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Daily Dose

Vaccine Safety

The MMR (measles, mumps and rubella) vaccine and Varivax (chickenpox) vaccine have both been licensed and recommended for many years. These vaccines are typically given to children between the ages of 12-15 months, and then again between 4-5 years.

In 2005, a new vaccine was released which combined MMR and Varivax  (MMRV) which reduced the number of needle sticks a child would receive from their routine immunizations. Vaccine safety is always a paramount concern and even after a vaccine is FDA approved there continues to be “post licensing” monitoring of the vaccine, looking for any reported adverse events. After the release of MMRV in 2005, there were noted to be an increase in the number of febrile seizures occurring within 10 days of receiving the combination vaccine.  As a result, the use of this combination vaccine was suspended in 2008 and then resumed in early 2010. A study released in the July issue of Pediatrics now looks at the vaccine safety data that was accumulated on MMRV post licensure,  and analyzed data on over 459,000 children who had been vaccinated between 2000 and 2008. In the retrospective study, 83,000 children received MMRV and 376,000 with separate MMR and Varivax vaccines. The study found that children between the ages of 12–23 months have about double the risk of developing a febrile seizure 10 days after receiving MMRV than those children that received separate MMR and Varicella vaccines. MMRV vaccination was associated with an estimated 4.3 additional seizures per 10,000 doses during the 7–10 days post vaccine. As discussed in previous blogs, febrile seizures are fairly common and are typically harmless to a child, but cause a lot of anxiety and fear for parents.  (my own son had a febrile seizure as a toddler).  The American Academy of Pediatrics endorses the use of single or combination vaccine for MMR and Varivax. The fact that there may be a greater likelihood (albeit small) for a child to develop a febrile seizure post MMRV vaccination needs to be discussed with parents as there is not going to be a “right” answer as to vaccine preference. Some parents would prefer minimize needle sticks and would opt to receive MMRV, while others would prefer to have MMR and Varivax given separately to minimize any risk of  an adverse event. Due to the fact that the increased seizure risk was seen in children between 12-23 months, one might advocate to use the separate vaccines for the initial series and the combination vaccine in the older child (who would probably vote to get one less STICK). Protecting against measles, mumps, rubella and chickenpox is the most important issue at hand.  Discuss the pros and cons of the combination vaccine with your own doctor, but be reassured that vaccines are continually being monitored for safety as well as efficacy. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue.

Daily Dose

Politics & Vaccines

1:30 to read

As we head into another election cycle, I bet many of you watched the recent GOP debates (23.1 million viewers).  I too was watching and listening, but I must say my ears perked up when I heard several of the candidates discuss the issue of childhood vaccines.  Suddenly I was hearing politicians or political “wanna bees” discussing whether or not children should receive vaccines?  I held my breath as I heard several of the candidates, some of whom are even physicians who presumably understand science, discuss vaccine safety, alternative vaccine schedules and the relationship of vaccines to autism.

I truly was aghast to hear Donald Trump discuss his anecdote of a child who purportedly had their vaccines and suddenly “became autistic” (which is a diagnosis made over time). Then there was Dr. Ben Carson, a pediatric neurosurgeon who stated  “we are probably giving way too many vaccines in too short a period of time”.  Had he forgotten children with meningitis?  As I sat in front of the TV and groaned I heard Dr. Rand Paul add, “vaccines are one of the greatest medical discoveries of all time, but even if science doesn’t doesn’t say bunching them up is a problem, you ought to be able to spread vaccines out a little bit”. Has he done a study to show that alternative schedules work?

Many of their statements were based on “faulty logic”, and had “no scientific basis” and some were entirely anecdotal. Numerous studies from around the world have proven that there is no link between vaccines and autism. Vaccines have only gotten safer and are essential for public health.  Stick to the facts…were the fact checkers watching?  Where was the rebuttal?

As a pediatrician who discusses vaccines with patients on a daily basis I must say I was horrified by these statements.  If politicians want to weigh in on childhood vaccines then it is incumbent upon them to be “briefed” and up to speed about the science behind the childhood vaccine schedule and vaccine safety.   While they are learning about foreign policy, economic decision making and the recent issues surrounding global immigration ( all of which seem to be more of a political policy issue than childhood vaccines) maybe they need a crash course in public health.  Misinformation about vaccines from those who have a national television audience is unacceptable. Having a child “go un-immunized”  due to statements that were made during  the GOP debate, has the potential to harm many children. Just look at the recent measles outbreak….these are serious issues. 

The president of the AAP quickly released a statement endorsing the childhood vaccination schedule, the importance of vaccines and vaccine safety. Many pediatricians as well as other physicians have also re-iterated the importance of vaccines being given according to the vaccine schedule. As Dr. Remley stated, “what is best for children is to be fully immunized”. plain and simple. I am hopeful that the 23 million debate watchers heard her message.

Your Child

HPV Vaccine: More Effective Than Thought

1:45

A study out of New Mexico finds that the vaccine against human papillomavirus (HPV) infection, which doctors believe causes most cases of cervical cancer, could be much more effective than previously thought.

"After eight years of vaccination, the reduction in the incidence of cervical neoplasia [abnormal growth of cells], including pre-cancers, have been reduced approximately 50 percent. This is greater than what was expected -- that's pretty exciting," said lead researcher Cosette Wheeler. She is a professor of pathology and obstetrics and gynecology at the University of New Mexico, in Albuquerque.

Researchers also found that one or two doses of the vaccine may provide as much protection as the recommended three.

"Right now, the recommendation is three doses for girls and boys before the 13th birthday, so that you are protected before you become exposed," Wheeler explained.

"People thought that three doses of vaccine were necessary, but there's a lot of people who are getting one and two doses, and people are getting protection from one or two doses," she said.

Another benefit is that the vaccines protect against more types of HPV than they were designed to do, noted Wheeler.

Other studies have pointed to the effectiveness of the vaccine, but this is the first study to show declines in precancerous lesions across a large population.

This study even took into account changes in Pap test screening over the last 10 years.

In 2009, the American College of Obstetrics and Gynecology said most women under 21 do not need Pap test screening and recommended longer times between screening. In 2012, the U.S. Preventive Services Task Force said women, regardless of age, do not need to get screened more than every three years, Wheeler said.

If these changes were not taken into account, the effect of the vaccine would appear even greater than it already is, because it would assume that more women were being screened than actually were, she said.

"Parents and doctors should pay attention. These vaccines are highly efficacious," Wheeler said.

Cervical cancer can take decades to develop so it’s important to protect children before they become sexually active.

The Centers for Disease Control and Prevention (CDC) recommends that the HPV vaccine be given to vaccine is preteen boys and girls at age 11 or 12 so they are protected before ever being exposed to the virus. The HPV vaccine also produces a more robust immune response during the preteen years. Finally, older teens are less likely to get heath check-ups than preteens. If your teen hasn't gotten the vaccine yet, talk to their doctor or nurse about getting it for them as soon as possible.

For the study, Wheeler and colleagues collected data on young women tested for cervical cancer with Pap tests from 2007 to 2014, who were part of the New Mexico HPV Pap Registry. New Mexico should be considered representative of the whole country, Wheeler said.

One expert said the findings make the case for HPV vaccination even stronger.

"These data highlight and provide even more evidence as to the efficacy of the vaccine in preventing HPV infections and related diseases," said Fred Wyand, a spokesman for the American Sexual Health Association/National Cervical Cancer Coalition.

Wyand suggests that one way to increase HPV vaccination rates is for health providers to stress the importance of the vaccine to parents.

Another way is to “normalize” the vaccine.

"Rather than treat it as something exotic, it should just be offered as part of the routine adolescent vaccine program," Wyand said.

The report was published online Sept. 29 in the journal JAMA Oncology.

Story sources: Steven Reinberg, http://www.webmd.com/sexual-conditions/hpv-genital-warts/news/20160929/hpv-vaccine-more-effective-than-thought-study#1

http://www.cdc.gov/hpv/parents/vaccine.html

 

Daily Dose

Exercise Patience During Swine Flu Season

I imagine that you may be getting tired of reading my blogs on swine flu, and I can assure you, we are all (pediatricians that is) tired of talking about it too. But, from the phone calls that our office is being inundated with, there are still more questions and concerns about the H1N1 (swine) flu.

Fortunately, in our part of the country it seems that we have started to see fewer “flu-like” illnesses and the waiting rooms at our office are not quite as crowded. That may not be the same in other areas of the country as now 46 states report widespread flu activity. Even though we seem to be seeing fewer cases of presumed H1N1 flu in our area, we do not know, and no one knows, if this virus is going to quietly fade away, or if we will see a second wave of H1N1 later this year and into 2010.  Unless you can truly predict the future, we will all just have to wait and see. With that being said, the H1N1 vaccine is becoming more widely available and there are prioritized groups that should begin getting vaccinated. There are two types of H1N1 vaccine, just like the seasonal flu vaccine. There is an injectable “killed” vaccine and there is a live-attenuated nasal vaccine (similar to seasonal Flu-mist nasal spray). Children between six months and two years of age should receive the injectable flu vaccine. This injectable vaccine should also be given to pregnant women and to children ages two to 24 years who have underlying chronic medical conditions that prevent them from taking the nasal flu mist (refer to http://www.cdc.gov/ to see the list of those conditions) for those children between the ages of two to 24 years who are otherwise healthy, the injectable or nasal H1N1 vaccine may be given (it is approved for use up to 50 years of age). The other targeted group to receive the H1N1 vaccine is parents, siblings and caregivers of infants under six months of age. Again, the majority of those may receive the nasal vaccine and injectable may be used when appropriate for older individuals. In our office the most current problem comes with trying to prioritize groups that receive the first doses of vaccine and to explain to others that they too will get the vaccine once the vaccine supply increases, as it should in the next several weeks. This is a true lesson in patience, and in taking turns, just like we teach our own children. Those with the most risk should get the first doses of vaccines. Don’t you agree? There is just not a way to vaccinate 100 million people in a day. Lastly, the Centers For Disease Control and Prevention in a news conference yesterday, reiterated that antivirals like Tamiflu, should be given to children who are at higher risk for complications. Tamiflu should not be given “routinely” to those patients who are above the age of two years, and who do not to appear to be extremely ill. It does not need to be given to all household contacts. For most, the illness is self-limited and may be treated with rest, fever control, hydration and TLC (tender loving care, for the younger set that looks at me like, “what does that mean?”). In all cases your doctor needs to see any child who seems to be having respiratory distress, is not taking fluids, or seems to be getting worse rather than better after several days. So, continue to wash your hands, cover your mouths and get your vaccines, as they are available. We have a long way to go this flu season and besides coughing into your elbow. I hope PATIENCE may be the other lesson everyone learns during the fall and winter this year. That’s your daily dose, we’ll chat again soon.

Daily Dose

Jimmy Kimmel's Vaccine Points

1:30 to read

The measles outbreak continues (156 cases in the U.S.) and more and more people are speaking up about vaccinations. In fact, Jimmy Kimmel did a great stand up discussing the importance of vaccinating children. He made several valid points, including the fact that many parents “trust” Facebook posts over doctor’ science and recommendations to vaccinate children.  He also mentioned the fact that there are people who believe Jenny McCarthy’s views on vaccine safety over science.

So, Jimmy Kimmel makes a good point...if you don’t trust your doctor to vaccinate you child (who has gone to school for at least 11 years to become a board certified pediatrician), why would you trust them to stitch up your head, or treat your other maladies. I guess it is a bit of a double edged sword.

But the measles outbreak points to the fact that when you choose not to vaccinate your child, you are not only putting your own child at risk, but you put other children who may be too young to get the vaccine (my grand-daughter included), or be immunocompromised at risk.

If your child does not get vaccinated and develops tetanus after stepping on a dirty nail...you are not putting any one else at risk of getting tetanus. But,  are you then going to take your child to the same doctors who recommended that you vaccinate them and you will now rely on them to save your child’s life. There is a lot of irony when thinking about that terrible scenario.

My granddaughter just had her 6 month vaccines, including the first half of her flu vaccine. She ran a fever that night and her worried parents called me. She was fussy, uncomfortable and deprived her parents of some sleep, but after receiving some acetaminophen and TLC from her parents she was back to her happy self in 24 hours.  A much faster recovery than from meningitis, rotavirus, tetanus, flu or polio, all of which could also be deadly.

She will be getting her booster flu in a month and her MMR (mumps, measles, rubella) the minute she turns one.  In the meantime, I am depending on everyone else to immunize their own children against measles to protect her.

Daily Dose

Why Vaccinate Your Child?

1:15 to read

Getting your child immunized against mumps, measles and rubella (MMR) may provide even more protection than previously thought. An interesting article was just published in the journal Science pointing out yet another reason to get your children vaccinated.  

While measles is still uncommon in the United States (but there have been over 170 cases this year), there are over 140,000 deaths around the world every year due to this disease. Studies have shown that once you have the measles you are more susceptible to other infections for up to 2 years.  But, in countries where most measles cases occur the researchers found that the children who had received the measles vaccine had a reduced death rate for up to 5 years, which suggests that the vaccine somehow provides protection against other illnesses.

A medical student at Emory University (bet he is going to be a great doctor) working with others from around the world found that the measles virus might cause “immunological amnesia”. It seems that the measles virus kills a large number of memory cells, which are white cells that prevent subsequent infections by the same disease. After the measles the body’s immune system somehow “forgets” to remember diseases  it has already beaten, which would then put you at increased risk of being susceptible to diseases you shouldn’t be vulnerable to.

While more research is necessary this secondary protection may be yet another reason to get vaccinated!! Good science continues to show us the value of vaccines....this study was funded in part by the Melinda and Bill Gates foundation which is doing incredible work around the world on vaccines and eradicating vaccine preventable diseases.  For this I am a grateful doctor.

Your Child

Getting Ready for a New School Year!

2:00

As summer break begins to wind down, preparations for a new school year are gearing up.  Whether it’s the first day of school for your little one or your teen’s first year of college, making the transition from vacation to a daily schedule requires some pre-planning.

Typically, the most difficult changeover for everyone is getting used to a regulated bedtime routine. Getting enough sleep will help family members handle the switch better. I know that’s much easier said than done, but it's worth the effort. Now is a good time to start preparing for a new school year schedule.

As pediatrician, Dr. Sue Hubbard, has said previously in her kidsdr.com Daily Dose article, a couple of weeks before the start of a new school year is when families should start getting used to a new schedule.

“In order to try and minimize grouchy and tired children (and parents too) during those first days of school, going to bed on time will be a necessity. Working on re-adjusting betimes now will also make the transition from summer schedule to school schedule a little easier. If your children have been staying up later than usual, try pushing the bedtime back by 15 minutes each night and gradually shifting the bedtime to the “normal” hour. At the same time, especially for older children, you will need to awaken them a little earlier each day to re-set their clocks for early morning awakening,” Hubbard noted.

Another important detail to take care of before school begins is making sure your child is current on all immunizations. Each state has its own requirements and exemptions. In Texas for instance:

K-12 grades are required to have - the Tetanus/ Diphtheria/ Pertussis (Tdap) vaccine, Measles, Mumps and Rubella (MMR) vaccine, the Polio vaccine, Hepatitis B vaccine, and the varicella vaccine. K through 6th grade are also required to get the Hepatitis A vaccine and 7th through 12 grades, a meningococcal vaccine.

Also highly recommended, but not a state law requirement, is the Human Papillomavirus Vaccination (HPV) for boys and girls.

You can find out exactly what your state’s school immunization program is by logging onto http://www.cdc.gov/vaccines/imz-managers/awardee-imz-websites.html and clicking on your state.

And lets not forget our college bound students! Universities have their own policies, but these vaccines and booster shots are highly recommended by physicians and most universities: Meningococcal conjugate vaccine (MenACWY), Tdap, HPV vaccine and the seasonal flu vaccine. Be sure to check with your child’s school to see what specific vaccines are required or suggested.

The first day of school for kindergarteners and / or first-graders can be unsettling for kids and parents. Here are a few ways you can help your child face the uncertainty:

·      Remind your child that there are probably a lot of students who are uneasy about the first day of school. This may be at any age. Teachers know that students are nervous and will make an extra effort to make sure everyone feels as comfortable as possible.

·      Point out the positive aspects of starting school.  She'll see old friends and meet new ones. Refresh her positive memories about previous years, when she may have returned home after the first day with high spirits because she had a good time.

·      Find another child in the neighborhood with whom your student can walk to school or ride on the bus.

·      If it is a new school for your child, attend any available orientations and take an opportunity to tour the school with your child before the first day.

·      If you feel it is needed, drive your child (or walk with him or her) to school and pick them up on the first day.

Nutrition is an important factor in children doing well in school. During the summer break kids often get off schedule with their eating habits. Start the early morning routine at least a week before school actually starts so that everyone has a chance to get used to having and preparing breakfast early.

Studies have shown that children who eat healthy, balanced breakfasts and lunches are more alert throughout the school day and earn higher grades than those who have an unhealthy diet. 

Back-to-school- shopping, new schedule arrangements, homework time and space, immunizations, after-school sports and activities – they’re all part of a new school year.

One way to help keep everybody on track is with a calendar that is placed where everyone can see it and update it.

Here’s to a new school year that is full of learning, exciting experiences and good grades!

Source: http://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Back-to-School-Tips.aspx

 

Daily Dose

Acetaminophen & Vaccines

1:30 to read

A recent article in Lancet was quite thought provoking as it studied the common practice of giving infants a dose of acetaminophen (Tylenol) with their routine immunizations.

Many parents and some pediatricians routinely dose their infants with acetaminophen prior to receiving their vaccines at two, four and six months of age. In the study of 459 infants from 10 different centers in the Czech Republic, patients were randomized to either receive three doses of acetaminophen every six to eight hours at the time of vaccination or no acetaminophen. The researchers then looked at both the reduction of febrile reactions post vaccination and at antibody titers among the two groups. Interestingly, there were both some expected and some not so expected results. Not surprisingly, the group that received acetaminophen had a lower incidence of fever post immunization. Of those that received acetaminophen 94 out of 226 (42 percent) developed a fever, compared to 154 out of 233 (66 percent) in the non-treated group after their primary immunization series. After booster vaccination 64 out of 178 (36 percent) in the treated group and 100 out of 172 (58 percent) developed fever. So the widespread perception by both many parents and doctors that routine acetaminophen use with vaccination does reduce the incidence of fever was supported.

The most interesting result of this study was the vaccine antibody response in the acetaminophen treated group. Surprisingly, antibody responses to several of the routinely administered vaccines (including tetanus, diphtheria, h. flu, and pneumococcal serotypes) were lower in the group who received routine acetaminophen. This was also seen after booster doses of the same vaccines between 15 to 18 months of age. The hypothesis is that acetaminophen may reduce the inflammatory response and that this may also induce less of an immune response. So, it would seem prudent to no longer encourage routine use of acetaminophen with vaccines unless a baby develops significant fever, or is at risk for fever and febrile seizures. As a parent you are always trying to “protect” you child, and this would include any pain or fever that might develop with vaccination. Now we have science to show how this may actually provide less protection, against disease. Thought provoking!

That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Why Doctors Fire Patients

1.30 to read

There was an article in the WSJ entitled “more doctors dismissing patients who refuse vaccines for their children”.  It was interesting to me as I too now only accept new patients who are going to vaccinate their children. This was not an easy decision on my part, and prior to the decision I had several families who refused vaccines completely, and another group that followed “an alternative” vaccine schedule. Even so, I was never comfortable with their decision and it always gave me pause and sleepless nights when their children would get sick. 

During the height of the debate over vaccine safety and the possible link to autism it seemed like much of my day was spent “debunking” vaccine myths. I spent a great deal of time discussing the reasons behind the AAP/ACIP (American Academy of Pediatrics and the Advisory Committee on Immunization Practices) recommended vaccine schedule and also explaining how vaccinations had saved lives, actually millions of lives. 

As more and more data was gathered, and the Wakefield papers were discredited, it became apparent that there was not a link between vaccines and autism. The arguments about thimerasol in vaccines were also moot as thimerasol is no longer the preservative used in vaccines (except for flu vaccine). With all of this being said I decided to take a stand and vaccinate all of my new patients, according to AAP guidelines. 

I discuss this decision with families even before their child is born. I tell them that it is important to pick a pediatrician that shares their beliefs as the  doctor patient relationship is a long one in pediatrics. (hopefully cradle to college)  It is analogous to dating; why would you pick a date on a match site if you held opposite beliefs to begin with?  

The same goes with picking a pediatrician, you need to start off the relationship on common ground. Even if there may be some other disagreements on subjects down the road, I think you need to begin the relationship holding similar beliefs. 

I have practiced long enough that I remember doing spinal taps in my office and treating children with meningitis or bacterial sepsis. There were long nights spent in the ICU with families and unfortunately a few patients died, while other survived but are deaf or have other residual effects from their disease.  It was devastating to me and I can’t even imagine for those families. I also bet that those families would have given anything to have a meningitis vaccine or a chickenpox vaccine for their now deceased children. 

I understand that every parent has to make their own decision for their children. At the same time I believe that it is also “my practice” and I get to choose how I practice pediatrics. With that being said, my parents choose to vaccinate their children and we happily start off the parenting/doctoring partnership together.  I also sleep better at night not worrying that their child will contract a vaccine preventable disease. 

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

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