What your kids do affects how their brains grow

Posted March 2, 2015 by Dr. Roy
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The Pediatric Insider

© 2015 Roy Benaroch, MD

A short study to review today—from Pediatrics, November 2014, “Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development.” Researchers looked at MRIs scans of healthy children that were being obtained as part of a larger study of normal brain development, correlating the development of several brain areas with musical training. They found that as kids age, the ones taking music lessons had more rapid growth and maturation of brain centers involving not only motor planning and coordination, but also emotional self-control and impulse regulation.

When you exercise a muscle, it grows bigger and stronger. The same thing, essentially, happens in the brain—but it’s more complicated, because different parts of the brain do different things. What this study confirms is that at least with music, the areas of the brain exercised with musical training become “stronger”—or, at least, larger and thicker, which in brain-terms means more effective. The authors speculate that conditions like ADHD, where those same areas of brain seem relatively under-functioning, might be helped by learning to play a musical instrument.

Think about the bigger picture, too. Whatever your kids are doing, that’s the area of the brain they’re exercising. If they’re reading, they’ll become better readers; if they’re playing tennis, they’ll get better at seeing and hitting a little fuzzy yellow ball. If video games are their main hobby, they’ll get better at making fast decisions and moving their hands quickly. Katy Perry fans will get good at dancing like sharks. You get the idea. At the same time, kids who don’t practice the self-control needed to learn a musical instrument might be missing out on at least one way to help their brains mature.

Get practicing!

A few surprising vaccine myths – Betcha didn’t know!

Posted February 23, 2015 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2015 Roy Benaroch, MD

Myth 1: Vaccines work by preventing disease in individuals who are vaccinated.

Nope, that’s not actually true—it’s quite wrong, but in a subtle way. And a misunderstanding of this concept, I think, has led to a lot of mischief. If people understood how vaccines really work, how they can best protect us from disease, it might help overcome some skepticism.

Vaccines do indeed prevent diseases in individuals, but that’s not how they accomplish their most important job. See, vaccines can’t be given to every individual—babies can’t get MMRs until they’re 12 month old, for instance, and many people on chemo or after transplants can’t get them at all. And even the absolute best vaccines don’t work all the time. Two doses of MMR gives 99% of recipients lifelong immunity from measles, but if you’re at Disneyland along with 40,000 other visitors that day, it means about 400 vaccinated people (1%) are not immune. That’s not a slam on the vaccine—it’s just that any medical intervention is imperfect.

So if vaccines don’t work by protecting vaccinated individuals, how do they work? By protecting populations. In a highly vaccinated population, even if measles pops up it’s got nowhere to go. If only a small number of people aren’t immune, it’s unlikely anyone else will catch it—and that means measles cannot spread, and everyone is protected. Not just the immunized, everyone. This is called “herd immunity”, and it’s the real way that vaccines work.

Vaccines aren’t about protecting just you, or your children, or just the person who gets the vaccine. Vaccines are about protecting all of us, even the babies, and the ill, and the unlucky few in whom vaccines don’t work. We’re all in this together. Maybe you’ll be the next in the neighborhood with a newborn, or maybe it will be your sister who’s diagnosed with lymphoma. Make sure your whole family is vaccinated to keep all of us safe.

 

Myth 2: Children are required to be vaccinated.

Nope. Children are required to be vaccinated in order to attend public school, just like you’re required to have a driver’s license if you want to drive. But you don’t have to get your children vaccinated as long as you make other arrangements for their education.

Even then, there are plenty of exemptions. Every state supports exempting children with legitimate medical contraindications to vaccines; almost all states support “religious objections” (though there is no common religion that’s against vaccines); many states also offer “personal belief” exemptions, too.

No government authority is forcing anyone to vaccinate, and no children are being taken away from parents who don’t vaccinate.

 

Myth 3: Vaccination, inoculation, immunization—they all mean the same thing.

In common usage, yes. But technically, they’re different.

Inoculation initially referred specifically to the historical practice of rubbing the skin of a healthy person with a little bit of crust from a smallpox victim. It was known that this could often induce a mild case of smallpox, which would protect the person from a full-blown, deadly case later. These procedures were fairy widely known especially in England in the 1700s, and remained in widespread use for hundreds of years. The word inoculate comes from the Latin root for ‘eye”, referring to the practice of grafting a bud from one plant to another.

Edward Jenner later started using scabs from cowpox to “inoculate” a milder disease, which was close enough to prevent smallpox, too. It’s thought that his inspiration was the fair, unblemished skin of English milkmaids—they universally caught cowpox as an occupational hazard, so rarely caught the disfiguring smallpox. “Vaccine” comes from the Latin word for cow, either referring to cowpox or perhaps to those fair-skinned milkmaid workers. For a while, the term “vaccination” referred only to using cowpox crusts to prevent smallpox, but later the term became more generalized to include the procedures developed by Louis Pasteur to prevent chicken cholera and anthrax.

Immunization was a later term that broadly referred to both using live infectious particles to induce active immunity, or using non-infectious toxins or other proteins. Typically, now, most of us use the terms vaccine, vaccination, and immunization pretty much interchangeably. Next time your children get one, thank a cow!

Concussions are brain injuries

Posted February 19, 2015 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2015 Roy Benaroch, MD

Many parents (and even some teenagers) realize that kids are going to be using their brains at some point in their lives. I’m getting more and more questions about the effects of concussions—are they going to lead to trouble, down the road? How can they be prevented and treated?

First: let’s abandon the term “concussion.” It’s a weird word that waters down a much simpler term: traumatic brain injury. A concussion is a mild brain injury caused by trauma. So let’s just call it that, “mild traumatic brain injury.” Wordy, but those words say a lot more to parents and children than “concussion.”

How do you know a brain has been injured? Simply enough, it stops working right. A person who’s had a blow to the head followed by a period of brain-not-working has had a brain injury, a “concussion”. The symptoms could include, after the injury, a period of confusion or dizziness or a feeling that you’re “not all there.” Sometimes, but not usually, there’s a brief loss of consciousness. That worth saying again: people who’ve had a mild traumatic brain injury usually do not get knocked out. They just feel knocked around. Later, there are continued symptoms like headache, dizziness, a “fuzzy brain” feeling; sometimes there are also problems with moodiness or irritability, or trouble with sleep cycles. Again, remember, these are all symptoms of an injured brain.

People understand the concept of injuries. You injure your ankle, you expect to need to rest it. Everyone knows rest is the best way to prevent an injury from getting worse, and rest is the best way to prevent an even-worse re-injury. We instinctively know that during rehabilitation for an injured ankle, you’ll kind of walk and run funny—which puts you at risk for other injuries, too.

All of these concepts are exactly the same for concussion, and that’s easy to explain if you remember to think of a concussion as a “traumatic brain injury”. Rest is the key, to allow the brain to heal, to prevent worsening damage from continued trauma, to prevent re-injury of the brain, and to prevent injury of other body parts because you’re not performing well with an injured brain. See? Easy as an ankle to explain.

Of course, resting a brain isn’t exactly as simple as resting an ankle. We can’t use a sling or an ACE wrap (well, you can, but you’ll look weird and it won’t help.) Resting a brain means, well, brain rest: no intellectual work, no school, no physical exercise. Just like you’d rest an ankle until it felt better, resting a brain after it’s injured should continue until there are no symptoms of injury. No headaches, no sleep problems, no fuzzy brain, no dizziness, no trouble focusing. When all of these symptoms have abated, people with mild traumatic brain injuries should gradually advance to more-intense schooling and activities, step by step, until the patient is back up to full activity. If there’s a step backwards—if brain symptoms begin—do exactly what you’d do if your ankle starts to hurt again. Back off the activity and allow more time to heal.

There’s good evidence that allowing a period of time to rest and heal after a mild traumatic brain injury can help prevent re-injury and longstanding symptoms—but we don’t know exactly how long the rest should be. One recent study showed that to a point, too much rest for too long can actually worsen and extend symptoms. Once symptoms improve, it’s a good idea to start back on activities (start slow and advance step by step) rather than continue through a fixed number of days of rest. We have some work to do to fine tune and individualize the best concussion care advice.

While a single concussion, especially with appropriate treatment, is unlikely to lead to long term problems, there are some sobering concerns about people who’ve had multiple concussions. There’s an increased risk of long term cognitive decline, movement disorders, and depression. And we know many athletes under-report concussions. In one study, 30% of high school football players reported a history of concussion, but only half of those had reported the injury. There may be far more concussions injuring far more high school brains than we appreciate.

As I said, many of those brains are going to be used later. Maybe we ought to try to do a better job keeping them in good shape.

Some solid reassurance about BPA – one more thing you don’t need to worry about

Posted February 16, 2015 by Dr. Roy
Categories: In the news, Nutrition, Pediatric Insider information

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The Pediatric Insider

© 2015 Roy Benaroch, MD

Remember BPA? It’s a chemical used in the manufacture of plastic things, food can liners, and lots of other things. For a while, everyone seemed to be worried about it. Stickers started showing up on bottles – “BPA FREE!”—which created all kinds of anxiety among people who had no idea there was BPA in their water bottles to begin with. It’s a scary sounding, chemically kind of thing, bisphenol-A, so we’d be better off without it. Right?

I last wrote about BPA in 2008. It wasn’t worth worrying about then, and it’s even less worth worrying about now.

There have been dozens of studies of BPA over the last few years. I’ll just highlight a few recent ones:

JAMA, 2011. Adults eating canned soup – from ordinary cans manufactured with BPA in the liners – had 1200% percent more BPA in their urine than adults consuming fresh soup. Bloggers like this one completely misunderstood the significance of this, with headlines like “BPA rises 1200% after eating from cans.” Yes, it does rise—IN THE URINE. That’s how you get rid of the stuff. High amounts in the urine are good, it means your body is excreting it. That’s what kidneys do. They’re the real detox system—not the expensive BS from the health food store. Want to rid your body of “toxins”? Drink some water and let your kidneys do their job.

Toxicology Science 2011. Adults consuming a high-BPA diet had blood and urine levels monitored. Urine levels were much higher than blood levels – good! It’s excreted! – and in fact blood levels remained extremely low, or undetectable. BPA doesn’t seem to have a chance to make it into body tissues, or concentrate there. It’s peed out. (This study is reviewed in detail here.)

Environmental Health Perspectives, 2013. High doses of BPA solutions were placed in the mouth of anesthetized beagles, and blood levels showed that this method of administration led to higher absorption of BPA than BPA swallowed into the gut. (Lesson: It may not be a good idea to just hold soup in your mouth for hours. Just swallow it, OK?)

Toxicology and Applied Pharmacology, 2015. To evaluate the potential for oral absorption of BPA in humans, adult volunteers were fed warm tomato soup with added BPA—after coating their mouths with every spoonful, they swallowed it. This recreated a genuine eating experience better than the beagle studies (the dogs were anesthetized and their BPA just sat in their mouths.) In this human study, BPA levels in the blood remained low, and as has been observed previously, almost all of the BPA absorbed was quickly deactivated and excreted in the urine.

What’s the harm in replacing BPA in food containers? There’s always a trade-off. Those other kinds of plastics may be more hazardous.

BPA is just one of many “chemical” bugaboos to attract media attention. Caramel coloring? Eek! BHT? Lawds! There are entire industries out there making money off of food fears and nutrition fears. And vaccine fears. There’s enough unnecessary fear out there to power an entire media empire based on one person with vain hair, a magnifying glass, and a kindergartener’s understanding of chemistry.

Don’t live in fear. If you want to avoid plastics, that’s great—eat fresh things, grow a garden, cook and eat with your family. The cans of beans in your pantry, they’re not going to kill you any time soon.

More about BPA from Science 2.0

Vaccines: Children have rights, too

Posted February 9, 2015 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2015 Roy Benaroch, MD

Some people who argue against vaccinations claim that vaccine policies infringe on their “rights”—their rights, as parents, to make medical decisions for their children. It’s a scary, misleading, and chilling message. We need to be careful about where one person’s rights end and the next person’s rights begin. We need to remember that children (their children, and your children too) have rights of their own.

For example, Dr. Bob Sears says in all caps “FORCED VACCINATIONS FOR CALIFORNIANS ARE ON THEIR WAY.” No, Bob. California lawmakers have introduced a bill to eliminate “personal belief exemptions” for public school attendance. No one is going to force any vaccines on anyone, and there are no jackbooted thugs on the way. But if you want to send your child to public school, they’ve got to be vaccinated. There’s still a religious exemption (which is odd—no major religions are against vaccinating) and of course a medical exemption. But “personal belief exemptions” shouldn’t hold water, because personal beliefs don’t prevent disease. Vaccines do. You want your kids in public school, with my kids? Then my kids’ right to have a safe school overrides your rights to not vaccinate your child. Simple.

How far do rights go? Until they start to infringe on the rights of others.

Dr. Bob goes on to say that mandatory school vaccines violate “a parent’s right to make all health care decisions for their child.” He seems to agree with statements from a few politicians in the news lately. Rand Paul, an ophthalmologist and Kentucky Senator, says “The state doesn’t own your children. Parents own the children, and it’s an issue of freedom.”

No, Dr. Paul. Children are not things to be owned. They are not property. They are people, and they have rights too. Do what you want with your own children—anything short of abuse or egregious neglect, and the government won’t interfere. But as soon as your “rights” start to threaten the health of other children, and of our entire communities, that’s where your rights end. And the rights of the rest of us begin.

Convenience and quality of pediatric care at retail-based clinics versus traditional practices: Where will you choose to take your kids?

Posted February 5, 2015 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2015 Roy Benaroch, MD

Clinics in drug stores and big-box retailers are here to stay. Often staffed by nurse-practitioners working alone, they’re much cheaper to set up and run than a traditional practice. They need only a little corner of real-estate in the back of the store, and rely on centralized billing to further reduce costs. These clinics can provide “one-stop shopping” for customers who’d like to get their prescriptions and fill them at the same place. So it’s a win-win for the retailer. They’re cheap, they generate income, and—bonus!—they drive store traffic and support the sale of prescription and non-prescription medications from a counter only a few feet away.

But are these places a win for kids and families?

A recent JAMA Pediatrics study interviewed about 1500 parents who brought children to retail-based clinics in the St. Louis area. The parents were recruited from the waiting rooms of their pediatricians. Among the findings:

Reasons for going to the retail clinic included: more convenient hours (37%), no office appointment was available (25%), didn’t want to bother the pediatrician (15%), or because parents thought the problem wasn’t serious enough to warrant a doctor visit (13%). About 50% of these pediatric visits occurred when their own pediatrician’s office was open.

About half of visits entailed a 30-60 minute wait; about 10% waited more than an hour. (BTW: Data from Kids Health First, an Atlanta-area consortium of dozens of pediatric practices, showed that overall our practices have similar wait times.)

There was striking evidence for over-prescribing of antibiotics at the retail-based clinics. 68% of colds and flu were prescribed antibiotics, as were 29% of sore throats with a negative strep test. These antibiotics were not needed. To be fair, these surveys relied only on parental recall. We also don’t know the antibiotic prescribing practices of local pediatricians. Other studies of quality of care at retail chains have not shown a big difference in antibiotic prescribing rates. Still, the numbers from this study are way out of line with national statistics and good medical practice.

Can traditional pediatric practices like mine compete on location and convenience? We  can’t open up satellites in every neighborhood. We’ve got after-hours clinics, but not as many as the retail clinics. But perhaps we can demonstrate that we’re worth a few minutes extra time to make the appointment and drive over:

  • Care at our office is by genuine, board-certified pediatricians. Yes, many simple things can probably be addressed by adult-trained advanced-practice nurses at a drug store. But how often does something that seems simple turn out to be something else?
  • We’re here for emergency phone follow-up, and we’ll be here to reexamine and help when your child isn’t recovering as expected.
  • Our office is happy to handle many medical issues over the phone—we don’t charge for this service, it’s just part of what we do for our patients. (Obviously we cannot keep doing that if our patients use us for free phone service but actually pay someone else for care.)
  • We’ve got all of your records, and we’re here to coordinate care with specialists. Labs, x-rays, consultations—you need it, we can arrange it.
  • We’re here to get to know you and your family. Your children will get to know us, and get to feel safe knowing that their own doctor is there to help.

Are these services from traditional pediatric practices worth the trade-off in “convenience” at the local retail clinic? Wal-mart and other huge chains have decimated many small businesses. Time will tell if private practices can continue to succeed.

Bottle and formula feeding questions and answers

Posted February 2, 2015 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2015 Roy Benaroch, MD

 

What’s the best way to warm up the bottle?

Cool formula can be warmed up safely by dunking the bottle in warm water. This method isn’t quick, but it works and it’s safe. There are also “bottle warmers” you can buy that surround the bottle with gentle warmth from all sides—though I am not sure they work any quicker than using warm water in the sink.

Bottle and formula manufacturers caution against using a microwave to heat a bottle. There is a possibility of creating “hot spots” either in the formula or on the nipple, with small areas becoming hot enough to burn.

 

Is it necessary to warm up a baby’s bottle?

No, it’s not necessary—but it’s traditional, and some babies get used to warm formula and don’t like it chilled. As babies get closer to weaning off the bottle at 12 months, many families back off the warming for convenience, and those babies do fine. There is no harm in trying cool or lukewarm formula to see if your baby likes it.

 

Should I use tap or bottled or boiled water to mix the bottles?

Ordinary city municipal tap water is fine. Tap water is very highly regulated, and is monitored far more closely than bottled water for purity. There is no reason to waste your money on bottled water or special nursery water. It is also unnecessary to boil tap water—it’s very clean right out of the tap. Heart surgeons wash their hands in that stuff, you know. And babies’ mouths (and mom’s breasts) are loaded with germs. Sterility is not necessary for feeding humans.

If your water supply comes from a well or cistern, check with your local water authorities for guidance on using that water for formula.

 

Do I need to boil or sterilize bottles and nipples?

No, running them through an ordinary dishwashing cycle or handwashing them is sufficient. Clean is good, sterile isn’t necessary.

 

How do I mix formula?

Always follow the instructions on the package, using the scoop that came with the product. Typically you’ll first measure the correct amount of water, then add the leveled scoops of powder. The exact proportions will be on the packaging. Mixed formula should be kept refrigerated and used within 24 hours. Once the package of powder has been opened, keep it in a cool dry place and discard any unused powder in one month.

 

What should I do with leftover formula if by baby doesn’t finish the bottle?

Throw it away. Once formula has been re-heated OR once a baby has taken any from the bottle, the formula should be considered contaminated and used within one hour, or discarded. Do not re-refrigerate warmed or partially-consumed formula.

 

Is there a kind of nipple or bottle system that’s best?

I don’t think so. There are many varieties, and some are marketed quite heavily with promises to reduce colic, or promises that they’re more like breast feeding. All of that is advertising hype. I suggest you purchase simple, cost-effective bottles and nipples.

Once choice you’ll have to make is to use traditional bottles versus the kind with the drop-in, disposable bags. While neither has any advantage for your baby, the drop-ins may save some trouble with fewer bottles to wash—in return for more plastic bags to throw away. Either style works well for most families.

 

Are generic or store-brand formulas any good?

They’re as good as name brand, commercial formulas. With name brands, you’re not getting a better or more-nutritious product—you’re just paying for fancier packaging and marketing hype.

 

Maybe I should just make my own formula. I found a recipe on the internet!

No, no, no, no. Do not make your own formula. It is not safe, it is not nutritious, and it is dangerous. Homemade cookies? Good. Homemade formula? Bad.

 

What about BPA and chemicals in plastic bottles?

In 2008 Congress banned BPA and several related compounds from baby products, based on sketchy and indirect evidence of potential harm. Still, it seemed prudent to avoid the chemical, as there were still unanswered questions about long term exposures. Since then, there’s now new concerns being raised about chemicals that have replaced BPA.

I say: there’s always something to worry about. And when things are really safe (ahem, vaccines), the modern media feeds into our own worries, especially about purity and food and children. I don’t think there’s any reliable evidence that parents need to worry about plastics used in baby bottles or spoons or anything else. But if you’re concerned, use glass bottles.

 

 


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