Caffeinated Kids - How Much is Too Much?

We've all seen the news articles on the harmful effects of high doses of caffeine in teenagers and college students.  Energy drinks are marketed for teenagers, and I see many teenagers in my practice who drink them. 
A recent study looking at the caffeine content of popular beverages (and foods) yielded some startling results.  The results indicate that children, who are especially vulnerable due to their lower weight and body mass, can easily consume enough caffeine to leave them jittery and anxious, or cause physical symptoms like abdominal pain and headaches.
The common culprits - dark-colored sodas and energy drinks, as well as Mountain Dew (well known on college campuses everywhere) and Sunkist orange soda.  Listed with mg of Caffeine per 8 oz. serving:
Red Fusion - 38 mg
Mountain Dew - 37
Pepsi - 27
Coca-Cola classic - 24
Sunkist orange soda - 23
Vanilla Coke - 21
Barq's Root Beer - 15
Some sodas that are caffeine free include: Minute Maid Orange, Slice, Sprite, 7-Up, Mug Root Beer.


In comparison, coffee drinks and other beverages:
Starbucks Coffee Frappuccino - 83 mg
AMP Energy drink - 77
Red Bull Energy drink - 70
Elements Atomic Jacked Apple Juice - 33
Sobe Energy Citrus - 25
Glaceau Vitaminwater Energy Tropical - 21
Snapple Lemon Ice Tea - 10


Most energy drinks (and some fortified waters) also include guarana, a caffeine-containing herb, and ginsing, which may intensify the effects of caffeine.


Some other surprising sources of caffeine:
Dannon Natural Flavors Low Fat Coffee yogurt - 36 mg
Starbucks Coffee Java chip ice cream, 1/2 cup - 28 mg
Haagen-Dazs Coffee ice cream, 1/2 cup - 24


Caffeine seems to have the same effects on kids and teens as it does on adults.  "At low doses, it produces an increase in wakefulness, alertness, feelings of energy and sociability", according to Roland Griffiths, a professor at Johns Hopkins University.  "As you increase the dose, you get into anxiety, insomnia, and tension.  Raise it further and you get things like nausea and upset stomach."
Some experts suggest "upper limits" for kids - no more than 45 mg per day for 4-6 year olds, 62.5 mg per day for 7-9 year olds, and 85 mg per day for 10-12 year olds.  However, there are a lack of studies on "safe" caffeine intake for any children, and no warning labels exist on many common caffeinated beverages.
It is far safer to avoid caffeine in children altogether, especially if you child seems sensitive to caffeine side effects.  In addition, as I have covered in my blog previously, there are serious concerns about soda in general (secondary to artificial coloring, sugar and non-sugar sweeteners) - enough concern, I think, to avoid giving your children soda in general.

How to tell the difference between strep throat and a virus? Some clues ...

How to tell the difference between a viral sore throat and strep? 

 It is common to have a sore throat with a viral infection, but there are some symptoms that are more suspicious for strep, a bacterial infection. Looking inside the throat might offer important clues - strep often produces white patches in the throat and on the tonsils, as well as red swollen tonsils or many red spots on the roof ...of the mouth above the tonsils. Coughing and post-nasal drainage can make your throat feel bad, but these symptoms are less likely to occur with strep. When congestion, runny nose, and other cold symptoms accompany a sore throat, a cold virus is usually to blame. 

 Colds and respiratory infections can cause fever, but it is generally low grade. A sore throat with a fever above 101 Fahrenheit raises the likelihood of strep. However, strep can be present even with little or no fever. Strep throat may cause the lymph nodes in the neck to become swollen and tender. Strep throat pain may be severe and cause difficulty swallowing. Strep can also be accompanied by headache, nausea, abdominal pain or vomiting. 

 A less common sign of strep infection is a rash appearing on the neck and chest, eventually spreading to the rest of the body. When this rough, sandpaper-like rash develops, the infection is known as scarlet fever. The rash may be alarming, but it will start to fade after several days. Antibiotic treatment can help protect against complications of strep infections. Many medical offices can do a "quick strep" right in the office, and start antibiotic treatment for strep if needed.

CDC says Children's sodium intake too high

More than 90% of children in the US are getting too much sodium in their daily diet, according to a recent study by the CDC.  Store bought foods accounted for 65% of consumed sodium, the majority coming from the following foods: pizza, yeast bread and rolls, cold cuts/cured meats, salty snacks like chips, pretzels and popcorn and chicken nuggets and patties.  Fast food and pizza restaurants accounted for 13%.  School cafeteria food only accounted for 9%, in line with national guidelines aimed at reducing sodium in school lunches.  Approximately 39% of sodium intake occurred during dinner, 29.5% at lunch and 16.4% at snacks.
Not mentioned in the study I read was sodium intake in beverages, both soda and sports drinks.
Doubtless to say, it is important to watch your child's sodium intake (we should be watching ours as parents, as well) in order to decrease long term risks of developing high blood pressure and heart disease in the future.
Be informed consumers and read packages when you shop.  Also - be aware of the high sodium content in fast foods.

Influenza Vaccine 2014 - Information for Parents

As pediatricians, we strongly recommend that all children receive Influenza vaccine to prevent Influenza.  Influenza (also known as the flu) is a virus that infects through the nose, throat, windpipe and lungs; the virus is highly contagious between people, as it is spread through respiratory secretions and transmitted by coughing, sneezing or talking.  Typical symptoms include fever, chills, muscle aches, congestion, cough and runny nose and difficulty breathing.  Some people who contract the flu will develop pneumonia and bronchitis, some needing hospitalization.  Unfortunately, some people who contract the flu die each year.  Over 100 children died as a result of Influenza last year.


The Influenza vaccine (flu vaccine) is recommended for everyone 6 months of age and older.  Children under 9 years old require 2 doses of vaccine separated by four weeks if they have never received a flu vaccine before.  There are two versions of the vaccine available for children: nasal and injectable.  Both versions are quadrivalent, which means they are made from 4 different strains of the Influenza virus.
The nasal vaccine (FluMist) is recommended for healthy people between the ages of 2 and 49, and has the advantage of inducing a faster and possibly longer-acting immune response without requiring a shot.  Recent studies indicate that children age 2-8 mount a better immune response to the nasal flu vaccine, so it is strongly recommended in that age group, as long as children do not have underlying lung disease.  FluMist is made from inactivated live virus and is cultured in eggs.  It is given as a nasal spray.  Side effects include mild congestion and  runny nose.
The injectable vaccine (known as a flu shot) is cultured in eggs as well, and the virus is then inactivated with the chemical formaldehyde.  The flu shot can be used in any patients, and is the only form recommended for children 6 months to 2 years old, as well as elderly patients.  Side effects from the flu shot include pain at the injection site, redness at the injection site, muscle aches or low grade fever.
Neither the FluMist or single dose vials of injectable Influenza vaccine contain Thimerosal.


Because the virus particles are completely inactivated, one cannot "get" flu from the flu vaccine.
The Influenza vaccine typically prevents about 70 of every 100 people who receive it from developing moderate to severe influenza infection.  Protection levels vary year to year, depending on which Influenza viruses are circulating, and how closely matched the Influenza vaccine is to the circulating strains.

Acute Neurologic Illness Associated with Enterovirus D-68 ..What's Going on in Colorado

The respiratory illness associated with Enterovirus D-68 has spread to many states at this point, and now a cluster of cases have been found in Colorado with limb weakness, possibly due to the same virus.
Starting in August, Colorado and the CDC have identified a cluster of children 1-18 years of age (median age of 10) with acute focal limb weakness.  At this time, there have been 9 confirmed cases.  Most of the children are in the Denver metropolitan area, and all of them have been hospitalized.  Specific testing has been done, including CSF analysis via lumbar puncture looking for meningitis.  None of the cases had bacteria or virus isolated from the CSF, though there were signs of inflammation present.  Spinal MRI scans showed lesions in the grey matter of the spinal cord, and some had brainstem lesions on MRI as well.  Most children report having a respiratory illness associated with fever in the two weeks prior to developing limb weakness.  No cases have had Enterovirus D-68 in the spinal fluid, although 6 of 8 cases did have Enterovirus D-68 isolated from nasal specimens.  Further testing is being done.
The CDC is working closely with Colorado, and they have posted a health advisory on their website at:
http://emergency.cdc.gov/HAN/han00370.asp

Concussion Diagnosis and Treatment in Children

Head injuries and resulting concussions affect many children and teenagers every year.  A concussion is a type of traumatic brain injury from a direct blow to the head or from a transmitted force causing linear or rotational acceleration.  The definition of concussion has evolved over the last decade, and loss of consciousness is no longer a criteria for the diagnosis.  Children and adolescents with concussions experience, on average, 10-14 days of symptoms.  Evidence suggests this may be longer in younger children.
Though organized sports are thought to be the primary arena for injuries, head injuries and concussions can happen from any recreational injury, even an injury first thought to be a minor one.  High schools in many localities have undergone extensive training in order to recognize concussions in athletes.  Concussion rates are highest in football (American football - not soccer), Boys' ice hockey and lacrosse,  and Girls' soccer. 
Many schools use an evaluation tool called IMPACT --this test is composed of a series of questions, as well as mental and reflex performance measures -- designed to pick up on key nuances and signs resulting from a head injury.  Athletes are given a baseline test at the beginning of the school year, or the beginning of the sports season, and further tests are done after injuries.  The scores are compared with one another to look for impairments.  Medical professionals find the IMPACT test useful as one tool in determining whether athletes are mentally able to return to school activities or sports participation.  Another tool that is useful is the SCAT3 (Sport Concussion Assessment Tool).  The SCAT3 has one section called the Sideline Assessment, designed to evaluate an athlete right away at the time of injury, as well as a symptom checklist (completed by the child) with severity levels for each symptom, a cognitive and memory assessment, and a physical balance and coordination test.  Again, this test is useful when performed multiple times in an assessment of a child who has had a concussion.
Common symptoms of traumatic brain injury and concussions include:
Physical symptoms - dizziness, problems with balance, headache, nausea/vomiting, sensitivity to light or noise, visual problems
Cognitive symptoms - change in school performance, difficulty paying attention or concentrating, difficulty remembering, feeling confused about recent events, feeling foggy/"in a daze", forgetfulness, slowed response times
Emotional symptoms - irritability, increased emotions/moodiness, sadness, nervousness or anxiety, loss of interest in activities
Sleep/energy symptoms - drowsiness, fatigue, sleeping more than usual or insomnia/difficulty falling asleep


Following an initial evaluation, your medical provider will likely talk about putting your child on "cognitive rest" for a minimum of 5 days.  This means absence from school and associated school work, as well as no sports or physical activity, no TV/computer/texting/video games/driving.  When symptoms improve, a gradual return to activity can be coordinated.  It is important to realize that the cognitive symptoms may remain even after the initial physical symptoms go away.  Close coordination with medical providers, school personnel, trainers and coaches is important to give a child a good environment in which they can return to full functioning. 

Enterovirus D68 - The New Respiratory Virus

A severe respiratory virus affecting children in Missouri and Illinois, and leading to a high rate of ER visits and hospitalization, has been identified as an Enterovirus and classified as Enterovirus D68.  The CDC has a nice synopsis about EV-D68 on their website.
The Enterovirus family contains over one hundred viruses that typically circulate in the summer and fall, and usually cause gastroenteritis (stomach flu, vomiting and diarrhea).  EV-D68 was first identified in California in 1962, and has rarely been reported in the US for the last 40 years.  EV-D68 is unique in that it causes respiratory symptoms similar to common cold viruses as well.


Hospitals in Missouri and Illinois started seeing severe respiratory illness in school-age children earlier this month.  At first, influenza was suspected, and due to the clustered nature of cases, cultures were sent to state and CDC laboratories.  This is how the EV-D68 was identified.
The CDC is involved and is actively tracking cases and assisting affected states with testing.  Regular hospital and commercial labs can isolate enterovirus from specimens, but cannot definitely type it as D68. 


Symptoms: mild to severe respiratory illness characterized by cough and runny nose (typical cold symptoms) that can progress to difficulty breathing, wheezing and pneumonia-like symptoms


Transmission: EV-D68 is not frequently identified, so some questions exist as to the ways it would usually spread; however, since the virus is found in respiratory secretions (saliva, mucus, sputum) it may spread from person to person when an infected person coughs, sneezes or touches common contaminated surfaces.  Since EV-D68 is an enterovirus, it may also spread by the fecal-oral route.


You can help protect yourself from respiratory illnesses by: washing your hands often with soap and water for at least 20 seconds, especially after changing diapers or helping children in the bathroom.  Avoid touching your eyes, nose and mouth with unwashed hands, since viruses can exist on surfaces.  Avoid sharing drinks, cups, eating utensils, washcloths and towels with people who are sick.  Disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone in the house is sick.


As with any other respiratory illness, if you or your children are sick, see a doctor if you have a high fever, difficulty breathing or lethargy.  Monitor your children's breathing - if they seem short of breath, or are tiring and breathing fast, you should have them evaluated.  Respiratory viruses can cause more severe infection in people who have underlying respiratory or lung diseases like asthma.


Update 9/17/14: The state health department in our state (VA) has confirmed that they are seeing confirmed cases here in Virginia.  As in other states, children are presenting with respiratory symptoms similar to the common cold - runny nose, nasal congestion, cough and sometimes wheezing.  As with many viruses that cause colds, symptoms can range from mild to more serious with difficulty breathing and wheezing noted.  Fall weather, and the return of many children to the school setting, is usually associated with an increase in the spread of upper respiratory viruses. 
Regular hygiene, good hand washing, and limiting your child's sick contacts (when possible) are important precautions to take.
There truly may be more widespread Enterovirus D-68 causing mild cold symptoms in children, in cases that would not prompt testing for specific viruses.  As is usually the case, if your child develops difficulty breathing, or abruptly worsens during the course of an upper respiratory infection, they should be evaluated by their medical provider.