Month: August 2012

Autism and Children’s Vaccines-still puzzling?

One of the joys of being a Family Physician is I have the opportunity to care for the entire family. With this, I care for many babies and children in my practice, giving physicals, providing school vaccinations, and seeing them when sick. So, of course, the conversation arises often of potential side effects of vaccines, and the most recent concern is that of Autism. It’s a difficult and passionate debate to have, and I try to present the information that I know and come to an agreement with the parents of my patients. I’ll try to briefly explain where the debate comes from below.

Autism is a devastatingly difficult mental condition that affects approximately 1 in 150 children per year in the United States (stats from http://www.cdc.gov). It is a puzzling condition for all involved, including the families and caretakers of these children. In fact, if you see the ribbon magnets on the cars of people that advocate research for Autism, it’s in the form of a jigsaw puzzle.

I believe that puzzle represents both the variety of signs and symptoms that can occur with this condition and the controversial factors and arguments that surround the causes and treatment of the condition. Autism is described as a “spectrum disorder” in that it breaks down into 5 different types and can vary from minimal to severe ranges of effects on the human brain and psyche. These types include autistic disorder, Asperger disorder, disintegrative disorder, Rett disorder, and pervasive developmental disorder. Studies haven’t shown a clear cause yet, although a genetic link has been found. Autism in general is usually diagnosed by age 3years old and is 4 times more prevalent in boys than in girls. It spans all socioeconomic and racial lines, and lasts a lifetime for both the patients and their families.

And so begins the debate-There has been a lot of controversy surrounding vaccines and Autism. You’ve probably seen or heard the story of actress, Jenny McCarthy, whose son was diagnosed with Autism and her concern with the administration of shots containing the preservative, thimerosal. The vaccine containing antibodies for measles, mumps, and rubella (MMR) is one vaccine that has received the most blame in the argued link. The MMR shot is given at age 12months during a well child physical, and now recently, is repeated at age 4-6years old for kindergarten physicals. As mentioned above, most children are diagnosed with Autism around age 2 or 3 years old.

Until 2001, thimerosal was used as a preservative for many vaccines, and it is a mercury-containing chemical. After Jenny McCarthy’s story came out, many parents became worried about the effects of this ingredient and how it might affect their children.

I have had this conversation with some parents in my practice and what we discuss is the following. Studies were done and reviewed on thimerosal by the Institute of Medicine. None showed conclusive evidence that the chemical caused Autism. However, even with these favorable studies, after 2001, levels of mercury and thimerosal were reduced if not taken out of most vaccines altogether.

Because we still don’t know for sure what the etiology of Autism is, the best screening tool we have is the monitoring of development of speech and social interaction by parents at home, along with routine well child physicals done with medical professionals. The discussion of vaccines and possible side effects likely will continue for a while between doctors and patients, particularly about Autism. But, it’s a healthy one to be had, as we continue looking for the key and solution to this huge puzzle.

Be healthy and be blessed,

Dr. Price

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‘Tis the season: Allergies vs. Sinus Infections vs. Colds

‘Tis the season for pollen, mold, and trees. Yesterday in clinic, I think half of my 20 visits involved complaints of “I think I have a sinus infection”. The answer to my “Why?” included many common truths and misconceptions, ranging from “because I’ve congested for a week” and “because I have green and yellow mucus” to “because this happens every year to me”. The truth is all of these signs of symptoms may be present, but I’d bet money that patients are correct less than 30% of the time when trying to self diagnose themselves with infection versus inflammation. Would you know the difference?

Let’s first review the common cold, which I’ve talked about many times before. A cold is a viral infection, which means there’s no great cure. There are ways we can shorten the duration of symptoms, but if I had the cure to a cold, I’d be a retired millionaire. If you read a medical textbook, it would say symptoms of a cold include, headache, muscle aches, low‐grade fever, runny nose, and cough, which can last for about a week. By day number 7, symptoms generally begin to dissipate. Because it’s a viral infection, antibiotics are not the treatment. Let me repeat myself—antibiotics do not treat colds. I can imagine what the next question might be after the last statement, and the answer is that you’re right. Doctors do and might prescribe an antibiotic when you present with a “cold”. However, this is incorrect and should not be done. This helps to produce super‐bacteria that are resistant to the drugs we currently have and create monsters, such as MRSA or methicillin‐resistant Staph aureus and other resistant bugs. This means it will be harder to treat you if and when you do have a bacterial infection in the future.

I hear the mumblings of the next question—then why do antibiotics seem to work when taken for a “cold”. I put cold in quotes on purpose, because what patients often think is a cold isn’t really a cold. It may be a bacterial sinus infection, walking pneumonia, or Strep throat. Or, what I believe is the most common reason, is that the cold was going away on its own, and it was coincidental that you were taking the antibiotic at the same time. In other words, it probably would have gone away without you doing anything. You just happened to be taking an antibiotic at the time.

What does help and what has been proven in studies to help includes, taking Zinc (such as Zicam) or eating chicken noodle soup at the first start of symptoms to cut your sick time by 2 days. Notice I didn’t say cure but shorten the amount of time you’re sick. After trying to shorter the duration of the cold, we treat the individual symptoms with antihistamines, cough medicine, menthol, tea, salt water gargling.

During the allergy season, it becomes even harder to differentiate, because symptoms are similar. Classic allergy symptoms include sneezing, runny nose, itchy, red eyes, congestion, and headache. Allergies don’t occur with fever and are treated with antihistamines, such as Zyrtec or Claritin. Other important treatments include steam, nasal saline and washes (such as Neti pot or saline spray), and cleaning one’s filters in the house and car. A chronic cough can be caused by allergies.

Another million‐dollar question is “Does green mucus mean I have an infection?”

Yes and no. It could mean an infection, but it doesn’t mean it’s bacterial. It is a sign of white blood cells fighting something, and that something could be an allergy or a virus. A bacterial sinus infection is when one‐sided facial pain, runny nose, fatigue,

congestion, tooth pain, and sneezing begin and is prolonged. Talk to your doctor about concerning symptoms.

Be healthy and be blessed,

Dr. Swiner

Back to school‐‐ADHD

Back to school‐‐ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a condition I see and treat often

in my practice as a Family Physician, and it is a controversial and passionate topic

for a lot of my patients. I have those parents and children who do not agree with the

opinions and impressions of teachers and school leaders who suspect the condition,

seemingly too quickly and too frequently. And in terms of treatment, I have those

parents who question the safety and effectiveness of the medicines used to treat the

condition.

A fairly representative depiction of this discussion usually goes as follows:

Elementary school aged child is brought in my Mom or Dad, frustrated by their

behavior at school and constant comments or calls made to them by his or her

teacher. He or she was doing well in school until 2

nd or 3rd grade, when Teacher

began to notice what she described as “fidgetiness.” Now, a perfectly intelligent,

previously well‐behaved child is slipping in his or her grades and is earning

demerits for bad behavior. He or she has begun interrupting class by talking, passing

notes frequently, and keeps forgetting his or her homework assignments. Teacher

has suspicions for ADHD and suggests an evaluation.

Or this: Mom or Dad brings elementary school child into the office to ask about his

or her being “yperactive” He or she won’ listen to directions, talks back, and can’

sit still. He or she does well in school otherwise, and the parents have become

frustrated when usual discipline no longer works.

There are 3 general types, including inattentive, hyperactive‐impulsive, or

combined. It was originally thought that boys have it more than girls, but more

recent studies have not shown a clear predominance. There are nine following

criteria must be present in both the home and outside of the home, must be present

for at least 6months, and must be identified before the age of 7. They also need to

have clear disruption of school or social functioning and cannot be due to another

mental or emotional condition, such as anxiety, depression, or a personality

disorder of some sort. These criteria are too many to list, however, they include:

‐difficulty paying close attention to direction

‐difficulty maintaining a level of attention

‐being “n the go”and talking excessively

‐interrupting or intruding often.

From recent studies, ADHD is a chronic disorder that may be associated with levels

of dopamine, nor‐epinephrine, and serotonin chemicals in the brain. (Am Fam

Physician. 2009;79 (8): 657‐665) Due to the imbalance of these chemicals, patients

with ADHD may suffer from academic, behavioral, emotional and social issues. Also,

because these chemicals have been identified, the medicines used to treat ADHD are

directed toward these chemicals. Most medications are called “timulants” which

are the medicines that interestingly have a calming effect on the child. These

include, Ritalin (methylphenidate), Concerta, and Adderall, among others. If used

correctly at the smallest needed dose, these medicines are very effective but can all

come with possible side effects of appetite suppression, weight loss, insomnia and

headache. I often am asked about their effect on growth of kids, and I explain it has

been shown that these medicines have had association with the trajectory of

growth, but not the amount of growth. This means, if a child’ growth spurt is to be

1‐2feet within a year, it may take a little longer for him or her to reach that 1‐2 foot

growth spurt yet it does not mean he or she will only grow half as much.

Non‐stimulants include Strattera and then other medicines you may have heard of

in treatment of depression or anxiety, such as Wellbutrin (bupropion), Clonidine,

and Imipramine, among others. The other important part of treatment is the nonmedication

based methods, or behavioral methods. Evidence has shown great

benefit from behavioral approaches with reward and consequence methods,

support groups for parents and patients, and parenting skills training. These things

should be done under the guidance and support of clinical providers. Studies show

the combination of both medicine and behavioral therapy of some sort has much

more success than either method alone.

This is how I usually proceed with most of my patients:

1. A patient and parent(s) present with one of the 2 questions I noted at the

beginning of this discussion.

2. I ask if there is any family history (parents, brothers, sisters) of ADHD and

what treatments helped them.

3. Can they identify problems starting before the child turned 7 years old?

4. I make sure there are no problems with hearing, vision, or other medical

issues (anemia, diabetes, thyroid disease among others) with the child. Are

they overeating sugary or caffeinated snacks or beverages?

5. Has there been any other traumatic event (death or illness of loved one,

divorce, abuse) to which the child is responding? Any signs of depression or

other emotional condition?

6. How much sleep does the child get at night? Is it restful, do they snore or wet

the bed? (Bed‐wetting and ADHD seem to occur often together. Snoring or

sleep apnea in kids can cause daytime fatigue and sleepiness).

7. Does the child like school and his or her teachers? If not, why?

8. If ADHD seems plausible, I then ask parent to answer a questionnaire about

patient’ behavior at home (there are various versions, such as Connors

Rating Scale, Vanderbilt Assessment Scales, etc.). Then, we give one to

patient’ teachers.

9. If there is concern from these questionnaires, I then refer to Child

Development and Psychology professionals to confirm our diagnosis, test IQ

and for learning disabilities, and offer treatments options.

10. If parents are comfortable, we can try a medication. If not, we can try

conservative methods and re‐evaluate.

Notice that number one was not “ut child on medicine” This is rarely the right first

thing to do without a thorough investigation. Seek medical advice if concerned

about your child.

Be healthy and be blessed (Have a good school year!),

Dr. Swiner