Top 5 Recommendations Go International!

Top 5 Recommendations Go International!

In May, 2011 a paper was published presenting the results of a process called the Good Stewardship Project.  In this Project, five doctors gathered in each of three specialties- internal medicine, family medicine, and pediatrics- to develop a list of five actions each specialty should stop doing.   Each recommendation had to improve the quality of care and reduce the cost of care.

Dr. Lavin was honored to lead the group of 5 pediatricians, who came from practices from across the nation.

Our five recommendations were published in the Annals of Internal Medicine:  http://www.ncbi.nlm.nih.gov/pubmed/21606090 

Now, nearly 4 years later, we have just been informed that our work has inspired a similar set of processes across the world.  Similar groups have published or begun similar work in the following countries, across 4 continents:  Canada, Australia, Germany, Italy, Japan, Switzerland, and the Netherlands.

Dr. Lavin is honored to have led the original pediatric team in this project and pleased the idea has spread across the world.

The top five recommendations were:

1.  Do not prescribe antibiotics for a sore throat unless it is proven to be a strep throat.

2.  Do not do CT or MRI scans for minor head injuries.

3.  Do not seek an ENT consultation for uninfected fluid in the ear early in the course of fluid present.

4.  Advise families not give their children cough and cold remedies.

5.  Use inhaled steroids in asthma when indicated.

These recommendations are now standards of good pediatric care and have been followed at Advanced Pediatrics for many years.

BOTTOM LINE

Advanced Pediatrics is pleased to see the approaches we take to care endorsed not only by a US paper in 2011, but now featured in the work of doctors in countries around the world.

To your health- 

Dr. Arthur Lavin

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

Say Nuts to Allergies: Another Illusion is Overturned

Say Nuts to Allergies, Another Illusion is Overturned--

Feeding Peanuts Early to Infants Actually Prevents Allergy to Peanuts

For many years, the ruling wisdom has held that if you expose your baby to various foods early, especially peanuts, you will increase the chance your child will develop an allergy to that food.

The advice based on this idea has been to ask pregnant women to not eat peanuts, for nursing mothers to not eat peanuts, and for all mothers to protect there infant and child from any exposure to peanuts for 3-4 years.

We have always been skeptical of this advice, mainly because the premise was invented, not actually observed.

About 5 years ago, in December, 2009, we posted a blog that presented the first indication that if you avoid foods, you do not protect your child, you actually make things worse:      https://www.blogger.com/blogger.g?blogID=6797182962943872595#editor/target=post;postID=2888210640457764870;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=12;src=postname

Since 2009, we have reassured families that not only is it OK to eat any foods during pregnancy, including peanuts, it was a good idea to introduce solids as early as 4 months of age.

Now comes a major new study in The New England Journal of Medicine, the world's leading medical journal:  http://www.nejm.org/doi/full/10.1056/NEJMoa1414850?query=featured_home#t=articleTop
(summarized in the NY Times here:  http://well.blogs.nytimes.com/2015/02/23/feeding-infants-peanut-products-could-prevent-allergies-study-suggests/?ref=health

This study not only proves that exposure to peanuts in infancy does not lead to peanut allergy, it prevents it.

The numbers are rather dramatic.  In the group of children that were fed peanuts during infancy, 1.9% developed peanut allergy by age 5 years.   Now, consider the children who were not exposed to peanuts , by age 5, 13.7% were allergic to peanuts at age 5.   Feeding an infant peanuts dropped the chance of becoming allergic to peanuts by 86%!

And this in a group of infants selected to be very prone to allergy- they all had either severe eczema and/or egg allergy.   The group just described had negative skin testing to peanuts in infancy.    But even in infants who tested positive for peanut allergy on skin test in infancy had less allergy at age 5 if they were fed peanuts: if not fed peanuts, 35% had peanut allergy if not fed peanuts, only 10% in this group were allergic if fed peanuts.

The findings are so dramatic that experts commenting on these findings are calling for a new approach to introducing solids to infants.   There is now real hope that if we feed infants peanuts (in a swallowable texture), we could stop the rise of peanut allergy in the developed world.

Five years after we called for a new look at the very suspect notion that avoiding a food in infancy would reduce the risk of allergy, the evidence appears to be convincing:  feed early, feed peanuts, and you can truly reduce the risk of your child developing food allergies, almost certainly to peanuts.

BOTTOM LINES
1.  For many years we have been told that it is best to "protect" your baby from exposure to various foods.  We were told that if you do this, your child is less likely to develop allergies to foods.  And, that this is all especially true in the case of peanuts.
2.  Starting in 2009, Advanced Pediatrics began questioning this concept, noting there was no actual evidence to support it.  And important studies actually proved that it was not true.  We began advising it was not only safe, but a good idea to introduce solids as early as families were comfortable doing so, as early as 4 months old.
3.  Now comes a powerful study that demonstrates that giving infants peanuts to eat sharply reduces the chance they will be allergic to peanuts at age 5, even amongst highly allergic children, whether skin test positive to peanuts early in life or not.
4.  The evidence has reached a level that experts are now moving official advice on infant feeding to one step beyond what we promoted in 2009:  that the introduction of solid foods earlier in infancy, and in particular, the introduction of peanuts into infant diets, could change the face of peanut allergy in the US.
5.  Very importantly: if an infant of any age is fed peanuts, the peanuts must be in a texture the infant can swallow without choking- a thin puree or paste, never a whole peanut.

To your health-
Dr. Arthur Lavin

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

HPV Immunization Update- 2015

HPV Immunization Update- 2015

HPV is an abbreviation for a particular species of virus called Human Papilloma Virus.   A papilloma is a small lump, the most common papillomas we have are warts.  So the HPV is the virus that causes all warts in people.

Warts

Warts are a usually harmless lump that is the product of a relatively quiet viral infection.  So a wart has a virus and on top of the viral infection, a lump.  For common warts on hands and feet, the wart infection is so quiet that no redness, or warmth occurs.  All the virus does is make that spot make more skin.  The extra skin piles up and the lump is the wart.  The virus does not go into the body, and the body tends to leave it alone, that's why warts sit there so long.

HPV Subtypes

There are many, many dozen subtypes of HPV, and the subtypes determine if the wart will be on your hands or feet, or genital area.  And of the ones that infect the genital area, the subtype will determine if the wart infection will cause cancer or not.

The vast majority of HPV subtypes do not cause genital warts and do not cause cancer.  But some do both.

The only subtypes the HPV immunization protect against, are the subtypes that cause genital infection and cancer.  Originally the HPV immunization protected against 2 subtypes, then 4.  The 4-subtype version was the standard until this year when a 9-subtype version came out.   

How Common is HPV genital infection?

Very.

Studies have found about 70-75% of all adult Americans, male and female, are infected with at least one HPV subtype.

It is the most common STD, by a very, very wide margin.

Preventing Cancer

The 4-subtype version, which is what everyone who has gotten an HPV immunization series prior to 2015 has had, protected against 70% of all cervical cancers.  It also protected boys and girls from genital warts, and protected males against throat cancer (which has gone up 30% in the US in the last 5 years).

Now comes the 9-subtype version, and it protects against over 95% of all cervical cancers.

When is Best to get HPV immunization?

The HPV immunization only works before one can get an HPV infection.   So it works best if you are immunized before you begin sexual activity.

It can be given in later elementary school, but we think it best to get it in later middle school or early high school, a bit closer to the onset of sexual activity, to increase the protective levels of antibodies closer to the time in your life when you need them.

What is the Timing of an HPV immunization series?

Currently the HPV is a 3 shot series.   You get your first shot, and the second then has to be at least 2 months later, but can be much later than that, just not sooner than 2 months.  The third dose has to be at least 4 months after the second.   Many families have their child get dose 1 at a check-up, come back 2 or months later for the second dose, and then get the third at the next annual check-up.

There is a new look being taken at a 2 dose HPV immunization schedule, where the two doses are at least 6 months apart, but studies that will measure if that works are still pending.

Cost of the HPV immunization

When HPV immunization was first started, many insurers did not cover it, and then when they did, they only covered girls.

For the 4-subtype HPV immunization that has all changed.  Most insurers cover this as they would any other immunization.

The 9-subtype HPV immunization costs about 15% more than the current 4-subtype one.  It is included as an immunization that any ObamaCare compliant plan has to cover, and is covered by Medicaid.  Any new insurance plan has to be ObamaCare compliant, but if you have a plan that you have used for many years, it might be grandfathered, exempt from being ObamaCare compliant, and not cover the new 9-valent HPV immunization.

What to Do

We see the 9-valent HPV immunization as an improvement on the old 4-valent HPV, boosting protection against cervical cancer to very high levels.

But it may be more costly if not covered.

We will have both the 4-subtype and the newer 9-subtype available.  If you want the newer 9-subtype version, we recommend you talk to your health insurance company first to see what your cost will be.

What if You have been Immunized with the 4-subtype version already?

This question is currently under review, clear recommendations are not yet available.

I suspect that if you are already sexually active and have been exposed to HPV (remember about 75% of Americans have HPV genital infection and almost all have no symptoms at all), that getting the new HPV immunization won't help.

If you have not yet begun sexual activity, it might help, but we await further information to see.

BOTTOM LINES

1.  HPV is the virus that causes all warts.  There are lots and lots of subtypes.

2.  Some subtypes only cause warts in the genital area and about 9 of these cause over 90% of all cervical cancers in women, and a rising number of throat cancers in men.  All 9 cause genital warts in males and females.

3.  HPV is a very, very common genital infection, about 70-75% of all adult Americans have HPV genital infection.

4.  The HPV immunization can prevent over 90% of all cervical cancers in women, a vast number of genital warts in all adults, and throat cancers in men.

5.  A new 9-subtype HPV immunization is now available, and increases protection against cancer.  It may or may not be covered by your insurer.  

6.  We will continue to carry the older 4-subtype HPV until insurance coverage of the 9-subtype version is widespread.

7.   We recommend immunizing your children against HPV genital infection before onset of sexual activity, and getting it in later middle school or early high school is good timing for this goal for most children.

To your health,
Dr. Arthur Lavin

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

The Influenza Epidemic of 2014-2015 is Ending: Overall an Unremarkable Epidemic

The Influenza Epidemic of 2014-2015 is Ending:  

Overall an Unremarkable Epidemic

Every week the nation's Centers for Disease Control and Prevention, the CDC, publishes a rich set of statistics on the course of the influenza virus in the United States.  It has done so for years, so we can both track the current progress of every winter's influenza virus, and compare it to prior years.

The good news is that, as with every other recorded influenza epidemic, this one is ending too, and it is ending now.  Very soon the winter epidemic if influenza viral infections will be over.

And so, we are also ending our administration of this winter's influenza vaccine.   We are very pleased at the level of protection it offered, and looking over the nation's experience, very pleased this year's influenza epidemic was very much like most years, it was not severe in any sense.

Reminder on what is the influenza virus

Readers of our postings on the influenza virus will be familiar with the nature of the virus.  The influenza virus is a specific species of virus that comes in various strains.    There is much confusion in the word flu.   Flu can mean a cold that is severe, it can mean the stomach flu, it can also mean the influenza virus.   To be clear, the influenza virus is a virus that can cause colds, achy respiratory flus, achy fevers, even ear infection and pneuomonias.  But in any winter, it is the cause of only about 1/3 of such illnesses.   So if you have the "flu" you have a 66% chance of it being caused by another virus, even at the height of the appearance of the influenza virus.

We also know that the influenza virus has a the odd pattern of only causing infections in the United States in the winter, except for rare pandemic forms of it.

Typical patterns of the influenza virus epidemics

Here are the typical patterns the influenza virus causes:

• It typically appears in mid to late December, peaks around New Years Day, and fades in February.
• It changes form slightly every year, so getting it in 2012 offers little protection in 2016.
• Even during its peak times, that is December-February, it causes only about 1/3 of all the colds and flus in the United States.
• It can be very deadly to the frail elderly, but the vast, vast majority of healthy people weather an influenza viral infection safely.
• There are tragic childhood deaths caused by the influenza virus each year in the United States, but the total numbers of these tragedies tend to be in the range of 100 out of millions of infections.
• The influenza vaccine works, even on off years, has reduced the number of deaths from this infection, and helps 

This year's epidemic was notable for how typical it was

This year, the media attention to the influenza winter epidemic suggested something very dangerous, ominous, and quite extraordinary was going on.  We all were made to feel frightened.

Well, now that the influenza epidemic of 2014-2105 is nearing its end, we can look at the actual data, and guess what, this year's epidemic was in nearly all respects very much like all the others, in a word, it was typical.

How so?

• The influenza epidemic of 2014-2015 began right on time in December, and is fading away as most do, right now in February.  In fact if you look at week to week incidences, the epidemic tracks remarkable just as the epidemic of 2012-2013.
• The influenza epidemic of 2014-2015, like all other influenza epidemics, featured subtypes the were different from prior years.   
• At its peak, which again was around New Years Day, only about 1/3 of the nation's colds and flus were due to the influenza virus.
• Much was made of the tragedy of young life lost to the influenza virus this epidemic, and each such death is indeed beyond understanding, the very definition of tragic loss.   But the influenza epidemic of 2014-2015 caused no more child deaths than expected in the United States.  As of February 7 the count stands at 80.  Last year the count was 109 and the year before 170.  This year's influenza epidemic was actually less deadly to children than the last two winter's influenza epidemics.
• The one aspect of this year's epidemic that was notable was that the most prevalent strain was not fully matched in this year's flu vaccines.  Even so 50% of those who got the flu vaccine never got infected with the influenza virus this winter.

Bottom Lines

1.  The influenza virus epidemic of 2014-2015 is coming to a close.

2.  It was a very typical influenza epidemic.

3.  The influenza vaccine, although missing an exact match with one of the prevalent strains, worked once again.  The number of childhood deaths from influenza actually dropped, so far this round.

4.  With the end of the influenza virus epidemic we are ending administration of influenza vaccine until next season, starting up again sometime around September, well before the time the germ will return, December.

5.  Of course, the influenza virus causes very few colds and flus in the spring and summer, but other viruses still do.  So, even though the influenza virus epidemic of 2014-2015 is ending, colds and flus will continue.

Be well,
Dr. Arthur Lavin

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

Why We Do Not Accept Anything from Pharmaceutical Companies: A Powerful and Funny Take

Why We Do Not Accept Anything from Pharmaceutical Companies:  

A Powerful and Funny Take on the Subject by John Oliver

For many decades, I have been pleased to keep to a very strict policy of not accepting anything free from pharmaceutical companies.   Many of those in our practice are familiar with the fact that we accept no gifts, no food, no advice, no payments, and no visits.   Our stance to the industry is two-fold:

1.  As manufacturers, the pharmaceutical industry is very trustworthy in delivering the drug that the label on the package claims is in it.   If I buy a vial of penicillin, I have tremendous confidence that the white powder is penicillin.   (This is in marked contrast to the purveyors of herbal remedies who recently were found to not put any of the labeled herbs in many of their most prominent herbal offerings- 80% rate of no trace of the top herbs in 4 top retail names in the state of NY).

2.  As marketers, the pharmaceutical industry has earned a very deep level of distrust based on many years of misleading information, denying harmful side effects, and a rather shocking degree of buying doctors' approval.

And so, we will buy products or recommend use of products that we have researched independently and found to be safe and effective, or whose risk of use is justified by the compelling nature of the benefit.

But we will not accept any known attempt to influence our decision-making on use of prescription or other drugs.

After all, isn't that one of the basic functions of your doctor, to be a trustworthy source of information and recommendations?  To be credible in stating that our recommendations are really only oriented to the best interest of your child?

Now along comes the comedian John Oliver, and presents a 17 minute take on the outrageous degree of influence peddling that pharmaceutical companies and doctors are colluding in.

Here is the riff.   http://youtu.be/YQZ2UeOTO3I

I believe most will find it very funny.   Warning, some may find, as with lots of comedic riffs, parts that are offensive.   But I found it to be one of the best presentations of what goes on and why the practice of taking items of value from drug companies strikes at the heart of our profession.

So be warned, if you find modern comedic routines offensive, don't watch.

But if you enjoy modern comedy, this presentation does more to make clear the problem with pharmaceutical companies advertising, pushing use of drugs beyond their need, than anything I have read or seen recently.

BOTTOM LINES

1.   Here is a very funny take on a very sad story, the collusion of doctors and pharmaceutical companies in promoting the use of prescriptions.

2.   We at Advanced Pediatrics remain proud of our record of not taking items of value from drug companies, and basing all our recommendations on the best data science can provide.

3.    For your other medical needs, it may be worth your while to find out if your other doctors' offices take samples, luncheons, or other items of value and ask your other doctors to stop, or find doctors who do not.

4.   Ultimately the issue is whether your medical professionals are completely oriented to the well-being of your child and family, or whether other interests might intrude.

To your health,

Dr. Arthur Lavin

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

Measles Epidemic Update- February 7, 2015 2:50 PM: How to Protect Your Child

Measles Epidemic Update- February 7, 2015 2:50 PM:  

How to Protect Your Child

The measles epidemic that started late in 2014 at Disneyland, California, continues to spread.

As of the last CDC update on January 30, 2015, there have been 102 documented cases of measles in the United States, across 14 states, including Illinois and Michigan, in just 2015.

There are no cases of measles known to have been seen in Ohio in 2015 so far.

Most of the 102 cases in the US this year are from the initial cases seen at Disneyland, California.

What is the Threat to Your Child?  (Spoiler Alert- not much)

The level of danger is actually incredibly tiny.  One could also say it is remote.  

You might ask, how can that be, the US is in the grip of a historic measles epidemic.  But keep in mind, an epidemic is a run of infections that exceed expected incidence.  The expected incidence in the US is 0.  In the year 2000, measles was declared eradicated. No measles cases occurred in the US from 2000-2007.

So, any group of cases is an epidemic.  

It turns out that this current outbreak, with 102 cases in January, makes the rate of measles quite tiny, about 100 out of every 300 million Americans got it it, or 1 in 3 million people.

Personally, if a threat is facing me, I prefer the chances of it happening to me be about 1 in to 3 million  rather than say 1 in 10 or even 1 in 100, which still gives me a 99% chance of it not happening.

Right now, the chance of not getting measles in America, is about 99.9999777%, not bad!

And, your odds are even better if you are immunized!

How to Prevent Getting Measles

Easy- get the MMR, the measles-mumps-rubella, vaccine.  The measles shot only comes in this form in the United States.

If you get one MMR, you have a 95% chance of not getting measles if you are heavily exposed, for the rest of your life.

If you get two MMR's, at least a month apart, you have a 99% chance of not getting measles if you are heavily exposed, for the rest of your life.

So, if you don't want to get measles, get the measles (MMR) shot.

If you have had 2 MMR shots, you have essentially nothing to worry about.

What if I am exposed?

If you have had 2 MMR shots, you have essentially nothing to worry about.

If you have had no MMR shots, you can get one within 72 hours of exposure and still be protected.

What precautions should I take with my child?

The most important and the only effective precaution to take is to have your child immunized with MMR starting at age 12 months old.  (See below for a comment on infants).

Many people are starting to get a little itch of worry, maybe even a little panic.  We would say that is not helpful.

The worry is that certain places are dangerous to go to, places like birthday parties, day care centers, even doctor offices.  The worry is that kids whose families have opted not to immunize their children have children who might be very likely to come down with measles, and then transmit it to their immunized children.  This fear has led to some rather unpleasant behaviors, like marking families who are not immunizing for stigmatizing actions, like barring their children from birthday parties, etc.

Here is why this makes no sense.   Over 15% of all the people who have come down with measles in this current outbreak, were immunized.  That means that the person we fear who may expose our child to measles could very easily be someone who was immunized.  Therefore, isolating your children from unimmunized children won't work.

Now, many might say, "Dr Lavin, you just said the chance of getting measles if you are immunized is very, very tiny, how could over 15% of the people with measles be immunized?"  The answer is very simple, if you take a 0.00001% chance or even less, which all would agree is a very remote possibility, and multiply it by the total number of Americans, about 300 million, you get a hundred or so people with measles, just what we have.  And about 16% of them were fully immunized.

That is why we at Advanced Pediatrics will conduct business as usual, and resist the temptation to react to a sense of worry, and strive to stick to the facts.  Since one can get measles in this outbreak from fully immunized people, there is no protection to be had from setting up special waiting areas for people with varying immunization status.

However, if anyone does come to our office with a fever and rash that might be measles, we will isolate that person immediately and inform all in the office of the event.  

MMR is only for those 1 year and older, what is the situation with infants?

Here is some good news, all mothers give their babies protecting antibodies during pregnancy, so all babies born to mothers who are immune to measles, are immune, for roughly 6 months.   If we give a 2 month old the MMR, her mother's antibodies will clear the vaccine measles virus and no additional protection against measles will occur.

Therefore, there is no point in giving a 0-5 month old infant the MMR, it isn't necessary, and it won't work.

For babies 6-11 months old, the mother's antibody has dropped enough that they could get measles, and so an MMR is a good idea.  But since mother's antibodies are still around in this age, the MMR does not as much as it would over 1 year of age, so if a 6-11 month old infant gets an MMR, they still need 2 at 12 months old and older.

What if I actually get exposed to measles?

Let us know.  

If you have had 2 MMR's, there is not much to do, you are to likely to be fine, that doing anything at this point would not be helpful.

If you have had 1 MMR at least one month prior to the exposure, come in within 72 hours to get a second.

If you have had no MMR's at all, come in within 72 hours to get your first.

That's it.

If you are not immunized and cannot get immunized, measles tends to appear in 7-21 days after an exposure, with an average time of 14 days.  The debilitating complication of SSPE, however, which causes permanent and devastating brain damage, can take an average of 10.8 years to appear.

BOTTOM LINES

1.  The US is experiencing a measles epidemic.   But the chance of any one of us or our children catching it remains incredibly remote.  There are no cases reported to date in Ohio.

2.  If you or your child has had 2 MMR's- you are very well protected, even if you are exposed to q case of measles.

3.   If you are worried about you or anyone in your family getting measles, make sure everyone 1 and up has had 2 MMR's.

4.   If you get exposed you are fine if you have had 2 MMR's.  If you have only had 1, get another within 72 hours.  If you have had none, get one within 72 hours.

5.   If you get exposed and are 0-5 months old, you are fine, no need for any action to be taken.

6.   If you get exposed and are 6-11 months old, get your first MMR, but know you will still need 2 more at age 1 and up.

7.   For those who have done some research, you may come across the option of using Immune Globulin (IG).  This contains measles antibody, but is only useful for a very intense exposure for someone not previously immunized.

8.   Given that during an epidemic many of those with measles are people already immunized, there is nothing to be gained from trying to isolate the unimmunized.

9.   The only way to contain and eliminate measles cases in a community is to have the community as completely immunized as possible.

10.  For many years people feared the MMR might cause autism.  That was never a proven fear, and over the years massive proof that this was not true has come to light.  The leading US Autism Non--Profit, has come out this week urging all who can to get the MMR.   Fear of autism should not put children or others at risk for getting measles through a misguided fear of the MMR vaccine.

Perhaps the most important item to note is that the United States has experienced nearly 20 measles outbreaks since 2007, every single one ended with elimination of measles across the country, making it likely this one will too.  And why is that?  Because of the use of the MMR vaccine.

We are confident that very few, and likely nobody, in our community will get measles.   We certainly look forward to that being the case, and pleased the solution to the problem, the MMR vaccine is readily at hand.

To your health,

Dr. Arthur Lavin

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

Tongue-Tie: The Power and Challenge of Trends in Diagnosis

Tongue-Tie: 

The Power and Challenge of Trends in Diagnosis

In the last few years, a great surge of interest in the condition commonly referred to as tongue-tie has emerged.

Tongue-tie is rapidly becoming the new, most compelling explanation for trouble with nursing one's newborn.

A close look at the evidence shows that this new interest fits into the well-known occurrence of trends in diagnosis.

What is a Trend in Diagnosis?

A great number of problems we experience are more complex than simple, meaning that there can be a variety of causes, and outcomes, for each such problem.  Examples include problems like struggling in school, oppositional behavior, back pain, having frequent colds.   In each of these problems, it is not always so clear exactly why the problem is present, or what the course will be over time, and so it is very hard to know what will "work" to get rid of the problem.

Such problems lead us to be very frustrated.  Someone must be able to do something, and so when an idea appears that promises to "fix" the problem, it is very hard to resist the promise.

Here is where the power of the diagnosis comes in.   A diagnosis, after all, is an explanation.  It answers the question why.   Why do I have my problem?  The diagnosis is why.

Our minds seek explanations so avidly, that we all will welcome an explanation, even before it is proven to be a true explanation.

And so, in our profession, we regularly see diagnoses,  suddenly appear, without much proof, but gain tremendous popularity as explanations for difficult challenges.   In these trends of diagnoses, it is typical that the diagnosis and its treatment will be perceived initially as a very convincing solution, until over time it emerges that it really wasn't as much of an explanation as we once thought.  Usually this cycle takes many years to fully appear, arise, and fade away.

What is tongue-tie?

Tongue-tie refers to the motion of the tongue in relation to a bit of tissue that connects the bottom of the tongue to the floor of the mouth.  This thin ridge of tissue is called the lingual, or tongue, frenulum.

Now, in every newborn, the face is structured dramatically different than ours.   All newborns have a much smaller mouth than an adult, their jaw is very small and recessed compared to an adult, and the frenulum tends to be attached much more forward towards the tip of the tongue than in an adult.  Overall, every aspect of a newborn face is far smaller than in an adult, and so everything is in a different relative position.

The tongue-tie theory states that some newborn's tongue frenulum interferes with nursing, and if that frenulum is cut the problem with nursing will go away.

Does tongue-tie explain trouble nursing?

Yes and no.

It does appear to be the case that some newborns' tongues and mouths are shaped such that clipping the frenulum is necessary for nursing to occur successfully and without pain.

The problem is that science has not yet actually developed a system that will allow us to really know who those babies are.

It has only been a few years since an attempt a classifying how tight the tongue is and how far forward or backward the frenulum sits has been created.

Curiously, studies using these classifications of severity have found little connection with more severe tightness and trouble nursing.   

Most of the studies looked at the impact of cutting the frenulum, but only in settings where the parents were told their newborn had a diagnosis, namely tongue-tie.

Knowing what-causes-what is tricky

Since our minds are so eager, really hungry, for explanations, when one comes along, it is very hard to resist being convinced.

A good example is the difficulty knowing what causes back pain.   It sure seemed as though bulging or herniated spinal disks caused most serious back aches until we found that about 60-75% of healthy people with no back pain have bulging and herniated spinal disks.   What a surprise, here were all these people with back pain whose CT scans showed bad disks, the disks must have been the cause- until a bigger look was taken and we found that having a bad disk on a CT or MRI is seen more with people with no back pain than with back pain.

So, to be really convinced that something causes a problem, one must take a look at those with the problem, and those without the problem.   To be convinced a treatment really works, one must take a look at those who got the treatment and compare them fairly to those who have not, or have had other treatments.

So, How Do You Know if you Have a Tongue Tie Problem, and if You Need the Frenulum Clipped during Infancy?

It turns out the science on this question is not well worked out or studied yet.

Here is what we do know:

1.  All babies born have jaws much smaller than we do, and their tongues sit in their mouth very differently than ours.  So seeing some difference should be something seen in every newborn.

2.  That strip of tissue, the frenulum, that connects the tongue to the floor of the mouth is very often positioned differently than in us.

3.  This point is very important, so simply noticing that the frenulum attaches to the tongue more forward or more back on the tongue than in us does not mean anything is wrong, and does not mean anything needs to be done.

4.  There are some newborns whose frenulum position AND tongue use, combine to cause painful nursing and poor latch and milk flow into the baby.  It looks like this is not a frequent event.

So, the way to know if the tongue and the frenulum are a problem, is if after thoughtful and effective lactation counseling, painful nursing continues, weight gain is not as expected, and the explanation seems to be that the baby's use of their tongue is playing a role.

Pitfalls to Avoid

The most common pitfall parents now experience, is in the newborn nursery, where someone will look at your baby's tongue and raise a concern that the frenulum is badly positioned or too short and recommend that it be clipped.

It turns out to be quite unusual for a tongue and frenulum problem to be clearly the problem and identifiable as such in the first few days of  life.   Breast feeding typically involves lots of transitions in the first three days after birth:  the baby learns to latch, starts to suck, milk often takes the full 3 days to come in, babies are born with an extra 10% of their birth weight to live on while waiting for milk to come in.  So if someone is not nursing well the first day or two, or even three, that can be due to a good number of reasons.

Keep in mind, it makes sense to consider other options before hurrying into clipping someone's tongue, no matter how safe that might be.

BOTTOM LINES
1.  Tongue-tie happens, but not that often, probably 98% or more of newborns have a normal tongue that can nurse just fine.
2.  The unusual circumstance of the frenulum and tongue being so dysfunctional that they need a procedure to work does happen, but one shouldn't come to that conclusion in the first few days of life unless a very atypically severe anomaly of the tongue is evident.
3.  The only reason to clip a newborn's tongue is if it has truly been demonstrated that the tongue-frenulum is causing the baby to fail to latch to the breast or cause painful nursing, a conclusion that should not be accepted until a skilled lactation counselor and your pediatrician ensure there is not another reason for trouble latching and painful nursing.
4.  We are currently right in the middle of a true diagnostic trend.  The popularity of diagnosing newborns with tongue-tie is rising rapidly, a true move towards making this diagnosis in many newborn nurseries is in full swing.  So beware.   Keep in mind there is no rush on this diagnosis, it should take in most circumstances at least several days to be sure this is the cause before your baby is asked to have their frenulum clipped.
5.  In the unusual circumstance that the frenulum does need to be clipped, then of course it should.

Here is easy and comfortable nursing to all who seek it!

To your health,
Dr. Arthur Lavin

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

It's Good To Know if What you Bought Contains What you Wanted to Buy

It's Good To Know if What you Bought Contains What you Wanted to Buy:

GNC, Walmart, Target, and Walgreen's Sell Herbal Medicines without the Herbs

The Attorney General of the State of New York tested samples of herbal remedies sold by top national stores and found 4 out of 5 times, the bottles contained no trace of the herb promised on the label.

http://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/?ref=health

Instead of ginko biloba, ginseng, St. John's wort, valerian, and other promised medicinal herbs, the NY Attorney General found powders of rice, asparagus, peanuts, peas, soybeans, carrots, radish, and other such items.

Imagine buying a bottle of ginko biloba at Walgreen's, or Target and only getting powdered rice!

How could top national stores like Walmart, GNC, Walgreen's, and Target sell products that do not contain the product 4 out of 5 times?

The answer is very simple, the companies that make herbal medicines and dietary supplements, once sold by Orrin Hatch, are now protected by laws created by Senator Orrin Hatch that specifically exclude their manufacture from testing and monitoring by the FDA.

The wild enthusiasm for "herbal" remedies and the laws that protect companies that sell them from ever being examined has led to the sadly predictable debacle that 80% of the goods are empty of the promised product.

Bottom Line

1.   The dietary supplement and herbal medicine market is rife with extreme fraud.

2.   80% of the time you buy some of the most commonly sold herbal remedies you are actually buying powdered foods.

3.  This level of failure to deliver the goods is happening right now at the top national retail stores with the biggest names, including:  GNC, Walgreen's, Walmart, and Target.

4.   At this time, there is no reason that you can trust a bottle of an herbal medicine contains the herb.

Dr. Arthur Lavin

 

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