No Guinea for Ghana

Congratulations to Ghana and the CDC, WHO, UNICEF, and Carter Center on the success of their efforts to eradicate Guinea Worm!!

What's Guinea Worm, you ask? Here's the CDC's diagram of the worm's life cycle:

Informative, but hardly explanatory of just how painful infections are, how completely they can destroy a community's ability to function since walking is often impossible when the worms are crawling out of your foot and most people in the developing world don't exactly have desk jobs. There's a certain grossness factor as well, one we Americans generally get to avoid thinking about.

But let's take a deep breath and try. Clean water, check. Freezer stocked with Breyers ice cream, check. A single moment of appreciation for how good we have it, bad economy or not? Yes.

I think that's the least we can do. And if you'd like to do more, Guinea Worm is still endemic in Southern Sudan. Read more here and consider fishing your spare change out of the sofa and sending it their way. A world without wormy feet would make a world of difference.

The Pox

When I was an intern, a family from Ireland who had given birth prematurely and were readying themselves to go home with their now fat and happy new baby, asked why we give the Hepatitis B shot at birth. It's a good question, since if a mother is not infected with the virus there is no harm in waiting to vaccinate the infant during the routine 2 month shots. But some women will catch Hepatitis B during pregnancy and after their screening labs were done. For these infants, the chance of chronic liver disease from the infection is 90%, which brings with it the danger of liver cancer and death, a horrible future for an infant who could have been entirely healthy. So the default in the U.S is to immunize.

In Ireland, they wait until 2 months of age for the first Hepatitis B vaccine, but at birth infants receive immunization against tuberculosis in the form of the BCG vaccine. This vaccine isn't used at all in the U.S., since the rates of tuberculosis are currently so low that the monetary costs of universal vaccination are not thought to be worth while.

There are several other differences as well. Infants in Ireland are routinely immunized (or immunised) against bacterial meningitis during infancy, a measure currently being debated here in the U.S. Hopefully we will follow suit since, having seen pus drain directly from a spinal needle placed in an infant's back, I can tell you that bacterial meningitis is absolutely not something you want your brand new babe to get.

But what about chickenpox? We vaccinate here against varicella but they don't necessarily do so in Ireland. Years ago my husband found himself embroiled in an online debate on the benefits of vaccines. Routine vaccination against chickenpox was only just beginning and there was, of course, objection to the addition of one more jab to the early childhood immunization schedule. Those opposed to vaccination protested that only about a hundred people die from chickenpox every year of the 4 million who contract the disease in the U.S.

My husband was agast. Surely, he protested, if two school buses filled with children were driven off the edge of a ravine and one hundred young and healthy kids losts their lives needlessly, you would think this was a tragedy. How is it different if they instead die horribly painful deaths in the hospital after their organs shut down from infection? And isn't it, in fact, worse to have a tool that could have saved them and decide not to use it?

But we are using it. Children are getting the vaccine and, as a result, the number of chickenpox cases ws down to 400,000 in 2005. More importantly, deaths in children and adolescents from chickenpox are down 97% here in the U.S. Canada and Australia have begun to adopt the vaccine. Perhaps soon Ireland will follow.

In the meantime, for those parents trying to avoid vaccination and considering the "chickenpox party" as a way to get your kids exposed early, good luck. I'll keep my fingers crossed that none of the kids at your party end up driving into the ravine.

Annie Get Your Gun

When the ER is quiet I don't feel guilty for not being more productive. I get to be relieved that children are not sick and are not getting hurt. If it is busy, if a particularly noxious virus seems to be making its way through the ranks of the young, I still try to take the time to encourage good hand washing. Breaking the cycle of infection is essential to keeping others in the household and a child's group of friends healthy and well.

So what if my patient has instead come to be seen for a head injury after a car accident in which he was not wearing a seat belt, a broken arm after a fall from a trampoline, a bad laceration after being allowed to play unsupervised with a knife? It would be remiss of me to not address appropriate safety measures, but it is also (by this time) almost beside the point. The accident has happened and the pain that it caused is a better warning than any I could ever give to be careful next time around.

Other pediatricians, those who work in offices and see patients before they have accidents, have a better chance of preventing such injuries before they occur. Keep in mind that the most likely thing to kill a child over the age of 1 is an accident. Is a pediatrician really doing his or her job by doling out shots and prescriptions for antibiotics but ignoring this fact?

No.

So regular well child visits at the pediatrician's office routinely involve discussion of age appropriate dangers. Mothers and fathers of infants are encouraged to be vigilant about not leaving children unattended on beds or changing tables, since falls in this age group can result in a skull fracture. When children get older, discussion turns to child proofing electrical outlets, use of bike helmets, rules about crossing the street. In 49 of 50 states discussions also include inquiries about whether anyone in the household owns a gun.

If a family answers in the affirmative then the pediatrician takes the time to cover the importance of gun locks, storing firearms and ammunition in separate places, and keeping guns locked up and in a place where children can not get them.

But in Florida, asking about exposure to guns is illegal. Under the auspices of protecting the privacy of households, pediatricians could now face jail time for this line of questioning. Theoretically the discussion of gun safety could still go forward in the hypothetical, but it's not likely to.

Pediatricians are already under extreme time pressures to discuss all of the necessary facets of development, injury and disease prevention, school readiness, and countless other topics of a typical well child visit within the time allotted by insurance companies. In Florida, not being able to ask which children are at risk of gun death will mean that counseling on safety is simply not done.

Had the parents of Seth Lasater not kept a loaded rifle in their home, the eleven year old would still be alive. Instead he died earlier this month. Would a frank discussion with his pediatrician have saved his life? Maybe, maybe not. We'll never know. But we'll unfortunately find out how many more children become statistics as the effects of this idiotic law play out over time.