Every day in my office I can see and hear tension in the faces and voices of parents as we discuss the introduction of solids into their baby's diet. Mothers take notes as I give advice on adding cereal and other baby foods. I receive requests for exact amounts a baby should be eating, as well as how to time breastfeeding or bottles with meals of solid food. Sometimes I sense that my answers and general guidance in this area are not specific enough to satisfy parents. An entire well visit for a four or six month old can be taken hostage by this topic, leaving little to no time to talk about anything else!
I can find myself baffled by this outcome. After all, feeding is only one of many topics I would like to discuss at a well visit. What about sleep issues, stooling patterns, infant development, behavior, illnesses, vitamins, safety, and immunizations? I have spent quite a bit of time thinking about this and discussing it with the other pediatricians in my practice. I think I understand why feeding solid foods can be such a source of confusion for parents, AND I want to help make it easier!
To first-time parents starting solid foods can be a complete mystery. Guidelines are vague and often seem to conflict. Lots of advice is given by friends and family members. Parenting magazines offer new suggestions in every edition. There are lots of feeding "myths" out there. Research on the dietary needs of infants is ongoing, which leads to changes in recommendations on when and what to feed. Some recommendations seem to be based on well-researched scientific evidence, while others are based on convention, custom, and experience. Parents often feel weighed down by the responsibility to provide good nutrition for their child. The baby food aisle at the grocery store is vast and overwhelming.
And then there are decisions to be made on whether to make or purchase your own baby food, in what order food should be introduced, and what foods to avoid until a certain age. If we top that off with the fear that one's baby will choke on thicker, textured, or chunky food, parents can be left completely paralyzed by the thought of introducing solid foods.
To first reassure you, I would like help you understand my overriding view on introducing solid foods. The following statements may help:
1. It's really hard to do it wrong!
2. There are many correct ways to introduce solid foods.
3. Even if you do something that you read, or hear is "wrong" it probably isn't really that bad. You can always stop what you are doing if you find out it really isn't advisable.
4. You can't "break" a baby by giving them solid foods in the wrong order.
5. Babies all over the world have been successfully introduced to solid foods since before the time of recorded history. This has been done in all different ways, with many different kinds of foods. Practically everyone was weaned from the bottle or breast and was eventually able to chew and eat chunks of food.
6. The mouths, tongues, throats, stomachs, digestive tracts, and fine motor ability of infants will naturally direct and allow them to consume solid foods.
7. Feeding solid foods isn't a competition between parents or babies. So what if your own mother had you eating steak by the time you were 3 months old? Or cereal, or squash, or prunes... Who cares if your sister's baby has tried all the vegetables and yours has only had green beans? This all will fade away in time, and you will move on to new arenas of competition: potty training success, behavior, reading ability, and athletic skills. But, I digress...
8. It's very difficult to really mess up on feeding solid foods. Try to relax.
9. I actually think feeding solid foods can be fun!
Now, on to specifics. In guiding you on how to introduce solid foods I have tried to take into consideration the available research on dietary concerns for infants. These include vitamin D supplementation, adequate iron intake, obesity, recommendations on exclusive breastfeeding, issues surrounding food allergies, asthma, and eczema, and more. After reviewing the research, policy statements, updates, and revisions on infant nutrition and feeding practices I, too, feel a bit overwhelmed! I have to let it all wash over me to condense it into some practical advice.
WHEN TO START
For a full-term healthy infant, introduction of solid foods should most likely take place somewhere between the ages of four to six months. Introducing solid food before four months is not recommended as it has been linked with a higher risk of obesity and may not supply a nutritionally complete diet. Formula or breast milk are the only nutrition a baby needs before he reaches four months of age. Contrary to popular belief, feeding solid foods such as infant cereal will not help your baby sleep through the night! Helping your baby sleep is an altogether different topic, and it does not involve solid foods.
As a general rule, to obtain maximum benefits from breast milk, exclusive breastfeeding (without adding solids) is encouraged until six months. Infants who are exclusively breast fed should receive 400 IU of vitamin D as a supplement starting in the first few days of life. In my experience, some individual infants are ready to eat solids before they reach six months of age. Infants who are ready to eat are able to sit (with a little support), hold their head steadily upright, reach for things, and grasp objects. They may show interest in what you are eating. When you put food in your mouth you may see them open their own mouths, or try to grab your spoon or fork. They may like to sit with you at the table, and seem to enjoy being present at a family meal. Even if your baby shows all these signs, if she is happy and content with nursing alone you can wait until six months to start solid foods. Or, if it would be enjoyable for both of you, you could start before six months in a relaxed, low-key way. Once again, how well your baby is sleeping at night should really not factor into your decision on when to feed solid food.
As you can see, except for encouraging you to wait until at least four months before introducing solids, I really encourage flexibility in determining when is best for your baby and your family.
Infants born at 36 to 37 weeks gestation will probably fit into these guidelines, as well. An infant born at less than 36 weeks gestation might need to be a little older, or an adjusted age could be used. Specifics for infants born early or with complex medical illnesses could be discussed with your own personal pediatrician, and are beyond the scope of this blog. Premature infants may need supplemental iron in addition to the recommended vitamin D supplements for breast fed babies.
WHAT TO FEED FIRST
My usual advice is to start with infant rice cereal. This comes in a dry, almost powdered form, that can be mixed with formula, breast milk, or water. You can find it in the baby food aisle at your grocery store. The rice cereal recommendation is traditional. I think it was originally made because hardly anyone is allergic to rice. Now we know a lot more about food allergies, and far fewer restrictions are in place for infants than in the past. However, traditionally the first food is still infant rice cereal. Probably infant oatmeal or barley cereal would be ok, too. Infant cereal is a good staple, and a good source of iron. Some extra iron is needed at around six months of age.
The nice thing about starting with cereal is that you can mix it to your desired consistency! There is no recipe here--just put a tablespoon of dry cereal into a bowl (not a bottle) and drizzle in some formula or breast milk (water is ok, but won't taste as familiar to your baby). Stir while dripping in the liquid and make the first little bowl of cereal kind of a thick cream soup consistency. Put your baby in a high chair and feed it to her with a little spoon. I generally discourage putting cereal in a bottle. That isn't the same as feeding solid foods, and it doesn't move a baby forward in her development.
This is the fun part! Get out your camera or video recorder. Watch the funny faces, and see the tongue push most of it out at first. Your baby has to learn how to handle the new texture, how to manipulate it with her tongue, and how to swallow it.
After feeding creamy soup consistency cereal to your baby once a day for a few days, if he is taking and swallowing it well, you can thicken the cereal to an applesauce or baby food consistency and continue to give it daily. After a minimum of three days you could think about introducing a new food, while continuing to give the cereal every day. Cereal usually stays in a baby's diet for months, generally twice a day. But there are lots of other foods to try, so after a while you will reduce its frequency.
HOW MANY TIMES A DAY TO FEED
One or two meals of solid foods per day is probably enough for the first month of feeding. The second month of feeding you could then go to two to three meals per day. By the third month three meals a day seems reasonable. However, there are no well-established rules, nor research-based evidence to direct you on how many meals a day to give your baby by a certain age. My guidelines here are general. Think about what fits into your schedule, how to work around naps, who will be providing the meals, etc.
Most babies seem to be eating three meals a day by nine months of age. By age one they are usually eating three meals a day, plus a few little nutritious snacks. Nursing or bottles just fit in around the meals. In the beginning just keep nursing and/or giving bottles as you have in the past. At first your baby won't eat enough food to fill himself up and he will still need the same amount of milk. Once solids are well-established and your baby is eating more of them (which might take a few months) you may naturally move to a different routine around nursing or bottles. Try not to feel stressed about this. Remember that, as you are introducing food, your baby's primary source of nutrition is still breast milk or formula.
WHAT ELSE TO FEED
After cereal has been started, and is being taken well, you can give other foods. These will include strained or pureed vegetables, fruits, and meats. Start only one new food at a time, and give that food to your baby each day for three days in a row. If your baby tolerates it without showing signs of an allergic reaction (hives, which look like welts, repeated vomiting, or wheezing and difficulty breathing), then you can add that food to your baby's list of safe foods and move on to another one. Your infant can have one of the safe foods at any time.
Just move through the single ingredient fruits, vegetables, and meats that are available as "First Foods" in your grocery store. I usually suggest alternating them. But there are no hard and fast rules here. Try a yellow vegetable, then a fruit, then a green vegetable, then a meat. Babies have taste buds that taste sweet things best, so you may find they especially like some of the fruits at first. To develop your infant's palate you should offer the full variety of foods, even the ones you find he doesn't like. Research shows that sometimes it takes 8 to 15 tries to get a baby to be willing to eat a food! Trying a variety also gives you some foods you can use if your baby's stools get too hard or soft. Bananas and rice cereal can sometimes be constipating, while prunes and pears can soften the stool. Oatmeal and barley cereals tend to be less constipating than rice cereal.
If you move through the foods (single ingredient cereal, fruits, vegetables, and meats) at a new food approximately every three days, then in about six weeks you will have tried all of the "First Foods." You can take it slower than this, especially if you start solids before six months of age. A typical meal plan after introducing all the "First Foods" would be cereal (mixed with formula or breast milk) plus a fruit, or vegetable, or meat for two meals in the day. An approximate serving size to work toward is one-half to one of the small baby food containers (2.5 oz.), plus an equal volume of cereal at a meal. I am trying to be quite general here. Your baby may advance more quickly or more slowly than this, and I am sure it will all work out just fine.
HOME MADE BABY FOOD
If you are making your own baby food (and please, no guilt here if you are buying food, I never made a drop of baby food for my children and I think they all turned out quite nutritionally replete!) then you might consider avoiding making a few foods that could be high in nitrates (spinach, beets, green beans, squash, and carrots) and simply buy these instead. Apparently baby food manufacturers use vegetables that are especially grown to be low in nitrates. According to the research the higher nitrate issue is more important for infants under three months of age, who won't be eating solid foods anyway. A more worrisome source of nitrates is contamination of wells, which makes it important to have your well water tested...another topic beyond the scope of this blog.
JUICE
Juice can be useful if your baby becomes constipated. A few ounces of pear, apple, or prune juice is quite helpful to loosen hard stools. In that case juice should be given from a cup or sippy cup, not a bottle. Maximum juice intake per day should be 4 to 6 ounces. Other than for constipation, I don't recommend juice. Infants learn to love it, and end up preferring it to milk. There is not much nutrition in juice. It is actually mostly sugar, and even though it is "natural" sugar, the child's body doesn't know any difference. Many toddlers end up preferring it to milk, and their nutrition suffers from lack of calcium and vitamin D. It can cause tooth decay because children like to sip on it all day long. And it can lead to excessive calorie intake, or poor food intake because the child is all filled up on juice. Excessive juice can even cause chronic diarrhea!
WHEN IS A RASH DUE TO A FOOD ALLERGY?
Babies get lots of rashes, so how do you know if one is a food allergy? For the three day food trial I have described above you are simply looking for hives. Hives look kind of like insect bites. They are raised welts of various sizes that are lighter in the middle raised part, and red on the flat skin around the welt. They change locations and can be here one minute and gone the next. They can be itchy.
A little red rash around the mouth is a common result of the messy eating process, and is almost always more of an irritation from acidic foods than an allergic reaction. Tiny red dots on the upper chest and back are probably more likely to be heat rash. And a diaper rash by itself is hardly ever an indication of a food allergy. However, lots of fruit or other more acidic foods and drinks can cause stool or urine to irritate the skin in the diaper area. This is an irritation, not an allergy. Eczema can be due to a food allergy, but it most likely won't develop in the three day trial I am suggesting. If your baby has eczema you could talk to his doctor about any possible relationship to food he is eating.
WHAT IF MY BABY GAGS ON FOOD?
Don't panic if she gags. Gagging is not choking. Gagging is the retching sound humans make when something unexpected hits the back of the mouth or throat. It is protective, and helps keep objects, food, and fluids from "going down the wrong pipe." A baby might turn red, make gagging noises, and have watery eyes or even vomit after gagging--but the presence of the noises and the pink or red color are signs that air is still moving and your baby is not actually choking. It is very unlikely that a healthy infant will actually choke (have airway obstruction) while eating infant cereal or other strained, pureed, or mashed baby foods.
If you are really worried about the possibility of choking then you should consider reviewing techniques to clear the airway of an infant, or take an infant CPR course.
If your baby repeatedly gags on food and doesn't seem to be making progress day-to-day in tolerating solid food then you should talk to his doctor. You may need to just back off for a week or two and then try again, but persistent difficulties should be discussed with your personal pediatrician.
WHAT'S NEXT AFTER CEREAL AND FIRST FOODS?
I'm exhausted after covering this topic, so I will have to save the next step for another blog. I hope this information is helpful and takes some of the mystery out of starting solid foods. What I really want is for you to enjoy this next stage of your baby's life, to take lots of pictures, and create wonderful memories of your incredible little person starting to grow up! Have fun!
Showing posts with label newborns. Show all posts
Showing posts with label newborns. Show all posts
Sunday, March 27, 2011
Thursday, March 24, 2011
Vitamin K at Birth
I'm here to talk about vitamin K deficiency bleeding in the newborn and its prevention. Is this a topic of general interest? Does it even concern you as a parent? Perhaps not, if your child is already two months of age or older. However, if you are expecting a baby, or have a newborn, this is something you should know about.
After birth an injection of vitamin K will be given to your baby. This routine, injected supplementation of vitamin K into the thigh muscle of a healthy newborn is extremely effective in preventing vitamin K deficiency bleeding and its resulting catastrophic effects. This practice is based upon reliable, scientific evidence that has been tested and retested over many years. I fully endorse, recommend, and request that all my patients accept the practice of providing an injection of vitamin K to newborns shortly after birth. My own children received their injection of vitamin K after birth with my full knowledge and consent. I rested easier knowing I had greatly reduced their risk of unpredictable severe hemorrhage or death due to vitamin K deficiency. I still am in awe, and filled with the wonder of a simple vitamin injection's ability to prevent such a terrible outcome.
Vitamin K deficiency bleeding in the newborn was formerly known as hemorrhagic disease of the newborn. There are several forms, which are usually described as "early" (or classic), and "late." Vitamin K deficiency can cause serious, life-threatening bleeding because vitamin K is an essential part of the blood's ability to form clots. Without vitamin K the blood will not clot properly, and the affected person will bleed excessively. Vitamin K deficiency bleeding is usually discovered when something catastrophic happens to the infant, such as bleeding into the brain (central nervous system hemorrhage).
Vitamin K deficiency bleeding has been recognized in infants for decades. In briefly reviewing the medical literature on this topic I found published articles dating as far back as the 1960s (I may have even seen the 1940's!) which deal with this topic.
The incidence (rate of occurrence) of unexpected bleeding due to vitamin K deficiency in apparently healthy neonates during the first week of life ("early") is 0.25% to 1.7% (ranging from 1 in 400 to 1 in 50 to 100 newborns). Late vitamin K deficiency bleeding (ages 2 to 12 weeks) rates have been reported from 4.4 to 7.2 per 100,000 births.
For some reason (and fairly often), there are newborns who are born deficient in vitamin K. This is discovered when they have a severe bleeding episode. These are major episodes of bleeding, such as bleeding into the brain. Although attempts have been made to correct this by giving supplements prenatally to the mother, this has not been consistently effective. Vitamin K does not cross the placenta well enough to ensure adequate vitamin K in the baby. In addition, breast milk does not reliably contain enough vitamin K to prevent vitamin K deficiency bleeding. Supplementing vitamin K to a breastfeeding mother will not consistently give enough vitamin K to prevent vitamin K deficiency bleeding. There is no readily available test that can be done on a newborn to tell if the infant is at risk for vitamin K deficiency bleeding. Obtaining a family history does not help determine if an infant is at higher risk for this condition.
The only way to be sure to reduce the risk of vitamin K deficiency bleeding in a newborn is to supplement with vitamin K. The most reliable and effective way to do this is a single injection of vitamin K shortly after birth. Oral supplementation has been presented as another option. However, the evidence shows that it is either less effective than injected vitamin K, or there is not enough evidence to be sure it is effective. Weighing the possible severe damage that can occur from vitamin K deficiency bleeding against unreliable evidence about how effective oral vitamin K will be in preventing it, it is clear that the best way to protect a newborn from early or late vitamin K deficiency bleeding is injected vitamin K.
For a while there was a flurry of concern about a possible link between injected vitamin K and childhood cancer. This evidence has been reexamined, and other studies have been done which show no association between the two. This concern has been put to rest by strong scientific evidence and should not factor into decisions regarding injections of vitamin K.
This is how I see it: A simple, small, one-time injection of a vitamin (vitamin K) into the thigh muscle of a newborn will drastically reduce the real risk of catastrophic, life-threatening, brain-damaging bleeding that can occur due to the fairly common state of vitamin K deficiency that occurs in newborns. Other methods of supplementing vitamin K have little evidence to recommend them, or have been found to be much less effective than injected vitamin K. How can we deny this simple, effective, preventative treatment to the most vulnerable and precious beings on earth, our newborns?
I have included some links which will give you a window into the world of scientific evidence on this topic.
http://pediatrics.aappublications.org/cgi/reprint/112/1/191
http://journals.lww.com/smajournalonline/Abstract/2006/11000/Intracerebral_Hemorrhage_due_to_Hemorrhagic.10.aspx
http://onlinelibrary.wiley.com/doi/10.1046/j.1442-200x.2000.01173.x/abstract
http://journals.lww.com/amjforensicmedicine/Abstract/1999/03000/Late_Form_Hemorrhagic_Disease_of_the_Newborn__A.12.aspx
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346300/
After birth an injection of vitamin K will be given to your baby. This routine, injected supplementation of vitamin K into the thigh muscle of a healthy newborn is extremely effective in preventing vitamin K deficiency bleeding and its resulting catastrophic effects. This practice is based upon reliable, scientific evidence that has been tested and retested over many years. I fully endorse, recommend, and request that all my patients accept the practice of providing an injection of vitamin K to newborns shortly after birth. My own children received their injection of vitamin K after birth with my full knowledge and consent. I rested easier knowing I had greatly reduced their risk of unpredictable severe hemorrhage or death due to vitamin K deficiency. I still am in awe, and filled with the wonder of a simple vitamin injection's ability to prevent such a terrible outcome.
Vitamin K deficiency bleeding in the newborn was formerly known as hemorrhagic disease of the newborn. There are several forms, which are usually described as "early" (or classic), and "late." Vitamin K deficiency can cause serious, life-threatening bleeding because vitamin K is an essential part of the blood's ability to form clots. Without vitamin K the blood will not clot properly, and the affected person will bleed excessively. Vitamin K deficiency bleeding is usually discovered when something catastrophic happens to the infant, such as bleeding into the brain (central nervous system hemorrhage).
Vitamin K deficiency bleeding has been recognized in infants for decades. In briefly reviewing the medical literature on this topic I found published articles dating as far back as the 1960s (I may have even seen the 1940's!) which deal with this topic.
The incidence (rate of occurrence) of unexpected bleeding due to vitamin K deficiency in apparently healthy neonates during the first week of life ("early") is 0.25% to 1.7% (ranging from 1 in 400 to 1 in 50 to 100 newborns). Late vitamin K deficiency bleeding (ages 2 to 12 weeks) rates have been reported from 4.4 to 7.2 per 100,000 births.
For some reason (and fairly often), there are newborns who are born deficient in vitamin K. This is discovered when they have a severe bleeding episode. These are major episodes of bleeding, such as bleeding into the brain. Although attempts have been made to correct this by giving supplements prenatally to the mother, this has not been consistently effective. Vitamin K does not cross the placenta well enough to ensure adequate vitamin K in the baby. In addition, breast milk does not reliably contain enough vitamin K to prevent vitamin K deficiency bleeding. Supplementing vitamin K to a breastfeeding mother will not consistently give enough vitamin K to prevent vitamin K deficiency bleeding. There is no readily available test that can be done on a newborn to tell if the infant is at risk for vitamin K deficiency bleeding. Obtaining a family history does not help determine if an infant is at higher risk for this condition.
The only way to be sure to reduce the risk of vitamin K deficiency bleeding in a newborn is to supplement with vitamin K. The most reliable and effective way to do this is a single injection of vitamin K shortly after birth. Oral supplementation has been presented as another option. However, the evidence shows that it is either less effective than injected vitamin K, or there is not enough evidence to be sure it is effective. Weighing the possible severe damage that can occur from vitamin K deficiency bleeding against unreliable evidence about how effective oral vitamin K will be in preventing it, it is clear that the best way to protect a newborn from early or late vitamin K deficiency bleeding is injected vitamin K.
For a while there was a flurry of concern about a possible link between injected vitamin K and childhood cancer. This evidence has been reexamined, and other studies have been done which show no association between the two. This concern has been put to rest by strong scientific evidence and should not factor into decisions regarding injections of vitamin K.
This is how I see it: A simple, small, one-time injection of a vitamin (vitamin K) into the thigh muscle of a newborn will drastically reduce the real risk of catastrophic, life-threatening, brain-damaging bleeding that can occur due to the fairly common state of vitamin K deficiency that occurs in newborns. Other methods of supplementing vitamin K have little evidence to recommend them, or have been found to be much less effective than injected vitamin K. How can we deny this simple, effective, preventative treatment to the most vulnerable and precious beings on earth, our newborns?
I have included some links which will give you a window into the world of scientific evidence on this topic.
http://pediatrics.aappublications.org/cgi/reprint/112/1/191
http://journals.lww.com/smajournalonline/Abstract/2006/11000/Intracerebral_Hemorrhage_due_to_Hemorrhagic.10.aspx
http://onlinelibrary.wiley.com/doi/10.1046/j.1442-200x.2000.01173.x/abstract
http://journals.lww.com/amjforensicmedicine/Abstract/1999/03000/Late_Form_Hemorrhagic_Disease_of_the_Newborn__A.12.aspx
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346300/
Sunday, November 28, 2010
My Advice on Immunizations
Here is the blog I've been dreading, avoiding, and wishing I didn't have to write. It SHOULD be an easy one for me because it is a topic I know well, discuss daily, and am quite clear on where I stand--which is YES, you should fully vaccinate your child, on time, using the schedule recommended by the ACIP (Advisory Committee on Immunization Practices), AAP (American Academy of Pediatrics), and CDC (Centers for Disease Control), and endorsed by me and my colleagues in my pediatric practice. In fact, I believe that immunizing children is one of the most important contributions I can make to maintaining, or even improving an individual child's health as well as a vital contribution to the health of my community.
To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.
I am asked daily to comment on the following questions or statements:
To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.
These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).
I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.
My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.
Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!
In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.
I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.
In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?
If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:
http://www.chop.edu/service/vaccine-education-center/home.html
http://www.cdc.gov/vaccines/
http://www.aap.org/immunization/
And, for an interesting article in the lay press (not a scientific journal):
http://www.wired.com/magazine/2009/10/ff_waronscience
To me, this is a "no doubt about it" kind of recommendation. It's not an easy subject to write about, however, because it has become controversial. I don't like to have conflicts with families in my practice, or even with parents trying to decide if they should choose me as their pediatrician. It's hard for me to have to disagree. I don't think I'm very good at presenting my opposing point of view in a tactful way. I don't want to offend anyone, or make them feel bad. Still, I am going to write this blog, and I am going to be very clear about my recommendations for vaccinating your child.
I am asked daily to comment on the following questions or statements:
To vaccinate, or not to vaccinate...? Which vaccines are "the most important?" Do vaccines cause autism? What about thimerosol? What about mercury? Tell me about aluminum in vaccines? We were told at our new baby class to ask prospective pediatricians about vaccinations... Don't babies get too many vaccines these days? I don't what to overwhelm their immune system... We aren't taking the baby to day care, so they won't get exposed to any of these diseases. Can you look at this "alternative" vaccine schedule and make recommendations? We are going to vaccinate, we just want to "delay" the vaccines. The diseases we vaccinate for are pretty rare, right? I don't want to do anything that might hurt my child.
These are only some of the questions that come up every day. And it's understandable. After all, you should be an informed health care consumer, right? You just want to do the right thing. And vaccines are a hot topic right now for new parents. Many parents would feel they are not doing their job if they don't ask about or question their pediatrician about vaccines. However, in having these discussions, and responding to all of these details, I think we can lose sight of our goal (which, in my opinion, is a healthy and safe child).
I often get the impression that parents believe I am blindly following vaccine schedule recommendations, just spouting the "party line." When this happens, I don't think I am being given enough credit for doing my job. It is my responsibility to know about each disease and each immunization given to prevent the disease. I take this responsibility seriously.
My colleagues and I have built a schedule of vaccines for our patients that will effectively immunize them at the time when they are at most risk for the diseases. We regularly review this schedule, the type of vaccines we provide, and the benefits versus risk of every vaccine. Our decisions are made based upon scientific evidence, meaning they are supported by deliberate testing and study of the effects of each vaccine. We then recommend a routine vaccination schedule that we have created or actively given our endorsement. This schedule takes into account which vaccines can be given at the same time (to ensure a good immune response while minimizing potential side effects), proper intervals between vaccines, appropriate ages to give vaccines, and the number of actual injections given each time a patient is vaccinated. It becomes a routine part of our well child visits. Having a routine schedule helps minimize the possibility of errors such as a vaccine given at the wrong interval, or age.
Benefit versus risk is an important concept to think about. There are very few things we do that are without risk. We get used to certain risks and simply live with them. Common activities that involve some degree of risk include transporting our child in a car (what if there were an accident?), living in our homes (potential exposure to lead, radon, or carbon monoxide, burns from the stove, hot coffee, or curling irons, cuts needing stitches from falls against coffee tables, falls down the stairs...), taking any kind of medication (acetaminophen carries the rare risk of liver damage, ibuprofen can cause anaphylaxis in those who are allergic, or rarely can damage the kidneys, amoxicillin or any other antibiotic can cause an allergic reaction in some people), and allowing our children to play outdoors or participate in sports (the monkey bars are one of the most common sources of fractures in children, trampolines can lead to neck and spine injuries as well as fractures in the legs, head injuries occur all the time in sports and from falls (especially when unhelmeted) off of bikes/skateboards/scooters). There must be some kind of benefit that outweighs the risks involved in these activities, or we wouldn't be able to allow our children to live a "normal" life!
In thinking about vaccines you should think about benefit versus risk. Like any medication there are some small risks, and for most vaccines these risks are fever and the possibility of an allergic reaction. However, the benefits of the vaccines far outweigh any risk they present to a child. In looking at risks and benefits I think it is important to look at scientific evidence, not anecdotal reports. Anecdotal reports are the reports of a few individuals who tell their own story, these people may or may not have any background qualifications to lend credibility to their claims. Scientific evidence, on the other hand, is the result of deliberate study of the effects of an intervention or treatment (such as a vaccine). Scientific evidence is subject to peer review (scientific experts evaluating the evidence and methods of study), and to statistical evaluation to determine if the results could just be due to chance.
I think your child deserves to be treated according to recommendations made using scientific evidence. As an experienced, board-certified, pediatrician it is my job to do the best I can to provide this kind of care. I also think that you should expect your pediatrician to provide, at a minimum, the same level and quality of care that she would want for her own children. And my children were fully vaccinated, on time, in accordance with our recommended schedule of vaccines.
In writing this blog I also have to say something about trust, and the doctor-patient relationship. Do you trust your pediatrician? Do you value her advice on growth, developmental milestones, sleep habits and position, feeding issues, how to start solid food, pacifiers, thumbsucking, stooling, urinating, behavioral concerns, potty training, car seat recommendations, among other issues often discussed at well exams? Do you call your pediatrician for advice on what to do when your child has a fever, is vomiting, or is otherwise ill? Do you take your ill child to be evaluated by your pediatrician, and place your trust in her to determine what is wrong and how best to treat it? Do you value all of your pediatrician's education, training, ongoing efforts to keep up with current science, and her expertise in helping you raise a healthy child? If you do, then why would you so easily dismiss your pediatrician's advice on immunizing your child? And if you don't trust your pediatrician, then why do you keep bringing your child to her office? Isn't preventing meningitis, polio, measles, and pertussis (among others!) more important that the correct order in which to introduce solid food?
If you are inundated with anti-vaccine messages, considering Dr. Sears' advice on delaying or altering the vaccine schedule, feeling overwhelmed and worried about vaccinating your child, and spending a lot of time researching the issue, then you should also look at the case FOR immunizations, and at sources that use scientific evidence to back up their claims. The following websites can be very helpful:
http://www.chop.edu/service/vaccine-education-center/home.html
http://www.cdc.gov/vaccines/
http://www.aap.org/immunization/
And, for an interesting article in the lay press (not a scientific journal):
http://www.wired.com/magazine/2009/10/ff_waronscience
Wednesday, August 18, 2010
Sunlight, Milk, Vitamin D
Vitamins! What a boring topic. I used to think so--in fact, a year or two ago I rarely recommended vitamin supplementation for my patients. My previous mantra was "Eat a healthy diet and you won't need vitamins." Then the new vitamin D supplementation guidelines were published in 2008. Study after study confirmed that children (and adults, actually) do not get enough vitamin D on a regular basis to reliably prevent problems with bone health. Some studies show that adequate vitamin D consumption is linked to lower levels of autoimmune diseases and helps fight infections.
In fact, I have been so convinced by this information that I actually take a vitamin D supplement myself! If you knew me well you would understand how amazing this is. I have always had trouble swallowing big pills, such as vitamins. Prenatal vitamins were impossible for me, and I actually took children's chewable vitamins during my pregnancies. However, I have gotten used to the vitamin D and I take it each night.
I have brought my kids along on this vitamin ride, too. They prefer gummy vitamins, and are supposed to take two each day. Sorry, Dr. VanEs--I know you don't like the sugar in these sticky vitamins--but I promise that they brush their teeth! My children will be the first to tell you that sometimes I forget to get a new bottle of vitamins for them when they run out. I resolve to do better, but I am a busy mom, and not perfect even in regards to my own medical advice.
The vitamin D recommended daily allowance for children from birth to age 18 is 400 IU (or international units) per day. Supplementation starts at birth. If a baby is formula fed, then after they reach one liter of formula per day they are getting enough vitamin D. Infant vitamins are usually given in drops, while children's vitamins are chewable or gummy. You should read the labels, especially in the infant drops. Normally 1 ml would give 400 IU, however some drops are super concentrated and provide 400 IU in a single DROP. It is possible to overdose on vitamin D and cause vitamin D toxicity, but there is a fairly wide margin of error. Most vitamin D supplements are in the form of vitamin D-3 (not 2).
It is possible to get vitamin D from sun exposure, and the lighter your skin the less sun exposure you need. The sun activates vitamin D that is inactively resting in your skin, making it possible for your body to use what is already there. In the United States, on average, it has been shown that we spend more than 90% of our time indoors! Top that with using recommended sunscreen during sun exposure and it doesn't add up to enough sun exposure to be sure you have enough vitamin D.
I have seen attempts to calculate how much sun exposure is needed per day on skin that is not treated with sunscreen, taking into account the degree of pigmentation in the skin. This seems too complicated and unreliable to me, plus I doubt most people will be pushing their kids out the door in just a bathing suit in the dead of winter. What about a break from vitamin D supplements in the summer? Are you organized enough to get your children to sunbathe without sunscreen for a set period of time each day in the summer, and then remember to apply the sunscreen right away when the timer goes off? How will you handle cloudy days? Will you remember to restart their vitamin D during the colder months of the year? I think you should just have them take the vitamin and use sunscreen liberally to prevent sunburn and skin cancer.
It is possible to get vitamin D through breast milk. However, mothers must take very high doses of vitamin D (much more than is in a prenatal vitamin) to achieve adequate levels for their babies. Even then the levels in the milk may not be consistent and the mother may be at risk for vitamin D toxicity. Not enough is known about this to recommend it.
It is possible to get vitamin D from formula and from vitamin D fortified milk. You must consume a liter (about a quart, or 32 ounces) per day to get enough vitamin D. So if kids are big milk drinkers (4 8oz cups per day) they probably don't need extra vitamin D. Newborns don't drink that much formula right away, so technically they should receive a supplement until they do. However, they will come pretty close to the recommended daily allowance in just a few weeks, and almost certainly by 4-6 months of age, so I don't usually recommend the supplement for a formula fed baby.
What about measuring levels of vitamin D? This is tricky, because the level in the blood at any particular point in time does not always reflect overall body stores of vitamin D. Except in cases of chronic disease with malabsorption of nutrients (such as children who have had large sections of their bowel removed) checking vitamin D levels is not very helpful in determining vitamin D status. Most insurance companies won't pay for this test anyway, and if I would order it for a patient I would have no idea what it really means. Please don't ask me to order a vitamin D level for your child. Why poke your child (causing pain and stress) and run a test that is imperfect, difficult to interpret, will cost you money, and won't change my advice to you? There are limits to technology, and this is one of them. Take the vitamin, life goes on.
Vitamin D supplementation is one of those recommendations where the intervention (taking the vitamin) doesn't have very many down sides, and the benefit is potentially pretty big. So I am recommending that all my pediatric patients take 400 IU of vitamin D3 per day, with less or no supplementation needed for formula fed babies and big milk drinkers (4 cups milk per day).
My primary source of scientific information for this blog was the following publication:
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents--Wagner et al.122(5):1142--AAP Policy
The publication is available online at the American Academy of Pediatrics web site (aap.org), and it has a large list of references/scientific studies on which the recommendations are based. As a member of the AAP I have no trouble accessing this study online, I don't know if it is accessible to a non-member.
Please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include www.uptodate.com/patients, or childrenshealth.org.
In fact, I have been so convinced by this information that I actually take a vitamin D supplement myself! If you knew me well you would understand how amazing this is. I have always had trouble swallowing big pills, such as vitamins. Prenatal vitamins were impossible for me, and I actually took children's chewable vitamins during my pregnancies. However, I have gotten used to the vitamin D and I take it each night.
I have brought my kids along on this vitamin ride, too. They prefer gummy vitamins, and are supposed to take two each day. Sorry, Dr. VanEs--I know you don't like the sugar in these sticky vitamins--but I promise that they brush their teeth! My children will be the first to tell you that sometimes I forget to get a new bottle of vitamins for them when they run out. I resolve to do better, but I am a busy mom, and not perfect even in regards to my own medical advice.
The vitamin D recommended daily allowance for children from birth to age 18 is 400 IU (or international units) per day. Supplementation starts at birth. If a baby is formula fed, then after they reach one liter of formula per day they are getting enough vitamin D. Infant vitamins are usually given in drops, while children's vitamins are chewable or gummy. You should read the labels, especially in the infant drops. Normally 1 ml would give 400 IU, however some drops are super concentrated and provide 400 IU in a single DROP. It is possible to overdose on vitamin D and cause vitamin D toxicity, but there is a fairly wide margin of error. Most vitamin D supplements are in the form of vitamin D-3 (not 2).
It is possible to get vitamin D from sun exposure, and the lighter your skin the less sun exposure you need. The sun activates vitamin D that is inactively resting in your skin, making it possible for your body to use what is already there. In the United States, on average, it has been shown that we spend more than 90% of our time indoors! Top that with using recommended sunscreen during sun exposure and it doesn't add up to enough sun exposure to be sure you have enough vitamin D.
I have seen attempts to calculate how much sun exposure is needed per day on skin that is not treated with sunscreen, taking into account the degree of pigmentation in the skin. This seems too complicated and unreliable to me, plus I doubt most people will be pushing their kids out the door in just a bathing suit in the dead of winter. What about a break from vitamin D supplements in the summer? Are you organized enough to get your children to sunbathe without sunscreen for a set period of time each day in the summer, and then remember to apply the sunscreen right away when the timer goes off? How will you handle cloudy days? Will you remember to restart their vitamin D during the colder months of the year? I think you should just have them take the vitamin and use sunscreen liberally to prevent sunburn and skin cancer.
It is possible to get vitamin D through breast milk. However, mothers must take very high doses of vitamin D (much more than is in a prenatal vitamin) to achieve adequate levels for their babies. Even then the levels in the milk may not be consistent and the mother may be at risk for vitamin D toxicity. Not enough is known about this to recommend it.
It is possible to get vitamin D from formula and from vitamin D fortified milk. You must consume a liter (about a quart, or 32 ounces) per day to get enough vitamin D. So if kids are big milk drinkers (4 8oz cups per day) they probably don't need extra vitamin D. Newborns don't drink that much formula right away, so technically they should receive a supplement until they do. However, they will come pretty close to the recommended daily allowance in just a few weeks, and almost certainly by 4-6 months of age, so I don't usually recommend the supplement for a formula fed baby.
What about measuring levels of vitamin D? This is tricky, because the level in the blood at any particular point in time does not always reflect overall body stores of vitamin D. Except in cases of chronic disease with malabsorption of nutrients (such as children who have had large sections of their bowel removed) checking vitamin D levels is not very helpful in determining vitamin D status. Most insurance companies won't pay for this test anyway, and if I would order it for a patient I would have no idea what it really means. Please don't ask me to order a vitamin D level for your child. Why poke your child (causing pain and stress) and run a test that is imperfect, difficult to interpret, will cost you money, and won't change my advice to you? There are limits to technology, and this is one of them. Take the vitamin, life goes on.
Vitamin D supplementation is one of those recommendations where the intervention (taking the vitamin) doesn't have very many down sides, and the benefit is potentially pretty big. So I am recommending that all my pediatric patients take 400 IU of vitamin D3 per day, with less or no supplementation needed for formula fed babies and big milk drinkers (4 cups milk per day).
My primary source of scientific information for this blog was the following publication:
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents--Wagner et al.122(5):1142--AAP Policy
The publication is available online at the American Academy of Pediatrics web site (aap.org), and it has a large list of references/scientific studies on which the recommendations are based. As a member of the AAP I have no trouble accessing this study online, I don't know if it is accessible to a non-member.
Please remember that the purpose of this blog is to provide you with more information and insight into how I personally think about health and illness. I am not trying to personally diagnose or treat your child. For that you need to discuss the problem with your medical professional. Other sources of information on the web could include www.uptodate.com/patients, or childrenshealth.org.
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