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August 16, 2018
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Earlier this month I spent a week at Disney World on a family vacation. It was a very special trip. My 5-year-old niece Emma, after a brutal year of chemotherapy and stem cell transplants for her neuroblastoma, was finally cancer-free. This was Emma’s big Make-a-Wish trip and since Auntie was there at her bedside in Minneapolis for the beginning of her chemo, I was darn sure I was going to be there at the end of it.

I was the early riser of the family so every morning, before the rest of the group awoke, I’d head to the lobby in the pre-dawn. There, I’d check my email, grab a cup of coffee and talk politics with the night staff of the hotel. It was a pleasant enough routine.

One morning, in the middle of our political discussion, a fierce riot scene played out on the lobby TV, muted in the background. My debate-mate immediately launched into his views of the Occupy Wall Street movement and the 99%. But we soon learned that it wasn’t an Occupy movement at all. Rather, it was some students from Penn State protesting the firing of their beloved football coach Joe Paterno, let go for not doing enough to help the alleged sexual abuse victims of former assistant coach, Jerry Sandusky. Now all these mornings in our political deliberations, my front-desk-man and I had not seen eye-to-eye on many things: Herman Cain’s alleged sexual dalliances, Mitt Romney’s waffliness, the future of Obama-care. But on this point we were aligned: where was the moral outrage at the predatory behavior of persons in positions of trust and authority in children’s lives? Why were these students placing the importance of college athletics over the care and protection of children? Did these students really understand the facts of the case or were they merely going along for the ride?

On the last night of Emma’s Make-a-Wish trip, we were standing in line at Santa’s village so Emma could have a turn on the big man’s lap. The line was snaking slowly but surely through the aisles of an auditorium. At one point two young children started swinging from the railings which were decorated with Christmas lights. The tiny white lights shook and clinked under their weight. I watched as a pair of brothers spied the burgeoning mayhem. With a gleam in their eyes, they, too, reached for the top railing, ready to swing with their friends. Their mother, who had been deep in conversation with me, turned toward her boys ever-so-slightly. With a roll of her eyes and a dismissive wave of her hands she said in her deep Southern accent, “You just followers. You know that? You nothin’ but a pair of followers.” The two boys looked at each other. They got a very sheepish look in their eyes. Finally they let go of the decorated railing and resumed their place in line with their mom.

Maybe those Penn State students could take a lesson.

August 16, 2018
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We were having a staff luncheon yesterday: me, Dr. Moran, Jennifer and Heather. This is Heather’s last week before her maternity leave. We were having a surprise shower for her. She thought it was just one of our usual monthly staff meetings until we started putting gift bags with onesies, hats and baby blankets in front of her.

“You guys ambushed me!” Heather stammered.

Over lunch, we discussed the newest member of our practice, a newborn baby whom Dr. Moran had rounded on at the hospital that morning.

“He’s from your side of the family,” he told me. Apparently I had been the baby’s father’s pediatrician since he was a little boy.

He smiled, then corrected himself. “I mean your side of the practice.”

But he wasn’t so far off the mark. We have been doctors in this community for almost twenty years now. Children we have known since birth are now having children of their own. In another reference to family, we refer to these children as our “grand-patients.”

So today, it was my turn to round on this new baby from “my side of the family.” I introduced myself to the mother, congratulating her on her beautiful new daughter.

“So, how are we related?” I asked her, as I examined the infant in her bassinette at the mother’s bedside.

She knew exactly what I meant. She didn’t miss a beat.

“Oh, Janice is my mother-in-law,” she told me.

There was no need for last names. I knew exactly who she meant. After all, we’re family.

Carolyn Roy-Bornstein MD

August 16, 2018
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We’ve never met. You just had a baby named Angelese with my cousin’s son George. I guess that makes us family. You had your baby at home. I am glad things went well for you with no complications. She’s beautiful. I’ve seen pictures of her on my cousin Christina’s FB page. Christina says you’re going all-organic as far as the baby goes. That’s the way to go. She doesn’t need all those antibiotics and hormones in commercial meat and milk. She also says you’re not planning on vaccinating your baby. Ever. Against anything.  No vaccines.

And that’s where we have a problem. Or at least I have a problem. You see, I’m a pediatrician. I vaccinate for a living. I’ve been around a while and have seen children die of diseases that have largely been eradicated due to vaccines. Vaccines I believe in.

The truth is Angelese will probably be just fine. She is afforded a certain amount of protection—called herd immunity—because most parents do vaccinate their children. That may not always be true. In fact if enough parents en masse refuse all vaccinations, herd immunity will evaporate and we will all be at risk, not just Angelese.

And that’s the thing. You have only your daughter to take care of. I have to keep all the other children in mind. If Angelese gets chicken pox, besides a few pox scars, she will likely do just fine. She’s strong with a healthy immune system. She can fight viruses just fine. But some children are not strong or fine and do not have healthy immune systems. My niece Emma just underwent chemotherapy and a stem cell transplant for neuroblastoma. For her, varicella could be deadly. Those are the children I need to think about. For me, there is also this is the ethical reason to vaccinate.

In my community there are some pediatricians who won’t accept you into the practice if you don’t go along with the immunization schedule as recommended by the American Academy of Pediatrics. In my practice, you’re welcome. (In fact, one solo practitioner’s, to me, over-the-top response is to threaten you with a call to DCF. He believes with-holding vaccines from your child amounts to child abuse.) I don’t believe that. I do believe deep in my heart, that all parents loves their children and no matter what decision they make, they are making the decision that they truly believe is in the best interest of their kids. I don’t believe in cutting those parents off from health care just because they disagree with me. But I do believe it’s my job to continue to defend and recommend vaccines.

We have parents in our practice who, for whatever reason, want to space out their children’s vaccinations, give just one at a time, delay some and defer others altogether. I take care of all of them.

When pregnant women come to the office to interview me as a possible pediatrician for their babies, the most frequently asked questions involve the vaccine schedule. I make it clear that they should not interpret my willingness to give them their shots on an alternative schedule to mean that I agree with them that it isn’t safe to give three shots at once. I don’t agree with them. And it is. One of the most compelling pieces of evidence for this was a June 2010 study in the medical journal Pediatrics that found no adverse neuropsychological outcomes in children who received on-time vaccines in their first year of life. These parents also need to understand that their children are at risk for whatever disease they’ve not vaccinated them against for as long as they’ve put off that vaccine. I also tell them up front that I’ll be hawking them at every visit to pony up and get vaccinated. I even email my patients news stories about disease outbreaks and clinical studies on vaccine safety and efficacy.

It was easier to convince parents about the efficacy of vaccination when their biggest worry was autism. The relationships between the MMR vaccine, thimerisol and autism have been roundly debunked for some time now. Parents’ concerns nowadays seem more to have to do with the necessity of vaccines at all. The vaccine program is in some ways a victim of its own success. Parents who have never seen encephalitis from measles, amputations after meningococcal infection or a seizure during a case of pertussis may not fully appreciate how aggressive some vaccine-preventable diseases can be.

No decision is easy when it comes to our children. There is always something to worry about. (My 28-year-old son announced recently that he is taking up sky-diving. Believe me. There will always be things to worry about.) You’d feel terrible if something happened to Angelese because you vaccinated her. You’d never forgive yourself if something happened because you didn’t. As parents, we all just do the best we can with the information we have. I hope you’ll consider listening to the information regarding vaccines.

Dr. Roy-Bornstein

August 16, 2018
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There’s always something to worry about as a parent. It begins the
moment we discover we’re pregnant. We start worrying about everything we put
into our bodies and how it will affect our unborn children. From that point on,
every developmental stage of childhood comes with a worry (or two, or three.)
Crib death looms in infancy. Drowning hovers over toddlerhood. Abduction fears
mark the school-age years. The teens usher in fears of drugs, drinking and
driving. Having children makes the world more joy-filled and more fear-filled
at the same time.

But it doesn’t end there. I wish I could tell you that once they’re out
of the house, college graduates, young adults with stable jobs and apartments
of their own, that everything’s fine and the worrying can end. It doesn’t. My
oldest just announced he’s taking up hang-gliding. See? It’s always something.
Just this morning as I cleaned lint from my clothes-dryer I wondered if I had
taught my boys to do this. And there it is: another worry. Dryer fires.
Nine years ago, my youngest son, then a teenager, was hit by a drunk
hit-and-run driver while walking his girlfriend home after a study date. She
did not survive her injuries. He carries his with him to this day in the form
of a traumatic brain injury. We helped our son during those early days in
intensive care, then through months of physical therapy. He took
anti-depressants for years and sees a therapist still. He worked hard at his recovery
and made impressive gains. He is currently in a graduate program for math
education in a nearby state.

But there’s always something to worry about. My husband and I mine our
conversations with our son for signs of depression or anxiety, residuals from
the accident. He recently told me that he went to the school’s Disabilities
Office seeking extra test-taking time and a distraction-free testing
environment. I immediately worried that he was overwhelmed and struggling. But
he assured me he was just trying to utilize available services and avoid a
stressful end to the semester.

And what more can a parent ask for? Seeing our children independent,
following their dreams, seeking the help they need to get there. It’s what
we’ve prepared them for since the day they were born. I guess I just thought
the days of worrying would someday come to an end. But as far as I can see,
worrying and parenting go hand-in-hand. Forever.

In a previous Pediatric Points column I wrote a few years ago, I made
the case for offering the (then new) HPV Vaccine against Human Papilloma Virus (HPV) to girls. HPV is the most common sexually transmitted infection. Within two years of first having sex, nearly 40% of young women are infected with one or more types of these viruses. Younger women are more susceptible to infection with HPV for several reasons including a lack of adequate cervical mucus production and incomplete immune systems.

The good news is that they will very often clear these viruses on their own. But for those young women in whom infection persists, the risks of eventually developing cervical cancer increases. Cervical cancer is the second leading cause of cancer deaths among women worldwide. Over 1/4 of a million women die from this disease each year. 70% of all cases of these cancers are caused by two especially high risk types of HPV numbered 16 and 18.  Gardasil is the name of the shot that protects against these two HPV types as well as against types 6 and 11 which are responsible for 90% of genital warts. These kinds of warts affect both men and women. The Food and Drug Administration approved HPV vaccine for boys in 2009. The Advisory Committee on Immunization Practices voted in October 2011 to
recommend the routine vaccination of boys between the ages of 11 and 21.

Although women are affected in larger numbers by HPV-related cancer (approximately 15,000 HPV 16- and 18-associated cancers each year) men are also affected by this sexually-transmitted virus. Approximately 7,000 cases of HPV-associated cancers, including anal, penile and oropharyngeal, occur each year in men. The HPV vaccine has been found to be very effective in males. In studies of men not previously infected who received all three shots, efficacy for prevention of HPV-related genital warts approached 90%. HPV vaccine for girls, in my opinion, is essentially a vaccine against cancer and I recommend it whole-heartedly to my patients. If I had girls of my own, I would vaccinate them in a heartbeat. But currently fewer than 50% of girls have completed the three-dose series.

Many pediatricians I have spoken to are reluctant to tackle this new recommendation for boys when we haven’t yet been successful with the population many of us feel would benefit enormously from vaccination. Some of us are skeptical that the vaccine for boys is truly cost-effective. Some also point to the Australian experience where mandatory vaccination of girls led to a decrease in genital warts in both men and women, suggesting successful herd immunity.

Also, we pediatricians are spending increasingly more of our time
defending proven, effective, life-saving vaccines to nay-sayers, reluctant
parents, and media pressure. To quote Dr. Stacey Humphries from a recent issue
of Consultant for Pediatricians, “To add controversial vaccination of boys to the mix with limited data available may only further taint vaccine acceptance.” So for now, while Dr. Moran and I will certainly give the HPV vaccine to any boy whose family requests it, for now, we’re now going to be pushing this one.

Dr. Roy-Bornstein

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