Archive for the ‘Pediatric Insider information’ category

Don’t waste your money on follow-up formulas and their ilk

March 9, 2018

The Pediatric Insider

© 2017 Roy Benaroch, MD

Leave it to marketers to find as many ways as possible for parents to waste their money.

A growing market is developing for what’s variously called “follow up formulas,” “toddler drink”, or “toddler milk.” Short version for those of you in a hurry: don’t bother buying these. You do not need to waste your money. Details below, after a (very) brief lesson on how to feed a baby.


How to feed a baby in the developed world, 21st century edition

Like all mammals, our newborns depend on liquid nutrition (AKA “milk.”) Mother’s milk works great for most families; commercial infant formula is a great choice, too. Between 4-6 months, start introducing complementary foods, using whatever the family is eating, kind of mushed up into a puree. You can use commercial baby foods, too, or commercial baby cereals and things – they’re not necessary, but they’re handy and easy. As babies grow from 6 to 9 to 12 months, they should take more and more of their food from first a spoon, and then by feeding it to themselves when their motor skills are up to the task. Be prepared for mess. At 12 months, if you’re bottle feeding, switch from commercial formula to whole or 2% or skim milk; if you’re nursing, feel free to continue. Have family meals for the next 18 years or so, and later on make your kids take you out to dinner on their dime. Ha!


Notice: nowhere in there is any mention of “toddler milk” or “followup formula” – those products are not recommended by the American Academy of Pediatrics or the American Academy of Family Physicians. Honestly, they have no use at all for routine use in children. So what are they, where did they come from, and why are the formula companies selling them? It’s time for the details!

Traditional commercial baby formula is an option to replace breast feeding for the first 12 months of life. Babies younger than that shouldn’t be fed straight up cow’s milk (unless, of course, we’re talking about a baby cow.) Baby humans need a different blend and amount of (especially) protein, and have different nutritional needs that are best met by human milk or a commercial copy of human milk, AKA “baby formula.”

But: and here’s the key thing: by 12 months of life, baby humans can do fine with cow’s milk as part of their diet. Remember, by now they should also be eating a good variety of other foods, so they’re not depending on milk, alone, for their nutrition.

A gallon of milk costs about $3.00, less if you catch a sale at Kroger. A gallon of infant formula costs about $21.00 (that’s reconstituted from powder, using the prices I found at Walmart today.) Are you starting to figure out where the idea of “follow up formula” came from?

It’s ingenious – these products are packaged to look like baby formula. And they have clever names that imply parents should be moving to them from baby formula, using words like “transitions” or “next step.” Some are named in a way that implies they’re a special kind of milk – “toddler milk” – that’s somehow superior to ordinary milk. Hats off to the marketers – they’ve come up with a product that’s much more expensive than the alternative (milk), and that’s completely unnecessary. But it’s selling, so I guess they win.

Look, I’m glad the good people at Mead-Johnson, Ross, Gerber, and even those faceless generic companies are producing good quality baby formulas. But I’m not so glad they’re trying to extend their markets by creating the illusion that infants past 12 months need their products. Spend your money on what your children really need – a variety of foods, or books, or a slide for the backyard. Save for college, or a family vacation. But you really don’t need to keep spending money on special milk or formula past your baby’s first birthday. The formula companies already got plenty of your moolah – don’t feel bad about keeping a little more for yourself.


Just for fun: below is a comparison of macronutrient compositions of cow’s milk versus infant formula versus 2 kinds of followup formulas (Enfagrow, marketed for 9-18 months, and Similac Go & Grow, marketed for 12-24 months.) Compared to milk, the big nutritional difference with these followup formula is more calories, and especially more calories from carbohydrates. That is not what American children need.


Kcal/8 oz Fat, g Protein, g Carbs, g cost, gallon
Whole milk 136 7 7 10 $3.00
2% milk 122 5 8 11 $3.00
skim milk 86 0 8 12 $3.00
Enfamil 168 9 3 18 $21.76
Enfagrow 160 8 4 17 $17.92
Similac 160 9 3 17 $21.40
Sim go & grow 150 8 4 16 $13.95



Help me raise money to fight childhood cancer — featuring a listicle and a blog update

March 6, 2018

The Pediatric Insider

© 2017 Roy Benaroch, MD

Hello Insiders! In a few weeks I’ll be getting my head shaved to help raise money with St. Baldricks to fight childhood cancer. It’s a great charity, and I’d sure appreciate if you’d click here to contribute! There are many compelling reasons to join in:

  1. Help children with cancer!
  2. Help me get a badly-needed haircut!
  3. Help me raise more money than son, who needs a haircut even more than I. He’s joining me at the event for the first time this year (or, contrarily, you can contribute to him. It’s all a good cause!)
  4. Help celebrate, if that’s the right word, my 50th Which happens to be today. Really. So I’m thinking that’s a good reason for you to pony up some cash.
  5. Help get yourself some nice warm fuzzies – guaranteed, you’ll feel great after donating, or you can get your money back* (*Note you cannot get your money back, and this is not a guarantee of warm fuzzies or anything else. What am I some kind of miracle worker or something?)
  6. Help keep this blog running! I don’t have sponsors or ads (though maybe WordPress runs some ads, but I don’t see them or get any of the filthy lucre) – and I barely remember to try to sell any of my courses and books here. This blog is purely a labor of love, and I’m thinking if you guys donate, why, I’d love you even more!
  7. Help celebrate, can you believe it, both the 10th year I’ve done St Baldricks, and the 10th year of this blog! Crazy!
  8. To summarize: I’m 50, I’ve been at this 10 years, I need a haircut, my son needs a haircut, you need warm fuzzies, and some great kids need your help – so donate if you can!

And now, a short blog update – things have been a but quiet around here, I know. I’ve been working on a new series for The Great Courses – you’ll love it. It’s called “A skeptic’s guide to medicine and the media.” It’s a romp through media portrayals of health stories, the good and the bad, and how you can equip yourself to tell a useful, reliable, and accurate story from a bunch of crazy lies and propaganda. I’m getting it written to tape around October, and it will be out… well, I’m not sure when, honestly, but I’ll let you know!

Meanwhile, please send in some new ideas to get the blog juices flowing again. You know the rules: Good questions about unique general topics that will interest a lot of people, especially me, will probably get answered quickly. Long questions that are specifically and obviously about a problem your child is having will probably not get answered at all.

Elderberry extract: The magic fix for influenza?

February 8, 2018

The Pediatric Insider

© 2017 Roy Benaroch, MD

A Facebook pal posted about using an elderberry extract to treat flu – apparently this stuff is flying off the shelves. Could it really help?

It’s certainly conceivable that a plant extract could have anti-viral or other health promoting properties. After all, plants battle with viruses, bacteria, and other microorganisms all the time. We know that there are tons of “natural” compounds right there in the plants we eat that are themselves pesticides or anti-microbials (in fact, there’s far more pesticide in a plant than is ever sprayed on a plant. Cool, huh?) There’s a certain plausibility that says some plants or plant exacts could help prevent or treat infections. There have also been a small number of in vitro studies of elderberry – that is, studies in a test tubes – that show some antimicrobial properties. And even one study in chimps!

But what we really want to know is whether elderberry can help fight flu in people. And to do that, we need a good study. A randomized controlled trial, to be precise, where some people with flu are given elderberry, and another group a placebo. And then let’s see how they do. Science!

In fact, one such trial was done about 20 years ago, by a team of researchers from Israel and Scandinavia. 80 adults from age 18 to 54 (no children) were candidates for inclusion, all with typical flu symptoms during the 1999 flu season, recruited from one of four health centers in Norway. 60 people participated in the study (it’s unclear how the 80 was whittled down to 60.) Half of the 60 were given a standardized elderberry extracted called “Sambucol”, made in Israel; the other half were given a syrup said to be identical in taste, but lacking actual elderberry. Both groups were told to take a tablespoon of their syrup four times a day for 5 days. No attempt was made to see if patients could guess whether they were in the placebo or elderberry group.

The patients judged how they felt on several scales of crumminess, rating their own aches and pains, degree of coughing, quality of sleep, and other measures each day. Their ratings at the beginning of the study were similar (which is good—that means the randomization didn’t put sicker people in unbalanced groups.) None of the patients had any important side effects.

The results – you can take a look at them in figure 1 – were impressive. The elderberry-takers quickly had a huge improvement in symptoms, and rated that they had almost no symptoms by day 4. Contrast with the placebo-takers, who really didn’t get back to feeling good until day 8. There are different ways to break down different symptoms in the text of the study, but the bottom line is that these authors found elderberry extract to be very effective at relieving the symptoms of flu.

I have some doubts. The results fail a kind of “sniff test” to me – they’re too good to be true. No one with flu has symptoms that disappear so quickly. And it shouldn’t have taken the control group 8 days to get better, even with no treatment at all. I wonder if the patients were truly blinded, or if they figured out their group assignment. I read a lot of studies, and these results show a huge effect size seldom seen with any intervention.

I also wonder what impact the funding source could have had – the study was funded by the maker of Sambucol, who also supplied the elderberry and placebo extracts. The study was performed in 1999 and published in 2004, and I cannot find any further human studies of any elderberry product to fight influenza since then.

So there you have it – that’s the evidence. A single, small, industry-paid-for study showing a remarkably positive effect of elderberry in treating influenza in adults. Color me skeptical. But I’ll also say that I don’t know of any down side to elderberry – as far as I can tell, it’s safe, and some people even like the taste. And other than fluids and ibuprofen, I don’t know of anything else that has a big impact on treating influenza. Is it worth a try? Sure. Let me know how it goes.


Use honey. Not Zarbees.

December 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

What if there were something cheap and effective for cold symptoms – something you could buy at your grocery store. Heck, you probably already have it in your house. It’s undergone at least three solid studies showing that it helps alleviate cough more effectively than established cold medicines. And it’s safe for just about anyone age 12 months or older.

Cool, huh? It’s honey. Good old honey, the stuff beloved by Winnie the Pooh, made by bees, and especially tasty drizzled on a peanut butter sandwich. You shouldn’t give raw, unpasteurized honey to babies less than 12 months of age, but other than that it’s safe as can be. Try it next time you or your child has a cough. (** TIP ONLY FOR ADULTS: I’m told mixing equal parts of honey, lemon juice, and Canadian whiskey together makes a fine toddy that will make it feel like you aren’t even sick. Until you pass out. This is for parents, not children.)

And that should be the end of the story. But what if instead of honey, you mix it with some other ingredients, double the price, and sell it in the medicine aisle? Then you’ve got Zarbee’s, which (according to their website), is the #1 pediatrician-recommended cough medicine sold for children less than 6.

Keep in mind Zarbee’s wasn’t what was studied in those clinical trials. I can’t find any clinical trials of Zarbees. Even the company that makes it carefully tiptoes around that issue on their website, where they avoid claiming that there’s any evidence that their products effectively treat any symptoms. They “support immune systems” and “soothe”, but those are just weasel-phrases that can’t be tested. That’s why the packaging also says, in all-capitals, “THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THIS PRODUCT IS NOT INTENDED TO DIAGNOSE, TREAT, CURE, OR PREVENT ANY DISEASE.”

Though the Zarbee’s line started with just the cough syrup, they’ve now got a variety of products to treat symptoms, all based on “wholesome ingredients” – meaning, as far as I can tell, “things not tested for safety or effectiveness in children.” But I guess they expect a pass, because, you know, the bees and all.

Look, I know coughs and colds are frustrating and miserable. If there were anything that actually worked, whoever comes up with it will make a mint. Until then, we’ll continue to see the dizzying aisle of hundreds of competing medicines – and every few years, a new one will become popular. Remember the one “invented by a teacher”? Or that adorable mucus-monster that showed up a few years ago? Now we’ve got Zarbee’s. None of these products works any better than any of the others, and none work any better than typical home remedies. But no one will make any money selling chicken soup and honey, so I’m sure we’ll bee (ha!) seeing more products from the Zarbee’s line. Save your money.


Halloween: What should worry parents, what should not

October 24, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD


Poisoned candy – not a worry!

There have been 5 deaths in the USA reported from poisoned Halloween candy. But: three were committed by family members (one using cyanide-laced Pixy Stix), one was by a child who ingested heroin (the family sprinkled more heroin on the candy afterwards to make it look like that was the source, but it turned out that the child had found and eaten his uncle’s stash) and one turned out to be related to an overwhelming strep infection – unrelated to the candy eaten the night before.

In 2000, several children in California found Snickers bars packed with marijuana. Funny story: a postal worker found a box of Snickers among the undeliverable mail, and brought them home to give to trick-or-treaters. It’s assumed that someone packed them with marijuana to sneak them through the US mail, but got the address wrong. There’s a lesson there. Anyway, no one ever found the culprit, and no one was hurt.


Metal objects in candy – not a worry!

 There have been about 80 reported cases of needles and razor blades and things in Halloween candy. But almost all of these were hoaxes that never actually happened. A few were true stories, but the objects were placed by family members (good old Uncle Bob, what a kidder.)

In 2000 there was a case in Minneapolis of a guy arrested after sticking needles into Snickers bars (What’s with the Snickers, anyway?) One teenager got stuck by a needle, but didn’t need medical attention. As far as I can find, this is the only documented case of a sicko randomly and deliberately handing out dangerously adulterated candy.

Some communities have had programs for x-raying candy – but I think these have been phased out. They’re expensive and unnecessary, and no one has ever spotted anything of concern on one of these.


Sexual assaults – not a worry!

 It’s been studied. Child sex crimes don’t increase on Halloween.


Getting your eye knocked out by a thrown egg – this is a thing, apparently

This report wasn’t about Halloween, but it did include several people with apparently severe eye injuries caused by assault by thrown raw eggs. So don’t do that. Raw eggs are for throwing at houses, not people. Wait, forget I even said that. Just leave the raw eggs at home. Make cookies or something.


Car accidents – the only serious possibility on this list

Now this is a real problem. Halloween is the #1 day of the year for pedestrian accidents among children, averaging 5.5 deaths per year in the US (that’s double the average for a typical day.) Be careful with your kids, and have them wear something light or (better yet) lit. Remind them to cross streets at crosswalks and corners, and not just dart around. If you’re driving, be very careful in residential neighborhoods, and don’t drink alcohol. Both drivers and pedestrians shouldn’t be messing with their phones. Pay attention, everybody.


Getting your brains sucked out by Alien Zombie Vampire Death Beings – rare?

As far as we know, this doesn’t happen. Much. Hardly ever. Really.


Tummy aches and weird nightmares from too much candy – yup, it happens

Don’t say I didn’t warn you!


More from Wikipedia, Snopes, Mental Floss, and Vince Guaraldi. Stay safe, have a good time, and remember: I like Almond Joys and Reese’s.


Physician rating sites deserve their own “Black Box Warning”

September 26, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

When a drug is especially dangerous, or even potentially-maybe-especially dangerous, the FDA requires manufacturers to put a “Black Box Warning” on the product insert. (As it happens, many of these are misleading, inappropriate, or factually incorrect – but that’s a subject for another day.) A “Black Box Warning” is supposed to very explicitly say “BUYER BEWARE”, more than just the typical list of potential side effects mumbled by Mr. TalkFast at the end of a drug ad. The normal warnings look like “ThisDrugMayCauseDrowsinessTailGrowthAnalFlameDischargeAnUnpleasantMetallicTasteOrAnInexplicableInfatuationWithSenatorJonTester(D-Montana)”. It’s easy to ignore the wordy mumbling. The Black Box, that’s supposed to get your attention. It’s doesn’t mean the drug is a bad idea for everyone, but it does mean you’d better think before you take.

I’d like to see a Black Box warning on physician rating sites, too. They’re not always wrong, and they might just be useful once in a while. But you’d better think twice before taking them at face value, or using them to make decisions about whom to see for health care.

A few recent studies illustrate some of the problems. One looked at mortality rates for 614 heart surgeons scattered across 5 states, comparing those rates to their physician ratings on several well-known rating sites. There was no correlation at all. Physicians with high death rates often had great ratings; physicians with low death rates might have very good ratings. If your goal is to survive heart surgery, those physician rating sites tell you nothing. That should be in the Black Box warning.

Another study looked at physicians in California, comparing ratings on popular sites between 410 docs who had been put on disciplinary probation versus docs in those same Zip codes who hadn’t been sanctioned. Keep in mind that medical boards do not take probation lightly – docs who’ve been nailed by their board have probably done something fairly bad, and probably more than once (although there’s considerable variability, some luck, and politics involved. Good docs are sometimes trapped by their boards, too.) Although it varied by the reason for the probationary status, for many doctors disciplined for lack of professionalism, substance abuse, or sexual misconduct there was no correlation between ratings and probation status. Looking at the overall averages, docs on probation had an average score of 3.7, compared to 4.0 for docs who had behaved themselves. Very little difference, there.

There are several reasons that these doc rating sites not reflect genuine physician competence:

  • Only people who are motivated to write ratings do so. The vast majority of patients who have a reasonably positive experience do not bother to do rate their docs. I’ve called this property of internet postings “Exaggerating Freakiness”, and it pervades social media. The internet brings far more attention to the outliers than it does to ordinary stories, and that distorts the impression we get from just about every web site.
  • How people feel about the medical care they received doesn’t necessarily correlate with whether they got good care or not.
  • It’s pretty much impossible to tell if a public posting is true. There are many reasons people write both positive (friends, neighbors, well-wishers) and negative (competitors, those with specific agendas) reviews.

Some docs (and other businesses) are using litigation to aggressively fight back against negative reviews. But that’s not always fair, either. People are entitled to their opinions, and as long as they’re not just lying about what happened, I think it’s best if the lawyers stay out of this. Still, I get the frustration that business owners feel if they’ve been unfairly targeted.

Online rating sites are here to stay, and they’ll continue to rate doctors and hospitals, and people are going to continue to use them (Google just shoves the rating down your throat when you search. There’s no avoiding this.) Just remember the Black Box warning: physician rating sites may have some use, but they can have unintended side effects. They may mislead you into making a poor decision about your doctors, and that’s not good for your health.

Physician rating sites deserve their own “Black Box Warning”


Be wary of infant jewelry and lead poisoning

September 5, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

A recent story reported by the CDC reminds us of a few important lessons about teething, lead, and the kind of jewelry you buy at craft shows. A mom had purchased a handmade “homeopathic magnetic hematite healing bracelet” from an artisan at a local craft show. Her 9 month old daughter wore it on her wrist, reportedly to help with teething symptoms, and occasionally chewed on it (as babies are known to do.) She was found on routine screening to have a blood lead level about 10 times the safe upper limit of safety.

Lessons to learn:

Babies really shouldn’t wear jewelry at all (they look good without it!) Some bling is probably OK (like small earrings), but you have to be sure they’re not made with lead. That’s because anything on a baby or near a baby will end up in the baby’s mouth. Seriously, everything.

This particular bracelet was triple-dangerous. Looking at the photo, it was made of little beads strung together, which apart from their poisonous lead content were a potential choking hazard. And: magnets are a very bad thing for kids to swallow, because they can glom onto each other in clusters, or even while pinching a piece of intestine. Magnets are less likely to make their own way out without causing big-time tissue damage. No lead, no beads, no magnets!

Babies should especially never wear any kind of jewelry around their necks. Even a small tug on a necklace can close off the airway and kill a baby. That includes those trendy amber teething necklaces, which are both a choking and strangulation hazard. There are media reports of deaths from those things. Look out for long cords or straps on pacifiers, or cords on window blinds or binoculars or anything else thin and round and shaped in a loop. Anything that could wrap around a neck can strangle a baby and needs to be cut to pieces or kept very far away.

And: teething. Most babies experience teething with no symptoms whatsoever – the only way you know, with most babies, is that you see teeth poking out. An occasional baby might have some fussiness with teething, and you can treat them with love and cuddling, maybe a teething ring, or some acetaminophen if needed. There is no great plague of terrible symptoms of teething that need constant treatment, especially not with dangerous things. Teething is just another thing most parents do not have to worry about.

Other dangerous teething “cures” have included “homeopathic teething tablets” which contained poison, and benzocaine-containing teething gels (now mostly off the market) that caused a potentially fatal blood disorder. The sad thing here is that none of these were ever really needed – they’re marketed based on fear of a normal, harmless condition. Don’t waste your money, or endanger your child’s health, on jewelry or potions to treat teething.