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Sunday, November 12, 2017

Sleep Deprived Teens: Health, Safety, & Mental Well Being Are At Significant Risk

Teens do not get enough sleep. Most teens need 8.5-10 hours of sleep each night. Not 6 hours. Not even 8 hours. Most don't get even close to meeting their needs and that's a bigger deal than many realize. Sleep is very undervalued, but we need to prioritize it.

sleep, insomnia, screen time, teens, circadian rhythm, school start times


Why don't teens get enough sleep? 


One of the most common reasons is that their biological clock (AKA circadian rhythm) makes it hard to fall asleep before 11 pm and school starts too early to allow them to sleep until 8 am, which would allow for 9 hours.

In addition to their circadian rhythm, some of their habits and activities can interfere with a healthy bedtime.

  • Screens are a big problem. The light interferes with our natural melatonin rising. I regularly ask teens (and parents) to limit screen use for at least an hour before bedtime, but most teens say that's impossible because they have to finish their homework at that time and they need their computer or tablet to do homework. If you can't turn off the screen, at least use a program that limits the blue light that prevents the rise of melatonin. I personally use f.lux. (It's free and works on PC, Mac, ipad, android, and Linux). I find that it really helps. (This is not a paid endorsement, just a personal statement.)
  • Phones. On a similar note, phones distract kids from what they're doing, delaying falling asleep. It takes longer to finish homework when there are distractions from the phone. Kids often are tempted to check in one more time on all their social channels, which delays sleep time. And then friends who are still up will text to see who's up (or who they can wake up). 
  • Activities are too late. I'm not talking about kids just out and about on a school night. I'm talking about regularly scheduled activities that otherwise help build a well rounded person. It's not uncommon for activities to be scheduled to run until 9:30 or 10 on school nights for middle and high school aged kids. They get home and are hungry, need a shower, and are ramped up so not ready for sleep. 
  • Activities start too early. I know many kids who must be at school before school actually starts. Whether it's band practice, church study groups, sports, or taking a missed test before school, they all interfere with sleeping in, which is what teens need.
  • School starts too early. Most school districts around the country start school well before the recommended 8:30 earliest start time. School districts that have initiated later start times have shown improved test scores, fewer absences and tardies, less depression, improved athletic performance, and better graduation rates. Unfortunately, those schools are still in the minority. 
  • Medical causes of sleep deprivation and fatigue can also occur. If you suspect any of these, you should schedule a visit with your doctor.
  • Anxiety 
  • Restless leg syndrome 
  • Sleep apnea - pausing of breath, often associated with snoring 
  • Medications that affect sleep cycles
  • Heartburn or acid reflux  
  • Hormone imbalances, such as thyroid problems 
  • Anemia, or low red blood cell counts 
  • Depression  
  • Nutrition: not eating enough, or eating foods that are not nutritious. If you eat foods that cause spikes in your blood sugar, as those sugars drop you feel fatigued.
  • Infections 
  • Celiac disease   
  • Chronic pain conditions 
  • Chronic sleep deprivation - I know this is counter-intuitive, but being tired can make it harder to sleep.


What happens with too little sleep?


Sleep deprivation can lead to many problems that are often not attributed to poor sleep, such as irritability, poor academic performance, accidents, obesity and more.

  • Moodiness. We all associate the teen years with angst, so we can easily attribute a teen's moodiness to just being a teen. But being chronically tired can lead to emotional dysregulation. This will look like irritability, frustration and anger. 
  • School problems. It has been well established that getting proper amounts of sleep can help with focus and learning. When our teens fail to get enough sleep, they often report problems with attention, memory, decision making, reaction time, and creativity. It's no surprise that teens report problems paying attention to a lecture or trouble completing homework in a reasonable time with full accuracy. Grades can easily fall, which leads to anxiety and depression, which in turn leads to more moodiness and trouble sleeping. 
  • Sleep deprivation mimics ADHD. Whenever I see a teen who wants to be evaluated for ADHD because of new loss of focus, falling grades, problems with behavior, or similar issues, I always look at sleep. Most often they don't have ADHD if this is a new problem. They need more sleep, not a stimulant medication. You can't put a band aide on a broken bone. Fix the problem, not the symptoms! (The same goes for a teen with ADHD who thinks the medicine that's worked for years suddenly isn't sufficient. Unless the medicine recently changed, they need sleep.)
  • Injuries. Teens with chronic sleep deprivation are more likely to be accidentally injured. 
  • Drowsy driving is comparable to drunk driving. Teens are at the highest risk for falling asleep at the wheel. Drowsy driving is the most likely to occur in the middle of the night (2-4 am), but also in mid-afternoon (3- 4pm) as teens drive home from school. 
  • Athletes are more likely to be injured while playing their sport, so it is in the best interest of the team to let players sleep. 
  • Risky behaviors. Teens with chronic sleep deprivation have been shown to participate in more risk taking behaviors, such as driving without a seatbelt, drinking alcohol, skipping the bike helmet and tobacco use. 


Pros and Cons of later school start times for our economy


There are many temporary issues with changing school start times. Parents might have to find solutions to child care of younger kids if they rely on teens babysitting after school. New bus schedules need to be started. Sports programs will need to change practice times. After school job availabilities will change.

Despite these common arguments, economic analysis from the Brookings Institution shows that a one hour delay of school start times could lead to a $17,500 earnings gain for students, compared to a cost of $1,950 during the student's school days.

Another study that presumed all students start school at 8:30, with a year-by-year economic effect. The study did not take into account other potential benefits of later school start times, such as decreased depression and obesity rates. They found an average annual gain of about $9.3 billion due to fewer automotive accidents, improved graduation rates, and other factors. 


What can teens do to get more zzzz's?


  • Go to bed when tired at night. Fighting sleep initially will make it harder to go to sleep when you finally go to bed. 
  • Attempt to follow a regular sleep schedule. Going to bed and getting up at about the same time every day helps. While sleeping in on weekends can help repair a sleep deficit, it can make it harder to get to sleep Sunday night and getting sufficient sleep every night is better than just getting more sleep a few days/week. Try to sleep in no more than 2 hours past your school day wake up time.
  • Follow the same routine each night at bedtime. Brush teeth, read a book or color, take a bath or shower -- do whatever helps you wind down and relax. Repeating this every night can help your brain get ready for bed. 
  • Nap to help make up missed sleep. A short 15-20 minute nap after school can help revitalize the brain to get homework done. Just don't sleep too long or it can interfere with bedtime.
  • Turn off the screens an hour before bedtime. This includes tv, computer games, computer/tablet use for homework, and smartphones for socializing. Use night mode screen lighting and apps that dim the screen (like the f.lux app I mentioned above). 
  • Avoid caffeine in the later afternoon. The time it takes half of the caffeine to be removed from your body is 5-6 hours. Ideally teens would sleep and never drink caffeine, but I know that isn't reality. Any caffeine in the later afternoon can make it harder to fall to sleep. Don't forget "hidden" sources of caffeine, such as chocolate, energy bars, and workout supplements.
  • One interesting concept that has scientific backing (but goes against the "no caffeine after 3 pm" rule) is the coffee nap. Basically, you drink coffee then quickly nap for 15-20 minutes. Sodas and teas don't work as well as coffee due to too much sugar and too little caffeine. The coffee nap has been shown to be more effective than either a nap or caffeine alone. Don't do this often -- use it at times you really need it. Don't do this too late in the day or the caffeine will inhibit your regular night's sleep.
  • Skip the snooze button. Set your alarm for the last possible moment you can, which allows your body to get those extra minutes of sleep. If you need to get out of bed by 6:45, but set your alarm for 6:15 and hit snooze several times, you aren't sleeping those 30 minutes. Set your alarm for 6:45!
  • Skip the late night studying. Studying too late is ineffective. When the brain's tired it won't learn as well and you will make mistakes more readily. It takes a lot longer to get anything done when you're tired. Go to bed and get up a little earlier to get the work finished if needed. Of course you should also look at your time management if this happens too often. Are you involved in too many activities? Do you work or volunteer too many hours? Did you waste too much time on tv, games, or socializing? Do you put off big projects until the last minute? Homework needs to take priority when you're more alert in the afternoon and evening. If you have problems with this, talk to parents and teachers about what you can do.
  • If you lay awake for hours or wake frequently, try these techniques to help fall asleep: 
  • a sound machine 
  • listen to Weightless - music that's been shown to help initiate sleep 
  • coloring 
  • journaling 
  • If these fail, talk to your parents and doctor to help find a solution.
  • Charge your phone in another room. Friends who decide to text in the middle of the night keep you from sleeping. Even phones on silent have blinking lights that can spark your curiosity. It's too tempting to look at your social media apps one more time. 
  • Don't use the excuse that you need your phone as an alarm. Alarm clocks are cheap. Get one and put your phone elsewhere!
  • Use your bed for sleep only. Stop doing homework in bed. Stop watching YouTube and Netflix in bed. Train your brain that your bed is where you sleep.
  • Exercise. Exercise helps our bodies sleep better, but it should ideally be earlier in the day. Too close to bedtime (which is common with athletes and dancers) wires us up.
  • Get natural sunlight in the morning. This helps to set your circadian rhythm. 
  • Keep the bedroom cool and dark. 
  • Keep pets out of the bedroom. Your animals might love you and you love them, but if they keep you up, it's just not worth having them around at night.
  • Nicotine and alcohol affect sleep. These should not be used by teens in an ideal world, but I know teens will not always follow the rules. Teens should know that if they are using nicotine or alcohol, their quality of sleep will be affected. 
  • Nicotine is a stimulant (like caffeine), which leads to more time sleeping lightly and less time in deep sleep. And yes, vaping and chewing lead to this problem too, since it's the nicotine that causes the problem. 
  • Alcohol reduces the time it takes to fall asleep but it increases sleep disturbances in the second half of the night, often leading to early wakening. Alcohol relaxes muscles, which can lead to sleep apnea (often noted as snoring). Sleep apnea does not allow the body to have restful sleep. Alcohol is also a diuretic, which might increase the need to wake to go to the bathroom during the night.


We all need to prioritize sleep: for our kids and for ourselves. Our bodies and minds will thank us.


Resources:

Tuesday, November 7, 2017

Active Shooters: Reflections and Talking to Kids

Area flags are at half mast today as we are mourning the loss of innocent lives from another mass shooting at a Texas church over the weekend. We are sad for grieving families once again. What we can do to protect ourselves and our loved ones from random violence and acts of hate?


My generally safe town has had two incidents of violence that have made national news in recent years. A man opened fire at a Jewish Community Center and a Jewish Retirement Home and killed three innocent people. Another man shot two men eating at a local restaurant after yelling racial slurs and telling them to leave his country. One of the men died.

My kids have been on lockdowns at their schools on several occasions over the years. Our kids are getting used to lockdown drills and even real events. Thankfully none of the local school lockdowns turned tragic. Being a parent who cannot do anything while a school is in lockdown is stressful. Not knowing what is happening during a lockdown when my children are most likely sitting on a floor of a crowded dark room is terrifying. My kids have never felt that scared, even when it's a real lockdown, probably because they've practiced and feel prepared. For many kids this seems to be the case, but I'm sure there are some who start having separation anxiety or other manifestations of trauma-related stress. 

Today my front office staff saw policemen with weapons in hand enter our building and run down the hall. They did not come into our office. 


We locked our front door, closed the blinds, and kept patients in exam rooms. We saw several police cars in the parking lot for our building and those near ours. 


Our office manager called the police department to find out what was happening and not a lot was learned, but there was a potential active shooter in the area, so they recommended lockdown


Because I was only in the office for meetings on my "day off" I was able to help tell staff and patients what we knew. I helped bring some of the families into the office. I checked Facebook and Twitter repeatedly to find out what was going on. (But I didn't grab these screenshots until hours later.)



 I had planned on updating our social media, but couldn't find any real information to post.




At one point we were told they apprehended someone in a creek area behind our building and got the all clear to open back up and let people leave. 
41ActionNews

A few minutes later we were told to put our building back on lockdown. No one knew what was going on.

Our receptionists covertly monitored the parking lot for patients so they could get the door for them - we didn't want families stuck in a potentially dangerous parking lot. Several patients called that they would be late to their appointments because police had blocked one of the roads into our parking area. 

I am very proud of my staff and the families that were in the building. Everyone remained calm. No one complained that they were told to not leave the building. I didn't hear anyone complain when the rooms started to fill, which affected the flow of seeing patients. I must admit that I didn't really feel scared during all of this, since it seemed like police were all over and our office felt secure. It was frustrating not knowing what was going on, but the anxiety was much worse when the potential shooter was near my children's school and they were on lockdown.

It is sad that a false alarm like this must be taken seriously. I've heard that it was just a man with a stick. Or maybe it was just a prank. No one really knows at this time.



But what I do know is that there are many good people in this world. We can help each other in times of need. We can support one another. Mr. Rogers says: 
When I was a boy and I would see scary things in the news, my mother would say to me, “Look for the helpers. You will always find people who are helping.”
When you have to explain these things to your children, remember to keep it simple. Answer their questions, but don't go deeper than they're ready to go. Find out what they already know and help them to understand it in ways that mean something to them. Try to keep the news off when kids are in earshot and monitor their screen time online. It's okay to share your feelings, but try to reassure their safety and list some positives, like Mr. Rodger's mother did.

Resources for parents to talk to kids about tragic news: 


Common Sense Media: Explaining the News to Our Kids
PBS: Talking with Kids About News - sorted by ages
HealthyChildren: Talking to Children About Tragedies & Other News Events
American Psychological Association: How to talk to children about difficult news

Sunday, October 29, 2017

10 Reasons Not To Get the Flu Vaccine, Reconsidered: Fight Flu!

Influenza is not a just a bad cold. People sick with with the flu can suffer from fevers, cough, sore throat and body aches. It can lead to complications, many of them severe, and death. Complications include pneumonia, ear infections, and sinus infections. Since 2010, influenza has resulted in between 9.2 and 35.6 million illnesses, between 140,000 and 710,000 hospitalizations and between 12,000 and 56,000 deaths each year. 

influenza, flu shots, cold, virus, tamiflu

There's good news though. There's a vaccine to help prevent the flu.

There are many reasons people don't get the flu vaccine, but many of those reasons deserve a second thought.


1. The flu vaccine doesn't work. 


While it's true that the vaccine has variable efficacy, it's important to get the vaccine each year. The more people vaccinated, the less likely the flu will spread through a community. Take a look at this really cool representation of how herd immunity works. How it was developed is described on IFLS.

No one claims that the vaccines against influenza work perfectly. The influenza virus can mutate by shifting and drifting. Until there's a universal flu vaccine, we must rely on experts to look at the viral patterns and predict the strains that will be most predominant in the upcoming season and make a vaccine against those strains.

Despite not working 100% of the time, the flu vaccine has been shown to lessen the severity of illness and decrease hospitalizations and deaths. Even if there's not a perfect match, it can still help those who are vaccinated have a lesser illness. That's worth something.

2. I got the flu from the vaccine.


The influenza vaccine that is currently available cannot cause the flu. Only live virus vaccines can lead to forms of the disease. The vaccines available in the US this season are either an inactivated or a recombinant vaccine. These do not cause flu symptoms. The vaccines cannot mutate to cause symptoms. They simply don't work that way.

There are many reasons you could have gotten sick after a flu vaccine that were not due to the vaccine.

  1. You were exposed to influenza before the vaccine had time to take effect and protect. 
  2. You  caught a strain of influenza that wasn't covered in the vaccine. 
  3. You caught one of a number of other viruses that cause flu - like illness. 
  4. The vaccine did cover the type of virus you have but your body didn't make the proper protection from the vaccine so you were still susceptible. 
In each of these scenarios, you still would have gotten sick if you hadn't had the vaccine, but if you recently had the vaccine it's easy to understand the concern that the vaccine caused the illness.

The FluMist is a live virus vaccine, so it could cause mild symptoms of influenza viruses, but it is not recommended for use in the US this year.

3. I can prevent the flu by being healthy.


It is important to eat right, exercise, get the proper amount of sleep, and wash hands. All of these things help keep us healthy, but they don't prevent the flu reliably.

We cannot boost our immune system with megadoses of vitamins. (Vaccines are the best way to boost our immune system.)

Organic and non-GMO foods don't offer any benefit to our immune system over other healthy foods. If these things did as some claim, people generations ago would have been healthier since they ate locally grown organic foods, got plenty of fresh air, and exercised more in their day to day life than we do these days. Instead of being healthier, they were much more likely to die from infections. The risk of death between the first and 20th birthday had decreased from over 3 in 100 children in 1900, to less than 2 in 1000 children today. One of the major causes of death historically (and still today) is from influenza, but it has been shown that the flu vaccine reduces the risk of death. Why not help your body prepare for flu season with the vaccine?

4. Flu vaccines shouldn't be used during pregnancy -- they've never been tested and can lead to miscarriage.


Pregnancy is considered a high risk condition for severe complications of influenza disease and the vaccine can help prevent those complications. It is recommended that all pregnant women get vaccinated against influenza. If a pregnant mother gets the vaccine, it not only helps to prevent complications during pregnancy, but it also helps prevent influenza in newborns since they can't be vaccinated until 6 months of age.

There are some who assert that since the package inserts state the vaccines have not been studied in pregnancy that they aren't safe, but in the next breath they say that they aren't safe because a study showed a high rate of miscarriage after the vaccine.
The first part of the argument is one of the many ways the package insert is misused. Discussions about using package inserts properly are found at The Logic of Science, another at The Logic of ScienceSkeptical Raptor, Harpocrates Speaks, and even this analogy of Package Insert Airline to vaccine package inserts.
Think about it... you can't argue that it's never been studied and then quote a study. It's been studied. A lot. The Vaccine Safety Datalink is a huge database designed to document adverse events associated with vaccination, allowing researchers access to a large amount of data.  
The flu vaccine has been safely given to pregnant women for over 50 years. Despite a recent small study suggesting a potential risk of miscarriage, the flu vaccine has been studied extensively around the globe and found to be not only safe but effective at decreasing the risk of influenza disease during pregnancy and beyond.

5. I have a chronic illness and don't want to get sick from the shot.


People with chronic illnesses (including diabetes, heart conditions, and asthma) are more at risk from serious illness from influenza disease. The influenza vaccine can prevent hospitalizations and death among those with chronic diseases. People with chronic diseases should be vaccinated, as should those around them to protect with herd immunity.

The flu shot cannot make anyone sick, even those who are immunocompromised. You do not need to avoid being around someone who is sick or immunocompromised if you've recently been vaccinated.

6. If I get the flu I'll just take medicine to feel better.


There is no medicine that makes people with influenza feel better reliably.

There is no medicine that decreases the spread of influenza to friends and family of those infected.

We can take fever reducers and pain relievers, but they don't treat the underlying virus. They suppress our immune system so we don't make as much inflammation against the virus, which decreases the symptoms and our body's natural defenses.

Cough and cold medicines simply don't work well.

As for antiviral medicines, I have written about Tamiflu previously and why I rarely recommend it.

Megadoses of vitamin C or other vitamins, homeopathic treatments, essential oils, and other at home treatments have not been shown to significantly help.

It is important if you get sick, you should limit contact with others. This means missed school and work for at least several days with influenza. Prevention with the vaccine simply is better than trying to treat the symptoms.

7. I don't like shots. (Or my child doesn't like shots.)


I'm a pediatrician. Most of my younger patients hate shots. Like really hate shots. They cry, scream, kick, try to run and hide -- you name it, they've tried it to try to avoid shots. They fear shots, but we can help them with techniques that lessen the pain, and they often say "it wasn't that bad" afterwards. For more on how we can help lessen the pain, check out Vaccines don't have to hurt as much as some fear.

8. I have an egg allergy so can't get flu shots.


In previous years there was a concern that people with egg allergy would have a reaction from the vaccine so it was not recommended, but it has been found to be safer and still appropriate to vaccinate with proper precautions.

People who have had only hives after egg exposure can safely get flu vaccines following standard protocols.

People who have symptoms of anaphylaxis with egg exposure that requires epinephrine (respiratory distress, lightheadedness, recurrent vomiting, swelling - such as eyes or lips) should still get the vaccine, but they should be monitored at the appropriate facility (doctor's office, hospital, health department) for 30 minutes to monitor for reactions.


9. Vaccines are only promoted to make people money. Doctors are shills.


Very little profit is made from any vaccine. Really. Some doctors and clinics lose money by giving vaccines. I often tell my own patients that I don't care if they get the vaccine at my office, the local pharmacy, or at the parent's office - whatever works for them best. I just want everyone vaccinated. This in the end will decrease my revenue because they will not come to the office seeking treatments for a preventable illness. But I am a pediatrician to take care of the health of children, not to make money. Pediatricians are consistently on the bottom of the list of physician salaries. If I was in it for the money, I would have gone into orthopedics or another surgical specialty.

There are many things to consider when addressing this argument and the Skeptical Raptor does it well, including links to more information.

10. The flu vaccine contains mercury.


While it is true that some flu vaccines contain thimerosal, not all do. Thimerosal was removed from the majority of childhood vaccines in 2001 due to lawmakers responding to constituent demands, not because it was shown to be a risk medically. Since the flu vaccine is not only for children, there are multidose vials that contain thimerosal. If that really bothers you, ask for a version without thimerosal. But since it was removed because people thought thimerosal caused autism and the rates of autism haven't gone down since it was removed, that's pretty strong evidence that it never caused autism. Just like the scientists said. It's a preservative that is effective. I would gladly get a flu vaccine with thimerosal, and have over the years, but the majority of flu vaccines given to children in the US are thimerosal free. Just ask.

Flu Vaccine Information and Recommendations for the 2017-2018 Season


  • Both trivalent (3 strain) and quadrivalent (4 strain) vaccines are approved for use this year. There is no preference officially of one over the other, but the vaccine should be appropriate for age.
  • No FluMist Nasal Spray flu vaccine is recommended. The nasal spray did not work well in the last few seasons it was used in the US. Until it is understood why it wasn't effective then how to make it effective, it will not be recommended.
  • Pregnant women should be vaccinated to protect themselves and their baby. 
  • Everyone over 6 months of age should be vaccinated. Children 6 months to 8 years who have only had one flu vaccine in their past will need two doses this season. This is because the first dose acts as a primer dose, then a booster dose boosts the immune system. Once the body has had a boost, it only needs a boost each year to improve immunity. 
  • Infants under 6 months of age can gain protection if their mother is vaccinated during pregnancy and if everyone around them is vaccinated. They cannot get the flu vaccine until 6 months of age.
  • People with egg allergy can be vaccinated. If there is a history of anaphylaxis to egg, they should be monitored for 30 minutes.
  • The CDC is encouraging everyone to be vaccinated by Halloween if possible, but it's not too late to be vaccinated after that if not yet done this season. It takes up to 2 weeks for the vaccine to be effective. Flu season typically starts in January, but the peak can be as early as November and as late as March.
  • It is acceptable and encouraged to give the flu vaccine along with other recommended vaccines needed.
CDC Blog-a-thon


Related blogs


Vaccines don't have to hurt as much as some fear
Tamiflu: Guest blogger Dr. Mark Helm
Tamiflu Status Downgraded

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Tuesday, October 17, 2017

7 Vitamin K Myths Busted

Social media has allowed the sharing of misinformation about many things, especially medically related things. When the specifics of something are unknown to a person, pretty much anything that's said can sound reasonable, so people believe what they hear. This happens with many things, such as vaccine risks, chelation, and vitamin K.

vitamin K, newborn, bleeding, clotting, VKDB, safety, hemorrhagic disease of the newborn, infant


I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth. This is a life saving treatment to prevent bleeding. Life saving.

Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it's too late to do anything about it. Why parents don't want to give this preventative life saving treatment is usually based on incorrect information.

This is a matter of a fairly low risk of bleeding if you don't give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable - it's hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there's very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?

Conspiracy Theories, Misunderstandings, and Science


This is not a governmental conspiracy to somehow kill children. It's a world wide attempt to help children survive and thrive. The World Health Organization (WHO) guidelines:


  • All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence) 


Most people look at scientific information and can't make heads or tails of what it means.

Photo Source: Hemorrhagic Disease of the Newborn

That coupled with the fact that things we read that make us react emotionally (such as fear that something will harm our child) makes us remember and associate with the information that created the emotion, whether it is right or wrong. This can lead parents to make dangerous decisions for their children while trying to do the right thing.

Myth Busting


I'm going to attempt to de-bunk the most common concerns I've heard because the best way to combat misinformation is to help explain the facts as we know them.

1. If every baby's born with too little vitamin K, that's the way we're supposed to be.
Babies are born with very little vitamin K in their body. If they don't get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won't be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you're using this argument because you want babies to be all natural, you probably won't be giving formula at this point.) 
Bacteria help us make vitamin K, but babies aren't colonized at birth with these gut bacteria. 
Just because they're born that way doesn't mean they're supposed to stay that way. Inside the mother the baby is in a very different situation. They don't breathe air. They don't eat. They don't have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?

2. The package insert has a big warning at the top that it can kill.
There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won't go into all the details but please see these great blogs on how to read and use package inserts:


It is true that there is a black box warning on the top of the vitamin K package insert. This has scared some parents from wanting to get the vitamin K shot for their newborn. 
Screen Shot from Package Insert 
Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don't give vitamin K by IV to newborns. 
IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection. 
I only found one report of a newborn with a significant reaction to vitamin K. The authors of the paper did note that IM vitamin K has been given for many years to babies all over the world without significant reactions and could not explain why the one infant had such a significant reaction. 
Since we must always look at risk vs benefit, the very, very low risk of a serious reaction from receiving vitamin K IM is preferable to the benefit of the prevention of VKDB.
Another great resource on this topic is Dr. Vincent Iannelli's That Black Box Warning on Vitamin K Shots


3. Vitamin K causes cancer.

Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found. 
Vitamin K does not cause cancer. 
Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.

4. Bleeding from vitamin K deficiency is rare or mild.
In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.
Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.

Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.

Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.
One out of five babies with VKDB dies. Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.
5. It's just as good to use oral vitamin K.
Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue. Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.
There is no liquid form of vitamin K that is proven to be effective for babies in the US. That is a huge issue. Some families will order vitamin K online, but it's not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose. It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses. 
Most of us get vitamin K from gut bacteria and eating leafy green vegetables. Newborns don't have the gut bacteria established yet so they won't make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K, so unless baby is getting formula, they will not get enough vitamin K without a supplement. It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.
Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.  
There are various oral vitamin K dosing strategies that can be reviewed in the linked abstract. In short:
  •  Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.) 
  • Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1may be as effective as parenteral vitamin K prophylaxis.
  • Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby's parents forgot the last dose.
When vitamin K is given IM, the chance of late VKDB is near zero. Oral vitamin K simply doesn't prevent both early and late bleeding as well -- especially if there is an unknown malabsorption disorder, regardless of which dosing regimen is used. 

6. My baby's birth was not traumatic, so he doesn't need the vitamin K.
Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it. Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later. 

7. We're delaying cord clamping to help prevent anemia and bleeding. Isn't that enough?

Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them. There is very little vitamin K in the placenta or newborn, so delaying the cord clamping cannot allow more vitamin K into the baby.  

Still not convinced?


Read stories about babies whose parents chose to not give vitamin K:

For More Information:

Evidence on: The Vitamin K Shot in Newborns (Evidenced Based Birth)

Lead by example

We've all heard the saying: kids will do what they're shown, not as they're told.

It is so true. Think about all the times your kids are watching you. They are learning from you. 

parenting, children do what they see


What can you do to help them have healthy habits?

  • Eat your vegetables.
  • Get daily exercise.
  • Wear your seatbelt. 
  • Stop at stop signs.
  • Don't use your phone while driving.
  • Wear a life vest near a lake or river.
  • Maintain your composure during times of stress.
  • No phones at the dinner table.
  • Don't tell lies- even little ones.
  • Get enough sleep.
  • Be kind to others.
  • Call home- your parents and siblings would love to hear from you.
  • Don't permit violence in your presence.
  • Give your time and talents to others.
  • Take care of your things.
  • Limit screen time.
  • Brush your teeth at least twice a day and floss daily.
  • Wear a helmet when on a bike.
  • Don't mow the lawn without proper shoes. 
  • Make time for family.



Tuesday, October 10, 2017

Breast is Best... Unless it's Not

We've all heard the well-intentioned slogan "Breast Is Best" in reference to supporting breastfeeding. Breastmilk is made just for our babies, so yes, it is a great source of nutrition. But it isn't the only option and there are many reasons mothers give formula and even with exclusive breastfeeding there comes a time that infants need additional sources of nutrition.

I decided to write on this topic because I see so many mothers struggle to feed their baby and they feel like a failure if they don't exclusively breastfeed. And then to top it off I saw a blog that encouraged exclusive breastfeeding without any foods or supplements until one year of age. I knew someone had to counter that thought before it becomes popular. It shouldn't be a badge of honor to breastfeed to the point of potential harm to the infant, and some ultra-crunchy moms are bragging about it as if it is.

You're not a failure if you feed your baby, regardless of what you feed your baby as long as it's age appropriate. Your baby needs nutrition and hydration. While most babies under 6 months of age can get all their nutrition from breastmilk, some need a boost, especially at the beginning of life. If you’re not producing enough milk, you’ll need to give your baby some formula as well (or use a milk donor). Usually this is temporary - just until your own milk supply increases or until your baby starts enough solid foods that the supplement isn’t needed. I'm not suggesting that every newborn who struggles at the breast should be supplemented, but if your doctor says the baby's blood sugar is low or the baby is losing too much weight, it's not only okay, but it's necessary to supplement.

breastfeeding, infant feeding, newborn, formula

Benefits of Breast Milk


Most of us have heard by now the many benefits of breastfeeding for the baby, including:
  • Immune system benefits. (Which means fewer infections, meaning not only helping babies stay healthy, but also leading to fewer lost work days for working parents and fewer sleepless nights for all parents.)
  • Decreased risk of Sudden Infant Death Syndrome.
  • Decreased risk of asthma in a child who has breastfed.
  • Decreased risk of diabetes when the baby grows up.
  • Decreased risk of obesity as the baby grows up.
  • Decreased risk of certain cancers in the child, such as leukemia.
  • Improved cognitive development of the child.
Benefits for mothers include:
  • Less bleeding, both in the immediate postpartum period from contracting the uterus after birth, and fewer menstrual cycles during breastfeeding. 
  • Decreased risk of getting pregnant while breastfeeding - though this is not 100% effective! If you're not wanting to get pregnant don't rely on breastfeeding alone.
  • Easier return to pre-pregnancy weight.
  • Decreased risk of ovarian and breast cancers.
  • Decreased risk of Type II diabetes.
  • Decreased risk of postpartum depression.
  • Decreased risk of heart disease.
  • Less missed work (see immune system benefits above).
  • Cost - breastmilk is free and formula is expensive. Breast pumps should be covered by insurance. 

When Breast Milk Isn't Enough, Isn't Desired, or Isn't Safe


Despite the benefits, breastfeeding not always possible or desired. In the US, 8 out of 10 mothers start breastfeeding during the newborn period. Only half are still nursing at 6 months, and less than a third are still nursing at 12 months.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding for 1 year or longer, as mutually desired by mother and child. Some AAP sources indicate starting foods at 4-6 months. The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends introducing foods between 4 and 6 months to prevent certain allergies.


There are very few contraindications to breastfeeding:

  • Classic galactosemia. Classic galactosemia is a rare genetic condition in which a baby is unable to metabolize galactose. It is one of the conditions we screen on the newborn screen. Galactose is the sugar made from the lactose in milk. When galactose is not metabolized, it will reach high levels in the blood and become toxic, causing cataracts in the eyes, damage to the liver and kidneys, and brain damage. The galactosemic baby will fail to thrive on breast milk or formula based on cow's milk. The treatment for this condition is to remove all sources of lactose from the baby's diet and give soy formula.
  • HIV. Mothers who have HIV and are able to feed formula made with safe water should not breastfeed according to current guidelines. However, there is growing evidence that HIV positive mothers who take proper medications can safely breastfeed.
  • Untreated active tuberculosis.
  • Chemotherapy or radiation treatment.
  • Certain drugs. Most medications are compatible with breastfeeding. You can look on Lactmed to learn if a particular medicine is safe or what other options are recommended. 

Some mothers do not want to breastfeed for various reasons. That's okay. It isn't for everyone. No one should say things that make these mothers feel guilty. They brought new life into the world. That alone is an amazing feat. As long as the baby is fed age-appropriate and formula that has been approved for use in infants, it is great.

Babies can thrive on formula. Just be careful of the many alternate formulas and milks that are advertised online. Discuss with your child's pediatrician if you plan on making your own formula or giving another alternative milk. There are many concerns with these, as discussed in Please Don’t Feed Your Baby Homemade Formula!

Some mothers really want to exclusively breastfeed but they have problems. Working with a lactation consultant and physicians (both mother's and baby's doctors) might help if there is a correctable condition, such as

  • insufficient breastfeeding attempts per 24 hours - not feeding frequently decreases supply
  • tongue tie treatment can improve latch and milk transfer from the breast into baby
  • jaundice, which makes baby sleepy and not feed as effectively
  • identifying and treating hormonal problems in mother
  • identifying and stopping medicines or herbs that might be inhibiting milk supply
  • stopping nipple shields as soon as possible - the use of nipple shields can decrease breast stimulation and lower supply
  • avoid unnecessary supplements - supplementing with formula can decrease supply overall because the mother's breast makes milk based on how much is used (This does not mean you should avoid formula if it is medically necessary.)

Even when breastfeeding goes well for both Mother and Baby, it is not sufficient to be the sole source of nutrition for the entire first year of life. There are some mom blogs that support exclusive breastfeeding for the first year of life, and that is not safe. I'm not linking any of them here because I don't want to promote them, but if you don't believe me just do a quick search and you will find some.

While breast milk is fantastic for young infants, it does not have the nutritional components to exclusively feed for the second half of the first year. Feeding with food from fingers or a spoon also encourages healthy development of fine motor skills.

It is important for older infants to learn to eat from a developmental standpoint. Once they can sit fairly well, turn away from food or open their mouth in response to food, they are showing signs that they are ready to start eating. They don't need teeth to move foods around in their mouth and make chewing motions. 

They are much less averse to new things typically when they're younger, so if babies are delayed past a year they are much more likely to be picky eaters and not get the nutrition they need during childhood.

Then there's the research that shows that delaying certain foods past a year increases the risk of allergy. If you've ever seen a child with anaphylaxis to peanuts, you won't want to increase this risk for your child! See the AAP's guidance on introduction of high-risk allergenic foods

Babies need a source of iron after about 4-6 months of age. If they are not eating foods rich in iron (meats, legumes, egg yolk, leafy greens) they will need an iron supplement. Many of the bloggers who support exclusive breastfeeding do not want any supplements at all. Just breast milk. It simply isn't enough to support the older infant's growing brain and body. 

Vitamin D is important for us all, but it is not passed through breast milk well unless a mother is taking at least 6400 IU/day. Historically we could make vitamin D with the help of the sun, but we now know that sun damages our skin so it is safer to protect against excessive sun exposure. This puts us at risk for vitamin D deficiency. The AAP recommends that newborns begin supplementing with 400 IU/day of vitamin D soon after birth, and increase to 600 IU/day at 6 months of age. The supplement should continue even if they transition to Vitamin D fortified cow's milk at 1 year of age.

Any problems feeding should be discussed with your child's doctor

If your baby struggles with feeding, whether it's breastfeeding, formula feeding, or eating foods, please discuss it with your child's doctor. There are many reasons feeding might not go well, and we need to insure that your baby is being adequately fed. We will look at your baby's overall growth and development in addition to discussing the specific details of the problems. 

Resources


Related Blogs on Quest for Health

Over and Under Supply of Breast Milk
Breastfeeding: Easier for Working Moms with New Insurance Rules

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Tuesday, September 19, 2017

Car Seats for Safety

It's been years since I've written about car seat safety and since September 17-23, 2017, is Child Passenger Safety Week I thought I'd take a moment to review car seat safety basics and share some of my favorite car seat safety links.



Most parents are now aware that all infants must be in a rear facing car seat, but many turn their toddlers around too early or let older kids move to the next level too soon.

I tell kids all the time that the state law is the bare minimum, but it isn't necessarily the safest way to ride. I use the example that in my state an adult can ride a motorcycle without a helmet, but that's not safe. They usually agree, and I think it helps them understand that just because it's legal to do something, it doesn't make it safe to do.

Kids learn from the behaviors they see their parents display, so all parents should buckle up for safety!

When looking for a car seat or booster seat, don't assume spending more money will buy a better seat. You need to be sure it fits your vehicle and your child.

Infants and children under 2 years should ride rear facing unless they are bigger than the height or weight maximum for the seat. Children over 2 years who still fit in the height and weight requirements of the rear facing car seat can still ride rear facing safely. Young children often fall asleep in the car. If sleep deprived (no parent is ever really well rested) and in a hurry, even the best parent can be distracted and forget about the sleeping baby. There are many tips to follow to be sure you don't leave your baby unattended in the car.

Children who are 2 years old or older (and those less than 2 years but larger than the rear facing car seat maximum height or weight) should use a forward facing car seat with a 5 point harness until they are capable of staying seated during the duration of the drive and meet the minimum height and weight requirements for a booster seat. Learn to use the tether properly with your forward facing car seat.

Children should remain in a booster seat until the vehicle's lap and shoulder seat belt fits them properly. This is generally between 10 and 12 years of age and about 4 foot 9 inches, but varies based on the size of the vehicle's seat. Everyone should always use the vehicle's seat belt (or car seat harness) when riding. Have your kids take the 5 Step Test to see if kids can safely ride without a booster.

Only teens and adults should sit in the front seat. It's always safer in the back seat. If you look at the sticker on the passenger side visor, it will say something to the effect that children 12 and under are safer in the back seat. That means wait until 13 years of age to sit up front. Airbags can be dangerous if a passenger is too short for it to hit properly in the chest. The force of the airbag can cause significant injury to the face or neck. If the airbag is turned off, the passenger is at risk of hitting the dashboard or being ejected from the car. Even big kids don't have the muscle or bone strength to be safe up front. They aren't mini-adults.

In the winter months it's important to avoid over bundling infants and children in car seats. The added layers and padding of clothing can increase the amount a child can move in the force of a crash or sudden stop. The Car Seat Lady has great tips to keep kids warm and safe in the cold weather.

Don't use car seat attachments and accessories that were not sold with the seat. They may look cute or seem to make your child more comfortable, but if they haven't been tested with the seat they may not be safe - even if they claim to be safety tested. This includes neck rolls, shoulder pads, winter covers that go between the child and the seat, dangling toys, and more. If you're in an accident and have these additions they might void the warranty of the seat.

Do you have a Houdini? If your toddler or preschooler is able to weasel out of the car seat harness, try this button down shirt trick.

Take your kids to a certified car seat installer to see if they're buckled in properly. Car Seats for the Littles has information about how to find an installer near you.

Register your car seats so you can be alerted if they are recalled.

Car Seat Stickers are a great way to notify first responders who to call if you've been in an accident and aren't able to communicate. I recommend putting them under the cloth part of infant seats so they aren't visible when you're carrying the seat in public. You can put a small sticker on the handle to let emergency personnel know to look under the padding for emergency contact information. Once kids are out of the infant seat you can put the sticker on the outside of the seat, just not over any important information (such as the height/weight max information). My office gives stickers from the W.H.A.L.E. Program to patients, but you can print your own at home and attach them to your seat with wide clear tape. Information to include would be:

  • Child's name, birth date, address, allergies, important health history, medications
  • Parent's names and phone numbers (cell and work)
  • One emergency contact name and phone number (not a parent) 
  • Doctor's name and number
  • Childcare provider name and number if applicable 


Remember that if you're in an accident, your car seats might need to be replaced. Talk to your insurance company.

Used and borrowed seats cautions

  • Be sure to know when your seats expire. The seats typically expire about 6 years after manufacturing due to unseen breakdown in the materials used to make the seat. 
  • Never buy a used seat from someone you do not know. A friend or family member should verify that it hasn't been in an accident and it's not expired before you use it. 
  • Don't just throw your old car seat away. Someone might try to use it past its expiration date. You can break it down into pieces to make it unusable or you can see if you can recycle it

For more information:




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Saturday, August 26, 2017

HPV vaccine concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still "want to do their research" or "have heard things" so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven't done their research, so their child remains unprotected. Sometimes they'll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.



I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough. 
It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).
Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection "to those who do not need it (adolescents)" at all. Yes teens need protection. I'll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It's kind of like saying that kids don't need to brush their teeth because they don't have cavities. If you wait for the cavities to develop, it's too late!

The second argument is based on old version of the vaccine. We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting. If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine. 

The risks listed have all been shown to not be as risky as once shown.

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage. There are so many things wrong with this. First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship. Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry. Or there could be infidelity in marriage. There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not. And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage. Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don't always protect against HPV transmission.  And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

They argue it hasn’t been tested in males. It has. And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

This article is several years old. It didn’t yet know that the cancer rates in Australia would fall like we now know. We’ve learned much more information than they knew in 2011 when it was written. We know the HPV vaccine is safe. It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely. It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn't worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn't need protection.

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can. If I had any concerns about its safety I would not have given it to my own children. I don't think I can list any study or give any argument stronger than that.