Earlier this year there was a massive Tylenol recall. The recall included Infant Tylenol drops, Children’s Tylenol, as well as many other children’s medications. I’m not exaggerating when I say massive, but generic medications (liquid acetaminophen made by Walgreens or CVS, for example) were not included. The recall was a great reminder that generics are just as good as brand-name medications.

The recall also serves as a great reminder that giving medications to children is never risk-free. Recalls like this remind us to use medications only when absolutely necessary. There is always risk when you intervene.

Tylenol (acetaminophen) is a great medication. It has a place in our medicine cabinets and in keeping children comfortable in the face of fever or pain. Teething, viral infections, ear infections, and minor injuries are great times to use Tylenol. But prior to shots is not. Or afterward, as it turns out. After shots, Tylenol will help prevent fever, but may also prevent the desired immune response. There is new data to support this that has changed the way I think and counsel families about Tylenol. Now when parents ask, I say,”If it were my child, no Tylenol before shots.”

Fever is a “normal” immune response to a trigger (medical school and residency taught me this). But being a mom has certainly shown me that fevers in my babies don’t feel “normal.” When we pediatricians say it’s “normal,”we neglect to connect with the experience of parenting a feverish child. I understand why so many parents reach for the Tylenol. I did; after F’s 2 month shots, he developed a low-grade fever and cried his little face off. I gave him Tylenol twice that night. I wouldn’t have, had I known this:

Fever is a part of the body’s natural inflammatory response to infectious triggers (viruses or bacteria). And to shots. Scientifically speaking, post-shot fevers demonstrate the immunization given is working!

So what if giving Tylenol (a fever-reducer) reduces the immune system’s response? Some Czech Republic doctors wanted to find out.

They published their findings in The Lancet. They wanted to evaluate a baby’s immune response after the standard 2 month-old immunizations. Researchers sorted babies into two groups, one in which the babies received the 2 month shots, and another in which the babies received the 2 month shots and then received Tylenol every 6-8 hours afterward for 24 hours. They looked at the outcomes of fever in both groups and observed the desired immune response (blood tests) in all babies. Since shots are given to trigger the immune system to remember a particular insult, if the baby’s immune system doesn’t respond and develop antibodies to the vaccine, the shot isn’t as effective. They wanted to know if Tylenol dulled the effect of the shots.

The Study Results:

High fever over 39.5ºC (103ºF) was uncommon in both groups (≤1% of all infants).

Low-grade fever around 38 ºC (100 ºF) was very common (in 42% of infants receiving Tylenol, and in 66% of kids without Tylenol).

Babies who received Tylenol had a reduced immune response. The study found antibody concentrations were significantly lower in babies who received the Tylenol compared with those who didn’t. This was true to all vaccine types tested. Even after booster shots later on (at 4 and 6 months, for example), the lower antibody concentrations existed in the group that originally got the Tylenol for 3 different vaccines.

Powerful stuff. The fact is, fever is a common and expected response after immunizations and shots. Tylenol will help prevent fever in some, but may also prevent the desired immune response. This study found that around 1/2 of all 2 month-old infants (42-66%) had temperature elevation in the first 24 hours. Most babies tolerate temperature elevation without complaint. Others may be sleepy, cranky, or decrease their feeding. Although Tylenol will reduce the likelihood that your infant has a mild temperature, this reduction in inflammation may reduce the effectiveness of the shot.

Mama Doc Tips: How To use Tylenol After Shots:

Never give Tylenol before shots. You may decrease your baby’s (or child’s) immune response to the shot for no reason. It’s okay for your baby to have a fever. It’s a safe and normal response to immunization.

Think about using Tylenol only when necessary. If your baby seems remarkably fussy, uncomfortable or has a high fever (over 103ºF) after shots, consider using Tylenol. If your baby or child has a low-grade temperature (100-101 ºF) after shots, avoid using Tylenol as it may interfere with the immune response.

Fever is “normal” but unsettling. Talk with your child’s pediatrician about ways to support your child when they have a fever.

Related concepts:

SIDS

Introduction to SIDS:

Everything dear to us causes pain. Becoming a parent opens up new landscapes within us: new hopes, fears, delights, and sorrows. There is no magic moment when you will stop worrying. Sometimes, even when we do everything right, babies die. The fragility and unpredictability of life underscore how precious each life is.

What is SIDS?

SIDS, or Sudden Infant Death Syndrome, is defined as the sudden, unexpected, and unexplained death of any infant or young child.
According to the CDC, SIDS is the leading cause of death among babies from 1 to 12 months of age. It is the third leading cause of overall infant mortality in the United States.

Who gets SIDS?

The peak period for SIDS is between two and four months old. It is very rare before one month of age, and at least 95 percent of all the cases have occurred before children reach six months old.
SIDS is rare in babies who sleep face up in a crib or who sleep face up with a mother not using alcohol, drugs, or cigarettes (and not on a waterbed or soft sofa).
SIDS is more common in babies who sleep in warm environments, who are over-bundled, who sleep in rooms with space heaters, who are exposed to cigarette smoke, who sleep on soft surfaces, who do not use pacifiers, and those who sleep face down or in a prone position. The rate of SIDS is also higher in those babies who do not receive timely well-child care and immunizations.
Events that occur even before the baby is born affect the risk of SIDS. Anything that causes less oxygen to get to the baby in the uterus will increase his or her risk. On average, smoking during pregnancy doubles the chances, and the odds increase with each cigarette. Other drugs of abuse such as cocaine or heroine increase the risk by as many as thirty times.
Genetics also plays a large role. SIDS is more common in boys than in girls, and it is more common in some population groups (Black, Native American, Hawaiian, Filipino, Maori). Affected infants may have been born with immature brainstems, making it difficult for them to wake up when they are in trouble.
In one study of 35,000 healthy babies in Italy, the babies had EKGs performed in the first week of life. They were then followed for a year. Most of those who ended up dying of SIDS had an abnormality on their original EKGs (a prolonged QTc interval). Those with this abnormality were more than 40 times more likely than their peers to die from SIDS. These findings hold promise for future screening and prevention.
While parents often feel horribly responsible after SIDS, sometimes there is nothing they could have done to prevent it. There are many factors outside of our control.

What are the symptoms of SIDS?

The child’s death is the first symptom of SIDS. The great majority of the children who are discovered dead from SIDS are found face down.

Is SIDS contagious?

SIDS is not believed to be contagious. But doctors first scoffed at the now-accepted idea that ulcers were often caused — not by excess acids — but by infections with the bacteria called Helicobacter pylori. One study suggests that infection with this same bacteria may also be responsible for many cases of sudden infant death syndrome. An article published in the Archives of Disease in Childhood reported evidence of Helicobacter pylori in 88 percent of examined children who had died from SIDS. The bacteria is found in about 2 percent of the general population. This cause is not generally accepted, but it underlines the fact that there is still much to learn about SIDS.

How long does SIDS last?

SIDS is a permanent tragedy.

How is SIDS diagnosed?

By autopsy, and by ruling out other causes of death.

How is SIDS treated?

What a horror for any parent! When surveyed about what they would have appreciated in those chilling moments after the death, SIDS parents responded with several concrete requests they were often too stunned to make at the time:

• To hold their baby one last time
• To have the clothing returned to them
• To have a print or mold of their baby’s hand
• To have a lock of hair

These poignant requests underline the tragedy of SIDS.

How can SIDS be prevented?

Putting children to sleep on their backs lowers the risk of SIDS by about three times. Use firm bedding in a slightly cool room. Avoid cigarette smoke, and even anything that smells like cigarette smoke. Take your baby in for regular well-child visits and immunizations. Breastfeeding may also reduce the risk of SIDS, but the studies remain inconclusive.
The media often focus on “crack babies,” but tobacco use continues in approximately 25% percent of all pregnancies in the United States. Nicotine exposure is responsible for many more SIDS deaths than any other drug of abuse, including cocaine. Stopping smoking during pregnancy is an important step we can take to save infants’ lives.
SIDS is becoming quite rare in children who sleep on their backs and who are not exposed to tobacco.
The following are the safe bedding recommendations agreed upon by the U.S. Consumer Product Safety Commission, the American Academy of Pediatrics, and the National Institute of Child Health and Human Development:

1. Place baby on his/her back on a firm, tight-fitting mattress in a crib that meets current safety standards.
2. Remove pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products from the crib, playpen, or portable crib.
3. Consider using a sleeper or other sleep clothing as an alternative to blankets, with no other covering.
4. If using a blanket, put baby with feet at the foot of the crib. Tuck a thin blanket around the crib mattress, reaching only as far as the baby’s chest.
5. Make sure your baby’s head remains uncovered during sleep.
6. Do not place baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

I believe that parents who choose to sleep with their babies (a wonderful choice for many families) should be taught how to do it safely. Anything that makes parents more difficult to wake up or anything that hinders babies’ ability to breathe should be avoided.
Babies are safer sleeping next to someone who is aware of their presence and easily awoken. Usually, this is the mother. Fathers, siblings, and babysitters do not tend to wake up as easily when needed, though there are exceptions.
Whoever you are, don’t sleep with a baby if you are taking something (alcohol, antihistamines, or other drugs) that makes you less aware of the baby when you sleep. The same holds true if you are so sleep-deprived that you would have difficulty waking up if the baby were in need.
Tobacco smoke, adult obesity, over-bundling, excess bedding, waterbeds, couches, and chemical irritants (fragrances that might irritate a baby’s nose and clog the air passages) could all make breathing dangerously difficult for babies.
Teaching babies to sleep in their own cribs is a good option for some families; sleeping with their babies is a good option for others. Many babies sleep in a crib most of the night, and then join the parents after the last feeding for some snuggle and sleep time together before starting the day.
Whichever arrangement you choose, enjoy these unrepeatable months when your child is a baby, and learn what you can about what helps you and your baby to thrive.
There is no way to completely prevent SIDS. This uncertainty makes the deep love we have for our children all the more poignant.

Related A-to-Z Information:

Anemia (Low hemoglobin), Infant Botulism, Respiratory Distress, Thumb-sucking

I sat enthralled at Grand Rounds as I listened to Jose Santos, M.D., Director of the National Vaccine Program for Mexico. While we struggle with the subtleties of further lessening the side effects of vaccines, Mexico is engaged in an enthusiastic, all-out push to immunize their children, resulting in a revolution in that nation’s health.

In 1990, when only 40% of their children were immunized, there were over 68,000 cases of measles. That year, the disease killed over 6,000 children. By 1996, the immunization rate had risen to an impressive 97.6%, and they had only 2 cases of measles — the last two they have had — even though other countries in the region (Canada, Brazil, Argentina, and last week Costa Rica) continue to have measles epidemics. Mexican resolve has resulted in similar dramatic success with other important immunizations.

I’m all for yearly re-evaluation of whether or not the benefits of each vaccine outweigh the current risks. I’m all for reformulating vaccines to make them as safe as possible. But it is refreshing to set these questions against the backdrop of the immense boon immunizations have been, and continue to be, to children’s health!

Any parent of multiple children can tell you that keeping track of their family’s medical history can be a challenge!  Every time I am asked for a child’s birthdate, I have to pause and think, let alone their most recent weight and height!  Back when I had one child, I could rattle off every state from the previous six months.  Now?  I know how big each of them was at birth…and that’s about it!

Technology simplifies keeping track of each family member’s personal health records. Just this morning I was filling out a form for a new doctor’s visit and I was able to refer to our electronic records to fill out my little one’s most recent height and weight.  These days it seems that your entire life can be accessed from your mobile device and it only makes sense that your family’s health information should be just as accessible, especially in emergency situations. If you have more than one child, it can be difficult, for even the most diligent of moms, to keep track of each child’s detailed record of immunizations, allergies, etc. How many times have you looked at a bottle of acetaminophen and tried to remember if your child gets one teaspoon or one and a half teaspoons?

There are a few categories of health related apps that I would like to highlight:

1. Medical Records
   If you do a search on TheiPhoneMom.com for the terms “medical” or “health”, you will come up with numerous results.  Most recently, we reviewed Microsoft Health Vault and Family Med Track.  Both of these apps allow you to store a complete medical history for multiple family members including medications, immunizations, health conditions, allergies and more.  They each have unique functions, so be sure to read up on all that they can do.  Medical record apps really allow you to have your full family medical history at your fingertips at all times making doctor’s visits much easier.   My Kid’s Healthfeatures a great display to keep track of milestones in weight, height, head circumference as well as vaccinations, appointment, allergies and illnesses.
2. Illness/Symptom Guides
   Do you ever obsess over your children’s symptoms?  A few days after one of my children’s friends had her appendix removed, one of my children had a stomachache. Who did I turn to?  Dr. Google!  Googling every symptom is not recommended by doctors as you can either miss important things that need treatment, or work yourself up into a panic over a simple virus. One great app for checking symptoms is the Merck Manual: Home Edition. It’s written simply and has been put together by hundreds of medical experts. iTriage is another symptom tracker app that was created by two emergency room physicians in order to help you figure out what you might be dealing with and where you should go to seek help. You can even connect this to your Microsoft Health Vault account.  Finally, for an emergency situation Medlert 911+works as an emergency response app, connecting you quickly with those you have designated as your emergency contacts.
3. CPR and First Aid
   I am a strong believer in a hands-on CPR and first aid course for anyone who lives with or works with children.  In an emergency, it is helpful to be trained so that your response is automatic.  Some babies tend to gag and choke when eating solids and if you know how to quickly flip them over your arm and pat their back, you will be much more confident in facing these challenges!  I have two apps in my “to be reviewed” folder that are waiting on a full write up. First Aid by American Red Crossis a comprehensive guide that takes you step by step through first aid and CPR responses to emergency situations.   Pocket CPR focuses on CPR only and includes a training program that allows you to see if your rhythm is correct.
4. Role Playing Games
   Finally, for any kids who are apprehensive of doctors, role playing games can help prepare them for their next visit. Play Hospital is a cute game that walks kids through each step of a doctor visit.

Dr. Greene`s Answer:

Everything dear to us causes pain. Becoming a parent opens up new landscapes within us: new hopes, fears, delights, and sorrows. There is no magic moment when you will stop worrying. Sometimes, even when we do everything right, babies die. The fragility and unpredictability of life underscore how precious each life is.

Thankfully, there are specific steps you can take to minimize the risk to your child.

SIDS, or Sudden Infant Death Syndrome, is defined as the sudden, unexpected and unexplained death of any infant or young child. What a horror for any parent! When surveyed about what they would have appreciated in those chilling moments after the death, SIDS parents responded with several concrete requests they were often too stunned to make at the time (Journal of Emergency Medicine, Sep 1997):

• To hold their baby one last time
• To have the clothing returned to them
• To have a print or mold of their baby’s hand
• To have a lock of hair.

These poignant requests underline the tragedy of SIDS, the most common cause of infant death in developed countries. SIDS accounts for about half of the deaths that occur between one month and one year of age.

Genetics plays a large role. SIDS is more common in boys than in girls, and it is more common in some population groups (Black, Native American, Hawaiian, Filipino, Maori).

Most of the affected infants have damaged or immature brainstems, making it difficult for them to wake up when they are in trouble. A recent series of autopsies has demonstrated visible brain abnormalities in over 70 percent of the SIDS babies examined (Pediatric Neurology, Jul 1998).

While parents often feel horribly responsible after SIDS, sometimes there is nothing they could have done to prevent it. There are many factors outside of our control.

Sometimes infants can even die of SIDS in the hospital. For example, a 5-month -old baby boy was admitted to Rotunda Hospital in Northern Ireland after he had experienced three near-SIDS events. He underwent a sleep study to try to identify what was causing these events. During the study he had no periods of slow heart rate or inadequate breathing. Nevertheless, he died of SIDS while he was still in the hospital. His heart slowed and stopped, and even expert medical care couldn’t prevent it (Archives of Diseases in Children, May 1998).

Infants at risk for SIDS may have abnormalities in heart conduction. Almost 35,000 healthy babies in Italy had EKGs performed in the first week of life. They were then followed for a year. Most of those who ended up dying of SIDS had an abnormality on their original EKGs (a prolonged QTc interval). Those with this abnormality were more than 40 times more likely than their peers to die from SIDS (New England Journal of Medicine, Jun 11, 1998). These findings hold promise for future screening and prevention.

There are already several important preventive measures available. Events that occur even before the baby is born affect the risk of SIDS. Anything that causes less oxygen to get to the baby in the uterus will increase his or her risk. On average, smoking during pregnancy doubles the chances, and the odds increase with each cigarette. Other drugs of abuse such as cocaine or heroine increase the risk by as many as thirty times.

The media often focus on “crack babies,” but tobacco use continues in approximately 25% of all pregnancies in the United States (J Pharmacol Exp Ther, Jun 1998). Nicotine exposure is responsible for many more SIDS deaths than any other drug of abuse, including cocaine. Stopping smoking during pregnancy is the most immediate step we can take to save infants’ lives. Other studies also show that ensuring babies are breathing fresh clean air may be important; for example use of a fan while babies are sleeping was shown in one study to decrease the risk of SIDS. It is not entirely clear why, but rebreathing exhaled air or accumulation of carbon dioxide may be associated with SIDS deaths (Arch Pediatr Adolesc Med, 162(10) Oct 2008).

Minimizing caffeine use during pregnancy is another way to protect your child. Those babies whose mothers drank 4 or more cups of coffee per day could have up to twice the risk of SIDS (Arch Dis Child, Jan 1998).

After birth, many things influence a baby’s susceptibility to SIDS. It is more common in babies who sleep in warm environments, who are over-bundled, who sleep in rooms with space heaters, who are exposed to cigarette smoke, who sleep on soft surfaces, who do not use pacifiers, and those who sleep face down or in a prone position. The rate of SIDS is also higher in those babies who do not receive timely well-child care and immunizations.

Putting children to sleep on their backs lowers the risk of SIDS by about three times. Use firm bedding in a slightly cool room. Avoid cigarette smoke, and even anything that smells like cigarette smoke. Take your baby in for regular well-child visits and immunizations. There is some evidence to support that breastfeeding may help reduce the risk of SIDS.

The SIDS rate has dropped by more than half in the last few years to 0.7 per one thousand live births in the United States. Changes in sleeping positions are being credited for the reductions (AAP News, Jan 98). Even with the change in sleeping habits, about 5 out of 6 babies found dead are found face down (J Pediatr, Feb 1998). SIDS is becoming quite rare in children who sleep on their backs and who are not exposed to tobacco.

Recent studies show that approximately 20% of babies who die from SIDS are discovered with their faces or heads covered, whether by bedding or clothing. While the chain of events in these tragedies is not known, preventing your baby from being able to cover his/her head with bedding or clothing may also be an important part of preventing SIDS deaths (Arch Dis Child, 93(9) 778-783, 2008).

The following safe bedding recommendations are written by sponsors of the “Back to Sleep” campaign:

1. Place baby on his/her back on a firm tight-fitting mattress in a crib that meets current safety standards.
2. Remove pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products from the crib, playpen, or portable crib.
3. Consider using a sleeper or other sleep clothing as an alternative to blankets, with no other covering.
4. If using a blanket, put baby with feet at the foot of the crib. Tuck a thin blanket around the crib mattress, reaching only as far as the baby’s chest.
5. Make sure your baby’s head remains uncovered during sleep.
6. Do not place baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.
7. Make sure everyone that cares for your baby knows the above recommendations for safe bedding.

There is no way to completely prevent or even predict SIDS. This uncertainty makes the deep love we have for our children all the more poignant. The peak period for SIDS is between two and four months old. It is very rare before one month of age, and at least 95% of all the cases have occurred before children reach six months old. But this doesn’t mean that when they pass six months all fear will subside. For as long as we live, this marvelous life we share is both strong and fragile, a treasure to be cherished moment by moment.

Dr. Greene’s Answer:

Many people are unaware of the problems associated with some of the components used in making vaccines (aside from the infectious agent itself). Potential toxicity from mercury in vaccines is a hot issue right now and has relevance for all newborns. This controversy has led to new (July 7, 1999) guidelines from the American Academy of Pediatrics (AAP) and the United States Public Health Service (PHS) that call for removing mercury in all forms from all vaccines.

Allergic reactions to vaccine components are another important issue. According to the 2006 Red Book (Report of the Committee on Infectious Diseases. 2006 AAP), allergic reactions to vaccine ingredients are rare. The most common difficulties are encountered with hypersensitivities to chicken or eggs, mercury, certain antibiotics, or to gelatin.

Chicken and Egg Allergies

The current measles-mumps-rubella vaccine (MMR) does not contain a significant amount of egg proteins (but two other vaccines do). As recently as 1994, the AAP recommended skin testing of all children with severe egg allergies before they received the MMR. This is no longer necessary. Even those with dramatic egg allergies are extremely unlikely to have an anaphylactic reaction to the MMR. The benefits of the vaccine far outweigh the risks.

Most people don’t know that the influenza vaccine (“flu shot“) contains egg protein. People who react to eggs, chicken, or chicken feathers with systemic symptoms (a drop in blood pressure, significant wheezing, difficulty breathing, or generalized hives) generally should not get the flu vaccine. Localized or less severe reactions (such as a mild rash) to feathers or eggs are not a reason to forgo the vaccine. Allergy to duck meat or duck feathers is not a reason to hold back on any vaccine.

The yellow fever vaccine also contains egg protein. Yellow fever is still a major problem for people living in or traveling to tropical South America or Africa. This vaccine can be very important. Thus, rather than skipping it, most candidates for the vaccine who have a suspected allergy should get a series of two skin tests with the vaccine. If both tests are fine, proceed with the vaccine. If either test shows a reaction, a process of desensitization is begun. Similar to allergy shots, a series of tiny doses of vaccine are given to reduce the risk of reaction.

Antibiotic Allergies

Several vaccines contain small amounts of antibiotics. Both types of polio vaccine include streptomycin, neomycin, and polymyxin B (also found in Polysporin, Neosporin, and Betadine Plus topical ointments). The MMR and the varicella vaccine have trace amounts of neomycin (found in Neosporin). Most allergic reactions to these antibiotics are nothing more than mild skin rashes. However, if your child has a severe allergy with systemic symptoms to these or related antibiotics, you should avoid these vaccines.

No vaccine contains penicillin or penicillin-related antibiotics. This type of allergy is not a reason to miss any vaccine.

Gelatin Allergies

With added sugar, flavoring, and coloring, gelatin is a popular dessert. It is also used as a thickener in soups, candies, ice creams, marshmallows and many other foods (not jelly, by the way, which uses pectin, a natural plant substance). Gelatin is used in cosmetics and in many pharmacy products including ointments, lozenges, capsules, and vaccines.

Some of the live vaccines do contain gelatin as a stabilizing agent. Gelatin is an animal protein substance made from collagen obtained by boiling animal skins, hides, bones, and other tissues after pretreatment with alkali or acid.

Gelatin is an ingredient in MMR, varicella, and yellow fever vaccines. People with severe allergies to gelatin should consider skin testing prior to receiving a gelatin-containing vaccine. The problem is that most gelatins in foods come from boiled cows, while the gelatin used in vaccines is from boiled pigs. People may not know that they are allergic to pig gelatin.

Mercury Allergies

Mercury (thimerosal) is an ingredient in several vaccines — included in order to kill any live contaminants. It is most likely to be used for a vaccine stored in a multi-dose vial. In rare instances, this causes allergic reactions. At much higher doses, mercury is a known cause of irreversible nerve and brain damage, especially before birth and in the first 6 months of life.

Mercury was responsible for the first known epidemic of cerebral palsy from a toxin when it was dumped into Minamata Bay in Japan in the 1950′s by a vinyl plastics factory. Might it also cause mercury toxicity in children who frequently get mercury-containing vaccines? This has long been a concern with the gamma globulin shot used to prevent Hepatitis A in travelers. Where practical, the Hepatitis A vaccine is a safer and more effective alternative that does not contain mercury. Still, getting a shot of gamma globulin is far better than getting hepatitis.

In the United States, all of the vaccines now in the routine schedule are available in thimerosal-free forms. Some forms of the influenza vaccine contain small amounts of thimerosal (a mercury-based preservative), but the AAP contends that the known benefits of the vaccine outweigh the hypothetical risk of small amounts of thimerosal. There are forms of the influenza vaccine that do not contain mercury (i.e., Fluzone & Fluvirin).

The vaccination of children in much of the world will continue to require the use of multi-dose vials for reasons of cost and storage capacity. Vaccines in multi-dose vials are more likely to contain thimerosal as a preservative.

Immunizations save lives

Immunizations remain one of the greatest discoveries in human history, having saved innumerable lives and prevented measureless suffering. Available vaccines continue to be improved, and vaccine schedules continue to be refined. I strongly support the immunization of children and I agree with US Surgeon General David Satcher’s July 7, 1999 statement in the midst of this mercury controversy.

To our Telluride reader:

Although egg protein in the MMR is no longer a big problem, if your child has severe allergies with systemic symptoms, whatever the cause, it pays to become familiar with the hidden ingredients found in products of all kinds. Thanks for asking about this important topic.

No matter how much is known about a vaccine before it is licensed for routine use, after it has been used in millions of people it is possible to discover side effects that are too subtle or too rare to show up in pre-license testing. The November 2000 issue of Infectious Diseases in Children reviewed the post-licensure report card of the varicella (chicken pox) vaccine. Whenever an unexpected event follows an immunization, we physicians are required to report it to the Vaccine Adverse Events Reporting System (VAERS), even if we think the event was not caused by the vaccine.

The chicken pox vaccine appears to be quite safe. Even if all of the bad things that happened after the shot were caused by the shot (unlikely), complications were still much less than what would be expected if no immunization had been given. No reaction occurred more often than occurs during chicken pox itself. I suspect that the individuals who do react to the weakened formed of the virus in the vaccine may be the same ones who would have an even worse reaction to the stronger virus in chicken pox itself.

This report card is very encouraging, but not definitive. Not all adverse events are recognized by doctors and not all of those that are recognized are reported. The complication rates for both the disease and the vaccine are probably under-estimated. On the other hand, many children receive several immunizations at the same time, and thus many reactions listed as possibly coming from the chicken pox vaccine have no relationship at all.

What safety news we have about the vaccine at this point is good. With any health decision, it is wise to evaluate both the possible risks and the potential benefits. While serious complications from chicken pox are uncommon, chicken pox remains the number one cause of vaccine-preventable death in the United States.

Many parents opt to wait on ear piercing until a child is able to make the decision for herself (or himself). Some parents find it desirable for their children to have pierced ears as babies. But how early is too early? I am a fan of waiting at least a bit for ear piercing. My reason? Tetanus. Even though tetanus is not very common (thanks to immunizations), the tetanus bacteria is everywhere. It usually enters the body through puncture wounds. For this reason, it is better for a baby to have at least one (better two) tetanus shots behind her before her big day . Two shots would put the event at 3-5 months old for most kids. Also, once babies are 3 months old, they are better able to handle the more common minor skin infections they might get.

Dr. Greene’s Answer:

The word croup comes from an old Germanic word for the voice box. Today, croup, or laryngotracheobronchitis, refers to swelling centered at the larynx or vocal cords. It is caused by an infection, an allergy, or a foreign body.

Croup tends to appear in children between 3 months and five years old. It is characterized by a brassy cough that sounds rather like a seal barking. It is usually (75% of the time) caused by parainfluenza viruses, but 6-8% of cases of croup are caused by RSV. Most children have what appears to be a mild cold for several days before one evening when the barking cough becomes evident. As the cough gets more frequent, the child may have stridor (a harsh, crowing noise made during inspiration).

Croup is typically much worse at night. It often lasts 5 or 6 nights, but the first night or two are usually the most severe. Home treatment usually consists of a mist treatment — a cool air nebulizer is best, but if that is unavailable, the steam from a shower or bath in a closed bathroom can be used. Increased temperature causes the body to need more oxygen (like working out). Acetaminophen can make the child more comfortable and lower any fever, making the respiratory needs less. Cough medicines should not be used in children under 6 years old. Most cases of croup can be safely managed at home.

Prior to the era of antibiotics and immunizations, croup was a deadly disease, usually caused by the diphtheria bacteria. Today, most cases of croup are mild, but it can still be a dangerous disease. I would recommend at least talking with your healthcare provider by phone for any case of croup, to let her or him listen to the child’s breathing and cough. If the child has stridor constantly, she should be seen immediately. If you suspect a foreign body or an insect sting as the cause of croup, she should be seen immediately. She should also be seen immediately if she has retractions (tugging-in between the ribs with inspiration), dusky lips, drooling, or is very agitated. She may need to be treated with vaponephrine aerosols or decadron, in addition to a cool mist, to help decrease the swelling in the larynx.

In 1988, polio still ravaged about 350,000 new people each year, causing damage that will last for the rest of their lives. The World Health Organization, UNICEF, the CDC, and Rotary International saw that polio could be entirely eradicated from the world. Their aim is to have it gone by 2005. So far, they have been 99% successful (only 2881 new cases in 2000). But enormous challenges remain in bringing immunizations to 16 million children in war-torn Central and Western Africa.

Reuters Health has reported on events as they transpire. Using bicycles, boats, and canoes (and an amazing variety of methods to keep the vaccine cold and fresh), courageous vaccinators are visiting children in the Democratic Republic of the Congo, Congo-Brazzaville, Gabon, and in Angola – one of the most war-torn and land-mine-infested areas in the world. And each child must be visited 3 times! The first round of vaccinations was launched on July 5th, 2001; the second round was launched on August 9th; and the final round will begin on September 13th. The first round was very successful – although one volunteer was killed. Five other vaccinators were arrested and then released.