Cholesterol - something to watch in childhood

Since our office has adopted new screening protocols based on the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, we have seen many questions and resistance. I suspect the resistance is due to the fact that kids hate needles and parents aren't sure if insurance will cover the cost of labs. Some families simply have a difficult time taking kids to a draw station.

These guidelines cover additional topics, such as blood pressure and tobacco exposure, but I will only discuss the most common questions specific to the cholesterol measurements here. A lipid panel includes the total cholesterol, triglyceride level, high density lipoproteins (HDL, "good" cholesterol), and low density lipoproteins (LDL, "bad" cholesterol). Some labs include other types of lipids.

My office website discusses the basics of cholesterol.

The dietary advice is summarized nicely in CHILD-1 Diet and Nutrition Recommendations -Childhood Nutrition Basics.

Preparing for the lab draw

If your child hates needles, I understand. But some things are important, and in pediatrics we focus on prevention. If we can prevent heart attacks, strokes, and other consequences of unknown risks of heart disease, we should.

Kids can be prepared before going to the lab. NEVER say it won't hurt. Everyone perceives pain differently, but if they know it might pinch or feel like a poke they will be prepared. Remind them it only pokes for a very short time usually and holding still helps it go faster. Tell them there will be a big rubber band called a tourniquet that will squeeze the top of their arm to help make it easier for the needle to find the right spot.

Let them watch this video on lab draws.  (Warning, this video does show a blood vial being filled... some people get queasy just seeing things like this.)

You can practice at home by letting them show you how they will hold still with their arm out. They can look away and take big breaths with a strong forceful blow out each time. You can wipe the arm with a cotton ball or tissue and talk about how that part tickles. Maybe they can pretend they're blowing out candles or they can blow on a pinwheel.

Make sure they are well hydrated with water before going to the lab. Remind the phlebotomist (who draws the blood) that studies show blowing out upon the insertion of the needle has been shown to decrease pain with injections, and I suspect also with lab draws. You can also use a video on your smartphone or tablet to distract during the draw.

What affects when you should take a child for the lab?

A child should be on his or her regular diet for 4-6 weeks before testing to reflect the child's true levels. If a child vacationed and ate fast food for a week but typically eats a healthier diet, the levels will be skewed toward the more recently eaten foods. If they often eat poorly, do not alter the diet for the purpose of the lab. Get a baseline that is accurate to their lifestyle.

Illness can also affect lipid levels, so ideally children will be overall healthy when the lab is drawn. If there was a recent significant illness, waiting 4-6 weeks to draw the lab is ideal. Significant illness would be one that requires hospitalization or surgery. If oral steroids were given, it would be best to wait at least 4 weeks. An upper respiratory infection, cough, or typical short term illness should simply be resolved before the draw. You would not need to wait 4-6 weeks for these common illnesses. If you are uncertain if an illness is significant, ask your doctor.

Fasting does not affect the total cholesterol significantly, but it does affect the triglycerides. It is recommended to fast 8-12 hours before having the triglycerides checked. This is most easily done by having children drink water in the morning without food or other drinks. Take them to the lab for the lab draw and then let them eat breakfast.

If it is not possible to take kids to the lab when they have fasted, be sure the lab knows that it is a non-fasting level. They will include this with the report so the doctor can evaluate the lab values with that important information. In general I do not enforce fasting if it is too inconvenient unless there is a history of a previous elevated triglyceride. If the triglyceride level has been high on a previous lab, it is important to do a fasting level to see if it is a real risk or due to a recent meal.

Why do we need to check cholesterol in children- isn't heart disease an adult problem?

We know that obesity increases the risk of having a high cholesterol and atherosclerosis.
Elevated triglyceride levels and obesity are associated with Type 2 diabetes. Children with obesity need routine monitoring of their cholesterol along with other chronic disease indicators.

Multiple studies show that parents often perceive their children to be a healthy weight, but in reality their diet and exercise are not healthy and their height and weight do not indicate health.

We know that a family history of people with high cholesterol or certain heart conditions increases the risk. Tobacco exposure increases the risk. Certain chronic diseases increase the risk of cardiac problems. All of these can be risks in otherwise healthy appearing children.

There are a significant number of children who have no known risk factors yet have an elevated lipid level. This can put them at risk for cardiovascular disease, but if it is known, steps can be done to lower that risk.

The simple answer is atherosclerosis (clogging of arteries) can begin in childhood, but has no symptoms at the early stages when treatment is most effective. There are some people who have a genetic predisposition to this despite healthy habits and an outward appearance of health.

Screening recommendations are done by age and risk.

Many things can alter the risk of cardiovascular disease, including genetics, recent illness, puberty, obesity, blood pressure and tobacco exposure. Guidelines take into account these factors to help determine when testing should be done. If risk factors are identified, a lipid panel should be done. All children, regardless of risks should be checked at 9-11 years and again at 17-21 years of age. If the levels are normal, a lipid panel should be repeated in 5 years. If abnormal or if risk factors change, the level will need to be repeated sooner, depending on risk.

From page 8 of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report 

What are you going to do with the results?

Many parents are frustrated if we find an elevated level but then "don't do anything about it." We are doing something. We just don't start with medicines because medicines are not the best answer. We recommend a healthy diet and daily exercise. Those two things are more important than many parents realize. They can make changes that benefit your child for life. But they must be done. Making healthy changes for the entire family benefits everyone and makes it easier for a child to comply with recommendations.

Repeat levels will be required to see if the diet and exercise changes make an impact. If the results are consistently elevated or significantly elevated to require medication, a referral to a pediatric lipid specialist is indicated.

See page 53 of the guidelines

See page 54 of the guidelines

If you have questions about cholesterol screening for your child, please talk to your child's doctor. 

Other Resources:

Pediatric Lipid Disorders in Clinical Practice Workup, Henry J Rohrs, III, MD et al

When should you potty train your kids?

It's common for parents to ask for help with potty training. Sometimes they're just done dealing with diapers. Or there's another baby coming soon. Often it's tied to wanting to be able to start preschool. Most preschools in our area require 3 year olds to be potty trained. Even daycares often require toddlers to potty train before moving up to the 3 year room. This move is usually accompanied by a price decline, which parents are excited to have.

Photo source: Wikimedia commons.
Fun seat, but I recommend smaller seats (potty chairs) for potty training.

Unfortunately, kids need to be ready to potty train. This typically happens between 18 months and 3 years, but it can be normal to not be ready until 4 years of age. Note: Nighttime dryness is not correlated with potty training. When kids are deep sleepers, they often urinate in their sleep despite perfect daytime control.

Types of potty training:

1. Infant potty training - the parent watches for infant cues and holds baby over the toilet (or wherever they want baby to pee/poop). The parent makes a noise each time baby pees/poops, and that sound becomes associated with toileting. 
2. Behavior modification - the parent gives the child a lot of fluids and puts him on the toilet frequently. When the child is successful on the toilet, he gets a reward. They are reprimanded for accidents. This is often called "train in a day."
3. Child-oriented - the parent educates a child about toileting and gets a potty chair for the child, but potty training only happens when a child shows interest. The parent uses praise and encouragement.
4. Parent-led - the parent sets the stage by allowing the child to get comfortable with the potty chair before the training begins. You do practice runs before going live. The parents offers praise and encouragement and simply changes clothing if there's an accident.
5. Bare bottom - just as this sounds, you let the toddler/preschooler run around naked with the expectation that they'll figure out what's going on.

Babies technically have the ability to hold their stool and urine much earlier than they are ready to potty train. Simply being able to hold urine or stool for a time doesn't mean a child is ready to potty train. Some kids tend to hold urine or stool too long if they potty train too early because they don't want to take the time to sit on the toilet. If they hold their urine, it can lead to over-distention of the bladder, daytime urine accidents, and urinary tract infections. If they hold their stool they become constipated, which can lead to abdominal pain, poor eating, and stool leakage.

There are infant training proponents. I am not one simply because I think it is time intensive and it trains the parent, not the child. If you're interested in training your baby, check out Infant Toilet Training. I haven't read any of the references listed after the article and have no experience with it. I'd love to hear comments from parents who have tried it - please comment below.

I hear many urologists discourage early potty training, but studies (here and here) fail to show that training early leads to long term problems. For one urologist's view, take a look at The Dangers of Potty Training Too Early.

There is relatively little research on the best approach to potty training, but the American Academy of Pediatrics supports the child-oriented approach based on expert opinions. One study found that children who had problems with daytime accidents or urinary tract infections were more likely to have been rewarded and punished during toilet training and children with no problems with the bladder and urination were more likely to have been encouraged by their parents to try again later. It also showed that waiting past 18 months correlated with fewer problems with urination years later.

I think a child needs to be mature enough to be able to stop what he or she is doing and take the time to go to a toilet. A child needs to be able to communicate the need (through words or sign) to go to the bathroom. Ideally a child will be able to remove clothing and get on the toilet without much assistance. Parents should encourage and praise kids for good results in the toilet. I would not recommend any negative consequences for accidents since negative consequences correlate with long term health consequences in studies.

Many kids show a temporary interest in potty training, but then it stops. I advise to not push the issue. Put them back in diapers for awhile and try again later. They know they will win this fight. They simply pee or poop whenever and wherever they want or they hold it too long, which can lead to physical health problems for them.

When to wait on potty training:

• If a child shows no interest in going to the toilet.
• If a new baby is on the way.
• If the child is afraid to sit on the toilet.
• If a move is planned.
• If there will soon be travel.
• If a child doesn't have the ability to communicate the need to toilet.
• If the child resists.

In the end, most children will potty train. They will not go to kindergarten in a diaper. Empower your kids with information on how things work. Praise them for good results. Don't yell or belittle kids for accidents. If you're frustrated, take a deep breath. Training doesn't last forever. If it's too much to deal with, give it a break. The more you can make it pleasant for your child, the more you will enjoy parenting!

References

• Among healthy children, what toilet-training strategy is most effective and prevents fewer adverse events (stool withholding and dysfunctional voiding)?
• Toilet training children: when to start and how to train
• The effectiveness of different methods of toilet training for bowel and bladder control
• Potty training problems: A evidence-based guide for prevention 

Motion Sickness

Summer travels bring a lot of questions about motion sickness, also known as car sickness, sea sickness, and air sickness.

Whether it's the threat of a long car trip, concern about flying, or anticipated problems on a cruise, there are many kids who suffer from motion sickness. Kids 2 - 12 years are the most likely to suffer from motion sickness. It's less common in teens and adults and very rare in infants and toddlers. It is more common in women and people with migraines.

Photo by Greg L via Wikimedia

Motion sickness is thought to be triggered when the inner ear senses motion but the eyes don't. These mixed signals coming into the brain can cause nausea, dizziness, vomiting, paleness and cold sweats. Motion sickness often happens on ships and boats, but it also can affect kids when they travel in planes, buses and cars. Motion sickness is often worst if there is a bumpy or curvy ride. It can also be triggered by strong smells, which is why avoiding gas stations (if possible) can help prevent it. Sometimes trying to read a book or watching a movie during travel can trigger motion sickness. In both children and adults, playing computer games can sometimes lead to motion sickness.

Some general tips to avoid motion sickness:

• Look out the window during travel. Don't watch other moving objects (such as cars) -- watch the horizon. Teens and adults can benefit from sitting in the front seat. Younger children (12 and under) are safer in the back seat. 
• Avoid strong smells, such as those at the gas station, if possible. 
• Eat small amounts of high protein, non-greasy foods during travel. Spicy and fatty foods can exacerbate symptoms. Crackers can help.
• Sleep. Or at least close eyes. 
• Take deep, controlled breaths.
• Use a headrest to prevent head movement.
• In a plane: sit over the wing and recline when possible.
• On a ship: stay on deck where you can see the horizon as much as possible. Avoid the bow and stern.
• Take breaks for fresh air and a short walk if possible.
• Some people believe that opening the car window for fresh air helps, but close windows if the air quality is poor or irritates the rider.
• No smoking or e-cigarette use in the car. Ever. Even when no one is in the car with the driver. The compounds left behind can be dangerous to children.
• Avoid reading books or playing video games when traveling. Movies are tolerated more often than reading, but if they are not tolerated, stop them.
• Be aware that some medicines increase the risk of motion sickness. Avoid these if possible. A full list is included in the link, but those more commonly used in children and teens are ibuprofen, some antibiotics, some antidepressants, and hormones (birth control pills). 

Medicines for motion sickness:

All medicines have side effects, but many of the ones that seem to help motion sickness can have significant side effects, so risks and benefits must be considered. Note that none of these medicines is approved under 2 years of age, but motion sickness is uncommon in infants and toddlers.

If you decide upon a medicine, be sure to keep it out of reach of children to avoid overdose. Remember that during travel childproofing is more difficult!

In case of suspected overdose, call your local poison control center at 1-800-222-1222. Put this number in all of your phones for easy access in times of emergency. 

If a person is not breathing or unconscious, first call 911 and initiate CPR.

• Benadryl (diphenhydramine) is an over the counter antihistamine that can help some kids over 2 years of age with motion sickness. Follow the over the counter package directions for weight - based dose and give it 30 minutes before travel and before meals and at bedtime if needed. It can lead to excessive sleepiness - or hyperactivity in some kids, so be careful! If your child has never had benadryl, I recommend doing a test dose at home before travel to be sure they don't get wired or irritable on it. 
• Dramamine (dimenhydrinate) can also help kids over age 2 and is available over the counter. It also should be started 30-60 minutes before traveling and every 4-6 hours (for 12 years and up) and every 6-8 hours (for children under 12 years) as needed. Side effects include drowsiness, dry mouth, blurry vision, thickened mucus in their airways, feeling excited or restless, and increased heart rate.
• Dramamine Less Drowsy (meclizine) is also available over the counter and can help prevent motion sickness in children over 2 years of age. Meclizine comes as a regular and chewable tablet and a capsule. It should be taken 1 hour before you travel. Doses may be taken every 24 hours if needed. Side effects include drowsiness, dry mouth, and blurred vision.
• Phenergan (promethazine) is sometimes prescribed for motion sickness. Some significant warnings exist for children, so see the attached link and talk to your doctor about the risks and benefits of this medication. The drug comes in suppository and tablet form. When promethazine is used to treat motion sickness, it is taken 30 to 60 minutes before travel and again after 8 to 12 hours if needed. On longer trips, promethazine is usually taken in the morning and before the evening meal on each day of travel. Side effects include dizziness, anxiety and drowsiness. It can slow or stop breathing in children.
• Zofran (ondansetron) is a prescription medicine that is used to treat nausea and vomiting. See your doctor to discuss if this prescription is appropriate for your child for motion sickness.
• Prochlorperazine is an antipsychotic that helps treat severe nausea and vomiting. It comes as tablets and suppositories. Prochlorperazine should not be used in children under 2 years old or who weigh less than 20 pounds. Prochlorperazine requires a prescription, and a full discussion of risks and benefits should be done with your doctor before taking this medicine. See the attached link for full list of potential side effects as well as other drug interactions. 
• Metoclopramide has been used for treatment of motion sickness, but carries significant risks. Please see the attached link for details. 
• A scopolamine patch can be considered for teens and adults but should not be used in kids under 12 years. Some experts discourage any use in all children due to significant side effects, which include sedation, blurred vision, disorientation and mouth dryness. See attached link for complete list of side effects. If it is used, the patch is placed behind the ear 4 hours before travel and left in place for up to 72 hours.

Alternative treatments:

• Ginger has been shown to help prevent motion sickness, but the specific dose is not clear. Kids can drink ginger tea or ginger ale or suck on a ginger lollipop or lozenge - only if old enough to not choke. To make ginger tea: dissolve 1/8 - 1/4 teaspoon of powdered ginger in a cup of hot water or boil two slices of fresh ginger root (each about 1/8 of an inch thick) in one cup of water for about 10 minutes. Sweeten to taste, and offer small sips throughout the day.
• Accupressure wristbands are sold in pharmacies and online, and though research is not conclusive, I have seen decent benefit from these. They fall into the "it won't hurt to try" category in my opinion. I don't know if it is the power of suggestion (placebo effect) or a real benefit, but I have seen several families rely upon these successfully.
• If your child suffers from motion sickness often, there are some studies that support vestibular training. It will not work for your vacation next week, but can be considered for children who suffer to help long term. Have your child work with a physical therapist trained in vestibular training. 

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Flu Vaccine 2016-2017 Season

Flu Vaccine Drama. Every Year It's Something!

Every year since I've been in practice there has been a hitch of some sort or another with flu vaccine production and/or administration. This year it's a big hitch. The Advisory Committee on Immunization Practices (ACIP) has recommended that the FluMist not be given to children.

Wow. That will make a lot of kids unhappy.

Dr Mellick and many of our staff have used FluMist over the years.

I always say we should never promise "no shots until ____".

This season' vaccine isn't here yet, but here's me getting a flu shot a few years ago. (I've gotten the FluMist for the past few years...)

Nasal Flu Vaccine (FluMist) Update

• The ACIP has advised that the attenuated influenza vaccine (LAIV), AKA “nasal spray” flu vaccine (FluMist), should not be used in kids during the 2016-2017 flu season. 
• About 8% of all flu vaccines were projected to be FluMist this year.
• FluMist uses live but weakened strains of flu virus to stimulate the immune system to protect against the flu virus strains in the vaccine.
• Initially FluMist was thought to work better than the injectable flu vaccine -- until the 2013/14 season. 
• The 2015-2016 FluMist is estimated to have been only 3% effective protecting against any strain of flu in children 2 years to 17 years of age. The injectable flu vaccine is estimated to have been 63% effective in this age group.
• The H1N1 component of the vaccine is the part that has not maintained effectiveness and has led to serious illness among people who have had the FluMist.
• The reason for the poor effectiveness of FluMist in recent seasons is not known. One thought is that the same strain in the vaccine year after year does not give the body the boost it needs since it already recognizes the flu strain.
• It has taken several years of data to show a pattern, which is why after the first year the nasal spray didn't seem as effective it was not pulled from the market. 
• There are many things to take into consideration when making flu vaccine recommendations. 

• It is difficult to know the overall number of cases of influenza since many people do not see a doctor when sick. This makes it difficult to assess effectiveness of flu vaccines in general. 

•  Flu vaccine effectiveness varies year to year because the strains of virus that circulate change.

• It could be one lot that wasn’t effective from a process problem, such as poor refrigeration. This is a fixable problem, so does not affect future lots if addressed properly. This was what vaccine manufacturers thought happened in 2014.  

• Studies in the UK do not show the same poor effectiveness in children, so it might be only US FluMist stock that was less effective for an unknown reason. Ongoing surveillance and studies will continue.

• It is possible that the FluMist will once again be recommended. It depends on what they find out most likely caused the decline in effectiveness and if they can overcome that obstacle.

Isn't something better than nothing? (In other words, my child hates shots... can't we just do the nose spray?)

I know many parents will wonder if their child can still get the nose spray because they hate shots. After all, they've had the nasal spray vaccine for several years and have been okay, so it should be fine for them, right? 

While one could argue that if the choice is a flu vaccine that might be less effective is better than no vaccine at all, most of us can see that 3% effectiveness isn't much to rely upon - especially if the injectable vaccine has a better track record. A few minutes of hearing a child cry due to a shot is preferable to watching them get seriously ill or die. I don't want to sound like a fear-monger, but death can be the consequence of influenza. My friend's niece was sadly one of the healthy children who died of flu last season after being vaccinated with the FluMist. Her family will forever wonder if the shot would have saved her life. 

We need to use the information we have to make the best decisions, and that is to use the injectable flu vaccine this season.

If your child fears shots, have them learn why they're important. Don’t Just Vaccinate Your Kids, Teach Them the Science Behind Vaccines has a number of links to games and booklets that can help. Knowledge is power. If your kids know why they're getting a shot, they are more likely to go willingly.

And if that doesn't help, teach them to blow out or cough during the shot. Those tricks really help! More shot survival tips are on Kid's Health.

Flu Vaccine General Facts

• Influenza virus kills between 4,000 and 50,000 people per year in the US. 
• Most deaths from influenza are among infants, elderly, pregnant women, or people with underlying illnesses (such as asthma and immune deficiencies). Some healthy children, teens, and young adults without known risks die from influenza.
• The flu vaccine continues to be recommended for everyone over 6 months of age.
• Every year the flu vaccine targets the anticipated types of flu for the season. This year’s strains are:

o A/California/7/2009 (H1N1)pdm09-like virus
o A/Hong Kong/4801/2014 (H3N2)-like virus
o B/Brisbane/60/2008-like virus (B/Victoria lineage)
o B/Phuket/3073/2013-like virus (B/Yamagata lineage) (quadrivalent vaccine only)

• The CDC does not expect any shortages of flu vaccine at this time despite the FluMist not being used.

Does this prove flu vaccines are not safe or worthwhile? Does our system work?

Many people wonder if this finding and recommendation supports that the flu vaccine in general is not effective and shouldn't be used. I don't think so at all.  

This shows that the continuous monitoring of vaccine safety and effectiveness allows changes to be made to make them more safe and effective. The process works. It takes time and isn't perfect, but it helps to continuously improve the vaccines we have.

I know some are angry that it took "so long" for this to come out. As mentioned above, the process takes time. The government wasn't hiding anything. They had to collect enough data to make an informed decision. Knee jerk reactions with limited information would cause its own problems. 

Scientists are working on a universal flu vaccine. Hopefully that will soon be available and the yearly flu vaccine won't be needed!

Until we know more or have a universal flu vaccine, please follow the ACIP recommendations and get everyone over 6 months of age vaccinated against the flu each season. The more people vaccinated, the better the herd immunity and the better we are all protected!