At Four Seasons Pediatrics, we want you to know that we want the greatest health and safety for the children we care for in our practice.  In the past year, there has been a steady increase in the number of parents choosing to not vaccinate, to follow their own schedule and or delay vaccination.  There have been pockets of increased vaccine preventable diseases in the United States.  Many of these pockets have involved un-vaccinated children as a strong component of these surges in disease.  Well funded, well polished Anti-Vaccine Groups have continued to re-cycle non evidence based hype regarding vaccines lending confusion to this issue.  This emotional appeal to parents leads to confusion and is a disservice to well intentioned parents who want to do what is best for their children.

We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.  We firmly believe in the safety of our vaccines, though we understand that they are a drug.  We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.  We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.

We also believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health care providers, and that you can perform as parents/caregivers. The schedule of the recommended vaccines are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.

We firmly believe that much of the protection of vaccines comes from herd immunity.  Most vaccines produce immunity in 90-95% of children.  The remaining 5-10% who do not produce immunity are protected from herd immunity, meaning that a highly vaccinated population limits the spread of most infections.  As more people choose not to vaccinate, herd immunity is eroded.  Now more than ever, it is important to protect children by vaccinating them.

These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccination.  Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky, who contracted smallpox and died at the age of 4, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:

“In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox…I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we have the luxury of considering whether or not they should be given. Because of vaccines, many have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR vaccine after publication of an unfounded suspicion that the vaccine caused autism.  In an un-precedented move, the journal which published this study (Lancet) redacted its article on February 2^nd, 2010 due to evidence that its lead author, Dr. Andrew Wakefield did not conduct a proper study regarding MMR.  Despite the scientific lack of evidence and the conflicts of interest that Dr. Wakefield has had, anti-vaccine groups have continued to defend his study.  As a result of this study leading to under-immunization, there have been outbreaks of measles and several deaths from complications of measles in Europe over the past several years.  These outbreaks are now becoming more common here in the United States with more frequency and involving more diseases.  In a study based on nationwide surveillance data from 1985 through 1992, children with non religious exemptions were 35 times as likely to contract measles as nonexempt children.¹ In another study in Colorado based on data for the years 1987 through 1998, children with exemptions, as compared with unvaccinated children, were 22 times as likely to have had measles  and almost six times as likely to have had pertussis.²

Each vaccine given, is timed to give the most protection at a critical age to prevent the most devastating infections.   Getting more than one shot at a time isn’t a huge physical stress. Their immune systems handle far greater challenges from everyday exposure to germs on shared toys, doorknobs, and the playroom floor.  As Dr. Paul Offit explains it: Think about the bugs that caused your child’s last ear infection. Each single bacterium has 2,000 to 3,000 components that stimulate an immune response from the body. As those bacteria multiply, the challenge to the immune system increases exponentially. Your baby feels awful and likely has a high fever and lots of pain. The body pulls out the stops to fight it off. NOW COMPARE THAT TO THIS: “The entire fourteen-shot course of childhood vaccinations contains only about 150 immunological components altogether,” says Dr. Offit. This is about a tenth of the challenge posed by exposure to just one microscopic germ.

What’s more, the bacteria and viruses used in vaccines are either killed or altered, says Martin Myers, M.D., author of “Do Vaccines Cause That?!” There are just enough to induce immunity, but not enough to make someone sick — and certainly not enough to overload the immune system of a healthy child.  In rare instances, some susceptible children experience fever-induced seizures following shots, but though these are frightening, they cause no permanent harm.  These same fever-induced seizures can occur with any viral illnesses.

Splitting Up Vaccines: One common response to these concerns is to break up combination vaccines (which may contain up to five inoculations in one) or to spread them out. But that carries significant risks of its own. “Too often, an immunization delayed is an immunization missed,” says Dr. Schaffner. “It’s hard enough for parents to keep track.”   Coming in to the doctors office to “spread them out” increases your child’s exposure to illness.  Children with mild illnesses ride it out at home.  The sicker children are brought to the doctor’s office to be seen.  While this risk is small, why expose your child to more illness or to the illness you may be trying to prevent, by spreading out the shots.   Finally, there is not even one controlled study that shows spreading out the shots prevents anything.

More troubling, during the gaps, kids are susceptible to catching serious diseases they could have been protected from. Vaccines are scheduled when they are for precise reasons: It’s a balance between finding the time when the baby’s immune system can respond and knowing when he’s most in danger of catching the infection, says Dr. Schuchat. Give a shot late and a child is left unprotected at his most vulnerable time.

Why start so early?

The decision as to when to give a vaccine is based on the epidemiology of the vaccine preventable disease. Often, these diseases are more severe in younger children. Therefore, we start early to ensure that the youngest and often most fragile are protected as soon as possible.  For example, most deaths due to pertussis occur in infants younger than 6 months of age.

Please remember that immunizations have been a major public health success story. The vaccine schedule has evolved over the past 50 years based on scientific evidence.   It is your pediatricians job to constantly review this evidence.  Each vaccine must be judged on its individual merit and evidence of benefit.

• Request something you left in the office (e.g. Daycare Form)
• Request a copy of forms
• Request a copy of medical records
• Request a routine prescription refill
• Ask a billing question
• Request test results
• Request a well visit appointment
• Request a referral or a list of specialists (e.g. list of Dermatologists)

For most parents, a phone call may still be your best option.  Using e-mail adds an element of convenience (e-mailing forms will reduce vists to pick up forms in the office).  To provide this service in a HIPPA compliant form (to protect your privacy), we are using a commercial service known as HouseDoc.  Almost all communications are free of charge.  There are some communications that involve a transaction fee of $2 along with other applicable charges.  For example a form request has a $5 fee + $2 transaction fee totaling $7.  Here’s how it works:

Go to Housedoc.us.   Register under patient registration (we recommend 1 parent register per family).  You may enter your preferred pharmacy.  Once you have registered, look for the link to “My Providers”.   Then click the link to “Search Providers Database”.   Under the first name field type “FSP”.  Under the last name field type “Office”.  Once you find our office, click “Request Access”.   Once we have confirmed your information, we will grant access and you may then proceed with any requests.  

Please note the following:

• At this time the only charges incurred are related to Form Fees and copies of medical records.  There are no other charges for use of the service
• We cannot send an email to you, we can ONLY respond to your email.  Please do not call the office to ask us to email something to you.  Use Housedoc to send the request.   We then send a response back to you with the appropriate file, form etc attached. 

• Avoid touching eyes, nose, or mouth.
• Consider greeting with a nod rather than a handshake
• Avoid close contact with people who are sick. When you are sick, keep your distance (e.g. 1 meter/3 feet or more) from others to protect them from getting sick.
• Stay away from crowds when you have a choice

TIP 2: Handwashing: Hand washing is a simple habit, something most people do without thinking. Yet hand washing, when done properly, is one of the best ways to avoid getting sick. This simple habit requires only soap and warm water or an alcohol-based hand sanitizer — a cleanser that doesn’t require water.

Antibacterial soaps have become increasingly popular in recent years. However, these soaps are no more effective at killing germs than is regular soap. Using antibacterial soaps may lead to the development of bacteria that are resistant to the products’ antimicrobial agents — making it even harder to kill these germs in the future. In general, regular soap is fine.  Wash before eating or preparing food, after coughing, sneezing or blowing your nose, after using the restroom, or after touching another person.

Follow these instructions for washing with soap and water:

• Wet your hands with warm, running water and apply liquid soap or use clean bar soap. Lather well.
• Rub your hands vigorously together for at least 15 to 20 seconds. (Sing the ABC song)
• Use a towel to turn off the faucet.

TIP 3: Cough Etiquette: Cover your mouth and nose when coughing or sneezing, using tissues and disposing of them in a trash receptacle immediately. If tissues are not available, cough or sneeze into your sleeve. Then wash your hands.

TIP 4: Boosting Your Immune System: Your immune system responds to how you treat your body.  Reducing stress, getting consistent rest, and eating plenty of fruits and vegetables are important in this regard.  Maintain your hydration

TIP 5: Get the Flu Vaccine: The Flu Vaccine is your safest and best treatment to prevent the Flu.  It is safe and effective.

Some say “the Flu is a bad cold”.  Please remember 35,000 people die in the United States each year from the flu.  This is the seventh most common cause of death in the US.  It exceeds the number of deaths from homicides and suicides combined.

Some say “the wrong virus is sometimes picked for the vaccine”.  The selection of the virus is amazingly accurate.  On average, selection is correct two out of three years.  Even when a different strain circulates, most people get partial protection from the vaccine.

Some say “the vaccine doesn’t work”. In Japan there was a mandatory school vaccination for children for influenza for 23 years. Parents did have the option to opt out, but if they did not children were vaccinated.  Vaccination rates for children were extremely high.  The vaccination of Japanese children prevented about 37,000 to 49,000 deaths per year, or about 1 death for every 420 children vaccinated. As the law was reversed and vaccination in school was discontinued, the excess mortality rates in Japan increased back to the high rate they experienced before (almost 4 times higher than the 23 years vaccines were given).^1,2

Some say “only do natural things, the vaccine is a toxin”.  There is nothing natural about the body being ravaged with influenza.  It releases toxins within the body called cytokines.  To get the natural infection, means more people would die without the vaccination.

Some say “I never get the shot, and I haven’t gotten the flu”.  Of all those who get influenza, not all have symptoms, but are just as capable of spreading the virus to others who may get very sick.  As the studies above show, the more we vaccinate, the more we protect each other.  Studies show that some people may transmit the infection to others without evening knowing you have the flu.

Some say “I got the flu shot once and got the flu”.  Today’s vaccinations are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.  The benefit of the Flu Vaccine leads us to strongly recommend it.

When to Call the Office for the Flu³:

It may help to start with a view of current flu activity.  You can click here for a map which shows the current epidemic in the United States.   A recent study at Purdue University has used statistical models to predict that 60% of the US population will be infected by the end of October.   Does this mean you should not get the vaccine?  The answer is no.  This model is much like the Spanish Flu of 1918.    We recommend that you get the vaccine as soon as it is available.  In the mean time, we wish to alert you to signs of the Flu.   Please remember, those who are most at risk of a serious complication are:

• Children under age 2
• Those between the ages of 2-24 who look extremely ill
• Those with a chronic disease, especially an underlying respiratory (lung) disease such as asthma, heart disease, kidney disease, liver disease, blood conditions (such as cancer) or metabolic problems including diabetes
• Those with conditions that can compromise respiratory (lung) function (cerebral palsy, spinal cord injuries, seizures, neuromuscular disorders)
• Those who are immunsuppressed (HIV) or on medications that can cause immunosuppression
• Children who are on long term aspirin

With all that said, please make the following considerations to be seen in the office:

Symptoms of the Flu:

The flu will cause a fever (which tends to be higher than other viruses) along with a cough and or sore throat.  Other features to look for include:

• a prominence of body or muscle aches, headache and chills than most other viruses
• an appearance of illness with a glassy look to the eyes
• a runny nose that will tend to be profuse

Most healthy people who develop the flu recover completely and do not need treatment.

Treatment with Anti-Viral Medications (Tamiflu)

Tamiflu is a medication that specifically stops the flu virus from multiplying.  It shortens the duration of illness by about 1 day if started in the FIRST 48 hours of the illness.  This is most beneficial in high risk groups.  Just like other medications, indiscriminate use, will cause resistance to this medication.  See Influenza Antiviral Therapy for information about Tamiflu if it has been prescribed.  Our practice will CONSIDER the use of Tamiflu for children (especially over the next 2-3 weeks who are in the first 48 hours of a Flu Like Illness AND are:

• Under 2 years of age OR
• Has a medical condition outlined above OR
• Appears ill to us when examined

We want to provide you with a strategy to manage the the next 3 weeks as Flu Activity peaks in our area.  We want to encourage you to come in for evaluation when you need to.  We also want you to avoid coming into the office if not necessary.   This is an important consideration.  Coming into the office may expose you to the Flu at at time when it is most contagious in the community.  The sickest most contagious children come into a doctors office.

When should I call 911?

• If your see severe difficulty breathing (struggling for each breath, making grunting noises with each breath, unable to speak or cry because of difficulty breathing, severe retractions – sucking in between the ribs)
• Bluish lips or face
• Not waking up or interacting
• Your young child is so irritable that they will not be held

When should I take my child to the Emergency Room?

• Under our advice if your appears very sick or weak

You should call us to be seen now (if the office is open) if:

• There is difficulty breathing, not relieved by cleaning out the nose 
• Fever >105°F, rectal or oral

We should see you today in the office if:

• You feel you child is sick enough that you want them seen
• Yellow scabs are around the nasal openings (possible impetigo)
• Fever is present >3 days – to make sure there is not a secondary infection like an ear infection
• Fever returns after going away for 24-48 hours - to make sure there is no secondary infection
• Symptoms have been present for 48 hours or less AND you fit one of the groups for consideration of Tamiflu (see at risk groups above)

Other considerations for an office appointment – we expect a high volume of office visits over the next few weeks.  The following are symptoms which do require an office visit.  There are symptoms listed below which could potentially wait for up to 3 days.  We will attempt to see most patients on a same day basis, but we may need to limit the following patients with these symptoms from same day appointments in order to accommodate patients who made need more immediate care.  Call to be seen within 3 days if:

• there is a daily nasal discharge present for greater than 10-14 days and it is not improving (possible sinusitis)
• there is a cough present for greater than 3 weeks
• Influenza lasts greater than 10 days

What can I do to help treat symptoms at home?

HOME ADVICE FOR INFLUENZA

For most people, the treatment of influenza is based on the symptoms.  

1. Bedrest is not necessary, but helpful for some.
2. For a runny nose with profuse discharge, blow or suction the nose.  The nasal discharge is natures way of washing out the virus.  Blowing the nose is all that is needed.
3. Apply petroleum jelly to the nasal openings to protect them from irritation.  Clean the skin first
4. For a Blocked Nose, Use Nasal Washes.  A young infant cannot nurse or drink from a bottle, unless the nose is open.  Use warm water or saline nose drops to loosen up the mucous followed by suctioning or blowing.  Repeat until clear.  Most stuffy noses are blocked by dried mucous.  Suctioning alone or blowing will not remove it.  Neither can medicines.  Do nasal washes especially to help with eating or sleeping.  We usually don’t advise suctioning for more than 3-5 days.    For Saline Nose Drops: 1/2 teaspoon to 8 ounces (1 cup) of warm water.
5. Humidifier: Use if the air is dry to sooth the air passages.
6. Fever Medicine:  For fever over 102 degrees F, use acetaminophen or ibuprofen (buffer with some food).  See the medication dosing area of our website.  The goal is comfort, fever does not need to be eliminated.  Do not use aspirin for fever due to the risk of Reyes Syndrome.
7. Cough Medicine: For mild cough or hoarseness use 2-5 ml of corn syrup or buckwheat honey for younger children > 1 year old, or cough drops for children > 4 years.  We want to encourage a productive cough, not suppress it.
8. Sore Throat Relief:  For mild sore throat, give warm chicken broth for children > 1 year old, or cough drops for children > 4 years.
9. Contagiousness:  Spread can be rapid because the incubation period is only 24-72 hours, and the virus is very contagious.
10. Expected Course:  The fever lasts 2-3 days, the runny nose 5-10 days, and the cough 2-3 weeks.
11. Call back if:  the fever lasts > 3 days, the fever returns after going away for 24-48 hours, the nasal discharge last > 10 days, or you feel your child becomes worse.

REFERENCES:

1. The Japanese experience with vaccinating schoolchildren against influenza. N Engl J Med. 2001 Mar 22; 344(12):889-96.

2. Mass vaccination of schoolchildren against influenza and its impact on the influenza-associated mortality rate among children in Japan.Clin Infect Dis. 2005 Oct 1; 41(7):939-47. Epub 2005 Sep 1.

3. Adapted from Pediatric Telephone Protocols: Office Version. Copyright © 1994-2009. Barton D. Schmitt, MD.  Dr. Schmitt is author of the book Your Child’s Health, a recommended book by Four Seasons Pediatrics.  It is available on line at amazon.com or at your local bookstore.

Croup

Definition:

Croup is a viral infection which occurs in the fall and winter.  Typically it begins with a runny nose and a loud barky or honking cough.  Most croup is caused by a virus called Para influenza, the same virus that causes laryngitis in adults. It causes swelling of the vocal cords, voice box, and the breathing tube.  The fever and barky cough may last 5 days. The virus can be spread from person to person like a cold.  Hand washing will limit the spread.  Cough medicine and antibiotics do not help croup.

Helpful Home Hints

1. Keep your childs room humidified for 24 hours a day or hang some wet sheets or towels in the room (as they dry, the room will become humidified).

2. Encourage your child to drink clear fluids and less milk.
3. Do not smoke near or around your child.

4. If your child has fever; acetaminophen will help.

Croup Attacks: 

Some children have croup attacks which consist of coughing spells accompanied by a sound which occurs while breathing in.  These can usually be controlled by one of the following:

1. Have the hot shower run with the bathroom door closed. While it is steaming up proceed to step

2. Open the freezer door and have your child breath in the mist from the freezer; if this does not allow significant improvement within 5-10 minutes proceed bring your child into the bathroom; which should be steamed up.  If this does not allow improvement within 5-10 minutes; proceed to step

3. Wrap your child in a blanket and take a walk in the cool night air.

Call Immediately if

1. The above measures do not work.

2. Your child is breathing fast, has blue lips or looks uncomfortable.

3. Your child is drooling or not swallowing right.

4. Your child is unable to lie down comfortably and wants to sit up.

5. Your child is unable to bend his neck forward.

6. If your child could be choking on something that was put in the mouth.

7. It started suddenly after taking a medication, an insect bite or new food.

8. The temperature is greater than 103 degrees.

9. Your child is not drinking well and has not been urinating at least 3 times in the last 24 hours.

Spasmodic croup:

Spasmodic croup is related to infectious croup. However, its cause and symptoms are slightly different.  Most cases of spasmodic croup are caused by an allergic reaction. Viruses may trigger the allergic reaction in some cases. In rare cases, the airway irritation seems to be triggered by regurgitated (refluxed) stomach acid.
Spasmodic croup is different in that it usually does not cause a fever and the symptoms typically last a shorter time than is the case for infectious croup.  Currently in the United States, infectious and spasmodic croup together account for about 15 percent of all respiratory illnesses seen by pediatricians. Infectious croup is most common in children younger than age 6, and boys are affected slightly more often than girls. Spasmodic croup usually strikes children who are older.
Instead of having a fever or cold symptoms, the child with spasmodic croup often looks fairly healthy before coughing starts. The rest of the family is usually not sick with any respiratory illness. Episodes of cough and loud, raspy breathing generally start without warning, often in the middle of the night. These symptoms often will pass if the child is carried into cool night air or taken into a steamy bathroom. Symptoms from spasmodic croup typically improve within a few hours, although it is common for the symptoms to reappear several nights in a row.

In most cases, we diagnose spasmodic croup based on your child’s recurrent history, symptoms and physical findings.

Treatment for spasmodic croup is similar to viral croup.
Other factors to consider:

Cover mattress and pillow allergy cover.
Limit dust collectors, like dressers, stuffed animals

What is autism?

Autistic spectrum disorders are a group of disorders characterized by varying degrees of poor social interactions and unusual behaviors and interests.   They are also known as Pervasive Development Disorders (PDD).  PDD can vary from mild to profoundly severe.  Current estimates from the CDC indicate that about 1 in 152 children have some form of autism.  The cause is not clearly understood.  We do know that genetic factors play a role, and there has been work done on our genetic make –up (DNA) identifying the location of the susceptibility.  We also know that more people have this genetic make up than show it.  It is speculated that some other event “activates” the gene.   However, except for congenital rubella infections, studies in epidemiology have not found a link between environmental causes and autism.  

There is also a debate about the number of people who have autism.  There have been a number of studies looking at the rise in the number of children diagnosed with autism.   There is a belief that most of the increase is coming from a change in how the diagnosis is labeled.  One of the best studies looking at autism tracked the diagnosis of autism from 1984 to 2003.  In that study published in Pediatrics, the growing prevalence of autism from 1994 to 2003 was associated with corresponding declines in the diagnosis of learning disabilities and mental retardation.  In other words, the diagnosis of autism increased while other non specific diagnosis categories increased.   Another study in England found that two forms of autism not recognized years earlier (Aspergers and PDD-not otherwise specified) accounted for almost 75% of the autism diagnoses in 1998-1999.    In addition, the diagnosis of autism allows financial coverage for school systems and insurance companies, making this an incentive in using this diagnosis.  While it may appear that most of the rise is from these issues, there are many who believe that there is also a small increase in autism beyond a change in labeling. 

What about the vaccines and autism?

With the rise in the number of diagnoses of autism and the increased number of vaccines, there are some that say the two must be linked.  In addition, the diagnosis of autism is commonly made between 15-24 months of age.  This is a time when many vaccines have been given or may be given.  It is important to note that this diagnosis is more apparent at this age because social communication really starts to take off, and difficulty in this area is more likely to reveal itself. 

There are two theories about the role of vaccines and autism.  The first involved the use of thimerosal (a mercury like compound used as a preservative).  Since thimerosal is no longer used in almost all childhood vaccines, has been disproven as a cause of autism and the number of cases has not been affected, we will focus on the other ongoing theory.  This theory involves measles vaccine.

The theory regarding measles vaccine first evolved in 1998 when Dr. Andrew Wakefield described 12 children with PDD and gastrointestinal symptoms.   The study reported that in eight of the cases, symptoms began within two weeks after receiving the MMR vaccine.  Although the report contained no proof of a link between MMR vaccine and autism, a headline in London’s The Daily Telegraph read “Vaccination may trigger disease linked to autism”.   Major news media picked this story up and it has been a recycled story for the past 11 years.  In 2004, 10 of the 13 authors of the Wakefield study formally retracted their hypothesis.  The Institute of Medicine reviewed 16 studies which all consistently showed no association between MMR and autism.    Wakefield and his team also claimed that measles virus lodged in the intestines, releasing toxins that affected the brain, thus causing autism.  Not only could other researchers not replicate Wakefield’s reports, but the methods that Wakefield used were also shown to have been flawed.  It claimed that the doctors or families of eight out of twelve children attending a clinic at the hospital had blamed MMR for their autism, and said that problems came on within days of the immunization. The team also claimed to have discovered a new inflammatory bowel disease underlying the children’s conditions.

In February 2009, The Times (London) revealed the following:  In most of the 12 cases, the children’s ailments as described in The Lancet were different from their hospital and physician records. Although the research paper claimed that problems came on within days of the immunization, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated. Hospital pathologists, looking for inflammatory bowel disease, reported in the majority of cases that the intestine was normal. This was then reviewed and the Lancet paper showed them as abnormal.  An investigative reporter with the same newspaper reported that Dr. Wakefield was paid handsomely to try to prove that the MMR vaccine was unsafe.  While you have likely heard the impact of Dr. Wakefield’s study, you are just as unlikely to have heard about all the faults and corruption with Dr. Wakefield’s study.

Despite involving just a dozen children, the 1998 paper’s impact was extraordinary. After its publication, rates of immunization fell from 92% to below 80%. Populations acquire “herd immunity” from measles when more than 95% of people have been vaccinated.   Official figures showed that 1,348 confirmed cases of measles in England and Wales were reported 2008, compared with 56 in 1998. Two children have died of the disease.

The theory that measles vaccine causes autism has been fully disproven.  Nevertheless, the MMR scare has attracted and continues to attract so much media attention that MMR immunization rates fell in part, if not completely, because of misinformation about this safety concern.  Subsequently, there have been outbreaks of measles in Great Britain, the Netherlands, Germany and Switzerland; and an epidemic of mumps in Great Britain (which was the likely source of an outbreak in the United States in 2006).

The IOM report in 2004 concluded that there was no evidence of link between vaccines and autism.  There has been a steady stream of studies that have been well done in the medical literature.  These well done studies have consistently disproven vaccines as a “cause” for autism.

The continued public “controversy” in the face of the scientific evidence is now considered to be misinformation.  Aggressive misinformation about vaccines causing autism-presented as fact by prominent individuals – has been featured in publications and by the news media, discussed on popular TV and radio talk shows, and been the subject of TV dramas and docudramas.  Because these articles feature compelling stories often by prominent people, it is little wonder that parents have been confused. 

For more information and more details we encourage you to read our reference

Reference:

Do Vaccines Cause That?! – A Guide for Evaluating Vaccine Safety Concerns by Martin G. Myers, MD and Diego Pineda

Times Story – Feb 2009 on Dr. Andrew Wakefield

——————————

Hand, foot, and mouth disease (Coxsackie Virus) is caused by one of several types of viruses.  Coxsackie viruses are a part of a family of viruses known as enterovirus. This family includes polioviruses. In fact, Coxsackie virus was discovered by a scientist named Gilbert Dalldorf in the late 1940s who was searching for a cure for polio. This virus he discovered was named after Coxsackie, New York, where the scientist had obtained some specimens in his research.

Hand, foot, and mouth disease is usually characterized by tiny blisters on the inside of the mouth and the palms of the hands, fingers, and soles of the feet. It is commonly caused by coxsackievirus A16 (an enterovirus), and less often by other types of viruses.

Anyone can get hand, foot, and mouth disease.  Virtually every child has coxsackie virus at some point.

Young children are primarily affected, but it may be seen in adults. Most cases occur in the summer and early fall. Outbreaks may occur among groups of children especially in child care centers or nursery schools. Symptoms usually appear 3 to 5 days after exposure.

Hand, foot, and mouth disease is usually spread through person-to-person contact.   People can spread the disease when they are shedding the virus in their feces. It is also spread by the respiratory tract from mouth or respiratory secretions (such as from saliva on hands or toys). The virus has also been found in the fluid from the skin blisters. The infection is spread most easily during the acute phase/stage of illness when people are feeling ill and have a fever, but the virus can be spread for several weeks after the onset of infection.

The symptoms are much like a common cold with a rash.  The rash appears as blisters or ulcers in the mouth, on the inner cheeks, gums, sides of the tongue, and as bumps or blisters on the hands, feet, and sometimes other parts of the skin such as the buttocks. The skin rash may last for 7 to 10 days.

There is no specific treatment for the virus that causes hand, foot, and mouth disease.  Cold drinks and or freeze pops help sooth the area.  Another option is to make a mixture of 1 part antacid (like mylanta) with 1 part benadryl liquid (generic is diphenhydramine).  Mix these into a paper cup.  Then swab the inside of the mouth and tongue with the mixture.  Older children may swish the mixture in the mouth and then spit out.  It is ok if some is swallowed.

Help prevent and control the spread of hand, foot, and mouth disease by:

>Washing hands well, especially after going to the bathroom, changing diapers and/or handling diapers or other stool-soiled material.

>Covering the mouth and nose when coughing or sneezing.

>Washing toys and other surfaces that have saliva on them.

>Excluding children from child care or school settings if there is a fever, or ulcers in the mouth and the child is drooling.

Call us if your child shows signs of dehydration (e.g. not urinating 3 times in 24 hours), or the mouth and tongue are dry with very little drinking.  You should also call if the initial fever goes away and returns (after 48 hours).

Ticks are widespread at this time. Deer ticks are active in May through July. It is these ticks that transmit Lyme Disease. We recommend that you check your child daily if they are outside. Most ticks can be found at the edge of properties in wooded areas. The overall risk of Lyme Disease from a TICK is less than 1-2%. The risk is low unless an engorged tick is attached for for at least 72 hours. For this reason, the best approach is prevention (use a repellant like Bug Out if outside for less than 4 hours and 3M Ultrathon if outside for more than 4 hours). We recommend one application rather than multiple applications.  In addition, check you child daily for TICKS and remove them carefully. We recommend using a TICK remover (we sell them) or tweezers. Gently pull up enough to tent the skin and wait for the TICK to detach. (Please have a seat and be patient, the Tick will usually release on its own in 1-4 minutes – do not attempt to pry the Tick off as it will likely break).  If you break the Tick, the embedded piece does not need to be removed, it will come out on its own.  As recommended by the American Academy of Pediatrics and local Pediatric Infectious Disease experts at the Childrens Hospital at Albany Medical Center, we do not recommend “preventive antibiotics” for children under 12. In some cases, we consider antibiotics for those with an engorged deer tick, especially if attached for more than 72 hours in a child 12 and over. The median incubation period of Lyme is 11 days. During the early stages, the diagnosis is best made by recognizing the characteristic rash (which is a red rash at the site of the bite). It has a red ring with central clearing, is painless and not itchy. There is a blood test available, but it is non specific. It is not helpful for non specific symptoms like fatigue and muscle or joint aches. Almost all positive results in those patients are false positive results. Lastly, we do not send ticks for identification since it has no bearing on the risk or outcome of Lyme Disease. Other preventive measures include: 1) wear light colored clothing and tuck pants into socks and shirts into pants 2) after removing a tick, disinfect the bite with soap, rubbing alcohol or hydrogen peroxide 3)monitor for the rash described above along with flu like symptoms in the next 30 days.</p>

SUNBURN PREVENTION

SUNSCREEN DO’S AND DONT’S:

DO SLATHER ON ENOUGH. People typically use about 25 to 75 percent less sunscreen than they should, according to studies. Be sure to apply 2 to 3 tablespoons of sunscreen for maximum full-body protection of an adult. 
DON’T USE EXPIRED SUNSCREEN. Sunscreens aren’t required to post expiration dates as long as manufacturers can prove that they’ll last for at least three years. So if your sunscreen doesn’t have an expiration date, be sure to write the date on it in permanent marker when you buy it. And remember to discard it after three years.
DON”T MISS THESE SPOTS. Lips, ears, feet, hands, bald spots, and the back of your neck are all areas that are easy to forget.
DO REAPPLY REGULARLY. The maximum protection time of a sunscreen is based on the number of minutes it takes for you to burn multipled by the SPF number. So say you have fair skin and burn within 20 minutes and you’re using enough of an SPF 15 sunscreen. That will give you about five hours of protection. Nevertheless, reapply sunscreen every two hours just to be on the safe side. If you’re swimming or doing lots of sweating on the beach or the tennis court, you may want to reapply it more often than that. Also, keep in mind that reapplying sunscreen after you’ve exceeded your maximum protection time doesn’t mean that you can safely stay in the sun longer. Instead, be sure to cover up or get out of the sun!</p>

Products to consider:

We tend to get more calls this time of year for rashes after being in the sun with sunscreen.  As many products have increased their SPF, they have added more chemicals to create the higher SPF.  This has meant more rashes for children.   Neutrogena has excellent UVA/UVB coverage at SPF’s of 15 or higher.  Higher is not better since some products (like Neutrogena) get 100% protection (if you reapply) and you only may increase the chance of a rash with a higher SPF.   There are also more options for SPF clothing than ever before.  Coverage with this clothing will give protection to areas that will not need to be re-coated with sunscreen.  Just google “SPF clothing for children” or “babies” to see options.  SPF clothing for a baby is ideal.  For babies under 6 months the only sunscreen made for this age is Blue Lizard.  We recommend SPF clothing as described above, a brim hat and avoidance during the peak high UV rays (10 am to 3 pm).  If you must use a sunscreen, for this age, limit to the areas you cannot cover.

What is autism?
Autistic spectrum disorders are a group of disorders characterized by varying degrees of poor social interactions and unusual behaviors and interests. They are also known as Pervasive Development Disorders (PDD). PDD can vary from mild to profoundly severe. Current estimates from the CDC indicate that about 1 in 152 children have some form of autism. The cause is not clearly understood. We do know that genetic factors play a role, and there has been work done on our genetic make –up (DNA) identifying the location of the susceptibility. We also know that more people have this genetic make up than show it. It is speculated that some other event “activates” the gene. However, except for congenital rubella infections, studies in epidemiology have not found a link between environmental causes and autism.

There is also a debate about the number of people who have autism. There have been a number of studies looking at the rise in the number of children diagnosed with autism. There is a belief that most of the increase is coming from a change in how the diagnosis is labeled. One of the best studies looking at autism tracked the diagnosis of autism from 1984 to 2003. In that study published in Pediatrics, the growing prevalence of autism from 1994 to 2003 was associated with corresponding declines in the diagnosis of learning disabilities and mental retardation. In other words, the diagnosis of autism increased while other non specific diagnosis categories decreased (also called diagnosis substitution). Another study in England found that two forms of autism not recognized years earlier (Aspergers and PDD-not otherwise specified) accounted for almost 75% of the autism diagnoses in 1998-1999. In addition, the diagnosis of autism allows financial coverage for school systems and insurance companies, making this an incentive to use this diagnosis. While it may appear that most of the rise is from these issues, there are many who believe that there is also a small increase in autism beyond a change in labeling.

What about vaccines and autism?
With the rise in the number of diagnoses of autism and the increased number of vaccines, there are some that say the two must be linked. In addition, the diagnosis of autism is commonly made between 15-24 months of age. This is a time when many vaccines have been given or may be given. It is important to note that this diagnosis is more apparent at this age because social communication really starts to take off, and difficulties in this area are more likely to reveal itself.

There are two theories about the role of vaccines and autism. The first involved the use of thimerosal (a mercury like compound used as a preservative). Since thimerosal has been disproven as a cause of autism, and it is no longer used in almost all childhood vaccines without a change in the number of children with the diagnosis, we will focus on the other ongoing theory; involving measles vaccine.

The theory regarding measles vaccine first evolved in 1998 when Dr. Andrew Wakefield described 12 children with PDD and gastrointestinal symptoms. The study reported that in eight of the cases, symptoms began within two weeks after receiving the MMR vaccine. Although the report contained no proof of a link between MMR vaccine and autism, a headline in London’s The Daily Telegraph read “Vaccination may trigger disease linked to autism”. Major news media picked this story up and it has been a recycled story for the past 11 years. In 2004, 10 of the 13 authors of the Wakefield study formally retracted their hypothesis. The Institute of Medicine reviewed 16 studies which all consistently showed no association between MMR and autism. Wakefield and his team also claimed that measles virus lodged in the intestines, releasing toxins that affected the brain, thus causing autism. Not only could other researchers not replicate Wakefield’s reports, but the methods that Wakefield used were also shown to have been flawed. It claimed that the doctors or families of eight out of twelve children attending a clinic at the hospital had blamed MMR for their autism, and said that problems came on within days of the immunization. The team also claimed to have discovered a new inflammatory bowel disease underlying the children’s conditions.

In February 2009, The Times (London) revealed the following: In most of the 12 cases, the children’s ailments as described in The Lancet were different from their hospital and physician records. Although the research paper claimed that problems came on within days of the immunization, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated. Hospital pathologists, looking for inflammatory bowel disease, reported in the majority of cases that the intestine was normal. In the medical paper “Lancet”, these cases were reported as being abnormal, despite the hospital pathologists reports. An investigative reporter with the same newspaper reported that Dr. Wakefield was paid handsomely to try to prove that the MMR vaccine was unsafe. While you have likely heard the impact of Dr. Wakefield’s study, you are just as unlikely to have heard about all the faults and corruption with Dr. Wakefield’s study. Journalists are likely to inform us of health risks when one or more of the following are present:

1) Questions of blame
2) Alleged secrets and attempted cover-ups
3) Human interest through identifiable heroes, villains, or victims
4) Links with high existing high-profile issues or personalities
5) Conflict
6) Many people exposed to the risk, even if at low levels (it could be you!)
7) Strong visual impact (pictures of suffering)

Despite involving just a dozen children, the 1998 paper by Wakefield had an impact that was extraordinary. After its publication, rates of immunization fell from 92% to below 80%. Populations acquire “herd immunity” from measles when approximately 95% of people have been vaccinated. Official figures showed that 1,348 confirmed cases of measles in England and Wales were reported 2008, compared with 56 in 1998. Two children have died of the disease.

The theory that measles vaccine causes autism has been fully disproven. Nevertheless, the MMR scare has attracted and continues to attract so much media attention that MMR immunization rates fell in part, if not completely, because of misinformation about this safety concern. Subsequently, there have been outbreaks of measles in Great Britain, the Netherlands, Germany and Switzerland. There was also an epidemic of mumps in Great Britain, which was the likely source of an outbreak in the United States in 2006.

Congress passed the national Childhood Vaccine Injury Compensation Act in 1986, to compensate children who the court considers to have been injured by vaccines. This is a “no-fault” program, that is, it does not require or mean scientific proof of injury. The act also specified that the Institute of Medicine (IOM) – part of the National Academy of Sciences – review the medical literature on health problems or injuries occurring after vaccination. The IOM report in 2004 concluded that there was no evidence of a link between vaccines and autism. Since 2004 there has been a steady stream of studies examining the relationship of autism and vaccines. These well done studies have consistently disproven vaccines as a “cause” for autism.

The continued public “controversy” in the face of the scientific evidence is now considered to be misinformation. Aggressive misinformation about vaccines causing autism-presented as fact by prominent individuals, has been featured in publications and by the news media, discussed on popular TV and radio talk shows, and has been the subject of TV dramas and docudramas. Because these articles feature compelling stories, often by prominent people, it is little wonder that parents have been confused.

For more information and more details we encourage you to read our reference

Reference:

Do Vaccines Cause That?! – A Guide for Evaluating Vaccine Safety Concerns by Martin G. Myers, MD and Diego Pineda

News Article in the London Times

The facts:Hannah Poling was born with a disorder that affects her mitochondria (the structures within cells that produce energy). And though the family won the settlement on the theory that this underlying vulnerability could have made her more susceptible to vaccine injury, there’s actually no proof that she — or any other child with mitochondrial disease — was in fact at any increased risk, says neurologist John Shoffner, M.D., associate professor of biology at Georgia State University, in Atlanta, Georgia, one of the doctors who diagnosed Hannah’s disorder.   “There is no evidence that the contents of vaccines are the cause of autism or mitochondrial disorders,” he says. What’s more, because even common illnesses like colds, the flu, and rotavirus can cause significant harm to these children, doctors strongly advise they receive all the recommended shots.

So what does all of this mean for parents of healthy kids? Not much — getting more than one shot at a time isn’t a huge physical stress. Their immune systems handle far greater challenges from everyday exposure to germs on shared toys, doorknobs, and the playroom floor.  As Dr. Paul Offit explains it: Think about the bugs that caused your child’s last ear infection. Each single bacterium has 2,000 to 3,000 components that stimulate an immune response from the body. As those bacteria multiply, the challenge to the immune system increases exponentially. Your baby feels awful and likely has a high fever and lots of pain. The body pulls out the stops to fight it off. Now compare that to this: “The entire fourteen-shot course of childhood vaccinations contains only about 150 immunological components altogether,” says Dr. Offit. This is about a tenth of the challenge posed by exposure to just one microscopic germ.

What’s more, the bacteria and viruses used in vaccines are either killed or altered, says Martin Myers, M.D., author of “Do Vaccines Cause That?!” There are just enough to induce immunity, but not enough to make someone sick — and certainly not enough to overload the immune system of a healthy child.  In rare instances, some susceptible children experience fever-induced seizures following shots, but though these are frightening, they cause no permanent harm.  These same fever-induced seizures can occur with any viral illnesses.

Splitting Up Vaccines:One common response to these concerns is to break up combination vaccines (which may contain up to five inoculations in one) or to spread them out. But that carries significant risks of its own. “Too often, an immunization delayed is an immunization missed,” says Dr. Schaffner. “It’s hard enough for parents to keep track.”   Coming in to the doctors office to “spread them out” increases your child’s exposure to illness.  Children with mild illnesses ride it out at home.  The sicker children are brought to the doctor’s office to be seen.  While this risk is small, why expose your child to more illness or to the illness you may be trying to prevent, by spreading out the shots.   Finally, there is not even one controlled study that shows spreading out the shots prevents anything. 

More troubling, during the gaps, kids are susceptible to catching serious diseases they could have been protected from. Vaccines are scheduled at certain times for precise reasons: It’s a balance between finding the time when the baby’s immune system can respond and knowing when he’s most in danger of catching the infection, says Dr. Schuchat. Give a shot late and a child is left unprotected at his most vulnerable time.

Why start so early?

The decision as to when to give a vaccine is based on the epidemiology of the vaccine preventable disease. Often, these diseases are more severe in younger children. Therefore, we start early to ensure that the youngest and often most fragile are protected as soon as possible.  For example, most deaths due to pertussis occur in infants younger than 6 months of age.

Please remember that immunizations have been a major public health success story. The vaccine schedule has evolved over the past 50 years based on scientific evidence.   It is your pediatricians job to constantly review this evidence.  Each vaccine must be judged on its individual merit and evidence of benefit.   

What are the current recommendations for Vitamin D?

1. Breastfed infants and partially breastfed infants should be supplemented with 400 IU/day of Vitamin D until your infant is weaned to at least 28 ounces of vitamin fortified formula.  When switching to milk at 12 months of age.  Whole milk should be used until age 2 unless overweight is a concern or in those with a family history of obesity, high cholesterol or early heart disease before the age of 55.

2. All nonbreastfed infants and older children who are ingesting < 30 ounces of formula or milk per day, should receive 400 IU per day of vitamin D.  Other dietary sources of vitamin D, such as fortified foods, may be included in the daily intake of each child.

3. Adolescents who do not obtain 400 IU of vitamin D per day through vitamin D milk (100 IU per 8 ounces) and vitamin D fortified foods (such as cereal and eggs) should receive a vitamin D supplement of 400 IU per day.

Here are some of the choices to supplement Vitamin D:

• Enfamil D Vi Sol - vitamins – contains vitamin D.  Contains 50 doses.  1 ml contains 400 IU of vitamin D

 

• Enfamil Tri Vi Sol vitamins – contains vitamins A, D, and C.  Contains 50 doses.  1 ml contains 400 IU of vitamin D
• Bio-D Mulsion – 1 drop contains 400 IU of vitamin D.  Contains 750 doses.  Just be careful using, there is a risk of incorrect dosing since this is very concentrated.  It is also inexpensive
• Just D – Sunlight Vitamins Inc.  Contains 50 doses.  Contains only vitamin D with no additives.  www.sunlightvitamins.com

What are the current recommendations for calcium?

How much calcium your body needs varies according to age. You need the most calcium between 9 and 18 years of age.

The American Academy of Pediatrics recommends the following daily intake of calcium:

How to get calcium

The best way to get the calcium that you need is by eating and drinking foods that naturally contain calcium. Many foods contain some calcium, but the best sources include the following:

• Low-fat milk, yogurt, and other milk products are generally super sources of calcium.
• Flavored milks, such as chocolate or strawberry, have as much calcium as plain milk but may have more calories.
• Dark green, leafy vegetables such as kale and turnip greens are low in calories and high in calcium. However, spinach is not a good source of calcium.
• Broccoli, tofu, chickpeas, lentils, split peas, and canned salmon and sardines (and other fish with bones) also are good sources of calcium.
• Calcium-fortified juices and cereals can help boost the calcium in your diet, but limit yourself to 8 to 12 ounces (1½ cups) of juice a day.