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

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!

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.