New High Risk Child RSV Prevention Guidelines

Today the American Academy of Pediatrics published a new policy statement, Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.

photo source: Shutterstock

This very long title is basically the roadmap that physicians should follow when deciding which infants and young children would benefit from a vaccine to prevent the virus commonly known as RSV (Respiratory Syncytial Virus). RSV is a very common virus, affecting nearly all children by 2 years of age. Reinfection seasonally (late fall to early spring) is also common. It typically causes common cold symptoms and ear infections, but in infants it can lead to bronchiolitis, a condition where there is wheezing and difficulty breathing. Most people who are infected can be treated with home therapies, but some infants require hospitalization for oxygen or iv fluids. The majority of hospitalizations occur during an infant's first year of life and are among otherwise healthy, term babies, not premature or otherwise at risk babies. This is likely due to the fact that parents of at risk infants tend to be much more cautious and aware of infection prevention and tend to avoid situations that could increase risks, such as daycare. It would be impractical for most working parents to stay home with their children the first winter, and the overall risk of hospitalization of a healthy baby is still very low despite the use of daycare. The virus is spread through close contact with others who have the virus and it can live on contaminated surfaces for several hours. Unfortunately since it only produces mild symptoms in older children and adults and can be spread before symptoms develop, caution must be taken throughout the cold and flu season to avoid spreading germs.

The palivizumab vaccine is commonly called Synagis. It has been used since 1998 to prevent RSV infection in at risk children ~ those whose lungs are underdeveloped due to prematurity, those with significant heart defects, and other risk factors. Due to cost and needs analysis, it has never been recommended for routine use in otherwise healthy children. When deciding which children will benefit from the vaccine, experts review its effectiveness, drug resistance, and cost analysis.

We are fortunate to live in a country that has high quality medical care for premature and sick infants. Preterm babies tend to be much healthier than they were in years past due to advances in medical care. The rate of hospitalization for RSV illness has declined over the years in both those who did and did not get the palivizumab vaccine.

Research now shows not only that palivizumab prophylaxis has a limited effect on hospitalizations for RSV, but also no measurable effect on mortality and only a minimal effect on wheezing. Due to these new findings, the new recommendations limit the use of palivizumab compared to years past. I am sure there are infants that were born last season whose parents anticipated they would get the vaccine again this season, but with the new guidelines they will not be eligible. While this might cause anxiety among parents, it is based on good data that they wouldn't benefit from it. And remember that RSV is only one of the many viruses that cause significant illness in at risk babies, so the primary preventions of infection control are important regardless of whether or not an infant gets this vaccine.

New guidelines recommend the use of palivizumab in

• infants born before 29 weeks gestation and in the first year of life (previously 32 weeks)
• infants with significant congenital heart disease in the first year of life (previously 2 years)
• infants with a compromised immune system under 24 months of age (similar to previous recommendations)
• infants with chronic lung disease or who require at least 28 days of oxygen after birth and in the first year of life. If they continue to have need for oxygen, diuretics, or corticosteroids, they may qualify the second year of life.
• infants with neuromuscular diseases that affect the ability to clear the airway in the first year of life (previously 2 years)
• Alaskan Native and Native American populations may have expanded uses 

For those infants who qualify, they can receive up to 5 monthly doses during the RSV season. If they are born later in the season, they may require fewer doses. If a child has a hospitalization for RSV despite the vaccine, they stop future doses of palivizumab. 

It is still important for all infants, especially those born preterm, to use infection prevention strategies, such as 

• use breast milk whenever possible
• frequent hand washing
• clean toys regularly
• immunize household members against influenza, pertussis, measles, and other recommended vaccines
• limit contact with ill people 
• avoid smoke exposure
• avoid large crowds during the first winter season
• limit use of large daycare centers during the first winter season

Remember that even infants who are getting palivizumab vaccine prevention are still at risk for other illnesses, so it is important to use the above precautions in them as well. For treatments of cough and cold symptoms, please visit Cough and Colds.

Getting kids to swallow pills

Kids fighting to take medicine is a commonplace occurrence. They don't like the taste. They're already sick so they don't want to do anything you want them to do. They want to wait 5 more minutes. There are as many reasons they don't want to take it as there are reasons we think they need it.

One of the biggest challenges for some people (not just kids) is swallowing pills. At some point transitioning to pills is important. They are easier to store. Some medicines do not come in liquid or chewable form. Some kids simply get so big that the volume of liquid they need to choke down becomes difficult.

When my son was a preschooler, I realized that he swallowed some things whole ~ usually things he didn't like, like a piece of meat. He sometimes needed oral steroids for wheezing. Steroids in liquid form are notoriously nasty. He would vomit it back up most of the time. The tablets are really small, so I decided to have him try those once. Easy as pie for him! I don't think we even had to practice. I just told him to not chew because it would taste bad and he knew what to do. I think he was so young, he didn't know that he should be scared of choking.

If only most people could teach themselves like that... Despite it being difficult to learn, most people can learn to safely swallow pills. Once the technique is learned, the size and the shape of the pill is not usually an issue.

There are many tricks people use to swallow pills. What works for one doesn't work for another. If your child isn't willing to give it a try, it's really not worth it. Since this is a mind over matter thing, it will be impossible if they're not on board. If they're not ready, every once in awhile you can mention how big of a bite of food they just ate and comment that they swallowed it easily. Remind them to let you know when they want to try to swallow a small piece of candy. (For many the temptation of extra candy is an automatic selling point.) Don't wait until they have an illness to start because no one wants to learn anything new when sick. Once they get the technique, be sure to do it often enough that they don't forget until they need to use it.

Never practice with real medicine, even if it's over the counter stuff. Kids should know that they are practicing without real medicine. At the same time as teaching them to swallow pills you can talk about medication safety: only take it when an adult says it's okay, keep it away from other children, never share medicine with others, take it as the doctor prescribed if it is a prescription, and how and when to use over the counter medicines. It's a great skill for kids to know all of these things, and good to review until they have it all down. I am sometimes surprised at nearly college aged kids not knowing what common medicines are used for if they have aches and pains or illness. They need to know!

When I had to teach my daughter to swallow pills, I bought a container of Tic Tacs and told her that when she could swallow 3 in a row without choking, she could have the rest and eat them without permission unless she already brushed her teeth at night. She loved that idea and took to the challenge excitedly!

If you try one of these methods and it isn't working, you can try another. You can practice with both round and oval shaped candies since medicines come in both forms. Avoid having your child take huge gulps because that can cause them to lose control of the swallow. There are special cups that you put the pill in and then drink from them. I have no experience with them, so will not review them here. Commonly used methods to learn pill swallowing:

Starting small and working up

photo source: Shutterstock

For kids who are very hesitant, it is possible to start very small and work up to a standard pill size. Start with cake decorating beads, balls or sprinkles. Avoid the ones that are very lightweight because they might float and not go down as easily. Most kids agree that something very small will be easy to swallow. Have them show you they can. Build confidence by starting really small so they have a good first try. After they do it enough that they feel confident moving up (usually 3-5 successful swallows), use a bigger piece. Keep working your way up to a size that resembles most medicines. If a child fails a size, go back down to the smaller size to gain confidence. Don't spend more than 10-15 minutes each session. If the child tires or the stomach fills with too much water, it will be non-productive. Remember to praise any successes. Always end on a positive note by having the child swallow whatever size he can. So if it is unsuccessful to move to a larger size, have him go down a size, swallow successfully, then don't go up again at that session. You can always try again another day.

Straw Method

Different people like different positions for swallowing pills. Some do best with their head back, as is typical with drinking from a cup, so the pill has a straight shot down. Others do best with the head turned to one side or another. Some even change their preference over time. For those who prefer to have the head neutral or a bit forward, using a straw avoids having to tilt back to drink. Have your child put the candy on the front half of the tongue, then drink out of a straw with the straw at the front of the tongue so the liquid comes out in front of the pill. Tell them to focus on the drink, not the tablet. Some people say to put the tablet as far back as possible, but I think that can trigger the choking reaction, which is not helpful at all. Most of the time the pill will naturally go down with the liquid without even thinking about it. If you like to be green and don't want to fill a landfill with plastic straws, check out these fantastic glass straws. (I don't typically endorse products, but this is an entirely unpaid endorsement. We've had these straws for years. They go in the dishwasher daily. We've dropped them from table height. They still look brand new. We love them for many reasons, and since we use straws all the time, I don't feel guilty about our environment.)

Hidden pills

Some people feel more comfortable swallowing food than pills, so putting a pill in a soft food helps. Common foods are yogurt and applesauce. I've even heard of parents putting the pill at the top of a yogurt tube, and having the child suck down the yogurt. The biggest issue with this method is that if a child takes too long to take it, the tablet or capsule might start to break down, and then the child can notice the taste (which is often bitter). Another problem is if the child tries to chew the food first because most medicines meant to be swallowed should not be chewed.

Research proven techniques

For more help on learning to swallow pills, check out these videos that show how to swallow pills (link fixed 7.22.17) in different positions. Kids might like to see the techniques themselves before they practice.

Learning and Behavior Series Part 5: Medications

This is the 5th post in a series of blogs on Learning and Behavior. It will focus on prescription treatments used primarily for ADHD.

There are many parts to the treatment of ADHD including behavior modifications; school accommodations; optimizing nutrition, sleep, and other healthy habits; and supplements -- all covered in previous posts in this series. This one will cover common medications that have been approved or are commonly used for the treatment of ADHD. I am not going to go into how to diagnose ADHD here, but it is of course of utmost importance to have the correct diagnosis before medication is considered.

There are many treatments out there that are not approved for the purpose being used, but if done properly might be a good consideration. Physicians sometimes use treatments that have not been approved for the purpose because they know from experience that it works or they are at a loss from approved treatments failing and they need to try something else.

One example is using a shorter acting form of guanfacine (Tenex) that has not been approved to treat ADHD, but is less expensive than the longer acting form (Intuniv) that is approved for ADHD.

Another common example is the use of albuterol, a medicine that helps breathing with conditions that cause wheezing. It is not approved for use under 2 years of age, but it is commonly used for younger children with difficulty breathing -- and it helps them breathe, which might keep them out of the hospital and off of supplemental oxygen.

I do not think that all non-approved medicines are good or bad. It is a very individual decision of what medicines to use. Discuss with your doctor if a treatment is approved or if they are using something that is not. Although this is relatively common among people who treat children because many drugs have not been tested in children and have been "grandfathered" into use through experiences that show benefit, be sure the provider is not picking something that has no basis or supporting evidence, especially if he or she profits from the treatment.

Be very wary of anyone who promises a cure - if one really existed everyone would use it.

Medications approved to treat ADHD

Medications to treat ADHD fall into the following categories:

• Stimulants

• Methylphenidates (Ritalin©, Focalin©, Concerta©, Daytrana©, Metadate©, Quillivant©) 

• Amphetamines (Adderall©, Vyvanse©, dexedrine) 

• Non-stimulants

• Atomoxetine (Strattera©) 

• Guanfacine (Intuniv©) 

• Clonidine (Kapvay©) 

• Others are used off-label (no FDA approval for the purpose of ADHD treatment): Tenex, Catapres patch, antidepressants, and antipsychotics

When a medication is needed to control symptoms of ADHD, the first line medications are the stimulants unless there are contraindications. Non-stimulant medications are not found to be as effective as stimulants in the majority of children, but they do have a place in the treatment plan for some children. They are sometimes used in addition to stimulants for optimal results. For information on how these medicines, see A Guide to ADHD Medications. It reviews how stimulants act on dopamine and norepinephrine and various time release patterns of different medicines.

Side Effects

Parents usually worry about medication side effects, which is a very legitimate concern. Overall the medicines listed above are very well tolerated. If a child has side effects to one stimulant, they can usually do well on a different class (methylphenidate vs amphetamine). I often hear concerns that parents don't want their kids changing their personalities or becoming "zombies". If the right medicine is used at the appropriate dose, this is usually not a problem. Finding that right medicine and right dose might take some trial and error, but work with your prescriber to get to the right one for your child.

The most commonly observed side effects of stimulants are:

• Decreased appetite – Appetite is often low in the middle of the day and more normal by supper time. Good nutrition is a priority, so encourage kids to eat the healthy "main course" first and leave the dessert out of the lunchbox. Short acting meds improve mid day appetite since they wear off around lunch time. Kids are often very hungry in the evenings when medicines wear off, so encourage healthy foods at that time. I have also seen some kids who have a really hard time off medicine sitting down to eat actually gain weight better on medicine because they can finish the meal.
• Insomnia – Trouble sleeping is common with ADHD, with or without medicines. If it is due to the stimulant medicine, trouble sleeping may be relieved by taking it earlier in the day.
• Increased irritability -- Moodiness is especially common as the medication wears off in the afternoon or evening and in younger children. It makes sense if you consider that all day they are able to focus and think before acting and speaking, but then suddenly their brain can't focus and they act impulsively. Typically kids learn to adjust to the medicine wearing off as they mature. Sometimes just giving kids 30 minutes to themselves and offering a healthy snack can help. Cognitive behavioral therapy can help. 
• Anxiety -- Anxiety does occur with ADHD and might be under-appreciated before the ADHD symptoms are treated. When kids can focus better, they might focus more on things that bother them, increasing anxiety. It is also possible that anxiety is misdiagnosed as ADHD, which is one reason for stimulant medication failure.
• Mild stomach aches or headaches -- Stomach aches and headaches are occasionally noted with stimulant medications. It is my experience that they are most common with a new medication or a change in dose. Because these have many causes, it can be hard to determine if they are really from the medicine or another cause. If they persist with the medicine, it might be needed to change to another.
• Tics - Tics are related to treated and untreated ADHD. People with ADHD are more likely to have tics than the general population. It was once thought that tics were caused by the stimulant medicines, but it is now thought that they happen independent of the medicine, and medicines might even help treat the tics.
• Growth -- Weight gain can be difficult for some kids on stimulant medications due to the appetite suppression on the medicine. Studies have shown a decreased final adult height of about 1-2 cm (1/2 - 1 inch), which most agree is not significant compared to the benefits in self esteem, academics and behavior children gain on stimulants.

Rare side effects of stimulants include hallucinations and heartbeat irregularities

• I have only seen two children who could not tolerate stimulants due to hallucinations, but it is very scary for the family when it happens. Unless there is a significant family history of them, I don't know a way to predict which child is at risk. These are a contraindication for continuing that medication, but another type of stimulant or medication can be considered. 
• Cardiac (heart) problems are overall a rare complication of stimulants and often times are not a contraindication to continuing the stimulant medicine. There is a small increase in blood pressure and heart rate, both of which should be monitored regularly while on treatment and if the treatment is stopped. 

A cardiologist should be considered to further evaluate a patient prior to starting a stimulant if there is any of the following:

• Shortness of breath with exercise not due to a known non-cardiac cause, such as asthma
• Poor exercise tolerance compared to children of the same age and conditioning 
• Excessively rapid heart rate, dizziness, or fainting with exercise 
• Family history of sudden cardiac death or unexplained death (such as SIDS) 
• Family or personal history of prolonged QT syndrome, heart arrythmias, cardiomyopathy, pulmonary hypertension, implantable defibrillator or pacemaker 

Common side effects for the non-stimulants include the following:

• Atomoxetine can cause initial gastroesophageal complaints (abdominal pain, decreased appetite), especially if the dose is started too high or if it is increased too rapidly. It can also cause tiredness and fatigue when it is first started or if the dose is increased too quickly. It can increase the blood pressure and heart rate, both of which should be monitored regularly during treatment with atomoxetine. There is an increased incidence in suicidal thoughts, though uncommon, so children should be monitored for mood issues on this medication. A rare complication of atomoxetine is hepatitis (inflammation of the liver with yellow jaundice and abnormal liver function labs). The hepatitis resolves with stopping the atomoxetine. 
• Guanfacine and clonidine both cause fatigue and tiredness, especially when first starting the medication or with increases in dose. Clonidine is often used at bedtime to help kids with ADHD sleep. Both of these medications can lower the blood pressure and heart rate, and these should be monitored closely while on guanfacine or clonidine.


Getting Started

The first step in treating ADHD is getting a proper diagnosis. This should be done with input from parents and teachers since symptoms should be present in at least two settings. ADHD symptoms overlap with many other conditions, and if the diagnosis is not correct, medications are more likely to cause side effects without benefit. Do not jump into medication until the symptoms have been fully evaluated and a proper diagnosis is made according to DSM criteria.

Stimulant medicines are considered first line treatment for ADHD in kids over 5 years of age. There are short acting and long acting formulations available for each type of stimulant. There are advantages and disadvantages to each. Short acting medications tend to last about 4 hours, so can be given at breakfast, lunch, and after school, allowing for hunger to return as each wears off to help kids maintain weight. They are often used later in the day after a long acting stimulant wears off for teens who need longer coverage. Long acting medicines tend to last between 6 and 12 hours, depending on the medicine and the person's metabolism. The benefit is that people don't need a mid-day dosing, which for school kids means avoiding a daily trip to the school nurse, which can be socially non-acceptable for older children. It is also easier to remember once/day medication versus multiple times/day dosing. The downside is that some children don't eat well mid-day with long acting medicines.

In general it is recommended to pick one of the stimulant medicines and start low and titrate to best effect without significant side effects. Feedback on how the child is able to focus and stay on task, and reports of other behavioral issues that were symptoms in the first place should be received from teachers and parents, as well as the child if he is able. There are many things to consider that affect focus and behavior that are not due to the medicine: sleep, hunger, pain, illness, etc. It takes at least a few days to identify if the medicine is working or not or if other issues are contributing to the focus and behaviors. The younger the child the longer I usually advise staying on a dose so a parent has a chance to hear from the teacher how things are going. I usually don't increase faster than once/week. I rely more on the student's report in middle and high school, since those students can be more insightful and they have so many teachers throughout the day that most teachers are not as helpful. Older students who are in tune with their problems and how they are responding to the medicine might be able to increase every few days, as long as there are no confounding factors that could influence symptoms, such as change in sleep pattern, big test or other stressor, or illness.

Which medicine to choose?

As you see above, there are two classes of stimulants, methylphenidates and amphetamines. While some children respond better to methylphenidates, others to amphetamines, some do equally well on either, and some cannot tolerate either. It is not possible to predict which children will do best on any type, but if there is a family history of someone responding well (or not) to a medicine, that should be taken into consideration of which to start first.


Another thing to consider is whether or not a child can swallow a pill. Some of the medicines must be swallowed whole. If you aren't sure if your child can swallow a pill, have them try swallowing a tic tack. Use a cup with a straw, since the throat is narrowed when you tilt your head back to drink from an open cup. Another option is to put it in a spoonful of yogurt or applesauce and have your child swallow without chewing. If your child cannot swallow a tic tac, you can choose a medicine that doesn't need to be swallowed. Some come in liquid or chewable formulations. Some capsules can be opened and sprinkled onto food, such as applesauce or yogurt. There is a patch (placed on the skin) available for the methylphenidate group.


I would love to say that cost shouldn't matter, that we pick the medicine based purely on medical benefit, but cost does matter. Before you go to the doctor to discuss starting medicine (this or any medicine for any condition) look at the formulary from your insurance company. All other things being equal, if one medicine is not covered at all (or is very expensive) and another is covered at a lower tier, it is recommended to try the least expensive option first. Of course, if the least expensive medicine fails, then a more expensive one might be the right choice. Also check to see if a medicine requires a prior authorization, which might require that other medicines are tried first.

The ADHD Medication Guide is a great resource to look for generics (marked with a "G"), which must be swallowed whole or can be opened or chewed (see the key on page 2). The age indications listed on page 2 are those that have FDA approval at the ages listed, but there are a lot of times that physicians use medicines outside the age range listed. Some do not even have an age indication listed. These ages are due to testing results, and can be limited because one age group might not have been tested for a specific medicine. Note that the 17 year and adult medicines are different. Is there really a difference between a 17 and an 18 year old? Not likely.

Finding the right dose

It is recommended to start with one of the two main classes of stimulants with a low dose, and slowly increase to find the best dose. If that stimulant doesn't work well or has side effects that are not tolerated, then change to the other class of stimulant. If that one does not work, you can try a different medicine from the class of stimulant that worked best. If the third medicine doesn't work, then a non-stimulant can be tried. I also recommend re-evaluating the original diagnosis at this point, since ADHD might not be the cause of the issues and finding the right cause can lead to a better treatment.

Titrating the medicine goes something like this:

• If symptoms are well controlled and there are no significant side effects, the medicine should be continued at the current dose. 
• If symptoms are not well controlled and there are no side effects that prohibit increasing, the dose should be increased as tolerated. 
• If symptoms are not well controlled (i.e. room for improvement) but there are side effects that prohibit increasing the medicine, consider a longer period of watching on this dose versus changing to a new medicine.

Things to consider

Time Off: Once a good dose is found, parents often ask if medicines need to be taken every day. Drug holidays off stimulants were once universally recommended to help kids eat better and grow on days off school. Studies ultimately did not show a benefit to this, and some kids really can't take days off due to behavior issues, including safety issues while playing (or driving for older kids). It also seems that when kids are off medicine they do not have good self esteem due to repeated failures, so taking medicine regularly is important to them.

When kids can manage their behavior adequately, it is not wrong to take days off. Stimulants work when they work, but they don't build up in the body or require consistent use. (This is not true for the non-stimulants, which are often not safe to suddenly start and stop.) Some kids fail to gain weight adequately due to appetite suppression on stimulants, so parents will take drug holidays to allow better eating. Days off the medicine also seems help to slow down the need for repeated increases in dosing for people who are rapid metabolizers.

Talk to your child's doctor if you plan on not giving your child the medicine daily to be sure that is the right choice for your child.

Remembering the medicine: It is difficult to get into the habit of giving medicine to a child every day. I wrote an entire blog on remembering medicines. My favorite tip is to put the pills in a weekly pill sorter at the beginning of each week. This allows you to see if you're running low before you run out and allows you to see if it was given today or not. These medicines should not be kept where kids who are too young to understand the responsibility of taking the medicine have access.

Controlled substances: Controlled substances, such as stimulants, cannot be called in or faxed to a pharmacy. They cannot have refills, but a prescriber can write for either three 30 day prescriptions or one 90 day prescription when they feel a patient is stable on a dose. Stimulants are not controlled substances because of increased risks to the individuals it is prescribed for, but because they have a street value -- teens often buy them from other teens as study drugs. This can be very dangerous since it isn't supervised by a physician and the dose might not be safe for the purchaser. It is of course illegal to sell these medicines. The DEA does monitor these prescriptions more closely than others. If the prescription is over 90 days old, many pharmacists cannot fill it (this will vary by state), so do not attempt to hold prescriptions to use at a later time.

Acids and Stimulants: It has been recommended that you shouldn't take ascorbic acid or vitamin C (such as with a glass of orange juice) an hour before and after you take medication. The theory is that ADHD stimulants are strongly alkaline and cannot be absorbed into the bloodstream if these organic acids are present at the same time. High doses of vitamin C (1000 mg) in pill or juice form, can also accelerate the excretion of amphetamine in the urine and act like an "off" switch on the med. In reality  have never seen this to be an issue. If anyone has noticed a difference in onset of action or effectiveness of their medicine if they take it with ascorbic acid or vitamin C, please post your comment below.

When Mom and Dad disagree: It is not uncommon that one parent wants to start a medication for their child, but the other parent does not. It is important to agree on a plan, whatever the plan is. Have a time frame for each step of the plan before a scheduled re-evaluation. If the plan isn't working, then change directions. If kids know it is a disagreement, they might fear the medicine or think that needing it makes them inferior or bad. Do not talk about the diagnosis as if it's something the child can control - they can't. Don't make the child feel guilty for having this disorder. It isn't fair to the child and it only makes the situation worse.


Having the medicine when you need it-- 

Refills: There is nothing more frustrating for a parent and child than to realize that there's a big test tomorrow and you have no medicine left and you're out of refills. Be sure to know the procedure for refills at your doctor's office. By federal law we cannot give more than 3 month's worth of a stimulant medicine. They cannot be called in to a pharmacy. In my office we see patients at least every 3 months (more often when starting a medicine or if changes are needed). I advise that they schedule the next appointment as they leave the office so they don't forget to schedule. I make these appointments longer than standard "sick" appointments, so it is hard to sneak one in on the same day. 

Travel: It is very important to plan ahead prior to travel. If you forget your child's stimulant, no one can call out a prescription since it is a controlled substance. You must plan ahead so that if a refill will be needed during the trip you will either be able to fill a prescription you have on vacation or you will need to fill the prescription in advance. Most people can get a prescription 7 days prior to the 30 day supply running out, but not sooner, so you might need to fill a couple prescriptions a few days earlier in the month each to have enough on hand to make it through your vacation. It takes planning! If you are out of town and you realize you forgot your child's non-stimulant, call your doctor to see if they will call it out. Many of the non-stimulants are not safe to suddenly stop, so they are likely to call it out. Insurance is not likely to pay for these extra pills though if it was recently filled. 

Lost prescriptions: We are able to give up to three prescriptions at one time, but most pharmacists will not keep the prescriptions. This means that you must know where the prescriptions are and not lose them for 3 months. Lost prescriptions are handled differently by different prescribers, but all should take them seriously due to the controlled substance rules of the DEA. If a parent reports losing them frequently, that usually leads to consequences, so be sure you know how your doctor handles this situation. I will generally allow a parent to write a letter documenting the lost prescription and I document this in the medical record in a way that is easy to see at future visits. If this repeats, I will not be able to continue to prescribe a controlled substance for that family, which only makes the child suffer. 

Mail order: Some insurance companies will allow mail order 90 day prescriptions. Some not only allow, but require them on daily medicines. Others do not allow it. In general I advise against a 90 day prescription if the dose is not established or if there are any concerns that it might not be the perfect dose. If there is any concern that it might need to be changed, a 30 day prescription is a better option. If you will need to do a mail order, be sure you schedule your appointment to get the prescription early enough to account for the lost time mailing. 

Before your visit:

Before you meet with your physician to discuss a new ADHD diagnosis or a possible change in treatment plan, be sure to get the following information and have it available at the visit or the visit will not be as productive as you desire:

• Insurance formulary
• Standardized testing from teachers, parents, and other significant adults 
• Verify if your child can swallow a tic tac or pill 
• Any contributing family history (family member responses to medications, family history of heart issues, etc)

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

References and resources:

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

ADHD Medication Guide

Parents Med Guide

Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder.

Learning and Behavior Series Part 4: Alternative Treatments for ADHD

This is the 4th article in a series of learning and behavioral problems. It will focus on non-prescription medicine treatments, natural treatments, psychological and occupational therapies, and complementary alternative therapy for the treatment of ADHD. This is a bigger topic than I initially thought, so there are many links that go more in depth with each subtopic.

Cognitive Behavioral Therapy

The first treatment for ADHD in children under 5 years should be cognitive behavioral therapy (CBT) with a licensed therapist. It also helps those of all ages learn techniques to control behaviors, screen thoughts before speaking, organize things, and more. Studies show that the best benefits for ADHD are a combination of medication and CBT for those over 5 years of age. CBT for younger kids involves a parenting style that is clear, consistent and has rewards and consequences. Working with a therapist involves parents more than the children. As kids get older, the therapist works with them to work on their own behavior.

Exercise and Going Green

Getting kids outside has many benefits for kids with ADHD. First, they are off all screens - which increase aggressiveness and impulsivity. Second, they are getting exercise. Studies show that when kids play outside their focus, attention, and behavior improve.

Exercise is beneficial to everyone on many levels, and in those with ADHD it is essential to help with overall focus and attention. Exercise helps to elevate the same neurotransmitters that are increased with stimulant medications, which helps with focus and attention and executive functioning skills (sequencing, working memory, prioritizing, inhibiting, and sustaining attention). Any exercise helps, but studies show the best are martial arts, ballet, ice skating, gymnastics, yoga, rock climbing, mountain biking, skateboarding, and whitewater paddling (I know not all of these are practical on a regular basis, but most are). These activities require sustaining attention, balance, timing, fine motor adjustments, sequencing, evaluating consequences, error correction, and inhibition.

Sleep

Sleep problems are common in many children, especially those with ADHD. Fixing the sleep cycle can have extreme benefits in learning and behavior. Sometimes it is as easy as getting a routine for sleep to ensure the proper number of hours for a child, but often they suffer from insomnia, nightmares, sleep apnea, restless leg, or other medical conditions that impair sleep time and/or quality. Symptoms of chronic sleep deprivation in kids are hyperactivity, poor focus, and irritability. There are many kids who can have all of their ADHD symptoms relieved when they simply get better sleep. I see this in many teens who suddenly "develop ADHD"- only it's really not ADHD at all. They are running on 4-5 hours of sleep a night. If your child has sleep troubles not improved with these Sleep Tips, talk to your child's doctor.

Occupational Therapy and Sensory Training

There are many kids with ADHD who benefit from using techniques that occupational therapists use with sensory processing disorder (SPD). In some kids, SPD might be the real diagnosis causing symptoms of ADHD, but in others they may co-exist. Treating SPD is usually fun for the kids, and there is no harm in doing their techniques even if a child doesn't have the disorder. Schools have started integrating these ideas into their classrooms as needed, such as having kids sit on stability balls or using tactile objects at their desks. Therapy for SPD involves playing in ways that use sensory input (such as with sand or play doh, rolling down a hill, manipulating tactile objects, and more). For a great list of ideas visit Sensory Integration Activities, but working with an occupational therapist is recommended.

Biofeedback and Neurofeedback

Biofeedback and neurofeedback are both approved therapies for ADHD. Children and adults with ADHD often have abnormal patterns of brain electrical activity on electroencephalographic (EEG) testing. EEG biofeedback is aimed at normalizing EEG activity by correcting the brain’s state of relative under-arousal and optimizing cognitive and behavioral functioning.

Neurofeedback trains kids to become more aware of their physiological responses and improve their executive functioning. Each neurofeedback session lasts 30-60 min and children usually need 10-20 sessions. Patients wear a cap that measures their brain activities, and it helps them train their brain to maintain focus during video games specific to this purpose.

The significance of most findings on neurofeedback and EEG biofeedback is limited by study design flaws that include small study sizes, heterogeneous populations, absence of a control group, inconsistent outcome measures, self-selection bias, and limited or no long-term follow-up. While this doesn't mean they don't work, I would like to see more studies showing their benefit.

Working memory training

Working memory training has been shown in studies to help with symptoms of ADHD, though there are some conflicting studies out there. Cogmed is the company that has studies showing benefit. It is a computer program that kids play like a video game, but it reportedly trains their brain to remember things. It is intensive: 1 hour a day, 5 days a week for 5 weeks, but can be done at home. It is expensive and not covered by insurance. About 70-80% of children show improvement immediately after the training, and of those who improved, 80% maintained the benefit over a 6 - 12 month window. Cogmed is designed to be used with medication, such as stimulants.

Herbs and other supplements

There are some studies (only 16 as of June 2011 -- 11 for nutritional supplements and 5 for herbal supplements, which in the research world is pretty small) supporting nutritional supplements or herbal medicines for ADHD, but many reported treatments have not been found effective. Pinus marinus (French maritime pine bark), and a Chinese herbal formula (Ningdong) showed some support. Zinc and iron both show benefit, but as discussed in Part 3 of this series, both can be dangerous at high doses. There was only mixed (mainly inconclusive) evidence for omega-3 and l-acetyl carnitine. Current data suggest that Ginkgo biloba (ginkgo) and Hypercium perforatum (St. John's wort) are ineffective in treating ADHD.

ADHD Coaching

Just like anyone who needs help improving a skill, such as a pitcher or golfer, working with a coach with experience helping others in that area, working with an ADHD coach can help many with certain aspects of their life. ADHD coaches can help with organization, motivate a person with ADHD to finish tasks, or help them learn techniques that makes them more effective at life skills. Coaches do not do psychotherapy or counseling, which is beneficial for people who are against therapy, but agree that coaches can help people improve skills. It does not work if the parent makes the child go. The child must be motivated to make changes in his or her life and be willing to work on things, then coaching can be great. Tips on finding an ADHD coach can be found on PsychCentral.

Nutrition

Nutrition is very important for learning and behavior in all kids. For more on components of nutrition, elimination diets, and supplements, see Part 3 of this series.

No strong evidence exists for the following: 

There are many alternative treatments out there that do not have scientific proof that they help. Many parents try these treatment programs in hope that their child's symptoms will go away. In general, if it sounds too good to be true, it probably is. Don't be fooled into thinking "alternative" or "natural" treatments are without risk. There are always risks, including the lost time not being on a proven therapy, leading to a child falling further behind academically and suffering emotionally from symptoms related to ADHD.

Brain Balance has a center in our city, and I've seen more than a few parents who waste time and money on their program. I don't know of any that noted significant and continued benefit. Although their website might look like there's impressive evidence to use it, there really isn't. Please see Science Based Medicine: Brain Balance for more information.

Caffeine is a stimulant but since it is available from grocery stores instead of pharmacies some parents feel more comfortable using it instead of a medication. If you're using it as a drug, it is a drug. Whether it comes in a beverage or a pill, it is a chemical with properties that act like other drugs in our bodies. Unfortunately studies don't really support its use. It is difficult to dose since it comes in so many forms, and most people develop a tolerance for it, requiring more and more, which can increase side effects. For details, see Science Based Medicine: Caffeine for ADHD.

I have not been able to find any valid scientific studies for chiropractic medicine for the treatment of ADHD.

Other complementary and alternative medicine (CAM) therapies that have been tried for ADHD but fail to show benefit include vision training and applied kinesiology. Insurance usually does not cover these and they can be quite expensive. I do not recommend them.

Remember...

There is no alternative medicine. There is only medicine that works and medicine that doesn't work. ~ Richard Dawkins

If it stays alternative, that must say something. Once an alternative treatment is shown to work, it becomes a preferred treatment, no longer an alternative...

Things to consider when choosing treatment plans: 

• First, be sure your child is properly assessed to make the best diagnosis on which to base the treatment plan.
• Natural isn't necessarily safe. Evaluate all the risks and benefits known before making a decision. Even exercise (which is always recommended) comes with risks, such as injury and at times sleep problems due to scheduled activity times.
• Talk with your doctor about any treatments you are doing with your child-- including vitamins, supplements, herbs, brain training, therapies, etc.
• Choosing one treatment doesn't mean you are married to it. If response doesn't prove to be beneficial, re-think your approach.
• There is no cure for ADHD known at this time. If someone claims that they can cure your child, don't buy into it. 
• Learn your costs. Does insurance cover it? Insurance companies often prefer certain treatments due to their cost and other factors. They also do not cover many treatments. Sometimes this is again due to cost, but other times it is because there is no evidence to show the treatment is effective. (Hint: This is a good clue to look at other treatments!)
• Is the treatment something your child can do and is your family willing to put in the time? CBT is proven to help, but it doesn't work if the child and parents don't work on the techniques at home. Neurofeedback and Cogmed take many hours of treatment over weeks of time and are not guaranteed to work in all children.  Medications must be titrated to find the most effective dose that limits side effects. This requires frequent follow up with your doctor until the best dose is found.

Sources:

The ADDitude Guide to Alternative ADHD Treatment
WebMD: Attention Deficit and Hyperactivity Disorder: Alternative Treatments 
American Psychological Association: Easing ADHD Without Meds
Psych Central: Neurofeedback Therapy an Effective, Non-Drug Treatment for ADHD

Psychiatric Times: Integrative Management of ADHD: What the Evidence Suggests

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan

Choosing a Physician For Babies and Children

I'm taking a break in the middle of my Learning and Behavior Series to answer a question that is often asked: How should parents choose a physician for their children?

photo source: Shutterstock

Most parents will spend a lot more time and effort in choosing a doctor for their children than they do picking a doctor for themselves. Finding the right fit is important. If you disagree with the doctor's treatments or don't feel comfortable asking questions, they aren't the right fit.

This blog will list a lot of questions to consider. It is mostly geared toward new parents, but if you have children already you should have an idea about what you liked and disliked about your child's last doctor. Use that knowledge to pick the new doctor. Unless you can book a three hour appointment with a doctor (I will say right now that no one really wants that), you will not get to all of these questions, so look ahead on their websites to see if you can find answers, then prioritize the questions that are important to you to ask first.

Pediatrician vs Family physician?

Family physicians and pediatricians both care for newborns. Some family physicians have quite a bit of experience with babies and children, others not so much.

I am of course biased toward pediatricians because they spend their entire three years of residency training after 4 years of medical school learning to take care of children birth through adolescence and transitioning into young adulthood. We continue to do continuing education in the area of children, giving us the opportunity to keep up on the newest recommendations. If you choose a pediatrician, ask how long they will see children. Most will see kids at least until 18 years of age. Many of us will see kids through college.

Family doctors learn to take care of people from birth until old age in that same three year period of residency, and much of their training is in the problems associated with getting old. Many do not keep up with the newest recommendations for children as research changes guidelines because there is so much information to keep up with adult medicine. If you choose a family physician, be sure they have experience with infants and young children.

References 

Ideally you will be able to ask friends, coworkers, and family members what they like and dislike about their pediatricians. Remember that everyone has different goals and experiences, so ask specific questions that might make a difference to you and remember that their view is colored by their experience. They might just say "the doctor's schedule is difficult to work with and they don't work with me" but they don't share that they had to reschedule an appointment because they were 30 min late and they were upset when they demanded that the doctor call out a prescription without being seen and the doctor refused. Or maybe they say that the doctor never does the right thing because they want "quick fixes" for all illnesses but the doctor uses standardized recommendations to avoid antibiotics for viral illnesses. Getting a variety of opinions helps to see if there's a trend toward that problem or if it's an isolated event.

Insurance

Unless you plan to go concierge, one of the first things you should do is look at the insurance of your future baby (or current children) to see which physicians are on the list. Compare the list of providers to the list of references you get from your friends and family. Don't forget to add your child to the insurance plan as soon as possible! There is usually a time limit of 30 days, and if you miss the opportunity, you will have to wait until the next open enrollment period. Mothers often assume the baby will be automatically added to her insurance, but if they don't get the paperwork and payment from you, baby is not added. Also watch your mail... insurance companies often will send a coordination of benefits that you must return to state whether or not baby is on another plan in addition to the one you signed up for. I suspect it is a delay tactic for paying claims, but  that is for another blog.

Prenatal visit 

Many physicians offer a prenatal visit. Some do individual one on one visits, others do a group visit so people can meet many faces at the same time. This is a time to get to know the practice style and bedside manner of the doctor. Don't limit your "interview" to just the doctor though... Look to see if the office is clean. Are the faces friendly? When you called to schedule was there a phone tree or did you talk to a live person? Are staff members helpful answering questions? I always recommend interviewing at least two offices so you can compare, even if your friends only have great things to say about one of the offices. You would never buy a house after just looking at one, right? See your options.

Hospital care

Once you limit the list of names down to a few that you can personally meet, see if they are on staff where you plan to deliver. Most hospitals require the baby's hospital doctor to examine him/her within 24 hours of birth, but their physician is usually not at the delivery. While it is not imperative that your child meets his pediatrician at the hospital (there will be plenty of time to get to know one another the first few months after birth), it is nice to know if you will need a different pediatrician in the hospital. If your chosen doctor is not on staff where you're delivering, you can ask if they recommend someone on staff at the hospital to "babysit" while you're there. I really think it is less important for a doctor to see your child in the hospital than many new parents perceive. They are often disappointed if a non-chosen doctor (even in the same group) is doing hospital rounds the days they are there, so they miss their chosen doctor. In reality, the hospital course is important, but with good communication between the hospital doctor and the long term doctor, good care will still happen. There is a lot of time later to get to know one another in the office setting. If you think about it, if your child's doctor spends too much time in the hospital doing rounds, he or she won't have as much time in the office to see your for visits for the next 18-22 years! Most newborns should be seen 1-2 days after discharge (unless they have been in the hospital longer than the typical 36 - 72 hours). Ask the doctors you interview when they usually see babies for the first visit in the office.

Office Availability and Policies and Physician's Practice Style

It is important that the office is accessible as much as possible. If it is far from home, work, and daycare, it will not be easy to run in when your child falls ill. The more hours they are open, the easier it will be to be able to go there for care, but the less likely you will see the same person each time. Things to consider (not all of these will be important to everyone, so think what your needs and goals are):

• What are the hours for scheduled appointments?
• Are there walk in hours, and if so what are they? Are they billed with an urgent care charge or a regular office visit?
• What are after hour options if a child is sick or injured? 

• Do they use a triage phone service or do they take their own calls? 
• Are there charges for after hour services? 

• Where do they recommend patients go after hours if needed? 

• How long is the average wait time for an appointment for a sick visit? 
• How long is the wait for a well visit (physical exam)? 
• Do they charge for forms to be filled out and will they fill out forms outside of visits?
• Do physicians outside of the office cover on weekends, vacation time, or after hours? If they do, how is that handled with billing and insurance? (Many solo or small group practices team up with trusted colleagues outside of their practice to help them all have a personal life. Yes. It's true. Even doctors like to see their families sometimes.) 
• Is there a portal that allows secure electronic messaging for non-urgent questions?
• Do they offer on line appointment requests or scheduling?
• Do they offer on line bill pay?
• Do they use electronic health records? If so, do they think it slows them down or has more benefits? Will you have access to the records?
• Do they have an in-house billing staff or do they use a billing service?
• How are medical questions during office hours handled? Is there a set time for phone calls to be returned or is it done throughout the day? Can you call and speak to a nurse? Do you have to schedule an appointment to talk to the doctor?
• Is the location convenient to home, work, and/or daycare? Is parking convenient? If there are multiple locations, does your doctor have set hours at each location or at just one? Will you be expected to drive to various locations depending on day of the week or time of day?
• If you choose a doctor in the practice, are you able to see other providers in the office if it is easier on your schedule or are you limited to just that doctor?
• If they have physician extenders (nurse practitioners and physician assistants) will there be times that you must schedule with or use them? Can you choose an NP or PA instead of a doctor if you like their style best?
• Are there other specialists in the office, such as nutritionists, psychologists, lactation nurses, etc?
• What is the general schedule for well visits? 
• Are immunizations available at the office?
• Are labs and X-rays done at the office or at a location preferred by insurance?
• Do they offer general advice on their website? Is it their own advice or do they purchase rights to use another database of information? If it's their own, is it updated regularly or out of date information?
• Is there a separate waiting room for well and sick kids? I included this because it's on just about every list of questions to ask and I think it's a really bad question. I have admitted two kids in my 15 years in practice from their "well visit" -- both times the parents knew the kids were sick, but waited until the well appointment so they wouldn't have to come in twice in one week. Both kids had pneumonia and required oxygen and iv antibiotics in the hospital. Both would have sat in the "well" waiting room if we had it structured that way. In the winter most kids have a runny nose and cough at their well visits. Research shows that it is falsely reassuring to sit in the "well" waiting room for a scheduled physical, because kids come in for "well" visits sick or have siblings with runny noses that tag along. Some "sick" appointments are for injuries-- should they sit next to the kid with the vomiting bucket? I prefer that the waiting room is regularly cleaned and people don't spend much time there. Exam rooms can be cleaned before each family, and if families spend most of the wait in the room, it is less risky for catching something. I also think toys in a doctor's office are means to spread germs. Bring your own toys and books. And have everyone wash (or sanitize) hands when they leave.
• Another question I usually see listed but don't like is "Do you run on time?" If they say "always" either they are 1. not popular, 2. brand new, or 3. lying. (I guess concierge docs can probably say always because they only see a few people per day.) Most doctors can run late at times -- it just takes one really sick patient, one parent with a lot of questions, or a room of behaviorally challenged children, to get a doctor behind. It happens. They can run on time 99% of the time, but if you're waiting with sick screaming kids, that doesn't help. What do they do to get back on track? Do they have other providers in the office help? Do they have "catch up time" built into the schedule? Do they shorten later visits to catch up? Do patients just wait? For more on waiting times, please see my previous post on Waiting Times.
• How do they educate and update parents on new practice information or new pediatric recommendations? Do they have a social media presence? Do they send out newsletters? Does their website have a News section -- and is it updated regularly? If you're not online, do they offer paper copies of that same information? 
• Are physicians board certified or board eligible? After residency new physicians must pass a standardized test to become board certified. Between the time they finish residency and pass the test they are considered board eligible. If they do not pass after 7 years (for pediatrics) they are no longer considered board eligible. They might just be bad test takers, but...

• What is the physician's recommendation for common questions, such as breastfeeding, circumcision, car seats, use of antibiotics, starting solids, etc? Pick topics that mean something to you. If they are not on the same page as you with these, they will probably not be on the same page for other things.
• How does the doctor keep up to date with current recommendations?
• Do physicians admit sick children to a hospital or do they refer to hospital based physicians? Use of hospitalists is becoming more common throughout the country and in some markets is standard.
• How does the doctor feel about specialist referrals? Some doctors like to handle a variety of issues, others are quick to refer before beginning a basic evaluation and treatments. Being able to stay in the medical home is great if the doctor is competent and comfortable managing issues. It is less expensive, comprehensive, and often more convenient for families. 
• Do physicians in the office handle minor emergencies, such as laceration repair, broken bones, concussions, etc? How do they work that in to their schedule?
• Are physicians able to manage most children with asthma? Can they monitor oxygen levels, do breathing treatments, check lung function, etc? 
• What is the policy on calling out medications? 
• Do the physicians in the office treat ADHD, depression, anxiety, and other mental health issues?
• What is the physician's view on vaccines? Do they require them? 
• Does the physician have an area of interest, such as infectious disease, endocrine, or behavior? 
• If you have a special needs child, does the physician have experience with that disorder? I'm not saying they should be excluded if they don't. Are they willing to learn about the disorder and help you identify needs? I have a couple patients with different rare disorders I had never heard of before knowing them. They also see specialists locally and each have a guru specialist outside of the area that is nationally known for that disorder since there are few patients with the issue. The important thing is that I was willing to spend time learning about the issues associated with each disorder and how to help the families get the help they need.

I really think that the most important thing in a doctor/patient relationship is trust. If you feel uncomfortable talking to the doctor or if you disagree with what they say, it is hard to have trust. If you and the doctor are constantly butting heads about treatment plans, it is best to find someone more on the same page as you. If you know you want an antibiotic for every runny nose, but the doctor limits antibiotics to medically indicated instances, you will not be happy. If you do not plan on immunizing your child and the doctor's office requires vaccines, it obviously won't be a good situation. 

Remember that there are many choices in parenting. Most of the time you will make the right one, but if not you can usually change directions and find what works for your family. The same is true with the choice of a physician. Pick the one that seems like the best fit. If you are having problems, talk with the doctor. Often times this is best done as a phone call or letter so that a long discussion does not interrupt their patient schedule, making others wait. But is still important to share your concerns. He or she might not realize that the front staff was rude or that it took so long to get an appointment. They might presume you were happy with the treatment plan because you didn't ask questions or state your opinion. If you don't speak up, they will never know. Lack of communication is the root of most problems. If after discussing your concerns things don't change, then it is time to make a change to someone that makes a better fit.

Learning and Behavior Series Part 3: Nutrition, Elimination Diets, and Vitamins

This is the third article in a series on Learning and Behavior. It covers some diets that have been recommended for various learning and behavioral benefits, including elimination diets and supplements that might benefit. There will be another part focused on supplements.

Most of us have heard of the claims of cures for all sorts of ills, including behavioral problems (especially ADHD and autism) with simple dietary changes (with and without supplements).

Fears of side effects from long-term medication or a history of medication failures cause families to look for alternative treatment options for child behavior issues. Diet modification and restriction is intriguing for parents since it fits into the ideal of a healthy lifestyle without added medicines and their potential side effects. However, there is a lot of controversy as to whether these restrictions help except in a small subset of children who have true allergy to the substance.

In general if a simple solution through diet was found, everyone would be doing it. That just isn't happening.

I do think that we all benefit from eating real foods -- the ones that look like they did when they were grown, not processed and packaged. Fruits, vegetables, protein sources, whole grains, and complex carbohydrates should be the basis for everyone's diet. It's just good nutrition. But the direct effect of special diets on learning, behavior, and conditions such as ADHD shows limited effects.

Natural does not equal safe. When my kids were young and picky eaters I never would have considered stimulating their appetite with organically grown marijuana. While it is all natural (even organic!) and it might increase their appetites, it would have risks, right? In this case I don't think the risks would outweigh the benefits. But so often parents think that if it's natural, it's healthier than something made by man. Drugs have been tested. They have risks too, but those risks are a known. Some natural therapies have not been as thoroughly tested and they are not regulated, so the label might not correctly identify the contents. For this reason, I think that healthy foods are a great option for everyone, but I hesitate to recommend a lot of supplements, especially by brand.

Over the years there have been many foods or additives that have been blamed for causing learning and behavioral problems. Some of the proposed problematic foods:

• food dyes
• refined sugars
• gluten
• salicylate and additives
• dairy products
• wheat
• corn
• yeast
• soy
• citrus
• eggs
• chocolate
• nuts

I'm sure the list goes on, but I've got to move on.

Food additives have long been blamed for learning and behavior problems. Back in 1975, Dr. Ben Feingold hypothesized that food additives (artificial flavors and colors, and naturally occurring salicylates) were associated with learning disabilities and hyperactive behavior in some children. Since then many case reports of similar claims have continued to surface, but those do not have the same weight as a double-blinded control study. Most studies done in a scientific manner have failed to show a benefit. There are studies that show improvement in some children who avoid artificial dyes. In my opinion it never hurts to eliminate artificial dyes in your child's diet. If it helps, continue to avoid them. But if no change is noted, don't continue to rely on dye avoidance as a treatment plan.

Another elimination diet that I would not recommend is the GAPS (Gut and Psychology Syndrome) diet, designed by Dr. Natasha Campbell-McBride. She asserts that a wide variety of health problems  (autism, ADHD, schizophrenia, depression, and more) are from an imbalance of gut microbes. Not only has it not been proven to work, I worry that it restricts healthy foods, such as fruits, and kids will develop other problems on this diet. I cannot go into details in this space, but for more information visit Science Based Medicine: GAPS diet.

Gluten is in the news to be the base of many problems. It seems to be a fad to go gluten free for just about any ailment you can think of. There are a subset of people who are really sensitive to gluten, and they benefit greatly from a gluten free diet. But the large majority of people gain no direct gluten free benefit from this expensive and restrictive diet. One indirect benefit of the diet is that it is nearly impossible to eat pre-packaged and processed foods, which leaves real fruits, vegetables, and other high quality foods. (As more people are going gluten free there are more pre-package products made gluten free. I wonder if the benefits people have noticed previously will wane when they eat these foods. ) Talk with your doctor before deciding if going gluten free will work for your child.

Sugar is often blamed on hyperactivity. By all means, no child needs extra sugar, so cut out what you can. Well controlled studies did not find a behavioral difference in kids after refined sugars. Interestingly though, parents still perceived a change (despite researchers finding none) in at least one study (Wolraich, Wilson, and White. 1995).

Food allergies are now commonly thought to be related to behavior and learning problems. In some children with true allergies, foods can affect behavior. However, most children do not have food allergies and avoiding foods does not alter behavior. It can be challenging to determine if there is a food allergy since some of the tests offered are not reliable. It is a small subset of kids that food avoidance helps, but in the large majority studies do not support avoidance of foods. If you think your child benefits from avoiding one or two foods, it probably isn't a big deal to restrict those foods. But if you suspect your child is allergic to everything under the sun, you will need to work with your doctor and possibly an allergist and a nutritionist to determine exactly what your child must avoid and how they can get all the nutrients they need to grow and develop normally. 

Supplementation with vitamins, minerals, and essential fatty acids [arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA)] is gaining popularity. There are some studies that show people with ADHD have low levels of certain vitamins and minerals. More studies are being done to determine if supplementing helps symptoms. There is growing evidence for vitamin supplementation, but there are no standard recommendations yet. For children without a known vitamin deficiency, a standard pediatric multivitamin can be used. Clinical trials using various combinations of high dose vitamins such as vitamin C, pantothenic acid, and pyridoxine suggest that these have no effect on ADHD. I don't recommend high dose vitamin supplements unless a specific deficiency is identified (and I don't routinely screen for deficiencies at this time). I have no problems with anyone taking a multivitamin daily, but cannot recommend any specific brand since none of them are regulated by the FDA and there are many reports that show the label often misrepresents levels of what is really in the bottle. My advice is to buy a brand that allows independent lab testing of their products if you choose to buy any vitamin or supplement.

The following is adapted from the University of Maryland Medical Center with the help of ADDitude Magazine and Natural Medicines Comprehensive Database.

• Magnesium -- Symptoms of magnesium deficiency include irritability, decreased attention span, and mental confusion. Some experts believe that children with ADHD may be showing the effects of mild magnesium deficiency. In one preliminary study of 75 magnesium-deficient children with ADHD, those who received magnesium supplements showed an improvement in behavior compared to those who did not receive the supplements. Too much magnesium can be dangerous and magnesium can interfere with certain medications, including antibiotics and blood pressure medications. Talk to your doctor. 

• Vitamin B6 -- Adequate levels of vitamin B6 are needed for the body to make and use brain chemicals called neurotransmitters. These include serotonin, dopamine, and norepinephrine, the chemicals affected in children with ADHD. One preliminary study found that B6 pyridoxine was slightly more effective than Ritalin in improving behavior among hyperactive children - but other studies failed to show a benefit. The study that did show benefit used a high dose of B6, which could cause nerve damage, so more studies need to be done to confirm that it helps. If it is found to help, we need to learn how to monitor levels and dose the vitamin before this can be used safely outside of research centers. Because high doses can be dangerous, do not give your child B6 without your doctor's supervision. 

• Zinc -- Zinc regulates the activity of brain chemicals, fatty acids, and melatonin, all of which are related to behavior. Several studies show that zinc may help improve behavior, slightly. Higher doses of zinc can be dangerous, so talk to your doctor before giving zinc to a child or taking it yourself.  

• Iron -- Iron deficiencies can occur in children due to inadequate dietary sources (kids are picky!) and many other causes. Iron is needed for the synthesis of dopamine, norepinephrine, and serotonin- all neurotransmitters in the brain. Low iron has been linked to learning and behavior problems. Too much iron can be dangerous, so talk with your doctor if you want to start high dose supplements. (Regular multivitamins with iron should not cause overdose if used according to package directions.) It is important to follow labs to be sure the iron dose is not too high if supplementation with higher than standard doses of iron are given. For information on sources of iron in the diet, labs done to check for iron, and more, visit Iron Deficiency Anemia.

• Essential fatty acids -- Fatty acids, such as those found in fish, fish oil, and flax seed (omega-3 fatty acids) and evening primrose oil (omega-6 fatty acids), are "good fats" that play a key role in normal brain function. The results of studies are mixed, but research continues. If you want to try fish oil to see if it reduces ADHD symptoms, talk to your doctor about the best dose. Some experts recommend that young school aged kids take 1,000-1,500 mg a day. Kids over 8 years should get 2,000-2,500 mg daily. For ADHD symptom control it is often recommended to get twice the amount of EPA to DHA.

• L-carnitine -- L-carnitine is formed from an amino acid and helps cells in the body produce energy. One study found that 54% of a group of boys with ADHD showed improvement in behavior when taking L-carnitine, but more research is needed to confirm any benefit. Because L-carnitine has not been studied for safety in children, talk to your doctor before giving a child L-carnitine. L-carnitine may make symptoms of hypothyroid worse, and may increase the risk of seizures in people who have had seizures before. It can also interact with some medications. It should not be given until you talk to your child's doctor. It is not generally recommended at this time.

• Vitamin C -- Vitamin C can help modulate the dopamine levels in the brain. It can affect the way your body absorbs medications (especially stimulants for ADHD) so it is best to avoid vitamin C supplements and citrus fruits that are high in vitamin C within the hour of taking medicines. Preliminary evidence suggests that a low dose of vitamin C in combination with flaxseed oil twice per day might improve some measures of attention, impulsivity, restlessness, and self-control in some children with ADHD, but more evidence is needed before this combination can be recommended.

• Proteins -- Proteins are great for maintaining a healthy blood sugar and for keeping the brain focused. They are best eaten as foods: lean meats, eggs, dairy, nuts and seeds, legumes, and fish are high protein foods. Most people in our country eat more protein than is needed. If your child does not eat these foods in good quantity, there are supplements available, but talk with your doctor to see if they are appropriate for your child. Many of the supplements are high in sugar and other additives. Some have too much protein for children to safely eat on a regular basis.

In general I think we all should eat a healthy diet that is made up primarily of fruits, vegetables, lean proteins, and complex carbohydrates. If children are on a restricted diet due to allergy or sensitivities to foods or additives (or extreme pickiness), be sure to discuss their diet with your doctor and consider working with a nutritionist to be sure your child is getting all the nutrition needed for proper growth. If supplements are being considered, they should be discussed with your doctor so he or she can help decide which are right for your child.

More Quest for Health blogs on ADHD:

• Why get diagnosed?
• Who's Who in ADHD Treatment
• Nutrition, Elimination Diets, and Vitamins
• Alternative Treatments
• Medications
• Generic Methylphenidate HCl ER (for Concerta)
• Red Dye #40 and Hyperactivity
• Homework Battle Plan