Is autism on the rise?

From Dr. P's Clinic

Billy, a 30 month old boy, comes into my clinic

with his worried parents because "he isn't talking."

During the evaluation he makes little eye contact with me or with his parents,

does not point for things he wants nor looks to where I point,

is fascinated by the spinning wheels of the toy car,

has no meaningful speech and seems, as his parents say,

"lost in his own world".

The prevalence of autism
In the 1995 first edition of my book for pediatricians (Developmental and Behavioral Pediatrics: A Handbook for Primary Care), we said autism occurred in 1/1,000 children. In the latest, 2005 edition we say it occurs in about 1/300. Recent estimates have suggested it could as high as 1/165. Has the prevalence of autism really tripled (or more) in the past few decades? There is much debate among professionals on this question.

Some say no. They believe the apparent increase to be due to more awareness and understanding of autism among parents and professionals. Additionally, we are now diagnosing children with only mild symptoms (who would not have been diagnosed 20 years ago) as being on the "autism spectrum".

Others say yes: the increase has just been too great. (By the way, this is my view. When I started my clinic 20 years ago, I diagnosed perhaps 3-4 children per year as autistic. Now our Developmental Assessment Clinic sees 25 new cases per year and our recently-started Pediatric Autism Clinic sees well over 100.)

What triggers autism?
Since children's genes haven't changed, if autism is on the rise there must be something about the modern environment that triggers it in a susceptible child. What might that be?

It is the subject of a lot of ongoing research but, at this point, the simple and honest (and frustrating) answer is: nobody knows. Yet, despite any convincing scientific evidence, a whole cottage industry has arisen by folks who claim to know the "truth", whose emphatic certainty is untroubled by the lack of scientific proof.

Let's look at the hunch that the MMR immunization triggered autism. It made sense: many parents had the experience of their child's autism developing following a vaccination. They were (some still are) convinced one caused the other. (In fact, the fear of MMRs led to a mini-epidemic of measles in England after many worried parents decided not to immunize their children.)

But subsequent excellent studies have clearly shown this hypothesis to have been wrong and based on a coincidence (kids happen to get an MMR at the age when autism often emerges). We don't know what might trigger autism, but it's pretty clear it's not the MMR immunization.

Anyone can take a guess - educated or otherwise - about what causes autism and/or how to 'cure' it. Who knows, maybe someday one will turn out to be true. I certainly hope so! But beware the gurus who declare they have the answer and the solution, and who reject scientific proof as important to their claims.

An anti-scientific bias in the US
In some ways, this is a cautionary tale. For reasons I don't really understand, there is an anti-scientific bias among many parents in the U.S. which, I believe, can be damaging to children by leading to unproved and even potentially dangerous treatments, and an unfounded suspicion of what modern medicine has to offer.

It is fine to have a hunch about a possible cause or treatment of autism, as long as you label it as such and you are willing to put its validity to the test, and to admit you were wrong when valid scientific studies are negative. Extraordinary claims require extraordinary proof. Unfortunately, since we don't know what causes autism and we have no 'cure', many heartsick parents are susceptible to offbeat theories, even in the absence of objective scientific proof.

I'm optimistic and convinced that some day we will solve the riddle of autism and have much better treatments - perhaps even a cure. Until that happy day comes, I'm truly sorry to report there is no magic out there, that we can only do our best with what we currently know to be true.

In the meantime, we need to make sure that our fond desire for simple explanations and quick fixes doesn't play into the hands of bogus therapists who prey on loving and desperate parents' understandable willingness to try (and pay) almost anything to cure their autistic child.

Related Topics (Updated): Study: Childhood Rise in Autism Cases Real, Gene Interaction Linked to Autism Risk

Tags: autism,MMR,autism spectrum

Preventing allergies: When to introduce solid foods

Dr. P's Pediatric Journal Club

The study
Data on 2,612 German infants was gathered from birth as part of an ongoing study looking at when solid food was first introduced and the development of allergies by two years of age.

What the study found

• Waiting until after 6 months of age to start solid foods did not have a protective effect on the development of eczema ("atopic dermatitis") or other recognized allergies at age 2 years.
• Waiting until 4 months of age to introduce solid foods may or may not have had a protective effect on the development of allergies. The data were not clear.
  

Dr. P comments
My WebMD Message Board is filled with parents who are agonizing about what, when and how to introduce solid foods to their infants. It's also filled with a ton of different opinions - "I fed my baby cereal at 2 months and she is fine!"... "Hold off until she is past 6 months or she will have allergies!" ... "My pediatrician says that 4 months is OK, but only cereal!" The only similarity between the varying opinions is that each side is 100% certain that their way is the right way!

Whenever there is such diversity in parents' and pediatricians' advice, you can bet it's because kids do fine almost no matter what the parents do, and because there isn't much scientific evidence to guide us one way or the other. (Interestingly, these are often the parenting issues about which the various camps feel most passionately.)

As the authors of this study state: "Scientific evidence supporting a delayed solid food introduction for the prevention of atopic diseases [allergies] is scarce, inconsistent, and based on a few studies only." This study helps by demonstrating there to be no benefit in waiting for more than 6 months, and suggesting that it's still up for grabs whether there is really a benefit in waiting 4 months.

Truth be told, this is a common scenario for pediatricians: often there is insufficient scientific evidence to strongly recommend one practice over another. So we essentially fly by the seat of our pants and make our best judgment based on meager evidence and our experience, and wait for definitive research to clarify the issue.

So here's my seat-of-the-pants advice on starting solid foods:

• Hold off the introducing solid foods until 4-6 months. (Remember that cereal does not increase sleeping through the night!)
• Introduce one new food every few days, so if there is a digestive problem or apparent allergic reaction, you will know what may have caused it.
• Always be sure the texture of the food is such that your baby doesn't cough and sputter when it is introduced.
• Introduce the small amount of the new food when your baby is hungry - before, not after, he has had her milk. Then gradually increase the amount.
• Don't let "neophobia" (fear of new foods) discourage you. Even if your infant doesn't take well to some (or all!) solid foods, never try to force feed him. Remember that milk alone can serve the baby's nutritional needs until at least 6 months. Gently and cheerfully reintroduce the hated taste/texture at another time.
• Most importantly: keep meal time fun and pleasant for all. In the long run, that's much more important than whether your bundle of joy eats his broccoli or not. More than anything else, emotional warmth and support at mealtime is what promotes a love of eating in the child and makes family meals a joy.

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Article cited:
"Timing of solid food introduction in relation to atopic dermatitis and atopic sensitization". Zutavern A, et al. Pediatrics, February, 2006, pp.401-411.

Related Topics: New Clue on How Babies Learn Words, Studies Short on Soy Formula Risk

Technorati Tags: parenting, infants, newborns, feedingsolids, foodallergies

Your child's fears: Banishing the Ogre

Tales from Dr. P's office

"Dr. P!" Ms. L exclaimed as she entered my office. "I'm really worried about Petunia [her three and a half year old daughter]! She has so many fears! She's scared of the dark. She is chased by monsters in her dreams. She's absolutely petrified that she might see a bug during the day. I can't figure out why she is so worried and now I'm worried that something is terribly wrong with her or that something bad has happened to her that I don't know about."

For her part, Petunia sat happily in the chair, drawing pictures of her family and singing a song. Having known her all her life, she looked as happy and carefree as ever.

I thought I probably knew what was going on without asking. Still, it's a pediatrician's job to hunt around for worst case scenarios before calling something "normal". But, no, nothing bad had happened to her that Ms. L knew of. No important changes in her life. Things at home were fine. Petunia was happy and doing great otherwise, including at her day care. No, she never was even bitten by a bug.

It was a mystery to Ms L why her Petunia is so fearful, and she was worried and not a little guilty about it.

Dr. P explains it all

After the age of two, almost all kids, including those who have no significant stresses in their lives -- whose lives are, in fact, butter -- develop fears.

Why is that?

I sum it up this way: Most of us have a romanticized notion that childhood is an uninterrupted idyllic time of innocence and delight and naive happiness. That's true to a certain extent, of course, but it's also true that some of the time it's scary to be a kid, no matter how great your life might be. Think about it:

• You are little and everyone else is huge.
• You feel powerless to affect the world in the way you want (of course, parents may beg to differ).
• In your short life, you have been buffeted around by forces you can neither control nor understand.
• You are pretty clueless as to how and why things happen -- especially bad things. It's all kind of magical, and magic can always have a dark side.
• You haven't had enough experience to anticipate how things are going to turn out.
• You are egocentric, so you assume that everything that happens (especially bad things) will happen to you and because of you.
• You want to be independent, but lessening the close reliance on your parents, while thrilling, is also terrifying.

Given this scenario, it's no mystery that most young children will develop fears: think of it as a developmental inevitability. That's why it does no good to rationally lecture how "there are no monsters", that the "bugs won't bother you", that "it's just a dream." At her developmental level, your child -- with great certainty -- knows otherwise.

And even if you could somehow fulfill every parent's fondest dream and banish all fears and stress and travail from your child's life, would that even be a good thing to do? A child who never has had a moment's worry (not that there has ever been one) would be especially ill-prepared to cope with life's later inevitable stresses.

Mastering these fears is an important developmental challenge for your child. In her wonderful book "The Magic Years", Selma Fraiberg expressed it this way: "The future mental health of the child does not depend upon the presence or absence of ogres in his fantasy life, or on such fine points as the diets of ogres -- perhaps not even on the number and frequency of appearance of ogres. It depends upon the child's solution of the ogre problem."

What to do? Help your child solve the ogre problem! Here are some tips on how to do that:

• Monsters have magical powers, but parents have even greater magical powers. Don't be shy to use them. "This flashlight is an anti-monster flashlight and will keep the monsters away." "I checked everywhere and there are no monsters in the closet. Earlier I sprayed monster spray to be sure none come tonight." "I talked to the bug queen and she promised the bugs won't hurt you." Use your creativity and follow your child's suggestions.
• Be sympathetic. Never belittle or demean her very real fears.
• Try biblio- or video-therapy. (I suggested Ms L watch "A Bug's Life and "Monsters, Inc" with Petunia.) Find some wonderful picture books to read together that depict the dreaded experiences.
• Give your child 'transitional objects', such as pictures of her all powerful parents to keep with her, a magic blankie, a "monster go-away" night lite.
• Find out what your child finds reassuring and use it: soft music, an open bedroom door, a doll, a Jerry Springer poster.
• Eliminate some of the uncertainty by anticipatory collaborative problem- solving. "If we see a bug when we go outside, what are we going to do so you don't get too scared? What would you like me to do?"
• Increase your child's sense of control by drawing pictures together of the feared situations and talking about them with her.
• Make positive statements and predictions. "I don't think any monsters will come tonight." "The bugs are very friendly today." "You are going to be brave when you see a bug today."
• Reassure and reassure again. TLC and TLC again.

Bottom line: As your child gets older and gains a better understanding of the world, with your loving support she will successfully solve the ogre problem and have learned an important lesson about her ability to successfully overcome her fears.

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A caveat: While this discussion applies to most kids, occasionally the fears and phobias are so severe that they have a very negative impact on a child's ability to function and on her happiness. This suggests the excessive fears could be a response to some sort of significant stress and/or an early tendency to anxiety (that often runs in the family). In such circumstances, more intensive professional help may be warranted. If you have any questions about that, run it by your pediatric provider.

Related Topics: WebMD Video: Too Scared: Tale of Social Anxiety Disorder, Guidelines for Your Child's Bedtime

Technorati Tags: early child development, fear, stress, anxiety, phobia

Cervical Cancer Vaccine: The Good, Bad and Ugly

The U.S. Advisory Committee on Immunization Practices (ACIP) met last month to make recommendations on the use of a safe and effective new vaccine against the human papilloma virus (HPV).

• HPV is a virus spread by skin-to-skin contact during sexual activity. It often goes away without symptoms or else causes genital warts. Once contracted, there is no effective treatment.
• HPV exposure is very common, with about 80% of sexually active Americans having been exposed.
• Sometimes the virus infects the female's cervix, where it usually lies dormant. It can, however, transform normal cells into looking "pre-cancerous" on a Pap smear. These abnormal cells are then at risk to progess to cancer.
• Most cervical cancer (perhaps 80%) is caused by HPV.

The American Cancer Society estimates that in 2006, 10,000 American women will develop cervical cancer and that 3,700 will die from it. Worldwide, cervical cancer afflicts 500,000 women per year and causes about 270,000 deaths. After breast cancer, it is the second leading cancer-killer in women.

The good
By immunizing children with three doses of the vaccine before they are sexually active, about 70% of HPV infections that could later lead to cervical cancer can be prevented. Put simply, this is a vaccine that can prevent cancer - a dream come true (hopefully not the last) for all of us, and a triumph of modern medicine!

The bad
HPV is a sexually transmitted disease. So, as you might guess, some "abstinence only" advocates oppose making the immunization mandatory because, as Bridget Maher of the Family Research Council stated: "...young women may see it as a license to engage in premarital sex."

I'll leave it to you to decide if there is any merit to this dubious claim, but I think Cynthia Dallard of the Guttmacher Institute said it best: "If we had a vaccine for lung cancer, I don't think anyone would hold it back from their children because it might encourage them to smoke."

The ugly
We will see what the ACIP recommends in a few months. To my horror, a recent article in The New Yorker magazine suggests that the Bush administration is quietly lobbying against its universal administration, not wanting to impinge on a parent's right to refuse to give his/her child the vaccine and to further the administration's abstinence agenda by "giving the right message".

Dr. P rants: My government not supportive of a vaccine that will prevent cancer? I'm getting old and thought I'd seen it all but, if true, this sets a new standard for misguided governmental interference with the health of our children.

I once cared for a young boy who contracted a meningitis that likely would have been prevented had his parents not decided to avoid the "dangers" of vaccinations. You can guess how sad it was for all of us - especially the parents. (It's why I now insist my patients be fully immunized if they want me to be their pediatrician.)

Similarly, I wouldn't want to be the parents who live to see their daughter contract an HPV-caused cervical cancer because, when she was 10 years old, they decided to give her the "message" that contracting HPV and potentially getting cancer was preferable to having premarital sex.

Related Topics: Cervical Cancer Vaccine Nearing FDA Review, Cancer: A Closer Look

Technorati Tags: cervicalcancervaccine, HPV, genitalwarts

Help for your overweight teen

Dr. P's Pediatric Journal Club

The study

This was a randomized, controlled trial (the most scientifically valid kind) lasting 6 months. Teens, age 13-18 years, were randomly divided into two groups:

1. Got zero-calorie beverages (water, diet soda) delivered to their home + a magnet on the refrigerator stating "Think before you drink" + phone reminders not to drink sugar-sweetened beverages.
2. A "control" group that did not change their dietary intake.
   

What the study found

• The zero-calorie beverage group decreased their sugar-sweetened beverage intake by 82%.
• The heavier a teen was initially, the greater effect this had on weight gain.
• The heaviest teens gained one pound / month less, compared to the control group.

What the study suggests
A simple intervention of eliminating sugar-sweetened beverages is an effective weight-loss strategy for overweight teens.

Dr. P comments
A true confession from Dr. P: my track record is pretty bad in helping overweight kids lose weight.

I'm not alone: many of my colleagues (and parents and kids) share my frustration. The sad fact is that there is no great treatment for overweight kids yet. This is especially frustrating given the serious epidemic of obesity in kids and its very real medical consequences.

There are many reasons for our dismal track record:

• Only 1/3 of parents actually recognize that their child is overweight.
• Many families aren't aware of how fattening the food is that they are feeding their kids.
• "Food is love". Who even wants to deprive their kids of fried chicken?
• Schools are not providing low fat, healthy meals and serve sugary beverages.
• As many of us sadly know, controlling one's appetite is easier said than done.
• Many diets are complicated and seem overwhelming to even attempt.
• Even if motivated, restraint is rarely a teenager's strong point.
  

This study gives me hope. It suggests that by simply decreasing intake of sugary drinks and juices (which have no real nutritional value and do not suppress appetite), we can knock off about a pound/month of weight gain. Not a huge amount, but it's a start. It's simple and, unlike most diet measures, not much of a deprivation.

One problem is that teens are brainwashed to think many sugar-sweetened beverages are healthy, energy boosting and, worst of all, cool. I suspect it may take a national campaign (such as has successfully occurred with smoking) to turn those perceptions around, to make drinking water the really cool thing to do.

Putting this information together with the advice of my blogs of 12/26/05 and 12/12/05, here is Dr. P's simple-as-can-be nutritional advice for overweight teens and their families:

• Increase exercise.
• Serve a low animal fat, low junk food diet most of the time.
• Zero-calorie beverages only.
  

Yes, yes, I know that these simple recommendations are not the magic answer for your teen's overweight. But don't let the perfect be the enemy of the good. You can implement these measures: they are relatively simple and pain-free, and they are proven effective. All and all, they'd make make a good start.

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A Dr. P "unidentified flying fact" to give you pause:

Drinking a single 12-ounce can of a sugar-sweetened soft drink / day --> one pound of extra weight gain every 3-4 weeks.

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A caveat from Dr. P:

So far, little is known about whether artifical sweetener intake by young children could lead to long-term adverse effects of some kind. Consult your pediatric provider should you want to use them in your pre-teen kids.

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Article cited:
"Effects of Decreasing Sugar-Sweetened Beverage Consumption on Body Weight in Adolescents: A Randomized, Controlled Pilot Study". Ebbeling C, et al. Pediatrics. March, 2006.

Related Topics: A Healthy Diet for Teen Girls Only, WebMD Video: Keeping Your Kids Active

Technorati Tags: teenagers, obesity, diet, fitness