Apr 2011
In the News: Early Autism Detection?
04/30/11 19:39
A study made the news this week from UC San Diego that may lead to earlier autism diagnosis in the future. In the study, researchers had pediatricians perform a 5 minute questionnaire, the Communication and Symbolic Behavior Scales Developmental Profile or CSBS-DP, to 10,500 infants. It asks parents a simple list of 24 questions such as: “When your child plays with toys, does he/she look at you to see if you are watching?”, “Does your child do things just to get you to laugh?” and, “Does your child pick up objects and give them to you?” Ou of the 10,500 children, 184 scored lower than expected and underwent further evaluation. Of those, 32 were found to have an autism spectrum disorder and 101 were found to have a language or developmental delay or other similar condition.
This study is important for a number of reasons. For one, it confirms what has been long known, which is that most children with autism show subtle signs of interaction issues with parents or caregivers even before their first birthday. For these children it is, therefore, not likely than an environmental exposure or event happening after the first birthday is the cause of their autism. So, for example, a vaccine given at fifteen or eighteen months of age could not be the cause.
The diagnosis of “autism”, also called pervasive developmental disorder, is currently given to children with a wide range of symptoms and severity. The common thread is that the children do not communicated normally. They may not look at people when they talk to them. The usually don’t understand facial expressions or body language. Often they engage in unusual self soothing behaviors such as rocking back and forth or hand flapping and may communicate less than expected with others. Some are “savants”, meaning that they may excel to a remarkable degree in some specific area, while being very delayed in a others.
The degree of severity can cover a wide range. I have patients who have been diagnosed with this disorder who are bright and functional, but just seem a bit “quirky” when someone talks to them all the way to teenagers who are unable to speak, are still in diapers and can have aggressive tantrums.
The most likely reason for this is that autism spectrum disorders are likely not one discreet entity, but a number of somewhat similar diseases. So, what causes it? Well, the difficult thing is that no one knows for sure. There are familial autisms where specific genetic defects have been identified. These all seem to be in genes involved with how nerves brow and connect to each other. there may be environmental factors at work as well. The current thinking in the medical community is that those factors may well bee ones that the mother is exposed to during pregnancy. It has been shown that some chemicals that the fetus is exposed to in the womb or in early development can actually turn genes off or on or alter there functioning. This is called an epigenetic effect.
Some of the possible culprits are plastics or pesticides. Both can contain chemicals that can mimic human hormones or other biologically active molecules. So, it would seem to make sense that they may effect gene expression.
Even accounting for increased awareness by physicians of this disorder and a broadening of the scope of children that are now labeled as autistic as opposed to simply developmentally delayed, there does appear to be a great increase in the number of children being diagnosed with some form of autism. The number now is a staggering one out of every one hundred fifty children. It is interesting that this increase seems to have begun after world war two when the widespread use of fertilizers became common and the use of plastics began to increase. That, of course, proves nothing, but does giver one food for thought.
People sometimes get confused, because there clearly are children who were developing normally, that at an age of, say fifteen months to two years, regressed. They stopped talking and communicating normally and developed the symptoms of autism. The fact that there illness started later does not rule out its being genetic or caused by an early exposure. For example, people with schizophrenia, which is clearly a genetic disease, do not usually develop symptoms until their late teens or early twenties. Not all of our genes are turned on at birth. There is, believe it or not, a mouse model of schizophrenia. Those mice have a defect in a gene that plays a role in nerve remodeling in adult rats. In these rats, as nerves try to make new cokeywordsnections, they over shoot their intended target and may make contact with a totally different part of the brain than they were supposed to. You can imagine that if a nerve from the memory storing part of the brain made contact with the parts of the brain responsible for vision or hearing, a memory might trigger a visual or auditory hallucination.
Much has been played up in the media about a supposed link between childhood vaccines, in particular then measles, mumps, rubella vaccine (MMR) that is given at fifteen or eighteen months of age. If you haven’t seen it in the news yet, the physician / researcher that started this whole debate has been found guilty of falsifying his data. All of the other authors listed on the original article have detracted their names from it. That physician was, at the time, working on the side for a company that was trying to market a screening questionnaire for autism, so he had personal financial gain at stake. Consequently, he has had his medical license permanently revoked in Britain where he was practicing.
The possible link between vaccines and autism was definitely not entirely out of the realm of reality to investigate. But, it has been looked at in many studies all over the world in the past couple of decades and the conclusion is clear - they are not the cause. I hope all of the parents reading this well please take this into account. Only a hundred years ago the US childhood mortality rate was in the order of 60-80%. People often had eight or ten children in the hopes that 2 or three would survive into adulthood. I don’t think any of us want to go back to those days. Also, please don’t assume that because these diseases are now less common that they are gone. That is far from the case. We had ten deaths last year in young infants in California from whooping cough, there was a measles outbreak in southern California last year, and, there was a confirmed case of mumps in Tehama County a few months ago. Remember, even if it seems like diseases such as polio are only still active in far away lands - all of them are only a plane ride away from your child.
This study is important for a number of reasons. For one, it confirms what has been long known, which is that most children with autism show subtle signs of interaction issues with parents or caregivers even before their first birthday. For these children it is, therefore, not likely than an environmental exposure or event happening after the first birthday is the cause of their autism. So, for example, a vaccine given at fifteen or eighteen months of age could not be the cause.
The diagnosis of “autism”, also called pervasive developmental disorder, is currently given to children with a wide range of symptoms and severity. The common thread is that the children do not communicated normally. They may not look at people when they talk to them. The usually don’t understand facial expressions or body language. Often they engage in unusual self soothing behaviors such as rocking back and forth or hand flapping and may communicate less than expected with others. Some are “savants”, meaning that they may excel to a remarkable degree in some specific area, while being very delayed in a others.
The degree of severity can cover a wide range. I have patients who have been diagnosed with this disorder who are bright and functional, but just seem a bit “quirky” when someone talks to them all the way to teenagers who are unable to speak, are still in diapers and can have aggressive tantrums.
The most likely reason for this is that autism spectrum disorders are likely not one discreet entity, but a number of somewhat similar diseases. So, what causes it? Well, the difficult thing is that no one knows for sure. There are familial autisms where specific genetic defects have been identified. These all seem to be in genes involved with how nerves brow and connect to each other. there may be environmental factors at work as well. The current thinking in the medical community is that those factors may well bee ones that the mother is exposed to during pregnancy. It has been shown that some chemicals that the fetus is exposed to in the womb or in early development can actually turn genes off or on or alter there functioning. This is called an epigenetic effect.
Some of the possible culprits are plastics or pesticides. Both can contain chemicals that can mimic human hormones or other biologically active molecules. So, it would seem to make sense that they may effect gene expression.
Even accounting for increased awareness by physicians of this disorder and a broadening of the scope of children that are now labeled as autistic as opposed to simply developmentally delayed, there does appear to be a great increase in the number of children being diagnosed with some form of autism. The number now is a staggering one out of every one hundred fifty children. It is interesting that this increase seems to have begun after world war two when the widespread use of fertilizers became common and the use of plastics began to increase. That, of course, proves nothing, but does giver one food for thought.
People sometimes get confused, because there clearly are children who were developing normally, that at an age of, say fifteen months to two years, regressed. They stopped talking and communicating normally and developed the symptoms of autism. The fact that there illness started later does not rule out its being genetic or caused by an early exposure. For example, people with schizophrenia, which is clearly a genetic disease, do not usually develop symptoms until their late teens or early twenties. Not all of our genes are turned on at birth. There is, believe it or not, a mouse model of schizophrenia. Those mice have a defect in a gene that plays a role in nerve remodeling in adult rats. In these rats, as nerves try to make new cokeywordsnections, they over shoot their intended target and may make contact with a totally different part of the brain than they were supposed to. You can imagine that if a nerve from the memory storing part of the brain made contact with the parts of the brain responsible for vision or hearing, a memory might trigger a visual or auditory hallucination.
Much has been played up in the media about a supposed link between childhood vaccines, in particular then measles, mumps, rubella vaccine (MMR) that is given at fifteen or eighteen months of age. If you haven’t seen it in the news yet, the physician / researcher that started this whole debate has been found guilty of falsifying his data. All of the other authors listed on the original article have detracted their names from it. That physician was, at the time, working on the side for a company that was trying to market a screening questionnaire for autism, so he had personal financial gain at stake. Consequently, he has had his medical license permanently revoked in Britain where he was practicing.
The possible link between vaccines and autism was definitely not entirely out of the realm of reality to investigate. But, it has been looked at in many studies all over the world in the past couple of decades and the conclusion is clear - they are not the cause. I hope all of the parents reading this well please take this into account. Only a hundred years ago the US childhood mortality rate was in the order of 60-80%. People often had eight or ten children in the hopes that 2 or three would survive into adulthood. I don’t think any of us want to go back to those days. Also, please don’t assume that because these diseases are now less common that they are gone. That is far from the case. We had ten deaths last year in young infants in California from whooping cough, there was a measles outbreak in southern California last year, and, there was a confirmed case of mumps in Tehama County a few months ago. Remember, even if it seems like diseases such as polio are only still active in far away lands - all of them are only a plane ride away from your child.
Comments
It's National Screen Free Week!
04/17/11 16:20
April 18-24
I urge all of you to try to honor this event. We’ve all become so separate from each other and our kids these days. In great part it’s because so many people and kids seem to be attached to TV’s, computers, video games, iPads, phones, etc. etc.
This week is a reminder that it is good to turn all of those things off every once in a while and just live life. It’s time to have a chance to actually communicate with each other, to get outside, to play games, to laugh with each other instead of the TV.
Click here to go to the main page for Screen Free Week and lots more information and materials. Enjoy your screen free time!
I urge all of you to try to honor this event. We’ve all become so separate from each other and our kids these days. In great part it’s because so many people and kids seem to be attached to TV’s, computers, video games, iPads, phones, etc. etc.
This week is a reminder that it is good to turn all of those things off every once in a while and just live life. It’s time to have a chance to actually communicate with each other, to get outside, to play games, to laugh with each other instead of the TV.
Click here to go to the main page for Screen Free Week and lots more information and materials. Enjoy your screen free time!
Numbing Gels for Teething Babies and Infants - the FDA Says No
04/12/11 14:53
I’ve known for twenty years that the use of numbing gels (Oragel, Anbesol. Baby Oragel and others) can be associated with a potentially life threatening complication in infants and toddlers if used in excess. I have always cautioned parents not to use them more than four or five times per day. The FDA now has data that even occasional use can be series in some infants. They just issued issued a recommendation that they not be used in children under age two at all.
The problem is that when absorbed, the benzocaine (the numbing agent in these medicines) can interact with the hemoglobin in your blood and change it into a form that cannot carry oxygen called methemoglobin. If you can’t carry oxygen normally, you will turn grey then blue, then pass out and, if untreated, eventually die. I have encountered this before a couple of times, but in children whose parents were applying it 10 to twenty times per day. Symptoms can develop within minutes to one to two hours after administration. The problem is that medical personnel may not think of methemoglobimemia right away if the child winds up in the emergency room leading to a delay in treatment as it is not something seen commonly.
There have been nearly four hundred reported cases in the U.S. including at least three deaths from methemoglobinemia. So, I have to agree with the FDA on this one. It is safer not to use these medicines in children under age two. However, that doesn’t mean there aren’t plenty of other ways you can help your teething child. Teething rings, water filled teething rings chilled in the refrigerator (never in the freezer as, if to cold, the gums can get frostbitten), a damp, chilled washcloth to chew on or the occasional Tylenol or ibuprofen can all be used to comfort your child. If you have questions or these techniques aren’t helping, talk to your child’s doctor.
Teething is a normal part of growing up. It can be uncomfortable at times, but usually simple measures (teething rings) for example are usually all it takes to sooth a teething child. So, the lesson is, don’t use medicines if you don’t really need to, and talk to your doctor before using over the counter medicines in any young child.
The problem is that when absorbed, the benzocaine (the numbing agent in these medicines) can interact with the hemoglobin in your blood and change it into a form that cannot carry oxygen called methemoglobin. If you can’t carry oxygen normally, you will turn grey then blue, then pass out and, if untreated, eventually die. I have encountered this before a couple of times, but in children whose parents were applying it 10 to twenty times per day. Symptoms can develop within minutes to one to two hours after administration. The problem is that medical personnel may not think of methemoglobimemia right away if the child winds up in the emergency room leading to a delay in treatment as it is not something seen commonly.
There have been nearly four hundred reported cases in the U.S. including at least three deaths from methemoglobinemia. So, I have to agree with the FDA on this one. It is safer not to use these medicines in children under age two. However, that doesn’t mean there aren’t plenty of other ways you can help your teething child. Teething rings, water filled teething rings chilled in the refrigerator (never in the freezer as, if to cold, the gums can get frostbitten), a damp, chilled washcloth to chew on or the occasional Tylenol or ibuprofen can all be used to comfort your child. If you have questions or these techniques aren’t helping, talk to your child’s doctor.
Teething is a normal part of growing up. It can be uncomfortable at times, but usually simple measures (teething rings) for example are usually all it takes to sooth a teething child. So, the lesson is, don’t use medicines if you don’t really need to, and talk to your doctor before using over the counter medicines in any young child.
Food for Thought
04/05/11 08:58
I’ve been coming across some interesting facts in the news lately that really got me thinking. I’ll share them with you now so you will (hopefully) ponder them as well. I am not an investigative journalist and have not done rigorous research to confirm these facts, but I have heard or seen them all in multiple places in the news.
HEALTHCARE
1. Most private insurance policies have doubled their premiums over the past 3-4 years while increasing deductibles and cutting back coverage.
2. The letters that accompany rate increases usually cite increased physician reimbursement as the reason. Sure, with the population increasing and aging the overall amount paid to physicians has increased. I can tell you though, at least for the pediatricians around here, our income has stayed the same or gone down the past few years.
3. In California, where medical insurance is for profit, about 73 cents of each dollar taken in in premiums goes back out to healthcare. In Minnesota, where insurers are required to be not for profit, around 90 cents per dollar goes back out for healthcare.
4. There are entire claims processing centers (I personally know someone who worked in one) whose main purpose is to review physician and patient claims for any loophole that allows the company to deny payment.
5. Similarly, there are centers that review patients who have high medical expenses because of a severe illness, to see if they can find a way to legally cancel the patient’s coverage.
6. The last few years, around 60% of new bankruptcies in the U.S. have been medical expense related.
It seems to me, that requiring California health insurers to be not for profit would be one big step to help the situation here.
MONEY
1. The U.S. is one of the largest economies on Earth. If California was its own country, it would be the fifth largest economy on the planet.
2. Nearly every public service, including schools, police, fire, and healthcare have had significant budget cuts in California over the past few years. So, where is all the money from our economy? I don’t have all the answers, but some things to think about:
3. There are quite a few of the very wealthy in California. The top 400 wealthiest Americans have more wealth combined than the poorest 150 million (yes, million) Americans. Many of them pay no U.S. income tax.
4. Of the top 100 earning U.S. companies, 80% pay no U.S. income taxes.
5. General Electric, one of the the largest conglomerates in the world, based in the U.S., not only payed no U.S. taxes last year, but received a 3.2 billion dollar tax credit from the US. government. This, while cutting thousands of U.S. jobs and simultaneously increasing their oversees workforce.
6. If those 80 companies payed their fair share of U.S. income tax, it would amount to about 100 billion dollars per year, enough to balance every state’s budget with money left over.
There seems to be a lot of fear that the U.S. is heading towards becoming a socialist economy. We don’t need to go anywhere near that far. All we really have to do is have everyone pay their fair share of taxes without the loopholes of off-shore holdings and using foreign subsidiaries as tax shelters. At least that’s my thought on the matter.
HEALTHCARE
1. Most private insurance policies have doubled their premiums over the past 3-4 years while increasing deductibles and cutting back coverage.
2. The letters that accompany rate increases usually cite increased physician reimbursement as the reason. Sure, with the population increasing and aging the overall amount paid to physicians has increased. I can tell you though, at least for the pediatricians around here, our income has stayed the same or gone down the past few years.
3. In California, where medical insurance is for profit, about 73 cents of each dollar taken in in premiums goes back out to healthcare. In Minnesota, where insurers are required to be not for profit, around 90 cents per dollar goes back out for healthcare.
4. There are entire claims processing centers (I personally know someone who worked in one) whose main purpose is to review physician and patient claims for any loophole that allows the company to deny payment.
5. Similarly, there are centers that review patients who have high medical expenses because of a severe illness, to see if they can find a way to legally cancel the patient’s coverage.
6. The last few years, around 60% of new bankruptcies in the U.S. have been medical expense related.
It seems to me, that requiring California health insurers to be not for profit would be one big step to help the situation here.
MONEY
1. The U.S. is one of the largest economies on Earth. If California was its own country, it would be the fifth largest economy on the planet.
2. Nearly every public service, including schools, police, fire, and healthcare have had significant budget cuts in California over the past few years. So, where is all the money from our economy? I don’t have all the answers, but some things to think about:
3. There are quite a few of the very wealthy in California. The top 400 wealthiest Americans have more wealth combined than the poorest 150 million (yes, million) Americans. Many of them pay no U.S. income tax.
4. Of the top 100 earning U.S. companies, 80% pay no U.S. income taxes.
5. General Electric, one of the the largest conglomerates in the world, based in the U.S., not only payed no U.S. taxes last year, but received a 3.2 billion dollar tax credit from the US. government. This, while cutting thousands of U.S. jobs and simultaneously increasing their oversees workforce.
6. If those 80 companies payed their fair share of U.S. income tax, it would amount to about 100 billion dollars per year, enough to balance every state’s budget with money left over.
There seems to be a lot of fear that the U.S. is heading towards becoming a socialist economy. We don’t need to go anywhere near that far. All we really have to do is have everyone pay their fair share of taxes without the loopholes of off-shore holdings and using foreign subsidiaries as tax shelters. At least that’s my thought on the matter.
Will My Child Ever Stop Wetting the Bed?
04/04/11 14:24
Bed wetting is a common problem in children from the age of potty training through the teenage years. Many parents don’t know when it is and isn’t “normal” or how to help the situation. This can lead to frustration in the parents and children involved, and over time can become a big self esteem issue for many children if left untreated as they get older.
The most common type of bedwetting is called primary nocturnal enuresis. This means simply, wetting that occurs only at night in a child who has never been dry at night for any significant length of time.
This is a common problem. At age 5, 15% of children are still wetting regularly at night. Each year after that about 15% of the remaining children stop wetting, so that by age 15 about 99% of children are dry at night.
The main problem in these children is simply that they are very deep sleepers and sleep through the signals of their bladder telling them it is full. These are the kids that sleep through their alarms many a morning. There is a familial component to this type of wetting. One or both parents of these children were often bedwetters.
What can be done about it? Well, for younger children, ages 6-7 or 8, bedwetting alarms can be something to try. They are available at pharmacies or online. TheBedWettingStore.com is one good resource for all kinds of bedwetting supplies. These alarms have two parts, a sensor and an alarm. The sensor often clips onto the front of the child’s pajamas or gets sewn into a pocket on the outside of the pajama bottom. As soon as the child starts to wet, it triggers the sensor. The alarms can be wired or wireless. Some clip on the neck of the pajamas, others go on like a wristwatch, some are bedside. The idea is that as soon as the child wets, the alarm goes off and either wakes the child, or gets the parent in there to help the child get to the bathroom and finish in the potty. About 80% of children will improve with a two to three month course of the alarm.
By the time the child is 7 or 8, often the child starts to become self conscious about the wetting. It can begin to interfere with sleepovers and camp. This is a time to consider medical treatment. For treatment, we usually use something called di-dearginine vasopressin (ddavp or desmopressin). This is a natural body hormone that decreases urine production temporarily. It is given at bedtime to help the child stay dry overnight. It doesn’t fix the problem though, only treats the symptom. As the child will eventually outgrow the wetting, we put the child on it typically for six months and then try them off. If they have outgrown the problem, great, if not they go back on it again for another six months. It works for about 80% of children. There are other medications that we can try such as imipramine for those that don’t respond to the ddavp.
If your child has been dry for a period of time and then started wetting again overnight, has daytime wetting in addition to nighttime wetting or has daytime or nighttime soiling, a more significant medical problem is likely the cause. Please consult your doctor if these symptoms occur in your child.
The most common type of bedwetting is called primary nocturnal enuresis. This means simply, wetting that occurs only at night in a child who has never been dry at night for any significant length of time.
This is a common problem. At age 5, 15% of children are still wetting regularly at night. Each year after that about 15% of the remaining children stop wetting, so that by age 15 about 99% of children are dry at night.
The main problem in these children is simply that they are very deep sleepers and sleep through the signals of their bladder telling them it is full. These are the kids that sleep through their alarms many a morning. There is a familial component to this type of wetting. One or both parents of these children were often bedwetters.
What can be done about it? Well, for younger children, ages 6-7 or 8, bedwetting alarms can be something to try. They are available at pharmacies or online. TheBedWettingStore.com is one good resource for all kinds of bedwetting supplies. These alarms have two parts, a sensor and an alarm. The sensor often clips onto the front of the child’s pajamas or gets sewn into a pocket on the outside of the pajama bottom. As soon as the child starts to wet, it triggers the sensor. The alarms can be wired or wireless. Some clip on the neck of the pajamas, others go on like a wristwatch, some are bedside. The idea is that as soon as the child wets, the alarm goes off and either wakes the child, or gets the parent in there to help the child get to the bathroom and finish in the potty. About 80% of children will improve with a two to three month course of the alarm.
By the time the child is 7 or 8, often the child starts to become self conscious about the wetting. It can begin to interfere with sleepovers and camp. This is a time to consider medical treatment. For treatment, we usually use something called di-dearginine vasopressin (ddavp or desmopressin). This is a natural body hormone that decreases urine production temporarily. It is given at bedtime to help the child stay dry overnight. It doesn’t fix the problem though, only treats the symptom. As the child will eventually outgrow the wetting, we put the child on it typically for six months and then try them off. If they have outgrown the problem, great, if not they go back on it again for another six months. It works for about 80% of children. There are other medications that we can try such as imipramine for those that don’t respond to the ddavp.
If your child has been dry for a period of time and then started wetting again overnight, has daytime wetting in addition to nighttime wetting or has daytime or nighttime soiling, a more significant medical problem is likely the cause. Please consult your doctor if these symptoms occur in your child.
What's going around 4/4/2011
04/04/11 09:39
It looks like the respiratory season is dying down a bit. There is still a bit of croup, Strep. throat as well as a non-Strep. viral sore throat, and general coughs and colds going around.
Now that it’s getting dry and warm and things are growing and the wind is blowing, allergies are hitting hard (See When Allergies Attack).
Also now that the weather is nice we are seeing lots of kids coming in with various injuries - sprains, cuts and broken bones. Please make sure your children are always wearing appropriate protective gear for what they are doing. For anything outside on wheels (bikes, scooters, skates, skateboards, etc.) make sure they have their helmet on. Even relatively low speed crashes can lead to sever head injuries - a brain is a terrible thing to waste. You should also consider knee elbow and wrist guards for skates and skateboards. For any organized sports, make sure your child were the appropriate protective equipment that is of the right size and is being worn properly. This may take some observation and teaching as children often hurry and skip steps in fastening equipment that can lead to serious injuries.
Have fun, be safe, and see your doctor if any questions or problems arise!
Now that it’s getting dry and warm and things are growing and the wind is blowing, allergies are hitting hard (See When Allergies Attack).
Also now that the weather is nice we are seeing lots of kids coming in with various injuries - sprains, cuts and broken bones. Please make sure your children are always wearing appropriate protective gear for what they are doing. For anything outside on wheels (bikes, scooters, skates, skateboards, etc.) make sure they have their helmet on. Even relatively low speed crashes can lead to sever head injuries - a brain is a terrible thing to waste. You should also consider knee elbow and wrist guards for skates and skateboards. For any organized sports, make sure your child were the appropriate protective equipment that is of the right size and is being worn properly. This may take some observation and teaching as children often hurry and skip steps in fastening equipment that can lead to serious injuries.
Have fun, be safe, and see your doctor if any questions or problems arise!
The recent lull
04/04/11 09:38
Sorry about the recent lull in posts. Things have been crazy busy for me for a number of reasons lately. But, I’m back - expect new things to come.
