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Category Archives: Children’s Health

Kalydeco: Science at Its Best

February 1, 2012 Dr. Pullen

I read with a personal interest the approval of Kalydeco (ivacaftor) this week for treatment of the 4% of cystic fibrosis patients carrying the G551D mutation. My first wife Lenore had cystic fibrosis and died at age 26. At that time in 1983 we knew a great deal less about CF than we know now. The introduction of Kalydeco this week brings several key issues in health care to the forefront. Development of drugs to treat disorders with a limited number of patients to use the drug can make the cost to each individual seem crazy expensive. The specific direct targeting of Kalydeco at a specific gene mutation is possibly an indicator of personalized treatments for more common disorders in the future. The whole fast-track process used by the FDA in approval of Kalydeco is an example of their faster approval of some drugs working as promised.

In the years since Lenore’s death CF has been found to be caused by a mutation in the cystic fibrosis trans-membrane conductance regulator (CFTR) gene that regulates ion transportation (ions like chloride hence the traditional sweat chloride test for CF) and therefore fluid flow within cells. One specific mutation is the G551D mutation (substitution of aspartic acid for glygine at position 551), and the new drug Kalydeco specifically targets the abnormal protein in these specific CF patients. Kalydeco helps the defective protein work more normally, and so reduces the abnormalities in CF patients with this specific mutation.

Unfortunately only about 1 in 25 CF patients have this specific mutation in the CFTR genetic code. The rest have some combination of the other at least 1000 known mutations. The most common CFTR mutation is called F508del (a 3 nucleotide deletion at location 508 leading to a missing phenylalanine amino acid “F”) and about 1 in 30 Caucasians have this specific mutation in the CFTR gene. Kalydeco is not effective in patients who are homozygous for the F508del mutation. This homozygous F508del mutation is the most common genetic code in CF patients. IN the 4% of CF patients with at least one copy of the G551D mutation Kalydeco has been shown to be effective in reducing CF symptoms, and is an exciting breakthrough.

Patients with the G155D mutation produce a protein that is able to make it to the cell membrane, where Kalydeco allows it to function much more normally. In patients with the F508del mutation the protein fails to fold in a way that allows it to move to the cell membrane, and so a drug like Kalydeco cannot function. Scientists are working on possible medications that could allow the migration of the other defective genes to the cell membrane where use in combination with Kalydeco could potentially be effective.

It is exciting not just for the 1200 U.S. patients with this specific type of CF, but also because it is an example of how genetic research, gene analysis in genetic disorders, and great basic science can lead to novel therapy for genetic disorders.

The rapid approval of Kalydeco is a great example of the new expedited FDA approval process for drugs that have the potential to be novel or breakthrough products where there is currently no effective therapy, or the drug is a major advance in therapy. It took only 3 months for Kalydeco to get FDA approval, even faster than the promised fast-track approval promised for special circumstance drugs.

The catch in this whole process is the incredible anticipated cost of Kalydeco. In a Wall Street Journal article the estimated annual cost of Kalydeco is reported to be $294,000. Since the anticipated number of patients eligible to receive this orphan drug is so small, and because of the novel and documented improvements demonstrated in patients using Kalydeco it is expected that insurers will pay for the cost of the medication. If all 1200 eligible patients take Kalydeco the annual cost at this price would be $353 million annually. Still this price is not Guinness world record. Two more expensive drugs are Soliris for a rare condition parosysmal nocturnal hemoglobinuria at $409K annually and Elaprase for the rare genetic disorder Hunter Syndrome , a polysaccharide storage disorder, at $375K annually. These are examples of orphan drugs with very limited markets where the cost of development is shared by very few patients.

I look forward to seeing more examples of genetic research leading to personalized medications for individuals.

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Doctors Die Too, but Maybe Differently

January 23, 2012 Dr. Pullen

I stumbled across this terrific article titled:

How Doctors Die by Ken Murray a FP at USC.

It is largely anecdotal, but is a really an interesting perspective on how at least some physicians choose to forgo futile end-of-life treatments because they know the limits of modern medicine first hand.

Also Enjoy:

Octogenerian’s Letter to Santa

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The Gluten Free Marketplace Explodes

December 5, 2011 Dr. Pullen

The Gluten Free Marketplace Explodes

Gluten Enteropathy, or celiac disease (sometimes called celiac sprue), is a condition where the lining of the small bowel is damaged by antibodies to gluten found in wheat, rye, barley, malt and some other grains. When people who are gluten sensitive eat food containing gluten their small bowel becomes inflamed, the villi that contain enzymes to help digest foods to allow their absorption become atrophic and dysfunctional, and they lose weight, become ill and just feel terrible. For many years it was felt that gluten enteropathy was rare in the United States, and was primarily a European problem. As late as 1999 the teaching in U.S. medical schools was that only 1:10,000 Americans had gluten enteropathy. Beginning in the early 1990’s research began to show that the incidence was much higher, and it is now estimated that as many as 1:100 Americans has gluten sensitivity. This for unknown reasons seems to be a real increase in the last half century, and not be just a product of increased awareness and better testing.

Gluten sensitivity can be dramatic or subtle, and difficult to diagnose. A battery of blood tests often including Anti-tissue Transglutaminase Antibodies(Anti-tTG) IgA, Anti-tG IgG, Anti-Gliadin Antibodies, Anti-Endomysial andibodies, or other antibody tests if positive can suggest the diagnosis. A negative test has a higher predictive value at ruling out celiac disease than a positive test has at confirming the diagnosis (the tests are more highly sensitive than they are specific). To confirm the diagnosis requires a small bowel biopsy that is usually obtained by upper GI endoscopic exam.

Once diagnosed with celiac disease a person has to learn how to eat a gluten free diet in a society where wheat and other gluten containing food is nearly everywhere. Fortunately more and more prepared foodstuffs are being marketed all the time, and more recipes, support groups, and nutritional advice is available than ever before.

I just read a very interesting article in the N.Y Times by Keith O’Brien that nicely outlines the history of the emergence of gluten enteropathy in the U.S., and the market leadership by General Foods in bringing gluten free food products to market to capitalize on the growing market for gluten free products. You may enjoy reading:

Should We All Go Gluten Free?

By Keith O’Brien November 25, 2011.

My guess is that you know someone dealing with the need to eat gluten free. Fortunately as awareness grows and resources become more easily available providing a gluten free meal is less onerous than it was just a decade ago.

I am also learning more about various nutritional deficiencies that can accompany celiac disease. The malabsorptive condition seen in patients with celiac disease can lead to several well documented vitamin deficiencies that are uncommon otherwise. Deficiencies in almost all of the fat soluble vitamins and B vitamins are more common in celiac patients than in the general population. I recently saw a 17 year old girl in the office with known celiac disease who had been well controlled on a gluten free diet for several years. She was found to be both vitamin B12 and folic acid deficient when evaluated for anemia and fatigue.

As a medical community we have become more aware and educated about celiac disease in recent years, and it is good to see that the marketplace is stepping up to meet the demand for gluten free products and make existence easier for this significant minority of Americans with gluten sensitivity.

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Cord Blood Stem Cells get FDA Approval as Hemacord™

November 11, 2011 Dr. Pullen

Yesterday the FDA approved the first cord blood product, to be marketed as Hemacord™ with indications for cord blood stem cell transplant procedures in patient with some types of blood malignancies like leukemia as well as some inherited metabolic and immune system disorders. I think this could be just the beginning of much more widespread use of cord blood products for therapy. Cord blood is the blood left in the umbilical cord and the placenta after childbirth. It is routinely discarded as biologic waste, although in recent years some patents with enough financial means and interest have been having a sample of their newborn infant’s cord blood saved at a cord blood bank, and some public blood banks have begun to collect and store cryopreserved cord blood for public use. The potential supply of cord blood for therapeutic use would seem to far outweigh the need, and I expect that if cord blood stem cells continue to be as promising as they appear to be, namely as effective as bone marrow or other stem cells for transplant, that their use will become commonplace.

Currently the primary reason cord blood is harvested and stored is by parents trying to insure that if their baby develops a medical condition requiring a stem cell transplant that they will have cord blood available for their therapy. Cord blood is usually harvested in a “closed” technique, where blood is aspirated from the umbilical vein after the cord is clamped. The blood is then put in an appropriate container and preserved by cryopreservation at a cord blood bank. When cord blood is saved and stored at a private cord blood bank the cost ranges from $775-$2000 initially with storage fees of about $100/year, making it an expense that many couples cannot afford. The American Academy of Pediatrics currently recommends against encouraging routine cord blood storage in families without a family history of a condition making the need for use of the stored cord blood more likely. They do recommend collecting and storing cord blood in families with a history of certain hereditary genetic conditions that make it much more likely that the need for use might arise. There has not been a great deal of experience with us of cryopreserved cord blood stored for long periods of time, and concerns about the long-term financial viability of some private companies currently storing cord blood leaves another potential risk that cord blood saved for future use could not be available despite a parent’s best intentions and expense. The AAP recommends consideration of donation of cord blood to public cord blood banks for availability to the general public.

A recent study showed that use of human cord blood led to similar effects and leukemia-free survival as bone marrow and peripheral blood donor cells. Currently there are public blood banks that store cord blood, using the “Be the Match Registry” as a central data repository for matching donor cord blood with patients in need. This gives great hope that now that the New York Blood Center(NYBC) has received FDA approval for Hemacord™ that a much larger set of potential transplant cord blood stem cells may become listed in this or another registry of preserved cord blood with known HLA typing. This could make a source of matching donor cells more readily available for patients who need a stem cell transplant without the current search for an acceptable donor that is currently needed.

A good question is, “Why is the news about Hemacord a big deal since public blood banks are currently saving and storing cord blood.” One potential benefit is that to obtain FDA licensure of Hemacord the NY Blood Center had to meet rigorous FDA standards for their product in several areas including purity, potency, and efficacy in actual use. The NYBC’s National Cord Blood Program has been operating since 1996 with an investigational New Drug exemption by the FDA, and the NYBC is rightfully excited about their FDA approval. This may pave the way for other centers to also get FDA approval and make the use of cord blood stem cell transplantation and potentially other uses of cord blood products much more realistic. It may also lead to more research of other uses of cord blood therapy. I’ll be interested to see what happens in this field over the next few years.

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Sequenom™ brings MaterniT21™ and a Whole New Set of Difficult Choices

October 22, 2011 Dr. Pullen

Coming to 20 major U.S. metropolitan areas this week will be a test called MaterniT21™ from Sequenom™. Over the past 25 years we’ve gone from alpha-fetoprotein testing, to adding 2, 3 and more recently 4 tests as “penta” screen to try to improve the estimation of a woman’s risk for having a trisomy-21, or Down’s syndrome pregnancy without actually obtaining fetal cells, but all they have really done is improve statistical prediction capability. Up to this point in order to tell if a woman is carrying a Down’s Syndrome baby required amniocentesis to obtain amniotic fluid at about 16-18 weeks gestation, or the arguably higher risk chorioamniotic villous sampling at 10-12 weeks gestation. Both of these tests ran low (estimated 1/350) but real risks of fetal injury and miscarriage. Now from a company named Sequenom™ comes a test on fetal cells obtained by a venous blood sample of the pregnant women’s blood as early as 10 weeks gestation that can do genetic screening for Down’s Syndrome without more invasive ways to obtain fetal cells. The initial study of 212 women showed a >99% accuracy rate. (1 false positive, 2 false negatives in 212 women tested).

This is both exciting and frightening. It raises huge questions including who if anyone should get this testing. Here is a list of some of the issues that come to my mind as we start the process of figuring out the role of this new technology:

Increased Abortions and Earlier Abortions of Down’s Syndrome Pregnancies: One consequence of a more accurate test for Down ’s syndrome if it leads to more widespread testing or women for this condition is that more women will face the decision of abortion or not. Now women first face the question, “Would I abort my pregnancy if I knew I had Down’s syndrome, and if so am I willing to undergo a test that could cause miscarriage to get that information.” With the Sequenom™ MaterniT21™ test women will be able to get much more definitive information without a test that puts their fetus at risk from the test itself. This may lead to more women choosing to be tested. Putting aside the whole “pro-life vs. pro-choice” debate, the opportunity for earlier diagnosis will make technically easier and less physically traumatic abortions possible in women who have a Down’s Syndrome pregnancy.
Who should be Eligible for the Test?: Although the risk of Down ’s syndrome rises with increasing maternal age many Down’s Syndrome babies have young Moms. With a more accurate and less dangerous test available should all or more women be offered the test?
Who should pay for the testing?: This is a very complicated question. This test is not going to be inexpensive. On the Sequenom™ press release they suggest that the cost will approximate the cost of amniocentesis testing. They do not make it clear if this means the cost of the amniocentesis test itself, the cost of the genetic testing of the cells obtained, or both. If the test is done it will lead to higher costs for prenatal care as the test itself will significantly increase the overall cost of prenatal care. On the other hand the cost of having a Down ’s syndrome baby is not inconsequential. Down ’s syndrome children sometimes have major other congenital deformities, and the long term cost of education, support as adults, and associated family and societal costs are real and significant. A comprehensive cost-benefit analysis of this process will be interesting to see when it becomes available. These issues themselves will lead to ethical and moral choices.
Lower Incidence of Down’s Syndrome: If this tests becomes widely used, and if more women choose to abort pregnancies with Down’s Syndrome fetuses, the incidence of Down’s Syndrome could significantly decline. While many may consider this the desired outcome, some Down’s Syndrome supporters fear that this may lead to reduced support and reduced research into drugs and other techniques to help Down’s children.

I’m sure I’ve only touched the surface of the ethical, emotional, medical, moral and financial issues this new MaterniT21™ test from Sequenom™ and likely others to follow will bring. It seems a near certainty that with the ability to sample fetal cells from maternal blood other genetic tests like tests for cystic fibrosis, sickle cell disease, and many others will follow.

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Moral Responsibility to Get Your Flu Shot

October 10, 2011 Dr. Pullen

Moral Responsibility to Get Your Flu Shot

I Got Mine

This topic comes to mind again this year as we have plenty of influenza vaccine, on time this year and ready for distribution. A prior version of this post was posted in 2010. I have strong enough feelings on the subject to repost an updated version. If anything good came of the Swine Flu epidemic on 2009 it was that more Americans get immunized not than ever before.

This year as every previous year Dr. Pullen was first in line at our office for my influenza vaccination. I take seriously the mantra primum non nocere, first do no harm. It’s hard to imagine doing more harm than seeing a patient with influenza on Monday, and on Wednesday, the day before I get sick, sneezing and passing the influenza germ to one of my vulnerable older patients, or a pregnant woman, or a young baby who then dies from influenza. This scenario is just inexcusable given that I could have avoided harming the patient if I had received the recommended and easily available influenza vaccination. It would be immoral and irresponsible to put my patients at that type of risk unnecessarily. I encourage, coax, tease, and everything short of intimidate my employees and fellow physicians to get their influenza vaccination also. School teachers, emergency workers, and others in close contact with the public should similarly feel morally compelled to get influenza vaccination. It is our moral responsibility.

I also got a Tdap vaccination last year also, even though was several years until I was due a tetanus shot. See Dr. Pullen Gets His Tetanus Booster Shot Years Early! My thinking was the same, try to avoid a pertussis infection, and not put my patients at risk.

It’s a small step from discussing health care workers and influenza and pertussis vaccination, to talking about parents and childhood vaccinations. The parent who chooses not to vaccinate their children against measles and pertussis puts not only their own child, but other children in the community and the school who may be at particular risk for complications from these infections in danger. These children at high risk may catch these infections from these unimmunized children. As a parent I’d feel terrible if my child died or became brain injured from measles, but I’d also feel horrible if my child passed Pertussis or measles on to a child with leukemia, or HIV because I chose to not immunize my child. I appreciate that this is a free society, and we can make our own personal choices about health care including immunizations. It’s not illegal to decline recommended immunizations, but in many cases it is irresponsible and not living up to our community moral responsibility. Parents who choose not to immunize their children and take advantage of the herd immunity of the majority of children whose parents responsibly immunize their kids are just ignorantly selfish. They think they are protecting their children from risks of immunizations, though a great mass of evidence refutes this point of view. In fact they are putting both their own child, and other children who lack immunity through no choice of their own or their parents at risk.

I’m anticipating a rash of angry comments calling me a mouthpiece of the brainwashed physicians of organized medicine. Don’t believe them.

See these references on the safety of childhood immunizations.

Prenatal and Infant Exposure to Thimerosal From Vaccines and Immunoglobulins and Risk of Autism (there is none).

Data Fail to Support Thimerosal-Autism Link

The end of the autism/vaccine debate?

Book Is Rallying Resistance to the Antivaccine Crusade

Also see the great video at the top of the Musical Docs page Immunize: The Vaccine Anthem.

Which Argument Shoots Down Your Excuse for Not Getting a Flu Shot.

September 16, 2011 Dr. Pullen

Got My Flu Shot Today

I really don’t like the term “flu” or “flu shot” because the term flu should not be used interchangeably with “viral illness.” Influenza is a specific, often very severe and even deadly viral illness and influenza vaccine is a very specific vaccine. Still the term flu shot is so integral to our everyday language that I’ll us the term, and encourage all of you to GET YOUR FLU SHOT. I hear excuses every day during the fall and early winter when I offer influenza vaccine to my patients. Here are some of the most common excuses (explanations?) I hear and my explanation (argument?) of the folly in that line of reasoning.

“I never get the flu. I don’t need a flu shot.” – Most people only get influenza once every several years. It is not unusual for any given individual to go 10-15 years without contacting influenza. Influenza is a severe illness much of the time and it is worth getting a flu shot every year to prevent one case of influenza every 10-20 years.
“The last time I got a flu shot I got the flu.” – This is just not true. An influenza vaccine simply does not cause influenza. Since the influenza vaccine contains a killed virus, it is not possible for it to cause influenza.During the season when we give flu shots minor illnesses are common. It is not unusual to become ill during the time shortly after getting a flu shot. Also a small percentage of people who get a flu shot may have some minor aching, low grade fever or malaise. This is not even close to as severe a problem as a real case of influenza, and is no reason not to get a flu shot.
“I just don’t like shots,” or “I hate needles,” or “Shots hurt.” – Nobody likes getting shots, or being stuck with a needle. The benefits of influenza vaccine, both for yourself and for those you care about are important enough to suffer through an injection. Just get it over with.
“I heard the flu shot this year is just the same as last year so I don’t need another shot.” – I heard this today from a medical student at the office. They should know better, and I tried to set them straight. It is true, that in 2011 the components of the influenza vaccine are the same as they were in 2010. I suspect that this student was just trying to find an excuse not to get a shot. It is good news that the vaccine has not changed this year. First it means that no new and very different influenza virus lurking and ready to cause a severe influenza pandemic was discovered. Getting a second vaccine will be the equivalent of a booster shot, making you even more immune to these strains of influenza, whereas the remaining immunization from last year’s flu vaccine are not adequate to provide immunity sufficient to prevent contacting influenza this year.
“I’m healthy and if I get the flu I won’t get all that sick.” — I’m happy that you are a healthy person who takes good care of yourself. Now get a flu shot and stay healthy, because influenza can be very severe or even lethal for even the strongest and healthiest of us. In addition if you catch influenza you will be putting others at risk. You’ll be sick enough that someone will need to take care of you, and they will be at risk needlessly because you chose not to be immunized. This is especially true if you are around the elderly, the very young, pregnant women, or persons with chronic disease. Respect yourself and those around you and get a flu shot.
“I want to leave my immune system alone so I will develop good immunity naturally. If I get a flu shot I weaken my immune system.” – - This is just faulty reasoning. There is no evidence to suggest that getting an influenza vaccination reduces your immunity against other germs. It simply provides antibodies against certain strains of influenza A and B. This immunity likely is increased by annual flu shots, so that by getting a flu shot annually you develop better influenza immunity each year.

Last year I posted on The Social and Moral Responsibility of Immunizations for health care workers, teachers and others in positions where others at high risk may be exposed to them if they contact influenza. I wrote earlier this year on the Flu Season. This health blog also links to an AFP article on The 12 Basic Rules of Influenza and I wrote on how to Avoid Getting Sick. I hopt that all of these are informative, but if I could accomplish one thing with this blogging effort, I’d convince every one of my patients and readers (except the uncommon patients with severe egg allergy or other valid reason to need to rely on the herd immunity that could occur if the rest of us got immunized) to get an influenza vaccination every year. If I could do that I’d feel that I’d have made a real difference in the tiny part of the world that I touch.

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Saline, Oral Rehydration and Neti Pot Solution Recipes

September 7, 2011 Dr. Pullen

There may be lots or reasons you want to make homemade saline solution, oral electrolyte rehydration solution, Neti pot sinus irrigation solution instead of going to the pharmacy to buy it premade. It may be late at night or a holiday and the stores may be closed, you may not have transportation, or you may just want to save money or feel self-sufficient. Whatever the reason you can safely make your own solutions for these purposes, but keep in mind that the concentrations of the various salts in these solutions needs to be accurately measured and mixed or you can do yourself or your child significant harm. That said here are recipes for these commonly recommended medicinal solutions.

Saline Solution Recipe: This is also called normal saline, or physiologic saline solution. The names all mean that the concentration of sodium chloride in the solution is very close to the same concentration of salts dissolved in the cells of the body, so the solution does not cause water to pass into or out of cells it comes into contact with leading to cell dehydration or swelling. This recipe is recommended for irrigation of wounds, soaking ingrown toenails, and such uses, but not for contact lens care or other uses where strict sterility is needed. For these “clean” but not sterile uses tap water is adequate. Better to use distilled water, but tap water is OK for most uses.

1/3 tsp non-iodized salt +250 ml boiled or distilled water (one cup is 240 ml and is close enough for most purposes.
For larger amounts use 1 liter boiled or distilled water + 1 1/3 tsp non-iodized salt.

Oral Electrolyte Solution Recipe: Oral Electrolyte Rehydration solution is among the most important advances in prevention of death worldwide from diarrhea. It has revolutionized the management of infant diarrhea and probably prevented more deaths than most much more widely acclaimed advances in medical care. It is estimated that the use of oral rehydration solution and zinc tablets has prevented 50 million infant deaths in the last 25 years. There are many recipes out there for homemade oral electrolyte solution, but this one is simple, is recommended by the Rehydration Project supported by the World Health Organization, and works fine:

1 liter clean water
6 level teaspoons of sugar
½ level teaspoon of salt

Neti Pot Solution Recipe: Neti pots are very popular, have almost a cult following, and work fine, but personally I prefer one of the simple nasal saline rince devices like the NeilMed Sinus Rinse product. It is very easy to use, and the key is to be gentle in the irrigation and in the blowing out of the solution after irrigation. Here is a recipe that works great for saline irrigation:

1 cup of lukewarm distilled water
1 tsp non-iodized salt. Sea salt or kosher salt are good options.
½ tsp baking soda.
Mix the ingredients until the soda and salt are dissolved.

If you decide to use any of these solution recipes remember that they need to be measured accurately and you need to use common sense. If you are getting worse not better, consult your physician. If you feel more comfortable using premade solutions at the pharmacy by all means buy them. If you want to make them yourself be sure to wash your hands carefully, take care to avoid contaminating the solutions, and do not store the solutions for future use, rather mix them fresh to avoid bacterial contamination and growth.

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Baby Teeth Are Important

August 31, 2011 Dr. Pullen

Baby teeth are much more important to overall health and the development of strong and healthy adult teeth than many people realize. Babies are almost always born without teeth, and begin the process of teething usually between 2 and 12 months of age. The first teeth to erupt are usually the bottom two central incisors, followed in order by the top two central incisors, the top outer incisors, the bottom outer incisors and then the then the first molars. These are followed by the canine or eye teeth and then at about 3 years of age the second molars. There are 20 baby teeth, also called deciduous teeth because they are shed, just like the leaves of deciduous trees.
The baby teeth play several key roles. One of the key functions of the baby teeth is to hold space open for the permanent teeth. If you baby develops serious dental decay and loses some of their baby teeth early the growth and formation of the jaw can be altered making less space for the permanent teeth and lead to orthodontic issues. In addition if a child develops caries in their baby teeth they are more prone to develop caries in their subsequent permanent teeth because of the colonization of the mouth with the bacteria that lead to plaque and caries.
So what can you do to keep your child’s baby teeth healthy and cavity free? There are several important aspects, some may seem intuitive, others less so. Here are some of the key things to do and to avoid:

Brush your child’s teeth at least twice a day. Start as soon as the first teeth erupt. Avoid using excessive amounts to fluorinated toothpaste. Use a grain of rice amount or less. If your child wants to brush their own teeth that’s great, but you need to also brush them as young children are not able to do an adequate job. Tell your child that they can brush but that you will polish after they finish.
Seek dental care early. Some experts recommend a dental visit at age 1. Most recommend by age 3 at the latest, but about age 2 years is usually recommended. The dentist will look for problems, clean away any plaque, and do fluoride treatments that are very effective at preventing decay.
Make sure your child gets fluoride supplementation. Some physicians recommend prenatal fluoride though this is not widely done there is some evidence of efficacy in prevention of cavities in the baby teeth. If your local water does not have fluoride added, ask your babies doctor for a fluoride supplement starting at age 6 months. This should be continued until all the permanent teeth are grown.
Do not give your baby a bottle with any milk or sugar to use in the crib. Finish the bottle prior to going to sleep to avoid bottle caries. This is a really important factor.
If you use a pacifier don’t dip it is honey, sugar water or anything with sugar. Also don’t put it in your mouth, as the germs that cause cavities are passed from parent to child easily.
Start using dental floss as soon as the teeth get close to each other.
If you child develops carries, be aggressive in getting dental care to prevent further decay and premature loss of the baby teeth.

Overall the key lesson is that baby teeth are important and good care of the baby teeth can give a child a big advantage in the likelihood of having healthy and well aligned permanent teeth.

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Rohypnol: What You Should Know About the Date Rape Drug

August 8, 2011 Dr. Pullen

Rohypnol, or roofies, is the name for what is more commonly called the date rape drug. Rohypnol has become notorious because of its potent amnestic and hypnotic effects which can lead a person given a dose of Rohypnol to have short term amnesia. This has led to its popularity as a “Club Drug” along with Ketamine, MDMA (Ecstasy) and GHB. Rohypnol has not been approved for use by the U.S. FDA and is considered an illegal drug in the U.S. Rohypnol is in the benzodiazepine class of medications along with more well known and commonly used drugs like diazepam: read diazepam side effects (Valium), alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonapin) and many others.

Rohypnol (chemical name flunitrazepam) is the most potent of the benzodiazepines on a mg-for-mg basis and is very fast acting, making it potentially useful in severe refractory insomnia, mostly in patients in the hospital. For the same reasons it is notorious for its abuse as a date rape drug. Rape by someone well known to the victim, often date rape, is unfortunately very common. Rohypnol has been found to be involved in a very small percentage of date rape, probably less than 1% of cases, but it undeniably is abused for that purpose. The much more common drug involved in date rape is simply ethanol, the alcohol in all alcoholic beverages which can also lead to blackouts, amnesia and vulnerability to sexual abuse.

This said, how should a woman avoid becoming a victim of date rape associated with Rohypnol? Probably the key is to avoid situations where heavy drinking and drug use is expected. In addition trying not to leave a drink unattended and then picking it back up to drink may be considered. Still if going to a dance club and drinking while there, if you dance you are likely to want to put your drink down. This issue makes nearly eveyone at a dance club who drinks alcohol at some risk for having their drink spiked with Rohypnol. This means other than completely avoiding dance clubs and drinking we need to depend on our friends to watch out for each other. That said the real issue is with the societal issues that lead to use of drugs like this in the first place.

That issue is with the perpetrator of the crime giving the drug to the victim. As a society we need to watch out for each other. We need to teach our sons and daughters that if they even suspect this type of behavior may be happening or going to happen that they take action to avoid being involved and if possible to stop the perpetrator of the crime. It is far too easy to explain away the odd behavior of a friend as just having had too much to drink, or to not want to interfere or embarrass their friend or themselves by taking action to intervene. We need to have the courage to step up and take actions to intervene when suspicious behavior is noted. Given that alcohol is probably the most frequent drug involved in date rape and other mishaps of intoxication thinking that behavior may be “just alcohol” is flawed thinking.

One helpful thing may be to recognize the effects of Rohypnol on someone around you. If a friend starts to look odd, dazed or confused we should take measures to protect them. Typical symptoms of ingestion of Rohypnol include confusion, uncoordination and sedation. These effects can come on quite quickly, and may look much like alcohol intoxication. Alcohol does in fact clearly increase the sedative and central nervous system depressant effects of all benzodiazepines. All told the best way to reduce the chances of being given Rohypnol is to avoid situations where heavy drinking and drug use is prevalent.

Rohypnol is also used recreationally, especially in conjunction with stimulants and heroin. Stimulants like cocaine and methamphetamine lead to severe insomnia and Rohypnol is sometimes used to “soften” the so-called crash from these stimulants. It is also used to achieve profound intoxication, and when combined with alcohol this can lead to fatal overdoses. Rohypnol has many street names including roofies, forget-me-pill, Mexican Valium, and many others.

Rohypnol has also been documented in Europe as an adjunct to robbery, with victims given Rohypnol and then robbed. This is a type of abuse of Rohyphol that also takes advantage of the potent amnesia that those who are under the influence of Rohypnol experience. In Europe where Rohypnol is available as a prescription drug the potential for misuse is certainly higher than in the U.S.

Rohypnol has no legitimate role in U.S. medicine, and is a drug of abuse. Rohypnol in the U.S. is imported from abroad where its use is apparently even more widespread. I pray that you as a parent or as a young person never have any first hand experiences with this drug, and that the word Rohypnol is something you only read about in places like this.

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