What really works to treat infant colic?

Posted April 17, 2014 by Dr. Roy
Categories: Guilt Free Parenting, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Colic is not fun.

You’ve got your little wee baby home, and you’re exhausted. Just when you need some rest the most, Junior cries. And cries, and cries. And nothing seems to help for more than a few moments.

Colic has a medical definition, sometimes called “Wessel’s criteria”: inconsolable crying in an infant less than three months of age, for at least three hours a day, for at least three days a week, for three weeks or more. I doubt many practicing pediatricians or parents rely on all of those “threes.” We use a simpler definition: lots of crying in a baby who we’d hope would cry less.

Babies cry. And that’s the catch, here. They all cry. They don’t have much else they can say. And they’re overwhelmed by all of the changes they’re experiencing, and they haven’t yet learned how to transition from wakefulness to sleep. And some of them don’t like the feeling of rumbly gas in their tummies. And some are scared of their little baby farts. And some of them have parents who are exhausted and strung out and depressed. Honestly, I’m surprised more of them don’t cry all of the time.

But the crying, it can really wear parents down. So all sorts of things have been tried to help soothe crying babies. The latest hip idea (for colic, and almost everything else) is probiotic supplements. These are oral powders that are made of billions of healthy bacteria meant to populate a baby’s gut to help digestion. There’s a lot of research into the “gut biome” and the effect of gut bacteria on the health, specifically relating to digestion and abdominal pain and allergy. Why not toss these at colicky babies, see what helps?

Some studies have shown good promise. Just last month, a study of 589 infants in Italy compared babies given probiotics versus placebo, and found that the babies on a probiotic L reuteri supplement cried for fewer minutes each day (38 versus 71 minutes, on average.) This study looked essentially at the prevention of colic, by giving probiotic supplements to babies whether they had excessive crying or not.

However, the most recent study, a controlled trial of the same probiotic supplement given to colicky babies, showed no effect on any important outcome. The babies, whether given probiotics or not, cried about the same.

Still, there is some good news in common between the studies. The babies, when followed over time, all experienced decreased crying. In other words, colic improved in all groups, whether or not probiotics were given. Also, there we no side effects observed in the probiotic groups. They’re safe, even if they don’t work.

So what does and doesn’t work to help decrease infant crying?

Medicines, universally, don’t seem to work. This includes simethicone (widely available as “Mylicon”, an OTC “gas reliever.”) Studies of medications that reduce acid have also failed to show any effectiveness in improving infant fussiness or crying.

For nursing moms, dietary changes seem to help sometimes—specifically, eliminating dairy consumption. However, this is effective <50% of the time, and you have to weigh a trial of no-dairy-intake versus the effect this has on mom. She needs to be able to eat. Eliminating dairy is difficult (but not impossible)—but eliminating all of the foods possibly implicated in infant crying would be ridiculous. What’s mom supposed to eat, rocks and water? Besides, I don’t like pinning the blame for an upset baby on Mom.

For bottle-feeding families, using a hydrolyzed (hypoallergenic) infant formula has some mixed support from studies. It may be worth a try. What’s unlikely to really help, though, is the endless parade of changing formulas based on manufacturer claims that some are “soothing” or some help in other vague ways.

An insider pro tip I’m not supposed to tell you: As a pediatrician, I can suggest countless alternative formulas for you to try. There are enough alternatives that I can keep changing formulas once a week for at least a few months. By then, baby colic improves. So you’ll think I was smart to finally find the right formula, when in reality I was just changing formula once a week until your baby was going to get better anyway!

So what works best? First, colicky babies need a good, thorough evaluation to make sure that there isn’t a medical problem going on that needs to be addressed. Sometimes that takes more than one visit, and sometimes, if things aren’t going as expected, we have to revisit and re-assess.

But as long as there isn’t a medical issue contributing to the crying, the most important interventions are reassurance, education, and social support. Reassurance that colic does get better, education about safe soothing techniques and signs to look out for, and social support so exhausted parents can get a break once in a while. If parents want to try some safe interventions, that’s fine. But colic isn’t necessarily a medical problem that needs probiotics, diet changes, or medicine. Sometimes, babies just need to cry.

Eat peanuts during pregnancy to prevent allergies

Posted April 14, 2014 by Dr. Roy
Categories: Guilt Free Parenting, Nutrition

Tags: , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

It wasn’t that long ago that the usual advice to prevent food allergies was to avoid or delay certain foods. Now, the pendulum has fully swung over to the other side. As more and more evidence accumulates, it’s becoming clear that the way to prevent allergy is by exposures, not avoidance. Immune systems need to see allergens early to develop tolerance.

I’ve recently written about studies that show that at least some cases of peanut allergy can be overcome by gradual, graded consumption of peanuts. We also know that some food allergies are less likely to occur if babies eat things like grains and eggs beginning at around four to six months of age (this is likely true for other allergens, like peanut and fish, though the evidence isn’t as strong.) Now a new study shows that exposures from before birth can help a developing baby’s immune system learn to tolerate food proteins.

Researchers in Boston prospectively followed 8200 children, born from 1990 to 1994. Among the group, 140 became allergic to peanut or tree nuts (about 2%, which may strike you as low—but that’s the rate of allergy when strict criteria and independent assessments are used rather than parental reports alone.) They then compared the maternal diets during pregnancy between children who became allergic, versus those that did not. Among moms who themselves were not allergic to peanut, eating more peanuts and tree nuts more frequently during pregnancy was associated with a dramatically decreased risk of later allergy in their offspring. The reduced risk was probably in the range of 25-75%. Not bad for an intervention that’s cheap and safe.

Of course, moms who are themselves peanut allergic should not consume peanuts. In the study, nut-allergic moms who ate nuts were not more or less likely to have nut-allergic children than nut-allergic moms who avoided nuts.

The immune system is complicated, and the development of food and other allergies depends both genetic and environmental factors. But it’s clear that we can’t just run away from foods in the hopes that we won’t become allergic. Moms who are not allergic to food should enjoy a rich, varied diet throughout pregnancy, including peanuts and tree nuts. Nursing moms should eat what they’d like. Starting at four to six months, little babies should start complementary foods, including basically anything they’d like off of their parent’s plate, mushed up and tasty. Want to avoid food allergies? Eat.

High BMI in children

Posted April 10, 2014 by Dr. Roy
Categories: Guilt Free Parenting, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Stephanie wrote in about a very common problem:

 My daughter is 4 years old. She isn’t the tallest cat in town (she is about the 15th-25th percentile for height), and her BMI always ends up being in the high range (like over 85%). I worry about it. I am very health conscious for myself and my family. We live by all of the ‘rules.’ And yet.

The family doctor doesn’t worry – been shrugging it off since day one. Maybe because both Dad and I are very lean. Maybe because, as patients of hers, she knows we are a very healthy family (regular exercise, healthy diet, no smoking, healthy pregnancy with aforementioned child). Family doc knows we have never fed our kid a drop of juice, no fast food, homemade meals, limiting screen time, healthy choices…

So I’m stumped. Why the high BMI for my daughter? I would love to hear some solid, scientific data about why this could be, as opposed to: ‘Meh, she’ll be fine.’

We know that obesity, in the long run, isn’t good—but we can’t even agree on what “obesity” is. BMI, or Body Mass Index, is a single number that basically reflects weight-for-height. We figure that the more someone weighs for their height, the more likely they are to weigh “too much.” What we really need is a measure that tells us when someone’s weight is unhealthy, or likely to lead to ill health. Instead, we use that BMI number, a very poor predictor of individual health outcomes.

There are several reasons why BMI is not a great way to discriminate between healthy and unhealthy weights:

A BMI doesn’t reflect the difference between lean muscle mass and fat mass. What’s unhealthy is excess body fat, not excess body muscle. A muscular, lean individual with little body fat may have a “high” measured BMI because muscle has weight.

BMI doesn’t distinguish between kinds of body fat. We know that visceral fat—the kind in your belly, or the kind that contributes to an “apple” shape—has far more long term negative consequences for health than fat distributed in the lower body.

Criteria for “healthy” versus “unhealthy” BMI are based only on statistics, not on individual health outcomes. We’ve decided that anyone above the 85 percentile for BMI (down to age 2) is overweight, and anyone above the 95 percentile for BMI is obese. This compares a child or adult’s BMI against historical data, which assumes that people thirty years ago had a BMI distribution healthier than today. While that’s generally true for the population (obesity-related health problems are genuinely much more common now), that doesn’t mean it’s specifically true for each individual or child. In other words, relying on statistics forces us to oversimplify and generalize instead of focusing on ways to individualize our approach to maximize health.

Finally, improved diet and exercise habits improve health outcomes, even if the BMI doesn’t change. Over-focusing on BMI can lead to discouragement, preventing steps that can really improve well-being in children and adults.

So what should Stephanie’s mom do? Forget the BMI and keep up those good healthy life habits. Stay active. Turn off the TV. Eat moderate-sized portions, slowly, eating mostly plants and whole-grains. Eat as a family, and share cooking and cleaning chores together. Avoid eating out or doing take-out too often, and stay away from sweet drinks (soda and juice are equally unhealthy). Enjoy eating and playing, together as a family, and don’t worry about the numbers on the scale. The BMI is one thing, maybe a starting point to remind us to keep up healthy habits. But it’s a terrible target to use as a goal for your child’s body.

Children discover: Adults just fattening them up to eat them

The Insider’s guide to allergy medications

Posted April 7, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Ah, spring is here. Time to plant my little seedings. Time to wash the yellow pollen off my car. And time to sniffle, sneeze, and snork. Confused by all of the choices of allergy meds? Look no further than this short, no-nonsense Pediatric Insider guide to allergy medications.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which still works well—but it’s sedating and only lasts six hours. Most people use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheapo generics. They work taken as-needed or daily. There are a few prescription antihistamines, but they have no advantage over these OTC products.

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as genertics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff he’s got in back.

Nasal cromolyn sodium (OTC Nasalcrom) works some, though not as strongly as rx nasal sprays. Still, it’s safe and worth a try if you’d rather avoid a prescription.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work—they actually work great—but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. The prescription nasal sprays, ironically, are much safer than OTC Afrin.

Nasal Steroid Sprays include OTC Nasacort, and Rx Flonase (or generic fluticasone), Rhinocort, Nasonex, Nasarel, Veramyst, and others. All of these are essentially the same (though some are scented, some are not; some use larger volumes of spray.) All of them work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Antihistamine nose sprays are topical versions of long-acting antihisamines, best for sniffling and sneezing and itching. They’re all prescription-only (though they’re super-safe). They’re marketed as either the Astelin/Astepro twins (Astepro came out later, when Astelin became available as a generic; it lasts longer) or Patanase.

Bonus! Eye allergy medications include the oral antihistamines, above; and the topical steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor, which works about as well as rx Patanol, which they’re trying to replace with rx Pataday.

Uncertainty isn’t good for health, and it isn’t good for healthcare

Posted April 3, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Doctor: “Phil, you have pneumonia.”

Phil: “Oh noes. What shall I do?”

Doctor: “Just take these red pills, here.”

Phil: “Great! I feel better already! When can I go back to work?”

Doctor: “I think in about 2 weeks. Or maybe 2 months. And actually, don’t take those red pills— these blue ones are better. It could take a few years for you to get better, and I’ll be retired by then. Here, have some yellow pills.”

Phil: “What? For pneumonia? I think I’m feeling sick again.”

Doctor: “I didn’t say pneumonia. Have some purple pills. And I have to refer you to a specialist, and get an x-ray. Or an ultrasound. That’ll take six weeks to schedule, or maybe you can do it tomorrow.”

What’s worse than being sick? Not knowing what’s wrong, or how to fix it, or when you’ll get well. It’s when everyone disagrees on what your problem is, and when you get different advice, and when the recommendations change. It’s when what your doctor says doesn’t make sense, and makes even less sense when he keeps changing his mind.

Remind you of what’s going on with the US Healthcare system?

We’re in the middle of the implementation of a huge change in healthcare delivery, based on a byzantine law that no one seems to understand. Unexpected provisions and complications seem to crop up daily. The law is just too complicated for anyone to know what’s that’s in there.

The complexity of the law isn’t the only problem. Not only are new rules and provisions continuing to creep above ground into the light, but established, simple rules seem to change daily. Deadlines? We don’t need no stinkin’ deadlines. While some of the changes seem fair, the uncertainty itself is making it impossible for businesses, patients, and health care providers to prepare. We can’t offer good care if we don’t know what to expect.

There’s even more uncertainty. Congress’s addiction to short-term fixes instead of responsible lawmaking has kicked in again, as they’ve just passed another one year “doc fix” for Medicare payments. They’re also about to delay implementation of a whole new coding system for health care delivery called “ICD-10”—just as thousands of hospitals and clinics have already spent millions preparing for that nightmare. And some states seem hell-bent on implementing unworkable technology “solutions”, in some cases as a requirement to hold a medical license.

It’s a tough time to be a doctor, and a tougher time to be a patient. I don’t think anyone can predict the next complication, and I don’t think anyone knows how to address the uncertainties and shortcomings of what’s coming down the road. My best advice: try not to get sick until we figure out what we’re doing. It’s going to be a long wait.

Keep your child safe from antibiotics

Posted April 3, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Here are some facts:

Antibiotic use is the direct cause of the rise of untreatable superbugs that are killing people.

Antibiotic use is also the cause of most cases of C diff colitis in kids, a potentially life-threatening, difficult-to-treat gut disorder. Antibiotics have also been linked with recurrent wheezing  in infants and inflammatory bowel disease. They can also trigger allergic reactions that can be severe or life-threatening. (I was going to link to photos of Stevens Johnson Syndrome, but decided not to be cruel. Go ahead and Google at your risk. Don’t say I didn’t warn you.)

Here’s some more facts:

Most infections in children are caused by viral infections. This includes all common colds, most coughs, most sore throats, most nasal congestion, and most fevers. It includes most bronchitis, most pneumonia, and most wheezing. Croup, laryngitis, tonsillitis, upper respiratory infections—they’re all viral. They are caused by viruses.

There is no circumstance where any antibiotic medication helps anyone with a viral infection get better. They don’t make viral infections go away faster, and they don’t prevent the development of later bacterial infections. They just don’t work.

Even “bacterial” infections often don’t need antibiotics to get better. Most ear infections will resolve without antibiotics, and good studies have shown that antibiotics, overall, are not effective in treating sinus infections.

So: the potential for great harm. And no upside. If you’ve got an accurate diagnosis of a viral infection, you know that the antibiotics aren’t going to help. Zero benefit. Some real risk. You’d think this would be a no-brainer kind of decision.

And yet, every single day I feel this struggle with some parents who just want antibiotics. It’s really strange, in a way— I listen to the story, I do a careful exam, and if possible I get a confident diagnosis. I talk about what will help the child feel better, and red flags to look out for to contact us if things get worse. And I get back a stare. “Can’t I just get an antibiotic?” or “He needs an antibiotic for his sinus” or “My doctor just gave me an antibiotic. He has the same thing.”

It’s our own fault, I know. Doctors have been way too quick to write antibiotic prescriptions. It’s much faster to whip out the prescription pad than talk about viruses and bacteria. And, more nefariously, writing antibiotic prescriptions creates a culture of dependency that guarantees future business. Patients, at least some of them, seem more satisfied if they just get a magic antibiotic prescription. Why anger people, why fight it, why not just give out the pills and move on to the next patient? Happy parents, happy cash register.

Besides: I know there’s a good chance they’ll go right to the QuickieClinic in the drug store across the street and get their peniwondercillin prescription anyway. (And then I’ll be the one called with the weird allergic reaction or when Junior didn’t get better because he needs a “stronger” antibiotic. QuickieClinic doesn’t offer 24/7 access to their doctor. They don’t offer any access to any doctor. But I’m getting off topic here.)

Why fight it? Because I’m your kids’ doctor. I’m not here to make you happy, or give you what you think you need. I’m here to try to get an accurate diagnosis and to do the best thing for my patient. I’m here to give solid advice about how to help your kiddo feel better, and to tell you when to worry, and when not to worry. I will not always get it right, but I’m going to try my best every time, even when that means I’m not giving you the prescription you want. And I’ll be here to help when things take an unexpected turn, because symptoms and diagnoses change. I can’t guarantee when your child will get better, but I’ll do my best to do the things that can genuinely help.

You want a burger your way? Go to Burger King. You want a quick antibiotic prescription? Go to the retail clinic in the drug store, or one of those docs or practitioners who see 60 kids a day. You want someone to use their professional skills and judgment to help your child? Find yourself physicians who’re stingy with the prescription pad.

What should a seven-month-old baby eat?

Posted March 31, 2014 by Dr. Roy
Categories: Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Naomi wrote, “I’d like to start letting my 7 month old try some of the foods we’re eating during dinner. He always sits at the table with us and seems fascinated by what we’re putting in our mouths. It seems like most baby books say not to give babies anything with added salt, however, and cooking for adults without salt would ruin dinner. My question: if we’re only talking about home made food, is a little salt really so bad for a baby that’s eating solids? And if it is, at what age can he start eating table foods? I get that the salt levels in processed foods might be too high, but I’ve always thought home made food had much less.”

Listen to your baby—he’s fascinated by what you’re eating, and wants to try it. As long as the food isn’t a choking hazard, let him enjoy!

We think of “traditional” baby food as the stuff in boxes and little jars and little plastic tubs. Cereal, pureed veggies, pureed fruits—single-ingredient, bland, with minimal salt and other stuff. Of course, this is hardly “traditional” at all. It’s just what the baby food companies have been selling in the developed world for the last 100 years or so. “Traditionally,” once babies started weaning, they ate whatever everyone else ate.

There are a few different reasons why some have recommended sticking with “baby food” for toddler-aged kids. None of them are really very good reasons—and in fact, moving towards “real food” as soon as practical is better for everyone involved.

Naomi asked specifically about added salt. The thinking goes: many of us consume too much salt, which has been linked to hypertension in some genetically-predisposed individuals. So why get Junior used to the taste of salt too early? Won’t that cause him to crave salt later? But there’s no evidence whatsoever that more or less salt at seven months is going to make any difference. Later on, he’ll get used to the kind of meals eaten by everyone else, salted or low salt. There’s no critical window for deciding how salty someone likes their food.

There are also concerns that the early introduction of a mix of foods to youngish babies might increase their risk of food allergies. The truth is the opposite. There’s no evidence that waiting until later than four to six months of life increases the risk of allergy to any foods—not peanuts, not eggs, not fish. Those and any other foods can safely be introduced starting within the usual four to six month window. In fact, there’s some evidence that this earlier introduction can make food allergies less common.

The only significant health concern I have about early “real food” is whether it could be a choking hazard. Early foods should be a mashed-up or pureed consistency that can easily be eaten without teeth. Once Junior can pick up a morsel with his hands, start with soft little bits (about the size of the last part of his thumb, past the knuckle.) It’s messy, it’s fun, and it’s the best way for Junior to learn about textures and flavors. Eat as a family, and eat the same things. Yum!


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