Conquering Those Growing Pains
As every parent knows, childhood is filled with all sorts of maladies, from sore throats and ear infections to broken bones. In the teen years, new dilemmas, like drinking and sex, emerge. Keeping up with the latest advice or treatment is all too often confusing. U.S. News talked to pediatricians, child development experts, and safety researchers to help sort it out. We focused on everyday ailments with new and better remedies-or where conventional wisdom took a flip-flop. No doubt you've heard that a steamy bathroom eases the croup. Now, experts say, a hug does just as well.
CRYING
Fussy babies and their parents may need a downshifting lesson
Shushing and rocking don't silence the squawker. A midnight car ride is no help. Even parking the bouncy seat on the running clothes dryer was useless. Babies, it seems, just need to cry, and some are fussier than others. A baby who cries more than three hours a day for three days a week is considered fussy or colicky, a phase that usually peaks around 6 or 8 weeks of age. Doctors still don't know if the inconsolable crying is due to physical distress such as excess gas or is just a developmental phase, but about 8 percent of mothers report considerable difficulty calming their babies.
Those days are not without cost. Mothers of finicky babies are far more likely to suffer postpartum depression, according to Pamela High, a pediatrician who directs the Infant Behavior, Cry and Sleep Program at Brown University. High looked at data from an ongoing Centers for Disease Control and Prevention study and found that 19 percent of the 2,927 new mothers experienced moderate to severe symptoms of postpartum depression. The depressed mothers were more likely to say their babies were inconsolable, and women with inconsolable babies were more than two times as likely to report depression.
Hands-on lessons can help. Nurses in a study in the March issue of Clinical Pediatrics gave parents four weeks of training in recognizing when their babies were getting tired or overstimulated, then in consistently soothing them by holding the baby upright on the chest and rocking gently. The 64 babies whose parents got coaching cried an average of 1.7 hours less each day than the babies whose parents didn't get the lessons. "If we can catch the baby early, help [him] shift down or take a nap, then that will actually prevent these long crying jags," says Maureen Keefe, dean at the College of Nursing at the University of Utah and the study's lead author.
Even without schooling, things start looking up at about 6 months, when babies outgrow their fussiness. And parents, here's a reality check: "Just like the rest of us, the baby could not be having a good day," says High. "It's perfectly OK to put the baby down for five to 10 minutes and give yourself a break." Often, High says, the child will drop right off to sleep.
SLEEP
Not so fast with the Benadryl
It's a tip that parents pass along as if it were an heirloom christening gown: Give your baby a dose of Benadryl, and she'll drop off to sleep like an angel.
That would be great if true, says Dan Merenstein, an assistant professor of family medicine at Georgetown University Medical Center. As a father of three kids under age 7, he's well aware of the confusion caused by the welter of expert advice, from pediatrician Richard Ferber's "cry it out" method to pediatrician William Sears's "cosleeping," in which the baby sleeps in the parents' bed. As a scientist, Merenstein says, "I realize they're all different because there's no science."
Indeed, almost no research has been done on sleep medication and young children. Despite that, 71 percent of families told one researcher they had given children medication to try to make them sleep. In a study in the July issue of Archives of Pediatrics and Adolescent Medicine, Merenstein recruited 44 families with healthy babies and asked half of them to give their children a dose of Benadryl, a widely used over-the-counter antihistamine, before bedtime. Benadryl is well known for its sedative effects-it's the same ingredient as in Tylenol PM. Merenstein expected to see a marked improvement in sleep problems. Instead, just one family in the Benadryl group reported better sleep, compared with three in the placebo group. "I was surprised," says Merenstein.
Benadryl may work better as a sleep inducer in older children, Merenstein speculates. But its lack of effect on infants proves once again that children are not tiny adults and that parents and doctors should never presume that what's good medicine for Dad will work for Junior, too.
CROUP
Time and tenderness may treat that scary cough
That tried-and-true remedy for croup-the steamed-up bathroom-probably won't do your child's airways any good. In March, doctors at Toronto's Hospital for Sick Children tested 140 kids with croup, a barking cough caused by viruses that inflame and narrow the airways. Their conclusion: The humidity didn't have any physical effect. "People may say it is steam, but it's really time," says study director Dennis Scolnik, a pediatrics associate professor at the University of Toronto. Indeed, the treatment's value may be that it gives parents something to do and calms them down, which calms the child down, too. "I'm sure there's a psychological element to it," says Paul Little, a professor at the University of Southampton in the United Kingdom who has also studied humidity treatment. "It seems to be soothing."
So what should you do for kids with the croup? "Cuddle them, stroke them, hold them, sing them a song," says Scolnik. And model deep, slow breaths.A walk outside in the cool air may also be beneficial. If the cough doesn't go away in 20 to 30 minutes, or if the child seems to have difficulty breathing or looks unaware, a trip to the hospital is in order.
EAR INFECTIONS
Hear this, Mom: Watchful waiting may be the best strategy
There's a new way to treat ear infections: not at all. In the past, children had ear tubes implanted to ventilate the ear, and in recent years, most infections have been treated with antibiotics. Now, however, a growing pile of research is showing that in many cases it might be better to wait to see if the child's infection resolves itself.
Most children will develop at least one ear infection before age 4, when their eustacian tubes are more vulnerable to blockage. Children with infections often cry, pull on their ears, have trouble hearing, or complain of an earache. The infection might clear up nearly as fast without an antibiotic, research now shows, and an over-the counter pain reliever might be just as effective in relieving symptoms. "If a child has a little pain, a little fever, but is still behaving normally, give them some pain medication and see how they do," says Margaretha Casselbrant, a pediatrician and chief of the division of pediatric otolaryngology at the Children's Hospital of Pittsburgh. "If they don't get better in 24 hours, take them to see the doctor."
But parents shouldn't dawdle if the child is very sick-he or she has a fever or is vomiting, for example-or is less than 6 months old. Chronic ear infections can cause balance, hearing, speech, and learning problems if they're not treated. Some of these children may still need minor surgery to have tubes put in their ears to drain fluid.
ASTHMA
Prevention remains a puzzle
Special diets. Anti-mite detergent. Hypoallergenic sheets. There are many schools of thought on how parents might keep their young children from getting asthma. "People come to me and ask me, 'Should I have a pet or should I not have a pet?'" says Fernando Martinez, director of the Arizona Respiratory Center and member of a National Institutes of Health advisory panel now working on an update of asthma treatment guidelines. The data, he says, are inconclusive. "I say do whatever your heart tells you."
Indeed, despite lots of effort, no one has yet figured out what works to head off asthma, which inflames the airways and obstructs breathing and, according to the Centers for Disease Control and Prevention, afflicts 9 million children. Inhaled corticosteroids, the most common asthma treatment, are often prescribed to reduce wheezing in high-risk kids-those who also have eczema, a parent with asthma, or allergies to airborne substances-before they get asthma. Many doctors have wondered if these drugs, given at an early age, might have a preventive effect. "Most of the lung function loss that occurs in persistent wheezers occurs before age 6," says Theresa Guilbert, a professor at the University of Arizona, who recently studied the practice in toddlers and showed that it doesn't work.
In May, Guilbert and colleagues reported in the New England Journal of Medicine that 2- and 3-year-old preasthmatic tots treated for two years with inhaled corticosteroids did experience a reduction in wheezing while taking the medication. But any benefits stopped when the treatment did. The results may argue for continuing to use the drugs to treat symptoms but in as low a dosage as possible to avoid hampering a child's growth, a possible side effect. According to Martinez, the two most important measures parents can take to prevent asthma are breastfeeding their children and protecting them from exposure to cigarette smoke.
FEVER
Two different painkillers is too much of a cure
When a child has a fever, a parent's top priority is bringing it down-and fast. Maybe that's why so many double up, giving their feverish tots ibuprofen and acetaminophen at the same time. "It's a very common practice," says Mary Hegenbarth, a pediatric emergency specialist at Children's Mercy Hospital in Kansas City, Mo., and a member of the American Academy of Pediatrics committee on drugs.
But not everyone agrees it's such a great idea. It is "a very unsettled issue" in pediatrics these days, says Hegenbarth. Experts say the dual dosing is a result of "fever phobia," a tendency by scared parents to fear fever's extremes, like febrile seizures or brain damage. Both are very unlikely, says Hegenbarth. And febrile seizures, while frightening, are generally harmless. Running a temperature is part of the body's normal immune response to many illnesses.
"The real issue is whether being this aggressive is warranted," says Ian Paul, assistant professor of pediatrics at Penn State College of Medicine and principal investigator in a clinical trial exploring the safety and effectiveness of dual dosing. Until there is conclusive research, Paul advises: "Treat the child, not the number on the thermometer." If a child is lethargic, especially uncomfortable, or dehydrated, a parent should talk with the doctor. Hegenbarth tells parents that using one drug, like Children's Tylenol, in its recommended dose is plenty.
CAR SAFETY
A big boost for booster seats
Quiz: Is it illegal for a 7-year-old child to ride in a car without a car seat? That depends. If you live in Pennsylvania, yes. Not so in neighboring Ohio. All states require children to be in a car seat until the age of 4. About three fourths of them mandate a booster seat past that age, but the standards vary and are becoming more stringent. For example, earlier this year, Kansas upped its booster seat age: Now kids who are under 80 pounds must be strapped in until they turn 8 years of age; before it was 4 years of age.
No matter the state, pediatricians recommend that all children under 4'9" be strapped in a safety seat. Why 4'9"? A seat belt doesn't fit and thus protect until that height, says Marilyn Bull, a neurodevelopmental pediatrician at Indiana University who has published studies on vehicle safety. Make sure the car seat fits the child correctly by checking the weight limit specified by the manufacturer and getting a seat that allows the child's knees to bend over the edge, says Bull. Installing the car seat correctly-including always putting it in the back seat-is just as important as using it. SeatCheck (www.seatcheck.org) can help parents locate a nearby inspection site.
HEAD INJURIES
Helmets are worth a bad hair day
It can't be stressed enough. If your child engages in an activity in which he or she is moving quickly, elevated above the ground, or apt to fall on a hard surface, make sure a helmet is worn. It's "the one single thing that will decrease the chances of serious injury or death," says Gary Smith, director of the Center for Injury Research and Policy at Columbus Children's Hospital in Ohio. In 2005, for example, nearly 37,000 children ages 14 and younger visited emergency rooms for bicycle-related head injuries. Studies indicate that helmet use can reduce the risk of head injury by at least 74 percent, preventing concussions as well as more serious brain injuries or even death.
You might also want to consider a helmet for your wannabe Sasha Cohen. In a report in the August issue of Pediatrics, Smith found that kids are more likely to injure their head and face ice skating than while in-line skating or roller skating.
STREP THROAT
Ask for proof positive before a pill
Your child says her throat really hurts. She's got a cough and a runny nose with a nasty green discharge. She's been home from school for three days. Strep throat, right? Wrong. Only 15 to 36 percent of children who have sore throats turn out to actually have strep, an infection caused by the streptococcus bacteria. The majority of kids' sore throats are caused by viral infections, and antibiotics have no effect.
Fever accompanying a sore throat is a surer indicator of strep than coldlike symptoms, although in children the signs vary widely. If your child has been sick for a few days, talk with your pediatrician; make sure he or she does a strep test before prescribing antibiotics. A rapid test is now available that can diagnose strep in just 20 minutes, but a 2005 report in the Journal of the American Medical Association found that over half of physicians prescribed antibiotics for children without performing a strep test first. Overprescribing antibiotics contributes to the rise of bacteria that are resistant to them, a major public-health concern.
Parents and doctors also make the mistake of believing that newer, broader spectrum antibiotics will deliver a stronger punch and flatten the strep bug better than old-fashioned penicillin, the best drug for the job. Bad call. "The bug that causes strep can be resistant to azithromycin and newer antibiotics," says Jeffrey Linder, a physician at Brigham and Women's Hospital in Boston and lead author of the study.
BROKEN BONES
Old methods are cast aside
Just a few years ago, a busted femur meant a kid would be stuck in bed for a month or more, leg elevated in a full-length cast and immobilized while the bone knit back together. These days, orthopedic surgeons often skip the cast and the traction and mend long-bone fractures in arms and legs by inserting a flexible titanium rod into the center of the bone to stabilize it. The child will have a half-inch long incision in the thigh, but no cast, and could be walking around with crutches the next day.
"We used to have an aversion to operating on children," says Michael Vitale, a pediatric orthopedic surgeon at the Morgan Stanley Children's Hospital of New York-Presbyterian. "Now we realize that there are minimally invasive ways of treating a fracture surgically that are absolutely appropriate for kids." Some hospitals are more likely than others to take the surgical approach, however. According to a 2004 study Vitale coauthored in the Journal of Pediatric Orthopaedics, children with broken femurs were significantly more likely to be treated with implanted rods at pediatric hospitals than they were at other hospitals.
Kids with wrist or ankle fractures that are stable-likely to remain in place as they heal-may be fitted with removable splints that slide on like a glove or a boot and fix in place with Velcro. And even when a cast is necessary, as in so-called monkey-bar injuries when a child falls on an outstretched arm and breaks an elbow, kids don't have to be sidelined. Instead of cotton padding, "waterproof Gore-Tex lining is the latest thing," says Daniel Hedequist, a pediatric orthopedic surgeon at Children's Hospital Boston. And a waterproof cast also means no excuses when it comes to one of kids' least favorite rituals: bath time.
ADHD
New cautions on heart problems and stimulant medications
Millions of children take Ritalin and other stimulant drugs each day to treat attention deficit hyperactivity disorder. Although the drugs have been used for more than 50 years, questions keep cropping up about their safety. The most recent concern reports of sudden death in children who were later found to have had undetected heart problems.
Last week, the Food and Drug Administration unveiled a new warning label for Dexedrine, an amphetamine, saying that normal use of the drug can cause sudden death and cardiovascular problems. This follows new, stronger warnings for Ritalin in June, and for AdderallXR, another amphetamine that is the most popular ADHD drug, and Concerta in July. The labels include admonitions that the drug should not be used in children with cardiac abnormalities, cardiomyopathy, or other serious heart problems and that use can worsen psychiatric problems. Similar new warnings are in the works for Strattera, an ADHD drug that is not a stimulant.
The FDA didn't go as far as an advisory panel that met in February and asked for the strongest "black box" warnings for all the stimulants because of increased cardiac risk. But Steven Nissen, head of cardiology at the Cleveland Clinic and a member of that advisory panel, is pleased: "This is a positive thing." Parents of children taking Ritalin or other stimulants should weigh the risk against potential benefits, he says. Unfortunately, there's no simple test for doctors to detect the rare, hidden heart problems involved in most of the deaths. "If you have a child who has minimal symptoms of ADHD, you need to think, is it really worth it?" On the other hand, Nissen says, the drugs really do help some kids. In those cases, he says, parents need to keep a close eye on the situation. "Make sure your pediatrician checks for heart murmurs and evidence of heart disease."
TONSILLECTOMIES
That incessantly loud snoring may be a sign that tonsils need to go
Until the last decade, kids typically got their tonsils out because they had recurrent sore throats, based in part on a lingering concern from the days before antibiotics when strep throat was a killer disease. Today, children who get a half-dozen or more strep throats a year are still often given tonsillectomies to minimize the chance for bacteria, food particles, or other debris to lodge there.
Now the majority of kids get their tonsils out because they have obstructive sleep apnea, which occurs when breathing is interrupted periodically during sleep because the airway is blocked or is too small. In children, it often occurs because their tonsils are simply too large. When they fall asleep, their tonsils temporarily block their throats, disrupting their breathing and often causing them to snore loudly. In obese children, however, fatty tissue rather than tonsils is generally the culprit in sleep apnea.
Obstructive sleep apnea in children can cause many problems, from daytime sleepiness and hyperactivity to high blood pressure and heart failure-and can have a long-term effect on their learning abilities. Doctors don't always make the connection. "If your child snores more than mildly, take it seriously until proven otherwise," says David Roberson, an assistant professor of otolaryngology at Children's Hospital Boston.
ACNE
Some good news for those plagued with pimples
For years, doctors have regularly tested the blood of patients on isotretinoin, or Accutane, the brand name of the drug, for high levels of cholesterol, triglycerides, and liver enzymes. Now one of the largest studies of the acne medication confirms that abnormal blood tests are common, but they are not usually dangerous. A study published in the August issue of the Archives of Dermatology of nearly 14,000 people between the ages of 13 and 50 found that these side effects are no cause for alarm. In the majority of people, the higher counts are mild and return to normal once the patient stops using the drug, says lead author Lee Zane, a dermatologist at the University of California San Francisco. "There are risks, but they can be managed."
Worry over the risks, specifically of severe birth defects, has plagued Accutane for years and was the impetus behind iPledge, a mandatory, national registry for those taking the drug (requiring women to be on at least two forms of birth control) that went into effect in March. Yet, despite the worry of some patients and regulators, the drug continues to work miracles for people whose acne can't be treated any other way. Isotretinoin "is undeniably the most effective therapy for acne that we have now," says Zane.
RECREATIONAL DRUGS
Be forewarned. Kids have a new refrain: Hey, it's "legal"!
Studies routinely show that many parents are clueless about how often their children are exposed to drugs and how often they try them. Now there's something new to add to the need-to-know list: Salvia, an herb that when smoked can produce powerful hallucinations, has become increasingly popular among teens. Although legal in most states, three have banned the leafy green, making its possession-like that of heroin or cocaine-a felony. At least seven other states are trying to outlaw it, while others are calling for a federal ban.
Salvia comes in liquid and powder form and is usually smoked. It costs anywhere from $20 to $60 a gram, depending on potency, and is easy to buy, especially on the Internet, where it is marketed as a "legal high."(A salvia high has been described by users as a 20-minute acid trip.) But lately, it has been finding an audience among teenagers looking for a legal alternative to marijuana and LSD. "Five years ago, maybe 3 percent of kids you asked about salvia would know what it is," says John Lieberman, director of operations for Visions Adolescent Treatment Centers in Southern California. "Now it's more like 50 percent." Lieberman notes that the "legal" moniker makes kids think the herb is harmless, but the same argument was made years ago about ecstasy. "Now we know it's one of the most brain-damaging drugs out there," he says.
ALCOHOL ABUSE
New science shows teen drinking threatens brain development
Now there's a new worry about underage drinking. Emerging research suggests that alcohol harms teen brains more than previously thought. In fact, it could make teens more prone to alcoholism. A recent report in the Archives of Pediatric and Adolescent Medicine surveyed more than 43,000 adults and found that 47 percent of those who began drinking before age 14 had alcohol problems later in life, compared with just 9 percent of those who started drinking at age 21. "The younger they are when they begin to drink, the more likely they are to develop heavy drinking problems," says lead author Ralph Hingson, director of epidemiology and prevention at the National Institute of Alcohol Abuse and Alcoholism. The correlation held even when the researchers accounted for family history of alcoholism and other common risk factors. "The fear and the hypothesis are that alcohol may affect the way in which the brain matures," says David Rosenbloom, director of the Youth Alcohol Prevention Center at Boston University. Those changes,he says, could hardwire the brain toward alcholism later in life. The new findings and previous rodent studies showing more damage from alcohol in the brains of adolescent rats suggest that early alcohol consumption could have severe and long-lasting neurological consequences. Whether that can be proved is "the million-dollar question," says Hingson.
The question is an urgent one, with two thirds of ninth graders saying they had tried alcohol at least once, according to the Centers for Disease Control and Prevention. "Parents believe they are helpless," says Rosenbloom. But, he says, they can have an influence by talking to kids early, at least by middle school, about the dangers of reckless drinking; knowing who their kids are hanging out with; asking questions about what their kids are doing; paying attention to, say, changes in behavior or appearance; and using alcohol responsibly themselves.
HIV
All teenagers may soon need screening for the AIDS virus
The Centers for Disease Control and Prevention has proposed that all teenagers beginning at age 13 be screened for HIV, the virus that causes AIDS. Current guidelines recommend testing primarily for people at high risk for the disease like injection drug users and homosexual men and their partners. The new guidelines, expected to be finalized this fall, would make HIV screening routine for everyone ages 13 to 64.
Why the change? About 25 percent of the estimated 1 million Americans currently infected with HIV don't know it, says Kevin Fenton, director of the CDC's National Center for HIV, STD and TB Prevention. "Knowing one's HIV status allows earlier access to effective treatment that results in a longer, healthier life," he says. If you're thinking that 13 is too young to be worried about HIV, think again. A 2005 CDC survey found that 47 percent of high school students have had sexual intercourse, and another study found that nearly half of all sexually transmitted diseases were contracted by young people between the ages of 15 and 24.
This story appears in the September 4, 2006 print edition of U.S. News & World Report.