Daily Dose of DrGreene

Babies' Social Insight

Young babies notice and assess the actions of those around them and use this to decide who they want as play partners, according to groundbreaking research described in the November 22, 2007 Nature. They learn to read people long before they learn how to talk. In this study, the babies were shown a character trying to climb (or descend) a hill. On the third attempt, another character comes along who bumps the first character toward the goal or who gets in the first character's way. When presented with the characters afterwards, 10-month-old and 6-month-old babies had strong preferences for the helper characters. They demonstrated a sophisticated and powerful social awareness. The test was repeated, introducing a neutral character, independently moving toward the same goal, but not interacting with the first character. The babies strikingly preferred the helpful character to the neutral one, and preferred the neutral character to the one who got in the way.

We may think that because babies are too young to talk, or to understand words, that they don't "get" what is going on in front of them. This study suggests that they understand actions, interactions, and body language long before they understand words. They are studying how we behave, and in particular how we behave toward one another. And they are always learning.

Perhaps, parents' making it a habit to help and support each other (and other kids) is a powerful way for each to connect with a new baby and to build closeness throughout a family. 

Alan Greene MD FAAP

Tonsils, Time, Throats, and Outcomes

Taking out the tonsils for throat infections isn’t nearly as common as it used to be, but tonsillectomy remains one of the most common operations in kids. When is the procedure worth it? When might it be a mistake? There is general agreement that tonsillectomy can help for kids with obstructive sleep apnea or with very frequent throat infections. But what about the child who has had about 3 recent episodes of throat infection with fever? To answer this question, Dutch researchers followed kids aged two to eight, at 24 different hospitals, who were sent to have their tonsils out for moderate throat infection problems (about 3 infections). Half were assigned randomly to have their tonsils pulled as planned, the other half to have watchful waiting. Both groups were monitored for almost two years afterwards. Those who had the tonsils out averaged about 0.2 fewer throat infections per year. In other words, they would have dropped from about 3 throat infections per year to about 2.8. They also had about 0.5 fewer colds per year during the follow-up. These benefits are real, but expected to decrease after the follow-up period. Balance this modest gain against the “sick days”, anesthesia, cost, and pain from the operation (if it went well) – it’s not clear to me the benefits outweigh the costs. Beyond this, 6 percent of the kids had minor complications from the surgery: 1 percent required a second operation; another 2 percent were admitted to the hospital overnight for observation, and 3 percent needed an IV after the anesthesia to treat nausea. Excessive bleeding was the most common complication (3.5 percent).

The researchers also added up the total costs for both groups. They included prescription and over-the-counter drug expenses, doctor visits, missed work from sick days, babysitters, travel expenses, and hospital and surgical charges. As you might expect, the tonsillectomy cost more –about 46 percent more – with no clear overall benefit. For the right child, watchful waiting with appropriate medical treatment could save hundreds of dollars and decrease risk, without increasing discomfort or days devoted to throat care.

Alan Greene MD FAAP

Phi Baby Kappa

We all want our babies to have the best start possible. How much do infant educational videos really help to boost the brain? Each hour of educational baby DVDs or videos that babies watch per day is associated with an additional 16.99 point decrease in language development scores on standardized testing, according to a study published in the October 2007 Journal of Pediatrics. This drop is large enough that parents could notice the smaller number of words learned each month. The results of the test used in the study often, but not always, correlate with overall intellectual development. The babies in this study were 8 to 16 months old. It didn’t make any difference if parents watched the video with the babies – watching was still associated with a large decrease in language skills. By contrast, reading to the baby at least once a day and storytelling at least once a day were each associated with about a 7 point increase in language scores. For older toddlers in the study, aged 17 to 24 months, reading and storytelling offered even larger intellectual advantages. No benefit to the videos was found in this age group, at least there was no harm. From previous studies we know that educational videos can have real learning benefits for kids over 30 months. My take home messages are simple. First, given the possible negative intellectual impact suggested in this study and the popularity of infant educational DVDs (and their enticing names and marketing) more research should be done quickly to verify or discredit the results of this single study. Second, in the meantime, interacting with our children is a time-honored and scientifically-validated way to boost their learning – especially if we read to our kids and tell them stories at least once a day. Third, children learn by imitation. Kids’ learning tends to reflect parents’ learning. If we are learning ourselves, we foster a culture of learning in our children.

Note: Freerice.com is a great example of a way to boost your own vocabulary while helping other people. The idea behind this site is every time you get a correct answer on a vocabulary test (that is cleverly targeted to boost your current language level) 10 grains of rice are given to someone who is malnourished. It’s simple, fun, free, AND a great way for us to learn vocabulary while providing rice to feed hungry children. The World Food Programme of the United Nations announced that the site has already generated enough rice to feed 50,000 people for a day in its first month of operation.

Alan Greene MD FAAP

Slash Your Child’s Cancer Risk!

Choices we make with our children can strongly influence their odds of getting cancer for the rest of their lives. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, released in November 2007, is comprehensive analysis of over 7000 different scientific studies. Based on these, the expert panel makes 8 core recommendations (and two special recommendations) for cancer prevention. Among other things, this is the first major report to recommend breastfeeding for preventing cancer in both mothers and their babies. The potential benefit from following all of these recommendations is huge (preventing as many as 1/3 of all cancers), but for many families they may feel overwhelming. Knowing the targets, though, may help to make some steps in the right direction. The report includes recommendations for all of us, but I will focus here on how their recommendations apply to children:

1) Get lean and stay lean. Aim for a body mass index (BMI) towards the lower end of the normal range throughout childhood and adolescence (and maintain this as an adult). This may be one of the most important ways to prevent cancer later in life. Excess fat increases levels of circulating hormones linked to cancer, and makes it more likely that cells undergo abnormal growth.

2) Get moving. Aim for 60 minutes or more of moderate activity, or 30 minutes or more of vigorous activity, every day. And limit sedentary habits such as watching television – especially where there is child-targeted marketing of junk food or sugary drinks.

3) Don’t think calories. Think calorie density. Calorie density is the number of calories per a certain weight of food (usually 100 grams). Watch out for calorie dense foods! Feed kids ‘fast foods’ sparingly, if at all. (By ‘fast foods’ they do not mean foods that are convenient, or ordered at chain restaurants, but foods that are high calorie density, eaten in large portions, and that easily become large parts of the diet -- such as burgers, fried chicken pieces, French fries, shakes, or sodas. Avoid sugary drinks, and choose calorie-dense foods sparingly. Calorie-dense foods are those with 225 calories or more per 100 gm. The target is to have the diet average about 125 calories per 100 gm, with some foods lower and some foods higher than the average. Per 100 grams, fruits and vegetables usually have 10 to 100 calories; cereals and legumes between 60 and 150, and breads, lean meats, fish, and poultry between 100 and 225 calories.

4) Plant foods rock! -- mostly. Kids should get at least 5 servings a day of fruits and non-starchy vegetables (more servings would be even more protective). Include whole grains or legumes at every meal (while limiting white rice or things made from white flour, such as bread, pasta, pizza, cakes, pastries, cookies or biscuits). Between the fruits and vegetables and the whole grains, most of the foods that children eat should be of plant origin.

5) Animal foods with caution. For those kids who do eat red meat, they should aim for less than 18 ounces a week. (Note: From my perspective, the issue with red meat is mostly the hormones found in conventional beef. Grass fed organic beef is far preferable.) Poultry or fish could be good options instead. It’s also best to minimize or avoid processed meats – especially those treated with nitrates, nitrites or other chemical preservatives. This would include many brands of ham, bacon, pastrami, salami, sausages, and hot dogs, as well as some hamburgers. The panel did not recommend reducing dairy, eggs, fish, or poultry for cancer prevention.

6) No alcohol for kids. Kids should not be exposed to alcohol, even before they are born. For cancer prevention, alcoholic drinks should be avoided entirely by children and by pregnant women. In addition, they recommend limiting alcoholic drinks to two per day for adult men, and one per day for non-pregnant adult women.

7) Manage molds and salt. Preservation, processing, and food preparation makes a difference. Limit salty foods, and processed foods with added salt. No one should get more than 2400 mg a day of sodium. (Kids shouldn’t get more than 1500 mg of sodium a day before age three, 1900 mg a day before age eight, or 2200 mg a day before age thirteen.) Don’t eat moldy foods made from grains or legumes, such as bread or peanut butter. Suspect hidden molds if these foods have been stored too long at room temperature.

8) Dietary Supplements. Aim to meet a child’s nutrition needs from real food. Except for Vitamin D supplements for exclusively breastfed babies, supplements have not been linked to cancer prevention in kids. (I recommend a multivitamin safety net for other purposes.)

Special Recommendation 1 - Breastfeeding. Aim to breastfeed exclusively for six months, and to continue breastfeeding as other foods are introduced. This has been shown to reduce the lifetime cancer risk for both the baby and for the mother.

Special Recommendation 2 - Cancer Survivors. The above core recommendations are all the more important for kids (and adults) who are cancer survivors. The report recommends that survivors receive the support of a trained nutrition professional to help them meet these goals for the future.

World Cancer Research Fund / American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007

Alan Greene MD FAAP

Autism Detection: Look and See

All children should be screened for autism spectrum disorders (ASD) at the 18-month and 24-month well child visit, according to November 2007 guidance from the American Academy of Pediatrics, which replaces the original 2001 policy. Implementing this would mark a big change. Right now, about 92 percent of kids are not formally screened for ASD. The new policy goes even further: If a child has a sibling with ASD, or if the parents, other caregivers, or pediatrician are concerned, then the possibility of ASD should be looked into at any age. And at every well child visit, pediatricians should be on the lookout for red flags that should prompt immediate evaluation, such as no babbling or pointing or other gesture by age 12 months, no single words by 16 months, no two word phrases by 24 months (just repeating back what others say doesn’t count), or loss of language skills at any age. The big message is that a “wait-and-see” approach is inappropriate: children should be referred immediately for either a worrisome screening result or if there are two other sources of concern (family history, parents, or other caregivers). This decidedly does not mean that these children will have ASD; it only means that they deserve a closer look to be sure either way. Good screening polices will prompt care for those who need it, but to be on the safe side, will also flag a number of completely healthy children. Here at DrGreene.com, I’ve suggested a very simple autism screen for more than ten years. At the appropriate ages, physicians should be using one of the more comprehensive formal screens such as the M-CHAT, which is not designed to be scored by the person filling it out. ASDs affect about 1 in 150 kids in the United States and Canada (and far more boys than girls). Early diagnosis and early help clearly results in better outcomes. Let’s join together to turn “wait-and-see” into “look-and-see”!

Alan Greene, MD, FAAP