Advanced Pediatrics: 2012

2012-12-24

What is a Virus?

What is a Virus?

Every child ever born, indeed every one of us, will experience an infection with a virus in our lives, on average about 8 a year. These infections cause the vast majority of colds, flus, stomach flus, fevers, aches, and so it makes sense that as parents, you know what is causing all this misery, and why it always seems that nothing helps.

What is a virus?

It turns out that a virus is a very, very peculiar thing. It is in someways alive, since like all living things, it reproduces. But in other ways it is not alive, since unlike living things, it an exist in a dried crystal form for nearly forever.

My own sense is that a virus is a form of information. You might wonder, how could knowing something make you so sick? It turns out the sort of information that is a virus is the information that commands and controls processes, in this case the genetic codes of our body's cells.

Every virus contains just two elements- a strand of genes and a coating of protein. Each of these elements has one simple purpose.

The coating of protein picks the locks of the cell and allows the strand of genes entry to the cell's genes.

The strand of genes also has only one purpose- to force the cell to stop what it was doing and turn all its resources towards making copies of the strand of genes and coating of protein. Once zillions of the strands of genes and coatings of protein are reproduced by the hijacked cell, zillions of new viruses are unleashed to repeat the process, zillions of times.

What does a virus do?

Often, the takeover of the cell is complete and the reproduction of the virus is so explosive that the cell is completely destroyed in the process. More rarely, the takeover of the cell and reproduction of the virus is very slow and does not kill the cell, just distracts it from its regular duties.

The pattern of slow control over the cell, leaving it alive but a touch altered is seen in very few acute viral infections, mainly in a set called retroviral infections, the most famous of which is AIDS. AIDS is so destructive precisely because the virus messes with the cell without destroying it, leaving it in place to malfunction.

But for every single cold and flu virus, the pattern is complete cell destruction. This causes a week or two of very real misery, but at least the infected cell is cleared away and what follows is completely normal function and health.

The heart of the usual virus experience is in very many ways exactly like having a burn. Cold and flu viruses, when all is said and done, simply burn off the lining of whatever the virus is infecting. If the virus gets into the cells lining the nose, then when zillions of viruses pop out of those cells, they are destroyed. And then they do the same thing to the cells right next to the ones just exploded. So like a slow burning flame, the infection burns slowly across the lining leaving the lining of the nose essentially destroyed, just like if it was burned.

The analogy continues, for the fuse once lit in the nose typically burns down the throat and into the lungs.

Nearly every symptom of a virus can be traced to its essential nature as a burn. Whatever is burned defines the problems experienced. Just like if you have a burn on your hand, your hand hurts but not your foot, if you have a virus in your nose, your nose hurts and weeps fluid, but not your chest.

Here is how the location of a viral infection defines your symptoms:

If the virus is in your nose you have a sore, runny nose, and lots of sneezing as a result.

If the virus is in your throat, you have a sore throat.

If the virus is in your lungs, you have a cough.

If the virus is precisely on your vocal cords, you have a barking cough, or hoarseness, or croup.

If the virus is in your eyes, you have pink eye (with redness and mucus, that can accumulate, and mat, but not cause constant pus dripping).

If the virus is in your stomach, you have vomiting, and stomach ache.

If the virus is in your intestine, you have diarrhea, and stomach ache.

The virus is doing the same thing in every spot, causing the lining of cells to be destroyed as more virus is made, but the experience varies according to which lining is being wrecked.

Whereever the lining is infected, some things happen to the body, caused by the body's attacks. Those symptoms would be fever, achiness, lethargy, loss of appetite, increased or decreased sleep. These are the famous symptoms of viral infection, and they are not caused by the virus alone. All these symptoms can be created by giving someone the chemicals found in our white blood cells, stuff like cytokines and interleukins. this is what make us all feel so miserable when we get sick from a virus.

How to Treat a Virus, how to Get Rid of a Virus?

Since having a viral infection with colds and flus is very much like a burn, we are stuck with the same frustration treating a virus as we are a burn- namely, waiting for it to heal.

Think about a cold. As we just saw, a virus infecting the nose, throat, and lung burns off the lining of these parts of our body. Once burned off they ooze fluid, just like any burn would. Initially the fluid is a clear fluid, but over time it starts to contain elements of healing tissue, as the burned off tissue regrows, making the oozing fluid more thick, more mucusy, and more yellow and green.

To get rid of the runny nose, sore throat, and most of all- cough- that this process creates, two things have to take place- all the remaining virus needs to be destroyed so no new burns are created, and the already burned tissue must be immediately healed.

I am all for both of these events happening, but there is one reason they cannot be quickly made to happen: no one has yet invented a substance that would either kill a virus [and leave your cells alone], or rapidly heal a burn.

Now, that does not stop companies from peddling products that claim to solve the problems viruses cause. One ruse most often used is to admit they cannot actually stop a cough or get rid of a sore throat, but they might offer temporary relief. That's not a hard thing to do, since even halting a cough for few seconds might qualify as helping.

But time and again, whenever cold and cough remedies are tested against water, water does as well or better than them all. In fact, in March of 2011, the FDA launched an investigation against 500 cold and cough remedies for fraud.

So, if no medication has yet been invented that would kill a virus or heal the burn and inflammation it causes, what to do?

Fortunately, there are things that can be done, and they all are about comforting:

1. Keeping warm.

2. Having warm, misty air around

3. Sitting up

4. Sipping soothing liquids

5. For sore throats, ice cream and popsicles.

6. Ibuprofen. (Avoid tylenol, a question on its power to increase the risk of asthma is being investigated.

7. Anything that distracts and comforts.

Keep in mind that if the goal is comforting, the judge of whether it works is the person being comforted.

For example, a humidifier might make one person feel much better but might bother someone else, simply ask your child or observe if it is comforting or irritating to them.

What's the Point of Viruses

Very briefly, there appears to be a very large component of our DNA and RNA, our genes, that has something to do with viruses. Viruses have been transporting bits of genes from cell to cell across every form of life since the beginning of life. There are major viruses that infect only bacteria, for example.

Over the eons, it is now estimated that as much as 60% of our genes originated in the viral sweep of DNA across the whole range of life. That means quite a bit of who we are, and how we became humans originated in the swirl of information that is the virus.

So as we ache, suffer, and groan from our colds and flus, it may help to keep in mind this may be the creaking of a very necessary machinery.

How to you know your illness is a virus, not something more serious, or treatable?

For coughs and colds and plain old fevers, the vast, vast majority of such illnesses are viruses.

They cause undue agonies, but no lasting harm.

They seem to last forever, but always end.

There are three common bacterial conditions seen in colds that can be treated with antibiotics:

1. Strep throat- usually causes a sore throat as a key symptom, usually not so much cough

2. Ear infection- causes bad ear pain

3. Pneumonia- suspected when your child struggles to breathe when not coughing

So if the sore throat is more scratchy than sore and seems due to a bad cough, and your ears do not hurt, and you are breathing in and out of your chest well when not coughing, it's likely a virus.

What would be a sign the illness is dangerous, like a bad pneumonia or meningitis?

These three signs:

1. Stiff neck

2. Can't breathe in and out of your chest without a lot of struggle.

3. Severe pain

A NOTE ON ANTIBIOTICS

Antibiotics kill bacteria, they do nothing to viruses. You can put a bottle of virus in a vat of antibiotic and they will live very comfortably there.

Bacteria are radically different than viruses. Viruses as we saw are little packets of information, not really alive. Bacteria are like us, they are cells that live and eat. Their chemistry is different than ours and antibiotics wreck their chemistry but not ours.

That is why antibiotics don't work when you try to treat a viral infection with them.

Not only do they not work, but since the vast, vast majority of colds and flus are viral, using antibiotics to treat them exposes millions and billions of people to these drugs for no very good reason. Worse, such mass and constant exposure of our species to antibiotics has caused real, observable harm. Many tens, likely hundreds of thousands of people have died as a result of this silly practice, from emergence of resistant bacteria and proliferation of harmful ones like C diff.

At Advanced Pediatrics we remain committed to not giving people drugs that do not good and can cause harm. Giving someone an antibiotic when we know you have a virus will not help at all, and could cause harm, so we don't do it.

BOTTOM LINE

1. A virus is a little packet of information that burns the lining of various parts of your body.

2. That burn can only heal, it cannot be suddenly cleared with medicine.

3. Comfort measures are the key help for our kids suffering with viruses, and the best way to judge if a comfort measure works is by asking your child if it helps.

4. When it comes to colds and flus, the vast, vast majority of them are caused by viruses and so antibiotics to do not help.

5. Cold and cough remedies are products riddled with fraud. None have been proven to work any better than water.

6. The key signs an illness is no longer viral and now may be dangerous are: Stiff Neck, Trouble Breathing when Not Coughing, Severe Pain.

All of us at Advanced Pediatrics hope your time with viral illnesses is as brief as possible. We stand ready to help. And hope you and your family have a wonderful holiday season and a Happy and Healthy New Year!

Dr. Arthur Lavin

2012-12-18

How Does A Nation Change the Chance of Tragedy Occurring?

How Does A Nation Change the

Chance of Tragedy Occurring?

The tragedy of Newtown, Connecticut sears our hearts and tears at our minds.

Since the outrage of December 14, we have all been overwhelmed by how to respond.

As a person, I share the grief we all feel, and concern for the impact of this outrage on all it has touched.

As a doctor, I am compelled to respond. It is in its ability to prevent needless tragedy that the medical profession is at its best. Why wouldn't the medical profession want to offer its best in response to the senseless loss of life in Connecticut? Particularly since without doing something, it is likely to happen again.

You might consider an expectation of this happening again too pessimistic, but consider that in our nation, nearly 3,000 children are killed every year by being shot. Compare this to the number of law enforcement officers who lose their lives every year across the country by being attacked, 75, and it becomes rapidly clear that something is so wrong, it may be time to do something about it. As a pediatrician, American, and person, I can no longer ignore the urgency of protecting the next child's life.

I have talked to many people since December 14, people from across the political spectrum, and for once I have found complete agreement- this must stop. We may disagree on what will stop it, but everyone seems to agree that it is no longer acceptable.

And here is where the power of the medical profession may prove important. Doctors have responded to a large number of causes of needless death, at times with dramatic success. It is time for our profession to turn such expertise to this epidemic afflicting our children, and communities. The process is always the same:

Determine the cause(s).
Determine the mechanism of how the cause(s) actually cause the problem.
Measure a variety of interventions to prove which one(s) work, and implement the best intervention(s).

If these three steps are not actually taken, then all we have is everyone's opinion, lots of strong feelings, large collection of guesses, and no changes. Early indications are that the causes may be found in one or all three of the following categories: guns, mental health, culture of violence. It is not clear to me exactly what role each of these will play in actual solutions that work.

So we are supporting a serious look at what actually causes the completely senseless deaths of nearly 3,000 of our children every year. We support efforts to find how those causes operate. And once we know what works, we will be working with all families to implement the changes that will save lives.

The word gun has become controversial in our nation, I am reassured that the idea of saving a child's life remains a point of broad agreement. I look forward to working together with our nation's leading public health groups, physician's organizations, and other groups to find a path toward changing our nation from one of the most dangerous for children to one of the safest. My expectation is that we may all be surprised at what will actually save lives, my mind certainly is committed to remain open to what will work. I remain hopeful that if a path is found that truly could assure saving nearly 3,000 children's lives every year, that all of us would rush to support it.

The events in Newtown could tempt us to simply grieve. As my heart goes out the families of Newtown, and to all who grieve for them, I also find that these events urge us to go beyond grief towards action, actions that will truly spare other towns and neighborhoods this all too common American experience.

Dr. Arthur Lavin

2012-12-14

Dr. Lavin appointed to national expert panel

Dr. Lavin appointed to national expert panel-

and he would like your help

Dr. Lavin has been appointed by the American Academy of Pediatrics (AAP) to serve on the national Middle Childhood Expert Panel for the Bright Futures program. http://brightfutures.aap.org/

Bright Futures is the program of the AAP, established with the Federal Government, to promote the health of America's children. One of the purposes of Bright Futures is to define standards of pediatric care.

One of the provisions of Obamacare will be implementing the Bright Futures standards of care as the definition of basic pediatric care all insurers will need to offer as part of the basic benefit package in the US.

The Middle Childhood Expert Panel that Dr. Lavin will be serving on is charged with developing updated standards of care for children aged 5-12 years old. When completed these standards will be the key reference for American pediatricians, guiding them on what needs to be done at the routine visit to the doctor for children ages 5-12 years old.

Here is where you come in. I would highly value your thoughts. What would you as a family like to see pediatricians doing for you while your children are in the age range of elementary and middle school?

Just let me know at info@advancedped.com, or drop a note to our office:

3733 Park East Drive- Suite 102

Beachwood, OH 44122

I look forward to bringing the best ideas to craft the best possible standards for the practice of pediatrics for these children in the United States.

Dr. Arthur Lavin

2012-12-11

Newborn Jaundice

de: Struktur von Bilirubin en: Structure of bilirubin (Photo credit: Wikipedia)

Newborn Jaundice:

Not Really Jaundice

Not Really Harmful

Nearly every newborn develops some sort of yellowish tinge to the whites of their eyes or their skin sometime in the first week of life. This tinge is commonly referred to as newborn jaundice, a phrase that suggests something is quite wrong.

But the facts are that this yellowish hue reflects normal functioning of healthy bodies. The chance that the accumulation of the yellow material that causes the color change causing any harm, you will see, is remarkably remote.

The story of the yellow hue in the first week of life revolves around a most interesting pigment, called bilirubin. Bilirubin turns out to be the waste product after the body is done getting rid of old stores of another brightly colored pigment, the red chemical hemoglobin. Now, in nearly every animal, hemoglobin is gotten rid of by a conversion to biliverdin. Biliverdin is a beautiful soft-blue pigment (its the pigment in robin's eggs), and it is cleared from the body simply via urination, it never accumulates. But in humans and only one other animal, the biliverdin is processed one more step to the yellow pigment bilirubin.

Bilirubin does not dissolve in water, at all, which means it must be further processed to be converted to a form that does, and that step requires your liver to take that action.

During pregnancy, the bilirubin made by the fetus is cleared from both fetus and mother by the mother's liver.

After birth, the newborn's liver takes 1-2 weeks to start clearing the bilirubin. This is exactly why all babies born see a rise in their bilirubin level. It's during that 1-2 weeks that they wait for their liver to process their own bilirubin that it rises, often to a point where the whites of the eyes and/or skin takes on the yellow hue of the bilirubin.

Most items written about this yellow glow seem to suggest this is a sign of liver dysfunction, that the 1-2 weeks of waiting for the liver to start clearing the bilirubin is a defect, a lapse. It is not clear this is the case.

It costs the body a lot to make bilirubin out of biliverdin, remember that not many animals do that. And once it is made, it costs a lot of energy to clear the bilirubin. So one could make the case that the body goes to a lot of effort to create bilirubin when it could simply clear old hemoglobin by letting it stay converted to biliverdin.

Dr. Anthony McDonough of the University of California in San Francisco offers an intriguing insight. Tony just won an award from the American Academy of Pediatrics as one of our nation's top research scientists. He has devoted his life to the study of these brightly colored molecules: hemoglobin, biliverdin, bilirubin, chlorophyll, all of which are closely related to each other. He taught me many years ago, and still teaches, that bilirubin is a very strong anti-oxidant. Not too long ago, proof of this concept was supported by an article demonstrating that the higher the normal bilirubin levels are, the more protected the group is from events like heart disease and cancer.

The point is that the body might actually be going to great lengths to offer the newborn a boost of bilirubin, the yellow glow may actually reflect something good happening.

Given all this, why is so much fuss made over this nearly universal occurrence? The reason is that in very special and unfortunate circumstances, bilirubin has been found to be irritating to the brain. Those circumstances are severe prematurity combined with very severe illness, such as a serious infection. In settings where the body is under rather extreme distress, bilirubin in the blood is able to enter the tissue of the brain and cause harm. When a newborn is healthy and full-term, a very sturdy barrier keeps bilirubin out of the brain.

So then why any concern about bilirubin in full-term, healthy newborns? Not too long ago, some reports documented an instance or so of bilirubin, when in excess levels, getting into the brain of even a healthy, full-term infant. The chance of that happening is nearly astronomically remote. About 4 million babies are born in the US every year, and the number of healthy newborns where bilirubin causes harm is less than one every year. To my mind, when a substance causes harm less than 1 in a million exposures, that says to me its pretty safe. Consider penicillin which causes serious harm in 10 of every million doses, and we consider that risk of harm so remote it is deemed to be very, very safe.

Another sign that the mild rise seen in nearly every baby in bilirubin after birth is normal and perhaps beneficial is that the rise is higher in babies who are breast-fed than formula-fed. For many years this was viewed as one of the only disadvantages to nursing, but it may be a further hint that the body is really trying to bump the bilirubin level up a bit for the few weeks after birth.

BOTTOM LINE:

Nearly every baby born experiences a transient, 1-2 week rise in their level of the yellow molecule, bilirubin.

Very many have sufficient increase to look a bit yellow. In healthy, full-term infants this experience is overwhelmingly harmless, and may even be designed and helpful.

When to worry? If the yellow glow becomes a deeper, more severe, orange hue. Bilirubin levels should not rise so high to cause your newborn's color to get too intensely orange. If that happens let us know.

But the mild yellow hue, the glow seen so often, is not harmful, and may turn out to be just what the baby needs.

Dr. Arthur Lavin

A New Edition Defining Mental Illness is Approved

A New Edition Defining Mental Illness is Approved

It was reported today that the DSM-V has officially been approved by the organization responsible for its editing and publication.

http://www.nytimes.com/2012/12/11/health/a-compromise-on-defining-and-diagnosing-mental-disorders.html?hpw

The DSM is the Diagnostic and Statistical Manual, and it plays an enormous role in many American's life.

How so? Because this book contains all the definitions used in the health care world in the US that define mental health, mental illness, and mental conditions.

If you turn to a doctor or clinician to determine if you have a mental health issue, it is very, very likely that the answer will rest on where the line defining normal and abnormal rests in the DSM.

The current edition is the DSM-IV, so the new edition which you will be hearing a lot about, is the DSM-V. These books are created and updated by the American Psychiatry Association (APA).

The most interesting aspect of the article describing the end of a 5 year process of creating the DSM-5 was how little agreement there was across the mental health and medical professions on just what is the definition of a wide range of mental illnesses and conditions.

For example, is someone grieving for the loss of a loved one depressed?

Or, does someone who has excellent language function but is awkward socially have a form of autism?

At what point does someone who eats in binges qualify for being designated as having an eating disorder?

I remember vividly when a top clinician at one of our country's leading mental health facilities once taught at a seminar that every symptom in the DSM is experienced by nearly every healthy person at some point in their life.

So how does one know if their symptoms are severe enough to reasonably be considered a mental illness or condition?

The story of how the DSM-V got approved suggests that this question has no clear answer. Senior leadership devoted to answering this question quit over the development of this edition. Patient advocacy groups became quite vocal in opposition or support of various definitions of mental illness.

The article documents a startling illustration of how tricky the line that defines abnormal thinking and feeling is. In the 1990's and 2000's there was a big jump in the number of kids told they have bipolar disorder. The article states that most of these kids, duly diagnosed by physicians with bipolar disorders, did not in fact turn out to have that.

Another very important consequence of this difficulty is that where the line where normal becomes abnormal is drawn automatically dictates how many people will be considered ill. By adding a new diagnosis, binge-eating disorder, literally millions of Americans will now be considered diagnosed with this condition, once the DSM-V is actually published; but, right now, and for the years prior to its publication, they were not considered mentally unhealthy. With one book being published, suddenly millions of people went from well to ill.

Of course, this is not to minimize the rather extraordinary reality that our human minds are not a finished product, and contain real instabilities that put us all at risk for serious difficulties. Just consider that no matter how one defines depression, nearly everyone has either experienced a very serious bout of it or loved someone who has.

So take a look at this article, it is a rare glimpse into the intricacies of defining just who is mentally well and not well.

It emphasizes the reason that we find the focus on functionality so helpful when thinking about how to help respond to issues relating to the mind. By that we mean, we take our stance as assessing and doing all we can towards helping each person function well- at home, with family, at school, and at work. This focus seems to be more productive than simply relying on diagnosis.

Dr. Arthur Lavin

2012-12-04

Younger members of a class get medicated more often

Younger members of a class

get medicated more often

The entire population of Iceland born in 1994, 1995, and 1996 was studied to see what impact your relative age in a classroom would have on performance and on your chance of being medicated with stimulants.

(Here's the article's abstract- http://pediatrics.aappublications.org/content/130/6/1012.abstract, it just came out this month)

What they found speaks volumes about how we use stimulants to change the grades of our children in school.

Between the ages of 7 and 14, if your child was someone younger than 2 out of 3 or more of the kids in their class, then he or she was 50% more likely to be placed in stimulant drug therapy than a child older than 2 out of 3 or more of the kids in their class.

The study also found that the younger third struggled more in math and reading than the older kids in the class.

Now, keep in mind that actual capacity of a child's mind to do school work does not change by age. Yes, skills develop with age, but not capacity.

Most importantly, mental illness and mental health conditions should not be determined by your age,but rather by the properties of your mind.

So imagine, the same child in 6th grade may have a 50% greater chance of being diagnosed with a mental health condition and placed in medication to succeed in school than if that child was in 5th grade that same year!

This is rather bold evidence that we often diagnose children with mental health conditions and put them on medication more as a result of unfortunate circumstances, rather than because they truly have a disease or condition.

This publication, a very strong study since it looked at every child in an isolated nation over a 3 year period, makes a very powerful point.

That is, before any family accepts the idea that their child truly has an internal abnormality of brain function, we should be very careful to be sure the trouble seen in school does not reflect external circumstances rather than a true medical condition. This distinction can be made with careful thinking and evaluation, and should be in every instance where a diagnosis of a medical condition is proposed to explain struggling in school.

Dr. Arthur Lavin

2012-12-03

The Agony of a Cough

The Agony of a Cough

Many troubles appear in their own season. Allergies plague many of us every spring and fall. This season, the season of fall and winter, the season of the school year, brings the troubles that come with colds.

And few problems that colds create can compare to the agonies suffered from having a cough.

What is a cough, how does a cold cause it to happen, what other problems besides a cold can cause a cough, when does a cough get worrisome, and what can be done to get rid of this horrible experience?

What is a cough?

A cough is a big spasm of muscles in the chest that happens whenever the lungs and their airways get irritated.

Because it takes so many muscles to create a cough, the muscles get sore, the chest hurts, the throat get sore, in not too many days of a cough people really get upset at the agony it causes, and for good reason, it is a true misery.

How does a cold cause it to happen?
After many years of thinking about just what is a cold, it appears we have an answer- a cold is a burn.

Literally.

A cold is when a virus infects your nose, eyes, throat, and lungs. When a virus infects, it really kills off the lining of what it infects. So when you get a cold, the virus literally destroys, or burns off, the lining of your nose, throat, and lungs, and sometimes- eyes. When the lining of your nose gets burned you get a runny nose, when its the lining of your throat you get a sore throat, but when the lining of your lungs burns off, you get a very awful thing- a cough.

Why?

Well, think about what would happen if you had a burn on your hand and someone rubbed a little sandpaper on it, Ouch!! That's the situation with a cold in the lungs- the lining of the lung is burned away and so with every breath you are rubbing air on a burn, OUCH!! When you hurt the lung, you cough.

Not all coughs are due to simple colds, how do you know your child's cough is from a cold?
During cold weather months, the vast majority of coughs are from colds.

But not all. The main causes of cough all have to do with the lung or throat being bothered, and include:
viral infections (aka, colds and flus), bacterial infections (e.g., pneumonia, bronchitis, and bacterial sinus infections), allergies and asthma, and irritations (e.g., smoke).

So, if you do not have allergies or asthma, if there has been no smoke exposure, and if your illness is less than 14 days old and not getting much worse over time, the odds are overwhelming your cough is from a cold.

When is a cough worrisome?
This is a critically important question. First of all, let's make sure we know what is meant by worrisome.

It turns out nearly all coughs are dreadful and quite bothersome. No question there, even if your child is quite safe from the illness causing the cough, he or she can be quite irritated by coughing all the time, in fact, will almost certainly be bothered terribly by it.

But by worrisome we mean that the cough or the illness causing it might cause actual harm.

Coughs caused by simple colds almost never actually cause any harm, meaning that when the cold goes away, the child is very much like they were before the cold came, fine and unchanged.

So, if someone has a cold, how do you know the cough or the illness has changed into something that is actually potentially dangerous or harmful?

The best indicator is to see how hard it is for your child to get air in and out of their chest when they are not coughing. Don't pay too much attention to how breathing is going in and out their nose, that is very often very difficult. Instead, look at how much work it takes to breathe air in and out of the chest in between coughing attacks. If someone is breathing comfortably when not coughing, it is very unlikely the cold has progressed on to something of concern.

Of course, other indicators that your child has left the world of a simple cold toward a more dangerous set of illnesses include a stiff neck, severe pain, difficulty waking up. Notice that fever is not on that list. Even the simplest cold causes fevers up to and including 105.8.

How do you stop or reduce coughing?
Even if you know the cough is from a simple cold, you still are faced with watching your child really suffer, a horrible place to be. The need for a medicine that relieves coughing is real, urgent, and acute.

Only one problem, that drug is yet to be invented.

The need is so strong, so urgent, however, that many companies sell stuff claiming to stop or even reduce a cough a bit. In March of 2011, the US FDA launched formal investigations of fraud for over 500 cold and cough remedies. From Robitussin to Mucinex (exactly the same drug!), from Comtrex to Triminic, essentially all the over-the-counter meds in the cough and cold aisle don't really do anything,

Now, keep in mind that the placebo effect is a wonderful and powerful thing. An astounding 30% of the time, whenever anything is administered as a medication (even salt water), it works. It really works, pain goes away, sugar levels in diabetes go to normal, walking improves, just about any symptom will get better about 30% of the time. And in essentially every study done on cough and cold remedies, they perform no better than salt water or other placebos.

And, that makes some sense. If you think back to how a cold is a burn, imagine again having a burn on your hand. What medication exists that you could take that could make that burn go away in a few minutes, or keep it from being uncomfortable if rubbed?

So, what to do? Well, it turns out the whole breathing apparatus shuts down whenever you swallow anything. If water or food is rolling down your throat, the lungs are closed. During a swallow there are no breaths, and therefore, no coughs.

The more seconds per minute you swallow, the less you will cough. That's how cough drops work, and you can offer your child the same relief by having them sip on a favorite drink, or if old enough, suck on their favorite treats.

How long is normal for a cold to cause a cough?
Colds last a lot longer than people can possibly imagine. We would like to think our colds will be 24 hour bugs, but the average length of a cold is 8 days.

That means half of all of our colds will last longer than a week, many go on for 2-3 weeks.

And, cough is almost always the last part of a cold, and gets worse every day until the cold finally heals and ends. That goes back to the cold being a burn. The virus typically lands in the nose or mouth, and begins the burning there. Like any good fire, the burn slowly progresses and eventually hits the lungs. The more lung burned, the worse the cough.

And, so, coughs often come at the end of a cold and worsen as the cold burns its way out. Another reason they cause such agony, after being sick for a week, who can stand a cough getting worse every day for another week? Who can resist being discouraged in that sort of setting?

But, keep in mind, the cough appearing and getting worse almost always means the end of the cough and the cold is getting closer.

BOTTOM LINE
In fall and winter, colds are by far the top reason for cough. Cough is the result of irritation to the lining of the lung and/or throat, and gets worse as the cold burns its way across the throat and lungs. No medicine has yet been invented that could make a cough better, but swallowing can interrupt coughing and that can help. Be on the lookout for trouble breathing when not coughing as the key sign that your child has something more serious than a cold, as well as other indicators of dangerous illness like stiff neck, severe pain, and/or trouble waking up.

Our hearts go out to all of us who suffer a cold, it is truly a miserable experience. Keep your child comfy, and know that the cold will pass.

Dr. Arthur Lavin

2012-11-16

Report from Dr. Lavin's Meeting with the American Academy of Pediatrics national Committee on Psychosocial Aspects of Child and Family Health

Report from Dr. Lavin's Meeting with the

American Academy of Pediatrics national

Committee on Psychosocial Aspects of Child and Family Health

This weekend, I was honored to attend my first meeting of the American Academy of Pediatric’s national committee charged with developing policy for the Academy in psychological and social issues confronting children and their families.

The American Academy of Pediatrics (AAP) is the world’s largest organization of pediatricians, founded in the 1920’s to promote the provision of free milk to children in need. As such, it is one of the only professional societies formed to help the client, not the professional, and the AAP continues to operate in that spirit, with a fierce devotion to the well-being of children. The Committee that I was recently appointed to is formally designated as the Committee on Psychosocial Aspects of Child and Family Health (the Committee). The AAP is the voice of America’s pediatricians, and as such has a widely respected voice here in America and around the world. It gathers leaders and experts in various fields to form its Committees that in turn, develop expert approaches to policies devised to respond to the most pressing challenges to children.

The Committee meets at AAP headquarters in Chicago (see photo), and included pediatricians, child psychiatrists, pediatric nurse practitioners, and child psychologists from around the country. I represented pediatricians from the Midwest region around Ohio. Our agenda presented us with the opportunity to develop policy responses to a very wide range of issues.

These included:

Helping children respond to the stresses of having parents in the military
Approaches to helping pediatricians determine the best approach to educational psychological evaluations
Thinking about how best to screen children in a pediatric practice for mental health problems
Preparing the child who may have to testify in court
Supporting the family in the event of the death of a child
An analysis of the roots and responses to poverty in the US
Presenting insights from emerging neuroscience on how best to parent children
Developing guidance on discipline
Enhancing the role of fathers in the raising of children

Over time, Committee deliberations lead to policy reports that are published in the leading medical journal of our specialty, Pediatrics.

The Committee also had the opportunity to review a wide range of emerging trends in policies relevant to families and children at the Federal level and across many states.

Finally, the Committee heard from their liaisons from a wide range of the nation’s leading professional societies devoted to helping children, such as American Academy of Child and Adolescent Psychiatry.

It was indeed an honor and privilege to participate in these deliberations and to add my voice to the development of important policy positions of the American Academy of Pediatrics. An added benefit to this work will be the opportunity for me to hear your voice on these issues. So, if you take a look at the list of issues that the Committee is addressing, as I report it to you from time to time, please let me know if you have thoughts on these important issues.

Finally, many thanks to the families of Advanced Pediatrics. It is truly the case that only by your trust in our care that we have had the opportunity to learn together and be in a position to even consider participating in this important work.

Thank you,

Dr. Arthur Lavin

--
Arthur Lavin, MD FAAP
Associate Clinical Professor of PediatricsAdvanced Pediatrics

A small, attentive, independent practice focused on the well-being and success of each child

3733 Park East Drive- Suite 102
Beachwood, OH 44122

216-591-1515 (Office)
216-591-1544 (Fax)

2012-11-06

Mono

Mono: What is this illness?

Of all the infections that afflict the nose and throat, few cause as much reaction and worry as mono. Just the word carries a lot more weight than the phrase viral illness, and certainly more than the word cold.

But is mono always a serious illness? How is it different than other infections of the nose and throat, such as strep and colds?

It turns out that many, many people can have the illness mono and not be very ill at all. So how do you know when mono is a problem, and what sort of problems can it cause?

The Germ

Mono is shorthand for an infection called infectious mononucleosis. It turns out that if you look at white cells, some have one nucleus in the center of their cells, and others have many. The ones with one nucleus can be referred to as monocytes, and in mono, there tend to be lots of them. Hence the term infectious mononucleosis- or an infection that causes there to be many white cells with one nucleus each circulating.

There are two germs that can cause mono, but the vast majority are caused by one. The infrequent cause is a virus called CMV which we will not discuss much further. The main cause of mono is a virus called the Epstein-Barr Virus, or EBV, because Dr. Epstein and Dr. Barr first described it. The EBV is one of 8 types of herpes viruses, and is also referred to as herpes virus 4. Other herpes viruses are very well known, including the ones that cause cold sores (herpes virus 1 and 2), chickenpox and shingles (herpes virus 3), the CMV we mentioned above (herpes virus 5), and roseola (herpes virus 6).

Although many familiar illnesses are in the Herpes family, EBV stands out as causing a particular illness, mono. Like all the illnesses in the herpes family, once you have had the illness, you tend not to be able to catch it again. There are no recurring features of mono like those seen in some other herpes virus infections.

But, the EBV germ, once it causes mono, hangs around for a very long time. It can take a year to no longer be contagious!

MONO- THE DISEASE

The EBV germ infects three main parts of the body:

1. The throat

2. The white blood cells

3. Certain parts of many cells called mitochondria
4. The Spleen

The Throat

For nearly everyone with mono, it is the infection in the throat that is how everyone experiences mono.

For the vast majority of people mono is a very bad sore throat, and swollen glands.

Many people find the sore throat of mono hurts quite intensely, and is more painful than most other viral sore throats, and even strep.

The swollen glands can be tremendously large. If some of the swollen glands are the tonsils, their enlargement can get in the way of breathing.

The White Blood Cells

The EBV that causes mono attaches itself quite well to a particular type of white blood cell, the cell that makes all the various antibodies, the B-cell. In infecting the B-cell, EBV provokes the immune system. This is what leads to such large swollen glands in the neck noted above. With the B-cells infected, the amount of various antibodies circulating in the blood goes way up, an event that usually passes without any symptoms. But one set of antibodies that is produced in mono leaves about 90% of people with it sensitive to amoxicillin during their infection. The antibodies to amoxicillin do not create an allergy, but if you take amoxicillin while infected with mono, you are likely to get a rash with a lot of small red bumps.

The Mitochondria
Mitochondria are the part of nearly every cell that makes the energy for the cell. This is where fuel we eat primarily gets burned, releasing its energy, which the mitochondria turn into a storable reservoir of energy.
No mitochondria, no energy, no work done. It turns out the EBV, and so mono, attacks mitochondria. This is more likely the older you are when you get mono. So kids who have not yet entered puberty rarely experience the lethargy mono brings to adolescents. Sometimes the mono can be so debilitating to the mitochondria that the affected person has little energy to even get out of bed. In adolescents a profound lethargy can often last 1-2 months. Rarely, it appears to be able to persist for years and cause chronic fatigue.

The Spleen
The spleen is an important organ of the immune system that lies just under the left lower edge of the ribs. It filters blood, and is a rich area of white blood cell activity. In mono, the spleen often is enlarged, usually not too badly. But sometimes it gets very tight, like a tight water balloon, and very rarely, the enlarged spleen can pop like a balloon. This is a very rare event, but is the reason people with mono might be told to avoid hitting that area of the body for 6 weeks from the start of the illness.

BOTTOM LINE
1. When it comes to sore throats, there are basically two types of infections: viral and strep. Strep is a bacteria, and the only type of bacteria that causes sore throats commonly in children.

2. If you have a sore throat and get tested for strep and find you do not have strep, you almost certainly are infected with a virus

3. Mono then, is one of a large number of possible viral infections of the throat.

4. As with all viral infections of the throat, antibiotics do not help at all. In fact, almost no drugs help beyond the pain relief of ibuprofen.

5. In one situation, medication might be helpful for mono. That is when the tonsils get so big, breathing is in danger. In that setting, a course of steroids can shrink the swelling enough to improve breathing.

6. Mono is also unique among viral infections for being able to cause the spleen to enlarge and to cause rather pronounced lethargy.

7. Key Point: If your breathing is fine, your spleen not too big, and your lethargy manageable, mono is like any other cold, and so testing for it will not bring any added benefit.

Dr. Arthur Lavin

2012-11-02

Mumps Outbreak in Cleveland Explained

Mumps Epidemic in Cleveland Explained

In this week's New England Journal of Medicine, the cause of a very peculiar outbreak of mumps was explained.

http://www.nejm.org/doi/full/10.1056/NEJMoa1202865

In the year June 2009- June 2010, there were significant outbreaks of mumps, mainly in the NYC area, but some cases erupted in Cleveland too. Two aspects of the mumps outbreak were striking and unusual- most of those who caught the mumps were already well immunized, and most were in the Orthodox Jewish community. Nothing we knew about mumps could explain either of these observations. After all, the whole point of being immunized to make sure you cannot catch the disease even if you are exposed. And, there is no reason a virus like mumps should only infect one group in a society.

After 2 years of painstaking epidemiologic detective work, the CDC scored another triumph of science in finding out how this happened.

The key elements turned out to be European immunization rates, the nature of a virus that spreads in the air, and how people study in class.

First the European immunization rates. Many countries in Europe do not require parents to immunize their children as a condition of attending school, and thus have much lower immunization rates than in the US.

This leads, of course, to epidemics of illnesses not seen in countries where children are immunized at high rates.

In the spring of 2009, England experienced serious outbreaks of mumps, presumably due to a drop in the number of kids immunized for mumps. That set the stage for the story that unfolded. The English mumps epidemic was the hot fire that kindled very wet wood.

The next factor to come into play was the nature of the classroom in a traditional Orthodox Jewish school. For boys, much of the day can be spent in paired study sessions, where two boys face each other and engage in intense study and verbal discussion of the texts at hand. A table can often hold several pairs of studying boys.

And the final factor is that the mumps virus is spread by breath, and it turns out that many respiratory viruses can overwhelm body defenses if enough virus is transmitted. In this case, being in close proximity to each other's breath for 4-10 hours a day can deliver enough mumps virus to cause an infection, even in someone immunized whose antibody levels to mumps would normally protect them from infection.

So what happened is that an 11 year old, American, Orthodox Jewish boy was studying in England and happened to sit across from an English boy who had caught mumps as part of that country's mumps epidemic. Although fully immunized, the contact with mumps overwhelmed the 11 year old's defenses and he got mumps. While contagious, he returned home in June 2009 and went to his traditional school in NYC.

At that school he spread mumps to study partners who also tended to be fully immunized, and then they spread it to their study partners. By the time a year had passed, about 3,500 children came down with mumps. Over 95% of them had confirmation of the infection by a lab test. Over 75% of them were male, and over 95% of them were from the Orthodox Jewish community. A number of the boys who got mumps lived in Cleveland, and nearly 90% of them had been fully immunized. Very few were girls, almost none were outside the Orthodox Jewish community.

This story is a dramatic example of a very unusual circumstance opening the door to a very selective pattern of infection. In the US, so many children are immunized against mumps that we do not see mumps very often if at all. In 2008, the whole country reported only 400 cases, mainly in unimmunized families.

It turns out that this outbreak could only occur in the special circumstance of a child getting mumps and then sitting in very close contact with one other child for extended hours every day. This special educational circumstance, limited to boys, and to boys in traditional Orthodox Jewish schools, created the unusual situation of a respiratory virus being able to accumulate enough numbers in someone to overcome good protection from immunization. The fact the children were immunized made their mumps far more mild, and limited spread mainly to boys in close contact. The outbreak did not spread very much to girls in these schools, or outside the schools.

The outbreak was mild, no deaths occurred. But it was an interesting window into the nature of viruses, and how our behaviors can influence our epidemiology.

Dr. Arthur Lavin

2012-10-23

Advanced Pediatrics Featured at InsideHealth.com

Advanced Pediatrics Featured at

www.InsideHealth.com

We were pleased to find Advanced Pediatrics featured on the front page of the important health care

news website, InsideHealth.com on October 18, 2012.

Here is the article:

Pediatric Practice at Cutting-Edge of Technology Use

Oct 18th, 2012 | By admin | Category: 2012 Current Feature

Pediatrician and author Dr. Arthur Lavin, M.D. has been practicing relationship-based pediatrics with the help of technology for more than 20 years. Based in suburban Cleveland, Ohio, Advanced Pediatrics is a small, independently-owned practice providing a wide range of services to patients and their families.

From its inception in 2003, Advanced Pediatrics has been an EMR-based practice. Setting off on his own nine years ago afforded Lavin a unique opportunity to go paperless from the onset. At its founding, Advanced Pediatrics had its own network, originally a peer to peer (P2P) network and then later an application service provider (ASP) based in Massachusetts. ASP data met Lavin’s needs and ensured the safety of patient data from physical disasters such as fire.

Using Technology

Lavin and his staff use mobile, wireless tablet PCs to chart patient information, access medical libraries and respond immediately to patient questions during clinical visits. For example, information on weight control, immunization and allergies is often printed on the spot, or emailed directly to the family for later reference

Lavin also relies heavily upon the website Epocrates.com, a comprehensive drug database site which features pediatric dosage charts, drug interaction checks and pill identification functions. Before prescribing any medication, Lavin often uses his wireless tablet to access the site’s drug referencing which allows a physician to plug in the drugs prescribed to a child and then determines any potential hazardous interactions.

In 2010, Advanced Pediatrics updated its EMR system. “We wanted a platform that we knew would be around in 20 more years,” Dr. Lavin tells Inside Healthcare IT. “We choose eClinical Works because of how they created, conceived and designed the integration of their disparate applications including a prescription writer, lab order, progress notes and billing program.”

Social Media

Advanced Pediatrics uses several technologies and avenues to push information out into the community. Dr. Lavin regularly writes informative articles on topical issues – everything from flu vaccinations to the hazards of trampolines to the epidemic use of stimulant drugs. These articles populate Advanced Pediatrics’ web page (http://www.advancedped.com), blog (http://advancedped.blogspot.com), Facebook site and Twitter feed. Additionally, an email blast to patient families several times a month provides electronic updates and resources.

“ The benefit of social media marketing is that a lot of people I have no direct contact with are reading my writings,” Lavin remarks. Social media helps Advanced Pediatrics reach thousands more than are connected via the traditional patient/doctor relationship.

Looking Forward

Despite advancements in technology, Lavin believes the practice of medicine – specifically pediatrics – is very much the same from when he began practicing medicine. “If someone has a cold, the family and I are still talking about it the same way we did in 1980,” Lavin comments.

Lavin believes the next wave of technology in medicine will be the use of algorithms to replace routine diagnosis. He cites examples in other fields already embracing algorithms, such as the algorithmic trading involving automated trading frequently used by pension funds, mutual funds and other buy-side, investor driven institutional traders.

“People are applying these technologies to medicine right now,” Lavin says. “Computer programs now on Skype can figure your pulse based upon the changing colors in your face and imagines of your chest beating.”

Medical tasks including taking your blood pressure and diagnosing an ear infection can already be done remotely with the help of smart-phone assisted applications.

But the real revolution in using technology comes from the enhanced patient care.

“Our access to information is incredible,” Lavin says. “Advanced Pediatrics uses technology to reduce the hassle of everything that gets in the way of valued medical conversation. That is technology’s real revolution: more personal connections.”

Lavin is a graduate of Harvard University (BA) and the Ohio State University (MD). He trained at MIT and is a board certified specialist in newborn medicine. He has served on a number of national committees of the AAP and as president of the Northern Ohio Pediatrics Society. He is the co-author of two parenting books, “Who’s the Boss? Moving Families from Conflict to Collaboration” (Collaboration Press, 2006) and “Baby & Toddler Sleep Solutions for Dummies” (Wiley, 2007).

–Correspondent Debra Mayers Hollander

Sidebar:

EMR has provided Advanced Pediatrics increased efficiency, 24-hour access to patient records and operational cost savings. Advanced Pediatrics worked with IT consultant, Frederick Johnson, President and CIO of Ross-Tek, a small business IT solutions company with offices in Cleveland, Chicago and Tampa. Ross-Tek is a Microsoft Certified Partner enabling its customers – particularly small businesses – to access the latest in network solutions using Microsoft-based applications.

Realizing the innovation and forward-thinking of Advanced Pediatrics’ use of technology in 2003, Johnson recommended Advanced Pediatrics to Microsoft for inclusion in their selective case-study-based-launch of Microsoft Windows Small Business Server 2003 and Microsoft Office Professional Edition 2003.

Advanced Pediatrics was selected by Microsoft as one of only 15 businesses – and the only medical practice – nationwide to be cast as a model of small business technology solutions. The ensuing video case study was distributed to 60,000 IT vendors across the world and in 2005 was ranked #5 in global viewing of all Microsoft small business video case studies.

2012-09-25

FLU MIST NASAL SPRAY NOW AVAILABLE FOR PARENTS OF ADVANCED PEDIATRICS

FLU MIST NASAL SPRAY NOW AVAILABLE
FOR PARENTS OF ADVANCED PEDIATRICS

Dear Families,

We are pleased to announce that we can offer the Flu-Mist nasal spray form of influenza immunization to parents this year.

We will be making the Flu Mist available to parents in the practice during our Flu Clinics only. These take place from 8AM to 11:30 AM this Saturday, September 29 and the following Saturday, October 6. The Flu Mist immunization will cost $30 per dose, a charge we will collect at the front desk.

In order to be sure we continue to provide the best service possible to your children, we will not be offering the Flu Mist for adults during the week, as it would disrupt our ability to attend to the children.

For whatever reason, it appears that it is difficult for adults to get the Flu Mist, hospitals, employers, and drug stores seem to only stock the shot. So we are very pleased we can help the parents of Advanced Pediatrics find a way to be protected from the flu without a shot.

To secure your Flu Mist immunization, simply call our office and make an appointment for Saturday, either Sept. 29 or Oct. 6. Two restrictions do apply- the Flu Mist format cannot be used if you are over 50 years old or if you have a chronic illness such as diabetes or asthma.

Dr. Lavin
Dr. Hertzer
Ms. Rieger

2012-09-24

Time to Put the Trampoline Away

Time to Put the Trampoline Away

For many years, it has been known that playing on a trampoline can hurt you, badly. But the use of them has continued.

Today, the world's largest professional organization of pediatricians, the American Academy of Pediatrics, made a very clear recommendation:

Do Not Let Your Children Use a Trampoline- they can hurt, they can kill

http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Advises-Against-Recreational-Trampoline-Use.aspx

The story of how trampolines came to be in our back yards is actually rather chilling.

The sport of trampoline jumping was until some years ago, an official NCAA sport across American colleges. But after a series of permanent brain and spinal cord injuries came to light, the NCAA banned trampolines.

When sales to colleges plummeted, the makers of trampolines decided it was time to market them to suburban families with back yards. And, it worked.

Trampolines now dot the American back yard, and kids love bouncing on them.

The trouble is that a lot of kids ended getting hurt, many very seriously.

And, adding netting and padding has done nothing to reduce the chance of getting hurt.

In 2009, nearly 100,000 (that's right, 100,000) kids got hurt.

Nearly 20% of them hurt their neck, spine, or brain.

I have personally seen children suffer injuries that they never recover from.

Some advisories talk about making sure only one child is on the trampoline at a time or that skilled spotters are present.

The AAP, and Advanced Pediatrics, however, have a much simpler message-

Put the Trampoline Away

Do not allow your children to play on others' trampolines either.

We have known the danger too long, the call to end it is now clear,

The time has come to put our kids first and put away the trampoline.

Dr. Arthur Lavin

2012-09-06

Turns out Formula Supplements have No Impact on Intelligence

Turns out Formula Supplements have No Impact on Intelligence

Every so often, something comes along that suggests that if we eat a certain thing, we will get smarter. Remember fish, the brain food?

This idea goes way back in our human history. Ancient cultures prized eating certain animals, or parts of animals, thinking they contained special enhancing powers. Eat a fierce lion's heart, and you would become braver. Eat a smart animal's brain, and you would get smarter.

Not that long ago, infant formula manufacturers used our tendency to think this way to market their goods.

All infant formulas are under clinical and legal pressure to be nearly identical, they all aim towards the same goal- to be just like human breast milk. This is why every infant formula on the market has essentially the same number of calories per ounce, grams of sodium, fat, and carbohydrate per ounce.

So if you make a formula, how do you pitch it as better than your competitor's, how do you imply it's competitive with breast milk.

One strategy was to add DHA and ARA to the formula. Not much, not enough to change its basic nutritional value. But enough to say, here is an infant food with extra DHA and ARA. And the claim?

That if your infant eats extra DHA and ARA they will be smarter.

What is DHA and what is ARA?

DHA and ARA are types of fat called fatty acids. It turns these fatty acids are important chemicals in the brain. Much of the brain's material is made up of these compounds.

DHA is docosahexaenoic acid and it makes up 40% of all the polyunsaturated fatty acids of the human brain.

ARA is arachidonic acid which is abundant in the cell membranes of brain tissue.

Does eating more DHA and ARA in infancy make you smarter?

Well, researchers looked at a group of children who did and did not have extra DHA and ARA in infancy.

They found no difference in intelligence or cognitive function between those who ate more and those who ate less DHA or ARA.

Bottom Line

Like getting younger, we seem to all long for something that will make us smarter.

There are no chemicals or compounds that have proven able to make our babies smarter adults.

So beware of claims by infant formula manufacturers when they present small supplements to the formula for special purposes.

Dr. Arthur Lavin

Stimulants- The Explosion, The Reasons, The Risk

Ritalin (Photo credit: Wikipedia)

Stimulants- The Explosion, The Reasons, The Risk

Stimulants are a group of drugs whose most famous example is Ritalin.

We are currently living at a time when the use of these drugs is truly epidemic, so it makes sense to take a moment and look at why they are so popular, and whether there is any risk (there is).

The Basics of Stimulant Chemistry

Let's begin with a few basics about these drugs. All stimulants can trace their chemistry back to the king of all stimulating chemicals- adrenaline, also known as epinephrine. Many of us are familiar with what adrenaline can do- it causes excitement. Adrenaline makes your heart race, your mind clear, your breathing go deeper, your alertness soar, and overall makes you very, very excited. But if you eat adrenaline, nothing happens, the gut destroys it before it can do anything.

For the last 5,000 years, the herb ma-huang has been used in China to give people the boost of adrenaline in an oral form. The chemical in the herb is ephedrine, and it was from this chemical that in 1887 a chemist created a new chemical, amphetamine. Amphetamine was not used in people until 1927, but it really took off. Various forms of amphetamine were widely used by German, British, and American military during World War II. Near the end of the war, in 1944, a chemist created a related chemical, methylphenidate, and he gave it to his wife to increase her low blood pressure. His wife's name was Rita, so he called the new drug Ritalin.

Today, these two drugs, amphetamine and methylphenidate, account for nearly all the stimulant drugs used to treat people who struggle with paying attention. They both work by stimulating the activity of various networks of nerves in the brain. Each of these networks help control and manage a wide range of functions in the human mind. The key network the stimulants stimulate is the dopamine network. The nerves in the brain that use dopamine to communicate with each other are very much involved in the overall alertness of the brain, as well as a sense of reward and pleasure.

Like many drugs, the chemicals amphetamine and methylphenidate are sold under many brand names.

Amphetamine is sold under two main brands today: Adderall and Vyvanse. Adderall is straight and pure amphetamine. Vyvanse is amphetamine with an amino acid attached. As long as the amino acid remains on, this drug will be inactive. But if you swallow a pill of Vyvanse, your gut will cut off the amino acid leaving you with straight amphetamine, now activated and ready to go. Therefore, Vyvanse (once digested) really is very much the same drug as Adderall.

In the methylphenidate side of the stimulants, there are a few more brands. They include: Ritalin, Concerta, Methylin, Metadate, Daytrana, and Focalin. Focalin is what's called an isomer of methylphenidate. It turns out most drugs and many chemicals in the body are like our hands, they come in right and left handed forms. Both forms are identical in structure in all ways, but physically are mirror images of each other. Focalin is the right-handed version of methylphenidate. All the other methylphenidates have both right and left handed versions of the drug in the pill. So a 20 mg pill of Ritalin has 10 mg of Focalin in it (the right handed form of methylphenidate) and 10 mg of the left handed form of methylphenidate. So aside from Focalin, all the other brands of methylphenidate are exactly the same. So 30 mg of Ritalin has exactly the same drug in it, really is the same thing, as 30 mg of Concerta, or Methylin, or Metadate, or Daytrana.

Lots of Kids are On These Drugs

Recent surveys reveal that lots of kids are on these drugs. Some years ago, one survey found that in the United States, 10% of boys age 10 take stimulants to get their homework done and do well in the classroom.

Just recently, an anthropologist conducted a study of undergrads at Case Western Reserve University. The question was how many college students take the stimulant Adderall during midterm or finals weeks?

The answer reflects a new reality in the lives of our children- 93%. That's right, nearly every college student at Case feels compelled to take the powerful drug Adderall in order to succeed.

What makes this incredible rate so amazing is that for the vast majority of these students, their use of Adderall is highly illegal. Use of Adderall without a prescription is no different than scoring speed off the corner. If the DEA finds out, you can easily spend many years in jail. And yet, 93% of college undergraduates are using this drug, most without a prescription.

And, just in the last few years, we have seen the number of kids being prescribed stimulants really taking off. The 10% of all American 10 year old boys is a rate quoted from several years ago, but that number is surely much higher now. In our office, we are seeing many, many children being referred by their teachers to us, with the express directive to see about starting their child on stimulants to succeed in school.

Why Are Stimulants Being Used So Much Now?

There is no doubt at all, as noted above, that the use of stimulants is galloping ahead. Why is that happening?

The most important reason is that they work. There is little mystery about this fact. It is a fact that if you stimulate or arouse the brain, it simply works better. This is likely a fact for all animals, but is certainly how we humans are built.

It makes a lot of sense. If you find yourself in real danger, your mind gets a little bath of adrenaline, and that causes it to get very excited. Once aroused, the mind has the energy and resource to become amazingly focused, to laser in on the task at hand and put all mental resources on getting the job done, thoughts fly faster and with more purpose. Think about a tiger suddenly jumping at you, all of a sudden your mind instantly organizes all thoughts and actions towards escape. The level of focus created by this excitement is intense and extremely effective. From the point of view of evolution, all humans whose minds do not focus at moments of danger tend to have a lot fewer kids than those whose minds do focus in response to a threat.

One could argue that all of us are descendants from humans whose brains got going and got focused when threatened. And so our minds have this response to arousal and stimulation. Of course, too much excitement and we move from focus to agitation, losing ability to get good work done.

We see the same thing happen with coffee. A cup or two seems to help nearly everyone wake up, be more alert, and be more productive. But too much coffee and our minds are whizzing into chaos.

So it is with the stimulants. A bit of Concerta, or Adderall, or Ritalin, will improve the focus and efficacy of 80% of any group of people! That's right, these drugs help nearly everyone do better work.

This has nothing to do with ADHD. Yes, about 80% of people with ADHD who take stimulants will produce better work and get better grades. But the point is that about 80% of all people, will do better work and get better grades when they take stimulants.

So the main reason that the use of stimulants is exploding is that they work.

The other reason is more cultural and complex. The drugs work, but they have always worked, and known to work since the 1950's. So why now in the 2010's is use booming so dramatically? I suggest that one reason is the move towards describing our problems in thinking as medical conditions. Another is the rise in complexity of thinking required to get good grades or do good work.

Going Medical

Consider a 6th grade boy named John. He is doing OK in school, but he is not doing as well as he could. He turns out to be a very, very bright young man, but seems bored in school. He is often seen not paying attention in class, even looking out the window most days. Parents find getting him to complete his homework is a great struggle. Lately his grades have been slipping from mostly B's to more and more C's.

His teacher meets with the parents, and although stating she cannot diagnose medical conditions or advise on medical therapies, she suggests they look at the issue of ADHD and the option of medicating the child.

The parents go to their doctor and let him know the school is worried about his ability to focus and ask if he has ADHD. A questionnaire is given to the parents and teachers and they confirm that he has many symptoms of ADHD, he is duly diagnosed with this mental health disorder or condition, and started on a stimulant. He suddenly improves dramatically, now a model student with all straight A's.

This is very, very common story in America today. But if you look at the story carefully, one could conceivably think of this in a different perspective. Not that long ago, one could have thought about this as a case of boredom, or mismatched interests. One could make the case that this 6th grader dislikes the subjects at hand and is defying the authorities in his life who want him to buckle down and do the assignments. I am not going to say which perspective is right in this case, only that it is conceivable that an explanation other than a medical condition is possible to explain at least some situations where our children underperform.

Are Stimulants Addictive? Can you stop taking them easily? Do people tend to use them for a short time or long time?

The stimulants are addictive. They tend to activate addiction when taken in high doses, high enough to get high, that is. We do not see addiction develop very often in children taking them to enhance performance in school. The doses are low enough to avoid causing a high.

If addiction is not activated it is a very simple matter to stop, one simply stops taking the pills. Normally very little if anything happens when you stop taking stimulants, even after many years.

Yet, curiously, most people who take stimulants for better focus tend to take them for many years, often many decades. Again, the reason is likely obvious. If you take a medication and on it you find your grades and work success soar, why would you stop? Why return to days of failure? The answer is for most people, not to return to failure, but to keep taking the stimulant.

If Stimulants Work, Doesn't that Prove ADHD is present?

But what about the fact this child's work got so much better on the medication? Doesn't that prove he has ADHD? The full answer is, no.

Remember, as noted above, about 80% of all humans will find their brain working better, often dramatically better, on these medications, whether they have ADHD, or not.

If Stimulants Work so Well for So Many, Why not Have Everyone on Them?

This is a very important question.

If these drugs were truly perfectly safe, I would be in favor of their very wide use. I would actually have no problem with 93% of college students taking them during exam week. They would turn out to be simply a stronger version of stimulants like coffee, just as safe, and more effective.

Sadly, the stimulants are not free of serious risk.

All stimulants carry a set of minor and major risks. Minor side effects are only minor because they go away if you stop use of the medication. Major side effects are major because they tend to be permanent.

The key minor side effects are: loss of appetite with real weight loss, disrupted sleep, headache, stomach ache, sensation of altered mind.

The three key major side effects are: Diminished final adult height, tics, and cardiac effects.

Height It is estimated that a number of kids (not an issue if you are already fully grown) will lose 1-2 inches of final adult height if they take a stimulant regularly over time.
Tics Tics are twitches of one or several sets of muscles. They can be very small, like a very partial wink of one eyelid every few days, or very severe, involving arms and legs and vocalizations every few seconds. Although proof is not yet complete, there are indications that use of stimulants can increase the chance of a person developing tics, permanently.
Cardiac effects There are two very serious risks here, these are the most dangerous aspects of use of stimulants. The chair of the Cleveland Clinic Department of Cardiology is Dr. Steven Nissen. Widely regarded as one of the world's top cardiologists, Dr. Nissen voiced his concerns about the impact use of stimulants would have on a heart as chair of an FDA Panel looking into this concern. His perspective was published in the world's leading medical journal, the New England Journal of Medicine http://www.nejm.org/doi/full/10.1056/NEJMp068049

Sudden Death. There are a number of children and adults who suddenly died after taking a dose of stimulant medication. This appears to be an event limited to individuals with rare abnormalities of their heart's electrical conduction system. The problem is that most people with these rare electrical conduction systems do not know they have them. A screening EKG prior to use of these medications could help prevent some, but not all of these tragic events.
Long-term Wear and Tear- the Risk of Congestive Heart Failure later in life Those who study how congestive heart failure develops use the fact that simply dripping amphetamine on an animal heart long enough will create congestive heart failure. There are reports in the medical literature of some older adults developing heart failure when used with amphetamine. Of much greater concern is that we are currently embarked on a rather worrisome experiment. As noted above, people who benefit from use of stimulants (about 80% of everyone who might try them), tend to stay on them for many years, even decades. We now have placed millions and millions of children on stimulants, and they will likely be taking them daily for many, many years. No one, including myself, who is currently prescribing these medications to children, will likely be in practice or even alive, when these children grow into later middle age. We simply do not know what the rate of heart failure will be in this group of many millions of children once they turn 40, 50, or 60, or more years old. But the experience with animal research clearly establishes the possibility that long-term, daily use of stimulants could set up a very real risk of very serious heart disease later in life.

Bottom Line

The use of stimulants is rising, very rapidly, and across populations that have nothing to do with ADHD
The notion that children who do not pay attention in school have a medical condition has grown and continues to increase dramatically
Stimulants come in two major forms- amphetamine and methylphenidate. They have a known set of side effects
Stimulants work very well, for everyone. In any group of people, about 80% will see improvements in their life when they use stimulants.
The biggest question mark on the risk of using stimulants is their long term impact on the heart. We do not know what that might be, but the chance that it could be very significant needs to be answered.

Putting all this together, at Advanced Pediatrics we only prescribe stimulants with the greatest of care. We take the following steps to ensure your children are exposed to the risk of stimulants only when necessary and only with your awareness of the risk:

We try to only use stimulant medication for the diagnosis of ADHD. If a child has trouble in school, we start with finding out why, not with a therapy. Causes might include other cognitive dysfunctions (e.g., dyslexia), emotional troubles, relationship concerns, or other problems. So first, see if the problem is really ADHD or some other cause.
We try to use interventions free of side effects first. Options include ADHD coaching, counseling, and cognitive training programs.
Use of stimulants should be used only if the impairment is very serious.

We live in an era when 93% of some college's students use Adderall to get a good grade! But these medications are not entirely free of risk. Advanced Pediatrics will continue to keep you informed as we learn more about how the brain works and how we can most safely improve how our children's minds work.

Dr. Arthur Lavin

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