Monday, 11 March 2019

Things you might not know about childhood asthma

When it comes to health supplements, glucosamine and chondroitin are among the most popular. Just how popular are they? According to one estimate, about one in five Americans takes glucosamine and one in 10 takes chondroitin. The cost of these and other non-vitamin supplements and herbal remedies is close to 15 billion dollars per year. So you’d think they must be highly effective. And yet, that’s not so clear.

They are touted not only as arthritis pain relievers but also as treatments to prevent joint disease. Yet, a number of past studies have come to mixed conclusions — some small studies found that people felt better taking glucosamine and/or chondroitin, but at least as many have found no benefit. A 2010 analysis of multiple studies (called a meta-analysis) found that among more than 3,800 people with osteoarthritis of the knee or hip, treatment with glucosamine, chondroitin, or the combination was no better than placebo. The case for these supplements protecting joint health or preventing arthritis is similarly weak.
A new study of glucosamine/chondroitin

A new study of glucosamine and chondroitin enrolled 164 patients with knee pain due to osteoarthritis and gave half of them a combination of glucosamine and chondroitin; the other half received an identical placebo pill. The study was stopped early for an unusual reason — those taking the supplement actually reported worse symptoms than those taking a placebo. This raises the possibility that taking glucosamine and chondroitin might make your joints feel worse than doing nothing.

Does this spell the end of people taking glucosamine, chondroitin, or both? It’s unlikely. While the evidence of benefit is certainly not compelling, people who feel it is helping them may not care so much about individual studies. Even if a treatment is not effective on average, there may be folks who, for whatever reason, get real relief from it. And, even if the benefit is from the placebo effect, the benefit is real and that is hard to give up on. Finally, people are taking glucosamine and/or chondroitin for a number of reasons and conditions other than osteoarthritis of the knee — so this study may not apply to them.
And what about the downsides?

In general, glucosamine and chondroitin are thought to be safe. However, as with any medication, there are potential risks. In this latest trial, people taking the glucosamine-chondroitin combination reported diarrhea and abdominal pain more often than those taking the placebo did. Other reported side effects include

    heartburn
    drowsiness
    headaches
    allergic reactions (especially if you have an allergy to shellfish).

A small 2013 study found that taking glucosamine may increase the risk of glaucoma, a condition that can threaten vision if not treated. Chondroitin may act as a blood thinner, so it comes with a warning about potential bleeding. Another concern is drug interactions, a problem that can develop with any combination of medications; check with your doctor or pharmacist before taking glucosamine and/or chondroitin. Many doctors warn patients that the FDA does not regulate supplements such as glucosamine and chondroitin, so they may not contain the amounts stated on the label or there could be contaminants in them.

And, of course, there is cost to consider — health insurance usually doesn’t cover these supplements. (I found a glucosamine-chondroitin supplement online for $17.50/month at a popular online supplement chain.)
Should you give it a try?

When my patients ask me about whether they should take glucosamine and/or chondroitin, I keep an open mind. I check on reports of interactions with my patient’s current medications, let them know that the FDA does not regulate these products, and that they are considered unproven. But if a patient is interested in taking these supplements, I rarely object. And if, after a period of time, they have noticed no improvement, I might suggest they discontinue them. As long as they have the information they need and the treatment seems safe, whether to take an over-the-counter supplement for joint symptoms is a decision I leave to my patients.

For advocates of glucosamine and/or chondroitin, this recent study is only the latest bit of bad news. But this is not likely to be the last word. There are different types and doses available and they are taken for a number of different conditions. There may be certain situations in which they are particularly helpful. We’ll need additional research to know what they are. Over the years, more than a few patients in my women’s health practice have told me that their hormonal birth control — the pill, patch, ring, implant, injection, or IUD — made them feel depressed. And it’s not just my patients: several of my friends have felt the same way. And it’s not just me who has noticed this; decades of reports of mood changes associated with these hormone medications have spurred multiple research studies.

While many of these did not show a definitive association, a recent critical review of this literature revealed that all of it has been of poor quality, relying on iffy methods like self-reporting, recall, and insufficient numbers of subjects. The authors concluded that it was impossible to draw any firm conclusions from the research on this subject.
A strong study on hormonal birth control methods and depression

However, a just-published study finally meets the criteria to qualify as high-quality, and therefore believable. The study of over a million Danish women over age 14, using hard data like diagnosis codes and prescription records, strongly suggests that there is an increased risk of depression associated with all types of hormonal contraception.

The authors took advantage of Denmark’s awesome nationalized information collection systems, including diagnosis and prescribing data. These exist because the country has had a well-run and organized national health system for decades. They have reams of data on every single person in Denmark going back to the 1970s. Additional available information used in this study included education level, body mass index, and smoking habits. All of this was de-identified to protect the individuals involved, so there was no potential violation of privacy.* Surprising connections between hormonal birth control and depression emerged.

This study looked at women aged 15 to 34 between 2000 and 2013, and excluded those with preexisting psychiatric conditions, as well as those who could not be prescribed hormones due to medical issues like blood clots, and those who would be prescribed these medications for other reasons. They also excluded women during pregnancy and for six months after pregnancy, and recent immigrants. This way they wouldn’t accidentally include women with an unrecorded history of any of these conditions.

The researchers analyzed hormonal contraceptive use and subsequent depression in two different ways. They evaluated women who had received a diagnosis of depression as well as women who had received a prescription for antidepressants; these analyses were run separately, and they obtained statistically equivalent results.
Risk of depression with hormonal birth control, small but real

All forms of hormonal contraception were associated with an increased risk of developing depression, with higher risks associated with the progesterone-only forms, including the IUD. This risk was higher in teens ages 15 to 19, and especially for non-oral forms of birth control such as the ring, patch and IUD. That the IUD was particularly associated with depression in all age groups is especially significant, because traditionally, physicians have been taught that the IUD only acts locally and has no effects on the rest of the body. Clearly, this is not accurate.

Should we stop prescribing hormonal birth control? No. It’s important to note that while the risk of depression among women using hormonal forms of birth control was clearly increased, the overall number of women affected was small. Approximately 2.2 out of 100 women who used hormonal birth control developed depression, compared to 1.7 out of 100 who did not. This indicates that only some people will be susceptible to this side effect. Which ones, we don’t know. But I plan to discuss this possibility with every patient when I’m counseling them about birth control, just as I would counsel about increased risk of blood clots and, for certain women, breast cancer. In the end, every medication has potential risks and benefits. As doctors, we need to be aware of these so we can counsel effectively. Asthma is one of most common chronic diseases of childhood; almost 9% of children in the United States suffer from it. And yet I find it’s a disease that lots of people don’t understand — even parents of children with asthma.

Lungs are made up of lots of little tubes that lead into bigger tubes; they look almost like sponges. In asthma, the tubes get irritated and narrowed, making it hard for air to get in and out. Lots of different things can cause that irritation, such as allergies, cold air, chemicals in the air, exercise, the common cold, or even stress.

As a pediatrician, I see children with asthma almost every day — and have lots of conversations with their families. Over the years, I’ve found that there are lots of misunderstandings about asthma, and those misunderstandings can cause real problems for children with asthma.

Here are three things you might not know about childhood asthma.
1. The symptoms can come and go

Many times, I’ve had parents tell me that their child doesn’t have asthma because they hardly ever wheeze. It’s certainly possible — common, even — to have some wheezing with a bad cold or lung infection and not have asthma. But if that has happened a couple of times or more, then we generally call that asthma.

It’s understandable to want to dodge the diagnosis — who wants their child to have a chronic disease? But it’s actually really helpful to make the diagnosis, because that way we can be watchful and figure out what triggers a child’s symptoms. Once we know the triggers, and know the signs that an asthma attack is beginning, there is so much we can do to help the child. We can avoid triggers, like by staying away from cats, or doing lots of hand washing to avoid illness. We can manage the triggers, like by wearing a scarf over the mouth and nose in cold weather, or by using an inhaler before vigorous exercise. We can be sure they get a flu shot, as influenza can make children with asthma very sick.

The goal is always to help children with asthma lead the healthiest, most normal lives possible. We can’t even begin to do that if we don’t make the diagnosis.
2. You can have asthma without hearing a wheeze

The wheeze is often not at all obvious; you may need a stethoscope and trained ears to hear it. Also, some children with asthma don’t wheeze at all: they just cough. Coughing is the main symptom of asthma in most children. It’s how the body tries to get and keep those airway tubes open.

Now, of course there are plenty of other reasons that children might cough. The common cold and postnasal drip from allergies are the most common. But if your child coughs often at night or after exercise, has a frequent nagging dry cough, or gets a really bad, lingering cough with colds, you should talk to your doctor because it could be asthma.
3. Asthma is really treatable

As I said above, what we most want is for children with asthma to lead healthy, normal lives. And here’s the thing: we can make that happen. Not only can we work to avoid and manage triggers, and not only can we use medications to relieve the symptoms; there are medications we can use that can prevent them. A steroid inhaler or other preventative medication, used every day or during periods when asthma is worse or might get worse, can make all the difference. While some parents get nervous about using steroids, the dose is very low — and while some families find daily medications challenging, there are all sorts of strategies to make it work. It’s worth it. For some children, preventative medication can be the difference between wheezing all the time and not wheezing at all.

Which, you have to admit, is pretty great. So if your child has asthma, or you think they might have asthma, talk to your doctor and get your child started on the healthy, happy life they deserve.

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