Immunization update

Let’s review some recent data reported on the unfortunate and ongoing attempts to create controversy regarding immunizations.

Firstly, Danish researchers have summarized 2 large studies. One followed > 530,000 children from 1991-98. Approximately 440,000 were immunized with measles, the rest were not. 738 were diagnosed with either autism or autism spectrum disorder(ASD).  No difference in the incidence of those conditions were discovered between immunized vs  non immunized children either short or long term. Subsequently a second study did the same thing 1999-2010 with > 650,000 children; again, no difference in autism or ASD in children immunized vs those not, despite sorting the data by age, sex, birth cohort, family history of autism, or other immunizations.  Let us note that these 2 studies take place over almost 2 decades and observed over a million people without identifying any association of measles to autism .  I hope all concerned parents will consider that enormous amount of data very carefully.

Another report reviewed injury claims filed and paid by the National Vaccine Compensation Program. The NVCP was developed as a “no fault” system to compensate people for vaccine related injury claims in an effort to help people AND protect the source of life saving vaccine production from destructive litigation.  It is “user friendly”–its default position is that the vaccine is “guilty unless proven innocent” to enable people to receive needed compensation for serious problems (whether there is proof of association or not) and it goes so far as to pay claimants costs for legal representation and witness time irrespective of whether a claim is ultimately paid or not. About 70% of claims received compensation from 2006-17. 3.4 billion vaccine doses were given in that time, and the claim rate was 2/million doses.  A large portion of the claims were localized shoulder injuries when the vaccine was inadvertently injected into joint space causing arthritic changes as opposed to any systemic medical reaction.  For all the heat generated by claims of vaccine risk in the lay press and social media, one must wonder, where are all the actual injury claims?

As of this past Tuesday, New York City has declared the local measles outbreak is over.  Keeping the above in mind, let’s assess the damage: 654 people were diagnosed; 52 hospitalized and 16 required ICU care.  The City spent an additional $6 million to send 500 health workers out to identify and vaccinate recalcitrant citizens.

Unfortunately, here in New Jersey, the infection marches on.  In fact, the Asbury Park Press reports a 53% increase in “religious exemption” claims in schools for measles since 2013-14 (1641 to 2516).  In Ocean County, the absolute number of exemptions has jumped from 145 to 363 students–an increase of 1.8-4.2% of students enrolled. This may sound like small potatoes, but public health studies indicate that we need 95% immunization coverage to achieve “herd immunity.” Less than that and vulnerable people–the old, young, and chronically ill–are at much greater risk of exposure to measles, a disease that historically hospitalizes 25% of its sufferers and kills 2 of every 1,000 who become infected. How is that right, smart, or fair?

Send along questions or comments, and thanks for following.

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Stye

A common problem in the office of primary care doctors and ophthalmologists is a stye.  These red, painful lumps form at the lid margin(the edge of the eyelid) and come in 2 basic forms:

  • Chalazion–from the Greek “hailstone” a non-infected lump
  • Hordeolum–from the Latin for “barley,” also a lump, but with more generalized redness and pain due to secondary infection. These can be further divided into internal or external  lid problems.

With both problems the cause is blocked glands within the lid itself; if on the inside surface a “Meibomian” gland, on the outside surface a “Zeiss” gland. In both instances, the purpose of these glands is to secrete lubricating mucous onto the lid as it slides over the eye; the gland’s duct becomes blocked and the mucous is unable to be pushed out.  So in some ways, it’s similar to acne–a pimple on your eyelid.

Risk factors for styes (either type) include blepharitis or conjunctivitis (either infectious or allergic), eyelid skin conditions like eczema, excessive sweating after play or workout, eye makeup, or unclean objects held against the face.

Given the above, the best approach is prevention–mainly, keep the eyelid clean.  Wash the child’s face well, launder blankets/stuffed animals and bedding regularly,  modest use of eye make up (editorial comment–isn’t that mostly better anyway?), use antibiotic (for BACTERIAL infection) or allergy drops where appropriate.

Generally, treatment for stye is conservative and supportive–OTC analgesics; moist, warm heat–teabag or washcloth against the eye for 5 minutes several times daily; do not use eye makeup or contact lenses until the problem has resolved.  Oral antibiotics are occasionally needed for more extensive infection, and surgical intervention with incision and drainage is even less frequently indicated.

In some instances, styes may be recurring.  Redouble efforts at keeping eyes clean from makeup, sunscreen, detergents, lotions, and other topical agents.  There is anecdotal, but good, data suggesting that regular supplementation with oral omega-3 oils can help prevent styes from recurring as well.

If you have questions about stye/chalazion/hordeolum  in your child please give me a call, and thanks for following.

Thanks to Eye Physicians of Northampton for featured image.

Tongue Tie

“Tongue Tie” (ankyloglossia) is a common condition in infants; it involves prominence– in length, thickness, or both–of the band of tissue that tacks the tongue to the floor of the mouth, as well as the similar tissue connecting the inner upper lip to the area above the upper teeth.  The exact frequency is unclear, but generally considered around 4-5%,  predominantly male.

I have avoided calling it a “disorder” or “abnormality” as ankyloglossia mostly appears to be an observation in search of a problem.  Some claim an association with poor dental hygiene, orthodontia, or bad breath, but tongue tie infants  don’t appear to grow up and require braces much more than the general population.  Another concern is speech problems; “dysarthria”(problems with enunciation) as opposed to problems of speech acquisition or comprehension–with tongue to teeth sounds of most concern (t, d, th, s, z, r, l).  However the little academic literature available on the subject suggests that the human tongue is a very agile muscle and mostly learns to adapt to the situation; children with prominent frenulums tend to speak at the normal time and ultimately clearly and normally without professional intervention.  Some worry over such activities as licking food, playing wind instruments, even “sexual expression” growing up or as adults, but, to my mind, none of these things should warrant aggressive intervention by parents for an infant(especially the latter one!).

The most immediate concern for ankyloglossia is breast feeding problems.  Here there is ample evidence that tongue tie babies may at least initially have some difficulties in latching causing frustration for both mother and baby, as well as variable nipple discomfort for Mom.  Even here, though, “problem” may be a stretch.  Most infants seem to gradually adjust and by 6 weeks are nursing well without disruptive discomfort for Mother.

So what to do?  Surgical repair is simple and straightforward–a mere “snip” of the frenulum with a scissors, scalpel, or laser, performed in a doctor’s office.  Complications are rare–post operative infections are very uncommon and the babies seem to tolerate the procedure well without significant increase in crying or fussiness afterwards.  The frequency that this procedure is utilized has dramatically increased recently and I’m not so sure that’s such a good thing.  However, as a man, far be it from me to tell a breast feeding woman to just “grin and bear it.”  6 weeks may seem a short time to me, but to a post partum woman, exhausted, nursing at 2am, may consider the experience very differently.

So context is important here.  My best advise to a nursing mother is that if you are mostly comfortable applying lanolin to nipples and using OTC pain meds, and your baby is feeding, voiding, and stooling well, then that conservative approach is always best.  Less is more–even for “minor” surgery. (I think most people legitimately feel that NO surgery is “minor” for one’s own baby–right?).

If that strategy is not working out, then come on in and let’s talk about it.

Thanks for following.

Image courtesy southlakeent.com

Nursemaid’s Elbow

Another in our recent orthopedic themed posts: a common toddler injury called “dislocated radial head.” I call it my favorite diagnosis, because  here a child walks into my office sick (elbow pain) and walks out cured (pain resolved).

A quick anatomy lesson illustrates what happens and how this disorder received its common nickname. As illustrated, the forearm consists of 2 bones–the ulna (pinky side) and the radius (thumb side). The elbow end of the radius is shaped like a knob which allows that bone to rotate over the ulna at the elbow, allowing you to turn your palm down or up (pronate or supinate); a U shaped sling like ligament holds that knob end against the ulna so the radius can rotate and turn the palm over.  In toddlers that ligament and the surrounding muscles are not as strong making the joint more injury prone.

That’s where the funny name from the title comes in: classically, the caregiver (nursemaid) gives a strong tug by the hand to the dawdling child to “keep up,” causing that knob end of the radius(at elbow) to get pulled under and past the U shaped ligament “dislocating” it.  Basically any vigorous pull at the hand from a considerably stronger individual can cause it: pulling the child up from or to avoid a fall, too vigorous play/pulling arm by an older sibling.

The child will often cry out in pain and then hold the injured arm flexed 90 degrees at the elbow against their trunk. Any attempt to move the arm is very painful and will be strongly resisted.  Noticeable swelling or discoloration at the joint is uncommon. The diagnosis is generally straightforward given the history of a pull at the child’s hand followed by pain and resistance against any movement thereafter.  It’s usually pretty easy to fix with a simple maneuver in the office.  (I encourage the “DIY”ers among you to leave that treatment to trained professionals–its your kid, not some kitchen appliance!) X rays aren’t required unless history isn’t clear, in which case, ruling out a fracture may be necessary. Curiously, it is not rare for the x ray tech to inadvertently reduce the injury while manipulating the arm to  get optimal views for the radiologist. That’s ok, too.

After the dislocation is reduced, I frequently find that the child will continue to resist moving the elbow out of fear of more pain: I hold the uninjured arm and offer a lollipop; after a while they can’t resist, take the candy with the cured arm and realize that now it’s ok again. Follow up care is ice for swelling and ibuprofen for pain.  Once the injury has occurred, the ligament is looser and more prone to re-injury.  It is best to avoid pulling any young child hard by the hand, ever.  In rare instances of multiple recurrences of this injury, orthopedic intervention to tighten the lax ligament can relieve that problem.

Please give me a call with questions and comments, and thanks for following. Featured image from: https://www.rch.org.au/clinicalguide/guideline_index/Pulled_elbow/

Patellofemoral Syndrome

Having previously discussed Osgood Schlatter, let’s stick with this theme and turn to another very common knee problem, patellofemoral syndrome (PS).  PS is actually THE most common cause of knee pain from non-acute trauma in adolescents, in either athletes or those not engaged in organized physically competitive endeavors.

The hallmark of PS (sometimes called “chondromalacia of the patella which is actually only one form of PS) is pain in the knee just behind the kneecap (patella).  PS is also often called “runner’s” or “jumper’s” knee, because the problem is closely associated with, and exacerbated by, those activities/movements.  Kids with PS also commonly complain of worsening pain after sitting still for extended periods.  Some PS sufferers will note a popping or crackling sensation in the knee, especially upon climbing stairs.

No one knows the exact cause and in fact it likely has several contributing and compounding issues. The most common factor is wearing/thinning of the cartilage BEHIND the patella (NOT “meniscus”). The soft, smooth cartilage behind the kneecap and covering the lower end of the thighbone(“femur”) is a much more lubricated joint surface for movement than rough, hard bone. When/if that cartilage wears down it causes inflammation and pain.

The condition is usually brought on by some aspect of sub-optimal exercise/training routine: too much training, a sudden increase in training intensity, improper training technique,  using improper equipment(or proper equipment improperly) including footwear, bad or sudden change in training surface.

One common factor is quadriceps asymmetry.  The quadriceps is the main thigh muscle, responsible for straightening the leg at the knee by pulling the shin (“tibia”) forward at the knee joint.  As its name implies, the muscle has 4 parts, and if some sections are stronger/weaker than others the patella is not pulled straight through that cartilage lined groove at the bottom of the bone but rather will shimmy and bounce through it, causing the surface to wear down over time, leading to PS.

Thus a mainstay of treatment for PS is a good quadriceps strengthening program.  Also along those lines, I encourage athletes to avoid full “squats” generally and in particular if you have PS.  Half squats are usually ok. if they don’t cause pain.  If you must do full squats with weights, I encourage flexing the knee < 90 degrees and only use machines/apparatus where the weight is placed past the feet and pushed away from the body as opposed to the weight on the shoulders to be lifted.  A period of rest before return to sports is optimal or at least a modified training program limiting running/jumping outside of actual competition(substitute bike, low impact aerobic machines like elliptical trainer, swimming, water running). Heat before, ice after all vigorous activity. Wear a neoprene knee brace open at the patella for support during exercise. Anti-inflammatory medications like ibuprofen are often beneficial but not essential. 

Of course, if the pain is more disruptive or persistent then please come on in and let’s take a closer look together.  Thanks for following.

Knee pain/Osgood Schlatter

Last time we reviewed growth plate issues of the heel, so called Sever’s Disease. Please reference back to that article for a review of apophysitis.

Another location for this problem is just below the knee, so called Osgood Schlatter syndrome.  Here, we have the same basic problem: the powerful patella tendon pulls against the tibial (shin bone) growth plate as it undergoes rapid lengthening during puberty;  the tendon moves up the bone as it lengthens, causing inflammation and pain.

The location of the pain is quite specific: the “tibial tubercle”– that bump at the top of your shin just below your kneecap (see heading illustration). The area is typically swollen with at least mild redness and tenderness.  Like Sever’s in the heel, this apophysitis is a problem of early adolescence (10-13 girls, slightly more common in 12-14 boys), and is caused by the repetitive jumping action of some of the same sports– basketball, volleyball, soccer, plus additional ones like skating(figure and speed) as well as dance.

The problem is differentiated from another common knee problem “patellofemoral syndrome” (“chondromalacia”) which is PROBABLY (its controversial) caused by wearing of the lubricating cartilage behind the kneecap (not meniscal cartilage) where the pain is higher up and behind the kneecap, without the bump below the knee and with a somewhat duller pain. Meniscal cartilage tears, ligament and tendon damage almost always follow acute, more severe injury.  Old guys like me can have meniscal injury just from overuse and age; young athletes do not suffer from those problems–only damage from big hits to the joint can injure a kid’s knee.

Usually treatment involves pain management.  Nonsteroidal antiinlammatory drugs (NSAIDs) like ibuprofen and naproxen are the mainstay. A big part of the problem is generated by quadriceps tightness, so stretching and flexibility training is very important. Modify the athlete’s training/practice routine to limit overuse and allow for best competitive performance is key, so a good trainer and understanding/smart coaching is essential. A good knee pad that limits hits to the tender inflamed tibial tubercle provides relief from that problem.

Regarding overtraining, let’s recall as I think its important–max 2 seasons at one sport, a third season of a completely different one, and one season with only not organized general fitness training is my recommendation for limits to training schedule (less is certainly acceptable). Remember, Mom and Dad, we are talking about CHILDREN–they are supposed to have fun and free time.

If your younger teen is troubled by knee pain, give me a call and let’s discuss it.  Thanks for following.

Heel Pain/Sever Disease

Presently children will be starting fall sports training–football for boys, field hockey for girls, soccer and cross country for both.  Foot problems are a common problem for these athletes. About the most frequent foot complaint not caused by trauma that I see is heel pain, and most often the problem is a condition called Sever’s disease (note– I’ve heard the name pronounced to rhyme with “leather” or “weaver,” so take your pick).

The technical term here is “calcaneal (kal-KAY-knee-al) apophysitis (ah-pah-fis-I-tis). The calcaneus is the main bone of the heel; you can feel it at the bottom of the foot.  The apophysis, or growth plate, typically  doesn’t close until 12-14 in girls and 13-15 in boys, so that is the upper range to see this problem with beginning being onset of rapid growth, about 8-9 for girls, 9-11 for boys.

Sever’s disease is caused by the powerful Achilles tendon pulling against the open growth plate of a younger adolescent  when the bone is growing most rapidly. The pain results from the tendon pulling at the growth plate while actually moving along the bone over time as it is growing in order to maintain proper anatomic condition, coupled with the constant pounding at the heel while running.  Pain is sharp and can be elicited by pinching the heel with the fingers at either side.  Bilateral involvement is not uncommon. That is one way to differentiate it from some other problems with similar though subtly different symptoms. Stress fractures are almost always one sided and typically further up the foot.  Plantar fasciitis pain is also further forward at the heel/instep junction and usually gets worse with more running (“second step” pain).  Achilles tendonitis is usually behind the ankle and above the heel and hurts worse with jumping, when the Achilles pulls and the foot flexes down.

Although the discomfort is unsettling,  Sever’s disease is fortunately not serious.  It can certainly disrupt an athlete’s training or performance; however as the child reaches adult stature, the growth plate closes and the disorder will gradually resolve on its own without any longer term disability.  Treatment consists of modified training: less running outside of competition, more non-weight bearing aerobic training like biking, swimming, water running; non-steroidal pain medications like ibuprofen(avoid caffeine with this drug).   Cushioned insoles–either “off the rack” which can be purchased at shoe stores or custom made by your podiatrist (make sure they aren’t TOO thick) can be helpful.  If very disruptive a period of rest from sports and physical therapy will usually work.

Prevention is also key: proper shoes, stretching before playing, conditioning (its more common in overweight athletes).  Too much training is a problem here as well–DON’T OVERDO!!(my advise–max 1 sport for 2 seasons, a different sport for the 3rd and take the 4th season OFF–no formal competitive program).

If your child is experiencing foot pain please give me a call and let’s discuss it.  Send along questions or comments, and thanks for following.