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 Sroufe’s claim that as a society we’re “drugging” our children to avoid dealing with societal issues is years out of date.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

Death from chicken pox declined 88%, from 4.1 in ten million people to just 0.5 per ten million.  The study by the CDC was published in the August 2011 issue of the AAP journal Pediatrics, comparing death rates in the early ’90′s (before introduction of the vaccine) to the mid-2000′s.

This improvement occurred with a single injection.  Subsequently, a 2-dose regimen has been introduced, because other research has shown that 5% of children don’t achieve proper immunity to chickenpox from a single injection.

So we can expect even better numbers, the next time the numbers are run!

–  David Epstein, MD

For decades, cough and cold medications were sold freely, over the counter.  Drug stores and pharmaceutical companies sold brands like Dimetapp, Pediacare, Delsym, Robitussin, and many others; there was a huge market for these medications, and companies competed fiercely.  They contained antihistamines, decongestants, and sometimes acetaminophen or other fever reducers.

Parents relied on these medications to suppress the cough and congestion from colds and viruses.   However, it’s been hard to prove that they actually work.  And there were so many kinds, and so many dosing regimens, that occasionally parents would be confused into administering an incorrect dose; on occasion, a child would suffer.

A few years ago, the FDA took these medications off the market for kids under 4 years old, citing the health risks and lack of proof of efficacy.  The FDA also discourages using the prescription version of these medications, although some are still available.

But if your child is suffering from cold and cough symptoms, some simple remedies can still help.

Run a vaporiser in the child’s room at night. (In winter, a steam vaporiser will make the room less clammy than a cold-water humidifier.)

Hot tea, especially with honey (buckwheat if you can find it), is helpful for cough.

And lots of fluids will help suppress a cough, and make a sick child feel better.

You can find more suggestions in this handout; click here to read more.

–  Dr. Epstein

The move is aimed at prescription medications that contain Chlorpheniramine, Brompheniramine, Phenylephrine, Dextromethorphan, Guaiafenesin, Pseudoephedrine, and a couple of similar ingredients.

I have prescribed these medications for my patients for many years, and never heard of any serious problems.  Unfortunately, they will no longer be available.  There may be other medications that I can substitute, but I suspect that they may be in short supply until their manufacturers can catch up with the demand caused by their competitors being knocked off the market.

This move does not affect the over-the-counter cold and cough medications still available that contain the same ingredients.  You can still buy Pediacare, Delsym, and several other medications that are sold to treat the symptoms of upper respiratory infections.  But the FDA also changed the labeling on these medications several years ago, to remove recommendations to use these medications for kids under 4.

To see the FDA’s list of newly banned prescription cough medications, click here.

To read my usual recommendations for treating the symptoms of the common cold, click here to be transferred to our practice website.

–  David M. Epstein, MD

Over a thousand mothers and their infants on an Indian reservation were studied.  Infants whose mothers received flu vaccines were 40% less likely to catch influenza themselves, and 40% less likely to be hospitalized for it.

The effect of fathers’ flu shots on the health of their infants was not studied, but one can assume that it would benefit the kids as well.

Since 1997, experts have recommended that pregnant women should be given flu vaccine.  But acceptance of this advice has been very slow.  Many of the families in my practice are happy to have the infants vaccinated, but the parents are reluctant to be vaccinated themselves.

But, as an accompanying editorial says: “Maternal influenza vaccination targets 2 high-risk groups with 1 vaccine dose – we can’t afford not to act.”  Perhaps this study will reassure these parents, and encourage them to get their own flu shots every year!

–  David Epstein, MD

Archives of Pediatric and Adolescent Medicine.  Vol 165, No. 2, Feb 2011, p. 104-111.

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.

The Government Accountability Office investigated commonly available supplements, and found heavy metals — including lead, mercury, cadmium and arsenic — in supplements available at drugstores and health food stores.

The FDA’s authority to regulate such supplements and treatments was rescinded during the Bush administration; since then, the sale of unregulated supplements has skyrocketed.

Sometimes I am asked about the value of various herbal or homeopathic treatments for children.  In general, there is no proof that they live up to their claims, nor is there supervision to ensure that they are free of foreign substances that might be harmful.

For my patients, I am skeptical that herbal and homeopathic supplements not regulated by the FDA are of benefit to children.  Labelling a treatment as “natural” does not assure us that it is effective, or safe.

Click here to read an article about the Congressional investigation from the New York Times.

–     David Epstein, MD

But now, we read in the news that the Institute of Medicine is about to publish a rebuttal to some recommendations for super-high doses.  (Click here for the Washington Post article, or here for the New York Times report.)

In fact, as far as I can tell, there’s not much disagreement between the Institute of Medicine and the AAP’s recommendations.  IOM recommends that all infants receive 400 International Units (IU) per day, and children over 1 year should receive 600 mg; the AAP recommends 400 IU for all infants and children. The AAP and the IOM agree that there is little evidence to support recommendations for huge doses of vitamin D (2000 IU or more).

Breast milk contains little Vitamin D, so all infants who get most of their milk from breastfeeding should be given Vitamin D supplement drops (with iron if possible).  For older kids, cow milk is fortified to give 400 IU per quart; so unless the kids drink a quart of milk every day, they need other sources as well, so I recommend daily vitamin supplements for them as well.  (Any brand-name or store-brand kids’ vitamin supplement will do; look for ones that also contain iron.  I’d stay away from any supplement made in China!)

So I still recommend once-daily vitamin supplements (with iron) for all children.  Don’t be put off by the news reports this week; the IOM is simply debunking claims for mega-doses of Vitamin D.

–  David Epstein, MD

“Iron deficiency is one of the most common problems among children, but it’s frequently not detected, and it has long-term health implications for children’s development and behavior.”

We test kids for iron deficiency anemia (and lead poisoning) at 1 year of age, but not all cases of iron deficiency are caught (especially if not accompanied by frank anemia).  It would be better to prevent deficiency by ensuring adequate iron intake, especially from food containing iron, but apparently relying on diet has not been sufficient.  And doctors don’t agree about whether to supplement all children routinely.

So, in October, the AAP issued new guidelines for routine iron supplementation:

- Term, healthy infants have sufficient iron for the first 4 months of life. Because human breast milk contains very little iron, breastfed infants should be supplemented with 1 mg/kg per day of oral iron beginning at 4 months until iron-rich complementary foods (such as iron-fortified cereals) are introduced.

- Formula-fed infants will receive adequate iron from formula and complementary foods. Whole milk should not be used before 12 months.

- Infants ages 6 to 12 months need 11 mg of iron a day. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced early. Liquid iron supplements can be used if iron needs are not met by formula and complementary foods.

- Toddlers ages 1 to 3 years need 7 mg/day of iron. It’s best if this comes from foods, including red meats, iron-rich vegetables, and fruits with vitamin C, which enhances iron absorption. Liquid supplements and chewable multivitamins can also be used.

- All preterm infants should have at least 2 mg/kg of iron per day through 12 months of iron, which is the amount of iron in iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.

By comparison, it’s worth noting that adult women should receive 18 mg iron/day, through menopause.

How often do kids receive the recommended amounts of iron, solely from the diet?  Judging by the rate of defiency, apparently not often enough.  So what’s a parent to do?

I recommend for our patients:

- Breastfed infants should receive iron, along with Vitamin D supplements, starting at 2 weeks.  (“Trivisol with Iron” is a good brand.)

- Solid food should be introduced by 6 months of age.  If meats are not introduced by 6 months, then vitamins with iron, such as Trivisol or Polyvisol with Iron, should be given.  (These vitamins also contain Vitamin C, which helps iron absorption.)

- All kids should start whole milk at 12 months (unless it’s prohibited by allergy or family social values).  Since infant formula is not given past 12 months, I think all kids benefit from a daily vitamin supplement with iron, unless they eat lots of meat.

- Kids should be tested for anemia and lead poisoning at 12 months of age, and perhaps at 24 months as well.

Patients often ask what brand of vitamins to buy.  For me, it doesn’t matter; drug store brands are reported to be just as efficacious as “Flintstones” or other brands.  Check the label, to be sure that the supplement contains the ingredients you seek.

–  David Epstein, MD

Next week (Sept. 19-25, 2010) is “National Turn Off the TV week.”  The idea is to unplug all the TV’s in your house for 7 days.  Check out the AAP’s website, or the Center for Screen-Time Awareness, to learn more.

Several families in my practice have tried this in the past few years.  The first couple of days sometimes are difficult.  “Where’s my show?” ask the kids.  “What about the big game, and my news?” complain the adults.  But after a few days, everyone adjusts, and finds other outlets.  Parents say, “I have my family back!”  By the end of the week, many families aren’t sure that they want the TV plugged in again.

Instead of screen time, you might try:

• reading a book out loud together (or a play, for older kids)
• visit a park
• have a drawing contest (“who can draw the ugliest dog?”)
• play hide-and-seek with the neighbors – parents too!
• draw on the driveway with chalk

You get the picture.

If you really want to wage guerrilla warfare on the TV, try this:  for $20, you can buy a legal gadget that turns off all the public TV’s within several yards.  I love the idea!  Check it out here.

–  David Epstein MD