Ensuring Kids Get the Right Treatment
Kian Yazdani was always an active boy, but it wasn't until second grade that he started having meltdowns nearly every day. "It seemed like the least little thing would set off a temper tantrum," says his mom, Melody, a 35-year-old photographer and mother of four who lives in Vienna, Virginia. Kian also had a persistent cough and severe headaches, so his doctors loaded him up with antibiotics and steroid inhalers to control his postnasal drip. At the same time, a psychologist believed his agitation, trouble focusing and anxiety suggested he should be tested for attention deficit hyperactivity disorder.
The testing showed Kian was gifted but had a severe processing speed deficit that caused him problems with his focus and impulse control. Yet a trip to the dentist's office revealed that Kian had a very different problem than ADHD. The dental exam showed that the boy's teeth were ground almost halfway down -- a telltale symptom of sleep apnea, a disorder in which breathing stops and starts often during sleep. Movement of the lower jaw can apply pressure, cutting off the airway, and the body must push the jaw forward to reopen it, causing the teeth grinding. A sleep study revealed that Kian was waking up dozens of times an hour gasping for air, so he was getting none of the restorative REM sleep. His sinuses were almost completely blocked and his adenoids were so swollen he was breathing through his mouth. Kian, now 8, has since had his adenoids and tonsils removed and can sleep through the night. After surgery, his tantrums ceased. "He's a completely different kid," Melody says. "He's calm, and he's not having behavioral problems."
For Kian, the real culprit was identified. But mistaking sleep apnea for another condition is just one way children can be misdiagnosed, given the wrong treatments or subjected to diagnostic tests that may be doing more harm than good, experts say. What follows are some of the major offenders and what parents need to know to ensure kids get the right treatment.
[See: 10 Things Pediatricians Advise That Parents Ignore -- and Really Shouldn't.]
ADHD Misdiagnoses
Despite diagnostic guidelines from the American Psychiatric Association, experts believe there is an epidemic of misdiagnosis of ADHD. More than 1 in 10 school-age children -- and up to 20% of high school boys -- do meet the criteria. However, a recent study of 50 pediatric practices found that only half of the physicians surveyed followed these established protocols to determine whether ADHD or another condition was causing symptoms. Yet nearly all of them -- a whopping 93% -- immediately prescribed medications to treat it. "That means many children are misdiagnosed" and are taking pills they don't need, says Michael Manos, head of the Center for Pediatric Behavioral Health at Cleveland Clinic Children's Hospital.
Part of the problem is that other ills that plague children -- bipolar disorder, depression, anxiety, trauma, seizure disorders, learning disabilities, vision or hearing difficulties, and chronic sleep deprivation, as was the case with Kian -- share many characteristics with ADHD.
Parents should keep in mind a few key points when dealing with a potential ADHD diagnosis. It typically begins before adolescence, and more than one observer -- teacher, parent, athletic coach -- should be able to document a persistent pattern of inattention or hyperactivity severe enough to interfere with how kids develop and function day to day in at least two or more settings -- at home, in school and in social situations. In addition, other conditions should be ruled out before treatment begins. Pediatricians must do a systematic evaluation, Manos says; that means questioning children closely and thoroughly, and analyzing their lifestyles to ensure there aren't alternative explanations for the symptoms.
Unnecessary CT Scans
Roughly half a million children arrive in emergency rooms each year with head injuries, and about half will receive a CT scan (a diagnostic procedure also used for other conditions, including spinal and stomach injuries, and abdominal pain). Yet a landmark study published in The Lancet in 2009 noted that only 5% of CT scans flagged potential trouble in kids with minor head trauma, and a mere 0.1% of those kids needed neurosurgery. And CT scans aren't risk-free: One head scan can emit 100 to 200 times more radiation than an X-ray, and estimates suggest an additional 1 in 5,000 kids may go on to develop cancer from that exposure. This radiation risk may seem minimal, but experts believe it outweighs the smaller likelihood that the scan will uncover significant brain trauma, particularly since doctors have other tools they can use to detect trouble. In the case of a head injury, unless a child has two or more potential indicators of trauma, such as evidence of a skull fracture or a scalp hematoma; or the child lost consciousness (even momentarily), seems disoriented, has a severe headache or is vomiting, then experts suggest parents can generally skip a head CT.
With suspected cases of appendicitis, CT scans are also often used as diagnostic aids. Yet blood tests, an ultrasound and an evaluation of symptoms are just as good at identifying trouble. "There are millions of CT scans done on children," says Dr. Nathan Kuppermann, a professor of emergency medicine and pediatrics at the University of California--Davis School of Medicine and lead author of The Lancet study. "If we could eliminate a big percentage of them, thousands of children's lives would be saved from cancer. That's why parents need to talk to doctors and share in the decision-making."
[See: 9 Sports Injuries That Sideline Kids.]
Antibiotic Overload
Family doctors and pediatricians write more than 50 million prescriptions for antibiotics every year, even though roughly 30% are unnecessary. Despite more than a decade of public health campaigns, the rate of inappropriate prescribing of these potent pills remains too high. That worrisome trend is contributing to the problem of drug-resistant infections that kill 23,000 people annually. Physicians often cave in to pressure from parents, who want their ailing kids treated, and end up sending families home with antibiotic prescriptions even for ills that don't respond to antibiotics, evidence suggests. "There is a culture of expectation -- when a doctor thinks that a parent wants an antibiotic, they are 23 times more likely to prescribe one," says Dr. Nicole Poole, a pediatric infectious disease specialist at Seattle Children's Hospital.
Antibiotics can also have nasty side effects, like diarrhea, rashes and yeast infections. Moreover "antibiotic exposure changes the intestinal bacteria, and those changes may promote the development of certain autoimmune diseases," says Dr. Mary Anne Jackson, a pediatrician and interim dean of the University of Missouri--Kansas City School of Medicine. Before filling a prescription, parents should confirm that their child has a bacterial infection; antibiotics are useless against viruses, the germs that cause common colds and some sore throats, most cases of acute bronchitis, and many sinus and ear infections. "Find out if there are any tests to confirm the presence of bacteria," Jackson says.
If antibiotics are a must, kids tend to do better with narrow-spectrum varieties -- amoxicillin -- than with broad-spectrum ones (azithromycin), since they cause fewer side effects. Watchful waiting may be best, although it may take a week or two for kids to feel better; some 80% of ear infections resolve on their own. Humidifiers can help clear out sinuses and help sickly children breathe better, over-the-counter remedies like acetaminophen and ibuprofen can rein in fevers and the inflammation of an ear infection, and a spoonful of honey can soothe coughs and sore throats, Poole says. "These small things won't decrease how long a kid is going to be sick, but they can provide temporary relief."
Dangerous Opioid Exposure
Despite strenuous efforts to curb the opioid epidemic, millions of youth are still being prescribed narcotic painkillers. A recent Harvard study examining prescribing patterns in the nation's ERs from 2005 to 2015 found that nearly 57 million ER visits -- of which about 15% were made by adolescents and young adults (ages 13 to 22) -- resulted in a prescription for these painkillers. Collarbone and ankle fractures were treated most frequently with opioids, but even 60% of teens with dental complaints left with a prescription. What shocked the Harvard researchers most was that kids were leaving with opioid scripts for headaches, sore throats and urinary tract infections.
This is happening despite research consistently showing how dangerous this can be for teens: Many young people are particularly susceptible to becoming addicted after being given an opioid for medical conditions, especially for wisdom tooth extraction. Parents "need to recognize the power of simple exposure to an opioid and how it might change an adolescent's risk profile if they're exposed while their brains are still forming," says Dr. Andrew Herring, an emergency room doctor at Alameda Health System- Highland Hospital in Oakland and a researcher at the University of California--San Francisco.
When Tim Rabolt was a freshman in high school, he had his wisdom teeth extracted and left the dentist's office with prescriptions for two potent opioids, Demerol and Vicodin. "When my prescription ran out, I bought them from friends who had similar surgeries, and we were taking them like candy," he recalls. Within a year, he was swallowing these painkillers every day and was, he says, "one step away from buying heroin on the street."
In his senior year, Rabolt got clean. Today, it's "absolutely worrisome that a high school student can get prescribed such strong drugs," Rabolt says. The 27-year-old is now executive director of The Association of Recovery in Higher Education in Minneapolis. He uses his own experience to help college students in recovery programs nationwide.
There are plenty of alternatives to opioids, including non-narcotic pain relievers that may work just as well, like acetaminophen, naproxen sodium and ibuprofen. Physical therapy, massage and nerve blocks (pain-relieving injections) can also ease pain. If narcotics are the only meds that will do the trick, find out how many days they will be needed. Usually, taking them for three to five days should be enough. And safe storage and disposal is critical, too. Two-thirds of teens who have reported misusing prescription medications got them from friends, family and acquaintances, says Pat Aussem, director of clinical content and development at the Center on Addiction, a national nonprofit that conducts research to identify the most effective strategies to combat addiction. So properly securing and disposing of unneeded meds is essential. "You can dispose of unused pills at your local pharmacy and some police stations," she says.
[See: 4 Opioid Drugs Parents Should Have on Their Radar.]
Excessive Use of Acid Blockers
New parents tend to fret when their infant is spitting up and crying, and they want to do everything possible to make their babies feel better. As a result, "Pediatricians prescribe acid blockers quite often," says Dr. Paul Kaplowitz, a pediatric endocrinologist and the American Academy of Pediatrics' "physician champion" for Choosing Wisely, a nationwide initiative that identifies unnecessary medical tests, treatments and procedures. These prescriptions can include liquid versions of acid-blocking medications called proton pump inhibitors, although PPIs aren't approved by the Food and Drug Administration for infants under age 1.
Yet stomach distress at this age is often not a cause for concern. In their first six to 12 months, some 40% to 70% of babies spit up at least once daily for various reasons. Many may also cry and be irritable, but with thriving babies, the irritability generally resolves by six months of age, notes Eric Hassall, a pediatric gastroenterologist in San Francisco. However, infants with these symptoms can often be misdiagnosed with gastroesophageal reflux disease. And acid blockers, if prescribed, can be problematic, especially if unnecessary.
Stomach acids are the first line of defense against infection and aid in the absorption of key nutrients babies need to thrive. Not only can acid blockers remove that defense, but they may also cause gastrointestinal and respiratory infections, impaired bone health and possibly food allergies, among other issues. Experts say these medications may only be helpful if a baby shows signs of more serious trouble. Spitting up frequently when combined with symptoms like not gaining weight, prolonged coughing episodes and irritability may be signs of GE reflux disease and warrant further evaluation. For other kids, you probably don't need medication, says Kaplowitz: "Just keep an eye on the child and make sure they're growing and are breathing normally."
