Mono

Mono:  What is this illness?

Of all the infections that afflict the nose and throat, few cause as much reaction and worry as mono.  Just the word carries a lot more weight than the phrase viral illness, and certainly more than the word cold.

But is mono always a serious illness?  How is it different than other infections of the nose and throat, such as strep and colds?

It turns out that many, many people can have the illness mono and not be very ill at all.  So how do you know when mono is a problem, and what sort of problems can it cause?

The Germ

Mono is shorthand for an infection called infectious mononucleosis.  It turns out that if you look at white cells, some have one nucleus in the center of their cells, and others have many.   The ones with one nucleus can be referred to as monocytes, and in mono, there tend to be lots of them.  Hence the term infectious mononucleosis- or an infection that causes there to be many white cells with one nucleus each circulating.

There are two germs that can cause mono, but the vast majority are caused by one.  The infrequent cause is a virus called CMV which we will not discuss much further.  The main cause of mono is a virus called the Epstein-Barr Virus, or EBV, because Dr. Epstein and Dr. Barr first described it.  The EBV is one of 8 types of herpes viruses, and is also referred to as herpes virus 4.  Other herpes viruses are very well known, including the ones that cause cold sores (herpes virus 1 and 2), chickenpox and shingles (herpes virus 3), the CMV we mentioned above (herpes virus 5), and roseola (herpes virus 6).

Although many familiar illnesses are in the Herpes family, EBV stands out as causing a particular illness, mono.  Like all the illnesses in the herpes family, once you have had the illness, you tend not to be able to catch it again.  There are no recurring features of mono like those seen in some other herpes virus infections.

But, the EBV germ, once it causes mono, hangs around for a very long time.  It can take a year to no longer be contagious!

MONO- THE DISEASE

The EBV germ infects three main parts of the body:

1.  The throat

2.  The white blood cells

3.  Certain parts of many cells called mitochondria
4.  The Spleen

The Throat

For nearly everyone with mono, it is the infection in the throat that is how everyone experiences mono.

For the vast majority of people mono is a very bad sore throat, and swollen glands.

Many people find the sore throat of mono hurts quite intensely, and is more painful than most other viral sore throats, and even strep.

The swollen glands can be tremendously large.  If some of the swollen glands are the tonsils, their enlargement can get in the way of breathing.

The White Blood Cells

The EBV that causes mono attaches itself quite well to a particular type of white blood cell, the cell that makes all the various antibodies, the B-cell.   In infecting the B-cell, EBV provokes the immune system.  This is what leads to such large swollen glands in the neck noted above.   With the B-cells infected, the amount of  various antibodies circulating in the blood goes way up, an event that usually passes without any symptoms.  But one set of antibodies that is produced in mono leaves about 90% of people with it sensitive to amoxicillin during their infection.  The antibodies to amoxicillin do not create an allergy, but if you take amoxicillin while infected with mono, you are likely to get a rash with a lot of small red bumps.

The Mitochondria
Mitochondria are the part of nearly every cell that makes the energy for the cell.  This is where fuel we eat primarily gets burned, releasing its energy, which the mitochondria turn into a storable reservoir of energy.
No mitochondria, no energy, no work done.  It turns out the EBV, and so mono, attacks mitochondria.  This is more likely the older you are when you get mono.  So kids who have not yet entered puberty rarely experience the lethargy mono brings to adolescents.  Sometimes the mono can be so debilitating to the mitochondria that the affected person has little energy to even get out of bed.  In adolescents a profound lethargy can often last 1-2 months.  Rarely, it appears to be able to persist for years and cause chronic fatigue.

The Spleen
The spleen is an important organ of the immune system that lies just under the left lower edge of the ribs.  It filters blood, and is a rich area of white blood cell activity.  In mono, the spleen often is enlarged, usually not too badly.  But sometimes it gets very tight, like a tight water balloon, and very rarely, the enlarged spleen can pop like a balloon.  This is a very rare event, but is the reason people with mono might be told to avoid hitting that area of the body for 6 weeks from the start of the illness.


BOTTOM LINE
1.  When it comes to sore throats, there are basically two types of infections:  viral and strep.  Strep is a bacteria, and the only type of bacteria that causes  sore throats commonly in children.

2.  If you have a sore throat and get tested for strep and find you do not have strep, you almost certainly are infected with a virus

3.  Mono then, is one of a large number of possible viral infections of the throat.

4.  As with all viral infections of the throat, antibiotics do not help at all.  In fact, almost no drugs help beyond the pain relief of ibuprofen.

5.  In one situation, medication might be helpful for mono.  That is when the tonsils get so big, breathing is in danger.  In that setting, a course of steroids can shrink the swelling enough to improve breathing.

6.  Mono is also unique among viral infections for being able to cause the spleen to enlarge and to cause rather pronounced lethargy.

7. Key Point:  If your breathing is fine, your spleen not too big, and your lethargy manageable, mono is like any other cold, and so testing for it will not bring any added benefit.


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.

Mumps Outbreak in Cleveland Explained

Mumps Epidemic in Cleveland Explained

In this week's New England Journal of Medicine, the cause of a very peculiar outbreak of mumps was explained.

http://www.nejm.org/doi/full/10.1056/NEJMoa1202865

In the year June 2009- June 2010, there were significant outbreaks of mumps, mainly in the NYC area, but some cases erupted in Cleveland too.   Two aspects of the mumps outbreak were striking and unusual- most of those who caught the mumps were already well immunized, and most were in the Orthodox Jewish community.   Nothing we knew about mumps could explain either of these observations.  After all, the whole point of being immunized to make sure you cannot catch the disease even if you are exposed.  And, there is no reason a virus like mumps should only infect one group in a society.

After 2 years of painstaking epidemiologic detective work, the CDC scored another triumph of science in finding out how this happened.

The key elements turned out to be European immunization rates, the nature of a virus that spreads in the air, and how people study in class.

First the European immunization rates.  Many countries in Europe do not require parents to immunize their children as a condition of attending school, and thus have much lower immunization rates than in the US.

This leads, of course, to epidemics of illnesses not seen in countries where children are immunized at high rates.

In the spring of 2009, England experienced serious outbreaks of mumps, presumably due to a drop in the number of kids immunized for mumps.  That set the stage for the story that unfolded.  The English mumps epidemic was the hot fire that kindled very wet wood.

The next factor to come into play was the nature of the classroom in a traditional Orthodox Jewish school.  For boys, much of the day can be spent in paired study sessions, where two boys face each other and engage in intense study and verbal discussion of the texts at hand.  A table can often hold several pairs of studying boys.  

And the final factor is that the mumps virus is spread by breath, and it turns out that many respiratory viruses can overwhelm body defenses if enough virus is transmitted.   In this case, being in close proximity to each other's breath for 4-10 hours a day can deliver enough mumps virus to cause an infection, even in someone immunized whose antibody levels to mumps would normally protect them from infection.

So what happened is that an 11 year old, American, Orthodox Jewish boy was studying in England and happened to sit across from an English boy who had caught mumps as part of that country's mumps epidemic.  Although fully immunized, the contact with mumps overwhelmed the 11 year old's defenses and he got mumps.  While contagious, he returned home in June 2009 and went to his traditional school in NYC.

At that school he spread mumps to study partners who also tended to be fully immunized, and then they spread it to their study partners.    By the time a year had passed, about 3,500 children came down with mumps.  Over 95% of them had confirmation of the infection by a lab test.  Over 75% of them were male, and over 95% of them were from the Orthodox Jewish community.  A number of the boys who got mumps lived in Cleveland, and nearly 90% of them had been fully immunized.  Very few were girls, almost none were outside the Orthodox Jewish community.

This story is a dramatic example of a very unusual circumstance opening the door to a very selective pattern of infection.   In the US, so many children are immunized against mumps that we do not see mumps very often if at all.  In 2008, the whole country reported only 400 cases, mainly in unimmunized families.

It turns out that this outbreak could only occur in the special circumstance of a child getting mumps and then sitting in very close contact with one other child for extended hours every day.  This special educational circumstance, limited to boys, and to boys in traditional Orthodox Jewish schools, created the unusual situation of a respiratory virus being able to accumulate enough numbers in someone to overcome good protection from immunization.  The fact the children were immunized made their mumps far more mild, and limited spread mainly to boys in close contact.  The outbreak did not spread very much to girls in these schools, or outside the schools.

The outbreak was mild, no deaths occurred.  But it was an interesting window into the nature of viruses, and how our behaviors can influence our epidemiology.

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.

Advanced Pediatrics Featured at InsideHealth.com

Advanced Pediatrics Featured at 

www.InsideHealth.com 

We were pleased to find Advanced Pediatrics featured on the front page of the important health care

news website, InsideHealth.com on October 18, 2012.

Here is the article:

Pediatric Practice at Cutting-Edge of Technology Use

Oct 18th, 2012 | By admin | Category: 2012 Current Feature

Pediatrician and author Dr. Arthur Lavin, M.D. has been practicing relationship-based pediatrics with the help of technology for more than 20 years.  Based in suburban Cleveland, Ohio, Advanced Pediatrics is a small, independently-owned practice providing a wide range of services to patients and their families. 

From its inception in 2003, Advanced Pediatrics has been an EMR-based practice.  Setting off on his own nine years ago afforded Lavin a unique opportunity to go paperless from the onset.  At its founding, Advanced Pediatrics had its own network, originally a peer to peer (P2P) network and then later an application service provider (ASP) based in Massachusetts.  ASP data met Lavin’s needs and ensured the safety of patient data from physical disasters such as fire.

Using Technology

Lavin and his staff use mobile, wireless tablet PCs to chart patient information, access medical libraries and respond immediately to patient questions during clinical visits.  For example, information on weight control, immunization and allergies is often printed on the spot, or emailed directly to the family for later reference 

Lavin also relies heavily upon the website Epocrates.com, a comprehensive drug database site which features pediatric dosage charts, drug interaction checks and pill identification functions.  Before prescribing any medication, Lavin often uses his wireless tablet to access the site’s drug referencing which allows a physician to plug in the drugs prescribed to a child and then determines any potential hazardous interactions.

In 2010, Advanced Pediatrics updated its EMR system.  “We wanted a platform that we knew would be around in 20 more years,” Dr. Lavin tells Inside Healthcare IT.  “We choose eClinical Works because of how they created, conceived and designed the integration of their disparate applications including a prescription writer, lab order, progress notes and billing program.”

Social Media

Advanced Pediatrics uses several technologies and avenues to push information out into the community.  Dr. Lavin regularly writes informative articles on topical issues – everything from flu vaccinations to the hazards of trampolines to the epidemic use of stimulant drugs.  These articles populate Advanced Pediatrics’ web page (http://www.advancedped.com), blog (http://advancedped.blogspot.com), Facebook site and Twitter feed.  Additionally, an email blast to patient families several times a month provides electronic updates and resources.

“ The benefit of social media marketing is that a lot of people I have no direct contact with are reading my writings,” Lavin remarks.  Social media helps Advanced Pediatrics reach thousands more than are connected via the traditional patient/doctor relationship.

Looking Forward

Despite advancements in technology, Lavin believes the practice of medicine – specifically pediatrics – is very much the same from when he began practicing medicine.  “If someone has a cold, the family and I are still talking about it the same way we did in 1980,” Lavin comments.

Lavin believes the next wave of technology in medicine will be the use of algorithms to replace routine diagnosis.  He cites examples in other fields already embracing algorithms, such as the algorithmic trading involving automated trading frequently used by pension funds, mutual funds and other buy-side, investor driven institutional traders.

“People are applying these technologies to medicine right now,” Lavin says.  “Computer programs now on Skype can figure your pulse based upon the changing colors in your face and imagines of your chest beating.”

Medical tasks including taking your blood pressure and diagnosing an ear infection can already be done remotely with the help of smart-phone assisted applications.

But the real revolution in using technology comes from the enhanced patient care.

“Our access to information is incredible,” Lavin says.  “Advanced Pediatrics uses technology to reduce the hassle of everything that gets in the way of valued medical conversation.  That is technology’s real revolution: more personal connections.”

Lavin is a graduate of Harvard University (BA) and the Ohio State University (MD).  He trained at MIT and is a board certified specialist in newborn medicine.  He has served on a number of national committees of the AAP and as president of the Northern Ohio Pediatrics Society. He is the co-author of two parenting books, “Who’s the Boss? Moving Families from Conflict to Collaboration” (Collaboration Press, 2006) and “Baby & Toddler Sleep Solutions for Dummies” (Wiley, 2007).

–Correspondent Debra Mayers Hollander

Sidebar:

EMR has provided Advanced Pediatrics increased efficiency, 24-hour access to patient records and operational cost savings.  Advanced Pediatrics worked with IT consultant, Frederick Johnson, President and CIO of Ross-Tek, a small business IT solutions company with offices in Cleveland, Chicago and Tampa.  Ross-Tek is a Microsoft Certified Partner enabling its customers – particularly small businesses – to access the latest in network solutions using Microsoft-based applications.

Realizing the innovation and forward-thinking of Advanced Pediatrics’ use of technology in 2003, Johnson recommended Advanced Pediatrics to Microsoft for inclusion in their selective case-study-based-launch of Microsoft Windows Small Business Server 2003 and Microsoft Office Professional Edition 2003. 

Advanced Pediatrics was selected by Microsoft as one of only 15 businesses – and the only medical practice – nationwide to be cast as a model of small business technology solutions.  The ensuing video case study was distributed to 60,000 IT vendors across the world and in 2005 was ranked #5 in global viewing of all Microsoft small business video case studies.

 Copyright 2012 Algonquin Professional Publishing, LLC

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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.

FLU MIST NASAL SPRAY NOW AVAILABLE FOR PARENTS OF ADVANCED PEDIATRICS

FLU MIST NASAL SPRAY NOW AVAILABLE
FOR PARENTS OF ADVANCED PEDIATRICS


Dear Families,


We are pleased to announce that we can offer the Flu-Mist nasal spray form of influenza immunization to parents this year.

We will be making the Flu Mist available to parents in the practice during our Flu Clinics only. These take place from 8AM to 11:30 AM this Saturday, September 29 and the following Saturday, October 6. The Flu Mist immunization will cost $30 per dose, a charge we will collect at the front desk.

In order to be sure we continue to provide the best service possible to your children, we will not be offering the Flu Mist for adults during the week, as it would disrupt our ability to attend to the children.

For whatever reason, it appears that it is difficult for adults to get the Flu Mist, hospitals, employers, and drug stores seem to only stock the shot. So we are very pleased we can help the parents of Advanced Pediatrics find a way to be protected from the flu without a shot.

To secure your Flu Mist immunization, simply call our office and make an appointment for Saturday, either Sept. 29 or Oct. 6. Two restrictions do apply- the Flu Mist format cannot be used if you are over 50 years old or if you have a chronic illness such as diabetes or asthma.

Dr. Lavin
Dr. Hertzer
Ms. Rieger

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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.

Time to Put the Trampoline Away

Time to Put the Trampoline Away

For many years, it has been known that playing on a trampoline can hurt you, badly.  But the use of them has continued.

Today, the world's largest professional organization of pediatricians, the American Academy of Pediatrics, made a very clear recommendation:

Do Not Let Your Children Use a Trampoline- they can hurt, they can kill

http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Advises-Against-Recreational-Trampoline-Use.aspx

The story of how trampolines came to be in our back yards is actually rather chilling.  

The sport of trampoline jumping was until some years ago, an official NCAA sport across American colleges.   But after a series of permanent brain and spinal cord injuries came to light, the NCAA banned trampolines.

When sales to colleges plummeted, the makers of trampolines decided it was time to market them to suburban families with back yards.  And, it worked.

Trampolines now dot the American back yard, and kids love bouncing on them.

The trouble is that a lot of kids ended getting hurt, many very seriously.

And, adding netting and padding has done nothing to reduce the chance of getting hurt.

In 2009, nearly 100,000 (that's right, 100,000) kids got hurt.

Nearly 20% of them hurt their neck, spine, or brain.

I have personally seen children suffer injuries that they never recover from.

Some advisories talk about making sure only one child is on the trampoline at a time or that skilled spotters are present.

The AAP, and Advanced Pediatrics, however, have a much simpler message-

Put the Trampoline Away

Do not allow your children to play on others' trampolines either.

We have known the danger too long, the call to end it is now clear,

The time  has come to put our kids first and put away the trampoline.

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.

Turns out Formula Supplements have No Impact on Intelligence

Turns out Formula Supplements have No Impact on Intelligence

Every so often, something comes along that suggests that if we eat a certain thing, we will get smarter.  Remember fish, the brain food?  

This idea goes way back in our human history.  Ancient cultures prized eating certain animals, or parts of animals, thinking they contained special enhancing powers.  Eat a fierce lion's heart, and you would become braver.  Eat a smart animal's brain, and you would get smarter.

Not that long ago, infant formula manufacturers used our tendency to think this way to market their goods.

All infant formulas are under clinical and legal pressure to be nearly identical, they all aim towards the same goal- to be just like human breast milk.  This is why every infant formula on the market has essentially the same number of calories per ounce, grams of sodium, fat, and carbohydrate per ounce.

So if you make a formula, how do you pitch it as better than your competitor's, how do you imply it's competitive with breast milk.

One strategy was to add DHA and ARA to the formula.  Not much, not enough to change its basic nutritional value.  But enough to say, here is an infant food with extra DHA and ARA.  And the claim?

That if your infant eats extra DHA and ARA they will be smarter.

What is DHA and what is ARA?

DHA and ARA are types of fat called fatty acids.  It turns these fatty acids are important chemicals in the brain.  Much of the brain's material is made up of these compounds.

DHA is docosahexaenoic acid and it makes up 40% of all the polyunsaturated fatty acids of the human brain.

ARA is arachidonic acid which is abundant in the cell membranes of brain tissue.

Does eating more DHA and ARA in infancy make you smarter?

Well, researchers looked at a group of children who did and did not have extra DHA and ARA in infancy.

They found no difference in intelligence or cognitive function between those who ate more and those who ate less DHA or ARA.

Bottom Line

Like getting younger, we seem to all long for something that will make us smarter.

There are no chemicals or compounds that have proven able to make our babies smarter adults.

So beware of claims by infant formula manufacturers when they present small supplements to the formula for special purposes.

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.

Stimulants- The Explosion, The Reasons, The Risk

Ritalin (Photo credit: Wikipedia)

Stimulants- The Explosion, The Reasons, The Risk

Stimulants are a group of drugs whose most famous example is Ritalin.

We are currently living at a time when the use of these drugs is truly epidemic, so it makes sense to take a moment and look at why they are so popular, and whether there is any risk (there is).

The Basics of Stimulant Chemistry 

Let's begin with a few basics about these drugs.   All stimulants can trace their chemistry back to the king of all stimulating chemicals- adrenaline, also known as epinephrine.   Many of us are familiar with what adrenaline can do- it causes excitement.  Adrenaline makes your heart race, your mind clear, your breathing go deeper, your alertness soar, and overall makes you very, very excited.   But if you eat adrenaline, nothing happens, the gut destroys it before it can do anything.

For the last 5,000 years, the herb ma-huang has been used in China to give people the boost of adrenaline in an oral form.  The chemical in the herb is ephedrine, and it was from this chemical that in 1887 a chemist created a new chemical, amphetamine.  Amphetamine was not used in people until 1927, but it really took off.  Various forms of amphetamine were widely used by German, British, and American military during World War II.  Near the end of the war, in 1944, a chemist created a related chemical, methylphenidate, and he gave it to his wife to increase her low blood pressure.  His wife's name was Rita, so he called the new drug Ritalin.

Today, these two drugs, amphetamine and methylphenidate, account for nearly all the stimulant drugs used to treat people who struggle with paying attention.  They both work by stimulating the activity of various networks of nerves in the brain.  Each of these networks help control and manage a wide range of functions in the human mind.  The key network the stimulants stimulate is the dopamine network.   The nerves in the brain that use dopamine to communicate with each other are very much involved in the overall alertness of the brain, as well as a sense of reward and pleasure.   

Like many drugs, the chemicals amphetamine and methylphenidate are sold under many brand names.

Amphetamine is sold under two main brands today:  Adderall and Vyvanse.   Adderall is straight and pure amphetamine.  Vyvanse is amphetamine with an amino acid attached.  As long as the amino acid remains on, this drug will be inactive.  But if you swallow a pill of Vyvanse, your gut will cut off the amino acid leaving you with straight amphetamine, now activated and ready to go.  Therefore, Vyvanse (once digested) really is very much the same drug as Adderall.

In the methylphenidate side of the stimulants, there are a few more brands.  They include:  Ritalin, Concerta, Methylin, Metadate, Daytrana, and Focalin.  Focalin is what's called an isomer of methylphenidate.  It turns out most drugs and many chemicals in the body are like our hands, they come in right and left handed forms.  Both forms are identical in structure in all ways, but physically are mirror images of each other.  Focalin is the right-handed version of methylphenidate.   All the other  methylphenidates have both right and left handed versions of the drug in the pill.  So a 20 mg pill of Ritalin has 10 mg of Focalin in it (the right handed form of  methylphenidate) and 10 mg of the left handed form of  methylphenidate.  So aside from Focalin, all the other brands of  methylphenidate are exactly the same.  So 30 mg of Ritalin has exactly the same drug in it, really is the same thing,  as 30 mg of Concerta, or Methylin, or Metadate, or Daytrana.

Lots of Kids are On These Drugs

Recent surveys reveal that lots of kids are on these drugs.  Some years ago, one survey found that in the United States, 10% of boys age 10 take stimulants to get their homework done and do well in the classroom.

Just recently, an anthropologist conducted a study of undergrads at Case Western Reserve University.  The question was how many college students take the stimulant Adderall during midterm or finals weeks?

The answer reflects a new reality in the lives of our children- 93%.  That's right, nearly every college student at Case feels compelled to take the powerful drug Adderall in order to succeed.

What makes this incredible rate so amazing is that for the vast majority of these students, their use of Adderall is highly illegal.  Use of Adderall without a prescription is no different than scoring speed off the corner.  If the DEA finds out, you can easily spend many years in jail.  And yet, 93% of college undergraduates are using this drug, most without a prescription.

And, just in the last few years, we have seen the number of kids being prescribed stimulants really taking off.  The 10% of all American 10 year old boys is a rate quoted from several years ago, but that number is surely much higher now.  In our office, we are seeing many, many children being referred by their teachers to us, with the express directive to see about starting their child on stimulants to succeed in school.

Why Are Stimulants Being Used So Much Now?

There is no doubt at all, as noted above, that the use of stimulants is galloping ahead.  Why is that happening?

The most important reason is that they work.   There is little mystery about this fact.  It is a fact that if you stimulate or arouse the brain, it simply works better.  This is likely a fact for all animals, but is certainly how we humans are built.

It makes a lot of sense.  If you find yourself in real danger, your mind gets a little bath of adrenaline, and that causes it to get very excited.  Once aroused, the mind has the energy and resource to become amazingly focused, to laser in on the task at hand and put all mental resources on getting the job done, thoughts fly faster and with more purpose.  Think about a tiger suddenly jumping at you, all of a sudden your mind instantly organizes all thoughts and actions towards escape.  The level of focus created by this excitement is intense and extremely effective.  From the point of view of evolution, all humans whose minds do not focus at moments of danger tend to have a lot fewer kids than those whose minds do focus in response to a threat.

One could argue that all of us are descendants from humans whose brains got going and got focused when threatened.  And so our minds have this response to arousal and stimulation.  Of course, too much excitement and we move from focus to agitation, losing ability to get good work done.

We see the same thing happen with coffee.  A cup or two seems to help nearly everyone wake up, be more alert, and be more productive.  But too much coffee and our minds are whizzing into chaos.

So it is with the stimulants.  A bit of Concerta, or Adderall, or Ritalin, will improve the focus and efficacy of 80% of any group of people!  That's right, these drugs help nearly everyone do better work.

This has nothing to do with ADHD.  Yes, about 80% of people with ADHD who take stimulants will produce better work and get better grades.  But the point is that about 80% of all people, will do better work and get better grades when they take stimulants.

So the main reason that the use of stimulants is exploding is that they work.

The other reason is more cultural and complex.  The drugs work, but they have always worked, and known to work since the 1950's.  So why now in the 2010's is use booming so dramatically?   I suggest that one reason is the move towards describing our problems in thinking as medical conditions.  Another is the rise in complexity of thinking required to get good grades or do good work.

Going Medical

Consider a 6th grade boy named John.   He is doing OK in school, but he is not doing as well as he could.  He turns out to be a very, very bright young man, but seems bored in school.  He is often seen not paying attention in class, even looking out the window most days.  Parents find getting him to complete his homework is a great struggle.  Lately his grades have been slipping from mostly B's to more and more C's.

His teacher meets with the parents, and although stating she cannot diagnose medical conditions or advise on medical therapies, she suggests they look at the issue of ADHD and the option of medicating the child.

The parents go to their doctor and let him know the school is worried about his ability to focus and ask if he has ADHD.  A questionnaire is given to the parents and teachers and they confirm that he has many symptoms of ADHD, he is duly diagnosed with this mental health disorder or condition, and started on a stimulant.  He suddenly improves dramatically, now a model student with all straight A's.

This is very, very common story in America today.  But if you look at the story carefully, one could conceivably think of this in a different perspective.  Not that long ago, one could have thought about this as a case of boredom, or mismatched interests.  One could make the case that this 6th grader dislikes the subjects at hand and is defying the authorities in his life who want him to buckle down and do the assignments.  I am not going to say which perspective is right in this case, only that it is conceivable that an explanation other than a medical condition is possible to explain at least some situations where our children underperform.

Are Stimulants Addictive?  Can you stop taking them easily?  Do people tend to use them for a short time or long time?

The stimulants are addictive.  They tend to activate addiction when taken in high doses, high enough to get high, that is.  We do not see addiction develop very often in children taking them to enhance performance in school.  The doses are low enough to avoid causing a high.

If addiction is not activated it is a very simple matter to stop, one simply stops taking the pills.  Normally very little if anything happens when you stop taking stimulants, even after many years.

Yet, curiously, most people who take stimulants for better focus tend to take them for many years, often many decades.  Again, the reason is likely obvious.  If you take a medication and on it you find your grades and work success soar, why would you stop?  Why return to days of failure?  The answer is for most people, not to return to failure, but to keep taking the stimulant.

If Stimulants Work, Doesn't that Prove ADHD is present?

But what about the fact this child's work got so much better on the medication?  Doesn't that prove he has ADHD?  The full answer is, no.

Remember, as noted above, about 80% of all humans will find their brain working better, often dramatically better, on these medications, whether they have ADHD, or not.

If Stimulants Work so Well for So Many, Why not Have Everyone on Them?

This is a very important question.

If these drugs were truly perfectly safe, I would be in favor of their very wide use.  I would actually have no problem with 93% of college students taking them during exam week.  They would turn out to be simply a stronger version of stimulants like coffee, just as safe, and more effective.

Sadly, the stimulants are not free of serious risk.

All stimulants carry a set of minor and major risks.   Minor side effects are only minor because they go away if you stop use of the medication.  Major side effects are major because they tend to be permanent.

The key minor side effects are:  loss of appetite with real weight loss, disrupted sleep, headache, stomach ache, sensation of altered mind.

The three key major side effects are:  Diminished final adult height, tics, and cardiac effects.

• Height  It is estimated that a number of kids (not an issue if you are already fully grown) will lose 1-2 inches of final adult height if they take a stimulant regularly over time.
• Tics  Tics are twitches of one or several sets of muscles.  They can be very small, like a very partial wink of one eyelid every few days, or very severe, involving arms and legs and vocalizations every few seconds.  Although proof is not yet complete, there are indications that use of stimulants can increase the chance of a person developing tics, permanently.  
• Cardiac effects There are two very serious risks here, these are the most dangerous aspects of use of stimulants.  The chair of the Cleveland Clinic Department of Cardiology is Dr. Steven Nissen.  Widely regarded as one of the world's top cardiologists, Dr. Nissen voiced his concerns about the impact use of stimulants would have on a heart as chair of an FDA Panel looking into this concern.  His perspective was published in the world's leading medical journal, the New England Journal of Medicine   http://www.nejm.org/doi/full/10.1056/NEJMp068049
• Sudden Death.  There are a number of children and adults who suddenly died after taking a dose of stimulant medication.  This appears to be an event limited to individuals with rare abnormalities of their heart's electrical conduction system.  The problem is that most people with these rare electrical conduction systems do not know they have them.  A screening EKG prior to use of these medications could help prevent some, but not all of these tragic events.
• Long-term Wear and Tear- the Risk of Congestive Heart Failure later in life  Those who study how congestive heart failure develops use the fact that simply dripping amphetamine on an animal heart long enough will create congestive heart failure.  There are reports in the medical literature of some older adults developing heart failure when used with amphetamine.  Of much greater concern is that we are currently embarked on a rather worrisome experiment.                         As noted above, people who benefit from use of stimulants (about 80% of everyone who might try them), tend to stay on them for many years, even decades.  We now have placed millions and millions of children on stimulants, and they will likely be taking them daily for many, many years.  No one, including myself, who is currently prescribing these medications to children, will likely be in practice or even alive, when these children grow into later middle age.  We simply do not know what the rate of heart failure will be in this group of many millions of children once they turn 40, 50, or 60, or more years old.  But the experience with animal research clearly establishes the possibility that long-term, daily use of stimulants could set up a very real risk of very serious heart disease later in life.

Bottom Line

• The use of stimulants is rising, very rapidly, and across populations that have nothing to do with ADHD
• The notion that children who do not pay attention in school have a medical condition has grown and continues to increase dramatically
• Stimulants come in two major forms- amphetamine and methylphenidate.  They have a known set of side effects
• Stimulants work very well, for everyone.  In any group of people, about 80% will see improvements in their life when they use stimulants.
• The biggest question mark on the risk of using stimulants is their long term impact on the heart.  We do not know what that might be, but the chance that it could be very significant needs to be answered.

Putting all this together, at Advanced Pediatrics we only prescribe stimulants with the greatest of care.  We take the following steps to ensure your children are exposed to the risk of stimulants only when necessary and only with your awareness of the risk:

1. We try to only use stimulant medication for the diagnosis of ADHD.  If a child has trouble in school, we start with finding out why, not with a therapy.  Causes might include other cognitive dysfunctions (e.g., dyslexia), emotional troubles, relationship concerns, or other problems.  So first, see if the problem is really ADHD or some other cause.
2. We try to use interventions free of side effects first.  Options include ADHD coaching, counseling, and cognitive training programs.
3. Use of stimulants should be used only if the impairment is very serious.

We live in an era when 93% of some college's students use Adderall to get a good grade!  But these medications are not entirely free of risk.  Advanced Pediatrics will continue to keep you informed as we learn more about how the brain works and how we can most safely improve how our children's minds work.

Dr. Arthur Lavin

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