An overweight infant: Time to worry?

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.

Generic baby formula

Sylvia wants to know: “Can I use generic baby formula?  I use generics for myself all the time, but get nervous about the idea with my baby.  (He only eats one thing – I want it to be good for him!)  Are generic formulas ok?  Do I just need to make sure it has the same nutrition info as the well-known brand?”

Generic formulas adhere to the same industry standards as the name brands, and are essentially the same. When you buy the name-brand products, you’re paying more for a label, and you’re paying more for their extensive promotional efforts and giveaways.

I almost always buy generics—including medications, when they’re available. (Except for JIF peanut butter. Mmmmm, Jif!) It’s a myth that brand-name products are superior, a myth allegedly maintained by false or misleading advertising campaigns. There have been times in the past when new developments in baby formula first appeared in the name-brand products, most recently the addition of the essential fatty acids ARA and DHA. At this time, however, the generics have entirely caught up, and you don’t need to spend extra to get the second best product available.

(I forgot Coca-Cola. OK, for the record, all other brands of cola are nasty, especially icky store brands. Mmmmm real Coke!)

Almost all formulas fall into one of these groups, with very little variation within the group:

1. Standard cow’s milk based formulas, like Enfamil Lipil or Similac Advance or almost any store brand. These are fine, the standard second best thing to feed your baby.
2. Partially hydrolyzed cow’s milk formulas. A few brands partially “digest” their milk proteins, supposedly making the formulas easier on the tummy. There’s very little data to support their use, but they’re fine if you want to try one, like Gentlease or Carnation Good Start.
3. Soy formulas, including many generics, Isomil, and Prosobee. There are very few, rare medical reasons to use these; many babies with genuine cow’s milk allergies can’t tolerate soy, and have to use a genuinely hypoallergenic formula. Still, if you’d like to avoid cow’s milk, go for it. These are probably fine.
4. Reduced-lactose formulas (Similac Sensitive, Lactofree). These are just silly—there is no such thing as lactose intolerance in babies, and these formulas are only there to pander to fears and misinformation. If your child is genuinely allergic to milk, these won’t help.
5. Hypoallergic formulas, like Alimentum or Nutramigen, are for babies with genuine milk allergies. This isn’t common, but for those babies these products are essential. There are no generics of these formulas, which are very expensive.
6. Spittin’ formulas, like Enfamil AR or Similac RS, add modified rice starch that thickens somewhat in the stomach, preventing spitting. They seem to help some, but keep in mind that almost all babies spit up sometimes, and most don’t need any medicine or special formula. There are no generics of these moderately-priced formulas.

(I like genuine Ivory soap, too. Smells nice.)

tl;dr summary: If you’re looking to save a few dollars, generic baby formula is fine.

Teething, Grandma, and John Locke

Magan asked “Is it a myth that children run a fever with teething?”

A good rule for pediatricians is: Don’t pick a fight with Grandma. But here at the Pediatric Insider, we don’t shy away from controversy—especially since Grandma isn’t reading the blog.

Teething had been thought for centuries to cause all kinds of ill effects, from fevers to seizures to death. John Locke (1632-1704), English philosopher and physician, wrote that “Convulsion fits before tootheing are from gripeings in the belly”, and recommended a form of opium, almond oil, and therapeutic bleeding to prevent fevers and “height of blood” from this scourge. Times were rough for babies then, and the doctors didn’t make life any easier.

A few recent studies (summaries here and here) have tried to pin down an association between teething and symptoms. Both of these had some important drawbacks: they’re not very big, and teething and symptoms were reported by parents who could easily figure out what the study was for. The data sets were incomplete, too—leading the authors to point out that parents were more likely to fill out logs when their children did have symptoms, rather than turn in reports of healthy days. Though both studies did find weak and inconsistent associations with a number of minor symptoms, reports of low fevers were inconsistent and didn’t reliably fit with days of teething. High fevers (> 102 F) definitely did not occur with teething.

Though it’s possible that minor symptoms or low grade fevers could occur with teething, it’s clear that significant symptoms and fevers do not. If your baby has a fever > 102 or any serious symptoms, don’t blame it on teething—or from “gripeings in the belly.” And don’t tell grandma I told you that!

Holiday twofer: Bananas, constipation, and corn syrup

I’ve got two short questions in the hopper, and I’ve come up with a fairly lame segue to tie them together. So let’s see how it works out: for the first time ever, two questions answered in one blog post! It’s like getting something free for half-price!

First, Claire asked: “Dr. Roy, can a child consume too many bananas to the point it is harmful? My son is a darling toddler who refuses to eat (literally) but he loves bananas. Less than 36 hours ago I bought 13 bananas and he ate them all. He seriously consumes at least 4 or 5 bananas a day (this is with me limiting the bananas-he would eat more if I let him). Every time he sees our bananas in the pantry he freaks out and wants them. Should I be worried? He only weighs 20 pounds so it seems like so much for him to be consuming but when offer other foods he just doesn’t eat. He has always been on the tiny side so sometimes I just want to eat anything.”

I’m not worried about a mostly-banana diet. The monkeys at the zoo look pretty healthy to me.

More seriously: You could try to broaden his diet a little by offering dips or spreads. A banana might be even more yummy smeared with peanut butter or Nutella. You could cut it into little rounds and top them with cottage cheese, or make little banana and cream cheese sandwiches.

As for his overall growth, review this with your pediatrician to make sure he’s tracking along an appropriate percentage. As long as he’s growing normally, I wouldn’t worry about his calorie intake. You should though ensure he’s getting enough calcium, vitamin D, and iron—these are not found in a limited diet. A daily multivitamin is probably a good idea.

The only problem I can foresee is that a diet rich in bananas might be constipating….which brings us to the second question of the post!

A question from Brad: “What is your opinion on using Karo syrup for baby’s constipation?”

Karo is a brand of corn syrup, useful for baking pecan pies. It’s safe and tastes sweet, and is often used to treat constipation in babies. I could find only one study looking at the effectiveness of this approach, lumping in corn syrup with other dietary modifications. It found that this approach relieved constipation about 25% of the time.

Keep in mind that the stooling patterns of babies can be quite variable. At about six weeks of life, breast fed babies may start to have especially infrequent stools, maybe just once a week or even fewer. The stools continue to be soft, and the babies are thriving and happy. Because the frequency of poops is so variable, it’s best to consider constipation only present if the stools are hard and uncomfortable. Infrequent stools, as long as they’re soft, are not constipation.

If your baby is having hard stools, one reasonable step to try is corn syrup. Check with your pediatrician on the exact dosing and how to use it. Keep in mind that corn syrup and honey are not the same thing– never give raw honey to a baby less than one year of age.

Melamine is here

Melamine in infant formula, here in the USA?

Yup. Trace amounts of this, as well as many other industrial chemicals, are found throughout the food chain. Plasticizers, solvents, cleaners, all sorts of chemicals are used in the processing and packaging of food. And shortly, you’re going to hear all sorts of grandstanding by politicians eager to make a splash in the news. But before you get caught up in the coming hysteria, let’s hear the rest of the story…

Melamine is an industrial product used in cleaning food equipment and packaging. It can also be used deliberately by ruthless food manufacturers to “fool” chemical assays of protein content—that’s probably why it was added in large amounts to several sources of milk used to make infant formula and other foods in China. That story broke in August, 2008, shortly after the Olympics. To date, the Chinese government has acknowledged 3 deaths and 50,000 sickened children from exposure to melamine, though many observers think the totals could be far higher. Melamine causes illness by binding with other chemicals in the urine and forming kidney stones. The tainted products were also exported from China to several neighboring countries, though very little was brought to the United States (only a few candies and novelty foods, mostly sold in Chinese markets, have been shown to be contaminated in high concentrations from the Chinese milk.)

Formulas and other foods in China that made babies ill have been found to have 2,500 parts per million (ppm) of melamine. Keep that number in mind.

In the United States, regulations prohibit the use of melamine as a food additive, but do allow melamine-containing solutions to be used as cleaners of food processing equipment (that regulation was passed over 40 years ago.) The FDA has established a “safe concentration” for most foods of less than 2.5 ppm, 1000x less than the toxic levels seen in China. However, this “safe concentration” does not apply to infant formula—for formulas, no “lower safe limit” has ever been established.

The commercial assays available for manufacturers to test for melamine have a lower detection limit of 0.25 ppm. This includes the published method that the FDA suggests food manufacturers use to test their own products. However, chemical methods continue to improve, and lower limits of detection have become possible with new technology.

The FDA began testing infant formula shortly after the melamine story broke, using the most sensitive assays available. They’ve found that several infant formulas in the US have measurable concentrations of melamine, about 0.14 ppm. It’s not known (or least I couldn’t find) assays of the concentration of melamine in breast milk or drinking water—but my guess is that it will be more than zero.

This concentration in formula is far less than the established safety threshold for most foods, and far far far less than the concentration that has made kids sick in China. Only a few years ago, this concentration wouldn’t even have been detectable; it’s only improved chemistry that has allowed us to know it’s even there.

Paracelsus (1493-1541), a Swiss chemist, is often credited for his statement of the most basic tenet in toxicology: “The dose makes the poison.” In other words, any substance is a poison at a high enough dose (for example, water, salt, and vitamin C will all kill you if you ingest enough of these.) And there is no substance that is poisonous if taken at a low enough dose. Even deadly rattlesnake poison or the most lethal nerve gases have a threshold of toxicity, below which they’re harmless.

Several politicians have already seized on the melamine issue, insisting on a “zero-tolerance” policy. From a science point of view, that’s silly: ordinary foods always contain traces of deadly chemicals, including arsenic (a natural element) and cyanide (which is produced in small amounts in each one of your body’s cells every day.) As chemical assays improve, it becomes possible to detect the most minute amounts of anything—does that mean that the small amounts, which may always have been present, pose a danger? And if all of the infant formula is recalled, what, exactly, are we supposed to feed our babies once they’ve weaned?

The harm of a mass recall of formula—babies being fed some kind of home-brew concoction, or products that are very demonstrably unsafe for infants (like plain whole cow’s milk)—is far, far greater than any harm that might be posed by these infinitesimal amounts of melamine. Besides, there’s an even higher amount of melamine allowed in whatever parents might use as formula substitutes. That couldn’t be an improvement.

The melamine issue requires some clear thinking. Formula manufacturers should work to find the source of the minimal contamination—probably a cleaning solution that could be rinsed more thoroughly—and eliminate that source. Studies to look for possible long-term effects of food-source melamine should be undertaken, and reasonable steps to minimize contamination with melamine and other chemicals should be taken at every step of food processing and preparation. But there is no reason for any sort of formula recall, and no reason for anyone to panic.

sources: http://news.yahoo.com/s/ap/20081126/ap_on_he_me/infant_formula;

http://sbk.online.wsj.com/article/SB122764783105057435.html

Peanuts, when?

Gretchen asked, “When is it ok to feed a child peanut butter? I have heard that you should wait until 4 years old because if you try sooner then the child could become allergic. I have been feeding my 14 month old peanut butter since his first birthday and he has shown no signs of allergy, but can he develop one if I give him peanut butter too often (another rumor I have heard)? He eats it about 3 – 4 times a week.”

There is no consensus among allergists or pediatricians about when kids can safely start peanut butter. There is no “official” recommendation from either the American Academy of Pediatrics (AAP) nor the American Academy of Allergy Asthma and Immunology (AAAAI). Since there’s really no evidence that delaying introducing peanuts prevents allergies, there’s no good reason to delay peanuts as long as many people suggest.

For a long time, a strategy proposed to prevent allergy was to delay introducing certain foods. You’ll find all sort of tables with specific “recommendations”—strawberries at 12 months, or peanuts at 3 years, or whatever. But until recently there really was very little research to help guide these sorts of suggestions. The tables were arrived at by a process of “expert consensus,” a fancy term for “making things up.”

The best recent studies, summarized here, do not support delaying food introduction. In fact, some studies have found that by delaying certain foods, you might increase your child’s risk of allergy.

Keep in mind that your child’s risk of food allergy depends very much on the parent’s history. If neither parent has food allergies, a child has a very low chance of food allergy, less than 2%. If one parent has a food allergy, it’s up to 8%; if both parents have food allergies, their child has about a 50% chance. You could also consider siblings—the more siblings with allergy, the higher the chance. And once a child has one food allergy, the risk of having others is fairly high. So if there is no family history of allergy, and a child hasn’t shown signs of any other food allergies, the chance of a peanut allergy is very small.

Since your child is tolerating peanuts fine, there is no reason to restrict them. It is not true that frequent peanut ingestion can lead to allergy. Your child can continue to eat peanut products safely as often as he’d like.

I routinely suggest that children who don’t have a strong family history of allergy can start having peanut products at twelve months of age. It’s important for all families to keep Benadryl in the house, and know their child’s dose (ask your pediatrician.) If a rash develops after peanut (or any other food) is ingested, give Benadryl. If there are any signs of trouble breathing, tongue swelling, or decreased consciousness, call 911. If you’re not sure what to do, contact your child’s pediatrician immediately.

Prolonged nursing

Isabella asked, “Are their health benefits to nursing a baby over the age of one year?”

While there are some health benefits, the best reason to continue nursing past a year is if mom, baby, and daddy are all enjoying it and would like to continue. If that’s the case, then I’d wholeheartedly endorse continuing to nurse. But if by a year someone in the family has had enough and would like breastfeeding to stop, there’s no compelling medical reason to push the issue.

Many families find prolonged nursing to be very rewarding and helpful. If you google that phrase, you’ll find some quite heartwarming stories. However, sometimes it just doesn’t work out that way. Some babies decide to wean before a year, and fighting their desire to stop isn’t going to work very well. Other times, mom finds that she’s just had enough. I’ve also met families where mom and baby are happy to continue, but dad is hoping that nursing will stop. He might feel that he’s lost some intimacy, or he might feel “left out.” The needs of a married couple are very important to the overall health of a family, and sometimes we cater too much to the needs of children at the expense of the parent’s own relationship.

Nursing can be a wonderful experience, and one very important way to help keep babies healthy. Many families are happy to continue nursing past a year. This doesn’t work well for everyone, though, and I wouldn’t want any family to feel guilty if they decide not to continue nursing.

Sunscreen for babies

KM writes, “I have recently read that it is ok to apply sunscreen to infants under 6 months. Is this true? Can it be applied to the face? Is there a certain product that is better for their sensitive skin? Also, any suggestions for skin protection this summer for an under 6 month infant besides minimal sun exposure and a hat ? Thanks.”

Sunscreen can safely be used at any age, but parents need to know that that young babies may be at special risk from too much sun exposure.