Asthma – How to Protect Your Child When the Steroid Inhaler Fails

According to an article published by WebMD, a new study by the National Institute of Health examined the effectiveness of step-up asthma treatment among children who continue to experience asthma attack on steroid inhalers.

Researchers concluded that the success of the step-up treatment varies depending on the population of children. The study focused on 182 children between the ages 6 and 17. All of the children enrolled in the study experienced asthma attacks despite regular steroid treatment. In this population, the following drugs were used: long-acting beta-agonists (LABAs), leukotriene-receptor antagonist (LTRA), and increased doses of inhaled steroids. According to the article:

The drugs with the best chance of success – 45% – are long-acting beta-agonists (LABAs)… . But safety concerns limit the use of these agents, the best known of which are Serevent and Foradil and the combination products Advair and Symbicort. About 30% of kids, the study found, do best either with a leukotriene-receptor antagonist (LTRA, brands include Accolate, Singulair, and Zyflo) or by doubling the dose of the child’s current inhaled steroid medication.

Although the study did not reveal a clear winner, researchers were able to identify the following correlations:

Hispanic and non-Hispanic white children were most likely to have the best response to LABA and least likely to have the best response to doubling inhaled steroid dosage. Black children were equally likely to have the best response to LABA or doubling inhaled steroids and less likely to have the best response to LTRA. Children who did not have eczema were most likely to have the best response to LABA.

Contributing author: Jon Stefanuca

Debating the Unknowns in Obesity Surgery for Children – NYTimes.com

Bariatric surgery – commonly referred to as weight-loss surgery, is apparently on the rise in the pediatric population.  A New York Times article – Debating the Unknowns in Obesity Surgery for Children – NYTimes.com – reports that these surgeries are on the rise in the United States.      

“I honestly believe that in 5 to 10 years you’ll see as many children getting weight-loss procedures as adults,” said Dr. Evan Nadler, co-director of the Obesity Institute at Children’s National Medical Center in Washington.

For those who may not be familiar with exactly what a surgeon does to the intestinal tract, there are numerous videos available on the internet that provide a good overview of this surgery – for example, here is an example showing one form of such surgery known as a by-pass.   There are a number of types of bariatric surgery, including two of the most common – Roux-en-Y gastric bypass and gastric banding procedures.

While such surgeries of often medically necessary and truly constitute a life-saving measure for some, they are not just an alternative to diet and exercise – that is, they are not without substantial risks no matter what form of bariatric surgery is being considered.

Here’s a list of just some of the potential complications -depending on the type of surgery – that are recognized risks of this surgery:

• Bleeding
• Complications due to anesthesia and medications
• Deep vein thrombosis
• Dehiscence (wound breakdown)
• Infections
• Leaks from staple line breakdown
• Marginal ulcers
• Pulmonary (lung) problems
• Spleen injury
• malabsorption
• nutritional complications
• death (reported as less than one percent)

On the other side of the equation, there is no doubt that when indicated, this surgery can certainly provide much needed restoration of health and longevity to these juvenile patients:

Obese children can suffer from a long list of problems better known in adults: insulin resistance, high blood pressure, fatty liver, a thickening of the left side of the heart, and even depression.

So far, the studies have found that the body starts to repair itself as the weight falls. For example, two years after gastric bypass, the left side of the heart has started to return to normal in most adolescents, according to cardiologists at Cincinnati Children’s. Research also suggested that for at least as long as the children have been followed, the procedure appeared safe, and about 85 to 90 percent of adolescents maintained their initial weight loss, Dr.  (Thomas H.)Inge [director of the surgical weight loss program at Cincinnati Children’s] said.

Those on the other side of this significant debate are not so confident in the long-term effects/benefits of having children undergo weight-loss surgery:

Some physicians, including Dr. Edward Livingston, chairman of gastrointestinal and endocrine surgery at the University of Texas Southwestern Medical Center at Dallas, say advocates could be drawing conclusions too early. No one can say whether the changes will translate into a health advantage later on. Dr. Livingston noted that a third of the children in the Australian gastric-banding study had to go back to the operating room over concerns about the device — and that even the children in the group that did not have surgery showed respectable improvements in blood pressure, insulin resistance and other measures. With or without surgery, he said, “both groups got better.”

The NY Times article reports: “No one knows exactly how many adolescents are turning to surgery to get thinner. One of the few studies, published in 2007, reported that bariatric surgery in teenagers was relatively rare but rising fast: from 2000 to 2003 (the last year examined), the number of operations tripled, to about 800.”

In one article, it is estimated that 220,000 bariatric procedures were performed in 2008 with an estimated increase of approximately 20,000 in 2009.

There is also an ongoing debate as to which form of weight-loss surgery is indicated for adolescents – bypass or banding.

Nor do surgeons agree on which of the two procedures used most — banding or bypass — is more appropriate for youths. Dr. Nadler, of Children’s National Medical Center, prefers banding, saying it is less radical and can be more easily undone if need be. In November, in The Journal of the American College of Surgeons, he described a study finding that among 41 teenagers followed for two years after gastric banding, their excess body weight had dropped by about half, on average, and other measures of their health had improved.

There is no doubt the debates will rage on for years to come.  What is evident, however, to those of us who have litigated many cases involving bariatric surgery performed on adults, is that this is not to be considered a ‘quick fix’ for being overweight.  It is not a form of cosmetic surgery.  This is serious stuff and reasoned considerations must be made: (1) is it medically indicated?; (2) what are the alternatives?; (3) who are the surgeons skilled in these procedures?; (4) is the adolescent properly being screened and counseled before undergoing surgery?; (5) what post-operative follow-up is needed?; (6) is the facility where the procedure is to be performed truly recognized as being capable of dealing with such patients and potential post-operative complications?; and (7) does the child and his/her parent(s) truly understand the risks associated with such procedures? – just to name a few of the many issues that must be addressed.

Generation 2 Worldwide and “ChildESIGNS” Drop Side Crib Brands Recalled; Three Infant Deaths Reported

This just came out today – Generation 2 Worldwide and “ChildESIGNS” Drop Side Crib Brands Recalled; Three Infant Deaths Reported.

Here we go with yet another wonderful crib design.

What is it that these manufacturers don’t get?  Recall after recall.  Can’t they figure out by now what it is about the design that makes these cribs potentially lethal to babies?

Yesterday we posted a blog on our site – Eye Opener – that provided a number of useful links to keep up with all the product recalls that seem to be coming out in a never-ending stream when we talk about children’s product safety.

Here’s the link to that blog – check the links in it and save them to your favorites/bookmarks bar.

Fall on ice puts girl in perilous position – Parents: be aware of the signs and symptoms of a potential life-threatening bleed in your child’s head.

Bad weather all around us – slip and fall incidents abound.

Are you familiar with the general signs and symptoms of a serious bleed in the head (e.g. subdural hematoma) that can cause permanent neurological injuries if not death?

Read this article from stltoday.com (St. Louis Post-Dispatch) – Fall on ice puts girl in perilous position – STLtoday.com.

The comments by the attending neurosurgeon, who timely and properly intervened to save this young girl’s life, are most informative.

Dr. Werner noted that Ava’s injury is unusual in children, and much more common in elderly people, because their veins are more fragile and they’re often on aspirin and other blood thinners.

Ava is a good example of the symptoms to look for after hard impact to the head, he said.

“Persistent pain that doesn’t get better as the hours go on. Vomiting more than twice in 24 hours. Changes in level of awareness,” he said. “And the last, most ominous sign is when the pupils are different sizes because one has dilated. That’s a sign that you have, not hours, but minutes to get treatment.”

While such injuries in children may be ‘rare,’ Ave – thank goodness – is living proof of the fact that head trauma in children (and adults) are not to be taken lightly.  Vigilance and knowledgeable observation after such an incident are potentially key to the survival of a loved one.

What’s Going On? – Birth Weights In The US On The Decline

A recent article  in Medical News Today reports a perhaps concerning trend in lower birth weights for infants in the United States.  The research was performed by the Harvard Pilgrim Health Care Institute’s Department of Population Medicine, an affiliate of Harvard Medical School, and analyzed 15 years of data from National Center for Health Statistics Natality Data Sets, looking at 36,827,828 U.S. babies born at full-term between 1990 and 2005.

As the author of the Medical News Today article, Jessica Cerretani, points out, there are potentially serious concerns about this trend.

While the decline may simply represent a reversal of previous increases in birth weights, it may also be cause for concern: babies born small not only face short-term complications such as increased likelihood of requiring intensive care after birth and even higher risk of death, they may also be at higher risk for chronic diseases in adulthood.

This study was published in Obstetrics & Gynecology, February 2010, Volume 115, No. 2, Part 1.

Maybe that picture of the chubby little cherub was ‘just right.’

As the authors of the Harvard-based study noted:

Future research may identify other factors not included in the current data that might contribute to lower birth weight, such as trends in mothers’ diets, physical activity,stress, and exposure to environmental toxins. “There’s still a lot we don’t know about the causes of low birth weight,” says Oken. “More research needs to be done.”

Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today

Over the course of my career in litigating  catastrophic newborn injury cases, a rather common  ‘defense tactic’ involves trying to prove a limited life expectancy for these catastrophically injured children.  Essentially, defense lawyers attempt to convince a jury that such children have a very limited chance of survival for more than 8 to 15 years of life.  The reason for this approach is  quite simple – the shorter the period of time that such children survive, the lower the potential damage award for future care needs and future pain and suffering.

Lawyers for the inured child and family, on the other hand, contend that with appropriate medical care, such children will live a relatively normal life expectancy – therefore, there is an absolute need for a substantial amount of money for future care needs.

The issue often becomes:  given a certain type of injury, what is the ‘probable’ life expectancy for such children?

A recent study published in the British medical journal, The Lancet, and reported in MedPage Today on January 19, 2010,  provides some further insight into this issue.   Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today.

It has long been suspected that if a child is unable to protect his/her airway because of an inability to roll-over and clear secretions, that child is at increased risk for breathing complications – potentially leading to early death.  A number of limited studies are cited for other ‘factors’ leading to limited life expectancy.

This new study offers some interesting insights into various types of anomalies and the probability of survival for children suffering from them.

Just a sampling of the data (see the article for more details) gives a sense of the ‘predictability’ of survival based on specific defects:

The investigators analyzed survival among specific subtypes of anomalies and found rates of 20-year survival exceeding 95% for the following:

Ventricular septal defects, 98.3% (95% CI 96.6 to 99.1)

Pulmonary valve stenosis, 98.1% (95% CI 96.1 to 99.1)

Cleft lip and palate, 97.7% (95% CI 94.6 to 99.1)

Atrial septal defects, 96.3% (95% CI 93.3 to 98)

Cleft palate, 96.3% (95% CI 92.8 to 98.1)

In contrast, subtypes with less than 50% one-year survival included arhinencephaly/holoprosencephaly, common arterial trunk, and hypoplastic left heart.

What the study also goes on to say, however, is that certain conditions, survivability is contingent on the quality of care being provided to these children.

What is obvious and beyond any argument is that funding is desperately needed for further long-term studies to clarify this issue for not only the physicians rendering care to these children, but also for the parents seeking a clearer picture of what the future holds for their families in terms of financial needs and planning.

Parents – be aware and read this article: Children Don’t Have Strokes? Just Ask Jared About His, at Age 7 – NYTimes.com

The New York Times reports a fascinating story about a 7 year old boy, Jared, who one day was a healthy, happy, fully functioning boy and a few short days later was lying in a hospital bed unable to walk, virtually unable to speak and hooked to tubes and wires to support his life.

NY Times photo of Jared

The theme of the story – Children Don’t Have Strokes? Just Ask Jared About His, at Age 7 – NYTimes.com – relates to a medically inaccurate concept – ‘children don’t have strokes.’

The author of the article, Jared’s father, has sage advice, based on accurate medical information:

How little we knew. It turns out that stroke, by some estimates, is the sixth leading cause of death in infants and children. And experts say doctors and hospitals need to be far more aggressive in detecting and treating it.

Dr. Rebecca N. Ichord, director of the pediatric stroke program at Children’s Hospital of Philadelphia, who continues to be deeply involved in Jared’s care, said that while conditions like migraines and poisoning could cause similar symptoms, “front-line providers need to have stroke on their radar screen as a possible cause of sudden neurologic illness in children.”

The sixth leading cause of death in infants and children and many in the medical profession believe that ‘children don’t have strokes’?!   Maybe, just maybe, the article has some wisdom not only for parents – but perhaps also for the doctors treating these children.

The ‘Times’ article has a good link for a basic understanding of the signs and symptoms of stroke.  Take a moment and familiarize yourself with these so that when you are told ‘children don’t have strokes’ – maybe you can ‘share’ the news that this is nonsense so that precious hours of needed care are not wasted!