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Vaccines: Truth and Experience Against False Fears From The Internet

Written by Walter Hoerman MD

Now that I am a “seasoned” pediatrician (greater than 20 years in practice), I have seen many changes all directly related to vaccines.

I used to worry about epiglottis with every child that has a cough. Now it hardly ever crosses my mind. I watched a child die of epiglottis, and I never want to go back there…

I used to have to do lumbar punctures at least a few times a year; now I haven’t done one in years and I am getting rusty (which is a good thing).

I have seen children go deaf from meningitis, have disabilities from meningitis, and even die from meningitis, and I don’t want to go back there…

I have never seen a case of the measles, and might have trouble diagnosing it. I don’t want to have to….

My mother used to tell me about terrible summers made tragic by polio. I don’t want to know it first hand.

These are all things I know personally. And most importantly, I can say I have never seen a child permanently damaged by a vaccine.

This is the message we need to get out.

Dr. Hoerman founded Lilac City Pediatrics in 1996. Since completing Medical School and his Pediatric Residency Training at the University of Connecticut, he has been practicing pediatrics in Rochester since 1988. Dr. Hoerman blogs at Lilac City Peds News

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For Pediatricians, Giving Vaccines Is An Ethical Dilemma

Written by Brandon Betancourt, MBA

One aspect of the vaccine controversy that doesn’t get discussed as often as I would like, is the notion of vaccine economics. Vaccine economics has to do with what I refer to as the distribution, consumption, management and cost of vaccines.

I was happy to see a blog post on the NPR that discusses some of the challenges, with regards to vaccine economics, many pediatricians face. Here is what they had to say:

After looking at what insurers paid more than 1,400 doctors for eight different vaccines, athenahealth concluded that almost half the time the payments weren’t large enough to cover estimated costs.

You don’t need to be an economist to know that loosing money isn’t good for anybody and certainly unsustainable; no matter how altruistic your motives maybe.

The blog post also highlighted that the problem might be worse than the research indicated.

The American Academy of Pediatrics came up with estimates for indirect expenses, concluding they range from about 17 percent to 28 percent of the purchase price of vaccines. So at least 17 percent should be tacked onto the purchase price for doctors to have a shot at breaking even, the group concluded.

By that measure, 47 percent of immunizations are money-losers, the athenahealth data show. If the 28 percent figure for indirect costs is used to calculate break even, then it’s an even grimmer picture: 79 percent of vaccination payments fall short.

This puts pediatricians in an ethical dilemma. On one hand, pediatricians will always do what is in the best interest of children. And there is overwhelming scientific evidence that vaccines are among one of the greatest medical innovations of our time.

On the other hand, preventing illnesses like Polio, Rubella and Measles in children cause pediatricians to actually lose money. In other words, pediatricians are in essence subsidizing – at their expense – the wellbeing of children.

The anti-vaccine movement

One of the anti-vaccine movement arguments is that vaccines are a profit center for doctors and that pediatricians are putting profits over the well-being of children. That is simply not true. And the research published by Athenahealth (click here to go the the study) clearly shows that profit is certainly not an issue.

When payment to physicians for vaccines often does not even cover the costs associated with administering those vaccines, this claim is so ludicrous as to be non-sensical.

The benefits of vaccines

  • The rate bacterial meningitis declined by 55%  in the US in the early 1990’s, when the hemophilus influenza type b otherwise know as Hib was introduced. (NEJM 364.21, May, 2011)
  • Varicella mortality declined 88% overall and 96% among subjects younger than 50 years (Pediatrics 128:2, August 2011)
  • Current immunization practice and herd immunity have virtually eliminated many infectious causes of serious morbidity and mortality in the USA.

It’s almost ironic that immunizations have done so much for public health, yet their value has not been recognized.

What is most frustrating to doctors is that immunizations are perhaps most cost effective preventive measure available to the pediatric population; especially when one considers the long term benefit in the equation for payment.

Yet insurance companies, driven by their bottom line, fail to view the long term benefits. For example, they reimburse a doctor for a polio vaccine below the doctor’s cost in an effort to improve the bottom line without considering the cost of a child actually getting Polio.

At what cost?

What would happen if pediatricians, driven by the cost of vaccine and poor reimbursement, decide they can’t immunize children any longer?

The poor and inadequate payment for immunizations could potentially create a public health problem if one considers that the lack of immunizations in children could break our developed herd immunity.

In fact, in the US, we’ve already seen over 150 cases of measles in 2011 and in California there were 9,500 cases of pertusis in 2010; and 10 infant fatalities which are attributed to lower vaccination rates.

As doctor Richard Oken said recently, “immunizations are perhaps the most cost effective preventive measure available to the pediatric population” thus me must consider the “long term benefit in the equation of payment.” Otherwise, “Inadequate payment could force pediatricians to outsource this healthcare benefits and bankrupt our developed herd immunity”

Perhaps more than any other physicians, pediatricians believe in, and focus on, PREVENTION of disease, stopping illness even before it has a chance to strike. If an ounce of prevention is really worth a pound of cure, skimping on spending for prevention today will surely result in spending much more tomorrow–not to mention causing more people, at all ages, to suffer from what are easily preventable diseases.

Brandon manages a pediatric practice in the western suburbs of Chicago. He blogs regularly on practice management issues at PediatricInc.com
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Fall Colds: What To Do, And When To Take Your Child To The Pediatrician

Written by Jennifer Gruen MD

The fall cold and cough season seems to be in full swing. The ragweed pollen and mold in the air is also causing a lot of congestion and cough symptoms. Below are a few hints on how to make your child feel better, and when you need to bring them in for a visit:

 What constitutes a common cold?

  • Runny nose, mild cough, sore throat, decreased appetite, occasionally low grade fever (<101.)
  • Children can have 7-10 colds in one season, particularly the first year they are in any sort of a daycare or school setting.
  • Colds are most contagious in the first two days – usually accompanied by a clear runny nose.
  • The change in color of the mucous to yellow or green after 5-7 days (in the absence of fever or headache) usually signifies the end of the cold and will be gone in 2-3 days. Green noses don’t automatically need antibiotics!

Is it an allergy or a cold?

Visit this link to read more on the diagnosis and treatment of allergy symptoms.

What will help?

For children under one use nasal saline, bulb syringe, elevating mattress (put rolled up towels underneath the head of the mattress) or allowing to sleep in car seat if they can breathe more easily this way. Use nasal saline drops, with suctioning only if there is a lot of loose mucous, before feeding and sleeping. A warm bath will help bring break up the mucous.

For children 1-3, nasal saline washes may help (try Simply Saline or the NeilMed sinus rinse for children). A trial of Benadryl may be necessary to relieve congestion. (click here for dosage information.) It is especially helpful at night if cough is interrupting sleep.

For older children (>4) with congeston try mint tea with 1 teaspoon of sugar or honey to soothe sore throats and help break up congestion. For difficulty breathing through nose at night try Breathe Right strips for children. (Dr. Nikki loves them!) For persistent nighttime cough try humidifier, elevation and possibly Benadryl. Other cough syrups that we have found help include Delsym and long acting single ingredient dextromethorphan preparations.

“Just a spoonful of sugar….”- sucking on a lollipop or a teaspoon of honey has been shown to decrease sore throat as much as cough medicines. Tylenol or motrin is appropriate for fever or sore throat, but doesn’t work for cough.

When to worry?

  • Any fever >100.4 in infants less than 6 months old – call for an appointment
  • Fever for greater than 3 days in any age child
  • Fussiness, not eating well, pulling on ears, breathing quickly or pulling in at ribs when breathing.
  • Green, yellow nasal discharge that is accompanied by fever, headache, sinus pressure or that persists more than 5-7 days.
  • Drainage out of ear canals.
  • A cold that persists longer than 2 weeks, or that after several days is suddenly accompanied by a fever.
Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.
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Baby Proofing Your House

Today’s video post comes from Wendy Sue Swanson MD AKA Seattle Mama Doc. In this video, Dr. Swanson gives some great tips on how to proof your house from inquisitive little hands as well as provides baby proofing tips to keep family and friends save in your home.

Dr. Swanson practicing pediatrician and the mother of two young boys.  She sees patients at The Everett Clinic in Mill Creek, Washington. She is also  on the medical staff at Seattle Children’s and am a Clinical Instructor in the Department of Pediatrics at the University of Washington. Dr. Swanson is passionate about improving the way media discusses pediatric health news and influences parents’ decisions when caring for their children. Dr. Swanson blogs regularly at SeattleMamaDoc.com

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Doctor, Back Slowly Away From That Sandwich!

Written by John Moore MD

In American health care, the era of the free drug-company sponsored lunch is definitely over. Gifts from companies to physicians and hospitals have essentially vanished. Samples have disappeared from our offices. Corporate-sponsored CME budgets have dried up. Next year, as a part of the Affordable Care Act, companies will be forced to disclose any gifts to physicians that cost more that $10. Physicians who accept those small gifts will be listed on a searchable database. No more sandwiches for us!

I am not an apologist for drug companies by any means. The negative impact they have on health care cannot be ignored. There is a lot of scientific data that support the claim that even small items may influence prescribing practices. Our journals are unfortunately full of bogus scientific studies claiming to “prove” one product is better than another with poor scientific support. We have all heard prepared lectures from paid physician spokespeople which provide no educational value beyond brand recognition for the sponsor. Transparency in any industry is good; patients should be able to know whom their physicians are taking money from.

However, we need to bring some balance back into this discussion. First, the headaches of maintaining such a database for small gifts seem far out of proportion to any benefit that patients can receive. Second, we need to remember that pharmaceutical companies can provide useful information to doctors. I know that it is out-of-style to mention anything positive that can come from talking to the local drug rep, but let’s think about it. I learn from my reps what vaccination strategies have worked in other practices in my area. I learn how disease-specific recall notes have worked for the group across town. I am not naïve enough to believe the slick brochures left on my desk (and in fact I throw most of them directly in the trash), but I do use them as a starting point to my own research.

We also should examine the effects of industry sponsorship on organized continuing medical education in America. While the potential biases are real, the positive impact of pharmaceutical industry money on CME is huge! From the most prestigious national conferences all the way down to local community hospitals, budgets for CME have been slashed, in part due to the lack of industry funding. Fees for participants have increased, and not surprisingly attendance has decreased at live CME events around the country.

The bottom line is that pharmaceutical companies and physicians have a complicated relationship, one that is not inherently good or bad. Like any business relationship, the association between pharmaceutical companies and physicians relies on real people on both sides doing what is right. No amount of oversight can force someone with questionable ethics to follow the rules. No amount of bribery can sway an honest doctor to prescribe a medication not in the best interests of their patients. The vast majority of pediatricians are caring advocates for their patients whose loyalty cannot be purchased by a pen or a sandwich.

 

Dr Moore is a pediatrician in Roanoke, VA. He schedules drug rep visits only one time per week and always ignores lunches, preferring to meet his family instead!

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Crossing State Lines: Crossing the Line?

In the search for reducing healthcare costs, some public policymakers have suggested allowing consumers to purchase health insurance across state lines. Theoretically, this would allow families to shop around for the best insurance deal, even if they aren’t a resident of the state in which the insurance is sold or regulated.

In general, increased access to choices drives down prices and increases competition; given the proliferation of online shopping for all kinds of other products, you might indeed find a great deal in another state. Even some state-based financial products, like 529 college savings plans, are marketed across state lines, allowing flexibility and consumer choice.

However, I’m opposed to selling health insurance plans across state lines: out-of-state insurance plans (including ERISA plans) can thumb their noses at a state’s consumer protection laws.

Here’s an example: Tennessee mandates that newborns be covered from the moment of birth to 30 days of age without any special action required on the part of the baby’s family (TCA 56-7-2301.) This is a good idea: moms shouldn’t have to call their insurance company’s 800 number in between contractions to ensure her baby gets added to her policy. The thirty-day rule gives families a short grace period to get their paperwork in order.

However, Tennessee law doesn’t apply to all infants born in Tennessee. Families who are employed by a big-box corporation headquartered in another state often have an insurance plan domiciled in that state. If mom and dad have, say, Blue Cross Blue Shield of Alabama — the company does not have to follow the 30-day rule of newborn care. They’re shocked to find out after their child is born (and too late to make other arrangements) that they owe hundreds or thousands of dollars to doctors and hospitals. It’s even more depressing when you realize these costs are incurred during a period when moms are taking time off work and family incomes are tight as a result.

Tennessee law also requires insurance companies to be transparent in their dealings with doctors: to pay clean claims promptly (56-32-126); to credential doctors fairly (56-7-1001), and to be up front about what doctors will be paid for their services ahead of time (56-7-1013). These laws protect employers, patients, and doctors from unfair insurance company tactics – but again, only as long as the company is an in-state company.

Our practice already spends a lot of resources policing our own state’s insurance companies. If they violate regulations, we can appeal to our state’s Department of Commerce and Insurance, our state’s legislature, and our state’s judiciary, all of whom are accountable to voters for their actions. Yet insurance companies in other states can blissfully ignore directives from our state, even though they’re insuring our state’s citizens. At last count, there were over 1300 out-of-state insurers during business in Tennessee; until consumer protections are more consistent, we need less of this, not more.

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Introduction to Solids – 6 Myths

Written by Natasha Burgert MD

 

At the 6-month check up, nearly all of my patient families want to talk about starting their babies on solid food. The conversations usually start like this…

“I go get all of Gerber stage 1 foods and then do all the greens, then the yellows, then the fruit. After she eats all of the stage 1 foods, then she goes on to stage 2, right?”

Or this…

“I have gone to the farmer’s market and bought all organic produce to make his baby food. I am following the [insert name here] recipe book that I got from a friend, and their baby is such a great eater. Do you think bulgar wheat or quinoa is better?”

Or this…

“I have already given some rice porridge with scrambled egg, and some broth with root vegetables. Can I start tofu now?”

As these real-life conversations demonstrate, the plan and expectation for introducing solid food to babies is different for every family. The food items that parents first feed children is influenced more by culture and generational upbringing, than by any scientific research or product marketing plan.

And, that’s OK! In fact, it’s wonderfully liberating news for parents who are really stressed out about first foods.

So, what are my general guidelines when it comes to starting infants on solid foods?

  • I encourage the families of healthy, normally-developing children* to start solids near or after 6 months of age.
  • I want parents to give babies a great variety of real food, in a safe way.
  • I think of pureed foods as practice and play to develop the skill of eating; nutrition is still from breast milk or formula.
  • I try to challenge my families to think outside of the Gerber-defined box and give babies interesting tastes, but no raw honey until after the first birthday.
  • That’s it. Go. Eat.

Wait a minute…. There has to be more. What about the rule about veggies first? Babies can’t have dairy, right? What about spicy stuff? They aren’t supposed to have strawberries or oranges, either!? My mom wanted to give her yogurt, and I told her “no.” Please don’t tell me she is right!?! And you have said nothing about rice cereal.

OK, so maybe there is a little bit more. But, likely not what you expect. When continuing the food conversation with families, some common myths creep to the surface.

It’s tIme to bust some common “starting solid food myths” … for good!

Myth #1: Rice cereal must be first.

Rice cereal has traditionally been the first food for babies in the United States for generations. But, why rice cereal? It is convenient – easy to obtain and easy to feed. Baby cereal is also fortified with iron and other nutrients. This promoted as a benefit for those infants who need some supplemental vitamins and minerals in their diet. Click here for information about iron recommendations for infants.

Giving rice cereal as a first food is under active debate. Specifically, Dr. Alan Greene is noted for starting a “White Out Now” movement. He encourages families to feed infants whole, natural first foods instead of rice cereal.

Dr. Greene discusses how the food industry has marketed and advertised to parents so heavily, the industry has created doubts in our minds regarding what is best to feed babies. We, as parents, start to believe that the healthy foods that we eat are not “good enough” for our babies.

Dr. Greene’s is also concerned that rice cereal primes infants to crave only carbohydrate-rich foods, contributing to the obesity epidemic. Other physicians have debated his theory,but I think his general concern for the quality of first foods is worth notice.

For the first few months of eating solids, an infant’s nutrition is still based upon the healthy calories given by breast milk and formula. That allows pureed foods of all forms to be first foods, as they have for centuries.

Expand beyond the rice cereal “default”. What about some pureed red meat as a first food? What about whole grain cereal, oatmeal, or a pureed fruit or veggie? Maybe, something you have in the fridge? (see #2)

Myth #2: Making baby food is hard (A.K.A. I don’t have time to make baby food.)

I hear this a lot; mainly from parents whose only experience with baby food making is observing a few moms with fancy baby-food makers, complicated recipe books, and bags of locally-sourced organic ingredients. This “all-in” approach to pureed food making can seem overwhelming and unreachable.

But, let me offer a suggestion…

In my clinical experience and personal experience, the earlier you get your baby eating the healthy meals that you provide your family (in a safe, modified way), the better they will eat as toddlers. So, I challenge all my families to try to make some first food… simply.

I do not talk about making baby food with the claims that it is of greater superiority to jarred baby food. There are some great commercial baby foods on the shelves today. But, babies have survived for many years before infant food was available in aisle 4B of the grocery store; and I think only offering what a food company can put in a jar is actually quite limiting to a baby’s early taste experiences.

To make baby food, you need soft foods (fruits, veggies, whole grains, meats), a little water, and a machine to puree. The machine could be a food mill, a blender/food processor, or a strong arm with a fork. Voila! Simple as that. I bet there is something in your kitchen right now that you could whip up for baby. Last night’s grilled chicken breast? Leftover green beans? Melon? Avocado?

As a working parent, I certainly bought prepared baby food. But, I made a lot of food for my infant, too. For me, it was easy, cheap, quick, and just part of the routine.

So, I challenge you to try to make some of your baby’s first tastes. Experiment and have fun! Decrease your family’s food cost, decrease shipping and packaging waste, and increase the palatable options for your baby to try.

Myth #3: Starting solids will help my baby sleep through the night.

Nope. It doesn’t.

Starting foods too early may actually have some negative consequence including obesity, food allergy, and decreased sleep!

Yikes!

Currently, it is recommended that first foods should be started around 6 months of age. This age is preferred for both the developmental ability of an infant to take food off a spoon, in addition to decreasing the risk of food-associated allergies and obesity.

Eating solid foods is a developmental skill, not a way to “fill baby up” to sleep longer. So don’t let this myth determine when you start solid food.

Myth #4: Greens, then yellows, then oranges.

There is no evidence to suggest that if you offer baby fruits first, she will never eat veggies. Regardless of what order food is introduced, kids (and adults!) will always prefer sweeter-tasting food items. Offer your baby foods of all colors of the rainbow, in no specific order.

Myth #5: My baby can’t really have the food that I am eating.

I think the origin of this myth/concern stems from parents knowing the kind of diet they have. Feeding our children is often an examination of what we, as parents, feed ourselves.

If a parent’s diet consists of fast food, takeout, and late-night snacks then the thought of feeding baby exactly what you eat is ridiculous. Agreed. But, if you are not willing to feed what you eat to your baby, maybe it’s time to think about the nutrition and healthy eating choices for the entire family.

If a family eats a healthy, well-rounded diet then the concept of offering baby what you eat is not such a scary idea. Make healthy, positive food choices, include your baby, and see the long-term benefits for the whole family.

Myth #6: Oh, no.. baby can’t have that.

Currently, for healthy babies who are not in a family with significant food intolerance and allergies, the only thing babies under the age of 12 months cannot have is raw honey. Honey may contain harmful botulism spores that could make small babies very ill.

That’s it.

The research regarding introducing solid foods is actively changing. This means the foods that have been traditionally restricted until later in toddlerhood (eggs, shellfish, peanut butter) are no longer on the “Do Not Have” list. In fact, some recent data suggests that delaying the introduction of high-allergy foods (shell fish, nuts, eggs) actually increases the risk of developing a food allergy.

Other studies do not show an increase in allergic disease by starting allergenic foods early. In addition, adding dairy sources (cheeses, yogurt) and animal proteins (meat, chicken, pork, fish) can be added at any time.

Expand the box. Think about your own diet, and what you want your kids to eat. What is acceptable for your family, your culture? Don’t let Gerber or Earth’s Best or [insert baby food company here] make those definitions for you.

Your baby just might surprise you… mine certainly did. Within a very short period of time, my 8-month old son’s favorite food was my husband’s recipe for chili (pureed) – extra spicy!

Have fun!

Dr. Burgert is a pediatrician. She works at Pediatrics Associates in Kansas City, MO .  She is a distance runner and enjoys road races around the city. She also has a passion for travel that will certainly lead to many memorable family vacations with her husband and two children. And, of course, she bleeds Husker red. Dr. Burgert regularly blogs at kckidsdoc.com

* Starting solid foods may be very different for children with a significant personal or family history of allergies, milk intolerance, or skin issues. It may be very different if a sibling had challenges with foods. It certainly will be unique if a child is not growing correctly. If your child has any of these issues, or you have specific concerns about your child, please ask your pediatrician for guidance.