Which Supplements Help Prevent and Treat Infections?

I don't know anyone who wants to get sick, so most of us try our best to avoid illnesses. We do this by washing our hands and encouraging our kids to cover their coughs. We avoid sick people as much as possible (though we don't always stay home when we should). We should routinely get enough sleep (most Americans fail in this regard) and eat more fruits and vegetables (again, most of us fail to get the minimum recommended amounts of plants in our diets).

All of these measures can help, but can we get more help from nutritional supplements or other natural remedies? What will boost our immune system?

I'm often asked if vitamin C, zinc, or essential oils will help various ailments or boost our immune system. I know that many people try natural products that are promoted to boost or support the immune system. They're hopeful that stimulating immune system activity will help the body fight off a virus. But research doesn't show that our immune system works that way. A virus can cause illness even in healthy people. If you want to read an in-depth summary of how our immune system works, the Skeptical Raptor has done a nice job discussing the complexities and why it's not as easy as eating healthy and taking supplements. Not to mention the fact that we don't necessarily want an overactive immune system, which is associated with allergies and autoimmune diseases.

One thing we need to remember first and foremost in the discussion of supplements is that this is an under-regulated industry. The FDA is not authorized to review dietary supplement products for safety and effectiveness before they are marketed. For this reason I hesitate to recommend supplements at all. Even though I do recommend Vitamin D supplements because studies support the need for additional Vitamin D in most people, I cannot endorse one particular product. Over the years many supplements, homeopathic products and herbs have been reported to have significant variances in amounts of product and unnamed contaminants, including lead and other hazards.

Summaries of supplement and other "natural treatment" effectiveness:

• Probiotics may actually help prevent the number of infections. There are many, many types of probiotics, so further studies are needed on how to choose the best strain.
• Zinc has been shown to help prevent upper respiratory tract infections in children and teens and to decrease the duration of the common cold symptoms. It is best given as a lozenge to help with absorption. Intranasal zinc has been linked to a permanent loss of smell and should not be used. High doses can cause significant side effects, so talk to your doctor and pharmacist before supplementing.
• Nasal saline rinses show benefit in treating symptoms of upper respiratory tract infections. Learn how to do these correctly before trying it though. I often recommend Nasopure products as an unpaid endorsement. They're a local company with a very helpful website. Use their library to learn how to properly use nasal rinses in kids as young as 2 years of age.
• Honey may reduce the frequency of cough and improve the quality of sleep for children with the common cold. Honey should never be used in children younger than 1 year of age because of the risk of botulism.
• Echinacea has consistently been shown to be ineffective in many studies. I know that many people have heard of its benefits, so if you aren't convinced that you shouldn't waste money on it, see the NCCIH's Echinacea page.
• Garlic shows overall low evidence of benefit.
• Vitamin C can shorten the duration of illness mildly with daily supplementation. 
• Chinese herbal medicines do not have high quality studies so effectiveness is unknown.
• Geranium extract (Pelargonium sidoides) has insufficient evidence of benefit for cold and cough symptoms.
• Turmeric's supposed anti-inflammatory properties have not been shown to be effective by research.
• Essential oils have the potential for beneficial effects – but they also have the potential for adverse reactions. Although they are touted as a cure for many ailments, published studies regarding the uses of aromatherapy have generally focused on its psychological effects on stress and anxiety or its use as a topical treatment for skin conditions. Both Young Living and dōTERRA have received warning letters from the FDA about improper marketing and unsubstantiated claims for uses of their oils. While many people think essential oils are safe, they can lead to significant problems. Some people suffer from allergic reactions to oils. They can increase sensitivity to the sun when applied topically. Tea tree oil and lavender have estrogen-like effects and caution should be used with these. Some of these substances can even lead to seizures, liver damage, and death if used improperly. Ingestion of the oils is a growing concern - as more households have them, more children are ingesting them.

Alice Callahan's “Immune-Boosting” Supplements Won’t Protect You from Back-to-School Germs is a great review of many of the supplements touted to prevent or treat illnesses. Her background in nutrition provides a solid base for reviewing claims that many of us don't understand completely. 

Generally supplements are not recommended, but if you choose to use them, use them cautiously.

• Supplements contain a wide variety of ingredients - including vitamins, minerals, amino acids, and herbs. Research has confirmed health benefits of some dietary supplements but not others. The woo can be strong in this area, so be cautious where you get your information. 
• Supplements have been known to include unlisted ingredients and to have inconsistent levels of product. When they are recalled, there is no mechanism in place to identify and notify people who have purchased affected products. 
• Find a reliable source to evaluate effectiveness and risks. Some reports have shown that people who take supplements have higher risks of cancer, liver damage, birth defects, bleeding, and other health problems. When looking for information, use noncommercial sites (National Institutes of Health, Food and Drug Administration, US Department of Agriculture, National Center for Complementary Health) rather than depending on information from sellers.
• Natural does not mean safe. I've always said that I wouldn't give my picky eater marijuana to stimulate his appetite and encourage him to eat. Not even if it was organic. That usually gets the point across. You need to know the risks of a product, even if it's natural. 
• If supplements will be taken, talk to your doctor and pharmacist about drug interactions. Sometimes it's difficult to know the risks because not all ingredients are included on the label and not all ingredients have been well studied, especially in combination with other supplements and medications. 
• Most dietary supplements have not been tested in pregnant women, nursing mothers, or children. Remember just because something's natural doesn't mean it's safe. Arsenic is natural but I wouldn't advise taking it in high doses.
• If something sounds too good to be true, it probably is. There are no miracle cures. Avoid being manipulated by advertising. It's easy to fall prey because we all want to feel better quickly and parents want their kids to be healthy. But if it claims to be 100% effective or to have no side effects, it's probably false advertising. Personal accounts of something working are as likely to be based on bias or coincidence as to be from real benefit. Rely on large clinical studies that have been reproduced by other researchers. Dr. Chad Hayes has a very long, but wonderful post on how many of the integrative medicines are not simply not beneficial but potentially dangerous - Citations Needed: The curious “science” of integrative medicineMy experience at "Get Your Life Back NOW!"

This post isn't about antibiotics, but they don't work against viral illnesses any better than supplements. They don't prevent the development of ear infections or pneumonia, so even if your child seems to always develop these complications, your doctor should not prescribe them preventatively. Don't use antibiotics for routine upper respiratory infections, stomach bugs, and other viral illnesses. 

Do you know what really boosts your immune system?

Vaccines

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. 

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 Science, Skeptical 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.

Related blogs

Flu Vaccine Recommendations for the 2016-17 Year

Vaccines don't have to hurt as much as some fear

To Tamiflu or Not To Tamiflu...

Tamiflu: Guest blogger Dr. Mark Helm
Tamiflu Status Downgraded

How To Keep Your Family Healthy This Winter

Evolution of illness

Fever Is...

My Child's Cough and Breathing Sounds Like...

Cough Medicine: Which one's best?

"But the snot is green…" Or "How can we treat cough and colds?"

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

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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.

• HPV Vaccine Not Linked To Autoimmune Disorders, Study
• Questioning Whether To Get Your Child the HPV Vaccine? Read This
• Is The HPV Vaccine Safe? v 2.0
• Gardasil HPV Vaccine Safety Assessed In Most Comprehensive Study To Date

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.

Hearing Loss

Most of us associate hearing loss with old age, but it is increasingly common for children and teens to suffer from mild to moderate hearing loss. Nearly 15% of kids have hearing loss according to the CDC. Hearing loss can be due to many things that are difficult to control, such as heredity, infection, and medications. In kids and teens it is oven due to a preventable cause: noise.

Where does the excessive noise come from?

Even young children are exposed to more loud noises through toys, television, and gaming devices than children of years past.

Widespread use of ear buds for prolonged periods can take its toll on hearing. Unlike the bulky headphones used when I was a child, earbuds deliver sound directly into the ear canal without any sound buffering in between. Most often the earbuds are used with iPods and other mp3 players are low to mediocre quality, so they are unable to transit the bass as effectively. Many kids turn the music up to hear the bass. If others can hear the music coming from ear buds, they are too loud!

Loud concerts or sporting events can also expose our ears to excessive volumes for a prolonged period of time.

Not all excessive noise is from kids being undisciplined - some kids are helping out the family or trying to earn extra cash by mowing lawns or using power tools, which puts them at increased risk.

How much is too much?

According to the Centers for Disease Control and Prevention (CDC), being exposed to more than 85 decibels (dB) of sound for eight hours can damage your hearing. At 105 dB, hearing loss is possible after a mere 5 minutes.

If you're like me, that means nothing because how much is 85 dB? There is a great chart of common sounds and how loud they are on this page from the CDC. There are also several free apps available for download on smartphones and tablets - search "sound meter" or "decibel" and read reviews before downloading. Take advantage of these -- and because it's in the phone, kids might actually have fun playing around with them and learning about their environmental risks at the same time!

Signs of hearing loss

One early sign of excessive noise is ringing in the ears, but most people with hearing loss never realize it's happening because it's slowly progressive. If you notice your child asking "what" more often or complaining that the television is too quiet when others hear it well, it is a good idea to have their hearing tested.

Consequences of hearing loss 

There are many potential consequences to hearing loss:

• Learning - you have to be able to hear the lecture. 
• Behaviors - if directions and instructions are missed, a child might incorrectly be seen as misbehaving. 
• Friendships and social skills - if a child can't follow a conversation they aren't easy to talk to or play with.
• Job availability - many jobs require hearing at a certain level. 

Prevention

Talk to your kids about the risks of their habits that involve loud sounds. Unfortunately kids won't always take parental advice to heart because they have a feeling of invincibility, but studies show if they learn about hearing loss they are more likely to use protection. Even more so, what their friends are doing alters their behavior. Teach not only your kids, but also their friends. If they're all going to a loud event, consider giving them all ear plugs. Once hearing is damaged they can't gain the hearing back, so prevention is key.

Ways to protect include:

• Wear hearing protection (earplugs) when mowing the grass and attending loud events, such as concerts or sporting events.
• Turn down your music! Some music players have alerts when the volume goes too loud, but those can be ignored if the child doesn't understand why it's important to lower the volume. If others can hear the music you're listening to through earbuds, turn it down.
• Lower the maximum volume setting on your iPod or mp3 player. To do this, go to "Settings" and select "Volume Limit" under Music. Set it at about 60% of the full volume, that way you can't accidentally turn your music too high.
• Use big headphones instead of earbuds. They offer more external noise cancelling, which allows the music to be heard better at lower volumes. They are also physically further from your eardrum, which helps.
• If you must use earbuds, use high quality buds that transmit bass if you are tempted to turn music up to hear the bass.
• Follow the 60/60 rule: No more than 60 minutes of listening at a time, and no higher than 60 percent of maximum volume. If you go under "settings," you can actually set your iPod for maximum volume setting of 60 percent, so you can't accidentally turn your music up too loud.
• Higher pitched sounds have greater potential to damage your ears than lower pitched sounds. Turn down the volume when a high-pitched song comes on.
• Try not to fall asleep with earbuds or headphones on. The time of exposure matters and why waste sleep time damaging your ears? 
• If you need "white noise" to fall to sleep, put together a playlist of soft songs or sounds and have it play at a low volume from a speaker on your bedside table. Use your clock's "sleep" function, which will automatically turn off your music after a set amount of time to ensure the music doesn't end up playing all night long, which saves energy in addition to your hearing.
• As always: model these behaviors for your children. If they see you mowing the grass with loud music blaring in your ears, they will grow up to do the same. If you wear ear buds many hours of the day, they will see that as a normal and acceptable behavior. 

What happens that hurts our hearing?

Keep the volume down – Too loud and too long can damage your hearing shows a man listening to music. Below it the music soundtrack and volume levels are shown. The video then breaks to showing what happens to the hair cells in our ear with these volumes, which makes the damage more understandable because you can see it happening. 

Resources:

Hearing Screening and Prevention of Hearing Loss in Adolescents

CDC's Hearing Loss main page

Help! I'm sick and I have a baby at home.

When we have newborns we don't want to expose them to germs. We avoid large crowds, especially during the sick season. We won't let anyone who hasn't washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

• Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting. Wash Baby's hands after diaper changes too. Make this a habit even when you're not sick... you never know when you're shedding those first germs!

• Wipe down surfaces. Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect. Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area. 

• Avoid touching your eyes, nose and mouth - these are the "doors" germs use to get in and out of your body. Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
• Resist kissing Baby on the face, hands, and feet. I know they're cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too. 
• Cover your cough. I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs. When you're responsible for a baby, the baby's head is often in your elbow, so I don't recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren't available.
• Vaccinate. If you're vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you're less likely to bring those germs home. Encourage everyone around your baby to be vaccinated. If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity. See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.
• Breastfeed or give expressed breast milk if possible. Mothers frequently fear that breastfeeding while sick isn't good for Baby. The opposite is true - it's very helpful to pass on fighter cells against the germs! Again see Jody Segrave-Daly's blog for wonderful explanation of how breast milk protects our babies. 
• Limit contact as much as possible. If possible, keep Baby in a separate area away from sick family members. Wash hands after leaving the area of sick people. If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.
• Insist on a smoke-free home and car. Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production. These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors. Change your shirt (or remove a coat) and wash your hands before holding Baby.

It's never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too. As with everything, you must take care of yourself before you can help others. Drink plenty of water and get rest! Most of the time medicines don't help us get better, since there aren't great medicines for the common cold. Talk to your doctor to see if you might need anything. Don't be falsely reassured that you aren't contagious if you're on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing. You need to be vigilant against sharing the germs!

Great News About the HPV Vaccine!

The HPV vaccine has been a controversial vaccine on social media, but anyone who knows me knows that I agree with the recommendations and wholeheartedly endorse it for the reasons given in my favorite HPV Vaccine article.

Photo Source: Jan Christian via Wikimedia

To add to the confusion and misinformation that circulates regarding the safety of the vaccine (which I don't have room to go into here, but is discussed here, here, here, and visually here), the vaccine itself has changed (covering 9 strains now compared to the initial 4 strains) and the dosing schedule is changing.

Don't presume the change in vaccine schedule is to answer the calls of the anti-HPV vaccine crowd. That isn't needed because their claims have been debunked (see all the articles referenced above).

Dosing schedule ~ Happy News!

HPV vaccines were initially approved to be administered as a 3-dose series: dose #2 given two months after the first and the 3rd dose at least 4 months after the second. Giving doses later is acceptable, but they cannot be given too early.

There is research that supports giving just two doses at least 6 months apart. A two dose schedule was approved earlier in Europe and this week was approved by the FDA in the US for children 9 to 14 years of age. The two doses should be given 6-12 months apart, which means for most kids they can get the vaccine at two regularly scheduled well visits (such as the 11 year exam and the 12 year exam) and not have to come in for additional visits.

The data support continuing a 3 dose series in those 15 years and up. This means they can get the 2nd dose 2 months after the 1st dose and then a 3rd dose at least 4 months after the 2nd dose and 6 months after the 1st dose.

The official ACIP Meeting Information is not yet available, but will be posed within 90 days of the October 19-20 meeting. (Note: I originally stated this was an October 11 meeting.)

I know that the two dose series will make many kids happy ~ one less shot for the same protection!

If two doses have already been given at less than 6 months apart or if the teen is 15 years and older, the third dose will still be needed.

Addendum: 

I don't want to confuse everyone... the FDA has approved a new schedule, but the Advisory Committee on Immunization Practices (ACIP) will need to give their input before the schedule actually changes. That will be decided at their October 19-20 meeting.

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:

• Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
• Kids who have turned 15 years old before the first dose should use the 3 dose series.
• Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.

Meningitis Risks and Preventions

Meningitis is thankfully uncommon, but when it happens it can be deadly. Meningitis is an inflammation in the membranes around the brain and spinal cord (meninges). It is usually caused by a virus, but many bacteria and fungi can also infect the meninges. Symptoms include headache, fever, and stiff neck and may include other symptoms depending on the organism causing the infection.

I wanted to write about meningitis because with the newest vaccine against meningitis, I am concerned that parents don't recognize what exactly their children are protected against and what risks remain after vaccination. I will break down meningitis by type of organism causing the inflammation, and include any vaccines and treatments available for that type within that grouping.

Bacterial Meningitis

Bacterial meningitis is a medical emergency. Even with early treatment with antibiotics, it can be devastating. If a person survives, many of the bacteria can cause permanent brain damage, hearing loss, learning disabilities, and loss of limbs. Anne Geddes, a photographer famous for her pictures of infants and children, has worked with Novartis Vaccines and the Confederation of Meningitis Organizations (CoMo) to create Protecting Our Tomorrows: Portraits of Meningococcal Disease, a book that is available for a free download on iTunes that shows people who have survived meningitis.

Photo by Mikael Häggström

The type of bacteria causing meningitis varies by age group. Fortunately the bacteria that cause meningitis are not as contagious as things we more commonly see, such as the common cold, but whenever there's a case of bacterial meningitis the health department will identify risks and help treat contacts at risk. The bacteria don't always lead to meningitis, but may be found in healthy people or cause other types of infections as well, such as ear infections, pneumonia, and urinary tract infections. 

• Newborns tend to be infected with bacteria that can be a part of the mother's urogenital tract. Group B Streptoccous (GBS), Escherichia coli, and Listeria monocytogenes are most common. Pregnant women are screened for GBS and treated with antibiotics prior to delivery if possible. Pregnant women should handle foods properly and avoid certain foods to protect against Listeria.
• Infants and children are most at risk from Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcal), Haemophilus influenzae type b (Hib). Thankfully starting at two months of age infants can get vaccines against Hib since 1985. A vaccine against 7 strains of pneumococcus became available in the year 2000, and it was improved to protect against 13 strains of pneumococcus since 2010. There are over 90 known strains of pneumococcus, but the vaccine covers the majority of strains that cause severe illnesses. Vaccination against N. meningitidis is not routinely given to infants at this time.
• Teens and young adults are at risk from Neisseria meningitidis and Streptococcus pneumoniae. Younger teens who are up to date on vaccines have been vaccinated against S pneumoniae, but since the vaccine was introduced in 2000, older teens might have missed this vaccine and it is not recommended to do catch up unless they are in a high risk group, such as if they are immune compromised or missing a spleen. 

• Vaccines are now available that help protect against all three serogroups (B, C, and Y) of meningococcal disease that are the most commonly seen meningococcal subtypes in the United States: 

• Meningococcal conjugate vaccine (Menactra®- which covers A, C, W, Y subtypes, Menveo®- which covers A, C, W, Y subtypes and MenHibrix®- which covers C, Y, and Hib) is recommended as part of the routine vaccine schedule at 11-12 years of age with a booster at 16 years. It is also recommended at younger ages for high risk people (immune compromise, spleen issues, and certain travel).

• Meningococcal polysaccharide vaccine (Menomune®- covers A, C, W, Y) is given to people over 55 years of age.

• Serogroup B meningococcal vaccine (Bexsero® and Trumenba®- both cover subtypeB). This is only recommended with a permissive use status, meaning it is not highly recommended for any age group, but it is allowed to be given to anyone over 16 years of age and is encouraged for high risk people, sometimes down to 10 years of age, depending on the risk. High risk people are those with known immune problems, specific chronic diseases, or who have no working spleen. High risk might include when there is a known outbreak, so if your college student hears of meningitis on campus don't let them think they don't need it due to vaccination with one of the vaccines that covers A, C, W, and Y. Some colleges require vaccination against meningitis B in addition to A, C, W and Y. 

Viral Meningitis

Viral meningitis is much more common but less deadly than bacterial meningitis. There are many types of viruses that cause meningitis, and usually there is no specific treatment for viral meningitis, just like other viral illnesses. Most people who get viral meningitis completely recover on their own within 7 to 10 days. People with meningitis caused by certain viruses such as herpesvirus and influenza may benefit from treatment with an antiviral medication. If there are symptoms of meningitis, it is important to quickly get the proper testing done to determine if treatment is needed or not. Prevention with standard hand washing and other measures to prevent the spread of viruses is important. Some vaccinations can protect against diseases that can cause meningitis, such as measles, mumps, chickenpox, and influenza. Since mosquitoes, other insects, and rodents can spread disease, avoiding bites can help prevent infection.

Fungal Meningitis 

Fungal meningitis is very rare and does not spread from person to person. It occurs when a person with a weak immune system is infected with a fungus that spreads to the brain or spinal cord.

Travelling around the world? Stay safe and healthy!

Spring Break is around the corner, which means many of my patients will be travelling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor's office) be sure to bring the records with you. Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic. Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness. As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the "T" zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

From: http://wwwnc.cdc.gov/travel/page/infographic-food-water-whats-safer

Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea. This is not recommended by many experts due to the rise of "superbugs" with the use of unnecessary antibiotics. In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods. The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day. Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome. Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting. Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children. Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos...

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.

Learn local laws prior to travelling.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn't matter if you're on the beach or on the slopes, you need to wear sunscreen every time you're outside. Don't ruin a vacation with a sunburn.

For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

• your name, address, and phone number
• emergency contact name(s) and phone number(s)
• immunization record
• your doctor's name, address, and office and emergency phone numbers
• the name, address, and phone number of your health insurance carrier, including your policy number
• a list of any known health problems or recent illnesses
• a list of current medications and supplements you are taking and pharmacy name and phone number
• a list of allergies to medications, food, insects, and animals
• a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC's travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria 

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

• Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
• Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression. 
• Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
• Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
• Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.  

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother's antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday. Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older. 

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel. 

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years. 

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure. It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body's immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

• Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years. 
• The oral vaccine for children over 5 years and adults is given in 4 doses over a week's time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years. 
• Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC's Zika page.