Tylenol, Swimmer’s Ear, and Lazy Eye – PediaCast 002

Posted by Dr. Mike on July 26, 2006

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Topics

Tylenol And Liver Disease
Benadryl And Sleeping Babies
Vaccine Prevents Cervical Cancer
FDA Approves New Sunscreen
Court Ordered Chemotherapy
American Cyclist Thanks Mom And Dad
Swimmer's Ear
Lazy Eye

Transcription

[Music]

Announcer: Hello, moms and dads. Welcome to this week's episode of PediaCast, a pediatric podcast brought to you by pediascribe.com. Visit pediascribe.com to explore a collection of thoughts from an American pediatrician. And now, here is your host, Dr. Mike Patrick, Jr.

Dr. Mike Patrick: Hi, everyone. This is Dr. Mike Patrick, Jr coming to you from Birdhouse Studio. I'd like to welcome you to this week's edition of PediaCast: A Pediatric Podcast for Parents.

For those of you who are coming back for the second week, a warm welcome back to you.

And for all the new folks out there, a quick introduction to our program. PediaCast is meant to be a conversation between a pediatrician and parents, kind of like of having a pediatrician over for dinner. And I'm happy to answer any questions that you might have. It's really easy to ask those questions, all you need to do is give us an email at podcast@pediascribe.com. Or you can go to our website, www. pediascribe.com/podcast and click on the Contact link and you'll be able to send us a message that way as well.

Now, keep in mind that we're not going to be able to give you specific advice about a specific child. And the reason for that, it's really inappropriate to give you advice about a specific disease without doing an interactive history and hands-on physical examination. You really have to do that in order to adequately and accurately assess what's going with your child and then, to give you appropriate advice.
But what we can do is answer just sort of generic questions that you might have about a disease, questions you might have forgot to ask your doctor while you were in the exam room. Or, if you already asked your four questions and you hated to keep him much longer because you knew there was a waiting room full of patients, but there still was a question about ear infections or poison ivy rash or something like that, then, just let me know what your questions are and we'll try to get them answered for you.

0:02:21

We have a full show for you today. In the News segment, we're going to be talking about Tylenol and Benadryl. There have been some studies released recently on both of those medicines that are commonly used. Also, a new vaccine is out that prevents cervical cancer and it's been approved for use in teenagers, that's why we're going to talk about that. The FDA has approved a new sunscreen ingredient. We're going to explore that a bit with you. And then, a court orders a boy to have chemotherapy and an American cyclist thanks his mom and dad. That's coming up in the News segment.

And then, after that, in our Feature segment, we're going to talk about swimmer’s ear. With it being summer, I've seen that a lot in the office this last week, and we're going to talk about what swimmer's ear is all about.

And then, in the Mailbox section this week, we got a question about amblyopia which is a fancy term for lazy eye. So we're going to talk about it as well.

All right, before we move on with the program, I just want to say a quick warm "Welcome, home" to my two kids. I have a 12-year-old daughter and a nine-year-old son. And during the course of this program, you're going to hear about them, because in addition to being a pediatrician, I'm a proud dad as well. So warm welcome home to them. They were visiting grandma and grandpa this past week. Grandma and Grandpa had a new puppy at their house so that won out over mom and dad. In fact, they weren't really happy about having to come home. They were helping to train to come and with housebreaking and all that business.

It was definitely quiet here at the house with the kids gone. I guess we got a little bit of a preview of what it's going to be like when we're empty nesters and I don't know, it's almost too quiet. We did get a lot of work done, though. We did some decluttering and went through some boxes in the basement, cleaned up some things, so I guess something good did came out of it. And, of course, we got to spend some quality time together, too, without the kids. But it is nice having them back home.

All right, so we're going to go ahead and move on to our News segment and we'll get that going right after this.

0:04:12

[Music]

Dr. Mike Patrick: All right, in the News segment today, we're going to first start talking about couple of medicines that almost everybody out there I'm sure is familiar with, and that's Tylenol and Benadryl. There had been a couple of studies that have come out very recently regarding both of these medicines. The first one with Tylenol, there was a study just in May of this year and then another one earlier in this month of this year. One in the Journal of Pediatrics and the other in the Journal of the American of Medical Association. So these are brand new studies and both of these basically confirm something we already knew, although a lot of parents out there might now have known this.

And that is that excess Tylenol intake can lead to liver damage and in some sensitive people, you can have some early signs of liver problems even at the maximum daily allowance that's recommended. So, there's some question about whether the maximum daily allowance of Tylenol ought to be decreased a little bit to prevent liver damage in some of these folks.

There was no one who actually had liver failure at the recommended daily allowance. Let me just make sure that's clear. It has been known for quite some time that large overdoses of Tylenol can cause liver failure and there had even been some folks who have passed away and had to have liver transplants because of Tylenol overdoses.

0:05:54

So the point with this study, even though it's something we already knew, it's to let parents know that even over-the-counter medicines can have some dangers associated with them, especially when you don't follow the instructions on the label. So you want to make sure you use the right dose of Tylenol. And also, you don't want to use it day in and day out. If there's a problem, make sure you bring it to your doctor's attention so that we can address the underlying cause of the pain or fever that you're using the Tylenol for.

Also, it's really important that you read labels because infant T Tylenol, it comes in a real small bottle and it has a dropper with a .4 and a .8ml marked on it. The reason that it comes in such a small bottles is because if the older kids were to open that up and drink it, because it does taste pretty good, it could damage their liver. So in order the decrease the chances of that happening, that's the reason it's in such a small bottle, the way that it is with the infant Tylenol. So you want to make sure that you're really careful with that.

Also, a lot of over-the-counter cold preparations have Tylenol in them. So, sometimes you give Motrin or Tylenol and the cold and cough medicine, but you want to make sure that your cold or cough medicine does not contain Tylenol in it because then, you're double dosing the Tylenol.

Acetaminophen, A-C-E-T-A-M-I-N-O-P-H-E-N, acetaminophen, probably seen that on labels before, that's the generic name of Tylenol. So that's the name that you want to look for when you're looking at the ingredient list of cough and cold medicines.

Also, keep in mind that there are some prescription medicines that contain Tylenol or acetaminophen as well and thus include Darvocet and Percocet among others.

So something to think about. The point of this is not to be afraid of Tylenol. Ibuprofen has its own set of problems associated with it. And certainly we want to make kids more comfortable when they have a fever. The point is just to make sure that you're using the amount that's appropriate on the label. And if you have questions about what amount you should give, you should call your doctor or your child's doctor. If other medicines that you're taking have Tylenol in them, then you want to be careful about double-dosing them.

0:08:11

OK, moving on to Benadryl. Now, this is an interesting study. One of the side effects to Benadryl is that it makes you sleepy. And for a while now, parents and some doctors have recommended giving Benadryl to babies who are having sleep trouble. So if they're waking up multiple times during the course of the night, one of the strategies is that you could give them Benadryl to help them sleep.

This study wanted to find out if that really works or not. So they took 44 infants who were between the ages of six and 15 months. So these are all babies we're talking about. And these are kids who woke up at least two times during the night and cried and got mom and dad up and out of bed. They divided these 44 kids into two groups. One group would hit low-dose Benadryl and the other one would just get a placebo, so something like sugar water.

It was a double-blind study. And when you hear those words together that means that the parents and the doctor did not know which child had the Benadryl and which one had the placebo or the sugar water. Now, of course, the investigators behind the scenes who are compiling the data, they had to know who is getting which one and then correlate that with the parents' reports on whether the medicine was helping or not. But the point is, the person who is obtaining the history and doing the physical examination and the parents who are reporting whether it seem like the medicine or child received help or not, did not know which of those medicines they got, whether it was the Benadryl or the placebo.

The medicines was given 30 minutes before bedtime and then, they used the parent report to judge whether it worked or not. Now, the interesting thing, of the 44 kids only one of them who got the Benadryl showed any improvement and three kids in the group that got the placebo reported improvement. So, it seem that according to this study, giving them Benadryl half-hour before bedtime did not help them sleep.

0:10:02

Now, there were some problems with this study. And I think I mentioned last week, we are going to try to let you know about problems with studies. I am not an expert investigator by any stretch, so when I see a problem with the study, you know it's a glaring problem. Because it's a subtle problem, I'm not going to probably see it. Also, I do have advantage of being able to read some critiques of studies that come out in the pediatric literatures. So some of the things that we talked about aren't completely my ideas. And we'll try to credit people, where it's appropriate, for those.

So some of the problems with the Benadryl study: number one, 44 kids is just really a small sample size. You read about a lot of studies that include thousands or even tens of thousands of kids. So you know that 44, it's hard to make generalizations based on that, to come up with a significant data.

So that's one problem with it. Another one is that a low-dose of Benadryl was used for this study and it could be that if a higher dose of Benadryl was given, maybe it would make them sleepy — the babies. Now, there's a bit of a problem with giving higher doses of Benadryl. If you give too high of a dose, it can actually decrease the respiratory drive so you could have babies stop breathing if you give them too big of a dose of Benadryl. That is theoretically possible.

Also, in some kids, we know that higher doses of Benadryl actually can cause stimulation rather than drowsiness. So that may actually make them wake up more and be louder and cry more and wake up more often during the night. So I think the investigators wanted to try to avoid that side effect as well as the decreased respirations or breathing and that's why they went with the low-dose Benadryl. But that may also have affected the outcome a little bit.

I think even though there were some problems with the study, it does have one good thing going for it. I think instead it turns upside down some of our old beliefs. The belief that "Well, Benadryl causes drowsiness, it's good to give it to babies." It does call that into question a bit, whether that really works.

0:12:07

There had been some similar studies in the past that had looked at cold medication. So if you have a kid with a runny nose and a cough and you give him some Dimetapp or Triaminic or Robitussin, that sort of thing, does it really help the cough and the runny nose? And there had been some studies that show that they probably doesn't help that much and more of what it does is help kids go to sleep. And if the kids are sleeping, they're not complaining and they're not coughing quite as much. And so, the parents kind of get this perception that they're getting better. But if you look at the number at some of the studies, it shows that giving the cough and cold medicines really does not decrease cough and running nose during waking hours as much as you think.

Same thing with vitamin C intake. Vitamin C, a lot of people start ramping up their intake of that during the winter months to try to avoid colds and flu. And there had been several studies that had divided people into two groups, giving one group vitamin C and the other group not giving them vitamin C. And there really was no difference between the two groups in terms of prevention of colds and flu. Now, of course, taking daily vitamin C probably is not going to hurt anything, but it probably doesn't help either.

So, these studies, I think, are interesting just in terms of being able to look at some of the things that we do on a regular basis. Whether it really helps or not, and as these programs continue, we'll try to bring more of those to your attention.

OK, moving on in the News Segment, there is a new vaccine that was recently recommended by the Advisory Committee on Immunization Practices, which is part of the CDC or Center for Disease Control. And this is a new recommendation, it just came out on June 29th of this year. And this vaccine protects against Human Papillomavirus which is the virus that cause genital warts in women and is also associated with cervical cancer.

0:14:07
& Now, in terms of who to give this to, it was approved for use down to as young as age nine. But the recommendation was that we give it to all girls and young women who are between the ages of 11 and 26 years of age. And the main reason for giving it is to try to prevent cervical cancer.

Now, there are some obstacles to the giving of this vaccine. Number one is the cause. It actually cost about $360 per three-shot regimen which is given over a six-month period. That makes it one of the most expensive shot or vaccines that's ever been released. And if insurance companies aren't paying for it, it's going to be hard to convince parents to pay for something that's not going to immediately affect their child's health. But I think as soon as the American Academy of Pediatrics comes out with their recommendation to add it to the immunization schedule, usually then, the insurance companies jump on board and they'll start paying for it.

I think compliance is also going to be an issue. Here, you have teenagers who aren't really excited about coming in to the office anyway. And when you tell them they have to come back in two months for a second shot and then, back another two months after that for a third shot, it's going to be hard to get them to come in. And a lot of times, parents forget and of course, the teenagers aren't saying, "Hey, mom, don't forget, you got to take me in to get another shot." So, I think compliance could become a bit of an issue. And there might be some people who get one of them and then think they're protected, they don't follow up on the vaccines and then, they really aren't protected in the long run.

Now, this is predictable, there are some religious groups who fear that it will actually encourage promiscuous sexual activity. Personally, I think that's ridiculous. Most teenagers are not going to decide whether or not they have sex based on whether they're going to get cervical cancer ten years from now. And I don't think that genital warts is really the first thing on their mind either. Hopefully, the first thing on their mind is more serious sexually-transmitted diseases like gonorrhea and chlamydia and, of course, pregnancy.

So, I think, the important thing here though is education. And both the pediatrician and the doctor should make it clear to kids that it's best to wait until you get married before you have sexual intercourse.

0:16:19

OK, we're going to move for next. I don't want to get an explicit rating from iTunes. So we'll move on to the next story.

The next one, the FDA did approve a new sunscreen ingredient. It is called Mexoryl. And it is an agent that can shield the skin from shortwave UVA rays. The current sunscreens in the United States do not shield shortwave UV or ultraviolet A rays. The A rays are the ones that are responsible for aging and skin cancer whereas the UV-B rays are responsible for sunburn and also skin cancer with that one, too.

Now, Mexoryl containing sunscreen have been available in Europe, Asia and Canada since 1993. But this is the first time that the FDA and the United State has approved these products. The first US product to include it will be Anthelios SX which is made by L'Oreal. And Anthelios SX also contains the two active ingredients that are available in most sunscreens. However, it's only going to have an SPF or sun protection factor of 15, which is pretty low especially when you're talking about kids. It's not going to give you long-term protection out in the sun.

It will be available this fall. A down side of it is it's expensive. It's going to cost around $40 for 4-oz bottle of it. Bottom line, I think this is a beauty product and not marketed as a true sunscreen to protect kids. You know, something that cost $40 for 4 ounces which doesn't even increase the protection against sunburn. It's really more to protect against skin cancer and ageing from those shortwave UVA rays. But without it protecting you get sunburn any more, it's certainly not worth the $40. You know, $40 for four ounces of it. Ten dollars an ounce is just simply too expensive for families who have young children at home. Also an SPF of 15 is not enough for kids. You really have to get at least 45.

0:18:21

And while we're on the topic of sunscreen, just to remind you, you do have to use a large amount of sunscreen in order to get the full protection. And that's because in addition to the chemical ingredients that provide a chemical protection against UV rays, there's a zinc oxide ingredient in most sunscreens. That's what gives its white color that you cannot see through. And that makes a physical barrier for the sun. So you want to put on a very large amount of it to make a nice thick physical barrier which would also protect you from ultraviolet rays.

Also, you have to reapply it often. A lot of people don't realize this. One of the reasons you have to reapply it is not because it wears off, but because the active ingredients actually break down in the sun, so it loses its effectiveness. And most skin experts recommend that you reapply sunscreen every two hours. You would want to reapply it after swimming because the water can remove some of it.

Also it's important to wear protective clothing wherever you can. They do make clothing now and swimsuits that have some ultraviolet protection in them, so you might want to look out for those. Also, it seems like more and more, the surf shirt kind of things that cover your arms and shoulders are becoming more and more popular to wear, both for boys and girls. So that's something to think about. A lot of those do come with ultraviolet ray protection.

Of course, you want to seek the shade. Stay out of the sun as much as possible and avoid mid-afternoon journeys into the sun when the sun is highest in the sky and you're most likely to get direct ultraviolet rays coming on to your skin.

So some things to things to think about with the sunscreen.

0:19:59

OK now, a 16-year-old boy in Virginia who has Hodgkin's lymphoma which is a type of cancer. He had some chemotherapy for his disease and it left him very weak and nauseated. And he and his parents want to stop the chemotherapy and they want to go to a sugar-free organic diet with herbal supplements supervised by a clinic in Mexico. Now, the local Children Services Agency where they live in Virginia filed custody and the Juvenile Court granted joint custody to the Local Children Services agent stating that the parents were neglectful in stopping chemotherapy for their 16-year-old son. And now, the court has actually ordered that chemotherapy be resumed for him. The boy says that he understands the consequences of his decision and he does not want any more chemotherapy.

Now, I have several things to say about this. First, I want to say that I really don't think that there's any scientific basis for sugar-free organic diets and herbal supplements in the treatment of Hodgkin's lymphoma. And the people who try those sort of things and their cancer goes away, I believe either their cancer was going to go away anyway or they just had a miracle happen, which you know, I do believe in God and I think there's definitely a place for prayers in our lives and it could be that God healed them.& But I don't think the sugar-free organic diet and herbal supplements are what healed people who have a good outcome when they switch from traditional chemotherapy and radiation kind of things.

Now, having said that, I also think that this is not really a question of whether that's the right treatment or not. It's really a question about educated choice. And I think if a 16-year-old and his parents look at all sides of the issues and they understand that doing a diet plan and herbal supplements are probably not going to be as effective as chemotherapy, but they understand that chemotherapy made him very sick and they want to make the choice not to have chemotherapy, then I think that their choice should be respected.

0:22:04

Even for a minor, because after all, 16-year-old girls are allowed to have abortions and we don't interfere with their rights because we say it's their body and they have the right to choose. So if a 16-year-old has the right to make choices about her body, then why is it that a 16-year-old boy can't make a choice about his body and what happens to it.

So I think that this is an important question because the next issue is what other parent and child choices will be taken away? Are they going to say now that if you're a Jehovah Witness and you don't believe in blood transfusions and you really don't want one and your 16-year-old& doesn't want a blood transfusion and you understand the consequences, are we going to have a court order to handcuff you to a gurney and make you get a blood transfusion?

And in immunizations, I am definitely an advocate of immunizations and I'm not a believer in its association with autism and some of the other problems that people report out there. However, I do believe in the parents' right to choose and I think as long as that choice is educated and they're able to deal with the consequences if a bad outcome happens, then that's up to the parents. Especially when we're talking about a teenager who can start to make some decisions regarding their own body which may have the precedent of saying, that's OK when we look at 16-year-old girls with abortion. Immunization in infancy maybe a little bit of a different story because the infant is not weighing in with the way that they would like to go with it.

But anyway, also homeschooling, we’re going to say parents who homeschool their kids are neglectful and we're going to have courts ordering kids back into the classroom. That may be appropriate in some situations where kids really are not getting much of an education at home. But where the parents are trying, they're probably getting a better education in the home than they are in the public school system.

These are all of course, controversial topics and ones that we will touch on a little bit more in some of our future broadcasts. But I think the point with this one is you have a 16-year-old, the court saying he has to have chemotherapy, is that the right thing to do? I definitely question it.

0:24:13

OK, and finally, in our News segment, American Floyd Landis won the Tour de France. He's a 38-year-old cyclist. He beat Oscar Pereiro of Spain by just 57 seconds in the 2,000-plus mile race that winds through the French countryside and through the Alps. And that was one of the slimmest margins of victory in the race's history. And, of course, this comes on the heels of Lance Armstrong's string of seven Tour de France victories.

Landis, said after his win, "My parents taught me that hard work and patience are some of the most important things in getting what you want." That is really nice of him to give his mom and dad a shoutout. And I just want to say to parents out there, it is important to teach your kids hard work and patience, and sometimes it pays off.

Interestingly, a note with this, there is a bit of strained relationship between Landis and Lance Armstrong. And after Landis won the Tour de France, Armstrong said "I'm glad a guy who came through our program has won. We can take a small bit of credit for helping develop Floyd." And then he goes on to say, "We're the ones who gave him the opportunity. For us, there is a bit of moral victory there because you gave a chance to ride for us, to learn from you." I don't know, I think Armstrong's quote seems a bit disingenuous if you ask me. And I think it's nice that Landis thanks his parents. &

[Music]

0:26:03

And in our Feature segment this week, we're going to talk about swimmer's ear. Seems like I've been seeing a lot of that in the office the last couple of weeks since we're here in the summer months. One of the questions that often comes up from parents is "What's the difference between an ear infection and swimmer's ear?"

When we use the term, ear infection, we're usually talking about a middle ear infection or an otitis media and that is an infection in the space behind the ear drum, sort of deeper in the head. Whereas, a swimmer's ear is a skin infection in the ear canal which is on the outside of the ear drums. That's the difference between the two.

Six weeks ago or so, I did write a column on PediaScribe called "The Swimming Ears of Summer". And to give you a little bit more details about swimmer's ear, I'm going to present that for you right now.

"The kids are out of school for the summer. The backyard pool is open and clean. The PH and chlorine level are just right. Don't have a backyard pool? No problem, maybe it's the Y or city pool or beach club. Wherever your kids swim this summer, they're likely to have an unwelcomed guest join them– swimmer's ear.
& Each summer, thousands of children visit their doctor for this painful condition. Are these visits necessary? They usually are. While it's true, most cases of swimmer's ear will resolve on their own, most kids experience quicker relief with a prescription medication.

Of course, it's best to prevent swimmer’s ears in the first place. To understand how to prevent it, let's first take a look at the factors that cause it.

Understanding swimmer's ear boils down to two facts. First, our skin is crawling with bacteria. Now, I know it's not the most pleasant fact in the world, but these little critters are normal part of our lives. You can't get rid of them, at least, not permanently. The second important fact is that prolonged water exposure leads to a breakdown in the skin of your ear canal. Think about what happens to fingers and toes when you swim or bathe too long. They get wrinkly, right?& The same thing happen in your ears.

0:27:59

Also, you have to keep in mind that some kids are more prone than others to getting swimmer's ear. The quality of our protective ear wax can make a& & big difference. Those with the moderate coating of wax throughout the canal tend to get fewer cases of swimmer's ear than those with no wax or thick forms of wax.

OK, now, let’s combine our basic facts. Bacteria is crawling over broken down skin. The bacteria gets inside the skin and cause infection. The immune system recognizes the bacteria as foreign invaders and attacks them. White blood cells come to the rescue but they cause pain, swelling and inflammation in the course of their fight. Knowing this, preventive strategy becomes easy to understand. You must decrease the number of skin bacteria and limit prolonged water exposure.

What if your child is a fish? What then? Well, if they're also prone to swimmer's ear, they need to take more frequent breaks to allow the ears to dry. Applying a few drops of rubbing alcohol in the ear will facilitate drying and will throw off much of the skin bacteria at least temporarily.

Ear plugs will also keep the ears dry. These are most useful for competitive swimmers who can't take frequent breaks and for children with surgically placed ear tubes. Most ear, nose and throat specialists can make custom plugs but the price is often high and kids lose them easily. An inexpensive alternative is silly putty. Simply break off a large piece, roll it into a ball and mold it into the outermost ear opening, not the little hole going into the ear. If you have trouble creating a seal, try coating the silly patty with a thin layer of Vaseline.

Sometimes the best efforts of prevention fail. If your little swimmer complains of a persistent ear ache, it's time to see your doctor. Although swimmer's ear is likely, there are other possibilities such as middle ear infection and tonsillitis. Because we treat those things differently than swimmer's ear, it's best to have your doctor take a look.

Ok, so let's say it is swimmer's ear after all, what next? Well, your doctor will likely prescribe a combination eardrop. One ingredient of this medicine is the steroid. Its job is to reduce the pain, swelling and inflammation. The other component is an antibiotic. You can guess its job, right? You want to help the immune system kill off the invading bacteria.

No question about it, supervised swimming is great exercise and certainly better for your child than an afternoon in front of the TV playing Xbox games. But if your child is prone to swimmer's ear, you and your child may have reservations about taking a dip. Go ahead and get in, the water is fine. Just to be sure to take frequent breaks to allow the ears to dry, consider using earplugs and treat the ear with a few drops of rubbing alcohol when you get out.