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ADHD treatment myth busted December 1, 2015

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Ritalin is commonly prescribed to children with real or imagined Attention Deficit Hyperactivity Disorder. For a long time it is believed to be not only effective but very safe which has led to many doctors without expertise in the disease prescribing it for children whose parents feel are a bit naughtier than average or performing below expectation at school.

Here’s what experts say after reviewing the evidence for Ritalin:

A comprehensive Cochrane Review shows there is very low-quality evidence to support the use of methylphenidate (Ritalin,Concerta, other brands) in children with attention deficit hyperactivity disorder (ADHD) leading the reviewers to urge more caution when prescribing the stimulant.

“The evidence is not as convincing as many clinicians have believed regarding the benefits of methylphenidate,” lead authors Ole Jakob Storebø, PhD, clinical psychologist, Region Zealand, Roskilde, Denmark, and Morris Zwi, MBBCh, consultant child and adolescent psychiatrist, Whittington Health, London, UK, told Medscape Medical News.

“In general, our findings raise concerns about how much we should expect of this medicine, and there needs to be more caution when prescribing methylphenidate. I think it probably calls for a change of mindset more than a change in practice,” the investigators note.

The review was published online November 25 in the Cochrane Database of Systematic Reviews.

Even though the authors couched their conclusion in the usual cautious respectful scientific medical language, the message is clear: it doesn’t work, stop prescribing it.

My scepticism about this drug is now confirmed. The solution to children’s behavioural problems does not come out of a bottle.



Crib bumper deaths: call for ban on crib bumpers. November 26, 2015

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Reuters news article on rise of crib bumper deaths.

Journal of Pediatrics article (Free abstract)

Background: NEJM Journal Watch Pediatrics and Adolescent Medicine coverage of the dangers of crib bumpers (Free)

More dire warnings on antibiotic resistance: “Antibiotic Apocalypse” BBC November 21, 2015

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Very strongly worded warnings from experts continue to largely fall on deaf ears in this country where antibiotic over-prescribing still runs rampant. The day is approaching when all we can get from doctors for a serious infection are a few kind words.


Public Confused About Antibiotic Resistance, WHO Says November 21, 2015

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(Medscape article Nov 2015) Misconceptions about antibiotics and the health threat posed by antibiotic resistance are common around the world, according to findings from a multicountry survey from the World Health Organization (WHO) released today.

The survey, conducted online and in person, asked nearly 10,000 adults about use and knowledge of antibiotics and antibiotic resistance. It was conducted in 12 countries (two countries per WHO region): Barbados, China, Egypt, India, Indonesia, Mexico, Nigeria, the Russian Federation, Serbia, South Africa, Sudan, and Vietnam. Among the common misconceptions highlighted by the WHO:

Three quarters (76%) of respondents think antibiotic resistance happens when the body (not bacteria) becomes resistant to antibiotics.

Two thirds (66%) believe individuals are not at risk for a drug-resistant infection if they personally take their antibiotics as prescribed. Nearly half (44%) of respondents think antibiotic resistance is only a problem for people who take antibiotics regularly.

More than half (57%) of respondents think there is not much they can do to stop antibiotic resistance, and 64% believe the medical community will solve the problem before it becomes a serious threat.

Nearly two thirds (64%) say they know antibiotic resistance is an issue that could affect them and their families, but how it affects them and what they can do to address it are not well understood.

Nearly two thirds (64%) of respondents believe antibiotics can be used to treat viruses, and one third (32%) believe they can stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.

The End of Modern Medicine?

Release of the survey findings coincides with the launch of a new global WHO campaign, “Antibiotics: Handle With Care,” during the first World Antibiotic Awareness Week, November 16 to 22. The aim of the campaign is to raise awareness and encourage best practices among the public, policymakers, and health and agriculture professionals to avoid the further emergence and spread of antibiotic resistance, the WHO said.

“The rise of antibiotic resistance is a global health crisis,” Margaret Chan, MD, WHO director-general, said during a media briefing. “Antimicrobial resistance is on the rise in every region of the world. We are losing our first-line antibiotics. This makes a broad range of common infections much more difficult to treat, and replacement treatments are more costly, more toxic, and need much longer durations of treatment,” she noted.

“With few replacement [antibiotics] in the pipeline, the world is heading towards a postantibiotic era in which common infections will once again kill. If current trends continue, sophisticated interventions, like organ transplantation, joint replacement, cancer chemotherapy, and care of preterm infants, will become more difficult or even too dangerous to undertake. This will mean the end of modern medicine as we know it,” Dr Chan added.

Thankfully, “more and more governments now recognize the importance of this issue as one of the greatest threats to health today,” she said. A global action plan to tackle antimicrobial resistance was endorsed at the World Health Assembly in May 2015. One of the plan’s five objectives is to improve awareness and understanding of antibiotic resistance through effective communication, education, and training.

Precious Commodity

Overuse and misuse of antibiotics in people and animals are the “fundamental” drivers of antibiotic resistance, Keiji Fukuda, MD, special representative of the director-general for antimicrobial resistance, noted during the briefing. Antibiotics are a “global good that we need to handle with care,” which is the theme of the WHO campaign, he added. “We believe that everybody, this means the general public, health workers, farmers, policymakers, everybody, has a critical role in turning this around.”

Health professionals, added Dr Chan, “need to treat antibiotics as a precious commodity and try to resist the pressure from individual patients who come in with a cold or flu or viral infection asking for antibiotics. It will be important for doctors who are very trusted by their patients to explain to them why for any viral infection antibiotics are not needed. And when they do prescribe a full course of antibiotics, they need to remind patients to take the full course,” she said.

More information on the survey and WHO campaign are available on the WHO’s website.

Antibiotics also make you fat October 23, 2015

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Children Who Take Antibiotics Gain Weight Faster Than Kids Who Don’t
October 21, 2015
BALTIMORE, Md — October 21, 2015 — Children who receive antibiotics throughout the course of their childhoods gain weight significantly faster than those who do not, according to a study published online today in the International Journal of Obesity.

The findings suggest that antibiotics may have a compounding effect throughout childhood on body mass index (BMI).

“Your BMI may be forever altered by the antibiotics you take as a child,” said Brian S. Schwartz, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. “Our data suggest that every time we give an antibiotic to kids they gain weight faster over time.”

For the study, the researchers analysed Geisinger Health System’s electronic health records on 163,820 children aged 3 to 18 years from January 2001 to February 2012. They examined body weight and height and antibiotic use in the previous year as well as any earlier years for which Geisinger had records for the children.

At age 15, children who had taken antibiotics 7 or more times during childhood weighed about 1.4 kg (3 lbs) more than those who received no antibiotics, they found. Approximately 21% of the kids in the study, or almost 30,000 children, had received 7 or more prescriptions during childhood.

Dr. Schwartz said that the weight gain among those frequently prescribed antibiotics is likely an underestimate since the children did not stay with Geisinger throughout childhood so their lifetime antibiotic histories, including antibiotic use outside the health system, would not have been recorded and because the effect of certain antibiotic types was even stronger than the overall average.

“While the magnitude of the weight increase attributable to antibiotics may be modest by the end of childhood, our finding that the effects are cumulative raises the possibility that these effects continue and are compounded into adulthood,” he said.

Dr. Schwartz said he thinks that physicians are becoming more judicious in their antibiotic prescribing, but it can be a difficult task. Often parents demand antibiotics for apparent cold viruses and other ailments that will not be helped by them. There have long been concerns that excessive antibiotic use is leading to bacterial strains that are becoming resistant to these potentially lifesaving drugs. But this study suggests that antibiotics can have long-term effects in individual children, he says.

“Systematic antibiotics should be avoided except when strongly indicated,” said Dr. Schwartz. “From everything we are learning, it is more important than ever for physicians to be the gatekeepers and keep their young patients from getting drugs that not only won’t help them but may hurt them in the long run.”

SOURCE: Johns Hopkins University Bloomberg School of Public Health

Top 5 common drug misuse in paediatrics October 14, 2015

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We have many powerful medicines today that when used correctly can be of great benefit. In their enthusiasm to use these medicines, especially if they are exciting and new, some doctors will prescribe medicines which are unsuited to the symptom or disease they are trying to treat, often causing harmful side-effects. Here is a list of 5 drugs or group of drugs that are frequently misused. Not included in this list are drugs like Tamiflu which is usually correctly prescribed for the treatment of influenza, but has questionable effectiveness and/or is not actually necessary as the condition being treated often resolve without treatment. These misuses are common in this country, but hopefully less common in most other countries where people are more sensible about medicinal usage.

5. Ritalin® in naughty children
This is a drug in the treatment of ADHD (Attention Deficit and Hyperactivity Disorder). It is relatively safe and can be very effective. Some children who are perhaps more lively than average are put on this drug without taking due care to establish the diagnosis of ADHD. Side effects include anxiety, nausea and sleep disturbance.
4. Hyoscine eg. Buscopan® for stomach pain

Hyoscine by injection is a commonly used as a pre-operative drug to reduce saliva and other secretions. Oral hyoscine  relaxes the muscle of the gut and can be helpful in cases of irritable bowel syndrome in adults, where it provides some symptomatic relief but does not actually treat the causes of IBS. In children it is often prescribed for treatment of abdominal pain, most commonly due to gastroenteritis, where its effectiveness is highly dubious and its side-effects common and troublesome. Abdominal pain in gastroenteritis is due to the insult that the gut is being subjected to by microbial infection. Often the outpouring of fluids into the gut and the increased activity of the gut is the body’s effort at expelling the harmful content of the gut. Hyoscine suppresses gut muscle contraction thus retaining the microbial poisons instead of expelling them, potentially prolonging the illness. Hyoscine also causes blurry vision and dry mouth, and while it relaxes some muscle it causes other muscles to tense up, including the bladder valve, which can mean the affected child is unable to pass urine, thus hugely increasing the child’s distress.

3. Antihistamine group of allergy drugs including Zyrtec, Telfast, Aerius (all ®) and many others, in the treatment of the common cold.

The new generation of allergy drugs are a great boon in the treatment of allergic rhinitis, eg hay fever, as they are highly effective, very safe and causes no drowsiness. Older antihistamines which cause drowsiness also have their uses, such as in the treatment of itchiness, and for mild sedation. The common cold is not allergy, the runny nose in the common cold is not caused by the same mechanism as when it is caused by allergy and so antihistamines are not effective in the treatment of the common cold. The usage, or misuse of antihistamines in the common cold has become so wide spread now that most children with the common cold are put on these drugs. While the drugs are very safe so usually no harm done and the placebo effect can often account for the perceived benefits of these drugs, to prescribe these drugs knowing that they are ineffective for the condition being treated, or to be ignorant of their proper use, is surely not the right way to practice medicine.

2. The brochodilators (asthma) drugs including Ventolin® (salbutamol) and Singulair®, in the treatment of cough.

The misuse of oral salbutamol is also so widespread that not to be given this drug for cough would be unusual. Yet many prescribers know full well that it is ineffective in the treatment of cough, in the absence of wheezing/bronchospasm, which is to say most cases of cough. Side effects are frequent and troublesome including heart palpitations, sleep disturbance and nightmares. Salbutamol by inhalation either via a nebuliser or as inhalers have also become widely misused. When administered by inhalation side effects are less troublesome and the placebo effect  much stronger, often resulting in demands from parents for this treatment when their child have simple common cold. The only effects on the body when salbutamol is given in the absence of wheezing are the side-effects and the placebo effect. Even when there IS wheezing, such as during an RSV infection, salbutamol is ineffective, or more accurately has 2% chance of being effective, in children less than 18 months of age. Singulair® (montelukast) is relatively new in the arsenal of asthma treatment. It is conveniently given by mouth just once a day and has far less side effect than salbutamol making it very popular. But again it is NOT a cough medicine, it is for treating asthma only and is ineffective when used to treat cough in the common cold. It also has more side-effect than previously thought with reports of neuropsychiatric disturbances in children given this drug.

  1. Antibiotics. To top this list of abused drugs there can be nothing else. Antibiotics, particularly the new, very broad spectrum, very expensive ones are so over-prescribed that most children are given several courses of antibiotic a year during the peak years for catching the common cold, about ages 2-4. It is impossible to know the true extent of the over-prescription but given that only around 1 in 20 episodes of respiratory tract infection is caused by bacteria, and that in some population this would be a gross over-estimate as nearly ALL respiratory episodes in children are viral, a reasonable estimate would be that antibiotics are misused 95% of the time, the true figure probably closer to 98%. Not only the frequency of misuse but the type of antibiotics being misused is a grave cause for concern. New, strong, broad-spectrum antibiotics invented to combat the ever increasing incidence of antibiotic resistance and aggressively marketed by drug companies as they have huge profit margins, are being prescribed with great abandon and very little regard for the increasing bacterial resistance caused in large part by irresponsible prescribing practices. The problem is approaching world crisis level but somehow the message is not reaching this country. A strept throat, the only bacterial respiratory tract infection which could be considered remotely common, can be very effectively treated by simple, inexpensive, penicillin or amoxicillin. The strept throat is the only type of bacterial throat infection any doctor is ever likely to come across but despite this well-known fact, doctors often favour very strong antibiotics like Augmentin® over amoxicillin. Worse still, Augmentin and most other hi-tech antibiotics are ineffective against the most common type of pneumonia found in middle-class population. The only type of pneumonia that a child living in good environment is ever remotely likely to catch is mycoplasma pneumonia, easily treated with inexpensive, old-fashioned macrolide group of antibiotic, and totally unresponsive to Augmentin, Omnicef and other popular, expensive medicines of these families.

It happens at the other end of the age spectrum too: patients are harmed by overtreatment September 19, 2015

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An article on Medscape 19/9/2015:-

“The greatest threat to older patients’ safety in primary care is the risk posed by treatment itself, not treatment error or negligence, according to an analysis of no-fault claims data from New Zealand.

These findings were published in the October issue of theAnnals of Family Medicine.

Katharine Ann Wallis, MBChB, PhD, MBHL, FRNZCGP, from the Department of General Practice and Primary Health Care at the University of Auckland in New Zealand, found that medication injuries were the main source (34%) of all treatment injuries among the elderly, and that within that category, antibiotics were, by far, the biggest culprit.

Of 294 medication injuries recorded in claims between 2005 and 2009 among patients aged 65 years and older, 150 of them (51%) were caused by antibiotics. Next highest among injury sources were nonsteroidal anti-inflammatory drugs (9%) and angiotensin-converting enzyme inhibitors (9%).

Antibiotics also topped the list for causes of serious or sentinel injuries for patients aged 65 years and older. Antibiotics caused 39% of such injuries in that age group, followed by warfarin (14%) and steroids (7%).

The serious/sentinel category was defined as having “the potential to result in” or “has resulted in” “unanticipated death or major permanent loss of function.”

In the elderly as in children, there are times when it is better to let a malady resolve on its own. Unnecessary interventions can cause harm while having little or no benefit. In the elderly it can be more difficult than in children to make a decision not to intervene, as children have much greater capacity for fighting off any illness. For most common illness episodes, children will recover without any treatment, often not any later than with treatment.

Over-prescribing in paediatrics is common, to be given 4 or 5 different drugs for a self-limiting illness is commonplace. In this country it is common  for an elderly patient to be put on upwards of 10 drugs simultaneously. Taking that many drugs side-effects are  almost a certainty. Indeed some drugs are given to treat the side-effects of other drugs, creating a chain of  sickness.  For example let’s say a drug is prescribed to treat high blood pressure. It causes nausea and insomnia so to treat these sleeping tablets and anti-nausea tablets are prescribed, which cause confusion and constipation, so a laxative is given which upsets the body’s chemical balance causing even more confusion etc etc.

Every day new drugs are being discovered which are ever more powerful. It is such a shame that instead of improving our lives we are frequently harmed by them.


Treating that pesky cough September 17, 2015

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Here is a commentary written by Dr. Michael L. Ginsberg, MD and recently published on Medscape. :-

“Treating Cough in Children

An acute cough is defined as one lasting less than 15 days. Cough is the third most common reason that patients see a doctor and the most common acute complaint in primary care physicians’ offices.[1]As a practicing pediatrician, I would estimate that visits for acute cough consume roughly a quarter of my average daily schedule between the months of December and March. The vast majority of acute cough in children is caused by self-limited viral upper respiratory infections (URIs).[2] While some otherwise healthy children may have as many as 15 URIs in a year, the average child has a URI five to six times per year, which means that normal children between 6 months and 2 years old will be sick at least once per month during the winter.[3] Consider what this implies: In an extreme case, if an acute cough is 14 days long, and a child becomes ill twice per month during the winter, an unlucky child might have acute cough on the vast majority of days during a given winter. Even without such extreme assumptions, a typical child under 5 years might be coughing on roughly 1 out of 2 average days during the winter.

Cough makes parents worry, it fills my schedule, and it makes me feel like a broken record. I walk into the room to see a smiling, drooling, happy baby with a light cough and a mother who has terror in her eyes worrying that “my mother said he might have pneumonia.” There is evidence that pneumonia is vastly overdiagnosed in both children and adults in both acute and primary care settings alike.[4,5] True pneumonia affects only 5% of children in industrialized nations per year.[6] Of course, it’s our job as clinicians to recognize those rare cases of cough that are “more than just a cough.” But for acute cough, our job is to provide peace of mind. Peace of mind doesn’t need to take the form of a teaspoon of medicine. That’s why machines will never replace us, and that’s what makes me get out of bed and go to work every morning.”

I am quoting here only the first section of his commentary. He goes on to discuss the ethics of giving placebos versus giving nothing at all.

What I hope you will see from this is how common it is for children to cough for 2 weeks or more, and how rarely this is cause for alarm. It is entirely reasonable to have your child checked out if cough is taking a bit longer to resolve than you expect and hopefully your child’s doctor will correctly give you the reassurance that this is benign, or recommend appropriate tests or treatments. Be aware however that overuse of X-rays and blood tests can lead to confusion and the results may make the doctor feel compelled to prescribe medicines, and that all medicines potentially have undesirable side effects, which for many so-called cough medicines these side effects are common and troublesome.

Two more reasons not to abuse antibiotics. September 2, 2015

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The inexorable rise of antibiotic resistance which will one day reach crisis level is enough reason on its own to control the use of antibiotic. Yet antibiotic over-prescription remains rife, often causing significant harm for no benefit. Here are two articles from Medscape citing studies which link antibiotic use to two perhaps unexpected diseases:

Antibiotic Use Linked to Increased Risk for Type 2 Diabetes

Antibiotic use was associated with an increased risk for type 2 diabetes in a new population-based, case-control study.

The findings were published online August 27, 2015 in theJournal of Clinical Endocrinology and Metabolism by Kristian Hallundback Mikkelsen, MD, a PhD student at the Center for Diabetes Research, Gentofte Hospital, University of Copenhagen (Hellerup, Denmark) and colleagues.

Data from three national Danish registries revealed that prior exposure to antibiotics was associated with a 53% increased risk of developing type 2 diabetes. The finding could mean that antibiotics play a direct causal role in type 2 diabetes or that people with as-yet-undiagnosed diabetes may have a greater risk for infection and therefore are more likely to use antibiotics.

“Both interpretations are supported by the literature and could contribute to the observed associations,” Dr Mikkelsen toldMedscape Medical News.

Clinically, the findings add a new argument to the current movement toward less frequent and more judicious use of antibiotics. “Microbiologists frequently remind clinicians not to overuse antibiotics because of the growing resistance problems and inadequate development of new antibiotics. If it appears that antibiotics also have long-term and potentially negative metabolic adverse effects, it of course puts additional weight behind a strict policy for antibiotics prescribing and selling,” he noted.

Asked to comment, Martin J Blaser, MD, the Muriel and George Singer Professor of Medicine, professor of microbiology, and director of the Human Microbiome Program at New York University Langone Medical Center, New York, called this an “important paper” and a “very well-conducted large-scale study” that provides further evidence of the importance of gut microbiota in human health and disease.

“The results are consistent with a growing body of data that antibiotics affect metabolism though their ‘collateral’ effects on the microbiome,” Dr Blaser said, noting that the findings are in line with those of a previous population-based study in the United Kingdom that also found an association between antibiotics and diabetes.


Can Antibiotics Increase Risk for Juvenile Arthritis?

The effect of antibiotic exposure on the infant gut microbiome is increasingly well recognized, and a growing body of evidence has linked this association with autoimmune conditions. A recently released retrospective study[1] conducted in children with newly diagnosed juvenile idiopathic arthritis (JIA) provided yet more evidence, finding that antibiotics were associated with newly diagnosed JIA in a dose- and time-dependent fashion.


“Flu in kids, treat early, treat often, a good idea?” March 5, 2015

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Recent article from Medscape states:

Weijen Chang, MD: Recently, Thomas Frieden, MD, director, US Centers for Disease Control and Prevention (CDC), in response to criticism about the reduced efficacy of this season’s influenza vaccination, has been prominentlyadvocating use of antiviral medications (oseltamivir [Tamiflu®] and zanamivir [Relenza®]) for the treatment of influenza infections in adults and children. In short, his philosophy can be paraphrased as, “Treat early, treat late, treat often.” This treatment recommendation, however, seems to be swimming upstream against a growing river of evidence that questions the efficacy of influenza antiviral medications, especially in light of an unfavorable adverse effect profile.[1]

In a previous blog post I commented that some experts recommend more frequent usage of Tamiflu, something which I did not agree with but felt I should indicate that there are researchers who advocate its use.

Evidently many experts are as sceptical about Tamiflu as I am.

The flu this year is unfortunately rather more severe than last year and so in a few cases where the child is really suffering from flu symptoms, I have been advising at least a trial of Tamiflu. For most flu cases however, I still very much feel that Tamiflu could make the patient feel worse than if he/she did not take it.