Safe cribs

As Kim and I are now blessed to have recently become grandparents, the forever pediatric issue of safe infant sleep now has renewed personal urgency for me.  In a 2012 policy statement the American Academy of Pediatrics urged parents to avoid soft bedding objects like pillows or bumpers in the crib with young infants.  In a study examining 1985-2012 researchers reported that infant suffocation in cribs, while rare(about 77 cases in that period), were almost always associated with bumpers: 2/3 caused by the bumpers themselves and the rest when the infant became tangled between the bumper and another object like a pillow or toy.  There were an additional 146 nonlethal choking and near suffocations also all associated with bumpers in that time period.

Parents who use bumpers usually express concerns about avoiding head injury or limb entrapment.  However, young infants lack both the strength and the coordination to slam their heads against the crib with enough force to cause any significant injury.  And while it is rarely possible for a limb to get stuck between the slats, it is virtually impossible for this to result in a fracture or any other serious arm or leg injury–so the worst that could likely occur is an uncomfortable and upsetting, but ultimately essentially harmless, experience.

So the basic recommendations are:

• To prevent suffocation, never place pillows or thick quilts in a baby’s sleep environment.

• Make sure there are no gaps larger than two fingers between the sides of the crib and the mattress.

• Proper assembly of cribs is paramount – Follow the instructions provided and make sure that every part is installed correctly. If you are not sure, call the manufacturer for assistance.

• Do not use cribs older than 10 years or broken or modified cribs. Infants can strangle to death if their bodies pass through gaps between loose components or broken slats while their heads remain entrapped.

• Set up play yards properly according to manufacturers’ directions. Only use the mattress pad provided with the play yard; do not add extra padding.

• Never place a crib near a window with blind, curtain cords or baby monitor cords; babies can strangle on cords.

The consumer Product Safety Commission recently reviewed the data and added these additional concerns regarding the use of crib bumpers:

• They limit mattress space
• Cover key failure points in the crib
• are difficult to install
• frequently used in older infants beyond even the manufacturer’s recommended age
• used outside cribs
• sends mixed signals about padded objects in crib

So we pediatricians usually advise that “bare is best:” a flat, firm mattress without pillows or toys, no crib bumpers or thick quilts or blankets.  Young infants can wear a head cap and be swaddled in a receiving blanket and older infants can just use warm pajamas for comfort.

For more information check out the following:

https://www.nichd.nih.gov/sts/Pages/default.aspx

https://www.cpsc.gov/s3fs-public/CBStatement.pdf?dhFXWQNHUqQ2yV4xuY654JrJ3K0Towc

https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Preventing-SIDS.aspx

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Fruit Juice Update

The American Academy of Pediatrics (AAP) recently updated guidelines for fruit juice consumption:

• No juice in the first year of life.  If medically necessary, use a cup and not a bottle to limit risk of cavities (bottle rot)
• For toddlers, 100% juice, max 4 oz, may be offered as a snack or part of a meal
• 4-6 yrs max 6 oz/d; >7 yrs 8 oz
• Watch for complaints of abdominal pain, flatulence and bloating, chronic diarrhea
• Eliminate in children with EITHER excessive or inadequate weight gain

Now, why is this?  Well, nutrition science is complex, so its hard to explain it all here.  Firstly, the sugar load of fruit juice is almost identical to soda and sport drinks–12 coca cola has 140 calories, 40 gm sugar compared to apple juice with 165 calories and 39.8 gm.  Your body sees that as almost the same.  Then there’s fiber–fruit has it, juice does not.  The fiber fills the stomach giving a sense of fullness that juice does not.  Fruit must pass on to the intestine to be broken down allowing for sugar absorption whereas the juice containing sugar rapidly diffuses across the stomach lining into the bloodstream.  So you don’t feel full and keep drinking or eating more.  Juices, therefore, like all sugary drinks, are the emptiest of “empty calories.”

Studies support those conclusions, showing that those who consume fiber tend to compensate by cutting back calorie consumption elsewhere but no such decrease after drinking juice.  One study indicates a 60% greater risk of obesity caused by regular consumption of sugar sweetened beverages; given the similarity of sugar loads stated above its a safe bet that juice can have the same effect.

As stated, the sugar in juice is floating in fluid and is rapidly absorbed whereas in fruit the sugar is encased in fiber cells.  These cells must first be broken down to enable the body to get at the sugar.  This leads to more rapid sugar absorption with juice compared to whole fruit resulting in a stronger and more rapid insulin release from the pancreas.  The effects of that more robust insulin load are profound; in the short term insulin stimulates the appetite and leads to greater calorie consumption and longer term it can promote insulin resistance, excessive insulin production and metabolic syndrome.  Several studies found eating fresh fruit decreases the risk of Type II diabetes while drinking juice INCREASES it.

Additionally, large percentages of fruit juice sugar is in the form of fructose–indeed, many “100% juice” brands actually ADD fructose.  Excessive fructose intake has its own list of potential problems; given the more rapid sugar absorption, consuming it in juice can just multiply those effects.

So the AAP guidelines are a strong step forward in child nutrition.  Drink mostly water or sparkling water–squeeze in some lemon, lime or a bit of cranberry juice for taste.  Then enjoy some fresh fruit.  While you’re at it, make it locally grown from farmers markets–helps the local NJ agriculture industry and our entire state economy.

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Stealing in younger children

Recently a mother brought concerns of her young school age child repeatedly stealing from family and school.  This is actually not too uncommon–teachers report about 5% of kids <10 years being caught taking from others.  There are lots of reasons for it to occur in otherwise well adjusted young ones–attention (my patient has a new sibling), anger if the offender judges some other who they think is rewarded unjustly or disproportionately, misplaced show of bravery to fit into a peer group, or as a way to impress and perhaps offer a gift to a desired friend.  Take note–it can even occur if your child mimics behavior that they witness in parents who might engage in something that people often view as small and innocuous like helping oneself to office supplies or keeping hotel towels and the like.

How should one react if confronted with an older toddler or young school age child who steals?  First, don’t panic or overreact.  Remember–children at this age have only limited impulse control and are not able to project out consequences too far beyond that moment.  Yelling, lecturing, and especially hitting (as almost always) are more typically counterproductive.  Be sure to discipline in a private one on one setting to avoid humiliating your child.  It is certainly proper to express great disappointment and also to require them to perform household chores as penance.  Explain this by saying that if he wishes to buy or own things of value then he needs to work for it.  Remove privileges like TV or video devices until all work is completed satisfactorily.  It can be good to do this work together and if able to praise his effort and performance since, as stated, sometimes these behaviors are manifestations of feelings of neglect or inadequacy.  Usually it is helpful to make your child return the stolen object and apologize.  This can even apply if objects are taken from stores or businesses however be cautious here as not all establishments will necessarily be forgiving even of these younger kids including with a first offense.

If you are concerned that these behaviors may be repeated try the following: make a written inventory of all of your child’s possessions and review it with her.  Explain that she is not allowed to own anything else beyond that list unless she has asked your permission first.  It will not be an acceptable explanation  that she “found” it or it was “given” to her unless she cleared it with you beforehand.  This can take some of the ambiguity out of these occurrences.

If these behaviors are repetitive, associated with poor or deteriorating school performance, or associated with any violence towards self, others, animals, or property it could indicate a more serious problem and should be brought to my attention. So give me a call.

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A few thoughts on DWI

I wish to make a brief comment about the deadly incident in Times Square last week.  All were horrified by the violence committed by an individual captured and charged with that awful crime( I refuse to publicize the alleged perpetrator’s name and give him even small satisfaction of notoriety).  So many people felt a somewhat understandable sense of relief when it was determined that there was no apparent link to any extremist terrorism.  It was “only” DWI.

Who are we kidding?  Of course all are concerned and fearful of the risk of terrorist violence in our society.  However, in reality, from 2004-13 there have been a total of 80 Americans killed in such incidents–36 on US soil.  Tragic, sickening, no doubt.  But for comparison, in 2014 alone there were 9967 Americans killed in drunk driving incidents; this is 28 people/day and one every 53 minutes.  19% of children 0-14 killed in auto accidents (total 209 that year) involved alcohol impaired drivers and over 1/2 who died riding in cars were operated by an impaired driver.  There are approximately 1.1 million DWI arrests yearly.

Other shocking statistics regarding DWI can be found here.

So let’s get real.  Our society has made major strides in DWI over the past generation or so but the above demonstrates that it is still a much greater public health problem in comparison to terrorism.

Obviously its extremely complex to address, but here are just a few simple policies that we as a society could adopt to help better control this terrible scourge:

• Raise the alcohol tax–the American Journal of Public Health estimates that doubling the tax would reduce DWI mortality by 35%.  Many pundits argue generally about raising taxes with the claim that “if you tax something you will have less of it.”  It is mostly an arguable point at best .  But less DWI?  Sign me up.
• Reduce the number of alcohol retail outlets.  The American Journal of Preventive Medicine reports that fewer liquor stores results in less alcohol related mayhem.  There is a “Goldilocks” effect here–too much or too few are both problematic.  But stricter licensing standards would likely be helpful.
• Studies from the RAND Corporation strongly suggest that outlawing the purchase of liquor by people convicted of alcohol related crimes would cut into these numbers quite dramatically.  The program could be implemented with special bracelets and/or breathalyzers to monitor compliance.
• RAND also found that state controlled–as opposed to privately operated–liquor stores are much safer and more protective against alcohol related criminal activity.

I believe that these are sensible and nonpartisan initiatives that all concerned citizens could support.  I encourage everyone to consider these policies and to encourage your elected representatives to advocate on their behalf.  Our society and especially our children will very likely be safer and healthier for your efforts.

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Baseball Arm Injuries

So we spent some time talking about warm weather and girls’ knees.  Let’s give equal time now to boy’s arms–pitchers’ injuries generally.  This is a huge topic, easily filling a textbook or weekend lecture series.  Let’s summarize some risk factors identified by researchers from the American Sports Medicine Institute.  These can guide us to develop safer training/competition schedules.

Firstly, a negative–number and age of breaking balls thrown had little positive correlation with injury.  Injured vs non-injured pitchers all threw on average 60% fastballs, 15%change ups, and 25% breaking balls.  There was also no difference in injured vs non-injured in relief appearances or for those who stayed in the game at another position after being relieved.

The 2 groups differed in size, with the injured group tending to be, on average, 4 cm taller and 5 kg heavier.  This may reflect the bigger boys throwing harder or having somewhat different mechanics.

The injured group threw more warm ups.  Possibly this may reflect a tendency of boys who are already “at risk” taking more time–and more throws–to “get loose.”

The injured group, not surprisingly, used ice and anti-inflammatories like ibuprofen more often and in greater amounts.  Again, this suggests boys with already stressed arms, and tells us a lot about  the folly of “playing through the pain” in kids.

9-14 year olds who lift weights had greater injury risk, possibly due to the strain on skeletally immature bones and joints in younger boys.  Probably best to avoid this until the boy has enough beard to shave somewhat regularly.

Competition issues are the big ones.  Injured pitchers competed at least 8 months/year  (5x risk of surgery) compared to boys pitching 5.5 months/year.  The Institute recommends refrain from all throwing activities(not all sports) for minimum 3 months/year.  Inured pitchers threw 6 innings/game and 88 pitches (2.8x risk of surgery) compared to non-injured at 4 innings, 66 pitches.  One study demonstrated a clear risk of a specific overuse shoulder injury with >100 pitches/week.  Velocity played a role–injuries were more frequent at 88 mph compared to 85 mph.  “Arm fatigue” is key.  67% of injured pitchers admitted to throwing with a “tired arm”–52% regularly– with 36x greater risk of needing surgery.  The non-injured group numbers were 42% and 11% respectively.  I’m sorry, but “toughing it out” in this age group is just crazy.

Finally “showcase” competitions caused greater risk of pitcher injury.  Injured players participated in an average of 4 of these events compared to just one in the non-injured group.  Showcases tend to be held in the off season when boys are not at peak conditioning and places added physical(and MENTAL) strain on young pitchers.  I recommend limiting the number of times boys participate here (if they cannot be avoided entirely) and closely monitor when throwing in this type of competition.

As always, I end by urging parents and coaches to remember the priorities for all youth sports: firstly–have fun and make friends; secondly–fitness, competition, and learning valuable lessons like persistence and commitment; and lastly–win games and glory.  College scholarships, should they occur, are icing on the cake.  Making the majors??–go buy a lottery ticket.

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ACL injuries in girls

As we move to warmer weather we can now really begin to enjoy the outdoors, which means lots of youth sports.  I say great–but I also will take a moment to discuss concerns about the absolute epidemic of anterior cruciate ligament (ACL) injuries in adolescent female athletes.  Over the past generation we’ve seen increasingly frequent ACL injuries by up to 900% due largely to the explosive growth of girls sports since Title IX; anywhere from 20,000-80,000 occurrences yearly.  Soccer, basketball, and gymnastics cause the most injuries; girls are up to 8x greater risk compared to boys.

Some background: the ACL is inside the knee and keeps the tibia (shin) from sliding forward relative to the femur (thigh) during ambulation.  >70% of injuries result from no contact with other players but rather from some sudden, awkward movement.  One example: a girl plants her right foot with extended knee and then tries to quickly cut right.  With sudden deceleration her weight is back with leg straightened moving under her upper body as her torso turns right and out and her thigh rotates inward(counterclockwise) and POP!! (there is often a loud snap that everyone close to the injured girl will hear when the tear occurs).  This is a common mechanism of injury.

There are many physiologic factors contributing to girls’ ACL risks:

• Hormones–testosterone surge in boys makes for greater muscle development allowing boys to control movement more with muscle strength; girls tend to rely more on bones and ligaments.
• Menstruation-the ACL actually gets slightly longer and more lax mid-cycle creating greater risk
• Neuromuscular factors–quadriceps (front thigh):hamstring (back thigh) muscle strength ratio is greater in girls compared to boys.  This puts greater strain on the ACL.  Girls also tend to have one leg stronger than the other compared to boys more symmetrically distributed leg strength which creates more problems in the weaker leg.
• Girls tend to run and land relatively flat footed.  Boys are up on their forefoot more which is a better shock absorber.
• Girls have relatively less core body strength.
• Wider pelvis makes for more uneven landing

Note that for both boys and girls being overweight increases risk.

There are many steps we can take to avoid ACL tears.  Proper fitting quality footwear for their sport is a nice start.  Core strengthening is key–lots of sit-ups and planks.  Neuromuscular training is a very important component.  Here is an excellent program.  A variation on that program is demonstrated here.  So besides dribbling, passing, shooting and SCORING, make these exercises a regular part of your daughter’s training routine, especially off and pre-season.

Chance of ACL injury does not at all mean that your daughter should shrink from enthusiastic participation and aggressive competition.  Like all risk it must be balanced by advantages and can largely be controlled by proper lifestyle.  Sports will help make her more confident, stronger, healthier and so often happier.  And most importantly–IT’S FUN!!  So get out there and play.

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Drug addiction–medicine disposal

Most of us have become aware of the terrible scourge of drug abuse that grips our nation.  Here in Ocean County, heroin kills one person every 48 hours.  Statewide we have seen a 214% increase in drug use since 2010 with approximately 128,000 New Jerseyans struggling with addiction at last count.  As a community, Toms River ranks 8th statewide in the rate of heroin addiction and overall Ocean County ranks 2nd in that sad list with 157 heroin deaths in 2015.

The problem is not just heroin, of course, but also prescriptions pain killers as well–including frequently used drugs like oxycontin, hydrocodone, and fentanyl(note–available as a dermal patch).  Many may have these drugs in their medicine cabinets left over from ailments like dental work, back pains, or surgical procedures.

What can we do with these medications when the problem is resolved but there are pills left over?  It’s NOT as simple as one might think.  The risks here are obvious–adolescents are impulsive and can be foolish: parents should never be too confident and should NEVER take anything for granted here.  And we must note that other youngsters visit and that just adds another variable to that safety equation:

• Do NOT discard medicines in the trash
• Be careful about flushing medications down the toilet
• Best to discard at a reputable center
• When in doubt, check with your pharmacist
• When disposing pill bottles, be sure to scratch off all identifying information
• Do not crush pills, but you can break them into halves or quarter
• If you are going to discard pills, mix them with undesirable substances like dirt, kitty litter, or coffee grounds and discard in trash in sealed plastic bags

One last suggestion:  ask me about keeping a prescription  for naloxone (narcan)–available as a nasal spray–for your home.  Naloxone is an absolute antidote for opioids, is easy and VERY safe to administer.  Because “you never can tell,”

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