Child Health ALERT

Volume 16 A Survey of Current Developments Affecting Child Health Care January 1998

Milk Really Does Build Strong Bones!

One of the major health problems in the elderly, and particularly among elderly women, is serious bone fractures resulting from skeletons that have too little mineral content. Since 90 to 95% of a person I s bone mass is formed by age 20. and since half of this amount is formed during adolescence, many health experts have begun to focus attention on ways to increase bone mass in adolescence, since this will very likely offer protection against serious fractures many decades later.

In Britain, as in the U.S., teenage girls consume well below the recommended amounts of calcium. Furthermore, the amount of milk consumed per person has been declining steadily since the 1970s. With this background, researchers from Sheffield, UK, studied whether milk supplementation could make a difference in the amount and strength of bone that children develop.

The authors studied 82 girls, with an average age of 12 years; on a random basis, half were instructed to continue their usual diet and the other half were instructed to drink more than a pint of whole or reduced fat milk per day. When they began the study, both groups of girls had been drinking an average of 5 ounces of milk daily, and during the study the girls in the "extra milk" group did drink, on average, another 10 ounces daily.

After 18 months, the girls drinking, extra milk had a significant increase in two different measures of their bone mass, without any differences in their height, weight, or other measures of growth.

The authors point out that most other studies have focused only on calcium, not milk. "Since milk contains other nutrients essential for bone growth, our results may be due, at least in part, to nutrients other than calcium. Milk supplementation resulted in significantly higher intakes of protein, calcium, phosphorus, magnesium, zinc, and range of other micronutrients. In public health terms, such a 'multi-nutrient' approach max not be without merit." They conclude that drinking more milk in adolescence could make a significant contribution to reducing bone fractures in older adults. (Cadogan J et al: British Medical Journal, November 15, 1997, pp. 1255-1260)

COMMENT: This simple study reinforces the importance of efforts designed to increase the amount of milk consumed by children, and particularly girls. Another intervention that is worth considering is exercise, since the combination of milk and exercise may further strengthen growing bones. Getting children to drink more milk and to get more exercise may sound awfully old-fashioned, but there's increasing evidence that it makes sense! 71

MEDICATION

Hyperactivity: Symptoms vs. Medication Side Effects

Even though there are many medications for the treatment of attention deficit hyperactivity disorder (ADHD--often called "hyperactivity"), stimulants remain the most effective. Though side effects tend not to be very serious, most treated children do experience them, and they are often the reason for stopping treatment. The most common side effects include difficulty sleeping, decreased appetite, stomachaches, and headaches; less commonly reported ones include dizziness, irritability, anxiousness, and proneness to crying.

Surprisingly, there have been very few studies that have directly compared the two most common stimulant medications, methylphenidate (Ritalin and other brands) and dexamphetamine (Dexedrine and other brands). While Dexedrine is less expensive and slightly longer acting, many believe that Ritalin is more effective and causes fewer side effects.

Researchers from Victoria, Australia, randomly assigned 125 children with ADHD to be treated with either Dexedrine or Ritalin, given twice a day for two weeks; then children received the other drug, for a second two week trial. Side effects were monitored by parents who used a standardized rating scale before treatment and at the end of each two week trial.

For Ritalin, parents reported more side effects (and more serious side effects) before treatment than during treatment; the same pattern was observed for Dexedrine, though to a lesser degree. When effects during treatment with either drug were compared, there was no significant difference in the number of Symptoms, but the ones that occurred while on Dexedrine were somewhat more serious than those on Ritalin (these included sleep difficulties, irritability, proneness to crying, anxiousness, sadness/ unhappiness, and nightmares). Whether they were treated with Ritalin or Dexedrine, less than 2% of children stopped their medication because of side effects.

The authors conclude that many symptoms that are commonly blamed on stimulant medication are actually characteristics of children with ADHD that existed before treatment and that improve with stimulant medication. They are careful to note, however, that only moderate doses were used only twice daily, and that subjects were all at least 5 years old, so the results may not apply to different treatments and younger children. (Efron D et al: Pediatrics, October, 1997, pp. 662-666)

COMMENT: Since so many children are treated for hyperactivity/ attention disorders with one of these two medications, it is surprising that there are so few studies that compare the two, head-to-head. So this report provides very useful information. Readers should bear in mind that, like most studies, these results may not apply to every child, since not every child will react (favorably or unfavorably) to these medications the way the majority of children in this study did.

However, we think this research offers a message that has importance not just for children treated with these medications, but for children who receive medication of any kind. The authors found that symptoms blamed on the medications were actually more common before the children were treated than during their treatment with either drug. In other words, many problems that are called "side effects" of medication are actually problems that are part and parcel of ADHD itself.

This sort of thing can happen quite often in a wide variety of other situations. For example, if a child is tired while on antibiotics, we might think that the tiredness is due to the medication, without considering that the infection that prompted use of antibiotics is actually causing the fatigue. So when we wonder whether a medication is causing a particular "side effect", it's important to consider whether these symptoms might actually be due to the illness being treated.

CHILD SAFETY

Seizures In Infants Due To Commercial Bottled Water

Parents who live in poverty may sometimes dilute their baby's infant formula with water to make it "go farther", and sometimes they will substitute water for formula. Unfortunately, too much water can change the baby's electrolyte (mineral) balance, and result in seizures. Young infants with vomiting and diarrhea-are especially likely to develop this problem if the fluids they are given don't contain the appropriate amounts of salt. In a three-month period in 1993. two 8-week old infants were seen at one hospital in Milwaukee with seizures resulting from supplemental feedings with bottled drinking water. In one case, the mother reported that the label on the bottle indicated that the product was especially made for infants.

The authors reviewed their hospital's experience over the past 10 years and found 25 other cases of seizures from low sodium -- not from bottled water but from tap water, tea, soda, Kool-Aid, or diluted formula. The two cases involving bottled water led the U.S. Food and Drug Administration to recommend that labels on infant drinking water products remind consumers that the product is not to be used as an electrolyte solution; however, the warning print tends to be quite small and some stores continue to stock bottled water products for infants next to oral electrolyte solutions. The authors urge that parents be educated about the hazards of feeding young infants excessive amounts of bottled water or any other liquids that aren't appropriate for young infants. (Bruce RC & Kliegman RM. Pediatrics, December, 1997; 100:e4 [electronic edition])

COMMENT: This problem first came to light three years ago (see CHILD HEALTH ALERT, October, 1994), when it was described in a weekly health bulletin. Now that a more detailed report has been published, we thought the issue was important enough to be worth revisiting.

We haven't heard further reports of this problem, but the authors present good reason to worry about it. We are particularly sympathetic to the mother of one infant, who figured that if a bottled water product is made for infants, it should be safe for them! Getting the word out is an important thing to do, especially in communities where the cost of formula or liquids to treat diarrhea (called oral rehydration solutions) might lead parents to consider using "infant" bottled water instead.

INFECTIONS/ILLNESS

Sugar For Infant Colic?

Any parent of a young infant who has had to deal with colic knows how frustrating this condition can be. Though it usually lasts only a few weeks, no one has yet found a cause or a single treatment approach that works. In recent years, many studies have found that small amounts of sugar water can relieve pain from certain procedures in the newborn period, such as circumcision or obtaining blood from the heel. With this in mind, a pediatrician in Norway wondered whether sugar might also work in colic.

Nineteen infants with colic were given about one-half teaspoon of a sugar solution or the same amount of water by oral syringe; the treatment was given any time the infant would cry inconsolably. Every 3-4 days the parents would visit the doctor, at which time the other bottle was given to the parents to use in the same way. Results were reported on each visit by the parents, who used a five-point scale ranging from "getting worse" to "complete stop of crying after each dose".

Colic in the study babies had lasted an average of 5 weeks and they were reported to cry an average of almost 6 hours daily. Prior to the study, all parents had tried one or more approaches to managing their baby's colic.

Of the 19 babies, 12 had consistent benefits on sugar but then got worse when they were given the placebo, 5 infants improved during treatment with the first solution (whatever it was) and didn't get worse on the second, so it was not possible to determine whether the treatment worked or the colic simply ended. Only one infant did not improve, and one responded specifically to placebo (with an effect described as "mild").

In discussing the findings, the author is careful to point out that some children may have gotten better simply because of the extra care and attention they were being given as part of the study. Even when children seemed to respond specifically to the sugar, it's hard to know how much of that benefit might be due to the calming effect that came from being in this study. (Markestad T. Archives of Disease of Childhood, 1997, pp :356-358)

COMMENT: This small study doesn't prove that a simple sugar solution is the answer to colic, but it does suggest that sugar might make a difference in some infants. Certainly this is something that should be studied further. Whether it might be worth trying in certain infants may be worth discussing with the baby's health care provider.

ENVIRONMENT

Some Good News On Pesticide Risks From Produce

Trace amounts of pesticides on fruits and vegetables pose practically no risk of cancer to people, a panel of experts has concluded. In fact, the risk was so small it would be riskier to stop eating produce. As one expert put it, "A diverse diet that has plenty of fruits and vegetables is very important in reducing cancer. Compared to that, the risk of cancer from man-made chemicals is negligible. "

Since 1994, when the panel was formed, it has reviewed at least 50 studies on pesticides to determine whether there was any cause for alarm. Their conclusions, published in the journal Cancer, found that for the average person, there is nothing to fear. (New York TimeslAssociated Press, November 16, 1997)

COMMENT: The public has become alarmed about the risks of pesticides for a number of reasons, some supported by good scientific evidence and others not. We do know that pesticides in very large and frequent doses can be toxic, and can cause various neurologic and other problems. We also know that older pesticides, such as DDT, could hang around in the environment and cause a host of problems, such as damaging the eggs of wildlife.

These proven hazards of pesticides increased many peoples' worries, and some began to think that because these synthetic chemicals weren't "natural", they probably were unsafe in many ways. However, this latest report finds that these fears are simply not supported by the evidence. No one is suggesting that we relax regulations that limit the amounts of pesticides in our food supply. On the other hand, we agree that the health of children and adults will be improved by eating more fruits and vegetables, and that this benefit will far outweigh any effects from the very small amounts of pesticides that might be present in produce.

There's another point to consider. While the threat of cancer from pesticides seems to be extremely small or nonexistent, "natural" products can produce real health problems, and these problems appear to be on the increase. For example, in just the last few years we've learned that "natural" herbal products can contain powerful and even fatal st1mulants. that raw (unpasteurized) apple drinks can cause infection from toxic E. coli bacteria, and that berries from South and Central America can contain "natural" parasites (such as C.vclospora) that can cause serious intestinal illness.

The message in all this is that the best way to protect ourselves and our children from food contaminants isn't to take an absolute stand that "natural is good" and "synthetic is bad". Our best hope is to be guided by the available scientific evidence, and in the case of pesticides in foods as a cause of cancer, the news is very reassuring.

RESOURCES

Deciding When To Keep Kids Home From School Or Child-Care

Teachers, child-care providers, and parents all struggle with the difficult question of when an "ill" child should be kept home from school or child-care. A new pamphlet, "Attendance At School: Should my child be in school with this illness?", may offer some very useful guidance to solving this problem. It lists the various symptoms that may make it difficult to decide whether to keep a child home: stomachache/vomiting/diarrhea, pain (such as earache, toothache, headache), cold/sore throat/cough, red eyes, fever, and rash. For each of these, the pamphlet provides a brief description of what to do and when the child may go to school.

We think this guide will be helpful to anyone who cares for children. Published by the Massachusetts Medical Society Alliance, the pamphlets are available for free (up to 5 copies) and may be photocopied for distribution. To obtain 1-5 copies and an order form, write Jennifer Day at the Massachusetts Medical Society Alliance, 1440 Main Street, Waltham, MA 02154-1649.

PRODUCT RECALLS

Recalls: Clock Tambourine Toys...

STK International, Inc., is recalling over 20,000 Clock Tambourine toys because small pieces could break off, presenting potential choking hazards to young children. The toy is shaped like a footed clock face with a handle. The numbers and hands on the clock are multicolored, and a blue sticker in the center of the clock displays the sun, moon, clouds, musical notes, and stars. The toy contains metal noisemakers, visible through slots on the back; it is made in China, but the model number (TC-186) is not on the toy or the packaging. It was sold at discount and dollar-type stores nationwide from June 1995 through June 1997 for about $ 1. Consumers should return the toys to STK International, Inc., 2602 E. 37th St., Vernon, CA 90058 for a refund and postage reimbursement; for more information, call the company at (800) 536-7855 between 10 AM and 4 PM EST Monday through Friday.

... Halloween Bounce Balls...

Novi Kids Inc. is recalling about 40,000 packages of Halloween Bounce Balls because the packaging suggests that the balls are "Great for favors and trick or treats!"; if they are used as Halloween treats, the balls could be given to children under 3, and they could pose a choking hazard. The Bounce Balls are collections of 8 multicolored rubber balls one inch in diameter, packed in a clear plastic tray with a cardboard backing. They were sold only at Target Stores, nationwide, beginning October 4 of this year, for about $2. Consumers should return the balls to the Target store where purchased for a refund. For more information, call Novi Kids Inc. collect at (619) 282-6692 between 9 AM and 4 PM PST Monday through Friday, or write them at 10222 San Diego Mission Road, San Diego, CA 92108

... And "Hot Pet Car"

United Tt-adeline Inc. is recalling over 4,000 battery-operated toy cars because small parts could break off, posing a choking hazard. The Hot Pet Car is a red car driven by a yellow dog with orange ears wearing a purple bow and using a cellular phone. The car is about 3.5 inches wide, 5 inches high, and 8 inches long. When turned on, the wheels turn crookedly and the car plays music and sound effects.

The car has decals reading "YAHOO!" and "NO. I". Made in China, the toy is packaged in a green box labeled " Hot Pet Car" and "I.C. Sound"; the model number, HK-736, is also written on the sides of the box. It was sold by small retail and toy stores, primarily in the Los Angeles area, from April through May, 1997, for about $3. For a refund, consumers should call United Tradeline Inc. toll free at (888) 898-9296 between 9 AM and 6 PM PST Monday through Friday or write the company at 11800 E. Clark St., Arcadia, CA 91006.