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

-- 
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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*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.