Here We Go Again

“What has been will be again, what has been done will be done again…” Ecclesiastes 1:9

“It’s like déjà vu all over again.” –Yogi Berra
 

My job is to try and help keep children as safe and healthy as possible. We treat their asthma so they can breathe and their strep throat to prevent rheumatic fever. We give them vaccines to help prevent fatal infections and to decrease their risk of certain cancers as adults as well as to protect the people they come in contact with. We talk about seat belts, bike helmets, smoking, and STDs. We discuss their emotional and mental health and their school progress to maximize their chances of becoming contributing members of society. We educate them to protect them from erroneous medical information lurking on the web and elsewhere.

There are other people who make medical discoveries that we can put into practice and people who teach the next generation of doctors and nurses. There are folks who know how to run lab tests, remove tumors, and replace joints that no longer work. There are people who publish medical journals to keep us up to date.

There are people who clean the hospital rooms well to reduce risk of transmitting infections to the next occupant, folks who monitor the temperature of the refrigerator so the medications and vaccines stay efficacious, and people who keep our buildings and medical equipment running. There are administrative safeguards put in place to make sure we are practicing medicine in a safe and ethical way.

This is just a small slice of the people in the medical system who help keep us healthy. And it is not just medical folks who keep us healthy. Most municipalities make sure the water supply is safe and waste is dealt with safely. There are systems in place to enforce the laws which protect us. There are people who build roads and bridges and buildings and maintain the electric grid so we can travel safely, cook our food, and stay warm. There is someone to get rid of the rabid raccoon wandering the neighborhood. There are people who produce and transport the food we eat. For a society to function and prosper and keep its citizens safe and healthy, there are many important roles to be filled.

And then a guy with an AR-15 or a .45 Glock with an extended magazine walks into a school/theater/church/synagogue/concert/mosque/store/bar and kills a bunch of people. And the people who died no longer benefit from all of the people who invested in their well-being; the guy who made sure their drinking water was clean, the teacher who taught them to read, the parent who loved them or the nurse who gave them their shots as gently as possible. And despite our best efforts at keeping them healthy, some people are disabled for the rest of their lives. No amount of clean water, healthy food, and preventive care stops a bullet from severing a spinal cord. And our society is similarly paralyzed. So we say a few prayers and fatalistically move on (if we don’t know anyone involved). And two weeks later I get an alert on my phone and say to my wife “There was another mass shooting in…”

Imagine if there was an immediately fatal virus that popped up every couple of weeks in a different part of the United States and no one could predict when and where it would hit next. It would just show up randomly and kill a dozen people and then vanish until the next time. I wonder what we would do.

 

 

Bad Sources of Medical Information

I think every physician is accustomed to having patients who have misunderstandings about the risks and prevalence of certain diseases. It is kind of built into the nature of what we do. But I nearly fell off my chair last evening while watching a clip from cable news in which they were warning about the risks of diseases such as tuberculosis, leprosy, and smallpox being brought to the United States by immigrants from Central America.

Tuberculosis is a reasonable thing to at least think about. In general, folks arriving from less developed countries are tested for TB. In my experience, it is unusual for anyone to test positive. If they do test positive, they are treated even if they do not yet have a contagious form of the disease. This keeps it from progressing to an active form that is contagious to others.

I have never seen a case of leprosy, now commonly referred to as Hansen disease. Approximately 95% of people are genetically resistant to Hansen disease if exposed. If one does acquire the disease, it can be cured with antibiotics. The prevalence of Hansen disease in Central America is less than .001%. So when factoring in all of those numbers, it seems like the risk of me catching leprosy from someone from central America is probably significantly less than my chance of dying in an accident on the way to work.

But the one that really made me scratch my head was the assertion that one had to worry about smallpox. The last case of naturally-occurring smallpox was in Somalia in 1977. There were two cases in the UK in 1978 after someone was exposed in a lab and spread it to another person. Even though I will be a grandfather in a few months, I am young enough that I never received the vaccine because it was no longer considered a threat by the time I got to the age when the vaccine was normally given. I seriously doubt that anyone fleeing poverty and violence in Central America has been working with smallpox virus in one of the few labs in which it still exists. Anyone who says there is a risk of smallpox from immigrants from Central America is either hopelessly uninformed or lying.

Meanwhile, influenza kills thousands of people every year in the United States. So if you want to keep yourself and your family safe, do not waste time worrying about getting smallpox from an immigrant. Get a flu shot.

Generational Pediatrics

One of the satisfying things about being a pediatrician is watching patients grow up to become adults. I have now been in pediatric practice long enough that some of my former patients bring their children to see me and I am becoming reacquainted with some mothers of patients from my early days who are now grandmothers of patients.

Several days ago I walked into a room to see a child I had not seen before. I said “Hello, I’m Dr. Sauder” and the grandmother who had brought the child replied “I know.” She then told me about her children who I had seen years ago. I find those interactions to be very meaningful and I think they are one of the best parts of what I do.

It has also become more apparent to me over the years how generational many of life’s circumstances are, both good and bad. There are always exceptions which prove the rule. But, in general, it does seem that, consistent with the old adage, the apple really doesn’t fall far from the tree. However, I do know some apples from the same tree that did not land particularly close to each other and once in a while an apple ends up in a different orchard than the tree which produced it.

The “trees” in question help determine future socioeconomic status and educational opportunities as well as a multitude of values about how one lives life. It is abundantly clear that each child starts life with a different set of advantages and disadvantages relative to his peers. People certainly have responsibility for their own actions as they get older, but denying that the situation they were born into plays a large role in their development is simply not consistent with reality.

Seeing the next generation of children in a family is fun for me. But knowing the family also helps me understand better how they see the world, what their strengths may be, what things they may need help with, and how I can best help them stay healthy. And it always makes me smile to hear someone say to a child “Did you know he used to be Daddy’s doctor too?”

The Placebo Effect

In medicine, it is not always clear exactly why someone got better or did not get better. Was it because of something we did or in spite of something we did? Many illnesses in children get better on their own so it may not be obvious whether a child’s cough got better because of what I prescribed or was just going to get better anyway.

One way to help figure this out is to randomly assign patients with the same problem to receive either the treatment being evaluated or a placebo. A placebo is something that resembles the actual treatment but is inactive (the proverbial “sugar pill”). By comparing the results of the treatment and the placebo, one can ascertain whether the treatment works by seeing if more people got better with the treatment than with a placebo. The results are most reliable when the doctors and patients do not know who is in the treatment group and who is in the placebo group.

But an interesting phenomenon known as the placebo effect occurs. That is, some people get better with the placebo. And when placebos are compared to no treatment at all, placebos are often more effective than doing nothing so it is not always things just getting better on their own.

Or is it? The placebo effect tends to work better for subjective symptoms which are modulated by the brain. Symptoms such as pain, fatigue, nausea, and insomnia are more likely to be amenable to the placebo effect than other signs and symptoms. A placebo will not make your femur fracture go away or cure a case of Meningococcal meningitis.

A placebo works better if it closely resembles what one would usually anticipate being the treatment for that symptom. In one study, 50% of participants with migraines improved from a placebo pill, even though they were told beforehand that it was a placebo. And there is some evidence that cultural expectations may also influence a person’s response to a placebo.

Is it simply the patient’s perception of their symptom that changes? We really do not know (at least I do not). But it is interesting to think about how our expectations can change our experience of our symptoms (as well as our experience of other things in the world around us).

Parsing the Prevalence of Pediatric Pooping Problems

One thing that we see a lot of that often seems to catch parents by surprise is constipation. Constipation in children is common enough that some days it seems like all we talk about is pooping. When I was in residency, we often referred to it simply as “The Big C.”

Occasionally difficulty stooling will be the presenting concern. However, often the reason for the visit is something else like abdominal pain or urinary symptoms and the underlying constipation causing the symptoms is not obvious. It can be difficult to sort out what the child’s stooling habits are if they are old enough to be going to the bathroom alone. Children are often reluctant to discuss their stooling habits and words like “fine” and “normal” may mean something different to them than it would to me or to the parent. And sometimes children who report stooling daily without any problems will be found to be full of stool if an X-ray is taken.

Constipation can start for a variety of different reasons. Diet can be a contributing factor with intake of excessive amounts of high-fat, low fiber foods and dairy products making constipation more likely. In general, eating a high fiber diet, drinking a lot of water, and exercising is helpful in preventing constipation. However, some people just seem to have more trouble with it regardless of their diet or activities and occasionally constipation can be caused by underlying anatomic or physiologic abnormalities.

Sometimes younger children can become constipated because they had a painful bowel movement at some point and start holding their stool in in an effort to avoid repeating the painful experience. This can be especially problematic if it coincides with attempts at toilet training.

If one has been constipated for a long time, the constant presence of stool stretches out the lower portion of the large intestine and rectum and children can lose the ability to feel when they need to defecate. This is called an “acquired megacolon” and can lead to stool accidents because the child can not sense when some looser stool may have worked itself around the edges of the resident poop.  Stool can then sneak out without them realizing it. This is obviously a concerning situation for the child and parents.

If a child is having significant difficulties with constipation, treatment with laxatives is often required. Relapses are common if the laxatives are not used long enough or in sufficient doses and, in general, the longer the constipation has been present, the longer it takes to resolve.

If your child has frequent abdominal pains, stool accidents, frequent urination, urinary tract infections, urinary accidents, painful bowel movements, or blood in the stool, constipation is one of the potential causes to consider. And don’t be shy when discussing poop with your child’s doctor. We are used to it.

A Few Thoughts on Civility

There has been a lot of talk about civility recently because of events in the news and it reminded me of this string of incidents.

My parents have a sign in their front yard which says “No matter where you are from, we’re glad you’re our neighbor.” This same sentence is repeated in both Spanish and Arabic.

Shortly after the 2016 election, my then 79 year old father was out in the yard. He had had several recent hospitalizations for heart problems so his activities were limited. While he was in the yard, a man approached him and began yelling at him about the sign. My father responded to him with the word “friend” and was abruptly told that they were not friends. He then tried to explain his view that all people are made in the image of God and have intrinsic value and tried to discuss some of the reasons people come here from other countries but he kept being angrily interrupted.

At another encounter several weeks later, this same man told my father that “his kind” (elderly Mennonites with yard signs?) were not welcome here and would be run out of the country. My father responded that he hoped they could talk more and eventually become friends. Most recently at another chance meeting, the other man greeted him by saying “Hi friend” and they were able to have a civil discussion.

In discussing it later, my father said he did not consider the other man to be an enemy, just someone with whom he disagreed. But he also stated that even if he was an enemy, it did not matter because Jesus instructed us to love our enemies.

This kind of love does not mean warm, fuzzy feelings. The Apostle Paul defined love this way: “Love is patient, love is kind. It does not envy, it does not boast, it is not proud. It does not dishonor others, it is not self-seeking, it is not easily angered, it keeps no record of wrongs. Love does not delight in evil but rejoices with the truth. It always protects, always trusts, always hopes, always perseveres.”

Imagine a world in which we all took that approach with each other. Sounds nice, doesn’t it? Sounds like a world in which an octogenarian could enjoy his lawn in peace.

I think civility is one of those things which is more caught than taught. Good or bad, I often see reflections of myself in our children. Leaders have a duty to model civility to their followers. Parents have a responsibility to model it for their children. And we all need to be aware of what those around us may be catching from us.

Warning Signs of Eating Disorders

It is always good to get constructive feedback from patients and their families. A parent of a patient recently let me know that more public information regarding the signs of potential eating disorders would be helpful. There are several different types of eating disorders and it is a complex topic. This is therefore not meant to be an exhaustive discussion of eating disorders but rather some general information regarding potential warning signs.

Eating disorders were previously felt to be mostly isolated to Caucasians in western countries but are now more prevalent in other regions and diverse ethnic groups. They are potentially life-threatening and are more likely to occur in women and girls. Certain personality traits such as perfectionism, anxiety, and behavioral inflexibility may increase one’s risk for developing an eating disorder.

Warning signs include:

·         Excessive dieting and exercise

·         Inducing vomiting after eating or taking laxatives. It may not be obvious that someone is making themselves vomit so be aware of this possibility if someone routinely heads to the bathroom right after eating.

·         Distorted body image – the assertion that one is overweight even when they are thin

·         Strictly counting calories

·         Obsession with food. Some people with eating disorders will spend a lot of time preparing food for others without eating it themselves.

·         Strictly limiting intake of foods or certain types of foods

·         Weight loss

·         Binge eating

·         Dental erosion from stomach acids from frequent vomiting

·         Loss of menstrual periods

Not everyone who exhibits one of these signs has an eating disorder. For example, some people would consider training for marathons to be “excessive exercise” and sometimes competitive athletes will stop menstruating during their season of play. But if you see any of these signs, it is worth noting and mentioning to your child’s physician.

Treatment can be difficult and involves both medical monitoring as well as addressing psychological factors. Treatment is also likely to be easier and more effective if the eating disorder is caught early so be proactive in mentioning concerns to your child’s doctor if you see any of the signs above.

 

 

Do you need to worry about mumps?

With the reporting of some cases of mumps close-by recently, we have been receiving inquiries about the need for an extra dose of the vaccine as well as other questions about how people should protect themselves.

Mumps is a viral illness which causes symptoms including low-grade fever, headache, body aches, swelling and inflammation of the parotid glands (salivary glands located close to the ears) and orchitis (inflammation of the testicles). The virus is spread from person to person through respiratory secretions and saliva.

A vaccine for mumps was first introduced in 1967 and now children are routinely vaccinated against mumps with a dose of the vaccine at 12-15 months and a second dose at 4-6 years. With this approach, the incidence of mumps has decreased by 99% as compared to the pre-vaccine era.

Over time, the immunity acquired from the vaccine decreases. Folks who were immunized years ago still have a lower chance of getting mumps and tend to get less severe symptoms if they do become infected. But the more time has elapsed since one was immunized, the more susceptible they are to acquiring the disease, if exposed.

During outbreaks, giving a third dose of the MMR (measles, mumps, rubella) vaccine to potentially exposed and susceptible individuals has been shown to decrease the number of persons who become infected. This is currently being advised for most students at James Madison University due to the number of cases that have been seen there recently. A third dose is not recommended routinely for people who are not part of an institution or community where there is an outbreak.

If you have questions or are not sure if you should be getting a third dose of the vaccine, contact your healthcare provider.

Why does Johnny use bad words?

As I was sitting at a public event recently listening to the folks behind me dropping F-bombs left and right, I began thinking about how we got into a situation as a society where it is just normal to hear this type of thing. Maybe it has always been this way and I was just clueless and am now turning into a grumpy old man but the things I occasionally hear in public now would have at least elicited appalled glares in the world in which I grew up.

Sometimes parents will ask me about how to address their young child’s foul language. It seems pretty obvious that children don’t invent these words on their own. They are simply repeating what they have heard. I am a firm believer that the behavior we model for children is far more influential than what we tell them to do or not to do. Children will mimic what they hear from the adults around them, the media they consume, etc.

How can you explain to children that they should not call others names when adults in positions of authority engage in name-calling and insulting others? How can you convince them not to use expletives when they are commonplace in the movies they watch or when the evening news involves having to spell words with asterisks in the place of some letters to report a story?

I am a UVA alumnus and fan but loved when Virginia Tech men’s basketball coach Buzz Williams grabbed the microphone at the scorer’s table during a recent game and told a person or group in the student section to “stop cussing.”

I do not think children should be raised in a bubble and then dumped into the world as adults. But there is a difference between being immersed in a world of vulgarity and incivility and knowing that that world exists but having a different one modeled for you.

So be the kind of person you want your children to be. Model civility and respect. Don’t hide the world from them but guide them through it. Be honest, answer their questions. But do it on their level. You can probably tell a five year old that it is a bad word that we don’t use and leave it at that. For an older child you may have to explain what the word means and that there are more acceptable words to use instead.

There are no easy rules to follow and every child is different. So this really involves knowing your child and listening to him so that when these situations arise, you have a baseline understanding to start the discussion. And if you get it right every time, let me know because you will be the first parent in history to do so.

Varicella Variations

One of the striking changes that has occurred during my career is the almost total disappearance of chicken pox in the United States. When I started out, chicken pox was commonplace, almost like seeing someone with strep throat. And it was not unusual for us to have children in the hospital with complications of chicken pox. But now that we routinely vaccinate children for it, I had not seen a case for years until I was in Zambia in July.

I was in a makeshift clinic in a mud brick building and a child was brought in by his mother for a rash which was the classic “dew drop on a rose petal” of chicken pox. He was not particularly ill and everything else was normal and I discussed with his mother through the interpreter what to expect as the illness ran its course.

It was not until they were gone that I realized the Zambians I was working with were surprised (appalled?) at my nonchalance. In their context, without routine vaccination, chicken pox remains a formidable foe. Because many folks lack easy access to clean water, they are more likely to see skin lesions which have become secondarily infected with bacteria. And due to limited transportation and access to medical care, the secondary infections can become severe before they come to medical attention.

So they typically treat aggressively with a combination of an antiviral called acyclovir and antibiotics such as dicloxacillin to prevent secondary skin infections. While this type of treatment would seem excessive in our context, it was a good reminder that chicken pox is not always a benign disease. Prior to the introduction of the vaccine, about 100 children died of chicken pox complications in the United States each year.

When an illness becomes a sort of historical footnote, it is easy to forget the misery it caused in the past, even if you saw some of that misery first-hand 25 years ago. And remaining pockets of diphtheria, polio and measles remind us that without continued vigilance, these diseases could jump out of history right back into our present.

HPV Confusion

I am all for parents making informed decisions about their children’s healthcare and not just being passive bystanders. The key to that is that they need to have accurate information on which to base their decisions.

One subject on which there seems to be a lot of confusion is the HPV vaccine. This vaccine was introduced in 2006 to decrease the risk of contracting the Human Papilloma Virus which can lead to cancer of the cervix, penis, and mouth. One of the early concerns was that by giving young people a vaccine against a sexually-transmitted disease, this would give them license to have sex. This reasoning never made sense to me. I doubt that when young people are contemplating having sex they spend much time considering the risk of cervical dysplasia years in the future. A study in the journal Pediatrics in 2012 found no increase in sexual activity in teens who had had the vaccine when compared to those who did not.

More recently, the concern has been about side effects of the vaccine. Parents sometimes cite “horror stories” they have heard but they often cannot remember exactly what they heard. They often just have a vague unease about the vaccine. In other situations, parents have concerns about specific side effects. When these arise, I have tried to trace their concerns to the original incident in question. When I have done this, I have either run into a dead end because there does not appear to be any actual evidence to support the concern or have found that the circumstances of the alleged side effect were very different from the headlines that end up on the internet.

One concern that has been raised was that the vaccine could cause premature ovarian failure in young women. Premature ovarian failure is when the ovaries stop functioning at an early age, essentially menopause happening at the wrong time. A parent gave me something they had printed from the internet about this. I investigated it as far as I could go and didn’t find anything concerning. In case I was missing something, I asked around and no other physicians I talked to were aware of any evidence of this. Because gynecologists would be the ones likely to hear if there was an increase in this problem in young women since the vaccine went into use, I contacted several gynecologists I know and they also were unaware of any evidence to support this link.

Prior to the introduction of the vaccine, the incidence of premature ovarian failure was reported to be around one in ten thousand women by age 20 and one in a thousand women by age 30. In the first nine years after the vaccine was introduced, six cases were reported in girls who had received the vaccine. During that time around 170 million doses of the vaccine had been given which means the rate was lower than the rate reported prior to the introduction of the vaccine.

Prior to licensure of the HPV vaccine, its safety was studied in 30,000 persons over seven years with no significant adverse effects noted.  Since licensing, more than a million more patients have been studied. In the past seven years, our practice has given almost 9000 doses of HPV vaccine with no significant side effects.

As physicians, we have all taken the Hippocratic Oath which states in part, primum non nocere, “First, do harm.” While we are humans who make mistakes, we would never do anything which we thought would harm a patient. If you have concerns about the vaccine, by all means have that discussion with your child’s doctor. You may even reach a different conclusion than the doctor. Just make sure the decisions being made are based on accurate information.