Archive for the ‘Medical problems’ category

Measles update: Which adults need a dose of MMR vaccine?

May 9, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

While the vast majority of measles cases in the US and worldwide are occurring in unvaccinated children, a fair percentage is also occurring in adults.  With more-widespread transmission of measles, it’s becoming more important for all of us – yes, that includes parents – to make sure we’re well-protected.

Measles is probably the single most contagious infection that humans face. The key to preventing the return of widespread measles is in keeping vaccination rates high, so even if there is a case it cannot spread or cause an outbreak. Once there’s a neighborhood, school, or community with a concentration of unvaccinated individuals, it’s only a matter of time before measles returns and spreads widely.

Though we’re used to our children getting vaccinated on well-established schedules that ensure vaccines are safe and effective, many adults have fallen through the cracks.

People born before 1957 are presumed to be immune, because measles was so widespread in the past that almost all children contracted the infection.

Adults considered at “high risk” include healthcare workers, international travelers, those who are living in communities with outbreaks, and university students (I would also include all adults who teach and work in universities, though that’s not part of the official CDC high risk group). If you’re in these groups, you should have had TWO doses of MMR to ensure immunity. If you’ve only had one, get another; if you’re not sure if you’ve had any, get two doses. The second dose should be 4 weeks or more after the first.

Other adults (those born after 1957 and who do not live in a community with measles transmission) are considered immune and protected if they’ve had one dose of MMR.

For people born between 1957 and 1968, there’s a catch. Some of the measles vaccine used then was an inactivated vaccine that didn’t confer good immunity. If you have documentation that your vaccine was the “live” vaccine, that’s the good one. If you’re not sure which you received, get one dose of the current MMR to make sure you’re protected.

An alternative to receiving the vaccine, if you’re unsure of your vaccine status, is a blood test for measles titers (IgG antibodies.) If your titers are high, you’re protected; if they’re low, you need another dose of MMR.

The MMR vaccine shouldn’t be given to people with compromised immune systems or pregnant women, though it is fine for nursing moms.

Bottom line: if you’re an adult and you’re not sure if you’re adequately protected, you should receive at least one dose of MMR.

 

From the CDC:

Current outbreaks

More info about measles

 

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What’s the best timing for my child’s measles vaccine doses? Should we give them early?

May 7, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

As the US endures its largest measles outbreak in 25 years – one that’s almost certainly going to get worse before it gets better – we’re getting a lot of calls and questions at my office. What’s measles, what’s the best way to prevent it, when should the vaccine be given to adults and children? I’m going to do a series of mini-posts, just focusing on one question at a time. We’ll see how this format works out – let me know if you like it!

The measles vaccine is given as “MMR”, which teaches the immune system to fight off measles, mumps, and rubella. It’s a very effective vaccine that confers lifelong immunity. A single dose is about 93% effective, and two doses get that up to 97%. There aren’t many other preventive interventions in medicine that are even close to that good.

The first dose should be given between 12 and 15 months of age, though at this point I’d say 12 months is better. Why wait until 12 months? Earlier than that, babies may still have enough antibodies from their mother to partially block the effectiveness of the vaccine.

But in some circumstances, you should get that first dose early, as early as six months. If there’s a high risk of exposure, an early dose (though imperfect) will give at least some protection. That dose should then be repeated at 12 months. Who’s at high risk of exposure? Anyone who’s living in a community with cases of measles – that includes, as I’m writing this, areas of New York, Michigan, and California. Plus the Philippines, Israel, and Ukraine. And, really, most of Europe. If you’re traveling with your baby under 12 months out of the US (or even within the US), you should look at the news and talk with your child’s doctor about getting an early dose of MMR.

The second dose of MMR is traditionally given at age 4-6 years, prior to school entry. But that timing was chosen for purely administrative reasons –kids almost always come in for a preschool physical, and they also need doses of polio and DTaP vaccines, which must be given after the fourth birthday. But that second dose of MMR can be given much earlier. It will be just as safe and effective if given any time 4 weeks or more after the first dose. So if the first dose is given right at 12 months, the second dose could be given at 13 months (or, more likely, at 15 months, since that’s when the next check-up age falls.)

Again, if you’re living in or traveling to an area experiencing a measles outbreak, you should get that second dose early. There is no downside. Honestly, there’s no reason why any of our young babies should wait until age 4 to get it – it’s just a bit of history and convenience that placed the second dose at age 4. If your children do get the second dose early, keep in mind that they do not ALSO need a dose at age 4 (though a third dose will not be harmful, it’s just not necessary.)

 

More info:

The nitty gritty details about the history of the MMR vaccine and its timing

Measles from the CDC

Recurrent vomiting in a baby – could it be FPIES?

March 8, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Not every diagnosis is easy, and not every diagnosis can be made correctly from a first impression. FPIES is one of those tricky ones, and parents and docs can get it right by paying attention to clues and keeping an open mind. Let’s start with a story, and then we’ll talk about FPIES (hint: these are not the kind of PIES you want to eat!)

5 month old Sally has had two trips to the emergency department and one to her pediatrician for vomiting episodes. Each time, she has a sudden onset of vomiting, diarrhea, and lethargy, and gets sick quickly – twice she ended up needing IV fluids. She recovers in a few days and seems to feel better. Overall she’s usually a happy baby, but her weight has been concerning. She’s not growing as fast as she should. Sally attends day care and has two older siblings.

What do you think? Vomiting illnesses are very common, and they’re usually caused by viruses (like Norovirus, especially this time of year.) If there had been one or two episodes like this, and Sally otherwise seemed OK, the story wouldn’t necessarily seem unusual. After all, she’s in day care, and probably is exposed to a lot of yuck.

But, still, there are some clues that there’s more to this story. Most vomiting illnesses do not require IV fluids – Sally’s needed that twice. And overall her weight isn’t great. Could there be a connection?

Making a medical diagnosis is like detective work. First collect the clues (which are almost always in the story), then find a diagnosis that fits. But keep in mind that every diagnosis is a “work in progress” that may have to change as new facts come it. Sally seemed like she had a viral gastroenteritis (a “tummy bug”), until the story continued to unfold. I warn medical students and residents: don’t lock yourself into a diagnosis. Stay curious!

Sally’s “mystery” diagnosis turned out to be “FPIES”, or “Food Protein Induced Enterocolitis Syndrome.” It’s a rare-ish allergic condition usually affecting young babies and toddlers, who react to certain foods with episodes of intense vomiting, often with diarrhea. Sometimes FPIES can be more of a chronic presentation, including lower-grade, ongoing symptoms like poor growth. Common triggers include cow’s milk and soy, but also grains like oats and rice. There’s no test for FPIES – ordinary ‘allergy testing’ is often misleading – so the diagnosis rests on the story.

The prognosis for PFIES is very good. Children usually outgrow it. The trick is making the diagnosis early, so parents can avoid the trigger food(s). And the key to making the diagnosis is paying attention to the clues your patients and their parents are trying to tell you.  I tell my medical students and residents: stay curious and pay attention!

More about FPIES

Interested in learning more about how doctors think, and how the best diagnosticians work through the clues to figure out the answer? I’ve made three courses about this, available from The Great Courses, in audio or video formats. They can be watched or listened to in any order. You can buy ‘em (money back guarantee!), or stream them from TheGreatCoursesPlus.

Help fight childhood cancer!

March 6, 2019

Hey hey! My teenage daughter and I will be getting our heads shaved on Saturday to help raise money to fight childhood cancer! Please donate to me, my daughter, or our team! (Since it is in fact my birthday today, you should probably donate to me. But any donations are appreciated!)

Pediatric cancer is more common than you might think. Every year in the US about 16,000 kids (birth through 19 years) get cancer — that means 1 in 285 people will be diagnosed with cancer during their childhood. That’s a lot of children and families affected.

In some ways, the statistics are encouraging. The rates of these cancers, overall, hasn’t changed much over the last 40-50 years — but the survival rates have improved dramatically. Overall there’s an 80% five year survival. But there’s a lot of variability in types of cancer, with some cancers making very little progress. Many types of childhood cancer still have a poor prognosis.

And sometimes the treatment itself can be very difficult. The goal of treating most pediatric cancers is a cure, which means that the treatment itself — surgery, radiation, chemo — is often more aggressive than the treatment for adult cancer. Two-thirds of childhood cancer survivors struggle with health problems related to their cancer or the treatment. There’s still a lot of progress to be made.

The funding for pediatric cancer research is far less than what we might expect. The NIH budget for adult cancer research was 5.6 billion in 2009; for pediatric-specific cancer research, it’s probably in the range of 30 million dollars a year.

Pediatric cancer research needs better funding. We’ve already shown that better treatment leads to dramatically better outcomes, but we need to keep making progress. And public awareness can support both charitable giving by individuals and better support for pediatric cancer among foundations, endowments, and large national cancer organizations.

That’s my why daughter and I will be shaving our heads with the St. Baldrick’s charity. It might seem like a silly sort of stunt — and in a way, it is — but it draws attention to the problem of pediatric cancer in a uniquely pediatric way. We’ll have fun with it, and we’ll have fun with the kids, but in a serious way we hope to raise more money and improve more lives. Please give if you can.

Spring is here! Allergy therapy update

March 4, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ah, the sounds of spring. Birds tweeting, bees buzzing, and noses sniffling and sneezing. Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

For my medicine guide this year, I’ve included some photos to make these easier to find. A new trend seems to be color coding, with generics matching the brands in color and “look and feel”. That’s good if it makes the cheaper generics easy to find — they work just as well, and really should be your first choice for any of the options below.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. There are better choices. Benadryl products are usually packaged in a pink, hidden sad and lonely in the bottom row.

Pink Benadryl makes people sleepy. There are better options.

It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheap generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Zyrtec and cetirizine come boxed in springtime green.

 

If Claritin’s for you, it comes in friendly blue.

 

Very few words rhyme with purple. This is Allegra.

There are a just a few differences between the modern OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day. A 2017 study showed that Zyrtec is marginally more effective than Claritin, so I’ve been recommending that one first.

This year, there is one new player among the OTC antihistamines, called “Xyzal.” OK, I admit the name is cool — but it is therapuetically identical to Zyrtec. I don’t think it’s worth its typically-higher price.

Arresting orange says “XYZAL!”

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff hidden in back.

Nasal Steroid Sprays include many choices, all of which are essentially equivalent in effectiveness: OTC Nasacort, Flonase, Rhinocort, Sensimist, and many generics are available. All of these products are essentially the same. They all work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Lots of steroid nasal sprays. They’re all essentially the same.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others. My personal favorite is Nasacort or its generic version. Here’s a quirk: Nasacort comes in 2 differently-packaged versions, for adults and for children. But the product itself is the same. The pediatric version sells for less, but it’s a smaller bottle. I guess because children are smaller. Weird.

Children’s and regular Nasacort (and generic triamcinolone) are the same product in a different-sized bottle.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work, but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. Steroid nasal sprays are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical nasal spray steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor. There’s a generic version, though some people have told me the generic stings a bit.

Zaditor? Who names these things?

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

This is an updated version of previous posts.

 

 

A user’s guide to the confusing world of milk – updated!

February 28, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Milk sure has gotten complicated. You’ve got, of course, milk—the white stuff that comes out of cows—in different varieties of fat content, and lactose-free versions, too. And soy milk, and rice milk, and almond milk, and hemp milk. And organic milk. Fortified with omega-3 acids, like DHA and ARA! And don’t forget goat milk, which has natural goaty goodness. How can you decide?

Let me suggest a definition to start with: milk is a beverage that’s high in protein, and has other nutritional stuff in there too. It’s a great food for mammal babies like our own. For about the last 8,000 years humans have domesticated animals to continue to drink milk and eat dairy products well past infancy.

Is milk necessary? For babies, yes—they can’t really eat other things. Rarely does one see a one-month-old thriving on Doritos Locos Tacos. By about 9 months of age, human babies are starting to get a significant chunk of their calories from solids, and by 12-15 months could probably do just fine without any milk at all. Some will just refuse it. Still, milk is an easy and tasty source of protein and calcium, so it’s traditionally a part of a child’s diet for many years.

A clarification: we sometimes refer to infant formula as “milk” — but it is very different stuff, designed to feed babies less than one year of age. Do not feed any ordinary “milk”, including all of the examples below, to babies before their first birthday.

What’s with all of the milk variants, then? Are they better than ordinary cow milk?

 

Mammal milks

Lowfat milk – Ordinary, full-fat milk has about 4% milkfat in the USA. It used to be thought that infants needed that high milkfat, but a 2008 AAP statement corrected that misimpression, and their most recent statement on cardiovascular health reiterated that for families with heart health or obesity concerns (that should be all of us), low fat milk is appropriate starting at age 1. Lowfat milk is usually available in a range from 1-2% milkfat.

Skim milk – Even lower in fat is skim (or “skimmed”) milk, which has 0% milkfat. It has correspondingly more protein and carbohydrate and even a little more calcium per serving than ordinary milk. But if you put it in coffee, it is an abomination.

Organic milk – I don’t think it’s worth the extra cost. The main concern seems to be the use of supplemental cow growth hormone by many conventional dairies to increase milk supply. There’s zero convincing evidence that this is harmful to humans, and zero biologic plausibility that it could cause trouble for our kids. To me, the most legitimate objection to conventional milk is that production may be unhealthy or cruel for the cows.

Raw milk – Ew. Stay away from unpasteurized things loaded with nasty microorganisms, OK?

Lactose-free milk – great for those with lactose intolerance. That means babies and young children almost never need it. Lactose intolerance is essentially non-existent in newborn humans and other mammals, because human milk is loaded with lactose. It develops later in life, typically in teens or young adults.

Goat milk –Expensive! It’s deficient in micronutrients like folate, and has no advantage over cheap and readily available cow’s milk. Still, it’s got that goat cache.

Omega-3 fortified milk – Omega-3s are so-called essential fatty acids that are part of brain and retina tissue. Children probably need some, and we really don’t know how much is ideal or sufficient. Conditions of omega-3 deficiency are difficult to identify, and may not even exist. Still, it’s probably a good idea to eat fish once in a while, or try an omega-3 supplement of some kind. I don’t know why it ought to be added to milk in particular. I wonder if they’ll make a Nestle Quik Fish Flavor?

A2 milk – Has a slightly different casein protein than ordinary cow’s milk (chemically, A2 differs by one amino acid.) The short version of the complex story is that there is no good, independent evidence that this version of milk is more healthful than conventional cow’s milk. The company that sells it claims otherwise.

 

Plant milks

All of these may be suitable for those allergic to cow’s milk protein. All are lactose-free, since plants don’t make lactose.

Rice milk – this isn’t milk. It’s high-carb, and low-protein. Drink it instead of apple juice, if you want. But it isn’t a milk substitute at all.

Coconut milk – I grew up with a coconut palm in my backyard. Coconut milk to me is when you get after you bash the husk off a ripe coconut and then pound a screwdriver through one of the spots on the inner, softball-sized thing. It takes 20 minutes to get about an ounce. The coconut milk you easily can buy as a beverage is high in sugar and low in protein, and really isn’t a milk at all.

Soy milk – Milk made from legumes (pea and soy, usually), often have the highest protein content of the plant-based milks. There may be some cross reactivity between cow’s milk and soy especially, so beware if you’re allergic. Fears about estrogen-like effects of soy are overblown and not worth the worry.

Pea milk – An unfortunate name, but a nutritious product, high in protein. If you want dairy-free and you don’t mind paying a premium price, brands like “Ripple” might be what you’re looking for.

Almond (and other nut) milk – Typically has about half the protein of cow’s milk. And some varieties add a lot of sugar, which makes them more of a delicious dessert than a milk.

Oat milk – Similar to nut milk in protein content (about half of cow’s milk), but the brands I’ve found also have quite a bit of added sugar too.

Hemp milkThis groovy milk has a moderate protein content, similar to nut or oat milk, and is also low in sugar.

Confusing? You bet. I pretty much just drink conventional skim. Though sometimes, a nice Café au Lait hits the spot.

Updated from a previous post

 

Can a genetic test tell you if a medication will work?

January 14, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

“Personalized” medicine sounds appealing. Rather than just guessing at what medication to try, a genetic test can figure out, in advance, which medications will be effective and which medications are more likely to make you sicker.

Except it doesn’t work. It’s mostly marketing and hype.

The FDA has officially warned consumers and physicians that genetic tests sold to predict patient responses to medications shouldn’t be used. They’re not FDA approved, and in most cases there’s no reason to think that these tests can accurately predict how a medication is metabolized or what it’s likely to do when you take it. These tests are being aggressively marketed to the general public and to physicians, and they don’t deliver what they promise.

Medicines for conditions like depression, acid reflux, and heart disease have been highlighted by the FDA – though many other medicines have become targets for these tests, too. And these tests do reveal certain genetic “polymorphisms” (variations) that all of us carry, variations that affect the way medicines are metabolized and processed in our bodies.

The problem is that our knowledge about these polymorphisms is rapidly evolving, and it’s far from complete. It turns out that dozens or maybe hundreds of genes can have overlapping functions, and (with few exceptions) we don’t yet know all of the genes involved. And for each gene, there may be hundreds or thousands of variations in the general public. Or, maybe, some of us have a unique variant that hasn’t been seen before. These companies have no way to test the gene variants to know their function. They rely on proprietary databases, riddled with incomplete data and assumptions.

Just one example: when the MTHFR gene and its variants was first described, it seemed like MTHFR polymorphisms could have wide-ranging and significant health effects. It turned out that’s completely wrong. MTHFR “variations” are so common in the general public that it’s fair to say we all have polymorphisms, and almost none of these has any clinical importance. Even the 23andMe company, which makes money selling genetic tests, discourages MTHFR testing, saying “Despite lots of research – and lots of buzz – the existing scientific data doesn’t support the vast majority of claims that common MTHFR variants impact human health.” Still, many families are still relying on misguided MTHFR testing pushed by naturopaths and chiropractors to make health decisions. And this is just one of the hundreds of genes these kinds of tests rely on.

Genetics shows great promise, and I think the future includes a big role for genetic testing. But we don’t have the knowledge, yet, to use the results of these tests to better-guide therapy. But that doesn’t mean that therapeutic decisions, now, are entirely guesswork. Reviewing a family history and the exact nature of a problem often gives physicians some good clues to help guide decisions. I know, that sounds old-fashioned. But talking and listening remain the best ways for docs and patients to work together to make the best decisions.