Zika Virus

The latest on everyone’s mind is the Zika virus.  Zika is named for the forest in Uganda where it was identified in 1947.  Generally, Zika is not serious–80% of infected people have no symptoms; most who become ill only develop nonspecific fever, rash, joint aches and red eyes lasting under 1 week.  Rarely, it has been associated with, (not proved a cause of) a serious neurologic condition called guillain-barre syndrome.

In the last year Zika has spread rapidly through the Americas.  No one knows exactly why this happened, but it had not previously been known in this part of the world and encountered a large “infection naive” population.  Those circumstances can frequently result in this type of infection spread pattern.  Zika spreads with a bite from infected aedes mosquitoes.  3 points about aedes: in warm weather aedes mosquitoes have been spotted as far north as Washington DC and possibly central NJ, aedes also harbors dengue and chikungunya virus, and climate change  will likely cause aedes’ habitat to expand.  There are unconfirmed reports of Zika spread via sexual contact.

zika in americas

The above map from the CDC shows the spread of Zika in the Western Hemisphere.  The epicenter is in Brazil (note: 2016Summer Olympics in Rio de Janeiro) but it has been identified as far south as Uruguay and has moved north inexorably through the Caribbean, Central America and Mexico.

Note this map of aedes mosquito locations:

aedes map


The above from The Lancet shows aedes in sub-Saharan Africa, south Asia, the South Pacific and parts of Australia, and most importantly for us Americans the US Gulf Coast and Hawaii.

The danger from Zika is to the unborn baby via maternal infection.  There is strong association with, but again no positive diagnostic proof of, Zika and poor fetal brain development leading to microcephaly (small, abnormally shaped skull) and brain calcifications.  Therefore, the center for Disease Control has issued several guidelines for women who are or may become pregnant (as 50% of all pregnancies are unplanned, these recommendations should be considered for all women of child bearing years):

  • Consider postponing travel to areas with Zika outbreak.
  • If traveling to those areas, as much as possible wear long sleeves and pants (preferably with insect repellent chemicals) and sleep in air conditioned rooms or under insect repellent netting.
  • It is not recommended that all pregnant women traveling to those areas be tested for Zika, only for those coming from infected areas who develop fever, rash, red eyes, and joint pains.
  • Women coming from Zika infected areas should have serial ultrasounds to evaluate for microcephaly and cerebral calcifications.
  • Women who may be carrying fetuses suspected with microcephaly or cerebral calcifications should be tested for Zika.
  • Women found to be Zika infected should be tested for dengue and chikungunya.

I am no alarmist but this is certainly a concern. It is spreading rapidly and no one knows where the limit may be.  Still, if we follow the above and keep our wits about us there’s no reason to panic.

Questions?  Comments? Thanks for following.

Snow shoveling

Here’s a timely topic–if, at most, only peripherally “pediatric:” snow shoveling safety.

First of all, please note that, each year, snow shoveling causes 11,000 ER visits–7% are cardiac events.  The cold and wet causes increased blood pressure and stress on the heart.  So, if you are not in good physical condition, have high blood pressure, diabetes, if you are a smoker or overweight, and especially if you are diagnosed with heart disease, please think carefully before trying to clear snow from your property yourself.  Also note that working with a snow blower is still work.  It may be a bit easier–but pushing and pulling that heavy machine isn’t so easy, so be careful even there.

Please keep these recommendations in mind:

  • Warm up and stretch out–shoveling is strenuous exercise. Get ready as you would with any other vigorous work out.
  • Dress appropriately–too heavily can lead to heavy sweating, too wet and hypothermia.  To0 light can lead to hypothermia too.
  • Take frequent breaks .  If you are sweating profusely or feel short of breath it’s time to rest.
  • Drink plenty of fluids–any time you exercise hydration is vital.
  • Don’t shovel after drinking alcohol or eating a large meal (wait > 30 minutes).  I mean–this should be obvious.
  • Use proper technique–bend at the knee, not the waist, don’t twist at the hips but rather turn your whole body, don’t throw snow over your shoulder , keep your arms close to your body, push the snow rather than lift as much as possible, keep your front hand close to the shovel head.
  • If you experience chest pain, shortness of breath, or dizziness you should stop immediately.  If these symptoms do not resolve promptly you should seek medical attention.
  • Here’s the pediatric part–USE YORU KIDS!!!  If they are +/- 10 years old and in good health they can certainly help.  Make your own life easier and SAFER with extra “hands on deck,” as well as a meaningful family activity.  IMHO–a little cool cash reward for their efforts is certainly not a bad idea here!!

Send along questions and thanks for following.

Reflux Medications

There is a new report about the risk associated with prolonged use of proton pump inhibitors (PPI) for gastroesophageal reflux (GER).  I have referenced this topic a few times previously.  A quick review: most infants reflux at least once daily.  This is mostly a benign condition; most babies will spit up and continue quite happily–BARF-smile-play. That was my experience with my youngest, Luke–nicknamed “the puke” at the time (now a handsome businessman aged 23).  Some won’t–but even there, the large majority of children who are a) very fussy and b) spitting up regularly are not suffering (a) BECAUSE of (b).  We infer GER in infants based mostly on parental history but its very inexact.  The children don’t complain of heartburn and cannot specifically localize their distress (pain?) as older people can.  Definitive diagnosis of GER requires endoscopy and biopsy, but given that this is very invasive, requiring sedation and considerable risk of complication, it is not done in most clinical situations.

So given the diagnostic uncertainty, my approach is to be as conservative as possible in a baby who is growing well and mostly playful.  Difficulty with sleep??? Don’t get me started!   

If we are going to treat, I try and keep it simple.  Formula changes are worth a try but are actually rarely effective (<5%).  I always recommend that only a dramatic improvement is real–“a little better” is usually observer bias (science speak for “wishful thinking”).  Smaller, more frequent feedings, frequent burping, positioning(keep baby upright for at least 1/2 hour after feeding), thickened feeding (1 tsp cereal: 2 oz formula) are all often helpful.

A small minority of children will experience more severe symptoms–poor weight gain, refusing to eat, vomiting blood.  Other more severe, if less reliable, symptoms include prolonged screaming and chronic cough.  In these cases, some medicine MAY be a reasonable try.  But we must be realistic.  There is substantial evidence that PPI’s are of no real benefit as well as studies that tie their use to some real risks : pneumonia and severe intestinal infections(clostridium dificile–“C dif”) due to the natural infection protection of stomach acidity neutralized; malabsorption of essential nutrients like calcium.  Now, the latest(as alluded above) is new information that strongly suggests chronic kidney disease with prolonged PPI use.

So the wisdom of medication for GER and the proper circumstances for its use are both limited.  Let’s keep that in mind.  Give me a call if your child is refluxing and you are concerned>  Let’s work on it together.

Send along questions and comments.  Thanks for following.

Tanning Salons

Happy New Year.  Here we are in January, the dead of winter (the current warm weather notwithstanding).  So naturally my thoughts turn to…suntanning.

The Food and Drug Administration(FDA) has proposed banning children under 18 from patronizing tanning salons.  I strongly support this idea, of course.  According the Melanoma Foundation, 2.5 million teens use tanning salons, including 35% of girls under aged 17 (some as early as 13).  The World Health Organization has determined that UV rays from tanning beds cause skin cancer, that the risk is greater for individuals who use them earlier than age 35, and that the  risk multiplies with increased exposures.  Please note that tanning beds deliver 15 times the UV light to the skin compared to the sun.

Melanoma in white women under 44 years old is increasing 6.1% annually, probably due to increased indoor tanning practices.  It is the most common cancer in people aged 25-29 and second most common in ages 15-29.  Since 1973 its incidence has increased by 61% in males and more than double in females(again, greater indoor tanning frequency).

Note that not burning is no protection against the UV risks above, simple exposure is all it takes.  So my advise to parents is, irrespective of whatever the FDA decides, do whatever you can to discourage your teens from too much sun exposure generally and avoid indoor tanning specifically.  Especially with my adolescent girls, I try to point out the older people they may see with tanned, leathered faces from sun worshipping and remind them that all of us are in a race with an old and wrinkled person.  None of us will win that race in the long run but we can stay in it longer–stay young and fresh faced–if we protect our skin from the aging effects of the sun and UV light.

Ultimately, of course, we want these young women to truly be comfortable in their own skin.  Winter or summer, they don’t need to be tanned to be beautiful or popular.

For information on sun screen please refer back to my earlier post.  Also, as the article above mentions, public comments are invited, so go the website and advocate for the ban.

Send along questions or comments, and thanks for following.