Newborn Jaundice

de: Struktur von Bilirubin en: Structure of bilirubin (Photo credit: Wikipedia)

Newborn Jaundice:

Not Really Jaundice

Not Really Harmful

Nearly every newborn develops some sort of yellowish tinge to the whites of their eyes or their skin sometime in the first week of life.  This tinge is commonly referred to as newborn jaundice, a phrase that suggests something is quite wrong.

But the facts are that this yellowish hue reflects normal functioning of healthy bodies.   The chance that the accumulation of the yellow material that causes the color change causing any harm, you will see, is remarkably remote.

The story of the yellow hue in the first week of life revolves around a most interesting pigment, called bilirubin.  Bilirubin turns out to be the waste product after the body is done getting rid of old stores of another brightly colored pigment, the red chemical hemoglobin.  Now, in nearly every animal, hemoglobin is gotten rid of by a conversion to biliverdin.  Biliverdin is a beautiful soft-blue pigment (its the pigment in robin's eggs), and it is cleared from the body simply via urination, it never accumulates.  But in humans and only one other animal, the biliverdin is processed one more step to the yellow pigment bilirubin.

Bilirubin does not dissolve in water, at all, which means it must be further processed to be converted to a form that does, and that step requires your liver to take that action.

During pregnancy, the bilirubin made by the fetus is cleared from both fetus and mother by the mother's liver.

After birth, the newborn's liver takes 1-2 weeks to start clearing the bilirubin.  This is exactly why all babies born see a rise in their bilirubin level.  It's during that 1-2 weeks that they wait for their liver to process their own bilirubin that it rises, often to a point where the whites of the eyes and/or skin takes on the yellow hue of the bilirubin.

Most items written about this yellow glow seem to suggest this is a sign of liver dysfunction, that the 1-2 weeks of waiting for the liver to start clearing the bilirubin is a defect, a lapse.  It is not clear this is the case.

It costs the body a lot to make bilirubin out of biliverdin, remember that not many animals do that.  And once it is made, it costs a lot of energy to clear the bilirubin.  So one could make the case that the body goes to a lot of effort to create bilirubin when it could simply clear old hemoglobin by letting it stay converted to biliverdin.  

Dr. Anthony McDonough of the University of California in San Francisco offers an intriguing insight.  Tony just won an award from the American Academy of Pediatrics as one of our nation's top research scientists.  He has devoted his life to the study of these brightly colored molecules: hemoglobin, biliverdin, bilirubin, chlorophyll, all of which are closely related to each other.   He taught me many years ago, and still teaches, that bilirubin is a very strong anti-oxidant.  Not too long ago, proof of this concept was supported by an article demonstrating that the higher the normal bilirubin levels are, the more protected the group is from events like heart disease and cancer.

The point is that the body might actually be going to great lengths to offer the newborn a boost of bilirubin, the yellow glow may actually reflect something good happening.

Given all this, why is so much fuss made over this nearly universal occurrence?  The reason is that in very special and unfortunate circumstances, bilirubin has been found to be irritating to the brain.  Those circumstances are severe prematurity combined with very severe illness, such as a serious infection.  In settings where the body is under rather extreme distress, bilirubin in the blood is able to enter the tissue of the brain and cause harm.   When a newborn is healthy and full-term, a very sturdy barrier keeps bilirubin out of the brain.

So then why any concern about bilirubin in full-term, healthy newborns?   Not too long ago, some reports documented an instance or so of bilirubin, when in excess levels, getting into the brain of even a healthy, full-term infant.  The chance of that happening is nearly astronomically remote.  About 4 million babies are born in the US every year, and the number of healthy newborns where bilirubin causes harm is less than one every year.   To my mind, when a substance causes harm less than 1 in a million exposures, that says to me its pretty safe.  Consider penicillin which causes serious harm in 10 of every million doses, and we consider that risk of harm so remote it is deemed to be very, very safe.

Another sign that the mild rise seen in nearly every baby in bilirubin after birth is normal and perhaps beneficial is that the rise is higher in babies who are breast-fed than formula-fed.  For many years this was viewed as one of the only disadvantages to nursing, but it may be a further hint that the body is really trying to bump the bilirubin level up a bit for the few weeks after birth.

BOTTOM LINE:

Nearly every baby born experiences a transient, 1-2 week rise in their level of the yellow molecule, bilirubin.

Very many have sufficient increase to look a bit yellow.  In healthy, full-term infants this experience is overwhelmingly harmless, and may even be designed and helpful.

When to worry?  If the yellow glow becomes a deeper, more severe, orange hue.  Bilirubin levels should not rise so high to cause your newborn's color to get too intensely orange.  If that happens let us know.

But the mild yellow hue, the glow seen so often, is not harmful, and may turn out to be just what the baby needs.

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.

A New Edition Defining Mental Illness is Approved

A New Edition Defining Mental Illness is Approved

It was reported today that the DSM-V has officially been approved by the organization responsible for its editing and publication.

http://www.nytimes.com/2012/12/11/health/a-compromise-on-defining-and-diagnosing-mental-disorders.html?hpw

The DSM is the Diagnostic and Statistical Manual, and it plays an enormous role in many American's life.

How so?  Because this book contains all the definitions used in the health care world in the US that define mental health, mental illness, and mental conditions.  

If you turn to a doctor or clinician to determine if you have a mental health issue, it is very, very likely that  the answer will rest on where the line defining normal and abnormal rests in the DSM.

The current edition is the DSM-IV, so the new edition which you will be hearing a lot about, is the DSM-V. These books are created and updated by the American Psychiatry Association (APA).

The most interesting aspect of the article describing the end of a 5 year process of creating the DSM-5 was how little agreement there was across the mental health and medical professions on just what is the definition of a wide range of mental illnesses and conditions.

For example, is someone grieving for the loss of a loved one depressed?

Or, does someone who has excellent language function but is awkward socially have a form of autism?

At what point does someone who eats in binges qualify for being designated as having an eating disorder?

I remember vividly when a top clinician at one of our country's leading mental health facilities once taught at a seminar that every symptom in the DSM is experienced by nearly every healthy person at some point in their life.

So how does one know if their symptoms are severe enough to reasonably be considered a mental illness or condition?

The story of how the DSM-V got approved suggests that this question has no clear answer.  Senior leadership devoted to answering this question quit over the development of this edition.  Patient advocacy groups became quite vocal in opposition or support of various definitions of mental illness.    

The article documents a startling illustration of how tricky the line that defines abnormal thinking and feeling is.  In the 1990's and 2000's there was a big jump in the number of kids told they have bipolar disorder.  The article states that most of these kids, duly diagnosed by physicians with bipolar disorders, did not in fact turn out to have that.

Another very important consequence of this difficulty is that where the line where normal becomes abnormal is drawn automatically dictates how many people will be considered ill.    By adding a new diagnosis, binge-eating disorder, literally millions of Americans will now be considered diagnosed with this condition, once the DSM-V is actually published; but, right now, and for the years prior to its publication, they were not considered mentally unhealthy.  With one book being published, suddenly millions of people went from well to ill.

Of course, this is not to minimize the rather extraordinary reality that our human minds are not a finished product, and contain real instabilities that put us all at risk for serious difficulties.  Just consider that no matter how one defines depression, nearly everyone has either experienced a very serious bout of it or loved someone who has.

So take a look at this article, it is a rare glimpse into the intricacies of defining just who is mentally well and not well.

It emphasizes the reason that we find the focus on functionality so helpful when thinking about how to help respond to issues relating to the mind.   By that we mean, we take our stance as assessing and doing all we can towards helping each person function well- at home, with family, at school, and at work.  This focus seems to be more productive than simply relying on diagnosis.  

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.

Younger members of a class get medicated more often

Younger members of a class 

get medicated more often

The entire population of Iceland born in 1994, 1995, and 1996 was studied to see what impact your relative age in a classroom would have on performance and on your chance of being medicated with stimulants.

(Here's the article's abstract- http://pediatrics.aappublications.org/content/130/6/1012.abstract, it just came out this month)

What they found speaks volumes about how we use stimulants to change the grades of our children in school.

Between the ages of 7 and 14, if your child was someone younger than 2 out of 3 or more of the kids in their class, then he or she was 50% more likely to be placed in stimulant drug therapy than a child older than 2 out of 3 or more of the kids in their class.

The study also found that the younger third struggled more in math and reading than the older kids in the class.

Now, keep in mind that actual capacity of a child's mind to do school work does not change by age.  Yes, skills develop with age, but not capacity.

Most importantly, mental illness and mental health conditions should not be determined by your age,but rather by the properties of your mind.

So imagine, the same child in 6th  grade may have a 50% greater chance of being diagnosed with a mental health condition and placed in medication to succeed in school than if that child was in 5th grade that same year!

This is rather bold evidence that we often diagnose children with mental health conditions and put them on medication more as a result of unfortunate circumstances, rather than because they truly have a disease or condition.

This publication, a very strong study since it looked at every child in an isolated nation over a 3 year period, makes a very powerful point.

That is, before any family accepts the idea that their child truly has an internal abnormality of brain function, we should be very careful to be sure the trouble seen in school does not reflect external circumstances rather than a true medical condition.   This distinction can be made with careful thinking and evaluation, and should be in every instance where a diagnosis of a medical condition is proposed to explain struggling in school.

Dr. Arthur Lavin

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

The Agony of a Cough

The Agony of a Cough

Many troubles appear in their own season.  Allergies plague many of us every spring and fall.  This season, the season of fall and winter, the season of the school year, brings the troubles that come with colds.

And few problems that colds create can compare to the agonies suffered from having a cough.

What is a cough, how does a cold cause it to happen, what other problems besides a cold can cause a cough, when does a cough get worrisome, and what can be done to get rid of this horrible experience?

What is a cough?

A cough is a big spasm of muscles in the chest that happens whenever the lungs and their airways get irritated.

Because it takes so many muscles to create a cough, the muscles get sore, the chest hurts, the throat get sore, in not too many days of a cough people really get upset at the agony it causes, and for good reason, it is a true misery.

How does a cold cause it to happen?
After many years of thinking about just what is a cold, it appears we have an answer- a cold is a burn.

Literally.

A cold is when a virus infects your nose, eyes, throat, and lungs.  When a virus infects, it really kills off the lining of what it infects.  So when you get a cold, the virus literally destroys, or burns off, the lining of your nose, throat, and lungs, and sometimes- eyes.  When the lining of your nose gets burned you get a runny nose, when its the lining of your throat you get a sore throat, but when the lining of your lungs burns off, you get a very awful thing- a cough.

Why?

Well, think about what would happen if you had a burn on your hand and someone rubbed a little sandpaper on it, Ouch!!   That's the situation with a cold in the lungs- the lining of the lung is burned away and so with every breath you are rubbing air on a burn, OUCH!!  When you hurt the lung, you cough.

Not all coughs are due to simple colds, how do you know your child's cough is from a cold?
During cold weather months, the vast majority of coughs are from colds.

But not all.  The main causes of cough all have to do with the lung or throat being bothered, and include:
viral infections (aka, colds and flus), bacterial infections (e.g., pneumonia, bronchitis, and bacterial sinus infections), allergies and asthma, and irritations (e.g., smoke).

So, if you do not have allergies or asthma, if there has been no smoke exposure, and if your illness is less than 14 days old and not getting much worse over time, the odds are overwhelming your cough is from a cold.

When is a cough worrisome?
This is a critically important question.  First of all, let's make sure we know what is meant by worrisome.

It turns out nearly all coughs are dreadful and quite bothersome.  No question there, even if your child is quite safe from the illness causing the cough, he or she can be quite irritated by coughing all the time, in fact, will almost certainly be bothered terribly by it.

But by worrisome we mean that the cough or the illness causing it might cause actual harm.

Coughs caused by simple colds almost never actually cause any harm, meaning that when the cold goes away, the child is very much like they were before the cold came, fine and unchanged.

So, if someone has a cold, how do you know the cough or the illness has changed into something that is actually potentially dangerous or harmful?

The best indicator is to see how hard it is for your child to get air in and out of their chest when they are not coughing.  Don't pay too much attention to how breathing is going in and out their nose, that is very often very difficult.  Instead, look at how much work it takes to breathe air in and out of the chest in between coughing attacks.  If someone is breathing comfortably when not coughing, it is very unlikely the cold has progressed on to something of concern.

Of course, other indicators that your child has left the world of a simple cold toward a more dangerous set of illnesses include a stiff neck, severe pain, difficulty waking up.  Notice that fever is not on that list.  Even the simplest cold causes fevers up to and including 105.8.

How do you stop or reduce coughing?
Even if you know the cough is from a simple cold, you still are faced with watching your child really suffer, a horrible place to be.  The need for a medicine that relieves coughing is real, urgent, and acute.

Only one problem, that drug is yet to be invented.

The need is so strong, so urgent, however, that many companies sell stuff claiming to stop or even reduce a cough a bit.  In March of 2011, the US FDA launched formal investigations of fraud for over 500 cold and cough remedies.   From Robitussin to Mucinex (exactly the same drug!), from Comtrex to Triminic, essentially all the over-the-counter meds in the cough and cold aisle don't really do anything,

Now, keep in mind that the placebo effect is a wonderful and powerful thing.  An astounding 30% of the time, whenever anything is administered as a medication (even salt water), it works.  It really works, pain goes away, sugar levels in diabetes go to normal, walking improves, just about any symptom will get better about 30% of the time.  And in essentially every study done on cough and cold remedies, they perform no better than salt water or other placebos.

And, that makes some sense.  If you think back to how a cold is a burn, imagine again having a burn on your hand.  What medication exists that you could take that could make that burn go away in a few minutes, or keep it from being uncomfortable if rubbed?

So, what to do?  Well, it turns out the whole breathing apparatus shuts down whenever you swallow anything.  If water or food is rolling down your throat, the lungs are closed.  During a swallow there are no breaths, and therefore, no coughs.

The more seconds per minute you swallow, the less you will cough.  That's how cough drops work, and you can offer your child the same relief by having them sip on a favorite drink, or if old enough, suck on their favorite treats.

How long is normal for a cold to cause a cough?
Colds last a lot longer than people can possibly imagine.  We would like to think our colds will be 24 hour bugs, but the average length of a cold is 8 days.

That means half of all of our colds will last longer than a week, many go on for 2-3 weeks.

And, cough is almost always the last part of a cold, and gets worse every day until the cold finally heals and ends.  That goes back to the cold being a burn.  The virus typically lands in the nose or mouth, and begins the burning there.  Like any good fire, the burn slowly progresses and eventually hits the lungs. The more lung burned, the worse the cough.

And, so, coughs often come at the end of a cold and worsen as the cold burns its way out.  Another reason they cause such agony, after being sick for a week, who can stand a cough getting worse every day for another week?  Who can resist being discouraged in that sort of setting?

But, keep in mind, the cough appearing and getting worse almost always means the end of the cough and the cold is getting closer.

BOTTOM LINE
In fall and winter, colds are by far the top reason for cough.  Cough is the result of irritation to the lining of the lung and/or throat, and gets worse as the cold burns its way across the throat and lungs.  No medicine has yet been invented that could make a cough better, but swallowing can interrupt coughing and that can help.  Be on the lookout for trouble breathing when not coughing as the key sign that your child has something more serious than a cold, as well as other indicators of dangerous illness like stiff neck, severe pain, and/or trouble waking up.

Our hearts go out to all of us who suffer a cold, it is truly a miserable experience.  Keep your child comfy, and know that the cold will pass.

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.

Report from Dr. Lavin's Meeting with the American Academy of Pediatrics national Committee on Psychosocial Aspects of Child and Family Health

Report from Dr. Lavin's Meeting with the 

American Academy of Pediatrics national 

Committee on Psychosocial Aspects of Child and Family Health

This weekend, I was honored to attend my first meeting of the American Academy of Pediatric’s national committee charged with developing policy for the Academy in psychological and social issues confronting children and their families.

The American Academy of Pediatrics (AAP) is the world’s largest organization of pediatricians, founded in the 1920’s to promote the provision of free milk to children in need.  As such, it is one of the only professional societies formed to help the client, not the professional, and the AAP continues to operate in that spirit, with a fierce devotion to the well-being of children.  The Committee that I was recently appointed to is formally designated as the Committee on Psychosocial Aspects of Child and Family Health (the Committee).  The AAP is the voice of America’s pediatricians, and as such has a widely respected voice here in America and around the world.  It gathers leaders and experts in various fields to form its Committees that in turn, develop expert approaches to policies devised to respond to the most pressing challenges to children.

The Committee meets at AAP headquarters in Chicago (see photo), and included pediatricians, child psychiatrists, pediatric nurse practitioners, and child psychologists from around the country.  I represented pediatricians from the Midwest region around Ohio.  Our agenda presented us with the opportunity to develop policy responses to a very wide range of issues.

These included:

• Helping children respond to the stresses of having parents in the military
• Approaches to helping pediatricians determine the best approach to educational psychological evaluations
• Thinking about how best to screen children in a pediatric practice for mental health problems
• Preparing the child who may have to testify in court
• Supporting the family in the event of the death of a child
• An analysis of the roots and responses to poverty in the US
• Presenting insights from emerging neuroscience on how best to parent children
• Developing guidance on discipline
• Enhancing the role of fathers in the raising of children

Over time, Committee deliberations lead to policy reports that are published in the leading medical journal of our specialty, Pediatrics.

The Committee also had the opportunity to review a wide range of emerging trends in policies relevant to families and children at the Federal level and across many states.

Finally, the Committee heard from their liaisons from a wide range of the nation’s leading professional societies devoted to helping children, such as American Academy of Child and Adolescent Psychiatry.

It was indeed an honor and privilege to participate in these deliberations and to add my voice to the development of important policy positions of the American Academy of Pediatrics.  An added benefit to this work will be the opportunity for me to hear your voice on these issues.  So, if you take a look at the list of issues that the Committee is addressing, as I report it to you from time to time, please let me know if you have thoughts on these important issues.

Finally, many thanks to the families of Advanced Pediatrics.  It is truly the case that only by your trust in our care that we have had the opportunity to learn together and be in a position to even consider participating in this important work.

Thank you,

Dr. Arthur Lavin

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Arthur Lavin, MD FAAP
Associate Clinical Professor of PediatricsAdvanced Pediatrics

A small, attentive, independent practice focused on the well-being and success of each child 

3733 Park East Drive- Suite 102
Beachwood, OH  44122

216-591-1515 (Office)
216-591-1544 (Fax)

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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.

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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