Infants with reflux–medication risk

I have touched on this subject before so I’m sorry to “go on” a bit.  However, the subject–the use of medications for babies with reflux–is very important, and there is some significant new information that I wish to share, so here goes.

Another large study now demonstrates additional risks of side effects besides those previously reported with the use of certain medications in the management of reflux in the first year of life: “PPI’s (proton pump inhibitors) like prilosec (omeprazole) or prevacid (lansoprazole) and the more commonly used “H2 (histamine type 2 receptor) blockers” like zantac (ranitidine).

The study reviewed cases in 874,447 children born between 2001-13 in the US Military System who had taken the above medicines in the first year of life and were followed for at least 2 years afterwards (so they had really good records and really good follow up). The children tended to be at least slightly premature and of lower birth weight.  Children who took PPI’s had on average a 23% greater risk of bone fractures and those receiving H2 blockers had 13% greater risk.  Taking both increased the risk by 32%; those who had one fracture had an increased risk of repeat fracture by a whopping 85%.  The risk was slightly greater in boys and the majority of the children received these medications in the first 6 months of life.  Longer treatment was associated with increasing risk.  For PPI’s, <1mo treatment had 19% increased risk, 23% for 60-150 days, and >150 days the risk was 42% greater.  For H2’s  the numbers were < 1 mo 14% greater risk, > 120 days of treatment demonstrated 22% increased risk.  Children who received both medications for > 9 months had a 50% greater risk of bone fractures.

These drugs are not infrequently prescribed for symptoms such as fussiness, poor feeding, arching, or frequent spitting up/vomiting.  Yet controlled double blind studies have not shown any discernible benefit for these symptoms from their use–children who receive placebos or no medicines appear to do just as well over time.  Now, I do not wish to imply that there is no place whatsoever to ever consider these treatments for children with some of those problems.  Nevertheless, we must remember that these are not benign medicines, as noted here; additionally, we should recall the other established risks from GER medicines in infants like malabsorption and poor weight gain, increased risk of infections like pneumonia, and kidney inflammation.  Let’s take the conservative, more natural approach for the large majority of children who’s symptoms are mild to moderate and will be well managed that way, and in particular for those “happy spitters”–the little kids who barf all over everybody and everything while happily growing and developing normally.

For babies with more severe and disruptive symptoms, give me a call and let’s discuss it.  And thanks for following.





Vaccines, Loss, Grief

The tragic loss of a young child from our area.  A father’s bottomless grief.  A social media cri de coeur.  All combine to drive a recent increased local trend toward questioning the validity and safety of childhood vaccinations.

As a physician and in personal life I have on several occasions reluctantly witnessed the catastrophe of a parent losing a child.  No human should have to endure such an ordeal; any compassionate person would feel the greatest empathy for someone in the throes of that awful experience.

However, we should make health decisions based on facts, not emotions.  The facts here are definitive.  I know essentially nothing about the recent incident in our community but it was reported that the child was immunized weeks before he died.  To establish a meaningful causal link between the 2 events, especially given that time frame, would be most difficult, and would require extensive scientific analysis that would take a significant amount of time.  The effectiveness of vaccines in preventing severe illness and in saving millions of lives and the evidence of their safety from serious problems in all but the remotest of circumstances (if measurable at all) is overwhelming.  The studies that have been conducted in the US and worldwide and are far too extensive to review here.  That Mt. Everest of data on the subject is simply too big to dismiss.  And to postulate a profit driven conspiracy to hide some contrary “facts” would entail believing in a plot that is large enough to encompass multiple countries across several major industries including millions of people.  Kind of hard to keep such a thing a secret.

The consequences of doubt and avoidance are often severe.  There are still outbreaks of vaccine preventable illnesses throughout the US and the world and so many of those are caused by suboptimal immunization rates.  Children are disabled, disfigured, or die as a result.  We can absolutely establish a causal link between under or lack of immunization and these tragedies.  Clearly these children are just as dead, and their families’ grief just as horrific, as our most unfortunate neighbor now must sadly face.

So let’s use our emotions–those of us who share this man’s life–to support him and his family as the try and bear the unbearable, and carry them on to a future where they may one day rediscover joy.  It is our duty to our fellow human beings.   But let’s use our brains to make policy choices that impact our children’s wellness based on facts carefully uncovered and reliably reproducible.  The only really productive way to deal with child loss is to do our best–based on reality– to limit its occurrence.

I encourage all of my patients with questions regarding vaccines and their children to bring those concerns to my attention.  Educating my patients about the advantages of immunizations and making them comfortable with that choice is among my most essential duties as your pediatrician.

And thanks for following.

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:

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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.

Thanks for following.


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.

Send along questions and comments and thanks for following.

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.

Send along questions and comments, and thanks for following