Because Duffy wants to know (and so do the readers on his blog!):
2 interesting stories in the news recently regarding adolescent health. One notes a crappy diet could be leading to more kidney stone formation….stones that are the same size as an adults….but have much smaller passageways to travel through (and that means more pain). And a second story regarding steroid nasal sprays. If Dr. Ketyer catches this update hopefully he can chime in with his professional opinion!
While we usually think of kidney stones as an adult affliction, pediatricians in recent years have put them higher up in the differential diagnosis when presented with a child with acute, severe abdominal pain. An article in the Pittsburgh Post-Gazette this week notes that kidney stones, which are more common in adult males than adult females, may be surging in American children:
Comprehensive studies have not been done, so estimates of the number of U.S. pediatric kidney stone cases are unavailable. However, doctors say they are seeing more children with the ailment, and some hospitals, including Children’s Hospital of Pittsburgh of UPMC, have established special programs to diagnose and treat it.
In the past year, Children’s saw about 100 patients who have had kidney stones, said Michael Moritz, clinical director of pediatric nephrology.
Kidney stones are tiny mineral deposits that form in some people’s kidneys. If they remain there, they cause no pain, and a person would be unaware of them.
Trouble comes when a stone leaves the kidneys and travels through or gets stuck in the narrow urinary tract. Blood is one symptom; intense pain is another.
“It’s extremely, extremely painful,” Dr. Moritz said, noting that some women have described kidney stones as being as painful as childbirth
Most kidney stones form when calcium and oxalate crystals combine in the urine. Healthy people with no underlying metabolic or kidney disorders can point a finger directly at the reason why: a “crappy diet.” Stone-promoting sodas (especially cola), coffee, tea (including iced tea), chocolate, and processed foods high in salt and fat are usually the first things that should be limited when kidney stones are diagnosed. Significantly increasing daily water intake instead of those other beverages can also help dilute calcium and oxalate crystals in the urine, effectively preventing kidney stones from developing.
The other subject on Duffy’s mind is about whether the use of intranasal steroids for allergic rhinitis causes growth suppression in children. It is well known that using oral steroids over a long period of time (or more frequent bursts for short periods) for a variety of conditions, including asthma, can adversely affect the linear (height) growth in children. Because steroids are so effective in dousing inflammation, inhaled forms of the medications were developed for the treatment of asthma and allergy symptoms in order to specifically target the affected body sites while minimizing the systemic side effects, like growth suppression. Previous studies found very small height suppression with some inhaled medications for asthma, but not with others. (By “very small,” we’re talking about less than one centimeter, or less than a half-inch.)
A new study, published this week in Pediatrics, showed a tiny bit of growth suppression with the use of triamcinolone intranasal spray (Nasacort) for allergic rhinitis — .45 cm when compared to placebo. (By the way, .45 cm equals .18 inches, which may be statistically significant, but certainly is not practically significant and, thus, does not earn the headline of “Nasal Steroids Can Stunt Growth.”) It should be noted, however, that the intranasal steroids most commonly prescribed by pediatricians and pediatric allergists — mometasone (Nasonex) and fluticasone (Flonase) — have been shown not to cause any growth suppression.
The researchers of the study have another beef about Nasacort: it’s available over the counter. This creates a problem when, according to Michael A. Fuoco, a patient self-diagnoses and self-treats for a very common symptom:
Although the drug is an effective medication that can be used safely, it should be used only under a doctor’s supervision and only after tests confirm the child has allergies, Dr. Skoner warned.
“It should not be available for unregulated, unmonitored use,” said Dr. Skoner, who testified before the FDA in 2013 in opposition to making the medication available over the counter.
“A parent picking this up and giving it to a child, first of all, might not have the right diagnosis and if the recommended dose doesn’t have the desired result, the natural tendency in the U.S. is to double the dose. If you do that and it’s not monitored by a physician there are going to be side effects of excessive steroid use.”
He said that because steroids are “the most effective therapy for nasal allergies and for asthma as well, therein lies part of the problem. You may have a child treated with inhaled steroids for asthma and then you start giving them nasal steroids. There have not been a lot of studies done, but my prediction is the outcome is worse with two steroids.”
A cynic might be excused for saying that if a medicine is available over the counter, then that means fewer prescriptions being written and less business for the doctor and the specialist. But pediatrics is different than adult medicine; children are not little adults. Dosage, compliance, and efficacy; metabolism and clearance; side effects and toxicity — all of these are very often unique and complex challenges that pediatricians and pediatric specialists consider on a daily basis with individual patients. It’s better if parents talk it over with one of us than mull it over with “Dr. Google.”