So what's the deal with CHOCOLATE toddler formula!?

I heard the oddest news report this morning. Apparently, unbeknownst to yours truly, Mead-Johnson, the makers of Enfamil have come out with chocolate flavored toddler formula! Their argument for doing so is rather compelling. Your toddler, between the ages of 12 months and 36 months, is at the pickiest eating stage of her life. There will never be an age at which you will be as concerned about how much your child eats than this age. Mead-Johnson, in their advertising, contends that your child still needs all the same vitamins, minerals and essential fatty acids in their diet for growth, yet here they are not eating.

Well this certainly caught my eye as two of my strong interests are kids and nutrition. The issue is critically important for the physical health of this nation. So I looked a little deeper into the subject. I must say, Mead-Johnson has done their homework on this one. I compared Enfamil Lipil, the standard infant formula with Enfagrow, their new chocolate flavored toddler formula. At first glance, the nutritional information appears great! The calorie count is actually down compared to regular formula. Fat content is down in the range of 2% milk. Sugar content is up a little, but not too much. The balance of vitamins and minerals is impressive and far better than 2% milk which is the current recommendation of professional medical societies. So what's the problem? Mead-Johnson is selling a food product that on the surface seems to meet the needs of both parents and toddlers.

Let me give you an example I think most of my readers will understand very clearly. Yesterday, I had a generous lunch. I like to eat... a lot! I exercise a lot and have good genetics, so I can get away with more than the average person. A couple of hours after this generous lunch, I heard the "Buster Bar" in the freezer calling my name. Now a "Buster Bar" is a wonderful Dairy Queen ice cream treat that boasts a whopping 460 calories! Even for my metabolism and exercise level, that's enough to fuel 1/6 of my day. And this was AFTER I had already eaten well through the morning and lunch hour. The LAST thing my body needed was a "Buster Bar!" So what did I do? I ate it!!! There's no justifying it. My body didn't need it. I didn't reduce the rest of my daily calories to adjust. That's 460 calories that will forever sit there until my body uses it... assuming it ever does!

By the same token, Mead-Johnson is correct in saying that the toddler years are the pickiest years of a persons life. Many days, it appears that the toddler isn't eating anything at all. Most parents and, especially grandparents, can't accept this, can't get their heads around it, and really think that it's bad for their charges to not eat. Nothing could be further from the truth! Toddlers don't eat because they aren't hungry! I hear you now. "But if I offer something different, they eat it. Doesn't that prove they're hungry?" Absolutely not! Did I eat that "Buster Bar" because I was hungry? No, I ate it because it tasted good. Likewise, I contend that if your toddler won't eat regular, healthy food, it is because they are not hungry. If they take chocolate flavored formula when they won't eat anything else, it's not because they are hungry. It's not because their bodies are crying out for the nutrition that is in the formula. It's because it tastes good! Plain and simple.

Whenever I have a question that doesn't make sense to me, I always say, "Follow the money." Mead-Johnson is gambling on the fact that concerned parents don't think their children eat enough, so they are producing a tasty alternative to get your children to eat more. In the process, it just so happens that the more Mead-Johnson can get your child to eat, the more money they will make. And, by the way, the more they can get your child to eat, the higher the risk that your child will be overweight.

If you are truly concerned about the nutrition of your child, discuss vitamins and minerals with your childs physician. There are alternatives that can be given that don't come loaded with 425 calories per 24 ounces with 65 grams of sugar added!

So what's up with concussions?

The weather has begun to warm again and the kids are really itching to get outside. With increased outdoor time comes increased participation in athletic events. Frequently, our young athletes will suffer some kind of head injury and the question always arises as to what to do with these kids.

There are two significant consequences of head injury, concussion and intracranial bleeding. Intracranial bleeding is relatively infrequent. These patients usually (but not always) have a significant head injury. They develop headache, nausea, vomiting and/or irritability that gradually worsens, usually prompting medical attention. We saw this recently with a famous model/actress who'd been skiing, hit her head and over the next 24-48 hours had headaches that came and went, gradually worsening. Unfortunately, she perished due to lack of nearby facilities, lack of recognition of a problem, and patient resistance to admitting her symptoms were getting worse. Anytime that there is a head injury, be very aware of symptoms that are getting worse and have worsening symptoms evaluated quickly.

The second significant consequence is far more common and usually considerably more subtle. A concussion is defined as ANY head injury, no matter how minor, that leads to neurologic symptoms. These symptoms can be as mild as several moments of dysorientation or as severe as "blacking out" for many minutes. Clearly, the more severe the injury or the symptoms, the more seriously physicians take the injury, but studies have shown that even minor injuries can lead to long term changes. These chronic changes include persistant headaches (especially with exercise), persistant trouble concentrating (including one patient I had who developed ADD like symptoms for years after the injury), irritability and other personality changes. These symptoms generally resolve spontaneously, but can persist for weeks, months and potentially even years. The symptoms are treated accordingly, but there is no treatment for the underlying cause, that is, the concussion.

While these symptoms are a serious problem for those who suffer from them, the bigger issue is the risk of secondary concussions and, more importantly, second impact syndrome. The research is very clear that individuals who have had a first concussion are at several fold higher risk of having more concussions in the future. All activities with risk for a head injury most be approached with this risk in mind. Any protection that can be afforded to these individuals to prevent a head injury is appropriate. Second impact syndrome is a rare, but potentially fatal complication of having a second head injury while the symptoms of the first concussion are still present.

With these risks in mind, there are certain guidelines for returning to a risky activity after a concussion. Most experts believe that a very mild concussion (head injury with a little dizziness lasting a minute or so) can return to play once COMPLETELY symptom free for more than five minutes. Any persistent symptoms are a reason to remain out of play. Any loss of consciousness should probably result in an athlete being pulled for the duration of the game. Return to play is determined by persistence of symptoms. There is a very gradual return to full activity. Athletes start with usual activities of daily living (walking, going to school). If there are headaches, difficulty concentrating, trouble with short term memory, or irritability, the athlete doesn't move to the next step. The next step includes basic, gentle exercise. Jogging, biking and swimming would fall in this category. Once these activities can be done completely without symptoms, then the athlete may return to sport specific activities including drills. At this point, weight lifting may be resumed. Only when extensive sport specific skills can be done without any return of symptoms may the athlete be returned to competitive play.

Head injury is a serious injury in any child. Athletes are at much higher risk of complication if they return to play too quickly. The key issue is if there are ANY symptoms that you as a parent can see, don't take any chances. Consult with your pediatrician, trainer or sports medicine specialist on how to proceed.

What IS that white stuff?

Another absolutely beautiful day in St. Louis. We don't get that many, so I hope you're out there enjoying it.

At least once a week, I get a visit or a phone call about white stuff in a baby's mouth. In spite of many warnings from grandparents about "thrash," not all that's white in the mouth is thrush. Thrush is a yeast infection in the mouth. Usually, we find it in babies whose immune system hasn't developed to the point of being able to fight it off. Breaset and bottle fed kids both get it. I seem to see it more often in breast fed kids, but I don't think that's generally true in all communities. The yeast comes off of the breast or bottle nipples. Sometimes, Mom will get the infection on her breasts and develop soreness and cracking.

Other kids will get thrush after a round of antibiotics. Thrush is also one of the primary side effects of inhaled steroids.

The best way to tell if a baby has thrush is to look for white patches on the insides of the cheeks. If these patches can not be scraped off, then it is likely thrush. Often, these same patches will appear on the gums. They usually do not appear on the tongue. There are several different treatments for thrush, all of which are reasonably effective. Preventing thrush involves boiling bottle nipples after use (or sending them through the dishwasher). Sometimes, we recommend mother be treated if it appears she is carrying the yeast and giving it to the baby.

Other white rashes in the mouth are also common. The most common misperception is that a white tongue is thrush. Again, if there are no white patches on the cheeks, there probably isn't thrush. The white tongue is usually caused by the environment in the mouth. Mild dehydration will dry the tongue a little and make it white. A recent meal can become somewhat adherent and look like a white coating on the tongue. Geographic tongue describes a tongue that develops serpentine patterns under certain conditions and these patterns are sometimes whitish, but sometimes reddish.

A big cause of white in the mouth is often confused for teeth coming through. The gums of newborns can develop little white cysts. These cysts are entirely developmental in nature. They seem to come and go over the course of the first several months of life. Unfortunately, they do not usually indicate teeth coming in and they are never an indication of thrush.

So next time it looks like there's white stuff in an infants mouth, think of the wide variety of things that turn the mouth white. Consider what part of the mouth has the white spots. Then, when all the information is in place, give your pediatrician a call.

It's summertime again

Ok, ok, so it's been a while. The in-laws were in town. Cold season is in full swing. The muse just wasn't quite hitting me. Excuses, excuses. Time to get back to work. Hopefully, I'll be back in full swing here now.
So my wife had me working out in the yard yesterday. While I love working out, running, lifting, biking, swimming, I don't actually like working very much and yesterday was work. However, I was enjoying the sun, listening to frogs do their chirping and listening to the birds. Here and there, there were splotches of green showing in the undergrowth in our landscape. So, I guess it was all good.
It reminded me, however, that more of my patients will be spending more time outside here soon. School is out in about 6 weeks. Daylight savings time has started, so evenings are spent outside. It's time for me to start considering problems that occur outdoors compared to indoors.
The most obvious is injuries. While many injuries are unavoidable (hence the word, "accident"), many can be minimized or avoided all together. Bike helmets are critical, especially in neighborhoods where drivers may not be constantly alert. Trampolines should be limited to one user at a time. Children should be supervised anytime they are outside running around. I still remember a camping trip we took with a group. During evening fireside time, several parents were enjoying themselves instead of watching their children dance around the fire. By the time I went to bed, I was a nervous wreck keeping everyone elses children out of the fire pit. Water time should always be supervised and the dangers of river swimming constantly appreciated, even while on a "lazy" float trip. Hiking trips often take hikers close to significant falls and children are very curious what is on the other side of that drop.
Insects and arachnids become a nuisance or worse over the next few weeks. Mosquitos carry West Nile virus. Ticks carry Rocky Mountain Spotted fever, Erlichia and Lyme disease. The occasional brown recluse spider is seen and carries a wicked bite. Chiggers are a constant problem in many grassy or woodland areas. DEET containing products are fairly effective at hiding our presence from many of these critters. Higher concentrations last longer and are probably more effective. Deep Woods Off may be the best. "Natural" insect repellants have not been shown to be effective in discouraging ticks, mosquitos or chiggers.
Sunburns are a constant threat during this time of year, as I found out yesterday, again... High levels of SPF are required as well as frequent reapplication of product. Mixed sunscreen/insect repellant products have not been shown to repell bugs. Sweat and swimming both dramatically decrease the useful life of the applied product. Reapplication as often as every 1/2 to 1 hour may be necessary.
Natural sources of water, while very entertaining, are not really good to be drinking, whether accidental or not. While e. coli tends to be the primary concern of most county health departments in neighborhood lakes such as Lake St. Loius, giardia tends to be a much larger problem. Giardia is a smal protozoa found in many lakes and streams in many parts of the country. It tends to cause loose stools several times a day, often for weeks before anyone discovers that it is the problem.
So, while being outdoors is important for the health of our children, it does pose many risks as well that are very different than their risks indoors over the winter. Until next time, enjoy the beautiful weather we've been having.

My "pee pee" hurts!

What do you do when this complaint comes out? I here it from all ages and both from boys and girls.

Pain in the genitalia comes from a large number of sources. The most common is the basic urinary tract infection. Both boys and girls can get these, though they are far more common in girls due to the proximity of urethra and rectum. Some experts maintain that wiping from front to back prevents contamination of the urethra, but I have my doubts. The ordinary urinary tract infection is caused by bacteria entering into the urethra and bladder and setting up camp there. Increasing fluids, altering the pH of the urine (drinking cranberry juice) and a simple antibiotic usually suffice.

Pyelonephritis is a basic urinary tract infection that has gone up past the bladder and entered the kidneys. Fever, back pain, vomiting, abdominal pain and pain when one urinates are the common symptoms. Depending on how ill the patient is, treatment can be as simple as an oral antibiotic as above, but if one becomes quite ill, IV fluids and IV antibiotics may be necessary.

Neither of these infections is considered "normal" the way ear infections and colds are. Especially in boys, there is sometimes an underlying reason the infection occured in the first place. The most common is urinary reflux. Instead of flowing out of the bladder when one urinates, some of the urine "refluxes" back up toward the kidney. This irritates the ureters, the tubes that go from kidney to bladder, and allows bacteria to persist. Also, abnormalities in the shape and structure of the kidneys can allow bacteria to cause trouble. Doctors often recommend studies to rule out these abnormalities when children develop urinary tract infections.

Other causes of dysuria, pain with urination, include yeast infections, skin infections and irritation of the urethra. Irritation often is caused by some chemical, hence the ubiquitous claim that bubble baths cause bladder infections. This is technically not true, but they CAN cause urethral irritation. Treatment for this is as simple as pushing fluids and avoiding the irritation. Physical manipulation (masturbation) can also cause urethritis in sensitive individuals. Obviously, trauma can also cause pain, and is sometimes the only indication that an individual is being abused.

So the causes of urethral pain are many and can be difficult to sort through. In anybody, if the pain seems to be persistant, give your doctor a call.

What to do with the sniffles and snuffles.

We're, hopefully, coming to the end of cold season. Part of the reason for my delayed posting is because cold season is very busy in the office and I'm just not always the most motivated writer. My apologies if you faithfully read my posts... Cold season is VERY frustrating to parents and causes pediatricians to often rethink how they approach their practices.

The fancy name for a cold is "upper respiratory infection." This unfortanate naming causes all sorts of trouble for pediatricians. This term encompasses ear infections, sinus infections, sore throats and infections of the airway below the nose, but outside the lungs, such as croup. Colds are triggers for all these problems, but don't necessarily include all these problems.

By definition, a cold is caused by a virus. There is a list of several dozen viruses that cause colds, each of which comes in a variety of sub-types. It is this large number of sub-types that causes people to catch cold after cold after cold instead of becoming immune to the common cold. This same variation in sub-types makes it impossible, for now, to create a working vaccine.

The symptoms of the common cold are well known to most people. Cough, congestion, sore throat and fever are the most common symptoms. Headaches, muscle aches, ear aches and chest pain are not uncommon other symptoms. Usually the fevers are low grade, 101 or less, and last no more than 72 hours. The congestion and nasal drainage usually starts out clear, but often will turn yellow or green within 72 hours and stay that way for several days. Our mothers always taught us that green means we need an antibiotic, but it's pretty clear now that this is not true. Your average cold will last 10-14 days, regardless of age. Some fortunate individuals seem to fight off their colds in a much shorter time frame.

Treatment of the common cold is symptomatic. Nasal saline or nasal saline washes (Netti pots) can help relieve congestion. A spoonful of honey as needed, for individuals older than 12 months, can be used to help supress cough. Cough drops may also be helpful. Running a humidifier keeps nasal congestion loose and easier to breath through. Elevating the head of the bed may help the drainage and cough to be more tolerable. Tylenol or Motrin (for those over 6 months old) helps with the muscle aches and fevers.

Cold medications available by prescription or over-the-counter have not been shown to make a difference in symptoms. Available studies suggest that they are merely sedating, which may help with sleep, but not with symptoms.

Colds that have fevers higher than 103, fever lasting longer than 72 hours, cough and congestion longer than 14 days or colds with unusual or severe symptoms need to be evaluated. A common question is "what is more severe?" The most concerning is a headache with neck stiffness as a symptom of meningitis. Shortness of breath and "windedness" may suggest pneumonia. Significant facial or tooth pain may indicate a sinus infection. As always, if you have concerns, discuss your symptoms with your regular physician.

What's the latest with ear infections?

It's time to return to a staple of my trade... ear infections. Ear infections remain one of the most common reasons that parents turn to their child's pediatrician. Often it's due to the middle of the night crying with ear pain. Sometimes it's due to the week long complaining that their child can't hear. Ear infections clearly come in several colors.
Usually, ear infections start off as a "cold" with cough and congestion, often for several days, before the classic sign of ear pain begins. Sometimes, but not always, there is fever. Often, the fever doesn't start until the children have had cold symptoms for a few days. Other times, the children will come in for a regular check up with no symptoms at all and, during their exam, we'll find an ear infection. Parents are always curious how that could possibly be true, but it is.
Probably most frustrating are the kids who complain of ear pain, have cold symptoms, come in to the office and I see no evidence of an ear infection on exam. This is probably due to eustacian tube dysfunction. Basically, the "relief valve" of the middle ear is so swollen and clogged with mucous that the children develop pain, much like the discomfort one has when ascending and descending in an airplane.
For decades, the treatment of choice for ear infections has been a round of antibiotics. That dogma is beginning to change. There have been a number of good studies demonstrating that 90-95% of ear infections resolve without antibiotic therapy. Fifty percent of them are viral infections and won't respond to an antibiotic anyways. There are also more recent studies that suggest that even if the infection is bacterial, antibiotics might not speed recovery or hasten the resolution of pain. The most recent American Academy of Pediatrics guidelines suggest that in children older than two, the pediatrician consider providing pain relief and not antibiotics for the infection. For pain relief, parents can use Motrin or Tylenol. A warm moist washcloth placed over the ear that hurts can also provide relief of pain. Some physicians recommend narcotics (codeine) though I find that these medications provide no more relief than Motrin. Finally, there are prescription ear drops that have a topical anesthetic in them that can temporarily provide relief.
However you choose to treat the ear infection, it is important that someone trained to evaluate ears look at the childs ears to confirm the presence of an ear infection as there are a large number of ears that hurt that are not infected.
As always, consult your child's pediatrician if you have specific questions.