Just Sip It: More Than Half Of U.S. Kids Not Properly Hydrated



One statistic jumped out at me from this study by researchers at the Harvard School of Public Health about whether U.S. kids are drinking enough water: “Nearly a quarter of the children and adolescents in the study reported drinking no plain water at all.”

When you think about the kinds of serious health problems your kids might have, not drinking quite enough water may not top your list.

But it’s serious: beyond the physical problems related to insufficient water-drinking, there are cognitive implications as well, researchers report:

Inadequate hydration has implications for children’s health and school performance. Drinking water can improve children’s performance on cognitive tests. Two studies have found that children’s cognitive performance improved as their urine osmolality [a measure of urine concentration] decreased. Increasing drinking water access in schools may be a key strategy for reducing inadequate hydration and improving student health, because schools reach so many children and adolescents and that they typically provide free drinking water to students.

The study was published online in the American Journal of Public Health.

I asked Erica Kenney, a postdoctoral researcher and one of the study authors, a few questions about the work. Here, lightly edited, is what she said, via email.

RZ: What’s the takeaway here?

EK: We often take for granted that kids will keep themselves hydrated automatically and will drink when they’re thirsty, or that their schools, summer camps, afterschool programs, child care centers, etc. will be providing them with enough opportunities to drink water during the day. But our study indicates that this may not be the case — over half of all children and adolescents in the U.S. are estimated to be inadequately hydrated. We need to do a better job of getting safe, clean, appealing drinking water to kids (and by “we” I don’t just mean parents and families — I also mean the places where kids learn and play during the day) and keeping them hydrated so that they have the opportunity to be at their best in terms of well-being, cognitive functioning, and mood.

Where do we go from here? Continue reading

Why The Primary Care Problem (Lower Status, Pay) Matters

By Jeff Levin-Scherz, M.D., M.B.A.
Guest Contributor

Medscape just published its annual physician compensation survey. The survey includes almost 20,000 physicians and is given online, so it’s probably not entirely representative.

Also, the survey results are self-reported, and physicians generally under-report their income. But the comparative reported income among specialties is informative. This survey is among the largest available, and does not require an expensive paid subscription.

(Courtesy of Medscape)

(Courtesy of Medscape)

The results are no surprise. But they’re worth noting: Specialists make 45 percent more than primary care physicians, and orthopedists make 224 percent more than pediatricians.

The majority of respondent physicians were employed, and men consistently make more than women in the same specialty. Women have the largest representation in specialties with the lowest incomes.

Physician income was a bit lower in the Northeast but higher in the Northwest. Massachusetts’ physicians report that their income is 46th in the nation.

Internists are the least satisfied in their job (47 percent), and the least likely to choose their specialty if they could choose again (25 percent), but high in the rankings of specialties where the respondent would choose medicine again (71 percent).

(Courtesy of Medscape)

(Courtesy of Medscape)

Family physicians were only slightly more likely to choose the same specialty again as internists (31 percent), yet they were the most likely to say they would choose to go into medicine again (74 percent).

Pediatrician income is among the lowest of all specialties, yet they are twice as likely to say that they would choose the same specialty. Internists and family physicians would go into medicine again, but they would go into sub-specialties, and not do general primary care. The high cost of health care in the U.S. is in part due not to a shortage of primary care physicians, but also due to a surplus of specialists.

Why does all this matter?

The American College of Physicians reported on the impending “collapse” of primary care in 2006. There have been efforts to change this situation since, including “patient centered medical homes,” and short-term enhanced Medicaid primary care fee schedules built into the Affordable Care Act.

The continued relatively lower pay of primary care physicians and the lack of job satisfaction of general internists and family physicians means that our historic way of delivering primary care is about to change. Much future primary care is likely to be delivered by nurse practitioners or physician assistants, and some office-based primary care will be supplanted by telehealth or by apps with underlying algorithms.

The Medscape survey suggests that we will continue to face serious challenges to continue to deliver the highly personalized primary care which many of us value, and the highly coordinated care needed by the frail elderly and those with serious chronic illnesses.

Continue reading

One Doc’s Oreos-And-Batman Perspective: TV Doesn’t (Necessarily) Make Kids Fat

(Donnie Ray Jones/Flickr)

(Donnie Ray Jones/Flickr)

By Steve Schlozman, MD

Here are three recent headlines that got me thinking about kids and fat:

“Watching one hour of TV per day increases risk for obesity by 50%”

“Watching TV for Just an Hour a Day Can Make Children Obese”

“Study makes surprising link between TV time and childhood obesity”

Oversimplifications? Um, yes. Each of these headlines greatly simplifies (dare I say, incorrectly simplifies) a critical social and health issue. Personally, I don’t think TV is the sole evil culprit here. It’s far more complicated.

The medical community has long known that the amount of TV that a child watches correlates with obesity. We can even make some leaps from these data towards implicating causality. Unless your little ones happen to be doing aerobic exercises while they tune in to their cartoons, it’s easy to see how passive watching can equal active weight gain.

However, be wary of oversimplification and especially of the “one-size-fits-all” policy statements that these headlines often generate. The study authors here do, in fact, suggest further limiting TV exposure based on the existing American Academy of Pediatrics guidelines for young children as a means of controlling the rate of obesity in this country. (Currently, the AAP recommends limiting screen time to one to two hours or less for children over the age of 2, and discouraging screen time altogether for those who are younger.)

So, here’s the big question: Is the recommendation that TV time be further limited an entirely appropriate conclusion?

Beyond The Headlines

The answer, like many answers to social policy questions, is both yes and no.

What we know for certain is that we can’t really discern from the headlines what we ought to do, though there is ample reason to believe that most American rarely go beyond the headlines. Thus, we run the risk of jumping to more draconian conclusions than might be appropriate simply because we don’t have or take sufficient time to examine the flood of information.

How do we guard against this leap to oversimplification?

Here are a few key questions:

•Was there a large and diverse population studied?

There have been solid links between lower socioeconomic groups and some ethnic minorities and increased television time, as well as between lower socioeconomic groups and obesity.

The causes for both of these issues are of course multi-factorial. Fatty foods and higher calorie foods are cheaper. TV can function as a babysitter in households where parents are busy working and living paycheck to paycheck. However, the study in the headlines above, conducted by the Department of Education in conjunction with physicians at the University of Virginia, was indeed both large and diverse.

Over 12,000 children starting kindergarten were enrolled in the investigation, and a year later follow-up data was available for more than 10,000 of these children. These data included height and weight, as well as statistical analyses to account for differences in race, gender and socioeconomic effects. In other words, the numbers here are sufficiently large and diverse for us to feel comfortable drawing at least preliminary conclusions.

Causality, Really?

But beware, always beware, of flashy headlines. A Google search yielded all of the headlines above with equal weight, and yet one of the headlines clearly implicates causality. “Watching TV for just an hour a day can make a child obese.” (My italics.)

However, this study does not in any way suggest causality. There are a number of potentially unrelated factors that also happen everyday that might be associated with obesity, but not function as a cause of obesity. These could include behaviors like longer baths to cool down. We don’t know until we do the study whether longer baths would be associated with obesity. In other words, always be wary of blanket statements of causality with regard to the complexity of human behavior.

•What about the ample availability of screen-based material on demand? Perhaps the fact that children can often watch both what they want and when they want it affects their activity patterns in negative ways. We could ponder the fact that TV content, even for kids, has arguably (though not in all spheres) gotten better and of higher quality. There is even evidence that TV watching can improve behavior among kids, and this evidence also comes from the American Academy of Pediatrics. Does that mean we ought to make a policy statement advocating that TV should be less compelling?

Confessing My Bias

Things get even messier when we take the necessary step of examining our own personal biases. In my case, that examination includes a shameless confession regarding the ways my own penchants might complicate my interpretation of these data. Continue reading

Sip Of Latte With Binky? Study Finds Coffee Drinking ‘Not Uncommon’ Among Boston Toddlers

When Boston researchers asked mothers what types of fluids they were feeding their babies, they expected typical answers: breast milk, formula, water, juice.

But what they heard was surprising: a number of moms were giving their 1- and 2-year-olds coffee to drink. Not much, but still.

According to a new study on the links between early feeding and childhood obesity, researchers report approximately 15 percent of 2-year-olds were receiving up to 4 ounces of coffee every day (though the average was just over an ounce). Among the 1-year-olds in the Boston-based study, the rate of coffee consumption was 2.5 percent of children.

“We didn’t ask if it was decaf,” says the study’s principal investigator, Anne Merewood, PhD, MPH, director of the Breastfeeding Center at Boston Medical Center and associate professor of pediatrics at Boston University School of Medicine. The majority of the coffee-drinking children had Hispanic mothers who were born outside the U.S., the researchers wrote; and female infants and toddlers were more likely than males to drink coffee.

Merewood said while she was surprised by the findings, the practice does make cultural sense. “I’m English and I’ve been drinking tea since I was a very small child,” she said. “It’s a cultural thing, they just feed the baby what everyone else is eating.”

The researchers did not ask whether the children’s minimal coffee consumption impacted behavior, or whether the kids got hyper with the additional caffeine. Still, Merewood said: “It’s probably not a great idea to give caffeine to young children. We we need to investigate more.”

(Soul 2 Amor/Flickr)

(Soul 2 Amor/Flickr)

The study of 314 pairs of mothers and babies specifically looked at breast feeding and other eating habits of children at age 1 and 2 years. The findings, published in the Journal of Human Lactation, which is edited by Merewood, cites some earlier research on the downside of coffee drinking by young children:

Although coffee consumption in the first years of life has not been well documented, several risks of coffee and caffeine consumption in older children and adolescents have been identified. Research suggests an association between coffee consumption and higher rates of type 1 diabetes in children. Caffeine use among children and adolescents has been associated with depression, sleep difficulties, substance use, and concerning physiological, behavioral, and psychological effects…

It is unknown if these same risks apply to very young children and coffee. One study that did explore the risks of coffee consumption among toddlers found that 2-year-olds who consume coffee or tea between meals or at bedtime had “triple the odds of severe kindergarten obesity.”

The researchers also point out that: “In a recent statement, the US Food and Drug Administration expressed an intent to establish an acceptable limit for caffeine use by children, recognizing that the AAP discourages this practice.”
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Study: Well-Water Can Raise Arsenic Levels In Formula-Fed Babies

Parents already concerned by recent revelations about arsenic in rice, grains and juices, brace yourselves: A new study found higher levels of arsenic excreted by infants exclusively fed formula, compared to breast-fed babies. A likely culprit: well-water.

In the small study of private well-water users in New Hampshire, overall arsenic exposure was relatively low for most 6-week-old infants regardless of how they were fed. “So that’s good news,” says Kathryn Cottingham, a professor of biological sciences at Dartmouth and the study’s co-lead author. “That said, infants fed exclusively with breast milk were less exposed to arsenic than infants fed with formula, and some infants fed with formula may have been exposed to very high levels of arsenic due to high concentrations in their home tap water.”

In the study, published in the journal Environmental Health Perspectives, researchers measured arsenic in the home tap water of 874 families, urine from 72 infants and breast milk from nine mothers.

(Donald Clark/Flickr)

(Donald Clark/Flickr)

Arsenic levels in the tap water tended to be well below the EPA’s recommended upper limit, researchers report. Still, they found that: “measured urinary arsenic concentrations were 7.5 times higher in exclusively formula-fed infants compared to breast-fed infants,” says Cottingham.

The bottom line, she says, is get your well-water tested.

“In terms of fear mongering, that’s the fear I’d like to instill: if you have well-water, get your water tested,” she says.”I don’t want to freak people out about feeding their babies formula.”

Arsenic is a naturally occurring element found in groundwater around the world — and in some places, in very high concentrations.

Exposure to high levels of arsenic, a human carcinogen, has a number of potential health consequences, the study authors note, including cancer, cardiovascular disease, diabetes, obesity, adverse birth outcomes and altered immune systems. Continue reading

How To Talk To Parents Who Oppose Measles Vaccines? We Don’t Know

In this Jan. 29 photo, pediatrician Charles Goodman vaccinates 1-year-old Cameron Fierro with the measles-mumps-rubella vaccine, or MMR vaccine, at his practice in Northridge, Calif. The measles outbreak that originated at Disneyland in December has prompted politicians to weigh in and parents to voice their vaccinations views on Internet message boards. (Damian Dovarganes/AP)

In this Jan. 29 photo, pediatrician Charles Goodman vaccinates 1-year-old Cameron Fierro with the measles-mumps-rubella vaccine, or MMR vaccine, at his practice in Northridge, Calif. The measles outbreak that originated at Disneyland in December has prompted politicians to weigh in and parents to voice their vaccinations views on Internet message boards. (Damian Dovarganes/AP)

Suddenly, measles is political. The Disneyland outbreak has turned the long-simmering issue of parents who decline vaccinations for their kids into a political hot potato, to the point that the New York Times just did a round-up of where potential presidential candidates stand on vaccination. (Classic Hillary Rodham Clinton tweet: “The science is clear: The earth is round, the sky is blue, and #vaccineswork. Let’s protect all our kids.”)

My thought: Great. The topic is already rife with fear and anger and parental conflict, and now we’re adding politics? And I wondered: Is there, in fact, a known way to discuss vaccine resistance constructively? When a pediatrician faces a hesitant parent, or when I encounter a parent in my community who fails to get a child vaccinated?

I asked Dr. Barry Bloom, an infectious diseases expert at the Harvard School of Public Health, who co-authored an editorial in the journal Science — “Addressing Vaccine Hesitancy” — and was also recently featured here: “Talking The Talk On Vaccines.” His reply:

One of the amazing things is that we don’t know the answer to your question. I chaired a meeting at the American Academy of Arts and Sciences on the subject of trust in vaccines. We brought in lots of people — from state governments, doctors — to find the answer to your question: What do we know about how to persuade people that it is in kids’ best interest to protect them against diseases they’ve never seen?

My take is that the answer is two-fold:

One, not everyone is the same. There are a myriad of reasons that people give when questioned about why they don’t vaccinate kids, or delay vaccinations. So there’s no one-size answer that will fit all.

The vast majority of people listen to their doctors — they’re very important — and they do what is recommended because they believe doctors wouldn’t want to harm their kid.

Then there’s a very small group of people who, for a variety of ideological, certainly not scientific, reasons, are opposed in any manner, shape or form to being told what to do, to having government make requirements for school entry, and so on.

The third part of that is people who are responding to discredited publications claiming that vaccines cause bad things to happen. I have to say when I saw one of the physicians in Congress, Rand Paul, say that he had heard vaccines cause neurological or psychological damage, I was absolutely stunned, because there’s no data to support that whatsoever. Continue reading

That Extra Slice: Study Finds When Kids Eat Pizza, They Eat More Calories

Pizza birthday party (Flickr Creative Commons)

Pizza birthday party (Flickr Creative Commons)

By Alvin Tran
Guest contributor

Parents, if you want to prevent your kids from eating too many extra calories, you might want to think twice about letting them have that “just one more” slice of chewy dough, tangy tomato sauce and glistening melted cheese.

In a new study, published Monday in the journal Pediatrics, researchers found that pizza contributed to children and adolescents consuming more calories, saturated fat, and sodium in their usual diet.

“They’re taking in substantially more nutrients we really want to be thinking about limiting,” said Lisa Powell, PhD, a University of Illinois at Chicago professor of health policy and administration and the study’s lead author.

Powell’s study, which analyzed 24-hour dietary recalls of more than 12,000 kids over a 7-year period, found that children between the ages of 2 and 11 consumed an extra 84 calories on the days they ate pizza, while adolescents consumed an extra 230 calories.

It’s not a good idea to eat pizza as a snack.

– Lisa Powell, PhD

They also consumed significantly more sodium and saturated fat, which nutrition and health experts often dub the “bad fat.”

There is a silver lining, however. Children’s overall caloric intake from pizza declined by 25 percent over the course of the study. The study’s adolescent population, which ranged from ages 12 and 19, also demonstrated similar trends: its caloric intake from pizza fell by 22 percent.

But while the number of calories that adolescents consumed dropped, their overall consumption, on average, did not significantly change over the course of the study. According to Powell and her co-authors, this may be due to a slight increase in pizza consumption.

“The average adolescent takes in 620 calories of pizza. By showing that they consume this extra 230 calories, that means that on days they consume pizza, they’re not adequately adjusting the caloric intake and other things they take in that day,” Powell said. “They may be eating pizza but they’re having this additional 230 calories that they’re taking in.”

Overall, pizza consumption remained highly prevalent across both groups. In 2009 to 2010, 20 percent of children and 23 percent of adolescents consumed pizza on a given day.

Powell and her colleagues also found that consuming pizza as a snack or from fast-food restaurants were the two greatest culprits influencing both children and adolescents’ overall daily calorie intake.

“It’s not a good idea to eat pizza as a snack. That’s one thing that teens and parents should keep in mind,” Powell said. Continue reading

Miralax Dilemma: As Common Laxative Studied, Parents Ask, ‘Is It Safe?’

Miralax is seen on a store shelf. (Robin Lubbock/WBUR)

Miralax is seen on a store shelf. (Robin Lubbock/WBUR)

By Ricki Morell

If you, like millions of parents, routinely give your child Miralax for constipation, recent reports that the Food and Drug Administration is studying a possible link between the common laxative and neuropsychiatric problems probably sounded scary.

After years of complaints from activists, two Children’s Hospital of Philadelphia researchers are now leading an FDA study of the ingredient — polyethylene glycol 3350, or PEG 3350 — to see how it affects children.

“We’re pleased that they’re going to be looking at behavior changes because that’s never been done before,” said Carol Chittenden, co-director of The Empire State Consumer Project, a nonprofit consumer group in Rochester, New York, that pushed the FDA to embark on the study. “Parents are feeling anxious but also validated because they’ve been telling their doctors for years about these symptoms.”

Just because the FDA is doing a study, doesn’t make it dangerous.

– Dr. Samuel Nurko

Miralax is sold over the counter as an adult laxative, but pediatricians and gastroenterologists routinely prescribe it to infants, toddlers and older children. And they often prescribe it for long-term daily use for chronic constipation, even though the label says it should be used for no more than seven days “unless advised by your doctor.”

Dr. Samuel Nurko, director of the Center for Motility and Functional and Gastrointestinal Disorders at Boston Children’s Hospital, said parents have little reason to worry. Dr. Nurko, who was involved in previous studies of Miralax, some partially funded by the drug company that used to own Miralax, argues that the drug isn’t approved for children because of the technicalities surrounding the FDA study process. He believes Miralax is safe for children.

“Just because the FDA is doing a study, doesn’t make it dangerous,” Dr. Nurko said. “From my perspective, the risk of not treating constipation is worse. Do you think the FDA would leave it on the market if it were dangerous? I think it’s an overreaction but I’m glad that they are studying it.”

About 5 percent of children suffer from constipation, according to the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, which has guidelines for long-term use of Miralax among other constipation treatments.

FDA spokesperson Andrea Fischer said in an email that the agency is funding the $325,000 study to explore pediatric safety concerns even though “the FDA has not determined that there is enough data to warrant additional warnings regarding these products, or to issue specific warnings about pediatric use of the drugs at this time.”

The FDA first tested Miralax in 2008 and found small amounts of ethylene glycol and diethylene glycol, toxic ingredients also found in antifreeze. In subsequent tests in 2013, it found no detectable levels of those ingredients.

Chittenden says any hint that PEG can lead to side effects known to be associated with ethylene glycol or diethylene glycol toxicity is disturbing. According to a 2009 FDA drug oversight report, neuropsychiatric side effects “may include seizures, tremors, tics, headache, anxiety, lethargy, sedation, aggression, rages, obsessive-compulsive behaviors including repetitive chewing and sucking, paranoia and mood swings.”

Diethylene glycol toxicity can also cause “metabolic acidosis,” or too much acid in the blood, which, in severe cases, can lead to shock or death.

But Fischer emphasized that the link between these side effects and Miralax is so far unproven. Continue reading

Sleepy Students: A Pediatrician’s Plea For Later School Start Times

(eltpics/Flickr via Compfight)

(eltpics/Flickr via Compfight)

By Dr. Marvin Wang, M.D.

Last August, the American Academy of Pediatrics (AAP) issued a statement regarding school start times, really a plea to all middle and high schools to start the school day no earlier than 8:30 a.m.

The statement emerged as a result of accumulating evidence showing that earlier school start times effectively restrict an adolescent’s ability to get regular healthful sleep.

The timing of the AAP’s statement came on the heels of another sentinel event in my family’s life. Just a month after its publication, my daughter started school. No big deal, except for the fact that she has never been to school before. Until this year, she was exclusively homeschooled here in Jamaica Plain, Massachusetts.

My wife and I didn’t have any major agenda driving this decision, other than the fact that we knew we could do it (we work part-time) and it seemed like it would be more family fun. The many details of our homeschooling adventures are really for another time, though.

The reason I even bring up the topic is that as a homeschooler, my daughter was able to wake up when she wanted to (usually within reason). On a regular day, she was used to getting up at 8:30ish (despite sometimes our having to pry her out later).

After a whole lifetime of this, imagine the draconian lifestyle shift of being asked to get up at 6 a.m. every weekday! This is the routine that is better known to most people as “going to school.” Now, let’s be clear about a few things: 1) our daughter wanted this. She asked to take the exam for the Boston Public Schools, in hopes of going to Boston Latin School, where she watched many of her friends attend; 2) she knew the early mornings were part of the routine; and 3) BLS actually has a relatively benign start time of 7:45 a.m., compared to many of its counterparts in the district and the state.

So what’s all the fuss? It cannot be a novel idea to most adults that the typical school teenager is a surly blob on most weekday mornings. Should we be surprised to learn that we have been breeding generations of sleep-deprived adolescents? Should we, as educators, parents and “concerned citizens” be worried about this?

First, let’s look at what’s new since the AAP statement came out.

Indeed, the movement is picking up steam in some parts of the country, as whole districts have approved later start times. In Massachusetts, districts like Sharon, Easton, Duxbury and Nauset have done so.

And there are some new studies corroborating the AAP’s stance:

In looking at the neurobehavioral issues in teens, it turns out that just one night of sleep deprivation in an adolescent has marked worsening of sustained attention, reaction speed, cognitive processing speed and subjective sleepiness. When the sleep was restored, the teens were able to significantly improve all their cognitive abilities.

One study showed that sleep restricted teens (average of five hours/night) were more likely to be lower academic quartiles than those who slept more (average 6 ½ hours/night…which is still two hours less than optimal!). But looking at the results, one also finds that the perceived sleepiness among the sleep restricted group was at least twice that the sleep appropriate group. Continue reading

Five Things You Need To Know About Sharing A Bed With Your Infant

By Melissa Bartick, M.D.
Guest Contributor

My recent analysis of the current infant sleep recommendations led many people to ask a simple question: where, exactly, is it safe for my baby to sleep?

In a recent blog post that generated huge reader response, I went through why the current sleep recommendations from the American Academy of Pediatrics against all infant bed sharing have backfired.

one deep drawer/flickr

one deep drawer/flickr

Based on the analysis my colleague Linda J. Smith and I conducted, a few facts are clear: No sleeping infant situation is completely safe. Infants may die in cribs as well as in bed with their mothers. SIDS and sleep associated suffocation and strangulation are different entities, but share some overlapping risk factors.

Both result in the same tragic outcome, so the recommendations tend to be lumped together.

However, infant bed sharing is not as great a risk for sleep associated infant death as is exposure to smoke (both prenatal and after birth), falling asleep on couches or recliners with one’s infant or sleeping with an infant while under the influence of drugs and alcohol. For many years, studies have demonstrated that formula feeding is an independent risk factor for SIDS when compared to breastfeeding.

So here are five safety tips:

1. Mattress Alert

Even if you never plan to share your bed with your infant, the safest assumption is that you may sometimes unintentionally fall asleep there with him. Therefore, the best advice would be for every parent to make their bed as safe as possible. The mattress should be away from the wall or so tight that there is no gap where an infant could get entrapped. Some parents solve these issues by putting their mattress on the floor. The bed should be away from dangling cords that could cause strangulation. The surface should be firm, without heavy or fluffy covers or pillows near the baby. The baby should sleep on his back. He should be lightly dressed- no more clothing on the baby than the parents are wearing. The baby should never be swaddled in a shared sleep situation.

2. Feeding At Night

Avoid feeding your infant on a couch or recliner at night or when you are tired. (There are anecdotes about tragedies that have occurred when mothers have fed their infants in their own beds while sitting up. We don’t have any evidence on whether this is dangerous.) However, if you are breastfeeding and can do so laying down, that may be preferable to nursing in bed while sitting up so the baby cannot slide off into a dangerous location.
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