The protective effect of Vitamin B6occurred in smokers, as well as those never exposed to smoke.

I have started recommending multivitamin supplements more frequently for my patients, because of recent findings that Vitamin D levels are associated with cardiovascular health and immune function (click here to see my previous post).  This study lends more support for that recommendation.  Listen to your grandma; give your kids their daily vitamins!

–  David Epstein, MD

The safety issue relates to the way that the safety belts themselves restrain the child.  In order for the belt to restrain the child without causing injury, the belt must nestle against the child’s bones, rather than soft tissue.

Delaware law (click here for interesting info) requires kids to be in their car seats while travelling until the 8th birthday, or 65 pounds, whichever comes first.  But following this rule does not guarantee safety, especially for smaller kids, because of the geometry of safety belts.

To convince yourself (and your child, if she is agitating to get rid of the booster seat), you can try this test:

Let your child (over 8 years old and 65 pounds) sit in the back seat of your car, with just a seat belt on.  Drive around the block once or twice, then park in your driveway.  BEFORE the kids get out of the car, go to the back seat and check the position of the seat belts on the child’s body.

The lap belt should strike the child’s lower hip bones.  And the shoulder belt should be laying across the hard clavicle (collar bone).  If the lap belt has slipped up across the soft tissues of the belly, or if the shoulder belt lays across the soft tissues of the neck, then it is not safe for the child to be transported this way: in an accident, the safety belts themselves could cause soft tissue damage.  The purpose of the booster seat is to raise the child, so that the safety restraints are in the proper position.

Frankly, I think the only reason that a child would want to get rid of a booster seat is to think of themselves as more “adult”.   But the booster seats let the kids see out the car window better!  My daughter, who was rather petite, needed to use a car booster seat until she was almost 10.  When she complained, I performed the demonstration above, and she quickly understood the need.

(For information about car seats for younger kids, click here.)

–  David Epstein, MD

The most important technique is to expose the base of the cord.  If the base is not exposed to air, then bacteria can thrive in the wet, low oxygen environment; this may lead to infection.

Hydrogen peroxide, wetted on a gauze or cotton ball, is perhaps the best choice for cleaning.  Rubbing alcohol was recommended in the past, but it tends to cause rashes.  A little mildly soapy water can also be used.

Grasp the cord with your fingers, and pull up gently.  At the same time, pull the skin away from the cord, all around the cord, to expose the yellow base.  Then you can clean, all around, with the gauze wetted with hydrogen peroxide.  If the cord smells bad or seems infected, you can smear a little antibiotic ointment (such as neosporin) around and on the base of the cord.

You can clean the cord as often as needed, perhaps 3 or 4 times a day.  You may be instructed not to bathe your baby in the tub until the cord falls off; but I don’t feel strongly about this.  If your baby seems dirty or sticky, you may give a quick (warm) tub bath, then dry the infant thoroughly; then open up the base of the cord (as above) to allow drying.

Textbooks say that the umbilical cord usually falls off by two weeks of age.  But my experience is that the cord may stay attached longer, sometimes as long as 4 weeks.  I suspect the reason is that patients take such good care of the umbilical cord that it takes a while to deteriorate!

If you see the skin around the umbilical cord getting red, he should be examined to rule out infection.  But this is unusual.

–  David Epstein, MD

But most babies who cry a lot don’t have colic.  I haven’t made this diagnosis more than 2 or 3 times in my 20+ year career.  There is usually some other explanation for a baby’s fussiness.

For starters, true “colic” refers to a baby who cries all day and all night.  If your baby cries only at night, for example, and seems fine during the day, she probably doesn’t have colic, and may not have any medical problem at all.

A persistently crying baby with no other symptoms should be examined, to rule out an ear infection or other medical illness.  But most commonly, the medical exam is normal.

Here are some of the possible causes for fussiness in babies.

Overstimulation:  When my daughter was born, our friends and relatives were as excited as we were.  We had many visitors.  She slept all day, but then screamed all night.  Once we finally figured out that we needed to limit visitors during the day, she was more alert in the day, we all slept better at night.  TV is another important cause of overstimulation; I recommend that the TV be limited to an hour a day within the baby’s hearing.

The “fussy period”:  At a few weeks of age, many infants will start crying every evening.  The infant may start to get wound up just after supper, then wail on and off until he exhausts himself before midnight.  These infants sleep fine the rest of the night, and they seem fine in the daytime.  This “Fussy Period” is well known.  It is frustrating but not serious, and most babies grow out of it by about 6 weeks of age.  This is another manifestation of overstimulation.  During the day, do what you can to limit the noise, and handle the baby gently; when the baby is wailing, certainly offer feedings, holding, and other comforts; and get through it as best as you can.

Parental excitement: The noise that a screaming newborn makes is close to intolerable.  Exhausted, frightened parents can be desperate to calm the baby.  But please be assured that if the baby is gaining weight, is feeding well, and has no other sign of illness, then it is very unlikely that the screaming represents a medical emergency.  In fact, parents can inadvertently overstimulate a screaming baby.  Vigorous bouncing, loud “shh”‘ing, and patting the baby may inflame his mood, causing a vicious cycle.  Instead, the most effective action is to role-model the calm behavior that you would like the baby to perform.  You can hold the baby close, move slowly if at all, and speak quietly if at all.  The louder the infant becomes, the more quiet and soothing you can try to be.  It may take an hour, or much longer!  But, through your role modelling, your infant will learn self-soothing; he will learn to manage his own emotional state, which is a very useful skill for anyone to learn early.

Teething: probably not a cause of infant colic.  Infants may start chewing and drooling for months before the first tooth breaks through.  But infants under 2 months old are unlikely to have behavior changes due to teething.

Formula “allergy”:  Most infants can handle any commercially available formula.  But some will have a formula intolerance, manifested as persistent vomiting, diarrhea, or constipation.  Simple crying without other symptoms is rarely due to formula intolerance; but a change in formula might be worth a try.  Try switching to a soy formula, or Nutramigen (or their generic substitutes).  Don’t bother with low-iron formula; there is not enough iron in formula to cause intestinal problems, although the iron is needed to prevent anemia.  Don’t switch to another formula in less than 5-7 days; rapid formula changes will leave you unsure which one helped the most.

Gastroesophageal reflux:  In my experience, “silent reflux” is the most common medical cause of persistent crying in infants.  Stomach contents may not reflux all the way into the mouth, but the discomfort of having stomach acid refluxing into the esophagus can cause crying and arching.  Keeping the baby upright during and after feeds can help.  If not, a visit to the office might be useful; the baby should be examined, then we might try thickening the milk with cereal, or medication.  Sometimes XRays are needed.

A persistently crying newborn can be frustrating, or even frightening.  But there’s usually a treatable cause.  So don’t give up hope – and try to get some sleep!

–  David Epstein, MD

Until now!  Recently, I have seen a steady stream of recent research suggesting that vitamin supplements, especially with Vitamin D, might be useful.

People with low blood levels of Vitamin D have reported 40% more frequent respiratory infections.  The association is even stronger for those with asthma or other lung diseases. (Arch Intern Med. 2009; 169:384-390.)

Teenagers with low Vitamin D levels are twice as likely likely to have high blood pressure, obesity, and high blood sugar.  They were also more likely to have cholesterol problems.  The same finding has been previously reported in adults.  Low Vitamin D levels have direct effects on blood pressure metabolism and insulin levels, and might also be a marker for poor diet.  Vitamin D tends to be drawn into fat tissue, so people with obesity probably need higher Vitamin D intake.  (Click here for the article. 1)

And, of course, Vitamin D’s relationship to bone health is well known.  This has led to universal supplementation of milk with Vitamin D, to complement milk’s calcium supply.  Kids should be happy about this; they don’t need to swallow cod liver oil any more!

Vitamin D deficiency turns out to be surprisingly common.  61% of American children have low serum Vitamin D levels, and almost 10% are frankly deficient.  Only 4% of kids take regular children’s vitamin supplements.  (Click here to see the data. 2)

As a result, the AAP now recommends Vitamin D supplements for all children, 400 IU (”International Units”) per day.  (Click here for the AAP report. 3) (Most children’s vitamin supplements provide this amount, but check the label to be certain.)  But even this may turn out to be insufficient for some kids.  Obese children, and kids taking seizure medications, might need more.

What do I recommend?

• Infants fed with breastmilk should be given a daily vitamin supplement, starting at 1 month of age (such as Tri-Vi-Sol).  (Formula already contains vitamin supplements, so infants taking more than 16 ounces of formula per day don’t need Tri-Vi-Sol.)
• For kids over 1 year, and actually into adulthood, a regular vitamin supplement (any brand) should be given daily.  Any brand should be fine; I suggest you find a brand that also provides mineral supplementation, such as iron, zinc, and even selenium.
• Unfortunately, blood testing for Vitamin D is problematic.  Some doctors recommend keeping levels above 20 ng/ml; but others recommend levels above 20 ng/ml.  Lab testing and reporting of Vitamin D levels are not yet standardized.  And Vitamin D levels vary normally with the seasons.  So I don’t recommend blood tests except under specific circumstances.

And don’t forget to check my handout on Calcium supplements (click here).

–  David Epstein, MD

1. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e371-e379]
2. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e362-e370]
3. [PEDIATRICS Vol. 122 No. 2 August 2008, pp. 398-417]

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 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

But what about little babies under 6 months?

For decades, doctors advised against sunscreen for babies under 6 months.  However, there seems to be nothing in the sunscreen itself that’s actually bad for little babies.  (I’ve even spoken to the engineers at Johnson & Johnson; they can’t explain the recommendation!)  I suspect that the recommendation to avoid sunscreen under 6 months of age came about because somebody was afraid that parents might get too relaxed.  Might a parent apply sunscreen to a little infant’s skin, then take him out on the boat all day?  I hope not!  Common sense will help guide us.

I think it’s perfectly safe to apply sunscreen to the skin of little infants, even under 6 months.  (Avoid the eyes; it stings!!)  But I wouldn’t take the baby out in direct sun for very long (use your judgement), and certainly avoid direct sun between 11 am and 3 pm.  Re-apply the sunscreen every 2 hours or so, just as with the older kids.  If you’re on the beach or by the pool, or if it’s really hot, pay attention to the baby’s hydration status and give extra fluids (water or the baby’s usual feeds).

I’ve heard dermatologists say that 85% of a person’s lifetime risk of skin cancer comes from the sun exposure accumulated before 15 years of age.  So slather on the sunscreen, especially on an infant!

–  David M. Epstein, MD