Advanced Pediatrics: 2009

2009-12-30

Football: Time to Admit the Danger

We Now Know that NFL Football
can Permanently Damage Your Brain

In October, 2009, the noted author Malcolm Gladwell published a rather
breath-taking analysis of football, particularly NFL football.

http://www.newyorker.com/reporting/2009/10/19/091019fa_fact_gladwell?printable=true

Gladwell is the author of Blink and Tipping Point, who has a powerful
way of getting the heart of various matters.

In this case, the point is quite clear and devastating. Pro football,
as currently played, routinely permanently damages players' brains.

More worrisome for families is the point that concussions are not a
reliable guide to the issue of brain damage.

For reasons that no one yet understands, the brain is one of the only
organs that accumulates injury. That means that if you have an injury
to the brain in 1986 and 2009, it is as if you had one injury in 2009 equal
to the two injuries added together. And, any further injury to the brain
leads further additions to those two injuries.

The experience in the NFL dramatically demonstrates that you can have
serious hits to the brain with no symptoms afterwards, but as they add up,
loss of brain function begins to appear, and does not go away.

The force an damaged delivered to the brain by an NFL blow to the head
now is clearly shown to cause lifelong loss of cognitive function.

We are pleased to say that kids under the age of 12 clearly cannot deliver
the force necessary to cause concern, as long as they play by the rules.

But by high school kids are getting big enough that the blows to the
head, as measured by scientists, can cause damage to the brain.

So please, read this article. If you know your child wants to tackle people
in the game of football, we would recommend it all happen prior to 7th grade.

Until the sport of football changes how the game is played, varsity high school and
college, and NFL football, places too high a risk on the functioning of the brain to
justify the risk.

Dr. Arthur Lavin

Vital Statistics 2009

The Annual Numbers on Health
in the United States

Every year, the American Academy of Pediatrics publishes a
truly fascinating collection of stats on the health of American
children.

The publication is always the first article of the January issue,
every year, of Pediatrics (www.pediatrics.org).

Now that Advanced Pediatrics has a solid connection to families
available via our web page, Tweeter, and Facebook, I thought
it might be interesting once a year to see how we can

The data presented each year represent information as of
the end of the previous year that are completed, typically of
2-3 years prior to the date of publication. So for this 2010 article
the stats reflect how things were for 2006 and 2007.

Here are the most striking facts, for the United States:

There were 4.3 million people born in 2007
There were 2.4 million deaths in 2007
Most births were to Moms ages 20-34
Teenage pregnancy remains much lower in 2005-7 than 1990
C-section rates continue to climb each year, now up to 28% nationwide for 20-29 y/o's
A slight but real rise in the percentage of children born early continues, now up to 8.3%
Infant mortality rate (IMR) is a valid measure of a nation's health, and health care system.
The United States ranks #29 in IMR. Japan's IMR is about 1/4 of ours!
Of the 2.4 Million deaths a year in the US, a total of about 50,000 are in kids (<20 y/o)
In infants (0-1 years old), about a third of the deaths are from prematurity and anomalies.
SIDS remains the third leading cause of death in the first year of life, but the number continues to drop.
Accidents are the number 5 cause of death in infancy.
For older children, by far the most common cause of death is injury, primarily accidental.
About 40% of all childhood deaths are due to accidents, from ages 1-19 years old.
The chance of loss of life with an accident jumps dramatically after age 15, reflecting the dangerous nature of driving, and the rise of violent fighting, and of suicide.
Once accidents of all sorts are eliminated, the good news is that childhood is by far the healthiest age to be. Very few children in the United States suffer dangerous illness. The rates of truly dangerous illness have dropped for most categories to the range of risk of 1 in 10-100,000.

Bottom Line:

By far and away the greatest threats to our children's health are prematurity and anomalies for infants, and accidents and injuries for children and adolescents.

The United States has much progress to make to claim the best health in the world.

Even so, although all diseases are far from conquered, this generation of children

remains the healthiest in the history of the world. We should toast to their health

and enjoy the fact that so many are indeed quite well, during this coming year of

2010.

Dr. Arthur Lavin

2009-12-29

Turns out it is good to eat food

More Evidence that Introducing Solids Early Helps

For a very long time, families have wondered:

What is the best age to introduce solid food to our infant?

In the United States, the reigning wisdom has been:

as late as possible.

Why?

The thought has been that the earlier you introduce solid foods,

the more food allergies the infant will have.

Now an important study on this question has been published in the

January, 2010 issue of Pediatrics. The study is from Finland, where

nearly 1000 children were observed from birth to age 5.

The study kept track of what age the kids started eating a variety of

solid foods, and to what extent they were nursed.

Now, in Finland, solids tend to be started at an average age of 3.5 months old.

The order of foods is different than in the US.

In Finland it goes like this: potatoes, fruits and berries, carrots,

cabbages, then cereals, meat, fish, and eggs. This whole sequence is

introduced, on average, by 10.5 months of age.

In contrast in the US, we tend to start with cereals about 4-6 months

of age, do a few pureed fruits and vegetables, and that's about it

until 12 months old. Very different.

In this study, a delay in introducing a solid food in Finland meant

introducing potatoes over 4, oats over 5, rye over 7,

wheat over 6, meat over 5.5, fish over 8.2, and egg over 10.5

months of age

Now here is what they found, at age 5 years old, if the food introduction

was delayed in infancy:

The later the introduction of solids, the more allergies at age 5
Food allergies were more common with late egg, oat, and wheat
Hay fever and asthma were more common with late potato, and fish
Age of introduction of milk had little impact on any allergy
Results were independent of parental history of any allergy types
Breast-feeding had no impact towards or away from allergy

The authors cite data from the US, Germany, and UK that are in line

with their observations.

As we have long stated at Advanced Pediatrics, the introduction of

solids is not an important nutritional event. You can live on breast-milk

and/or formula for a very long number of years.

And, for many years, we have been deeply skeptical that avoiding

foods like berries, eggs, and milk will prevent developing allergies.

Well, it looks like the evidence is coming in, and it is leaning heavily

towards starting solids early, and starting a wide variety of them.

By early we mean about 3.5 months old!

Think about a wide range, not just cereals, but be sure to introduce

only purees to young infants, no one at any age should eat something

they cannot chew and swallow.

Dr. Arthur Lavin

2009-12-24

Many Thanks to All

Dear Families,

As we enter the holiday season I wanted to wish everyone
a wonderful time, and very importantly a happy and healthy New Year.

I also wanted to thank every one in the practice, parents, children, families,
for your most valuable gift, your trust in us at Advanced Pediatrics.

And, I wanted to thank Ms. Elise Provident for drawing a special
rendition of this year's trip to the White House. You can see Elise and
her wonderful drawing below. Her drawing is actually hanging in our
waiting room as well.

So Happy Holidays, Happy New Year to all,

We look forward to working as hard as we can to help everyone in 2010!

Dr. Arthur Lavin
Dr. Julie Hertzer
Ms. Kelley Muldoon Rieger
And our staff, Sue, Bobbi, and Samantha

2009-12-17

STD Screening at Advanced Pediatrics

STD Screening at Advanced Pediatrics

Sexually transmitted diseases include a diverse range of infections, some more dangerous than others. The ability to detect some of these infections has improved dramatically over the last few years.

Two of these infections, in particular, are very common, can cause a lifetime of difficulty, and are easy to detect with a simple urine test.

The two infections are chlamydia and gonorrhea. Both infections tend to infect the duct work of the reproductive system. They tend to cause no symptoms, but if left untreated, are responsible for at least 10% of all infertility in the United States.

To detect these infections, all that is required is a sample of urine sent to the lab, no blood test is required, no pelvic exam, no swab of the urethra. This is because we can detect the DNA of the germ in the urine.

A recent article in the leading journal, Pediatrics (http://tinyurl.com/ycaw7tn) finds that nearly one in 20 adolescents ages 14-18 are infected with chlamydia or gonorrhea.

Given a one in 20 chance of a problem that can cause a lifetime of infertility, and a painless test to find and treat such infections in good time, and that the vast majority of those sexually active deny being so, and of those infected have no symptoms, the case for screening is compelling.

As a result, Advanced Pediatrics is now recommending that all adolescents be screened at least twice for chlamydia and gonorrhea by a single urine sample at ages 15 and 17.

If positive, of course, the adolescent will be informed, counseled, and treated. Further testing for other STD’s will be pursued as well. If the tests are negative, an opportunity for important counseling will still be opened, but no further evaluation will be indicated.

STD’s can be an uncomfortable subject, clearly they involve the issue of sexuality. But beyond sexuality, STD’s are basically an infection. Because of the link to sexual activity, STD’s are the least well-diagnosed and treated infections people get. It is really for this reason that they continue to lead to 10% of all infertility, and for this reason we propose the neutral stance of screening everyone. It really is the best way to protect your children from what could be a very serious infection.

Advanced Pediatrics Recommends HPV Immunization

New Information on HPV Immunization

Several studies have recently been published regarding HPV immunization.

The key findings are:

The HPV vaccine is safe
It does, in fact, prevent genital warts
It can save several hundred lives a year from cervical (and oral) cancer
It can reduce the number of positive PAP smears
But, the lives saved from cervical cancer depend on women continuing to have regular PAP smears, even if they get vaccinated, after they begin sexual activity.

HPV is the Human Papilloma Virus, the virus that causes warts. A few of the many, many types of HPV cause most of the cases of cervical cancer in women. Four of these types are in the HPV immunization.

The best strategy for HPV prevention is to make sure the vaccine is active during the peak time of risk. In the

United States

, that peak risk time is ages 20-29, but there is clearly a rise in onset of HPV infections in ages 14-19.

An important article published in the December issue of Pediatrics (http://tinyurl.com/ycaw7tn) finds that in girls ages 14-19 in the

United States

, the chance of being infected with HPV was 18.3%, close to 20%!

The chance of developing HPV skyrockets after age 20, reaching rates of 60-80% amongst Americans by age 30.

An important remaining question is how long the HPV immunization lasts. Recent reports secure that period to at least 5 years, but there are early indicators that the protection may actually last for a lifetime. How so? It turns out that after immunization, exposure to the virus acts like a booster. If that really happens with HPV, the protection set up by the immunization series could last for many decades.

Over the last year or two, Advanced Pediatrics had issued concerns about the possibility of protection from HPV immunization only lasting 3 years, and further, that the actual benefit might be quite minimal.

These recent studies, however, are convincing.

Therefore, effective immediately, Advanced Pediatrics is recommending
that girls begin HPV immunization before onset of any sexual activity,
including oral sex, but no later than age 15.

For girls ages 15-22, who have not yet been immunized against HPV,
we also recommend they be immunized.

Disclaimer*

Radiation, CT scans, and Cancer

Radiation, CT scans, and Cancer

A recent set of reports in the Annals of Internal Medicine has
brought to our attention the risk of developing cancer from
excessive CT scans.

The relationship between radiation and cancer is well-established.

Everyone knows that if you get exposed to enough radiation, your
risk of cancer goes up. The more radiation, the more risk of cancer, too.

What is not so well known is that the body retains a memory of every dose
of radiation it experiences. That means if your body turns out to need
say 100 units of radiation to spark a new cancer, an exposure at age 2 to
45 units will actually add to an exposure at age 25 of 40 units, meaning that
at age 50, all you have to do is be exposed to just another 15 units of radiation
and cancer can be sparked.

What is not known is how much actual radiation in a lifetime is the least
amount to cause a case of cancer to not only begin, but take hold.

We do know that well under a certain total amount of radiation, there appears to be no
risk of increased cancer. So, for example, the amount of radiation you
are exposed to when you get a chest X-ray is very minimal, comparable
to the increased exposure you get when flying from Boston to Denver. This
tiny amount does not seem to cause any cases of cancer.

But some X-ray images take a lot more radiation to get the image.
The most is generated by CT scans.

The least is by MRI scans which generate no X-rays or radiation at all,
only magnetic fields, which appear to be very, very safe.

But CT scans need to shine alot of radiation on the area under study, to
get all the level of detail necessary to create the incredibly detailed CT image.

The information is so detailed and helpful that the number of CT scans done
in the US has exploded in the last 30 years. This year, the United States will
get 72 million CT scans done. That is 23 times the number done in 1980!

One would hope that with the explosion in the use of CT scans that there would
also be increased control and caution in the amount of radiation used to do each one.
Turns out, in San Francisco and Alabama, that the amount of radiation turns
out to be quite variable. The CT scan with the most radiation delivered
13 times as much radiation as the CT with the least, for the same CT
imaging!

The studies published go on to estimate how many cases of cancer are generated
by the use of CT scans in the United States.
Their conclusion was that roughly 23,000 new cases of cancer will be caused
by exposure to CT scan radiation, every year. And that in time there will
be 15,000 deaths from cancer each year in the US from CT scanning.

What is a Reasonable Response?

At Advanced Pediatrics we have developed this stance:

We do not recommend you ever get an X-ray or CT scan unless it is clearly needed.
If detailed imaging is needed, but an MRI will work as well, we would recommend using an MRI rather than CT.
If a CT scan is done, it should be done at a facility known to be able to keep exposure to a very clear and consistent minimum. We are pleased to state that our neighbors in our office building, Advanced Diagnostics, goes to great lengths to keep their use of radiation to the minimum. To that end, they have made a commitment to only use state-of-the-art CT scanners that use a small fraction of the radiation older scanners require.

Bottom Line

Radiation causes cancer and each exposure is added to subsequent exposures, the body remembers.
CT scans deliver more radiation than usual X-rays, MRI scans deliver no radiation
We should avoid getting CT scans unless they are truly necessary.
Keep in mind that routine X-rays such as chest X-rays and finger and toe films use tiny amounts of radiation. It takes 100-400 chest X-rays to equal one CT scan.
No X-ray should ever be done without good reason, but CT scans will require more caution in their use than other imaging choices.

Dr. Arthur Lavin

2009-12-03

Reminder on the Essential Value of Knowing if your Child's Illness is Mild or Serious

Reminder on the Essential Value of
Knowing if your Child's Illness is
Mild or Serious

On December 2, 2009, CNN asked me to present a list of highly
specific signs that would indicate a mild viral illness (cold or flu)
had become severe.

The segment was aired on CNN's morning news program, and
since it does a good job of visually presenting just what these
signs are, I am distributing the link:
http://www.cnn.com/video/#/video/health/2009/12/02/cohen.h1n1.saving.your.child.cnn

I also want to emphasize that knowing these signs allows you to draw
an incredibly important line that can help you achieve two incredibly
powerful goals:

If your child has none of these six signs, chances are overwhelming that the illness is mild, and there is on danger. The line can help you be calm as you comfort your child, knowing no danger is here.
If your child has some of these six signs, you know you need to get medical attention. The line can help you know when to call for help, reassuring you that you can know just when to call or intervene.

To recap, the six signs are:

Trouble getting air in and out of your chest
Stiff neck- cannot move the neck
Blue fingernail beds
Severe pain in one spot or area of the body
Altered consciousness- cannot wake, or acting very oddly
Just a sense that something is very wrong

I hope you find this list, the line it creates, and the video demonstration

helpful.

I have also appended an earlier post, from October, outlining the difference

between mild and serious illness in a bit more detail. It is specific for H1N1,

but so many families found it helpful and so I copy it below so you have this post,

that post, and the video all in one place. (Note that I added blue fingernails and
serious pain to my list of indicators of serious illness.)

Dr. Lavin

MILD versus SERIOUS ILLNESS:

or, Knowing When to Worry

and Knowing What to Do

As our nation and community encounter and try to deal with the very

serious epidemic of H1N1 (swine) influenza virus, it makes sense

to take a moment to think about how do you know, when your

child gets sick, when to worry and what to do?

It turns out that the best guide to knowing when to worry and

to know what to do is not the name of the virus.

That is, finding out if the virus causing your child's illness is H1N1

or not, does not help you know how worried to be or what to do.

The key item you need to know is how sick your child is, not the name

of the virus.

So how do you know how sick your child is?

The answer is actually fairly easy, since there are only two possible

answers: mildly ill or seriously ill.

Symptoms of Mild Respiratory Illnesses:

Fever (100.8-105.8)
Runny nose
Sneezing
Congestion
Cough
Sore throat
Achiness
Feeling tired
Trouble sleep
Decreased appetite

Symptoms of Serious Illness:

Struggling to get air in and out of your chest
Alterations in consciousness
Stiff neck
A "sense" that something very terrible is happening

Use the above symptoms to tell you how worried to be.

Mild illnesses, even if caused by potentially dangerous germs,

are still mild illnesses.

If you child only has mild symptoms of illness, and no symptoms of

serious illnesses, you have little to worry about.

Of course, should symptoms of serious illnesses ever develop,

one has alot to worry about.

What to Do if You Have A Mild Viral Illness

It turns out that medical science has very little to offer that would

actually make a difference to someone with a mild viral illness.

Antibiotics do not work.

More to the point, antivirals do not work very well either for mild

influenza infections.

So the use of Tamiflu is not recommended for use in mild viral

infections, it does little good, and could lead

to the drug not working if you really need it.

What you can do is to keep your child comfortable:

lots of fluids, lots of hugging, lots of distractions (videos),

perhaps ibuprofen or acetaminophen if fever or pain is

bothering them.

What to Do if you Have Symptoms of Serious Illness

Call us immediately.

If severe enough, call 9-1-1 first.

If severe enough, we will recommend immediate evaluation in an ER.

Once at the ER, if tests reveal influenza is present, Tamiflu will be used.

If influenza is not present, then the cause will be sought and treated.

BOTTOM LINE

H1N1 (swine) influenza virus is potentially dangerous, like almost all

germs.

The rules for knowing when to worry and what to do are the same for

H1N1 (swine) influenza virus and all other viruses.

If you have mild illness, you are in no danger, and should be treated with

comfort measures.

If you have serious illness, you should seek immediate medical care. It is

only serious infections with H1N1 (swine) influenza virus for which

Tamiflu is helpful.

Dr. Lavin

2009-12-02

Large Shipment of H1N1 now at Advanced Pediatrics

Good News!

The Crisis is Over

Advanced Pediatrics Just Received a Large

Shipment of H1N1 vaccine- shot and nasal spray

There is now currently plenty of H1N1 vaccine

for everyone.

Today Advanced Pediatrics received a good number of

three forms of the H1N1 vaccine:

The nasal spray
The shot for infants 6 months and older
The shot for children and adults older than 3 years

The fact that we have a good supply now means that we can offer the

H1N1 vaccine to everyone who is 6 months or older and not allergic to eggs.

This includes:

All children in our practice ages 6 months and up*
All parents of children in our practice*

*Unless, as noted, allergic to eggs, or have another reason a flu

vaccine would be harmful to them.

The material of H1N1 vaccine is free and we have not

and will not charge anyone for the material.

A charge for administration of the vaccine is made.

For children in the practice, those fees are submitted to the

family's insurer, as we are the primary doctor.

For parents in the practice, we are offering a discounted

fee of $20 that must be paid at the time of service, prior

to the H1N1 vaccine being given to the parent. We will

also register the parent to document the vaccine was given.

Supplies are expected to be abundant, but of course that

is totally dependent on demand, so we will see.

With regard to seasonal flu vaccine, our supplies remain

limited and we do not expect that to change, the manufacturers

only made a certain amount and that turns out to be a too small

amount for the US this year. We still have seasonal flu vaccine, but

expect to run out in the next few weeks.

Dr. Arthur Lavin

2009-11-29

Advanced Pediatrics on CNN this Wednesday on H1N1

Advanced Pediatrics on CNN

this Wednesday, December 2

on knowing when H1N1 infection

becomes serious

We are pleased to share the news that this Thanksgiving weekend the national health editor
for CNN, Dr. Elizabeth Cohen, flew with her producer and a film crew from CNN
headquarters in Atlanta to Cleveland to ask Advanced Pediatrics about how to know
if your child's viral illness becomes serious.

The segment, featuring Dr. Elizabeth Cohen of CNN, Dr. Arthur Lavin of Advanced
Pediatrics, and a family from the practice, will air on CNN in the 7PM hour this
Wednesday, December 2.

They called Advanced Pediatrics to seek our advice on specific signs parents could use to
know if a viral illness, such as H1N1 infection, moves from being a mild to a serious disease.

Readers of our web postings on H1N1 infection know that the distinction between mild and
serious illness has been the key concept to keep in mind when caring for your child with
any viral infection, including H1N1.

A family from the practice was gracious enough to open their home to the recording of the
segment, and we put together an approach built on six key signs of serious illness.

The Six Signs that a Viral Infection has Moved from Mild to Serious are:

Struggling to breathe- a certain sense that it is now very hard for your child to get air in and/or out of his/her chest
Stiff neck- this means you cannot move your neck, not that it is sore. If you can move your chin to your chest your neck is not stiff.
Severe pain in one area of the body- if one area of the body, such as a spot in the belly, or chest, or limb, develops severe and persisting pain, this is a sign for concern.
Blue fingernail beds and lips- lips and fingernail areas should be pink, turning blue means something could be seriously wrong, unless they are simply chilled.
Altered consciousness- this is happening if your child cannot wake up, has lost consciousness, or when awake seems quite odd- unaware of their name, or situation, or time. This is not the tiredness and exhaustion of being sick. When you are tired, you still wake up and act pretty much like you usually do when tired. Altered consciousness always is alarming and not hard to notice.
A sense that something is seriously wrong- Very importantly, even if no specific sign is present, if a parent feels that something is seriously wrong, we urge you to call. We have almost never found that a parent felt like nothing was seriously wrong only to find out the situation was serious at that time.

Dr. Cohen at CNN will be broadcasting a segment discussing these six signs in an effort to help parents understand two key points:

When to know if your child's illness is mild and not dangerous (none of these six items are present)
When to know if your child's illness is now potentially serious (one or more of these six items are present).

A very strong thank you to all the families in the practice who were part of preparations for this broadcast.

Most importantly, I hope the broadcast on CNN helps further clarify just when to know your child is safe when ill, and when it is important to call us for help.

Again, the segment is airing sometime during the 7PM hour (Cleveland time) on Wednesday, December 2.

We really do hope you find it helpful.

Dr. Arthur Lavin

2009-11-24

H1N1 is Here!

Our Second Shipment of H1N1 Vaccine
Has Arrived

Advanced Pediatrics is pleased to announce that just this morning,
November 24, 2009, we received our second shipment of H1N1
vaccine.

At this time, therefore, we are opening up appointments during regular
office hours for all those interested in having their children protected from
infection from the H1N1 virus.

A few points:

This shipment includes the nasal spray and injection formats.
This means we can immunize from age 6months up
And we can immunize those with asthma.
At this time we will offer vaccine to all those who need their first dose.

On our recommendation to be immunized against H1N1 illnesses

The fall epidemic of H1N1 illness in the Cleveland area ceased about

two weeks ago. However, H1N1 could very easily return. Further, if it

does return we have no idea if it may cause more dangerous.

And so, once again, Advanced Pediatrics recommends you immunize all

your children 6 months of age and older for H1N1 infections. This is a

reasonable if not urgent recommendation.

Bottom Line:

Advanced Pediatrics has H1N1 nasal spray and shot.

Appointments can now be made to have your child receive

their first dose of H1N1 vaccine.

Call soon while supplies last, but we do expect more

shipments over time, too.

Dr. Lavin

2009-12-30

Football: Time to Admit the Danger

Vital Statistics 2009

2009-12-29

Turns out it is good to eat food

2009-12-24

Many Thanks to All

2009-12-17

STD Screening at Advanced Pediatrics

Advanced Pediatrics Recommends HPV Immunization

Radiation, CT scans, and Cancer

2009-12-03

Reminder on the Essential Value of Knowing if your Child's Illness is Mild or Serious

2009-12-02

Large Shipment of H1N1 now at Advanced Pediatrics

2009-11-29

Advanced Pediatrics on CNN this Wednesday on H1N1

2009-11-24

H1N1 is Here!

Tags

Twitter Updates