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

Posted March 9, 2018 by Dr. Roy
Categories: Nutrition, Pediatric Insider information

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

 

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

Posted March 6, 2018 by Dr. Roy
Categories: Pediatric Insider information

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?

Posted February 8, 2018 by Dr. Roy
Categories: Pediatric Insider information

Tags: ,

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.

Rabies, bats, and a tragedy in Florida. How to protect your kids.

Posted January 17, 2018 by Dr. Roy
Categories: In the news, Medical problems

The Pediatric Insider

© 2017 Roy Benaroch, MD

You’ve probably already seen the news: a 6 year old boy in Florida has died of rabies. He had handled a sick bat (some reports said he was trying to rescue the critter), and that was enough contact to transmit the virus. Once symptoms begin, rabies in almost always fatal – so the only way to prevent this from happening again is to avoid contact, and get rabies prophylaxis (a series of injections) if there’s an exposure.

 

Is rabies common?

Yes – in a way. In the US there are only a handful of human cases a year (43 cases from 2000 through 2013, the most recent statistics I could find.) But there are an estimated 60,000 deaths a year worldwide. So, travelers, be especially wary of animal exposures overseas. In fact, if you’re traveling to the developing world to an area with likely animal exposures and no access to medical care, it may be wise to get rabies immunizations beforehand.

 

How can people catch rabies?

It’s a zoonotic infection, meaning we catch it from animals. Only the saliva transmits rabies virus, so most infections come from bites (or sometimes scratches, since animals aren’t always so keen on washing their hands with soap and water.)

Any mammal could potentially become sick with and transmit rabies, but in the US almost all transmission is from a few carnivorous animals: bats (by far the most common source, accounting for all but 4 of those 43 cases), raccoons, skunks, foxes, coyotes, and bobcats. Small rodents (rats, mice, squirrels) and lagomorphs (rabbits, hares, and pikas) would very rarely be possible carriers. Animals with rabies may act sick, and may be especially aggressive or bitey, so always be wary of any sick mammal, especially bats.

Worldwide, the most common source of human rabies are domesticated and semi-domesticated dogs. A campaign to vaccinate pets and farm animals has virtually eliminated this kind of transmission in the US – so keep vaccinating your animals!

 

What are the symptoms of rabies?

The incubation period is typically 1-3 months, though it can be days or years after exposure before symptoms develop. It’s a quickly progressive illness that often begins with acute anxiety, pain and other sensory abnormalities, unstable blood pressure and pulse, and sometimes “hydrophobia”, an extreme fear of water. (Hydrophobia is a historic name for rabies.) These symptoms progress to coma and death.

There have been three reported survivors of rabies over the last 20 years, all teenage girls treated with a very aggressive protocol of intense medical support, including medical-induced coma and artificial ventilation. Despite this care, most patients will die.

 

What should I do to prevent rabies?

Make sure domestic animals are vaccinated, and take them to the vet if they’re sick.

Approach wild animals with respect, and teach this to your kids, too. Wild animals should not be approached, or trapped, or captured, or kept as pets. If you see an animal that’s acting sick, especially a mammal, stay away. If it’s the kind of mammal that’s likely to transmit rabies (a sick or wild dog, or a raccoon, skunk, fox, coyote, or bobcat), contact animal control or your county health department. Keep children away.

  

What if someone gets bitten or scratched by one of these animals?

First, clean the wound with soap and running water. Then go see your doctor, or go to the emergency department. Do not delay. If necessary, post-exposure injections can be given which will virtually guarantee that rabies won’t occur. These injections will not help once symptoms begin – they must be given before rabies develops. Public health people and other experts consider the circumstances of every case before deciding whether rabies prevention is needed – don’t rely on this post, or what you read on the internet, to decide if you need rabies shots. Go see a doctor right away if there’s been a potential exposure.

If it is possible to do it safely, trap or capture the biting animal. That will prevent other people from getting exposed, and will allow health authorities to test the animal for rabies.

In some circumstances, a biting animal can be observed in captivity for 10 days for signs of illness.

 

What about bats?

Bats are a special circumstance. They’re the most common rabies transmitter in the US. And small bats, especially, could potentially bite a sleeping person without anyone noticing. Young children may not be able to communicate exactly what happened during a bat incident. So if there’s a bat that’s been in a room with a sleeping child, or a child who’s been playing with a bat or near a bat for any reason, go see a doctor. (If you can capture the bat, or kill the bat and bring the carcass including the head, that can help – only if you can do this safely.)  Even if the risk of transmission is low, the consequences of not treating a rabies exposure are horrible.

Use honey. Not Zarbees.

Posted December 26, 2017 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: ,

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.

Some reassurance about football and your child’s brain

Posted December 4, 2017 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2017 Roy Benaroch, MD

Concussions and football have come up before on this blog, and the news so far has been discouraging. We want kids to stay active, and football is one of the most popular boys’ sports out there. But we know that some prominent professional athletes have had serious, cumulative brain damage from years of football – sometimes brain damage that has destroyed their lives. What about high school football, or football starting even earlier? Are we encouraging a sport that’s a cause of serious, lifelong disability?

A recent publication gives at least some reassurance. From the August 2017 issue of JAMA Neurology comes a study titled “Association of Playing High School Football with Cognition and Mental Health Later in Life.” It’s not a perfect, definitive study, but it’s got some solid long term data.

Researchers have been studying a cohort of about 10,000 Wisconsin high school graduates – students who graduated in 1957, so they’re now about 78 years old. Of those, about 2700 have complete data, including formal testing of their mental condition at age 65 and 72. Tests were done of intelligence and brain functioning using several standard assessments, as well as testing for things like depression, anxiety, and alcoholism. They also went through the high school yearbooks to figure out which of these students played football (it turned out to be about 30%. Football was, and still is, big in Wisconsin.)

When the data was analyzed, it looks like football players were no more or less likely to have problems with dementia or mental illness 60+ years later; nor were they more likely to consume too much alcohol. What was different was that they were somewhat more likely to stay physically active (which may have protected them from memory problems as they became older.)

There are some shortcomings of a study like this. We don’t know which if any of the participants played football starting younger than high school, or which positions they played, or whether they had one or more concussions. And, I think even more significantly, it’s apparent that football now is played quite differently than in 1957. Players are bigger and stronger and faster, and collisions are more high-energy. It may be that there are more brain injuries happening now on high school football fields than there were back then.

Still, 60+ years is some great long-term follow-up. It’s good to know that at least one long term study shows that football in high school isn’t associated with later cognitive or mental health problems. We still need to minimize concussion risks and identify and treat them correctly, but this study should provide some reassurance that high school football might not be so bad for high school brains.

What causes dark circles under the eyes in children?

Posted November 6, 2017 by Dr. Roy
Categories: Guilt Free Parenting

Tags:

The Pediatric Insider

© 2017 Roy Benaroch, MD

Rachel wrote in a topic suggestion:

My 8 year old daughter has for years had dark circles under her eyes. What causes this? She is very healthy and hardly ever gets sick. I have ‘heard’ this can be caused by food allergies or liver problems, but I’ve been very skeptical about that.

Rachel, I see these in kids all the time. Most commonly, I think it’s just normal – especially in children with a fair complexion. It’s easier to notice these in kids with thin, light, milky sort of skin (often with light eyes and light or red hair, too.)

One medical issue that can contribute to darkness under the eyes is congestion in the veins lining the nose. This makes the blood vessels dilate and become more noticeable. You’ll see this in children with nasal allergies or “hay fever” to airborne allergens like pollen or dust or molds. That’s why these dark areas are sometimes called “allergic shiners.” If the nasal allergy symptoms are bothering the child, this can be treated by avoiding the triggers (not always easy), or nasal spray OTC allergy sprays like Nasacort or Flonase. Oral antihistamines like Zyrtec or Claritin will be less effective for nasal congestion.

I’ve also often heard that lack of sleep can cause dark circles – Google it, and there are plenty of people who say this. I couldn’t find any evidence that this is true in children, but it might be. And more sleep couldn’t hurt.

As for food allergies – you know, I wouldn’t have thought so, at least not in my experience. But this report showed that about 50% of kids who had classic GI symptoms of food allergy also had allergic shiners. So, yes, in a child who has GI symptoms of food allergies, they might get shiners too. But in a child with no GI symptoms, I don’t think allergic shiners would be a likely isolated finding of food allergy. And liver disease? No, I don’t think so. I couldn’t find any evidence for that at all, at least not in children.

So: pretty much benign, maybe related to allergies, and probably best ignored unless the allergic symptoms themselves are bothering the child. You can add “dark circles under eyes” to our ever-growing list of things parents really don’t need to worry about!