A Pediatrician's Blog

Post #28 Respiratory Syncytial Virus (RSV) - Dispelling Some Myths

2012-01-28T11:17:00.001-08:00

One of the common fear-inducing germs that moms ask me about during the wintertime is the Respiratory Syncytial Virus commonly known as RSV. Most moms correctly recognize the germ as a potentially devastating illness, however there are some common misconceptions about the germ that I would like to clarify.

Probably the most common misconception is that RSV is dangerous; while RSV can be dangerous it typically is not. RSV is one of many known viruses which causes the common cold (there are over 200). The majority of people who acquire RSV will go on to have typical cold symptoms including cough, runny nose, and possibly fever. Most people will recover within a few weeks without any long term complications.

However, the very first time a human being catches RSV, there is a higher probability of lung involvement leading to either bronchiolitis (inflammation of the small airways) or pneumonia (inflammation of the lungs involving the air sacs); as such the younger you are the more likely you will have lung involvement with an RSV infection. Additionally, there is greater risk of severe disease in children who were born premature (especially less than 35 weeks gestation).

So if your child is younger than 6 months of age and in particular if they were under 35 weeks gestational age when born, there is greater risk of serious illness from an RSV infection.

The older your child becomes three things will favor them against serious complications.

1. There immune systems will mature.
2. They will become physically larger (as will their airways).
3. They will encounter the RSV germ repeatedly giving them greater antibody protection with each subsequent illness.

It should be noted that the elderly are also affected more significantly by RSV than a healthy young adult, however as a pediatrician I do not have any expertise in this population.

The second common misconception is that RSV can be avoided - it cannot. Almost every child will become infected with RSV at least once by their second birthday and reinfection is common.

RSV, like other cold viruses, is spread through respiratory droplets (i.e. sneezes and coughs) but more commonly it is spread via direct contact with other infected children and the surfaces they touch. It really is a matter of WHEN and not IF your child will catch RSV. As stated above, children's bodies handle RSV better as they get older.

Thus if your child is a preemie and/or they are under 6 months of age, it makes sense to take some precautions to delay the initial onset of the inevitable first acquisition of RSV. Typical hygienic habits are what serve you best: washing hands, portable hand cleanser, and covering sneezes appropriately (elbow method is best).

The last misconception is not as common and is not really a true misconception. As a pediatrician, I am often asked whether RSV lung infection will increase the risk of asthma in the future. The short answer is - it's complicated.

A good way to think about this is the chicken or egg analogy. Do kids that are more prone to asthma genetically have a greater propensity of having lung involvement with their very first RSV infection? Maybe. Or does an early infection with RSV increase the chances of having asthma later in life? Maybe.

One of those statements is likely true and possibly both. The research has not definitively answered either question adequately and we will likely never know for sure. What we do know is that RSV infection in the lungs (everyone eventually gets it but not everyone gets it in the lungs) has some correlation with recurrent wheezing. But we also know that long-term there are not permanent changes found in the lungs of these same children - at least not as a result of RSV.

The bottom line is that your child will catch RSV at some point in their life and it will likely manifest itself as nothing worse than the common cold. However if your child is under 6 months of age and particularly if they were born premature, healthy hygiene may prevent lung involvement and thus reduce the risk of serious illness. Finally, should your child have lung involvement with their RSV illness, they have a greater risk for recurrent wheezing, however the RSV germ should not cause long-term changes in their lungs.

Post #27 Proper Swaddling of Babies to Prevent Hip Dysplasia

2011-10-19T07:19:00.000-07:00

In ten years of pediatrics I have only had a handful of cases of hip dysplasia. Hip dysplasia is when the hip joint (a ball and socket joint) does not develop appropriately and can lead to dislocation and improper development which in turn can lead to mobility issues in the future. Mostly, I have seen this occur in breech babies (legs are in funny positions in the womb), females (hip anatomy makes it have a higher propensity for issues than males), first born babies (the womb is tightest in the first pregnancy leaving less room for the baby and his/her hips), and low amniotic fluid (less room in the womb).

Recent evidence indicates that improper swaddling may contribute to hip dysplasia. Like other parts of the baby, the hip continues to develop and mature even after the baby is born. Proper assessment of the above risk factors and routine physical exams by your pediatrician can catch infants who have hip dysplasia. Parents can do their part in minimizing risks by using proper swaddling techniques which will allow for proper maturation of the hip joints.

The below information is from the International Hip Dysplasia Institute. There is a link embedded in the text that takes you to their web page where 3 different techniques for proper swaddling are demonstrated in a YouTube video. Although the risks with most current swaddling techniques are minimal, this intervention carries no side effects, incurs no costs, and is easy to do - so there is no reason not to try it!

Hip-Healthy Swaddling

Are you swaddling your baby properly?

Improper swaddling may lead to hip dysplasia or developmental dysplasia of the hip. When in the womb the baby's legs are in a fetal position with the legs bent up and across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.

Many parents find that swaddling can provide comfort for fussy babies, reduce crying, and develop more settled sleep patterns. When babies are swaddled, care should be taken to swaddle properly so the baby is safe and healthy.

There are many ways to swaddle babies by using blankets or commercial products designed for swaddling. In order for swaddling to allow healthy hip development, the legs should be able to bend up and out at the hips. This position allows for natural development of the hip joints.

The baby’s legs should not be tightly wrapped straight down and pressed together. Swaddling infants with the hips and knees in an extended position may increase the risk of hip dysplasia and dislocation.

Instructions on how to swaddle properly

Watch the video at this link to learn three, hip-healthy methods to swaddle your baby:

If you can't view the above video, here is one of the methods described in text:

1. If using a square cloth, fold back one corner creating a straight edge.

2. Place the baby on the cloth so that the top of the fabric is at shoulder level. If using a rectangular cloth, the baby's shoulders will be placed at the top of the long side.

3. Bring the left arm down. Wrap the cloth over the arm and chest. Tuck under the right side of the baby.

4. Bring the right arm down and wrap the cloth over the baby's arm and chest.

5. Tuck the cloth under the left side of the baby. The weight of the baby will hold the cloth firmly in place.

6. Twist or fold the bottom end of the cloth and tuck behind the baby, ensuring that both legs are bent up and out.

It is important to leave room for the hips to move.

What about sleepsacks and commercial products?

Some parents choose to wrap their babies in sleepsacks specifically designed for swaddling, instead of using a simple cloth or blanket. Commercial products for swaddling should have a loose pouch or sack for the baby’s legs and feet, allowing plenty of hip movement. However, even some of these commercial products can confine the legs if they are tightened around the thighs.

It's especially important to allow the hips to spread apart and bend up. In the womb the legs are in a fetal position with the legs bent up across each other. Sudden straightening of the legs to a standing position can loosen the joints and damage the soft cartilage of the socket.

Final Thoughts

When put down to sleep, a swaddled baby should be placed on his or her back, face up.

If the baby can roll onto his or her stomach this may increase the risk of suffocation. Seek the advice of your child’s healthcare provider if swaddling an older or more active baby.

Post #26 Flu Shot Update 2011

2011-09-03T01:10:00.000-07:00

Flu viruses are always changing. Each year, experts study thousands of flu virus samples from around the world to figure out which viruses are making people sick and how these viruses are changing. With this information, they forecast which three viruses are most likely to make the most people sick during the next flu season. These strains are then used to make the flu vaccine for the next flu season.

This year’s three flu strains included in the vaccine remain the same as last year’s vaccine:

* A/California/7/2009 (H1N1)-like virus
* A/Perth/16/2009 (H3N2)-like virus
* B/Brisbane/60/2008-like virus)

As noted above, this year's seasonal flu vaccine will again include the Novel 2009 H1N1 flu strand (A.K.A. A/California/7/2009 (H1N1)-like virus) which was used during the global pandemic and which was also included in last year's flu vaccine. This means your child will only need to get vaccinated with one type of flu immunization this year.

However, if your child is under 9 years of age AND did not receive the seasonal flu vaccine last year (the 2010-2011 flu vaccine), they will need to get 2 immunizations this year. This rule applies to both the nasal flumist and the injectable vaccine.

Flu shots given prior to the 2010-2011 flu vaccine (including the single strand Novel 2009 H1N1 vaccine) do not factor into this year's decision making tree. Please note that this is a different policy from previous years.

Here is a decision tree to help you know how many flu vaccines your child needs this year (you must answer both questions in the order shown):

Is your child 9 years or older?

Yes: Only one immunization is needed this year.
No: Go to the next question -->

Did your child receive at least one 2010-2011 seasonal flu vaccine?

Yes: Only one immunization is needed this year.
No: Two immunizations are needed this year.

If your child needs 2 flu vaccines this year, they should be spaced apart by a minimum of 4 weeks. There is no deadline by which the 2nd flu vaccine needs to be completed, but once the minimum 4 weeks has passed, the sooner the better.

Yearly flu vaccination should begin in September or as soon as the vaccine is available and continue throughout the influenza season, as late as March or beyond. The timing and duration of influenza seasons vary.

While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in February or later. About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.

In general, it is best to get your flu shot a.s.a.p. because you never know when the flu season will start!

For more information on the flu vaccine from the CDC click on this link.

Post #25 Pediatrics is Priceless

2011-06-26T21:46:00.000-07:00

An extra blue scrub top is tucked away in the lower right cabinet of the nurse's station. Every so often, after being sprayed with bodily fluid, I have to make a midday swap of my work clothes. However, it's a small price to pay to be a part of children's lives; one day the baby who spits up on your shoulder will be the same kid who runs down the hall screaming your name and clings to your leg with the dexterity of a koala. What makes pediatrics so rewarding is the long-term relationships that you build with children and their families who every day make you feel like a small hero.

Practicing general pediatrics often feels like searching for a needle in a haystack. Hidden in a sea of upper respiratory infections, reflux, eczema, and diaper rashes is a cystic fibrosis diagnosis, for example, that the astute clinician must not overlook. There are enough challenging cases to keep you on your toes to make everyday clinic interesting, but they don't overwhelm you. As a result, you'll have plenty of time each day to build new relationships and foster old ones. These relationships create the backbone of a successful pediatrician's practice.

To finish reading click here.

Post #24 A Follow-up to the Risks of Cell Phones

2011-04-15T09:43:00.000-07:00

I think employing the precautionary principle with cellphones is a reasonable idea depending on the circumstances. If it starts to impair your quality of life, I would argue the current safety profile of cellphones justifies a fairly liberal approach to their usage.

For example, as a pediatrician I get a lot of calls and I try to use my cellphone to return calls during downtime moments of my life so that when I get home I can maximize my time with my kids. I use my cellphone a lot (rather than waiting to arrive home and use my landline) and would not change this facet of my life as the risk of a brain tumor to me seems so remote and the time with my kids is tangible and valuable.

However with my kids, I will likely employ a stricter application of the precautionary principle. My children's skull bones are thinner secondary to physical immaturity and their brains are more plastic and still developing. Furthermore, their lifestyles will not dictate a heavy need for constant connectivity (at least early on in life). Perhaps a cellphone that will only connect to my phone and my wife's phone? I doubt that this would be over-utilized!

I realize that this sounds contradictory to my previous blog where I concluded that I felt comfortable sending my kids to a school where a new cell phone tower is being built. My wife and I remain comfortable with that decision. As written previously, we are happy with our neighborhood elementary school and the good certainly outweighs any risk I might ascribe to radiaton from a cell phone tower (risk that I still believe is very low as further supported by a NYT article from April 13, 2011 - snippets of which I have posted below).

However, when it comes to the weighing of pros and cons in regards to my child carrying a cell phone and using it habitually, not many pros come to mind. Of course safety and better communication are a few positives, but I hope to achieve that with other means and I would not be opposed to a cell phone programmed to only communicate with a set directory.

Of course, as my child matures - both physically and emotionally - I will likely liberalize their phone usage. Even if there were no health concerns, there are other issues at stake - sexting, distractions at school, driving and dialing, and over-usage to name a few.

The bottom line is that the health risks seem small and possibly zero. However, there are many reasons to limit the habitual use of a cell phone in a young child and the precautionary principle adds one more reason to the list, but it likely is just that - a precaution.

From the April 13, 2011 NYT. . . here are some excerpts from an excellent article titled "Do Cellphones Cause Brain Cancer" written by Siddhartha Mukherjee who is an assistant professor of medicine in the division of medical oncology at Columbia University. He is the author of “Emperor of All Maladies: A Biography of Cancer.”

The most exquisite — and arguably the most sensitive — means to identify a carcinogen is to study the effects of the substance not on humans or animals but on cells. In the 1970s, a Berkeley biochemist named Bruce Ames devised a cellular test to do just that. Ames’s test is based on a series of simple principles. Normal cells in the body grow through cell division, or mitosis, which is carefully regulated by genes. Certain genes accelerate growth, while other genes dampen or stop it. Cancer originates when the “accelerator” genes are permanently activated or when the “brake” genes are permanently damaged. Since genes are encoded by DNA, chemicals that mutate DNA — mutagens — can alter the growth-controlling genes and thereby cause cancer. Ames devised a special strain of bacterial cells that act as a “sensor” for mutations and therefore can also detect mutagenic chemicals. Chemical mutagens are so commonly carcinogenic that versions of the Ames test represent the gold standard by which most carcinogens are found.

Cellphone radiation is not a chemical, of course, but the rules about mutagenicity still apply (X-rays, for instance, are known to cause cancer and are detectable by Ames’s test). Laboratory experiments that link phone radiation to DNA mutation using a version of the Ames test have been largely contradictory. In 2005, a panel of experts, including a biomedical engineer, an epidemiologist, a genetic toxicologist and a radiation biologist, published a review of nearly 1,700 scientific papers on the cellular effects of radiation emitted by phones. In the review of more than 50 experiments linking phone radiation to DNA damage in animal or bacterial cells, evidence of damage has been negative in more than two-thirds of the studies. Since nonionizing radiation cannot directly affect the structure of DNA, experiments linking phone radiation to DNA damage are generally unconvincing. The most striking study linking cellular phone radiation to DNA damage, published in 2005 by researchers from the Medical University of Vienna, has recently been embroiled in even deeper scientific controversy: researchers studying the data intensively have argued that the original study is fraudulent.

But it is possible for something to be a carcinogen without directly damaging DNA. Some chemicals might activate growth pathways or survival pathways in cancer cells (eventually damaging DNA and mutating genes — but indirectly). Exogenous estrogen, for instance, activates growth pathways in breast cells and can cause breast cancer but doesn’t damage DNA. Others may provoke inflammation, creating a physiological milieu in the body that allows malignant cells to grow and survive. Yet others — the class of substances that we know least about — might not damage DNA directly but chemically modify genes so that their regulation is changed. These substances are like the dark matter of the carcinogenic world: they are barely visible to our current tests for carcinogens and thus lie at the boundaries of the knowable universe. Cellphones and their radiation have been tested for many of these properties — for instance, their ability to chemically modify DNA without causing mutations — but evidence linking this form of radiation to such cellular changes remains largely negative.

This section is about animal studies. . .

Nonetheless, biologists have exposed mice and rats to chronic nonionizing radiation (comparable to that emitted by phones) to determine whether it causes cancer. In rats prone to developing breast cancer, there was no acceleration of breast cancer. In another experiment, rats were treated with a chemical carcinogen in utero (to “prime” them to develop brain tumors) and then exposed to radiant energy comparable to cellphone radiation for two hours per day, four days a week, for 22 months. The experiment revealed no increased incidence of brain tumors in rats. Nor was there any accelerated growth in previously established brain tumors. From 1997 to 2004, six independent experiments on mice and rats studied the effects of chronic radiation on brain cancer. No experiment revealed an increased risk of brain cancer.

An excellent article and if you would like to read it in full here is the link.

Post #23 Assessing the Risk of Cell Phones to Children's Health

2011-03-23T22:01:00.000-07:00

Recently, our local elementary school allowed a cellular company to hoist a cell phone tower next to the cafeteria. Apparently, the school district will receive some monetary subsidy in exchange for allowing the tower to be built. I am unaware of the politics, legislation and deal-making that allowed this to happen; however, as a local pediatrician (with one child and many patients who attend this school) I felt compelled to do some cursory research into the potential health hazards (if any) regarding long term exposure to a cell tower.

As I am not an expert in epidemiology, radiation, cellular technology or cancer, I have posted snippets of the most relevant research I have found. And although I have my personal misgivings about the actual process that led to the cell tower being erected, I have tried to stick to the facts in regards to the health risks (the editorializing comes mostly at the end).

The main bias may be in the selection of websites that I chose to research - mostly government agencies - which I realize may be a problem for some.

Like most debates, evidence for both sides can be found on the web. The evidence in general seems to favor that there is no appreciable risk from cell phone radiation. Most organizations that I trust (CDC, WHO, FDA, NIH) all post evidence on their websites that generally conclude that cell phone usage has not shown a statistically relevant risk in developing cancer.

1. National Cancer Institute
This link is a nice primer on the health risks of cell phone use and a good summary of the reputable information available. The general conclusion is that "there is currently no conclusive evidence that non-ionizing radiation emitted by cell phones is associated with cancer risk."

The National Cancer Institute also reports that a "Nordic study is expected to provide some results on children in the next few years. Plans are also under way for a study called MOBI-KIDS, which would evaluate risk from new communications technologies, including cell phones, and other environmental factors in people between age 10 and 24."

2. National Institutes of Health
This link is to a subsection of the NIH website which summarizes an interview with Toxicologist, Dr. Michael Wyde, who is overseeing the National Toxicology Program (NTP) cell phone studies.

In the interview Dr. Wyde states, "Currently, there’s little or no evidence to suggest that cell phone usage is associated with brain tumors or any other adverse health effects in humans."

3. World Health Organization
Key facts listed in this link show:
• Mobile phone use is ubiquitous with an estimated 4.6 billion subscriptions globally.
• To date, no adverse health effects have been established for mobile phone use.
• Studies are ongoing to assess potential long-term effects of mobile phone use.
• There is an increased risk of road traffic injuries when drivers use mobile phones (either handheld or "hands-free") while driving.

4. Center for Disease Control
This blog commented on a large epidemiologic study called INTERPHONE which was funded by the European Union and health agencies in 13 countries. From 2000 to 2005, INTERPHONE interviewed 14,000 adults about their cell phone use, other exposures to RF radiation, and other factors conceivably related to brain cancer.

The study concluded that, "overall, no increase in risk of [brain cancer] was observed with use of mobile phones. There were suggestions of an increased risk... at the highest exposure levels... However, biases and errors limit the strength of the conclusions we can draw from these analyses and prevent a causal interpretation... The possible effects of long-term heavy use of mobile phones require further investigation."

5. Food and Drug Administration
This webpage focuses on the risks of cell phone radiation to children. "The scientific evidence does not show a danger to any users of cell phones from RF exposure, including children and teenagers."

6. Wikipedia
Under the cancer subheading in this Wikipedia entry there are is a list of studies both for and against the risks of cell phone radiation.

7. British Medical Journal

BMJ 2010; 340:c3077 doi: 10.1136/bmj.c3077 (Published 22 June 2010)

This case-control study looks at mobile phone base stations and early childhood cancer risk in children born to mothers who lived near cell phone towers during pregnancy.

Paul Elliott, professor of epidemiology and public health medicine, head of department, director, MRC-HPA centre for environment and health, concludes that "there is no association between risk of early childhood cancers and estimates of the mother’s exposure to mobile phone base stations during pregnancy."

Overall the current body of evidence gives me solid relief about cell phones and the lack of health risk they pose.

However, one thing that frustrated me in my research was that I could not find a significant amount of information on health risk secondary to cell phone towers. Understandably, most of the research is concentrated on cell phone usage.

Several articles did comment that cell phone usage exposed the body (and more specifically the brain) to higher radiofrequency energy then a cell phone tower did; however none of the articles really went into detail about distance from the tower, hours near the tower, etc.

One could then extrapolate that if studies are showing that cell phone usage is safe, then exposure to a cell phone tower must also be. But as a parent, I would obviously feel safer and less anxious if there were clear studies in regards to cell phone towers.

The BMJ article cited above discusses cell phone towers and finds no risk to the children of woman who lived near the towers during pregnancy. However there were some debatable flaws to the study and although the conclusion is assuaging, the more studies the merrier.

Interestingly, several websites cautioned that the risks of driving while using a mobile phone were greater than the risks from the radiation exposure itself. Guilty as charged!

In the end my research made me feel better about my child's (and patients') exposure to a cell phone tower, but not completely at ease. It's the unknown that gnaws at me – but I suppose there will always be some level of unknowing.

Would I rather the cell phone tower not be built? Yes. But this may be more NIMBYism than true health concern.

Would I vote to stop it? Yes.

Am I going to fight a long battle to stop it? There are probably better and more productive ways my time could be spent for my child (unless of course the risk of cell phone towers becomes more real in future research).

Am I going to move schools because of this? I doubt it. Our family as a whole is very happy with the school and this potential but unlikely risk doesn't seem to warrant a move.

As in life, every decision carries some risk. We take some risk every time we send our child to school, but as parents we have to decide if the good outweighs the bad. And while my wife and I would rather not see a cell phone tower erected, ultimately, as of this writing, the research leads me to believe very little has changed with the bad.

Post #22 Fever Phobia Deconstructed

2011-03-09T03:41:00.000-08:00

An excellent article detailing how parents and pediatricians should approach fever. I absolutely agree that the comfort of the child supersedes the fear-driven need to bring the number of the fever down.

My motto in the office is "treat the child, not the fever". In fact this motto can be extended to almost any other symptom, i.e. "treat the child, not the cough". As with all symptoms, it is far more important to elucidate the source of the fever rather than to focus on the fever itself.

The same goes with cough, runny nose, rashes, etc. If the source is benign then one need not worry about the symptom itself. Which does not mean you shouldn't treat the symptom - if there is discomfort it should be addressed.

On the otherhand, if a pediatrician suspects that the source may be of concern, i.e. pneumonia, meningitis, kidney infections - a more extensive evaluation, closer monitoring and treatment will be called for.

Sweating Out a Fever
Focus on Symptoms, Not Just the Number on the Thermometer, Doctors Advise
Wall Street Journal March 1, 2011
By MELINDA BECK

When a child's temperature begins to rise, worried parents often spring into action, marshaling cool washcloths and pain relievers, making frantic calls to the doctor or even visiting an emergency room.

Now, the American Academy of Pediatrics is telling parents that the number the thermometer displays is just a number—and that making a feverish child comfortable is far more important than bringing his temperature to 98.6 on the dot.

Fevers are the main reason for one-third of calls and visits to pediatricians.

"The signs and symptoms provide much more information than just the fever itself," says Janice E. Sullivan, a professor of pediatric critical care at the University of Louisville School of Medicine in Kentucky and co-author of an AAP report on fevers, released Monday.

The report, aimed at calming what it calls "fever phobia," also says there is no evidence that lowering a fever will help a child get well faster, or that leaving a fever untreated could cause seizures, brain damage or death, as some caregivers fear.

Many pediatricians have given parents a similar message for decades, but it hasn't sunken in. There's widespread confusion over what fevers in both children and adults signify, when to treat them—even what constitutes an official "fever" (100 degrees Fahrenheit? 100.4?) Many parents also rely on the thermometer to tell them how sick a child is when he's too young to talk. To some, it's an objective measure, which can't be faked, of whether an older child should be packed off to school or sent back to bed.

Fevers are the main reason for one-third of calls and visits to pediatricians, the report notes. Yet many beliefs about them are based more on culture, tradition and playground chatter than scientific evidence. Ads showing parents fretting over thermometers confuse things further.

Drugstore Dangers
These days, navigating the world of children's pain relievers is almost as tricky as interpreting a child's temperature.

Johnson & Johnson's McNeil Consumer Healthcare unit recalled 136 million bottles of liquid Tylenol, Motrin, Zyrtec and Benadryl for infants and children last year after federal investigators found bacterial contamination and other problems at a plant in Pennsylvania. Subsequent recalls included Children's Tylenol Meltaway strips in bubblegum flavor, Junior Strength Motrin caplets and Children's Benadryl Allergy Fast Melt tablets in cherry and grape.

Problems ranged from moldy smells to floating metal particles to the possibility of excess concentrations of an ingredient. In a legal filing last week, Johnson & Johnson said alternative supplies are expected to be available in the second half of this year.

In their absence, many parents have turned to generics and drugstore brands, children's Advil or Triaminic, another liquid acetaminophen for children.

Experts are still concerned about combination cough-and-cold syrups. Manufacturers voluntarily withdrew those labeled for children under age 2 in 2007 after pediatricians complained that they didn't work well and posed a risk of accidental overdose. But this week's American Academy of Pediatrics report warns that parents should not give cough-and-cold products containing acetaminophen even to older children, given the risk that they might unknowingly take other products with acetaminophen, which can cause fatal liver damage at high doses.

Many liquid medications for children still on the market have confusing dosing information, according to a study in the Journal of the American Medical Association in December. For example: a label calling for a one-teaspoon dose packaged with a cup marked in milliliters. Since the study was conducted, the Food and Drug Administration issued voluntary guidelines for making children's medication labels easier to understand. The researchers, from New York University, plan to repeat the study to see if the guidelines have made a difference.

In the meantime, experts say, parents should pay very careful attention to dosing information since even small errors can have big consequences in children.

Melinda Beck ."There's a huge desire to do the right thing, but when we think we're healing the child, we may be really treating ourselves" by taking action, says Glen Stream, president-elect of the American Association of Family Physicians.

Experts stress that a fever isn't an illness, it's a response, probably an evolutionary adaptation to help fight infection. Setting the body's thermostat (the hypothalamus gland in the brain) a few degrees higher slows the reproduction of bacteria and viruses and boosts white blood cells.

There's some evidence that illnesses may resolve faster when fevers are left untreated, the report notes. At the same time, elevated temperatures themselves can cause discomfort in children by interfering with sleep, appetite and activities.

"If your child looks uncomfortable, then treat the discomfort with acetaminophen or ibuprofen," says Dr. Sullivan. But she says a fever alone with no other symptoms doesn't need treating. "The fever itself doesn't tell us how ill the child is. There isn't a good correlation."

The report, which is aimed at pediatricians, not parents, doesn't specify other ways to make a sick child more comfortable. But Dr. Sullivan says parents should be on the lookout for rashes, irritability and altered mental status.

"Anytime you have a significant change in behavior, you need to talk to your doctor," says Henry Farrar, who practices pediatric emergency medicine at Arkansas Children's Hospital and co-authored the report. It also stresses the need for rest and proper fluid intake.

If a fever-reducing medicine is warranted to make a sick child more comfortable, the report says there is no substantial difference between acetaminophen and ibuprofen in safety or effectiveness. But it warns against combining them or alternating them—which some doctors recommend—because it compounds the risk of errors.

COMMON AILMENTS ASSOCIATED WITH FEVERS
Some temperatures are cause for concern all by themselves. But going strictly by the numbers on a thermometer can be misleading, since people can react differently to the same infections.

The report also stresses the importance of checking package labels for the correct dosages, which are based on weight and age in children. As many as half of all U.S. parents give children incorrect doses, according to the report.

And if a child is asleep, he shouldn't be awakened just for medication, the report notes. In one study, 85% of parents said they had done so.

There are some cases where a fever alone can be worrisome. Parents should contact a doctor immediately if an infant under 3-months old has a fever of 100.4 or higher, which could signal a serious infection. Children with underlying conditions, such as weak heart muscles, may not be able to tolerate a fever and should get medical attention if one appears.

Children and adults can spike fevers as high as 106 due to hyperthermia, or "heat stroke," a malfunction in the body's ability to cool itself, often after physical exertion in hot weather. Drinking fluids and being immersed in cool water can help; fever-reducing drugs don't.

Fevers can occur in children and adults for many other reasons, including auto-immune diseases like lupus, cancers like leukemia and lymphoma and just normal teething. Some people routinely run fevers even with minor illnesses, and some people seldom get them. (Rare fevers that last for weeks with no apparent reason are known as FUOs—fevers of undetermined origin.)

Even the classic 98.6 isn't so much "normal" as "average," experts note. A healthy person's temperature varies much as a full degree during the day, reaching highest in the evening and lowest between about 6 a.m. and 9 a.m. (just when tough school-or-bed decisions are being made.)

Given all that variability, does it make sense to check the thermometer at all?

Yes, doctors say. Since most fevers accompany viral infections, experts agree that children with temperatures above 100.4 should stay home until they are fever free, without medication, for at least 24 hours, whether they have symptoms or not.

The same goes for adults—and they shouldn't be under the illusion that lowering a fever with medication also lowers their chance of infecting coworkers, experts say. "We really don't want people with fevers to be in the workplace," says Robert Hopkins, a University of Arkansas professor of internal medicine who serves on the American College of Physician's clinical guidelines committee.

The illnesses with little or no fever pose more of a dilemma. Some viruses are most contagious in the early stages, before a fever has developed. Others, like last year's H1N1 virus, made many people miserable but seldom caused fevers.

That can make for tough calls for parents and school nurses when it comes to deciding whether a child who complains of illness, but doesn't have a fever, should be in school.

"Sorting out the difference between a math-anxiety headache and an illness that could be contagious or prevent a child from learning is a judgment call," says Amy Garcia, executive director of the National Association of School Nurses. It helps to know the child very well, she says. "I had three boys myself, so I know the drill pretty well."

Post #21 When Should I Send My Sick Kid Back To School?

2010-07-30T14:19:00.000-07:00

School and daycare criteria are often overly restrictive in their back to school policy for sick kids. This can unnecessarily hamper the education of your child without benefitting the health of the other kids in his/her classroom.

Below is an excellent article highlighting policy from the American Academy of Pediatrics that helps parents (and doctors) understand when exclusion does and does not make sense.

AAP Updates Guidelines for Infectious Disease Exclusions

Pediatric News Volume 44 Issue 2 February 2009

DIANA MAHONEY (New England Bureau)

Conjunctivitis: It's red, it's itchy, it's crusty, but it is not—repeat NOT—cause for automatic exclusion from day care or school, according to the latest edition of the American Academy of Pediatrics' “Managing Infectious Diseases in Child Care and Schools.”

The rationale behind this seemingly revolutionary recommendation is the fact that neither treatment nor exclusion of children with conjunctivitis from group settings reduces the spread of infection, Dr. Laura A. Jana discussed at the annual meeting of the American Academy of Pediatrics.

The same goes for many of the common childhood infections that incite knee-jerk reactions among schools, day care providers, and parents.

“Multiple studies have shown that most viruses are spread by children who seem well, which means that exposure happens before the school or day care facility can make the first phone call for the child to be picked up,” said Dr. Jana, a pediatrician and owner of a child care facility in Omaha, Neb.

So while conventional wisdom says that automatically excluding kids with conjunctivitis, fever, and stomachaches will prevent the spread of these infections, “the evidence doesn't back this up,” she said, noting that “hand and surface hygiene continue to be the best way to reduce infections in group care.”

The confusion regarding exclusion is understandable, said Dr. Jana. Unlike the best-practice guidelines issued in 2002 by the AAP, American Public Health Association, and others, state guidelines for exclusion from child care or school lack detail, are not based on medical evidence, and vary considerably by state.

“Most states do not require center and school policies to follow national guidelines, and individual exclusion policies must only comply with state licensing, which means children are often excluded for harmless conditions,” she said. The consequences of inappropriate exclusion policies and practices, she added, include excess health care visits, antibiotic-seeking behavior, and lost work and school time.

The one exclusion criterion from the national guidelines that is excluded most frequently, according to Dr. Jana, is the directive that a child should be excluded if the illness prevents him or her from participating comfortably in activities. “This child should really be at home,” she said. “Additionally, a child should be excluded from school or day care if the illness results in greater care than the staff can provide,” she noted, or if the illness poses a risk of spreading a harmful disease to others. (See box below.)

The common cold, for example, does not warrant exclusion, “unless the child is too uncomfortable to participate in routine daily activities,” Dr. Jana said. “The virus itself can be spread before, during, and well after the time of symptoms, so preventing a child's attendance won't significantly reduce the chance of spread.”

The updated “Managing Infectious Diseases in Child Care and Schools” (Elk Grove Village, Ill.: American Academy of Pediatrics, 2008), also recommends against exclusion for the following conditions that often incite red flags, according to Dr. Jana:

▸ Hand, foot, and mouth disease. “Children should not be excluded unless they have sores in their mouth with drooling or if the rash is associated with fever or behavior change,” Dr. Jana explained. “Good hygiene is the best way to minimize the opportunity for the spread of this common virus.”

▸ Fifth disease. Because there is little virus present when the telltale rash appears, exclusion has no preventive benefit.

▸ Draining skin infection, including methicillin-resistant Staphylococcus aureus (MRSA) infection. “Because of the media attention surrounding MRSA, there's a lot of anxiety about this, but the reality is, these children should be excluded only if the infection is accompanied by fever, pain, or behavior change,” said Dr. Jana. “There is no need for the caregiver to request a culture, because it won't affect how the infection will be handled. Some kids without symptoms have MRSA, and there is no good way to eradicate the germ yet from individuals, families, or classrooms.”

▸ Diarrhea. According to the revised guidelines, diapered children with diarrhea may remain in care if the diarrhea is contained in the diaper and the child has no more than two stools above normal baseline. “This is a departure from the previous recommendation that all diapered children be excluded until the diarrhea resolves or is deemed noninfectious,” said Dr. Jana. Children who are able to use the toilet may remain in care with good hand washing, as long as they don't have accidents. “Exclusion is appropriate for children with blood in their stool not explained by medication, hard stool, or diet,” she said.

▸ Vomiting. Exclusion is recommended for a child who has had two or more episodes of vomiting in the previous 24 hours and continuing exclusion until the vomiting resolves or a health care provider determines the cause is not contagious.

▸ Fever. “Children with fever should not be excluded automatically, unless the fever is accompanied by behavior change or other signs or symptoms of illness,” explained Dr. Jana. The exception to this is children younger than 4 months old with unexplained fever.

▸ Respiratory illness. Most respiratory illnesses do not require exclusion; however, a child with persistent coughing or trouble breathing should be evaluated for pneumonia, asthma, or serious respiratory infection, such as whooping cough.

▸ Earache, no fever. “This child should be excluded if he or she requires more care than the staff can reasonably provide,” said Dr. Jana. “Often, these kids are in a lot of pain and cannot participate in routine activities.”

▸ Lice. “Lice are a nuisance, but they're not a health hazard,” said Dr. Jana. “Children with lice should be excluded, but they don't have to be sent home right away. It can wait until the end of the day, and they can return once treatment occurs,” she said.

“Of course, all of these are recommendations, and while they are based in evidence, they are not binding,” Dr. Jana concluded.

Revised ‘When to Exclude’ Criteria

With the exception of the noted updates, most of the exclusion criteria outlined in the revised “Managing Infectious Diseases in Child Care and Schools” are consistent with the national illness exclusion guidelines published jointly in 2002 by the AAP, APHA, the Maternal and Child Health Bureau, and the National Resource Center for Health and Safety in Child Care. These include:

▸ Tuberculosis, until an appropriate health care provider or health official certifies that the child is in appropriate therapy and can attend care.

▸ Impetigo, until 24 hours after treatment has been initiated.

▸ Chickenpox until all sores have dried and crusted (usually 6 days).

▸ Mumps, until 9 days after an onset of parotid gland swelling.

▸ Hepatitis A virus, until 1 week after an onset of illness or jaundice or as directed by the health department.

▸ Measles, until 4 days after an onset of rash.

▸ Rubella, until 6 days after an onset of rash.

▸ Fever, when accompanied by behavior changes or other symptoms such as a sore throat, rash, vomiting, diarrhea, earache, etc.

▸ Diarrhea (frequent, runny, watery stools).

▸ Blood in the stool not explained by dietary change, medication, or hard stool.

▸ Vomiting two or more times in a 24-hour period.

▸ Body rash with fever.

▸ Sore throat with fever and swollen glands or mouth sores with drooling.

▸ Severe coughing with the child getting red or blue in the face or making a high-pitched whooping sound after coughing.

▸ Persistent abdominal pain (more than 2 hours) or intermittent pain with other signs and symptoms.

▸ Signs of possible severe illness such as irritability, unusual tiredness, or neediness that compromises caregivers' ability to care for others.

▸ Uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.

Post #20 Why I Canned the Cable by Laura Rowley

2009-08-20T21:40:00.000-07:00

An interesting read I found on the Yahoo finance page. Talks a little about financial prudence, but delves into the importance of teaching delayed gratification to children and backs it up with oft-cited studies. I totally agree that children need to be taught self-control (modeling is key!).

I often tell my families that pre-college school years is mostly about learning how to learn; and mastering self-control is critical to maximizing the return from any level of education (especially once they are on their own in college).

This is further delineated in Malcolm Gladwell's book Outliers, where he distills success and talent down to a critical investment of 10,000 hours into whatever the gift or task may be. Success, it seems, finds those individuals who can put in the hard work now and wait for the reward later.

Why I Canned the Cable

by Laura Rowley author of Money and Happiness

Posted on Wednesday, August 19, 2009, 12:00AM

This week I went cold turkey and eliminated our cable television service entirely -- even the basic channels.

Despite our family's participation in the library summer reading program, educational camp activities (including the dissection of a sheep's eyeball), trips to museums, daily swim team practice and the new trampoline in the backyard, my kids still zoomed back to the big screen whenever they had a second of downtime -- a 48-inch, high def, Pied Piper living in the basement.

The breaking point came when my 6-year-old, Holly, got $5 from the tooth fairy and offered some of her stash to my 9-year-old, Charlotte. Charlotte said, "That's okay Holly, you should save your money." Holly literally glazed over and responded: "Save money. Live better. Wal-Mart."

My decision to ditch Comcast was fortified by a recent interview with researcher Angela Lee Duckworth of the University of Pennsylvania. After graduating from Harvard, Duckworth taught high school, and found a number of students were reading far below grade level despite high IQ. A lack of self-control was the problem.

She returned for her Ph.D. at Penn to study something she calls "grit" -- a combination of courage, focus, the ability to delay gratification and persevere over the long-term -- that leads to success. (It's something I talk about in my values class at Seton Hall University, but we call it fortitude, one of the cardinal virtues of Western philosophy -- along with prudence, justice and temperance.)

Duckworth has conducted a range of studies with students, from middle school, to Ivy League undergrads, to West Point cadets, testing both their ability to delay gratification and their intelligence. "The basic findings are that we could predict grades much better from self-control scores than from IQ scores," Duckworth says. For example, a study of eighth graders she conducted with Penn's Martin Seligman found self-control was twice as predictive as IQ in academic success.

Learning Self-Control

Duckworth's research builds on the work of Walter Mischel, who pioneered self-regulation psychology. He conducted a series of experiments in the 1960s with four-year-olds, offering them a marshmallow treat and then testing their ability to resist. He continued to follow the participants and found that the pre-schoolers who could delay gratification had better outcomes as adults in a variety of areas. The child who could wait 15 minutes had an SAT score that was 210 points higher than one who could wait only 30 seconds. The more impulsive children also had a higher body-mass index as adults and were more likely to have had problems with drugs.

What does all this have to do with our cable service? Self-control is not just a genetic blessing, but something that can be taught and enhanced with practice. Duckworth and Mischel have both found that one key is simply eliminating distractions that hijack focus and attention. (Although we don't allow the kids to watch TV during the school week, the stations were constantly churning out new inane junk I had to ban on weekends and holidays. Ever seen "Total Drama Island" on Cartoon Network? Or frankly, most of the programming on Cartoon Network?)

Another technique that boosts grit is goal-setting and planning. "It's good to have a specific goal that's challenging as opposed to just a vague inclination: 'I'm going to do great in school this year' is not a good goal because there's no clear feedback," says Duckworth. "A better goal would be 'I'm going to turn in homework five days out of five in math class, which I'm always struggling with' because when the week comes along and it's four out of five, you have clear feedback."

Researchers also favor basic parenting rituals that encourage kids to wait and make waiting worthwhile -- whether it's not eating snacks before dinner or requiring them to do chores or practice piano before they play on the computer. If a kid asks for an iPod or other expensive item, offer to match the funds they save up. It was amazing to watch my oldest get entrepreneurial and save up $75 for her half of the Nano. Don't abandon your expectations in the face of tantrums or sulking.

Another key to self-control is managing the background cues. Researchers Andrew Ward of Swarthmore College and Traci Mann of the University of Minnesota have conducted a series of studies on what people pay attention to and how that affects their self-control.

For instance, in a study of smokers who expressed an interest in quitting, participants were exposed to cues encouraging them to quit (including an ad for the annual "Kick Butts Day"). When their attention was unconstrained -- that is, they weren't focused on any task in particular -- participants exposed to the "quit smoking" cues tended to rebel against the messages and smoke excessively. But when their attention was narrowed with a cognitive task, participants exposed to the background antismoking message substantially reduced their smoking.

In other words, once attention is focused on a specific task, supportive background cues can boost someone's ability to accomplish a goal. "Try to arrange (the) environment such that the most prominent cues aid self-control efforts," Ward wrote in an email. "So, for example, try keeping salient reminders around that help one stick to a (task)."

Setting Specific Goals

For short-term tasks like homework, that might mean prominently posting the assignments for the night, time limits and a possible reward for finishing everything on time. Have kids write out longer-term goals and deadlines for the month or semester and post them in their study space. Minimize distractions such as television, cell phones, iPods and the like.

The same concept works for parents trying to reach a financial goal, Ward says, because the wrong background cues can actually undermine discipline. Certain distractions "can sabotage attempts at self-control, such as when someone sees an enticing ad on TV for an attractive product and ends up impulsively purchasing it," Ward notes. "Remove from that environment those stimuli that try to undermine your efforts; turn off the TV, especially when distracted or fatigued -- times when we might be most susceptible to the influence of advertising."

Another strategy: Put a piece of masking tape on your credit card with a reminder of your larger goal ("college," "retirement" or "home down payment") to thwart short-term temptations.

One of my biggest goals as a parent is consciously guiding my kids toward the things in life that are worth paying attention to (and away from Total Drama Island).

"Deciding what to pay attention to for this hour, day, week or year, much less a lifetime, is a peculiarly human predicament, and your quality of life depends largely on how you handle it," writes Winifred Gallagher in her recent book "Rapt: Attention and the Focused Life." "We must deliberately select targets, from activities to relationships, that are worthy of our finite supplies of time and attention."

Self-control psychology is enormously important in personal finance, as well. Over the years I've found the biggest financial blunders are not made by investing in the wrong stock or launching an ill-conceived business, but by failing to pay attention, by earning and spending unconsciously and by ignoring the basics. The people who focus on identifying their values, set specific goals with crystal-clear dollar amounts and timeframes, and show enough discipline to monitor their progress, typically succeed, even when life throws them curveballs -- or marshmallows.

Post #19 Sunscreen Advice

2009-06-24T13:26:00.000-07:00

A sure sign that spring and summer are upon us is the location of your local retailer's sunscreen shelves, which are now front and center - not to mention the dazed look of frazzled folks overwhelmed by so many options.

SPF, UVA, UVB, what does it all mean? IMO, all those TLA's are enough to make a person crazy.

Let's start at the beginning.

Sunscreen 101:
UVA/UVB – both of these are ultraviolet rays. Basically, UVA are the aging rays, and UVB are the burning rays. You don't want too much of either of these, which is why a "broad spectrum" sunscreen is the best option. Sunscreens contain chemicals that absorb or reflect UV rays.

SPF means Sunburn Protection Factor. Basically, SPF tells you the protection offered against UVB rays but not against UVA rays. If it's SPF 15, that means you can be in the sun 15 times longer than someone without sunscreen before beginning to burn. The higher the SPF, the greater the protection against UVB rays; however a high number can give a false sense of security. Furthermore, the effectiveness of the sunscreen is affected by a number of things including how often it is applied, how much is absorbed into the skin, the activity engaged in, and the skin type of the user.

Currently, there is no benchmark rating used for UVA rays. For good UVA protection look for products containing zinc oxide, avobenzone, and ecamsule.

And then, there are the water resistant and waterproof sunscreens. According to FDA regulations, "water resistant" means the product maintains its level of protection after 40 minutes of water immersion. The FDA doesn't like to see any label stating "waterproof," because no sunscreen truly is. However, manufacturers will label it "waterproof" if protection levels are maintained after 80 minutes.

Applying:
The general rule of thumb is that it should take a handful of sunscreen to properly cover the body. For you, that would be an adult-size handful. For your child, it's a child-size handful. As they grow, their hands get bigger, and you'll automatically be putting enough on.

Sunscreen comes in a lot of different forms. Sprays, lotions, gels, fun colors, there's plenty to choose from. When possible, find a broad spectrum UVA/UVB sunscreen that contains either zinc oxide, avobenzone, or ecamsule.

Babies under 6 months of age should be kept out of the sun as much as possible, and try to use a wide brimmed hat and loose fitting clothing to shield them. For all children over 6 months I recommend to use at least SPF 30.

Reapplying:
In one word – frequently. For best results, follow instructions on the sunscreen container. And while you're doing that, check the expiration date. Sunscreen loses its effectiveness beyond the expiration date or if it’s over 2 years old.

Sticking with it:
Make sunscreen application a part of the established "going out" routine, similar to how a bedtime routine includes brushing teeth.

You can say "Okay Jane, we're going to the swimming pool, but you know the drill. First, get undressed and let me put on your sunscreen. Jimmy, you can set the timer on the microwave for 30 minutes. Then go get your swimsuits on. When the timer goes off, we're off."

Hopefully, by the time Jane and Jimmy are teenagers – when they will be more inclined to think whatever you tell them is wrong - you will have established a habit of sun safety to where they won't think twice about going out without sunscreen.

If they hesitate, tell them to get on the computer and Google "skin cancer." If they find a site with photos, that's even better. Tell your daughter to Google "aging" so she can see how a suntan today means wrinkles tomorrow.

Vitamin D or sunscreen?
Lately, there's been a debate in the medical community. The AAP (American Academy of Pediatrics) has come out with a very strong statement about the need for Vitamin D, which comes from food and exposure to the sun (UVB rays).

They are tying low levels of Vitamin D to poor bone health, a higher risk of certain cancers, and diseases such as diabetes and multiple sclerosis.

Until we get more information and data, my take on this is that it's a work in progress. An appropriate level of Vitamin D is necessary for good health, but so is an appropriate level of sun protection.

One thing we do know to be fact is that too much sunlight increases the risk of melanomas and other skin cancers.

On that note, here's a question for you. Are you, or your child, the type that "tans, never burns?" If so, you're still at risk of developing skin cancer. It's a myth that only those who sunburn get melanoma. It's exposure, which adds up throughout your life, particularly too much exposure in early life.

Summer sun:
I suggest Houstonians plan outdoor activities before 10 a.m. or after 4 p.m., when the sun is not at its peak. I highly recommend full body swimwear for both girls and boys. Cover up with clothing – T-shirts can be worn over the top of bathing suits – the darker the better. A wet white T-shirt offers little protection against the sun. Wear wide-brimmed hats at the park. Sunglasses will protect your eyes – kids love wearing "cool" sunglasses. Use a lip balm with SPF on your lips, and sunscreen of at least SPF 30 on your skin.

Remember, sunscreen is only as good as where you put it. Don't forget to apply it to the tips of the ears, backs of the knees, between the toes…and anywhere else the sun does indeed shine.

SIDE BAR:

The ABC's of safe sun:

A is for Away: stay away from the sun in the middle of the day, when rays are most damaging, even on cloudy days. In Houston, this means from 10 a.m. – 4 p.m.

B is for Block: Block the sun's rays by using a sunscreen with a minimum SPF of 30. Apply it 30 minutes before going out, and reapply often throughout the day.

C is for Cover up: use protective clothing such as long-sleeve shirts, hats, or clothing with a tight weave to keep out as much sunlight as possible. Use lip balm for your lips, and sunglasses for your eyes. Babies under six months of age should be kept out of direct sunlight.

Post #18 Swine (H1N1) Flu: Cautiously Optimistic

2009-05-01T14:32:00.000-07:00

When the first reports of the swine flu (now renamed the H1N1 flu) reached my desk at the end of last week, I was curious. . . however my weekend plans were about to swing into full gear. So other then a quick glance at the fax, pigs did not cross my mind again the entire weekend (BTW, to avoid misappropriated fear about pigs/pork being a potential source of the flu, the formerly known swine flu has been renamed. . . I use thoughts about pigs for literary purposes only).

By Tuesday (4/28/09) of this week, the media was on an information blitz, inundating the public and medical community with factoids, articles and history on past flu epidemics and the potential dangers of this new swine flu. I thought of pigs a bit more.

Generally, my friends and patients know that I am not an alarmist. When their children are sick, they turn to me to offer a voice of reason, and generally I am able to assuage their anxiety. However, being a mild connoisseur of flu history, I began to get a queasy feeling in my stomach as I read each additional article on the evolving potential swine flu pandemic. All the hallmarks were there for a possible incendiary public health threat. Any time my mind idled, it turned to thinking about pigs.

Dr. Sandro Galea, director of the Center for Global Health at the University of Michigan and a professor of Epidemiology at the University's School of Public Health, says that generally speaking, at the beginning of events such as the swine flu outbreak there is confusion, which quickly gives way to rational behavior.

And this makes sense. After all, it is often the lack of information and the fear of the unknown that drives many of us to initially overreact. With more information, we can make greater and greater rational decisions.

Early in this week, many of my patients asked my advice on the breaking swine flu. Other then a few tidbits of information from CDC.GOV I had little to offer. However, each passing day has brought forth crucial information which is being used to formulate public policy.

Over this weekend the CDC and WHO will gather more information on the virus itself, the pattern of the outbreak/spread and research the known cases/deaths. Already facts are coming in suggesting a milder threat than initially perceived. I believe by Monday they will have a much better feel of the scope and magnitude of this problem.

A few things that we already know about this virus:
1. This strain of H1N1 does not seem nearly as virulent as the deadly 1918 H1N1 flu strain.
2. As of the writing of this blog there has only been 1 known death in the U.S. and it was to a child who had underlying medical issues prior to contracting the flu. Additionally, this child came from Mexico via Brownsville to Houston, Texas for the purposes of receiving greater medical expertise/care.
3. The number of deaths in Mexico are unclear. As of the writing of this blog there were only 12 confirmed deaths, which contrasts to the >150 deaths speculated by certain media sources.
4. A possible theory as to why a greater number of deaths have occurred in Mexico is that there is a cultural tendency to seek medical care later in the course of illnesses. Which may mean that this virus is not as deadly for those who are appropriately treated. See NYT Article for more details.
5. Northwestern University researchers have a computer model they say is doing a good job predicting the spread of swine flu and it is predicting the entire United States will have between 1,600 and 2,000 cases one month from now.
6. This strain of flu is a mixture of pig, bird, and human flu (although some people believe all flu strains originated from birds at some point).
7. They expect a vaccine against this strain to be ready in 4-6 months in time for the winter flu season.

An often-used analogy during this outbreak has been preparing for a hurricane. Having resided in Houston since 1982, I have lived through many evacuations, news blitzes and the hurricanes themselves. Recently, in 2005, following the fallout of Hurricane Katrina, Hurricane Rita was set to strike the Gulf Coast. In an effort to protect its constituents, Houston was advised to evacuate. Many people did. What ensued was hours of gridlock leading to cars running out of gas with people languishing under the brutal Texas sun with no AC.

Ultimately, although Rita was the fourth-most intense Atlantic hurricane ever recorded, Houston as a whole remained safe during the storm. Our family chose to stay, and after hearing the stories of friends trapped on the highway, we were glad that we had avoided the gridlock.

On the flip side, had we lived and stayed in New Orleans during Hurricane Katrina or in Galveston during Hurricane Ike, my wife and I would have regretted our decision to not evacuate as the consequences would have been quite severe.

Whether this pandemic ends in a whimper or a bang has yet to be determined. The more we know, the more it seems a whimper is the more likely of the two. However, even if things do not end in a bang, we should be prepared to expect more cases and more deaths.

In fact, every winter the United States suffers approximately 36,000 deaths from the seasonal flu, albeit mostly in the elderly and ~100 deaths in young children. And thus, as with any seasonal flu outbreak, there will be expected deaths. However, this fact alone should not create fear.

The initial fear was that many of us have never encountered this new strain of flu either by actually catching it or by being vaccinated against it. Coupled with the fact that middle aged people were dying from the flu in Mexico, the media and public were led into a frenzy. However, as stated above, it seems the flu is milder than initially thought and that the original statistics out of Mexico may need to be revised.

If things do end in a whimper, one thing to be wary of is that the virus may mutate and come back with a vengeance this winter. This is not a certainty but a distinct possibility (as this is what happened to some extent with the 1918 outbreak).

Balancing the well being of the public is not for the faint of heart. It is often a damned if you do, damned if you don't position that I do not envy.

My point in writing about hurricanes is that like weather, pandemics (and epidemics) are difficult to predict and as such public guidance is a difficult task. Like medicine, public health is as much an art as it is a science, which involves the delicate juggling of statistics, public perception, fear, medical facts and politics (yes, unfortunately politics).

And as in medicine, when decisions are made, the potential benefits must be weighed with the potential risks as well as the potential costs to form a cost-beneficial plan that minimizes risk and maximizes the well-being of the public at large.

Unlike a hurricane threat, the great thing about a potential pandemic is that for the most part, conservative measures carry little risk or cost from an individual standpoint. Currently, the safest thing for a family to do is to stay put and avoid unnecessary interaction with others. At the very least avoiding large crowds - especially places where children spread a lot of germs - will decrease the risk of acquiring the H1N1 flu. Additionally, if your child is sick, there should be greater vigilance in keeping them at home.

Time.com, May 1, 2009
But when it comes to slowing the overall spread of a pandemic flu, the best thing we can do is keep sick people away from everyone else. It's called "social distancing," and studies of the deadly 1918 Spanish flu showed that cities that instituted distancing measures quickly suffered lower death tolls than cities that did nothing or reacted slowly.

Employing these measures, while somewhat constrictive socially, are easy to do and carry little risk or cost other than the potential for cabin fever!

Some mothers have asked me if they should keep their kids home from school. Until more is known (which may be as soon as this Monday - I would see how this unfolds over this weekend), for children in mother's day out programs and other elective-type school settings it might be a good idea. As for regular grade school, I believe that over the weekend the government will make that decision for us. They seem to be relatively conservative thus far in shutting school downs.

Other easy-to-employ protective measures include basic hygiene, which everyone should have a firm handle on by now.

An additional measure that may also be prudent will be to get the flu vaccine in the fall. Whether they add the swine flu H1N1 strain or not remains to be seen. One potential cost to receiving this vaccine is that during a different swine flu outbreak in 1976, a vaccine was mandated by the Ford administration. Within weeks, reports surfaced of people developing Guillain-Barré syndrome, a paralyzing nerve disease that can be caused by the vaccine. By April, more than 30 people had died of the condition, in contrast to the one soldier that actually died from the virus. Note: this is NOT an issue with the current flu vaccine.

Extensive testing will need to be done to prepare a vaccine which avoids the pitfalls of the 1976 vaccine. And like everything else in medicine, the risks of this particular flu virus will need to be weighed against the potential harms of the vaccine. Speaking personally, I will almost certainly be getting the vaccine for myself and my family like I do every fall.

Besides the measures detailed above, here are a few other smart pointers from Time.com:

1. Don't Rush to the ER
With the cable news networks reporting nonstop on swine flu, it feels like the disease is lurking everywhere, and that your slightest sniffle is a sign that you've contracted the virus. That would explain why people with no outward symptoms of illness are flooding emergency rooms in swine flu–affected states, afraid that they might be sick. That's a really bad idea.

First of all, having to examine people who aren't really sick only stresses the already strained resources of hospitals that are trying to prepare for a pandemic. Plus, going to an emergency room unnecessarily may even pose a slight risk to you. In past outbreaks, including SARS in 2003, hospitals were actually loci of infections — all those sick people in close proximity — and the same could be true of swine flu.

If you actually have flu-like symptoms — a fever above 100° F, headache, sore throat, body aches, chills or fatigue — and you live in an area where there have been confirmed swine flu cases, by all means report to your doctor. Otherwise, leave the hospital to the sick people.

2. Don't Be Afraid to Eat Pork
On April 29, the CDC announced that swine flu would no longer be referred to as swine flu, but as the "2009 H1N1 flu." It's less catchy, but more accurate. For one thing, there is no evidence that this virus makes pigs really sick. And the H1N1 virus actually contains genes from swine, avian and human flus. The virus also cannot be spread through pork products — you can't contract swine flu by eating bacon, hot dogs or anything else that was once a pig. Nor will culling pigs, as authorities did in Egypt, do anything to stem the spread of the disease. H1N1 has jumped to humans and is passing easily from person to person, so it's now a human flu that needs to be controlled in us, not the pigs.

3. Don't Hoard Antivirals
The H1N1 virus has so far proven vulnerable to the antiviral drugs Tamiflu and Relenza, which is good news. A cornerstone of the government's pandemic preparations was the stockpiling of 50 million doses of those drugs over the past few years, enough to ensure that doctors would be able to respond sufficiently to new outbreaks. But that capacity could be compromised if people begin stockpiling antivirals for their own use. Already there are reports of pharmacies running short of Tamiflu, and many hospitals in the U.S. have begun restricting the power to prescribe antivirals to just a few doctors. Also, the misuse or overuse of Tamiflu or Relenza by patients can promote resistance in the flu virus — effectively removing the only bullets from our gun.

Hopefully, after reading this (lengthy, I know!) blog you have a clearer understanding of the current H1N1 flu situation. However, please be advised that things may change rapidly in the very near future.

One final note: I have read a slightly alarmist email circulating that subtly recommends purchasing nutritional supplements from a Wimberley Pharmacy at the end of its message. I am not sure as to the validity of the facts in this email, but I am personally sticking to the guidance and facts put forth by the CDC and will not be purchasing any nutritional supplements to combat this flu virus.

Post #17 Autism Top Exec Quits Because She Doesn't Think Vaccines Cause Autism

2009-03-31T21:51:00.000-07:00

The media/publicity pendulum continues to swing the other way (in the correct direction!) with Allison Singer, the executive vice president of communications and awareness at Autism Speaks, conceding that vaccines are not linked to autism.

She advocates using public research money to further delineate the genetic role of autism in lieu of further studies searching for a link to vaccines - "Dozens of credible scientific studies have exonerated vaccines as a cause of autism," she wrote in a statement. "I believe we must devote limited funding to more promising avenues of autism research."

Mrs. Singer is not a scientist or a doctor. However, she is the mother of an autistic child and through the organization Autism Speaks, Mrs. Singer has had contact with some of the brightest minds and studies delving into this delicate issue.

It takes no small amount of courage for her to break stride with her former group by essentially exonerating any causal link between vaccines and autism. In short, the evidence must have overwhelmed her.

Newsweek Interview Below. . .

Newsweek Web Exclusive
January 16, 2009

The warfare over vaccines and autism is heating up yet again.

This week, Alison Singer, the executive vice president of communications and awareness at Autism Speaks, one of the nation's leading autism advocacy groups, announced her resignation, citing a difference of opinion over the organization's policy on vaccine research. "Dozens of credible scientific studies have exonerated vaccines as a cause of autism," she wrote in a statement. "I believe we must devote limited funding to more promising avenues of autism research."

Singer, who has an 11-year-old daughter with autism, joined the organization when it launched in 2005. Singer praised Autism Speaks and its founders, Bob and Suzanne Wright, but said she could no longer work for a group that supports spending limited resources on vaccine research.

Calling Singer's resignation "disappointing and sad," Bob Wright says more authoritative research needs to be conducted on the safety of vaccines given to children under 2. "We all know that autism has genetic causes, but it's highly associated with environmental factors we can't get our hands around," says Wright. "Vaccines fall into that category."

NEWSWEEK's Claudia Kalb spoke with Alison Singer about her resignation.

NEWSWEEK: Describe Autism Speaks.
Alison Singer: Autism Speaks is an amazing organization. It has really been a privilege for me to work there. Autism Speaks has raised so much awareness of autism and has supported literally thousands of families around the world. I could not be more proud of Autism Speaks and the work that we've done.

But you disagree with their vaccine position?
In general, I disagree with a policy that says, "Despite what this study shows, more studies should be done." At some point, you have to say, "This question has been asked and answered and it's time to move on." We need to be able to say, "Yes, we are now satisfied that the earth is round."

What do you believe the science shows?
There are more than a dozen studies that show no causal link between the MMR [measles-mumps-rubella] vaccine and autism, and thimerosal [a mercury-containing vaccine preservative] and autism. Over and over, the science has shown no causal link between vaccines and autism. My feeling is that if there was an unlimited pot of money at the NIH [National Institutes of Health] from which to fund autism science then it would be fine to say let's study it more. But we don't have that. We have very limited resources and every dollar we spend looking where we know the answer isn't is a dollar we don't have to spend where we might actually find new answers. In general, yes, more research is always better than less. But again, we have limited dollars to spend and we have to use our limited money wisely in ways that are likely to yield new information for families.

How confident are you in the studies that show no vaccine-autism link?
I've read the studies and I've talked to many doctors. One thing that has been a hugely wonderful part of being at Autism Speaks is that I've been able to consult with the top scientists in the field. We work with the top minds. I think that there's this feeling [among some parents] that the vaccine decision is a choice between, "Do I want to risk measles or do I want to risk autism?" That's not a good characterization. We know for a fact that the measles vaccine reduces the risk of getting measles. One choice is backed by science, one choice isn't.

Where would you like to see the research money go?
I think the genetics work has the potential to point us toward important answers. When we can determine which proteins are associated with various genes we can start to understand the mechanism of action that causes autism. Once you understand the mechanism of action, you can start to look for targeted therapies. I would also focus on prenatal exposures. What is a mom exposed to during pregnancy with regard to hormones or maybe medications or even pesticides? Or what's happening in the environment? During flu season, people are more prone to infections so we should look at the incidence of viral infections, flu, hormonal fluctuations and toxins in the environment for both mother and baby.

How is your daughter doing now?
Jodie has benefited tremendously from applied behavioral analysis therapy. She has learned to have some actual communicative speech. She's able to make her wants and needs known. That's really a breakthrough. For three years, she was in private school that focused intensively on language. She gained enough skills to be in a special class in a public middle school. She's not mainstreamed, but she's able to be in that large environment. So she's making great progress.

What do you think caused your daughter's autism?
Jodie had difficulties from the day she was born. She cried constantly, she had difficulty feeding, difficulty sleeping. She was diagnosed in the first few days as having "failure to thrive." I also have a brother diagnosed with autism. He's 44. My first cousin has a son diagnosed with autism. I strongly believe that there is a genetic component.

What do you say to the families who believe their child's autism was triggered by vaccines?
It's very hard because people feel very strongly and love their families so much. But not all opinions are created equal. Some are based on fact and science and some are not. Do you remember when Jenny McCarthy went on Oprah? She said she doesn't need science. Her science is at home and his name is Evan. That's not science.

Here's another story. A few weeks ago, Jodie went to the pediatrician. She had Tdap [tetanus-diptheria-pertussis] vaccine, a flu shot and a vaccine against meningitis. The next day her teacher remarked to me that Jodie was much more attentive and participated in class much more than usual. Her gym teacher said that for the fist time Jodie was able to compete in an obstacle course. Should I start pontificating that vaccines are a great treatment for autism? Of course not, that's not science. That's called coincidence.

Some families want more money spent on services for people with autism. Thoughts?
I think that's true. There's a growing number of people with autism and they're going to need services and supports. We really need to think about autism as a lifespan issue. We need to start planning now for our children's future.

What about federal health officials? Some scientists have critiqued them for not being outspoken enough about vaccine safety. Do you agree?
I think the media has to start to change. In our culture, we love celebrities. We need to listen to experts and not actresses. The media culture, feeling compelled to give both sides of an argument has lent a legitimacy to the anti-vaccine movement that is very over-weighted. They're a small number of people with very loud voices. The vast majority of parents of children with autism are very supportive of the importance of vaccines. I've had hundreds of emails in last 24 hours from parents supporting me. The media need to show both sides to make it look like both sides are equal. One side is backed by evidence, one side is not.

I think the government needs to be more vocal and I think scientists have to be more vocal. Scientists are an interesting group. They are very reluctant to speak to the media. There needs to be change in that culture. Scientists need to be more comfortable speaking out about the good science being done. I think when we see the scientists speaking out more, we will see a change.

In an interview in 2006, you said, "I am planning to stay at Autism Speaks until the day we find a cure." Now what?
Now I'll revise that to say I plan to stay in autism advocacy. I plan to take all the energy and passion that I committed to Autism Speaks and apply it elsewhere in the autism advocacy community. I'm certainly not going to be leaving. If anything, I hope to be more vocal.

Will you become more vocal on the vaccine issue specifically?
I think by talking to you today I already have.

Post #16 Malpractice: Wash Your Hands or Risk a Lawsuit

2009-03-25T19:11:00.000-07:00

I was cleaning out some of the interesting articles that I have collected over the past year and came across one of my favorites from the Wall Street Journal 2008 (posted below). The essential premise of the article is that certain nosocomial (hospital-acquired) infections can be 100% averted if proper hygiene regimens are followed - beginning with, of course, hand washing.

Certain facts in the article jump out at me:

1. Nearly all hospital infections are avoidable when doctors and staff clean their hands and rigorously practice proper hygiene and other preventive measures.

2. Since October of 2008 (according to the article) Medicare no longer reimburses hospitals for nosocomial infections following orthopedic or heart surgeries.

3. Beth Israel Medical Center in New York City hasn't had a central line (a large IV placed in a major blood vessel) bloodstream infection in the cardiac intensive care unit in nearly 3 years!

Bottom line: Infections can be avoided with good hygiene beginning with hand washing. This is important not just in the O.R. but in every aspect of healthcare.

A great additional read is an entire chapter dedicated to hand washing in Atul Gawande's book Better.

Wall Street Journal August 14, 2008
By BETSY MCCAUGHEY
On July 30, a jury awarded over $2.5 million to James Klotz and his wife Mary in a medical malpractice lawsuit against a heart surgeon, his group practice and St. Anthony's Medical Center in St. Louis, Mo. In 2004 Mr. Klotz, now 69, was rushed to the hospital with a heart attack and a pacemaker was surgically implanted. He developed a drug-resistant staph infection called methicillin-resistant Staphylococcus aureus (MRSA). It was so severe that he underwent 15 additional operations, spent 84 days in the hospital and lost his right leg, part of his left foot, a kidney and most of his hearing.

This verdict should send a warning to physicians, hospitals and hospital board members. Until recently, infection was considered an unavoidable risk. But now there is proof that nearly all hospital infections are avoidable when doctors and staff clean their hands and rigorously practice proper hygiene and other preventive measures.

Hospital infections will cause the next wave of class-action lawsuits, bigger than the litigation over asbestos. The germ that Mr. Klotz contracted, hospital-acquired MRSA, infects about 880,000 patients a year and accounts for only 8% of all hospital infections. Hospital infections caused by all kinds of bacteria sicken millions.

The Klotz verdict is not the first sign that hospitals are in a new legal environment. In 2004, Tenet Healthcare Corporation agreed to pay $31 million to settle 106 lawsuits by patients who contracted infections after heart surgery at Palm Beach Gardens Medical Center in Florida. Since then, numerous lawsuits have been filed against hospitals in Florida, Kentucky and elsewhere by infected patients. Hospitals being sued are saying that their infection rates are within national norms. But for most infections, the only acceptable rate is zero.

Medicare calls certain device-related bloodstream infections, urinary tract infections and surgical infections after orthopedic and heart surgery "never events." Starting in October, Medicare will stop reimbursing hospitals for treatment of these infections. Hospitals will be barred from billing patients for what Medicare doesn't pay, forcing them to take a loss. Next year Medicare will add other types of infections to the list of "never events."

The evidence justifying Medicare's new policy is compelling. Central line bloodstream infections, caused by the contamination of certain devices, are preventable. Hospital patients in intensive care are commonly medicated through a tube inserted into a vein. The risk is that bacteria will invade the tube and enter the bloodstream. Rigorous hygiene, including clean hands, sterile drapes, and careful cleaning of the insertion site with chlorhexidine soap, can keep bacteria away from the tube.

Beth Israel Medical Center in New York City reports that it hasn't had a central line bloodstream infection in the cardiac intensive care unit in over 1,000 days. Dr. Brian Koll, chief of infection control there, explains that the key is using a checklist that doctors and nurses must follow. Implementing the checklist cost $30,000 and saved $1.5 million in treatment costs. Lives saved: priceless.

Other hospitals -- from Johns Hopkins Medical Center in Baltimore to Sutter Roseville Medical Center in Sacramento -- have reached the goal of zero central line bloodstream infections. No wonder Medicare calls these infections "never events." Why should jurors reach a different conclusion in a lawsuit?

We have the knowledge to prevent infections. What has been lacking is the will. A recent survey from the patient-safety organization Leapfrog found that 87% of hospitals fail to consistently practice infection prevention measures. Insurance companies that sell liability coverage to hospitals could change that by offering lower premiums to hospitals that rigorously follow infection-prevention protocols.

To be sure, lawsuits are not the best way to improve patient care. Many verdicts are unjustified, and few truly injured patients find a lawyer to take their case. Still, the coming wave of lawsuits, as well as financial incentives from Medicare and insurers, will fight complacency about hospital hygiene.

Ms. McCaughey, a former lieutenant governor of New York State, is chairman of the Committee to Reduce Infection Deaths.

Post #15 An Allergy Update

2009-03-10T21:14:00.000-07:00

If you (or your loved one) suffer from allergies and you want some good evidence-based facts - keep reading. This particular blog entry is a bit tedious as I have tried to include a complete amount of information on allergies (their causes, the tests to diagnose, and treatment).

The article (published in August of 2008) posted below is essentially a doctor's CliffsNotes on allergies. It is a practice guideline reviewing a vast amount of articles and research on allergies; the actual article is 84 pages long with a bibliography of 998 articles. The task force has made the article user friendly by summarizing the essential 109 points that the group wanted to highlight.

You ask, "How essential can a list of 109 items be?"

Excellent question.

I have further pared down the article from 109 points to the 40 most essential "essential points" that the lay person would be interested in.

Each recommendation is listed with a letter demarcating the strength of evidence supporting the "essential point's" statement. For example an "A" indicates relatively strong evidence, with each lower letter grade representing lesser strength.

However, take careful notice that a weaker letter does not mean the statement is any less true; it simply denotes that currently, the body of evidence supporting the statement has not been fully flushed out in strong clinical studies (which may or may not happen in the future).

The take home points (with a sprinkling of my spin on things) are these:

1. Allergies are complex and can be confused with COLDS as they present very similarly. Treatment however is different. Colds cannot be treated (for the most part), allergies can be treated (more on this below).

2. Testing for allergies can be done by skin tests or blood tests. Generally, the skin tests are more sensitive and preferred.

3. Common sense: Avoid the things that make you allergic. A few allergen specific recommendations are listed below. For example, if you have a pollen allergy, track pollen counts and avoid the outdoors accordingly.

4. Intranasal corticosteroids (Flonase, Rhinocort, Nasonex) are the most effective medication class for controlling symptoms of allergic rhinitis.

5. Antihistamines (intranasal and oral) are also good to control symptoms. For the most part, second generation oral antihistamines (Claritin, Zyrtec, Allegra) are preferred over the first generation oral antihistamines (Benadryl) because they are less sedating.

6. Most allergy medication brands are interchangeable in terms of effectiveness, i.e. Claritin, Zyrtec, and Allegra are all equally effective.

7. In general, regardless of the cause of the allergy (whether it be pollen, dust mites, pets, etc.), the battery of medications used will be the same. Therapy only deviates when allergen immunotherapy (weekly allergy shots) are necessary. Thus, it is probably only necessary to visit the allergy specialist when medication therapy has been exhausted and the patient potentially requires either exact identification of the offending allergen (in order to better avoid the cause) and/or desires to initiate allergen immunotherapy.

8. For cases, uncontrolled by above said medications, it is probably time to see the allergist.

9. The key is to expect reasonable control of symptoms and not a cure and gear therapy towards achieving that goal.

The article's key points posted below. . .

The diagnosis and management of rhinitis: An updated practice parameter
Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, et al. J Allergy Clin Immunol. 2008 Aug:122(2).

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology.

Classification of recommendations and evidence

Category of evidence

Ia. Evidence from meta-analysis of randomized controlled trials
Ib. Evidence from at least 1 randomized controlled trial
IIa. Evidence from at least 1 controlled study without randomization
IIb. Evidence from at least 1 other type of quasi-experimental study
III. Evidence from nonexperimental descriptive studies, such as comparative studies
IV. Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both
LB Evidence from laboratory-based studies.
NR Not rated.

Strength of Recommendation

A Directly based on category I evidence
B Directly based on category II evidence or extrapolated recommendation from category I evidence
C Directly based on category III evidence or extrapolated recommendation from category I or II evidence
D Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence

ESSENTIAL POINTS

Burden and epidemiology of rhinitis
10. The influence of early childhood exposure to infections, animals, and secondary tobacco smoke on the development of atopy and allergic rhinitis is still unknown. C

ALLERGIC RHINITIS

Pathogenesis
13. The symptoms of allergic rhinitis result from a complex allergen-driven mucosal inflammation caused by interplay between resident and infiltrating inflammatory cells and a number of vasoactive and proinflammatory mediators, including cytokines. Sensory nerve activation, plasma leakage, and congestion of venous sinusoids also contribute. C

Associated allergic conjunctivitis
19. Intranasal corticosteroids, oral antihistamines, and intranasal antihistamines have similar effectiveness in relieving ocular eye symptoms associated with rhinitis. A

Infectious rhinitis
24. Viral infections account for as many as 98% of acute infectious rhinitis and the majority of rhinitis symptoms in the young child. Routine nasopharyngeal cultures when bacterial infections are suspected do not add diagnostic value. C

TESTING FOR SPECIFIC IgE ANTIBODY

Skin Testing
39. Skin tests are the preferred tests for the diagnosis of IgE-mediated sensitivity. The number of skin tests and the allergens selected for skin testing should be determined on the basis of the patient’s age, history, environment, and living situation, such as area of the country, occupation and activities. D

In vitro asaays for specific IgE
40. The precise sensitivity of specific IgE immunoassays compared with skin prick/puncture tests is approximately 70% to 75%. Immunoassays have similar sensitivity to skin tests in identifying those patients with nasal symptoms elicited after natural or controlled allergen challenge tests. C

41. Interpretation of specific IgE immunoassays may be confounded by variables such as potency of allergens bound to solid support systems, cross-reactive proteins and glycoepitopes, specific IgG antibodies in the test serum, and high total IgE. D

43. Nasal smears for eosinophils are not necessary for routine use in diagnosing allergic rhinitis when the diagnosis is clearly supported by the history, physical examination and specific IgE diagnostic studies but may be a useful adjunct when the diagnosis of allergic rhinitis is in question. C

46. The measurement of total IgE and IgG subclasses for the diagnosis of allergic rhinitis has limited value and should not be routinely performed. C

MANAGEMENT OF RHINITIS

Environmental control measures
52. The most common allergic triggers for rhinitis include pollens, fungi, dust mites, furry animals and insect emanations. B

53. The types of pollen responsible for rhinitis symptoms vary widely with locale, climate, and introduced plantings. B

54. Highly pollen-allergic individuals should limit exposure to the outdoors when high pollen counts are present. B

57. Clinically effective dust mite avoidance requires a combination of humidity control, dust mite covers for bedding, high efficiency particulate air (HEPA) vacuuming of carpeting and the use of acaricides. B

58. Avoidance is the most effective way to manage animal sensitivity. D

59. Cockroaches are significant cause of nasal allergy, particularly in inner-city populations. C

PHARMACOLOGICAL THERAPY

Oral antihistamines
63. There are important differences among the second-generation antihistamines in regard to their sedative properties: fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses; loratadine and desloratadine may cause sedation at doses exceeding the recommended dose; cetirizine and intranasal azelastine may cause sedation at recommended doses. A

64. Among the newer, nonsedating antihistamines, no single agent has been conclusively found to achieve superior overall response rates. C

Intranasal antihistamines
66. Intranasal antihistamines are efficacious and equal to or superior to oral second-generation antihistamines for treatment of seasonal allergic rhinitis. A

69. Intranasal antihistamines are generally less effective than intranasal corticosteroids for treatment of allergic rhinitis. A

Oral and topical decongestants
70. Oral decongestants, such as pseudoephedrine and phenylephrine, are α-adrenergic agonists that can reduce nasal congestion but can result in side effects such as insomnia, irritability and palpations. A

71. Oral and topical decongestants agents should be used with caution in older adults and young children, and in patients of any age who have history of cardiac arrhythmia, angina pectoris, cerebrovascular disease, hypertension, bladder neck obstruction, glaucoma, or hyperthyroidism. C

72. Topical decongestants can be considered for short-term and possibly for intermittent or episodic therapy of nasal congestion, but are inappropriate for regular daily use because of the risk for the development of rhinitis medicamentosa. C

Over-the-counter cough and cold medications for young children
73. The efficacy of cold and cough medications for symptomatic treatment of upper respiratory tract infections has not been established for children younger than 6 years. Because of the potential toxicity of these medications, the use of these over-the-counter (OTC) drugs generally should be avoided in all children below 6 years of age. A

Intranasal corticosteroids
74. Intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis. A

75. In most studies, intranasal corticosteroids have been shown to be more effective than the combined use of an antihistamine and leukotriene (LT) antagonist in the treatment of seasonal allergic rhinitis. A

76. Intranasal corticosteroids may provide significant relief of symptoms of seasonal allergic rhinitis when used not only on a regular basis but also on an as-needed basis. B

However, as-needed use may not be as effective as continuous use of intranasal corticosteroids. D

77. When comparing the available intranasal coriticosteroids, the overall clinical response does not appear to vary significantly between products irrespective of the differences in topical potency, lipid solubility and binding affinity. C

78. Intranasal corticosteroids may be useful in the treatment of some forms of nonallergic rhinitis. A

79. Intranasal corticosteroids when given in recommended doses are not generally associated with clinically significant systemic side effects. A

80. Although local side effects are typically minimal with the use of intranasal corticosteroids, nasal irritation and bleeding may occur. Nasal septal perforation is rarely reported. B

Oral corticosteroids
81. A short course (5-7 days) of oral corticosteroids may be appropriate for the treatment of very severe or intractable nasal symptoms or to treat significant nasal polyposis. However, single administration of parenteral coritcosteroids is discouraged and recurrent administration of parenteral coritcosteroids in contraindicated because of greater potential for long-term corticosteroid side effects. D

Oral anti-leukotriene agents
85. Oral anti-LT agents alone, or in combination with antihistamines, have proven to be useful in the treatment of allergic rhinitis. A

87. There is evidence that topical saline is beneficial in the treatment of the symptoms of chronic rhinorrhea and rhinosinusitis when used as a sole modality or for adjunctive treatment. A

Allergen immunotherapy
88. Allergen immunotherapy is effective for the treatment of allergic rhinitis. A

89. Allergen immunotherapy should be considered for patients with allergic rhinitis who have demonstrable evidence of specific IgE antibodies to clinically relevant allergens, and its use depends on the degree to which symptoms can be reduced by avoidance and medication, the amount and type of medication required to control symptoms, and the adverse effects of medications. A

90. Allergen immunotherapy may prevent the development of new allergen sensitizations and reduce the risk for the future development of asthma in patients with allergic rhinitis. B

SPECIAL CONSIDERATIONS

Pregnancy
100. A sufficient amount of human observational data has now been accumulated to demonstrate safety for second-generation as well as first-generation antihistamines. C

104. Intranasal corticosteroids may be used in the treatment of nasal symptoms during pregnancy because of their safety and efficacy profile. C

105. Immunotherapy for allergic rhinitis may be continued during pregnancy but without dose escalation. C

Consultation with an allergists/immunologist
109. Consultation with an allergist/immunologist should be considered for patients with rhinitis who have inadequately controlled symptoms, a reduced quality of life and/or ability to function, adverse reactions to medications, a desire to identify the allergens to which they are sensitized and to receive advice on environmental control, or comorbid conditions such as asthma and recurrent sinusitis, or when allergen immunotherapy is a consideration. C

Post #14 Why don't friends with kids have time?

2009-02-07T07:11:00.000-08:00

Sometimes (but not often) I forget how hard my wife works to raise our three children. In my biased opinion she is doing an incredible job. It's nice to read articles-like the one posted below-to remind me that being a mother, while being one of the most rewarding jobs in the world, is also one of the toughest.

By Carolyn Hax, Washington Post
Wednesday, May 23, 2007

Carolyn:

Best friend has child. Her: exhausted, busy, no time for self, no time for me, etc. Me (no kids): Wow. Sorry. What'd you do today? Her: Park, play group . . .

Okay. I've done Internet searches, I've talked to parents. I don't get it. What do stay-at-home moms do all day? Please no lists of library, grocery store, dry cleaners . . . I do all those things, too, and I don't do them EVERY DAY. I guess what I'm asking is: What is a typical day and why don't moms have time for a call or e-mail? I work and am away from home nine hours a day (plus a few late work events) and I manage to get it all done. I'm feeling like the kid is an excuse to relax and enjoy -- not a bad thing at all -- but if so, why won't my friend tell me the truth? Is this a peeing contest ("My life is so much harder than yours")? What's the deal? I've got friends with and without kids and all us child-free folks get the same story and have the same questions.

Tacoma, Wash.

Dear Tacoma:

Relax and enjoy. You're funny.

Or you're lying about having friends with kids.

Or you're taking them at their word that they actually have kids, because you haven't personally been in the same room with them.

Internet searches?

I keep wavering between giving you a straight answer and giving my forehead some keyboard. To claim you want to understand, while in the same breath implying that the only logical conclusions are that your mom-friends are either lying or competing with you, is disingenuous indeed.

So, since it's validation you seem to want, the real answer is what you get. In list form. When you have young kids, your typical day is: constant attention, from getting them out of bed, fed, clean, dressed; to keeping them out of harm's way; to answering their coos, cries, questions; to having two arms and carrying one kid, one set of car keys, and supplies for even the quickest trips, including the latest-to-be-declared-essential piece of molded plastic gear; to keeping them from unshelving books at the library; to enforcing rest times; to staying one step ahead of them lest they get too hungry, tired or bored, any one of which produces the kind of checkout-line screaming that gets the checkout line shaking its head.

It's needing 45 minutes to do what takes others 15.

It's constant vigilance, constant touch, constant use of your voice, constant relegation of your needs to the second tier.

It's constant scrutiny and second-guessing from family and friends, well-meaning and otherwise. It's resisting constant temptation to seek short-term relief at everyone's long-term expense.

It's doing all this while concurrently teaching virtually everything -- language, manners, safety, resourcefulness, discipline, curiosity, creativity. Empathy. Everything.

It's also a choice, yes. And a joy. But if you spent all day, every day, with this brand of joy, and then, when you got your first 10 minutes to yourself, wanted to be alone with your thoughts instead of calling a good friend, a good friend wouldn't judge you, complain about you to mutual friends, or marvel how much more productively she uses her time. Either make a sincere effort to understand or keep your snit to yourself.

Write to Tell Me About It, Style, 1150 15th St. NW, Washington, D.C. 20071, ortellme@washpost.com.

Post #13 A Conflict of Interest

2009-01-24T22:47:00.000-08:00

Recently, one of my Urology friends confided in me about his personal angst over a proposition he had received to invest in a radiation treatment center. The root of the angst was not financial; he was confident that at the very least he would not lose his initial investment. Rather, his internal conflict stemmed from a 4th century oath that all physician's swear to - the Hippocratic Oath.

In some urology oncological cases, radiation therapy is considered by some the standard of care (prostate particularly). However, it is not always the best option, as there are other modalities to care for tumors, such as chemotherapy, surgery, hormone therapy, radioactive seed implants and watchful waiting. As part of his routine practice, he utilizes radiation therapy for particular tumors; and currently aside from his initial diagnosis and management of the tumor, he does not financially benefit from any referrals he makes when he sends his patients for radiation.

His concern is simple and honest: Would he lean ever so slightly towards utilizing radiation therapy greater if his pocketbook were to gain from every new referral? This question was addressed in more depth in an article in a December 1, 2006 New York Times article titled, "Profit and Questions on Prostate Cancer Therapy."

It is a question that the U.S. government addressed in 1989. Stark law, actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.

However, since the law has been passed amendments have been made to work around the law provided certain conditions are met.* Critics of the law contend that while problems exist, they are not widespread. Further, these observers note that, in many cases, physician investors are responding to a demonstrated need which would otherwise not be met, particularly in a medically under served area.

Per the Dept. of Health & Human Services Website:
"Concern about the ethical risks inherent in physician self-referral dates back at least to a 1986 Institute of Medicine study. A 1989 HHS Inspector General study documented that physicians who owned or invested in independent clinical laboratories referred Medicare patients for 45 percent more laboratory services than did physicians who did not have such financial interests."

45 PERCENT MORE?!?

For those wanting to read which services are exactly governed by Stark law, I posted an additional excerpt from the website at the bottom of this blog.**

Obviously, in pediatrics, the potential financial gain from self-referrals is far less lucrative than those made in a surgical subspecialty. Nonetheless, even as I listened to my friend's story, I could empathize. As honorable as I'd like to think I am, if I stood to financially gain from ordering x-rays and lab work - especially if I had money already invested in a machine - I believe that I would probably order more tests to, at the very least, recoup the costs of the machine.

This is one reason my practice has resisted purchasing our own blood work machine and x-ray machine. (Prohibitive entry costs are another reason.) Certainly, it could improve turn around time on specific tests and possibly (but likely not) improve patient care. However, in my personal experience, I have seen medical doctors aggressively utilize x-rays and labwork far more then I thought clinically necessary when there was a "financial kickback" woven into the infrastructure of their practice - as the Institute of Medicine Study cited above exemplifies.

The cost is not limited to only finances either. If children are receiving x-rays that may not have been ordered otherwise, they are receiving unnecessary radiation in addition to the small risk of detecting incidental findings that may set off a battery of additional exams (and possibly more radiation) only to discover that everything is normal; slightly akin to opening up a small medical Pandora's box. Not to mention the pain and fear needles and claustrophobic exams induce in young children.

I 100% advocate the use of x-rays and labwork, and utilize both regularly in my own office-without any financial gain whatsoever. However, in my regular day to day flow, I resort to tests only when I am on the fence about a potentially important diagnosis that requires additional insight.

Luckily for me, I am paid mostly to think and counsel. I believe that surgeons have an inherent conflict of interest in their everyday occupation. The fact is they will (in general) make more money if they perform more surgical procedures.

Levitt and Dubner write in their book Freakonomics, "In a medical study, it turned out that obstetricians in areas with declining birth rates are much more likely to perform cesarean-section deliveries than obstetrician in growing areas-suggesting that, when business is tough, doctors try to ring up more expensive procedures."

Ultimately, my friend declined to partake in the radiation treatment venture; a decision he credited to his mores and faith. The truth is even the best of doctors can fall prey to the mighty dollar no matter how straight our moral compass. It is this author's opinion that the best solution to avoiding these conflicts of interest is to steer clear of them to begin with.

*From Wikipedia regarding self-referrals:
However the exceptions designed to allow necessary testing in physicians offices have been exploited to largely nullify the intent of the law. In particular, the in-office exception, which allows testing on equipment in the physicians office, has resulted in many physicians purchasing high-tech and expensive equipment such as CT scanners, MR scanners, and Nuclear Scanners for their own offices. Such purchases were not foreseen at the time that the laws were written.

The incentive for this practice is in large part the result of rapidly declining reimbursements for what has been termed “cognitive” physician care, i.e. the time spent talking to a patient and determining what course of diagnostic testing or treatment is best for that patient. Many clinical physicians feel that in order to have a financially viable practice, it is necessary to have income streams derived from patient testing.

The risk to the physician-owner of such a venture is minimal, since the physician-owner has it in his power to increase the volume of scans to any point necessary to insure profitability.

Defense of the practice of self referral is often rationalized and cloaked in a single word, "convenience". The self-referring physician claims that he or she performs the examination in the office strictly for the convenience of the patient. This is the primary explanation for self referral. However, the convenience argument does not justify unnecessary exams, increasing medical costs to society, or the absence of peer-reviewed quality imaging performed for the sake of profit. Often, the patient cannot be seen by the physician on the same day the study is performed, negating the argument.

**From the Dept. of Health & Human Services concerning tests covered under Stark law:
"Limits on self-referral were first enacted into law as part of the Omnibus Budget Reconciliation Act of 1989. The law took effect January 1, 1992. It bars referral of Medicare patients to clinical laboratories by physicians who have, or whose family members have, a financial interest in those laboratories. The Omnibus Reconciliation Act of 1993 expanded the scope of the ban on self-referral to 10 additional designated health services, including:

physical therapy;
occupational therapy;
radiology services;
radiation therapy services and supplies;
durable medical equipment and supplies;
parenteral and enteral nutrients, equipment and supplies;
orthotics, prosthetics, and prosthetic devices and supplies;
home health services;
outpatient prescription drugs; and
inpatient and outpatient hospital services."

Post #12 Videogames and Violence

2008-12-29T21:41:00.000-08:00

It seems like every time you turn around, the "latest and greatest" videogame console is coming at you.

It's not the consoles I caution parents against. It's the videogames that go with them.

With videogames, just as with television, studies show too much violent material increases the propensity for violence in children.

Games come with ratings to guide you on what's appropriate for your child, but the ratings are provided by the same industry that makes the games. It's basically self-policed, and not very objective. There's some conflict of interest.

Some experts believe the rating system is an advertising gimmick. Just as an R-rated movie might be alluring and tempting to kids, to where they might try to sneak in and see it, a videogame with a Mature rating seems edgy and mysterious to gamers.

The ratings are a start, but the best thing parents can do is take responsibility for the content they are introducing their children to.

Only about 10 percent of parents screen the games their kids play. Parents tend to be passive when it comes to this, because they don't realize the violence their kids are being exposed to.

Michael Rich MD, MPH, FAAP is a Harvard medical doctor often quoted in studies relating to videogames. His basic stance is that if there was poison in the water, or if the food supply was tainted, people would be up in arms in a second if it was hurting our kids.

But studies show there is a higher likelihood of videogame-playing leading to violence than there is smoking leading to cancer. He's asking, "why are parents so concerned about cigarettes when they are not concerned about what's going into their kids' minds?"

Dr. Rich continues, “The Center on Media and Child Health has catalogued 956 scientific articles that provide nearly unanimous evidence that exposure to media violence contributes to elevated fear and anxiety, sleep disturbances, desensitization to human suffering, and increases in aggressive thoughts and behaviors.” (Pediatrics Volume 119, Number 6, June 2007)

Avoid games that have a shooter or killing-type mentality; the games where you are the first-person shooter looking through the eyehole of a gun. The Columbine school killers were known to play these types of videogames for hours on end.

So is there anything good about videogames?

Yes.

Gaming introduces children to computer technology, practice following directions, problem solving and logic, fine motor skills, provides occasions for parents and children to play together; and they're entertaining and fun, which is the main reason kids like it.

I recommend parents look for games that encourage group play, or involve puzzle-solving.

But no matter how safe and great the game, you should still limit the amount of time your children are sitting in front of the console.

A general rule of thumb, as recommended by the American Academy of Pediatrics, is one to two hours of quality television or media time a day. That would include computers and videogames.

But the actual amount of time kids are exposed to media is far greater than that. According to an Oct. 31, 2008 study in the Journal of Pediatrics, kids average 13 hours a week of playing videogames. When it comes to boys, it's closer to 18 hours a week; and that’s not including extra television and internet time.

My concern in hearing this is that kids are not doing more productive things, like reading or being physically active. And the interactive sports games that come with the Wii console are a start, but nothing beats the actual sport.

Also, kids can develop a skewed sense of reality if immersing themselves too frequently in a fantasy world, and they are putting themselves in a secluded, isolated, individualistic environment instead of interacting in group settings with friends.

We live in a world where our children are more computer-savvy than parents. Video-gaming is at their fingertips, it's their generation, even more so than our days of Atari and Intellivision.

But we are the adults, these are our children, and it is our job to ensure their safety.

I urge you to sit down with them and watch the videogames they're playing. Better yet, play it with them. If you don't like it, get rid of it.

And remember, don't let ratings fool you.

SIDENOTE:
What are the ratings?

EC-Early Childhood: contains content that may be suitable for ages 3 and older

E-Everyone: Content that may be suitable for ages 6 and older; may contain minimal cartoon, fantasy or mild violence, or infrequent use of mild language

E10+: Content that may be suitable for ages 10 and older; may contain more cartoon, fantasy or mild violence, mild language and/or minimal suggestive themes

T-Teen: Content that may be suitable for ages 13 and older; may contain violence, suggestive themes, crude humor, minimal blood, simulated gambling and/or infrequent use of strong language

M-Mature: Content that may be suitable for persons ages 17 and older; may contain intense violence, blood and gore, sexual content and/or strong language

A-Adults Only: Content that should only be played by persons 18 and older; may include prolonged scenes of intense violence and/or graphic sexual content and nudity.

*Source: Entertainment Software Rating Board, www.esrb.org

Post #11 Darius Goes West (A Movie Review)

2008-10-17T20:50:00.000-07:00

So why review a movie on a pediatric blog?

A couple of months ago I received an email from a blog reader who was a participant in a movie project that ultimately produced a unique documentary titled Darius Goes West.

Their ultimate quest: raise awareness and money for Duchenne Muscular Dystrophy research.

For those unfamiliar with Duchenne Muscular Dystrophy (DMD), it is a heartbreaking disease that cripples otherwise healthy children by deteriorating their muscles, eventually leading to loss in ambulation, paralysis and death. The average life expectancy for a child afflicted with DMD varies from the early teen years to the mid-30s.

As a pediatric resident, I witnessed, up close and personal, several brave patients who battled doggedly against the recessive X-linked killer. Inevitably and unfortunately, the genetic defect always prevailed.

However, there is light at the end of the tunnel; promising new therapies including stem cell replacement, DNA repair techniques, new uses for old medications and completely new medications set an auspicious foundation for the future.

For Daruis Weems, the future may not be soon enough. But rather than succumbing to Muscular Dystropy, Darius has tackled the disease head-on, creating a documentary film to assist in the fight. The documentary begins in the summer of 2005, with then 15-year-old Darius setting off on a road trip across the United States with the ultimate goal of reaching Los Angeles in the hopes of having his wheelchair souped up on MTV's show "Pimp My Ride".

Eleven of his friends (one of whom emailed me about the cause) join him on this crusade, and what ensues is a remarkable story about courage, friendship and love of life, regardless of the cards life deals you. And while the storyline revolves around the quest to "pimp" Darius' ride, the real story that is ultimately revealed is that life is only as precious and fulfilling as you are willing to make it. And Darius lives life large.

It was neither the best movie nor even the best documentary that I've watched, but I thorougly enjoyed the film and its authenticity. And for certain, it is the best money I have ever spent in purchasing a movie (10 DVDs to be exact... I wanted to share). I cried, I laughed, and I especially enjoyed the rap numbers Darius performs throughout the documentary. The boy has skillz (I doubt I'll ever use that word in another blog again), and so too does the documentary, winner of over 25 separate film awards.

Ultimately, it is an excellent way to spend an evening. And even if you do not thoroughly enjoy the film, you can walk away knowing your money went to a good cause. One day in the not-so-distant future, Duchenne Muscular Dystrophy will meet its match. Until that day comes, Darius and his team will help lead the charge in his pimped-out wheelchair.

More information (and how to purchase the DVD) can be found at www.dariusgoeswest.com, but to simplify things I have inserted a snippet from the website.

The Million DVD fundraiser has begun! The goal of the DGW Foundation is to sell one million copies of Darius's Award winning film, in roughly one year. The "year" began Sept. 1st '08 and will end on Darius's birthday, Sept. 27th 09.

The best way you can help with our "One million DVD in one year" campaign is to purchase a DVD or a set of DARIUS GOES WEST DVDs. By set we mean multiple DVDs for a group of friends or family...for your entire church, synagogue, or Sunday school class...for everyone who works in your company...or for an entire classroom (or school) of students in middle or high school. Your generosity, at any level, will not only help spread awareness for Duchenne Muscular Dystrophy, but it will also help fund promising research intended to treat or cure this fatal disease.

Because we are a non-profit Foundation, any time you buy a DVD, or a set of DVDs, a portion of the purchase is a tax-deductible donation. The fair market value of each DARIUS GOES WEST DVD is $3. When you make a purchase (of $250 or more), we will send you an official thank-you letter that you can use for tax filing purposes.

Post #10 The Changing Landscape of Fever

2008-08-20T05:28:00.000-07:00

Fever today is not the same fever of 30 years ago.

What does this mean?

To begin with, one must understand that fever itself (for the most part) is not dangerous. Fever, defined as 100.4 degrees Farenheit or higher, is not a disease in and of itself; rather it is a symptom or a sign of an underlying disease. Viewing fever as a disease will lead to accepting common misconceptions and evoke unneccessary anxiety.

Several times a week in my office I see children with a fever reaching 104-105 degrees who recover without incident. Studies have indicated that fever itself is not worrisome until a child reaches 106 or higher. Fortunately, fever greater than 106 will usually occur only in a child with an underlying neurological deficit or, very rarely, an environmental heatstroke (e.g. being locked in a car inadvertently in the middle of a Houston summer).

When your child has a fever, his body is telling you that he is sick (or sometimes overheated by external causes). In the majority of cases, a fever indicates that your child has become infected with a germ. There are other causes of fever as well. For example, after your child has received immunizations, he may exhibit a non-worrisome fever for a day or two. In this case the body is reacting to either dead or weakened germs or germ fragments that have been purposefully introduced to create beneficial lasting immunity.

Most parental anxiety with fever revolves around the fear that there may be potential harm to the child as a result of the fever. Specifically, the parent is often worried about damage to the brain.

In truth, fever will rarely damage or hurt the child (as mentioned above), although the underlying germ causing the fever potentially could. Which is why as a pediatrician, I am seldom concerned about the fever itself; I am always far more concerned about the source of the fever. My job as a pediatrician, when presented with a febrile child, is to deduce the source of the fever and then to decide whether the source is of concern or not (and it most often is not).

If the fever is coming from a brain infection, pneumonia or kidney infection, I am very worried about the child because all of these infections are quite serious and potentially life-threatening if not treated properly. However, if the fever is coming from a cold virus or stomach virus (which is far more likely, statistically), I am not worried about the child because most of these infections resolve on their own with time and pose little to no threat to the well-being of a child.

Which brings me back to my opening statement: fever today is not the same fever of 30 years ago.

The reason is simple: vaccines. The current gamut of immunizations, while currently controversial (although the tide is finally shifting - thank goodness), are perhaps the greatest advancement of modern medicine in the past century. The vaccinations we currently administer confer protection against the deadly germs which our parents' generation grew up with. Germs which cause meningitis, diphtheria, tetanus, pneumonia, measles, whooping cough, epiglottitis . . . and the list goes on and on.

In present day, when a child who follows the recommended vaccine schedule presents to me with fever, there are many germs that I can automatically factor out while making my diagnosis. As a result of immunizations, I already know what a child CANNOT possibly have as the source of the fever. As a result, I can focus on a much more narrow list of the usual suspects as I begin my detective work.

Imagine playing the game Clue, knowing that Professor Plum, Colonel Mustard and Mrs. Peacock are already behind bars. It just makes the game that much easier (although not as easy as peeking in the envelope like my brother often did). Likewise, if I can evaluate a fever already knowing that measles, mumps and diptheria are out of the running, it makes my job a lot easier. Which is why as a pediatrician I have a leg up on my father, who had to do the same job without the benefits of many of the newer vaccines.

Of course, as antibiotic resistance is on the rise, the landscape of our usual suspects is beginning to change once again, hence the vital need for judicious use of antibiotics (but that is a topic for a separate blog). Nonetheless, fever today represents a far more limited field of possible dangerous causes than the fever of 30 years ago. That is why I sympathize when a grandmother is still apprehensive of her grandchild's fever. She lived through the years of measles, mumps and diphtheria. Many of them remember what a fever could represent in their days and understandably harbor anxiety about their grandchild's temperature.

But as a new generation grows up with a legion of vaccinated and protected children (for the most part), there will hopefully be a societal shift in the right direction concerning the fear of fever.

Let me conclude by noting that fever can still and sometimes does represent meningitis, pneumonia or a dangerous infection. As far as vaccines have advanced, there is still more work to be done. So when a child with a fever is acting sick (i.e. not playing, not eating, appears ill, doesn't smile, lacks energy) he or she must be evaluated by a doctor.

However, over time, with the proper communciation between a well-informed pediatrician and an attentive mother, a parent can begin to grasp when to be worried and when not to be worried. This maternal instinct can be honed over time if a mom is equipped with the right information and the proper guidance from her pediatrician.

I am proud to say that in my practice I now have many veteran mothers who don't come in for every fever (although they initially may have), but only when there is an accompanying noticeable change in the activity level of her child. I could write oodles of blogs to delineate this skill, but there is a level of understanding that can only come from repeated communication and hands-on experience.

The end result is a family that has a far lower level of anxiety about fever and a far higher understanding of what fever truly is and represents. It is a benefit to the parent and to the pediatrician alike. It saves the mom unneccesary trips to my office, copay money and frustration while it frees up my appointment slots for the kids who truly need to be seen.

There are many aspects of fever I did not cover in this blog, but hopefully this can serve as a primer in building a firmer knowledge base for the anxious parent who wants to learn more!

Post #9 "Dry Drowning": How Worried Should You Really Be?

2008-07-04T22:56:00.000-07:00

On June 1, 2008 10-year old Johnny Jackson got water in his lungs while swimming in the pool. He walked home, took a bath, and went to bed; he died in his sleep during a nap an hour later. The county coroner reported water in the boy's lungs.

On June 5, 2008 todayshow.com reported the following:

"According to the Centers for Disease Control, some 3,600 people drowned in 2005, the most recent year for which there are statistics. Some 10 to 15 percent of those deaths was classified as “dry drowning,” which can occur up to 24 hours after a small amount of water gets into the lungs. In children, that can happen during a bath."

While the 3,600 number is fairly accurate (3,582 to be exact), the 10-15% statistic is erroneous and the CDC enterprise communication officer Sandy Bonzo has since issued a statement as such. There are no statistics on the percentage of "dry drownings."

Soon after Johnny's unfortunate drowning, there was a full-on media blitz with the Today Show spearheading the charge. The media did what the media does best: it struck the "Moms you had better take note for your chid's sake or else suffer the consequences" nerve. What followed was a slew of stories on multiple websites, newspapers and local news channels on "dry drowning". . . the story at 10 and you had better not miss it if you care about your child. . .

Although the phrase "dry drowning" is an ideal term for a newscaster hoping to invoke fear in the heart of the average mother, it is a somewhat misleading phrase. In fact, there are so many different phrases used to describe drowning (such as wet drowning, dry drowning, near drowning, secondary drowning, passive drowning) that it leads to ambiguity in what physiologically has actually occurred in each individual case. In an attempt to simplify matters, the 2002 World Congress on Drowning held in Amsterdam defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.

So what do people mean by "dry drowning" then?

It's hard to pinpoint exactly as there is no set definition, but it seems to be any situation where a person cannot breathe and water does NOT enter the lungs. In this sense "dry drowning" could conceivably apply to laryngospasms (spasms of your windpipe) and such external causes such as a lung puncture or a heavier-than-air gas filling the lungs. Even in an underwater drowning, it is conceivable that a person could suffer laryngospasms and die from oxygen deprivation without water entering the lungs, and hence be classified as a dry drowning when in fact the person was fully submerged underwater. You can see how there is ambiguity and confusion in using these terms, which is why the 2002 Congress uses one universal definition.

So exactly what happened in Johnny's case then?

Most likely Johnny did swallow some water while he played in the pool and some of the water made it into his lungs (which then technically is not a "dry drowning" even though the death occured out-of-water). This water then led to a loss of pulmonary function after the "loss or inactivation of surfactant" of the alveoli in the lungs. Surfactant is an amphiphilic compound which reduces the surface tension of your lungs allowing you to breathe. Basically, it helps your lungs to expand easily allowing oxygen to enter. The water that made it into Johnny's lung disrupted the ability of his natural surfactant and therefore as he napped, he was unable to breathe properly leading to his unfortunate demise.

This type of situation is uncommon, although there are no exact statistics on it. And although it is scary to every mother whose child goes swimming during the summertime and then on occasion takes a nap (which is every mother), things must be put into perspective.

First, most drownings do not occur this insidiously. Rather, the majority of drownings happen where it is clear that the child has been submerged under water. In this sense, things can be done to avoid the obvious drowning: close supervision, fences/covers/alarms around unused pools, CPR training, etc.

Second, even in a case such as Johnny's, there will be some warning signs: accidental ingestion of water, forceful coughing >1 minute right after coming out of the water, difficulty breathing, extreme fatigue and changes in behavior. And while any one of these symptoms by itself may be normal, if your child clearly is having an excessive amount of coughing and difficulty breathing right after swimming, it would be obvious to the observant mother. I never underestimate maternal instinct.

Finally, there is more risk in driving your child to the local movie theater than there is in monitored water play. And I know you've seen either Kung Fu Panda or WALL*E!

The bottom line is that like many other risks that the media has over-hyped, "dry drowning" is a real risk but a very unlikely one if you follow safe water practices. One good thing about this media blitz has been an increased awareness about general water safety, which only benefits summer activities. In this sense, hopefully Johnny's life will serve as a beacon to every mother and child swimming this summer.

Post#8 A Car Seat Conundrum

2008-06-11T13:44:00.000-07:00

Henary B, Sherwood C, Crandall J, et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007;13(6): 398-402

A 2007 study on injury prevention, cited above, shows that children ages 1-2 years of age who were placed in a forward-facing car seat had a 5.32 times greater risk for serious injury as opposed to children in a rear-facing car seat. Five times the risk. WOW.

It is common practice to keep children rear-facing until 1 year of age AND 20 lbs. However, after children turn 1, most moms can't wait to turn the car seat forward. The change in position allows greater visibility of the child, more interaction with the child (perhaps a negative in terms of accident prevention), easier access to the child (again maybe not so good for accidents), and a perception that the child will now be happier with the new and improved view of the mother and the world through the front windshield. I certainly thought our first child cried less after we turned her forward.

But this new finding indicates that the child will be safer facing the world through the rear window, as children in Sweden do until 4 years of age. In fact, the study found that for children under 12 months, the safety factor of a rear-facing car seat was only 1.79 times higher than a forward-facing car seat. Meaning, from a statistical standpoint, it is even more important to keep them rear-facing from 1-2 years of age then it is before they turn 12 months.

This data poses a conundrum: At what point does the comfort and well-being of the child/family trump a statistical safety factor?

There is no question in my mind that my first child hated her car seat for the first 12 months of her life. No, hated is too weak of a word. Loathed. My wife and I counted the days until we could turn her forward, and in fact we cheated by graduating her a few weeks shy of her first birthday. Life in our car became significantly more serene once we made the change, and driving no longer raised our blood pressure.

And though the above study clearly demonstrates we took a risk in making the switch, I could argue a significant counterpoint. I believe the harrowing cries produced by my daughter while driving posed a risk in and of themselves. The amount of anxiety that her crying generated was a driving distraction which could have (but never did) led to an accident.

Did her crying offset the potential 5X increase in risk we took by turning her forward? I'm not sure and never will be. Would I change what we did with her based on this new data? Perhaps, but probably not.

However, I do plan to keep my third child (and would have with my second child) rear-facing for as long as he (and my wife) will tolerate. Seems the boys (child #2 and #3) are more content facing the world from the rear. (I'm not sure if there are any implications here about their future!)

And like many pieces of advice available to mothers out there, each must be weighed and individually determined for each family. Not only that, depending on the demeanor of the child in his/her car seat, an individual family may use different timelines to make the switch forward for each of their children.

One thing is clear: I do believe that this information is pertinent, and pediatricians need to make it available to their patient population so that each family can make an informed decision as to what is best and ultimately safest for them.

Post #7 The Vaccine Controversy

2008-05-25T22:55:00.000-07:00

An excellent article covering the controversy over vaccines and autism. I have 3 children and they are all following the A.C.I.P. immunization schedule. They are all healthy and doing well. . . slightly mischievous, but healthy!

VACCINES & AUTISM: Myths and Misconceptions
The Anti-Vaccination Movement
Despite the growing scientific consensus that vaccines are safe and that neither vaccines nor mercury cause autism, a stubborn vocal minority claims otherwise, threatening the effectiveness of this public health program.

STEVEN NOVELLA

Steven Novella, MD, is an assistant professor of neurology at Yale University School of Medicine. He is the host of The Skeptics’ Guide to the Universe, a weekly science podcast (www.theskepticsguide.org), author of the NeuroLogica blog (www.theness.com/ NeuroLogicaBlog), and president of the New England Skeptical Society www.theness.com).

--------------------------------------------------------------------------------

Michelle Cedillo has autism, which her parents believe is the result of her childhood vaccines. In June 2007 they had the opportunity, along with eight other families, to make their case to the Autism Omnibus—a U.S. Court of Federal Claims that was presided over by three “special masters” appointed for the purpose. These nine cases are the first test cases that will likely determine the fate of 4,800 other claims made over the past eight years for compensation for injuries allegedly due to childhood vaccines.

Vaccines are one of the most successful programs in modern health care, reducing, and in some cases even eliminating, serious infectious diseases. Public support for the vaccination program remains strong, especially in the United States where vaccination rates are currently at an all-time high of >95 percent (CDC 2004). Yet, despite a long history of safety and effectiveness, vaccines have always had their critics: some parents and a tiny fringe of doctors question whether vaccinating children is worth what they perceive as the risks. In recent years, the anti-vaccination movement, largely based on poor science and fear-mongering, has become more vocal and even hostile (Hughes 2007).

Of course, vaccines are not without risk (no medical intervention is), although the benefits far outweigh those risks. Because vaccines are somewhat compulsory in the United States—although opting out is increasingly easy—a National Vaccine Injury Compensation Program was established to streamline the process for compensation for those who are injured due to vaccines (USDOJ 2007). It is this program to which the Cedillo and 4,800 other families are applying for compensation.

In the last decade, the anti-vaccine movement, which includes those who blame the MMR (mumps-measles-rubella) vaccine for autism, has largely merged with those who warn that mercury toxicity is the cause of many of the ills that plague mankind. The two groups have come together over the issue of thimerosal, a mercury-based preservative in some vaccines. They believe that it was the use of thimerosal in childhood vaccines that led to the apparent autism epidemic beginning in the 1990s.

Autism is a complex neurological disorder that typically manifests in the first few years of life and primarily involves a deficiency of typical social skills and behavior. In the 1990’s, the number of autism diagnoses significantly increased, from between one and three to about fifteen cases per ten thousand, although the true incidence is probably between thirty and sixty per ten thousand (Rutter 2005). During this same period, the number of vaccines given in the routine childhood schedule also increased. This led some to assume, or at least speculate, causation from correlation—perhaps the vaccines or something in them created this “epidemic” of autism.

We can now say, from multiple independent lines of evidence, that vaccines do not cause autism. For one thing, the autism “epidemic” probably does not represent a true increase in the disorder, but rather an artifact of expanding the diagnosis (now referred to as autism spectrum disorder, ASD) and increased surveillance (Taylor 2006).

In 1998, researcher Andrew Wakefield and some of his colleagues published a study in the prestigious English medical journal Lancet that claimed to show a connection between the MMR vaccine and autism (Wakefield 1998). Wakefield’s theory was that the MMR vaccine, which contains a live virus, can cause in susceptible children a chronic measles infection. This in turn leads to gastrointestinal disturbances, including what he calls a “leaky gut” syndrome, which then allows for certain toxins and chemicals, like those from bread and dairy that are normally broken down by the gut, to enter the bloodstream where they can access and damage the developing brain.

Although the study was small and the evidence was considered preliminary, this article sparked a firestorm. As a result of the study and the media coverage that followed (and continues to this day), MMR compliance in Great Britain plummeted, resulting in a surge of preventable disease (Friederichs 2006).

Subsequent to the seminal article in the Lancet, many follow-up studies were performed testing the autism-MMR vaccine correlation. As the follow-up studies began to be published, however, it became increasingly clear that there was no link between MMR and autism. For example, a study in the British Medical Journal found that autism rates continued to climb in areas where MMR vaccination rates were not increasing (Taylor 1999). Another study found no association with MMR and autism or GI (gastrointestinal) disorders (Taylor 2002). Other studies showed no difference in the diagnosis rate of autism either before or after the MMR vaccine was administered (Honda 2005), or between vaccinated and unvaccinated children (Madsen 2002). Most recently, a study found that there was no decrease in autism rates following removal of the MMR vaccine in Japan (Honda 2005).

In 2001, the Institute of Medicine (IOM) reviewed all of the MMR-autism data available to date and concluded that there was no association and essentially closed the case (IOM 2001)—a conclusion confirmed by still later studies, such as the Honda study in Japan cited above.

If Wakefield had simply been wrong in his preliminary findings, he would be innocent of any wrongdoing—scientists are not faulted if their early findings are not later vindicated. However, in May 2004, ten of Wakefield’s co-authors on his original paper withdrew their support for its conclusions. The editors of Lancet also announced that they withdrew their endorsement of the paper and cited as part of the reason an undisclosed potential conflict of interest for Wakefield, namely that at the time of its publication he was conducting research for a group of parents of autistic children seeking to sue for damages from MMR vaccine producers (Lancet 2004).

It gets worse. Investigative reporter Brian Deer has uncovered greater depths to Wakefield’s apparent malfeasance. Wakefield had applied for patents for an MMR vaccine substitute and treatments for his alleged MMR vaccine-induced gut disorder (Deer 2007). So, not only was he allegedly paid by lawyers to cast doubt on the MMR vaccine, but he stood to personally gain from the outcome of his research.

Andrew Wakefield. (Credit: Tom Miller) [Photo via Newscom]

Further, during the Cedillo case testimony, Stephen Bustin, a world expert in the polymerase chain reaction (PCR), testified that the lab Wakefield used to obtain the results for his original paper was contaminated with measles virus RNA. It was therefore likely, Bustin implied, that the PCR used by Wakefield was detecting this contamination and not evidence for measles infection in the guts of children with autism who had been vaccinated, as Wakefield claimed. And finally, Nicholas Chadwick testified that the measles RNA Wakefield found matched the laboratory contamination and did not match either any naturally occurring strain or the strain used in the MMR vaccine—a fact of which he had informed Wakefield (USCFC 2007).

All of this, plus other allegations still coming out, has caused Britain’s General Medical Council to call Wakefield before its “Fitness to Practise” panel for review of his alleged professional misconduct (GMC 2007).

Believers in the MMR-autism hypothesis dismiss the findings of the larger and more powerful epidemiological studies that contradict a link. Instead, they have turned Andrew Wakefield into a martyr, dismissing the evidence of his wrongdoing as a conspiracy against him designed to hide the true cause of autism from the public. Wakefield is unrepentant and maintains his innocence (Gorski 2007).

With the MMR-autism hypothesis scientifically dead, attention soon shifted to thimerosal, a mercury-based preservative found in some childhood vaccines (although not the MMR vaccine). There is little doubt, and no controversy, that mercury, the major component of thimerosal, is a powerful neurotoxin, or poison to the brain. However, toxicity is always a matter of dose. Everything becomes toxic in a high enough dose; even too much water or vitamin C can kill you. So the real question is whether the amount of mercury given to children in vaccines containing thimerosal was enough to cause neurological damage.

Author of the book Evidence of Harm: Mercury in Vaccines and the Autism Epidemic David Kirby (center) speaks as president Harvey Fineberg (left) of the Institute of Medicine listens during an interview by moderator Tim Russert (right) on NBC’s Meet the Press August 7, 2005, at the NBC studios in Washington, D.C. Fineberg and Kirby talked about the rising number of autism diagnoses among children and the controversial charges of a government conspiracy to allow mercury exposures from childhood vaccines to more than double between 1988 and 1992. The Institute of Medicine reviewed all MMR-autism data and concluded that there was no association. (Photo by Alex Wong/Getty Images for Meet the Press) [Photo via Newscom]

Proponents of the mercury hypothesis argue that the ethylmercury found in thimerosal was given in doses exceeding Environmental Protection Agency limits. This load of mercury should be considered with prenatal vaccine loads possibly given to mothers, and to other environmental sources of mercury, such as seafood. Furthermore, underweight or premature infants received a higher dose by weight than larger children. Some children, they argue, may have a specific inability to metabolize mercury, and perhaps these are the children who become autistic.

Fear over thimerosal and autism was given a huge boost by journalist David Kirby with his book Evidence of Harm (Kirby 2005). Kirby tells the clichéd tale of courageous families searching for help for their sick children and facing a blind medical establishment and a federal government rife with corruption from corporate dollars. Kirby echoes the core claim that as the childhood vaccine schedule increased in the 1990s, leading to an increased cumulative dose of thimerosal, autism diagnoses skyrocketed.

In the end, Evidence of Harm is an example of terrible reporting that grossly misrepresents the science and the relevant institutions. As bad as Kirby’s position was in 2005, in the last two years the evidence has been piling up that thimerosal does not cause autism. Rather than adjusting his claims to the evidence, Kirby has held fast to his claims, which has made him a hero alongside Wakefield of the mercury-autism-connection crowd as he has squandered his credibility.

There have now been a number of epidemiological and ecological studies that have all shown no correlation between thimerosal and autism (Parker 2004 and Doja 2006). I have already mentioned that the current consensus holds that there is no real autism epidemic, just an artifact of how the diagnosis is made. If there’s no epidemic, there’s no reason to look for a correlation between thimerosal and autism. This has been backed up by The Institute of Medicine, which has also reviewed all the available evidence (both epidemiological and toxicological) and concluded that the evidence does not support the conclusion that thimerosal causes autism (IOM 2004).

Especially damning for the thimerosal hypothesis are the recent studies that clearly demonstrate that early detection of autism is possible long before the diagnosis is officially made. Part of the belief that vaccines may cause autism is driven by the anecdotal observation by many parents that their children were normal until after they were vaccinated—autism is typically diagnosed around age two or three. However, more careful observations indicate that signs of autism are present much earlier, even before twelve months of age, before exposure to thimerosal (Mitchell 2006). In fact, autism expert Eric Fombonne testified in the Autism Omnibus hearings that Michelle Cedillo displayed early signs of autism clearly visibly on family video taken prior to her receiving the MMR vaccine (USCFC 2007).

Meanwhile, evidence is accumulating that autism is largely a genetic disorder (Szatmari 2007). This by itself does not rule out an environmental factor, but it is telling that genetic research in autism has proven so fruitful.

Mercury alarmists, in the face of this negative evidence, have been looking for rationalizations. Some have argued that the thimerosal in prenatal vaccines may be to blame, but recent evidence has shown a negative correlation there as well (Miles 2007).

What we have are the makings of a solid scientific consensus. Multiple independent lines of evidence all point in the same direction: vaccines in general, and thimerosal in particular, do not cause autism, which rather likely has its roots in genetics. Furthermore, true autism rates are probably static and not rising.

A demonstrator carries a sign protesting the use of mercury in vaccines past the U.S. Capitol in Washington July 20, 2005. Some three hundred people marched demanding that mercury not be used in vaccines anymore amid concern that it is the cause of autism and other neurological diseases in children. However, numerous studies show no correlation between Thimerosol and autism. (Nicholas Kamm/AFP/Getty Images) [Photo via Newscom]

The only researchers who are publishing data that contradicts this consensus are the father-and-son team of Mark and David Geier. They have looked at the same data and concluded that thimerosal does correlate with autism. However, the hammer of peer-review has come down on their methods and declared them fatally flawed, thus rendering their conclusions invalid or uninterpretable (Parker 2004). Also, like Wakefield, their reputations are far from clean. They have made something of a career out of testifying for lawyers and families claiming that vaccines caused their child’s autism, even though the Geiers’ testimony is often excluded on the basis that they lack the proper expertise (Goldacre 2007). The Geiers were not even called as experts in the Autism Omnibus hearings.

The Geiers are now undertaking an ethically suspect study in which they are administering chelation therapy to children with autism in conjunction with powerful hormonal therapy allegedly designed to reduce testosterone levels. Chelation therapy removes mercury, and so it is dependent upon the mercury hypothesis, which is all but disproved. Moreover, there is no clinical evidence for the efficacy of chelation therapy. The treatment is far from benign and is even associated with occasional deaths (Brown 2006).

With the scientific evidence so solidly against the mercury hypothesis of autism, proponents maintain their belief largely through the generous application of conspiracy thinking. The conspiracy claim has been made the loudest by Robert F. Kennedy Jr. in two conspiracy-mongering articles: Deadly Immunity published on Salon.com in 2005 (Kennedy 2005), and more recently Attack on Mothers (Kennedy 2007). In these articles, RFK Jr. completely misrepresents and selectively quotes the scientific evidence, dismisses inconvenient evidence as fraudulent, accuses the government, doctors, and the pharmaceutical industry of conspiring to neurologically damage America’s children, and accuses scientists who are skeptical of the mercury claims of attacking the mothers of children with autism.

Despite the lack of evidence for any safety concern, the FDA decided to remove all thimerosal from childhood vaccines, and by 2002 no new childhood vaccines with thimerosal were being sold in the U.S. This was not an admission of prior error, as some mercury proponents claimed; instead, the FDA was playing it safe by minimizing human exposure to mercury wherever possible. The move was also likely calculated to maintain public confidence in vaccines.

This created the opportunity to have the ultimate test of the thimerosal autism hypothesis. If rising thimerosal doses in the 1990s led to increasing rates of autism diagnosis, then the removal of thimerosal should be followed within a few years by a similar drop in new autism diagnoses. If, on the other hand, thimerosal did not cause autism, then the incidence of new diagnoses should continue to increase and eventually level off at or near the true rate of incidence. In 2005, I personally interviewed David Kirby on the topic, and we both agreed that this would be a fair test of our respective positions. Also, in an e-mail to science blogger Citizen Cain, Kirby wrote, “If the total number of 3-5 year olds in the California DDS [Department of Developmental Services] system has not declined by 2007, that would deal a severe blow to the autism-thimerosal hypothesis” (Cain 2005).

Well, five years after the removal of thimerosal, autism diagnosis rates have continued to increase (IDIC 2007). That is the final nail in the coffin in the thimerosal-vaccine-autism hypothesis. The believers, however, are in full rationalization mode. David Kirby and others have charged that although no new vaccines with thimerosal were sold after 2001, there was no recall, so pediatricians may have had a stockpile of thimerosal-laden vaccines—even though a published inspection of 447 pediatric clinics and offices found only 1.9 percent of relevant vaccines still had thimerosal by February 2002, a tiny fraction that was either exchanged, used, or expired soon after (CDCP/ACIP 2002).

Those who argue for the link have put forth increasingly desperate notions. Kirby has argued that mercury from cremations was increasing environmental mercury toxicity and offsetting the decrease in mercury from thimerosal. The Geiers simply reinterpreted the data using bad statistics to create the illusion of a downward trend where none exists (Geier 2006). Robert Kennedy Jr. dodges the issue altogether by asking for more studies, despite the fact that the evidence he asks for already exists. He just doesn’t like the answer. Kennedy and others also point to dubious evidence, such as the myth that the Amish do not vaccinate and do not get autism. Both of these claims are not true, and the data RFK Jr. refers to is nothing more than a very unscientific phone survey (Leitch 2007).

The Autism Omnibus hearings have concluded, and while we await the decision due early next year, I am optimistic that science and reason will win the day. Just as shown in the 2005 Dover trial of intelligent design where the full body of scientific evidence was given a thorough airing in court and subjected to rules of evidence and the critical eyes of experienced judges, science tends to win out over nonsense. By all accounts, the lawyers for those claiming that vaccines caused their children’s autism put on pathetic performances with transparently shoddy science, while the other side marshaled genuine experts and put forth an impressive case.

But the stakes are high, and not just for the 4,800 families. If the petitioners win these test cases despite the evidence, it will open the floodgates for the rest of the 4,800 petitioners. This will likely bankrupt the Vaccine Injury Compensation Program and will also risk our vaccine infrastructure. Pharmaceutical companies will be reluctant to subject themselves to the liability of selling vaccines if even the truth cannot protect them from lawsuits.

Thimerosal still exists as a necessary preservative in multi-shot vaccines outside the United States, especially in poor third-world countries that cannot afford stockpiles of single-shot vaccines. Anti-thimerosal hysteria therefore also threatens the health of children in poor countries.

And of course a victory for the anti-vaccination activists would undermine public confidence in what is arguably the single most effective public health measure devised by modern science. This decrease in confidence will lead, as it has before, to declining compliance and an increase in infectious disease.

The forces of irrationality are arrayed on this issue. There are conspiracy theorists, well-meaning but misguided citizen groups who are becoming increasingly desperate and hostile, irresponsible journalists, and ethically compromised or incompetent scientists. The science itself is complex, making it difficult for the average person to sift through all the misdirection and misinformation. Standing against all this is simple respect for scientific integrity and the dedication to follow the evidence wherever it leads.

Right now the evidence leads to the firm conclusion that vaccines do not cause autism. Yet, if history is any guide, the myth that they do cause autism will likely endure even in the face of increasing contradictory evidence.

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Post#6 Does Infant/Mother Nutrition Affect Allergy-Related Problems?

2008-03-02T14:12:00.000-08:00

Sorry for the long delay between entries. Our family has recently been blessed with baby #3! My wife and I are now the proud parents of Ellie, Matthew, and now Michael Jung.

For years I have been telling my mothers that there is weak evidence available to support the implementation of restrictive diets (either for the breastfeeding mother or the baby) in hopes of preventing allergy-related problems in their newborn.

Recently, the American Academy of Pediatrics came out with a comprehensive statement further validating this advice. I felt this information was so refreshing and liberating - much like the recent recall on cough/cold medications - that I wanted to pass this on to the readers of this blog! Breastfeeding moms, eat what you want, and do it with a clear conscience!! Now go hit the buffets!!

Frank Greer M.D., the principle author on this article, is the chairman of the American Academy of Pediatrics Committee on Nutrition. The below statement was developed in cooperation with the academy’s Section on Allergy and Immunology.

The highlights of the article (posted below) are this:

1. The idea that egg, fish, and foods containing peanut protein should not be introduced before 1 year of age is not based on good science.

2. Maternal dietary restrictions during pregnancy do not appear to play a significant role in the prevention of atopic [allergy-related] disease in infants.

3. There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.

4. For infants beyond 4-6 months of age, there is insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.

5. In Infants who are at risk of developing atopic disease, the current evidence does not support the hypothesis that exclusive breast-feeding protects against allergic asthma occurring beyond the age of 6 years.

6. For a child who has developed an atopic disease that might be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment could require specific identification and restriction of causal food proteins .

For those who want to read the entire article. . .

This policy is a revision of the policy posted on August 1, 2000.

CLINICAL REPORT
PEDIATRICS Vol. 121 No. 1 January 2008, pp. 183-191 (doi:10.1542/peds.2007-3022)

CLINICAL REPORT
Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas

Frank R. Greer, MD, Scott H. Sicherer, MD, A. Wesley Burks, MD and the Committee on Nutrition and Section on Allergy and Immunology

ABSTRACT

This clinical report reviews the nutritional options during pregnancy, lactation, and the first year of life that may affect the development of atopic disease (atopic dermatitis, asthma, food allergy) in early life. It replaces an earlier policy statement from the American Academy of Pediatrics that addressed the use of hypoallergenic infant formulas and included provisional recommendations for dietary management for the prevention of atopic disease. The documented benefits of nutritional intervention that may prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy (i.e., infants with at least 1 first-degree relative [parent or sibling] with allergic disease).

Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation. There is evidence that breastfeeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood. In studies of infants at high risk of atopy and who are not exclusively breastfed for 4 to 6 months, there is modest evidence that the onset of atopic disease may be delayed or prevented by the use of hydrolyzed formulas compared with formula made with intact cow milk protein, particularly for atopic dermatitis. Comparative studies of the various hydrolyzed formulas also indicate that not all formulas have the same protective benefit. There is also little evidence that delaying the timing of the introduction of complementary foods beyond 4 to 6 months of age prevents the occurrence of atopic disease. At present, there are insufficient data to document a protective effect of any dietary intervention beyond 4 to 6 months of age for the development of atopic disease.

Key Words: atopy • food allergies • breastfeeding • complementary foods • hydrolyzed formula • atopic dermatitis • asthma

Abbreviations: AAP—American Academy of Pediatrics • IgE—immunoglobulin E • OR—odds ratio • CI—confidence interval

INTRODUCTION

Over the past several decades, the incidence of atopic diseases such as asthma, atopic dermatitis, and food allergies has increased dramatically. Among children up to 4 years of age, the incidence of asthma has increased 160%, and the incidence of atopic dermatitis has increased twofold to threefold. The incidence of peanut allergy has also doubled in the past decade. Thus, atopic diseases increasingly are a problem for clinicians who provide health care to children.

It has been recognized that early childhood events, including diet, are likely to be important in the development of both childhood and adult diseases.

This clinical report will review the nutritional options during pregnancy, lactation, and the first year of life that may or may not affect the development of atopic disease. Although atopic diseases have a clear genetic basis, environmental factors, including early infant nutrition, may have an important influence on their development and, thus, present an opportunity to prevent or delay the onset of the disease. This clinical report replaces an earlier policy statement from the American Academy of Pediatrics (AAP) that addressed the use of hypoallergenic infant formulas and included provisional recommendations for dietary management for the prevention of atopic disease. This report is not directed at the treatment of atopic disease once an infant or child has developed specific atopic symptoms.

DEFINITIONS

The following definitions are used throughout this clinical report (adapted from work by Muraro et al)

Allergy: A hypersensitivity reaction initiated by immunologic mechanisms.

Atopy: A personal or familial tendency to produce immunoglobulin E (IgE) antibodies in response to low-dose allergens, confirmed by a positive skin-prick test result.

Atopic disease: Clinical disease characterized by atopy; typically refers to atopic dermatitis, asthma, allergic rhinitis, and food allergy. This report will be limited to the discussion of conditions for which substantial information is available in the medical literature.

Atopic dermatitis (eczema): A pruritic, chronic inflammatory skin disease that commonly presents during early childhood and is often associated with a personal or family history of other atopic diseases.

Asthma: An allergic-mediated response in the bronchial airways that is verified by the variation in lung function (measured by spirometry) either spontaneously or after bronchodilating drugs.

Cow milk allergy: An immunologically mediated hypersensitivity reaction to cow milk, including IgE-mediated and/or non––IgE-mediated allergic reactions.

Food allergy: An immunologically mediated hypersensitivity reaction to any food, including IgE-mediated and/or non––IgE-mediated allergic reactions.

Hypoallergenic: Reduced allergenicity or reduced ability to stimulate an IgE response and induce IgE-mediated reactions.

Infants at high risk of developing allergy: Infants with at least 1 first-degree relative (parent or sibling) with documented allergic disease.

The following definitions are from various industry sources:

Partially hydrolyzed (PH) formula: Contains reduced oligopeptides that have a molecular weight of generally less than 5000 d.

Extensively hydrolyzed (EH) formula: Contains only peptides that have a molecular weight of less than 3000 d.

Free amino acid––based formula: Peptide-free formula that contains mixtures of essential and nonessential amino acids.

DIETARY RESTRICTIONS FOR PREGNANT AND LACTATING WOMEN

The earliest possible nutritional influence on atopic disease in an infant is the diet of the pregnant woman. However, studies generally have not supported a protective effect of a maternal exclusion diet (including the exclusion of cow milk and eggs) during pregnancy on the development of atopic disease in infants, as summarized in a 2006 Cochrane review. Although previous AAP publications have suggested that pregnant women avoid peanuts, a more recent study has reported that there is no association between the maternal consumption of peanuts during pregnancy and childhood peanut allergy.

Previous AAP publications have advised lactating mothers with infants at high risk of developing allergy to avoid peanuts and tree nuts and to consider eliminating eggs, cow milk, and fish from their diets while nursing. Dietary food allergens can be detected in breast milk, including peanuts, cow milk protein, and egg. Two studies found a preventive effect of maternal dietary exclusion of milk, egg, and fish while breastfeeding on the development of atopic dermatitis in the infant. Other studies found no association between the development of atopic diseases and a maternal exclusion diet. A 2003 study found no association between breastfeeding and peanut allergy, and there was no difference in peanut intake during lactation between mothers with and without children with peanut allergy. Dietary food allergens in human milk may interact with the mucosal immune system and induce allergic reactions in infants who are known to be clinically allergic to the antigen. Rare cases of anaphylaxis to cow milk protein present in human milk have been described even in exclusively breastfed infants.

Consideration of a large number of studies on maternal diet, not all of which were randomized or included dietary restriction during lactation, demonstrated no impact on various outcomes among the majority of the studies, particularly when follow-up was beyond 4 years, and led one recent group of reviewers to conclude that there is no convincing evidence for a long-term preventive effect of maternal diet during lactation on atopic disease in childhood. A 2006 Cochrane review also concluded that there was insufficient evidence that antigen avoidance during lactation was beneficial in preventing atopic disease in the breastfed infant, with the exception of atopic dermatitis. Because the available published trials have had methodologic shortcomings, more data are necessary to conclude that the avoidance of antigens during lactation prevents atopic dermatitis in infants.

ROLE OF HUMAN MILK AND EXCLUSIVE BREASTFEEDING ON THE DEVELOPMENT OF ATOPIC DISEASE

Since the 1930s, many studies have examined the benefits of breastfeeding on the development of atopic disease. In general, these have been nonrandomized, retrospective, or observational in design and, thus, inconclusive. Of course, it is not possible to truly randomize breastfeeding, which is always a confounding variable in these studies. Acknowledging this difficulty, Kramer proposed 12 criteria to apply to studies designed to assess the relationship between atopic disease and breastfeeding. These criteria included nonreliance on late maternal recall of breastfeeding, sufficient duration of exclusive breastfeeding, strict diagnostic criteria for atopic outcomes, assessment of effects of children at high risk of atopic outcomes, and adequate statistical power. Unfortunately, no studies to date have completely fulfilled these criteria.

Atopic Dermatitis

A 2001 meta-analysis of 18 prospective studies compared the incidence of atopic dermatitis in infants who were breastfed versus infants who were fed cow milk formula. Overall, there was a protective effect of exclusive breastfeeding for 3 months (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.52–0.88), the stronger effect having been shown for infants with a family history of allergy (OR: 0.58; 95% CI: 0.4–0.92). No protective effect of breastfeeding was seen in children who were not at risk of developing allergy (OR: 1.43; 95% CI: 0.72–2.86). A 2005 study published from Sweden found no effect of exclusive breastfeeding for 4 months on the incidence of atopic dermatitis in the first year of life with or without a family history of atopic disease. On the other hand, another 2005 study from Sweden found that exclusive breastfeeding for more than 4 months reduced the risk of atopic dermatitis at 4 years of age (OR: 0.78; 95% CI: 0.63–0.96) with or without a family history of allergy. In their review, Kramer and Kakuma also found no benefit of exclusive breastfeeding beyond 3 months of age on the incidence of atopic dermatitis in studies in which parents were not selected for risk of allergy.

A series of recent reports from the German Infant Nutritional Intervention Program also found that breastfeeding reduces the incidence of atopic dermatitis, supporting the results of the meta-analysis. In the interventional arm of this study, 1834 newborn infants identified as being at high risk of developing atopic disease were enrolled in a 3-year longitudinal, prospective study. Breastfeeding infants at risk for atopic disease were enrolled in the study before 14 days of life and, at that time, were exclusively breastfed and had no history of formula supplementation. Infants were randomly assigned at the time of entry to receive supplements of 1 of 3 hydrolyzed formulas (2 extensively hydrolyzed formulas and 1 partially hydrolyzed formula) or a cow milk formula, if formula supplementation had begun. Eight hundred eighty-nine mothers exclusively breastfed for 4 months and did not use any of the formula supplements they were randomly assigned to use. Nine hundred forty-five infants were introduced to the randomly assigned formula before 4 months and, thus, were not exclusively breastfed. Of these, 689 infants were randomly assigned to receive one of the hydrolyzed formulas, and 256 were randomly assigned to receive cow milk formula. The incidence of atopic dermatitis in infants who were exclusively breastfed, breastfed with supplemental hydrolyzed formula, and breastfed with supplemental cow milk formula was 9.5%, 9.8%, and 14.8%, respectively, at the 1-year follow-up.

Thus, exclusive breastfeeding for 4 months showed a positive effect compared with breastfeeding with supplemental cow milk formula in these infants at high risk of developing allergy. Breastfeeding with supplemental hydrolyzed formula (both partially and extensively hydrolyzed) also showed a positive effect compared with breastfeeding with supplemental cow milk formula; however, breastfeeding with supplements of hydrolyzed formulas showed no advantage compared with exclusive breastfeeding. Both groups showed a one-third decrease in the risk of atopic dermatitis compared with the risk of breastfeeding with supplements of cow milk formula. Thus, exclusive breastfeeding or breastfeeding with hydrolyzed formula is not enough to prevent the majority of cases of atopic dermatitis.

The advantages of breastfeeding are less clear for infants who are not selected for high risk of developing atopic disease, as shown in the noninterventional arm of the German Infant Nutritional Intervention Program. In this arm, mothers unselected for a history of atopy who either formula fed or partially breastfed their infants were free to select cow milk–based or hydrolyzed formulas. No differences in the incidence of atopic dermatitis occurred among the 3 groups of infants (exclusively breastfed for 4 months, cow milk formula fed with or without breastfeeding, and hydrolyzed formula fed with or without breastfeeding). This lack of effect has been attributed to reverse causation; thus, mothers who knew that their infants were at risk of developing allergy were more likely not only to breastfeed but also to breastfeed for a longer period of time. Alternatively, mothers who were not going to breastfeed or were going to supplement with formula were more likely to choose hydrolyzed formula if they believed that their children were at risk of developing atopy. This reverse causation effect may explain why some studies have found an increased incidence of atopic dermatitis in breastfed infants.

In summary, for infants at high risk of developing atopy, there is evidence that exclusive breastfeeding for at least 4 months or breastfeeding with supplements of hydrolyzed infant formulas decreases the risk of atopic dermatitis compared with breastfeeding with supplements of standard cow milk–based formulas. On the basis of currently available evidence, this is less likely to apply to infants who are not at risk of developing atopy, and exclusive breastfeeding beyond 3 to 4 months does not seem to lead to any additional benefit in the incidence of atopic eczema.

Asthma

The evidence for the protective effects of human milk on the development of asthma is more controversial. A 2001 meta-analysis of 12 prospective studies that met preestablished criteria found that exclusive breastfeeding for at least 3 months was protective against the development of asthma between 2 and 5 years of age (OR: 0.70; 95% CI: 0.60–0.81). The effect of breastfeeding was even stronger when the analysis was limited to children from families with a history of atopic disease (OR: 0.52; 95% CI: 0.35–0.79). No benefit was seen in children from families without a history of atopic disease (OR: 0.99; 95% CI: 0.48–2.03). Two more studies not included in this meta-analysis supported these results. On the other hand, a 2002 Cochrane review found no benefit of exclusive breastfeeding beyond 3 months on the incidence of asthma in families not preselected for a history of atopic disease.

Two additional reports in the literature with a more accurate definition of asthma made a distinction between the wheezy bronchitis associated with viral infections in younger children and that of the allergic disease seen in older children associated with respiratory spirometric changes. In the first of these studies, a cohort of 1246 children in Tucson, Arizona, was followed from birth to 13 years of age. The study found that an association between breastfeeding and asthma at 13 years of age depended on the presence of maternal asthma in children with atopic disease. Infants whose mothers had asthma were at greatest risk of developing asthma by 13 years of age if they had been breastfed exclusively for 4 months (OR: 8.7; 95% CI: 3.4–22.2). When infants with atopic disease whose mothers had asthma were exclusively breastfed for any length of time (either greater than or less than 4 months), the risk of developing asthma between 6 and 13 years of age was also increased (OR: 5.7; 95% CI: 2.3–14.1). An increased risk of developing asthma was not found in breastfed children of mothers without asthma. However, in this same study during the first 2 years of life, exclusive breastfeeding was associated with significantly lower rates of recurrent wheezing of infancy (OR: 0.45; 95% CI: 0.2–0.9), similar to results from a recent study performed in Perth, Australia.

In the second of these studies, a long-term longitudinal study from New Zealand, 1037children from a general population (not selected for risk of allergic disease) were followed from 3 to 26 years of age. Five hundred four infants were breastfed for 4 weeks or more, and 533 infants were formula fed from the time of birth or breastfed for less than 4 weeks. Breastfeeding for more than 4 weeks significantly increased the risk of developing asthma at 9 years (OR: 2.40; 95% CI: 1.36–4.6) and at 21 years (OR: 1.83; 95% CI: 1.35–2.47). This increased risk was not related to the presence of maternal atopic disease, unlike in the Tucson study. The study has been criticized for retrospective determination of breastfeeding and unclear definitions of atopic heredity. There was also no evidence of a "dose-response" effect of breastfeeding on the incidence of atopy or asthma.

In summary, at the present time, it is not possible to conclude that exclusive breastfeeding protects young infants who are at risk of atopic disease from developing asthma in the long term (>6 years of age), and it may even have a detrimental effect. On the other hand, breastfeeding seems to decrease the wheezing episodes seen in younger children (<4 years of age) that are often associated with respiratory infections.

Food Allergy

Food allergy, similar to atopic dermatitis and asthma, is more likely to occur in infants with a family history of atopic disease. In a prospective study of infants born to families with a history of atopic disease, it was determined that 25% will develop food allergy between birth and 7 years of age. Because both atopic dermatitis and asthma are closely associated with the development of food allergy, it is difficult to sort out the effect of breastfeeding on the development of food allergy. As reviewed above, maternal dietary exposure during pregnancy and lactation is unlikely to contribute significantly to the development of food allergy in the infant, although many food antigens can be found in human milk.

In theory, human milk should inhibit food antigen absorption; however, prospective studies have failed to show a protective effect of human milk–specific antibodies to cow milk on infant sensitization. Investigations of the role of breastfeeding on the outcomes of allergies to specific foods have been few, and the results may have been influenced by additional dietary variables such as length and degree of breastfeeding exclusivity. In reviewing the available studies, Muraro et al concluded that exclusively breastfeeding for at least 4 months in infants who are at risk of developing atopic diseases is associated with a lower cumulative incidence of cow milk allergy until 18 months of age. A Cochrane review included only 1 study with a blinded challenge (using the double-blind, placebo-controlled food-challenge technique) and concluded that at least 4 months of exclusive breastfeeding did not protect against food allergy at 1 year of age. Overall, firm conclusions about the role of breastfeeding in either preventing or delaying the onset of specific food allergies are not possible at this time.

ROLE OF HYDROLYZED FORMULA ON THE DEVELOPMENT OF ATOPIC DISEASE

The role of partially hydrolyzed and extensively hydrolyzed formulas for the prevention of atopic disease has been the subject of many studies in both formula-fed and breastfed infants in the last 15 years. Most studies with published results have been of infants at high risk of developing allergy.

Approximately 100 studies in the literature have examined the role of hydrolyzed formulas on the development of atopic disease. However, using the criteria of a 2006 Cochrane review, only 14 randomized or quasi-randomized (eg, using alternation) trials in term infants compared the use of partially or extensively hydrolyzed formula with the use of human milk or an adapted cow milk formula. All of these trials have followed up with at least 80% of study participants. It is important to note that none of these studies reported any adverse effects, including any adverse effect on infant growth. No long-term studies have compared partially or extensively hydrolyzed formula to exclusive breastfeeding. Thus, there is no evidence that the use of these formulas is any better than human milk in the prevention of atopic disease.

Three studies of 251 infants examined the effect of partially hydrolyzed formula on reduction of the occurrence of any allergy compared with cow milk formula in infants at high risk of developing allergy. Two of these studies found no significant effect, and a third study found an OR of 0.45 (95% CI: 0.22–0.94) for partially hydrolyzed formula versus cow milk formula. Three more studies examined prolonged feeding of extensively hydrolyzed formula compared with partially hydrolyzed formula in 411 infants at high risk of developing allergy. None of these studies found a significant difference in the incidence of atopic dermatitis between the 2 feeding groups. Two of these studies of 352 infants also examined other manifestations of atopic disease and did not show a significant difference in the occurrence of food allergy, cow milk allergy, or asthma between the groups of infants who were fed extensively or partially hydrolyzed formula.

A very large published study from the German Infant Nutritional Intervention Program raised additional issues. In the interventional arm of this study, 945 newborn infants were identified as being at high risk of developing atopic disease and were enrolled in a longitudinal, prospective study through 12 months of age. Although the majority of infants were breastfed initially, formula was introduced in the first 4 weeks to most infants. The infants were randomly assigned to receive 1 of 3 hydrolyzed formulas (n = 689) or cow milk formula (n = 256). The 3 hydrolyzed formulas were a partially hydrolyzed whey-based formula, an extensively hydrolyzed whey-based formula, and an extensively hydrolyzed casein-based formula. The incidence of atopic dermatitis was significantly reduced in those using the extensively hydrolyzed casein-based formula (OR: 0.42; 95% CI: 0.22–0.79; P < .007) and the partially hydrolyzed whey-based formula (OR: 0.56; 95% CI: 0.32–0.99; P < .046) but not the extensively hydrolyzed whey-based formula (OR: 0.81; 95% CI: 0.48–1.4; P < .44), compared with the incidence in those in the cow milk formula group.

However, the overall results for prevention of allergic disease (atopic dermatitis, urticaria, and food allergy) for the 3 hydrolyzed formulas compared with cow milk formula were less impressive (extensively hydrolyzed whey-based: OR: 0.86; 95% CI: 0.52–1.4; partially hydrolyzed whey-based: OR: 0.65; 95% CI: 0.38–1.1; and extensively hydrolyzed casein-based: OR: 0.51; 95% CI: 0.28–0.92; P < .025). Thus, this study indicated that different hydrolysates have different effects on atopic disease, and there may be an advantage for the extensively hydrolyzed casein-based formula. However, as the study demonstrated, it is difficult to show that partially hydrolyzed formulas have a very large effect on the reduction of atopic disease in infants who are fed formula or mixed feedings of human milk and formula, even if they are at high risk of developing allergic disease. If atopic disease associated with cow milk allergy has occurred, partially hydrolyzed formula is not recommended, because it contains potentially allergic cow milk peptides. More studies are needed to determine if any of the hydrolyzed formulas have any effect on the incidence of atopic disease later in childhood and adolescence and whether the modest effects of the use of extensively or partially hydrolyzed formulas in early childhood can be confirmed and are sustained. Such studies should also include a cost/benefit analysis of the use of the more expensive hydrolyzed formulas. It should be noted that the potential benefit of these formulas has only been documented in infants at risk of developing atopic disease.

Additional studies are needed among unselected infants or infants at low risk. The use of amino acid–based formulas for prevention of atopic disease has not been studied. Soy formulas, on the other hand, have a long history of use for atopic disease in infants. In a recent meta-analysis of 5 randomized or quasi-randomized studies, the authors concluded that feeding with soy formula should not be recommended for the prevention of atopy in infants at high risk of developing allergy.

ROLE OF INTRODUCTION OF COMPLEMENTARY FOODS ON ATOPIC DISEASE

Many studies have examined the duration of breastfeeding and its effect on atopic disease. However, few studies have examined the timing of the introduction of complementary foods as an independent risk factor for atopic disease in breastfed or formula-fed infants. An expert panel from the European Academy of Allergology and Clinical Immunology has recommended delayed introduction of solid foods for 4 to 6 months in breastfed or formula-fed infants. The AAP has also recommended that solid foods be delayed until 4 to 6 months of age and that whole cow milk be delayed until 12 months of age. Before publication of this clinical report, AAP recommendations for infants who are at risk of developing atopic disease were to avoid eggs until 2 years of age and avoid peanuts, tree nuts, and fish until 3 years of age. These guidelines for solid food introduction and avoidance of specific allergens were based on the evidence of a few studies with various limitations. Three newer studies have reported mixed results regarding the timing of the introduction of solid foods and development of childhood atopic disease.

In a prospective (nonrandomized) study of infants at risk of developing atopic disease by Kajosaari, atopic dermatitis and history of food allergy were reduced at 1 year of age if the introduction of solid foods was delayed until 6 months compared with at 3 months of age. However, in a 5-year follow-up study, no difference was seen in the incidence of atopic dermatitis or symptoms of food allergy. In a second prospective study of a birth cohort of 1210 unselected children between 2 and 4 years of age, there was more atopic dermatitis but not asthma in infants who were fed 4 or more solid foods compared with no solid foods before 4 months of age. This difference was maintained in a 10-year follow-up study in 85% of the original study infants.

In a study of 257 preterm infants (34.4 weeks’ gestational age; birth weight: 2.3–2.4kg), the introduction of 4 or more, compared with fewer than 4, solid foods before 17 weeks after term was associated with a higher risk of atopic dermatitis (unconfirmed by skin-prick testing) at 12 months after term (OR: 3.49; 95% CI: 1.51–8.05). Also in this study, the introduction of solid foods before 10 weeks of age or atopic disease in either parent increased the risk of atopic dermatitis in infants (OR: 2.94; 95% CI: 1.57–5.52).

In a more recent prospective, longitudinal cohort study in which atopic dermatitis was confirmed by skin testing, 642 infants were followed until 5.5 years of age. The history of the introduction of solid foods was carefully recorded during the first year of life. Most children had at least 1 parent with a positive skin-prick test result. Rice cereal was introduced at a median age of 3 months, milk was introduced at a median age of 6 months, and egg was introduced at a median age of 8 months. However, the later introduction of solids had no effect on the prevalence of asthma or atopic dermatitis (confirmed by skin-prick testing), although there was an increased risk of atopic dermatitis in relation to the late (6–8 months) rather than the earlier introduction of eggs (OR: 1.6; 95% CI: 1.1–2.4) or milk (OR: 1.7; 95% CI: 1.1–2.5).

Finally, an ongoing prospective, cohort study of 2612 infants (without a risk of developing atopic disease) found no evidence to support delayed introduction of solid foods beyond 6 months of age for prevention of atopic disease. However, in the same study, the effect of delayed introduction of solid foods for the first 4 months of life was less clear. Another study has even suggested that children exposed to cereal grains before 6 months of age (as opposed to after 6 months of age) are protected from the development of wheat-specific IgE.

In summary, the evidence from these conflicting studies, in balance, does not allow one to conclude that there is a strong relationship between the timing of the introduction of complementary foods and development of atopic disease. This raises serious questions about the benefit of delaying the introduction of solid foods that are thought to be highly allergic (cow milk, fish, eggs, and peanut-containing foods) beyond 4 to 6 months of age; additional studies are needed.

SUMMARY

It is evident that inadequate study design and/or a paucity of data currently limit the ability to draw firm conclusions about certain aspects of atopy prevention through dietary interventions. In some circumstances in which there are insufficient studies (pregnancy and lactation avoidance diets, timing of introduction of specific complementary foods), the lack of proven efficacy does not indicate that the approach is disproved. Rather, more studies would be needed to clarify whether there is a positive or negative effect on atopy outcomes. The following statements summarize the current evidence within the context of these limitations.

At the present time, there is lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of atopic disease in infants. Similarly, antigen avoidance during lactation does not prevent atopic disease, with the possible exception of atopic eczema, although more data are needed to substantiate this conclusion.

For infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic dermatitis and cow milk allergy in the first 2 years of life.

There is evidence that exclusive breastfeeding for at least 3 months protects against wheezing in early life. However, in infants at risk of developing atopic disease, the current evidence that exclusive breastfeeding protects against allergic asthma occurring beyond 6 years of age is not convincing.

In studies of infants at high risk of developing atopic disease who are not breastfed exclusively for 4 to 6 months or are formula fed, there is modest evidence that atopic dermatitis may be delayed or prevented by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, in early childhood. Comparative studies of the various hydrolyzed formulas have also indicated that not all formulas have the same protective benefit. Extensively hydrolyzed formulas may be more effective than partially hydrolyzed in the prevention of atopic disease. In addition, more research is needed to determine whether these benefits extend into late childhood and adolescence. The higher cost of the hydrolyzed formulas must be considered in any decision-making process for their use. To date, the use of amino acid–based formulas for atopy prevention has not been studied.

There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.

Although solid foods should not be introduced before 4 to 6 months of age, there is no current convincing evidence that delaying their introduction beyond this period has a significant protective effect on the development of atopic disease regardless of whether infants are fed cow milk protein formula or human milk. This includes delaying the introduction of foods that are considered to be highly allergic, such as fish, eggs, and foods containing peanut protein.

For infants after 4 to 6 months of age, there are insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.

Additional studies are needed to document the long-term effect of dietary interventions in infancy to prevent atopic disease, especially in children older than 4 years and in adults.

This document describes means to prevent or delay atopic diseases through dietary changes. For a child who has developed an atopic disease that may be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment may require specific identification and restriction of causal food proteins. This topic was not reviewed in this document.

Committee on Nutrition, 2006–2007
Frank R. Greer, MD, Chairperson
Robert D. Baker, Jr, MD, PhD
Jatinder J. S. Bhatia, MD
Stephen Robert Daniels, MD, PhD
Marcie B. Schneider, MD
Janet Silverstein, MD
Dan W. Thomas, MD

Liaisons
Sue Ann Anderson, PhD, RD
Food and Drug Administration
Donna Blum-Kemelor, MS, RD
US Department of Agriculture
Margaret P. Boland, MD
Canadian Paediatric Society
Laurence Grummer-Strawn, PhD
Centers for Disease Control
Capt Van S. Hubbard, MD, PhD
National Institutes of Health
Benson M. Silverman, MD
Food and Drug Administration

Post#5 The Blame Game

2007-11-03T09:47:00.000-07:00

As parents, we rarely want to see our children sick. Not only does it affect our children's temporary well-being, it often thwarts our everyday routine. Of course, we all know and accept (for the most part) that catching colds and vomiting are an immutable fact of life. As a pediatrician, I view children combating regular illnesses as a rite of passage; with each passing fever and sniffle, our immune systems become stronger, more mature and smarter.

Regardless, when our children become sick, it is sometimes hard not to dissect the past 72 hours in an effort to deduce which of our friends' children made little Johnny sick. Sometimes it is simply an innocent fact-finding mission with little malice or misgiving. Other times, however, we rack our brains, pursuing a mini witch hunt, until we have concluded who passed the unfortunate germ to our child.

From a public health standpoint, it is a well researched fact that an average healthy child will come down with 6-8 viral illnesses each year; if the child attends daycare, this number jumps to 8-12 viral episodes. Furthermore, it is also known that children will often shed a virus for several weeks, even after they themselves appear perfectly healthy. Viruses, especially during the winter time, are rather hardy and can survive for several hours on fomite surfaces, including door handles, countertops, grocery carts, toys, and wherever else they happen to slobber, touch, or lick (in other words everywhere!).

Thus, when investigating the possible places or people that a child may have acquired a germ, it really is a total crapshoot. And assigning fault, especially if there is any ill will involved (pun intended!), is a dangerous and inaccurate game to play.

I often counsel my families that they should resign themselves to the fact that their children will become sick multiple times each year, with the bulk of the illnesses occurring during the winter time (the lower humidity and increased tendency for people to remain indoors leads to a greater survivability and sharing of germs). With this in mind, I believe that it is an impractical standard for people to avoid public gatherings when their children have a simple viral illness (or vice-versa, to impose this standard on others). The fact of the matter is, most of the time, whether their "sick appearing" snotty child joins the party or not, there will be plenty of germs abounding regardless.

If we truly want to avoid becoming ill, we would have to essentially live in a bubble. Even the most cautious, Purell-addicted family will encounter their fair share of germs each year. And even if they only socialize with well-appearing children, some of these kids may still be shedding germs from an illness they got over several weeks prior.

A simple but practical set of guidelines I pass on to parents is as follows:

1. Babies under 3 months should avoid contact with sick children. Anyone who plans to physically touch the baby should always wash their hands thoroughly before playing with the child, no matter how healthy they appear.

2. If a child is harboring a significant illness such as chicken pox or scarlet fever, they should be quarantined from other children until they are no longer contagious. For a full list of illnesses that should be quarantined, a pediatrician should be consulted with a quick phone call. The scope of this discussion is too exhaustive for a simple blog.

3. If a child is playing happily but has some mild symptoms (i.e. runny nose, cough, mild non-bloody diarrhea), they should NOT be quarantined and free to attend church, school, birthday parties, political functions, poetry readings, etc.

There are other circumstances that also need more detail; for example, an immunocompromised member lives in the household. However, the above general rules cover most circumstances.

It is this author's opinion that playing the blame game with colds and viral illnesses can not only be inaccurate, but ultimately fruitless. Rather focus on the upside! Your child's immune system has just been battle tested one additional time, and this can only strengthen him in the long run. Perhaps, rather than consigning blame, you should send the offending germ donor a thank you note. And maybe a little Purell.

Post#4 Did My Doctor Miss the Diagnosis?

2007-10-03T09:29:00.001-07:00

Every so often, I will walk into an exam room to meet a new patient who has come to elicit a second opinion. Many will readily explain what they are concerned about, who their primary doctor is, what they were told, why they are worried and for what they are seeking a second opinion. Others will tread more lightly, offering vague clues as to why they are seeking a second opinion - either they are slightly embarrassed to second guess their doctor, or they fear that too many facts will bias my mind, thus tainting the objective second opinion they seek.

There have been a few times, after listening to a parent's story and examining them, it seems clear that the previous doctor did not accurately diagnose or work-up the patient before me. I use the word "seems" because there are two sides to every story, and were I to ask their doctor his/her take on the matter, my judgment on the matter may sway.

However, more often than not, my overall impression usually does not find fault in the previous doctor; rather, I often assess mentally that the patient's disease(s) has probably evolved from their initial presentation, and had the family followed-up with their primary doctor, the correct diagnosis would have eventually been made.

I need to qualify this blog with a few thoughts:

1. Pediatrics is a different beast than adult medicine. In adults, debilitating diagnoses such as cancer, heart disease, stroke, etc. are more common, hence there is a greater propensity in adult medicine to misdiagnose a life altering ailment.

2. Doctors do make mistakes. This is not an attempt to exonerate myself or all pediatricians from errors. We are all human and every doctor has their share of war stories. Of course, we all try to keep these stories to a minimum.

3. I practice in an area of Houston where, for the most part, my surrounding colleagues are all excellent well-trained physicians, for whom I hold mutual respect. There is excellent camaraderie and perpetual educational conferences where we freely exchange information and medical trends. Thus, when a patient of their's seeks my second opinion, it is rare that I discover an egregious error.

4. Most of the mistakes I have personally witnessed are not from when patients have seen another pediatrician, rather they are seen at follow-up visits after a family has visited a non-pediatric emergency room where the physician on call did not regularly see children. The suburban strip mall after-hour clinics tend to be the most frequent offender. Of course, I have also met and know some excellent doctors in each of these settings. It just tends to be more of a crapshoot.

To fully demonstrate the point of this blog, I will delve for a moment into the minutiae of pediatric medicine. Let's take a look for a moment at the pathophysiology of bacterial pneumonia. Pneumonias can actually be categorized into 3 general groups divided by etiology (cause): bacterial, viral and atypical bacteria. Of these 3 groups, the one that can turn into an ICU nightmare is the bacterial pneumonia. The other 2 etiologies are of less clinical significance and, for the most part, are not dangerous. However, should a bacterial pneumonia not be properly treated, a normally healthy child can suffer significant consequences including the infrequent ICU hospitalization.

So how does a bacterial pneumonia evolve?

1. First, a child will catch the common cold (caused by one of many viruses). This will turn his nose into a faucet, which causes many to suffer from post-nasal drip, where the mucus runs from the back of their nose down their throat and into their lung. This essentially turns their trachea (windpipe) into a water slide, or more specifically, a mucus slide.

2. Second, the water slide of mucus/phlegm will accumulate in a pocket of their lung. Interestingly, the very cough that many parents want to alleviate and squelch, offers the best protection against the formation of these biological cesspools. In effect, cough is protective and beneficial! God is smart!!

3. A bacteria (often being harbored harmlessly in the child's nose) will ride the water slide down from the nose into the lung. Should it find an acceptable domicile of collected mucus, it will set up house and began to multiply. Once a sufficient army of bacteria are formed, the germs will infiltrate the surrounding lung tissue, firmly establishing a pneumonia.

This entire process usually takes 1-2 weeks, however should the offending agent be an aggressive bacteria, the timeline can be significantly shorter. The pathophysiology for ear infections and sinus infections is also very similar. So should a parent bring in a child during the first few days of this timeline, the appropriate diagnosis would be an upper respiratory infection (cold) caused by a virus, and thus the appropriate treatment would be tender loving care and watchful waiting.

As the child evolves from having a cold into a pneumonia, there is usually a clear change in their overall appearance. Often they will appear less energetic, have shallow labored breaths, their appetite/play will decrease, and there may be a second peak of fever. Most mothers will pick up on this and bring them back to their pediatrician for a second check. However, should the mother decide to switch doctors at this point, it may appear that the original doctor who diagnosed a cold made a mistake, when in actuality the disease has evolved since the initial presentation.

Second opinions are certainly warranted in certain situations, especially if you feel that your doctor is not adequately addressing a deteriorating illness. Either a lack of guidance and roadmapping may leave a parent feeling slightly lost and scared, or the doctor may simply be missing the boat on the underlying diagnosis.

However, it is more often the case that your child has simply progressed from their initial presentation, and allowing your own doctor to observe the change in symptoms will often be your safest recourse. Having seen how your child originally presented and then being able to see the change in presentation, will proffer your physician a bird's eye view on the entire history of the illness. Hopefully, you have enough faith in your pediatrician that you trust he has made the correct original diagnosis, and will also make a change in his assessment, should the opportunity necessitate itself. If this faith does not exist, it may be time to find a doctor in whom you can put it!

This blog is not to deter you from seeking second opinions, but rather to help you understand that sometimes a change in clinical diagnosis is not always indicative of a mistake but rather an evolution in the natural history of a disease process. And it may be in your child's best interest to stick with one doctor through thick and thin, especially if you've already found a doctor who you trust.

Post#3 Who to Believe?

2007-09-10T23:17:00.000-07:00

"The irony of the Information Age is that it has given new respectability to uninformed opinion."
Veteran reporter John Lawton speaking to the American
Association of Broadcast Journalists, 1995

As a pediatrician, I try to log in a respectable amount of hours in a noble attempt to keep up with the latest research concerning new treatment modalities, changes in immunization guidelines and patterns in endemic outbreaks of particular germs. Not only do I find articles concerning such topics intriguing, I feel an innate sense of duty to my patient population to stay well-informed. After all, parents spend their hard-earned money and valuable time to seek out my advice whenever they have a question that concerns their child.

Overall, the internet has, for the most part, made my job as an educator easier. Many parents log in their due diligence on various topics prior to their visit, maximizing the value of our conversation. Furthermore, the internet acts as an external screening tool for parents wishing to validate the advice they receive from me; generally, the informDation found on the web is quite reliable and I not only condone this, I encourage it. I will often end a patient visit by writing down my presumptive diagnosis and suggest that the parents read more about their child's condition at home in order to fully understand the natural history of what is to transpire. It is a luxury that my father (a retired pediatrician) did not have.

However, it is not unusual in the course of a busy workday to stumble upon what I deem "disinformation". Most of the time, it is simply loving, however misguided advice/warnings from a grandmother or aunt. The bulk of this "disinformation" comes in the form of old wives' tales that have been passed down from generation to generation, e.g. "not wearing socks will make a baby sick" or "green mucus needs antibiotics". For the sake of brevity, I will refrain from discoursing on why these adages are not scientifically accurate.

Suffice it to say, they are not true. However, neither statement is overtly precarious. Of course, should we start to treat (or continue in some cases) every green runny nose with antibiotics (most of which are viral in origin and thus do not require them), it would contribute significantly to the current surge in antibiotic resistant bacteria. However, case to case, it is hard to argue that a single misdirected prescription of Zithromax can be qualified as hazardous.

Other issues are more frustrating and ominous in nature. Of particular consequence is the issue of immunizations. This is often a touchy subject, which can at times evolve into an insurmountable divide between a family and their pediatrician. It is clear that in their short history in the world, vaccines have had their share of misgivings. Specific examples range from Rotashield-related cases of intussusception (a dangerous condition where your bowel involutes) to seizures related to whole-cell pertussis (whooping cough) vaccine. Both products have now been replaced with safer next-generation immunizations which have fared better in terms of safety profile.

Even with these setbacks, the overall safety profile for immunizations as a whole has been tremendously innocuous. What's more, the overall benefit to humanity is as Mastercard so aptly states: "priceless".

Per the CDC 2006:
"Vaccination is among the most significant public health success stories of all time. However, like any pharmaceutical product, no vaccine is completely safe or completely effective. While almost all known vaccine adverse events are minor and self-limited, some vaccines have been associated with very rare but serious health effects."

Even the CDC readily acknowledges serious side effects amongst the many success stories vaccines have enjoyed. In fact, if you pick up a copy of the regularly updated Bible of vaccines, Epidemiology and Prevention of Vaccine-Preventable Disease, it is refreshingly transparent about past side effects associated with particular immunizations.

The largest current scare to sweep the globe links autism to either the MMR vaccine (Measles, Mumps, Rubella) or thimerosal (a preservative which is currently being phased out in order to increase public confidence in vaccines). The initial stir begin following a 1998 Lancet article in which lead author Andrew Wakefield and colleagues posited a link between the MMR vaccine and autism.

Multiple studies by respectable scientific organizations have since been unable to validate any type of statistical correlation between either the MMR vaccine or thimerosal and autism. In fact, the Lancet journal (as well as 10 of the original 13 authors) itself has renounced the article that it originally published in 1998. Currently, Dr. Wakefield is facing multiple charges of medical ethical misconduct in the U.K. As for thimerosal - Denmark, a country that abandoned thimerosal as a preservative in 1991, actually saw an increase in autism beginning several years later.

Ultimately, I have no problem with a mother or father concerned about the possible deleterious effects of immunizations. Often, these parents are educated individuals who are well-informed and have nothing but the safety of their child in mind. Certainly no one can fault them for this. Furthermore, they have a reason to be antsy about vaccines. There has been some checkered success with certain immunizations in the past.

However, there has to be a filter through which a family decides who and what to believe. Often it is their pediatrician, who hopefully has gained their trust through a history of smart decision making and thoughtful care. And while there are internet sites galore which still tout the harm of MMR as a risk factor for autism, many of these sites rest the foundation of their case on an article which has since been widely discredited. Unfortunately in some cases, the newer data, rather than discrediting Dr. Wakefield, has conversely made him a martyr for parents not wanting to vaccinate their children.

At some point, these same parents hopefully will wonder why the vast majority of pediatricians continue to vaccinate their own children with the MMR vaccine. After all, if anyone has studied immunizations up close and personal, it is a pediatrician. Our education bound with the Hippocratic Oath hopefully qualifies our profession to make judicious decisions for each patient of ours. And like any loving parent, we do what we think is best for our own children. We just happen to have chosen a profession which equips us to be a little more discerning about what we come across on the world wide web. Hopefully, with well placed effort and knowledge we can do our part to keep informed opinion respectable in the era of the Information Age.

Post#2 The Power of Follow-up

2007-08-24T20:16:00.001-07:00

Of the many doctors that will one day infiltrate your life and perhaps your body, you as an individual/mother/father/caretaker will no doubt ask yourself, "Do I trust this doctor?" It is a fair and necessary question. But it is likely that of all the M.D.s who come in and out of your life, the one who you will scrutinize the hardest is your pediatrician (and perhaps your OB/Gyn). And for good reason - they are your partners in caring for what is likely the most important thing in your life, your child. And you pray and hope they don't screw up. Talk about pressure.

By "trusting" your pediatrician, you likely hope for a cost-effective yet effective, innocuous yet proven, thorough yet uncomplicated treatment each time your child becomes ill.

When presented with a sick child, there is a careful and structured thought process that I go through to come up with the best treatment plan. But before concocting a solution, I must first ascertain what the correct diagnosis is. I would estimate that 60% of the diagnoses I make each day are bread and butter pediatrics, simple enough such that an astute pediatric resident at the end of their 1st year of training could come up with the correct answer without assistance.

Another 30% of my patients may not present as cut and dry, but I can easily group them into an unofficial diagnostic category such as "viral illness with a funky rash which should resolve without any complication".

It is the final 10% where my experience, fund of knowledge and creativity come into play. And truth be told, the majority of this 10% will go on to good health, regardless of any intervention or medication. It is in this last 10% where follow-up visits are my most powerful and cost-effective ally.

Imagine you are a contestant on an updated version of the 5o's game show Name that Tune. If you are an iPod junkie, you may be able to correctly name 80% of songs with just a few bars of music. Certain songs are so distinct, that it wouldn't take even an average music fan but a few notes to decipher what they are listening to. Ala You Give Love a Bad Name, Hit Me with Your Best Shot, Play That Funky Music, White Boy, etc.

But other songs may take a few more lines. For example, the notorious Ice Ice Baby could easily be mixed up with Queen's classic song Under Pressure (not that Vanilla plagiarized. C'mon - he was keeping it real!). You get my point. Some diagnoses only take a few notes, others may require a follow-up visit or two.

At the end of a visit in which the diagnosis is not clear, a pediatrician can:

A. Order a battery of tests to shed some light on the matter.

B. Try medication(s)/treatment(s) and hope something works.

C. Consult a specialist.

D. Send the child to the ER.

E. Have the child return for a follow-up visit.

Each of these choices is appropriate in certain situations. However, each has a potential downside. Tests are often expensive and possibly harmful (radiation) or painful (blood draws). Medications can also be expensive and can lead to possible side effects. Specialists are often expensive as well and may feel compelled that the buck has to stop here, leading to unnecessary treatments/tests. The ER is insanely expensive, and you may have a less qualified doctor than your pediatrician helming the ship. Finally, a follow-up visit may be the most cost-effective measure; however, the child may become sicker or there may be no additional clues which present themselves at the follow-up visit.

The pediatrician must carefully choose which of these options is the most appropriate in each situation. If I think I have a bead on a possible diagnosis, I will sometimes order a test to see if I am correct. If I have a strong hunch on a possible diagnosis, I may even empirically treat. If I am perplexed, I may elicit the help of a specialist. If I am worried that a child is decompensating, I may send them to the ER. However, the most likely scenario is that I just need to see the history of the disease play itself out. And thus, it is the almighty follow-up visit which aids me the greatest in murky situations.

Once a child is deemed stable, a follow-up visit is usually the cheapest, most pain-free, side-effect free and hassle-free plan of action that can be taken for the family. Given that most kids are resilient, many will improve by the time they follow-up with me. Or in the event that they remain ill, a few more symptoms will surface to help make the proper diagnosis and treatment plan. Simply by waiting a few hours or days, I can avoid the egregious error of crediting Vanilla Ice with a true Queen classic. And all this whilst I am under pressure.

Post#1 The Art of Medicine

2007-08-16T20:25:00.000-07:00

A long initial blog to get things rolling. . . I will work at word/thought economy henceforth.

As I have evolved as a pediatrician, I have come to appreciate how practicing medicine is truly an art. During my formative medical school years, I always pondered what people meant when they spoke of "the art of medicine".

As a pragmatic science-minded individual who majored in Biology, which lends itself to classifying everything, even when a species may pose a classification conundrum, I had viewed the world as black and white. Math made sense to me. Chemistry made sense to me. Picasso did not make sense to me.

So when I entered medical school in 1995, I assumed that medicine, having it's foundation built on science, would be as methodical and formulated as math and chemistry. The first 2 years of medical school confirmed my belief in this systematic world of diseases and drugs. Patient gets sick with disease, doctor makes diagnosis. Doctor prescribes medication, patient gets well.

And really, through my clinicals of medical school and later my early years of residency, medicine, for the most part, remained very systematic in my brain. I could barely keep up with trying to fill my head with formulas, decision trees, syndromes, treatment guides, etc. Barely wading with my cranium (I learned that word in med school!) above an ever increasing pool of facts and figures, I failed to take a breather to take a bird's eye view of pediatrics (or medicine in general).

As a resident, the fact that I was, for the most part, regurgitating orders from my attending superiors only further augmented my belief that the vast majority of medicine was based on a cookbook (albeit a rather large one). It was a cookbook that my superiors were familiar with and one which I would need to master.

This type of thinking was not only naive, it also carried an air of cockiness - a belief that Western medicine had for the most part completed this cookbook with all necessary recipes to ensure good health, long life, peace and happiness. Perhaps my first rude awakening from this rudimentary mindset arrived in the form of the common cold.

I was surprised to learn in residency that, for the most part, we as pediatricians had very little to offer the unfortunate individual afflicted with perhaps the world's most ubiquitous ailment, the upper respiratory infection. Modern medicine, for all its bells and whistles, could stop neither the running of the nose nor the coughing of the lungs. But what of all the wonderful ads and medications that I had seen lining the aisles of every Walmart? What about the previous winter when Nyquil held my hand during those torturous and snotty all-nighters? My mouth gaped open when I learned that it had all been the placebo effect.

Five years of private practice and fifty articles on cold medications later, it all seems so obvious to me that we as physicians have little to offer not only children, but their adult counterparts as well, when they catch a cold. What I have come to realize is that the best thing I can offer my parents when they bring their child in with a cold is "the art of medicine".

Really, what most moms are looking for is reassurance. Many are also looking for a good night's rest. Unfortunately, it is only the former that a good pediatrician can offer. So with a tired mother who has been up all night with a coughing child, a pediatrician must be delicate and artful in helping the mom (and/or dad, grandma, grandpa, Aunt Bessie, Uncle Ed, etc.) understand the natural history of the cold, realize the lack of evidence for cold medications, weigh the risk of side effects from cold medications vs. the zero benefit, and be attentive to the possible complications a cold can evolve into (such as pneumonia).

It is of particular importance to give mothers a clear contingency plan, such that they know what to look for should a child develop a secondary infection like pneumonia, an ear infection, or a sinus infection. I am infinitely better at this type of counseling now than when I started private practice 5 years ago. Or perhaps mothers are far more willing to listen to a pediatrician with 5 years of experience under his belt then a newbie straight out of residency. It is probably a little of both.

But just like there are politicians who are better at rhetoric and teachers who are better at explaining calculus, there are pediatricians who are better at putting a worried mom's mind to ease (assuming that the cold really is just a cold). It is the proper balance of a thorough exam
mixed with the sprinkling of the right factoids added to a clear contingency plan, that can allow a mother's mind to be at peace, even when she is up all night with her coughing child. And this is art.

Another way to understand the art of medicine is (and really it would take several more blogs to put this in proper perspective) to dissect a simple treatment plan for a simple ailment such as a middle ear infection. After making the correct diagnosis and educating the mother on what her child has, the next step is to come up with the proper treatment plan. And even with a rudimentary pediatric illness such as an ear infection, a proper treatment plan should be tailored to the individual family.

When a child is diagnosed with an ear infection, he should receive antibiotics (unless they are over 2 years of age, in which case there are other options. However, for the sake of simplicity, I will assume treatment is necessary). The doctor should then take into consideration many factors in coming up with the best plan. Are they cash pay or insurance? Are they going out of town this weekend? Can they follow-up? Are they allergic to penicillin? Can the child take oral medications without throwing up? Has this child had previous ear infections? Are there other underlying conditions to consider?

Answers to each of these questions can and should sway the physician to tailor the plan to meet the needs and desires of the parent(s). And in order to create the proper plan or the "best" plan, it requires not only a strong fund of knowledge to pull from, but also a creative mind (and likely a compassionate mind) as well to fit each scenario as best as possible. And here again it is the "art of medicine" that can separate the good physician from the special one.