When your child wakes up in the middle of the night, sometimes it is difficult to determine whether they have had a nightmare or night terror, and more importantly, what to do to help them get back to sleep.
Here are some key differences between nightmares and night terrors:
Nightmares are, by definition, scary dreams followed by complete awakening. They are more common in school-age children. Your child may wake you immediately to tell you about the dream. Nightmares happen during the second half of the night, when dreaming is at its most intense. Your child may be crying or fearful after waking, and may want to be comforted or calmed. Unlike night terrors, a child having a nightmare will wake to be completely lucid and will be aware of you and your presence. Fear and the accompanying "adrenaline rush" may make it more difficult for your child to get back to sleep. They likely will have an immediate memory of the dream, and may or may not want to describe it and talk about it. Use their cues to guide you, reassure them that it was just a dream, and practice calming mechanisms in order to get them back to sleep. It may help to speak softly and tell them that it was just a dream, they are safe, in their own room/bed, etc. For repeated episodes of nightmares, it sometimes helps to establish pre-bed rituals - checking for monsters, turning the pillow to the "good dream" side, hanging a dream catcher, etc.
Night terrors are more common in younger children between the ages of 2 and 6. With a night terror, your child will partially awaken from a very deep sleep. They will not be very aware of you or your presence, and may physically push you away, screaming and thrashing more if you try to restrain them. Parents often describe their children as "out of it" during this period of agitation. Children may sit up in bed, thrash or show unusual movements, cry, scream, moan or talk nonsensically. Physically, you may notice bulging eyes, a fast heart rate or sweating. Night terrors occur early in the night, usually within 1-4 hours of falling asleep. After the initial event is over, your child will be calm and will usually return to sleep rapidly without completely waking up. Your child will have no memory of the event. Night terrors may last 10-30 minutes. You can speak to your child reassuringly; they may not recognize your presence or want any physical contact. Do not try to wake your child from a night terror, just standby until they are able to go back to sleep.
Wednesday, September 25, 2013
Wednesday, April 24, 2013
Insect Repellents - A Comparison
I recently read an article comparing insect repellents published by The Medical Letter. I have decided to summarize that information, since insect season is fast approaching.
The CDC recommends insect repellents to prevent West Nile virus infections, as well as to protect against ticks which transmit Lyme disease.
DEET - the topical insect repellent with the highest documented effectiveness; varies in concentration of DEET between products. DEET is considered safe in children and infants over the age of 4 months, and the AAP recommends using formulations containing no more than 30% DEET in children. A long-acting formulation originally developed for the Armed Services contains 34% DEET and has been shown to be effective for 6-12 hours (Ultrathon lotion). Sawyer manufactures controlled release products in both 20% and 30% concentrations, and states that the 30% Liposome Controlled Release product protects up to 11 hours. DEET can cause side effects of skin rash and irritation; serious side effects are rare. DEET can damage clothes made from synthetic material, plastics and watch crystals. Obviously, one should wash hands well after applying.
Picaridin - pesticide used against flies, mosquitoes, chiggers and ticks; studies have shown 19.2% picaridin was as effective as Ultrathon with 34% DEET in preventing mosquito bites. Picaridin does not cause as many local reactions on the skin as DEET, and does not damage fabric or plastic.
IR3535 - Available in concentrations of 7.5% and 20% in combination with sunscreen (includes Avon Skin So Soft Bug Guard Plus IR 3535 and Bull Frog Mosquito Coast). Several studies found the 7.5% concentration to be ineffective, and the 20% concentration to be effective for several hours. The CDC does not recommend its use because of the included sunscreen, which would need to be applied more often for sun protection. IR3535 is effective for both mosquitoes and ticks.
Oil of Lemon Eucalyptus (OLE) - In studies against mosquitoes, may provide up to 6 hrs of protection; should not be used in children under age 3. Several sources suggest OLE may be effective against ticks as well, and I found one study that concluded that 30% OLE was as effective as 10-15% DEET in preventing mosquito bites.
Citronella - provide short-term protection against mosquitoes, and are probably not effective against ticks.
Essential Oils - including clove, geraniol and patchouli, provide limited and variable protection against mosquitoes.
Permethrin - A contact insecticide used commonly in head lice remedies, it is used on clothing, mosquito nets, tents and sleeping bags for protection against mosquitoes and ticks. It remains active for several weeks, through repeat laundering.
The CDC recommends insect repellents to prevent West Nile virus infections, as well as to protect against ticks which transmit Lyme disease.
DEET - the topical insect repellent with the highest documented effectiveness; varies in concentration of DEET between products. DEET is considered safe in children and infants over the age of 4 months, and the AAP recommends using formulations containing no more than 30% DEET in children. A long-acting formulation originally developed for the Armed Services contains 34% DEET and has been shown to be effective for 6-12 hours (Ultrathon lotion). Sawyer manufactures controlled release products in both 20% and 30% concentrations, and states that the 30% Liposome Controlled Release product protects up to 11 hours. DEET can cause side effects of skin rash and irritation; serious side effects are rare. DEET can damage clothes made from synthetic material, plastics and watch crystals. Obviously, one should wash hands well after applying.
Picaridin - pesticide used against flies, mosquitoes, chiggers and ticks; studies have shown 19.2% picaridin was as effective as Ultrathon with 34% DEET in preventing mosquito bites. Picaridin does not cause as many local reactions on the skin as DEET, and does not damage fabric or plastic.
IR3535 - Available in concentrations of 7.5% and 20% in combination with sunscreen (includes Avon Skin So Soft Bug Guard Plus IR 3535 and Bull Frog Mosquito Coast). Several studies found the 7.5% concentration to be ineffective, and the 20% concentration to be effective for several hours. The CDC does not recommend its use because of the included sunscreen, which would need to be applied more often for sun protection. IR3535 is effective for both mosquitoes and ticks.
Oil of Lemon Eucalyptus (OLE) - In studies against mosquitoes, may provide up to 6 hrs of protection; should not be used in children under age 3. Several sources suggest OLE may be effective against ticks as well, and I found one study that concluded that 30% OLE was as effective as 10-15% DEET in preventing mosquito bites.
Citronella - provide short-term protection against mosquitoes, and are probably not effective against ticks.
Essential Oils - including clove, geraniol and patchouli, provide limited and variable protection against mosquitoes.
Permethrin - A contact insecticide used commonly in head lice remedies, it is used on clothing, mosquito nets, tents and sleeping bags for protection against mosquitoes and ticks. It remains active for several weeks, through repeat laundering.
Monday, April 15, 2013
Roseola
It's April, and flu season (for the most part) is behind us. Starting in the Spring and Summer, another family of viruses visit us causing fevers and rashes, particularly in younger children. Most of these viruses belong to a larger group called Enteroviruses, though Roseola belongs to the herpes virus family.
Roseola, also called Exantema subitum, "Sixth's disease" or "Three day fever", typically affects children under the age of two. Roseola is caused by two human herpes viruses (predominantly HHV-6, and sometimes HHV-7) - these are not the herpes viruses that cause fever blisters or genital herpes.
Infection with Roseola viruses tends to occur more often in children between the ages of 6 months and 2 years. The infection begins with a sudden fever, which can be quite high (102-104 degrees). The abrupt rise in body temperature may cause a febrile seizure, but in most cases, the children otherwise appear normal, with no other associated symptoms. After a few days of daily fever (classically 5 days), the fever subsides THEN a red or pink bumpy rash develops. The rash begins on the trunk, may be more noticeable after a bath, and then spreads to the arms and legs. The rash is not itchy and may last several days.
Roseola is self-limited, there is no vaccine and no specific treatment is necessary. Tylenol (Acetaminophen) or Ibuprofen may be used to decrease your child's fever, and you should make sure your child is drinking plenty of fluids.
Here are pictures of the typical Roseola rash on the trunk:
Roseola, also called Exantema subitum, "Sixth's disease" or "Three day fever", typically affects children under the age of two. Roseola is caused by two human herpes viruses (predominantly HHV-6, and sometimes HHV-7) - these are not the herpes viruses that cause fever blisters or genital herpes.
Infection with Roseola viruses tends to occur more often in children between the ages of 6 months and 2 years. The infection begins with a sudden fever, which can be quite high (102-104 degrees). The abrupt rise in body temperature may cause a febrile seizure, but in most cases, the children otherwise appear normal, with no other associated symptoms. After a few days of daily fever (classically 5 days), the fever subsides THEN a red or pink bumpy rash develops. The rash begins on the trunk, may be more noticeable after a bath, and then spreads to the arms and legs. The rash is not itchy and may last several days.
Roseola is self-limited, there is no vaccine and no specific treatment is necessary. Tylenol (Acetaminophen) or Ibuprofen may be used to decrease your child's fever, and you should make sure your child is drinking plenty of fluids.
Here are pictures of the typical Roseola rash on the trunk:
Monday, March 25, 2013
Update on High Fructose Corn Syrup and Sugar
I previously posted about the health dangers associated with High Fructose Corn Syrup, a "super sweetener" used in everything from pastries to sweetened beverages, breakfast cereal and even ketchup. It is ubiquitous it seems.
My house is HFCS-free, and thankfully all the kids like to drink water. We have orange juice, and make our own fruit smoothies. I don't keep any other fruit juice in the house, and don't do juice boxes. I am alarmed at how much juice some of the children I see at my office drink. Children of any age should not be drinking more than 6 oz. of juice daily; it is even better if they DON'T drink juice at all. Unfortunately, there is a huge industry pandering juice boxes and pouches to families with children. Some parents mistakenly feel that the "Capri Sun Roarin' Water" is good for their children because it is mostly water -- these beverages may actually be WORSE than juice because they are all sweetened with high fructose corn syrup.
My husband recently e-mailed me an article entitled "9 Reasons to Avoid Sugar As If Your Life Depended On It". Pretty catchy, but is a good summary about the dangers of sugar. Both sugar and HFCS contain fructose. Simple glucose is easily digested and eliminated by the body, but the same is not true of fructose. Fructose is metabolized by the liver; since our liver is busy maintaining normal blood sugar levels in our blood, "extra" fructose is converted into fat -- for us to use later. Too much fructose being diverted this way leads to excess deposition in the liver. Over time, "fatty liver" develops. As we ingest more sugar, our body has a harder time struggling to keep blood sugar levels stable, and our pancreas will make more and more insulin to keep blood sugar levels in a normal range. This "hyperinsulinemia" leads to obesity and increases in fat deposition throughout the body, as well as increases in cholesterol.
Studies looking at people who ingested 25% of their calories in glucose or fructose-sweetened drinks showed that these people had increased levels of LDL ("bad cholesterol"), triglycerides (another blood fat), higher fasting blood sugar and insulin levels and, worse, decreased insulin sensitivity. Increasing amounts of insulin resistance leads to obesity, type two diabetes and metabolic syndrome.
What can be said additionally to all of the above mentioned science is that sweetened beverages add empty calories, calories devoid of nutritional value.
Fructose-sweetened beverages have also been shown to interfere with the normal satiety reflex - fructose drinkers felt less satisfied and were still hungry. Fructose ingestion also did not lessen the body's level of ghrelin - the "hunger hormone". The higher the level of ghrelin, the hungrier one is. Fructose also causes resistance to leptin, another hormone that is released by our fat cells after we have eaten. Leptin basically tells the body, "I am full; stop eating". Obviously, in someone leptin resistant, this signal does not function as intended.
There are also many studies that suggest that the high sugar, western diet can lead to "sugar addiction" or at least a form of sugar toxicity leading to the above medical problems.
As parents, we are responsible for setting examples for our children. If we stress activity and exercise, our children will be active and exercise. If we stress healthy eating habits, our children will be healthier. Beware the dangers of high fructose corn syrup - limit or eliminate fruit juice, and get into the habit of reading labels. Know what you are eating and drinking, eat more fruits and vegetables and limit processed foods.
My house is HFCS-free, and thankfully all the kids like to drink water. We have orange juice, and make our own fruit smoothies. I don't keep any other fruit juice in the house, and don't do juice boxes. I am alarmed at how much juice some of the children I see at my office drink. Children of any age should not be drinking more than 6 oz. of juice daily; it is even better if they DON'T drink juice at all. Unfortunately, there is a huge industry pandering juice boxes and pouches to families with children. Some parents mistakenly feel that the "Capri Sun Roarin' Water" is good for their children because it is mostly water -- these beverages may actually be WORSE than juice because they are all sweetened with high fructose corn syrup.
My husband recently e-mailed me an article entitled "9 Reasons to Avoid Sugar As If Your Life Depended On It". Pretty catchy, but is a good summary about the dangers of sugar. Both sugar and HFCS contain fructose. Simple glucose is easily digested and eliminated by the body, but the same is not true of fructose. Fructose is metabolized by the liver; since our liver is busy maintaining normal blood sugar levels in our blood, "extra" fructose is converted into fat -- for us to use later. Too much fructose being diverted this way leads to excess deposition in the liver. Over time, "fatty liver" develops. As we ingest more sugar, our body has a harder time struggling to keep blood sugar levels stable, and our pancreas will make more and more insulin to keep blood sugar levels in a normal range. This "hyperinsulinemia" leads to obesity and increases in fat deposition throughout the body, as well as increases in cholesterol.
Studies looking at people who ingested 25% of their calories in glucose or fructose-sweetened drinks showed that these people had increased levels of LDL ("bad cholesterol"), triglycerides (another blood fat), higher fasting blood sugar and insulin levels and, worse, decreased insulin sensitivity. Increasing amounts of insulin resistance leads to obesity, type two diabetes and metabolic syndrome.
What can be said additionally to all of the above mentioned science is that sweetened beverages add empty calories, calories devoid of nutritional value.
Fructose-sweetened beverages have also been shown to interfere with the normal satiety reflex - fructose drinkers felt less satisfied and were still hungry. Fructose ingestion also did not lessen the body's level of ghrelin - the "hunger hormone". The higher the level of ghrelin, the hungrier one is. Fructose also causes resistance to leptin, another hormone that is released by our fat cells after we have eaten. Leptin basically tells the body, "I am full; stop eating". Obviously, in someone leptin resistant, this signal does not function as intended.
There are also many studies that suggest that the high sugar, western diet can lead to "sugar addiction" or at least a form of sugar toxicity leading to the above medical problems.
As parents, we are responsible for setting examples for our children. If we stress activity and exercise, our children will be active and exercise. If we stress healthy eating habits, our children will be healthier. Beware the dangers of high fructose corn syrup - limit or eliminate fruit juice, and get into the habit of reading labels. Know what you are eating and drinking, eat more fruits and vegetables and limit processed foods.
Thursday, March 21, 2013
Sleep Tips for Teens
I have previously written about sleep issues in toddlers, and have been seeing more older children and teens with sleeping issues lately - specifically, the inability to fall asleep at night or get adequate amounts of sleep.
In studies addressing sleep and children, researchers have found that over 15 million kids get poor sleep. Not getting adequate sleep can lead to poor school performance, daytime sleepiness and mood changes. As parents, sometimes we recognize the cranky, moody, irritable symptoms and blame those on lack of sleep -- even teens sometimes don't have the insight to recognize sleep deprivation as the cause.
Here are some tips to get your older child or teen sleeping better:
1. Aim for an adequate amount of sleep each night - this may vary person to person, although research suggests teens should get 9 hours a night.
2. Maintain a regular sleep-wake cycle -- go to bed the same time every night (weeknight or weekend) and wake up at the same time every morning. This should not vary by more than an hour (as far as bedtime) and one should set an alarm on weekend mornings. This allows you to "jump start" your normal circadian rhythm and biological clock.
3. Sleep in a dark, comfortable room. Maintain a cool room temperature (about 68 F), close all blinds and curtains at night, and open the blinds on waking in the morning. Turn on lights when you wake up in the morning.
4. Use the bed only for sleep -- no computer, cellphone or TV watching in bed. Period.
5. Relaxing bedtime routine - eliminate screen time 30-45 min. before bed. Again, this means no cell phone, e-mail, texting, computer use, video games or TV. Listening to relaxing music is ok, as well as reading.
6. Include a warm bath or shower at night to help relax your child. Soothing scents in the bath or bedroom may also help - try orange blossom, majoram, lavender or chamomile. Chamomile or Valerian herbal teas may also be used prior to bedtime, since they may help you fall asleep easier.
7. No caffeine dinnertime or later; no nicotine/smoking cigarettes.
8. Don't go to bed hungry. Have a late night snack before bed if needed - milk, a glass of cereal, fruit or crackers. Avoid a heavy meal within 1-2 hours of bedtime since this can interfere with sleep.
9. Exercise regularly - 30-40 min. 4-5 times per week; exercise when it makes sense for you/your family but try to avoid any exercise within 2-3 hours of bedtime (as this can interfere with sleep).
10. No naps as a general rule; if your child needs to nap while adjusting to a better sleep schedule, limit the nap to 20-30 min. Napping for a long period or later into the evening will make it harder to fall asleep at night.
In studies addressing sleep and children, researchers have found that over 15 million kids get poor sleep. Not getting adequate sleep can lead to poor school performance, daytime sleepiness and mood changes. As parents, sometimes we recognize the cranky, moody, irritable symptoms and blame those on lack of sleep -- even teens sometimes don't have the insight to recognize sleep deprivation as the cause.
Here are some tips to get your older child or teen sleeping better:
1. Aim for an adequate amount of sleep each night - this may vary person to person, although research suggests teens should get 9 hours a night.
2. Maintain a regular sleep-wake cycle -- go to bed the same time every night (weeknight or weekend) and wake up at the same time every morning. This should not vary by more than an hour (as far as bedtime) and one should set an alarm on weekend mornings. This allows you to "jump start" your normal circadian rhythm and biological clock.
3. Sleep in a dark, comfortable room. Maintain a cool room temperature (about 68 F), close all blinds and curtains at night, and open the blinds on waking in the morning. Turn on lights when you wake up in the morning.
4. Use the bed only for sleep -- no computer, cellphone or TV watching in bed. Period.
5. Relaxing bedtime routine - eliminate screen time 30-45 min. before bed. Again, this means no cell phone, e-mail, texting, computer use, video games or TV. Listening to relaxing music is ok, as well as reading.
6. Include a warm bath or shower at night to help relax your child. Soothing scents in the bath or bedroom may also help - try orange blossom, majoram, lavender or chamomile. Chamomile or Valerian herbal teas may also be used prior to bedtime, since they may help you fall asleep easier.
7. No caffeine dinnertime or later; no nicotine/smoking cigarettes.
8. Don't go to bed hungry. Have a late night snack before bed if needed - milk, a glass of cereal, fruit or crackers. Avoid a heavy meal within 1-2 hours of bedtime since this can interfere with sleep.
9. Exercise regularly - 30-40 min. 4-5 times per week; exercise when it makes sense for you/your family but try to avoid any exercise within 2-3 hours of bedtime (as this can interfere with sleep).
10. No naps as a general rule; if your child needs to nap while adjusting to a better sleep schedule, limit the nap to 20-30 min. Napping for a long period or later into the evening will make it harder to fall asleep at night.
Wednesday, March 20, 2013
Side Effects of Psychiatric Medications in Children
More children and teens are being treated with daily psychiatric medications, including ADHD medications (most often stimulants) and antidepressants. Practitioners should discuss monitoring children for side effects when prescribing these medications. Following is a list of side effects to look for with psychiatric medications:
Stimulants (methylphenidate and amphetamine families) - typically prescribed as first-line therapy for ADD and ADHD; all stimulants have the following common side effects - weight loss, insomnia (difficulty falling or staying asleep), headaches, stomachaches, dry mouth, dizziness. Dextroamphetamines typically have more associated weight loss than methylphenidates. Stimulants can also, less commonly, cause new psychological symptoms such as irritability, moodiness, depression symptoms, obsessiveness and anxiety. Rarely, stimulants can be associated with hallucinations (visual or tactile) or manic-type symptoms. Overdose can cause heart arrythmias or seizures. Stimulants, as a rule, may raise a child's pulse and blood pressure slightly. This is usually not significant or any cause for concern. Your child's pulse and blood pressure should be monitored by your health provider.
If your child has any new symptoms after starting any of these medications, mention them to your health provider.
Atomoxetine (Strattera) - a nonstimulant used for ADD/ADHD as well; can cause mood swings, irritability, nausea/stomachaches; chance of weight loss and decreased appetite are less than with stimulants; insomnia may occur but is relatively infrequent. Serious but rare side effects may include suicidal thoughts/behavior and liver toxicity. Your provider may order periodic liver enzyme tests (referred to as LFTs) to monitor for any liver side effects.
Clonidine, Guanfacine, Intuniv - blood pressure-lowering medications originally, they are sometimes used for ADD/ADHD. Since they are blood pressure lowering agents, they may cause dizziness, headache and low blood pressure, but the major side effect is sedation. Often, providers will dose these medications in the evening to decrease notable side effects. These medications may also cause dry mouth, nausea, abdominal pain and constipation.
Anti-depressants in the SSRI class - include fluoxetine, sertraline, fluvoxamine, citalopram, escitalopram; as a class, these drugs have similiar side effects but individual patients can vary greatly in their response to certain medications or the side effects they encounter with the specific medication they are taking. The most common side effects include "changes in alertness" (which may be sedation or insomnia), increased or decreased appetite, nausea, constipation, restlessness and headaches. Rarely, some children may have develop a phenomenon known as "behavioral activation" - hypomanic symptoms of impulsivity, agitation, irritability, silliness and mood changes. A serious, but very rare risk is serotonin syndrome - extreme agitation, ataxia, diarrhea, hyperactive reflexes, mental status changes and tremor. Any serious side effects should be reported to your medical provider immediately. There is a "black box warning" for the SSRI class regarding suicide ideation. There have been conflicting studies looking at this topic, but it is important to realize that depressed children who develop suicidal thoughts (medication-related or otherwise) should seek immediate medical attention.
Anti-psychotic medications - most commonly in a class known as "atypical antipsychotics", they seriously but rarely cause extrapyramidal symptoms including muscle rigidity, tremors and muscle tics. More commonly, these medications can cause longer term issues with weight gain, excessive appetite, high blood sugar and high cholesterol. Your medical provider will monitor your child's weight and will order lab work periodically to monitor blood sugar and cholesterol levels. Any significant weight gain is cause for concern and should be discussed with your provider.
It is also important to realize that children who are on two (or more) psychiatric medications are at higher risk for side effects. Safety issues, as well as periodically reassessing the need for medication in general, should be discussed with your medical provider.
Stimulants (methylphenidate and amphetamine families) - typically prescribed as first-line therapy for ADD and ADHD; all stimulants have the following common side effects - weight loss, insomnia (difficulty falling or staying asleep), headaches, stomachaches, dry mouth, dizziness. Dextroamphetamines typically have more associated weight loss than methylphenidates. Stimulants can also, less commonly, cause new psychological symptoms such as irritability, moodiness, depression symptoms, obsessiveness and anxiety. Rarely, stimulants can be associated with hallucinations (visual or tactile) or manic-type symptoms. Overdose can cause heart arrythmias or seizures. Stimulants, as a rule, may raise a child's pulse and blood pressure slightly. This is usually not significant or any cause for concern. Your child's pulse and blood pressure should be monitored by your health provider.
If your child has any new symptoms after starting any of these medications, mention them to your health provider.
Atomoxetine (Strattera) - a nonstimulant used for ADD/ADHD as well; can cause mood swings, irritability, nausea/stomachaches; chance of weight loss and decreased appetite are less than with stimulants; insomnia may occur but is relatively infrequent. Serious but rare side effects may include suicidal thoughts/behavior and liver toxicity. Your provider may order periodic liver enzyme tests (referred to as LFTs) to monitor for any liver side effects.
Clonidine, Guanfacine, Intuniv - blood pressure-lowering medications originally, they are sometimes used for ADD/ADHD. Since they are blood pressure lowering agents, they may cause dizziness, headache and low blood pressure, but the major side effect is sedation. Often, providers will dose these medications in the evening to decrease notable side effects. These medications may also cause dry mouth, nausea, abdominal pain and constipation.
Anti-depressants in the SSRI class - include fluoxetine, sertraline, fluvoxamine, citalopram, escitalopram; as a class, these drugs have similiar side effects but individual patients can vary greatly in their response to certain medications or the side effects they encounter with the specific medication they are taking. The most common side effects include "changes in alertness" (which may be sedation or insomnia), increased or decreased appetite, nausea, constipation, restlessness and headaches. Rarely, some children may have develop a phenomenon known as "behavioral activation" - hypomanic symptoms of impulsivity, agitation, irritability, silliness and mood changes. A serious, but very rare risk is serotonin syndrome - extreme agitation, ataxia, diarrhea, hyperactive reflexes, mental status changes and tremor. Any serious side effects should be reported to your medical provider immediately. There is a "black box warning" for the SSRI class regarding suicide ideation. There have been conflicting studies looking at this topic, but it is important to realize that depressed children who develop suicidal thoughts (medication-related or otherwise) should seek immediate medical attention.
Anti-psychotic medications - most commonly in a class known as "atypical antipsychotics", they seriously but rarely cause extrapyramidal symptoms including muscle rigidity, tremors and muscle tics. More commonly, these medications can cause longer term issues with weight gain, excessive appetite, high blood sugar and high cholesterol. Your medical provider will monitor your child's weight and will order lab work periodically to monitor blood sugar and cholesterol levels. Any significant weight gain is cause for concern and should be discussed with your provider.
It is also important to realize that children who are on two (or more) psychiatric medications are at higher risk for side effects. Safety issues, as well as periodically reassessing the need for medication in general, should be discussed with your medical provider.
Wednesday, February 27, 2013
The "Dirty Dozen" - Produce with the highest amounts of pesticides
I was asked to recap the "Dirty Dozen" list - fruits and vegetables with the highest amounts of pesticides. I buy organic produce whenever I can, and recommend this practice for the families I see, as well. I will also choose local produce whenever it is available at farms and farmers' markets. Statistically, these have been shown to be lower in pesticide residue as well.
Here is the list based on 2012 studies:
1. Apples - not a surprise, they are usually high on the list every year; apples are also notorious for being loaded with bacteria on their exterior surface as well; organic apples are easy to find - please buy those :)
2. Celery - a surprise for me; can't say I see much organic celery or find it often at the farmer's markets
3. Strawberries - usually a good local find for many people; I love picking my own at the local farms when I can
4. Peaches
5. Spinach - yes, it is a great thing to eat; obviously buy organic if you can
6. Nectarines
7. Imported grapes - interestingly, domestic grapes didn't make the list - shop accordingly
8. Sweet (red) bell peppers
9. Potatoes - a little surprise, evidently they absorb pesticides that are applied after harvest; peel and cook them to minimize risks
10. Domestic blueberries - another fruit that I never buy unless it is organic/local
11. Lettuce
12. Kale - see comments for spinach above
The normal rule of thumb for any produce is this - any fruit or vegetable that is eaten raw with the peel intact exposes you to pesticide residue. Wash all produce well, and buy organic when you can. I can now find organic bananas at my local grocery store, and even though bananas are seldom on the list, I buy those now. The price difference between organic and nonorganic is pretty small in most cases.
Here is the list based on 2012 studies:
1. Apples - not a surprise, they are usually high on the list every year; apples are also notorious for being loaded with bacteria on their exterior surface as well; organic apples are easy to find - please buy those :)
2. Celery - a surprise for me; can't say I see much organic celery or find it often at the farmer's markets
3. Strawberries - usually a good local find for many people; I love picking my own at the local farms when I can
4. Peaches
5. Spinach - yes, it is a great thing to eat; obviously buy organic if you can
6. Nectarines
7. Imported grapes - interestingly, domestic grapes didn't make the list - shop accordingly
8. Sweet (red) bell peppers
9. Potatoes - a little surprise, evidently they absorb pesticides that are applied after harvest; peel and cook them to minimize risks
10. Domestic blueberries - another fruit that I never buy unless it is organic/local
11. Lettuce
12. Kale - see comments for spinach above
The normal rule of thumb for any produce is this - any fruit or vegetable that is eaten raw with the peel intact exposes you to pesticide residue. Wash all produce well, and buy organic when you can. I can now find organic bananas at my local grocery store, and even though bananas are seldom on the list, I buy those now. The price difference between organic and nonorganic is pretty small in most cases.
Wednesday, February 13, 2013
Store Brand Infant Formulas - "Are they just as good?"
The short answer is: yes, they are -- according to recent studies comparing store brand formula with the name brand competitors.
Store brand formulas are manufactured primarily by Perrigo Nutritionals - they produce more than 50 different global infant formulas, including those offered by major chains WalMart, Target, Babies R'Us and others (see the list below). These formulas are made at the company's Vermont and Ohio facilities - both ISO (International Standards Organization) certified. Perrigo Nutritionals is 1 of only 4 FDA inspected US Infant Formula Manufacturers. This means that they have a quaility management system in place that demonstrates consistent conformity to guidelines. I recently read that there are over 2300 safety and quality checks performed per batch of formula.
The FDA published regulations in 1971 regarding minimal concentrations of vitamins and minerals necessary for each infant formula. An amendment in 1980 called the Infant Formula Act allowed the FDA to establish quality control procedures for the manufacturing of formula, as well as regulate labelling.
As pediatricians, we strongly recommend breastfeeding as the best nutritional support for infants, but realize parents make choices regarding supplementing or switching to formula. It is never a good idea to "water down" formula to make the can last longer; if cost is an issue, I definitely advise patients to switch to store brand formulas.
Store brand infant formulas and their designations:
WalMart - Parent's Choice
Toys R'Us - Babies R'Us
Target - Up and Up
Sams Club - Simply Right Baby Care
Kroger - Comforts for Baby
Walgreens - Walgreens
CVS Pharmacy - CVS Pharmacy
Rite Aid Pharmacy - Rite Aid Tugaboos
Store brand formulas and the brand name equivalents:
Premium formula = Enfamil Premium
Advantage formula = Similac Advance
Tender formula = Gerber Good Start Gentle
(has partially digested whey protein - to address fussiness/gas issues)
Gentle formula = Enfamil Gentlease
(has partially digested whey protein - to address fussiness/gas issues)
Sensitivity formula = Similac Sensitive
(has low lactose for babies with lactose intolerance)
Soy-based formula = Enfamil Prosobee or Similac Isomil
(soy protein instead of cow's milk protein)
Added rice formula = Enfamil AR
(added rice starch designed to aid babies with reflux)
Organic formula = Similac Advance Organic
(certified organic by USDA)
Toddler formula = Similac Go and Grow, Enfagrow Premium Toddler
Newborn formula = Enfamil Premium Newborn
Store brand formulas are manufactured primarily by Perrigo Nutritionals - they produce more than 50 different global infant formulas, including those offered by major chains WalMart, Target, Babies R'Us and others (see the list below). These formulas are made at the company's Vermont and Ohio facilities - both ISO (International Standards Organization) certified. Perrigo Nutritionals is 1 of only 4 FDA inspected US Infant Formula Manufacturers. This means that they have a quaility management system in place that demonstrates consistent conformity to guidelines. I recently read that there are over 2300 safety and quality checks performed per batch of formula.
The FDA published regulations in 1971 regarding minimal concentrations of vitamins and minerals necessary for each infant formula. An amendment in 1980 called the Infant Formula Act allowed the FDA to establish quality control procedures for the manufacturing of formula, as well as regulate labelling.
As pediatricians, we strongly recommend breastfeeding as the best nutritional support for infants, but realize parents make choices regarding supplementing or switching to formula. It is never a good idea to "water down" formula to make the can last longer; if cost is an issue, I definitely advise patients to switch to store brand formulas.
Store brand infant formulas and their designations:
WalMart - Parent's Choice
Toys R'Us - Babies R'Us
Target - Up and Up
Sams Club - Simply Right Baby Care
Kroger - Comforts for Baby
Walgreens - Walgreens
CVS Pharmacy - CVS Pharmacy
Rite Aid Pharmacy - Rite Aid Tugaboos
Store brand formulas and the brand name equivalents:
Premium formula = Enfamil Premium
Advantage formula = Similac Advance
Tender formula = Gerber Good Start Gentle
(has partially digested whey protein - to address fussiness/gas issues)
Gentle formula = Enfamil Gentlease
(has partially digested whey protein - to address fussiness/gas issues)
Sensitivity formula = Similac Sensitive
(has low lactose for babies with lactose intolerance)
Soy-based formula = Enfamil Prosobee or Similac Isomil
(soy protein instead of cow's milk protein)
Added rice formula = Enfamil AR
(added rice starch designed to aid babies with reflux)
Organic formula = Similac Advance Organic
(certified organic by USDA)
Toddler formula = Similac Go and Grow, Enfagrow Premium Toddler
Newborn formula = Enfamil Premium Newborn
Tuesday, February 12, 2013
Treating Iron Deficiency Anemia
Iron deficiency is still on the list as a cause of anemia in children, though we see it somewhat less often than we did 10-20 years ago. Typically children with iron deficiency anemia present at 9 months - 2 years of age, the toddler transition period in which some of them drink large amounts of milk (which interferes with iron absorption) or do not adjust well to a solid/table food diet that has adequate amounts of iron. A second "peak" age for iron deficiency is noted in teenagers, particulary in teenage girls, whose menstrual cycles can be a source of blood loss coupled with a poor, low iron diet. I recently read an article about iron deficiency in teens that touted the effectiveness of iron-fortified breakfast cereals as a source of iron. Many teenagers may be willing to eat breakfast cereal several times a day, as opposed to taking oral iron tablets. I have included a list of cereals below.
Oral iron medication can be pretty distasteful, so much of our education in the office is spent stressing foods that either help iron absorption or foods that contain large amounts of iron. For some "picky" children, this can sometimes be difficult. Teenagers may be able to tolerate oral iron tablets, but can sometimes forget to take the medication. In this group of patients, discussing iron-rich foods is again an important aspect of treatment.
Iron deficiency may be suspected if a child's hemoglobin or hematocrit are low, and a dietary history is suggestive. If a complete blood count (CBC) is done, the Mean Corpuscular Volume (MCV) will typically be low in iron deficiency, and the Mean Cell Hemoglobin Concentration (MCHC) may also be low. The Red Cell Distribution Width (RDW), which measures the span of red cell size in circulation will typically be high in iron deficiency. If further labwork is done to confirm iron deficiency, your provider will typically measure an iron level, as well as transferrin, ferritin and iron percent saturation.
In iron deficiency, oral iron therapy will stimulate new red cell formation in 5-7 days. Some providers will check a reticulocyte count (which measure the amount of new red blood cells) to confirm the benefit of therapy. Once someone has been on iron therapy for a month, a repeat blood count can be done (or the more complete CBC - as mentioned above). Iron therapy is usually continued for a minimum of 3 months.
FOOD SOURCES OF IRON
GOOD - raisins, dried fruits, potatoes with skin, tomato juice
BETTER - oatmeal and breakfast cereals, beans, nuts and nut butters, bread, pasta, cooked spinach, eggs
BEST - beef, fish and shellfish, pork, chicken and turkey
FOODS THAT AID IN IRON ABSORPTION
Foods with Vitamin C can increase the absorption of iron; eat these foods along with iron-rich foods to increase your body's ability to absorb iron
bell peppers, mango, tangerine, oranges and orange juice, papaya, grapefruit, strawberries, broccoli, melon, green leafy vegetables, tomatoes, cabbage
FOODS THAT INTERFERE WITH IRON ABSORPTION
Some foods block iron absorption, and should be eaten at seperate times from iron supplements or iron-rich foods.
milk, cheese, yogurt, coffee, tea, chocolate, blueberries, grapes, popcorn, tofu
IRON-RICH BREAKFAST CEREALS
The list of the best cereals based on milligrams of iron present per serving:
General Mills - Total and Total corn flakes, Total raisin bran and cranberry crunch, all Chex (corn, rice, honey nut, multi-bran, frosted), Cheerios yogurt burst or multigrain, Kix
Kellogg's - Crispix, Frosted Mini-wheats, All Bran complete wheat flakes, Product 19, Complete oat bran flakes, Smart Start, Rice Krispies, Shredded Wheat
Malt-O-Meal Puffed Wheat, Puffed Rice, Frosted Mini Spooners, Crispy Rice, Honey Graham Squares, Toasty O's
Kashi Mighty Bites, honey crunch
In my practice, I routinely give patients with iron deficiency a handout with the above foods and cereals listed. In most cases, changing one's diet can treat iron deficiency effectively without the need for iron medication.
Oral iron medication can be pretty distasteful, so much of our education in the office is spent stressing foods that either help iron absorption or foods that contain large amounts of iron. For some "picky" children, this can sometimes be difficult. Teenagers may be able to tolerate oral iron tablets, but can sometimes forget to take the medication. In this group of patients, discussing iron-rich foods is again an important aspect of treatment.
Iron deficiency may be suspected if a child's hemoglobin or hematocrit are low, and a dietary history is suggestive. If a complete blood count (CBC) is done, the Mean Corpuscular Volume (MCV) will typically be low in iron deficiency, and the Mean Cell Hemoglobin Concentration (MCHC) may also be low. The Red Cell Distribution Width (RDW), which measures the span of red cell size in circulation will typically be high in iron deficiency. If further labwork is done to confirm iron deficiency, your provider will typically measure an iron level, as well as transferrin, ferritin and iron percent saturation.
In iron deficiency, oral iron therapy will stimulate new red cell formation in 5-7 days. Some providers will check a reticulocyte count (which measure the amount of new red blood cells) to confirm the benefit of therapy. Once someone has been on iron therapy for a month, a repeat blood count can be done (or the more complete CBC - as mentioned above). Iron therapy is usually continued for a minimum of 3 months.
FOOD SOURCES OF IRON
GOOD - raisins, dried fruits, potatoes with skin, tomato juice
BETTER - oatmeal and breakfast cereals, beans, nuts and nut butters, bread, pasta, cooked spinach, eggs
BEST - beef, fish and shellfish, pork, chicken and turkey
FOODS THAT AID IN IRON ABSORPTION
Foods with Vitamin C can increase the absorption of iron; eat these foods along with iron-rich foods to increase your body's ability to absorb iron
bell peppers, mango, tangerine, oranges and orange juice, papaya, grapefruit, strawberries, broccoli, melon, green leafy vegetables, tomatoes, cabbage
FOODS THAT INTERFERE WITH IRON ABSORPTION
Some foods block iron absorption, and should be eaten at seperate times from iron supplements or iron-rich foods.
milk, cheese, yogurt, coffee, tea, chocolate, blueberries, grapes, popcorn, tofu
IRON-RICH BREAKFAST CEREALS
The list of the best cereals based on milligrams of iron present per serving:
General Mills - Total and Total corn flakes, Total raisin bran and cranberry crunch, all Chex (corn, rice, honey nut, multi-bran, frosted), Cheerios yogurt burst or multigrain, Kix
Kellogg's - Crispix, Frosted Mini-wheats, All Bran complete wheat flakes, Product 19, Complete oat bran flakes, Smart Start, Rice Krispies, Shredded Wheat
Malt-O-Meal Puffed Wheat, Puffed Rice, Frosted Mini Spooners, Crispy Rice, Honey Graham Squares, Toasty O's
Kashi Mighty Bites, honey crunch
In my practice, I routinely give patients with iron deficiency a handout with the above foods and cereals listed. In most cases, changing one's diet can treat iron deficiency effectively without the need for iron medication.
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