Sunday, September 25, 2011

Got Milk? Cow, Coconut, Soy, or Almond?

A Facebook follower asked about how to choose a milk substitute recently. There is not a simple answer.

For many years it was easy:  The American Academy of Pediatrics recommended whole milk from 1 year to 2 years of age, then 2% until 4 years.  At 4 years it was recommended to switch to skim milk. If kids couldn't tolerate cow's milk they were given soy.

Then came questions about the estrogen like effects of soy and the problem that soy allergy is common in milk allergic kids.

The obesity rates climbing in kids has put into question whether whole milk is needed until 2 years and if lower fat milks should be given at younger ages.  The answer to this is probably not routinely, but toddlers who are overweight can benefit from a lower fat milk.

Grocery store shelves now offer not only whole, 2%, 1%, and skim cow milks (regular, hormone free and organic of each of these!) and soy milk, but they also sell lactose free milk (in several fat concentrations),  rice milk, almond milk, coconut milk, and goat milk.

How do you make the right choice for your child?  Below is a nice chart from comparing calories, fat, protein, and calcium contents of various milks.  Taste is a very important consideration for the picky child.  If they don't like the taste, they will not drink it.  Even the textures of the milks can vary quite a bit and might require acclimation.  Food allergies and intolerances drive many of the choices.  Note: none of these are appropriate for infants under one year.  Breast milk or formula are the only healthy options for infants due to other nutrients needed in an infant's diet! 

Historically it has been felt that toddlers need more calories from milk, and should not regularly drink a low fat/low calorie milk.  Because of the rising obesity rates (even among toddlers and preschoolers) this recommendation is changing and kids can drink lower calorie products if their caloric intake from foods is sufficient.  Beware of high calories in milks like coconut milk, goat milk, rice, or soy milk.  They have nearly as many calories (or more!) than whole fat cow's milk.

One cup of coconut milk has over 50 grams of fat and over 460 calories!  A special treat: yes. A routine daily drink: no!  
(For comparison, a BK vanilla milkshake has 412 calories and 23 grams of fat in 227 grams (just 1/2 oz shy of a full cup).

Calcium levels vary widely in various milks and should be taken into consideration when choosing a milk for your child.  Other foods, such as calcium fortified orange juice, yogurt, tofu, leafy greens, cheese, and fortified cereals, can (and should) incorporate calcium into the diet.

Vitamin D is very difficult to get through diet alone and it is recommended that everyone take a Vitamin D supplement.  For more information, click here.

There is no consensus that organic milk offers any health benefit.  Due to it's high cost, it is prohibitive for many families to buy organic.  Hormone free milk is available for a mid-range cost without the potential (yet unproven) risks of hormones given to cows.  There isn't any nutritional benefit of the hormone free milk or organic milk compared to conventional milk, but if you are concerned about hormone exposure from milk, hormone free is less expensive than organic.

Lactose free milk: 160 calories, total fat 9g, protein 8 g, calcium 30%
Lactose free reduced fat milk: 130 calories, total fat 5g, protein 8 g, calcium 30%
Lactose free fat free milk: 80 calories, total fat 0g, protein 8g, calcium 30%
(Lactose milk nutrition facts based on one cup, from

Screen Free Week Reflections

I have been a fan of Screen Free Week since I heard about it.  Even before I heard of the official week, it was a popular negative consequence in our home.  

I used to enforce unofficial screen free weeks at our house regularly when I saw my kid's behaviors turn toward selfishness, fighting, and whininess.  Turning off the tv and video games help.  Maybe it's because the screen activities wind up their brains.  Maybe it's because it is "down" time and they need active time.  Maybe because I was guilty of using the tv as a babysitter so I could get my own things done, yet the kids needed time with me.  There are many more maybes, but all I know is that turning off the tv and video games seems to always help.  I get a bunch of complaints at the beginning of the week, but by the end of the week the kids are in a new habit of finding things to do without electronics.  It's fun. We all get along better.

This Screen Free Week I realized that it is harder than ever though.  Not for the kids, but for me.  I can never get off computers completely.  We use electronic records at my office.  I use the internet to search for information related to my job.  Those are allowable uses, since electronics for work and school are exceptions to turning off the screen.  Computers are simply a part of our life.

We are all relatively new to all the opportunities for wasting time on tv (remember when there were just a couple channels?) and internet offerings.  We are plugged in from our computers and our Smart Phones.  We get a lot of work done and learn information on these Screens.  When can we unplug? How do we learn to manage our time?

This week I was going to at least stay off Facebook, since that is mostly fun stuff that I share with patient families. Work related, yes.  Necessary, no.  I feel that by posting to Facebook it encourages others to look at Facebook.  Facebook is a huge time waster for many. (And yes, this is from someone who is totally addicted to facebook... I spend quite a bit of time searching around on it to scope great things to share!) A great reason to turn off the screen for a week!  

But then I need to reevaluate the "Necessary, no."  What is necessary?  I still had to look at Facebook to be sure the office page was not being abused with posts that were inappropriate.  Most things I post are not timely.  There are some recalls that are important, but not really imperative to share NOW.

But there were several things that happened in this one week that Social Media could really benefit.   Where do you draw the line of staying off Social Media and when does it become "work" so it is excluded?

We did post two things to our wall that did seem to meet the criteria of important and timely.  One was a request from the Health Department to spread the word about an outbreak.  Why is this important?  Because 8 people in Kansas have been sick and 2 have died.  Warn people: good.  But then to see it, people are checking their Facebook posts: bad.  Such a slippery slope!

The second post was about our own office's access.  We were not warned that our parking lot was to be resurfaced.  Staff arrived to work and found the whole thing blocked with no access to our main door (until we convinced them it was unacceptable during office hours).  Yikes!  How to spread the word quickly?  Yes, we can call the patients with appointments and tell them where to park, but what about walk ins?  Facebook is fast.  It can be helpful!  But we told people to stay away for the week.  Sigh.  Just can't win!

A third post that didn't end up getting posted because it is a bit hazier in importance and timeliness.  We have promised that when we open flu clinic appointments we will share on our website and Facebook page.  Of course we were able to secure a couple dates during this Free Week.  We posted to the website, since people always use that for health matters, not "fun".  We sent out an email to registered website users.  But we didn't post immediately to Facebook, again to encourage people to stay off Social Media for the week.  But Facebook isn't purely Social.  It is used to share information in a way that wasn't possible years ago.  (No worries for those of you who haven't signed up yet... there will be plenty of time to sign up!) 

Other posts that aren't timely were easy.  Save for later.  I am using a scheduling system that schedules posts, so I don't have to post daily.  That is helping manage my time on Facebook.  I still have to look daily to check on posts, but it does help with time management.

I think that is where the secret lies.
We all need to learn time management with the Screens.  What is important? What are time wasters?  Time wasters aren't always bad.  It can be great to vege in front of the tv after a long day and just relax without any bothers.  It is fun to catch up on what friends are up to on Social Media.  It can save time if you have exciting news and post once for all your friends and family to see (less personal than a phone call or visit, but faster!)

We need balance.
We need to make time for family, faith, exercise, healthy family meals, and sleep.  Cutting out those important things in life to waste more time in front of the screen simply is dangerous.

Monday, September 12, 2011

Kid's Weight is Weighing in my Mind

Reports of increasing obesity levels have been circulating for years on the news.  I see kids in my office regularly who are in the overweight or obese category and we all struggle how to treat this growing problem.  Excess weight in childhood is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty- leading to overall shorter adult height.  Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Why is weight so much more of a problem now than it was years ago? As a child I did not have a perfect diet, yet I was not overweight because we spent most waking moments outside if we weren't in school. My mother packed a dessert in every lunch box.  We ate red meat most days.  We usually had white bread and butter on the table at dinner.  We drank 2% milk and I ate ice cream every night.  But we walked to school-- without a parent by the time I was in 1st grade (gasp!)  There were only a couple tv channels, and Saturday morning was the only time we could watch tv.  We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it - we found something to make it fun!  Today's kids are shut up in the house after school watching one of many tv channels or playing video games. Even those who are shuttled to activities get overall less exercise because it is structured differently.  They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction. Simply put: they don't get to do things at their own pace with their own creativity for as long as they want.

What to do???  On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders.  I think this is possible if we focus on the word healthy, not weight.   Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall.  If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI.  We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.  I focus on 3 things we all need to be healthy (not healthy weight, but healthy):
  1. Healthy eating
  2. Exercise (with proper safety equipment- but that's another topic!)
  3. Sleep (again, another topic entirely!)
Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.  If we are lucky our kids like one or two vegetables and some fruits.  We might even be able to sneak a whole grain bread in the mix.  If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about).  We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want.  We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy.  The perception of calorie needs and actual calorie needs can be very mismatched.  I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:
  • turn on the tv and feed the child while the child is distracted
  • reward eating with dessert
  • refuse to let the child leave the table until the plate is empty
  • allow excessive milk "since at least it's healthy"
  • allow snacking throughout the day
  • legitimize that a "healthy" snack of goldfish is better than cookies
Any of these are problematic on several levels.  Kids don't learn to respond to their own hunger cues if they are forced to eat.  If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?  If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating.  They can, however, over time slowly kill themselves with unhealthy habits.  

So what does your child need to eat? Think of the calories used in your child's life and how many they really need.  Calorie needs are based on age, weight, activity level, growing patterns, and more.  

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.  Do parents realize how damaging this can be?  
  • A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
  • A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
  • A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
  • Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.
Now consider those famous treats at games.  Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:
  • Typical flavored drinks or juice range 50-90 calories per 6 ounce serving. 
  • Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
  • Fruit roll up (28g) 104 calories
  • 1 medium chocolate chip cookie: 48 calories
  • Orange slices (1 cup): 85 calories
  • Grapes (1 cup): 62 calories
  • Apple slices (1 cup): 65 calories
So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.  The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.  And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...
What's wrong with WATER?  And eating real food after the game.  As a family. Around the table.  That snack is likely to decrease appetite for the next meal, and it isn't needed.  And if they're hungry, they're more likely to eat the healthy foods on their plate.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.

Simple suggestions:

  • Offer a fruit and vegetable at every meal. Fill the plate with various colors!
  • Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways - like with a toothpick. Don't forget to lead by example and eat your veggies!
  • Buy whole grains. 
  • Choose lean proteins.
  • Eat together as a family as often as possible.
  • Turn off the tv during meals.
  • Encourage the "taste a bite without a fight" rule for kids over 3 years. But don't force more than one bite.
  • Don't buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren't in the home, they can't be eaten!
  • Drink water instead of juice, flavored drinks, or sodas.
  • Choose low fat milk (1% or skim) after 4 years of age. (Whole milk from 1-2 years is okay for the normal weight toddler. 2% milk is okay for the normal weight 2-4 year old.  It is now acceptable for most kids to take in lesser milk fat than previously recommended.) 
  • Limit portions on the plate to fist sized. Keep the serving platters off the table.
  • Don't skip meals!
  • Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks.
  • Don't forget to move every day and get enough sleep!

Tuesday, September 6, 2011

On the Job Training for Doctors?

A recent report showed a large discrepancy between what pediatricians believe they should do to advise parents and kids on sleep, and what they were actually trained to do, which begs the question: What are pediatricians NOT trained to do but must do as a routine part of their job?

What is this discrepancy?  The Journal of Pediatrics published a report that only 18% of pediatricians reported having formal training in sleep disorders, but 96% felt it was their job to treat them.  Their conclusion is that training programs should provide sleep education.

While on the surface this sounds like a great idea, reflecting back on my training and early years in practice, residency would have to be extended by many years to teach all that I need to know at my job. Teaching sleep hygiene (or not teaching it) is just the tip of the iceberg. Not to mention that there is new information all the time about how to do things better, so the learning should really never end.

I learned about car seats after my son was born during the end of my 3rd year of residency.  
How did I make it 3 years without learning about car seats???  I would simply mention to parents to be sure to use one.  If they had specific questions about if the baby was properly in the seat, I referred them to a car seat expert.  (We refer to a lot of experts in residency.)
We took my son home from the hospital on an icy February day in a warm jacket  buckled into the car seat.  When we got home and I went to unlatch the buckle I realized it had never clicked. The jacket was too bulky!!!  We went to a car seat check a couple weeks later and his car seat wasn't even tight enough ~ this is before the LATCH system helped secure the seat.  My own baby had been unsafe.  How awful is that after nearly 3 years of pediatric residency?  Of course now, 12 years later, many car seat rules/recommendations have changed.  Gotta keep learning!

I had a little formal education about breastfeeding, but it was mostly the technical aspects of how milk is produced, not how to help a mother/baby be successful with breastfeeding.  That I learned when struggling to breastfeed my first baby, and along the way with other moms and their various problems.  My second came along and breastfeeding went great, but she wouldn't take a bottle.  Boy, did I learn a lot from my own kids with two very different feeding problems.

I don't remember a single lecture on nutrition, though I'm sure we had them.  Not much on exercise that I recall.  These would have been considered "easy" topics and as a resident we were more focused on studying acid base disorders and intricate diseases because that would be what we would be tested on.  I wish I learned more about nutrition and exercise psychology because of the current level of obesity, but it is a relatively new problem in pediatrics -- one even the specialists aren't sure how to manage. 

It is estimated that 40% of primary care visits involve behavior problems, yet I only had a single one month rotation on psychiatry.  I am still learning new tricks 12+ years into practice.  Many of my experiences as a parent color what I have learned in this arena.  I also have the privileged position to learn from the families I see at work.  All of this information I use to counsel families about these issues.  I could never have learned this in a lecture, or even in a clinic with a preceptor for a one month rotation.

Simple things, like what to do with a baby who has a nose filled with mucus, were not discussed in lectures because there were more advanced things to learn, like how to manage a child on a ventilator.  I don't ever manage ventilator's now, but I had to learn how in residency.  Why learn that?  Because it teaches doctors to think.  

We need to learn the basics in school about how the body works.  The psychology, pharmacology, physiology, and all the other -ologies.  

Residency teaches us how to apply these things to the human person.  Treating the sickest of the sick in the hospital setting teaches us to recognize sick and become independent learners.  

Starting up in practice teaches us more about common illnesses and concerns. We sharpen the skills of disease management and normal growth and development with all of its variances from following the same kids over years.  We must incorporate everything we know from books, lectures, clinical experiences, personal experiences, and more into caring for our patients with the most current evidence based and practical methods available.
And that keeps changing, 
          keeping pediatricians life long learners!

Friday, September 2, 2011

Concussions in Athletes

Concussions in athletes has been the subject of many headlines over the past couple years.  For as much as we know about concussions, there is still much more we need to learn about head injuries and their healing. While most kids recover from concussions within days to weeks, there are some who suffer for months.  This can disrupt not only sport participation, but also reading, concentration, and the ability to learn.

What we know:
  • We know that children's brains are still developing and are more at risk with concussions than mature brains. 
  • We know that many athletes attempt to hide symptoms of a concussion so they can continue to play. (Bad idea!)
  • After a concussion -- even serious ones that affect the daily activities of a teen -- kids are often eager to return to the game that puts them at risk for another injury.
  • Symptoms of a concussion range from mild to severe.
  • headache
  • nausea or vomiting
  • slurred speech 
  • dizziness 
  • ringing in the ears
  • trouble concentrating
  • sensitivity to light or noise
  • sleep problems
  • balance problems
  • memory loss  

  • There are no specific treatments for concussion.
  • Rest is important. This includes not only avoiding activities that increase the risk of another injury, but also brain rest. Some kids need quiet time in bed without lights, sounds, television, computers, or books.
  • Headaches can be treated with pain relievers and sometimes migraine medications.
  • Memory and thinking problems are treated with rehabilitation and memory devices (like a calendar or planner).  Occasionally stimulants (the medicines used for ADHD) are used temporarily.
  • Depression and anxiety should be managed by someone experienced in dealing with post-concussion syndrome.
Return to play is a gradual process, in which the athlete progresses in a step wise manner.  If any symptoms return during the stepwise process, the athlete must stop activities and return to a medical practitioner for evaluation.

Step 1: Light aerobic exercise 5-10 minutes without weight lifting, resistance training or other exercises
Step 2: Moderate aerobic exercise 15-20 minutes of running at moderate intensity without a helmet or other equipment.
Step 3: Non-contact training drills in full uniform. May begin weight lifting and resistance training.
Step 4: Full contact practice.
Step 5: Full game play.

Kansas has a new Concussion Law effective July 1, 2011, that requires the State Board of Education and the Kansas State High School Activities Association to provide information about the risks of head injury to coaches, athletes, and parents and guardians of the school athletes. This information should include the risks of playing or practicing with a concussion.  Under the new law an athlete may not participate in a school sport or practice unless the athlete and the parent/guardian have turned in a signed head injury release form each year.  Any school athlete who is suspected of having a concussion or head injury will immediately be removed from play or practice and will be allowed to return to play only after a health care provider gives medical clearance to return to play.

Athletic trainers are available at many local schools to help identify the athletes at risk of concussion. They will be testing kids with various methods, and at this time there is still a lot of variability in what each school program is doing.  It is best to have baseline testing done BEFORE any brain injuries (ie the start of the season) to compare to testing done after a suspected concussion.

If your child is suspected of having a concussion, bring any available test results (both from before and after injury if possible) to your appointment with a healthcare provider.

Prevention is still the best medicine!

  • Wear proper gear at all times.  
  • Be sure helmets are in good condition and fit properly. 
  • Wear mouth guards at all times.  
  • Follow the rules of the game. 
  • Sit out if injured.  
  • If you suspect someone might have a concussion, speak up!

To read the Kansas State High School Activities Association Recommendations for Compliance with the Kansas School Sports Head Prevention Act and Implementation of the National Federation Sports Playing Rules Related to Concussions, click here