Don’t sit so close?

The Pediatric Insider

© 2010 Roy Benaroch, MD

Will sitting too close to the television hurt your eyes?

No.

As recently reviewed in a short article from Scientific American, there’s no risk to eyesight from watching TV too close, despite what momma told you. Apparently there was a television sold in the 1960 that was recalled because of excessive radiation, which may have led to the lasting myth of too-close television watching hurting a child’s eyes.

Kids who are nearsighted might prefer to sit closer so they can see better, but it’s not the television that caused the vision problem. Actually, most children I see whose parents are worried about vision issues because of close-watching have perfectly normal vision. I think some kids just like to watch sitting very close.

Television isn’t off the hook though– there are plenty of bad things that are related to excessive screen time: depression, poor speech skills (yes, even in toddlers who watch allegedly “educational” shows), overweight, and many other problems. TVs in children’s bedrooms are an especially bad idea.

So: though watching TV too closely won’t hurt anyone’s eyes, the best distance to watch a television is far, far away. From a different room, or a different house.

There’s nothing good on, anyway!

Boys and girls in the classroom

The Pediatric Insider

© 2010 Roy Benaroch, MD

They’re not the same, boys and girls.

Some differences are easy to spot. Girls sometimes dot their i’s with little hearts. Boys punch each other and make jokes about bodily noises. Girls are interested in shoes, and in the feelings of others. Boys like robots, and missiles, and mud– ideally, a robot that launches mud missiles. At his sister.

And those recipes with sugar and spice, and frogs and snails? As a doctor, I’ll tell you, that’s more-or-less accurate.

There’s a huge number of studies quantifying the learning and school differences between girls and boys. Girls are better at reading; boys are better at math. Girls are better at art; boys are better at building missile launchers.

The problem is that a lot of this literature can be justifiably criticized for not really looking at root differences, but only at inferences, foregone conclusions,  and (possibly biased) observations. Are boys really fundamentally better at math, or are they pushed harder at math so they become better? Are the boys with artistic talent belittled, so their talents wither?

Is it nature, or nurture, or what?

Here’s a study to further stir up the pot: researchers looked at the academic success of preschoolers, relating it to how many girls versus boys were in their classrooms. For girls, it didn’t matter: girls in mostly-girl classes did as well as girls in mostly-boy classes. But for the boys, there was a strong association between academic success and sharing a classroom with mostly girls. Preschool boys who were surrounded by girls did far better than boys surrounded by more boys.

What does that mean for classrooms? Should academically-challenged boys get the advantage of classrooms with mostly girls? And what will educators do with all of the excess boys if they start designing some classes to be more girly?

The study also doesn’t try to determine if it is the presence of the girls, per say, that made the experience more academically successful for the boys, or if it was a difference in the way teachers interact with groups of mostly-boys versus mostly-girls.

At this point, studies like this don’t give us much practical information on improving education, but do highlight areas for further speculation and research. There’s no denying that there are some basic differences, and further good, unbiased, objective  studies like this one ought to be able to help us improve our educational system to take of the unique advantages of both boys and girls.

Kindergarten penmanship– and a contest!

The Pediatric Insider

© 2010 Roy Benaroch, MD

Katie’s son has a kindergarten teacher that’s worried about his handwriting: “I have a 5.5 year old who loves kindergarten and is doing great in all subjects except handwriting. His teacher says he is behind the other kids and has suggested that I take him to get evaluated by an occupational therapist.” Mom says his handwriting is “legible, but not great,” and wonders if there are unreasonable expectations at his high-performing school.

Handwriting and penmanship are not skills that should be stressed in kindergarten. Kids ought to be coloring and doing mazes and painting and practicing hand-eye skills, but not by drilling and practicing letters all day. A kindergartener with handwriting that’s legible is already ahead of the game.

As I’ve written about before, schools have gone overboard with early academics and are stressing out kids and parents. Psychologists, occupational therapists, neurologists, developmental specialists, pediatricians, vision experts– we’re all involved now, and many children have multiple specialists to manage their academic shortcomings. Some children do need and benefit from early intervention for learning disabilities and other school problems, but that ought to be the exception, not the rule. Every child doesn’t need an evaluation, diagnosis, and therapy.

As long as your child’s handwriting doesn’t look like this, he’ll be fine. Even if it does, he can grow up to be a pediatrician!

Announcing The “Guess What Roy Wrote” contest!

The first person to post a comment deciphering even one of the three things on my hand-written todo list will get a free copy of one of my books! Enter as many times as you’d like, just post your guess as a comment below. My wife is disqualified, as is my kindergarten teacher.

That belly ache isn’t all in your head

The Pediatric Insider

© 2010 Roy Benaroch, MD

About 25% of children experience frequent belly aches, and abdominal pain is a very frequent cause of pediatrician visits and school absences. The majority of kids with belly aches don’t have any serious underlying disease, which might lead some parents and doctors to say “It’s all in their heads.” A recent study contradicts that opinion, and  reveals some new insights into the cause of belly aches in children.

First, some terminology. Traditionally, we’ve divided abdominal pain into two categories: “organic” and “functional.” Organic means that some organ is involved or broken—there’s something abnormal you can see on a biopsy or blood test. “Functional” pain is an awkward term, but it means that the pain is arising not from tissue damage or pathology, but from the functioning of the gut. We can’t find anything objectively wrong, but there is still pain. Functional abdominal pain is more specifically often diagnosed as “Irritable Bowel Syndrome” (IBS). The older term Chronic Recurrent Abdominal Pain is discouraged, because of its unfortunate acronym.

So what is Irritable Bowel Syndrome, if it isn’t a disease that you can see or prove with a microscope? We know it runs in families, and that the pain can be intensified by emotional stress. Psychotherapy or treatment for depression can help the pain, at least sometimes, as can regular exercise and stress-reduction strategies. Diet can certainly make IBS worse, especially a diet with lots of refined sugars and weird processed chemicals. All of this has been known for years. What’s new is an emerging understanding of what makes kids (or adults) with IBS different from other people.

A study published in the January, 2010 issue of The Journal of Pediatrics looked at a potential new test that could be used to diagnose IBS. (Skip the rest of this paragraph if you’re extra-squeamish, but you’ll be missing the cool part). The authors determined the “Rectal Sensory Threshold for Pain” in kids with abdominal pain caused by IBS versus children with abdominal pain caused by organic diseases. To do this, a balloon was inserted into the rectum, and inflated until the child reported pain. What they found was that most of the children with IBS experienced pain at much lower pressures than children with organic disease. The authors suggest that this method could be used as a diagnostic tool.

The study shows us something more important about children with IBS: they have an increased sensation of pain to stimuli that doesn’t cause pain in other children. Both groups of kids had the same amount of distension from the balloon—not enough to cause any harm—but the children with IBS found that procedure painful. The biopsies and tests are normal because there isn’t any actual tissue damage, yet the pain sensitivity these kids experience is very real and testable. Irritable Bowel Syndrome is a disease of increased sensitivity to pain, when bubbles of air or stool masses or other feelings that most of us do not find uncomfortable cause pain. The pain itself is real, and isn’t “all in their heads”.

If your child is experiencing frequent abdominal pains, go see your pediatrician. There are other potential causes that need to be explored—lactose intolerance and constipation are both common. Usually, a careful history and physical is all that’s needed to confirm a diagnosis, though sometimes some blood or stool tests are needed. If your child does have Irritable Bowel Syndrome, it’s good to know that it’s not serious, and that some simple lifestyle and dietary modifications can help. More severe cases can be referred to a pediatric gastroenterologist for further evaluation and treatment. And the balloons are optional.

The ears, they are a-piercin’

The Pediatric Insider

© 2010 Roy Benaroch, MD

BB has mixed feelings about getting her daughter’s ears pierced: “What are your thoughts on the safety of piercing a baby or toddler’s ears? I’ve read mixed info about the ‘best’ age to pierce a young girl’s ears. I’d like to know what pediatricians typically recommend. I know this isn’t likely a pressing medical issue, but I want to make a safe, wise, informed choice for my daughter.”

Early or later piercing are both safe, so it’s mostly just a matter of family choice. Some families prefer to pierce early, before a baby could remember it; others want to let a child decide for herself when to do it. Some people like to pierce ears even in the newborn period, and I’ve never seen or heard of any sort of important complication from early piercing.

In fact, the few complications I have seen have been in teenagers rather than babies. Teens aren’t always as good about keeping new piercings clean (new piercings are far more likely to get infected than old, established holes.) I’ve seen a few teens (boys, naturally) ignore their posts completely, so skin grows over the front or the back. Also, teens are more likely than young children to develop keloid scars after piercing.

Whenever you do pierce, follow the instructions on keeping the area clean and using an antiseptic solution. It’s best to do the first pierce with good gold posts, and leave them in for a long while; don’t swap them over to little skinny loops until the hole is mature. The backing should never be tight against the back of the ear—leave a little wiggling for growth and to allow good air and blood circulation. Though the backing shouldn’t be tight against the ear, it does need to be tight on the post to keep the earring in the ear and out of a young child’s mouth. If there are signs of infection like increasing pain, warmth, redness, swelling, or drainage, go see your doctor.

Every once in a while, I get asked about doing ear piercing in my office. I’m not so sure that’s a great idea. Personally, for my own daughters, I’d rather have a piercer who does these all day, every day.

What about piercing other body parts? Holes through ear cartilage are somewhat more likely to get infected, and those infections can be more difficult to treat. Still, they’re usually fine. Lips and noses and eyebrows don’t seem to lead to many problems. However, tongue pierces can increase the risk of some very serious infections—like brain abscesses—and can cause speech problems and broken teeth. As for more exotic piercings south of the mouth—I don’t even want to know.

How much milk does a newborn need?

The Pediatric Insider

© 2010 Roy Benaroch, MD

Honk honk honk. (Traditionally, this would be “beep beep beep,” but I have my phone set to alert me with a bicycle honk for new text messages. It’s a riot at 3 am.)

“Newborn nursery.”

“Yeah, this is um… the doctor, calling back…someone.”

“The nurse needs to reach you, please hold.”

…and that’s why you shouldn’t kiss a pig. Did you know it’s bicycle safety awareness week?Your call is very important to us. Please hold for the next available…

“Yes, this is the nurse. What do you need?”

“You called me.”

“Who?”

“Me. The doctor. Doctor Me.”

“About Baby Grisham?”

“I don’t know who about. You called me. I’ll be there in the morning.”

“This can’t wait. The baby is spitting a lot, and needs a change in formula.”

“What?”

“We’ve been giving him Enfalac, but he’s spitting, so I need an order to change him to Simamil.”

“How old is this baby? What baby?”

Sigh. “Baby Grisham, born at 2300 hours.”

Doing math in my head. I can’t ever figure out those ‘hours’ times. “So he’s…three hours old?”

“Yes, mom’s not breastfeeding, and he’s spitting up his Lactosimacare.”

“How much?”

“A lot.”

“No, I mean, how much are you giving him?”

“Only 2 ounces.”

“OK, here is what I want you to do. Let the baby sleep in the room with mom, and stop feeding him so much. In two or three hours, give him just a little bit.”

“A little bit?”

“Yes, just a teaspoon. Five ccs, that’s it.”

“He’ll be hungry!”

“No he won’t. Normal newborns less than a day old barely need anything to eat. If you look at breastfed babies—and those are the babies eating the way they’re really supposed to eat—they get maybe, tops, an ounce of milk taken in over the whole first 24 hours of life. And they do fine. Just stop drowning this baby, and he’ll be fine, too.”

A study just published in The Journal of Pediatrics confirms what I’ve been saying for years: normal newborn babies need to take in very, very little over their first day of life. Ninety healthy, term, exclusively-breastfed babies were weighed very carefully with an ultra-sensitive scale before and after feedings to determine exactly how much milk was ingested. The average intake for the entire first 24 hours of life was 15 ccs—that is, one tablespoon. The range was from 1 to 30 ccs. That fits with exactly what we ought to expect from the physiology of a newborn and of a new mom. A newborn has just been through a traumatic transition, and has a gut that’s filled with sticky mucus. The normal “peristaltic waves” that push food along through the gut to help digestion haven’t yet begun. So it makes sense that a normal newborn isn’t quite ready to accept a full meal on the first day of life. It also fits exactly with what we know about a normal, healthy mom. Milk doesn’t “come in” until about 48-72 hours after a baby is born. Moms aren’t supposed to have a good milk supply during a baby’s first day of life. Now, some babies are going to get impatient and yell about this. That doesn’t mean they’re extra-hungry. It does mean that some babies, like some nursery nurses, don’t like to wait!

All of this assumes a healthy full term baby without additional risk factors for low blood sugar or other problems. If you’ve got a baby with special health circumstances, you need more specific advice and guidance.

H1N1 update: Can we relax now?

The Pediatric Insider

© 2009 Roy Benaroch, MD

While no one is ready to call it over, H1N1 season seems to winding down in most parts of The United States. In my practice, we’ve seen only a handful of cases in the last few weeks. We’re also getting far fewer panicked phone calls for Tamiflu (the wonder-drug, as in “I wonder why so many people think this stuff works so well?”) The vast majority of children and adults who had H1N1 (or “Swine”) flu recovered after four or so days of fever and misery.

Whew.

There are definitely some sobering statistics. About 1 in 6 Americans probably came down with this flu by mid-November, an astonishing number that reflects just how rapidly and thoroughly a new virus can spread. There have been far too many deaths among children: about 212 at last count, a number that is certain to rise as further reports are processed. Obese adults and pregnant women also turned out to be particularly vulnerable.

The vaccine turned out to be both safe and effective, but probably didn’t reach a “critical mass” of widespread availability until a little too late for most people. Cases of H1N1 are waning just as the vaccine is becoming easy-to-find, and it’s difficult to know for certain just how big an impact the vaccine has had on the epidemic. The Swine Flu of 2009 illustrated some important lessons for dealing with an epidemic: it takes too long to make influenza vaccines using current technology, and it’s difficult to distribute millions of doses of vaccines through 50 states and thousands of health departments. Hopefully lessons from this pandemic can spur development of improved vaccine technologies and public health infrastructure to support a massive delivery of vaccines, medicines, and  other stuff needed to keep a country healthy.

Some dosing issues for the H1N1 vaccine were confusing. Early studies showed that a single dose was effective in adults, but that two doses were needed in children. Because of poor availability and quirks in the FDA licensing, getting two doses into children proved quite challenging, and I’m doubtful that even now most families have gotten both doses for their kids. A more recent study from Australia trumpeted in the headlines just this week announced that a single dose is effective for most children—but that formulation used twice as much influenza antigen in each dose, so the results really don’t apply to the H1N1 vaccines available in the United States.

At this point, I still recommend that children who haven’t yet reached their ninth birthday get two doses of the H1N1 flu vaccine. Though the epidemic is winding down, in some years flu comes back when the coldest part of winter hits, after children return to school in January. Also, H1N1 is not going to disappear after this year—you can bet it will be part of next year’s flu season. Getting two doses this year means that your child is primed for good immunity next year (when presumably H1N1 will be included in the ordinary seasonal flu vaccine.)

There was also a recent recall of some lots of children’s H1N1 vaccine, about 800,000 doses in total. These lots were found to be a little less potent than they were supposed to be, by about 10-12%. The affected lots were only designed for children less than three, who all are supposed to get a second dose. Even if your child got one of these sub-par doses, as long as you get that second dose of vaccine your child will be well-protected.

So: yes, H1N1 was pretty bad—many people got sick, and some died. But it wasn’t a huge catastrophe. Hopefully, the worst is behind us. Keep washing your hands and using that hand sanitizer, and if you haven’t been immunized yet, it’s still a good idea. Children less than 9 still ought to get two doses of H1N1 vaccine, which has been remarkably free of serious side effects.

Not that anyone wants to hear about this, but there’s the “regular” flu season, still to come! Just because H1N1 has overshadowed other causes of flu so far, don’t expect that we’ll get to skip the ordinary flu season. That’ll be here, probably in January. Did I mention you ought to keep washing your hands?

I know the kids are delighted to have to get two kinds of flu vaccines this year, for both H1N1 and for ordinary seasonal flu—so plan to stop by QuikTrip for a tasty chocolate-mint milkshake on the way home. Or pick up a box (or three*) of Trader Joe’s Candy Cane Joe-Joes. Either one will put a smile back on a child who had to get a shot. Heck, they’re probably more effective than Tamiflu for a child who ends up getting the flu.

*One for child, one for you, one to mail to me!

Lessons from Dr. Patty

The Pediatric Insider © 2009 Roy Benaroch, MD

For Dr. Patty de Urioste (1954-2009), a great pediatrician, partner, and  friend

1. Don’t rush. Even if you’re behind. Even if you’re waaaaay behind. Someone needs your time, and lunch (or dinner, or bedtime) can wait.
2. Have a plan. There is something that needs to be done next, even if the diagnosis is unclear. Decide what to do next, explain it, and do it. Parents need to know there is a plan.
3. Ask for help when you need it. No one knows everything. Call the specialist, call the ER, call the radiologist. Nag them if you have to, politely of course, until they tell you what you need to know. And remember it for next time.
4. Listen to your gut. If the kid looks sick, or the kid looks wrong, do what you need to do. Don’t trust the history or the labs or the x-rays more than you trust your own gut.
5. Help the patient. You might not have all the answers, and parents don’t expect a cure every time. Do what you can to help.
6. Treat your employees like family. Pay well, listen, and make your business a good place to work. They’ve got your back if you’ve got theirs.
7. Don’t miss an opportunity to learn. Every question is a chance to learn something new, and you never know when you’ll need that new tidbit again.
8. Eat lunch. Whatever happens, however late you are, you must eat. And use the bathroom, too.
9. Love books. Order them, buy them, smell them. You’ve seldom seen someone as happy and excited as Patty with a new load of medical textbooks.
10. Don’t complain to patients. They care about you, but they’re there for their own problems. Focus on them.
11. Listen. Someone is trying to tell you something.
12. Wake up early. There’s time to sleep… later. No one regrets not getting enough sleep. Many people regret things they never got to do.

Refusing milk from a cup

The Pediatric Insider

© 2009 Roy Benaroch, MD

 

Analise is trying to get her daughter to continue drinking milk: “My daughter is 14 months old and will only drink milk from a bottle. We introduced a sippy cup at 9 months but made the mistake of only putting water in it. Now she associates the cup with water and the bottle with milk. We’re in the process of weaning her from the bottle but don’t know how to convince her to drink milk from a cup. Do you have any tips or is it just try, try again until she accepts it? Thanks for any behavioral insight or advice!”

 

First, let me get myself in trouble with the dairy council and moms everywhere by letting this secret out: there is no essential need for toddlers to drink milk. It’s a good source of protein and calcium, sure, but there are plenty of other good sources. Lots of children stop drinking milk, and many adults never touch the stuff. There’s no reason to consider milk something crucial for children to drink once they’re outside of the young baby years and able to take solids well.

 

At fourteen months, whether or not your child is willing to drink milk from a cup, you ought to stop using baby bottles. They’re bad for her teeth, and they’re preventing her from developing normal eating habits. Don’t worry that your child won’t get enough fluids—she’ll drink water, and she will not become dehydrated without milk.

 

Though milk isn’t essential, it’s handy and most children continue to drink it. There are, of course, tricks worth trying to get her to drink milk from a cup:

 

• Add a little milk to the water in a cup, and day-by-day start adding more milk and less water. In a few weeks, you can wean up to full strength milk. Do this gradually and maybe she won’t notice.
• Add something to the milk to make it extra tasty: chocolate syrup, or maybe a mashed-up, very soft banana. Little girls (and boys) deserve a little chocolate in their lives.
• Try a different sort of cup, like one with a straw—maybe even a crazy bendy cool straw.
• Make sure she sees you and dad drinking milk from a cup. You two can even use sippy cups for a little while. If parents don’t drink milk, children are far less likely to want it.
• If you’ve been using whole milk, give 2% or skim a try. Older advice did recommended whole milk, but that’s not necessary.
• Try a different sort of milk, like soy or almond milk. These provide similar amounts of protein and calcium as cow’s milk. Rice milk, on the other hand, is a low-protein beverage more similar to juice than milk—stay away from it if you’re looking for something with nutritional value for your children.

 

What to do during the transition? Don’t worry about it. There is no reason a child can’t go weeks or months or even years without milk. If your daughter gets the impression that milk is something very special and important, she’s less likely to touch the stuff—this is called “yanking your parents’ chain,” a skill that all children learn sooner or later. Don’t get caught up in the drama by letting her know you’re worried about this. Win the chain-yanking match by dropping your end.

 

If in the long run your daughter still won’t touch milk, you’ll need some other good calcium sources:

 

• Any other dairy: cottage cheese, yogurt, cheese, ice cream
• Calcium fortified juices
• Calcium supplements, like the little chocolate squares marketed for women as Viactive
• Non fat dry milk powder. Don’t mix this in water to try to drink it—bleach—but sprinkle it in casseroles, soups, eggs, sauces, that kind of thing. Once it mixes in it’s just about impossible to taste. Think of it as cheap calcium –n- protein powder.

 

Try some simple tricks to see if you can get your daughter back on milk, but remember there is no hurry here, and this is not a crucial or even a very important issue. Milk is easy and cheap, but there are many other nutritious things your daughter can take that can replace milk if she’s decided she just won’t drink it any more.

Blink blink blink = tic tic tic

The Pediatric Insider

© 2009 Roy Benaroch, MD

Mark’s frustrated. His son has gone through several months when he seems to blink a lot—then it goes away, then it comes back later. It doesn’t seem to bother the boy. One doctor said it was allergies, and prescribed an eye drop; another one says it’s a compulsion, and that dad should ignore it. What’s going on here?

Most likely, he’s got a tic. Not a tick—that’s a blood sucking beetle-looking thing—but a tic, which is a quick, short involuntary muscle movement. The most common tics seen in kids are blinking, followed by throat clearing; sometimes kids have a little quick facial grimace or a neck-turn.

You’ve got the wiring for a tic, too. Let’s watch yours. Go ahead, stop blinking. I’ll wait here. Dum dee dah dum. Still not blinking, right? It’s getting hard….hard to not blink…have to concentrate…so, do any fishing lately? no? ….wait …no blinky….wait….arrrgh blink blink blink blink blink blink. Aaaaaaa. That’s better.

What happened? Believe me, your eyes didn’t dry out that quickly. So why did you feel an urge to blink?

That’s basically what a tic is. It’s an involuntary movement—you can’t put it off, you’ve just got to do it. If you don’t, it gets harder and harder to stop it…until…blink blink blink! Blinking, in all of us, is like a helpful tic, an automatic mechanism to keep your eyes healthy. But sometimes that mechanism causes excessive blinking, or other sorts of quick involuntary movements that can’t be suppressed.

About 1 in 20 of us has a tic, and tics usually start to develop in early childhood. Usually, the individual tic goes away after a few months. But children who’ve had a tic in the past are quite likely, even after several months or years, to once again develop a tic, often a different one.

Do not tell a person with a tic to stop it. If he tries, the tic will become harder and harder to resist, until it returns in a more exaggerated fashion. The best therapy? Don’t talk about it.

Tics do get worse with emotional upset, anxiety, or tiredness. They stop completely when you fall asleep. Many people blame incessant throat clearing on “allergies”—but oddly enough, when they sleep, there’s no need for throat clearing at all. You’d think lying down would just encourage a nice pool of mucus, wouldn’t you? So why is there no need to clear the throat during sleep? Most throat clearers aren’t allergic—they’ve got a tic. But their minds “invent” the feeling of phlegm and the allergy story. Amazing, the mind, what it will come up with.

Most children with tics have only one, and it goes away on its own after a few months. No treatment is needed. Rarely, children develop multiple complex motor and vocal tics, often associated with difficulty concentrating at school. This is Tourette’s Syndrome—more serious, but far more rare than an ordinary tic. If your child has multiple tics and especially if school is becoming a problem, see a pediatric neurologist. Medicines are almost never necessary for simple, non-bothersome tics, but for the rare child with more serious tic issues medication can be very helpful.