Do Your Vaccines Contain Mercury?

We are often asked if our vaccines contain mercury. Some parents even want to see the package insert to check. Note: even if they do contain mercury, it usually doesn't say "mercury", so I suspect some of these parents wouldn't notice. Why wouldn't they notice? Because they learn one tag word that they should avoid, but they really don't understand what it is and why they need to avoid it. It's hard to talk to some parents who are adamant that they don't want vaccines for their children, but they don't know why... they just "heard they aren't safe." Really? You're not going to give your child something that has been shown time and time again to not only be safe, but that also saves lives? Just because you heard something you don't even remember details to you'll skip something that could save your child's life?

Short answer to the above question: No standard vaccine for children has had thimerosol since 2001. Some flu vaccine for older children and adults continues to have thimerosol, but most that we order for our office does not. If we offer a type with thimerosol, we will notify you before you choose to vaccinate. Not that we think it matters, but we know parents worry and want to know.

Most years I get the FluMist, but I think the year pictured it was in short supply.

Parents worry about thimerosol despite not really understanding when or why it's used. It's really sad when they ask if we have the "new" MMR without thimerosol. The MMR has never had thimerosol in it. Not ever. Yet many people share the mis-information online that it was/is the cause of autism. And people believe it. That's how much their online research has taught them.

If you hear that vaccines aren't safe from someone but don't ask for and understand the details, including looking at research papers and written articles that address the issue (along with evaluating the reliability of each research report and article) then you really shouldn't take the advice blindly. They might know as little as you on the subject and are just passing along bad information. Or the article you read might just be filling you with incorrect information. It's easy to do when a writer has a motivating factor, such as when the CDC Whistleblower "reanalyzed" data.

Mercury comes in many forms. Thimerosol (one form) is felt by scientists to be safe for use in vaccines at the very low levels required for its effect in vaccines. It has been removed from most vaccines given to children though due to a very vocal group of anti-vaxers getting some congressmen on their side. Not scientists or doctors, but law makers. This has increased the cost but not the safety, in my opinion. We use single dose vaccines except for staff flu shots, for whom we use the cheaper multi-dose vial. The multi dose must have preservatives, such as thimerosol, to keep it from getting contaminated with multiple uses. We usually have a few doses left out of that to give to patients so it's not wasted. When this type is given to patients, their parents are always told it is a multi dose type. There were only limited doses left over this season and they were gone long ago. Many parents were just happy to be able to get a flu shot for their child when they were in short supply early in the vaccine season and they trusted that it was safe.

So... would I give a vaccine with thimerosol to my kids? Yes. (And my oldest is a teen who did get the standard back when he was a baby, which was vaccines with thimerosol.)

Do we give them now? Not usually.

I think that many smart people still get blindsighted by well written but technically not correct information. They simply can't read all the studies, know how to understand the statistical significance of each study, and all the science behind everything. I have a degree in medicine and still rely on experts to do reviews and summarize the vast amount of information. I read some of the studies, but don't have enough information to make truly educated decisions based on what I have access to. Too many studies are behind pay walls and I don't want to pay to read them, nor do I have the time to read every study. 

But I trust expert panels that do.

Here are some links to pages that list the studies if you want to read them for yourself:

http://www.vaccinesafety.edu/cc-thim.htm
http://www.immunize.org/journalarticles/conc_thim.asp
http://www.immunizationinfo.org/science/mercury-vaccines

What if the flu vaccine doesn't cover the right strains?

Recent news reported that the FluMist nasal spray might not cover the Influenza A H1N1 strain as well as the injectable might. I know this may cause concern for parents whose children have already gotten the FluMist vaccine this season.

Don't panic! (Gee, I've said that a lot this year with the delayed shipments of flu vaccine...)

Why not panic? 

First, this is a theoretical concern. It is based on the findings that the FluMist didn't cover the H1N1 well last season and it is the same vaccine this year.

Second, the main strains of influenza that are starting to circulate this year are NOT that H1N1 strain anyway.

I thought FluMist was preferred this year...

The CDC continues to state that the preferred vaccine for 2-8 year olds is the FluMist because it seems to be more effective than the injectable form against the other strains contained in the vaccines. (This is of course only if the child doesn't have contraindications to the FluMist and the FluMist is available. No one should delay vaccination if one form is available to wait for another form.)

Should we wait to get the shot? I know there are shipping delays...

Both the CDC and the AAP state to give whatever vaccine is available as appropriate and to not delay giving the vaccine to wait for another type. This makes sense. If you can be vaccinated with only one type due to the shipping delays, why risk being completely unprotected when you can get a vaccine that will most likely protect. No vaccine is 100% effective. With influenza we have the additional difficulty that the flu virus changes each year, but there is some protection across types when the flu vaccine is given.

Why doesn't the strain match?

Flu strains change every year and scientists predict what strains will be circulating. The vaccine companies all make vaccine against the predicted strains. This year the main strains that have been identified in people sick with the flu are Influenza A H3N2 and Influenza B. It is still early in the season, so findings might change, but so far both the FluMist and injectable vaccines seem to be effective against those strains. The FluMist appears to offer better protection than the injectable if the strains are not quite matched.

In short: 

Any age-appropriate influenza vaccine should be used as soon as possible to protect as many people as possible against the flu.

Do kids who got the FluMist need to be given a shot this year?

No. It is not recommended to do a second vaccination unless it is the first flu vaccine and a child needs a booster dose this season. It is appropriate to use either form of the vaccine for eligible children over 2 years, and mixing and matching is okay, but there is no recommendation specifically to do that.

The good news: 

We are starting to see shipments of flu vaccine! Hopefully we'll soon be able to vaccinate your children!

Menthol for Sore Throat, Colds and Coughs... Should we use it?

I am often asked about the use of Vick's Vapo Rub (or other menthol products and refer to all brands in this post).

We see menthol for vaporizer dispensers, in cough drops, and the good ole jar of rub that mom used on our chests when we were sick.

But should we use it?

Cough drops 

Menthol is a mild anesthetic that provides a cooling sensation when used as a cough drop. The menthol is basically a local anesthetic which can temporarily numbs the nerves in the throat that are irritated by the cold symptoms and provide some relief. (Interestingly, menthol is added to cigarettes in part to numb the throat so new smokers can tolerate the smoke irritation better. Hmmm...)

Menthol cough drops must be used as a lozenge and not chewed or swallowed because the menthol must slowly be exposed to the throat for the numbing effect. They are not recommended for young children due to risk of choking. Since science lacks strong evidence, but the risk to most school aged children is low and it is safer than most other cough medicines, I use the "if it seems to help, use it" rule for children not at risk of choking. Do not let any child go to sleep with one in his mouth. First, he might choke if he falls asleep with it in his mouth. Second, we all need to brush teeth before sleeping to avoid cavities!

Vaporized into the air

When it is put into a vaporized solution, menthol can decrease the feeling of need to cough. It should never be used for children under 2 years of age. They have smaller airways, and the menthol can cause increased mucus production, which plugs their narrow airways and may lead to respiratory distress. Infants can safely use vaporizers (and humidifiers) that put water into the air without any added medications.

The rubs for the skin

We've all seen the social media posts supporting putting the menthol rubs on the feet during sleep to help prevent cough. That has never made sense to me, and the link provided discusses that it is not a proven way to use the rubs.

Menthol studies show variable effectiveness. It has been shown to decrease cough from baseline (but the placebo worked just as well) and did not show improved lung function with spirometry tests (but people stated they could breathe better) in this interesting study. (So people felt better, but there really was no objective improvement.) Putting menthol rubs directly under the nose, as opposed to rubbing it on the chest, may actually increase mucus production according to a study published in Chest. In children under age 2, this could result in an increase in more plugging of their more narrow airways. There is a more recent study that does show children ages 2-11 years with cough sleep better with a menthol rub on the chest.

Note: There is a Vick's BabyRub that does not contain menthol. Its ingredients have not been proven to be effective and some of the ingredients have their own concerns, but that does not fall into this discussion.

Cautions

Menthol products should never be used in children under 2 years of age. It can actually cause more inflammation in their airways and lead to respiratory distress.

If a child ingests camphor (another ingredient along with menthol in the rubs) it can be deadly. It has been known to cause seizures in children under 36 months when absorbed or ingested in high concentrations. Menthol rubs sold in the US contain camphor in a concentration that is felt to be safe if applied to intact skin in those over 2 years of age. Mucus membranes absorb medicines more readily than intact skin, so do not apply to nostrils, lips, or broken skin. Do not allow children to handle these rubs. Apply only below their necks to intact skin. 

Many people using the menthol rubs experience skin irritation. Discontinue use if this happens.

Talk About Bullying With Your Kids

Bullying. Fist fights. Cyberbullying. Mean girls. Playground scuffles.

There are many labels and many variations on the same theme. Kids aren't always nice. Even nice kids get caught up in mean behaviors. We all remember being young and getting picked on. Or maybe we were the instigator of trouble. Chances are we've been on both sides of the line. Whatever roll we had, we know that this is not new behavior. But that doesn't make it any easier for parents to watch their kids suffer at the words and actions of other kids.

photo source: Shutterstock

We all need to talk with our kids often about their lives: what they are doing, how they feel about things, what they are looking forward to, dislikes, and more. Many kids clam up when it's time to open up, and sometimes the best thing for a parent to say is simply, "I'm here if you want to talk later."

Sometimes a general talk about bullying behaviors is a good idea, whether you suspect some bullying is going on or not. As with most things, a little prevention is worth a pound of cure.

If you see your own child saying or doing something that could be interpreted as mean, pull them aside and point it out as soon as possible so the memory is fresh in their mind. Children and young teens often don't even realize what they've said or done can be taken in a negative way. Don't punish or yell at them for the words. Don't belittle them. Making them angry will only block their mind to seeing another point of view. Use this time as a teaching moment to point out what was said. They might not get it right away, but later you can role play and see if they can understand better in a different situation.

I've put together things to use as talking points. Don't try to tackle this all in one sitting. Talk about one subtopic at a time, but talk often.

What else would you add?

• A small comment that seems to not be so bad to you can make someone else feel awful, even if you didn't intend for it to be. Those comments often come out of the blue and you don't give it a second thought, but the other person can dwell on its negativity for a long time. Even worse are the comments that are repeated over time. 
• You cannot change what others do or say, but you can change how you respond to what they do and say. 
• If you did or said something hurtful, it can't be taken back, but you can ask for forgiveness.

• If you know you're tired or in a bad mood, try to be extra careful before you say anything. 
• Don't send texts when you're angry, sad, or tired. 
• Don't reply to a text that makes you angry, scared, or sad. Show an adult if it is a threatening text or if it really upsets you.
• If you have negative thoughts, keep them to yourself. This might mean that you think someone got something they didn't deserve, someone's a teacher's pet, or their hair is awful. Whatever. Nothing good comes from sharing a negative opinion. In the end, people will see that you are negative and won't want to be around you as much if you share those thoughts. 
• If in doubt about saying or sending something, save the thought overnight and see if you still think it needs to be said. Think about the wording to make it constructive and not destructive if it does need to be said. Talk to an adult if you're not sure.
• If you wouldn't say something to someone's face, don't say it at all.
• If you hear someone saying something negative, tell them to stop. Let them know you don't like hearing negative comments. This might teach them what they are saying is hurtful, because sometimes people don't realize what they are saying. They can learn to be a nicer person- what a great friend you can be to help them in this way! If they don't change their behaviors over a few days or weeks after being told what they are doing (depending on how severely or intentionally they are being hurtful) then you need to tell an adult. Doing nothing or agreeing with them puts you down to the level of being a bully, even if you didn't start it. If you don't feel comfortable telling them to stop, leave. If you stay, you’re part of the cruelty. Leaving means you refuse to be part. If they don't have an audience they won't continue.
• If you realize that something you said was hurtful to someone, talk to them about it. If you have a hard time talking face to face, a nice note can work. Have a trusted adult help you wordsmith what you will say so the words don't get twisted. You must be careful to not put blame back on the person or put them down again when you apologize. It can be tricky to find the right words, but it is possible. 
• Texting is a dangerous way to communicate emotional or sensitive issues. It is great for simple questions and answers, but short phrases in texts can easily be misunderstood or incomplete. If you are disagreeing with someone, do not use texts to talk it out. Remember that anything shared electronically is public and permanent. Even if you think you are sending it to just one person, there are many ways for it to be seen by others. These words and pictures can be very hurtful. Never send anything you wouldn't want to put on a sign on your front door for all to see.
• Kids are often afraid to tell adults things for many reasons. It is okay to tell an adult if you are trying to help someone or yourself, but not if you are trying to get someone in trouble. Think about it. There's a difference. 

Positives drown out the negatives...

• Every day write down (or discuss as a family) one thing that you really appreciate or are grateful for. It can be anything, but think of things that really mean something to you. It can be as simple as a person said something really nice when you were feeling down, or you did well on a test you studied hard for. It doesn't have to be a huge thing like winning the lottery, but it should be something that you really feel thankful or happy about. Focusing on the good things really helps keep life in a healthy perspective. It can help protect you from the negative effects of other people's behavior.
• Smiling really can make you feel better, so try it.  
• If you see a friend struggling because negative things have been said, say kind words to him or her. Be extra nice to him or her so they know they aren't alone.
• Praise people when they say nice things. Recognize the kindness. Make it contagious!
• Try to do something nice or say something nice to at least one person each day. Notice the response over time in yourself as well as others.

Everyone needs a circle of respect. You don't have to like everyone, but you need to treat everyone with respect.

• Respect yourself enough to do what is right. Eat right. Exercise. Get 9-10 hours of sleep each night. Don't take unnecessary risks, such as smoking or drinking alcohol. 
• Respect others. Say kind words and keep negative thoughts to yourself. Don't make anyone else do something they aren't comfortable doing. Don't make fun of people. 
• Be sure people respect you. If someone says or does something that you feel is disrespectful, let them know. If they don't change their behaviors, avoid them and find other people to have fun with. Get away from people who make you uncomfortable or scared immediately. Find new friends if your friends repeatedly disrespect you. Get help from an adult when needed.

Teal Pumpkins for Non-Food Items at Halloween

Teal pumpkins have a new meaning this Halloween. Displaying one means that your home has non-food items available for the little goblins and superheroes as they come looking for treats.

Some might wonder why this is important.

Because what child likes to be left out of the fun of Trick or Treating?

And what happens if that child has severe food allergies, diabetes, or another condition that limits the types of foods the child can eat? Or what about all the parents who worry about the excessive intake of sugar this time of year?

Show parents that you are giving kids the option of a safe treat by displaying a teal pumpkin. There are many non-food treats that kids would love ~ stickers, pencils, glow sticks, bubbles, plastic jewelry, vampire teeth, pencil toppers, hair pieces, magic trick cards, and many more. Be sure you have some that are safe for toddlers.

Non-food items are better than nut-free, because kids have allergies to all kinds of things, and it is impossible to know in advance what all those allergies are. And for kids who must limit their overall sugar intake, non-food treats rule.

We put together some reusable teal pumpkins at the office. My initial plan was to spray paint some plastic pumpkins, but decided to use Duct tape to cover plastic pumpkins instead. Less smell, no time waiting for them to dry, and if we ever want to use them outside, they will be fairly weather-proof.

Pretty cute, huh?

And yes, plenty of people have asked if they are to celebrate our KC Royals. Not exactly. But hey, we can double their duty during Blue October!

Share this idea with your neighbors and friends. Use social media. Put a note in your neighborhood bulletin. Share with your school nurse. Ask stores to display a flyer.

Get the word out!

For more information and a free printable flyer (like the one pictured in our office above), see the original post where I learned about this great idea: The Teal Pumpkin Project

Why We Should Cherish the Gift of ADHD

Ok, so I know most parents of children with ADHD will read this title and think I'm crazy. Kids with ADHD wreck havoc on family life. Spouses with ADHD can do the same. How in the world can we cherish ADHD? It involves impairments in executive functioning... how can anything causing a broken executive functioning system be cherished?

photo source: Shutterstock

First, we must realize that everyone has gifts. ADHD has many variables in the way it shows up, so people with it also have many variations in gifts. But they do have gifts. I want parents, spouses, siblings, grandparents, aunts, uncle, neighbors, teachers, and more to understand the value of these gifts and help children (and adults) recognize the benefits that people with ADHD can have. I'm not saying life for them is easy. It's not. They struggle with many things other people can easily manage. But they still have gifts. I want kids to grow up building their confidence by using their gifts, not by measuring their failures when they don't conform to norms.

People with ADHD tend to think outside the box. They have lots of energy. They are often very creative. We all think of their inattention and poor focus, but they also hyper focus on things they love. If they become passionate about something, they can sustain attention and work on it for long periods of time. If they use this hyper focus wisely (with setting time limits so they can do other daily activities) they can become an expert in that area. For young children the hyper focus tends to be on "kid" things, like trains or video games, but as they get older, allowing kids to experience activities that interest them will give the opportunity to find a life passion that could turn into a fantastic career.

"ADD people are high-energy and incredibly good brainstormers. They will often happily work 12 to 15 hours by choice. The business community should not fear ADD. Instead, they should see that they have a potential gold mine here.” - Dr. Kathleen Nadeau, psychologist

With all that good, we are more quick to see the negatives. Kids can lose their drive and ambition if they are not supported along the way. School is not favorable to kids with ADHD. Kids must follow rules. They need to color in the lines. They need to do all the steps in the order the teacher wants. Doing things someone else's way is not easy for kids with ADHD.

For example, kids need to learn the steps to solve a mathematical problem. They need to solve the math problem the way the teacher did it and show their work. They lose points if they get to the right answer but didn't show their work or if they get there a different way. The teacher might assume they cheated to get the answer, but some kids just skip steps. To me that might just show brilliance. They can skip steps. Their brain just "gets" to the right answer. I never could figure math out without being told how to do it, but there are kids out there who can. What a gift! Unfortunately they feel dumb if they can't show the steps just like the teacher taught. And it would be quite typical for a child with ADHD to have a brain that thinks this way if math is that child's gift. What a shame that our schools tend to make these kids feel inferior because in the end they might resist working on math and will never reach their potential.

For a fun look at ADHD that will continue to show you the better side of the diagnosis, check out this short documentary, A.D.D & Loving It. I promise it will have you laughing, but you will get a lot of great information from respected ADHD experts.

If your child struggles with the diagnosis, consider reading about real people who have done well despite (or due to) ADHD (link with many articles about successful people with ADHD and other learning disorders). Have them read Percy Jackson (link to a book review). He's a fictional character with ADHD and dyslexia that kids can look up to.

Throughout history many successful people have had ADHD. Your child with ADHD can also become a leader, an inventor, an artist, or an otherwise excellent contributor to society. We just need to help them find their gifts and work on their challenges so that they can flourish. Support them so they do not lose self confidence. Celebrate what they do right more than harping on what they do wrong. Encourage them to develop their talents. Help them find ways to accommodate for their struggles and to learn tools to help with some of the executive functioning problems they have. Cherish them!

Heart Screenings for Athletes - Are they worth it?

In recent years I've been getting more and more reports of athletic heart screenings. The schools and sports clubs locally are offering for athletes to get a heart work up for a relatively small fee.

Why are they offering this? Because sudden cardiac death in athletes has been in the news a lot over the years, and we all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk. Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator. (Side note: if you've not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow "A B C" so it is very different. CPR is recommended for all teens and adults.)

Is the cost of a heart screen worth it?

A new report, Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology, is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation and is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD). Complex issues from the Statement linked above:

1. the low prevalence of cardiovascular diseases responsible for SD in the young population
2. the low risk of SD among those with these diseases
3. the large sizes of the populations proposed for screening
4. the imperfection of the 12-lead ECG as a diagnostic test in this venue 

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: To do an ECG screening on all athletes is not inheritantly unwarranted nor discouraged, but it isn't recommended either.

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is available below.

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time, so one normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so. The evidence does not support mass required screenings.

If however, your child has identified risks based on the questionnaire, a more thorough testing should be done.

These 14 points are listed in Table 1 of the above linked statement:

The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history* 
  Personal history
    1. Chest pain/discomfort/tightness/pressure related to exertion
    2. Unexplained syncope/near-syncope†
    3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
    4. Prior recognition of a heart murmur
    5. Elevated systemic blood pressure
    6. Prior restriction from participation in sports
    7. Prior testing for the heart, ordered by a physician
 Family history
    8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
    9. Disability from heart disease in close relative <50 y of age
    10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination
    11. Heart murmur‡
    12. Femoral pulses to exclude aortic coarctation 
    13. Physical stigmata of Marfan syndrome
    14. Brachial artery blood pressure (sitting position)§

AHA indicates American Heart Association.
*Parental verification is recommended for high school and middle school athletes.
†Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
§Preferably taken in both arms.
Modified with permission from Maron et al.3 Copyright © 2007, American Heart Association, Inc.