular for the same reason Trump is popular. It taps into mothers’ collective anxiety, anger and fears over a highly emotional topic, and then hold up twin “culprits”: breastfeeding zealots and bad science. The only problem is, the actual zealots are few (though offensive), and the science is not as Jung states.

Here are some facts: Breastfeeding mothers still get harassed in public and at work, and formula feeding mothers are subject to shame as well. For decades, formula feeding has been the norm in this country, and for much of our society it’s still the norm. CDC data show low-income women and African-American women have lower breastfeeding rates than middle class white women.

Not everyone can breastfeed and not everyone wants to breastfeed, but data show 68 percent of women who want to exclusively breastfeed do not meet their own goals.

To be fair, Jung does a few things right. For instance, a 2007 report from the Agency for Health Research and Quality (AHRQ) found that exclusively breastfeeding for three months cuts the risk of ear infections in half. To her credit, Jung highlights the same data from a different perspective, illustrating that six babies would need to be exclusively breastfed for three months to prevent one ear infection. And, also to her credit, she highlights fairly recent data showing little if any link between breastfeeding and lower risk of asthma, eczema and type 1 diabetes.

But overall, Jung’s grasp on the medical research is poor. Scientific papers are peer reviewed by other researchers who are experts in the same field and must pass rigorous standards before publication. Jung is not a medical researcher. While I don’t know if Jung’s book was reviewed by any medical authority, as a reviewer myself I can say it never would have made it past the first stage of the peer review process. It was reviewed by editors whose goal is to sell books.

She misstates so much of the medical literature, one wonders if she did more than just skim through these papers. Here are a few examples of inaccuracies:

• The rate of HIV transmission from mothers to their 6-month-old infants via breast milk is 4 percent among those exclusively breastfed, according to a study in The Lancet; Jung wrongly puts that number at 22 percent. Continue reading

Sweeping Harvard Study Finds Skin-To-Skin ‘Kangaroo Care’ Helps Preemies Thrive

If a premature baby is medically stable, a study finds the practice of holding the tiny child might well do some good. (BradleyOlin/Flickr)

If a premature baby is medically stable, a study finds”kangaroo care” — including prolonged skin-to-skin contact — might well do some good. (BradleyOlin/Flickr)

You want to hold your baby. It’s surely one of the deepest of human instincts. But if your newborn is among the nearly 10 percent who arrive prematurely in America each year, you may need to wait — until the days of tubes and high-tech monitors in the incubator have passed.

Now, a new study, apparently the most sweeping yet, offers added evidence that if a premature baby is medically stable, the age-old practice of holding the tiny child — skin to skin, heartbeat to heartbeat — might well do some good. A survey of more than 100 previous studies, it found that overall, the skin-to-skin cradling widely known as “kangaroo mother care” may cut a premature, low-birth-weight baby’s risk of death by 36 percent.

The findings may rightly spur parents to advocate for holding their preemies once they’re medically stable enough, says the study’s senior author, Dr. Grace Chan of Boston Children’s Hospital and the Harvard Chan School of Public Health.

“With this degree of evidence, it doesn’t hurt to ask,” she says. High-tech medical interventions “are necessary for many conditions,” she says. “At the same time, for your preterm, low-birth-weight baby who’s otherwise stable, this is the best thing for the baby.”

Kangaroo care is considered most useful in low-income areas where high-level-care hospitals — and incubators — are few. But Dr. Chan says it seems to offer benefits across all settings. The new study, in the journal Pediatrics, quantifies those benefits, finding both the 36 percent drop in risk of death and a 47 percent drop in infection or sepsis. It looked at newborns who weighed less than 2 kilograms, or 4.4 pounds.

My own son weighed just about that when he was born two months early, back in 2004. And I remember the joy of the brief periods when we were allowed to extract him from his incubator home for a few minutes and hold him close. Judging by that Boston hospital experience, I asked Dr. Chan, kangaroo care is fairly widely accepted, right? Continue reading

Parents: Kids Spurn Emotional Help For Fear ‘They Might Think I’m The Next Shooter’

Candles spelling UCC -- for Umpqua Community College -- are displayed at a candlelight vigil for those killed during a fatal shooting at the school, Thursday in Roseburg, Oregon. (Rich Pedroncelli/AP)

Candles spelling UCC — for Umpqua Community College — are displayed at a candlelight vigil for those killed during a fatal shooting at the school in Roseburg, Oregon. (Rich Pedroncelli/AP)

By Lisa Lambert
Guest contributor

Lisa Lambert is the executive director of the Parent/Professional Advocacy League, which is subtitled “The Massachusetts Family Voice For Children’s Mental Health.”

“He doesn’t want to take the risk and have someone think he could be a shooter,” one mother said, “just because he has a mental health diagnosis.”

I was at a meeting with other parents whose children have mental health needs. This mother told us her son was reluctant to leave his high school classroom for an important evaluation, which included psychological testing.

Like much of America, we were talking about the recent and not-so-recent shootings on campuses and in communities across the country. For this mother, as with many parents whose children have mental health issues, the conversation is far more personal and troubling than for most.

Some parents said that in response to recent shooting incidents, their children are dropping out of services or refusing school supports so they won’t risk their peers or teachers finding out why they get treatment.

As a parent, this breaks my heart. Young adults shouldn’t have to choose between the safety found in avoiding treatment and the healing found in seeking it.

Lisa Lambert (courtesy)

Lisa Lambert (courtesy)

During our discussion, another mother reported that her son was in his first year of college and struggling to complete all his coursework. Freshman year is a stressful time for many students and even more so for students with depression. Because her son had had special education services in high school, he could access supports there to help him manage his academic and emotional stress.

She encouraged him to go to the college student services office to get help. He responded, “I’d rather drop the classes I am most behind in. If I go there, the professors and other students will know I have mental health problems. They might think I could be the next shooter.”

Often, as a news channel covers the latest shooting, the speculation immediately jumps to mental illness. Continue reading

Study: Thousands Of Injuries As Ziplines Proliferate, Younger Kids Most At Risk

In 2012 alone, there were over 3,600 zipline-related injuries, according to a recent report, or about 10 a day. (popejon2/Flickr)

In 2012 alone, there were over 3,600 zipline-related injuries, according to a recent report, or about 10 a day. (popejon2/Flickr)

Hannah Weyerhauser was 5 years old, playing on the zipline at her family’s house in New Hampshire, when she started complaining that her older cousins and siblings were going faster than she was. So her mother, Annie, gave Hannah an extra big push. But when Hannah sped to the end of the zipline, she stopped short, flew into the air, did a back flip, and landed on her neck.

“For a few minutes she was really pale and out of it,” said her mother, a Boston doctor (and a friend of mine). She called an ambulance, and paramedics put a collar on Hannah’s neck on the way to the local emergency department. Ultimately, the little girl was fine, although she probably had a minor concussion, her mother said. But Annie shudders as she thinks of what could have happened: “If she had fallen a little differently she could have broken her neck.”

Others are not so lucky. Increasingly, zipline disasters are making the news. A 12-year-old girl in North Carolina died after falling off a zipline at the YMCA’s Champ Cheerio in June. And last year, a 10-year-old boy died after a backyard zipline accident in Easton, Massachusetts, in which the tree holding the line fell on the child.

Indeed, injuries related to ziplines are rising as the lines proliferate, according to a new report: In 2012 alone, there were over 3,600 zipline-related injuries, or about 10 a day. The study, which researchers say is the first to characterize the epidemiology of zipline-related injuries using a nationally representative database, found that from 1997-2012, about 16,850 zipline-related injuries were treated in U.S. emergency departments.

Which states have zipline regulations (Source: Association for Challenge Course Technology)

Which states have zipline regulations (Source: Association for Challenge Course Technology)

The report on ziplines (first used over a century ago to transport supplies in the Indian Himalayas) found that most of the injuries resulted from falling off the zipline, and many involved young children. I asked one of the study authors, Tracy Mehan, manager of translational research with the Center for Injury Research and Policy at Nationwide Children’s Hospital in Ohio, a few questions about the report, published in the American Journal of Emergency Medicine.

Here, edited, is what she said.

Rachel Zimmerman: Are you surprised by this sharp increase in zipline injuries?

Tracy Mehan: The number of commercial ziplines grew from just 10 in 2001 to over 200 by 2012. When you include the number of amateur ziplines that can also be found in backyards and at places like outdoor education programs and camps, the number skyrockets to over 13,000. The increase in the number of injuries is likely due largely to the increase in number of ziplines and shows this is a growing trend. 

What are the most common types of injuries?

The majority of zipline-related injuries were the result of either a fall (77 percent) or a collision (13 percent) with either a tree, a stationary support structure or another person. The most frequent type of injuries were broken bones (46 percent), bruises (15 percent), strains/sprains (15 percent) and concussions/closed head injuries (7 percent). Approximately one in 10 patients (12 percent) were admitted to the hospital for their injury. Continue reading

Bugs And Kids: Indoor Insecticide Use Linked To Childhood Cancers, Study Finds

(Tom Simpson/Flickr)

(Tom Simpson/Flickr)

I just threw out my spray can of Raid for flying insects. With kids in the house, I never did like the idea of spewing toxic stuff around, and only ever used it when a bug was driving me to feral insanity. Now, after reading the paper just out in this week’s issue of the journal Pediatrics, I’ll stick with the flypaper and swatter no matter how intense my irritation.

The paper concludes that the sum of previous research suggests a significant link between indoor pesticide use and childhood cancer.

To be more exact, senior author Chensheng Lu says the results “suggest that when kids are exposed to pesticides — especially a group of pesticides we call insecticides — in the indoor residential environment, kids have 43 to 47 percent more chance of having childhood cancers, specifically leukemia and lymphoma.”

Dr. Lu is an associate professor of environmental exposure biology at the Harvard T.H. Chan School of Public Health. He acknowledges the study’s limitations, in particular that it could find only 16 relevant previous papers to analyze. But, he says, it showed “consistent results in terms of the positive correlation between exposure to insecticide indoors and childhood cancer.”

The study does not aim to “cause fear in parents,” Lu says. “But it’s to give you a precautionary principle that those exposures can be prevented, can be mitigated or can be completely removed.”

Of course, these findings only heighten the dilemma for households or schools that are tormented by pests, with infestations too fierce to be dented by anything but the big toxic guns. Are we supposed to just let the roaches and mosquitoes run wild?

Dr. Lu points out that preventive measures like window screens and hole-plugging can help, and among pesticides, some applications are safer than others — for example, “bait houses” that try to attract the pest inside a box-like structure to be poisoned.

“The worst-case scenario in terms of indoor pesticide use and human exposure it to use some kind of fogger,” he says. “Also, some kind of open-air application, a broadcast application, a spray can. Those are bound to significant exposures.” Continue reading

CDC: One-Third Of Children With ADHD Diagnosed With The Disorder Before Age 6

(Vivian Chen/Flickr)

(Vivian Chen/Flickr)

One-third of children diagnosed with ADHD were diagnosed young — before the age of 6 — according to a new national survey from the U.S. Centers for Disease Control and Prevention.

Earlier, the CDC found that based on parental reports, 1 in 10 school-aged children, or 6.4 million kids in the U.S., have received a diagnosis of ADHD, a condition marked by symptoms including difficulty staying focused and paying attention, out of control behavior and over-activity or impulsivity.

The percentage of children diagnosed with ADHD has increased steadily since the late 1990s and jumped 42 percent from 2003-2004 to 2011-2012, the CDC says. Last year, concerns flared when a report found that thousands of toddlers are being medicated for ADHD outside of established pediatric practice guidelines.

In the current analysis, also based on parental reporting, and using data drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, the CDC also found:

•The median age at which children with ADHD were first diagnosed with the disorder was 7 years old

•The majority of children (53.1%) were first diagnosed by a primary care physician

•Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist

•Children diagnosed at age 6 or older were more likely to have been diagnosed by a psychologist

•Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%)

•Someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%)

•For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment

What are we — parents, educators, doctors — to make of all this? In particular, what does it mean that so many very young kids are being diagnosed with an attention disorder? (Has anyone ever encountered a 4- or 5-year-old child who is not hyperactive, impulsive and inattentive??)

I asked two doctors — a pediatrician and a psychiatrist — for their impressions of the CDC report. Both agreed that we seem to have two problems when it comes to ADHD: over-diagnosing and under-diagnosing. Here, lightly edited, are their responses.

First, the pediatrician:

James M. Perrin, MD, is a professor of pediatrics at Harvard Medical School and associate chair of MassGeneral Hospital for Children. Dr. Perrin is also the immediate past president of the American Academy of Pediatrics and chaired the 1990s committee that wrote the first practice guidelines for ADHD (and he was on the committee for the 2011 revision).

RZ: How difficult is it to diagnose ADHD in children under 6 years old?

JP: In the pediatric community, we have worked over last 15 years to train general pediatricians to make diagnoses of ADHD reliably and follow very clear, specific guidelines on how to do so. In 2011, the AAP revised its practice guidelines for ADHD and included the opportunity to diagnose children ages 4 and 5 years old.

At the same time we recognize it’s very hard to do that well in that age group…because a lot of children are inattentive at 4 — you don’t expect them to work hard and read a Hardy boys book for an hour and half. Five is often impulsive, active, so it’s not unusual to have symptoms that children with ADHD would also have at age 4, 5. So, it’s not easy.

We did say [in the guidelines] pretty clearly that you shouldn’t make the diagnoses without significant impairment of normal behavior. What we mean by that is a child whose symptoms impair her ability to play with other children, or whose behavior is so out of control that it’s dangerous, for instance she runs out in front of cars, or has many accidents, that’s when the symptoms become impairing. Continue reading

Bleeding Disorder? National Expert Discusses Questions Around Cambridge Baby’s Death

Aisling Brady McCarthy

Aisling Brady McCarthy watches as her attorney addresses the court during a status hearing at Middlesex Superior Court in Woburn in May. McCarthy, a nanny from Ireland, was accused of killing a 1-year-old Massachusetts girl in her care two years ago. (Charles Krupa/AP)

Aisling Brady McCarthy is back in her native Ireland now, after murder charges against her were dropped in the death of Rehma Sabir, a Cambridge infant in her care. But while the case is over, the mystery remains: How did Rehma die?

The Middlesex County district attorney’s office says a review of the case raised the question of whether 1-year-old Rehma had an undiagnosed blood disorder that could have caused her brain hemorrhage. A press release from the office cites these details from the medical examiner:

“Review of Rehma’s coagulation and hematology testing, her history of bruising, the NIH guidelines for diagnosis of von Willebrand disease, and literature on the subject suggest to me that Rehma’s low von Willebrand factor could have made her prone to easy bleeding with relatively minor trauma.

“Given these uncertainties, I am no longer convinced that the subdural hemorrhage in this case could only have been caused by abusive/inflicted head trauma, and I can no longer rule the manner of death as a homicide.  I believe that enough evidence has been presented to raise the possibility that the bleeding could have been related to an accidental injury in a child with a bleeding risk or possibly could have even been a result of an undefined natural disease.  As such I am amending the cause and manner of death to reflect this uncertainty.”

So, then, a bleeding disease might have caused a spontaneous hemorrhage? Or the combination of the disease and a minor head injury led to death? And if so, could it be that quite a few of the contested accusations of baby abuse in recent years could be thus explained away?

Dr. Shannon Carpenter (courtesy)

Dr. Shannon Carpenter (courtesy)

I turned to Dr. Shannon Carpenter, a bleeding disorders specialist who has done research and written American Academy of Pediatrics reports on checking children for bleeding disorders when there’s a question of abuse. She’s the chief of hematology at Children’s Mercy Hospital in Kansas City, Missouri, and the director of the Kansas City Regional Hemophilia Center.

Dr. Carpenter was not involved in the Cambridge case, but speaking generally she says that sadly, no, there’s no kinder explanation here: Abusive head trauma — a better term than “shaken baby syndrome” because abuse can involve more than shaking — is far more common than serious bleeding disorders, and even children with severe disorders are extremely unlikely to have fatal brain bleeds. Our conversation, lightly edited:

Dr. Carpenter, what are we to make of the medical examiner’s mention of Von Willebrand disease — a not-very-rare bleeding disorder — and the suggestion that death could have resulted from disease or “an accidental injury in a child with a bleeding risk”?

One thing I would say is, most patients with von Willebrand disease have a mild disorder, mostly manifested by nosebleeds, bruising, and gum bleeding, and do not seem to have an increased risk for intracranial hemorrhage. Research is ongoing in this area and I think there may be more information coming, but from a clinical perspective, when we see patients with the most common types of von Willebrand disease, we do not have a high concern for intracranial hemorrhage in those patients, certainly not spontaneously.

“Unfortunately, child abuse is more common than bleeding disorders.”

– Dr. Shannon Carpenter

The most severe forms of von Willebrand disease occur in about 1 percent of people with von Willebrand disease, probably less than that. And even in the most severe forms, the risk of having a bleed inside of the head is probably less than 2 percent. So it’s a very rare event. This would be an unusual presentation for von Willebrand disease. I don’t know the specifics of this patient’s case, and I don’t know what her actual von Willebrand factor level was, but even if she was low enough to be diagnosed with the most common form of von Willebrand disease, this kind of bleeding would not be typical for that kind of diagnosis.

But, I suppose, possible?

While anything is possible, you have to look at what’s probable and what other patients have experienced. And patients with bleeding disorders are not immune to trauma, whether it’s inflicted or non-inflicted. I would say if a child came to me with type 1 von Willebrand disease, the most common type, the mild form of von Willebrand disease, with a typical toddler head bump that would not otherwise cause someone to seek medical care, I would not worry about intracranial hemorrhage in that patient.

And if a child had a more severe form of von Willebrand disease?

Then I might be concerned.

But if it were a severe form, wouldn’t it have likely shown up by 1 year of age? Continue reading