Tag Archive: medical mumbo jumbo

The Doctor Is In: H1N1 Vaccine

My husband is a pediatrician.  Once a week(or so) I share this space with him so that he can give you up-to-date and  pertinent information about a variety of medical topics.  If there are topics that you would like to see him address, please email me at queenofhaddock(at)gmail(dot)com.

***Disclaimer – this is my personal statement regarding influenza and includes things that I tell my own patients/parents in visits to my office. This is not meant to be a substitute for a visit to or discussion with your pediatrician. For any questions regarding your child’s health you should of course discuss them with your pediatrician. This is meant only to provide information, which I hope you find helpful.***

So there have been a ton of questions regarding the H1N1 flu vaccine.  There are a lot of concerns over whether or not it is a safe vaccine, if it has been tested enough, etc.  Let me go ahead and say that the H1N1 vaccine is just as safe as the seasonal flu vaccine.  As far as whether or not it has been “tested,”  we already have years of clinical experience with the seasonal influenza vaccine, and the H1N1 vaccine is prepared in exactly the same manner as seasonal flu vaccine.  (For my previous post on influenza, go here).

To understand how the vaccine works, let’s go over a little background information on the virus.  The flu virus has on its surface proteins that help it to cause infection and duplicate itself.  For influenza A, these are hemagglutinin and neuraminidase.  Hemagglutinin plays a role in helping the virus to attach to cells in our body, and neuraminidase plays a role in allowing the virus to penetrate into the cells and start using the machinery of our cells to reproduce itself.  These unique proteins help to type the virus.  The “swine flu” virus that is circulating this year has hemagglutinin 1 (H1) and neuraminidase 1 (N1) on its surface, therefore it is termed “H1N1.” These two proteins on the surface of the virus change slightly every year from either mutations in the DNA that code for them (termed “antigenic drift”) or occasionally change greatly by recombination of genes between two different types of flu viruses (termed “antigenic shift”).  If the flu was exactly the same every year then after your immune system saw it one time with infection or immunization, then re-exposure would allow the immune system to recognize it and attack it before it caused infection.  These yearly subtle changes in the surface proteins are what allow the flu to evade our immune system, appearing as a “new” virus that the immune system does not recognize.  This is why you have to get a flu vaccine every year.  Information is collected every year on what strains of flu virus were the most common circulating strains.  Using the prior years’ trends to predict which strains will most commonly circulate in the coming year, the flu vaccine is prepared with these proteins from what is believed will be the most common flu virus strains for the upcoming flu season.  The flu vaccine has to be incubated for months using eggs, which is why the flu vaccine isn’t always perfect in preventing flu.  Sometimes the best models for predicting which flu virus strains will circulate aren’t 100% accurate, so therefore neither will the vaccine be.  Even if the vaccine isn’t perfect, some protection may still be provided.  One might ask why not wait and see which strains show up at the start of flu season, which would be a reasonable question.  The issue there is that if we waited until we knew which strains would be circulating, then by the time the vaccine was ready after months of incubation, flu season would be over.  For more detailed information on how the viruses for the seasonal flu vaccine are chosen go here.

That brings us to the H1N1 vaccine.  Unlike the seasonal flu, we know which surface proteins are present on the virus (H1N1!!) and therefore the vaccine is specific for the swine flu strain.  The vaccine is prepared in exactly the same manner as the seasonal flu vaccine, and therefore is just as safe to receive.  There are two types of vaccine – the injectable vaccine and the nasal spray (FluMist).  For H1N1 specific information on each vaccine click here for info on the shot and here for info on the nasal spray vaccine.  Much more information in the H1N1 vaccine may be found here

The exact timing of availability of the H1N1 vaccine will vary by state, but in general the higher risk populations will be targeted first

  • Pregnant women
  • Household and caregiver contacts of children younger than 6 months of age (e.g. parents, siblings, and daycare providers)
  • Health care and emergency medical services personnel
  • Persons from 6 months through 24 years of age
  • Persons aged 25 through 64 years who have medical conditions associated with a higher risk of influenza complications

(Above target groups via http://www.cdc.gov/h1n1flu/vaccination/clinicians_qa.htm)

This grouping does not mean that you won’t be able to get it if you’re not in one of the above groups.  As production of the vaccine continues the supplies will eventually cover all those who desire it.  Early on, however, supplies will be limited.  Therefore the initial target groups are those at higher risk from complications of infection.   Currently in the state of Georgia healthy children aged 2-4 are being targeted to receive the intranasal (FluMist) vaccine, as they are among the most common group responsible for transmission of the virus to others.  Check with your pediatrician or local health department to see if/when the vaccine is available for you or your child.

In deciding whether or not to be vaccinated or to have your children vaccinated, know that it is a safe and effective vaccine.  Also consider that while H1N1 has not been the great pandemic killer it was feared to be, there’s always the possibility, however remote, than the virus may mutate or acquire a gene that allows it to cause much more severe disease (this was what caused the 1918 strain to be so deadly – it had a particular gene that provided it much higher virulence).  Now is the time to be vaccinated before such an event occurs.

One other thing that should not be overlooked is that the H1N1 vaccine only protects against the H1N1 flu virus.  It does not protect against the seasonal flu virus, which is still out there circulating.  If you want to be protected from the seasonal flu virus, you will need to be immunized with the seasonal flu vaccine in addition to the H1N1 vaccine.

The Doctor Is In: Flu

My husband is a pediatrician.  Once a week I share this space with him so that he can give you up-to-date and  pertinent information about a variety of medical topics.  If there are topics that you would like to see him address, please email me at queenofhaddock(at)gmail(dot)com.

***Disclaimer – this is my personal statement regarding influenza and includes things that I tell my own patients/parents in visits to my office. This is not meant to be a substitute for a visit to or discussion with your pediatrician. For any questions regarding your child’s health you should of course discuss them with your pediatrician. This is meant only to provide information, which I hope you find helpful.***

Influenza and Swine Flu

There has been a lot of attention given to flu this year with the advent of a novel H1N1 influenza virus, aka Swine Flu. Panic seems to be widespread, and misinformation is running rampant. The first thing I would love for everyone to do is calm down. Take a deep breath. If you remember nothing else from me today remember this – swine flu has, to date, been no worse than regular seasonal flu. It has not been the great pandemic killer that it was feared to be. Your risk of a bad outcome from swine flu is no higher than your risk of a bad outcome with “regular” flu.  So if normal seasonal influenza was not a cause for you to panic in years past, then neither should swine flu. The media has hyped up swine flu beyond reason, and lost in the panic of swine flu is the fact that seasonal influenza still accounts for about 30,000 deaths every year.

That being said, let’s get a basic background on flu. The usual influenza course begins with sudden-onset fever, and a combination of chills, headache, fatigue, diffuse muscle aches, and a non-productive cough. Later signs and symptoms include sore throat, congestion, runny nose, and a worsening of the cough. Most healthy children who contract the flu have an illness that lasts 3 to 7 days followed by complete recovery. Certainly there are children who are at higher risk for complications from flu (secondary pneumonia, bronchitis, etc.). The major categories of individuals who are at high risk for complications of influenza are listed here:

  • Children younger than 5 years old, with the most severe complications from seasonal influenza in children younger than 2 years of age.
  • Adults 65 years of age and older
  • Persons with the following conditions:
    o Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus);
    o Immunosuppression, including that caused by medications or by HIV;
    o Pregnant women;
    o Persons younger than 19 years of age who are receiving long-term aspirin therapy;
    o Residents of nursing homes and other chronic-care facilities.

Flu is spread from person to person by respiratory droplets from coughing or sneezing. It may also be contracted from a surface contaminated by droplets from another individual. There are three types of flu – A, B, and C.   Type A and B are the cause of epidemic disease, with type C being only sporadic.  Type A has two surface proteins which identify each strain, Hemagglutinin and Neuraminidase, and these proteins are used to type each strain of flu A (i.e. H1N1).

Swine flu is a novel H1N1 (type A) flu virus. There have been H1N1 viruses seen in prior flu seasons. The swine flu currently circulating has two genes normally found in a type of influenza virus circulating in pigs, but also has genes found in flu viruses that circulate in humans and birds as well. As noted earlier, swine flu has, to date, has not caused illness any more severe than recent seasonal influenza strains. In fact, in the state of Georgia, the Public Health Laboratory is no longer testing anyone with flu for swine flu unless they are hospitalized, as the outpatient population has not had any more severe an illness than with the usual seasonal influenza.

Treatment and prevention of seasonal influenza and swine flu are essentially identical. Prevention of the flu starts at home. Frequent hand washing, covering your coughs and sneezes into your elbow or a tissue which is then thrown away will be critical to preventing spread of the flu. You can also protect yourself by being vaccinated against the flu every year. The vaccine for swine flu is still being developed. Those currently targeted as priorities for vaccination against swine flu are pregnant women, household contacts and caregivers for infants younger than 6 months of age, health care personnel and emergency medical personnel, children and adults from 6 months through 24 years of age, and adults aged 25-64 years with health conditions that place them at greater risk for influenza-related complications.

Treatment of influenza is primarily with supportive care: Tylenol for fever, plenty of fluids to maintain hydration. Antiviral medications are available, but are not warranted in all cases of flu. For routine seasonal flu, much of the circulating influenza virus is resistant to the antivirals Tamiflu and Relenza. Swine flu has so far proven to be sensitive to Tamiflu. The current AAP recommendations (along with the Georgia Department of Community health and the CDC) do not recommend swine flu be treated any differently than seasonal influenza. Treatment is recommended for those who are at high risk for complications (see above list). In other words, if you are an otherwise healthy individual treatment is usually not needed if you do have the flu. Consider also that unless treatment is started within 48 hours of the first symptom onset, then you get no benefit from treatment. (One exception may be if you are sick enough to be hospitalized). The maximum benefit from treatment with Tamiflu is one day’s less symptoms. So instead of feeling like a Mack truck hit you for six days, you feel that way for five. Tamiflu is expensive (over $100 for a five day course of treatment), and many insurance plans do not cover it. Side effects are not insignificant, either. A recent study from the British Health Protection Agency found that over 50% of school-aged children who take Tamiflu have at least one side effect, (nausea, vomiting most commonly), and nearly 18% had at least one neuropsychiatric side effect. So unless you have a chronic health condition prior to becoming ill, you probably do not need antiviral medication. (As always, you should discuss the need for treatment with your physician).

So to summarize, the flu, be it seasonal or swine, is an illness that most individuals are able to handle with good supportive care. To be sure, there are those who are perfectly healthy and still have very bad outcomes due to influenza complications, but the numbers are not climbing with the advent of swine flu. Wash your hands, cover your coughs and sneezes, and should you get the flu anyway take Tylenol and plenty of fluids, and see your doctor if you have any concerns or questions!

Sources cited/quoted:
* http://www.cdc.gov/h1n1flu/recommendations.htm
* http://www.cdc.gov/h1n1flu/qa.htm
* www.aap.org
* American Academy of Pediatrics. Influenza. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:400-412.
* Pediatric News Aug. 2009: 8-9.

The Doctor is In: Fever in Kids

So, I’m giving in and giving my husband a space to talk about what he knows best: pediatric medicine.

Everyone?  This is Marshall.  Say hi(and ignore his visually maddening Twitter background). Today he’ll be talking about fever in kids.  But if there’s something else you’d like to see him write about, email me at queenofhaddock(at)gmail(dot)com and we’ll see what we can do.

***Disclaimer – this is my personal statement regarding fever and includes things that I tell my own patients/parents in visits to my office.  This is not meant to be a substitute for a visit to or discussion with your pediatrician.  For any questions regarding your child’s health you should of course discuss them with your pediatrician.  This is meant only to provide information, which I hope you find helpful.***

So as far as fever goes, it certainly carries a lot of parental anxiety with it, and often a lot of caregiver anxiety as well.  Fever has been recognized for centuries as part of the body’s mechanism for fighting infection.  Many species of animal have been able to survive because of their ability to mount a febrile response to invading pathogens, be they virus, bacteria, or other.  Certainly fever should be considered in the context of the individual patient’s presenting signs and symptoms (i.e. a child with a fever of 104 who is bouncing all over the exam room warrants a different response than a child with a temperature of 104 who is lethargic and unresponsive).  There are always exceptions to every rule or statement, so for the purposes of this discussion we’re talking about “normal” kids – those with normal immune systems, no complex medical history, etc.

To talk about fever we should also consider what’s normal.  Most people consider a temperature of 98.6 a normal temp, and start worrying as soon as you hit 99.  The 98.6 is often not where someone’s temperature is found to be even when well, just as most women don’t actually deliver on their “due date.”  The number considered by many to be “normal”  came about when a physician by the name of Carl Wunderlich conducted one million measurements of temperature on 25,000 adults using a 12 inch thermometer and obtaining readings from under the arm.  He then obtained the average of those readings to be 98.6, with ranges from 97.2 to 99.5.  An individual’s body temperature varies throughout the day and can change by more than a degree, with the normal low for the day being in the early morning and the normal high occurring in the early evening.  The definition of a true fever begins at 100.5 – so when the daycare calls you and says “your child has a temp of 99.5, come get them,” you can educate them on what defines fever.

The first thing I tell all my patients/parents is that fever is not harmful in and of itself. It certainly makes a child uncomfortable, and brings with it an increase in heart rate and breathing rate.  Most healthy children can handle these things well (again, those with chronic illness, heart or lung disease, immune system problems, or other abnormalities may not be as straightforward).  I’m often asked how high a fever can go before a parent should worry, and my answer is that there is no magic number at which I hit the panic button.  Certainly, if a patient has a 106, I’m going to want to examine them to see what’s going on, but the height of the fever is not nearly as reliable a predictor of serious illness – rather, the child’s clinical appearance is a much more reliable tool for assessing them.  One common concern is brain damage with high fevers.  Brain damage has never been shown to be caused by high fever, even in children with temperatures as high as 107.6 (although if my patient has a 107.6, I’m sure going to figure out why!).  In other words, a 104 is not “worse” than a 101, per se, just makes you feel really crummy.  Fever can easily be 104, 105 with common viruses as with bacterial infection.

Another common concern is seizures due to fever.  Certainly they can occur, and although scary for all involved, a single simple febrile seizure won’t cause any long-term ill effects (certainly still talk to your pediatrician, and if a child has more than one they may warrant further evaluation).  For info from the AAP(American Academy of Pediatrics) website regarding febrile seizures, go here.   Simple febrile seizures often occur with the initial temperature elevation at the beginning of the illness.  Often the seizure occurs first and fever is only discovered later.  As far as febrile seizures go, even though higher temperature has been shown in some studies to be an independent risk factor, the most aggressive fever treatment with Tylenol/Motrin won’t reduce the risk of a febrile seizure – so basically if a young child is going to have one, it’s going to happen.  When they do, they don’t cause any long term ill effects (although they’re quite scary at the time).  Any seizure activity, associated with fever or not, should of course be discussed with/evaluated by your child’s pediatrician.

As far as the fever response in the body, it has several potential benefits.  First, it elicits several inflammatory mediators which activate/enhance certain components of the immune system so the body can more efficiently fight off whatever bug (virus, bacteria, etc.) that’s causing infection.  It also makes it harder for the invading bug to do its thing (I like to compare it to yard work – it’s a lot easier to pull weeds when it’s 75 degrees outside than when 95 degrees. Likewise, it’s harder for invading bugs to work efficiently when body temp is higher).  So fever does provide some measure of protection.

Fever management is also a common point of inquiry.  Fever does bring with it an increased metabolism, so replacing the nutrients and water lost as a result will be crucial to good fever management.  Pushing fluids (Pedialyte is best) and making the child comfortable will help a great deal in accomplishing this.  Lukewarm bathing/sponging provides only a marginal improvement in temperature, and can make a child uncomfortable, so should largely be avoided.  Cold water or rubbing alcohol can constrict the surface blood vessels that help the child to dissipate heat, and therefore should absolutely be avoided.  A common misconception is that it’s more successfully managed with alternating Tylenol and Motrin every 3 hours or so.  (Interesting side note, AAP did a survey of pediatricians regarding that, and about 1/3 of those surveyed thought that AAP recommended alternating.  There is in fact no AAP stance/statement stating that one should alternate the two).  Alternating Tylenol and Motrin carries several risks. First, dose confusion is common, especially when it’s 2:00 in the morning and you can’t remember what you last gave your child.  Motrin and Tylenol are both metabolized in the liver, and Motrin can inhibit production of a protein (glutathione) that assists in the metabolism of Tylenol.  So, alternating the two over time can lead to increased Tylenol levels in the blood.  (**Any child with liver disease should not be dosed prior to discussion with a physician!!).  Dosing of either Tylenol or Motrin is based on weight, so especially for young children talk to your pediatrician about the best dose for your child’s weight (all 8 month olds are not created equal – my 8 month old weighs as much as some kids twice his age!).

Several studies have shown that Tylenol and Motrin are about equally effective in temperature reduction.  One thing to realize with treatment is that at proper weight-based dosing, the average response to treatment is a drop in 2 degrees that lasts for 2 hours.  So if you were to treat a 103.8 and it only went down to 101.8 that would not be a failure of treatment; rather, that would be a reasonable response.  The only reason to treat fever is for comfort – other than discomfort there are no generalized ill effects from fever.  Certainly I’m happy if a 103 goes to 98 with treatment, as that makes the child feel better, but we don’t always get that.  As far as which one to use, my office recommends Tylenol rather than Motrin for several reasons: First, Motrin can be irritating to the stomach, especially in a child who isn’t eating/drinking well and has a largely empty stomach.  Second, Motrin can inhibit some of the types of white blood cells that fight infection – there are some white blood cells whose job is to find the invading bug and eat it.  Motrin inhibits them in their activity (can provide you a link to the study from 1997 if interested), and therefore can slow the body’s ability to eliminate infection, especially if bacterial.  Third, Motrin has a slightly increased risk of decreasing blood flow to the kidneys if a child is already a little bit dehydrated.  (In fact every pediatric nephrologist I’ve spoken to is adamant that if a child has fever along with vomiting/diarrhea that they absolutely should not get Motrin).  Some may disagree with me on that last point, but if Tylenol and Motrin are fairly similar in effectiveness, and Motrin has potential for a short-term hit to the kidneys if the kiddo has a decreased circulating blood volume, (which is possible with fever) I say why chance it (could write several paragraphs on that, but I’ll spare you that one…).  Tylenol is effective, and carries none of those risks.

Those are the main points I usually cover.  Take home message is that fever does tell us there’s something going on (virus, bacteria, etc.), but is not harmful in and of itself, and can help the body do its job.  Keep in mind that if a cause for the fever is found (i.e. ear infection) and treatment is initiated, fever can persist for 24-48 hours after starting treatment, and even with good old fashioned cold viruses we expect fever to last 3-5 days.  Persistence of fever beyond that would warrant another look by your pediatrician to make sure nothing else is going on.  Certainly any concerns regarding fever and associated symptoms should be directed to your pediatrician.

Sources cited in this article:

  1. www.aap.org
  2. Avner, Jeffrey R. “Acute Fever.” Pediatrics in Review 30 (2009): 5-13.
  3. Hirtz, Deborah G. Pediatrics in Review 18 (1997): 5-9.
  4. Zielinska, Malgorzata, and Wladyslaw Fenrych. “The application of a flow cytometric assay for evaluation of phagocytosis of Neutrophils.” Acta Biochimica Polonica 44.1 (1997): 121-26.

DL05 Dr. Marshall Ivey, M.D.  joined Milledgeville Pediatrics in July of 2008.  He is  originally from Athens, Georgia.  He obtained an undergraduate degree in Microbiology from the University of Georgia.  He then attended medical school at the Medical College of Georgia in Augusta, Georgia.  He remained in Augusta after graduation from medical school to complete his training in Pediatrics at the Children’s Medical Center, completing both an internship and residency in Pediatrics.  Upon completion of residency he sat for the American Board of Pediatrics certifying examination and is currently board certified in Pediatrics.  He is married with three children, ages 4, 3, and 8 months.

The Doctor Is In

So, for a while now I’ve been considering something but not acting on it: letting my husband post on my blog.  This is, after all, my space.  It’s where I talk about…well…the stuff he’s tired of hearing me talk about.  So, we made a deal.  I’ll let him post every now and then as long as he promises not to blog about sports.

See, my husband is a pediatrician(a very good one, I might add).  And he has a lot of soap boxes that I’m tired of hearing about really good information to share with parents everywhere.

BUT…here’s the deal: main concern with medical blogging is the whole liability thing.  It wasn’t until the Healthcare by Committee session at BlogHer this year that I realized that there are physicians who do blog(like Dr. Gwenn and Dr. Jennifer Shu).   And as long as he doesn’t violate any HIPAA regulations, and as long as everyone remembers that what he writes here is for informational purpose only, we’ll be fine.  You can’t sue him because this is not a doctor-patient relationship.  And if you have a specific problem, an usual situation or just think that what he says doesn’t sound right…then call your child’s actual physician, and talk to him or her.

Also, he’s a pediatrician, not a god.  (We don’t do the god complex thing around here.  And along those same lines, I hate being referred to as “a doctor’s wife”.)  And although he’s pretty awesome, he’s a real person with real feelings.  So if you disagree with him, be nice about it.  Or I will block you.  ‘Cause it’s my blog and I’m the queen of The Ivey League, and I can do what I want here.

Check back later today for his first post: Fever in Kids.