Routine vaccination prevents illness.  Another recent study has confirmed the value of these shots.  In the June 2009 issue of Pediatrics, doctors in Denver, Colorado investigated 156 cases of clinically proven whooping cough (Pertussis) in children, ages 2 months to 18 years.  When compared with kids who received the standard immunization schedule, children of “refusers” were much more likely to get sick from whooping cough – 20 times more common!

This study demonstrates two things.  First, vaccines prevent illness (not surprisingly).  Second, these kids didn’t get much protection from “herd immunity.”  They weren’t protected by the fact that other kids in their community had been immunized.

Bottom line: don’t delay!  Get your kids vaccinated according to the recommended schedule.  If you have questions, I’d be happy to discuss them with you.

–  Dr. Epstein

http://pediatrics.aappublications.org/cgi/content/abstract/123/6/1446

–  David Epstein, MD

The safety issue relates to the way that the safety belts themselves restrain the child.  In order for the belt to restrain the child without causing injury, the belt must nestle against the child’s bones, rather than soft tissue.

Delaware law (click here for interesting info) requires kids to be in their car seats while travelling until the 8th birthday, or 65 pounds, whichever comes first.  But following this rule does not guarantee safety, especially for smaller kids, because of the geometry of safety belts.

To convince yourself (and your child, if she is agitating to get rid of the booster seat), you can try this test:

Let your child (over 8 years old and 65 pounds) sit in the back seat of your car, with just a seat belt on.  Drive around the block once or twice, then park in your driveway.  BEFORE the kids get out of the car, go to the back seat and check the position of the seat belts on the child’s body.

The lap belt should strike the child’s lower hip bones.  And the shoulder belt should be laying across the hard clavicle (collar bone).  If the lap belt has slipped up across the soft tissues of the belly, or if the shoulder belt lays across the soft tissues of the neck, then it is not safe for the child to be transported this way: in an accident, the safety belts themselves could cause soft tissue damage.  The purpose of the booster seat is to raise the child, so that the safety restraints are in the proper position.

Frankly, I think the only reason that a child would want to get rid of a booster seat is to think of themselves as more “adult”.   But the booster seats let the kids see out the car window better!  My daughter, who was rather petite, needed to use a car booster seat until she was almost 10.  When she complained, I performed the demonstration above, and she quickly understood the need.

(For information about car seats for younger kids, click here.)

–  David Epstein, MD

But medications can be expensive!  Your insurance plan’s drug benefit should help cover the cost, but sometimes there’s a problem.

If you arrive at your pharmacy and discover that your prescription is much more expensive that you expected, please have the pharmacy call us right away.  Perhaps we’ve prescribed a brand that your insurance company doesn’t cover.  Or perhaps there’s an equivalent medicine that works the same but costs less.   Or maybe the drug manufacturer has a “trial program” that would get you started at minimal cost.

We are quite happy to make a switch if we think it will work as well.  But we don’t know about the cost problem unless you tell us.   Don’t be shy!  Unfortunately, we can’t keep track of all the insurance formularies, because they’re all different.   And we don’t keep drug samples in our office.  But with the help of your pharmacist, we can find out which effective treatment will result in the lowest out-of-pocket expense for your family.

I’m always sad to hear that a family has decided not to purchase medication that I’ve prescribed because they can’t afford the cost, or that the family spent more than necessary.

Whether the medication is for eczema, asthma, ADHD or an infection, there’s almost always a way to make sure that you can afford your medication.   PLEASE call us before deciding that you can’t afford a medication that we’ve prescribed!

–  David Epstein MD

Until now!  Recently, I have seen a steady stream of recent research suggesting that vitamin supplements, especially with Vitamin D, might be useful.

People with low blood levels of Vitamin D have reported 40% more frequent respiratory infections.  The association is even stronger for those with asthma or other lung diseases. (Arch Intern Med. 2009; 169:384-390.)

Teenagers with low Vitamin D levels are twice as likely likely to have high blood pressure, obesity, and high blood sugar.  They were also more likely to have cholesterol problems.  The same finding has been previously reported in adults.  Low Vitamin D levels have direct effects on blood pressure metabolism and insulin levels, and might also be a marker for poor diet.  Vitamin D tends to be drawn into fat tissue, so people with obesity probably need higher Vitamin D intake.  (Click here for the article. 1)

And, of course, Vitamin D’s relationship to bone health is well known.  This has led to universal supplementation of milk with Vitamin D, to complement milk’s calcium supply.  Kids should be happy about this; they don’t need to swallow cod liver oil any more!

Vitamin D deficiency turns out to be surprisingly common.  61% of American children have low serum Vitamin D levels, and almost 10% are frankly deficient.  Only 4% of kids take regular children’s vitamin supplements.  (Click here to see the data. 2)

As a result, the AAP now recommends Vitamin D supplements for all children, 400 IU (”International Units”) per day.  (Click here for the AAP report. 3) (Most children’s vitamin supplements provide this amount, but check the label to be certain.)  But even this may turn out to be insufficient for some kids.  Obese children, and kids taking seizure medications, might need more.

What do I recommend?

• Infants fed with breastmilk should be given a daily vitamin supplement, starting at 1 month of age (such as Tri-Vi-Sol).  (Formula already contains vitamin supplements, so infants taking more than 16 ounces of formula per day don’t need Tri-Vi-Sol.)
• For kids over 1 year, and actually into adulthood, a regular vitamin supplement (any brand) should be given daily.  Any brand should be fine; I suggest you find a brand that also provides mineral supplementation, such as iron, zinc, and even selenium.
• Unfortunately, blood testing for Vitamin D is problematic.  Some doctors recommend keeping levels above 20 ng/ml; but others recommend levels above 20 ng/ml.  Lab testing and reporting of Vitamin D levels are not yet standardized.  And Vitamin D levels vary normally with the seasons.  So I don’t recommend blood tests except under specific circumstances.

And don’t forget to check my handout on Calcium supplements (click here).

–  David Epstein, MD

1. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e371-e379]
2. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e362-e370]
3. [PEDIATRICS Vol. 122 No. 2 August 2008, pp. 398-417]

This is certainly not a “new” vaccine;  the H1N1 vaccines are just like the regular seasonal vaccine, made by the same manufacturers, who use the same egg-culture process.  There’s a different flu virus inside, but that’s little different than the “new” seasonal flu vaccine that comes out each autumn.

Side effects?  I’ve heard of no reactions from my patients so far, other than occasional 1-2 days of fever.  So there’s no reason to be more fearful of the Swine Flu vaccine than any other routine immunization.  (Click here to visit my post last month about the safety of flu vaccines.)

It’s unfortunate that there’s so much noise and misinformation about flu vaccines.  Much of it stems from recent political activity from groups who oppose universal vaccination.  (Click here to see my thoughts about that issue.)

But the facts are plain.  Thousands of people die each year from influenza.  The CDC reports that 324 Americans have died from Flu since April (as of 2/10/10), including 260 children.  (Click here to see the data.) Thousands more have been hospitalized.

But I’m not aware that anyone ever died from a flu shot.  The balance of safety is certainly convincing: we’re all better off getting vaccinated!

–  David Epstein, MD

We’ve only received 100 doses of the shot for infants and toddlers so far.  We hope to have further shipments soon, so that we can vaccinate everybody, but it’s possible we’ll run out temporarily.  Remember that you need 2 doses (at least 3 weeks apart) for the best immunity (estimated at 85%), but the first shot gives some useful protection (estimated at 75%).  So we’ll try to give everybody the first dose before we start giving boosters.  Once we have received enough vaccine, we’ll start administering the boosters.

We have also received a second shipment of the H1N1 shot for older kids (with preservative).  So now we have enough H1N1 vaccine to vaccinate all our high-risk patients for their first vaccine.  If your child has asthma (or other high risk illness), you should be on our schedule now to receive the first dose.  I’ll post a note here when we have enough for boosters.  We now have enough seasonal flu vaccine for all our patients as well; all kids should be given both.

To give you some perspective, Delaware Modern Pediatrics has received only 300 of the 2300 doses of H1N1 we ordered for our patients.  Obviously, supplies are still tight.  This is not the fault of the Division of Public Health; the manufacturing process for flu vaccine is antiquated and slow.  We have similar supply problems with the seasonal flu vaccine in most years (though not this year); but the shortages haven’t been as noticeable because demand for flu shots has never been this high.

Should you have your kids vaccinated through school?  Yes, absolutely, if you can!  The only exception is for kids with asthma (or other serious underlying disease) who are being offered only the nasal flu vaccine at school; those patients should be given the injection (available through our office for our current patients).

Children and teens copy the behaviors they see in the movies and on TV, according to research.

Cigarettes:  If the characters in a show are smoking, kids who see the show are more likely to smoke.  Research shows this effect, even if it’s the “bad guys” who are smoking.  What’s scary is that over two thirds of shows and movies kids see do include on-screen smoking, even PG-13 movies – and the latest movies are no better than the old ones.  Magazines that kids read have just as much advertising for cigarettes as ever, despite new laws prohibiting it.

Violence:  Research shows that kids who see TV shows that model hitting and fighting, even cartoons, increase their real-life physical violence.  This effect is noticed at very young ages, and persists for years after the TV shows were watched.

Obesity:  Experts say that TV watching, all by itself, is responsible for two thirds of our nation’s pediatric obesity epidemic.  The problem is not just that the kids sit and watch; they’re watching one advertisement after another for junk food!

Alcohol:  Kids watch broadcasts of sports events, often with their families.  But beer manufacturers advertise heavily, despite laws forbidding alcohol ads on shows that kids are likely to watch.  Research links this exposure to a tendency to drink later.

So why can’t something be done?  Hollywood has been resistant to criticism, TV ratings are not well understood (and may not be accurate), the internet cannot be regulated, and devices like Ipods and cell phones will only increase kids’ access.  So what are parents to do?  The best advice is for the parents to watch the shows with kids together, with your finger on the “pause” button, and talk about the implied messages.  Ask: “Is that character making a good choice?  What would you do?”

(Download my handout about TV watching (click here) for specific suggestions.)

A recent commentary in JAMA (June 3, 2009, p. 2265) points out “the extraordinary positive power of the media.  Antiviolence attitudes, empathy, cooperation, tolerance, respect for older people — the media can be powerfully prosocial.”  But we, as the parents, must watch out, every time the kids see a show or movie.  Ask yourself:  “How would I react if a real person were behaving like the characters in this show, in front of my children?”

–  David M. Epstein, MD

A.  There is probably not much direct harm; no study has yet shown medical disease of any sort in children to be caused by artificial sweeteners, except for an occasional allergic reaction.  But I don’t think kids need them, unless they have a medical condition such as diabetes or obesity.

Although an occasional diet soda is probably fine, I’m not comfortable with kids having lots of artificial sweetener, for two reasons:

1) Even though there’s no studies showing actual harm, I’m concerned about the unknown effects of large amounts of these chemicals.

2) Even though artificial sweeteners have no calories, I worry that kids will get used to drinking sweetened drinks; if this becomes a habit, their learned preference for sweetened drinks may translate into excess calorie intake as older kids or adults.

People asK: “Which is best for kids, regular soda or diet?” But the question frames a false choice: to offer sugary drinks and snacks, or chemically sweetened ones.  There is a third choice, which is the one I recommend: unsweetened drinks such as milk, water, or unsweetened ice tea and flavored waters, and snacks (such as fresh fruits, vegetables, and crackers) which have no additional sweetener.

–  David Epstein, MD

A:  Absolutely.  Headphones pose a risk of hearing damage for children; this is an important issue.  Several recent news reports have spotlighted cases of permanent hearing damage in older adults due to their listening habits in childhood.

Noise induced hearing damage is caused by a combination of loudness and prolonged listening times; giving the ears a “break” of a quiet period after listening for a while may offer some protection.  Most people use open-air style headphones, or the “ear bud” style such as iPod earphones.  In noisy areas, users may crank up the volume in an attempt to drown out ambient noise.  Unfortunately, this puts the hearing at risk.  Noise-blocking or noise-canceling headphones may be less dangerous.

Some experts fear that aerobic exercise may increase the danger of noise-induced hearing loss, because blood is diverted from the organs of hearing (not to mention the risk of injury due to distraction from the music).

Permanent damage may occur before any symptoms (such as ringing in the ears or difficulty understanding speech) are apparent, so prevention of hearing loss by moderation of listening habits is crucial.

David Epstein MD