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Your Child

Back-To-School Immunizations

2:30

Is your child up-to-date on his or her immunizations for the new school year?

Each state has its own set of immunization requirements, but there are a few that are found in nearly all states. Make sure you know which are required for your child’s school.

The typical list includes:

DTaP (Diphtheria, Tetanus, Pertussis)

·      Most children have five dosages by the time they start school, including one after their fourth birthday

·      Remember that children also need a tetanus booster when they are around 11 to 12 years old

·      The Tdap vaccine (Boostrix or Adacel) is recommended for teens and adults to protect them from pertussis in 2006 and replaces the previous Td vaccine that only worked against tetanus and diphtheria

MMR (Measles, Mumps, Rubella)

·      Two doses of MMR are usually required by school entry. In the past, the second dose was given when a child was either 4 to 6 years old or 12 years old. Now, it is usually given earlier, but some older children may not have gotten two doses yet.

·      Having two doses of MMR is important in this age of measles outbreaks.

IVP (Polio)

·      Most children have four or five dosages by the time they start school, including one after their fourth birthday.

Varivax (Varicella, or the Chickenpox vaccine)

·      Your older child will need the chickenpox shot if he has not already had chickenpox in the past. Most toddlers young receive it when they are 12 to 18 months old. Although younger children used to be given just one dose, it is now required that kids get a chickenpox booster shot when they are 4 to 6 years old. Older kids should get their booster at their next well child visit or as soon as they can so that they don't get chickenpox.

Hepatitis B

·      A series of three shots that is now started in infancy. Older children are usually caught up by 12 years of age if they haven't received this vaccine yet.

Hepatitis A

·      A set of two shots for children over 12 months years of age. All infants and toddlers are now getting this shot as a part of the routine childhood immunization schedule, but there is currently no plan for routine catch-up immunization of all unimmunized 2- to 18-year-old children, unless they live in a high-risk area with an existing hepatitis A immunization program or if the kids are themselves high risk. Kids are high risk for example, if they travel to developing countries, abuse drugs, have clotting-factor disorders, or chronic liver disease, etc.

·      Hepatitis A vaccine is required to attend preschool in many parts of the United States.

Hib

·      While required for school entry, children do not usually receive this shot after they are five years of age, so children who have missed this shot don't usually need to get caught up before school starts if they are older than 5 years old.

Prevnar

·      A vaccine that can help to prevent infections by the pneumococcal bacteria, which is a common cause of blood infections, meningitis and ear infections in children.

·      Prevnar is typically given between the ages of two months and five years, and isn't approved for older kids, so your older child wouldn't need this shot if he didn't get it when he was younger. It is often required to attend preschool though.

·      A newer version of Prevnar, which can provide coverage against 13 strains of the pneumococcal bacteria, is approved and replaces the older version (Prevnar 7) in 2010, which means that many older children in preschool may need another dose of Prevnar 13, even if they finished the Prevnar 7 series.

·      Another version of this vaccine is available for certain older high-risk children though, including kids with immune system problems, although that wouldn't be required for school.

Meningococcal vaccine

·      Menactra and Menveo, the newest versions of the meningococcal vaccine, is now recommended for children who are 11 to 12 years old, with a booster dose when they are 15 to 18 years old.

The American Academy of Pediatrics (AAP) recommends that all school age children stay up-to-date on all their immunizations.

As well as the vaccines recommended above, AAP includes a few others in its 2016 list. They include:

Influenza

·      Administer influenza vaccine annually to all children beginning at age 6 months. For most healthy, non-pregnant persons aged 2 through 49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) persons who have experienced severe allergic reactions to LAIV, any of its components, or to a previous dose of any other influenza vaccine; 2) children 2 through 17 years receiving aspirin or aspirin-containing products; 3) persons who are allergic to eggs; 4) pregnant women; 5) immunosuppressed persons; 6) children 2 through 4 years of age with asthma or who had wheezing in the past 12 months; or 7) persons who have taken influenza antiviral medications in the previous 48 hours.

Human papillomavirus (HPV)

·      Administer a 3-dose series of HPV vaccine on a schedule of 0, 1-2, and 6 months to all adolescents aged 11 through 12 years. 9vHPV, 4vHPV or 2vHPV may be used for females, and only 9vHPV or 4vHPV may be used for males.

·      The vaccine series may be started at age 9 years,

·      Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks), administer the third dose 16 weeks after the second dose (minimum interval of 12 weeks) and 24 weeks after the first dose.

·      Administer HPV vaccine beginning at age 9 years to children and youth with any history of sexual abuse or assault who have not initiated or completed the 3-dose series.

Many states have added an “opt out” choice for parents on some vaccines but not all. For the health and safety of all children, the AAP recommends that parents follow each state’s immunizations requirements and not opt out unless there is a medical necessity.

Story sources: Vincent Iannelli, MD, https://www.verywell.com/school-immunization-requirements-2633240

http://redbook.solutions.aap.org/selfserve/ssPage.aspx?SelfServeContentId=Immunization_Schedules

 

 

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.

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

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.

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.

Your Baby

No Link Between Vaccines and Autism

1.30 to read

A new study slated to appear in the Journal of Pediatrics, says that there is no association between the amount of vaccines a young child receives and autism. Some parents have worried that there may be a link and have opted out of having their child vaccinated or reduced the number of vaccines recommended.

The percentage of children diagnosed with autism spectrum disorder (ASD) has increased by 72% since 2007. Some experts believe that changes in the diagnostic criteria may account for some of the increase as well as better screening tools and rating scales.

According to a statement released from the journal, researchers from the Centers for Disease Control and Prevention and Abt Associates analyzed data from children with and without ASD.

Researchers examined each child's cumulative exposure to antigens, the substances in vaccines that cause the body's immune system to produce antibodies to fight disease, and the maximum number of antigens each child received in a single day of vaccination, the journal's statement said.

The antigen totals were the same for children with and without ASD, researchers found.

Scientists believe genetics play a fundamental role in the risk for a child developing autism (80-90%), but recent studies also suggests that the father’s age at the time of conception may also be a contributor by increasing risks for genetic mistakes in the sperm that could be passed along to offspring.

Parents have worried about a link between vaccines and autism for decades despite the growing body of scientific evidence disproving such an association.

Source: Luciana Lopez, http://www.reuters.com/article/2013/03/29/us-usa-health-autism-idUSBRE92S0GO20130329

Daily Dose

Thimerosal In Flu Vaccines

Confusion about thimerosal in flu vaccinesI received an email from a reader who “had a problem with my statement about vaccines being thimerosal free”.  Since 2001 all vaccines given to children under the age of 6 are thimerosal free, with the exception of the influenza vaccine.

She is correct in pointing out that influenza vaccines may contain a minimal amount of thimerosal (a mercury based preservative), but influenza vaccines are also available thimerasol free.  The LAIV (live nasal vaccine/flumist), is also thimerasol free and is available for use in children 2 and older.

Although injectable influenza vaccines may contain a minimal amount of thimerosal, the amount is negligible and is deemed safe by both the FDA and the CDC. Infants are not receiving a series of vaccines containing thimerasol, and at most would receive 2 influenza vaccines after they are 6 months of age during the first season that they are vaccinated, and subsequently would receive one dose per year thereafter.  There are also thimerasol free influenza vaccines available (this year both seasonal and “swine flu” vaccines) for use. By the time a child is 2 years of age, they would at most have received 3 doses of an influenza vaccine that had  0.01% thimerasol or less which would be between <1 mcg – 25 mcg/0.5ml vaccine dose. (Do you know how much mercury is in the fish you eat or other products you consume daily?)  After the age of 2 parents may choose to have their child immunized for influenza with the LAIV nasal vaccine that is also thimerasol free. As with many things in life one must weigh the risk benefit ratio, in this case of giving a vaccine that contains minimal thimerasol. In my opinion the science has quite eloquently proven that there is not a link between the preservative thimerasol and autism. With that being said,  I also believe that the risk of an infant developing flu and having complications from their infection, far outweighs any hypothetical or anecdotal concern about thimerasol. As I have said before, we know what does not cause autism and it was not thimerasol in vaccines. In fact the rate of diagnosis of autism has gone up, rather than down, since thimerasol was removed from vaccines. We need to continue to devote research dollars to finding the cause of autism. In the meantime, I stand corrected and wanted to give all of you more detailed information about thimerasol and influenza vaccines. That's your daily dose.  We'll chat again tomorrow! Send your question to Dr. Sue! (click here)

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

 

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