Motion Sickness

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

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

Photo by Greg L via Wikimedia

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

Some general tips to avoid motion sickness:

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

Medicines for motion sickness:

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

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

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

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

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

Alternative treatments:

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

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Flu Vaccine 2016-2017 Season

Flu Vaccine Drama. Every Year It's Something!

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

Wow. That will make a lot of kids unhappy.

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

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

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

Nasal Flu Vaccine (FluMist) Update

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

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

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

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

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

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

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

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

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

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

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

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

Flu Vaccine General Facts

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

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

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

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

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

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

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

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

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

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

Stool colors & patterns in infants: What's normal & when should you worry?

Help! My baby is constipated. She hasn't pooped for days.

We hear versions of this all the time.

Constipation isn't defined by how often babies have a bowel movement. A breastfed baby might have a bowel movement every time he eats (and in between) or he might go less than once a week. (Watch out when it finally comes - it often escapes the diaper!) Most formula fed babies have a bowel movement 1-3 times a day. Babies who get some breast milk and some formula can have characteristics of each feeding type.

During the first few days of life the stool looks black and is thick. This is called meconium. It occurs in both breast fed and formula fed babies. If your baby doesn't have meconium within 24 hours of birth an evaluation to decide if there's a problem should be done. Be sure to talk with your baby's doctor if he doesn't poop within 24 hours of birth or if the meconium is formed like a plug. (See a photo on Stanford's newborn page.)

Meconium stool. Photo by Azoreg via Wikimedia Commons

After the first few days there is a period of transition stool. The stools become more green and sticky. This is the meconium mixed with breastmilk or formula stools. It happens earlier in formula babies and after mother's milk comes in for breast fed babies.

After the transitional stools, the stools will vary in color and consistency depending on if the baby gets breastmilk or formula. If breastmilk is the primary food, the stools can vary quite a bit. They often look like yellow cottage cheese, with a lot of liquid and chunks. It often becomes a bit thicker (like pudding) as a baby gets older. It is not diarrhea just because it is watery. Breast fed stools can vary in shades of yellow to brown or green, often changing depending on what the mother ate. Bright green and frothy stools can indicate a low fat diet in a breast fed baby. The fore milk has less fat than the hind milk, so if the baby consistently has frothy bright green stools we will monitor the baby's weight closely to ensure adequate growth and evaluate the amount of milk the mother is producing and baby is drinking.

If a baby is taking formula, the stools can look shades of yellow and brown and be the consistency of peanut butter, pudding, or thick oatmeal. Formula fed stools tend to smell more foul than breast milk stools, but even breast fed baby poops can stink.

Once a baby eats solids (or pureed foods) the stools can thicken a bit but should never be hard. They usually become more foul smelling at this time. Sometimes chunks of food (especially carrots, corn, and raisins) can be seen in the stool. This is normal.

If a baby takes an iron supplement the stools might turn dark green or black. This is normal and not a concern. This does not happen from the amount of iron in baby formula. All formula should have iron. It is an important nutrient for all babies and low iron formula is not recommended.

What's important?

• A term baby should gain about 15-30 grams per day after the first week of life.
• Blood in the stool can be from swallowed blood (often from a crack in mother's nipple), constipation, food allergy (usually cow's milk protein), or infection and should be evaluated.
• It is normal to have different shades of yellow, brown, and green stools.
• A baby with a swollen (distended) abdomen and discomfort or a change in feeding patterns should be examined.
• A baby should not have formed stools as long as they are on primarily breast milk or formula.
• Poop should never be a shade of white (liver concerns), red (blood), or black -if not on iron supplements (digested blood).
• Mucus in stool could be simply swallowed mucus but can be a sign of infection or food allergy.

Meningitis Risks and Preventions

Meningitis is thankfully uncommon, but when it happens it can be deadly. Meningitis is an inflammation in the membranes around the brain and spinal cord (meninges). It is usually caused by a virus, but many bacteria and fungi can also infect the meninges. Symptoms include headache, fever, and stiff neck and may include other symptoms depending on the organism causing the infection.

I wanted to write about meningitis because with the newest vaccine against meningitis, I am concerned that parents don't recognize what exactly their children are protected against and what risks remain after vaccination. I will break down meningitis by type of organism causing the inflammation, and include any vaccines and treatments available for that type within that grouping.

Bacterial Meningitis

Bacterial meningitis is a medical emergency. Even with early treatment with antibiotics, it can be devastating. If a person survives, many of the bacteria can cause permanent brain damage, hearing loss, learning disabilities, and loss of limbs. Anne Geddes, a photographer famous for her pictures of infants and children, has worked with Novartis Vaccines and the Confederation of Meningitis Organizations (CoMo) to create Protecting Our Tomorrows: Portraits of Meningococcal Disease, a book that is available for a free download on iTunes that shows people who have survived meningitis.

Photo by Mikael Häggström

The type of bacteria causing meningitis varies by age group. Fortunately the bacteria that cause meningitis are not as contagious as things we more commonly see, such as the common cold, but whenever there's a case of bacterial meningitis the health department will identify risks and help treat contacts at risk. The bacteria don't always lead to meningitis, but may be found in healthy people or cause other types of infections as well, such as ear infections, pneumonia, and urinary tract infections. 

• Newborns tend to be infected with bacteria that can be a part of the mother's urogenital tract. Group B Streptoccous (GBS), Escherichia coli, and Listeria monocytogenes are most common. Pregnant women are screened for GBS and treated with antibiotics prior to delivery if possible. Pregnant women should handle foods properly and avoid certain foods to protect against Listeria.
• Infants and children are most at risk from Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcal), Haemophilus influenzae type b (Hib). Thankfully starting at two months of age infants can get vaccines against Hib since 1985. A vaccine against 7 strains of pneumococcus became available in the year 2000, and it was improved to protect against 13 strains of pneumococcus since 2010. There are over 90 known strains of pneumococcus, but the vaccine covers the majority of strains that cause severe illnesses. Vaccination against N. meningitidis is not routinely given to infants at this time.
• Teens and young adults are at risk from Neisseria meningitidis and Streptococcus pneumoniae. Younger teens who are up to date on vaccines have been vaccinated against S pneumoniae, but since the vaccine was introduced in 2000, older teens might have missed this vaccine and it is not recommended to do catch up unless they are in a high risk group, such as if they are immune compromised or missing a spleen. 

• Vaccines are now available that help protect against all three serogroups (B, C, and Y) of meningococcal disease that are the most commonly seen meningococcal subtypes in the United States: 

• Meningococcal conjugate vaccine (Menactra®- which covers A, C, W, Y subtypes, Menveo®- which covers A, C, W, Y subtypes and MenHibrix®- which covers C, Y, and Hib) is recommended as part of the routine vaccine schedule at 11-12 years of age with a booster at 16 years. It is also recommended at younger ages for high risk people (immune compromise, spleen issues, and certain travel).

• Meningococcal polysaccharide vaccine (Menomune®- covers A, C, W, Y) is given to people over 55 years of age.

• Serogroup B meningococcal vaccine (Bexsero® and Trumenba®- both cover subtypeB). This is only recommended with a permissive use status, meaning it is not highly recommended for any age group, but it is allowed to be given to anyone over 16 years of age and is encouraged for high risk people, sometimes down to 10 years of age, depending on the risk. High risk people are those with known immune problems, specific chronic diseases, or who have no working spleen. High risk might include when there is a known outbreak, so if your college student hears of meningitis on campus don't let them think they don't need it due to vaccination with one of the vaccines that covers A, C, W, and Y. Some colleges require vaccination against meningitis B in addition to A, C, W and Y. 

Viral Meningitis

Viral meningitis is much more common but less deadly than bacterial meningitis. There are many types of viruses that cause meningitis, and usually there is no specific treatment for viral meningitis, just like other viral illnesses. Most people who get viral meningitis completely recover on their own within 7 to 10 days. People with meningitis caused by certain viruses such as herpesvirus and influenza may benefit from treatment with an antiviral medication. If there are symptoms of meningitis, it is important to quickly get the proper testing done to determine if treatment is needed or not. Prevention with standard hand washing and other measures to prevent the spread of viruses is important. Some vaccinations can protect against diseases that can cause meningitis, such as measles, mumps, chickenpox, and influenza. Since mosquitoes, other insects, and rodents can spread disease, avoiding bites can help prevent infection.

Fungal Meningitis 

Fungal meningitis is very rare and does not spread from person to person. It occurs when a person with a weak immune system is infected with a fungus that spreads to the brain or spinal cord.

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.

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.