A Child Grows has a monthly column by Dr. Hugh Gilgoff at Long Island College Hospital. I am thrilled to have his expertise on this blog. To read his previous articles, please check them out at the end of this post.

Dr. Gilgoff is a pediatrician relatively new to the Brooklyn community. He has a balanced approach to medicine, combining a westerntraining at top institutions with an alternative outlook shaped by a mom who is both a midwife and creator of Mother Nurture Inc. – a Doula company since 1987. Dr. Gilgoff worked in Manhattan for 11 years, and now practices on 185 Montague Street. Dr. Gilgoff is available for free prenatal consults, second opinions, and accepts new patients with all types of insurance plans. To see his listing information, check the blog here under “Recommended Pediatricians”.

Vaccines:  Efficacy and Safety

Why do we need vaccines anyway?
There are tons of germs out there, and unless we make our baby the “boy in the bubble” we are going to have exposure to a lot of dangerous bacteria.  Indeed, our natural immunity can fight off many viruses and even certain bacteria, but there are some very serious illnesses that we just can’t fight off without help.
When pediatricians are evaluating a seriously ill child with a high fever, we conduct tests – blood, urine and even spinal fluid exams.  After a few days, we get back our results, and we have clear statistics on the rates of the bacterial illnesses we see each year.  Luckily, many of these diseases are not very common – but they are still very real and pose a significant risk to a young child.  One of the benefits of a cleaner society has been fewer epidemics and fewer deaths attributable to infectious diseases.  But if we relax, and fail to protect our children, we will definitely see an increase in some horrible infections.
We need to take a look to our not so distant past to realize just how far we have come in preventing some of the most dreaded infectious diseases.  Back in the 1940’s and 50’s, people lined up around the block for their polio vaccines. Polio was one of the most dreaded childhood diseases of the 20Th century in the U.S.  Polio epidemics crippled thousands of people, mostly young children each year.  Most of us don’t remember how terrified parents were that polio would leave their children unable to walk or force them to spend the rest of their lives in an iron lung.  Since the polio vaccine became available, the disease has more or less disappeared from the US.  But it still is rampant in many parts of the world, and we have travelers come to New York all the time!  If our immunity as a society waned, surely there could be another outbreak here.
Then there is the HIB germ – which was so rampant in the 1980’s, but because of a successful vaccination program has plummeted in its incidence.  It was a leading cause of meningitis and pneumonia in children and thousands of deaths have been prevented.  The pneumococcus germ (a form of strep) remains one of the most common causes of meningitis and pneumonia (as well as ear infections).  Since the creation of the prevnar pneumococcus vaccine, the rates of children admitted to the hospital with this germ have gone down significantly.  This germ specifically affects younger children – so that once a child is over 2 years old, the risk goes down.  But the risk is highest among those 6 to 24 months old – thus the reason that delaying vaccines puts a baby at risk!
Measles is also a very serious disease.  Measles is a leading cause of death among young children even though a safe and cost-effective vaccine is available to prevent the disease. In 2007, there were 197,000 measles deaths globally – nearly 540 deaths every day or 22 deaths every hour. More than 95% of measles deaths occur in low-income countries with weak health infrastructure. Measles vaccination efforts have reaped major public health gains, resulting in a 74% drop in measles deaths between 2000 and 2007 worldwide – a drop of about 90% in the eastern Mediterranean and Africa regions.  If we fail to vaccinate against measles, the disease burden seen abroad will surely return to the U.S.

But why so many?
Surely, there are more vaccines now than before.  But the body’s immune system reacts to the antigens in each vaccine and that number has actually decreased.  Indeed, the smallpox vaccine was a strong vaccine – it had so many antigens, and there were many local skin reactions.  But it worked – and now smallpox is eliminated!  Nowadays, the vaccines are better targeted and therefore do not overwhelm a baby’s immune system.  We conduct specific studies to make sure we give small doses, and slowly boost the immune system with “booster shots”.
Gone are the days where doctors say medicines and vaccines are without any potential side effects, but when you weigh the risks and benefits, vaccines have significantly improved the well being of our children.

Why the scare?
There has been a media frenzy for almost 10 years now which has led to a real cynicism regarding vaccine safety, and specifically their relationship to autism.  This started in 1998 when Dr. Wakefield, a gastroenterologist from England published a study postulating a link between the MMR vaccine and autism.  The problem was his study was very flawed.  He used a self-selected group of patients – those already referred to him with problems (not a random placebo controlled double blinded study with neutral unbiased observers) and his numbers were very small – not enough to have the power needed to prove anything.
Nonetheless, when word got out that there was even a possibility of a link to autism, fear spread like wildfire.  Indeed, autism diagnosis continued and still continues to go up.  Moreover, the timing of the diagnosis of autism was often right around the failure to say the first words – around 12 or 13 months.  The MMR is given at 12 months, so the timing seemed to support the link as well.
Since 1998, there have been numerous large randomized clinical studies that have clearly shown that there is no link between MMR and autism.  Dr. Wakefield has actually retracted his results, and the Lancet journal that published the article has issued an apology for the flawed study.  The studies are pretty straight forward: take a large group (in Denmark over 250,000 patients) who did not get the MMR vaccine, and have neutral blinded experts compare the rates of autism.  It is clear that in kids who have NOT received the MMR vaccine, the rate of autism is the same.

Why is autism on the rise?
Nowadays, we are able to screen for and identify signs of autism much earlier than before.  Therefore, before a child reaches their first birthday, we can usually tell whether the child has developmental delays and any signs of autism.  Clearly, there has been an alarming increase in the incidence of autism.  A major factor for this is observer bias – the fact that we are all looking for, and therefore seeing more autism.  It was not too long ago, that children with autism were underdiagnosed – they were labeled as mentally retarded, or speech delayed, or just missed altogether.  Nowadays, everyone from teachers, to parents, to doctors are vigilant in their search for autism, or any pervasive developmental disorder (PDD) and this contributes to an increase in cases officially diagnosed.
There definitely is a genetic basis and researchers are locating a gene that predisposes someone to autism.  However, there may indeed be something in the environment that is causing more autism.  That may actually be something that mom was exposed to while pregnant, as the most common forms of autism are probably with a child since birth.  The case we all have heard of a child developing normally, and talking well, only to spontaneously regress is actually quite rare, and NOT your typical autistic child.  The usual presentation of autism includes the inability to form interactions, connections, or communication skills that are appropriate all along – and not a loss of skills that were already acquired.

What about thimerosal?
Thimerosal is a preservative for vaccines that was used for a long time.  It is broken down to a mercury compound.  The toxic effects of mercury have been known for a long time.  Indeed, the mad hatter in Alice in Wonderland, like many hatters of the old days, handled mercury in their trade and suffered the consequences.  But there is a big difference between methyl mercury (toxic, and can get into the central nervous system) and the thimerosal compound, which is ethyl mercury (less potent and can’t get into the nervous system).  Nevertheless, after a fear developed, the American Academy of Pediatrics demanded that all vaccines were made without this preservative, and since 2001 all vaccines (with the exception of some adult flu vaccines) are not preserved with any mercury component.  Nonetheless, in these 8 years autism cases continue to increase, so it was not the thimerosal.
The causes of, and potential cures for autism will take a large effort from scientists, politicians and activists, and pediatricians are 100% behind those efforts.  But it now seems clear that vaccines are not the root of the problem.

Splitting or altering the vaccine schedule:
Nowadays, people worry that there are too many vaccines, and the immune system will be overwhelmed.  This question has been thoroughly studied by scientists and that is how the present recommendations have been created.  Before a vaccine is added to the schedule, there are huge studies conducted where they measure the success of the immunity based on blood tests (titers) and any side effects.   The most common side effects are fever (less than 10%) and muscle aches or soreness.  The vast majority of babies and children have absolutely no reaction to any vaccines.
We have already determined that giving a vaccine to a child before they are 6 weeks old is NOT as effective – so we don’t recommend that!  But after 6-8 weeks, a child’s immune system can and does accept and incorporate the passive immunity afforded by the vaccines.  The vaccine schedule allows a child to develop enough immunity to have the best chance to fight off the germ by the time the child is most likely to see that germ.  Any delay in giving the vaccines is obviously increasing the chances that you will not be able to fight off that germ at that time.  Nonetheless, if a caretaker feels more comfortable splitting the first few rounds of vaccines into two – in other words getting some shots 6 different months (month 2-7) instead of  3 different months (2,4,6), the delay of one month is not a big risk to the child.  I think the child would rather get it all over with in three different days, rather than face six days of pain, but I insist on trying to make my parents feel comfortable.
Dr. Sears is a good pediatrician who promotes an alternative, delayed schedule.  He raises many good theoretical questions – like can an aluminum preservative cause harm, but he offers little answers, and I fear he just adds fuel to the fire.  I wish that he offered the schedule without making people pay to see it, and I wish he didn’t have car commercials or coupons for vitamins on his website.  There is a recent article in the Pediatrics journal about the harm some babies have encountered after delaying their shots and getting the illnesses that were preventable.  I don’t want that to happen to any of my patients.

Who can we trust?
I was raised by a midwife mom who created a doula company over 20 years ago, and a Dad who was one of the original consumer reporters – always looking out for the scam, or the company not telling the whole truth!  Indeed, I entered western medicine a bit skeptical, and I challenge a lot of what is taught. I agree that the pharmaceutical companies have a huge financial incentive, and I have observed first hand the shortcoming of the FDA.
But that is balanced by a window to a world that others just can’t see.  In my 13 years caring for children, I have seen meningitis take a baby’s life more than once, and I have seen hundreds of children suffer with pneumonia or blood infections.  I think that I have a balanced approach to medicine on the whole, and I am sure the benefits of vaccines clearly outweigh any theoretical risks.  I had to reexamine all of my feelings as I went through the vaccine schedule with my own daughter, and she received them all and did just fine.
Perhaps the best plan is to find a good pediatrician who you can trust.  Someone who was very very well trained, who is extremely intelligent and can analyze the scientific studies.  They must then also possess the bedside manner and compassion to work with a family that has real concerns.  It is our job to synthesize all of the information out there and present our unbiased opinion.  Of course, I believe that my informed parents have the ultimate decision making capacity when it comes to their children, and I don’t turn away any family, even if they refuse all vaccines.  But the question is how informed (even with the great internet) we can be when it’s not our area of specialty.  Indeed, I stand over the plummer when he fixes the sink, and I nod my head a lot when the mechanic fixes the car.  I even try to research the stock market or certain laws.  But I think that sometimes, even with our children’s health at stake, we have to be comfortable following the advice of unbiased experts.  I hope that I can be that person when it comes to infectious diseases, vaccines and the full array of perplexing pediatric issues.
More information for parents and caregivers issued by the American Academy of Pediatrics about vaccinations and autism, go to the following link: www.aap.org/healthtopics/Autism.cfm
www.cispimmunize.org/
www.cdc.gov – the governments center of disease control
www.vaccinateyourbaby.org – a nice site started by an unbiased mom.
www.aap.org – the general American Academy of Pediatrics website.

Look for other columns by Dr. Gilgoff:

Column one: fevers in all ages
Column two: breathing, rashes, spit-up, jaundice and fevers.
Column three: colic and nutrition

Related Posts:

1. Vaccine and Autism Study Doctor Found Guilty (February 1st, 2010)
2. Swine Flu Vaccines Started Today (October 6th, 2009)
3. Dr. Gilgoff (January 19th, 2009)
4. Colic and Nutrition for Your Baby from Dr. Gilgoff (December 5th, 2008)
5. Fever, Jaundice, Rash, Spit Up and More: by Dr. Gilgoff (September 29th, 2008)