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Andrew Nowalk, MD, PhD, joins us again for the second part of his interview. In this podcast, he discusses the infectious issues faced by children treated at the Down Syndrome Center at Children’s Hospital and ways to help reduce those risks.
Dr. Vellody: Hello again, everyone, and welcome to the 3rd episode of the Down Syndrome Center podcast. As always, I am your host, Dr. Kishore Vellody. We are pleased in this episode to once again welcome back Dr. Andy Nowalk who is a pediatric infectious diseases physician here at Children’s Hospital of Pittsburgh of UPMC. In the last podcast, we talked about why Dr. Nowalk is so involved in the Down syndrome community as a parent as well as an advocate through the Down Syndrome Association of Pittsburgh. Today, we’re going to explore the infectious issues that Dr. Nowalk deals with in his clinic. We’ll get into some of the reasons why kids with Down syndrome are at increased risk of infections and what can be done to reduce those risks. Hey Andy, thanks again for joining us for this podcast. Can we just jump right in? Can you tell us why kids with Down syndrome seem to get more infections than other kids?
Dr. Nowalk: Sure, the issue of infections in Down syndrome is one certainly, too, that we know about from way back. As soon as people started describing children with Down syndrome, they noted in almost all of the earliest papers, besides heart disease which is one of the really big associations with Down syndrome, that children with Down syndrome got infections all the time. Those reasons are complicated, but we can really put them into two big categories that predispose children with Down syndrome to infection. Number one is the simple anatomy, how they are made, how they come to us. We notice certain features of children with Down syndrome that make them noticeable to your eye immediately. You can pick another child with Down syndrome out of a crowd almost instantly. They have the very, very specific shape to their eyes and the tilt of the lids of the eyes. Their nose tends to be a little flatter in the bridge. In fact, if you really look at them, the whole center of their face is a little flatter and a little less sloped outward than other children. Unfortunately for kids with Down syndrome, what that means is that the bones that make up the middle of the face also are a little bit flatter. Things behind those bones – the nasal passages, the Eustachian tubes – all of the anatomy of the nose and throat and ear area is smaller and tighter. So we’re talking about much smaller and tighter tubes. When they get inflamed and clogged up with a virus, it’s a lot harder for them to drain out. Therefore, children with Down syndrome are easily going to get infections in those areas where another child with more typical anatomy in those areas would not.
Dr. Vellody: I have to say, it’s kind of sad to me that the things that make people with Down syndrome have such distinctive beauty are also the same things that can increase their risk for infections. Can you give us an idea of what types of infections are seen in Down syndrome because of the anatomical issues?
Dr. Nowalk: We see ear infections almost monotonously in the first few years. One of the most frequent introductions of a child with Down syndrome to the medical system is not only the Down Syndrome Center of Pittsburgh but it’s to the Ear, Nose, and Throat division of Children’s Hospital of Pittsburgh. Those children will often end up needing an ear tube to help them out with their frequent ear infections. Later on or coincident with that, those kids get sinus infections all the time. One of the most common reasons for me to see a child with Down syndrome in my clinic is the treatment of recurrent antibiotic resistant sinus infections. I work very frequently with folks in the ENT division and see this quite a bit. All of those come from not necessarily weakness of the immune system but just the way God made those children. We have to deal with the tightness of those connections, and we’re often very successful. Ear tubes will help out the children who get frequent ear infections. With sinus disease, age more than anything else helps them out, but antibiotics can certainly help. We have another bunch of tricks up our sleeve if we need too.
Dr. Vellody: Thanks, Andy. You mentioned that there was possibly some weakness to the immune system in people with Down syndrome? So does their immune system play a role beyond those issues with anatomy that you just explained?
Dr. Nowalk: There are some things in children with Down syndrome that suggests that it’s not just their anatomy that’s not normal. If you look at a child with Down syndrome around this time of year when we have a lot of respiratory viruses running around so everybody has a cold and everybody has a runny nose. Some of those viruses in the first year of life are particularly hard on children. One of those viruses is called RSV. RSV has been studied in children with Down syndrome. If you correct for all of the other things that go on with kids with Down syndrome, especially heart disease, it seems that RSV infection is much more severe in children with Down syndrome. What that points out to us is there is probably some issue with the immune system in children with Down syndrome. When we’ve looked at them in the past, and studies have looked at how they react to vaccines, they seem to react to vaccines a tiny bit less well than other children. We’re not sure if that explains everything that goes on, but there does seem to be some immunology behind this, as we say. Something about the immune system in Down syndrome is a little less good than other children. We’re not discussing an immune problem that’s dramatic where the children have no immune system or like a child who’s getting chemotherapy that can’t react to an infection. But children with Down syndrome do seem to have some trouble handling typical infections when you compare them to other children.
Dr. Vellody: Well, Andy, here’s what I hear from some parents that I see in clinic. They’ve heard from other people or in their own research on the internet that children with Down syndrome have a weaker immune system. So, then they naturally wonder, should we not immunize our child with Down syndrome? After all, if the immune system is weak, aren’t they running a risk by immunizing their children with all these vaccines?
Dr. Nowalk: So I’ve done a lot of thinking about this to try to help with the guideline development in kids with Down syndrome. My point of view when I know your immune system is a little bit off is that I would give you more vaccines rather than less. The question you bring up whether an immune system can’t handle it . . . in actuality we know that children with Down syndrome do react to vaccines. For that matter, because we know that they’re susceptible to these infections, we have even more reasons to vaccinate them not less reasons. When your child has Down syndrome, the first thing you should do is make sure that that vaccine schedule that you get from your pediatrician or family doctor is followed to the letter. We really don’t want to see any child with Down syndrome be behind on their vaccines. We want to make sure that they’re up to date on the latest vaccines - many of which have been designed to help them protect against the infections we just talked about. We talked about sinus infections and ear infections. Some of the vaccines we give like Prevnar 13 really provide some level of extra protection against those infections. We’re really interested in those children getting the most vaccinations that they can.
Dr. Vellody: Okay, Andy, so let me just clarify this point because I know its an area where some of our families have questions. What you’re saying is that even though the immune system is a little bit weaker in a child with Down syndrome that they are more than capable of handling the all of the recommended vaccinations? You’re saying that by giving them the vaccines on the regular schedule, we can help protect them from potentially serious infections?
Dr. Nowalk: That is correct. I think they need to be on the regular schedule and there should be any difference from them from another child.
Dr. Vellody: Thanks. I agree completely and wanted to be sure that our listeners completely understood your expert advice. Are there any vaccines in particular that families should be especially aware of?
Dr. Nowalk: There are some vaccinations that we really think are critical every year. We know Down syndrome, both children and adults, have a particular problem with getting pneumonia and suffering some difficulty with it. This is influenza season. Influenza is one of the most common pneumonia causing viruses around now. We have a vaccine every year. It’s typically available at your pediatrician or family doctor’s office in August or September. The vaccine companies have really pushed to get it out there early. Make sure your child gets influenza vaccine. Because we know that people around the child shouldn’t get sick and pass it on to the child, make sure everyone in the house gets influenza vaccine. One of the best ways to protect your child or an adult with Down syndrome is to make sure everyone else around them is protected too. That’s a really simple and easy way to prevent what may be very severe infections in children with Down syndrome.
Dr. Vellody: So, Andy, you are saying that influenza vaccine is especially important for a child with Down syndrome to receive?
Dr. Nowalk: Yes, I can’t stress that enough. Yearly vaccination with influenza is one of the easiest ways to protect your child with Down syndrome. I think of it like putting on their seat belt. Nobody ever forgets the seat belt for those little kids. We should remember influenza vaccine in the same way.
Dr. Vellody: I like that analogy. We have had a lot of children get admitted this year, some of them seriously ill, with influenza illness. I think what makes it hardest for me is that the illnesses were all potentially preventable with a vaccination. I think you’ve got a slogan in there – buckle up and go get your flu shot! Well, before we run out of time, let me ask you if there are any other vaccines for kids with Down syndrome that our families should pay special attention to?
Dr. Nowalk: There’s one other vaccine that I’ll mention because it’s a vaccine that we think about more as an adult vaccine. It’s got a funny name – Pneumovax. It’s a vaccine we had previously given mostly to elderly people over the age of 65. Pneumovax is one vaccine that has really been moved very dramatically into the childhood vaccine schedule in the last 5-10 years. Children with Down syndrome who get tons of ear infections, tons of pneumonias, and tons of sinus disease are pretty much the ideal target population for Pneumovax. This is a recommendation that is very strong from most infectious disease practitioners for any child at increased risk of respiratory disease. Children with Down syndrome fit that bill perfectly. Pneumovax is a vaccine that I would really encourage any parent to explore with their practitioner if they haven’t received it already.
Dr. Vellody: Thanks, Andy. This is one vaccine that most pediatric practitioners will not be as familiar with because, you’re right, we do usually associate with the elderly. Just so our listeners know, the 2011 American Academy of Pediatrics guideline for the care of children with Down syndrome states that all children with Down syndrome and any chronic cardiac or respiratory condition should receive the Pneumovax vaccination after the age of 2 years. This is currently a one time vaccination but future guidelines may update it for regular booster immunizations at later dates. We should remember that the ears and sinuses are technically part of the respiratory system so I’ve been recommending this vaccination for many of my patients and not just the ones with cardiac conditions.
That wraps up the time we have for this podcast. Thank you, Andy, for being with us again for this podcast. It was a pleasure exploring the personal and medical interests you have when it comes to Down syndrome. For our listeners, don’t forget to keep sending in your questions to firstname.lastname@example.org. We’ll be back next time with another topic. Until then, take care, and get your flu shots! Bye bye.
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