Posts for: November, 2012
What is CAM and what does it mean for my child?
CAM is an acronym for complimentary alternative medicine. The arm of the National Institute of Health (NIH) dedicated to providing information on CAM therapeutic options, and evidence for efficacy defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine is medicine as practiced by holders of M.D., D.O. degrees and by other allied health professionals, such as physical therapists, physician assistants, registered dieticians, psychologists, and registered nurses.
As the US health system migrates from an episodic care based model to a patient centered continuous care model among other changes in the offing, this crisp distinction between CAM and conventional medicine is certain to evolve.The 2007 National Health Interview Survey (NHIS), which included a comprehensive survey of CAM use by Americans, showed that approximately 38 percent of adults use CAM. As a practicing fellow of the American Academy of Pediatrics, this means at least 1:3 of the patients in my care may be using forms of CAM alongside conventional therapies with their parents or may elect to adopt it wholly (Alternative medicine) now or later.
Is CAM bad for my child?
Frankly any judgment on CAM is outside the realm of expertise of graduates of allopathic or osteopathic schools of medicine. The emphasis rather should be to equip the population with adequate information for informed decision-making. All care providers owe it to their patients to use the best of scientific evidence based health care practices whenever appropriate and to provide compassion and sensitivity to the patient's cultural, spiritual and emotional needs. Numerous CAM therapies are widely available to the public. Some of these CAM therapies maybe effective, there isn’t enough body of evidence in the medical literature to support efficacy of all CAM therapeutic options and more research is needed. This is where the quasi- caveat emptor and caveat venditor principle applies. There have been concerns about the safety of some CAM therapies, as reported in a small study from Australia in 2010 published in the Archives of Diseases in Children and Adolescents though the pedigree of controlled clinical trials required to evaluate the safety profiles of these CAM therapies are lacking in this study and the vast majority of others published to date.
CAM therapies have been broadly classified into (1) mind-body medicine, (2) biologically based therapies, (3) manipulative and body-based methods, (4) alternative medical systems, and (5) energy therapies. Biofeedback, Acupuncture, Music therapy, Animal therapy, and guided imagery are some of the popular CAM options commonly seen in pediatric centers and hospitals today.
Biologically based CAM therapies especially herbal therapies are especially common in my experience. They are classified as dietary supplements and outside the jurisdiction of the FDA sparing them the scrutiny of documented safety, efficacy and a profile of adverse effects before being made available for public consumption unlike conventional medications. This lack of regulation, purification and standardization presents unique challenges for the practicing pediatrician, since similarly labeled products from different manufactures may differ significantly in ingredient content and potency. This is especially concerning when pharmaceutically active ingredients like St John’s wort, melatonin etc. are involved. Heavy metal poisoning with lead after ingesting “tea” brewed specially at home for asthma in pottery imported from northern Africa led to significantly higher levels of lead in a patient in my care some years ago. Exposure to heavy metals like lead and arsenic is a key concern with use of some biologically based CAM therapies imported from Asia. Certain cosmetic products while not strictly form of CAM but when imported from exotic places may pose similar risks from absorption of heavy metals through the skin with attendant health effects.
Credible sources as the National Center for Complementary and Alternative Medicine (www.nccam.nih.gov), the natural standard (www.naturalstandard.com) and discussing all treatment options being considered with your physician go a long way in safe guarding desired healthy outcomes. Our goal as aptly stated by Dr. Edward Trudeau in the 1800’s remains, “To cure sometimes, to relieve often, to comfort always”.
It might not surprise you that video games are big business, but you may find it interesting to learn that the 2009 video game sales in the U.S alone totaled more $19.5bn which actually beats the GNP (the economic performance of a country) of about 90 of the 192 independent nations of the world! The popularity of screen media based devices that have a system of rewarding, or incentivizing the participant, through competitive and interactive plots and designed for recreational use hardly escapes notice wherever you find yourself today in the U.S and indeed most of the developed and developing world.
Do video games have any positive effects on our health? Can video games be useful in improving health outcomes? “Most research related to video games and health has focused on their potential for harm. Ample violence is portrayed in video games, even when they are not labeled as such, and exposure to violent video games has been linked to aggressive cognitions, aggressive behaviors, desensitization to violence, and decreases in pro-social behavior. Research further suggests that active participation with violent video games may increase aggression more than equivalent time passively exposed to movie violence.” A team of researchers led by Dr B.A Primack at the University of Pittsburgh, set out to address some of these questions and published their findings in the June 2012 issue of the American Journal of Preventive Medicine, reviewed in this commentary.
Play is fun and instinctive across many life forms and it captured the attention of the ancient philosopher, Plato who stated in 400 BCE “You can discover more about a person in an hour of play than in a year of conversation”. Certainly, Plato had no ideas about the remarkable vivid imagery seen on many platforms and real-life simulation of combat scenes obtainable today or even the extreme and sad story from a couple’s obsession with raising a virtual child in an online video game, during 12hr long online game sessions that eventually blurred their perception of reality and cost them the death of their own living child from starvation in South Korea in 2010.
The researchers combed through six premium medical literature databases and with proper scientific scrutiny chose 38 studies for analysis from an initial pool of >1400 studies. Only the studies that met the high pedigree of testing known as RCT and lent information to the question, whether video games may be useful in improving health outcomes were reviewed. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. There is still a need for higher quality research in this regard; for example, two thirds (66%) of studies had short follow-up periods of <12 weeks, longer follow-up periods of participants give a clearer sense of what the long term effects of the intervention applied would be and generally a better sense of its applicability to the vast majority of the public. More so only 11% of the selected studies enhanced the scientific rigor applied further by blinding researchers during the test period and making themselves unaware which participant was getting what intervention and vice-versa to avoid biased observations.
Far from making this out as a eulogy on video games, we need to remember also that video gaming demands substantial screen time that has been associated with inactivity and the development of obesity. As a pediatrician this has been a recurring area of concern. The playing of video games also has been linked to adolescent risk-taking in traffic, poor school performance,video game addiction,unfavorable changes in hemodynamic parameters, seizures, motion sickness, and physical injuries related to repetitive strain.The American Academy of Pediatrics recommends that children get no more than 2hours of educational content screen time daily, this includes both TV and video gaming time.
The typical gamer today in the US is actually not always the gawky pre-adolescent and 10th grader holed away for hours in his chosen corner of our good planet as one might be quick to assume is the case. The researchers showed that long-held stereotypes do not apply here and the average game player is 34 years old; 40% of players are female, and 26% are aged >50 years. In 2009, 67% of U.S. households owned either a console or a personal computer (PC) used to run entertainment software or both. Therefore, video game playing is now a phenomenon woven into the fabric of American life. This didn't escape the attention of policy makers who in West Virginia made substantial investments in the active video game “Dance Dance Revolution” in all of its 765 public schools to increase physical activity, despite a lack of comparative effectiveness data.
There are clearly gains to be made with these gaming consoles just as there are ills inherent with abuse, their visibility and impact on everyday life hopefully will foster more quality research from the medical community to guide us all. Plato’s surmise of the potential benefits of a hour of play sounds to me like a good spot to begin, game on!
We will follow through on addressing other therapeutic options for infantile colic in addition to the comfort measures discussed last week.
There is enough evidence in the medical literature suggesting that newborn infants go through a brief period of intestinal enzyme insufficiency simultaneously at the same time colic symptoms peak and wane. The specific enzyme tested for in these studies is called lactase. This enzyme plays a key role in the breakdown and digestion process of milk sugar otherwise known as lactose. A transient deficiency affecting lactase leads to poor milk digestion and lots of gas and other by products are produced. The gas produced contributes to abdominal discomfort and spasm we believe plays a key role in the progression of symptoms leading to infantile colic.
Medications aimed at attenuating this progression of symptoms have always being met with variable amounts of success. There isn’t any one therapeutic option that consistently gives symptomatic relief. A careful evaluation by your physician is always necessary since there are conditions that may mimic infantile colic and yet be very different and distinct disease processes.
Anti-gas over the counter drops often contain a drug known as simethicone. This medication has been described as an “anti-foaming” agent. The medication makes it less likely for the smaller gas bubbles from the maldigestion process described above to coalesce and form even bigger bubbles which end up making it more difficult for the infant to pass the gas as flatus. When simethicone was subjected to a high pedigree of scientific scrutiny known as randomized controlled trial, there was no scientific proof of its usefulness for infantile colic. Our experience has shown a variable response and because its not absorbed or pose toxicity concerns when used as recommended, it continues to be a favorite for colicky infants among parents.
There are other over the counter medications formulated to contain preparations of the lactase enzyme whose transient deficiency is believed to be central to the evolution of colicky symptoms. Lactase is an enzyme and can easily be denatured when exposed inappropriately to the elements. There are scientific studies with a small number of participants showing satisfactory response rates after 3 days of use in more than 20% of enrollees. We would advise readers to discuss with their physician before administering all medications.
Changing the infant formula to products that do not contain lactose sugar in the milk may sometimes be necessary as determined by your physician. These products contain a different form of sugar from corn-syrup. It is noteworthy that human milk contains lactose sugar and these products often contain other partially digested forms of milk protein as well.
The symptoms of infantile colic described in these series eventually resolve between the 3rd and 4th month of life when the partial lactase deficiency resolves and the infant gut usually resumes the production of adequate lactase. Preparing parents for the possibility of colicky symptoms that can affect as many as 20% of newborns during preventive health visits by far seems to be the best weapon against colic, after all to be forewarned is to be forearmed.
Parenting is a joyful and rewarding experience and the appearance of a concern in the newborn can be very distressing. We frequently encounter parental concerns themed on crying and suspicions of colic in newborns. This post on Infantile colic is the first of two addressing this concern commonly seen in about 1:5 newborns. The most widely used definition of colic is set in the rule of threes. These seriously fussy babies cried for more than 3 hours a day, more than 3 days a week, and for longer than 3 weeks. This cascade of events is Illustrated below.
Baby’s been home for more than 2 weeks already and everyone’s settling into the routine of caring and nurturing the newest member of the family, then here comes along these crying bouts, with a higher pitch than mom or dad ever recalled before. These crying episodes now occur more frequently and baby is only about 3 weeks old, and oh yes- they go on for hours, sometimes for as long as 3hours! It happens up to three times weekly! Even more perplexing to everyone is the fact that baby is dry, was fed recently, and doesn’t appear ill or unwell. The crying goes on and on, despite efforts to soothe and calm the baby and this is all happening in the evening – just when everybody is getting tired and getting ready for bed! Did the doctor also say this can go on for up to 3 or 4 months?
Crying is a welcome response to stimulation especially right after the newborn is removed from the birth canal during the birthing process and pretty much a normal feature of infancy. When it occurs in the context described above, Infantile Colic becomes a strong possibility in the affected infant. Physician notification and evaluation is necessary in these situations to exclude other potentially serious conditions that may be amenable to medical and occasionally surgical intervention that can also present with prolonged crying bouts.
The mnemonic PURPLE, developed by the National Center on Shaken Baby Syndrome, is designed to reinforce parental education which as we discuss in this post is the cornerstone of treatment and to help reduce the incidence of shaken baby syndrome, which sadly still happens. Never shake a baby. This mnemonic PURPLE helps to remind parents of the characteristics of infant crying: P for the peak pattern occurring around the third week of life to about 3 months, U for the unexpected timing of episodes, R for resistance to soothing, P for pain-like look or drawing up of knees, L for long bouts lasting for 3hours are not uncommon, and E for the evening pattern of occurrence of these symptoms.
What Can I do to help my baby with colic? “Anticipation is more potent than surprise”, once quipped a very successful military commander. Anticipating colic and having a plan in place during these fussy periods can be a particularly potent intervention. In our practice, parents are encouraged to first ensure that the baby is dry and fed. Soothe the baby by swaddling, or gentle rocking motions. Certain distracting sounds, not subjected to scientific scrutiny at any level yet, but commonly generated in the home e.g., from a kitchen blender or vacuum cleaner or the static noise from a poorly tuned TV or radio have oddly worked sometimes too. A short car ride with the gentle din of the engines etc. have anecdotally worked too. These interventions take the infant’s attention away from the discomfort central to colic. When crying continues despite these interventions, parents should allow the infant to cry for a short period and observe. This approach allows parents to reassess the situation and is a cautious reminder that crying is a feature of infancy. This can assuage parental concerns however momentarily. The rule remains, never shake a baby. Calling your pediatric office to review the situation offers much needed support and a follow up plan on the infant's symptoms usually follows. Parents should not neglect themselves, their overall health and well being directly affects their ability to care adequately for the infant. Good amounts of rest, and enlisting the help of family members or friends to take over from time to time to reduce stress on themselves.