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By David Cotlar
April 11, 2018
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An important part of the safety awareness  portion of a well baby/child visit has always been a review of safety measures appropriate for the child at the age of the particular visit.  Most of the subjects discussed–car seats, secure storage of medication and household products, electrical subjects–have been standard for decades.  But every so often a subject of a newly recognized hazard presents itself, such as electronic “button” batteries or small magnets over the last five or so years.  And just within the last year or two, another new source of serious injury has developed:   concentrated laundry detergent pods which  have resulted in more than 10,000-12,000  calls yearly  to poison control centers, currently about 30 a day.

Although conventional laundry detergent  has been sampled by children in presumably enormous numbers for many years, even decades , it  seldom caused significant injury. But these newer  single-use highly concentrated packets with multi-colored packaging containing Tide, Gain, Purex and other well-known detergent names are really different in this respect.  For reasons that are not fully understood by experts in toxicology–but probably related to the rapid ejection of the super-concentrated product– the injuries from them are far more threatening .   They include profuse vomiting, respiratory distress, and depression of the central nervous system, and ventilator support has at times been required due to aspiration into the lungs.  There has also been at least one serious eye burn reported. The number of fatalities in the last couple years is about seven, and they have not all been in children.  These severe ingestions  have also occurred in some elderly people with dementia.

Detergent manufacturers have already tried to make some packaging changes to reduce the eye appeal and risk of children’s getting into them, although other steps have been suggested but not yet implemented.  But as with all those other potential opportunities for toddlers and children to sustain serious injury–or worse–through  the countless common and less common accidents for which they are at risk, this is one more thing for parents to know about and take the basic measures to prevent.

By David Cotlar
April 11, 2018
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Although the news coverage has  receded a bit,  many  articles still describe the recent enterovirus 68 outbreak as a “mystery virus.”   While there have been hundreds of children affected with the illness and spread to additional states being reported, it is not really a new virus or a particularly mysterious one.  While enterovirus is not a household health term, it is a fairly large group of viruses and part of a larger family of common ones.  There are a few things about this particular agent that are notable.  One  is that serotype 68 is not a common type for this time of year. Two,  that the outbreak has developed unusually rapidly  (though it does coincide with the start of school, so not so remarkable) and  this agent  has currently been reported in twelve states.  Most significantly is that while it usually presents with  the common symptoms of many other respiratory viruses–runny nose, sneezing, cough–it does often take on a complicated course in many children with asthma.  It is the severe cough and wheezing with the resulting breathing difficulty that is responsible for the large number of children who have had to be hospitalized and in some cases be given  respiratory assistance.

As with most respiratory viral illnesses, there is no specific treatment.   The approach parents should take if children come down with these symptoms is essentially what is the usual for respiratory viral infection:  rest, adequate fluids, appropriate fever control and, generally, avoidance of OTC cold/cough medications.    A doctor’s office visit is not necessary for every cold-like illness. The most important component of care is really good observation for  indicators  that a more severe infection is developing: watching for high fever, severe cough, wheezing or other breathing difficulty, and poor fluid intake or keeping down liquids.  And we always add, anything else that suggests a worsening, really sick-appearing child.  There should be prompt notification of a physician to determine if a timely office visit (or after hours, an appropriate urgent-care facility evaluation) is warranted.

It is also important to recognize that like most viruses, this one is transmitted from person-to-person. This means that  frequent, really careful hand washing with soap,  covering the face when coughing or sneezing, and avoidance of shared cups or eating utensils of sick children, is very important.   Such measures can help prevent infection or limit its spread to fewer individuals.  And, in case you are wondering, there is no vaccine for this or similar respiratory viruses.

As of this posting,  there have not been any cases in the Houston area or elsewhere in Texas.  Should this change, it will certainly be prominent in the City’s media outlets.  Until then, parents should treat respiratory viruses as they generally have, keeping in mind that other viruses can sometimes cause more complicated illnesses, and the same observation as is above is always appropriate.

 

By David Cotlar
April 11, 2018
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With a source of discomfort as common as teething in infants–that would be an incidence of about 100%–parents are familiar with the wide variety of approaches to the pain that are utilized.  Probably the most familiar is the use of topical products, that is, liquids that are rubbed on the gums for relief.  One those, viscous lidocaine (a prescription agent) became the subject of an FDA warning on June 26 that will carry the strong “black box” warning requirement.  A study by the agency earlier this year revealed several cases of severe side effects including  jitteriness, confusion, swallowing problems, seizures and heart problems, and several fatal cases were reported. These  problems occurred either due to overdose due to medication swallowed when the syrup was put in a bottle or on a cloth,  or was too frequently or generously applied to the gums.  In other cases a child ingested the medication from a bottle.  Viscous lidocaine is more often used in older children and adults for more severe and painful mouth sores from viruses or other causes.   But this warning has made clear that is should not be used for infant teething.

Lidocaine has never been used as commonly as benzocaine, which is over-the-counter and is found in those well-known products such as Orajel, AnbesoL, Hurricaine, and Orobase.  However, benzocaine  itself was the target of a 2011 FDA warning due to its role in causing a rare condition called methemagobinemia, in which the capacity for the blood to carry oxygen is impaired, causing cyanotic color,shortness of breath, fatigue, and some other problems.   This warning was not as strong, and the risk is probably quite low, but any medication should be safely stored to avoid accidental ingestion.

So what did the FDA  suggest for teething pain?  Reflecting the AAP’s own recommendations only some pretty simple stuff:  gently rubbing the gums with the caretaker’s finger and offering the baby a cool (not overly cold or frozen) teething ring or clean wet washcloth to chew on.  The coolness offers some good anesthetic for a short while, and does so without side effects–as long as there is  supervision to prevent aspiration of the cloth or teething ring.

The FDA did not appear to address the other common  measure for  teething discomfort,  acetominophen ( Tyenol, ect.) and ibuprofin (Motrin, etc.),  and this was a curious omission in the recommendations.  These are widely recommended by pediatricians and reliable online sites, and their safety profile is well established. Ibuprofin should not be used under six months of age, and acetominophen  has some safety preference.

Final note: teething is as normal part of childhood and on average there is going to be a new tooth to deal with almost monthly starting on average from six months and continuing   to about three years of age.  That’s 20 episodes.  So it makes sense to perceive any “need” for treatment in balance,  and certainly to avoid any agents with the potential for harm.  As an aside, it is worth noting that families often incorrectly  attribute symptoms to teething which it does not cause.  When there is significant fever, diarrhea, vomiting or impressive irritibility some other source must be sought.

By David Cotlar
April 11, 2018
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In Houston, and perhaps in a lot of other places summer and intense sun exposure having been a little slow in showing up this year.  Well, good.  We’ll take that.  But with summer just about upon us, it’s important to keep in mind that adherence to sun protection is particularly vital in children because of thin skin and less pigment (melanin), and evidence suggesting higher risk of later melanoma with frequent childhood sunburn.  So  anything that facilitates the process of protection of great benefit,  especially because frequent reapplication is necessary during water activities.

A recent  article in the publication, “Consultant for Pediatricians”   presents the case of the use of a relatively new form of protective products, sunscreen sticks.   Like  lotions, creams, and sprays,  sticks some products contain only agents  those that physically block solar UVA and UVB radiation, zinc oxide and titanium dioxide, while others add organic chemical absorbers which affect UVB only.  The article points out that while many parents have a preference to avoid the chemicals in the latter, the authors prefer the combination products for children beyond six months or of any age with sensitive skin.

What are the advantages of the stick products?  Several.   Unlike creams and lotions, they will not trickle down the skin, making them more comfortable and acceptable near the eye.  They are also easy to apply to the really sub-exposed areas of the face such as nose,ears, and cheeks.  Their general convenience makes the frequent reapplication more convenient and quicker, providing a more reliable means of getting the children protected every hour or two when water play can cause loss of that protection more quickly.

They also  offer several advantages over spray products:  they avoid the risk of the chemicals in the spray aerosol from getting in the eyes and nose, are more likely to contain both the forms of protection mentioned above, and provide an easier and more reliable techniques for application that is more evenly distributed and more thoroughly applied.  So adherence–acceptance and reliable use–is the bottom line important advantage. And the container size is small and handy.

The article listed well over a dozen specific products with SPF’s ranging from 28 to 50, and varying combination of ingredients, though most were titanium dioxide and zinc oxide.  The products vary in age use recommendations, water protection effectiveness, and specific facial use or face and body use.

An article on sunscreen should always either start or end with what might be the most important point:  sunscreen should never  be regarded as the only (or most important) component in protection from sunburn.  Time of day, duration of exposure,  sun-protective clothing and hats should always be the first tiers of protection.  And don’t forget the sunglasses, even in very small children.  Hats and sunglasses make for cuter pictures as well.

Acknowledgment:  Suncreen Sticks in Children: An Adjuvant Method of Optimal Sun Protection, by Antonov, Garzon, Morel, and Lauren in “Consultant for Pediatricians,” April 2014. HMP Life Sciences Division

By David Cotlar
April 11, 2018
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Claims about the benefits of probiotics in both children and adults have been emerging for some years already, with the alleged benefits so numerous that it can be tricky to know just how much to believe.   In January of this year, there was a study from Italy published in  the AMA’s pediatrics journal which showed, as some previous one had,  benefit from lactobacillus reuteri in many infants with colic.   However, in April, there is another large study,  reported in the British Medical Journal.  In this report,  167 formula or breastfed infants between three weeks and three months of age enrolled,  with approximate half given lactobacillus reuteri and half given a placebo.  Using a pretty detailed protocol, these  investigators found no benefit in the treated babies.  The  conclusion was that this probiotic “did not reduce crying or fussing, nor was it effective in improving infant sleep, maternal mental health, family or infant functioning, or quality of life.”

In an article on use of probiotics for a different pediatric problem, the  April, 2014  issue of  Pediatrics (the AAP journal) contains  a study from Mexico,  looking into  the value of a probiotic for  preventing diarrhea in children attending day care.   As the article notes, there had  been previous investigations in Finland, India, Taiwan, and Indonesia which had suggested less diarrhea and respiratory infection in young children supplimented with probiotics.  Lead author Dr. Pedro Gutierrex-Castrellon and his co-investigators set out to design and carry out a  particularly well-controlled study to investigate these benefits   In a group of six to 36 month old children, 168  were  given a standardized amount of a type of lactobacillus reuteri  and and equal number were given a placebo.    The period of treatment was three months and then children were followed another three months.  There were  a number of specific measures by which benefit could be measured in a statistically reliable way

Without getting into the details of all this, the results of this research  demonstrated a lower risk of developing diarrheal illness or upper respiratory infection in those children who were given the daily dose of this bacterial supplement.  In addition, cost effectiveness was noted, as parents benefited from fewer missed school and work days as well as medical visits and antibiotic prescriptions.  The authors end the study by pointing out that their findings confirmed the results of early ones, but with an even better designed protocol, and concluded that  the preventive use of this agent can be recommended.

So?  Not helpful for colic, but helpful to prevent diarrhea and respiratory illness in daycare attendees? This is a very brief update on a big subject, we can expect to see more evaluation on probiotic use in the future.

 





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