Children Health Wizard

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By Jonathan J. Cooper
/ The Associated Press

Published: April 14. 2012 4:00AM PST

SALEM — Lab tests confirmed that four children under the age of 15 have contracted E. coli linked to raw milk from a small Oregon farm, state health officials said Friday.

Three of the Oregon children have been hospitalized, officials said, two of them with kidney failure, and Foundation Farm near Wilsonville has voluntarily stopped distributing milk. Health officials said 11 other customers of the dairy are reporting recent diarrhea and other symptoms typical of E. coli.

Federal regulations outlaw interstate sales of raw milk, but 30 states allow it to be sold within their borders. Oregon law prohibits retail sales, along with other restrictions, but allows on-farm sales.

State officials say Foundation Farm distributed to 48 households that were part of a “herd share” — an arrangement in which people own a portion of a herd of cows. The Associated Press left a message at a Foundation Farm phone number listed on state corporation records.

Public health officials have long battled with raw milk advocates over safety and health benefits.

“Raw milk can carry harmful bacteria that can make you very sick or kill you,” said Dr. Katrina Hedberg, the state epidemiologist. “Pasteurized milk has many health benefits. Raw milk is not any healthier than pasteurized milk and can carry illness-causing bacteria.”

The federal Centers for Disease Control and Prevention warns that raw milk can be contaminated with listeria, salmonella and other bacteria. Unpasteurized milk from a Pennsylvania farm was linked to more than 40 illnesses in four states earlier this year, and three children were hospitalized with E. coli linked to raw milk in California last year.

Investigators are still awaiting test results from samples taken from the farm but have not found any other food common to the patients that could be a source of the E. coli, Hedberg said.

Pasteurized milk is heated to kill bacteria. Raw milk drinkers say the process also kills bacteria beneficial to human health. Some say they want to be sure they’re drinking milk from cows fed grass and not treated with antibiotics or hormones. Advocates point out that traditional food supplies aren’t immune from pathogens that sometimes contaminate fruits, vegetables and meats.

“We believe that people should be able to choose what they eat, and that it is not the government’s role to tell us what we can and cannot eat,” said Michele Knaus, director of Friends of Family Farmers, an Oregon-based advocacy group for small farmers. “We do not believe that access to raw milk should be eliminated, and are saddened by this singular episode.”

More than 60 Oregon farms are listed as raw milk producers on a website maintained by the Weston A. Price Foundation, which promotes the consumption of “nutrient dense” foods.

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Two things most stood out for me in Kaitlin Bell Barnett’s new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI’s, started in early adolescence, when they decide to get pregnant. The second is Bell Barnett’s review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:

Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.

Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett’s book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled “Side Effects.” Here are a few sample quotes.

A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn’t mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.

And this important point:

Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.

And this from Elizabeth, who started taking SSRIs in 9th grade:

I am not sure I can [over]state the extent to which it impacted things. I didn’t grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn’t understand back when I didn’t have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a “normal’ way.

There’s more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett’s book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as “Generation Rx.” Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett’s book is a good place to start.

The success of the healthcare reform law’s massive Medicaid expansion could hinge on new regulations that are expected as early as next week.

While the 20 million people who will gain subsidized coverage on the new insurance exchanges have gotten most of the attention, President Obama’s health law also expands Medicaid and the Children’s Health Insurance Program to 17 million low-income families starting in 2014. Medicaid, however, is already straining to care for the more than 58 million already in the program because it doesn’t pay doctors enough to participate.

The law’s expansion “could generate unsustainable pressure on Medicaid’s already taxed network of primary care providers,” the nonprofit Center for Health Care Strategies warned in a report last year.

To alleviate some of the pressure ahead of the law’s expansion, House Democrats included in their version of the bill a provision requiring states to pay primary care physicians no less than 100 percent of Medicare payment rates in 2013 and 2014 for primary care services. The temporary increase would be fully funded by the federal government.

Republicans say the temporary expansion is a “bait and switch” that either hides the true cost of the Medicaid expansion if Congress ends up extending the rate bump indefinitely or promises millions of people coverage that will turn out to be worthless if patients can’t find a doctor.

“There will be calls to extend this after 2014,” a House Republican staffer told The Hill. “And if we extend it, shouldn’t that have been calculated into the overall cost of the bill, or is that just another budget gimmick? And if we don’t extend it, who’s going to take care of the 20 million new Medicaid beneficiaries?”

Even a two-year provision, the Center for Health Care Strategies report concluded, could be beneficial.

“The increased reimbursement,” the report said, “could be a powerful tool for bolstering the delivery system, enhancing access, and improving the quality of primary care for current and new beneficiaries.”

The nonpartisan Congressional Budget Office has estimated that the two-year provision would cost the federal government $8.3 billion. Average Medicaid rates for primary care services were only 66 percent of Medicare rates in 2008, according to the Kaiser Family Foundation, with wide variations among states (New York and Rhode Island Medicaid rates were only 36 percent of Medicare, while Alaska paid rates that were 40 percent higher than Medicare).

The provision could end up costing more than that if the upcoming federal regulation broadens the definition of primary care, however. While congressional intent clearly focused on internists and general practitioners, said a health policy analyst who is tracking the issue, other doctors are lobbying the Department of Health and Human Services to also be covered by the regulation.

“The big fight is over who counts for primary care,” the analyst said. “And what’s happening is you have … all of these specialties saying hey, I’m primary care too, because they want the rate bump too.”

Expanding the primary care definition would cost the federal government more money, the source said, but on the flip side Obama administration regulations so far have largely kept the healthcare industries who supported the law happy.

In any case, it’s not clear regulators have much leeway.

A spokeswoman for the American Congress of Obstetricians and Gynecologists told The Hill the group hasn’t written to the Department of Health and Human Services because “it’s pretty clear who qualifies for the bonus, but we want Congress to amend the statute to get us included.”

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The hacking of Utah’s Medicaid computer records has dreadful implications for the future of health care reform. If patients cannot trust the state to keep their private health and financial information secure, they will be less willing to allow that information to be shared. Yet, in a data-driven industry, that sharing is key to cost containment and better care.

The security breach of Utah’s Medicaid files last month jeopardizes that trust. If the state accidentally allows hackers to get into the private information of an estimated 780,000 patients on Medicaid and the Children’s Health Insurance Program, people are going to think twice before they sign up for any program that shares their private information electronically.

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One such non-Medicaid program is the Clinical Health Information Exchange (cHIE). Late last year the Utah Health Information Network created it to encourage individual patients to allow their health information to be available to multiple providers who treat them. The idea makes good sense because it provides authorized medical professionals a way to share and view patient information. That way a doctor knows a patient’s medical history, medications, tests and treatments that may have been provided by someone else. That gives the doctor a fuller picture of the patient’s health and reduces the need for duplicative tests. It should save money and lead to better care.

The network that sponsors cHIE includes insurers, providers and the Utah state government.

A spokeswoman for cHIE reports that it shut down its connection to the Medicaid database as soon as the Medicaid breach was discovered. In addition, unlike the Medicaid system, the cHIE system includes encryption both when the data is in motion and when it is at rest. Medicaid claims, by contrast, are only encrypted in transit. That may be a violation of federal law that could bring penalties.

There are other implications of the Medicaid breach beyond cHIE. Under the Affordable Care Act — the federal health reform that will go fully operational in 2014 — Medicaid eligibility will be greatly expanded to insure more low-income Americans. That makes strengthened database security even more important because Medicaid will serve more people.

The Medicaid breach has been blamed on human error and, now, on an old system that lacks adequate encryption. All systems are vulnerable to error. People make mistakes. But in terms of trust, this is a particularly costly one.

Copyright 2012 The Salt Lake Tribune. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

Neal Halfon

U.S. News World Report

April 13, 2012

Three of the Oregon children have been hospitalized, officials said, two of them with kidney failure, and Foundation Farm near Wilsonville has voluntarily stopped distributing milk. Health officials say other customers of the dairy are reporting recent diarrhea and other symptoms typical of E. coli.

Federal regulations outlaw interstate sales of raw milk, but 30 states allow it to be sold within their borders. Oregon law prohibits retail sales, along with other restrictions, but allows on-farm sales.

State officials say Foundation Farm distributed to 48 households that were part of a “herd share” — an arrangement in which people own a portion of a herd of cows. The Associated Press left a message at a Foundation Farm phone number listed on state corporation records.

Public health officials have long battled with raw milk advocates over safety and health benefits.

“Raw milk can carry harmful bacteria that can make you very sick or kill you,” said Dr. Katrina Hedberg, the state epidemiologist. “Pasteurized milk has many health benefits. Raw milk is not any healthier than pasteurized milk and can carry illness-causing bacteria.”

The federal Centers for Disease Control and Prevention warns that raw milk can be contaminated with listeria, salmonella and other bacteria. Unpasteurized milk from a Pennsylvania farm was linked to more than 40 illnesses in four states earlier this year, and three children were hospitalized with E. coli linked to raw milk in California last year.

Pasteurized milk is heated to kill bacteria. Raw milk drinkers say the process also kills bacteria beneficial to human health. Some say they want to be sure they’re drinking milk from cows fed grass and not treated with antibiotics or hormones. Advocates point out that traditional food supplies aren’t immune from pathogens that sometimes contaminate fruits, vegetables and meats.

“We believe that people should be able to choose what they eat, and that it is not the government’s role to tell us what we can and cannot eat,” said Michele Knaus, director of Friends of Family Farmers, an Oregon-based advocacy group for small farmers. “We do not believe that access to raw milk should be eliminated, and are saddened by this singular episode.”

More than 60 Oregon farms are listed as raw milk producers on a website maintained by the Weston A. Price Foundation, which promotes the consumption of “nutrient dense” foods.

Careful controls can give raw milk drinkers confidence they won’t get sick, said Chrissie Zaerpoor, who left her job as an engineering manager at Intel to work full-time on safely producing fresh foods on her Yamhill farm. Zaerpoor said she worries every day about the safety of her food. She thoroughly cleans her cows before every milking and regularly tests her animals and their milk, she said.

“We really run our raw dairy in a very controlled way with a lot of testing and validations and strong process control systems,” Zaerpoor said.

A federal judge in Iowa this month threw out a lawsuit challenging the federal ban on interstate sales of raw milk.