Why Our Office Requires MMR Vaccine

Written by Nelson Branco MD FAAP

Vaccines have been a hot topic among parents, pediatrician and in the media for many years. Recently, there have been many news stories about pediatricians who will not care for families who either choose not to vaccinate their children or who do not follow the recommended schedule.

These policies are based on knowledge about the safety of vaccines, the effectiveness of the recommended schedule and concern about the spread of a vaccine-preventable disease in the community.

No pediatrician wants to see a child suffer from a condition that could have been prevented, and we certainly do not want those illnesses to be spread in our offices.

My practice is in Marin County, California – an area that is known for high rates of vaccine delay and vaccine refusal . After much thought and careful consideration, my partners and I recently decided to change our policy related to immunizations.

Starting this spring, we will require that all patients age 2 and older be immunized with the Measles, Mumps, Rubella (MMR) vaccine in order to remain patients of our practice.

We have a responsibility to protect the health of all of the children in our practice, and decrease the risk of vaccine-preventable diseases in our community. We have chosen to require the MMR vaccine because we are extremely concerned about the possibility of a Measles outbreak in our community.

Vaccine preventable diseases are still a threat to the health of our children and our community. In 2010, the Pertussis (Whooping Cough) epidemic in California affected children in Marin County at eight times the rate seen in California overall, in part because of low immunization rates.

There was recently a case of Mumps in a school-aged child in our county, and last year there was an outbreak of Mumps in a dormitory at the University of California at Berkeley.

There have been Measles cases and outbreaks associated with the 2012 Super Bowl, and in recent years in San Diego, Quebec, Indiana and Minnesota. In 2011, there were 222 reported cases of Measles in the US, the highest rate in 15 years. Ninety percent of these cases were associated with air travel, but not all cases were in travelers.

Measles has become much more common in Western Europe, Africa, Asia and the United Kingdom due to dropping vaccination rates. The CDC is already warning us that with the Summer Olympics in London and the Eurocup Soccer Championship in the Ukraine, the possibility of a US traveler to these countries coming back with Measles is high. Because of this, we are concerned that Marin County is at risk for a Measles outbreak.

Because Measles is so easy to spread, in order for a community to be protected from an outbreak, 95% of the population must be immunized. Right now, the number of Kindergartners in our county who are up to date on all of their vaccines is 83%, and there are schools and communities in Marin County where less than 50% of Kindergarten students have had all of their required vaccines.

Certain areas in our community are clearly at risk of a Measles epidemic. In our practice, we have many children who are too young to receive the MMR vaccine as well as many children who have chronic illnesses that compromise their immune system and put them at risk. This policy is meant to protect not only these children, but also our entire community from a Measles outbreak.

We respect that the parents in our practice have the ultimate responsibility for making decisions about their children’s health care, but we have to weigh their personal decisions against the available data and the needs of our community.

In our practice, we feel strongly that communicating and collaborating with our patients and their families is the best way to provide excellent care. We also feel strongly that vaccines save lives and that this policy protects our patients and our community from a preventable disease and all of its repercussions.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

Let’s Talk About Pertussis Also Known as Whooping Cough

Written by Richard Lander MD FAAP

What is pertussis?

Pertussis is an infectious disease caused by bacteria. Sometimes referred to as the hundred day cough, it can be quite debilitating. The cough is persistent and recurs day in and day out. Once you hear this cough, you will never forget it. The cough is repetitive, easily lasting 30 seconds or more and has a whoop sound at the end of it. This whoop is what gives rise to its popular name whooping cough. If you are curious, you can hear the whoop sound on the internet.

Who gets Pertussis?

Many people do-all ages and from all walks of life including: young children, teenagers, adults in middle age and senior citizens.

Is Pertussis contagious?

Yes it is. I have seen Pertussis several times in my practice this year. I have seen it spread from mother to child, among siblings and even from teacher to students.

Treatment of Pertussis

There are different phases of Pertussis. When the diagnosis is made during the first phase of the illness, it can be treated with antibiotics. This may shorten the duration of the disease. Otherwise physicians can offer supportive care and medication to help the patient sleep.


Pertussis is preventable by a vaccine. This vaccine, DPT (Diptheria, Pertussis and Tetanus) is typically given during childhood. The vaccine is given as a series of three injections in the first year of life, a booster during the second year of life and another booster before the start of elementary school. An additional booster is given at 11 year of age.

Because this last vaccine is relatively new, many children older than 11 year of age will be receiving it. Additionally the Tetanus booster which has always been recommended to be given every ten years has been change to include the Pertussis vaccine.

Therefore, adults of almost all ages are urged to obtain it even if you received a Tetanus booster a year ago. Many hospitals across the country are giving the vaccine to new mothers right after delivery and in some progressive hospitals the vaccine is being offered to new dads and to grandparents.

With this approach the State of California, which had seen deaths from Pertussis in the last few years, has dramatically decreased their rate of Pertussis. These dramatic results have persuaded many pediatricians to offer this vaccine to parents and grandparents of their patients.

Why talk about Pertussis now?

Pertussis is on the rise in the United States. From January through March in 2012 there were seven times the number of cases seen in Washington, D.C. than in the same time frame the year before in 2011. So why you might wonder: why this rise in Pertussis now? Several years ago we experienced a number of parents refusing to have their children vaccinated against childhood diseases including Pertussis.

These refusals were based on fears of the vaccines and components of the vaccines such as aluminum or mercury. Thankfully, these fears have been proven to have been unfounded. Unfortunately, once people stopped vaccinating their children, herd immunity was lost.

Herd immunity is gained when a majority of people in a geographic area receive a vaccine. These vaccines then protect even the few who were not vaccinated.

As the number of vaccine refusers climbed, we lost herd immunity. Hopefully today with increased knowledge through education, the number of vaccine refusers is beginning to decline and more people are again protected against infectious diseases such as Pertussis. Scientists are working tirelessly looking for clues to currently unanswerable medical questions.

Every day they race the clock in an effort to look for a treatment for currently untreatable medical conditions and diseases. Pertussis is not one of them. Pertussis is preventable with a vaccine It is criminal that there are people living in the United States in 2012 suffering from a disease they did not have to have. Please don’t be one of them. Ensure that you and your loved ones do not get Pertussis. Get vaccinated! Get vaccinated now!

Dr. Lander has been practicing pediatrics for 32 years in New Jersey and is the immediate past chairman of the American Academy of Pediatrics Section on Administration and Practice Management.  He says if he had to do it all over again he wouldn’t hesitate to be a pediatrician.

How Do You Select The Right Bike Trailer For Your Child?

Written by Denise Somsak MD

My autistic son’s latest request is both timely and ironic, “Mommy, I want to hear Bicycle Race.”

David has zero interest in riding a bike, hates the heat, and only wears a helmet with lots of cajoling, but he’ll listen to that Queen anthem for an hour straight if we let him.

“I don’t believe in Peter Pan, Frankenstein or Superman…Don’t wanna be a candidate for Vietnam or Watergate.  Cos all I want to do is bicycle bicycle.”

The fact that he knows EVERY word without understanding the song only adds to the irony.  He used to ride a bike with training wheels indoors with his occupational therapist, but it was never an activity he approached with any sort of enthusiasm.

In fact, he looked quite joyless and a little frustrated.  Compare that to music and dancing, and it makes me wonder if I should force him to learn.

I’d love it if our family could bike together.  If we could talk, laugh, share the sites and maybe a slurpee at the end of the ride.  But that’s fantasy, not my family, not my reality.

Instead my husband takes the girls biking while I hang out with David.  Honestly, it’s safer that way.  Pee Wee Herman looks like a triathlete compared to me.

Seriously, please consider your own skill and comfort level in riding before you make your child a passenger.  And I don’t care if you cycle like Lance Armstrong, the AAP recommends slower speeds, bike paths, and quiet streets when kids are on board.

Consumer Reports and the AAP recommend trailers instead of mounted seats for safety.  One study (about 10 years old) in the Archive of Pediatrics and Adolescent Medicine found that children in trailers were less likely to be injured than those on mounted seats.

Mounted seats are higher off the ground than the trailer, so children have farther to fall in an accident.  Mounted seats can make steering and balance more difficult and thus accidents more likely.  However trailers proximity to the ground make them less visible to drivers and more likely to stick out into the road.

Check out the tips from Cascade Bicycle Club Education Foundation to maximize your safety with either option:

What to look for in a trailer:

  • ASTM (American Safety Testing Materials) safety standards sticker
  • A full metal roll-cage
  • 16 or 20-inch wheels with inflatable tires: they roll on uneven surfaces more easily
  • A rotating hitch that allows the trailer to remain upright even if the bicycle falls or
  • is laid on its side
  • A safety flag to increase visibility

What to look for in a bike-mounted seat:

  • ASTM safety standards sticker
  • A back that comes up around the child’s head
  • Sides that wrap around the child
  • Straps that connect around shoulders, waist, and between legs
  • Straps for the feet in the foot wells (so that feet don’t get caught in the wheel or brakes)

Children less than one year of age should NEVER be passengers on a bike. They have big heads relative to neck strength and body mass.  Don’t do it. Even the best helmet won’t make up for the weak neck muscles.

Kids need good helmets that fit correctly (video link).

With all those safety tips, enjoy the ride.  I’m staying home.  If typical children or adults can choose their leisure activities,  why can’t David?

He’s not concerned with popular conventional play or the world’s bigger troubles (“Don’t wanna be a candidate for Vietnam or Watergate”), he just wants to listen to his favorite music and dance with me.  I’m a better dancer than biker anyway.  Maybe it’s genetic?

Dr. Somsak was born and raised in the heartland. She recently joined Pediatric Associates of Cincinnati. She’s a no frills, practical gal. Dr. Somsak blogs regularly at Pensive Pediatrician


Excessive milk can cause anemia? How?

Written by Kristen Stuppy MD

Photo Credit: Gawker

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk. Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer: Cow’s milk has little iron. When kids drink a lot of milk, they don’t eat iron-containing foods in sufficient volumes. Cow’s milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut, but less blood produced because less iron in the diet = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies. Too few red blood cells in the body is called anemia. Red blood cells are made in our bone marrow and they live for about 3 months. It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

  • too little blood produced (iron deficiency being a major risk for this)
  • increased blood loss (ie excessive bleeding)
  • increased destruction of blood cells in the body (typically from abnormal blood cells or infection)
  • Iron deficiency can be due to several factors:
  • poor iron absorption due to disease (some studies show milk inhibits iron absorption)
  • poor iron in the diet (the most common cause)
  • long term slow blood losses (such as heavy monthly periods or GI bleeding)
  • increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter?

Because the most common symptom of anemia is no symptoms. It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.

Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother’s milk. Humans have learned to make formulas that can nourish babies if they aren’t able to drink their mother’s milk for whatever reason.

Cow’s milk, soy milk, and goat’s milk are not acceptable for infants due to the nutritional voids they have (not just iron). After about 1 year of age babies tend to wean from mother’s milk and/or formula onto whole milk. (Newer recommendations allow weaning onto low fat milk–another topic entirely.) Unfortified non-human milks contain very little iron.

The iron in human milk is better absorbed and iron is supplemented into formula. If toddlers and children drink too much milk, they fill up on it and don’t eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

  • meats and poultry (especially organ meats, such as liver)
  • lentils, peas, and dried beans
  • eggs
  • oysters, clams, and fish
  • molasses
  • peanut butter
  • soy
  • pumpkin or sesame seeds
  • fruits such as prunes, apricots, and raisins
  • vegetables such as spinach, kale, broccoli, and other greens
  • whole grain fortified breads and cereals
  • Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Pink Eye: Is it all the same?

Written by Melissa Arca MD

I get so many questions from parents about this, mostly it goes like this: “ewww…I hope it’s not pink eye!”

Pink eye is one of those afflictions that causes us to squirm, think “oh no!”, and inspire us to wash our hands a million times throughout the day. Most of us tend to hide away inside our homes until the icky looking discharge oozing from our child’s eyes disappears.

So, what exactly is pink eye, and what do we truly need to do about it? Not all pink eyes are created equal. Only half of the cases in children are truly bacterial.

Here are some quick facts about pink eye:

  •  Pink eye is a general term for what we pediatricians call conjunctivitis.
  • Conjunctivitis is the inflammation of the mucus membrane of the inner eyelids.
  • Conjunctivitis can be caused by viruses, bacteria, environmental allergies, or a topical irritant.
  • Viral conjunctivitis in young children is very common, especially during the summer.
  • Viral conjunctivitis will go away on it’s own, without antibiotic drops.
  • Only bacterial conjunctivitis needs to be treated with antibiotic eye drops.

How do we know if it’s bacterial conjunctivitis?

  • With bacterial conjunctivitis, the eye discharge is more likely to be yellow/green and “icky”.
  • Children with bacterial conjunctivitis often wake up with their eyes “sealed shut”.
  • Can be associated with an accompanying ear infection.
  • These cases need to be treated with antibiotic drops.
  • A child with bacterial conjunctivitis may return to school 24 hours after initiation of treatment and obvious signs of improvement.

Five factors pointing to a non-bacterial culprit for conjunctivitis:

  • The child is older than 6 years old
  • It’s summer time: viral conjunctivitis is more common during the late spring and summer months.
  • The discharge from your child’s eye is clear, watery, and may or may not be associated with allergy symptoms such as sneezing and eye itching.
  • No yellow/green eye discharge
  • Child does not wake with his eyes “sealed shut”.
  • If your child meets most of the criteria above, her conjunctivitis is more likely due to a virus or may be part of her allergy symptoms.

Tips for Treatment and Prevention:

  • Be vigilant about hand washing. Both viral and bacterial conjunctivitis are extremely contagious.
  • HAND WASHING. It’s worth repeating.
  • If it’s bacterial and your child is prescribed antibiotic drops, finish the designated days of treatment.
  • In most cases, treat both eyes even if only one appears to be infected at the time. Young children will inevitably spread it to the other eye. Avoid the ping pong effect.

Tip for antibiotic administration: have your child lie down, it’s okay if her eyes are closed. Place the drop in the inner eye, near the nose. Once your child starts blinking, the drops will enter the eye.

Look for the signs above, consult with your pediatrician, and above all…keep on washing those hands.

Dr. Arca is a pediatrician. She works part-time while raising her two young children, Big Brother (age 6) and Little Sister (age 3). She is passionate about writing and writing about motherhood, parenting, and children’s health is what she does best. Dr. Arca blogs regularly at Confessions of a Dr. Mom