Archive for the ‘Nutrition’ category

Eat peanuts during pregnancy to prevent allergies

April 14, 2014

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.

When to start solid foods, and what to start with

November 11, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

I like writing about food and feeding issues, especially for babies and toddlers—mostly because there is so much misinformation out there, information that’s complex and confusing and difficult for anyone to keep straight. Start avocados at 33 weeks, start egg whites at 42 weeks, move from stage 1 to stage 2 jars after baby gets 1 ½ teeth. Rules, rules, rules.

All that stuff is a crock. Feeding babies is much simpler.

When to start solids: somewhere between 4 -6 months of age is an ideal window. Babies are happy to meet new things and have new experiences then, and they’re really interested in what you’re eating. So give them a taste.

There’s plenty of medical evidence that 4-6 months is an ideal time. You’ll minimize your child’s risk of celiac and type 1 diabetes, and provide essential iron and vitamin D that’s inadequately supplied by nursing alone. Starting earlier than this window seems to increase the future risk of obesity; starting later can lead to problems with oral motor functioning, and can increase the risk of food allergies.

What foods to start with: anything you like. The old advice, to start with (and stick with) rice cereal never made any sense. There’s nothing magic about rice cereal.

The only requirement for first foods is that it can be mushed up. Junior isn’t going to chew anything just yet, so whatever you’re feeding him needs to be, essentially (but not literally) pre-chewed. You can start with a banana or avocado, and mash it up with a fork; you can start with some well-cooked noodles, and mush them up; you can start with some soup vegetables, or a bit of egg, or ground meat, or just about anything else. Don’t be afraid of flavor, and don’t limit yourself to what the baby food companies put in jars.

The only foods to watch out for are choking hazards, foods that are too stiff or unmushable for babies to handle. Think steak, pecans, raw vegetables, or Al Gore.

There’s also a special admonishment against honey for babies less than 12 months of age, because it can transmit botulism in babies. That’s a really short list of things that babies shouldn’t be fed.

If you like, you can start with a single food and build up from there, starting a new food every few days. That’s been advised for years, to help parents tell which foods might have caused which reaction. But most babies will not have food allergies; and most food reactions in babies are mild. If there is a strong family history of genuine food allergies (say, in both parents or in siblings), you can take feeding slowly, one food at a time—but it is probably a mistake to delay solids altogether. Remember: introducing foods later may increase the risk of allergy.

That’s it—it’s almost too simple. Start at 4-6 months. Start with, pretty much, whatever you’re eating, just mushed up. Let your baby enjoy many different flavors, and share the meals (and the mess!) together. Yum!

The Guide to Infant Formulas: Part 5. The Final Recommendations

September 12, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Choices for bottle feeding are truly overwhelming. There are at least 20 different formulas out there—and I’m not even counting the special medical formulas for specific medical indications. Which one is the best for your baby?

The best “formula”, of course, is human milk. It’s cheap, it’s nutritionally super-good, and for many women it’s very convenient and easy. But it’s not for everyone. Some families like to supplement, or some families choose to bottle feed; some moms try their best but for whatever reason exclusive breastfeeding doesn’t work out. That is not a disaster, not by any means. We’ve got very good and nutritious formulas to use. Being a mom is tough enough—we don’t need to give anyone a hard time about not nursing.

So, when choosing a formula, what’s the best one to choose? Drum roll, please….

#1 for almost all bottle-fed babies

I’m giving the nod to one of any of the generic, store-brand, cow’s milk based products. They’re all fine. Save a few bucks for the college fund, or (even better) hire a babysitter with the extra $$ you would have spent on name-brand formula and go out to dinner without your baby. You deserve it.

Runner up: It’s a tie! All other ordinary cow’s milk formulas go here! Yay!

#1 if you’re avoiding cow’s milk for personal reasons

 

Any generic soy-based product, yay! The runner-up is any of the other soy products. You probably saw that coming.

#1 for fussy babies

 

It’s probably not the formula, you know. And it’s probably not a medical problem at all. Some babies are just kind of anxious or fussy, and need more holding and soothing. I like this guy’s approach. But if you’d like to try a formula change, feel free to try either a soy formula (which has different proteins) or one of the partially hydrolyzed products like Enfamil Gentlease, Similac Total Comfort, or any Gerber Good Start product. Don’t bother with any formula for lactose intolerance—I promise, that is not the problem.

#1 for babies with real protein allergy

These are babies with bloody stools or persistent vomiting or other health problems, and they ought to be monitored by a physician. Appropriate formulas for these babies are Similac Alimentum or Enfamil Nutramigen. Those formulas have very little role for any other babies, but are essential for babies with true allergy.

#1 for babies who spit up

If you really need to treat spit up (and usually you don’t), ask your pediatrician or family doc about adding rice cereal to the bottles—it’s cheap and easy and can reduce spitting. Or, you could try one of the “spit up” formulas (generic, or EnfamilAR or Similac Spit Up.) But I rarely recommend them.

Now I’ll take a few questions from the audience:

Do we really have to stick with one formula? What if I have coupons?

Most babies don’t care if you switch around. Save money, use samples and coupons. The taste might be a little different, but it’s not such a bad thing for babies to have to get used to different meals not tasting exactly alike.

Can I mix formula on my own, from scratch?

In the old days, before the wide availability of commercial formulas, people used to mix up baby formula with evaporated milk, added vitamins, and added carbohydrates or fats. Don’t mess around with any of that now—formulas are complex emulsions of many ingredients, and your baby will do much better on commercial varieties. Do not try this at home.

What about those follow-up formulas for babies after age one?

Traditionally, babies move to milk as a beverage at around age one, and stop drinking formulas. Often that’s a good age for nursing babies to wean. Really, there’s seldom any need for any specific “formula” other than a varied diet. Toddler formula is an unnecessary expense.

Are you expecting a Pulitzer for this series on infant formulas?

Not expecting, no. But it would look nice here next to my computer. Thanks for contacting the Pulitzer committee to suggest it!

The Guide to Infant Formulas

Part 1: What’s in formula?

Part 2: The Similac Products

Part 3: Enfamil and friends

Part 4: Gerber and the Generics

Part 5: The final recommendations

The Guide to Infant Formulas: Part 4. Gerber and the Generics

September 4, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Abbot’s Similac and Mead Johnson’s Enfamil are the big players, but they’re not the only formula choices out there.

What used to be called “Nestle Good Start” is now part of the Gerber Good Start line of formulas, which are often priced just a little less than those of the two better-known formula companies.

Good Start, whether from Nestle or Gerber, has always had a slight difference from the flagship products from Similac and Enfamil: it uses partially broken down elements, which they market as “comfort proteins”. They say this is easier to digest. Their products are similar in that way and in that claim to the partially hydrolyzed Similac Total Comfort or Enfamil Gentlease—and similarly lack any good data supporting this “easy digesting” claim. Still, like all formulas, it’s nutritionally complete to the best of our knowledge.

Like the other companies, Gerber has lately jumped on the “market segmentation” bandwagon, coming out with multiple similar products to grab market share. But their products are even less dissimilar from each other. There’s Gerber Good Start Protect, which I think is their flagship. “Protect” here refers to their probiotic mix of bacteria, which per their literature “may support the protective barrier in the digestive tract.”

There’s also Good Start Soothe, which has reduced lactose—but isn’t lactose free. So it’s treating a condition that doesn’t exist (lactose intolerance in human babies) with a treatment that would be ineffective. It of course has those probiotics and things, too.

Then there’s Good Start Gentle which is based on only the whey portion of cow’s milk protein, partially hydrolyzed like other Good Start products. So you get to choose, with Good Start: Gentle, or Protect. Or Soothe. Can’t have them all!!

One more Good Start product, this one with an intuitive name: Soy. That’s right, a soy based product, with partially broken-down soy proteins that may or may not be better in some vague way. These Gerber products are all nutritionally equivalent.

The Gerber line is priced a tad lower than the Enfamil or Similac lines, but is still more expensive than generic baby formulas. Those generics, like all formulas, are tightly regulated by the FDA, and offer essentially identical nutrition.  There are generics marketed as “Premium” or “Advantage” that are similar to the flagships; there are generics often labeled as “gentle” which are similar to the partially hydrolyzed formulas Gentlease, Total Comfort, and the Gerber Line. There’s a generic lactose-free labeled “sensitive” and “tender” which seems similar to Gerber’s “gentle,” with 100% whey. Soy, organic, or even with added rice starch—the generic versions are out there, though sometimes they’re named differently. Between the generics and Gerber, that’s at least 10 more varieties of infant formula to choose from.

One formula you won’t find: “Low Iron.” There used to be Low-Iron formulas around, because iron was blamed for fussiness and constipation—despite there never having been any evidence that in the doses found in formulas, iron was causing these symptoms. What we did know what that low iron formulas were nutritionally inadequate. Iron is essential for normal brain development, and restricting iron from babies is not a good idea. The formula manufacturers quietly increased the iron in their low iron formulas several years ago, and a few years later phased them out entirely. Good.

We’ve covered a lot of formulas, and a lot of detail. So what’s the bottom line? What’s the best formula for you baby? See you next time!

The Guide to Infant Formulas: Part 3. Enfamil products

August 30, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

There certainly are a lot of choices when it comes to infant formula, aren’t there? Last time we saw all of the colorful ones offered by Abbot. Let’s see what else it out there.

The other big manufacturer of infant formulas is Mead-Johnson, with their Enfamil line. Enfa, I guess like enfant, which I think is a baby elephant; -mil meaning, I don’t know what. I couldn’t find anything about where that name comes from on their site. What I did find, unlike Abbot’s Similac site, are lots of photos of cute babies.

Enfamil introduced a new twist: staging different formulas for different-aged babies. They claim that human breast milk varies as a baby grows, which is true; and they claim that their newborn-oriented product has a protein mix that more-closely matches that of moms who are nursing newborns (as opposed to older babies). The catch here is that there’s a lot of variability among women. That ratio of the protein mix varies quite a bit, and isn’t really the same among women; when it starts to change is variable, too. Plus, there’s no actual clinical evidence that somehow more-closely matching the whey-casein ratio makes any difference, especially because it can’t be matched individually to each mom. But in any case, that’s the shtick, and that’s what makes the Enfamil line at least a little unique.

Enfamil’s flagship product for littler babies is “Enfamil Newborn”, which of course has a similar blend of DHA and prebiotics as everyone else. They also say it has a “tailored” level of vitamin D for its target age – 0 to 3 months – though the AAP recommends the same 400 IU/day for babies of all ages.

Moving past of their newborn-specific formula, the next “flagship” product is Enfamil PREMIUM Infant (that’s their capitals, not mine.) This is product says it’s tailored for babies 0-12 months, which overlaps their other product tailored differently for 0-3 months, but perhaps they used a different tailor. In any case, Enfamil Infant (I’m not typing PREMIUM every time) is a fine cow’s-milk based formula for babies. It’s got all of the stuff we’ve been talking about.

Enfamil, of course, can’t just stop there. They’ve got a product with partially hydrolyzed proteins (similar to Good Start and Similac Total Comfort) called “Enfamil Gentlease”. That’s named maybe after the word “Gentle”, or less-likely the word “Lease”. Though I like the name, as I’ve said before there’s no clinical evidence that these partially hydrolyzed formulas are an improvement, but they’re certainly nutritionally equivalent to ordinary formulas.

Enfamil has a spit-up formula, similar to Similac for Spit Up, called EnfamilAR. I can’t tell if AR means “added rice” or “anti-reflux,” but they claim it reduces spit up by “over 50%”. That sounds suspiciously like the 54% that Similac for Spit Up claimed, though the number is less specific. Advice for Enfamil people: use exact numbers, they look more “sciency.” In any case, Sim for Spit Up and EnfAR seem about the same in every important way.

Enfamil’s soy-based product is Enfamil ProSobee, and their extensively hydrolyzed product is Nutramigen. There’s very limited need for these. They also have a formula for preemies, and a whole host of metabolic and other formulas for specific medical needs that are very rarely needed—but kudos to them for developing and selling them. For babies that need special formulas, Mead-Johnson has come through.

So: Mead-Johnson’s Enfamil line has your basic milk and soy and hydrolysate formulas, plus a slightly-different-in-an-unimportant-way Newborn formula, plus a few bonus versions. We’ll call it 6 formulas, plus the 7 from the Similac line. Are thirteen enough choices already? Of course not! Next up: the “minor” company and the generics.

The Guide to Infant Formulas: Part 2. The Similac choices

August 26, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Last time, in Part 1, we talked about the ingredients in infant formulas. Despite the advertising, they’re all much more similar to each other than you’d think. This time I’ll go through the products from the major companies. Infant formulas have complicated and overlapping names—what’s really the differences, and how should you choose?

First, Abbots’ Similac family of products. Get it, “Similac”? Lac, referring to milk; simil, like similar? I like the name! So what have they got in their stable?

Their flagship product for “routine feeding” is “Similac Advance,” a cow’s milk based product that has as much good stuff as any other formula. It’s got the DHA. It’s got the lutein. It’s got a nice baby-blue package. They also market for “routine feeding” Similac Advance Organic, in a green package (green = natural and organic!), which has the same stuff, though a “unique Lutein and DHA blend.” Does unique mean better? Who knows. What it does have as a carbohydrate source is organic cane sugar, which probably makes Similac Organic taste sweeter than human milk or other formulas. I’m not sure that’s a good thing, to get baby used to sweeter tastes, but it might not matter one way or the other. Still, if you’re choosing Similac Organic, you’re choosing the sweet stuff.

On a separate page, Abbott has a number of formulas “for sensitive tummies.” I guess Sim Advance is for those tougher babies! The “for sensitive tummies” choices include Similac Sensitive, which is essentially the same as Similac Advance, but without lactose. Now, lactose intolerance is just about unseen—ever—in human babies, so there is really isn’t any biologic basis for this product to be any better for any babies than Similac Advance. It does come in a soothing orange package. There’s also “Similac Total Comfort”, which has milk-based proteins that are broken down to some degree, “for easier digestion.” In a way, this is their version of Carnation’s “Good Start”—more about that later. There’s no good independent evidence that breaking down these proteins aids in digestion, and it certainly won’t help treat protein allergy. The package is a lightish purple, and reassuringly says it’s FOR DISCOMFORT, then in smaller type “due to persistent feeding issues.” If discomfort is from other things, I suppose the purple packaging won’t help much.

Similac has two more “sensitive tummy” formulas. One is “Similac Soy Isomil” (or what used to be just “Isomil”) which uses soy rather than milk protein. The AAP recommends soy formulas for very few babies—including those from families who wish to avoid cow products, and for the very rare babies with hereditary inabilities to digest certain sugars. For almost all babies, soy is not necessary, and it’s certainly not more digestible than cow’s milk base formulas. The last “sensitive tummy” formula is “Similac for Spit Up” which adds rice starch to thicken the formula, especially once it’s in the low-pH environment of the stomach. They claim it reduces “frequent spit up” by 54%, a nice science-sounding number, based on “data on file”. That means they did the study and haven’t published the result.

There’s also a “Similac for supplementation” formula, designed they say “for breastfeeding moms who choose to introduce formula.” My read of the ingredients shows it’s almost entirely identical to ordinary Similac. It comes in a green container, though a slightly different shade of green than Similac Organic. They claim that by tinkering with the prebiotics, this product may lead to softer stools, though there’s no clinical evidence to support that. I can’t imagine why there needs to be a different formula for supplementing breastfeeding than for routine feeding, but then again I’m not in marketing.

Similac also has an “expert care” area, including Alimentum (genuinely hydrolyzed proteins for the relatively rare babies with real protein allergies), Neosure (for preemies), and Similac Expert Care for diarrhea. I won’t spend much time on these, but they really are for use only when recommended by a physician for specific medical reasons.

Whew. A lot of formulas to choose from! So many colors!

Next: The Enfamil line. Can’t wait!

The Guide to Infant Formulas: Part 1. What’s in formula, anyway?

August 23, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

There used to be only a handful of infant formulas. The ordinary kind, made from cow’s milk; plus ones made from soy protein. There have also been extensively hydrolysed products with broken-down proteins available for babies with protein allergies. That was it. Three choices for bottle-feeding.

Not any more. There are dozens of formulas, each one claiming to address some kind of need—there are choices that “soothe”, or other ones that provide “comfort”. There’s even one specifically for supplementing. There are the top-tier name brands, then a cheaper name brand (with multiple choices), and the store brands. Which is best? Which one should you choose if you’d like to give your baby formula?

We at The Pediatric Insider are here to help. Presenting The Guide to Infant Formulas, untainted by commercial interests, with all of the marketing stripped away.

So what’s in that stuff, anyway? Commercial formula manufacturers all claim to make a product that’s closest to human milk—but by law, most of the nutrient components of these products are all the same. The net content of almost all of the significant nutrients has to fit within a narrow range dictated by the FDA, including the content of the macronutrients fat, protein, and carbohydrates. There are also vitamins, minerals, and nucleotides in specific amounts. Though the sources of these nutrients can vary, and there is a little bit of wiggle room, the bottom line for all of these formulas is that in almost every important respect, the nutrient quality and quantity is the same.

All the manufacturers can do is to tinker about at the margins, adding a little of this, a dash of that. All of the important decisions about what’s in there have already been made.

About the sources of these nutrients: there are some differences, though for most babies it doesn’t matter. For instance, most baby formulas get their proteins from cow’s milk, which contains both whey and casein proteins. The different companies use different proportions of whey and casein, or sometimes claim to break these proteins down into smaller fragments that are (they say) easier to digest. Some use only the whey portion. But there is no good evidence that any of these differences will make any difference to any babies—and certainly not your baby.

Some formulas are based on soy proteins rather than cow’s milk. This may be a selling point especially for vegans, but for most babies it makes no difference. Milk protein allergy does occur, but many babies who are allergic to cow’s milk protein are also allergic to soy, so switching from one to the other makes little sense.

The fat and carbohydrate sources can be different. Some manufacturers use palm-derived oils, or oils from other sources; some use lactose (which is abundantly present in human milk as well), and others use sugars more similar to cane sugar, or use a broken-down form of sugar. Again, the nutrient quality of these is the same. Some like to market their products as lactose-free (because so many parents are intolerant of lactose), but lactose intolerance is very, very rare in human babies. It really just doesn’t happen. These choices of carbohydrates are all about marketing, not about nutrition.

There are some formulas that are “extensively hydrolysed” to cut up the proteins into little bits. These are appropriate for babies with genuine milk protein allergy (which isn’t very common, and certainly isn’t a common cause of fussiness unless accompanied by other symptoms.) They’re expensive, but are crucial for those few babies who genuinely need them.

So fats, carbs, and proteins—very little important differences there, for most babies. What else can the formula companies add or change to distinguish their products from one another?

Many products now contain additives advertized to change the “intestinal flora”—that is, to help babies establish helpful, healthy bacteria in their guts. The additives include “probiotics—those are actual bacterial colonies that may or may not make their way to the colon—or “prebiotics”, which are compounds that provide nutrition for bacteria, or otherwise change the intestinal contents to be more supportive of healthy bacterial growth. An even newer word is “synbiotics”, which are a mix of probiotics and prebiotics. Though there is a lot of research on these going on, there’s currently very little to zero actual clinical evidence that these improve the health of babies when added to their formula. Available studies might show a change in the composition or quality of stool—but is that even important? We don’t know what kinds of pre- and probiotics are best, we don’t know the doses, we don’t know how they interact, and we certainly don’t know that routinely adding them to formula is a good thing. For what it’s worth, they seem harmless. But all of the marketing about the proportions and amounts and special kinds of pro- & pre- biotics is just that: marketing.

About ten years ago, formula manufacturers started adding long-chain fatty acids, often from chemical sources abbreviated “AHA” or “AA” or “DHA.” These compounds are found in varying amounts in human breast milk, and seem important for brain and eye development—though studies of their actual clinical benefits have not been impressive. We honestly don’t know the exact amounts of these nutrients that are ideal, especially because the amount in breast milk varies very much with mom’s diet. Still, it’s probably a good idea to have them in breast milk, and almost all available infant formulas in the US now contain them. Some claim to have more than others, but again, we don’t even know what the “best” amount is.

A few formulas have additives to help with spitting up. Typically, it’s a modified rice starch that makes the formula a little thicker, or one that thickens even more when in the acidic environment of the stomach. These are meant to be used instead of just adding rice cereal to the bottle—and there is an advantage over adding rice, because you don’t end up giving extra calories. But these products are seldom necessary. Spitting is normal, and all babies spit at least some. For most babies who spit up, the best solution is to feed less, or feed slower, and worry less about the spitting. Babies who genuinely have health problems because of regurgitation (such as poor growth or esophagitis or recurring pneumonias) need a thorough medical evaluation, not an “added rice” formula.

Next up: I’ll go through the products out there and tell you what you need to know. And then: my final recommendations!

Vitamin D update: Your kids probably need more

May 23, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Charles wrote in about Vitamin D: “I read your post about Vitamin D from 2008. I continue to read about scientists learning how Vitamin D playing an important role in the immune system and how a significant portion of the population’s health (both adults and children) would benefit from having their Vitamin D checked. My doctor checked my Vitamin D during an annual checkup and recommended I supplement. Have your thoughts on Vitamin D changed much with 5 additional years for Vitamin D research? Do you recommend children have their Vitamin D levels checked?”

I last wrote about vitamin D in 2008? Wow, it has been a while! It is about time for an update—

First: As I sort-of-predicted in 2008, the AAP did increase their recommendation for Vitamin D intake from 200 to 400 IU/day for children of all ages. They’re also recommending that all babies who get less than 1 liter a day of formula (that includes all breastfeeding babies) get a supplement of 400 IU/day. US government authorities have settled on 400 IU/day for babies  less than 12 months, and 600 IU a day for older children and teens. These recommendations were based on widespread studies showing vitamin D insufficiency was common at all ages.

It’s still not entirely clear that 400 IU/day is adequate for all children—some have advocated for 1000 or 2000 IU/day for routine intake. It’s a difficult number to pin down, because many children make plenty of their own vitamin D in their skin when they’re exposed to sunlight. Less vitamin D is made that way in the wintertime, and among children with darker skin, children who live in cooler places, and children who for whatever reason don’t play much outside, or don’t have their skin exposed outside. A single, blanket recommendation for everyone may not be realistic.

What new have we learned since 2008? In addition to vitamin D’s well-known role in bone health, it seems to have some influence on the development of obesity and diabetes. It may also affect the way other hormones work, including steroid hormones and similar molecules that are used in asthma medications.

It’s also become even more clear to me that just about everyone is vitamin D deficient. I’ve been routinely checking vitamin D levels in kids (usually while drawing blood for other tests), and I will tell you that easily 90% of children are insufficient. The only “normal” vitamin D level I’ve seen recently was in my own child, who I know takes a daily supplement.

So: I’m not so sure it’s cost effective to test children, but it’s certainly a good idea to have children take a supplement routinely. 400-1000 IU a day of vitamin D3 (that’s the usual variety found in supplements) will make sure most children keep a good level of vitamin D. I’m not usually a huge fan of supplements, but this one makes sense.

Are sweets at bedtime a bad idea?

April 18, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jack wrote, “What is the deal with not allowing kids to eat dessert before bed? That’s how I was brought up, and how my kids have been brought up. My fiancée doesn’t allow her kids to have sweets after about 7:30 because she fears it will interfere with their sleep. Any truth to that theory? Or is it an old wives tale like not swimming after eating?”

That’d be one of those handy “little white lies.” Medically speaking, there’s no particular reason not to have sweets before bed, or (gasp!) not to eat prior to swimming.

I suppose if Junior does have a big bowl of ice cream, he’d better be sure to brush his teeth at bedtime. And a full belly at bedtime might just increase the chance of a nightmare. But I don’t think it really matters what the bedtime snack is.

There is a persistent feeling among many parents (and grandparents) that sugary, junky food gets kids hyper. I think that’s because these kinds of foods are often eaten at birthdays and happy occasions, when kids do get worked up. But when it’s been studied, simple carb meals don’t seem to change behavior in children, at least not when the kids and the observers are blinded. One study even looked at a small number of children with attention-deficit disorder, and found that sugar didn’t worsen their behavior. Those authors suggested that the perception of worse behavior may be related to those kids’ difficulty in adjusting back to classroom behavior after a snack.

In any case, I’ve found that it’s just about impossible to dispel the sugar-misbehavior contention, and I suspect it will be just as hard to convince parents that desserts before bed are no worse than desserts with dinner. It’s never bothered me or my kids, but if you’ve found it’s better to not have sweets later, that’s fine with me. It will at least make your dentist happy too.

Who needs to worry about arsenic in rice?

March 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

“Wemberly worried about everything. Big things. Little things. And things in between. “ – Wemberly Worried, Kevin Henkes

The bottom line: you can add arsenic in rice to your long list of health risks you don’t need to worry about. And you can add Consumer Reports to your long list of media outlets that you can’t depend on for reliable health advice. Inaccuracy and breathless scaremongering abound.

The latest Thing That Is Killing Us: Arsenic in rice. The scare started from a Consumer Reports article from November 2012, which they titled “Arsenic in your food”. Following up on their equally-flawed arsenic-in-juice scare article, Consumer Reports has now investigated the arsenic content in rice and other cereals. What they found wasn’t particularly compelling, so, predictably, they gussied it up to exaggerate the impact of their article.

Chemicals are a modern boogeyman. Ew, chemicals. But arsenic is a natural element, and it’s part of the earth’s crust. We cannot ever get 100% of the arsenic out of our food. Our bodies have developed coping mechanisms for arsenic and other toxins. We do need to minimize exposures, and we need to be sensitive to industrial and farming practices that increase the toxin content of food. But it is unreasonable and silly to pretend that any exposure to “chemicals” is bad, or that exposures need to be driven to zero, no matter what the cost.

Arsenic in food sources occurs in two forms, organic and inorganic. Both are toxic, but inorganic arsenic is the far-more-toxic kind, the kind that we really need to think about.  The Consumer Reports article actually makes that point, but then in their text and tables often reports total arsenic in contexts where inorganic (toxic) arsenic is what they ought to be reporting. For instance, they mention that a proposed World Health Organization upper limit for inorganic arsenic in white rice is 200 ppb; then in the table at the end of the article they report out total arsenic in ppb.

There is no set federal standard for the arsenic content of rice (nor many other foods), and Consumer Reports in the line right under their headline points out that these is a need for such a standard to be developed. Fair enough—because of the way it’s farmed in water, rice naturally seems to pick up more arsenic than other crops, and can account for a large portion of the exposure. But to make their point that the numbers come out too high, Consumer Reports comes up with a risk-per-serving limit of 5 mcg/serving, based on the acceptable EPA estimate for water. I’m thinking that most people consume water all day, every day, in large amounts. Rice? Probably not so much.

And even the number they use is kind of weird. They say that the federal limit is 10, but decide to use the state of New Jersey’s limit of 5. Why? If they used 10, the column of inorganic arsenic data in their table would only include measurements less than 10, so none of the numbers could be shown in scary red bold type. Go with the New Jersey number, then at least some of the quantities pop over the limit they extrapolated from water. (By the way, that’s what Consumer Reports did with their juice article, too. The federal or New Jersey limits of arsenic in water can’t just be directly applied to apple juice, rice, or other foods. The consumption patterns and exposures are very different.)

Anyway: I’ve written recently that rice cereal shouldn’t be a baby’s only food—starting at four to six months, babies can start a variety of complementary foods, including some rice, but also including other grains, fruits, veggies, meat, all sorts of things. Variety is better, both to minimize whatever toxins are present in whatever food Consumer Reports decides to test next, but also to decrease the risk of allergies and to get Junior used to the taste of different foods. It’s also more fun to mix it up a bit. So even though I disagree with their methods and the scary tone of their article, I agree with Consumer Report’s conclusion that little babies shouldn’t eat rice cereal exclusively.

Health reporting has turned into “write the scary headline, then write something to back up the headline”. Even when the primary source actually gets it right, or nearly-right, the thousand and one internet sites who amalgamate and reprint stuff turn reasonable articles into breathless screeds of horror.

If even a fraction of internet stories about the stuff that’s killing us were true, we’d all be dead.


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