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

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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)

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

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

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

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

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.