Don't ignore warning signals or bad vibes. The downside is that they might live and/or work nowhere near you, and they might just be in it for a holiday fling. Do new things to flirt better, like surprising your crush by turning up with tickets to her or his favorite movie or show. Be sure to always have a cell phone and cash for a cab so that you never feel you have to rely on your date for a ride home. Listening is a Chicago Dating Websites part of creating humor. How to Find a Date at the Beach. Don't be shy towards him. Pursue online dating like you would a job When you're on the hunt for a new job, you invest time in putting together a clean résumé that presents you well and searching for the perfect positions to apply for. Don't obsess about the details. Tell him if you're shy or quiet - he loves you, so he'll understand! Be playful. And if you're thinking you're all high and mighty because you're not single and don't need this, well, goody goody gumdrops for you, but be a saint and share this shit with your single friends.

ADHD in preschoolers? Be cautious.

More than 10% of school-age American children have been diagnosed and treated for Attention Deficit Disorder.  Many are helped by medication; treatment can truly be life-changing for them and their families.

But some children younger than school-age are being prescribed ADHD medications, and it may not be appropriate.

An article in the Washington Post this past May 3 points to data from the CDC, suggesting that too many children under 6 may be prescribed medication, although behavioral therapy may be more appropriate.

The cardinal symptoms of ADHD include easy distractibility, short attention span, and impulsive behavior.  In school-age children, these symptoms can cause poor academic progress, because the child finds it hard to learn, and even harder to demonstrate what you’ve learned and do classwork, if your learning style is impulsive and disorganized.  In addition, children with ADHD find it hard to cooperate with adult routines. And the social life may suffer because other children find it difficult to be friends with a kid who is distractible and impulsive.

But with pre-school children, I am impressed that distractibility, short attention span, and impulsiveness is normal behavior!  Most kids this age have some difficulty managing their impulses; their task in “growing up” is to learn self-restraint.  As with any other skill, some kids learn self-restraint faster than others.  We should be cautious about “medicalizing” such normal behavior.

I agree with the American Academy of Pediatrics that kids under 6 who have behavior problems should generally be evaluated by a psychologist or other behavior health professional, before starting medication.  Frequently, such behavioral therapy can teach a child (and their parents) techniques to alter behavior, so that their behavior becomes more socially acceptable and they can integrate with their peers.  If behavioral therapy is not successful in orienting the child towards more acceptable behavior, then medication might be more appropriately considered.

Why does this not happen?  Why are young children being treated more often with stimulants and other neurologically active medications?  Behavioral therapy may not be easy to arrange, or to follow through with, especially if trained therapists in the area are in short supply.  And the dramatic (and apparently easy) success of medical treatments in older children can be seductive.

We are fortunate in our area to have seen the number of well-trained child therapists increase recently, and I am pleased that I have such resources available to my patients.

If your preschool children are acting out, don’t assume that they have ADHD – seek a professional evaluation first!

To see the Washington Post article, click here:

To read an essay about “responsibility and cooperation” on my website, click here:

For a list of some local pediatric psychologists that I have had good experience with, click here:

—  David Epstein MD

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Iron for infants helps development.

A new study shows that giving iron supplementation to young infants helps their gross motor development.

The study followed more than 1000 infants, most of whom were solely or mainly breastfed.  Iron supplementation (or a placebo) was started by 6 weeks of age, and continued every day until 9 months.  By that age, an improvement in gross motor scores was seen in the infants who received the iron supplementation, compared to placebo.  No side effects were reported.

Vitamin D and iron are found in breast milk only at very low levels.  For many years, experts have recommended that breast-fed infants should be supplemented with daily oral Vitamin D.  But there has been no consensus about iron supplementation for breast-fed babies; the American Academy of Pediatrics has at times recommended it, but the AAP’s own breastfeeding committee has disagreed.

I have recommended iron supplementation for breast-fed babies (along with the Vitamin D), because some children do show low iron levels or even iron-deficiency anemia on the one-year routine blood screen recommended by the AAP.  The only preparation with both iron and Vitamin D that I’m aware of is “Poly-vi-sol with iron.”

This new study confirms to me the value of routinely supplementing breast-fed infants with iron.  (It should be noted that mainly formula-fed infants already receive iron and vitamins in the formula, so they should not usually be given any extra supplements.)

—  David Epstein MD

Rosa M. Angulo-Barroso, PhD, et al.:  PEDIATRICS Volume 1 37, number 4 , April 2016: e2 0153547


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Old-style toys are better.

Children’s toys and books sell because they engage.  So any “doodad” that catches the eye of a kid, or his parents, helps to generate sales.  Nowadays, lots of kids’ toys make noise or flash lights – even board books and  traditional games like Monopoly have electronic versions.  And screen-based entertainments have proliferated; apparently 3/4 of kids have their own cell phone or tablet by age 4.

Is this good?  I think not.  Kids need to learn language and social skills, as well as self-regulation.  Toys that “do the work” for the child may entertain, but kids don’t learn these difficult skills by reflexively responding to noises and lights.

Now, a new study supports this view.  According to a study in JAMA, such toys suppress language interactions between parents and children.  “Conversational turns during play do more than teach children language. They lay the groundwork for literacy skills, teach role-playing, give parents a window into their child’s developmental stage and struggles, and teach social skills such as turn-taking and accepting others’ leads,” according to pediatric researchers. (Click here for a commentary.).

Kids learn more from open-use toys that require imagination, not just rote following directions or completing tasks.  Old-style toys such as legos, building blocks, plastic dolls and animals, “craft” activities, and board books fit the bill.  (You might have noticed that I have filled my waiting rooms with such toys; this is intentional.)  Give a kid a rubber ball, and watch what happens!

Newer toys are also available.  The “Melissa and Doug” line of toys will give gift-givers more ideas.  And consider EBay for inexpensive used options, such as Playskool Village (about $15).

I haven’t tried “Bunchems” but they look cool (but keep them away from long hair!).

As you sort through all the presents this year, encourage your kids to keep the non-electric toys at hand.

— David M. Epstein, MD

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Non-drug treatment of ADHD

Parents often ask how their children’s symptoms of ADHD can be treated without “stimulant” medication such as Focalin or Adderall.

In fact, we know that treatment of ADHD with stimulant medication has a stronger research basis, and more data, than any other treatment.  But often parents rightly ask, “Isn’t there treatment besides drugs?”

Certainly, “alternative” therapies such as herbal treatments, dietary manipulations, and chiropractic treatment for ADHD work no better than placebo.  But there are some important strategies that parents can and should try, before (or along with) a trial of stimulant medications.

Note that each of these suggestions is thought to have a long-term effect, if the intervention is sustained.  This is different than the impact of medication, which works quickly but wears off by the end of the day.

–  Sleep deprivation impairs judgment and memory, and increases impulsiveness and irritability.  So not getting sufficient sleep mimics and exacerbates the symptoms of ADHD.  ADHD patients must be sure to get enough hours of sleep.  Just as importantly, poor quality of sleep should be addressed.  ADHD patients should get to bed at a reasonable hour, and electronics and “screen time” should be restricted within an hour or so of bedtime.  Quality-of-sleep issues, such as insomnia, sleep apnea or snoring, must also be addressed.

–  A study this past July demonstrates that teens who increase their physical activity, such as joining a sports team, helps improve their ADHD behavior 3 years later.  (J Am Acad Child Adolesc Psychiatry, 2015 July; 54:565-70.

–  Excessive “screen time” is well known to stimulate subsequent ADHD symptoms, even as early as age 1.  It is recommended to limit total TV and movie watching, video games, “smart phone” and tablet use to 1-2 hours per day.  Pleasure reading, hobbies, and family activities such as cooking together are good alternatives.  (Pediatrics April 2004; Vol 113(4):708-713)

–  Pediatricians recommend good nutrition for all our patients, such as encouraging milk, fruits and vegetables, and grains over a diet high in fat, salt, sugars and processed starches.  There is some research to suggest that these recommendations may also help improve ADHD symptoms, though it is hard to prove.

–  Musical training seems to cause more rapid development in the areas of the brain related to “executive functions” such as motor planning, and emotion and impulse regulation.  This development was measured by noting thickening of the brain cortex on MRI.  (J Am Acad Child Adolesc Psychiatry, November 2014, 53(11): 1153–1161.)

–  Early evidence suggests that long-term dietary supplementation with Omega-3‘s, like those found in fish oils, might improve ADHD symptoms.  The benefit is “modest” compared with that of traditional stimulant treatment for ADHD, and the optimal dose is unknown, but there is probably no harm and might be some benefit.  (J Am Acad Child Adolesc Psychiatry, October 2011: 50(10):991–1000.)

Other studies suggest that more complex interventions such as mindfulness training, behavioral training, and even Canine-assisted therapy might be of some benefit; parents must balance the effort involved (for both them and the affected student) against the suggestion of benefit for these interventions.  Other therapies, such as chiropractic treatment and vision exercises, have been shown not to carry any benefit.

One particular intervention that has been shown NOT to be helpful is the accommodation of extended time for school exams.  Neither the patient’s score on tests, nor their learning, have been shown to improve by giving ADHD students extra time to complete their exams.  (J Atten Disorders, February 2015, (19)2:167-172 )

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Egg Allergy and Vaccines

There are three vaccines that are manufactured using chicken eggs:  MMR, influenza, and yellow fever vaccine.  If your child has a history of allergic reactions to eggs, you might be concerned about reactions to these vaccines.  But for most children, they are perfectly safe.

Experts are much less concerned about reactions in children with mild allergic reactions to eggs, such as hives or other rashes, vomiting or diarrhea.  Severe wheezing or “anaphylaxis” might be of more concern, but even in these children, reactions are very unusual.

MMR vaccine has been extensively studied.  Serious reactions to MMR vaccine in people known to be severely allergic to eggs are extremely rare; serious reactions in people who are only mildly allergic to eggs are nonexistent.  This is not surprising, because the vaccine is produced using egg fibroblasts (a type of cell found in eggs), not whole chicken eggs.  Children with known allergy to eggs should receive MMR vaccine as usual, although for safety the child should be observed for reactions.

Most flu vaccines are produced using whole eggs.  But there are very few reports of dramatic reactions after flu vaccine is given to children with severe egg allergy.  Most experts recommend that flu vaccine should be given as usual to children with severe egg allergy, with an observation period in the office afterwards.  For children with milder allergy, flu vaccine may be given without special concern.

(For more information, see this CDC website:

Yellow Fever vaccine is also produced using chicken eggs.  We do not administer this vaccine.  If you are visiting a 3rd-world country which recommends it and your child is allergic to eggs, you should discuss the risks and benefits with the provider who administers the vaccine.

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Too much fast food!

American children eat too much fast food.  Surprised?  Me neither … but I am indeed surprised that it’s not improving.

9% of what American children eat is “fast food.”  A whopping 17% of what American teenagers eat is “fast food.”  It doesn’t matter if you’re rich or poor, highly educated or not; it doesn’t matter if you read the nutritional labels that restaurants are now required to provide; the numbers are the same.  And the numbers are not improving over time; children eat just as much fast food as 10 or 20 years ago.

“Fast food” is BAD for us, kids and adults.  People like how it tastes; it’s convenient and inexpensive.  But it’s just plain bad for us.  And the habits we develop as children we tend to keep as adults!  Talk with your kids about avoiding fast food, and stay away from it yourself, so that you can role-model healthy eating for your kids.

Fast food isn’t going away.  But if we can limit ourselves to visiting fast food restaurants once per week (no mare), this will limit the damage.

You can NY Times: Kids eat too much fast food


—  David Epstein, MD

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“Life before vaccines.”

The February 16th issue of New Yorker magazine included a thoughtful article about the anti-vaccine movement.  (Click here to read it.)

One interesting “letter to the editor” commented on the article with a remembrance of life BEFORE vaccines, by a woman old enough to have “been there.”  People were hurt by these infections.  Here are her comments.

“There are still a few of us around who remember life before vaccines.  It’s hard watching each generation reinvent the wheel, when we wish that they could learn from our memories:

“Of the two children in my mother’s family who died of diphtheria; of the big red signs on houses under scarlet-fever quarantine; and of the little girl up the street who died of the disease show.

“The one vaccine available to us was smallpox:  nobody questioned whether to get it.  We lined up at school to receive the little scratch on the arm, and delighted in comparing scabs afterward – they meant that the vaccine “took.”

“As a naval-aviation cadet during the Second World War, my husband fell behind in his class when he came down with the mumps.

“We all knew somebody who limped for life – or worse – as a result of polio.

“Measles, mumps, chicken pox, whooping cough – I had them all.  I’d have gladly risked the “hazards” of the vaccines.”

Vivian Douglas Smith, Falls Church, Va.

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We’re making progress (a little) with childhood obesity.

Rates of obesity in young children, age 2 to 5, have dropped 5% in the past 10 years.  (Click here to see a review of the study.)  This is a good thing!  But pediatric obesity rates in older children have not changed.

It all has to do with simple choices about food and lifestyle.  Unfortunately, it’s easy to be swayed by our culture and our friends into using “convenience” processed foods, and electronic entertainments.

I’ve been speaking with my patients frequently about lifestyle.  Click here for a look at my routine recommendations; they’re not difficult to implement with a little attention.

It’s worth remembering that the lifestyle kids live with are really hard to change as they get older.  The life you save may be your kids’!

— Dr. Epstein

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Should we give peanuts to infants?

A new study suggests that giving infants peanuts might reduce their rate of peanut allergy.

This is important because peanut allergy is a difficult problem to manage.

The problem, though, is that news organizations are implying that we’ve found a cure for the high rate of peanut allergy by giving all infants peanuts.  But the study was performed only on infants known to be at high risk, not all healthy infants.

Here’s a statement from the AAP:


Study: Feeding peanut to high-risk infants may reduce allergy rate

by Scott H. Sicherer, M.D., FAAP

The early introduction of peanut among infants with high-risk atopic disease is a promising approach to prevent the development of peanut allergy, according to a study released in the New England Journal of Medicine on Feb. 23 (

The Learning Early About Peanut Allergy (LEAP) study randomized 640 infants ages 4 months up to 11 months of age to eat peanut consistently until 5 years of age or to avoid peanut. Families randomized to introduce peanut were instructed to give a soft peanut snack of a smooth peanut butter spread (not whole peanuts or peanut butter, which are potential choking hazards) at least three times per week. The study only included infants at high risk of peanut allergy, having severe eczema, egg allergy or both. All potential participants were allergy tested using skin prick tests, and those with larger test results were excluded from the study, assuming likely peanut allergy.

The first feeding of peanut was under direct medical supervision using a slower graded feeding for infants with positive tests.

Results following supervised feeding at 5 years of age showed that the rate of peanut allergy was 17% in those avoiding peanut compared to 3% in those who ate peanut. Among infants entering the study with negative allergy tests, there was an 86% reduction and for those with small positive allergy tests, there was a 70% reduction in peanut allergy in the group randomized to eat peanut compared to avoidance.

The remarkable reduction in peanut allergy reported by the study suggests that this approach can significantly reduce the rate of peanut allergy in this high-risk group. Various professional organizations, including the Academy, are working on recommendations that follow from these results.

To safely recapitulate the approach used in the study, infants at high risk of peanut allergy could be skin tested; feedings medically supervised as necessary; and for those for whom peanut was tolerated, families instructed on safe approaches to routinely incorporate peanut into the diet. Issues regarding avoidance of peanut for allergic family members would need to be addressed.

There remain several unknowns. The effect of introducing but not routinely incorporating peanut into the diet or ingesting amounts different from those used in the study remain unexplored. Additionally, it is not known if a period of abstinence from peanut would leave some children apt to react to peanut on re-exposure. This latter concern is under evaluation in the LEAP study population by having those on peanut avoid it and then undergo another medically supervised feeding. The results are forthcoming.

In addition, the study did not address healthy infants. The Academy, in a clinical report released in 2008 (Pediatrics. 2008;121:183-191), noted that there was no convincing evidence that delaying introduction of allergenic foods, including those containing peanut protein, has a protective effect on the development of atopic disease. There are no studies to support a specific ideal age of introduction of peanut for healthy children. Furthermore, peanuts and many peanut products are potential choking hazards for very young infants.

A study comparing the dietary approach of Jewish children in Israel to those in the U.K., the latter having a 10-fold higher rate of peanut allergy at school age, noted that U.K. infants generally were not ingesting peanut products. In contrast, for the Israeli children, peanut protein usually in soft snack foods was introduced into the diet at around 7 months of age. Additionally, the median monthly peanut consumption at ages 8-14 months was approximately the equivalent of 2 tablespoons of peanut butter for Israeli children compared to none in those in the U.K.

Although specific studies are lacking, the results of the LEAP study, prior observations and AAP guidance all support the notion that introduction of peanut in the infant diet need not be delayed. It is not envisioned that peanut should become a “first food” for infants. Rather, it could be incorporated into the diets of healthy infants who have tolerated other first foods without difficulty and are developmentally ready to ingest peanut-based foods without choking.

Dr. Sicherer is immediate past chair of the AAP Section on Allergy and Immunology Executive Committee.

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Should You Tell Your Children How Much You Make?

Do you talk with your children about money? It’s a sensitive topic in most families.

It’s one thing to talk about value. It’s useful to start a conversation like this: “Is the toy in that TV ad really worth the cost? Suppose it were your own money?” Or, even: “Is there another toy you would sell, to get the money for the new one you want?” Also, different people might value things differently; that’s another useful point to make.

Understanding the value of a “thing” is a useful skill. Budgeting is another. For example, some parents will give a child a weekly allowance, but then make her use the money for most toys and treats; this gives kids practice with budgeting (“do I have enough?”) and value (“is a $12 toy worth four $3 ice cream cones?”).

But it takes things to another level to talk with children about family finances. Should you tell the kids you can’t (or choose not to) afford a big vacation right now? Should you show them the numbers?

I know that my own parents never talked with us as kids (or even as adults) about family income, expenses and savings. And there are good reasons to be cautious. If the parents don’t make much money, it wouldn’t be good for the kids to feel insecure. If the parents are wealthy, there’s a risk that the kids might become lazy or feel “entitled.”

So a recent article in the New York Times comes as a surprise. Here’s a father who took his entire monthly salary in $1 bills, dumped it on a table in front of the kids, and started peeling off the bills: this much for the mortgage, that much for utilities, and so on, to demonstrate why the family budgeted with the priorities that they had chosen.

It’s a useful idea to think about. Obviously the children’s reactions to the family finances, laid bare, would depend on their ages and sophistication. This approach is probably not right for every family.

But it strikes me that in the past, our society avoided talking about sexuality and puberty with kids until far too late; it’s a good thing that modern families discuss these sensitive topics with kids early enough for them to be properly prepared.

Perhaps we should be more proactive in talking about money with our children as well.

To read the New York Times article, click here:

— David Epstein, MD

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