Gun Safety

I wish to make brief comments on an important, serious, and (unfortunately) controversial public health issue–gun violence.

Firstly, let’s state the obvious: American citizens have an absolute Constitutional right to keep and bear firearms in their homes.

But let’s review a few other facts.  In 2013 alone, guns were used in 3924 homicides and accidents and 2347 suicides ages 0-24 (17/day) as well as 36,205 injuries (100/day).  Guns are the most commonly used method in suicide attempts, with a “success” rate of 90%. (Thanks to Dr. Elliot Rubin, President of the NJ American Academy of Pediatrics, for the above statistics).

A 1993 study published in the New England Journal of Medicine demonstrated a statistical association between home firearm ownership and homicide occurrence in gun owning homes.  To summarize, the study demonstrated that for every episode where a gun was used in home self defense there were 4 unintentional shootings, 7 assaults/homicides, and 11 attempted or completed suicide attempts.  Equally important is that this data has been corroborated  elsewhere.  The Violence Policy Center, utilizing FBI crime data, found that in 2013 there were 211 justified homicides and 7838 criminal firearm homicides and from 2012-2014 there were 18,328,600 victims of violence and 163,000 gun related self protective behaviors (0.9%) and 51,685,500 victims of property violence with 99,000 gun related self protective behaviors (0.2%) along with >200,000 guns stolen from US households.  So, the reported data shows strongly that, rather than being a protective factor against home or personal violence, household gun ownership carries significant risk as a cause of such mayhem.

In response to this data, Congress in 1997 passed the “Dickey amendment” to the Omnibus Consolidated Appropriations Bill, mandating that “none of the funds made available for injury prevention and control at the Center for Disease Control and Prevention may be used to advance or promote gun control.”  This has strongly limited our ability to study the problem and develop effective solutions.  It has been disavowed by its namesake, Rep. Jay Dickey of Arkansas.  Additionally, virtually every conceivable medical and healthcare society has come out in opposition to the Dickey Amendment.  I wish to stress that these are all moderate professional societies who’s principle function is to advance the ability of member healthcare providers to deliver the best, safest, and most effective  care to patients rather than any partisan political entities endeavoring to advance some selfish economic or social agenda.

I am proud to to be a member of the American Academy of Pediatrics which is at the forefront of this movement.  According to the AAP,  the only safe way to keep firearms in a home is in a locked gun case with the ammunition stored in a separately locked container and my advise is that, if you are a gun owner, this is how you should do it. The AAP advocates for several other sensible policy initiatives in this area, but it only makes sense that collecting and analyzing data will help our efforts to understand and control the problem of gun violence in our society (if that is our purpose).

Please send along questions and comments, and thanks for following.

HPV vaccine

After my last blog post there was a comment about the Human Papilloma Virus (HPV) vaccine.  I’d like to say a bit about that vaccine to be sure that people have the science and not the rumors.

HPV vaccine was approved for females aged 9-26 years in 2006 and males–same age–in 2015.  Most people infected with HPV are unaware of it–prior to the HPV vaccine it is estimated that 80% of American adults had been infected whether they know it or not.  There are many strains of the virus.  Some cause cervical cancer and others cause only painful, nasty genital warts.

There are 2 HPV vaccines currently on the market.  Gardasil (Merck) covers a broad range of virus serotypes and gives good protection against both cancer and wart causing strains and is approved for both males and females. Cervarix, (GlaxoSmithKline) prioritizes cancer causing strains giving somewhat greater protection against cancer and less for only warts. It is approved for females only.

We have had mixed success in gaining public acceptance for HPV vaccine.  This is unfortunate because, needless to say, cervical cancer is a serious public health concern and preventing it can only be a benefit to our society.  Due partially to its nominal association with adolescent and pre-marital (especially female) sexuality there has been an inordinate amount of controversy surrounding HPV.  It has even filtered into national political debates.  And despite only partial coverage we have seen a marked drop in the incidence of HPV infection in vaccinated young adults.  This is important to remember.  Among the numerous inaccurate claims for adverse reactions from HPV is increased incidence of Guillain Barre syndrome (GBS), a serious neurologic disorder.  Now, while the decreasing rate of HPV infection is well documented, there has been no such increase in the incidence of GBS generally or among teenagers and young adults.  Remember: we must be careful in assuming that temporal association establishes causation.  The rooster crowing each dawn does not cause the sunrise.  There is an old joke about what a doctor should do if a person walks out of his office and drops dead.  Answer?  Turn him around and make it look like he was walking in.   The point is that reports of “a child got x vaccine and then got y disease”is not necessarily “evidence” but is at least as likely to be a coincidence.  It takes much more rigorous analysis to establish “evidence.”

One other assertion by HPV vaccine opponents is that it could empower young women to more active (read : promiscuous) sex lives.  Not supported by good evidence, we have found.

There is so much more false information about HPV vaccine out there. Here’s a good summary of the various claims and the scientific reality .

The immunization schedule calls for 3 shots over a minimum of 6 months.  Its ok for it to take longer and there is no time limit requiring the patient to “start over.”  Please give me a call with questions and we can discuss HPV vaccine.  I strongly recommend it.

Those Pesky Needles

For those who regularly visit this site as I comment on children’s health, you have seen several entries regarding the advantages that immunizations bring to children specifically and the greater public generally.  Unfortunately, we still have the unpleasant issue of the painful needles necessary to administer most of those treatments.  Nobody likes those things.  What can we do together to minimize that discomfort associated with that maximum health benefit?

First, let’s address options that are ineffective and often counter-productive:

  • Divided or half doses given more frequently will not result in a full and effective immune response and, as it requires double the actual needle sticks, actually increases the pain.
  • Warming the vaccine in one’s hands can alter the vaccine effectiveness.
  • Pre-treatment with oral analgesics like acetaminophen may also compromise vaccine immunogenicity.
  • Altering the route of administration.  Intramuscular immunizations are effective only if given intramuscularly.  Giving them subcutaneously may be less painful but is largely useless for the purpose of infection prevention.

Here are strategies that I recommend and try to employ:

  1. Quickly inject and administer vaccine.  There is no need to aspirate(pull back) on the needle–there are no large blood vessels in the belly of these muscles.  Aspirating slows vaccine administration and prolongs the pain.
  2. Administering analgesics like acetaminophen after injection when the child is symptomatic is certainly helpful.
  3. Younger children should be held by parents during injection.
  4. Allow mother to breastfeed infants during injection if she desires.
  5. Allow infants to suck on a pacifier soaked with 25% sucrose solution (which I now stock)is helpful.
  6. Cold compresses, like ethyl chloride solution sprayed in a cotton ball and held against the skin for 15 seconds prior to injection has been shown to be useful for children > 3 years old.
  7. Topical anesthetics.   Ask me for a prescription for EMLA cream to be applied for 1 hour before injection.  EMLA is not covered by all insurance plans but is generally not expensive.

One more thing:  as I point out often, you are your child’s best teacher.  If you have a relaxed and positive attitude about immunization, confident that the pain is only a momentary and small inconvenience for a strong and useful health tool, you can convey that lesson to your child.  As Aunt Catherine states in “Marty”–one of my favorite old movies, “Don’t make an opera out of this.”

Send along questions and comments, and thanks for following.

Video entertainment

By definition, the digital world is constantly changing and it’s almost impossible for parents or even us healthcare professionals to keep pace with it.  The Pew research Center has reported that 30% of children ❤ yrs old play on mobile devices, 75% of teens have smart phones and 24% admit to “almost constant” use.  So, of course, it has immense impact on children’s lives, and we all must try our best.

The original guidelines developed by the American Academy of Pediatrics regarding video entertainment were actually published in 2011 before the first IPod was marketed and the innumerable child aps were developed.  I have often stated that I believe those guidelines are overly blunt and simplistic: no use < 2 years old and < 2 hours/day for children beyond age 2.  Where does Skype/Facetime with a parent traveling on business or hours spent researching a school project fit into those rigid boundaries?

In May 2015, the AAP held a meeting called “Growing Up Digital:Media Research Symposium” to discuss updating these recommendations.  As reported by Dr. Ari Brown in the September issue of AAP News, some of the findings were:

  • Media is just another environment with potential positive or negative effects.
  • Content is important: choose programming from reputable educational sources like PBS or Children’s Television Workshop
  • Role modeling is important:  what is the nature of use of video media by you, the parent?  Can you, yourself put your tablet down?  If not, how can you expect to persuade your child to put their’s aside?
  • Interaction is best: games/aps that require the child to engage is far superior to those where simple observation is all that is available.  Playing the games  and using the aps with your child is far superior to using those media as (I call it) “the electronic babysitter.”
  • Limits are essential: no activity is healthy if it is 24/7.  At some point it’s time to do something else.  Need to establish gentle but firm time limits on video media activities.
  • Unstructured time:  endeavor to not have every hour of your child’s free time scheduled.  The idle mind is by no means always the devil’s playground.  Often it is a source of relaxation and energy regeneration.  Sometimes it can be the inspiration for great new ideas.

So the bottom line is as always: its on us parents.  There is no specific time for video entertainment that is good or bad, too much or too little.  The child’s best toy: his parents.  The child’s best teacher: her parents.  Best strategy: play with your kids, be involved with your kids, take an interest in their lives and in their interests.  In the real or digital world: BE INVOLVED!!  Don’t farm out your supervision of and your involvement in your children’s lives.  

Send along questions and comments, and thanks for following.