Child Health ALERT

Volume 16 A Survey of Current Developments Affecting Child Health Care June 1998

Children With Stomach Pain--What Happens When They Grow Up?

Children who have frequent stomach aches make many visits to their health care providers, but the most typical result is that no clear medical diagnosis is found. Researchers have looked into psychological causes, and their studies have suggested that children with repeated stomach aches may come from anxious families or from families with physical health complaints. However, our understanding of what really causes this problem is far from clear-cut. Furthermore, there is little known about what becomes of these children when they become adults.

Now, researchers from the United Kingdom report findings from a national study that followed a representative group of 5362 children born in 1946: the children were studied when they were 7, 11, and 15 years of age, and again at age 43. Children were considered to have repeated problems with stomach pain if they reported having pain during the previous year at each of the three interviews at ages 7, 11, and 15.

For comparison, the authors studied survey participants who didn't report abdominal pain or reported it only occasionally. The researchers also took into account a variety of other information, including physical symptoms and psychiatric disorders reported in adult life.

Only a small number (about 2%) of the children reported having had stomach pain in the previous year at each of the three surveys. Among these children, none developed inflammatory bowel disease (such as Crohn's disease or colitis) by age 43. On the other hand, children with stomach pain were more likely to have parents who had complaints about physical health.

As adults, children with frequent stomach aches were not especially prone to physical symptoms, but they were almost 3 times more likely to suffer from psychiatric disorders. The authors conclude that "Overall, the results suggest that the outcome in terms of symptoms of persistent pain is good. Though there is some evidence that persistent abdominal pain in childhood is associated with medically unexplained physical symptoms in adult life, it is a more powerful predictor of adult psychiatric disorder." Put another way, they state that ... little belly achers' do not grow up to be big belly achers but do grow up to suffer from anxiety and depression. " (Hotopf M et al: British Medical Journal, April 18, 1998, pp. 1196-1200) COMMENT: Those who provide health care to children are probably as frustrated by the child with repeated stomach aches as are the child's parents. Medical explanations are rarely found (as was the case in this study, too), and psychological explanations are terribly difficult to identify.

This particular research effort, like so many on this complicated subject, has a number of problems, but we think the authors' general conclusion makes a good point. In particular, when children have frequent stomach aches over a period of years, and there is no medical explanation for the problem, the children may indeed be at a higher risk for having anxiety and depression in adulthood.

It's not clear whether the problems in childhood cause the psychological problems in adult life or whether the stomach aches are actually the first signs of anxiety and depression; in either event, we think it makes sense not to ignore these problems but rather to view repeated abdominal pain as a "cry for help" from the child (or parents), and health care providers should, together with the parents, consider psychosocial factors that may be involved in the child's pain.

We think it's worth reminding readers that there is one "medical" cause of repeated stomach aches that may be overlooked by parents and health care providers alike. A lot of evidence shows that there are certain dietary causes of abdominal pain, and if they're not recognized, a child could experience repeated episodes over a period of years. In particular, children may have problems absorbing certain sugars, and these sugars can lead to bloating, gas, diarrhea--and abdominal pain.

In some cases, it may be a problem with the sugars in certain fruits or fruit juices, while in other cases it might be from eating lots of diet candies, gums, and the like, which contain a hard-to-absorb sugar called sorbitol. We don't know how often these kinds of sugars might lead children to have repeated episodes of abdominal pain, but checking the child's diet in relation to the stomach aches might provide a simple solution to a complicated problem.

PRODUCT RECALLS

Recalls: EpiPen and EpiPen Jr....

Early last month, Meridian Medical Technologies recalled about one million devices, called EpiPen (for adults) and EpiPen Jr. (for children); these special injectors contain epinephrine (also known as "adrenalin") that can be easily injected for the emergency treatment of allergic reactions. The devices are particularly popular among adults and children who have severe allergies to insect stings and foods; they can be carried in a pocket or purse, and they have an automatic injector that makes it simple to use in an emergency situation, where an injection of epinephrine can be life-saving.

The EpiPens were recalled because the manufacturer found that certain batches weren't potent enough. Unfortunately, the company hasn't been able to make enough replacements to satisfy the demands of frightened people who now worry that the device they have won't work or that they won't be able to get a fresh one when they need it. In fact, the company hopes to have drug stores re-supplied with fully potent forms of the injectors by mid-June.

For the time being, experts recommend using an alternative epinephrine kit, such as the Ana-Kit, but that requires someone who knows how to give a typical kind of injection, which might be difficult in an emergency situation. One expert pointed out that even the recalled EpiPens are better in an emergency than nothing. The company's hot line for information on the current recall is 1-800 240-5788. (Boston Globe, May 14,1998)

The Food Allergy Network, of Fairfax, Virginia, has been following this problem closely, and in a recent update points out that though one-million EpiPen and EpiPen Jr. devices have been recalled, the manufacturer believes only a small number are less than fully potent.

Until replacement devices are widely available, those who are seriously allergic are advised to be extra cautious--for example, people with severe food allergies shouldn't try new foods or a new restaurant. They also encourage patients to talk to their doctor about whether they should use an Ana-Kit or even epinephrine with a needle and syringe. (Food Allergy Network, Fairfax, VA, May 13, 1998; to contact FAN, call 703 691-3179; by fax, 703 691-2713)

COMMENT: This recall has created quite a panic. Until new supplies become available at drug stores, we would urge parents of children who are at risk for serious and life-threatening allergic reactions to contact their health care provider to find out what strategy is best for them. In some cases, the recommendation might be to keep the current EpiPen device, while for children at particularly high risk, the recommendation might be to rely only on epinephrine from an Ana-Kit or from epinephrine given by a regular needle and syringe, i which case those who are responsible for the child's care would need to know when and how to give an injection.

... Arby's Toy Saxophones...

The Arby fast food franchise group, of Atlanta, Georgia, is recalling about 220,000 toy saxophones that were distributed with Arby's Adventure Meals. The small keys and part of the mouthpiece on the saxophone could separate from the toy, presenting a potential choking hazard to young children.

The toy is made of orange-colored plastic, and measures about 9 inches long. There are 4 small finger-operated keys and a mouthpiece that are white. The saxophone came in a plastic bag labeled in part "Musical Notes ... Arby's...Adventures in Music ... Made in China." It was distributed at Arby's restaurants nationwide from January through March of this year.

No other "Adventures in Music" toys distributed with Arby's Adventure Meals are included in this recall Consumers should return the saxophone to their local Arby's for a free replacement toy. For more information, call Arby's Customer Relations Department at 1-800 487-2729 between 8:30 AM and 5 PM EDT Monday through Friday.

... And Baby Monitors

Gerry Baby Products of Denver, Colorado, is recalling about 86,000 rechargeable baby monitors sold under the Clear Choice brand name. When an electrical short occurs, the rechargeable battery can cause the monitor's "parent" unit to smoke and flame. The Gerry Clear Choice monitor being recalled is Model 618, and the model number is found on the front of the monitor's AC adapter. The monitor consists of a "baby" unit, a parent unit, a recharging base for the parent unit and AC adapters. All the units are white with a light blue accent color. Because it contains the battery, only the parent unit presents a hazard. The monitors were sold for about $40 in mass merchandise and baby stores throughout the U.S. from April, 1996 to March, 1998. Consumers should disconnect and throw away the blue battery pack from the parent unit and contact Gerry Baby Products at their 24-hour toll-free line (1-800 273-3521) to receive a free replacement black battery pack with a safety fuse; consumers can also write to Gerry Baby Products Company at 1801 Commerce Drive, Piqua, Ohio 45356. Until the replacement arrives, the parent unit can be used safely with its AC adapter. (Saxophone and baby monitor recalls from U.S. Consumer Product Safety Commission, Washington, D.C.)

Summer Hint: Cook That Hamburger!

Summertime to many children means barbecues and cookouts, whether at home or at camp. For that reason it's a good time to remind readers (and for them to remind children) that they should make sure their hamburgers are well cooked. Under-cooked hamburger (as well as unpasteurized apple cider) can be a source for certain kinds of E. coli bacteria, and these have caused both epidemics and isolated cases of serious and sometimes fatal illness in children. To be safe, hamburgers should be cooked so there's no pink in the middle. I

PARENT/CHILD

How Trustworthy Is Health Information On The "Web"'.

In the last few years, more and more people have come to rely on the computer to find health information through the Internet. As anyone who has "surfed the web" knows, the Internet offers rapid access to an amazing amount of information. Special instruments on the Internet, known as ''search engines", can help users locate information from websites in this vast network.

However, almost anyone, from legitimate scientists to snake oil salespeople, can create a website, and search engines can't tell you whether the information you've found at different sites is useful--or even more importantly--whether it's accurate.

Since health information is so critical, it's particularly important to develop tools that can rate websites on the value and accuracy of the facts and advice they offer. Researchers in Canada recently located and studied 47 websites that claim to evaluate the health information available on other websites--in other words, these researchers were "evaluating the evaluators". The first thing they looked at was exactly how these rating tools worked, and particularly, what criteria did they use for deciding what was good and what wasn't?

Of the 47 tools these researchers analyzed, only 14 listed what criteria they used, and only two of these explained how they chose those criteria. Importantly, none of these tools provided any evidence that the way they rated websites really helped users tell which provided accurate information and which didn't.

The authors comment that "the dynamic and complex nature" of the Internet makes it extremely difficult to evaluate the content of websites and they wonder whether this job may actually be impossible. They conclude that "the Internet is creating new opportunities to improve decisions and communication in health care, but it can also generate many unprecedented problems." (Jadad AR & Gagliardi A: Journal of the American Medical Association, February 25, 1998, pp. 611-614)

COMMENT: Choosing trustworthy websites from among the countless sources of information on the Internet can be an overwhelming task. In theory, tools that evaluate websites may seem to be valuable guides, but this report suggests that there isn't yet any tool that truly provides users reliable guidance on what to believe.

Our advice is to exercise a healthy amount of skepticism when hunting for information on the Internet, particularly about a topic as important as your health and the health of children in your care! While the Internet is certainly an extremely valuable resource, we would highly recommend that users continue to check what they find with a trusted physician or other health care provider. (This article and comment were written by Deborah Freedman, a Boston based health writer.)

RESOURCES

A Useful Resource: "Let's Face It"

There are as many reasons for facial differences as there are faces themselves. They may result from birth defects (such as cleft lip), genetic syndromes, burns, and disease. A very good general resource about facial differences is published by "Let's Face It", an organization dedicated to helping people with facial differences, their loved ones, the professionals who care for them, and the communities in which they live, to understand and solve the problems of living with this disability.

The guide, called "Resources for People with Facial Differences", provides a wealth of information about facial disabilities themselves, and it also offers valuable resources that can help a person cope with the emotional challenges and adjustments that accompany these conditions. What makes this particularly useful is that the booklet isn't limited to facial differences; rather, it covers a wide range of problems that parents and children may experience when they have various chronic conditions.

This resource will obviously be of interest to parents and professionals who deal with (or know of) children with many challenging conditions; it is also ideal for a resource bulletin board or parent library, or for a health care provider's waiting room or library.

Through the kindness of the publisher, "Resources for People with Facial Differences" is being made available free to Child Health ALERT readers. Those interested should send a 9x 12 inch self-addressed envelope with $3 for postage to Let's Face It, P.O. Box 29972, Bellingham, WA 98228-1972.

READER'S MAIL BAG

Sun Safety

Q: 1 found the issue on sun safety (June, 1997) and the flyer on sun protection informative. Could Child Health ALERT address the issue of sun protection and darker skinned ethnic groups?

- S.I, Health Manager, Chicago, Il.

A: The same pigment that makes skin dark also offers protection against the damage done by the sun's rays. However, except for the darkest skin, ultraviolet rays can still be a problem, so experts recommend that sunscreens be used if someone with moderate or lightly pigmented skin is out in the midday sun for more than an hour. When sunscreens are used at all, it probably makes sense to apply one with an "SPF" ("sun protection factor") number of 15 or more.

While we're on the subject of sunscreens, dermatologists recently offered advice in response to a report suggesting that sunscreens may not offer much protection against skin cancers. That report got a lot of media attention, and the dermatologists at their recent national meeting pointed out that the study in question didn't apply to modern sunscreens, and they argued that the evidence is quite
strong that excessive sun exposure, especially if it produces sunburn and blistering, increases the risk of skin cancers, including the very serious kind called malignant melanoma.

In its continuing educational effort, the American Academy of Dermatology launched a program to teach children in kindergarten through third grade "how to be sun smart all year long". The "Block the Sun, Not the Fun!" pro,-ram includes a teacher's guide with lesson plans, and is directed at educating children at an early age to follow appropriate sun protection practices. (Lamberg L: Medical News and Perspectives, Journal of the American Medical Association, May 13, 1998, pp. 1426-1427)

COMMENT: Experts have suggested a number of tips for effective sun protection, which we think are worth passing along:

1) Sunlight is strongest between 10 AM and 3 PM.

2) Water, sand and snow make the sun's rays stronger.

3) Clouds don't stop the sun's rays.

4) Babies under 6 months old should stay out of the sun.

When children (and adults) are in they sun, they should

1) Use a sunscreen (with SPF of 15 or more).

2) Wear sunglasses

3) Put on a hat

4) Wear clothing for sun protection

5) Take breaks in the shade.

...And A Special Sun Safety Flyer

To help encourage sun-protection, Child Health ALERT is including a flyer in this issue, entitled "Sun Protection is for Everyone!", which was specially prepared by Judith DuFour Love for Child Health, ALERT readers . It is designed to be posted on bulletin boards, copied, or sent home with children to color and share with their families.