Relocating to Dallas

Written by: Dr. Adrian Clarke

Dear Patient Families,

As many of you already have already read or heard, I am relocating to Dallas and will no longer be practicing at Blue Fish Pediatrics, effective December 21, 2013. All of my patients should receive a letter of notification via US mail in the next few weeks.

I have thoroughly enjoyed my three years at Blue Fish and, although it will be difficult to leave my practice, patients and colleagues, I am confident that your child will continue to receive the highest level of care at Blue Fish Pediatrics.

As part of the effort to ensure a smooth transition for your family, Blue Fish is pleased to announce that Dr. Eric Lindsay will be joining the Memorial office in January 2014. For a complete bio please click on this link: http://bit.ly/1bZAS2N. I am thrilled that such an outstanding pediatrician has been lined up to accept any of my patients who wish to continue at Blue Fish. Dr. Lindsay will be available to accept my patients to the extent that his schedule allows.

I will honor all of my visits scheduled through December 20, 2013. All visits currently scheduled after December 20, 2013 will be receiving a phone call to either reschedule or to keep your appointment and be seen by Dr. Lindsay.

If you have any questions please contact Denny Yu, Practice Manager, by phone at 713-467-1741 or by email at bluefish@bluefishmd.com.

If you would like access to your medical records, please contact Blue Fish Pediatrics for forms and instructions.

I would like to thank you for your continued support and confidence. This is a bittersweet transition for me since I have been in practice in the Houston area for over 11 years. Serving as your family's pediatrician has been a privilege, an honor and a distinct pleasure.

In January 2014, I will be joining Forest Lane Pediatrics at their Medical City location in Dallas. You may contact at:

Forest Lane Pediatrics
7777 Forest Lane,
Building B, Suite 445
Dallas TX, 75230
Phone: 972-284-7770
Fax: 972-284-7780
www.forestlanepediatrics.com

Very truly yours,
R. Adrian Clarke, MD

Avoid codeine after tonsillectomy surgery

Written by: Dr. Adrian Clarke

Earlier this year the FDA issued a warning and changed the label on pain medications that contain codeine because of unpredictable serious adverse effects including death in children.

Codeine is metabolized into morphine and some children are genetically predisposed to be "ultra-rapid  metabolizers". Some of these children have had fatal or life-threatening morphine overdoses after taking typically safe codeine doses for post-op pain management after tonsillectomy. 

The most common codeine-containing medication is acetaminophen with codeine (aka Tylenol #3). 

The FDA now "strongly recommends" against codeine use in post-op tonsillectomy pain management. 

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm315497.htm

Flu vaccine common misconceptions

This March 2013 New York Times health blog entry does a good job summarizing and answering common myths about the flu vaccine. 

http://nyti.ms/VZer7M

How to be prepared before, during, and after the shots

Pediatricians are often asked how to treat vaccine injection anxiety, how to recognize abnormal post-vaccine reactions, and how to treat a reaction if it occurs.

Here are 2 links to parent-oriented handouts on this topic:
www.cdc.gov/vaccines/parents/tools/tips-factsheet.pdf
www.immunize.org/catg.d/p4015.pdf

In summary:
1. Don't pre-medicate with a pain/fever reducer unless there has been a history of prior adverse reaction.  At least one recent study suggests that pre-medicating may alter the immune response of the vaccine.  It is not clear if this is clinically significant. 
2.  Stay calm and help your child deal with the immediate discomfort of the injection with techniques such as swaddling and nursing for infants and distraction techniques for older children.
3. If a reaction such as painful redness and swelling does occur, use pain/fever reducers and cool compresses.
4. For specific information about any particular vaccine and its typical post-vaccine reaction symptoms,  review that vaccine's Vaccine Information Statement (VIS) handout.  At our office, we give you a VIS packet with all of the VIS's at your first vaccine visit (usually 2 months old).  Individual VIS's are available at our office and at www.goo.gl/6kiGV. 

Answers to Expecting Parents' Frequently Asked Questions

What’s the big deal about pertussis? (www.cdc.gov/pertussis)

Pertussis (aka whooping cough) is a highly contagious bacterial respiratory illness that causes severe cough and/or trouble breathing in young children and infants.

Pertussis vaccines are effective, but not perfect.

- Protective immunity from the current (post-1990s) childhood vaccine wanes after 5 to 10 years and rarely lasts more than 12 years.  This is why booster vaccination has been recommended for adolescents and adults since 2005.  

- Before pertussis vaccines became widely available in the US in the 1940s, about 200,000 children were infected each year and about 9,000 died as a result of the infection. 

2012 had the most reported cases since 1955 with over 41,000 cases and 18 deaths (15 deaths under 1 year old).  In more typical years there are ~10,000-25,000 cases reported and ~10-20 deaths.

Infants are at greatest risk for getting pertussis and then having severe complications from it, including death (even when appropriately treated).

- About 50% of infants < 1 year old who get pertussis are hospitalized

- 1-2% of hospitalized infants die.  Most deaths < 6 months old.

When the source can be identified, ~80% of infants with pertussis catch it from someone at home:

a.     55% parents (mom 30-40%; dad 15%)

b.     15-20% siblings

c.      10-25% friends, cousins, others

d.     10% aunts or uncles

e.     5% grandparents

f.      2% other caretakers

What’s the big deal about the flu? (www.cdc.gov/flu)

Influenza (aka the flu) is a highly contagious viral respiratory illness with annual Fall/Winter seasonal peaks.

The annual flu vaccine varies in its effectiveness; therefore flu infection will occur among some individuals who received the flu vaccine that season.

6 months old is the minimum age to get the flu vaccine.

15-40% of preschool and school-aged children catch the flu each year.

Infants younger than 6 months are at the highest risk for flu-related hospitalization and death.

In the 2012-2013 flu season, there were over 100 pediatric deaths:

- 90% had not received the flu vaccine for the current season.

- 60% had identifiable risk factors for flu-related complications.

I knew the baby needed shots, but we probably need them too? (www.vaccine.chop.edu)

Confirm that all future household contacts (such as older siblings) and all potential caregivers (grandparents, close friends, nannies, etc.) are up-to-date on all of the recommended adult vaccines (www.goo.gl/W6GJM).

Pertussis booster: One booster dose of tetanus, diphtheria, and pertussis (Tdap) vaccine if you have not previously had this vaccine.  Starting in 2013, pregnant women should get a Tdap during each pregnancy.  Tdap may be given regardless of when the last tetanus and diphtheria (Td) dose was given.  

It takes about 2 weeks for the pertussis vaccine to produce immunity.  (www.goo.gl/JF8Pg)

Influenza: once per flu season (each school year, i.e. Fall/Winter).  The flu vaccine is especially recommended for household contacts of infants under 6 months old.

International Travelers:  specific travel vaccines and/or malaria prevention medications may be required. 

Do your own research: www.cdc.gov/travel.

Get vaccinated and/or get prophylactic meds for malaria via an international travel medicine clinic or your doctor.

What info should I make sure to bring/know about my baby's birth when we go to the first pediatrician appointment?

In a perfect world, all of your baby's essential medical records would seamlessly and legibly arrive at your pediatrician's office well before your first appointment.   This does not always happen.

 Do your best to gather the following minimum information for that first appointment:

- Birth weight

- Gestational age

- If the baby was born by C-section, why?

- Was the baby in the breech position at birth? In the third trimester?

- Were there any problems with jaundice?

- Was the hepatitis B vaccine given, and if so when?

           

How and what should I feed her?

All pediatricians strongly encourage and support giving human breast milk as the exclusive source of nutrition for newborns.  I have listed the numerous health benefits in a prior blog post.

If it turns out that exclusive breast feeding is not possible and/or is not your choice, the following link from the AAP gives useful guidance on choosing the right formula, bottles and nipples for your infant: www.goo.gl/QDdTP

She’s been fed and changed, but she’s still upset.  Now what? (www.goo.gl/rEW5n)

Taking care of a newborn is challenging. 

Newborns eat, sleep, pee, poop, hiccup, sneeze, burp, pass gas, spit up, cry and fuss.

Happiest Baby on The Block (see the resource section at end of this post) is an excellent summary of well-established calming techniques to help with excessive crying and fussing.

What do I need in my medicine cabinet?

Diaper cream, fragrance-free moisturizing cream/ointment, thick diaper cream, vaseline, water soluble lubricant (KY jelly), small gauze pads, infant rectal thermometer, alcohol wipes, infant acetaminophen (newborn dosing is not always on the package), 1% hydrocortisone cream, 1% clotrimazole cream, NoseFrida (preferred over the regular bulb suction aspirator), infant fingernail clippers, small tweezers, and a small emery board.

How do I minimize the risk of SIDS? (www.cdc.gov/sids)

Sudden infant death syndrome (SIDS) is defined as the "sudden death of an infant younger than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."

SIDS is the leading cause of death 1- 12 months of age and is most common 1- 4 months old, with 90% of cases occurring before 6 months old.

More than 95% of SIDS cases are associated with one or more risk factor.   

Major Pre-natal SIDS Risk Factors:

a.     Young maternal age (less than 20 years old)

b.     Maternal smoking during pregnancy

c.      Late or no prenatal care

d.     Preterm birth and/or low birth weight

Major Post-natal SIDS Risk Factors:

a.     Sleeping on stomach

b.     Sleeping on a soft surface and/or with bedding accessories such as loose blankets and pillows (www.goo.gl/nbes3)

c.      Bed-sharing (aka co-sleeping)

d.     Overheating

SIDS Risk Reducers

The following factors are somewhat protective against SIDS, but they are outweighed by the modifiable risk factors described above:

a.     Breastfeeding

b.     Room-sharing without bed-sharing

c.      Pacifier use that does not interfere with breastfeeding.

d.     Fan use

Do not use infant sleep positioners in order to keep baby on his/her back.

Do not put your baby down in a crib with crib bumpers, no matter how nice they make the crib look.

Resources:

Happiest Baby on The Block by Harvey Karp (Book, DVD, or iTunes/Amazon download)

Heading Home With Your Newborn by Laura Jana and Jennifer Shu.

www.healthychildren.org

http://newborns.stanford.edu
www.vaccine.chop.edu

www.vaccine.texaschildrens.org

www.dhhs.ne.gov/publichealth/Pages/sids_environment.asp

www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM227719.pdf

www.cdc.gov/sids

www.cdc.gov/pertussis

www.cdc.gov/flu

www.cdc.gov/travel

www.fridababy.com/shop/nosefrida

www.mayoclinic.com/health/induced-lactation/AN01882

www.webmd.com/parenting/baby/bottle-feeding-9/choosing-a-bottle

www.youtube.com/watch?v=VCYWqni0TeM

Don't minimize the importance of the Hepatitis B Vaccine

As all of my patients know and any readers of this blog can tell, I strongly believe in the importance of sticking to the AAP-endorsed pediatric vaccine schedule.

Occasionally, I have parents who wish to delay the Hepatitis B virus (HBV) vaccine.  The typical rationale is that they know that mom doesn't have Hep B disease (therefore there is/was no risk of vertical transmission during the birthing process) and they are not concerned about their infant and/or young child exhibiting the types of high-risk behaviors that can expose humans to blood and bodily fluids.

Unfortunately, this strategy is not supported by the evidence.  Take a look at the following link on the HBV vaccine from the Children's Hospital of Philadelphia Vaccine Education Center (bit.ly/ynJrve).  

Before the HBV vaccine was available, 50% of the 18,000 annual pediatric cases of HBV under 10 yrs old did not come from mother-to-newborn vertical transmission during birth. 

The most likely causes of non-vertical transmission are incidental exposures to microscopic amounts of infected blood from asymptomatic (but still infected and contagious) close contacts.  This could happen innocently via toothbrushes, razors and washcloths or towels.  

The bottom line is that "being careful" is not enough to prevent these kinds of cases, the best protection is infant HBV vaccination starting at birth.

SIDS: How to minimize your infant's risk

Sudden infant death syndrome (SIDS) is defined as the "sudden death of an infant younger than one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."

SIDS is the leading cause of death for infants between 1 month and 12 months of age and is most common between 1 to 4 months old, with 90% of cases occurring before 6 months old.

Fortunately, the SIDS rate in the United States has dropped significantly over the last 30 years. The greatest reduction occurred in the first 10 years after the American Academy of Pediatrics (AAP) started the "Back to Sleep" campaign to reduce the risk of SIDS which recommends placing infants in a supine position (on the back) for sleep. Between 1992 and 2001, the SIDS rate in the United States fell from 0.12% to 0.06%, while the proportion of infants sleeping in the supine position increased from 13% to 72%.

More than 95% of SIDS cases are associated with one or more risk factors, and in many cases, the risk factors are modifiable (usually sleeping position, sleep environment, or parental co-sleeping).

Major Pre-natal SIDS Risk Factors:
-Young maternal age (less than 20 years old)
-Maternal smoking during pregnancy
-Late or no prenatal care
-Preterm birth and/or low birth weight

MajorPost-natal SIDS Risk Factors
-Sleeping on stomach
-Sleeping on a soft surface and/or with bedding accessories such as loose blankets and pillows
-Bed-sharing (sleeping in parents’ bed)
-Overheating

SIDS Risk Reducers
The following factors are somewhat protective against SIDS. However, these effects are outweighed by the modifiable risk factors described above:
-Breastfeeding (36% lower risk of SIDS, if BF lasts more than 1 mo)
-Room-sharing without bed-sharing
-Pacifier use that does not interfere with the establishment of breastfeeding.
-Fan use

In summary, infants whose mothers received appropriate prenatal care and who sleep on their backs in an appropriate sleep environment (see first link below for picture), are breastfed beyond 1 month old, and have never been exposed prenatally or postnatally to tobacco smoke are at the lowest risk for SIDS.

Take a look at the following links for more information:

http://dhhs.ne.gov/publichealth/Pages/sids_environment.aspx

http://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

http://www.cdc.gov/sids/

http://www.uptodate.com/contents/sudden-infant-death-syndrome-sids-beyond-the-basics?source=search_result&search=Sids&selectedTitle=1%7E4&view=outline



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5/7/13 Addendum

Here is a link to the recent FDA warning to NOT use infant sleep positioners because of the risk of death by suffocation.
http://www.fda.gov/downloads/ForConsumers/ConsumerUpdates/UCM227719.pdf

Autism risk is not related to more vaccines under 2 years old

A new study published on 3/29/13 is the latest of more than 20 studies showing no connection between autism and vaccines.

What is noteworthy about this study is that it is the first to prove that neither the total number of early vaccines nor the total number of vaccine antigens (the proteins in vaccines that trigger an immune response) lead to an increased risk of autism.

This is an important study because it should help address the fear that pediatricians frequently hear from parents (and grandparents) that the modern multiple vaccine schedule will "overwhelm" their (grand)child's immune system.
This study concludes that children who receive the full schedule of vaccinations in the first two years of life have no increased risk of autism. "Splitting them up" is not going to lower the risk of autism and it delays protection against life-threatening infections in vulnerable infants and young children.

Also of note, in order to fully vaccinate a 2 year old the 2012 CDC vaccine schedule uses 315 total antigens, whereas in the late 1990s it took several thousand antigens to do the same job. This is because modern vaccines need fewer antigens to stimulate adequate immune responses.
To state it plainly, while we don't know why there had been an increase in autism prevalence over the last two decades, we do know that it is not due to a increased antigen load overwhelming the immune system. On the contrary, we have been able to add protection against more bacteria and viruses over the last 20 years while at the same time decreasing the antigen load.

Here is the NPR blog post about the Journal of Pediatrics paper:
http://www.npr.org/blogs/health/2013/03/29/175626824/the-number-of-early-childhood-vaccines-not-linked-to-autism

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Vaccines during pregnancy

As all of my patient families know, I strongly agree with the AAP and CDC recommended vaccine schedule for children.
In addition to these recommendations for the direct protection of our pediatric patients, pediatricians also support specific vaccinations for household and other close contacts of our pediatric patients.

I really like this recent blog entry written by Rachel Cunningham, MPH, a vaccine expert at Texas Children's Hospital Immunization Project.  In addition to her professional expertise, the article includes her parental perspective as a mother of two young children: http://www.texaschildrensblog.org/2013/03/what-vaccines-to-expect-when-youre-expecting/

The CDC's webpage on this topic also has specific and useful information: http://www.cdc.gov/vaccines/parents/pregnant.html.


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AAP Drowning Prevention tips

With the weather getting nicer and many of my patients having access to swimming pools, I thought I should post some info on pediatric drowning prevention and overall water safety.

In May 2010, the American Acedemy of Pediatrics revised the minimum age that pediatricians recommend swim/water safety lessons down from 4yo to 1yo, in developmentally appropriate children.

Take a look at following summary of the May 2010 updated recs: http://tinyurl.com/ce3ojgf

Busy 2012-2013 Flu Season

As I'm sure almost everyone is aware, this has turned into a heavy flu season. Here are a couple of web links to info on what to look out for if you suspect or know that your child has the flu.

http://www.cdc.gov/flu/pdf/freeresources/updated/fluguideforparents_brochure.pdf

http://www.texaschildrensblog.org/2013/01/flu-symptoms-when-to-bring-your-child-into-the-emergency-center/


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