pediatrics

RECENT POSTS

Height, Hormones And Your Child’s Mental Health

I’m short — a hair over five feet tall. And my daughters, likely, will be too.

So, at some point in parenting, I briefly entertained the prospect of growth hormones. You might have too, thinking (with Randy Newman in the background) that maybe your petite child might be just a tad better off in life with a couple of extra inches.

And then, if you’re like me, you never acted on this thought: you kept your interventionist parenting ideas to yourself and simply told your daughters how smart, strong and beautiful they are.

(David Wheeler/flickr)

(David Wheeler/flickr)

A small, but compelling, report backs up this self-censorship. Research presented at the annual meeting of the Endocrine Society, by Dr. Emily C Walvoord of the University of Indiana School of Medicine, found that otherwise healthy children treated with growth hormones may have gained those extra inches, but they paid an emotional and psychological price. The tradeoff, researchers concluded, might not be worth it.

From the abstract:

“…children treated with GH [growth hormones] had worsening emotional symptoms over time when compared to children of the same age and height who were not treated with GH. Medical intervention with daily injections, frequent clinic visits and repeated discussions about height might exacerbate instead of improve psychosocial concerns for short, otherwise healthy children. This novel longitudinal study of both the cognitive and emotional effects of GH therapy in…children raises concerns that psychosocial benefits may not be achieved despite improvements in height.”

Obviously, this type of study is not definitive, and sometimes there’s a medical necessity for such intervention. But I found its basic “Whoa” approach to drugs for kids even more interesting given the principal investigator has financial ties to drug giant Eli Lilly.

Readers, parents, have you grappled with the growth hormone question? How did you weigh the pros/cons? Please tell us your story.

Work-Family Crunch: Parents Resort To ER To Get Kids Back Into Daycare

(Bob Reck via Compfight)

(Bob Reck via Compfight)

Some of the tension between work and family is inevitable. If your child comes down with the flu on the very day you’re supposed to give a major presentation, there’s just no way you can be everywhere you’re needed at the same time.

But a study just out in the journal Pediatrics shows that the discrepancy between the sick-child policies at many daycare centers and accepted medical wisdom could often make the work-family crunch harder than it has to be. (Meanwhile, a day-long White House “summit” today is looking at ways to ease that crunch for American parents, from promoting more flexible work schedules to paid maternity leaves.)

From the study’s press release:

Substantial proportions of parents chose urgent care or emergency department visits when their sick children were excluded from attending child care, according to a new study by University of Michigan researchers.

The study, to be published June 23 in Pediatrics, also found that use of the emergency department or urgent care was significantly higher among parents who are single or divorced, African American, have job concerns or needed a doctor’s note for the child to return.

Previous studies have shown children in child care are frequently ill with mild illness and are unnecessarily excluded from child care at high rates, says Andrew N. Hashikawa, M.D., M.S., an emergency physician at  C.S. Mott Children’s Hospital. This is the first national study to examine the impact of illness for children in child care on parents’ need for urgent medical evaluations, says Hashikawa.

In the study, 80 percent of parents took their children to a primary care provider when their sick children were unable to attend child care. Twenty-six percent of parents also said they had used urgent care and 25 percent had taken their children to an emergency room.

“These parents may view the situation as a socioeconomic emergency,” Dr. Hashikawa says.

He got interested in this topic, he told me, when he was a med student working in an ER, and one night, a family brought in children who looked fine, they just had a little bit of red in their eyes. “And it was midnight, and I asked them, ‘Why are you here?’ I was just so curious. And they said ‘Well, I’ve got to work, I’m not going to get paid, and I really need a doctor’s note for both my work and for my daycare so I can send them back.’”

A bit more of our conversation, lightly edited:

How much does daycare keep kids out unnecessarily?

There are different ways to look at it…A Maryland study showed that for every one appropriate exclusion (from daycare) approximately five or six were inappropriate exclusions. I did a study from a daycare provider standpoint: If we gave you a hypothetical scenario, how many of these kids would you send home that probably didn’t need to be excluded? It seemed that 57% of kids would be unnecessarily excluded at that point.

The American Academy of Pediatrics has guidelines on when children should actually be kept home, right? Continue reading

‘I’m Not Stupid, Just Dyslexic’ — And How Brain Science Can Help

Sixth-grader Josh Thibeau has been struggling to read for as long as he can remember. He has yet to complete a single Harry Potter book, his personal goal.

Growing up with dyslexia: Josh Thibeau, 12, imagines his brain as an ever-changing maze with turns he must learn to navigate. Here he is with his mother, Janet. (George Hicks/WBUR)

Growing up with dyslexia: Josh Thibeau, 12, thinks of his brain as an ever-changing maze with turns he must learn to navigate. Here he is with his mom, Janet. (George Hicks/WBUR)

When he was in first grade, Josh’s parents enrolled him in a research study at Boston Children’s Hospital investigating the genetics of dyslexia. Since then, Josh has completed regular MRI scans of his brain. Initially, it seemed daunting.

“When we first started, I’m like, ‘Oh no, you’re sending me to like some strange, like, science lab where I’m going to be injected with needles and it’s going to hurt,’ I’m like, ‘I’m never going to see my family again,’ ” says Josh, who lives in West Newbury, Mass.

Josh and his three biological siblings all have dyslexia to varying degrees. Pretty much every day he confronts the reality that his brain works differently than his peers’. He’s even shared scans of his brain with classmates to try to show those differences. Some kids still don’t get it.

“There was a student that said, ‘Are you stupid?’ Because my brain was working in a different way,” Josh says. “And I’m just like, ‘No, I am not stupid…I’m just dyslexic.’ ”

The Pre-Reading Brain 

On average, one or two kids in every U.S. classroom has dyslexia, a brain-based learning disability that often runs in families and makes reading difficult, sometimes painfully so.

Compared to other neurodevelopmental disorders like ADHD or autism, research into dyslexia has advanced further, experts say. That’s partly because dyslexia presents itself around a specific behavior: reading — which, as they say, is fundamental.

Now, new research shows it’s possible to pick up some of the signs of dyslexia in the brain even before kids learn to read. And this earlier identification may start to substantially influence how parents, educators and clinicians tackle the disorder.

Until recently (and sometimes even today) kids who struggled to read were thought to lack motivation or smarts. Now it’s clear that’s not true: Dyslexia stems from physiological differences in the brain circuitry. Those differences can make it harder, and less efficient, for children to process the tiny components of language, called phonemes.

And it’s much more complicated than just flipping your “b’s and “d’s.” To read, children need to learn to map the sounds of spoken language — the “KUH”, the “AH”, the “TUH” — to their corresponding letters. And then they must grasp how those letter symbols, the “C” “A” and “T”, create words with meaning. Kids with dyslexia have far more trouble mastering these steps automatically.

For these children, the path toward reading is often marked by struggle, anxiety and feelings of inadequacy. In general, a diagnosis of dyslexia usually means that a child has experienced multiple failures at school.

But collaborations currently underway between neuroscientists at MIT and Children’s Hospital may mark a fundamental shift in addressing dyslexia, and might someday eliminate the anguish of repeated failure. In preliminary findings, researchers report that brain measures taken in kindergartners — even before the kids can read — can “significantly” improve predictions of how well, or poorly, the children can master reading later on.

Implicated in dyslexia: The arcuate fasciculus is an arch-shaped bundle of fibers that connects the frontal language areas of the brain to the areas in the temporal lobe that are important for language (left). Researchers found that kindergarten children with strong pre-reading scores have a bigger, more robust and well-organized arcuate fasciculus (bottom right) while children with very low scores have a small and not particularly well-organized arcuate fasciculus (top right). (Zeynep Saygin/MIT)

Implicated in dyslexia: The arcuate fasciculus is an arch-shaped bundle of fibers that connects the frontal language areas of the brain to the areas in the temporal lobe that are important for language (left). Researchers found that kindergarten children with strong pre-reading scores have a bigger, more robust and well-organized arcuate fasciculus (bottom right) while children with very low scores have a small and not particularly well-organized arcuate fasciculus (top right). (Zeynep Saygin/MIT)

Pinpointing The White Matter Culprit

Using cutting-edge MRI technology, the researchers are able to pinpoint a specific neural pathway, a white matter tract in the brain’s left hemisphere that appears to be related to dyslexia: It’s called the arcuate fasciculus.

“Maybe the most surprising aspect of the research so far is how clear a signal we see in the brains of children who are likely to go on to be poor readers.”
– MIT neuroscientist John Gabrieli

“It’s an arch-shaped bundle of fibers that connects the frontal language areas of the brain to the areas in the temporal lobe that are important for language,” Elizabeth Norton, a neuroscientist at MIT’s McGovern Institute of Brain Research, explains.

In her lab, Norton shows me brain images from the NIH-funded kindergartner study, called READ (for Researching Early Attributes of Dyslexia).

“We see that in children who in kindergarten already have strong pre-reading scores, their arcuate fasciculus is both bigger and more well organized,” she says. On the other hand: “A child with a score of zero has a very small and not particularly organized arcuate fasciculus.”

She says we’re not quite ready to simply take a picture of your child’s brain and say “Aha, this kid is going to have dyslexia,” but we’re getting closer to that point. Continue reading

A Bittersweet Graduation For Patients At The Mass. Hospital School

Brian Devin, CEO of The Massachusetts Hospital School, speaks with student Miguel M. in the cafeteria after lunch. (Jesse Costa/WBUR)

Brian Devin, CEO of The Massachusetts Hospital School, speaks with student Miguel M. in the cafeteria after lunch. (Jesse Costa/WBUR)

By Gabrielle Emanuel

CANTON, Mass. — It’s lunch break and there’s a wheelchair traffic jam in the school hallway.

Friendly shouts of “Beep! Beep!” and “You’re blocking traffic” interrupt chatter about one kid’s new backpack and another guy’s birthday plans.

It’s a typical school scene, except a bunch of the kids are using computers to talk and others breathe through ventilators.

Like students across the country, many of these kids are getting ready for graduation. It’s a bittersweet time for graduates of all stripes, but perhaps nowhere is it more bittersweet than here.

All of the 91 students in these hallways are also patients. When they graduate – as about a dozen will this year – they’re not only leaving their friends and teachers, they’re leaving the hospital they’ve called home for years, and in some cases, a decade or more.

The campus’ main entrance is on a rural road in Canton, where a flashing sign reads: The Massachusetts Hospital School.

Brian Devin, the CEO, says that when cars zip past drivers often “think it’s a school where they teach people to work in hospitals.”

Devin says it’s a fair assumption, but completely wrong. This facility is part pediatric hospital, part elementary and secondary school. It serves children with severe disabilities — muscular dystrophy, cerebral palsy, brain injuries — and is run jointly by the state Department of Public Health and the Department of Education.

Children as young as 6 or 7 can be admitted to the hospital and they often stay at this lakefront campus until the kid’s clock strikes 22 years old, when it’s time to graduate and it’s time to go, regardless of whether there is another alternative place to go.

A Non-Institutional Hospital

As the hallway traffic starts moving, the students wheel themselves out into the brisk spring air. They race down covered ramps toward horseback riding lessons, speech therapy sessions and wheelchair hockey practice.

Those white ramps create a web that connects all the brick buildings on this idyllic, 160-acre facility.

“The kids are all over the place. They are not always with staff — we don’t want them to always be with staff,” Devin says. “We want them to be with themselves and with other kids as much as possible. There is no real institutional flavor.”

The Massachusetts Hospital School’s ultimate goal is to cultivate as much independence as possible for these children. Continue reading

Tracking The Rising Backlash Against Sugar

Years ago, on my daughter’s first birthday, my mother-law, an avid cook, baked her a cake. I don’t remember if it was chocolate or layered. What I do remember is forbidding my baby from eating it — not even a nibble. Why, I thought, would I introduce processed sugar into a one-year-old’s diet when she’d been perfectly content with avocados and bananas? “Don’t you want to see pure joy on her face?” asked one friend. Yeah, sure, but not from frosting.

Needless to say, the birthday cake prohibition triggered a bit of a backlash among some family members, and earned me labels like “rigid” and “crazy.”

But these days, with the huge national backlash against sugar — from the new film “Fed Up” and Eve Schaub’s popular family memoir, “Year Of No Sugar,” to Mark Bittman’s regular columns hammering on the message of sugar’s toxicity — I feel somewhat vindicated.

Here’s a snippet from Bittman’s latest, “An Inconvenient Truth About Our Food” on why “Fed Up” is such an important film:

The experts carry the ball. The journalist Gary Taubes calls the “energy balance” theory — the notion that all calories are the same, and that as long as you exercise enough, you’ll avoid gaining or even lose weight no matter what you eat — “nonsense.” One Coke, we learn, will take more than an hour to burn off. The pediatrician Rob Lustig, a leading anti-sugar campaigner, notes that “we have obese 6-month-olds. You wanna tell me that they’re supposed to diet and exercise?” David Ludwig, another M.D., notes that there is no difference between many processed foods and sugar itself, saying you can eat a bowl of cornflakes with no added sugar or a bowl of sugar with no added cornflakes and “below the neck they’re the same thing.” Lustig reminds us that anyone can develop metabolic syndrome: “You can be sick without being fat; this is not just a problem of the obese.”

And so on. Senator Tom Harkin says, “I don’t know how they (the food industry) live with themselves,” comparing them to the tobacco industry. Bill Clinton says, effectively, “We blew it,” when it came to this struggle.

The movie has some splendid moments: A mother cries at the difficulty of the choice she must make between giving her child what she wants and giving her what’s best. Her struggle is common, and she’s fighting against an almost overwhelming tide of marketing and, yes, even addiction. A school lunch worker, speaking of the fact that few kids choose the healthy option at lunch, says, “You can’t choose for them.” But they are children; we must choose for them. Not only are their parents not present, but their parents often don’t know what’s best.

Just to be clear, this isn’t simply rationalizing my own personal food obsessions (though there’s some of that) or about our cultural sickness around achieving “thigh gap” thinness. It’s about overall health — for instance, heart disease. Continue reading

My Baby’s Head Is Flat! Study: Expensive Helmet Likely Won’t Help

Miles, a patient at Boston Children's Hospital, wearing his corrective helmet (Photo: Katherine C. Cohen/BCH)

Miles, a patient at Boston Children’s Hospital, wearing his corrective helmet (Photo: Katherine C. Cohen/BCH)

When my son was an infant, we followed modern medical wisdom and always put him to sleep facing upward. Within a few weeks, he developed a noticeably flat plane on one side of the back of his soft, bald little head.

“Deformational plagiocephaly” is the technical term, and it’s a widespread condition that has risen sharply since public health campaigns to put babies to sleep on their backs began in the 1990s. It affects at least one-fifth of American babies and possibly closer to half. My own overwrought, sleep-deprived diagnosis sounded more like, “Oh, no, my baby’s head is going flat!”

We brought him to specialists who raised the prospect that he might need to wear a helmet virtually non-stop for a few months, to protect his flat spot from pressure and help it round back out.

A helmet? All day and night? But there was no actual danger from his moderate head-flattening, no known risk except perhaps of future ridicule. In the end, we tried a custom-carved foam “head cup” and special “positioner” pillows to help vary which side he slept on. And we consoled ourselves that he just wouldn’t be able to become a skinhead when he grew up, which was surely just as well.

It’s the kind of parental decision you can second-guess yourself about forever. (There’s no sign of any flatness nine years later beneath his full head of hair, but what happens if he goes bald?) So I found welcome reassurance in a study just out in the journal BMJ on “Helmet therapy in infants with positional skull deformation.”

The paper is small but it’s the first randomized, controlled study — the gold standard in medical research — of helmets for plagiocephaly in babies. And it found that, at least in 84 babies without other risk factors, the helmets don’t help. The babies tended to improve with or without helmets. From the press release:

There was no meaningful difference in skull shape at the age of two years between children treated with therapy helmet and those who received no active treatment. Both groups showed similar improvements although only a quarter made a full recovery to a normal head shape, according to the team of researchers based in The Netherlands.

The results are especially underwhelming when you consider that the helmets, made of firm foam in a hard plastic shell, can cost as much as several thousand dollars, even in Great Britain, where the national health system doesn’t tend to pay for them.

The findings can also seem a bit daunting when you consider that once the flat-headedness developed in babies, only about a quarter of them fully “normalized,” helmet or not.

Dr. Carolyn Rogers-Vizena, a craniofacial surgeon in the department of plastic and oral surgery at Boston Children’s Hospital, emphasizes this point: By no means should concerns about head flatness dissuade parents from putting babies to sleep on their backs, which is known to protect against Sudden Infant Death Syndrome. Back-sleeping alone should not be blamed, she added; babies who develop flat heads usually have other risk factors that lessen mobility, including neck tightness, prematurity or developmental delays.

Also, the study offers useful new knowledge but it’s only one small study, she said, “it’s certainly not the be-all and end-all.”

Because the study is the first of its kind and has not yet been reproduced by other researchers, “it won’t yet dramatically change my practice,” Dr. Rogers-Vizena said. “But it gives me something new to tell parents when we’re counseling them, and hopefully bigger, higher-powered studies will come out so we can get a sense of who’s an appropriate candidate for a helmet and who’s not.” Continue reading

Circumcision Boost: Study Cites Benefits, Notes Foreskin-Related Health Problems

New findings may offer a boost to proponents of newborn male circumcision: Researchers in the U.S. and Australia report that the health benefits of undergoing the procedure “exceed the risks by over 100 to 1,” and note that “over their lifetime, half of uncircumcised males will contract an adverse medical condition caused by their foreskin.”

The review, published online in the Mayo Clinic Proceedings, bolsters the position of mainstream physician groups, such as the American Academy of Pediatrics, which supports insurance coverage of the practice and full access for families who choose circumcision for their infants. But the new report is unlikely to silence critics of the practice, who have called it “insane” and a “disservice to American parents and children.”

Here’s some context, from the study, which shows a slight increase in circumcision among older men, but a decline among newborns:

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

“The latest data on male circumcision in the United States show a 2.5% overall increase in prevalence in males aged 14 to 59 years between 2000 and 2010. In contrast, there has been a downward trend in neonatal circumcisions, with the present analyses finding that the true extent of this decline is 6 percentage points.”

And here’s more from the news release:

Whereas circumcision rates have risen in white men to 91%, in black men to 76%, and in Hispanic men to 44%, the study authors found an alarming decrease in infants. To get the true figures they had to correct hospital discharge data for underreporting. This showed that circumcision had declined from a high of 83% in the 1960s to 77% today.

There seemed to be two major reasons for the fall.

One is a result of demographic changes, with the rise in the Hispanic population. Hispanic families tend to be less familiar with the custom, making them less likely to circumcise their baby boys.

The other is the current absence of Medicaid coverage for the poor in 18 US states. In those states circumcision is 24% lower. Continue reading

Study: In ‘Healthy’ Fast Food Ads, Kids Mostly Just See French Fries

Just watch the video here and you’ll immediately get the gist of this study. To sum up: when fast food companies try to advertise to children their “healthier” dining options, (like apple slices) the kids, for the most part, don’t see beyond the fries.

The takeaway, according to researchers at Dartmouth, is that these ads from fast food giants like McDonald’s and Burger King “don’t send the right message.”

Here’s more from the Dartmouth news release:

In research published March 31, 2014 in JAMA Pediatrics, Dartmouth researchers found that one-half to one-third of children did not identify milk when shown McDonald’s and Burger King children’s advertising images depicting that product. Sliced apples in Burger King’s ads were identified as apples by only 10 percent of young viewers; instead most reported they were french fries.

Other children admitted being confused by the depiction, as with one child who pointed to the product and said, “And I see some…are those apples slices?”

The researcher replied, “I can’t tell you…you just have to say what you think they are.”

“I think they’re french fries,” the child responded. Continue reading

CDC: Autism Rate Up To 1 in 68 Kids, But Still No Why

A new CDC analysis of autism prevalence shows a nearly 30 percent jump in cases between 2008 and 2010: that means 1 out of every 68 eight-year-olds in the U.S. is diagnosed with the disorder.

But health officials still don’t agree on what’s driving the increase. Debate continues to rage over whether the increase in cases is due to changing definitions and greater awareness of autism spectrum disorders, or if it’s due to some environmental or other factor.

Karen Weintraub reports for USA Today:

…virtually every grade in every elementary school has at least one child with autism – a seemingly astonishing rise for a condition that was nearly unheard of a generation ago.

What’s still unknown is the driver of that increase. Many experts believe the rise is largely due to better awareness and diagnosis rather than a true increase in the number of children with the condition.

(Jesse Costa/WBUR)

(Jesse Costa/WBUR)

“We don’t know the extent those factors explain in terms of the increase, but we clearly know they do play a role,” said Coleen Boyle, director of the National Center on Birth Defects and Developmental Disabilities at the CDC. “Our system tells us what’s going on. It (only) gives us clues as to the why.”

The aging of parents is also known to be a factor; the chances of autism increase with the age of parents at conception.

“But that’s not the whole story is it?” said Robert Ring, chief science officer for Autism Speaks, a research and advocacy group. Whether something in the environment could be causing the uptick remains “the million-dollar question,” Ring said.

Despite their concern, experts said they were not surprised by the increase, because other data had suggested the numbers would continue to climb. In New Jersey, for instance, autism rates were 50% higher than in the rest of the nation in 2000, and they remained that much higher in 2010 – suggesting the national rates will continue to rise to catch up, said Walter Zahorodny, a psychologist who directs the New Jersey Autism Study. “To me it seems like autism prevalence can only get higher,” Continue reading

Care Parents Should Question: Medicating ‘The Happy Spitter’ And More

(Wikimedia Commons)

(Wikimedia Commons)

News bulletin: The American Academy of Pediatrics is encouraging parents to question their children’s medical care.

Well, at least on certain very specific procedures that the academy says are not “wise choices.”

“Choosing Wisely” is a new campaign stretching across many medical specialties, aimed at getting doctors and patients alike to “think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.” (I’d add, and in virtually all cases cost lots of money.)

The Academy of Pediatrics had already put out five “things physicians and patients should question,” including the use of antibiotics for viral infections and the use of cold medicines for children under 4, and today they add five more. I’d like to think most doctors wouldn’t do these things anyway, but am also thinking maybe the full list should be handed out to new parents before they leave hospitals. The list is here, and the latest five include:

Don’t perform screening panels for food allergies without previous consideration of medical history.
Ordering screening panels (IgE tests) that test for a variety of food allergens without previous consideration of the medical history is not recommended. Sensitization (a positive test) without clinical allergy is common. For example, about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. When symptoms suggest a food allergy, tests should be selected based upon a careful medical history. Continue reading