CONCUSSION IN CHILDREN AND ADOLESCENTS

Head trauma and concussion is currently a hot topic. Our wars in Iraq and Afghanistan have left us with numerous surviving veterans permanently disabled by brain injuries. Former NFL players are suing for damages related to repetitive concussions sustained during their careers.

A concussion from any cause is a brain injury and there is unequivocal data showing that concussions are much more damaging to children and teens than was previously thought. Football, hockey, and lacrosse, helmets were designed to reduce the risk of skull fracture. They offer limited protection against concussions. Nonetheless, helmets should be worn for them as well as for bicycling, horseback riding, skateboarding and winter sports such as skiing and snowboarding.

Often when people think of a concussion they associate symptoms more characteristic of stroke (loss of consciousness, motor and speech impairment, CT or MRI changes). Most concussions do NOT involve loss of consciousness, and they typically do NOT show changes on neuro-imaging such as MRI or CT scan. Concussions are primarily diagnosed based on symptoms, with the occasional addition of ancillary computer testing.

After a head injury, symptoms suggestive of a concussion include confusion, dizziness or balance problems, headache, sensitivity to light or noise, double or fuzzy vision, nausea or vomiting, feeling sluggish, hazy or groggy, and difficulty paying attention and remembering. In most cases it is more effective (and efficient) to see you in the office than have you rush to an emergency room. If you wonder whether you need to go to the ER, please call and we will help you with the decision. If your child has a more than one episode of vomiting after a head injury, please call right away as this may merit an ER visit.

The degree and duration of post-concussion symptoms are not necessarily related to the severity of the initial head trauma so it is wise to err on the safe side; we have become much more conservative in post-concussion management. Initially, it is best for your child to rest at home as much as possible. "Cocoon therapy" a quiet and dark room, is increasingly recommended. That means no physical activity or mental activity. No reading, no computer, cell phone, or video games, no driving or even riding in a vehicle, no loud music, and minimal television. This may be the last thing a teenager wants to hear, but you only get one brain and it needs time a quiet to heal. After the initial rest period, the child or teen may begin reading and screen time in 15-20 minute sessions, increasing gradually as tolerated. For moderate to severe concussions, children may need to stay home from school for several days or more! We can help decide if this is necessary.

It is very important to remember than concussion can affect academic performance. When your child gets the all-clear to return to school there may still be difficulty functioning in the classroom, learning new material, completing homework and studying for tests. He or she may need a variety of accommodations (e.g. going to the nurse's office to rest during P.E., only taking essential classes, etc). Parents of older teens also need to be aware that driving may be impaired during recovery from a concussion.

When the child or teen is able to handle school without increasing symptoms, you should bring them for a follow-up visit to see if they are ready for a gradual return to physical activity (sports). Persistent headache, dizziness, or inability to pay attention are indications that a child or teen is doing too much and needs to slow down. If your child requires more than two weeks of recovery we may refer you to a specialty program for follow up. Our goals are complete recovery and and prevention of recurrence, regardless of how long that takes.

Remember, the damage caused by repeated concussion is cumulative. At best it can complicate or prolong return to full activity. At worst it can cause permanent brain damage.

Kristen Walsh, MD

 

Ring in the New Year with Wellness and Healthy Habits

If you made New Year's resolutions, congratulations! If you haven't made any, it isn't too late! Here are some suggestions for setting those New Year's resolutions so they are accomplished, and not abandoned!

Make SMART goals! Giant goals like "lose 50 lbs" or "exercise more" sound great, but how are you going to do it? You are better off being SMART. SMART stands for Specific, Measurable, Attainable, Realistic, and Timed. When setting goals, try to think about these five things, and you will be more likely to achieve them.
v First: Specific goals. Instead of "exercise more" try "I want to exercise for 15 minutes, 3 days a week for 1 month," and after one month you can set another goal. Instead of "lose 50 lbs," how about a goal to eat three or more vegetable servings each day, or drink a certain amount of water each day? Being as specific as you can will help you better achieve your goals because you know what you are reaching for!

Next: Measurable goals. You have to be able to measure the goals you set. If you say "eat better", what does that mean? How do you know when you have accomplished it? How about "eat 25 grams of fiber each day" or "eat two fruit servings each day". You can easily see each day if you were able to meet that goal!

Third: Attainable goals. Don't set yourself up for failure! Pick goals you will able to accomplish. If you have not exercised at all the last 6 months, to set a goal of "exercising 2 hours every day", even though it is specific and measurable, may not be attainable. Set a target that you will be able to hit.

Fourth: Realistic goals. This is similar to attainable goals. Like our example above, if you set a goal to exercise 2 hours each day, even though you have trouble fitting in 30 min, it really isn't realistic. Set something that works with your daily routine. If you only drink 8 oz of water a day, setting a goal to drink 80oz, is not realistic. Think 16-24oz a day at first. Think about making small goals and working up from there. This will help you stay organized and make your life easier! Once you hit that goal, remember to set another and continually improve those healthy habits!

Finally: Timed goals. When goal setting, you want to give yourself a time frame or interval to either reach your goal by, or re-evaluate. With our exercise example, you could resolve "to exercise 20 minutes, 3 days a week for 1 month". When you get to a month, you can re-evaluate, and increase the amount of time, or the days for the next month. It is easy to forget about the goals we set, or even procrastinate, when we have a year to complete them in. Try setting goals you are working towards in a shorter amount of time, and I bet you will see better results!

So, as you review and revise your New Year's resolutions, remember to make them SMART! By keeping your goals specific, measurable, attainable, realistic, and timed, you will see results, and make strides in improving your health and wellness! Here is too 2012 as your healthiest year yet!

Jenna Stephens, RD

 

TYPE 1 (JUVENILE) DIABETES

Lily Louise Chandler is my four year old daughter. She is named after my grandmother and loves playing with princesses, reading, playing Barbie dolls, coloring, and eating lollipops. Now her daily routine includes some other things: glucose monitoring, insulin injections, carb counting, and dietary restrictions.

I do not like the date September 11th. Not only was it the day my dear grandmother Louise died, and the fatal day of the World trade Center attacks, but it was also the day Lily was admitted to intensive care when a suspected virus rapidly progressed to heavy breathing and a blood sugar of over 700.

My reaction was shock, confusion, and disbelief when I heard the doctor utter the words "Your daughter has type 1 diabetes." I had so many questions: How could this happen? What caused this? How could Lily have diabetes when no one in our family had it? Can it be related to all the apple juice she drinks? Is it food related? Is it something she caught from someone? What do you mean she has to take insulin forever?!!!

Things are always more clear in retrospect. Lily had been very thirsty and she often complained about a stomach ache. She had also been cranky and crying more than usual but I assumed it was because she is four. I have recently learned that symptoms of type 1 diabetes (Juvenile Diabetes) are often subtle to the untrained eye. They can include increased thirst, dry mouth, nausea, vomiting, abdominal pain, frequent urination, unexplained weight loss, fatigue (weak, tired feeling), blurred vision, heavy, labored breathing and frequent infections.

Lily was in Pediatric Intensive Care at Goryeb Children's Hospital where several other cases had just been diagnosed. I asked the nurse how many new patients they treat and she told me something startling....they used to have 2-3 new cases of juvenile diabetes a month and now they have up to 10-20 new cases a week! The disease is becoming an epidemic!

Over the ensuing months I have asked a lot of questions and have gotten a few answers, but not the only ones I really want; what caused this and how can it be cured? The exact cause of type 1 diabetes is unknown. I have been told that it appears to occur when something in the environment -- a toxin or a virus (doctors aren't sure) -- triggers the immune system to mistakenly attack the pancreas and destroy the beta cells of the pancreas to the point where they can no longer produce sufficient insulin. This answer seemed inadequate to me.

I decided to go on a quest for information and to do everything in my power to help cure and prevent juvenile diabetes. I started contacting and meeting with the worlds experts in this disease and in the past month I have spoken with leaders at JDRF (Juvenile Diabetes Research Foundation), National Institute of Health, Center for Disease Control, Children's Hospital of Philadelphia, Merck Research Labs, Novo-Nordisk who produces and manufactures the insulin my daughter takes. I have met with researchers, physicians, patient advocates, and non-profit organizations and asked all my questions. In brief, I went on the offensive! What I learned from all these interactions was that though basically there are a lot of breakthrough treatments being investigated and coming in the future, they are not here yet. Right now the best thing I can do for Lily is to use intensive insulin therapy, meal planning and exercise to keep her blood sugar levels within a target range.

Lilly adjusted rapidly. She reminds us when it is time to have snacks and check her blood. She asks before she eats anything. We educated her on what foods she can and cannot eat and how to tell her high and low symptoms. She is our inspiration.....she is doing this like it is so normal.

My husband and I did not do as well. I was angry at God that he did this to my daughter. I worry that she will not live a normal life and have complications later. I feel guilt that I caused this; that somehow when I was pregnant with her I did something wrong. I have cried more in the past three months than I have my entire life. By turns I have been devastated, depressed, and overwhelmed.

Then one day.......I decided to stop fighting so hard and accept that she has type 1 diabetes and will have it forever. There is no magic cure in Brazil. There is not a holistic center with natural remedies in Switzerland to cure this. There is not reality in the idea of moving to Vermont and starting a farm to provide whole foods to cure her. For Lily's health and our sanity I needed to stop fighting her diagnosis and instead do whatever I could to keep her healthy and under control. I surrendered. I felt a huge weight lift from my shoulders......now I am focused purely on helping to keep her disease under control.

Lilly has the resilience that comes naturally to children; adults have to consciously master 5 critical skills to regain it. We have to re-learn how to be:

POSITIVE: I am grateful that my daughter is alive and can live a normal life. I am also grateful that we have the access to the care and treatment and leading doctors that we do. I appreciate that my company has amazing medical coverage and are taken great care of us. I am happy to have amazing family members and friends that are there for us.

PROACTIVE: I am continuing to seek the best medical care for her and obtain critical knowledge so I can be a strong advocate and champion for her. We are surrounding ourselves with the best team including: Dr. Menkin, and diabetes leaders, researchers, caretakers from Morristown Memorial Hospital and the Children's Hospital of Philadelphia.

ORGANIZED: I have organized our life to support her diabetes. Have automatic monthly orders for her supplies, pantry has bins of snacks that Lily can easily access that are healthy for her. We have charts at home where we write down everything she eats, blood levels, and insulin levels. We do meal planning in advance and ensure we have her favorite snacks and drinks on hand. When we leave the house we always take a bag for Lily with supplies, two snacks, and a juice just to be prepared if needed. I love being organized.

FOCUSED: We are laser focused on keeping her blood sugars in control and monitoring her daily exercise and diet. Nothing is more important than this.

FLEXIBLE: When days don't go as planned and we are off-schedule or her glucose levels are higher or lower than expected.....we accept it and act appropriately and move on. We try not to play the blame game or identify who was at fault or what we should have done differently. Instead, we identify issues, learn from our mistakes, and take action. This one has been the most difficult but we are working on it.

Our lives have changed significantly since September 11, 2011, but thankfully every day gets a tiny bit easier. I am finally at a point I can tell the story about what happened to Lily without crying. However, I still do cry a little every day. Last night I was while watching "Steel Magnolias" which tells about a young woman's complications having type 1 diabetes and had to turn it off after 30 minutes. One day I might be able to watch it...but not yet.

One day in the future, Lily will have an artificial pancreas with an automatic blood glucose monitor. There will be a vaccine to prevent type 1 diabetes and different treatment options that are more effective. One day stem cell research will be an option. I cannot wait for that day.

Natasha Maximoff Chandler

References:
"Managing Change with Personal Resilience: 21 Keys for Bouncing Back" Mark Kelly Linda Hoopes, Daryl Conner.

"Type 1 Diabetes for Dummies" Alan Rubin"

Think Like A Pancreas" by M.S. Gary Scheiner M.S. and Ph.D. Barry Goldstein M.D. M.D.

We are proud to have been chosen one of Morris/Warren/Sussex Counties Top Practices by NJ Family Magazine for the third consecutive year. Special recognition as Top Children's Doctors was awarded to Drs. Libert, Caruso, Walsh, and Menkin.

We could not have achieved this without a highly skilled, dedicated management team and support staff. For the last five years we have been ranked as one of America's Better Managed Practices by the Medical Group Management Association. For 2011 we were honored as one of America's Superior Managed Practices and featured in the Association's annual report. Congratulations and thank you to Joseph Nocilla, Ellen Meyer, and our clinical and administrative staff.

 

ADHD AND THE CASE OF THE COMMON CAMS

ADHD is the most commonly diagnosed neuro-behavioral disorder of childhood. Left untreated it can have permanent adverse effects on children and adolescents. Existing medication is safe, non-addictive, and highly effective in both the short and long term, (an inadequately supported FDA warning about cardiac side effects of stimulants notwithstanding). However medications can have annoying side effects and require periodic visits to the doctor. Over the last 40 years there has been an incessant, often repetitive drumbeat of claims for a wide variety of alternate treatment modalities. These are generally referred to as Complementary and Alternative Medicines....CAMs.

Here is a brief list of CAMs that have been recommended for ADHD. Some of them may serve a useful purpose for other diagnoses, but none have been demonstrated effective for the treatment or prevention of ADHD.

• Neurofeedback
• Essential polyunsaturated fatty acid (PUFA) supplements
• Chiropractic care
• Electro-acupuncture
• Repetitive transcranial magnetic stimulation
• Anthoposophic therapy (treatment of a presumed imbalance between "low metabolic" and "high metabolic" limbs of the "nerve-sense system."
• Meditation
• St. John's wort
• Iron supplementation
• Zinc supplementation
• Magnesium supplementation
• Gingko biloba

Naturally occurring or artificial foods or additives of any kind, with the possible exception of caffeine. After decades of sometimes conflicting studies it is probable that poor dietary choices and excesses are a consequence rather that a cause of ADHD and many other neurobehavioral disorders. Caffeine in any form may or may not have some benefit. But why would anyone give their child an unknown dose of an addictive, unproven drug when they can get a measured dose of a non-addictive medication that has been proven effective/ A large variety of over the counter preparations.

Allen Menkin, MD

 

Potpourri

Don't Forget Flu

Flu season is yet to come. There is still time to get your children immunized.

According to the CDC children and young adults diagnosed with neurological and developmental conditions should be given flu vaccinations because they face a higher risk of flu-related complications.

Rotavirus Vaccine Not Linked to Intussusception

The number of babies hospitalized for intussusception continued to decline after the reintroduction of the rotavirus vaccine in 2007, researchers wrote in the journal Archives of Pediatrics & Adolescent Medicine. The study cited a slight decline in hospitalization rates for blocked intestines from about 42 out of every 100,000 babies in 1997 to 37 out of 100,000 by 2006, and a continued decline to about 33 out of every 100,000 babies in 2009.

Acetaminophen Alert

Double check the label on liquid acetaminophen before giving it to a child or infant to avoid giving your child the wrong dose.

The FDA is urging parents and caregivers to carefully read the label on liquid acetaminophen marketed to infants and children as a new, less concentrated form of the popular pain reliever arrives on store shelves.

Acetaminophen products include several over-the-counter brands, including Little Fevers, PediaCare, Triaminic, Tylenol, and store brands or generic versions of the drug.

While the new 160 mg per 5 mL concentration is now arriving in drugstores, much of the older, more concentrated 80 mg per 1 mL or 80 mg per 0.8 mL versions may still be in people's medicine cabinets.

Giving too little liquid acetaminophen could cause the drug to be ineffective. Giving too much could possibly lead to death.

For those of you who are mathematically inclined, you can calculate the correct dose and preparation. Divide your child's weight by 2.2. That converts it to kilograms. Multiply the weight in kilograms by 15 and that is the number of milligrams of acetaminophen your child gets. Do the same thing but multiply by 10 and you get the milligrams of ibuprophen. If you lose this, it is in the "Owner's Manual" at www.pfcmd.com.

Events Beyond Our Control Redux

Our phone system can be disabled by events beyond our control. If you call us during regular hours and there is just no response at all it means the system is down. Dial (877) 844-5225 to contact our answering service directly. They will connect you to the doctors on call. Please do not use this number as a shortcut or to circumvent a busy switchboard. That will only make it more difficult for us to help you.

In the event of inclement weather please call the office to make sure we are open before coming for an appointment.

Talk about dumb and dumber

The medication Adderall, commonly used to treat ADHD, continues to be scarce as manufacturers work to produce enough to meet a growing demand in the face of Federal limits on the drug's active ingredient, which is a controlled substance. Did you get that? The Federal government can't get its competing agencies to decide whether to limit the production of Adderall to prevent abuse or encourage it to treat your children. Give me a break!

According to a study in the journal Archives of Pediatrics & Adolescent Medicine about 23.6% of girls vaccinated for the human papilloma virus considered themselves less at risk of contracting other sexually transmitted diseases because of the shot. This almost beats out the one about a teenage boy I had to take off the Daytrana patch for ADHD because he told his girlfriend it was for birth control...and she believed him! At least the kids aren't spending tax dollars to be foolish.

 

Latest Update: Electronic Health Record (EHR) Installation.

We are implementing a Federally mandated EHR that encompasses every aspect of our practice.

The good news: We are on schedule. We have loaded the program, our servers and tablets have been configured, the practice management section is up and running, and we are training our doctors and nurses to use the clinical programs.

The bad news: Installing the hardware and configuring the software was relatively easy. Learning to use the new system has been much more disruptive. Closing the offices for weeks while we installed clinical protocols and trained both our business and medical staffs was never an option. So we have been trying to simultaneously train and see patients. That has stretched personnel thin and severely limited our doctors' availability. Appointment scheduling has been tight and we have been running late. We know that you have had trouble reaching us by phone and we are taking steps to correct the situation. Virtually every patient has to be re-registered in the new system. That is time consuming. Federal standards require that we gather and keep more personal information than in the past. That may seem intrusive, but we have no choice.

We "go live" on a limited basis the week of January 16th and anticipate it will be challenging for everyone. During that week we will only see patients in the Hackettstown office. Chester will be closed. We do not expect the new system to work smoothly for several months.

We are determined that the new EHR will not depersonalize the individual attention you expect from us and will do all that is humanly possible to insure that your healthcare needs are met during the transition. At the end of the day we should have better access to your medical information and be able to care for you more conveniently and more efficiently. In the meanwhile, we apologize for any inconvenience and ask for your understanding.

Allen Menkin, MD
Editor

Information about the practice can be found on www.pfcmd.com

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