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  Measles Retrospective Analysis in a Pediatric Practice
  

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By: Karl-Reinhard Kummer

Original German title: "Masernverlauf in einer Kinderarztpraxis" in Der Merkurstab 1992; 45: 180-190. English by Anna R. Meuss, FIL, MITI.

Part I — Parent's experience of measles and the child's development

Anthroposophic medical practitioners are criticized for the stance they are taking with regard to immunization and childhood diseases; 1 it is considered out of date in an age of world-wide programs designed to eradicate childhood diseases. The Standing Committee for Immunization at the Federal Department of Health in Germany is now recommending that all children should be given their measles-mumps-rubella booster from the age of six onwards. 2 The indications are that physicians who go against the accepted view may be held legally responsible. In Switzerland the demand is for an individually differentiated approach. 3,4 One problem is the lack of retrospective studies of measles treated homeopathically or anthroposophically.

1) The sample

The number of children treated for measles in my practice between the end of 1987 and the spring of 1988 was unusually large, so it seemed a good idea to review individual progress and the children's state of health after they had gone through measles. 251 questionnaires were sent out to parents in June 1988, with 224 (89.3%) returned. Some questionnaires were also sent out in August 1988 and early in 1990. 69.2% were returned three months, 82.6% four months and 86.2% five months after the measles, the rest up to six months later. The data may therefore be considered to be fairly reliable.

Stage two was to consider the frequency of medical treatment required before and after measles. The data for this, the above sample and the histories were taken from the practice records and include data for children for whom no questionnaire was available. The criterion was continued care during the period of the study (see also Part 2). The sample cannot be said with certainty to be representative: 227 children were German (93%), 16 of other nationalities (7%). 127 were insured for restitution of costs (52%), 78 with employers' insurance companies (32%) and 39 privately (16%). Most of the children (91.5%) were of pre-school age, as one would expect. Five were less than six months, 19 six to twelve months old. The oldest in the sample was a girl of 17 (see Table 1).

Table 1

Age group                  No. of children                 % 

< 6 months                5                                     2.1

6-12 months              19                                   8.7

1-2 years                   37                                   15.2

2-3 years                   31                                   12.8

3-4 years                   38                                   15.6

4-5 years                   41                                   16.9

5-6 years                   32                                   13.2

6-7 years                   20                                   8.2

7-8 years                   10                                   4.1

9 years and over       10                                   4.1

                                 243                                 100.0

 
The age of the insured parent was generally known from the insurance records; if not, an estimate was made. Again, the parents' ages were not representative: The majority were 36 – 40 (31.8%), with only 10 below the age of 25 (4.1%).

The number of children in the family was above average, with 10.2% of only children, 55.1% two-child, 26.1% three-child, and 8.6% more than three-child families. 43.6% were first, 40.6% second and 12.7% third children. Ten children (4.1%) came fourth in the family. Every case record includes the full history. Problems during pregnancy were noted in 21 records, problems with the birth in 28, and 25 children had both kinds of problems (10.5%). 165 children (68.2%) had had no problems.

Previous illnesses had also been recorded: 145 children (60.2%) had had none. 50 children (20.7%) had been treated for allergies such as eczema, hayfever and urticaria. 46 (19.1 %) had other problems, e.g. heart disease. One child had a cerebellar condition with full diagnosis still outstanding. The group as a whole may therefore be considered to have a negative health record.

Children were only included in the sample if the diagnosis was confirmed. 126 (51.5%) were diagnosed following examination by the physician. 120 children (48.5%) were siblings or had had other, confirmed contact. The data were taken from records, files on fees charged or emergency case records.

Treatment was essentially anthroposophic and homeopathic, e.g. giving Pulsatilla and Pneumodoron 1 and 2. Almost all children were given expectorants. Strict bed rest was considered most important. The exanthem was enhanced by means of external applications. Many children had already been treated by their parents who had consulted guides such as books on natural child care 5,6, and in many cases home treatment followed the lines recommended for siblings. One child who had pneumonia was given an antibiotic. Children with otitis did not require antibiotics.

By the end of 1990, 227 of the 251 children were still in my care. 24 could not be followed up because the family had moved away or changed to another physician. The practice records were consulted in their case. One girl developed focal seizures of unknown origin in 1991. When she had measles, two examinations had shown normal neurological findings; the post-measles EEG was also normal. She may have had an untreated encephalitis at the end of 1990. Another child had been retarded prior to measles, which was due to a cerebellar condition that was not fully diagnosed. The records of the remaining 225 children show no neurological problems after 1988.

2) The parents' experience of measles

The replies to the questionnaire reflect the well-known highly febrile nature of the disease. 31.3% of children had temperatures between 39.5 and 40°C, 19.3% between 40 and 40.5°C, and 12.9% above 40.5°C. The high temperature would generally persist for three to five days. 9.8 % of the children had a temperature for more than a week.

One question was about complications: "Were there any problems in addition to the measles: severe diarrhea, inflammation of the ear, pneumonia? (Which?)" 145 parents (64.4%) reported no problems:

Table 2

Problems accompanying measles             No. of replies     %    

None                                                         45                      64.4

Diarrhea/vomiting                                      22                      9.8

Otitis                                                          30                      13.3

Pneumonia                                                  2                        0.9

Other                                                         26                      11.6

                                                                225                    100.0

 

The incidence of diarhea and vomiting was remarkable, but probably does not rate as a complication. 60 children had the accompanying condition for up to one week, 19 took longer to recover.

Parents were asked when the child was "feeling completely well again". 38 (35.3%) said their child had recovered after one week, almost 40% said between one and two weeks, and 13.6% between two and three weeks. No less than 26 children (11.8%) did need more than three weeks to recover fully (n = 221). Some children needed more time to overcome the mental state relating to their measles (see below).

In reply to the question, "How did your child feel when he or she had the measles?" 33 parents (14.7%) said they had hardly any problem at all. 92 parents (41.1%) referred more to physical problems, 39 (17.4%) more to the mental aspect. 60 parents (26.8%) mentioned physical and mental effects (n = 224).

3) Parents' fears

Two questions related to parents' fears. The first was: "Were you worried about the high temperature?" 30 parents (13.5%) said "yes", giving no further details. Six added that a temperature would always worry them; eight gave special reasons why a temperature worried them in the case of this particular child (previous illnesses, or that the child was 17).

178 parents (80.2%) stated that a temperature did not normally worry them. Ten said this was due to the medical care available, six that they generally considered a temperature to be a positive reaction. Just under 20% of parents (19.8%) therefore stated that temperatures did worry them, compared to 80.2% who answered the question in the negative.

Table 3

Worry if child has temperature              No. of replies         %   

Yes, no further comment                      30                          13.5

Yes, because special case                     8                            3.6

Yes, general fear                                   6                            2.7

No                                                         162                        73.0

No, secure w. medical care                   10                          4.5

No, temperature seen as positive         6                            2.7

                                                            222                        100.0

 
In view of this, the following came as no surprise: Parents who were not worried about a temperature were less liable to report a negative change in their child after measles (chi square = 2.82, significance 9.3%).

Another question was:

"Were you worried about permanent damage, or about measles complications?" 77 parents (34.7%) answered in the affirmative, 51 (23%) giving no further details, two saying this was because their child had special problems, and nine that it was because of the course taken by the disease. 15 parents went into more detail.

145 parents (65.3%) said they were not worried about permanent damage, with eight of them stating that this was because of the medical care available:

Table 4

Fear of permanent damage                 No. of replies       %

Yes, no further comment                        51                    23.0

Yes, because special case                       2                      0.9

Yes, because of course disease took      9                      4.1

Yes, general fear                                     15                    6.8

No, no further comment                          136                  61.3

No, secure w. medical care                      8                      3.6

No, other                                                 1                      0.5

                                                            222                  100.0

Again, parents who had stated that they were not afraid of permanent damage were less liable to report negative changes after measles (chi square 2.91, significance 8.79%).

4) Child's condition after measles

The next question was about changes after measles. Negative changes were expressly included in the question. A good third of parents (35.3%) reported no change between before and after measles. 54.3% noted positive changes, and 23 parents (10.4%) negative changes:

Table 5

Changes after measles                No. of replies   % 

None                                            78                    35.3

Positive physical changes            21                    9.5

Positive mental changes              30                    13.6

Positive general maturity             56                    25.3

Combinations of above                13                    5.9

Negative changes                        23                    10.4

                                                   221                  100.0

Poor recovery from measles was independent of the time when the questionnaire was answered. Only five of the 'negative changes' came from questionnaires filled in soon after the illness.

Parents' replies are quoted verbatim below to define the changes they noted more clearly:

a) positive physical changes

"He has grown taller and more slender; he's stretched; his facial features, too, no longer show the roundness one sees in young children." "Started to walk after she'd had measles." "Positive, for our daughter is eating better now." "Yes, he had more of a rosy complexion." "Physical growth, otherwise nothing definite as yet." "The form of her face is longer now." "Big step forward in development, physically evident in growth and new teeth... ." "Fine motor functions more developed... ." "Has made a good recovery, with physical and mental state highly satisfactory at present." "...made remarkable progress in development of body, mind and spirit, bursting with health and energy, appetite good... ." "Movements now full of energy; will power has been strengthened." "Child recovered quickly, was perfectly robust again after 2-1/2 weeks, and now impresses us as being thoroughly healthy."

b) with positive mental changes

"Became more wide-awake and a lot cheekier (and more balanced)." "Seemed a little more self-confident afterwards; the 'I' seemed to have been strengthened, and his whole personality emerged more clearly." "More active in motor functions." "More independent." "Has accepted his new environment; more ready to go to nursery school, has made friends, is testing his limits more than he did before." "Definitely positive, physical maturation, onset of puberty." "Has grown a bit calmer; observes things more intently." "Starting to talk, which he did not do at all before, in spite of being 18 months old; healthy and very cheerful where before he tended to whine a lot, very well balanced now." "Is getting more sensible and accessible; no more sleep disturbances at present." "Altogether calmer and more balanced." "Altogether positive development, particularly in social sphere." "Remarkable improvement in ability to concentrate." The list could be continued.

Again, four parents spontaneously stated that the medical care received was a vital element, and four parents referred to the importance of fevers and childhood diseases for a child's development. Eleven parents said there had been a definite change in their relationship to the child.

c) negative changes

Some of the children still had mental measles signs when the actual disease had been overcome. Parents said they were "whining, moody, insufferable", "rather weepy; anxiety states, especially at night, for some time, "...because he always wants to be carried...", "was exhausted for a long time afterwards...", "generally more nervous than before; great fear of being left alone...", "tends to break into tears easily, had become hypersensitive, but has now returned to normal..."

Remarkably, 12 of the 28 parents who reported negative changes after measles did not give a higher incidence of complications during measles, whilst 16 of them reported no complications. On the other hand, 49 children who according to their parents had had an "accompanying disease" were said to have shown positive development after measles.

Cross reference tables were used to try and establish social differences on the basis of known social data. The only available criteria were the above-mentioned insurance status and the age of the insured parent. No difference was found regarding parents' fear of pyrexia or of permanent damage. Nor did the three different insurance groups show differences with regard to measles outcome.

Part II – Number of contacts with physician before and after measles

The practice records provided information as to how frequently children had required medical treatment before and after measles. The obvious assumption would be that they became more susceptible to disease and therefore needed more treatment.

The total number of occasions for personal contact with the physician because of illness was determined for the following periods: 12, 6 and 3 months before measles; 3, 6 and 12 months after measles. Visits during measles were excluded. The duration of measles was put at 21 days.

Case records include the codes for fees charged for particular services. This makes it easy to reconstruct the evolution of both disease and treatment. Specific codes indicate personal contact with the physician. In the case of privately insured patients, a check was made for the figure "1" which indicates personal contact. A count was also made of outpatient treatment at the hospital, medical emergency services, etc.

The counts included all contacts due to illness, including all check-ups, e.g. follow-up examination after otitis media. Contacts required for immunization or preventive check-ups were excluded, as were those occasioned by injuries and accidents. Some children were given series of own-blood injections to treat allergies, and in this case only the first treatment was included in the count. Contact to take a follow-up EEG after measles was also excluded.

During the 3-month period before measles, 70.3% of all children received none or only one medical treatment. The corresponding figure for after measles is 81.9% (chi square = 32.5, significance 0.0002):

Table 6

Medical contacts   3-month period before measles     3-month period after measles

                             No. of contacts     %                       No. of contacts            %

0                           103                       41.4                   131                              52.6

1                           72                         28.9                   73                                29.3

2                           51                         20.5                   26                                10.4

3 or more             23                         9.2                     19                                7.6

                             249                       100.0                 249                              100.0

 
Similar results were obtained for the 6-month periods before and after measles. For 6 months before they had measles, 45.9% of the children did not require treatment or only required treatment once. After measles the percentage rose to 59% (chi square = 44.0, significance 0.002) (See Table 7)

Table 7

Medical contacts   6-month period before measles     6-month period after measles

                             No. of contacts     %                       No. of contacts      %

0                           68                         27.6                   79                          32.0

1                           45                         18.3                   67                          27.1

2                           51                         20.7                   46                          18.6

3                           41                         16.7                   22                          8.9

4                           14                         5.7                     19                          7.7

5                           12                         4.9                     6                            2.4

6 or more              15                         6.1                     8                            3.2

                             246                       100.0                 247                        100.0

The children were also ill less frequently during the 12 months after than during the 12 months before the illness. The probability of error is again less than 1 % (chi square = 76.2, significance 0.0000) (See Table 8)

Table 8

Medical contacts   12-month period before measles   12-month period after measles

                             No. of contacts      %                       No. of contacts            %

0                           32                         13.1                   40                                16.5

1                           44                         18.0                   48                                19.8

2                           32                         13.1                   44                                19.2

3                           30                         12.2                   35                                14.5

4                           38                         15.5                   23                                9.5

5                           24                         9.8                     17                                7.0

6-9                        35                         14.3                   25                                10.3

10 or more           10                         6.1                     10                                4.1

                             245                       100.0                 242                              100.0

 

For 12, 6 and 3 months after measles, the children included in the sample required medical treatment on fewer occasions than they had before the measles. During all three periods, the percentage of children needing frequent treatment was also reduced.

Part III – Discussion

Part I of this paper gave the results of a questionnaire sent to parents. Retrospective studies of this kind do, of course, present problems, but in the given situation this was the only choice. The questions were open ones, and in no way leading. Negative changes were specifically asked for. The parents did not gloss over the facts in describing their child's development and their own fear of complications. It may therefore be concluded that their replies were honest.

The many individual observations made by the parents speak for themselves. Particular attention was paid to factual observations when evaluating the questionnaires. Facts like "Suddenly able to call himself 'I"', "look is more direct", etc had not been suggested by the question but were spontaneous, with a high probability of being reliable.

Altogether 120 parents referred to a positive step in development. Many of them spontaneously rated greater independence as a positive sequel to measles.

On the other hand, 28 parents listed exactly the kind of symptom normally seen as subjective measles symptoms as negative effects: clinging, discontent, dependence, etc. It seems that the struggle between the ego and the model body described by Steiner 7 had not been taken to its conclusion in these children and therefore continued after the measles.

The general care and attention given in sickness does of course also play a role. It provides "the nearness and tender loving care given by a familiar person that had often been missing in this particular form".8 The positive effect of minor illnesses is well known.9,10 Nevertheless, the descriptions given by the parents in the questionnaires explicitly state that the measles were the key agency. Many of the parents also described their own fears and anxieties, and this may be seen as an indication of the special role played by the measles.

The evolution of an illness is greatly determined by the initiative and certainty shown by the parents. This transfers to the child. With measles in particular, children tend to be weepy and psychologically unstable, so that a protective environment is an important part of treatment. Scientific discussion of measles immunization largely ignores this. It is to be assumed that most of the parents of children included in the sample approached the childhood disease of their child consciously and were confident in their approach to care. In this respect the sample does not compare with the normal population. Parents also made spontaneous mention of the importance which medical care had for their own confidence and the outcome of the illness. This is another factor influencing the disease which is not reflected in the answers given by specialists, for instance, to demands to reduce measles immunization.11 Providing information and guidance for patients is one of the strengths of anthroposophic medicine, as has been recently demonstrated.12

Initially it seems surprising to see that the children needed less medical care after measles than before. It is possible that the parents' increased confidence plays a role in this. After coping with an illness that was a strain on everyone, the physician is called only in cases of serious need. Thus the number of children who did not come to see the doctor at all had increased after measles, and the number of children who previously came to see the doctor very frequently had decreased after measles. This suggests a decrease in serious illness after measles and is the opposite of what happened in previous decades.

The age distribution is fairly standard in the sample, so that errors incident on the nature and composition of the group can be largely excluded; e.g. acclimatization to nursery school. The large number of siblings means that the parents in the sample had some experience and would be less likely to consult a doctor. This, however, is equally true before and after measles. On the other hand the incidence of infection would be higher in families with more children.

In recent years there have been reports of local measles epidemics in areas where protection by immunization had been adequate.13-16 Even immunization of 99% of children and more than 95% immunity will not prevent this.16 Measles imported from abroad played only a minor role.15 This raises the question as to whether the "elimination" of measles is in fact possible. In spite of the questions that remain (see 4), demands are made to increase the level of immunization.15-19

Even authors who are in favor of measles immunization admit that the disease is on the increase in age groups that are particularly at risk, infants and young adults.19-20 The shift to these age groups also raises doubts as to the generally accepted incidence of side effects. 4,21,22 It is interesting to note that with adults, liver problems are specifically mentioned. 23 Compared to this, diarrhea was the main problem in the children included in the sample. The incidence of measles encephalitis ranks high in many arguments, 11,14,20 but this is unknown in West Germany. 24 There is doubt as to the accuracy of the stated figures in this respect 4,21,22,25 Immunizing the whole population against measles reduces the incidence of measles encephalitis but not the number of serious cases of encephalitis. 26

It is difficult to assess the effect of immunization on measles evolution. On the one hand it is assumed that immunization also has a positive effect in the tropics.27 On the other hand, it is suspected that immunization is followed by negative changes (see 4 for full list of literature). The frequent demand for 100% immunization schemes in pursuit of the evidently illusory goal of total eradication of measles, mumps and rubella take no account of the changing measles evolution in the population. The difference in immunization cover between 99% in the USA and about 45% 17 and 70% 18 respectively in Germany is merely considered as an argument in favor of increasing the percentage. Yet it appears that even in the tropics, where the disease takes a more severe course, the effect of immunization programs is to reduce the number of fatalities rather than "eradicate" the disease. The efficacy of immunization is stated to be 68 and 73% respectively. 27

More recent studies of measles evolution in Western Europe are needed, as immunization levels are distinctly lower there than in the USA. 4,17,18  The protagonists of immunization generally base their arguments on data from developing countries in the tropics or on marginal groups with measles outbreaks despite high immunization cover (e.g. 16). Other studies relate to wild measles in outsider communities such as the Amish.28

Socioeconomic factors and health management play a key role. Detailed investigations have indeed shown higher correlation with immunization than the individual socioeconomic factors considered in Haiti.19 Yet even there children from a higher social level (probably well below the European level) gained no statistically significant advantage through immunization. Instead of a critical assessment, the authors try to apply the positive effect of measles immunization in Haiti to industrialized countries, though this proved impossible even with the population under investigation. Other workers connect measles mortality not with the social situation but with clustering of measles in the area, yet again do not make an adequate critical assessment of the nature and problems of differences between industrialized and developing nations.29 Instead, the conclusion drawn even after describing a mild measles situation among the Amish is that measles represent a dangerous condition. 28

Both protagonists and antagonists compare the risk of contracting the disease with the risks of immunization. 10,25 Few authors outside the field of anthroposophic medicine make the positive effects of childhood diseases part of their argument. 21 In anthroposophic medicine, childhood diseases play a central role.5,6,30 The sample presented in this paper is too small to assess the risk of wild measles. Nevertheless it has shown clearly that both development and morbidity showed positive changes.

Few authors discuss the method of medical treatment. It is evident that even with the same level of medical care, there may be considerable differences in frequency of complications and/or mortality within the same hospita1. 31 A method of treatment that takes its orientation from the nature of the disease should give demonstrable results.

It will also be necessary to follow the discussion on immunology 32 closely and make our own investigations in this area.

Abstract

A questionnaire was used to ask parents about the effect of measles on their children. 120 of 221 parents (54.3%) said that their children had taken a positive step forward in development after measles. The negative changes reported for 23 children (10.4%) were mainly subjective signs such as weepiness and clinging. Two children developed measles pneumonia from which they made a complete recovery. 30 children (13.3%) had otitis and also recovered completely.

Parents were asked about any fears they had during their child's illness. 44 (19.8%) said they were worried about the pyrexia. 178 (80.2%) said the pyrexia did not worry them. 77 parents (34.8%) were concerned about permanent damage, compared to 145 (65.3%) who did not share their concern.

The number of occasions when a doctor was consulted 3, 6 and 12 months both before and after measles was assessed. Comparison showed that during each time interval, the doctor was contacted fewer times on account of illness after measles than before. This permits the conclusion that the children included in the sample were in a better state of health after they had had measles.

Basic research in anthroposophic medicine will require prospective studies to provide effective arguments against mass immunization campaigns.

(Prospective studies of measles evolution by anthroposophic physicians are urgently required. Assessment of minimal changes in motor skills, autonomic stability and fine psychomotor function requires a standardized follow-up examination for minimal impairment. The author has started on a project and asks as many of his colleagues as possible to join in the effort.)

 

References

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30 Husemann F, Wolff O. Childhood Diseases. In The Anthroposophical Approach to Medicine. Vol. 1, p. 40 ff. New York: Anthroposophic Press 1982.

31 Witsenburg BC Measles Mortality and Treatment. Tr. A. Meuss. JAM 1992; 9:2

32 Griffin, D.E., B.J. Ward, J. Janregui, R.T. Johnson, A. Vaisbergl Immune Activation in Measles. NEJM 320 (1989),1667-1672.

 

The author is most grateful to Prof. Klein, Institute of Sociology, University of Karlsruhe, and Mrs Seidel for their assistance and evaluation based on SPSS (Statistical Package for the Social Sciences).

 

Author's address: Dr Karl-Reinhard Kummer, Pediatrician, Jaegerstrasse 19, W-7500 Karlsruhe 41.





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