Advanced Pediatrics: October 2014

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

Good Rx- a great app

A New App to Help you Find the Right Price-

For Prescriptions

UPDATE 1/29/15

I wrote this note some months ago, and just today, Good Rx let me know that 7 patients in the practice have used it and saved a total of $980.68! (NOTE: I have NO relationship with Good Rx, I do not collect any fees from them, or the drug stores. I only recommend it as a fellow consumer and advocate for your family).

Take a look at GoodRx

It's an app that will, based on your location, and the medication your are buying, lists the cost of your prescription at area pharmacies, and available coupons.

Some of the ranges can be quite dramatic- one place may tell you that it will cost you $100 and another, with coupon, $30, for example.

Once you locate the best price, many pharmacies will then price match.

So take a look, see if it helps.

Dr. Lavin

What is a Virus?

What is a Virus?

In the last few months, three viruses have gripped our attention. The influenza virus because of a few weeks of possible flu immunization shortage, the emergence of the Enterovirus D68 a summertime virus that turned into a real attack on the breathing system, and of course, the Ebola virus.

And, of course, we all know about colds. Everyone gets them, they cause so much agony, and they are so common.

All these, and many other infections are caused by a very peculiar type of life, the virus. So we thought it might be interesting to present in a little more detail what is a virus.

The Basics- what's in a virus, how do they work?

Viruses are the simplest and one of the oldest forms of life. Other forms of life include the bacteria, the yeasts and fungi, the animals, and the plants. All these forms of life consist of either single cells (bacteria, yeast), or groups of cells (fungi, animals, and plants). But not viruses. Viruses are the only type of life that has no cell. Because they are not cells, some even wonder if they are really alive.

But all agree that viruses can reproduce and adapt, so by that skill many consider them very much alive.

Viruses are also a very old form. They are at least several billions year old. Compare that to the current human line, which at most is 150 thousand years old. No comparison.

Viruses do reproduce and change, but can only do so using some other form of life's cells. No cells, no viruses. Without their own cells, how do they reproduce and evolve?

The answer is very interesting. They are actually packages of information. Every virus has a bit of genetic material (DNA or RNA) inside, wrapped in a protein coat.

The protein coat picks the lock to the cell that virus can infect. Once inside, the protein coat then delivers its inner contents, the genetic core, to the cell's genes. There the virus takes over the cell's machinery and forces it to spin out a huge number of copies of the viral genes and their protein coats. In this way, one virus in one cell can lead to the creation of a staggering number of new viruses, ready to repeat the cycle over again.

Why Viruses are Often so Specific to One Type of Life
So this means that to live, a virus has to find a way into a cell, and a way to go from cell to cell. This is no mean feat, in fact it is astounding. It is so challenging, that with few exceptions, every virus can only get into the cells of one species.

The cold virus for a chicken can only give chickens colds. Measles virus can only give humans measles. Other viruses can only infect certain bacteria, others only one species of plant, and so forth.

There are also viruses that have figured out how to crack the code of various species, usually on type of life. So there are viruses that can infect several animals. But there are few, if any, that can infect various animals and plants.

Perhaps the most prolific virus is the influenza virus which infects nearly all humans during the winter, but only infects animals in the spring and summer- usually barnyard animals and birds.

How do Viruses Make us Ill?
The answer to this question has two answers:
1. Viruses destroy cells
2. Viruses change the function of cells

In many of the most common and mild viral illnesses, like colds and flus, viruses actually destroy the cell they use to reproduce. Remember that the way all viruses work is that their genetic material takes over the host cell gene machine and forces it to make copies of the viral genes, to make more viruses. If in that process a zillion viruses are copied, the cell often pops from the expansion, and dies, releasing the zillions of viruses. This kills the cell. If enough cells die, then a patch of tissue is left destroyed and inflamed. This is what happens to your nose when you get a cold. It really is very much like a mild burn, the lining of the nose gets destroyed by viruses popping sheets of cells.
Any viral infection like this makes us ill by literally burning away a sheet of cells, causing pain, inflammation (this is where fever comes from), and lost of fluid leaks (runny nose, vomiting, diarrhea, for example)

Sometimes, though, the cell is not exploded from rampant viral copying. In these situations, the virus still takes over the cell's gene machine, but the virus has it create an ongoing production line of viruses, not enough to pop the cell, so the cell continues to live, but it stops working normally. The most famous example of such an infection is AIDS, where the cells of the immune system are infected but not destroyed. In many ways, we are better off with viruses that kill cells, especially if they are superficial cells, for then the body makes new, healthy cells to replace the dead ones. But if the cell lives and lives well enough, it will continue to work (even if abnormally) and this can cause much and long-lasting dysfunction and trouble, as in AIDS.

And then, some viruses can lie dormant for years. They insert there genes into the host cell and then just sit there and do nothing. In this situation the person is not ill, but if the virus kicks on and starts making tons of copies at some point, an illness could erupt. This is the story of chickenpox and shingles, where once the chickenpox illness is over, the same virus just sits dormant in the cells near the spinal cord. Every now and then they reactivate, travel down the nerve to the skin and this is shingles.

How do we Recover from a Viral Illness?
The only way our body can recover from a viral illness is to kill every cell that is actively infected with a virus. We can't actually kill a virus since on its own it is hardly alive. But if our body kills every cell that contains a certain virus, then that virus will be cleared from our body. This strategy works only if the body can identify every cell containing that virus and kills all of them.
And, this is exactly what happens in colds and flus. Our body goes after every infected cell, and the infection and virus is completely eliminated, new cells are made to take the place of those destroyed by the virus, and we heal.
If our body cannot do this, the viral infection becomes chronic, like AIDS, and many hepatitis viral infections.
And, in the case of dormant viruses, the body leaves these alone, the cells that contain the virus look no different from normal cells because the virus is not doing anything, so the infection is lifelong, but dormant, like dormant chickenpox that simply sits there unless a shingles flare occurs.

How do We Treat Viruses?
A handful of viruses can be cured by treatment with anti-viral drugs, viral antibiotics.
These include influenza, hepatitis C, and some herpes viruses such as CMV and herpes simplex.
In each of these examples, the drugs do help, but are not 100% effective.

But, for nearly all other viruses, there are simply no drugs that actually kill the virus, speed up the healing from all the havoc they cause, or even end the symptoms they create. This is most vividly experienced with common colds and stomach flus, where drug stores have shelves bursting with products promising an end to runny noses and coughs, or diarrhea, but always fail to deliver. At this time about 500 drugs promising relief from viral symptoms are under investigation by the FDA for false claims. Five hundred such drugs under investigation!

Two viral symptoms that can be treated by drugs are fever and pain, and we recommend ibuprofen (Advil, Motrin) over acetaminophen (Tylenol) due to questions about whether acetaminophen may boost the development of asthma.

How do we Prevent Viral Infections?
We are all strongly drawn to the idea that if we simply take this or that action, we can stop the spread of viruses through a classroom, school, or home. The evidence, however, is overwhelming that viruses travel from person-to-person astounding well, despite kids being kept home when ill, despite hand-washing, despite nearly any effort. Just looking at the sweeping waves of viral infections that cover continents in a matter of days dramatizes the fact that trying to stop a virus from spreading, especially common, very contagious ones, is like trying to stop the wind.

Given that very few viruses can be treated, and none of the very contagious ones can be stopped from spreading, that leaves us with only one control measure that has had any real impact- immunizations.

The body has figured out how to protect itself in one of the great triumphs of clever evolution, one we recover from a virus, it is almost always the case we cannot get it again. If you get measles, you never get it again. If you get cold variety #281, you never can get sick from cold #281 again (of course, you can still get cold #282).

This very natural, very important key to our survival is the whole basis of the idea of immunization. If you can't get a viral illness twice, why not deliver a very mild case of that illness, so when the real thing comes along, you can no longer get it.

Do immunizations work? Just take a look around. Smallpox in the 20th century killed 500 million people, more than World War I, World War II, the Korean War, and the Vietnam War, and all other wars in that century, combined. But because of immunization, and only by this strategy, smallpox is now eliminated from the planet. It worked.

And, it has worked in every case- measles, mumps, rubella, even chickenpox, hepatitis B, polio, all are sharply reduced. In areas where immunizations are used by nearly everyone, these diseases are essentially eliminated.

Bottom Lines
1. Viruses are curious packages of genes wrapped in proteins. The proteins gain access to the target cell, the genes make the cell make more viruses.
2. In destroying the cell, the virus causes the illness. When sheets of cells are destroyed, the illness is where the irritation takes place- runny nose in the nose, sore throat in the throat, cough in the lung, diarrhea in the gut.
3. Only a small number of viruses can be killed by a medication, almost none of their symptoms can be relieved by medication.
4. It is next to impossible to stop the spread of a very contagious virus. Some viruses are quite rare and do not spread well, and these are the very, very rare examples of viral infections that can be controlled by containment (e.g., SARS, Ebola).
5. The only action that has ever really spared us from the diseases caused by viruses has been immunization, which has had a spectacular and dramatic record of success.

To you health,
Dr. Lavin

2014-10-22

Thoughts on Crying in Infancy

When Babies Cry- What are they Saying, What can You Do?

Everyone alive has felt the power of a young baby crying. Their cry for help pierces our minds, demands a response, and leaves us suffering if no response happens, quickly.

All parents have felt the tie their baby's cry creates. All airline passengers have felt the power of a baby's cry.

But what is the baby's experience of the cry, and what sort of response is the baby looking for?

At one level, nothing could be more obvious about an infant's crying- it is simply a cry for help. To be held, to be fed, to be cleaned, to be helped.

But it may be helpful to think for a moment about the situation we all find ourselves in when we were infants, needing some way to communicate with the world. As full grown adults we have a tremendous range of ways to communicate with the world. We can talk, email, text, video call, even write letters. Our communications can be crafted to the most subtle level of nuance. We can describe with great accuracy exactly what we are wanting, and we can do so directly, indirectly and with a broad pallette of emotional flavoring.

An infant's communication situation could not be more different. The infant has no words, none. This leaves all communication forced into a very narrow range of choices. For the newborn who also has not yet learned to use their hands or face, and so cannot even gesture or smile, there are very, very choices to get a message of any sort out to the world. For the first days after birth, babies cannot even fix their eyes in a gaze.

In fact, the only communication channel open to a very new newborn is crying and some very rudimentary grunts and breathing noises. Crying is the main vehicle for newborns to communicate.

Equally interesting is how very wired all adults are to the communication of infant crying! That is the power of the baby's cry. After all, if we did feel the urge to respond, the cry would never work. But we do feel it, our minds create a very, very powerful urge to do something. As parents, we are compelled to find out what our baby wants and make sure it happens, as an observer we are compelled to pray that the parent is around and can do something to quell the cry.

What do Babies Want?

If the cry of a newborn is their total communication channel and medium, what are they communicating?

The list is very familiar to all, here is the list and what to do:

"I am hungry" Feed your baby
"I want to be held, cuddled, rocked" Hold the baby and provide the requested comfort]
"I want to go to sleep" Initiate the sleep routine that helps your baby get to sleep
"I want my diaper changed" Change the diaper
"I am in pain" Find out what is causing the pain (e.g., a bad position, a reaction to a food, a stomach ache, etc.)

Bottom Line

Crying is often experienced as a crisis. The baby is crying, now what do we do??

But if we see crying as the newborn's way of talking writing, and emailing us, we can respond to it as we would any communication: figure out what the person is asking for, and respond accordingly.

This approach sets up a nice dance of parents and their young babies communicating and connecting and caring for each other. Crying moves from hazard to connection.

Dr. Lavin

2014-10-20

Ebola- Finally some good news in the US

Ebola- Finally some good news in the US
[updated October 20, 2014 11:34 AM]

As those who have followed our account of the story of the Ebola virus in the US already know, there has been no Ebola virus epidemic in the United States to date, and the chances of one actually occurring have been very low all along.

Today, the first actual data on how well an exposure to Ebola virus in the community can spread in the US has been reported. The information comes from Dallas, Texas, the only city in the nation where Ebola has spread, so far.

As we all know that spread to date has been to a total of two people. These two people, and the original patient, have been found to have exposed 149 people in Dallas and two flights, one to Cleveland and one from Cleveland.

Today we now know how many of the first 43 [was reported as 50 earlier today] of these 149 exposed people actually caught Ebola virus infection from these two nurses and the patient. These 43 are the first of the 149 to be tested and fully monitored for the full 21 days needed to prove or disprove if they caught the disease.

And how many of these 43 people were proven to catch the Ebola virus? The answer is zero!

Not a single person of these first 43 to be observed for a full 3 weeks caught the virus, none of them!

We of course need to wait a full 21 days for the rest of the 155 in Dallas and on the planes, and for another 153 people here in 16 of Ohio's counties to know for sure if the patient and Dallas and two of his nurses spread Ebola to anyone in the United States. Note that another 5 people in Dallas are so far negative and are only a few hours from full clearance later today.

But these initial results from the first 43 exposed Americans to reach the 21 day waiting period mark could not possibly be more reassuring. A very low rate would have been better news than a high rate of contagion, but zero transmission across 43 people clearly bolsters the evidence that this virus is not very contagious.

One of the 43 who did not catch it was a man who used the ambulance used by the actual patient in Dallas to get to the hospital before the ambulance was cleaned. The fact that he did not catch it increases the chance that people on the nurse's plane but not same flight are more likely to be safe, too. Another two, lived with one of the nurses who got infected, the one who did not come to Ohio. One of these two people was her fiance who cared for her while ill at home and the other her child who lived with her. Both of these people with very close contact were cleared today, they did not catch Ebola.

The fact that 0 of 43 exposed people caught Ebola should go a long way towards reassuring all of us in Ohio that the risk of an Ebola virus outbreak or epidemic in Ohio is exceedingly remote. We have every hope that the next days will establish that there is no Ebola risk in Ohio.

Again, until all 258 in Texas and Ohio, who are waiting to be cleared like the 43 already cleared, are cleared, caution and concern are still in order. But indicators are good that there will be on Ebola crisis here, at least for now.

To your health,
Dr. Arthur Lavin

2014-10-17

Ebola Update- A Broader View, and a Clarification from Hathaway Brown

Ebola Update- A Broader View,

and a Clarification from Hathaway Brown

[as of October 17, 2014 at 8:45 AM]

As we take a look at the state of the Ebola virus in the United States at this time, a few key observations seem most relevant:

We have had two phases of the infection, and wait to see if other phases will develop or not.
The first phase was the arrival in the United States of a small handful of people who got the Ebola virus infection in Western Africa, primarily Liberia. By a small number, we mean less than a dozen.
The second phase has been the spread of Ebola virus from those infected in Africa to people in the United States. At the time of this posting, a total of two people have been infected in the United States. Further, everyone who has actually been infected by Ebola virus in the United States has gotten infected only by caring medically for a person ill with Ebola.
There has been no third phase of infection at all so far. Of course, it is too early to know if there will be a third phase, but as of today, we know of no one who has actually been infected by either of the two nurses, the only people who actually got infected to date in the United States.

The Broad View, Right Now

These facts lead to the following observations:

Ebola is a scary illness because it is so deadly and there is no specific treatment for it.
There is no Ebola epidemic active at this time in the United States. Out of a population of 300 million people to have a disease spread to a total of two people does not constitute an epidemic.
It is also striking that the only people who have caught Ebola infection in our country were two nurses who were placed in very close physical contact with an infected person's bodily fluids. Early reports suggest their infection may have resulted from breaches in protocols that can protect medical caregivers. If so, the only documented infections in the United States, to date, are the result of something almost none of us will be actually experiencing- providing very close medical care with someone dying of Ebola infection and doing so with breaches in the proper technique.
At the same time, very careful vigilance is in order to prevent or minimize a third wave of infection, the spread of the Ebola virus from the two nurses to others.
The main observation to make at this moment is that although Ebola is raging in Sierra Leone, Liberia, and Guinea, it is really not raging in the United States. At this time, there is very little danger of infection to nearly all of the 300 million people who live in the US.
And again, the experience of Nigeria is instructive. Even if a third wave of infection occurs, this disease is containable, and I have every confidence that if a third wave occurs, the US will be able to keep it from actually moving into epidemic mode. That is, we are all very safe right now, and the outlook remains very good that we will continue to be safe.

The Clarification from Hathaway Brown

A number of highly reputable news sources reported yesterday that at student at Hathaway Brown was asked to remain home yesterday because the infected nurse who flew from Cleveland had visited the home of a Hathaway Brown student. Please note that these news reports, and my posting, were very clear to avoid stating or implying that anyone else at Hathaway Brown actually was exposed to a contagious person.

Hathaway Brown has clarified what took place. It does turn out to be true that Hathaway Brown asked a student to stay out of school pending further information, and asked her to stay home because of a possible exposure. The clarification is that the exposure was not to the infected nurse, but to a person who was a passenger on the plane with the infected nurse. But that passenger and the infected nurse shared a flight on October 10, not the 13th, that is, the flight to Cleveland, not from Cleveland. At that time the infected nurse was most certainly not contagious, if it remains true that her first symptoms occurred on October 13. As Hathaway Brown put it in their statement, they asked their student not to attend school for now, out of "an abundance of caution."

In re-reading our post yesterday, it is clear that our message was not that any risk of infection with Ebola had come to the Hathaway Brown community. This welcome clarification from Hathaway Brown makes this point even more emphatically. These facts, as we currently understand them, establish that the student was never in contact with anyone who could have been contagious. It makes sense for any school to be cautious, we make no comment on the whether the student should attend school or not, or when. But we can say with this clarification, and assuming no new facts emerge, we still have no reason to believe anyone in NE Ohio is infected with Ebola virus.

Bottom Line

This virus is very scary, for good reason. Fortunately, it has not spread in the United States to any degree that makes us think we are in any danger.

Let us hope this remains the case, even if several more cases of infection are identified.

Here is to your health, and to this threat passing as soon as possible.

Dr. Lavin

2014-10-16

A Masterpiece- A New Book Presents a Magnificent Treatment on Thoughts on Immunizations

A Masterpiece

A New Book Presents a Magnificent Treatment on Thoughts on Immunizations

On Immunity: An Inoculation
by Eula Biss, Greywolf Press, 2014

Many people, families and doctors both, have struggled with questions relating to immunizations.

It turns out these questions have a rich and compelling history, and also relate to very powerful trends in concerns that inform our current society.

For families and doctors alike, it only helps to better understand the questions and concerns that are raised surrounding immunizations.

Now comes Ms. Eula Biss who is an award winning essayist and observer of our society, with what I think may be the best book ever written on the topic of immunizing, and perhaps on the overall topic of medical care.

This book stands out for several reasons.

First, the author is an outstanding writer, so it is a great read, well crafted, deeply thoughtful.

Second, the author is recounting her own recent experiences of giving birth, experiencing crises, living through weighing scary choices. This is not a dry listing of various arguments for and against immunization, but a deeply felt exploration of what it is truly lived when you have to decide amongst conflicting choices for the health of your baby and child.

A third distinction, is that Ms. Biss takes a very serious look at all the concerns raised by immunizations. She discusses each concern in its deep historical and societal context. It turns out people have been concerned about immunization for many centuries. Also, many of today's concerns about immunizations are rooted in very deep trends in modern American society. Ms. Bliss presents each of these concerns, their history and their context in an incredibly thorough and open-eyed manner.

As a result, Ms. Bliss has created a book that should be read by every doctor and by any parent with any questions about immunizations at all. It's an important book for doctors, because it gives a clear picture of what families are contending with whenever they make any medical decision for their loved ones, in particular immunizing their children. It's an important book for parents, because it presents one of the best and most thorough discussions of current concerns available.

I have found the debates surrounding immunizations too often sink into stalemate. On one side are the scientists, armed with powerful facts about what life is like without the protection of immunizations. On the other side are organizations militant against immunizations, presenting frightening scenarios of possible harm. The scientists have little patience for worries in the face of facts. The opposition has little patience for those who do not take their sense of potential harm seriously. As a result, facts have little impact on those worried; and, worries have little impact on those with facts. Stalemate.

This is the special power of On Immunity: An Inoculation. I think it breaks the stalemate with poetry. This is not a scientific paper, and it is not a cry of terror. It really is a poem. It is a set of essays, there is no formal chapter or topic organization. Each essay is a very poetic reflection on what this Mother's thoughts were on this or that issue that immunization confronted her with. The special power of a poem leads to everyone being able to relax and consider the issues at hand. It allows for facts and feelings to come together towards figuring out what makes sense.

Here are a few choice examples from the book, that hopefully will demonstrate that this is a special read.

On fear and facts, Biss notes that the noted philosopher, Cass Sunstein has observed: "Perhaps what matters," Sunstein muses, "is not whether people are right on the facts, but whether they are frightened."
On the nature of danger from a substance: "For toxicologists, 'the dose makes the poison.' . . But most people prefer to think of substances as either safe or dangerous, regardless of the dose."
On the appeal of alternative medicine: "One of the appeals of alternative medicine is that it offers not just an alternative philosophy or an alternative treatment but also an alternative language." This launches a very interesting exploration of the power of the concepts of being "cleansed," "supplemented," protected from the corrosive effects of oxidation.
On the development of two sides to the immunization debates: "These dualisms pit science against nature, public against private, truth against imagination, self against other, thought against emotion."
A powerful experience in being denied access to her child during a procedure: "The implication that I was a hysterical woman and a threat to my child was making me so angry that it seemed possible I might actually become hysterical."
On the Sears approach to immunization: "The Vaccine Book is not even-handed as much as it is equivocal."

These examples are just a small sample of her eloquence, passion, thoughtfulness, that allow a very full treatment of today's debates on immunization.

The book is also a treasure trove of interesting facts. For me, one of the most powerful was that smallpox, once truly a great killer, was a killer up until its end. Smallpox was made extinct from the natural world in the 1970's. The virus only exists today in the military labs of the US and Russia.
But prior to its elimination, smallpox killed 500 million people, just in the 20th century. Smallpox killed more people in the 20th century than all the wars of the 20th century, combined!

This fact reminded me of a very central fact about viruses. Medical science, with rare exceptions, has been unable to find any treatments to rid us or effectively manage or limit the harm of a viral infection. The only real exception to this is the use of immunizations. The smallpox example is very relevant. Without smallpox vaccine, the world's first immunization, it would be killing about 500 million people a century, even today. Instead, it is now effectively extinct. Remarkable.

I will not go into any further details, but rather leave you to enjoy this extraordinary book, a most helpful guide, and incredible read.

To your health,
Dr. Lavin

Ebola Update- Solon and Hathaway Brown

Ebola Update- Solon and Hathaway Brown
This morning, two schools in Solon- the middle school and the Parkside Elementary School- and the Hathaway Brown School took steps relating to the Ebola virus.

In Solon, a staff person in the middle school was said to be on the same plane, but a subsequent (not the same) flight, as the nurse who flew from Cleveland to Dallas on October 13. The two schools are closed today for disinfection.

At Hathaway Brown, a student was said to have had contact with the infected nurse who was visiting NE Ohio, and that student is not attending the school today.

In both instances, Solon Schools and the Hathaway Brown Schools are taking precautions. There is no indication that anyone in NE Ohio, or any part of Ohio actually has an Ebola virus infection, even today.

In the case of the middle school staff person in Solon, being on a flight following the infected nurse's flight, even on the same plane, should not pose any risk to that person getting the Ebola virus infection. But, even if that person did, she would not be contagious for typically a couple of weeks, and so could not be contagious now, and is very very likely not even infected at all.

In the case of the student at Hathaway Brown, it is again, likely that she is not infected. But, even if someone did get infected this week, again, they would not be contagious now.

This note is no comment on the decisions taken by the Solon Schools or the Hathaway Brown School. They have all the facts of their situation, we do not. But it is clear that these steps were taken, as a precaution, not because anyone else in Ohio has been found to be infected with the Ebola virus.

Precautions are quite fine and prudent, of course, but the message has to be very clear: there is no Ebola virus epidemic in Ohio, or even one threatening to occur.

Again, we appreciate that even the mention of Ebola virus in our own community is a frightening event. We take your concerns very seriously, and respect the concerns of all involved.

We will continue to update you as information becomes available to us.

Right now, the situation is actually quite good and reassuring. To the best of everyone's knowledge, there are no people in Ohio currently infected with Ebola virus. Steps are being taken to track and contain any such possibility. And so today we are safe, and the outlook is excellent that we will remain so.

Dr. Lavin

2014-10-15

No Evidence of Ebola Exposure in Akron or Cleveland as of October 15, 2014

Questions on Ebola Exposure in Akron or Cleveland

[NOTE: This is an update from our original post earlier on 10.15.14]

Many of you have contacted our office with questions and concerns regarding the recent Ebola news. We appreciate that you have reached out to us for information and support during this time.

It was reported on Wednesday, October 15, 2014, that the second health care worker in Dallas to come up positive for Ebola virus infection was in the Cleveland area a few days ago.

At this time, there is no evidence that this person exposed anyone to her Ebola infection in the NE Ohio region.

Here is what we know.

September 28, 2014

The second health care worker, who I will refer to as Ms. SW (second worker), was exposed to a contagious patient with Ebola virus infection on September 28, while caring for the patient in the Dallas hospital.

September 28 -October 12, 2014

Ms. SW felt perfectly well and had no fever or sense of being ill.

Ms. SW was in the Akron/Cleveland area during some of this time.

October 13, 2014

Ms. SW flew from Cleveland to Dallas on Frontier AIrlines #1143 which landed in Dallas at 8:16 PM.

She is now known to have had a fever while on this flight.

October 15, 2014

It was reported that after getting ill, Ms. SW was tested for Ebola infection and found to be positive.

KEY POINTS

1. Ebola, to the best of our knowledge, is not contagious until symptoms such as fever appear. That means if you spend time with someone with Ebola virus infection before they get sick, you cannot catch Ebola virus from them.

2. Since Ms. SW had a fever on October 13, she was possibly contagious during her flight. Anytime prior to her getting symptoms, such as fever, she was not contagious, and contact with her prior to onset of symptoms should not lead to catching the Ebola virus.

3. All the passengers on Flight #1143 of Frontier AIrlines Ms. SW was on are being evaluated, since they were in the airplane with while she had symptoms.

4. Ebola virus is contagious only by contact, NOT by breath. So one would have to be touching Ms. SW in some way, have actual physical contact sometime after she got symptoms, that is, sometime October 13 or later, to be at risk.

4. ANYONE who is concerned that they may have been in contact with Ms. SW on the flight on October 13 or later, should call the CDC HOTLINE at 1-800-232-4636.

My impression, at this time, is that this second health care worker from Dallas, who spent time in Akron/Cleveland, is likely not to have spread her Ebola virus infection while in Akron/Cleveland, unless someone was actually in physical contact with her around October 13. To be clear, if someone did have physical contact and did so while she was contagious, they may have been infected with Ebola virus, but that person could not spread it until they developed symptoms.

We will keep you updated as more information becomes available. We understand the anxiety and fear that this Ebola outbreak is causing here in Northeast Ohio, as well as nationwide. We endeavor to be a voice of knowledge and reason and will keep you updated on the most recent facts and concerns as they become available. We appreciate your trust in our opinions regarding this issue.

Again, any questions on worries about exposure to this person should be directed to the CDC at 1-800-232-4636.

Dr. Lavin

2014-10-10

Enterovirus D68- What is it, What to Do?

Enterovirus D68- What is it, What to Do?

This summer a new outbreak, an unusual outbreak, from a virus called Enterovirus D68. This virus is causing some very serious trouble, and so we thought it would be helpful to explain what we know about it, and what to do.

What is a Virus?

As the name makes clear, all enteroviruses are types of virus.

Viruses are very strange sort of thing, they are packages of information wrapped in a coating that forces cells to make more copies of themselves. The information comes in the form of genetic material, either DNA or RNA and in every virus known these genes always code for instructions that force a host cell to activate the viral genes and then create a huge number of copies of the genes and new protective coats.

The protective coats of viruses are always made of a set of proteins that shield the virus from attack from an immune system, and contain properties that allow the virus to spread from person to person, find the right cell to infect, enter the cell, and deliver the viral genes to that cell to make copies.

What is an Enterovirus?

An Enterovirus refers to a very large number of viruses that cause a large number of viral illnesses in people. One subset of the Enterovirus family is the common cold virus, or Rhinovirus, but most Enteoviruses are described as belonging to a several subsets designated by letters, such as Enterovirus A, Enterovirus B, Enterovirus C, etc.

The prefix entero-, means having to do with the intestines, so the word enterovirus really minus, a gut or intestinal virus.

This makes sense since the typical Enterovirus causes a range of illnesses that include most of the stomach flus that happen in the summer, hand-foot-mouth disease, a high fever/stiff neck illness, and a simple bout of very high fever without any other symptoms.

One curious property of these, the typical Enterovirus illnesses, is that they only happen in the summer months, or close to them. This is a very important point and quite striking. The usual enterovirus is nowhere in the US in the winter. Almost no city in the US in the winter has the typical enteroviruses that cause stomach flu around in January. But come July, suddenly every city in the country is loaded with these viruses, in every neighborhood. No one knows why they disappear in cold weather and how they so suddenly erupt in the summer everywhere.

Another key property of Enteroviruses is that each subset or type has its own character, and some subtypes appear in clusters of cases over discrete periods of time. So there can be an outbreak of one particular Enterovirus subtype that creates a large number of cases over a few months, or even a few seasons, then disappears for many years, perhaps to never return, or to return in a few or many years hence.

We have seen years in which an Enterovirus creates a large number of cases of high fever, stiff neck, and very severe headache, for example. There have been stretches of 4-5 years of many such cases, followed by 10-20 years of far fewer.

So a particular subtype of Enterovirus can appear suddenly, then disappear as quickly, causing a stretch of time in which a striking illness occurs across the nation, followed by a stretch of time when such an illness disappears or becomes far less frequent.

What is Entervirus D68?

Remember that there are groups of Enteroviruses grouped by letters, like Enterovirus A and Enterovirus B? Well, this Enterovirus D68 is part of the Enterovirus D species of Enterovirus.

And it happens to be the 68th one in the group, hence Enterovirus D68. (There really are hundreds of all the different subtypes, or serotypes, of Enteroviruses, and five known Enterovirus D's.)

Enterovirus D68 is one of the subtypes of Enterovirus that come in clusters. There have been prior outbreaks of infection with Enterovirus D68, but none as large or concerning as the current one.

We do not know yet, but the hope is that with winter, this Enterovirus D68 will act like prior outbreaks, and like most Enteroviruses and stop causing illness during the winter.

Even more importantly, the hope is that this outburst of Enterovirus D68 is only this season, or if more, just a few years. This is a real hope, as noted such striking subtypes as Enterovirus D68 often drop off over time.

What Illnesses Does Enterovirus D68 Cause?

The Enterovirus D68 is different than most classical Enteroviruses in that it infects the lungs more than the guts, so it causes more breathing problems than vomiting and diarrhea. But sadly, it also seems to attack the nervous system, although not as commonly as the lungs.

Here are the key symptoms seen. That means, if one gets an infection with Enterovirus D68, it causes these symptoms most commonly. It does not mean if you have these symptoms you have Enterovirus D68:

Nose symptoms: runny nose, sore nose, sneezing, headache
Throat symptoms: sore throat, hoarseness
Lung symptoms: cough, wheeze, real trouble breathing
Nerve and Muscle symptoms: less commonly than the above- weakness, inability to move limbs (paralysis). These symptoms are not yet proven to be caused by Enterovirus D68, in one outbreak in Colorado, nine children developed loss of movement function (paralysis) and have Enterovirus D68 infection, but none of the virus was found in their cerebrospinal fluid, so we need further study to know if this symptom is indeed possible with this infection.
Some gut symptoms: mildly loose stools, stomach aches
Skin symptoms: various rashes

What to DO!

The answer to what to do is the same for Enterovirus D68 as it is for every virus: if symptoms are mild, just keep your child comfortable. If symptoms are worrisome, call us for help, and we will arrange for care to reduce the danger the infection presents.

Why do all viral illnesses have the same advice? Because for nearly all viral infections, there is no drug or treatment that kills the virus or heals its inflammations.

When to Worry

Even if one is infected with Enterovirus D68, if the only symptom is a mild runny nose, there is no cause for any concern.

And of course, even if the virus is not Enterovirus D68, if someone is struggling to breathe, you should call for help right away.

So, for Enterovirus D68, we are less concerned and there is very little to do, if symptoms are limited to this list:

runny nose, sore throat, cough, mild stomach aches, mild rash, and/or slightly soft stools; but, breathing fine when not coughing.

If any of the following symptoms appear, call for help right away:

Severe difficulty breathing, meaning your child has to work very hard to get air in and out of his or her chest
Muscle weakness beyond the mild tiredness of being ill. Your child seems very weak, and of course, if they cannot move an arm or leg

If we see your child and they have the mild symptoms, the treatment will be to keep your child comfortable at home without any specific testing. As long as the symptoms remain mild, it makes no difference what the virus is, the treatments and care remain the same.

If we speak to you or see your child and they have the more severe troubles of struggling to breathe or having significant changes in muscle strength, then the treatment is quite different. In this situation we would arrange for evaluation and care at the hospital. Tests for Enterovirus D68 and other viruses and germs would be done, and specific therapies to help a person breathe and to help a person who is getting weak, would all be started.

Bottom Line

The Enteroviruses are a very common and large number of viruses that typically cause the summer stomach flu, hand-foot-mouth disease, and other mild summertime illnesses.
Now and then subtypes of the Enterovirus family show up in outburts that bring unusual and severe disease. This is what is happening with Enterovirus D68, a strain causing quite severe and unusual breathing problems.
As with nearly every virus, there are no drugs to cure or heal the infection.
When it comes to knowing when to worry, when your child gets a cold or respiratory infection, it does not matter so much what the name of the virus is, even if it is Enterovirus D68. What does matter is how sick your child is. If the cold or respiratory infection is mild, no worries. If the infection is causing your child to struggle to breathe or become severely weak, then it is time to worry, to call us for help. Again, this is true no matter the name of the infecting germ.
Lastly, this outbreak of Enterovirus D68, which has caused so many cases of severe trouble breathing, will hopefully go away. Time will tell. Enteroviral outbreaks of severe illness typically appear mainly in the summer for several years, then seem to stop happening. Our hope is that this round of Enterovirus D68 is limited solely to the summer of 2014, goes away this winter, and does not return. We will watch to see how it goes.

To your health!

Dr. Lavin

2014-10-30

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

2014-10-27

Food Allergies: Do you have them or not?

2014-10-23

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

Good Rx- a great app

What is a Virus?

2014-10-22

Thoughts on Crying in Infancy

2014-10-20

Ebola- Finally some good news in the US

2014-10-17

Ebola Update- A Broader View, and a Clarification from Hathaway Brown

2014-10-16

A Masterpiece- A New Book Presents a Magnificent Treatment on Thoughts on Immunizations

Ebola Update- Solon and Hathaway Brown

2014-10-15

No Evidence of Ebola Exposure in Akron or Cleveland as of October 15, 2014

2014-10-10

Enterovirus D68- What is it, What to Do?

Tags

Twitter Updates