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 Sroufe’s claim that as a society we’re “drugging” our children to avoid dealing with societal issues is years out of date.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

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

Children are now recommended to stay in rear-facing car seats until age 2.  Booster seats for older kids are recommended until they reach 4′ 9″.  All kids should ride in the back seat until age 13.

Parents sometimes worry that growing toddlers will run out of leg room, but it doesn’t seem to be a problem with properly-designed car seats.  If needed, you should buy a new one.

It will take a while for state car seat laws to catch up, so what’s legal now may not be what’s recommended by the AAP.  (I’ll also have to update all my handouts!)

To read the AAP’s statement, click here.

–  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

People ask if I recommend the Swine Flu vaccine.  Yes, I certainly do!  When we receive it, I’ll administer it to my staff and myself (at the direction of the Division of Public Health).  Then we’ll offer the vaccine to our most frail patients (with cerebral palsy, chronic lung diseases, etc).  Then we’ll invite you to schedule an appointment to receive it.

Just as for the regular “seasonal” flu vaccine, there will be a nasal mist Swine Flu vaccine, as well as shots.  We’ll offer these to our patients as we receive them.  I doubt that we’ll receive our entire allotment at once, so some patients may have to wait to receive it.

Are you worried about the vaccine?  Please be reassured.  The H1N1 vaccine has been tested on thousands of patients already.  The manufacturing processes are the same as for the “regular” seasonal flu vaccines.  So the new vaccines can be expected to give the same immunity, and the same low chance of side effects, as the vaccines against “regular” flu.  And we are certainly seeing cases of H1N1 flu in the office (perhaps two cases a week now), so it’s a good idea to get immunized.

–  David Epstein, MD

We are able now to vaccinate all our patients against seasonal flu, regardless of insurance.  (The only exception is for Medicaid patients between 3 years and 7 years old who have asthma; that vaccine is still back-ordered.)

I invite you to call our office (392 – 2077) and speak to our staff to schedule a convenient appointment.

–  Dr. Epstein

For patients with “Commercial” insurance (Blue Cross, Aetna, Coventry, etc.): we have all “regular flu” vaccines:
-  shots for all children under 3
-  nasal spray for all children over 2 (EXCEPT those with asthma)
-  shots for all children over 3 (INCLUDING those with asthma) (This is *new!* as of 9/25/09; so if we delayed giving flu vaccine last month because your child has asthma, NOW you can call us to schedule a flu shot.)

For patients with “Medicaid” insurance (Delaware Physician’s Care, Unison, etc.):
-  We have flu vaccine ONLY for patients over 8 years old (healthy or asthmatic).  I will post a note here when they are delivered; we hope to have them by Halloween.

“Swine Flu” (Novel H1N1) vaccines:  As of 10/7/09:
-  NO vaccines yet.  They will be delivered in shipments spread across many weeks.  The CDC is just starting to distribute Swine Flu vaccine to hospitals.
-  Eventually we will have both nasal vaccines and injections
-  “High Risk” patients will be vaccinated first
-  I will post a note here when they are available, we hope by Halloween.

We are able to immunize most of our patients against “seasonal” (regular) flu.  We have been immunizing kids under 3 with flu shots since mid-August.  We are also able to immunize most kids over 2 with the nasal “FluMist,” except kids with asthma; we can give them flu vaccine injections.

Separate vaccinations against both regular flu and Swine Flu are needed for the best protection.  I strongly recommend that all patients receive flu vaccine, both “seasonal” and H1N; parents should also be vaccinated if possible.

Currently, physicians are being asked to “prioritize” testing for the H1N1 flu virus.  In general, we are advised not to run tests unless the patient is sick enough to consider hospitalization.  If we test everyone with fever, the labs will be overwhelmed, which will delay really sick patients from getting test results.  Also, not every case of Swine Flu must be treated with Tamiflu.  There is concern that overuse of antiviral medications like Tamiful may induce the Swine Flu virus to mutate and develop resistance.

Some patients have asked about taking the children out in public.  But I don’t think it’s necessary to “huddle” at home.  Only a general curfew would be effective at curbing transmission; most people who contract flu (H1N1 or regular) will recover anyway; and in the meantime we have to live our lives.  Kids need social stimulation too!  Frequent hand washing (or hand sanitizer) is your best protection.

–  Dr. Epstein

So far, Swine Flu hasn’t seemed very serious.  Most cases have recovered fully; fewer than 500 people have died from it in the US so far this year.  This is a remarkably low number, considering the high rate of transmission.

But the concern is that if the Swine Flu virus mutates into a more virulant strain, but retains its high contagiousness, things could get much worse.  This is what happened during the 1918 pandemic of H1N1 flu, which killed 100 million people (5% of the world’s population).

Our medical care is certainly better than it was in 1918, and we hope that another pandemic like 1918′s would not be as lethal.  We now have antiviral medications, better hospitals, antibiotics, and better worldwide communications.  But we are not completely protected:  strains of Swine Flu resistant to antiviral medications have been reported.  And many people in the world have never seen a doctor and can’t get to a hospital at all!

I recommend that everyone get a flu vaccine.  Adults should get them, for their own protection and so that it doesn’t spread to the kids.  Kids should get them, for their own protection and so it doesn’t spread to their friends and classmates.

Flu shots are routinely given to kids 6 months and older.  (Nasal spray vaccination is a nice alternative for kids over 5 years old who don’t have asthma.)  Two vaccinations, one month apart, are required if you’ve never had flu vaccine; one vaccine per year is required after that.  This year, vaccine against Swine Flu will be administered separately; we probably won’t get ours in stock until Thanksgiving according to the Delaware Division of Public Health.

Never had a flu shot?  This year is a good time to start!  Afraid of the flu vaccine?  There’s no reason to be; people who claim that the “flu vaccine made me sicker” are usually confused by a coincidental illness unrelated to the flu vaccine.

Keep checking my website (click here); I’ll keep posting updates about flu vaccine and Swine Flu.

–  David Epstein MD

Everyone is concerned.  However, worldwide, fears of a global “pandemic” are starting to recede.

For the latest information about the status of Swine Flu in Delaware, click here to go to the Medical Society of Delaware’s website.

For information about the symptoms and medical care of Swine Flu, click here to go to the CDC’s website.

Without fever, there’s not much concern about Swine Flu.  Don’t forget that most kids with fever have something else!! Our office is still seeing several kids a week who have been sickened by Strep Throat, for example, which is treatable with standard antibiotics.  Viral tonsillitis is also giving our patients high fevers as well; these kids get better in a few days with supportive treatment.

Some patients have asked to stockpile Tamiflu at home.  I urge my patients to resist this temptation.  I am very concerned about the flu bugs developing resistance to our medications (which they do very easily).  The Tamiflu should not be administered without a good indication, such as a close eposure to a sick child with culture-proven flu.  Exposure to a sick child who has not been tested, no matter what country they’re from, is not a good indication for starting Tamiflu.

But our office does have the ability to obtain nasal swabs for Swine Flu testing, for transport to local laboratories.  Please call if you are concerned about your child.

–  Dr. Epstein

Now, a review article in the AMA’s pediatrics journal (April 2009) reassures us that pacifiers may be okay for breastfed babies, after all. 4 randomized trials were reviewed; babies were assigned to the “pacifier” or “no pacifier” groups. All four studies showed no effect of pacifier use on breastfeeding outcomes. In fact, more than half of babies in the “no pacifier” groups actually were given pacifiers by their parents, but these babies breast-fed just as well.

In several observational studies, babies not using pacifiers did breastfeed somewhat more, but the authors speculate that this might be due to family attitudes towards breastfeeding, rather than an effect on breastfeeding by pacifiers. That effect would be difficult to distinguish with this type of study, which is why the randomized trials carry more weight.

Why does it matter? The American Academy of Pediatrics recommends that babies should be offered a pacifier for naps and sleep after 1 month of age (after nursing is established), for the first year or so of life. (Some studies suggest that pacifiers during sleep might reduce the chances of SIDS, although this is not definite.)

So now I feel comfortable reassuring parents that it’s ok to use pacifiers when their infant sleeps. I still recommend that an alert but fussy infant should be offered a feeding before giving a pacifier, to encourage on-demand feeding. And in any event, the use of pacifiers (and bottles) should be ended by 15 months.

(Archives of Pediatric and Adolescent Medicine 2009; 163(4): 378-382)

– David M. Epstein, MD