Advanced Pediatrics: 2014

2014-12-26

The best source of data on the influenza virus- http://www.cdc.gov/flu/weekly/

The Best source of Data on the Influenza Virus-

http://www.cdc.gov/flu/weekly/

We have gotten such a wonderful and enthusiastic response to recent posts about infectious diseases, that I thought it would be of interest to share a great source of information- the CDC.

In particular, I want to share how the information about the influenza virus is presented every week by the CDC.

Keep in mind that viruses, like animals, are classified into a variety of species, each of which are different in many important ways. The influenza virus is one species of virus, that comes in many subtypes. Colds and flus are caused by many different species of viruses, including RSV, rhinovirus, adenovirus, coronaviruses, etc. Influenza virus causes only about 1/3 of winter-time respiratory colds and flus.

The CDC actually tracks the presence of the influenza virus in America, in great detail, for all sorts of reasons. The primary one is actually to specify which varieties are in circulation so that the right types enter each year's vaccine, and to monitor this major cause of illness.

This webpage: http://www.cdc.gov/flu/weekly/ gives anyone access to a veritable gold mine of data on the influenza virus.

Here is a brief tour of the six types of trends this web page follows on this virus:

First of all, all the data are reported weekly and usually lag 1-2 weeks behind. Today for example the page reports on Week 50 of 2014, and we are in week 52.

Viral Surveillance

This is a very interesting report, as it tells us what percentage of respiratory swabs in people with colds and flus are positive for influenza. It also tracks which subtypes are in the swabs- Type A, Type B, and subtypes like the now famous H3N3. Note that as of December 13, 2014, about 25% of people with colds and flus had influenza. This means that even in the thick of the influenza onslaught, 75% of us with a cold or flu do not have an influenza infection.

The graph in this section is a bar graph with green, red, and yellow bars, color coded for the subtype of influenza virus on the swabs. Bar graphs going up means more swabs are positive for the influenza virus.

Pneumonia and influenza mortality

This is a jagged red line going up and down between two wavy black lines.

The red line is the percentage, every week, of deaths in 122 American cities due to pneumonia and influenza.

Even without an influenza virus epidemic happening, about 6-7% of all American deaths are due to pneumonia, usually in the elderly. That number goes up in the winter and down in the summer. When the red line goes above the top wavy black line, that means pneumonia and influenza deaths have reached epidemic proportions, they have not yet done this in the US as of December 13.

Influenza Pediatric Deaths

These are the green bar graphs, and they track a very sad set of facts, how many children die of influenza in the US each week. The numbers here, thankfully, are very small. About 20,000 people die of influenza infection in the US every year, but only 100 or so each year are children, so far this year that number is 11. A terrible loss, but quite rare.

Influenza associated hospitalizations

This line graph has many colored lines, one each for an age range, that tells us how many people, per 100,000, are hospitalized for influenza virus infections each week. Note that by far the most hospitalizations occur in the elderly, and as expected these rates go up in the winter.

Outpatient Illness Surveillance- This is the section I refer to most to report the progress of each winter's spread of all viral respiratory illnesses.

This is a set of different colored lines set against a dashed black line. Each line traces the percentage of visits to a doctor in the US for a fever of at least 100.0 with cough and/or sore throat.

Note how the typical year really takes off in December, peaks around New Years, and slowly fades across January and February. 2014-2015 is the red noted by the red triangles, and seems to be following a course very similar to 2012-2013.

Geographic spread of influenza virus, state-by-state

The final two graphics are state maps of the US that report levels of all viral colds and flus (green and red) and levels of influenza virus activity (Yellow and brown) for the week being reported.

BOTTOM LINES:

1. Respiratory colds and flus do indeed peak in the winter.

2. This year is not exceptional in the rate of illness, as of December 13.

3. We are in the midst of the great peak of respiratory colds and flus for this winter.

4. Even in this peak season, about 75% of the respiratory colds and flus are from viruses other than influenza virus.

5. The detail does indicate a large proportion of the influenza virus actually circulating, unfortunately, is a subtype not included in this year's influenza vaccine. Keep in mind this vaccine is manufactured every spring and as such, has to be a prediction of what subtypes will circulate the following winter. This year the mismatch was significant. FluMist offers more protection across varying subtypes than the injected flu shot.

6. MOST importantly. As with most years reported, infection with influenza in healthy children, although a miserable experience, tends to be quite harmless. At it's worst, so far this year, about 99.99% of children who get this infection recover without need of hospitalization.

Again, we offer this guide to the CDC data, since we find it helpful and reassuring. We will continue to report the trends for colds and flus, and the influenza virus, as the season progresses.

Here is to a Happy and Healthy New Year,

Dr. Arthur Lavin

2014-12-24

Croup- What is It, When to Worry?

Croup-

What is It, When to Worry?

What is Croup?

Croup is a variety of a cold that presents the greatest worry and perhaps the greatest risk of all forms of a cold.

The word croup is actually derived from ancient root words that mean "to call out, to cry, to shout hoarsely"

Like all colds, croup is an infection of the respiratory system by a virus. What makes this respiratory infection croup is not the germ as much as the geography.

When a virus causes a cold or respiratory flu, what happens physically is that the virus burns the lining it attacks. If the virus attacks the nose, the lining of your nose gets burned and you develop a sore, runny nose. If the virus attacks the throat, you get a sore throat, and if it burns the lining of the lungs you get the all too familiar cough of a cold.

Croup happens only when the virus attacks a very specific area of the respiratory tree- the vocal cords and voice box. What is so special about this area? Think about narrowing and where narrowing counts. If your nose gets very swollen and clogged with mucus, you can always get around that by breathing through your mouth. And if some part of the lungs gets swollen and filled with mucus, you can always get around that by having the air go in and out of other parts of the lung.

But, if the vocal cords get badly swollen, so swollen that the gap between them is closed, then no air can flow, and that is very bad.

So, croup is a cold that has landed on the vocal cords, and caused enough swelling there to create some problem with air flowing, usually a barking cough.

When to Worry

As with all infections, the amount of irritation, swelling, and mucus production varies from mild to severe.

The sequence of severity for croup is as follows:

1. Croup always starts off as a barking cough with no trouble breathing when not coughing.

2. The next stage, if it gets more severe, is some difficulty breathing noted by a whooping sort of sound on breathing in. This is called stridor. It is a sharp, moaning sound on breathing in.

3. If croup gets even worse, then not only is there a barking cough, and stridor, but now you can see your child tugging and pulling air hard to get it into their chest.

4. At the most severe, it becomes truly challenging for the child to get air in their chest.

Fortunately, the vast majority of cases of croup we see never go beyond the mildest stage, simply having a barking cough. If your child has a barking cough, but breathes easily and without that sound we call stridor, there is no danger, this croup is too mild to cause any harm.

A small number of children we see go on to have stridor, but not many go beyond that.

So, when looking at your child with a cold, if you hear a barking cough but hear no stridor and see that he or she is breathing comfortably, no reason for worry.

And, of course, if you hear stridor or see any difficulty getting air in and out of the chest, that is when to be concerned and contact us.

In very, very instances, breathing is really very hard for the child and there is a great deal of struggle. This is the situation that truly is emergent and indicates the need to call 9-1-1.

What to Do?

If your child's croup is mild, only the barking cough, there is not much to do. As with other colds and coughs, there is no medication that will actually change the cough. Comfort measures may help, such as sipping comfort foods and drinks.

If the cough goes on to stridor, give us a call. While at home, you can sit in a steamed-up bathroom which will dissolve some mucus around the vocal cords and ease breathing. And/or, you can step outside which will allow cold air to shrink some of the swelling around the vocal cords.

If the stridor is mild, we can start a prescription of oral steroid for a short time which will shrink the swelling around the vocal cords and restore easy breathing.

Again, if trouble breathing is pronounced, the right course of action is to call 9-1-1.

Bottom Lines

Croup is a cold with a specific location, the vocal cords. We see croup every cold and flu season.

It tends to be mild, with only a barking cough, but can be more severe.

If it is mild with only a barking cough, not much to do.

If it starts to make breathing difficult, then you need to call.

Here is to a happy and healthy holiday season,

Dr. Lavin

2014-12-20

Influenza 2014-2015 UPDATE December 19, 2014

Influenza 2014-2015 UPDATE

December 19, 2014

The influenza epidemic of the winter of 2014-2015 continues to evolve, here is what we know as of today.

No one needs a doctor to know that respiratory viruses are infecting many, many people right now.

In the Greater Cleveland area, it seems almost everyone is sick with a cold or flu, or knows someone who is. The numbers are so great that absences have forced at least 3 area schools to close for one or more days in December.

Here are some key facts about this year's epidemic:

The infections

1. Many of these cases are caused by one species of virus, the famous influenza virus, but not all.

For an entire winter, about 1/3 of all colds and respiratory flus (that is not stomach flus) are caused by the influenza virus.

2. We are in a period of lots and lots of influenza virus activity. The CDC tracks this carefully. We are on track to have this virus cause most of its havoc in its typical time period, namely, appear in December, peak in middle to the end of December (now), and fade slowly through February, vanishing by spring.

3. As many know, the flu vaccine is always a prediction. Typically about 3-4 subtypes of influenza virus circulate every winter, but the subtypes vary year to year, and so in making a vaccine in the spring for use in the winter, a prediction has to be made. We always hope the subtypes that are in the community turn out to match those in the flu vaccines.

4. This year, one strain, called A-H3N2, is different in our community than in the vaccine. That means the vaccine will not protect so well, or in some cases, at all, if the A-H3N2 that is circulating infects you. The influenza vaccine given this year does protect against the other 2-3 strains.

5. Putting all this together, we are seeing a big burst of influenza virus activity, much of which is not protected against by this year's influenza vaccine. These two facts combine to explain why so many of us are sick.

The course of this infection

Influenza viral colds and respiratory flus are very much like all viral colds and flus- you feel awful, fever, lots of mucus, sneezing, prolonged coughing, sore throat, and a variety of other experiences like headache, stomach ache, neck ache, achiness.

This year the fever is especially high, more in the 103-105 range than the more usual 99-102 range.

Like all such viruses, the illness itself typically lasts about 8 days, but if the cough is intense, it can go only without complications for 2-3 weeks.

When to Worry

Fever itself is a harmless, if miserable and agonizing, experience. That is, once fever ends, there is never any sign of ongoing harm caused by it. The normal range of fever in humans is 100.4-105.8. Now high fevers of 103-105.8 are miserable to experience, but even these high fevers are harmless.

So when to worry? If one of these four symptoms occur:

Stiff neck (not sore neck or achy neck). A stiff neck means you can't bend your neck. If you can touch your chin to your chest, your neck is not stiff.
Trouble breathing when not coughing. Simply look at your child and if he or she is breathing comfortably in and out of their mouth when not coughing then they are not having trouble breathing.
Severe pain anywhere.
Fever, 106 and beyond. Temperatures below 106 are harmless.

Treatment

Medical science has very limited options to treat viruses, including influenza. So most treatments that are safe and helpful are comfort measures, like using ibuprofen, comfort foods, back rubs, ice cream, soup, tea, etc.

A word on three medications:

Tylenol or acetaminophen

Acetaminophen has been associated with increasing the risk of a child developing asthma, so we do not recommend its use. People should also know that if you give your child ibuprofen, adding tylenol does not tend to control the fever any better.

Tamiflu

This has been a very good year for those who sell Tamiflu. A run on the drug has been ignited by the widespread use of rapid influenza testing and recommendations to use this drug.

There are two issues with the use of Tamiflu in children.

1. Particularly in children, the risk of Tamiflu causing a child to have a seizure is increased. This risk is strong enough that TV ads for Tamiflu actually feature this risk as one to be especially concerned about. Tamiflu is also known to cause delirium and behavioral disturbances, and propel those who take it to commit acts of self-injury that at times can be quite serious. This pattern of side effect- seizure, delirium, and serious behavioral disturbance all point to Tamiflu having some effect on brain function.

2. Tamiflu sometimes works well giving people relief, we all know those who have had this experience. But many people, including most people in careful studies of the drug, don't really have much relief from Tamiflu, especially children.

Given that nearly all influenza infections in healthy children cause no lasting harm, exposing children to a drug that can cause significant impact to the brain seems to be causing more harm than good.

If Tamiflu is not used, there is no benefit to testing for the influenza virus, since if the test is positive, no change in treatment will be made.

Over the counter cough and cold remedies.

With the exception of ibuprofen, the hundreds of cold and cough remedies, including decongestants, expectorants, and cough syrups, don't work. This is based on many, many studies, and reflects consensus statements from many professional societies. The FDA is currently investigating 500 of these medications for fraud!

BOTTOM LINES

Every winter influenza virus comes to make us ill, usually in December.
True to form it is here in December
This year, a dominant subtype sadly does not match its subtype in this year's flu vaccine, so a lot more people than usual are ill.
Influenza, like all respiratory viruses, causes much misery, but in healthy children, not much harm.
Tylenol may increase the chance of developing asthma and is not recommended.
Tamiflu causes more harm to children, particularly to their brains, than adults, and often has little benefit, so it is not recommended in routine cases of flu in otherwise healthy children.
This year's flu is a high fever flu, but fever is harmless at 105.8 and below.
It is important to call if fever reaches 106 or above, if significant pain is present, if there is trouble breathing, or if there is a stiff neck.

Here is to a happy and healthy holiday season,

Dr. Arthur Lavin

2014-12-09

Winter Cold and Flu Virus Update- December 9, 2014

Winter Cold and Flu Virus Update- A word on Fever and Cough

December 9, 2014

The Cleveland community is being hit hard with a blast of viruses that is causing very high fevers, prolonged coughs, and much suffering.

Part of this onslaught is clearly the annual winter arrival of influenza virus, which typically appears every December, so it is showing up as expected. But the high fevers and coughs are not just from the influenza virus, which tends to cause only about 1/3 of all such illnesses.

Fever

Whatever the virus causing our children's fevers and coughs right now, these viruses are giving everyone lots of very high fevers. So here is a reminder on the key points to keep in mind with regard to fever:

Fever, although very unpleasant, is completely harmless in the setting of these viral fevers and coughs. Fever is unfortunately an experience that every single person will have, many times in their life. The normal range of fever is 100.8-105.8. Temperatures in this range are common and safe.
The temperature over which fever becomes abnormal or of any concern is 106.0. It is important to note that going to 106.0 and beyond is an extremely rare event. As universal as fevers in the range of 100.8-105.8 are, fevers beyond that range are never seen in most people. Fever often seems to be something out of control, but in fact, the body is very careful in setting the higher temperature. The fact it stays at 105.8 and lower shows that fever is actually a very controlled and safe event.
The main problem with fever is the discomfort it causes, and it is clear that the higher the fever, the more discomfort. So it's a good idea to use ibuprofen to reduce fever to make your child more comfortable.
The main question fever raises, from our point of view, is what is causing it, not how high it is. Fevers always indicate that some inflammation is present. In the vast majority of situations, the inflammation is due to a viral infection that will come and go without causing any harm, despite all the discomforts.
How do you know if your child's fever is from a simple viral infection that will be harmless,or a more serious cause? Three key items that tell us something more serious than a simple viral infection is happening are important to look for. If you don't have any of these three problems, you are likely dealing with a simple viral infection that should be harmless:

A stiff neck in older children
Severe pain
Trouble breathing

Ibuprofen and acetaminophen. These are the key medications available to reduce fever. They don't always work. It is very important not to give too much of these medications when they don't fully eliminate the fever. As noted, fever is harmless, but overdose with either of these medications can be harmful. Here are some key points on use of fever medications:

We recommend using ibuprofen as some studies raise concern that acetaminophen use is associated with greater risk of developing asthma.
Ibuprofen is a helpful drug and should be used properly. The safe interval for children is using it every 6-8 hours. Occassionally, during the peak of a round of fever, it is safe to give ibuprofen every 4 hours, but there should never be more than 5 doses in a 24 hour period.
If you give your child ibuprofen every 6-8 hours, there is no further reduction in fever, and therefore no benefit, to adding acetaminophen between doses

Cough

No symptom of viral respiratory illnesses causes as much suffering as cough. Fever is very uncomfortable and causes tremendous distress, but cough truly is a misery.

Cough is the result of inflammation of the airways. That means the lining of the lower throat, voice box, upper lungs, and lower lungs gets red, swollen, and irritable. When air passes over this inflamed tissue, the tissue is quite bothered and you cough.

Airway inflammation is usually due to one of three causes: viral infection, bacterial infection, and allergies and asthma.

Bacterial infections are the least common cause of cough in children. When a serious bacterial infection of the lungs is present, usually the person is struggling to breathe or breathing very rapidly, even when not coughing.

Most coughs in children with fever involve viruses. Some of these children will also have some asthmatic inflammation with their colds and flus.

How do viral coughs and asthmatic coughs differ?

Viral inflammation is like a burn of the airway lining. The lining gets destroyed by the virus and the inflammation remains in place until the burn heals. It is entirely the result of the damage done by the virus.

Inflammation from asthma is from our own body's immune attack.

But the main difference is that if your airway inflammation is from asthma, medications like inhaled albuterol or inhaled steroids can get rid of the inflammation and the cough.

But, if the inflammation and cough are purely from a virus, no treatments actually can make the cough better or go away, only healing the burn from the virus will help, and only the body can do that.

So if a cough lingers and there is no reason to think bacteria are present, it makes sense to try Albuterol. If it works there is an element of asthma present and the cough can be alleviated. If it does not work, it is more likely a viral cough and not much will make it go away any faster than healing will.

One word on over the counter cough remedies: they do not work. Like any intervention, about 30% of the time it will appear to help, due to the power of the placebo effect. But, in study after study, cough syrups do not better than water in comforting or treating a cough. The FDA is currently investigating 500 of them for fraud.

BOTTOM LINES:

1. Fever is a normal and universal experience, and although very uncomfortable, quite harmless.

2. The normal range of fever is 100.8-105.8, all temperatures in this range are harmless.

3. Ibuprofen is the preferred medication for fever, adding acetaminophen offers little if any help.

4. Cough in the setting of fever is usually the result of a viral infection. For prolonged coughs a trial of Albuterol will tell if there is a component of asthma.

5. Over the counter cough syrups don't work.

6. The key signs to watch for to tell you if your child with cough and/or fever has an illness of concern are:

Stiff neck
Severe pain
Trouble breathing when not coughing

If these appear, call us right away.

If these worrisome symptoms aren't present, you are still welcome to call, but what your child will need is to be comforted as they go through the viral infection.

To your health,

Dr. Lavin

2014-12-05

Flu Vaccines 2014-2015- Update on What Works

Flu Vaccines 2014-2015-

Update on What Works- December 5, 2014

The influenza virus feels very familiar, who hasn't had the flu, or knows it comes in the winter and goes in the summer?

But it also seems to throw surprising dangers our way. In 2009 it was the spring pandemic, in other years it is very mild, and in some years it seems to target unusual populations in upsetting ways, like the 2009 pandemic susceptibility of pregnant women.

And now this year, we are hearing reports about mutations of the influenza virus for 2014-2015, and that this year's influenza vaccines may not work.

So, what is the story with influenza? Why is it a different problem every year? How can a vaccine work one year and not another? Will your child's influenza immunization work this year?

Here are some answers. The bottom line is that this year's influenza immunizations should work very well, and do far more good than not getting one.

Why is influenza a different story every year?

The influenza virus, as familiar as it is, is actually unusual, perhaps unique. Almost all viruses can only infect one species. Chickenpox only infects humans, and the same is true of measles, colds, stomach flus. Dogs have their own viruses that do not infect us.

But the influenza virus infects humans in the winter and barnyard animals every spring and summer, every year. To go from human to cows/horses/pigs requires the virus to change in each direction. So it has to change to go from humans to pigs, and again from pigs to humans.

As such, influenza is the only common virus that changes every year.

What changes?

Every virus is a string of genes wrapped in a protein coat. The protein coat contains patterns that allow the virus to open a cell and get their genes inside. The patterns differ from species to species.

So when the influenza virus enters a human cell, it needs a different protein coat than when it enters a cow cell.

So every spring the protein coat changes to go from human to animal, and every winter it changes again to come back to humans.

It turns out there are just two main types of chemicals on the coat of an influenza virus: an chemical called H and one called N. There are a whole bunch of H types, and a whole bunch of N types.

One famous combination is H1N1- the spring pandemic version of the influenza virus in 2009, and still around.

Making a Vaccine Work

Most vaccines are made against an unchanging virus, so they work forever. The polio vaccine was created in 1953 and still works fine, since the polio virus has not changed at all.

But since the influenza virus changes every year, returning with a new H and N combination to pick our cell's locks, the vaccine must change too.

To make an influenza vaccine that will work, every spring the World Health Organization and the CDC actually sample influenza viruses in cows and pigs and horses around the world, to see how the H and N combinations are shifting. They then take their best guess as to how the influenza virus will change and reappear in humans the upcoming winter. Tens of millions of doses of influenza shots and mist are made.

Every year, no one knows until the influenza virus returns in the winter, just how the H and N combinations will be, and if the vaccine matches it for real.

In almost every winter there are three to four types of influenza virus that hit humanity, and so the vaccine contains 3-4 strains.

We only give the vaccine that has 4 strains.

Mist versus Shot

The big difference between Flu Mist (the nasal spray) and the flu shot is that the mist has live virus and the shot has dead virus in it. They are the same viruses, with the same 4 combinations of H and N.

The major result of this difference is that the shot only protects against the four influenza viruses in it.

This year, the combinations are:

A/H1N1

A/H3N2

B/Yamagata/16/88

B/Victoria/2/87

(NOTE- the H and N system fully describes the A strains of influenza, a second group of influenza the B strains use a different system to describe combinations on the protein coat, but it's the same idea)

So the flu shot will protect against these four influenza viruses, none else.

The flu mist will protect against these four influenza viruses, but since it is live virus, the immunity is stronger and can protect against other combinations.

How are this year's influenza vaccines doing against the actual influenza viruses now in circulation?

As with most years, the answer to this has some details.

For both the flu mist and flu shot, the A/H3N2 combination placed in the vaccine turns out not to match the A/H3N2 combination actually infecting people across the US this winter, now.

This is not a failure of the vaccine, missing the exact match is inherent in the process. Since the influenza virus changes every year when it goes into animals and when it comes back to humans, there is no choice but to guess every spring, and find out every winter how the virus will be.

For the other three combinations, the shot is a 100% match and direct hit.

The flu mist has a twist this year all its own. For some reason it's version of the A/H1N1 is not working in the A/H1N1 circulating across the US this winter. The good news, though, is that of these four versions and combinations now circulating, there is not much A/H1N1 around as of now, so the flu mist is working very well.

BOTTOM LINES

1. The influenza virus is highly unusual in changing every year.

2. It changes as it goes to animals in the spring and back to humans every winter.

3. This means every winter we need a new version of the flu vaccine to contain our best guess version of the flu viruses that will be here in the winter.

4. All the flu vaccines we offer contain 4 strains.

5. The flu mist nasal spray is live and therefore gives protection to more than just the 4 strains in it.

6. The flu shot is dead and so only can protect against the 4 strains in it.

7. Both the flu mist and flu shot for this winter contain an A/H3N2 combination that does not match the actual A/H3N2 in circulation.

8. The flu mist's A/H1N1 does not work well, but there is not much of this A/H1N1 version of influenza virus actually in the community.

9. Final thought: influenza viruses cause about a third of all colds and flus in the winter. Despite some misses on the guesses about what should be in them, you will get fewer colds and flus if you get a flu vaccine- mist or shot. None of the variance between the guessed virus in the vaccine and the actual virus in circulation present any danger or increased side effect, they just may not work as well.

Here is to a happy and healthy holiday season,

Dr. Lavin

2014-11-24

Influenza is Arriving, Flu Shots are In

Influenza is Arriving, Flu Shots are In

The winter of 2014-2015 influenza season is now arriving.

We are seeing cases of influenza A and B infection across the US and Ohio starting to pick up.

As with most years, we anticipate the number of influenza infections peaking in December and January.

Influenza shots are in.

This year many families expressed a preference for the flu shot over the flu spray, but the flu shot manufacturer had delayed shipment.

We are pleased to report we now have all the flu shots needed for this winter season.

Bottom Line

The influenza virus is arriving.

Flu shots are in.

If you are not yet immunized against influenza infections, there is still time to get it done.

Dr. Lavin

2014-11-19

Got Milk?: You Really Shouldn't- New studies expand this no need list to any added calcium

Got Milk?: You Really Shouldn't-
New studies expand this no need list to any added calcium

About a year ago, we shared this essay on how milk really offers no benefit to bones.

Now, in the fall of 2015, two new studies have been published that clearly demonstrate eating foods rich in calcium or taking calcium supplements have no real impact on bones and certainly offer no substantive help in preventing fractures.

Calcium Doesn’t Improve Bone Density, Analysis Finds http://nyti.ms/1RrfiqU

These are important findings, since nearly everyone was raised, and is continued to be told, that if you don't take calcium supplements of some sort, or fail to eat foods rich in calcium (like milk), you will miss the unique opportunities of childhood to build strong bones. And what's the value if having strong bones? Having fewer fractures.

Turns out your bones are as strong as they are going to be whether you eat calcium in food or take it in pills. The body knows how to pull calcium out of a normal diet, one sufficient to support normal growth. Adding more makes no difference.

So, the point made a year ago not only stands, but is made stronger.
Drinking milk, taking calcium supplements, and taking other measures to enrich the diet with calcium has no impact on the strength of your bones, and need not be done.

Here's the post from last year. To your health, Dr. Lavin

Milk has had a good run.

During times of famine across the last 10,000 years, milk and milk products sustained human populations in Europe and parts of Africa. This was milk's finest moment.

But as food supplies became more secure and reliable, milk faced a challenge, was it really still a good food to make part of our regular routines?

A new report in the NY Times makes clear the answer should be no:

http://www.nytimes.com/2014/11/18/upshot/got-milk-might-not-be-doing-you-much-good.html?ref=health&_r=0

In the mid-twentieth century, the US Department of Agriculture tried to answer the question: What do people really need to eat, what are the best foods for us? What they found was very simple- it's fruits, vegetables, and whole grains. A sprinkling of some meat, fish, and chicken is good too. But milk was not listed as an important food for people. When it came time to educate the American public on these findings, an industry group stepped forward to print up a graphic display and distribute it to every school across the nation. The USDA agreed, and the poster was circulated to every school for many decades. The sponsor turned out to be the Dairy Council, and the poster had nothing to do with the USDA findings. Instead the poster promoted the idea of four food groups, and one of them was milk!

Now come two very large studies, one published in JAMA Pediatrics and the other in the British Medical Journal, following a report from the Journal of Bone and Mineral Research that look at the experience of over 400,000 people and compares the outcome of those who drink milk to those who do not.

The NY Times report on these studies also looked at a number of studies examining the impact of taking supplemental calcium and of taking supplemental Vitamin D on bone health.

Here is what they found:

1. Drinking milk has no impact on the chance of a hip fracture later in life. In fact, in one of the studies, the women who drank milk during their life actually had a higher incidence of hip fracture.

2. The mortality rate in the group that drinks milk is actually higher than in the group that does not.

3. Taking supplemental calcium failed to protect against fractures with age, in fact it may lead to more hip fractures.

4. Taking supplemental Vitamin D had no impact on the bone density of the spine, hip, forearm, or overall body, but may have increased the bone density of at the top of the thighbone (femur).

5. Milk promotes obesity as it is a major source of needless calorie. Even skim milk delivers an extra 250 calories in every 3 cups, from the sugar in it.

The influence of industry promoting the use of milk is known to all. The got milk campaign was lots of fun, seeing prominent celebrities sport a white milkstache. But beyond that, as recently as 1983, the US Congress continued to pass laws to make milk promoted in the food marketplace.

These studies, taken together, debunk the notion that milk is good for you. Like any beverage loaded with calories and offering no health benefit, it probably is fine to enjoy it from time to time. But the time has come for all of us, especially parents of children, to stop using milk as a health promoting food.

Milk turns out to offer no important nutritional benefit, has no protective power on bones, and contributes to the obesity epidemic.

Also of note is the fact that although we have been promoting calcium and Vitamin D supplementation across the country for decades, when someone actually took a look at whether doing so actually helps strengthen bones, it turns out that it fails to do so.

So, take a look at this NY Times review: http://www.nytimes.com/2014/11/18/upshot/got-milk-might-not-be-doing-you-much-good.html?ref=health&_r=0

Bottom Line

1. Milk is not a good food.

2. Regular milk contains needless fat, skim milk contains needless calories.

3. The calcium and Vitamin D in milk have no impact on the actual experience of bone fractures later in life.

4. Even supplemental calcium and Vitamin D don't help strengthen bones.

5. Milk is OK to enjoy from time to time, like juice and soda, but should not be a regular part of anyone's diet, even toddlers and young children.
6. Milk has been supported as a natural and important part of our diet by marketing efforts, supported by large budgets and even Congressional legislation.
7. The best thing to drink is water and the best foods to eat are fruits, vegetables, and whole grains.

Be well.

Dr. Arthur Lavin

2014-11-17

School Lunches, Obesity, the American Marketplace, and Your Child

School Lunches, Obesity, the American Marketplace,
and Your Child

An extremely important article in the world's leading medical journal, The New England Journal of Medicine, makes clear how important the role of school lunches is in the explosion of childhood obesity in the United States, and how the food industry wants to keep it that way.

http://www.nejm.org/doi/full/10.1056/NEJMp1409353

School lunches tend to provide our children with a caricature of what a responsible person would feed their child. In almost every category of what matters when it comes to what our kids should eat, the school lunch stands out as a example of what not to do.

What type of foods are good for your health- fruits and vegetables. This is the one category of food school lunches deliver most poorly.

How much food should a child eat at a meal? School lunches typically deliver 500 extra calories a day!

What sorts of foods can cause the most harm? That would be fat and sugar, school lunches deliver these in abundance as well as excess salt.

There are two big problems with this picture:

1. Schools provide about half of all the food our children eat during their school aged years. So whatever school lunches are, our kids have no choice but to be at least 50% nutritionally defined by that offering.
2. Schools are responsible. We place our children there with hopes that they will learn skills that will provide a long, healthy, and successful life to them. Children think that what happens at school reflects our best wishes for them.

Put those two simple facts together, and it becomes all the more outrageous that on every count of what a reasonable person would do to eat to become healthy rather than ill, that our schools do the exact opposite of what should be done.

The article then goes on to point out that we the people have actually tried to fix this terrible situation. In 2010 a law was passed that would move school lunches towards less caloric overloading, more fruits and vegetables, and less fat and sugar and salt. Not a very radical idea, really more of an act of care and responsibility to our children.

Now, we come to why the doctors from Boston wrote and published this article. The food industry is trying to kill the law. It actually is fighting to make sure our kids continue to be stuffed with large extras of calories, fat, and sugar. Most shocking? That schools are joining industry in fighting the new standards.

Their main objections to the law are that the improved nutrition leads to more food being thrown away and more students dropping out of school lunch programs. The data proves neither happens.

So here we are, finally doing something about the scandal of the grown-ups of our country feeding our children exactly the wrong things, and the industry that makes the food, and schools (!) are organizing to keep hurting them.

About 1/3 of our children, at this time, will end up obese. At the very least this dooms millions of our children to diabetes and a shorter life for no very good reason.

As parents who care for our children, we urge everyone to make sure their school district chooses to make the improvements in school lunches the Health, Hungry-Free Kids Act of 2010 (HHFKA) ask it to. Make sure your schools do not seek a waiver from this law. From our point of view, the idea that our kids need to be fed food that will not make them ill over time is a rather basic responsibility of their parents and schools.

http://www.nejm.org/doi/full/10.1056/NEJMp1409353

To your health,
Dr. Arthur Lavin

2014-11-16

Antibiotics- A brief review

Antibiotics:

A Brief Review

With the terrible fright of the danger of Ebola, the emergence of the unusual Enterovirus 68 causing breathing troubles, and the re-appearance of measles, the idea that we have conquered infectious diseases seems less solid.

Some basics
So it seems like a good time to briefly review one of our two great success stories in creating a world in which we can feel safe from harm from infections. Those two great defenses are immunizations and antibiotics.

The word antibiotic literally means, against life, but really refers to chemicals that kill bacteria but not us. There are 4 forms of life that infect us: Bacteria, virus (e.g., colds, flus, measles, chickenpox, Ebola), parasites (e.g., giardia, worms), and fungi (e.g., ringworm, yeast infections). Antibiotics only kill bacteria. There are some medications that kill a very few viruses, such as acyclovir for herpes, but these are called anti-virals. And there are many drugs that kill parasites and fungi, but these are called anti-fungals and anti-parasitic drugs.

That leaves drugs for bacteria, the antibiotics. Of all the drugs that kill the various germs, antibiotics have been the most remarkable in their ability to kill the germ, but not harm the person (more on that below).

They have this rather strong safety record because bacteria have many different chemistries than animal cells. So a drug could stop a bacterial chemical reaction without interfering with ours.

Resistance
But this is the first problem with antibiotics, they attack a living cell, the bacteria. And all life tends to find a way to adapt. Bacteria adapt by mutating and reproducing rapidly. Bacteria divide so rapidly that one can become millions in a relatively short period of time. Add in the ability to mutate, and a one in 10 million change can appear in a short time. If that change alters a chemical reaction that the antibiotic for that bacteria blocks, the antibiotic will no longer harm the bacteria- this is what is meant by resistance.

Keep in mind that if one person takes a course of one antibiotic, it is very, very unlikely a new bacteria no longer affected by that antibiotic will appear. Resistance is almost always the result of millions of doses of antibiotics across a population.

But we do see this happening when millions of animals are given antibiotics every day. Or when people are given antibiotics for common viral problems that antibiotics, exposing millions of people and their bacteria to antibiotics for no actual benefit (remember, antibiotics do nothing to viruses).

Harm from antibiotics
Compared to most cures for other diseases, antibiotics are pretty gentle. Think of surgery and chemotherapy as the main curative interventions, and you can see 10 days of an antibiotic often has no or few side effects compared to other cures.

But, there are three ways antibiotics can cause serious trouble:

Allergic reactions. Antibiotics can allergic reactions more than most drugs. Usually the reactions are mild, mainly an itchy rash, but sometimes the reactions can be very severe, even dangerous. In the case of penicillin, it is estimated that the most severe reaction, a deadly anaphylaxis, occurs 1 in every 100,000 doses!
Discomfort. Antibiotics are associated with stomach ache, changes in stooling, headache, and other discomforts.
Changes in your natural bacterial environment. This is potentially the most worrisome side of using antibiotics. They kill bacteria, which is incredibly important when it comes to curing dangerous bacterial infections, but they kill not just your infection, but your normal bacterial populations, especially in your gut. It turns out our guts require healthy thriving bacteria in order to work well. Without them, inflammations of the gut with diarrhea and abdominal pain, can begin to appear. This is the power of probiotics, to replenish diminished normal gut bacteria after a course of antibiotics.

Bottom Lines

1. Antibiotics are the drugs that kill bacteria and should be used to cure significant bacterial infections. They have no power over or impact on viruses- that's why they don't help anyone with a cold.

2. Resistance is not seen with one course of antibiotics in one person, not even in several, but rather from millions of doses across large populations.

3. Use of antibiotics is safe, but comes with some risks, so they should never be used for situations they will not work (like viral infections), and only when curing the bacterial infection is important.

One last point, it is very hard for science to find or create new antibiotics. Most development efforts by drug companies fail to create new antibiotics, and they do not generate big sales as people take them for a week or two, not every day like a cholesterol lowering drug.

As a result of both facts, nearly all pharmaceutical companies have stopped trying to create new antibiotics. As resistance to our known antibiotics grows, an inevitable result of evolution, we may find ourselves in a time when no available antibiotics will work, which would be a rather horrible development.

This last point leads to two imperatives:

1. We must all be careful not to use antibiotics for viral infections, such a practice leads to the millions of extra doses that breeds resistance.

2. We must find a way to make the creation of new antibiotics a viable pursuit, or no matter what we do, the ones we have will one day no longer work.

To your health,

Dr. Arthur Lavin

2014-11-12

Ebola Update November 12, 2014 Good News

Ebola Update
November 19, 2014 The Facts Hold, Ebola Fades

First of all, thank you to everyone who has responded so enthusiastically to this series on the Ebola virus.

This update will hopefully be our last for some time on the occurrence of Ebola virus infection in the United States.

And, the update is quite good- as of now, we know of no one present in the entire United States who is infected with Ebola. The feared spread of Ebola never happened in this country.

It is worth a moment to reflect on the course, not of Ebola, but our fear.

The fear was not surprising given how deadly this disease is, in fact. Fear is a natural response to a threat, particularly one that is unfamiliar.

What was disappointing was how little the impact of the actual facts of the matter had on our fear across the nation.

And the fact that no one in the United States is currently infected with the Ebola virus confirms every fact put forward in discussions of this virus.

The key facts were very simple:

The Ebola virus is not contagious when you first get infected, but gets more contagious as the disease progresses, becoming very contagious as the infected person nears death from the illness.
The virus cannot be spread once it dries out. That means to catch it you need wet body fluids contacting an open surface in your body. Saliva and sweat can spread it, but dried out droplets from cough and sneeze cannot.
This disease is very containable. With proper isolation techniques, the spread of Ebola can be reliably stopped.

If we had really thought about these three facts, the visit of an infected nurse who was not very ill to Ohio should have caused no concern in Ohio. And, as it all turned out, not a single person in Ohio she contacted caught her Ebola, not a single person. More dramatically, if we look at the entire planet of 7 billion people, the complete total of cases of Ebola seen in any country outside of Africa is a grand total of 15 to date. This is indeed dramatic proof that this virus can be contained.

I am also very relieved to see that all but two of the patients infected with Ebola treated in the US (all but two caught it in Africa) survived. There appear to be treatments available that work well. The two deaths, including one just this week, were in people whose infection was in advanced stages before arriving in the US.

Of course, biology can be complicated, and viruses evolve, so I am very pleased, and relieved the nature of Ebola virus and its three key facts did not change. It is really because of these three facts that no one in the US has the infection.

Bottom Line

There is no Ebola virus infection in the United States today.
The three key facts about Ebola have turned out to remain true, making the threat from Ebola, even in the future, quite tiny to Americans in the US.
Treatments are in development that worked quite well.
Thanks to all who have found these posts helpful

Dr. Arthur Lavin

2014-11-04

Flu Immunization Update- New Shipment of Shots Due at end of Month

Flu Immunization Update:

New Shipment of Shots Due at end of Month

Today marks the completion of two of our three FluFest 2014 sessions. The program has been a big hit in large part due to the generosity of Mitchell's Ice Cream, making a scoop of their great ice cream or sorbet available to those getting their flu immunizations on FluFest days. Our last FluFest session will be Saturday, November 8.

We have also just received notice that a shipment of the flu shot for older children (age 3 and up) has been delayed to the end of the month of November. At this time (November 4) we have no flu shots for older children in hand, but we will be getting a shipment in a few weeks, by December, we are told by the drug manufacturer.

We have abundant supplies of flu shots for infants and young children (age 6 months to age 3 years) and plenty of the nasal form (FluMist) for anyone in good health over age 2.

Many thanks to all the families for protecting your children and participating in FluFest 2014. It is such a pleasure to see everyone, we are very happy we were able to make it more fun this year. And, most importantly, we have seen this active influenza immunization program really drop the chances of getting a cold or flu in January-March.

Here is to your health!

Dr. Lavin

2014-10-30

New Guidelines for Bronchiolitis- What is it, what to do?

New Guidelines for Bronchiolitis-

What is it, what to do?

New guidelines for care of infants with bronchiolitis have just been published. This is a wheezy viral infection in young infants. The new guidelines offer a great opportunity to re-think just what is a wheezy infection, what is bronchiolitis, and what do the new guidelines teach us?

Background on wheezy colds

Every winter, colds and flus come to make us sneeze and cough, and overall cause a tremendous amount of misery.

About a third of these respiratory infections are caused by the now famous influenza virus, and yearly influenza immunization has worked well to dramatically drop the number of colds and flus we get.

But influenza only causes one-third of such infections, there are lots of other viruses out there to cause colds, including rhinovirus, adenovirus, RSV, and others.

For many children, these respiratory infections cause other problems in addition to sneezing, coughing, fever, and feeling lousy. Perhaps the most common additional symptom is wheezing.

Wheezing happens when the small airways- the tubes in your lungs that are smaller than your big airways like the trachea, but bigger than the tiny air sacs- get swollen, make extra mucus, and narrow from muscle tightening around the airways.

This wheezing is different than the sneeze and cough of a cold because someone can wheeze for two reasons- the virus irritated the airway or the airway tends to irritate easily on its own. Sneezes and coughs are more usually just due to the virus.

The reason this is important is that if the wheezing is only the fault of the virus, then it won't happen again very often, since it only occurred with that particular virus. But if the wheezing is the result of your child's airway being easily provoked into wheezing, then those airways will tend to wheeze in a recurrent pattern, that is, over and over.

What is bronchiolitis?

Bronchiolitis is a wheezy cold seen in infants. The cause is the same set of viruses that cause all respiratory colds and flus. What makes it different in infancy is that the airways in their lungs are so small. It turns out everyone's airways get inflamed when you get a cold, but our airways are so big that the swelling that happens makes us cough, but not typically wheeze. In young infants, they can get very, very wheezy when their small airways get swollen.

Bronchiolitis is not asthma, even though both situations make you wheeze. Asthma is a condition where your own airways have the tendency to get inflamed, and that inflammation can be triggered in all sorts of ways, including any airway virus, exercise, cold air, etc. Asthma always recurs. Bronchiolitis usually only happens once. Usually once you have another cold that makes your airways really inflamed you have grown out of early infancy and don't wheeze with a cold again (unless you have asthma).

So bronchiolitis is unique in two ways- unlike most colds in older kids and adults, it causes heavy wheezing in young infants. And unlike asthma, it usually only happens once.

What to do
Because a child with bronchiolitis and an asthma attack look very similar, for years it was thought that treatments for asthma would help babies with bronchiolitis.

This is the big news from the new recommendations, the treatments that work so well for asthma do nothing to help babies with bronchiolitis.

This means if you give an infant with bronchiolitis albuterol or steroids, nothing happens, they do not work.

The new guidelines for treatment of bronchiolitis now clearly state that albuterol and steroids should not be used.

Another, very important new point, is that a chest X-ray is not helpful, and in fact can cause harm. The harm comes from the fact that all the airway inflammation in bronchiolitis causes wispy shadows to appear on the X-ray, leading most radiologists to make the mistake of calling it pneumonia.

So, the new guidelines now explicitly state that there is no reason obtain a chest X-ray for routine bronchiolitis, and if one is obtained, an expert in reading infant chest X-rays needs to be involved to avoid the mistake of calling bronchiolitis pneumonia.

Finally, the new guidelines note that blood tests and cultures of the airway are not helpful. About a third of infants with bronchiolitis have more than one virus causing the infection so testing for one will 30% of the time miss others.

The guidelines clearly state that there is on reason to obtain blood tests such as a blood count, or airway swabs for RSV, they simply do not help.

BOTTOM LINES

Bronchiolitis is a very unpleasant and far too common type of viral infection of the respiratory system. It is seen primarily in young infants since their airways are simply smaller than older children's.
It is essentially a very wheezy cold in young infants. The key symptom is wheeze, the result of swelling of the airway, increased mucus production in the airway, and muscle tightening around the small airway.
Drugs that relieve the wheezing seen in asthma do not work in bronchiolitis. New guidelines advise that we do not use albuterol or steroids for this condition anymore.
Tests for blood counts and cultures for airway viruses do not help the infant and the new guidelines advise that we do not do these tests if an infant has bronchiolitis.
Care must be taken in considering getting a chest X-ray, it does not help the infant with bronchiolitis to get a chest X-ray. If there is a question, however, of whether bronchiolitis is the problem, or only problem present and a chest X-ray is obtained, care must be taken not to interpret the changes of bronchiolitis as pneumonia.
Therefore, if your young infant develops a wheezy cough, we will help determine if bronchiolitis is present. The most important question at that point will be if the degree of wheezing is actually interfering with breathing to any significant degree. Sometimes it is not clear if the wheezing is purely from viral irritation (as in colds and bronchiolitis) or from the airway's own tendency to inflame (as in asthma). When that is not clear, a course of albuterol can help make the distinction, as it helps with wheezing from asthma and does not from bronchiolitis.

As we enter into winter, and our children have already started having lots of colds, we stand ready to help.

Dr. Arthur Lavin

2014-10-27

Food Allergies: Do you have them or not?

Food Allergies: Do You Have Them or Not?

A recent study found that there is a large difference between testing positive for a food allergy, and having one, so we thought it would be helpful to clarify, how do you know if you have a particular allergy to a food?

Let's start by making clear that food allergies are very, very real. There is no question that lots of kids have them and that they can cause lots of trouble.

It turns out that there are essentially three types of tests available to find out if someone has an allergy to a food (or anything else).

To understand how these tests work, it will help to know a few basics about allergies.

An allergy is a reaction that happens when something you are allergic to connects with a very specific antibody, unleashing a general reaction.

To be clear on each of these elements of an allergic reaction:

The something you are allergic to: This is usually a unique molecule, often a protein, in the food or thing one is allergic to. For example, if someone is allergic to milk, they react to just one protein in the milk. So, the whole reaction will not happen unless that protein is present.
A specific antibody: Antibodies most distinctive property is that they only bind (connect) to one type of molecule. The body can make trillions of different antibodies, but only chooses to make many thousands. You cannot be classically allergic to something without making an antibody that attaches to that item, and only that item.
A general reaction: Here is how the allergic reaction actually happens: the thing you are allergic to connects with the specific antibody, once that happens that connection activates the antibody to turn on the allergic reaction. No exposure to what you are allergic to, no reaction. No specific antibody to that item, no reaction.

So you need 4 things to happen to be have an allergic reaction to a food:

1. You have to eat or contact the food.

2. There has to be an antibody to that food not only present in the body, but armed and ready to ignite the reaction once the food comes by.

3. The food molecule and antibody need to connect, that complex needs to activate the allergy reaction, and then the allergic reaction happens.

The Three Tests

So with that in mind we can understand the three test for food allergy:

Blood Test
Skin Test
What Happens if You Eat it Test

Blood Test

This test simply measures how much specific antibody to the food in question is circulating in your blood. This is not the same as measuring how allergic you are, since only antibody linked to particular cells that actually activate the allergic reaction are relevant. That is, one could have enormous quantities of antibody to shrimp, for example, circulating around in your blood, but none actually connected to the cells that cause a reaction. You could do the blood test, find a very high level of antibody, but nothing happens when you eat the shrimp. Or the other way happens too, where there is no or little antibody circulating, but lots on the relevant cells, the blood test is negative, but every time you eat shrimp you have a big reaction. Now, it does turn out that the more antibody to a food circulating, the more likely someone will react when they eat it; and, the less antibody present the less likely someone will react when eating the item, but not always.

Skin Test

This test actually sees if exposure to the food can create a visible allergic reaction. The problem is that it only really tells us if scratching the food molecule into the skin will cause a reaction. Again, it does turn out that the more skin reaction to a food being scratched into the skin, the more likely someone will react when they eat it; and, the less reaction in the skin the less likely someone will react when eating the item, but not always.

The What Happens if you Eat it Test

This is by far the most reliable of all three tests. And for an obvious and good reason- if you eat a lot of peanuts and you experience no reactions, then either you have no antibody to peanut molecules, or the antibodies are not activated to create a reaction, you are not allergic. And if every time you eat peanuts you develop hives, lip swelling, and wheezing, you are most definitely allergic. This test, therefore, trumps all other tests. For that particular meal, there is no error rate, you either react or you do not, that time.

The Study

In 2010 Dr. Liu et al (J Allerg Clin Immunol. 2010; 126(4): 798-806) found that about 17% of children in the United States have a positive blood test for allergy, but only 2.5% of children in the United States actually react when they eat any food.

Simply put, a person is nearly 7 time more likely to have a positive blood test for food allergy, than to actually have a food allergy.

What to do?

Given all the above, what's the best way to find out if your child is allergic to any particular food?

Here are some tips on how best to proceed:

Guage how urgent finding out is. If your child has a very slight symptom that has only occurred once, that is clearly less urgent than if your child has trouble breathing each time something is eaten.
If the reaction is very mild (and the best guage on severity of reaction is the degree of trouble breathing caused by the reaction), you have the option of trying to see if the symptom goes away if your child stops eating the suspected food. This is half of the "What Happens if You Eat It" test. If you are very confident that the reactions you are seeing are very mild, one can try out the other half of this test, see if any reaction happens when your child eats the suspected food. Of course, if there is no reaction on eating it, and no change in symptoms when not eating, he or she is not allergic. And, if there are allergy symptoms when he or she eats it and those symptoms go away, there is an allergy to that food present.
If the reaction is not mild, then it becomes prudent to do some of the indirect tests noted above, namely skin and/or blood tests. These tests, as noted, are not 100% predictive of food allergy, in fact the national survey quoted above suggests the blood test will overcall a food allergy diagnosis quite a bit. But if the skin and/or blood tests are negative, it gives you a bit more ease of mind (not proof) that you can do the "What Happens If You Eat It" test, at least with less risk.
If the reaction is severe, that is, trouble breathing in the chest or mouth/throat, occurs, then the first step needs to be elimination of the suspected food(s) from your child's diet immediately and consultation with an allergist to sort out just what is causing the reaction. Again, skin and blood tests will likely be used in this situation, too, and will again help point the way to a conclusion, but even here they cannot be the final word on what your child is allergic too.

Bottom Line

The question of whether your child has a food allergy always will hinge on whether they actually have an allergic reaction when they eat that food.

Skin tests and blood tests measure indicators that one may or may not be allergic, they are not proof of an actual allergy sequence being active in your child.

In the case of blood tests, nearly 7 times as many children test positive as actually react.

This makes the What Happens if I Eat it Test the most reliable way to know if your child has a food allergy to that food. This test is safe when the reactions are very mild.

But, if there is any question of a reaction involving trouble breathing, an allergist should be consulted to sort out what is causing this level of reaction.

As always, we hope this information proves helpful.

To your health,
Dr. Arthur Lavin

2014-10-23

A Special Ebola Update: A Briefing by Dr. Tony Fauci set by The White House

A Special Ebola Update:
A Briefing by Dr. Tony Fauci set up by The White House

[Updated October 23, 2014 9:00PM]

Dear Families,

At Advanced Pediatrics we have worked hard to try to keep up to date with the rapidly changing picture that the Ebola virus and its infection has been presenting to the world. Lately, we have focused on the nature of this infection in the US.

The Briefing
Tonight, I am very honored to share with you the very latest information available in the United States on Ebola. As a state director for Ohio in the organization, Doctors for America, I was invited this evening to be part of a special, invitation only, briefing by Dr. Anthony Fauci put together by The White House, on the state of Ebola. No press were invited, so this information is not part of the usual news cycle.

The White House selected a small group of doctors from across the United States to help get as accurate a picture of what is happening with Ebola right now. This posting is the first communication I have made to anyone on what I learned from Dr. Fauci.

Dr. Tony Fauci
Leading the briefing is one of the world's great minds in the area of new, deadly, viral infections. Dr. Fauci currently serves as director of the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute of Health charged with research and care of such diseases. He is known across the world as one of two scientists who led the work that revealed the cause of AIDS and its nature, namely HIV. As such, he is uniquely positioned to know in depth the details of the virus Ebola.

The briefing was moderated by Ms. Andrea Purse, The White House Director of Broadcast Media.

I was joined by roughly 15-20 doctors, each from a state across the US, from NY to Utah.

What We were Told, What We Learned about Ebola Tonight
Here are the key points communicated to us tonight:

Ebola is not changing its nature much despite many mutations. Dr. Fauci did note that the Ebola virus is a type of virus in which the genes change rapidly as it transmits across a population, but the vast, vast majority of these changes in its genes, have no impact on it actual nature or function. These sorts of virus change their genes frequently, but do not really change their behavior much over time.
How it spreads remains very stable and unchanging. An enduring feature of the Ebola virus spreading is that all strains studied need direct contact. None of them have developed the ability to survive being dried out and spreading across the air for any large distance. The virus must remain in a wet state, hence the repeated references to bodily fluids. It is most concentrated in sweat and blood. Sneezing and coughing can produce wet particles that can travel several feet and create direct contact. So for example, if someone with Ebola coughed, in particular if they had bloody sputum, wet droplets landing on an uninfected person who then wiped their eyes while the droplets were wet, could catch Ebola. But if that person coughed and the droplets in their cough dried out before landing on someone else, which is what typically happens with sneezes and coughs, then it will not spread. Dr. Fauci noted that across the whole history of viruses, none that required direct wet contact have ever mutated into one that could be spread by dried out airborne transmission.
There is no American outbreak now, nor is there likely to be one. A total of two people to date have caught Ebola in the United States and not one of their contacts so far have caught it from them. Therefore, the only instance of Ebola spreading, in the United States, is in the very unusual setting of being a health care worker exposed during care of a sick patient in protocols that are no longer current.
A note on how the two nurses in Dallas got Ebola. Dr. Fauci is also the doctor caring for the nurse from Dallas now in an NIH hospital in Washington. He shared his impressions after having had the chance to talk with her about her exposure. It turns out that when she was caring for the patient with Ebola in Dallas, the protocols in place were developed in Africa, for exposures limited to care such as IV placement in a relatively informal quonset hut like setting. These protocols contained over 20 Ebola outbreaks in Africa in such settings. But in the ICU setting in the US, so much more can be done, including intubation, deep central IV lines, etc. This leads to a far more intense level of exposure to far more bodily fluids, and the old protocols did not protect against that. These protocols are now updated which will protect health care workers much better. But the main point here is that the Ebola case caught in the US, are limited to only 2 cases, to situations that no longer exist: health care workers intensely exposed in an ICU setting without the new protocols for ICU exposures in place.
The status of the Ebola vaccine. There are two vaccine trials in place. Each use a harmless virus as a transport virus to deliver the not infectious Ebola fragment to the immune system- thereby creating safe immunity to Ebola virus infection. Both have worked in monkeys. One is being tested in humans now and as of Sept. 22, has not shown any harm to people. By sometime in November, results should be known of how well it protects people. The plan, if the results look good, is to have a many thousand person trial in West Africa launched by the end of November. If that goes well and no bad reactions are found, a vaccine for Ebola that can stop this illness may be in hand.
Our current US Strategies. The key challenges are threefold:

Identify all those infected
Transport without spread to qualified facilities
Care for those with Ebola infection

The US plan is to have every hospital in the country able to identify anyone who comes to their facility who has an Ebola infection.

There are currently 3 hospitals in the US, per Dr. Fauci, that are fully ready to care for anyone with an Ebola infection: one in Nebraska, the NIH hospital in Washington, DC, and the Emory Hospital with the CDC in Atlanta.

Plans are to focus actual care of those infected in these three hospitals, but to develop a small network of hospitals with various levels of expertise in a tiered system providing care across a range of regions.

The current Ebola strains seem to affect children less than adults.
What about travel bans? Many people wonder, why not simply keep everyone from the most concentrated areas of infection, Sierra Leone, Liberia, and Guinea out of the US. It turns out a complete travel ban may have a paradoxical effect. Right now, the US has a policy that travelers from these 3 countries can only enter the US via two airports in NYC, and one at Dulles, Atlanta, and Chicago. Anyone from these 3 countries must go through an intensive Ebola screening process before they enter the US. About 96% of travelers from these three countries entered the US via one of these five countries before the policy was in place that all had to. Now 100% do and they all undergo the Ebola screen. If a ban were imposed, we would not know where they are coming from, their travel will then go undetected, perhaps via another country and go anywhere into the US. Further, the only real hope of eliminating the chance of a US outbreak is to eliminate the outbreak in W Africa. A travel ban would not only be cruel and deliver a signal that the US shuns them, but such a signal could lead to a collapse in efforts to contain and conquer this outbreak in W Africa, leading to an explosive spread across their borders.
What are the key misunderstandings? The #1 key misunderstanding is that impression that some mis-steps constitute an actual outbreak. There is no Ebola outbreak in the United States at this time. Dr. Fauci anticipates a small number of people with Ebola will continue to get through even the best policy to limit US exposure [one man in NYC may be such a case, he came in from Liberia], but seriously doubts that number will rise beyond a handful of people, particularly if efforts to reverse the outbreak in W Africa succeed. But he does recognize that having some cases come into the US, a hospital missing the diagnosis, 2 nurses getting Ebola, all erode trust, and raise worry. But that worry must be put to good use, to learn about how Ebola really acts, to support good science and its principles in winning the fight against Ebola. Dr. Fauci sees no benefit in reacting purely out of fear. Diverting planes, closing businesses when there is little reason to believe anyone could catch Ebola on these planes or in these businesses only raises fear, and does not reduce the spread of the virus.

Bottom Line

Ebola is a dangerous virus that will require great human ingenuity to contain and, ultimately eradicate.
At this moment, there is no Ebola virus epidemic in the United States. The total number of people who we know have been infected with Ebola in the US is 2.
A key feature of the Ebola virus spreading is that all strains studied need direct contact. None of them have developed the ability to survive being dried out and spreading across the air for any large distance. The virus must remain in a wet state, hence the repeated references to bodily fluids.
There is good hope for an effective vaccine. This along with a worldwide effort in West Africa establishes a good reason to believe that human ingenuity will indeed defeat this virus.
It is critical that efforts to eradicate Ebola infection in West Africa prevail, that careful care of the small number of infections that will appear in the US and other countries is very doable, and is being done.
Ebola demands our respect and care. But a very thoughtful response is rapidly coming into place. We have every reason to not only hope, but expect this infection will not pose danger to us here in the US, and that the world can defeat it in West Africa.

We will of course continue to keep you as informed as we can be.

To your health,
Dr. Lavin

2014-12-26

The best source of data on the influenza virus- http://www.cdc.gov/flu/weekly/

The Best source of Data on the Influenza Virus-

http://www.cdc.gov/flu/weekly/

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Winter Cold and Flu Virus Update- December 9, 2014

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Flu Vaccines 2014-2015- Update on What Works

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Influenza is Arriving, Flu Shots are In

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Food Allergies: Do you have them or not?

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A Special Ebola Update: A Briefing by Dr. Tony Fauci set by The White House

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