Winter 2012        Newsletter
WELCOME to our eleventh issue of the Pediatric Specialists newsletter.
Early Morning Urgent Care Clinic continues!
Our walk-in hours from 8-9 AM Monday through Friday in the Foxboro office have been a great addition to our practice.   As always, parents can book a same day sick appointment by calling during business hours. We will continue the walk-in hours through Memorial Day with the exception of holiday breaks on 12/26, 1/2, 1/16, 2/20, 4/16.
Flu Vaccine Time
We are continuing to give flu vaccines and have both injectable vaccine and FluMist available.  Please call the office for an appointment if you have not yet received flu vaccine!
Winter Health:
Water is best!
From chocolate milk to juice to soda to sports drinks, the number of sweetened beverages marketed to children is a growing challenge for parents.
With our national focus on obesity, the topic of what drinks are appropriate for kids has become more relevant.  The marketing of sugared drinks to children is pervasive with soda, juices, juice drinks, sweetened iced teas, flavored milks, sports drinks and energy drinks found in every store frequented by kids, every type of media that impacts them, and often even in school.  This has been a popular subject in both the national media and scientific publications.  In May 2011, the American Academy of Pediatrics released a clinical report entitled “Sports Drinks and Energy Drinks for Children and Adolescents: Are They Appropriate?”
First, the topic of sports and energy drinks.  “Sport” drinks (such as Gatorade, Powerade, All Sport Body Quencher, and Accelerade) are flavored beverages that contain carbohydrates (sugar), minerals, electrolytes, and sometimes vitamins or other nutrients.  “Energy” drinks (such as Red Bull, Monster Energy, Power Trip, Rockstar, Full Throttle, or Java Monster) usually contain caffeine or another stimulant with varying amounts of carbohydrate, protein, amino acids, vitamins, sodium, and other minerals.  The American Academy of Pediatrics report states that “energy drinks have no place in the diets of children or adolescents” For the child or adolescent participating in routine physical activity or sports practice, water remains the best source of hydration.  The AAP report states that “water is generally the appropriate first choice for hydration before, during, and after most exercise regimens.  Children should have free access to water, particularly during school hours”   A carbohydrate containing sports drink is only recommended for youth who “exercise with prolonged vigorous activity. . . which results in a need to supply an ongoing carbohydrate energy substrate to avert fatigue and maintain performance.”  Energy drinks should not be used in place of sports drinks in this situation as they “can result in ingestion of potentially large amounts of caffeine or other stimulant substance” which can cause serious adverse effects.
Juice has also been a hot topic in the media recently.  Juice has been marketed as a healthy alternative but product labeling is confusing.  Even a product labeled “100% juice” can often have added sugar.  When the ingredients are examined, the list may include apple, white grape and/or pear juice concentrate.  These concentrates can be juices stripped of flavor, color, vitamins, and minerals, leaving only sugar and water.  For a child unwilling to eat fruits and vegetables, small quantities of real fruit juice are permissible, but no more than 6 oz per day.
Chocolate milk is another culprit.  The sugar content of some chocolate milk can be similar to that of soda (Hood’s low fat chocolate milk contains 26 grams of sugar per 8 oz serving.  Coke has 27 grams of sugar per 8 oz serving).
Dr. Marion Nestle, a renowned professor of nutrition, states that an occasional soda or chocolate milk is OK as a treat; juice is fine in small amounts and parents can always cut it with seltzer to stretch it out and dilute the sugar.  But, in terms of sugary drinks, says Nestle, “It helps to start thinking about these things as candy.  If you think of them that way, it’s not something you want to give your kids all day.”

Safety:
Medication Safety
A recent study in The Journal of Pediatrics found that despite childproof caps and safety warnings, the number of accidental drug poisonings among young children increased 22% from 2001 to 2008.
In 95% of cases the poisoning occurred because the child accidentally ingested the drug, as opposed to a labeling or dosing error by the parent or health care worker.  Most serious injuries were due to prescription drugs, with the biggest culprits being opioids for pain relief (like oxycodone and codeine); sedatives (like sleeping pills); and prescription heart drugs.  The authors of the study suggested that manufacturers could improve safety by designing packaging which would make it more difficult for a young child to ingest large quantities, for example pill bottles designed to release only one tablet at a time.
There are some steps that parents can take to keep their children safe:

• All medications both prescription and over the counter should be kept in a locked cabinet or medication box with a childproof latch.  This should be enforced both at home and in other homes frequented by  young children (e.g. grandparents’ house)
• Parents should have the Poison Control phone number posted on their refrigerator or in another conspicuous place where it is easily available to parents and sitters. 
• Acetaminophen can be a very dangerous ingestion if taken in large quantities and it’s sugary flavor makes it attractive to young children.  It should certainly be stored out of the reach of young children. 

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NUTRITION
Slow cooker
I’m always happy to take out my slow cooker in the cold weather.  There are so many healthy recipes that are great for cold winter nights.

Brown Rice Risotto
This is a great slow cooker recipe which is simple to make and can be endlessly adapted to use either as a side dish or main course.

2 tsp olive oil
1 cup chopped onion
1 cup uncooked brown rice
3.5 cup low sodium chicken or vegetable broth
¼ cup grated Parmesan or other cheese

Lightly coat the liner of the slow cooker with cooking spray.  Add all ingredients except cheese and stir to blend.  Cover and cook 3 hours on high or 6-8 hours on low, until all liquid is absorbed.  Stir in Parmesan cheese and serve hot. 

There are endless variations.  Some suggestions:
Add in chopped fresh spinach, roasted fresh tomatoes, or uncooked shrimp during last half hour of cooking.
Leftover risotto can be shaped in patties and sautéed for a quick side dish.

Bean and Barley Soup
1 cup dried multibean mix
6 cups water
1 (14oz) can of petite diced tomatoes
3 cloves garlic, smashed
2 ribs celery, chopped
2 medium carrots, chopped
½ medium onion, chopped
½ cup pearl barley
1 bay leaf
1 Tbsp kosher salt
1 tsp oregano
1 tsp basil
½ oz dried porcini mushrooms
3 cups cleaned baby spinach (about      3 oz)
1 cup grated Parmesan
1 Tbsp balsamic vinegar
Extra virgin olive oil
Put beans, water, tomatoes and their juices, garlic, celery, carrots, onion, barley, bay leaf, salt, herbs, and  mushrooms in a slow cooker; cover and cook on LOW until beans are tender and soup is thick, about 8 hours.
Stir in the spinach, cheese, and vinegar, cover and cook 5 more minutes to wilt spinach.  Add salt and pepper to taste.
Ladle into bowls and drizzle each serving with olive oil.

Ask the Doctor

Question: My 10 year old wants to start a weight lifting program.  Is this safe?
Answer:  Most medical experts feel that it is safe to include strength training into a child’s overall sports training as early as 7-8 years old, however this does not mean that the sport of competitive weight lifting is appropriate for the skeletally immature child.
Strength training, also referred to as resistance training, refers to the use of gradually increasing forces exerted on the body to improve the strength of the musculoskeletal system.  The American Academy of Pediatrics released a statement in 2008 which included the following recommendations:

• Children and adolescents should be medically cleared before beginning a strength-training program. 
• Aerobic conditioning should be combined with strength training for general health benefit.
• Strength-training programs should include a 10–15 minute warm up and cool down.
• Exercise should be initially learned with no load.  Once the exercise has been mastered, young athletes should start with low weights (1-3lbs) and perform exercises in 2-3 sets of 8-15 repetitions, 2-3 times/wk.  Once a certain amount of weight has been mastered, the resistance could be increased by a minimal amount (eg 10%).
• Any sign of injury from strength training should be evaluated fully before resuming the program.

Question:  My child would like to participate in youth boxing.  Is this ok?
Answer: No! New data, especially regarding pediatric concussions, reinforces opposition by the American and Canadian Pediatric Societies to children and adolescents participating in boxing.  US data shows that youth ages 5-14 years old suffered more than 1200 boxing injuries in 2007, while 15-24 year olds sustained more than 8,000 injuries.  Nearly half of all injuries occur during training.
Dr. Laura Purcell, co-author of the statement on boxing states “Boxing organizations have a vested interest in promoting boxing and feel that it teaches children discipline and allows them to have some success.  However, the literature shows that there is a significant risk of neurological injury including deaths from severe brain injuries.”
Question: The Tylenol packaging has changed.  What happened?
Answer: To correct confusion about acetaminophen dosing infant drops are no longer being manufactured.  The new form does not contain a dropper.  Liquid acetaminophen (Tylenol) only comes in a single preparation which gives 160mg of acetaminophen per teaspoon.  We have dosage charts available in the office, please ask for one next time you come in.  Acetaminophen continues to be available in chewable and meltaway tablets as well. 
We always recommend dosing acetaminophen by weight.  Below are recommended dosages by weight for the Acetaminophen Liquid Elixir
6-11 lbs: 1.25ml (1/4 tsp)
12-17 lbs: 2.5ml (1/2 tsp)
18-23 lbs: 3.75ml (3/4 tsp)
24-35 lbs: 5 ml (1 tsp)

Suggestions:
We always appreciate your help in improving our practice and welcome any feedback you provide.  Please let us know if there is any way we can improve your experience at Pediatric Specialists. 
For the Foxboro office, please send feedback and comments to:
customerservicefoxboro@pediatricspec.com and for the Wrentham office to customerservicewrentham@pediatricspec.com.  

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