Advanced Pediatrics: 2011

2011-12-25

A True and Astounding Scientific Breakthrough: Genes Changed, Christmas Disease Reversed

A True and Astounding Scientific Breakthrough:

Genes Changed, Christmas Disease Reversed

A profound triumph was reported in the New England Journal of Medicine this week. On December 10, 2011, investigators in London made history.

Image via Wikipedia(http://www.nejm.org/doi/full/10.1056/NEJMoa1108046?query=featured_home)

For the first time in the history of the world, a virus was altered and then given to people, successfully changing the DNA of the infected person, thereby actually reversing a genetic disease, and ending the suffering caused by the genetic disease.

The report establishes that for the duration of the change in the infected person's DNA, their genetic disease is cured.

The disease is the second most common form of hemophilia, variously known as hemophilia B, Factor IX deficiency, or Christmas disease, after the name of a 10 year old boy with the disease, Stephen Christmas. Stephen was the first person in whom the cause of hemophilia was defined as a deficiency of a clotting factor, specifically Factor IX.

Background: The Basics of Why and the How Blood Clots

To understand the astounding nature of this breakthrough, a little background on hemophilia. Hemophilias are diseases of too little clotting. Blood is a very peculiar liquid. It has to have two opposite properties available to it, at all times. For most of the time, blood must be very liquid, it must be able to flow. After all, it supplies all the oxygen and nutrient to the cells of the whole body. No flow, no life.

But at the same time, the delivery of blood depends on intact pipes to deliver it. Leaks in the pipes lead to loss of blood, which can ultimately end flow. Those leaks can be small or large. All the pipes, or blood vessels, are made of living cells, whose edges always need to be kept nice and close to prevent any blood from leaking out. The pipes can also be injured by tears and cuts. So when tiny leaks occur or big tears, the blood right there needs to patch the hole if blood flow is to be saved. And so blood has the incredible ability to convert from a liquid to a solid, right where the hole is, sealing the leak, in a process called clotting.

Now, for blood to always be liquid when necessary and at the same time be able to always be a solid when necessary, the body has devised many, many processes that keep the blood liquid, and allow it flash into being solid. The fact that many, many processes are active in both directions, allows the body to fine tune the situation to a remarkable degree of accuracy, keeping the blood liquid and flowing whenever that is required, and converting it to a solid, in just the one spot it needs to be at just the one time it needs to be, whenever or wherever a leak occurs.

One of these complex systems of checks and balances is called the coagulation cascade, and it is made up of over 13 different enzymes, each called by their Roman numeral number. So the #5 enzyme in this cascade is called Factor V. In order for a clot to form, a sequence of one enzyme activating another needs to be launched before the final step of a clot forming can occur. Of course, the body has various counter measures to stop the cascade from proceeding at every step, so that the jump towards making a clot can be very carefully controlled.

Hemophilia, then, is a disease where one of these 13 or so clotting factors is missing. There are two clotting factors whose absence makes up nearly all of hemophilia, Factor VIII and Factor IX. In Christmas disease, the gene that makes Factor IX is defective, and the affected person makes essentially no Factor IX. This leads to life-threatening, painful, and damaging bleeding into bones and muscles. This is the disease that the descendants of Queen Victoria had.

If the person is given Factor IX, the bleeding does not occur and the disease is controlled. But Factor IX is not easy to get, and to prevent bleeding one has to have a steady supply. If one depends on getting Factor IX from donated blood, that exposes a person to lots of donors and a real risk of AIDS. In fact, hemophiliacs were the people at highest risk for getting AIDS until the blood supply could reduce the amount of AIDS to essentially zero.

Background on Gene Therapy

Now one more piece of background before we unveil the incredible nature of this news.

Genes are bits of DNA that make proteins. And proteins, in turn, are the main signals of the body, directing it to do nearly each and every one of its myriad chemical reactions. In the case of hemophilia,the gene for Factor IX makes the protein Factor IX, which we just learned is an important cog in the wheel that allows blood to clot at the right time and place.

No gene for Factor IX, no Factor IX, lots of painful and destructive bleeding.

So, if one could find a way to fix the gene for Factor IX in people with Hemophilia B, or Christmas disease, they would no longer have hemophilia. To fix such a gene, one would have to succeed in each of these steps:

Insert the normal gene for Factor IX into living cells of the person with hemophilia B.
The normal gene would have to be active in the cells that normally make Factor IX.
The cells with the inserted gene would have to actually make normal Factor IX in sufficient quantity
The new gene making the cells make Factor IX would have to continue operating the rest of the person's life.

Notice that in contrast to interventions like transplanting there is no risk of rejection or bad side effects. At its heart gene therapy is the most harmless of ideas. It simply restores normal function to your cells.

But the great challenge of gene therapy has always been, how to get a new gene operating in your cell without disrupting that cell? The answer these scientists came up with requires one more piece of background before we unveil the extraordinary breakthrough.

Background: How does a Virus Work and how does that help make gene therapy happen? Therapy?

Most of us know viruses as a major nuisance and creator of agonies. Viruses make us sick, they give us colds, flus, stomach flus. They cause warts and rashes and cold sores. Really, what good could come from that? What sort of good science could possibly come out of a week of sneezing and coughing, and being up all night with your suffering child?

Well, it turns out that viruses are barely alive. One could make the case that they are more little packets of information than of life. Every virus that we know of is a very simple package of 2 elements. A coating of a handful of proteins and within that coating a strand of DNA or RNA. Each of these 2 elements have one specific task to complete.

The coating of proteins contain codes that open the door of a cell the virus. Keep in mind every cell in every bit of life must take in certain compounds, keep out certain compounds, and secrete certain compounds if it wants to live. Cells are extremely clever about keeping what is needed in, what is dangerous out. The proteins on the outside of every virus, then, are proteins that talk to their target cell to talk that cell into letting the whole virus into the cell. Now, keep in mind that one virus is about one thousandth the size of one human cell. So from a size point of view it is nothing for one virus to enter one cell, it just needs the right key, and that is what its coating proteins are, a key.

Once inside the cell, the second element of any virus comes into play. That element is a strand of DNA or RNA. Either way, that strand is really a piece of information. And in the case of viruses, the information this strand of genetic material contains is limited to 2 items: make more coating protein, make more viral DNA/RNA. That's it. That's the only message a virus delivers to the cell once it is inside, make more virus.

That information gets expressed by the viral DNA/RNA inserting itself into the cell's DNA thereby forcing your cell to stop what it is doing and make viral proteins and genes.

Now, for most cells, that's a bad message. For once the cell has been commanded to make more viruses, it makes billions of them and the cell pops. That's how colds work, all the cells lining your nose, throat, lungs, sometimes eyes pop. That leaves the lining of these areas actually burned, weeping and watery, red and swollen, and they stay that way until the cells are replaced and the virus is killed. That is, a cold.

So why use such a marauding system to help someone get well?

It turns out there is no machine for delivering a new gene to your cell's genes like a virus. Imagine, just plop the new gene into the protein coating of a virus, let the new gene sit next to the viral DNA/RNA, then let the virus into the patient's body, and whammo, the virus inserts all its genes into your genes and your cell now has the missing gene.

That's why science turned to viruses for gene therapy, they can deliver, implant, and activate the new gene!

But, to use a virus to fix your gene now demands these steps be met:

Put the desired new gene inside the protein coat of a virus.
Once assembled, this new gene-virus combo still has to be able to enter the target cells. The target cells are the cells of the patient's body that the new gene should help restore to the lost function. In this case, the target cells are the cells that make Factor IX in the human body, and those turn out to be liver cells. So, it does no good to have a virus with the gene for Factor IX strapped into it, if the virus cannot get into a human liver cell.
Once the new gene-virus combo is launched in the body, it would be ideal to have the virus enter the target cell, insert the new gene into that cell's genes, but stop there. That is, let the new gene in the virus be active in the target cell, but don't let the viruses own genes activate. If the viral gene activates we know what will happen, billions of viruses will be made and the cell just cured of its genetic defect will pop, and the patient will just end up with a cold.

The Breakthrough

Now we are ready to be amazed. The report from the New England Journal of Medicine establishes that this all has been done in people with hemophilia.

Scientists took a virus called the adeno-associated virus. This is very unusual virus, in that it does invade and multiply in people, but does not cause illness. A perfect sort of virus for gene therapy.

So what happened was that scientists altered the adeno-associated virus in two ways: they inserted a normal healthy gene for Factor IX, and they weakened or deleted the ability of the virus to cause harm to the cell.

With this new machine in hand, they simply injected a bunch of this virus into 6 people with hemophilia B, or Christmas disease.

Here is what happened:

Not a single person got sick
Every one of the six people with hemophilia needed less Factor IX injections to remain free of bleeding. Four of the six went off Factor IX completely for the many months of the study.
The immune system did notice the virus and did make antibodies to it.

To put it in the simplest possible words, if this change sticks, 4 of 6 of these first people treated will be cured of their hemophilia! And, the other two were nearly cured!

This is the first instance in the history of the world that a person had a normal gene inserted to take over from a faulty gene, curing a serious illness, with essentially no side effects.

The door is now very much open to addressing problems caused by single gene abnormalities. Now, most of human suffering is not due to simple, one gene problems, but many problems are, like cystic fibrosis, muscular dystrophy, sickle cell anemia, for example. And there may be conditions of more complex genetics where altering one or two genes could make a very large difference.

Think about, 6 people who did not make enough Factor IX to prevent serious bleeding now are making it on their own with no further intervention beyond one single injection of a very weak virus that did not make them ill.

I thought it quite poignant to report this astounding breakthrough to you on the Christmas of 2011.

After all, the first disease truly reversed with one gene therapy turns out to be Christmas disease.

The promise of medical science continues to amaze. Modern surgery transformed our ability to remove harmful entities from our body, untwist clogged structures, repair wounded or malformed parts of the body.

Antibiotics gave us the unheard of power to kill deadly bacteria and push back the scourge of infectious disease. And now, we can for the first time meet people who had one gene changed curing a once incurable disease. We now have our hands on the genome, and the possibilities for helping life have suddenly taken another leap forward. I am especially pleased that the approach to touching the genome was done so responsibly and safely. As with every advance, a dark side always threatens, the dark side of unintended consequences. But when I look at the interventions of surgery, antibiotic, and gene therapy, we may ultimately find gene therapy the safest of them all. It's end point is clearly the most harmless, adding a normal gene to a normal cell, really simply restoring a cell to its intended and natural function. No surgery or even antibiotic can claim that level of process, each involve killing normal cells (cutting) or disrupting normal functions (hurting helpful bacteria in the body) as they reach their goals. If the delivery of the healthy gene can be made fully harmless, gene therapy could be the safest intervention yet invented.

So, I wish all families today a very Merry Christmas, a Happy חנוכה (Hannukah), and starting tomorrow Kwanzaa. This breakthrough adds more hope that 2012 will be a Happy and Healthy New Year for all of us as well.

Dr. Arthur Lavin
December 25, 2011

2011-11-24

The Shortage of Adderall

The Shortage of Adderall

Earlier this year, reports began emerging in various cities in the United States, that a shortage of the drug Adderall was occurring. Just today, November 22, 2011, I was called by the first family to find that their pharmacy was out.

Adderall is the brand name for the drug amphetamine, which is used by many people to treat ADHD.

There are other forms of amphetamine available that are not in shortage (Vyvanse, amphetamine), and other related medications that treat ADHD (Ritalin, Concerta, Methylin, Metadate, Focalin), but for those being treated with Adderall, the shortage is of concern.

The reasons for the shortage are not entirely clear, not even what forces are driving it.

The manufacturer is making as many doses as it usually does, and doctors are prescribing it at relatively steady rates.

A curious feature of the stimulant drug market has emerged as this issue has been looked at. The stimulants are all variations of the street drug amphetamine, which is illegal to use without a prescription. Therefore, the use of amphetamines is tightly monitored by two major Federal agencies, the FDA (Food and Drug Administration) and the DEA (Drug Enforcement Agency). Each prescription for any stimulant is monitored and the government works hard to detect any trend towards illegal use. This is why prescriptions for stimulant medications cannot be called in and why, at the pharmacy, refills cannot be authorized.

As part of the government's effort to allow the use of legally prescribed stimulants but bad the use of illegally non-prescribed stimulants, the FDA sets a total amount of drug that can be manufactured in the US. That amount is set by the number of prescriptions. So, if in the US, say some number of tons of Adderall are prescribed each year, the FDA will allow the manufacturer to produce that number of tons, with some extra to make sure the supply meets the demand.

Officials at the FDA are clear that they have continued to allow the amount of Adderall to be manufactured that will meet the demand as defined by the number of prescriptions written. The manufacturer disputes this.

And so we have a situation in which families go to their pharmacy and find the pharmacy is out of Adderall, and cannot get more.

Possible reasons include:

The government has it wrong, prescriptions are up and manufacture is not.
The government has it right and there is enough being made but not enough reaches the drug stores

A problem with distribution has occurred with problems in shipping or stocking causing the shortage
Manufacturers are allowed to make enough but for some reason enough batches have gone bad to affect availability
Manufacturers are making enough and distributing it well, but illegal use could be exploding, diverting the limited supply to those not prescribed the medication.

We do not know the reason at this time.

But, if you are on Adderall and find you cannot get the medication, try various pharmacies as your first step.

Consider mail order of the prescription as well.

If you are part of the Advanced Pediatrics practice, call our office to inquire about other approaches to helping your child with ADHD, including use of related medications that are not in shortage, non-medication options for therapy, and use of non-stimulant medications.

Happy Thanksgiving,
Dr. Arthur Lavin

2011-11-18

Don't Spank- The Controversy has Led to Tragedy

Don't Spank-

The Controversy has Led to Tragedy

Recent news reports bring to light the fact that 3 children have been killed by parents following the advice of a preacher in Tennessee whose book that calls for parents to use beating to discipline children has sold over 600,000 copies.

http://www.nytimes.com/2011/11/07/us/deaths-put-focus-on-pastors-advocacy-of-spanking.html

The preacher is Michael Pearl and he promotes a religiously informed conviction that an essential tool in teaching children rules and how to follow them is to beat them. He goes so far as to call for children to be trained just as mules are trained, and his book recommends the type of instruments that are best to use when hitting your children.

Clearly, this call for hitting children is an extreme, but it taps into a controversy that all parents in America face- is spanking a good tool for teaching kids rules and encouraging them to do so?

To my mind, it is a controversy that is worth our attention about as much as arguing if the earth is flat. This question has actually been measured and studied, and in every instance the studies find the same conclusion:

Spanking does not work.

What does that really mean? The facts are dramatic:

Kids who are spanked do not behave better than kids who are not.
Kids who are spanked are not more likely to follow the rule the spanking was meant to teach
Kids who are spanked are more likely to have trouble in their life than similar kids who are not spanked. Spanked kids tend to be more likely:

To be more violent
To have more trouble having healthy relationships
To hit their children

So, not only does spanking fail to teach kids to behave well, it also actually hurts children.

If a drug failed this miserably and hurt people this much it would be off the market very rapidly.

This makes the attraction of hitting kids in today's climate all the more striking, and yet hitting kids has become a politically sensitive subject with some constituencies taking on the use of spanking and corporal punishment as important actions to support for a variety of reasons.

This news story reminds us that it is important, from time to time, to look at the facts when it comes to how we teach our children. There may be religious or philosophical concepts that promote the idea of hitting children, but the facts establish that it doesn't work and it causes harm. The tragedies of these three families should bring that message home quite forcefully.

Bottom Line

Spanking is a nice word for hitting our kids.

It turns out that hitting kids does not work, it does not help control behavior and it fails to teach kids rules.

Further, hitting kids can cause harm, at the time, and later in life.

We strongly urge all families to be careful not to hit their children.

Dr. Arthur Lavin

2011-11-14

Screening for cholesterol and lipids in childhood

Screening for cholesterol and lipids in childhood

On November 13, 2011, three major medical societies announced new recommendations for screening children for elevated cholesterol levels.

Major medical societies are endorsing the concept of treating elevated cholesterol levels with powerful medications at younger and younger ages.

In this instance, the American Academy of Pediatrics, the American Heart Association, and the National Heart, Blood, and Lung Institute (part of the NIH), all are agreeing that drugs such as Lipitor should be used in children before puberty.

There are several reasons to agree with these recommendations, but one reason suggests the recommendations are flawed and should not be followed, yet. What is missing is any evidence that treating high cholesterol at young ages leads to longer or better life later on.

Does lowering cholesterol at age 10 help someone be healthier at age 50 than lowering cholesterol at age 20?

This is important, because if someone starts a drug like Lipitor at age 10, they will have daily exposure to that drug during the critical years of puberty, and, compared to starting such treatment at age 20, will have 10 extra years of drug exposure.

Elevated cholesterol has been an interest of mine for many years. In the late 1980's, I practiced in Boston, and led a cholesterol screening clinic there. I helped form the New England Pediatric Preventive Cardiology Network, which came to include such clinics at Harvard, Yale, Dartmouth, and Brown. We eventually published our experiences in Boston.

http://www.ncbi.nlm.nih.gov/pubmed?term=lavin%20AND%20newburger

Why look at cholesterol in childhood?

I got interested in this issue because it is well known that the arteries begin to clog with fat deposits as early as 2 years of age. So it made sense to stop the clogging before the arteries get clogged. It still makes sense to do that. The key question is what actually succeeds in keeping the vessels from clogging?

With that goal in mind, we drew lipid panels on every child whose family had a history of heart attack or bypass surgery prior to age 55-60 years old. We were able to find close to 100 children, some as young as 2-3 years old, with quite elevated cholesterol levels, sometimes as high as 400!

So we had a purpose in mind, stop arteries from clogging early. We had a way to find those at highest risk, those with a positive family history of early age heart attacks or clogging. And, we did succeed in finding children with very seriously elevated cholesterol levels.

Why not look at cholesterol in children?

But then we found the problem. Here we had several dozen young children with very high cholesterols in whose families many people had suffered serious heart attacks in young adulthood. It was obvious this group could benefit from treatment, right? Not so.

First we attempted to lower cholesterol by strict dietary control: no cholesterol, very low fat, high fiber, in the diet. Every family consulted with a skilled dietician, but even with extremely strict diets, we could not lower cholesterols more than 10%. That meant a child with a cholesterol of 290 could not get below 260 with diet alone.

Then we tried a variety of relatively safe medications, like cholestyramine, that bind cholesterol but do little to interfere with the body's chemistry. These drugs had little impact.

The only class of drugs left that would make a real difference were statins, like Lipitor. But these drugs are very powerful, could have significant side effects. It was not clear then that it would be safe to put a 3 year old on them for their entire childhood.

When all was said and done, we had created a group of children whose families now knew their cholesterol was dangerously high, but but nothing to do to really help.

Thoughts on Effective Screening Programs

What I learned from this experience is that a good screening program really has to fulfill all steps of being useful to really be useful. Those steps are:

The condition being screened has to be important. No sense in screening for how long your hair can grow, finding that out does not improve anyone's health.
The condition being screened for must have a treatment that makes a difference, and a treatment that is safe and available when the test comes back abnormal. This is where our clinic in Boston ran into an obstacle.
The timing of treatment should make a difference in actual outcome. It makes little sense to screen if treating the condition leads to the same outcome whether one treats early in the course or later in the course of the condition.

When it comes to cholesterol, only one of the three key criteria for a good screening program is present- a high cholesterol is an important problem.

But the safety of treating young children with a very powerful category of medications, statins, is simply not yet known.

And perhaps most worrisome, no one actually knows if treating someone for high cholesterol at age 10 will indeed lead to a better or healthier life than starting treatment at age 20.

For both these reasons, it seems like a bad idea to screen young children for cholesterol elevations much before puberty- we do not know if the key drugs used are safe at this age, and we do not know if someone is better off starting treatment at the earlier age.

Bottom Line

A major recommendation came out Sunday, November 13, 2011- young children should be screened for high cholesterol and if found to be high enough, start the powerful drugs in the category of statins.
Proof of safety of statins in young children is not established, so starting such a drug will commit a child to taking a potentially dangerous drug every day for many, many years, during development.
Most importantly, because it is not known at all whether starting treatment for high cholesterol in childhood yields a healthier adulthood, we do not even know if any benefit comes from starting statins as such early ages.
Therefore, Advanced Pediatrics is not recommending that young children be screened for high cholesterol or other lipid abnormalities. Clearly if a specific child has a problem requiring a look at the lipid profile, such testing makes good sense, but not as a test required of all children.

Dr. Arthur Lavin

2011-11-10

Good news on Urinary Tract Infections

Good news on Urinary Tract Infections:

UTI's in Childhood Cause no Harm to Adult Kidney Function

Over the last 50 years there has been a very disturbing idea put forward that urinary tract infections (UTI's) in children, given the right complications, could cause damage to kidneys that could cause kidney problems later in adult life.

This idea has fueled a great deal of worry and a lot of studies, the most uncomfortable of which is the VCUG, a test involving catheterization of the bladder.

The idea was based on the observation that children who have both a UTI and urinary reflux [this is when urine flows up to the bladder towards the kidneys, not just out of the bladder when one urinates] can develop scars in their kidneys, and that scars appear to be associated with the need for dialysis later in life.

The good news it that over the last year or so, important research has tested this idea, and found that it is not true.

Most recently, a very important study was reported in our lead journal, Pediatrics (128(5) Nov 2011, 840) where 1,576 cases of chronic renal disease in adults were reviewed. In no instance could a clear connection to a UTI in childhood be linked to the cause of the adult chronic renal disease. An accompanying editorial puts the matter very clearly: "It's a Myth--UTI Does Not Cause Chronic Kidney Disease."

So now, we can safely say that a UTI is like most any other infection, worth treating to become more comfortable, but not an infection that puts one at risk later in life.

And, it means that the use of VCUG's in childhood is going to drop quite a bit, which is comforting news.

Bottom Line:

Urinary tract infections in children do not cause problems with kidney function later in life if the kidneys were normal to begin with.

UTI's should be diagnosed and treated to help your child feel better, not to prevent a danger.

If your child has UTI's that are severe or frequent enough to cause concern, a renal ultrasound is still a good idea to be sure the kidneys are normal, but the VCUG study will no longer be used routinely.

Dr. Arthur Lavin

2011-11-07

Cough- When to Worry, What to Do

Cough- When to Worry, What to Do

Cough is one of the most agonizing experiences a healthy person can have.

More than runny nose or itchy eyes, a cough really causes a lot of suffering.

The sound is irritating, and coughing whenever you breathe is exhausting, robs you of sleep, and hurts.

Also, cough, more than most problems, can keep happening. Some people can cough every day for months and months. But even a few weeks of coughing is enough to create tremendous discomfort.

And yet, cough is one of the most common experiences of humanity. Everyone coughs at some time in their life.

Here we have a problem that everyone experiences, literally everyone, so how can a parent tell if there child's cough is different from what we all see come and go without any harm done.

So what is a cough, when is it a problem, what helps?

What is a Cough?

A cough is a sharp exhalation, really an explosion of air out of the chest.

Coughs occur always in response to an irritation in the airway, and typically an irritation somewhere in the throat, vocal cord area, and/or lungs.

There are only a small number of causes of the irritations that cause us to cough:

Viral infection (tend to last no more than a few days or weeks)
Bacterial infection (tend to make one rapidly ill with high fever and getting sicker every hour or day)
Allergy (may go on with no change in intensity for months)
Irritation (such as smoke)

So coughs can cause a great deal of suffering, and last for many weeks and months, but the number of types of causes of cough is actually fairly small.

When to Worry?

Most of us get worried about a cough if it sounds bad, lasts too long, or is bothersome.
One would think these are good signs to watch for, but it turns out that these clues tend not to help figure out if you are in trouble.

Keeping in mind that a cough almost always is a sign that the lining of the airway is inflamed, the key thing to worry about with a cough is if it indicates that the inflammation is serious enough to interfere with air coming in and out of the body.

Here is another way to think about this. The air moves in and out of our body via a set of hollow tubes. Every one of those tubes has a living lining. That lining often gets inflamed, meaning it can get swollen, make lots of mucus, and get very tender. If the lining of a tube gets swollen and makes mucus, the whole tube gets more narrow. If the tube gets narrow enough, air does not pass in and out of the tube very well.

So, a cough is a clear sign that the tubes that carry air in the body are inflamed. So now the key question becomes: how inflamed are the tubes? Are they inflamed enough to interfere with air flow or not? If so, then we have a serious problem, a potentially dangerous problem. If not, then the cough is a sign of an inflammation that is harmless and will go away.

This leads us to the key signs that someone with a cough is of concern:

Most Important: Do you have any trouble breathing when not coughing?
The best indicators of trouble breathing are:

breathing rapidly
tugging or working hard to get air in or out of the chest (not nose)
skin on the chest tightening with each breath
grunting with breaths
if the child says they are having trouble getting air in and out of the chest

If none of these symptoms are present, and your child looks very comfortable breathing when not coughing, then the tubes carrying the air are likely not too swollen, and the inflammation is very likely mild and harmless.

If ANY of these symptoms are present, you should call for medical attention.

How to Get Rid of Cough?

The next question when it comes to cough is how to get rid of it.

That all depends on the cause:

Bacterial infections are best treated with antibiotics, and antibiotics are only helpful for this cause.
Allergic reactions are best treated with antihistamines and inhaled steroids
Irritations are best treated by removing the irritation.
Viral infections are incredibly resistant to all known drugs. There are no drugs yet invented that can significantly reduce the inflammation caused by viruses. This includes cough syrups. No cough syrup has yet been shown to decrease the number of coughs one has per hour or days one coughs. In fact, the FDA launched an investigation of over 500 cold remedies in March of 2011 with an eye towards exposing which are frankly ineffective and/or fraudulent.

Bottom Line

Cough means the airways are inflamed.
The causes are usually one of four causes
The best indicator that a cough is worrisome is how you are breathing when not coughing.
The cough itself can be quite agonizing even if the underlying condition is harmless
Coughs caused by viruses (colds, flus) cannot be stopped by any known medication, including cough syrups and antibiotics.
If you think your child is having any trouble breathing, getting air in and out of their chest, call for medical help immediately

Dr. Arthur Lavin

2011-10-11

Vitamin Pills Not so Good For You

Tetrahydroimidizalone or Tomato:

New Evidence that Foods are Better than Vitamins

The word vitamin is a marketing triumph. It speaks of vitality, it speaks of Superman, and put those ideas and feeling together and you have a winner. As a result, any chemical that can bear that name has had extraordinary success in the marketplace. About 50% of all American adults take a multivitamin every day.

This makes vitamins the #1 set of chemicals that Americans take. The question is, does taking a multivitamin really deliver? Or like any other drug, are there down sides?

A new study published in the Annals of Internal Medicine, took a look at the fate of 38,772 women, average age 62, some who took multivitamins, and some who did not. The study looked at how each group fared over a nearly 20 year period. What they found was that the group that took multivitamins died a bit faster. The study looked at a number of supplements. The most dangerous was iron which substantially increased the rate or risk of death. Just taking Vitamin A or D had little impact on the rate of dying, but taking a multivitamin did, it increased it.

This study adds further fuel to the argument that taking any drug, even one that sounds safe like vitamins, is not nearly as good for you as eating good food.

Consider just one vitamin. This vitamin contains tetrahydroimidizalone, and is found in abundance in tomatoes. Imagine someone trying to get you take a tetrahydroimidizalone pill every day, it would be a very tough sell. All your warning flags would be aroused. What is tetrahydroimidizalone? Sounds very technical and dangerous. What side effects does it cause? And yet, about 50% of all adult Americans take this chemical every day, as long as it is called Vitamin B7, or biotin.

Now, there is no doubt that if you do not eat enough biotin, bad things happen to you. But the question is, are you better off eating biotin-containing foods, or taking a pill of it? The evidence for food is overwhelming at this point. And the reason that makes sense is clear. A tomato has lots of tetrahydroimidizalone-rich biotin in it. But it also has thousands and thousands of other compounds. Further, humans and tomatoes evolved together. As our ancestors found vines whose fruits helped us live, we cultivated those vine more. As the benefit from a food grew over time, humans helped that food prosper. The trend led to the evolution of highly complex foods that help us live. Vitamins are a part of nearly all plants that we cultivate.

And yet, with only one exception, we have found that taking the vitamin out of the plant helps us in any way. Vitamins work best when they work in concert with the tens of thousands of other chemicals in plants that we evolved to live on. The one exception to date is folic acid, which as a pill, does prevent the development of spina bifida in pregnancy.

This study of so many women adds a dramatic extra level of evidence for this point. In fact, now we can say that not only do multivitamins offer no benefit over eating a piece of fruit, but they may cause harm.

BOTTOM LINE

Despite the reassuring sound of the category, vitamins are like every other pill, they can cause harm. A recent study demonstrates that the harm might include dying at a younger age.

We recommend that all your vitamin needs, with the exception of folic acid, be met by eating food.

We recommend that no one take a daily multi-vitamin, unless you have a specific medical condition requiring it.

Dr. Arthur Lavin

2011-10-08

A Word on Screening

The Uproar over Screening for Prostate Cancer:

A Lesson in the World of Screening for us All

One of the most surprising aspects of modern medicine is how hard it is to create a screening test that works well.

After all, what could be simpler than screening? Screening just involves measuring something in everyone and finding those few whose measures are abnormal. And then, knowing which of us has the problem, we can cure or eliminate it before it does any harm.

This is, in fact, the idea behind screening. Find the problem early, reap the benefits of taking care of the problem before it causes any harm.

Some screening test methods do just that. The best of them is the newborn screening test for a condition called PKU. It was the first of all the newborn screening tests and it has all the features of a good screening program:

The test is simple, inexpensive, and extremely safe.
Essentially everyone with PKU tests positive, and everyone without PKU tests negative.
If you are found to have PKU in the newborn period, there is an action that can be taken that will ensure no harm will come to you. If you have PKU and no one knows it, the intervention, which is simply to change your diet, cannot be offered and severe mental retardation will result. The test result makes a dramatic difference.
There is a system that allows all Americans to be tested at birth, for all positive results to be reported to the family and their doctor, and for those with PKU to receive the life-saving intervention.

The dirty little secret of screening, however, is that most techniques to do this do not work very well. With few exceptions, most screening tests used in medical practice have a tremendous overlap, that is, people with positive results often do not have the problem. Also, too often there is no clearly defined intervention or treatment that leaves the person reliably better off.

And yet, there is an explosion in the number of screening tests being developed. As a result, every American is asked to be screened for a widening variety of problems, often without a good screening technology in place. The test is available, but the test is often not a very good performer, not like the PKU test at all.

This has all come to our attention with the recent announcement that the screening test for prostate cancer, PSA, does not work very well. This was the finding of the nation's leading authority on screening tests, the United States Preventive Services Task Force (USPSTF). The USPSTF exists for only reason, to study screening tests and see if they work.

How could a screening test fail? Well, it turns out that when you study them, they nearly all fail in some way or another. The bottom line is that a screening test fails if, when all is said and done, it is likely not to help you.

How could a screening test turn out to cause more harm than good? Here are some ways:

The test could be so expensive, painful, and/or dangerous, that you are left more hurt than the problem you are looking for could have made you.
The test could tell far too many people that they have the problem or disease when in fact they do not. Imagine taking a test that told you had cancer when in fact you do not. This turns out to be the most common problem with screening tests.
The test could tell far too many people that they do not have the problem or disease when in fact they do. This is a potentially devastating outcome, but fortunately, one problem current screening tests tend to avoid most of the time.
When you look at everyone with a positive result and see how their problem eventually pans out, you might find they fare no better than those who skipped being screened who have the same problem. That is, early detection may not make any difference.
For some tests, there is no treatment available to help. This makes the finding out early about the problem a rather futile exercise.

Figuring out how well a screening test actually performs turns out to be a tricky and complex task. That is why the United States Preventive Services Task Force (USPSTF) deserves nothing but gratitude. The USPSTF is a very thoughtful and careful group. They review thousands of studies and look at screening tests for years before coming to a decision. In the case of the PSA screening test for prostate cancer, they spent a very long time looking at the data, came to a conclusion in 2009, and then decided to spend two more years looking at the data again, to be sure they were advising us as accurately as possible.

What the USPSTF found was that the PSA test for prostate cancer is really a miserable failure as a screening test. About half the men who are told they have prostate cancer as a result of this test turn out to not have any sort of cancer that would ever cause them harm. Worse, of any group of men who have a positive PSA, no one can tell which of these men have actual, dangerous cancer, and which do not. That dooms all men with a positive PSA to endure the burden of thinking they have cancer, and undergoing serious and potentially dangerous treatments.

The USPSTF found that when all is said and done, no lives have been saved by the PSA screening test, but tens of thousands of men have been rendered impotent, incontinent, or both, for no very good reason.

It is the response to this finding that exposes the power of the screening test in today's modern medical world.

In a more rational world, one would expect the findings of an organization like the USPSTF to be accepted with tremendous interest and even gratitude. Years of careful review and study should be.

But the medical world has reacted to this report with a howl. Leading the charge are the urology associations. Their response is clearly emotional and contains little data. They state that they refuse to stand by and let their patients die by not having them screened with the PSA. Of course, they have no information that demonstrates dropping the PSA test would actually lead to anyone dying. Rather, they present stories of individuals whose lives appear to have been saved by the PSA test turning positive.

Now, we all know which story is most convincing:

A harrowing story of a 58 year old man who thought he was well, only to find his PSA level was elevated, getting a prostate biopsy that shows he has prostate cancer, and then having his prostate removed and cured of a disease that could have killed him if he hadn't been screened.

A highly technical scientific report looking at the sensitivities, specificities, negative predictive values, and positive predictive values of the PSA test. And in that same report, numbing tables and graphs looking at the statistical patterns of outcome for men screened with the PSA.

And yet, that really boring scientific report demonstrates that the 58 year old man in the first story has a very good chance of being misled. The odds are so good that he did not really face any threat from prostate cancer, that he would have been just as likely to live out a healthy life without the PSA test!

Turns out facts do matter.

Sadly, as an outstanding group of epidemiologists at Dartmouth have found (and reported in their book Overdiagnosis, an outstanding book that I have blogged on earlier), money often trumps facts. And the money element of screening is that it can turn a whole nation of healthy people into paying patients.

BOTTOM LINE

I present this story of the USPSTF, of PSA, of prostate cancer, to illustrate why we at Advanced Pediatrics take the science of screening so very seriously.

We look at every screening test recommended and look for data that groups like the USPSTF have on its performance. If the test is a lousy performer, we do not recommend it. We will never recommend a screening test simply because it screens for a serious illness, the test must actually deliver some benefit for us to tell you it's a good idea.

In the meantime, do trust the USPSTF. They are careful, deliberate, and quite wise.

Dr. Arthur Lavin

Intuniv- A Newer Medication for ADHD May Improve Working Memory

Intuniv- A Newer Medication for ADHD

May Work By Improving Working Memory

Not too many years ago, a new medication was approved for use in treating attention deficit/hyperactivity disorder (ADHD). That drug was brand-named Intuniv, an extended release form of the drug guanfacine.

Guanfacine was originally developed as a drug that could treat high blood pressure, but adults taking doses large enough to lower their blood pressure got quite sleepy. The sedative properties of guanfacine led to it being used in lower doses to help quiet the raging behaviors of children with severely abnormal behaviors. That version of guanfacine was called Tenex and it was fashioned to last about 4-6 hours per dose. Now, children treated with Tenex often had problems with attention as well as extreme behaviors, and when they took Tenex an improvement in their ability to focus and pay attention was noted.

This led to the development of a form of guanfacine that was low enough in dosage to not sedate but enough of a dosage to improve attention and focus. That is Intuniv, and one dose tends to last 12 hours. It is a remarkably safe medication with few side effects aside from those relating to tiredness noted in many decades of use.

On October 6, 2011, the New England Journal of Medicine (365:14, p. 1346-7) published an article reviewing recent research describing what physically is causing the nearly universal loss of memory function as we get older. That is, the normal loss of memory, not dementia. What the article demonstrates is that the key type of thinking ability lost with age that explains the loss of memory is working memory. This is yet another indicator of the central power of working memory to help the mind get tasks done. Working memory is not really a type of memory, rather it refers to the ability of one's mind to hold more than one piece of information in the mind at one moment in time and do something with it.

In this article, monkeys had the parts of their brain that creates working memory wired for measurement of activity, but also to allow various medications to be administered. What they found was that when guanfacine was applied to the nerves that create working memory, older monkey's working memory was restored to that of young monkeys. This, in turn, led to better ability to remember items, and to improved ability to get tasks done.

This is the first indication I have read of a medication demonstrating the ability to improve working memory.

As such, guanfacine, or Intuniv, works in a radically different way than stimulants such as Ritalin, Concerta, Adderal, Focalin, or Vyvanse. The stimulants work by arousing the brain. As we know a brain that is more alert works better. That, after all, is what coffee is all about. But Intuniv appears to work by actually changing the ability of the brain to create working memory function.

If this impact can be proven to be reliably present on use of Intuniv, and shown to be safe, it could make Intuniv a very interesting, powerful, and safe medication to consider when seeking to improve attention and focus. It could yield changes that lie at the heart of attention deficits, without all the significant side effects of stimulants.

At the same time, it should be noted that there are interventions that have been proven to increase working memory without the use of any medication. One of the most promising of such interventions is Cogmed, the product of serious neuroscience research and development in Sweden. Cogmed, whose impact on working memory has been verified by independent laboratories, including the one, in England, that developed the concept of working memory, increases working memory significantly in 80% of those who complete the 5 week intervention.

Research into how the brain works is rapidly expanding our knowledge and our ability to help our minds work. This recent report in the New England Journal of Medicine puts working memory once again at the center of how the mind gets tasks done. It raises the possibility that a very safe medication, Intuniv, may be a specific intervention to boost working memory, and it increases the chance that interventions that require no drugs, e.g. Cogmed, are devoted to changing the right cognitive function.

Dr. Arthur Lavin

2011-09-14

HPV in the News: A Review of the Basics

HPV in the News:

A Review of the Basics

You never know when or which topic in science will become a hot topic in politics, but when science and politics mix, the facts usually take a beating. This is not because politics sets out to wage war on facts, but rather that politics always has a goal in mind, and it typically is happy to twist a few facts to reach that goal.

We have seen this all in play during the recent explosion of interest in the HPV vaccine by those some politicians vying to become their party's nominee to be president. The controversy surrounds a 2007 executive order as governor by one of the candidates mandating that all middle school girls in the state be immunized against HPV infection. Other candidates reacted strongly to that decision in a recent debate, and suddenly HPV immunization leapt to the headlines. Large numbers of people began registering their anger at the idea that government could force someone to be immunized, and bristled at the idea that families could be forced into decisions that could promote promiscuity.

Given the furor over HPV, we thought it would be timely to take a step back from the political excitement and think about just what this virus is, what the immunization does, and how to make a good choice for your family.

What is HPV?

HPV stands for human papilloma virus. This is the virus that causes all warts. The word papilloma is the Latin way to say wart. So the HPV is the virus that causes warts in humans.

The HPV is different sort of virus. Most viruses make you sick, but with one exception, HPV does not.

All infections with HPV cause an infection isolated to the one spot the virus has landed. At that spot the skin is goaded into making more skin, causing a lump of skin material to form, the lump that we call a wart. That lump of material, with one exception, causes no harm. Often the virus can sit in the skin without any lump appearing, but with lump or no lump, the virus can sit in its spot under the skin for a very long time, sometimes for decades. It looks like it can sit there for such long times precisely because it is very quiet about its business. Often not spreading to other spots in the skin, and really not doing much where it sits.

Consider how strikingly different this is from the usual virus, say the virus that causes the common cold, the rhinovirus. Once the rhinovirus lands in your nose, it starts a real fire. It burns off the lining of the nose, and in rapid sequence goes on to burn the lining of the throat, all the sinuses, and then the entire lung. The burning only stops once all the linings are burnt. Luckily for us, the burn is very shallow, so it is not dangerous, but it causes all the suffering of a cold- fever, feeling lousy, achiness, cough, and a river of mucus wherever the virus has been- nose, eyes, throat, and lungs. The whole infection causes an uproar in the body with a big response from our immune system that kills the invader and ends the infection. The whole drama is over in 1-2 weeks.

HPV does none of that. As we noted, it does not spread well, wherever it sits it causes little harm, and it can stay in its quiet, isolated spot for decades, not weeks.

There is one exception to this peaceful portrait of HPV. That is the ability for infection with HPV in the area of the cervix to start a sequence that can end in cancer. The cervix is the neck-shaped end of the uterus that lies at the top of the vagina. HPV infection of the cervix by certain subtypes of HPV, can start a process that allows cells there to start growing in a disorganized fashion, and sometimes that can end up with a cancerous tumor called cervical cancer.

It is worth repeating that HPV infection is not rare. Essentially every single person will come into contact with the skin HPV's. The skin HPV's are spread by simple contact, and appear to be a nearly universal experience. The genital HPV's spread by sexual contact, but are nearly as common, causing infection in as many as 75% of all humanity. As such HPV is, by far, the most common sexually transmitted disease (STD).

So HPV causes three types of warts. The common warts of the external skin. Genital warts in men and women. And the special genital warts of the cervix that can become cancer. Since each type is caused by a separate type of HPV, an immunization against one type of HPV will protect against the infection that type causes.

Of course, only the HPV that causes serious disease, the subtypes that can lead to cervical cancer, has been targeted with an immunization that can prevent HPV infection. That means the HPV shot only prevents infection with the HPV's that cause infection in the cervix of the uterus, not the ones that cause common skin warts.

This is a smart choice. After all would one rather have a shot that prevents harmless skin warts, or one that prevents a type of cancer that kills more young women in the world than any other?

What is the HPV Immunization?

What does the HPV shot try to do? Prevent cervical cancer

Of the many types of HPV that cause infection of the cervix and that can then lead to cancer, the HPV immunization prevents infection from the HPV's that are most likely to lead to cervical cancer. That is not all HPV's and it not all the HPV's that cause cervical cancer.

So the first thing to say about the HPV immunization is that it does not protect against all HPV infections and cannot prevent all cervical cancer. But it does protect against the HPV infections that are responsible for roughly 70-80% of all cervical cancer. Not a bad start.

Does the HPV shot work? Yes

The next question is how well HPV immunization works. The answer is that it works very well. If you get HPV immunization before you are exposed to cervical HPV, that is before sexual activity begins, it will block infection with the HPV subtypes in the shot. And it looks like it lasts. Since the HPV's are so widespread, people get exposed to them for a very long time and this acts like a booster for the shot, helping it provide protection for many, many years.

Is the HPV shot safe? Yes
As those familiar with Advanced Pediatrics know, we take do not allow any representatives of the drug industry to be in our office and accept no materials from them, all in effort to be sure when asked about their products, that we can offer the most trustworthy observations that science can provide, as free as possible from market influences.

It is with this commitment and approach in mind that we took a look at the facts of how safe this vaccine is.

The data are very strong and compelling that this is a safe vaccine.

The list of possible side effects are limited those seen with any shot- irritation, allergic reactions, fever, headache, and fainting. That's about it.

Like with any intervention, however, when upsetting events happen after the intervention, one cannot help but believe the intervention caused it. This is the power of guilt by association. A good example would be getting a haircut and then right afterwards getting into a car accident. The accident did immediately follow the haircut, and so is definitely associated, but did the haircut cause the accident, clearly not.
Just so, there have been stories circulating that a person became mentally impaired after getting this shot, but there is no evidence that this shot causes any sort of mental impairment. The impairment may have started on the day of the shot, but there is no reason to believe the shot caused it.

A wide body of study has looked carefully at whether the HPV immunization causes serious problems, and the observations are strong, consistent, and reassuring, the HPV immunization does not cause serious problems.

How to be immunized against HPV?
Immunization to prevent HPV infection takes three shots. The second dose has to be 1-2 months or more after Dose 1, and the third dose 6 months or more after Dose 1.

It is best to be immunized before you get exposed to HPV, meaning before sexual activity begins. If people are immunized in middle school or early high school, that seems to provide the best timing.

Keep in mind that human papilloma viruses (HPV's) can cause three types of infection in people- common skin warts, genital warts, and cervical warts. Only the cervical wart infection can lead to cancer. And that is why the HPV immunization only protects against the HPV's that cervical wart subtypes.

This is good to remember, because it introduces a difference in benefit between boys and girls getting HPV immunization. Boys can only get two of the HPV infections mentioned, skin and genital wart infections. So even if a boy gets an infection with a subtype of HPV that can cause genital warts, that virus cannot physically ever lead to cervical cancer, boys do not have a cervix. Girls, of course, can and do get all three type of HPV infections.

As a result, if a girl gets the HPV immunization, she may prevent developing cervical cancer someday. No boy will ever have that benefit.

So why immunize boys? For the same reason we immunize everyone for rubella (German measles). Rubella is a very harmless infection for children and adults, but deadly and deforming to the developing fetus. We actually never immunize those really at risk for rubella, the fetus. Instead, we immunize everyone else, all children and adults who need it. That immunization offers essentially no benefit to those immunized, but since we all agree to be immunized, no fetus can be exposed. This strategy has led to the nearly complete disappearance of all fetal rubella infections, a stunning triumph.

Just so with immunizing boys against HPV.

Remember, as many as 75% of all humanity, is infected with genital HPV. It is literally everywhere.
Boys carry it as much as girls. So it does help to immunize all girls, but it is not enough to prevent all the cervical cancer that we can. If boys get immunized too, it greatly strengthens the defence against these HPV infections.

So we recommend boys get immunized, knowing that they will never gain the benefit of cancer prevention, but knowing that if they do get immunized it will help prevent cervical cancer in half of humanity. And, the boys will have fewer genital warts, offering some benefit.

BOTTOM LINE
American presidential politics have thrusted HPV immunization into the nation's spotlight. As is to be expected, the discussion has promoted the temptation to throw facts out and let strong feelings carry the argument.

But when it comes to your child's health, it makes sense to take a step back, a bit of a breath, and try to base decisions on facts.

The salient facts are these:

The human papilloma viruses (HPV) cause warts on our skin, genitals and the cervix of the uterus.
HPV infects nearly all of us. The skin types are likely present in all people at some time. About 75% of people, men and women, are infected with genital HPV. The genital HPV in women is the major cause of cervical cancer.
HPV immunization can prevent infection with the subtypes that cause cervical cancer in women.
The HPV vaccine works and is safe.
Sadly, politics is having some of its way with science, obscuring facts, trying to raise fears, hopefully the facts can help you keep your focus on keeping your children healthy.

Dr. Arthur Lavin

2011-08-31

Flu Vaccines for 2011-2012: Flu Shot Days set for September 10 or 17

Flu Vaccine 2011-2012

Advanced Pediatrics is pleased to announce that this year’s influenza immunizations are now available in our office.

Call now for your appointment on September 10 or September 17 for our Flu Vaccine Days.

Influenza is a virus that sweeps across our region every winter, typically appearing in December and leaving our community around April.

This virus is responsible for a rather astounding amount of winter illness, causing fully 1/3 of all colds, flus, and ear infections.

Influenza immunization is now recommended for everyone, except for those less than 6 months old.

Influenza immunization comes in two formats: a shot and a nasal spray. The shot contains dead virus and is fine for anyone to use. The nasal spray contains live virus and should not be used by anyone less than 2 years old, older than 50 years old, or anyone with a chronic illness, including asthma.

With regard to how many influenza vaccines is a complete series, the answer is very simple. Anyone under age 9 who has never had an influenza vaccine, needs two influenza vaccines at least one month apart to be fully protected.

That also means anyone who has had an influenza vaccine in the past only needs one this year.

Overall, the data show that the nasal spray tends to work a little better- the immunity covers more strains than are in the vaccine and lasts longer. But, at the same time, the shot works quite well, too.

Getting Your Influenza Vaccine at Advanced Pediatrics

In order to make sure the entire practice gets the chance to be protected from influenza infection in a timely and easy manner, we are going to offer influenza vaccinations in two ways:

Any child in the practice 6 months of age or older can get their influenza vaccine at any visit to office, whether it be for a health supervision visit (check-up), sick visit, or conference.
We will once again offer special Flu Vaccine Clinic days to allow a large number of people the chance to simply come in and get their flu vaccine in a few minutes time.

The Flu Vaccine Clinic days will be held on two Saturdays in September:

September 10 and 17, each starting at 9AM. You can call now to set up your time for these days.

The outlook for our supply looks good, no shortages are expected. And the H1N1 strain is once again included in this year’s flu vaccines, eliminating the need for a separate flu vaccine routine.

Even so, we would like to limit our flu vaccine offerings to children in families. Once we are truly sure that no shortages are expected will be opening up flu shot availability to parents.

We at Advanced Pediatrics are very pleased to be able to help make sure this winter is as healthy as possible.

Dr. Arthur Lavin

Dr. Julie Hertzer

Ms. Kelley Muldoon Rieger

2011-08-23

New Book by Dr. Lavin: The 5 most important things To do during pregnancy to insure the health of your new baby.

Dr. Lavin's Newest Book:

The 5 most important things

To do during pregnancy to insure the health of your new baby

Advanced Pediatrics is pleased to announce the publication of Dr. Lavin's 5th book, The 5 most important things To do during pregnancy to insure the health of your new baby (Collaboration Press, 2011).

This book was written for pregnant women who are seeking substantive information about what can they do to make sure their newborn is as healthy and smart as possible. In this book, Dr. Lavin takes a look at the following 5 areas in which mothers can have an impact on the health of their baby:

Nutrition
Mood
Exercise
Cognition
Planning

In each instance The 5 most important things offers parents-to-be solid advice about how each of these areas can impact the outcome of newborn development, and what the mothers-to-be can do to make a positive difference.

The 5 most important things is being distributed at no cost to pregnant women. This availability has been generously supported through a welcome collaboration with Berg's Baby and Teen Furniture store (http://www.bergsbaby.com/), a place of rare commitment to high quality, and rated as one of America's top baby stores.

Copies of The 5 most important things To do during pregnancy to insure the health of your new baby are available at our office, again at no cost.

If you are pregnant, or have friends or colleagues who are pregnant, let us know, we would be happy to get a copy of The 5 most important things To do during pregnancy to insure the health of your new baby to them.

Dr. Arthur Lavin

also by Dr. Arthur Lavin:

Who's the Boss? Moving Families from Conflict to Collaboration, with Ms. Susan Glaser (2nd edition, Collaboration Press, 2010)

Baby & Toddler Sleep Solutions for Dummies, with Ms. Susan Glaser (Wiley Publishers, 2007, to be translated into Italian in 2012)

The Advanced Pediatrics Guide to Newborns, with Dr. Julie Hertzer, Ms. Kelley Muldoon Rieger, and Ms. Susan Glaser (2nd edition, Collaboration Press, 2009)

The Advanced Pediatrics Guide to Finding a Medical Home for Your Child, with Dr. Julie Hertzer, Ms. Kelley Muldoon Rieger, and Ms. Susan Glaser (Collaboration Press, 2010)

and, Dr. Lavin is currently working on a new book Not To Worry, which will discuss dozens of common and not so common situations, to let families know when the situation is worrisome and when it is not.

2011-08-16

Mosquito Bites on the Face: When to Worry

Image via WikipediaMosquito Bites on the Face:
When to Worry

A warm hot summer has yielded an explosion of mosquitos in our area, and with the jump in the number of mosquitos has come a dramatic jump in the number of mosquito bites.

Recent reports document this is happening and that we can anticipate a big jump in the number of mosquito bites through October.

At the office, we have seen the beginning of this big jump, with a large increase in the number of calls about mosquito bites.

Families have expressed two types of concerns about mosquito bites, are the infected, and is it really just mosquito bites or possibly chickenpox.

Mosquito Bite Basics
As the picture above shows, mosquitoes are tiny insects that live on the blood of animals they bite. To make their living, they must slide a tiny tube into a blood vessel and suck some blood out the tube, all without you noticing in time to smash them.
Aside from being noticed and killed, their other challenge is to make sure your blood does not clot while their snout is in your capillary.
Here is why most people get a reaction. To keep your blood from clotting during their visit, the mosquito first injects a little anticoagulant. This material has an impact on your immune system, and this impact leads to inflammation at the site of the bite. It's this inflammation that causes the very familiar sight of a mosquito bite, namely, a red bump, often with a tiny dot in the middle where the bite occurs, and surrounding redness:

Another basic to keep in mind is that the younger you are, the more vigorous your immune system, and so the more dramatic inflammation from mosquito bites can be. Think of how young children can easily generate fevers to 105, but adults rarely go past 102. Just so with mosquito bites. Young children can get quite big red areas from even one bite.

Chickenpox
Now, take a look at this picture of the rash of chickenpox, and you can see why it makes sense for people to wonder if their child gets a bunch of mosquito bites, whether it really is mosquito bites or chickenpox:

But there is a difference. Notice that chickenpox nearly always ends up having three types of rash:
starts with red spots which become blisters, which become scabs. The red spots of chickenpox and small mosquito bites look about the same, really quite similar. That makes the two conditions confusing to sort out.

In a few days the red spots of mosquito bites are still red spots, or gone, or scratched to scabs; but the red spots of chickenpox become tiny yellow-filled blisters that we call vesicles. These vesicles then turn into scabs without any scratching.

Of course, if you are not sure that your child's mosquito bites are not chickenpox, feel free to call.
Hopefully this guidance will help, but should not stop you from inquiring.

Is the bite infected?
The other major concern that mosquito bites cause is whether the bites are infected. This is most commonly feared when the mosquito bites are on the eyelids.
Take a look:

What do you think, is this eyelid infected? Let's talk about mosquito bites and infections, then you decide.

The skin of the eyelid is very loose and capable of rather impressive swelling. Even a simple mosquito bite can cause swelling enough to close the eyes shut. The inflammation of a mosquito bite causes a lot of fluid to accumulate in the eyelid, especially if you lie down for a night's sleep or a nap. The swollen eyelid has a pale pink color, is not warm, often only involves one lid- just the upper or lower. The redness of the swollen eyelid from a mosquito bite is pale, not deep red, and the swelling is soft, like a partially inflated water balloon. The eyelid feels a little bouncy, not hard. The eyelid can be itchy, not typically painful, and often there is a red dot where the bite occurred.

When an eyelid is infected, all those properties of the eyelid are different. Infections almost always spread to both eyelids, the redness is deep not pale, the eyelid feels hot and often hurts, and there can be pus. The whole look is more like an angry red, hot appearance, and not the soft watery pale red of a mosquito bite.

Now with that in mind, what do you think of the picture of the swollen eyelid, mosquito bite or infection?
The answer is mosquito bite- only one lid, the upper is swollen, the redness is faint, the swelling is soft looking.

One last clue, swelling from mosquito bites almost always gets worse after lying down for awhile, since most of the swelling is simply water accumulating in the area. Sitting or standing helps the fluid move and the swelling gets better. This is why when young children get a mosquito bite on their eyelid, they frighten parents after sleeping- their eye is swollen shut! But ofter after an hour or so of getting up, the swelling is much less.
Swelling from infections almost never shrinks after getting up.

Again, these tips are meant to help. Of course, if questions still remain feel free to call us.

BOTTOM LINE
The key points to keep in mind are:

This looks like a big year for mosquitoes. Expect lots more bites, more swollen eyelids, more patches of great numbers of bites.
Chickenpox and mosquito bites look alike early on, but mosquito bites stay looking like mosquito bites and chickenpox rashes become tiny blisters and scabs.
Mosquito bites on the eyelid typically cause big swelling, but the redness is fainter, the pain is less, the spread is limited, compared to actual infections.
Call if you are concerned.

Dr. Arthur Lavin

2011-12-25

A True and Astounding Scientific Breakthrough: Genes Changed, Christmas Disease Reversed

2011-11-24

The Shortage of Adderall

2011-11-18

Don't Spank- The Controversy has Led to Tragedy

2011-11-14

Screening for cholesterol and lipids in childhood

2011-11-10

Good news on Urinary Tract Infections

2011-11-07

Cough- When to Worry, What to Do

2011-10-11

Vitamin Pills Not so Good For You

2011-10-08

A Word on Screening

Intuniv- A Newer Medication for ADHD May Improve Working Memory

2011-09-14

HPV in the News: A Review of the Basics

2011-08-31

Flu Vaccines for 2011-2012: Flu Shot Days set for September 10 or 17

2011-08-23

New Book by Dr. Lavin: The 5 most important things To do during pregnancy to insure the health of your new baby.

2011-08-16

Mosquito Bites on the Face: When to Worry

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