In August, for the first time in more than a decade, the American Academy of Pediatrics (AAP) has revised its policy on male circumcision.

The policy is confusing. While we at Performance Pediatrics understand the AAP's desire to support parents no matter what their decision is, not taking a stance one way or the other leaves most parents unsure what to do.

One thing's for sure: By stating that male circumcision can be medically necessary (and not purely religious or elective cosmetic surgery) it ensures that the procedure must be covered by most insurance plans.

That said, we hope parents who elect not to circumcise understand that they also have the support of the medical community in that decision.

It's unclear the impact the statement will have on circumcision rates in the U.S., which have declined from a peak of around 80 percent of baby boys in the 1970s and 1980s, to 55 percent in 2010.

VIDEO form PBS News Hour 8/22/2012: As Whooping Cough Rebounds in U.S., Infants at Greatest Risk

Pertussis is a very serious disease with a high risk of damaging complications. The pertussis vaccine is very safe and effective. Dr. McAllister agrees with the expert recommendations that all children receive a DTaP vaccine at 2-months, 4-months, 6-months, 15-months and 4-years, and all adolescents should receive a Tdap vaccine at 11. In addition any older adolescent or adult who has not had a Tdap vaccine should also get one.

Whooping cough, another name for pertussis, is a very contagious disease caused by the bacteria Bordetella pertussis. It can be serious for anyone, but life-threatening for newborns and infants.

Whooping cough in infants is very concerning because infants suffer the most serious complications. In infants younger than 1 year old who get whooping cough, more than half must be hospitalized. For infants who are hospitalized, 1 out of 5 develops pneumonia (lung infection), and, sadly, about 1 out of 100 dies.

Disease Description
Whooping cough begins like a common cold-runny nose, low-grade fever, and coughing. Unlike the common cold, which lasts 7-10 days, the pertussis cough continues past day 10 and may get worse. For adolescents and for older children, coughing can last up to 10 weeks or more. That's why this disease is called the 100-day cough.

Coughing can come in violent fits. The name "whooping cough" comes from the high-pitched noise-a "whoop"-that infants and children make when they gasp for air after a fit of coughing. Very young infants may not actually cough as the disease gets worse. Instead, they may have hard time breathing, or even stop breathing for short periods. Adolescents and adults usually do not whoop.

Neurologic complications such as seizures and encephal­opathy (a diffuse disorder of the brain) may occur as a result of hypoxia (reduction of oxygen supply) from coughing, or possibly from bacterial toxin. Neurologic complications of pertussis are more common among infants. Other less serious complications of pertussis include otitis media, anorexia, and dehydration. Complications resulting from pressure effects of severe paroxysms include pneumothorax, epistaxis, subdural hematomas, hernias, and rectal prolapse.

Effectiveness of Vaccine
Before the availability of vaccine, pertussis was common among children. During the period from 1940 through 1945, more than 1 million cases of pertussis were reported, an average of 175,000 cases per year (incidence of approximately 150 cases per 100,000 population). Following introduction of whole-cell pertussis vaccine in the 1940s, pertussis incidence gradually declined with 15,000 reported cases in 1960 (approximately 8 per 100,000 population). By 1970, annual incidence was fewer than 5,000 cases per year, and during 1980-1990, an average of 2,900 cases per year were reported (approximately 1 per 100,000 population).

What's concerning is that pertussis incidence has been gradually increasing since the early 1980s. During 2001-2003, the highest average annual pertussis incidence was among infants younger than 1 year of age (55.2 cases per 100,000 population), and particularly among children younger than 6 months of age (98.2 per 100,000 population). In 2002, 24% of all reported cases were in this age group. However, in recent years, adolescents (11-18 years of age) and adults (19 years and older) have accounted for an increasing proportion of cases. In 2004 and 2005, approximately 60% of reported cases were among persons 11 years of age and older. Increased recognition and diagnosis of pertussis in older age groups probably contributed to this increase of reported cases among adolescents and adults.

There are two vaccines available to protect against pertussis, DTaP and Tdap. Both vaccines provide protection against three diseases (diphtheria, tetanus, and pertussis) there are no vaccines which protect only against pertussis. DTaP is approved for children under 7. Tdap, which has a reduced dose of the diphtheria and pertussis vaccines, is approved as a booster for adolescents starting at the age of 11 and adults ages 19 to 64.

Risk of vaccine
All immunizations have a risk of side effects, but most of them are mild and serious side effects are very rare.
The most common side effects are usually mild and occur in about 1 out of 4 children. They include the following:

• Redness, swelling, and pain from the shot
• Fever
• Vomiting 

More serious side effects include:

• Nonstop crying for 3 hours or more occurs in about 1 out of 1,000 children
• Seizures (jerking or staring) occur in about 1 out of 14,000 children; the seizures do not cause long-term harm
• A fever over 105 degrees occurs in about 1 out of 16,000 children 

Severe reactions have been reported but are very rare, less than 1 out of 1,000,000 children. These reactions are so rare it is impossible to tell if they are caused by the vaccine or just occurred coincidentally to the vaccine administration. These reactions include:

• Serious allergic reaction
• Long-term seizures
• Coma, or lowered consciousness
• Permanent brain damage  

Dr. McAllister has a confession to make: He loves video games. Lately, he spends most of his gaming time (no more than 2 hours/day) playing MINE CRAFT, but he has enjoyed a number of different games over the years.

The problem is that Dr. McAllister knows that video games, and screen time in general, can lead to all kinds of health problems. Research published recently from the American Academy of Pediatrics (AAP) has linked  video games to attention problems and have also shown that game addiction can lead to serious mental health problems.

Because of this research, Dr. McAllister firmly stands by the AAP's recommended limit of 2 hours of screen time/day (just ask his 8-year-old son how serious this limit is). That said, there is still the question of how best to use those 2 hours/day.

For Dr. McAllister (and his son) they chose to play games together. Building a trusting relationship is one of the 8 reasons Parents magazine lists for why you should get involved with your child's video game choices.

What is truly exciting, however, is research on measurable health benefits of video games. This past July, the Wall Street Journal ran an article about two companies seeking FDA approval for video games as treatment for ADHD.  A pilot study at Boston Children's Hospital tests an intervention game designed to help kids with anger management. Our current favorite, though, is Jane McGonigal's online Superbetter game where players are given small tasks and tools to get them to their own personal epic health win.

At Performance Pediatrics we are big fans of author and researcher Jane McGonigal. Her bestseller, Reality is Broken, is available in our patient lending library. Ms. McGonigal has two, 20-minute online Ted talks we recommend as well. Her first is about 2 years old and talks about the power of games to make a better world:

Jane McGonigal: Gaming can make a better world

The second talk is from this year and talks specifically about how the Superbetter came to be and how it works:

Jane McGonigal: The game that can give you 10 extra years of life

As excited as we are about the promise of video games, it is so important to remember that there is a limit on the benefit and a very real danger in letting our kids have too much screen time. If needed, you can blame it on us by saying, "Dr. McAllister says 2 hours is limit, now go read a book or play outside. Or, let's play a family board game together." We know that's easy for us to say (we don't have to be there when your kid has a tantrum), but know that we have been there, too.

Be Well!