New 2012 vaccine recommendations in USA - Why is Cervical Cancer vaccine being recommended for boys ?

There are more than a dozen changes in the latest 2012 children, adolescent and adult immunization recommendation in the USA. 
One of the major changes in the 2012 children and adolescent vaccination schedule in the USA is the recommendation for giving the Cervical cancer vaccine to boys aged 11-12 years.
Why is this being recommended ? Here is what Dr. Brady, Chairperson, American Academy of Pediatrics Committee on Infectious Diseases has to say. 

Medscape: In October 2011, the Advisory Committee on Immunization Practices voted to recommend routine use of human papillomavirus quadrivalent vaccine (HPV4) in boys aged 11-12 years, and this recommendation is included in the 2012 schedule. Can you discuss some of the reasons for this recommendation, a stronger position than the Advisory Committee's previous recommendation that HPV4 may be given to boys to prevent genital warts?

Dr. Brady: When the HPV vaccines -- HPV4 or HPV2 -- were created, it was with the goal of prevention of cervical cancer. It was known that there are HPV strains that could also produce genital warts, and so those initial studies were primarily done in females. As you know, HPV is a sexually transmitted disease. If you look at mathematical modeling, it appears that if you had coverage of females in the range of 80% or more, you might be able to reduce heterosexual transmission to the point that you could have a benefit for both males and females.

A couple of things have happened since the initial approval. First of all, we haven't had an uptake above 80% for the entire series, and so we have not been successful in trying to implement a public health approach that is going to have a significant impact on heterosexual transmission of HPV. Because males are also participants in heterosexual transmission, this was an opportunity to approach the issue of transmission in another way.

Additionally, it became clear that HPV not only causes cervical cancer but is also capable of causing a number of other cancers, particularly oropharyngeal cancers, which have been increasing dramatically over the past couple decades. Those occur in both genders. Therefore, it was recognized that there would be a significant health benefit to males from receipt of the vaccine for the prevention of oropharyngeal cancers.

The other thing that was recognized was that giving HPV vaccine to females only does not have any impact on transmission of HPV between men who have sex with men. That is a group that has significant risks for both cancers as well as genital warts.

When you put all of the different new pieces of information together, it became very clear that a female-only approach was not going to reduce cervical cancer, oropharyngeal cancer, the other cancers that are seen, and genital warts, as would be seen with a gender-neutral approach.

By having a gender-neutral approach and identifying HPV vaccine as primarily a cancer vaccine, we are also hoping that it will approve acceptance to a greater degree than has been seen with singling out one particular gender. We are just going to make it a routine practice for all children. We hope that that will improve acceptability and eventually get us above the 80th percentile for both.

Source

My view - So male cervical cancer vaccine is being promoted for essentially 4 reasons ...

1. May prevent heterosexual transmission - since males are carriers

2. May prevent gay / homosexual transmission 

3. May prevent other cancers caused by HPV - like oropharyngeal cancer.

4. By making it gender neutral, may increase immunization coverage.

To me, from a strictly epidemiological perspective, the first point is most important. And from a practical point of view, the last point also seems appropriate. Though convincing parents regarding the applicability of cervical cancer vaccine for their son may be difficult.

MSM (Male sex with male) and other HPV related cancers are relatively less common, and to my mind right now may not be appropriate indication for universal vaccination in all kids. 

Laxatives Cure Bed-Wetting for Many Children

 Laxatives are the answer for many children experiencing bed-wetting, according to a report from Wake Forest University in Winston-Salem, North Carolina. Investigators report that occult megarectum is a commonly overlooked cause of nocturnal enuresis, and that it can be detected simply by an abdominal X-ray and treated with laxatives.

Lead author Steve Hodges, MD, assistant professor of urology, and coauthor Evelyn Anthony, MD, from the Department of Radiology at the university, found that 30 children and adolescents aged 5 to 15 years seeking treatment for bed-wetting had large amounts of stool in their rectums, even though they reported having normal bowel habits. The report, published online December 14 in Urology, showed that 3 months of laxative therapy cured 25 patients (83%) of their bed-wetting.

The authors note that stool retention reduces bladder capacity (and possibly leads to bladder overactivity) and explains why many therapies aimed at the bladder, such as fluid restriction or alarms, may be ineffective.

A landmark study performed more than 25 years ago showed that constipation, defined as abnormal rectal distension, was a commonly unrecognized cause of enuresis. However, those findings did little to change practice. This definition of constipation differs from that of the International Children's Continence Society (ICCS) guidelines, which rely on bowel habits and stool consistency. The researchers hypothesized that undiagnosed megarectum underlies many cases of nocturnal enuresis, and that laxative treatment may be effective.

They performed a retrospective review of 30 consecutive patients (19 boys and 11 girls) seen in their clinic who presented with a chief complaint of nighttime enuresis. They used a novel method to determine the rectal/pelvic outlet ratio and the Leech criteria for assessing fecal loading, using a plain abdominal radiograph, and compared these findings with the reported constipation history according to the ICCS guidelines. According to the guidelines, a diagnosis of constipation is made based on parents' and children's reports of a bowel movement less frequently than every other day, and on whether the stool consistency is hard.

The rectal/pelvic outlet ratio is the ratio of the maximum diameter of the rectum when distended by stool, divided by the diameter of the pelvic outlet between the obturator stripes at the level of the femoral heads.

All the patients showed rectal distension, based on a rectal/pelvic ratio greater than 1, and 80% met the Leech criteria for constipation. Only 3 of the children or families (10%) described bowel habits consistent with constipation. There was a statistically significant difference between the radiographic findings for fecal loading by the Leech criteria and self-reported constipation (P < .001), with the radiographic findings revealing otherwise unknown constipation. For example, for 27 cases in which the self-reports were negative, radiographs showed constipation in 21.

Initial therapy was a bowel clean-out with polyethylene glycol 3350 laxative (PEG), followed by a daily maintenance dose "titrated to keep the stools the consistency of a milk shake," the authors write. If follow-up imaging at 1 and 3 months showed persistent megarectum, daily phosphate enemas or stimulant laxatives were added to the PEG regimen.

The researchers reported that all of the 4 adolescents and 80% of the younger children in the study were cured of their enuresis by these methods. Persistent enuresis at 3 months with no rectal stool on X-ray was considered a treatment failure.

Because some of the cases may have improved over time on their own, a more rigorous test of the efficacy of laxative therapy would require a randomized trial assigning some constipated children to the therapy and others to an inactive therapy, Dr. Hodges noted in a press release from Wake Forest University. He also advised that any medical therapy for bed-wetting be done under the supervision of a physician.

Proper treatment in many cases may require the recognition of occult megarectum, and physicians would do well to focus on rectal distension, and not just functional constipation. In addition to X-ray, Dr. Hodges suggested, in the press release, that rectal distension could also be determined using rectal ultrasonography, with the advantage of avoiding ionizing radiation. He emphasized the importance of a correct diagnosis to avoid unnecessary surgery and the adverse effects of medication (such as desmopressin), and he urged physicians to first obtain an X-ray or ultrasound.

Urology. Published online December 14, 2011

Source

My view - A fascinating study, that tells us quite a few interesting things about a common, yet under-diagnosed condition. For starters, it states that laxatives may work even without any clinical evidence of constipation (only 10 % parents suggested a history of constipation). Also it suggested a simple test, plain abdomen X ray, could help diagnose children that may benefit from this therapy. I can foresee a problem in making the diagnosis of megarectum though, since the regular radiologist may not be trained in doing so, and we pediatrician's may not be able to make the diagnosis confidently. Finally a very large number of children benefited from this intervention, all 4 adolescents, and 80 % of kids, which is as high or even higher than children using the bed wetting alarm/ DDAVP (desmopressin).

Once large scale trials are conducted, we may want to give a trial of laxatives for most children with bed wetting. On a side note, I found the "consistency of stool of a milk shake" quite informative, and would suggest this to the parents, though this may put some of them off milk shakes for good :)

A Child’s Mind and the Seven Dwarfs - Seven seemingly simple disciplining lessons that make a big difference

The first post of the new year is by our guest author, Ms. Garima, a Psychologist with special interest in childcare issues. Enjoy !

There is no short cut to disciplining children. One must be willing to spend a lot of time with them to understand their mental landscape. Children do not just see the world from eyes that are placed lower in height than the average adult. Their understanding of cause and effect, of motivation, and their own place in the hugely confusing world of adults is different from ours in a very basic sense. For one, kids place themselves in the centre of the universe. This works fine as long as their world is full of attention, laughter and play. But they continue to see themselves in the centre (and as a cause) of all the shouting, seething or helplessness too, if that is what their little world is made up of.

Secondly, children have vast stores of highly active imagination. One cutesy mark of this is when they see ghosts in flying curtains or monsters in the dust balls under the bed. But this also means that they may feel cheated, rejected, even hated at seemingly commonplace life events like birth of a sibling or relocation. Such emotions can get amplified by a third tendency of kids, which is to see everything in black and white mixed with plenty of exaggeration for good measure. Say you are nursing a new baby when your 5 year old returns from school. Immediately he/ she asks to rest in your lap. Lovingly you ask him to wait his turn so the baby can finish his milk. This sequence is enough to trigger a fit of rage, sea of jealousy and extreme pangs of rejection and sorrow in a child if he is already facing adjustment difficulties.

Now imagine a scenario wherein you are still nursing the baby. The older child returns from school, seeks out his younger sibling and kisses him, puts away his bag and settles down for lunch. Dream sequence? Yes! But believe it or not dream sequences are acted out in your own home every day. Only they are taken for granted, not focussed on or appreciated, and all attention gets diverted to “problem areas”. In actual fact your child may be displaying behaviours that are a dream for another family but since you never faced a problem in that, you just presume it is nothing special while you fret about what is missing.

So how do you bring up a happy, healthy child without making yourself miserable and obliterating all non-parenting pleasures from your own life? It is both simple and tough. The simplicity is that children are really forgiving, loving and adaptable, which means they respond quickly to changes in their environment. It is tough because short cuts don’t work. You have got to walk the mile, and then the extra mile. But results are achieved and often provide a lifetime of happiness, contentment and support. And of course, oodles of love! Once you have taken care of a child’s hunger, tiredness and boredom, here is what you need to focus on.

A few pointers which should help avoid the most common pitfalls in bringing up children.

1.         Shower the gift of understanding. Kids presume guilt and shame where none exists. They also imagine fears and exaggerate simple refusals to mean the worst. So it is necessary to develop the ability to scratch the surface of your child’s uncalled for reactions and find the real issue that is bothering him. Only then will u be able to handle tricky situations or mould his behaviour. If he is fussy, is he afraid? If he is yelling, does he need positive attention? If he is rebelling, does he feel unappreciated? Rather than getting caught up in the emotion of the moment your interests will be better served if you can take a step back to reach the root cause. If all your child’s bad behaviours are met with “I don’t know why she always does this”, it is time for introspection or analysis.

2.         All for Attention. Nearly half of a child’s misdemeanours can be attributed to this. Remember that what your child values the most is your attention. More than the gifts, the treats, the trip to the gaming arcade, what your child loves is your attention. Knowing how to use this is crucial to changing undesirable behaviour. There is a fundamental difference between punishment and denying attention. When you deny attention (by giving time out, or sending the child to his room, or simply ignoring) you increase the chance of stopping bad behaviour manifold. But in many cases yelling at the child may be acting as a reinforcer in itself. So a child who is feeling deprived of positive attention or praise will repeatedly enact bad behaviour because he gets your attention that way, even if it means having to bear your anger. As a fundamental rule, being yelled at is more desirable to a child than feeling ignored; punishment is better than no attention at all. So as parents your job is to catch them “being good”. If they did their homework without whining, or shared a toy with a friend, or just put away their dinner plate without being told, pay attention immediately and show your appreciation. Something simple like “that was nice” will suffice. Once you start to see when a child’s bad behaviour is just his solution to feeling attention deprived, you can help him and also regain sanity in your own life.

3.         Count your blessings. This means focussing on the positive aspects of your child’s personality and behaviour. May be your child is madly jealous of the new sibling but is excellent in taking initiative? May be your child is socially shy to the point of shame but excels at creative problem solving? May be he cannot sit still even for a count of ten but can lead a gang of energetic toddlers to play as he wills? Focusing on strengths will make you feel more positive towards your child and it will immensely build his own self esteem and confidence. Children with high self esteem tend to take more initiative, be leaders and act responsibly.

4.         Eyes on the future. Bringing up a child is about preparing him or her for the life ahead. It is like teaching him to swim before you leave him alone in the ocean. Short term solutions may make your life easy in the moment, but will not provide the necessary skills and training to the child to adapt happily to the grown up world in the future. So whether you are answering “Why do I have to go to school” or handling an “I don’t want to take a bath”, “Can I have one more candy” or “But he beat me first”, always bear in mind what skills will help this child cope with situations in the future. What values do you want him to grow up with? Choose your responses carefully in accordance with the longer term goals.

5.         Be reliable- no lying. When your child is late from school do you want to hear the truth or just a really smart excuse? Children will pick up what you do more than what you preach. Do you routinely skip certain commitments and cover up with an excuse? Be the first one to admit a mistake. Know that it takes courage to speak the truth and to be ready to face the consequences. Children “get” more than what you explain. So don’t make a false pretence for missing his football match. Lying will hurt your relationship with your child in two ways. One, he will subconsciously pick up on this habit, finding it easier to give a clever excuse than fess up. This can mean you will not know what is going on in his life until he is in big trouble. The second danger is that there will be no trust in the relationship. Promises like “I will take you there tomorrow” will mean nothing and you can expect a barrage of manipulation, temper tantrums and resentment from the child. So say what you mean and mean it.

6.         Have a schedule for the major chunk of daily activities. When kids know what to expect they are more relaxed. A predictable routine, especially for younger children, keeps them calm in the face of life changes. So in case you are integrating the presence of a new baby in the family, if the older one knows what he has to do when he returns from school, that you will be nursing the baby for another 15 mins, that once the baby is asleep you two will be sharing the news of the day for an hour etc., it can help him cope with the unfamiliar feelings he may be experiencing. A routine shows him what to do, and also when it is time share you with someone else and when he gets to be your top priority again. Believe it or not, if you have a routine you can actually claim a couple of hours for yourself everyday as long as the child knows when he gets to have you to himself again.

7.         Give but also take. One of the biggest gifts you can give your child is to teach him gratitude. The biggest predictor of happiness is not wealth, health, education, success or relationships but an attitude of gratitude. And this attitude can be taught by making them work hard and appreciate the hard work of others. Let them see you be grateful for the bounty before you cook and teach them to appreciate your effort when they eat what you have made. Make them help you in the daily chores and take weekly breaks from certain duties like folding the laundry when only the kids do the task. Not only will you be more rested and feel appreciated, your children will feel important and more positive about themselves. Win-win!

While parenting can be a roller coaster ride of emotions it is also your biggest opportunity for getting out of your comfort zone and really growing. Enjoy the ride while it lasts!

Garima is a practicing Psychologist and Life Coach. Her special interests are parenting, mind-body connection and wellness. She lives in Pune with her husband and two daughters. She can be reached at info@manodasha.com, website www.manodasha.com