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




*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.

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.

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.

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.

 
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
 



*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.

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




*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.

2015-09-16

Safe Sound Levels to Protect from Hearing Loss

Safe Sound Levels to Protect from Hearing Loss

Sadly, our ears are not built for loud noise, when exposed to it loud enough or long enough, the nerves that sense sound begin to lose their function.  If that happens enough, we lose hearing.

Hearing is one of the only senses where overuse leads to permanent loss.  Think about vision.  A bright enough light can cause sudden loss of vision, but a blink and some time almost always allows vision to recover fully.   It takes a very unnatural amount of light to lead to permanent blindness, a level none of us are likely to experience.  The same goes for taste, touch, and even smell.

Why do the nerves of hearing lose function is overstressed, and at what level of loudness does that happen?

Why the nerves of hearing can lose function permanently
Hearing a sound happens when vibrations in the air are translated into nerve signals, that are then transformed into the experience of hearing.   That sentence lists 4 distinct steps that have to happen if we are to hear anything:

1.  Air vibrating.  If there is no vibration in the ear, there is no sound, and nothing to hear.  It is interesting that everything we, or any animal, hears is the result of air shaking regularly, vibrating.

2.  Translation of air vibrating to nerve signals.  This is the step that explains how hearing ability can be lost from loud sounds.   The translation occurs along the pathway of ear to nerve.  When you hear a sound, that means that the little column of air is vibrating in a pattern specific to that sound, and that air is vibrating in your ear.  Those vibrations make your eardrum, then auditory bones (remember the anvil, stirrup, and hammer?), vibrate.   Once these tiny bones vibrate they create identical patterns of vibration in a spiral of fluid they connect to.  The spiral is called the cochlea.
Now, lining the spiral of the cochlea are the nerves of hearing.  Each of these nerve cells have a border featuring little hairs.  Each cell has a set of these hairs that go from very short to longer, creating a brush like structure of varying hair lengths.
These hairs have one end inside the nerve cell, and the other end is dipped in the fluid that fills the spiral of the cochlea.  When the fluid in the cochlea vibrates, hairs that are the right length to vibrate at those frequencies begin to vibrate.  Whenever a hair on the nerve cell begins to vibrate, it creates an electrical signal.   Now air vibrating has been translated to an electrical nerve signal.

3.  The nerve signal is delivered to the brain.  Once the nerve fires, that electrical signal is shot down the auditory nerve from the inner ear to the auditory part of the brain.

4.  You hear.  This happens when patterns of these nerve signals excite the auditory part of the brain in such a way that you perceive hearing that sound.

Here is the sad news.  If you make the hairs on the nerve cells of hearing vibrate too strongly, they break off or separate, and will never again translate a vibration into a nerve signal.  If you lose all your hairs on all the nerves of hearing, you would be forever unable to hear again on your own.

Seeing involves no such moving parts, and neither does touch or smell, so they are not as prone to damage as this mechanism of hearing.

The ear does have a muscle in it called the stapedius muscle that can protect.  When we hear very loud sound, the muscle contracts and thereby keeps one of the bones of hearing, the stirrup (stapes) from vibrating, making the sound much softer.  But it takes a moment for that to happen, and if the sound is loud enough, even that protection will not prevent permanent loss of some hairs on the nerves of hearing.

What level is harmful?

Now that we know that loud sounds can cause permanent loss of hearing, what levels of sound are safe, and in what settings is sound not safe but harmful?

Loudness can cause harm in two ways, as noted above.   The first is a burst of loud sound.  Even a few milliseconds of sound loud enough can damage hair cells of hearing.  
The other way is by sustained sound.  By sustained we mean either for a few minutes, or few hours, or all day.

Loudness is a real physical force.   It relates to how powerful the vibrations are in the air.  A more powerful vibration is experienced as louder.   Sound vibrations are not usually experienced as physical forces, but the vibration of a loud bass can be felt in your body and on tables and floors, and certainly cars.

The unit of loudness usually used is the decibel.  The decibel is a complex number for two reasons: it is created by the ratio of two measures- the actual loudness of the sound, divided by a reference value for loudness.  The other aspect of decibels that make it complex is that they are the logarithm of that ratio.   But good news, all we need to know is that the higher the decibel level of a sound, the louder it is.

The rate at which increasing decibel levels gets louder goes like this.
Start with a sound that is generating 0 decibels of loudness, and call that 1 Unit of Loudness- this is barely loud enough to hear.

If you go up to 10 decibels, you go up to 3.162 Units of Loudness- the loudness of a rural night
If you go up to 20 decibels, you go up to 10 Units of Loudness- the loudness of a whisper
If you go up to 40 decibels, you go up to 100 Units of Loudness- the loudness of a library
If you go up to 50 decibels, you go up to 316.2 Units of Loudness- the loudness of a dishwasher one room over
If you go up to 60 decibels, you go up to 1,000 Units of Loudness- the loudness of normal conversation at a distance of 3 feet away
If you go up to 80 decibels, you go up to 10,000 Units of Loudness- the loudness of a garbage disposal 3 feet away.
If you go up to 100 decibels, you go up to 100,000 Units of Loudness- the loudness of a lawn mower 3 feet away.]
If you go up to 110 decibels, you go up to 316,200 Units of Loudness- the loudness of a rock band 15 feet away.


You can see doubling the decibel level more than doubles the loudness of the sound.

Sounds that are softer than 80dB do not hurt the hair cells of the nerves of hearing over any length of time.  Note- that means sounds should be softer than the loudness of a typical garbage disposal 3 feet away.

If you go over 80dB, permanent hearing loss begins to occur.  The louder the sound, the faster that happens.  At 85dB, one needs to be exposed to this level of loudness several hours a day for many years to lose hearing.

But, at 100dB you can start to lose hairs on the nerves of hearing in two hours, and at 115dB it only takes 15 minutes.  Much over 115dB, one loud burst of sound at that level can cause permanent loss so at least some hearing.

How does that connect to our audio devices?  The main problem is with earbuds and headphones.
One study found students listen to music at these levels:
55% of kids listen to music at 85dB or higher

Another reference is that the earbuds that come with Apple products, when plugged into an iPod at maximum volume, will deliver 102 decibels of loudness, loud enough to cause hearing loss in 2 hours.

For most devices, 80% of maximum volume will deliver about 90 decibels of loudness.  This is safe for listening for under 90 minutes, but over many hours for many years, hearing loss will happen even at this level.

Bottom Lines
1.  Sound is just vibrating air, but it has power in those vibrations.  Too much power and the delicate hairs on the nerves of hearing can be lost, never to return.  As these hairs are lost, hearing begins to weaken, and can lead to real hearing loss.
2.  The damage to these delicate hairs and loss of hearing are related to how powerful the air is vibrating and how long the nerve cells are exposed.   More force takes less time to cause damage, but some lighter forces can cause damage if the exposure lasts long enough.
3.  The force of sound is measured in decibels.  The very, very faint sound in a hearing test can be as low as 0 decibels.   The safe level of loudness for our ears is 80 decibels, or 10,000 times louder than that barely audible signal at 0 decibels.   
4.  The loudness of a garbage disposal at 3 feet, or ear buds on a device set at about 75% of maximum is what 80 decibels sound like.
5.  Keep sounds in your home, around your infants, children, adolescents, and adults to 80 decibels or less and sound will not harm your hearing.
6.  If you do listen to TV or music above 80 decibels, hearing loss begins to happen.  At 85 decibels you need to have sound of that loudness blaring in your ear for many hours a day for years to see actual hearing loss.  But at the max on many devices, you hit 100 decibels and hearing loss can appear within 2hours.   115 decibel blasts can hurt those hairs on the nerve cells in 15 minutes.

So, keep sound levels at 80 decibels or below and spare your hearing for your long life!

To your health,
Dr. Arthur Lavin

PS- Many thanks to a family with a young infant in the practice for asking me the threshold of loudness that is safe!




*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.

2015-09-11

Hives- What are they, When to worry

Hives- What are they, When to worry

Hives are a paradox with a happy ending.  Typically harmless, and more treatable than nearly any other rash, hives cause a tremendous level of concern.

The concern is based on the association of hives with a far more serious condition: a very severe form of allergic reaction called anaphylaxis.   In anaphylaxis, not only does the person have hives, but they develop very dangerous levels of trouble breathing and even drop blood pressure.

Even though nearly everyone with anaphylaxis has hives, almost nobody with hives has anaphylaxis.
How can this be?   Because millions of people, including millions of children have hives, but far, far fewer people actually ever experience anaphylaxis, fortunately.

What are Hives?

Hives are a rash caused by the release of a chemical called histamine.  The word hives has an unknown origin, the main guess is that it comes from a very old Scot word for rash.  The other name for hives is the very medical term for the rash, urticaria, which comes for a Latin word meaning burn.

Whatever the origin of the word, hives are a very distinctive rash that has these elements:

  • The appearance is described as welts.  Specifically hives, or welts, are a patch of skin that is raised or swollen, typically a pale red or even pink in color, and often with a central area that is pale or even whitish
  • Itch.  This rash is one of the itchiest known, for good reasons which we will note below.
  • It shifts.  Described medically as evanescent, the pattern and location of the hives moves over time.  In an hour entirely different parts of the skin can show the rash.  Where it was is now normal, and where it wasn't now has hives.
  • Antihistamine clears it up.  Most hives respond to use of benadryl, claritin, or other antihistamines.  More than any other rash, one dose of a medicine can make them vanish.
All these features come from the basic cause of hives.  As noted above, hives are almost always the result of cells in the skin releasing a particular chemical- histamine.   Histamine is a chemical found in a type of cell that populates all our skin, the mast cell.  Histamine, once released, makes all the capillaries around it leaky.  This is designed to allow elements in the blood stream to flood into an area that needs help.   But if a big pulse of histamine floods a patch of skin, the blood vessels in that patch get very leaky, fluid accumulates, and the skin develops the swollen, pale red, whitish look of hives.  Histamine is also a very powerful stimulant of itch.  It turns on the itch signal in nerves in the skin.  Finally, histamine usually once released is quickly cleared, so the release is like a flowing wash of histamine, it comes and it goes.  Releases of histamine can happen wherever there is skin.

These properties of histamine release easily explain all the features we see in hives:
  • The property of histamine to make local blood vessels leaky explains the swollen appearance
  • It's ability to cause itch nerves to fire explains the intense itch
  • The fact that histamine is like a wash explains why hives seem to appear and vanish so quickly, to move around the body.
  • And the fact that hives are due entirely to histamine release explains why antihistamines work so well.
What Makes Hives Happen?
Most people think hives are mainly the result of allergic reactions, but this is not true.  The most common reason hives appear is viral infections.  For some reason, having viruses growing in you often leads to histamine release, and so, hives.  Kids with colds and flus often get hives. 

At the same time, hives are of course a common experience of those with allergies.  This makes sense since the classic allergic reaction almost always includes the release of histamine.  It's histamine, along with other like compounds, that makes our noses run, our eyes itch, and our lungs wheeze and cough when an allergic reaction hits.  So it's no mystery that with all that histamine released in an allergic reaction, that hives appear, too.


When to Worry?
If hives appear and no change in breathing is seen, there is nothing to worry about at that time.
Hives are always harmless, it's other types of reaction that are potentially dangerous.
This bears emphasizing, if someone develops hives and their breathing is fine, the hives themselves are 100% harmless.  They do cause discomfort, they itch like crazy, but itch is not dangerous, it causes no threat to any important function of the body.
Further, hives typically respond well to antihistamine, so not only are they safe, but they can often be cleared away with use of a very safe medicine.

If when hives appear breathing starts to be labored, then it is time to worry and take emergency action.
Of course, whenever breathing begins to be hard, that is cause for concern.
In the setting of hives, any sense that your child is starting to struggle to breathe raises concern for an allergic reaction that is going to cause serious lung reactions.   This is quite different than a rash, or skin reaction.  As noted, skin reactions are harmless if unpleasant, but lung reactions can be dangerous.
The first step when you see hives with trouble breathing is to give a teaspoon of benadryl.  If the trouble breathing appears to be worrisome, call 9-1-1.  If the trouble breathing is very mild and not at all worrisome, you then have time to call us.

How to use Benadryl
Benadryl, or diphenhydramine (di-phen-hy-dra-mene) is a very, very safe, old medicine, a basic antihistamine.  It comes in liquid and pills, there is no child version.  So it's the dose that makes it right.  
For mild reactions and rashes, like just hives, the dose for young children is 6.25 mg and for older children 12.5mg.
For breathing issues, the dose for young children is 25 mg and for older children 50 mg.
The liquid comes as 12.5 mg/tsp, and the pills are 25 mg or 50 mg each.
The main side effect is tiredness, but in young children it can cause agitation.

BOTTOM LINES
1.  Hives are a particular type of rash, notable for their appearance as welts, intense itch, ability to come and go rapidly, response to antihistamine by clearing and itch ending.
2.  Hives are most commonly caused by viruses, but of course are also seen in allergic reactions.
3.  Hives by themselves are harmless.  If there is no accompanying trouble breathing or threat of trouble breathing, there is no danger.
4.  It is only in the setting of a very serious allergic reaction with struggle breathing that hives are of concern.  If trouble breathing is present in any situation, seeking medical help is very important and urgent.
5.  The use of an antihistamine can help clear away hives and restore comfort.


To your health,
Dr. Lavin 




*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.

2015-09-03

The new meningitis B vaccines

The new meningitis B vaccines-
Not yet recommended for routine use

As you have recently read in our postings, bacterial meningitis is a particularly horrible and deadly infection, and there are immunizations that can prevent it.

A very new immunization for meningitis is now available, and being heavily marketed to the public and to doctors.  The immunization is for a very specific subset of meningitis, the bacterial meningitis caused by one of the five types of the meningococcal germ, Type B meningococcus.

The meningococcal type B immunization is being marketed under two brand names, Bexsero and Trumendba.  (These names once again remind me of my wonder at how drug names are created, these, like most drug brand names, are so odd and unusual).  Our office has received very expensive promotional materials, including audio materials, very compelling photography, multi-color layouts.
Of course, as with all promotional materials, we do not accept or keep, or refer to them, but instead we try to get the information directly from trustworthy scientists.

With that in mind, I recently asked Dr. Walter Orenstein his thoughts on this new immunization.
Dr. Orenstein headed the National Immunization Program for many years, and currently heads the vaccine program of research and study at Emory University, down the street from his old office at the CDC.

It turns out that Dr. Orenstein attended the meeting of the ACIP this summer that weighed the case for and against use of the meningococcal type B immunizations.   The ACIP is the nation's group of experts that weighs all data concerning immunizations and crafts the best recommendations on their use.  ACIP stands for Advisory Committee on Immunization Practices.

The ACIP met this summer and reviewed these new vaccines.  After careful review of the new meningococcal Type B vaccines, their recommended that these vaccines not be given routinely, but that patients and their doctors can discuss its use.  They also recommended this vaccine be given to those few individuals with immune system deficiencies that make getting meningococcal infections more likely.

The ACIP decided against recommending routine use for two key reasons:  they had concerns about safety, and they had concerns about how well it would help.

Safety concerns from the ACIP
The safety concerns had to do with reports that adolescents who got this immunization had some serious problems, including a painful condition called rhabdomyolysis in which muscle can become inflamed severely, and seven other serious events.   It is not clear if the adverse events were due to the vaccine, but until that is settled, routine use is not recommended.

Does it really help?
The ACIP, according to its report, and what Dr. Orenstein told us, raised concerns that trends showing meningococcal Type B infections are becoming less common even before this vaccine was created.   It is also not clear how long this vaccine remains effective.  These and other concerns made the ACIP wonder if use of this vaccine would offer enough benefit to recommend it.  At this time, the ACIP concluded it did not, but awaited further information to see if it might be someday.

BOTTOM LINES
1.  The meningococcus is a nasty bacteria that causes very dangerous infections, including meningitis.
2.   The Menactra immunization protects against 4 types of meningococcus- the A, C, Y, and W-135 types.  We use this routinely and it works well and safely.
3.   There is a tremendous amount of publicity and marketing heralding the arrival of an immunization for the 5th of the 5 types of meningococcus, the B Type.  And it is sold under two brand names, Bexsero and Trumenba.
4.   We consulted one of the country's top authorities on immunizations, Dr. Walter Orenstein, who reviewed the nation's top agency's (ACIP) thoughts on the pros and cons of use of the meningococcal Type B vaccine.
5.    The ACIP has concluded that concerns about the safety of this vaccine, and of how limited its benefits may be lead them to recommend that it not be used for routine use.
6.    At the same time, the ACIP did recommend that patients and doctors discuss its use.
7.    We at Advanced Pediatrics have concluded that we will keep the meningococcal Type B vaccine in stock, and available.   It is to be given to those with specific defects of their immune system.  But also, for families that have a strong concern about the risk of any meningococcal infections, the vaccine can be given with the understanding that its safety and ability to protect are not yet fully established.  Finally, families should know that it is not yet known if insurers will pay for it.

To your health,
Dr. Arthur Lavin



*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.

2015-09-01

Tetanus- A distant but not eliminated danger

Tetanus- A distant but not eliminated danger

Tetanus is most likely the most widely accepted of the immunizations, and so more people are immunized against the disease tetanus than any other, and so we are likely to never see someone with it.

And yet a recent report on tetanus in India is a reminder that this illness is not yet gone, and that the only reason we do not see many cases is that so many of us are immunized against it.

http://www.nytimes.com/2015/09/01/health/india-virtually-eliminates-tetanus-as-a-killer.html?_r=0

Tetanus comes from a Greek word meaning stretch because the hallmark of the infection are extreme muscle spasms that literally stretch the body.  The muscles remain in intense spasm for 3-4 weeks, and full recovery can take months.  The toxin the tetanus bacteria makes is considered one of the most poisonous substances known in nature.  

Tetanus is a very unusual infection for several reasons:
  • The germ is a bacteria that does not really invade or attack the body like nearly all other bacterial infections.
  • The germ simply grows a bit in a cut and then produces a toxin.
  • The toxin forces the body's muscles into extremely painful and constant spasm, to such an extreme extent that the jaw, along with all other muscles, is locked into a tensed position, hence the nickname lockjaw.
  • Unlike nearly any other infection, the germ goes dormant outside of living bodies, and turns into a spore that can rest out in the world for many, many years.   Much of the earth has tetanus spores on the surface of land.  Tetanus spores are found in every country, and even in the air of clean spaces.
The report from India dramatically demonstrates that tetanus only becomes rare when nations immunize most of their children against it.   

Before worldwide immunization work succeeded, there were about 800,000 newborns died every year from neonatal tetanus.  Newborns are especially susceptible if their mothers are not immune and if their cords are not clean.

The advent of higher immunization rates has dropped the number of newborns dying from tetanus to 50,000 per year.  India has achieved a 95% immunization rate and has seen newborn tetanus nearly disappear.

BOTTOM LINES
  • The key message from this story is that tetanus is a terrible and deadly disease that we no longer see only because of tetanus immunizations.
  • The many years of immunization against tetanus in the US has done nothing to clear our land from very widespread tetanus spores.
  • There is nothing to stop tetanus from occurring in unimmunized infants, children, and adults.
  • Finally, the story of India dramatizes how tetanus occurs when immunization rates are low, and disappears when they rise.
  • So, we do urge all infants to get immunized, the risk of developing tetanus begins at birth, and never goes away, unless immunization occurs.
To your health,
Dr. Arthur Lavin






*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.

New Schedules for Immunizations before College

New Schedules for Immunizations before College

An increasing number of American colleges and universities have sharply increased the formality of their requirements for students attending college.

As a result, students are increasingly finding that as they prepare to go to school, these requirements must be met before they can begin attending college.

In response to these more formal requirements, Advanced Pediatrics is making the following recommendations regarding three required, and one recommended vaccine.

The Tetanus Shot (TDaP)
Actually this immunization protects against 3 diseases: tetanus, diphtheria, pertussis (or whooping cough).   In the past, the accepted practice was to give this immunization every ten years starting at 7th grade.  But now colleges are requiring many to have a recent TDaP the year of entry to college.
So our new recommendation is that a TDaP be given to every senior at their senior year health supervision visit (check-up).

The Chickenpox Vaccine (Varicella)
The universal use of varicella immunization across the US has essentially eliminated naturally occurring chickenpox in America.  As a result, it is very unlikely a child will emerge into adulthood protected from getting chickenpox as an adult by having chickenpox as a child.  It turns out that one dose of the varicella vaccine gives very good protection from the serious danger of getting a full case of chickenpox as an adult.   Getting two varicella immunizations goes further and nearly eliminates the 10% chance those with one dose have of getting a very mild bout of chickenpox (a handful of red dots, no serious illness.
With these facts in mind, elementary schools have been requiring everyone who enters kindergarten to have two varicella immunizations, for many years.
In the fall of 2015, colleges began to also require two doses of varicella be received to attend class.
So our new recommendation is that everyone have two doses of the varicella immunization by their senior year health supervision visit (check-up)

The Meningitis Vaccines
Bacterial meningitis is a very serious infection of the brain and spinal cord.  There are a number of bacteria that can cause such an infection, but most of these bacteria cause meningitis in the very young and the elderly.   The Hib and pneumococcal immunizations of infancy protect against these bacteria.  But there is one bacteria that causes bacterial meningitis in young adults, and that is the meningococcus.

Although a devastating disease, meningococcal meningitis is thankfully very, very rare, happening in about 1 in 100,000 young people a year.  There is a slight rise in the risk in crowded living conditions, so the risk goes to 4 in 100,000 for the first year of college dorm living, and much higher in military barracks.

The meningococcal germ comes in at least 5 types, referred to as A, B, C, Y, and W-135.  The currently used meningococcal immunization, Menactra, has been proven to be safe and effective in reducing the risk of meningococcal infections for the 4 types A, C, Y, and W-135.   This immunization only lasts 5 or so years, and since the risk of this infection begins to increase in high school, the standard practice is to give a dose in 7th grade, then again in 12th.
So our new recommendation is that everyone have the Menactra immunization going into 7th and then again going into 12 grade.

A note on the Meningococcal B immunization
You may notice the Menactra immunization does not protect against the B-type of the meningococcal germ.  A new vaccine is now available to protect against Meningococcal B infections.  However, the nation's review board for immunization practice, the ACIP of the CDC, met in the summer of 2015 and concluded that they do not recommend routine use of this immunization at this time.  The experts found that the actual incidence of meningococcal infections from Group B is already decreasing even without immunization, that we do not yet know how long it lasts, and that some people have had serious reactions to this immunization.
Our recommendation is that unless there is reason to take the risk of an immunization not yet approved for universal use, we would not recommend your young adult receive the new Meningococcal B immunization at this time.

HPV Immunization
The human papilloma viruses cause all the warts on all the parts of our bodies.   There are many hundreds of types of these HPV's.  Nearly every human alive has had an HPV infection from at least one of these wart viruses.
But a small subset of these HPV's cause warts only in the genital area of the body.  These genital HPV's are transmitted by sexual contact, but still are very widespread- about 2/3-3/4 of all adults have genital HPV's.
The real danger from these genital HPV's is that they, on rare occassion, can cause cancer- throat cancer in males, cervical cancer in females.
The HPV vaccines available protect against 4-9 of these genital HPV types, and are recommended
for use prior to onset of sexual activity.
Colleges are not requiring HPV immunization, but Advanced Pediatrics recommends that this three shot series be started near the end of middle school or the start of high school.

Summary
We are all familiar with the fact that infants need their baby shots.
Now there are four vaccines that becoming a routine part of the high school aged child's routine.
In summary, here is there timing of recommended immunization:

  • 11-12 years old, going into 7th grade:  TDaP, Menactra
  • 14-15 years old, going into 9th grade:  Begin HPV series (three shot series)
  • 17-18 years old, going into 12th grade:  Menactra, 2nd Varicella if needed


Having these immunizations up to date will protect your adolescent from tetanus, diphtheria, whooping cough, meningococcal meningitis, HPV caused cancers, and chickenpox.  

Having them done in this timely fashion will also prevent rushes to vaccinate before the first day of college, and avoids having to give too many shots at one time.

To your health,
Dr. Arthur Lavin




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.

Flu Immunizations at Advanced Pediatrics 2015-2016

Flu Immunizations 2015-2016- later this fall

Advanced Pediatrics is pleased to announce that this year’s influenza immunizations will be available in our office this fall.

Many of you may already know that the influenza virus changes every year.  That's why it's the only immunization that needs to be done every year.   Just think about the measles vaccine, you get it twice then never again the rest of your life, because the measles virus in 1880, 1995, 2015, and likely 2054 will be exactly the same.

Not so with influenza virus, so every year public health experts monitor the world to see trends that will help them predict which strains will appear this winter.

This year the public health experts recommended that the flu immunizations for this year change their strains, causing those manufacturing influenza immunizations to delay shipment.

We are told we should have influenza immunizations- by nasal spray and shot- available sometime later in October.

The good news is that the influenza virus only begins to arrive in the United States around late November, rising to real epidemic levels only by mid-December.  So if you get your influenza immunizations by mid-November, you will be protected against the flu epidemics of 2015-2016.

Advanced Pediatrics will be announcing the dates of when influenza immunizations will be available soon, and once again we will be offering our FluFest as the easiest and most fun way of getting your child(ren) protected.

Keep in mind that the influenza virus is responsible for a rather astounding amount of winter illness, causing fully 1/3 of all colds, flus, and ear infections.

Influenza immunization is now recommended for everyone, except for those less than 6 months old.

Influenza immunization comes in two formats:  a shot and a nasal spray.  The shot contains dead virus and is fine for anyone over 6 months of age to use.  The nasal spray contains live virus and should not be used by anyone less than 2 years old, older than 50 years old, or anyone with a chronic illness, including asthma.

With regard to how many influenza vaccines is a complete series, the answer is very simple.  Anyone under age 9 who has never had an influenza vaccine, needs two influenza vaccines at least one month apart to be fully protected.
That also means anyone who has had an influenza vaccine in the past only needs one this year.

Overall, the data show that the nasal spray tends to work better- the immunity covers more strains than are in the vaccine and lasts longer.  But, at the same time, the shot works quite well, too.

We at Advanced Pediatrics are very pleased to be able to help make sure this winter is as healthy as possible.

So, stay tuned.   The immunizations for influenza for 2015-2016 will be here later in October.  We will be announcing when they will be available as soon as we are informed.   FluFest 2015 will be announced soon, too, so stay tuned.


*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.