Refusing milk from a cup

The Pediatric Insider

© 2009 Roy Benaroch, MD

 

Analise is trying to get her daughter to continue drinking milk: “My daughter is 14 months old and will only drink milk from a bottle. We introduced a sippy cup at 9 months but made the mistake of only putting water in it. Now she associates the cup with water and the bottle with milk. We’re in the process of weaning her from the bottle but don’t know how to convince her to drink milk from a cup. Do you have any tips or is it just try, try again until she accepts it? Thanks for any behavioral insight or advice!”

 

First, let me get myself in trouble with the dairy council and moms everywhere by letting this secret out: there is no essential need for toddlers to drink milk. It’s a good source of protein and calcium, sure, but there are plenty of other good sources. Lots of children stop drinking milk, and many adults never touch the stuff. There’s no reason to consider milk something crucial for children to drink once they’re outside of the young baby years and able to take solids well.

 

At fourteen months, whether or not your child is willing to drink milk from a cup, you ought to stop using baby bottles. They’re bad for her teeth, and they’re preventing her from developing normal eating habits. Don’t worry that your child won’t get enough fluids—she’ll drink water, and she will not become dehydrated without milk.

 

Though milk isn’t essential, it’s handy and most children continue to drink it. There are, of course, tricks worth trying to get her to drink milk from a cup:

 

• Add a little milk to the water in a cup, and day-by-day start adding more milk and less water. In a few weeks, you can wean up to full strength milk. Do this gradually and maybe she won’t notice.
• Add something to the milk to make it extra tasty: chocolate syrup, or maybe a mashed-up, very soft banana. Little girls (and boys) deserve a little chocolate in their lives.
• Try a different sort of cup, like one with a straw—maybe even a crazy bendy cool straw.
• Make sure she sees you and dad drinking milk from a cup. You two can even use sippy cups for a little while. If parents don’t drink milk, children are far less likely to want it.
• If you’ve been using whole milk, give 2% or skim a try. Older advice did recommended whole milk, but that’s not necessary.
• Try a different sort of milk, like soy or almond milk. These provide similar amounts of protein and calcium as cow’s milk. Rice milk, on the other hand, is a low-protein beverage more similar to juice than milk—stay away from it if you’re looking for something with nutritional value for your children.

 

What to do during the transition? Don’t worry about it. There is no reason a child can’t go weeks or months or even years without milk. If your daughter gets the impression that milk is something very special and important, she’s less likely to touch the stuff—this is called “yanking your parents’ chain,” a skill that all children learn sooner or later. Don’t get caught up in the drama by letting her know you’re worried about this. Win the chain-yanking match by dropping your end.

 

If in the long run your daughter still won’t touch milk, you’ll need some other good calcium sources:

 

• Any other dairy: cottage cheese, yogurt, cheese, ice cream
• Calcium fortified juices
• Calcium supplements, like the little chocolate squares marketed for women as Viactive
• Non fat dry milk powder. Don’t mix this in water to try to drink it—bleach—but sprinkle it in casseroles, soups, eggs, sauces, that kind of thing. Once it mixes in it’s just about impossible to taste. Think of it as cheap calcium –n- protein powder.

 

Try some simple tricks to see if you can get your daughter back on milk, but remember there is no hurry here, and this is not a crucial or even a very important issue. Milk is easy and cheap, but there are many other nutritious things your daughter can take that can replace milk if she’s decided she just won’t drink it any more.

Blink blink blink = tic tic tic

The Pediatric Insider

© 2009 Roy Benaroch, MD

Mark’s frustrated. His son has gone through several months when he seems to blink a lot—then it goes away, then it comes back later. It doesn’t seem to bother the boy. One doctor said it was allergies, and prescribed an eye drop; another one says it’s a compulsion, and that dad should ignore it. What’s going on here?

Most likely, he’s got a tic. Not a tick—that’s a blood sucking beetle-looking thing—but a tic, which is a quick, short involuntary muscle movement. The most common tics seen in kids are blinking, followed by throat clearing; sometimes kids have a little quick facial grimace or a neck-turn.

You’ve got the wiring for a tic, too. Let’s watch yours. Go ahead, stop blinking. I’ll wait here. Dum dee dah dum. Still not blinking, right? It’s getting hard….hard to not blink…have to concentrate…so, do any fishing lately? no? ….wait …no blinky….wait….arrrgh blink blink blink blink blink blink. Aaaaaaa. That’s better.

What happened? Believe me, your eyes didn’t dry out that quickly. So why did you feel an urge to blink?

That’s basically what a tic is. It’s an involuntary movement—you can’t put it off, you’ve just got to do it. If you don’t, it gets harder and harder to stop it…until…blink blink blink! Blinking, in all of us, is like a helpful tic, an automatic mechanism to keep your eyes healthy. But sometimes that mechanism causes excessive blinking, or other sorts of quick involuntary movements that can’t be suppressed.

About 1 in 20 of us has a tic, and tics usually start to develop in early childhood. Usually, the individual tic goes away after a few months. But children who’ve had a tic in the past are quite likely, even after several months or years, to once again develop a tic, often a different one.

Do not tell a person with a tic to stop it. If he tries, the tic will become harder and harder to resist, until it returns in a more exaggerated fashion. The best therapy? Don’t talk about it.

Tics do get worse with emotional upset, anxiety, or tiredness. They stop completely when you fall asleep. Many people blame incessant throat clearing on “allergies”—but oddly enough, when they sleep, there’s no need for throat clearing at all. You’d think lying down would just encourage a nice pool of mucus, wouldn’t you? So why is there no need to clear the throat during sleep? Most throat clearers aren’t allergic—they’ve got a tic. But their minds “invent” the feeling of phlegm and the allergy story. Amazing, the mind, what it will come up with.

Most children with tics have only one, and it goes away on its own after a few months. No treatment is needed. Rarely, children develop multiple complex motor and vocal tics, often associated with difficulty concentrating at school. This is Tourette’s Syndrome—more serious, but far more rare than an ordinary tic. If your child has multiple tics and especially if school is becoming a problem, see a pediatric neurologist. Medicines are almost never necessary for simple, non-bothersome tics, but for the rare child with more serious tic issues medication can be very helpful.

Roy gets lazy: A web roundup

The Pediatric Insider

© 2009 Roy Benaroch, MD

I’ve always thought it’s kind of lazy to make a blog post of a bunch of links to other people’s stuff. It’s sort of like slapping a book cover over “The Brothers Karamazov” that says “Here, read this, By Me”. On the other hand, perhaps you wouldn’t otherwise read Dostoevsky’s final novel, a philosophical exploration of the existence of God and the contradictions of free will. I know I haven’t. But I mean to, and if I’m going to ever get through it, I’ll need to spend less time writing, and more time posting rehashed material and lists of my latest favorite web sites. So here you go!

TwoPedsinaPod is a homey, very readable, and very practical blog full of pediatric advice written by two smart docs I met at a big peds conference.

Need help paying for prescription medications? Try this site first. Needymeds is a genuine non-profit that will help guide you towards drug assistance and other programs to help you pay for medicines. They also offer a free drug discount card that you can download, print, and start using right away.

Need reliable (rather than hysterical) information about the H1N1 flu epidemic? Go to the CDC’s comprehensive site of info, and stop watching the local news.

Shot of Prevention is an unabashedly pro-vaccine site providing thoughtful, well-researched articles to weigh against the proliferation of anti-vax lunacy on the web.

Is your child a beginning reader, or an almost-beginning reader? The Starfall website has lots of free, fun stuff to help kids on their way! For education stuff for elementary school age kids, check out Funbrain.

And this is just funny.

Enjoy, and post your own links below!

Tongue tie

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kelly has a six-year-old son who has tongue-tie, but there are “…no speech problems, no eating problems…he just can’t stick his tongue out and taking temp under tongue is a challenge. Our ENT is recommending to clip. This requires general anesthesia.”

This is one of those questions that could get you some different answers… but since you posted it to my blog, you’re stuck with my response!

Tongue-tie means that the little flap of tissue under the tongue (the “frenulum”) is kind of short, so the tongue can’t lift off the floor of the mouth easily. The doctor-word for this (God forbid we talk like normal people) is “ankyloglossia”. Most of the time, the tongue also can’t extend far past the gums or out of the mouth. I’m not sure I’ve ever seen exact data on how far out a tongue should stick out, but most people can easily poke their tongues at least past their lips, so that’s probably “normal.”

In the good old days, if a tongue was perceived as “tied”, the pediatrician would take a little scissors and snippity-snip right there in the newborn nursery, packing some gauze under the tongue. Simple, I guess. But is it necessary?

Most of us feel that tongues come in all sorts of shapes and sizes and stick-out-ability. Rather than fixate on what the tongue looks like, I think a more reasonable way to look at it is just how the tongue-tie affects the child. If it’s a newborn who genuinely can’t nurse well
or a child with a speech problem, that probably should be repaired. But I don’t see the need to fix a tongue just because it can’t be stuck out very far. Maybe it’s better for children to find other ways to express themselves!

H1N1 Vaccine: One dose or two?

The Pediatric Insider

© 2009 Roy Benaroch, MD

I seem to be spending a lot of time on H1N1 here, and a lot of time on H1N1 issues in my office. I can see myself, an old retired doctor in 50 years, sitting in my holo-rocking chair, listening to my octophonic MP6 player through my aural uplink (a new, never-released Michael Jackson tune!), reminiscing about the winter of 2009, the Swine Flu. “What’s a swine?” my grandchildren will ask.

 

For now, though, we’re in the thick of it. And some very smart people with brains larger than I are guessing that about a third of us in the USA are going to get this darned thing this winter. A third. Imagine that.

 

We still need to keep this in perspective. That’s a lot of sick people, but the vast majority of children and adults who get H1N1 flu recover fully in about five days. It’s uncomfortable and unpleasant and, well, pretty miserable for five days, but H1N1 has a very low rate of complications. Still, with perhaps 100 million Americans getting ill, even rare complications are going to occur more frequently than I want to see them. Some people are going to get quite ill, some people are going to be hospitalized, and some people are going to die. We should do what’s safe and effective to slow this epidemic.

 

How to prevent it? Stay away from sick people. Wash your hands. Don’t touch your face. Don’t go to work when you’re sick, and don’t send your kids to school when they’re sick. Workplaces should not encourage sick employees to work, and schools should not reward perfect attendance.

 

And please, get the dang vaccine. Forget the AM radio and internet nonsense: the government and the doctors do not want to kill you.

 

Getting all of this vaccine made and distributed has not been an easy task, and I wouldn’t call the government’s efforts one of their finest moments. At my office we’re depending on the folks at the Fulton County Health Department, who’ve so far sent us a tiny smidge of our expected order. With no advance warning, and no word on when we’ll get more. But the overall picture is improving—though the vaccine is dribbing out, it is getting out, and the trickle should become faster soon. Meanwhile, good studies continue to support the safety and effectiveness of immunization.

 

We’ve known for many years that children younger than 9 don’t seem to mount a strong immune response to flu vaccines, especially in their first year of immunization That’s why current recommendations for ordinary, seasonal flu vaccines suggest that if a child less than 9 is getting a flu vaccine for the first time, the dose should be repeated 28 days later.

 

It turns out that the swine flu vaccine is no different—and that’s no surprise, as it’s essentially the same vaccine that’s used to prevent influenza year after year, designed in this case to prevent this new H1N1 strain. The science, the development, the studies, and the factories are all the same as ordinary flu vaccines. Ignore hype that claims this vaccine is somehow more “new” than other flu vaccines.

 

So: it’s recommended by the ACIP (the advisory board on immunization practices of the CDC) that children less than 9 get two doses of the H1N1 vaccine this year for best protection. (Actually, some studies were done using a 10 year cut-off; so in some places the recommendation is up to age 10; but since that recommendation is up to 9 for seasonal flu, that’s the way most health departments and doctors’ offices are handling it.)

 

At the same time, we know that from a public health standpoint that the best way to put the brakes on the epidemic is to get as much of the population immune as quickly as possible. That will prevent the virus from spreading from person to person. Once the “herd” is mostly immune (or at least more immune), then all of us—vaccinated and unvaccinated—will be less likely to come in contact with anyone with flu, and therefore we’ll all be protected.

 

Though two doses are better than one, the CDC does not recommend that doctors “hoard” doses back to ensure that those second doses are given. We’ve been told—and it does make sense, when you think about it—that we ought to get as many kids vaccinated as possible with first doses, and continue vaccinating as long as we have vaccines, as quickly as possible. Since more and more doses are expected to be distributed in the coming weeks and months, it’s probable that second doses will be available, thought it can’t be guaranteed; and the timing might get tricky. Though a minimum of 28 days between doses is recommended, the interval can be longer than this. By the way, this recommendation is identical to what’s been recommended in previous years with ordinary, seasonal flu vaccines. Hoarding has never been encouraged by CDC or World Health Organization guidelines. Though two doses are better than one, one dose is far better than zero, and getting as many people as possible that one dose is going to help your child, and all of us, stuff this H1N1 genie back in the bottle.

 

Older H1N1 wisdom:

H1N1 vaccine after H1N1 illness?

A pandemic primer for parents

Flu: to shot, or not?

 

The CDC’s H1N1 site

I’m walkin’…on my toes…I’m talkin’…

The Pediatric Insider

© 2009 Roy Benaroch, MD

“My newly-two year old loves to walk on her toes. She’s been doing this for awhile, and it doesn’t seem to bother her (although it looks painful to me!) Should I be concerned about this, or is she a budding ballerina?”

This is one of those “dangerous to google” questions. Dr. Google, displaying his usual tact and lack of context and experience, will tell you there are three kinds of toe walking:

• Associated with spastic cerebral palsy
• Associated with diseases like muscular dystrophy
• Or, the one that isn’t caused by anything and is nothing to worry about

So there you go. It’s either something serious, or it’s not. I lurves the internet! Fortunately, we at The Pediatric Insider are here to guide you through this with a minimum of worry.

The kids with cerebral palsy are usually quite easy to spot. They have delayed milestones—they walk late, and often talk late, and do other motor things late. Sometimes they have small heads. They often have an asymmetry to their walk and their use of their body in other ways, strongly preferring one hand over the other. The physical examination of these kids will show that their muscles are tight, and difficult to relax, and that their reflexes are quite strong and overly brisk.

With muscular dystrophy, toe-walking develops later, as the big muscle of the calf starts to overpower the weaker muscles of the shins. They don’t toe walk when they start walking at age 15-18 months, but develop toe walking later, maybe at age 6 or so. That’s always a “red flag”.

The majority of “toe walkers” seen in a pediatric office fall into the last group, the normal kids who just like to toe walk. These kids start walking at a normal age (by 18 months), and have a symmetrical gait. They don’t always walk on their toes, and if you ask them to they will walk flat-footed, at least for a little while. Their developmental history is normal. On the physical exam, you can gently bend the foot into a nice 90 degree angle with the leg without any pain or undue resistance, and the remainder of the neurologic exam is normal. Almost all of these kids will stop toe walking by age three, and really don’t need a referral or any further tests—though sometimes, if the exam isn’t quite right, I’ll get an orthopedist involved for reassurance.

If a child continues to toe-walk habitually past age three, even with an otherwise normal exam and history, it becomes more likely that the toe-walking will continue. Keeping the foot extended like that will over-strengthen the calf, and it will become physically more difficult for these kids to flat-walk. In some cases, a special orthotic can be made that fits into normal shoes. This “articulated molded ankle-foot orthosis” or “MAFO” extends along the back of the leg and has a hinge that allows the foot to flex up, but not extend downwards past 90 degrees. These seem pretty acceptable to the kids, and do help, but they have to be worn for several months. I wouldn’t really look into one of these until age three or later, and even then only if the child is walking on toes more than 50% of the time.

So: I don’t know if she’s destined to be a ballerina, but as long as your two year old is otherwise doing fine, toe-walking is probably nothing to worry about. I would make sure your pediatrician knows it’s happening at your next appointment, so a careful neurologic and muscular exam can be done. After that, invest in some Tchaikovsky!

A smooch for the trial lawyers

The Pediatric Insider

© 2009 Roy Benaroch, MD

In case you were wondering what’s included in the 1900 page behemoth that is the current health care reform bill, here’s one provision:

Section 2531, entitled “Medical Liability Alternatives,” establishes an incentive program for states to adopt and implement alternatives to medical liability litigation. [But]…… a state is not eligible for the incentive payments if that state puts a law on the books that limits attorneys’ fees or imposes caps on damages.

 So: we’re going to encourage states to reform the medical liability mess—but not if in any way it might affect the incomes of the trial lawyers. More details here.

For those of you who may have naively thought that comprehensive health care reform would address the huge cost of defensive medicine and malpractice litigation, the intentions of Nancy Pelosi’s House Bill couldn’t be more clear. The bill discourages any meaningful reform. As for what’s in the other 1898 pages, a PDF version has been posted online—but honestly, there’s so much legal gobbledygook, I doubt anyone could possibly understand it, and I doubt anyone has read the whole thing. As I feared, it’s getting ugly. Put on your galoshes, America: you’re about to get hosed.

H1N1 vaccine after H1N1 influenza?

The Pediatric Insider

© 2009 Roy Benaroch, MD

Liz asked about influenza vaccines. If her son already had the flu this year, should he still get a flu vaccine? The regular seasonal one, the H1N1 one, or both?

If Junior got the flu in the United States so far this year, it was almost certainly the novel-H1N1 strain (the so-called “swine flu.”) In ordinary winters, people who have the flu with a specific viral type are protected somewhat against having that same flu again, at least in the same winter. The protection isn’t 100%, but neither is the protection from the vaccine.

But this isn’t an ordinary winter. We don’t really know if people infected with H1N1 have decent immune protection, or how long it will last. And most people who say they’ve had the flu haven’t been tested with a highly accurate test—the office-based, quick test that’s often used is not reliable for knowing for sure that it’s a case of H1N1 influenza.

Studies in past years have shown that giving an influenza vaccine to someone who’s already had the flu doesn’t seem to increase the rate of adverse reactions or problems.

So the CDC recommends (scroll down to the “prior illness” paragraph) that this year, people who’ve been told that they already had the swine flu should still get the H1N1 vaccine. If I were designing a system to vaccinate the highest-priority patients first, I’d figure your son has at least some immunity; so perhaps other, more at-risk kids ought to be vaccinated first. But for best protection for your son and the community, he ought to be vaccinated as well.

But really, for all of us, the best way to get thru this winter is going to be for as many people as possible to get H1N1 vaccines as soon as possible. At a recent national meeting, smart eggheads from the ivory towers of infectious disease told me that their models show that at least half of us in the Unites States are going to get H1N1 influenza this year—the only way to prevent this is if most of us get vaccinated, and quickly, to interrupt transmission of the virus. If the “herd” is mostly immune, the virus will slink away. But if many of us remain un-immune, then there will always be another nice warm body to infect, and then spread to others.

As for the “seasonal” flu vaccine—I think he ought to get that one, too. Seasonal flus other than this novel-H1N1 will start circulating soon, probably by December, and I would hate to think what a regular flu season on top of this H1N1 flu epidemic is going to look like. I got my flu vaccines, and I’m still stockin’ up on Purell!

Allergy myths

The Pediatric Insider

© 2009 Roy Benaroch, MD

I’m writing from my hotel in Washington, DC at the American Academy of Pediatrics annual national convention. It’s definitely pediatrics—some of the exhibitors were handing out lollipops today, and one even brought along a puppy to play with!

One of the best talks I heard today was from an allergist, reviewing the science behind allergy testing, when to do it, what it means, etc. But the biggest eye-opener for me occurred during the questions afterwards. I’m embarrassed to say that it’s obvious that many pediatricians haven’t got a clue about how to diagnose allergies. And if the peds aren’t getting it right, where does that leave the parents? So I’m going to skip right past your pediatrician, and today reveal…the deep dark insider story. It’s time for a top ten list, the top ten myths about allergy that pediatricians are getting wrong.

#1 Food allergies are common

Many people think they’re allergic to foods, but rigorous studies using the best, most reliable diagnostic tools find food allergies to be present in about 2-8% of the population. Most of these reactions are mild. True, life-threatening food allergies are quite rare—in the United States, about 150 people die each year from food allergies, which is only a little higher than the number of people struck by lighting.

#2 Most reactions to food are allergies

An allergy refers to a specific kind of reaction, most commonly hives or wheezing. Other, more common reactions include lactose intolerance (an inability to digest milk sugar, leading to abdominal cramps and diarrhea) and gastroesophageal reflux related to spicy or acidic foods. The distinction is important because rare, very serious allergic reactions can occur. If the reaction was not allergic in nature, it will not possibly be life-threatening if exposure occurs again.

#3 Most reactions to medicines are allergies

The most common adverse reaction to a medication is a rash, but these are usually not caused by allergy (the only common truly allergic rash is hives, which are raised, itchy areas that move about the body.) Most people labeled as “allergic” to penicillin are not in fact allergic, and can safely use this medication. Only a careful history and exam can determine this—there is no accurate test to confirm or refute true drug allergies. If you or your child is thought of as drug allergic, review the exact circumstances with your physician to see if it is a good idea to try the medication again (do NOT do this on your own!)

#4 People who are allergic to a medicine should never take it again

Certainly, if a life-threatening reaction occurred you need to be very careful. And be much, much more wary of medications given as a shot or intravenously (I’m not sure anyone has ever died as a result of an allergic reaction to oral penicillin.) But unless the reaction was a true allergic reaction, usually manifested by hives or wheezing, a medication can usually be given safely in the future (again, do NOT do this on your own!)

#5 If you’re allergic, but can tolerate “a little bit” of the allergic trigger, it’s good to keep taking that little bit

This one was new to me, but someone brought it up. The idea is that there may be some people who seem to be able to tolerate “a little bit” of their trigger, let’s say a little cheese, but has a belly ache if they consume a lot of milk. So maybe it’s OK for them to take that little bit.

No! First, you have to ask, is the patient really allergic? In my cheese example, the patient probably has lactose intolerance, not an allergy—so it’s fine to take some dairy, if it doesn’t hurt.

But in a truly allergic individual—one with true allergic symptoms—even consuming a little bit of the trigger is going to perpetuate the allergy and make it less likely to outgrow it. So if your child is really allergic, don’t cheat!

#6 People with any history of egg allergy shouldn’t get a flu shot

There is a tiny amount of egg protein left over from the manufacturing process of making influenza vaccines. If your child has a severe egg allergy, flu vaccines cannot be given; but for children with far-more-common mild reactions, flu vaccinations are safe and a good idea. If in doubt, egg allergy testing can be done, or the flu shot can be given at the allergist’s office.

#7 People with egg allergy shouldn’t get an MMR vaccine

This just isn’t true. It’s a myth. MMRs can safely be given to anyone with egg allergies.

#8 Allergy testing can tell you if a child is allergic to something

Hoo boy, pediatricians seem to miss this one! The way to know if a person is allergic is entirely in the history: do symptoms of allergy occur upon exposure? If they do, that’s allergy; if they don’t, that is not allergy. If the history is clear, the diagnosis is nailed, done, confirmed, and set. No tests are needed; in fact, tests are quite likely to confuse the picture.

Allergy tests are for when the history is not clear, to help separate exposures that are “likely” from “less likely”, so that further history can be explored and attempts at avoidance attempted to see what the response is. Allergy testing, either with blood tests or skin testing, is far too inaccurate to be used in any other way.

Be especially wary of web-based labs that promise extensive allergy testing to investigate vague symptoms like weight gain, abdominal pain, low energy, fatigue, and behavior problems. These symptoms are not caused by allergy, though fraudulent testing will inevitably lead to false positives and incitements to purchase detoxifying supplements. This is quackery, and expensive quackery at that. Stay away!

#9 Hives are usually caused by allergies to foods

In adults, this might be true; but in kids, hives are more often triggered by minor infections than by food exposures. Sure, if there are hives you ought to think about potential new foods, and if there is a correlation you ought to look into that. But in the majority of cases in pediatrics, isolated or even recurrent episodes of hives are not necessarily from food allergies.

#10 Specific allergies run in families

“Don’t give him penicillin! Mom’s allergic!” While the predisposition to allergies, asthma, and hay fever run in families, it isn’t to the same specific trigger. Junior has a mom with shrimp allergies? That means that he might more likely have food allergies of his own, but not more likely to shrimp than to peanut or egg or anything else. Same for medication allergies.

If your physician is telling you myths from the above list, it’s time to ask for a referral to an allergist to get the best information. If it’s an allergist tell you one of these myths, well, I’m stumped.

Why parents refuse vaccines

The Pediatric Insider

© 2009 Roy Benaroch, MD

Ask 98% of my patients, and they’ll tell you they’ve gotten all of their kids’ vaccines, without qualms or hesitation. Ask the other 2%, and you’ll hear all sorts of reasons why they’ve skipped them. What makes some people look at vaccinations so differently than the rest of us?

Along with clean food and water, vaccinations are generally accepted as one of the greatest public health triumphs of the modern world. We are safe from diseases like polio and measles, which once ravaged millions. We no longer, really, have to worry about most kinds of bacterial meningitis, and we’re able to even prevent some kinds of cancer. Newer vaccines in development include protection against HIV and malaria. At the same time, immunizations are very safe, compared to just about any other medicine or medical intervention. Yet despite their incredible effectiveness and well-documented safety, suspicions remain. Many families choose to skip some or all vaccinations.

We know that vaccine refusers tend to be wealthier, and come from more socially advantaged communities. There also seems to be a neighborhood effect, where people from one small area tends to follow each others’ lead in vaccinating or not vaccinating. But these observations don’t tell us much about the psychology and thinking that leads individual parents to refuse vaccination.

Based on my own observations and conversations with parents who refuse vaccinations, and also with parents who are more eager for vaccines, I’ve come up with my own list of “profiles” of the kinds of parents who are most steadfast in their refusal. I don’t think this list is likely to be complete, and there’s a lot of overlap between the groups. But I think this is a good starting point to understand just where people are coming from. Hopefully, better understanding will lead to improved trust and better decisions for children.

If you are a vaccine refuser, please join in the comments. Does one of these profiles fit you? Have I neglected to understand perhaps your own reasons for refusing vaccines? What sort of information is missing that can help guide parents along this decision? My goal here isn’t to belittle anyone, but to understand and appreciate the concerns of parents. I welcome any comments.

Profile #1: The Government Distruster

I certainly understand that some people feel the government doesn’t always make the best decisions for us. The two parties bicker, and special interests and money seem to have more influence on decisions than the needs of ordinary people. Look at the Clowns in Congress, or service reps at the post office, or IRS telephone screeners– there’s no doubt that government and government employees are not always paragons of virtue and judgment.

Decisions on vaccine recommendations aren’t only made by government employees at the CDC. There is input from all of the major medical associations—pediatricians, family practitioners, internal medicine physicians, obstetricians, and infectious disease specialists are all involved. Specific recommendations are made by the CDC’s Advisory Committee on Immunization Practices, which is comprised of 15 vaccine experts from various fields. There are also vaccine recommendations made by government and health agencies around the world, including the United Nation’s World Health Organization. It is difficult to believe that all of these organizations and experts reviewing the studies and making recommendations have gotten the facts entirely wrong. Though there are some differences in the exact recommendations from country to country, by and large vaccine schedules and recommendations are identical throughout the world.

Some people believe not only that the government is irresponsible and incompetent, but that it’s actually twisted and evil. Like people who believe that the US government itself planned the 9/11 attacks, some people sincerely believe that vaccinations are a great threat to mankind, deliberately put in place by malevolent forces within the government to harm us. To believe this, you have to believe that evil pervades every step throughout government, from the statisticians and analysts at the CDC and university medical centers, all the way up to the surgeon general and president himself. Furthermore, you’d have to believe that this whole vast conspiracy has somehow been successfully hushed up, because there’s no actual evidence for this whatsoever. Is this even remotely possible?

#2 The Science Distruster

Science itself is not a series of facts, or a group of people wearing white coats. It’s a system meant to discern how the natural world behaves, in a way that allows us to predict what will happen in the future. Key features of science include:

• Natural law. There are rules about how things happen, and these rules can’t change. For instance, when a force acts on an object, it’s going to move in a predictable direction, in a predictable way. Natural laws are developed based on observations of real things that happen in real, measurable ways. They can then be tested, to make sure the predictions work accurately and consistently. If an observable case doesn’t fit what we thought of as the natural law, then the law has got to be refined and improved. Though we certainly don’t know how everything works, we’re very reluctant to accept propositions that fly in the face of natural law. You claim you have a machine that extracts energy out of perpetual motion? I want to see it before I believe it. Things that are beyond natural law—the “supernatural”—cannot be part of any scientific theory.
• Testing hypotheses Science relies on experiments. You can’t just say you think something is right, or that something ought to be true based on scientific knowledge. Anything that’s worth knowing through science is testable, and can be tested, and ought to be verified. Things that are not testable (or “unfalsifiable”, a more precise word) are not things that science can support or substantiate. Something like “Michelangelo was a better painter than Da Vinci” isn’t a question that science could test.

Some people who are deeply religious have a distrust of science, but it doesn’t have to be that way. There are many important questions facing mankind for which science may not provide an answer. Why are we here? How should be treat each other? Questions of law, ethics, morals, and aesthetics may not lend themselves to scientific study, and other manners of investigation of these issues are more appropriate. Science is one tool to help us understand their world, but it isn’t the only tool. Trusting science does not have to mean turning your back on religious or other convictions.

Some people refuse vaccines because they do not trust science, or because they feel it is more “natural” to suffer infections. If these infections weren’t good for us, why would they be here on earth? Though “Why do people suffer?” is not a question for science, I personally don’t think that God would have given us the intellect and wisdom to find answers if He didn’t want us to us those answers.

Another potential knock against science: scientists don’t know everything, and don’t pretend to. The very nature of science is to question and to allow new knowledge to replace old. When you read in the paper that a medicine has been found to have a new side effect, that isn’t a failure of science—it means that science did what it was supposed to. Question, learn, repeat; question, learn, repeat. Some people feel more comfortable with absolute truths, but that really isn’t what science is all about.

Which brings us to another problem with science: the language. Scientists use “science terms”—like “This study fails to confirm any link between vaccines and autism,” or “This study adds to the evidence that vaccines are not a cause of autism.” What parents want to read is an unequivocal “Vaccines don’t cause autism.” But it is impossible to completely rule out a negative statement using the tools of science. We can say that the odds against this are very, very small, and getting smaller, but we cannot prove with absolute certainty that it could not possibly in any circumstance at any time be true. Those language of science is exact, but can sound “weaselly” to many people, leading to distrust.

Profile #3: The Big Pharma Distruster

Big Pharma is The Big Boogeyman on the anti-vaccine web sites, and perhaps they do deserve some distrust. Basically, their duty is to their shareholders: to make a profit. Their business is to develop and sell medicines and vaccines, and to make money doing so. Vaccines and medicines create billions of dollars of profit. Does that mean that drug companies cannot be trusted?

It’s wise to view promotional material from drug companies as you would advertising from any other company: with great skepticism. Advertisers want to sell you things, as do drug companies. But most patients don’t buy their drugs or get a vaccine because of ads from the drug companies, but rather because of the advice of their physicians. Distrusting the drug companies because they make money by selling drugs is sort of like distrusting the tire manufacturers for selling you tires, or the paint people for selling paint, or … well, anyone for selling anything. Sure, the computer guy wants you to buy a more expensive computer, and sure, the grocery store wants you to buy more groceries. That doesn’t make people who sell tires or groceries evil or twisted. People who buy things should be wary of salesmen, but c’mon now. Just because a profit is involved doesn’t mean that drug companies are to be trusted less than any other company. If their product is good, you benefit, and they benefit, and everyone wins.

Profile #4: The Doctor Distruster

As I said, most people don’t buy medicines or get vaccines because of the promotional efforts of drug companies, but rather based on the recommendations of their physicians. But can physicians be trusted? Couldn’t we be but shills of the drug and vaccine manufacturers?

There are doctors who’ve accepted quite a bit of money from drug companies, as “experts” or “thought leaders.” Some of them travel around the country, giving talks to other doctors to convince them to use a certain drug or vaccine. I think this is a violation of the trust patients put in their physicians, and I won’t do it. Furthermore, the truth is that the vast majority of physicians are never offered such perks. We’re in the trenches, doing our work, and most of us just don’t attract that kind of fawning attention from the drug companies.

Is it possible that the pharmaceutical companies have fooled the doctors into blindly trusting their vaccines? I don’t think so. Most of us have seen diseases disappear once a vaccine is introduced, and most of us have seen vaccine-preventable diseases in unimmunized kids. Personally, I saw my last case of pneumococcal meningitis kill a patient of mine in 1996, right before the vaccine came out. I would prefer to never see that again.

Physicians as a group are intelligent and motivated—or we wouldn’t have made it this far. We’re certainly not monolithic, single-minded thinkers; many doctors harbor opinions of health issues that are far outside the mainstream. Yet with vaccinations, it’s only a very small handful of fringe doctors who are leery of established immunizations. There is a reason why so many pediatricians are so pro-vaccine.

It’s certainly not the money. Pediatricians actually lose money on some of the vaccines we give; for the majority of them, it’s pretty much a wash. They’re very expensive for us to buy and store, yet we do it because we know it’s best for our patients.

Looking at the trust issue from another angle: I have a mechanic I’ve known for years. When I bring him my car, he tells me what’s wrong, and I pay him to fix it. I know nothing about cars, and I seldom question his advice. Sure, if he suggested something really weird, I’d go elsewhere—but I’ve known him a long time, and he’s earned my trust. Likewise, I’ve seen my own patients for years and years. Parents ask for and want my advice on all sorts of things: feeding, sleeping, school issues, medical problems. I prescribe medications, and we talk about the side effects and risks and benefits, and we make our decisions. I would say that most patients trust my advice—or they’d find another pediatrician. Yet for some reason, for some families, vaccines seem to be a very separate issue. Sure, mom has trusted me as a source of information on everything else, yet immunization issues seem to be “off the table.” Mom would rather make vaccine decisions based on advice from random people she doesn’t know posting on the internet than based on information from me. Why am I perceived as an expert on health and childcare, but not as a trusted source of vaccine information? And if I can’t be trusted for that kind of advice, why are you depending on my judgment for anything else?

Profile #5: Paging Dr. Google

Everyone knows that the internet is a wild place. It’s full of all sorts of information, some great, some outdated, and some wildly misleading. No one believes that a Nigerian price wants to give you millions if you help him transfer assets, yet web sites that spread misleading lies about vaccines have somehow become a leading source of (mis)information for parents.

I’m going to google the word “vaccine” right now, and take a peek at the top 10 sites. I won’t provide links, because I can’t guarantee that any of the information is accurate, but here’s a quick summary of what I get:

• 5 sites with good, useful, dependable information—including information from the CDC and well-established medical sites.
• 2 news stories that more-or-less accurately talk about recent vaccine news. One of the stories has an odd sort of tangent including a brief interview with a well-known anti-vaccine propagandist, who plugs her usual misinformation (that’s irrelevant to the main point of the story, but it’s part of the standard boilerplate for some journalists to interview someone from the short-list of anti-vaccine spokespeople.)
• 3 sites retelling outlandish, truly bizarre misinformation. One strongly suggests that Americans should not get a flu vaccine because they contain squalene, a chemical that they claim caused Gulf War Syndrome. This is just a flat-out lie; there is no vaccine currently licensed in the USA, flu or otherwise, that contains squalene, which hasn’t been conclusively linked to any health problems anyway. The sites link and re-link to old, long-disproven canards based on tiny, unreproducible studies of questionable authenticity, with no effort whatsoever to present the best, most recent research. These sites explicitly state that I as a physician, in cahoots with government and big business, want to poison your child.

If you want good, accurate information that you can trust about vaccines, side effects, and actual real research into vaccine issues, try these sites first:

• The Centers for Disease Control
• The Immunization Action Coalition
• Children’s Hospital of Philadelphia vaccine information center
• Respectful Insolence, a blog that frequently discusses the efforts of the anti-vaccine lobby (this site can be a little salty, but it’s good reading and eye-opening.)

Profile #6: The alternative medicine believer

There isn’t an exact definition for “alternative medicine,” (a term I don’t like) beyond “things outside of mainstream medicine.” Most people feel they just know it when they see it. Because it encompasses such a broad array of philosophies and modalities, from acupuncture to chiropractic to massage to energy healing to prayer to herbal supplements to homeopathy, it doesn’t make a whole lot of sense to lump them all together. Nonetheless, some people feel that these sorts of “remedies” are better than what most doctors prescribe, and some alternative health devotees are suspicious of immunizations.

One argument is that the “natural” remedies of the world of alt-med are somehow better, or less dangerous. This doesn’t make a whole lot of sense—the small pox virus is natural; getting bitten by a tiger is natural; falling 60 feet out of a tree or building is natural. Burning and freezing and starvation and pestilence are as natural as can be. Potent poisons from jellyfish or tropical frogs are natural. Many mushrooms and plants are poisonous, and naturally occurring radiation from elements in the Earth and cosmic radiation cause plenty of cancers. There’s nothing inherently more safe about natural things than about “unnatural” things that come from a laboratory. Sure, medications have side effects, and some can be quite toxic—just like many natural plant products. In fact, if someone tells you they’ve got an herb or something with no toxic effects whatsoever, you ought to think again: any biologically active product, whether a medicine or something “natural”, is going to have multiple effects on a complex living organism. Some will be beneficial, some will be harmful. There’s no such thing as a medicine or herb with no side effects or potential for harm, unless that herb or medicine is 100% placebo.

Alt-med proponents also sometimes feel that manufacturers and businesses involved in alternative health products are more ethical or trustworthy than manufacturers of traditional medicines or vaccines. This is a completely unfounded opinion—just take a quick glance at a sampling of this week’s stories from the world of alternative medicine:

• The FDA has established a web site listing over a hundred bogus products to treat H1N1 influenza. The list currently has 136 (!) specific products, almost all of which are marketed to appeal to alternative-health consumers.
• Resveratrol is the latest product to be marketed heavily through national magazines as a product to reverse aging. There’s no magic cure for aging, despite what they’re trying to sell to you.
• A clinical trial was published looking at the “Gonzales Protocol” for treating pancreatic cancer with hundreds of supplement pills, coffee enemas, and a special diet. The treatment failed miserably—patients pursuing this alternative medicine approach died more quickly and had a poorer quality of life.

(These three examples were all taken from the last 2 weekly issues of Consumer Health Digest, a free listserv from Quackwatch and the National Council Against Health Fraud. You can sign up here.)

There have certainly been abuses and violations of trust from the world of conventional medicine, too. But as an unregulated industry, supplement and alternative health providers are more free to commit fraud and rely on questionable marketing tactics than traditional pharmaceutical and vaccine companies, whose products and advertising materials are tightly regulated.

There’s no logical reason to think that “natural” cures are safer, unless they’re just placebo. There’s plenty of evidence showing that alternative medicine companies are more likely to engage in shady marketing and business practices. Yet distrust of traditional medicine, including vaccinations, seems to be more common among users of alternative medicine modalities.

A very small number of alt-med proponents really goes to the extreme of non-scientific thought—they reject the very notion that infections cause disease, and thus reject all medical preventions and treatments for infection. These believers have a cult-like devotion to their ideas, and no amount of scientific evidence is going to sway them. Though from what I’ve seen few people really believe this, their web sites get plenty of hits from people looking for reliable vaccine information. The philosophy and background of people writing web pages isn’t always transparent, and some people with a vastly different worldview—one that many people would reject as ridiculous—are trying to sway your opinion. Beware the “yellow brick road” of alternative medicine, for far down that path are some truly bizarre beliefs.

Profile #7: Me, too!

This one frustrates me, but it seems to account for a big percentage of non-vaccinating parents. I ask why they’re reluctant to vaccinate, and the answer is something like “Well, a lot of my neighbors don’t,” or, “I heard that lots of people are scared of vaccines,” or, must frustrating of all, just “Well, you know.”

As momma used to say: “If your friends decide to jump off a bridge, are you going to jump too?”

There is a perception that vaccine refusal is a common phenomenon, though overall rates run in the 1-2% range (some individual communities are much higher, but that’s the usual quoted rate for most parts of the country.) The vast majority of parents get their kids immunized—but they don’t talk about it as much as the non-vaccinators. Refusing some or all vaccines is chic, and the people who do it like to talk about it. You might hear of neighbors who skip vaccines for their kids, but you can bet that you won’t hear about the majority of neighbors who get them on schedule. Don’t let the amount of noise made by anti-vaccine spokespeople hide the fact that they’re a very small minority.

Please, decide for yourself what’s best for your children. Rely on advice from people who know what they’re talking about, people who who’ve trusted for years for reliable health information. These decisions should not be made based on flippant whims and rumors.

Conclusion

Many pediatric practices have chosen to “ban” vaccine refusers from their practice. I can see their point of view—it takes a lot of extra time to talk with parents about these complex issues, and some parents become argumentative and, well, ugly about these things. Who wants a fight? The anti-vaccine lobby seems to create an endless stream of rumors and moving targets that are difficult to keep track of and continually swat back down. Besides, medical offices serve many patients with special health care needs, including newborns who are at special risk for vaccine-preventable diseases. Why put those kids at extra risk by allowing unvaccinated children nearby?

Countering this is my own philosophy, that it’s not the kids fault they’re not vaccinated; and with patience and continuous discussions, I can usually get even the most stubbornly misinformed parents to vaccinate. So finally, with a lot of extra work, the kids get protected. That’s my goal.

There should be no doubt that vaccines are very effective at preventing diseases, and are still necessary to prevent serious illnesses. Just one recent example: a study published in May, 2009 showed that unvaccinated kids were 23 times more likely to contract whooping cough than children who were fully vaccinated. Do not doubt that the diseases that are prevented by vaccines are themselves quite serious and sometimes deadly. There are certainly some side effects of vaccines, as there are with any medical intervention, and serious vaccine reactions, though very rare, do occur. In my judgment and that of every respected health care agency, world-wide, the benefits of vaccinations far ought weigh the risks. Please don’t fall for internet hysterics and unfounded rumors. Protect your kids, and make sure they’re fully vaccinated.

Further resources

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All. From Wired magazine, 10/2009, about just how unhinged antivaccine groups have become, and how their unjustified influence could affect the health of your children.

A review by me of Paul Offit’s Autism’s False Prophets, a book that reviews the long history of anti-vaccine sentiment, and how a very small number of misguided and sometimes malicious characters have steered parts of the autism community to distrust doctors and shovel their money into pointless and sometimes dangerous quackery. The book also offers promising hope for further discovery into the causes and cures of autism.

John Stewart on the daily show with some humor to illustrate the rampant scaremongering that pervades media attention to vaccines.

From Science-Based Medicine, a very well-referenced resource reviewing all of the evidence and the history of the “controversy” regarding vaccines and autism.