Posts for: April, 2012
Airway Injury Associated With Humidifier “White Dust”
Physicians at the University of Utah, Respiratory medicine department reported a case involving a patient seen in their facility in the January 2011 issue of, Pediatrics. After exposure to “white dust” dispersed incidentally from the use of an ultrasonic home humidifier machine, the 6-month old infant went on to have lower respiratory tract injury with attendant clinical features and a prolonged recovery.
Home Humidifiers are commonly used to relieve symptoms associated with acute respiratory tract infections in young children and are especially popular in the winter months annually. Benefits with the use of these devices have not been documented. It is noteworthy that the Environmental Protection Agency has not found any adverse health effects related to humidifier use as well.
Humidifier white dust can be generated as part of the normal functioning of these devices and while in full adherence to manufacturer specifications for usage. This may represent a concern for airway injury or reactivity in infants and young children, yet the true risks of home humidifier use have not been well studied and the case report mentioned above rank lower in the hierarchy of medical evidence and do not prove causality. Humidification may reduce patient discomfort in the setting of cold symptoms and nasal congestion, further evaluation by a medical professional is recommended if parental concerns should arise or symptoms worsen.
This case however raises important questions about the safety of exposing infants and young children to humidifiers and emphasizes the need for further study.
My baby is crying, can I use a pacifier?
Many mothers find themselves seeking answers to this question especially in the breast feeding mothers, who often have been schooled pre-discharge not to administer anything other than the breast when a desire to breast feed is expressed. The 1998, 10 steps to successful breast-feeding issued by the World Health Organization was very clear on the recommendation not to use pacifiers or artificial nipple devices.
Will pacifier use disturb successful breast-feeding?
Breast-feeding on demand is ideal and depends on many steps some of which need to be identified in the prenatal period during counseling and too many problems with successful breastfeeding later may have been excessively attributed to the pacifier . This question was generated by medical researchers recently and their results were published in March 2001 in the Cochrane Database of Systemic Reviews. They set out to assess the effects of pacifier use compared to a no pacifier use in healthy full-term newborns whose mothers initiated breast-feeding and the intend to exclusively breast-feed.
Does the scientific evidence suggest harm?
They pooled prior studies addressing this problem using rigid criteria. Cumulatively their efforts involved studying about 1900 infants. Rigorous scientific and statistical methods were applied and the results show that the use of pacifier in healthy full-term breast-feeding infants either at birth or after successful lactation is established did not significantly affect the regularity or duration of exclusive and partial breast-feeding up to 4 months of age. The data reviewed here does not answer short term breast-feeding difficulties faced by mothers and the long term effects of pacifier use on infant health, considering that breast-feeding is often encouraged through the first 6 months of life and beyond.
Pacifier use is not in encouraged in our practice in the first 2 weeks of life. In this situation, we believe it may actually point to hidden problems with the feeding process which may later on hamper successful breast-feeding. Pacifier use may also increase the likelihood of nipple contamination and diarrhea illnesses. Some of the benefits identified in clinical practice with pacifier use however include reducing the chances of the dreaded sudden infant death syndrome since it obligates the newborn to breathe while sucking.
Mothers who are breast-feeding can use the pacifier appropriately, without feeling guilty but need to remain conscious of the fact that each mother-infant unit is peculiar and the goal of breast-feeding on demand remains key. Breast feeding on demand requires frequent feeding sessions anywhere between 8 to 25 feeds in the 24-hour cycle on the average with attendant age appropriate number of stools and voids. Prolonged use of the pacifier can significantly interfere with this process and compromise newborn nutrition and hydration especially in a hot climate like Arizona where frequent nursing helps to offset increased evaporative moisture losses through the breath and skin by the environment in exclusively breast fed newborns.
Am I Too Clean?
Is it conceivable to believe that an individual can be too clean for their own good?
Maybe. We know that immune system has an adaptive capability that matures and becomes more savvy as the challenges mounted by invading germs continue over a lifetime and the body prevails. This has been cast as a potential mutually beneficial relationship for the body and thankfully the invading germs in a theory proposed to explain the rising trend of allergy and immune system mediated diseases called the ‘hygiene hypothesis’. This theory maintains that living in very clean and hygienic environments robs one of the ample exposure to microbial organisms which are beneficial for the maturation and cutting edge ability to distinguish invaders from what belongs to the body. A disorderly maturation may then arise and predispose individuals to varying levels of abnormal immune responses which manifest in various allergy mediated disease forms.
What explanations exist?
Needless to say, this is still a theory and not validated as a scientific fact yet. Researchers from the University of Michigan School of Public Health observed a pattern corroborating another aspect of this theory, more amenable to scientific scrutiny. They examined data from the National Health and Nutrition Survey (NHANES) for the period 2003-2006. Two common environmental toxins, Triclosan and Bisphenol A both of which have known effects on the delicate balance of the immune and hormonal systems respectively in the body were looked for in patients aged 6 and older who also had diseases attributable to immune dysregulation e.g, Hay fever. Their findings published online in November 2010, showed a relationship between having high levels of this Triclosan in the body and immune dysfunction associated disease. Triclosan, is an antimicrobial agent and is ubiquitous in the home environment. Diapers, antibacterial soaps, and toothpaste are some household items that contain this product. The higher levels of Triclosan seen in this patients may have sufficiently altered the population and type of microbes that these individuals would have been normally exposed to and therefore led to maldevelopment of the immune system and allergy related disease states.
Does this apply?
This writer has personally observed trends not subjected to scientific testing at any level yet and not valid for general application, in children of first generation West African immigrants born in the USA who go on to develop varying levels of allergy symptoms which are mediated at some level by immune dysregulation. The parents demonstrate no such problems and a cautious assumption may be to say their earlier childhood exposures in the developing world to different microbial agents in childhood may have fostered a proper maturation and development of their immune systems. This perhaps fostered the innate ability of the immune system to distinguish self from non-self and keep the focus on the invading germs.
Oh! Doc, her fever just won’t go away and keeps coming back!
An often heard comment in primary care settings, I daresay, globally! A study in the March issue of Pediatrics. 2011;127:580-587 led by researchers from the American Academy of Pediatrics Section on therapeutic use of medications came up with recommendations that challenges the instinctive approach to febrile illness most parents demonstrate when their children develop fever. Treatment of febrile children should focus on improving the child's comfort rather than bringing the temperature down to normal levels or preventing the onset of fever, according to the report.
Is the fever bad for her?
"Many parents administer antipyretics even when there is minimal or no fever, because they are concerned that the child must maintain a 'normal' temperature," the study authors note. "Fever, however, is not the primary illness but is a physiologic mechanism that has beneficial effects in fighting infection," they write. "There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications." An individual needs to have an immune system functioning optimally at many levels to respond to the presence of an invading germ and fever often is one the responses mounted by the body during this process. There are other conditions where the patient age, or severity and pattern of the fever could be a cause for additional concerns and these should be addressed with your doctor.
My cousin had seizures with her fever when we were little, is this going to happen to my baby?
These researchers state, there is "no evidence that reducing fever reduces morbidity or mortality from a febrile illness" or that it decreases the recurrence of febrile seizures. Febrile seizures can occur in any child usually between ages 6 months to 6 years often when there’s a rapid rise in core body temperature. There are a few cases when these febrile seizures especially when recurrent and complex may be indicative of potential problems in the developing nervous systems in these children and merit further evaluation.
Her Daddy gave her a second dose of fever medication without asking me first, is she going to be okay?
The appropriate dosing for acetaminophen (Tylenol) is 10 to 15 mg/kg per dose given every 4 to 6 hours orally, which produces an antipyretic effect within 30 to 60 minutes in approximately 80% of children. The appropriate dosing for ibuprofen (Motrin) is 5-10 mg/kg per dose with 6 hourly to 8 hourly dosing. These dosages should determined by your physician.The dangers of excessive and inappropriate medication administration are real and proper communication among all care providers helps with adherence to treatment plan. Children, especially the very young often do not handle the consequences of dosing errors well. Tepid sponging with lukewarm water is a useful adjunct for fever management in concerned parents. When done appropriately, the evaporation of lukewarm water dabbed repeatedly on the skin, cools the extremities and gradually begins to decrease the core body temperature accordingly.
The study also emphasizes the importance of clear labeling, dosing, and proper storage of medications used to treat fever. It also warns against the use of combination therapy with acetaminophen and ibuprofen because this approach may place infants and children at increased risk for dosing errors and adverse outcomes.
The title song in this 1966 classic, Follow me, boys! is more than ode to the Boy Scout movement or the last production with Walt Disney’s thumbprints on it. The redemption of the troublesome youth in town and the odyssey of Lemuel “Lem” Siddons intertwine as he earns the respect of the town folk and loyalty of the youth. Disruptive youth behavior with attendant global socioeconomic stressors makes parenting more challenging today and remains a widely prevalent problem. The dim reality that pharmacologic therapy with pills alone will not suffice even in the 21st century and indeed needs a full spectrum of support for success when indicated makes me wonder if Lem’s experience, expertise and approach to solving this problem fictionally would be applicable today
The town of Hickory and the trouble it faced with it’s youth in the 1930’s bear some semblance to the disruptive behavioral problems plaguing youth in diverse neighborhoods nationwide today with a view from 30,000 feet. Perhaps, the remarkable gains at the end of the story and community empowerment through the selfless leadership shown by Lem Siddons’ character played by Fred MacMurray certainly appeals as plausible to common sense but it may have found even more traction scientifically in a Randomized Controlled Trial study published in the March 13, 2012 issue of the British Medical Journal.
The team of investigators selected one of the poorer boroughs of London in 2010 and set out to evaluate the effectiveness of a peer led parenting intervention for disruptive behavior problems in children ages 2-11. 116 children and their respective parents were recruited for the study and split into two identical groups at baseline.
Peer mentors from the community were selected, paired and assigned to administer the intervention to small groups of about 7 to 14 parents drawn from the one-half of study participants to be treated. The intervention consisted of a structured manual and using validated methods themed on, social learning, structural, relational, and cognitive behavioral theories and methods for the treatment of disruptive behavior in children. These total of 8 weekly, 2-hr sessions involved sharing of information, group discussion, role play, reflection, and planning/review of homework tasks.
These peer mentors, the study reports were themselves parents from the local community who had successfully completed an accredited training program that included workshops (totaling 60 hours), submission of a written portfolio, and a period of supervised practice.
The results are promising and showed that this peer led parenting intervention dubbed “empowering parents, empowering communities” by the investigators could significantly address child behavior problems and improve parenting competencies, just like Lem Siddons’ bold intervention through the Boy Scout program the town of Hickory decided to spare from the blocks redeemed the youth. This could evolve into a promising method for providing effective and acceptable parenting support to families considered hard to reach otherwise, as their parents try to grapple these issues and others.
The study design had its strengths and flaws but inherently met the well regarded pedigree of a randomized controlled trial and other questions raised as a result of this merit further evaluation. Formal economic evaluations are yet to be completed, the interventionmay in the interim offer an economically viable method for increasing provision of evidence based parenting support for families oblivious to the benefits of equipping parents with skill sets to specifically address disruptive behavior problems in their children. I hope we’ll find the will to follow the gains of this study, explore ways of implementation and lead the children away from disruptive behavior, the way Lem Siddons has showed us all for more than a half century. Follow me, Folks!