Let’s look at the evidence for transmission of the various STDs by oral-genital contact.

HIV:  Human Immunodeficiency Virus, the cause of AIDS, is the STD many fear most.  It can be transmitted when a body fluid containing the virus gains access to another person’s mucous membranes or bloodstream.   Unquestionably HIV is transmitted by anal and vaginal intercourse.  There are at least a few cases where it is believed that the HIV virus was transmitted to the receptive partner after oral sex with ejaculation.  Oral sex without ejaculation into the mouth is theoretically possible, but is felt to be extraordinarily unlikely. The risk of contracting HIV from a single incidence of anal intercourse with with ejaculation and no condom use with an HIV infected male has been estimated at 1:100.  Extensive study has been done in trying to find out what the incidence of contracting HIV from oral sex with ejaculation with an HIV infected male, but these studies all have confounding variables.  The real problem is that all of these studies have been in gay male populations, and a low percentage of the men had only oral sex.   On second and subsequent interviews many times the history changed, and made other routes of transmission more likely.  In one study it was estimated that there were zero cases of conversion in a population after over 35,000 incidences of oral sex.  All said, although it is possible to contact HIV from oral sex, the chances are very low. Low enough that if oral sex is a behavior that replaces anal intercourse in gay men the benefit of avoiding the high risk behavior likely greatly outweighs the risks of oral sex in this situation.

Herpes Simplex:  This may be the most common STD transmitted by oral sex.  Up to 70% of teens are estimate d to have been infected with the herpes simplex 1 virus, the cause of >90% of oral herpes cases.  Many others, and many of the same people also have been infected with the herpes simplex 2 virus, the cause of >90% of genital herpes.  The problem with herpes simplex is that despite popular belief, an infected person can shed the herpes virus at times when they have no symptoms or visible evidence of infection. It is believed to be  fairly common to transmit the herpes simplex virus either from the mouth to the genitalia, or from the genitalia to the mouth during oral sex.  The incidence of HSV transmission by oral sex is not well studied.

Gonorrhea:  Gonorrhea, caused by the bacteria Nisseria gonococcus, is an STD that typically causes painful urination and  a discharge of pus from the urethra in men.  In women it can be asymptomatic, can cause a vaginal or cervical discharge, or can cause more serious infection of the fallopian tubes and or ovaries, called Pelvic Inflammatory Disease (PID).  Gonorrhea can also infect the throat or tonsils.  The route of this infection appears to be oral sex, generally receptive oral sex with the penis in the mouth.  It is less clear whether cunnilingus can transmit gonorrhea although it is felt that this is very rare if it ever happens.  Men likely only contact gonococcus from vaginal or anal intercourse or from an infected partner during receptive oral sex.

Chlamydia:  There is less data about transmission of Chlamydia by oral sex.  It is generally felt to be possible to transmit Chlamydia both as the person performing and the person receiving fellatio.  The incidence of this is just not known.

Syphilis:  Syphilis is fairly uncommon in the US, but transmission of syphilis during oral sex is relatively easy, and is felt to be a relatively common cause of transmission, possibly up to 15% of cases in some areas of the US.

HPV:  HPV is probably the most prevalent STD in the world today. The HPV virus can be transmitted to the throat or mouth during oral sex.  The incidence of this is poorly understood, but there is an increasing rate of HPV positive head and neck cancers in the last 30 years.  Many experts feel that this correlates to increasing acceptance of oral sex.  Oral cancer has historically been primarily a disease of older adults with a long history of smoking and drinking, or in younger persons who use oral tobacco.  In recent years the incidence in younger non-tobacco users has increased, and many of these cancers are HPV positive on testing.

Hepatitis:  There is debate whether hepatitis B can be transmitted by oral sex, but if possible it is felt to be very unlikely.   Hepatitis A can clearly be transmitted by oral-anal sex, and is much more common in the gay male population than in the heterosexual population.

In summary oral sex is not safe sex, but it is far less risky than either vaginal or anal intercourse regarding STD transmission.  In addition the risk of pregnancy in heterosexual oral sex is near zero.   Avoiding receiving ejaculate in the mouth greatly lowers the risk of transmission of HIV, though probably not the risk of herpes, gonorrhea, or HPV.  Condom use for men, or use of a dental dam in women seems effective in markedly reducing the risk of most STDs with oral sex, but may not be common practice.

Psychological Issues:  Oral sex is clearly an intimate act.  Most psychologists agree that sex, either oral sex or sexual intercourse, brings a relationship to a different level.  How this type of intimacy affects a relationship, the self esteem of the participants, and future feelings about relationships and intimacy are subjects worthy of consideration, but I know of no research into this topic.

So, “How safe is oral sex?”  What do you want to tell your children about oral sex as a part of their sex education? You can decide now based on the discussion above and whether it involves men having sex with other men (MSM)  vs. heterosexual oral sex.  One risk of labeling oral sex a high-risk behavior in MSM is that it may leave gay men feeling that its risk is equal to anal intercourse, which is far from the truth.  If oral sex is an alternative to anal intercourse for MSM then it greatly reduces the risk of HIV transmission.

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.

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:

1. 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.
2. 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?
3. 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.
4. 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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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.

1. “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.
2. “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.
3. “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.
4. “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.
5. “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.
6. “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.

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.

Molluscum contagiosum is a viral skin infection that causes small, usually 2-5 mm size raised skin colored to pinkish bumps on the skin that usually have a small dimple in the center, so we call them umbilicated in appearance (like an umbilicus in the middle).  They are almost always painless, and unless you scratch or dig at them they resolve without scarring usually.  So what’s with the descriptive terms above:

Least Serious Warts: These are often called water warts, but are really not closely related to most other human warts.  They are not in the human papilloma virus family with genital warts, plantar warts, flat warts, etc. but rather are caused by a member of the pox virus family.  Molluscum lesions painless and almost always resolve on their own faster than most other types of viral warts.  The typical total course of molluscum contagiosum in any one individual usually ranges from 6-18 months, although it can be longer in a small minority of people.  Any one molluscum contagiosum lesion itself tends to go away sooner, often in 2-3 months.  These lesions, unlike genital warts which are clearly associated with cervical, penile and tonsil cancer, are not felt to be associated with any serious or long term consequences.

Molluscum Contagiosum as an STD: Although in practice we mostly see molluscum contagiosum in children, they are also a sexually transmitted disease in older adolescents and adults.  Molluscum contagiosum gets its name because it is fairly contagious.  You tend to get the infection by skin-to-skin contact with another person with an infection, or contact with a fomite carrying the virus.  A fomite is an inanimate object like a towel, clothing, toys, or any other object that has the virus attached to it.  In sexually active persons the skin to skin contact tends to be on the genitalia, the torso and the proximal extremities.   In children they are seen virtually anywhere except the palms and soles, although in my experience they are not common on the face.

Diagonsis: The diagnosis of molluscum contagiosum is usually easy for an experienced practitioner.  The appearance is so typical we can often at a glance know with a high degree of certainty the diagnosis.  If in doubt we can simply squeeze one of the lesions after using a small needle or scalpel blade to nick the roof of the lesion and express a cheesy whitish material that is very unique and confirms the diagnosis.  In really odd appearing lesions a punch biopsy can be done to send for pathologic exam, but this is almost never necessary.

Treatment: In children I try to convince the parent to just wait out the course of the molluscum.  Any treatments involve some sort of discomfort to the child, and unfortunately often even a thorough search for lesions and careful destruction of all the apparent lesions is fruitless as new lesions usually pop up shortly after the treatment requiring returning for another round or treatment.  If I can convince Mom or Dad to just leave these alone, knowing they may get worse before they get better, they are happy to see them resolve after a few months or a year or two.  In older children, adolescents or adults who really want to get rid of these they can be treated by many types of destructive therapy.  Liquid nitrogen cryotherapy is effective.  Simply unroofing each lesion and expressing the core works well.  For this I use a larger needle, about 20 gauge, to nick the top, and gloved thumbs to pinch out the core between my thumbnails.   Blistering agents can also be used.

Molluscum contagiosum in an adolescent or adult is a clue to discuss STDs, consider screening for other STDs, and if a severe case a reason to question immunity.  In HIV patients or others with a suppressed immune system molluscum contagiosum can develop rapidly spreading and severe cases.

Overall molluscum contagiosum is usually an easy diagnosis where in children the biggest task is to assure the parents have realistic expectations and ideally the patience to just wait out the course.  Unless there is undue anxiety or parental concern, this is a reassuring diagnosis to many parents if presented calmly and with confident reassurance.  At least it’s usually easy to be confident of the diagnosis.

To understand why the scotch tape test work works we need to first review the interesting life cycle of the pinworm.  Enterobius vermicularis is known as the pinworm because it is about the size of a common pin.  It lives in the human small intestine and proximal colon.  After living a few weeks the female worm migrates down the colon, exits the anus and lays its eggs on the skin of the perianal area at night.  The female dies after laying her eggs. The worm and the eggs seem to lead to itching, which initiates scratching which helps facilitate the eggs getting on the fingers and then reingested.  The infection is most common in children who have less concern about putting their hands in their mouth after scratching or touching their anal area, and self-inoculate themselves.  The ingested eggs then hatch in the duodenum, the males and females mate, the male dies and the female moves to the distal small bowel after molting twice as she passes through the bowel, and the process is repeated.

This sounds disgusting but the fecal-oral route of spread is a common way that infections are spread.  The unique thing about the pinworm is that it’s probably the only common human infestation that depends on people perpetuating and sustaining the infestation by repeatedly ingesting more eggs over and over.  If no eggs were reingested the infestation would die out as the worms die after laying their eggs.

All this sounds terrible, but there are a few good things about pinworms.  The first is that the infection is almost harmless.  Infection tends to either be asymptomatic, or just cause perianal itching.  In girls it can sometimes cause a vaginal itch if the organisms inadvertently crawl into the vagina instead of the rectum after coming out to lay their eggs.

The second good thing is that pinworms are easily diagnosed.  When I see a child I suspect of having pinworms I have their parent wake them about 2-3 AM and look at their anus with a flashlight.  Often the worms can be seen on the outside.  Sometimes they are also seen in the diaper or the toilet after a bowel movement.  If not seen the scotch tape test is done by taking a piece of scotch tape, applying the sticky side to the child’s anus on awakening in the morning, and sticking the piece of tape to a microscope slide.  I just give a few microscope slides to the parent to collect the specimens at home on two or three mornings, and have them bring the slides in for me to examine.  The pinworm eggs are easy to see under the microscope, and a diagnosis is made if eggs are noted.

The third good thing about pinworms is that treatment is very easy and effective. A single dose of mebendazole, a 100 mg chewable tablet, is effective in most cases.  We do routinely treat the whole family at once to eradicate the organism from any unsuspecting family members and increase the chance of long term cure.

Unfortunately reinfection is common, especially in children in daycare or when they originally contacted the organism from another child who remains undiagnosed.  If your child contacts pinworms, don’t be overly concerned.  It’s common, easily treated and not at all serious.

The Epstein-Barr Virus is a member of the Herpes family of viruses. The typical presentation of mono is in a teenager who develops a severe sore throat and fever. Keep in mind that the usual office blood test for mono, the “mono spot” test, is often negative until up to 10 days of symptoms. The presentation can be clinically indistinguishable from strep throat initially, and up to 50% of patients with mono have positive throat cultures or rapid strep tests. Pair this with the 20-30% false negative rates of the office rapid strep tests, and the initial diagnosis is often not made until a second or third office visit when it becomes apparent that the child is not responding to treatment for strep throat and the mono test becomes positive. If treated with amoxicillin a patient with mono will often develop a reddish macular rash all over, and this can be mistaken as a penicillin allergy; see amoxicillin side effects for a nice resource. Still the classic thick white exudate on the tonsils of a child or teen with mono can be very suspicious to an experienced examiner, and if paired with really big 3-5 cm anterior or posterior cervical lymph nodes or an enlarged spleen we can often suspect the diagnosis on the initial visit even if it’s too early to confirm the diagnosis with lab tests.

Because of the wide variety of symptoms that mono can cause, and the wide variety of severity of illness, it is the disease that comes to my mind first when I hear the old med school adage, “Uncommon manifestations of common problems are much more common than common manifestations of uncommon problems.” Despite its peak incidence in children and young adults, mono is seen at all ages. Presentation in young children is often quite subtle, and not diagnosed. In older adults it often presents with sore throat, enlarged tonsils with a thick white exudate, and swollen cervical nodes like in teens, but can also present with florid hepatitis, simple fatigue, or abdominal pain from hepatosplenomegaly. Rare presentations include aseptic meningitis and leukocytosis found on a routine CBC.

One of the frustrating aspects of mono is the long duration of fatigue some patients get. This can be very debilitating, and mono is one of the few diagnoses where rest is especially important. Listening to your body and not trying to push yourself to your limit and allow the symptoms to resolve more quickly than if you try to push yourself to exhaustion every day. Half days of school, with naps and focus on the key subjects can allow students to stay on course throughout the course of the illness. Antiviral medications are not helpful in mono. In severe acute presentations a short course of prednisone can quickly shrink the tonsils and allow the patient to eat and drink enough to stay hydrated and nourished. Fever can persist for several weeks in some cases.  (See prednisone side effects)

The relationship between EBV and chronic fatigue syndrome is not clear, and although I believe chronic fatigue syndrome is a real condition, I don’t believe it has been shown to be related to EBV. Some recent research suggests a virus called XMRV as a cause of chronic fatigue syndrome, although this is very controversial. Most patients with EBV can get back to school or work within a few weeks. Management of athletes in contact sports has been better defined in recent years. Most sports medicine experts allow participation in contact sports after the fatigue has resolved if absence of hepatosplenomegaly can be documented with ultrasound. In past years we insisted on at least 8 weeks time after diagnosis prior to contact sports. The newer approach seems more appropriate, and allows both individualization of advice, and gives confidence to the physician who does need to keep a young athlete out of competition.

For a graphic look at a goofy teen with mono and a flashlight see this video. Note the very white exudate on the very large tonsils. Thanks kid.

Here are 5 of the best mistakes you owe your child the opportunity to endure:

1. Forgetting their lunch. Seems really simple, but no child ever died of starvation from missing lunch at school a couple of times.  All of our lives we will need to be responsible for remembering tasks.  Forgetting to bring lunch to school is a nice simple mistake with predictable and acceptable consequences that every child can afford to make.  This counts not just for lunch. It can include homework, sporting equipment to a practice session etc.  You can fill in the blank here.
2. Spending their money and not having enough left for something they want.  Children at a young, and not-so-young age can benefit from learning to budget for the things they want.  If we simply allow ourselves to be the piggy-bank for every desire we don’t give our child the chance to learn to make financial decisions as they mature.
3. Learn to calm themself:  As an adult having the ability to calm ourselves when things are not going our way is an important skill.  As parents of infants, toddlers and youth it is tempting to quickly step in and help comfort our child when they are upset.  Sometimes this is mandatory and appropriate.  Other times giving the child the chance to help themself by thoughtful ignoring or casual observation for a bit first, and allowing them to develop self-quieting skills can be an early step in helping them to acquire this key life skill.  Nonverbal touch is a good parenting skill to learn to help with this in your young child.
4. Fail at Business:  Lots of kids want to start a business of some sort.  It may be selling lemonade, mowing lawns, delivering newspapers or collecting sports cards.  Unless the endeavor is one that your family values just cannot allow strongly consider allowing your child to try and succeed or fail on the merits of the business.  If they want to sell lemonade help them buy the ingredients, a good lesson in credit here if you loan them the money to buy the materials, and in business planning  If they price he lemonade too low, they will lose money, too high may lead to no customers.  Many great entrepreneurs have failed at early business ventures.  Why not get the first one or two under their belt before Jr. High?
5. Pay the consequences:  If you child makes a mistake, it’s important to be very selective in the times you choose to protect them from the consequence s of a mistake.  If they learn that there are natural consequences of behaviors, and that Mom or Dad is not going to bail them out from every situation they find themselves in as a result of poor choices, they learn to make good choices.  If they learn that they are immune to natural consequences because a parent rescues them consistently then they are likely to make choices as an older child or adult where we cannot escalate our interventions to the level needed to avoid more serious consequences.  If you refuse to wear mittens when you go out to play your hands get cold.  If you spend your money on candy you don’t have money to buy the comic book you want. Later in life if you don’t use condoms you get an STD or pregnancy.  Learn from the little mistakes so you choose not to make the big ones.

I also got a Tdap vaccination this year also, even though it’s 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 unimmunizd 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 immoral. 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 immuinzations.

Prenatal and Infant Exposure to Thimerosal From Vaccines and Immunoglobulins and Risk of Autism  i.e. NOT.

Data Fail to Support Thimerosal-Autism Link

The end of the autism/vaccine debate?

Book Is Rallying Resistance to the Antivaccine Crusade

 Originally published Thursday, June 17, 2010

Only YOU can develop your child’s brain!

Child centered parenting is a relatively new phenomenon, made possible by the increased security and increased leisure of contemporary life. Where once it was commonplace to send even young children out to work to contribute to the family’s support, childhood is now acknowledged as a protected space.

The change in philosophy has led to a change in the expectations about mothers. After World War II mothers, who were previously held responsible for raising healthy children with good manners, were also tasked with raising emotionally secure adults. This responsibility was seen as requiring a “child centered” approach, giving pride of place to children’s needs over mothers’ needs.

So far, so good. But in the intervening years, the purported responsibilities of mothering have grown dramatically, notably expressed as a commitment to “intensive mothering” also known as attachment parenting. Among those responsibilities is one entirely new claim, the notion that mothers are not responsible merely for physical health, acculturation and emotional security, but are also responsible for a child’s brain development. Whereas there is copious scientific evidence to support assigning the health and socialization tasks to mothers, there is little to none supporting the notion that mothers exercise substantial control over children’s brain development. No matter. An virtual industry has arisen to promote the idea that only mothers can develop a child’s brain.

Canadian sociologist Glenda Wall details the new responsibility in her paper HYPERLINK “http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBD-4YJ14B4-2&_user=10&_coverDate=06%2F30%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1370757039&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=5b94801a0d125d0dc70be71a733e1ab6″HYPERLINK “http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VBD-4YJ14B4-2&_user=10&_coverDate=06%2F30%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1370757039&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=5b94801a0d125d0dc70be71a733e1ab6″Mothers’ experiences with intensive parenting and brain development discourse.

Over the 1990s and into the current decade government agencies, non-profit foundations, and child-rearing experts undertook to educate parents and the public in general about the importance of spending ample, one-on-one quality time with children in order to stimulate brain development and future brain potential…

The claims being made in the advice literature that has resulted, while presented as fact, have been the subject of some scientific debate. Several authors suggest, among other things, that there is in fact little evidence in the field of neurology to support the claim that ‘extra enrichment’ … has any beneficial effect on future intelligence or success.

Despite scientific critiques however, the brain development advice itself borrows from the language and authority of neuroscience to frame children’s brains as technologically complex machines that need the correct inputs in order to attain maximum efficiency at a later time …

Wall explains how this new responsibility has put increased pressure on mothers.

Parents and caregivers are cast as the engineers and programmers charged with the task of making the correct inputs, and the potential consequences of neglecting to give children what they need in this regard are portrayed as dire…

In other words, there are now new ways for mothers to screw up and bring opprobrium down on themselves. Not only are mothers blamed for children’s poor manners and psychological issues, but they are now held to be at fault if their children are not intellectually superior.

Wall’s critique is insightful, not merely because she explores the lack of evidence for our new found belief that mothers are responsible for optimal brain development. Wall also casts light on the cultural assumptions that buttress this belief: the assumption that we exercise far more control over health and development than we actually do, and the assumption that parents should do more than aspire to intellectual and professional success for children, they should consciously plan for it.

In an age of intensive, and child-centered parenting, the imperative for parents to plan for, control, and manage the lives of their children to optimize their future chances … The institutional practices that have grown up around prenatal education and planning, the promises made in the marketing of educational toys, and the promotion of lessons, and various types of cultural enrichment all contribute to a cultural understanding that parents (and especially mothers) have a duty, and the ability, to control and shape the lives of their children to a very fine degree.

These assumptions have profound implications for mothers and children.

The view of childhood embedded in brain development discourse is certainly one of children as highly malleable, as parental projects full of potential, but potential that can only be activated with appropriate and intensive parental inputs. Children’s current happiness is also emphasized less in this discourse than is their future potential for success.. Rather it is desirable only in so far as it contributes to potential success, and coincides with parental behavior that promotes brain development. At the same time childhood intelligence has become elevated as an important virtue (over and above happiness) and manifestations of it are more likely to be seen as evidence of good parenting.

Hence the moralizing and hectoring that is so common among attachment parenting proponents. Everything they champion – breastfeeding, babywearing, etc. – is not merely a choice, but it is supposedly a demonstration of commitment to raising smarter, more successful children. In other words, mothering has become a competition.

The focus on intelligence in brain development discourse is linked to an implicit endorsement of competition in this regard between children and between parents. As Nadesan notes … the brain development turn in the 1990s accelerated a trend in parental desires to have children who exceed the norm intellectually…

Proponents of attachment parenting need to look carefully at the assumptions underlying their philosophy and stop the hectoring and moralizing that seem to flow from their philosophy.

AP proponents assume that they can enhance the neurodevelopment of their own children and disparage mothers who refuse to optimize the neurodevelopment of their children. Yet there is really no evidence that mothers’ choices enhance neurodevelopment and hence no basis to assume that mothers who make different choices don’t care about their child’s intelligence.

AP proponents assume that children in their role as future adults are in competition with one another and that mothers should strive to give their children competitive advantages. They also assume that parents are in competition with each other and that a child’s achievements are weapons in that competition. The parent with the smartest child wins.

Of course it takes many years to find out whose child is the smartest and no one wants to wait. Because of their implicit belief in their ability to control outcomes, AP proponents don’t bother to wait. They simply compete on the basis that their children are going to be smarter than those of women who make different choices!

Attachment parenting is a parenting philosophy, but it is also a reflection of cultural assumptions and simple human competitiveness. AP proponents believe that they are fashioning superior children and have contempt for those who make different parenting choices. They assume, imply and often flat out assert that mothers who make different choices don’t care to give their children a competitive advantage. It hasn’t occurred to them that many mothers know that AP practices don’t give children a competitive advantage and indeed reject the notion that raising children has anything to do with competition.

I urge readers to submit a guest post. I’d love to give you a forum to be heard.

Treatment of nocturnal enuresis consists begins with education.  First, and most important, is making sure the child and the parents realize that this is not something the child can stop by just trying harder.  Punishment, derision, and reward systems just don’t work well, and can diminish the self esteem of these children.  Once the child finds the bedwetting to be a big enough problem that they really want to try to treat it, attempts at treatment are appropriate.

The most effective and best treatment is use of alarm systems for most families.  It is important for physicians to warn parents away from some of the heavily advertised and grossly overpriced alarm systems they may see promoted in some places.   An AFP article has links to several good commercially available systems.  A good alarm system consists of a moisture sensor that is placed in the underwear to detect the first little bit of urination, and triggers an alarm that wakes the child so that  the child can turn off, and after going to the toilet can rearm.  The biggest cause of failure of the alarms is that they often wake everyone in the house except the child wetting the bed.   Some of the newer systems have a buzzer rather than a loud alarm that can be a better choice for some children if waking the rest of the family is a problem.  Once the child has matured to a point where the alarm wakes them, the alarm systems often work.   Success rates with alarm systems have been shown to be up to 60% in some studies.  They can be retried every few months if they are unsuccessful initially.  Often use for up to 15 weeks is needed.

Medications to treat nocturnal enuresis are also available.  The FDA approved medication is DDAVP nasal spray or oral tablets.  It is used at bedtime, and reduces the production of urine and therefore reduced bedwetting.  It is fairly effective when used, but does not work on nights not used, and is very expensive.   I find this medication most often used for special occasions, like overnight stays and summer camp. 

Some studies show that only about 1/3 of children with nocturnal enuresis are brought for medical attention.  It’s important that when they are brought in we are prepared to give solid advice and realistic expectations.

Waterbirth dangers to newly born babies

by Amy Tuteur, MD

Waterbirth has become a central component of “natural” childbirth dogma, despite the fact that for primates giving birth underwater is entirely unnatural. You don’t need a medical degree to appreciate the idiocy of birth in water.  read more

I watched as he got down eye to eye with the little girl and her Mom, and he told the child that this cough was from an invisible frog in her throat, and that to get the frog  out of her throat she and her Dad needed build a frog trap to catch it and get rid of it forever.  They needed to get a match box, and they  needed paint it green, with spots and eyes, and let it dry.  Then her Dad would hold it open in front of her mouth, she would cough really hard, and the frog would be pushed out and her Dad could catch the frog in the matchbox and close it quickly.  Then they could throw the trap away with the frog caught inside, and the cough would be gone.

I called the girl’s Mom a couple of days later, and the method worked perfectly.  I have tried this at least twice since, and it has not failed yet.  Feel free to add this to your parenting or pediatric doctor’s  bag of tricks.  It makes you look really wise and you’ll be a hero to at least one set of parents.  I’m sure this could work with a single parent, but like the one day potty training method, having Dad, who often is around less implement this gives him some good time with the child, and seems to work better.

As Girls Become Women, Sports Pay Dividends

Almost four decades after the federal education law called Title IX opened the door for girls to participate in high school and college athletics, a crucial question has remained unanswered: Do sports make a long-term difference in a woman’s life?

A large body of research shows that sports are associated with all sorts of benefits, like lower teenage pregnancy rates, better grades and higher self-esteem. But until now, no one has determined whether those improvements are a direct result of athletic participation. It may be that the type of girl who is attracted to sports already has the social, personal and physical qualities — like ambition, strength and supportive parents — that will help her succeed in life.

Now, separate studies from two economists offer some answers, providing the strongest evidence yet that team sports can result in lifelong improvements to educational, work and health prospects. At a time when the first lady, Michelle Obama, has begun a nationwide campaign to improve schoolchildren’s health, the lessons from Title IX show that school-based fitness efforts can have lasting effects.

Title IX of the Education Amendments of 1972 required schools and colleges receiving federal money to provide the same opportunities for girls as they did for boys. Relatively few students, male or female, participate in intercollegiate sports. But the effects in high school were remarkable. Just six years after the enactment of Title IX, the percentage of girls playing team sports had jumped sixfold, to 25 percent from about 4 percent.

Most research on Title IX has looked at national trends in girls’ sports. Betsey Stevenson, an economist at the Wharton School of the University of Pennsylvania, has taken it a step further, focusing on state-by-state variations.

“I looked to see what it means to add sports to girls’ lives,” she said. “How does it change things for them?”

States with large boys’ sports programs had to make bigger changes to achieve parity than states with smaller programs. Looking at the state-by-state statistics allowed Dr. Stevenson to narrow her focus, comparing differences in sports participation with differences in women’s educational and work achievement.

So her study untangles the effects of sports participation from other confounding factors — school size, climate, social and personal differences among athletes — and comes far closer to determining a cause and effect relationship between high school sports participation and achievement later in life.

Using a complex analysis, Dr. Stevenson showed that increasing girls’ sports participation had a direct effect on women’s education and employment. She found that the changes set in motion by Title IX explained about 20 percent of the increase in women’s education and about 40 percent of the rise in employment for 25-to-34-year-old women.

“It’s not just that the people who are going to do well in life play sports, but that sports help people do better in life,” she said, adding, “While I only show this for girls, it’s reasonable to believe it’s true for boys as well.”

Another question is whether Title IX has made a difference in women’s long-term health. In a carefully conducted study, Robert Kaestner, an economics professor at the University of Illinois at Chicago, compared rates of obesity and physical activity of women who had been in high school in the 1970s — as Title IX was taking effect — with similar women from earlier years. Controlling the results for other influences, like age and changing diets, Dr. Kaestner was able to tease out the effects Title IX had on women’s health.

He found that the increase in girls’ athletic participation caused by Title IX was associated with a 7 percent lower risk of obesity 20 to 25 years later, when women were in their late 30s and early 40s. His article was published this month in the journal Evaluation Review.

Dr. Kaestner notes that while a 7 percent decline in obesity is modest, no other public health program can claim similar success. And other studies have shown that even a small drop in weight can lower risk for diabetes and other health problems.

There is still room for improvement. Today about 1 in 3 high school girls play sports, compared with about half of all boys. And participation varies widely by state, according to Dr. Stevenson’s research. Southern states like Alabama, Louisiana and Tennessee still have big gender gaps, while Northern states like Maine, Minnesota, New Hampshire, Pennsylvania and Vermont are closer to parity.

“While we have more girls than ever before, we still have far more boys playing sports than girls,” said Nicole M. LaVoi, associate director of the Tucker Center for Research on Girls and Women in Sport at the University of Minnesota. “The research clearly states that when anybody, boys and girls, are physically active, they can reap developmental and health benefits. But we haven’t reached equality yet.”

Non-verbal touch is a technique where a parent catches their child doing a desired behavior, and taking care not to interrupt them gives them a gentle touch to reinforce that behavior.  If your infant is staring at a brightly colored picture on the wall, rather than interrupt them to tell them about the nice red stripe or blue star, simply gently pat them on the head.  If your three year old is working diligently to put the square peg in the square hole, rather than verbally encourage them simply gently pat their back.  If your teen is reading a book rather than comment that you are happy they are reading rather than watching TV or playing Nintendo, simply quietly touch them lovingly on the foot or shoulder.

The key to this technique is to not interrupt the behavior you want to reinforce, and to do it ridiculously often.  Experts say over 100 non-verbal reinforcing touches a day is ideal for young children.  It will take an effort at first to become natural at this parenting technique, but with practice it will become second nature.  Verbal encouragement is more effective to redirect a child to a desired behavior, or as praise after a desired behavior is completed.  Non-verbal touch is used during the desired behavior to subtly reinforce the behavior and increase the chances of it being repeated. 

Try it, you’ll like it.

Table 1
American Academy of Sleep Medicine 2006 Guidelines for Prolonging Sleep in Infants

*— American Academy of Sleep Medicine classification of evidence: level 1 = high-quality randomized studies; level 2 = lower-quality randomized studies.

Information from reference

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