Talking to Your Girls: The Best Vaccine of All

In a previous posting, I noted that there are almost no studies looking at whether giving the human papillomavirus (HPV) vaccine to adolescents increases unsafe sexual behavior -- what some call a passport to promiscuity for girls and a license to drill for boys.  Although there are still no studies looking at behavior post-vaccine, the Archives of Pediatric and Adolescent Medicine just published a study on the attitudes and beliefs of girls who got the HPV shot.
The authors asked the girls (ages 13-21) to agree or disagree with statements like, "After getting the shot against HPV, I am less worried about getting a sexually transmitted disease other than HPV," and "After getting the shot against HPV, I think that condom use (or having fewer sexual partners) is less necessary."

First, the good news:  Only 4% of the girls felt less of a need to practice safe sex because of the vaccine.  The investigators then looked at what factors were associated with this belief.  Some risk factors were predictable, but a few were surprising.  A lower perceived need for safe sex was associated with:

• Lower knowledge about HPV and the vaccine
• Lack of condom use at last intercourse
• Lack of maternal communication about the HPV vaccine
• Teacher or physician serving as the source of HPV vaccination information

The last one threw me for a loop.  Surely the most reliable information about the vaccine and STDs comes from doctors and sex education teachers?  The problem is that even if they are dispensing appropriate advice (which may or may not be a correct assumption) , they may not be doing so in a way that's understandable to teens and their mothers.  On the flip side, it looks like moms can have a positive impact in their daughters' behavior, particularly if they talk to them about the limitations of the vaccine, including its lack of protection against some HPV strains, other STDs and pregnancy.

Though very few girls agreed that the vaccine would allow them to have more unprotected sex, survey answers don't necessarily predict behavior.  Even before the vaccine, over half of the adolescents in this clinic were sexually experienced, and most were not using condoms reliably.  It's doubtful that the vaccine will decrease the rate of unsafe sexual practices, unless it's accompanied with appropriate counseling.

So does this mean we shouldn't be vaccinating our daughters against, because of the theoretical increased risk of unsafe behavior?  Of course not.  The advent of effective antiretroviral therapy for HIV in the late 1990's was accompanied by an increase in the rate of unprotected sex, and subsequent gonorrhea and syphilis epidemics, in gay and bisexual men.*  Yet it would be completely unethical to withhold effective drug therapy because of its unintended behavioral consequences.  No, it simply means that doctors and, more importantly, parents have our work cut out for us when it comes to educating our kids.

*Despite the increases in other STDs in the San Francisco Bay Area, there was no increase in the HIV incidence in gay men during this time period.  The theory is that HIV-positive men had unsafe sex only with HIV-positive men, and HIV-negative only with HIV-negative.

Does Being a Mom = Letting Yourself Go?

I missed my 20th college reunion, having given birth just 6 weeks prior.  I wasn't worried about travelling with a newborn.  I just didn't want to chance a meeting with any old exes, while I was looking puffy, poochy and sleep-deprived. (On the plus side, I was rather buxom). Afterwards, I prevailed upon a friend to dish on all our old classmates.  As he ran the "hot or not" list, I noticed that the former was comprised mostly of his single, childless pals, while the latter was made up of couples with kids.  It wasn't an entirely fair comparison, as my friend is gay, and he and his buddies start with a level of fabulousness lacking in us breeders.  But is it a given that having children will make you look older, fatter and less attractive?

This is what having 2.5 kids does to you.*

Let's start with the easiest question to answer:  Do children make you fat?  In a word, yes.  Numerous studies have shown that mothers have a higher body mass index (BMI) than non-mothers.  Those pregnancy pounds don't just convert into postpartum pounds; they translate into post-post-postpartum pounds.  One study looking at 2,000 women over 65 years of age found that the risk of obesity increased 7% with each live birth.  Polishing off those half-eating chicken nugget meals obviously takes its toll, not to mention the lack of exercise.  Several studies have found that physical inactivity increases with the onset of parenthood.  One study in over 8,000 young women found that when someone becomes a mother, her risk of physical inactivity rises from about 40% to 60%.  Although moms bear the brunt of the weight burden, dads aren't exempt from the curse:  Men also have a 4% increased risk in obesity with each additional child.

What about looking older?  Before my first son was born, I had a grand total of three white hairs; within a year, I was spending 20 minutes a day plucking them.  Nine years later, I've stopped, with the fervent hope that my bald spots will recover.  I couldn't find any studies on whether parenting causes premature greying.  While acute, severe stress can cause diffuse hair loss, there's no evidence that chronic, low-lying stress induces baldness.  What about wrinkles, or other facial signs of aging?

One well-designed study looked at the effect of environmental factors, including parenthood, on perceived age.  Nurses were asked to estimate the age of over 1,800 elderly twins based on facial photographs.  I was relieved to discover that the number of children did not affect perceived age.  Then again, all of these twins were at least 70 years old, so maybe other, stronger environmental factors, such as smoking and sun exposure, obliterated any small effect fecundity might have had on appearance.  (One silver lining, for those of us still working off that baby bump:  thin people in this study looked older than chunky ones.)

A similar study was performed in Shanghai in 250 women, aged 25 to 70 years.  The researchers didn't look specifically at whether the number of children affected one's perceived age, presumably because of China's one-child policy.  However, they did find that having more than 3 members in your household made you look, on average, 2 years older.  Whether this was due to the stress of having that extra, illicit child, or more likely, an aging parent or in-law in the home, wasn't clear, but it might be a good reason to push your kids out of the nest when they turn 18.

Finally, for those of you with babies or young children, don't underestimate the benefit of a good night's sleep.  The research on beauty sleep is scant, but leave it to the Swedes to publish the one controlled study on this topic.  Twenty-three young adults were photographed after 8 hours of normal sleep, and again after a night of only 5 hours of sleep.  The photographs were then rated by observers blinded to the intervention.  Sleep deprivation reduced attractiveness by about 4% and perceived health by about 6%. 

Despite the meager evidence, I'm convinced that having kids makes you look frumpier, but the trade-off is worth it.  My advice is simply to put on some make-up, lose the mommy jeans, eat healthier, exercise more, get eight hours of sleep every night....

Oh, forget it.  Just call the plastic surgeon and be done with it already.

*Actually, this photo came from Faces of Meth.  But who's to say she didn't have a baby in the intervening years?

Catching Your Death of Cold

Growing up, many of us were admonished by our moms to wear our coats, or we'd "catch our death of cold."  Chinese grandmas have a particular fondness for bundling kids so tightly that they're splinting their joints.  We know now, of course, that being cold doesn't cause colds; viruses do. 

But like many things in science, the evidence isn't as clear-cut as you might think.  Multiple studies have found a strong link between outdoor temperature, as well as low humidity, and the risk of respiratory infections.  One study, for instance, found a 4% increase in upper respiratory infections with every 1 C decrease in temperature.  Influenza shows strong seasonality in temperate regions, with peak infection rates in winter, but none in tropical areas.  Of course, this doesn't prove cause and effect.  The conventional wisdom is that colds and the flu are more common in winter because of an increase in indoor crowding.

There is another possible explanation for this phenomenon.  Our first line of defense against respiratory viruses is that cozy mucus blanket lining our noses.  Microscopic hairs sweep the germ-laden mucus towards the back of the throat, where it's swallowed and sterilized by stomach acid.  "Nasal mucus velocity" drops significantly in cold weather, preventing viral clearance.  (Sounds like one of the less popular Magic School Bus episodes.)  Cold also impairs the function of macrophages, white blood cells that ingest germs.  Finally, many respiratory viruses replicate best at lower temperatures.


Guinea pig studies do confirm an increased risk of transmission of the flu in cold, low humidity lab conditions.* 

However, there are no studies on the protective

properties of the Snuggie, in guinea pigs or humans.

While there are no human trials on the direct effects of low temperature on influenza infection, controlled studies exist for the common cold.  In one 1968 study, forty-nine "volunteers" from the Texas State Department of Corrections were nasally inoculated with "virus-containing fluids" collected from sick Marines.  Half were then subjected to cold conditions, involving, among other things, sitting in a 4 C (39 F) room in shorts and undershirts for a couple of hours.  The two groups showed no difference in the rates of rhinovirus shedding or cold symptoms, and you can bet this study had 100% follow-up.


Another study took the opposite approach, looking at the effects of hot, humidified air in university students who were also experimentally infected with rhinovirus.  This time, the subjects were comfortably ensconced in private hotel rooms and administered either placebo vapor or warm steam.  There was no difference in the primary outcome of viral shedding.  Another randomized, double-blind trial found a reduction in cold symptoms with hot, humidified air, but again, no decrease in viral shedding.

Case closed, right?  Believe or not, research in this area continues, almost 2,000 years after the Greek physician Galen wrote about the four humors ("phlegmatic" being the "cold and moist" humor).  The latest was a study published by the Common Cold Centre in the UK, which randomized180 volunteers to place their feet in cold water or an empty bowl for 20 minutes.  Why did the investigators decide to chill feet instead of noses?  Their rationale was that chilling of the body surface decreases the temperature of mucosal surfaces, via reflex constriction of the blood vessels in the nose.   Over the next five days, significantly more of the chilled subjects developed cold symptoms than the control group - 29% vs. 9%.  Despite the relatively large sample size and achievement of "statistical significance," this study sounds like an grade school science project, and not a winning one at that.  The subjects were aware of the hypothesis of the study -- that chilling might affect the development of cold symptoms -- so the nocebo effect may have been in play.**  None of the volunteers underwent viral cultures to confirm infection.  And it's hard to believe a mere 20-minute foot dip could triple your chances of getting sick.  So is bundling up really going to protect you from infection?  Probably not.


Then again, would it kill you to listen to your mother?


*Guinea pigs were discovered in 2006 to be an excellent experimental model for the flu.  I have no idea why it took so long figure this out, when guinea pigs have been, well, guinea pigs since time immemorial.
**A nocebo is the opposite of a placebo: something that makes you feel worse, though it has no actual, independent effect.

Game On!

My husband and I caved in and bought handheld Nintendoes for our kids this Christmas.  (Thank you, Craigslist!) Though we usually set a 15-minute limit on schooldays, we let our kids play as much as they wanted over the holidays.  When I couldn't stand the peace and quiet anymore, I shooed them out of the house for a little sunshine and exercise.  I quickly learned the downside of handheld gaming devices:

So did those hours of nonstop gaming irreversibly damage our children's vulnerable brains?  Don't worry, I won't rehash the numerous studies linking video games with aggression, attention problems, obesity, depression and suicidality, poor academic performance, addiction, reckless driving, smoking, alcohol and drug use, hypertension and high cholesterol, inadequate sleep, seizures, pulmonary embolism*, ruptured eyeballs, internal bleeding**, five out of the seven deadly sins (greed, sloth, gluttony, lust, avian anger) and the decline of Western civilization.

Because that could get really tedious.


Let's focus instead on the benefits of video games.  As you know, I'm the master of finding evidence to back up how I would parent anyway.  And just to make it a little more challenging, I'm excluding studies of educational games.

Although traditional video games have been linked to obesity and physical inactivity, the newer generation of exergames, like the Wii, have the potential to reverse the trend.  But how much energy is actually expended playing?  A meta-analysis of 18 pediatric studies found that on average, gamers achieve 3.3 "METS," or metabolic equivalents, of activity, which is the equivalent of brisk walking or skipping.  A 60-pound kid would have to play for 90 minutes to burn off one single-serving bag of Doritos (150 calories).  Dance Dance Revolution uses the most energy, followed by Wii Boxing, Wii Tennis, and Wii Bowling.  Only in the virtual world could bowlers be considered reasonably fit.  Unfortunately, video games did not reduce body mass index.

Traditional video games do seem to improve visuospatial skills.  One trial in 10-year-founds found that playing the game Marble Madness improved tests of spatial skills compared to those who played computer word games.  The benefits were greater in girls, who have lower spatial skills at baseline.  Another randomized study found that undergrads who played a total of 6 hours of Tetris improved in tests in mental rotation and spatial visualization, compared to no improvement in those who were assigned to no video games.  Habitual video game players also test higher in measures of visual attention.  They're better at identifying multiple targets and ignoring visual distractions, and they have faster reaction times. In other words, playing video games makes you better at....playing video games.

So can these skills be translated into something marketable?  Well, if you're thinking about getting your tubes tied, maybe you should let your teenager take a crack at it.  One study found that teenaged expert video gamers outperformed obstetric interns on a laparascopic simulator.  (Laparoscopy is surgery performed through 1-inch incisions, with camera guidance.)  At least 10 other studies have found a positive correlation between surgical skills in doctors-in-training and video game experience.  I didn't find this too surprising.  I've done a few sigmoidoscopies (i.e., partial colonoscopies), and they're a lot like video games, only smellier.

And that's about all I found in my research.  I have to admit that the evidence to support gaming in kids isn't the strongest.  At least there aren't any studies showing that video games cause cancer.


Yet.

*A 24 year-old died after playing video games for 80 hours straight.
**A woman fell off her sofa while playing Wii Tennis.  You can get anything published these days, as long as the mechanism of injury is novel.

Still Smoking? Think of the Children!

How's the second week of winter break going for you?  How many times have you screamed at your kids?  Fed them Christmas candy for breakfast?  Confiscated your toddler's new set of horns, a gift from your relative with a grudge?


I've found a surefire way to cheer myself up whenever I feel exhausted and guilty at the end of a Bad Mommy day.  No, I don't look through my kids' "You're the best mom in the world!" cards -- you do realize their teachers force them to write that.  No, I cope by thinking about other women who are much worse mothers than I am.  I'm talking celebrity moms.  Moms who are impossibly rich and beautiful but can't be bothered to whip up some Kraft mac n' cheese.  Moms like Britney Spears, who not only smokes around her kids, but also allows them to play with her cigarettes and lighter.

It's probably not fair of me to pick on poor Britney.  If the paparazzi were tailing my family, they'd probably catch my kids setting the dog on fire.  And I wouldn't look half as good in that bikini.

While Brit probably knows about smoking's ill effects on her own health, she may not be fully aware of the dangers of secondhand smoke, including increased risks of sudden infant death syndrome, ear infections, and asthma, not to mention a higher likelihood that her own children will smoke in the future.  In fact, half of parents who smoke claim they have never been counseled by a pediatrician to stop.


Keeping your child healthy should be a powerful motivation to quit, but is this protective instinct enough to overcome the addiction?  A meta-analysis published in Pediatrics this week found that programs that counsel parents on the dangers of secondhand smoke do increase the chances of quitting successfully, though the benefit was small: 23% in the intervention groups quit, compared to 18% in the control groups.  Interestingly, parents of children over the age of 4 were more likely to quit with counseling, while those of younger children weren't.  The authors speculated that despite the increased risk of SIDS, mothers with newborns may be less able to stop smoking during this particularly stressful time.  Another possible reason is that as kids get older, parents may be more motivated to model healthy behaviors.


So for those of you still trying to quit, stick with it.  Make a New Year's resolution.  Ask your pediatrician to give you a pep talk at your child's next visit, and make an appointment with your own doctor to see if you should be prescribed any medication to help you quit.  Don't be surprised if this is the hardest thing you've ever had to do.  In fact, the tobacco companies are on to you -- there are more cigarette ads in January and February than any other month.  If you relapse, don't beat yourself up.  It takes the average smoker eight tries before she's able to quit for good.  


If all else fails, just think of Britney.

 

Meeting Mr. Sa (a.k.a. Frank Pus)

As a working mom, I accept that my toddler is going to be exposed to drool, snot and microscopic fecal contamination from his fellow daycare inmates.  But I draw the line at pus.  So imagine my dismay when one of my son's caregivers pulled me aside and said, "I get a lot of boils. Would you mind taking a look?"  Whereupon she rolled up her shirt, revealing a lovely specimen, which fortunately had already burst and dried up.  Most boils and abscesses are caused by Staphylococcus aureus, and in my area, about 60% are methicillin-resistant.

MRSA (along with some forms of strep) is commonly described as the "flesh-eating bacteria" in the media.  While MRSA can result in serious, life-threatening infections, more often it causes nettlesome skin infections that may require incision and drainage and treatment with specific classes of antibiotics.  The classic presentation is that of a "spider bite," sans spider.

                                                 Source: Dermatlas.org

It used to be that MRSA was seen primarily in hospitalized patients, but in the past 10 to 15 years, we've seen a meteoric rise in a particular strain in the community.  MRSA is contagious, and pediatric outbreaks have been described in daycare centers and on sports teams.

So what can you do to protect your child?  Unless you plan on raising a bubble boy or girl, MRSA is not entirely preventable.  It's best to avoid sharing sweaty sports equipment and towels, which are often colonized.  And there is another thing you can do to reduce the risk: Avoid unnecessary antibiotics.  Antibiotics wipe out the good bacteria with the bad, allowing resistant strains to flourish.  And many conditions frequently treated with antibiotics, such as ear infections, tend to resolve on their own anyway.

A recently published study looked at all the MRSA diagnoses in kids from 400 general practices in the U.K., and compared them to same-age controls.  They then looked at the kids' exposure to antibiotics 1 to 6 months prior to the MRSA infection.  Children who were infected with MRSA were three times as likely to have received antibiotics during that time period than those who weren't infected.  The more antibiotics received, or the stronger the antibiotic (i.e., those with the broadest spectrum of activity), the stronger the association.  Of course, it's possible that a child receiving multiple antibiotics is just more prone to infections, and the antibiotics per se are not causing the MRSA.  The authors still found a correlation after controlling for baseline diseases, such as diabetes and asthma. 

Here's another disturbing possibility:  some of those kids might have actually picked up the MRSA from the doctors' office.  Healthcare workers have colonization rates of up to 15%, and you know that most of us don't wash our hands after we pick our noses.  Even worse, one study found that a third of stethoscopes in one ER were contaminated by MRSA.  Since I work in a hospital, I could hardly blame my daycare if my son had become infected.

Bringing home the superbug

I admit I was caught flat-footed by this curbside consult, and I ended up advising my son's caregiver to see her own doctor.  I told her a little about decolonization protocols, which involve bathing with antiseptics, taking antibiotics and lacing your nostrils with Bacitracin.  Unfortunately, unless you place all your clothes, bedding and pets on a bonfire*, re-colonization is the norm, so these protocols aren't often used.  Though I told her she had a bacterial infection, I avoided using the M-word in front of the other parents.  I also didn't recommend staying home during her outbreaks, though I did suggest she cover up her boils with gauze.  Afterwards I tried to hand off my kid to the other providers as discreetly as possible.  This happened many years ago, and I still wonder whether I did the right thing.


What would you have done?


*Kidding!  I don't want to be held responsible for any hamster roasts.

Cuckoo for Cocoa Puffs?

A visit to Jelly Belly heaven....

will I be paying for this later?

One of the enduring myths of Christmas (aside from the man with the bag) is that eating all those candy canes will make your kids go bonkers.  There are certainly observational studies showing that sugar ingestion leads to inattention and impulsivity.  But if you look at only the well-designed, double-blind, placebo-controlled studies (there have been at least a dozen), not one has found that sugar has a deleterious effect on behavior in kids, even in those with attention deficit-hyperactivity disorder (ADHD).

The definitive study was performed in normal preschoolers, as well as 6- to 10-year olds whose parents had identified as being "sugar sensitive."  The care involved in the design of this trial was remarkable.  A dietician supervised the removal of all the food from the home, except for coffee and alcohol "as long as they were not consumed by the children."  The families were then provided with meals for the next 9 weeks.  The experimental diets, which rotated every three weeks, included one that used sucrose (sugar) as a sweetener, one that used aspartame (Nutrasweet), and one that used saccharin.  The families were not told the hypothesis, or what substitutions were made.  In fact, the investigators created sham diets that changed every week, to throw the parents off the scent.  One sham diet, for instance, consisted mainly of red and orange foods (although no artificial food coloring or additives were allowed).  Every three weeks, children underwent tests of their memory, attention, motor skills, reading and math performance.  Interviewers also surveyed parents and teachers about their kids' behavior.

The blinding was near perfect; only one parent correctly identified the sequence of diets.  Even though 48 tests and surveys were conducted per child, almost none found a difference in cognition or behavior among the three diets.  The one exception? Children on the sugar diet scored significantly better on the cognition portion of the Pediatric Behavior Scale.  I'm tempted to use this as a post hoc justification for letting my kids eat Cap'n Crunch, but it's probably just a chance finding.

Nonetheless, some parents continue to insist that sweets make their kids hyper.  Once you believe something, you're more likely to see it.  In one study, thirty-five 5- to 7-year-old boys who were reported to be sensitive to sugar were randomized to two groups.  In one group, the mothers were told their sons would receive a sugary drink; in the other group, they were told that they would receive a Nutrasweet drink.  They then videotaped the boys playing by themselves and with their mom.  The boys also wore an "actometer" on their wrists and ankles as an objective measure of their activity level.

Here's the twist:  Both groups actually received Nutrasweet.  As expected, there was no significant difference in the boys' activity levels by videotape review or actometer readings.  But the mothers who thought their sons consumed sugar reported significantly more hyperactivity during the play session than those who knew they were drinking Nutrasweet.  The videotape reviewers (who were blinded to the intervention) also found that the mothers who thought their boys drank sugar were more likely to hover around them, yet they scored lower in warmth and friendliness.  It was kind of a mean study, if you think about it.  First, they lied to the moms, then they slammed them for being more vigilant.

So why, despite the plethora of data to the contrary, has the sugar myth persisted?  It's possible that something else in the sweets, such as food coloring or caffeine, causes hyperactivity.  And think about it: When do we do let our kids consume copious amounts of sugar?  On birthdays, Halloween, and Christmas -- all recipes for going a little nuts.