Can sitting or standing hurt a young baby’s bones?

Posted May 2, 2016 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Desiree wanted to know: “Is it true that putting an infant (2-4 month old, before they can sit unassisted) in a sitting position can damage their spine? I’ve read posts by people about this but don’t know how much truth there is. Assuming child can hold head up enough to be able to ‘sit’ on someone’s lap or on a sitting device for relatively short periods of time? Is there a limit to how long this should be or that it becomes dangerous?”

Little babies love to master new things. And they have fun doing it, too—their eyes sparkle when they learn to stand in your lap, or when they sit up with a little help to see the whole world. When they’re lying down on the floor or their bed they can only see the ceiling. Where’s the fun in that?

Their little minds and bodies are made to grow and develop and try new things. Spending time on their tummies helps babies develop muscles in the front of their chests, and helps practice the coordination to lift their heads and look around. Time sitting up exercises different muscles, too. And bones themselves grow and develop based on the stresses and loads that they feel—so, yes, standing up is a good thing to help babies grow stronger and more confident of their skills.

A few caveats – keep a little common sense in mind. Those gizmos that help babies sit up are fine, but not if you put them on top of a table or counter. They can still topple out of them, so never use them on a raised surface. Also, a baby has to be able to hold his or her head up unsupported to stay in an upright position.

Is there a limit to how long babies should try these new positions? Sure – let the babies tell you. If it starts to hurt, they’ll get upset, and that’s when you’ll pick them up or move them or try a new activity. If bones are being “damaged” by the stress of a new activity, they’ll hurt, and you’ll know it. That’s why people feel pain when they should stop doing something. Babies are very good at telling you when something hurts.

They’re also very good at telling you when they’re happy. So help your baby learn new things and try new ways of standing, sitting, and getting around. Have fun!

This is a baby

Whole milk best for children? Not so fast

Posted April 25, 2016 by Dr. Roy
Categories: Nutrition, The Media Blows It Again

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The Pediatric Insider

© 2016 Roy Benaroch, MD

A flurry of recent reports has supported the health benefits of whole-fat milk. Increased dairy fat has been linked to lower rates of diabetes, and to improved cardiovascular health. The traditional advice – that low-fat or skim milk can help reduce weight, and help improve health – may have been based on faulty assumptions about the way ingested dairy fat affects metabolism. These new studies of dairy fit in with a shift away from the “fat is bad” story to a more nuanced “some fat is bad, but other fat is good, and it’s complicated” way of looking at things.

But it’s important to remember that none of the studies driving this change were done in kids. We don’t really know the long-term health impact of full- versus low- versus no-fat milk in infants or children, and there are still some good reasons to think that lower fat dairy might be a good choice for many families.

Until about ten years ago, the AAP recommended full-fat milk starting at age 1. That changed in 2008, when a position statement about cardiovascular health supported the use of reduced-fat dairy products starting at 12 months of age if there were any concerns about overweight or a family history of obesity or heart disease (that would include just about everyone.) This recommendation was based on research showing three things: (1) growth and neurologic function was the same in children raised on low-fat milk (ie, extra fat was not needed for brain and body development); (2) lipid profiles and weights were healthier in children raised on low-fat milk; and (3) children who consumed low-fat milk tended to have healthier diets, overall, than kids drinking whole milk.

That position statement “expired”, as all AAP statements do, 5 years after it was published. Currently, the AAP officially has no position on the relative merits of these varieties of milk. (They do have a position vaguely endorsing chocolate milk in schools, and another position strongly discouraging unpasteurized milk. All AAP policies can be searched here. There are a lot of them.)

The bottom line, now: there really isn’t any solid, new information from studies in children since that 2008 AAP position. Though I agree that the adult studies are compelling, adults and children are very different, especially when looking at metabolism, growth, and the long-term health consequences of dietary choices. For example, milk constitutes a much higher proportion of caloric intake in kids than in adults (children drink more milk, and they’re smaller. Usually.) They need proportionally more calcium and vitamin D and phosphorus for growing bones. And we know overweight children are very likely to continue to struggle to maintain a healthy weight as adults.

The best current evidence in children supports the use of reduced fat milk. If that changes, I’ll let you know.

Edward Elric does not like milk

 

Grunting Baby Syndrome – A whole lot of show for very little poop

Posted April 21, 2016 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

Lemelon wrote in:

“Grunting Baby Syndrome. Is this really a thing? My 6 week old son grunts, strains and writhes from ~approximately 3-6am every night. Most of the time he sleeps through it. My GP suspects reflux but ranitidine has not helped. Also, he’s very happy/calm all day rarely fusses or cries. My google searching came across Grunting Baby Syndrome. Is that a real thing? When do babies grow out of it on average?”

One of the fun things about writing this blog are good questions, or questions about things I had never heard of before. And, yes, Grunting Baby Syndrome is a real “thing”, and something I’ve talked with parents about for years. I’d just never heard this name for it. I think the name is mostly used in the UK (most of the sites I found referring to it come from across the pond), but it seems to be catching on here. Whatever you call it, it’s one of those things that makes sense with a little explanation.

Anyone who’s had a newborn knows that poop doesn’t always come easily. There’s often a big show, with grunting and a red face, and sometimes crying (this is the baby we’re talking about, here. Not dad. I think.) But the poo itself isn’t hard or even firm – it’s normal, ordinary baby poo, soft as applesauce or weird yellow pudding. So why the big show? Why all the grunting?

Two reasons, I think. One is that it’s genuinely difficult to have a bowel movement while lying on your back. Go ahead, try it yourself. We’ll wait here.

See? With nothing to push your feet against, it just doesn’t work. I’ll bet you were pushing and grunting and your face turned red too. Perhaps your behavior was puzzling to your spouse, who chased you out of the bedroom with a broom. You should probably go back and explain, later.

But there’s a second reason for the grunting. Have you ever thought about the steps you’re taking to poop? You need to tighten up your abdominal muscles to push, while simultaneously relaxing your pelvic floor and anus. Tricky! It’s like patting your head while rubbing your stomach – another trick that newborns can’t do well. Tightening one set of muscles while relaxing another isn’t easy. You can tell a baby’s having trouble coordinating this if you pat their bottoms while they’re grunting. Their little buns are squeezed together, all tense. It’s no wonder the poop can’t come out! And it’s no wonder that when it eventually does, it’s a noisy explosion that startles Junior and parents alike.

So: what should parents do? Relax. Don’t get anxious – that will not help your baby get through this. Gently bicycle his little legs, and hold him, and help him relax. When gas passes, and it will, make a little joke. “You sound like Daddy!” would be appropriate, or “Here comes Grandma!” if she’s not in the room. A bad thing to do is to get wrapped up in the drama, and add more worry. If it’s at night, and the grunting is keeping you awake, turn down the baby monitor. The poop will come, I promise.

This isn’t constipation, which requires hard stools. Giving a stool softener won’t work, and neither will changing formulas (though it will get you off the phone with your pediatrician’s office. I probably shouldn’t have told you that.) Rectal stimulation with a thermometer will work, but only in the short run—that won’t help Junior figure this out himself, which is the only long term solution.

If you’re worried that your child just cannot pass stools, talk with your child’s doc. There are some rare conditions that prevent poopage. But the vast majority of grunting, red-faced babies have this “Grunting Baby Syndrome”, which is another thing you don’t have to worry about.

Monica Seles

Serious allergic reactions to vaccines: Something else not to worry about

Posted April 18, 2016 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2016 Roy Benaroch, MD

A huge study of over 25 million doses of vaccines has shown that serious allergic reactions are super-rare, and even when they do occur they’re typically easy to treat.

Published in the October, 2015 edition of The Journal of Allergy and Clinical Immunology, the study looked at a huge database of 17,606,500 visits for a total of 25,173,965 vaccines. This is seriously Big Data, people. After all of these vaccines, only 33 cases of a severe allergic reaction occurred. Even among those 33, only one child required hospitalization, and none died.

More reassurance: there were zero serious reactions among children less than four years of age. And most of the 33 reactions (85%) occurred in children who had a history of other allergic diseases.

Despite its rarity, anaphylaxis is a potentially serious reaction. If your child experiences a widespread rash, trouble breathing, severe GI symptoms, or fainting after a vaccine, it might be an allergic reaction – a medical evaluation is needed. Most of these reactions won’t turn out to be serious or life-threatening, but they do need attention. Almost all teenagers who faint after vaccines have just fainted, and will be fine, but they need to be watched and their blood pressure checked. If further evaluation shows it’s an allergic reaction, medical therapy given quickly can help stop the reaction.

But: we need to keep these reactions in perspective. They’re really phenomenally rare. 33 out of 25 million vaccines means that your children have a higher chance of being hurt in a car accident on the way to their appointment than of having a serious allergic reaction to a vaccine. Other, non-allergic but serious reactions are really very rare, too. The internet has made otherwise well-adjusted people into parents worried stiff over vaccines. Don’t let it happen to you. Don’t live in fear and worry. Immunizations save lives, they’re safe, and they’re something you don’t need to worry about.

Wemberly Worried

You can’t always get what you want

Posted April 13, 2016 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2016 Roy Benaroch, MD

“Customer service” is the new buzzword in health care. (Yes, I know it’s two words. Stay with me here.) Health care has become a service industry, like a restaurant or a company that comes to your home to replace a broken windshield. The shrimp is too salty, or the tech left footprints on your floor mat? You complain, and you send the shrimp back, and the tech apologizes and says “yes sir” and vacuums out your car. The customer, as we know, is always right.

Except in health care. Administrators and patients don’t want to hear this, but in health care the “customer” is not always right. And pretending that the customer is always right is costing us a whole lot of money and a whole lot of preventable sickness. We’re customer servicing ourselves into crappy health care, and docs and nurses seem to lack the power to prevent this from getting worse.

I’m part-owner of a few after-hours pediatric health clinics. Our sites are open when traditional pediatric practices are closed. Our patients – not customers– see genuine, board certified pediatricians for things like fever or sore throat or cough or ear pain. Common pediatric stuff. Rarely, we get complaints about or service or ugly remarks on Yelp, etc. Almost all of the negative reviews can be summarized like this: “I paid my money, and I didn’t get an antibiotic. I expect my antibiotic. I am the customer, and the customer is always right.” We don’t get comments about whether our doctors did a good and careful assessment, or whether they made a careful decision about recommendations. Nope, the customer is always right, and the customer wants an antibiotic. And if one isn’t given the customer is darn tootin going to complain about it.

We’ve had similar complaints on review sites about my own medical practice: “I brought in my child with a bad cold, and I didn’t even get an antibiotic! Zero stars for you!” I consider not giving antibiotics when they’re not needed – for a cold — a mark of a good practice. But someone skimming the reviews might just choose to go somewhere else. Perhaps a place that sees twice as many patients per hour, because explaining how to treat a cold correctly takes much longer than a quick antibiotic prescription.

It’s not just antibiotics, of course. In emergency departments all over the country, customer service and positive “reviews” are what drives physician salaries and hiring. You don’t make your patients happy, you’re going to take a pay cut or lose your job. But what if your patients – I’m sorry, customers – want something that isn’t good for them, like narcotics for chronic pain? We know narcotic addiction, driven by prescription products, is now the leading cause of accidental death in the US. But once patients become customers, they’re always right. And once doctors realize that negative reviews are going to cost them a job, what do you think is going to happen?

Of course, docs are being squeezed simultaneously in the other direction. The Feds don’t want us to “overprescribe” narcotics, either. They just want us to treat pain, quickly, and without our customers complaining. How exactly to do that is entirely up to us – we’re the doctors, of course, and no one would ever tell us what to prescribe – as long as we don’t use too much of the only drugs that work. Whatever “too much” is. That’s a secret. We’ll just monitor everything you do via your shiny new electronic medical record that you’re required to use. Which you hate. Please, don’t mind us.

One more example: I have here, mailed to my home, a flyer from my health insurance company. (I guess I shouldn’t tell you which one, but they’re huge, and you can rearrange the letters in their name to spell “Aetna.”) They offer a service, Teladoc, which costs “$40 or less”. Available “anytime, anywhere”, you get 24/7/365 access to “U.S. board-certified doctors” to treat things like “sinus problems, bronchitis, allergies” and “ear infection” over the phone! The doc can diagnose and prescribe medication for “many of your medical issues.” All without, you may have noticed, even pretending to do a physical exam. Or maybe they have a really long stethoscope that they can shove through the little tiny holes in their phones, or a 7 mile long swab to do a strep test. These clowns are going to know whether or not you need antibiotics without an exam, without touching you, without seeing you or without even being in the same room as you. That’s not medicine. It’s dark magic.

But you know what? They program will probably be successful. Because we know that many people don’t want a physician’s judgement – they just want antibiotics and prescriptions. So, with a wink and a nod, “Teledoc” gives us exactly what we’ve come to expect. The customer is always right. $40 out of pocket, and you can bet “Aetna”, or whoever they are, is saving some serious money by paying Teledoc next to nothing instead of paying a real doc to do a real evaluation. Everyone wins. Except you.

As philosopher Mick Jagger famously said, “You can’t always get what you want.” And at least in health care, you shouldn’t. Unfortunately, even if you try, it’s becoming harder to get what you genuinely need.

Mick

Medical School for Everyone: Pediatrics Grand Rounds – my newest course, now available!

Posted April 11, 2016 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2016 Roy Benaroch, MD

Hey Insiders! I’ve got a fresh, new course available from The Great Courses, called Medical School for Everyone: Pediatrics Grand Rounds. Please check out the link, and enjoy the short video promo they’ve put together (yes, I’m doing my own voiceover this time. That’s me.) It’s on sale now, and for all of the work that went into this puppy, I’d say it’s a bargain! If you have any interest in children’s health – and I’m thinking you do, why else would you be reading this blog? – this course is the single best way to learn how doctors think about children. Sure, you could go to medical school, and then do a peds residency. But my way is much cheaper, and a heck of a lot faster too! Plus: no icky dissecting dead people! Amirite?!

Thanks for clicking over, and maybe even buying my new course! There’s a 100% money-back guarantee, so nothing to lose. And, honestly, I think you’ll like it.

Zika update!

Posted April 4, 2016 by Dr. Roy
Categories: In the news, Medical problems

Tags: , ,

The Pediatric Insider

© 2016 Roy Benaroch, MD

I last wrote about Zika in January*, and there’s a whole lot more we now know about this mosquito-borne virus. And still a lot we don’t know. Time for a Q&A-styled** update!

 

Give it to me straight, doc. Does Zika really cause birth defects?

Yes. As is typical for scientist-written press releases, early reports this winter were equivocal—you’d see phrases like “is associated with” or “likely caused by”. That’s because unlike pushers of GMO-free foods, real scientists try to respect the intelligence of their audience. Back then, it was clear that there was both a big spike in cases of Zika-associated illness during pregnancies (mostly in South America), and a big spike in cases of microcephaly and other neurologic birth defects. But did one cause the other?

More-recent reports have included evidence of Zika in the brain tissue of affected fetal brains, and also in the brain and nerve tissues of children and adults suffering from neurologic symptoms during Zika infections. It’s clear that Zika is a neurotropic virus – it likes to invade neurologic tissue.

We also know more about the structure of Zika. At the molecular level, we know it has a structure that interacts with brain cells. That is completely cool—we know exactly what the virus looks like and how its molecules are arranged. That’s one step away from designing a vaccine. All of this research was done in just a few months. Science!

 

Is Zika coming to America?

It’s already in America, dummy. South America, which (last time I looked) was part of America. Oh, you mean North America? Which includes Mexico? Which is also part of America? Maybe you should just start over.

 

Is Zika coming to the United States?

It’s already here. Zika-virus associated infections have been reported in almost every US State, though at least so far the only locally-acquired cases have been transmitted through sex. (No, not sex with mosquitoes, you sicko.)

 

OK, so that means as long as I don’t have sex with anyone who’s been traveling, I’m protected, right?

Maybe for now, but not for long. Over 300 cases of Zika have occurred in the continental US, and even more in our Caribbean territories. And the mosquitos that transmit ZIka, by mid-summer, will be found in a wide swath of the US, across the entire souther border, reaching up into Ohio and Missouri. It is only a matter of time before local mosquitos stare biting people with Zika infection, and then spreading it to other people.

 

 Yikes. I’m glad I’m not a pregnant woman!

So are we. We’ve seen the quality of your questions here, and frankly it would be better if you didn’t reproduce.

 

I meant I’m glad only pregnant women need to worry about infections. Right?

Nope. Pregnant women, and their unborn babies, are clearly at the highest risk. It looks like about 25% of the time, infection during pregnancy results in fetal damage—though that’s an estimate based on preliminary data.

We do know that most infections in otherwise-healthy children and adults result in no symptoms whatsoever. Probably only 1 in 4 or 5 people with Zika develop symptoms, which include fever, joint aches, and rash. But a small number of people also go on to develop serious complications, which can include brain inflammation or Guillain-Barre Syndrome. Though these conditions after Zika infection are rare, we really don’t know exactly what the risk is, or who’s likely to progress to serious Zika-related illness.

 

What should I do if I think I have a Zika virus infection?

Testing is available through public health agencies, and is routinely recommended for pregnant women living in or traveling to areas with active transmission. For the rest of us, health-care providers can help decide whether testing is needed. Go see your doctor.

 

What’s the best way to prevent infection?

Right now, there’s no vaccine, though one is actively being developed. The best way to prevent infection is to avoid mosquito bites and travel to areas with high rates of infection. You can find maps and other resources through the CDC Zika Prevention site.

The bottom line with mosquitoes: wear long sleeves and long pants, keep mosquitos out of homes with nets, screens, doors, and air conditioning, and use a mosquito repellant that actually works. Those typically contain the active ingredients DEET, picaridin, or “oil of lemon eucalyptus.” Of these, DEET is the standard—it’s been around since 1957, and it works, and as long as you don’t drink the stuff it’s safe.

 

*I wrote about it weeks before the story was picked up by the so-called “mainstream media.” Yet, still, no Pulitzer. Am I bitter? Of course not.

**Some “journalists” say slapping together a blog post in Q&A format shows laziness and a lack of creativity. Those people should go stick their journalistic heads in buckets of icy cold water. It’s Saturday morning, it’s beautiful outside, and you guys are getting get what you pay for. Srsly.

 

Coming to America


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