Swine Flu 4.8: 'Tis mad, 'tis true, 'tis true, 'tis pity, and pity, and pity 'tis 'tis true

9 positive A’s yesterday in the first 2.5 hours of work before running out of flu tests; shipment promised for tomorrow.  As per Health Department recommendations, will consider everyone with flu-like illness without another diagnosis to have Swine Flu.  As always, the problem is not Swine Flu, but the possibility of another, more dangerous, febrile infection masquerading as flu. Schools are back to the practice of sending children straight to the doctors.  Bad idea.

And, the weather in New York has been beautiful, as it had been in Mexico when their outbreak started; any idea that flu is caused by winter cold is a non-starter.  I did this interview a while ago:


“Alaskans and Canadians living year-round above the Arctic Circle have no more winter colds than folks who live in Australia. These are old wives’ tales from an era when we had no ability to treat fever or other complications of infection. Folks created myths to explain what happens to protect their children from getting sick.”

Cold Weather Myths
Cold weather’s association with colds probably evolved from confusion, similar to beliefs about the origin of malaria. “Bad air around swamps was once believed to cause malaria,” says Anatoly Belilovsky, MD, a pediatrician in Brooklyn, N.Y. “Mosquitoes, also plentiful in swampy areas, actually carried the disease. Cold air and respiratory disease are connected, but the connection is more complicated than just ‘cold causes colds.’”

On the contrary, cold weather appears to activate the immune system, according to a study by the Army Research Institute of Environmental Medicine, says Dr. Belilovsky. “Researchers examined the immunological responses to cold exposure and found that acute cold exposure, such as going outside without a jacket, actually appears to activate the immune system.” This occurs in part by increasing the levels of circulating norepinephrine, one of the body’s hormones, which works as a natural decongestant.

Weather as an Indirect Cause of the Cold
While simply stepping outside in cold weather without a jacket doesn’t cause a cold, hypothermia (the lowering of the body’s core temperature) suppresses immunity, which can lead to colds. “Most cold symptoms are produced by the body’s immune system physically responding to the rhinovirus,” says Belilovsky. “So, someone with a stronger immune system in the cold will produce more [mucus], while the one with the weaker immune system will sniffle longer, but less dramatically.” The person with the weaker immune system probably will have more complications, such as sinusitis or ear infections, Belilovsky adds.

Cold weather may be indirectly responsible for colds, however. Vasoconstriction, when blood vessels close to the outside of the body narrow, such as those found in the nose, leads to dryness. “This dryness compromises the nose’s ability to filter infections,” Belilovsky explains. “On returning to warm air, rebound vasodilation occurs, where your hands get pink and your nose starts running as blood returns to it.” The cycle continues if the runny nose is severe enough to cause mouth breathing. Bypassing the nose’s ability to filter inhaled air, combined with dry indoor air, allows the inhalation of virus-bearing mucus, which may trigger colds and lower respiratory infections.

Cold-Induced Asthma
“Cold-induced asthma can certainly masquerade as a recurrent cold when it is not severe enough to produce acute attacks,” Belilovsky cautions. People may think that going outside with a wet head or no jacket solely causes a cold, but people in the early stages of an illness may actually feel hot. As a result, they may go outside without proper clothing and return with a full-blown fever. This makes it appear that the cold weather triggered a cold, but it was already under way.

Cold temperatures are only indirectly linked to symptoms of the common cold. So bundle up and enjoy the winter.

Last Updated: 02/20/2009


Swine Flu 4.7: A Million is a Crowd

Just got a fax from NYC Health Department: it made a very sensible recommendation — to consider every child with unexplained fever to have swine flu and treat accordingly.  This means Tamiuflu for the young (2 and under), the old, the chronically ill, and anyone else who appears to be significantly sick.  School closings are not specifically recommended; panic is definitely not recommended, for individuals or for public officials (nudge nudge, wink wink, hint hint).  As of now, approximately 1% of our entire patient population has confirmed Flu A, and another 2 or 3% are suspected — if this holds true for the rest of the city, the cases must be in the tens of thousands, heading into millions by the end of next month.  Two fatalities so far: sad, but lower than what would be expected from a “regular” flu epidemic.

Several of the parents seen today were in acute danger of heart attacks from anxiety caused by the media’s shrill hysterics over the flu — a danger far greater than that to their children from the flu itself.  Enough, already, with hyperbole, before we run out of Xanax like we are running out of Tamiflu!

PS: 19 positive for Flu A today. Thus ends another day, as for tomorrow –

To-morrow, and to-morrow, and to-morrow,
Creeps in this petty pace from day to day…

And, while Tamiflu is quite effective, and Vitamin D does support the immune response and is also recommended, this homeopathic preparation, in particular, is not:

Eye of newt, and toe of frog, 
Wool of bat, and tongue of dog, 
Adder's fork, and blind-worm's  sting, 
Lizard's leg, and owlet's wing, 
For a charm of powerful trouble, 
Like a hell-broth boil and  bubble.         

With this, I bid adieu…


Swine Flu 4.6: The Undiscovered Country

Well, this is a new experience for us: a major, rapidly progressing epidemic that is being tracked in real time with the most modern tools.  It is, still excellent training for all involved for the event of a really dangerous epidemic (which this is NOT.)
Still seeing lots of sick children; 10 tested positive for Flu A on Thursday, 21 positive for Flu A yesterday (Friday); at least one of the positives was negative 2 days previously, on the first day of fever, underscoring the importance of not running to the doctor immediately as soon as symptoms start.  The CDC surveillance says swine flu now accounts for 73% of all flu tested.  The newest incidence and mortality curves continue to confirm my suspicions: there’s lots and lots of swine flu around, and it is no more dangerous than regular flu, and most probably less dangerous:

(from cdc.gov/flu/weekly)
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Swine Flu 4.5: Told You So!

In War and Peace, I noted the similarity between medicine and military.  At no time in the 20 years that I have been a practicing pediatrician has this been more true.  We are right there in the trenches, with the enemy sniping at the people we are here to protect, and we have to make our decisions immediately, without waiting for the generals (CDC and the Health Department) to make up their minds about the intelligence that we ourselves are providing on the enemy.  Another unfortunate similarity is that truth appears to have been the first casualty of the flu pandemic, much as it is in war.  A cursory glance at local newspapers bears witness to the appalling mishandling of the situation by the media: the stories are all about panic while the sidebars mention, in passing and small print, that the panic is entirely unwarranted.  If the media are so capable of distorting what is happening within stone’s throw from their editorial offices, I think we can safely ignore what they are saying about our troops overseas, and believe only what we hear from the soldiers at first hand.

In Kennel Cough, I argued that letting children with mild symptoms miss school would be a good way to slow down epidemics.  Closing a number of schools in New York is, I suppose, just as effective, although a bit of an overkill.  There seems to be no end of effort that the educational establishment will expend to avoid the simple, and heretical, solution of simply trusting families to send or not send their children to school in accordance with their best judgment.

In Epstein’s Mother I deplored the schools’ insatiable appetite for doctors’ notes with often unacceptable requests.  A side example was a child who was told not to come back without a doctor’s note that there was no alcohol in her blood — a request that shows utter ignorance of technical (alcohol is completely gone the next day, which is when she came in) and legal aspects of this testing.   But far more egregious is the current practice of school personnel telling families to take their children with runny nose and low grade fever to the doctor IMMEDIATELY, and not to come back without a note of clearance.

OK, ready?  Deep breath taken.  Begin rant:

Is there no one in schools with the brains to realize that  we have a huge influx of TRULY sick children to evaluate and treat?  Yes, the flu really is here, and we give it the same attention we give any epidemic influenza — which is lots.  Yes, there is ample evidence that this “swine” flu is milder than seasonal flu, with lower mortality — but any flu can be fatal, and we absolutely need to see the children with high fever, vomiting, headache, body aches, lethargy, shortness of breath, severe cough, or any combination of these.  Having to pander to schools’ misguided directives places these children at risk.  Also, while we continue to do influenza tests, they rarely show positive results in the early phase, before high fever starts, so it is a waste of time even for the children who have contracted flu to be seen that early.  This is, once again, a shining example of educational establishment’s ignorance of any considerations outside their own policies, and of their utter disrespect for the families they serve.

I have met teachers, and I have met school administrators, and school nurses, and none of them so far have been stupid enough to have perpetrated the idiocies I have seen.  Do they check their brains at the schoolhouse door?  Is it confiscated by security at the mental detector?  Or is it the pattern of groupthink, well-known as the source of flash-mob occurrences, that causes the dumbest ideas of each member of any committee to be incorporated into that committee’s final product?
End rant/. Must get back to work.


Swine Flu 4.4: Graphic FAQ

Is there much swine flu in New York?

Yes; there is much swine flu everywhere:

From the CDC: During week 18, the following influenza activity was reported:

  • Widespread influenza activity was reported by eight states (Arizona, California, Delaware, Georgia, New Jersey, New Mexico, Texas, and Virginia).
  • Regional influenza activity was reported by 14 states (Alabama, Alaska, Colorado, Connecticut, Florida, Hawaii, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New York, Tennessee, and Utah).
  • Local influenza activity was reported by the District of Columbia and 15 states (Idaho, Illinois, Iowa, Kansas, Michigan, Montana, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Washington, Wisconsin, and Wyoming).
  • Sporadic activity was reported by 13 states (Arkansas, Indiana, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Vermont, and West Virginia).
On both of these graphs (from the CDC), there is an obvious jump in the number of flu cases all over the US.  Not all are swine flu, but it appears to be more prevalent now than any of the seasonal strains.INFLUENZA Virus Isolated
View WHO-NREVSS Regional Bar Charts| View Chart Data | View Full Screen

national levels of ILI and ARI

Is it more dangerous than “regular” flu?

No. The overall mortality is staying well below the 2007-08 and 2004-05 levels, while the pediatric mortality is far below what we were seeing in February of this year, from seasonal flu.

Pneumonia And Influenza Mortality

Influenza-Associated Pediatric Mortality

Should I worry?
Think back to February: there was a lot more flu around then, it was just as dangerous, if not more so, much of it was Tamiflu-resistant (swine flu is very sensitive to, and treatable by, Tamiflu), there were many more deaths from the “regular” flu than are reported from swine flu — the level of concern should not be any higher now than it was back in February.   All precautions you took then should be in force now; and you should have the same criteria for going to the doctor.
Are the schools handling this epidemic appropriately?
Mainly, yes; the only criticism I have is their policy of requiring a doctor’s note stating that a child DOES NOT have swine flu to return to school.  I have had a few children who tested negative on the first day of fever and positive on second or third, when virus shedding is much higher, and only the health department can test for the difference between seasonal and swine flu, so asking for such letter from a general pediatrician is grossly inappropriate.
I also would like to see how the schools handle make-up exams for the many children who will miss finals this year; if past experience holds, we are in for another avalanche of doctor’s notes which I will once again be tempted to sign, Epstein’s Mother.


ParentDish ADHD interview: more complete answers

Parentdish.com interviewed me a few weeks ago, about ADHD.  I do not treat ADHD myself, which allows me to have a kind of broad, unbiased perspective on it — and, like most diseases considered “new”, history tells us it is old but “newly named”.  The very popular article, widely reblogged, is here:


and here are my original answers in the interview :

> Please provide me with your definition of ADHD and ADD. Is this a truly physiological disease? I am skeptical, I admit. It seems like when I was a kid, students with ADD or ADHD were just called “hyper” or “active.”

Look, forget about clinical definitions; let’s talk about people.  ADD/ADHD is the disease that caused Alexander to be The Great.  It also caused him to drink himself to death.

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Asthma Article Published In: thefamilygroove.com



Every Breath You TakeQ: What is asthma, really?
A: Asthma is the reversible narrowing of bronchi,
the pipes through which air reaches your lungs.
Look at it this way: Imagine breathing through
your eyes. Have you heard of bronchospasm?
That’d be like your eye was closed. Bronchial
inflammation? That’d be like your eye was swollen
shut and filled with gunk. Reversible obstruction? That’d be like your eye was shut one minute (a trigger response) and wide open the next.


Q: Why is there so much asthma lately?
A: The theory that makes the most sense, and is best backed up by evidence, is the hygiene hypothesis. In several studies, it was found that in developing countries, people who were infested by intestinal parasites had less allergy and asthma than those who were not, and in a German study, less asthma was found in children who survived a life-threatening infection. The immune system is constantly on the lookout for infections and parasites and, lacking real targets for the immune cells to attack, sometimes attacks healthy tissues or overreacts to minor infections. There are a number of infectious agents such as respiratory syncytial virus or mycoplasma that have been identified as commonly associated with asthma, and, of course, pollutants can trigger attacks. Blaming all asthma on outdoor pollution is probably incorrect, as the air is cleaner now than it has been for hundreds of years because of stricter environmental controls.

Q: How is asthma treated?
A: There are medications like albuterol, which relaxes the muscles holding the airway closed; steroids, which decrease the swelling; and antibiotics, which treat the infections that may either trigger or complicate asthma episodes. A common mistake is to assume that, if shortness of breath is absent, all is well. This error is best avoided with the use of a little toy called a peak flow meter. It measures how fast you can breathe out, compared with both your personal best and the ideal calculated for your age and height. Peak flow numbers will drop long before actual shortness of breath appears, allowing you to adjust your treatment or seek help early. Another dangerous mistake is to treat with beta-agonists (like albuterol) alone. They work quickly, but in the worst attacks, they fail without warning; dependence on beta-agonists has caused many deaths in asthmatics. Think of them as fire extinguishers; if you use one daily, there is something wrong in your kitchen, and they are useless against a big fire. There are a number of preventive medications that keep attacks from happening, and a number of rescue medications that stop breakthrough attacks, but the old “can’t breathe, take a puff” routine is not only useless, but potentially deadly.

Q: What are alternative treatments for asthma?
A: First of all, emotional distress is a well-known asthma trigger. The lungs and the brain are connected by the vagus nerve, and vagus activity is known to produce asthma attacks, so whatever makes you feel less anxiety will probably have an effect against asthma. Secondly, a number of plants produce toxins that, in small quantities, have an asthma-blocking activity. Unfortunately, as these toxins are needed by the plants to keep them from being eaten by animals, they tend to have serious side effects. Ephedrine in ma huang, theophylline in tea, and scopolamine in deadly nightshade are examples of such poisons. Many currently used medications are “declawed,” less toxic derivatives of natural plant poisons. Thirdly, human and animal adrenal glands produce steroid hormones, some of which fight the inflammation that is part of an asthmatic event. Both natural versions of these hormones and synthetic derivatives are used sparingly, as they produce their effect by suppression of immunity. “Declawed” versions of these hormones are easily destroyed in the bloodstream; they are given as inhalations directly into the airways and do not produce measurable effects anywhere else in the body.

Physical activity appears to help more often than not; exercise-induced asthma appears to be less common than asthma that gets better with consistent exercise. In any case, asthma should never serve as an excuse for reduced activity. Finally, anything that controls heartburn will probably reduce asthma severity as well—and since caffeine, fat, overeating, spicy foods, alcohol, smoking and tight clothing can all induce heartburn, avoiding them might be worth a try.

Dr. Anatoly Belilovsky is a New York pediatrician whose 365-day practice, Belilovsky Pediatrics, won an AmeriChoice award for Center of Excellence in asthma care. He is a graduate of Princeton University and served as a clinical instructor in pediatrics at Cornell’s Weill Medical College. For more information, visit his website and blog www.babydr.us.


Swine Flu 4.3: I know karate, kung-fu, kendo, and many other scary words

Another exciting weekend went by, families less anxious I think than before (must be watching Fox News and Telemundo); Saturday 5/2/09 — 3 positive Flu A, 4 positive for Strep Throat; Today, Sunday 5/3/09 — 1 positive Flu A, 13 (!) positive for Strep Throat.  Let’s not ignore Group A Beta Hemolytic Streptococcus pyogenes (the active ingredient in strep throat) — people die of strep.  George Washington did, as did Jim Henson and Lou Costello. People who have Strep get treated and followed up, just like children with flu.
Seriously, folks, we may be nearing the end of this hysteria. A Hong Kong hotel may still be sealed with people in it as you read this,  but here in New York, most people seem aware of swine flu being common and moderate rather than rare and severe; not so much snakes on a plane as geese in front of one.  If I helped any, I’m happy.  If you look at other stories from Tuesday 4/28 (when I had my radio interviews) and Wednesday 4/29 (when I was on Telemundo and Fox News), they tend to be far more alarmist.  Infections are, generally, not good for you.  Nature is not our friend; it is, at best, a disinterested observer in our ongoing disputes with the sabretooth tiger (which we won), Rickettsia rickettsii (which we are winning), and the human immunodeficiency virus (which is down but not out).  Should there ever be a real reason for elevated concern, watch this space: I will then –

“Cry havoc, and let slip the dogs of war”.


Swine Flu 4.2: Acute postprandial upper abdominal distention

In yet another Star trek reference, words spoken by Dr McCoy to create a sense of extreme urgency — actually mean “eating too much”: “acute” = (of disease) brief and severe; “postprandial” = after a meal; “upper abdominal” relating to the area of the stomach; “distension” = the state of being stretched beyond normal dimensions.  And, yes, I am enjoying paying homage to the TV show from which I learned spoken English.  And, yes, “deadly”, “swine”, and “pandemic” are being thrown around with abandon to create a panic that need not happen.  “Deadly” may apply to anything of which anyone ever died (and, in a rather confusing email from CDC, I learned that apparently the Mexican confirmed swine flu death toll is downgraded to… 7…?


Well, that’s way below what seasonal flu causes every season, but, technically still deadly.

Calling it “swine” (or “bird”) flu is also misleading, as most new strains are produced by reassortment in pigs and poultry in close contact passing the infection back and forth; and a “pandemic” means the whole world is sick with it — which applies equally well to common cold and athlete’s foot.  Reminds me of the obsessive-compulsive agnostic dyslexic insomniac — stays up all night wondering if there is a dog.

Anyway, only one positive yesterday (out of a many many anxious families) and that one not very sick either.  “Acute postprandial upper abdominal distention” also means being fed up, and it seems that the media have had their fill of hysteria, and voices of sanity are beginning to prevail:


Five days after my interview with a Miami radio station:…


…and the Fox News TV interview:


… most news and official statements are beginning to confirm what we saw.

As a training exercise, or a dress rehearsal, for handling a really severe outbreak (which this was not), the official response to this epidemic has been of great value.  I think it will be analysed for years to come to assure better preparation for a potential emergency.  So for local, state, federal and international health authorities I have nothing but praise (especially let’s give a big hand to NYC Health Department, whose actions were an incredibly short 24 hours behind the frontline view).  I am less happy about the media; this is not the time to be crying “wolf”, no matter how it improves sales, ratings, or hit counts.  Let’s save the hyperbole for when we need it.

In case anyone forgot, Star Trek V is titled “The Final Frontier”; I don’t think the flu story has a final anything in it, so I’ll stay with 4.x for the time being.

Once I post them, click “Comments” for my videos on the swine flu subject.