Advanced Pediatrics: 2015

2015-12-21

New Insights on How we Know Where We are and Going

New Insights on How we Know

Where We are and Where We are Going

Ever wonder how we know where we are at any point in time, or how we move our bodies to just the spot we want them to be?

We do it so effortlessly, and with no real thinking we are aware of, it seems simply natural. But as with all functions, something has to direct them and make them happen,

Recent insights in neuroscience have revealed that the way the brain operates our motions is nothing less than astounding.

A recent review in Scientific American (Jan. 2016) reports that inside our brains are sets of neurons, individual cells, that each have the remarkable ability to map our space, and know where we are in it.

Where in the brain is our map-making centers?

These cells reside in a part of the brain at the level of our ears, deep inside the brain, in two structures- the hippocampus and the entorhinal cortex. The hippocampus is named after a mythic creature in Greece that had the head of a horse and rear of a dolphin, and seems to have the shape of a sea-horse. The hippocampus is where many of our long-term memories are formed. The entorhinal cortex is just in front of the hippocampus, and just behind the cells that receive signals from our noses to register the perception of smells, hence the word rhinal (or of the nose), in its name. It is the area of the brain that connects the hippocampus to the main cortex.

So much for the technicalities, the amazement comes from what the special cells in the hippocampus and entorhinal cortex do. To really appreciate what comes next, one has to stop a moment to consider what we are talking about are single, individual nerve cells knowing where you are.

What do the special map-making cells actually do?

The special cells come in two forms, at least- grid cells and place cells.

Grid cells fire only when one approaches the angle of a hexagon in space. This is worth explaining. The existence of grid cells reveals that our brain converts our space into flat sheets of hexagons. One on sheet the hexagon may be about one foot in length per side of the hexagon. Other sheets of hexagons created in our minds could be several yards in length per side of the hexagon.

Once the brain has laid a set of hexagons on the space around us, wherever we are, then the grid cells only fire when we walk to an actual angle of one of these hexagons.

This neat process allows the brain to know precisely in which direction we are moving, and how quickly.

A subset of grid cells only fires if one approaches the side of one of the maps' hexagons that lies along an actual wall, or divide, an actual boundary to the space on is in.

Another set of cells in the brain only fire if one moves in a particular direction, thereby allowing us to perceive, to know, what direction we are moving in.

Another set of cells is devoted entirely to firing only at set speeds of motion, allowing us to know how fast we are moving.

All these special cells combine to give as complete a picture as possible of where we are and where we are going. It is the combination of all this information that determines if one last special cell to be mentioned, fires. That cell is called a place cell, and it fires only when all sorts of conditions- where one is in the hexagon at hand, the direction of motion, the speed of motion, the colors and details of the space- come together to define an actual place. To me, this is the most incredible fact- there are such nerve cells in our brains that only fire when we are in an actual, real, place. It is as though one cell can actually, and does, have the power to recognize, in this case recognize a space or place.

Incredible.

Just to help understand all this a bit more, grid cells will fire whenever anyone approaches a corner of any hexagon mapped to any place the person is at. They fire when you are inside, or outside; in the bathroom, or bedroom; while you are home or away. But place cells only fire in specific places, hence the name place cells.

Space and memory

You may have noticed much of this mechanism takes place in or near the hippocampus, the brain's memory machine. There is no coincidence here. Once the brain has mapped a space you are in with its hexagons, and lined up the special place cells to fire in specific places, those patterns are kept in mind, placed in memory.

These areas of the entorhinal cortex that preserve place memory are often the first to go in Alzheimer's disease, explaining why getting lost out in the world is such a common and early experience when this dread disease begins.

BOTTOM LINES

The brain has incredible approaches to knowing where we are and where we are going.
It starts with mapping any room or place we are in with a set of hexagons, then tracks how we are moving in those hexagons. That and other information combine to allow single cells to remember any spot we have been.

The ability to know where you are and where you are going is extraordinary, the fact that much of this sense and perception is mediated by single, individual nerve cells is even more amazing.

We at Advanced Pediatrics hope everyone has a wonderful holiday, wherever your brain's maps may take you!

To your health,

Dr. Lavin

2015-12-06

Stomach flu is here- What you Need to Know

Stomach flu is here- Vomiting is usually OK

The community is, right now, experiencing a massive epidemic of stomach flu.

Kids with stomach flu typically vomit, have diarrhea, and fever.

Stomach flu is a miserable experience but it rarely presents any danger.

The way it works is that a virus is caught, like any virus, but in the case of stomach flu the virus goes to the gut.

The first stop is the stomach where it causes lots of swelling and inflammation. Once this hits you will see vomiting. As the virus goes along the gut the intestine gets red, swollen, and inflamed and this causes diarrhea.

Stomach flu is overwhelmingly harmless in a healthy populatoin, in the sense that nearly everyone who gets it recovers without the need for medical interventions. The main risk faced is dehydration, which is discussed below. But even in the unlikely event that should occur, the treatment for the mild dehydration seen in stomach flu is very effective.

On the vomiting

The vomiting from stomach flu lasts about 2-6 days and often frightens parents.

Sometimes the vomiting can be quite intense. So bad that nothing is kept down and what appear to be great quantities of fluid keep getting vomited all day and all night.

The most helpful thing to do for intense vomiting is to retreat to giving small amounts of fluid, about one teaspoon, every five minutes. One teaspoon every five minutes over 8 hours is 16 ounces of fluid a day, plenty to prevent dehydration. Why one teaspoon? Because that's a small enough amount it might be absorbed in the mouth and esophagus, before it hits the stomach, so you can drink it, absorb it, and not vomit it.

We would recommend resorting to the one teaspoon every five minutes approach only if the vomiting is so severe it is clear that your child is not able to stay hydrated. Once the vomiting eases off and your child can hold meals down, no restrictions on eating or drinking what they can.

On the diarrhea

The diarrhea usually lasts longer than the vomiting. Where vomiting might go on for a few days, diarrhea can to on for a few weeks. As long as there is on blood or mucus in the stool, it is likely viral diarrhea, not a dangerous or worrisome event. It tends to cause less dehydration than vomiting because you can drink enough water to match the water lost in diarrhea.

How do you know when you are dehydrated?

Nearly everyone with stomach flu gets dry, but that's different than dehydrated. You are dehydrated when you have lost so much more water than you take in that functions begin to suffer. Signs of dehydration include markedly reduced or cessation of urination, dry and cracked lips, sunken eyes, and marked lethargy.

Dehydration leads to not peeing, looking very sagged and tired, and a sallow-sunken-dry-cracked face.

Treatment

There is no drug that cures stomach flu.

Water is the best treatment as it resolves the only danger stomach flu can pose- dehydration.

The most frequently used drug used for nausea and vomiting is Zofran, or odansetron. This is a powerful drug, and does present risks, so we recommend it not be used for any but the most severe stomach flus. To use it with every stomach flu vastly increases the chance some serious harm could occur from uncommon side effects.

There are no drugs that can stop the diarrhea, like a runny nose with a cold, it simply has to run its course.

BOTTOM LINES
1. Stomach flus, like colds, are a universal human experience.
2. They can happen anytime of the year, but the community experiences waves of them. We are in one now.
3. The stomach flu is not the flu of the flu vaccine, so that vaccine does not prevent it. There is a vaccine for one cause of stomach flu, the rotavirus, but as that vaccine has been used, the noravirus has simply taken its place, so there is still plenty of stomach flu around.
4. Stomach flu is a viral infection, typically starting with 1-3 days of heavy vomiting followed or also including a week or so of diarrhea, with fever often.
5. Drugs for nausea and vomiting should not be used for every stomach flu as this would greatly increase the harm from such drugs.
6. The best treatment is water as it treats the only real danger from uncomplicated stomach flus- dehydration. Water can be give orally, but if that fails, there is always the IV route which can always quickly and safely restore water.
7. We at Advanced Pediatrics are happy to help if your child comes down with a stomach flu, particularly if you need help knowing if dehydration is appearing.

To your health,
Dr. Arthur Lavin

Bronchitis and sinusitis- What do these words mean?

Bronchitis and Sinusitis-

What do these Words Mean?

Every winter, when colds and flus create floods of runny noses and blasts of prolonged coughing, the words bronchitis and sinusitis erupt. It makes sense to take a moment and understand what these words mean, and how they are currently used, and misused.

-Itis and Inflammation

The best place to start is with the common medical suffix, -itis. This ending keeps showing up in all sorts of places when we talk about illness and disease. Some uses are very familiar, like dermatitis, or appendicitis, or arthritis. But in every instance, the ending -itis always means the same thing, inflammation.

Inflammation means that some tissue is red, swollen, tender, warm, and or has lost some function. Perhaps the most familiar example of inflammation is a mosquito bite, where the skin gets red, warm, tender, swollen. The inflammation is so mild there is no loss of function in this example. But the point is that inflammation is a response to a threat in the body. That threat can be a chemical in the mosquito's bite, and infection, or the body's own self attacking itself for no good reason.

In the case of bronchitis and sinusitis, the inflammation is in the airways of the lung (bronchitis) or the sinuses of the head (sinusitis). And for both, the cause is an infection. This is where it gets interesting.

Bacterial v. Viral infection

The real confusion in the use of the terms bronchitis and sinusitis comes from the widely assumed meaning, namely that if you say the word bronchitis or the word sinusitis, you have proven you have a bacterial infection. But the truth is that bronchitis and sinusitis can be caused be either viruses or bacteria. If a virus infects your lung's airways or sinuses, you have a viral bronchitis or sinusitis. If a bacteria infects either, it's a bacterial bronchitis or sinusitis.

A major difference between any respiratory viral infection (except influenza) and any bacterial infection is that there is no antibiotic or medication that can decrease the impact of a viral illness, but regular antibiotics kill bacteria very well.

Bronchitis
Now to the illnesses themselves. Bronchitis literally means, inflamed airways of the lungs. This can happen, as noted, as a result of either a viral or bacterial infection. It turns out that, with few exceptions, every time you get a cold, you have a viral bronchitis. After all, a cold is when the virus inflames the lining of the nose, throat, and lungs, and when the lungs get inflamed, you have a viral bronchitis. It's the lung inflammation in a cold that causes the horrible experience of a cough. And you can't really get your lungs inflamed without the airways being affected. So, all colds are bronchitis.

But that's not what is meant when a doctor tells someone has bronchitis. When that happens, what is usually implied is that a cold has developed into something more complicated, that a bacterial infection has erupted.

Now, the question is, how does one tell if your child has a viral bronchitis (a cold) or a bacterial bronchitis?

It turns out this is very hard to tell, since both cause the same symptoms.

There are no findings on exam, or blood tests, or X-rays that can tell the difference.

At a certain point, the question really turns on how long your child has been ill, since typical cold symptoms last up to about 25 days, and symptoms persisting longer than that may be due to bacteria getting involved. Or, sometimes it is clear that the illness is getting much worse when it should be getting better. As you can see, this question is truly best answered by a judicious weighing of all the facts, more than a test.

Sinusitis
The exact same discussion goes for sinusitis.

Literally the word simply means inflamed sinuses, that is sinus linings that become red, swollen, and make a lot of mucus. But the word is usually used as a code word to imply that someone has a bacterial infection and that antibiotics are needed and will cure the condition.

Unfortunately, as with bronchitis, most sinusitis situations are caused by infections with viruses.

In fact, a cold can be truly thought of as a viral sinusitis. A cold is a situation where a virus attacks the lining of the airways. That attack destroys the linings of the nose and its sinuses, throat, and lung. This is physically no different than a shallow burn. The viral burn in the sinuses cause the lining to get very red, swollen, and make loads of mucus. This is clearly a sinusitis.

But, as noted above, viruses are not killed or slowed by antibiotics, and antibiotics do nothing to heal the burn created by the virus. So if your child's sinus infection is due to a virus, an antibiotic offers no help, only harm from side effects.

And, as with bronchitis, X-rays and CT scans and MRI's do not help. These imaging technologies cannot tell the difference between mucus from a virus and pus from bacteria.

So once again ,the distinction relies on the course of illness. Colds typically last 1-3 weeks. So, unless some unusual experiences are noted, someone with a runny nose, fever, achy and feeling ill, for less than 10 days almost certainly has a viral infection, and antibiotics will not help.

BOTTOM LINES
1. Everyone gets colds. These are viral infections that cannot be helped in any way by antibiotics.
2. Bronchitis and sinusitis are terms broadly used to imply that a person's illness has advanced beyond a cold to a bacterial infection that antibiotics could help.
3. If someone has been ill with runny nose, fever, cough, and feeling achy and ill for less than 10 days, unless some other unusual symptoms are present, it is very, very likely the illness is a viral infection, and antibiotics will not work. These viral infections can cause some symptoms, especially cough, to last well beyond 10 days, often for 3-4 weeks!
4. So the words bronchitis and sinusitis turn out not to mean one has a bacterial infection, only the course of the illness can determine that.
5. We at Advanced Pediatrics are happy to help you determine if your child's runny nose, cough, or such illness is typical for a viral infection, or if other signs have appeared to suggest bacteria are now involved. This will help determine if an antibiotic would help or hurt the situation.

To your health,
Dr. Arthur Lavin

Inflammation- A Universal Function and Experience

Inflammation-

A Universal Function and Experience

Inflammation is the heart of a wide range of experiences, from mosquito bites to arthritis.

Every person alive has had some experience of inflammation. And, as it is at the heart of so many troubles we all experience, I thought it would be interesting to share what we know about it.

What is inflammation?

The word inflammation means just what it sound like, to catch on fire.

The idea is that all complex living organisms, from algae, to plants, to insects, to us, need some way to destroy dangerous cells, to protect our own cells. All of such life actually monitors every square inch of living tissue at all times, and when a germ, or an errant cell appears, the body stands ready to zap it.

What does zapping it mean? It means delivering compounds that literally burn the unwanted germs and cells.

Our immune system makes high powered peroxides and other such compounds that actually deliver oxygen to an unwanted material as surely as a fire delivers oxygen to wood.

But here's the problem. It's very powerful to have a cellular flame-thrower handy to obliterate intruders, but how do you keep that fire from burning your self?

That's the key problem, the most important balance inherent in inflammation- how to keep the destruction available at every place in the body, ready to burn at any moment, keep the destruction off when not needed, and only focused on the harmful when on.

Good inflammation

Inflammation is vital to some of the most basic of functions of life- healing, recovery from infections, and even cancer prevention.

Any time we get a cut, it is inflammation that largely destroys the germs that pour into the cut. Without that protection, no cut would heal, every infection (including colds) would be fatal, and we would all have many cancers at a much younger age. How does inflammation protect us from these fates?

The most important function the immune system plays is to identify who is friend and who is foe. The immune system looks at every cell, at every compound, in the body and asks, at every moment: is this cell or material me or not me?

The ability of the immune system to be present in every place and at every time is what allows us to be protected in every spot of the body, no matter when.

Consider a cut. A cut breaks the seal the skin makes to keep literally trillions of bacteria out of our body. So when we have a cut, bacteria pour in, right there, right then. Only because our immune system is ready to go on the attack anywhere and anywhen, any cut is controlled. Cuts can get infected, but over 99% do not, even without doctors. This is an essential mechanism for healing.

Infections are all examples of germs, typically viruses and bacteria, finding a way past such defenses and getting a foot hold in our tissues. Uncontrolled they can destroy vital organs and pose a dangerous threat.

Perhaps the least well known and least appreciated powers of inflammation is to eliminate our own cells, cells that have gone astray. The most dramatic example of this gift from inflammation is the control of emerging cancer cells. It is our own immune system, and ultimately, its powers of inflammation that keep a very large number of cancer cells from ever getting the chance to grow and spread.

Short-term bothers from inflammation

Nearly every misery from cold and flus, stomach flus, insect bites, irritating plants, and injuries, comes from inflammations. These sorts of bothers are short-term inflammations, they only happen during the illness, irritation, or injury. Once the cold, or poison ivy, or bruise, is gone, the symptoms of the inflammation go away too.

One of my favorite illustrations of short-term inflammation is the mosquito-bite. I actually hate them like everyone else, but they contain all the features seen in all short-term inflammations:
1. Something happens to provoke inflammation- the mosquito bites you
2. The inflammation only happens where the provocation occurs- at the site of the bite and nowhere else.
3. The classic signs of inflammation are all present: swelling, pain or itch, redness, warmth.
4. Once the irritation of the bite goes away, so does the inflammation- that is bites clear in a short period of time.

The exact same sequence is seen with colds:
1. Something happens to provoke inflammation- the virus infects you
2. The inflammation only happens where the provocation occurs-
if the virus infects the nose- a runny nose
if the virus infects the throat- a sore throat
if the virus infects the lungs- a cough
the exception is that viruses can cause inflammation to release chemicals that a cause a couple of body wide troubles- tiredness, aches and pains, and fever.
3. The classic signs of inflammation are all present when it is active: swelling, pain or itch, redness, warmth.
4. Once the irritation of the virus goes away, so does the inflammation- fever, aches and pains, tiredness, runny nose, sore throat, cough- all go away completely once the virus goes and the inflammation heals.

The same sequence is seen in every short-term inflammations- including the bruises, stomach flus, and other short term illnesses, including migraine headaches.

Long- Term Inflammation

In contrast to the short-term inflammations, the long-term inflammations persist, linger, and sometimes last a lifetime. We do not understand how such long-term inflammations get started, and we certainly have no idea how they get sustained.

A bigger contrast to the short-term inflammations is that nearly all long-term inflammations serve no good purpose. They represent the darker side of our ability inflame. They hurt, they cause suffering, and cause damage to the body, all for no very good reason.

Familiar examples include the chronic, recurring inflammations of the gut (e.g., Crohn's disease), brain (multiple sclerosis), insulin producing cells of the pancreas (diabetes), joints (arthritis), lungs (asthma) you get the idea.

Perhaps the most benign of the long-term inflammations are the allergic variety. They can cause much suffering, but tend to be intermittent, and cause no actual long-term damage to the body in most instances. And, in contrast to the other long-term inflammations noted, there are often good treatments with few side effects available for allergy-related inflammations.

What Role Should Inflammation Have in our Life?

It is tempting to hope that one day we will eliminate inflammation, and rid ourselves of all the awful diseases long-term inflammation cause. Not to mention all the miseries the short-term inflammations bring to us.

But keep in mind that inflammation is a necessary weapon to protect our bodies from infections and even cancers.

So the goal will ultimately be to have some fine tuning control over the mechanisms of inflammation in our body. That fine tuning would turn off attacks on the valuable, healthy parts of our body, and eliminate the suffering such attacks create, but would leave intact, and even enhance, the power of our body's inflammatory mechanisms to keep us free of infection and cancer.

This is a very tall order, but one of the reasons for this tour of inflammation is to help us be familiar with one of the great powers of our body, to understand how it works for us, and how so much of what causes our health to be challenged is related to this particular power we all carry inside, inflammation.

BOTTOM LINES
1. Everyone has heard of inflammation, but it is helpful to understand a bit more about just what it is.
2. Inflammation is the power of the body to attack, and literally burn away, threats to our health.
3. Inflammation is vital to keeping our body clear of infection, and surprisingly, of cancer.
4. Short-term inflammations cause the universal bothers of viral symptoms such as runny noses, malaise, aches, fever, diarrhea; the itch of insect bites and plant reactions; as well as the pain of bruises and migraine headaches.
5. Long-term inflammations are the more serious challenges to health that come from uninvited and unwelcome, sustained attacks on our own bodies, such as seen in Crohn's disease, arthritis, and multiple sclerosis.
6. Science right now is working on preserving and even strengthening our protective uses of inflammation, and preventing or turning off unwanted flares of this powerful mechanism.

To your health,
Dr. Arthur Lavin

2015-11-11

Interesting News from the American Academy of Pediatrics-

Updates from a Meeting on November 5, 2015

This Thursday, I was attended a meeting of an important policy-making committee of the American Academy of Pediatrics (AAP).

For the last 3 years, I have been honored to be a member of the Committee on the Psychosocial Aspects of Child and Family Health (COPACFH). This Committee is charged with developing and publishing policy for the Academy on matters pertaining to the psychological well-being of children and their families.

Over the years COPACFH has crafted, or played a role in crafting the Academy’s policies regarding such issues as:

The best, evidence-based interventions for behavioral problems in children

The impact of poverty on childhood

The impact of divorce on families and children and how pediatricians can help

Promotion of teaching American pediatricians how to be most effective in helping diagnose and manage mental health problems

Issues regarding pain management in childhood

The best approaches to the pre-natal visit

The impact of sexual orientation on families and children

The best approaches to discipline, with special statements regarding corporal punishment

The role of the father in the life of a child

Many of these policies have had an enduring impact on American life, and certainly on the practice of pediatrics. This makes my participation on this committee a special opportunity.

Another compelling aspect of COPACFH is that it brings together a wide range of professional societies to share their special insight on topics such as those noted above. At today’s meeting we had representatives of the following national societies participating:

AAP Section on Developmental and Behavioral Pediatrics

American Academy of Child and Adolescent Psychiatry

National Association of Pediatric Nurse Practitioners

National Association of Social Workers

Society of Pediatric Psychology

This week the committee reviewed a number of interesting topics, which I am very pleased to share with you.

Integration of mental health services in the pediatrician’s office

This topic may be one of the hottest topics in the fields of pediatric psychology and general practice. At our meeting, we heard from the national societies representing pediatric psychiatry, psychology, social work, as well as the AAP, and its offices in Washington, that finding a way to provide counseling and therapy, in the pediatrician’s office, was an urgent and very high priority.

Why such intense interest in this concept? Two reasons come to mind. The first is the great need for help with emotional support and behavioral advice. It is estimated that at least one in four children will have enough difficulty with their emotions and/or behavior to benefit from extra help from a counselor or therapist. The second reason has to do with the power of the trusting relationship. Across the country, professionals are noting that if a family has an established relationship with a pediatrician they know and trust, it makes the collaboration of a counsellor or therapist known to that pediatrician not only easier, but far more effective for the family. This is all the more so for one actually in the pediatrician’s office.

Interestingly, this model of care has been put into place for 100,000 children of the US military who receive their care from the US Department of Defense (DOD). We learned that the DOD mandates that every pediatrician office have mental health services present in their office. We also heard of a wide range of solutions to this challenge from Boston to Minneapolis to Seattle.

Personally, I was very pleased that Advanced Pediatrics has been pursuing this concept of care for many years. For a number of years we were fortunate to enjoy the collaboration of Dr. Solomon Zaraa, of child psychiatry, once a week in our office. And we have been tremendously blessed to have one of our region’s most effective therapists available in our office for many years, Mr. Sam Selekman. Further, we are also tremendously blessed to have one of our region’s most brilliant neuropsychologists, Dr. Carl Weitman in close association with our office for many yers. We have long known just how powerful these collaborations are. Time and again we have been so pleased to see very important issues addressed in such an effective manner through these collaborations. This week’s meeting at COPACFH made clear much of the nation is seeking the sort of solutions we have been able to enjoy for some time.

Telehealth

The use of technology to connect the doctor to the patient has been exploding recently. At our meeting we reviewed the intriguing development of a collaboration amongst a growing number of states to allow a doctor licensed in one state to offer long-distance video medical advice in other states. So far 11 states have signed up for this consortium, Ohio is not yet one of them, but the list is growing.

At Advanced Pediatrics, we have been exploring new ways to be helpful, and many of the insights shared at this week’s COPACFH meeting may lead to exciting developments at the office, stay tuned.

The impact of policy at the state and Federal level

Without taking sides in our nation’s ongoing political debate, the meeting was able to remind us all that decisions made in state legislatures and Congress have a very concrete impact on the health and well-being of children. We were told of many states in which the election of a governor and/or legislature with a particular approach to policies placed millions of children at risk.

At every meeting we get to hear from the offices at the AAP that remain in close contact with Congress and all 50 state legislatures and it was their reports that dramatically demonstrated that elections do matter, policy decisions can help or hurt so many children.

The impact of poverty on being medicated for behaviors

One particularly disturbing fact presented to us at the meeting was the relationship between family income and the chance your child will be medicated for their behaviors.

We all know that poverty usually tends to make a service less available to a family. But when it comes to the use of medications to inhibit a child’s behavior, the opposite is true.

It turns out that children living in poverty in the US are 3 to 4 times more likely to be prescribed stimulants or powerful sedatives to control their behavior than children from middle class or wealthy families.

Now, one could argue that the stress of poverty will increase the chances of having emotional and behavioral problems requiring medication, but the increase of 300-400% raises the concern that poor children’s behavior may be less tolerable than better off kids.

BOTTOM LINES

1. The American Academy of Pediatrics (AAP) is the country’s leading professional society for pediatricians. The committee of the AAP charged with creating and publishing its policies relating to the psychosocial health of children is called COPACFH and I have been honored to serve on it for the last 3 years. I attended our last meeting this week.

2. Over the years COPACFH has published a number of policies for the AAP on a wide range of important issues.

3. At this week’s meeting some key policy issues discussed included the urgency of having mental health services available in the pediatrician’s office, the emergence of telehealth, and the very real impact of policy decision making by politicians at the state and Federal level on the lives of children in the US.

4. I remain very grateful for the opportunity to take part in fashioning policies that impact pediatricians, families, and children across the nation. Specifically, over the last 3 years, a number of policy statement from this committee have been published in the journal Pediatrics with my name on them as a member of the committee.

To your health,

Dr. Arthur Lavin

A Thank You to All for Flu Fest 2015

A Thank You to All for Flu Fest 2015

Dear Families,

This is a note of thanks to the families of Advanced Pediatrics, and to Mitchell's Homemade Ice Cream, for a successful series of Flu Fest this year.

Last weekend we concluded our third and final Flu Fest of the year. Through the Flu Fest concept, we have been able to provide protection against infection from the influenza virus to a large segment of the practice, in a fun manner that is quick and easy.

Special thanks go to everyone for what could have been a very challenging year in which manufacturers of the vaccine stumbled, failing to ship on time, and in the case of FluMist, denying

doctors' offices access to the nasal spray form for this season. All of you were incredibly flexible as we needed to move the Flu Fests from September to November, as well as moving to use of the shot rather than the spray version. We hope and expect that manufacturing will go more smoothly next year and we can return to early fall Flu Fest with Flu Mist.

We also want to give a special thanks to Mike Mitchell and his colleagues at Mitchell's Homemade Ice Cream. Their generous contribution of pre-scooped Mitchell's Ice Cream allowed us once again to take some of the sting out of getting a shot, and greatly enhanced the whole experience. It really puts the Fest into Flu Fest!

Finally, many thanks to the staff here at Advanced Pediatrics for coming in on weekend days to make Flu Fest available at convenient times, and to our dedicated team of young helpers who got the ice cream into your children's hands: Margo Hertzer and her friends, and Colin and Katie Rieger and their friend Christopher.

Most importantly, we are so pleased that so many children are now protected. With your flu immunization, you just got rid of 1/3 of all your winter colds and respiratory flus. That's a lot fewer cold and flus and we are so happy we could help, with you, to make that happen.

To your health,

Dr. Arthur Lavin

2015-10-25

Dietary Supplements: Neither dietary, supplements, or even for sure safe

Dietary Supplements: Neither dietary, supplements, or even for sure safe

In October 2015, the New England Journal of Medicine published a review of how many people get so sick from taking a dietary supplement they sought care in an ER or got hospitalized.

They found that the answer was thousands.

What is a dietary supplement?

The concept of a dietary supplement has nothing to do with medical science, but rather is a creation of Congress.

A law passed by Congress in 1994 created the category of chemicals now referred to as dietary supplements (the Dietary Supplement Health and Education Act of 1994). This law essentially defined a set of chemicals that could be sold to relieve symptoms with legal protection against ever having to prove they work or are safe. The only safeguard provided was that if someone could prove they hurt people, the FDA would be allowed to take them off the market.

But any substance deemed by the law to be a dietary supplement could be sold to the public with no proof that it worked, that it was safe, or even that bottles of the product actually contain the product described in the label. This law was largely the creation of the industries that make these substances.

The law defines a dietary supplement as one of three products:

1. Herbals- botanical products, that is plants, such as echinacea

2. Complementary nutritionals- purified chemicals known to be part of nutrients, such as amino acids.

3. Micronutrients- purified forms of vitamins and minerals.

The Findings

The article found that about 23,000 Americans have to go the ER every year due to adverse effects from taking dietary supplements. About 2000 of them end up hospitalized.

By far the age group that came to the most harm were young adults, ages 20-34.

Three main categories of harm found were:
1. Heart problems in young adults taking weight loss and energy supplements.

2. Kids experiencing overdosages from getting into supplements of micronutrients.

3. Elderly people choking on pills.

The heart problems in young adults was the largest group.

Why this matters

Dietary supplements are hot.

The industry that makes them has been wildly successful in getting us to take them. About half of all American adults have taken a dietary supplement in the last month. We spend about a third of all we spend on prescription drugs on dietary supplements.

This is one of the great marketing successes in history, all the more remarkable for selling products that in most cases have no proof of doing anything.

Of course taking something in hopes that it will work is fine if it is harmless. But if it can hurt you, it seems all the more important to know if it works.

By law, dietary supplements are excused from finding out if they work, and so very few have ever been studied to find out if they do anything in reality.

That makes this finding that so many young adults end up in the ER from them very important.

BOTTOM LINES

1. Dietary supplements are a category created by Congress as part of an industry strategy to sell product, not a product of any medical or science related research.

2. It turns out that none of them are actually a food, and as such are not really dietary. They are chemicals and should be judges by the same two standards all chemicals should be held accountable to: do they work? do they hurt?

3. We now know that weight loss and energy supplements cause heart problems in thousands of young adults.

4. Our recommendation is that no one should take any chemical on a regular basis without knowing if it really does work and what harm it can cause.

To your health,
Dr. Arthur Lavin

More evidence that Vitamin D does not deliver

More evidence that Vitamin D does not deliver

The New England Journal of Medicine in October, 2015 published an important study on an interesting claim that Vitamin D has made for several years.

Some years ago, the case was made for Vitamin D being an extremely important chemical in a wide range of body functions. Even more, that taking extra Vitamin D, boosting one's levels, could deliver a very wide range of substantial health benefits. These included stronger bones (less osteoporosis and bone fractures in old age) and a reduced chance of developing a rather breath-taking range of very scary diseases, including diabetes, multiple sclerosis, and colon cancer. When these fairly well thought out claims were first proposed, we recommended use of supplemental Vitamin D pending further findings.

At the time we observed that some skepticism was in order, as only one vitamin in the last 100 years has actually been shown to offer any benefit when taken in supplement form. Folic acid when taken by women of child-bearing age sharply reduces the chance of an infant developing spinal cord anomalies and may sharply reduce the chances of autism. But that's it. Taking any other vitamin has panned out to be a complete waste of time, and in most studies associated with poorer health.

So we have monitored the literature on Vitamin D, hoping it would join folic acid as a helpful supplement, but concerned the odds were against it.

Since that time, the further findings have been universally disappointing for Vitamin D supplementation. Now abundant results clearly show taking Vitamin D or calcium- by pill or milk- has no impact on bone. Elders who take or don't take Vitamin D and/or calcium have the same risk for bone fractures when falling, and no difference in bone density.

Now comes the New England Journal of Medicine to look at the impact of taking Vitamin D on disease prevention, in this case colon cancer. After studying thousands of cases, the evidence is clear, Vitamin D has no impact on the chance of developing colon cancer. This is a very serious blow to the idea that taking extra Vitamin D can prevent illness, certainly colon cancer.

Our recommendations at this time remain that vitamins should be obtained by eating food, not taking pills. The only exception is folic acid, from the first period to the last period, women should take 400 micrograms of folic acid. This is the only way that one can be sure the embryo is exposed to levels of folic acid high enough to prevent spina bifida, and perhaps autism.

To your health,

Dr. Arthur Lavin

On being a toddler- The Wonder of Curiosity

On being a toddler- The Wonder of Curiosity, The Power of Language.

As many know, we have had the tremendous fortune of being able to visit our son and his wife, and our granddaughter Evie, in Hong Kong for most of October.

Last time we had some extended time together, Evie was about 9 months old and inspired some thoughts on infancy and grandparenting that I shared. Now she is about 15 months old, and the changes and time have once again inspired some thoughts.

I think every age of life is infinitely fascinating. Our whole lives we are filled with potentials and possibilities, and at each stage of life these potential vary.

For a very long time I have found the age of 15 months fascinating for being on the verge of so many momentous changes that open up great vistas. We saw all this in full view during our visit with Evie who turned 15 months while we were there.

I think the most evocative property of being 15 months old is that by this age most toddlers have achieved a remarkably good understanding of language, even though their ability to formulate and speak thoughts is very limited. This is likely the only time in any of our lives when we know the words of our mother language, but cannot yet really speak it. At 4 months of age, very few infants if any know any words in their native language. By 3 years of age, nearly ever child not only understands their first language, but speaks it. Even by 18 months of age, their is so much more ability to state intention. This makes 15 months a very tender and powerful moment in life. It is the peak of potential, when so many ideas are coming into the young child's mind, but not yet expressible in full sentences and paragraphs. It is a time when you aren't really sure what the child is thinking, but are repeatedly surprised to find how much is going in in there.

For us that meant many wonderful hours singing nursery songs and reading many books to 15 month old Evie. For every new book or nursery song, Evie would seem to be attending, she would stop moving around, look intently, be in the moment, but who could tell what and how much actually being understood? Then about 1 or 2 repetitions later, sometimes during the first introduction, she would say a word or form a hand gesture exactly on the point of the song or book, at just the right time. We loved her saying so sweetly, "No, no, no, no" when we sang or read what the doctor said about no more monkeys jumping on the bed. Or forming her hands into a horn when singing about little boy Blue blowing his horn.

She was completely unable to read back any of her books to us, or repeat any songs sung to her, and only barely starting to make single words anyway, but these well-timed words or gestures signaled that she was understanding the point of the story in the song or book and at the time it was said.

We also saw that a whole world of preferences and styles was appearing. As Evie was on the brink of using words to express thoughts, her thoughts were becoming more complex, and on the verge of creating stories.

This is the really exciting part of this age- it dramatizes how much of our lives are the expression of stories. Our understanding of stories we experience, and our creating our own stories for others to experience.

To a large degree, it is the ability to craft stories and to join them to each other's that makes us human. That ability sits ready to emerge from birth onwards, but to see it coming together in the second year of life, and to see the full power of being human activate and take hold is so powerful.

We also saw the power of blocks of thought. Evie had a set of a dozen or so playful narratives that she could activate at any time- pretending to answer a phone, pretending to take her dolls on a walk, caring for her dolls and stuffed animals, and many other stories that we could not know exactly what they meant. In each instance, when a story was activated, she went through the same motions, almost exactly. We were watching her create set pieces, each very complex, that could be expanded or connected in time to create complex narrative behaviors. We fully grown adults use the power of established narratives all the time. It's how we get through much of our days, repeating functions like buying groceries, driving to work, doing house chores, even much of our social conversing and work.

Putting it all together, being with Evie this visit brought to home the big difference between being a baby and a child. It's mostly language, but also walking. When we are born, not just unable to walk or talk, but unable to imagine doing either, we are unable to craft stories that create new realities on the world, the reality of who we are. Once we walk, and in particular, talk, we begin to present our stories to the world, and learn from other stories. It is the emergence of being able to create and respond to stories that really marks the end of infancy and the beginning of the childhood.

It was beyond wonderful to spend so much time with our son, daughter-in-law, and granddaughter for the last 3 weeks. Many thanks to all the families in the practice for their support and interest. I look forward to being back in the office this week.

To your health,
Dr. Lavin

2015-10-14

Announcing our Second and Third FluFests for 2015-

once again Featuring Mitchell's Ice Cream

Advanced Pediatrics is pleased to announce the second and third FluFests of this season will be held during the day on Election Day, Tuesday, November 3, and from 8AM to 11:00AM on Saturday, November 7, 2015

An important difference this year is that the company MedImmune, the only manufacturer of FluMist, had a major factory mishap and so shipments of FluMist, the inhaled version of the influenza vaccine, will be in such short supply, we will NOT have the option of the nasal flu vaccine, (flumist), the inhaled flu immunization, for our November FluFests or at our checkups and sick visits.

Therefore, this year will be a SHOT ONLY year for our November FluFests and for influenza immunization during sick visits and check ups.

Our first FluFest for 2015 is on October 24, 2015. And after that FluFest, we will also be making flu shots available during regular check-ups and sick visits.

We have long appreciated the ease of how well the FluMist works, and share all disappointment that the maker of FluMist failed to produce enough for the nation this year.

But we do look forward to protecting the community against the coming flu this winter, even by shot rather than sniff.

This later timing of our flu clinics will be well before the influenza virus begins to reach epidemic levels which is usually until mid-December or sometimes as late as January.

Many thanks once more to Mitchell's HomeMade Ice Cream, and to all of you, the families of Advanced Pediatrics, for your trust in us. We hope making the provision of flu vaccine in a friendly and easy fashion can express some of our gratitude to you.

See you at the FluFests!

To your health,

Dr. Arthur Lavin

2015-09-30

Visiting our Granddaughter for a Few Weeks

As many of you already know, my wife and I have a son who with his wife and daughter lives in Hong Kong. We like to visit of course, and about once a year we try to find time. Going to Hong Kong is a long trip and so it makes little sense to go there for a weekend.

The time for our yearly visit to our Hong Kong family is coming up soon. This year we are fortunate to be able to visit for about 3 weeks.

Of course that means I will be away from the office during that time. So, my last day of being in the office will be Friday, October 2, and I will be back seeing everyone on Monday, October 26.

During my time away, care will of course be available with my esteemed associates Dr. Julie Hertzer and Kelley Muldoon Rieger, APRN.

I also wanted to thank all the families of Advanced Pediatrics for being understanding of my time away, which I have taken twice before in the last 3 years.

In earlier posts, I have commented on the powerful joy of being a grandfather, and of the special type of observations and appreciation you develop looking at your granddaughter grow up. Those comments were all about early infancy. Now our granddaughter is 14 months old, an entirely different time of life than infancy. I look forward to sharing thoughts on my return and seeing all again.

My best to all, and my apologies for any inconvenience my journey may cause anyone.

To your health,
Dr. Arthur Lavin

Announcing the First FluFest for 2015- once again Featuring Mitchell's Ice Cream

Announcing our Second FluFest for 2015-

once again Featuring Mitchell's Ice Cream

Advanced Pediatrics is pleased to announce the second FluFest of this season will be held from 8AM to Noon on Saturday, November 7, 2015

Once again, we are very grateful for the donation of ice cream from Mitchell's Homemade Ice Cream.

Our first FluFest for 2015 is October 24, 2015. And after that FluFest, we will also be making flu mist and flu shots available during regular check-ups and sick visits.

One more FluFest days will be taking place in November, once we know that the vaccine is certain to be in hand. Announcements for that third FluFest will be made in the coming weeks.

Again, this timing, though later than most years, will work well, since the influenza virus does not hit epidemic levels until mid-December.

To your health,

Dr. Arthur Lavin

2015-09-23

An Invitation to Participate

in a Research Study

Dear Family,

I want to invite you to consider participating in a research study for families with children ages 1-7 being conducted at Case Western Reserve University.

The research is examining how well an on-line questionnaire can perform in identifying children with developmental delays.

I am interested in helping the researchers out primarily to learn more about the specifics of screening for developmental delay. We have met with the research team, and they are incredibly thoughtful and deliberate. Their work is at the highest level, we will all likely learn quite a bit from working together on this study.

This study is not being conducted out of any concern about your child. In fact, we are not seeking any family to participate for any reason beyond having a child in the age range of 1-7 years old.

If you participate in the study, all we ask is that you complete an online questionnaire that asks you, the parents, to share your observations about your child's development.

Neither the Case team nor I will have any idea what your scores are. The scores are kept anonymous. The only data that will travel with the scores will be information such as age, zip code, and other such demographic information, nothing that would allow anyone to identify who the child or family is.

To participate, simply open the link below which will take you to an informed consent document. If you agree to continue, then you will be brought to the online questionnaire, fill it out, and you are done.

https://redcap.uhhospitals.org/redcap/surveys/?s=acuYbRHvdu&siteid=2

It could be very interesting to take the opportunity to create a developmental screening tool that actually works, and you can have the opportunity to participate in that creation.

The sponsors of the study are the grants that fund the investigator's work. No financial benefit will come from the study to anyone at Advanced Pediatrics or to any participating family.

In that sense, this study is not the usual clinical research that tends to be well funded by pharmaceutical companies and expose children to testing of drugs. In this instance, no commercial companies are involved, the actions taken are simply filling out a questionnaire, no side effects are possible, and no money exchanges hands.

The study will be limited to the first 100 families to complete the questionnaire.

As noted, we have met with the research team. They have deep and thoughtful experience trying to determine the best way to help children. I believe their work, and our participation in it, may open the door to further exploration and understanding. It will almost certainly help me to further consider the up and down sides to screening for developmental concerns.

Thank you for your consideration, and here is to a healthy and safe summer.

Dr. Arthur Lavin

Dr. Julie Hertzer

Ms. Kelley Muldoon Rieger

Advanced Pediatrics

2015-09-21

Are our children getting more immunizations than we did?

The answer is both surprising and interesting.

For reasons not fully apparent, immunizations excite our imagination. The idea behind them is actually fairly boring, give a person exposure to a harmless part of a germ, and when the real germ comes along it won’t work, thereby preventing potentially very serious illness at little cost or risk.

But that’s not how the issue is often felt. For many decades, there has been something about immunizations that excites fear and dread. This article is about the concern that we are giving our children a great many more immunizations, creating a big jump in the burden to their immune systems, and that this burden is of concern.

Recent Fears about Immunizations that have been Resolved

In the 1970’s and 1980’s the key fear was that giving your child the DTP shot would cause mental retardation. It took 10-15 years and hundreds of millions of dollars to see if that fear was true, and then another 5-10 years once it was proven not to be so before we reached our current state- essentially no one believes or even worries that giving any immunization will cause their child to become mentally retarded.

In the years 2000-2014, the fear was that immunizations cause autism. The exposure to mercury, the measles vaccine, and immunizations in general were widely feared to cause autism. Once again, it took many years and hundreds of millions of dollars to find out if this fear was true. And again, observations of children with and without immunizations proved immunizations had nothing to do with autism. This time, a specific individual who helped create the fear was exposed as a charlatan.

And as with mental retardation, it took many years for the proof that immunizations did not cause autism to lead to our national community to drop its fear of it doing so. We are right now living through the collapse and resolution of that fear.

The remaining fear: we are exposing our infants to far more immunizations than we had

That leaves the question of overload as the dominant fear surrounding immunizations today.

The fear goes something like this. A long time ago, infants got one shot at most at a visit, now they can be expected to receive 3 or 4 shots or immunizations at a visit. The fear is that this overloads their immune system, causing harm to the baby and child.

Amazingly enough, our infants are receiving a fraction of the burden our grandparents did when they were babies. In fact, the current immunization schedule delivers 96% less (!) burden than it did in 1960!

Let’s take a look at how this is possible.

First of all, how many shots do our infants get compared to our grandparents? When our grandparents were kids, they got one shot series and one oral vaccine series. The shot was the DTP (for diphtheria-tetanus-pertussis [whooping cough]), and the oral drops were for polio. The DTP required 5 shots over 5 years, and the polio required 4 doses over 5 years. That made for a total of at most one shot at infant visits, and a grand total of 5 shots, or 9 immunizations if you include the 4 oral polio doses.

But today, there is a proliferation of diseases we now can prevent. The list has expanded from the starting point of diphtheria, tetanus, pertussis, and polio to now include the following: meningitis from three different germs (Hib, pneumococcal, meningococcal), hepatitis (A and B), stomach flu (rotavirus), measles, mumps, rubella (German measles), and the diseases from the HPV (genital warts, throat and cervical cancer). That’s a jump from 4 diseases, to 14 if you count all the germs for which routine immunizations are now available.

So, how can you almost quadruple the number of shots and immunizations and still reduce the burden by 96%?

The answer lies in a key word for this worry- antigen. At the heart of any plan to immunize lies a neat trick. Give the body what looks like the germ, and it might just think it’s infected and create a response, even if the item given is a dead germ, or a piece of a germ. Then, if the real germ shows up, as noted above, the body is ready, kills the germ rapidly, no real infections from that germ can happen.

For example, if you give someone a polio shot, that child receives a dead part of the virus, the body reacts as if the real thing is there, and so if a real polio virus shows up later, the child cannot get polio.

This trick works so well that we have eliminated smallpox from the planet, polio is almost gone, and infants almost never get meningitis or tetanus.

For every germ there is at least 1 protein, sometimes a few more, that give the signal to the body that this germ is here and lead to a reaction that leaves the body protected. Any protein on any germ that the body uses to recognize it and create a response against it is called an antigen.

Now we come to how is it possible to give so many more shots, but reduce the burden so dramatically.

Yes, we give 14 rather than 4 immunizations, but each immunization contains far, far fewer antigens.

Consider the pertussis, or whooping cough, vaccine. Prior to the 1980’s that immunization was made by taking the whole pertussis bacteria and grinding it up. The pertussis shot contained hundreds, if not thousands, of antigens. The current pertussis immunization has only those proteins from the germ that actually make the immunization create a response that leaves one protected, which turns to be only 3-4 antigens.

The same is true for nearly all immunizations. Today’s immunizations contain as few antigens as possible, and in most cases that means a massive reduction in the number of antigens. Fewer antigens means fewer responses in your child’s immune system, a lighter load, a reduced burden, while at the same time getting a lot more protection. We are actually able to protect our children from many more deadly diseases, but with a tiny fraction of the antigens being delivered.

What does this mean for the worry about giving so many immunizations at one time?

If you think about it, the reason given for wanting to spread out the immunizations, to give as few as possible at one time, is to reduce the burden on your baby’s immune systems.

But now we know that even giving 3-4 immunizations protecting against 7-8 illnesses, at one time, actually injects 96% fewer items than the single DTP shot and polio drink.

Further, there is no evidence at all that babies who get 3-4 immunizations at once suffer any harm compared to those who get 1.

Another item to keep in mind is that immunizations actually do serve a purpose. People who get immunized for meningitis by and large do not get meningitis, whereas people who do not get this protection can get meningitis. The same is true for each disease we immunize for: polio, measles, whooping cough, tetanus, etc.

What that means is that a decision to delay an immunization, is a decision to extend the time your child is at risk for very serious diseases.

To make that last point more clear, we all know if someone decides not to immunize their child against measles, they could get measles. What is not so well appreciated is that if one decides to delay the 1 year old measles immunization to age 3 years, then that child is put at risk to develop measles from age 1-3.

Given that we are now exposing our infants and children to 96% fewer antigens, the argument to spread out immunizations offers no benefit and exposes children to needless risks.

BOTTOM LINES

1. Immunizations should be yet another boring science event. A harmless part of a germ is given, the body thinks the real germ is in the body and creates defenses against it, and when the real germ shows up, it can do no harm. A disease is prevented or wiped out.

2. Public reactions to immunizations have been very dramatic, over many, many years.

3. Two waves of profound concern have come and gone since the 1970’s The first was the fear that giving the DTP vaccine would cause a child to become mentally retarded. The second was the fear that giving the child the MMR vaccine, or other vaccines, would cause a child to become autistic. Both of these propositions have been soundly disproven. The fear of retardation from vaccines has since completely disappeared, and the fear of autism from vaccines is rapidly disappearing right now.

4. The main worry about vaccines that persists is that we are exposing our babies and children to a huge increase in germs and their components in today’s immunization schedule. Surprisingly, that fear turns out to be dramatically untrue. In fact, just the opposite is true- our children are exposed to 96% fewer types of proteins from germs in today’s immunizations compared to those few shots in 1965.

5. Delaying immunizations provides no known protection against any known harm, but does expose our children to prolonged periods of risk during which they can come down with quite serious diseases- in fact, that unnecessary risk lasts as long as one chooses to delay the immunization.

6. The common practice of spreading out immunizations is actually a very specific choice based on a fear that is likely the next to fade away. As we all become more familiar with just how dramatically the burden on the immune system has disappeared, even with a full schedule, this fear will also go the way of other past fears.

7. We at Advanced Pediatrics will of course be most interested in addressing all your questions regarding immunizations, and will respect parents’ choices about them. We look forward to working with parents to discuss and implement approaches that maximize the well-being of your children, and minimize the risks they face.

To your health,
Arthur

2015-12-21

New Insights on How we Know Where We are and Going

2015-12-06

Stomach flu is here- What you Need to Know

Bronchitis and sinusitis- What do these words mean?

Inflammation- A Universal Function and Experience

2015-11-11

A Thank You to All for Flu Fest 2015

2015-10-25

Dietary Supplements: Neither dietary, supplements, or even for sure safe

More evidence that Vitamin D does not deliver

On being a toddler- The Wonder of Curiosity

2015-10-14

2015-09-30

Announcing the First FluFest for 2015- once again Featuring Mitchell's Ice Cream

2015-09-23

2015-09-21

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