The American Academy of Pediatrics’s current position states “circumcision has potential medical benefits and advantages, as well as risks. The existing scientific evidence is not sufficient to recommend routine circumcision.” The AAP is reportedly working on an updated statement that is more in favor of circumcision, although the medical argument for or against has not changed.

I, personally, feel that the medical benefits from circumcision are too small for it to play a role in the decision whether or not to circumcise:

• Over 100 male infants would need to be circumcised to possibly prevent 1 urinary tract infection.
• The likelihood of penile cancer is too low to even be considered.
• The studies on reduced rates of sexually transmitted infections often do not translate to our patient population, who are less likely to be having unprotected sex in areas with endemic HIV.  Plus, the cost/benefit analysis between teaching your child to use a condom (as well as not having unprotected sex in an area with 40-60% HIV rates) or getting a circumcision seem pretty obvious.
• The care of the circumcised penis is nearly identical to the care for the uncircumcised penis.
• The rates of foreskin infection or phimosis (a narrowing of the foreskin that prevents retraction and may require surgery) are similar to the rates of further surgical revisions in the circumcised males.

However, the side against circumcision also lacks good data that circumcisions are causing problems. I have only been a pediatrician for 5 years, but none of the circumcised teenage males in my practiced have complained that they don’t enjoy sexual activity. Severe complications from circumcision are extremely rare; it is certainly safer to have a circumcision than to drive in your car on any given day. While the procedure is clearly painful, we also have no evidence that it has lasting effects on children.

From my perspective, the decision to cut or not to cut is entirely personal/cultural and needs to be made by the family.

Helpful links:

• AAP HealthyChildren.org: “Should we have our son circumcised?”
• Seattle Mama Doc: “What is Foreskin”  (Great blog on foreskin with links for care of the uncircumcised penis.)
• Parenting Magazine: “Should We Circumcise Our Son?” (A fairly balanced and comprehensive discussion of the pros and cons of circumcision.)

I hate sinusitis in a totally different way than all of the adults out there with a stuffy nose, pain when they lean over and achy teeth.  I hate it in a “Seriously? You expect me to diagnose this is someone?”-kind of way.  I secretly long for the days before Internal Review Boards told people that doing sticking a needle through someone’s face to drain the sinuses seemed too cruel to justify the information they might yield.  Let me explain:

Sinusitis is the 5th most commonly used pediatric diagnosis.  It accounts for 5-10% of most pediatric practice patient visits.  If treated, it is recommended to treat for 10-14 days with antibiotics (= a lot of antibiotics).   But there is NO GOOD WAY of diagnosing it.   The only difference between most cases of sinusitis and a common viral upper respiratory infection is that on day 10 of symptoms, most colds are getting better and most sinus infections are not.  (http://www.cdc.gov/getsmart/campaign-materials/info-sheets/child-rhin-vs-sinus.pdf)  That’s it.  The color of the drainage doesn’t help either.  Let me repeat.  Green or yellow boogers does not mean it is or isn’t a sinus infection.  

From the Cincinnati Children’s Hospital Evidence Based Medicine Guidelines
     It is recommended that the character of the nasal discharge not be used to make a diagnosis or as an indication for antibiotic treatment. The quantity, quality, and color of nasal discharge are not helpful in differentiating ABS from other upper respiratory illnesses (e.g. common cold, allergic rhinitis) (Wald 1981 [B], Aitken 1998 [C], McLean 1970 [D], Gungor 1997 [S], Wald 1994 [S]). Note: Physical exam is likely to reveal purulent nasal discharge and/or posterior oropharyngeal drainage. These findings, however, are non-specific and of little diagnostic usefulness (Wald 1981 [B], McLean 1970 [D], Williams 1993 [S], Fireman 1992 [S]).
(http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/b0f1d374-b4fd-444c-8422-8041f8863f1d.pdf)

“Well, Scott,” you say. “That doesn’t seem too bad, just treat the kids who have had symptoms for over 10 days and quit your whining.”   But wait, there’s more – From the Cochrane Library a review of 59 randomized controlled studies showed:

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

So do I wait until 14 days and treat the 20% not better?  Or will you have already gone to Patient First to get your antibiotics?

*This post is supposed to teach people about the difficulty of diagnosing and treating Sinusitis.  Please know that I understand how difficult it to care for a sick child (Read: not sleeping) for 10-14 days just waiting for symptoms to get better .   I also know how stressful a 10 day illness can be on your job; as a doctor with patients scheduled in advance it is VERY HARD to “just take a sick day” when my kids can’t go to school.

Nearly every parent eagerly awaits the day that our child starts using the potty consistently.   In our family, we even do a little dance of excitement. But parents always ask “what about nighttime?” When can my kids stop sleeping on a big sheet of plastic? Or wearing night diapers?

While most children “potty train” while awake around age 2 or 3, many children don’t achieve consistent nighttime dryness until much later.

The numbers for isolated nighttime wetting (only have accidents at night):

• 5 years old: 16% still wet the bed
• 6 years old: 13% still wet the bed
• 7 years old: 10% still wet the bed

Nighttime bed wetting is 2 x more common in boys than girls. The vast majority of these cases of isolated nighttime wetting resolve on their own with time and have no underlying problem.

Parents are sometime to blame… OK, maybe your genes are to blame. I know that I am not bringing helpful genes to the table.  According to my parents, it took a long time to have me night-trained, and I vaguely remember that when I did start waking up to go to the bathroom, I often confused the closet for the potty. (See, it really could be worse).  If neither parent is a bed-wetter, the chances of having a prolonged bed-wetter is only 15%. But, if both parents were prolonged bed-wetters, the likelihood of your child wetting the bed is 70-77%.

How do we “fix” it?  Most of the time we just need to wait and it will go away on its own.  The most important rule is DON’T PUNISH YOUR CHILD!  They aren’t doing it on purpose and punishing them DOES NOT DECREASE BEDWETTING!

What works?  Here is a parent handout that has treatment recommendations. The key points are Behavioral Management, Motivational Training, Bladder Training and Alarm Therapy. The data on the effectiveness of these methods is inconsistent. There is some evidence that biofeedback may improve symptoms.  Be sure to talk to your pediatrician if bed-wetting is limiting your child’s ability to do sleepovers, camps, etc. because there are medications that can be very helpful in these situations.  As always, talk to your pediatrician about any other concerns you might have around bed-wetting.

So the good news is that the bed-wetting will almost definitely end at some point, but maybe you should put a potty in the closet just in case.

The following is a video response to the question of introducing nuts, eggs, fish, and other allergens in infants as the evidence to support or refute recommendations has recently changed.  Note: Introducation of solid foods should definately be avoided until at least 4 months of age due to growing evidence linking it to increased allergies and possibly obesity.

Please know that I appreciate how terrifying an allergic reaction in your child must be.  My recommendations are strickly based on my reading of current recommendations and guidelines, which indicate that there is little we can do to change the likelihood of having an allergic reaction.  Please consult your pediatrician to discuss their recommendations about introducing potential food allergies.

Links:

Dr. Frank Greer of the American Academy of Pediatrics Committee on Nutrition on forthcoming guidelines on complimentary foods  – Very interesting ideas about the introduction of solids

F-A-S-T Formula for managing food allergies (Stollen from SeattleMamaDoc - a GREAT website for parents)

For the those who like to read guidelines – AAAAI Food Allergy Guidelines

            As a parent, it is hard to know if your child’s diet is giving them everything they need.  We were raised knowing, “If we want to get tall, we need to drink our milk.”  I still remember not being able to leave the table until I ate all my Brussels sprouts (Ick!).  There have been weeks in my house when my son has lived on Mini-Wheats and apple slices, and the closest he has come to “Eating the Rainbow” was the bag of sour patch kids my wife let him have for breakfast.   

            Luckily there is a small chewable pill that in our medicine cabinet that should be labeled “PARENTAL GUILT-REDUCER.”   Multivitamins make us feel better when we think we did a “bad job” parenting.  The question is: Do they work?

            A study in the Archives of Pediatric Adolescent Medicine in 2009 showed that the children who were most likely to use vitamins were the least likely to need them.  Those who used vitamins had “higher milk intake, lower total fat and cholesterol intake, increased dietary fiber intake” compared to those who did not use vitamins. (Arch Pediatr Adolesc Med. 2009;163(2):150-157)  So, there is a good chance that if you are worried enough to think about giving a vitamin you are already giving your child a well-rounded diet. 

Very few quality studies have shown reproducible benefits from multivitamin supplementation on things like prevention of upper respiratory infections, ADHD, improved appetite or weight gain, or prevention of other infections. However, a few areas of continued research show definite benefit from a few specific vitamins. 

• Ensuring that your child gets the recommended amount 400 IU (and not an excessive amount!) of Vitamin D and Calcium leads to improved bone health.  There is some conflicting evidence that 400 IU of Vitamin D may help prevent infections, cancer and autoimmune disease, but I wouldn’t bet on it.
• The AAP recently recommended an increase in the iron supplementation for infants and toddlers.  For a short summary go here (http://bit.ly/9ojJUb ) or read my summary: If you are breastfeeding, consider poly-vi-sol with iron (of course, also consider that it stains and it smells), be sure to add iron containing foods early in your solid food rotation, keep giving iron containing foods throughout toddlerhood.  Oh and don’t eat paint-chips.
• There is some very early research that shows that fish oil (200-300 mg) taken by moms-to-be improves vision and IQ in infants.  Early research also indicates that fish oil supplements for children at a level of 100mg daily may decrease number of upper respiratory infections and decrease likelihood of developing asthma.  DHA consumption in the elderly also appears to help prevent dementia.

While the AAP may not recommend it, a standard Flintstone chewable vitamin with iron +/- some fish oil is very unlikely to hurt your child.  If a multivitamin allows you to fall asleep focusing on the 20 other things you feel guilty about as a parent instead of how poorly your toddler over-whom-you-have-no-control ate today, then give it to them.  Just remember to brush their teeth afterwards because those things will tear up your tooth enamel.

(just kidding NEJM – please don’t beat me up)     

So one of the down-sides of evidence-based medicine is that the data seldom seems to stand for itself.  The papers always need a conclusion/discussion of the results to help you understand what just happened.  Conveniently this here doctor-person happens to have an even smarter super doctor-person older brother (also see link – He’s REALLY smart) who helps me decode the data and come to my own conclusions. [Mind you if I misinterpreted what he said, he is not responsible.]

On January 13th, NEJM published an article about the treatment of acute otitis media (read: inner ear infection) in children under age 2.  According to the Editorial attached to the article:

“The results of each study showed a significant benefit among children who received the drug with respect to the duration of acute signs of illness…more young children with a certain diagnosis of acute otitis media recover more quickly when they are treated with an appropriate antimicrobial agent.” 

So clearly, all truly diagnosed cases of Otitis Media should be treated?  Not so fast.

Looking at the data, there are a couple of take home points for kids age 6 to 24 months:

• In cases that are diagnosed by stringent criteria including acute onset, otoscopic exam and parental point of view about their child’s symptoms, slightly more than 1 in 10 kids treated with antibiotics are likely to still feel pretty badly 10 days out.
• If a parent wants their child treated with antibiotics it will likely have their children feel better about 12-24 hours before a child who didn’t receive antibiotics.  (Which is good to know, because I wasn’t entirely sure my antibiotics were doing anything at all!)
• The flip-side being: If you are a parent who would prefer not to use antibiotics, your child will likely only feel sick for 12-24 hours more than they would have with antibiotics.
• Although the long-term follow up in this study isn’t great, it doesn’t look like long-term outcomes are not at all different for the placebo vs antibiotic groups.
• If you follow a “watchful waiting” approach (my interpretation of their clinical failure at day 4 arm of the study), we will give out 50% less antibiotics and 50% of kids will get better without treatment at all.
• 25% of kids on antibiotics got diarrhea

In the end – antibiotics or not for acute otitis media for this age range still seems to be a discussion between a parent and their doctor with no definitive evidence to support one side or the other.  The decision has more to do with how important it is to get better quicker (a VERY valid choice) and how you feel about giving antibiotics to your child (a VERY personal choice).

A note about the case of mastoiditis in the study (which is really rare):  I don’t love giving antibiotics, but I feel fairly comfortable that I would have given an 11 month old with a 14 out of 14 score on the AOM-SOM on day 1 of symptoms antibiotics if he/she had come into clinic -  regardless, this child had a penicillin-resistant bug, so he/she still wouldn’t have gotten better.  By day 2-3, I would have seen the child in my clinic and admitted them to the hospital or changed antibiotics.  Hooray for practicing pediatrics with parents who are able to come in for follow up reliably and often!

One night during my pediatric residency a young family went out for a drive to a local store. They were driving 25 miles an hour down a two lane road when a pickup truck also traveling 25 miles an hour in the other direction swerved into their lane and collided head on.  Both parents were killed on impact and the three year old in the middle rear seat was ejected from her improperly used car seat.  We were able to stabilize her body, but she was declared brain-dead a few hours after coming to the pediatric intensive care unit.   I was the pediatrician who had to help the social workers attempt to reach living relatives and to explain the tragedy to them. 

A few weekends ago while attempting to wash my daughter’s vomit off of her car seat, I realized I had made a mistake.  Clearly labeled on the car seat were two holes that said in large writing “USE HERE FOR FORWARD FACING.”  I had installed the car seat wrong after switching from rear-facing to forward facing.   Admittedly, the change had come some time after she had been screaming for what must have seemed like hours and my wife and I had gotten into a heated discussion about the preferred safety of rear-facing seats, so a little user-error seems understandable.   But, I never went back and looked at the manual after re-installing the seat and switching cars multiple times.  I’m lucky there were no consequences.  

Unintentional injury is the leading cause of death in children ages 1 to 24.  Car related injuries make up the highest number of unintentional injuries in this age group.  See:  http://www.cdc.gov/injury/wisqars/pdf/Unintentional_2007-a.pdf

We all like to think that tragedies like the story above will never happen to us, but the truth is they could happen any time.   Please take a few minutes tonight to read over your child safety seat manual (if you lost it, call the number on the car seat and they will email you a pdf of the manual) and be sure you are using it properly.   Or you can go to this website and find a car seat inspection site that will help be sure you are using your seat properly.    Using your car seat how it is meant to be used could be the single best thing you do for your child’s health and one of the easiest.

Helpful Websites:

 Search for a local child safety seat inspection site by zip code:

http://www.nhtsa.gov/cps/cpsfitting/Index.cfm

 Great overall child safety seat website, including link to “ease of use” rating for carseats and much more:

http://www.nhtsa.gov/Safety/CPS

 AAP education on child safety seat:

http://bit.ly/cIIasp

It is hard to get through a new parent magazine or pregnancy magazine without reading at least one advertisement for private cord blood banking.  The magazines promise a new and exciting future of medical health where simple cells taken from the placenta and umbilical cord can cure illness lurking in your child’s future.  Cord blood is also very promising because it does not have to match a recipient’s tissue type as closely as bone marrow.  The idea that simply storing these cells could save your child’s life down the road is too amazing to ignore. 

Cord Blood samples are taken from the placenta and the attached cord AFTER the cord has been clamped and cut – samples are not taken from your baby or your baby’s belly button at any time and sampling doesn’t change the birth process at all.

We did not bank our children’s cord blood because at this time there are no Richmond area hospitals participating in PUBLIC cord blood banking.   Unlike the private cord blood banks you find advertised in the magazines, a public cord blood bank does not store your child’s individual cord sample for your use later on.   Instead, cord blood from patients who meet a stringent set of criteria  are stored in a public bank to be used whenever needed by a matching recipient.  This allows for the largest possibility of matching donors for future transplants.   Public banks greatly increase the availability of a usable cord blood sample if your child were to need it because  a disadvantage of PRIVATE cord blood banking is that for most leukemia, lymphomas and other cancers, private cord blood runs the risk of reintroducing the same line of cancer cells into the patient. 

Private cord blood banking has become a multi-million dollar industry and private banks tend to use anecdotal stories to advertise the benefits of  cord blood banking while misrepresenting facts. Private cord blood banks continue to overstate the uses of having your child’s cord blood available.  They have even hired Dr. Bob Sears to endorse CBR, the largest private cord blood bank in the United States.  CBR in their own “common misperceptions” website even argues that “thousands” of autologous [a transplant using the patient’s own stem cells] are performed every year.

According to the American Academy of Pediatrics’ Joanne Kurtzberg, MD director of the Carolinas Cord Blood Bank:

 Most pediatric transplants using cord blood require a donor cord, not their own cord blood because of contraindications to using an autologous transplant [ a transplant using the patient’s own stem cells].  [She] notes that the odds of someone using their own stored cord blood is very, very low and probably is in the range of one in 200,000.  -AAP News 2010 31:22                       

Given the facts about cord blood uses, I agree with the American Academy of Pediatrics position, which endorses the use of PUBLIC cord blood banking.  If it had been available in Richmond, I would have tried to participate without any reservations.  At this time, I do not recommend private cord blood banking unless there is an older sibling who has already been diagnosed with cancer (there is a 25% chance of siblings being a match) or specific genetic disorders in the family.   Otherwise I do not think private banking warrants the cost and think it is very unlikely to be helpful.   

For more information and to advocate for public banking in Richmond, I recommend this excellent website.

My Favorite Book for Expecting Parents:   Heading Home with Your Newborn: From Birth to Reality by Laura Jana MD and Jennifer Shu MD   (Two mom/pediatricians give practical information for expecting parents that reads easily and does not feel like a textbook.  Full of helpful, real-life hints on everything from breastfeeding to sleep.)

Thing That Needs to Be on Your Registry: 

My hippie wife’s answer: 

• Sling or moby wrap (Made a world of difference for our difficult sleeper and made it so we didn’t feel trapped in the house; I used it way more than my Bjorn – we can discuss the details of recent baby sling safety concerns). 

My answers:  

• Sleep sack swaddle-wearable blankets or a few good swaddling blankets (I thought the sleep sack swaddler was fool proof and you didn’t have to go to pediatric residency or nursing school to be able to get a good quality swaddle.  If you have faith in your swaddle ability, a good big swaddle blanket works as well)
• Caffeine (Why doesn’t Babies “R” Us sell coffee?)  
• The real practical life things are the most helpful:
  • Diapers
  • Wipies
  • Baby shampoo/soap (if you have a family history of eczema, I recommend staying away for the old Johnson and Johnson we grew up with and buying Aveno (also made by J&J) or some other brand as these tend to be less drying.)
  • Good lightweight pack ‘n’ play (How cool is this thing? The GoCrib)

Things Currently on Your Registry That You Should Take Off or Return:

• Baby sleep positioner (Although the Nap Nanny looks like an awesome baby la-z-boy, newborns don’t roll over and when they are old enough to roll over, it’s no longer a SIDS risk)
• Wipey warmer (Seriously people, seriously?  Does a wipey being warm make the experience of your butt being wiped that much better? Also, by 1 month in, you will be changing your baby anywhere you are in the house – not traveling back to a certain room to find a wipey at just the right temperature)
• Crib bumper (Parents often fear that their children will be bashing their heads into the rails of the crib – most kids don’t. And if they do, they will find a way around the bumper.  Bumpers are possibly a SIDS risk, and when your kids are 2 years old, they will use the bumper as a step to launch themselves out of their crib).

Parents who have already done this, what was the most important thing on your registry and what was on there that you never used?