I am baffled by his article.  There has been no doubt about the effectiveness of stimulants, such as Ritalin, Adderal, Focalin, and other medications that have been successfully used for decades.  Dr. Sroufe does not quote any new studies or information, except one from 2009 (which I have not seen, and he does not reference).  He claims that there is no “long term” benefit, but he acknowledges that many studies have demonstrated benefit for 3-8 years or longer, which he calls “short term.”

Dr. Sroufe makes some puzzling claims:

1.  His claim that “to date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems” is simply not true.

2.  Properly prescribed stimulants are not “habit forming”.  They are chemically similar to amphetamine street drugs; so manufacture is regulated by the FDA to avoid illegal stockpiling and inappropriate administration to non-patients.  In fact, studies show that correct treatment of ADHD with prescribed stimulants actually protects kids from eventual drug addiction, because they help prevent school and social failure.

3.  Dr. Sroufe states: “Putting children on drugs does nothing to change the conditions that derail their development in the first place.”  I do agree with Dr. Sroufe that diagnosis and treatment of ADHD must include attention to the child’s home environment, learning environment, and other sources of stress.  This is the purpose of a proper workup and ongoing followup, which should include screening for stress at home, discipline techniques, sleep dysfunction, and other nonpharmacologic issues.  The pediatrician must also screen for conditions that might mimic ADHD, such as depression, anxiety, hearing loss, and a host of other medical conditions.  However, ADHD is a real and treatable condition.

Dr. Sroufe’s claim that as a society we’re “drugging” our children to avoid dealing with societal issues is years out of date.  Of course, some patients are given stimulants after an inadequate workup, either due to lack of resources or poor education (or attention) by the prescribing practitioner.  Many medications are similarly overused; antibiotics are another good example.  But this is no reason to completely stop using safe, effective medications that show clear and visible assistance to children who would otherwise struggle unneccesarily.

Parents should remain reassured that if they see their children succeeding because of their ADHD medication, that continuing this treatment is the right thing to do.

–  David M. Epstein, MD

There are some surprises.  Using plug-in outlet covers?  Most adults don’t plug them back in.  Video monitors?  There are reports of kids getting strangled on the cords.

But some old suggestions are still valid.  The best way to start babyproofing is to get down on your hands and knees, and look for trouble at your child’s level.  Then fix it.

–  David Epstein MD

No surprise, right?  But it’s not good, and not inevitable!

Here’s the comment I posted about this NY Times article.  (Or see the posting HERE.)

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As a pediatrician, I’m especially alarmed by 2 statistics in this article:

1.  Kids under 2 spend twice as much time being read to as they do watching TV.
2.  6 of 7 parents said that their doctor had never discussed “media”.

Where’s the anticipatory guidance from the pediatrician?

Pediatricians and other health professionals should be discussing regularly both reading and TV with patients.  We have overwhelming evidence that school performance, weight issues, attention problems, and interpersonal skills are all affected.  The issue is at least as important as issues like sugar intake and exercise, which doctors are expected to discuss routinely.

There are loads of well-funded programs (ReadAloud.org, ReachOutAndRead.org, etc.) which can assist doctors in encouraging their patients to choose books over TV (or cell phone apps).  There are many recommendations over 15 years, from respected medical organizations such as the AAP, encouraging doctors to discuss TV and media use by children.

But many doctors are slow to incorporate these resources and recommendations.  They may discuss reading and TV only as an afterthought, if at all.  They may even have TV or DVD’s playing continuously in their waiting room!

Why is this?  Are doctors dubious about the data? Are we worried about a backlash or resistance from their patients?  Or perhaps, are we reluctant to examine their own personal viewing habits?

In my practice, at every checkup starting from birth, I ask parents how much TV the kids are exposed to.  I also encourage reading, and I suggest specific books just to get started.  I also pay attention to our role modeling:  there is no TV in our office, but we have many children’s books available.  In my practice, parents accept these suggestions with gratitude, and they generally follow the advice – often changing their own TV viewing habits in the process.

Doctors should counsel parents, early and often, to avoid TV, and encourage reading.

–  David Epstein, MD

A study presented this week at the American Stroke Association International Stroke Conference (ISC) suggests a 61% increase in stroke for people who drink diet sodas regularly.  (Click here to read more.)

Does diet soda cause stroke?  Or does the association merely mean that people who choose diet soda also have other lifestyle habits that predispose to cardiovascular disease?

My view is that this study’s results are most likely due to an association with lifestyle habits.  The study authors tried to control for such associations, but that’s hard to do in a questionnaire-based study like this one.  I’d have guessed that if drinking diet soda caused stroke and heart disease, we’d have noticed it before now.  But I don’t agree with the American Beverage Association that this makes the study meaningless.

People who choose diet sodas don’t usually do so because they prefer the flavor to sugar; often they are trying to counterbalance other issues, such as obesity, which are already known to be related to stroke and heart disease.

Especially for children, my concern is that diet sodas may reinforce kids’ preference to drink other sweetened beverages, like juices, sports drinks and sugary sodas, which are clearly associated with obesity.

The best use for diet sodas for kids is probably for children whose weight is a concern, as a temporary or infrequent stepping stone to teach better lifestyle habits.  Diet sodas may not be harmful themselves, but it’s better to teach kids to drink water or milk.

Babies start “gumming” and drooling on hard objects, starting at a few months of age.  This might be due to teething, or it might just be oral exploration.  You can try rubbing some teething medicine, such as Baby Anbesol or Baby Oragel, on the gums.  Ribbed teething rings, or a washcloth dipped in ice water, can give some relief.

Sometimes babies wake up fussy in the middle of the night.  If your baby has been fussy and gumming things during the day, then an occasional night waking might be due to teething.  You can try giving some acetaminophen or ibuprofen, in the usual dose for fever.  But if the waking is persistent, it’s probably not due to teething.

Some babies will pull on their ears when they’re teething;  you can try the usual teething remedies.   But if there are cold symptoms also, especially if persistent, an ear infection is also possible; give us a call if you’re concerned.

But I really doubt many of the other symptoms attributed to teething.  How could teething cause a diaper rash?  Or diarrhea?  Or a runny nose?  I can’t figure out what the mechanism would be!

Fever is supposed to be another symptom of teething.  I might believe that a low-grade fever, for an hour or two, might come from teething.  But a baby with a high fever for a day or more needs to be seen by the pediatrician.  It might be something like a virus or an ear infection, but I never find that such babies are simply teething.

Visually inspecting the gums doesn’t help much.  Generally, the white lumps under the mucous membranes lining the gums are just irregularities of the jaw bone, not new teeth.  This is especially true of lumps and irregularities on the sides of the jaw.

You can’t “feel” teeth coming in, unless they’re actually breaking through the mucous membrane.  If you see the actual surface of the tooth on the top of the jaw, then “teething” might explain a baby’s fussiness.  Sometimes there’s a little bleeding; that’s normal.  Occasionally, a dark-colored blood blister will develop over a tooth as it’s coming through; nothing needs to be done about this, since it will “pop” on its own.

But if your baby is sick, please don’t assume that teething is the cause.  It’s best to assume that a baby’s symptoms are due to a virus or other illness.  Please don’t hesitate to call us if you’re concerned.

The bottom line on teething?  I think its bark is worse than its “bite!”

–  David Epstein, MD

Here’s how the survey is performed.  Researchers associated with the CDC made random calls to thousands of households (73,000 for this survey), and asked the parents a series of questions about the health of members of the house.

Childhood ADHD was one of the conditions they asked about.  The researchers asked if the child had “ever” been diagnosed, if he was “currently” diagnosed, and if the child was currently on medication.  The survey data was based solely on these randomized calls; no medical records were examined, and no independent assessment of the patients were made.

This week’s newspapers are stressing the “9.5%” number.  Headlines say “One in ten American children has ADHD.”  But what does this mean?  The excitement stems partly from the perception of an increase; in the past, most studies have found that 5% of American children have ADHD.  Delaware’s numbers are the 4th-highest in the country.  But does this make sense? How could the rate of ADHD double in just 4 years?

Certainly, the sense of acceptance of a diagnosis of ADHD in parents and health professionals is increasing.  And treatment with medication is better accepted, due to shifting social acceptance, adn decreasing side effects and cost.

But frankly, I doubt that there has been an increase in the actual, biological prevalence of the symptoms of ADHD.  A close look at the CDC’s data supports such skepticism.  Although parents said that 9.5% of their children “had ever” been diagnosed with ADHD, only 4.8% were actually being treated with medication, a small increase from the 4.3% rate reported in 2003.

The 4.8% figure much more closely matches other studies, which have reported a stable 5% incidence of ADHD for many years.

Clearly, ADHD is a debilitating problem for a significant number of children.  Treatment with medication can give dramatic relief, in my experience and in many studies.  But I doubt that the CDC’s most recent report reflects an actual increase in the problem.

Click here to see the CDC’s data.

Click here for more information about how I diagnose and treat ADHD.

–     David Epstein, MD

But pressure against these videos has continued to mount.  Disney, who bought Baby Einstein in 2001, calls the bad publicity a “smear campaign.”  But on September 4th, as reported this week on the New York Times front page, the Campaign for a Commercial-Free Childhood convinced Walt Disney Studios to offer a full refund.  The refund applies to any Baby Einstein DVD purchased after mid-2005.  Return your DVD, and get a check for $15.99 – no questions asked!  You don’t even need the original receipt, or even the box.  Just mail in your Baby Einstein DVD before March 4, 2010.

To download the refund form, click here. Or go to the Baby Einstein website, and search for “einstein moneyback;” the link for the refund form will be on the right-hand side of the page.

Remember that the American Academy of Pediatrics still recommends that there’s no reason to turn on the TV at all, for children under 2 years old; and for kids over 2, limit screen time to 10 hours a week.

–  David Epstein, MD

We had favorite books, which would get read every day.   We all knew the words by heart!  I’ve listed some of our very favorite books in my handout about reading, which you may download (click here).

But my daughter is in high school now, and I know there are newer books available.  I’d love to know what you’re reading to your baby.  And I bet other parents would like to know too.  If other children read some of the same books that you read to your child, then the kids can share their common knowledge when they get together.  (The term for this is “cultural literacy,” a shared knowledge base that binds a community together.)

So:  Please collect the books that are your favorites to read to your infant, toddler, or child.  Post them in a comment to this blog.  And let’s watch the list grow, as parents post their favorites!

Thanks!!

–  David Epstein, MD

Children and teens copy the behaviors they see in the movies and on TV, according to research.

Cigarettes:  If the characters in a show are smoking, kids who see the show are more likely to smoke.  Research shows this effect, even if it’s the “bad guys” who are smoking.  What’s scary is that over two thirds of shows and movies kids see do include on-screen smoking, even PG-13 movies – and the latest movies are no better than the old ones.  Magazines that kids read have just as much advertising for cigarettes as ever, despite new laws prohibiting it.

Violence:  Research shows that kids who see TV shows that model hitting and fighting, even cartoons, increase their real-life physical violence.  This effect is noticed at very young ages, and persists for years after the TV shows were watched.

Obesity:  Experts say that TV watching, all by itself, is responsible for two thirds of our nation’s pediatric obesity epidemic.  The problem is not just that the kids sit and watch; they’re watching one advertisement after another for junk food!

Alcohol:  Kids watch broadcasts of sports events, often with their families.  But beer manufacturers advertise heavily, despite laws forbidding alcohol ads on shows that kids are likely to watch.  Research links this exposure to a tendency to drink later.

So why can’t something be done?  Hollywood has been resistant to criticism, TV ratings are not well understood (and may not be accurate), the internet cannot be regulated, and devices like Ipods and cell phones will only increase kids’ access.  So what are parents to do?  The best advice is for the parents to watch the shows with kids together, with your finger on the “pause” button, and talk about the implied messages.  Ask: “Is that character making a good choice?  What would you do?”

(Download my handout about TV watching (click here) for specific suggestions.)

A recent commentary in JAMA (June 3, 2009, p. 2265) points out “the extraordinary positive power of the media.  Antiviolence attitudes, empathy, cooperation, tolerance, respect for older people — the media can be powerfully prosocial.”  But we, as the parents, must watch out, every time the kids see a show or movie.  Ask yourself:  “How would I react if a real person were behaving like the characters in this show, in front of my children?”

–  David M. Epstein, MD

This is not surprising, because the skills required are different.  Daytime bladder control is under voluntary control, and can be taught.  (This is why it’s best to wait for potty training until your child is interested in staying dry.)  At night, though, the child is (hopefully) asleep, and has no voluntary bladder control.

Nighttime dryness is an unconscious act; it happens when the child’s brain becomes sufficiently mature.  Everyone achieves this state eventually, except in the rare event of a medical problem.  We label bedwetting as a problem only when it becomes a social issue, usually after age 6 or so when many children start to receive invitations for sleepovers at friends’ homes.  The medical term for this is “primary eneuresis,” indicating that the eneuresis or bedwetting does not have another medical cause.

Bedwetting often runs in the family.  Many children with prolonged bedwetting will have relatives who have also suffered with it (though some family members may be reluctant to discuss it).  These children generally are dry during the day, but they wet the bed several times per month, in some cases nightly, throughout childhood until they grow out of their bedwetting.  Limiting fluids in the hours before bedtime, and planned night awakenings for bathroom trips, can help.  Electronic beeper-style alarms, available for under $100, can teach kids to wake themselves over time.  If these measures are ineffective, there are safe and effective prescriptions available.

If a child begins bedwetting repeatedly after a dry period of months or years, it may be a sign of a different medical disorder requiring treatment.  This is called “secondary eneuresis,” and is less common than the inherited primary eneuresis.  A urine infection would be the most frequent culprit.

–  David Epstein, MD