Author: Vincent Iannelli, MD

Vincent Iannelli, MD

Breastfeeding Recommendations

The AAP recommends exclusive breastfeeding for about six months and to continue for at least the first year.

Parents often have a lot of questions about breastfeeding.

One thing that they shouldn’t question is that breastfeeding provides a number of “short- and long-term medical and neurodevelopmental advantages” for their baby.

That’s why the American Academy of Pediatrics, in their 2012 policy statement on Breastfeeding and the Use of Human Milk recommended:

“Exclusive breastfeeding for about six months…”

And for breastfeeding “to continue for at least the first year and beyond for as long as mutually desired by mother and child…”

Since the AAP has concluded that “breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development,” be sure you get all the help you need to effectively breastfeed your child.

And remember, if breastfeeding was easy, we wouldn’t need lactation consultants. So don’t be afraid to ask for help.

For more information:

Circumcision

The American Academy of Pediatrics policy statement has shifted over the years.

They still don’t recommend that boys routinely get circumcised though.

Instead, the latest recommendation, which was published in a 2012 policy statement, states that:

…the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.

While the health benefits of getting circumcised, including prevention of UTIs, penile cancer, and transmitting some STIs, outweigh the small risks of the procedure, the AAP states that parents still need to decide if circumcision is in the best interest of their male child, thinking about their own “religious, ethical, and cultural beliefs and practices.”

Don’t get your child circumcised because you think it will be too hard to clean his intact penis and don’t get your child circumcised because you think everyone else is doing it and he will have problems in the locker room. Those aren’t good reasons.

It is also important to keep in mind that if your child is circumcised, the AAP also states that babies should be given “adaquate analgesia,” (that’s pain control) including:

  • penile nerve block techniques
  • nonpharmacologic techniques, like positioning and sucrose pacifier, can be used as an adjunct to a penile nerve block

And of course, the AAP came out with a policy statement in 2010 against the “traditional custom of ritual cutting and alteration of the genitalia of female infants, children, and adolescents, referred to as female genital mutilation or female genital cutting (FGC).”

For more information:

Helping Kids Cope With Stress

Get help recognizing signs and symptoms of stress in your kids and helping them cope when stress gets to be too much to handle.

Children, especially teens, often have stress in their lives.

Whether caused by the loss of a friend or loved one, a recent move, being teased or bullied, difficulties at home, or problems at school, childhood stress can lead to behavioral problems, anxiety, depression, headaches, drug use, and insomnia, among many other symptoms and medical problems.

Other symptoms of stress can include mood swings or temper tantrums in a younger child, withdrawing from friends and family, and aggression.

What Causes Kids to Have Stress?

Unfortunately, the source of stress for a child is frequently not so easy to recognize and parents are not always very good at noticing things that could be stressors, which can include things like:

  • a change at daycare for preschool age children, including attending daycare for the first time, moving to a new room, having a new teacher, or changing to a new daycare, etc.
  • having too much homework
  • being over-scheduled with sports and other extracurricular activities
  • having expectations for his performance that are unrealistic and too high or a fear of failure, despite of having good grades, having a lot of friends, etc.
  • a divorce or death in a friend’s family, which can raise fears that the same thing could happen to his own parents
  • poor self esteem
  • watching something stressful on the news, such as a school shooting, terrorist attack, or natural disaster
  • a chronic medical problem, like asthma or diabetes, or an acute medical problem, like a burn or broken leg
  • a medical problem in a family member
  • a traffic accident
  • financial problems at home

Keep in mind that common childhood transitions, such as moving to a toddler bed, starting kindergarten, going to camp, starting puberty, beginning high school, and going off to college, etc., can be very stressful for some children.

The other confusing thing about stress is that the symptoms of being stressed do not always immediately follow whatever is causing the stress and the same situations don’t cause stress in all children or even for the same child at different stages in their life.

Helping Kids Cope With Stress

Although overlooked as many parents and children look for a quick fix for their problems with stress, it is important not to overlook the importance of regular exercise, a healthy diet, and a good night’s sleep to help them cope with any problems with any stress they are having.

Other ways to help your child cope with stress can include:

  • scheduling more free time for your child, especially if being too busy is the source of her stress
  • spending quality time with your child and give them plenty of opportunities to talk about their worries and problems
  • eating dinner together each night as a family and having other routines or rituals that you stick to on a regular basis
  • helping your child set realistic expectations for himself
  • be prepared for stressful situations that you can anticipate, such as the birth of a new sibling, a move to a new city, or a parent who is going to have surgery
  • giving your child age appropriate responsibilities and allowing him to overcome simple challenges on his own without always bailing him out, which can help teach them basic problem solving skills that he will need throughout his life
  • teaching your child ways to relax, including diaphragmatic breathing, progressive muscle relaxation, visual imagery, listening to music, reading, keeping a journal, and drawing, etc.

Your pediatrician can be a good resource if your need help managing your child’s level of stress, especially if your child’s symptoms from the stress are not temporary. A mental health professional, such as a counselor, child psychologist, and/or child psychiatrist, can also be very helpful for the overly stressed child or even for a child who does not routinely handle stress well.

Sources:

American Academy of Child and Adolescent Psychiatry. Facts for Families. No. 66; Updated Feb 2013. Stress Management and Teens. Accessed May 2016.

Rotavirus Vaccines and Infections

Rotavirus is a life-threatening disease that was once very common in childhood but can now be easily prevented with either the RotaTeq or Rotarix vaccines.

Rotavirus is a now vaccine-preventable disease that can cause vomiting and diarrhea in young children.

While rotavirus isn’t the only cause of diarrhea in children, it was once the most common cause of severe diarrhea in young children.

Norovirus, several bacteria (Salmonella and Shigella), parasites, and other organisms still cause gastroenteritis (stomach flu) in children, but we don’t see rotavirus as much anymore. The National Respiratory and Enteric Virus Surveillance System (NREVSS) now reports low levels of rotavirus infection each year, with only about 5% of rotavirus tests now being positive during the peak of rotavirus season vs over 25% in the pre-vaccine era.

Rotavirus Infections

Children can develop symptoms of rotavirus symptoms about 1 to 3 days after being exposed to someone else who is sick with a rotavirus infections (the incubation period). These symptoms could include vomiting, watery diarrhea (without blood or mucus), fever, and abdominal pain. Although the fever and vomiting typically only last a few days, the diarrhea can often last at least 3 to 8 days or longer.

A rapid antigen stool test is available to test for rotavirus, but the diagnosis a typically made clinically, which means without testing and based on your child’s symptoms, especially if rotavirus infections are going around in your community.

Of course getting diagnosed with rotavirus is much less likely these days, now that we have a safe and effective vaccine.

While rotavirus was once the most common cause of severe diarrhea in children, leading to about 3 million cases of diarrhea, 55,000 hospitalizations, and 20 to 40 deaths in the United States each year, that has been greatly reduced in the post-vaccine era.

During the 2007-2008 rotavirus season, rotavirus activity decreased by more than 50% as compared to the 15 previous rotavirus seasons from 1991 to 2006. And during the 2010 to 2012 seasons, “the number of positive rotavirus tests declined 74%-90% compared with the pre-vaccine baseline and the total number of tests performed annually declined 28%-36%.”

Rotavirus Vaccines

The first rotavirus vaccine, Rotashield was quickly taken off the market in 1999 after it was found to be associated with an increased risk of intussusception, a type of bowel obstruction.

Newer rotavirus vaccines include:

  • RotaTeq – approved in 2006 and given to infants as a 3 dose vaccine series, it provides protection against five common strains of rotavirus, including serotypes G1, G2, G3, G4 and P1
  • Rotarix – approved in 2008 and given to infants as a 2 dose vaccine series, it provides protection against the most strain of rotavirus that most commonly gets kids sick

Both are live vaccines that are given orally and are thought to provide protection for at least two to three rotavirus seasons.

How good is that protection?

Completing either series of vaccines has been found to provide up to 98% protection against severe rotavirus gastroenteritis and up to 87% against any rotavirus gastroenteritis.

Infants should not get a rotavirus vaccine if they have had a severe allergic to a previous dose of the vaccine, to latex, if they have a history of intussusception, or if they have severe combined immunodeficiency (SCID).

They can usually get the rotavirus vaccine if they simply have some chronic stomach issues, like acid reflux or a milk intolerance, or if someone in the house has a problem with their immune system (just wash your hands after diaper changes). An immune system problem that is not SCID, an episode of acute, moderate or severe gastroenteritis, or other acute illness would be considered precautions to getting the rotavirus vaccine.

What To Know About Rotavirus

Rotavirus is a life-threatening disease that was once very common in childhood but can now be easily prevented with either the RotaTeq or Rotarix vaccines.

 

Sources:

American Academy of Pediatrics. Rotavirus infections. In:Pickering LK, Baker CJ, Long SS, eds. RedBook: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2015

Gershon: Krugman’s Infectious Diseases of Children, 11th ed.

Live attenuated human rotavirus vaccine, Rotarix. Bernstein DI – Semin Pediatr Infect Dis – 01-OCT-2006; 17(4): 188-94.

Outbreaks of Acute Gastroenteritis Transmitted by Person-to-Person Contact, Environmental Contamination, and Unknown Modes of Transmission — United States, 2009–2013. MMWR. December 11, 2015 / 64(SS12);1-16

Tate JE et al. Trends in national rotavirus activity before and after introduction of rotavirus vaccine into the national immunization program in the United States, 2000 to 2012. Pediatr Infect Dis J. 2013;32(7):741-744.

Are Drug Coupons Behind the Jump in the Cost of an EpiPen?

The high price of Mylan’s EpiPens is getting a lot of attention lately.

In a way that’s good. Not just so that something will finally be done about high drug prices, but because more people need to know about food allergies and about the importance of having and using EpiPens. That is one thing Mylan got right. Their education and awareness campaigns not only encouraged parents to get EpiPens for their kids, but they strongly encouraged them to use them.

Just a ploy to sell more EpiPens? Not when you realize that many people are afraid to use their EpiPens, even when they are having a severe allergic reaction.

Still, they certainly got greedy with the continued price hikes.

Although we are getting used to hearing about high drug prices, they typically aren’t for drugs that your pediatrician prescribes everyday.

You were likely outraged when Martin Shkreli raised the price of Darapim to $750 a pill, but you probably still have no idea what it is used for. On the other hand, you may have or almost certainly know someone with an EpiPen.

An epinephrine autoinjector is traditionally the only treatment for people having anaphylactic reactions to peanuts, insect bites and stings, or other serious allergic reactions.

Why fuss about the cost of a life-saving drug or device? A product that can save your child’s life in a manner of seconds would be priceless to most people.

Much of the issue is that they went from costing about $100 in 2006 to over $600 today. Even last year, a set of two EpiPens (one dose) cost up to $450. So it would be nice to have that option to save lives and save money. Afterall, the very same EpiPens are much cheaper in most other countries.

Surprisingly, it has been the media and not parents or patients who are doing most of the complaining about the high cost of EpiPens. Most of us have insurance and can use a coupon to waive their copay and effectively get their EpiPens free. Those without insurance may not be able to see a doctor to get a prescription, but if they can, may be eligible for Mylan’s patient assistance program.

So who is paying full price?

Mostly people with high deductible insurance plans, at least until they realize that they might save money going with a more costly insurance plan without a deductible, especially if family members have other medical problems, like asthma.

Why asthma?

Have you priced an asthma inhaler lately? Those that you use to prevent asthma can easily cost $300 to $400 each month. A rescue inhaler can cost another $100.

Competition hasn’t helped us get less expensive asthma inhalers. You will need a coupon for that.

Drug coupon use by patients could “come at the cost of higher long-term expenses for themselves and society.” That was a warning in the New England Journal of Medicine editorial “Prescription-Drug Coupons — No Such Thing as a Free Lunch.”

Unfortunately, instead of heeding the warning back in 2013, some companies adopted it as a business model.

Martin Shkreli didn’t do anything original when he bought the rights to the antiparasitic drug pyrimethamine and rebranded it as Darapim, raising the price 5,000%.

For example, although Lupin Pharmaceuticals makes many generic medications, they chose to license Suprax, an expensive antibiotic with a coupon, as a branded generic. So while a similar generic antibiotic, such as cefdinir, might cost about $50, Suprax costs about $250 to $400 for a 10 day course. It will also likely be on the highest and most expensive tier of your insurance, which is why they offer a coupon.

Impax Laboratories, another big maker of generic drugs, takes the cake though. They are selling Emverm for $596 a pill. A chewable pill that is used to treat pinworms, with two doses over two weeks, that means one treatment to stop your child’s butt from itching can cost almost $1200 – unless you use their coupon. An inexpensive generic version of the very same medicine, Vermox, was discontinued in 2011.

It was discontinued by Teva Pharmaceuticals, who then sold the rights to the drug to Amedra Pharmaceuticals, which was then acquired by Impax.

An off-patent, generic drug, Vermox should have been getting cheaper, not having its price soar. The fact that they offer consumers free coupons, meaning they won’t actually pay for the drug, likely explains how they get away with it.

Of course, we all end up paying. There is no free lunch, except maybe when the drug reps for these companies drop off those coupons at your doctor’s office.