Avoid Toxins

Nutritious  food and a safe environment is, of course, a basic requirement for a healthy upbringing.  Currently there are > 10,000 chemicals allowed as additives in food and food contact materials in the US.  There is growing evidence that at least some of of these products pose significant health risks for children.  There are several reasons why these chemicals are riskier for kids.  Children are smaller so the per kilogram ingestion dose is typically larger; their organs are still developing; and lastly children will likely carry these ingested materials internally for decades longer.

Questions raised by some of the newer research involve odd sounding chemicals with even stranger spellings–bisphenols, phthalates, perfluoroalkyls, perchlorates–used to enhance the functionality of food storage products made of plastic or metal, that may seriously impair  the function of endocrine, neurologic, or metabolic function.  The American Academy of Pediatrics feels that the Food and Drug Administration needs to take additional steps to “raise its game” with respect to these and many other additives. Some of the steps recommended include update and strengthen the “generally regarded as safe (GRAS)” process, prioritize retesting of previously approved agents, leverage expertise across agencies to streamline communication for better policymaking, dedicate more resources ($) to the effort, expand the scope of research and testing, and expand efforts at transparency of information for the public.

Under the current federal Administration, the present priority is clearly in the opposite direction towards cutting back on research and regulating these products as they feel that those steps are burdensome to industry and thus a drag on economic development and job creation.  I will limit my political commentary about that here to pointing out that generally the AAP does not agree with that priority and feels that children’s health is placed at risk by that approach.  Suffice to say that it is unlikely that we will see these policy preferences, as expressed by the AAP, become reality any time soon. Thus it is left to us to take the initiative to shield children from exposure to these potential hazards.  Keep the following in mind:

  1. Prioritize consumption of fresh or frozen fruits and vegetables when possible and support that effort be developing a list of low cost sources of that type of produce.
  2. Avoid processed meats, especially maternal consumption during pregnancy.
  3. Avoid microwaving food or beverages (including infant formula and pumped human milk) in plastic
  4. Avoid placing plastics in dishwashers.
  5. Use alternatives to plastic, such as glass or stainless steel, when possible.
  6. Check the recycling code on the bottom of products to find the plastic type, and avoid products with recycling codes 3(phthalates), 6(styrenes), and 7(bisphenols) unless they are labeled “biobased” or “greenware” indicating that they are corn based and do not contain bisphenols.
  7. Encourage hand washing before handling  foods and/or drinks, and wash all fruits and vegetables that cannot be peeled.

Bottom line: be aware that as a matter of public policy in the present environment it is largely up to you to monitor the safety of the products used for your children.  Keep that in mind during future political campaigns.

Thanks for following.

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Toys and learning

Kind of “a day late and a dollar short” after Christmas–let’s discuss best toys for child learning and development.  The American Academy of Pediatrics recently published new data on this (we are not directly addressing toy SAFETY here).

Firstly, if you like computers and tech–great.  However, recall that extended screen time has numerous disadvantages–limits imagination and creativity, can disrupt sleep and cause headaches.  To say nothing of expense! AAP guidelines suggest NO screen time < 2 years, 1 hour/day thereafter(excluding screen communication like Facetime with grandparents!).  Many of these toys claim to be “educational” but that is of questionable validity.  How are we defining the term?   Increased screen time may compromise impulse control, critical thinking, problem solving, and imagination (the program often does things for you) as well as language skills development.  Humans learn to interpret language in conjunction with cues like tone, volume, facial expression, body stance and position(“body language”).  Staring at a screen provides nothing here and may even inhibit that learning.  As so much of screen time is still a solitary endeavor it adds little to social interaction learning as well.

A related issue is “bells and whistles.”  Toys with lots of lights, sounds, actions/movements can be fascinating; but can do “too much”–distracting the child and preventing free imagination and creativity, again, doing those things for the player instead of the player doing it himself.  Often the fewer moving parts/components the better.

So what do good toys do?  Basic principles like cultivating good fine and gross motor function, language and social interaction skills are a good starting point.  It should allow her to play, explore, stimulate imagination and creativity, cultivate problem solving and critical thinking skills. Principles like “imitation” and “approximation”–aka “make believe” –mimicking adult daily activity and functioning skills are beneficial.

More specifics?  Blocks, shapes, balls of all sizes, push/pull/ride on toys promote gross motor development.  Puzzles, interlocking objects, toys with sand and water benefit fine motor skills.  Art objects are terrific–paint, crayons, colored pens and pencils, coloring books, play-doh, “silly putty”–provide endless possibilities to explore and create.  Traditional board games (“Chutes and Ladders”, “Candyland” checkers  for younger kids, “Monopoly”, “Clue”, “Life”, chess for older kids–lots of others) and old fashioned playing card games can enhance math, strategy, even team work as well as social exchange.  Imitation objects like tea and/or kitchen sets, make believe cleaning objects (brooms, vacuum cleaners),  toy tools, dress up objects, even SIMPLE action figures like toy soldiers and cowboys or dolls are flexible and versatile play enhancers/stimulators.

See?  Look how much you’ve done without logging on or using any electricity!

Bottom line? The key component to make a toy “educational” is YOU.  I always say–you are your child’s best teacher and their best toy.  So whether a computer or just a cardboard box–the more you engage, interact, participate in their play, the more educational the toy becomes.  Best of all-you’ll HAVE FUN, and create happy memories for you both while doing it.

Happy New Year to all, and thanks for following.

Discipline: Do’s and Don’ts

A “disciple” is a student, and “discipline” is “teaching”–not “punishment.”  Doing it properly is straightforward, but hard.  Implementing effective methods vary with a child’s age, development, and temperament.  Support for the statement “a good hard spanking is sometimes necessary to discipline a child” has dropped from 84% in 1986 to below 70% in 2012, and <50% of parents <36 years report EVER having spanked their child.

This is a positive trend.    The American Academy of Pediatrics officially opposes all forms of corporal punishment(CP)–parents should NEVER hit, slap, threaten, insult, humiliate, or shame their child.  There is sound reason for this.  A 2016 study found no evidence of long term benefit to the child from CP and only one study from 1981 could demonstrate any short term advantage.  A 1998-2000 study of >5000 children showed increased aggressiveness among 3 year olds subjected to CP with increased externalized behaviors and lower vocabulary scores by 9–they acted out more and communicated less.  Other studies associate depression in either parent with more negative appraisals and increased frequency of CP.  And there were these increased risks:

  • physical injury
  • more negative parent/child interactions
  • increased–not decreased–levels of defiance
  • mental health and learning disorders
  • child abuse
  • conduct problems in adolescence
  • adverse events(suicide, substance abuse) in adults

There were even biologic consequences–decreased brain volume(both white and gray matter) as well as higher cortisol levels (toxic stress hormones).

So what does work? Basic principles for younger children, but with applicability across the age spectrum include:

  1. “Show and tell”–explain “good” behaviors.  Note that this should be done at a “calm time”–when parent and child’s tempers are under control–NOT when the offense has just occurred and everybody is upset.
  2. Consequences should be clear, relevant, and explained at the same time and in the same way–calmly, when things are under control.  Emphasize the situation and not the child (“if things go well/badly”–NOT “if you are good/bad”)
  3. Appropriate intervention–“the punishment should fit the crime”(so to speak).  Don’t overdo.  If the child breaks something they must make restitution–simple. The intervention should have a beginning, middle, and END. Adjust attitude and MOVE ON.
  4. Say what you mean and mean what you say.  Threats are counterproductive, especially when not fulfilled.  “If you don’t hurry we aren’t going to Grandma for Christmas.” STUPID–you ARE going to Grandma’s, of course.  So you cannot back up that statement.  You just lost the battle, and the war. The kid now KNOWS he can call your bluff. And threatening the same thing repeatedly without desired result is similarly foolish–if that intervention did not produce success before, time to think of a new strategy, not just repeating the same thing LOUDER.
  5. Never lose an argument: don’t start something you cannot finish. Example–you cannot make her eat, so don’t endlessly argue over it.  But she cannot make you give her dessert, so when she melts down just ignore her, saying “tomorrow if you eat a good dinner you can have dessert.”
  6. Be prepared–many adverse behaviors are predictable.  You often know when/where they will misbehave.  Yelling and hitting is usually a tantrum on the parent’s part. Know what you are going to do when it happens, explain it (as above) and then calmly implement it when necessary. This is CONTROL.
  7. Ignore tantrums–NEVER try and”get them out of it.”  You cannot–they are unreachable then.  Put the child in a safe place(playpen, bedroom)–“when you calm down we will talk.” Let it blow over.  Then deal with the problem.
  8.  Nobody is perfect about discipline, and everyone will do better and worse at times.  It’s a daily process. So do your best, every day.

Finally–perspective, and humility.  They are children; misbehavior happens. They’ll NEVER be as perfect as we were back then, right? Just ask Grandma!

Thanks for following.

Holiday Safety

Happy Holidays to all! As a Jewish American, I still, like everybody else, so enjoy seeing all of the holiday decorations coming out. Who doesn’t get excited about this time of year?

Let’s review some highlights for indoor holiday decoration safety.  My advise about outdoor decorations is actually very simple–the younger the child, the less involved in the decorating process, the better.

  1. Trees
  • if using “artificial” make sure they are “fire resistant”
  • For live trees–fresh trees are green, have some sticky resin on the trunk, needles don’t snap in half when bent and don’t fall off if the tree is shaken.
  • Cut off approximately 2″ from the base and keep in water
  • Keep away from fire or heat source like heaters, radiators
  • Keep away from traffic areas like doorways.
  • Secure to walls with thin wire for stability

2. Trimmings

  • use only non-flammable
  • avoid sharp or breakable objects
  • avoid leaded materials (note–besides patriotism, “Made in America” is usually, but NOT ALWAYS, best)
  • Avoid small parts
  • avoid artificial candy or food

3. Candles

  • Keep away from trees
  • Keep away from paper
  • Non-flammable holders
  • Extinguish all flames if you go out or retire for the evening (this means YOU, fellow Jews celebrating with the Hannukah menorah!)

4. Lights

  • Check for broken or cracked sockets
  • Check wires
  • Never use electric light on metal tree–the tree can conduct electricity causing shocks or fires
  • Shut off all electric ornaments upon retiring for the evening
  • Do not overload sockets–no more than 3 standard light sets per extension cord

5. Paper

  • Don’t keep paper by open flame like fireplace or candles (DUH!!)
  • Do not burn used wrapping paper in fireplace

6. Spun glass–“angel hair” decorations of sprayed artificial snow can be inhaled and              cause serious lung injury

7. Poinsettias are poisonous–is it really necessary to include them in decorating your              house when there are young children around?

Bottom line that I remind all patients : Christmas decorations, and in particular, the tree, are the definition of “attractive nuisance”–little kids are drawn to them.  I mean–that’s the point, isn’t it?  So you cannot keep the child away from the tree.  You must endeavor to keep the tree away from the kid.

Please keep all of these things in mind.  And let’s make this the Happiest and HEALTHIEST Holiday Season yet!!

Send along questions and comments and thanks for following.

 

Safety Update

Let’s take note of 2 consumer products with troubled safety records for children.

The first is instant soup/”ramen” noodle preparations for microwave ovens.  An 11 year study finds that 20% of all scald burn injuries presenting to the ER, 9500 children aged 4-12 each year, are caused by microwaved soup containers.  The peak age is 7 years; girls make up 57% of injuries.  Most burns occurred when the small package was opened after heating, spilling contents on the child, causing burns to the torso (40% of all injuries).  The added water can quickly overheat and when tipped over can cause a scald wound.  While most incidents result in only mild burns with full and uneventful recovery, still up to 10% were more severe, including those requiring scar management and skin grafting.  So prudence is still the order of the day.

The authors recommend that improved product design, like smaller opening and wider base, will help to limit risk here.  But, of course, there is no substitute for common sense: Don’t let younger children handle these products; close supervision for adolescents. Counsel them to focus on the task at hand–PUT THE DARN PHONE DOWN when using microwave and handling hot food.

The other warning references hover boards.  Between 2015-16 researchers report almost 27,000 youth injuries treated in US Emergency Departments.  As one might expect, boys predominate here (52%) wth peak incidence at age 12.  Most injuries involved the upper extremity(34%) with fractures making up 40% of those problems; head injuries were second  but the most common to result in hospitalization (14%). Burns from the board spontaneously catching fire was actually a rare occurrence.  A frequent risk factor was “multitasking” involving–you guessed it–the child trying to use a smart phone or listen to music while operating the hover board.  Wouldn’t it be at least a small  welcome change if reading a book while hover boarding caused some of this problem(sorry, couldn’t resist)?

One added comment: this same study reported >120,000 skateboard injuries in the ED over the same 2 year period; 75% of those among boys.  One word: HELMETS!!

Send along questions and comments, and thanks for following.

The Measles Outbreak

By now I hope most of you are aware of the evolving measles outbreak right here in Ocean County--4 confirmed cases SO FAR.  The “index (first) case” is an unimmunized child who contracted measles while visiting family in Israel. That nation itself has its own epidemic–1200 cases in 2018, including the death of an 18 mo old, the first Israeli measles fatality since 2003.  Israel’s public health system is state of the art and had previously maintained strong 2 dose compliance but recently has seen its immunization rate slip, mostly among a few groups of ultra-Orthodox worshippers. That problem has been imported to Rockland County NY and now here.

We should pause and note that this is becoming something of a worldwide phenomenon–its happening in Europe too.  In 2018 there are 41,000 cases of measles SO FAR including 41 deaths.  We can all recall other recent outbreaks–2013 383 Amish children in Ohio,  2014 starting with an un-immunized child in Disneyland in California, and in 2015 among un-immunized Somali immigrants in Minnesota.  Furthermore, latest data here in the US are that the rate of un-immunized children, while still low,  has quadrupled in the last 15 years–from 0.3% to 1.3%. It is also important to recall statistics from prior to measles vaccine licensure in 1963.  In the preceding decades, virtually all Americans contracted measles in childhood (3-4 million cases) with 48,000 hospitalizations, over 1,000 children with encephalitis complications and 400-500 deaths every year.  By  2,000, US measles was essentially eradicated, with no instances of epidemic spread reported domestically anywhere.

So, unfortunately, it would seem that this developing problem is very predictable and largely self inflicted–we are doing it to ourselves.  We have taken note of the effects locally of  recent social media posts which are very emotional, very sympathetic, but also very wrong.  Additionally, the current infected Ocean County individuals–and large segments of the so called “anti-vaxxers”– site “religious exemptions” as their justification.  But a review of established US religious groups demonstrates only one smaller denomination–Dutch Reformed–which includes vaccine refusal as an accepted tenant of faith.  All other groups official position is to actively encourage their congregants to be immunized.  So this rational is simply untrue; its mostly a myth.  Their is essentially NO organized US religious group basis to decline to immunize.

But here we are in 2014 and, like “Poltergeist”–“their BA-ack…”  I urge you all to keep these things in mind the next time someone tries to convince you of the “dangers” of vaccines.

Thank you for following.

 

 

Formula Feeding Your Baby

Let’s really go back to the very beginning and review some basics of baby formula preparation.  Of course, we pediatricians still advise that the best infant nutrition is breastfeeding, but at some point most babies’ diets will likely include some formula.   The AAP recommends the following:

  1. Prepare the formula according to the manufacturer’s directions ONLY.  DO NOT dilute the formula (to save money) or concentrate it (to increase calorie concentration).  Both can cause diarrhea at least and sometimes disruption of blood electrolyte levels like sodium and potassium which can lead to severe problems with normal nerve or heart function.
  2. Make sure the water source is safe.  If your home has well water, it’s best to boil the water for 1 minute (“rolling boil”) and then allow 30 minutes to cool before mixing your formula.
  3. Be careful to maintain proper formula temperature.  Use a bottle warmer or place the bottle in a container of hot water for 5-10 minutes.  It is best not to microwave the bottle.  Microwaving can heat the insides of any container in an uneven fashion which can cause burns, and also it can disrupt the nutritional value of some formula ingredients.  At any rate, its best to always check the formula temperature on yourself prior to giving it to the baby.
  4. “Cleanliness is next to Gdliness.”  Always wash your hands prior to preparing or feeding your baby.  Wash all countertops and surfaces carefully.  A dishwasher will not clean the inside of a long, thin bottle very well, so wash by hand using a bottle brush for the inside.  Bottles and nipples should all be cleaned with hot, soapy water and be sure to rinse all soap off thoroughly.  By the way, best to boil nipples for approximately 10 minutes prior to using for the first time.  This is not for cleanliness as much as to boil off residue of chemicals used to soften the rubber.
  5. Be aware of proper storage times.  All leftover formula should be discarded 1 hour after feeding to the baby.  Powder based preparations can be refrigerated for 24 hours; bottles of unused concentrate can be refrigerated for 48 hours prior to usage.

As stated initially, breastfeeding is still best and what I and all pediatricians recommend as the first line nutritional source for your baby’s best health.  This seems like a good place for me to give a shout out to Dr. Rose St. Fleur and my colleagues at the Center for Breastfeeding at Jersey Shore Medical Center.  They can be reached at 732-776-3329 and are an excellent resource/clearinghouse for questions from nursing mothers.  Tell them Dr. G sent you (they won’t care).

Thanks for following.