Vol. 216 August 1, 2019 Parenting Choices and Other “Conventional Wisdoms”

August 1, 2019

 

The evidence supporting some of our most popular opinions is often not so compelling.

 

In 2015 31% of first time mothers were over 30 years old. In 1980 it was 8.6%, and it is safe to assume that those 2015 first time mothers got more of their parenting advice from the internet rather than from an experienced grandmother. One of those first time mothers, an economics professor at Brown, has written a book examining the presence, or absence, of real data on the conventional wisdom surrounding breast feeding, sleep training, and working mothers.

Breast Feeding
According to Emily Oster in her book Cribsheet, the current mantra is that it is best to breast feed your infant: it is easy to do, produces smarter babies with less diarrhea and ear infections, and makes “happier moms with better friendships”. In reviewing the evidence on the internet she notes that breast-fed babies in many of the observational studies of breast feeding are generally being fed by a mother with a higher IQ and in a higher educational and economically class than non-breast feeding mothers. “So which is the cause?” The difference in ear infections in one very large study was 2%. The difference in diarrhea episodes was 4%. One study of siblings, one breast fed and one not, found no difference in IQ or incidence of obesity at 6 1/2 years of age. Her conclusion: “The good news for guilt-ridden moms [who don’t breast feed their infant] is that there is very little evidence for long term effects [of not breast feeding]. Moms often feel selfish about thinking about their own wants and needs with decisions about their kids. In this case, the data gives you permission to put yourself first for once.”

Sleep Training
The internet is apparently full of stories of the extensive long-term damage to your infant if you let them “cry it out”, the code word for “sleep training”. This is apparently based on 1980s studies in orphanages in Romania. Dr. Ferber’s careful studies of sleep training and in 1986 outlined in detail how to do it. (“Ferberizing”)(1) Many studies of sleep training show sizable improvements in maternal depression, family functioning, and no negative effects on infants. But, one small study quoted all over the internet suggested that more stress was demonstrated by the infants a few weeks after sleep training even though the mothers were less stressed. Her conclusion: “Every family is different, and you may not want to let your baby cry. But if you do want to sleep train, you should not feel shame or discomfort about that decision.” ( Since it might take two or three nights to train the infant, I suggest to apartment dwellers to let the neighbors know what you are doing.)

Working Moms

In our pediatric practice we use “SAH” to describe the non-working mom as “stay-at-home”. Also for the non-working dad, but Oster restricts her discussion to the moms. She notes that there is very little data about the pros and cons of mothers working outside the house except for the evidence supporting longer maternity leave which is beneficial to mother and infant in those first months. Like other working parents I have observed, Oster finds that the switching back and forth from work mode (academic research) to child-care mode and back again can be satisfying (she uses the economic term: “marginal value”) as a change of pace that can reduce boredom and fatigue. The economic value of working outside the home is clear. Her conclusion: “Do whatever fits your family best.”

Oster relates that after she had unloaded a lengthy, multi-faceted, escalating stepwise concern to her pediatrician about what to do if her non-allergenic 2 year old child was stung by a bee on an upcoming vacation trip, she responded, “Hmm. I’d probably just try not to think about it.”

That reminds me of the old story of the 100-leg caterpillar merrily progressing along a road when a fly asked him how he coordinated all those legs. The more the caterpillar thought about it the more entangled his legs became, and he ended up curled up in a ball in the gutter.

Who Are the Real Screen Addicts?
Nielsen research found that Americans aged 35 to 49 used social media 40 minutes MORE each week than those aged 18 to 34. They were more apt to pull out their phones at dinner and spend more time on multiple devices, but they peeked at their phones while driving LESS than millennials. One researcher reported that her interviews of elementary school kids about screen times sometimes indicated that “Parents are the worst.” (2)

Stand or Sit At Work?
The 2015 studies suggesting that sitting for prolonged periods increased your risk of cardiovascular disease spawned a widespread wave of popularity for “standing desks”, but repeat analysis of the data indicated that alternating standing and sitting “may be useful for some people with low back or neck pain . . .but there is no scientific evidence for improved cardiovascular health”. (3)

References:
1.
Solve Your Child’s Sleep Patterns, Richard Ferber, MD, 1986 and revised 2006
2.
Wired, April 2018, pg. 67
3.
This Week, December 7, 2018, pg. 20

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Vol. 217 July 15, 2019 NON-POLITICAL TIDBITS TO START CONVERSATIONS AT SUMMER COOKOUTS

July 15, 2019

READING TO CHILDREN: PRINT OR ELECTRONIC?

The prevalence of electronic media has spawned a number of pediatric studies of video gaming, use of smartphones, effects of media on learning, etc. A recent small study of 37 toddlers being read to by a parent using 3 book formats (print, basic electronic, and enhanced electronic – included animation and sound effects) showed some differences in interactions between parent and toddler. Parents showed twice as much dialogue with the child while reading print books than basic electronic. Interestingly the use of the enhanced electronic books came in third. Toddler book-verbalization was slightly higher when being read print books. (1)

These study result is certainly no blockbuster, but the authors opined that reading print books slightly increased “positive interactions between child and parent” and slightly decreased negative directions (“don’t touch that button”). With electronic media parents commented less about the story line and read the text out loud less often. At least one reading specialist I know and discussed this study with plans to continue her own reading on Kindle (even though she easily loses track of the book’s title) and will continue to use electronic media in her reading recovery work with elementary school children.

AN ANTI-CANCER VACCINE THAT IS REALLY EFFECTIVE

HPV (human papilloma virus) is the leading cause of cervical cancer and is sexually transmitted. The HPV vaccine (Gardasil), if administered prior to sexual activity, can prevent the asymptomatic, silent infection by HPV that can lead to cervical cancer or genital warts later on. The vaccine has not been around long enough to show a lowering of actual cervical cancer rates, but a Canadian study showed a 83% decrease of HPV presence among girls aged 13 to 19 since 2006 when the vaccine was introduced. the authors consider this result as “a first sign that vaccination could eventually lead to the elimination of cervical cancer as a public health problem.

LESS THAN 10,000 STEPS A DAY IS OK

A  Harvard study gave fitness trackers to 16.000 women over 62 yrs. old, counted the number of their steps for 7 days, and then monitored their health for 4 years. Those walking 4,400 steps a day had a lower “premature death” rate than those walking 2,700 steps a day. Those walking more than 4,400 steps only had a moderate additionally decrease in death rate and there was no advantage for taking over 7,500 steps. Where did the 10,000 steps a day target come from?— a 1960 marketing campaign by a Japanese pedometer manufacturer that recognized that the Japanese character for 10,000 resembles a man walking! (2)

TASTE?— THERE’S AN APP FOR THAT

IBM is developing a flavor-identifying device (“e-tongue”) which when dunked into a glass of liquid will analyze the composition of the liquid using an array of electrochemical sensors. The data is then sent via the cloud to an artificial intelligence program that compares the composition to a database of known liquids. It is currently able to accurately distinguish between different brands of water, identify counterfeit wines and whiskeys. 

The speculation about the potential medical use for dealing with unsavory biological fluids reminds me of the old, old story about the medical school professor showing the class how to diagnose a diabetic by tasting the sugar in their urine. After demonstrating by dipping his finger into the cup of urine and tasting it, he instructed the class to come up one at a time and do the same, so they would learn how it worked. It was only after the entire class did so that the professor revealed that the demonstration had nothing to do with diagnosing diabetes, but was actually a lesson about careful, accurate observation. “I dipped my forefinger into the urine, but tasted the third one.”

SUVs OR SMART PHONES?

The number of pedestrians deaths was 50% higher in 2018 than the 2009 rate, even though the overall rate of traffic deaths decreased for the second year in a row in 2018. Analysts blamed the proliferation of SUVs with their greater weight, higher bumpers, and diminished visibility, but anyone who has ever driven in a city might alternatively speculate that it is the increased number of “oblivious” pedestrians crossing the street while listening to, talking on, or even texting on their smart phones.

MILLENNIALS ARE NOT THE MOST ADDICTED TO THEIR DEVICES

Research by Nielsen found that americans aged 35 to 49 used social media 40 minutes more each week than millennials. Middle aged americans were more likely to pull their phones out at the dinner table and spent more time than millennials on every type of device—phone,computer, tablet. Millennials do win the prize for the most use while driving. Obligations of work and the ease of maintaining friendships and social connections after the kids have grown up are cited as “reasons” for these findings. But, a researcher interviewing elementary school children uncovered a lot of complaints from the kids about prying their parents away from their screens. “Parents”, she sighed, “are the worst.” (3)

HOW TO SILENCE YOUR SMARTPHONE

Just send $500 to Cohda  for a Komoru ( Japanese for “ to seclude oneself”)  which is a miniature Zen garden bowl of “sand-like” nickel-coated microspheres that block electromagnetic signals from reaching the buried phone. The microspheres won’t scratch the phone nor enter into any ports. (4) It will be ready for distribution just in time for Christmas for “those who have everything else.”

References:
1.  Pediatrics.2019;143 (4)
2. JAMA Internal Medicine 2019 May 29
3. Wired magazine, April 2018
4.  http://www.cohoda.com/projects/komoru/


Vol. 216 July 1, 2019 Public Opinion About High Health Care Costs

June 30, 2019

‘TIS THE SEASON FOR POLS AND POLLS

 

As the presidential election summer season heats up with Democrat’s TV food fights and President Trump’s relentless echoes of 2016 campaign rhetoric, the frequency of public opinion polls on political issues and candidates is increasing. What do polls show about what people think about health care costs? The New England Journal of Medicine just published an analysis by three authors of 14 public opinion polls on health care costs done in 2018-2019 (1)

Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019 (second only to “strengthening the economy” at 70%).

About 90 % of respondents picked the following priorities as “extremely important”:
Reduce prescription drug prices
Reduce the overall cost of healthcare
Do not cut Medicare insurance benefits
Maintain insurance coverage for pre-existing conditions.

Half of respondents reported that health care costs had “actually affected their household a lot”.
40% were “not satisfied” with how much they had to pay for health care.

Why did respondents think that health care costs were so high?
drug companies charge too much …………. 78%
hospitals charge too much ……………………. 71%
Insurance companies charge too much ….. 71%
new drugs, treatments, and technology…….62%

The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.

“At this level, unnecessary health care costs and waste exceed the 2009 budget for the Department of Defense by more than $100 billion (OMB, 2010). Health care waste also amounts to more than 1.5 times the nation’s total infrastructure investment in 2004, including roads, railroads, aviation, drinking water, telecommunications, and other structures. To put these estimates in the context of health care expenditures, the estimated redirected funds could provide health insurance coverage for more than 150 million workers (including both employer and employee contributions), which exceeds the 2009 civilian labor force. And the total projected amounts could pay the salaries of all of the nation’s first response personnel, including firefighters, police officers, and emergency medical technicians, for more than 12 years.” (2)

How did people think we could reduce healthcare cost?
Nearly 90% want the federal government to negotiate drug prices for Medicare
65% want the government to limit charges by hospitals and health professionals
65% want to allow 50-64 year olds to buy into Medicare
52% support “Medicare For All” with little or no private insurance.

Which government?
State 50%  (favored by 60% of Republicans)
Federal 50%  (favored by 70% of democrats)

By what mechanism?
Private insurance competition  (60% of Republicans)
Government insurance program (65% of Democrats)

A majority agreed on two unacceptable ways to reduce costs?

  1. Restrict access to treatments and prescription drugs via “expert opinion” of cost/benefit ratios.
  2. Tax incentives to individuals to buy high-deductible insurance plans.

Only 25% of the public polled were concerned that Medicare would run out of money in 10 years, i.e. little concern about the aggregate cost of health care. Most considered the cost problem as one of high prices rather than of over utilization.
Also, the public is highly skeptical that ANY approach will greatly reduce healthcare prices.

So, despite the consensus that reducing health care costs should be a high priority for President Trump and Congress, there is an obvious partisan divide about how to do it; a partisan divide that continues to make us (the U.S.) unique as the only developed nation lacking universal health care insurance for its people.

References
1. NEJM 380;26 June 27, 2019
2. Best Care At Lower Cost, National Academy of Medicine, Institute of Medicine, 2013


Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.


Vol. 214 June 1, 2019 JUULING AND SCHOOLING

June 1, 2019

“Nicotine addiction begins when most tobacco users are teenagers, so let’s call this what it really is: a pediatric disease.”
-David Kessler, MD. Commissioner of FDA, 1995

 


When I was a young parent my kids’ souls were threatened by the dangers of  “sex, drugs, and rock ‘n roll”. THEIR kids are facing a new triple threat, “marijuana, video games, and vaping”. Vaping? (pronounced with a long ”a”) Really? (pronounced with a short “a”)

How can inhaling flavored water vapor with either no or just a touch of nicotine be dangerous? Let Jonathan Winickoff, MD, MPH, Professor of Pediatrics at Harvard Medical School and Director of the MGH Tobacco Research Treatment Center list the reasons:

First of all, there is no water in vaping solutions. Vaping is NOT inhaling water vapor. It is inhaling particulate matter of numerous chemical compounds in mostly propylene glycol and glycerin. When heated these compounds degrade to formaldehyde. The vapor also contains carcinogenic organic and inorganic chemicals, cytotoxic nano-sized metallic particles from the heater coil, silicates (like in sand), and ALWAYS nicotine. All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Currently there are no FDA regulations about labeling vaping solutions. Companies can label and market anyway they wish without any accountability.

Vaping solutions are flavored to lure teens into using because teen age vaping does lead to dependency on nicotine and a significant percentage of teenage vapers go on to smoking cigarettes (“combustible tobacco”). This assures a continued revenue stream for tobacco companies. Mint, menthol, and mango are apparently the favorite vaping flavors (gives new meaning to “3M” doesn’t it). Flavors in cigarettes were banned by federal law in 2009 except for “menthol and mint”, but the federal ban specifically did not apply to e-cigarettes. There are over 8,000 vaping flavors available.

Juul (jewel) is the most successful vaping company owning about 75% of the market. Juul is so successful that it has become a verb, as in “Do you Juul?, Lets Juul.”

A Juul pod of vaping solution contains about 200 “hits” or puffs which is the equivalent of a pack of 20 cigarettes. Pods are used in devices that previously looked like cigarettes, hence the term e-cigarette, but now vaping devices can look like pens, superhero figures, a miniature coke can, and, most  commonly, a computer thumb drive. One middle school kid laughed at his father’s confusion by saying, “We don’t use thumbdrives any more. Every thing is in the Cloud. If you see a kid with a thumb drive, he is vaping.”

Taking 300-400 hits a day is common. Unfortunately taking an occasional hit as an “experimental rite of passage” can progress to increased use and an unrecognized dependency. JuuLing periodically on the week ends can lead to withdrawal symptoms of anxiety, distraction, and increased body movements on non-use school days. Those are the same symptoms of ADHD.

A popular device, a Sourin Drop, is available in many different colors and is small enough to hold (“conceal”) in the palm of your hand/ It is a refillable device (unlike a JuuL pod which you buy pre-filled) that lets you mix flavored vaping solution and marijuana (THC) so that they can be inhaled together as a mixture.

Juuls are much easier to use than cigarettes to use; you don’t need a match, there is very little aroma, there is no butt to get rid off, they can be used in NO SMOKING zones, and there is certainly no tell-tale stain on your fingers.

A pod cost about $4 and can be bought online easily without proof of age despite the requirement to be over 18.. Needham, MA was the first town in America to ban sales to those under 21, and Hawaii was the first to establish a state-wide ban. Fourteen states have now followed Newton’s example and prohibit stores from selling vaping solutions to those under 21.

Tobacco companies are investing heavily in e-cigarettes. They know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user. They deliberately, purposefully, and relentlessly market vaping to young people. Nearly 40% of high schoolers and nearly 15% of middle schoolers have vaped at “least once”. Use of vaping in places where smoking is prohibited also helps produce a second income stream for tobacco companies.

A lot of this “threat-to-teen-agers-talk” does sound like old hat to some of us old guys , but vaping has the potential of some serious unattended future consequences for our youths. Most of us did survive the dangers of sex, drugs, and rock’n roll after all, and what will be the inevitable triple threat for future teen agers : “space dust, AI simulations (‘feelies’), and audio-visual implants?”

Action plan:

  1. Call your Massachusetts statehouse representative to support the passage of H. 1902 which bans the sale of “all flavored tobacco products” in Massachusetts.
  2. Lobby in your own town to ban the sale of flavored tobacco products to anyone under 21 years of age.
  3. Let your kids and grandkids read this blog.

Vol. 213 May 15, 2019 Fake Nutritious Foods

May 15, 2019

        “Food packaging can be very confusing”

                           -Whitney Linsenmeyer, Ph.D, R.D., St. Louis University

In case you haven’t noticed, the widespread proliferation of nutritious sounding labels in food marketing continues; as in “natural”, “local”, “fresh”, “farm-to-table”, “organic’, and even “gluten-free”. Consumer Reports On Health has tracked food marketing and packaging trends for years. Its June 2019 issue highlights “8 foods that seem healthier than they really are”.

Veggie Sticks – Even if not always green, what could be more nutritious than vegetables?
A professor of nutrition at Boston University calls them “produce pretenders”. Made with potato flour and starch, oil, salt, and just enough vegetable powder to give it color, it is “not much better nutritionally than a potato chip”. A better choice: 4 cups of air-popped pop corn with less calories and much more fiber. Hold back from adding salt and butter.

Rice Cakes– Even the whole-grain brown type of rice lacks fiber and, like other rice products, may contain arsenic.
Flavored varieties can load up on sugar and salt. If you are going to use a rice cracker/cake at least put peanut butter, sliced banana, or humus with a tomato slice on it for more protein and fiber.

ARSENIC!? – It has been known for years that rice picks up arsenic from the soil in which it grows. Arsenic (chemically a “heavy metal” ) is a natural element in the soil. It’s truly “natural”, as in “found in nature”. It is found in trace amounts in all types of rice.  Brown rice can have 80% more arsenic than other types.  The region also makes a difference with Texas rice at the high end and California rice at the lower end. Can it poison you? NO. The FDA permissible arsenic level in drinking water is 10 parts per billion (ppb). One brand of rice cake grown in Mexico tested at 17 parts per billion, and the FDA directed the U.S. company importing it to change its manufacturing process.

Spinach Wraps – That healthy-looking green hue is often just due to food coloring.
The amount of spinach in it can be negligible. Most wraps are made with refined white flour so have very low fiber content.

Protein Powder – Most Americans consume enough protein in their daily food. No supplement is necessary.
The downside of these powders is that some brands have been found to have significant levels of heavy metals and other toxins. Peanut butter in your smoothie is a more reasonable way to add protein if you wish.

Turkey Burgers – They may be no more nutritious than regular beef burgers. Wait a minute, is nothing sacred?!
“Butterball ground turkey” has the same calories and saturated fat amount of a beef burger because of the inclusion of dark meat and skin, but “Butterball ground turkey breast  has about one-tenth the saturated fat.

Bran Muffins– Here it is a matter of size. Muffins are often cupcakes.
The Au Bon Pain raisin bran muffin weighs in at 5 ounces and packs 430 calories and 31 grams of sugar. If really desiring more bran, go with all-bran cereal.

Granola – How can a mixture of oats, fruit, and nuts not be good for you?
It’s the calories of the added sugars, fat, or whey protein concentrate. Better choice: make your own with shredded wheat cereal with some sugar and almonds added.

Instant Oatmeal – It is so “instantly” digested that it can give you a spike in your blood sugar and a shorter period of hunger satisfaction.  Packets flavored with brown sugar or maple syrup can contain more than 9 grams of added sugar. Cooking “steel-cut” oats (round kernels) or microwaving “rolled” oats (steel-cut oats crushed flat) and serving with fruit, a little fruit butter, or cinnamon is a better choice.

Obviously its the added sugar, salt (sodium) and/or saturated fat that belies the “nutritious” label. A recent report from the National Academy of Medicine recommends that the maximum adult daily sodium intake should be 2,300 mg. The average daily sodium intake of Americans is above 3.400 grams.

Now that restaurants are listing calorie counts in their menus you may think you are home-free in striving to eat healthy, BUT Applebee’s Cedar Salmon has only 370 calories AND 19 grams of sugar and 1530 mg of sodium, Chipotle’s Vegetarian Bowl has a whopping 11.5 grams of saturated fat and 1830 mg. of sodium, while even Panda’s Express “Black Pepper Chicken” has close to one-half of the daily requirement of salt.

Reading food labels can be difficult . . . confusing. . . and time-consuming.

PS: A couple of my kids and their kids are not going to like this blog since some of these foods are their favorite “healthy snacks.”


Vol. 212 May 1, 2019 MMR Vaccination Updated and DTaP Explained

May 1, 2019

YET ANOTHER STUDY PROVES THAT MEASLES VACCINE DOES NOT CAUSE AUTISM
An eleven year study of 657,000 Danish children showed that those who received the MMR vaccine had no increased incidence of autism. In fact, the girls who received the vaccine had a 5% reduction in their risk for autism. In Denmark all vaccinations are free of charge and voluntary. When 95% of children in a community are vaccinated against measles the 5% of unvaccinated children are protected through “herd-immunity” due to the reduction of exposure to the highly contagious measles virus.

Measles was declared “eradicated” in 2000. Since then we have had unexpected U.S. measles outbreaks in 2014 and presently we are breaking all records for new cases (78 cases just this very week). Since January 1, 2019 the U.S. has had 465 cases in 19 states. Recent U.S. measles outbreaks in Brooklyn, NY, Portland, Oregon, and Rockland County, NY were caused by unvaccinated visitors to an annual Jewish pilgrimage in the Ukraine returning to their unvaccinated orthodox Jewish communities in the U.S.

Surrounded by states with nearly 700 new measles cases Dayton, Ohio is voicing concern about a measles outbreak in their city. Of the 9 counties in Ohio 8 have measles vaccination rates between 90 – 93%. Montgomery County, Dayton is the county seat, has a rate of only 88%. Remembering that herd immunity is achieved at 95%, Ohio, which requires proof of vaccination within 14 days of school attendance, is considering rewriting their current reasons for exemption (about 9% in Montgomery County) of “religious, medical, or reasons of conscience.”

THERE IS NO HERD-IMMUNITY FOR TETANUS
The “T” in the DTaP vaccine stands for tetanus. Tetanus is not a contagious disease like measles. It is caused by wound contamination with a bacteria that causes intense, painful muscle spasms, clenched jaw (“lockjaw”), and extremely unstable vital signs.  The tetanus vaccine is the only protection against tetanus.  It is rare because most children receive the tetanus vaccine. Oregon in 2017 reported its first case of tetanus in thirty years. An unvaccinated 6 year old sustained a cut on his forehead while playing on a farm and developed tetanus. His 2 month hospitalization cost $800,000. The total bill for his care including rehab services and transportation exceeded $1 million. Upon discharge the parents continued to refuse any immunizations for him  including a tetanus vaccine booster to complete their child’s protection!

PERTUSSIS (“WHOOPING COUGH”) OUTBREAKS HAPPEN IN THE SPRING
The “P” in DTaP immunization stands for pertussis and the standard recommendation is to get 4 DTaPs before age 18 months ,starting at 2 months, with a booster at 6 years and as a teenager. Our periodic pertussis outbreaks can not be blamed wholly on anti-vaxxers who refuse immunizations because the pertussis vaccine is not as effective as other vaccines in maintaining protection; the immunity created by the vaccine wanes over time. The little “a” in front of the “P” stands for “acellular”. The acellular vaccine has less of the side effects of injection site pain, temporary fatigue, and a fever than the earlier vaccine that contained cells of the bacteria. But, this newer vaccine (introduced in the late 1990s) produces a smaller increase in and a shorter duration of immunity. “P” vaccinated people can get pertussis, but unvaccinated children and adults are 8 times more likely to get pertussis.

Pertussis immunization is now recommended for all pregnant women since protective antibodies pass through the placenta to the unborn child affording protection to the infant in the first months of life. Pertussis can be diagnosed in some one with a persistent cough by a simple nasal swab done in the office, and it can be treated effectively with antibiotics.

WHAT ABOUT THE “D” IN DTaP?
Diphtheria is a bacterial disease with a terrible sore throat. When severe it can form a membrane in your throat that blocks off your air and sometimes it produces a toxin that attacks the heart, causing death.  In 1921 the U.S. had 206,00 cases of diphtheria with 15,420 deaths.  The diphtheria vaccine is so effective that such cases are extremely rare in the U.S. Herd immunity is important in diphtheria. The CDC estimates that 94% of kindergarten pupils in U.S. are immunized against it. The Soviet Union, India, and Yemen remain areas with large numbers of diphtheria cases.

“Good ole” Montgomery County, Ohio had one of the last reported U.S. diphtheria cases; a teen age girl with a bad sore throat in 2014. That rare event got lots of press coverage which might be why Montgomery County is a particularly skittish about a possible measles outbreak in 2019.

Diphtheria can be treated effectively with antibiotics and anti-toxins. Any contacts of the person with diphtheria can also be treated to prevent spread of the disease. A simple skin test (Schick test) identifies people with no immunity to diphtheria, so efforts to control its spread can be highly targeted.

MY MODEST PROPOSAL MAY NOT BE THAT “FAR OUT”
My previous blog suggesting that one way to change the behavior of anti-vaxxers would be to sue the parents of an unvaccinated child for neglect to recover the cost of the medical treatment, loss of wages of caretakers, loss of school performance, continued rehabilitation of complications, etc. of any person who then got measles from the unvaccinated case. Perhaps that might send an effective message to anti-vaxxers of a personal financial risk where scientific data holds no sway. What if the parents of the Oregon tetanus-afflicted child were sued by tax payers in Oregon to “recover” the medical care costs of nearly a million dollars presumably borne by Oregon’s tax payers?


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