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Daily Dose

Why 'Herd Immunity' Does Not Work

With all of the recent anxiety surrounding Swine Flu and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available.There is an article in the June issue of the journal Pediatrics, which looked at whether parental refusal of pertussis vaccination could be associated with increased risk of pertussis infection in those unimmunized children. The study was conducted between the years 1996 - 2007 and looked at case controlled studies which compared a child with documented pertussis (whooping cough) to 4 other randomly selected children who did not develop pertussis. This study is important as many parents believe that if they choose not to vaccinate their child, that their child is protected by herd immunity (in other words, by all of the rest of us that are immunized).

In this case the study showed that 11% of all pertussis cases in this pediatric population were attributed to parental vaccine refusal. This study is important for several reasons. It is one of the first to document that herd immunity does not seem to completely protect unvaccinated children from pertussis. Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. One would assume, but further studies need to be done, that similar results would be found if you looked at diseases like measles, or H. flu meningitis. Herd immunity is important to the general health and well being of all of us, but it is not 100% at any time and risk of disease is still there. As we see increases in whooping cough in many communities across the country the need to educate parents about the importance of vaccines is paramount. Parents need to be protected too and we should all have a TdaP as an adult to provide pertussis protection for ourselves, as well as for those infants around us who are too young to be immunized. With all of the recent anxiety surrounding Swine Flu (H1N1) and the possibility of epidemics, lets be pro active in protecting all of us from diseases that we can prevent with the current immunizations that are available. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Whooping Cough Epidemic!

1.30 to read

For the first time in many years, being a pediatrician in Dallas means that I am seeing children with pertussis (whooping cough). That is due to the fact that Dallas-Ft. Worth is in the midst of a whooping cough epidemic, the worst in over 20 years. But pertussis is not just a problem in the DFW area, the entire country continues to see rising pertussis cases.  

The CDC reported that in 2012 the U.S. had more whooping cough cases reported( >41,000) than since 1955. There are currently 16 states, including Texas reporting higher pertussis rates than last year. In 2012 there were 18 reported deaths in the U.S.  due to whooping cough.  Sadly, there have already been more than 2,000 cases of whooping cough reported in Texas this year,  and there have been 6 deaths in infants and children.    

Unfortunately, one reason for increasing pertussis cases seems to be that some parents are choosing to either not vaccinate their children, or to vaccinate them on an “alternative” vaccine schedule.  A study just published shows that unvaccinated or under-vaccinated children between the ages of 3 months and 36 months of age are at greatest risk for getting whooping cough. The study from The Institute for Health Research at Kaiser Permanente Colorado stated that “children who had not received the  recommended 3 or 4 doses of DTaP (diptheria, tetanus, pertussis vaccine) were about 18-28 times more likely to have had pertussis than children who were fully vaccinated”. 

These children are not only at risk for getting ill from pertussis themselves,  they also pose a public health risk for others as they spread the bacteria (bordetella pertussis) with their coughs. This is especially true for innocent infants under the age of 2 months who have not even started their DTaP vaccines. The recommended schedule for DTaP is 2,4,and 6 months of age with a 4th dose between 15-18 months of age.  

What we doctors do know is that vaccines are safe, effective and save lives. They are given on a schedule for a reason.  We also know that when too many children “opt out”, or rather their parents choose not to vaccinate them, we see increase in disease numbers. This is not only true in this country with pertussis, but with measles as well. Measles cases in the United States are also at their highest in years.

The other group of people who need to be immunized are teens and adults. Many adults incorrectly think that they “don’t get more shots”.  But, adults need “booster” shots as well as children. This is especially true with the TdaP (adult version of the pertussis vaccine). While this vaccine is safer than the older whooping cough vaccines, it doesn’t seem be as effective at providing long term immunity. This too may account for increased whooping cough rates in teens and adults.  Research is looking at giving the TdaP more often as well as the possibility of a more effective vaccine.

The bottom line? Everyone needs to be up to date with their vaccines. Don’t depend on others to get vaccinated to protect you either, not everyone “plays by the rules”.  Help protect those innocent babies under 2 months of age. In the meantime, try to limit your baby’s exposure to crowds until they have started their vaccines. 

Daily Dose

No Needle Shots?

1.00 to read

Over the last several months I have had a lot of patients (especially those that are old enough to talk) ask me about the new needless jet injectors for vaccinations. Of course anything that says “no needle” and “painless” has a lot of appeal for both doctor and patients, especially in pediatrics.  Our practice has not decided whether to try out the new jet injectors and we are still giving the standard shots, not always with smiling patients. How do jet injectors actually work? By using a thin high pressure of liquid to penetrate the skin with the vaccine.

Well, now that it is flu vaccine season, there has been a lot of advertising about needless injections for flu vaccine. Many drug stores and/or grocery stores had advertised that you could get your flu vaccine, “pain free”.  Sounds great, right?

Not so fast, the FDA recently announced that “all vaccines including flu vaccine be administered in accordance with their labeling.” This means that flu vaccine has not been studied when given by the new jet injectors. The FDA also stated that there “was no data to show the safety or efficacy of flu vaccine or other vaccines given by injectors”.  The only vaccine that has currently been approved to be given by the jet injectors is the MMR (measles, mumps, and rubella) vaccine.

The flu vaccine may be given by the traditional method with a needle, or as a nasal mist (for use in children 2 years of age and older). Most of our patients opt for a “flu mist” if they can talk and sniff. It is amazing that there are several children who really do prefer a shot, and they tell me that they would “never” sniff something up their nose. Different strokes for different children.

But in the meantime, I am not jumping on the jet injector bandwagon. The FDA is now stating that each vaccine needs to be evaluated for both safety and efficacy when given by a jet injector. I am sure that those studies will be forthcoming.

In the meantime, RUN to get your flu vaccine, it is time to get vaccinated as sick season is starting and who wants the flu!

That’s your daily dose for today.  We’ll chat again tomorrow.

Your Baby

Infant Ear Infections Declining

2:00

Ear infections in infants are very common and can be quite unsettling for parents. The good news is that ear infections among U.S. babies are declining according to a new study.

Researchers found that 46 percent of babies followed between 2008 and 2014 had a middle ear infection by the time they were 1 year old. While that percentage may seem high, it was lower when compared against U.S. studies from the 1980s and '90s, the researchers added. Back then, around 60 percent of babies had suffered an ear infection by their first birthday, the study authors said.

The decline is not surprising, according to lead researcher Dr. Tasnee Chonmaitree, a professor of pediatrics at the University of Texas Medical Branch, in Galveston.

"This is what we anticipated," she said.

That's in large part because of a vaccine that's been available in recent years: the pneumococcal conjugate vaccine, Chonmaitree said. The pneumococcal conjugate vaccine protects against several strains of pneumococcal bacteria, which can cause serious diseases like pneumonia, meningitis and bloodstream infections.

Those bacteria are also one of the major causes of children's middle ear infections, Chonmaitree said.

She added that flu shots, which are now recommended for children starting at 6 months, could be helping as well. Many times an ear infection will follow a viral infection such as the flu or a cold.

Vaccinations "could very well be one of the drivers" behind the decline in infant ear infections, agreed Dr. Joseph Bernstein, a pediatric otolaryngologist who wasn't involved in the study.

Other factors could be having a positive impact as well, such as rising rates of breast-feeding and a decrease in babies’ exposure to secondhand smoke.

"The data really do suggest that breast-feeding -- particularly exclusive breast-feeding in the first six months of life -- helps lower the risk of ear infections," said Bernstein, who is director of pediatric otolaryngology at the New York Eye and Ear Infirmary of Mount Sinai, in New York City.

There's also the fact that breast-fed babies are less likely to spend time drinking from a bottle while lying down, Bernstein noted. That position can make some infants more vulnerable to ear infections, he said.

The study findings were based on 367 babies followed during their first year of life. By the age of 3 months, 6 percent had been diagnosed with a middle ear infection; by the age of 12 months, that had risen 46 percent, researchers found.

Breast-fed babies had a lower ear infection risk, however. Those who'd been exclusively breast-fed for at least three months were 60 percent less likely to develop an ear infection in their first six months, the study showed.

But whether babies are breast-fed or not, they will benefit from routine vaccinations, Chonmaitree said. "Parents should make sure they're on schedule with the recommended vaccines," she said.

Parents can have a difficult time recognizing an ear infection in an infant or a child to young to tell them that their ear hurts.

Some symptoms to watch for are:

·      Tugging at the ear

·      Fever

·      Crying more than usual

·      Irritability

·      Child becomes more upset when lying down

·      Difficulty sleeping

·      Diminished appetite

·      Vomiting

·      Diarrhea

·      Pus or fluid draining from ear

Treatment for ear infections rarely requires medication, such as antibiotics, except when an infection is severe or in infants. 

According to the American Academy of Pediatrics (AAP), most children with middle ear infections get better without antibiotics, and doctors often recommend pain relievers -- like acetaminophen -- to start. But with babies, Bernstein said, antibiotics are often used right away.

The AAP recommends antibiotics for infants who are 6 months old or younger, and for older babies and toddlers who have moderate to severe ear pain.

The study was published online in the March edition of the journal Pediatrics.

Story source: Amy Norton, http://www.webmd.com/children/news/20160328/infant-ear-infections-becoming-less-common

Your Teen

Study: 1 in 4 Girls Received HPV Vaccine

A new government study shows that one in four teenage girls have received the new HPV vaccine. The vaccine protects against strains of the virus that cause about 70 percent of cervical cancers. The study done by the Centers for Disease Control and Prevention covered children ages 13 to 17 years old. The recommended age that girls get the shots is 11 to 12 if possible, before they become sexually active. The vaccine is a three-shot series that costs about $375, although many health insurers now cover it.

Merck, the maker of the Gardasil vaccine, said they were pleased with the vaccination rate.

Daily Dose

Another Case for Vaccinating Your Child

The American Academy of Pediatrics issued an alert last week that identified several more cases of invasive HIB disease in Pennsylvania and two deaths. One of the deaths occurred in an unimmunized child. Several months ago there were five cases of HIB disease in Minnesota, again resulting in one death, also in an unimmunized child. All of the cases involved unvaccinated or under-vaccinated children.

Prior to routine vaccination against HIB (H. flu) disease, which began in 1988, about 20,000 children developed infections each year, and 12,000 cases of HIB meningitis were diagnosed, with about five percent of children dying. Over the last 20 years the rates of HIB disease have decreased exponentially and deaths were no longer reported. The vaccine was a tremendous victory in preventing childhood meningitis and other serious infections. Over the last several years with parental anxiety related to vaccines, the number of unvaccinated children has been on the rise, especially in "pockets" throughout the country. At the same time, there has been a HIB vaccine shortage since December of 2007, which may have also resulted in children not completing their primary series at 2, 4, and 6 months of age. These two factors may have led to the cases of HIB disease and doctors are worried that we may see a recurrence of HIB disease and deaths. The community as a whole is often protected due to "herd immunity" and the herd must be immunized to provide maximum protection for everyone. This underscores the importance in vaccinating your children. If your child has missed any of their primary vaccine series, now is the time to update them. HIB disease is serious and unfortunately may be on the rise again. This is a vaccine preventable disease. That's your daily dose, we'll chat again soon.

Daily Dose

MMR Vaccine Update

vaccine, virus, health, parenting

Although there is more and more data to confirm that childhood vaccines are safe, and DO NOT cause autism….there  continues to be some parental concern surrounding the timing of a child’s vaccines.  The majority (read as all of my patients) receive their vaccines according to the CDC guidelines…and for the most part my patients realize the importance of vaccines and how many lives have been saved as more vaccines are given to children today than 25 years ago.  

But, when it comes time for the MMR (measles, mumps, rubella) vaccine, there are still a few parents who express concerns and some who would “like” to defer the vaccine to a later date when their child is “older”….typically after their child reaches the age of 18-24 months. Concerns are not only about safety, but also about efficacy of the vaccine at a younger age.   There have been several recent studies that should help to allay fears and actually reassure parents that giving the vaccine at 12 months of age is preferable and may have even have fewer side effects, if any, than when given when the child is older.

A study from Finland (which uses the same MMR vaccine)  looked at whether the antibody response (protection) from the MMR vaccine was any different when given at 12 months vs 18 months of age.  This study showed that the antibody response and protection from the MMR vaccine was similar when given at 12 months vs 18 months. Good news for giving it younger and protecting the child earlier.

Another study looked at the risk of febrile seizures after the MMR vaccine. This study reported that the risk of a seizure was more than 6 times higher during the 7 - 10 day interval after the MMR vaccine among children who were 16-23 months, as compared to those who were 12 -15 months.  So..in fact, delaying the vaccine actually put a child at more risk for a seizure than if given earlier.

These studies point to the win-win in giving the MMR vaccine to children at their 1 year old well child visit.  Not only does it provide earlier protection against measles, mumps and rubella ( a new outbreak of measles in the Amish community in Ohio was just reported), the chance of your child having any adverse effects are actually even lower. 

But remember, while this study showed “twice the risk” for delaying the vaccine…it is still a VERY LOW number, out of 10,000 kids there may be 4 extra febrile seizures.  While that number may seem insignificant,  when your child is one of the 4 to have a seizure it is significant. This is coming from a mother whose child had a febrile seizure (unrelated to vaccines) and who is a pediatrician.  It was even frightening for me to watch my child have a febrile seizure and I knew what was happening. While most febrile seizures only last 1-2 minutes he of course decided to have a prolonged seizure, (always doctor's kids). I am happy to report that he is of course totally fine and never had another febrile seizure…as most children “outgrow” febrile seizures during the pre-school years. 

Bottom line,  with these studies in hand…you should feel reassured that immunizing at 12 months is  preferable, safe and prevents serious illnesses.  

Daily Dose

HPV & Risky Sexual Behavior

1.30 to read

I have written many articles on the HPV vaccine and have been a big advocate for giving this vaccine to all adolescents . I let my patients know that I even gave it to all of my sons in their teen and early adult years (off label at the time, as it was not initially approved for males in the U.S.), as I had looked at the European data as to HPV vaccine efficacy in both males and females. 

At any rate, some parents, while proponents of vaccines, did not want to vaccinate their children during their teen years, “for fear that it might promote early sexual behaviors”.  I myself had not been concerned about that issue, as I have seen too many teens who never gave getting a sexually transmitted disease a second thought (though they should), prior to having their first sexual experience. I told parents, “I just wish they were thinking with their brains rather than with hormones and genitalia”. 

My own impression was that by giving the HPV vaccine while re-iterating to teens and young adults the ongoing risks about STI (sexually transmitted infections), we might see more “thinking” before engaging in pre-marital sex. My hope was that by providing information about developing a STI  (including those not covered by the HPV vaccine such as chlamydia, herpes, gonorrhea etc) doctors and parents could also be influential in helping adolescents realize that even with HPV vaccine, “there is no safe sex”. Double win, right?

There is now an article in Pediatrics (February 2014) which confirms that HPV vaccine was not tied to initiation of riskier sexual behavior.  A study done at Cincinnati Children’s Hospital surveyed 339 female adolescents and young adults aged 13- 21 years following HPV vaccination. They also did follow up questionnaires 2 and 6 months post vaccine.  The study showed that giving a young girl HPV vaccine did not lead to the perception that she was protected against STI’s nor did it promote sexual activity. The study did show that the girls that received HPV vaccine understood that it only protected them against HPV related disease and the possibility of developing a HPV-related wart or cancer.

Another finding in the study, was that most girls held appropriate perceptions that there was still a need to practice safe sex even after HPV vaccine, including the use of a condom.

So, if a parent is worried that HPV vaccine may lead their teen to initiate earlier sexual behavior, at least there is one study confirming that there is no association in girls. Further studies including boys should also be undertaken.

Could there be an association between not discussing risky sexual behavior, not giving the HPV vaccine and early initiation of sex?  Food for thought.

Daily Dose

Deciding to Vaccinate Your Child

1.15 to read

I was recently doing a 4 year old well-child check up. This little girl was the youngest in a family of 4 girls with the oldest daughter being 18.

Through the many years of taking care of this family of girls, I have come upon new issues and changes that have occurred in pediatrics.  There have also been and will continue to be, different parental concerns. 

When this child was born, there was still a lot of discussion about immunization safety and parental concerns surrounding vaccines and autism. Although all of her older siblings had been immunized on schedule, without any issues at all, when the “baby” was born her mother and I had many discussions about giving this little girl her vaccines. 

The mother told me that she was now “hanging out with younger parents and they had made her concerned about vaccines, specifically as they related to autism.”  

Well, after much discussion and hand wringing on the mother’s part, the little girl was vaccinated on schedule just as her siblings had been. In fact, the father brought the daughter for her 1 year old vaccines (which include the MMR) just because the mother was anxious.  The dad and I had a bit of a chuckle about this, but nevertheless the child received her MMR without problems. 

So, fast forward to the 4 year old check up. This little girl is quite precocious and worldly as well, being the youngest in the family. She has always been exceptionally verbal, and doesn’t mind telling you exactly what she has on her mind. (sometimes with words she may have picked up from her older siblings!). Birth order, a daily dose for a later date! 

At the end of the check up, as it became time to discuss vaccines, I turned to the mother and said, “ Sally, is going to get her immunizations today including her MMR”.  Are you still concerned about giving her vaccines as surely you don’t think that Sally is autistic?” 

As the mother was getting ready to speak, little Sally quickly interrupted in her usual loud voice and said, “ Dr. Sue I am to artistic, I drew those pictures for you!” 

Enough said, ice broken, subject over and vaccines all given on time and without a problem. 

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