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

What is a Bone Age?

Bone age is helpful in assessing a child who is shorter or taller than predicted based on parent heights or if a child has early or late pubertal changes. It is simply an x-ray of the child's hand and wrist. It involves minimal radiation and does not hurt. The bone age can help us approximate how much longer a child will grow and the expected height, but does not tell us why a child is shorter or taller than expected or hitting puberty at an unexpected age.

A delayed bone age means that the bones think they are younger than the child actually is. This can mean catch up growth after peers have stopped growing. A delayed bone age can happen for many reasons, but a common one is due to late puberty and can run in families. A history, physical exam and possibly labs can help asses the reason for delayed bone age.

If a child has an advanced bone age it means the bones appear older than the child's actual age. With this we expect them to stop growing earlier than most kids. This means that even if they are tall for their age, they could end up shorter than average. This is often associated with early puberty and childhood obesity. An advanced bone age needs further evaluation to identify the cause.

If the bone age equals the actual age, you can estimate the final height to be about the same percentage as the current height.

We often repeat bone ages to see if they are changing at a different rate than the child grows.

Radiologists and endocrinologists use books with x-rays of standard bones of various age groups to assess which age the child's x-ray most closely resembles. Since there are different bones that can develop at different rates, it is possible that two doctors will assign a different bone age. It is not an exact science, but can give a good estimate of how much longer a child may grow. 

The photo above is from Amazon's bookstore. You can see how the bones of the youngest hand on the left are very different from those in the hand on the right. The radiologist or endocrinologist finds the image that is most like the child's x-ray and call it that bone age. 

In the boy growth charts pictured below, the top set of lines is the height (stature) for age chart. The bottom set is the weight chart. The ages that are used to plot a height at a given time are listed at the top and bottom. The heights are listed on the right and left of the graph. The middle line is 50%, which reflects a height of 50% (taller than half/shorter than half of boys of the same age). The other lines are also labeled for their respective height percentiles on the far right. Hopefully this looks familiar because you've seen a graph like this at your child's doctor. If you haven't, be sure to ask to see it next time you're there.

There are many "normal" heights, usually determined by genetics. Tall parents tend to have tall kids, short parents have short kids. There is no "correct" height or "best" height, the percentiles simply give us a way to follow the growth over time and estimate final adult height if a child hits puberty at a typical age (early puberty stops the growth early, late puberty allows for later growth).

In Figure 1, I filled in a fictitious child's heights with blue dots. You can see that from 3 to 5 years this boy was at the 50th percentile for height. That means he was taller than half the boys his age and shorter than half. The fact that he's in the middle doesn't make it "normal" it just means that if his parents are average height, he is growing as expected because it's consistent year to year and he is of average height like his parents. At 6 years, he dropped to the 25th percentile, and at 8 years he fell to the 10th percentile. This consistent drop in growth often triggers a physician to look for reasons of the drop. Maybe the parents are both very short. Maybe there is a medical problem. Or maybe there is a family history of people having late growth spurts (something called "constitutional growth delay"). Treatment (if needed) varies depending on the cause.

Figure 1

The red arrow on the right marks the actual height at 8 years (blue) at about 47 inches (120cm). For this fictitious child, the bone age is 7 years, and if you plot 47 inches (the actual height at the time) at 7 years (the bone age), you will see this white dot is at the 50th percentile and marked by the red arrow on the left. A delay in bone age often coincides with a late growth spurt. I finished out the growth plots, and this kiddo actually fell more (down to the 5th percentile) before he hit a late puberty and grew into late teens/early 20s to hit a final height at the 50th percentile.

In Figure 2 below a fictitious boy is tall for his age early on. At 6 years old his height (black dot) is at the 97th percentile (he is taller than 97 out of 100 of boys his age) at about 49.5 inches (125.5cm). His bone age at the time (red dot) is 8 years 6 months, which is at the 25th percentile for height. A year later he is off the height chart, taller than over 97% of boys his age, but the bone age is 10 years 9 months, again at the 25th percentile. This chart shows an early growth spurt (as he looks taller than his peers) but an early puberty and a slowed growth faster than other boys. His final height is only at the 25th percentile, much shorter than his early heights would have predicted.

Many parents are super excited when their children are tall and can't comprehend when I talk about the possibility that it might not last. (I typically discuss this if both parents are short but the child is tall, if I see signs of early puberty, or if the child is obese - especially if parents are not as tall as the child's height predicts.) The bone age does not give a reason for the altered growth rate, but can help identify a need for further evaluation and treatment if indicated.

Figure 2

Bone age is difficult to understand, and I hope this helps parents understand with some pictures. I completely made up these growth charts. They do not reflect any real patient or any real diagnosis. They are solely to illustrate how we estimate the bone age on the growth chart to help assess final predicted height. The reasons behind altered growth patterns are many and might require further evaluation.

Take home point: At every well visit your child should have a height and weight measured. If the yearly growth accelerates too fast or slows, talk to your doctor about possible reasons. If a bone age is done, you can use a growth chart to put the bone age in at your child's height (instead of actual age) and see how tall the final height estimate would be. It isn't a guarantee, but can be helpful.

Screen Free Challenge

Are you up for a challenge?

Join thousands of other families who want to reconnect by going screen free for the week of May 5 – 11, 2014.

What does screen free mean? To put it simply: do not use anything with a screen unless it is directly related to work or school. Televisions, computers, smart phones and other screens are all a part of our world, but they can overtake our lives. By consciously avoiding non-essential screen time, we can reconnect with our family and friends and even ourselves.

Does going screen free for a week sound impossible?

For many people screens are an essential part of our lives. We use online calendars so we can remember our daily schedule and share it with family. We use online resources to make purchases, or research a topic. Computers help us conduct business and more. Texting allows quick communication. Less essentially we use screens to keep up with friends or to share what we’re up to. We play games. We watch movies and television shows. We use screens as a cheap babysitter. It is a huge recreational pastime. It’s easy and inexpensive.

But there are many costs.

• Do your kids complain that you’re always on your phone or computer? Maybe they don’t verbalize it but they might show it with disruptive behaviors. And remember you’re their role model. They will do as you do. But they’d rather spend time with you. Even the teens who deny it. 
• Do your children throw a fit when you tell them to turn the screen off? This can be a sign of addiction, or at least poor self-control. Aggressive tendencies are often exacerbated by screen time.
• Children lose time outdoors and in other active and creative play because they’d prefer to watch television or play a video game. Screen time is directly correlated with obesity, behavior issues, and sleep problems. Active play and social interactions can help with each of these problems.
• Infants and children learn best through human interactions and exploration, yet a screen sometimes mesmerizes them for hours at a time. Some of us feel comforted that our kids are learning by playing some of these games or watching certain “educational” programs, but this is often not the case. Studies do not show beneficial learning, especially in young children, with screen interactions. In many cases time spent on these games and programs is detrimental to their development.
• The typical school aged child has more screen time than ANY other activity except sleep!

Just think of all the free time you will make by turning off the screens. Have every member of your family make the commitment and help each other find new ways to connect.

Because most of spend over 2 hours a day with recreational screen time, we can capture that time to play a game with our kids, take a walk, read a book, write poetry, do a craft project, clean out the garage, garden… the list goes on. Let your kids do things and experience life instead of letting them watch or play with something someone else created for them. And it’s okay to just spend time together talking. Sometimes it’s those simple times that become our most special memories.

Unplug. Start with just one week. See where it takes you!

101 Screen Free Activities

Related posts:

Screen Free Week April 29-May 5, 2013

Screen time: Do you have a love - hate relationship with it?

Quest for Health: Why Screen Free?

Quest for Health: Screen Free Week Reflections

Resources and More From Around the Web:

Screen Free Week is Just around the Corner!

Following FTC Complaint, Baby App Developer Stops Making Educational Claims

These Apps Will Not Educate Your Baby

ScreenFreeWeek.org

Private discussions with the pediatrician

photo source: Shutterstock

Every once in awhile a parent will tell the nurse that they want the child out of the room to discuss an issue with with the doctor privately. This is usually something they perceive as a negative thing for the child to hear, such as the child being overweight or having behavior problems.

While I understand the parent's intentions, I find this to be disruptive and counter productive. As much as I try to find an excuse to have a child leave, it is usually obvious that the nurse keeps them out longer than needed.

If we have the child leave the room, he knows something is up. We are talking about him. But not sharing with him. What could possibly be so bad that we won't talk to him about it? (How do you feel when you suspect people are talking about you?)

Then there's the issue of any patient needs to know what the issue is so we can address it. My guess is most of these kids already know what the concerns are. They need help working on them. If they are overweight, we need to talk about what they eat, how they exercise, and how they sleep. If it's behavior problems, they need to give insight into how they feel and what leads to the behaviors. They need to be a part of the plan to fix the problems. If they aren't on board, they won't change their habits. I can talk about weight (or behavior, or drugs, or whatever the concern is) sensitively and in an age appropriate manner with the child. The kids at school are likely talking about it in a not-so-sensitive manner, so it's best to not make it worse by secretly discussing it.

If a parent really wants to let a physician know specific points without the child present, find a way to do that outside of a visit with the child.

Send in a letter or secure electronic message with your concerns before the appointment. Be sure it's at least a few days before the appointment so the doctor has a chance to review it!

Schedule a consult appointment for just parents to come in without the child.

Call in advance to tell the phone nurse your concerns so she can pass it on to the physician.

Don't bring siblings to an appointment where you want to discuss a private matter about another child.

All of these means allow the physician (or other provider) to know your concerns without blatantly kicking a child out to talk about something privately.

 

Screen Free Week April 29-May 5, 2013

For several years now I've been a supporter of Screen Free Week, a time to turn off all screens (television, computers, video games, social media, smart phones) unnecessary for school or work.

As you know, I am a Facebook junkie. I post often and follow many. How can I support Screen Free Week?

Because it is a good reminder. I don't think we should never use screens, but we should learn to limit. Sometimes the best way to cut back is to go cold turkey.

Screens (television, smart phones, computers, movie screens) dominate our lives. I recently saw this picture show up on PreventDisease.com's Facebook page:

I wish I thought it was an exaggeration, but it seems so true.

I have seen a group of teens all dolled up for prom sitting across each other at a restaurant table, all texting instead of talking.

I often see preschool aged kids watch another kid play a handheld video game. I've tried watching someone else play, and I can't even see the screen, so I have no idea why they like to watch each other so much. It is like a drug... they have to watch.

I ask kids what their favorite activities are at their well visits, and a large percentage of the time "play video games" is the top answer. 

Screen Free Week gives us time to reconnect. Turn off all screens not required for work or school. Limit the off-hours work-related screen time. Stop answering texts and emails during family time. Turn it off!

Not sure what to do with all your free time? Check out this list of 101 Screen Free Activities.

Want your kids to get on board? Talk to them about the fun things you can do with them. Have them sign a Pledge Card. Share the cards with their friends or teacher.

Do I realize how hard this is? Yes. See my Screen Free Week Reflections blog for some of the issues I encountered while going screen free in 2011. Despite the logistics of going Screen Free, it is overall a great experience!

Why is this needed?

• Screen time is associated with obesity, loss of sleep, aggression, and attention problems.
• Children are exposed to marketing, negative events, and age-inappropriate themes.
• Preschoolers spend an average of 32 hours a week on a screen. That's almost a full time job! Where's the free play time?
• School aged children average 7.5 hours of screen time a day-- that's over 50 hours a week!
• Screen time cuts into sleep time for many kids and adults. Sleep is one of my big three needs: proper nutrition, daily exercise, and adequate sleep. These should be among the top priorities of every day.
• For more facts and research on screen time, see this pdf from Campaign for a Commercial-Free Childhood.

I challenge you and your family to a Screen Free Week April 29th - May 5th.

Reflect on the changes you made at the end of the week. What new habits can you initiate long term? Hopefully you can keep family time more protected from the screen interruptions. Instead of watching tv with your kids, play a game. Resist answering that text during your child's replay of his school day. Stay off the computer until the kids go to bed. Turn the tv off during meals and keep the television set to age appropriate programming if your kids are in the area. (For ideas on age appropriate television, movies, books and games, check out CommonSenseMedia.)

In the long run the real answer is balance, not complete avoidance. Screen time offers a lot of benefit: relaxation, entertainment, knowledge sharing. But it becomes a problem when it overshadows other things. Small doses are acceptable. Too much of anything isn't good. Find the balance!

Share what changes you made during your week and which ones you think your family can do long term. I'd love to hear from you!


Previous Screen Free blogs:
Why Screen Free
Screen Free Week Reflections

Why Screen Free?

Every April and September there is a nationwide Screen-free Week to unplug from the screens and plug back in to our families.  Why do I support this wholeheartedly? Because I see the benefit from getting away from it all every once in awhile.  We live in a media-rich society, so I know that it is impossible to completely turn everything off... most of us couldn't do our jobs without a computer.  But I challenge you to substitute recreational screen time with other activites for just one week and see what happens. 

Some facts and statistics:

• Screen Time = television, video games, computer time, handheld games, social media, movies -- anything with a screen.
• The typical school aged child has 7.5 hours of screen time daily. That's more time than ANY other activity except sleep!
• The typical preschool child watches over 4.5 hours of screen time daily.
• Screen time is linked to aggression, ADHD, and obesity among other things.
• The American Academy of Pediatrics (AAP) recommends NO screen time under 2 years of age and no more than 10 hours per week for older children.
• The AAP recommends no televisions, computers, or other electronic media in children's bedrooms.
• An average preschool child sees nearly 25,000 commercials.
• Screen time inhibits sleep.   
• More from the links below!

Since my family has been doing this I find an interesting pattern: 

• my kids initially grumble (ok, it is a stronger disagreement, but...) 
• they quickly find other things to keep busy
• they play better together with less fighting
• they argue less with me when asked to do something
• we overall enjoy one another more
• at the end of the week they choose to do things without the tv or computers
• they slowly start to watch / do more on the screens
• they are once again addicted to the screen and I have to pull them away.

What can you do besides watch tv or play on the computer or game system?

• Go for a walk.
• Ride a bike.
• Play ball.
• Have a picnic.
• Play a board game.
• Read a book.
• Make up a play.  Be creative!
• Dance.
• Cook dinner together as a family.
• Talk to a friend or family member. Talk, not text!
• Go to the park or zoo.
• Check out the new aquarium.

It is an overall good experience. Read my post-Screen-Free Week Reflections from the last screen-free week here.

I will try not to be on line during the Screen Free Week, April 30-May 6th. (Hard work, I know... scanning the internet is my biggest pastime/hobby ~ AKA timewaster.)  

Join me off line and plug in to your families!  Have a fun week and I'll see you back on Facebook and Twitter May 7th!  

For more information:

Fact Sheets from Commercial Free Childhood

Common Sense Media 

Dr. Christakis on Media and Children

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!

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?

  

Too Little Sleep in Athletes

I am very concerned on many levels about late nights required for local sport programs from a parent perspective and as a pediatrician.

Many physical and emotional problems have been linked to sleep deprivation.  I see many kids who struggle in school and at home with behavior and learning problems that are directly related to loss of adequate sleep.  Poor sleep is also related to obesity, poor growth, depression, anxiety, poor school performance, and so many other issues.  Sleep is needed for release of growth hormone, which is needed for bone and muscle growth, muscle repair, fat burning, and learning.  Sleep loss leads to poor attention spans, inconsistent performance, decreased aerobic endurance, delayed response times, and increased illness, and will therefore affect their game!  There is increased risk of injury in these tired athletes.

You can argue that one late night a week will not have devastating consequences, but I disagree. We have all heard that consistent bedtimes are important for sound sleep.  Ironically sleep deprivation often leads to insomnia and more sleep problems. You cannot sleep "extra" to bank sleep hours.  Kids will often sleep in on weekends to attempt to catch up on the sleep hours missed during the week, but that means a week of struggles emotionally and physically.  It also gets their sleep routine off balance, which again contributes to poor sleep.

It is recommended to exercise at least 2-3 hours before bedtime because exercise is stimulating, making it difficult to fall asleep after exercise until the body temperature and metabolism return to normal.  Yet I find that many school aged kids have practices and games in the late evening into night hours.

School aged kids up to 12 years of age need 9-11 hrs of sleep per night to function adequately.  Practices and games late in the evening shortchange their night's rest by far too many hours.  Don't forget to consider that the time to settle down after the game is up to 3 hours. The following day they are likely to have problems at school.  An overtired child often has MORE problems getting to sleep, which affects the rest of the week.  These younger kids tend to have a lot of noticeable behavior and learning problems. Many are misdiagnosed with ADHD and treated with medication, when all they really need is better sleep. It is simply not acceptable to set them up for this failure.

As kids enter middle school they often need extra sleep due to puberty.  (Growth hormone is released during sleep.)  Unfortunately, school tends to start earlier and their game/practice times are often later, meaning they might be getting up just a few hours after they are falling to sleep.  Do we really want to affect their growth during these important years? 

No wonder many middle and high schoolers fall to sleep in class and struggle with falling grades, irritability, depression, and more.

Kids shouldn't have a hard time getting up in the morning.  If they are, it's a sign of not enough sleep!

I should also include coaches and parents in this, since we will be required to teach and transport these kids. Adults will fall short of their recommended 7-9 hrs of sleep, which affects mood, weight gain, and attentiveness.  This affects not only health, but also home and office life.  Can you wake up before your alarm?  If not, can you get to bed earlier?  That is a healthier choice than adding an extra cup of coffee or energy drink to your day.

We as parents and coaches want our kids to succeed in all areas of life. We want to give them the tools they need for this, which must include proper sleep.  Practice and game times on school nights must take into consideration the sleep requirements of these kids.  I do not want to be responsible for allowing  my child to be out late on school nights, therefore contributing to increased risk of poor school performance, behavior issues, immune deficiencies, depression, growth and obesity, and all the other known consequences of poor sleep. Once these issues surface it is too late to prevent them and the snowball effect begins!

The question: What can parents do?????

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

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

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

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

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

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

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

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

One cup of coconut milk has over 50 grams of fat and over 460 calories!  A special treat: yes. A routine daily drink: no!  

(For comparison, a BK vanilla milkshake has 412 calories and 23 grams of fat in 227 grams (just 1/2 oz shy of a full cup).

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

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

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


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

Kid's Weight is Weighing in my Mind

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

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

What to do???  On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders.  I think this is possible if we focus on the word healthy, not weight.   Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall.  If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI.  We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.  I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

1. Healthy eating
2. Exercise (with proper safety equipment- but that's another topic!)
3. Sleep (again, another topic entirely!)

Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.  If we are lucky our kids like one or two vegetables and some fruits.  We might even be able to sneak a whole grain bread in the mix.  If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about).  We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want.  We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy.  The perception of calorie needs and actual calorie needs can be very mismatched.  I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:

• turn on the tv and feed the child while the child is distracted
• reward eating with dessert
• refuse to let the child leave the table until the plate is empty
• allow excessive milk "since at least it's healthy"
• allow snacking throughout the day
• legitimize that a "healthy" snack of goldfish is better than cookies

Any of these are problematic on several levels.  Kids don't learn to respond to their own hunger cues if they are forced to eat.  If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?  If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating.  They can, however, over time slowly kill themselves with unhealthy habits.  

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

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.  Do parents realize how damaging this can be?  

• A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
• A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
• A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
• Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.

Now consider those famous treats at games.  Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:

• Typical flavored drinks or juice range 50-90 calories per 6 ounce serving. 
• Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
• Fruit roll up (28g) 104 calories
• 1 medium chocolate chip cookie: 48 calories
• Orange slices (1 cup): 85 calories
• Grapes (1 cup): 62 calories
• Apple slices (1 cup): 65 calories

So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.  The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.  And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...

What's wrong with WATER?  And eating real food after the game.  As a family. Around the table.  That snack is likely to decrease appetite for the next meal, and it isn't needed.  And if they're hungry, they're more likely to eat the healthy foods on their plate.

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


Simple suggestions:

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