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Talking to Kids about Lebron - July 9, 2010

About two months ago, my 13 year old son, Joey, who is a basketball player, announced that he wasn’t interested in playing basketball this coming season.  No reason.  I suspect that he was consciously or unconsciously protecting himself for what happened last night.  Today, we have heard many comments from parents about how crushed their children were, asking for guidance in dealing with this issue.  The following is a letter that I wrote last night to Joey who is away at camp.  I hope that it will provide some insight as to the type of discussions that are appropriate to have with your children.  Remember, crisis, health related or sports related, is always an opportunity for growth.   

Dear Joey,

Well by now you have heard that Lebron is going to Miami.  I cannot tell you how angry and betrayed Mommy and I felt when we initially heard the announcement.  We actually went walking around the block for about an hour, talking about what happened and why we felt so bad.  And I think the main reason we felt so bad is that for a moment it made us feel like losers.  If Lebron can reject you, then you must really be a loser.

But Joey, think about how silly that sentence sounds.  Cleveland is no different now than it was before we heard Lebron was leaving.  To be sure, there will be a huge financial impact on Cleveland.  I feel sorry for the businesses that will lose a lot of money because the Cavs will not be selling out games.  And I feel sorry for the salesmen who will lose money because people will not be buying his shirts and other memorabilia.  I even feel sorry for Dan Gilbert who truly invested in his team, perhaps more than any other owner of a Cleveland franchise.  But remember Joey, being rejected by a 25 year old person who puts a basketball in the hoop for a living doesn’t make you any smaller or less important and it certainly doesn’t make you a loser.

Despite what he said  in his prime time, self-promoting interview on ESPN that he chose winning over everything else,  in Mommy’s and my opinion, Lebron did not choose to be a winner.  If that were really true he would not have put himself first.  He chose the easy route in Miami. A true winner would have stayed with his loyal fans even if it meant working harder.  Maybe at 25, he is tired of shouldering responsibility.  Maybe that is what happened in Game 6 of the Boston series.  Maybe he doesn’t have the fire in his belly that Kobe and Michael have/had.  Although I started out feeling angry, as I think about it more, I feel sorry for him.  Because what he has shown with this decision is that at least at this point in his life he doesn’t understand what a true winner is. The fame and the grandeur that goes with winning a game or a playoff or a championship ring cannot buy loyalty and it often doesn’t buy happiness.  His face told it all during the ESPN extravaganza.  He looked nervous and he almost gulped when he said he was going to South Beach, Florida.  He knew he was abandoning his hometown but he wasn’t able to look beyond himself and give back to those who supported him and who indirectly made him so famous.  Betrayed Akron fans turned on him almost immediately and were burning his t shirts while Cleveland sportscasters quite correctly pointed out that over time, he may be one of the most hated people around Northeast Ohio, just a little bit ahead of Art Modell who brought the Browns to Baltimore.  This morning’s Plain Dealer quoted him as saying “…I wanted to do what was best for Lebron James and what would make him happy.” He may have a lot of money but the people who paid for tickets and bought his shirts feel that he has been disloyal to them and all the money in the world won’t be able to buy him happiness.  I hope he finds happiness in Miami but I doubt it because true happiness doesn’t come from what you get, it comes from what you give.

Until last night, Lebron was a hero to many here in Northeast Ohio.  He brought 7 good years to the Cavaliers and by extension to the city of Cleveland. We all wanted Lebron to continue being a hero.  Human beings want to believe in heroes.  We need heroes because they challenge us to rise above our own weaknesses and soar.  You may remember the Greek tragic story of Icarus who had wax wings and believed he was invincible only to find that when he flew too close to the sun, his wings melted and he came crashing to the ground.  Since he was 13 years old, Lebron has been called the King and the Chosen One.  He has been worshipped and adored and been granted every wish he could want. Just like Jafar, the evil sorcerer in the Aladdin movie. But the danger of living a life of privilege with no limits or boundaries is it may lead to a wish to become the most powerful genie and you end up getting put right back in the bottle, you fly too close to the sun and your wings melt.  A true hero quietly and modestly works to make the world a better place.  Even one person at a time.  At times like this, we have to remind ourselves more than ever to be on the lookout for the true heroes in our life, the firemen who risk their lives to save others, the police who keep our cities safe, the doctors who heal people, the teachers who nurture the next generation, and maybe just the person who, with a kind word, puts a smile on someone else’s face.

Joey, you know that one of my favorite lines in all of literature is the Peter Parker quote in the Spiderman comic book that with great power comes great responsibility.  Lebron has great power.  I don’t believe he used it with great responsibility.  Remember, however, that you too have great power, in some ways as much or more than Lebron.  Learn from tonight’s experience to use your great power with great responsibility.

ADHD and insecticides– May 19, 2010

In a study published online in the journal, Pediatrics, researchers at the Harvard University School of Public Health and Epidemiology found an association between ADHD and the urinary presence of insecticide derivatives.  Researchers studied 1400 children between ages 8-15 culled from the National Health and Nutrition Examination Survey that was conducted between 2000-4.  Parents of children in this group said to be representative of the US population in general, were interviewed and asked about the diagnosis of ADHD in their child.  12% of children met the criteria for ADHD.  In that group, a 10 fold increase in the urinary presence of breakdown products of common insecticides was associated with a 1.5 times greater chance of being diagnosed with ADHD and an increase above the mean of the most common insecticide byproduct, was associated with a 2 times greater chance of being diagnosed with ADHD.  There was no way of knowing how these insecticide byproducts ended up in the urine of these patients.

Senders Says:  This study raises some disturbing questions.  Previous studies by this group have found traces of insecticide in strawberries, blueberries and celery.  To be sure, there are some potential problems with this study.  To begin with, there is a much larger percentage of patients with ADHD than in other studies suggesting that it may not be a representative study.  Moreover, this study is a retrospective study, meaning that it was done after the fact.  The authors admit that a prospective study that evaluates the ADHD prevalence in children eating organic fruits and vegetables versus those who eat non organic foods, needs to be conducted.  Until such studies can be conducted, parents should wash fruits carefully.  Strawberries and other fruits and vegetables that are very fragile and will be destroyed with vigorous washing, should be eaten with caution unless you know about the insecticides used in their processing.

The Truth about the Tylenol, Motrin, Zyrtec and Benadryl  Recall – May 4, 2010

On Friday, April 30, 2010, McNeil, a subsidiary of Johnson and Johnson, voluntarily recalled 7 product lines of children’s over the counter (OTC) medications including 44 different formulations.  Included in the recall, which was not mandated by the Food and Drug Administration (FDA), were all formulations of Tylenol Infant Drops, Children’s Liquid Suspension and the Tylenol Plus Cold, Cough and Allergy combinations, all formulations of Motrin Infant Drops, Children’s Liquid Suspension and the Motrin Cold combination, Sugar Free, Dye Free Zyrtec Liquid and Sugar Free, Dye Free Children’s Benadryl. 

According to the company “Some of the products included in the recall may contain a higher concentration of active ingredient than is specified; others may contain inactive ingredients that may not meet internal testing requirements; and others may contain tiny particles. While the potential for serious medical events is remote, the company advises consumers who have purchased these recalled products to discontinue use.”  Visit http://www.mcneilproductrecall.com/ or call 888-222-6036 for information on how to obtain a coupon for a free bottle of the recalled product once it is available.

What does this all mean?  According to Wall Street, not much!  Shares of Johnson and Johnson were actually up 1% in the first day of trading following the recall notice.  From a medical standpoint, it probably doesn’t mean much either.  There have been no adverse reactions reported to the FDA, nor is the FDA making this a mandatory recall.  The thought that there might be too much active ingredient might be frightening to some but in reality, means very little.  All medications have a range of potencies and each lot or batch is required to conform to that range.  If it goes slightly above or slightly below, the product is recalled.  Similarly, not meeting internal testing requirements means little in the real world.  The standards used by the pharmaceutical industry in the area of OTC medications are very high because the potential for misuse in untrained hands is so great. As a result, not meeting internal testing requirements still usually means that it far exceeds the requirements mandated by the FDA and that is why there is no mandatory recall.  Similarly, the presence of tiny particles usually means that one of the ingredients hardened, rather than remained in solution.  In and of itself, this also probably has no impact on safety, efficacy or potency.

There is always a silver lining to any medical recall story and that is the learning opportunity for us all.  Brand name OTC medications are rarely necessary!  Tylenol is the brand name for acetaminophen, Motrin is the brand name for ibuprofen, Zyrtec is the brand name for cetirizine and Benadryl is the brand name for diphenydramine.  All brand name products have excellent generic equivalents sold by all the local pharmacies including Walgreens, Walmart, Target, CVS and Rite Aid.  The product is almost always 100% equivalent and the price is as much as 33% less expensive.  So use this recall as an opportunity not to get a coupon for the brand name product that we are told, will perhaps take months to reappear on the shelves.  Rather, use it as an opportunity to switch to a less expensive generic equivalent.  In the short run, not taking the McNeil coupon will cost a few dollars.  In the end, you will be increasing competition and reducing your healthcare expenses.   

The following are the NDC numbers for the recalled products.  If you have purchased one of the recalled products with these NDC numbers, simply dispose of the product as you would any medication and purchase a generic equivalent or contact the company as directed above.


 

Zyrtec Recall – April 9, 2010

There was a recall last week for Zyrtec Grape Flavored liquid.  It was recalled for potential sub-standard packaging.  The UPC codes for the ones recalled are:  30045020922 & 30045020904.  This is a precautionary recall.  There have been no untoward effects found in patients who have received these affected lots.  If you have purchased any of the affected lots, please contact your pharmacy for further information about the recall procedure. 

Mumps Outbreak – March 11, 2010

There has been an outbreak of mumps in Orthodox Jewish communities in Brooklyn, New York and Lakewood, New Jersey, leading to confirmed disease in over 2000 people of all ages.  Mumps is generally a mild disease that causes cheek swelling (the child looks a little like a chipmunk).  In rare cases, it can cause damage to the testes which is why it is a public health concern.  The Centers for Disease Control and Prevention has actually been involved in this matter, providing guidance to communities that may be affected tangentially by this outbreak.  Because there is a lot of family movement around the holiday of Passover (celebrated this year at the end of March), there is concern on the part of local public health officials and the CDC, that there will be spread around the country.  For some time now, there has been a recommendation to give a second MMR vaccine prior to kindergarten.  This is because up to 5% of people are non responders - they don't develop immune protection with the first dose and therefore would benefit from a second dose.  There is almost no incidence of waning immunity, meaning that you either respond or you don't but almost no one loses immunity to mumps over time. 
 
The recommendations for Cleveland are that children between 12 months and 5 years, who have received only one dose of MMR and who are visiting relatives in Brooklyn, New York and Lakewood, New Jersey over the Passover holiday or are being visited by relatives from these communities, should receive their second dose of MMR by the end of this month.  Children who are not travelling or welcoming visitors from communities with mumps outbreaks do not need to get their 2nd MMR at this time.  And there is no need for anyone to receive a 3rd dose of MMR.  If you are part of this small group of individuals, please call the office to schedule an MMR for your child.  We have reviewed our records of vaccinated individuals and with our attention to providing the proper vaccination to all of our patients, we believe that very few people are potentially impacted by this recommendation.   
 
Mary Alice Dombrowski – February 23, 2010

Unfortunately, for us, Mary Alice Dombrowski will be leaving our office at the end of March. Click here to view her letter to the practice.

FDA Advisory on Advair – February 19, 2010

Many of you have read the article posted on February 18 on Cleveland.com and on February 19 in the Cleveland Plain Dealer regarding new Food and Drug Administration (FDA) recommendations on the use of Advair and Symbicort, medications that are commonly used for the treatment of asthma.  The FDA announced yesterday that it was placing new restrictions on the use of a category of medications called long acting beta agonists (LABA).  In understanding what the concerns are, it is important to understand the mechanism behind asthma and the mechanism of action of the most common asthma medications.

Asthma is now known as an inflammatory disease of the lungs.  In more simple terms, people who suffer from asthma have twitchier or itchier airways than other individuals.  When airways are so irritated, they produce more mucus or inflammatory substances, causing the typical blockages that are heard as a musical sound called wheezing.  The causes of asthma are multiple including viruses, allergies, exposure to smoke and exercise but in all cases, the underlying problem is irritability and mucus plugging. 

There are 3 categories of medications that are used to reverse the irritation of airways found in asthma. 

1. Short Acting Bronchodilators  (SAB)– The classic SAB is albuterol (known under many brand names such as Ventolin, Proventil and ProAir).  Albuterol works by directly reversing the irritability of the airways. The best way to understand this is to imagine albuterol as a toothpick.  If you placed a toothpick (figuratively of course) in an irritable airway, it would work quickly to keep it open but as soon as you removed the toothpick, the irritability would continue. That is how albuterol works.  It works rapidly but once it wears off, the irritability returns. A newer kind of bronchodilator is called xopenex which works in a similar fashion but without a lot of the side effects (less heart racing and fussiness) of albuterol.  It is also 10 times more expensive and so, is not covered by many insurance plans.
2. Inhaled steroids – Inhaled steroids (Flovent, Qvar and others) get at the underlying cause of the wheezing process by reducing the inflammatory process.  They function much like scaffolding for repair of a building.  It takes longer to build scaffolding but once in place, the building is kept solidly in place.  Similarly, it takes longer for inhaled steroids to work (typically 3-5 days) and they have to be maintained for about 14 days for maximum effect. 
3. Singulair – This medication prevents the release of histamine which is the major cause of the inflammatory process to begin with.

The class of medications under review by the FDA are called Long Acting Bronchodilators (LABAs) which include Salmeterol (Serevent) or Formoterol (Foradil).    It is about this class of medications that the FDA has issued its highest level warning, telling physicians not to prescribe them alone without inhaled steroids because they relax muscles in the lungs without affecting the root cause of inflammation, predisposing to worsening of asthma symptoms or sudden death. For a parent to hear that last expression is very frightening.  The good news is that we and most physicians have known about these concerns almost from the licensure of these drugs and HAVE NOT PRESCRIBED them for almost 6 years.  Nationwide, fewer than 5% of all asthmatics are on this class of medications without inhaled steroids. 

What we have used quite a bit are combinations of LABAs and inhaled steroids which are prescribed under the names Advair and Symbicort.  The FDA said nothing about these combinations of drugs because they are truly life saving.  The current recommendations to which most pediatricians adhere are to start with SABs like albuterol and xopenex.  If the child is continuing to wheeze or having coughing at night on SABs, then we add an inhaled steroid like Flovent.  But we have many patients who simply need more control and those are the kids who end up on Advair and Symbicort. They have a long safety record and the FDA simply stated that health care providers be vigilant and use these medications for as short enough period as possible (months rather than years). 

At Senders Pediatrics, we understand that management of asthma is a balancing act.  The disease itself is one of the most common causes of pediatric hospitalizations and death when it is not effectively treated.  The medications that we use routinely have long safety records and there is evidence that appropriate treatment of asthma actually helps remodel the lungs and increases the likelihood that a child will outgrow the disease.  We follow national standards in developing Asthma Care Plans for every patient with more than one wheezing episode and encourage you to schedule an appointment to develop and update your child’s asthma care plan. 

Crisis is an opportunity for growth.  This new FDA report has the potential to education millions on the appropriate use of asthma medications.  A generation ago, children coughed all winter.  Now we have diagnosed most of them with asthma, have medications that can help them breathe, sleep and conduct normal lives.  (With a nod to the Vancouver Olympics:  25% of all Olympic participants have been diagnosed with asthma and are able to function at the highest levels).  Thanks for your trust!


Graco Stroller Recall – January 21, 2010

Normally, we place recalls on our Consumer Product Safety Commission link on our website.  However, given the enormity of this recall (1.5 million strollers) and the likelihood that many of our patients have a Graco stroller, we are highlighting this program on our email blast. There have been 7 children who have lost fingers or parts of fingers because their hands have become caught in the closing mechanism. The recall involves providing a safety cover that will prevent such accidents.This recall involves Graco Passage™, Alano™ and Spree™ Strollers and Travel Systems with the following model numbers and specific hinge mechanisms:

Model Numbers
6303MYC, 6303MYC3 7240DNB, 7240DNB2
7240MKL2, 7240MKL3 7F02GLM3
6320IVY, 6320LAU 7241DDH2, 7241DHO3 7F04TAY3
6330CAP, 6330THR,
6330THR3 7255CLP, 7255CLP2,
7255CRA2, 7255CRA3,
7255CSA3, 7255GPK3,
7255GRN, 7255GRN2,
7255JJB3, 7255ORC2,
7255WLO2, 7255WLO3 7F07EMA3
6F00QIN3, 6F00RRY3 7256CLO2, 7256SPM2,
7256SPM3 7F08DSW3, 7F08LAN3
6F03GLN3 7260BAN, 7260BAN2,
7260BAN3, 7260MRA2,
7260MRA3, 7260PKR,
7260PKR2 7G00DLS3, 7G00DLS4
6G10CSE3 7270BIA, 7270BIA2 7G01CRL3
7235GGA, 7235GGA2 7E01JON2, 7E01JON3 7G04KRA3
7236CDR2 7F00LPE3, 7F00RSH3 7G05GPR3, 7G06WSR3
7237HOL2, 7237HOL3 7F01FOR3 7G07ABB3, 7G07BAT3

For additional information, contact Graco at (800) 345-4109 between 8 a.m. and 5 p.m. ET Monday through Friday, or visit the firm’s Web site at www.gracobaby.com

Details at: http://www.cpsc.gov/cpscpub/prerel/prhtml10/10115.html
or by calling the US Consumer Product Safety Commission Recall Hotline: (800) 638-2772

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