On the Spectrum: What Autism Really Is

Autism. It's a diagnosis that many families fear and is grossly misunderstood. Last month, I did a rotation in developmental pediatrics, where children with concerns of development are referred and autism is often diagnosed. I've seen a host of patients where there were concerns that turned out to be unfounded. So, in light of that, I decided a crash course in autism was warranted.

So, what is Autism? Simply put, it's a developmental disorder that affects social interactions. They don't engage socially, so they have decreased eye contact, and don't have shared social experiences. For instance, a normal child will point to show things of interest and will try to get a caregiver's attention when something interests them. Those with autism are not interested in sharing the experience, so may simply watch whatever is interesting them. Communication also plays into this, as these children don't communicate their needs and often seem more independent than normal children because they simply figure out a way to get what they want, instead of communicating that desire to another. Thus, a child who wants a glass of milk may figure out how to set up the stepstool to get a glass out of the cabinet, rather than simply ask for a glass of milk.

Children with Autism have few, detailed interests. For instance, they may enjoy trains (which is not abnormal), but know exactly how the train runs or be more interested in train schedules, much more than another child his age. Or they may be more interested in part of the toy--such as the wheels on the train, and not use the toy itself appropriately. Going along with this, they love routine, and get upset when their routine is disrupted.

Autism is defined by the Diagnostic and Statistical Manual of Mental Disorders, or DSM. In it's fourth edition (DSM-IV), there were several categories of autism: Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Autistic Disorder, Asperger's Disorder, and Childhood Disintegrative Disorder. Each had slightly different criteria for diagnosis. For instance, children with Asperger's disorder had to have limited social behaviors, repetitive behaviors, and no delay in language and a normal IQ. These were the 'high functioning' autistics.

The fifth edition (DSM-V) came out in 2013, and redefined these categories so that all of them fell under 'Autism Spectrum Disorders'. They made this determination because it had proven difficult to categorize all individuals with these disorders into discreet categories. That is, the same patient, seen by two different providers, may provide two different diagnoses, even though the child has the same symptoms. Thus, the DSM-V eliminated the confusion by making it a spectrum. Those who previously had Asperger's Disorder now are reclassified as having an Autism Spectrum Disorder (ASD), and being on the higher functioning end. There is thus less focus on the exact diagnosis, and more focus on the exact symptoms of the particular child. This also allows children who would not have had access to services before to fit the criteria and be labeled with an ASD so that they may have access to these school services.

In general, there are three patterns of autistic development. Previously, there had been considered to have two, but more recent data on these individuals indicates the presence of a third pattern. The first pattern is normal development to a point, and then loss of previously acquired skills. This is referred to 'regression'. The second is normal development and then failure to gain new skills. This is referred to as 'plateau'. Finally, there is early delays that never catch up with peers. This is referred to as 'no regression, no plateau' (I know, creative name, isn't it?).

So, we have the criteria. But how are children monitored for concerns? Well, each pediatrician does it slightly differently, but the American Academy of Pediatrics (AAP) recommends surveillance at every well-child check. If you are a parent, you may recognize this as either written or verbal questions along the lines of 'is your child pulling to stand?' or 'does your child use a fork appropriately?' As Pediatricians, we have a list of developmental milestones that children are supposed to reach at certain ages. In fact, we get tested on them in every test related to pediatrics starting in medical school, in order to identify children who are behind. You can look at the milestones for yourself, by age, here.

In addition to surveillance, there are certain visits where a child should also undergo formal screening. This is typically done in the form of a questionnaire, such as the M-CHAT. These help us determine whether the child should be referred to a developmental pediatrician for further evaluation. Many children who screen as abnormal do not have autism, but may have some other behavioral or developmental abnormality, especially if they are school-age and having difficulty in school.

However, the limitations in these methods are that it is primarily by parent report. One study looked at social behaviors in children diagnosed with autism by analyzing both parental reports and looking at home movies of the children. This study supported the assertion of three distinct patterns of development (as mentioned above), but showed that parents were bad at judging how their children developed.

Less than half of participants (9 of 20) whose home video displayed clear evidence of a major decline in social-communication behavior were reported to have had a regression by parents. Similarly, only 8 of 20 participants with evidence of early delays in social-communication behavior and little evidence of skill decline on video were reported as having an early-onset pattern by parents. Of the 10 parents who described a plateau in development, only three had home video trajectories consistent with such a pattern.

These difficulties are partly why the incidence of autism has climbed so dramatically in recent years. Thirty years ago, the only people being diagnosed with autism were the classic non-verbal and aggressive patients that were sent to institutions. Now, people with much milder forms of social impairment are being classified as having an autism spectrum disorder, because Early Intervention services have been shown to help those with these problems succeed more later in life.

All this is just the tip of the iceberg with regard to Autism, but I hope it was a good primer and gives you some insight into the disorder.

Eating Right: Infant Nutrition

My training is filled with newborn medicine. The first year, I spend one-third of the year taking care of babies, plus I see a lot of babies in my clinic each week (we have at least 2 newborn visits each week). So, naturally, I have learned a lot about infant nutrition. This post, I'm going to primarily talk about formula and transition to table foods, but in another post, I'll talk about the reported benefits of breastfeeding. We'll do this Q&A style today.

What's with all these different formulas? 

There are dozens of different types of formula. For the most part, they are marketed for different groups. There are two main categories: cow's milk based formulas, and soy formulas.

Cow's milk formulas process cow's milk heavily into something resembling human breastmilk. The proteins are broken down and adjusted to look more like human breastmilk, additional lactose (milk sugar) is added, and the milk fat is removed and replaced with different types of fat. Note that all this adjustment actually makes the formula very different from cow's milk, so there is no contraindication when we say that you should not give your child milk until they are 12 months old.

A subset of cow's milk formulas are the hydrolyzed, or hypoallergenic, or sometimes called elemental, formulas. These are based on cow's milk, but are further broken down so that the proteins are short, and thus less likely to cause allergic reactions.

Soy milk formulas are designed primarily for vegetarian/vegan parents who do not want to give their child cow's milk based formulas.

There are also a handful of special formulas for children with very specific metabolic syndromes, which are determined by the newborn screen, and not applicable for most children. They tend to be more expensive, and out of the price range of many parents as well.

So, which formula is best?

There isn't a hard and fast rule for this. For most babies, a general cow's milk formula fortified with iron is sufficient. This also tends to be the one that most people start out with, and as such, makes up a huge portion of the market. So, it also tends to be easier to find and sometimes cheaper.

When should I switch formulas? 

You want to talk this over with your pediatrician. Some reasons your pediatrician may recommend a different formula may include a significant family history of allergies (especially food allergies), a milk protein intolerance, or a metabolic disorder that requires a certain type of formula.

A significant family history of allergies may predispose your baby to getting allergies to foods, so to minimize that risk, a hypoallergenic, or elemental, formula may be recommended. These may help up to 90% of babies in these situations delay the onset of allergies or avoid them all together.

A milk protein intolerance most commonly presents as blood in the baby's stool. It does not represent a true allergy, but rather a minor reaction to the protein in the cow's milk formulas. However, there can be significant cross sensitivity to the proteins in the soy formulas, so again, a hypoallergenic formula may be recommended.

Generally, babies do not have lactose intolerance. This is something that tends to develop in older children and adults due to a deficiency in the chemical in the gut that breaks down the milk sugar. Babies are designed to break down this sugar, as human breastmilk has it in large quantities. However, there are rare cases of lactose intolerance in babies, and in these children, a lactose-free formula may be used.

How long should I give my baby formula?

You should give your baby formula or breastmilk ONLY until they are at least 4 months old, unless otherwise suggested by your pediatrician. They should not be given juices, sodas, or table food. Formula or breastmilk will provide all the nutrition they need up to about 6-7 months of age. After that, they should continue to get formula until 1 year of age, when they can be switched to cow's milk (or soy milk, etc) as their milk requirement.

How should I introduce foods? 

When the child is able to sit up on their own and express interest in the rest of the family eating, you may start introducing 'solid' foods. These should be completely pureed. Most pediatricians will recommend starting with an iron fortified rice cereal or oatmeal or something of that nature, but it's acceptable to start with another iron-rich food, such as finely ground meat.

Following that, you can start introducing different vegetables and fruits. Babies tend to like fruits more than the vegetables, because they are sweeter, but it is important for them to have a balanced diet, so introduce different vegetables early and often. You should feed your baby only single ingredient foods at first--sweet potatoes, peas, carrots, apples, whatever, so long as there is only one thing in the puree. Then, wait three days before introducing a new food. This technique allows you to monitor any allergies or intolerances that may develop in the baby, so you know exactly which food caused it.

If your baby does not like a certain food when you first introduce it, don't give up. Mix it with a food they previously did like and tolerated, and then slowly increase the amount of the new food until there is no more of the former food.

As they get older, you can start introducing new textures, and by 1 year of age, they should be able to eat small finger foods on their own.

Is there any food I can't give my child?

Infants under one year of age should not be given honey. This is because in the processing of honey, there is a change for a bacteria called botulism to get into it, which can then multiple in the infant's intestines and cause a serious illness.

You should also not give your infant under age 1 cow's milk. Yes, I know I just talked about cow's milk formula extensively, but these formulas have been heavily altered and processed to meet the needs of babies. Cow's milk does not have the nutrients babies need and has a high amount of sodium, potassium, and other solutes that may stress the kidneys of an infant. After 12 months, their kidneys have matured enough to allow this. Note that unless your pediatrician says otherwise, you should start with whole milk, because toddlers need the extra fat for brain development.

How's that for a whirlwind tour of nutrition? Any additional questions, let me know at the contact button above or in the comments below.

Emergency Room Visits: When is the Right Time to come in?

It's been a crazy couple weeks. I'm on vacation now, so I'm hoping to get a few of these cranked out so that I don't miss any for a while. Apologies for not keeping up with my self-imposed schedule!

I'm on my Emergency rotation this month, and after having only worked a handful of shifts, I've learned a ton. I've also seen a wide variety of anxious and worried patients and parents. However, I've also seen families who are frustrated by a perceived lack of help.

I encourage all parents, if they think there is a problem, to first call their pediatrician. This is not idle advice... half the things I see in the Emergency Department can be seen in a pediatrician's office, not only faster, but generally cheaper for both the family and the insurance company. I also recognize that there is a trend among primary care physicians in general to refer their patients to the Emergency Department if anything is concerning to them, rather than working it up themselves. This isn't necessarily a bad thing--it can just be very frustrating for the parents.

Let's go through some cases to see who is best treated in the Emergency Department (henceforth referred to as ED), and what expectations for them are.

Patient 1: 3 week old infant comes in with a fever to 101. Otherwise looks healthy.

Should the patient come to the ED? Yes, Absolutely. Infants are not good at localizing infection because their immune system--what helps them fight off disease--is not developed yet. Virtually all their protection comes from mom--either from that protection crossing the placenta prior to delivery, or in the breastmilk afterward. So, these babies are at risk of getting serious infections, and sometimes the only outward sign of those serious infections is fever.

What should you expect in bringing this child in? Because we cannot easily identify the source of the infection, we check the major areas where infections can hide: the urine, the blood, and the spinal fluid. This means collecting urine, drawing blood, and doing a procedure called a lumbar puncture to get the fluid from around the spinal cord. The child will then have to be admitted to the hospital to await the results of those tests.

Patient 2: 3 1/2 year old girl with a few red spots on her back. Otherwise looks and feels healthy. No fever.

Should the patient come to the ED? This one can probably be treated best at the pediatrician's office. If the child has a fever and it's after hours, it's reasonable to bring her in, but without a fever, the spots are either bug bites, hives, or maybe a viral rash. In any case, there isn't a whole lot that the ED is going to do for you other than reassure you that these things are not serious, and that might be better conveyed by your local pediatrician.

What should you expect if you do bring the child into the ED? Long wait times. We have kids that are legitimately sick, so they get priority. I will not fault you for bringing your child in if you are worried, but again, you're probably going to be seen faster and have a better relationship with your pediatrician in the office.

Patient 3: 14 year old who nearly passes out on the toilet, and has gained weight and been overly tired for a year.

Should the patient come to the ED? This is a soft call. Passing out is something that raises red flags for us in the pediatric population, but in this case, there was no actual passing out. So either we're going to say he's sick with some virus, dehydrated, or something along those lines, or we're going to say that maybe he was straining a little too hard on the toilet and that's why he suddenly felt lightheaded.

What should you expect if you do bring this child in? A lot of reassurance. Maybe a few tests if something in the history raises a red flag for us. However, you should NOT expect us to magically cure your child or figure out what is wrong with him, nor should you expect us to be able to expedite your wait to get in to see a specialist. We can rule out any life-threatening causes of the passing out, but we are not going to solve the mystery as to why he has been tired so long, especially if you've already been seen recently by a pediatrician. That is not the purpose of the ED.

Patient 4: 8 year old who has had headaches on and off for months at various times of day. They go away with ibuprofen/Motrin/Advil, but usually come back.

Should this patient come to the ED? This patient was a little complex, but as he only had a minor headache when he came in, there really wasn't anything we could do for him. Since it was a chronic problem, and the headaches were going away, this is really a patient that should be seen in a general pediatrician's office.

What should you expect if you do bring this child in? Again, a lot of reassurance. While there is some diagnostic testing we can do, unless the child is getting worse, vomiting with the headaches, or they do not resolve with medication, the testing really isn't needed on an urgent basis, so we're probably going to refer him back to his primary pediatrician. If you don't have a primary pediatrician, we will gladly give you some numbers for some.


The bottom line? I won't fault you for bringing in your kid to the ED if you are worried something is wrong. But please, if the problem has been going on for a while, and your child doesn't appear to be getting worse, please call your primary pediatrician and have your child be seen there. You will probably get in and out faster anyway (since waiting times in the ED for non-urgent problems can be several hours, even after you are initially seen).

Safety: What Should I Worry About?

As we discussed last week, safety is a big issue, and some recommendations are summarily ignored. Why do we care so much about safety? Why do we push the bike helmets and childproofing homes and whatnot? Why do we have so many products aimed at safety? After all, 'when I was growing up, our parents didn't care about any of that stuff.'

Well, unintentional injury is the most common cause of death in children (aged 1-14). More than cancer, heart disease and every other disease children get, combined. The only reason it isn't so for the under 1 crowd is because we have a lot of babies born with various congenital conditions that lead to an early death.

Of course, those stats include all unintentional injuries, which covers a lot of things. What, specifically, causes death in children? Well, the CDC puts together that information for us too. The causes that are in the top 10 for all age groups through age 14 are:

1. Unintentional Suffocation (1117 deaths in 2012, differentiated from homicidal suffocation and undetermined suffocation)
2. Homicide (730 in 2012)
3. Drowning (725 in 2012)
4. Motor Vehicle Accidents (437 in 2012)
5. Burn (277 in 2012)

Others high on the list are those related to firearms (317 in 2012, but none in <1 year), pedestrian accidents (104) and environmental causes (89). All of these are something that we're concerned about. Many of these can be prevented by simply educating parents about what to look for. For instance, unintentional suffocation is the most common cause of unintentional injury death in children less than 1 year of age. So, we as pediatricians recommend that the beds not be lined with bumper pads, remove large fluffy pillows from the couches, etc, and careful supervision of these children. The number of children dying from suffocation drops dramatically after age 1. I'll cover safe sleep and SIDS in another blog post. For homicides, there isn't much we can tell the parents. Living in a bad neighborhood, violence at schools--these are things that are often beyond the parent's control. We deal with these as best we can. Drowning is most common in the 1-4 age group, and while pools are a concern, most children actually die in bathtubs, dog bowls, etc. It only takes 3 inches of water to drown--enough to cover the nose and mouth. So, watching the child, especially in the bathtub, is key for preventing these injuries. Motor vehicle accidents are very common, so we focus on making sure the kids are strapped in appropriately. This is likely a whole blog post in and of itself, but the gist is that children under age 2 need to be in a rear-facing seat, and should be in a car seat until they meet the weight recommendations for that seat. Then they should be in a booster seat until they can comfortably wear a seat belt (at about 4 ft 9 inches tall).

Burns are most commonly caused by hot water, and so we make the recommendation to keep water heaters set at 120 degrees F. Not because this is a safe temperature, but because it takes about 5 minutes at this temperature before a serious burn injury develops. Baths should be slightly warmer than body temperature, about 100 degrees F.

There are plenty more safety issues that can be discussed, from medications and poisonings to firearms to falls, but I feel this post is already long enough, so we'll save those for another time.

In the meantime, if you have any questions or comments, feel free to post in the comments below or use the 'contact me' form available as a tab at the top of the page.

Children and Heat Safety

Hopefully you've heard of some of the recent deaths after leaving children locked in a car on a hot day: Cooper Harris, Benjamin Seitz, and many others. Some of these stories are a little old, but these stories happen every summer. In fact, roughly 35 children die in hot cars every year. Thirty-five. Countless other pets and elderly individuals also die each year.

Why does this happen? It could be intentional. It could be an accident. It could be lack of awareness. I'm hoping for the latter two, and want to hopefully change thinking.

First and foremost, children should never be left in a car (or anywhere, really) unattended. There's a whole host of things that can go wrong, and without quick intervention, many of these can lead to serious injury or death.

Now, let's speak generally about what heat does to us.

Our bodies produce heat constantly. This leads to a body temperature around 98.6 degrees F (37 degrees C). Actually, your body temperature fluxuates during the day, and is lowest around 2-3 am. If your temperature drops below 36 degrees C (96.8 F), you are considered hypothermic. If your temperature is over 38 degrees C (100.4 F), you are considered to have an elevated temperature. If this is due to an infection or inflammation (a reset in the body's 'normal'), we call it a fever. If it is due to a breakdown in the body's ability to cool, we call it hyperthermia.

When the body's temperature is above it's normal set point (about 37 degrees C in children without a fever), the body responds by sweating. From experience, I'm sure you've noted that you start to sweat even in temperatures below your own body temperature. As I said before, the body produces its own heat, and has to get rid of this heat to the environment. This is fairly easy when the environment is 'room temperature', but as the temperature starts to climb (or there is more body heat to get rid of, as in exercise), it becomes more difficult to do so, and sweating is one way this is done. Sweating gets rid of excess body heat because the water takes the heat with it as it evaporates off the skin. (This is why wiping sweat off can actually make you feel hotter, and why a cool mist can make you feel cooler).

When it is hot outside (>90 degrees F/32 degrees C), and the humidity is high, it can impede the ability for sweat to evaporate, and thus the body to cool down. When the body temperature starts to go up, it means bad things for the person.

Heat exhaustion occurs when the core body temperature is still below 104 degrees F (40 degrees C), and the person is awake and alert. They may complain of dizziness/lightheadedness, headache, rapid heart rate, fast breathing, tiredness, and so forth. But, importantly, they are still able to appropriately answer questions. Heat exhaustion is considered the precursor to heat stroke. This person needs to be moved to a cool place, be given water, and allowed to rest. If symptoms do not improve in 20-30 minutes, they should be brought to the Emergency Department for further evaluation.

Heat stroke is characterized by a core body temperature greater than 104 degrees F (40 degrees C), and an abnormal level of consciousness--the person is not awake or is not able to appropriately answer questions. This is a medical emergency, as it can very rapidly result in multi-organ failure.

You'll notice that heat stroke is defined by the temperature. However, there is a difference between having a fever and being hyperthermic to the point where you are at risk for heat stroke. In fact, rapid cooling with ice packs, water, etc does not help in cases of fever, which is why they are given two separate terms (fever vs. hyperthermia), despite having the same characteristic (elevated core body temperature).

What a fever does to a child is raise the body's set point to higher than 98.6F. Thus, when they have a fever, they may not be sweating, because the body is trying to stay hot. It is when you 'break' the fever and they start to come down to their normal temperature that they start to sweat. People tend to get worried for 'high' fevers, up above 103 degrees F, but the body cannot really produce temperatures above 105 degrees F on its own, and children with fevers, even high fevers, do not have the same complications as children with heat stroke. The take home from this point is that if your child has a high fever, you should bring them to see the physician just in case it is not a fever and to make sure that you are treating the infection appropriately.

So, what can be done to prevent heat exhaustion and heat stroke?

Since most often, these occur when children are outside playing sports (exertional heat stroke), it is important to incorporate several breaks, and emphasize adequate hydration (with a sports drink solution, since sweat causes the loss of some important electrolytes) during play.

As for the origin of this article--the publicity of automotive heat deaths in children--you should not be leaving a child in a car during the warmer months. It can get very hot inside the vehicle, even if it is only left for a few minutes. If the vehicle is in the sun, it can get even warmer. Leaving the windows cracked is not enough to prevent this rise in temperature. Putting up a sunshade may delay the time for the temperature to rise slightly, but not enough to safely leave a child in the car.

Just don't do it. Take your child with you, even if they are sleeping. Especially if they are sleeping. I would rather your child annoy you in the store than for you to live with the devastation of losing your child.

Wet Bedsheets: When Nighttime 'Accidents' Become a Problem

One of the questions I've heard more than a couple times in clinic is: "Is my child's bed wetting a problem?" The answer? It depends.

Toilet training typically begins around age 2. Some kids show interest earlier, some later. Many things have to be in place before toilet training can be successful, ranging from the ability to sense the need to use the bathroom, to the ability to indicate that need to a caregiver, and finally to the ability to 'hold it' and control the muscles responsible for going. And, of course, the child must show interest, else attempts at getting them to use the bathroom are futile.

Nighttime bathroom use is generally the last stage of toilet training. At this point, children are usually able to use the bathroom appropriately during the day, but frequently have accidents at night. It is important to note that it is not their fault. Usually bed wetting is a result of deep sleep, when the signals of a full bladder are not processed to result in waking up to use the bathroom. It may take years after daytime training for nighttime training to be complete.

Importantly, if mom or dad (or both) were bed wetters as children, the child is more likely to take longer to achieve nighttime dryness. Boys are also more likely to wet the bed than girls, so don't use an older sister as a comparison.

If a child is still wetting the bed at age 5, it should be brought up to the pediatrician. In one study, most children had stopped bed wetting by age 41 months, or about 3 1/2 years old. However, at age 5, up to 25% of children are still wetting the bed, so it's not outside the realm of normal. The reason you should bring it up with your pediatrician is that it might be indicative of a developmental delay, so that possibility should be explored. It could also be an ongoing issue of constipation, as excessive stool may compress the bladder and lead to more accidents. However, it is not really considered 'abnormal' until the child is 7 years old or so.

There are some behavioral modifications you can do to help reduce your laundry load. This includes making sure the child stays well hydrated during the day (so they don't need to catch up on fluid intake at night), and reducing the amount of liquid at dinner time. The child should be asked to use the bathroom before bed, and even woken up when the parents go to bed to use the bathroom again. There are some sensors and alarms that can also be used to wake a child when they start wetting, but these tend not be very effective. Finally, there are some medications that can be used to decrease urine production during the night in extreme cases.

This is assuming the child has never had a period of dryness at night. I'm not talking about a day or two stretch here and there, but a period of consistent dryness lasting several weeks. If the child begins bed wetting again after this point, you should always bring it up to your pediatrician, because this is always abnormal.

In some cases, it will be due some sort of stress (divorce, new family member, etc), which can be treated with therapy. In others, though, it may signal another condition, such as diabetes (one of the early symptoms of diabetes is increased urination), a urinary tract infection, or even issues with sleep.

Bed wetting can be a stressful thing for both children and parents, but allow time to take its course and most of the time, it will resolve on its own.

Comments? Questions? Concerns? Comment below or send me a note through the Contact form located above!

Contraceptives and Abortifacients

So, originally this week I was going to write about some of the developmental delays I've been seeing this past week in clinic. But after multiple Supreme Court rulings on the contraceptive mandate, I decided I really can't stay quiet about this.

For those of you who haven't heard of these rulings, allow me to summarize them for you.

First, we have Burwell vs. Hobby Lobby. Hobby Lobby is an arts and crafts store owned by the Green family, who are devout Christians. Their argument was that their corporation remains a family owned business, and they should be able to run that corporation in line with their religious beliefs. The particular argument was that the contraceptive mandate of the ACA (the section that required insurers to cover at no additional cost all 20 FDA approved contraceptives) violated their religious beliefs because 4 of the contraceptives covered (two forms of IUDs and two forms of 'emergency contraception') are abortifacients, that is, they have an action that may prevent implantation and thus result in 'abortion' of a fertilized egg.

A linked case, Conestoga vs. Burwell, had a similar argument. The Hahn family is the sole owner of the company and also believe that these four contraceptives are abortifacients.

In these cases, the Supreme Court voted 5-4 in favor of the companies. It should be noted that all three female justices voted against this decision.

Wheaton College vs. Burwell was not decided this week, but was allowed to abstain from the contraceptive mandate until they can gather arguments to go in front of the Supreme Court in the future.

I see multiple issues with these decisions, but for now am only going to focus on the medical aspect: Whether these contraceptives are abortifacients or not.

Before we get into how these contraceptives work, here's a crash course on what needs to happen for pregnancy.

First, there needs to be a viable egg. Each month, roughly, an egg is released from the ovary following a hormonal signal called the LH surge. This is referred to as ovulation. The egg then travels down the Fallopian tube towards the uterus (you can view of diagram of this here, if you're more of a visual person). Somewhere in this Fallopian tube, it is met by the sperm released after sex. The sperm fight to be the first inside the egg, and the now fertilized egg (soon to be an embryo) travels down to the uterus, where it implants in the rich lining and starts to form an actual baby. Progesterone, another hormone, is produced by the ovary following ovulation to promote the growth of the lining of the uterus until the placenta (the direct connection between baby and mama) forms and can produce this hormone on its own.

You'll note that I said the sperm meet the egg in the Fallopian tube. Sperm can live inside the female body for up to 5 days after sex. The egg can only survive without being fertilized for 24 hours or so after ovulation. So the most fertile time for women is actually having sex prior to ovulation so that the sperm can already be present when the egg is released.

When the embryo does not implant, there is obviously no development of a placenta, so after a period of time (usually 2 weeks), the ovary stops producing progesterone, and the uterine lining sheds, resulting in a period. Birth control pills work by supplying the body with a continuous dose of progesterone (and some estrogen, yet another hormone), so the body thinks its pregnant and doesn't release another egg. Thus, when you are on the placebo pill week, you have your period because you are not producing progesterone.

Onto the 'emergency contraceptives'. Plan B, Plan B One-Step, and Next Choice are levonorgestrel, a progesterone-like hormone. Thus, it acts like progesterone by preventing ovulation. As already described, progesterone is necessary to keep the uterine lining intact for the developing embryo. So, if this pill was taken after ovulation, the ovary would continue to produce progesterone, allowing the implantation of the embryo into the uterine lining. This is taken after sex, so it wouldn't prevent the sperm from getting into the Fallopian tube in the first place (as daily birth control pills might). The only way it would prevent pregnancy is if it prevents ovulation. So, not an abortifacient.

Now, an aside, taking the pill after ovulation doesn't mean you'll get pregnant. Everything else has to go right for that to happen. Successful implantation is estimated to occur in 15-30% of natural cycles. Many miscarriages are not realized because the body simply rejects the embryo before the woman knows she's pregnant. Most of the time, this is because there is some major genetic issue--an extra set of chromosomes, or something of that nature. Trust me, after studying genetics and embryology, I was amazed that this process worked at all.

There are some studies showing that there may be some changes in the uterine lining following administration of loveonorgestrel, but as far as I can tell, these studies were all done in the 80s, and much more recent studies have shown that there is little to no effect on the lining. Medications have also changed a great deal in that time.

Ella, ulipristal acetate, is another pill form of emergency contraception. It acts as a mixed progesterone receptor agonist and antagonist, which means it sometimes acts like progesterone and sometimes blocks the action of progesterone. Its effect is determined by the timing of the cycle. It can prevent the LH surge if given early enough, but can also block the effect of the LH surge (ovulation) if given after this hormonal signal. Essentially, it directly delays ovulation, ideally long enough so that the sperm are no longer viable. If given after ovulation, though, it diminishes the ability for the ovary to produce progresterone, thus affecting the uterine lining. Because of this action, I can see its potential for 'abortion', by preventing implantation. Ella is a relatively new contraceptive medication, so there are relatively few studies out there--it was difficult for me to pin down its exact mechanism of action.

Intrauterine Devices (IUDs) are implants placed by an OB/GYN or another clinician trained in the insertion that are used for long-term contraception. Historically, they were thought to have effects primarily in the post-fertilization phase of pregnancy, but other evidence now suggests otherwise.

There are two types available on the market today. First is the copper IUD. This one has been around forever. There is no hormonal effect to this contraceptive, and it is cited as an effective emergency contraception. It seems the effect is primarily toxic to the sperm as they move through the uterus, but it also produces an inflammatory response in the uterus which may affect implantation. So, potentially disrupts implantation.

The second type of IUD is the hormonal IUD, such as Mirena or Skylar. It is a small plastic device that contains progesterone, which acts in much the same way that the progesterone pills function. They are effective for about 3-5 years after insertion and prevent 99% of pregnancies. In theory, these can cause a foreign body reaction in the uterus that prevents implantation, but women can still get pregnant using this device, and it's not very effective as an emergency contraception, so it doesn't seem that this is an active issue. Therefore, I say it's not an abortifacient.

Conclusions: Hobby Lobby may have had a case. As I mentioned, I disagree with the decision on multiple fronts, and this was only the start of it. At minimum, they should not be permitted to object to Plan B and hormonal IUDs on the basis of them being abortifacients, because the science indicates that they are not, and thus it is a flawed argument. Ella and other similar oral emergency contraceptives need to be studied more before we determine for certain whether they result in decreased implantation of a viable embryo. Copper IUDs likely produce an environment that is hostile to life in general in the uterus, and thus potentially disrupt implantation.

There is some disagreement about the term 'abortifacient' as well, since by definition an abortion is the termination of a pregnancy, and a pregnancy can only occur if there is implantation of the embryo, but I chose not to get into this discussion for now.

Thoughts? Questions? Concerns? Feel free to comment or use the contact me form located at the top of the blog. See you next week!

Growing Big: When Health and Self Esteem Collide

When I was growing up, I was big. I'm not sure where exactly I fell in relation to other kids my age, because I rarely went to the doctor. That's what happens when you don't play sports and move every couple years, and thus don't have a good relationship with a doctor. But, I was definitely bigger than most kids. And I got teased for it. Throughout high school, I wore a giant, baggy jacket, because I was so ashamed about my body. As a sophomore in high school, I was asked by another student if I was pregnant. One of my friends desperately wanted me to go to the homecoming dance as a freshman so that I could have a Cinderella moment.

Point being, I know what it's like to have a low self-esteem.

But, as a doctor, I also know the harms of childhood obesity. I've talked about it before. So, I want young girls to get healthy and be at a healthy weight.

Problem is, weight is a very sensitive subject for adolescent girls. I saw a girl in clinic who completely shut down on me, to the point where we got a social worker to come talk to her, because I mentioned she was heavier than was healthy. It's not an easy subject to discuss, and I hate bringing it up, but I do it because it's in their best interest.

Well, a recent study has come out that may affect how I bring up the topic. This study took a group of girls and asked if someone had ever called them 'too fat'. They specifically asked about family members, teachers, and peers. Girls who were labeled as such at age 10 were significantly more likely to be obese at age 19 than those who were not, independent of what weight they started at.

Makes you wonder about all that media that girls consume now, doesn't it? How they are comparing themselves to the size 0 models in magazines, or worse, real women who are photoshopped to be unrealistic in proportions. Or how Ursula and the Queen of Hearts underwent a makeover to make them skinnier.

Yes, obesity is a problem.

But you know what? I was at my healthiest weight when I felt great about myself. It took me a long time to get there--years of affirmation by someone I loved. But I became happier with myself, accepting of myself, and started to walk around with confidence. And those extra pounds melted off.

So maybe the focus should be on body image, and not weight. After all, there is also such a thing as being too skinny.

The Elusive Good Night's Sleep

I know, I haven't posted the past 2 weeks. This is what happens when you have to move and lack internet for a week.

Sleep is a very important part of our lives. After all, we spent roughly 1/3 of our lives sleeping. There are several theories on why, exactly, we need sleep. My favorite is the converting of short-term memory to long-term memory. Essentially, if you don't get enough sleep, you won't learn anything new. But for now, I'm going to focus on how much we need and how to get that sleep. In fact, this was the focus of a recently published article that has caught the attention of many news sites.

It's more than just memory, though. Getting less sleep than you need can result in poor academic performance. According to a small study by the American Academy of Sleep Medicine, this effect is as much as binge drinking or smoking marijuana, independent of other risk factors such as psychiatric disorders.

Sleep has also been linked to weight, particularly in adults. A recent study published in Pediatrics shows that getting less than the recommended amount of sleep in infancy and childhood is linked to obesity by age 7. Indeed, even how much a parent sleeps can affect how much the child sleeps, and thus his or her risk of obesity later in life.

Finally, sleep is the time when many hormones are released. For children, the most important of these is growth hormone. That's right--if children don't get enough sleep, they might not grow properly. As an aside, the unbalance of hormones is likely part of the reason why lack of sleep can lead to obesity--the body produces hormones to increase alertness, which promote deposition of fat for future use.

So clearly sleep is important. But how much do we need?

The amount of sleep we need is entirely based on age. Infants sleep most of the day, while adults only need 8 hours or so. Infants also don't sleep at 'normal' times, because they are accustomed to being in the womb and rocked to sleep while mom was awake and walking, and awake when mom was resting. When adults don't get enough sleep, they tend to develop quick tempers and have low energy. When children don't get enough sleep, though, they tend to become hyperactive. Many parents have experienced this with infants that cry more when they aren't put to bed on time.

By two months of age or so, the circadian rhythm starts to develop. This is our body's innate way of telling time, and is based on light clues. In a completely cut-off environment, a normal circadian rhythm lasts about 25 hours. Of course, we don't live in a world where the day is 25 hours long, so this is where the light cues come in.

One of the first things we, as pediatricians, do when we hear a child is not getting enough sleep is to ask about sleep hygiene. Where do you sleep? What time do you go to bed? What time do you get up? What else is in your room?

Lack of light triggers the release of melatonin, a hormone that helps us feel sleepy and fall asleep. If your room is filled with light, even lights from computers, iPads, televisions, etc, you could inhibit your release of melatonin and have a harder time falling asleep. So, one of the first things we recommend is to get those computers and televisions and whatnot out of the bedroom. Even if you don't use them right before bed, the lights that stay on can influence your melatonin production. You can also condition yourself unintentionally into not associating the bedroom with sleep, but rather with activity.

Getting up and going to bed at the same time every day, even on weekends, can also help your body just get used to going to sleep at the same time. I realize this isn't ideal for adults, but there's no reason kids shouldn't have a consistent bedtime.

Finally, as we get older (by early elementary school), our sleep cycles become more consistent and average out to 90 minutes each. Waking in the middle of a sleep cycle can be very disorienting, and can make you feel tired all day. So, bedtime and alarms should be planned so there is a multiple of 90 minutes in the sleep time. In other words, you should try to ensure you are getting 6 hours, 7.5 hours, 9 hours, or 10.5 hours of sleep (depending on age, with younger kids needing more sleep), rather than 8, 10, or 6.5 hours.

This is only an introduction, and I'm sure I'll talk about it more in the weeks to come, but to not bore you too much, I'll leave it there for now.

Have additional questions? Leave them in the comments!

Yes, All Women...

This happened after I posted my blog post last week, and rather than take it down and post this one to make it timely, I decided to wait a week and see what sort of clarity that brought to the situation.

On May 23, 2014, there was a shooting near the UCSB campus in California. Elliot Rodger was identified as the shooter, and he killed his three roommates, two young women in a sorority, and a bystander before taking his own life. Thirteen other people were also injured. Prior to his killing spree, he posted a Manifesto and YouTube video explaining that he was doing this because he had been shunned by women. Because he did not feel he had gotten the attention he deserved, as a male, from women his age. How he hated other men for getting that attention.

Evidently, there was a cry of support for Rodger's actions on some social media sites, some even stating that more young women needed to die because feminism was destroying society. In response, Twitter started trending #YesAllWomen, essentially an outcry against rape culture and victim blaming. This hashtag trended for at least 4 days, and has sparked plenty of discussion since. If you haven't read any of the tweets yet, I encourage you to stop and do so now.

As a young woman, I've experienced this rape culture myself. During my first year of medical school, I went to a bar with some girlfriends. It was crowded, and we easily got separated. A guy came up to me and asked if I wanted to dance. I turned him down, and went to seek out my friends. He came up to me about 5 minutes later asking if I was here with someone. I gestured to my friends and moved away. Still a third time, when I was dancing, he came up and started dancing with me. My friends quickly moved me to the inside of our dance circle. Thankfully, that was the end of it.

A friend and I were walking to a bar with her boyfriend. We had to walk through a less than desirable part of town. Down the block, on the opposite side of the street, a lone man was standing, watching us. We continued on our path and actively had to block my friend's boyfriend from crossing the street near the man: he had not noticed the man standing there.

In my town, we get an e-mail whenever there is a report of violence near the University campus or involving University students. Nine times out of ten, probably more, the victim is female. For instance: "The victim was walking [after dark] when an unidentified male approached her from behind, putting an arm around her neck and fondling her breast and genitalia with the other hand." "The victim reported she was sexually assaulted after being forced into the bathroom of the apartment where she was attending a party."

Young girls are taught to never go out alone, to always order their own drinks and not leave them unattended, to dress conservatively so as to not draw attention to themselves. We're taught to use the line 'I have a boyfriend,' or give out a fake number when we're not interested in a guy, because 'no' isn't good enough. It's the reason I'm not okay with going out by myself at night, but my male friends don't think twice about it. It's the reason my dad gave me pepper spray when I was in high school.

How prevalent rape is in our society is debatable, because many believe that it is grossly underreported. However, the CDC cites that roughly 1 in 5 women report being sexually assaulted sometime in their life. In a surprising statistic that I will expound more on at a later time, over 50% of the time, the perpetrator is an intimate partner. Men are not victimless either, as 1 in 71 men also report being sexually assaulted during their lifetime.

The lesson? A girl is not 'asking for it' by wearing a low-cut or high riding dress. She's not asking for it by having a bit too much to drink. She has the right to walk down the street, day or night, without getting catcalls or being fondled, or worse, raped. We need to have real punishments for those who violate the personal boundaries of others. We need to empower those who are victims and allow them to tell their stories without feeling shame. Men and women alike need to take these lessons to heart, as women can be just as bad as the men in perpetuating the victim-blaming.

Most social media campaigns do little to change the status quo, but I have a feeling that the popularity and insight this one has produced will change something, even if it's just getting a few men more interested in the lives of their female friends and family members.

This is not about blaming men. This is about getting the good ones to help us fight back enough that women don't need to feel this way anymore.

Race and Medicine

I'm taking a bit of a different turn this week, spurred on by an article I read recently, and some discussions we've had among our classmates. There are two prongs to this discussion: first, the concept of race or ethnicity in health, and second, the role of the medical provider in ethnic communities.

One of my classmates was African. As in, she immigrated from Central Africa (I, sadly, forget the exact country) to the US, and much of her family still lives there. During the first two years of medical school, when we were learning about various diseases that can afflict people, she became irritated with the idea that race and certain diseases had a correlation. She felt that we should be race blind, because it's impossible to tell someone's background by just looking at them.

In some ways, I see her point. Race is a human construct. It is more useful to define people by culture than by race, as there is more genetic variation within a given 'race' than between them. And with how open we've come to interracial couples, it really is hard to determine someone's race by simply looking at them.

But, at the same time, there is a correlation in several diseases, and race or ethnicity can help us narrow the list of diseases a patient is likely to have. For instance, individuals descended from Africans are more likely to have sickle-cell disease. Why? Because malaria is very prevalent in Africa, and there is an evolutionary advantage to having sickle cell trait, as it protects you from dying from malaria. But, when two people with sickle cell trait have a child together, there is a 1 in 4 chance of their child having sickle cell anemia, a disease that can cause loss of limbs and intense pain. If you are descended from an Ashkenazi Jew (Jews who lived in northern and central Europe), you are far more likely to have a number of diseases, including Tay-Sachs (a disease that causes multiple problems with the brain) and breast cancer, just to name a few. This is because the Jewish population of Europe had a great deal of intermarriage, partly due to religion and partly due to various anti-semitic pressures in the area. Even Caucasians are not immune to this racial bias, as Cystic Fibrosis is 4-5 times more common in Caucasians than in African Americans, and is even more rare in Asians.

All these are genetic diseases. What about those that aren't genetic? According to the CDC, non-Hispanic black patients are 50% more likely to die of cardiovascular disease than their non-Hispanic white counterparts. Adult diabetes is much more common in Hispanic and Native American populations than it is among white and Asian populations. A good portion of this is due to socioeconomic pressures; you're more likely to develop diabetes if you live in a low-income neighborhood than if you live in an affluent neighborhood, likely due to the access to fresh and healthy foods. Some of it is due to healthcare access: either these individuals cannot afford proper healthcare, they don't have access to the proper healthcare, or they choose not to seek healthcare due to cultural norms.

In this sense, I think ethnicity is a very important part of medicine.

Recently, I have heard discussions over medical school admissions and what role race should play in these decisions.

See, in many cases, patients reportedly like doctors of the same race as them. Thus, black patients prefer black doctors, Hispanic patients prefer Hispanic doctors, etc. There are many reasons for this; there is a certain distrust of the US medical system, and specifically white physicians, among black patients, thanks to experiments such as the Tuskegee Syphilis Experiment, there are subtle differences in culture, such as how patients perceive and express pain, etc. Even my own classmates have noticed that when they speak to Hispanic patients in Spanish, even if the entire interview is not conducted in Spanish, the patient tends to open up more and express their concerns more. Whether this actually helps in all cases is debatable.

So, the goal among many medical schools is to train a more diverse student body, to train more black and Hispanic physicians, rather than white and Asian or Indian physicians, in order to better meet the needs of these underserved populations. The degree to which race plays a role in medical school admissions is uncertain, based on what I've heard from friends on admissions committees. But there is no doubt that it does play some role. Some argue that this tactic is necessary in order to develop more mentors in underrepresented minorities, so that more of these individuals will enter medicine in the future. Others argue that it's a poor way judge a person's experiences, in that an African American from a well-off family will have a much different experience than a white person from a poor family, but the African American will naturally be judged to have better experiences thanks to the color of his skin. In essence, it's attempting to combat racism with racism, and is not the best way to go about things.

I'm not sure what the answer is from that front, but I do have no doubt that some people are inherently more comfortable with people from similar cultural backgrounds. Whether we should select medical school candidates based on that trait--I don't know, but I don't have a better solution for the fact that African Americans, Hispanics, and Native Americans are less likely to make it to the level of med school than a white or Asian person.

Racism, even 'benign' racism such as that we use in medicine, is still prevalent in our society today. It's not going to be an easy fix to change that, but I think we're trying. Hopefully within the next generation, this won't need to be a topic of discussion any longer.

Differences in Expectations: A Tale of Two Countries

As I mentioned a few weeks ago, I spent a few weeks studying in another country. It was actually my last two official weeks of medical school, and I went and spent time at the Hospital Nacional de Niños in San José, Costa Rica. My first day on the rotation, we sat down with our supervising physician and talked about the similarities and differences in health care in Costa Rica and in the US. He had experienced both systems, having done his fellowship training in the US before returning to Costa Rica to practice. Since I was privy to this discussion (and since I'm graduating today and have a lot of other things on my mind), I thought I might share some of the points with you.

First and foremost, medical education. I told you all about the system in the US back in my first post. So, how does it differ? As in most foreign countries (many European countries included), students enter medical school right after high school. Depending on whether they go to a public or private school, the schooling lasts for 5-6 years. The first two are spent in the classroom, and they spend the next four doing various clinical activities. The final year is referred to as their internship, and is similar to our first year of residency, except they aren't specializing. They spend 3 months each in Internal Medicine (Adults), Surgery, OB-GYN, and Pediatrics. After this schooling, they can choose to work as a general practitioner, or they can elect to do a residency. The residency could be in either Costa Rica or the states, though it is more difficult for them to get into residency in the states due to the licensing requirements. Competition for the residency slots is tough, and really the best and brightest are the ones who end up doing residency.

So, similar, but different.

Where things get really interesting is how the health system is set up. They have health care for every citizen. It's funded by a 10% tax on the citizen's paycheck--the employee pays 5% and the employer pays another 5%. The government matches this 5% contribution, so, in essence, 15% of each citizen's paycheck, regardless of what they make, goes into the Seguro Social. These public hospitals are set up all over the country. Primary care offices are the first line to the citizens, and in theory, the Primary Care offices know everything about the patients in their neighborhood. Then, there are the hospitals: primary, secondary for more advanced or specialty care, and tertiary. The Hospital Nacional de Niños is the only tertiary children's hospital in the country; the secondary hospitals have pediatric floors and some specialists, but the complex kids all get referred.

Under this system, everyone gets the healthcare they need. They may have to wait for it if there are more urgent cases to be seen, but everyone eventually gets what they need. A truly social system. Of course, they've also developed a private system on top of the public system, where you can go and get things done faster if you have the money for it. And, because they increased the government funding to healthcare, they elected to abolish their military, relying on international courts to resolve disputes with neighbors.

It was a little amusing to talk about the health systems to the students and residents, because everyone seems to be so astounded that the US, a first world country with a better standard of living than Costa Rica, doesn't provide healthcare to everyone. We are, of course, in the process of changing that now, but it's still in infancy.

A few more interesting tidbits more specific to pediatrics. First, which astounded me, particularly after last week's post, was that parental refusal of vaccines is a justifiable reason to call social services. In other words, they've deemed vaccines so important that they will overrule parents in whether or not their child gets the vaccine. If we did that in the US, we wouldn't be seeing these outbreaks.

Second, their age range for pediatrics is very different. In the US, Pediatricians care for children from infancy up through college-aged, sometimes well into their 20s depending on their overall health. When I was working in our Pediatric Emergency Department (I am not currently in a stand-alone children's hospital, so our Peds ED was attached to the adult ED), we'd see patients all the way up to 26 or 28, depending on who was working. In the PICU, they took a harder cut-off at age 18.

But in Costa Rica, they start transitioning over to the adult physicians at age 13. Which does make some sense--adolescents are more like adults than they are like infants--but they still aren't small adults. I'm not sure where this age came from--whether it was due to a lack of pediatricians or a universally decided on age, but it's interesting none-the-less.

Then, of course, the mix of diseases is very different there. I spent a week working in the Pediatric Endocrine clinic, and saw a grand total of 2 kids with diabetes while I was there. Contrast to my month on Pediatric Endocrine here, where 2 full clinic days per week were dedicated to kids with diabetes (only one full day was dedicated to other endocrine disorders). And I saw a couple patients with Bartter syndrome, which is apparently most frequent in Costa Rica.

They also have stricter laws on abortions, though I didn't delve too much into that discussion, so I'm not entirely sure what those laws are. But I do know that it is not legal to have an abortion due to a prenatal diagnosis of Down Syndrome.

Overall, they seem to have a well run health system. They do most all the same things we do, with some minor differences in tests (hypoglycemic growth hormone stimulation test instead of arginine). They do not have the same number of nurses (1 nurse per 4-5 patients in the NICU), so their NICU was much louder than I was accustomed to. They have slightly different instrumentation and ways of sterilizing, but still maintain aseptic technique and clean religiously. Based on my perception, I wouldn't deem them a third-world country. Maybe a second-world country, because they aren't quite up to the first world yet. But they're getting there, and seem to have made great strides.

Plus, it's an absolutely beautiful country.

Vaccines: Building Our Immunity One Shot at a Time

I hope I'm not just preaching to the choir with this post, but I feel like I can't have a blog written from the Pediatrician's perspective and NOT talk about vaccines. It's too big a part of our practice.

Vaccines truly form one of the cornerstones of a pediatric practice. They are among the few interventions that are cost-saving. One of the others is providing clean drinking water. In the US, we have a schedule of vaccines for all children, and will provide them to everyone because they are cost-saving. These include Hepatitis A and B, Diptheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Polio, and Chicken Pox. It is because of these vaccinations that polio no longer exists in the Western Hemisphere (the reason it has not been eradicated in the Eastern Hemisphere is because there is resistance to vaccination efforts), and partly the reason smallpox only exists in labs.

And yet, despite all the data showing that vaccines work, there is a huge anti-vaccine movement in industrialized nations. Organizations such as the Vaccine Liberation and the Think Twice Global Vaccine Institute advocate to parents not to get their children vaccinated.

Don't get me wrong. I'm all about informed consent and vaccine safety. I think all vaccines should be rigorously tested before they are given to millions of children. I think vaccine reactions should continue to be monitored, and that vaccines aren't necessarily a one-size fits all thing. There are some children who can't get vaccines, either because they are allergic to something in the vaccine itself, or because they do not have a strong enough immune system to make the vaccine effective (or worse, they could contract the disease if a live vaccine is used). But, considering that, all children who are able to get vaccines should, in order to protect those who can't. When the healthy population doesn't get vaccinated, they serve as possible source of infection to those children.

Let's look a little more in depth into their arguments.

First, the supposed link with autism. While this could be a blog post in and of itself, let's run through a quick history of this argument. Back in 1998, Andrew Wakefield, a surgeon from the UK, published a paper in Lancet, a well renowned medical journal, claiming that MMR vaccines had a link to autism. Around this same time, the FDA published guidelines requesting the removal of mercury based products from foods. Thiomersal, a mercury-based solvent and preservative, was being used at that time in several vaccines, and the CDC and AAP requested vaccine manufacturers to remove it. Note that these two episodes were linked in time, but not by anything else. In the ensuing decade, thousands of studies have been done. None have been able to replicate Wakefield's results, and none have shown harm to thiomersal, though it is no longer used in vaccines. In 2004, the Lancet partially retracted Wakefield's paper, after Brian Deer (a reporter in London) demonstrated that there were conflicts of interest that were not disclosed. Then in 2009, Deer determined that Wakefield had actually falsified much of his data. In 2010, the Lancet fully retracted the paper, and Wakefield was banned from practicing medicine by the General Medical Council in the UK.

Moral of the story: vaccines do not cause autism. There has not been a single study that shows that it does. The vaccine schedule is set up in a way that children are going to have developmental changes shortly after administration of the vaccines. That's what happens when kids get older.

Vaccine Liberation makes the claim that cleanliness can prevent all diseases, and 'proves' this with graphs showing that the death rate of several vaccine-preventable diseases and several where there is no vaccine available. The primary problem with these graphs is that they only look at death rates. Death isn't what we're concerned about in most cases. Polio, for instance, causes paralysis. We can prevent death through a variety of interventions, including the ventilator. It's the paralysis that we want to prevent. Mumps? It rarely causes a complication resulting in death; we give the vaccine to prevent inflammation of the testicles or ovaries, which can result in infertility. It also just doesn't sound like a fun illness to have. Complications from measles are more common, but it's especially bad to be pregnant and exposed to measles (same with chicken pox; most complications are in pregnant women). The graphs don't take into account any of these complications; they just look at the death rate.

Think Twice claims "Recently vaccinated children do carry the disease germ and are able to spread it to other children. Many so-called epidemics are initiated and spread in this manner, even though the unvaccinated are blamed." It is true that some vaccines are live vaccines, meaning that the virus was altered to cause an immune response, but not disease, and the virus itself is still functional. These vaccines tend to be more effective than other vaccines, because they act more like a disease-causing virus than the segments that are used in the inactivated or subunit vaccines. These include the varicella (chicken pox), oral polio, and MMR vaccines.

However, the idea that children can spread disease after getting these vaccines, especially that this accounts for most of the cases of these diseases, is incorrect. Most measles cases are imported, meaning that they were brought back from people traveling overseas, usually to Asia. These were most commonly unvaccinated people who contracted the illness, though some vaccinated people remain susceptible. Of course, the recent outbreaks of measles may change that assumption in the near future.

This post is already getting long, so I'll end it here, but if you know of any other arguments against vaccines, please feel free to bring them to my attention and I will do my due diligence in examining the data. But in the meantime, please vaccinate your children. For the good of society, and for their own health.

Need more evidence that parents not vaccinating their children is causing harm? Check out this map. It shows the vaccine-preventable diseases Measles, Mumps, Rubella, Polio, and Whooping Cough (Pertussis) on a world map where all the epidemics are occurring, along with how many cases are in each epidemic.

To Cut or Not To Cut: The Debate Over Circumcision

Apologies for the hiatus. I went on an out-of-country vacation and due to everything else going on leading up to it, I didn't have the opportunity to write-up posts for when I was gone. This one was actually supposed to be published on 4/20, but I didn't actually finish it, so you get it today instead.

This has come into press a lot more than I expected it to lately, so I figured it was good enough for another topic. Circumcision has been around for thousands of years. Traditionally, it was a way of distinguishing the Hebrews from everyone else, but in Western society as a whole, it has become fairly popular. In fact, in the US, we had a rate of 83% circumcision of newborn males in the 1960s. This has declined to 77% in 2010, but this is still high compared to, say, Hispanic cultures (44% of Hispanic men in America are circumcised, compared to 91% of white men), and may be more reflective of the population of the US than a change in attitudes about circumcision.

The main argument against circumcision is that it is a surgical procedure that has lifelong consequences and only serves a cosmetic function. Some will go to the point of comparing it to female genital mutilation. Others will argue only that it is an issue of informed consent, and that males should be able to make the decision for themselves when they reach a certain age. This particularly argument is usually rebutted with the fact that parents make many decisions for their children, medical or otherwise, which have more notable consequences than the presence or absence of a foreskin.

The primary argument for circumcision is that it reduces the risk of a variety of diseases, including early urinary tract infections (which can lead to renal scarring), the transmission of HIV, and the risk of penile cancer. Most of the studies looking at the transmission of HIV were done in subSaharan Africa. These studies were so compelling that they were stopped early, and demonstrated a 66% decrease in the HIV transmission rate. Granted, these studies were done in adults. But, circumcision in infant boys is generally considered to be less costly, easier to perform, and safer than adult circumcision, so if it poses such a great benefit later in life, it'd be best to do it in infancy.

It should be noted, however, that the advocates for circumcision do not claim that it reduces all sexually transmitted diseases. One study shows that there is no difference in Herpes (HSV-2) transmission in circumcised vs uncircumcised men.

Currently, physicians take a more neutral stance. The AAP states that circumcision has benefits that outweigh the risks, but that the benefits are small enough that it's up to the individual families on whether or not to do the procedure. In the past, the AAP has taken a more negative view of circumcision, claiming in the 70s that there was no medical benefit to circumcision, but not taking a stance against it. However, there are those that take a hard stance one way or the other: one compares circumcision to vaccines, believing that the benefits are so great that circumcision should be routine.

What are your thoughts on the matter?

Eating Right: How to Read Nutrition Labels

A young boy comes into clinic, concerned about his weight. He's above the 95%ile for weight, so qualifies as being obese. His mother is thin as a rail, so there is likely some genetic component from Dad's side playing in, but he wanted to know ways to reduce his weight. Other than giving him the general schpiel about good nutrition, his mom wanted me to talk about how to read a nutrition label.

When I first heard this request, I was a little confused. After all, I had learned how to read a nutrition label way back in elementary school. I usually don't unless I'm directly comparing two products, but I know how. Have things really changed so much that this isn't taught anymore?

Compounding this, you may have heard the news from a couple months ago that the FDA is considering a change in how nutrition labels are organized. Personally, I think the new recommendations are great: they put greater emphasis on things that a lot of people have difficulty with with the current label.

If you haven't had experience with this, I'll try to start basic. If you have, then skip down a bit to read some of the common pitfalls people have when reading labels. Those are useful to review even if you read the labels themselves all the time.

Let's look at a basic label now:



The first thing listed on any nutrition label will be the serving size. This determines how the rest of the label is read, and is the source of problem with most Americans. See, we don't really have a good concept of a serving size. An easy example is bread: one slice of bread is a serving size, but most people will have two at any given time (a sandwich), and consider that to be one serving. A serving of chicken is about the size of a deck of cards. The serving is not a glass of milk, it's 8 oz. Most adult glasses fit at least 16 oz. So, pay attention to this size, and when in doubt, measure it out.

The next line reports servings per container. This is useful to helping determine the serving size if you aren't able to measure it out. A Gatorade bottle, for instance, typically contains 2.5 servings of Gatorade.

Next up is what a lot of people get hung up on: the calories. Scientifically speaking, a calorie is a measure of how much energy something provides. We know that carbohydrates, like sugar and flour, give us 4 calories per gram, as does protein like chicken or steak. Fat, on the other hand, provides 9 calories per gram. Alcohol, for those interested, falls somewhere in the middle at 7 calories per gram.

Calories are a great way of measuring how much you eat. It allows you to compare foods, and eat better by having less calorie dense foods. But they are not the be-all-end-all to weight management.

Below the solid line, the food gets broken up even more. We start to see a column for % Daily Value, essentially how much of what it recommended daily is contained within this one food. In the case of fat, sodium, cholesterol, and sugar, we want that percentage to be low. Keep in mind, you still need some of these things to function properly, so I am absolutely not advocating only eating non-fat or non-sugar foods. Just to keep them low. One person has suggested less than 5%, but this may not always be possible. Definitely, you should keep these below 20% in one serving.

Some things, though, are actually good for you, and you may want to increase your intake of them. Fiber is the most commonly listed in this category--you need fiber to help keep your digestion regular, and most Americans don't get enough fiber in their diets. This is one that it'd be impressive if there were 20% or more of your % DV.

Lower down, there is usually a list of vitamins. Labels present these in different ways, some listing the actual amount per serving and others only listing the %DV, but again, these are ones you want a high value of. It's not necessary to get 300% of a certain vitamin, but 20% is great for a serving.

Now, some of the things that labels can trick you about.

1) Low fat foods
- Be wary and really look at the label when you see this presented on a package. Most often, the food will be manufactured to include more sugar to make up for the lack in fat, which may actually be worse for you than the fat in the first place.

2) Whole grain!
- I was reading a label the other day, trying to decide between what was essentially regular Wheat Thins, and ones made with 'whole wheat'. The fiber content is what is really affected by using whole vs. processed wheat, but there was only 1 extra gram of fiber per serving with the whole wheat variety. What was different was the amount of sodium (salt) was nearly triple what the regular wheat ones were! Not worth it.

Those are the two most common ones I see. Do you know of any others? Tell me about them in the comments below!

I hope this was a useful exercise for some of you. Hopefully, the FDA's proposed label changes will go through and make it easier for everyone to interpret these labels.

Expressive Writing

I'm at a Medical Humanities Conference this weekend, so I felt it was appropriate to talk a little bit about what I've learned. It's' been a lot of things like Yoga and self-reflection, and mainly focused on student wellness, but we've also talked about expressive and narrative writing, and how to go about this. My favorite session was by Nancy Morgan, from the Georgetown Lombardi Cancer Center, who talked about the effects of expressive writing in cancer patients. It made me think about whether the same effects would be seen in pediatric patients, and I think if it hasn't been studied yet, that might be a project I work on.

So, for this post, I'm going to delve a little more into expressive writing: what it is, and what benefits have been reported.

In a nutshell, expressive writing is the writing of emotions. It is intensely deep and personal, and focuses much more on feelings rather than facts. Basically, it's what people think of when they consider a diary or a journal of some type.

Expressive writing has been studied extensively in the past 20 years or so. The pioneer of this research is considered to be James Pennebaker, who has focused his research on traumatic experiences and expressive writing.

Since it is an emotion-based activity, the short-term effects of the writing often include heightened distress, increase in negative mood symptoms, and a decrease in positive mood symptoms. However, the long-term effects can include fewer doctor's visits, improved lung and liver function, reduced blood pressure, improved mood, reduced absences, better working memory, etc.

However, it should be noted that the act of writing itself is not what causes the benefit. Expressiveness was determined to be the deciding factor on whether it was beneficial, with individuals with high expression benefiting more than individuals with low expression. This study concluded that having patients not likely to express their emotions naturally take place in this exercise may actually be harmful, but this is something that may be hard to assess in someone who hasn't written in the past.

Of course, most of these studies looked at 1) traumatic events, and 2) controlled environment with 15-20 minute writing exercises for 3-5 sessions. Nancy Morgan, though, decided to push the conclusions a bit--she had cancer patients write for 20 minutes in a clinic setting--with interruptions and everything included. Essentially, she wanted to look more at real-life scenarios. Participants only did one writing exercise, and were evaluated before and after the exercise. Under these circumstances, patients reported an improvement in perceived quality of life, indicating that it'd be a very useful exercise for these patients, and their caregivers.

Anecdotally, she also reports that the same effects can be seen even if the patients themselves are not the ones writing. In patients who are illiterate, whose stories she is copying down, they have the same overall benefits of the expression than those who are able to write.

So, if you're feeling a little stressed, turns out writing it out in a journal may actually be a good thing to do.

E-cigarettes? Viable alternative to smoking?

Let me start by saying smoking is bad. You shouldn't do it. Period. I wouldn't be doing my due diligence as a physician if I didn't say that out front. Now that we've established that, let's talk about e-cigarettes.

Why does this matter for pediatrics? Simple. Second-hand smoke is a serious problem with kids, to the point where it can severely damage their overall health, especially if they have diseases like asthma. So, at every single well-check, we ask about smoke exposure. Most people I've dealt with seem to have gotten smart and are at least limiting smoking to outside and not in the car. This is a huge reason why there has been such an effort at eliminating smoking in the workplace.

Enter e-cigarettes. They were developed in the early 2000's as an alternative to smoking. Essentially, there's a liquid cartridge with nicotine and other staff that is heated by a coil and inhaled by the smoker.

Lots of concern about e-cigarettes has hit the news recently. So much that one blog post probably won't do it justice, but at least I can attempt to hit the high points. So, let's play a game of myth or fact?


1. E-cigarettes reduce smoking.
Myth.

One study done in September demonstrates a very small percentage of people were more likely to quit using e-cigarettes vs nicotine patches. The effect was very small, with only 1.5% more e-cigarette users quitting after 6 months. What's more, the confidence intervals (CI) crosses 0, which means the difference wasn't really a difference.

Another study in JAMA Internal Medicine shows a similar result: no difference in quitting between users of e-cigarettes and users of conventional cigarettes.

However, a study done in JAMA Pediatrics that hit the press earlier this month shows that e-cigarette use has doubled in teens in the past few years, and about half of current e-cigarette users also smoked conventional cigarettes. In fact, those who smoked conventional cigarettes were more likely to have tried e-cigarettes in the past. This goes against the claim that e-cigarettes are good for quitting smoking.

The increased usage might have something to do with the fact that while ads for cigarettes have been banned for 40 years, there is no ban in place for e-cigarettes, so an ad for such a device actually ran during the Super Bowl this year. It doesn't help that only about half states have bans against minors buying e-cigarettes, and there is relatively little attention to buying them online.


2. Second hand exposure from e-cigarettes is better than regular cigarettes.
True.

A review looking at several studies examined this question from the perspective of occupational health. That is, if an industrial worker was exposed to the same chemicals in the vapor of an e-cigarette, would this worker be at a higher risk of disease. They did negate the nicotine, since it is legal and the smoker is already voluntarily consuming more than the recommended exposure limit by using the device. It was the secondary exposures that they specifically wanted to look at.

The primary chemicals exposed to with e-cigarettes are propylene glycol and glycerin, which do not have known exposure thresholds, and volatile organic compounds. Polycyclic Aromatic Hydrocarbons are most of the cancer-causing chemicals in cigarettes; these were not found in most vapors.

I don't think anyone doubts that e-cigarettes produce fewer chemicals than regular cigarettes, thus reducing second-hand exposure. What seems to be the big debate right now, and the subject of e-cigarette bans in places like Los Angeles, is whether there is ANY risk for e-cigarette exposure, and the public health implications of encouraging e-cigarette smoking in public.


3. E-cigarettes are safer.
Generally true, as alluded to above, with a few exceptions.

Nicotine in cigarette form is relatively difficult to ingest. Smoking is the best way to do this. However, as I mentioned earlier, the nicotine for e-cigarettes is in liquid form. That makes it much easier to either drink or absorb through the skin, which could cause serious harm, especially to children. The number of calls to poison control centers related to the nicotine liquid went up 300% in 2013.

Why is it so dangerous? Well, nicotine is similar to a chemical naturally used by the body at the point where either two nerves meet or a nerve meets a muscle. That means it can cause any amount of damage to the brain, the spinal cord, and to muscles. Commonly, it affects the GI tract first, and the person gets vomiting, but if it is not caught early, it can result in seizures or other problems with the brain. In a small child, it doesn't take a lot of nicotine to have this effect.


Bottom line is that while e-cigarettes are safer than conventional cigarettes, we don't know the long-term effects of e-cigarettes because they are so new, and they do have unique safety concerns. It took a good 20-30 years before we saw lung cancer deaths spike from the cigarette usage in the 1960s, and it's very possible we'll see a similar rise 20-30 years down the line from e-cigarettes. But maybe not. As I'm pretty sure e-cigarettes are cheaper and generally less toxic, I'd encourage people who are smoking to switch to them, but that doesn't mean I'd encourage their blanket marketing.

Until then, I'll hold to my general recommendations: Don't smoke around kids. Don't smoke indoors or in the car. And when you do smoke, wear a jacket that can be removed when you are done, so you don't bring those chemicals inside with you.

Eating Right: The Moving Target of Good Nutrition

Between the various 'diets' (which should more accurately be called 'weight loss technique') and trends going around, it can be hard to get a good idea of what you should be eating. There are those who say meat is horrible (for one reason or another), others who say you should eat the way of the cave-man. There's the low-fat, the low-protein, and the low-carb fabs. But, really, what should you eat?

In elementary school, I was taught the food pyramid. You know, the one where sugar and salt were at the top, and meant to be used sparingly, and grains made up the heavy base at the bottom. In fact, in 1990, the US government recommended 2 servings of fruit, 3 servings of vegetables, and 6 servings of grain daily, along with a diet low in fats, and especially saturated fats.

Recently, the food pyramid has changed. The new pyramid, referred to as My Pyramid, changed the recommendations some. It placed a heavier emphasis on whole grains (at least 3 servings per day), oils for fats, and fewer meat and more of other sources of protein. It also placed heavier emphasis on physical activity with the stairs on the side of the pyramid.

Even more recently, the pyramid has been done away with completely, in favor of the My Plate method. Personally, this is my favorite way of showing portion sizes during meals, because it can be easily demonstrated with hands. You place your hands together. Your left palm represents the amount of meat or protein you should eat. For smaller kids, it's a smaller amount, and for adults, it's a larger amount. Your right palm represents the amount of grains, such as rice, bread, etc, you should have with each meal. Your fingers, then, represent the vegetables you should eat. You can spread your fingers to get more vegetables, but cannot expand your palms to get more protein or grains. Since most kids don't get enough vegetables on a day-to-day basis, this is a great way of encouraging them to eat more if they are still hungry.

For general child health, we make a few other recommendations. For instance, the dietary guidelines put out by the government only apply to those over age 2. Under that, we recommend whole milk because the children need the extra fat for brain development. Things like soda and koolaid are not recommended, because they provide no vitamins, minerals, or any other nutrients besides sugar. Even fruit juice, which provides some of the benefits of fruits and vegetables, aren't recommended in lieu of the actual vegetables, because you get the fiber and feel fuller when you actually eat the vegetables.

Milk is both good and bad. Kids all need calcium in order to develop strong bones, especially in adolescence. However, too much calcium can also work against you, and decrease the ability of the blood to carry oxygen, resulting in a very tired and potentially sickly kid. So, we recommend a total of 2-3 cups (or 16-24 oz) per day of milk or other dairy products. Another issue we see a lot is that kids who drink a lot of milk will get full, so won't eat as much solid foods, and it is still important once they are past 6 months to a year for them to get other nutrients. And please, no milk at bedtime--it does have sugar that can rot the teeth.

Fiber is also super important. Why? Because all kids are constipated. I've seen so many kids come in with abdominal pain, we get an x-ray, and see their intestines just filled to the brim with stool. I've seen one kid who was so constipated, that he had to get surgery to fix the problem. Fiber comes in all fruits and vegetables, but also whole grains. And when in doubt, Miralax is an amazing medicine.

So, a summary of our recommendations:
- A generally balanced diet, with sufficient protein, fat, and carbohydrates for growth. If they're gaining weight, they're getting enough calories.
- Lots of vegetables, and some fruits. In whole form.
- Limit juices, even fruit juices
- Lots of fiber
- Milk, but in limited amounts and not at bedtime