Category Archives: Children

Here are all articles pertaining to children’s health and wellness.

Childhood Obesity: What Can We Do?

It’s no secret that children all over the world are putting on too much weight; in the US, an astonishing 1/3 of children are overweight or obese.  Being overweight as a child can lead to many diseases as an adult, including heart disease, diabetes, arthritis, high blood pressure, and some cancers. Also, overweight kids have lower self-esteem and higher risks for depression. So what can parents, or society really do to stop this epidemic? And how can family doctors and pediatricians help?

The first step parents should take is to find out where your child fits on a Body Mass Index (BMI) chart. Your doctor should be doing this at the well-child exams, but you can easily find childhood BMI calculators online (such as this one) and find out yourself. A child above 85% is considered overweight, and above 95% is obese. Many parents are surprised at finding their child is officially overweight or obese, which is why these objective BMI standards are important for tracking, as well as assessing progress.

There are quite a few weight loss approaches that most doctors can agree on; one major agreement is that diets almost never help, at any age. Any diet plan designed for quick weight loss is almost guaranteed to long-term failure, and many people frequently end up even heavier than before. The healthiest option is always slow and steady weight loss. One pound a week of weight loss for many children, from very conscious changes in diet and exercise routines, is appropriate.

Another major approach involves cutting back on TV time. The American Academy of Pediatrics just published a major policy statement stating that “the evidence linking excessive TV viewing and obesity is persuasive“. They specifically recommend a ban on junk- and fast-food advertising in all children’s TV programs, and they set specific limits of TV time for age groups. They also detail multiple studies showing how having a TV in the bedroom is another independent risk factor for obesity, both as a child and later as adults. They also recommended that “pediatricians need to ask 2 questions about media use at every visit: 1. How much screen time is being spent per day? and 2. Is there a TV set or Internet connection in the child’s bedroom?”

One approach I mentioned before was to have a good breakfast. Many studies have shown that eating a nutritious breakfast is crucial for a child’s physical growth and school performance, and that breakfast-skippers actually end up more overweight, both in childhood and later as adults.

Of course, the main treatments for obesity are the obvious: more exercise and eating proper foods in moderate amounts. It’s important that there be a family effort to help your overweight child lose weight. Parents also need to lead by example; it’s much harder for a child to lose weight if their parents are also overweight and don’t exercise. As for diet recommendations, the most obvious choices to eliminate are sodas and fruit drinks. Sodas truly have almost no redeeming value, especially for children. Any child drinking a daily soda is adding extra pounds of fat each year, and they are also increasing their risk for diabetes as well as teeth problems. Most fruit juices are also quite poor substitutes for natural fruits and should be used at a minimum. For exercise, most kids should be getting 60 minutes a day, but this can be broken up into multiple sessions. The key is finding something they love to do. And don’t forget that any exercise is better than nothing!

 

Another effort involves reviewing the foods at school. I recently heard the great news that milk producers in America reformulated their flavored milk to have 1/3 less sugars and calories. Many (but not all) nutritionists consider this a positive step, as schools that totally eliminated flavored milk encountered a large drop in milk drinking, which raises the risk of kids not getting enough nutrients such as calcium. What does your school do?

Parents who want to learn more about childhood obesity and how to fight it can find excellent resources at the website healthychildren.org, which is officially run by the American Academy of Pediatrics. And at familydoctor.org, the American Academy of Family Medicine also offers many tips on weight loss for all ages.

 

This post was originally published on my new blog at MyFamilyHealthGuide.com. Please follow my new blog! (and my Facebook page

Curing a Cough: What’s the Best Medicine?

Coughing from a cold or flu is probably the most frustrating symptom we can have — for children, their parents, and even the doctor treating them. Why? Because there’s honestly very little that we can do to treat it. That’s a hard pill to swallow, and it’s especially humbling for me as a family physician. But it’s also very frustrating for me as a father of two toddlers, as they just started daycare and are fighting new viruses every week. As we comfort them at two in the morning with a hacking cough, I’ll face same question from my wife as from parents in my clinic: “which cough syrup should we use?

First, it’s important to note that a cough is generally a good thing. It’s our body’s natural attempt to get germs and toxins out of our bodies, so it’s not such a healthy idea to suppress the cough too much. Of course, a cough can become too severe, or painful, and lack of sleep isn’t good for anyone’s immune system. So in terms of that, I think it’s reasonable to try something safe. But it’s clear that no matter what you use, nothing makes a cough completely go away for more than a couple of hours. And it’s also important to note from the graph below that the cough is always the last symptom to get better, and may linger even for a couple of weeks:

a graphical image and time line for cold symptoms

Having said that, I’d like to help you cut through the confusion at your pharmacy and make this simple: don’t bother with almost any of the OTC cough syrups. First, try some honey.

Your pharmacy shelves have a bewildering assortment of cough and cold medicines. It’s confusing for me as well, even with my training! Overdosing is quite a problem, especially for children. In fact, drug makers in 2008 voluntarily changed their warning labels (with a gentle push from the FDA), pulling off the shelves all cough medicines used for children under two years old, and changing warning labels to say “do not use in children under 4 years of age” (you can read the FDA statement here). The American Academy of Pediatrics is even more strict: no OTC cough medicines for any child under 6 years old, and caution from ages 6 to 12. The major concern has been the number of overdoses, even deaths, in children taking too much of these medicines — especially acetaminophen, otherwise known as Tylenol, which is added for pain and fever relief. In a proper dose it works wonderfully, but in high doses it causes liver failure.

Not only are these medicines potentially dangerous, they also barely work anyway. For example, the decongestant phenylephrine, which is now in almost every combination medicine, is no better than placebo in the best research results. In other words, there’s a good reason your runny nose isn’t getting better — it’s because the medicine doesn’t work. This medicine a couple of years ago replaced the far more effective drug pseudoephedrine — but this is now only behind the pharmacy counter, because people were buying pseudoephedrine-containing pills in bulk and cooking it down to make methamphetamine. So if you really want sinus relief, you have to ask the pharmacist for pseudoephedrine. It’s still OTC, so you don’t need a prescription from your doctor, but you’re only allowed two boxes.

The bright side to all this is that the most useful cough syrup may be in your home right now. It’s honey! A Cochrane database review from 2014 showed that honey helped better than dextromethorphan and also diphenhydramine for cough frequency, severity and quality of sleep, for children and their parents, with minimal side effects.

My advice for a cough in different age groups is as follows:

Age one and under: no OTC syrups are safe, including honey, which carries the risk of botulism. The best advice is to take care of the cause of the cough, often from post-nasal drip, by using nasal saline drops or spray. A bedroom humidifier can also help if the room is too dry, especially in cold winter nights. Probiotics also can be helpful, as a growing number of studies are showing their effectiveness in reducing duration of a cold, less severe symptoms, and less time away from school or work. The best research is on bifidobacteria and Lactobacillus GG probiotics. Also, don’t forget to get the annual flu shot for any child over 6 months of age. If they’re younger, they’re vulnerable to get the flu — which is why it’s even more important that all caretakers and family members get the annual flu shot, so they won’t pass along the flu virus to the baby. Coughing can also cause pain from a sore throat or rib inflammation, so if your baby is fussy but has no fever, they may be in pain, so don’t be afraid to give them ibuprofen or acetaminophen syrups for comfort (and better sleep).

Ages 1-6: I think honey or honey-based herbal mixtures (not homeopathic) should be the first choice for a cough. Probiotics should also be used during the illness. Taking care of nasal congestion often can help decrease a cough, again including the safe remedy of nasal saline rinsing. As a second choice of syrups, a cough syrup containing only dextromethorphan could also help a bit, as was shown in that Cochrane review from 2014. This medicine is the “DM” part of many labels.

Ages 6-12: Again, honey-based syrup is not only the most effective but also the safest choice. At this age, the risk-benefit ratio of other treatments becomes more favorable, including my favorite nasal decongestant combination: pseudoephedrine pills and oxymetazoline nasal spray. Probiotics during the illness also are helpful. But don’t forget that many doctors would still be hesitant to recommend any OTC medicines until 12 years of age. Also, while the oxymetazoline nasal spray works rapidly for nasal congestion, never take it for more than 5 days in a row, otherwise you can develop rebound nasal congestion and could become dependent on it (we call it “Afrin addiction”).

Ages 12 and up: We’re finally at the “adult” age where most OTC medicines at least are safe to use, whether or not they’re effective. I would still stick with honey syrup, and the decongestants as I mentioned above. Again, don’t forget about probiotics. Also, don’t forget about common sense items such as a healthy amount of sleep, as well as foods full of antioxidants, and light exercise to boost your immune system. In terms of natural medicines, elderberry syrup has some evidence to help decrease symptoms of the flu.

Ages 65 and older: Here we start getting cautious again with OTC medicines, as many might have unwanted side effect combinations with the prescribed medicines for chronic diseases that many elderly people take. As we get older, we can’t fight off infections as well as we could when younger. So it’s important not to get sick in the first place — with the annual flu vaccine, as well as the pneumonia vaccines. If you do get a cold, some OTC medicines may cause more side effects in the elderly, such as dangerously high blood pressure from pseudoephedrine, or confusion, urinary retention and lethargy from diphenhydramine. I would focus on honey or dextromethorphan syrups, and nasal saline spray for a decongestant.

Which OTC medicines don’t work at all, at any age? I would advise not to use any homeopathic remedies, such as Oscillococcinum or Zicam, which may seem appealing to many but literally have no evidence of effectiveness, as you would expect from a product which by definition has zero molecules of any active drug. The FTC recently issued an enforcement requiring homeopathic labels to state ” (1) There is no scientific evidence that the product works and (2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts.” And it’s also dangerous to assume that homeopathic medicines are safer, as noted by this winter’s warnings by the FDA against homeopathic teething tablets, which tests show may have toxic amounts of belladonna, and which could be related to ten deaths of infants. Clearly this is a case where the risks far outweigh benefits.

For more information about treating the common cold, you can read my family practice academy’s parent handout about treating the common cold in children ; and more articles about the common cold at my wellness blog at MyFamily Health Guide.


Follow me on Facebook at Bainbridge Baba Doc. Website: www.myfamilyhealthguide.com. 博客: http://meiguoyisheng.com/

Digital Media and Children: Not All Screens Are Equal

 

I knew it was inevitable, but I was hoping to delay it a bit longer: my son Alex has discovered the digital world. Almost two years old, he’s increasingly fascinated with mommy and daddy’s smartphones, tablets, and laptop computers. As I help him drag Curious George toys on an iPad app to complete a puzzle, I feel a pang of guilt knowing I’m breaking a taboo to have no screen time of any type for any child under two (and two hours maximum total screen time for older children), policies long recommended by the American Academy of Pediatrics (AAP) and the Obama administration, among others.

Am I already ruining his chances to go Ivy League?

This hard and fast two-hour policy, beaten into parents’ brains by their pediatricians, troubles me and many others partly because it was last updated in 2011 before the astounding boom of tablets, smartphones and touch screens among both kids and adults. The policy warnings had focused very reasonably on TV and its clear long-term harms to healthy development in kids under two—especially harmful when passively watching non-interactive, non-educational TV.

But such traditional passive TV watching, while still the dominant form of media consumption for most children, is rapidly becoming meaningless for many. Clearly, an interactive video game that parents and toddlers are playing together or watching family vacation videos on a smartphone can have huge value compared to zombie-like staring at an episode of Spongebob or China’s popular Pleasant Goat (喜羊羊) cartoons—these kinds of shows are shown in studies to harm a young child’s executive functioning, a prefrontal brain skill set including memory, attention, and setting goals.

Not all screens are equal, and guidelines need to be updated to reflect these differences.

The policy also doesn’t reflect the reality on the ground: a recent survey of parents by Common Sense Media shows that toddlers under two are spending almost one hour a day using screen media anyway. This is why, in my own efforts to offer better advice to my patients as well as myself and my wife, I set out to find the most recent research that focuses on digital media with young children.

Teachers are an obvious source to assess what’s working for children’s education. In a Joan Ganz Cooney Center 2013 survey of 694 American teachers of kindergarten to eighth grade, most teachers (74%) reported they were already using digital games as part of their classroom teaching. A great majority (78%) thought that digital games were improving student mastery of basic curriculum (especially math), and 71% agreed that they helped with extra-curricular skills such as critical thinking, collaboration and communicating. Only 21% thought that digital games in classrooms led to behavioral issues.

We often, and by default, assume that video games are inherently antisocial and couldn’t truly be healthy for our society. But much research has shown that many of these games are quite the opposite, actually helping to foster social skills such as empathy, caring, and sharing. I encountered the term “prosocial” quite often in the new research, and I think it’s a powerfully evocative word to help understand digital media’s positive potential.

An impressive study published last August in Pediatrics, surveyed 5,000 children ages 10 to 15 and found that those who played video games up to one hour a day had higher levels of life satisfaction, prosocial behavior, and behavioral control compared to those who played no games. The study also showed that playing too much (more than three hours a day) had the opposite effects. Another main point was that both positive and negative effects were actually quite small.

It’s also helpful, and important, to distinguish between types of screen time. Passive TV watching is clearly the worst type of screen time. An excellent review published last year in British Medical Journal surveyed 11,000 mothers in the UK and compared whether TV and electronic game use in five-year-old children led to behavioral issues when they reached seven. They found that excessive TV (or DVD) watching (over three hours) led to worsening social behavior, conduct, and hyperactivity, compared to light TV watching, under one hour a day. And light video game playing also showed improved social behavior compared to no playing.

I still generally agree with most of the AAP’s family media plan advice, especially no TV ever in bedrooms and no screens at certain times of the day, including during meals, and screen time limits depending on age. With children under two, I definitely believe that screen time should never be spent alone: kids always benefit more from any activity when parents are playing along.

Even more practical advice about which digital media may be helpful or not is in the outstanding website from non-profit Common Sense Media. The site has a handy list of best apps for preschoolers, along with very practical ratings including quality, learning potential, positive role models, ease of play, and consumerism. This is where I discovered highly rated apps like Busy Shapes, which I’ve played with Alex and has positive developmental benefit—but still probably isn’t nearly as beneficial as an old fashioned wooden puzzle set. I tried the e-book version of Dr Seuss’ My ABC Book, but he ignored the lovely rhymes and kept tapping to hear the noises (some, but not all, research does show that e-books are often inferior—as children who focus on the distracting technology absorb and understand less of the story).

For all the redeeming qualities of interactive screen time, however, what is clear to me after all my research is that even a highly-rated app or video games could never be as stimulating or educational as actual 3D games. Stacking, matching, reading books—all of these flat 2D-screens just can’t compare to a pile of crayons, wooden blocks and Legos. But I’ve also decided that Alex, at 21 months, can continue to dabble in some digital media. My wife and I haven’t watched traditional TV in many years and only use it for DVD or ad-free TV shows, and we always keep the kids away from this passive exposure. In all cases, we still limit total time to far below one hour a day, and almost none of it is ever unsupervised.

I think we’re doing a pretty good job in this new digital world. Screens are an ever-rapidly essential and inescapable part of modern and future life, and with a bit of evidence-based guidance, our kids will be just fine.

 

© 2014 Richard Saint Cyr, as first published on Quartz

What’s The Best Bedtime For Kids?

baby sleeping on big pumpkin

A good night’s sleep is crucial for all of us, but especially for children. My Alex is now 17 months old and is pretty good with his routine, being put to bed at 8 pm and usually waking up around 7:30 am. Along with a nap or two, he easily gets his recommended 12 hours a day of sleep. But our upstairs neighbors’ toddlers are bouncing on our ceilings until at least 10 pm most nights. Many Chinese parents tell me their child goes to bed at 9, 10 or even 11 pm — much later than the typical children of my expat and American colleagues. What explains this cultural difference, but more importantly — is either one healthier for a child?

One study from 2005 confirmed my personal observations that Chinese children not only go to sleep later than American children, they also wake up earlier. This comparative survey showed that Chinese children in elementary school sleep a full hour less than American children (9.25 vs. 10.2 hours); more worrisome were the Chinese children’s complaints of daytime sleepiness.

The main issue isn’t so much what time your child goes to bed: more importantly is their total amount of daily sleep, including naps (which very few children over five years take). Sleep research has shown that preschool-aged children need 11-12 hours, while school-aged children need at least 10 hours, and teens need 9-10 (infants need 16-18, and adults need 7-8). If your five year old is going to bed at 9:30 and waking up at 6:30 and already no longer takes naps, then their 9 hours a day of daily sleep isn’t enough for their long term health.

One of the main problems with insufficient sleep is the daytime sleepiness, an obvious consequence of not sleeping enough. A fascinating series of tests in children in China just published this year showed that insufficient sleep and daytime sleepiness both lead to worse school performance. Most of these children went to bed at 9-9:30 am and almost all got up at 7 am, causing a daily sleep debt of 1/2-1 hour for many children. While that may seem like a small amount, like any debt, it must be paid back, and most children cannot recover all of this lost time by sleeping late on weekends. Over time, this cumulative sleep deficit causes problems with attention spans, motivation, and also achievements on tests. Researchers hypothesize that the brain’s prefrontal cortex, which processes attention, creative processing, motivation, and abstract reasoning, is especially vulnerable to poor sleep. They conclude that “our results provide a cautionary tale for the practice in Chinese society that children spend a lot of time on studies even with the sacrifice of sleep time.”

One good bit of news from the same study describes how delaying school start times even by just a half hour can significantly improve sleep duration and daytime sleepiness. In their interventional study with six primary schools in Shanghai, delaying school openings from 7:30 to 8 or 8:30 gave the children almost an hour of extra sleep — and more importantly, less complaints of daytime sleepiness. This fits with studies in other parts of the world and supports the growing movement, led by pediatricians, to delay school opening times to 8:30 am. Just doing this could allow better sleep and improved test scores for all students!

Besides school performance, poor sleep also leads to an increased risk of overweight and obesity in children (as well as adults). A 2007 meta-analysis of 36 studies across the world showed a strong, independent association between short sleep duration and weight gain in children, which continues into adulthood. One study of 500 adolescent twins in Anhui, China showed an association between less sleep and more weight gain. Another survey of over 4,000 children in rural northeast China found that obese children were more likely to have insufficient sleep (less than 7.5 hours, including naps). While this isn’t a cause-and-effect, the association certainly is worrisome. There may actually be a physiological base to this, as research shows that inadequate sleep causes changes in the hormones which control appetite. Less sleep leads to less leptin and more grehlin, which increases our instinctive hunger reflex. Since the obesity rate in Chinese children is rising alarmingly, I think all parents at least should consider proper sleep in this context.

I can’t control the noisy kids upstairs, but in my own home I’m happy that we’ve taught Alex good sleep patterns, and we have plenty of leeway for 8:30 or 9 pm times if needed, all the way until his teen years. And when we choose schools we would definitely consider later start times as a positive factor.

 

UHT Milk: Is It Safe — and Nutritious?

uht

When I moved to China eight years ago, I was quite shocked at seeing milk in small boxes piled high on store shelves — at room temperature! With expiration dates longer than six months! How could this be safe — and nutritious? Like most other Americans, our milk was bought and sold at refrigerator temperatures, and kept fresh only for a week or so.

One of the greatest public health advances in the modern world is pasteurization. All milk must be sterilized after being delivered from the cow (or sheep or goat), mostly to kill dangerous bacteria and spores that otherwise can seriously harm and even kill people. To kill the pathogens, milk is exposed to high heat at specific lengths of time — this is called pasteurization, named after the famous 19th century French scientist Louis Pasteur. Heating not only kills pathogens but also slows down spoilage, which is triggered by other sets of bacteria.

Pasteur’s heating technique doesn’t kill all bacteria, which is why it must be kept cool and used within a couple of days after opening. Normal pasteurization heats milk to around  70 – 75 °C for 15 seconds, — but the newer technique heats at up to 150 °C for 5 seconds. This is why it is called ultra-high temperature (“UHT”) milk, which is what you see written on these cartons. At such a temperature, all harmful pathogens, including spores, are killed, as well as the enzymes which could spoil the milk, which is why you can keep at room temperature for months. The milk also goes directly into the container after heating, which eliminates possible contamination.

Pouring milk in the glass on the background of nature.

But what about nutrition — surely this higher temperature must destroy vitamins and other molecules? While there are some very minor changes, all of the major governmental and nutritional sites I’ve seen, including the US CDC; the European Union; and New Zealand all state the same essential facts, summed up by the US CDC: “all of the nutritional benefits of drinking milk are available from pasteurized milk without the risk of disease that comes with drinking raw milk.” And while I’ve read reports that milk’s enzymes are damaged even more with UHT processing, as the US CDC again summarizes, “the enzymes in raw animal milk are not thought to be important in human health.” 

Most Europeans will find my initial hesitancy of UHT milk quite amusing, as it’s become the popular choice in most EU countries for many years. In China, almost all milk in stores is still the traditional pasteurized milk sold from the chilled containers, with UHT mostly still only available as imported brands in expat and upscale supermarkets. Fortunately, this UHT milk is now easily available on all major shopping websites for home delivery anywhere in China.

I have many patients and online readers, both expat and local Chinese, who are desperate to find quality milk sources ever since the melamine scandal of 2008 — especially for their children. My response to all is that UHT milk is a great choice — especially imported, and why not get organic as well!  Such milk certainly is a far better choice for toddlers than toddler formula, which has no medical indication from any pediatric groups anywhere for its preference over milk.

I drink imported organic UHT milk mostly as a food safety precaution, but I also feel very reassured that my toddler son and family are all drinking milk 100% free of pesticides, heavy metals and growth hormones, from cows fed on grass in healthy organic farms. Given all the constant uncertainly here with food safety scandals, why not have some peace of mind with your milk?