New Juice Guidelines!

The American Academy of Pediatrics is releasing new guidelines for introducing and giving fruit juice today.

Juice that comes from fruit is not the same thing as eating fruit. It's missing the fiber and even the feeling of fullness that comes from eating foods rather than drinking. Too many kids drink excessive juice, which fills them with empty calories and can contribute to obesity and tooth decay.

How much juice should kids have?

• Juice is not recommended at all under 1 year of age in the new guidelines. 
• Toddlers from 1-3 years can have up to 4 ounces of 100% juice a day. 
• Children ages 4-6 years can have 4-6 ounces (half to three-quarters of a cup). 
• Children ages 7-18 years can have up to 8 ounces (1 cup) of 100% fruit juice as part of the recommended 2 to 2 ½ cups of fruit servings per day. 

General tips and tricks:

• Offer only 100% juice if you're giving juice at all. Fruit flavored drinks are not the same thing as juice.
• Water is always healthy! If your kids want it flavored, cut up fruit and put it in the water. There are many recipes online to get ideas, but kids don't need anything fancy - just put cut up pieces of their favorite fruit with water in a glass container. Put the container in the refrigerator for 2-4 hours and then pour the infused water into their cup without the fruit (which could pose a choking risk). The infused water will stay fresh in the refrigerator for up to 2 days.
• Some kids like to start the day with a frozen water bottle. Simply put a 1/2 to 3/4 full water bottle in the freezer overnight - don't fill it too much because ice expands! Add a bit of water in the morning to help it start melting so it's drinkable when they want a sip. Adjust the amount of water to freeze as needed depending on how insulated your water bottle is.
• If your kids demand more than the recommended amount of juice for their age per day, water it down. By mixing water (or sparkling water for a bit of zip) with juice, you decrease the amount of sugar in every serving. You can give 1/2 the recommended daily maximum amount of juice with water twice and still stay within the daily limit. 
• Never let kids drink juice out of a bottle.
• Never put kids to bed with juice. They should brush teeth before bed and be allowed only water until morning.
• Offer only pasteurized juice. Unpasteurized juice can cause severe illness.
• Give kids real fruits and/or vegetables with every meal and snack.
• Make smoothies! Putting fruits and vegetables in a blender to make a smoothie is a great way to give the full fruit or vegetable instead of juice. Consider adding plain yogurt**, chia, flax, oats, nuts, and other healthy additions to increase the nutritional components of the smoothie! **Flavored yogurts often have added sugars. Look for just milk and cultures in your yogurt. 
• Most juice boxes have more than a day's supply of juice. Don't use juice boxes. Offer juice in cups so you can limit to the age appropriate amount. 
• Organic juice is not healthier than other juice. Many parents presume it has less sugar or more nutrients, but it doesn't.
• Vegetable juices may have less sugar and fewer calories than in the fruit juice, but are often mixed with fruit juices so you must read ingredients. They also lack the fiber of the actual vegetable, so eating the vegetable (or pureeing veggies into a smoothie) is healthier. 
• Beware of labels that look like juice but aren't 100% juice. The label might say "juice cocktail," "juice-flavored beverage" or "juice drink." Most of these have only small amounts of real juice. Their main ingredients are usually water, small amounts of juice, and some type of sweetener, such as high-fructose corn syrup. Nutritionally, these drinks are similar to most soft drinks: rich in sugar and calories, but low in nutrients. Avoid them.
• Sports drinks are not healthy substitutes for water. They are sugar-sweetened beverages that contain sodium and other electrolytes. Unless one is doing high intensity exercise for over an hour (such as running a marathon, not playing in a baseball tournament), water and a regular healthy diet provide all the calories and electrolytes we need.
• Water's the best drink for our bodies. Buy fun reusable water bottles and challenge your kids to empty them throughout the day. The old rule of "8 cups a day" is outdated, but we should get enough water (from the water content in foods + drinks) to keep our urine pale. We need more water when it's hot, when we exercise, when we're sick and when the air's really dry. Once we feel thirsty we're already mildly dehydrated, so drink water to prevent dehydration.

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Distracted eating

We all do it sometimes. We grab a snack and plop down on the couch to watch a movie. Before we know it the whole thing is gone. We only meant to eat some of it, but downed it in one sitting.

That is distracted eating at it's finest. It exemplifies the problem of eating without intention. Not because of hunger. Not even healthy foods typically. Just eating because it's there.

What happened to sitting around the table and eating as a family without the tv or cell phones?

Photo source: Wikimedia

I see many kids who always have distracted eating.

The youngest might fit into another category all together, but they certainly aren't intentionally eating. These are the babies who parents "dream feed" - basically feed them while they're sleeping. This can be because they don't eat as parents think they should when they're awake or because parents want to get one more feed in before they go to bed so baby will let them sleep. I know many parents rely on it, but I will never recommend it for many reasons. It can disrupt their normal sleep cycles if you feed during periods of deep sleep.  Dream feeds also feed a baby who might not be hungry or need to eat, and it is hard to know when to stop. After the first few months most babies don't need to eat at night, but they are trained to eat at that time. Once they get teeth it can increase the risk of cavities if they eat without brushing teeth before returning to sleep. There are also risks of choking. And again, I firmly believe that we all need to eat when hungry and not just because there's food offered.

As kids move into the toddler years, they often become picky with foods and eat small volumes. This is normal. Parents need to offer healthy foods and feed small frequent meals. Think of snacks as mini meals so you will offer healthy foods - and no, goldfish crackers are not healthy foods. Young children tend to eat about six small meals a day. Each meal offer either a fruit or a vegetable and a protein to help insure your child gets enough of these food groups daily.

Unfortunately, some parents solve the "problem" of kids not eating a lot at meal times by allowing them to carry around food all hours of the day. This might be cereal, crackers, milk, or whatever the favorite food of the week is. This allows the child to snack all day, which means they are never hungry, so they don't eat at meal times. Parents will think it's better than eating nothing, and even think that since it's cereal or milk it's healthy. But it's not. These foods are usually highly processed and have little nutrition. Constantly nibbling doesn't allow the body to learn hunger cues. It also doesn't allow saliva to clean teeth between feedings, which increases the risk of cavities. If kids drink excessive milk they are at risk of severe malnutrition. Parents argue that milk is healthy, but they are thinking of mother's milk or formula for infants. Cow's milk has protein, calcium, and other nutrients, but it is not a complete meal substitute. I have seen children need blood transfusions due to severe iron deficiency anemia from excessive milk intake. Blood transfusions. It can be that bad. Yes, your child might like milk. And he might refuse to eat at meal time. But if you keep giving milk he will never get hungry enough to eat the food offered.

Other parents realize that kids will eat more if they feed the child, especially if the child is watching tv. This is wrong on many levels.

• Once kids are able to feed themselves, it is a great skill to use. They work on fine motor skills when self feeding. 
• Kids need to learn to pick (from healthy choices hopefully) which food they will eat next and to stop when full. When parents do the feeding, they keep pushing foods until the plate is empty. Many parents have an unrealistic appreciation of how much food a child should eat. 
• If a child is watching tv while eating, the focus is on the screen, not the food. Again, the child then doesn't listen to hunger and satiety cues.

I see several kids each year who will be going to full day school (kindergarten or 1st grade depending on the child) and parents worry that they won't be able to eat lunch because they never self feed. Many of these kids are overweight because they've been overfed for years but the parents often think the child doesn't eat enough.

If families eat while watching television or playing on smart phones or tablets, no one is connecting during the meal. No one is really enjoying the food or the conversation. There are many studies that show the more often families eat together (really together, not sitting at a table connected to a screen) the less likely kids will develop obesity, get depressed, do drugs, smoke, and consider suicide. Kids who eat with their families are more likely to eat healthy foods, do well in school, delay having sex, and have stronger family ties.

Help stop the habit of mindless eating. Encourage eating at the table as a family as much as possible. Offer healthy food choices and let everyone decide how much of each thing to eat. If you worry that your child isn't eating adequately, talk to your pediatrician.

For more, see my related blogs:

• Nutrition for the Picky Eater
• Taste a Bite Without a Fight
• Food Strike!
• Kid's Weight Is Weighing On My Mind
• Excessive Milk Can Cause Anemia? How?
• My Child Won't Eat... What Should I Do?

Resources:

MyPlate offers portion sizes for children, tips on healthy foods, activities for kids to learn about nutrition, and more.

If you're a Pinterest fan, check out my Nutritional Sites and Getting Kids to Eat Vegetables and Other Healthy Stuff

Staying healthy as an athlete

Many people assume that kids who are active in sports are automatically healthy, but that can be far from the truth. Sports do provide exercise, but not all kids participate at the same intensity level, some sports are more inherently challenging, many kids don't eat the needed foods to provide optimal nutrition, and many kids fall far short of the sleep they need to maintain healthy body and mind. There needs to be a balance: eat right, sleep adequately, and exercise daily. Kids also need time to be kids with unstructured time in addition to school, homework, and activities.

Not a typical team sport, but my kids don't do typical sports. This is from an office Bubble Soccer game. 

Eat right

First and foremost with nutrition, we all need to maintain hydration. Many kids avoid drinking at school so they don't have to use the restroom. This is of course not healthy. Talk to your kids about the importance of drinking throughout the day and troubleshoot toileting issues. When kids exercise, be sure they stay hydrated. The large majority of athletes need nothing more than water to stay hydrated. Water is by far the preferred drink of sports nutrition experts unless there is intense exercise longer than 60 - 90 minutes. This does not mean a child playing a baseball game for more than 60 minutes because they are not maintaining the level of intense exercise for the entire game. If a child is running a marathon, added electrolytes might be needed, but short of that type of intensity/duration, water is fine. Sports drinks add far too much sugar and unneeded salts to the diet. Encourage kids to take a sip or two of water every 15-20 minutes of exercise (more or less depending on how hot it is and the intensity of exercise).

As for foods, not all are equal and not all that are marketed as healthy really are healthy. Get in the habit of reading labels. The longer the ingredient list, the less healthy it probably is unless the ingredients are all foods themselves (such as a trail mix with a number of dried fruits and nuts). I've previously addressed the issues of kids getting too many calories. Far too many of our kids are overweight or obese. Many of them are active in sports, but they take in more calories than they use.

• Carbohydrates give quick energy for activity. Examples of healthy carbs are bananas, berries, oats, pasta, rice, and whole grain breads. These are recommended before exercise for energy (but kids don't usually need to carb load unless they are doing an endurance sport), and after exercise with a protein. 
• Protein is important for building and maintaining muscle. I like kids to eat foods with protein and to avoid protein shakes and powders, which are expensive and could possibly lead to too much protein. Examples of good protein sources include nuts and nut butters, eggs, lean meats and fish, yogurt (look for a brand without added sugar) and other dairy products. About 5 -15 g of protein (or about 0.5 to 0.8 grams of protein for every pound of body weight) is all that's needed after a workout, depending on age, size, and workout intensity. Many Americans get far more daily protein than is needed.
• Fat is not as bad as many people make it out to be. It is an important energy source for our bodies and helps us absorb fat-soluble vitamins. Healthy fats come from nuts, avacados, meats, dairy products, and eggs. 

Sleep

Many athletes (and teens in general) fail to get sufficient sleep for good health. They are torn between the demands of school, sports, clubs, volunteering, and making the time for sleep. The spiral typically has them staying up late to catch up on homework, only to be more tired the following day, which leads to poor focus at school - then everything takes longer to do. This encourages them to stay up even later to finish homework, which reinforces the problem. It is not uncommon for me to hear teens report anywhere between 4 and 8 hours of sleep. None of this is enough. Kids who are chronically sleep deprived suffer from more injuries, falling grades, general irritability and depression. I see many teens who want me to find a reason for their fatigue with labs, but it commonly is simply due to sleep debt.

Try to get kids to get enough sleep so they are easy to wake in the morning, stay alert all day, and aren't irritable or hyper in the evenings. If they have trouble sleeping, talk with their doctor.

From the National Sleep Foundation

I see far too many kids who claim to be very active and eat healthy, yet they have problems keeping up with other kids running or have BMIs that seem too high for the reported habits (not due to muscle mass). This could be due to an underlying problem, such as asthma, or habits that aren't as healthy as you think. Bring your child in for a yearly physical to review eating, sleeping, and exercise habits in addition to other health related issues. With most insurance companies there is no co pay for well care, so make the most of your insurance dollars and schedule a well visit! If there are any concerns, you can work with your child's doctor to find help.

My child won't eat... what should I do?

I hear from worried parents often that their kids won't eat. There are many reasons for this. Usually as long as a child is hydrated, gaining weight appropriately, and getting a variety of nutrients, I am not worried.

Some reasons kids don't eat:

• They're really getting enough food, parents just have unrealistic expectations. This is very common. Portion sizes are smaller than many parents think. They vary with age and size of a child as well as his activity level. If your child is growing well and has plenty of energy throughout the day, why should he eat more? Kids tend to eat small meals frequently and even on holidays they don't overeat like the adults tend to do. When offering snacks, think of them as mini meals to help balance out the nutrients of the day. Don't let them snack all day long though or they'll never really be hungry. Schedule meals and snacks and allow water in between. We have an obesity epidemic in this country, so if you're comparing your child to another child, chances are that your thin child is healthy and normal, but the other one is one of the 30% who is overweight. Or maybe not. It doesn't matter. Just be sure your child is getting a proper variety of nutrients, he should determine how much to eat. Talk to his doctor about his growth at regularly scheduled well visits (more often if you're concerned) to be sure it's appropriate.
• They're sick and it's temporary. When kids are sick they lose their appetites. This is normal. It usually returns with a vengeance when they're feeling better. They need to drink to stay hydrated and can eat what they feel up to it, but don't force it. See their doctor if you're worried.
• It's a new food and they just aren't sure yet. I encourage that kids over 3 years old take one bite of a food. Kids often hear me say, "taste a bite without a fight." The bite needs to be enough that they taste it. If they like it they can keep eating. If they don't want more, resist trying to convince them to eat more. Allowing them to take ownership of the decision of what to eat empowers them. Kids like power, right. Give it to them while modeling healthy eating behaviors yourself. They learn from what you do, not what you say -- and not from what they're forced to do. When preparing a new dish, include familiar foods they like to balance out the meal so they can enjoy at least something on the plate.
• They're picky eaters. Aren't they all? Most kids go through phases where they love a food then they suddenly dislike it. They might dislike a certain texture or a whole food group. While there are kids with real problems eating, most picky eaters can be encouraged to eat a healthy variety of foods as described above. Some children really suffer from being overly restrictive. Children with autism, sensory problems, food allergies, and other issues are not included in this "typical" picky eater category. A great series of blogs on picky eaters (typical and more concerning) is found on Raise Healthy Eaters. 
• They're more interested in something else. Make meals an event in itself. Sit together and talk. Turn off the television. Put away your phone. Have everyone focus on the meal, which includes the food and the conversation. Try to keep the conversation pleasant and not about the food. Take the pressure off eating!

In general, parents should choose what foods kids are offered so that there's a balance of nutrients, but kids determine how much they eat. If they're hungry, they'll eat. If they're not hungry, they shouldn't eat. Learning to eat when not hungry is something that causes many of us to struggle with weight. Most kids are able to limit intake to needs. Don't force them to change that great quality!

For more, see my other blogs on the subject:

• Nutrition for the Picky Eater
• Taste a Bite Without a Fight
• Food Strike!
• Kid's Weight Is Weighing On My Mind

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

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

If you don't want to miss a post, be sure to sign up for an e-mail subscription on the right!

From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety. 

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths. 

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

• Allergy Tips

• Generic Concerta Not Working Like the Brand Used T...

• Screen Free Week April 29-May 5, 2013

• Help! My child has ___ up his nose!

• Group Teaching With Physicals

• Waiting times...

• Feeding Your Newborn

Is an apple a good bedtime treat?

Photo source: Shutterstock

As parents we try to get as many fruits and vegetables in our kids as they will take, so when Junior asks for a bedtime snack, it is tempting to allow a piece of fruit. Sounds healthy, right?  Surely better than ice cream...

An apple is healthy and can be a great part of a healthy snack, but kids (and adults) shouldn't have a high carbohydrate snack before bed without some protein and / or fat.

Why?

When we eat, our body senses the increase in blood sugar and sends out insulin to store the sugar in cells for future energy. An apple (or other fruit) is high in carbohydrates (sugar) and low in fat and protein. Sugars and can be quickly stored, lowering the blood sugar pretty fast unless there is fat or protein to stabilize it.

Fats and proteins are more complex to digest.  They must first be converted into smaller molecules before insulin can store the food for energy.  This allows a more gradual fall of the blood sugar.

Why is this important at bedtime?

We always have some sugar in our blood, ideally 70-100 mg/dl, but rising after eating and falling when fasting (not eating).  Normal sugar levels give our cells energy for all they need to do. We go for many hours without eating again when we sleep all night. If the insulin level is still high after storing all the easy to store carbohydrates but there aren't more molecules from the breakdown of protein or fat around to start storing, the insulin lowers the normal blood sugar to unsafe levels.  This is especially dangerous at night because one early sign that the blood sugar is too low is tiredness, which is unnoticed when asleep.

Diabetics should be especially aware of this response because their body does not regulate insulin normally, and they can suffer from severe low sugar if too much insulin is given without the proper balance of nutrients.

It would be extremely uncommon for a person with normal sugar management to have serious consequences of low blood sugar (such as coma or seizures) from this apple before bed, but without a good sugar level, the body will not get the most benefits of sleep: restoration of the body and growth in children.

So what's my recommendation for that bedtime snack? Go ahead and give that apple-- with a glass of milk, yogurt, peanut butter, cheese, or other food with protein.

And ice cream isn't all that bad as far as a snack that won't lower blood sugar too much... it just has less nutritional value.  So as a fun treat when kids are eating enough fruits and veggies the rest of the day and have gotten exercise and not an overabundance of empty calories, it's okay to have an ice cream once in awhile.  After all, it's made from milk, so not all bad!

Which reminds me of this great Bill Cosby clip: Chocolate Cake  (Who says we can't have a little fun when talking nutrition?)

Taste a Bite Without a Fight

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Here's another blog inspired by a facebook question:

Megan Brower Lynberg My 2.5 year old son is super picky and I swear he looks at certain foods and decides not to eat them. I know most parents have the try it rule, or just one bite, but we can't even get him to do that most times. Any suggestions on how to implement that? Or should we just let it go and know that for the most part he gets a balanced diet and hopefully he'll branch out as he gets older?

Picky eating is synonymous with most toddlers and school aged kids. I smile inwardly when parents boast that their one year old will eat anything, unlike "other kids" who are picky, as if the other parents did something wrong.

It is between 15 months and 3 years that kids who used to eat anything go through phases of pickiness. I say phases, because sometimes it is a favorite food one week, only to be "yuck" the next week.  I knew this when my kids were young, so I took pictures of my toddlers devouring things like broccoli, so I could show them later that they did, in fact, love it.  (It didn't help.)

Overall the two biggest food groups kids dislike, vegetables and meats, are two of the most nutritious, so parents fret about how to get the nutrition in.  My general advice: parents decide what foods are offered, kids decide how much they eat.

My kids learned "Taste a bite without a fight" at daycare. Why silly rhymes work, I don't know, but sometimes they do.  I usually advise to enforce a bite after 3 years.  Before this age, they might just be too young to fight the battle yet. They simply don't know how to follow rules until about 3. I have heard of parents turning on the tv so the child mindlessly eats what the parent puts in his mouth. Don't do that! It sets up so many bad eating habits!!!

Until the taste a bite rule can be enforced (and even after that) I like to use hidden foods as nutrients. We are having pumpkin french toast this morning-- pumpkin puree added to the eggs/milk. This is not much vegetable, but more than they would get from a bowl of cereal or standard french toast. If this is done with many meals, it all adds up. Find foods your child likes, then "tweak" to fit in needed nutrients.

Vegetables and fruits can easily be pureed and put into sauces, casseroles, smoothies, and ground meats (meatballs, burgers, meatloaf).  Put a can of beets into the blender with your spaghetti sauce for a funky colored sauce. If your kids don't like sauce on noodles, try making pizza with a zucchini/carrot/beet jazzed up sauce. Some people just finely shred or chop. I find that puree works better because they don't see it and pick it out! There are many recipes for this online and in cookbooks for parents.  Check out my Pinterest Meal Ideas page for starters. (Not all ideas are healthy on this page... some are things I just want to try!)

Putting a cheese sauce over vegetables or offering a dunking sauce (yogurt, catsup, ranch dressing) makes it more acceptable to many kids. 

Add fruits and vegetables to breads or noodles. Most kids love the bread group. Banana bread, pumpkin bread, zucchini bread, spinach noodles, and more are all ways to add a little fruit or vegetable into something they will eat. Yes, they will get more sugar this way, but ...

Try a soup or stew. This is a great time of year to throw things in the crock pot in the morning and come home to the smell of dinner already ready!  

If it's meat he doesn't like (most don't at this age) use other forms of protein and iron (eggs, nuts, legumes, etc). Dairy helps with the protein, but has no iron, so don't only use cheese - a common food they love! You can also try meat hidden in casseroles or in fun forms, but remember there are entire countries of people who don't eat meat. Just make sure your kids are getting the nutrition they need.

Play with the food: make the food fun to eat by arranging into shapes. Use a cookie cutter for fun shapes. Arrange food into a face on the plate. There are many ideas of this online! 

Let kids help prepare the meals in an age/ability safe way, starting with washing vegetables, or arranging them on a plate. Start a garden next season so kids can see the food grow! 

A tip from my mother-in-law: kids will eat anything on a stick or fun appetizer sized! Make roll ups with a tortilla, cream cheese, lunch meats, spinach, or whatever sandwich fillings you use and cut into circles. Put a toothpick in small pieces of fruit or jazzed up meatballs (or load up fruit or vegetables on a skewer for a fun kabob).  

Read books that involve foods. I have put some ideas on my Pinterest Books page. Two of my favorites: "I Will Never Not Ever Eat a Tomato" by Lauren Child and "Green Eggs and Ham" by Dr Seuss. Use the books to stimulate ideas-- like making green eggs!

Above all, try to keep meal time pleasant. It should be a time the family gathers to talk, laugh, and enjoy one another. If the focus is a fight about eating, it is not serving one of the big benefits of eating together.  Work the nutrition in, but keep the meal itself fun!

Post suggestions of what has worked for your family. I always love to hear new tricks!  And if your child is really restricted in foods, talk with your doctor.  Sometimes it's more than just picky!

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

• height/weight measurements

• blood pressure screenings

• lab screenings (anemia, lead, cholesterol)

• vision and hearing screenings

• development assessments

• mental health screens

• more...    

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

• it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
• it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

Red Dye #40

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A recent facebook post asked about the link between red 40 dye and hyperactivity.

Nicole Rousset WilliamsPediatric Partners, PA. Overland Park, Kansas

Would love to see an article on red 40 dye and thoughts from a professional medical standpoint. As the mom of a very strong-willed child, I've gotten advice from other moms who swear this is the "poison" that creates so much difficulty in kids. Wondering how you feel..... So"What's up, doc?"

Tolerability and safety of food additives and their influence on behavior have been questioned since the 1970s after a pediatric allergist alleged that there was risk of hyperactivity due to food additives. This allergist, Dr Feingold, supported the Feingold Diet.  Scientists reviewing his studies found he had no control group, limiting the validity of his study. Several other well designed studies have not found a risk except to those allergic to the food dye (FD&C Yellow No.5 leads to hives in 1 out of 10,000).

Studies attempting to show a link between food additives (including Red dye #40) have been inconclusive, inconsistent, or inadequate.

In 1982, a Consensus Development Panel of the National Institutes of Health concluded that for some children with ADHD and confirmed food allergy, dietary modification provided some benefit to behavior. They did not recommend all children alter their diet since there was no proof that it helped anyone but the small group with ADHD and food allergy.

In 1997, a review of several studies on this topic showed minimal evidence of benefit and extreme difficulty getting children and adolescents to adhere to a restricted diet.

In 2007, color additives specifically were questioned in relation to hyperactivity in a study by the UK Food Standards Agency.  Both the FDA and the European Food Safety Authority independently reviewed the results and concluded that there is no substantial link between color additives and behavioral effects.

Parents could argue that simply omitting foods with additives wouldn't hurt their child, and on many levels they are correct.  But...

We should all attempt to eat a nutritious diet rich in fruits and vegetables and minimize processed foods.  Unfortunately, that becomes very difficult in our society.  Many foods, including dairy, breads and cereals, and more have food additives.  It is difficult to eliminate these entirely and continue to get a balanced diet.  

Kids with true food allergies who must avoid certain foods often feel singled out and "different" or "fragile".  While this is very important for kids who have direct health risks to foods, it is psychologically difficult and if not a real risk/benefit, do we really want our kids suffering psychologically?  

Avoiding these foods also might allow the child to place blame on an external factor, leaving less responsibility for their action.  "I ate jelly beans, that is why I am out of control today.  It's not my fault."  

Trying an elimination diet also might delay the initiation of seeking professional help to try things that have been shown to work, such as behavioral modification, improved sleep, routines, and sometimes medication.

I believe in recognizing real risks, looking at the risk benefit ratio, and then making a decision.  If you have not noticed a difference with your child's behavior when eating only real whole foods (not from a package) then food additives likely aren't the culprit.

Behavior is very complex and is related to the child's temperament, sleep effectiveness, environment, hunger, emotional support, and more.  If there was one easy solution (ie removing food dyes) parents would all be doing it!

Sources:  

FDA: food ingredients and colors

FDA: Import Alert

Food Insight

Red40

New Year's Reflection

I was fortunate to be able to spend New Years with my extended family in the St Louis area.  Conversation led to my mother remembering old family videos in the basement. After a little digging around, my brother found the never before seen footage!

We had a blast watching videos of past holidays and vacations.

Some things were fun to compare. My daughter is better at ballet than I was at her age.

Other things were simply laughable.  Although I was impressed at my grandmother looking fit and trim in short shorts, most clothing choices of the 70s should never be repeated.  What will they think of our current clothes in 30 years?

One thing that struck me sadly was the average weight of people at all ages in the 70s seemed to be less than the average weight of people the same age today.  I'm not saying my friends and family have gained weight ~ I would get into trouble for that!  It was simply noticeable that people of today are heavier when comparing large groups.

I've read the statistics before...

Self Reported Weight up Nearly 20 Pounds Since 1990
Mean Body Weight, Height, and Body Mass Index, US 1960-2002

... but it was interesting to see large groups of people from my past vacations and comparing to what I see daily when out and about.  It made it real.

If the US is such a great nation, how have our individuals as a group gained weight in this unhealthy manner?

Is it the convenience of pre-packaged foods, many of which are processed and/or high in fat?   More women work now than previously. Does this contribute to less home-cooking and more fast foods?

Is it that the meal size increasing?  Large sodas of my childhood are now the smallest size available.  Who needs 64 ounces of acidic bubbly sugar?  We eat larger servings both at home and at restaurants. 

Are we less active than we used to be?  I can easily see how today's kids are tempted with tv, video games, and other sedentary activities.  As a child, I only had one tv channel, and most often it had adult programming. (There were no recordings available!) I had many other things to do both in the house and outside.  We didn't have many structured activities, so we just made it up as we went along.  And we had a blast!   What about adults? Are they less active? Do we work more hours than our parents?  Do we spend more free time in front of the tv/computer than our parent's generation? What did they do for fun?  Was it out of a chair?

Do we sleep enough? With many tasks to do and distractions, such as tv programming and internet available all night, do people stay up too late to get a good night's rest?  More and more research supports that sleep is needed for concentration, endurance, immune functions, as well as weight control and more.  How often do we feel tired?

I suspect that there are many reasons for our generalized weight gain, which means that there are many potential fixes, and not one alone will help.  I have tried to limit processed foods at home, but they are convenient and easy, so I sometimes splurge.  We try to eat as a family at home most nights, though activities sometimes interfere.  Portion control is relatively easy for my kids: they eat minimally by nature.  My husband and I need to check ourselves.  My kids are much better at exercise than I am, mostly because they have time and they love to move!  I don't want to forego sleep to fit in exercise. No one gave me time for Christmas... but I'm working on finding some free time!

What do you find helps keep your family healthy?

  

Excessive milk can cause anemia? How?

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk.  Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer:  Cow's milk has little iron.  When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes.  Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut

                              but less blood produced because less iron in the diet

                                                 = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies.  Too few red blood cells in the body is called anemia.  Red blood cells are made in our bone marrow and they live for about 3 months.  It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

• too little blood produced (iron deficiency being a major risk for this)
• increased blood loss (ie excessive bleeding)
• increased destruction of blood cells in the body (typically from abnormal blood cells or infection)

Iron deficiency can be due to several factors:

• poor iron absorption due to disease (some studies show milk inhibits iron absorption)
• poor iron in the diet (the most common cause)
• long term slow blood losses (such as heavy monthly periods or GI bleeding)
• increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms.  It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.  Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk.  Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.  Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron).  After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk.  (Newer recommendations allow weaning onto low fat milk--another topic entirely.)  Unfortified non-human milks contain very little iron.  The iron in human milk is better absorbed and iron is supplemented into formula.  If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

• meats and poultry (especially organ meats, such as liver)
• lentils, peas, and dried beans
• eggs
• oysters, clams, and fish
• molasses
• peanut butter
• soy
• pumpkin or sesame seeds
• fruits such as prunes, apricots, and raisins
• vegetables such as spinach, kale, broccoli, and other greens
• whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!