Archive for the ‘Nutrition’ category

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

August 20, 2015

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.

An overweight infant: Time to worry?

July 20, 2015

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.

A tired traveling two-year-old, exercise and weight loss, and a big-tonsilled tooth grinder

May 6, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

I’ve been writing a follow-up course to my first video lecture series, and falling behind on blogging. Never fear! Once this baby is taped I’ll be back here, full time. Or nearly full time—I have a job, too, you know. For today, I’ll post a bunch of brief answers to questions that have been sent in lately. Keep the questions coming, I’ll get to them eventually!

 

“Graham is 2 ½, and every time we travel and he sleeps somewhere other than his crib, he goes crazy. Even if we do his same routine at home (and have even tried packing up his crib to bring with us!), he takes hours to go to sleep, and usually wakes up in the middle of the night screaming and nothing will calm him down. My husband usually ends up driving around with him in the car all night. I keep thinking he will outgrow it, but at almost 3, it is still happening. Any ideas of what we could do to help him sleep so we can still travel?”

Graham sounds like he likes his routines. And I’m not so sure you’ll be able to perfectly recreate his home setting and routine when you’re on the road.

Instead, it might help to start the process even before you travel. Have him start sleeping in his travel crib or pack n play a week or so before the trip, or mix things up in other ways—maybe move his crib to another part of the room, or even into a different room. Try to make it a fun adventure! Let him choose what “crazy place” to sleep at night. Maybe then the broken routine when you travel won’t seem as jarring.

 

“I’ve seen reported in the media recently that exercise doesn’t help with weight loss so there’s no point in even trying.”

 Whether or not exercise helps with weight loss, it’s still a good thing to do. People who exercise improve their cardiac and metabolic risks—think less diabetes and fewer heart attacks– whether or not they lose weight. Exercise helps sleep, prevents depression, decreases stress, and has turned me into the glistening man-hunk that I am (OK, I may have exaggerated that last point a bit.)

And: exercise can help you lose weight, too. You just have to not eat more when you do it.

 

“My 10 year son has been a super nighttime teeth grinder for as long as I can remember.  He also has very (naturally) large tonsils.  The dentist today said that the grinding is likely because his airway is partially obstructed when he sleeps and he’s trying to get air, and referred me to an ENT to have his tonsils removed.”

 There does seem to be an association between sleep-disordered breathing—loud snoring and pauses caused by upper airway obstruction—and teeth grinding (AKA “bruxism”). In a 2004 study from Brazil, about half of 69 children referred to an ENT group for adenotonsillectomy had bruxism; after surgery, the percentage dropped to 12%. If your child has large tonsils and sleep-disordered breathing, tonsillectomy may improve the teeth grinding. An ENT eval is a good idea.

Food allergy “testing” is usually a bad idea

March 23, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

People like tests. You get numbers, and maybe a printout, and there’s science and blood and things just feels more… serious, when testing is done. You can picture Marcus Welby  (or perhaps a more modern physician), looking solemn, declaring “We’d better run some tests.”

Are medical tests magical and mysterious, and can they unlock the secrets of life? Usually, no. And among the worst and most misunderstood tests we do are food allergy tests.

A few recent studies illustrate this well. A review of about 800 patients referred to an allergy clinic found that almost 90% of children who had been told to avoid foods based on allergy testing could in fact eat them safely. The study, bluntly titled “Food allergen panel testing often results in misdiagnosis of food allergy” also found that the positive predictive value of food allergy blood tests—the chance that a positive test accurately predicted real allergy—was 2.2%. That much, much worse than the odds if you flipped a coin, and much, much worse than your odds of winning at a casino. If someone told you that a positive test was only correct 2% of the time, would you even do the test?

What about the other way of food allergy testing, with skin scratch or prick tests? A recent study about peanut allergy made big news when it turned out to show that early peanut exposure can prevent allergy. (This isn’t new news, by the way—I’ve written about that before. But I get fewer readers than the New England Journal of Medicine.) But hidden in the methods and statistics of that paper was another gem. The authors tested all of the enrolled babies for peanut allergy, at the beginning of the study. And most of the babies who “tested positive”, whether or not they then ate peanuts, did not turn out to be allergic. A true statement from the data from that study would be: If your baby tests positive for peanut allergy, your child is probably not allergic to peanuts.

Read that sentence again. Kind of makes your brain hurt, doesn’t it?

It is true that positive-tested kids were more likely than negative tested kids to be allergic—among the group with more allergies later (those who avoided peanuts), 35% of those who had positive tests developed allergy, versus 14% who had tested negative. But still, in either case, most of the kids who tested positive did not turn out to be allergic, whatever they ate or did.

The fundamental problem, I think, is that doctors either don’t understand or can’t seem to explain the difference between sensitization and allergy. None of these tests can actually test for allergy—they test for sensitization, which is different. We gloss over that distinction, and end up giving out bad advice. People should not be told to avoid food based on the results of allergy testing alone.

Bottom line: if you child eats a food without having a reaction, he or she is not allergic, and you should not do any testing for that food as a potential allergen. You should never do broad panels of “allergy tests”—they’re much more likely to mislead and confuse than to give useful information. Any food allergy testing that is done should only look at foods that seem to have caused reactions in the past, and even then any positive testing should be confirmed by what’s called an “open challenge.” Under safe conditions, usually under an allergists’ care, give the child some of the food to eat to see what happens. That’s the only real way to “test” for allergy.

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

February 16, 2015

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

Milk and health: Wading thru the hype

December 29, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Fiona wrote in: “I’ve seen in the news recently there’s been studies showing concern about milk consumption, especially for adults. They’re linking high milk consumption to health issues later in life. Is this true? Can you write a post on this?”

Food information, like so much else on the internet, has become one-sided and anxiety-provoking. I suppose that’s because people are more likely to click on a link like “Milk is killing you” than “Milk is a nutritious food and a reasonable part of a healthy diet, but you don’t need a ton of it, and there are plenty of other sources of calcium and protein.”

In the latest kerfuffle, we’ve got the dairy peeps versus the anti-milk crowd. On one side, people say milk and other dairy products are a good source of calcium and vitamin D and protein, all of which is essential especially for growing children and people at risk for osteoporosis; on the other side are people claiming that research shows that increased milk drinking will kill you, and doesn’t help keep bones healthy anyway. Who to believe?

Let’s back up a second. Like all mammals, our newborns thrive on a liquid diet made by our mommas called “milk.” The exact composition varies by species—for instance, goat milk has no folate, because goat babies don’t need folate—but overall it’s stuff made of water, nutritive protein, fat, carbohydrates, micronutrients, and immunologically active proteins and cells. In other words, it’s food. It’s really good for newborns and little baby mammals who cannot eat solid food yet. In nature, the amount of time newborn mammals stay on mother’s milk pretty much correlates with how much time they need to grow to the point they can eat the food their mommas eat. Then they wean, and consume bamboo, penguins, green bean casseroles, or whatever else their species typically eats. After weaning, no other animal species continues to consume milk.

Humans are unique animals, because we’ve come to rely on a system of nature-taming developments called “civilization”. Farming, which dramatically increases the food availability per acre, started about 10,000 years ago; dairy milk consumption from non-human animals began maybe 5,000 years later, once goats and proto-cows and sheep were domesticated. Milk had the advantages of being cleaner and less disease-ridden than ordinary water, and also offered good, easily-digestible calories at a time when food could be scarce. Once milk-preservation methods were developed, butter and cheese and yogurt could keep fresh for a much longer time. In many cultures, dairy products became a big part of daily intake.

So, while it’s true that no other adult mammal consumes milk—which is a favorite talking point of the anti-milk crowd—no other adult mammal consumes any farmed food, or any domesticated animals, or any cooked foods, or any omelets. We are not like other animals, and our food sources are entirely unique. Yay us.

While milk and milk products are a historically reasonable thing for humans to eat, their health benefits for mammals old enough to consume ordinary food have been overblown. Yes, they’re a convenient source of calcium and protein and sometimes vitamin D (which, along with vitamin A, is added to cow’s milk—it’s not there naturally.) But these products aren’t the only source of these nutrients. Children who don’t like milk or families who don’t want to consume cow’s milk for other reasons have plenty of other, good, healthful alternatives to get these nutrients.

Recent research has raised valid questions about the wisdom of considering cow’s milk to be an essential part of the diet. A 2014 Swedish study, widely reported in the press, is touted to have shown that higher milk consumption increased overall mortality and did not improve bone health. But the study relied on self-reported food intake dairies, and the study subjects were divided into many cohorts, only some of which showed these effects. And epidemiologic studies like these are fraught with issues of potential reverse causality and uncontrolled confounders. The authors of the study itself went out of their way to list these and other limitations of their study, and explicitly warned people not to change their eating habits until their study could be replicated and better understood; nonetheless, when reported in the press, the study was characterized as having proven that milk will kill you. That’s not what the study showed—that’s what the scaremongers want you to believe.

Milk is fine as a reasonable part of a diet. It’s not essential (at least after weaning), and if you or your children don’t care for milk or would rather eat and drink other things, that’s fine. It certainly shouldn’t be a huge part of any human’s diet after weaning, any more than any other one single foodstuff should account for most of what anyone eats. Want your family to eat healthy? Do these things:

  • Eat as a family
  • Don’t eat too much.
  • Eat a variety of things.
  • Slow down and enjoy your food.
  • Cook, clean, and shop together.
  • Grow vegetables in your garden.
  • And stop reading or even clicking on internet scare sites about food!

The economic benefits of breastfeeding: A call for honesty

December 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Lookie here: I am a breastfeeding supporter. I regularly help new moms breastfeed successfully, and I even took special class to learn how to do a brief procedure to help babies overcome breastfeeding problems caused by tongue-tie. I’ve got a happy breast support sticker, right on my AAP card.

But I think honesty is (or should be) the breast policy. Some women and babies find nursing to be difficult, and some moms don’t want to nurse, and some moms, yes, don’t make enough milk to fulfill the health needs of their babies. Other moms or babies have their own health problems that prevent effective breastfeeding. Breastfeeding is not in any way an essential part of raising a healthy and happy kiddo—at least in the developed world, we’ve got great, healthful substitutes for mother’s milk. Babies do not have to be nursed to be loved and raised in a healthy manner, and moms who don’t nurse don’t need more pressure or guilt.

So I have mixed feelings when I read studies like this one. Researchers in Great Britain published a study in October 2014, “Potential economic impacts from improving breastfeeding rates in the UK.” They used computer models to look at the savings reached by preventing diseases in children that have higher rates in formula-fed kids, including ear infections and GI problems ($17 million a year); they also added in savings from having to treat fewer women for breast cancer ($50 million a year, estimating current exchange rates). At first glance, those savings figures look modest—that’s because the effect of breastfeeding on preventing breast cancer and childhood infections in developed countries like Great Britain is really quite small. But let’s accept those figures as they are. The bigger problem I see is that the authors made no attempt to quantify the economic costs of breastfeeding.

We should be honest, here. We know that breastfeeding is the major risk factor for hypernatremic dehydration, which has been estimated to occur in about 2% of term newborns. This is caused by inadequate fluid intake in a newborn, and can cause seizures, brain damage, and death; it usually requires hospitalization to treat. And breastfeeding is also a major factor leading to health consequences from newborn jaundice, including hearing loss and later learning problems. The authors of this paper didn’t try to quantify the costs of these health problems, any more than they tried to look at the economic impact of breastfeeding on family finances or a woman’s career.

Like all pediatricians, I think it’s best for babies if they’re breastfed. But we’re not doing anyone any favors by exaggerating the benefits of nursing, either in terms of economics or health. We do need good social supports and laws to protect the rights of women to nurse in public and at their jobs; but we don’t need formula feeding to be a mark of poor parenting. Honest information is what parents need. Can we stop the hyperbole?


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