Friday, 8 February 2019

Why parents should use responsive feeding with their babies

Should you get the influenza (flu) vaccine this year? The short, quick answer (barring any medical reasons you shouldn’t, such as severe allergies), is yes! But recent research raises another important question: When should you get the shot?
Why a flu shot every year in the first place?

Getting infected with the flu can be dangerous — we’ve seen patients in the ICU who were previously healthy but had a horrible response to a strain of the virus and became very sick.

Every year the Centers for Disease Control and Prevention (CDC) and other agencies release flu vaccination guidelines in late summer to early fall. The flu vaccines are usually available by the end of the summer season. Figuring out exactly which strains of flu viruses the vaccine should protect against is often complicated. Basically, experts look at the influenza virus strains that were making trouble in previous years, and attempt to predict which strains are likely to cause the flu in the upcoming season.

The inactivated flu vaccine is the form of flu vaccine that is most commonly injected and contains parts of the virus but no live virus. Therefore, you should not be infected with the flu from the vaccine itself. Some people may feel “sick” after the vaccine with symptoms such as mild fever, pain in the injection site, fatigue — all of which may just be your body mounting an expected immune response against the foreign virus particles. For the 2017-18 season, the CDC and Advisory Committee on Immunization Practices (ACIP) have recommended against the alternative intranasal live attenuated vaccine, due to concerns about its ineffectiveness during the previous seasons.
Get your flu shot as soon as possible? Maybe not…

Recent studies have suggested that the flu vaccines may not be as effective when given too early. The US Influenza Vaccine Effectiveness Network compiled data on patients seeking care at outpatient clinics during the four previous flu seasons from 2011-12 to 2014-15. Although the data varied for different influenza strains, it did show that the vaccine was most effective at approximately two weeks after it was given. Protection against the flu then decreases every month. There could be many explanations for this: people may lose immunity during the season; different patient populations receive vaccines at different times; the virus may mutate during the course of the flu season, etc. This decrease in protection over time may even account for why some people who did get a flu shot go on to get the flu later on in the season (February or March). However, more research needs to be conducted to evaluate this further.
It gets even trickier

The problem is that we cannot predict exactly when the flu season will begin each year. In clinics and in the emergency department, we often see the flu season starting around December and lasting until the spring. And the flu shot is not 100% effective. Over the past few seasons, studies have shown that the vaccine reduced the risk of flu infection by 40% to 60%. For patients who are immunocompromised or have chronic medical conditions, it may still make sense to receive the vaccine earlier so that your body is protected against the virus whenever the season comes. But if you’re generally healthy, it may make sense to get the vaccine a little later in the fall.

But, as physicians, we really aren’t sure yet.
So, what should you do?

We need more research to determine the optimal timing of influenza immunization. Until we have more information, I still recommend getting the flu vaccine each year before the flu season starts, especially if you have other health problems, have a weakened immune system, or if your child is young enough to require two doses. Even if you are exposed to the flu virus later in the season and your immunity is not as strong against it, your body may still be able to fight off the virus quicker and more effectively than if you did not receive the vaccine at all. For those who are healthier and have access to primary care physicians, you could consider holding off until later in the fall; however, you may risk getting the flu if the season comes early.
There is a saying that being poor is expensive. From personal experience, I know this to be true. But I think it also needs to be said that, especially in the United States, chronic illness can be quite expensive as well. In fact, there is a huge intersection between poverty and disability/illness. As with many intersections, it is a chicken-or-egg scenario, difficult to determine which is begetting which. But one thing is clear: there are often blind spots about these expenses in the medical community and how they can impact chronically ill people already struggling with finances.

Recently I attended a seminar on the topic and was immediately struck by the lack of attention to the expense of the nonpharmacological treatments being advised to take the place of opioids. I watched the doctors on the panel enthusiastically promote acupuncture, yoga, chiropractic care, biofeedback, massage, lidocaine patches, and TENS units. Yet, many of these treatments are not covered by most insurance plans and can be very expensive to pay for out of pocket. In the case of something like massage or acupuncture, it can cost well over $100 per visit. Since these therapies usually require multiple visits to achieve long-term outcomes, it can cost patients hundreds or thousands of dollars to cover the costs of such treatments. Considering that most people with disability live below the poverty level, many people with chronic pain may not be in a financial position to fund these alternative treatments — meaning they are basically unavailable to them.

Likewise, insurance doesn’t cover so many of the nutritional and herbal supplements and compounded medications that offer chronic illness patients a modicum of relief. Recently, my physiatrist wrote me a prescription for compounded low-dose naltrexone, or LDN, to treat my chronic pain. LDN is an opiate antagonist that has been demonstrated during limited clinical trials to reduce symptoms associated with many autoimmune diseases, including pain. However, I was informed by the pharmacy that my insurance plan would not cover it, and it was $80 for a month’s worth of daily dosages. I could not afford it, so I didn’t fill the prescription. Due to its expense, I couldn’t try a non-opioid medication that could have improved my function and quality of life.

Another example is one I face right now as someone with the connective tissue disorder Ehlers- Danlos syndrome. While there is no cure for EDS, I find that one thing that helps relieve some of my pain and minimize further injury is stabilizing my joints and soothing my spastic muscles. This requires generous use of splints, braces, and Kinesiology Therapeutic (or KT) Tape. None of these are covered by my insurance and can add up quickly — especially the KT Tape, which needs to be replaced weekly — straining my limited budget. Likewise, insurance also does not pay for the seat cushions that offer me better ergonomics at my home office so that my spine and hips don’t constantly lock up.

Insurance also didn’t cover the new bed I got last year that offers better back support, or the full-body pregnancy pillow (note: I am not pregnant) that I credit as only thing that has significantly improved my sleep in the past six months. Additionally, I am interested in obtaining some compression clothing, which has been indicated as having potential to improve mobility and pain in EDS patients. But because insurance won’t cover this either, it will require a financial investment on my part that is a huge gamble. If the clothing is not helpful, I’ve sunk in a significant amount of money I cannot recover. As a low-income individual, each choice is one I weigh heavily — the possible positive outcomes versus the potential for failure, and then the money wasted on it and what it could have otherwise gone to, such as rent or utilities.

I am not sure what can be done, except to pressure insurance plans to offer coverage of alternative treatments, and for more companies that offer such treatments or distribute supplements to offer sliding-scale or discounted rates to those of limited means. Hopefully, more pain clinics will start utilizing complementary methods to holistically treat pain symptoms, such as biofeedback and acupuncture, which will offer more incentives for insurance plans to cover them. This begins with awareness and needs to escalate to active advocacy to get us there. Richard Hoffman, a professor of internal medicine and epidemiology at the University of Iowa Carver College of Medicine in Iowa City, led a team that reviewed survey data that men filled out one, two, five, and 15 years after they were treated for prostate cancer. All 934 men included in the study were 75 or younger when diagnosed, each with localized tumors confined to the prostate gland. Approximately 60% of the men had low-risk prostate cancer that was expected to grow slowly, and the others had riskier cancers. Most of the men (89%) were treated with surgery or radiation. The rest were lumped together as having had conservative treatment: either medications to suppress testosterone (a hormone that makes prostate cancer grow faster), or “watchful waiting,” meaning doctors delayed treatment until there was evidence that the cancer was spreading.

Overall, 14.6% of the entire group expressed some treatment regret — 16.6% of the radiation-treated men, 15% of the surgically-treated men, and 8.2% of the men treated conservatively. Among the causes of regret, treatment-related bowel and sexual problems were cited most frequently. Surgically treated men reported the highest rate of significant sexual side effects (39%), while radiation-treated men reported the highest rate of significant bowl problems (15.6%). Remarkably, complaints over urinary incontinence differed little between the groups, ranging from a low of 15.5% for the conservatively-treated men to a high of 17.6% among men treated with radiation.

Results also showed that regret tends to increase with time, suggesting that when initial concerns over surviving prostate cancer wear off, the quality-of-life consequences of treatment become more apparent. Regrets were especially pronounced among men who felt they hadn’t been sufficiently counseled by their doctors before settling on a particular treatment option, and also among men who were preoccupied with changing levels of prostate-specific antigen, a blood test used to monitor cancer’s possible return.

Given these findings, the authors emphasized how important it is that men be counseled adequately and informed of the risks and benefits associated with various treatments. But men should also be reassured that treatment for prostate cancer has improved since the mid-1990s, and that bowel and urinary side effects in particular “don’t occur as frequently now as when the men in this study were diagnosed,” says co-author Peter Albertsen, a professor of surgery and chief of the division of urology at UConn Health in Farmington, Connecticut. “Earworms” are unwanted catchy tunes that repeat in your head. These relentless tunes play in a loop in up to 98% of people in the western world. For two-thirds of people they are neutral to positive, but the remaining third find it disturbing or annoying when these songs wriggle their way into the brain’s memory centers and set up home, threatening to disrupt their inner peace.
Which songs become earworms?

Certain songs are catchier than others, and so more likely to “auto repeat” in your head. When music psychologist Kelly Jakubowski and her colleagues studied why, they found these songs were faster and simpler in melodic contour (the pitch rose and fell in ways that made them easier to sing). And the music also had some unique intervals between notes that made the song stand out. The catchiest tunes on the UK charts between 2010 and 2013 were “Bad Romance” by Lady Gaga, “Can’t Get You Out Of My Head” (somewhat ironically) by Kylie Minogue, and “Don’t Stop Believin’” by Journey.
What predisposes to earworms?

In order to get stuck in your head, earworms rely on brain networks that are involved in perception, emotion, memory, and spontaneous thought. They are typically triggered by actually hearing a song, though they may also creep up on you when you are feeling good, or when you are in a dreamy (inattentive) or nostalgic state. And they may also show up when you are stressed about having too much to think about. It’s as if your stressed-out brain latches onto a repetitive idea and sticks with it. Also, if you have a musical background, you may be more susceptible to earworms too.

Certain personality features also may predispose you to being haunted by a catchy tune. If you are obsessive-compulsive, neurotic (anxious, self-conscious, and vulnerable), or if you are someone who is typically open to new experiences, you may be more likely to fall prey to an earworm.
Why might earworms be good for you?

There is a particular characteristic of music that lends itself to becoming an earworm. In contrast to our daily speech, music typically has repetition built into it. Can you imagine how absurd it would be if people repeated themselves in chorus? Yet, though repetition of speech is associated with childishness, regression, and even insanity, in the case of music it may signify a process that becomes pleasurable when it is understood through repetition. Also, each time music repeats, you hear something subtly different. This learning may constitute one of the positive aspects of earworms. Also, earworms are a form of spontaneous mental activity, and mind-wandering states confer various advantages to the brain, contributing to clear thinking and creativity.
Are earworms ever worrisome?

Not all “stuck songs” are benign. Sometimes they occur with obsessive-compulsive disorder, psychotic syndromes, migraine headaches, unusual forms of epilepsy, or a condition known as palinacousis — when you continue to hear a sound long after it has disappeared. Persistent earworms (lasting more than 24 hours) may be caused by many different illnesses, such as stroke or cancer metastasizing to the brain. A physician can help you determine if your earworm is serious or not.
How do you get rid of earworms?

If you’ve had enough of your earworm and need to stop it in its tracks, you would be well warned not to try to block the song out, but rather to passively accept it. A determined effort to block the song out may result in the very opposite of what you want. Called “ironic process” and studied extensively by psychologist Daniel Wegner, resisting the song may make your brain keep playing it over and over again.

Some people try to distract themselves from the song, and it works. In one study, the most helpful “cure” tunes were “God Save The Queen” by Thomas Arne and “Karma Chameleon” by Culture Club. Others seek out the tune in question, because it is commonly believed that earworms occur when you remember only part of a song; hearing the entire song may extinguish it.

Other techniques found to be helpful include those from cognitive behavioral therapy, such as replacing dysfunctional thoughts like “These earworms indicate I am crazy” with “It is normal to have earworms.” A less intuitive cure for earworms is chewing gum. It interferes with hearing the song in your head. The habits we learn early can stay with us for a lifetime — which is why it’s better to learn good habits early, not bad ones. This is especially true with eating habits. More and more, research shows that overweight babies grow into overweight children, who grow into overweight adults. One of the very best ways to prevent obesity is to start before they are two years old, preferably right at birth.

That’s why the American Academy of Pediatrics really wants parents to know about responsive feeding.

Most parents feel better when their baby eats more — and eats on a predictable schedule. It’s comforting and reassuring. It helps parents feel certain that their baby has had enough to eat. It also makes it easier to organize the day or give instructions to babysitters. But when we push babies to eat more than they want, or to eat when they aren’t hungry, it can teach them bad habits that put them at higher risk of obesity.

It’s really important that babies eat when they are hungry and eat only as much as they need. That’s where responsive feeding comes in. Responsive feeding is learning your baby’s cues for hunger, and for being full, and responding appropriately to those cues.

If a baby is showing these signs, parents should stop feeding, even if the baby has eaten less than usual, or less than the parent would like them to eat. That way, the baby learns to listen to her hunger cues and stop eating when she’s not hungry anymore, habits that can help keep her at a healthy weight for life.

If a parent is worried that their baby isn’t getting enough to eat, or isn’t growing well enough, the best thing to do is call the doctor and make an appointment. At the appointment, the baby can be weighed and examined to check for any problems. If there are problems, the doctor and parents can make a plan to address them and get the baby back on track. If there aren’t any, parents can feel comfortable listening to and following the baby’s cues.

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