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In this category you will find answers to many common newborn questions.

Squirt several drops a saline solution into the baby's nose and then suck out as shown. This may be repeated several times if needed. Saline is very safe, even if the baby coughs or gags a little bit. This can be done as about as often as needed (before feedings, before bed).

apply a little K-Y lubricant to the tip of the suppository and gently insert it into the anus until it passes the opening completely, then hold the buttocks together for a moment until the urge to push it back out passes.

Gripe water's ingredients vary, and may include alcohol, a bicarbonate, ginger, dill, fennel and chamomile.


A 2000 review in the Journal of the Royal Society of Medicine found that most of the ingredients in Woodward's gripe water are of questionable value in relieving infantile discomfort. (Blumenthal, I (April 2000). "The Gripe Water Story" (PDF). Journal of the Royal Society of Medicine 93 (4): 172–174. )

These tablets contain the following ingredients according to the manufacturer:

Calcarea Phosphorica 6X HPUS - supports dentition
Chamomilla 6X HPUS - for irritability
Coffea Cruda 6X HPUS - for wakefulness and diuresis
Belladonna 12X HPUS (0.000000000003% Alkaloids) - for redness and inflammation
In a base of Lactose (milk sugar) NF.

Belladonna is a hallucinogen, though the amount in hylands is small enough that it should not cause problems.

In fact, it is a "12X" dilution. That means taking 1 ounce and diluting to 10 ounces (1X) and then taking one ounce of that and diluting it to 10 ounces (2X)... 12 times. It is estimated that a 12X dilution has less than one molecule of the ingredient (Belladonna) per dose. That means you are paying for NOTHING!

However the FDA does NOT regulate these homeopathic products so it is possible that the amount of any given ingredient may vary from batch to batch. Also, reactions to Dietary Suppliments are not monitored, so there is no way of knowing when problems occur.

I see no benefit in this product.

Newborn girls will typically have a whitish vaginal discharge. as the first weeks pass, sometimes there may be some blood mixed in with that discharge, which is normal and thought to be due to the hormonal changes ocurring within her. It is usually harmless.

New babies frequently sneeze, even soon after birth. This is related to new airborne irritants they did not experience in the uterus. This is their natural way of clearing these irritants from their nose. If your baby is well otherwise, this in normal and nothing to worry about.

There was a recent study that suggests that the vaccines may actually work BETTER if anti-fever medicines are NOT given with the vaccines.


I would hold off on fever medication unless the baby is very fussy or has a definite fever, except when told otherwise by your doctor (such as in children prone to febrile seizures).

Here you will find dosing information for common medications.

Information about respiratory illnesses.

Experts such as the A.A.P. recommend not giving cough syrup to children under 6 years of age. This is because:

  • There is no evidence that cough syrup helps small children get better
  • There is no evidence that cough syrup is safe for small children
  • Coughing serves a purpose

What can be given to small children to help with coughs?

  • a little honey (over 1 year of age only)
  • more liquids to drink (keeps mucous thinner)
  • cough drops (for children old enough not to choke on one)

Answers to questions about formula and breast feeding.

The North Carolina WIC program has an exclusive contract with Abbot (Similac). This contract guarantees the company a large market share and so in exchange the State can buy the formula at a lower price. However, with a prescription from your doctor, WIC will provide some formulas that are medically necessary.

It is not usually needed. In general breast milk or formula is all that your baby needs, even in hot weather. 

There is usually no harm in giving a healthy baby a small amount of water (1 ounce or so), but you should ask your doctor first.

AMERICAN ACADEMY OF PEDIATRICS:
The Use and Misuse of Fruit Juice in Pediatrics 
Committee on Nutrition 

[excerpts]
Historically, fruit juice was recommended by pediatricians as a source of vitamin C and an extra source of water for healthy infants and young children as their diets expanded to include solid foods with higher renal solute. Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. 

COMPOSITION OF FRUIT JUICE 

Water is the predominant component of fruit juice. Carbohydrates, including sucrose, fructose, glucose, and sorbitol, are the next most prevalent nutrient in juice. The carbohydrate concentration varies from 11 g/100 mL (0.44 kcal/mL) to more than 16 g/100 mL (0.64 kcal/mL). Human milk and standard infant formulas have a carbohydrate concentration of 7 g/100 mL. 

ABSORPTION OF CARBOHYDRATE FROM JUICE 

The 4 major sugars in juice are sucrose, glucose, fructose, and sorbitol. Sucrose is a disaccharide that is hydrolyzed into 2 component monosaccharides, glucose and fructose, by sucrase present in the small bowel epithelium. Glucose is then absorbed rapidly via an active-carrier-mediated process in the brush border of the small bowel. Fructose is absorbed by a facilitated transport mechanism via a carrier but not against a concentration gradient. In addition, fructose may be absorbed by a disaccharidase-related transport system, because the absorption of fructose is more efficient in the presence of glucose, with maximal absorption occurring when fructose and glucose are present in equimolar concentrations.14 Clinical studies have demonstrated this, with more apparent malabsorption when fructose concentration exceeds that of glucose (eg, apple and pear juice) than when the 2 sugars are present in equal concentrations (eg, white grape juice).15,16 However, when provided in appropriate amounts (10 mL/kg of body weight), these different juices are absorbed equally as well.17 Sorbitol is absorbed via passive diffusion at slow rates, resulting in much of the ingested sorbitol being unabsorbed.18 

Malabsorption of carbohydrate in juice, especially when consumed in excessive amounts, can result in chronic diarrhea, flatulence, bloating, and abdominal pain. Fructose and sorbitol have been implicated most commonly.

Fruit juice offers no nutritional advantage over whole fruit. In fact, fruit juice lacks the fiber of whole fruit. Kilocalorie for kilocalorie, fruit juice can be consumed more quickly than whole fruit. Reliance on fruit juice instead of whole fruit to provide the recommended daily intake of fruits does not promote eating behaviors associated with consumption of whole fruits. 

INFANTS 

The American Academy of Pediatrics (AAP) recommends that breast milk be the only nutrient fed to infants until 4 to 6 months of age.36 For mothers who cannot breastfeed or choose not to breastfeed, a prepared infant formula can be used and is a complete source of nutrition. No additional nutrients are needed. There is no nutritional indication to feed juice to infants younger than 6 months. Offering juice before solid foods are introduced into the diet could risk having juice replace breast milk or infant formula in the diet. This can result in reduced intake of protein, fat, vitamins, and minerals such as iron, calcium, and zinc.

It is prudent to give juice only to infants who can drink from a cup (approximately 6 months or older). Teeth begin to erupt at approximately 6 months of age. Dental caries have also been associated with juice consumption.39 Prolonged exposure of the teeth to the sugars in juice is a major contributing factor to dental caries. The AAP and the American Academy of Pedodontics recommendations state that juice should be offered to infants in a cup, not a bottle, and that infants not be put to bed with a bottle in their mouth.

Fruit juice should be used as part of a meal or snack. It should not be sipped throughout the day or used as a means to pacify an unhappy infant or child. Because infants consume fewer than 1600 kcal/d, 4 to 6 oz of juice per day, representing 1 food serving of fruit, is more than adequate. Infants can be encouraged to consume whole fruits that are mashed or pureed. 

OLDER CHILDREN AND ADOLESCENTS

Juice consumption presents fewer nutritional issues for older children and adolescents, because they consume less of these beverages. Nevertheless, it seems prudent to limit juice intake to two 6-oz servings, or half of the recommended fruit servings each day. It is important to encourage consumption of the whole fruit for the benefit of fiber intake and a longer time to consume the same kilocalories. 

Excessive juice consumption and the resultant increase in energy intake may contribute to the development of obesity. One study found a link between juice intake in excess of 12 oz/d and obesity.

Committee on Nutrition, 1999-2000 

NO, this is very dangerous and there have been numerous severe mouth burns in infants because of this. Please heat the baby's bottle in warm water, shake well to establish even temperature in the bottle and check a few drops on your wrist.

In an otherwise healthy, term infant, four months is a common time to start cereal. But there is NO hurry! Some people wait until six months. Babies that start solid foods early may be at an increased risk for food allergies.


First start with rice cereal milked with breast milk or your formula. Make it thin and offer it with a spoon, NOT a feeder bottle. If the baby rejects it, back off and try the next week. If she likes it, try making it a bit thicker each time until is has a reasonable texture.

It this is going well, try adding a new fruit or vegetable every 4-5 days, watching for colic, rashes, etc. Wait on meats until at least six months.

Some people set a routine of two meals a day- cereal and fruit in the morning, and maybe a fruit and a vegetable in the evening. Consider three meals after about 6 months or later.

The dessert foods are mostly junk. They often have added sugar and starch which your baby does not need.

Most babies spit up, and some babies spit up a LOT! If your baby is thriving, gaining weight well, and otherwise happy, we will often tell you to keep doing what you are doing.

The first things to do for MILD SPITTING UP are as follows:

1. Smaller feedings. Discuss with your doctor how big your baby's feedings should be. In general, "smaller feedings more often" will help some.

2. Keep the baby upright for 20-30 minutes after each feeding. This gives time for good burping, and for the stomach to empty.

3. Don't use an infant carrier (except in the car). That position compresses the stomach and promotes spitting up.

4. Ask your doctor if it would be appropriate to thicken the feedings with rice cereal.

5. Spitting up is rarely a problem with the type of formula or the breast milk.

Spitting up is NOT the same as FORCEFUL VOMITING. This must be discussed with your doctor. Please call if you have any questions.

Information about fevers in children

Teething is often associated with fever but as far as we know there is no direct correlation. Theoretically teething may lower your child's resistance leaving them with more susceptibility to viral respiratory illnesses ("colds") and viral gastroenteritis (Diarrhea). Also, when children have teething, they have swelling of their gums and this may lead to swelling and obstruction of their eustacian tube (the drainage canal fur the middle ear) and this could lead to an ear infection. If a child has a fever of 101 degrees or higher, there is always something else going on (i.e. infection) because teething does not cause temperatures to this level.

So the answer to your question is that teething is associated with some of these problems but as far as we know does not directly cause then.

I would say that the height of a fever is not nearly as important as how the child looks. I am much more worried about a child with a 101' fever who looks *sick* than a child with a 105' fever that is playing with toys, drinking, and reasonably happy.


I would recommend trying to reduce fevers to 102' F or less. By doing so, you decrease the child's fluid requirements, and unnecessary stress on the body.

It is very rare for a fever to ever get above 105 degrees. Start treating the high fevers as soon as you notice it- Tylenol or Advil, (NO ASPIRIN), and get the child in the tub and pour water over him. Evaporation of water from your child's skin is very effective in reducing fever.

The choices are Acetaminophen (Tylenol, Panadol, Feverall) and Ibuprophen (Advil, Motrin).


Acetaminophen is a safe medicine if used correctly. However, in large doses (overdoses) it can damage the liver. It works for about 4 hours.

Ibuprophen has no toxicity really, except for stomach irritation even in large doses. It works for about 6 hours.

For these reasons, I prefer Ibuprophen over Acetaminophen.  

However, acetaminophen comes in suppositiories (Feverall and others) which is an excellent way to bring down a fever in a child that is nauseated or vomiting, or who will not take an oral medicine.

Sometimes, if a fever is stubborn, we will tell parents to go ahead and give the ibuprophen every 6 hours, and then 3 hours later slip in a dose of acetaminophen (each medicine being given every 6 hours, but staggered 3 hours apart).

Remember, a nice lukewarm bath and pouring the water over your child's shoulders and head is a great way to bring down the fever also.

NEVER give your child ASPIRIN for fever. Aspirin has been associated with Reye Syndrome- a condition producing coma. Even if it is the only thing you have- don't give it. The bath is better and safer.

If the fever is 102' or less and your child is happy, relax. You don't need to get the fever down any further.

If the fever is above 102', go back to the bathtub and resume bathing. Remember to pour water over your child so that he will lose heat through evaporation.

Some children, generally under 3 years of age, are more likely to have a seizure when the have a fever. This condition is called Febrile Seizures.


The majority of children will never have a seizure even with a high fever.

If your child has a history of Febrile Seizures, follow your doctor's advice in the specific management of fever. In general though, if your child has Febrile Seizures it is wise to try reasonably hard to keep his temperature from getting too high. Use Ibuprophen alternating with Acetaminophen and aggressive bathing to bring the temperature down, usless specifically told otherwise.

Answers to some common parenting questions.

This is a very common problem at this age. These children are just beginning to get some mobility and they are checking out their environment as well as defending it. The old adage to bite or hit them back to show them how it feels does not appear to work and may even promote the feet that adults also bite and hit. A consistent firm response is the best approach. The child should be separated immediately and told firmly that the behavior is unacceptable and placed in time-out (good guideline is approximately one minute per year of age). If a child is resistant to changing their behavior, the length of the "time-out" may be increased. In extremely resistant children, they may lose the privilege of being with other children but with patience and consistency, the extreme approach in rarely needed. However, in reference to Daycare; sometimes for the safety of all the children, a child with this problem may be needed to be removed from the Daycare, at least temporarily.

Any toddler should be able to learn to put themself to sleep in their own
bed; it just may take some persistence.

The general principle is to set up a several step routine that is the same
every night- a bath, a story, brushing the teeth, etc and then bed time.
Most people then recommend tucking the child into bed, and leaving the room
(with a nightlight on). Return every ten minutes or so to check on the
toddler. At that time, summarily pat him on the back and acknowledge him,
and then leave again. This may go on for quite some time, but is important
not to give in. after a few nights of the routine, it should start to get
easier, as the child learns that you are not going to give in.

It is important that ALL caregivers have the same rules. Otherwise the
child will exploit this weakness and you will not succede.

For a further discussion, please consider an office appointment at Rainbow
Pediatrics.

During childhood human beings are going through constant changes in several parameters (growth, development, intelligence, hormonal, psychological and social). Pediatrics was the first area of medicine to initiate preventative care and is still in the forefront in this area. Your child's checkup should evaluate all the changing parameters mentioned and then this is compared to the "normals" (wide range of variability) for their age. If there are any deviations, the child should be evaluated for cause and possible therapy. Preventative care includes early detection of problems with easier resolution if possible. Preventative care also includes dealing with lifestyle issues that can make a difference in short term and long term health (such as immunization, diet, accident prevention, etc.) Another aspect of checkups is to help parents understand and deal with their children. A major part of this is called anticipatory guidance which means your physician should talk with you about what changes your child may go through before their next visit so you can be prepared for their changes and look forward to them.

Generally, a baby under perhaps six months old will have a reason for crying- hunger, dirty diaper, colic, or something. These infants should be checked, fed or changed if necessary, and returned to their crib.


As babies get older, towards a year old, they may wake up for no reason. If they use a pacifier, they may look for it and start to fuss when they can't find it.

If you determine that there is nothing wrong with your baby who is over six months old, return him to the crib. Every 15 minutes or so return to him, pat him on the back calmly and walk away. He will most likely go back to sleep eventually. The more consistent you are with this routine, the better it will work, and the more you both will sleep.

Even before you plan to begin toilet teaching, let your child accompany you or an older sibling to the bathroom, and let her flush the toilet, so she learns to feel comfortable with the routine.


Place a potty chair (a scaled-down, freestanding version of an adult toilet) in your child's living and play environment, and encourage her to sit on it fully clothed for as long as she likes. Over time try removing her clothing and diaper so she becomes accustomed to sitting unclothed on the potty seat.

Choose appropriate and positive terms to describe body parts, urine, and bowel movements. "Pee" and "poop," for example, are fine, as are "urinate"and "have a BM (bowel movement)."

One of the best opportunities for toilet teaching is when your child signals--either physically or verbally--that he is about to urinate or have a bowel movement. "This is a good time to say to him, `It seems that you're pooping (or peeing)--would you like to do it on your potty seat?'" says Dr. Hagan.

Ask calmly, in a regular tone of voice. If the child says yes, lead him quickly to the potty seat or toilet, and help him remove his clothing. Let him sit on the seat for as long as he likes (for boys, sitting to urinate should come before standing), but don't force him to remain there until he actually urinates or has a bowel movement.

If the child succeeds in urinating or defecating into the toilet, praise him calmly, but don't overdo it. Show enthusiasm the first few times, then be matter-of-fact about the process.

For a thorough cleanup, it's best to help your child with wiping (always front to back, especially for girls, to help prevent infections). Premoistened baby wipes are gentle to use after a bowel movement. 

On the other hand, if nothing happens when the child is seated on the potty, of if he urinates or defecates in his diaper before you reach the bathroom, simply say, "That's OK, maybe you can pee (or poop) on the potty seat next time."

There is a wide range of what is 'normal' for stooling. In general, anybody who is not passing hard, large, uncomfortable stools is stooling often enough. Likewise, anybody who is stooling often enough that it interferes with normal daily activities probably has a problem.


Stools that are bloody or contain a lot of mucous are abnormal.

Most people beyond infancy stool somewhere between every other day and twice a day.

Answers to common questions about vomiting and diarrhea.

Most cases of vomiting and diarrhea in children are due to viruses and are self-limited. In those cases there are no medications to kill the virus and our goal is to get them through the illness without complications, the main one being dehydration. The injured gastrointestinal system should be pampered with easy to digest items but provided with adequate calories and fluids. The first 6 to 12 hours should be clear fluids (preferably with sugar and electrolytes such as Pedialyte) in small, frequent volumes. We generally recommend as little as 1 teaspoon to 1 ounce per hour until this is tolerated, then a gradual increase in volume. After that solids can be introduced slowly, also in small volumes initially. Easy to digest items with adequate nutritional value for the GI system to heal itself include: toast, bananas, rice, applesauce, pears, noodles, baked potatoes. Dairy products which are difficult to digest should be avoided for 48 - 72 hours.


If your child continues to vomit, has reduced urine or no urine for 10 - 12 hours, or is lethargic, you should contact your physician.

The Canadian Journal of Paediatrics 1994; 1(5): 160-164

Oral rehydration therapy with an inexpensive glucose and electrolyte solution as promoted by the World Health Organization has reduced substantially the number of deaths from dehydration due to diarrhea. In addition, recent research suggests that these solutions have advantages over conventional therapy. Yet, oral rehydration therapy has not been used extensively in developed countries.

Acute gastroenteritis is one of the most common illnesses affecting infants and children in Canada and the world. The average child under age 5 experiences 2.2 diarrheal episodes per year.1 Treatment from resulting dehydration accounts for an estimated 200,000 hospitalizations per year in the U.S.2 with comparable rates occurring in Canada. Worldwide as many as 4,000,000 children per year die as a result of gastroenteritis and resulting malnutrition. Prolonged diarrhea and malnutrition are a primary cause of morbidity and mortality in Canadian native populations. 

Oral rehydration therapy (ORT), using a simple, inexpensive, glucose and electrolyte solution promoted by the World Health Organization (WHO) has reduced the number of deaths from dehydration due to diarrhea by about a million per year.1,3 In spite of its efficacy, ORT has not been used extensively in developed countries. Recent research, summarized in this report, suggests that the use of oral rehydration solutions have advantages over conventional therapy. In an effort to encourage the use of ORT, a simple approach to rehydration is outlined. 

Oral rehydration takes advantage of glucose-coupled sodium transport,4 a process for sodium absorption which remains relatively intact in infective diarrheas due to viruses or to enteropathogenic bacteria, whether invasive or enterotoxigenic. Glucose enhances sodium, and secondarily, water transport across the mucosa of the upper intestine.5 For optimal absorption, the composition of the rehydration solution is critical. The amount of fluid absorbed depends on three factors: the concentration of sodium, the concentration of glucose and the osmolality of the luminal fluid. Maximal water uptake occurs with a sodium concentration from 40 to 90 mmol/L, a glucose concentration from 110 to 140 mmol/L (2.0 to 2.5 g/100 mL) and an osmolality of about 290 mOsm/L, the osmolality of body fluids.6 Increasing the sodium beyond 90 mmol/L may result in hypernatremia; increasing the glucose concentration beyond 200 mOsm/L, by increasing the osmolality of the solution, may result in a net loss of water. CHO to Na ratio should not exceed 2:1 in these solutions. 

For practical purposes in Canada, rehydration can be accomplished using solutions with higher sodium, i.e., 75-90 mmol/L. These are termed rehydration solutions (ORS). Prophylaxis of dehydration and maintenance involve solutions with 45-60 mmol/L of sodium. These are termed maintenance solutions. High sodium rehydrating solutions used to treat acute dehydration may be used for maintenance by giving the solution alternately on a 1-to-1 basis with a no-sodium or low-sodium fluid such as water, low CHO fluids, or breast milk. The high sodium ORS should not be used as the sole fluid intake for maintenance of hydration. Fruit juices and pop are not efficacious because of their high carbohydrate concentration, osmolality and the inadequate sodium concentration.7 Individualized dietary management of the patient during acute diarrhea is the key and should be emphasized. 

Oral rehydration and maintenance solutions presently in use, although effective in rehydration, do not decrease stool volume because of the relatively high osmolality of the glucose which they contain. The challenge, therefore, is to provide adequate glucose to the sodium pump without increasing the osmolality of the rehydration solution. 

This has been done successfully by substituting short chain glucose polymers (starch) from rice and other cereals for glucose in the oral rehydration mixture.8 In field trials in developing countries,8,9 ORS containing glucose polymers, primarily from rice and corn, were found not only to be as effective in correcting dehydration as glucose-based ORS, but also to offer the additional advantage of reducing the amount and duration of diarrhea by 30%, thereby reducing morbidity and costs of treatment and increasing acceptability. The effectiveness in diarrhea typical of North America may be less marked, i.e., reducing stool output by 18%. 

Defined short-chained glucose polymers from rice may also be safe and effective in the treatment of acute diarrhea.10 Wapnir et al11 found that a solution containing 30 g/L of rice syrup solids (180 mOsm/L) resulted in 40% more water absorption than a similar solution which contained 20 g/L of glucose (230 mOsm/L). A clinical study with solutions containing rice-syrup solids confirmed their efficacy in the rehydration of infants with acute diarrhea. Further, such solutions decreased stool output, and promoted greater absorption and retention of fluid and electrolytes than did a glucose-based solution.12 

Amino acids have also been suggested as additives to ORS. The addition of alanine alone to the WHO oral rehydration solution (ORS) was not found to give additional benefits.13 However, Khin-Maung-U and Greenough8 found that alanine, added to a glucose polymer-based ORS, decreased the amounts of stool by a further 10% to 40%. Nevertheless, these are not currently recommended by WHO. Rice-based corn and lentil-based oral rehydration solutions have been extensively tested and may eventually be made available. 

Along with improved oral rehydration solutions have come advances in the field of early refeeding. Fasting has been shown to prolong diarrhea. This may be due to undernutrition of the bowel mucosa which delays the replacement of mucosal cells destroyed by the infection. Although there is general agreement that breast-feeding should continue in spite of diarrhea,14 early refeeding with a lactose-containing formula is usually well tolerated.15 Early refeeding should commence 6-12 hours into therapy. 

On the basis of these findings and recent recommendations,16 the following principles should be followed in treating diarrheal disease: 

Fluid therapy should include the following three elements: rehydration, replacement of ongoing losses, and maintenance. 
Fluid therapy is based on an assessment of the degree of dehydration present. Principles are as follows: 
No dehydration - If diarrhea is present, but urinary output is normal, the normal diet and breast-feeding may continue at home with fluid intake dictated by thirst. High osmolality fluids such as undiluted juices should be avoided, and maintenance oral electrolyte solution (Na 45-60 mmol/L) offered "ad libitum." 

Mild - If symptoms and signs are limited to decreased urinary output and increased thirst, mild dehydration is suspected. Assessment and treatment under close supervision are indicated. Rehydration consists of ORS or maintenance solution 10 mL/kg/hr with reassessment at 4-hour intervals. Breast-feeding continues. Early refeeding with the child's customary formula at the usual concentration is recommended. Extra ORS or maintenance solution (e.g., 5-10 mL/kg) may be given after each stool if diarrhea persists.

Moderate - If at least two of the following signs, sunken eyes, loss of skin turgor ("tenting" of abdominal skin lasting less than 2 seconds), or dry buccal mucous membranes are present, moderate dehydration is diagnosed and rehydration consisting of ORS 15-20 mL/kg/hr with direct observation and reassessment at 4-hour intervals. If dehydration is corrected, therapy for ongoing losses and maintenance are continued as outlined above. If not, treatment is repeated as indicated by clinical signs or symptoms. 

Severe - If, in addition to signs of moderate dehydration, there is rapid breathing, lethargy, coma, a rapid thready pulse or "tenting" of the skin lasting more than 2 seconds, severe dehydration and shock are present. Blood pressure should be measured. Prompt intravenous therapy is indicated with rapid infusion of saline plasma or colloid sufficient to replete blood volume (10-20 mL/kg over 30 minutes may be necessary). Intraosseous infusion should be used if an intravenous line cannot quickly be inserted. 
General comments. Vomiting is not a contraindication to ORT. ORS should be given slowly but steadily to minimize vomiting. Fluids may be administered by nasogastric tube if required. The child's clinical condition should be frequently assessed. A child should never be kept on ORS fluid alone for more than 24 hours. Early refeeding should begin within 6 hours. A full diet should be reinstituted within 24 to 48 hours, if possible. 

There are certain contraindications to the use of ORT:

-Protracted vomiting despite small, frequent feedings 
-Worsening diarrhea and an inability to keep up with losses 
-Stupor or coma 
-Intestinal ileus. 

As ORS can be administered easily by a properly instructed parent, and because dehydration can be corrected quickly, it lends itself well for use in an outpatient department or nursing station. At the end of 4 hours, the child can either be sent home on maintenance therapy or, if dehydration persists, be observed for further therapy. Intelligent use of ORT can decrease hospital admissions, an important consideration in a time of decreasing hospital budgets. Although in our society intravenous therapy is often considered more convenient than ORT, clinicians should feel more comfortable as they become more accustomed to the use of ORT. 

TABLE 3: Simplified ORT protocol in mild to moderate rehydration 

mild moderate
1st hour 20 mL/kg/hr 20 mL/kg/hr
next 6-8 hours 10 mL/kg/hr 15-20 mL/kg/hr

Reassessment at 4-hour intervals

There are many different equations for calculating administration rates in oral rehydration. ORT may be given in amounts equal to
fluids calculated for intravenous administration. Alternately, fluids may be delivered by nasogastric tube



Recommendations
Dehydration accompanying infantile gastroenteritis should be treated with early oral rehydration and early refeeding strategies. 
Infants with gastroenteritis should be offered maintenance solution to prevent dehydration. Parents and daycare centres should keep maintenance solution on hand in anticipation of episodes of infectious diarrhea. 
ORS and maintenance solutions and instructions in their use should be made available at reasonable costs. 
Medical facilities should have ORT protocols available for staff and patients. 
Antidiarrheal drugs, antibiotics and antiemetic therapy are rarely indicated in gastroenteritis in childhood and should be discouraged. 
Home-made oral rehydration solutions are discouraged since serious errors in formulation have occurred. 
Infants with mild to moderate dehydration should be treated under medical supervision with ORT in preference to intravenous rehydration. 
Infants with severe dehydration should initially be treated with intravenous or intraosseous rehydration. 
Breast-fed infants with dehydration should be given ORT in conjunction with continued breastfeeding. 
Early refeeding should commence as soon as vomiting has resolved, approximately 6-12 hours. 
Non-lactose containing formulae or milks may be used if diarrhea and abdominal cramps persist beyond expected 5- to 7-day course suggesting clinical lactose intolerance. 
Further initiatives to encourage ORT use by patients and professionals should be developed. 

If your child is vomiting, start Oral Rehydration Therapy (ORT). Use ONLY Pedialyte or some other brand of oral electrolyte solution. Gatorade is ok in a pinch for a child that is keeping fluids down fairly well and is not particularly ill, but still, Pedialyte is the safest. Do NOT use soda pop, juice, or plain water for this purpose.

for an infant or toddler, start with 5cc (1 tsp) every 2 minutes. If he vomits, start again immediately. Do NOT wait 30 minutes after he vomits to start again. It has been shown that dispite vomiting, some of the fluids get absorbed. Keep going, and gradually increase the amount of Pedialyte if you are having success.

If vomiting persists without diarrhea, your child will need to be seen, to make sure that there is nothing else going on.

Do NOT use anti-diarrhea medicines. Many children get sicker with these medicines.

Do NOT give or other anti-vomiting medicines without calling us first. These medicines, by suppressing the vomiting, may delay diagnosing conditions such as appendicitis.

If fluids are going well, advance to not only the BRAT diet (Bananas, Rice, Applesauce, Toast) but also most other low fat foods- perhaps macaroni and cheese, yogurt, baked or mashed potatoes, chicken soup, and then baked meats next. Avoid juices and sugar, and Fat/grease as long as possible.

Answers to common questions about avoiding injuries.

Doctors used to discourage the use of sunscreen on babies less than six months old, but the American Academy of Pediatrics now states that sunscreen is probably safe to use on younger children.


Even so, younger children should be kept out of direct sunlight because they can burn easily and may not be able to handle getting overheated as well as older children. So while it is safe to use sunscreen on kids less than six months old, it is best to keep them out of the sun. 

Other tips: 

•Use a water resistant sunscreen with an SPF of at least 30.

•Use hypoallergenic and fragrance free products.

•Apply enough sunscreen to protect your child. Most experts estimate that many parents only use about half of the recommended amount of sunscreen on their children, providing less protection than they think. 

•Be sure to reapply sunscreen at least every 2 hours, or more often if your child is swimming or sweating.

•Remember to apply sunscreen at least 30 minutes before your child will be exposed to the sun.

In 1996, the US Consumer Product Safety Commission estimates that 83 000 patients received treatment for trampoline injuries in US hospital emergency departments (EDs), and that ~75% of these patients were <15 years of age.


Privately owned trampolines accounted for 99% of PTI. Most injuries (66%) occurred on the trampoline, 28% resulted from falls off.

Spinal injuries were common (12%), including 7 patients with cervical or thoracic fractures, and 1 with C7 paraplegia. Fractures were more frequently associated with falls off the trampoline, whereas spinal injuries more frequently occurred on the trampoline. Eighty patients (11%) required prehospital medical transport to our ED, 584 (80%) had ED radiographs, and 382 (53%) required pediatric surgical subspecialty involvement. Seventeen percent of PTI patients (125 out of 727) were admitted to the hospital, including 9 to the pediatric intensive care unit; 99 (14%) required one or more operations. 

Home trampolines are an accident or a lawsuit waiting to happen.

In 1999, an estimated 14,313 cases with non-fatal BB/pellet gun injuries and an estimated 12,748 cases with non-fatal firearm related injuries among persons aged 19 years and younger were treated in US hospital emergency departments. 

31% of injuries were self-inflicted, and 33% were caused by friends, acquaintances, or relatives. Data on 76% of the incidents indicated the type of injury: although most (66%) resulted from unintentional shootings, approximately 10% were assaults.

The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation).

Proponants of BB Guns and guns in general will say that with proper supervision these non-powder firearms can be used safely. Unfortunately they generally are poorly supervised.

BB Guns, like any other gun, need to be kept in a gun safe along with the ammunition.

Although this is not a new problem, it can be fatal. 


Typically school-aged children will do a variety of maneuvers to make each other get dizzy or pass-out. this may involve lifting each other up around the belly after hyperventilating, or using some method of choking each other.

This "game" is an unfortunate and sometimes fatal way to "get high" without using drugs.

Please discuss this with your children and explain that it is not a game, and it works by cutting off the flow of oxygenated blood to their brain, and can be fatal.

AMERICAN ACADEMY OF PEDIATRICS:

Strength Training by Children and Adolescents 
Committee on Sports Medicine and Fitness 

INTRODUCTION 

Strength training (also known as resistance training) is a common component of sports and physical fitness programs for young people. Some adolescents and preadolescents may use strength training as a means to enhance muscle size and definition or to simply improve appearance. 

Strength training programs may include the use of free weights, weight machines, elastic tubing, or body weight. The amount and form of resistance used as well as the frequency of resistance exercises is determined by specific program goals. Table 1 defines common terms used in strength training. 

BENEFITS OF RESISTANCE TRAINING 

In addition to the obvious goal of getting stronger, strength training programs may be undertaken to improve sports performance, rehabilitate injuries, prevent injuries, and/or enhance long-term health. Studies have shown that strength training, when properly structured with regard to frequency, mode (type of lifting), intensity, and duration of program, can increase strength in preadolescents and adolescents.1-4 Gains in strength, muscle size, or power are lost after 6 weeks if resistance training is discontinued.5 Maintenance exercises may offset these losses, but specific recommendations for maintaining strength gains have not been defined for preadolescents and adolescents. 

In preadolescents, proper resistance training can enhance strength without concomitant muscle hypertrophy. Such gains in strength can be attributed to neuromuscular "learning," in which training increases the number of motor neurons that will fire with each muscle contraction.2,6,7 This mechanism helps explain strength gains from resistance training in populations with low androgen levels, including females and preadolescent males. Strength training can also augment the muscle enlargement that normally occurs with pubertal growth in males and females.3,6,8,9 

Strength training can improve an adolescent athlete's performance in weight lifting and power lifting. Strength training is a common practice in sports like football in which size and strength are desirable. Despite theoretical benefits, scientific studies have failed to consistently show that improved strength enhances running speed, jumping ability, or overall sports performance.6,10 

Evidence that strength training programs help prevent sports-related musculoskeletal injuries in preadolescents and adolescents is inconclusive.11 Furthermore, there is no evidence that strength training will reduce the incidence of catastrophic sports-related injuries. 

RISKS OF STRENGTH TRAINING 

The US Consumer Product Safety Commission, through its National Electronic Injury Surveillance System (NEISS), has estimated the number of injuries that are associated with strength training equipment. The NEISS data neither specifies cause of injury nor separates recreational from competitive weight lifting injuries. From 1991 to 1996, an estimated 20 940 to 26 120 injuries occurred each year in individuals under 21 years old.12 According to NEISS data and other studies,13 muscle strains account for 40% to 70% of all injuries. The lumbar back is the most commonly injured area.11,14 

A limited number of case reports have raised concern about epiphyseal injuries in the wrist and apophyseal injuries in the spine from weight lifting in skeletally immature individuals. Such injuries are uncommon and are believed to be largely preventable by avoiding improper lifting techniques, maximal lifts, and improperly supervised lifts.12,15,16 

Strength training programs do not seem to adversely affect linear growth and do not seem to have any long-term detrimental effect on cardiovascular health.2,417-19 Young athletes with hypertension may experience further elevation of blood pressure from the isometric demands of strength training.8 

STRENGTH TRAINING GUIDELINES 

A medical evaluation before commencing a formal strength training program can identify possible risk factors for injury and provide an opportunity to discuss training goals, techniques, and expectations. Risks involved with use of anabolic steroids and other body-building supplements are appropriate topics for discussion with any adolescent interested in getting bigger and stronger.20,21 

If children or adolescents undertake a strength training program, they should begin with low-resistance exercises until proper technique is learned. When 8 to 15 repetitions can be performed, it is reasonable to add weight in small increments. Exercises should include all muscle groups and be performed through the full range of motion at each joint. To achieve gains in strength, workouts need to be at least 20 to 30 minutes long, take place a minimum of 2 to 3 times per week, and continue to add weight or repetitions as strength improves. There is no additional benefit to strength training more than 4 times per week.5 

Young people who want to improve sports performance will generally benefit more from practicing and perfecting skills of the sport than from resistance training. If long-term health benefits are the goal, strength training should be combined with an aerobic training program. 

RECOMMENDATIONS  

1. Strength training programs for preadolescents and adolescents can be safe and effective if proper resistance training techniques and safety precautions are followed. 

2. Preadolescents and adolescents should avoid competitive weight lifting, power lifting, body building, and maximal lifts until they reach physical and skeletal maturity. 

3. When pediatricians are asked to recommend or evaluate strength training programs for children and adolescents, the following issues should be considered: a. Before beginning a formal strength training program, a medical evaluation should be performed by a pediatrician. If indicated, a referral may be made to a sports medicine physician who is familiar with various strength training methods as well as risks and benefits in preadolescents and adolescents. 

b. Aerobic conditioning should be coupled with resistance training if general health benefits are the goal. 

c. Strength training programs should include a warm-up and cool-down component. 

d. Specific strength training exercises should be learned initially with no load (resistance). Once the exercise skill has been mastered, incremental loads can be added. e. Progressive resistance exercise requires successful completion of 8 to 15 repetitions in good form before increasing weight or resistance. 

f. A general strengthening program should address all major muscle groups and exercise through the complete range of motion. 

g. Any sign of injury or illness from strength training should be evaluated before continuing the exercise in question.

Turn down your water heater

Each year the Children's Hospital of Wisconsin Emergency Room treats children who have been scalded by hot water from taps. It takes just three seconds for a child to sustain a third degree burn, which would require hospitalization and skin grafts, from water at 140 degrees Fahrenheit. Water at 110 degrees will scald the skin if contact is prolonged.

To prevent painful scalding injuries:

Find out how hot the water coming from your faucet is. It should be no hotter than 120 degrees Fahrenheit. If the water is too hot, turn down your water heater setting so it is set below 120 degrees Fahrenheit or to the lowest setting. (If necessary, call your landlord or ask your plumber to turn down your water heater setting.) 


Follow the proper procedure for filling a bath tub. First turn on the cold water. Then add hot water. When the tub is almost filled, turn off the hot water. Then turn off the cold water. 
Never put your child in the bath tub while the water is running. 
Check the water with your hand before you put your child in the tub. Children have sensitive skin. It can burn easier than adult's skin. When testing the water, put your hand all the way in, spread your fingers and move your hand back and forth throughout the length of the tub to check for hot spots. The water should feel comfortable to you. 


Always stay with your child when he or she is in the tub. Don't leave the room for even a moment to answer the phone or the door. Some children can turn the hot water on by themselves. It only takes seconds for small children to drown or burn themselves. 
Never bath a baby in the kitchen sink if the dish washer is running. Changes in the dish washer cycle can cause scalding water to bubble up into the sink.

ABSTRACT. Pickup trucks have become increasingly popular in the United States. A recent study found that in crashes involving fatalities, cargo area passengers were 3 times more likely to die than were occupants in the cab. Compared with restrained cab occupants, the risk of death for those in the cargo area was 8 times higher. Furthermore, the increased use of extended-cab pickup trucks and air bag-equipped front passenger compartments creates concerns about the safe transport of children. The most effective preventive strategies are the legislative prohibition of travel in the cargo area and requirements for age-appropriate restraint use and seat selection in the cab. Parents should select vehicles that are appropriate for the safe transportation needs of the family. Physicians have an important role in counseling families and advocating public policy measures to reduce the number of deaths and injuries to occupants of pickup trucks.


Motor vehicle trauma remains a leading cause of death of children. Occupants in pickup trucks should receive the same level of protection provided in other vehicles according to national policies that address protection of motor vehicle occupants. The safety issues relevant for pickup trucks include the following: 1) prohibition of cargo area travel; 2) age-appropriate restraint use; 3) appropriate seat location in the cab; 4) appropriate use of rear seating positions in various models of extended cab vehicles; and 5) risk of air bag-related injuries.

Pickup trucks have become increasingly popular vehicles for passenger transportation. Pickup truck registrations numbered 36.2 million in 1998, representing 17% of registered motor vehicles in the United States.1 Census data for 1992 indicated that 73% of pickup trucks were used for personal transportation.2 Restraint use in the cab of pickup trucks has been reported to be lower than restraint use in other passenger vehicles.3

TRAVEL IN THE CARGO AREA

Travel in the cargo area of the pickup truck is a major occupant protection issue that disproportionately involves youth. Because the cargo area is not intended for passenger use, it is neither required nor designed to meet occupant safety standards applicable to passenger locations. Nevertheless, the cargo area is used for transporting passengers. In 1997, 161 deaths of occupants riding in the cargo area were reported; 77 (48%) were children and adolescents younger than 20 years. Of these occupants, 7 (9%) were younger than 5 years; 15 (19%) were 5 through 9 years of age; 14 (18%) were 10 through 14 years of age; and 41 (53%) were 15 through 19 years of age.4

Persons who are injured when traveling in cargo areas of pickup trucks are more likely to sustain multiple injuries and injuries of greater severity and have a greater likelihood of death than do occupants in the cab. The most significant hazard of travel in the cargo area of a pickup truck is ejection of a passenger in a crash or noncrash event (eg, sudden stop, turn, swerve, or loss of balance, as well as intentional or unintentional jumps and falls). Studies have demonstrated that the proportion of occupants ejected from the cargo area markedly exceeds the proportion ejected from the cab.5-11

In a recent study of fatalities in pickup trucks from 1987 through 1996, nearly one third of the deaths among occupants of the cargo area were a result of noncrash events. Of the deaths that occurred as a result of cargo area occupants being ejected, 40% were children and adolescents 17 years or younger. Cargo area passengers were 3 times more likely to die than were occupants in the cab. Compared with restrained cab occupants, the risk of death for those in the cargo area was 8 times higher.12

Enclosed cargo areas (camper shells) do not provide adequate protection against injury to occupants. In 1997, 14% of cargo area deaths of children and adolescents younger than 20 years were in enclosed cargo areas.4 Carbon monoxide poisoning, which may result in death, is an additional hazard to those traveling in the enclosed cargo area of a pickup truck.13

Fewer than 50% of the states restrict transport of passengers in the cargo area. No 2 states have identical laws, and only 1 state fully prohibits travel in cargo areas. Restrictions in other states vary according to the age groups to which they apply, conditions of travel (eg, if restrained), and presence of an enclosed cargo area.14 The application of seat belt and child passenger safety laws to travel in pickup truck cargo areas may be an option in some states; however, in certain states, even occupant area seat belt laws do not apply to pickup trucks. Many Native American nations have adopted occupant restraint laws that apply to pickup trucks as well as passenger cars; other nations use the laws of the state.15 

EXTENDED CABS

With increased sales and use of pickup trucks for personal and family transportation, manufacturers have produced vehicles that can accommodate an increased number of occupants. A variety of extended cab vehicles are available with additional seating capacity that may include a rear bench seat, side-facing back seats, a full back seat with lap/shoulder belts, and/or a middle front seat position with a lap belt (also available in standard pickup trucks). Crash data for occupants in these seats are limited. Compatibility issues exist between vehicle seats and safety seats, including booster seats in some pickup truck seating positions. Car safety seats can only fit and be properly secured in a full-size rear or front seat. Many rear-facing car safety seats do not fit in pickup seats with limited space in front of them, and this limited space may not provide adequate head excursion distance for children in untethered forward-facing car safety seats. For older children, booster seats must be used with lap/shoulder belts to provide adequate protection; however, lap/shoulder belts may not be available in pickup rear seats.

AIR BAGS

Concerns about the safety of children in front passenger seats equipped with an air bag are the same as those for other passenger vehicles. Infants must always ride in rear-facing car safety seats in the back seat until they are at least 1 year old and weigh at least 20 pounds. Infants must never ride in the front passenger seat when it is equipped with an air bag. All children should be properly restrained in car safety seats, booster seats, or lap/shoulder belts appropriate for their size and age. The safest place for children is in the back seat in vehicles with a full-size rear seat. However, if there is no rear seat, the rear seat is not full-size, or the rear seat is incompatible with use of a car safety seat or booster seat, the front passenger air bag should be equipped with an on/off switch to accommodate the safe transport of children. The switch should be off when transporting children in the front seat.

Hospital Record Keeping

A need for data exists about injuries in extended cabs, use and nonuse of occupant protection systems, and comparisons of injuries and injury mechanisms between enclosed and unenclosed cargo areas. Documentation of the circumstances of injuries that occur in pickup trucks is needed to contribute to epidemiologic data and to develop preventive counseling guidelines.

RECOMMENDATIONS

The most effective prevention strategies to reduce the number of deaths and injuries to children in pickup trucks are the prohibition of travel in the cargo area and age-appropriate restraint use in an appropriate seat location in the cab. 
Parents should be counseled about the following considerations for selecting or using vehicles to meet the safe transportation needs of the family: 
No passengers should be transported in the cargo area of a pickup truck or a nonpassenger section of any vehicle. 
Trips should be planned in advance so that an appropriate seat position and restraint device are used for each passenger. 
Compatibility should be checked between the vehicle seat (front and back seats) and the car safety seat before purchasing a vehicle or a child safety seat. 
Infants in rear-facing car safety seats should not be placed in front passenger seats when an airbag is present and activated. If no appropriate rear seating position is available, only place the infant in the front passenger seat if an airbag on/off switch is installed and turned off. 
Car safety seats should fit completely on the rear seat of the pickup truck and can be properly secured facing the rear for infants younger than 1 year or weighing <20 pounds, and facing forward for older children. The addition of a tether may improve the security of a car safety seat. 
All forward-facing car safety seats should be installed using a top tether in addition to the vehicle belt. 
Teenagers should agree that they will not ride or transport others in the cargo area of a pickup truck.
The who, what, when, where, why, and how of the injury event should be recorded.16 
Physicians should serve as educators and public policy advocates for measures that will decrease the number of deaths and injuries to children and youth who travel in pickup trucks. 
Physicians need to be effective advocates for more stringent and comprehensive state legislation that would prohibit any occupant from traveling in the cargo area of a pickup truck. If the state exempts pickup trucks from seat belt laws, efforts should be made to modify these laws to include all passengers in all seat locations. The American Academy of Pediatrics has developed a model state legislation packet related to travel in pickup trucks.17 
Law enforcement agencies should be strongly urged to enforce laws relating to occupant travel, including restraint and seat belt use laws, as well as laws prohibiting travel in cargo areas of pickup trucks.

TWO-WHEELED VEHICLES 


Miniature motorcycles intended for off-road use by children and adolescents have enjoyed wide popularity since the 1960s. However, manufacture of these vehicles is not regulated by federal motor vehicle safety standards. Neither the rider nor the vehicle is required to be licensed. Some of these cycles are small enough to be operated by children as young as 4 years, and many have been sold for use by school-aged children.1 

Minibikes, the smallest and most primitive of the 2-wheelers, are motorized bicycle-style frames that weigh <45 kg and are powered by engines operating at <4 horsepower. The more sophisticated and higher-powered minicycles are constructed with suspension systems and transmissions that resemble miniature motorcycles. Trailbikes or trailcycles are larger than minicycles and have power and design characteristics that make them suitable for rough terrain. They are generally only approved for off-road use. Mopeds are bicycles with small, unenclosed assist motors and top speeds of about 30 mph. They are intended for street use but, in many states, neither the mopeds nor their drivers must be licensed.2 Two-wheeled vehicles generally have a short and relatively unstable wheelbase, small tires, slow acceleration, borderline brakes, and poor visibility in traffic (both of the cycle and by the cycle operator).2,3 Motorcycles are also 2-wheeled cycles, but require licenses in all states; these vehicles are not specifically discussed in this statement. 

About 40 000 injuries related to 2-wheeled motorized off-road cycles were treated in emergency departments each year, 1994 through 1996.4 Of the injuries, 26% were sustained by children younger than 15 years. From 1990 through the first quarter of 1995, the US Consumer Product Safety Commission (CPSC) collected at least 50 reports of deaths related to minibike and trailcycle use. All but 1 of the victims were male, and 42% were 16 years of age or younger.5 

Injury typically results from loss of control of the cycle after striking rocks, bumps, or holes, or from illegal on-road use. Mopeds are more often involved in collisions with other vehicles, presumably because they are legally used on-road, and frequently in urban areas.2 Shoulder, knee, and leg injuries account for more than one third of emergency department visits for moped-related injuries. Head injuries account for about half of the deaths.5 Laryngotracheal trauma may result from driving across open fields into poorly visible wire fences. Thermal burns occur when engines are not enclosed, which is usual for mopeds.6 Deaths are more likely to be associated with racing or jumping.5 

THREE- AND FOUR-WHEELED VEHICLES 

All-terrain vehicles (ATVs) are motorized cycles, with 3 or 4 balloon-style tires, designed for off-road use on a variety of terrains. Although ATVs give the appearance of stability, the 3-wheeled design is especially unstable on hard surfaces. The ATV stability is further compromised by a high center of gravity, a poor or absent suspension system, and no rear-wheel differential. The danger is magnified because these vehicles can attain substantial speeds (30-50 mph).7 

Most injuries associated with ATVs occur when the driver loses control, the vehicle rolls over, the driver or passenger is thrown off, or there is a collision with a fixed object.8 Studies in Alaska and Missouri have identified a number of risk factors for injury, including rider inexperience, intoxication with alcohol, excessive speed, and lack of helmet use.9,10 The recognition of the significant hazards associated with ATV use led to a federal investigation and the acceptance of consent decrees by the ATV manufacturers in early 1988.11 Under the decrees, the industry agreed to cease production and sale of new 3-wheeled ATVs (but not to recall old ones), to implement a rider-safety training program nationally, and to develop a voluntary standard to make ATVs safer. Warnings and age recommendations were included on the vehicle and in advertising. ATVs with engines >70 mL could be used only by children 12 years and older; "adult-sized" engines (those >90 mL) were not to be used by children or adolescents under 16 years.11 Although the decrees did not prohibit the sale of the ATVs with engines <70 mL, which previously had been promoted for children younger than 12 years, none have been manufactured since 1986. After acceptance of the decrees, problems have occurred with some dealers not communicating the age restrictions to consumers, although pressure and enforcement by the CPSC have improved the situation. Nevertheless, children under 12 years still represent 15% of the deaths related to ATVs.12-14 It is probable that the most effective outcome of the 1988 consent decrees was the attendant publicity that led up to the decrees and the educational campaigns that occurred after them. The consent decrees expired in 1998. At that time, participating manufacturers agreed to an ATV Action Plan in which they agreed not to market or sell 3-wheeled ATVs, not market or sell adult-size ATVs to or for use by children younger than 16, promote training, and conduct safety education campaigns.15 

The approximately 2.4 million ATVs still in use are associated with significant morbidity and mortality. Almost 2800 deaths have been attributed to ATVs (about 200 to 300 annually) since 1985.14 The risk of death, approximately .8 to 1.0 per 10 000 ATVs, has remained fairly steady since 1987. Annual emergency department visits for treatment of ATV-related injuries reached a peak of 108 000 in 1986 and declined after that to the present level of about 54 500.14 Children younger than 16 years account for 47% of the injuries in 1997 and >36% of the deaths since 1985.15 Head injuries account for most of the deaths, which usually are instantaneous.12 Serious nonfatal injuries include head and spinal trauma, abdominal injuries, and multiple trauma.4 Abrasions, lacerations, and clavicle and extremity fractures are common and less serious.4,13 Some studies have suggested that children suffer more severe injuries. The severity of injury is the same for 3- and 4-wheeled ATVs.10,13,16 Currently, 4-wheeled vehicles account for 75% of the injuries, largely because of changes in the manufacture and sales of 3-wheeled ATVs after the 1988 consent decree, although many 3-wheeled ATVs remain in use. More injuries occur when ATVs are used for recreation than when they are used for nonrecreational purposes, for example, as farm vehicles.4 

It is clear that deaths and injuries began to decline in 1986, possibly as an effect of the publicity before the consent decrees on the driving behavior of ATV users. A decline in sales, as well as diminished use by children, occurred after the decrees, but well before the ban on 3-wheelers and design changes to make "safer" vehicles could have had a great effect. 

RECOMMENDATIONS 

The American Academy of Pediatrics (AAP) now updates its earlier recommendations10,17 to decrease death and injury related to the use of all 2-, 3-, and 4-wheeled ATVs: 

Education, public and individual patient and parent, about the hazards of all ATVs should continue. (Besides benefiting the riders, it may increase public demand for greater regulation; eg, helmet laws and limitation on use by children.) 
During anticipatory guidance, families should be asked, either by direct questioning or intake survey, about the kinds of recreational activities in which they engage. Just as those who have a swimming pool merit special counseling, so do families who engage in off-road vehicle use. The following points should be emphasized: 
Off-road vehicles are particularly dangerous for children younger than 16 years who may have immature judgment and motor skills.10 Children who are not licensed to drive a car should not be allowed to operate off-road vehicles. 
Injuries frequently occur to passengers, therefore riding double should not be permitted. 
All riders should wear helmets, eye protection, and protective reflective clothing. Appropriate helmets are those designed for motorcycle (not bicycle) use, and should include safety visors/face shields for eye protection. 
Parents should never permit the street use of off-road vehicles, and nighttime riding should not be allowed. 
Flags, reflectors, and lights should be used to make vehicles more visible. 
Drivers of recreational vehicles should not drive after drinking alcohol. Parents should set an example for their children in this regard. 
Young drivers should be discouraged from on-road riding of any 2-wheeled motorized cycle, even when they are able to be licensed to do so, because they are inherently more dangerous than passenger cars. 
Although the consent decrees required some equipment modifications to make ATVs safer, further changes have been suggested. They include the following: 
Install seat belts on 4-wheeled ATVs and require that the vehicles also have a roll bar to prevent the driver from being crushed by the weight of the vehicle in the event of a rollover. 
Headlights that automatically turn on when the engine is started should be routinely installed on all ATVs to improve visibility by other vehicles. 
Speed governors (devices that limit maximum speed) should be installed on ATVs used by inexperienced operators. 
Efforts should be made to design ATVs so that they cannot carry passengers. 
Engine covers on small 2-wheeled vehicles, such as mopeds and minibikes, could reduce burn injuries resulting from body contact with the engine and exhaust system. A sturdy leg guard could avoid injuries from sideswiping solid objects or being pinned to the ground. 
All of these proposed modifications should be thoroughly evaluated before use and monitored after introduction. 
Laws should be passed in all states requiring motorcycle-style helmets for off-road use as well as for on-road use. Motorcycle helmet laws have been proven to increase helmet use, and helmet use has been proven to reduce death and serious head injuries.16,18 
Many injuries are caused by various disruptions in the driving surface such as, bumps and holes. Developing and maintaining trails for the use of off-road vehicles may help reduce injury rates. 
Prehospital care networks and emergency services should be improved in rural areas, which may minimize the effects of injuries and reduce deaths.11 
The AAP recommends a ban on the sale of all 3-wheeled ATVs, new and used, and a recall with a refund for present owners of the 3-wheeled models. 
Laws should prohibit the use of ATVs, on- or off-road, by children and adolescents younger than 16 years. An automobile driver's license, and preferably some additional certification in ATV use, should be required to operate an ATV. The safe use of ATVs requires the same or greater skill, judgment, and experience as needed to operate an automobile. 
ATVs should not be used after sunset or before sunrise, and carrying passengers should not be allowed. These provisions should be included in legislation. 
Pediatricians should advocate for the passage of the AAP's model bill19 that: 
prohibits the use of ATVs, on- or off-road, by children and adolescents younger than 16 years; 
requires an automobile drivers' license, and preferably some additional certification in ATV use; 
prohibits the use of ATVs on public streets and highways; 
prohibits passengers from riding on ATVs; 
prohibits operating an ATV under the influence of alcohol; and 
prohibits the use of ATVs between sundown and sunrise. 

Answers to questions about diet, weight, activity, and food.

In most cases, No. 


There is no evidence that healthy kids need vitamins. There are exceptions though.

1) exclusively breast fed babies need vitamin D and iron and so a vitamin with iron is often prescribed.

2) Girls who have started having their periods should take a multivitamin with folate (a prenatal vitamin).

3) There is some evidence that many adults don't get enough Vitamin D.

4) Children with specific health problems may need a vitamin.

Children generally will get enough fluids if they are available, but many times they get so involved in their play that they forget to stop and respond to their thirst. Hotter temperatures result in more body fluid losses, so their need is higher in the summer. Some suggestions are to


1) have your child drink 8-10 oz. of fluids before outside activity,
2) try to get them to drink some fluids every 15 to 20 minutes during activity and
3) drink another 8 ounces after activity is complete.

These simple suggestions will greatly reduce any chance of excessive fluid imbalance due to the heat.

Answers to common questions about immunizations.

It is not uncommon for me to hear a parent in my office say something like 'I've done a lot of research on the Internet and I don't think I should vaccinate my child."


Statements like this really upset me as a Physician; not because I don't want my patients to think or to educate themselves, but because it implies a simplistic arrogance that is all to common today.

I trained at an academic medical center. I was prepared for a career in research or a sub-specialty. I was trained to read scientific literature and to understand statistics. However even with that training, I feel unprepared to understand the complicated research and interpretation that goes into vaccine research. I feel I have to defer my decision to those highly trained professionals that I trust, rather than rendering my own opinion about immunizations.

So, I find it particularly disturbing when a parent tells me, often without any scientific education, that they "have done some research"- looking at random web pages or by watching Jenny Jones, and have come to the conclusion that vaccination is not a good thing.

I ask these people to please rethink their decision for the sake of their child, whose health or even life is in the balance.

Measles-Mumps-Rubella Vaccine and Autism: The Rise (and FaIl?) of a Hypothesis


Jason L. Kastner, MD; and Bruce G. Gellin, MD, MPH
Pediatric Annals 30:7, July 2001

Two recent independent studies examining the hypothesis that the measles-mumps-rubella (MMR) vaccine is linked to the development of autism came to the same definitive conclusion-the hypothesis, derived from an initial observation that was presented in a small case series (n = 12), is not supported by the evidence.

Although two of the highest scientific courts (the American Academy of Pediatrics [AAP] and the Institute of Medicine) have come to the above conclusion based on thorough reviews of the evidence-published and unpublished, it remains to be seen whether the issue will be put to rest, or whether this unsubstantiated hypothesis will live on and become an urban legend in the folklore of medicine. In the 3 years since it first surfaced, the MMR-autism theory has received international attention and has been amplified by debates in the medical literature, professional circles, Internet chat rooms, and even state and national legislative bodies.

The most important setting in which this issue has surfaced is in the countless conversations between pediatricians and their patients' families. Reports from the pediatric front lines of parental and grandparental anguish and anger surrounding this issue suggest that questions and concern are likely to linger. No recent national surveys have specifically documented the proportion of parents who are concerned about the MMR-autism theory. However, a recent study found that more than 90% of pediatricians and 60% of family physicians reported that at least one parent had refused to allow his or her child to receive at least one recommended vaccine in the past year for some reason. An apparent increase in questions from parents and physicians directed toward the Centers for Disease Control and Prevention's (CDC's) National Immunization Information Hotline (CDC, personal communication, February 21, 2001) and an increase in requests to the manufacturer of the MMR vaccine for monovalent measles, mumps, and rubella vaccines (Merck Vaccine Division, personal communication, February 21, 2001) both suggest that the MMR-autism theory is part of the dialogue about immunizations.

MMR VACCINE AND AUTISM

At a time when vaccine-preventable diseases are at historic lows, the need to inform and edu cate patients and physicians about the scientific basis of our current immunization practices and policies has never been greater. Recent national surveys have documented that 1 in 4 parents of young children may have serious misconceptions about immunizations (eg, "too many vaccines will weaken my child's immune system"), and that up to one-third of family physicians and 12% of pediatricians do not recommend particular vaccines to parents routinely or occasionally.

The bottom line from both the AAP and the Institute of Medicine is clear-the combined MMR vaccine is not the cause of autism, nor can it be implicated in the apparent increase in the number of children being diagnosed as having autism spectrum disorders. By extension, there is no scientific or epidemiologic basis to support administering these three antigens separately
over time to prevent autism. Each of these reports provides a valuable synthesis of published and unpublished data that were made available for these comprehensive reviews and subjected to the principles of causality: strength of association, consistency, specificity, temporality, biologic gradient, plausibility, coherence, experimental evidence, and analogy.

Unfortunately, the science does not speak for itself. Although we can hope that the media, the Internet, and public deliberations will put their anecdotes into appropriate context and perspective, pediatricians can and must know the facts when they discuss these issues with patients' parents. The information age and the consumer movement provide ready access to a wealth of information from an array of sources. Most parents�often armed with clippings, articles, and Internet printouts�look to their pediatricians as the most important and trusted source of information and advice on childhood issues, particularly childhood immunizations.
Therefore, the purpose of this article is not to summarize these extensive reports, but rather to provide the pediatrician with an overview of the issue and a clearer understanding of the evolution of the MMR-autism theory. To be able to move forward, we must better understand how we got to this point.

THE GUT-BRAIN CONNECTION

The etiology of autism remains a medical mystery and is most likely multifactorial. Genetic, environmental, infectious, metabolic, and immunologic factors have all been investigated with
no clear-cut, single answer. According to the theory, put forth by Wakefield et al., autism results from a primary intestinal pathology whereby a leaky gut infected with measles allows the absorption of exogenous "gut-derived" opioid peptides from the intestinal lumen. It is then postulated that these unidentified peptides overwhelm the liver's filtering mechanisms and spill over to cross the blood-brain barrier and steer a genetically predisposed developing central nervous system on a path toward autism. Among the many unresolved issues in this theory is the fact that no abnormal gut-derived peptides have been detected in autistic children. Although such a "leak" may be plausible, why it would be in only one direction or so specific as to permit the passage of some molecules but not others of similar size, shape, and charge is unexplained."

The origins of the MMR-autism theory began with earlier investigations suggesting that "multifocal vasculitis" in the intestinal submucosa, perhaps due to persistent viral infection, is an early event in patients with Crohn's disease. Although there are several theories about the etiology of inflammatory bowel disease (IBD), a precise cause is unknown and the etiology is likely multifactorial (due to some combination of genetic, infectious, immunologic, and possibly psychological factors). The postulation that persistent viral infection could ultimately lead to IBD was fueled by a report from Wakefield et al. that measles virus had been identified in the intestinal tissue of individuals with Crohn's disease by electron microscopy, in situ hybridization, and immunohistochemistry.l5 However, other investigators failed to reproduce this finding. Rather, they isolated a cross-reacting intestinal antigen that was determined to be of human, not viral, origin.

Shortly thereafter, researchers published two epidemiologic studies that linked perinatal measles infection (defined as occurring during late pregnancy to 3 months of age) and in utero exposure to measles with the development of IBD. However, when they identified the study population, these researchers had prior knowledge that two cases of Crohn's disease had occurred in the offspring of women who were infected with measles during pregnancy. This selection bias limits the strength of the conclusions drawn by these studies. Another study published in the wake of these conclusions, suggesting a link between measles vaccination and IBD, drew significant national and international attention. In contrast, several other epidemiologic studies have consistently failed to show an association between either perinatal measles infection or vaccines containing measles virus and the subsequent development of IBD

O'Leary et al. reported isolating measles RNA in the intestinal tissue of autistic children with gastrointestinal complaints. The details of this study have yet to be published. However, when samples from O'Leary's laboratory were shared with an independent reference laboratory, the reference laboratory noted that ". . . there is questionable specificity as, on occasion, non-infected control tissues/cell have been recorded by O'Leary's laboratory as positive for measles virus" and "repeated tests of the same RNA were sometimes read differently by the O'Leary laboratory on sequential trials. Other investigators have presented data suggesting that paramyxovirus nucleic acid sequences were found in a portion of intestinal samples from patients with IBD, as well as a
smaller number of normal control subjects. One group identified measles RNA in peripheral blood cells from patients with IBD and autism. However, other researchers failed to demonstrate measles nucleic acid in IBD tissue using polymerase chain reaction. There is some evidence suggesting that measles virus may persist in unaffected tissue. However, presence does not necessarily imply pathology.

THE LEAP FROM IBD TO AUTISM: A VIRAL CONNECTION?

Although there is little epidemiologic evidence that children with autism experience a higher incidence of IBD, the connection between measles vaccination and autism rests on such a measles related abnormality in the intestine. The current MMR-autism debate came to the forefront with the publication and publicity of a small case series in 1998.2 In this report, Wakefield et al. described 12 children with intestinal symptoms and developmental regression. They observed that the onset of developmental problems was reported─by the parents or referring physicians─following the administration of MMR vaccine in 8 of 12 children. The average interval from vaccine �exposure� to symptom onset ws 6.3 days (range 1 to 14 days). However, the emphasis of their report was the endoscopic and histologic findings: of the 12 patients, 9 had evidence of ileal lymphoid nodular hyperplasia and 8 had what was described as "nonspecific colitis." On histologic examination, 7 children had ileal reactive lymphoid follicular hyperplasia without neutrophilic infiltrate or granulomata and all 12 had colonic lamina propria inflammatory cell infiltrates without granulomata. None of these endoscopic or histologic findings were seen in any of the 7 "normal" control subjects.

It was suggested, based on these findings, that MMR vaccination leads to an inflamed and dysfunctional intestine that results in autism, presumably via the hypothesized pathophysiologic process described earlier. Amplified by press briefings and extensive media coverage, this theory, portrayed as a medical alert, led to a measurable dip in MMR vaccine coverage in the United Kingdom.

INVESTIGATION OF A VACCINE SAFETY CONCERN

Concerned that media coverage of this proposed link among MMR vaccine, bowel disease, and autism could affect parental confidence in immunization and further reduce the use of the MMR vaccine, the United Kingdom's Medical Research Council reviewed the existing data and concluded that there was no evidence to support the proposed hypothesis.4l Subsequently, the United Kingdom's Medicines Control Agency established the Working Party on MMR Vaccine, and it also concluded that "the available information did not support the suggested causal association or give cause for concern about the safety of MMR or MR vaccines."

In a subsequent study, Taylor et al. performed an epidemiologic investigation into the proposed association between MMR vaccination and autism.43 Children with "autism" born in 8 health districts in the United Kingdom since 1979 were identified using special needs and school registers. The diagnosis of autism was confirmed in nearly 300 cases and these were then linked to immunization databases.

This study demonstrated a steady increase in the number of cases of children with autism (by year of birth) with no "step-up" when the MMR vaccine was introduced in the United Kingdom in October 1988. It also showed that vaccine uptake in children with autism was no different from that in children without autism and that there was no difference in age at diagnosis regardless of vaccination status or timing of vaccination. Finally, there was no evidence that regressive behavior clustered in the time intervals following vaccination.

Subsequent epidemiologic studies from Finland, the United Kingdom, and the United States demonstrated the same findings: a lack of correlation between the use of the MMR vaccine and new diagnoses of autism in the populations studied.264445 This evidence refutes the theory that the "epidemic" of autism in many countries followed the introduction of MMR vaccine. As the Institute of Medicine Committee concluded:

. . . the biological model linking MMR and [autistic spectrum disorders] ASDis incomplete and fragmentary. Possible immunologic and metabolic mechanisms have been described but have not been supported by validated and replicated controlled studies. While some believe that disrupted
viral immunity following administration of polyvalent vaccines could lead to atypical or persistent measles infection, possibly resulting in ASD or bowel disease, there is no biological precedent or sufficient evidence from existing research to support this scenarios

IS THERE AN EPIDEMIC OF AUTISM?

Autism was first described by Leo Kanner in 1943. However, the diagnostic criteria have changed over time and the criteria of the Diagnostic and Statistical Manual of Mental

Disorders, 4th edition, focus on three areas of impairment: social interaction, communication or language, and the display of restrictive or repetitive interests or behaviors. A diagnosis of "autis-
tic disorder" requires impairment in all three areas with onset in at least one area before the age of 3 years.46 Autistic disorder is actually a subtype in the larger category of pervasive developmental disorders, which includes Asperger's disorder, Rett's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. The average age at symptom onset is approximately 18 months,47 shortly after the period when children receive most recommended childhood immunizations. For example, the MMR vaccine is recommended between 12 and15 months of age.

Although an apparent increase in the number of children being diagnosed as having autism spectrum disorders has been noted in many countries, less clear is whether this represents an epidemic. Wakefield and Montgomery argue that there is an epidemic of autism occurring in the United States, the United Kingdom, and elsewhere. A review of 8 epidemiologic surveys of autism between 1963 and 1983 estimated the prevalence of autism to be between 4 and 5 per 10,000. More recent studies estimated the prevalence of autism to be 7.5 per 10,000 and all pervasive developmental disorders to be 22 per10,000.51 Despite what appears to be a clear increase during that time, this may reflect a broader concept of autism, detection of cases with normal intelligence, changes in criteria, and increased detection due to better available services. Access to many special educational programs requires documentation of an appropriate diagnosis, so it is possible that this may contribute to the increasing number of children receiving this diagnosis.

The public debate about the epidemic of autism, and the hypotheses that it corresponded with the use of MMR vaccine, pointed to this report as supporting evidence. However, the data in this report have often been misrepresented as the incidence of autism in California. This report focused only on those served by the California Department of Developmental Services. Without an appropriate reference population (denominator), no conclusions can be drawn about changes in the incidence of autism over time. Factors such as population growth, migration flux, and changes in the birth rate make such interpretations difficult. Also, the diagnosis of autism occurs at younger ages, as reflected in the California data. Therefore, under these circumstances, arranging data by birth cohort can be misleading. Finally, the diagnostic criteria for autism have changed greatly during the past two decades. Thus, it seems likely that improving detection and expanding criteria to include more subtle cases that would have previously gone undiagnosed or been classified elsewhere account for at least a substantial proportion of the increases in children diagnosed as having autism in California.

SEPARATING ANTIGENS COMPARED WITH COMBINING THEM IN MMR VACCINE: DIVIDE AND CONQUER OR BETTER SAFE THAN SORRY?

Whereas the paramyxovirus theory of autism (mediated through intestinal pathology) hinges on measles virus (wild or attenuated), the suggestion that autism can be prevented by separating the MMR vaccine into its components (measles, mumps, and rubella) and administering each of these antigens separately over time stems from several lines of thought.

The first is that there is a transient period (weeks) of measurable but clinically insignificant immunosuppression following a measles infection. This finding is the basis of the recommendation to delay tuberculosis skin testing for at least 4 weeks following a measles infection or measles immunization to eliminate the possibility of a false-negative result. The recommendation to separate varicella and MMR immunizations, if not given concomitantly, by at least 4 weeks is also based on this transient immunosuppression. Although there are several theoretical mechanisms in which viral interaction could impair or affect the clearance of one or more of the vaccine strain viruses, the Institute of Medicine concluded that "there is no biological precedent or sufficient evidence from existing research to support this scenario."

The second comes from two European epidemiologic studies of early childhood exposures. These suggested that measles and mumps infections in the same year of life were risk factors for the subsequent development of IBD. The first study examined persons with IBD in Iceland born
between 1915 and 1984 who would have been younger than 6 years during epidemics of measles and mumps occurring in the same year. However, it is impossible to determine from these data
whether affected individuals experienced both diseases and experienced them during the same year. The second study examined persons with IBD using British cohort data from 1970. The data from this study relied on parental recall of how old the child was when he or she experienced several common childhood infections. Parents were asked this question when cohort members were 10 years old. Validation of the documented actual age of these infections was not performed.

The third is derived from ecologic studies. Although largely misrepresented, these suggest that the increase in autism diagnoses followed the introduction of MMR vaccine into national immunization programs. Before this, immunization had been based on monovalent measles vaccine.

The fourth is the theory that the earlier a person encounters a natural measles virus infection, the more likely he or she is to develop IBD. A recent examination of this theory showed "an indication"of a higher risk of IBD with younger age at measles infection; however, this finding was not statistically significant.59 The theory is also at odds with the global epidemiology of IBD because most early measles virus infection occurs in the developing world, where the incidence of IBD is lowest. Finally, although not specific to the measles, mumps, or rubella viruses, the "immune overload" hypothesis has been applied broadly to childhood immunizations. The anxiety stems from the belief that a developing infant's fragile immune system is somehow overwhelmed by the multiple antigenic load of an increasingly complex childhood immunization schedule. Although the evidence does not support the immunologic basis of such a theory, it is a widely held belief.

Although studies that have attempted to validate these various hypotheses have focused on measles virus (wild virus, vaccine virus, or both), the underlying assumption is that the combined MMR vaccine is somehow the "Trojan horse" that leads to autism. Thus, proponents of the vaccine connection theory of autism have proposed that delaying the administration of this vaccine until later in life, separating the combined vaccine into individual antigens, or both will somehow affect the host-virus interaction and thus prevent the initiation of the process that leads to autism. Given the fragmentary evidence supporting this model, the only impact of such a recommendation will be to make the current childhood immunization schedule even more complicated. The likely result of separating these three vaccines would be that an increasing number of children would not receive adequate immunologic protection against these three viral infections.

TOWARD THE ELIMINATION OF MEASLES: THE PARADOX OF EFFECTIVE PREVENTION

Vaccinations have had a tremendous impact on improving health globally. Measles immunization has decreased disease in the United States by more than 99% since the introduction of the vaccine in 1963. Currently, estimated vaccination coverage for one or more doses of MMR vaccine by 24 months of age is 88% nationwide. During the past several years, there have been fewer than 100 cases of measles in the United States each year. Most of these have been traced to importation from countries that continue to experience outbreaks of Measles.

Worldwide, measles still accounts for 36 million cases and 1 million deaths per year; most disease burden is in the developing world. Measles also accounts for 10% of mortality worldwide from all causes in children younger than 5 years. Indigenous measles was considered interrupted in the United States in 1993.64 However, an outbreak of measles occurred in the United States between 1989 and 1991. During this period, there were more than 55,000 cases and more than 125 deaths.65 The Netherlands experienced more than2,300 cases of measles and 3 measles-associated deaths during the past year. Ireland also recently experienced an outbreak of measles with more than 1,600 cases and 2 reported deaths. Coupled with international travel, the infectiousness of the measles virus makes it likely that there will continue to be periodic outbreaks, especially in populations with a large pool of individuals who remain susceptible.

However, because of the widespread use of vaccines containing the attenuated measles virus, measles is now an unusual childhood infection in most of the developed world. Yet, when it does occur, measles can still be severe. Respiratory complications include bronchopneumonia and croup. As a mucosal infection, measles can also acutely Prefect the gastrointestinal tract, leading to diarrhea, dehydration, malabsorption, and malnutrition. Acute central nervous system complications include encephalitis. The long-term consequence of subacute sclerosing panencephalitis has largely disappeered with the elimination of wild measles virus. Death, primarily due to respiratory and neurologic complications, occurs in 1 to 3 cases per 1,000.

CONCLUSION

Although recent independent reviews of published and unpublished research have rejected the hypothesis that the MMR vaccine causes autism, the public concern raised by this theory cannot be dismissed. Fear of the vaccine has led some parents to search for "measles parties"-actually seeking exposure to children with active measles infections in the hope that a natural infection would relieve them of the difficulty of deciding whether to immunize their child.
A better understanding of the willingness of parents to believe such a theory is beyond the scope of this article. However, the perception that this theory might somehow be true may cause some parents to operate on the principle of "better safe than sorry," regardless of the evidence. Because the science does not speak for itself, pediatricians should be familiar with this subject, prepared to discuss it with parents, and able to guide those who wish to do their own review of this hypothesis to credible resources.

Pediatric Annals 30:7 July 2001

Sharon G. Humiston, MD, MPH

The facts of vaccine safety are stubborn indeed. It takes years of careful research to find them, but then the facts have a way of hiding again in scientific reports. Of course, once grasped, facts are stubborn in another sense��they are durable and persistent.

The facts of vaccine safety are of great concern to parents, health care providers, and public health administrators. Concern centers on both actual safety we are all working to optimize the well-being of our children and perceived safety. If parents lose confidence in vaccination, that fear, even if unfounded, could lead to decreased immunization coverage and, consequently, to rising rates of disease. It is difficult to maintain public confidence in vaccines. The rare "one-time-in-a-million" reaction to vaccination can happen because huge numbers of children virtually the entire birth cohort of four million American children will receive the vaccine. No serious reaction is considered acceptable because this is, after all, preventive medicine given to otherwise healthy children. Additionally, vaccines are man-made, often considered involuntary, and given under memorable circumstances, all of which increases our sense of their inherent risk.

Years ago, medical and public health groups were not getting vaccine information on the Internet and to the press at anything like the rate that the anti-vaccine groups were getting out their perspective. That has changed now, but many misconceptions took root during our silence.

Indeed, a telephone survey of 1,600 parents4 showed that 25% thought too many immunizations could weaken a child's immune system. Twenty-three percent believed that children receive more immunizations than necessary. Nineteen percent felt that immunizations are not always proven safe before being approved for use. For parents in your practice who need a better understanding of the many layers of pre-licensure testing and regulation, this issue of Pediatric Annals offers a clear and straightforward article on this topic by Macartney and Offit.

Recently, while hosting television broadcasts and telephone conferences, I have heard the "call-in" questions of many health care providers. I would like to share with you the most frequent questions and either answer them or point you to the answers in this issue or the June issue of Pediatric Annals.

DO VACCINES OVERLOAD THE IMMUNE SYSTEM?

Vaccines contain few antigens compared with the barrage of germs an infant encounters in the cleanest of homes.5 A fact sheet from the Vaccine Education Center at The Children's Hospital of Philadelphia puts it succinctly:

In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunologic cells circulating in their bodies. Therefore, the vaccines given in the first two years of life are literally a raindrop in the ocean of what an infant's immune system successfully encounters in the environment every day.

DOES THE MERCURY IN THIMEROSAL (A VACCINE PRESERVATIVE) CAUSE BRAIN
DAMAGE?

Excessive mercury exposure can lead to brain and kidney damage. Because the unborn fetus is particularly susceptible, three federal agencies have developed guidelines, which leave a margin for safety, regarding how much methyl mercury a fetus could be exposed to with out suffering any known health effect. Because each guideline was developed using a different method, they differ. The Food and Drug Administration (FDA) considers 0.4 ,ug/kg/d of mercury safe, the Agency for Toxic Substance & Disease Registry (ATSDR) considers 0.3 ug/kg/d safe, and the Environmental Protection Agency (EPA) considers 0.1 ug/kg/d safe.

Thimerosal is a mercury-containing preservative that was in some brands of vaccines against diphtheria, tetanus, and pertussis (DTP); Haemophilus influenzue type b (Hib); hepatitis A; hepatitis B; and influenza. (It is not used in live vaccines such as measles- mumps-rubella [MMR] and varicella.) Therefore, vaccines became a focus of the recent FDA review.

Many toxicologists believe that ethyl mercury (the kind in thimerosal) is much less toxic than methyl mercury and that infants metabolize mercury differently from the way that fetuses do. However, no ethyl mercury guidelines were available for infants, so the FDA extrapolated from the chronic fetal methyl mercury guidelines. The FDA found that if a small infant received vaccines containing thimerosal for each of his or her recommended vaccines, the infant could be exposed to total levels of ethyl mercury that would exceed the EPA (although not the FDA or ATSDR) guidelines.

The Public Health Service, the American Academy of Pediatrics (AAP), and pharmaceutical companies agreed that thimerosal should be removed from pediatric vaccines to reduce children's
exposure to mercury. Now, at least one formulation of all routine childhood vaccines is thimerosal-free. A listing of the mercury concentration in all vaccines licensed in the United States is available at www.vaccinesafety.edu / thi-table.htm.

The changes have reduced the potential exposure to mercury. Much research is now under way
to determine how long ethyl mercury from thimerosal stays in the bodies of young children and
what effect it has on their development. In one recent study, scientists at the University of Rochester Medical Center tested the blood mercury levels of 16 full-term infants shortly after
vaccination. They found that blood mercury levels in all of the infants tested were lower than
the level of maternal blood mercury believed to represent a health risk.8 The infants were found to rapidly excrete the ethyl mercury in their stool.

On July 16, 2001, the Institute of Medicine, an independent panel of scientists from many fields, will hold a scientific meeting examining the available data on thimerosal and neurodevelopmental disorders. To learn more about this meeting, contact the Immunization Safety Review Committee at www.iom.edu/iom / iomhome.nsf / pages /
immunization+safety+review.

CAN WE SAFELY GIVE HEPATITIS B VACCINE AT BIRTH?

July 1999, the U.S. Public Health Service, the AAP, and the vaccine manufacturers announced that pediatric vaccines containing thimerosal should be removed from the U.S. market. The birth dose of hepatitis B vaccine (given at birth, when the body weight is lowest and, thus, the mercury exposure per kilogram of body weight is highest) was the first priority. While a thimerosal-free version of the vaccine was in development, hepatitis B vaccination of newborns (with hepatitis B-negative mothers) was temporarily suspended. Within 2 months, a thimerosal-free formulation of hepatitis B vaccine was available, and shortly thereafter both licensed pediatric hepatitis B vaccines no longer contained thimerosal as a preservative. In July 2000, the Centers for Disease Control and Prevention (CDC) published a notice that "efforts should be made to reintroduce routine hepatitis B vaccination policies for all newborn infants."

Health care providers should recognize that, because of the risks associated with both acute and chronic hepatitis B. it is critical that a birth dose of hepatitis B vaccine be given to infants born to mothers whose hepatitis B surface antigen is positive or unknown. Giving a birth dose of hepatitis B vaccine to the infant of a mother whose hepatitis B surface antigen is negative will increase the infant's likelihood of completing his or her hepatitis B immunization series on timely and is not associated with an increase in adverse reactions.

DO VACCINES CONTAIN THE "MAD COW" INFECTIOUS AGENT?

Bovine spongiform encephalopathy (BSE), also known as "mad cow disease," is a fatal disease of the nervous system of cows that was first diagnosed in 1986. Variant Creutzfeldt-Jakob disease (vCJD) is a disease of the nervous system of humans that begins with serious psychiatric problems or sensory problems and is later manifested by muscle spasms, loss of coordination, and confusion. On average, death follows the first symptoms of vCJD in approximately 13 months. Consumption of food contaminated with the BSE agent (which may be a modified cell protein) has been linked to vCJD in the United Kingdom, Ireland, and France.

In 1993, the FDA asked all vaccine manufacturers to eliminate bovine materials from countries affected by BSE, but recently FDA officials discovered that some vaccine manufacturers were not strictly following these recommendations. For this reason, the FDA convened a meeting of BSE and vaccine experts on July 27, 2000. After taking many factors into account (eg, the number of infected animals, the concentration of infectious units in infected animal blood, and the amount of blood used per dose of vaccine), they estimated the risk of vCJD from the use of European bovine-derived materials to be 1 in 2 billion doses for a bacterial toxoid or 1 in 40 billion doses for a viral vaccine. Officials noted that no cases of vCJD have been attributed to vaccine use and that there is no evidence that any vaccine actually contains the BSE agent.

Researchers in Britain have found that, of the original 52 British cases of vCJD (all of the cases that were diagnosed at the time of the study in October 2000), 49 patients were born before 1930 and, therefore, would have received the vaccines before BSE emerged. The other 3 patients with vCJD were born in the 1980s, so they were not exposed to the disease through vaccination because the vaccines used for them also were manufactured with bovine materials obtained before 1936. This study eliminates concern that the original 52 British cases of vCJD were vaccine related, but it does not eliminate the possibility that a person could get vCJD from immunization some day.

The CDC has responsibility for vCJD surveillance in the United States and, to date, this surveillance shows no vCJD. To keep the U.S. public safe, the FDA sent a letter to manufacturers in April 2000 requesting that they stop using any materials derived from European ruminants (eg, cows or sheep) in FDA-regulated products for humans. The concerns about the theoretical risks of vCJD infection through vaccines have resulted in additional scrutiny of vaccine manufacturing processes. A current list of vaccines using bovine-derived materials from countries on the U.S. Department of Agriculture BSE list or from countries in which the status of BSE is unknown can be found at www.fda.gov / cber / bse / bse.htm#usda. Scientists will continue to study how the BSE agent can be transmitted to humans, but the facts reassure health care professionals that the risk of BSE contamination of vaccines is miniscule compared with the risk of physical disability, mental damage, or death from infectious diseases such as Hib, diphtheria, or tetanus.

SHOULD WE USE UP OUR SUPPLY OF ORAL POLIO VACCINE?

Because of the true causal association between oral polio vaccine and paralytic polio, oral polio vaccine is no longer recommended for routine childhood immunization.l4 The switch to an all-inactivated polio vaccine schedule has not decreased polio immunization coverage in the United States; parents are willing to accept the injection for the sake of safety.

DO VACCINES CAUSE SUDDEN INFANT DEATH SYNDROME?

The Institute of Medicine reviewed the evidence and concluded that DTP did not cause sudden infant death syndrome. The incidence of sudden infant death syndrome has actually decreased during the time period when hepatitis B vaccine has been given to infants routinely. However, this decrease is probably due to the AAP's "Back to Sleep Program," an effort to get parents to put infants to sleep on their backs.

DOES HEPATITIS B VACCINE CAUSE MULTIPLE SCLEROSIS?

In 1994, the Institute of Medicine published a review of the evidence showing that vaccines did not cause diseases of the nervous systemic Subsequent reviews by the World Health Organization and the National Multiple Sclerosis Society came to the same conclusion. Recent studies have shown no association between hepatitis B vaccination and multiple sclerosis. A controlled study of individuals reporting demyelinating diseases to the Vaccine Adverse Event Reporting System also failed to show an association between hepatitis B vaccination and either multiple sclerosis or optic neuritis.

DOES THE HIS VACCINE CAUSE DIABETES?

Finish researchers have shown that the rates of type I diabetes in Hib-vaccinated and unvaccinated children were not different. In 1999, the Diabetes Workshop Panel of the Institute for Vaccine Safety concluded that "no vaccines have been shown to increase the risk of type I diabetes in humans."

IN MY PRACTICE, IT SEEMS THAT THE DIPHTHERIA AND TETANUS TOXOIDS AND ACELLULAR PERTUSSIS (DTAP) VACCINE CAUSES FEWER ADVERSE REACTIONS THAN THE DTP VACCINE DID. ARE THERE DATA ON THIS?

Reports to the Vaccine Adverse Event Reporting System concerning serious adverse events believed to be caused by whole-cell pertussis vaccine have declined.26 Common mild side effects (eg, fever or local soreness) are less common after acellular pertussis vaccine than after whole-cell pertussis vaccine, but temporary swelling of the entire limb has been noted in some children who receive DTaP boosters.

DOES THE MMR VACCINE CAUSE AUTISM? WHAT SHOULD I TELL PARENTS WHO WANT THEIR CHILD TO RECEIVE THESE THREE ANTIGENS GIVEN SEPARATELY?

The article by Kastner and Gellin in this issue of Pediatric Annals contains a full discussion of the MMR vaccine and autism.

HOW SHOULD I RESPOND TO QUESTIONS ON CONTRAINDICATIONS TO VACCINATION?

In this issue, Bahta et al. provide guidance on the true contraindications to vaccination. Please note that allergy to eggs is no longer considered a contraindication to the MMR vaccine.

WHAT DO YOU SAY TO PARENTS WHO WANT TO WAIT BEFORE VACCINATING THEIR CHILD?

Waiting to vaccinate is not a neutral, risk-free stance. All parents (and providers) should read the article in this issue about one family that put off making this serious decision.

HOW SHOULD I RESPOND TO QUESTIONS ON THE TIMING AND SCHEDULING OF VACCINES?

The most common questions that I am asked relate to the timing and scheduling of vaccines. The article by Humiston and Strikas in the June issue of Pediatric Annals provides information on this complex topic. Questions regarding the catchup schedule for pneumococcal conjugate vaccine are also addressed by Baiter and Van Beneden in that issue.

HOW SAFE IS THE PNEUMOCOCCAL CONJUGATE VACCINE?

Baiter and Van Beneden review this topic in detail in the June issue of Pediatric Annals. In the first 9 months of distribution of the new vaccine, Vaccine Adverse Event Reporting System forms were consistent with expected side effects already appreciated before licensure.
WHAT SHOULD WE TELL PARENTS ABOUT THE RISK OF MENINGOCOCCAL DISEASE AND THE VACCINE?

Recent outbreaks of meningococcemia have parents worried. Dull and Rosenstein review meningococcal disease and prevention through vaccination in the June issue of Pediatric Annals.

WILL VARICELLA VACCINE LEAD TO WANING IMMUNITY AND SERIOUS DISEASE LATER IN LIFE?

A huge number of providers have expressed their concern and confusion about the long-term effects of varicella vaccination. The article by Watson in the June issue of Pediatric Annals discusses this further.

WHAT WEB SITES DO YOU RECOMMEND FOR PARENTS WHO WANT TO KNOW MORE ABOUT VACCINES?

Fredrickson et al. explain in their article in this issue of Pediatric Annals that we need to layer information for parents, giving them as much as they need without overwhelming the faintly curious. The Internet is often a good tool for this. To me, the single best web site is www.vaccine.org because it is actually seven sites, including the AAP, the Immunization Action Coalition, the National Network for Immunization Information, the Vaccine Education Center at The Children's Hospital of Philadelphia, and Parents of Kids with Infectious Diseases. Other web sites include those of Johns Hopkins University (www.vaccinesafety.edu), the CDC (www.cdc.gov / nip /vacsafe), and the FDA (www.fda.gov).

WHAT OTHER TOOLS DO YOU RECOMMEND FOR PARENTS WHO WANT TO KNOW MORE ABOUT VACCINES?

The CDC's Vaccine Information Statements (VISs) are one page documents that answer most of the questions that parents have about specific vaccines (eg, What are the benefits? What are the common side effects? What are the potential severe side effects?). The article by Wolfe in this issue of Pediatric Annals provides a full description of their use.

Parents who want additional print material can be referred to other sources, including a one page "Q & A" fact sheet by the Vaccine Education Center at The Children's Hospital of Philadelphia (215-590-9990 or vaccines~email.chop.edu.); a set of immunization information sheets produced by the National Network for Immunization Information (877-341- 6644); an immunization booklet called The Parents' Guide to Immunizations produced by the National Immunization Program of the CDC (www.cdc.gov / nip); and two books on vaccines, Vaccinating Your Child:Questions and Answers for the Concerned Parent (Humiston and Good) and Vaccines: What Every Parent Should Know (Offit and Bell) that are available through bookstores and web sites. For parents who would benefit from a videotape on vaccine safety, there is "Vaccines: Separating Fact from Fear" by the Vaccine Education Center at The Children's Hospital of Philadelphia (215-590-9990 or vaccines~email.chop.edu). This videotape is not only informative, but also emotionally compelling because of the stories of parents who have lost or almost lost children to vaccine-preventable diseases.

HOW CAN PARENTS, MY STAFF, AND I GET OUR NEXT QUEST10N ANSWERED?

The most comprehensive service for answering vaccine questions is provided by the CDC National Immunization Program's National Immunization Hotline, which can be reached by telephone (1-800-232-2522) or e-mail (nipinfo~cdc.gov).

THE BEGINNING

It takes more time to developthe scientific evidence on vaccine risks and benefits than it does to develop fear and doubt. It takes more time to build trust and open communications than to destroy them. We do not live in an era of unquestioning reverence for vaccines, so we must develop the science to evaluate vaccine safety and the skills to communicate the results or we will return to the problems of an earlier age. We have only just begun.

1. Henry LC, ed. Best Quotations for All Occasions. Greenwich, CT: Fawcett Publications; 1986.

2. Gangarosa EJ, Galazka AM, Wolfe CR, et al. Impact of anti-vaccine movements on pertussis control: the untold story. Lancet. 1998;351:356-361.

3. Sandman PM. Responding to Community Outrage: Strategies for Effective Communication. Fairfax, VA: American Industrial Hygiene Association; 1993.

4. Gellm BG, Maibach EW, Marcuse EK, et al. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000;106:1097-1102.

5. McPhillips H. Marcuse EK. Vaccine safety. Curr Probl Pediatr. 2001;31:91- 121.

6. Vaccine Education Center at The Children's Hospital of Philadelphia. Q ~ A: The Facts About Childhood Vaccines, vol. 2. Philadelphia: Vaccine Education Center at The Children's
Hospital of Philadelphia; 2001. Available at vaccine.chop.edu.

7. Ball LK, Ball R. Pratt RD. An assessment of thimerosal use in childhood vaccines. Pediatrics. 2001:107:1147- 1154.

8. Pichichero M, Clarkson T. Lopreiato J. Cernichiari E, Treanor J. Blood mercury levels in infants receiving vaccines containing thimerosal. Pediatr Res. 49(4), Part II of II, Abstract #1385.

9. Centers for Disease Control and Prevention. Update: expanded availability of thimerosal preservaUve-free hepatitis B vaccine. MMWR. 2000;49: 642, 651.

Measles-Mumps-Rubella Vaccine and Autistic Spectrum Disorder: Report From the New Challenges in Childhood Immunizations Conference Convened in Oak Brook, Illinois, June 12-13, 2000. Neal A. Halsey, MD, Susan L. Hyman, MD, and the Conference Writing Panel. 


Background. Parents and physicians are understandably concerned about the causes and treatment of autism, a devastating disease that affects the entire family. Although much has been learned about autism, there are many gaps in our knowledge about what causes the disorder and how it can be prevented. Autistic symptoms occur along a spectrum, often referred to as autistic spectrum disorder (ASD). Concern has been raised about a possible association between measles-mumps-rubella (MMR) vaccine and inflammatory bowel disease (IBD) and ASD, especially autism with regression. Also, increased requests for educational services related to ASD have raised concerns about possible increases in the incidence of ASD.

Methods. On June 12-13, 2000, the American Academy of Pediatrics (AAP) convened a conference titled "New Challenges in Childhood Immunizations" in Oak Brook, Illinois. At this conference, parents, practitioners, and scientists presented information and research on MMR vaccine and ASD. Attendees included representatives from select AAP committees and sections as well as federal and other organizations that address related issues. The multidisciplinary panel of experts reviewed data on what is known about the pathogenesis, epidemiology, and genetics of ASD and the available data on hypothesized associations with IBD, measles, and MMR vaccine. Supplemental information was requested from authors who have proposed the hypotheses and other experts in relevant areas.

Results. Autism is a complex disorder of uncertain and probably multiple etiologies. Genetic predisposition to ASD may involve as many as 10 genes. Many experts believe that the abnormal brain development in autism occurs before 30 weeks' gestation in most instances. In utero rubella is a known cause of autism. Animal model data support the biologic plausibility that exposure to yet unrecognized infectious or other environmental agents could cause ASD.

Several factors may contribute to apparent increases in incidence of ASD in recent years. Most data indicate increased recognition and reporting as primary factors, but the epidemiologic data are insufficient to determine if there has been a true increase in the incidence of ASD. Increased reporting of ASD in recent years has occurred long after the introduction of MMR vaccine in the United States in 1971 and widespread use of this vaccine in the 1970s for routine immunization of children at 12 to 15 months of age. Appropriate detailed studies are needed to define the true incidence and prevalence of ASD. Epidemiologic studies in Europe indicate no association between MMR vaccine and ASD.

Some children with ASD have gastrointestinal symptoms, but an increased rate of any specific gastrointestinal disorder in children with ASD has not been established. Studies to detect evidence of measles virus in intestinal tissue specimens from patients with IBD or autism with gastrointestinal symptoms have not used uniform techniques. Several laboratories have found no evidence of measles viruses in tissue specimens from patients with IBD, but 2 groups have found evidence of measles virus using different techniques. A group that found evidence of measles virus in affected tissue specimens from patients with IBD has also reported detecting portions of measles virus in peripheral blood Iymphocytes and intestinal tissue specimens from patients with autism and gastrointestinal disorders. Finding a portion of a virus using molecular techniques does not constitute evidence for a causal relationship, because some viruses persist in unaffected hosts. Additional controlled studies in several laboratories are needed to determine if portions of measles virus persist in intestinal and other tissues of people with and without gastrointestinal disease and/or ASD.

Conclusions. Although the possible association with MMR vaccine has received much public and political attention and there are many who have derived their own conclusions based on personal experiences, the available evidence does not support the hypothesis that MMR vaccine causes autism or associated disorders or IBD. Separate administration of measles, mumps, and rubella vaccines to children provides no benefit over administration of the combination MMR vaccine and would result in delayed or missed immunizations. Pediatricians need to work with families to ensure that children are protected early in the second year of life from these preventable diseases. Continued scientific efforts need to be directed to the identification of the causes of ASD. Pediatrics 2001;107(5). URL: http://www.pediatrics.org/ cgi/content/full/107/5/e84; autism, measles-mumps-rubella vaccine, autistic spectrum disorder, inflammatory bowel disease, measles, measles vaccine, epidemiology.

This discussion addresses many of the concerns raised by �non-vaccinating� families regarding vaccine safety and effectiveness. 


The original material presented against vaccination comes from a web page written by Alan Phillips:

DISPELLING VACCINATION MYTHS:
An introduction to the contradictions between medical science and immunization policy.
c by Alan Phillips (aphillip~email.unc.edu). Last Revision: February 1997.
See the Informed Parents Vaccination Home Page" on the World Wide Web at URL:
http ://www.unc. edu/~aphillip/www/vaccine/imformed.htm
*Permission freely granted to copy and redistribute in full for any nonprofit purpose. Persons concerned with for-profit distribution, electronic postings, and other concerns should contact the author at Vaccine Awareness, P.O. Box 62282, Durham, NC 27715 or by email (see above).

The text from Mr Phillips will be dissected and addressed paragraph by paragraph by Dr Horwitz, to review each concern raised. This article is presented to demonstrate how difficult it is to refute some arguments against vaccination, even if they are untrue.

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INTRODUCTION: Is there a legitimate controversy?

When my son began his routine vaccination series at age 2 months, I did not know there were any risks associated with immunizations. But the clinic's literature contained a contradiction: the chances of a serious adverse reaction to the DPT vaccine were 1 in 1750, while his chances of dying from pertussis each year were 1 in several million. When I pointed this out to the physician, he angrily disagreed, and stormed out of the room mumbling, "I guess I should read that sometime..." Soon thereafter I learned of a child who had been permanently disabled by a vaccine, so I decided to investigate for myself My findings have so alarmed me that I feel compelled to share them; hence, this report.
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COMMENTARY BY DR HORWITZ
The risk of 1: 1,750 refers to Moderate Problems only, which includes a possible seizure (a simple febrile seizure that is extremely unlikely to have any complications), and "shock/collapse" or anaphylaxis (a temporary condition of low blood pressure and poor circulation which is usually either self limited or treatable with an adrenalin injection, but unlikely to produce permanent complications).
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Health authorities credit vaccines for disease declines, and assure us of their safety and effectiveness. Yet these seemingly rock-solid assumptions are directly contradicted by health statistics, medical studies, Food and Drug Administration (FDA) and Centers for Disease Control (CDC) reports, and reputable research scientists from around the world. In fact, infectious diseases declined steadily for decades prior to vaccinations, U.S. doctors report thousands of serious vaccine reactions each year including hundreds of deaths and permanent disabilities, fully vaccinated populations have experienced epidemics, and researchers attribute dozens of chronic immunological and neurological conditions to mass immunization programs.

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COMMENTARY BY DR HORWITZ
True. The rate of many of the diseases for which we now immunize did decrease in the middle of this century for a number of reasons. Improved hygiene and waste removal throughout the industrialized world has had a huge impact. However, 10,000 cases of Polio is not acceptable just because 20 years before there were 100,000 cases when the disease can be eradicated completely.
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There are hundreds of published medical studies documenting vaccine failure and adverse effects, and dozens of books written by doctors, researchers, and independent investigators that reveal serious flaws in immunization theory and practice. Ironically, most pediatricians and parents are completely unaware of these findings. However, this has begun to change in recent years, as a growing number of parents and healthcare providers around the world are becoming aware of the problems and starting to question the use of widespread, mandatory vaccinations.

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COMMENTARY BY DR HORWITZ
True. Most practitioners who administer vaccinations are under-educated regarding many of the issues surrounding vaccination such as SV40 in Polio vaccine, and many of the issues discussed by the general public. We need to be more knowledgeable of the controversies and not just accept the word of the Academy of Pediatrics, WHO, and other "medical establishments" without question.
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My point it not to tell anyone whether or not to vaccinate, but rather, with the utmost urgency, to point out some very good reasons why everyone should examine the facts before deciding whether or not to submit to the procedure. As a new parent, I was shocked to discover the absence of a legal mandate or professional ethic requiring pediatricians to be fully informed, and to see first-hand the prevalence of physicians who are applying practices based on incomplete--and in some cases, outright mix--information.

Though only a brief introduction, this report contains sufficient evidence to warrant further investigation by all concerned, which I highly recommend. You will find that this is the only way to get an objective view, as the controversy is a highly emotional one.

A note of caution: Be careful trying to discuss this subject with a pediatrician. Most have staked their identities and reputations on the presumed safety and effectiveness of vaccines, and thus have difficulty acknowledging evidence to the contrary. The first pediatrician I attempted to share my findings with yelled angrily at me when I calmly brought up the subject. The misconceptions have very deep roots.

VACCINATION MYTH #1: "Vaccines are completely safe..." Or are they?
The FDA's VAERS (Vaccine Adverse Effects Reporting System) receives about 11,000reports of serious adverse reactions to vaccination annually, some 1% (112+) of which are deaths from vaccine reactions.[1] The majority of these reports are made by doctors, and the maj ority of deaths are attributed to the pertussis (whooping cough) vaccine, the "P" in DPT. This figure alone is alarming, yet it is only the "tip of the iceberg." The FDA estimates that only about 10% of adverse reactions are reported,[2l a figure supported by two National Vaccine Information Center (NVIC) investigations. [3] In fact, the NVIC reported that "In New York, only one out of 40 doctor's of flees [2.5%] confirmed that they report a death or injury following vaccination," -- 97.5% of vaccine related deaths and disabilities go unreported there. Implications about the integrity of medical professionals aside (doctors are legally required to report serious adverse events), these findings suggest that vaccine deaths actually occurring each year may be well over 1,000.

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COMMENTARY BY DR HORWITZ
These statistics are intentionally confusing. If it is true that 112 Reports of death are received, it does NOT mean that the deaths have been caused by the vaccinations. There is not only serious doubt that any deaths are caused by the DaPT vaccine, but a total lack of causal evidence.

As for the New York doctors where "only one out of 40 doctor's offices [2.5%] confirmed that they report a death or injury following vaccination," It is unlikely that any one doctor's office has even seen a death or severe reaction following vaccination! In this office we give Thousands of doses of vaccines each year and have of course NEVER seen a death, and have not had a Severe reaction in the 8 years that I have been here.

Also, we DO report every single suspected reaction, regardless of how questionable it may be, to the VAERS program.
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With pertussis, the number of vaccine-related deaths dwarfs the number of disease deaths, which have been about 10 annually for recent years according to the CDC, and only 8 in 1993, the last peak-incidence year (pertussis runs in 3-4 year cycles, though vaccination certainly doesn't). Simply put, the vaccine is 100 times more deadly than the disease. Given the many instances in which highly vaccinated populations have contracted disease (see Myth #2), and the fact that the vast majority of disease decline this century occurred before compulsory vaccinations (pertussis deaths declined 79% prior to vaccines; see Myth #3), this comparison is a valid one--and this enormous number of vaccine casualties can hardly be considered a necessary sacrifice for the benefit of a disease-free society.

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COMMENTARY BY DR HORWITZ
Once again, the author uses misleading statistics. First, there simply are no deaths that have been proven to be attributed to pertussis vaccine. Even so, understand that if the population were totally non-vaccinated, as opposed to the current situation with over 90% vaccination, there would be many times more deaths from pertussis than the 10 per year quoted. I suppose that if these people really do 'die' from the pertussis than the statement is correct that the vaccine is 10 times for lethal than the disease, but ONLY because almost all pertussis infections that would have occurred without vaccination have been prevented!
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Unfortunately,the vaccine-related-deaths story doesn't end here. Both national and international studies have shown vaccination to be a cause of SIDS[4,5] (SIDS is "Sudden Infant Death Syndrome," a "catch-all" diagnosis given when the specific cause of death is unknown; estimates range from 5 - 10,000 cases each year in the U.S.). One study found the peak incidence of SIDS occurred at the ages of 2 and 4 months in the U.S., precisely when the first two routine immunizations are given,[4] while another found a clear pattern of correlation extending three weeks after immunization. Another study found that 3,000 children die within 4 days of vaccination each year in the U.S. (amazingly, the authors reported no SIDS/vaccine relationship), while yet another researcher's studies led to the conclusion that half of SIDS cases--that would be 2500 to 5000 infant deaths in the U.S. each year--are caused by vaccines.[4]

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COMMENTARY BY DR HORWITZ
SIDS is the single most common cause of death in infants under one year of age. By definition there is no identifiable cause for the deaths. It is not surprising that SIDS peaks at 2 and 4 months "precisely when the first two routine immunizations are given" That is like being surprised that Strawberries are ripe in May. Finding "a clear pattern of correlation extending three weeks after immunization" covers half of the days in the life of an infant under 6 months of age! That has to leave a lot of room open for coincidence. It is like saying "the weather tonight will be dark, followed by a brighter forecast for tomorrow."
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There are studies that claimed to find no SIDS-vaccine relationship. However, many of these were invalidated by yet another study which found that "confounding" had skewed their results in favor of the vaccine.[6] Shouldn't we err on the side of caution? Shouldn't any credible correlation between vaccines and infant deaths be just cause for meticulous, widespread monitoring of the vaccination status of all SIDS cases? In the mid 70's Japan raised their vaccination age from 2 months to 2 years; their incidence of SIDS dropped dramatically. In spite of this, the U.S. medical community has chosen a posture of denial. Coroners refuse to check the vaccination status of SIDS victims, and unsuspecting families continue to pay the price, unaware of the dangers and denied the right to make a choice.

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COMMENTARY BY DR HORWITZ
When a number of well controlled studies were conducted in the 1980's, the investigators found, nearly unanimously, that the number of SIDS deaths temporally associated with DTP vaccination was within the range expected to occur by chance. In fact, most studies have shown no association or a decreased rate of SIDS among immunized children. (Adapted from CDC info.)
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Low adverse event reporting also suggests that the total number of adverse reactions actually occurring each year may be more than 100,000. Due to doctors' failure to report, no one knows how many of these are permanent disabilities, but statistics suggest that it is several times the number of deaths (see "petitions" below). This concern is reinforced by a study which revealed that 1 in 175 children who completed the full DPT series suffered "severe reactions," [7] and a Dr.'s report for attorneys which found that 1 in 300 DPT immunizations resulted in seizures. [8]

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COMMENTARY BY DR HORWITZ
According to the CDC, the rate of severe reactions is more like 1 in 1 million. From my own experience, in practice for 8 years, I have supervised about 17,000 DPT injections and have never seen a severe reaction. It is absurd to even consider that a study would show a rate of 1 seizure per 300 immunizations with DPT.
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England actually saw a drop in pertussis deaths when vaccination rates dropped from 80%
to 30% in the mid 70's. Swedish epidemiologist B. Trollfors' study of pertussis vaccine efficacy and toxicity around the world found that "pertussis-associated mortality is currently very low in industrialized countries and no difference can be discerned when countries with high, low, and zero immunization rates were compared." He also found that England, Wales, and West Germany had more pertussis fatalities in 1970 when the immunization rate was high than during the last half of 1980, when rates had fallen.[9]

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COMMENTARY BY DR HORWITZ
Pertussis fatalities are mostly in infants and elderly persons. The death rate for these persons will rise and fall with the cyclic waves of Pertussis in the community. It is likely that 1970 was a peak year for pertussis and 1980 was a low year for the infection.
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Vaccinations cost us much more than just the lives and health of our children. The U.S. Federal Government's National Vaccine Injury Compensation Program (NVICP) has paid out over $724.4 million to parents of vaccine injured and killed children, in taxpayer dollars. The NVICP has received over 5000 petitions since 1988, including over 700 for vaccine-related deaths, and there are still some two thousand total death and injury cases pending that may take years to resolve. [10] Meanwhile, pharmaceutical companies have a captive market: vaccines are legally mandated in all 50 U.S. states (though legally avoidable in most; see Myth #9), yet these same companies are "immune" from accountability for the consequences of their products. Furthermore, they have been allowed to use "gag orders" as a leverage tool in vaccine damage legal settlements to prevent disclosure of information to the public about vaccination dangers. Such arrangements are clearly unethical; they force a nonconsenting American public to pay for vaccine manufacturer's liabilities, while attempting to ensure that this same public will remain ignorant of the dangers of their products.

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COMMENTARY BY DR HORWITZ
While I cannot verify that $724.4 million has been payed by NVICP, the alternative would: higher health care insurance premiums and other costs for everyone. The main purpose for the fund is to 1) allow US companies to continue producing needed vaccines which would otherwise be unprofitable and therefore not produced in a capitalist free market, 2) to encourage practitioners to continue giving the immunizations without undue fear of litigation (which also increases health care costs), and 3) to reduce the number of alleged injury cases that would be brought to trial (at the taxpayer's expense).
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It is interesting to note that insurance companies (who do the best liability studies) refuse to cover vaccine adverse reactions. Profits appear to dictate both the pharmaceutical and insurance companies' positions.

VACCINATION TRUTH #1: "Vaccination causes significant death and disability at an astounding personal and financial cost to families and taxpayers."

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COMMENTARY BY DR HORWITZ
(The above discussion demonstrates that this claim is not true.
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VACCINATION MYTH #2:

"Vaccines are very effective..." or are they?

The medical literature has a surprising number of studies documenting vaccine failure. Measles, mumps, small pox, polio and Hib outbreaks have all occurred in vaccinated populations. [11, 12, 13, 14 ,15] In 1989 the CDC reported: "Among school-aged children, [measles] outbreaks have occurred in schools with vaccination levels of greater than 98 percent. [16] [They] have occurred in all parts of the country, including areas that had not reported measles for years." [17] The CDC even reported a measles outbreak in a documented 100 percent vaccinated population. [18] A study examining this phenomenon concluded, "The apparent paradox is that as measles immunization rates rise to high levels in a population, measles becomes a disease of immunized persons." [19]

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COMMENTARY BY DR HORWITZ
The above studies refer to the 1980's, when children only received one dose of MMR. Now children receive two doses, which has solved the problem of Measles outbreaks in schools and Measles is close to eradication.
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A more recent study found that measles "produces immune suppression which contributes to an increased susceptibility to other infections."[l9a] These studies suggests that the goal of complete immunization is actually counterproductive, a notion underscored by instances in which epidemics followed complete immunization of entire countries. Japan experienced yearly increases in small pox following the introduction of compulsory vaccines in 1872. By 1892, there were 29,979 deaths, and all had been vaccinated. [20] Early in this century, the Philippines experienced their worst smallpox epidemic ever after 8 million people received 24.5 million vaccine doses; the death rate quadrupled as a result. [21]

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COMMENTARY BY DR HORWITZ
Please do not compare the effectiveness and safety of 1999 vaccines with those of 120 years ago! In addition the immunization doses and schedules from back then are not equivalent and cannot be compared. Further, Small Pox vaccine was a live vaccine, and produced cases of Eczema Vaccinatum which may have been reported as cases of Small Pox back then.
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In 1989, the country of Oman experienced a widespread polio outbreak six months after achieving complete vaccination. [22] In the U.S. in 1986, 90% of 1300 pertussis cases in Kansas were "adequately vaccinated." [23] 72% of pertussis cases in the 1993 Chicago outbreak were fully up to date with their vaccinations.[24]
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COMMENTARY BY DR HORWITZ
People may not realize that Pertussis vaccination "wears off" by age 11-13 years. Virtually no adults are "adequately vaccinated" for Pertussis. Although "adequately vaccinated", many cases in Kansas 1986 were over the age of 11 years and therefore susceptible. The goal of the Pertussis vaccine is not to wipe out pertussis; it is to avoid infecting infants because for them it is often a fatal infection.
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VACCINATION TRUTlI #2:

"Evidence suggests that vaccination is an unreliable means of preventing disease. "

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COMMENTARY BY DR HORWITZ
The author's point is not well taken, as his examples are irrelevant, drawing on 120 year old ~ Vaccine data and unfair expectations.
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VACCINATION MYTH #3:

"Vaccines are the main reason for low disease rates in the U.S. today..." or are they?

According to the British Association for the Advancement of Science, childhood diseases decreased 90% between 1850 and 1940, paralleling improved sanitation and hygienic practices, well before mandatory vaccination programs. Infectious disease deaths in the U.S. and England declined steadily by an average of about 80% during this century (measles mortality declined over 97%) prior to vaccinations. [25] In Great Britain, the polio epidemics peaked in 1950, and had declined 82% by the time the vaccine was introduced there in 1956. Thus, at best, vaccinations can be credited with only a small percentage of the overall decline in disease related deaths this century. Yet even this small portion is questionable, as the rate of decline remained virtually the same after vaccines were introduced. Furthermore, European countries that refused immunization for small pox and polio saw the epidemics end along with those countries that mandated it. (In fact, both small pox and polio immunization campaigns were followed initially by significant disease incidence increases; during smallpox vaccination campaigns, other infectious diseases continued their declines in the absence of vaccines. In England and Wales, smallpox disease and vaccination rates eventually declined simultaneously over a period of several decades.[26]) It is thus impossible to say whether or not vaccinations contributed to the continuing decline in disease death rates, or if the same forces which brought about the initial declines--improved sanitation, hygiene, improvements in diet, natural disease cycles--were simply unaffected by the vaccination programs. Underscoring this conclusion was a recent World Health Organization report which found that the disease and mortality rates in third world countries have no direct correlation with immunization procedures or medical treatment, but are closely related to the standard of hygiene and diet. [27] Credit given to vaccinations for our current disease incidence has simply been grossly exaggerated, if not outright misplaced.

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COMMENTARY BY DR HORWITZ
True, improved sanitation and hygienic practices have done a great deal for prevention of disease in the modern world. Epidemics, however, are 'Epidemics'- a temporary rise in the rate of prevalence of a disease. Epidemics come, and go- often with and without vaccines. However the decline in Polio and Small Pox has been to a level below the "base line" level of the disease's prevalence. In the case of Small Pox, it has been eradicated. That level of decreased prevalence certainly would not and could not have happened without the vaccine. Polio, too, has been virtually eliminated from the globe with the exception of one continent.
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Vaccine advocates point to incidence statistics rather than mortality as proof of vaccine effectiveness. However, statisticians tell us that mortality statistics can be a better measure of incidence than the incidence figures themselves, for the simple reason that the quality of reporting and record-keeping is much higher on fatalities.[28] For instance, a recent survey in New York City revealed that only 3.2% of pediatricians were actually reporting measles cases to the health department. In 1974, the CDC determined that there were 36 cases of measles in Georgia, while the Georgia State Surveillance System reported 660 cases.[29] In 1982, Maryland state health of ficials blamed a pe~tussis epidemic on a television program, "D.P.T.--Vaccine Roulette," which warned of the dangers of DPT; however, when former top virologist for the U.S. Division of Biological Standards, Dr. J. Anthony Moms, analyzed the 41 cases, only 5 were confined, and all had been vaccinated. [30] Such instances as these demonstrate the fallacy of incidence figures, yet vaccine advocates tend to rely on them indiscriminately.

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COMMENTARY BY DR HORWITZ
Most cases of most of the diseases we immunize against do NOT result in mortality if untreated. For that reason, mortality statistics target exceptions, such as indigent people, those with other concurrent illnesses, and do NOT give an accurate measure of the amount of the disease in the community. Incidence statistics (the number of reported cases) are the best figures available despite the author's claims to the contrary. Also, any test performed in a hospital or reference laboratory that is positive for one of these diseases is automatically reported to the Health Department- without question and automatically. Since none of the tests for these diseases are performed in physician of lice laboratories, there is really no chance that a significant number of documented cases will go unreported!
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VACCINATION TRUTH #3:

"It is unclear what impact vaccines had on the infectious disease declines that occurred throughout this century."

VACCINATION MYTH #4:

"Vaccination is based on sound immunization theory and practice..." ...or is it?

The clinical evidence for vaccinations is their ability to stimulate antibody production in the
recipient, a fact which is not disputed. What is not clear, however, is whether or not such antibody production constitutes immunity. For example, agamma globulin-anemic children are incapable of producing antibodies, yet they recover from infectious diseases almost as quickly as other children.[31]

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COMMENTARY BY DR HORWITZ
The author is taking a fact out of context and only telling past of the truth. Children with Agamaglobulinemia often do remain asymptomatic until later in childhood dispite the lack of antibodies. On the other hand, many of them die of overwhelming infection at a very early age. The human immune system is extremely complicated and has many distinct components that perform different jobs and fight different kinds of infections. Agamaglobulinemics (persons with no antibodies) often die from viral infections. Patients with no T Lymphocytes often die of fungal infections (as seen in AIDS). People with no phagocytes often die from bacterial infections.
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Furthermore, a study Published by the British Medical Council in 1950 during a diphtheria epidemic concluded that there was no relationship between antibody count and disease incidence; researchers found resistant people with extremely low antibody counts and sick people with high counts. [32] Natural immunization is a complex phenomenon involving many organs and systems; it cannot be fully replicated by the artificial stimulation of antibody production.

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COMMENTARY BY DR HORWITZ
True. The height of the antibody count (the absolute amount of an antibody to a given infectious agent) in the body is NOT related to 'how good' the protection is. However, a lack of antibody count, or a sufficiently low level of antibody IS predictive of susceptibility to infection to a given organism, and a level over certain proven thresholds most often provides immunity to infection.
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Research also indicates that vaccination commits immune cells to the specific antigens involved in the vaccine, rendering them incapable of reacting to other infections. Our immunological reserve may thus actually be reduced, causing a generally lowered resistance. [33]

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COMMENTARY BY DR HORWITZ
Fortunately for us, our immune system has an astronomical number of B lymphocytes. A number which is far greater than the number of known infections that exist. We won't run out. Furthermore, exposure to a vaccine, or any infection, does not magically change a B lymphocyte and commit it to fighting only a certain infection. Each B lymphocyte has a 'hot spot' on it that can bind to a certain antigen. This is programmed before birth even. When that lymphocyte comes in contact with an antigen that matches up with its Not spot' it then transforms and starts producing antibody. In other words, if a lymphocyte responds to the Polio vaccine and starts producing antibodies, it probably is NOT the one that was going to protect you from AIDS or the flu.
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Another component of immunization theory is "herd immunity," which states that when
enough people in a community are immunized, all are protected. As Myth #2 revealed, there are many documented instances showing just the opposite--fully vaccinated populations do contract diseases; with measles, this actually seems to be the direct result of high vaccination rates.[19]

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COMMENTARY BY DR HORWITZ
No, the goal of "Herd immunity" is Eradication. That is why we don't have Small Pox any more. By immunizing the 'Herd', we have eradicated the virus- it no longer exists on the planatein the wild.
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A Minnesota state epidemiologist concluded that the Hib vaccine increases the risk of illness when a study revealed that vaccinated children were five times more likely to contract meningitis than unvaccinated children.

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COMMENTARY BY DR HORWITZ
This is sheer fantasy! It is well know that the Hib vaccine has made Hemophilus Influenzae meningitis almost disappear. To quote the Red Book, published by the American Academy of Pediatrics Committee on Infectious Diseases "Since 1988 when Hib conjugate vaccines were introduced, the incidence of invasive Hib disease has declined by 95% in infants and young children." Hib will be eradicated.. When I was a Pediatric resident, all winter long I watched infants die of Meningitis caused by Hib infections. Now, fortunately, that is a rarity.
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Carefully selected epidemiological studies are yet another justification for vaccination programs. However, many of these may not be legitimate sources from which to draw conclusions about vaccine effectiveness. For example, if 100 people are vaccinated and 5 contract the disease, the vaccine is declared to be 95% effective. But if only 10 of the 100 were actually exposed to the disease, then the vaccine was really only 50% effective. Since no one is willing to directly expose an entire population to disease--even a fully vaccinated one--vaccine effectiveness rates may not indicate a vaccine's true effectiveness.

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COMMENTARY BY DR HORWITZ
Fortunately, the epidemiological studies that the CDC relies upon take into account the prevalence of the disease (how much of the disease is out there to be exposed to), attack rate, (how likely a non-immune person is to be infected if exposed to the disease), and host immunity (what portion of the population is protected from the disease). Note that the author does not cite any examples of flawed studies.
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Yet another surprising concern about immunization practice is its assumption that all children, regardless of age, are virtually He same. An ~ pound 2 month old receives the same dosage as a 40 pound five year old. Infants with immature, undeveloped immune systems may receive five or more times the dosage (relative to body weight) as older children. Furthermore, the number of "units" within doses has been found upon random testing to range from 1/2 to 3 times what the label indicates; manufacturing quality controls appear to tolerate a rather large margin of error. "Hot Lots"--vaccine lots with disproportionately high death and disability rates--have been identified repeatedly by the NVIC, but the FDA refuses to intervene to prevent further unnecessary injury and deaths. In fact, they have never recalled a vaccine lot due to adverse reactions. Some would call this infanticide
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COMMENTARY BY DR HORWITZ
To a great extent, the actual dose of vaccine given is not critical, so long as enough is present to provoke an immune response. There is no known danger to receiving 2, 5, or 10 times as much vaccine in a given shot. As for Hot Lots, "the FDA has the legal authority to immediately recall any suspicious lot. The FDA inspects vaccine manufacturing facilities regularly to ensure adherence to manufacturing procedures and testing regulations. The FDA also reviews the weekly VA~ERS reports for each lot searching for unusual patterns. There is no benefit to the IDA or the manufacturer in allowing unsafe vaccine to remain on the market. The American public would not tolerate vaccines if they did not have to conform to the most rigorous safety standards."
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Finally, vaccination practice assumes that all recipients, regardless of race, culture, diet, geographic location, or any other circumstances, will respond the same. This was perhaps never more dramatically disproved than an instance a few years ago in Australia's Northern Territory, where stepped-up immunization campaigns resulted in an incredible *50%* infant mortality rate in the native aborigines.[34] Researcher A. Kalokerinos, M.D. discovered that the aborigine's vitamin C deficient "junk food" diet (imposed on them by white society) was a critical factor (studies had already shown that vaccination depletes vitamin C reserves; children in shock or collapse often recovered in a matter of minutes when given vitamin C injections). He considered it amazing that as many survived as did. One must wonder about the lives of the survivors, though, for if half died, surely the other half did not escape unaffected.

**********************
COMMENTARY BY DR HORWITZ
I am not sure where the author is going with this. Dr Kalokerinos' research was interested in SIDS, and the role Vitamin C played in treating anaphylactic shock occurring after immunization. If these statistics are true, they are certainly unfortunate, but they have no clear bearing on the effect of immunization of American children.
**********************

Almost as troubling was a very recent study in the New England Journal of Medicine which revealed that a substantial number of Romanian children were contracting polio from the vaccine, a less common phenomena in most developed countries. Correlations with injections of antibiotics were found: a single injection within one month of vaccination raised the risk of polio 8 times, 2 to 9 injections raised the risk 27-fold, and 10 or more injections raised the risk 182 times [Washington Post, February 22, 1995].

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COMMENTARY BY DR HORWITZ
The actual report and editorial appeared in The New England Journal on February 23, 1995, Vol. 332, No. 8. Dr. Strebel, et al, did show through a well accepted study that those children clearly had a higher rate of Polio when a live OPV dose was followed by an intramuscular antibiotic injection within the following 30 days. If I lived in Romania, I would worry a great deal about this issue in my child. A few issues remain. In the US and Western Europe this phenomenon has not been found at all. The Romanian children receive their first live Polio dose at a much later age than ours (typically at 7 months), when maternal polio antibodies which have crossed the placenta have lost their effect, perhaps increasing their susceptibility to the vaccine. Second, There was documented wild polio in the region actively circulating at that same time. Finally, paralysis that may have been due to Sciatic nerve injury (injuries from the needle stick itself) was not adequately ruled out. Finally, American children are now getting 2 doses of DEAD Polio vaccine first, before getting live OPV for the last 2 doses. This gives them some immunity before exposure to the live vaccine, giving them further protection.
**********************
What other factors not accounted for in vaccination theory will surface unexpectedly to reveal unforeseen or previously overlooked consequences? We will not begin to fully comprehend the scope of this danger until researchers begin looking and reporting in earnest. In the meantime, entire countries' populations are unwitting gamblers in a game that many might very well choose not to play if they were given all the "rules" in advance.

VACCINATION TRUTH #4:

"Many of the assumptions upon which immunization theory and practice are based have been proven false in their application."

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COMMENTARY BY DR HORWITZ
That is exactly why vaccination recommendations change very frequently. To avoid injury due to incorrect information.

VACCINATION MYTH #5:

"Childhood diseases are extremely dangerous..." ...or are they, really?

Most childhood infectious diseases have few serious consequences in today's modern world. Even conservative CDC statistics for pertussis during 1992-94 indicate a 99.8% recovery rate. In fact, when hundreds of pertussis cases occurred in Ohio and Chicago in the fall 1993 outbreak, an infectious disease expert from Cincinnati Children's Hospital said, "The disease was very mild, no one died, and no one went to the intensive care unit."

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COMMENTARY BY DR HORWITZ
On a local note, I have taken care of at least 5 babies with Pertussis in the past 8 years, all of which were hospitalized, and at least two were transferred to the intensive care unit. During my training, I watched one baby die with Pertussis.
**********************

The vast majority of the time, childhood infectious diseases are benign and self-limiting. They also may impart lifelong immunity, whereas vaccine-induced immunity is only temporary. In fact, the temporary nature of vaccine immunity can create a more dangerous situation in a child's future. For example, the new chicken pox vaccine has an effectiveness estimated at 6 - 10 years. If effective, it will postpone the child's vulnerability until adulthood, when death from the disease is 20 times more likely.

I don't know where the author gets his information about the Varicella Vaccine, but all the available literature indicates that the vaccine will give life-long immunity. There is no entrant recommendation for booster doses in adulthood. Certainly, if the vaccine were ever found to 'wear off' after time, a booster dose could then be given to prevent adult Chicken Pox.
**********************

About half of measles cases in the late 1980's resurgence were in adolescents and adults,most of whom were vaccinated as children,[35] and the recommended booster shots may provide protection for less than 6 months.[36] Furthermore, some healthcare professionals are concerned that the virus from the chicken pox vaccine may "reactivate later in life in the form of herpes poster (shingles) or other immune system disorders." [37] Dr. A. Lavin of the Dept. of Pediatrics, St. Luke's Medical Center in Cleveland, Ohio, strongly opposed licensing the new vaccine, "Until we actually know...the risks involved in injecting mutated DNA [herpes virus] Into the host genome [children]."[38] The truth is, *no one* knows, but the vaccine is now licensed and recommended by health authorities.

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COMMENTARY BY DR HORWITZ
Because of the 1980's measles outbreaks, the recommendation for giving a second dose at age: 5 evolved. Reliable studies disagree with the author's citation of "protection for less than 6 months". As for the claims about the Chicken Pox vaccine, this is sheer speculation at best.
**********************
Not only are most infectious diseases rarely dangerous, but they can actually play a vital role in the development of a strong, healthy immune system. Persons who have not had measles have a higher incidence of certain skin diseases, degenerative diseases of bone and cartilage, and certain tumors, while absence of mumps has been linked to higher risks of ovarian cancer.

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COMMENTARY BY DR HORWITZ
Again, the author confuses speculation of a relationship between '`absence of mumps" and "higher risks of ovarian cancer" with proven fact. There simply are no well designed studies that have shown truth to any of these claims.
**********************

VACCINATION TRUTH #5:

"Dangers of childhood diseases are greatly exaggerated in order to scare parents into compliance with a questionable but profitable procedure."

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COMMENTARY BY DR HORWITZ
Vaccination certainly is not profitable in my office. We have absolutely nothing to gain financially by immunizing children. In addition, if they work and do what I and most other professionals believe they do, I am "putting myself out of business" by immunizing children.
**********************

VACCINATION MYTH #6:

"Polio was one of the clearly great vaccination success stories..." ...or was it?

Six New England states reported increases in polio one year after the Salk vaccine was introduced, ranging from more than doubling in Vermont to Massachusetts' astounding increase of 642%. In 1959, 77.5% of Massachusetts' paralytic cases had received 3 doses of IPV (injected polio vaccine). During 1962 U.S. Congressional hearings, Dr. Bernard Greenberg, head of the Dept. of Biostatistics for the University of North Carolina School of Public Health, testified that not only did the cases of polio increase substantially after mandatory vaccinations (50% increase from 1957 to 1958, 80% increase from 1958 to 1959), but that the statistics were manipulated by the Public Health Service to give the opposite impression.[39]

According to researcher-author Dr. Viera Scheibner, 90% of polio cases were eliminated from statistics by health authorities' redefinition of the disease when the vaccine was introduced, while in reality the Salk vaccine was continuing to cause paralytic polio in several countries at a time when there were no epidemics being caused by the wild virus. (For example, in the U.S., thousands of cases of viral and aseptic meningitis are reported each year--these were routinely diagnosed as polio before the Saulk vaccine; the number of cases needed to declare an epidemic was raised from 20 to 35; and the requirement for inclusion in paralysis statistics was changed from symptoms for 24 hours to symptoms for over 60 days; it is no wonder that polio decreased radically after vaccines--at least on paper.) In 1985, the CDC reported that 87% of the cases of polio in the U.S. between 1973 and 1983 were caused by the vaccine, and later declared that all but a few imported cases since were caused by the vaccine--and most of the imported cases occurred in fully immunized individuals.

Jonas Salk, inventor of the IPV, testified before a Senate subcommittee that nearly all polio outbreaks since 1961 were caused by the oral polio vaccine. At a workshop on polio vaccines sponsored by the Institute of Medicine and the Centers for Disease Control and Prevention, Dr. Samuel Katz of Duke University cited the estimated 8-10 annual U.S. cases of vaccine-associated paralytic polio (VAPP) in people who have taken the oral polio vaccine, and the [four year] absence of wild polio from the western hemisphere. Jessica Scheer of the National Rehabilitation Hospital Research Center in Washington, D.C., pointed out that most parents are unaware that polio vaccination in this country entails "a small number of human sacrifices each year." Compounding this contradiction are low adverse event reporting and the NVIC's experiences with confining and correcting misdiagnoses of vaccine reactions, which suggest that the actual number of VAPP "sacrifices" may be many times higher than the number cited by the CDC.

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COMMENTARY BY DR HORWITZ
Polio, and Polio immunization is a very complicated story. In preparation for the trials of the
IPV (dead Polio Vaccine), the definitions of Polio infection had to be revise, to facilitate
accurate reporting and surveillance. This, and increased reporting accounts for some of the
author's statistics. To avoid a long winded debate about the actual effectiveness of the Polio
Vaccines, it should suffice that Polio has all but disappeared from the globe with the
exception of the African continent. That did NOT occur by natural remission of the disease.Polio vaccine works. True, there are children injured by live Polio vaccine, but with the current regimen (giving dead vaccine for the first 2 doses) that risk should be minimized and practically absent for American children. And, if we can continue this important vaccination program, Polio can be Eradicated from the Globe in a few years and then we won't have to give the vaccine any more- just like Small Pox. "
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VACCINATION TRUTH #6:

"Vaccines caused substantial increases in polio after years of steady declines, and they are the sole cause of polio in the U.S. today."

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COMMENTARY BY DR HORWITZ
Perhaps in the US, but not the World. In other parts of the world, Polio is very real, and very crippling. Again, this problem will be practically eliminated with the new immunization regimen.
**********************

VACCINATION MYTH #7:

"My child had no short-term reaction to vaccination, so there is nothing to worry about..." ...or is there?

The documented long term adverse effects of vaccines include chronic immunological and neurological disorders such as autism, hyperactivity, attention deficit disorders, dyslexia, allergies, cancer, and other conditions, many of which barely existed 30 years ago before mass vaccination programs. Vaccine components include known carcinogens such as thimersol, aluminum phosphate, and formaldehyde (the Poisons Information Centre in Australia claims there is no acceptable safe amount of formaldehyde which can be injected into a living human body).

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COMMENTARY BY DR HORWITZ
Again, the author confuses 'reported adverse effects' with 'proven' adverse effects. There simply is no proof what so ever that any of the above illnesses have been linked to immllni7~tions.
**********************

Medical historian, researcher and author Harris Coulter, Ph.D. explained that his extensive research revealed childhood immunization to be "...causing a low-grade encephalitis in infants on a much wider scale than public health authorities were willing to admit, about 15-20% of all children." He points out that the sequelae [conditions known to result from a disease] of encephalitis [inflammation of the brain, a known side-effect of vaccination]: autism, learning disabilities, minimal and not-so-minimal brain damage, seizures, epilepsy, sleeping and eating disorders, sexual disorders, asthma, crib death, diabetes, obesity, and impulsive violence are precisely the disorders which afflict contemporary society. Many of these conditions were formerly relatively rare, but they have become more common as childhood vaccination programs have expanded. Coulter also points out that "...pertussis toxoid is used to create encephalitis inlab animals."

A German study found correlations between vaccinations and 22 neurological conditions including attention deficit and epilepsy. The dilemma is that viral elements in vaccines may persist and mutate in the human body for years, with unknown consequences. Millions of children are partaking in an enormous, crude experiment; and no sincere, organized effort is being made by the medical community to track the negative side-effects or to determine the long term consequences.

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COMMMENTARY BY DR HORWITZ
Harris L. Coulter, PhD, has been an outspoken critic of immunizations as a cause of most every blight on society. Unfortunately, the studies he uses to support his positions are old ( 10 years old), and he misquotes them. The bottom line is, many neurological illness such as epilepsy, autism, and cerebral palsy are detected during infancy, and the times that they would be detected is at the very same check up visits when immunizations are given. Of course there will be a clustering of detection dates with immunization dates.
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VACCINATION TRUTH #7:

"The long term adverse effects of vaccinations have been virtually ignored, in spite of direct correlations with many chronic conditions. "

*********************
COMMENTARY BY DR HORWITZ

Again, note the use of the words 'correlations with' rather than 'causes of' many chronic conditions.
VACCINATION MYTH #8:

"Vaccines are the only disease prevention option available..." ...or are they?

Most parents feel compelled to take some disease-preventing action for their children. While there is no 100% guarantee anywhere, there are viable alternatives. Historically, homeopathy has been more effective than "mainstream" allopathic medicine in treating and preventing disease. In a U.S. cholera outbreak in 1849, allopathic medicine saw a 48-60% death rate, while homeopathic hospitals had a documented death rate of only 3%.[40] Roughly similar statistics still hold true for cholera today.[41] Recent epidemiological studies show homeopathic remedies as equaling or surpassing standard vaccinations in preventing disease. There are reports in which populations that were treated homeopathically after exposure had a 100% success rate--none of the treated caught the disease.[42]

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COMMENTARY BY DR HORWITZ
Homeopathic treatment may work for cholera, but not for Polio. Cholera can be prevented by sanitary hygiene controls (that is why we don't have it in the USA). Even the author does not specifically say which diseases have been prevented with homeopathic prevention.
**********************

There are homeopathic kits available for disease prevention. [43] Homeopathic remedies can also be taken only during times of increased risk (outbreaks, traveling, etc.), and have proven highly effective in such instances. And since these remedies have no toxic components, they have no side effects. In addition, homeopathy has been effective in reversing some of the disability caused by vaccine reactions, as well as many other chronic conditions with which allopathic medicine has had little success.

VACCINATION TRUTH #8:

"Documented safe and effective alternatives to vaccination have been available for decades but suppressed by the medical establishment."

The medical establishment does not suppress alternative treatments. Practitioners such as myself who are not well educated in alternative treatments will often shy away from them for fear of harming our patients. Feel free to ask your doctor to 'read-up' on a treatment that you are interest in that he may not be familiar with.

VACCINATION MYTH #9:

"Vaccinations are legally mandated, and thus unavoidable..." ...or are they?

There are three exemption possibilities in the U.S.:

1) Medical Exemption: All 50 states in the U.S. allow for a medical exemption. A few states allow licensed naturopathic or chiropractic doctors to issue medical exemptions in addition to medical doctors. However, few pediatricians check for indications of increased risk before administering vaccines, so it is advisable for parents to research this matter for themselves. Epilepsy, severe allergies, and siblings' previous adverse reactions are but a few of the many conditions in child or family history which may increase the chances of an adverse reaction, and thus qualify for a medical exemption;

2) Religious Exemption: Nearly all states allow for a religious exemption. This may or may not require membership in an established religious organization, as individual state laws vary; and

3) Philosophical or Personal Exemption: An increasing number of states allow one of these exemptions, in recognition of the controversy and/or violation of freedom that mandated vaccination laws impose.

Generally, exempted children may not be banned from attending public schools and colleges except during local outbreaks. It is best to contact local school officials in advance to determine their particular procedure for handling exemptions.

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COMMENTARY BY DR HORWITZ
The best source for a copy of your state's vaccination laws is state health of finials or your public library. A phone call to the state Department of Epidemiology may be all that it takes to get a copy mailed to you.
**********************

VACCINATION TRUTH #9:

"Legal exemptions from vaccinations are obtainable for most--but not all--U.S. citizens."

VACCINATION MYTH #10:

"Public health officials always place health above all other concerns..." ...or do they?

Vaccination history is riddled with documented instances of deceit designed to portray vaccines as mighty disease conquerors, when in fact many times they have actually delayed and even reversed disease declines. The United Kingdom's Department of Health admitted that vaccination status determined the diagnosis of subsequent diseases: Those found in vaccinated patients received alternate diagnoses; hospital records and death certificates were falsified. Today, many doctors are still reluctant to diagnose diseases in vaccinated children, and so the "Myth" about vaccine success continues.

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COMMENTARY BY DR HORWITZ
There simply is no reason why a practicing physician would be pressured to, or reluctant to diagnose a patient with a vaccine-preventable illness. There is no earthly reason for this claim today.
**********************

However, individual doctors may not be wholly to blame. As medical students, few have reason to question the information taught (which does not address the information presented in this report). Ironically, medicine is a field which demands conformity; there is little tolerance for opinions opposing the status quo. Doctors cannot warn you about what they themselves do not know, and with little time for further education once they begin practice, they are, in a sense, held captive by a system which discourages them from acquiring information independently and forming their own opinions. Those few that dare to question the status quo are frequently ostracized, and in any case, they are still legally bound to adhere to the system's legal mandates.

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COMMENTARY BY DR HORWITZ
True. As a student most doctors receive little information about alternative treatments. However, contrary to the authors claim, physicians not only do learn after their training, they are required to do so- typically 50 hours each year of continuing medical education (CME). I learn every day. Furthermore, I feel no pressure to avoid alternatives from either my peers, my partners, or my hospital.
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SUMMARY

In the December 1994 Medical Post, Canadian author of the best-seller "Medical Mafia," Guylaine Lanctot, M.D. stated, "The medical authorities keep lying. Vaccination has been a disaster on the immune system. It actually causes a lot of illnesses. We are actually changing our genetic code through vaccination... 10 years from now we will know that the biggest crime against humanity was vaccines." After an extensive study of the medical literature on vaccination, Dr. VieraScheibner concluded that "there is no evidence whatsoever of the ability of vaccines to prevent any diseases. To the contrary, there is a great wealth of evidence that they cause serious side effects." John B. Classen, M.D., M.B.A. has stated, "My data proves that the studies used to support immunization are so flawed that it is impossible to say if immunization provides a net benefit to anyone or to society in general. This question can only be determined by proper studies which have never been performed. The flaw of previous studies is that there was no long term follow up and chronic toxicity was not looked at. The American Society of Microbiology has promoted my research...and thus acknowledges the need for proper studies." To some these may seem like radical positions, but they are not unfounded. The continued denial of the evidence against vaccines only perpetuates the "Myths" and their negative consequences on our children and society. Aggressive and comprehensive scientific investigation is clearly warranted, yet immunization programs continue to expand in the absence of such research. Manufacturer profits are guaranteed, while accountability for the negative effects is conspicuously absent. This is especially sad given the readily available safe and effective alternatives.

Meanwhile, the race is on. According to the NVIC, there are over 250 new vaccines being developed for everything from earaches to birth control to diarrhea, with about 100 of these already in clinical trials. Researchers are working on vaccine delivery through nasal sprays, mosquitoes (yes, mosquitoes), and the fruits of "transgenic" plants in which vaccine viruses are grown. With every child (and adult, for that matter) on the planet a potential required recipient of multiple doses, and every healthcare system and government a potential buyer, it is little wonder that countless millions of dollars are spent nurturing the growing multi-billion dollar vaccine industry. Without public outcry, we will see more and more new vaccines required of us and our children. And while profits are readily calculable, the real human costs are being ignored.

Whatever your personal vaccination decision, make it an informed one; you have that right and responsibility. It is a difficult issue, but there is more than enough at stake to justify whatever time and energy it takes.

INFORMATION SOURCES:

(1) National Technical Information Service, Springfield, VA 22161, 703-487-4650,
703-487-4600.
(2) Reported by KM Severyn,R.Ph.,Ph.D. in the Dayton Daily News, May 28, 1993. (Ohio
Parents for Vaccine Safety, 251 Ridgeway Dr., Dayton, OH 45459)
(3) National Vaccine Information Center (NVIC), 512 Maple Ave. W. #206, Vienna, VA 22180,
703-938-0342; "Investigative Report on the Vaccine Adverse Event Reporting System."
(4) Viera Scheibner, Ph.D., Vaccination: 100 Years of Orthodox Research Shows that Vaccines
Represent a Medical Assault on the Immune System.
(5) W.C. Torch, "Diptheria-pertussis-tetanus (DPT) immunization: A potential cause of the
sudden infant death syndrome (SIDS)," (Amer. Adacemy of Neurology, 34th Annual Meeting,
Apr 25 - May 1, 1982), Neurology 32(4), pt. 2.
(6) Confounding in studies of adverse reactions to vaccines [see comments]. Fine PE, Chen RT,
REVIEW
ARTICLE: 38 REPS. Comment in: Am J Epidemiol 1994 Jan 15;139(2):229-30. Division of
Immunization, Centers for Disease Control, Atlanta, GA 30333.
(7) Nature and Rates of Adverse Reactions Associated with DTP and DT Immunizations in
Infants and Children" (Pediatrics, Nov. 1981, Vol. 68, No. 5)
(8) The Fresno Bee, Community Relations, 1626 E. Street, Fresno, CA 93786, DPT Report,
December 5, 1984.
(9) Trollfors B. Rabo, E. 1981. Whooping cough in adults. British Medical Journal (September
12), 696-97.

(10) National Vaccine Injury Compensation Program (NVICP), Health Resources and Services
Administration,
Parklawn Building, Room 7-90, 5600 Fishers Lane, Rockville, MD 20857, 800-338-2382.
(11) Measles vaccine failures: lack of sustained measles specific immunoglobulin G responses in
revaccinated adolescents and young adults. Department of Pediatrics, Georgetown University
Medical Center, Washington, DC 20007. Pediatric Infectious Disease Journal. 13(1):34-8, 1994
Jan.
(12) Measles outbreak in 31 schools: risk factors for vaccine failure and evaluation of a selective
revaccination strategy. Department of Preventive Medicine and Biostatistics, University of
Toronto, Ont. Canadian Medical Association Journal. 150(7): 1093-8, 1994 Apr 1.
(13) Haemophilus b disease after vaccination with Haemophilus b polysaccharide or conjugate
vaccine. Institution Division of Bacterial Products, Center for Biologics Evaluation and
Research, Food and Drug Administration, Bethesda, Md 20892. American Journal of Diseases of
Children. 145(12):1379-82, 1991 Dec.
(14) Sustained transmission of mumps in a highly vaccinated population: assessment of primary
vaccine failure and waning vaccine-induced immunity. Division of Field Epidemiology, Centers
for Disease Control and Prevention, Atlanta, Georgia. Journal of Infectious Diseases.
169(1):77-82, 1994 Jan. 1.
(15) Secondary measles vaccine failure in healthcare workers exposed to infected patients.
Department of Pediatrics, Children's Hospital of Philadelphia, PA 19104. Infection Control &
Hospital Epidemiology. 14(2):81 -6, 1993 Feb.
(16) MMWR, 38 (8-9), 12129189).
(17) MMWR (Morbidity and Mortality Weekly Report) "Measles." 989; 38:329-330.
(18) Morbidity and Mortality Weekly Report (MMWR). 33(24), 6122184.
(19) Failure to reach the goal of measles elimination. Apparent paradox of measles infections in
immunized persons. Review article: 50 REFS. Dept. of Internal Medicine, Mayo Vaccine
Research Group, Mayo Clinic and Foundation, Rochester, MN. Archives of Internal Medicine.
154(16):1815-20, 1994 Aug 22.
(19a) Clinical Tmmunology and Immunopathology, May 1996; 79(2): 163-170.
(20) Trevor Gunn, Mass Immunization, A Point in Question, p 15 (E.D. Hume, Pasteur
Exposed-The False
Foundations of Modern Medicine, Bookreal, Australia, 1989.)
(21) Physician William Howard Hay's address of June 25, 1937; printed in the Congressional
Record.
(22) Outbreak of paralytic poliomyelitis in Oman; evidence for widespread transmission among
fully vaccinated children Lancet vol 338: Sept 21, 1991; 715-720.
(23) Neil Miller, Vaccines: Are They Safe and Effective? p 33.
(24) Chicago Dept. of Health.
(25) See Note 23 pp 18-40.
(26) See Note 23 pp 45,46 [NVIC News, April 92, pl2].
(27) S. Curtis, A Handbook of Homeopathic Alternatives to Immunization.
(28) Darrell Huff, How to Lie With Statistics, p 84.
(29) quoted from the internet, credited to Keith Block, M.D., a family physician from Evarlston,
Illinois, who has spent years collecting data in the medical literature on immunizations.
(30) See Note 20, p 15.

(31) See Note 20 p 21.
(32) See Note 20, p 21 (British Medical Council Publication 272, May 1950)
(33) See Note 20, p 21; also Note 23 p 47 (Buttram, MD, Hoffman, Mothering Magazine,
Winter 1985 p 30;
Kalokerinos and Dettman, MDs, "The Dangers of Immunization," Biological Research Inst.
[Australia], 1979, p 49).
(34) Archie Kalolerinos, MD, Every Second Child, Keats Publishing, Inc. 1981
(35) Reported by KM Severyn,R.Ph,Ph.D. in the Dayton Daily News, June 3, 1995.
(36) Vaccine Information and Awareness, "Measles and Antibody Titre Levels," from Vaccine
Weekly, January 1996.
(37) NVIC Press Release, "Consumer Group Warns use of New Chicken Pox Vaccine in all
Healthy Children May Cause More Serious Disease".
(38) See note 35 (quoted from The Lancet)
(39) Hearings before the Committee on Interstate and Foreign Commerce, House of
Representatives, 87th Congress, Second Session on H.R. 10541, May 1962, p.94.
(40) Ullman, Discovering Homeopathy, p 42 (Thomas L. Bradford, Logic Figures, p68,
113-146; Coulter, Divided Legacy, Vol 3, p268).
(41) See Note 27.
(42) See Note 27.
(43) Golden, Isaac, Vaccination? A Review of Risks and Alternatives.