Reclaiming Skepticism

The other day, while poking around on the Interwebs, I ran across a quote that I’ve seen more than once, never attributed, along the lines of:

To the believer, no proof is required; to the skeptic, no proof is sufficient.

Though this statement is partially accurate — a person who believes in God, for instance, does so on faith and neither requires nor looks for evidence to justify those beliefs — its inaccuracies distress me. The term skeptic seems to have come to mean, at least in common usage, a person who does not believe in {xyz}, even when presented with evidence. For instance, those individuals (mostly Americans) who continue to doggedly refuse to acknowledge the reality of global warming, despite overwhelming evidence to the contrary, are often called (and call themselves) climate skeptics. I take issue with this. A skeptic is a person who insists upon seeing and evaluating the evidence before passing judgment. A skeptic appropriately reassesses his or her beliefs when presented with new evidence. A skeptic is a critical thinker, and is not emotionally attached to the outcome of his or her thinking process. A person who found the hypothesis of global warming interesting — but not necessarily convincing — back in the late 1970s when the National Academy of Sciences released the first major report on climate change would have been appropriate called a skeptic. A person who refuses to believe in global warming today — when every major government on Earth except that of the U.S. openly acknowledges the problem, when empirical evidence drawn from weather patterns, animal behavior patterns, and atmospheric data all support significant warming patterns — is not a skeptic, but a denier.

In my attempt to find an original source for the believer/skeptic quote, I ran across the following on a web forum for discussion of paranormal phenomena; I thought it was absolutely fabulously stated:

To the skeptic, evidence is everything. To the believer, everything is evidence.

-A forum user who calls himself TheBoyPaj on JREF

As there appears to be no other reference on Google to this particular quote, I believe it’s an original. As such, to TheBoyPaj — wherever and whomever you are — thank you. I’d like to shake your hand.

“To the skeptic, evidence is everything,” he says. No doubt. In this age of the University of Google, though, examining evidence is less a matter of finding information than it is of evaluating that information for its quality. Take, for instance, the growing concern in some circles that vaccines are linked to autism. I had one of my university classes read Seth Mnookin’s wonderful book The Panic Virus recently; in it, Mnookin explains that the “evidence” used to support this conviction ranges from the wildly inaccurate to the irrelevant. An example of the former is the poorly conducted, fraudulent study published in The Lancet by Andrew Wakefield et al. An example of the latter is toxicological data on methyl mercury (the kind in seafood), which is a potent neurotoxin in very small doses. Anti-vaccine advocates refer to such data in support of their objection to the presence and quantity of mercury in vaccines. However such references are almost always made without specification of the particular form of mercury present; thimerosal, used as a vaccine preservative, contains not methyl but ethyl mercury. This distinction seems small (after all, mercury is mercury, right?), but is, in fact, critical. Methyl mercury and ethyl mercury are as different as methyl alcohol and ethyl alcohol: the former is lethal even in small doses, while the latter is the alcohol in beer, wine, and liquor; while toxic in large doses, it’s safe and pleasurable in appropriate quantities. Maybe the most descriptive and accurate phrasing would be, “To the skeptic, the quantity and quality of evidence is everything,” but then, that wouldn’t sound nearly as graceful.

On the flip side, there’s the matter of blind belief. The Panic Virus is excellently researched and beautifully written, and I won’t do it the disservice of trying to summarize it here. To the point, though, Mnookin interviews a number of higher-ups in autism societies who firmly believe in the thoroughly-debunked vaccine-autism link and who tell him (in paraphrased terms) that it doesn’t matter what the science shows; we will continue to believe — we know in our hearts — that vaccines cause autism. “To the believer, everything is evidence,” TheBoyPaj says, and he’s absolutely right.

 

References

Wakefield et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998 Feb 28;351:637-41. RETRACTED (see Lancet. 2010 Feb 6;375:445)

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Chemicals and Toxins — What Is Safe?

One of the most common questions I get from SquintMom readers is along the lines of is item/substance/compound XYZ toxic? I’d like to go ahead and answer this once and for all: YES, it is.

Now let me explain what I mean, and how I can answer this very generic question in a catch-all way without specifying the item/substance/compound to which I refer. Because he said it so well that it doesn’t need rephrasing, I’ll quote the Renaissance-era botanist Philippus Aureolus Paracelsus, who said:

All substances are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy.

Phrased more generally, this is simply that any substance can be either safe or toxic; the dose (quantity) to which one is exposed is what makes the difference. I’ve mentioned in previous posts (like this one about oxybenzone in sunscreen) that the notoriously jumpy Environmental Working Group (EWG) systematically fails to recognize this particular principle; they have a tendency to vilify anything that proves toxic in any dose, under any conditions. This attitude, however well intentioned, leads us to some interesting places. Pause for a moment and check out the cautionary website DHMO.org. Note that the highly toxic dihydrogen monoxide (DHMO) is associated with cancer (it’s found in every tumor ever identified), has serious environmental impact (it’s a major greenhouse gas and overexposure is associated with thousands upon thousands of deaths every year), and, per the website:

[DHMO’s] basis is the highly reactive hydroxyl radical, a species shown to mutate DNA, denature proteins, disrupt cell membranes, and chemically alter critical neurotransmitters.

Sounds horrid, doesn’t it? No doubt we should ban it. Except that…DHMO.org is a joke website, and dihydrogen monoxide is the almost never-used, formal chemical name for water.

None of the information on DHMO.org is false, which is what makes it both amusing and apropos to this discussion. Water does, in fact, directly result in many deaths. Not only through “overexposure” via flooding and/or drowning, but also through overconsumption. For instance, in 2007, a radio station held a contest (“Hold your wee for a Wii”), the idea of which was to drink as much water as possible without a bathroom break; the caller who drank the most would win a coveted Wii game console. Contestant Jennifer Strange won (and then lost) by consuming more than 2 gallons of water in the space of less than an hour. She died shortly thereafter of hyponatremia, a condition in which there is an insufficient concentration of sodium in the body fluids to support life (sodium is critical to cellular function, neural conduction, muscular contraction, brain function, and so forth). This is not the only incident of water toxicity on record; similar cases have resulted from fraternity hazings, bizarre diet plans, and overconsumption of water during endurance sporting events like marathons.

On the other hand, there are substances that we typically consider highly toxic that are, in the right dose, of great medicinal utility. Clostridium botulinum is a species of bacteria that produces botulinum toxin, generally considered the deadliest substance on Earth. The average 150 pound man would have a 50:50 chance of survival if exposed to merely 341 ng (that’s less than a millionth of a gram) of pure botulinum toxin. Regardless, marketed under the trade name Botox, botulinum toxin is used for cosmetic purposes (wrinkle treatment and prevention). Of perhaps greater medical importance, it’s also used to ease the painful symptoms of temporomandibular joint syndrome (TMJ) and other spasmodic disorders, and mitigate the symptoms of diabetic neuropathy (damage to peripheral nerves, often in the feet, due to diabetes).

Further complicating matters, our perception that “natural” substances are somehow safer or better for us than “artificial” substances is misinformed. A simple example is the flavoring agents found in many foods. While the common perception is that natural flavors come from the food of which they taste (strawberry flavor, for instance, comes from strawberries), nothing could be further from the truth. In reality, natural and artificial flavors are generally identical chemicals, collected or produced in different ways.* Natural almond flavor, for instance, isn’t a mixture of “natural substances” that come from almonds. Instead, it’s a chemical called benzaldehyde that is extracted from peach pits. Artificial almond flavor is also benzaldehyde, but unlike natural almond flavor, the artificial stuff is made in the lab. Funnily enough, it’s possible to get benzaldehyde made in the lab much more pure than that extracted from peach pits. Further, the stuff that comes from peach pits — the natural almond flavor, remember — contains small amounts of deadly cyanide that occurs naturally in those same peach pits (one of many reasons it’s not wise to eat the pits of stone fruit).

*Eric Schlosser’s excellent book Fast Food Nation contains a very interesting chapter on this topic, for further reading.

Where does this leave us, in trying to avoid toxins? First, as a chemist, let me just say that the word toxin is very often misused in popular sources and conversation, and the word chemical is almost always misused. “Chemicals” are not bad things that cause harm and should be avoided. Instead, they are matter; they are what makes up the physical universe. Nothing that has mass and occupies space — nothing we touch, eat, drink, breathe — is not chemical. There’s no such thing as chemical-free bread, shampoo, or paint. Water is a chemical (and — let’s not forget — a toxic one at that). With regard to toxins, the word is used too often in a vague, handwaving sense on the Interwebs. I see pop-authors (who are generally trying to sell something) write about how Product X contains “toxins,” and should therefore be avoided, or Product Y (which they’re selling) contains no toxins.* I’m not sure what these folks mean when they say “toxins” (and since they rarely name said toxins, I’m not sure they know either); after all, let’s not forget that all substances are toxic in the right dose.

*Or worse yet, Product Y (which they’re selling) is a detoxifying agent. This is ridiculous; almost all humans (with the exception of a few with significant disease) are possessed of one of the most powerful detoxifying mechanisms known to man — a liver. Livers work really well, particularly when they’re left alone to do their job.

This is not to say that we should all go about our business with no concern whatsoever for the things we touch/eat/drink/breathe; it’s simply to say that we simultaneously worry too much and worry too little about “chemicals.” To take one particular example, a few scare-articles about bisphenol A (BPA) have some of us so worried (and confused) that we’re willing to shell out extra cash for BPA-free diaper wipe containers, toys, and even a bath toy organizer. In reality, if BPA has any effect at all in doses to which we’re routinely exposed (which has not yet been established), it would require significant physical contact with the compound to absorb it. Holding, playing with, or storing one’s bath toys in a BPA-containing item would not be a problem, particularly given that while the absorption rate of BPA through human skin hasn’t been thoroughly evaluated or established, it nevertheless appears to be significantly lower than the (already modest) rate of absorption through the skin of other animals (Marquet et al). Based upon the current research, might it be worth avoiding storing food in BPA-containing plastics? Possibly. This is because food might leech BPA out of the plastic in sufficient quantities to possibly have some effect on people (because we eat the food, which gives it an easy route into the system). Is it worth it to avoid all BPA in our houses, however? Simply, no. And on that note, it particularly amuses me to watch women with painted nails shopping for BPA-free toys for their daughters (also with painted nails), given that the exposure to potentially harmful substances (like toluene) is much greater when one physically paints said chemicals on one’s body.*

*For those who are curious, I do paint my nails, because I really don’t think this is that big a deal. But it’s certainly a more significant exposure to chemicals (ew! chemicals!) than touching a rubber ducky in the tub.

So, we worry too much. But we also worry too little. In our desire for the “natural” (whatever that means), we choose the cyanide-laced flavoring agent over the one made under strict conditions and control in the lab. We go to the natural foods store and buy herbs to treat our ailments — which are essentially unregulated for either safety or efficacy, and which may interact unsafely with prescription and over-the-counter drugs or be toxic in their own right — rather than using the “unnatural chemicals” prescribed by medical professionals, despite the fact that the latter have undergone many years of pre-marketing research, followed by decades of post-marketing surveillance. We’re more willing to expose our children to the 1/330 risk of death due to the measles than the 1/3000 risk of a moderate side effect of measles vaccination (e.g. seizure with no permanent effects, mild rash), and immeasurably small risk of serious side effect. We further eschew the vaccination because, in a complete failure to understand the mechanics of human immunity, we have come to believe that “natural” immunity from disease is superior to “artificial” immunity from vaccination. When it comes to the “natural” versus the “toxic” and/or “chemical,” we’re chasing flies out of the chicken coop while the foxes sneak in.

So what do we do about it? This is difficult. We know that all substances are toxic in the right (wrong?) dose, but when it comes to many substances, we still don’t know what that dose is. Some exposures are unavoidable (by virtue of living in a city, for instance, one is going to be exposed to a certain amount of benzene from exhaust, industrial processes, etc). Some exposures are avoidable, but avoiding them reduces quality of life (no one HAS to eat foods containing coloring agents, for instance, many of which are of questionable safety, but the complete avoidance of these would make for a stoic existence, particularly for children). In most cases, when it comes to toxic chemicals (and once more, all substances are chemicals, and all chemicals are toxic when one is exposed to them…all together now…in the right dose), one must do a risk-to-benefit analysis. Some cases are relatively clear. Is codeine toxic? Yes, in the right dose. Is it worth the risk to take codeine for recreational purposes? Probably not. Is it worth the risk to take codeine after a painful surgery? Probably. Is water toxic? Yes, in the right dose. Is it worth the risk to drink water when one is thirsty? Absolutely. Is it worth the risk to drink water to win a contest? Probably not. Some cases are less so, as with the previous example of BPA. With the evidence still equivocal, financial means and convenience likely become a large part of the decision. Those of greater means or with greater willingness to be inconvenienced might buy the BPA-free rubbery ducky, the BPA-free cabinet safety locks. Others might decide to buy the BPA-free food storage, but be content with the plain old, BPA-containing bath caddy. Regardless of these personal decisions when it comes to substances of yet-unknown safety, it’s worth remembering that the media, the product manufacturers, and the fad-authors capitalize upon the lucrative combination of public confusion and fear, and that the words “chemical,” “toxic,” “artificial,” and “natural” are as powerful as they are misused and misunderstood.

References:

Marquet et al. In vivo and ex vivo percutaneous absorption of [14C]-bisphenol A in rats: a possible extrapolation to human absorption? Arch Toxicol. 2011 Sep;85(9):1035-43. Epub 2011 Feb 2.

Are Vaccines Safe?

The World Health Organization (WHO) has declared the week of April 21, 2012 to be World Immunization Week. The purpose of the initiative is to spread information about the importance and safety of vaccines.

The question are vaccines safe and effective? weighs heavily on many parents. I’ll admit that even I, as staunch an advocate of vaccines as you’ll find anywhere, pondered that question on my way to the pediatrician with W. Not that I didn’t ultimately trust — no, KNOW — that they are both. Rather that the doctor was going to Stick A Big Needle! In My Baby! Regardless of where a mother or father stands on the vaccine issue, we’ve all had to answer this central question in our own minds.

Edward Jenner, By Vigneron Pierre Roch (1789-1872)

As this is World Immunization Week, I want to take some time to acknowledge and thank the father of modern vaccination, Edward Jenner. Dr. Jenner was an English country doc, born in the mid-18th century. During his time, smallpox was still very much epidemic, and was deadly in up to 60% of infected adults and 80% of infected children. Jenner was intrigued by the fact that milkmaids didn’t generally contract smallpox. They did, however, contract an illness called cowpox early in their milking careers. Cowpox wasn’t particularly serious. The milkmaids recovered and went on to live full cow-milking, smallpox-free lives. On the basis of these observations, Jenner inoculated (this word means to introduce an infective organism) several individuals with pus from an infected sore on the hand of a milkmaid with cowpox; this was the first modern vaccination. The vaccinated individuals felt a little sore and feverish, but did not contract full- blown cowpox. Those that Jenner vaccinated — including his own 18-month-old son — though certainly exposed in the course of everyday life, did not contract smallpox. They proved immune to the disease.

A child with smallpox, 1973. Photo from the CDC.

As parents, we might recoil in horror at the thought of a mad scientist father “experimenting” on his baby boy. Let me make it clear, though, that all this took place well before the development of germ theory (the notion that bacteria and viruses cause disease). Jenner and his contemporaries didn’t know WHY people got sick, they simply knew that people DID get sick (this actually adds to Jenner’s brilliance). As such, there would have been no possible mechanism for testing the vaccine in a laboratory, on animals, or anything of that nature. Jenner’s only options for testing his theory would have included stabbing a random passerby with cowpox pus and then exposing the unwilling victim to smallpox (not ok!), collecting many willing volunteers from the general public (not likely, since most people were afraid that if they were injected with cowpox pus, they’d grow cow limbs*), or using a combination of his own family and a very few willing volunteers. The natural question, of course, is did he vaccinate himself? The answer is no, but only because he was already immune to smallpox, having been inoculated as a boy through the hideously dangerous practice of purposeful exposure to the scabs and pus of smallpox patients.

*This seems ludicrous, I know. Then again, we’re 200 years after the fact now, and we can look back and laugh. Similarly, I’m sure the notion that vaccines are linked to autism will amuse future generations, who will think us peasants for having entertained that fear.

Some people shake their heads and say Jenner may have been a good doctor, but what a horrible parent, to expose his son to such risk. I would counter and say Jenner WAS a good doctor. Such a good doctor that he was DARN sure his theory would hold water. Such a good doctor that he wanted his theory tested so that, if accurate, it would literally save millions of lives. And I suspect he agonized about it. We don’t know; that part isn’t on record. But I suspect Jenner asked himself, in his own way and as we all do, will this be safe and effective? Then, too, there’s the fact that Jenner wasn’t exposing those he vaccinated — including his son — to a deadly disease. Rather, he was exposing them to cowpox. He suspected (and was correct) that they wouldn’t get a full-blown case of cowpox, but even had they done so, that wouldn’t have been a serious consequence. He didn’t vaccinate his son just to test a theory. He vaccinated his son because he believed in his theory, and wanted the boy protected from the disease. He engaged in some scientific critical thinking — a risk-to-benefit analysis — and decided that the risk of contracting cowpox was nothing compared to the benefit of immunity from smallpox.

Jenner has been strongly criticized in modern anti-vax circles for his “questionable experiments.” For instance, the website Vaccine Side Effects states:

Convinced of the virtue of vaccination Edward Jenner inoculated his 18-month-old son with swinepox, on November 1791 and again in April 1798 with cowpox, he died of tuberculosis at the age of 21 [sic]. James Phipps was declared immune to smallpox but he also died of tuberculosis at the age of 20.

That is to say, inoculating the children caused them to contract tuberculosis and die. This is out-and-out ludicrous. First of all, tuberculosis was rampant at that time, and was responsible for the death of about 25% of the population. Not 25% of the infected population, 25% of the ENTIRE population. Let’s put that another way; any one otherwise healthy person had a one-in-four chance of dying from tuberculosis. This makes it entirely unremarkable that both the boys referred to above died of the disease. Note that Jenner vaccinated many, many children, and the overall rate of death from tuberculosis among the vaccinated was no different than that in the general population. Oh and also? Tuberculosis is completely unrelated to pox, be it cow, small, or otherwise. The quote above is tantamount to saying The flu shot causes death! Every single person who gets the flu shot dies! Some of them die of heart attacks! Some die of strokes! Some die by overdosing on meth! The flu shot causes heart attacks, strokes, and meth use!!!

Those among us who are uncomfortable with Jenner’s experiments can rest assured that things are different now. Armed with germ theory and mechanisms for testing medical hypotheses in the lab long before they’re ever tested on people, no one needs to expose their toddler son to a microorganism in order to advance the science of medicine, or to a vaccine that hasn’t been tested in hundreds of different ways for safety and efficacy.

These days, smallpox exists only in biological laboratories. Photo from the CDC.

In any case, modern vaccines (named for the cows that carried the cowpox Jenner used to inoculate those early patients — vacca is Latin for cow) have indeed saved millions of lives. The CDC has a page that’s well worth a read on what would happen if we stopped vaccinating today. So Edward Jenner, during this World Immunization Week 2012, let me just say thank you. Thank you for being an excellent scientist, a true naturalist, an observer of the world and generator of ideas. Thank you for following through in testing your hypotheses, despite public fear and negativity. Thank you for being willing to put your own family on the line to save so many lives. Thank you for advancing the field of immunology. Thank you for the modern vaccine. Thank you.

On May 8, 1980, the World Health Organization officially endorsed a resolution declaring the global eradication of smallpox. Modern vaccinations are based upon the theories developed by Edward Jenner during his work with cowpox and smallpox.

 

What do you think about Jenner and his work?

 

 

Pain Relief Techniques For Immunization Shots

The World Health Organization (WHO) has declared the week of April 21, 2012 to be World Immunization Week. The purpose of the initiative is to spread information about the importance and safety of vaccines.

Immunizations protect children and save lives. However, the idea of a shot (or two, or three) can be intimidating to young people, and the shots themselves are generally uncomfortable. In a recent blog post, I discussed the analgesic properties of sugar and — to a certain extent — of breast milk. For young infants, sugar water before or nursing during immunizations can provide significant analgesia. For older babies, toddlers, and young children, however, sugar water loses its analgesic properties. A study published in Pediatrics (Schechter et al) reviews some of the pain relief options that parents and doctors can use to help reduce the discomfort of vaccinations. These techniques not only reduce the perception of pain during the procedure, they also lessen the extent to which children associate the doctor’s office with discomfort, which reduces the likelihood of battles on the way to the pediatrician’s office.

The authors found that the effective techniques for reducing pain during immunizations included better preparation for both parent and child. Nervous parents make for a nervous child, so the authors recommend that health care providers review with parents the facts about vaccinations, including the reason for each shot, the benefits conferred by the shot, and a realistic discussion of side effects and discomfort associated with the injection. The parents can then use this information to educate their children in an age-appropriate way. For the youngest patients (those younger than two years of age), there’s not much in the way of pre-shot coaching that is helpful or relevant. Nevertheless, an informed, relaxed parent provides a reassuring presence. Older toddlers and preschoolers tend to anticipate upcoming events (which increases anxiety), so the authors suggest waiting until as close to the shot as possible to talk to them about what’s coming. In talking to a child about vaccinations, parents should address what will happen (in specific terms, including how many shots and where they’ll be given), what it will feel like (during and afterward), and various coping strategies (deep breathing, thinking about something pleasant, etc).

The authors also found that the injection site can make a difference. While the thigh is the vaccination site of choice for children younger than 18 months, and the deltoid is common in children older than three, there’s ambiguity regarding the best site for children between 18 months and three years. Generally, however, injection in the thigh is considered more painful, so the authors recommend making the switch to the upper arm as soon as the arm has adequate musculature. Further, they note, there is some compelling research to suggest that the “hip site,” which sits on the lateral buttock, is much less painful than many other injection sites. There isn’t currently enough research on the delivery of vaccinations in this location to recommend its routine use, but hopefully research will support the use of the hip site in coming years.

During the injection, parental behavior appears to significantly impact a child’s ability to cope. Children respond best to parents who interact in a calm, distracting way with the child (telling an interesting story, for instance, or using humor), or who help the child remember coping skills. Parents who are overly critical, apologetic, or — strangely — overly empathetic tend to increase their child’s distress. The best thing a parent can do during a child’s shot(s) is to stay calm and relaxed, help the child use pre-determined coping skills, or talk about something totally unrelated to the shot.

Another simple technique that can reduce pain is applying pressure to the injection site after a shot. There is not a significant body of controlled scientific research on the effectiveness of this technique, but anecdotal evidence suggests it’s effective, and there appear to be no risks, so it’s worth trying. Parents can ask the health care provider to put pressure (with a finger) on the shot site after withdrawing the needle. The idea here is that the brain can’t process multiple types of stimulation at once, so the sharp pain of the injection is “lost” beneath the more powerful stimulus of pressure. This is the same reason that people instinctively rub a bumped shin or funny bone.

 

Science Bottom Line:* Being informed, informing your child (in an age-appropriate way), encouraging coping skills, and helping to provide distraction can all reduce immunization-associated pain. Pressure on the site afterward also helps. Remember, vaccinations save lives; the discomfort associated with the shot is not a reason to skip or delay vaccinations!

 

How do you help your kids cope with shots?

 

Reference:

Schechter et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007 May;119(5):e1184-98.

2011 U.S. Measles Rates Highest In 15 Years

I’m willing to bet he would have been happier with the shot.

Misconceptions and fear have been fueling the anti-vaccination movement in recent years, particularly with regard to the measles, mumps, and rubella (MMR) vaccine. This is in part because a study published in The Lancet that linked the MMR vaccine to autism (Wakefield et al). In addition to rampant misinformation spread via the Internet, the Wakefield study continues to fuel public concern, despite thorough and unanimous scientific debunking by more than 20 studies (Poland), retraction by all but one of the authors – Wakefield himself — and retraction by The Lancet.

Unfortunately, despite overwhelming scientific evidence that the risks associated with the MMR vaccine are small and uncommon, particularly relative to the serious and more common risks associated with contracting the measles, some parents continue to refuse to immunize their children.

A report by the U.S. Centers for Disease Control and Prevention (CDC) not only underscores the significant risks associated with being unvaccinated for the measles, it also helps demonstrate the fallacious nature of many of the arguments against vaccination and highlights the importance of vaccination in protecting the community.

According to the CDC report, there were more measles cases reported in the U.S. in 2011 than in any of the prior 15 years. A total of 222 cases were reported, the majority of them in people less than 20 years of age. 65% of cases were in unvaccinated individuals, and another 21% of cases were in individuals whose vaccination status was unknown or not on record. Of those who were unvaccinated, a fraction (27 total cases) were under 12 months of age, and were therefore too young for the vaccine.

In light of this disturbing report, some common myths about measles…and the facts:

Myth: Measles is exceedingly rare in the U.S., as vaccination rates are generally high. Unless my children will be traveling to Europe or other parts of the world with higher measles rates, they don’t require measles protection.

Fact: While measles isn’t as common in the U.S. as it is elsewhere in the world (there were no U.S. cases in 2000, for instance), it’s imported from other countries (either by foreign travelers or by U.S. travelers returning from a measles-prone area) and can spread in the U.S., mainly due to unvaccinated individuals. Measles is contagious for about four days before any rash appears, meaning that travelers from foreign countries can bring the disease to the U.S. without being aware that they are doing so. The CDC notes that most cases of measles in the U.S. were brought in from Europe. Further, measles is so contagious that casual exposure to an infected individual (even one who doesn’t yet show signs of the disease) is very nearly 100% effective in transmitting the infection. Measles is spread through the air, meaning that it’s possible to get the disease without any physical contact with an infected individual.

Myth: Measles is a common, routine childhood illness, and there’s no reason to vaccinate for it.

Fact: Measles was common in the U.S. before the introduction of the vaccine in 1963. The disease is so contagious that essentially 100% of the population contracted it prior to the development of the vaccine. Simply because a disease was once common, however, does not mean it is “routine” or harmless. Measles complications are relatively common, and include severe dehydration and pneumonia. 32% of individuals who contracted measles in the U.S. in 2011 had to be hospitalized for complications. Thankfully, there were no deaths among these individuals. However, swelling of the brain and death are possible complications of the disease, occurring in about 3/1000 cases. Even among the individuals who do not require hospitalization, measles is a truly miserable experience. It comes with a high fever, which is accompanied by muscle aches, headache, and sensitivity to light. Unlike chicken pox, to which measles is sometimes erroneously compared because they both cause skin rashes, measles is respiratory and causes a dry cough and extremely sore throat, which contributes to dehydration. The rash can be very extensive (in many cases, it enters the mouth), and itches.

Myth: The MMR vaccine is more dangerous than the measles.

Fact: The MMR vaccine is associated with some mild side effects, including an innocuous and temporary rash in about 5% of vaccinated individuals. Moderate side effects, such as seizure, are very rare, occurring in about 1/3000 doses. Note that the moderate side effects (which are not life-threatening) are three times rarer than the risk of death from the measles. Serious side effects of the MMR vaccine, including death, are so rare that they can’t be statistically quantified. In other words, people die so rarely after getting an MMR that no one can be sure the death was due to the shot.

Myth: Since almost everyone in the U.S. is vaccinated against measles, my child will be protected.

Fact: The vast majority of U.S. citizens are vaccinated against measles. This means that measles won’t be able to take hold and spread across the country in the form of an epidemic, as it could have done before 1963. However, the disease can still spread from one individual to the next, particularly in areas of lower MMR compliance. The 222 cases of measles in the U.S. were primarily due to small outbreaks (there were 17 such outbreaks), where the average outbreak size was 6 individuals. Put another way, for every one case of measles brought into the country by a foreign traveler or returning U.S. citizen, five people who had never left the country got sick.

Myth: If I choose not to vaccinate my children, I’m not hurting anyone but my own family.

Fact: This is not so. To protect a group of people from a disease as effectively as possible, it’s important to keep the vaccination rate as high as possible. The fewer unvaccinated individuals in a population, the less likely that someone with measles will come into contact with an unvaccinated individual, which reduces the likelihood of an outbreak. Vaccines are highly effective — vastly more so than most other medical treatments — but they’re not 100%. This is especially true in children who have had only one of their MMR shots (the CDC recommends a booster at age 4-6). Maximizing the number of immunized individuals helps to protect those for whom vaccination may not be effective. There are also those, including babies under one year of age, who are not eligible for vaccination. Maximizing the vaccination rate among the eligible minimizes the risk to vulnerable members of the population.

 

If you vaccinate, do you worry about those who don’t? If you don’t vaccinate, what about it makes you uncomfortable?

 

References:

Poland. MMR Vaccine and Autism: Vaccine Nihilism and Postmodern Science. Mayo Clin Proc. 2011 Sep;86(9):869-71.

Wakefield et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted in: Lancet. 2010;375(9713):445]. Lancet. 1998;351(1903):637-641.

Breast Milk For Pain Relief

Image from Melimama, Wikimedia Commons

There are two interesting studies on breast milk as an analgesic (pain reliever) in this month’s issue of Pediatrics. Each compares the effects of breast milk to those of oral sugar (either glucose or sucrose) for relieving pain during the ubiquitous neonatal heel stick procedure.

The first study looked at late preterm infants (gestational age 34-36 weeks), and measured pain as indicated by crying and pain response (evaluated using the Premature Infant Pain Profile [PIPP] scale) [1]. All infants were being breastfed and were fed at least an hour before the procedure. They were randomized into two groups, one of which received expressed breast milk (from the infant’s mother) and one of which received a solution of glucose. (Glucose is a type of sugar; it’s exceedingly common in nature and in food, but is only about 70% as sweet as table sugar. Sugar solutions have been well established as a method of delivering pain relief to neonates [2]). The researchers found that infants given glucose displayed significantly less discomfort during and after the procedure compared to those given expressed breast milk. Interesting though these results are, they don’t particularly excite me. They can be taken to mean oral glucose is a superior analgesic to oral breast milk in late preterm newborns, but they can’t be taken to mean oral glucose is a superior analgesic to breastfeeding in late preterm newborns. This is because breastfeeding consists of more than simply oral administration of breast milk.

I’m more interested in the findings of a second study, also conducted on late preterm infants undergoing heel stick [3]. In this study, breastfed infants were randomized to one of three conditions: oral sucrose (table sugar) solution, expressed breast milk, or breastfeeding. Infants were fed or given sucrose during the heel stick procedure. Those being breastfed were held in their mother’s arms, while those receiving expressed breast milk or sucrose were held by a nurse. As in the first study, the researchers measured crying and pain response via PIPP. There was no significant difference in PIPP score for infants receiving breast milk versus those receiving sucrose. Interestingly enough, this was true for both the expressed breast milk group AND the group being breastfed. I have to admit to being surprised by the results; I would have guessed that there would be no difference between sucrose and expressed breast milk (or possibly that sucrose would be more effective), but that breastfeeding would provide superior analgesia!

Note that these results apply only to neonates (and, to be rigorous, only to late preterm neonates). It’s entirely possible that the establishment of a solid breastfeeding relationship over the course of the first weeks or months of life would change the relative efficacy of sugar solution versus expressed breast milk versus breastfeeding as analgesics (follow-up post on this issue forthcoming).

One final note — in the discussion portion of the second study (where the researchers talk about what their results mean and what they noticed while doing the study), there was a line that jumped out at me. The researchers were apparently, like me, surprised that they didn’t discover that breast milk was a superior analgesic. They suggested that one reason could have been that preterm infants have an “immature competence for sucking,” which could have reduced their ability to take enough milk to make a difference. Further, they noted (and this is what caught my eye), “We observed that these [preterm] newborns are more easily annoyed than term neonates…” Alrighty then!

 

Science Bottom Line:* In late preterm newborns, sugar solutions provide pain relief for procedures such as a heel lance. Breast milk, either expressed or obtained via breastfeeding, may provide similar pain relief, though some evidence suggests that breast milk is not as effective as sugar.

 

Do you think breast milk helps relieve pain?

 

References:

1) Bueno et al. Breast milk and glucose for pain relief in preterm infants: a noninferiority randomized controlled trial. Pediatrics. 2012 Apr;129(4):664-70. Epub 2012 Mar 5.

2) Harrison et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child. 2010 Jun;95(6):406-13. Epub 2010 May 12.

3) Simonse et al. Analgesic effect of breast milk versus sucrose for analgesia during heel lance in late preterm infants. Pediatrics. 2012 Apr;129(4):657-63. Epub 2012 Mar 5.

Options, Ethics, and Moral Imperatives

Vaccinations. Circumcisions. Birthing interventions. These are among the parenting topics that stir up strong feelings and can lead to the exchange of strong words. The recent heated debate over a circumcision post I wrote is one example of this, but there are countless others in fora and on blogs all over the web. In any case, all of this has gotten me thinking about differences in parenting styles. When do philosophical differences become true cases of “right” versus “wrong”?

To illustrate, while discipline styles fall along a continuum, involved parents can generally be classified as authoritarian (strict disciplinarians who don’t display much affection), authoritative (moderate disciplinarians with a warm parenting style), or permissive (non-disciplinarians who display significant affection). Several studies have demonstrated that authoritative parents raise the most well-adjusted, competent children (see, for instance, Lamborn et al, Steinberg et al, Dombusch et al). Furthermore, a recently published study on the topic suggests that authoritarian parenting is associated with future delinquent behavior (Trinkner et al). Still, though the evidence is mounting that children of authoritative parents do best in school and are least likely to engage in risky behaviors of various sorts later in life, parenting style is considered a matter of philosophy, and is left up to the parent (provided the child is not being neglected or abused). Abuse and neglect aside, the overarching social philosophy regarding discipline is that the parent(s) know the child best, and will act in the best interest of the child.

Let’s take another example. As I’ve pointed out here and here, there is neither scientific evidence to support routine infant circumcision, nor is there scientific evidence proving it is harmful in any way. As such, while it’s possible to debate circumcision on moral/ethical grounds (and to feel very strongly about it), the overarching social philosophy is that it’s up to the parent(s) to make the decision regarding circumcision. While there are some who feel very strongly about circumcision (including both those who think circumcision is a violation of the infant’s rights AND those who think that to forgo circumcision is an affront to god), the procedure is not legislated in the United States. Neither is it either supported or opposed by large medical organizations in this country (at this time, at least; there are stirrings that the American Academy of Pediatrics might support circumcision to some extent in the coming years).

Moving on. Vaccination gets a bit trickier, as both camps that feel strongly about the vaccination issue think that there is actual, physical harm being visited upon the child being (or not being) vaccinated. Anti-vaccination advocates think that vaccinating parents are exposing their children to unsafe substances, while proponents of vaccination worry about the children of the anti-vaxers AND about their own children (because the higher the percent of vaccinated individuals in a population, the better EVERYONE, including the vaccinated individuals, is protected). Vaccinations are legislated to some extent; the U.S. Centers for Disease Control and Prevention keeps a database of which vaccinations are required for entry into public school by state. The legislation of vaccinations helps improve compliance among those parents who don’t feel strongly either way about immunizing children, but parents who are fervently anti-vaccination can get an exemption on any one of a number of grounds (philosophical, religious, etc). Nevertheless, some pediatricians feel strongly enough about the dangers associated with children remaining unvaccinated that they won’t accept unvaccinated children into their practice (both to avoid exposing patients to unvaccinated children and to try to motivate parents to vaccinate). Other pediatricians feel that this exclusion of unvaccinated children is unethical. Given that the scientific evidence unequivocally supports childhood vaccination (more articles on this topic archived here), is it ethical to allow a parent who claims that vaccinations are harmful to make a potentially dangerous decision for their child? Is being wrong about the science the same thing as being wrong about the parenting?

Here’s yet another example. There was an ethical discussion written up in the medical journal Pediatrics last year about a case in which parents refused antibiotics and hospitalization for a septic (that is to say, bacterially-infected) newborn (Simpson et al). The mother had been trying for a home birth with a midwife, but had developed a fever and was brought to the hospital. The parents refused fetal monitoring and wanted to continue with their natural birth plan, despite concerns on the part of the medical team that both the mother and newborn had a bacterial infection. The mother eventually accepted IV antibiotics. She refused any treatment for her newborn, however, and asked to be discharged same-day. She and her husband wanted to leave against medical advice because they felt the newborn “didn’t look sick.” The medical team ended up contacting CPS, and the parents agreed to an antibiotic treatment for the newborn. Medical protocol would have been for the newborn to remain in the hospital for 48 hours of monitoring. Instead, however, the parents found another doctor who had privileges at the hospital and who agreed to discharge the baby early. The purpose of the article was to discuss what had been done and what should have been done. The authors of the article, all medical practitioners, agreed that the parents were doing what they (the parents) thought (in the absence of any medical knowledge) was in the best interest of the baby. This was not a case of purposeful abuse or neglect. However, the parents refused to allow the majority opinion of medical experts to guide their decision-making, and instead found a rogue practitioner willing to do what they wanted. Everyone agreed that, given the parents clearly loved the child, it was a shame to have had to bring CPS into the equation Still, the authors further agreed that when it comes to medical decisions, there’s a line between a parent exercising a parental right…and a parent simply being wrong.

With regard to some parenting issues, there’s no clear right or wrong answer. For instance, a few real sticklers on either side of the fence might butt heads over whether a 22-month-old should be allowed to watch TV, but there’s no rational argument that can be made for legislating this issue either way. There are other parenting issues that are clear-cut cases of moral imperative. For instance, it is wrong to keep a child in a kennel. No discussion, no ifs, ands, or buts. It’s wrong. And it’s illegal. Unfortunately, though, the waters are pretty muddy with regard to many other parenting decisions. Sure, the science supports breastfeeding, but what if mama hates it? What if she has to return to work and can’t pump? What if…whatever? Even when science comes down (either weakly or strongly) on one side of an argument, there’s often room for different philosophies. But then again, sometimes there isn’t.

Isaac Asimov, ca 1965

I guess the real question is how do we know what delineates a difference of philosophy and what’s simply a case of right and wrong? Should a set of parents be allowed to feed their newborn nothing but raw vegetable juice — because, say, they’re vegans who further happen to believe that soy is unhealthy due to…whatever — given that this diet would result in massive malnutrition (and eventually death)? Is it the right of a parent who wants a “natural birth experience” to leave the hospital against medical advice with a neonate that the medical staff feel needs antibiotics? If the parents leave and the infant lives, does that make them any less negligent than if they had left and the infant had died? Where’s the line between persevering in a philosophy…and perseverating? When does adherence become obstinance? The availability of free information (much of it erroneous) on the Internet has made many of us feel like armchair Experts In Everything. We tend to turn to the Internet rather than true experts, or we choose to trust only those experts who agree with our preformed, Interwebs-derived conclusions. Further, somehow it has become acceptable — in some circles, even admirable — to defy the medical and scientific establishments, and to refuse to acknowledge the validity of well-performed, oft-repeated, well-accepted research. How did this happen? In the words of Isaac Asimov, who said it so gracefully, “Anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that ‘my ignorance is just as good as your knowledge.’

 

What do you think a parent should — or should not — be able to choose for their child?

 

References:

Dombusch et al. The relation of parenting style to adolescent school performance. Child Dev. 1987 Oct;58(5):1244-57.

Lamborn et al. Patterns of competence and adjustment among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1991 Oct;62(5):1049-65.

Simpson et al. When parents refuse a septic workup for a newborn. Pediatrics. 2011 Nov;128(5):966-9. Epub 2011 Oct 24.

Steinberg et al. Over‐time changes in adjustment and competence among adolescents from authoritative, authoritarian, indulgent, and neglectful families. Child Dev. 1994 Jun;65(3):754-70.

Trinkner et al. Don’t trust anyone over 30: parental legitimacy as a mediator between parenting style and changes in delinquent behavior over time. J Adolesc. 2012 Feb;35(1):119-32. Epub 2011 Jun 12.

 

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