Sunday, November 28, 2010

My Advice on Immunizations

Here is the blog I've been dreading, avoiding, and wishing I didn't have to write. It SHOULD be an easy one for me because it is a topic I know well, discuss daily, and am quite clear on where I stand--which is YES, you should fully vaccinate your child, on time, using the schedule recommended by the ACIP (Advisory Committee on Immunization Practices), AAP (American Academy of Pediatrics), and CDC (Centers for Disease Control), and endorsed by me and my colleagues in my pediatric practice. In fact, I believe that immunizing children is one of the most important contributions I can make to maintaining, or even improving an individual child's health as well as a vital contribution to the health of my community.

To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.

I am asked daily to comment on the following questions or statements:

To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.

These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).

I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.

My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.

Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!

In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.

I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.

In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?

If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:

And, for an interesting article in the lay press (not a scientific journal):

Wednesday, November 17, 2010

Get Smart About Antibiotics

Did you know that this week has been deemed "Get Smart About Antibiotics Week?" As a health care provider I am supposed to help educate the public about the proper use of antibiotics. You might wonder why it's important to educate people other than health care providers about when to use an antibiotic. After all, isn't it up to me (and other prescribers) to decide when to write a prescription? As you will see, it's not always that easy. I need YOUR help to prescribe antibiotics appropriately!

First of all you need the basic information. Germs cause infectious illnesses like colds, flu, strep throat, pneumonia, sinusitis, conjunctivitis (pinkeye), bronchitis, croup, etc. Many of these germs are viruses, some are bacteria. Viruses cause most of the coughs and colds we see all winter. They are contagious, can cause fevers, coughs, runny noses, green and yellow mucous, sore throats, body aches, red eyes, and other symptoms. They are not treatable (except for a very few, specific, viruses--and these don't cause cold symptoms) with antibiotics. If you take an antibiotic and you have a virus it will not help you get better. It probably won't even help prevent you from getting a bacterial complication later. In fact, an unnecessary antibiotic is more likely to cause problems for you later by making the bacterial organisms already living in you more able to resist the effects of an antibiotic.

Wow, that sounds really good, even easy. Don't take an antibiotic if you have a virus. Don't prescribe an antibiotic if your patient has a virus. Simple. Done. No worries.

It is up to me to decide, and at the same time, sometimes it isn't. You might be surprised to learn that there are some grey areas when it comes to prescribing antibiotics. Some illnesses are clearly bacterial. Others are clearly viral. And then there are some which could be either, or are probably from a virus, but could be from a bacteria. And, because of these uncertain types of illnesses, there are some situations in which it can be just easier to write a prescription than to explain why one might not be needed, or why the parent will have to bring the child back in a few days if things get worse. Don't be too shocked. Did you really think we (doctors) are beyond influence?

So what should I do in the following situation? My patient has missed several days of school. Dad had to take time off work to bring her to the office. They have a $30 copay for an office visit. She has been sick for at least a week with a cough and low-grade fever. I diagnose bronchitis, because I can hear the phlegm and mucous in her lungs. Yet I don't think it is pneumonia because most of this clears with her cough. I know that about 85% of the time, bronchitis is likely to be caused by a virus (this is true). There is nothing I can do to determine if I am dealing with a virus or bacteria. It could develop into pneumonia, but usually doesn't. Still, there is no way to tell if it will, or not. This is a grey area!

I can hear my professors in medical school saying "NO ANTIBIOTIC is needed in this situation. Have the patient return in a few days and recheck her. Educate the family about the proper use of antibiotics." Then I look at my patient and her family and explain my dilemma. They might say "What do you recommend, Doc?" Or "What would you do if it were your daughter?" Or "We'll take the antibiotic, because we can't afford to miss more work or school." Or "Can we just have the prescription? We can't afford another copay." Or "Last time this happened you didn't let us have the antibiotic and we ended up in the ER because she developed pneumonia." And then, the unspoken reproach, not said but seen in the family's facial expression, "We've been waiting for you for an hour and you're going to send us home with nothing?"

Another common scenario is that of a toddler who has had a runny nose and cough, and now a low-grade fever plus difficulty sleeping. Examination reveals some fluid behind both ear drums. This is called serous otitis media, and is not usually caused by a bacteria. It is just fluid in the middle ear, building up because of all the congestion. It probably has an 80% chance of clearing on its own, without ever needing antibiotics. However, let's say in this case the little one has already had six full blown ear infections in the last eight months. We could just be days away from another one. Ideally I should not prescribe an antibiotic, but should have the patient return for rechecks (as a toddler he won't be able to let us know in a reliable way if he is feeling worse) and give the antibiotic if I start seeing pus in the middle ear. Then I am obligating the family to take more time off of work, pay additional copays, and possibly have difficulty scheduling the follow-up appointment(s).

I'm here to tell you that sometimes, as the one prescribing the antibiotic, faced with the above scenarios, it's easier just to write the prescription.

I try to do as much education as I can--about the strong possibility that what I am looking at is a virus, my uncertainty that an antibiotic would be helpful, the possible need for a follow-up appointment. If I don't give an antibiotic prescription I am often asked "Can I just call back for a script if things get worse, or will they make me come in?" Sometimes I can agree to just call something in if things get worse--but in the case of a small child or infant I can't safely do that. Occasionally I will give a prescription and extract a promise from the family not to fill it for 48 hours, then only if nothing has improved. I have started to write an expiration date on those prescriptions as I have noticed they sometimes get filled a month later, for a totally different illness! I don't think that's a good idea at all--at that point how do I know an antibiotic is needed, let alone if it's the right one?

An antibiotic is not a back up plan or a safety net, "just in case." Antibiotics don't "ward off" complications of viruses. They have no magic. An antibiotic will work only in a very specific situation: when the infection is caused by a bacteria and the antibiotic is the correct one for that particular bacteria.

As a parent you can help by not asking for, expecting, or even wanting an antibiotic when your child has a virus. That could mean waiting a little longer before making an appointment to check out minor symptoms like a runny nose or slight cough. It could mean a statement when you come in for an appointment such as "I know it could just be a virus, but we wanted to make sure we weren't missing anything." It could mean educating yourself a bit about common cough and cold viruses, understanding that symptoms from these viruses easily last two weeks (and sometimes three!), mucous color doesn't mean much in terms of diagnosing a virus versus a bacterial infection, and being willing to simply comfort your child as the cold symptoms run their course.

Hey, look--I know it's frustrating to have a sick child and not have anything you can do to make it get better faster. I have three children of my own, remember? I know the grey areas make it even harder to know what to do. I can offer you my pledge--to treat your children the way I would want my own children to be treated, to communicate to you what I am thinking, and why, and to try my hardest to do what is best for your child. I need your pledge that you will try to want what is the best thing for your child, to understand and listen to what I am saying, and not just to extract an antibiotic prescription from the appointment. I want you to trust me, work with me, communicate with me. I will work with you!

The CDC has a website about antibiotics. I can't get the linking option to work on my blog--but you can type this in yourself.

Saturday, November 13, 2010

Hypoglycemia is a myth?

Parents worry their child might have hypoglycemia (or low blood sugar). They notice that when their child has not eaten for a while they get really mean and cranky. Or their teenager (who skips breakfast and lunch) becomes low on energy, possibly even feeling dizzy in the afternoon. Parents worry that this could mean their child has diabetes. It looks the same as when the child's diabetic grandparent seems "out of it" when their blood sugar level drops. Then they have to get the grandparent to drink orange juice to bring the level back up.

This concern brings itself to my office with a parent asking that their child's sugar be checked, or asking for a diabetes check, or simply with questions about hypoglycemia. Many believe this is a very common condition, and some think that it is a sign of diabetes.

My goal in this blog post is to dispel the myths--the myth that hypoglycemia is a sign of diabetes (it definitely is NOT), and the myth that hypoglycemia is a common and likely explanation for children being mean, cranky, low on energy, or dizzy.

First lets talk about diabetes. The main problem in diabetes is either lack of insulin, or decreased ability to respond to insulin. Insulin is a chemical that is made in the body by the pancreas. Its purpose is to make glucose (sugar) available and usable as a source of energy. Without the important, life-sustaining effects of insulin the result is HIGH blood sugar, or HYPERglycemia. In that case there is lots of sugar circulating in the blood, but it is useless to the body as energy. If a blood test is done, the blood sugar level will be very high.

Diabetes comes in two forms. Type I is insulin dependent--meaning that insulin must be injected into the body--and usually starts at a young age. Type II is not usually insulin dependent, is often controlled with diet or pills, and is traditionally thought to start in adulthood. The SIDE EFFECT of insulin or pills used in diabetes can be HYPOglycemia. If a diabetic person has low blood sugar it is usually an undesirable, and sometimes unavoidable, side effect of the medication they are using to treat their diabetes.

Is that point clear? Having diabetes means you will have HIGH blood sugar levels. Treatment of diabetes could have the occasional side effect of low blood sugar (hypoglycemia), but this is a result of the treatment, not the diabetes itself.

But, now that you know that hypoglycemia (or low blood sugar) does not suggest your child has diabetes, I must go on to dispel the myth that hypoglycemia is a common symptom.

Blood sugar levels are very tightly regulated by your body. Think of this as an algorithm: Levels get high and more insulin is released so the sugar can be processed as energy. Levels start to drop and natural body chemicals stimulate your body to release glucose from various places where it is stored (the liver is a big storage center for glucose). If blood sugar levels are starting to drop there might be a feeling of hunger or thirst as your body is stimulating you to replace your energy stores.

We could not live without this tight regulation of blood sugar levels. If our blood sugar levels were constantly getting low we would be passing out, having seizures, becoming brain damaged, and having terrible things happen to us. Our bodies are so sensitive and so good at preventing low blood sugar that we can often feel the effects of just a slight drop in an otherwise normal blood sugar level. This might be a feeling of hunger, crankiness, headache, or jitteriness. If we tested our blood sugar at that time it would likely be in a "normal" range! Yet the slight drop stimulated the symptoms we are having.

Similarly we might respond to rapid metabolism of simple sugars by feeling a quick boost in energy, followed an hour later by the "crash" as the sugars are absorbed from the blood stream. However, if we test the blood sugar level during the "sugar high" and the "crash", it will most likely fall into a medically normal range. We feel the tiny changes as the sugar is used and then leaves the blood stream, but these changes do not show up on a blood test. And, these adjustments are a NORMAL part of the process of using the energy we put into our bodies. Your body makes you hungry and cranky so you will EAT, and replace the energy you are using.

Is your child feeling jittery, hungry, cranky, low on energy, and mean? Obviously these are unpleasant symptoms. Possibly they are related to the body's metabolism of sugar, but they almost never translate into hypoglycemia that we can identify on a blood test. Other explanations for these symptoms could be fatigue, poor sleep, sensory overload, need to exercise or play, thirst, hunger, illness, or need for some quiet alone time.

It is definitely possible to smooth out the feelings we have as our body makes slight adjustments in our blood sugar levels. Protein, especially, helps even out the ups and downs of otherwise normal blood sugars. The body will first use the simple sugars in the blood, as they are the easiest to digest, then move on to other sources, such as protein, to help maintain smooth blood glucose levels. Some protein at breakfast, lunch, and snack can go a long way toward helping your child feel better throughout the day. An all carbohydrate diet (such as a breakfast pastry in the morning, followed by graham crackers for snack, and then a granola bar at lunch) sets your child up to feel bad, noticing all those little ups and downs as the body tries to maintain normal blood glucose levels.

You don't believe me? You were diagnosed with hypoglycemia, you say? I'm not saying it's impossible to have hypoglycemia--I'm just saying it's much more likely that your child is feeling the effects of normal body metabolism, and that if we check the blood sugar levels they will look normal!

As a physician, I have had patients and parents who did not believe me, who needed proof their child was not hypoglycemic. I have sent blood glucose monitoring units home with families, to check blood sugars throughout the day and record symptoms. Years ago one teenager did a beautiful job with this. He monitored his levels throughout the day, recorded his cranky, weak, and hungry symptoms, checked levels before and after eating, upon getting up in the morning, after exercise, etc. Despite having many symptoms he thought were attributable to hypoglycemia, ALL of the blood sugar levels recorded were in the medically normal range!

So, when you think about it, were you really diagnosed with hypoglycemia? Or did someone offer that diagnosis to you as an explanation for the symptoms I have described, without explaining in detail how the body works to maintain normal sugar levels? It would be easy for a health care provider to offer hypoglycemia as an explanation for such symptoms (it's hard to explain, after all), and then put the focus on improving the diet to help minimize those unpleasant symptoms.

Now that I have hopefully dispelled the common myths around hypoglycemia, I do have to mention some true examples of hypoglycemia! Newborn babies are at risk for hypoglycemia. Through the pregnancy the fetus makes its own insulin to respond to its mother's blood sugar levels. So the newborn baby sometimes comes out of the womb making much more insulin than it will end up needing, and there will be low blood sugars for a period of time. These levels can be very low, and sometimes need to be treated for a few days after birth.

There is also a condition that can affect young, usually tiny, toddlers and preschoolers. They might have true hypoglycemia after a long fast (often over night). Their symptoms are pretty dramatic--a seizure or loss of consciousness, inability to wake up--not just cranky. There are some rare conditions that can affect older kids, as well. Again, the symptoms will be dramatic--loss of consciousness, seizures, inability to wake up. Usually these symptoms are on a level that an ambulance must be called to take the patient directly to the hospital.

And, by the way, symptoms of Type I, childhood, insulin dependent, diabetes (which is HIGH blood sugar, remember?) are excessive thirst, excessive urination, excessive appetite, and weight loss.

Please keep in mind that the comments in my blog are meant to provide you with useful information and things to think about, but not to diagnose or rule out any particular medical condition in your child. My blog is not meant to be a comprehensive analysis of any particular condition. For that you need the personal attention of your child's own doctor.

Friday, November 12, 2010

Fatigue, Teens, and Tweens

I see many tired teenagers in the office every day. They take naps after school, can hardly get out of bed in the morning, sometimes sleep half the day on weekends, and generally are low on energy. They always seem low on energy when it is time to get up to go to school, do homework, or do chores. They often revive in an amazing way when it is time for sports practice or competitions, or time to engage in some way with peers.

Their sleep habits are often poor--bedtime of 10:30 or later, then up at 6:30 on school days (teenagers should be getting about 10 hours of sleep at night, averaged over the week, without counting naps). Their phones, computers, TVs are in their rooms to distract them as they try to fall asleep. They often skip breakfast, or have a high sugar treat on the way out the door. Lunch is fast food, or the equivalent in high fat and low nutritional content. Or they don't eat lunch. Fluids can be minimal throughout the day. Some teens barely exercise. Most spend lots of time in front of a screen (TV, computer, games, phones).

Then there is the stress of being a teenager--six or seven teachers making demands, tests, homework, sports, clubs, applying to college (fatigue is VERY common for seniors in high school!), lack of spending money, or the added pressure of a job, relationships with family and friends, a boyfriend or girlfriend, fitting in socially...Actually listing this makes ME feel a little tired and stressed. Wouldn't YOU want a nap after school, too?

There are many causes of fatigue, both physical and emotional. Of course there are important medical causes of fatigue, and mental illness (such as depression) can lead to fatigue. However, fatigue is a common symptom, and MOST OF THE TIME it reflects common, ongoing, physical and emotional stress in a teen or tween's life.

My medical training leads me to think of the most likely things first. There is a kind of medical school joke about zebras and horses. You need the background information that in the United States of America you would be more likely to see horses than you would zebras. In fact, you would probably have to go to a zoo to see zebras, while you could just drive out to the country to see some horses.

So, in south west Michigan, if an animal looked and smelled like a horse, was the same general size as a horse, walked and sounded like a horse--but you just couldn't see its hide to tell if it was striped or plain--would it be more likely a horse or a zebra? The right answer here, of course, is that a HORSE would be more likely than a zebra. It would not be impossible to see a zebra (I guess a farmer could have one as a pet, or one could have escaped from a zoo), but out in the country in south west Michigan you are probably looking at horses.

That means, that when I am assessing someone for the cause of their fatigue, I keep the possibility of zebras (or less common illnesses) in mind, but I do NOT usually end up seeing stripes. I am going to ask general questions about the patient's life, and these answers will factor in an important way into what I think is causing my patient's fatigue. I might ask any or all of the following questions, or even think of other questions that are centered around lifestyle, home, and school:

1. How is school going? Grades, attendance, completing assignments, behavioral concerns at challenges, perfectionism, getting behind in school?
2. How are you getting along with your family? Who do you get along with best? worst?
3. How are things at home?
4. Anything changed at home? Divorce, separation, illness, pets, job loss, troubled sibling...
5. How are things with friends?
6. Dating? How is that going? How long? Physically involved with this person?
7. Are you in trouble with anyone? Suspended? Grounded? Have a probation officer?
8. Substance use/abuse? Tobacco, alcohol, illegal drugs, prescription drugs...
9. What is your daily schedule like?
10. When do you have free time? What do you do with it?
11. What are your eating patterns like? Do you eat three meals? Drink enough water? Take a vitamin?
12. Are you happy with your weight? Dieting? Losing or gaining weight?
13. When and how much do you exercise?
14. Are most teenagers happier than you?
15. Are most teenagers having more fun than you?
16. Do most teenagers have more friends than you?
17. Are most teenagers more popular than you?
18. Are most teenagers thinner than you?

I think this list could be endless. Hopefully you see my point, that any number of these factors could be important considerations in figuring out why your child is tired all the time.

Of course there are the so-called "red flags" when it comes to fatigue. Here I am thinking about signs of depression, deliberate self-harm ("cutting"), thoughts of suicide, a suicide plan. I am also looking for excessive, paralyzing anxiety or panic.

And finally, last on my list, still important but much less likely, the reason most parents bring their fatigued teen or tween to see me, PHYSICAL ILLNESS as a cause of fatigue. Here is where I see parents worry. They believe their teenager has hypoglycemia, or diabetes, or a thyroid condition, or anemia. Now I am asking about weight loss, blood in stools, diarrhea, urinary frequency, excessive thirst, excessively heavy periods, palpitations, dry skin, constipation, night sweats, absent or fewer periods, joint swelling or pain, and other physical symptoms. I always ask about headaches and stomachaches as well, but many people have these symptoms so it doesn't usually help me narrow things down.

Follow all of the above by a physical exam, and sometimes blood work (often just general screening for anemia, hypothyroidism, and a general metabolic panel that includes a blood sugar level), and I am usually left with a physically normal appearing teenager who has normal blood tests. Parents are relieved. BUT THE TEENAGER IS STILL TIRED!

In my respectful, and humble opinion, the blood tests have contributed very little to the evaluation of the fatigued teen/tween. The physical/medical disorders that could have led to abnormal blood tests just aren't that common in comparison to the psychological, lifestyle, and mental health issues that can lead to fatigue. And while it may relieve YOU, as the parent, to know the blood tests are normal, it didn't help your teen overcome his fatigue!

I am not advocating skipping the medical work up for a fatigued teenager. What I want is for parents and teens to take a close look at their lifestyle, diet, sleep habits, stress, and mental health, and to consider these issues as a possible important cause of fatigue. MOST OF THE TIME these issues will be THE cause of the fatigue, so I don't think we can ignore them.

I don't want to miss an important physical cause of fatigue any more than you do, but I do want to help your child feel better. That will probably take us looking at the whole picture, not just ordering a blood draw. And it may involve a solution that is not as easy as taking a pill. It could include changes in lifestyle, diet, nutrition, sleep habits, exercise. Or a recommendation may be made for counseling or family therapy.

You might also be able to tell from this blog that an evaluation for fatigue deserves its own appointment in my office. This is not a work up I can easily add on to the end of a visit for a cough, strep throat, or wart, or piggy-back on to a sibling's appointment. We need to give this symptom the time and attention it demands. After reviewing the information above, however, you may have more insight into the problem and have some ideas for helping your teen. It's usually ok to try some things before making the appointment.

As I always say, this blog is intended to provide general information for situations that are not specific to any patient or family. My blog is not meant to be medically comprehensive and cannot take every situation or symptom into consideration. Every one deserves to have their concerns personally addressed by their own doctor, and the information in my blog is not a substitute for that kind of attention.

Friday, November 5, 2010

Norovirus in Kalamazoo

Our office received a "Health Advisory" from the Kalamazoo County Health & Community Services this week. It announces laboratory-confirmed cases of Norovirus in Kalamazoo County. Norovirus is the new, official name for viruses previously known as Norwalk viruses. Noroviruses have been responsible for relatively large outbreaks of vomiting and diarrheal illnesses on cruise ships, in schools, and in day care centers.

My factual information in this blog comes directly from that Health Advisory, and a fact sheet about Norovirus from the Michigan Department of Community Health, Communicable Disease Division, 201 Townsend Street, CVB-5th floor, Lansing, Michigan. The advice on oral rehydration is the general advice I and my colleagues at Trestlewood Pediatrics give to parents whose children are suffering from a vomiting and diarrheal illness.

Noroviruses are contagious viruses that cause stomach and intestinal illnesses in people. These kinds of illnesses are often incorrectly referred to as "stomach flu" or "flu". Actually, the correct term is gastroenteritis. Gastroenteritis has no relation to influenza (correctly termed "flu"), which is primarily a respiratory illness.

The most common symptoms of a norovirus infection are nausea, vomiting, diarrhea, and abdominal cramps. They occur 10 to 48 hours after exposure to the germ. Other symptoms can include fever, chills, headache, muscle aches, and fatigue. The symptoms last 1 to 2 days, and can be very severe for some people. Dehydration is the most worrisome problem that can result from a Norovirus infection. This would occur if the sick person cannot drink enough fluids to replace what they are losing in vomit and diarrhea.

Treating Norovirus infections means replacing fluids and waiting for the symptoms to subside. There are no antibiotics or vaccines for Norovirus. Fluid loss should be replaced with clear liquids. The best fluids, especially for children five and under, are oral rehydration solutions such as Pedialyte. Sports drinks are not a good substitute because they have too much sugar. Diluted juice or water could also be given, but preferably to an older child. Infrequently a child may need to see a doctor to determine if intravenous fluids are needed.

When orally rehydrating an infant or young child you may need to give them the oral rehydration solution in a syringe. Wait one hour after the last vomiting episode, and then syringe feed Pedialyte 1 to 2 teaspoons (5-10 ml) at a time every ten minutes for two hours. Set a timer on your stove so you can stay on track.

If vomiting starts over, wait an hour and start the oral rehydration process again. If your child tolerates 5 to 10ml every ten minutes for two hours, you can then let them have more at a time (maybe 20-30ml every 15 minutes). Continue with only clear liquids for at least half the day. If everything is going well after that you could try a little milk, or one small cracker or piece of cereal. Start over if they vomit again. Don't let your pathetic little sick child sweet talk you into giving them food or milk until you know they are tolerating the clear liquids quite well. If you introduce food or milk too soon you will set everything back by hours because it will almost certainly induce more vomiting. Crackers do NOT settle the stomach of a vomiting child. First go slowly with oral rehydration solutions such as Pedialyte. Don't let your child refuse the Pedialyte, give it to them in a syringe, as if it were medicine.

The nice thing about Pedialyte is that it can be partly absorbed from the stomach (instead of having to travel all the way to the intestine first)--so even if some of it gets vomited back up, some will still be absorbed. This is not true of sports drinks, water, or juice.

The most interesting thing about Noroviruses is how very contagious they are. They are quickly spread from person to person, by ingesting contaminated food and drink prepared by infected food preparers, by touching contaminated surfaces and then touching the mouth, or having direct contact with an infected person and then touching the mouth before washing hands. Stool and vomit from an infected person is definitely contaminated with norovirus. In some cases undercooked oysters or drinking water contaminated with sewage have been the cause of an outbreak.

If you have norovirus, you are contagious from the time you start feeling ill or nauseated until at least 3 days after recovery. The contagious period after recovery can last as long as two weeks for some people.

Good hand washing with SOAP AND WATER is important to prevent further spread of the virus. Infected people should not prepare food, work in nursing homes, or take care of patients while they have symptoms, and for three days after the symptoms are gone. Children may return to school and daycare when the diarrhea and vomiting is gone. Then hand washing with soap and warm water must be strictly enforced. Alcohol based hand sanitizers do NOT work against norovirus. Soap and warm water is the best way to eliminate the germ from your hands. A household chlorine bleach-based cleaner should be used to disinfect contaminated surfaces.

So, wash your hands with soap and water, disinfect your surfaces with some kind of bleach solution, don't go to work or school if you become nauseated, vomit, and/or have diarrhea, and don't return to work for three days after you are better if you have a job preparing food or taking care of patients. Don't return to school until vomiting and diarrhea have stopped, and then use careful handwashing methods with soap and water. Have some Pedialyte on hand, or know where you can get it. Stock up on medicine syringes in case you must force feed the Pedialyte. And wash your hands again.

Please call your own personal pediatrician for more specific advice for your child. My blog is meant to provide you with general information, and is not a good substitute for the personal attention your own doctor can provide.

The Michigan Department of Community Health norovirus cleaning and disinfection guidelines, as well as other information, are available at the following link. Once at the main web site, click on the icon for Health and Services, then type Norovirus into the search box.