14 May 2007
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
1. General question - Do multiple immunizations ever have contraindications or side effects? If so, which ones? For example; if my son was given a Meningitis C vaccine (only offered in the UK) and a PCV 7 vaccine (only offered in the US) would there be a problem? I am concerned about my son receiving vaccinations in both the UK and US and the UK being relatively uneducated about the specifics of the types of vaccines given elsewhere.
2.They do not give (and will not give) the Prevnar- PCV 7 injection here. My son had his first one in the US in June. We plan on being back in the US in Nov. and then in Feb. for certain (possibly sooner). Can we catch up then or should we forget about this vaccine all together and vaccinate him when we actually move to the US full time?
3. They recommend a Meningitis C vaccine here. The literature that I have read states that although it does not happen very often, it is the most common cause of death among children aged 1-5 and the most common infectious disease causing death in children and young people. Last year there were 1530 cases of group C in UK, 150 resulting in death. Also it is most common in babies and that it is easily spread by coughing, sneezing, or direct contact. I would like for my son to have it. Do you have any concerns with it? I am concerned about meningitis altogether because my 18 yr. old cousin died within several hours of meningitis 2 years ago.
4. Although it is too late now because we have had other injections, I recently read that no injections should be given in the same arm as the BCG injection within 3 months. Have you heard of this? If so, why?
5. The UK gives a DTP injection and not the DTaP. I am able to order the acellular version through a private physician in another part of town. Do you highly recommend the DTaP?
6. The UK vaccination schedule is 2, 3 and 4 months. I have read that this is bc they have found, through research, that it is safe to give them closer together and that way the child will become immune faster. If this seems right, please disregard. If not, could this be bc their vaccinations are less potent?
7. I have had to special order the IPV Polio injectable and again it is from another different source. Do you highly recommend it vs. the oral?
-May
Dear May: 1. There are no vaccines which interfere with each other. They can all be given together. There is no evidence that giving multiple vaccines at the same time increases the risk. There is a theoretical concern that if two live virus vaccines (MMR, Varicella, or Sabin [Oral Polio]) are given within a few weeks of each other the immune response to the second one may not be adequate; however, they may all be given at the same time or at least 1 month apart with no such concern.
2. The protection against pneumococcal disease provided by Prevnar will be valuable any time your son can get it. By all means resume the immunization when you visit the US.
3. The Meningitis C vaccine is actually very similar to the HIB vaccine and Prevnar and protects against disease caused by Meningococcus group C. Although I have no experience with the vaccine, I would expect it to be as safe as the HIB and Prevnar because of their similarities. I would always recommend taking advantage of immunizations available to protect against diseases prevalent in your area. Meningococcal disease is not common, but when it occurs it can spread to others and can be devastatingly rapid in its progression. It may very well be what your cousin had.
4. I looked in a booklet about TB and found nothing about avoiding vaccines in the same arm as BCG. I know of no reason why this would be so. Since we don't give BCG in the US, we have no experience with it. If you can find out anything about this question from your doctor, I'd love to know about it. I'd be happy to discuss what he tells you if it seems unclear or questionable.
5. The DTaP is a safer alternative than the DTP since it causes less reaction. Considering that the brouhaha about the safety (or lack thereof) of the Pertussis vaccine started in Great Britain I'm amazed that they use DTP. If it was the only choice, I'd go for the protection afforded by that vaccine, but I'm glad you had a choice.
6. Most immunizations can be given at a minimum dosing interval of 1 month and still be safe and effective. I don't know if giving them closer together will actually provide more complete protection earlier. Apparently the powers that be in the US have not been convinced of a need to change the recommended schedule. Each dose of vaccine does provide immunity, but since infants don't mount as good an immune response as older children the doses must be repeated regularly to continue immunity. Children who start their immunizations later require fewer doses, but since infants have the greatest risk with these diseases, it makes sense to get the immunizations started at the earliest age at which they will be effective.
7. OPV is a safe vaccine and is actually recommended in situations where a person might be exposed to polio such as travel to a country where polio is still prevalent. The safety of the OPV vaccine has not changed. It is a live vaccine which carries a risk of causing paralytic polio at a rate of about 2 cases per million doses. In a country where there is no polio, even that small number is not an acceptable risk. In the US we were seeing about 6 cases per year of polio, all caused by the OPV. To eliminate that risk we were advised to switch to IPV. IPV is an effective, killed polio vaccine which carries no risk of paralytic polio. In a country such as the US and UK where the risk of polio is nil IPV is the safer, and therefore better alternative, but if IPV could not be obtained, I would still consider OPV safe. All my kids had it.
Sincerely,
Dr. Warren
-Mokm of Six
Dear Mom of Six: While it is true that night terrors don't have to be caused by stress, stress may certainly contribute to the problem. If the night terrors started right after your daughter's reintroduction to her biological mother, and especially if there is any evidence that your daughter is stressed during the day, you should consider exploring the emotional link further.
Waking your daughter to use the toilet, even if she is just barely awake, interrupts the night terror, but does nothing to prevent nightly recurrences. The only technique I've heard of which is purported to work is to wake the child each night just prior to the usual time of onset of the night terror. After a few days to weeks of doing that, hopefully the cycle will be broken. The only thing else I can tell you is that this problem will eventually come to an end.
Sincerely,
Dr. Warren
Thank you.
-FO
Dear FO: In 29+ years as a pediatrician I've never run across a child who was too hot to wear night clothes. Children's preferences do develop early on and include an element of the child's personality as well as the habits they develop based on their life and environment, but this degree of heat intolerance (or intolerance of items touching the skin, e.g., clothing) seems extreme and calls out for evaluation. Start with a complete medical evaluation including testing to make sure your daughter is not hyperthyroid. If all is normal, consider a neurological evaluation to make sure that your daughter isn't experiencing hyperesthesia (overly sensitive nerve endings in the skin). Finally, depending on how much of a behavioral and cooperation problem there is regarding keeping clothes and shoes on when it should be expected, consider a psychiatric evaluation.
Sincerely,
Dr. Warren
-TK
Dear TK: The average height for a 4 month old is 24 inches with a weight of 12.5 pounds, but why worry about averages. Everyone isn't supposed to be average. Average and normal are not equivalent. The normal range goes from the 5th percentile to the 95th percentile. Those children whose growth parameters fall outside the normal range have a greater risk of having a problem causing their growth to be outside the normal range; however, these normal ranges were derived statistically from looking at measurements for normal children, so even a few healthy children are bound to have their growth outside the normal range. Your daughter's height and weight are appropriate for each other and just above the 95th percentile. There are many factors affecting adult size, so the fact that she is large cannot be used to predict her future growth. As long as she is healthy, there is absolutely no cause for concern about her size.
Sincerely,
Dr. Warren
Thank you for your prompt response.
-Patti
Dear Patti: As long as the baby does not have an ear infection at the time of the flight she should tolerate it perfectly well. If she is nasally congested, it would help to use a decongestant nose drop before the flight such as pediatric Afrin or 1/8% Neosynephrine. It might make her more comfortable to be sucking on something during takeoff and landing.
Note to my readers: Even medications as simple as nose drops can cause adverse reactions. In addition, these drops are only for accasional use since after 3 days of use discontinuation may result in rebound stuffiness. The point about ALL medication is Use only when needed, as directed, and with caution.
Sincerely,
Dr. Warren
Thank you for your time and I hope that you will be able to provide us with some insight.
Sincerely,
-Suzanne
Dear Suzanne: When there is a problem, it's easy to focus on something visible in the hopes that it will provide the solution to the problem. Unfortunately, "milk bumps" or epithelial pearls on the gums of newborns are perfectly normal so finding it did not provide you with any explanation or possible solution to this baby's feeding problem.
In my experience, babies with feeding problems do not do well going back and forth from breast to bottle. The mother's milk can only come in if the baby does a good job of nursing. Giving bottles very often interferes with the infant's putting extra effort into sucking and usually results in less time spent on the breast, less milk production, and less effective nursing. Unless the baby has a medical problem interfering with eating, this is not a medical problem, although it could become one if the baby becomes dehydrated or malnourished.
If La Leche League is looking to help this mother they need to get her in touch with a lactation consultant who can visit her home and help her with nursing. Few physicians, including myself, are equipped to provide the kind of help this mother needs; however, the pediatrician should be monitoring the situation and counseling the mother appropriately.
Sincerely,
Dr. Warren
Thank you.
-Concerned
Dear Concerned: If a man had both testicles removed he would require testosterone replacement (hormone treatment) in order to develop normal adult male body characteristics. Such treatment would be continued to maintain normal body build, facial hair, etc. Continued hormone treatment would result in a normal sex drive, but the man would be sterile.
If a man had one testicle removed he would not require any treatment, would have a normal libido, and be able to father children.
Sincerely,
Dr. Warren
-(unsigned)
Dear Student: As a veterinary student you probably have more access to information about the toxicity of Tylenol in cats than I do. Most people don't realize how complex the process is whereby medication taken by mouth gets into the body and does its work. First, ingested medications must be digested and absorbed. Then they must be metabolized. All intestinal circulation makes its way to the liver where complex molecules are detoxified. Sometimes the active part of a medication doesn't even get into the body until after metabolism in the liver.
Since many medications are metabolized in the liver, they are liver toxic when taken in overdosage. My understanding is that the cat's liver is unable to detoxify acetaminophen, and therefore Tylenol is toxic to cats. If you need more detailed information you should probably check your school library or talk to one of your professors.
Sincerely,
Dr. Warren
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