Where did this virus come from?

The virus seems to have originated from birds (pigeons and/or poultry) in Shanghai.  So far, there are 18 known cases of human infection in China. All of these human infections took place in or around Shanghai. Experts do not think that humans are spreading this flu to other humans.  Rather, it is more likely spreading via animal-to-human transmission.

Why is this being depicted as a “big deal” in the media?

Scientists and health organizations have expressed concern about this new virus because it appears to be quite deadly.  Of the 18 humans who have thus far contracted the disease, 6 have died and 4 are in critical condition.  Until we develop a better understanding about what’s going on, there will be an understandable level of concern and caution.

How concerned should people be?

For those living in or travelling to/from China, especially Shanghai and surrounding areas, it is important to take careful precautions to avoid contracting the illness.  See the Center for Disease Control’s recommendations here.

For all others (i.e. not travelling to or living in/near China), there is little, if any, precaution to take at this stage.  Since humans do not appear to be spreading this to other humans, the likelihood of a global outbreak is low.  WHO advised, on April 4th, 2013: “At this time there is no evidence of ongoing human-to-human transmission. WHO does not advise special screening at points of entry with regard to this event, nor does it recommend that any travel or trade restrictions be applied.”

Is there a vaccine for H7N9 influenza A virus? 

These are the first reports of this virus ever infecting humans, so there is not yet a vaccine available.  The vaccine development process, from virus identification to mass production, takes at least 6 months. So, if vaccination becomes advisable, it will not be until the end of the year that an immunization targeting this virus will be available for use.

What precautions are being taken at Kindercare Pediatrics?

At this time, we do not feel that our patients and families (assuming that they are not travelling to or from China) are at significant risk of catching H7N9 Influenza A. Patients and families should feel safe coming to clinic for well-baby care and sick visits.

On the other hand, if anyone (whether our patients/families or otherwise) has flu-like-symptoms AND recently traveled to China, it is important to go immediately to your local emergency department. The sooner the illness is identified and treated, the higher the chance of recovery/survival.

We will keep you updated with key information as this situation evolves.

Any questions or comments are welcome below.

The post Information about the new (H7N9) influenza A virus in China appeared first on Kindercare Pediatrics.

Carolyne’s message really resonates with me both as a father and a pediatrician. I would like to spread as widely as possibly this empathic, constructive, respectful and child-honouring approach to supporting parents and children through this very difficult time:

Dear School Families,

We have all been greatly saddened by the events in Newtown, Connecticut. Our hearts go out to the families and our sadness is expanded by having yet again, to write an email to you about how to talk with children about such awful events.

Our students are young and it is our hope that they have been protected against the news of these terrible events, however, we realize that some of our students have older siblings and as a result may have some knowledge about the shootings. Below you will find some suggestions to help guide you if you feel the need to talk with your child.

1. Young children have little understanding of geography. If they have heard about the tragedy in Connecticut they may not understand that it is NOT in their neighbourhood. Let them know they are safe. Let them know It is all of our jobs to help to keep them safe.

2. Children 3 to 6 years have wonderful ‘magical thinking’ and have a different perception about death. They can believe it is reversible, and have difficulty verbalizing what they are feeling. We need to make our children feel secure, providing routine, a sense of calm and reinforce a sense of normalcy.

3. In school, if children mention the events, our plan is to acknowledge their comments and respond, in a very matter of fact way (the purpose is to allow our children to feel confident and secure at school) – “yes, sometimes terrible things happen but we are so lucky to be here where we are safe and can have fun with our friends’.

Below are some links that might help you if you or your child feels the need to discuss the terrible events.

Links to Alyson Schafer
http://alysonschafer.com/2012/12/how-to-talk-to-your-children-about-the-newtown-conn-school-shootings/

http://alysonschafer.com/2012/06/talking-to-your-children-about-traumatic-events/

How Not to Talk With Children About the Sandy Hook Shooting
http://parenting.blogs.nytimes.com/2012/12/15/how-not-to-talk-with-children-about-the-sandy-hook-shooting/?hp

I will be greeting at the door tomorrow. Please let me know if your child is aware of the events in Newtown and if you have any concerns. And please, hug your children close today,

Sincerely,

Carolyne

The post Sheltering Preschoolers from the Wake of Newtown’s Tragedy appeared first on Kindercare Pediatrics.

My Thoughts on Doctors Dismissing Vaccine-Refusing Patients/Parents

Earlier this spring, the Toronto Star published a piece about a local pediatrician who dismisses from her practice any patients whose parents refuse to immunize their child(ren).  (See this Interesting editorial published in response). This has also been an issue in the United States for a number of years.

I have been stewing over this for months and finally, this Father’s Day, have mustered up the guts to express some of my associated thoughts.  These views are neither comprehensive nor fully distilled, but I hope that sharing them here will get us all thinking about productive ways to solve the deeply concerning decade-long problem of falling vaccination rates.

1. I find that just like parents who readily vaccinate their children, the vast majority of ‘vaccine-refusers’ are loving and caring parents who sincerely want what is best for their kids.  I don’t agree with their position on vaccines, but I do not doubt their love for and commitment to their children.  It is for this very reason that I can’t see eye-to-eye with doctors who dismiss these families from their practice.
2. If parents want what’s best for their kids, and given that vaccinations are so important for the wellbeing of children and the community, then it follows that parents would choose to vaccinate their children if they were armed with the appropriate information. I see it as my job to facilitate parents obtaining this legitimate information.
3. More and more, patients expect their physicians to earn their respect and trust.  We no longer live in times when doctors are considered all-knowing and fully trustworthy simply because they have an MD after their names.  I can understand a family choosing to hold off on a doctor’s recommendation in the spirit of first building a trusting and therapeutic relationship.  This can take weeks, months, or even years.  But, more often than not, once this relationship is healthily established, parents tend to reconsider their contrary views.
4. The mandate of a physician goes far beyond giving vaccines.  Just because a given parent is ‘anti-vaccine’ does not mean that her views will be diametrically opposed to her physician’s on all other health matters. A parent’s poor (or uninformed) choice should not dis-entitle her child to the right to health care.
5. We physicians and scientists have a big PR Problem. It is gravely concerning that for many families today (up to 25%!!), when it comes to the science of immunizations, Jenny McCarthy seems to have more credibility than medical scientists, international health organizations and history books rich with countless examples of the great health achievement that has been immunizations.
6. Click here for a summary of vaccine-preventable illnesses that have occurred in the US over the past 5 years.
   Click here for a summary of vaccine-preventable deaths that have occurred in the US over the past 5 years.
   Click here for a curated list of sources that refute claims that Autism is associated with the administration of childhood vaccination
   *Please note – I do not think it is fair to Ms. McCarthy that this website implicates her, directly or indirectly, as responsible for all of this mortality and morbidity.  Nonetheless, the information shared on the site is compelling, credible and effectively presented.  

Do feel free to share your thoughts experiences and opinions below.

The post My Thoughts on Doctors Dismissing Vaccine-Refusing Patients/Parents appeared first on Kindercare Pediatrics.

—

I am writing on behalf of the authors and endorsers of the attached paper entitled ‘A Consensus Statement on the Use of Domperidone To Support Lactation’. The statement can also be found online at http://kindercarepediatrics.ca/wp-content/uploads/Domperidone-Consensus-Statement-Final-May-11-2012.pdf
We are 22 Health Professionals – Physicians, Lactation Consultants, Nurses, Researchers, Epidemiologist – with specialized expertise in supporting breastfeeding mothers and babies. We have concerns about the advisory statement regarding domperidone which you endorsed – http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/advisories-avis/prof/2012/domperidone_hpc-cps-eng.pdf. Across Canada, this advisory may be interfering with our mandate to support breastfeeding.

For over 20 years, Canadian physicians have prescribed domperidone as a galactagogue to support milk production in mothers struggling to breastfeed. Since the advisory’s release, physicians have expressed significant fear of prescribing the medication.  When prescribed, pharmacists have been reticent to fill the prescriptions.  There is a risk that this advisory will adversely impact Canada’s breastfeeding rates.  Please review the attached consensus statement which reflects our efforts to meaningfully address this concerning situation.

In submitting this consensus statement, we would like to achieve the following 3 goals:

1) Critically evaluate the papers to which the advisory statement refers.
2) Promote and encourage high quality scientific research to better understand the safety and efficacy of domperidone when used to support breastfeeding.
3) Define a national standard of care for the use of domperidone as a galactagogue.

It is our hope that after reading this document you will consider revising the advisory.  More specifically, please consider addressing the risks, or lack thereof, associated with domperidone when used solely to support lactation.

Yours sincerely,

Daniel Flanders, MD FRCPC.

On behalf of:

Dr. Yoel Abels, MD MHSc CCFP FCFP. Department of Family and Community
Medicine, University of Toronto. Medical Director, Forest Hill Family
Health Centre. Toronto, ON.

Dr. Elizabeth Asztalos, MD MSc FRCPC. Director, Neonatal Follow-up
Programme, Division of Neonatology, University of Toronto. Director,
The Centre for Mother, Infant, and Child Research, Sunnybrook Research
Institute, Sunnybrook Health Sciences Centre. EMPOWER investigator.
Toronto, ON.

Marsha Campbell Yeo, PhD NNP-BC. Maternal and Newborn Program , IWK
Health Centre. EMPOWER investigator. Halifax, NS.

Lenore Goldfarb, PhD CCC IBCLC. Herzl Family Practice Centre –
Goldfarb Breastfeeding Clinic, Jewish General Hospital. Montreal, PQ.

Dr. Michael Kramer, MD. Professor, Departments of Pediatrics, and of
Epidemiology, Biostatistics and Occupational Health. McGill
University, Faculty of Medicine, Montreal, PQ.

Dr. Orlando da Silva, MD MSc FRCPC. Associate Professor, Department of
Paediatrics, Division of Neonatal-Perinatal Medicine. Children’s
Hospital, London Health Sciences Centre. London, ON.

Dr. Hilary de Veber, MD FRCPC. Newman Breastfeeding Clinic, Toronto, ON.

Carole Dobrich, RN IBCLC. Herzl Family Practice Centre – Goldfarb
Breastfeeding Clinic, Jewish General Hospital. Montreal, PQ.

Dr. Daniel Flanders, MD FRCPC. Lecturer, Department of Pediatrics,
University of Toronto, Faculty of Medicine. Newman Breastfeeding
Clinic. Toronto, ON.

Edith Kernerman, IBCLC. Co-Director, Newman Breastfeeding Clinic. Toronto, ON.

Lynda Kirby, IBCLC. Better Breastfeeding Clinic, Toronto, ON.

Dr Cathryn Kuzyk, MD. Foothills Breastfeeding Clinic, Calgary, AB.

Dr. Aviva Lowe, MD FRCPC. Newman Breastfeeding Clinic. Toronto, ON.

Dr. Howard Mitnick, MDCM. Faculty Lecturer, Department of Family
Medicine, McGill University. Herzl Family Practice Centre – Goldfarb
Breastfeeding Clinic, Jewish General Hospital. Montreal, PQ.

Dr. Jack Newman, MD FRCPC. Assistant Professor, Department of
Pediatrics, Faculty of Medicine, University of Toronto. Co-Director,
Newman Breastfeeding Clinic. Toronto, ON.

Dr Graham Pratt, MD. Herzl Family Practice Centre – Goldfarb
Breastfeeding Clinic, Jewish General Hospital. Montreal, PQ.

Dr. Leah Roth, MD FRCPC. Better Breastfeeding Clinic. Toronto, ON.

Dr Mary-Jo Woolgar, MD CCFP IBCLC FCFP. Foothills Breastfeeding
Clinic. Calgary, AB.

Dr Anjana Srinivasan, MDCM CCFP IBCLC. Faculty Lecturer, Department of
Family Medicine, McGill University. Medical Co-Director, Goldfarb
Breastfeeding Clinic – Herzl Family Practice Centre, Jewish General
Hospital. Montreal, PQ.

Dr Meira Stern, MD. Medical Co-Director, Goldfarb Breastfeeding Clinic
– Herzl Family Practice Centre, Jewish General Hospital. Montreal, PQ.

Dr. Eitan Weinberg, MD FRCPC. Newman Breastfeeding Clinic. Toronto, ON.

Dr. Jean Zigby, MD. Herzl Family Practice Centre – Goldfarb
Breastfeeding Clinic, Jewish General Hospital. Montreal, PQ.

The post A Response to Health Canada Regarding the March 2nd Domperidone Advisory appeared first on Kindercare Pediatrics.

• If patients are Elderly
• When taken with other drugs, such as ketoconazole
• If patients have heart disease
• If patients have low potassium and/or magnesium
• If the domperidone dosage is higher than 30 mg per day

Though not considered or discussed in this document, this advisory may undermine success for mother-baby dyads struggling to successfully breastfeed. The use of domperidone for breastfeeding problems is common practice among lactation physicians across Canada. The drug increases mother’s levels of prolactin, a hormone that promotes lactation. Without the availability of this medication, I suspect that a significant number of mothers will fall short of achieving their breastfeeding goals.

I very commonly prescribe domperidone to lactating mothers who have low breastmilk supply and/or flow. The starting dose is 90 mg per day and I sometimes bump up the dose to as high as 120 to 160 mg per day – 5x the maximum recommended dose in the advisory! In fact this prescribing practice is standard of care among Canadian lactation specialists – with some variation from clinic to clinic. Interestingly, in the decades that domperidone has been used at these higher doses for lactation support, Canada Health has not received any adverse reaction reports of serious heart-related problems “in relation to the use of domperidone used to stimulate milk production in breastfeeding women.” 

The big question, now, is what are breastfeeding mothers on domperidone to do in light of this advisory. And what about the healthcare providers who prescribe/dispense domperidone on a daily basis? Doctors have already started calling breastfeeding patients on domperidone to strongly recommend discontinuing the medication immediately. Pharmacists are doing the same. I suspect that this type of intervention will not ‘save’ any lives, but will disrupt breastfeeding for thousands of current and future mother-baby dyads. Since not breastfeeding is associated with health-risks for baby and mother, there is significant morbidity and mortality that is likely to arise as a consequence. I propose a more sensible and prudent approach:

1. Mothers on domperidone who are experiencing heart palpitations, dizziness, fainting, or seizures should stop taking the medication and get medical help immediately.
2. Mothers who are well established on domperidone and without any of the above symptoms should contact a healthcare provider familiar with lactation medicine for further guidance. Some good resources include
   a. The Newman Breastfeeding Clinic and Institute 
   b. Better Breastfeeding Clinic 
   c. The Goldfarb Breastfeeding Clinic
   
3.  Healthcare providers who practice lactation medicine should get together and critically review the literature pertaining to the use, efficacy, and risks of domperidone specifically in breastfeeding mothers. This process has been initiated.
4. After the above review, a position statement should be published giving expert-opinion-driven guidelines that can serve as a reliable reference for healthcare practitioners who wish to support lactation with this medication.

I will periodically update this post with new information as it arises. Do feel free to comment below.

Addenda:

2012/05/11 – A consensus statement, composed/endorsed by 22 breastfeeding across Canada

see A Consensus Statement on the Use of Domperidone To Support Lactation

2012/05/11 – A Response to Health Canada Regarding the March 2nd Domperidone Advisory 

see Letter to Health Canada

2012/03/15 – A critical review of the scientific papers upon which the advisory’s authors based their recommendations.  

See Domperidone study limitations

2012/03/10 – Comments from Dr. Howard Mitnick, Goldbarg Breastfeeding Clinic:

This is an important public health issue. The health risks associated with early discontinuation of breastfeeding in Canada is very well established and very large. Correspondingly, the data for moms taking domperidone demonstrates that the actual cardiac risk to Canadian mothers is theoretical at best.

2012/03/10 – Comments from Dr. Jack Newman, Newman Breastfeeding Clinic and Institute
Based on a study that was published in Belgium which looked at over 1000 cases of sudden death and found that some of the people who died suddenly were taking domperidone, Health Canada has put out a warning about possible concerns about treating with domperidone. This is a bit of an overreaction on the part of Health Canada. Well, a big overreaction given the data.

Note that in the study, the youngest person who died was 55 and the average age of those who died was 75 years. What has this to do with breastfeeding mothers who are rarely older than 45 years and are usually in reasonably
good health? Furthermore, this information came from a data base with no clinical information. It simply has information that so and so died  suddenly and was taking such and such a drug. The thing is that domperidone in these patients was used for reflux and we know that heart disease is frequently misdiagnosed as reflux; severe pain at the top of the abdomen or lower part of the chest is typical of both reflux and cardiac pain.
Misdiagnosis is particularly possible in Europe where domperidone is available in countries like the United Kingdom, Belgium and the Netherlands without a prescription and it is likely that many people are self-diagnosing
and self-medicating.

So that’s it and it does not mean that domperidone kills. I will continue to prescribe domperidone at our doses which are based on many years of clinical experience. I have treated many thousands of women with it with only minor side effects. I believe this article from Belgium proves nothing and does not require us to stop prescribing it.

It would be a pity that mothers and babies not benefit from domperidone when used in conjunction with our Protocol to manage breastmilk intake.

If you live in Toronto and would like nutrition support for your child, feel free to learn more about the Kindercare Pediatric’s clinical nutrition programs.

The post The (Not So) Great Canadian Domperidone Debacle appeared first on Kindercare Pediatrics.

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1. Rotavirus Vaccine

Rotavirus infections cause severe diarrhea, vomiting and dehydration in infants and children. In Canada, seven per cent of children who acquire rotavirus disease require hospitalization.  The vaccine, given to infants at 2 and 4 months of age, dramatically reduces the chance of acquiring this disease (or more specifically, the severe forms of this disease). Rotavirus vaccine has been used in the United States for the past 5 years during which hospitalizations due to rotavirus-associated illness dropped dramatically (by as much as 96%).  It has been extensively tested and demonstrated to be safe and effective.  As of August 2011, rotavirus vaccine will be offered (and fully subsidized) to all Ontario infants less than 6 months of age as part of the routine childhood immunization program.

2. Varicella (Chickenpox) Vaccine

An interesting study was conducted by the Centers for Disease Control and Prevention and published this week in the peer-reviewed journal Pediatrics. The study reviewed mortality data in the United States over the first 17 years since the chickenpox vaccine was introduced.  The results showed that deaths associated with chickenpox infections declined by over 97% during that period of time.  This suggests that 90 lives are saved per year in the United States as a result of this vaccine.  Recent studies have also demonstrated that only 85% of people immunized with the varicella vaccine actually achieve long-term immunity. With a booster this number is expected to increase significantly.  The vaccine has been extensively tested and demonstrated to be safe and effective.  As of August 2011, a varicella vaccine booster will be offered (and fully subsidized) to children in Ontario as part of the routine childhood immunization program.

Ontario Public Health’s updated childhood immunization schedule now look like this:

2 Months of Age: DPTPH, PC13, Rota
4 Months of Age: DPTPH, PC13, Rota
6 Months of Age: DPTPH
12 Months of Age: MMR, MC, PC13
15 Months of Age: Var
18 Months of Age: DPTPH
4 Years of Age: MMRV, DPTP

Legend:
DPTPH = Vaccine against Diptheria, Pertussis, Tetanus, Polio,  H-flu type B Vaccine
PC13 = Vaccine against Pneumococcus – 13 strains
Rota =  Vaccine against Rotavirus
MMR = Vaccine against Measles, Mumps, and Rubella
MC = Vaccine against Meningococcus
Var = Vaccine against Chickenpox (Varicella)
MMRV = Vaccine against Measles, Mumps, Rubella, and Varicella
DPTP = Vaccine against Diptheria, Pertussis, Tetanus, Polio

The post New Changes to Ontario’s Childhood Immunization Program appeared first on Kindercare Pediatrics.

In all likelihood, the medical research published thus far is only unveiling the tip of the iceberg in terms of how media is adversely affecting the physical,psychological, and emotional well-being of our children and adolescents. In the AAP publication AAP News highlights, Victor Strasburger, MD, FAAP, is quoted as saying “We’ve created a perfect storm for childhood obesity – media, advertising, and inactivity. American society couldn’t do a worse job at the moment of keeping children fit and healthy – too much TV, too many food ads, not enough exercise, and not enough sleep.”

The new policy statement focuses on getting pediatricians to advocate more strongly for limiting this powerful reach and negative impact of kids’ media. Below is a summary of the policy statement’s recommendations:

• Encourage parents to discuss food advertising with their children as they monitor children’s TV viewing and teach them about good nutrition.
• Continue to counsel parents to limit total, non-educational screen time to no more than two hours per day, and avoid putting TV sets and Internet connections in children’s bedrooms.
• Work with community groups and schools to implement media education programs in classrooms, child care centers and community centers.
• Be aware that children with high levels of screen time also have more stress, putting them at risk not only for obesity but for a number of other conditions such as diabetes, mood disorders and asthma.

The statement also advises that pediatricians and primary care providers advocate on local, state, and national levels for:

• a ban on junk food advertising
• restrictions on interactive food advertising to children via digital media
• funding for research into the health and psychosocial effects of heavy media use in children
• more prosocial media platforms and resources for children that encourage them to choose healthy foods

It will be interesting to see, over time, whether these recommendations translate into some meaningful success in the fight against the worldwide obesity crisis.

Do you think that kids’ media is as sinister as the AAP is making it out to be or is their position right on the mark? Should there be more focus on encouraging parents and/or the children themselves to take more responsibility for their individual health and lifestyle circumstances? Please share your thoughts as comments below.

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