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

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.

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

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

The ads recall a time when many children were crippled or killed by contagious diseases.  Grandparents hold their own young grandchildren, while talking about members of their own families who died or were crippled by illnesses that nowadays we rarely experience.  Vaccinations that we routinely administer to our patients are highly effective at keeping children safe from these dangerous diseases.

To view these ads, click here.

–  Dr. Epstein

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