Archive for the ‘Medical problems’ category

Concussions are brain injuries

February 19, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Many parents (and even some teenagers) realize that kids are going to be using their brains at some point in their lives. I’m getting more and more questions about the effects of concussions—are they going to lead to trouble, down the road? How can they be prevented and treated?

First: let’s abandon the term “concussion.” It’s a weird word that waters down a much simpler term: traumatic brain injury. A concussion is a mild brain injury caused by trauma. So let’s just call it that, “mild traumatic brain injury.” Wordy, but those words say a lot more to parents and children than “concussion.”

How do you know a brain has been injured? Simply enough, it stops working right. A person who’s had a blow to the head followed by a period of brain-not-working has had a brain injury, a “concussion”. The symptoms could include, after the injury, a period of confusion or dizziness or a feeling that you’re “not all there.” Sometimes, but not usually, there’s a brief loss of consciousness. That worth saying again: people who’ve had a mild traumatic brain injury usually do not get knocked out. They just feel knocked around. Later, there are continued symptoms like headache, dizziness, a “fuzzy brain” feeling; sometimes there are also problems with moodiness or irritability, or trouble with sleep cycles. Again, remember, these are all symptoms of an injured brain.

People understand the concept of injuries. You injure your ankle, you expect to need to rest it. Everyone knows rest is the best way to prevent an injury from getting worse, and rest is the best way to prevent an even-worse re-injury. We instinctively know that during rehabilitation for an injured ankle, you’ll kind of walk and run funny—which puts you at risk for other injuries, too.

All of these concepts are exactly the same for concussion, and that’s easy to explain if you remember to think of a concussion as a “traumatic brain injury”. Rest is the key, to allow the brain to heal, to prevent worsening damage from continued trauma, to prevent re-injury of the brain, and to prevent injury of other body parts because you’re not performing well with an injured brain. See? Easy as an ankle to explain.

Of course, resting a brain isn’t exactly as simple as resting an ankle. We can’t use a sling or an ACE wrap (well, you can, but you’ll look weird and it won’t help.) Resting a brain means, well, brain rest: no intellectual work, no school, no physical exercise. Just like you’d rest an ankle until it felt better, resting a brain after it’s injured should continue until there are no symptoms of injury. No headaches, no sleep problems, no fuzzy brain, no dizziness, no trouble focusing. When all of these symptoms have abated, people with mild traumatic brain injuries should gradually advance to more-intense schooling and activities, step by step, until the patient is back up to full activity. If there’s a step backwards—if brain symptoms begin—do exactly what you’d do if your ankle starts to hurt again. Back off the activity and allow more time to heal.

There’s good evidence that allowing a period of time to rest and heal after a mild traumatic brain injury can help prevent re-injury and longstanding symptoms—but we don’t know exactly how long the rest should be. One recent study showed that to a point, too much rest for too long can actually worsen and extend symptoms. Once symptoms improve, it’s a good idea to start back on activities (start slow and advance step by step) rather than continue through a fixed number of days of rest. We have some work to do to fine tune and individualize the best concussion care advice.

While a single concussion, especially with appropriate treatment, is unlikely to lead to long term problems, there are some sobering concerns about people who’ve had multiple concussions. There’s an increased risk of long term cognitive decline, movement disorders, and depression. And we know many athletes under-report concussions. In one study, 30% of high school football players reported a history of concussion, but only half of those had reported the injury. There may be far more concussions injuring far more high school brains than we appreciate.

As I said, many of those brains are going to be used later. Maybe we ought to try to do a better job keeping them in good shape.

Vaccines: Children have rights, too

February 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Some people who argue against vaccinations claim that vaccine policies infringe on their “rights”—their rights, as parents, to make medical decisions for their children. It’s a scary, misleading, and chilling message. We need to be careful about where one person’s rights end and the next person’s rights begin. We need to remember that children (their children, and your children too) have rights of their own.

For example, Dr. Bob Sears says in all caps “FORCED VACCINATIONS FOR CALIFORNIANS ARE ON THEIR WAY.” No, Bob. California lawmakers have introduced a bill to eliminate “personal belief exemptions” for public school attendance. No one is going to force any vaccines on anyone, and there are no jackbooted thugs on the way. But if you want to send your child to public school, they’ve got to be vaccinated. There’s still a religious exemption (which is odd—no major religions are against vaccinating) and of course a medical exemption. But “personal belief exemptions” shouldn’t hold water, because personal beliefs don’t prevent disease. Vaccines do. You want your kids in public school, with my kids? Then my kids’ right to have a safe school overrides your rights to not vaccinate your child. Simple.

How far do rights go? Until they start to infringe on the rights of others.

Dr. Bob goes on to say that mandatory school vaccines violate “a parent’s right to make all health care decisions for their child.” He seems to agree with statements from a few politicians in the news lately. Rand Paul, an ophthalmologist and Kentucky Senator, says “The state doesn’t own your children. Parents own the children, and it’s an issue of freedom.”

No, Dr. Paul. Children are not things to be owned. They are not property. They are people, and they have rights too. Do what you want with your own children—anything short of abuse or egregious neglect, and the government won’t interfere. But as soon as your “rights” start to threaten the health of other children, and of our entire communities, that’s where your rights end. And the rights of the rest of us begin.

Can getting cold give you a cold? A win for Grandma!

January 29, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Grandma says, “Bundle up or you’ll catch cold!”

Research just published in the Proceedings of the National Academy of Sciences explains why Grandma may have been right.

A team from Yale University looked at rhinovirus–the most common of the common cold viruses—and the immune response in mice. They found some solid science:

Mouse airway cells infected with mouse-adapted rhinovirus 1B exhibited a striking enrichment in expression of antiviral defense response genes at 37 °C relative to 33 °C, which correlated with significantly higher expression levels of type I and type III IFN genes and IFN-stimulated genes (ISGs) at 37 °C.

In other words, when the nose is at the ordinary body temperature (37 C = 98.6 F), there is a more-robust immune response than when the nose is cold (33 C = 91.4 F). Cold temperatures allow the rhinovirus to replicate and spread more easily.

Does this mean you ought to put a muffler on your pet mouse this winter? Maybe so. And maybe your children, too!

Immunity, breastfeeding, and the timing of measles vaccine

January 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Leave it to Disney to make a splash—any day now, we’ll hear that Anna and Elsa have caught the measles themselves (imagine a link to the sisters all covered with spots, looking miserable in the hospital, with a worried snowman and moose cowering in the background. “For the first time in forever… measles is back….”)

I’ve already covered the outbreak in detail. Briefly: over the December holiday someone at one of Disneyland’s theme parks in California brought in measles. At least 5 employees and probably about 40 park visitors caught it, almost all of whom were unvaccinated. Since then, despite a massive public health effort to identify and isolate potentially infectious contacts, the outbreak has spread to about 100 cases in 6 states. Again, and this can’t be repeated too much, almost all of the cases are occurring in people who have not been fully vaccinated, either because they’re babies who are too young, or for other reasons. It’s not yet clear exactly what that breakdown is. Some of the cases could have and should have been vaccinated; it’s likely that others had health issues that prevented timely vaccination. In any case, since measles is super-contagious, it will likely continue to spread, especially among communities with poor immunization coverage. Sadly, this has been an entirely predictable and avoidable outbreak.

A few comments and notes sent in—thanks especially Emily and Jennifer–have asked for more details about the MMR vaccine and how immunity affects how it works. I feel another Q&A coming on….

 

Aren’t newborns pretty well protected against measles, from mom’s antibodies?

The placenta sends lots of important things to baby—oxygen, nutrition, growth factors, love, and what’s called “passive immunity” via maternal antibodies. These are large molecules, a kind of immunoglobulin called “IgG” which mom had made previously after exposures to diseases or vaccines. Good maternal immunity to things like influenza and measles does provide good protection for their newborns. That’s why it’s important for pregnant women to get flu vaccines, and for all girls to get all of their vaccines—so later, when they’re pregnant, their little babies get protection, too.

But those IgGs from momma, they don’t last so long. The “titers” drop off fairly rapidly, and the protection falls quickly. Best protection probably lasts weeks, with some protection falling off over months. By six months of age, there’s probably no protection from maternal IgGs.

However, there’s still some small amount of IgGs circulating. Though they’re not protective, they can interfere with some kinds of vaccines (especially live, attenuated vaccines like MMR and chicken pox.) That’s why these vaccines are ordinarily given at 12 months of life or later. It’s not dangerous to give them early—it’s just that they probably won’t work as well to provide strong, lasting protection. Maternal IgGs do not interfere with the effectiveness of many other vaccines, like the Hepatitis B, DTaP, polio, and the other vaccines given in the first year of life.

 

Can you give MMR vaccine earlier, say if exposure risk is high?

Yes, though it may not work as well or provide protection that’s long-lasting. Current recommendations are to give the first dose of MMR routinely at 12-15 months of life. It should be given early (as early as 6 months) if the risk of exposure is high. For example, the CDC currently recommends early MMR for international travel to Europe, Asia, the Pacific, and Africa. I think it would also be prudent to vaccinate early for travel to California, especially if your baby will be in crowded places like airports or theme parks (California officials have said that these places are safe—IF you’re vaccinated.)

A dose of MMR vaccine given in the 6 – 11 month window will provide some protection, but since the lingering maternal IgGs will prevent it from being fully effective the dose doesn’t “count.” Two further doses will still be needed, following the typical schedule at 12-15 months and at 4-5 years of age.

 

Doesn’t breastfeeding give baby antibodies? Wouldn’t that prevent measles? Or can breastfeeding interfere with the MMR vaccine?

Breastmilk does contain antibodies, but they’re a different kind of antibodies. They’re not the IgG antibodies that circulate in the blood, they’re IgA antibodies that concentrate more in body secretions, including nasal mucus and breast milk. These IgA molecules don’t interfere with vaccines. They provide modest protection against mostly gastrointestinal infections (think diarrhea and vomiting illnesses)—which makes sense, because the breastmilk IgA molecules are swallowed. They don’t make their way into the blood, or at least not very much—like other proteins, if you swallow them they’re mostly torn apart during digestion. Breastmilk IgA provides just a little protection against infections that are caught via the respiratory tract, including the common cold and measles. For instance, a breastfed baby on average statistically will likely get one half of an ear infection fewer in the first year of life. Not a huge impact, at least not in respect to those kinds of infections.

 

Is there any way to test for those maternal measles IgG antibodies? I mean, if my baby’s antibodies are low enough at 9 months of age, could I get him vaccinated then?

Well, you can test for them, but the exact amount doesn’t perfectly correlate with whether the baby will become immune after the vaccine. You won’t know if the vaccine given at 9 months worked well unless you test your baby afterwards—and even then, there’s a grey zone in the measurements.

 

Maybe we should test for immunity? I mean, should we be testing children after the MMR to make sure it worked?

After one dose of MMR, about 85% of children will get complete, lifelong protection against the three components: measles, mumps, and rubella. The second dose, traditionally given at age 4-5, will pick up almost all of the remaining unprotected 15%, leaving only 1% non-immune. Those odds are really, really good—and if a community has high vaccination rates, that 1% of kids whose MMR didn’t take are still well protected by herd immunity. Of course, if vaccine rates fall, it all falls apart. The 1% who didn’t respond are vulnerable, as are babies too young to vaccinate and people with health conditions that preclude vaccination.

Testing for immunity can done under special circumstances, sometimes to help control an outbreak, or in people at risk for losing immunity after chemotherapy, for instance. But the testing is expensive and kind of a hassle (it’s not always easy to draw blood from children, and they don’t like it very much.) Because the vaccine is so safe, it makes more sense to just give the two doses than to test everyone.

Top ten things you didn’t know about mono. And kittens. (You won’t believe what happens next!)

January 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

So I noticed that blog posts cast as questions and answers, or “top ten lists”, seem to get a lot of hits. It also seems to help to include gratuitous references to high school, and pictures of kittens. And pleas to share with friends, and vague connections to charity. So let’s give it a try! If you love kittens and sunshine, be sure to share this with every human on the planet! For every share, some kind of charity will get loads of money. Probably.

Thanks to Kristi for the mono questions.

 

1. What’s mono?

“Mono” is short for “infectious mononucleosis”, a common viral infection of childhood. The “monocytosis” refers to what the blood smear looks like under a microscope– there are often a lot of white cells called “monocytes.”

Kids with mono have a wide range of illness. Some, especially younger children, are barely sick– maybe with a bit of sore throat and fever. Teenagers often fare worse, sometimes with a severe sore throat, swollen lymph nodes, fevers, and very low energy that can linger for weeks. And some people have active mono, spreading virus, with no symptoms at all.

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2. What causes mono?

Classic mono is usually caused by a virus called “Epstein Barr” (often abbreviated EBV). A very similar illness can be caused by other viruses (CMV, or acute HIV), or other infections (toxoplasmosis.)

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3. Is it true that you can only get it from kissing?

Well, maybe not only. During mono illness the saliva is loaded with mono virus, so sharing spit is the best way to give it to a friend or loved one. Mono can also spread by sharing utensils or cups, but the most efficient way to share saliva is kissing. Especially when standing upright in a high school hallway. So watch out!

Mono does not spread through casual or household contact.

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4. How long is mono contagious?

It’s likely that people are most contagious when they feel the sickest with fever– but at least some people will continue to shed EBV in their saliva for many months, maybe even a year or two. And yes, they’re contagious that whole time. Did I mention kissing in the hallway wasn’t a great idea?

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5. How long is the incubation period? I mean, how long does it take to get sick?

The incubation period varies. It’s probably in the range of 30-90 days. So when a teenager comes down with mono, it’s just about impossible to figure out who they caught it from.

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6. What’s up with the spleen thing? I don’t even know what a spleen is!

IKR! I thought a spleen was a word Shakespeare used to confuse people:

“Saint George / Inspire us with the spleen of fiery dragons!”

“Haply my presence / May well abate the over-merry spleen”

But it turns out the spleen is an organ at the top left of your abdomen, usually tucked up under your ribs there. In about 40-50% of teenagers with mono, the spleen will get enlarged.

The problem, though, isn’t just that the spleen is large– it’s that rarely the spleen can rupture. And that’s really bad. A spleen rupture can occur even without mono, usually from trauma (like a car accident.) It’s thought that the enlarged spleen that can occur during mono might increase the risk of rupture, especially during tackle or rough sports (though that’s not entirely proven.) It’s also not clear if children with non-enlarged spleens are at risk for rupture during mono, or how long the risk lasts. Some people restrict everyone with mono from rough or tackle sports, regardless of spleen size; others use an ultrasound to measure spleen size (though that’s never been shown to help prevent rupture.) Should kids sit out for a fixed number of weeks, or until the spleen size returns to normal? There is no consensus on this issue. Spleen rupture itself is really quite rare, so it’s hard to do a study of the best way to prevent it.

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7. Is it true that you can only get mono once?

Yes, or at least usually. Mono caused by EBV will only happen once in most people, even though the virus itself lurks in your body afterwards. Mono-like symptoms can rarely recur at times of immune compromise. The EBV virus can resurface to cause other health problems if the immune system is really knocked out (during chemotherapy, say, or with advanced HIV infection.)

It’s also possible that other infections trigger mono-like symptoms in some people after EBV infection.

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8. Wait a minute. I’ve been tested for mono a bunch of times, and I’ve been told I had it more than once. What’s the deal?

It turns out that there are bunch of different tests for mono. Some show “past infections” that may have occurred years ago. Because you “test positive” for mono, that doesn’t mean you have acute mono right now. It might just mean you got over mono years and years ago. It depends on the test.

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9. How is mono treated?

Rest, rest, rest. Fever reducing medicine can help if fevers are making you feel bad (though the fever itself won’t hurt you.) Extra fluids, pain medicine for the sore throat, and sleep.

Rarely, steroids are used. This can help especially if the swollen glands in the throat are making it hard to drink or talk or breathe.

Fully resting at the worst part of the illness seems to help prevent mono from turning into weeks or months of malaise and low energy. However, you don’t want to rest and miss school too long– once you’re starting to feel better, try to make it back to school at least part days, and work up from there. Though rest is important, too much rest for too long leads to deconditioning and social isolation, which can make it hard to return to full activities. Teens with more-severe mono sometimes need an individualized treatment plan with a roadmap to get them recovered and back to school.

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10. Did you pad this out to ten questions?

Yes.

Measles at Disneyland: A predictable, avoidable public health nightmare

January 12, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

On January 8, NPR reported “Measles makes an unwelcome visit to Disneyland.” Nine people who visited Disneyland theme parks in California over winter break had caught measles, almost all of them unvaccinated children. The next day, January 9, ABC reported that the number of cases has grown to 19. Of these, only two had been fully vaccinated. Some of the cases were too young to receive vaccines, others apparently chose not to get vaccinated. Since measles is one of the most contagious illnesses on earth—it can spread just through the air, with infectious particles floating around for hours after a victim has left the room—we can expect these cases to lead to dozens, or hundreds more. A lot of these sick people were probably traveling on planes all over the country. Who knows how many people have now been exposed?

Measles is a serious illness. Prior to widespread vaccinations, 3-4 million people caught measles each year in the USA; of these, 400-500 died, 48,000 were hospitalized, and 4,000 developed encephalitis (brain swelling, which can lead to death or permanent disability.) We’ve kind of forgotten that, because measles has become so rare. We do not want measles to come roaring back.

Measles vaccine itself is very, very effective—98% of people who’ve gotten the two dose series remain completely immune for life. That’s incredibly effective, and just as effective as “natural immunity” from the disease, but without the misery and risk of the disease itself. But 98% effective means that 2% of vaccinated individuals are still susceptible. In a huge Disney theme park with thousands of people wandering around in mouse ears, even a highly vaccinated crowd is going to include some people who are not well protected. And they don’t know who they are.

Some people can’t be vaccinated at all. Babies less than one (who have a high risk of complications from measles) can’t receive the vaccine; nor can many people who have immune deficiencies.

The only way to protect susceptible individuals (those who can’t get the vaccine, or those in whom the vaccine didn’t work) is to avoid contact with measles. If measles is very rare, even unvaccinated people will probably be safe. But once measles isn’t rare, well, we’re asking for trouble.

We had measles beaten—in the 2000’s, it had been completely eliminated from transmission in the US, thanks to a very safe and effective vaccine. Then one nutjob created anti-vaccine hysteria with one fraudulent study. He made the damn thing up. And we’re paying the price.

We can beat this. Parents need to make sure they’re vaccinating their kids, on time and on schedule. They need to let their neighbors know it’s the right thing to do. Parents who are genuinely afraid need honest, reliable information about the great wealth of information we have, which overwhelmingly supports the safely and effectiveness of vaccines. People who are just loudmouths and liars, fanning fear for their own twisted reasons, should be shunned. It is time to end the fake “vaccine controversy” to protect the health of our children and our communities.

More:

Dr. Bob Sears says skipping vaccines is not good for public health

Dr. Bob’s alternative vaccine schedule? He made it up

Vaccine posts on this site

Vaccine information from the Immunization Action Coalition

Child dying? Call your insurance company, first!

January 5, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.


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