New Cholesterol Guidelines for Kids

The lure!........................ The bad guy?........................ The problem.

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On 7/7/08, the American Academy of Pediatrics issued new guidelines for monitoring and treating children with high blood cholesterol levels.* The stakes could hardly be higher. At issue is whether we pediatricians and parents can prevent long term cardiovascular disease in our children by detecting high cholesterol levels early on and by promptly intervening to lower those levels.

The problem is (as I will discuss), the scientific returns are not in as yet, so this is an open question about which you should keep current and discuss with your pediatrician. Because it's so important, I've read the guidelines very carefully. As your faithful cyber-pedi (or am I your pedi robo-cop?), I wanted to share my thoughts.

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First, what do the guidelines recommend?

1. Most importantly, a healthy diet and increased physical activity for all children, including low-fat dairy products for all children over two years of age.


2. Low-fat dairy products for children 12 - 24 months who are overweight.


3. Screening (a fasting lipid profile) - starting at age 2 years and then every 3-5 years - for all children and adolescents with a family history of high cholesterol / high fat levels or early cardiovascular disease.


4. Screening for all children whose family history is unknown or who are overweight, have high blood pressure, or diabetes.


5. Weight management should be the primary treatment for overweight kids with high lipid levels.


6. For patients 8 years and older with an LDL concentration greater than 190 mg/dL (or 160 mg/dL with a family history of early heart disease or two additional risk factors present; or 130 mg/dL if diabetes is present), medications should be considered.

(LDL = low density lipoprotein = the bad guy cholesterol that appears to clog up the works, as opposed to HDL = high density lipoprotein = the good guy cholesterol that protects against atherosclerosis).

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What I like about the guidelines:

• The prevention of adult diseases during childhood is one of our great challenges. These guidelines reinforce that vital pediatric mission.


• It makes sense to me to aggressively intervene with children who already show signs of disease (diabetes, metabolic syndrome) or who are at great risk by virtue of genetics.


• The emphasis on a low animal fat, high fiber diet will serve to improve the health of all humans (see my blogs on this favorite subject of mine: Overweight toddler, overweight teen? Dr. P's 8 steps to a healthier family ).


• I like being given the OK to put chubby one year-olds on low fat milk products.

My concerns about the guidelines:

• I wish they had put more emphasis on fitness, i.e., more exercise for our kids (see my blog: Your teen's physical fitness). Even an overweight child can and should be physically fit, just as even a skinny child can be an unrepentant couch potato.


• Since we know that artery clogging atherosclerosis begins in childhood, it makes sense to intervene early. But, in fact, we don't really know whether lowering cholesterol levels in childhood will, in any significant way, prevent long term cardiovascular disease. Since that is the case, our interventions should at least "do no harm".


• The potential short-term and long-term consequences of using cholesterol-lowering agents during childhood simply aren't known. Just because they appear to be safe in old fogies like me doesn't mean that they couldn't have some sort of unanticipated effect on the growing, changing child's body (especially since cholesterol and fatty acids are essential building blocka for many organs, including the brain).


• For that reason - and until long term studies are done and we know more - unless the risks seem especially high, I'm still not going to recommend medications for my healthy pediatric patients with high cholesterol levels.


• I worry about you all needlessly obsessing about a high cholesterol level in your otherwise healthy, happy, active child, especially since we don't really know what it will mean for your child over time.


• I worry (hey, I worry a lot!) about the loss of a carefree childhood. As I wrote in my old blog: What is lost from childhood when the glorious taste of a hot fudge sundae is confounded by the worry that it is causing blood vessel sludge?

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Dr. P's bottom line: Unless your child has one of the risk factors listed above, don't worry about their cholesterol 'number'. Worry instead about their general fitness and nutritional well-being. Feed them a healthy, low animal fat, low junk food, high fiber diet, make sure they get plenty of exercise, and you'll be doing a superb job.

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* "Lipid Screening and Cardiovascular Health in Childhood"
Daniels S, Greer F and the Committee on Nutrition

Related Topics:

• Kids to Get Heart Disease Screening
• Helping Your 'Not-Thin' Kids

Technorati Tags: pediatrics, childrens health, cholesterol, healthy diet, exercise

A Ticket For Poor Kids

Sometimes the best ideas are the simplest.

I just read an inspiring article in my hometown newspaper. It has provided me with renewed hope that, if only we mustered sufficient political will, we could successfully solve one of our most important social challenges: How to improve the academic performance of poor kids?

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I regard childhood poverty as the single greatest public health menace facing our children. Like most public health threats, we have some good (albeit imperfect) solutions.

After working with inner-city children for almost a quarter of a century (ouch!), I've come to believe that the best ticket out of poverty, the ticket that allows economically disadvantaged kids to become productive members of society, the ticket to their personal fulfillment, is educational success (by that I mean at least finishing high school and, better still, going on to higher level education or training).

How can we achieve this noble but daunting goal, especially given the myriad reasons almost half of poor kids never complete high school: their underfunded, overcrowded schools, parents who neither demand nor expect school success, the myriad psychosocial issues they are dealing with, the unsafe neighborhoods, a peer culture that demeans 'brainiacs', the learned hopelessness... Pick your poisons.

One can become depressed by the intractable complexity of academic failure. It's easy to throw up your hands and declare it hopeless: let's just invest in more police, bigger prisons and unemployment benefits!

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The newspaper article was about the "Say Yes to Education" project, the brainchild of a smart, caring, rich guy named George Weiss. It started over 20 years ago when, while giving a talk to a class of 6th graders in a Philadelphia inner-city school, he made the following promise: "I will pay your college tuition if you graduate high school." In the article, a 25 year old man discusses how Weiss made this same pledge to him when he was in 2nd grade and how it changed his life and the lives of the majority of his classmates.

How simple and how brilliant! Of course we need to improve our public schools. But what about enhancing a child's learning by raising her own internal motivation and aspirations? Mr. Weiss' pledge gave the students (and, of course, their parents) - at an early age - the hope and the inspiration and, most importantly, the means to attain their dreams of making it in this hard world.

The success of this simple strategy has been replicated over and over in the last two decades and gives lie to the perceived hopelessness of the situation. For you evidence wonks (I hope there are a few of you out there), below is an outcome graph you can click on (better still, go to their website, from which it is taken) showing that about 75% graduate high school (compared to the average of about 55% of economically disadvantaged kids), and about 1/2 of those continue beyond a high school education.

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Feeling down in these trying times? For an inspirational pick-me-up and for instructive lessons, do yourself a favor and go the Say Yes To Education website and read about this fabulous project which now provides children with not only the promise of college, but health care and educational supports along the way.

I can't help but wonder, why aren't our federal and state departments of education following their lead? I can think of a lot of worse (and few better) ways to spend my tax dollars.

Related Topics:

• Parental Absence Stifles Kids' Learning
• Less Education, Higher Death Rates?

Technorati Tags: children, education, poverty, Say Yes to Education

Preventing allergies: When to introduce solid foods

Dr. P's Pediatric Journal Club

The study
Data on 2,612 German infants was gathered from birth as part of an ongoing study looking at when solid food was first introduced and the development of allergies by two years of age.

What the study found

• Waiting until after 6 months of age to start solid foods did not have a protective effect on the development of eczema ("atopic dermatitis") or other recognized allergies at age 2 years.
• Waiting until 4 months of age to introduce solid foods may or may not have had a protective effect on the development of allergies. The data were not clear.
  

Dr. P comments
My WebMD Message Board is filled with parents who are agonizing about what, when and how to introduce solid foods to their infants. It's also filled with a ton of different opinions - "I fed my baby cereal at 2 months and she is fine!"... "Hold off until she is past 6 months or she will have allergies!" ... "My pediatrician says that 4 months is OK, but only cereal!" The only similarity between the varying opinions is that each side is 100% certain that their way is the right way!

Whenever there is such diversity in parents' and pediatricians' advice, you can bet it's because kids do fine almost no matter what the parents do, and because there isn't much scientific evidence to guide us one way or the other. (Interestingly, these are often the parenting issues about which the various camps feel most passionately.)

As the authors of this study state: "Scientific evidence supporting a delayed solid food introduction for the prevention of atopic diseases [allergies] is scarce, inconsistent, and based on a few studies only." This study helps by demonstrating there to be no benefit in waiting for more than 6 months, and suggesting that it's still up for grabs whether there is really a benefit in waiting 4 months.

Truth be told, this is a common scenario for pediatricians: often there is insufficient scientific evidence to strongly recommend one practice over another. So we essentially fly by the seat of our pants and make our best judgment based on meager evidence and our experience, and wait for definitive research to clarify the issue.

So here's my seat-of-the-pants advice on starting solid foods:

• Hold off the introducing solid foods until 4-6 months. (Remember that cereal does not increase sleeping through the night!)
• Introduce one new food every few days, so if there is a digestive problem or apparent allergic reaction, you will know what may have caused it.
• Always be sure the texture of the food is such that your baby doesn't cough and sputter when it is introduced.
• Introduce the small amount of the new food when your baby is hungry - before, not after, he has had her milk. Then gradually increase the amount.
• Don't let "neophobia" (fear of new foods) discourage you. Even if your infant doesn't take well to some (or all!) solid foods, never try to force feed him. Remember that milk alone can serve the baby's nutritional needs until at least 6 months. Gently and cheerfully reintroduce the hated taste/texture at another time.
• Most importantly: keep meal time fun and pleasant for all. In the long run, that's much more important than whether your bundle of joy eats his broccoli or not. More than anything else, emotional warmth and support at mealtime is what promotes a love of eating in the child and makes family meals a joy.

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Article cited:
"Timing of solid food introduction in relation to atopic dermatitis and atopic sensitization". Zutavern A, et al. Pediatrics, February, 2006, pp.401-411.

Related Topics: New Clue on How Babies Learn Words, Studies Short on Soy Formula Risk

Technorati Tags: parenting, infants, newborns, feedingsolids, foodallergies

Green Our Vaccines?

Two well-publicized events caught my attention last week. Each is terribly sad in its own way, but each offers insight into what remains a contentious issue: the safety of vaccines for children

Story #1: On May 28, 2008, a thunderstorm knocked out the electrical power in Memphis. Unfortunately for 61-year-old Dianne Odell, the emergency generator in her house also failed. Tragically, her family was unable to keep the iron lung - in which she had lived for the past 58 years - working, and the last polio victim in America still using an iron lung to breathe, died.

Story #2: Exactly one week later, on June 4, 2008, celebrities Jenny McCarthy and Jim Carrey sponsored a "Green Our Vaccines" (GOV) Rally in Washington (attended by either 1,000 or 8,000 people, depending on whom you believe). Its goal, they insisted, was simply to make vaccines safer by taking the 'toxins' out of them and by delaying some immunizations.

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For me, these events offer an instructive point-counterpoint.

Ms. Odell's death reminded me of how lucky we are to be free from the diseases that have been eliminated by childhood vaccinations. I'll bet you have never known anyone who had polio or smallpox or diphtheria or tetanus or whooping cough or... When I was in pediatric training, H Flu bacteria frequently caused meningitis and other fatal infections. I well remember a two-year-old patient in my private practice who went stone cold deaf after such an infection. Now our pediatric residents may never see a single case.

In addition to the millions of children who owe their lives to vaccines, UNICEF estimates that more than one third of the 10,000,000 children who die world-wide every year would live if they were properly vaccinated. Let me repeat that: 3,000,000 kids a year wouldn't die if they were given the immunizations that the GOVs decry.

There is zero doubt: childhood immunizations are one of the great inventions of the 20th century (really in the history of mankind). Their stunning success, however, has spoiled us and, especially if you lack imagination and a historical sense, you might not grasp what a blessing they are. You might even argue that children would be safer without them because of their rare (real or imagined) side effects and because you have never seen a child suffering with measles. It's a profound miscalculation, with potentially devastating consequences.

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Enter the "Green Our Vaccines" campaign.

First: a brilliant name! After all, who is against 'greener' (i.e., safer) vaccines? Who does not want to make our already very safe vaccines even safer? Sign me up on that one. But if you object to their movement (as I do, for reasons I'll explain), their clever name makes you appear to be anti-green (would that be 'brown' or 'puce'?) and a heartless advocate of loading kids up with nasty toxins.

Their name, however, is the only brilliant thing about this 'movement'. The rest is sadly misguided. I take no pleasure in saying this, as these parents (mostly of autistic children) are just being admirably she-bearish about their kids. But in doing so, they have taken a wrong turn, with the potential to cause great collateral harm to their naive followers. Here's why.

• Their agenda is more than anti-preservatives, it is anti-immunizations. Here's what Jenny McCarthy had to say in an unguarded moment: "I am surely not going to ask anyone to vaccinate. But if I had another child, there's no way in hell...for my next kid - which I'm never going to have - there's no way." I suspect some of the sponsors of GOV see the elimination of 'toxins' as a first, more acceptable step in eliminating vaccines altogether via scare tactics.


• They rally for "100% safe immunizations." While the rate of side effects (mostly minor) is not zero, there is no such thing (nor will there ever be) a 100% safe vaccine (nor a 100% safe car, nor a 100% safe medicine, nor a 100% safe life). Of course we can and should seek - as we have - to make them safer. However, if one objectively weighs the benefit/cost ratio of current vaccines, they (along with clean water) remain the greatest health boon for children in the proud history of medicine.


• The GOVs continue to argue that vaccines and/or the preservatives in them cause autism. There's not enough space here to refute this argument (see my blog + see the reports from the FDA + Institute of Medicine on this). Suffice it to say that, given how much damage would be visited upon unimmunized kids, you would think they would muster very strong evidence to support their hypotheses. In fact, the preponderance of studies show them to be mistaken (for example, the incidence of autism has not declined with the withdrawal of thimerosal from most vaccines). But scientific evidence does not dissuade the GOVs from their absolute certitude. I find their apparent indifference to the potential consequences of their anti-vaccine screeds to be irresponsible and, in the end, unconscionable.


• They promote distrust and paranoia about the "establishment." If you do not accept their view, you are the bad guy. Perhaps you are part of the vast profit-over-well-being pharma industries. Perhaps you are part of the FDA, which has vested interest in not being proved wrong after all these years. Perhaps you like making money off autistic kids. Any way you slice it, you're just another conspiratorial evil-doer.


• They claim that the sheer number of immunizations (which I view as a blessing) somehow overwhelms the immune system, so immunizations should be spread out or postponed. Sounds reasonable. Could be true. The problem with this interesting hypothesis is that there is no evidence that it is true and accumulating evidence that it is not. Therefore, why postpone and thereby increase the potential risks for our children?

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I can't help but wonder what Ms Odell might have said to the Green Our Vaccine parents and to all parents who are reluctant to immunize their kids. Of the many gifts you give your children, being a fully immunized human is right up there at the top.

Related Topics:

• FAQ: Vaccine Court Hears Autism Cases
• Autism-Vaccine Link: Evidence Doesn't Dispel Doubts

Technorati Tags: vaccines, immunizations, autism, Green Our vaccines, Jenny McCarthy, Jim Carrey, pediatrics, healthy children

The Potty Whisperer

As some of you know, many years ago I was a fellow in developmental and behavioral pediatrics with T Berry Brazelton at Boston Children's Hospital. Among his many accomplishments, Dr. Brazelton is the populizer of the "child-oriented" approach to toilet training, which has become the standard toilet training in the U.S.. Basically, it involves watching for developmental signs of readiness for toilet learning and to proceed slowly, with no pressure, at the child's pace. (For much more of my scoop on poop, go here)

During my fellowship training, a curious article was brought to my attention. In it, the authors described the "toilet training" (actually no toilet is involved!) practices of the East African Digo tribe. The Digo begin toilet training in the first weeks of life by making whooshing sounds whenever their diaperless infant shows signs of impeding pee or poop. Then they whisk the infant out of doors where, in his mother's arms, he happily relieves himself in the dirt. With this "nurturant" conditioning approach, night and day dryness was accomplished by 5 or 6 months, a far cry the method I was being taught by Dr. Brazelton (which typically doesn't start until about 2 years of age)!

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As if to prove there is nothing new under the sun, enter the latest rage: The Potty Whisperer(http://www.pottywhisperer.com/). I've come to learn that "whisperers" are really big these days and, not coincidentally, a marketing force to be reckoned with.

[Quick digression. If you Google the word "whisperer" you'll get 9,660,000 hits. Just for fun, here are some of the whisperers already out there: "The Horse / Dog / Cat / Pet Whisperer" (correct the animal of your choice), "The Angel Whisperer" (vibrational healing - don't ask) , "The Plot Whisperer" (for writers), "The Wood Whisperer" (for woodworkers), "The Breast Whisperer" (not porno, but a lactation consultant), "The Boss Whisperer" (tame your abrasive boss), "The Baby Whisperer"(how to calm, connect and communicate with your infant), and my favorite "The Maui Horse Whisperer Experience" (which combines horse whispering, equine facilitated learning, equestrian skill building and corporate training in leadership).]

Anyway, the Potty Whisperer, is catching parents' attention, so I've done some investigative reporting on it for you.

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As far as I can tell, the Potty Whisperer has simply appropriated the Digo method! The "whisper" part of it is the Digo's whooshing sound associated with the impulse to pee or poop. Motivated parents can attempt to train their infant to be dry in the first year of life. For later starters, the Potty Whisperer recommends the Toilet Training in Less Than A Day method to get the job done quickly and efficiently. One way or another, the diaper dependency days of your little poopster are numbered .

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You may be surprised to hear - aside from the wacky name - I'm pretty OK with the Potty Whisperer's techniques and advice, just as I am with Dr Brazelton's. Here's why.

In big letters at the very front of their web site are the "Potty Whisperer's No-Nos":

• no punishment


• no pressure


• no coercion


• no shaming


• no competition


• no showing off


• no obsessing


• no perfectionism


• no rushing toilet learning


• no attachment to time goals


• no negativity

I completely agree with this terrific list! (Of course, it's a bit ironic they are recommending "no rushing toilet learning" to parents who are interested in potty training their 6 month old infant! Perhaps I should become "Dr. P - The Fetus Whisperer" to start the whole process in-utero.)

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In my view, when and how potty training is initiated is far less important than making sure the process is not distorted by one or more of the above no-nos. As long as it is a positive experience for the infant or toddler, as long as it is not done to win a competition, as long as it is done with humor and flexibility, as long as the child's needs and abilities are respected, as long as it doesn't somehow have a negative impact on your relationship with your little poop machine, it's going to turn out OK, almost no matter how you play it.

Freud was wrong. Except in extreme nasty cases, toilet training is just not a big deal psychologically and has no lasting effects on our personalities. So how it's done is not a life and death issue (unless, I must reiterate, it engenders bad feelings, low self esteem, and/or a contemptuous relationship that persists).

So avoid the no-nos and feel free to pick the time and place and method of toilet training that best fits with your beliefs and with your heart and with your child's development and temperament. I guarantee, like pretty much every other human in the history of the world, your child will - sooner or later - master this earliest of the developmental challenges of childhood.

Related Topics:

• WebMD Video: When to Introduce Potty Training
• WebMD Video: Potty Training 101