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The Call For “Meaningful Action” After Newtown

Written By Jennifer Shaer MD, FAAP, FABM, IBCLC

Nobody would argue that there should be meaningful action after such a massacre. However, I would argue that the focus on gun control as that meaningful action is misguided.

Someone disturbed enough to walk into an elementary school and start shooting is going to find a way to inflict tragedy in one way or another. There will always be access to guns or bombs or whatever the device of destruction for those motivated to find them.

I am not saying that there should not be a meaningful discussion about gun control but the crux of the issue here is prevention.

You stop a tragedy like this by recognizing signs and intervening in the potential shooter before he becomes a shooter. What possesses a twenty year old young adult to walk into an elementary school and start shooting? An act like this does not come out of nowhere.

In the field of pediatrics, we are experts in prevention. We use vaccines to prevent life threatening illness. We support things like breastfeeding, exercise and helmets to promote wellness and safety.

However, when it comes to supporting mental health, we ourselves are ill prepared. In our busy pediatric offices we do not have the time or the advanced training to help our patients who need mental health support.

When we look to refer them to psychiatrists, psychologists or social workers all too often the patient cannot find one who takes their insurance.

Gun control or not, tragic incidents like this murder of so many innocents will not stop unless we figure out how to provide affordable and accessible mental health wellness to our children and young adults.

That is the meaningful action that needs to take place in the wake of this tragedy.

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York.

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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.

Prevention

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.

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Is it Too Late To Get the Flu Shot?

The short answer is, no. It is not too late to receive the Flu Vaccine.

In a recent update on current influenza activity, the Centers for Disease Control and Prevention (CDC) stated that the influenza season is off to a very late start.

The update summarized that influenza activity remains low in the US, but has recently increased. Influenza viruses have been reported from all 50 states this season; the viruses Influenza A, H3N2, 2009 Influenza A H1N1, and Influenza B have been identified in the US. All influenza virus strains are susceptible to the antiviral drugs Oseltamivir and Zanamivir.

The CDC said that it is not too late to get the influenza vaccine and recommends that everyone 6 months of age and older, who has not already received the vaccine, do so.

If you haven’t gotten the flu for your child(ren), give you pediatrician a call, and schedule an appointment. While you are at it, you may call your own “adult” doctor and see if they have any left. Remember, it is not too late to be protected.

The full update can be viewed on the CDC website.

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Confused Which Vitamin To Give To Your Child?

Written by Sandra Graba, MD

With so many vitamin options available, choosing the right vitamin for your child can be a daunting task.

Not all vitamins are all the same! The age and health history of your child are important factors to consider. A premature infant will have different requirements than a healthy 2 year old.

My goal here is to give a sense of direction in the vitamin isle, but it is important to discuss individual needs with your doctor.

Often doctors will prescribe vitamins for your newborn, so that makes it much easier! Other times, they tell you the name of the vitamin to choose in the isle. The vitamins your pediatrician recommends at this age is a little different depending on whether your breastfeeding your child or not.

Vitamins For Newborns

Vitamin K is very important in the newborn period but thankfully all babies get a vitamin K shot right at birth and the subsequent needs are met by breastmilk and formula. Breast-fed babies need extra vitamin D: 400 IU and iron supplement of ~ 11mg daily starting at 6 months.

Six Month Old

Typically, pediatricians will give D-visol (vitamin D) through 6 months of age, then switch to poly-vi-sol (multivitamin) with iron starting at 6 months, but some pediatricians opt to start the multivitamin from the start. Either choice is fine. All formulas are iron and vitamin fortified to contain at least the recommended daily amounts for the first year of life.

12 Month Old

After the 1st birthday, life is completely different! Your little baby is turning into a toddler and with it comes a whole new challenge: feeding. We switch them from their vitamin fortified breastmilk or formula to whole milk and table foods.

Toddlers

The tricky part is that toddlers are inherently picky! They manage to get enough calories through all of the “picking” of their food, but do they get enough vitamins and minerals?

Consider this: One cup of whole milk (about 8 oz) has only ¼ of the recommended daily allowance of vitamin D, ½ to 1/3 of the amount of calcium, and no iron. This means that your child will need to drink 16- 32 oz (2-4 glasses) of milk to get all the vitamin D and calcium they need – but you would still need to consider their iron needs.

Also, high volume of milk intake (more than 16 oz a day) can lead to anemia. Translation: your mom was right that milk is good for you but there is too much of a good thing.

So, what to do? In general, all vitamins and minerals are important, but some are easier to get them to eat than others. We can focus on a few important ones: vitamin D, calcium, iron, B vitamins, and folate.

Iron is important in red blood cell formation and neurologic development among other things. It is plentiful in meat, dark leafy green vegetables, beans, tofu, cereal and bread. 1-3 year olds need about 7mg per day, 4-18 year olds about 10-12 mg per day except for menstruating adolescent girls who need about 15mg daily.

B vitamins are important for production of oxygen carrying cells and can be found in fish, poultry, meat, eggs, dairy, leafy green vegetables, beans/peas, breads and cereals. B6 and B12 are fairly easy to get in the diet. 1-8 year olds need about 0.5 – 0.6 mg per day and teenagers need about 1.0-1.3 mg/day.

Calcium is very important for growing bones. Some sources of calcium include cheese, yogurt, orange juice, fortified breads and cereals, spinach, and salmon. 1-3 year olds need ~ 500 mg a day, 4-8 yo need ~ 800 mg a day. and 9-18 year olds need ~ 1,300 mg a day.

Vitamin D is a tough one! The best source is the sun…but we spend most of our year bundled in sweaters, coats, scarves…you get the idea. There are a few natural food sources: cod liver oil, salmon, mackerel, tuna, liver, and egg yolk. My 3 year old definitely won’t eat liver. Thankfully, cereals and dairy are fortified. The current recommendation for all age groups is a minimum of 400 IU daily.

After sorting through the vitamin isle, it seems that either Flintstones’ Complete – it is ½ tablet for 2-3 year olds and a full tablet for older than 4 years or Centrum Kids Complete Multivitamin are the best bet for toddlers and school age kids.

Even still, they don’t provide 100% of the calcium and vitamin D in 2-3 year olds but they are pretty good for iron, B vitamins, and folate.

There are so many character and flavor choices available but the nutrition guide for these two vitamin types can at least provide a guide to compare the other vitamins to while your head is spinning in the isle. Overall, remember that vitamin supplements are just that – supplements to a healthy diet. Children with any special needs will have different requirements.

A few words on Gummy vitamins…

Though they taste good and are probably easier to get your children to take, the vast majority I have seen fall short in providing the necessary daily nutrients. Many contain ¼ to ½ the amount of vitamin D and 10% or less of the needed calcium;No gummies contain iron. Many have the minimum amount of B vitamins but less than the recommended folate. Each gummy does, however, contain about 3g of sugar. If the serving size for your child is 2 gummies, giving them their vitamins is about the same as giving them a ¼ cup of soda!

 

Dr. Graba is a practicing pediatrician at Salud Pediatrics.

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Insurance Companies Make It Difficult For Pediatricians

The human papilloma virus (HPV) vaccine (Gardasil, Cervarix) has been approved for use in girls for several years now, allowing us to protect our young female patients from many cases of cervical cancer and genital warts. While the benefits likely will not be seen for some time, as pediatricians we are excited to be able to provide, for the first time, definitive protection against a virus-caused type of cancer.

Approval for use of the vaccine against HPV in boys has been slower in coming, however. While they do not get cervical cancer, for obvious reasons, males are susceptible to other forms of disease caused by HPV, including genital warts, and they can also serve as a vector for transmission of this virus to their sexual partners, so including them in the target group for protection makes good scientific sense.

Recently, however, the American Academy of Pediatrics came out with a recommendation to use the vaccine (Gardasil) in males as well as females. This was followed by a similar recommendation by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). Having received this “official” approval, many of us have begun immunizing our adolescent male patients, and the acceptance of the vaccine by these patients and their parents has been encouraging. Initially, payment for the vaccine was an issue, but the vaccine has been approved for use by the Vaccines for Children (VFC) program, and most health insurance carriers are covering the vaccine for their insureds as well.

Most, but not all, however.

Our group, along with a number of others, has been told by the large national insurance company United HealthCare that the HPV vaccine is NOT a covered benefit for adolescent males. While other national insurance companies have been paying for the vaccine for months now, UHC was first waiting for the CDC to recommend it. Now that that has occurred, they state that they are waiting for that recommendation to be published in MMWR, the weekly report of the CDC, which can take time to occur, And after that, they claim that, by their contracts, they have an ADDITIONAL 60 days to begin to pay for it.

So despite the fact that this vaccine has been recommended and recognized as important for good health by many organizations and governmental bodies, United HealthCare is using SEMANTICS to delay covering a medical procedure which has been shown to be effective in preventing disease in patients who are paying premiums to United for just that sort of health assurance.

Frankly, in my opinion, this is a disgrace. The only reason for refusing to cover this vaccine upon CDC recommendation can be that United HealthCare does not want to cover the expense of this admittedly costly vaccine.

As physicians, we recommend that all adolescents, male and female, be vaccinated against HPV. And as parents, we want to do all that we can to protect our children, of both genders, from a preventable disease. If United HealthCare is your insurer, call them and object to their short-sighted and greedy policy. There is no reason that your children should be denied the protection paid for by virtually every other major health insurance company.

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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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Does Apple Juice Contain Dangerous Levels of Arsenic?

Written by Lacey Raburn, MS, CLC

On September 14, 2011, “The Dr. Oz Show” claimed that, through independent testing of selected samples of apple juice, they found unsafe levels of arsenic. This report would, of course, alarm many parents who provide apple juice to their children. Unfortunately, Dr. Oz failed to convey the entire story to the general public. For this the ABC News Health and Medical Editor, Dr. Richard Besser, publicly accused Dr. Oz of “fearmongering” on the popular show “Good Morning America.” 1

A little background on arsenic

Arsenic is a metal found in everything from our water to air. There are two types of arsenic: organic and inorganic. Organic arsenic is naturally occurring and not absorbed by our bodies. Because of this, it is not thought to have any harmful effects. Inorganic arsenic is not naturally occurring and can be harmful if consumed in large amounts and for a long period of time. The level of arsenic determined to be safe in drinking water is less that 10 parts per billion; most of the arsenic found in drinking water is inorganic. 2 3. Apples and apple juice contain organic arsenic. 4 Additionally, there are some levels of inorganic arsenic in apple juice; however, this is usually a fraction of the total arsenic and well below acceptable levels of inorganic arsenic in drinking water. 4

Measuring arsenic in apple juice

When arsenic is tested in apple juice, first the total arsenic levels are reported.4 This is a measurement of both organic and inorganic arsenic. If the total arsenic levels are high, the levels of inorganic arsenic are measured. Usually, the inorganic arsenic levels are well below what is considered safe. If they are too high, the Food and Drug Administration (FDA) will alert consumers. The FDA has regularly tested arsenic levels in foods and juices for many years to guarantee the safety of those foods. 4

Dr. Oz only reported levels of total arsenic in the apple juice, not inorganic levels. Also, he obtained all of these reports from one lab. When the FDA learned of Dr. Oz’s intent to report these findings on television, a letter was written that alerted the producers that this data did not accurately reflect inorganic arsenic levels. 5 Additionally, two more labs obtained samples from the same lot that Dr. Oz tested to determine total arsenic levels.6 Their results indicated much lower results of total arsenic compared to those that the lab Dr. Oz used. From this, the FDA concluded that the first lab’s results were unusually high and most likely a result from an error in the testing process. Another letter was written to the producers of the show encouraging them not to air the episode as it would cause unnecessary fear among consumers. 6 The following is an excerpt from this letter:

“In short, the results of the tests cited above do not indicate that apple juice contains unsafe amounts of arsenic. The FDA reaffirms its belief, as stated in our September 9, 2011 letter, that it would be irresponsible and misleading for the Dr. Oz Show to suggest that apple juice is unsafe based on tests for total arsenic.”

The FDA also released an update reassuring consumers of the safety of apple juice. 4

The bottom line

According to the FDA, apple juice is safe to drink and the levels of arsenic found in apple juice are well below what is considered safe and acceptable.

If you would like to read more information on this topic, please visit the FDA website.

References:

1. Gann, C. Apple juice and arsenic: Dr. Besser vs. Dr. Oz. 2011. Available at: http://abcnews.go.com/Health/dr-richard-besser-dr-mehmet-oz-debate-arsenic/story?id=14526426. Accessed September 15, 2011.

2. Arsenic in Drinking Water. 2010. http://water.epa.gov/lawsregs/rulesregs/sdwa/arsenic/index.cfm. Accessed September 15, 2011.

3. Questions and Answers: Apple Juice and Arsenic. 2011 http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm271595.htm. Accessed September 15, 2011.

4. FDA: Apple Juice is Safe to Drink. 2011 http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm271394.htm. Accessed September 15, 2011.

5. Zink, D. Letter from FDA to “The Dr. Oz Show” Regarding Apple Juice and Arsenic (09/09/2011). 2011. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm271630.htm. Accessed September 15, 2011.

6. Zink, D. Second Letter from the FDA to “The Dr. Oz Show” Regarding Apple Juice and Arsenic (9/13/2011). 2011. http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm271632.htm. Accessed September 15, 2011.

Lacey Raburn, MS, CLC is a dietician at Plateau Pediatrics in Crossville, Tennessee.

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Why Can’t The Pediatrician’s Office Tell Me What Services Will Be Covered By My Health Insurance Company?

Written by Cliff Wu M.D.

Medical insurance in the United States has to be one of the most complicated and frustrating systems that a family can endure. One question that has arisen recently has been whether a clinic can tell what services are covered by a given insurance plan and whether or not our clinic is in network.

Unfortunately, the answer to both of those questions is no. We frequently do not have access to that information because of all the different insurance plans, and each plan will have different variations. For example, we can be in network for Branch A of Insurance X but not for Branch B within Insurance X and there is no way for us to tell until after we submit the bill to Insurance X. In fact, we won’t even know that there is a Branch A or a Branch B. Of course, that doesn’t help when we try to determine whether we’re in network at the appointment time.

So what’s a family to do? The only answer we have is for each family to check with their own insurance company about what benefits are offered and which clinics are in network. The insurance carriers will release a book every year with which clinics are in network; they may also post clinics and doctor names on their website. Even then, it’s not always foolproof because the carriers may or may not keep these resources up to date.

As pediatricians, we would absolutely love to be able to streamline the process for families, verify our network status, and determine the coverage and benefits, but we simply do not have access to that information, and we are just as frustrated by this process as the families that run into this problem are. Again, a family’s best bet is to check with the carrier using the policy number in hand because that is something that we cannot do until it is too late.

This piece is just a small part of American healthcare complexities. If you are interested in a bigger picture of this nightmare, Planet Money did a blog and an eye-opening podcast entitled “The Pain-In-The-Butt Index” in July 2010 that details the staggering burden that we all endure.

Dr. Wu is a practicing pediatrician in Lakeville, MN. He runs a family-oriented practice built on love for children and the desire to make them feel comfortable with healthcare. 

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Hello world!

Frustrated by the poor representation that physicians (particularly pediatricians) get, we decided to take matters into our own hands. This blog is about giving pediatricians a voice and a presence on the web. We wish to participate in the discussion, be included at the table, and share our ideas.

We feel that we can provide a unique perspective that often gets overlooked when healthcare issues are discussed; which is the perspective of front line pediatricians.

Between politicians, interest groups, lobbyist, pharma companies, insurance companies and many others, front line pediatricians are not being heard. After all, we are the ones that provide care for the children of America. Should we not be heard?

We think so.