Immunizations and Epidemics

I think its time for a quick update(and a bit of editorializing) about immunizations.  Of course, its the absolute best option for your child.  Beyond that, its important for us as citizens of a society to protect each other.  In 1624, the English poet John Donne said “no man is an island.” Yes, our first duty is to protect our own.  But I believe that we also still owe a strong commitment to our neighbors and fellow citizens.

Current research demonstrates that recent dangerous outbreaks of pertussis and measles had their origins in unvaccinated children bringing these infections to their surroundings.  So I wish to stress that this decision has implications beyond one’s own family to the larger community.

One of my favorite proverbs comes from the Talmud, one of Judaism’s most sacred texts.  It begins ” If am not for myself, who will be?” And that’s important, isn’t it?  We have to look out for ourselves and those closest to us; it’s only natural, and it’s a good thing.  But then the proverb continues–” But if I only for myself, what kind of a man am I?”  So, noting the above,  the decision to immunize impacts not only one’s own family, but also our neighbors and fellow citizens.

And my question to vaccine skeptics: if a given person refuses vaccination, subsequently contracts that illness, and then infects a child (and note–these things are traceable) who is injured or dies as a result–then what are the moral implications of the decision to not immunize?  Now, leave aside the many well documented benefits of immunizations to each child AND the strong scientific evidence against any serious risk.  If one seeks to enjoy the benefits of living among neighbors in a community (commerce, companionship, recreation, security) then I believe that it is a contingent responsibility to support the safe, efficient functioning of that society (eg, pay your taxes, maintain your property, take steps to not put your neighbor at risk by, for example, not driving impaired, and immunizing to prevent disease spread).  I say it is simply mature and proper citizenship to accept responsibility  for our fellows along with the advantages derived from living among them.

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I’d like to make a few short comments about recent topics regarding ADHD.  Now, this is a very large subject.  A full discussion of ADHD is way beyond the scope of my short blog posts.  Let’s just examine some new data.

First there has been noted a significant correlation between diagnosis of ADHD  at younger age.   In a given grade cohort,  statistically,  younger children tend to be diagnosed as ADHD more frequently.  So this begs the question with a given child–is it a learning disorder or just immaturity?  Another important observation is the association of anxiety and ADHD–we note that some children diagnosed ADHD are actually suffering from anxiety and still others have elements of both.  And the treatment approach for each of these differs.  So my point is (as usual) that every troubled, ill mannered, or immature little chooch  in class is not necessarily an immediate candidate for medication.  I always try and take the long view in these situations and consider all of the many possibilities before turning to medication.

Another important consideration that we are beginning to see is the relationship between physical activity and academic achievement for children with ADHD.  Actually, according to the Institute of Medicine, this is true for children generally. And this doesn’t even get into the issue of obesity and general conditioning.  Nevertheless, the trend f0r school funding of physical education is down, not up.  Similarly for art and music classes.  Now, a recent Harvard study has debunked some of the claims about art/music study and improved basic skills.  But that same study went out of its way to emphasize that it was not advocating any specific cuts in non-core curriculum areas but quite the opposite: it was their opinion generally that art/music study itself brought real value to students and the greater society.  Without it, as Glenn Holland–the reluctant but beloved music teacher played by Richard Dreyfus in 1995’s “Mr. Holland’s Opus” said, “pretty soon there won’t be anything for these kids to read and write about.”

Keeping these courses available to help kids with ADHD, and students generally, to succeed is so important and it is certainly not free.  Therefore it falls onto us citizens to commit to the program and that means we have to pay for it.  As a pediatrician, a child advocate, I say a broad based education for every child is our first duty as a society.  I think about that every time I hear politicians arguing about “bloated education budgets.”  Lean and efficient–yes.  But let’s not throw the baby out with the bath water.  I encourage you all to keep it in mind as well.

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Newborn Jaundice

Newborn jaundice is common but nevertheless a source of significant anxiety for young parents.  First, some background: jaundice is caused by a buildup of bilirubin–produced by the metabolism of hemoglobin from old red blood cells–in the bloodstream.  Now, all human beings have a small amount of bilirubin in their bloodstream(< 2mg/dl) which is excreted by the liver and eliminated with stool.  This process is how it works with “regular” people.  In the fetus, bilirubin crosses the placenta and then is handled by mother’s liver.  Once the baby is born and the umbilical cord is cut, then the baby is “on his own” and his liver must “take over.”  But that doesn’t happen immediately-it usually takes 3-4 days for the infant liver to “jump start” and begin clearing bilirubin . The liver has an enormous capacity to detoxify the blood, so once it starts, only minute, innocuous amounts will persist.  But meanwhile the bilirubin builds up and the baby can look a bit yellow–first on the face and, as the blood level increases, on the neck, trunk, and, rarely, the extremities.

So what’s the problem?  Well, bilirubin is very insoluble in water based solution like human blood.  If the level rises too high it can “precipitate out” of solution–like putting too much sugar in your coffee–forming crystals which can settle in the brain causing serious injury.  The good news is that it’s very easy to monitor(check blood levels) and treat.  “Phototherapy” (purple lights), sometimes holding breast feeding, and occasionally giving intravenous fluids are effective ways to control the bilirubin concentration until the “jump started” liver addressed the issue permanently.

Also, remember that jaundice is an “either/or” thing.  If you don’t get to the precipitation point “magic number” then nothing happens. As I always say–its not brain damage at a level of 20 mg/dl and C-‘s if its 19.   There are no adverse consequences whatsoever to having elevated bilirubin levels below the precipitation point and its so easy to prevent(again:just check the blood)–I have, thankfully, never seen it in >30 years as a pediatrician.  We follow and treat it to keep from drifting towards that dangerous level.

Certain factors may increase jaundice:

  • Breastfeeding–“Breast milk jaundice” is the most common cause of a yellow baby.  It is completely innocuous and absolutely no reason to stop nursing.
  • Premature baby
  • Small baby
  • Bruising caused by delivery trauma
  • Certain blood group differences between parents, if baby inherits Dad’s blood–can cause jaundice.  This is “ABO setup”and special to me–all 3 of my children were very jaundiced from this.
  • There are medical conditions which can cause more pathological causes of jaundice.

Jaundice may be more serious if:

  • It lasts > 2 weeks
  • Associated with fever > 100.2
  • Poor feeding or listless baby
  • White cottage cheese colored stools

I am happy to report that, despite their jaundiced start to life, my 3 kids are healthy and proud to brag that they are all highly educated professionals.  That is what I always assume will be the ultimate outcome for my jaundiced newborns.

So try not to worry too much, call with questions, and thanks for following.