Advanced Pediatrics: 2013

2013-12-15

Pregnancy- the time to start Obesity Prevention for your Child

Pregnancy- the time to start Obesity Prevention for your Child

In December, 2013, the New England Journal of Medicine published an important essay on the timing of preventing obesity in one's life. http://www.nejm.org/doi/full/10.1056/NEJMp1310577

The compelling point of the essay is that the situation during pregnancy and early infancy can, to a large degree, determine if the child will become obese. The article establishes that a critical opportunity to prevent obesity in your child is during your pregnancy and the months after birth.

Of course, eating habits remain central to the effort to prevent obesity, but the actual structure of fat cells in a person can be determined during that person's pre-natal period and during their early infancy.

The article notes three major influences on whether a baby will grow up to be obese:

The weight status of the baby's mother during pregnancy.
Rapid weight gain during 3-6 months of age.
Whether solid foods are introduced before 4 months of age or not.
Exposure to endocrine-active compounds during pregnancy, after birth, in the food.

The weight status of the baby's mother during pregnancy.

The evidence strongly suggests that if the mother is obese during pregnancy, the developing child is more likely to have more and larger fat cells. If those structures move in that direction, that person may be more likely to be obese, even eating the same foods as someone who has fewer and smaller fat cells.

Obesity during pregnancy also greatly increases the chance of the mother developing the diabetes of pregnancy, or gestational diabetes. Gestational diabetes can directly impact the development of fat cells in the baby leading to greater risk for obesity for that baby when an adult.

Rapid weight gain during 3-6 months of age

Surprisingly, if an infant gains weight very rapidly during the period 3-6 months of age, that baby will grow up to have a significantly greater chance of being obese and of having heart problems. This is an issue whether the infant is nursed or formula-fed.

Whether solid foods are introduced before 4 months of age or not.

In formula-fed infants only, starting solid foods before 4 months of age increases the child's risk of being obese by age 3 years old sixfold!

Exposure to endocrine-active compounds during pregnancy, after birth, in the food.

This category of risk was not described in any detail, but there are substances, mainly in plastics, which have estrogen-like impact on people. The include specific substances such as BPA, and categories of substances such as phthalates. Exposure to such substances during pregnancy can increase the risk of obesity later in life for the developing child.

Bottom Line

What happens during pregnancy can have a powerful impact on whether your child will be at risk for developing obesity, no matter how much they eat.

We recommend that:

Women exert any effort possible to keep their BMI in the, or at least towards, the normal range during pregnancy.
We should resist the excitement of explosive weight gain during 3-6 months of age. Steady weight gain is quite fine.
Solid foods should not be started until 4 months of age
Efforts to minimize exposure to phthalate or BPA containing plastics should begin at conception and throughout the pregnancy, infancy, and childhood.

Dr. Arthur Lavin

2013-12-05

Is Soy Safe for Pregnancy, Safe for Baby?

Is Soy Safe for Pregnancy, Safe for Baby?

The soybean is a wonderful food. It is rich in a wide range of nutrients, and an excellent source of protein.

From a food use perspective, the soybean is nearly infinitely adaptable in its ability to take on any taste and texture.

As a result, soy finds its way into a surprising number of foods we eat. Of course these include foods where the soybean is visible in the food or name, such as edamame, soy sauce, tofu, soy-based infant formulas, and soy milk. But if you consider the number of foods that have an ingredient with the word vegetable in it, with phrases such as vegetable flavoring, vegetable emulsifier, vegetable gum, vegetable starch, the exposure to soy in our food is extensive.

If soy is so wonderful, what controversy surrounds it? The controversy is limited to one chemical in soybeans, phytoestrogens. Phytoestrogens are molecules in plants that look like the molecule found in humans called estrogen. As you know, estrogen is the paradigm hormone of being female. It is estrogen that makes breasts develop, that helps control the menstrual cycle, and that helps maintain pregnancy and nursing.

The concern is whether the estrogen-like compounds in soybeans actually have estrogen effects in the human body. It turns out very tiny differences in hormone molecules lead to dramatic differences in function. Estrogen, for example, when altered by a very tiny amount becomes testosterone, the male hormone. So we know tiny differences change function quite a bit!

So the question is, if you eat phytoestrogen from soy, does it do anything? So far, the evidence leans heavily towards this answer: No. If it did act as an estrogen in humans, we should see breast development in children, puberty pushed early in girls, and later in boys. There is no evidence that any of these events occur in people who eat soy products. Some research actually raises the possibility that phytoestrogens may decrease the incidence, in adults, of developing breast and prostate cancer. But again, there are essentially no data on any group of people having a measurable difference in their lives in any way from eating or not eating soy.

Therefore, at this time, pending finding any actual impact on people, we are recommending to people that eating soy is safe for pregnant women, for infants, and all people.

2013-11-13

Breaking News on the Prevention of Autism (Really)

Breaking News on the Prevention of Autism (Really):

Folic Acid in the First Days of Pregnancy

I have been honored to be working with Dr. Irva Hertz-Picciotto of the University of California at Davis, who is widely regarded as the world's leading expert on the epidemiology of autism. She has very recently informed me of some very exciting news, news that for the first time opens the door to possibly preventing autism.

Many of you may recall that I met Dr. Hertz-Picciotto roughly 2 years ago in preparation for leading a roundtable on finding the reversible causes of autism convened and hosted by Senator Sherrod Brown in the US Senate Meeting Rooms.

The exciting news is the result of years of work on the part of Dr. Hertz-Picciotto and her team in the MARBLES study (Markers of Autism Risk in Babies). Her colleague Dr. Rebecca Schmidt has just reported that mothers who take sufficient folic acid in the days prior to and just after conception have sharp reduction in their risk of their babies developing autism. This is how dramatic the news is: if your folic acid levels are high enough, your baby's risk of developing autism drops FIVE-FOLD. This is very dramatic news.

The impact is supported by other studies, so it is a replicated result, making it unlikely to be disproven with further studies.

How much is enough? When do you have to take it to get the protection? These are key questions.

How much is enough?

The actual answer is only determined by testing a blood level of folic acid, but Dr. Schmidt states that for nearly everyone, taking 800 micrograms a day will get you to the levels needed to see a five-fold reduction in the chance your child will develop autism.

When do you have to take it to get the protection?

The protection works best the earlier in pregnancy that it is taken. After one month of pregnancy, the protective effect already weakens. This means for best protection, your folic acid levels should be at the protective level before conception. We recommend that all girls and women take 800 mcg of folic acid a day from their first period to their last. That way, whenever pregnancy occurs, the protective effect of folic acid will be in place for the first days of embryonic development, the key time the protection is necessary. If this routine cannot be sustained, then it is critical that the folic acid be taken the whole period of your life when you think you may be having a baby.

How certain is this finding to work?

At this point it is highly likely to work. The last step in proof is for the population to take 800 mcg before every pregnancy and then see if autism does drop five-fold as anticipated.

Bottom Line:

Good evidence is now in hand to strongly suggest that if you take 800 mcg of folic acid every day the month before and then throughout pregnancy, your child will drop their risk of developing autism quite substantially, perhaps as much as five-fold.

2013-11-08

Beware the Untested Drug

Herbal Supplements may not Have Herbal Supplements in Them

This week, the New York Times reported one of the most interesting health articles:

http://www.nytimes.com/2013/11/05/science/herbal-supplements-are-often-not-what-they-seem.html?src=me&_r=0

Someone took 44 bottles of various herbal supplements and analyzed the DNA in the herbal supplement in each bottle.

In one-third of all the bottles tested, the DNA revealed there was no herb present that the label promised would be in the bottle.

For example, one bottle of echinacea, had no echinacea in it, only rice. Rice was a common substitute, as were various weeds, and even plants that could cause harm. Bottles with no herbal remedy in them included bottles of ginko balboa.

In our view, herbal supplements should be held to the same standard as any drug, namely:
1. Does it work?
2. Is it safe?

For us the answer has to be yes to #1 for sure, and it has to be safe enough to justify use if it works.

Herbal supplements have been given a pass on both questions, very few have been tested to see if they work, and often when they are tested they are found to be powerless.

The price paid for pretending is now upon us. In this study, 1/3 of the herbal supplements were frank frauds, the worse type of scams- the label promises you are buying one thing, but the truth is you are buying powdered rice or lawn weeds that have no relation to the herb you seek.

BOTTOM LINE
Herbal supplements were recently tested using DNA analysis proving that in 1/3 of the samples, there was no trace of the herb promised on the label.

This is yet more reason to value actual proof that something works before believing it works.

It turns out it is very hard to find substances that reliably can end a problem.

Dr. Lavin

2013-10-16

Arsenic: What it Does, Why to Worry, and What to Do

Arsenic: What it Does, Why to Worry, and What to Do

Recent reports have brought to all our minds the concern that arsenic may be causing us harm in our food supply, particularly from rice and apple juice.

This note will take a look at arsenic. What is arsenic? What sort of harm can it cause? Should we be worried, and if so, what exactly is worrisome and what is not? And given any real worry, what can be done?

What is Arsenic?

Most of us know arsenic as a poison, perhaps out of familiarity with the 1939 play by Thomas Kesselring, Arsenic and Old Lace. And, indeed, this grey metal can be made into a powder that is quite poisonous to nearly every form of life, including insects and humans. But what is arsenic? Arsenic is an element that forms metal-like crystals, and is useful in making copper and lead more better in items we use, and is an important element in the materials that make electronic components.

How does Arsenic cause Harm?
Arsenic hurts nearly any living cell by blocking its ability to make energy. Only a handful of unusual bacteria can live in the presence of arsenic, all other life is killed by the ability of arsenic to block the production of ATP, the currency of energy for all life. Another famous poison, cyanide also blocks ATP production, but this poison creates a total and complete cessation of energy production, and hence sudden death. Arsenic leads to varying levels of blocked energy production and so its typical method of harm has more to do with various organs and systems not working well, and eventually failing. Death from arsenic is the result of various organs failing to work.

What is the Sort of Harm Most Often Seen Caused by Arsenic?
More typically, at the lower levels of the more common exposures, arsenic weakens organ functions, leading to a variety of complex problems and scenarios. There is some indication that over time, continued exposure to even low levels of excessive arsenic can shorten life, but the most typical problems are more chronic in nature rather than deadly.

On September 20, 2013, the New York Times published an important article on findings on what arsenic is actually doing to us now. http://well.blogs.nytimes.com/2013/09/20/the-arsenic-in-our-drinking-water/?ref=health

The current evidence suggests that ongoing, low level exposure to excessive arsenic can cause people to increase their chance of having heart disease and strokes, diabetes, and cancers of the skin, bladder, and lung. Curiously, the recent studies have found that arsenic can cause people to experience far more colds, even during infancy!

Some studies found that people exposed to levels of 19 parts per billion (ppb) in their drinking water began to show signs of chronic lung dysfunction, and at 120 ppb, their lung function was as abnormal as a chronic smoker. In one country whose drinking water had levels of arsenic as high as 1,000 ppb, 24% of all deaths from all chronic illnesses could be blamed on the impact of arsenic.

Who Should be Worried?

Drinking Water
In the United States, arsenic is found in varying concentrations in the drinking water, depending on two key items:
1. Does the family use a water system supply, or a private well?
2. If they use a well, do the rocks in their region have a lot of arsenic in them or not?

The areas of the United States that have the highest levels of naturally occurring arsenic in the ground water are:
1. The Southwest. Areas of Nevada have well water with levels as high as 500 ppb.
2. The Upper Midwest.
3. A band of New England- from the coast of Maine to an area midway in Massachusetts.

Water supplied by a municipal water system is mandated by Federal law to keep the level of arsenic below 10 ppb. This means you are very unlikely to be exposed to arsenic in your tap water if the water is from a municipal source. Private well users must measure their arsenic level to be sure it is not over 10 ppb, particularly in the US Southwest, Upper Midwest, and the swath of New England noted above.

Food
Arsenic exposure can cause harm via the ability to concentrate in certain foods. Rice, for example, is a plant that sucks arsenic out of the soil quite well, and so if it is planted in soil with arsenic contamination, that arsenic will end up in the rice grains and potentially cause harm to those eating rice.

Other foods that concentrate arsenic include leafy vegetables, seafood, and apple and grape juice.

Juice
In July, 2013, the FDA set a standard of 10 ppb, the same as drinking water, for apple juice, ensuring that apple juice that meets the FDA standard is as free of arsenic as safe, metropolitan, drinking water.

Rice
The problem with American-grown rice is that much of it is grown in fields that used to grow cotton- for a very long time. Cotton was doused with arsenic very heavily- after all no one ate it. But over the last few hundred years that meant the soil of these fields got good and soaked with arsenic. As noted, rice sucks arsenic out of soil really well, and so rice from the American South can contain too much arsenic.

Bottom Line
Arsenic is a very dangerous and very insidious poison. If you get too much you don't just keel over, you get chronic illnesses. It is worth taking efforts to avoid exposure. Here are the top 3 things to do to avoid eating too much arsenic:

1. Make your water tap water. If you must use a well, find out the arsenic concentration and don't drink it if it is over 10 parts per billion (ppb)
2. Commercial apple juice is now regulated to have arsenic levels below 10 ppb, it should be safe.
3. Rice is a real problem. American rice from California is probably the safest bet. Rice from the American South likely cannot be trusted to have low enough arsenic levels to be safe, and rice from the rest of the world, who knows. So try to stick to California rice.

Our best,
Dr. Arthur Lavin

Much of the powdered arsenic in our food and water supply got there through the extremely widespread use of arsenic as insecticide.

The Back Up Throat Culture Becomes Optional

The Back Up Throat Culture Becomes Optional

Summary
The back up throat culture has been done in our office for many years when the rapid strep is negative. The accuracy of the rapid strep in our office combined with increased regulatory requirements to perform in office throat cultures leads us to a decision to move back up throat cultures to a reference lab and to make the back up throat culture process optional. That lab will be Child Lab (http://www.childlab.com/, 1-800-934-6575).

Nearly every child gets a sore throat at some point in their life that makes us wonder, is the child infected with strep?

There are two ways to tell. Both involve swabbing the back of the throat. With one of those swabs we do a chemistry reaction in our lab that within 5-10 minutes tells us if any proteins found on the strep germ are on your child's throat. This is the rapid strep test.

The other way is to take the second swab and rub it on a culture plate. This is like planting seeds in a garden. We then wait a day and see if any strep grows. This is the back up throat culture.

For many years we have used the two tests as follows:

1. If the rapid strep test is positive, we diagnose your child with strep throat and offer antibiotic therapy. In this situation there is no need for a back up throat culture.

2. If the rapid strep test is negative, we make an initial diagnosis that your child does not have strep and has some other cause of their sore throat- usually, but not always, a viral infection. We have done back up throat cultures in this instance, because the manufacturer of the rapid strep test informs us that a negative test is not 100% reliable.

Over the last 10 years, we have seen the rapid strep perform very, very well, even when negative. Of course, we do occasionally see someone with a rapid strep test negative on one day, only to have the back up throat culture come back positive.

Recently we have conducted three surveys of just how accurate a negative rapid strep test is.

In the first two surveys, we simply looked at 200 negative rapid strep tests and asked, how many of the back up throat cultures came back positive? We did this twice.

In the first run of 200 consecutive negative rapid strep tests, 0 of 200 of were found to have their back up throat culture come back positive.

In the second run of 200 consecutive negative rapid strep tests, we found 1 of 200 back up throat cultures came back positive.

Then, in August of 2013, we chose one person from each month of the last 2 years who had a back up throat culture, and found in 25 cases reviewed, not one had a positive back up throat culture.

So, out of 400 consecutive throat cultures, one back up was positive. And in a 2 year review of fairly randomly selected cases, no back up throat culture was positive in that 2 year review.

Put it all together, and the data are compelling. Yes, some people come back positive after a negative rapid strep test, but it turns out to be a very small number.

The key finding is that if your child is found to have a negative rapid strep test, there is a 99.9975% chance they do not have strep and do not need a back up throat culture.

Because of these findings and increased regulatory requirements to perform throat cultures in a doctor's office setting, we decided to stop doing back throat cultures in our office.

We will still make the back-up throat culture available to your family at the sore throat visit.

But instead of that back up throat culture happening in the office, we will send it out to our reference laboratory, Child Lab.

We have been impressed over the years with Child Lab. Based out of Nationwide Children's Hospital in Columbus with labs in Cleveland, they only do tests for children. As such they are the only such lab in our region with special expertise in pediatric lab services.

So, we will continue to use two swabs when we test your child for strep throat. And we will continue to run the rapid strep test in our office so you can get results in a few minutes. The back up throat culture, however, will only be done at the family's request, or if your child's history suggests a strong chance of a wrong rapid strep test.

Keep in mind, that if we run a back up throat culture, it will be done by Child Lab. So we want you to check with your insurer to be sure that will cover a back up throat culture for strep throat at Child Lab.

Their official name is Child Lab, their web page address is http://www.childlab.com/, and their phone number is 1-800-934-6575.

Bottom Line

The performance of the rapid strep test in our hands is highly reliable. If positive, we are confident your child has a strep throat. And, if negative, we are so confident that your child does not have strep throat, we can say that the chance we are right is 99.9975%. And so we are no longer going to do in office back up throat cultures for negative rapid strep tests.

But, we will continue to offer the back up throat culture to any family that wants that test done, and in those unusual situations where someone has had several positive throat cultures when the rapid strep is positive.

These throat cultures will be sent out to Child Lab, so check with your insurer to make sure that you are covered if we, together, decide your child needs a back up throat culture after a negative strep.

We hope our efforts to improve quality of care continue to advance your child's health, and we continue to appreciate the opportunity to work together to do so.

Dr. Arthur Lavin

2013-08-29

Flu Immunizations at Advanced Pediatrics 2013-2014

Flu Immunizations 2013-2014

Advanced Pediatrics is pleased to announce that this year’s influenza immunizations are now available in our office.

Call now for your appointment on September 21, October 12, or November 9 for our Flu Vaccine
Days (appointments are 8AM-Noon each of the three days).

Influenza is a virus that sweeps across our region every winter, typically appearing in December and leaving our community around April.

This 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.

Getting Your Influenza Vaccine at Advanced Pediatrics

In order to make sure the entire practice gets the chance to be protected from influenza infection in a timely and easy manner, we are going to offer influenza vaccinations in two ways:

Any child in the practice 6 months of age or older can get their influenza vaccine at any visit to office, whether it be for a health supervision visit (check-up), sick visit, or conference.
We will once again offer special Flu Vaccine Clinic days to allow a large number of people the chance to simply come in and get their flu vaccine in a few minutes time.

The Flu Vaccine Clinic days will be held on three Saturdays:

September 21
October 12 and
November 9,
Each starting at 8AM. You can call now to set up your time for these days.

The outlook for our supply looks good, no shortages are expected.

Even so, due to regulations we have to limit our flu vaccine offerings to children in families, we are not able to offer influenza vaccinations to parents anymore.

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

2013-08-19

Dr. Lavin Publishes a Letter in The New York Times

English: Book 1, page 1, of De Rerum Natura by Titus Lucretius Carus, from the 1675 edition by Tanaquil Faber (Photo credit: Wikipedia)

Dr. Lavin Publishes a Letter in

The New York Times

On August 13, 2013, The New York Times published a letter to the Editor by Dr. Arthur Lavin on a topic of science.

Here is the link:

http://www.nytimes.com/2013/08/13/science/space/atoms-everywhere.html?ref=science&_r=0

The letter was in response to an article in the Science Times about the notion that everything in the universe is made out of the same stuff- atoms. That is, the atoms in stars, in trees, in rivers, in Saturn's rings, in birds, and in us, are exactly the same material.

The Times article noted that the first person to make such a claim made it in 1929.

My letter noted that this notion, that we are all made of the same stuff, actually goes back over 2,400 years to the Greek philosopher Epicurus, who developed the original notion of atoms made by Democritus over 2,500 years ago. The notion that stars, tables, and humans are all made of exactly the same material was deeply offensive to many religions early in their history, leading to a vilification of Epicurus.

That is why we tend to think of his thinking as simply promoting a life of pleasure, hence the phrase Epicurean. But Epicurus was not a hedonist, he was a very thoughtful philosopher whose core thought was indeed that we are all made out of atoms, that the atoms themselves are forever. But they tend to aggregate into various forms that are temporary. Some of these forms work well, some do not. Those that work well continue, and so he was the first person to write about natural selection and evolution. He did speak about pleasure, but his thought was that it is so extraordinary that of all ways atoms could combine, some form living beings, and against all odds, some form each of us. The moral of his view of things was that to be alive is so extraordinary, that each of us should be profoundly grateful to be alive and take pleasure in this tremendous gift. This was the pleasure he promoted, not hedonism.

Epicurus' philosophy was expressed in a magnificent poem by the Roman Lucretius about 2100 years ago, in a piece called De Rerum Natura. The reaction to Epicurus philosophy was so extreme that nearly every copy of this masterpiece was destroyed. For over a thousand years it was forgotten, until its rediscovery in a remote German monastery by a great Italian bibliophile in the 1400's. The rediscovery of this poem inspired thinkers across Europe, and revived the notion that we are of the same stuff as all else. Many credit the power of this idea coming back into European minds as a great source of the power of the Renaissance. We know, for example the poem had a great impact on Galileo and helped propel him towards his discoveries, which in turn created the foundation for modern science.

Lately science has gotten a bad rap. Certain products of science pose great risks to us, including military technology, nuclear reactors. Others cause great worry such as genetically altered foods. And science seems behind the relentless creation of products that continue to be hawked such as prescription drugs.

But science is also the entire basis of all the extraordinary benefits of modern life. We now live over twice as long as people did, as recently as 1900. Our children now live to adulthood nearly free of the once nearly universal threat of disease. Food is more abundant than ever in history. We live in clean homes that are adjusted to stay at a comfortable temperature the year round. And the explosion of information and innovation allows me to write this essay and have it available to everyone in the world with the stroke of one button.

So, enjoy the brief letter. It is a reminder that science was not always allowed to flourish in human societies. I do think we live in an era where science is vulnerable. Let the story of Epicurus and Lucretius remind us that we can only count on science continuing to help us live well if we defend the very idea of science.

My best,

Dr. Arthur Lavin

Reference

All the information regarding Epicurus and Lucretius in this essay is credited to Stephen Greenblatt and his book The Swerve. This is perhaps one of the most interesting and powerful books about science and humanity I have read.

2013-07-21

Time to put the Vitamins Away

Time to put the Vitamins Away

Over the years, many of you have heard me talk about how needless it is to give your children "vitamins."

The evidence for their benefit has never been found, and many studies have actually found them to cause some harm.

But a recent essay by Dr. Paul Offit gathers the evidence together better than any piece I have seen, and simply stated, makes it clear that no one should be taking multivitamins, they do no good, and they indeed cause grave harm.

http://www.theatlantic.com/health/archive/2013/07/the-vitamin-myth-why-we-think-we-need-supplements/277947/

Dr. Offit is one of our nation's most thoughtful pediatric infectious disease experts. A true scholar, a professor at the University of Pennsylvania, he has devoted much of his career to sorting out fact from fiction in our wild medical marketplace. Most recently he has published a book reviewing 51,000 claims of cures called Do You Believe in Magic (Harper, June 2013). He finds that only 4 of the 51,000 claims have any proof behind them.

But in this essay he traces the history of how we came to be a nation where about half of the country takes a vitamin pill every day. He then reviews all the published studies on whether taking such pills work. And then he looks at whether they cause any harm.

It turns out that any of us who take a vitamin owe our interest in doing so to one man, Dr. Linus Pauling. Linus Pauling is one of the most brilliant scientists of the 20th century. A towering genius in the field of chemistry, he is responsible for our very understanding of how molecules form. But in the last phase of his career he made a speculation that turned out to be untrue, but still lives on in our imagination- that if you eat a huge amount of vitamins, you will be healthier. His claim was actually that if you eat enough vitamin pills, you will never get a cold, or cancer, or maybe even heart disease.

http://www.theatlantic.com/health/archive/2013/07/the-vitamin-myth-why-we-think-we-need-supplements/277947/

But take a look at the evidence, which is deep, abundant, and rich.

VITAMINS OFFER NO BENEFIT (except folic acid)

Studies have spanned over the decades and enrolled vast numbers of people. In every instance, the evidence points to taking vitamin pills as being no more helpful than a cup of water. Taking vitamins has no impact at all on how many colds you will get, how severe the colds will be, how long they will last.

Taking vitamins will not prevent one case of cancer, or one event of heart disease, or any other illness or condition.

The only exception proven to date is that taking extra folic acid will prevent the development of spina bifida, meaning women should take folic acid (400 mcg a day) from their first to their last period.

VITAMINS DO CAUSE HARM

Those who have followed the vitamin story should not be surprised to find that taking a multivitamin is a waste of time. It offers no benefit. But the evidence for the harm they do is deeply disturbing and perhaps surprising.

In nearly every study, the group that took multivitamins did not live as long as those that did not.

How so? Mainly due to increased chances of getting cancer or having a heart attack. The numbers are not tiny. One study cited looked at 18,000 people from Seattle and found if you took multivitamins your chance of getting cancer went up 28% and your chance of heart disease went up 17%, compared to people who didn't take multivitamins!

Another study found that men who take multivitamins double their risk of developing prostrate cancer.

Linus Pauling himself died of prostrate cancer.

http://www.theatlantic.com/health/archive/2013/07/the-vitamin-myth-why-we-think-we-need-supplements/277947/

BOTTOM LINE:

It is time to stop giving our children multivitamins.

They do no good.

They do cause harm.

Time to stop.

Read the article, and let your friends know about it, too.

To your health,

Dr. Arthur Lavin

2013-06-24

The Current situation with the Rotavirus Vaccine- The Advanced Pediatrics Perspective

The Current situation with the Rotavirus Vaccine:

Not a very dangerous illness

Norovirus is taking the place of Rotavirus

Vaccine carries some risk

Rotavirus was the #1 cause of stomach flu in the United States prior to the introduction of a vaccine to prevent this infection in 2007. Prior to the development of the vaccine for rotavirus, this virus would sweep across our region every year sometime in February and disappear sometime in the summer.

Rotavirus infection is no fun, it causes vomiting, diarrhea, and stomach upset. It is the stomach flu that almost everyone has experienced, unpleasant, uncomfortable. The vomiting and diarrhea can lead to enough loss of fluid to require IV hydration. For most children, the rotavirus stomach flu is unpleasant, but fluids can be given at home and no need for an IV develops. For some, IV fluid is needed, and for a very few, enough IV fluid is needed that a brief stay in the hospital occurs.

More rarely, rotavirus infection can cause the intestine to telescope. Think of the intestine as a long tube and imagine one segment sliding over the next segment, like a telescope can do. When that happens the gut gets very swollen and can even become blocked or act blocked. That situation goes by the difficult to spell and pronounce name of intussusception.

In our own experience with rotavirus, we have been able to monitor the impact of this infection in families who come to Advanced Pediatrics over the last 10 years. During this period the vast majority of children in the practice have experienced rotavirus stomach flu, and many dozen have had to go to the ER for IV fluids to be given over a several hour period. Less than a dozen have needed IV fluid for long enough to require a day or so in the hospital, and even fewer have developed intussusception. During this time period, essentially single child in the practice who has had a stomach flu infection has had a full, complete, and uncomplicated recovery- to the best of our knowledge.

So, given this experience, we have studied whether offering rotavirus vaccination would be, overall, a benefit to the families at Advanced Pediatrics.

There are three reasons why it might not offer much benefit:

1. The actual infection the vaccine is trying to prevent is too minor to detect much benefit.

2. The vaccine may carry side effects that make the situation worse.

3. Eliminating rotavirus may become irrelevant if another stomach flu virus takes its place.

The first rotavirus vaccine came out in the 1990's, and our first response was that the actual experience of stomach flu was to mild that even if the vaccine had very rare but serious side effects, a child was better off not getting it, so we held off recommending its use. Not long after it was found that that first version of the rotavirus vaccine indeed caused a jump in the chance of the child's bowel obstructing via the condition of intussusception, described above. That vaccine was taken off the market.

In 2007, a second version of the rotavirus vaccine was introduced. At Advanced Pediatrics we came to our earlier conclusion. Namely, since no child in the practice with stomach flu had ever suffered a serious consequence, it made sense to be sure that this new version of a vaccine be observed, to make sure it too did not turn out to be harmful enough to be taken off the market.

Fortunately, this time, the vaccine did not cause enough of an increase in the rates of intussusception to be taken off the market, and no other serious side effects have emerged over the last 6 years.

This month, June of 2013, a major paper on the chance of developing intussusception after use of this and a third and newest rotavirus vaccine was published. Together with other studies, we now have a clearer picture of whether getting the rotavirus vaccine raises risk or lowers it, and if the lower risk is sufficient to justify its use.

What the studies have found is that for infant ages 8-11 weeks, which is the age the first dose of rotavirus vaccine is to be given, the chance of intussusception does increase over the chance of getting it if you are not vaccinated. The chances are remote in either case, the rates are per 100,000 infants. But if you are not vaccinated the chance of being admitted to a hospital for intussusception is about 7 per 100,000 infants, and if you are vaccinated the risk goes up to 11.5.

So the risk of intussusception is increased if you get the rotavirus vaccine, not by much, but by some.

A second trend has also emerged, and that is the appearance of the norovirus. Noroviruses are famous as the cause of cruise-ship stomach flu epidemics, but they are also the #1 cause of food related illness with an incubation period of about 12 hours.

About 85% of American infants have become vaccinated for rotavirus, but norovirus has stepped into the gap and now causes more stomach flu than any other virus. In fact, there is so much norovirus around that even if you are vaccinated for rotavirus, you are just about as likely to get stomach flu. The drop in rotavirus stomach flu has been matched by the rise in norovirus stomach flu.

BOTTOM LINE

Putting it all together the case for using the rotavirus vaccine seems quite weak:

Our experience with stomach flu is reassuring

No lasting harm from a case of stomach flu has occurred

Norovirus has replaced rotavirus

Giving the rotavirus vaccine will have little impact on the chance of your child getting stomach flu.

Intussusception risk

A large body of data from the last 6 years establishes that getting the rotavirus vaccine increases the chance that your child will develop intussusception- a process that can cause bowel obstruction.

Not much protection from getting stomach flu and an increased risk of a serious complication combine to lead us to continue recommend against the routine use of rotavirus immunization at Advanced Pediatrics. The American Academy of Pediatrics and Centers for Disease Control both do recommend universal use of rotavirus vaccine in early infancy, and so we do make the vaccine available, and remain happy to discuss the topic.

A Moment to Mark an Important Success;; The HPV Vaccine

A Moment to Mark an Important Success:

The HPV Vaccine

A recent report has proven that the use of the HPV vaccine in the United States has cut the chance of a 14-19 year old young woman being infected with key HPV strains in more than half.

Since 2006, the chance of a 14-19 year old young woman being infected with key HPV straind dropped 56%!

That is a very dramatic success, and occurs even with the rate of immunization for HPV not reaching 100%.

The trend suggests that if everyone got the HPV immunization, the chance of being infected with strains of HPV most likely to cause cervical cancer would dramatically disappear.

Why is this so exciting?

Because the 4 strains in the HPV vaccine account for the vast majority of cases of cervical cancer. We now have facts on the ground establishing that the HPV immunization program could nearly eliminate the chance of a woman experiencing cervical cancer, and sharply reducing the chance she could experience the terrible experience of a questionable Pap smear.

When the HPV vaccine was first introduced we raised questions about how well would it work. How long would it last after the 3 shot series was concluded? Was there enough cervical tissue abnormality in the US to see a benefit from less HPV infections?

Well, now we have some real world answers. The 3 shot series works, and works well, and lasts. It works so well we can now be confident that getting the HPV series will change the lives of a large number of women, nearly eliminating cervical cancer and the risk of such.

Bottom Line

This report moves Advanced Pediatrics towards enthusiastically recommending that all girls and boys receive the 3-shot HPV immunization series in late middle school or early high school.

Dr. Arthur Lavin

2013-05-07

SPRING ALLERGIES!

SPRING ALLERGIES!

Right now our community is experiencing a fierce burst of allergies, so it makes sense to go over what this is, and what can be done.

Why such a rough year? I believe it is because an unusually cold spring kept the grass and trees (see below) from blooming for many weeks, leading to a supercharged, nearly instant, explosive amount of blooming. A very unusual phenomenon that has, locally, created such a pulse of pollen that it is overwhelming therapies.

What are allergies?

The word allergy is derived from the Greek words for other and energy, and so it literally means energy from otherness.

What it really means is that something that is not you, from outside your body, gets your immune system to react in certain particular ways that we call allergies.

At its heart, an allergy occurs when your body develops an antibody to a particular molecule, and everytime your body contacts that molecule, the immune system attacks, causing inflammation.

There are three key differences between the inflammation caused by allergic reaction and other inflammations (like infections, auto-immune disorders), and the are:

1. The inflammation in allergies itches

2. The inflammation in allergies does not tend to cause severe pain.

3. The inflammation in allergies causes very little damage.

On this last point consider the inflammation seen in untreated bacterial pneumonia or arthritis- one actually can destroy the lungs and the other, the joints. Allergic reactions tend not to destroy tissue or organs, once the allergic reaction passes, your body returns to very much how it was before the allergic inflammation.

The inflammation of allergies is so distinctive, in these three ways, because there is a special class of antibodies that cause it, the E-class. Infections are dealt with by M and G type of antibodies, only the E type of antibody, or Immunoglobulin E, or IgE, cause true allergies.

And so, one cannot be allergic to something unless you make IgE to that particular thing.

Spring Allergies

The allergies that are afflicting Ohio now are all due to the E-class of antibody, or IgE, to pollen.

If you are having itchy eyes, sneezy nose, cough, from allergies and it just hit the last week or so, you are allergic to pollen, via having the antibody (E-class) to pollen.

Pollen is the grain that holds the sperm of plants and some plants need to make zillions of such grains to get their seeds fertilized, or pollinated.

All the misery of this time is due to two types of pollen- tree and grass. Not so much flowers. Why? Because garden flowers simply do not pump the volumes of pollen into the air that grass and trees do.

So these spring allergies are due to pollen in the air, and so, the areas of the body that react and get inflamed (and miserable) are the parts the pollen hits- eyes, nose, throat, and lungs.

In each instance, the story of cause and effect is the same, pollen hits the body, the body, if it has the right IgE antibody to that pollen, reacts with itchy inflammation- including swelling, redness, itch, and fluid

Let's see how it shakes out then at each site:

Eyes

The pollen hits the eyes, and if your allergic to it, the eyes get red, intensely itchy, swollen, and fluid (mucus) accumulates. If you lie down overnight, the swelling and mucus can combine to cause the eyes to swell shut and be matted with dried, caked mucus. When all is said and done, though, the eyes return to normal, there is no change in vision, no harm done, only intense suffering during the period of inflammation.

Nose

The pollen hits the nose, and if your allergic to it, the nose get red, intensely itchy, swollen, and fluid (mucus) accumulates. If you lie down overnight, the swelling and mucus can combine to cause the nose to swell and be matted with dried, caked mucus. When all is said and done, though, the nose returns to normal, there is no change in smell, no harm done, only intense suffering during the period of inflammation.

Throat

The pollen hits the throat, and if your allergic to it, the throat gets red, intensely itchy and sore, swollen, and fluid (mucus) accumulates. When all is said and done, though, the throat returns to normal, only intense suffering during the period of inflammation.

LungsThe pollen is breathed in to the lungs, and if your allergic to it, the lungs get red, intensely itchy, swollen, and fluid (mucus) accumulates- causing the main experience of lung allergies: cough and wheezing.

When all is said and done, though, the lungs return to normal, there is no change in breathing, no harm done, only intense suffering during the period of inflammation.

No Anaphylaxis

Although reported, the very dangerous reactions seen to some drugs and foods where breathing actually is compromised and blood pressure drops, known as anaphylaxis, is very, very rare in spring allergies to pollen. Another reason to know the terrible allergies being seen now are miserable, but not dangerous.

What to Do?

There are basically three therapies that help control allergies:

Antihistamines and other blockers- These drugs block key sequences in the chemical pathways that cause the itchy inflammation to occur. Good blocking means no reaction, no suffering, problems controlled.
Steroids- These drugs kill the cells of the immune system that cause all inflammation, including allergic inflammation. When these drugs work allergy symptoms tend to improve since the cells making the reaction happen are wiped out.
Allergy Shots- This technique creates a different class of antibody to the thing you are allergic to, so when that thing comes in contact with you, there will be no reaction.

Antihistamines and other blockers

One of the key tools in finding relief from all the swelling, itch, and fluid of allergies are antihistamines.
There are basically four oral forms and several eye forms available, and they are available to everyone since they are all over-the-counter and so safe even young infants can use them safely.
All four are truly very safe medications, the only significant side effect seen is sleepiness, and three of the four are formulated to make that uncommon.
It turns out everyone is different when it comes to which work. For some, this one works and that one does not, so it is best to try one, if it doesn't help, try the other.
Here are the four:

Loratidine or Claritin- each dose (ranges 5-10 mg) lasts 24 hour, less drowsy
Cetirizine or Zyrtec- each dose (ranges 5-10 mg) lasts 24 hour, less drowsy
Fexofenadine or Allegra- each dose (ranges 60-180 mg) lasts 24 hour, less drowsy
Diphenhydramine or Benadryl- each dose (ranges 6.25-25 mg) lasts 4 hours, more drowsy

People tend to try the three non-drowsy, once a day preparations first, but keep in mind that diphenhydramine is the most powerful of the four, so if the allergies are very irritating, some drowsiness may be worth the relief diphenhydramine can sometimes deliver.

EYE ANTIHISTAMINES are a powerful and wonderful therapy.

They come in over-the-counter brands and prescription brands. Potency in OTC and prescription brands is comparable, but changing the brand when one does not works makes good sense.

One more blocking drug to mention is Singulair, which has very few side effects, does not cause drowsiness, and is taken once a day. It blocks another chemical in the allergy chemistry, and can work very well, too.

Steroids

There are many types of steroids, the ones used for allergies are technically the glucocorticoid steroids, not the ones used in sports. As noted these steroids kill the cells that orchestrate the whole allergy cycle, so they work better than anything.

One problem- steroids have an encyclopedia of very serious side effects.

The solution- use the topically. Essentially all of the hazards of steroid use can be avoided with the topical strategy for two reasons- the amount needed is a small fraction of that needed in oral treatments, and the drug is being applied to the inflamed area directly, allowing for a much smaller dose to still have a big impact.

The most familiar example of topical steroid use is steroid cream for eczema. Rub a little hydrocortisone cream on a patch of eczema and the inflammation clears, with very little hazard.

There are two topical strategies of steroid use in spring allergies: the nose and the lung.

The nasal steroid systems are essentially nose sprays that deposit a small amount of steroid on the lining of the nose. There are many, many brands of these sprays, and they all work about equally well. There is not much point in switching brands except for price.

The lung steroid systems are inhaled steroids and they are delivered by a hand-held inhaler or a mist making machine called a nebulizer. Again, the brands work about equally well, only price should cause a change in brand.

Both the nasal and inhaled steroids work well and are very safe.

There are oral steroids too, Prednisone and Prednisolone, but this strategy requires a much, much larger dose of steroid use and it being delivered to the entire body. This is a far riskier move, and we typically reserve its use for more serious conditions such as life-threatening allergic reactions and severe breathing distress from severe asthma attacks. We do not recommend the use of oral steroids in the routine of treatments for spring allergies.

Allergy Shots

Allergy shots create antibodies to the pollen that block future allergic reactions. When they work, you are left no longer allergic to the pollen your treatment targeted.

The problem with allergy shots is that it requires a weekly injection, sometimes for years. The benefit can take quite a long time to realize.

We recommend trying all the available antihistamines and topical steroid treatments first.

These treatments work well for most people, spring allergies tend to be well-controlled by them, and treatments with them are painless, do not require a doctor's visit every week, and give relief nearly immediately.

BOTTOM LINE

This year we are seeing a true explosion of spring allergies. Here are some key points to remember:

This is an unusually severe year of allergy. Don't make long-term treatment plans based on the severity of this year's reactions.
Spring allergies are the result of an allergy to pollen, mainly the pollen from grass and trees, not flowers. There is no need to go searching for what your child is allergic to if their symptoms are itchy eyes and runny nose without fever in the spring during peak blossom times- the cause is pollen allergy.
Treatments include oral antihistamine for all allergic symptoms, and:

Eye antihistamines for inflamed eyes
Nasal steroids for inflamed nose
Inhaled steroids for inflamed lungs

Spring allergies are harmless- they cause great agonies, but no harm. And they are very temporary, passing as the blooming intervals pass. And they are very treatable.

So no need for panic. The cause is easy to describe, the treatments are readily at hand, and the outcome is outstanding.

Here is to an enjoyable Spring for us all.

Dr. Lavin

2013-04-24

The Prescription Drug Epidemic- Important Points to Teach Your Kids

The Prescription Drug Epidemic-

Important Points to Teach Your Kids

It even sounds strange to say it, "prescription," "drug," and "epidemic" all in one phrase.

But here we are, a study of nearly 4,000 teens just published demonstrates that the abuse of prescription drugs in the US in teens, had popped up 33%.

About 1 in 4 US teens have abused a prescription drug at least once in the last year!

http://www.cbsnews.com/8301-204_162-57580869/prescription-drug-abuse-by-teens-up-sharply-study/

What is prescription drug abuse? It's taking a drug that requires a prescription, without a prescription.

This is actually an extremely dangerous category of drug abuse, since it opens the door to use of drugs that, in the right combination,will kill you.

The reason the abuse of prescription drugs is so deadly is that they are designed to pack a punch, and if the punch is not delivered carefully or mixed with other punches, you can come to grief.

Very recently, we were deeply shocked to find that about 6 kids who had graduated from Orange High School not long ago died of use of prescription drugs. Some died from taking too many, some died from mixing the wrong mix, none intended to die to the best of our knowledge.

When you read findings from the study you will note following key points:

This problem is now officially rampant. When you get to the level of 1 in 4 teens abusing prescription drugs, that means nearly every family with teens has a child with or a friend with this problem.
The #1 category of abused drugs in the US in teens are the stimulant medications such as Ritalin or Adderall. About 1 in 8 teens in the US abuse stimulants. Combining these drugs with others can be quite dangerous.
It's not new, but it's newly big. The rates are up 33% in the last 5 years!
Kids use them to enhance performance, and to experiment. Consider skittle parties- where teens dump all the family's drugs into a bowl and pop away.

It wasn't that long ago that the use of steroids in sports was the great scandal- Barry Bonds may never enter the Baseball Hall of Fame for his alleged use of them. The outrage was that great athletes would risk hurting their bodies to enhance their performance.

Today we see a parallel fad hitting, the phenomenon of performance enhancing in school. The problem is similar to steroids, in both instances the drugs really do work. Steroids boost batting averages, stimulants boost grade point averages.

The major difference is that nearly all prescription drugs also have quite good uses, but they should be limited to use under the direction of a licensed, thoughtful medical professional.

WHAT TO DO:

Know that the abuse of prescription drugs demands the attention of every parent of a child over age 8-10. With the rate hitting 1:4, no one can assume that their child is not at risk.
Know that this is a very dangerous problem. Children and teens really do come to harm from this practice.
So, talk to you children, let them know a prescription drug is a chemical with power. It's build to change the body, for real.
Let your children know that using prescription drugs without a prescription is common, and dangerous. Let them know combining drugs can be deadly.
**Keep every prescription drug in your home under control** That means knowing where every such bottle is, and checking the pill count at regularly timed intervals, to make sure that the number of pills leaving the bottle does not exceed the prescribed amount or rate.

Obviously, the use of prescription drugs as prescribed can be very important.

But, just as clearly, we have reached a point where every parent of an older child or adolescent should be talking to their child(ren) and monitoring every bottle of pills in the home.

Dr. Arthur Lavin

2013-04-01

Stomach Flu- Noro Takes over from Rota

Stomach Flu- Noro Takes over from Rota

This information is already known to most families in our community, but you might find out why it is so interesting.

This winter, even right now, we are experiencing an intense amount of stomach flu- that is, feeling sick, with fever, vomiting, and diarrhea. Not everyone has all these symptoms, but most do. The illness lasts a few days, and the diarrhea can go on for as much as a week or two. You can feel pretty lousy with this illness, and even get too dry.

Not long ago, there were hopes that the stomach flus of December through April would be gone. Those stomach flus were once caused mainly by one virus, the rotavirus, and a vaccine was developed to end its impact. As with other vaccines, the use of Rotavirus vaccine across the United States sharply reduced the incidence of infections of Rotavirus, and if all had gone according to plan, we would be seeing a sharp decrease in the rate of stomach flus this winter and early spring.

But nature has responded, with the rise of the Norovirus group, which includes what once was the cause of most of the non-Rotaviral stomach flu- the Norwalk agent. As one might have guessed, when Rotavirus was knocked out of the running, Noroviruses stepped in.

Just last week, the New England Journal of Medicine reported that the Noroviruses now are causing more stomach flu than Rotavirus, and they causing enough trouble that rates of stomach flu in the United States are about the same as they were before the Rotavirus vaccine was given.

This is unfortunate, but it explains why there is still so much stomach flu around, even as Rotavirus has decreased. It also is an argument against the use of the Rotavirus vaccine- it prevents a normally harmless illness, and over the course of the last few years, the illness it was designed to prevent is becoming more common as the Norovirus emerges and takes its chance to cause stomach flu.

Dr. Lavin

2013-03-18

The Flu, Influenza, Testing, and Treating

The Flu, Influenza, Testing, and Treating

As the 2012-13 influenza epidemic continues its sharp decline, rapidly approaching its disappearance, it seemed timely to review some of the key facts about the influenza germ, about what is flu, the utility of testing for the influenza virus, and the pros and cons of using Tamiflu.

The Influenza Virus v. The Flu

Let's start with some definitions. As we all know, the vast majority of all infections in childhood are caused by a category of germs called viruses. In fact, aside from the example of strep throat, ear infection, and urinary tract infections, nearly all the common infections of childhood are viral.

It turns out there are lots of different types of viruses, and that when it comes to infections of the nose, throat, and lungs, they can all cause the same looking disease: runny nose, sore throat, fever, terrible coughing, achiness, loss of appetite, disrupted sleep, feeling miserable. This illness goes by a few different names, but most typically is called a cold or a flu. Often the illness is called a cold if the family thinks it's not such a bad illness, but if people feel it's causing more than the usual misery, it's called a flu. So the definition of a cold or a flu is not a medical choice, it's really based on the sense the family and child have about how miserable it is making them.

Now, of the many, many types of viruses causing colds and flus, there is one whose name has the word flu in it, and that would be the influenza virus. Not all flus are from the influenza virus and not all infections with the influenza virus are flus. If we look at all the colds and flus (of the respiratory tree, not stomach flus), then the influenza virus is responsible for about 1/3 of them every winter.

So the influenza virus is one species of virus that causes colds and flus, but about 2/3 of colds and flus are caused by other viruses than the influenza virus.

The Seasonal Nature of the Influenza Virus

The influenza virus has a striking quality of showing up every fall, burgeoning into an epidemic, then completely vanishing in the spring and summer. This year the influenza virus had its peak at the end of December and since New Year's Day has been in very rapid and sharp decline. That means today, if your child has a cold or flu, it is becoming very unlikely that it will be caused by the influenza virus.

http://www.cdc.gov/flu/weekly/

Are there antibiotics for viruses? What does Tamiflu do?

As many of you know, most antibiotics only kill bacteria. That's because bacteria are radically different than viruses, and us. Bacteria are little one-celled organisms with their own special chemistry. Drugs like penicillin wreak havoc on their special chemistry, but since viruses and us do not use that chemistry, these antibiotics are harmless to us.

That leaves us fairly powerless to treat nearly all viruses, since we have very few drugs that really interfere with their chemistry.

There are a couple of exceptions, a group of drugs that kill viruses, although when it comes to killing viruses, each drug tends to kill only one type of virus. This is a bit different than antibiotics killing bacteria, where one antibiotic can kill a very wide variety of bacteria of many diverse species. So there are drugs like Acyclovir that kill herpes but not influenza virus. And then there is Tamiflu which can halt the infection process of influenza species viruses, but not herpes or other viruses.

Now Tamiflu, or oseltamivir, actually does not kill the influenza virus, at all. It interferes with one step in its reproduction. Viruses work by invading our cells, commanding them to make copies, and then spewing out the new viruses to repeat the cycle. Tamiflu simply keeps the newly created viruses from separating from our cells, they get stuck, and the infection does not continue.

How well does Tamiflu work?

In thinking about how well Tamiflu works, it is good to keep in mind that it can only control infections with one species of virus, the influenza virus. So if you have a cold from some other virus, Tamiflu will not do anything to help at all. As of mid-March, 2013, the number of colds caused by the influenza virus has dropped to the point that 95% of all colds and flus are not caused by the influenza virus.

But what if you know your virus is the influenza species of virus? Tamiflu turns out to be a very weak drug in actual practice. One of its failings is that if you take after 48 hours of being sick with the influenza virus, you likely will notice no benefit at all. And, if you take it right at the start of symptoms, on the average, your viral infection will last only 36 hours less.

Now why is the help it offers measured in average numbers less of being ill? That's because it's impact is so mild that if you take Tamiflu with an influenza viral infection, you will still be sick, and so it's hard to know if it "worked." To get some measure of if it works, the studies take a bunch of people all infected with influenza virus and give half of them Tamiflu, and half nothing. All of them get well in a week or two, or less. And so the effect of Tamiflu is measured in the difference in the average number of hours the treated group is sick compared to the untreated group. And that difference was 36 hours.

To our minds, that's not a very dramatic impact. If you get an influenza viral illness, you might be sick for 9 1/2 days without Tamiflu and, on average, 8 days with Tamiflu.

But what about everyone's friend who was treated with Tamiflu and was well the next day? That happens, but when it does, it is impossible to know if that person was about to get well without the Tamiflu. That's the value of the studies, we can actually measure how groups fare with and without treatment. No study has ever demonstrated any pattern towards rapid and complete recovery within a day of taking Tamiflu.

So the evidence strongly suggests that if you have had the flu from the influenza virus for a week, get so exasperated about being ill that you go to the doctor, get placed on Tamiflu, and are fine the next day; then, you are far more likely to have been on the last day of your illness and destined to feel well the next day, than for your recovery to be so dramatic from use of Tamiflu.

A review of the impact on the health of those infected with influenza in England concluded that the use of Tamiflu may have reduced symptoms by about a day (in line with the 36 hours quoted above), but had no impact on the risk of anything serious happening- including complications and hospital admissions.

What harm can Tamiflu cause?

It turns out that Tamiflu is not harmless. Lots of people who take it get nausea and even vomit.

More rarely it can damage your liver and cause dangerous heart rhythms.

And, it is becoming clear that taking Tamiflu can have a serious impact on your moods and thinking.

In countries where Tamiflu has become a common drug to use with influenza infections, there has been a rise in dangerous neurological and/or psychiatric reactions.

Should otherwise healthy children who catch a cold or flu, and found to have it by an influenza virus, be treated with Tamiflu?

The answer to this question, as all such questions should be answered, hangs on how well Tamiflu might help and how badly it might hurt.

The consensus across nearly all studies is that Tamiflu doesn't really do much. It clearly fails to stop the illness to any dramatic degree. It is useless after 48 hours of being ill. And even in the best of circumstances, can only be expected to shave a day or so off the illness. It prevents no complications. This is a very weak intervention. So the benefit is quite limited.

On the negative side, there are very serious harms risked in taking it. Harm to the liver is a very dangerous event, as are dangerous heart arrhythmias. The prospect of inducing dangerous psychological events, particularly in children, is deeply disturbing. And for what benefit are these risks being taken- 1 day less of a cold or flu.

In balance, the choice seems clear that a city's children will be better off without using Tamiflu for routine, uncomplicated infections with the influenza virus, and clearly better off in not using it for other viral infections for which it does even less.

One last point, there is no doubt whatsoever that if we begin to use Tamiflu routinely for childhood influenza viral infections, the virus will develop resistance. So this practice, which offers so little benefit and very real risk, will in the space of a few years render the drug completely useless. This is an issue for the rare instance of a very serious infection with an influenza virus where even a very limited bit of help from a drug like Tamiflu could save a life. Using up the potential of this drug saving a life for rare infections with the influenza virus by letting its use go widespread for fairly mild illness seems like a very dangerous plan.

Testing for influenza virus

When someone has a cold or flu of the respiratory system (nose, throat, lungs) it could be caused by a dozen or so various species of virus. When should your child get a test to see if it is influenza? Our recommendation is that such testing is useless in mild, uncomplicated situations. The only reason to find out if a cold or flu in an otherwise healthy child is due to the influenza virus or not would be to see if Tamiflu might help. But if we agree that the use of Tamiflu is more likely to cause harm than help, then even if the test showed the infection was from influenza, the right decision most likely would be not to treat, in which case the test led to no change in plan, and would be unhelpful.

Now, there are situations when testing makes sense. They nearly always involve some degree of complexity-either the child has a serious underlying condition, or the presenting symptoms are dangerously severe. In either case, the very minimal help offered by Tamiflu might make an important difference, so testing to see if the virus is influenza makes sense.

BOTTOM LINES

Most respiratory colds and flus are not caused by the influenza virus
The influenza virus is here usually from November to April. It is right now vanishing from the US, until its return at the end of this year.
Tamiflu only has an impact on viral infections caused by the species influenza (not on all colds and flus).
Tamiflu has no or very little impact on your colds or flus if you have been sick for 48 hours or more.
If you take Tamiflu before you have been ill for 48 hours, it has very little impact, at best shaving about 36 hours of illness of your course.
Tamiflu is not harmless. It can hurt your liver, cause dangerous heart rhythms to appear, and especially for children it can cause serious psychological problems.
Countries and communities that get excited about using Tamiflu for mild colds and flus risk hurrying the emergence of resistant influenza viruses, eliminating the use of Tamiflu for very serious situations.
Tamiflu has a good role to play, with its very limited impact on an influenza infection, when that infection is very severe or in a very unhealthy child.
Putting it all together, we do not recommend the use of Tamiflu in otherwise healthy children with uncomplicated influenza infection, and therefore do not see a purpose in testing for influenza virus in such situations as well

Colds and flus are a source of great trouble and discomfort. We support the effort to find a cure and to keep them from happening. Tamiflu is neither. We are still waiting for the medicine or immunization that will truly reduce the burden from colds and flus.

Dr. Arthur Lavin

2013-12-15

Pregnancy- the time to start Obesity Prevention for your Child

2013-12-05

Is Soy Safe for Pregnancy, Safe for Baby?

2013-11-13

Breaking News on the Prevention of Autism (Really)

2013-11-08

Beware the Untested Drug

2013-10-16

Arsenic: What it Does, Why to Worry, and What to Do

The Back Up Throat Culture Becomes Optional

2013-08-29

Flu Immunizations at Advanced Pediatrics 2013-2014

2013-08-19

Dr. Lavin Publishes a Letter in The New York Times

2013-07-21

Time to put the Vitamins Away

2013-06-24

The Current situation with the Rotavirus Vaccine- The Advanced Pediatrics Perspective

A Moment to Mark an Important Success;; The HPV Vaccine

2013-05-07

SPRING ALLERGIES!

2013-04-24

The Prescription Drug Epidemic- Important Points to Teach Your Kids

2013-04-01

Stomach Flu- Noro Takes over from Rota

2013-03-18

The Flu, Influenza, Testing, and Treating

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