Posted tagged ‘autism’

Maternal illness and autism

November 15, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

This week’s autism headline: Flu, fever during pregnancy linked to autism risk.

Researchers in Denmark reviewed health information from a group of about 100,000 children born between 1997 and 2003. The mothers had been interviewed during and shortly after their pregnancies to determine who had had infections, fevers, or other health issues during pregnancy. Now that the children had grown to 8-14 years of age, the study looked backwards to see if the children developed autism had mothers who reported more infections or fevers during pregnancy.

The good news: for many minor infections, including common colds or short-lived fevers, there was no significant association with autism. However, mothers who had recalled having the flu had about double the risk of autism in their children, and mothers who reported a fever lasting over a week had triple the risk.

The authors themselves stress that these are preliminary findings, and that their complicated mathematics could have exaggerated trends that aren’t really significant. Still, there is animal data that shows inflammation from infection during pregnancy can indeed influence fetal brain development. These findings about flu and fever are plausible.

This study adds to the growing evidence that at least in many cases, the causes of autism begin well before a baby is born. Previous research has shown in increased risk of autism with older fathers, maternal obesity, and closely spaced pregnancies. It is very likely that there are numerous, overlapping causes of autism that include genetic, prenatal, and environmental factors. We’re learning more and more, but we’ve still got far to go.

Back to the current study: the overall risk of having a child with autism following influenza is still low—there is no need for panic or extensive watchfulness. However, this study provides yet more evidence that pregnant (or expecting-to-get-pregnant) moms need to protect themselves from infection. Eat right, sleep right, wash your hands, avoid sick people. And please, get yourself and your children influenza vaccines. Want to avoid autism? Vaccinate!

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Book review: The Panic Virus: A True Story of Medicine, Science, and Fear

June 6, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

It could have been a riveting fictional thriller, the story of how a handful of unscrupulous scientists took advantage of parents’ fears to create a false hysteria that dominated the media and led to a resurgence of diseases in the developed world. Unfortunately, the tale of The Panic Virus by journalist Seth Mnookin is true.

Mnookin recounts the history of vaccines, and the history of accompanying anti-vaccine worries. From very early on, some parents and politicians were distrustful of vaccination, perhaps because it seemed to subvert nature’s plans for our children. There is something inherently odd—and maybe a little creepy—about deliberately inoculating a child with germy material to prevent disease.

But prevent disease, it does. Mnookin’s book isn’t heavy on the details of the public health impact of vaccines, but it does make the point in chapters about children suffering from vaccine-preventable illnesses that vaccines have been tremendously successful in keeping children healthy.

Rather than focusing too heavily on the science of vaccinations or the epidemiology of shifting patterns of disease, Mnookin’s book focuses on the people involved in the story. One point is abundantly clear: parents from both sides love their children, and want the best for their kids. Mnookin doesn’t criticize non-vaccinating parents for their belief, but rather explores how loving, educated parents can be manipulated to feel that way.

His strongest, most direct criticism is directed at the media, who time and again failed to even do cursory research into the stories that they reported. It took only a handful of fringe “scientists” to manufacture (and profit) from the story—and that was only possible because the media chose to portray their side as the David versus the cold, uncaring Goliath of the medical establishment. The media found a story that captivated, enthralled, and (above all) sold. Media figures including Oprah Winfrey, Don Imus, and Jennie McCarthy relied on their own manufactured frenzy, public health be damned. You want information that can genuinely help you raise your kids? Mnookin makes the case that the mainstream media is the last place on which you can depend.

Mnookin’s strongest material explains the “cognitive biases” that color how we perceive our world. Our feelings and impressions guide us through our days, but aren’t always the most objective, best way to make decisions. You want to pick a shirt that looks best on you? Go with your gut. You want to choose the best medicine to keep yourself healthy? It’s better to rely on science—real science—to do the plodding, slow work of separating fact from fiction.

But people, especially people desperate for help and answers, may understandably find it difficult to wait for science to untangle the complicated story. Mnookin’s book covers in great detail the characters and charlatans that took advantage of people—robbing them blind, and steering them into years of false hopes and promises.

Readers will also learn the complex history of the autism advocacy movement within the United States. They may be surprised to learn that not all—not even most—parents of autistic kids buy into the anti-vaccine rhetoric. There have been great schisms among the large autism charities about this very issue, and unfortunately it has become a great divider and distraction. Years from now, parents may place the blame squarely on the anti-vaccine propagandists for over a decade of wasted time and money and heartache. Tremendous strides are being made in researching the causes and treatment of autism. How much further ahead would be have been without this unnecessary dead-end?

Mnookin’s book ends with a detailed and fascinating recount of the Special Master’s rulings from the Vaccine Court in 2009. After a full seven years of proceedings, during which reams of evidence and documents were reviewed, the ruling was unmistakably strong and unambiguous. Calling the evidence “so one-sided”, the vaccine court ruled that there was no possibility that vaccines had caused autism in the petitioner’s children.

There are stronger books about the science of autism and vaccines, and about the real progress that’s being made in early identification and treatment of autism. (The nearly 100 pages of references provide more-than-ample sources for further reading.) Mnookin’s book concentrates on the people and the emotions, to help the reader see how vaccine distrust became such a powerful dogma in the autism community. False, yes; but it was a common thread of hope, and it bound families together who had otherwise felt alone and helpless. There are far-better resources now for parents. Books like this illustrate a far more helpful message: there is no reason to distrust vaccines, and there is far greater hope for understanding a real cure from the science community than from the virulent anti-vaccine crowd. Perhaps Mnookin’s book will be a way to bring a new hope and a new community to families fighting autism.

Diet and ADHD: Anything new?

February 12, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

The Lancet has published another terrible, worthless study guaranteed to confuse parents.

Back in 1998, the world-renowned British medical journal The Lancet published a study that singlehandedly created the entire MMR-autism “manufacturversy.” The study itself was an absolute fraud based on fake data, designed to make money for its lead author. Red flags about the study were ignored by The Lancet’s editorial board for years; but finally most of its authors retracted the study, and then The Lancet withdrew it. Still, the damage was done. Falling vaccine rates led to a return of measles and surging rates of pertussis. Fooled by an unscrupulous liar and a media relishing any opportunity to sensationalize garbage, many parents still distrust vaccines.

And now, The Lancet has done it again. A terrible, worthless study has been published, guaranteed to confuse parents. Maybe their motto ought to be “anything that’s fit to make headlines.”

The study, titled “Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial”, was supposed to examine the relationship between diet and behavior in ADHD. It’s an important topic. Many children have trouble with focus and attention, and many parents feel that diet may play a role. Though many older studies have been unable to confirm a consistent effect of foods on behavior, a 2007 BMJ study did show at least a small effect of preservatives and dyes in worsening behavior in children.

What has made studying diet and behavior difficult is separating out what is called “confirmation bias.” Parents who are convinced that, say, a sugary meal will worsen their child’s behavior are very apt to notice when bad behavior follows a junk food meal. But those same parents probably don’t notice when relatively good behavior occurs after sugar, or when bad behavior doesn’t really come after a meal. This isn’t because those parents are dumb or delusional—it’s just human nature. We all subconsciously find evidence to support what we already believe, and ignore evidence to the contrary.

Good science seeks to minimize the effects of this kind of bias by using “blinded control groups”, where the observers don’t know if the child was exposed to a surgary diet or not. In the older 2007 BMJ study, the families were truly blinded: neither they nor the researchers knew which kids received a supplement that was a preservative-n-chemical cocktail, versus which ones got a supplement of “nothing”. Only after the parents made their behavioral observations, and after the researchers performed their statistics, were they allowed to know which kids got which diet. That’s good research. The BMJ study did show a statistically significant change in behavior, though the effect was fairly small. Still, it’s a tantalizing start, and the group is now pursuing a more-specific study trying to identify which chemicals and preservatives might be the culprit. It’s a slow process, but carefully-done, well-controlled research should give us a clear answer on this topic.

Unfortunately, the research group publishing in The Lancet didn’t feel the need to bother with these sorts of protocols. In the initial phase of their study, 100 kids were divided into two groups of 50. One group continued to get an ordinary diet (though they did receive counseling about healthy food choices), and the other group was put on a highly restrictive diet of mostly rice, meat, vegetables, pears, and water. But all of the parents knew exactly what group their child was in. At the end of this study period, about 60% of parents of children in the restricted diet group had improved, compared to “none” of the children in the non-restricted diet.

Wait a minute here. If something completely random happens—let’s say I ask parents to flip a coin, and tell me heads or tails—about 50% of the parents should report “tails.” In this behavioral study, if I ask parents to just decide, “did things get worse or better,” if there was just a random scatter of observations, 50% of the parents should say “worse”, and 50% should say “better.” How could “none” of the parents have seen any improvement? Surely at least some of the children had a few good weeks, even with no change in diet, no?

And if 60% improved in the restricted group, that means 40% didn’t improve, or got worse. A 60-40 split isn’t really that impressive, is it?

Besides, with no blinding whatsoever, what does it even mean?

The study gets worse. There was a phase 2 that took the “diet responders” and put them on even more restricted diets based on blood testing for allergies—but using an outdated, worthless test that’s been invalidated for years. This further phase found that the blood tests didn’t help guide parents to diets that would help, which is no surprise because those blood tests don’t work. We already knew that.

There you have it, another terrible study from The Lancet, which demonstrates nothing in a perniciously misleading way. Perhaps there is a link between diet, chemicals, preservatives, and behavior—and certainly, trying to put children on a diet that avoids these sorts of chemicals can’t do any harm. But these authors, and the editorial board of The Lancet, ought to be ashamed of publishing such a worthless study. Do you think the media, and the public, are ready to get duped again?

Exaggerating freakiness

March 12, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

Two stories:

#1: “I went to see the doctor because my foot hurt that morning. At first the doctor didn’t want to do any tests, but I insisted on xrays and a CT scan and an MRI and a bone scan and blood tests. It turns out that I have cancer!”

#2: “My foot hurt when I woke up. I’m not sure why. Now it feels better.”

Which one of these are you more likely to read about on the internet?

Things happen every day, and most of them are routine and boring. Your child has a sore throat, then he gets better. You eat a donut, and then you don’t get pregnant. You read about a celebrity in the newspaper, then later that day you don’t meet a long-lost friend who has the same first name. Thousands, maybe millions of things happen to each of us each week that don’t seem particularly strange or interesting or ironic or coincidental.

When these ordinary things happen, we don’t tell all of our friends. We’d be pretty boring if we told stories like this:

You won’t believe it! I went to Starbucks and I ordered my usual Venti-1/2-caff-double-foam-smack-my-behind-double-Splenda, then I drank it!

But if something like this happens, you’re going to talk about it for months:

The foam in my coffee cup was shaped exactly like the face of Mother Theresa, and as soon as I finished drinking it I found a $100 bill! And our Shawn was accepted to Harvard, he’s barely out of diapers!

OK, that’s fine, human nature. The stories that are weird and interesting and freakish are the ones we hear about. But something has changed, and it’s drastically exaggerated the impact of weird stories.

Days gone by, if your neighbor’s child was born with a tail, he’d know, you’d know, and the other 200 or so people in your village would know. Maybe by the 1950’s, there were enough televisions so that “news of the weird” traveled further.

But now: the freak stories are blogged and reported and turn into mass emails, and everyone hears about everything. Not everything, really– just everything freakish and weird and unexpected. The normal stuff slides under the radar, even tough there are zillions more normal things than freakish things. But everything freakish, that’s what the internet exaggerates. The stories go around in circles, and never die.

There’s no way of knowing if any of these stories are even true. That doesn’t matter, of course– it’s not “truthiness” that keeps stories circulating, it’s impact and color and weirdness.

In 1998 a researcher in Great Britain published a single study involving 12 children, claiming indirectly that their autism was caused by the MMR vaccine. It doesn’t matter that this single study was never confirmed, or that dozens of studies involving millions of children haven’t found any link, or that it turns out that this researcher probably faked his data, took advantage of the children involved, and was being paid by lawyers who were trying to extort money from vaccine manufacturers.  The entire study has since been retracted, and the researcher fled to the United States, where he’s since been dismissed from his employer after British courts found him guilty of misconduct. None of this matters on the internet, because of the innate power of an unexpected and interesting story. It’s a power that has led in this case to the return of infectious diseases that we already had defeated.

It just isn’t very interesting to recall the millions of children who are vaccinated every day without any problems, or talk about the millions of children who don’t get pertussis, measels, or meningitis because they’re protected by immunizations. Maybe not interesting, but it’s true, and it’s good information that parents need to make the best decisions for their children.

So I’ll just keep writing about it.

Why parents refuse vaccines

October 21, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

Ask 98% of my patients, and they’ll tell you they’ve gotten all of their kids’ vaccines, without qualms or hesitation. Ask the other 2%, and you’ll hear all sorts of reasons why they’ve skipped them. What makes some people look at vaccinations so differently than the rest of us?

Along with clean food and water, vaccinations are generally accepted as one of the greatest public health triumphs of the modern world. We are safe from diseases like polio and measles, which once ravaged millions. We no longer, really, have to worry about most kinds of bacterial meningitis, and we’re able to even prevent some kinds of cancer. Newer vaccines in development include protection against HIV and malaria. At the same time, immunizations are very safe, compared to just about any other medicine or medical intervention. Yet despite their incredible effectiveness and well-documented safety, suspicions remain. Many families choose to skip some or all vaccinations.

We know that vaccine refusers tend to be wealthier, and come from more socially advantaged communities. There also seems to be a neighborhood effect, where people from one small area tends to follow each others’ lead in vaccinating or not vaccinating. But these observations don’t tell us much about the psychology and thinking that leads individual parents to refuse vaccination.

Based on my own observations and conversations with parents who refuse vaccinations, and also with parents who are more eager for vaccines, I’ve come up with my own list of “profiles” of the kinds of parents who are most steadfast in their refusal. I don’t think this list is likely to be complete, and there’s a lot of overlap between the groups. But I think this is a good starting point to understand just where people are coming from. Hopefully, better understanding will lead to improved trust and better decisions for children.

If you are a vaccine refuser, please join in the comments. Does one of these profiles fit you? Have I neglected to understand perhaps your own reasons for refusing vaccines? What sort of information is missing that can help guide parents along this decision? My goal here isn’t to belittle anyone, but to understand and appreciate the concerns of parents. I welcome any comments.

Profile #1: The Government Distruster

I certainly understand that some people feel the government doesn’t always make the best decisions for us. The two parties bicker, and special interests and money seem to have more influence on decisions than the needs of ordinary people. Look at the Clowns in Congress, or service reps at the post office, or IRS telephone screeners– there’s no doubt that government and government employees are not always paragons of virtue and judgment.

Decisions on vaccine recommendations aren’t only made by government employees at the CDC. There is input from all of the major medical associations—pediatricians, family practitioners, internal medicine physicians, obstetricians, and infectious disease specialists are all involved. Specific recommendations are made by the CDC’s Advisory Committee on Immunization Practices, which is comprised of 15 vaccine experts from various fields. There are also vaccine recommendations made by government and health agencies around the world, including the United Nation’s World Health Organization. It is difficult to believe that all of these organizations and experts reviewing the studies and making recommendations have gotten the facts entirely wrong. Though there are some differences in the exact recommendations from country to country, by and large vaccine schedules and recommendations are identical throughout the world.

Some people believe not only that the government is irresponsible and incompetent, but that it’s actually twisted and evil. Like people who believe that the US government itself planned the 9/11 attacks, some people sincerely believe that vaccinations are a great threat to mankind, deliberately put in place by malevolent forces within the government to harm us. To believe this, you have to believe that evil pervades every step throughout government, from the statisticians and analysts at the CDC and university medical centers, all the way up to the surgeon general and president himself. Furthermore, you’d have to believe that this whole vast conspiracy has somehow been successfully hushed up, because there’s no actual evidence for this whatsoever. Is this even remotely possible?

#2 The Science Distruster

Science itself is not a series of facts, or a group of people wearing white coats. It’s a system meant to discern how the natural world behaves, in a way that allows us to predict what will happen in the future. Key features of science include:

  • Natural law. There are rules about how things happen, and these rules can’t change. For instance, when a force acts on an object, it’s going to move in a predictable direction, in a predictable way. Natural laws are developed based on observations of real things that happen in real, measurable ways. They can then be tested, to make sure the predictions work accurately and consistently. If an observable case doesn’t fit what we thought of as the natural law, then the law has got to be refined and improved. Though we certainly don’t know how everything works, we’re very reluctant to accept propositions that fly in the face of natural law. You claim you have a machine that extracts energy out of perpetual motion? I want to see it before I believe it. Things that are beyond natural law—the “supernatural”—cannot be part of any scientific theory.
  • Testing hypotheses Science relies on experiments. You can’t just say you think something is right, or that something ought to be true based on scientific knowledge. Anything that’s worth knowing through science is testable, and can be tested, and ought to be verified. Things that are not testable (or “unfalsifiable”, a more precise word) are not things that science can support or substantiate. Something like “Michelangelo was a better painter than Da Vinci” isn’t a question that science could test.

Some people who are deeply religious have a distrust of science, but it doesn’t have to be that way. There are many important questions facing mankind for which science may not provide an answer. Why are we here? How should be treat each other? Questions of law, ethics, morals, and aesthetics may not lend themselves to scientific study, and other manners of investigation of these issues are more appropriate. Science is one tool to help us understand their world, but it isn’t the only tool. Trusting science does not have to mean turning your back on religious or other convictions.

Some people refuse vaccines because they do not trust science, or because they feel it is more “natural” to suffer infections. If these infections weren’t good for us, why would they be here on earth? Though “Why do people suffer?” is not a question for science, I personally don’t think that God would have given us the intellect and wisdom to find answers if He didn’t want us to us those answers.

Another potential knock against science: scientists don’t know everything, and don’t pretend to. The very nature of science is to question and to allow new knowledge to replace old. When you read in the paper that a medicine has been found to have a new side effect, that isn’t a failure of science—it means that science did what it was supposed to. Question, learn, repeat; question, learn, repeat. Some people feel more comfortable with absolute truths, but that really isn’t what science is all about.

Which brings us to another problem with science: the language. Scientists use “science terms”—like “This study fails to confirm any link between vaccines and autism,” or “This study adds to the evidence that vaccines are not a cause of autism.” What parents want to read is an unequivocal “Vaccines don’t cause autism.” But it is impossible to completely rule out a negative statement using the tools of science. We can say that the odds against this are very, very small, and getting smaller, but we cannot prove with absolute certainty that it could not possibly in any circumstance at any time be true. Those language of science is exact, but can sound “weaselly” to many people, leading to distrust.

Profile #3: The Big Pharma Distruster

Big Pharma is The Big Boogeyman on the anti-vaccine web sites, and perhaps they do deserve some distrust. Basically, their duty is to their shareholders: to make a profit. Their business is to develop and sell medicines and vaccines, and to make money doing so. Vaccines and medicines create billions of dollars of profit. Does that mean that drug companies cannot be trusted?

It’s wise to view promotional material from drug companies as you would advertising from any other company: with great skepticism. Advertisers want to sell you things, as do drug companies. But most patients don’t buy their drugs or get a vaccine because of ads from the drug companies, but rather because of the advice of their physicians. Distrusting the drug companies because they make money by selling drugs is sort of like distrusting the tire manufacturers for selling you tires, or the paint people for selling paint, or … well, anyone for selling anything. Sure, the computer guy wants you to buy a more expensive computer, and sure, the grocery store wants you to buy more groceries. That doesn’t make people who sell tires or groceries evil or twisted. People who buy things should be wary of salesmen, but c’mon now. Just because a profit is involved doesn’t mean that drug companies are to be trusted less than any other company. If their product is good, you benefit, and they benefit, and everyone wins.

Profile #4: The Doctor Distruster

As I said, most people don’t buy medicines or get vaccines because of the promotional efforts of drug companies, but rather based on the recommendations of their physicians. But can physicians be trusted? Couldn’t we be but shills of the drug and vaccine manufacturers?

There are doctors who’ve accepted quite a bit of money from drug companies, as “experts” or “thought leaders.” Some of them travel around the country, giving talks to other doctors to convince them to use a certain drug or vaccine. I think this is a violation of the trust patients put in their physicians, and I won’t do it. Furthermore, the truth is that the vast majority of physicians are never offered such perks. We’re in the trenches, doing our work, and most of us just don’t attract that kind of fawning attention from the drug companies.

Is it possible that the pharmaceutical companies have fooled the doctors into blindly trusting their vaccines? I don’t think so. Most of us have seen diseases disappear once a vaccine is introduced, and most of us have seen vaccine-preventable diseases in unimmunized kids. Personally, I saw my last case of pneumococcal meningitis kill a patient of mine in 1996, right before the vaccine came out. I would prefer to never see that again.

Physicians as a group are intelligent and motivated—or we wouldn’t have made it this far. We’re certainly not monolithic, single-minded thinkers; many doctors harbor opinions of health issues that are far outside the mainstream. Yet with vaccinations, it’s only a very small handful of fringe doctors who are leery of established immunizations. There is a reason why so many pediatricians are so pro-vaccine.

It’s certainly not the money. Pediatricians actually lose money on some of the vaccines we give; for the majority of them, it’s pretty much a wash. They’re very expensive for us to buy and store, yet we do it because we know it’s best for our patients.

Looking at the trust issue from another angle: I have a mechanic I’ve known for years. When I bring him my car, he tells me what’s wrong, and I pay him to fix it. I know nothing about cars, and I seldom question his advice. Sure, if he suggested something really weird, I’d go elsewhere—but I’ve known him a long time, and he’s earned my trust. Likewise, I’ve seen my own patients for years and years. Parents ask for and want my advice on all sorts of things: feeding, sleeping, school issues, medical problems. I prescribe medications, and we talk about the side effects and risks and benefits, and we make our decisions. I would say that most patients trust my advice—or they’d find another pediatrician. Yet for some reason, for some families, vaccines seem to be a very separate issue. Sure, mom has trusted me as a source of information on everything else, yet immunization issues seem to be “off the table.” Mom would rather make vaccine decisions based on advice from random people she doesn’t know posting on the internet than based on information from me. Why am I perceived as an expert on health and childcare, but not as a trusted source of vaccine information? And if I can’t be trusted for that kind of advice, why are you depending on my judgment for anything else?

Profile #5: Paging Dr. Google

Everyone knows that the internet is a wild place. It’s full of all sorts of information, some great, some outdated, and some wildly misleading. No one believes that a Nigerian price wants to give you millions if you help him transfer assets, yet web sites that spread misleading lies about vaccines have somehow become a leading source of (mis)information for parents.

I’m going to google the word “vaccine” right now, and take a peek at the top 10 sites. I won’t provide links, because I can’t guarantee that any of the information is accurate, but here’s a quick summary of what I get:

  • 5 sites with good, useful, dependable information—including information from the CDC and well-established medical sites.
  • 2 news stories that more-or-less accurately talk about recent vaccine news. One of the stories has an odd sort of tangent including a brief interview with a well-known anti-vaccine propagandist, who plugs her usual misinformation (that’s irrelevant to the main point of the story, but it’s part of the standard boilerplate for some journalists to interview someone from the short-list of anti-vaccine spokespeople.)
  • 3 sites retelling outlandish, truly bizarre misinformation. One strongly suggests that Americans should not get a flu vaccine because they contain squalene, a chemical that they claim caused Gulf War Syndrome. This is just a flat-out lie; there is no vaccine currently licensed in the USA, flu or otherwise, that contains squalene, which hasn’t been conclusively linked to any health problems anyway. The sites link and re-link to old, long-disproven canards based on tiny, unreproducible studies of questionable authenticity, with no effort whatsoever to present the best, most recent research. These sites explicitly state that I as a physician, in cahoots with government and big business, want to poison your child.

If you want good, accurate information that you can trust about vaccines, side effects, and actual real research into vaccine issues, try these sites first:

Profile #6: The alternative medicine believer

There isn’t an exact definition for “alternative medicine,” (a term I don’t like) beyond “things outside of mainstream medicine.” Most people feel they just know it when they see it. Because it encompasses such a broad array of philosophies and modalities, from acupuncture to chiropractic to massage to energy healing to prayer to herbal supplements to homeopathy, it doesn’t make a whole lot of sense to lump them all together. Nonetheless, some people feel that these sorts of “remedies” are better than what most doctors prescribe, and some alternative health devotees are suspicious of immunizations.

One argument is that the “natural” remedies of the world of alt-med are somehow better, or less dangerous. This doesn’t make a whole lot of sense—the small pox virus is natural; getting bitten by a tiger is natural; falling 60 feet out of a tree or building is natural. Burning and freezing and starvation and pestilence are as natural as can be. Potent poisons from jellyfish or tropical frogs are natural. Many mushrooms and plants are poisonous, and naturally occurring radiation from elements in the Earth and cosmic radiation cause plenty of cancers. There’s nothing inherently more safe about natural things than about “unnatural” things that come from a laboratory. Sure, medications have side effects, and some can be quite toxic—just like many natural plant products. In fact, if someone tells you they’ve got an herb or something with no toxic effects whatsoever, you ought to think again: any biologically active product, whether a medicine or something “natural”, is going to have multiple effects on a complex living organism. Some will be beneficial, some will be harmful. There’s no such thing as a medicine or herb with no side effects or potential for harm, unless that herb or medicine is 100% placebo.

Alt-med proponents also sometimes feel that manufacturers and businesses involved in alternative health products are more ethical or trustworthy than manufacturers of traditional medicines or vaccines. This is a completely unfounded opinion—just take a quick glance at a sampling of this week’s stories from the world of alternative medicine:

  • The FDA has established a web site listing over a hundred bogus products to treat H1N1 influenza. The list currently has 136 (!) specific products, almost all of which are marketed to appeal to alternative-health consumers.
  • Resveratrol is the latest product to be marketed heavily through national magazines as a product to reverse aging. There’s no magic cure for aging, despite what they’re trying to sell to you.
  • A clinical trial was published looking at the “Gonzales Protocol” for treating pancreatic cancer with hundreds of supplement pills, coffee enemas, and a special diet. The treatment failed miserably—patients pursuing this alternative medicine approach died more quickly and had a poorer quality of life.

(These three examples were all taken from the last 2 weekly issues of Consumer Health Digest, a free listserv from Quackwatch and the National Council Against Health Fraud. You can sign up here.)

There have certainly been abuses and violations of trust from the world of conventional medicine, too. But as an unregulated industry, supplement and alternative health providers are more free to commit fraud and rely on questionable marketing tactics than traditional pharmaceutical and vaccine companies, whose products and advertising materials are tightly regulated.

There’s no logical reason to think that “natural” cures are safer, unless they’re just placebo. There’s plenty of evidence showing that alternative medicine companies are more likely to engage in shady marketing and business practices. Yet distrust of traditional medicine, including vaccinations, seems to be more common among users of alternative medicine modalities.

A very small number of alt-med proponents really goes to the extreme of non-scientific thought—they reject the very notion that infections cause disease, and thus reject all medical preventions and treatments for infection. These believers have a cult-like devotion to their ideas, and no amount of scientific evidence is going to sway them. Though from what I’ve seen few people really believe this, their web sites get plenty of hits from people looking for reliable vaccine information. The philosophy and background of people writing web pages isn’t always transparent, and some people with a vastly different worldview—one that many people would reject as ridiculous—are trying to sway your opinion. Beware the “yellow brick road” of alternative medicine, for far down that path are some truly bizarre beliefs.

Profile #7: Me, too!

This one frustrates me, but it seems to account for a big percentage of non-vaccinating parents. I ask why they’re reluctant to vaccinate, and the answer is something like “Well, a lot of my neighbors don’t,” or, “I heard that lots of people are scared of vaccines,” or, must frustrating of all, just “Well, you know.”

As momma used to say: “If your friends decide to jump off a bridge, are you going to jump too?”

There is a perception that vaccine refusal is a common phenomenon, though overall rates run in the 1-2% range (some individual communities are much higher, but that’s the usual quoted rate for most parts of the country.) The vast majority of parents get their kids immunized—but they don’t talk about it as much as the non-vaccinators. Refusing some or all vaccines is chic, and the people who do it like to talk about it. You might hear of neighbors who skip vaccines for their kids, but you can bet that you won’t hear about the majority of neighbors who get them on schedule. Don’t let the amount of noise made by anti-vaccine spokespeople hide the fact that they’re a very small minority.

Please, decide for yourself what’s best for your children. Rely on advice from people who know what they’re talking about, people who who’ve trusted for years for reliable health information. These decisions should not be made based on flippant whims and rumors.

Conclusion

Many pediatric practices have chosen to “ban” vaccine refusers from their practice. I can see their point of view—it takes a lot of extra time to talk with parents about these complex issues, and some parents become argumentative and, well, ugly about these things. Who wants a fight? The anti-vaccine lobby seems to create an endless stream of rumors and moving targets that are difficult to keep track of and continually swat back down. Besides, medical offices serve many patients with special health care needs, including newborns who are at special risk for vaccine-preventable diseases. Why put those kids at extra risk by allowing unvaccinated children nearby?

Countering this is my own philosophy, that it’s not the kids fault they’re not vaccinated; and with patience and continuous discussions, I can usually get even the most stubbornly misinformed parents to vaccinate. So finally, with a lot of extra work, the kids get protected. That’s my goal.

There should be no doubt that vaccines are very effective at preventing diseases, and are still necessary to prevent serious illnesses. Just one recent example: a study published in May, 2009 showed that unvaccinated kids were 23 times more likely to contract whooping cough than children who were fully vaccinated. Do not doubt that the diseases that are prevented by vaccines are themselves quite serious and sometimes deadly. There are certainly some side effects of vaccines, as there are with any medical intervention, and serious vaccine reactions, though very rare, do occur. In my judgment and that of every respected health care agency, world-wide, the benefits of vaccinations far ought weigh the risks. Please don’t fall for internet hysterics and unfounded rumors. Protect your kids, and make sure they’re fully vaccinated.

Further resources

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All. From Wired magazine, 10/2009, about just how unhinged antivaccine groups have become, and how their unjustified influence could affect the health of your children.

A review by me of Paul Offit’s Autism’s False Prophets, a book that reviews the long history of anti-vaccine sentiment, and how a very small number of misguided and sometimes malicious characters have steered parts of the autism community to distrust doctors and shovel their money into pointless and sometimes dangerous quackery. The book also offers promising hope for further discovery into the causes and cures of autism.

John Stewart on the daily show with some humor to illustrate the rampant scaremongering that pervades media attention to vaccines.

From Science-Based Medicine, a very well-referenced resource reviewing all of the evidence and the history of the “controversy” regarding vaccines and autism.

A good week for science & parents

February 13, 2009

It was a good week for science, and a good week for parents. In the long run, it will have been a good week for the many families struggling with children who have autistic-spectrum disorders.

News #1: The entire MMR-autism link has been resting on a study that has now been revealed to be entirely fraudulent. Andrew Wakefield published a paper in The Lancet involving twelve children in 1998. In it, he claimed that they developed autistic behavior very shortly after receiving their MMR vaccinations. He formulated a new theory, that the MMR vaccine caused gut damage that allowed foreign proteins to invade, triggering autism.

This study has been widely refuted, and The Lancet has retracted the paper based on revelations that Dr. Wakefield didn’t reveal money he was taking from plaintiffs’ attorneys seeking damages based on an MMR-autism link. Furthermore, his study has never been replicated; several labs have tried, with uniformly negative results. His own technicians have testified that their results differed from what was published in the paper, and Dr. Wakefield has refused to share his original data or biopsy specimens. Almost all of the co-authors of this paper have seen recanted and asked for their names to be removed.

And now, the nail in the coffin: a reporter has uncovered documents showing that Dr. Wakefield made everything up. The children in the paper didn’t have autism after the vaccines; most already had abnormal symptoms well before receiving the vaccine. And their gut pathology specimens didn’t show any inflammation at all. They were entirely normal, according to hospital records and pathologists reports.

Dr. Wakefield’s study, upon which the entire MMR-autism link was founded, is a fraud. He took money to make up data, and it turns out shortly before publication he sought to patent a new kind of measles vaccine—so he stood to profit mightily by scaring the public away from the existing MMR.

Now, measles is no longer considered “controlled” in Great Britain. As vaccination rates have fallen, the disease is back. Here in the USA, outbreaks of measles and mumps are common.

All the result of the greed of a single man.

For details, with plenty of links to the source material: http://scienceblogs.com/insolence/2009/02/why_am_i_not_surprised_it_looks_as_thoug.php

News #2: The United States “vaccine court” has unequivocally rejected the possibility that the MMR vaccine causes autism. In very strong language, the ‘special masters’ (essentially judges) in the case declared that the scientific evidence overwhelmingly supported the safety of the MMR vaccine.

short summary:

http://www.webmd.com/brain/autism/news/20090212/vaccine-court-rejects-autism-claims

more details, including several quotes from the ruling:

http://www.theness.com/neurologicablog/?p=478

I’d like to say that this should be the end of the MMR hysteria, which I’ve written about before. Unfortunately, the anti-vax movement includes a truly delusional fringe that rejects any sort of science, and certainly isn’t going to care that their entire foundation is a lie. But I’ve found that most parents just want to do the right thing, and with good solid information they’re eager to protect their children. Good for them, and good for all of us.

Best of all, perhaps we can move beyond the entirely discredited vaccine-scare theory and spend more time and research dollars looking into what really does cause autism. That should be a rallying cry of hope for suffering families and their children. It’s time to move on, together, to find a cause and a cure.

For a detailed historical account of autism and the many sleazeballs who’ve taken advantage of suffering families for their own egos and wealth, read Paul Offit’s Autism’s False Prophets, reviewed here.

Subtle developmental clues

November 4, 2008

A post from Day: “Dr Roy, what is considered “normal range” for a one year old’s speaking ability? My 13 month old doesn’t speak yet and this concerns me. He might babble “gagaga” but it has no meaning. I stay at home with him and every day I try to teach him words such as momma, daddy, bye bye, cat etc and he isnt learning to say them. His pediatrician told me this would be something we would address at 15 months(my pediatrician was not worried at all that he wasn’t speaking) but as a mom who sees other 12 month old’s ability I am worried. Also, he 100% understands what I am saying. I can say simple commands such at ‘lets eat’ and he knows to go to his high chair so I know he understands me. Thank you!”

From my point of view, how many words a 13 month old is using really isn’t a useful marker of how well the child is developing. Some normal 13 month olds have 4 words, some fewer; some have no words at all. There’s a lot of variability there, and concentrating on word count at this age can create a lot of unnecessary worry.

A neurologically normal 13 month old should do all or almost all of these things:

  • Follow simple directions.
  • Use gestures like waving or nodding.
  • Point to things he wants, or point to things he wants you to look at.
  • Look at things you point at.
  • Bring things to show you.
  • Show off—that is, do cute things, then look to make sure you’re paying attention.
  • Combine sounds with a melodic quality, similar to speech. Even if words don’t make sense, the overall “sound” of his babbling should sound like a monologue, with pitch and speed changes and pauses.

The easiest “milestones” to talk about and compare between children are things like when they start walking, or how many words they say at a certain age. However, the subtle things like the ones I’ve listed are far more important, and offer far more insight into how a child is developing.