Preventing Birth Defects with a Healthy Diet

     Recent research published in the Archives of Pediatrics & Adolescent Medicine showed that a high-quality diet during pregnancy lowers the baby's risk of neural tube defects (such as spina bifida) and cleft lip and palate. Take a prenatal vitamin when you are trying to become pregnant and throughout the pregnancy. And eating a healthy diet is important.
     A healthy diet should include (1) a variety of fruits and vegetables, (2) dairy and calcium-rich foods, (3) lean protein (lean meat, fish, eggs, tofu, beans, and peanut butter), (4) breads and grains, and (5) iron-rich foods (lean red meat, poultry, fish, breakfast cereals, nuts, and dried fruit).
     Vitamins are important during pregnancy and these vitamin-rich foods help the babies growth and development: (1) Folic acid is a B vitamin that prevents the serious abnormalities of the brain and spinal cord called neural tube defects, including spina bifida. Cereals, leafy vegetables, and beans are all good sources of folic acid. (2) Vitamin C is in many foods, including oranges, grapefruit, strawberries, honeydew melon, papya, broccoli, cauliflower, green peppers, tomatoes, and brussel sprouts. (3) Vitamin D helps a baby have healthy bones and teeth. Good sources of vitamin D include fatty fish (salmon and tuna) and fortified milk or juice.
     The Mayo Clinic's website has helpful information about this topic here.

Kelch-Teller Syndrome

     Over the years, Dr. Lisa Kelch and I have noticed many cases of "pull-up dermatitis" in our office. Although we see it commonly, after a literature search a few years ago, we realize it is not something previously mentioned in the medical literature.
     We note that quite a few 3-5 year olds who are wearing big kid underwear during the day but still wearing a pull-up at night will have a rash on their bottom. It is often rough small to medium sized reddish bumps. They sometimes can itch but do not always. They seem to completely disappear when the pull-up is no longer worn at night as the child gets a little older.
     Although it seems as if changing to a different brand of pull-up would help, it rarely seems to help. We have found that doing a layer of Aquaphor(r) Healing Ointment at bedtime helps. It also may be needed again in the morning. If that does not help the itching, doing a thin layer of 1% over-the-counter hydrocortisone cream in the morning every few days can help.

Sunscreen

     As your children become older, their growing independence means we have to rely on them remembering to take care of some of their daily needs. One of those regular needs I want to remind you about is sunscreen. Although the current generation of children is doing so much better than previous generations with regular use of sunscreen. A recent study (Pediatrics, February 2012, Dr. Dusza and others) showed that many preteens have had a sunburn in the past year. Preventing this sun damage helps prevent skin cancer later.
     Remind your children to regularly use sunscreen before times outside, whether hanging out with friends, going to the pool, or playing sports. The Spring sports season starts soon and it is a good time to get back into the habit of using sunscreen -- for tennis, soccer, baseball, and softball, field hockey, lacrosse, and all the other awesome Spring sports. Follow the directions on the package. It is best to reapply if out in the sun for a long time. Use at least a SPF of 30. Higher SPFs have not been shown to be "much better" (and can be more expensive). If the cost is the similar, using a higher SPF makes sense.

Getting your children to take medication -- part 1

     One of my sons has not been the best medicine taker in our family. We have struggled over the years, especially with getting him to take liquid antibiotics. I will post here my sons method and follow up this with another post sometime soon about other methods.
     I will be honest. Before I had children and then before my one son has been a difficult medicine taker, I thought families that struggle with this were "just not trying". But the truth is many children make taking a routine medication difficult. No medication is liked by all children. Sometimes it is the taste. Sometimes the texture. But I have certainly come to appreciate that getting a child to take their medicine is not a given.
     Through trial and error (plenty of error), my son has found this to work pretty well. We pour the medicine into a medication dosing cup. He sprinkles the top with of the liquid medicine with Nerds(r) candies. He often will then chew up a few Nerds(r) to "get the taste in his mouth". Then he quickly drinks the antibiotic (or other liquid medicine) and chews the candies that were on top. He often follows this with a few more Nerds(r) to "get rid of the taste".
     From discussing this method with other parents, I know others have found this helpful. I hopes this helps someone!

ADHD and diet

     Much has been written over the years about the affect of diet on ADHD. It can be a challenge to help children with ADHD and no treatment (medication, diet, supplements, etc.) works for or is right for everyone. There was recently an excellent review article about this topic in the 'Pediatrics' journal February 2012 issue. It was written by Dr. Millichap and Nurse Practioner Yee of Children's Memorial Hospital in Chicago.
     To summarize the big picture of this topic: there are options to try with supplements or modified diets; they work for some but not all children; it is hard to predict who they work for and who will tolerate the diet; overall side effects are rare with supplements or modified diets; and most children needed prescription stimulant medications to control their ADHD symptoms.
     Omega-3 and -5 Fatty Acid Supplements: Probably the easiest to try and certainly could help. Dose: Nordic Gummie Bears (3 per day) or Nordic Fishes Chews (3 per day) or Nordic ProEFA (2 seoftgels per day) or Nutrigold Softgel (1 per day). They should be used for at least 2-3 month, longer if needed.
     Feingold Diet or Oligoantigenic Diets: A small group of children with ADHD symptoms respond well to these elimination diets. They are difficult to pull off (months of avoiding milk, cheese, wheat cereals, egg, chocolate, nuts and citrus (Oligoantigenic) or avoiding apples, grapes, lunch meats, sausage, hot dogs, and cold drinks with artificial flavors or colors (Feingold)). You and your child may benefit from meeting with a dietician to follow one of these diets. They certainly require patience and perseverance.
     Food sensitivities or allergies: Although a few children respond to avoiding certain foods, allergists will tell you this is not a likely help unless there is a very specific worry that "he is fine unless we eat this food and then things are a disaster". Also, avoiding sugar or artificial sweeteners in children with ADHD only needs to be done if you clearly notice that the child's behavior is worse when they have more intake of these. Otherwise, do not stress these.
     Iron or zinc deficiency: Although some studies have shown that children who are low on iron or zinc have ADHD-like symptoms, not enough has been done to help me feel strongly about investigating this (with blood work) or supplementing iron or zinc for the average child with ADHD. More studies are likely to follow in the coming years.
     I think this is a good summary of where we stand now with these issues. I hope this is helpful. If you have further questions about this, please discuss it with your physician.

New Prescription Lice Treatment

     Lice is a frustrating condition. I know it brings on a major "ick!" factor for parents and children. At the Hilliard Pediatrics website there is a protocol about lice treatment here.
     There is a new prescription only medication called Natroba (r) by ParaPRO. If the over the counter medications do not work, this is an option. Potentially we can call this in to the pharmacy during regular office hours or after seeing your child here in the office. It is approved for children 4 years of age and above. It is applied to the hair for 10 minutes then washed off with warm water. You reapply the Natroba (it is a "suspension") in a week if you still see live lice. Because Natroba kills live lice and the nits, nit combing is not required. One huge drawback: the cash price (with no insurance coverage for the prescription) is almost $300. This price will likely drop over time and the insurance coverage will improve. It remains an option, however.
     Our most used generic prescription strength lice treatment is malathion (the generic of Ovide), which often works when the over the counter medications do not work. It is less expensive than the Natroba at this time.

Keratosis pilaris -- a common rash

     One of the most common every day rashes we get questions about is keratosis pilaris. It often runs in families, starts at an early age, and lasts for years. Keratosis pilaris is fine, dry bumps on the side of the face, back of the arms, and side of the legs. It sometimes is easier to feel than to see the bumps. It can start at a very early age (in the first year of life) and cannot be cured. The rash is almost never itchy. The rash is more common in families who have a history of allergies, asthma, and eczema. It generally looks less noticeable and the bumps are softer if we regularly moisterize the skin with "keratolytics" (to break up the thick keratin layer of the skin at these areas). The two major brands of these moisterizers are Lac Hydrin and Carmol, both of which are available over the counter. Other moisterizers like Eucerin and Aveeno work also, but less so. Try using these once or twice a day on a regular basis. Feel free to ask us about this rash when you are in the office.

Lavender and Tea Tree Oil

     We get questions sometimes about the use of ingredients such as lavender and tea tree oil in topical products. Although these may be generally safe and helpful, many "natural" products can cause side effects. I just read a report today by Dr. Stan Block, MD in Pediatric Annals about an issue with lavender and tea tree oils used in various "calming creams" applied to the chest for young children. He reported a number of cases of breast swelling (premature gynecomastia) in these children after the cream had been repeatedly massaged into the chest. The vast majority of the cases of breast swelling stopped after the creams were stopped. It is not known for sure how these products caused the swelling.
     This information is not meant to stop you from using these products all together, but if something unusual such as breast swelling is occurring at a young age, it is good to examine the possible causes. And it is possible that a product that is generally safe and tolerated by others may be causing more harm than good.

Hives with illnesses

     This is a common time of the year for illnesses. Some of these illnesses (pneumonia, ear infections, sinus infections, Strep throat, etc.) require antibiotics. If hives (urticaria) occur during the illness, it can be quite tricky to figure out what has caused the rash: the illness? the antibiotic? the fever reducer? something else?
     A study was done by allergists that looked at school aged kids who had hives develop while ill and taking an antibiotic. They found if the children took the antibiotic during the study, they developed hives again only 15% of the time (about 1 in 7 times). That fits for what is commonly reported: that at least 80% of the time, illnesses cause the hives. It is thought that this happens when your immune system's reaction to the illness spills over in your body and triggers your allergy system to react. The hives typically last for a few days to two weeks.
     The majority of times, oral over-the-counter diphenhydramine (Benadryl(r)) offered every 6 hours while awake will treat the hives. Although food allergies and bee sting allergies can trigger off a life-threatening allergic reaction (anaphylaxis), it is extraordinarily unlikely an illness or antibiotic would trigger a scary allergic reaction. If someone did have throat tightening, difficulty swallowing, hoarse voice, or lip or tongue swelling with hives, it is a medical emergency and 911 should be called so that your child can receive immediate medical attention.
     You may ask "What is the big deal? Why not just call it an allergic reaction to the antibiotic?" The issue is: we really only have 4 good antibiotic groups for kids (penicillins, cephalosporins, macrolides, and sulfa). If we start crossing off groups we will no longer use for your child, we have less good choices when your child needs an antibiotic. And sadly, there are no new terrific antibiotics being developed for use in common childhood illnesses for the near future.
     So what to do? We want you to call us if your child is on an antibiotic and develops hives. We want to help guide you through what to do in this situation. Based on the situation, we may change the antibiotic. Other times, we may continue the antibiotic and have you do diphenhydramine
 for a few days.

The common cold and its treatment

     We are in the middle of the common cold (viral upper respiratory infection) season. Runny nose, cough, and congestion are the common symptoms. It is hard to go anywhere at this time of the year without being exposed to the virus.
     The over-the-counter medications are available in the stores and are tempting to use to reduce the symptoms. Millions of dollars every year are spent in the U.S. on these medications. Although there is much information about these medications available elsewhere (including on Hilliard Pediatrics website at http://www.hilliardpeds.com/), I want to provide an update on some of the latest medication information.
     Antihistamines such as chlorpheniramine and diphenhydramine are often labelled as for sneezing and runny nose. Although they can cause drowsiness, these are quite safe. And most studies have shown they are the most effective over the counter medication for cold and cough. They probably help a cough by slowing down any drainage that is causing the cough. Another thing folks find helpful about the antihistamines is simply that you may sleep better as a side effect (and getting more rest is a good thing).
     Expectorants increase mucous production -- that does not sound like a good thing, does it? While these medicines can help you cough and clear your mucous (and reduce congestion in the sinuses), they will not help you cough less. As a matter of fact, they generally increase how frequently you cough. The
expectorants do not taste good and can cause an upset stomach. They are probably best used during the day to help clear mucous. Good scientific studies do not demonstrate much benefit to kids with using expectorants.
     There is some good scientific research that shows that acetaminophen (for fever and achiness) suppresses a normal immune response our body has to an upper respiratory virus. This can result is worse nasal symptoms and a longer period of being contagious to others. So be cautious about routinely using acetaminophen for the pain or achiness of upper respiratory infections.
     Both echinacea and zinc are commonly used at the beginning of a "cold" to keep from getting worse and to get better faster. However, every scientific study done with children has not shown any benefit. That does not mean to stop these if your family finds it helpful. If you have found them helpful, it is quite possible that the illness was just going to be less severe and shorted that illness.
     I recall having Vicks(r) VapoRub slathered on my chest and under my nose during colds. However, I have been not often recommended the menthol vapor rub to my patients because no good scientific study had ever shown any promise -- until now. In 2-11 year olds with a cold and cough, there was improved sleep, less cough, and less congestion when compared to children who just used petrolatum or no treatment. So using these products may certainly help you fight your child's symptoms while they have a cold.
     We still like to recommend using saline drops and nasal suction for the infants and vaporizers for all ages to help reduce the cough and congestion by mouisturizing the air.
     Good luck. I hope you find this information helpful!