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Understanding American Health Insurance

Health insurance in the U.S.A. frequently changes and is never to simple. Two different people may both have “Aetna PPO”, for example, but with different plans within that insurance company, because they work for different companies, or signed up for different levels. Therefore the same plan name may cover different physicians, procedures, and medications, and have different deductibles or fee schedules, so that two people who think they have the same insurance actually have very different medical bills.

For PPOs: Before seeing your physician for anything, check with their office as to the officially billed name or doctor’s name (often only the main doctor that owns the practice) that is billed to your insurance, then check with your insurance that this physician is covered. Ask ahead about any regular procedures for your child’s next check-up (like vision screening at 6 months old, and lead screening at 9-12 months old), then you can check with your insurance company ahead of time to make sure those individual procedures are covered benefits, and if not, how much they will cost.

For HMOs, your primary care physician name is on your insurance card, and you can only go to that person’s office for your primary care. You must also see this doctor in order to get an official referral before seeing a specialist or having any imaging or lab tests done.

Here are some handy blog links to help you learn more about insurance. Good luck!

Health Insurance Overview: Here and here.

Health Insurance Basics from the U.S. Government

U.S.A. Insurance Today

Prior Authorization Calls

 

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A Spoon-full of Sugar Helps the Medicine Go Down

Lots of parents have trouble getting their children to take medicine, so here are some tips to help:

Some techniques to help medicine go down easier:

Marry Poppins was right- a spoon-full of sugar helps the medicine go down! More accurately, a spoon-full of chocolate syrup will cover up the taste of most yucky medications. Apple sauce and yogurt are other common foods used to mask bad tastes. Many medications can be made to taste like your child’s favorite flavor by the pharmacist before you even pick it up, so ask about this when you submit your prescription. Some medications come in “orally dissolving tablets” which kids (age 3 and older) can put in their mouth and they will dissolve without having to chew or swallow.

Liquid meds are often easiest to give to babies with a syringe (a tube that looks like shot, but does NOT have a needle on it), which you can get at any pharmacy, baby store, or from your physician. Squirt small amounts of medication into your baby’s cheek and they’ll usually swallow it. Don’t squirt it directly onto their tongue or into the back of their throat, as this can lead to gagging. Follow-up with breast milk or formula (whatever they normally drink), before giving the next part of the dose. Alternatively, you can put the liquid medication in a bottle nipple along with a little breast milk/formula, and have them suck directly from the nipple, without the bottle attached. I do not recommend mixing the medication in a whole bottle, unless you know the baby will take the whole thing regardless of taste.

Most baby stores also sell special devices to help kids swallow medications,such as something that looks like a bottle, but keeps the medication separate, so you know exactly how much the child takes. I do not recommend giving children medications with droppers, because it’s difficult to measure the amount you’re giving, difficult to get all of the medication out of the dropper, and difficult to clean and dry the dropper fully between each use.

Learning how to swallow pills:

Once your child is ready to swallow pills (often by age 5!), it’s a great help to teach them how, since many medications are easier to take in pill form, the older they get, the bigger the dose, and some medications are not available in liquid/ chewable form. Starting young can also be beneficial in preventing anxiety associated with swallowing pills. Adolescents and adults often have trouble swallowing pills because they fear that the pill will get stuck in their throats. Relaxation techniques and deep breathing can help. Looking in a mirror, sticking your tongue out, and saying “aaah” out loud (this lifts the palate so you can see your throat), can help people see that their throat is much bigger then the pill, and ease some of the anxiety.

The first step in learning how to swallow a pill is to practice with something that is NOT medication. I recommend starting with small, smooth, round candies (such as mini m&m’s), and progressing to slightly larger candies (such as regular m&m’s). People with anxiety may want to start with tiny candies, such as sprinkles. Other people prefer to start with tiny bread balls (made from mashing a tiny piece of bread between your fingers), and go progressively bigger, since the bread dissolves easily in the throat. You will also need a big glass of water, juice, or carbonated beverage (such as plain soda water, which the pill can float on).

Younger kids can be told to just try swallowing the candy without chewing, because they are often successful without thinking about it. Older children, or those without a natural tendency to swallowing whole pieces, can start by visualizing the item floating down their throat on water, like a little boat. They should start by making sure the mouth is moist, by salivating or taking a sip of their drink. Nest place the candy as far back on the tongue as possible, using the teeth to scrape the candy to the back of the tongue (a mirror helps some people see how far back it is). Then take a big gulp of the liquid, which should float the candy and allow it to be swallowed, just as you would usually swallow any regular drink. Some children will swallow the candy (and later pills) more easily by drinking the liquid through a straw.

When it comes to taking real medicine, some people hide their pills in mini-marshmallows, which are slippery when wet, and therefore easier to swallow. I recommend trying this without medication first, since these are bigger then most pills. You can also try covering the pills in chocolate syrup, applesauce, yogurt, or jam (but see the warnings below before trying that).

I suggest experimenting with these techniques in a relaxed environment until you find something that works for you.

Warnings:

These techniques are for generally healthy children, with normal anatomy and mentation! They should not be used for children with any anatomical abnormalities, dysphagia (trouble swallowing regular foods or drinks), or any medical conditions that effect swallowing, the head/face, the GI system, or the neurological system.

All children should be supervised when practicing swallowing candies, and when taking ANY medication. NEVER tell your child that the medication is candy, as this can cause them to sneak some more when you’re not looking (many medications these days actually do taste like candy). Always keep medications (over the counter and prescription) and vitamins/ supplements out of reach AND in a LOCKED container. Kids are good at climbing and getting into high cabinets, purses, closets, and other hiding places.

Please speak to your pharmacist (who is usually in the back of the store, who has spent at least 5 years in post-graduate university studies, getting a doctorate degree in pharmacy), about what you can take your medication with, and whether you can cut, crush, chew, or open the medication. Many medications should NOT be taken with grapefruit juice. Some medications should NOT be taken with anything dairy. Some pills can be crushed and mixed with foods, where as others can not. Your pharmacist and/ or physician are the best people to speak to before taking your medication with anything but water.

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Stomach bugs: what to do if your child is throwing up or having diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as “viral gastroenteritis”. Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?

– their mouth/lips are very dry

– they are peeing less than usual

– they are thirsty

Now what?

You need to keep your child hydrated!

– A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.

– A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it’s just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.

– For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?

– Let their tummy rest.

– Call your pediatrician, or go to the hospital, if they have signs of dehydration tat are not resolved by giving fluids by mouth (see more below).

– Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.

– Start with no food, but still give an electrolyte fluid (like pedialyte or ORS above), for the first 12 hours.

– When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup broth, apple sauce) and avoid foods that are fried, acidic, oily, or contain milk.

But what if they have icky diarrhea?

– Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake – this acts as a barrier layer, to prevent acidic poop from sitting on the skin.

– Feed them binding foods, like rice.

– Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow’s milk) intolerance, so avoid lactose-containing stuff, like cow’s milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.

– Try a children’s probiotic with lactobacillus once per day, such as children’s culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:

http://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics?detectedLanguage=en&source=search_result&search=patient+information&selectedTitle=7~150&provider=noProvider

or this one on diarrhea in children:

http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=see_link

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?

– they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/teenager)

– they are crying, but can not make tears

– they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual

– eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?

– persistent high fever (above 102.5 F)

– any fever in an baby younger than 3 months old

– severe abdominal (tummy) pain

– abdominal pain that moves to the lower right side

– lethargy or decreased responsiveness

– bloody (red or black) or bright green (like pea soup) vomit or diarrhea

– diarrhea not improving after 1 week

 

The good news is that most of these illnesses pass quickly without any medications, so hang in there, and keep washing your hands with soap and warm water!

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Coughs, Colds and Croup

Even though it’s a beautiful Spring here in Southern California, we are still seeing some coughs, colds and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

–          Use a nasal saline mist (the kind that comes in a metal can, not drops) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don’t have to worry about the water source. The mist is gentle and cleans out the nose better than the drops.

–          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

–          If your child suffers from allergies and is over age 4, you can use an over the counter antihistamine to help dry her up (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

–          If your child is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!

–    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

–          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a snot sucker device such as the Nose Frida (http://www.fridababy.com/) -you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

Helping a child with a “wet” or “phlegmy” cough:

Do all of the above for nasal congestion plus the following:

–          Have your child sleep propped up at 30 degrees so the mucus drains easily.

–          Give children over age 1 year a big spoonful of honey twice a day. The honey has been shown to help relieve cough symptoms in kids & help them sleep, in published randomized control trials (scientific studies). The honey they used was NOT “raw”, which can have dangerous bacteria in it. nor was it Menuka. Just plain pasteurized honey from the store works.

–     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better.

–          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them). If your child is over age 6 years you can give him the zinc cough drops that are available at all pharmacies, but please supervise to prevent choking.

Helping a child with a dry, barking, or croupy cough:

Do all of the above for nasal congestion & wet coughs plus the following:

–          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out. Do not put oils in the water.

–          If the child is having a coughing fit, or breathing like Darth Vader, take him/her for a walk outside in the cool air, or hold him/her in front of an open freezer for a few minutes, to reduce the swelling in the throat. If that is not helping, call your pediatrician for immediate medical advice, take the child to the office or ann ER. Please call 911 if (s)he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:

http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

–          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

–          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

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Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice. 

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Vaccine Science Made Simple

This is a guest post by Kimberly Mulligan, PhD from the department of biological sciences at California State University Sacramento

Hi parents! Scientist here. I decided to write a long post about vaccines to help shed some light on how vaccines work and, hopefully, bring some clarity to topics of debate. The amount of misinformation about vaccines feels a little out of control to me. And no matter what you think about vaccines, it’s tough to wade through this information without a scientific background. FYI, my science background: PhD in developmental biology from Stanford University, postdoctoral research at UCSF on the molecular basis of brain development with an emphasis on a group of genes implicated in autism and other neuropsychiatric disorders, and I just joined the faculty at CSUS this January where I teach molecular cell biology and will have a research program focused on the molecular basis of neurodevelopment and neuropsychiatric illness. Ok, on to the fun stuff.  (It’s long because I wanted to be comprehensive and address all of the questions I usually get about vaccines.)

First, I ask that you read this with an open mind.  Having an open mind is an integral quality of good scientists – it is the only way to objectively analyze data. (Open minds are wise minds!) I also want to add that this debate gets nasty, but in the end we all love our kids and want what’s best for them (as a mama of two, I get that).  I am not judging, I do not feel that is my place as a scientist – my place as a scientist is to arm you with information and help you better understand that information.

Important vocabulary: pathogen = disease-causing bacteria or virus

Q: Ok, so what are vaccines? (I feel like this very basic question is often not clearly answered.) 

A: Usually they are viruses or bacteria that have been modified so they cannot hurt you, but still look like pathogens to your immune system. That part is key. When a weakened pathogen (or “acelluar” pieces of a pathogen) enters your body your immune system responds by making antibodies that will bind specifically to that pathogen, and target it for destruction. Here’s the really cool part – our immune system makes cells called memory B cells that will stay in our body for a really long time (depending on how strong the vaccine is). These memory B cells are primed to make antibodies specific for that pathogen if you were to get infected again. This is important because our immune response can take a long time – long enough for pathogens to have debilitating and sometimes lethal consequences. If you have those B cells ready to go, your body makes specific antibodies that will get rid of the pathogen before it hurts you.

Q: What about the other scary sounding stuff in vaccines?

A: They are all there to make sure the vaccine stays safe and effective. And while they sound awful, they are all actually totally safe in the amounts present. For example, formaldehyde sounds scary, but did you know that it is a normal metabolic byproduct that your body produces in small amounts constantly? You produce more formaldehyde over a matter of minutes than you get from a vaccine. Another fun fact: there is 4-15 times more formaldehyde in a single apple than any one vaccine. And your body simply processes it and gets rid of it (again, it knows how since you are always producing it). Aluminum?  Present in things ranging from organic pears to natural breast milk. One of the first things biochemistry students learn is that dose matters. Yes, large amounts of aluminum and formaldehyde are bad…but large amounts of water can be lethal. Oh, and mercury-containing thimerosol is no longer in early childhood vaccines because it was removed due to public outcry. However, there is still zero scientific data to suggest that thimerosol has any detrimental effects. In fact, the type of mercury in thimerosol is ethyl mercury, which is readily flushed from the body. The bad mercury that our body has a harder time getting rid of is methyl mercury (found in tuna).

Q: Why should you trust a big pharma who profits from vaccines? 

A: My first answer is that you don’t have to. There are a lot of scientists who have published research on the safety of vaccines that are not affiliated with big pharma and do not profit from the results of their findings. They are people like me – who became scientists because they wanted to help learn more about biology in order to diminish human suffering. We work for academic institutions, not big pharma. We ask questions without a vested interest in the answers. These are the scientists that can provide you with unbiased information. You can do a search for yourself on the largest database of scientific journals here: http://www.ncbi.nlm.nih.gov/pubmed

You will find that when you search for studies on autism and vaccines, of the hundreds of studies conducted, there is still no scientific data to suggest a link between the two. For example, every epidemiological study conducted on populations of children living in the same community has shown autism occurs at the same rate in vaccinated and unvaccinated children.

  1. What is currently thought to be the cause of autism?

A: It is currently thought that autism is a neurodevelopmental disorder that often begins in utero. A number of the autism risk genes identified affect how the brain develops during gestation. There were actually a couple of papers very recently published indicating specific mutations in a large number of candidate risk genes for autism1, 2. There has also been research showing the influence of environmental factors like maternal antibodies that are present in the womb, which were identified by scientists at the UC Davis MIND Institute3. Autism is a very complicated disorder, and we certainly don’t have all of the answers! But, again, there has been an overwhelming amount of time and money dedicated to investigating a potential link between autism and vaccines, and every study has come back with the same results: there is no data to suggest a link between autism and vaccines.

Q: Back to the big-pharma-makes-a-lot-of-money-argument.

A: Yes, they do. They make money on every drug they produce. I have opinions on big pharma’s business practices that I won’t go into now because it actually has nothing to do with the argument about vaccine effectiveness or safety. For better or for worse, our entire medical system is profit based (our entire economy is, actually). The people at the forefront of the anti-vaccination movement also make a lot of money. That is not why I don’t believe them, though. I don’t believe anti-vaccination proponents because of the absence of scientific data to support their claims. As a scientist, I only believe what the scientific data supports. I read research, not opinions. (That is not meant as a slight to anyone!  I am simply stating my practices. I know that reading primary research papers can be like reading a different language if you do not have a science background, so I would not really expect any non-scientist to have this practice. It’s the same reason I don’t read economics papers. Bleh!)

Q: What about vaccine-related injury?

A: The overall risk is something like 0.003%. And the VAST majority of those 0.003% have minor allergic reactions. Severe allergic reactions can occur, though they are extremely rare. There have been a few cases of autoimmune disorders being triggered by a vaccine. It is not entirely clear whether the vaccine was actually the trigger because it could have been triggered by any pathogen. Importantly, people who are immunocompromised, meaning they have a weakened immune system (chemotherapy patients, HIV patients, genetic immune deficiencies, etc.), cannot be immunized because their immune systems are so weak that even the weakened virus might hurt them. All of these people fall into the class of people who should not get vaccinated and for whom herd immunity is so important!

Q: What is herd immunity?

A: It’s kind of basic math. Viruses cannot replicate on their own. They need to infect a host cell in order to replicate. If they don’t make it into a host cell, they will eventually die. Here’s an easy example: a person infected with a virus walks into a room where there are 20 vaccinated people separating him from a single unvaccinated person. That virus cannot move from the infected person and replicate in any of the vaccinated people because once it gets into their bodies, those memory B cells start pumping out antibodies that kill it before it can replicate and spread. Therefore, those 20 vaccinated people make it harder for the virus to make it to the single unvaccinated person. If half of the people were unvaccinated, that virus would get to have a replication party in all of their cells and would have a much easier time surviving, multiplying, and spreading. Herd immunity is just a basic principle about how infectious pathogens spread. If someone tells you it doesn’t exist, you should be wary of any other scientific information they give you because it means that they have never taken or studied immunology or microbiology and are not qualified to have an educated discussion about those topics.

The tricky thing about vaccines and herd immunity is that herd immunity really only works when a high percentage of the population are vaccinated. If not, then viruses have an easier time spreading around our communities, putting at risk our neighbors who cannot be vaccinated (newborns, cancer patients, etc.), and who are also much more likely to die as a result of infection. That is why the scientific community is so scared.  We feel that even a single death from a vaccine-preventable disease is a tragedy.

Q: Isn’t natural immunity better than vaccine-induced immunity?

A: Well, the immune response is stronger because the pathogens are not weakened, so if you make it through the illness you will, in theory, have a great supply of those memory B cells. The problem is that a lot of these vaccine-preventable pathogens can cause blindness, deafness, brain damage, paralysis, or death. I know of a mama who has a sister who contracted rubella while she was pregnant. Her baby was born blind and deaf because of the infection. So, yes, she now has great immunity to rubella. But she would give anything to have had vaccine-induced immunity prior to her pregnancy.

Q: Why do some vaccines not give lasting immunity? 

A: Each vaccine has a varying degree of effectiveness. By effectiveness I specifically mean the quantity and quality of memory cells that will stick around in the immune system post-vaccine. For example, the smallpox vaccine gave immunity for 65 years whereas the pertussis vaccine only lasts for about 10 years. This is the purpose of boosters. Boosters essentially tell your immune system that it is still important to mount a defense against the pathogen, and replenishes your stock of memory cells.

Q: I heard a lot of adults are to blame for the current measles outbreak. Should adults get vaccinated, too?

  1. Absolutely! If you are unsure of your immunity, you can talk to your medical provider about checking your titer (a measure of your immunity), or you can just get a booster. Even if you’ve had a booster, but can’t exactly remember when and your provider doesn’t do the titer test, getting another booster cannot hurt you.

Q: Why do babies often get fevers after being vaccinated?

A: Part of the natural immune response is the release of molecules called chemokines, which cause fever. As a mama, I know how scary it can be when your little one has a fever, but a post-vaccine fever is indicative of a robust immune response and means they are making great memory B cells. That does not mean you shouldn’t treat your baby’s fever!  (Please consult your pediatrician on when you should treat your baby’s fever.)

Q: What’s up with vaccine shedding?

A: Vaccine shedding is something only possible with a live attenuated virus. This is different from the pertussis vaccine, for example, which is an acellular vaccine, meaning it contains various pieces of the pertussis bacterial molecules and is not infectious at all, cannot cause illness ever, and cannot shed. Again, a live attenuated virus is a weakened virus that reproduces so slowly that a normal immune system will take care of it before it causes any harm. If a person is immunocompromised, live attenuated vaccines cannot be used because their immune system might not be able to handle even a weakened virus. The nasal spray flu vaccine does have a risk of vaccine shedding because the vaccine is administered directly to the mucus membranes of the nose. Therefore, if that recently immunized person were to sneeze onto an immunocompromised person, there is a theoretical possibility that the attenuated virus could give that immunocompromised individual the flu. This is why it is recommended to stay away from immunocompromised individuals for a week after getting the nasal spray flu vaccine.  Other live attenuated viruses are injected into muscle. Some of the weakened virus will get into the lymphatic system, which is where all that good immunity will happen (production of specific antibodies, effector cells, and memory cells that will stay around for a long time). From there, some of the vaccine can enter saliva and mucus, although it is going to be a much lower amount. I think this is why the CDC only has the recommendation to steer clear of immunocompromised individuals in the case of the nasal spray flu vaccine. BUT, and this is critical, the virus that would potentially be shed post-vaccine is the attenuated (weakened) virus that does not cause illness in a person with a normal immune system. This is why vaccine shedding does not cause disease EVER in a person with a normal immune system. It would essentially be like getting an ultra-tiny dose of a vaccine (not enough to even cause an appreciable immune response that would lead to acquired immunity). This is anecdotal, but when my daughter was newborn, my husband did not realize this about the nasal spray flu vaccine when he took our 2 year-old to the doctor…and he got him the nasal spray form of the flu vaccine. I’m happy to report that my newborn daughter did not get the flu. I actually wasn’t really worried; it’s a very minimal risk….but when a person is severely immunocompromised it is important to worry about any potential risk.

Q: If I have a baby that is too young for MMR, could a booster given to a breastfeeding mama give the baby passive immunity through antibodies present in the breast milk?

A: Passive immunity is the transfer of active antibodies from one person to another. This happens during pregnancy when antibodies present in mama cross the placenta to the developing fetus. I recently spoke to an immunologist friend about passive immunity through breast milk. I myself was considering getting the MMR booster to help my 7 month-old baby girl, but he said (sadly) it probably would not boost her passive immunity an appreciable amount (for a virus as strong as measles, anyway). There are five classes of antibodies (IgA, IgG, IgD, IgE, and IgM). The type that is most effective in preventing infection from something like the measles is IgG. These antibodies cross the placenta during pregnancy and give passive immunity to the baby when it is newborn. The primary type of antibody that gets into breast milk is IgA. It provides some protection, but it’s just not as great as IgG.

Q: If newborns get passive immunity from mama during pregnancy, why are they susceptible to illness? 

A: Passive immunity only lasts for a short time. That’s because antibodies tend to not survive very long (a few weeks to a few months, on average). Unfortunately, the effector cells and memory cells that are responsible for making the antibodies in mama do not cross the placenta. The memory cells are the cell types that stick around for years to provide lasting immunity. I read a study that indicated 88 percent of babies of vaccinated mothers have passive immunity to measles at 4 months, and that number dropped to 15 percent by 8 months of age4. Although, and this is important, the amount of antibodies acquired through passive immunity may not be sufficient to protect the baby from a strong pathogen.

Q: What about the alternative vaccine schedule versus the CDC recommended vaccine schedule?

A: I’ve never found evidence to support the alternative vaccine schedule. It is my understanding that it is something to make parents feel more comfortable. There are a lot of factors taken into account for the CDC schedule, which have to do with considerations like when the acquired immunity will be best. For example, MMR is not given until 12 months because they want to make sure that all passive immunity acquired from mama during pregnancy is gone by the time the vaccine is administered because those circulating antibodies would decrease the immune response to the vaccine. So MMR can be given at 6 months, but is better at 12 months…and I recently read a study indicating even a little tiny bit better at 15 months5; but, you could possibly do the initial shot earlier than 12 months and then get the booster early if you are concerned about measles in your community (of course, talk to your doc about these decisions).

I hope this was helpful! Again, I have no financial interest in this debate. As the mama of a 7 month-old baby girl who is not old enough to have MMR, a 2 year-old little boy who only now has partial immunity, and as the stepdaughter to a wonderful man who spent his final 9 months severely immunocompromised due to chemotherapy, I am certainly emotionally invested in the debate. But as a scientist who has read thousands of pages of scientific research, I only want to help spread knowledge and quell fear.

For links to more information about vaccines please check out the blog post just prior to this one.

References

1 Iossifov I, et al., The contributions of de novo coding mutations to autism spectrum disorder. Nature. (2014) 515(7526)

2 De Rubeis S, et al., Synaptic, transcriptional and chromatin genes in autism. Nature. (2014) 515(7526)

3 Bauman MD, et al., Maternal antibodies from mothers of children with autism alter brain growth and social behavior development in the rhesus monkey. Transl Psychiatry. (2013) 9;3

4 De Serres, et al., Passive immunity against measles during the first 8 months of life of infants born to vaccinated mother or to mothers who sustained measles. Vaccine. (1997) 15(6-7):620-3.

5 Hinman A., et al., Comparison of Vaccination with Measles-Mumps-Rubella Vaccine at 9, 12, and 15 Months of Age. J Infect Dis. (2004) 189