I’ve had more than a few children coming in with some wicked poison ivy rashes over the past few weeks. Seems like a good time to review the basics:
DO teach your children to recognize the leaves.
DO check your yard and play areas carefully for the vine and safely eradicate it.
DO stay on the trail when hiking.
DO wash thoroughly after a walk or hike where poison ivy may have been.
DON’T forget to wash off the shoes and the dog if you think your children were playing/walking near it.
DON’T burn poison ivy to get rid of it (the smoke can cause serious damage!)
DON’T let brush grow unchecked in your yard.
DON’T forget to do a ‘tick check’ as well after hiking/walking.
Poison ivy can get really nasty and last for a long time so prevention is really the key. Yes, doctors can give steroids for bad cases but most kids really don’t need them for mild rashes and they do not come without side effects. The best advice is to give kids an oral antihistamine like Benadryl or Zyrtec to prevent itching and seek the care of your doctor if the rash is looking particularly bad, covering an extensive amount of skin or affecting the eyes/mouth.
I threw in the last ‘DON’T’ about checking for ticks because tick-borne diseases like Lyme aren’t going anywhere. It is important to get kids outside but it is equally important to keep them safe. Where there’s poison ivy, there may also be ticks. The good news is a tick check and a shower are effective prevention because ticks normally ‘walk around’ looking for a place to bite for more than 24 hours. Get to them first.
For more information, see our respective pages on poison ivy and dealing with insect bites. With a little forethought, your kids can enjoy a fantastic spring outside!
May 17, 2012
According to CDC, 2011 marked a 15 year high with 222 cases of measles, 90% of which were imported from other countries. It is not really a surprise, I suppose, with measles sweeping through Europe over the past year. Some of that was bound to make its way here with international travel as frequent as it is.
All children should receive two doses of MMR, unless a doctor advises against it in rare circumstances. Luckily outbreaks in our country tend to die off quickly as the majority of children are vaccinated. Even with both doses of vaccine, there is still a small chance of infection in one of these outbreaks so remain vigilant for news of measles in your local community.
To learn more about measles, see our summary of the measles disease and our complete profile of the vaccine.
This should serve as a wake up call for all of us. These diseases are still with us and can rebound in a heartbeat. Let’s do our best to get the facts, get informed, and keep our communities safe.
April 23, 2012
How do you feel about naturopathic medicine? I’ll be the first to admit, as an allopathic MD, I haven’t had any training in this sort of thing. Some feel we should be reaching out and incorporating CAM (Complementary and alternative medicine) and others think it is on the fringe for a reason: it doesn’t do anything. To quote Paul Offit from a recent article in the January 2012 edition of Infectious Diseases in Children, ‘one could argue there’s no such thing as alternative medicine. If a medicine works, it’s not an alternative. And if it doesn’t work, it’s not an alternative.’
Natural supplements with purported benefits need to stand up in blinded trials. If there is a clear benefit, these should be adopted into our overall approach. As the argument goes, it isn’t alternative anymore but real medicine at that point.
Many people who seek out CAM are doing so because the pills and therapies we provided didn’t seem to work; people still have joint pain or high blood pressure. They still feel symptoms of depression or are still getting debilitating migraines. Despite treatment, the cancer is back. Their toddler still has a runny nose and won’t eat his dinner. From the mildest to the most serious issues, we don’t always have the solutions people want.
Some medications have smaller effects than we would like to believe and we often use them incorrectly. I wonder how many Z-paks are given each year for the common cold. 60 minutes recently ran a story on the placebo effect, pointing out the limited efficacy of SSRI’s in mild to moderate depression. We know this and yet we still write these scripts. How many of the FDA approved scripts that we write each year have good efficacy and how many are, well, placebos?
The healers of the past relied on the limited power of certain medicinal plants, and the power of ritual. Evidence based medicine has moved us beyond this, but in many ways only to point out how limited our therapies can be. People will still come looking for an answer or a pill. We are doing our best to provide them but I wonder at the purity of our traditional medicine when I see elephants and stretchers and now even bathrobes following people around on TV commercials.
When it comes to preventative medicine, maybe it is time to consider a less invasive, more ‘naturopathic’ approach. It would be far better if many of the disease states we are trying to re-calibrate never occurred in the first place. Naturopathic providers may do a much better job with this message than I can do in my busy practice.
The human body really can heal itself. Many alternative medical providers tap into this, as healers have for centuries: exercise, meditation, and healthy diet all have profound effects. There are limits to this healing power. Naturopathy will never catch or cure leukemia. It cannot stop MRSA but it may be a great help with hypertension, diabetes, sleep disorders, behavioral disorders and on and on. It may be a great help with things that are influenced by diet, lifestyle and mood. In the same way that our therapies, drugs and antibiotics are sometimes used in less than optimal ways, naturopathic care can easily go astray and venture in dangerous directions. When I hear some naturopaths espouse the benefits of NOT vaccinating a child, I see blindness to the evidence. Anything, including the healing power of healthy living, can be taken too far, to conclusions that are unsupportable by evidence.
If we can stick to the evidence, we see there is great power in both forms of medicine as well as potential for abuse. With a looming healthcare crisis of cost, regardless of which direction the political winds blow, we will need to be creative about getting our population healthy. A pill may not always be the cheapest or even the most efficacious therapy.
April 9, 2012
A recent Canadian study showed that the youngest children in each grade (born in the earliest month of the Canadian grade cutoff: December) were 30% more likely to be diagnosed with ADHD than the oldest children (born in January). For girls, who overall have a lower incidence of ADHD, the difference was even more pronounced: 70%.
Interestingly, the overall rate of ADHD diagnosis in the sampling of children from this Canadian study (900,000 children) was 6.9% for boys and 2.2% for girls. Rates of diagnosis here in the United States are much higher, creeping up on 10% of all children.
What does all of this mean? Well, you can look at this data many different ways, depending on your point of view and feelings about ADHD, but it stresses to me what seems to be common sense: many factors play into our expectations of what normal behavior should be. It is often the school which prompts parents to have their child evaluated for attention problems and this comes from a comparison to other children in the class. A six year old may be significantly less mature or able to stay on task than a seven year old. Likewise, boys tend to have more trouble with the expectations of the school environment than girls in the younger grades.
Both of these groups, boys, and the younger ones in class are diagnosed and treated for ADHD at higher rates. I have ambivalent feelings on the matter. Medications are not without their side effects but most parents see an improvement in behavior with minimal negative effects. If these compounds work, if they create better students, what difference does it make what groups have higher rates of diagnosis and treatment?
I don’t know if it makes any difference, provided the medications are safe and effective. There is still, however, some part of me that questions the introduction of a medication to a mind that is still maturing, unless it is absolutely necessary. Is there a ‘natural process’ for the creation of self control in the brain? Are we creating a reliance on an artificial substance, or missing some environmental piece of the puzzle, like sleep? I simply do not know.
Most clinicians and experts would argue ADHD is like any other organic disease. You do not choose not to treat diabetes. If that is the right way of looking at it, I think this study tells us we need to be more careful about how we choose who is selected for this diagnosis, at the very least.
April 2, 2012
I was reading an article recently about the amount of food we throw away each month and it got me thinking about how we manage food in the home. Here’s an excerpt from the article:
The average American throws away 33 pounds of food each month — about $40 worth — according to the Natural Resources Defense Council, which plans to publish a report on food waste in April.
In a year, that means each person throws away almost 400 pounds of food, the weight of an adult male gorilla.
I have to admit that I was a complainer at the dinner table as a kid. My mom got an earful every time she served up some baked chicken and a potato. The good woman made it through my mouthiness and got me to eat the whole plate, though. I was always encouraged to be in the ‘clean plate club,’ and baked chicken or not, I usually was.
As you may know, kids aren’t supposed to be encouraged to clean their plates anymore. With an epidemic of obesity and wars being fought between parents and toddlers at the dinner table, the expectation that a child should clean her plate is declasse.
Parents choose what is in the cupboards. They choose what goes on the table and they choose when.
The child chooses how much to eat.
There are several things I like about the new approach: It is simple and gives parents the freedom to provide good foods without worrying about their child’s intake. It also gives a child some authority. A child gets to choose how much to eat and he doesn’t need to stuff himself if he simply isn’t hungry. Finally, it sidesteps tension and bad habits. Mothers: you are not short order cooks. Fathers: you are not either. There will be no force-feeding and no yelling. You don’t have to eat it but this is dinner.
Why is it, then, that I can’t shake the idea that the Clean Plate Club was a good thing?
I guess the idea of throwing food away is simply repugnant to me. I can’t even throw away some bones after dinner without wishing I had time to make some soup out of them. When we look to the past, we see how hard our ancestors had to work to pull together the basic necessities. It wasn’t a matter of parent/toddler power struggles but human/earth power struggles. If you remove abundant, cheap, carbon based fuel, meeting basic necessities turns into a full time job.
We need to teach children not to overeat. We also need to teach them to respect the world they live in and understand how lucky we are to have so much. How do we meld the two ideas? How do we let kids self regulate intake without wasting food? A few obvious ideas:
1. Make portion sizes small.
2. Promptly wrap up the uneaten food for a snack later.
3. Send Mom or Dad to work with it the next day. Yum!
As feeding has become a frequent question, we have added a new article on the topic to our nutrition section. Practical tips are important, though: Do you have any other creative ideas for ‘recycling’ uneaten food?
March 22, 2012
Most adults are familiar with the concept of a body mass index, or BMI, but how many parents understand how to interpret this value for their children? We have come up with a simple guide for figuring out the numbers and interpreting them using the CDC’s growth charts:
BMI Calculator for Kids
Keep in mind that kids are ‘less dense’ than we adults are. They are lighter for their size and they are supposed to be! Their bones have not fully mineralized and they don’t have the same lean muscle mass. Because of all this, their BMI’s are smaller than ours and that is perfectly healthy.
If your child’s BMI falls outside of the range of normal values, talk to your pediatrician and take a look at our Nutrition Section. Is the child receiving enough food? Too much? Not the right kinds? We break down nutrition for you and talk about the nuts and bolts.
Exercise is the final ingredient: one hour of vigorous exercise each day for everybody. I’ll be the first to admit I have trouble fitting this into my day but my 13 month old seemed entertained by watching me run around the family room this morning. She liked it even more when she was on my shoulders. There’s 10 minutes right there…
March 8, 2012
Food allergies are a big deal these days and for good reason: a peanut or tree nut allergy can be life threatening for a child. What’s more, these allergies seem to be on the rise. Effectively identifying children with a potentially serious food allergy, providing Epinephrine injectors to be accessible at home and school, and making sure parents and other caregivers are clear on the allergy and when to use medication are all critical steps in preventing a life-threatening reaction. When a child has a true allergy, it is imperative that it is taken seriously.
As more and more children are diagnosed with food allergies it helps with awareness but there is also a watering down effect: In schools across the country, more and more children are marching into the nurses office to report an exposure and a possible reaction and there doesn’t seem to be anything wrong with them. I’m happy for the raised awareness but worried about the muddling effect: are we overdiagnosing these allergies and labeling kids that aren’t actually allergic? Does this have any effect on how we percieve the kids who actually have a serious allergy?
The overdiagnosis problem starts with how we use the medical tests we have available. For example: your child undergoes a large battery of skin prick tests or blood is drawn. Peanut reacts as highly positive. What does this mean?
A. The child has a peanut allergy and needs an Epipen for home and school.
B. By itself, this means absolutely nothing.
As you probably guessed, the answer is B, not A. Of kids who react positive to peanut on an allergy panel, the majority DO NOT have a peanut allergy. This information needs to be corelated to an actual clinical reaction to the allergen. That’s why the gold standard in allergy testing is an oral challenge done safely in an allergist’s office. Serum tests like immunocap and skin prick testing alone can only tell you if you DO NOT have an allergy. Shellfish wasn’t positive? You are good to go on that clam bake. It was positive? Well, you may or may not have an allergy. Many parents relate to me that a child has a number of food allergies to foods but the child has never even tried them. Clearly, someone didn’t properly explain these tests to the parents.
We need to get a handle on what a positive allergy test means and who really has one. In general, we should be using allergy testing to confirm and tease out a clinical allergic reaction that has occurred, not to find new ones that have never happened. The exception to this is the child with atopy. For managing asthma, it may be a good idea to test for allergies even in the absence of a previous reaction. The results may help optimize an asthmatic child’s environment.
For more, see our story on the main site here.
February 29, 2012
I just saw a blitz of headlines about a new study indicating an ‘optimal’ amount of sleep for teenagers. The study (see here) indicates that less sleep, down to about 7 hours, is better than more sleep. At least, that’s the take away headline in the popular press articles but I see it as an example of data taken out of context.
If you read the article, the data is self reported and correlated with test scores to determine the most successful students. This reveals the most successful students only slept seven hours compared to longer sleep duration for less well performing teens.
The actual article fairly points out some limitations: the experimenters can not state a causal relationship between seven hours of sleep and good test scores. Young adults with more drive, perhaps, study more and sleep less leading to better scores. The authors further point out that ‘our estimates do not account for overall health and well-being,’ just test performance. What they are making clear is that high scoring students may sleep less but this isn’t necessarily healthy.
I don’t think this study in any way refutes the idea that our kids really aren’t sleeping enough, despite what the headlines today might indicate. Is lack of motivation or laziness bad for teens? Sure. Is sleep bad for them? No way.
Take the headline that lead me to this study as an example: “Study: teens perform best with less sleep.”
The inference is that sleeping less aids performance and that conclusion is not supported at all by this study. I wish journalists were held to a higher standard!
I also hope parents don’t get the wrong idea.
February 23, 2012
Parents worry about the injections that their babies receive. What thoughtful parent wouldn’t? Concerns are varied: why so many? Why so early? What substances are being injected into my child? What are the risks?
The subject is broad and by no means simple. We tackle it head on here but in this post, I just want to relate one point that seems to get glazed over in the conversation about vaccines: I would make the argument that vaccines are the least invasive way we have to fight disease.
The algorithms, the standards of care, that doctors use to treat sick children have changed over the past twenty years. There was a time when an infant or child with a fever was treated much differently than they are today. In my daily practice, I have the luxury of taking a ‘wait and see’ approach with trusted families. I have always felt the least invasive intervention we can get by with is the best. I do not order chest x-rays and blood tests every time a child has a fever without an obvious source because I can assure a child’s parents that the process is almost certainly viral and will ‘run it’s course.’ This was not always the case.
Before the Strep. pneumonia and HIB vaccines were introduced about twenty years ago, the possibility of more serious bacterial infections with these encapsulated organisms was real and taken very seriously when a young child came down with a high fever. Children under two are very poor at fighting off these organisms. Some folks on the internet make light of HIB and Strep. pneumo. ‘Those just cause ear infections,’ or, ‘my child’s immune system can fight those off on his own.’ Unfortunately, neither of these is true. HIB and Strep can easily cause life-threatening cases of meningitis, pneumonia and epiglottis. The immune system of a child under two isn’t ready to fight off these infections. They are the most vulnerable. That is why it is so disheartening to hear parents talk about delaying these vaccines. That is missing the whole point! Wait until a child is two years old and you have missed most of the benefit of the vaccine. HIB alone causes hundreds of thousands of deaths worldwide, mostly in children under 5. I’m talking present day here, not some distant past.
It doesn’t happen here because we vaccinate. The algorithm for fever used to involve a full septic workup including a spinal tap for any child under 3 months. That number is down to one month. The algorithms we use for fever in other infants under one year depend on the child’s vaccine status. We are learning to be more and more hands off as doctors. Instead of xrays and intramuscular ceftriaxone injections at the first sign of fever, we can more confidently step back and say to a parent, ‘let’s watch this. Let’s not use any medications and let your child’s own immune system fight off this virus. We’re going to hold off on bloodwork and urine catheterizations and xrays for now. Here are some of the warning signs that we may need to recheck him/her…’
Back in the day, a high fever was still most likely to be a virus. Not everyone contracted meningitis but it happened much more routinely than it does now. Doctors still had those cases in mind. Maybe it was last week, or maybe it was a few years back but they all saw it. Better safe than sorry- let’s work this fever up with some tests and give some antibiotics.
We don’t have to do it that way any more because of these vaccines. They change the whole way we deal with fever in kids.
February 23, 2012
Is spanking ever justified?
Many current experts wonder why it isn’t illegal when study after study links spanking and corporal punishment in general with bad outcomes, notably aggressive tendencies later in life and even lower IQ. A recent article in the popular press relating to a Canadian study on spanking is illustrative of all of the negative impacts of spanking (news article). The AAP has long disapproved of spanking (AAP Policy Statement).
Despite all the negative data, there is still a great debate on the subject of spanking and I think that’s because it touches a certain American nerve. The idea being that no one has the right to come into your home and tell you how to raise your own children.
When I see a parent lash out at a child, either verbally or physically, what I see is a person who has lost composure and given in to anger and irritation. The spanking is no different from yelling or taunting, or bribing, or any other sign of an irritated adult who has lost control of the situation.
Some people argue that there is ‘good’ spanking and ‘bad’ spanking. Good spanking is done when a child is clearly told the negative outcome of a certain action and in a controlled, non-emotional way, a spanking is administered as punishment for the transgression. Bad spanking is done impulsively under the cloud of anger. I think there is a grain of truth in this idea but, overall, I think it is missing the point. It isn’t the spanking or the lack thereof that imprints itself on the child. It is the way the parent conducts him or herself.
To raise a child properly takes focus, patience and consistency. Toddlers aren’t supposed to understand the rules. They are supposed to be wild and attempt deceit. They are supposed to throw tantrums when, one tiny revelation at a time, they begin to realize that they are not the center of the universe. This is how we start out: little selfish animals.
All children require training and example to be transformed into polite and thoughtful children. As a pediatrician, every day I see the results of overindulged and poorly disciplined children who literally walk all over their parents. We expect toddlers to test the limits of their environment and we expect them to try hitting and biting and screaming. It is how we react to these things which determines whether or not children are still doing them as they leave toddlerhood behind.
A child can be taught to ape good graces out of fear. Corporal punishment and physical fear can create superficially well behaved children. A child learns not to grab or hit or throw a tantrum in order to avoid being hit afterwards. In the best of circumstances, parents who spank are not doing it out of anger, are careful to set a consistent example and are also teaching the child why what they did was wrong. The irony here is that all of those things alone would have been enough without the spanking. An alternate symbolic gesture of punishment and parental authority would work just as well. It is the emotional disapproval, the way the parent conveys that the action was wrong, that really counts.
As much as I don’t agree with it, I don’t think spanking should be illegal. A certain amount of physical restraint and sternness is warranted for some very rambunctious children. While children should not be raised in fear, they should have respect for parental authority. I don’t think parents should be afraid to be stern with or restrain an unruly child. By hyper-focusing on whether or not a controlled spank is ever warranted, I think we are really missing the point. I would wager all of these studies show bad outcomes from spanking because of an overall environment of bad parenting. If you simply made spanking illegal, it would not make people magically become better parents. It would not force them to show more self control or be more consistent with their children.
What creates a truly well behaved and thoughtful child is a thoughtful and well behaved adult. The consistent example of good behavior and control by a caregiver is the best discipline for a child and it is also the most challenging thing for a parent to do.
February 9, 2012