It's All Fun and Games, Until Someone Loses...

My husband did that to our son.  Before you call CPS, allow me to explain: JJ was hit in the eye by his dad's fly ball.  Fortunately, he didn't suffer a serious injury, and by the next day, he was proudly showing off his shiner at school.

With opening day approaching and JJ now playing AAA ball, I'm getting more nervous than a mole in a Chuck-E-Cheese arcade. (I'm the kind of gal who ducks when a frisbee is thrown at her).  Those balls are being thrown faster and wilder, now that it's 100% kid pitch.  My one consolation is that he's not playing football.  In fact, baseball has one of the lowest rates of injury among youth sports.  The problem is that it has the highest rates of facial injuries, including fractures and eye and dental injuries.

This is what happens to an eyeball when it's struck head-on by a 66-mph ball:

Most kids my son's age can't pitch faster than 50 mph, but 66 mph is well within the range of 13-and 14-year-old pitchers.  While this degree of deformation rarely leads to globe rupture (think of a squished grape), it can cause retinal detachment and vision loss.


There are two ways to reduce the risk of baseball facial injuries: safety balls and faceguards.  Safety balls include the reduced-impact balls, which contain a polyurethane core instead of yarn wrapped around cork.  There haven't been any randomized, controlled trials of this preventive equipment.  In fact, one group of researchers approached a youth league in Indiana about performing an RCT of faceguards, but the league "refused to cooperate," so  they ran a nonrandomized study instead.  The 136 coaches who chose to make faceguards mandatory reported fewer facial impacts or injuries (12.3%) than the 102 who made them voluntary (15.7%).  Most of these injuries were minor, as only 10 children (8 of whom were on the control teams) sought medical treatment.


USA Baseball commissioned a more rigorous observational study looking at the rates of ball--related injuries and the effectiveness of safety balls and faceguards.  The authors used the data on injuries compensated by Little League's insurance for their calculations, so by design, these were more serious injuries. The overall risk of ball-related injury resulting in compensation was extremely low -- 28 per 100,000 players per season.  As expected, the risk of injury increased with the level of competition, while the use of safety balls and faceguards decreased.  After adjustment for level of competition, safety balls were found to decrease the rate of injury by 23%, and faceguards by 35%.


Despite this data, safety balls and faceguards aren't mandated by most youth leagues.  Safety balls just don't bounce like hardballs, and the most common argument against faceguards is the reduction in visibility.  Recommending faceguards won't significantly increase their use; leagues would have to mandate them, to level the playing field.  I would love to see a randomized, controlled trial of faceguards, not for safety reasons, but to see whether they affect one's batting average.  For younger kids, faceguards may have the advantage of reducing their fear of the ball, and possibly increasing their chances of hitting it.  As a team photographer, I have too many shots to count of 6-year-olds swinging with their eyes shut.


The last argument against faceguards is purely from a numbers perspective.  With an injury rate of only 28 per 100,000, and a 35% reduction in risk, you would have to add faceguards to 5,714 helmets to prevent one injury.  It would be helpful to know if leagues that require safety balls and faceguards pay less in insurance premiums than those that don't.  And it sure would be nice if insurance companies would cut them a break for making the safety of their players paramount.

Flying the Fussy Skies

 Carseat, check. Breastpump, check. Diaper bag, check. 

Big brother, check.  Baby...baby??

Three and a half million U.S. travelers are expected to fly over the Thanksgiving holiday this year; and about 1% of passengers are children under the age of 2.  That's a whole lotta caterwauling at 25,000 feet.  Few things can be as stressful as flying with young children.  Here are the answers to some common questions about traveling with kids:

Should I pay for an extra ticket, so my child can sit in her carseat?  The FAA has long considered a proposal to require carseats for children under two.  Thankfully, they haven't mandated this rule, and here's why:  a carseat is highly unlikely to save the life of your kid.  That's because plane crashes are extremely rare, and of those, 30% aren't survivable.  Even extreme turbulence resulting in serious injury is uncommon.  One analysis found that requiring a carseat for every child under two would save 0.4 lives a year in the U.S.  I'm not sure, but I think you need at least 50% of your body to survive!  They estimated that the additional cost of saving one life would be $6.4 million per each dollar cost per round trip.  With the average price of a domestic ticket being $360, that's $2.3 billion dollars to save one life.  Now, my kid may be worth that much, but yours isn't -- and I'm sure you'd say the same to me.  Not only that, but some families will be deterred by the cost of the extra ticket and end up driving several hundred miles, which is significantly more dangerous than flying.  The study concluded that because of this expected shift in air to land travel, requiring carseats on planes will end up killing more children than it saves.  That said, bring the carseat along, just in case you win the lottery and find yourself next to an empty seat.

How can I prevent ear pain?  Ear pain is greatest on ascent and descent, as cabin pressure drops and then increases.  The pressure lags behind in the middle ear, leading to an changes in the volume of air in the ear, causing discomfort.  If the Eustachian tubes leading to your middle ear are open, pressure equalizes quickly, relieving pain.  Children have smaller Eustachian tubes that often clamp down with viral infections and allergies, so they're more susceptible to pain.


Swallowing helps open the Eustachian tubes, so you can try nursing or bottle feeding your baby, or having your older kids chew gum.  The decongestant pseudoephedrine has been shown in randomized, controlled trials to reduce ear pain in adult air travelers.  Unfortunately, a small study performed in children under the age of 6 found no reduction in ear pain with ascent or descent.  

If your kid has a history of ear pain with flying, you could consider giving an over-the-counter analgesic 30 minutes prior to descent, when the pain is worst.  There aren't any studies looking specifically at prevention or treatment of barotrauma ("baro" = pressure), but if I had to choose a medicine, I'd go with ibuprofen, which was shown in a randomized trial to be more effective than Tylenol in treating the pain of ear infection.


I saw a blurb in a parenting magazine about "EarPlanes," ear plugs designed for kids to wear on flights.  The problem is, there's no evidence that they work.  In one study, each volunteer was given pressure-equalizing earplugs in one ear, and a placebo earplug in the other.  The pressure-equalizing earplugs were useless: 75% experienced ear pain on descent.  So save the earplugs for yourself, so you won't have to hear the little tyke yowling.


Should I slip my kid a mickey?  Some of you will no doubt have trouble with the idea of sedating a child for your own comfort.  I don't have a moral objection, but I do have an evidence-based one:  It doesn't work, at least with any over-the-counter medications.  Diphenhydramine, which is Benadryl, is the most studied OTC sedative.  Although there are no studies of pediatric in-flight sedation, we can extrapolate from the TIRED* study.   The exhausted parents of 44 infants with frequent night-time awakenings drugged their progeny with either diphenhydramine or placebo.  Almost no child (and by extension, no parent) was reported to have improved sleep by the end of the trial.  In addition, Benadryl can cause paradoxical excitation in children -- the last thing you need when they're already giving the passenger in front of them a back massage with their feet.


Bottom line:  There's not much you can do to make the flight more comfortable for you, your baby or your fellow passengers, other than the time-tested methods of feeding, holding, and walking him up and down the aisles.


Here's hoping we aren't on the same flight.

*Trial of Infant Response to Diphenhydramine.  They kind of had to work for that one.

The 5-Second Rule

The other day, JoJo chucked his binky in one of his typical fits of pique.  Normally, I follow the 5-second rule, scoop it off the floor and plop it back into his mouth (in order to terminate his fit of pique, of course).  This time, though, his aim was true:*

After I plucked it out, Rick suggested running it through the dishwasher, but I knew that I could never give that pacifier to my son without making myself queasy.  I threw it out, which meant that JoJo's fit of pique matured into a full-blown tantrum.


Afterwards, I wondered whether my husband's blase attitude about "eau de toilette," or my laissez-faire one about food and binkies hitting the floor, could be justified by any data.  My go-to source for health information, Yo Gabba Gabba, seems to contradict my practice:

Brobee picks up his Melba toast in a scant 3 seconds, but already it's swarming with tiny, ugly germs.  The little monster learns that germs can make him sick, but sadly, not that Melba toast makes for a terribly tasteless snack.


Since YGG didn't include any references in its credits, I did a literature search, and there was indeed a published study on the "5-second rule."  The microbiologists gleefully painted floor tiles, wood and carpet with Salmonella typhi, the agent of typhoid fever, and then dropped bologna and bread on these surfaces for 5, 30 and 60 seconds.  They then made some poor undergraduate eat the samples and observed him for signs of illness.  Kidding!  They probably couldn't get that experiment past an institutional review board.  No, they simply cultured the food afterwards, and found that there was almost no difference in the bacterial contamination rates among the 5-, 30- and 60-second groups.  They did find that the colony counts were 10 to 100 times lower on the food that fell on the carpet, so think twice before yelling at your kids for snacking on the expensive Oriental rug.


Of course, most households aren't teeming with typhoid fever.  So how dirty are your floors?  The vaguely sinister Journal of Hygiene published a study of microbial contamination in over 200 homes in Surrey, England.  Investigators cultured over 60 sites in the bathroom, kitchen and living room.**  Bacteria was found on most surfaces, though the majority of isolates were not pathogens.  However, E. coli, which can make you sick if ingested, was found in two-thirds of all households.  In general, dry surfaces were rarely contaminated: kitchen and bathroom floors grew E. coli only 3-5% of the time.  Toilet water, as you might expect, had E. coli 16% of the time, though at surprisingly low colony counts.  The worst area?  The kitchen sink, which grew E. coli 19% of the time, with much higher colony counts than toilet water.  Dishcloths and drainers were almost as bad.


So what do I make of this data?  I think you can safely say that the 5-second rule has been debunked.  Fortunately, it turns out that the average household floor isn't that dirty, which means that the rule can be extended to 60 seconds!  I usually throw JoJo's binkies into the kitchen sink to wash, but I've learned that reusing his toilet-tainted pacifier would have been less likely to make him sick.  

If only I could get past the ick factor.


*True story, but the photo is a re-enactment.  I thought about taking a photo when it really happened, but let's just say the bowl was, er, not clean. Like all the other moms I know, I bring my toddler into the bathroom with me so he's not left screaming outside the door.  Don't worry, I threw away the second binky too.
**The participants were recruited from "ladies' social clubs," so you could argue that maybe the ladies were scrubbing down the house before the arrival of the research team.  The scientists thought ahead and paid repeat, surprise visits and found no significant difference in their culture results.

Surviving Fright Night

  Who's the most likely to get hit by a car?

Check your children's candy before they eat it.  Can they can see through their eye holes?  Better yet, don't let them wear a mask at all.  Make sure that costume isn't flammable.  Now, make sure it isn't inflammable.

We get the same advice from  so-called experts every year on Halloween safety.  How much of it, though, is evidence-based?  Let's run through the potential dangers of Fright Night, and see which ones you should really be worried about:

Tampered treats.  FALSE (mostly).  I think this one has been thoroughly debunked, but for those of you who have never wasted an afternoon on Snopes: A criminal justice professor concluded in a 2008 review of Halloween sadism that no child has ever been killed or seriously injured by a contaminated trick-or-treat sweet.  Only 1 child has died of Halloween candy poisoning, and he was poisoned by his own father. 

That’s not to say that sharp objects haven’t found their way into candy bars and apples.  There is exactly one published case report of an adult whose stomach was perforated by a needle thought to be hidden in a Halloween caramel apple.  Most tamperings end up being hoaxes, though, perpetrated by kids who want to freak out their parents.  Some hospitals go so far as to offer free x-rays of Halloween treats, but two published studies discovered no cases of tampered treats in over a thousand bags of candy.  Alarmingly, the authors of one study hid a needle in an apple as a quality control measure, and one out of the five hospitals tested missed the needle.
 

Drunken teenagers in costume.  TRUE.  I always feel like I’m being shaken down when surly, Goth teenagers appear at my door on Halloween night, thrusting empty pillowcases into my face.  Assuming the Goth get-up isn’t a costume, I should really be thankful that they’re not wearing disguises.  One survey of Halloween behavior in college students found that wearing a costume is significantly associated with alcohol use.  Not only that, but Halloween is one of the hardest drinking times of the year for college freshmen, outstripping even spring break.
 
Sex offenders lying in wait.  FALSE.  Many states have laws against registered sex offenders passing out treats on Halloween night.  There’s no evidence, though, that molesters use this holiday as an opportunity to prey on kids.  One analysis of over 67,000 nonfamilial child sex crimes found that there was no increase on Halloween, even before the advent of these restrictive policies. These sickos are just as likely to strike on Arbor Day as they are on Halloween.

Getting hit by a car.  TRUE.  The Centers for Disease Control reported in 1997 that pedestrian deaths quadruple on Halloween night.  It’s a good idea to have your kid carry a flashlight or glow stick.  Just beware of….

Glow stick injuries.  TRUE (but minor).  My husband experienced this firsthand when my daughter’s glow stick exploded in his face.  He ran screaming to the sink to rinse out his eyes, which were red and painful for the next eight hours. Witnessing their dad’s chemical burn didn’t traumatize my kids in the least.  On the contrary, they were mesmerized by the glowing splatter on the rug, which resembled an alien crime scene.

The number of glow product exposures reported to poison control centers has been increasing over the years, and the largest spike always occurs around Halloween.  Fortunately, no one has ever been seriously injured, including the twelve misguided individuals who swallowed intact glow sticks.

Sporotrichosis from hay bales.  TRUE.  Sporotric--what?  It’s a rare but ugly fungal skin infection transmitted from contaminated plant material. 

                                                Source: Dermatlas.org

One outbreak of sporotrichosis was traced to hay bales from a Halloween haunted house.  And you thought it was just the scratchy hay from the wagon ride making your butt itch!

Pumpkin carving injuries.  TRUE – unless you use Pumpkin Masters^TM tools.    While there aren’t any epidemiologic reports related to these injuries, there was a controlled study of kitchen knives vs. specially designed pumpkin carving tools, performed on cadavers who raised their hands to volunteer:

Kitchen knives caused tendon lacerations in 4 out of the 6 fingers tested, while Pumpkin Masters^TM caused none.  (Pumpkin Kutter^TM severed one finger tendon, much to the company’s dismay, as it had donated its tools for the study.)

Pumpkin seed bezoars.  TRUE.  A bezoar is a collection of ingested, undigested material that causes gastrointestinal obstruction.  Bezoars are most commonly made of hair (usually the patient’s own), but come October, these poor disturbed souls switch to pumpkin seeds.  There are multiple case reports of unshelled seeds getting stuck in traffic somewhere along the GI tract, including the rectum.*  I'll spare you the photo, but for those of you who get a kick out of that sort of thing, you can purchase the article itself.

The undead.  TRUE.  You think I’m kidding?  Then why would the CDC post guidelines on how to survive a zombie attack? Some of their tips include, “Make a list of local contacts like the police, fire department and local zombie response team.”  They also recommend having a first aid kit on hand, though they concede that “you’re a goner if a zombie bites you.”  Reassuringly, the CDC has a plan to investigate and contain any outbreak of what they term “Ataxic Neurodegenerative Satiety Deficiency Disorder.”

Now if only they could teach us how to handle drunken, costumed teenagers.

Stay safe, everyone.

*There are also case reports of rectal bezoars due to watermelon seeds, sunflower seeds, popcorn and prickly pear cactus.  No glow stick bezoars, thankfully.

Never Looking Back!

I have a confession to make.  Well, actually, my husband Rick has a confession to make, and I’m going to make it for him.  When my daughter Sarah was a month old, the grandparents came out for a visit, and we decided to go out for dinner.  We couldn’t all fit in one car, so Rick and my dad took Sarah, while I rode with my mom and 2-year-old son.  As the two men walked through the doors of the restaurant, my husband turned to my dad and said, “Where’s the baby?”  Grandpa’s answer?  “What baby?”  A look of panic crossed both their faces as they dashed back to the parking lot to rescue her from the July sun.   Ever since that incident, if my hubby asks me to change the baby’s diaper, or put him down for a nap, and I’m feeling particularly put out, all I have to do is shoot him a quelling look and say, “What baby?”

As amusing as this episode seems now, the tragedy is that the number of deaths in children who have been inadvertently left in hot cars has been rising significantly in the U.S.  Just a couple of weeks after I posted an entry about forward vs. rear-facing carseats, the San Jose Mercury News posted a front page story noting that the rise in heat deaths appeared in the mid-1990’s, around the same time that warnings were issued to move children to the back seat, to avoid airbag injuries.  ("Tragic consequences of car-safety push"). The number of deaths due to airbags dropped significantly, but the total number of deaths skyrocketed, as more children died from heatstroke:

 

There are probably other explanatory factors, such as increased parental distraction related to texting and smartphone use.  While the data doesn’t prove cause and effect, it’s certainly compelling.  And with the recent recommendation that children be left rear-facing until at least 24 months, doesn’t it stand to reason that heatstroke deaths will rise even further? 

E is for Ernest, Who Choked on a Peach

(With my apologies to Edward Gorey)

Ah, gummy worms.  My two older children love making their “worms and dirt” dessert every year for the Halloween school fair.  (Gummies + crushed Oreos atop chocolate cupcakes.)  But imagine my surprise when I saw the teacher at Joseph’s daycare passing out gummy worms to all the 1-year-olds!  Aside from being concentrated sugar bombs, aren’t gummies a choking hazard?  Fortunately, she stopped handing them out when I pointed out the danger, but it got me wondering – what are the most common choking hazards in children?  I’m constantly scooping Jojo out of the Lego Room, lest Darth Vader finds himself lodged in his airway.

I started with a simple search for “gummy” on Pubmed, and got a respectable 158 hits.  Turns out almost all of these papers were about the treatment of “gummy smile,” which sounds like the kind of smirk you wear when you’re trying to chew Bubbalicious surreptitiously.  It’s actually a description of when a person flashes too much of his or her upper gums, vampire-style.  Not that this has anything to do with choking, but FYI, gummy smile can be treated with Botox or a medieval procedure called “miniscrew anchorage.”  I also uncovered a case report from the Journal of Emergency Medicine (they have the craziest cases in there!) about a patient with abdominal pain who had an abnormal CT scan after ingesting a bag of gummy bears from the hospital gift shop. 

I don’t think they ever uncovered the official cause of his abdominal pain, but maybe the hospital should stop selling gummies?

Since I couldn’t find any papers specifically about choking on gummy candy, I broadened my search to look at all causes of foreign body aspiration and asphyxiation (the medical terms for “choking”) in children.  One registry of over 700 choking injuries from 19 European countries found that 85% of foreign bodies were “organic” (meaning “food,” not meaning “from Whole Foods”), only 3% were due to toys or toy parts, and in 72% of cases, an adult was present during the event.  In other words, the most dangerous thing you can do to a young child is feed him.  Of course, what you feed him is the most important determinant of choking risk:  54% of foreign bodies were nuts, seeds, berries, peas, corns and beans, and 19% were fish bones and bones (though interestingly, in Finland, 69% of foreign bodies were fish bones).  Surprisingly, only 1 child died in this study, which was published in the European Archives of Otolaryngology.  Which foods are most likely to kill you, if you do choke on them?  To answer this question, I looked at an older article, published in 1984, in the Journal of American Medical Association.  Of 103 childhood deaths over a 3-year period, here were the most common culprits:

Hot dogs (17%)

Candy (10%)

Nuts (9%)

Grapes (8%)

So there it was – candy.  There wasn’t a breakdown of what kinds of candy were implicated, but that was enough for me to keep the worms out of Joseph’s reach, at least until he’s old enough to start going to Halloween school fairs.