The Zika epidemic- UPDATE February 4, 2016

The Zika pandemic:  
UPDATE FEBRUARY 4, 2016 

The major development since our first posting was the report of a case of Zika virus infecting a person via sexual contact with another person with Zika virus infection.

http://www.nytimes.com/2016/02/03/health/zika-sex-transmission-texas.html?ref=health&_r=0

This event changes the chances of getting the Zika virus infection.  Until yesterday, it was thought it could only happen via a mosquito bite in areas of the world the mosquitoes carrying Zika virus live and are very active, currently tropical Americas.  

Now the possibility of catching the virus from a sexual partner has developed.  We do not know if this is an extremely rare happening, or common, or anywhere in between.  But it has happened so it is very likely to happen again, we just don't know how often.

It still remains the case that by far the gravest danger posed by the Zika virus is to developing babies.

This means only pregnant women are a great risk from the infection, because only if a pregnant woman gets infected can the developing baby be harmed.

Our observations and recommendations remain largely unchanged, but for the consideration of partners traveling to the tropical Americas, Samoa, and the Cape Verde Islands.

For any woman who might even possibly become pregnant, it is important that if their partner travels to the tropical Americas, Samoa, and the Cape Verde Islands that they be sure their partner did not get a Zika virus infection during the trip.  This turns out to be impossible to know without testing, as 80% of adults infected develop no symptoms.    There are tests, though that can be done.

The incubation period of the infection is 1-7 days, so your partner could get the infection 1-7 days after being bitten by a mosquito in the tropical Americas, Samoa, or the Cape Verde Islands.

The blood banks are accepting blood after 28 days after a person leaves a Zika active area, so the risk of transmitting the virus is likely to have passed after 28 days.

We recommend that if you are a woman who has any chance of becoming pregnant with a partner who has traveled to the tropical Americas, Samoa, or the Cape Verde Islands, that you abstain until your partner has been tested and determined to be free of Zika virus infection.  This should be done under medical guidance.   It is helpful to know that simply waiting 28 days, as far as we know today, should be sufficient to be safe.

BOTTOM LINES

1.  A virus long dormant in Africa spread to French Polynesia in 2007, and now is exploding across the tropical Americas, the Zika virus.

2.  In adults, the vast majority of infected people either don't get sick at all or have mild symptoms.

3.  Less commonly, adults can get significant pain in muscles and joints.

4.  Adults with the infection can have the neurologic complication of Guillan-Barre syndrome which is typically transient.

5.  The most disturbing aspect of the Zika virus is its ability to infect babies of pregnant women and cause damage to brain development.

6.  Adults and children need to weigh the risk of serious infection if they plan to travel to tropical Americas, Samoa, and Cape Verde Islands.  The risk is low.

7.  Pregnant women should know that traveling to tropical Americas, Samoa, and Cape Verde Islands could be catastrophic for their developing baby.
8.  If a woman who even may become pregnant has a partner who has traveled to the  tropical Americas, Samoa, or Cape Verde Islands, she should abstain from sexual contact until her partner is proven to be not infected.

The main point is that no one in Ohio can currently, or is likely ever to, catch Zika virus while in Ohio, except through sexual contact with an infected partner.  Adults traveling to Zika areas are at low risk.  Pregnant women face real danger to their babies if they travel to Zika active areas.  Given that it can be transmitted sexually, women who even may become pregnant must take precautions if their partner travels to Zika active areas.

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.

2016:  

An Exciting Year Ahead- 

Starting with Refridge Art!

Dear Families,

Happy New Year, Welcome to 2016, we hope the year brings much health and happiness to us all.

This year promises to be one of tremendous activity, renewal, and excitement at Advanced Pediatrics.

THE OFFICE

The first change is the office itself.  Those who have been in have noticed a major renovation in the works, and it is almost completed.

Thanks to the generosity and personal attention of our tremendous landlords at ORG Property, a gifted young architect helped us redesign our floor and wall color schemes, and create a new front desk and reception structure.  The new carpeting, the new wood-like flooring, the calm greens create a new, updated look.  Our TV is now flush with the wall eliminating any chance of bumping heads.

We also have a new look to our alcove in our check-in area.  We have elevated the look from the lovely clouds to the inspiring artwork that reminds some people of stars across the universe, and others of neurons connecting across our brains, and still others of atoms blinking their light.

Still to come are re-framed diplomas and art work to fit with the new decor, a really neat set of coat hooks that look like type-set letters.

We have had many, many thank yous from families for taking this step.  We are so, so glad the changes are accomplishing what we hoped, to let everyone enjoy an updated look, one that reflects our way of providing care- calm, effective, uncluttered, and friendly.  We even think of our waiting room as no longer built as a place to wait, but rather a place to check-in.  There will be some waiting, especially of parents waiting for their older child's appointment to be over, but hopefully not many will be sitting there long.

REFRIDGE ART

Our landlord had this wonderful, whimsical idea and our architect made it work.

So now there is a truly very old refrigerator door that has been re-enameled and mounted on our office wall.  No worries, there is no refrigerator to open to, it is just a door to hang your child's art.

The concept is really easy.  Just offer any art your child has made that can be held by a refrigerator magnet, and we'll display it for a time on that door.

Art will be cycled, as new art comes in, already displayed art will go into a box.  Any family member can retrieve the child's art from that box during regular office hours.  Art not collected after some time will end being disposed of.

So bring the art in, it should be a great addition to our office look.  It will be fun to see your child's art on display.  Do know that we will occasionally take photos of that door and post them on public social media, such as Facebook and Instagram, etc.  So the art may be seen by many!

EXCITING INITIATIVES

Reducing Autism

There are few fates as frightening as autism.  Rates are on the rise, and no one has found a way to reduce the chance that the next child will have it.

I am very excited to be one of 10 members of a national Organizing Committee that is doing something that could reduce the chance of a family having a child with autism for the first time in history.

The project is called Project Targeting Environmental NeuroDevelopmental Risks, or Project TENDR.  Our Organizing Committee has assembled 45-50 of the country's leading experts, from Harvard, and the NIH, and across the country, to help identify the top chemicals implicated in causing not just autism, but ADHD and learning disorders.  The Project is soon to release its first statement, identifying these compounds.  The experts anticipate a reduction of exposure to these compounds of even 25% could lead to a 15-40% drop in the risk of a child developing autism!

I am also very honored to represent the Project TENDR in direct conversations with Senator Sherrod Brown and the Surgeon General of the US, Dr. Vivek Murthy.  I am working with them and their staff to ensure Project TENDR has the best approach to changing actual US policy to see real reductions in the exposure of our children to the neuro-toxins.

I hope soon to be distributing this first Project TENDR report, it will state what compounds we should all avoid.  

In early March I will be attending the workshop in California that will devise specific policy approaches to reaching this incredible goal of actually dropping the risk of autism, ADHD, and learning disorders.

ADHD

Although I cannot yet state the outcome of work being done with the American Academy of Pediatrics, I can share that I am on the Committee of the Academy charged with developing policy for matters relating to the psychological well being of children in America.  And, that I am working on what may be an important report on ADHD.  I hope in 2016 I will be able to share more on this very important topic.

NEW BLOGS, NEW PUBLICATIONS, NEW SOCIAL MEDIA

2016 promises to be a very exciting year in the practice, especially in a look on-line.

E-mail Essays

We will continue our many year tradition of writing substantive pieces that are geared to really help families deal with many common, and some uncommon but troubling, issues.   A word of thanks to all the families who have expressed such wonderful enthusiasm for these email essays.  It really encourages us to keep it up.   And many thanks for sharing these emails with friends and family, we have been very touched by the spread of these ideas, and so glad they help.

Edible Cleveland

In 2016, I will continue to serve as the health columnist for a gorgeous and very thoughtful journal, Edible Cleveland.  This publication comes out 4 times a year, one for each season, and so do its sister magazines across the US.  It is a great honor to be part of this publication effort, and I encourage all to get a free copy in our office whenever you like.

Our New On-Line Look and Functionality

The last couple of years have seen Advanced Pediatrics begin to have an online presence.  

2016 promises to be a year of a whole new look to our web page with much greater integration of our web page and our social media presence.  Look for this to be unveiled later this year.  The new look will also feature a far more robust delivery of messages, and will in time include many of the technology innovations listed below.

Exploring New Ways to Connect
We are very excited about exploring new approaches to helping you connect with us to answer questions and concerns.  We have already initiated explorations of on-line services.  The services we are exploring include approaches to online appointment requests, a virtual office visit process, and even some exciting approaches to examination from a distance.  We are definitely in the exploration mode, but are finding very good leads, and hope to have some solid news about these ideas in the coming weeks.  

CONTINUED COMMMUNITY BOARD SERVICE

This year, 2016, will continue to see Drs. Hertzer and Lavin offer their time to two of our community's great non-profit organizations.  Dr. Hertzer serves on the Board of Trustees of Bellefaire, which will be reaching 150 years of extraordinary service to the youth of our region (http://www.bellefairejcb.org/).  And, Dr. Lavin serves on the Board of Trustees of the Saint Luke's Foundation, formed by the sale of St. Luke's Hospital, it is now one of the five largest private foundations in NE Ohio and grants funds for improving life in the old St. Luke's neighborhoods, and Cleveland (http://www.saintlukesfoundation.org/).

BOTTOM LINES

1.  Happy New Year.  We hope 2016 is a very Happy and Healthy Year for us all!

2.  We have a new look to the office, and are so glad so many families have found that its great.

3.   Part of our new look is Refridge Art.  Feel free to post your child's art on our refrigerator door, we would love to see it on display.

4.   Advanced Pediatrics is very much in the center of  big developments in the world of autism- helping to do something never done before- actual reduce the number of families whose children will develop autism.

5.   E-mail essays continue, columns in Edible Cleveland continue.

6.   A whole new look to our webpage, and a much advanced approach to social media is coming in 2016.

So, lots happening for families at Advanced Pediatrics, be sure to let your friends know we are welcoming new families to the new practice this year.

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.

Thermometers are Inherently Inaccurate, and That's OK

Thermometers are Inherently Inaccurate, 

and That's OK

One of the most common questions we get asked is what thermometer do we recommend, and questions related to temperatures taken.  Is an ear thermometer better than an axillary thermometer?  Do you add a degree if you take it axillary (under the arm)?

Some background on fever

These questions all have to do with the question of fever itself.  At the heart of the concern of fever is the very real worry, how will I know if this illness is going to be dangerous or mild?  Fever turns out to be a bad guide.   How is that possible?  Just think, someone can have a very mild illness, a harmless cold, but still have a fever of 105.8, or someone could have a very dangerous infection such as a meningitis, and only have a fever of 101.  The height of the temperature does not indicate the seriousness of the infection.

So when we hear your child has a fever, we think, the fever means an infection is present, now let's determine if it is a mild or serious infection.  Mild by the way means that the infection poses no harm and once gone will leave no trace, not that your child will feel good while they have the mild infection.  In fact, most mild infections, like colds, flus, and stomach flus, cause tremendous discomfort, but they don't cause any lasting harm.   So even though the discomfort is not mild, the danger is very mild, because there is no real danger in such infections, as long as they do not change into more serious conditions, of course.

What is normal temperature inside the body?
So with the fact that the temperature, as long as it remains at 105.8 or below, is not an issue of concern by itself, in mind, let's take a look at how thermometers used in our homes work, or don't.

The real definition of fever by the way, is an elevation in core, not skin temperature.  The core temperature is very close to constant if no fever is present.  Across all humanity, the average core temperature is 98.6 degrees Fahrenheit (or 37 degrees Celsius).  This is an average, normal temperature for an individual ranges from about 97 to about 99 or even 100.  That range is a range across all people measured.  For any one person, their normal temperature is a number in that range, with some, but not much variation from time to time.  Again, these numbers describe the actual temperature of organs inside your body, like your blood, lungs, kidneys, etc.

The temperature of our skin varies quite a bit as part of our body's mechanism to keep our inner core temperature as constant as possible.  If our inner body temperature is dropping, the skin diverts blood flow away from the skin to preserve heat, this causes the skin to get cold.  This is experienced by anyone outdoors for some time in the cold, or if a fever is going up and is experienced as feeling chilled.  If the body's inner temperature is too warm, the skin boosts blood flow causing it to flush and feel warm.

But the temperature that counts is the actual temperature of the inside of the body, the temperature of the organs all of which only function well in a very narrow range of temperatures, really about 96-105.8, and typically around 97-99.

How do the thermometers in use perform?
About 40 or more years ago, the standard thermometer parents used was the rectal thermometer, and it gives a pretty accurate read of the actual temperature of the inside of the body.

But no one uses this technique routinely anymore.  The new thermometers are ear, axillary, and infrared thermometers.  All of these thermometers measure skin temperature, and as we just discussed, the skin and inner temperature often vary.

One recent study found they vary quite a bit:

http://www.ncbi.nlm.nih.gov/pubmed/26571241

This study looked at 75 publications with about 8,600 patients tested.  They found that if a surface thermometer (ear, axillary, or infrared) found an elevated temperature, the child had a 96% percent chance of having a truly elevated inner or core temperature.   So a temperature over 100.4 by any thermometer in common use almost certainly means your child has a fever for real.

The surface thermometers were fairly inaccurate with common levels of error hovering around 1/2 to 3 full degrees Fahrenheit.  So the actual number on your thermometer is not nearly as important as whether it is over 100.4.

BOTTOM LINES
1.  Fever is not as important as how your child is doing to determine if the illness present is mild or serious.  (See post from 2011 below).  Therefore, the number of the thermometer is not that important.
2.  What is important is whether your child with a fever is having trouble breathing, in significant pain, or has a stiff neck.   If none of these symptoms are present and they seem comfortable, a serious infection is much less likely.
3.  Therefore, taking a temperature is not a very helpful indicator of how sick your child is.  A rise in temperature is related, however, to how uncomfortable one is.
4.  The relative unimportance of the temperature is good news given how unreliable the read of the temperature is on the surface in relation to the inner or core temperature.  Whether using ear, axillary, or infrared technology, you are getting mainly surface temperatures which vary from 1/2-3 degrees Fahrenheit off the actual core temperature.
5.  But, if your thermometer registers a temperature of 100.4 or higher, it is almost certain a fever is present.
6.  If you do take a temperature and report it to us, just tell us the number the thermometer gave you and how you took it.  There is no value in adding a degree or subtracting a degree for various techniques.
7.  Put it all together and we have that taking a temperature is not very important, it often bears little relation to the actual inner temperature.  This is fine because of much more value is knowing if your child has symptoms of more severe illness, such as trouble breathing, stiff neck, or significant pain.

To Your Health,
Dr. 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.

 Reminder that Fever is Harmless (Posted March, 2011)

Advanced Pediatrics was very pleased to be contacted by a reporter from Suite 101.com to discuss the recent American Academy of Pediatrics (AAP) campaign to remind families that fever is not a harmful symptom.

Suite 101.com is rated as one of the top 10 blog spots and receives 28 million hits a month, so we were especially pleased that we could get our message out to over 300 million people a year.

Here is our interview, we hope you find it informative and helpful.

http://www.suite101.com/content/american-academy-of-pediatrics-launches-fever-phobia-campaign-a357897

Our key points are:

• Fever remains a fearsome symptom for two key reasons:

1. For most of human history, infections were the number one cause of death in childhood, causing as many as one in four children to pass.
2. Even today, fever makes everyone feel terrible.

• Fever today should no longer create fear for two key reasons:

1. In the US and the rest of the developed world, death from infection is now very, very rare in childhood.  Fever no longer indicates a likely hazard.
2. Fever, although uncomforrable, is not dangerous.  Everyone gets fevers, everyone.  With almost no exceptions, fever itself causes no actual harm.

• More important to be concerned about than fever are signs of serious infection:  Stiff neck, trouble getting air in and out of the chest, severe pain, worrisome rashes.

Dr. Arthur Lavin 

Updates on Three Key Infectious Epidemics This Winter (2015-2016)

Updates on Three Key Infectious Epidemics 

This Winter (2015-2016):

• Influenza
• Stomach Flu
• Hand-Foot-Mouth Like Illness

As we approach February, we thought it would be of interest to hear how the winter flus and illnesses are shaping up for this year.

Every December we brace for the onslaught of influenza virus infections, the germ for which we offer flu vaccine, but this year was a surprise in two big ways.

INFLUENZA VIRUS

The first very big surprise has to do with the 2015-2016 influenza virus epidemic.  Keep in mind that every typical year, the influenza virus suddenly appears across North America sometime in December, peaks around New Years, and fades away in the next 2-3 months.

Not this time.  This year, so far, is officially a big dud.   We are experiencing some of the lowest incidences of illness from the influenza virus.  No one knows why.  It may have to do with more people getting the influenza vaccine, but we await more information before knowing if that is the case.

Take a look at the map and graphs at the CDC influenza tracking site:

http://www.cdc.gov/flu/weekly/index.htm#ILIMap

The US map turns red as the virus becomes epidemic, green means hardly any has appeared.  In January, nearly every year, the US looks very red, I have never seen it this green in this graphic.  Truly a very low influenza year, very nice!

STOMACH FLU

The stomach flu is an illness usually unrelated to influenza, which causes more respiratory troubles.  It's typical season, during the era of rotavirus infections, was in February.  But rotavirus infections have nearly disappeared given mass immunization against it in the US.  But now comes noravirus, the famous virus of the big cruise ships, taking the place fully of rotavirus, and causing the same symptoms:  fever, vomiting for a few days, and diarrhea for a week or two.

We have been impressed at the number of cases of stomach flu starting late in November of 2015 and cooking along at a good clip still in January 2016.

No surprises here.  The good news is that if your child can sip some fluids during the 1-2 days of heavy vomiting, we don't see much dehydration or any other complications from this year's infection in the gut.

THE HAND-FOOT-MOUTH LOOK ALIKE

A few weeks ago, we saw a number of children in the office all with the same unusual rash:  blotchy red bumps on the face around the mouth along with small pimple-like dots on the body, sometimes including the palms and soles.  On the body, the rash appeared in a variety of forms on the same child:  blotchy red bumps that could be 1-2 inches across, red bumps with a tiny white head to them, red bumps that look more like mosquito bites do.  The mouth is often fine, but sometimes large cold-sore like lesions are seen on the back of the throat.  None of these children have tested positive for strep.

The occurrence of rash on the mouth, foot, and hand, is reminiscent of hand-foot- mouth disease (HFMD), but HFMD usually has more uniform rash, and rarely has that blotchy large red bump appearance on the face.  Further, HFMD is caused by a species of virus called enterovirus which typically appears in June and goes away by September.

This infection may be an odd winter appearance of an atypical enterovirus, but is more likely simply a different virus, and not true hand-foot-mouth disease.

The course and care are similar though:  no drugs clear the rash, but comforting helps and should be offered.

BOTTOM LINES:

1.  GOOD NEWS:  Almost no influenza infections this winter, so far.

2.  NO NEWS:  Stomach flu is rampant but that's expected.

3.  BAD NEWS:  An odd hand-foot-mouth like illness is here, completely unexpected.

4.  For all three infections, the approach is the same for all viruses, know that antibiotics do not kill or heal viruses, comfort and care is the best treatment, fever is a normal event, but call if signs of serious illness occur:  severe pain, trouble breathing, not urinating or looking limp or weak, stiff neck.

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.

2016: An Exciting Year Ahead- Starting with Refridge Art!

2016:  

An Exciting Year Ahead- 

Starting with Refridge Art!

Dear Families,

Happy New Year, Welcome to 2016, we hope the year brings much health and happiness to us all.

This year promises to be one of tremendous activity, renewal, and excitement at Advanced Pediatrics.

THE OFFICE

The first change is the office itself.  Those who have been in have noticed a major renovation in the works, and it is almost completed.

Thanks to the generosity and personal attention of our tremendous landlords at ORG Property, a gifted young architect helped us redesign our floor and wall color schemes, and create a new front desk and reception structure.  The new carpeting, the new wood-like flooring, the calm greens create a new, updated look.  Our TV is now flush with the wall eliminating any chance of bumping heads.

We also have a new look to our alcove in our check-in area.  We have elevated the look from the lovely clouds to the inspiring artwork that reminds some people of stars across the universe, and others of neurons connecting across our brains, and still others of atoms blinking their light.

Still to come are re-framed diplomas and art work to fit with the new decor, a really neat set of coat hooks that look like type-set letters.

We have had many, many thank yous from families for taking this step.  We are so, so glad the changes are accomplishing what we hoped, to let everyone enjoy an updated look, one that reflects our way of providing care- calm, effective, uncluttered, and friendly.  We even think of our waiting room as no longer built as a place to wait, but rather a place to check-in.  There will be some waiting, especially of parents waiting for their older child's appointment to be over, but hopefully not many will be sitting there long.

REFRIDGE ART

Our landlord had this wonderful, whimsical idea and our architect made it work.

So now there is a truly very old refrigerator door that has been re-enameled and mounted on our office wall.  No worries, there is no refrigerator to open to, it is just a door to hang your child's art.

The concept is really easy.  Just offer any art your child has made that can be held by a refrigerator magnet, and we'll display it for a time on that door.

Art will be cycled, as new art comes in, already displayed art will go into a box.  Any family member can retrieve the child's art from that box during regular office hours.  Art not collected after some time will end being disposed of.

So bring the art in, it should be a great addition to our office look.  It will be fun to see your child's art on display.  Do know that we will occasionally take photos of that door and post them on public social media, such as Facebook and Instagram, etc.  So the art may be seen by many!

EXCITING INITIATIVES

Reducing Autism

There are few fates as frightening as autism.  Rates are on the rise, and no one has found a way to reduce the chance that the next child will have it.

I am very excited to be one of 10 members of a national Organizing Committee that is doing something that could reduce the chance of a family having a child with autism for the first time in history.

The project is called Project Targeting Environmental NeuroDevelopmental Risks, or Project TENDR.  Our Organizing Committee has assembled 45-50 of the country's leading experts, from Harvard, and the NIH, and across the country, to help identify the top chemicals implicated in causing not just autism, but ADHD and learning disorders.  The Project is soon to release its first statement, identifying these compounds.  The experts anticipate a reduction of exposure to these compounds of even 25% could lead to a 15-40% drop in the risk of a child developing autism!

I am also very honored to represent the Project TENDR in direct conversations with Senator Sherrod Brown and the Surgeon General of the US, Dr. Vivek Murthy.  I am working with them and their staff to ensure Project TENDR has the best approach to changing actual US policy to see real reductions in the exposure of our children to the neuro-toxins.

I hope soon to be distributing this first Project TENDR report, it will state what compounds we should all avoid.  

In early March I will be attending the workshop in California that will devise specific policy approaches to reaching this incredible goal of actually dropping the risk of autism, ADHD, and learning disorders.

ADHD

Although I cannot yet state the outcome of work being done with the American Academy of Pediatrics, I can share that I am on the Committee of the Academy charged with developing policy for matters relating to the psychological well being of children in America.  And, that I am working on what may be an important report on ADHD.  I hope in 2016 I will be able to share more on this very important topic.

NEW BLOGS, NEW PUBLICATIONS, NEW SOCIAL MEDIA

2016 promises to be a very exciting year in the practice, especially in a look on-line.

E-mail Essays

We will continue our many year tradition of writing substantive pieces that are geared to really help families deal with many common, and some uncommon but troubling, issues.   A word of thanks to all the families who have expressed such wonderful enthusiasm for these email essays.  It really encourages us to keep it up.   And many thanks for sharing these emails with friends and family, we have been very touched by the spread of these ideas, and so glad they help.

Edible Cleveland

In 2016, I will continue to serve as the health columnist for a gorgeous and very thoughtful journal, Edible Cleveland.  This publication comes out 4 times a year, one for each season, and so do its sister magazines across the US.  It is a great honor to be part of this publication effort, and I encourage all to get a free copy in our office whenever you like.

Our New On-Line Look and Functionality

The last couple of years have seen Advanced Pediatrics begin to have an online presence.  

2016 promises to be a year of a whole new look to our web page with much greater integration of our web page and our social media presence.  Look for this to be unveiled later this year.  The new look will also feature a far more robust delivery of messages, and will in time include many of the technology innovations listed below.

CONTINUED COMMMUNITY BOARD SERVICE

This year, 2016, will continue to see Drs. Hertzer and Lavin offer their time to two of our community's great non-profit organizations.  Dr. Hertzer serves on the Board of Trustees of Bellefaire, which will be reaching 150 years of extraordinary service to the youth of our region (http://www.bellefairejcb.org/).  And, Dr. Lavin serves on the Board of Trustees of the Saint Luke's Foundation, formed by the sale of St. Luke's Hospital, it is now one of the five largest private foundations in NE Ohio and grants funds for improving life in the old St. Luke's neighborhoods, and Cleveland (http://www.saintlukesfoundation.org/).

BOTTOM LINES

1.  Happy New Year.  We hope 2016 is a very Happy and Healthy Year for us all!

2.  We have a new look to the office, and are so glad so many families have found that its great.

3.   Part of our new look is Refridge Art.  Feel free to post your child's art on our refrigerator door, we would love to see it on display.

4.   Advanced Pediatrics is very much in the center of  big developments in the world of autism- helping to do something never done before- actual reduce the number of families whose children will develop autism.

5.   E-mail essays continue, columns in Edible Cleveland continue.

6.   A whole new look to our webpage, and a much advanced approach to social media is coming in 2016.

So, lots happening for families at Advanced Pediatrics, be sure to let your friends know we are welcoming new families to the new practice this year.

To your health,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic sour- ce 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.

Those Odd Bumps in our Neck- What is a Lymph Node?

Those Odd Bumps in our Neck- 

What is a Lymph Node? When to Worry about Them

One of the most common questions we are asked in our practice is what is that lump in your child's neck, or behind the ear, or on the back of the head, or even in the crease where the leg meets the body?

Usually the question comes with some sense of worry, could that lump turn out to be something serious.

The most common answer to these questions, by far, is that the lump is a normal part of everyone's body- the lymph node.  So we thought it would be of interest to know what a lymph node is, and how to know if a lump is a normal lymph node, or something else.

What is Lymph?

To understand what a lymph node is, we should mention something about the lymph system that these nodes are part of.

Most everyone is familiar with one vascular system, the one where the heart pumps blood out into arteries that then deliver the blood back to the heart via the veins.  As most people know, the arteries branch into smaller and smaller blood vessels, eventually thinning out into the filigree nets of capillaries.  Blood flowing in the capillaries leads to fluid seeping into the tissues these nets feed, and then the fluid is absorbed back into the tiny veins in all tissues, leading to it going back to the heart for another round.

But a small bit of fluid that seeps out of the capillaries remains out of the circuit, it gets absorbed by another network of tiny vessels that deliver this extra fluid into ever larger vessels, eventually delivering it all back to a very large vein near the heart.  This network of collected fluid is called the lymphatic system, and lymph is the name of the fluid collected and returned to the heart.  Lymph is not blood, it is all fluid.   

What is a Lymph Node?

Along the way as the lymph fluid travels into ever-larger lymphatic vessels before ending up in the heart, the fluid flows through a small lump of tissue.  That small lump is a lymph node.  There are about 500 or more lymph nodes in every human body.  Each of these little lumps serve two main functions:

1.  They read the lymph fluid to see if the part of the body the lymph is from contains any germs or other cells of concern.

2.   If the node finds germs or other cells to destroy, the node enlarges to manufacture enough antibodies and white blood cells to destroy the unwanted intruders.

The node itself contains a complex labyrinth of tissues which contain a huge number of immune system cells that can do both these functions:  monitoring and defending.

In fact, if you put all the hundreds of lymph nodes together, that is the main material of what we call the immune system.

This makes sense.  After all, what does our immune system do?  It looks for cells that can cause trouble and destroys them.

Why do Lymph Nodes Get Big and then Small?

The best way to think about lymph nodes is that they are factories.  What to do they make?  Antibodies and white blood cells.  Why do they make these materials- to fight off infections and other threats.

So, if there are no infections to require lots of antibodies or white blood cells, the factory lies dormant, and can remain small.

But if a germ invades, the factory comes to life and starts making a huge amount of material to fight it off.  The node can only do that by getting bigger.  It stays big after the effort succeeds, to continue making material to keep the body immune to the last threat.

After many months of no threat, the node can once again go dormant, which makes it slowly get smaller.

Where do we See Nodes Appear?

Most of the 500 or more lymph nodes in the body are deep inside the main body, but there are two areas they can be seen or felt very easily:  the head/neck area, and in the crease where the leg meets the body.

By far the most common area we can see our lymph nodes get bigger and smaller is around the head.

There is a chain of them along the front of either side of the neck, along the lower edge of the jaw line, along the back of either side of the neck, behind the ears, and on the back of the head.

Inside the mouth are 2 pair of very famous lymph nodes, the tonsils and adenoids.  If you can think of the roof of the mouth meeting the back of the throat, the lymph nodes on top of the roof of the mouth near the back of the throat are called adenoids. And, the lymph nodes on the back of the throat are called tonsils.

All these lymph nodes do the same thing, the tonsils have their own name because they are visible with the unaided eye..

Now, every person born gets colds and these infections turn the lymph nodes of the head and neck on, making them grow to make their protective goods.  When they enlarge enough to feel or see, they are often called swollen glands.  Essentially every child will have their head/neck lymph nodes become enlarged to fight off such infections.  The "swollen glands" typically remain enlarged for quite some time, but after many months, slowly shrink, often back to the small size they started from a size so small it cannot be seen or felt.

When to Worry?

If a lymph node enlarges to defend a person from an infection, there is no cause for concern, just the opposite.  It's a wonderful thing to have a working immune system, and for it to work.  And that's all a lymph node enlarging to fight off an infection is about.  It is very normal.

There are two situations when an enlarging lymph node no longer is normal.

One is if the node itself falls prey to a bacterial infection.  The nodes screen for bacteria and so now and then a living bacteria lodges in the node and turns it into an abscess.  This is fairly unusual, the vast majority of children never experience this.  But here is how you would know this is happening:

the node gets incredibly big, and dramatically painful. Often infected nodes feel bouncy like a water balloon, but the key sign of trouble is getting far, far bigger than the usual swollen gland, and amazingly painful.

The other way nodes can go bad is incredibly rare, and yet is the one outcome all fear somewhere in the back of our minds- cancers- particularly leukemias and lymphomas.  The best reassurance that an enlarging lymph node is not a sign of cancer is that this is an incredibly rare event.  Most pediatricians may see this happen less than five times in a 50 year career!  

But a more useful sign that an enlarged node is not cancer is that cancers continue to grow.  So if a node suddenly appears, and gets bigger, and then stops getting bigger, and never gets bigger than 1/2 an inch across, you are safe.  Nodes that are cancers don't stop growing, and almost always get bigger than 1/2 an inch across.

Be sure to know, though, that many simple, healthy, activated nodes, growing to fight off an infection, can get bigger than 1/2 an inch across, but they too stop growing.

BOTTOM LINES

1.  Lymph nodes are perhaps the key component of the immune system.  Not only are they normal to have, they are necessary for our good health and lives.

2.  Everyone has hundreds of lymph nodes as a normal part of our bodies.  Put them all together and they constitute much of what we call the immune system.  
3.  Lymph nodes monitor all body spaces for evidence of infection and other worrisome cells, and if they find them, they destroy them in that space.
4.  Lymph nodes typically lie dormant most of the time, but now and then they activate to make the antibodies and white cells necessary to defend their space.  When they do this they get much bigger and even a bit sore.  Not only is that normal and OK, but it is necessary for life.  If we didn't have lymph nodes, or if our lymph nodes didn't activate and get big when needed, we would have no immune system.
5.  The two main reasons to think your child's lymph nodes are big for a worrisome reason are:
      a.  If they get very, very tender, red, and even feel fluid-filled.
      b.  If they keep growing, rather then enlarge and stay the same size for many months
6.  Both of these worrisome signs are very unusual, by far the vast majority of enlarged lymph nodes, or swollen glands, stay about the same size, do not get very red or very, very tender.
7.  So unless the unusual signs appear, enjoy your lymph nodes, they are what keeps us safe.

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 Sleepy Adolescent: When to Worry

The Sleepy Adolescent: 

When to Worry

Many families notice that when their perky elementary school aged child hits puberty and adolescence, they often get very sleepy.  By the time our children hit high school they often become very hard to wake up in the morning, sleep long hours into the morning if allowed to, and seem to drag themselves through the day.

What's going on?

The first thing to say is that this is exceedingly common.

An interesting article from the University of Michigan documents that in college about 70% of students get less sleep than they should and half go about the day groggy.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075951/

No one who has been adolescent or whose child is an adolescent should be surprised.

There are several theories about why so many adolescents go about the world looking exhausted, dragging their bodies from class to class at school, from room to room at home, staying up late, and able to sleep 'til Noon.

Three Theories on Why Adolescents are Tired
(spoiler: no one really knows why they are)

Puberty
A common theory proposed, but not yet proven, is that adolescents are tired because of the physical drain on the body.  The combination of rapid growth, big swings of new hormones, the impact of stormy emotions all make this a plausible possible cause.

Busy
Another very reasonable theory is that adolescents are tired because they are so busy.  After many hours of intensive high school classroom work, followed by many hours of grueling sports practices and games, plus the extra hours of working on the school paper, in the band, and/or the school play, it would be more shocking if your adolescent can't open their eyes.

Altered Biorhythms
A third, intriguing theory has to do with actual observations that the internal clock changes during puberty in many adolescents.  The clock seems to shift several hours backward, to that the 5th grader who gets tired at 8:30 PM and is ready to get going at 6:30 AM suddenly wants to stay up until 1AM every night, and yearning to stay in bed until Noon.   Not because of wear and tear, or hormones, but because their inherent, structural, circadian clock is reset.  Those holding to this theory have been proposing that high school should start at Noon and end at 7PM.  Perhaps a good plan for the students, but not the staff.

How to Know, What to Do, When to Worry

We are frequently asked when to worry about your tired adolescent?  When to know that the tiredness might indicate a problem like low thyroid levels, anemia, or some hidden illness?

It turns out that many conditions like hypothyroidism and anemia often present with few other symptoms and so there is a lot of overlap between the healthy adolescent who is simply tired and the adolescent with a health problem, but some clues can help.

First, those with a medical problem can have other symptoms- changes in stool patterns, paleness, unsual rashes, unexplained fevers, for example.

Second, those with a medical problem tend to get worse over time, while the healthy tired adolescent tends to be about the same week after week, month after month.

For most adolescents who have no other symptoms, and who drag through the day with no worsening, testing will reveal they have no underlying conditions.

But if the lethargy gets worse over time and if other symptoms appear, it's time to call us.

How Much Sleep is Needed?

Everyone appears to have a number of hours each day we need to sleep.  Ongoing failure to get this sleep has an impact on both mind and body.  The impact on the mind is experienced as slower thinking, deterioration in being able to complete complex tasks, and decreased comprehension.  For the body, the impact worsens the longer the sleep deprivation continues, with some data suggesting that very serious health consequences follow many years of sleep deficits.

The problem is that each person has a different number of hours for optimal sleep.   For some age groups the average is about 8 hours a night, but some may need as few as 3 or 4 hours a day, and others 10 or 12.  There are no tests to measure what your, or any specific person's needed hours are.
We have often seen adolescents who only sleep 6 hours a night, only to find out one of their parents sleeps about 5 a night and all are well rested on waking, a hint that the adolescent does not need 8 hours.

Perhaps an indication about whether one is getting adequate sleep is indeed how they wake up and feel in the morning, and how that compares to mornings over the years.  A person who has tended to wake up ready to go who then, after sleeping less, struggles to wake up, could be someone who has started sleeping few hours than they need.

The main point is that although it is tempting to say the tired adolescent is not getting enough sleep, and that is often the case, we cannot assume that is the case, a careful consideration of trends and current nature and timing of the tiredness can help sort this out.

BOTTOM LINES
1.  Sleep is an essential, getting too little can cause trouble with thinking and with physical health.  Lots of adolescents get too little sleep, but for each individual adolescents, it is not always so easy to find out if they are sleeping enough.

2.  Seeing a bright-eyed grade schooler transform into a sluggish adolescent is a common happening.   This is a common and harmless occurrence for the vast majority of adolescent.  Some think this is due to the impact of the physical changes of puberty, some of the hormonal shifts, and some because of a tremendously demanding work schedule.  It happens a lot, but on one knows why for sure.

3.  There are health problems that can cause adolescents to lose energy.  These conditions typically, but not always, also cause other symptoms, such as weight gain in hypothyroidism, and paleness in anemia, and changes in appetite and mood in depression.   And, untreated, the lethargy caused by medical conditions tends to worsen over time.  Although this is not proof, the tired adolescent who has no other symptoms, and whose tiredness does not worsen, likely is well.

4.  If all seems well, trends are stable, no other symptoms are present, it is reasonable to observe, but if any questions come up, we are happy to have you call to ask.

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.

Troubles with Pre-School Indicate Troubles with School

Troubles with Pre-School Indicate 

Troubles with School

A worrisome trend we have observed over the last several years has been the steady increase of pressure on our children to perform in school.  That pressure has been increasingly unrelated to their own ability or interest in learning.

From Yale comes a very important commentary on the situation our children are facing from Erika Christakis.  Her essay appears in the January 2016 issue of The Atlantic Monthly.  http://www.theatlantic.com/magazine/archive/2016/01/the-new-preschool-is-crushing-kids/419139/

Ms. Christakis documents a grim reality facing American 3 and 4 year olds who are being enrolled in pre-school.  To an alarming degree, the natural approach in which teachers connect to their young charges is being replaced by a rigid set of teaching protocols.  The author cites a study of many hundreds of pre-school classrooms across the country:

"One major study of 700 preschool classrooms in 11 states found that only 15 percent showed evidence of effective interactions between teacher and child. Fifteen percent."

What is driving the abandonment of one of the deep fundamentals of teaching, in particular with these very young, pre-school students?  According to Ms. Christakis, the key driver of these changes is found in the same changes taking place in schools for older children- the increasing dependence on very rigid protocols, with pre-written lesson plans, all designed to meet set criteria, often with an eye towards a higher score on a standardized test.  This is a very familiar trend to all parents of children in schools.

These trends have led to Kindergarten being transformed from what once was a relaxed, open exploration of new ideas and learning how to be in a classroom with other children, to a very regimented set of expectations of academic performance, including that all children become proficient at reading by the end of the year.

The expectation of reading is such an established criteria for completing Kindergarten, that pre-schools now feel pressure across the United States to prepare their 3 and 4 year olds to be able to read well by the time they complete Kindergarten.  The implication is that these very young children should be ready to learn to read in the first weeks of Kindergarten.

It is this set of expectations that is transforming pre-school from what it is meant to be, a place to play, into a place of work where now very young children are exposed to the fear of failure.

The essay also makes clear that the move towards rigid, pre-set curricular goals allows teachers to be trained to simply know the goals, and not to teach or help children learn.  This makes training teachers much simpler, and allows those with little interest or ability in actually connecting to young children able to be hired and maintain positions in pre-schools.   The result is the current situation, described in the study of 700 pre-schools across 11 states:  the vast majority of teachers in American pre-schools today no longer connect to their very young children in their pre-schools.

Perhaps the most upsetting observation, and at the same time the most hopeful, comes from Finland.  Students who graduate from high schools in Finland are considered some of the best educated students across the world.  They know more and are able to solve more problems than students from any other country.  And here is the extraordinary observation:  students in Finland are not exposed to any lessons in reading until they reach the age of 7!

That's right, the best schools in the world do not begin teaching reading until 2nd grade.

This is the most upsetting observation, because over the last 5-15 years, we have observed a crescendo of pressure in our country to push children to learn to read at earlier and earlier ages, not reaching to the age of 3-4.  And the upshot is that teachers and young students are now essentially separated from each other's realities.  About 85% of their interactions involve no actual connection.

It is a hopeful observation, because it reminds us that despite all our anxieties, our worries that our children will not succeed or compete effectively on the world stage, the kids who actually are winning that competition do very well learning at a natural pace, without pressure.  It is not pressure, but the invitation to enhance curiosity to learn to solve problems that advance learning.  Pressure at best simply creates a mechanical mind that can respond to the rigid set of protocols applied.  At worst, pressure creates a sense of distress or failure for the 1 in 6 students who falter under such pressure.

The essay also outlines the evidence that the current high pressure approaches to teaching have yielded pitiful results.  The approach of set protocols monitored by proficiency tests have been found to fail to deliver any improved academic performances.

This essay is an excellent review of our current trends in education, across all ages, but highlighted in today's pre-schools.  It is deeply disturbing, but at the same time points to a better way.

http://www.theatlantic.com/magazine/archive/2016/01/the-new-preschool-is-crushing-kids/419139/

BOTTOM LINES

1.  American schools have moved in the direction of defining education by applying a set of tightly defined expectations tied to a frequent application of standardized tests.

2.  This approach has fundamentally altered what it means to be a teacher and a student, moving both away from a collaborative approach to learning within an exciting relationship, towards a more sterile delivery of uniform demands in which both student and teacher have fewer and fewer opportunities to explore.

3.  These trends are now clearly established across America's preschools.  To a degree that now 85% of teacher-student interactions are now devoid of effective interactions.  This is a stunning development!

4.  We support the central role of play in the life of children, even in school, particularly at the very early and tender ages of the pre-schooler, 3-4 year olds.

Our recommendation is that parents evaluate their choices in pre-school very carefully.  Keep in mind that there is no evidence that pre-school programs are necessary for academic success long-term.  We urge families to make sure if they enroll their children in pre-school, that it be fun.  That's right, fun.

Fun pre-schools offer your children a much higher chance that their teacher will indeed have effective interactions with their teachers, a rather minimal, but highly essential qualification for any educational program, including pre-school.

Here is to a Happy and Healthy New Year to all!

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.