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Saturday, February 22, 2020

Post #47 How to Optimally Utilize Tamiflu

The take home message is that because of side effects and costs, using Tamiflu during the flu season should not be a knee-jerk reaction.

Every year in the United States, the CDC estimates that influenza results in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations, and between 12,000 – 61,000 deaths (approximately 100 – 200 being pediatric fatalities). 

In the United States, the immense burden of the flu is unparalleled by any other pathogen, but fortunately there is a vaccine and antiviral medications which help to mitigate the yearly morbidity and mortality wrought by influenza.

Because the flu changes its shape every year by a process called antigenic shift and drift, it is necessary for individuals to receive annual flu vaccines to maintain optimal protection against the virus. Protection from illness proffered by the immunization typically wavers between 40 – 60% in any given year; it is by far the best, no-brainer weapon that modern medicine has to offer against influenza. This author races to have it completed for his entire family every flu season as soon as the vaccine is available.

Beyond the vaccine, there are several antiviral medications that are also helpful in combatting the flu. To be clear, the antiviral medications are second line treatment as they are less effective, more expensive, and carry more side effects. 

The most common antiviral medication we use in pediatrics is Tamiflu (Oseltamivir), which is the only medication approved in children under 7 years of age. It works by inhibiting one of the key enzymes of the flu virus called neuraminidase. Tamiflu does not kill the flu virus, rather it slows down its ability to replicate, allowing the body's immune system to eventually (hopefully) overcome the virus. 

When given within the first 48 hours of the illness, it has been shown to reduce the overall duration of symptoms by approximately one day. In patients who are sick enough to warrant hospitalization, there are benefits to utilizing Tamiflu even outside of the initial 48 hour window.  

Overall, Tamiflu is well tolerated; but there are side effects, the most common being:
  • Gastrointestinal complaints (such as vomiting) in 14% of Tamiflu recipients
  • Neurological complaints (such as hallucinations) in 5% of Tamiflu recipients

Although Tamiflu can be an effective anti-flu medication, because of its side effects, timing constraints, and cost, like every other tool in medicine it must be utilized with judicious discretion. It is important to note that unlike the flu vaccine, where the protection lasts throughout the flu season, the benefits of Tamiflu are short-lived and are limited to when it is being ingested.

During the flu season parents often request Tamiflu as either treatment for an ill child or for prophylaxis to protect their healthy children. 

Some quick (but not all encompassing) criteria for when to consider Tamiflu, given that a flu test is positive, is as follows:

Child has had symptoms less than 48 hours AND is less than 2 years of age OR has an underlying health condition such as asthma, diabetes, or some other type of chronic illness.

In most children, who meet this criteria, Tamiflu should be strongly considered; however, if the child appears well and has good follow-up available, Tamiflu can be deferred.

Conversely, some quick (but not all encompassing) criteria for when to consider NOT utilizing Tamiflu, even when a flu test is positive, is as follows:

Child has had symptoms for longer than 48 hours OR appears well and is responding appropriately to fever reducers. Especially, if they are vaccinated, the necessity of Tamiflu decreases.

The three most common scenarios we are confronted with in our pediatric practice are as follows:

1. Child is sick and has a documented positive test confirming the flu.

Generally, if the child has been sick for less than 48 hours AND is less than 2 years of age or has any underlying heath conditions such as asthma, it is prudent to start a five day course of Tamiflu ASAP. If the child is acting well and responds favorably to fever reducers 
there is less onus to giving Tamiflu, especially if they are appropriately vaccinated against the flu.

2. Child is sick but does not have a documented positive test confirming the flu.

Because of the side effects and cost of Tamiflu, whenever possible, it is prudent to have a confirmatory test of flu completed before committing to treatment. One caveat to this is if a recent family member has tested positive for flu AND it has been less than 48 hours since exposure AND the child clearly has flu-like symptoms, there may be value in starting Tamiflu ASAP. However, similar to scenario one above, unless they are under 2 years of age or there is a chronic medical condition, Tamiflu may not be needed - especially if they have been properly vaccinated.

3. Child is well but has been exposed to the flu.

Per Uptodate.com:

"Postexposure prophylaxis is not routinely recommended for otherwise healthy children but may be warranted within 48 hours of exposure for children who have had close contact with a confirmed or suspected case of influenza during the infectious period (ie, one day before the onset of symptoms until 24 hours after the fever ends) AND who are at high risk for complications of influenza. Postexposure prophylaxis should be used only when antivirals can be started within 48 hours of the most recent exposure."

The bottom line is, whenever possible, a confirmatory flu test can help best guide treatment. And of course, consulting your pediatrician can help you make the best decision as to if and when to initiate treatment. 

It is always a bit confounding, each flu season, to observe several families who openly embrace Tamiflu, while shunning the flu vaccine because they are concerned about putting "synthetic" material into their child's body. 

Our pediatric offices deal with far more side effects from Tamiflu yearly - including vomiting and hallucinations - compared to the relatively nominal side effects of the flu vaccine, which are redness, swelling, and pain at the site of injection.

When used properly, Tamiflu is an effective weapon against the flu, but the best protection for your child is to immunize them against influenza each and every winter. The flu can be a dangerous disease, but with proper preparation and care, you can significantly mitigate the risk to your family.

Tuesday, April 30, 2019

Post #45 How to be Optimally Measles Immunized


Measles is a highly contagious disease caused by a virus. It spreads through the air when an infected person coughs or sneezes – the kicker is this can happen 2 hours AFTER said person has left the room. Measles starts with a fever; soon after, it causes a cough, runny nose, and red eyes. Then a rash of tiny, red spots breaks out which starts at the head and spreads to the rest of the body.

It is important to recognize that fever and rash are extremely common in children and the vast majority of fever/rash cases will not be Measles. Unless you are reading about local cases of Measles in the news – it is highly improbable that your child has Measles, especially if they are vaccinated.

Per the CDC, two doses of the MMR (Measles/Mumps/Rubella) vaccine are about 97% effective at preventing measles; one dose is about 93% effective.
The typical pediatric office will offer the first MMR at the 1yo check-up and the second MMR at the 4yo check-up. Note that the 4yo MMR is typically administered as part of a combination vaccine which includes both the MMR vaccine and the Varicella (Chicken Pox) vaccine, while the 1yo MMR is not part of a combination vaccine – so they may show up in different parts of your vaccine record.

If you are concerned about the current measles outbreak and you would like to proactively make sure your child’s MMR vaccine coverage is optimal, below are some options:
  1. If your child is under 6 months of age, MMR is not recommended. At this age the antibodies of the mother against Measles (which are the protective proteins your immune system makes in response to vaccines) are still quite prevalent in the baby, thus rendering the immunization mostly ineffective.
  2. If your child is 6-12 months of age, an early MMR dose can be given for protective purposes. By 6-12 months of age, the maternal antibodies are less prevalent (but not completely gone) and thus an early MMR can be beneficial – one prospective randomized trial showed an 87% level of protection at 9 months of age. The early MMR is recommended for any 6-12 months of age baby traveling internationally. Please note that any MMR given before 12 months will not count towards the completion of the routine MMR series and the normal 1yo and 4yo MMR vaccine should still be given in the future. Unless you have concern for exposure to non-vaccinating populations, at this time, this vaccine is not routinely warranted by current CDC recommendations.
  3. If your child is 1-4 years of age, two doses of the MMR vaccine, separated by 28 days can be given. Typically the two doses are given at the 1yo and 4yo check-up; however, the 2nd MMR dose can be given early. If the 2nd dose is given early it does satisfy the CDC criteria for future school enrollment and does not need to be repeated. The early 2nd MMR is recommended for any 1-4 year old child traveling internationally. A small percentage of children will not respond adequately to the first MMR; however, nearly all children who do not respond to the first MMR will respond adequately to the second MMR. Unless you have concern for exposure to non-vaccinating populations, at this time, this vaccine is not routinely warranted by current CDC recommendations.
  4. If your child is over 4 years of age and two doses have been given, no further MMR vaccines are recommended. A third dose may sometimes be recommended during a MUMPS outbreak, but it does not help increase the protection against measles.
  5. If you are an adult born after 1957 but before 1989, you may need an additional MMR vaccine. Most people born before 1957 are assumed to have naturally been infected with the virus through Measles outbreaks. Anyone born 1989 or later should have received two MMR vaccines, as that is when the CDC changed routine recommendations from one MMR to two MMRs. However, if you were born between 1957-1989, there is a good chance you only received one MMR vaccine and to give yourself the best protection it would be prudent to get a second MMR. If you are unsure or cannot find your record, you can either get a blood test to measure the level of your protection, or it would probably be simpler to get an MMR booster as there is no harm in getting extra MMR immunizations.

Bottom line is if you have some concern for exposure to non-vaccinating populations or you are traveling internationally, a proactive early first or second MMR is reasonable. But in most cases, unless there is a known outbreak in the community, following the routine CDC schedule for MMR is sufficient.

Per Uptodate.com: Concern has been raised about a possible link between measles, mumps, and rubella vaccination and autism and other chronic diseases. Multiple studies have failed to demonstrate any such association. However, there is an association between congenital rubella syndrome and autism, highlighting a potential role for rubella immunization in the prevention of autism spectrum disorders.

To find out more about measles, please visit the CDC Measles FAQ page at www.cdc.gov/measles/about/faqs.html

Friday, June 3, 2016

Post #44 Transitioning Babies to Solid Foods

This is an unedited excerpt from my 2nd book, "What to Know Before Having Your Baby" - coming out in February of 2017.

Because infants begin their life on breast milk, parents often think that milk is essential for their child’s diet even beyond the first year of life.  While milk is absolutely important for the first few months of life, once babies can start eating solids, the value of milk (breast, formula, or cow’s) quickly diminishes.  Milk’s main purpose is for humans (and animals) to provide an easy source of nutrition to their babies until they are ready for solid foods – which offer a far greater diversity of nutrition.

By one year of age, the bulk of a child’s nutrition should be from solid foods – ideally they should be eating a well-balanced diet pulling from all of the food groups.  At a maximum, a one year old should be taking no more than 24 oz of milk or formula, and as long as they are eating a balanced diet, there really is no minimum amount of milk that a one year old needs.  And though milk does offer vitamin D and calcium – you can get plenty of vitamin D from the sun and all the calcium you need from meat, certain vegetables, soy, nuts, beans and other solid foods.

Solid food introduction can begin anywhere between 4 to 6 months of age.   Traditionally, parents in the U.S. start with cereal, move to fruits & vegetables, and add meats as the last food group.  However, many experts now recommend reversing that order as meats are the most nutritious in vitamins and minerals and cereals are mostly filler foods with the least amount of nutrition.  Regardless of the order, by 8 to 9 months of life at the latest, babies should be eating from every food group, and ideally the sooner the better. 

Past concerns about causing food allergies led to a very conservative approach to introducing solid foods. Recommendations were to give only one new food every 3 days and certain foods such as peanuts and eggs were to be avoided until several years of age.  New data has clearly shown that this thinking was incorrect and it is now known that early introduction of foods (particularly highly allergenic foods) is helpful and reduces the risk of food allergies in the future.  Outside of honey, which can cause botulism, all other foods are safe to eat for babies as long as parents are careful of choking hazards. 

As for the “one new food every 3 day rule” – although this rule might help figure out what food caused an allergy by making the process of elimination easier, most kids with true allergies will have to undergo a series of tests if a true food allergy is suspected, thus making this rule unnecessary and a bit overly restrictive.   It is perfectly reasonable and definitely easier to be aggressive and introduce several new foods at a time.

While there is a whole line of baby foods available at the supermarket, feel free to offer bite size portions of soft foods that parents eat for their own meals.  Foods such as pastas, baked potatoes, soft meats, and steamed vegetables are all safe, nutritious, and tasty for babies to consume as soon as they can chew well.  The more flavors children encounter early on, the less picky they will be later!

So go ahead and give them a bite of your dinner – they’re probably eyeing you as you eat it and wondering where their portion is!  As long as you can mash a food between your pointer finger and thumb, even with no teeth, baby’s gums are powerful and can handle it.  The sooner they are eating real foods, the sooner you can cook one meal and make your life easier.  And ultimately if it is nutritious for you, it is nutritious for them.

So how should you incorporate the solid foods into your current feeding schedule?  The truth is there is no singular best way, but here is one method of doing it.  Pick one meal to begin with such as the feeding closest to breakfast time.  Before giving formula or breast milk, start by allowing your baby to eat as much solid food as they will take.  When they will no longer take any more solids, top them off with their normal bottle or breastfeeding until they are full.  Once they seem to have the hang of one meal, add a second around lunchtime, and soon thereafter a third around dinnertime.  It is that simple!

Some simple rules of thumb with feeding:

1.     You are in charge of the quality of food, the child is in charge of the quantity of the food.  They will never shortchange themselves!

2.     Aim for a balanced diet over a week at a time.  Not every day and certainly not every meal needs to be perfectly balanced.  It all goes to same place!

3.     A child’s growth controls their appetite, not the other way around.  Your kids will grow in spurts controlled by their hormones and appetite will follow accordingly.  Again, they will never shortchange themselves!


Ideally, your child should be eating 3 solid food meals a day covering all of the different food groups by 8 to 9 months of life.  And by one year of age, children should essentially be eating what their parents are eating.  The bottom line is there is a lot of freedom in how to start solids.  Try lots of different foods and have some fun with it!

Thursday, December 10, 2015

Post #43 My Father the Pediatrician


I recently wrote a new book geared to help parents have more meaningful conversations with their pediatrician and which will hopefully save them a copay or two as well!  As I reflect back on the five year journey in writing this book, I wanted to highlight the contributions of my biggest influence – my dad.

In the summer of 1973, my father, thirty years at the time, boarded a plane with his best friend to fly overseas for the very first time in his life.  Having recently finished medical school and his mandatory army training in South Korea, he was headed to the United States to begin his residency in Passaic, New Jersey.  He would leave his recently espoused and pregnant wife behind to pave the way for a better life in the land of opportunity.

On a layover in Tokyo, a fancy new camera caught my dad’s eye.  Japan at the time was light years ahead of Korea in terms of technology and my father reckoned that electronics were cheaper in Tokyo than they would be in New Jersey.  He and his friend saw an easy opportunity to arbitrage a quick profit and spent what little money they had in hopes of selling the camera as soon as they immigrated into the States.  As fate would have it, the camera was cheaper in America – is a good deal ever to be found at the airport other than possibly duty-free goods?

With even less money now but a fancy state-of-the-art camera to chronicle his adventures, my father began working long hours and preparing for the arrival of my mother who was ready to give birth to moi soon.  The camera was an inauspicious start that would belie the incredible blessing that the United States would be to our family.

My parents both took huge risks (most have paid off better than the camera) and made many sacrifices to give my brother and I a better life.   As a father of three now, although I am much more cognizant and thankful for what they must have encountered to establish life here in America – learning the trade of medicine in a foreign tongue, racism, no nearby family support, and the lack of any good Korean restaurants in Passaic (the travesty!) – I will likely never fully comprehend their early difficulties.

My father actually completed two separate residencies in America.  When he first arrived in the United States, he trained as a family practice doctor and for a while after moving to Virginia, my family enjoyed a comfortable life.  But as a foreign medical school graduate, my father was not allowed to sit for the board certification exam for family practice and so he decided to pursue a second residency in pediatrics (who did allow foreign graduates to sit for board certification).  I will forever be grateful for his career change!

We returned to New Jersey, replete with a new little brother having been born in Virginia, and for three years the four of us lived on the meager salary of a pediatric resident.  We lived in the bottom floor of a tiny two-bedroom duplex that had a scrumptious bakery at the foot of the hill we lived on.  Although we were poor, my brother and I were always happy, catching fireflies in the summertime and throwing snowballs and eating warm pumpkin pies from the bakery during the cold winters.  After finishing his training, my parents were eager to start their future elsewhere, so we headed south to Houston, Texas.

My father’s first practice was on Bingle road next to a diner that served the best chocolate ice cream shakes.  I still remember the antiseptic smell that would overpower you as Donna the nurse would walk you to the back, tempting you to lose the recently consumed shake.  There are many memories of me wailing as I received various vaccinations and penicillin shots – a tradition that my daughter has taken to new depths of sobbing. 

My father opened his first solo pediatric practice in 1985 at Memorial City hospital on Frostwood road in Professional Building One.  My mother served as the office manager and ran the business operations and the never-aging Masako, who still works for me today, was one of their first new hires.  Many of my friends from church worked for my father at one time or another, a tradition that I still carry on today.

I finished my own residency training in 2002, and after a short mission trip to Vladivostok, Russia joined my father’s practice – a true mom and pop organization with their newly minted pediatrician son in tow!  In late 2004 my father retired to go to the mission field in Yanbian, China, after which Dr. William Pielop and I started Blue Fish Pediatrics which just opened its third office in Katy and hired its thirteenth doctor this year. 

Looking back at my career and life, it is easy to appreciate the outsize influence my dad has had on me.  I love the Lord.  I married a beautiful Korean woman.  I am mildly OCD.  And I love my work as a pediatrician.  Lucky for me and because of the sweat equity that both my mom and dad put into his practice, I never had to flip a camera to get my start in medicine. 

Dad, thank you for your hard work, sacrifice, and your love for the Lord.  For everything you have done for me, I would like to dedicate my new pediatric book to you.  Without you, I would never be where I am today.