“Apparently you can leave your heart in San Francisco, but your foreskin is going home with you.”
-Lewis Black on The Daily Show Nov.16, 2010
Age-old Circumcision Debate Heats Up in San Francisco
The 7,000 signatures required to put a question on the ballot in San Francisco have been obtained for a proposal to outlaw male circumcisions. A fine of $1000 or a year in jail would be levied against anyone circumcising a male under 18 years of age. A group called Bay Area Intactivists (check out their website at www.sfmgmbill.org -“mgm” stands for “male genital mutilation”) has been campaigning for the bill for years.
The debate, of course, has been going on for decades (see “The Rape of the Phallus” published in 1965). (1) The Cons have called it “unnecessary surgery”, “a needless expense”, a waste of excellent tissue for grafting if the person gets a serious burn in the future, and “something that diminishes sexual sensitivity for the male”. That last one is a particularly hard one to prove or disprove, or even get public testimony on. The Pros say it reduces the occurrence of penile cancer (a study done in Bowery bums), reduces risk of urinary tract infection in males in the first year of life, reduces HIV infection in African males, and may reduce the spread of HPV (a cause of venereal warts and cervical cancer) to females. Up until this point no one has opposed it as a form of genital mutilation.
Given the religious and cultural traditions of male circumcision (Jews and Muslims consider it a religious event, not a medical one. Australian Aborigines have practiced it probably the longest) and the non-compelling medical evidence of its benefits despite low risks, the American Academy of Pediatrics and the American Medical Association neither recommend nor advise against male circumcision. A reflection of this lack of compelling medical evidence either way is the family of one of my pediatric colleagues. Half of his sons are circumcised, and half are not. None of them are Jewish or Muslim, and they all seem to be doing very well in life, and love.
Screening for Autism in the Pediatric Office
Of 800 toddlers screened for autism in a Utah pediatric office 10 children “had significant signs of autism”. This is close to the CDC estimated occurrence rate of 1 in a 100.(2) 192 (24%) kids had “positive results for autism” on the 23 question paper checklist, MCAT (Modified Checklist for Autism in Toddlers), completed by a parent. Only 47 (25%) of these were deemed “still positive” after a 6 question, structured telephone interview, and they were asked to return for an in-person evaluation. Of the 30 who returned, 10 of them “remained positive for significant signs of autism”.
The messages here are: 1) ask your pediatrician for the MCAT questionnaire if s/he hasn’t offered it by age 18 months, 2) obviously don’t panic if s/he asks for more information since the MCAT is designed to be very sensitive and has lots of “false positives”, and 3) remember, the sooner that educational and behavioral resources are supplied to the child who shows significant signs of autism, the better the outcome.
Autism is the biggest unspoken fear of new parents and has replaced fear of SIDS.
At least, that is my impression in my pediatric practice. Sudden Infant Death Syndrome (SIDS) occurrence has dropped dramatically in the U.S. from a level of 1.53 deaths per 1000 live births in 1980 to the current rate of 0.51 per live births. Since the cause (or causes) of SIDS is still unclear, the reason for this great reduction in risk is also unclear. Most people credit the extensive campaign of the American Academy of Pediatrics to get parents to put their infants to sleep on their backs, “Back To Sleep”, started in 1990 on the basis of studies done in Australia. Unfortunately, SIDS remains the leading cause of death for children in the U.S. under 1 year of age, and the American SIDS Institute is striving to reduce the occurrence rate this year to 0.25 per 1000. The Institute of Medicine has found no association between SIDS and vaccinations.
Most kids who avoid certain foods because they are allergic are NOT ALLERGIC TO THAT FOOD.
The “gold standard” for diagnosing a food allergy is an “oral challenge”; you give the food to the child to eat and see if an allergic reaction occurs in a medically controlled setting. 93% of food oral challenges were NEGATIVE in 44 children who were avoiding 111 foods because of non-threatening allergic reactions (eczema, atopic dermatitis, hivesalso) AND also had positive allergy skin tests or blood tests. Only 23% of the children who were avoiding peanuts were truly allergic to peanuts. Milk allergy was the most common over-diagnosis with only 13% of the children who were told that they were milk-allergic based on blood or skin tests actually were. Children who had had life-threatening allergic reactions to food previously were excluded from the study. (3)
Caffeine can reduce sleep time in children, just like in “real people”.
A study of 228 children from age 5 to 12 years showed that increased caffeine consumption during the day slightly reduced their total sleep time at night. Not surprising, but what was interesting to me was that the average cola beverage consumed per day was 12 oz. for 5-7 year olds and 24 oz. for 8-12 year olds. Reassuringly, the average sleep duration for 5-7 year olds was 9.5 hours and 8.7 hours for the 8-12 year olds. (4)
But what about getting the child to actually go to sleep?
A study of over 500 New Zealand healthy 7 year olds showed that on average they took about 26 minutes to fall asleep. The range of this “sleep latency” was 13 to 42 minutes. The 10% of these children whose parents had identified as “having difficulty falling asleep” had a much longer average sleep latency of 41 minutes. Increased physical activity during the day and sleeping longer during the night were associated with shorter sleep latencies. Each hour of sedentary time during the day added about 3 minutes to the duration of sleep latency. There was NO association between duration of TV exposure and length of sleep latency. (5)
Are those adolescents really asleep?
An estimated 75% of teens own cellphones. Since 54% of the teens use their phones for texting and about 25% log on to social media sites more than 10 times a day, cell phone use “under the covers” at night might be contributing to teen sleep deprivation(6) . An amazing 86% of 14 year olds take their cell phones to bed (7). Reminds me of the “old days” of reading magazines under the covers at night with a flashlight (note to younger readers: a flashlight is a silent tubular device without a screen that requires batteries).
1. JAMA vol.193, 1965 pg. 123
2. Pediatrics 2011 May 127:866
3. J Pediatric 2011 Apr;158:578
4. J Pediatric 2011 Mar 158:508
5. Arch Dis Child 2009 Sep: 94:686
6. Pediatrics 2011 Apr; 127:800
7. Robin D’Antona, EdD, BU School of Medicine Developmental and Behavioral Pediatrics Conference, Mar 25, 2011