Tagged Hygiene and Cleanliness

Thumb Suckers and Nail Biters May Develop Fewer Allergies

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Credit Getty Images

Babies have been seen sucking on their fingers in utero weeks before birth. But the sight of an older child with his fingers constantly in his mouth, sucking her thumb, biting his nails, can drive parents crazy, bringing up fears about everything from social stigma to germs.

A new study suggests that those habits in children ages 5 to 11 may indeed increase exposure to microbes, but that that may not be all bad.

When a pediatrician discusses thumb-sucking, it’s usually because a parent is worried. The thumb is in the mouth so constantly that there’s a worry about speech or about whether the teeth may be affected. It’s gone on too long, and an older child is being teased about it. And in those situations, especially when a child is over 4, we work with parents and children on how to break the habit.

Nail biting worries parents for similar reasons, and we often end up giving similar advice: Don’t make negative comments; look for the situations that bring on the behavior and find alternate strategies; praise and reward the child for not doing it; put a glove or a bandage on the hand to remind the child.

In a study published Monday in the journal Pediatrics, researchers drew evidence from an ongoing study of New Zealand children to show those whose parents described them as thumb-suckers and nail-biters were less likely to have positive allergic skin tests later in life.

The children were in the Dunedin Multidisciplinary Health and Development Study, in which 1,037 children born in 1972-73 in Dunedin, a coastal city in New Zealand, were assessed and tested as they grew up, with the most recent assessment done at age 38. Stephanie Lynch, a student at Dunedin School of Medicine and the first author of the paper, had the idea of using the data to look at a possible relationship between children who tend to have their fingers in their mouths and allergic sensitization.

The question of such a connection arose because of the so-called hygiene hypothesis, an idea originally formulated in 1989, that there may be a link between atopic disease — the revved-up action of the immune system responsible for eczema, asthma and allergy — and a lack of exposure to various microbes early in life. Some exposure to germs, the argument goes, may help program a child’s immune system to fight disease, rather than develop allergies.

In the study, parents were asked about their children’s nail-biting and thumb-sucking habits when the children were 5, 7, 9 and 11 years old. Skin testing for allergic sensitization to a range of common allergens including dust mites, grass, cats, dogs, horses and common molds was done when the children were 13 years old, and then later when they were 32. Thirty-one percent of the children were described as “frequent” nail biters or thumb suckers (or both) at one or more of those ages.

The study found that children who frequently sucked a thumb or bit their nails were significantly less likely to have positive allergic skin tests both at 13 and again at 32. Children with both habits were even less likely to have a positive skin test than those with only one of the habits.

These differences could not be explained by other factors that are associated with allergic risk. The researchers controlled for pets, parents with allergies, breast-feeding, socioeconomic status and more. But though the former thumb-suckers and nail-biters were less likely to show allergic sensitization, there was no significant difference in their likelihood of having asthma or hay fever.

Robert J. Hancox, one of the authors of the study, is an associate professor in the Department of Preventive and Social Medicine at Dunedin School of Medicine, a department that is particularly oriented toward the study of diseases’ causes and risk factors. He said in an email, “The hygiene hypothesis is interesting because it suggests that lifestyle factors may be responsible for the rise in allergic diseases in recent decades. Obviously hygiene has very many benefits, but perhaps this is a downside. The hygiene hypothesis is still unproven and controversial, but this is another piece of evidence that it could be true.”

Malcolm Sears, one of the authors of the paper, a professor of medicine at McMaster University in Hamilton, Ontario, who was the original leader for the asthma allergy component of the New Zealand study, said, “Early exposure in many areas is looking as if it’s more protective than hazardous, and I think we’ve just added one more interesting piece to that information.”

Dr. Hancox pointed out that the study does not show any mechanism to account for the association. “Even if we assume that the protective effect is due to exposure to microbial organisms, we don’t know which organisms are beneficial or how they actually influence immune function in this way.”

Thumb sucking, especially in an older child, can still be a problem if it interferes with the teeth, or causes infections on the fingers, or gets a child teased. Lynn Davidson, a developmental pediatrician who is an attending physician at the Children’s Hospital at Montefiore in the Bronx, and the author of a review article on thumb sucking, said she tends to be “very low-key” about thumb sucking, since children often stop on their own as they grow.

With older children, Dr. Davidson suggests that parents, if they are worried, should try to analyze when and why the child resorts to thumb sucking or nail biting, and then try behavioral techniques, like offering a child a foam ball to hold and squeeze at those moments. “In an older child you can use their input, ask, what would you do with your hands instead of putting them in your mouth,” she said.

Dr. Sears said, “My excitement is not so much that sucking your thumb is good as that it shows the power of a longitudinal study.” (A longitudinal study is one that gathers data from the same subjects repeatedly over a period of time.) And in fact, as researchers tease out the complex ramifications of childhood exposures, it’s intriguing to look at long-term associations between childhood behavior and adult immune function, by watching what happens over decades.

So perhaps the results of this study help us look at these habits with slightly different eyes, as pieces of a complicated lifelong relationship between children and the environments they sample as they grow, which shape their health and their physiology in lasting ways.

Picking Up an Infection in the Hospital

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Credit Stuart Bradford

When the emergency room doctor pulled the blanket aside, looked at my elephant-size inflamed leg and said, “Whoa!” I knew that wasn’t a good sign.

Nor was the reaction of the emergency room nurse, who glanced down at my bizarrely swollen extremity, then started nervously backing away.

Health care practitioners are trained not to show their feelings, but there are clearly times when things look so bad that even they can’t hide their reactions.

I was in the emergency room at Los Robles Hospital in Thousand Oaks, Calif., because a few days earlier I had undergone what was supposed to be a relatively straightforward outpatient procedure to remove a skin growth on my leg. A couple of days after the surgery I felt fine. The surgeon told me I could drive whenever I was up for it, so we took our grandchildren to the Magic Castle in Hollywood. Running from room to room to see the different sleight-of-hand acts, I no longer felt fine. Now I felt a searing knife-like pain in my leg, which soon began to swell in size.

I went back to see my surgeon, who looked a little concerned. You have an infection, she said. Take these two antibiotic pills, schedule a Doppler scan for the next day, and all should be well.

That night, my leg got even bigger; from the waist down one side of me looked like I weighed 350 pounds (I’m not even half that.) My wife and I spoke to the surgeon, who was vague. “You could go to the E.R. if you want,” she said. “Or wait.”

I went and was admitted immediately. That night, a Doppler study showed no life-threatening blood clots. With no beds available, I was kept in the emergency department overnight, taking catnaps while trying to blot out the screams and moans from down the hall, before being given a room, and intravenous antibiotics, the next morning.

“This is very serious,” said Dr. Barry Statner, the infectious disease specialist who came to see me the next day in my hospital room. “We’ll cure you,” he said while firing questions at me about my medical history. “But you need to know, this is very serious.” I wondered if I was going to lose my leg.

For the first time in my life, I had entered the world of the powerless sick. Like most people, I had long heard about the dangers of contracting infections in hospitals or surgical centers, but I never took them seriously. I assumed that, except for the worst cases, such as those caused by improperly disinfected scopes and other instruments, they were little more than a minor annoyance.

In fact, infections kill, and they do so regularly, even to people who are otherwise healthy.

“There are diseases that can take a regular healthy person and destroy them within hours,” Dr. Statner told me. “You don’t get a second chance. People don’t realize how rapid and lethal infections can be.”

In the United States in 2014, one in 25 patients contracted a hospital-borne infection on any given day, according to the Centers for Disease Control and Prevention. Some 722,000 Americans developed such infections in hospitals in 2011, and about 75,000 died during their hospital stay.

I count myself as somewhat lucky. My wound was infected with a relatively run-of-the-mill strain of Staphylococcus aureus, and after a week in the hospital, followed by two weeks hobbling around the house, where a nurse visited daily to pack my wound with prodigious amounts of gauze, I was on the road to recovery. I was fortunate it wasn’t one of the more serious infections that lurk around hospitals, like MRSA, a “super bug” strain of Staph that is resistant to most antibiotics, or C. difficile, which can cause months of relapsing and severe diarrhea.

No one knows how my infection happened. It was the first, and only, case of this type of infection at the surgical center that year, I was told by Dr. Richard Hoberman, the medical director and the anesthesiologist who had put me under general sedation during my surgery. Clearly shaken by what happened to me, he unexpectedly popped in to my hospital room early in my stay to apologize.

My infection resulted in my being “the subject of several very uncomfortable meetings with the hospital administration” and a five-page written report, Dr. Hoberman said. (They passed on sharing a copy of that report with me.)

Hospitals are anxious to reduce hospital-borne infections, to reduce deaths and improve their reputations. There are also immediate financial incentives: Medicare may penalize hospitals for infections acquired in the facility.

The medical center I’d gone to for my surgery, associated with Los Robles Hospital, practices all the well-known standard forms of infection prevention: constant washing of hands; sterilizing equipment; giving patients preoperative antibiotics; cleaning operating room surfaces and thorough cleaning at night. In addition doctors are not allowed to enter the operating room wearing the same scrubs they wear in the street. To prevent the spread of microbes, cellphones and jewelry are banned, as well as ties.

But infections still happen. While most infections happen at the time of surgery, according to Dr. Statner, they can occur in the hospital room as well. A break in the skin, a lapse in the handling of a paper surgical cover, lackluster cleaning, intravenous lines or catheters that remain in too long — all can result in infection.

In the end, stamping out infections depends on the vagaries of human behavior. “Medical care is done by people. There can be gaps in quality. People must remember to do certain things,” said Dr. Arjun Srinivasan, the associate director for health care associated infection prevention programs at the C.D.C.

“Far too many Americans get sick in the hospital,” said Dr. Thomas R. Frieden, director of the C.D.C. “The importance of making care safer cannot be overstated.” One limitation is that the C.D.C. can only recommend, not mandate, practices to reduce infection, he said. And because hospitals are owned by various corporations, it can be a challenge to know how effectively patients are being protected in any one hospital. If a patient is moved from one hospital to another across town, he said, it “can cause problems,” given that one hospital may have less rigorous infection-reduction policies than another.

Hospitals are experimenting with new disinfection techniques. For example, some disinfecting machines using ultraviolet light are so powerful that no one is allowed in the room when they are in operation. And routine measures like thorough hand washing, and having patients thoroughly shower using chlorhexidine before surgery is helping bring infection rates down in the United States in recent years. In the three to six years before 2014, depending on the type of infection, the rate of surgical-site infections has dropped by 17 percent, C. diff by 8 percent and hospital-borne MRSA by 13 percent, according to the C.D.C. However, there was no change in the rate of urinary tract infections caused by catheters between 2009 and 2014.

Infection rates have dropped even more steeply in Britain, where total MRSA reduction from 2004 is now 80 percent, according to Dr. Mark Wilcox, the head of medical microbiology at Leeds Teaching Hospitals and the head of the C. difficile task force for Public Health England. Leeds Hospital used to see 15 to 25 MRSA infections per month; now it gets five per year, he said.

Dr. Wilcox attributes their success in part to having a coordinated, single health system for the entire country. To encourage hygiene, National Health Service hospitals post current infection rates on boards that can be seen by doctors, patients and visitors. Hospitals are “obsessional” about hand hygiene, Dr. Wilcox said. To do the best cleaning job, health workers must be “bare below the elbows,” with no watches on the wrist. Lab coats, while making a doctor look professional, are also banned, as they can brush up against patients and transfer bacteria from one patient to the next.

Hospitals that fail to meet infection reduction targets are visited by a “hit squad improvement team” that demands a new plan, Dr. Wilcox said. Those that fail lose the right to decide how to spend some of their annual budget.

“A decade ago, people would say that only a small proportion of infections are preventable,” said the C.D.C.’s Dr. Srinivasan. “Now we know that a large proportion are preventable. We’ve turned that paradigm on its head.”

Staying Healthy While Traveling the Globe

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Credit Paul Rogers

On a recent trip to Tanzania with four grandsons, my most important task (beside protecting them from the jaws of a lion or leopard) was to keep them, and myself, in good health. It would not have been much fun to be stuck in a tent next to the commode or flattened on a cot while the rest of the gang viewed a dazzling array of wild animals from the safety of a Land Rover.

Although I came prepared for the worst, I did everything I could to make our trip the best. And I’m happy to report, no one got sick and we all had a great time.

When I described the steps I took to friends and physicians, they urged me to write about them. So here goes, along with a host of other helpful travel hints from well-informed professional sources.

No. 1: I reminded my grandsons daily, any water you drink or use to brush your teeth must come from a sealed bottle that you open. Ice wasn’t an issue in the bush, but that too should be prepared from bottled water. When you take a shower or swim in a pool, keep your mouth shut. (This warning was particularly pertinent for one grandson who always sings in the shower.)

No. 2: Before every meal, we each chewed one pink tablet of bismuth subsalicylate (sold as Pepto-Bismol and various store brands).

I have used this preventive since first reading about it in 1980 in The Journal of the American Medical Association in a study led by Dr. Herbert L. DuPont, an infectious disease and travel medicine specialist at the University of Texas, Houston. The study described how using these tablets greatly reduced the risk of traveler’s diarrhea among American students traveling to Mexico. In a subsequent study published in 1987, Dr. DuPont and colleagues reported that two tablets chewed four times a day reduced the risk of developing diarrhea by 65 percent. (Each tablet contained the standard dose, 262 milligrams of bismuth subsalicylate.)

I have relied on these tablets, albeit in a lesser dose because I’m a lot smaller than average, during trips to Vietnam, Thailand, Peru, Indonesia, India and Nepal, and never got sick despite eating salads and peeled fruit, which one is warned to avoid. In fact, in India and Nepal, my traveling companion, who also took the tablets, and I were the only ones who stayed healthy even though the others in our group assiduously avoided those no-no foods and we did not.

So for the five of us going to Tanzania, I packed 15 tablets for each day of our trip — and no one experienced the slightest gastrointestinal upset. That wasn’t the case, though, for most of the others on our itinerary. However, if you choose to try this preventive, I suggest you check first with your doctor and perhaps consider using Dr. DuPont’s larger dosage.

Without a preventive, which is no guarantee against food-borne illness, stick to “safe food” that is cooked and served hot, and fruits and vegetables you have washed in bottled water and peeled yourself. Never eat undercooked foods — eggs, meat, fish or poultry — or any food sold by street vendors.

Reduce your exposure to germs by washing your hands often, and always before eating. A hand sanitizer with at least 60 percent alcohol can be used if soap and water are unavailable.

I took no chances, especially since I was responsible for four children. I had an emergency supply of Lomotil (for digestive problems) and azithromycin (Zithromax Z-pak, for infections) just in case.

No. 3 (really No. 1 chronologically): I made sure we were all up-to-date on routine vaccines — measles-mumps-rubella, varicella (chickenpox), diphtheria-tetanus-pertussis, polio and an annual flu shot — and added two (for hepatitis A and typhoid) that the Centers for Disease Control and Prevention recommends for travelers to Tanzania. You can review recommendations for other destinations on the C.D.C. website at cdc.gov/travel. We also each filled prescriptions for generic Malarone (atovaquone proguanil) to prevent malaria, and I checked daily to be sure the boys remembered to take it.

I also packed an ample supply of sunscreen, insect repellent with 20 percent or more of DEET, and a first-aid kit of hydrocortisone cream, antibiotic ointment and a variety of bandages, though happily the latter two were never needed. For one grandson prone to motion sickness, I took some meclizine as well.

As the oldest traveler in the group (and the shortest now that my youngest grandson, at age 11, has passed me), I am acutely aware of the risk of blood clots when flying long distances. I always book an aisle seat so I can get up every hour or so and walk around for a minute. It also helps to move your legs and flex your ankles frequently. You might also wear graduated compression stockings on very long trips. Similar precautions apply to long car or train trips.

Although the risk of clots is generally very small, they can be life-threatening. At greatest risk are people over 40, those who are obese or pregnant or have limited mobility (for example, because of a leg cast) or who have a personal or family history of clots. Estrogen-containing medications also raise the risk; I usually take one of those, raloxifene, prescribed to protect my bones. But it can increase the risk of a clot, so I stop taking three days before a plane trip of four or more hours. For more information, check the C.D.C. advisory on blood clots and travel, and talk to your doctor.

Even when traveling alone, I always purchase travel health and medical evacuation insurance because, well, you never know. People on my various trips have broken bones or become seriously ill and had to return home mid-trip. Two men died while snorkeling on separate trips of mine.

Consider carrying a card that lists your blood type, any chronic illnesses or serious allergies and the generic names of prescription medicines you take. Bring some extra doses in case of travel delays.

Other worthy precautions: To avoid nasty parasitic diseases like schistosomiasis, do not swim or wade in fresh water in developing countries or wherever the sanitation is poor. Pools should be chlorinated. However adorable an animal (domestic or wild) may be, keep your distance. Do not touch or feed any animal you don’t know. Some carry rabies. Should you get bitten or scratched by an animal, wash the wound immediately with soap and clean water and, if at all possible, get to a doctor quickly.

If you expect to be at a high altitude (8,000 feet or higher), consult your doctor about medicine to prevent altitude sickness, which can take more than the starch out of a person. I was glad I did when traveling to Cusco, Peru (11,154 feet) and climbing in the Sacred Valley of the Incas (9,000 feet). The recommended preventive is acetazolamide (generic version of Diamox).

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