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.

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: 

• mindfulness (see my Mindfulness Pinterest page with many free apps) 

• deep breathing 

• 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:

• Later school start times in the U.S.: An economic analysis
• Sleep Duration and Injury-Related Risk Behaviors Among High School Students — United States, 2007–2013
• School Start Times for Adolescents: (AAP) ADOLESCENT SLEEP WORKING GROUP, COMMITTEE ON ADOLESCENCE, AND COUNCIL ON SCHOOL HEALTH
• Melatonin for Children? A guide for parents by Dr. Craig Canapari
• I Just Want To Go To Sleep! How to Sleep Better (According to Science)I Just Want To Go To Sleep! How to Sleep Better (According to Science) by "Hey Sigmund"
• Start School Later, Inc.
• Back to Sleep Basics by Dr. Melissa Welby

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

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.

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:

•  ChristopherJohnsonMD 

• HarpocratesSpeaks   

• TheLogicOfScience   

• SkepticalRaptor    

• ScienceBlogs

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:

• Judah's story
• Olive's story, more on Olive, and the final words on Olive's story
• Tennessee babies

For More Information:

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

Frequently Asked Questions (FAQ’s): Vitamin K and the Vitamin K Shot Given at Birth (CDC)

Hemorrhagic Disease of the Newborn (eMedicine)

Vitamin K in Breast Milk - Can it Replace the Shot? (Nurse and Nourish)
Vitamin K in neonates: facts and myth (NCBI) 

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.

It's Back to School Time, Time to Think Safety!

Walking to school is wonderful for kids because they get exercise, which can help with focus at school and their overall health. It can be also be a time to talk with friends or family and build community bonds.

But it also can pose dangers, especially if drivers are distracted talking to their own children or texting. Please stop texting and driving. Don't touch your phone at all while driving. Calls and texts can wait. If they can't, pull over and check the message while parked. Really.

Talk to your kids about safety.

• Kids should walk with an adult until they show the maturity to walk safely without direct supervision. The specific age will depend on the area as well as the child's maturity. Are there safe sidewalks? Are there busy roads to cross? Are there other kids walking the same route? Are there homes along the way they can go to in case of emergency? How long is the walk?
• Find the safest route: Choose sidewalks wherever possible, even if that means the trip will be longer. If there are no sidewalks, walk as far from vehicles as possible, on the side of the street facing traffic. If possible, avoid areas near high schools, where there are more teen drivers.
• Cross streets safely. If there are crossing guards, use those intersections. If there are street lights, wait until the "walk" symbol appears. Never cross in the middle of a block, use intersections. Look both ways twice before crossing. Do not text or play games when in the street. 
• Remind kids that if they are crossing a street, they should make eye contact with a stopped driver before crossing, even if there's a "walk" symbol. Drivers turning right might turn on red and not notice small pedestrians.
• Teach kids to use the same route every day or discuss which route they will take each day if they use different routes. If they don't arrive to school or home as planned, you know the route to search. Walk the routes with them until they know how to safely navigate each.
• Have kids stay in groups or with a walking buddy as much as possible. 
• Avoid distractions. Listening to music (especially with earbuds), playing video games, watching videos, and texting all keep kids from paying attention to their surroundings. Even talking on the phone is distracting, so don't assume they are safer if they talk to you all the way home when you're at work. They are more likely to trip and fall, step into a street without looking first, or not notice that they're being followed if they're distracted. They should be aware of their surroundings at all times.
• Remind kids to never accept a ride from anyone unless you pre-plan it. Rain, snow, and cold weather make it tempting to hop in a car, so have kids dress appropriately for the weather and arrange safe rides as needed. 
• Have kids keep important contact information in their backpacks in case of emergency. At least two people should be on this list. People on the list could include a parent, grandparent, or trusted adult friend/neighbor. Names and phone numbers should be included.
• Related: If they are riding a bike, scooter, or skateboard to school, they should follow the rules of the road and proper safety.

See if your school can help arrange walking buses, where kids all walk the same route to school with adult walk leaders.

Suggestions for adults:

• Be extra cautious when driving in the before and after school times, especially near schools and in neighborhoods.
• Be nice and don't use your sprinklers in the before and after school times so kids can stay on the sidewalks and not wander into the street to avoid getting wet.
• Never text and drive. Put your phone on silent and in a place you can't reach it while driving. Texts can wait.
• If kids are in your car, make sure they are properly buckled. Only teens and adults should be in the front seat. Use an appropriate car seat or booster seat. Kids shouldn't wear their backpack in the car, nor should they unbuckle while in a drop off line to get their backpack on before the car is stopped. 
• If your kids will carpool with other families, be sure they are in proper seats at all times. It's tempting to not use boosters for short drives, but it's never safe to have kids improperly restrained. Find boosters that are easy to move between cars.

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My child swallowed....

It happens all the time. Kids put things in their mouth that aren't supposed to be eaten. Parents often call about what to do when their toddlers or children swallow things. Most of the time things will just pass -- though I'm not a fan of watching the stools for the swallowed object because it just worries parents if they miss it.

The biggest risk group is children between the ages of 6 months and 6 years, but anyone can be at risk. I have seen an older school aged child swallow a magnet after putting 2 small strong magnets on either side of their tongue to look like a tongue piercing. Adults have been known to swallow things such as needles (many sewers put the needle in their mouth if you think about it).

If you are around kids it is a good idea to know child CPR and refresh your skills every couple years. Classes are often held at local Red Cross stations, hospitals, or fire departments. You can also find classes by searching "CPR" and your zip code. For great information on signs and symptoms of choking and general treatment of choking, visit this KidsHealth Choking link.

If your child seems to put more non-food items in his mouth than other kids, he is at risk of pica. Pica is when a person compulsively puts non-foods in his mouth. For more see the KidsHealth Pica link.

Always keep the poison control number (1-800-222-1222) stored in all your phones! You will see below that I refer to them often. If you call your doctor about a potentially toxic substance, chances are we will refer to poison control. They have the best database of substance risks and their treatments. Don't delay treatment by calling the doctor!

For more information: http://www.aapcc.org

Here's a list of common things and what to do.

• Balloons: Balloons are statistically some of the most inhaled or ingested foreign bodies. One reason is they are so popular with kids, and often are found at parties or other large crowds, where toddlers and young children are often less directly supervised. They can suffocate a child quickly if they are inhaled. Call 911 if there is any difficulty breathing, drooling, or other signs of distress. If swallowed, they will pass on their own.
• Batteries: If you think your child has swallowed a battery, whether or not he appears distressed, immediately take him to an emergency room. If there is distress, call 911. Batteries can cause voltage burns or leak, causing acidic burns as soon as four hours after being swallowed. X-rays will confirm if the battery is in the chest or abdomen. They usually need to be removed to prevent serious injury. Be sure to keep all of your batteries, especially the small button batteries, safely stored away from children.
• Bugs: Most of us has swallowed a bug some time in our life. You might not even know if a small one hides in your soda can and you take a big gulp. A little extra protein, right? Unless your child chokes, or if it has a stinger (bee, wasp) there is nothing to worry about. If he's choking, follow choking instructions (link at top). If you suspect a bee or wasp was swallowed, especially if your child seems to be reacting to a sting in the mouth, or there's sudden difficulty breathing, drooling, or choking, call 911. Serious reactions to stings in the mouth can occur.
• Buttons: Buttons, much like coins, are generally harmless unless they get stuck. See the information on coins. Unlike coins, they are not easily seen on X-ray, which can make identification of a stuck coin a little trickier, but if you suspect an issue, talk to your doctor.
• Cleaning products, laundry detergent, and other chemicals: These are highly dangerous and you should call poison control with any suspicion of ingestion or 911 if there are signs of distress. These should always be stored away from children to prevent the possibility of swallowing in the first place. Even the "green" products are usually not safe with ingestion.
• Coins: Coins are some of the most frequently swallowed objects. These usually pass through the body without any problems. Unfortunately many parents never see it come out the other end. Since it is so common you would think there would be a consensus as to how to manage it. There isn't. Of course if there is any distress, drooling, breathing difficulty or coughing, your child should be seen immediately, ideally in an ER so that an immediate surgical consult can be made if necessary. If it was inhaled into the windpipe instead of swallowed into the esophagus or stuck high in the esophagus causing compression on the wind pipe, it may need to be removed. As for kids who swallow coins and have no symptoms, it isn't as clear cut. Some doctors get X-rays for all children who swallow a coin to be sure it isn't stuck in the esophagus (about a third of those stuck eventually end up passing, but most need to be removed). Others only X-ray if there are symptoms. Some remove the ones in the esophagus immediately, others will wait up to 48 hours if there is no distress. Generally once it reaches the stomach it will pass.
• Crayons or play doh: I used to wonder why so many things were labeled "non-toxic" -- at least until I had a child of my own. They put everything in their mouth! These are generally safe (again, unless they choke), although it is possible that these things contain lead or other contaminants. If your child frequently puts them in the mouth, it is probably a good idea to not allow them near your child and talk to your doctor about pica (see link above for more information). 
• Dirt or rocks: Unless your baby chokes or bites down on a rock and breaks a tooth, dirt and rocks are generally harmless. If your child seems to crave these and eats dirt compulsively, see the pica link above.
• Energy drink: Energy drinks are a popular choice for many, but they contain caffeine and other stimulants that can make them dangerous for children. Call poison control for instructions.
• Grass or plants: Unless the grass was recently chemically treated or if the plant is poisonous, there is little to worry about here. If you're unsure about a plant being poisonous, contact poison control. If there is choking, do CPR or call 911.
• Gum: Contrary to popular belief, the occasional swallowed gum does not stay in your gut for years. It isn't digested like other foods, but unless it gets stuck along the way, it finds its way out just like all your other food. 
• Hand sanitizer: Hand sanitizer in small amounts, such as putting fingers in the mouth after rubbing sanitizer on the hands, is generally safe. Larger amounts can be dangerous and you should call poison control if you suspect ingestion.
• Magnets: A single magnet is not a worrisome as multiple magnets, but since it often is not known exactly what a child swallows, it is always recommended to take your child to be evaluated if there is a suspicion of swallowed magnets. They will need X-rays and if there are multiple magnets, they must be removed to prevent perforation of the gut.
• Medicines, vitamins, supplements: If your child swallowed (or potentially swallowed) a medication or supplement, call the poison control number ASAP. Have the bottle with you so you can answer their questions.
• Nicotine: Sadly ingested nicotine has been an increasing problem since e-cigarrettes have been on the market, but even regular cigarettes, cigars, and their ashes pose problems. Effects of nicotine poisoning include vomiting, sweating, lethargy and tremors in mild poisoning and confusion, paralysis, and seizures in severe poisoning. If you even think your child has eaten a nicotine product, call poison control (or 911 if significant symptoms).
• Pet food: As disgusting as it smells to me, kids love to eat pet food. The biggest risk here is choking. If they choke, use your CPR skills. If you're not confident with CPR, call 911 and they will walk you through it.

• Pop-top from a can: The flip top that opens a soft drink can is usually not a concern unless a child chokes on it. It generally will pass through the intestines if swallowed, but if there are signs that it was inhaled or is stuck in the intestine, a child should be seen. These do not show up on X-ray because they are made of aluminum. 
• Poop: This one is gross, but happens more than any parent wants to know. Many babies stick their hand down their diaper and then the hand goes to his mouth. While this is really gross, it does not cause any danger to the child. If it is his own poop, he will not be exposed to any new germs. If your child finds someone else's poop, usually animal poop, there is a little more concern for infection but still pretty low risk. Symptoms of nausea, vomiting, diarrhea, and low grade fever usually happen within 30 minutes to 4 hours after the ingestion if they are affected. In this case, treat symptoms as you would any other stomach bug and call your doctor. For specific information of various types of poop (even raccoon!) check out the Illinois Poison Control blog on poop. 
• Salt and baking soda: These common kitchen items do not raise fear in many people, but if either is taken in large amounts, they can cause serious problems. One tablespoon of salt in a toddler can cause seizures due to electrolyte imbalances. More can be deadly. One tablespoon of baking soda changes a body's pH and can cause serious injury. If your child swallows either of these, call poison control immediately. 
• Sharp objects: Any pointed object such as toothpicks, wire, chicken bones, open safety pins and hair pins can pierce the gut. If you think or know your child has swallowed one of these, get the child to the emergency room immediately.