Can more vitamin D improve the health of nursing moms and babies?

Posted February 11, 2016 by Dr. Roy
Categories: Nutrition

Tags: , ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

“Breast is best” is a simple, catchy phrase—but to be honest, it’s one that should be followed by a bunch of asterisks and qualifiers. Some mother-baby pairs have a hard time with nursing, and need support and understanding (rather than a simple dismissal of their concerns.) And breast milk, we know, isn’t a great source of absorbable iron, which is especially an issue for premature babies. But the biggest drawback of human breastmilk, compared with commercial formula, is that it is an inadequate source of vitamin D.

A new study shows that this doesn’t have to be the case. Perhaps insufficient vitamin D isn’t really a fundamental problem with breast milk, but a problem with mom’s vitamin D intake.

Backing up a second – we’ve known for a long time that breast-fed babies are much more at-risk for nutritional rickets than formula-fed babies. This is especially true for families with dark skin. Rickets is caused by insufficient vitamin D, and can lead to poor growth, bowed limbs, and other health problems. For most of human history our vitamin D came from sunlight exposure. The skin of babies and mothers can manufacture vitamin D, though it requires sunlight to do it. Darker skin is less efficient at making vitamin D than lighter skin.

To combat the risk of insufficient vitamin D in breast-fed babies, the AAP has recommended a daily vitamin D supplement, starting from birth. In practice, this recommendation is followed maybe 20% of the time. Parents don’t like to give their newborns medicine, and I think pediatricians are reluctant to focus on the possible inadequacies of human breast milk.

In the current study, researchers sought to determine if giving higher doses of vitamin D to nursing moms could result in enough vitamin transfer in their milk. 334 mother-infant pairs were recruited, and randomized into three groups. In group one, moms were given an ordinary vitamin supplement, and their babies a vitamin D supplement (400 IU/day, matching the current recommendation.) In group 2, the babies were given no extra D, but moms took 2400 IU/day; in group three, moms were given 6400 IU each day. Babies and moms underwent regular blood and urine tests to see if these doses resulted in good vitamin D levels in the babies, and to see if these doses caused any metabolic problems with vitamin D, phosphorus, or calcium metabolism.

There was a relatively high drop-out rate—of the original 334 pairs, just 148 stuck with the plan for exclusive breastfeeding, and were thus able to complete the trial (families who discontinued breastfeeding or added formula supplements were not included in the final analysis.)

All of the babies who received regular supplementation had robust vitamin D levels and normal biochemical testing – we know, if that 400 IU a day for babies is given, it works. That was group 1. Group 2, where moms were given vitamin D 2400 IU/day,  was a failure—they actually stopped this arm of the study early, because many of the babies in this group did not have adequate vitamin D levels on their blood tests. But the babies in group 3 – who themselves received no direct vitamin D supplements, but whose moms got 6400 IU/day—did as well as group 1, with perfectly good vitamin D levels and no evidence for any side effects or problems. And, bonus, their moms also benefitted, with normal vitamin D levels and no side effects.

A reasonable question, though—is 6400 IU of D a day safe for moms to take? A prior guideline from the Institute of Medicine had suggested an upper limit of 2000 IU/day (though that has since been increased to 4000); the Endocrine Society now sets their upper limit at 10,000. During the past decade many studies have used adult D supplementation in the range of thousands of units per day, and according to the authors of this paper not a single adverse event was observed.

This study supports a safe alternative for families, and perhaps one that’s easier to do. Moms are used to taking prenatal vitamins, and continuing to take them while nursing. Adding 6,000 IU of D to the typical 400 in a prenatal isn’t expensive, and seems to be safe and effective at making sure their babies get enough D. Breast milk can have enough D – but only if mom gets her own supplement.

Bear and sun

It’s time to rethink pertussis prevention

Posted February 8, 2016 by Dr. Roy
Categories: In the news, Medical problems

Tags: , , ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

A large, sobering study published in the March, 2016 edition of Pediatrics illustrates just how far we still need to go to effectively control pertussis.

Pertussis, also known as ‘whooping cough’, is a serious illness. Older children and adults get to enjoy a horrible cough for about three months—a cough that sometimes makes people vomit, break ribs, or pass out. Seriously. You haven’t seen a “bad cough” until you’ve seen the cough of pertussis. Worse: in little babies pertussis can cause breathing problems, seizures, and death. Though its caused by a bacteria, antibiotics (unless given very early) are ineffective at reducing the length or severity of pertussis. Prevention, in this case, is worth far more than a pound of cure.

Up until the mid-1990s, infants and children routinely received the whole-cell DTP vaccine (DTP = diphtheria, tetanus, pertussis.) It worked at preventing all three of these diseases, but had a relatively high rate of side effects, mostly fevers. Many of the suspected more-serious side effects (like encephalopathy and seizures) are now known to have been caused by genetic conditions, not the vaccine, but nonetheless parents and doctors alike welcomed a newer vaccine, the acellular DTaP. This newer vaccine, which replaced DTP in the United States by around 1998, caused fewer fevers, and was thought to cause fewer serious reactions, too.

The problem is that it just doesn’t work as well. And as the first generation of infants to get an all-DTaP series starts to go through adolescence, we’re starting to see the unintended consequence of that vaccine change.

In the current study, researchers used a huge database of information from the Kaiser Permanente system of Northern California. We’re talking solid, big-data research, here, the kind of study that requires consistent and reliable data across a huge set of patients. In this case, about 3.5 million patients across 55 medical clinics and 20 hospitals, using centralized labs and an integrated medical records system. If health things happen to this population, Kaiser knows it.

In 2010 and again in 2014, California experienced large epidemics of pertussis. A total of 1207 cases were among Kaiser teenagers, all with complete records of their pertussis vaccination status. And the results aren’t anything to be happy about. In the first year after an adolescent pertussis (Tdap) booster, the vaccine was about 70% effective in protecting against pertussis. Not great, but not terrible, either – until you look a few days down the road. The vaccine effectiveness drops off dramatically, year after year, down to only about 9% by four years after receipt of the vaccine.

Why does Tdap seem to provide such poor protection—much worse than was seen in the original licensing studies? It’s a generational change, and it goes back to the shift from DTP to DTaP in the mid-1990s. By now, these teens in California are old enough to have received DTaP, not DTP, as infants. The authors looked at the specific ages of pertussis cases during the 2010 and 2014 outbreaks, and the trends support the conclusion that teens who received DTP as infants get good, lasting protection from Tdap; teens who got DTaP do not.

Now what? Clearly, we need a more-effective vaccine, perhaps even resuming the use of whole-cell pertussis vaccine, at least for the earlier doses. But in the meantime, we have to do the best we can with what we have. Vaccinating pregnant women with Tdap does effectively prevent pertussis in their babies, especially when they’re the youngest and most-vulnerable. And adults (who got DTP as children) should get Tdap boosters too, to protect the children around them. Another idea (floated by the study authors) is to use Tdap in teens not as a routine booster, but as a strategy to control local outbreaks, taking advantage of the higher effectiveness seen for the first year after vaccination.

I don’t have the answers. I’m not happy to see studies like these, but examining and re-examining vaccine safety and effectiveness is something we need to continue doing, with an open mind, relying on solid evidence. Bottom line: with pertussis, we need to do better.

Whooping crane

Which doctors get sued the most?

Posted February 4, 2016 by Dr. Roy
Categories: Medical problems


The Pediatric Insider

© 2016 Roy Benaroch, MD

A study published this week in the New England Journal of Medicine can teach us a few things about doctors and lawsuits. While many docs will go their entire careers without a single malpractice suit, a small proportion seem to attract a whole lot of litigation. There might be a lesson there.

It’s a big-data study, to say the least. Professors from both the Stanford, CA medical and law schools put their huge-brained heads together, along with collaborators from Australia and the US Department of Health and Human Services. They used the National Practitioner Data Bank (NPDB), a “confidential” depository of all paid lawsuits in the US, along with American Medical Association data on every single doctor, MD and DO. 10 years of data, from 2005 through 2014, were examined, including information on 66,426 malpractice suits from 915,564 physicians. The NPDB only includes information on “paid claims”—meaning a verdict or settlement that results in money going to a plaintiff. Lawsuits that were dismissed or dropped could not be included in this study.

Some interesting findings:

  • Only 6% of physicians, overall, had a paid claim in the 10 year study period. In other words, the vast majority of docs don’t settle or lose lawsuits.
  • Only about 30% of filed claims result in any payments at all—most lawsuits are just dropped without money changing hands (this was not from the data of the current study, but from a reference in the ‘discussion’ section.)
  • Only 3% of paid claims went to satisfy court verdicts. When malpractice suits end with money changing hands, it’s nearly always as a settlement, not as a verdict. These things, it turns out, rarely “go to court.”
  • The mean claim payment was $371,000; the median was $204,000. If you wish to learn more about the difference between mean and median, go back to middle school.
  • Though most physicians had zero claims, a disproportionate number accounted for multiple claims. Approximately 1% of all physicians owned 32% of all monies paid to plaintiffs, and just 0.2% accounted for 12%.
  • A physician’s risk of future claims – of being successfully sued ‘again’ – increased by more and more as the number of previous lawsuits accumulated. Compared with physicians who had been sued once previously, physicians who had been sued twice had twice the risk of a subsequent lawsuit; physicians with three previous claims had three times the risk of another recurrence. It goes up even more from there.
  • Male physicians had about a 38% higher risk of a subsequent lawsuit, and younger physicians had a lower risk than older docs.

What can we learn from all of this? Though malpractice litigation and a “fear of lawsuits” is a frequent topic of discussion among physicians, most of us don’t get sued, most suits don’t get paid, and even suits that do get paid are usually in settlements, not at the end of court dramas. And a relatively small number of docs seems to account for a disproportionately large percentage of legal action.

The authors of this study didn’t speculate on why some docs are sued more frequently than others. An overly-simple answer is that some docs just aren’t very good—but that misses some important truths. The risk of a lawsuit is only partially related to bad medicine and bad outcomes. A lot of the risk, really, comes down to poor communication, and sometimes bad luck. It’s also likely that some of these “frequent targets” are docs who serve the riskiest, sickest patients that no one else will touch. Those very fragile patients likely have the worst chance of a good outcome, even though thy might be under the care of the most talented and smartest docs. No good deed goes unpunished, you know. Still, if you learn that your doc has been sued 7 times, it might be time to go looking for another physician. You don’t want to end up on the plaintiff’s side of the table.

I fell asleep.

More water means slightly less weight in New York schools

Posted February 1, 2016 by Dr. Roy
Categories: In the news, Nutrition, The Media Blows It Again

Tags: ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

A simple, safe, and cheap intervention looks like a good way to help fight obesity in our schools. But not by very much.

A study published January 2016 in JAMA Pediatrics, “Effect of a school-cased water intervention on child body mass index and obesity”, looked at the effects of installing new water dispensers in New York City school cafeterias. 1227 schools, including 1 065  562 students,  participated in the observational study, which tracked student weights and BMIs, comparing trends before and after the new equipment was installed.

Those new dispensers are called “water jets” in the study, and I *think* they’re just those typical water cooler things that offices use, with a big jug of water on top and a little flappy valve to get cooled water into a cup below. The study description says they both chill and oxygenate the water “to keep it tasting fresh”, and cost about $1000 bucks each. Furthermore, they “are relatively easy to use” (pretty clever, those New York kids.) The authors pointed out that participants were weighed and measured by PE coaches, whose scale-using skills have “previously been found reliable” (pretty clever, those New York coaches.)

The results: after these water jets became available, there was a statistically significant drop in BMI of about 0.025 points (it was just a touch more effective in boys than girls), and the percentage of children in the schools who were overweight dropped by .6-.9%. (from about 39% to about 38%).

I know, not very impressive. The statistics are solid—whether the authors looked at trends over entire schools, or at trends among individual students before and after water jet availability, these weight parameters did drop. And the drop is, technically, statistically valid and real. That’s how it’s been reported in the media. The New York Daily News said “Water machines available in schools can help kids lose weight.”

But the drop really wasn’t very much. Going from 39% to 38% overweight is good, but I think we ought to try to do better. You can lead a student to water, but studies like this show it’s hard to make them actually lose weight.

What should we do with all of this yellow paint?

Vitamin D for winter eczema – Try it

Posted January 28, 2016 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

Eczema is a chronic, itchy skin condition seen in about 1 in 3 children. The skin is dry and scaly, and often red and inflamed. Eczema often seems to get worse in winter, in part because hot dry air from the furnace further dries out the skin.

Or, maybe, there’s another reason. Researchers in Ulaanbaatar, Mongolia (which, by the way, looks lovely) postulated that another reason for eczema to worsen in winter was decreased vitamin D levels. Most of us get our vitamin D from sunshine, and in the cold winters people spend less time outside. Less outside, less sunshine, less vitamin D. So what happens if you supplement children with eczema, and have them take a drop of extra vitamin D in the winter?

107 children were enrolled in the study, which was published in 2014. The average age was 9, and almost all of the children had what the authors characterized as “moderate” eczema. Half of the children were randomized to receive a vitamin D supplement (1000 IU once a day), and the other half a placebo drop; all of them were instructed to continue their typical eczema care, which usually consistent of skin moisturizers. A simple, clean study.

A month later, data were collected. There were no significant (or even mild) side effects in either group. 64% of the children who received extra vitamin D had improved skin, versus 43% in the control (placebo) group. Not a huge difference, but with an intervention that’s safe and cheap, that’s an important result that can potentially help a lot of children.

Some criticisms of the study: the authors didn’t check vitamin D levels before or after the intervention—so we don’t know if the children were actually vitamin D deficient, or if vitamin D supplementation was more likely to work in children with low levels. And the study didn’t involve many younger children (who are more likely to have eczema), and didn’t include any children less than 2 years of age.

Still: many children, we know, are vitamin D deficient, especially in the winter; and many children suffer from itchy eczema. At usual doses (like 1000 IU a day), vitamin D supplements are virtually free of risk. Worth a try, if your child has winter eczema? You bet.


Parents are tired

Posted January 27, 2016 by Dr. Roy
Categories: Medical problems

The Pediatric Insider

© 2016 Roy Benaroch, MD

This just in, from the CDC: many adults wake up not feeling well-rested, especially those with children, and especially-especially those with young children. Here’s the graph:

I need a nap

See? Of adults surveyed, aged 18-64, about 35% said that they often wake up unrested. That increases to about 40% if they’ve got school-aged children, and 50% if they have children in the house less than 3. Women in every category feel less well-rested than men.

Glad that’s settled.

Food Theater: Grab some popcorn, and enjoy the show

Posted January 25, 2016 by Dr. Roy
Categories: Pediatric Insider information

Tags: ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

Welcome, ladies and gentlemen! Step into the Food Theater, and be amazed and befuddled!

Our first star is Chipotle, a chain of restaurants that sells burritos the size of your forearm. Organic (sometimes), GMO-free (sorta), better ingredients, they care about the environment, all of that, and more! You may have heard of a little bacteria called E coli – by the way, that’s found naturally in your own feces, did you know that? – but keep in mind that Chipotle’s food has only been a little bit contaminated with E coli. And norovirus, also naturally found in human poop. It’s not like they were literally selling poop burritos, no sir! Keep your eye on the billboards, and the fact that they claim to be GMO-free, which they’re not, actually. But they say they want to be, and that’s a whole lot more important than selling food free of human excrement! Or selling lunches that have twice the calories any reasonable person needs. Yessir!

Wait, don’t leave! There’s more! Here’s a whole aisle of organic produce, right from your local store! Free of pesticides, unless you count all of the pesticides they’ve decided they can use.  And GMO-free, too. Except they’re not actually GMO-free. And much more nutritious (in terms of, well, not really any more nutritious at all, but this is theater, remember, stop interrupting me.) One thing is for sure: they do cost more!

Look at this item I found in my own kitchen, right here, a tasty cylinder of delicious potato sticks!

That's not how you spell "picnic"

You’ll note, right on the label, it’s GMO-free. Whew! And none of that awful gluten, which I’m told turns you into Hitler. Sure, they’re pretty much just potato chips in stick form – yum! – and you’d have to be pretty dim to think of this as anything but junk food. But GMO- and gluten-free! Sign me up!

GMOs, GMOs, they’re everywhere, amiright? We want food that’s exactly the way it developed in nature. Unfortunately, at the Food Theater today, we can’t show you any examples of that, because every food we eat has been genetically modified by human interventions for hundreds or thousands of years. Still, yeah, slap a GMO-free label on something, and that’s what I want to eat!

And chemicals! Chemicals with weird names! OMG can you believe some foods have chemicals in them?! Unfortunately, again, here at the Food Theater today, we can’t actually show you any examples of any foods that don’t contain chemicals, because it turns out that all foods have actual “substances” in them, and that’s what chemicals are. So we tried to show you how healthy our Bob was – that’s Bob, he worked in the back, he wouldn’t eat any chemicals at all! But he died, because, you know, no food. He died healthy, that’s for sure! Better luck next time, Bob!

New idea: maybe we can come up with a vacuum jar of nothing in it we could show you—not only chemical free, but GMO-free and gluten-free too! A health bonanza!

Well, that just about wraps it up at the Food Theater today. I hope you’ve enjoyed your tour, and please help yourself to some tasty snacks – we’re offering both rocks and water, your choice. Though I’m told the water was processed in a facility that also processes peanuts. Better skip dessert.


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