Better Kid Care and Child Development Health

Ideal duration of daily physical activity for children: In the Journal Pediatrics, a study reviewed 850 articles that discussed how physical activity influenced the health and behavior of 6 to 18 year olds. It was determined that the ideal duration for fitness benefit of school-age children should be participation in 60 minutes or more of moderate to vigorous physical activity per day. The activity must be developmentally appropriate, enjoyable, and involve a varied number of activities. (63)

Assessment and Plan: Basic Standard Preventive Healthcare for Infants, Toddlers, Children, and Adolescents

• Breast feeding an infant is highly recommended instead of using formula or cow’s milk. When breast milk cannot be used for any reason, use a formula with hydrolyzed whey.

• U.S. Preventive Services Task Force (USPSTF) recommendations:

• Prevent gonococcal ophthalmia neonatorum (conjunctivitis occurring from bacteria of the birth canal which may result in blindness) with 0.5% erythromycin applied to the newborn’s eyes within 1 hour of birth (1).

• Screen for congenital hypothyroidism after birth is necessary according to the U.S. Preventive Services Task Force (USPSTF) (2).

• Test newborns between 24 hours and 7 days of age for phenylketonuria (PKU) (4).

• Screen newborns for sickle cell disease (5).

• Evaluate for hearing impairment under 1 month of age, followed by a comprehensive audiological testing by 3 months of age (6, 7).

• Provide assessment of communication skill development during routine visits starting at 2 months of age. (7)

• Routine iron supplementation for asymptomatic children aged 6 to 12 months with prematurity, low birth weight, and other infants who are at risk for iron deficiency anemia (8) This includes vegetarian children.

• Screen children ages 3–5 for visual impairment (12).

• Counsel and offer lifestyle modifications for children with obesity over 6 years old (14).

• Screen teenagers between 12 and 18 years old for depression if appropriate professionals are available for accurate diagnosis, effective treatment, and follow-up (15).

• Screen sexually active adolescents for sexually transmitted infections (16).

• Prevent sun damage of the skin and eyes with sunblock (at least spf 30) and UV eye protection along with counseling on minimizing their exposure to ultraviolet radiation to reduce risk of skin cancer (18)

• For sexually active adolescents at increased risk for sexually transmitted infections, provide intense behavioral counseling to prevent these infections (16,19).

• Fluoride prescription is supported by the Centers of Disease Control (CDC), American Dental Association (ADA), and the U.S. Preventive Services Task Force (USPSTF) if the water source is deficient in fluoride (27,28,48). Water is considered deficient in fluoride if the concentration is under 0.6 mg per liter. The ADA recommends that high-risk children with fluoride in drinking water under 0.3 mg per liter should be prescribed fluoride as follows: 0-6months old: Do not prescribe fluoride. 6 months to 3 years: 0.25 mg per day, 3-6 years old: 0.5 mg/day, 6-16 years old: 1 mg/day. If drinking water contains 0.3-0.6 mg per liter of fluoride, 3-6 year olds should take 0.25mg per day of fluoride, 6 to 16 year olds should take 0.5 mg per day.

• Counsel the adolescent not to start smoking. If they do, reinforce need to quit. Many resources are available to assist in smoking cessation such as the online sites http://smokefree.gov/, http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/ and the phone number for free help 1-800-QUIT-NOW.

• Primary care pediatrician should emphasize maintaining compliance and follow-up intervals based on diagnoses, school physicals, or vaccine requirements.

• Complete routine infant and childhood vaccinations, provide influenza vaccination should be given each year in October (11). For more information see the immunization schedules posted by the Centers for Disease Control. For those 0-18 years of age please visit the link: http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

• Children on a vegetarian diet may be at risk of multiple nutrient deficiencies such as iodine, iron, vitamin B12, zinc, and vitamin D.

• Fruit and vegetable consumption as well as encouraging water and milk intake throughout the day improves the free water reserve and hydration status of children (17).

• Keep a watchful eye for unusual changes of the body such as wounds that are not healing, skin problems, ongoing cough, persistent shortness of breath, unresolved pain, lasting fevers, unexplained weight loss, lumps and other new problems which do not go away or continue to worsen with time. Report these to the primary pediatrician.

• Infants and children do well with predictable schedules for sleep, meals, school and playtime. Avoid erratic sleep patterns which cause unnecessary stress.

• Ensure adequate vitamin A intake in children: The supplementation of Vitamin A in children with measles was documented to have an association with lower mortality rate in both malnourished and overall healthy children diagnosed with the disease. Vitamin A may reduce in morbidity and mortality by about 50% and may also prevent eye damage and blindness. The World Health Organization recommends that all children diagnosed with measles throughout the world receive vitamin A supplementation regardless of which country they live. See vitamin A for more information about this nutrient.

• Vitamin B12 deficiency may lead to solid food refusal (25).

• Ensure adequate iodine intake.

• Hearing improved permanently in iodine-deficient children who took continuous iodine supplementation (33).

• Iodine supplementation in children age 10-13 with mild iodine deficiency improved cognitive test scores (30-32) over placebo at a dose of 150 mcg for 28 weeks (30), and a dose of 400 mcg for 28 weeks in children age 10-12 (31).

• Iodine supplementation also improved thyroglobulin levels (31) and goiter size in children (32-33).

• Ensure adequate iron intake.

• Iron supplementation improved attention and concentration in anemic adolescents and increased intelligence (IQ by 2.5 points) (34).

• Sachdev H P et al found that iron supplementation was beneficial in mental development and in intelligence scores (IQ scores) in children 7 years or older, and in those who are initially anemic or iron-deficient anemic, but found no evidence to prove iron supplements improved cognitive development for children under age 27 months, and there was no significant effect on children’s motor development (35).

• Iannotti LL, performed a review of 26 randomized controlled trials which evaluated the iron supplementation in children (aged 0-59 months) and found that many trials showed that iron supplementation improved mental and motor development, but it may reduce a child’s weight gain and is associated with nausea and constipation. Rare genetic conditions such as hemochromatosis may make a child susceptible to iron overload (36).

• Iron absorption was studied among infants using iron supplementation of infant cereals and in milk- and soy-based formulas. Iron supplementation in cereals did not provide a good source of iron for infants, but iron sulfate in milk- and soy-based formulas may help more than infant cereals to meet the dietary needs of infants. (37)

• One study reported that riboflavin, or (vitamin B2) may treat migraine headaches in children and adolescents at a dose of 200 or 400 mg/day of riboflavin orally for 3 – 6 months with a reduction of 50% in the number of migraines in 68.4% of patients and in 21%, a reduced migraine intensity was seen (38). However, in another study, placebo was more effective that riboflavin (39).

• Concerns of maternal consumption of meats: Some cohort studies have shown that consumption of certain meats either by the pregnant mother, or by the child may result in an increased risk of childhood cancers.

• In a study, Preston-Martin S et al conducted an interview of each mother of 549 children under age 20 with a diagnosis of primary brain tumor and 801 children without cancer. The odds ratio is the ratio of the odds of an event occurring in one group to the odds of it occurring in another group and an OR of 1 means it equally occurred in both groups. Researchers found an increased brain tumor risk in offspring of mothers with relatively high consumption levels of nitrite from cured meats during their pregnancies with an odds ratio (OR) = 2.1 for eating at least twice a day compared to not eating nitrites (40).

• Sarasua S et al found that children whose mothers consumed one or more hot dogs per week during pregnancy had twice the normal risk of developing brain tumors (OR = 2.3). Among children, eating hamburgers one or more times per week was associated with risk of lymphocytic leukemia (OR = 2.0) and children who consumed one or more hot dogs per week were also at higher risk of brain cancer (R = 2.1). (41)

• Peters JM et al found that children eating more than 12 hot dogs per month have 9 times the normal risk of developing childhood leukemia (odds ratio [OR] = 9.5). A strong risk for childhood leukemia also existed for those children whose fathers’ intake of hot dogs was 12 or more per month (OR = 11.0). Interestingly, when fruit was consumed in the diet with the meats, it was not found to provide any protection from the cancer risk. (42)

• Richardson AJ et al found that 7-9 year-old children taking 600 mg of DHA initially scoring under the 20^th percentile, gained a reading age of 0.8 months more in scores with the DHA supplement. Those in the 10^th percentile or under gained 1.9 months in reading age score. Working memory of children taking DHA did not improve. This study also evaluated 14 specific measurements of an ADHD (Attention Deficit Hyperactivity Disorder) symptom scale in the children such as restlessness, change in mood, and resistant behavior. There was a significant placebo effect, but a significant amount of improvement in 8 of the 14 ADHD parameters measured over placebo. The parents of the children noted the benefit, but no significant improvement was seen by the teachers. (43)

• According to Van Winckel M et al, the vegan child with a diet void of all animal source foods would need to supplement with vitamin B12, but may otherwise obtain the necessary nutrients if the child’s diet includes dairy products (64). A study on mostly Polish ovo-lacto vegetarian children aged 5-11 on vegetarian diets were found to have adequate range of vitamin B12, vitamin A, iron and folate, low normal vitamin E, but had much lower blood levels of vitamin D than children on omnivorous diets and according to the author this should be monitored and supplementation considered (44).

• Please see all vitamin recommendations within the respective sections to meet the additional nutritional needs of children.

• Caffeine consumption may not be beneficial for teens who slept fewer hours at night and took more naps during the day than those who had less caffeine (45).

• Children and digestive health:

• Constipation: Miralax is the most commonly prescribed treatment for constipation but glucomannan is a natural fiber alternative. 46 chronically constipated children, each of whom was treated with glucomannan at a dose of 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg was more effective than placebo for alleviating constipation and this natural fiber also appeared to reduce abdominal pain (46).

• Irritable bowel syndrome: 42 children with irritable bowel syndrome (IBS) took coated peppermint oil caps containing187 mg of peppermint oil, 1 capsule 3 times daily for those weighing 30-45 kg or 2 capsules 3 times daily for those more than 45kg for 2 weeks, and at the end of the study, pain due to IBS was reduced in 75% of those taking peppermint oil (47).

• Children, colds, influenza, and respiratory health:

• Pelargonium sidoides was found to reduce the total duration of non-group A beta hemolytic strep tonsillopharyngitis by 2 days (on average) in the treatment group (n=73) as compared to the placebo group (n=70), and treatment was considered safe by the authors (48). Please see the section on this herbal agent, Pelargonium sidoides for more information.

• According to the Centers of Disease Control, prevention of the flu starts with vaccination for anyone 6 months and older at the start of each flu season in October.

• With any suspicion of the flu, prevent the spread to others by washing hands after touching the face nose or eyes and use hand sanitizer when hand washing is not available. Cough should be contained into a tissue or into the sleeve at the elbow since influenza may be transmitted by air droplet exposure. Do not share utensils and drinking cups. A surgical mask or any simple mask which covers the mouth and nose will help prevent exposure to others. Spreading the flu virus to others is of greatest concern in patients younger than age 2 or over 65 years old, patients in a nursing home, pregnancy, or those with chronic diseases of the lungs, heart, kidneys, cancer patients (especially those on chemotherapy), and patients with diabetes. Within 24 hours of onset of symptoms, the physician may prescribe anti-viral medication which may reduce the duration of the illness but in mild cases it is not needed. (49)

• In 8-11 year olds, Cook and colleagues reported that forced expiratory volume in 1 second (FEV1), a measure of lung function, was positively linked with the frequency of fresh fruits, green vegetables, and salad consumption but was not associated with blood vitamin C levels. Compared to children who ate fresh fruit more than once a day, those who did not had a 79 ml or 4.3% lower FEV1 value. (52)

• In children aged 6–7 yrs, those who ate at least 5 serving of fruit rich in vitamin C per week were less likely to have respiratory-related health problems including wheezing, shortness of breath, or night coughing compared with those who never ate fruit. Those eating 5-7 servings of citrus and kiwifruit per week had 44% less risk of wheezing compared to children eating the least (less than once a week). Shortness of breath, wheeze, nocturnal cough, chronic cough, and runny nose were all significantly reduced. (53)

• Andrographis paniculata (AP) administered as two tablets three times daily for 10 days (30 mg of andrographolide and deoxyandro-grapholide per day) or Echinacea, 10 drops three times daily for 10 days each showed improvement in upper respiratory tract infection symptoms by days 2−3 but faster improvement was seen in the AP group with few side effects (55). See the section on Andrographis paniculata for further information.

• Young athletes and sudden cardiac arrest:

• Mayo Clinic published the concerns of sudden cardiac arrest in athletes (56): A young athlete with symptoms such as lightheadedness, passing out, fainting, chest pain, shortness of breath without known cause, and seizures, especially during physical activity should be further investigated for risk of sudden cardiac arrest prior to participating in sports. Factors such as family history of young cardiac related death under 50 years old should also warrant further evaluation.

• According to The American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee (ACC/AHA/ESC), concerning symptoms should warrant testing with an electrocardiogram (EKG) and echocardiogram plus extensive comprehensive guidelines on this topic which may be reviewed at http://eurheartj.oxfordjournals.org/content/27/17/2099.long (59).

• According to a study in Italy by Corrado D et al, the rate of mortality due to sudden cardiac death was reduced in athletes by 90% after screening all with pre-participation history and physicals plus electrocardiogram (EKG) then additional testing based on positive findings (57).

• Probiotics and atopic dermatitis: Researchers found that probiotic use during pregnancy or by the child resulted in an approximately 20% reduction in the rate of atopic dermatitis (RR = 0.79) which according to the authors, suggested that probiotics have a moderate role in the prevention of atopic dermatitis (60). See the section on atopic dermatitis for further information.

• Children, adolescents and exercise: The ideal duration for fitness benefit of school-age children should be participation in 60 minutes or more of moderate to vigorous physical activity per day (63). Both aerobic and resistance training by children and adolescents under supervision is believed to be safe. Young athletes may increase muscular strength through resistance training safely with supervision (61) which may result in improved performance. A meta-analysis showed that physical activity improved cognitive ability of children significantly in their perceptual skills, intelligence quotient, achievement, verbal tests, mathematic tests, developmental level and academic readiness (62).