Archive for the ‘Medical problems’ category

Nursing and vaccines: Two good things, great together

April 28, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Stefanie wrote in:

My question is related to the MMR vaccine. Would it be better to stop breastfeeding at 11 months and then get the MMR 1st shot vaccine at 12 months? Or did I understand correctly that the maternal antibodies from breastmilk will not interfere with the MMR vaccine to work? If they do not have an effect on neutralizing the vaccine, I would prefer continuing to breastfeed.

Stefanie, you can continue to nurse if you’d like – there’s no recommendation for anyone to stop or delay nursing before any vaccine.

What Stefanie is talking about here are the immunoglobulins in breast milk, and whether they could somehow interfere with the effectiveness of vaccinations. There are no clinical studies that have shown this to be a problem for MMR or any other vaccine. Breast milk antibodies don’t make vaccines less effective or less safe.

One study of a different vaccine, one that protects against the diarrheal illness caused by rotavirus, confirmed that breast milk contains antibodies against the virus. The titers of these antibodies were especially high among women from the developing world, compared with women from the United States. The authors speculated that this might explain why the vaccine is more effective in more-developed countries, and proposed a study to see if delaying (not stopping) breast feeding could make the vaccine more effective. In the US, the rotavirus vaccine is highly effective at preventing severe disease and hospitalization, both in nursing and formula-fed babies. Moms can continue nursing right before or after the vaccine is given (it would be awkward to nursing during administration of this vaccine—it’s given orally. Not sure how that could be done.)

I’ve had a run of questions about nursing and vaccinations, some implying that breastfeeding is better than vaccinations, or that vaccinations and breastfeeding are somehow competing with each other, or that those that support vaccinations are somehow shortchanging or weak on breastfeeding. These kinds of stories seem to be a new “fad” among those who wish to sow an overlay of vague mistrust and doubt about vaccinations. Please, the science is overwhelmingly positive. Don’t rely on the Googlers and scaremongers. Immunizations are safe and effective. You do not need to worry. Protect your children. Vaccinate.

National Infant Immunization Week Blog-a-thon with woman holding baby. #ivax2protect

 

Vaccinations are the best immune booster

April 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

The human immune system is an amazing thing. There are thousands of microorganisms – millions, maybe – that are lurking out there, eager to make you sick. You breathe them in. They’re in every bite of food, and all over your hands when you rub your nose. We live in constant bombardment.

And they’re sneaky, too – with changing DNA and proteins to fool us. We’ve got soap and water and some pretty good antibiotics to fight them off, but, really, the vast majority of the work to keep us healthy is done by our own immune systems.

Wouldn’t it be nice to give your immune system a boost, to help it fight off infections? We know moderate (but not heavy) exercise can help, as can a good night’s sleep. What about those “immune booster” vitamin packs they sell? Hint: there’s a reason they say right on the package that they don’t prevent or treat any disease. Save your money.

Another idea: you can just get sick, and at least the next time around your immune system can recognize the germ and fight it off more effectively. Of course, you have to get sick first to enjoy those benefits. And some of those sicknesses can be pretty serious. Or might kill you. Still, no pain no gain, right?

Wrong. There’s a great way to get a real immune boost – a way to help your own immune system, or that of your children, fight off diseases without having to get sick first. They’re vaccinations. They give your immune system a glimpse, a quick safe view, of an infection in a way that won’t make you sick, but will still teach your immune system to recognize the infection if you ever have to fight it off. It’s the best way to prepare your immune army for battle against the infectious enemy, in a way that’s almost risk-free.

Get your sleep and exercise, and eat tasty, home-made foods. Grow a vegetable garden. Hug your kids. Sing like no one is listening, and dance like no one is watching. And vaccinate, too.  These are all great ways to keep your children happy, healthy, and safe.

National Infant Immunization Week Blog-a-thon with woman holding baby. #ivax2protect

Breastfeeding and vaccinations protect your baby in different ways

April 24, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

“Since I’m nursing my baby, she’s getting all of the antibodies in my breast milk. Doesn’t that protect her the same way vaccines do?”

There are antibodies in breast milk, and they can help protect your baby from some kinds of infections. But those kinds of antibodies are different from the ones your baby will make herself after vaccinations. Breastfeeding contributes to one kind of protection, but the protection from vaccines is more powerful and longer-lasting.

Antibodies (also called “immunoglobulins”) are proteins that are part of your immune system. They work by attaching to invading microorganisms and viruses, which helps signal your immune system to attack. Antibodies have to be specific to each kind of infection—one antibody doesn’t fight multiple germs—and your immune system learns how to make different antibodies based on your body’s exposures to infections.

There are two ways for your baby to get antibodies. She can get them passively, from mom, either across the placenta or via breastmilk. Both are important. Placental antibodies are IgGs, which circulate in the blood. These kinds of antibodies help fight off invasive diseases. After a baby is born, placental IgG antibodies fade away over several months. Moms can boost their own ability to give these IgGs by being vaccinated, themselves, during pregnancy (that’s why moms should get influenza and pertussis vaccines while they’re still pregnant.) Breast milk contains a different kind of antibody, IgAs, which aren’t found in the blood. They are a part of intestinal and respiratory mucus, protecting people from infections before they get to the blood. The effect of these IgA antibodies in breastmilk is especially important in the developing world, where safe water and food is harder to find, and where moms have especially high titers of their own antibodies from ongoing infectious exposures.

The other way for babies to get antibodies is to make them on their own. To learn to do this, they must either be exposed to the infection, or get an immune-boosting “glimpse” of the infection by receiving a vaccine. That’s the point of vaccines: to allow someone to make their own strong, protective antibodies without the risk of having to suffer through the disease. These antibodies, made after “active immunization”, are of very high titers and are long-lasting – in some cases, for a lifetime. They’re much more protective than the passive antibodies gained across the placenta or through breast milk.

Bottom line: families can help protect their babies from infection in many ways. Sick people should be kept away from newborns. Moms should get their own recommended vaccines. Nursing can help (though in the developed world, the impact of nursing on infections is modest.) And babies should get their own vaccines, as recommended, on schedule, to get the best possible protection.

National Infant Immunization Week Blog-a-thon with woman holding baby. #ivax2protect

Obesity: It’s not just the sugar

April 18, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

For a while, fat was the culprit – eating too much fat was making us fat. We were swamped by low-fat products, like cheese and salad dressings and even low-fat potato chips. Briefly, Burger King even offered low-fat French fries (Those quickly disappeared from the menu. Don’t mess with the fries.) Yet, with or without the low-fat foods, obesity rates continued to climb.

More-recently, sugar has emerged as the “deadly villain” in the obesity epidemic. Forget the fat – it’s the sugar, or the refined high fructose corn syrup, that’s messing with our metabolism and expanding waistlines. Just cut back—or eliminate—added sugar, and our weight problems will be over.

But a recent study from Australia shows that maybe it’s not so simple as blaming the sugar, either. Researchers there found that, on a population level, reduced sugar consumption was associated with an increasing rate of obesity. It’s funny how real-world data seems to clash with our little pet theories sometimes.

The authors used data about food consumption from several different academic and government sources, creating graphs of overall per capita sugar consumption among Australian adults and children from 1980 and 2011. Although the exact numbers vary by demographic groups, there was a clear overall trend towards less sugar intake over those years. They then looked at obesity rates, based on national surveys.

The combined data is in the graph below. Sugar consumption is in blue, and though it goes up and down some years, the overall trend is downwards. In red you can see the Australian obesity rates. There’s more data in the paper about specific groups (men versus women, children versus adults), but overall the trend is clear: less sugar consumption is associated with more obesity.

The authors conclude, “There may be unintended consequences of a singular focus on refined sugars…”

So if it’s not the sugars, and it’s not the fat, what is it? I think it’s unlikely that there is a single boogeyman, or a “one thing” we can point our fingers at as the culprit. Obesity has many contributors, including decreasing physical activity, eating bigger portions, and eating more frequently. Low-quality “fast food” is quick and convenient, but it’s certainly not cheap in the long run. A ton of extra sugar can’t be good for your teeth, and is one source of extra calories you don’t need. But it’s not just the sugar that we’re eating too much.

What’s the best peanut policy to prevent severe allergic reactions in schools?

April 12, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Peanut-free schools, peanut-free rooms, peanut-free tables – they’re all an effort to protect children who have severe peanut allergies from accidental exposures. We’d all like to make sure our school are as safe as possible for everyone. So what’s the best policy on peanuts and tree nuts?

A study in press at the Journal of Allergy and Clinical Immunology adds some science to the debate.  Researchers looked back at peanut allergy experiences at Massachusetts public schools from 2006-2011. They polled every public school from K through 12 to determine their “peanut policy”. Though the response rate was only about 55%, the policies varied a lot – from completely no-serve, no-bring peanut schools (about 2-3%), to no peanuts allowed from home (about 10%), no peanuts served by the school (60%), to keeping some classrooms peanut free (70%), to having designated “peanut free tables” in the cafeteria (this was the most common policy in place, accounting for about 90% of the schools). (Some schools had multiple policies, so the numbers are > 100%). The peanut policies remained about the same for the 5 years of the study, and didn’t vary too much from elementary to high schools.

Data was also collected on every episode at school where epinephrine was administered. Epinephrine is the drug given to treat a serious allergic reaction (that’s the medicine in those weirdly expensive Epi-pens.) It turns out that Massachusetts schools must file a form when epi is given, so those were easy to track. Over the 5 years, epinephrine was given to children having an allergic reaction to peanuts in Massachusetts public schools about 20-40 times per year, with a modest increase from year-to-year during the study. We’re not talking huge numbers, here. Epinephrine administration was used as a “proxy”, or substitute number, for the actual number of peanut reactions in the schools – though it’s possible that epi was sometimes given when it wasn’t indicated, or sometimes was withheld when it should have been given.

The results are interesting. Of the peanut policies in place, the only one associated with a significantly decreased number of epinephrine uses was the presence of peanut-free tables in eating areas. Other policies, including having an entirely peanut-free school, did not result in fewer instances of epinephrine use. In other words, a school with a policy to be completely free of peanuts didn’t seem safer for peanut-allergic kids than a school that allowed peanuts to be brought from home.

These results aren’t super-strong. The number of serious reactions was small, and the number of absolutely peanut-free schools was small, too. There were only two nut reactions in the peanut-free schools (and one of them was in a boy that brought his own walnut cookie from home, despite being known to be walnut allergic.) When you crunch the numbers, the per capita chance of reactions in nut-free schools was actually higher than in schools with less-restrictive numbers, but with numbers so small I don’t think you can hang your hat on that conclusion.

A few lessons can be learned from this study. Even among schools that claimed to be “peanut free”, many allowed peanuts to be brought from home. Schools should have clear policies that make sense to parents. It’s also clear that even truly peanut-free schools aren’t a guarantee that no peanut exposures will occur—schools shouldn’t just declare no nuts, and leave it at that.

I wonder if the relative superiority of peanut-free tables is because that policy is easier to enforce. When an entire school is meant to be “peanut free”, you might be more likely to have some families break the rules. Also, “peanut free” policies might lead to a false sense of security among children who are nut allergic. They still have to watch what they eat. This study didn’t look into these factors, or how well peanut policies were enforced, or exactly how children were exposed in every instance.

Allergic reactions to peanuts are not common in schools, but when they do occur they can rapidly become life-threatening. Avoidance of exposures is the main way to treat peanut allergies; and when a serious reaction does occur, epinephrine should be given immediately. Beyond that, we just don’t know what the most-effective school policy should be. This study gives us some insight, but we’ve still got more to learn.

 

edit: Here’s a tangentially-related, sickening story about the apparent hazing of a peanut-allergic college student. What the hell is wrong with people? Accidents happen, but this is just…. just… I have no words.

 

 

 

What’s the exact, best age to start solids for your baby?

March 9, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A commenter objected to advice I’ve given about when to start complementary foods in infancy:

Why, when the WHO, UNICEF, and the AAP all recommend exclusive breastfeeding until 6 months of age, do you still have the introduction of solid foods at 4 months. It’s confusing for women who want to do the right thing for their child to come across your articles on starting solids at this age. Study after study show the benefits for both mother and child of exclusive breastfeeding until 6 months.

I wouldn’t rely on WHO and UNICEF recommendations. I’m not so sure that what they say is entirely relevant to babies in the developed world. I’m going to focus here on the AAP recommendations, which reflect the needs of babies in the USA and other highly developed countries.

Current AAP recommendations are deliberately vague about the precise timing of introducing solids. They say that complementary foods shouldn’t be introduced “until 4 to 6 months” – see the phrasing in this abstract and under point 2 of this article. Since AAP recommendations automatically expire 5 years after they’re published, there isn’t a valid AAP published statement on this exact issue right now. These two citations reflect the most-recent recommendation: solids can be introduced during a window of time, from 4 to 6 months.

Why then? Earlier solids are associated with obesity and nutritional problems; later solids are associated with feeding issues, iron deficiency, and an increased risk of allergy. The 4 to 6 month window maximizes nutrition while minimizing allergy risk, and works well for most babies.

But it is a window, not an exact time. We don’t have any research that says 4 months is perfect, or 5 months is perfect, or 6 months is perfect. I know of no studies from a developed country that show an important health advantage of starting to feed at six months rather than four, or starting at four months instead of six.  Probably all of these times are fine. The absolute best time depends on a baby’s development and temperament (as well as the family’s style and feeding preferences.) There’s no perfect, one-size-fits-all answer here.

When I talk about this with families, I try to figure out what the baby thinks about all of this. A 4-month-old baby who’s watching his siblings eat intently, or lunging at their food, or becoming disinterested in the breast or bottle – that’s probably a baby that’s ready to be fed solid foods. Babies of the same age who aren’t so interested in food, those babies can wait another month or so. And if solids aren’t going well at first, it’s fine to stop and wait a few weeks before trying again. We can make all of the plans we want, as parents and pediatricians – but the bottom line is that this is one of many decisions that babies help make on their own. Good for them!

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When to start solid foods, and what to start with

Want to avoid celiac? Don’t delay wheat past six months

Help fight childhood cancer!

March 2, 2017

To help raise money to support kids with cancer, on March 12 I’m having my head shaved! I’m joining a nationwide charity event along with thousands of other soon-to-be-bald volunteers through the St. Baldrick’s foundation. Click here for more information or to donate to the cause.

Thanks for your support!