Are Immunizations Safe?

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The health benefits of immunizations are immense. Smallpox has been eliminated and polio is no longer seen in the United States. Common diseases including tetanus, measles and diphtheria have become rare. The most common cause of meningitis in children is also now rare. Millions of children no longer die each year due to illnesses prevented by immunizations. The most written about downside, autism, has been disproven as a side effect of the MMR vaccine.

One of the problems with immunization success, however, is the lack of visible illness due to these diseases. Parents no longer see the severe health sequellae including life changing illness, mortality or even acute hospitalization due to these diseases. The remarkable success of our immunization program has made it difficult for many parents to see the actual benefits of immunizations. This has led to an increasing number of parents not immunizing or delaying immunizing their children. Measles-mumps-rubella vaccine is the most frequently refused and is followed closely by varicella vaccine, pneumococcal conjugate vaccine, hepatitis B vaccine, diphtheria and tetanus toxoid and pertussis vaccine.

The American Academy of Pediatrics strongly endorses universal immunization. We support immunizing all children and endorse the American Academy of Pediatrics Schedule.

There are many reasons given by parents to not follow the recommended immunization schedule. Some parents disagree due to philosophical or religious concerns and others are concerned about the risks of immunization. When the risks raised by parents are analyzed the claims are found to be unsupported or lower than the risk of sequellae due to contracting the disease the vaccine protects the child from.

As a parent what should you do? Most parents decide to immunize their child. Yet, an increasing number of parents are choosing not to immunize their child. If you decide not to immunize then you are relying on a highly immunized population providing your child with a relatively low risk of contracting the disease. If the frequency of the disease is high, however, then the safety margin for your child is lessened and your child by contracting the illness will place other unimmunized children at risk. In this situation you are making decisions that no longer only effect your child. This community or herd immunity is important for every parent who chooses not to immunize to understand. Your decision can and does place others in your community at risk. Those at highest risk will be young children, the elderly and anyone who is immunocompromised including those being treated for cancer.

We believe our job is to answer all of your questions regarding immunization benefits and risks. We will listen to your concerns and not minimize them. We realize many parents do not use the same decision making criteria that we use and everyone weights risks differently. We explain that vaccines are not 100% risk free or effective, and we will ask you what your concerns are. We will work with you to answer your individual concerns. Our goal is to use our relationship with you as your child’s pediatrician to foster and allow a dialog to discuss the vaccines. We will ask you if you are interested in discussing your decision. If your answer is no then we will document your decision. We will continue, however, to ask you at follow-up health maintenance visits if you have changed your mind about immunizing your child. Our hope is that communication and our relationship will build over time, and you will reconsider a prior decision not to immunize your child.

Some parents ask about delayed or alternative schedules. Many of these schedules have been written about in various publications and on the web. If you ask for an alternative immunization schedule we will work with you to provide the immunizations you choose at the time you choose. We cannot, however, decide for you which immunization to give and when to administer it since all the immunizations are important, and we will not endorse alternative schedules. We will, however, help you decide which illnesses place your child at greatest risk and make sure the immunizations that are given are administered in a way that allows your child to receive the benefits of the vaccine. All vaccines have specific interval schedules between vaccine administration and this can cause altered schedules to be very
cumbersome.

The final decision whether and when to immunize is always yours. We will explain to you, however, that your decision not to immunize is against our advice and we are not responsible for any harm that comes to your child due to an illness contracted due to a lack of immunity. We will not discharge your child from our practice but will discuss any trust or communication issues that arise due to our difference in opinion over immunization administration. Our intent is to work through any of these issues and continue to provide you and your child the pediatric care every child deserves.

Facts About Obesity

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Obesity is defined by using age and sex specific body mass index (BMI) information. The Center for Disease Control (CDC) defines overweight as a BMI at or above the 85th percentile and below the 95th percentile as compared to children of the same sex and age. Obesity is defined as having a BMI at or above the 95th percentile.

For school aged children the average weight gain is 7 pounds per year and average height gain is 2.5 inches per year. When weight increases more rapidly than expected the first step is to look at healthy lifestyle choices including food intake and calorie expenditure. Frequent concerns include sweet flavored drinks, snacks and fast food with a lack of healthy fruits and vegetables. Other concerns can include the intake of whole milk instead of skin milk and general portion sizes.

As a parent you must focus on good health not weight management. A healthy lifestyle will lead to the right weight for your child. Along the way your child will also develop improved self-esteem and a healthy body image. For good health to be sustainable it must be linked to a positive self-image built around the importance of a healthy dietary intake and an active lifestyle rather than labeling a child as being obese or overweight.

By understanding the importance of lifestyle changes your child will develop the consistency and confidence needed to respond to future lifestyle decisions. By involving your child in all the decisions, including cooking and shopping, your child will become competent to manage their own dietary choices.

Physical activity can help this process. Exercise has clear benefits to the heart, lungs and musculoskeletal systems. The addition of 60 minutes of aerobic activity to your child’s daily schedule will also have longstanding social benefits. Aerobic social activities, such as family walks, provide talk and listening time for the entire family.

These family activities allow other family members to share in physical benefits.

Another benefit to physical activity is the association between physical activity and enhanced cognitive and academic performance. At least half of all studies have shown clear benefits including improved concentration, memory reaction time, attention, perceptual skills and verbal skills.

Sudden Cardiac Arrest in Children and Adolescents

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The leading cause of non-traumatic sudden death in children and young adults is sudden cardiac arrest (SCA). There are numerous causes including structural, electrical, muscle and metabolic causes. Early recognition and diagnosis can be difficult. Many children and young adults who experience a SCA have had warning symptoms or a family history of premature cardiovascular disease. This makes it essential that all children be screened with a comprehensive family history and a thorough physical examination.

The focus during routine well-child visits is not on the detection of cardiovascular warning signs. Most well-child visits focus on health promotion, disease prevention, anticipatory guidance and some level of disease detection. An increased emphasis on cardiovascular disease prevention is essential and this is especially important for pre-participation physical examinations for sports.

Although between 50% and 80% of all athletes who experience a SCA did not experience previous symptoms, those that did have symptoms reported some of the following: dizziness, chest pain, fainting or syncope, palpitations and shortness of breath. For those children and young adults lucky enough to have symptoms these complaints cannot be missed. Similarly, a family history of sudden death from a cardiac cause must be looked for.

Although not everyone who experiences a SCA will have a warning sign those that do must not be missed. It has been reported that if the following risk factors are looked for up to 1/3 of all of those at risk could be detected. The risk factors include: history of syncope (fainting), history of unexplained seizure activity and a family history of sudden death caused by heart disease at an age younger than 50 years.

Many children experience syncope (fainting) that is triggered by prolonged standing, fear, excitement or the sight of blood. This is called vasovagal syncope and is associated with symptoms prior to fainting. Symptoms include lightheadedness, dizziness, sweating, nausea and tunnel vision. Children who experience cardiac syncope do not have these symptoms and usually experience a sudden collapse without warning. This is due to a potentially lethal heart rhythm abnormality. It is important any child with a history of syncope receive an electrocardiogram (ECG) and a thorough history.

Any syncope that occurs during exercise must be treated with caution. These children and young adults require a cardiac consultation and other testing including a cardiac ECHO, stress ECG and possibly advanced cardiac imaging.

Seizures can occur in association with a SCA and is due to the sudden loss of brain perfusion. The child will collapse and then develops some involuntary body movements after several seconds. If the loss of consciousness is due to seizure activity the muscle movements begin at the same time there is loss of consciousness.

It is important everyone is aware of the risk for sudden cardiac arrest (SCA) so that improved aware can allow ominous warning signs to be recognized early and prevent death or injury to many children.

Football Injuries

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Football has the highest frequency of injury for high school sports. Head and neck injuries, heatstroke and musculoskeletal injuries are very common. The risk of repetitive minor brain injuries is also a major risk. Sport related head injuries make up over 20% of all traumatic brain injuries in children and adolescents. Although there are education and safety programs concerning sport injuries the risk of injury and death has not decreased. Between 10 and 15 children die each year from sports related injuries.

40,000 high school players suffer concussion each year. A concussion is a traumatic injury to the brain where a mechanical force causes direct disruption of brain function. It is associated with changes in metal status and does not need to be associated with loss of consciousness. If a child has a concussion a CT scan of his or her brain is normal. Only in cases where there has been bleeding within or around the brain or swelling of the brain would the CT scan be abnormal. This can be seen in cases of subdural or epidural hematomas. These events are frequently life threatening and require immediate intervention.

Long-term effects of repetitive brain injuries have been identified. These include an increase frequency of memory related diseases such as Alzheimer disease, depression and even brain atrophy. Studies of professional football players have strongly supported this link between repetitive minor brain trauma and long-term health problems. The risk of Alzheimer disease in professional football players aged 30-49 is almost 20 times higher than the general population.

Up to 15% of football payers each year receive neck and spine injuries. These injuries are the result of excessive flexion or extension of intervertebral joints. This leads to secondary injury to muscles, ligaments, discs and nerve roots. Pain can range from mild numbness or stinging to severe radiating pain. The pain may be at the site of the injury such as the back or shoulder or it may extend down an arm or a leg. Often the pain is not associated with muscle weakness and is related to muscle spasm. Gait changes and joint movement limitation are often seen and are usually due to pain or discomfort. Pain or weakness symptoms may begin immediately or may be delayed due to secondary problems due to swelling and inflammation.

Neck injuries can involve direct damage to the cervical spine or alignment of the spine. These injuries are often due to a force being directed to the top of the head and transmitted down to the neck during a tackle. Such a tackle is called “spearing” and can lead to permanent paralysis. If such an injury occurs during a game or in practice then extreme precautions are taken to immobilize the head and neck until appropriate radiographic and physical examinations have been performed.

Another type of neck injury is damage to the disks between individual vertebras. Chronic injury to the neck often leads to degenerative disc changes and long-term problems with pain, muscle function and gait.

Musculoskeletal injuries involving the extremities are common. About one-third of all limb injuries in childhood are sports related. The most common knee injuries include damage to one or more of the four ligaments that stabilize the knee. These are the medial collateral ligament (MCL) that stabilizes the inside of the knee; the lateral collateral ligament (LCL) that stabilizes the outer knee; the anterior cruciate ligament (ACL) the stabilizes the knee from rotating and slipping forward and the posterior cruciate ligament (PCL) that stabilizes the knee from rotating and slipping backwards. Often ligament injuries occur together. It is common for the ACL and MCL to be torn as well as the meniscus. When the meniscus is damaged this is called a tear. The knee meniscus is a C shaped cushion that the knee bones rest upon. A PCL injury is usually due to hyperextension of the knee or results from a flexed knee being forced backward causing direct damage to the PCL.

Traumatic injuries to hands, wrists, fingers, hamstrings, toes and shoulders are common as are overuse injuries to the iliotibial (IT) band. The IT band extends from your hip down across your knee on the outside of your leg. It stabilizes your knee and hip during running and can become irritated from rubbing on the bones on the outside of your knee. Pain is common on the outside of your knee and can run up the outside of your knee extending to your hip. Muscle strengthening exercises and stretching are often prescribed as are cold and rest.

When your child engages in any sport the best way to prevent injury is with proper preparation, proper guidance and the proper use of appropriate equipment. Injuries can and do happen even with the best preparation. Exercise and movement are needed for your child to grow into a healthy adult. At the same time you must make sure your child avoids and recognizes injuries and obtains proper treatment when injured.

Adolescent Preventative Care

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Preventive care includes advice and information concerning physical growth and development as well as social and academic issues. Topics include a balanced diet as well as the importance of physical exercise and ongoing health maintenance activities including immunizations. School and after school activities are also important as are discussions about violence and injury prevention. Specific risk reduction topics include the use of tobacco, alcohol or other drugs as well as sexual practices.

One of the easiest ways to reduce risk in adolescents is through appropriate immunizations.

The HPV (Gardasil) vaccine prevents certain HPV types (HPV types 16 and 18) that have been associated with cervical/ vaginal cancer in women, penile cancer in men and anal and oropharyngeal cancer in men and women. It is a three dose series that is given at age 11 or 12 years and then a booster is given 2 and 6 months later. There must be at least 2 months between the first dose and the first booster and 4 months between the first booster and the second booster. A longer period can occur between doses but the adolescent is not adequately immunized until all three immunizations have been given. It is recommended for males and females.

The MCV4(Menactra) vaccine is a meningococcal conjugate vaccine that protects against 4 of the 5 serotypes that affect humans.

The Tdap (Boostrix) vaccine is a combined tetanus, diphtheria and pertussis vaccine that includes a pertussis component to prevent whooping cough.

The last vaccine is influenza vaccine and should be administered to everyone over 6 months every year.

If any immunizations have been missed they need to be administered to allow the adolescent to “catch-up”. This includes a three shot hepatitis B (HBV) series as well as inactivated polio series for those younger than age 18 years. Two doses of MMR and Varicella vaccine should also be verified. A two dose hepatitis A vaccine series (HAV) is also recommended for all adolescents.

If the adolescent is immunocompromised a pneumococcal vaccine is also recommended to prevent invasive pneumococcal disease. A booster dose of MCV4 (Menactra) is recommended 5 years after the initial dose at age 11 or 12 years.

In 2010 the HPV initial dose compliance for females was 40% and only 32% completed the three dose series. The compliance rate for Tdap and MCV4 were both under 70%. The rate for a second dose of varicella vaccine was only 58%. The best way to improve immunization compliance is through a top to bottom awareness of the benefits of immunizations and a review of immunization status every time an adolescent is seen in the office. All adolescents should have an annual healthcare visit and if a teen is seen who has a minor illness and they are behind in their immunizations catch-up immunizations should be given at the illness visit.

In terms of safety concerns the HPV vaccines are extremely safe. Almost 50 million doses have been given in the US and there have not been any serious safety concerns raised. The HPV vaccines are given at age 11 or 12 years so they are received and the child is immunized before there is a risk for exposure to the virus (HPV). Since teens are engaging in sexual activities at younger ages it is imperative they are protected early or the vaccine is not effective.

We believe every adolescent should receive these immunizations. We are confident they are safe and provide vital protection for your child from illness and cancer. We want to reassure you the risks for any of the immunizations are minimal when compared to the actual benefits. You are doing the right thing when you immunize your adolescent.

Influenza Vaccination Rates

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Although influenza vaccination works and prevents minor and severe illness due to influenza almost half of all children and teens from 6 months to 17 years do not receive influenza vaccine in 2010. This was at the height of influenza concerns due to H1N1 influenza. The highest unimmunized groups are adolescents and black children. School aged children and teens are at the greatest risk of contracting and spreading influenza yet their immunizations rates are low. The reasons are multiple for the low adherence with the American Academy of Pediatrics (AAP) recommendation that annual influenza vaccine be given to all children and teens from 6 months to 18 years.

Barriers to immunization include cost and insurance coverage as well as infrequent visits to doctors. Reminder systems are inadequate and outreach programs to provide low cost and affordable immunizations at accessible and visible locations are inadequate. School based immunization programs and the use of social media, including text messaging directed towards encouraging adolescents to take on the responsibility of obtaining a flu shot to maintain their own health improve immunization rates. Ownership is associated with improved outcomes and immunization compliance for adolescents. Education and availability go hand in hand with success.

Sunburn Protection

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Ultraviolet light exposure is dangerous. UV light radiation (UVR) exposure is the most important risk factor you can manage to decrease your risk of melanoma. Melanoma cases are increasing. In the year 2011 it is estimated almost 9,000 people died from melanoma. Studies have shown that recurrent sunburns and sunburns at a young age place you at highest risk for developing melanoma. The risk for melanoma later in life doubles if there is a history of a single sun burn during childhood.

There have been numerous education programs in schools, in doctor’s office and in the media but children and adolescents have not changed their habits. Children and adolescents continue to report sun burn episodes and are not wary of the proven life threatening risks. Most adults are much more aware of the risks and willing to curtail UVR exposure to decrease their risk. The younger age groups do not look at the long terms risks. Due to their age they feel immortal and are preferentially influenced by short term social, behavioral and brain mediated benefits. Many adolescents seek a “tan”. They are not interested in spray on tan options. They seek the social benefits and enjoy the sensation of well-being they feel from a tanning session or lying in the sun. New studies support the activation of centers in the brain that are normally activated by addictive substances including cigarettes and alcohol.

It is imperative that all children and adolescent, not just those with fair skin be protected. Try to avoid the highest periods of midday sun exposure and avoid behaviors, such as tanning beds that further increase UVR exposure. Parents need to emphasize the importance of safe skin care. The routine use of products that block both kinds of cancer causing rays is essential. UVA and UVB protection both are needed. SPF numbers in the past only reflected UVB protection. The FDA has recently released new rules for sunscreen. The new rules list “broad spectrum” coverage as applying to both UVA and UVB protection. UVA penetrates the skin deeply and causes wrinkles. UVB is the type that causes sunburn. Both cause cancer. The FDA has also replaced the word waterproof with water resistant (40 minutes) or water resistant (80 minutes). This supports the need to reapply protection frequently.

Always apply enough sunscreen to cover all exposed areas of skin. Try to apply 1-2 ounces of sunscreen every 2 hours and wear clothes that provide high SPF protection. All clothing screens out some sun but darker colors and a tighter weave protect you more than others. You can increase the UV-blocking capability of any washable garment by using a laundry aid like SunGaurd that can boost a clothing items protection manifold. Sunglasses that block 99-100% of UVA and UVB are also a must and should be worn all day even though light hits the eyes more directly in the morning and the afternoon.

HPV Vaccine

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Human Papillomavirus (HPV) is a common virus that is easily spread from skin to skin during contact. It causes various types of cancer including cervical, vaginal, penile, vulvar and certain mouth and throat cancers. HPV also causes genital warts in men and women.

HPV is a silent virus. Most of the times when you have HPV you have no symptoms. This means HPV can be spread without you knowing it. There is a vaccine to help stop the spread of HPV in both girls and boys. It is safe and effective and can protect males and females against some of the most common HPV types and the health problems that the virus can cause.

HPV is the main cause of cervical cancer in women with over 12,000 new cervical cancer cases each year in the United States. 4,000 women die each year from cervical cancer in the United States. Over 15,000 HPV associated cancers in the United States may be prevented each year by vaccination.

There are two HPV vaccines licensed by the FDA and both are effective against diseases caused by HPV types 16 and 18. These are the types of HPV that cause the most cervical cancers and other associated cancers. One of the vaccines, Gardasil, also protects against HPV types 6 and 11 and is licensed for use in males.

Girls and boys should receive the vaccine at age 11 or 12 years and if they did not receive all three doses then they should be immunized with three doses through age 26 years. The recommendation for boys is more recent than for girls and hence many boys over age 10 have not been immunized. It is important for preteens to get all three doses long before any sexual activity with another person begins. When immunized at a younger age higher protective antibody levels are produced. HPV infection can occur after a single contact with HPV during intimate body contact. This vaccine is an important tool to protect against cancer and genital warts.

HPV vaccine can be given safely with the other vaccines given at age 11 years. These are the meningitis vaccine (Menactra) and the diphtheria-pertussis-tetanus (Boostrix) vaccine. Three vaccine doses are given over six months. The second dose is given 1-2 months after the first and the third dose 6 months after the first. An easy way to remember is 0-2-6 months.

HPV vaccines do not treat or get rid of existing HPV infections and cervical cancer screening (PAP Tests) are still needed even if the HPV series has been completed.

Most health insurance plans cover HPV vaccine. Don’t wait. Protect your child now.

Sudden Cardiac Arrest in Children

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Identifying children at risk for sudden cardiac arrest (SCA) is vital to prevent the death of a child and a tragedy for a family. Causes include structural and functional abnormalities, cardiomyopathy, coronary abnormalities and electrical abnormalities are causes for SCA.

Warning signs associated with SCA include fainting or syncope with exercise, chest pain with exercise, shortness of breath not associated with asthma in response to exercise, a family history of sudden cardiac arrest in someone younger than 50 years of age or having a family member who is affected with a condition that can cause sudden cardiac arrest.

It is very important you talk to family members to learn about your family history.

Many parents are not aware of their family history of SCA. You must ask and investigate any history of a relative who died from a sudden cardiac problem and discuss this information with your pediatrician. Obtaining a comprehensive and accurate family history and pedigree can help prevent a death due to an inherited cardiac genetic disorder.

Consider encouraging your child’s school to have an emergency response plan that includes cardiopulmonary resuscitation and automated external defibrillator (AED) use. With this preparation survival rates increase from 10% to 64%. Symptoms, as discussed above, are present in fewer than 50% of all children who have a SCA. Options to improve outcome for these children include obtaining an electrocardiogram (EKG) for all children involved in athletics. This type of testing can identify 70-90% of all children at risk. Remember to support education programs for effective bystander cardiopulmonary resuscitation (CPR) and appropriate AED use. Such intervention can save the life of your child.

Adolescents and Influenza Vaccine

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Although influenza vaccination works and prevents minor and severe illness due to influenza almost half of all children and teens from 6 months to 17 years do not receive influenza vaccine in 2010. This was at the height of influenza concerns due to H1N1 influenza. The highest unimmunized groups are adolescents and black children. School aged children and teens are at the greatest risk of contracting and spreading influenza yet their immunizations rates are low. The reasons are multiple for the low adherence with the American Academy of Pediatrics (AAP) recommendation that annual influenza vaccine be given to all children and teens from 6 months to 18 years.

Barriers to immunization include cost and insurance coverage as well as infrequent visits to doctors. Reminder systems are inadequate and outreach programs to provide low cost and affordable immunizations at accessible and visible locations are inadequate. School based immunization programs and the use of social media, including text messaging directed towards encouraging adolescents to take on the responsibility of obtaining a flu shot to maintain their own health improve immunization rates. Ownership is associated with improved outcomes and immunization compliance for adolescents. Education and availability go hand in hand with success.