Monday, February 27, 2012

A 20 second neonatal neurological assessment in the ER !

Here are some great pointers from an ER Pediatrician for general specialists (& of course Pediatricians) on how to figure out if a neonate has possible neurological problems, within 20 seconds of reporting to the ER.

The most important thing that is different between a baby and an adult is that you get a ton of information just from picking up the baby. It's the first thing you are going to do when you see a neonate with one of these complaints or concerns — when the caregiver says, "I think he had a seizure," or "I think he stopped breathing," or "He threw up and changed color."
You undress them from top to bottom so you can see everything. Then you pick them up so that you can feel whether that baby is in respiratory distress. You're going to feel whether they have the right tone. They may be curled up, kind of in a little ball, with some flexor tone, which means their arms are curled in a little bit, their head's a little bit tucked, their legs are drawn up a little bit, kind of as if they had just come out of the womb. And if they are floppy, you're going to feel that. You're going to get a sense that this baby is not where he or she needs to be.
Then you lay them back down and you pull up on their arms, and you see at the very end of that if they can get their head a little bit righted. By about 3 weeks of age, they should have a nice increase in their head control and be able to pull it up a little bit on their own.
The third thing — and these things all take under 20 seconds to do — is to check whether they can visually fix on an object and follow it a full 180 degrees from left to right.
With those 3 things — tone, head control, and visual fix and follow — you're going to have a really good preliminary idea of what your baby's neurological exam is. If it's not normal, that's going to open up a whole different evaluation than if it's normal.
Comments: This is by no means a comprehensive neurological examination, and should be supplemented by further tests as appropriate if the above examination is equivocal / abnormal. But by doing the above, you are unlikely to miss a gross neurological problem in a newborn.

Friday, February 24, 2012

14 Shocking Statistics About Children and Divorce

I’ve compiled these statistics about children and divorce for the “I’ll believe it when I see it” type of people who don’t accept anything as true unless it’s from a credible source or it’s been PROVEN in a convincing study.
If you are NOT one of these people, you need to read this anyway.
These days most people accept divorce as a way of life, completely unaware of the damage they are doing to their children. Tell your friends, acquaintances and co-workers to read these shocking statistics about divorce and children. It may help save a child’s life down the road. (And no, I’m not figuratively speaking either….just keep reading to find out what I mean.)
The EMOTIONALLY Damaging Statistics about children and divorce
1. Studies in the early 1980’s showed that children in repeat divorces earned lower grades and their peers rated them as less pleasant to be around. (Andrew J. Cherlin, Marriage, Divorce, Remarriage –Harvard University Press 1981)
2. Teenagers in single-parent families and in blended families are three times more likely to need psychological help within a given year. (Peter Hill “Recent Advances in Selected Aspects of Adolescent Development” Journal of Child Psychology and Psychiatry 1993)
3. Compared to children from homes disrupted by death, children from divorced homes have more psychological problems. (Robert E. Emery, Marriage, Divorce and Children’s Adjustment” Sage Publications, 1988)
These statistics about children and divorce are pretty shocking, aren’t they?
The DEATH of a parent is LESS devastating to a child than a DIVORCE
The PHYSICALLY Damaging Statistics About Children and Divorce

4. Children of divorce are at a greater risk to experience injury, asthma, headaches and speech defects than children whose parents have remained married. (Dawson, “Family Structure and Children’s Health and Well Being” National Health Interview Survey on Child Health, Journal of Marriage and the Family)
5. Following divorce, children are fifty percent more likely to develop health problems than two parent families. (Angel, Worobey, “Single Motherhood and Children’s Health”)
6. Children living with both biological parents are 20 to 35 percent more physically healthy than children from broken homes. (Dawson, “Family Structure and Children’s Health and Well-being” Journal of Marriage and the Family)
7. Most victims of child molestation come from single-parent households or are the children of drug ring members. (Los Angles Times 16 September 1985 The Garbage Generation)
8. A Child in a female-headed home is 10 times more likely to be beaten or murdered. (The Legal Beagle, July 1984, from “The Garbage Generation”)
This is what I mean when I said “these statistics on divorce and children could save a child’s life someday.” Did you read #12? A child raised by his/her mother is 10 times more likely to be beaten or murdered.
The Long Term Effects and Statistics About Children and Divorce
9. A study of children six years after a parental marriage breakup revealed that even after all that time, these children tended to be “lonely, unhappy, anxious and insecure”. (Wallerstein “The Long-Term Effects of Divorce on Children” Journal of the American Academy of Child and Adolescent Psychiatry 1991)
10. Seventy percent of long-term prison inmates grew up in broken homes. (Horn, Bush, “Fathers, Marriage and Welfare Reform)
Problems Relating to Peers
11. Children of divorce are four times more likely to report problems with peers and friends than children whose parents have kept their marriages intact. (Tysse, Burnett, “Moral Dilemmas of Early Adolescents of Divorced and Intact Families. Journal of Early Adolescence 1993)
12. Children of divorce, particularly boys, tend to be more aggressive toward others than those children whose parents did not divorce. (Emery, “Marriage, Divorce and Children’s Adjustment, 1988)
Suicide Statistics About Children and Divorce
13. People who come from broken homes are almost twice as likely to attempt suicide than those who do not come from broken homes. (Velez-Cohen, “Suicidal Behavior and Ideation in a Community Sample of Children” Journal of the American Academy of Child and Adolescent Psychiatry 1988)
High School Drop Out Statistics About Children and Divorce
14. Children of divorced parents are roughly two times more likely to drop out of high school than their peers who benefit from living with parents who did not divorce. (McLanahan, Sandefur, “Growing Up With a Single Parent: What Hurts, What Helps” Harvard University Press 1994)
I can’t stress how important it is to know all the facts before you get a divorce. Your child’s life is in your hands. If you’re seriously considering divorce and you haven’t attempted to save your marriage , I’ve just given you 14 reasons why it’s at least worth a try to keep your family together. 


Wednesday, February 15, 2012

7 signs that your child loves you .. and a few more !

Here are some 'clues' that your child loves you .. from the excellent BabyCenter website .. 

Your newborn stares into your eyes.
He's actually working hard to memorize your face. He doesn't understand anything else about the world, but he knows you're important.

Your baby thinks about you even when you're not around.
Between 8 and 12 months old, she'll start to scrunch her face and look around when you leave the room — and she'll smile when you return.
Your toddler throws wicked tantrums.
Nope, those screaming fits don't mean he's stopped loving you. He wouldn't be so hurt and angry if he didn't trust you so deeply.
4 Your toddler runs to you for comfort when she falls down or feels sad.
Kids this age may not truly understand the meaning of "I love you," but their actions speak louder than words.
5 Your preschooler gives you a gift.
A flower picked from a garden, a finger-painted heart, a sparkly rock, or another small token is his way of saying you're special.

6 Your preschooler wants your approval.
She'll start to be more cooperative around the house, and she'll look for chances to impress. "Look at me!" will become a catchphrase.
Your grade-schooler trusts you with secrets, like his first crush or his most embarrassing moment.
You're his confidante, even if he shies away from your hugs in public.

And here are a few more that I could think of ... remembering my two year old daughter ...
Feel free to add more in the comments section :)

Your preschooler repeats everything you say.
Even if words don't make sense to her, she (tries to) repeat everything you say ... goal, sixer etc.

Remembers your likes & dislikes 
Gets a glass of water, or your favorite slippers when you come back from office 

Thursday, February 09, 2012

New 2012 vaccine recommendations in USA - Why is Cervical Cancer vaccine being recommended for boys ?

There are more than a dozen changes in the latest 2012 children, adolescent and adult immunization recommendation in the USA. 
One of the major changes in the 2012 children and adolescent vaccination schedule in the USA is the recommendation for giving the Cervical cancer vaccine to boys aged 11-12 years.
Why is this being recommended ? Here is what Dr. Brady, Chairperson, American Academy of Pediatrics Committee on Infectious Diseases has to say. 

Medscape: In October 2011, the Advisory Committee on Immunization Practices voted to recommend routine use of human papillomavirus quadrivalent vaccine (HPV4) in boys aged 11-12 years, and this recommendation is included in the 2012 schedule. Can you discuss some of the reasons for this recommendation, a stronger position than the Advisory Committee's previous recommendation that HPV4 may be given to boys to prevent genital warts?
Dr. Brady: When the HPV vaccines -- HPV4 or HPV2 -- were created, it was with the goal of prevention of cervical cancer. It was known that there are HPV strains that could also produce genital warts, and so those initial studies were primarily done in females. As you know, HPV is a sexually transmitted disease. If you look at mathematical modeling, it appears that if you had coverage of females in the range of 80% or more, you might be able to reduce heterosexual transmission to the point that you could have a benefit for both males and females.
A couple of things have happened since the initial approval. First of all, we haven't had an uptake above 80% for the entire series, and so we have not been successful in trying to implement a public health approach that is going to have a significant impact on heterosexual transmission of HPV. Because males are also participants in heterosexual transmission, this was an opportunity to approach the issue of transmission in another way.
Additionally, it became clear that HPV not only causes cervical cancer but is also capable of causing a number of other cancers, particularly oropharyngeal cancers, which have been increasing dramatically over the past couple decades. Those occur in both genders. Therefore, it was recognized that there would be a significant health benefit to males from receipt of the vaccine for the prevention of oropharyngeal cancers.
The other thing that was recognized was that giving HPV vaccine to females only does not have any impact on transmission of HPV between men who have sex with men. That is a group that has significant risks for both cancers as well as genital warts.
When you put all of the different new pieces of information together, it became very clear that a female-only approach was not going to reduce cervical cancer, oropharyngeal cancer, the other cancers that are seen, and genital warts, as would be seen with a gender-neutral approach.
By having a gender-neutral approach and identifying HPV vaccine as primarily a cancer vaccine, we are also hoping that it will approve acceptance to a greater degree than has been seen with singling out one particular gender. We are just going to make it a routine practice for all children. We hope that that will improve acceptability and eventually get us above the 80th percentile for both.
My view - So male cervical cancer vaccine is being promoted for essentially 4 reasons ...
1. May prevent heterosexual transmission - since males are carriers
2. May prevent gay / homosexual transmission 
3. May prevent other cancers caused by HPV - like oropharyngeal cancer.
4. By making it gender neutral, may increase immunization coverage.
To me, from a strictly epidemiological perspective, the first point is most important. And from a practical point of view, the last point also seems appropriate. Though convincing parents regarding the applicability of cervical cancer vaccine for their son may be difficult.
MSM (Male sex with male) and other HPV related cancers are relatively less common, and to my mind right now may not be appropriate indication for universal vaccination in all kids. 

Sunday, February 05, 2012

Laxatives Cure Bed-Wetting for Many Children

 Laxatives are the answer for many children experiencing bed-wetting, according to a report from Wake Forest University in Winston-Salem, North Carolina. Investigators report that occult megarectum is a commonly overlooked cause of nocturnal enuresis, and that it can be detected simply by an abdominal X-ray and treated with laxatives.
Lead author Steve Hodges, MD, assistant professor of urology, and coauthor Evelyn Anthony, MD, from the Department of Radiology at the university, found that 30 children and adolescents aged 5 to 15 years seeking treatment for bed-wetting had large amounts of stool in their rectums, even though they reported having normal bowel habits. The report, published online December 14 in Urology, showed that 3 months of laxative therapy cured 25 patients (83%) of their bed-wetting.
The authors note that stool retention reduces bladder capacity (and possibly leads to bladder overactivity) and explains why many therapies aimed at the bladder, such as fluid restriction or alarms, may be ineffective.
A landmark study performed more than 25 years ago showed that constipation, defined as abnormal rectal distension, was a commonly unrecognized cause of enuresis. However, those findings did little to change practice. This definition of constipation differs from that of the International Children's Continence Society (ICCS) guidelines, which rely on bowel habits and stool consistency. The researchers hypothesized that undiagnosed megarectum underlies many cases of nocturnal enuresis, and that laxative treatment may be effective.
They performed a retrospective review of 30 consecutive patients (19 boys and 11 girls) seen in their clinic who presented with a chief complaint of nighttime enuresis. They used a novel method to determine the rectal/pelvic outlet ratio and the Leech criteria for assessing fecal loading, using a plain abdominal radiograph, and compared these findings with the reported constipation history according to the ICCS guidelines. According to the guidelines, a diagnosis of constipation is made based on parents' and children's reports of a bowel movement less frequently than every other day, and on whether the stool consistency is hard.
The rectal/pelvic outlet ratio is the ratio of the maximum diameter of the rectum when distended by stool, divided by the diameter of the pelvic outlet between the obturator stripes at the level of the femoral heads.
All the patients showed rectal distension, based on a rectal/pelvic ratio greater than 1, and 80% met the Leech criteria for constipation. Only 3 of the children or families (10%) described bowel habits consistent with constipation. There was a statistically significant difference between the radiographic findings for fecal loading by the Leech criteria and self-reported constipation (P < .001), with the radiographic findings revealing otherwise unknown constipation. For example, for 27 cases in which the self-reports were negative, radiographs showed constipation in 21.
Initial therapy was a bowel clean-out with polyethylene glycol 3350 laxative (PEG), followed by a daily maintenance dose "titrated to keep the stools the consistency of a milk shake," the authors write. If follow-up imaging at 1 and 3 months showed persistent megarectum, daily phosphate enemas or stimulant laxatives were added to the PEG regimen.
The researchers reported that all of the 4 adolescents and 80% of the younger children in the study were cured of their enuresis by these methods. Persistent enuresis at 3 months with no rectal stool on X-ray was considered a treatment failure.
Because some of the cases may have improved over time on their own, a more rigorous test of the efficacy of laxative therapy would require a randomized trial assigning some constipated children to the therapy and others to an inactive therapy, Dr. Hodges noted in a press release from Wake Forest University. He also advised that any medical therapy for bed-wetting be done under the supervision of a physician.
Proper treatment in many cases may require the recognition of occult megarectum, and physicians would do well to focus on rectal distension, and not just functional constipation. In addition to X-ray, Dr. Hodges suggested, in the press release, that rectal distension could also be determined using rectal ultrasonography, with the advantage of avoiding ionizing radiation. He emphasized the importance of a correct diagnosis to avoid unnecessary surgery and the adverse effects of medication (such as desmopressin), and he urged physicians to first obtain an X-ray or ultrasound.
Urology. Published online December 14, 2011
My view - A fascinating study, that tells us quite a few interesting things about a common, yet under-diagnosed condition. For starters, it states that laxatives may work even without any clinical evidence of constipation (only 10 % parents suggested a history of constipation). Also it suggested a simple test, plain abdomen X ray, could help diagnose children that may benefit from this therapy. I can foresee a problem in making the diagnosis of megarectum though, since the regular radiologist may not be trained in doing so, and we pediatrician's may not be able to make the diagnosis confidently. Finally a very large number of children benefited from this intervention, all 4 adolescents, and 80 % of kids, which is as high or even higher than children using the bed wetting alarm/ DDAVP (desmopressin).
Once large scale trials are conducted, we may want to give a trial of laxatives for most children with bed wetting. On a side note, I found the "consistency of stool of a milk shake" quite informative, and would suggest this to the parents, though this may put some of them off milk shakes for good :)