Your Children's Health

By Roy Benaroch, MD

True story: I saw a 2-year-old as a follow-up to his trip to the emergency room a few days previously. He was a healthy boy who developed vomiting and diarrhea, and his worried parents took him to the ER. There, a truckload of x-rays, blood tests, and stool tests were done. Among the pages of results were a few that were somewhat abnormal, so they kept him in the hospital for about ten hours and repeated them. They were still “abnormal”, but since the child had stopped having any symptoms—he was “running around, tearing up the place,” Dad said—they sent him home, to see me in a few days.

The tests, combined with radiologists’ fees, cost about $3,000. None of them helped the child, and none of them were necessary. In fact, they led to a prolongation of his ER stay (more money!), scared the parents, and ended up getting the poor child stuck with needles two more times.

What’s the harm in doing extra labs or x-rays?

• They cost a lot. Patients may be upset to discover that they have a separate deductible for labwork—that money is going to come from somewhere.
• Labs beget more labs. I can’t tell you how often kids need repeat labs just to confirm that an abnormal has become normal. If enough labwork is done, something is going to come up as “abnormal” in anyone. That doesn’t mean there is anything actually wrong with the patient.
• Abnormal tests lead to unnecessary worry.
• Drawing blood (and many other medical procedures) is painful, and will scare your child, and will make future health interactions difficult and upsetting.
• Some tests (like x-rays) actually create problems—though the amount of radiation exposure is small, it can add up. About 1 to 3 out of 1000 cancers in the United States are actually caused by diagnostic radiation exposure.

There are, of course, times when labs and tests really are needed. For instance, a child with a fever and sore throat needs to have a strep test, because even a very experienced doctor cannot reliably distinguish between a viral and bacterial throat infection. It’s best to do the test first, so you treat the kids who genuinely need antibiotics correctly. Tests are needed when they help determine the best plan to help the child. But if the results of tests aren’t going to make any difference, the tests are not needed.

To help avoid the cost, hassle, and worry of excessive medical testing, keep these tips in mind:

• Avoid going to the emergency room or urgent care centers. These places will do far more testing than your pediatrician or family doctor.
• Don’t push for labwork. Labs should be not be done “just in case.” Unnecessary tests are much more likely to lead to mischief and misery than to anything medically important.
• If labs or tests are suggested, ask what they’re for. How will they help? When will the results be back?
• Know your insurance—how will labs be paid? Do you need to go to a specific “in-network” lab? Do you have a separate lab or radiology deductible or copay?
• If testing is done, be sure to get copies of results for your pediatrician. Don’t accept “we’ll call you only if they’re abnormal.” If tests really needed to be done, then the results really need to be reviewed and kept in the record.

By Roy Benaroch, MD

Here it is, folks: the annual Physician Compensation survey from Medscape/WebMD. Pediatricians made it to number one!

Number one, that is, for the least paid doctors. We’re right on top when it comes to making less than other physicians. The top three lowest paid docs are the three primary care physicians: pediatricians, family medicine, and internal medicine.

The highest paid doctors are radiologists, orthopedic surgeons, and cardiologists. Why the big difference? The top-paid docs are the ones who do the procedures. They catheterize things and poke scopes into you. They line up their patients and cut and poke and cash the checks. Radiologists don’t even have to talk to their patients—they just mumble a dictation and move on to the next film.

I’m not sure that this system works out the best for patients. I talk, and explain, and discuss, and explain some more. I spend most of my time talking. All of that time, to the insurance company, is just yapping. Hopefully, my patients and their parents leave my office better-educated, reassured, and able to handle things. What they don’t leave with is a big bill from a procedure.

Over the last few weeks I’ve had one patient, a teenager, who has missed a lot of school because of belly aches. I’ve spoken to him, and his mom, and the GI specialist, and the ER doc multiple times to coordinate care and make sure nothing was missed. I’ve talked to the school, I’ve written letters to the guidance counselor. All of this helped my patient get back into his usual routine. None of it paid me a dime. Here’s the thing: the financial incentives in place don’t reward doctors who talk and explain and coordinate. I could have made more money freezing off a single wart than I did for about three hours of phone calls.

Don’t get me wrong: I love my job, and I’d do it for even less money. But the American penchant for action—for doing something—is part of the reason our health care system is so expensive. Paying doctors for keeping people healthy, rather than doing things to them, might be one way to reduce health care costs while improving our wellbeing.

By Roy Benaroch, MD

Sometimes a simple idea can have a big payoff.

A small study published last August looked at using standing-style desks in Texas classrooms to see if children could be encouraged to be more active. In two classrooms, traditional desks were swapped out for desks at a natural standing height, accompanied by higher stools for comfortable seating. Children with these high desks were compared with children who sat at traditional desks in classrooms nearby. Children in both groups wore electronic devices to determine activity levels.

After three months, almost all of the children with high desks were standing most or all of the time, and teachers and students both reported improved behavior and classroom performance. Better yet, students at high desks burned 17% more calories. The effect was even more pronounced among children who were overweight—given high desks, they burned 32% more calories during the school day than overweight children at traditional desks.

This was a small study, involving only 58 students. Still, the results are impressive, especially considering that both the teachers and students liked the new arrangement. These desks improved not only rates of physical activity but also school performance. Though I wouldn’t say high desks would be great for everyone—easily distracted kids, I think, might be more prone to wandering around—this simple, inexpensive, and safe change could have a big impact on weight problems and health.

Standing at work isn’t just for kids. Parents, think about your own desks—could you get your work done mostly standing in front of a high desk instead of sitting all day? Most of us would be healthier with more physical activity, but it can be hard to make it to the gym or have set time for actual exercise every day. Higher desks make it more comfortable to stand, which just might be a safe, painless, and easy way to help you and your kids keep a healthy weight. Give it a try!

By Roy Benaroch, MD

I suppose there’s always something new and stupid for people to do. You can thank Youtube for the latest craze—“The Cinnamon Challenge.” Can you eat a tablespoon of cinnamon in 60 seconds, without drinking any water?

I’m not going to post any links, but Youtube is filled with videos of people trying, and coughing, and vomiting. Fun for the whole family? Maybe not.

Cinnamon is quite irritating, and the tiny powder absorbs fluid quickly. It also seems to clog up the glands that produce saliva in the mouth. People who try to eat cinnamon this way end up with dry, caustic powder in the throats and down their esophagus. Without water or saliva to wash it down, the powder clumps and sticks. Coughing and gagging are inevitable. Worse, it’s very possible to suck the powder down into the lungs themselves, causing trouble breathing and maybe even respiratory failure.

The Cinnamon Challenge can be especially dangerous for people with lung disease, like asthma. It’s also an especially bad idea if the reflexes that protect your lungs are blunted, which happens when alcohol or other drugs are taken.

Facebook, Youtube, and other internet fun sites have made it quick and easy for fads to spread. Some are probably silly and harmless—though even planking has led to some deaths. Other trends, like The Choking Game, are very dangerous. While The Cinnamon Challenge hasn’t killed anyone—yet—it’s a dumb thing to try.

By Roy Benaroch, MD

Protecting your kids from the sun involves more than just slathering on whatever sunscreen’s lying around.

FDA regulations meant to help consumers choose the right sunscreen have kicked in this year and may be causing some confusion. The “Sun Protection Factor,” or SPF, reflects how much protection is offered against UV-B rays, the main cause of sunburn. But it’s never meant anything about UV-A rays, which cause skin damage and aging. UV-A and UV-B both contribute to skin cancer. The new regulations still allow manufacturers to include an SPF against UV-B, but they can only label their products as “broad spectrum” if both UV-A and UV-B are blocked.

You’ll also no longer see sunscreens claiming to be “waterproof” or “sweat proof” because, well, they never really are. Some might be labeled “water resistant,” but like all sunscreens they’ll recommend reapplication after two hours. No one has been able to make a sunscreen that lasts much longer than that.

It’s also very important to use a full dose of sunscreen, which is about one full ounce for an adult. That’s a shot-glass full, or two tablespoons—a whole lot. Most people use much less, which drastically reduces the effectiveness.

You can get good sun protection without relying on as much sunscreen. “Rashguard” shirts like surfers wear are impregnated with sunscreen, and even an ordinary T-shirt offers some protection. It’s also best to avoid direct sun altogether when the sun is directly overhead—that’s when rays are the most intense.

Don’t forget about eyes. Long-term sun exposure contributes to damage to the eye as well, and kids need sunglasses just as much as adults.

Any sunburn—that is, redness in the skin after sun exposure—means that some sun damage has occurred. Repeated sunburns are bad news, and even a single blistering sunburn will increase the risk of cancer. While some sun exposure helps the body make enough Vitamin D, excessive sun exposure can really add up. Just how careful you need to be will depend on your child’s skin type (fairer skin is more likely to be damaged by sun) and your family history (skin cancer does run in families, and sun damage increases the risk.) Smoking is another risk factor for skin cancer that parents may need to keep in mind for themselves. Sunburns, cancer, and aged wrinkly skin are summer’s gifts that your family doesn’t need.

By Roy Benaroch, MD

There was a recent post on one of the WebMD boards about a child suffering from abdominal pains. From the details provided, it was pretty clear that there wasn’t anything seriously wrong with the child, but these belly aches were causing a lot of worry and missed school, and the child wasn’t feeling good at all. Then someone suggested a product that was obviously a placebo. And it worked! The child felt better! So what’s wrong with that?

A placebo can be any medical intervention—a pill, a “brain scan”, any sort of treatment at all—that doesn’t have any biologic effect. We commonly describe them as “sugar pills” or “sham treatment.” In giving the placebo, there’s always an element of dishonestly. The person receiving the placebo has to believe it will work.

And they do, indeed, work. As illustrated in this brief video, placebos can very powerfully reduce symptoms. Studies have confirmed that placebos can drastically and consistently reduce pain, anxiety, and blood pressure; they can even improve diabetes control, help treat ear and sinus infections, improve school performance, and improve the confidence and performance of public speakers. Ever hear the story of the magic ballet slippers? A young ballerina performs brilliantly when she thinks her shoes are enchanted. That’s a great example of how placebos can really work.

But doctors aren’t supposed to prescribe placebos. Doing so is considered deceitful, and we’re supposed to be honest with patients about the risks and benefits or treatment decisions. Of course, if we’re entirely honest about a placebo, it won’t work.

Here’s a secret, though: doctors do indeed prescribe placebos, every day. Whether knowingly or not, doctors suggest and prescribe things to patients that have been proven to be essentially placebos—that is, to work only as well as a sugar pill. That antibiotic for bronchitis? Placebo. Often physical therapy, or antacid medicines, or pain medicine, or medicine to help you sleep—for almost all of these, the “effect” is only a little bit better than a placebo, though they’re all more effective than doing nothing. In other words, most of the effectiveness of many medical treatments is your own mind deciding that you feel better, encouraging you to act more healthy.

True placebos are, mostly, harmless. By their very nature, they have no biologic effect and can’t harm your body. The harm they can do is in developing habits and expectations—people used to “medicines” to treat problems, whether they’re “real” or “placebos”, are far more likely to keep returning to the doctor and health food store for remedies. It can add up to a lot of money. At other times, placebos are chosen rather than a potentially more-effective therapy, which can delay or prevent a cure. Plus, many of the doctor’s placebos, though ineffective, are still genuine medicines that have genuine side effects. For this last reason, homeopathic and alternative-medicine placebos are at least somewhat less harmful than the doctor’s medicine placebos.

So, should doctors prescribe placebos or not? Certainly not, if there is a genuinely effective and safe medicine that will help. Certainly not, if the placebo itself is a medicine that can cause harm. But what about a truly harmless placebo for a condition that otherwise doesn’t have an easy or effective treatment? What if the placebo can really help alleviate pain and suffering? These are good questions, and ones that thoughtful doctors and patients ought to be asking themselves.

Have you ever taken a placebo? Would you be upset if you found out your doctor had prescribed one? Share your thoughts in the comments below.

By Roy Benaroch, MD

Concussions can cause real, lasting brain damage. After a concussion, athletes (both professional and student) can suffer from poor attention, headaches, memory problems, and depression—symptoms that may or may not improve with time. Fortunately, big changes seem to be occurring on playing fields that will protect athletes. Parents need to know how to protect their children, too.

A concussion is a brain injury resulting from a blow to the head. By definition, there is no “structural injury”— x-rays or CT scans or MRI scans will not show any problem. Yet there obviously is a problem: the brain, after a concussion, doesn’t work right. Neurologic symptoms after a concussion can include unconsciousness, but more often the symptoms are more subtle: disorientation, confusion, and problems with memory and balance. With time and rest, these symptoms will usually improve, especially after a first concussion

New attention lately has been focused on symptoms of concussions that don’t improve. Among pro athletes, rising concern about permanent damage has led 106 former NFL football players to sue, accusing the league of negligence in diagnosing and treating their injuries. The NFL, it seems, is listening. They’ve taken recent stories about one pro team paying extra for tackles that cause game-ending injuries like concussions very seriously.

Unfortunately, young athletes may be more at-risk than the pros. Young brains are still developing, and are more likely to be injured. Repeated concussions appear to be especially dangerous—a “second hit” after a concussion that hasn’t completely healed can be catastrophic.

What can parents and coaches do to help keep their kids safe?

• Provide good training so young athletes know how to play safely. Support coaches who teach student athletes well, and take potential brain injuries seriously.
• Make sure that athletes have good protective equipment, including helmets and mouth guards. These don’t prevent all (or even most) concussions, but using them consistently and correctly is still important.
• School systems need to have mandatory, science-based concussion management systems, developed in accordance with national guidelines.
• Officials and referees need to call fouls, and discontinue play when it’s dangerous. Players who put themselves or others at risk should be sent off the field without hesitation.
• Coaches on the sidelines need to look for even subtle signs of concussion in their players, and pull them out of the game if there are any signs at all. When in doubt, players should sit out.
• Players themselves need to know that they should never tough it out—any “dinger” needs to be reported, even if that means they’ll be pulled from the game. Young brains are far more important than scores.
• If your child does have a concussion, be sure to follow the guidance of his physician. A gradual return to sports should not begin until all signs and symptoms of concussion have resolved. If your child has had more than one concussion, or a concussion with prolonged symptoms, consider working with a neurologist to ensure that there’s no lasting damage.

By Roy Benaroch, MD

Unsuspected constipation may be a common cause of bedwetting in children—and treating constipation might just be one of the quickest and easiest ways to help children stay dry through the night.

In a small but impressive study published last year, researchers at a pediatric urology referral clinic performed simple abdominal x-rays on 30 children who were brought to the clinic for help with bedwetting. Of the 30 kids, 80% seemed to be constipated by the appearance of their x-rays, even though almost all of them denied symptoms of constipation. More impressively, when these constipated children were treated with a safe stool softener, over 80% had resolution of their bedwetting within three months.

We know that constipation can contribute to bedwetting in several ways. The hard stool presses on the bladder, reducing its capacity. Constipated children also seem to become less aware of the feeling of a full bladder. Most doctors probably ask about symptoms of constipation in children with bedwetting, but this study shows that asking alone may miss most of the constipated kids.

If your child is wetting the bed at night, consider constipation as a cause. Even children who have a bowel movement every day may be significantly constipated if they’re not emptying completely. A quick x-ray can help confirm if constipation is present. Or, it seems reasonable to me to give your child a trial of a stool softener. That’s safe and easy, and just might help!

By Hansa Bhargava, MD

In a recent article in Vogue magazine, a mother talks about how she put her 7-year-old daughter on a strict, no-nonsense weight loss program. By her own admission, her methods included depriving her daughter of dinner as well as publicly and emotionally derailing her choices of snacks. Additionally, she also chastised her daughter about the way she looked, telling her ‘the fat girl is a thing of the past’. As a mother of a 6-year-old and a pediatrician, I was really concerned about this.

Is this the best way to handle your child’s weight issue? With one third of the children in the U.S. being overweight or obese, you may be asking this question. Having extra weight can certainly be a health issue, putting children at risk for illnesses such as diabetes, heart disease, and liver disease just to name a few. And picking healthy food choices, as well as exercising, is key. But a child’s self-esteem is also at stake. Kids who are overweight may already feel chastised and, frankly, bad about themselves. Many studies have shown that overweight kids are more likely to be socially isolated at school and have significantly fewer friendships. Additionally, they are more at risk for bullying and social alienation.

Has your daughter ever bought up how she looks? My daughter has, already. Our society imposes the belief that ‘being skinny’ is linked to beauty and power on all of our girls. This is furthered by celebrities as well as marketing tactics using unrealistic images of young women to sell their product. This eventually gets internalized and many girls, whether they are overweight or not, feel the pressure to fit into the mold and the ‘skinny jeans’ and end up being pulled into a lifelong battle of food and eating-related issues.

Helping your overweight child is important but how you do it is important as well. Talk to your child about being healthy and how this makes you strong and less likely to get sick. Help her choose the right foods by going to the grocery store and cooking with her; limit eating meals outside the home. And do this for the whole family; eating well is important for everyone. Demonstrate this through your actions and she is more likely to comply. Lastly, don’t forget to incorporate exercise and sleep. A few simple ways to do this is to do a physical activity every weekend as a family, take the stairs, and turn off the TV. The entire family should be involved — this will be good for everyone.

A mother pushing the message that how her daughter looks (and being in a magazine picture) are linked to who she is can be very damaging. Just like all mothers, she probably meant well. But it is really important to remember this — being at the right weight is not supposed to be about looks, it is about preventing disease and being healthy. And good self-esteem is one of the most important tools that a parent can empower their child with, so don’t mix up the message.

How do you feel about this? How would you help your overweight child?

By Roy Benaroch, MD

National Poison Prevention Week is here, highlighting ways for families to prevent poisonings in and out of their homes. Poisonings remain one of the most common causes of death and ER visits among children, though most of them are preventable with a few simple steps.

The most dangerous potential ingestions in your home are medications, insecticides, antifreeze and other automotive chemicals, cleaning products, nail-care products, and alcohol. These kinds of things need to be locked up and physically out of reach of children. You can’t depend on child-proof caps and packaging alone—kids can be clever and persistent and will get through child packaging (sometimes quicker than you!)

Even medicines that you might think would be safe—vitamins or simple painkillers—can be very toxic or deadly in overdoses. Never refer to medicine as candy or allow children to help themselves to medicines or play with the bottles. Remember that visitors to your home, like Grandma, may keep medicines in their purses. For young children even one pill can be very hazardous. Keep medicines in their original containers and safely discard old medicines or leftovers (the best way to get rid of old medicines is to bring them to a pharmacy or doctor so they can be incinerated.)

Be careful giving medication to your children. Measure carefully, using the device included in the package, in a well-lit room—and write down when the last dose was given. An overdose can occur not only when you give too much medicine, but when you give the next dose too soon. After giving a dose of medication, make sure to put the package away securely.

Pesticides and other chemicals should always be kept in the original containers. Children can be especially tempted by things kept in re-used soda bottles or cups, and a single mouthful of these chemicals can kill.

If your child does swallow something potentially dangerous, your first call should be to 1-800-222-1222, which will connect you to the nearest poison control center. (Outside the USA, ask your doctor about the best poison resources.) You’ll need to describe what was ingested and how much. Don’t try to induce vomiting or give anything else to eat or drink unless instructed to do so by the poison center. Don’t give ipecac—it may do more harm than good. The poison center will tell you if you have to go to the hospital. Follow their instructions! Call them before you call your own doctor, who may not be able to access information about the specific poisoning as quickly as a poison center.

Have you ever faced a poisoning crisis? What did you do? What do you do now to keep your kids safe? Share your stories and tips in the comments below.