“The Science of Mom” – a great new book for parents

Posted August 27, 2015 by Dr. Roy
Categories: Medical problems

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The Pediatric Insider

© 2015 Roy Benaroch, MD

New parents have access to plenty of information. Websites, Facebook pages, blogs, tons of stuff, all ready to answer any question. The problem is that many answers are just plain wrong. Not just “your-opinion, my-opinion” wrong, but flat out stinking lies of wrongness, repeated over and over, until one has to figure, hey, I saw that somewhere. I guess it’s true.

You don’t have to guess. If you want reliable and honest information, let me suggest a new resource: a book by Alice Callahan, PhD, called The Science of Mom: A Research-based Guide to Your Baby’s First Year. Dr. Callahan’s blog has been a favorite of mine, with solid, well-referenced, and very readable articles on parenting topics.

Her new book is organized into chapters covering many “hot topics” concerning a baby’s first year. There’s an introductory chapter that concisely explains how science can turn you into a better parent, and how to tell good science from bad. Other chapters cover topics both expected (vaccines, breastfeeding, sleep training) and unique (how newborns learn and interact with the world.) The breastfeeding chapter did a particularly good job presenting this nuanced subject – in fact, the science says more than just “breast is best.” Her chapters on sleep training and sleep safety were also very good, though I would have been even more direct about SIDS prevention. Still, that’s a style thing—she’s got the science down, solid.

Dr. Callahan isn’t bossy, and isn’t out to tell you what she thinks. Her book tells you what the science says, and explains how we know what we know, and what things we still need to learn more about. There’s humility and warmth, here, which I think parents of newborns will find reassuring. There are many “controversies” that you really don’t need to worry about.

This book is great for parents of newborns and babies, and I think it would make a very good gift for expecting couples. In the spirit of full disclosure, I got my copy for free (thanks!), though I’m planning to donate it tomorrow to my local little free library. Stop by Womack near ChamDun to grab my copy, or get it from Amazon or whatever. It’s good.

Is general anesthesia safe for children?

Posted August 24, 2015 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Meghan wrote in:

My 10 month old son (a twin) has a mild hypospadias and chordee. The recommendation from our pediatric urologist was surgery at 6 months. Another specialist said that we could wait a few months, which may even lead to better outcomes (due to difference in size) but that we would absolutely need to operate before he was walking and reached ‘genital awareness.’

This surgery requires general anesthesia, and there have been a number of studies published recently (i.e. NEJM and Pediatrics) that suggest that this poses serious risks (learning disabilities, etc.) Of course for life threatening conditions, you would need to operate, but for a non-life threatening condition (mild hypospadias) I wonder if the pros outweigh the potential cons?

I would greatly appreciate your thoughts. The specialists whom I have tried to engage (urologists and anesthesiologists) have been unfortunately, very dismissive to entering into discussions around this issue. Even guidance on who to approach for their thoughts would be so appreciated!

First: hypospadias, if mild, probably doesn’t have to be repaired at all. But that chordee—if that’s present, Junior would appreciate it if you’d get that fixed for him before he has painful erections that don’t (for lack of a better term) work.

What Meghan really wanted to know about was the potential risks of anesthesia, especially in light of recent publications that have brought up questions about anesthesia’s long term affect on children’s brains. Some of these studies have been on animals (both rodents and primates), showing “anesthetic neurotoxicity”—the death of brain cells with exposure to anesthetic agents. But rats and monkeys aren’t people, and we know that brain cells (especially cells in brains of children in intellectually stimulating environments) can regrow and regain function. In fact, it may well be that younger children could conceivably recover from this kind of damage better than adults.

Other studies have been observational, retrospective studies—looking at groups of children who did and did not have exposure to anesthesia. One from a few months ago did show that kids who had anesthesia before age four did have slightly lower IQ scores (tho IQ remained in the normal range for both groups, it was 5-6 points higher in the children who had not had anesthesia.) But these kinds of studies aren’t very reliable. It’s difficult to know, for instance, if the difference is from the anesthesia itself, or from the health condition that necessitated the surgery. That is, kids who require surgery and kids who don’t require surgery aren’t equal in many ways. The ones who need surgery are more likely to have health problems, and maybe that’s why their measured IQ at age four could be lower. Besides, does the IQ at four even matter? What if it’s recovered to the same by school age?

Meghan might think that for what’s going on with her son, which is a genital concern, there wouldn’t be any expected difference in brain strength. But statistically, that’s not true. We know babies born prematurely are more likely to have hypospadias; and we know that babies born prematurely are more likely to have intellectual deficits, ADHD, autism, and cerebral palsy. Statistically speaking, having a hypospadias means you’re more likely to have these other things, too. We also know that the most effect on development and IQ is seen in children who’ve had multiple surgeries (who are also the children most likely to have the most complicated medical histories, like heart disease or brain malformations.) So was is it the anesthesia that’s the risk?

Chicken, meet egg.

The best studies to tease this out haven’t been completed yet, but they’re underway. Children with the same health conditions (for example, a group of boys with hypospadias) need to be randomized so some have surgery now, and some wait a few years. Then they can be followed with periodic neuropsychiatric testing to see how they do. This kind of randomized, prospective study is the best way to isolate a variable (in this case, anesthesia) and establish whether that’s really a risk.

Since those studies haven’t been done yet, for now I’d say: if general anesthesia isn’t required – if the procedure is entirely cosmetic, or can safely be put off until a child is older – it makes sense to wait. But in some cases, there’s a medical benefit to doing surgery earlier. Cleft lip repair early allows for better language development and feeding; a shunt to treat hydrocephalus prevents brain damage when done young; eye muscle surgery allows the development of sharp vision. The potential risk of general anesthesia has to be balanced against the risk of waiting, and there’s no “general rule” that you can apply that could account for all circumstances.

The most troubling part of Meghan’s question was her last comment—that the surgeons and anesthesiologists were dismissive of her concerns. Those are the people she ought to be able to depend on to follow the literature closely and be able to discuss this. If they’re unwilling to take these questions seriously, it’s probably best to Meghan to find some new doctors.

A preschooler wants to be a vegetarian. And Simpson quotes!

Posted August 20, 2015 by Dr. Roy
Categories: Nutrition

Tags: , , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

 

Leslie wanted to know:

 

 Dr. Roy, do you have any advice about a preschooler who wants to be a vegetarian? A few days ago at a family party an older cousin decided to tell my four-year-old aspiring veterinarian, who loves animals so much she sobs if she accidentally steps on an ant, what her hamburger was made out of. She…did not react well to the information, and has since steadfastly refused to eat any type of meat. Thankfully she’s too young to know that veganism is a thing so she’ll still eat dairy products and eggs and such, just not meat, which I’ve always heard is a pretty important part of a growing child’s diet. Is it safe for a kid so young to *never* have meat? Should I get her on some special vitamins or supplements or make sure she eats plenty of certain other foods to make up for it? Or do I just need to put my foot down and insist that she eats whatever I make? All of the advice I’ve found so far basically boils down to that, but it seems like that would be so traumatizing and send her the message that I don’t care about how she feels or what she values. I just want to keep her healthy, physically AND emotionally, but I don’t know what to do!

 

This reminds me of a Simpsons episode…

 

Lisa: “I can’t eat this. I can’t eat a poor little lamb.” [pushes her plate away]

Homer: “Lisa, get a hold of yourself. This is lamb, not a lamb.”

Lisa: “What’s the difference between this lamb and the one that kissed me?”

Bart: “This one spent two hours in the broiler!” [takes a big bite]

 

From a nutritional point of view, meat is a great source of easily-digested protein and bioavailable iron. But, really, very few American kids have a problem with not getting enough protein in their diet. All dairy products are complete proteins, as are eggs and peanut butter and delicious bacon. I mean tofu.

 

Homer: “Lisa, honey, are you saying you’re never going to eat any animal again? What about bacon?”

Lisa: “No.”

Homer: “Ham?”

Lisa: “No.”

Homer: “Pork chops?”

Lisa: “Dad! Those all come from the same animal!”

Homer[chuckling] “Yeah, right, Lisa. A wonderful, magical animal.”

 

Iron, though—iron might be another story. Iron can be found in some vegetables, especially those dark leafy green ones that Lisa loves, and beans and grains. But that kind, called non-heme iron, isn’t easily absorbed. The heme iron found in meat and seafood really does get into your body better. Absorption of non-heme iron can be increased by consuming foods with vitamin C (like citrus fruits), eating your non-heme iron with a little meat (not Lisa’s first choice), or cooking with a cast-iron pot. If none of that is practical, it’s easy enough to get an iron supplement to replace the iron in meat.

 

Lisa: “Uh, excuse me? Isn’t there anything here that doesn’t have meat in it?”

Lunchlady Doris: “Possibly the meat loaf.”

Lisa: “Well, I believe you’re required to provide a vegetarian alternative.”

[Doris picks up a hot dog, shakes the wiener out, and slaps the bun down on Lisa’s tray]

Doris: “Yum. It’s rich in bunly goodness.”

Lisa[dryly] “Do you remember when you lost your passion for this work?”

 

I’m assuming, here, that the child is willing to continue eating dairy products—without those, it’s difficult to get enough calcium and vitamin D. I think a family can easily follow a lacto-ovo vegetarian diet (including dairy and eggs) without much worry, and in fact such a diet is almost certainly more healthful than that of many families. But strict veganism, with no eggs and no dairy, is tricky, especially with younger children. I suggest any family who’s raising vegan kids spend some face-to-face time with a registered dietician (NOT a “nutritionist”! Don’t get me started on nutritionists.) That way they can learn what they need to know to ensure an adequate diet and correct use of supplements. It can be done, but it requires some work and planning.

 

Paul McCartney: “Linda and I both feel strongly about animal rights. In fact, if you play ‘Maybe I’m Amazed’ backwards, you’ll hear a recipe for a really ripping lentil soup.”

Lisa: “When will all those fools learn that you can be perfectly healthy simply eating vegetables, fruits, grains and cheese?”

Apu: “Oh, cheese!”

Lisa: “You don’t eat cheese, Apu?”

Apu: “No, I don’t eat any food that comes from an animal.”

Lisa: “Oh, then you must think I’m a monster!”

Apu: “Yes, indeed, I do think that.”

 

Leslie asked if she should just put her foot down, to force her daughter to eat meat. I don’t think that’s the way to go. I can respect her daughter’s wish to not harm animals, and she can have a perfectly healthful diet that fits her own moral philosophy. Yes, even four year olds can and should have a sense of right and wrong, and I’m not so sure we meat eaters are in fact morally superior to a vegetarian preschooler. Or Lisa Simpson.

Try out The Great Courses – free!

Posted August 17, 2015 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2015 Roy Benaroch, MD

Heya! For all of my loyal followers (and anyone else who stumbles onto this page, thank you Google), I’ve got a very cool, completely legit, no-strings attached way for you to try out lectures from my publisher, The Great Courses.

These guys produce top-quality audio- or video- lectures about all sorts of things—science, philosophy, history, music, basically all of the things you wished you learned about in college. But this time, there’s no tests and no pressure. Just the best lecturers in the world, gabbing on about cool stuff. Seriously—they find great people to write and perform the lectures, and then they record them on state-of-the-art equipment to make us look like we’re not yahoos. I was a customer of theirs for years before they invited me to join their stable, and I will honestly say that if you like to learn, you’ll love these lectures. You can buy the lectures in audio or video formats for all kinds of devices, and they’ve got this weirdly too-good-to-be-true, no-time-limit money back guarantee.

And now they’re rolling out a new way to enjoy the lectures, a subscription streaming service that gives you access to just about entire catalog, to watch or listen to as many or as few lectures as you want, from any of the courses. Even mine! (BTW you should click the video preview in that link—slick, amiright?!)

Best of all, this is your exclusive chance to try out the new Great Courses Plus subscription service—at no cost at all. They’re beta testing the system, and for a limited time you can sign up and enjoy for free!

To sign up, follow this link to The Great Courses Plus and use invitation code “BENAROCH”. Be sure to check out my course! Some of my other favorites include history lectures by Rufus Fears, music by Dr. Robert Greenberg, and history lectures by Patrick Allitt, But, honestly, just click around and check out what looks interesting. It’s all good, and this is a great free chance to sample whatever you’d like!

Right now, only my first lecture series is available—Medical School for Everyone: Grand Rounds Cases. (56 reviews! All 5-star! I’d like to thank the academy! Etc!) It’s a series of medical mystery cases for anyone to solve—and to learn about medicine and medical decision making along the way. My next lecture series, Medical School for Everyone: Emergency Medicine, should come out in November or so. And I’m currently writing a third series, called Medical School for Everyone: Pediatrics, we’ll be taping in November. All

Things are busy around here at The Pediatric Insider headquarters! Thanks to everyone for visiting, commenting, and sending in topic suggestions– I’ll almost certainly get to every single question long before the sun burns down to a teeny lump of coal. I also really appreciate all of your Twitter follows and retweets, Facebook reposts, and whatever the heck else is happening to these posts. We’re up to about 2 million hits since this blog began in 2008, which I think is good, and makes me at least as influential as Surgeon General Vivek H. Murthy (Who, you ask? Exactly. Though he did get to meet Elmo. I am jealous.) You guys rock!

Dumb, dangerous things in your home

Posted August 3, 2015 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Little kids are curious by nature. They like to get into things, and they like to put things in their mouths. Manufacturers of many dangerous things take all kids of steps to prevent that from happening. For instance, children’s liquid acetaminophen is packaged in bottles that are relatively small—even if a bottle of liquid is swallowed, it’s less likely to cause toxicity. And those Gummi-style vitamins never contain iron, because iron is the one “vitamin and mineral” that’s really, really toxic in overdoses. I’m still not so sure it’s a great idea to make multivitamins into Gummi candy, but at least the people who make them are trying to keep them safe.

A few products seem to have missed the boat on this whole “safety for children” thing.

First, here’s a pocket or purse sized container of ibuprofen from a prominent national brand (don’t try to guess which one—I’ve cleverly covered the label with my thumb.) The child-proof cap is a joke—you can’t really screw it back closed, so it’s really easy to open.

Ibuprofen tablets

Worse, the tablets themselves look pretty much exactly like candy M&Ms. They melt in your mouth, not in your hand:

IMG_3275

And, worst of all, the little tablets are coated in sucrose. Lick ‘em, and they’re sweet and tasty. So: packaged so they’re easy to open, and designed so they look and taste like candy. Far be it from me to disparage a national brand, but one might come to the conclusion that these people hate toddlers and want to kill them. Of course, I wouldn’t say that on my blog, because I’m allergic to lawyers.

Next on the “Products that seem to have been designed for maximum toddler maiming potential” are laundry pods. These are those little prepackaged things that cleverly save us the trouble of measuring out laundry detergent with a scoop. (What are we, cavemen?) They’re colorful and cool and – guess what!?—toddlers like to put them in their mouths. Ingestion of these things is very dangerous. Worse, manufacturers don’t have to tell anyone what’s inside, making it difficult for doctors and poison centers to manage ingestions. They’re looking into adding bitter substances to laundry pods, making them less likely to be eaten. (I can see it now, pods flavored like brussels sprouts.) But still: if they look cool and are easy to break open or swallow, someone little is going to get hurt.

Laundry-detergent-pods-jpg

You can’t rely on product manufacturers to protect your kids. Use common sense. Dangerous things—like medicines, cleaning supplies, oven cleaners, pesticides, and laundry detergents should be kept way out of sight and unreachable by curious kids. Keep the phone # of the poison center (1-800-222-1222) handy, and call them immediately if there’s been an ingestion. And just say “no” to laundry pods and medicines that look and taste like candy.

Gluten and children’s health: The New Boogeyman?

Posted July 27, 2015 by Dr. Roy
Categories: Behavior, Medical problems

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.

 

*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

An overweight infant: Time to worry?

Posted July 20, 2015 by Dr. Roy
Categories: Nutrition

Tags: , ,

The Pediatric Insider

© 2015 Roy Benaroch, MD

Megan wrote in: “My son is 6 months old, weighs 10.1 kg and 70 cm long. I am concerned about his weight as he doesn’t seem to eat and drink excessively. He can’t roll over and my GP said this is probably due to his weight. What do I do? Cut back on protein and replace with extra veggies? Could he have a health issue?”

For those of you more used to traditional units, that’s about 22 pounds and 27 ½ inches. For comparison, the average for a 6 month old boy is about 17-18 pounds and 26 ½ inches.

Megan wants to know, first, if there’s really a problem here. My definitive answer is:  Maybe. Or, more accurately, no… but there might be later. Having a few extra pounds, now, isn’t hurting Megan’s baby. If he’s otherwise healthy and his development is normal and he’s being fed appropriately, I think it would be very reasonable to wait and see.

But if there are some habits starting now that in the long run might increase his risk for obesity, now would be a good time to address those. Megan said he doesn’t seem to eat and drink excessively, but I’d want to take a better history of his intake over a few days to see exactly what’s meant by that. Is he getting excessive calories? Is he drinking an excessive amount of mother’s milk or formula? Does he get cereal added to his formula, adding calories he doesn’t need? Megan asked about cutting back on protein and increasing vegetables, but is a good idea—though I wonder where he’s getting extra protein from. I’d try to use mostly veggies as complementary foods at mealtimes.

Another thing to ask about, and this can be a difficult question: has eating become the main pacifier or soothing activity? Some babies are temperamentally more difficult to soothe, and sometimes parents fall into a rut of always soothing with food—which can sometimes contribute to a lifetime habit. Many adults eat when they’re worried or upset, and sometimes we get our babies used to doing this, too. I’d ask Megan, what do you do when your son is upset or worked up?

Megan also said he cannot roll over, which to me is unexpected. I see plenty of chunky babies, but almost all of them roll by 6 months. I’d want to do a careful physical exam and developmental assessment, here, before blaming the lack of rolling over on his size.

The question was also asked, “Could he have a health issue?”—meaning, could he have some kind of medical condition be causing his excessive weight. There are some conditions that can do this, but they’re fabulously rare. Incredibly rare. Incredibly as in most-doctors-will-never-ever-see-a-case-of-this rare. So without other history or physical exam findings to suggest something like this, I don’t think it’s very likely.

The most important steps when I evaluate a baby whose growth is not as expected—too big or too small—starts with a careful history and physical exam, and then continues with following the baby closely. Watch those numbers over the next few months to see if they level out. Though there are no immediate dangers here, overweight babies are more likely to become overweight children who are more likely to become overweight adults. Now may be the time to make a few dietary adjustments to prevent a whole lot of trouble later. It’s not time to panic, but it is time to pay attention.


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