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Spring 2006
Complementary Medicine Children Can these therapies help children? I by Jennifer Cohen, M.D., pediatric hospitalist, and Laura Miyashita
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ith today’s fast-paced world, many adults use meditation to find peace. But ALL AGES what about children? Can therapies such as meditation, hypnosis or acupuncture benefit them? “Most complementary therapies for adults can be appropriate for children, depending on the circumstance,”says Jennifer Cohen, M.D., pediatric hospitalist at California Pacific Medical Center. According to Dr. Cohen, therapies such as hypnosis, acupuncture and massage therapy are successfully used in children for pain and stress management, and can complement Western medicine. She adds,“Increasingly, there are practitioners in the community who are willing to provide these services to children.” In general, therapies such as acupuncture, biofeedback, dietary supplements, meditation and hypnosis are classified as “complementary and alternative medicine,”or CAM. The National Institutes of Health defines CAM as “a group of diverse medical and health care systems, practices and products that are not presently considered part of conventional medicine.” While these therapies may not fall under conventional medicine, some have become mainstream enough to qualify for insurance coverage. Finding a CAM practitioner Many parents would like to pursue CAM for their children or themselves, but are unsure where to start. Because there are many practitioners and online resources available, it’s hard to know what information is reliable. The first step is to ask your doctor what he or she knows
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INSIDE: 2 Welcome to HealthyKids! 3 Treating a child’s headache 4 Keeping temper tantrums under control 5 Ear infections in children 6 Bird flu: What you need to know 7 Breastfeeding guidelines for vegetarians
Welcome to HealthyKids Bringing you helpful news from California Pacific Medical Center I by David Tejeda, M.D., chair, Department of Pediatrics, and Oded Herbsman, M.D., medical director, Pediatric Inpatient Services elcome to our inaugural issue of HealthyKids! The Women & Children’s Center at California Pacific Medical Center is sending you this quarterly publication to help get your child off to a healthy start.
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Our pediatricians receive numerous inquiries about children’s health, so we hope this newsletter will help answer your questions. If there are specific questions or topics you’d like addressed in future issues, please tell our editorial team (contact information is on the last page). We plan to include a Q&A column in future issues, so we want your questions about children’s health!
As you may know, California Pacific has been caring for children for more than a century. Our physicians and nurses provide family-centered care for a wide range of pediatric conditions, including asthma, autism, congenital heart defects, diabetes and cancer. We also have a comprehensive Pediatric Unit should your child have an emergency or need to be hospitalized. And we’re proud of our outstanding pediatric patient satisfaction scores (among the top 1 percent nationwide). For more information, visit www.cpmc.org/pediatrics. We hope this finds your family healthy and enjoying the New Year! #
David Tejeda, M.D.
Oded Herbsman, M.D.
Complementary Medicine continued from page 1 about the therapies you’re considering and where to find a reliable practitioner. Additionally, you can contact the professional organizations for the therapy that interests you. These organizations can be found online at http://dirline.nlm.nih.gov by simply typing the name of the therapy into the search field. If you take your child to an alternative medicine provider, be sure to
Complementary therapies like meditation and hypnosis may benefit children.
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ask the practitioner about his or her experience in treating children.You should also discuss CAM therapies with your pediatrician to avoid any hazards. You can search individual practitioners’ credentials at the California Department of Consumer Affairs, www.dca.ca.gov/r_r/r_rdca.htm. Lastly, the National Institutes of Health’s Web site offers a guide to finding a practitioner at http://nccam.nih.gov/health/practitioner. In the Bay Area, an excellent resource for CAM is The Institute for Health and Healing (IHH), an affiliate of California Pacific Medical Center. It offers many CAM therapies, including acupuncture, massage, tai chi and hypnosis. The IHH staff suggests making an initial appointment with their clinical nurse specialist, who can help decide what treatments may be appropriate for your situation and direct you to a provider within the Institute. IHH’s physicians have special training in CAM, and the Institute also offers an extensive resource library. The IHH accepts insurance where applicable, but does not turn away patients for inability to pay. #
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To Learn More
For more information about the Institute for Health and Healing, visit www.cpmc.org/ihh or phone 415-600-HEAL.
What Should I Do About My Child’s Headache? An interview with Farhad Sahebkar, M.D., pediatric neurologist arents will often joke about their children giving them headaches, but it’s no joking matter when your child is the one suffering from headaches.
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Potential triggers for headaches can include illness such as a cold or the flu, stress or tension related to school or family problems, or even eating certain foods.
” Farhad Sahebkar, M.D., a pediatric neurologist at California Pacific Medical Center
Headaches can result from a variety of causes, and vary greatly in their severity. Many times, the headache is caused by something simple, such as not getting enough sleep. Sometimes, however, a headache is more than just a passing pain, and it’s important to recognize when your child’s headache requires medical attention. “Headaches are very common among children and teens,” says Farhad Sahebkar, M.D., a pediatric neurologist at California Pacific Medical Center.“Generally, the headache itself isn’t really an illness, but a symptom that something underlying the headache is wrong. Potential triggers for headaches can include illness such as a cold or the flu, stress or tension related to school or family problems, or even eating certain foods — particularly foods with nitrate preservatives or monosodium glutamate (MSG).” What kind of headache is it? Dr. Sahebkar notes that headaches in children usually fall into three categories: tension, migraine and psychogenic. Tension headaches often result from stress or physical strain and cause the muscles around the back of the head or neck to “tense up.” Migraines cause pounding or throbbing pain — often on just one side of the head — as well as other possible symptoms, such as nausea or vomiting, dizziness, visual disturbances, and sensitivity to light or noise. Psychogenic headaches are associated with emotional factors such as anxiety or depression. “Most headaches do not indicate a serious medical problem,” Dr. Sahebkar says. “For the occasional simple headache,
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parents can treat their children at home with analgesics such as acetaminophen or ibuprofen. Aspirin is not recommended because of the danger of developing Reye’s syndrome, a serious illness associated with viral infections.“
When to seek help “You should see your child’s doctor to determine the cause of unexplained or recurring headaches,” Dr. Sahebkar says. “The doctor should evaluate factors such as the family and school environment, for example, when the child’s headaches occur during the week but not during weekends. It’s important for parents to keep track of their children’s headaches and symptoms to help the doctor determine both the cause and the appropriate treatment.”#
Headaches in children usually fall into three categories: tension, migraine and psychogenic.
Serious Headaches Although serious headaches are uncommon, Dr. Sahebkar recommends that parents seek medical attention if their child’s headaches: Are more frequent than once a month. Result from a head injury. Are accompanied by a fever over 100.4 F or by vomiting, neck stiffness, toothache or jaw pain. Produce visual disturbances, such as blurred vision or spots. Are acute in the onset, causing intense pain. Wake the child up in the middle of the night or are present when the child wakes up in the morning, or Are accompanied by seizures, tingling sensations, weakness or dizziness.
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Giving Temper Tantrums a Time-Out An interview with Lalaine Dimagiba, M.D., developmental pediatrician our 3-year-old is in the midst of a nuclear meltdown, screaming, kicking and holding his breath. To make matters worse, it’s the third time today that he’s gone ballistic. What’s a parent to do?
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A rule of thumb is one minute of timeout for each year of age.
“First of all, parents need to recognize that temper tantrums are fairly common among children ages 1 to 4,” says Lalaine Dimagiba, M.D., a developmental pediatrician at California Pacific Medical Center with certification in neurodevelopment disabilities. “Children’s tantrums are generally caused by frustration, anger, fatigue or simply the desire to be in control and show their independence. Even the most good-natured child can have an occasional temper tantrum.” Typically, 50 to 80 percent of children ages 2 to 3 have tantrums weekly, while 20 percent have at least daily tantrums. Dr. Dimagiba notes that giving your child a “time-out” can be an effective means of controlling temper tantrums. “Before you administer a time-out, give your child a warning,”she says. “If the tantrum continues, then choose a quiet, safe place to take the child for the timeout — a chair in the corner of a room, for example. Make sure there’s nothing the child can break or throw, and there should be nothing to distract the child, such as toys or a TV. Then gently guide the child to the chair without raising your voice.You need to be calm, but firm.You can stay in the room to watch over the child and make sure he’s safe, but you should not talk to or interact with him until the time-out is over.” Timing a time-out A general rule of thumb for time-outs is one minute for each year of age — and consistency is key to effective time-outs. “Set a kitchen timer,”Dr. Dimagiba suggests.“If the child gets out of the chair before the time is up, gently lead him back and start counting the time all over
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again.You must do that every TODDLERS time in order to be consistent and give your child a clear message as to what behavior you expect.” After the time-out is over, it’s time to promote and reward good behavior. “Wait a few minutes and allow the child to regain self-control,”she explains. “Then watch for good behavior and praise it. Take your child to another room and involve him in a new activity, such as reading a book together. It’s important to assure your child that the time-out was the sole consequence for the misbehavior — don’t keep mentioning the bad behavior.” Keeping a united front Dr. Dimagiba observes that time-outs can be effective for children up to age 10, and that they can be administered for other unacceptable behaviors such as hitting, biting or not asking permission. She cautions, though, that the adults in the home must come to an agreement as to what behaviors warrant a time-out and how long the time-out should last. Once children reach school age, it may be appropriate to send them to their rooms to calm down. Instead of setting a specific time limit, you might tell them they must stay in the room until they have regained self-control. Some children are more prone to tantrums than others, she adds. “If your child is having a temper tantrum more than three times a day, and the tantrums last longer than 15 minutes, you may need to seek professional help to determine if your child has a medical, psychological or developmental problem that is the cause of repeated tantrums,” she says. “It’s also important to note that physical punishment doesn’t help a child to understand the consequences of being out of control. It doesn’t help children learn to control their anger, and it often instills even more rebellion.”#
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Lalaine Dimagiba, M.D.
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Wait a few minutes and allow the child to regain selfcontrol, then watch for good behavior and praise it.
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Ear Infections in Children
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New recommendations for pediatricians and what they mean for you I by Tim Nicholls, M.D., pediatric hospitalist iddle ear infection is the most common reason for a sick visit to the pediatrician. An infection occurs when the body reacts to foreign organisms growing in the space behind the eardrum.
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Although ear infections in the United States commonly are treated with antibiotics alone, recent recommendations from the American Academy of Pediatrics (AAP) give pediatricians new options in treating your child.
Tim Nicholls, M.D.
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Breastfeeding in the first six months of life reduces ear infection risk.
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Antibiotics: Are they necessary? Doctors cannot determine by looking at one’s eardrum whether the infection is caused by a virus (such as influenza or a cold) or by bacteria. Many ear infections are caused by viruses alone. Viral infections clear up on their own and do not require antibiotic treatment. Ear infections caused by bacteria, which can be treated by antibiotics, also often resolve on their own. In reality, most ear infections (whether viral or bacterial) self-resolve without antibiotics. If this is true, do we need to give antibiotics to every child with an ear infection? With too many antibiotics, patients may develop a resistance — a common problem in the Bay Area. If you and your child’s pediatrician decide to watch an ear infection without antibiotics, the pediatrician will make sure antibiotics are available to you in case your child worsens.Your pediatrician will also provide a plan for followup with your child to ensure the infection resolves. He or she may also recommend that you come back if your child becomes lethargic or very sick. Preventing ear infections Before an infection starts, you can reduce the chance that your child will get an ear infection. Breastfeeding in the first six months of life reduces ear infection risk. The pneumococcal vaccine
that is typically given in the first year of life also reduces the chance of ear infections. Similarly, research has shown that, when given to children age 2 and older, the flu vaccine reduces the risk of ear infection by 30 percent. If your child uses a bottle, do not have him or her lie down flat while drinking, as this increases ear infection risk. Smoke exposure also increases the risk of ear infections.You can ask your pediatrician about other ways to prevent ear infections. #
Doctors cannot determine by looking at the eardrum whether the infection is caused by a virus or by bacteria.
AAP Recommendations A new part of the AAP recommendations is to: 1) Provide medications to relieve the symptoms (such as pain and fever) that go with an ear infection; and 2) With the parents’ help, watch the child closely without giving antibiotics. The pediatrician uses your child’s age, medical history, family history, the severity of the infection and your plan for another appointment to determine if your child should be watched without antibiotics.
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Protecting Your Family From Bird Flu What you need to know to reduce risk I Colleen Panina, M.D., and Jennifer Cohen, M.D., pediatric hospitalists ith international attention focusing on the “avian flu,”many parents have been wondering how to protect themselves and their children. The following are some frequently asked questions about flu season and, particularly, the bird flu.
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What is the difference between bird flu and human flu? Avian influenza, or “bird flu,”refers to a group of influenza viruses that primarily affect birds. Avian H5N1 is a strain that has infected humans, most of whom caught it from infected birds. Since this flu has started to infect humans, it can adapt to become contagious from person to person. Once this adaptation occurs, it will no longer be a bird virus — it will be a human influenza virus. This is how a pandemic begins.
While vaccines are a primary weapon in the fight against a deadly flu strain, there is currently no FDA-approved vaccine for the H5N1 virus.
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What is the difference between an epidemic and a pandemic? ALL AGES An example of an epidemic is the annual strain of the human flu that circulates every winter. Each year, the strain is only slightly different, so we all have a little immunity. Because the avian flu is new to humans, we have no pre-existing immunity and are likely to experience more serious disease than that caused by normal influenza. That would result in a flu pandemic, an outbreak caused by a new strain that has either never been seen in humans, or was last seen so long ago that very few people have any immunity.
Is the bird flu expected to surface in the U.S.? While the bird flu has not yet surfaced in the United States, public health officials are concerned about its potential. Specifically, they are concerned about the possibility of a pandemic starting if and when the bird flu becomes able to spread easily among humans. This may happen this flu season, or it may not happen for years or ever. Hopefully, when and if it comes, there will be a vaccine available.
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What is the likelihood of a bird flu vaccine? While vaccines are a primary weapon in the fight against a deadly flu strain, there is currently no Food and Drug Administration-approved vaccine for the H5N1 virus. Like vaccines, antiviral medications such as Tamiflu® (oseltamivir) play a key role in minimizing the severity of illness during a flu pandemic. However, acquiring Tamiflu doses now is premature, as the bird flu has not become widespread in humans, nor has it surfaced in the U.S. If it does become widespread, the virus may not be sensitive to Tamiflu. #
While the bird flu has not yet surfaced in the United States, public health officials are concerned about its potential.
How Do I Avoid the Flu? The best way to keep yourself and your children safe during a pandemic, or any flu season, is to maintain good hygiene through the following steps: Wash hands thoroughly (at least 20 seconds) and regularly, or use an alcohol-based hand gel — especially in public places and before eating. Encourage children to use their arms, not their hands, to cover their mouths when coughing or sneezing. Keep sick children and adults home from school or work whenever possible.
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Breastfeeding as a Vegetarian Guidelines provide best benefits for baby I An interview with Trudy Theiss, M.S., R.D., CDE, registered dietitian vegetarian diet that includes the proper balance of nutrients can provide a variety of health benefits, including reduced rates of obesity, heart disease, high blood pressure and diabetes.
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“ The percentage of protein and fat in breast milk does not change with a vegetarian diet.
” Trudy Theiss, M.S., R.D., CDE, Registered Dietitian at California Pacific Medical Center
Some people may worry, however, that a vegetarian diet cannot provide enough nutrients for a breastfeeding mom and her child.Yet according to California Pacific Medical Center Registered Dietitian Trudy Theiss, M.S., R.D., C.D.E., a vegetarian can easily breastfeed and supply herself and her baby with the nutrition they both need. “The fact that a woman is a vegetarian is no reason to avoid breastfeeding,”says Theiss. “Breastfed infants with vegetarian mothers can be very well-nourished, as long as the mothers eat well.” The benefits of breastfeeding are well-documented, Theiss notes. For the infant, they include: reduced incidence of certain infections, reduced incidence of diabetes, food allergies and obesity, improved bio-availability and digestibility of nutrients, and establishment of a mother-baby bond. Common-sense guidelines Theiss recommends that all breastfeeding moms follow some basic, common-sense guidelines, such as consuming adequate calories (generally 500 calories above their normal intake), maintaining adequate calcium and vitamin D intake, and ensuring that they get enough protein. It is also a good idea for mothers to discuss diet with their obstetrician and pediatrician. Vegan mothers, by definition, consume no animal products.Vegans can obtain adequate protein from a variety of plantbased foods such as legumes (especially soybeans, soybean milk, tofu and soyderived meat substitutes), nuts, grains and vegetables. “A basic concern with the vegan — as opposed to an ovo-lacto vegetarian diet that includes milk and eggs — is that
vegans need a reliable source of vitamin B12. As B12 usually comes from animal products, vegan mothers must get this essential nutrient from fortified cereals and some brands of soy milk, as well as from vitamin supplements,”says Theiss. “The percentage of protein and fat in breast milk does not change with a vegetarian diet, but the fat composition of breast milk can be affected by the type of fats the mother consumes,”she says. It’s important to make sure the mother gets enough essential fatty acids, specifically linolenic acid, from sources such as canola, soybean and flaxseed oils, and walnuts. In the body, linolenic is converted to DHA, which appears to improve baby’s neuronal function and visual acuity. Since DHA levels can be lower in the breast milk of vegetarian moms, it is important that they consume adequate levels of its precursor, linolenic acid. Nutritional counseling Theiss encourages all pregnant women and breastfeeding moms — vegetarian or not — to seek nutritional counseling with a registered dietitian in order to ensure their health and that of their babies. “It’s always good to get individualized, professional guidance,” she says, “as there is often confusion about what is recommended.” Many breastfeeding moms take advantage of the nutritional consultations offered by California Pacific’s Community Health Resource Center (www.cpmc.org/chrc). Additionally, Newborn Connections has two certified lactation consultants on staff who are registered dietitians.You can reach them at 415-600-BABY. #
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Vegan mothers may get vitamin B12 from fortified cereals and some brands of soy milk, as well as from vitamin supplements.
To Learn More
For more information regarding vegetarian nutrition, Theiss suggests the Web site of the American Dietetic Association, www.eatright.org, for information and links to local dietitians in the association’s Vegetarian Practice Group.
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Teaching the Next Generation of Healers eaching future doctors how to provide childfriendly and family-centered care is as much an art as it is a science. While few in number, children’s hospitals train almost one-third of our nation’s pediatricians and half of all pediatric specialists, such as neurologists or cardiologists.
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If you have children, they’ve probably been cared for by a pediatrician or a family practice physician who trained at a children’s hospital at some point in her career. Because children’s hospitals often take care of children with very serious and complex conditions, such as cancer, cystic fibrosis or heart transplants, they must provide the most technologically advanced care available. Doctors in training at children’s hospitals get specialized education and unique experience that no other hospital can provide. But teaching great physicians takes time and money. While Medicare pays for training physicians in adult hospitals,
NACHRI National Association of Children’s Hospitals and Related Institutions www.childrenshospitals.net
children’s hospitals don’t qualify for this funding because they don’t treat adult patients. That’s why, in 1999, the National Association of Children’s Hospitals (NACH) successfully lobbied Congress to create the Children’s Hospitals Graduate Medical Education payment program. This program provides federal funding to nearly 60 children’s hospitals that train physicians and ensures children’s hospitals can continue to provide quality care while they train the next generation of healers. However, NACH and children’s hospitals must appeal to Congress for this funding each year. Ask your children’s hospital how you can help make sure children’s hospitals get the money they need to train the doctors that care for children. Children’s hospitals also train nurses, occupational therapists, social workers, dentists and other health professionals. By receiving professional training in a children’s hospital, our nation’s future health care professionals gain an appreciation of the specialized needs of children and develop the skills and compassion needed to care for families. #
To Learn More
To learn more about the importance of graduate medical education to children’s health and children’s hospitals, visit www.childrenshospitals.net.
www.cpmc.org Articles in this newsletter are written by professional journalists or physicians who strive to present reliable, up-to-date information. But no publication can replace the care and advice of medical professionals, and readers are cautioned to seek such help for personal problems. ©2006 Health Ink Communications, 780 Township Line Road, Yardley, PA 19067, 267-685-2800. Some images in this publication may be provided by ©2006 PhotoDisc, Inc. All models used for illustrative purposes only. Some illustrations in this publication may be provided by ©2006 The Staywell Company; all rights reserved. (106)
For Q&A contributions or to opt out of this mailing, please contact Laura Miyashita at miyashl@sutterhealth.org or 415-600-2986. Editorial Team Jennifer Cohen, M.D. Oded Herbsman, M.D. Laura Miyashita David Tejeda, M.D. Contributing Writer Susie Caragol
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