Daily Dose of DrGreene

Winter Groceries, Pesticides, and Kids

How does kids’ pesticide exposure vary over the course of a year? To answer this question, Dr. Chensheng (Alex) Lu and colleagues at Emory University and the CDC followed a small group of suburban Washington children, aged 3 to 11, who ate a conventional suburban diet. They sampled their urine for evidence of organophosphate (OP) pesticides twice daily for a week or more in each of the four seasons. OP pesticides have been linked to neurodevelopment concerns both in animals and in children. Strikingly, in this study there was a seasonal pattern to the OP pesticide exposure, with levels during the winter and spring higher per amount of produce than in the summer and fall seasons. We know from USDA testing that imported produce such as grapes and tomatoes often have more OP insecticides, even after they have been washed. Probably the majority of imported grapes, tomatoes, and other fresh produce is consumed in the US during the winter and spring season. In this study, as in previous studies chronicled by The Organic Center, the children were given 5-day holidays from their regular diets, where they got mostly organic versions of what they had been eating previously. None of the samples of organic food tested contained OP pesticide residues. During these windows of mostly organic eating, the evidence of OP pesticides in children’s urine virtually disappeared.

These findings suggest that the diet is the main source of exposure to these pesticides for kids. Eating food that is local, organic, or in season could greatly decrease this pesticide exposure – and may be especially important in the winter and spring.

Alan Greene MD FAAP

Mom’s Diet; Kid’s Asthma

What Mom eats during pregnancy can help protect her children from asthma and allergies, according to a study released by Thorax in January 2008. In particular, elementary school kids whose mothers had followed a Mediterranean diet during their pregnancy were less likely to develop asthma or allergies. The peers of those fortunate children were about twice as likely to have positive allergic skin tests, more than four times more likely to wheeze, and more than three times more likely to have both positive allergy tests and wheezing. What separates this study from others on the same topic is that it was a forward looking (prospective) study. The researchers put forward their hypothesis in advance, and then followed families in Spain until the children were 6.5 years old. The participants weren’t aware that this study was about the Mediterranean diet when the data were being collected, to avoid introducing bias.

So what is a Mediterranean diet? The authors of this study defined it as a diet high in plant foods (fruits, vegetables, wholegrain breads and cereals, legumes, and nuts), moderate amounts of dairy products and eggs, and very little red meat. The diet is also high in olive oil and fish. Let’s consider some typical specific amounts:

Fruit or fruit juice daily
Another serving of fruit daily
Fresh or cooked vegetables more than once a day
Legume more than once a week
Fish at least two or three times a week
Wholegrain as part of breakfast daily
Pasta or rice at least five times a week
Two dairy products (e.g., milk, cheese, yogurt) daily
Nuts two or three times a week Olive oil used at home daily
Fast food less than once a week
Sweets and pastries less than once a day

In this study, women received one point each if they ate above the median amount of vegetables, of fruits and nuts, of whole grain cereals, of legumes, of fish, and of dairy products compared to all the women in the study. They also received one point if they ate below the average amount of red meat. The maximum possible score was 7. Those who scored at least 4 points enjoyed the dramatic benefits detailed above compared to those who scored 0 to 3.

What we eat changes our bodies, and pregnancy, nursing, and early childhood hold the greatest potential for lasting benefit.

Alan Greene MD FAAP

Seawater, With a Grain of Salt

Washing the nasal passages with a saline solution is better than OTC cold meds both at treating and preventing common colds, according to a study published in the January 2008 Archives of Otolaryngology-Head and Neck Surgery. After describing this study, I’ll also discuss briefly the concern I’ve been asked about regarding preservatives in some saline solutions. This study included over 400 children of elementary school age who were randomly assigned to get either standard OTC meds or standard OTC meds plus a nasal wash. They were followed when they caught a cold, and for the rest of the winter. The saline wash, in this study, was processed from Atlantic Ocean seawater, so it had more minerals in it than just salt. At the beginning of the study, children in the two groups had, on average, similar scores on nasal secretion amount and type, nasal obstruction, sore throat, cough, expectoration, sneezing, itching, and loss of taste or smell. At the first follow-up, the children who received the nasal wash had significantly less nasal secretion, clearer nasal secretion when present, less nasal obstruction, and were less likely to have a sore throat. They had also been less likely to take oral decongestant medications, even though they were available to both groups. There were few complaints from the kids about the wash. Continuing to use the wash resulted in fewer colds, fewer missed school days, and less use of medication for the rest of the winter.

This study relied on people’s reporting of cold symptoms rather than on objective observation. And the people in the study knew which children were getting the wash and which were not, which could introduce subtle bias. These factors raise questions about the results. But the results were consistent across eight different pediatric clinics. They were also consistent with the results of a 2007 objective analysis of eight other clinical trials which concluded that topical nasal saline improves the symptoms of chronic congestion and chronic sinusitis, whether used alone or in combination with other remedies.

A number of parents have asked me recently about the preservative benzalkonium chloride found in some saline solutions. There have been recent placebo controlled prospective studies suggestion a link between ongoing chemical preservative intake and hyperactivity -- but the amount in short-term saline drop use is tiny compared to what most kids get in the diet. More to the point, though, in some people benzalkonium has been linked to rhinitis medicamentosum -- a stuffy nose from the medicine. It's been implicated as a possible cause of the rebound congestion from people using nasal decongestant sprays for more than 3-5 days. Other studies suggest that the chemical damages the lining of the nose. There have been at least 18 studies on the safety of this ingredient, with inconclusive results.

For most children, I don't think this a big deal, but why use it if you don't need to? You don't even need to make your own saline solution or go to a natural products store. With my last cold, I picked up a product called Baby Simple Saline at a national drug store chain. It’s preservative free, creates a pleasant gentle mist, and comes in a container that can stay sterile after opening without a preservative.

Alan Greene MD FAAP

Partnering with Your Doctor for Better Healthcare

In November 2007, Scott Haig, MD, an orthopedic surgeon and medical columnist for TIME, wrote an article for the magazine called “When the Patient is a Googler”. He described a patient of his he called Susan, whom he felt was emblematic of patients who research important aspects of their own health issues (and background information about their doctors). Haig writes:

Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived…

Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.

…Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within.

Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way.

The core of his article seems to be that the favorite patients of this type of doctor are those who just trust them or those who at least have the decency to think in the same way the doctor does, who agree with the doctor for their own reasons.

In response, Kaiser pediatrician and writer Rahul K. Parikh, MD, penned “Is there a doctor in the mouse? Arrogant doctors criticize their patients who go online to research ailments. But they’re wrong. The best health sites are a boon to patients and doctors alike” this month at Salon.com. Dr. Parikh offers an inspiring look at how e-patients can help heal our healthcare system:

The medical establishment, in fact, has taken way too much time to understand that the Internet is a disruptive innovation that has overturned the status quo. It has leveled the playing field between expert and novice -- in this case, doctor and patient. While some doctors like Haig may find that challenge threatening to their status as an expert, the Web is now providing the kind of information doctors need to be aware of if we want to continue to be good at our job, and the kind of trends that can help patients be smarter and healthier.

Like me, this pediatrician is happy when his patients are online:

Patients who, prior to a visit, consult information online can better share in the decision-making process with their doctor. Afterward, they can go online to find information that reinforces their decision or introduces them to viable alternatives.

Dr. Parikh urges physicians to incorporate the health internet into their practice routine:

Today, there are many accurate, high-quality health sites, and doctors should make it a standard practice to recommend them to each and every patient. Besides reducing the randomness of a Web search, this can reinforce a physician's advice during a visit, which is especially helpful, as studies show that patients typically remember no more than half of what their doctor tells them.

Obviously, my perspective is similar to Dr. Parikh’s, and I appreciate his articulate response to the resistance that too many e-patients still encounter. Patients and doctors alike have much to learn as we embark on healthcare in the 21s century.

We live in a time of rapid tectonic shifts in what it means to be a doctor and what it means to be a patient. I’m not surprised that there are clashes of ideology and practice. Our labyrinthine, barnacle-encrusted healthcare system resists change. So do our social structures that have lasted for millennia.

But already many e-patients and many e-doctors are actively enjoying a new way of relating, rooted in mutual respect and open access to health information.

I believe encouraging and equipping patients to search for health information is central to being a good doctor in the 21st century.

I believe that helping patients find great doctors is another piece of the solution, which is why we’ve created DrGreene’s Find a Great Doctor tool. I encourage you to use this tool to tell others about the great doctors you know and to search for great doctors in your area.

Alan Greene MD FAAP

Eggs, Fish, Milk, Nuts, and Peanuts for Babies?!

Get ready for some surprising recommendations. Eczema, asthma, and food allergies are all on the rise in children, each having more than doubled in the last several decades. This rapid increase has lead to many differing recommendations on the timing and selection of foods offered to babies, to err on the side of caution before scientific studies were completed. A January 2008 evidence-based policy from the American Academy of Pediatrics turns some of this conventional wisdom on its head. For preventing allergies, when is it best to start solids for babies? Previously, it was recommended to delay solids until 6 months if possible, and to limit the choices to things like rice cereal, oatmeal, or barley if they must be started sooner. The new policy reports that solids should not be started before 4 to 6 months, but that there is no convincing evidence that delaying any solids beyond this period helps to prevent allergies. In fact, with some foods, starting on the earlier side may even help. What about highly allergic foods such as eggs, peanuts, milk, or fish? The previous guidelines were that in allergic families, whole cow milk should be delayed until 12 months of age; eggs until 2 years; and nuts, peanuts, and fish until age 3. The new guidelines say that there is no convincing evidence that delaying even eggs (yolks or whites), fish, milk, nuts, and peanuts beyond 6 months prevents allergies!

A few things to keep in mind: First, this discussion is only about preventing asthma, eczema, and food allergies. There are other reasons to delay certain foods (e.g. honey to prevent botulism, whole peanuts to prevent choking). Second, if a child does show signs of an allergic reaction, removing the possible culprits from the diet is wise – these guidelines are about preventing, not treating allergies. Third, these new guidelines are not the final word, they are just the current state of the science. Other benefits of particular timing may one day be uncovered. Finally, I am a fan of introducing a wide variety of healthy foods to babies between 6 and 12 months old – but I prefer organic foods for babies in the first year when possible. Particularly, if I were going to give some of the more allergenic foods like eggs, or cheese, milk, or nuts, I would be even more inclined to choose organic.

Alan Greene MD FAAP

Temper Tantrums - When to Worry

Temper tantrums can be a normal and common part of early childhood, but sometimes they are a sign of a problem that needs to be addressed. Parents often ask me whether their child’s tantrums are beyond what is normal. When is a red-faced preschooler screaming and flailing about normal; when is the tantrum a cause for concern? What’s too often? What’s too long? What’s too extreme? Stay tuned for the top 5 reasons to be concerned. Researchers at Washington University School of Medicine analyzed the tantrums of 279 children from 3 to 6 years old. Their results will be published in the January 2008 Journal of Pediatrics. They divided tantrum behaviors into aggressive-destructive (kicking others, hitting others, throwing objects, breaking objects), self-injurious (hitting self, head banging, holding breath, biting self), non-destructive aggression (non-directed kicking, stamping feet, hitting wall), and oral aggression (biting others, spitting on others). The authors suggest that parents need not worry about isolated or occasional extreme tantrums, especially if the child is hungry, overtired, or ill. Instead, they should pay attention to “tantrum styles” – the overall pattern of tantrums. They identified 5 high risk tantrum styles and suggest that kids over age 3 with any of these deserve further evaluation by a mental health specialist. The results of the study are preliminary, and by no means proven, but at least give parents and pediatricians a place to start.

1. Aggressive tantrums. If a child shows aggression toward a caregiver or tries to destroy toys or other objects during most tantrums, the child may have ADHD, oppositional-defiant disorder, or another disruptive disorder. Specifically, if more than half of a series of 10 or 20 tantrums includes aggression to caregivers and/or objects, consider an evaluation. Depressed children may also have a pattern of aggressive tantrums.
2. Self-injurious tantrums. By the time a child reaches age 3, a pattern of trying to hurt oneself during a tantrum may be a sign of major depression and should always be evaluated. At this age tantrums that include behaviors such as scratching oneself till the skin bleeds, head-banging, or biting oneself are red flags no matter how long the tantrums last or how often they occur. In this study, they were almost always associated with a psychiatric diagnosis.
3. Frequent tantrums. Tantrums at home are more common than tantrums in daycare or school. Having 10 separate tantrums on a single day at home may just be a bad day, but if it happens more than once in a 30 day period, there is a greater risk of a clinical problem. The same goes for more than 5 separate tantrums a day on multiple days at school. In this study, when tantrums occurred at school, or outside of home or school, more than 5 times a day on multiple days, there was a higher risk of ADHD and other disruptive disorders.
4. Prolonged tantrums. A normal tantrum in this study averaged about 11 minutes (though I’m sure it seemed a lot longer to parents!). When a child’s typical tantrums last more than 25 minutes each, on average, further evaluation is wise.
5. Tantrums requiring external help. Kids who usually require extra help from a caregiver to recover from a tantrum were at higher risk for ADHD, no matter how frequent the tantrums were or how long they lasted. Speaking calmly to your child in the midst of a tantrum, or acting reassuringly, is normal. But if you find you can’t stop a tantrum without giving in or offering a bribe, pay attention. By age 3, kids should be learning how to calm themselves.

It’s normal for healthy preschool kids to have extreme tantrums sometimes, and to lash out at people or things on occasion. Starting to pay attention to tantrum styles rather than individual tantrums may help sort out what’s healthy and what’s not, and how to respond. What’s your experience with tantrums?

Alan Greene MD FAAP

Beldon, AC, Thomson NR, Luby JL. Temper tantrums in health versus depressed and disruptive preschoolers: defining tantrum behaviors associated with clinical problems. Journal of Pediatrics. 10.1016/j.jpeds.2007.06.030. January 2008.