H1N1 (Swine Flu): To Vaccinate or Not To Vaccinate

A week or so ago, our friends at StrollerTraffic.com came to us with their readers' most pressing questions about the new H1N1 vaccine. Seems their inbox (like ours) has been overflowing with questions, confusion, and dare we say, a little bit of panic.
Being on their panel of experts, we of course were happy to field the most frequently asked questions, break down the facts, explain some of the issues and controversies surrounding the vaccine, and hopefully talk a couple of readers down off the ledge so they could make a sound, educated decision about whether to vaccinate or not to vaccinate.
Here, the full unedited version of "Worth a Shot? H1N1 (Swine Flu) Vaccine Update", originally written for and published by StrollerTraffic.com.
(Disclaimer, it's a bit long...but we think, worth the read...So fill up your coffee cup, put up your feet, break it down into 2 parts if you have to, and enjoy!):

WHEN WILL THE VACCINE BE AVAILABLE?
The first 7 million doses of H1N1 vaccine began shipping the week of October 5. Another estimated 60-195 million doses are anticipated to ship over the next few months in weekly batches. Currently we have no information as to the where the rollout of the doses will occur. The best strategy is to watch your local news and keep abreast of notices posted or sent by your health care provider.

ARE THEY ANTICIPATING ENOUGH TO MEET DEMAND? WHO ARE THE PRIORITY RECIPIENTS?
Hopefully, yes -- especially as it pertains to high risk individuals. The first groups who will be targeted for immunization are the following:

• Household members/caregivers of babies under 6 months of age
• Children 6 months - 4 years of age
  
• Children 5 years - 18 years of age with high risk health conditions (asthma, lung disease, sickle cell anemia, heart disease, chronic kidney disease, immune compromise, chronic asprin therapy, blood diseases, neuromuscular diseases, diabetes, and HIV)
• Pregnant women
• Adults with high risk health conditions
• Health care workers
• Very obese individuals (BMI >35)
• Elderly living in nursing homes & assisted living facilities

IS THERE ANYONE WHO THE VACCINE IS NOT RECOMMENDED FOR?
For individuals with severe egg allergy, or history of anaphylaxis to egg or any components of the vaccines, immunization is not recommended. In addition, individuals with a history of Guillain-Barre Syndrome shouls not receive the influenza vaccine.

WHAT ARE THE DIFFERENCES AMONG THE 4 VERSIONS OF THE VACCINE?
Currently 4 manufacturers have been producing H1N1 vaccine. Three are producing shots, and one is producing a nasal spray.

• CSL Brand: FDA-approved for individuals 18 years of age or older
• Novartis Brand: FDA-approved for people 4 years of age or older. There are 2 forms of this shot:
  1: Multi-dose vials -- using thimerosal as a preservative
  2: Pre-filled single-dose syringes -- thimerosal used in the manufacturing process but extracted before final production
  

• Sanofi Brand: FDA-approved for children 6 months of age or older. There are 2 forms of this shot.
  1: Multi-dose vials -- thimerosal-free
  2: Pre-filled single-dose syringes -- thimerosal-free
  
  
• Medimmune: FDA-approved nasal spray for individuals 2 years of age to 49 years.

The SAME stringent manufacturing standards and processes used for the production of regular seasonal influenza vaccine apply to the H1N1 vaccine as well.

WHAT SHOULD I KNOW ABOUT THE VACCINE IN NASAL SPRAY FORM AND HOW DO I CHOOSE BETWEEN THE SHOT AND THE NASAL SPRAY FORM?
The mist form of H1N1 vaccine is very similar to Flumist - the vaccine used for seasonal flu protection. It is a live-attenuated vaccine, and is thimerosal-free. It is FDA approved for healthy people 2-49 years of age. Two doses are needed for kids under 10 (given a month apart), and one dose for kids 10 years of age or older.
If your child does not have a history of asthma, recent wheezing, or a high-risk health condition, the mist form of the H1N1 vaccine is a non-painful option for your child. The downside might be a day or two of sore throat, sniffles and/or a low-grade fever. Live virus preparations typically activate a different arm of the immune system and may result in more prolonged immunity. The H1N1 pandemic vaccine in mist form is free, however your health care provider will likely charge an administrative fee to cover the cost of staff time, disposal of syringes, and administrative time necessary to obtain the vaccine.
Certain individuals SHOULD NOT receive the mist form of H1N1 vaccine. They include:

• Individuals with severe/anaphylactic reaction to egg or components of the vaccine (gentamicin, gelatin or arginine)
• Pregnant women
• People with asthma or active wheezing; children under 5 years of age with recurrent wheezing
• People with immune deficiencies
• People with underlying medical conditions that may be aggravated by live vaccine (always check with your health care provider)
• Children under 2 years of age
• People with extremely stuffy, congested noses (as absorption of the vaccine may not occur)
• Children or adolescents on chronic aspirin therapy
  

SHOULD I WORRY IF MY CHILD CAN ONLY GET A FLU SHOT THAT USES THIMEROSAL PRESERVATIVE?
No. Priority for thimerosal-free vaccine will be given to pregnant women and children. However, if the only flu vaccine available for administration is one in which thimerosal was either used in manufacturing or a tiny amount in the final product, it is still a good idea to get the vaccine.
Thimerosal is a preservative that has been used since the 1930's to prevent contamination isn some multi-dose vials of vaccines (preservatives are not required for vaccines in single-dose vials). Thimerosal contains approximately 49% ethylmercury, not to be confused with Methlymercury (found in sushi and large pelagic fish such as halibut, swordfish and tuna). The kidneys excrete thimerosal very effectively, while methylmerciry is fat-soluble and more likely to be absorbed by its host.

There is no convincing evidence of harm caused by the low doses of thimerosal in vaccines, except for minor reactions like redness and swelling at the injection site. However, in July 1999 the Public Health Service (pHS0 agencies, the American Academy of Pediatrics (AAP) and vaccine manufacturers agreed that thimerosal should be reduced or eliminated in vaccines as a precautionary measure.
Thimerosal-free influenza vaccines are available, but in limited quantities (availability will improve as manufacturing capabilities are expanded). Priority for thimerosal-free vaccine will be given to pregnant women and children. However, if the only flu vaccine available for administraion is one in which thimerosal was either used in manufacturing or a tiny amount in the final product, it is still a good idea to get the vaccine. To date, there is still not any substantial proof that thimerosal is harmful in any way.

ARE THERE ANY CONTROVERSIES AROUND THE VACCINE, ITS INGREDIENTS, ETC?
The H1N1 vaccine does NOT contain any aluminum or other adjuvants (products that increase a body's response to a vaccine). Other countries have used adjuvants since 1997 but the US manufacturers have never done this. As a result all H1N1 vaccine (in all forms) is adjuvant-free. This has been a source of debate because using an adjuvant makes it easier to create more vaccine to meet demand.
Many parents have come to use with concerns that the H1N1 vaccine may cause Guillain-Barre Syndrome (GBS). Certainly on the internet this concern is a hot topic. It's worth a little extra reading on the CDC website to set the record straight.

IS IT A ONE DOSE SHOT OR IS A BOOSTER REQUIRED?
H1N1 vaccine has slightly different ground rules* than regular seasonal flu vaccine. Think of the first dose as "priming" the immune system, and the second one as "activating" the child's immunity. One dose will NOT protect a child 6 months of age through 9 years.
*Normally, regular seasonal flu vaccine requires 2 doses the FIRST YEAR it is given for children under 9 years or age, and then once yearly after that.)

ARE THERE ANY POSSIBLE SIDE EFFECTS CAUSED BY THE VACCINE?
Typical reactions to the H1N1 vaccine are anticipated to be the same as those experienced with regular seasonal flu vaccine. For the shots, these include possible pain/soreness at the injection site, muscle ache, headache, low grade fever (usually for a day or two), fainting (usually in adolescents) and rarely allergy to one of the components of the vaccine. For the nasal mist preparations (since they have low levels of the live virus) nasal congestion and stuffiness are fairly common for a few days after administration, in addition to possible low grade fever, muscle aches and fatigue.

HOW HAS THE VACCINE DONE IN CLINICAL TRIALS?
Two different 2009 H1N1 influenza vaccines have been enrolled in clinical trials as of July 2009 -- one made by Sanofi Pasteur in Swiftwater, PA and the other by CSL Limited in Melbourne, Australia. Initial review of the data involving more than 500 healthy adult volunteers showed both vaccines to be safe and effective. Because of these positive results, clinical trials began on children on August 18, 2009 using the Sanofi H1N1 vaccine.
The pediatric trials have involved eleven medical centers nationwide, and more than 1200 children between the ages of 6 months to 17 years have been given the vaccine. Preliminary results published 9/21/09 showed that an effective immune response was seen in the majority of 10-17 year old eight to ten days after receiving the vaccine. Younger children generally had a weaker early response to the vaccine.
Current ongoing studies are addressing whether there is a dose:response relationship with the vaccine - i.e. is giving more of the vaccine going to yield better or longer immunity? In addition, the effectiveness of combining seasonal influenza vaccine with the 2009 H1N1 vaccine is also being examined. Data will be updated as it comes in from the National Institutes of Alelrgy and Infectious Diseases (NIAID) and from the National Institute of Health (NIH).

SHOULD MY CHILD GET BOTH THE SEASONAL FLU VACCINE AND THE H1N1 VACCINE?
Yes, it's a good idea to protect your child from all threatening strains of flu this year. Most health care providers already started administering regular seasonal flu vaccine early in September. Unfortunately, full production and shipments of vaccine to all health care entities were held in order to produce H1N1 vaccine. As a result, your health care provider may be awaiting shipment of more regular seasonal flu vaccine (especially preservative-free formulations) -- and all any of us can do is wait patiently for the remainder.
Both seasonal flu shots and H1N1 shots can be given on the same date and if a repeat dose is needed, those doses can be given together as well. The only tricky part here is that a child cannot receive protection from two MIST preparations on the same day. So a parent has the prerogative to opt for one shot/one mist. If you only want your child to receive flu protection in mist form exclusively, you must separate all those doses by 4 weeks -- thus stretching out immunization over 4 months and possibly delaying the timely administration of second doses, if required.
Also, keep in mind that if your child has had any other live virus vaccine (ie MMR, Chicken Pox or Rotavirus vaccine) within the last month, you should wait FOUR weeks after that vaccine before administering any flu vaccine.

AFTER WHAT DATE IS IT TOO LATE TO GET THE VACCINE?
Peak flu season varies across the US -- on the East Coast and Northern regions flu season peaks around the holidays, whereas on the West Coast and Southern regions, often it peaks as late as February. Unfortunately, since H1N1 novel strain seems to know no "season" (having surged in the Spring, quieted a bit in summer, now ramping up again) anytime is appropriate, but the earlier the better. What we have yet to know is whether we will need to have to repeat inoculations more than once yearly, given the propensity of H1N1 to occur year round (as typical influenza vaccines last generate only 4-6 months of immunity).

For regular updates on H1N1 and its vaccine, we suggest you visit the CDC Website regularly, and/or follow @CDCflu on twitter.

To read the edited version of this article, "Worth a Shot? H1N1 (Swine Flu) Vaccine Update" visit StrollerTraffic.com and their health and safety section.

AAP Considering Update: Rear-Facing Carseats Until Age 2

In case you haven't heard, the American Academy of Pediatrics is considering changing their carseat policy in 2010 to recommend REAR-FACING carseats for ALL children up to the age of TWO YEARS. Not official at this point (though that implication is making the rounds...even to our offices!).
Even if little feet touch the seat, injury rates and severity have been shown to decrease dramatically with kids in the rear-facing position. In fact, according to research, toddlers between the ages of 12 and 23 months who ride rear-facing in a car seat are more than FIVE times safer than toddlers in that same age group who ride forward-facing in a car seat.
We're thinking it's a great idea to turn your tots back to rear-facing -- for their health and safety. Your sanity may suffer a little bit, but safety comes first!

We want to know what you think. How do you feel about this potential recommendation? Will you turn your kids back to the rear-facing position?

Health & Safety Tip: Are you keeping your New Year's Stay-Healthy Resolutions?

Well, we're 22 days in to the New Year and it's awe-inspiring to think how much change we've all been surrounded by of late! With all this excitement, it's sometimes easy to forget the promises we made to ourselves at the top of the year, so we thought we'd check in and see how your progress is going on your New Year's resolutions. We know how difficult it is to keep them, however well-intended they may be. So we're sharing our favorite stay-healthy resolutions that are actually easy to keep (and easy to pick up again any time of year)!

1. "I resolve to use sunsreen on my family every day."
   We know, we know..."But it's January! And we're not at the beach!" Believe it or not, harmful UV rays don't just make their appearance Memorial Day through Labor Day. Exposure to UV rays adds up all year round. The most effective way to prevent skin cancer (aside from staying out of the sun) is to use sunscreen 365 days a year. Our favorite (though we know we're biased) is the Babysafe Sunscreen Towelettes SPF 30+. These indispensable sunscreen wipes are so easy to pop in the pocket of your winter coat and have a perfect amount of sunscreen to cover any exposed areas like face, ears & back of the hands -- any time of year.
   
   
2. "I resolve to wash my hands...a lot!"
   In our pediatric practices we are constantly bombarded with nasty germs, yet we rarely get sick. Our most tried & trued stay-healthy secret is surprisingly simple: We wash our hands constantly! Hand washing is the most effective (and easiest) way to prevent the spread of germs that cause colds, the flu, and several gastrointestinal disorders. Help your kids get in the habit early by teaching by example. Make it fun and lather up to a rousing rendition of the ABCs! If you don't have soap and water handy, go ahead and use a great multipurpose alcohol-free wipe or all-natural hand sanitizer.
   
   
3. "I resolve to adhere to the 30-second rule."
   Did you know the most effective way to maintain your and your baby's precious moisture barrier is to smooth on a moisture balm within about 30 seconds of patting dry? We like to call it the "30-second rule", and it's one of our favorite techniques to recommend to parents of children with eczema and dryness. Especially as the temperature continues to drop and winter dryness threatens even normally supple skin, we suggest at least a once-daily dose of moisture balm. A note to parents of children with very dry skin or eczema: One key to successfully treating these conditions is REPEATED application throughout the day.
   
   
4. "I resolve to up the antioxidant ante."
   Antioxidants protect us (and our babies) on the inside and out, aiding in skin repair and strengthening blood vessels. Blueberries are our top "superfood" choice for little ones (they're packed with antioxidants, phytoflavinoids, Vitamin C and potassium!) and a recent British study even showed that an antioxidant-rich Mediterranean diet may even prevent allergic rhinitis and asthma symptoms in youngsters. When it comes to the outside, be sure to look for antioxidants like Vitamin E, Avocado Oil, Grapeseed Extract and Olive Squalane to protect baby's uniquely delicate skin from environment damage.

These resolutions we know we can keep... Now if only somebody would make it easier for us to stop eating chocolate and start jogging!

October is Breast Cancer Awareness Month

Philanthropy is an essential core value of ours, both in our personal and professional lives as pediatricians and through MD Moms. As physicians, women and mothers we are committed to raising awareness when it comes to both child and family health.
As you may or may not know, October is Breast Cancer Awareness Month. While we love that there is a month of the year dedicated to awareness, we hope it will just be a kickoff to what is an entire year, and lifetime, of action.

It is nearly impossible to encounter a family that has not been touched by this dreadful disease in some way. For some of us it is our mothers or fathers, our sisters, our aunts, our grandmothers. For others it is a best friend, a friend of a friend, an acquaintance.
Many of you reading this have bravely fought and gloriously triumphed over a most devastating diagnosis. Too many women (and men) have not.
One more mother, one more grandparent, one more individual dying from breast cancer is one treasured person too many.

During the month of October, we will be donating 15% of the web sales of Baby Silk on our site mdmoms.com to The Breast Cancer Research Foundation.
This global organization, founded by the extraordinary Evelyn Lauder fifteen years ago, is dedicated to finding a cure in our lifetime and we hope we can help make that goal a reality!

We hope you will be inspired by a person you know, or even one you don't, to join us, get involved, and take action to fight breast cancer.

Health Tip: How to Perform a Breast Self-Exam

Get the facts.
Breast self-exam, as part of a 3-part program (including self-exam, mammograms and clinical breast exams every 3 years starting at age 20) can be an important element in the early detection of breast cancer. But how many of us really know how?

Here, a step-by-step guide on 3 different ways to perform a breast self-exam:
IN THE SHOWER

• Put one hand behind your head, elbow facing upward
  

• With the pads of your three middle fingers, move your hand over the entire breast area
  

• Use right hand for left breast, left hand for right breast
  

• Use one of the three following patterns to examine your breasts: 1)Circle: in a series of circles around your nipple, middle of breast, and outside perimeter of breast; 2) Up & Down: up and down in a zig zag pattern from top to bottom over the entire breast; or 3) Wedge: in a series of "wedges", working from the nipple outward in 8 or so sections
  

For consistency, be sure to examine the same way each time, using the pattern and technique recommended by your healthcare professional at your clinical breast exam. (The American Cancer society recommends the up & down pattern.) Check for lumps, knots or thickenings.

LYING DOWN

• Place a pillow or towel under your right shoulder, with your right hand behind your head.
  

• Using your left hand, follow the same technique (using one of the above patterns) as in the shower. Then lower your right arm slightly and with your left hand, check your right underarm.
  

• Check for lumps, knots or thickenings.
  

• Repeat on the other side, using your right hand to check the left breast and underarm.
  

IN FRONT OF A MIRROR

• With your hands firmly pressing down on your hips, check for changes in shape, size or skin texture of your breasts. Then raise your arms overhead and check again. Be sure to note any swelling, redness or skin dimpling. Also be sure to check for any changes in your nipple or unusual discharge.
  

Be sure to perform a self-exam monthly (perhaps after your periods when your breasts are not full or tender) and report any changes or irregularities to your healthcare professional immediately.

An important note: This guide is not intended as a replacement for medical care. For a complete diagnosis and course of treatment, please see your doctor.

The Breast Cancer Research Foundation has a great resource in its Breast Cancer Basics Library. Be sure to check it out for video and articles about everything from more details on how to perform a self exam to understanding the stages of breast cancer.

Health & Safety Tip: Have Fun in the Sun...Safely!

☼Summer time is for relaxing and having fun in the great outdoors. It’s also time to think about sun safety. The most common type of skin cancer in the US is caused by unprotected sun exposure (specifically UVA and UVB ultraviolet rays) in childhood and adolescence.

☼ Between 60% to 80% of sun exposure happens before we turn 18 years of age. That’s because children spend more time outdoors than most adults, especially in the summer.

☼ The majority of lifetime sun damage occurs before the age of 18, and did you know that just two or three blistering sunburns during childhood can DOUBLE the risk of skin cancer later in life? More than 90% of all skin cancers are caused by the sun, and yet less than 33% of adults, adolescents, and children routinely use sun protection.

☼UVA (the “AGING rays”) cause wrinkling, spotting and skin cancer by penetrating deep into skin. UVB (the “BURNING rays”) sizzle the top layer of skin and contribute to skin cancer risk.

Here are some practical tips to help reduce these risks:

• Avoid direct sun exposure during the peak hours of the day, usually between 10AM to 4PM. Harmful UV radiation is maximal during this interval. Stay in the shade if possible. Reapply sunscreen at 2-4 hour intervals if your child is dry, at 1-2 hour intervals if swimming or wet.

• Dress your child in UV infused clothing (Cabana Life and Wallaroo Hat Company are examples) or use an SPF rinse on tightly woven cotton clothing to raise the SPF value from 5 (regular cotton t-shirt) to spf 30 (we like SunGuard Laundry Aid).

• Your child should wear sunglasses that offer 99-100% blockage from ultraviolet rays (check for ANSI rated UVA & UVB protection). Also, remember a hat with a wide brim that will shade the face and cover the ears.

• Be more diligent about consistent sunscreen use around the water, sand and snow as they all reflect the sun’s rays, increasing the risk of sunburn. (Our Baby Silk Babysafe Sunscreen Towelette Singles are a convenient way to take sun protection on the go...no matter the locale or temperature!)

• The American Academy of Pediatrics and the American Academy of Dermatology recommend that, if avoidance of sun exposure is not possible, babies - no matter how young - should be protected with a sunscreen that has at least a SPF15 and offers both UVA and UVB protection (broad spectrum.) In addition, due to the sensitivity of young children’s skin, the ideal sunscreen should be one containing Zinc Oxide and Titanium Dioxide (pure physical block ingredients). These two ingredients offer the safest protection with the least potential for skin irritation. Unlike a chemical block, which needs minimum 20 minutes absorption time to be fully effective, a physical block will work immediately upon application, as the sun’s rays are reflected from the barrier on top of the skin.

• Use enough sunscreen for effective protection. One ounce (the size of a shot glass) is recommended per application. If a chemical sunscreen is used, apply it to your child’s face and body, wait 20 minutes and re-apply (so that any missed spots are covered, and areas that wear against clothing or sweat get double coverage). Reapply at 1-2 hour intervals if swimming or wet, and at 2-4 hour intervals all through the day. (Our Baby Silk Babysafe Sunscreen Towelettes have a premeasured dose of sunscreen to adequately cover the average 2-year old from head-to-toe.)

• Always patch test any new topical product on a small area of skin on the extremities or trunk. Wash off or discontinue use if redness, itching or irritation occurs. Discard sunscreen that has passed its expiration date. A good rule of thumb is that, if it is more than 2 seasons old, it has lost its potency.

"Safe sun" doesn't have to be a contradiction in terms. Know your sun facts, be prepared ( a little Girl Scout motto that has stuck with us!), and HAVE FUN! Happy Summer!