Friday, January 31, 2014

Raw Milk

      Pasteurization of milk heats the milk to a specific temperature and then cools it down. This process kills harmful bacteria. If the milk is then stored properly (40 degrees or less), it is dramatically less likely to pass dangerous bacteria to someone drinking the milk.
      Milk sold in stores and breast milk from milk banks is pasteurized. What is called "raw milk" is not pasteurized. Raw milk does not have proven benefits AND it is NOT safe: the bacteria that are in raw milk are dangerous. Although raw milk and unpasteurized breast milk is available on some "secondary markets" (such as Craigslist), do not offer it to your children.
      I would strongly recommend that raw milk never be consumed by anyone, but children and pregnant women are at most risk. Please see these links at Healthy Children for more information here and also here

Tuesday, January 21, 2014

Tamiflu and Influenza in Children

     So far this 2013-2014 influenza season, the H1N1 influenza strain is what is circulating in the United States. That was included in both the flu shot and the FluMist (flu spray) vaccine this year. It has also been circulating the last few years. This means that between having had the vaccine or the illness in the recent past, many folks will be protected against the major strain this year. Despite that protection, many kids and adults will get influenza, some worse than others.
     What our grandparents would have said about influenza years ago is still true: you need rest, plenty of fluids, eat bland foods as you can, and treat the fever. Those things are still what I tell families battling influenza. A late fever (especially if there was an initial fever, none for a day or two, and now there is a fever again), a worsening cough a few days into the illness, or poor intake with less than three times urinating in 24 hours are worrisome signs or symptoms for the two most common complications of influenza in children: pneumonia and dehydration. And remember that the fever with influenza is often higher than many other illnesses: 106-107 degrees. Even with those high temperatures, what is important is whether your child perks up when the fever is coming down.
     I am certainly all for children 6 months to 18 years of age (that do not have some reason they cannot get the vaccine) receiving the flu vaccine each year. Since the recommendation changed a few years back (now saying everyone would benefit from the vaccine each year), we have routinely had my three sons vaccinated. One of my twins had influenza in first grade (he is now in 8th grade) before he ever received the flu vaccine. He felt like he got run over by a truck (very achy), had a fever up to 106.3 for 4-5 days, a sore throat, and a cough. Luckily, he did not get dehydrated or a case of pneumonia. He recovered well with rest, plenty of fluids, and fever reducers.
     So what about the antiviral medications, including Tamiflu? (a). These medications can shorten the course of influenza from 5-6 days to 4-5 days (shortens the illness by 1-2 days) if started in the first 48 hours of the illness. They also can prevent someone with a direct exposure to influenza from developing it, if it is given early after the exposure. (b). They are fairly expensive prescriptions -- we recently had a family that decided against filling the prescription for Tamiflu as the co-pay was over $100. (c). The supply of the Tamiflu liquid was in short supply early this flu season. The supply is better at this point (1-21-14). (d). Almost 40% (2 out of 5) of children taking Tamiflu will have stomachaches and nausea from the medication. Every year, we have people ask if they can stop the Tamiflu early because of the stomach symptoms. (e). There are no new promising antiviral medications under development that will be available soon. That means that when the influenza strains evolve and become resistant to the Tamiflu, we will have limited or no options for treating or preventing influenza. Since I began medical school in 1987, at least two prominent antiviral medications are no longer used because the influenza strains are resistant to the medications. (f). Tamiflu can lessen the chances of an ear infection, pneumonia, hospitalization, or death from influenza. (g). Very few people experience these issues, but some adolescents and adults have had self-injury or delirium while being on Tamiflu. These issues, interestingly, have been most prominent in persons in Japan with influenza who have been treated with Tamiflu.
     So when do I recommend Tamiflu in children? 1. A confirmed case (with the rapid influenza test which can be done in the office or at urgent care or emergency department) of influenza in a high risk (asthma, diabetes, heart disease, and some others) patient AND in the first 48 hours of the illness. 2. A confirmed case of influenza with severe symptoms that suggest someone is so ill they may require hospitalization for dehydration or pneumonia, especially if in the first 48 hours of the illness. 3. The rare case when a very high risk patient could not receive the flu vaccine (because of a severe egg allergy, for instance) but has a known direct exposure to influenza (such as a family member having the virus).
     I actually only prescribe Tamiflu a few times each year. I want to use it when it is appropriate. However, I also want to have an effective, safe antiviral medication for real emergencies and urgencies when the medication is truly needed. Now and in the future.

Tuesday, January 14, 2014

Probiotics and Prebiotics

     Probiotics are supplements or foods that contain live bacteria that change the types and number of healthy bacteria in our system. Prebiotics are supplements or foods that contain an ingredient that stimulates the growth or activity of healthy bacteria in our system. Breast milk contains prebiotics
     I am often asked what I think of probiotics. I will try to summarize what we know scientifically about probiotics and prebiotics. Most of what I know about them is from the "Clinical Report -- Probiotics and Prebiotics in Pediatrics", Dec. 2010, by Drs. Thomas and Greer and others.
     Realize that when things are scientifically studied, the gold standard for studies about probiotics or prebiotics are randomized clinical  trials (RCT). With RCTs, the patient and the doctor do not know whether they are getting the "real treatment" or the placebo. That way, when answering the "Was it really better because of the treatment?" question, the doctor, patient, and family are not biased by knowing what they were taking. If I think probiotics really help with diarrhea as a side effect from antibiotics, I may be more likely to say "Yeah, that diarrhea really was better that time I took the probiotics with the Augmentin!". That is why it is so much more helpful to know that "80% of kids on antibiotics have less diarrhea if they take SuperPro [I am making this up as an example]" than "my sister's friend's child took SuperPro while on an antibiotic and they did not have any diarrhea".
     A few things to know from the start: 1. Probiotics are available over the counter without a prescription. 2. There has not been enough studies to help us say "this is the brand to buy!" and feel super-confident about it. 3. Probiotics and prebiotics positive effects only last as long as you take them. If you stop taking a probiotic, the "good bacteria" benefits quickly get out of your system. 4. The top three bacteria in available probiotics are Lactobacillus, Bifidobacterium, and Streptococcus. These bacteria are believed to be the most helpful based on current research. 5. It makes sense that the health probiotic bacteria will help more if more of them are alive. Some probiotic products are kept refrigerated, potentially keeping the bacteria at their best. However, we still do not know for sure if these probiotics are necessarily more effective.
     By 2-4 days of age, vaginally delivered infants have millions of bacteria in our intestines. Breastfed infants have more "healthy" bacteria in their system, even by 7 days of age. After infancy, the average person has 10,000,000,000,000 (!!) bacteria in their intestines, the vast majority being healthy bacteria. These healthy bacteria play a vital part in our immune defense system. Science is still studying all of the particulars of how these bacteria interact and play a role in our immune system.
     Because of where probiotics work (in the intestine), the most hope for probiotics are diseases or illnesses that occur in or are effected by the intestines and its immune system. That means that diarrhea, eczema, inflammatory bowel disease, irritable bowel disease, colic, and constipation are the conditions studied in children with regards to whether probiotics have had an effect.
     So far, the research shows probiotics can 1. help prevent some cases of viral "stomach flu" (acute viral gastrointestinal infections) in children in child care, 2. reduce how long (by about a day and a half) rotavirus diarrhea illness lasts, and 3. reduce by about half the diarrhea associated with antibiotic use when started when the antibiotic is started. Probiotics may be helpful in eczema prevention, treating inflammatory bowel disease, infant colic, and constipations, but we need more large RCTs to know for sure. In addition, large studies on side effects of probiotics have found them to be well tolerated with no significant side effects.
     Foods that include can or do contain probiotics include yogurt (look for the Live & Active Cultures seal), kefir, and aged cheeses (cheddar and Gouda). In addition to foods that include probiotics, many over-the-counter brands are available. To emphasize, there has not been a well done head-to-head study comparing these probiotic brands against each other. In addition, the Federal Drug Administration does NOT evaluate the "this is how helpful we are" claims by probiotics. Therefore, the "helps" and "supports" words used to promote probiotics need to be taken with a grain of salt.
     A good friend of mine exercises every day, eats healthy, does not smoke, and does many other things well to take care of his general health. For a long time, he claimed why he was so healthy was the $80-100 worth of vitamin and mineral supplements he took every month. This is despite the fact that he was getting all he needed of vitamins and minerals from what he ate. This is a thousand dollars a year of unnecessary expense. Realize when zinc supplements (again, not evaluated by the FDA) claim to "support your immune system" that the immune systems that are likely respond to zinc supplements are those folks with zinc deficiency. And zinc deficiency is quite rare.
     Commonly available brands include:
Culturelle Kids Packets or Chewables (contain Lactobacillus)
Dosing for age 1-3 years of age: 1 packet once a day. If using for diarrhea: 1-2 packets every few hours with a maximum of 7 packets in 24 hours.
Dosing for age 3 and above: 1 chewable once a day. If using for diarrhea: 1 chewable 4 times a day.
BioGaia ProTectis Chewables or Drops (contain Lactobacillus)
Dosing: one to two capsules once a day or 5 drops daily.
Florastor for Kids Capsules or Powder Packets (contain Saccromyces and lactose)
Dosing: one to two capsules or packets twice daily.
Florajen4Kids Capsules (can be opened and powder sprinkled on food; contains Bifidobacterium and Lactobacillus; best if refrigerated)
Dosing: one capsule once a day.
     Based on all of the above information, if you are going to try a probiotic for your child, here is what I would recommend.
For colic: BioGaia ProTectis Drops 5 drops daily. If no change in 1-2 weeks, you are not likely to notice a change for the better after that first couple weeks. If it is helping, continue until 3-4 months of age.
For diarrhea: Culturelle, Florastor, or Florajen4Kids. Dosing as above. Start as soon as the diarrhea begins and continue until significantly improved.
For prevention of diarrhea while taking an antibiotic: Culturelle, Florastor, or Florajen4Kids. Dosing as above. Start taking when you take the antibiotic and continue for the full 10 days of antibiotic.
For constipation or irritable bowel symptoms: Florajen4Kids, Florastor, or Culturelle. Your child will likely need to continue the probiotic for 4-6 weeks or more to be able to tell if it is helping. If it does help, feel free to continue the probiotic.
     Summary: 1. Probiotics may be helpful to treatment or prevention of some conditions. 2. Probiotics are very safe and free of side effects when used with the proper dosing. 3. Many more scientific studies need to be completed to know all we need to know about probiotics. 4. If you chose to try a probiotic for your child, I would recommend following the above information.
     Good luck and call if you have questions.

Monday, January 6, 2014

Teen driving

     I have a responsible 18 year old son who had a scary car accident last year. The car was totaled. Thank goodness no one was significantly injured. Teens, for many reasons, are more likely to be involved in accidents and other driving incidents than young and older adults. Improving their skills at driving can save lives, save money, and give us all peace of mind. Although I am grateful that my children are all terrific about using their seatbelts every time they are in the car, I am also grateful that was reinforced when the police officer that responded to the crash told my children they would have had serious injuries if they were not using their seatbelts. When I was in middle school, my best friend died in a car accident when the teen driver of the vehicle drove recklessly.
     There are many resources available to you in helping your child be a safer driver. One is the Check Points Program through the Young Driver Parenting website. Here is the website where this information is available. I think this program has an excellent chance at enhancing the safety of teen drivers. Please check it out!

Wind Chill and Frostbite

     Today (January 6th, 2014) schools in Central Ohio are closed due to the very cold conditions. The wind chill will be talked about frequently this week and beyond. The wind chill is the temperature it "feels like" outside. The windier it is, the faster the skin and the rest of the body cools. The wind chill dropping makes frostbite more likely. Frostbite is an injury due to frozen body parts. Exposed extremities including fingers, toes, ears, and the nose tip are the most likely to be injured by frostbite. Frostbite causes white, numb skin. See this link to the Healthy Children website for more information. Here is the National Weather Service's brochure on Wind Chill. It includes the updated Wind Chill Chart. This is how the temperature and wind speed are used to calcite wind chill. It is also possible to see how many minutes until frostbite will occur.
     So dress warmly, dress in layers, keep extremities covered, and stay indoors as much as possible. Stay warm out there!