CHILDHOOD MIGRAINES
treatment options DI D Y OU KN O W ?
And now, some surprising news about migraines — and how to prevent them
Migraine headaches are one of the five most prevalent chronic diseases of childhood. They affect up to 10% of children age 5 to 15 years and up to 28% of adolescents 15 to 19 years old.
Cincinnati Children’s research shows the “placebo effect” is just as effective as the two leading medications MIGRAINE HEADACHES CAN BE R E A L LY T O U G H O N C H I L D R E N .
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ow, new research at Cincinnati Children’s has brought a surprising discovery. A mere sugar pill, given as a placebo in a clinical trial, could be as effective as the two leading medications. The reason: Researchers believe that the act of taking a pill, and the anticipation that it will work, actually helps kids feel better. Also, all the kids in the study received behavioral therapy from a medical professional. That means kids learned coping skills like minimizing the stress of anticipating a migraine, and staying calm and focused when they do have one. That’s good news for kids, their parents and doctors. The study, published Oct. 27 in The New England Journal of Medicine, shows no significant differences among amitriptyline, topiramate and placebo in reducing headache days or related disability. The study was led by Cincinnati Children’s and conducted at 31 sites across the U.S. The lesson for doctors: just prescribing a medication isn’t always the best way to treat kids with migraine problems. “This study suggests that a multi-disciplinary approach and the expectation of response are the most important, not necessarily the prescription provided,” says Andrew Hershey, MD, PhD, of Neurology.
“This study suggests that a multi-disciplinary approach and the expectation of response is the most important, not necessarily the prescription provided.” ANDREW HERSHEY
He’s also co-director of the Cincinnati Children’s Headache Center with his research partner, Scott Powers, PhD. Powers is a psychologist in Behavioral Medicine and Clinical Psychology. They say more research is needed, and that the findings don’t mean the two leading medications don’t work. They do. But so does the power of positive thinking and teaching kids the skills to do that. “The good news,” Powers says, “is we can help children with migraines get better.”
Andrew Hershey, MD, PhD, (left) and Scott Powers, PhD, are co-directors of the Headache Center at Cincinnati Children’s.
About Our Headache Center Since it was founded in 1996, our Headache Center has seen over 15,000 children, adolescents and young adults with headaches. For appointments, referrals and general information about the Headache Center at Cincinnati Children’s, call the Division of Neurology at 513-636-4222 or email us at neurodesk@cchmc.org. OF F IC E H OU R S
8 am-4 pm Monday - Friday F OR M OR E IN F OR M AT ION
visit the center’s website at: https://www.cincinnatichildrens.org/service/h/headache-center
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JILLIA N K LE IN , MD
ASK THE
Pediatrician, General and Community
pediatrician
Pediatrics at Cincinnati Children’s
advocate
Vitamin S
F OR YO UR CHIL D’S HE A LT H THE FAMILY RESOURCE CENTER The center helps families, community providers and agencies find health information, community resources and support. Call 513-636-7606 for
PA R T 2
Why Sleep Is So Important
assistance.
SPECIAL NE EDS RESOU R CE DIRECT O RY
In the last issue, we looked at how sleep affects kids’ school performance. In this issue, our “Ask the Pediatrician” expert, Jillian Klein, MD, explains how sleep factors into kids’ eating habits, growth and behavior. Some of the doctor’s answers might surprise you!
Use this directory to find information, resources and advocacy strategies at www.cincinnatichildrens.org/ special-needs.
J OIN SP ECI A L CON NEC TI ONS Our new online community connects with others parenting a child with special healthcare needs: www.cincinnatichildrens. inspire.com.
JOIN A
This is the second in a three-part series of “Ask the Pediatrician” articles that examine how sleep, nutrition, growth and good health are interwoven.
research
S T U DY
PEDIATRIC ADENOTONSILLECTOMY TRIAL FOR SNORING (PATS)
Study for children 3 to 9 years old who snore and have mild sleep disordered breathing (MSDB) What: This research study will look at the effect of tonsil and adenoid surgery on children who have MSDB. It involves overnight sleep studies. Who: Children 3 to 9 years old who: Snore during sleep, have not been diagnosed with obstructive sleep apnea, and have not had their tonsils and adenoid removed Pay: You will receive pay for your time and be reimbursed for your expenses. Contact: Belinda Carter at 513-636-2814 2
SICKLE CELL RESEARCH STUDY
Study for adults 18 to 35 years old who have Sickle β° thalassemia, or Sickle β+ thalassemia followed by Hb SS What: The reason for doing this research study is to look at using a new procedure called “gene transfer” to get your body to permanently make red blood cells that don’t sickle, and to see if this is safe and effective. Current sickle cell treatments only help with the symptoms. Who: You must: have Sickle β° thalassemia, or Sickle β+ thalassemia followed by Hb SS, be 18 to 35 years old, and live or be willing to live within a 120-mile drive of Cincinnati Children’s for three to six months Pay: You will receive reimbursement to participate in this study. All research procedures will be covered by the study. Contact: Courtney Little at 513-803-0226 or courtney.little@cchmc.org
HAVE QUESTIONS?
If you have a question for the pediatrician, email youngandhealthy@cchmc.org.
Q: How does sleep affect how often kids feel hungry? A: It’s complex, and it creates a vicious cycle when it
goes wrong. Sleep helps maintain a healthy balance of the hormones that make you feel hungry (ghrelin) or full (leptin). When you don’t get enough sleep, your level of ghrelin goes up and your level of leptin goes down. This makes you feel hungrier than when you’re well-rested. Q: Can a lack of sleep impact the kinds of food kids eat? A: Yes. Worn-out kids also eat differently than those
who are well-rested. Research shows that children, like adults, crave higher-fat or higher-carb foods when they’re tired. When sleep-deprived, people make poor diet choices. They choose foods that are high in caffeine, high in sugar and carbs for a quick burst of energy. But there is no sustainable energy from those foods. People get a sugar low and crash just a few hours later, then reach for the same foods for a boost.
Q: How does sleep affect how active kids are during the day? A: Tired children tend to be more sedentary, so they burn fewer calories. Research has shown that kids who participate in more vigorous sorts of exercises are able to fall asleep much faster than those with sedentary lifestyles. Q: Can a lack of sleep lead to serious health problems? A: Yes. Sleep affects how your body reacts to insulin, the
hormone that controls your blood glucose (sugar) level. Sleep deficiency results in a higher than normal blood sugar level, which may increase your risk for diabetes.
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D ID YOU KNOW ? Rapid Eye Movement (REM) or “active” sleep: Our brains are active and dreaming occurs — and we convert things that we learn to long-term memories. Non-Rapid Eye Movement (NREM) or “quiet” sleep: Blood supply to the muscles is increased, energy is restored, tissue growth and repair occur, and important hormones are released for growth and development.
Q: How does sleep impact how much kids grow? A: Deep sleep triggers the body to release the hormone
that promotes normal growth in children and teens. This hormone also boosts muscle mass and helps repair cells and tissues in all people. Q: Can poor sleep habits affect children’s behavior? A: Sleep and behavior are very interdependent in
HOW MUCH SLEEP DOES YOUR CHILD NEED? Infants (2 – 12 months)
1 3 -1 7 H O U R S
children! Kids develop sleep habits very early on and it continues to play a large part in their development and their behavior. Children who consistently sleep fewer than 10 hours a night before age 3 are three times more likely to have hyperactivity and impulsivity problems by age 6.
Toddlers (1 – 3 years)
Q: Can sleep deprivation really appear as symptoms of ADHD? A: Yes. The symptoms of both, including impulsivity and distractibility, mirror each other almost exactly. So tired kids can be impulsive and distracted even though they don't have ADHD.
School age (6 – 12 years)
1 2 -1 4 H O U R S Preschoolers (3 – 5 years)
1 1 -1 3 H O U R S
1 0 -1 1 H O U R S Adolescents (13 – 18 years)
9 -9 . 5 H O U R S
ABOUT TH I S I S S U E HOME AIR PURIFIER STUDY
Study for Children 10 to 16 years old who have asthma and live near a highway or interstate What: A study to look at whether an air purifier can reduce air pollution in the home and how it might help children with asthma Who: Children and teens 10 to 16 years old who: have been diagnosed with asthma, and live near a highway or interstate Pay: Families may receive up to $115 for time and effort. All study visits will be conducted at the participant’s home. Contact: Chris Wolfe at 513-803-1661 or chris.wolfe@cchmc.org
F A L L 2016
YOUNG AND HEALTHY is a quarterly publication from Cincinnati Children’s Hospital Medical Center. For more health news and patient stories, subscribe to our monthly e-newsletter online at www.cincinnatichildrens.org/subscribe © 2016 Cincinnati Children's Hospital Medical Center PRODUCED BY
The Department of Marketing & Communications Cincinnati Children’s Hospital Medical Center 3333 Burnet Ave., MLC 9012, Cincinnati, OH 45229-3026 Phone: 513-636-4420 Advisers: Chris Peltier, MD, and Zeina Samaan, MD Editorial Consultant: Jillian Klein, MD Editorial Staff: Tom O’Neill, managing editor Design: Christina Ullman & Alix Northrup, Ullman Design 3
FOCUS ON
protect your child's health
va c c i n e s
Preventing the flu? C O M E ON , G I V E I T A S H O T!
The FluMist nasal spray vaccine is not recommended this year, but your child’s good health is. The most important day to get your children a flu vaccination is today.
LAUR EN HUFF, M D , is affiliated with Cincinnati Children’s and a physician at Pediatric Associates of Mt. Carmel.
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hat’s especially important for school-age children, for a simple reason. Schools are basically factories for all kinds of germs. And timing is everything. It takes about two weeks for your immune system to protect you fully against the flu virus. The flu season typically runs from December through April. Everybody six months of age or older should be vaccinated against flu. So parents, that includes you too. Lauren Huff, MD, shares her thoughts on the flu: everything from the importance of a flu shot to the best way to administer one. And a lot of other smart insights, too.
Bottom line, doctor, how important is the flu shot? Very. Disease prevention is one of the biggest things we do as physicians, and the flu vaccine plays a huge role. Every year, healthy children are admitted to the hospital and even die from the flu. The flu vaccine is even more important for children in higher-risk populations: children younger than 5 years of old and those with a chronic health care conditions like asthma, neurologic issues or diabetes.
Can you get the flu from the flu shot? Impossible. The virus in the flu shot is a killed virus. The most common side effect is sore arm, maybe a low-grade fever.
A lot of the families at our practice were fans of the FluMist and were disappointed that it's not being offered this year. New data showed it simply wasn’t effective at prevention. The shot is.
What are common misconceptions parents have about the flu? One is the symptoms. They include high fever, dry cough, headache, runny nose, sore throat, muscle aches, and tired feeling. These are also seen in other viral upper-respiratory tract infections like the common cold. But the flu tends to be much more severe and long-lasting.
How tough can the flu be on children and their family? From just plain feeling crummy to missing out on school and extracurricular activities to being admitted to the hospital, the flu can really throw a wrench in a family’s life… especially if other people in the home catch the flu, too.
The CDC doesn’t recommend the nasal spray this year, until it can be improved. Has that impacted families?
I M M U N I Z AT I O N
advice
A lot of the families at our practice were fans of the FluMist and were disappointed that it’s not being offered this year. New data showed it simply wasn’t effective at prevention. The shot is.
Giving children a flu shot, what’s the best approach?
Yes to the flu shot The national Centers for Disease Control and Prevention (CDC) found that the flu shot can reduce a child's chance of flu-related intensive-care hospitalizations by 74%, according to a 2014 study.
For infants, sucking on a pacifier or nursing during or immediately after vaccines can help. For older children, sitting on their parent’s lap, reading a book, singing a favorite song, watching a video on mom or dad’s phone, or other activities they like can distract them. Also, tell them ahead of time instead of it being a surprise.
No to the nasal spray Immunization experts doesn’t recommend the FluMist spray because it was ineffective each of the past four years. This might be a bummer for children who fear the shot, but there is good news: further studies will be conducted to determine why the nasal spray was not effective, and how to improve its effectiveness.
DI D Y OU KN O W ? Cincinnati Children’s requires all staff members to be immunized against influenza. n
We have a very active immunization program for our high-risk patients. n
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FOCUS ON
AMY GUIOT, MD, is a hospitalist
infection control
in Hospital Medicine and associate director of Medical Student Education at Cincinnati Children’s. She’s also a mom to two fabulous teenagers. (A hospitalist, by the way, is a physician who focuses on care while you are hospitalized.)
When to keep your child home from school — and when not to There’s a fine line with certain minor illnesses, but when in doubt, ask your doctor. Or read this! Parents have been grappling with the question for, well, decades. My child isn’t feeling well. Should I send them to school or keep them home? Now that we’re in cold, flu and strep-throat season, here’s a “101” course in how to deal with various symptoms. Your child, their classmates and school staff will thank you. Amy Guiot, MD, works in Hospital Medicine at Cincinnati Children’s. She’s also an associate director of Medical Student Education and a mom to two teenagers. “As parents,” she says, “we’ve all been there.”
7 COMMON CHILDHOOD ILLNESSES AND W HAT TO DO AB OUT THEM
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Fever: Many schools require your child
be fever-free for 24 hours — without feverreducing medications — before returning to school. Most schools define fever as higher than 100.4
Diarrhea: It’s a tough one while in school. Diarrhea can last a week or longer, so plan to keep your child home until the stools are controllable and more formed. It also is highly contagious. Best prevention: hand washing. n
FIRS T, A BIT ON C O L DS A N D M I N O R E A R IN FEC TIO N S .
“The average child (daycare through elementary school) can catch several ‘colds’ or upper respiratory infections per year,” Guiot says. “If they stayed home for every cold they would miss a lot of school. If your child has a runny nose, occasional cough, and even scratchy throat without a fever, it is reasonable to send them to school. The cold will last 10 to 14 days. And ear infections are not contagious.” Many parents struggle with finding someone to watch their child at home when needed. Guiot’s been there too. “It is truly a balancing act,” she says. “Sometimes this just isn’t possible. Hopefully one’s boss is understanding and most parents take a personal sick day to be with their child. No regrets for that. Even with teenagers, I didn’t want my kids home alone when sick. Parents make difficult sacrifices. Parents should realize they can only do the best they can.” But it’s good to have contingency plans lined up.
03 04 05
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Vomiting: This is simple. If your child is vomiting, no school until they’ve stopped vomiting for 24 hours. The viruses that cause vomiting are highly contagious. Best prevention: hand washing. n
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Cough and congestion: Minor
coughing is usually not a problem. But keep them home if they’re unable to pay attention in school, are a distraction or are feeling tired with a poor appetite.
Sore Throat with Fever: This could be a viral or bacterial infection. With fever, keep home. It could be strep throat, which means a trip to the doctor. If they have a sore throat with cold symptoms, it is most likely a viral infection so back to school whenever they feel better. n
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Rash: A rash can be a sign of a
bacterial skin infection, which can be contagious. Keep them home until you get a doctor’s evaluation.
Flu-Like Illness: The flu can last five to seven days, and your child will be contagious until the fever breaks. Keep them home until the fever is gone for 24 hours. n
SPOTLIGHT ON
patient research 7 0 0 R E A S O N S WH Y THIS HLH BIKE RIDE I S R E A L LY S P E C I A L Friends, family and Cincinnati Children’s employees raise money to fight deadly immune disorder
“It’s wonderful to see patients go home and go back to school. It’s very rewarding.”
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here are a quarter-of-a-million reasons to love the 19 bicyclists who completed the annual “700 Miles to Hope” bike ride from Natchez, Miss., to Cincinnati Children’s. That’s how many dollars were raised for the Cincinnati Children’s HLH Center of Excellence. The center is one of the world’s best at treating an immune disorder called hemophagocytic lymphohistiocytosis (HLH). The cyclists raised the money through the Matthew and Andrew Akin Foundation. It was started by Kristin and Justin Akin of St. Louis, whose sons Matthew and Andrew both died here from HLH. Years of research — funded in part by family efforts like this year’s ride — is making a difference. HLH is fatal in about half the cases. But that’s changing. “We are already seeing the benefits as many more children are surviving, thanks to the innovative research done here and the resources pushed along by the Akin Foundation,” says Ashish Kumar, MD, PhD. Kumar, of the Cancer and Blood Diseases Institute at Cincinnati Children’s, was one of four employees who made the ride. It was his third. I am hopeful,” he says, “but we are far from done.” Justin Akin says he and his wife can finally see the tide turning against HLH. “Tremendous progress is being made in the fight against HLH, and many lives have been saved because of increased awareness and creation of the HLH Center of Excellence,” he says. “More patients are getting diagnosed correctly, and our foundation is very proud that we've helped so many of them transfer their care to the HLH experts at Cincinnati Children’s. The goal of our foundation is to save one life at a time, and I think we're accomplishing that goal.”
F OR M O R E I N F O R M AT I O N O N OUR HL H C E N T E R F O R E XCELLE NCE
Website: www.cincinnatichildrens.org/service/h/hlh/about Phone: 877-920-3590 Email: HLH@cchmc.org
SONATA JODELE, MD
The unbreakable bond between a little girl and the doctor who helped save her life Sonata Jodele, MD, is the medical director of Bone Marrow Transplant and Immune Deficiency at Cincinnati Children’s. She’s also something of an art collector. The walls of her office are covered with photos and artwork from the kids she has treated. One is a girl from upstate New York named Ava Pannozzo. Ava was treated for HLH at Cincinnati Children’s in 2013-14. “We make a difference in people’s lives,” Jodele says of her colleagues at Cincinnati Children’s. “It’s wonderful to see patients go home and go back to school. It’s very rewarding.” Ava is now a second-grader who loves to read and is taking ballet lessons. Ava’s dad, Chris, is one of Jodele’s biggest fans. “She gave us a chance and the fact that she has all those photos on her wall, that’s tremendously humbling,” he says. “As a father, there aren’t enough adequate words. I think we should have a shrine to her.”
HLH 101 What is it? HLH stands for Hemophagocytic Lymphohistiocytosis. It is a life-threatening immunodeficiency condition that basically throws the immune system into irreversible overdrive. What does it do? The uncontrolled inflammation destroys blood cells and immune systems. The immune system then begins to damage the patient’s own tissues and organs, including the bone marrow, the liver and the brain.
How is it treated? Patients are usually treated with steroids and chemotherapy. They also may receive other medications that suppress the immune system. Many patients must also have their immune systems replaced through a bone marrow transplant, which can cure HLH but is a complicated and risky procedure. What causes it? HLH is often hereditary and affects people of all ages. Common symptoms are fever, enlarged spleen, low blood counts and liver abnormalities.
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inside
T H I S I S S UE
3333 Burnet Avenue, MLC 9012 Cincinnati, Ohio 45229-3026
WHEN TO KEEP KIDS HOME Providing a breakdown of symptoms that prevent kids from going to school.
sign up FLU VACCINES 101 Looking at changes in procedure for this flu season and the importance of getting children vaccinated.
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BRV175173
FALL 2016
healthy
young and
A guide to your child’s good health
Migraine research,
plus flu vaccine update, healthy sleep, and when to keep your child home from school