16 January 2006

1. ADHD and Diet
2. Benefit to Delaying Vaccines?
3. Green Diarrhea
4. Failure to Thrive Due to Neglect
5. Difficult Child
6. TB Immunization for Travel?
7. Anal Tag
8. Taking a Long Trip with a 10 Month Old
9. Disclaimer

• Read Questions & Answers in Another Column

ADHD and Diet

All this to lead to the question I have for you today. In reading about adhd and ritalin there are doctors who recommend certain diets and vitamins to help with the problem. One in particular suggests that diets high in sugar and processed foods have an adverse effect on ADHD behavior. He goes on to say that a history of antibiotic use for childhood infections could lead to a yeast problem in the digestive tract which can cause some of the hyperactivity as well. The recommendation is for a diet high in fiber and whole grains, while low in sugars and processed foods. He also suggests vitamins, especially B-6. My question is about the vitamins. All literature I have read lists the RDA for adults. Where do I find information for RDA for children? What vitamins would you recommend for a ten year old boy about 65lbs? Or what readings could you point me to become better informed. My personal pediatrician is a fine doctor but reluctant to try anything new and prefers the ritalin treatment.

Thanks for your time. I'm sorry this turned out so long for a simple question.

-JB

Dear JB: Alternative medicine approaches are rife with nutritional therapies. The pharmaceutical industry which also manufactures vitamins and nutritional supplements is more than happy to provide formulas which imply benefit for a variety of conditions. Since they are being sold as nutritional supplements rather than drugs, the FDA doesn't require testing for therapeutic efficacy. In fact, such testing would be very difficult to manage in a controlled trial since we cannot have people going without vital nutrients to test nutrient combinations. The benefits to health with proper nutrition are obvious, but the claims for special benefits from megadoses and nutrient combinations do not stand up to the test required to prove medical efficacy. The problem is, that such testing requires large patient populations in order to gather statistical evidence of benefit and specific effects. While this approach is required for medical practice, unfortunately, it could miss small segments of the population who derive minor benefits from specific therapies. Lack of proof that something works is not proof that it doesn't. For that reason, if parents want to offer nutritional supplements to their children, my feeling is that it's fine as long as the ingredients are safe, and the diet being followed provides sound nutrition.

That having been said, there is no evidence that nutritional supplements can benefit ADHD. The American Academy of Pediatrics has classified the Feingold diet, a popular diet that eliminates food colorings and additives, as ineffective in the management of ADHD. Although I can no longer remember where I read the study, a study on the relationship between sugar and hyperactivity found NO EFFECT on hyperactivity levels in children who have ADHD and those who don't. While antibiotics may contribute to yeast infections, there is no evidence that yeast infections contribute to hyperactivity or attention problems nor is there evidence that most healthy people who have been on antibiotics have chronic intestinal yeast infections with no visible evidence of yeast infection such as thrush or anogenital yeast infection. As to the high fiber diet high in whole grains and low in sugar, it sounds healthy to me, but its effect on ADHD is unproven regardless of anecdotes and testimonials to the contrary.

With regard to vitamins, most children on a balanced diet should not require any vitamin supplement, but if you want the insurance of taking a vitamin, a vitamin/mineral supplement like Centrum Jr. should meet your needs and will have a label which tells you what percentage of the RDA it is providing. Many people question whether or not RDAs adequately deal with situations where additional nutrients are needed. While I don't recommend megadoses of vitamins the only vitamins which the body stores are A, D, E, and K, so you don't have to worry about exceeding a recommended dose of B vitamins or vitamin C.

Sincerely,
Dr. Warren

Note to Readers:Please read The Feingold Diet Revisited in my 8 October 2007 column, for an informative letter from Shula Edelkind, the Feingold Program Research Librarian. She calls me to task for outdated and what she believes is just plain wrong information in the above response. Aside from the information she provides which I present unedited for your evaluation, she provides links to the research she quotes and to resources with information about the Feingold Diet.

Thank you.

-LH

Dear LH: I understand parents fears and concerns about vaccines. You need to educate yourself about the vaccines so that you have a better understanding of both the risks and benefits. Check the Immunization Action Coalition's web site at http://www.immunize.org/ and the CDC's National Immunization Program site at http://www.cdc.gov/nip/ for up to date information. Allergic reactions to vaccines are rare. Your family history of allergy does not play a role in deciding what age to give the vaccines. Delaying introduction of foods to a potentially allergic child makes a difference because of the differences between immature and mature intestines with regard to the size of molecules which can be absorbed. Delaying vaccines does not decrease their allergic potential.

There is no evidence that I'm aware of that immunizations are better tolerated at 6 months than at 2 months. The risk of delaying is that you prolong the time an infant is susceptible to certain serious diseases. One of the reasons for our immunization schedule is that diseases like whooping cough and diphtheria are more serious in young infants. The fact that parents today fear the vaccines more than the diseases is a testament to the fact that the vaccines have controlled these dread diseases effectively enough for most of us to be unfamiliar with the tragedy of the diseases, no less the horrors of epidemics. Even though we have successfully eradicated smallpox from the world with our effective immunization program, many diseases remain potential threats causing outbreaks in underimmunized or unimmunized populations.

Depending on your living situation and how successfully you isolate your infant from other people, you could conceivably delay your son's immunizations with minimal risk (although of doubtful benefit). You need to be aware, however, that diseases like whooping cough may be carried by asymptomatic adults, even Grandma.

Sincerely,
Dr. Warren

Thanking you.

-AS

Dear AS: Many nursing infants have a bowel movement after each feeding. They are generally loose, yellow, and seedy in appearance. A greenish yellow to green color is of no significance if the baby is not ill. If she is feeding well and not irritable, the change in her bowel pattern could be related to a change in mother's diet and to a greater intake of milk.

There is no medication to take if an infant has diarrhea. If the stools become increasingly more watery and frequent, the concern would be the risk of dehydration. Management then should include administration of oral electrolyte solution under the watchful eye of your pediatrician.

Sincerely,
Dr. Warren

Her physician and I have the following questions: Could the previous malnutrition be affecting her height at this time? If so, how long should we expect an increase to begin? Should we expect a full recovery of her height potential and how long should this take if she is getting her nutritional and developmental needs met? Likewise - with her head circumference. Could her slow recovery at this time be attributed to previous malnutrition and what amount of recovery and what time frame should be expect of this recovery?

We appreciate your help and information. Whereas many legal, medical and social questions and pressures come up every day, we would appreciate a timely response to give us further guidance. Furthermore, do you have any recommendations for concise, authoritative and helpful resources regarding these specific questions and issues?

Sincerely,
-Social Worker

Dear Social Worker: While following growth percentiles is an excellent way to assure the adequacy of an infant's and child's growth, one must be careful not to over-interpret the significance of a particular percentile or a percentile change. An infant's size at birth and for the first few months reflects the adequacy of the placenta as much as it does genetic potential. Many large, healthy babies drift down to a lower percentile during the first year of life and then grow along that lower percentile once they have found their niche. Head size percentiles do not always match other percentiles. If the head continues growth along the 10th percentile, even if the body is in a larger percentile, that does not indicate a problem. Head growth is affected by genetic factors as well as the growth of the brain. To the extent that the child's head circumference is currently within the normal range and growing steadily along a percentile curve, there may be no problem at all and no significance to the head size never exceeding the 10th percentile. To the extent that there was any loss of brain tissue during the period that the head was not growing, I cannot offer any assurance of complete recovery, but any neurological consequences can be ameliorated by continued early intervention services.

The child's prior nutrition should not be affecting her growth now unless she developed thyroid or other gland dysfunction when she was malnourished, or unless she has malabsorption due to intestinal damage (which would cause intestinal symptoms). As long as growth continues along a percentile you needn't pay too much attention to which percentile. But if linear growth is not keeping pace, her poor growth should not be ascribed to prior conditions and should be evaluated. If she has rickets, she may require more than the usual amount of vitamin D to return to normalcy. She may also need to be evaluated for conditions which may have been overlooked when the state of her nutrition appeared to be the main problem. This could include chronic infection (for example UTI), congenital infection, heart disease, and, as previously mentioned, glandular disorders.

Sincerely,
Dr. Warren

-Pat

Dear Pat: In all fairness to your daughter, she may have developed her approach to child rearing because your granddaughter is a tough kid to deal with. Unfortunately, tough kids never become easier to deal with by having things their way. While I would not engage in a campaign to teach her that she can't always have her way, her mother needs to decide that adults are in charge on important matters and find the strength to make and enforce decisions that she feels are in hers and her child's best interest. The child is not going to take kindly to these changes. No matter how clearly the changes are beneficial, she's going to be upset that her world is turning upside down. Her mother will need outside support to get through this. I would suggest counseling.

Sincerely,
Dr. Warren

Sincerely,
-EL

Dear EL: BCG, which is used to immunize children against tuberculosis in some countries where there is a lot of TB, is not used in the USA. To the best of my knowledge it is not recommended for travel or available in the US. For more information about immunizations for travel check the Travel Information CDC Home Page at http://www.cdc.gov/travel/.

Sincerely,
Dr. Warren

-Gina

Dear Gina: Hemorrhoids would be unusual in an 11 month old, but not impossible. If the item you are questioning looks like a skin tag, it is probably an anal tag rather than a hemorrhoid. Anal tags develop from anal fissures when they heal. Anal fissures are tears in the tissue surrounding the anus which usually result from passing a large, hard stool.

Sincerely,
Dr. Warren

-Gina

Dear Gina: You will probably always be able to see the anal tag, but if there are no further fissures, as she grows it will become relatively small compared to her size and will not cause any problem.

Sincerely,
Dr. Warren

Thanks alot.

-CM

Dear CM: Bring small toys that amuse the baby along on the trip and be prepared to sing, read, play peek-a-boo, and generally entertain the baby in any way you can. When you ask if you can give the baby something, I assume you are asking about medication. I don't recommend giving children sedatives for trips. Giving high doses of sedatives as are given for medical procedures carries certain risks. The response to small doses of sedatives or antihistamines which some times make children drowsy can be unpredictable. Some children become drowsy enough to be difficult but don't sleep, and others become totally wild from the medication.

Sincerely,
Dr. Warren

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