Gluten and children’s health: The New Boogeyman?

Posted July 27, 2015 by Dr. Roy
Categories: Behavior, Medical problems

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.


*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

An overweight infant: Time to worry?

Posted July 20, 2015 by Dr. Roy
Categories: Nutrition

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Megan wrote in: “My son is 6 months old, weighs 10.1 kg and 70 cm long. I am concerned about his weight as he doesn’t seem to eat and drink excessively. He can’t roll over and my GP said this is probably due to his weight. What do I do? Cut back on protein and replace with extra veggies? Could he have a health issue?”

For those of you more used to traditional units, that’s about 22 pounds and 27 ½ inches. For comparison, the average for a 6 month old boy is about 17-18 pounds and 26 ½ inches.

Megan wants to know, first, if there’s really a problem here. My definitive answer is:  Maybe. Or, more accurately, no… but there might be later. Having a few extra pounds, now, isn’t hurting Megan’s baby. If he’s otherwise healthy and his development is normal and he’s being fed appropriately, I think it would be very reasonable to wait and see.

But if there are some habits starting now that in the long run might increase his risk for obesity, now would be a good time to address those. Megan said he doesn’t seem to eat and drink excessively, but I’d want to take a better history of his intake over a few days to see exactly what’s meant by that. Is he getting excessive calories? Is he drinking an excessive amount of mother’s milk or formula? Does he get cereal added to his formula, adding calories he doesn’t need? Megan asked about cutting back on protein and increasing vegetables, but is a good idea—though I wonder where he’s getting extra protein from. I’d try to use mostly veggies as complementary foods at mealtimes.

Another thing to ask about, and this can be a difficult question: has eating become the main pacifier or soothing activity? Some babies are temperamentally more difficult to soothe, and sometimes parents fall into a rut of always soothing with food—which can sometimes contribute to a lifetime habit. Many adults eat when they’re worried or upset, and sometimes we get our babies used to doing this, too. I’d ask Megan, what do you do when your son is upset or worked up?

Megan also said he cannot roll over, which to me is unexpected. I see plenty of chunky babies, but almost all of them roll by 6 months. I’d want to do a careful physical exam and developmental assessment, here, before blaming the lack of rolling over on his size.

The question was also asked, “Could he have a health issue?”—meaning, could he have some kind of medical condition be causing his excessive weight. There are some conditions that can do this, but they’re fabulously rare. Incredibly rare. Incredibly as in most-doctors-will-never-ever-see-a-case-of-this rare. So without other history or physical exam findings to suggest something like this, I don’t think it’s very likely.

The most important steps when I evaluate a baby whose growth is not as expected—too big or too small—starts with a careful history and physical exam, and then continues with following the baby closely. Watch those numbers over the next few months to see if they level out. Though there are no immediate dangers here, overweight babies are more likely to become overweight children who are more likely to become overweight adults. Now may be the time to make a few dietary adjustments to prevent a whole lot of trouble later. It’s not time to panic, but it is time to pay attention.

Cootie Shots under fire

Posted July 16, 2015 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2015 Roy Benaroch, MD

Circle circle dot dot

Now I have a cootie shot

It’s a rite of passage for Kindergarteners, something we’ve all gotten used to accepting, without question. Now, an increasing number of concerned parent activists are raising concerns about Cootie Shots. They’re asking some uncomfortable questions. Are they even safe?

Last year, Ms. Emma Jane McGucket noticed her 5 year old son acting oddly. “He’s like a different boy,” she said. “His clothes no longer fit. And he smelled like grass.” Later that day, she says, she heard him say something that really started to make her wonder. “He said something about a Cootie Shot to his younger brother. It made my hair stand on end. What were these Cootie Shots? Have they been tested? Is this just another government plan to poison our children, like putting fluoride in the water or thiamine in the bread?”

After asking questions at her son’s school, Ms. McGucket still wasn’t satisfied. “It’s like they didn’t even know what was going on. They pretended these Cootie Shots are perfectly safe, even though they couldn’t list all of the ingredients.”

Ms. McGucket has formed a Facebook page, Families Against Cootie Shots (FACtS), and hopes to draw attention to what she considers “…the most important thing, ever, that everyone has to stop whatever they’re doing and worry about more than anything else.”

And she’s not alone. Her neighbor, whom Ms. McGucket refused to name, is also said to be worried. When we spoke with her though her closed door, she may have said something about toxins or GMOs used in their production.

“It’s not that I’m against Cootie Shots,” said Arlene Monger, president of the Calhoun County chapter of FACtS. “What we want, what our children deserve, are greener, safer Cootie Shots free of toxins and chemicals. We don’t need to give in to Big Cootie just to protect our children.”

“No one wants children safe from Cooties more than me,” she said. “But we have to read the product label and the government hazardous material sheets. These things are being injected directly in our children’s bloodstreams. They might even contain gluten.”

When contacted, Jamie Rosen of the 2nd grade’s Cootie Surveillance Section pointed out that Cootie Shots aren’t actually injected into anyone’s bloodstream. “They’re pretty much just touching the skin of the arm, you know, circle circle dot dot?”

“Those are the kinds of ‘facts’ we don’t need,” responded Ms. Monger. “A typical response from a typical official who’s been paid off. Like my son’s pediatrician. He said he wasn’t worried, which just proves it.”

Some activists are also concerns about the number of Cootie Shots being administered. On some playgrounds, they say, boys are giving themselves up to 6 or 7 doses in one recess. They say they need it to protect themselves from the girls, but parents are worried. “Too many, too soon!” says Ms. Monger. “They’re using a schedule that’s only been in use worldwide for what, 50 years? I’m supposed to be reassured by that?”

“I don’t need any studies,” Ms. Monger concluded. “I know what I know, and that’s enough for me to say no.”

cootie shots

Mammography isn’t always a good idea

Posted July 13, 2015 by Dr. Roy
Categories: In the news

Tags: ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Draft guidelines from the US Preventative Services Task Force (USPSTF) are concerning to some breast cancer advocates. The suggested guidelines no longer recommend routine mammography for women of average risk until age 50. For women from 40-49 years of age, the task force recommends an individualized assessment rather than screening all women.

These recommendations can have great economic weight. Under the Affordable Care Act, preventative services recommended by the USPSTF must be covered by health insurance with no cost-sharing. In other words, they’re not part of a deductible, and you’ll seem to get it for “free”. If these new draft recommendations stick, women in their 40’s will not have automatic free coverage for their yearly mammos (they could still get coverage if they’re in a special risk category.)

How’s this news going over in the breast cancer advocacy community? Not well. Full page ads ran last week, including on the back of the A section of the Washington Post, urging people sign a petition to get the US House of Representatives to step into the fight.

The petition starts:

Early detection saves lives. With one in eight women developing breast cancer during her lifetime, the earlier we can detect breast cancer, the better. After all, these are our mothers, daughters, grandmothers, wives, sisters, and friends, the people we care about most.

How can you argue with that? Where to these USPSTF numbskulls get off, letting more women die of cancer?

With the best intentions, the petitioners and many in the Breast Cancer advocacy community are getting it wrong. They say “Early detection saves lives”. But in this case, it’s not actually true.

Several good studies have shown that screening women in their 40s for breast cancer with mammography does not in fact save lives. In 2014, Canadian researchers did a randomized, controlled study– following over 50,000 women, half of whom were assigned to annual mammos, and half to no mammos from age 40-49. These women were then followed until age 60 to see how many died of breast cancer. In the mammo group, 134 died; in the non-mammo group, 122 died. That’s right, more women died who got mammos then women who did not (the difference was not statistically significant.) Screening mammos in this large, well designed clinical trial did not save lives.

Another study, from Great Britain, randomized about 160,000 women, starting at age 39. Again, those randomly assigned to get annual mammography were not less likely to die of breast cancer. It didn’t matter– whether or not yearly screening mammos were done, the death rates were the same. Screening mammos, again, didn’t save lives.

How could this be? Don’t we know that the earlier you detect cancer, the easier it is to treat? Unfortunately, medicine isn’t so simple. It turns out that many early breast cancers will regress (go away on their own), or grow so slowly that they never cause health problems. Of course, other breast cancers are aggressive and deadly– and women with those kinds of cancer benefit from treatment. But that has to be balanced against the genuine harm from therapy for breast cancer in many women who never needed treatment at all. And that therapy—it’s far from benign. Some women will die of complications caused by breast cancer therapy.

I’ve had two women very close to me killed by breast cancer, and I do not want to see more women suffer. But catchphrases — “Early screening saves lives”– are more to help fundraising than to guide policy. We need to figure out which women need earlier diagnosis and therapy, and how to best use mammography and other tools to help find women at-risk. But what we’re doing now, screening all women with mammos starting at 40, isn’t helping. It’s time to admit that, and move on.

A pediatrician reviews Inside Out

Posted July 7, 2015 by Dr. Roy
Categories: Pediatric Insider information


The Pediatric Insider

© 2015 Roy Benaroch, MD

inside out

As a pediatrician and a father, I wonder: what’s going on inside of kids’ heads? Pixar’s new movie takes us inside the mind of Riley, an 11-year-old girl whose life is turned inside out by her family’s sudden move to San Francisco. Or “San FranStinktown,” as Anger calls it.

Inside Riley’s brain are five emotional beings. When she was born, there was only Joy. Glowing yellow Joy controlled her life with one single button to push—parents smile, Joy pushes button, and baby Riley smiles. But within seconds, a contrasting emotion shows up. Sadness, in blue, stands alongside Joy. And Baby Riley cries. Over the next ten years they’re joined by Disgust, Anger, and Fear, and the control panel morphs from a single button into a complicated array of dials and levels, with the five emotions at times pushing each other aside to control how Riley interacts with the world. Hockey and acting silly brings Joy to the front. Broccoli—which is green and not shaped like a dinosaur—calls Disgust into action, so young Riley can push it away. Which, Disgust thinks, has saved her life.

Pixar’s film did many things very well. As Riley matures and faces new challenges, it becomes more and more clear that emotions are complicated. The idea that one emotion is in charge works for a toddler, but not for a pre-teen—and, in fact, by the end of the movie the control panel has morphed again, allowing multiple emotions to simultaneously control the action, rather than fighting over who’s in charge. (Also, Anger gets a new slew of curse words. Pixar nailed that one.)

The film also illustrates that memories aren’t just videotapes or computer-like recordings of reality. Our memories change to match our emotions; something once remembered as happy can become fearful. The way we feel about the past is accurate in an emotional sense, even when it’s not accurate literally—and that’s a hard concept for kids and adults to understand.

Another good point: these emotional struggles don’t end with childhood. Some of the funniest moments of the film showed the internal workings of adults, too—Mom and Dad and Riley’s teacher. Their mature emotions talked more, and seemed to decide things as a committee. But they still overreacted and sometimes did unwise things.

Still, Inside Out did miss some important things about the mental life of children. Riley’s personality was entirely created by her emotions and her life experiences—there wasn’t really a nod to genetics, or one’s makeup or resilience or other things that children are born with. More importantly, the film just teased with the idea of mental illness, and may have done a disservice to struggling families.

SPOILER ALERT: when Riley had given up hope and ran away, on the bus she was said to have no feelings at all. No Joy, no Sadness, no nothing. That’s an accurate description of how many people with Major Depression feel. But moments later Riley realized that she had made a mistake, and leapt off the bus—and after a good hard cry with Mom and Dad, she turned her life around. Real mental illness isn’t like that. It’s not a few minutes of hopelessness, and it isn’t fixed when you decide yourself to fix it, and it isn’t fixed because you break down and cry for a few minutes. Riley’s story was an accurate depiction of feeling sad and confused and angry, the way we all feel at times. It was not an accurate depiction of mental illness.

Still—I really liked the film, and I think it can be a great conversation starter about emotions and the way they affect kids and adults. Riley herself, and her emotions, were just adorable, even Anger. And the film made a great point about how emotions enrich our lives, even when they’re uncomfortable and complicated. Go see it, with your kids. It will probably make you cry. And that’s good.

Whining and negativity in a nine-year-old girl

Posted June 29, 2015 by Dr. Roy
Categories: Behavior, Pediatric Insider information

Tags: , ,

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© 2015 Roy Benaroch, MD

Anna wrote in:

My daughter is now 9, and I’ve noticed a steady increase in negativity in the past several months.  She has become whinier, she has an attitude (more “entitled”), etc.  The latest is whenever I don’t let her have her way she says “you’re mean”. We try to enforce manners, for example, saying thank you when we give her something, but even the thank-yous seem grudging. I have a feeling most of this is normal (I hope), but do you have any suggestions to help me modify her behavior?

I’d look at this two ways: First, is there a reason for the change, especially a reason you could address? And second, forgetting about any possible reason or whatever, what can you do about whining and negativity to change a child’s behavior?

Why do kids act like this? Sometimes, there really is specific reason. A new sibling, marital discord, medical problems, bullying in school, a friend moving away, not getting enough sleep, over-scheduling, boredom, attention-seeking… all sorts of things. I’m not sure it’s always obvious, or that it’s always possible to know *for sure* what led to a behavior change, but sometimes there really is a reason staring you in the face. Perhaps that’s worth talking about, or at least thinking about.

One of the most common reasons for negativity and whining is attention-seeking. If a child doesn’t feel like she’s getting your attention—maybe you’ve been preoccupied with work—she may develop, let’s say, “maladaptive” ways to forcing you to pay attention to her. In other words, she may become a pain in the ass not because she’s a pain in the ass, but because she’s figured out that the behavior gets what she craves: more attention. One way to “fix” this is by giving more attention, but not at times that reward the whiney and negative behavior (see this prior post, under “love,” for a method called “magic time.”)

But sometimes there really doesn’t seem to be a specific reason, or at least not one that you can easily figure out. Maybe it’s just a phase, or a “normal thing.” Even without worrying about the specific “why”, there are ways to help a child change this behavior:

#1: Don’t reward it. She’s looking for a reaction. Don’t ignore her, but don’t get into it, either. Be bland and boring and non-reactive to negativity, and it tends to go away.

#2: At the same time, do reward times when she’s not negative, or at least when she’s less negative. Make sure to not only tell her that it makes you happy to hear her say something positive, but (more importantly) do what it is she’s asking for, if she’s asking for it in a reasonably nice way. Now, sometimes you just can’t do this (“Mom, can I please have a bazooka? No.”), but other times you might be saying “No” a little too reflexively, because, I know, they never stop asking for things. Surprise them with a yes, or even better, with some happy silliness:


Good: Child: “I want a bubble bath!”

Mom: “No.” (Looks away, bored. Not a lot more talking and explaining and attention.)

Better: Child says “Can I have a bubble bath?”

You: “Good idea!”

Best:    Child says “Can I please have a bubble bath?”

You: “That’s a great idea! I know—why not take some shaving cream and spray it on the wall of the tub, too?”


You’ll also want to set a good example. Kids only sometimes, barely, pay attention to what we say. But what they really pay attention to is what we’re doing and how we act. If you’re whining and negative and complaining, don’t be surprised if your kids do that too. Your kids learn far more by watching and modeling what you’re doing than by listening to your explanations. Be gracious with your partner and all of your children, say your own thank-yous (like you mean it!), and maybe even try to work in other expressions of gratitude. Kids notice these things.

Don’t stay mad. This is a tough one—but children, they don’t think like we do. You might still be steaming over those dirty looks at dinner (It’s tortellini for God’s sake! Eat it!), but 20 minutes later your child is over that and thinking about other things. Giving her grief, then, isn’t going to help.

Use humor, too. I know it can be hard, but next time your child tells you you’re mean, make a bear face and say “I’m going to eat you!” and chase her around the house. Mmm, tasty child!

Another idea: talk with a child about what would work best. Not when she’s all upset and whiney, but at another time, bring it up. “Sweetie, you seem to get so mad sometimes, is there something I can do to help keep you happy?” You might just learn something.

Every age brings its challenges—it’s not just terrible twos, but terrible threes and nines and (OMG!) sixteens. Though chasing your teenager around pretending to eat her might not be the best specific idea for that age, the basic principles are the same. Look for causes, reward what you want to encourage, and ignore what you want to discourage. Use humor, and try to solve problems as a family. Meanwhile, remember to forgive. You have bad days too. You’ll make it through, together.

Hey! Some of the best—heck, probably all of the best—ideas I give parents come from you guys. What other advice do you have for Anna? What did I say that was stupid and off-base? Add a comment! You’ll be glad you did! Probably!

Guest post: “Viral Shedding” is not something to worry about

Posted June 22, 2015 by Dr. Roy
Categories: Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Today features the first-ever guest post at The Pediatric Insider, from a pediatrician buddy of mine. He wrote this as an open letter to Bob Sears, the most well-known vaccine doubting physician in the USA.  Thanks to the author for helping to fight unnecessary fear!


Hello, Bob Sears, M.D., FAAP.  Before I continue, I’d like to disclose that my sole source of income is from my employer* and that I am not selling any books (I haven’t written any).  I do not have any financial or business relationships with any vaccine manufacturer, nor have I ever accepted any gift from a vaccine manufacturer.  My only financial incentive with respect to vaccines is that I get a small (about 1.5% of my annual income) “quality of care” bonus from my employer at the end of the year if a certain percent of my patients are fully vaccinated according to CDC/ACIP guidelines.**  I’m writing and researching this post in my off time and I’m not expecting any compensation for it.

I just read this post of yours in which you raise concern that recently vaccinated patients might shed their vaccine viruses.  Certainly, I’m not familiar with this as a major danger to public health, so I decided to look into it.

sears bob shedding

As a fellow pediatrician, you are doubtlessly aware that only five types of live attenuated vaccines are currently use in the United States.  Those are the Live Attenuated Influenza Vaccine (LAIV), the two competing rotavirus vaccines RV1 (“ROTARIX”, GlaxoSmithKline) and RV5 (“ROTATEQ”, Merck), MMR, and the Varicella Zoster Vaccines.  These latter two are often combined into a single injection called MMRV.  As you are aware, the remaining routine vaccines (DTaP/TdaP, IPV, HBV, HAV, PCV13, HiB, MCV4, HPV4/9, IM/ID flu) are inactivated and incapable of shedding.(1)

We can ignore LAIV given that it’s June and I doubt anyone here in the Northern Hemisphere is currently using it.  That said, while 98% of recent vaccinees do shed LAIV, the rate of actual transmission is less than 1% (2).

As far as MMR is concerned, we know that the wild viruses are spread by respiratory secretions and that infection occurs by mucosal contact with the virus, but I was not able to find any cases in the medical literature documenting that the vaccine-strain Measles, Mumps, or Rubella viruses are shed in respiratory secretions after receipt of the MMR vaccine used in the United States or Canada.  I could find only a single report of possible vaccine-strain rubella (HPV-77 [unrelated to Human Papilloma Virus]) horizontal transmission from 1968 (3) and that did not result in symptomatic infection.  It is also possible that the seroconverted contact in that study actually had subclinical wild infection.  But I was also able to find a study in 1972 in which 67 rubella-nonimmune teachers were monitored after their classes of children were vaccinated and none showed evidence of seroconversion.(4)  Clearly, the risk of horizontal transmission of HPV-77 vaccine strain rubella virus is very low if it is not zero.

For the mumps component, I was able to find that the Leningrad-Zagreb mumps vaccine strain commonly used in Russia and India can rarely spread horizontally (5), and one case of the now disused Urabe mumps vaccine strain transmitted (6) but I was not able to find this for the Jeryl-Lynn strain used in the United States MMR vaccine.  Perhaps you have a reference that this has occurred?  If so I’d appreciate if you shared it.

It certainly is true that the vaccine measles strain may be shed in the urine of recently vaccinated individuals (7), but given that transmission requires mucosal contact this should not be cause for concern.  I certainly hope that nobody at your gathering will be drinking the urine of recently vaccinated infants!  In all of medical history since the time MMR has been in use there has only been one case report of horizontal transmission of the measles vaccine strain (8) and that was between siblings.  I cannot find any others, so I would say that this risk is so vanishingly small that it would be unreasonable to worry about it at a gathering like yours.

The other two live attenuated vaccines used in this country carry a bit more risk of horizontal transmission.  Cases of transmission of varicella zoster vaccine virus have been described (9) but in all of these cases, the individuals who transmitted the vaccine virus had a visible varicella-like rash and the recipients either had no symptoms or mild clinical disease.  There is, to my knowledge, one case of varicella vaccine transmission without a rash, but that was from a new mother to her infant(10).  It’s possible that it might have been transmitted in breast milk.  For this reason, both Merck and the CDC recommend that the <3% of children who do develop this rash be kept away from susceptible contacts until the rash resolves (10).  I’ll note than in ten years of clinical practice, I estimate that I have given over 2,000 doses of VZV either as a single-component vaccine or as the MMRV combination product and I am only aware of six such rashes in my patients (actually, one was in my medical student’s recently vaccinated wife who was not my patient, but I count her among the cases).  Thus, my own clinical experience has been about ten times better than Merck would claim.

Similarly, for rotavirus vaccine, the transmission rate to unvaccinated twins was 18.8% for the “ROTARIX” product in one placebo-controlled study in twins (11). But in these cases, these were twins living in the same household and having their diapers changed by the same parents.  It’s important to note that none of the transmission cases caused clinical gastroenteritis symptoms.  There is also a single case report of a recently vaccinated child with “ROTATEQ” transmitting a symptomatic infection to an unvaccinated older sibling (12), which resulted in an emergency department visit but no long-term sequelae.  Because transmission of rotavirus vaccine would only occur in very young infants (the vaccine should only be given <7mo) (13)(14), and the transmission is fecal-oral, simple good hand washing after changing a recently vaccinated infant’s diaper should reduce the risk of transmission to unvaccinated non-household contacts at a public gathering like the one you are holding.  Either way, the risk of transmission of a symptomatic case from a recently vaccinated child to an unvaccinated child appears to be vanishingly small, based on the available evidence.

But I also wonder why you would be so concerned about transmission of vaccine viruses at your event.  Perhaps you feel that people should consent to being exposed to infectious agents.  That would be nice, but that has never been the case.  My parents did not consent to my exposure to varicella at age 6 that caused me to spend a week in misery and left me with two scars on my face to this day.  Similarly, my parents did not consent to the exposure to (likely) rotavirus that hospitalized me as an 8mo infant.  Moreover, I have never consented to any of the symptomatic infectious diseases from which I have suffered as an adolescent or adult.  But certainly, as I have demonstrated, the risk of poor health outcomes after accidental exposure to attenuated vaccine-strain viruses is much lower than the risk for the wild-type viruses.  Yet you propose to have a gathering with a very high rate of unvaccinated children present.  To me, your risk-benefit calculation just doesn’t work out.

Perhaps you are concerned for any immunocompromised members of your audience, but we do not isolate recently vaccinated children and adults from contact with the general public, even though immunocompromised individuals live and walk among us.  They are as much at risk traveling to your gathering as they are at the gathering.

To further confuse matters, you have no way of knowing if any of the unvaccinated children attending your gathering might be in the asymptomatic but contagious prodromal phases the precede most symptomatic viral infections.  Diseases like measles and chicken pox are so contagious that virtually all children contracted them before the vaccines were available, even though it has always been policy to immediately exclude children with symptoms of these illnesses from attendance at school.

So perhaps you could explain your reasoning for this unusual restriction.  I’d appreciate it if you’d demonstrate that you have done your research as I have.


*I am technically an independent contractor.

**We get other “quality of care” bonuses for other “best practices,” like not treating viral infections with antibiotics, testing sexually active patients for STIs, and keeping problem lists in the medical record up to date.



(2) Vesikari T, Karvonen A, A randomized, double-blind study of the safety, transmissibility and phenotypic and genotypic stability of cold-adapted influenza virus vaccine. The Pediatric Infectious Disease Journal 08/2006; 25(7):590-5.

(3) Lefkowitz LB, Rafajko RR, et al. A Controlled Family Study of Live, Attenuated Rubella-Virus Vaccine — Seroconversion of a Susceptible Contact. N Engl J Med 1970; 283:229-232

(4) Fleet WF, Shaffner W, et al. Exposure of Susceptible Teachers to Rubella Vaccinees Am J Dis Child. 1972;123(1):28-30

(5) Atrasheuskaya A1, Kulak M, et al. Horizontal transmission of the Leningrad-Zagreb mumps vaccine strain: a report of six symptomatic cases of parotitis and one case of meningitis. Vaccine. 2012 Aug 3;30(36):5324-6

(6) Sawada H, Yano S, Oka Y, Togashi T. Transmission of Urabe mumps vaccine between siblings. Lancet.1993;342:371. doi: 10.1016/0140-6736(93)91515-N.

(7) Rota AS, Kahn AS et al. Detectin of Measles Virus RNA in Urine Specimens From Vaccine Recipients J Clin Microbiol. 1995 Sep;33(9):2485-8.

(8) Millson D. Brother-to-sister transmission of measles after measles, mumps, and rubella immunisation. Lancet. 1989; 1(8632):271.

(9) Tsolia M, Gershon AA, et al., National Institute of Allergy and Infectious Diseases Varicella Vaccine Collaborative Study Group Live attenuated varicella vaccine: evidence that the virus is attenuated and the importance of skin lesions in transmission of varicella-zoster virus. J Pediatr.1990;116:184–9. doi: 10.1016/S0022-3476(05)82872-0

(10) VARIVAX package insert, Merck.

(11) Rivera L, Peña LM, et al. Horizontal transmission of a human rotavirus vaccine strain–a randomized, placebo-controlled study in twins. Vaccine. 2011;29:9508–13. doi: 10.1016/j.vaccine.2011.10.015.

(12) Payne DC, Edwards KM, et al. Sibling transmission of vaccine-derived rotavirus (RotaTeq) associated with rotavirus gastroenteritis. Pediatrics. 2010;125:e438–41. doi: 10.1542/peds.2009-1901.

(13) ROTATEQ package insert, Merck

(14) ROTARIX package insert, GlaxoSmithKline


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