Soothing Tender Gums — Pharmaceutical Options

Teething. In some children, it starts as early as a few months of age, and it generally continues on and off through the acquisition of the second deciduous molars around age 2. While some babies and toddlers don’t appear particularly bothered by teething, others exhibit a host of symptoms including irritability, sleeplessness, fever, drooling (with rash around the mouth and in the diaper area as a result of increased secretions), and loss of appetite. While it’s difficult to gauge the level of pain a pre-verbal child is experiencing, most parents have a good sense of when their baby is uncomfortable. The question is whether to treat teething pain with anything more than a frozen washcloth to gnaw on, and some extra love and understanding. This article evaluates pharmaceutical options for teething pain.

Many pediatricians recommend acetaminophen, commonly sold under the brand name Tylenol, for infant and toddler teething discomfort. Acetaminophen is generally safe if given in the appropriate amount (Lesko et al), but is highly toxic and can lead to liver damage and death in the case of an accidental overdose (Heubi et al). While parents may dismiss concerns about acetaminophen overdose — how hard can it be to follow the directions on the package? — there are several confounding factors here. First, acetaminophen for infants and children is sold in the form of a liquid. Until quite recently, there were two suspension strengths: one for infants (80 mg/0.8 mL) and one for children (160 mg/ 5 mL). This resulted in the potential for significant confusion, as well as the potential for overdose. In response to recommendations from an FDA advisory committee meeting (Krenzelok), the infant-strength suspensions have been dropped, which should help minimize confusion. There are additional problems, however. Many cold medications contain acetaminophen in addition to other active ingredients, meaning that giving a child Tylenol for pain and a cold medication for the runny nose often exhibited during teething could lead to inadvertent acetaminophen overdose. This underlines the importance of knowing the active ingredients in all medications given. Even if parents avoid combination medications and watch dosing carefully, however, it’s possible to overdose a child through poor communication; multiple doses delivered in close temporal proximity by two well-meaning parents, or a parent and another caregiver, pose a significant risk. Additionally, while acetaminophen is reasonable and low-risk when used carefully and occasionally, it’s not appropriate for long-term pain-management. Not only does long-term use increase the risk of accidental overdose (purely as a matter of probability), it is also associated with damage to the kidneys (Perneger et al).

Because teething symptoms can go on for weeks at a time, some parents turn to alternate pain-relievers. Teething gels containing benzocaine were popular until recently; rubbed on gums, they provided temporary numbing. There has been some question as to whether numbing of the gums — which almost always leads to at least some degree of tongue-numbing — might affect a breastfeeding baby’s ability to latch properly. There does not appear to be any scientific evidence to support this notion, and while it’s hypothetically plausible, it’s unlikely that an older baby (i.e., one who would be teething) with well-developed breastfeeding habits would experience significant latch issues in response to oral numbing gels. Numb tongues aside, benzocaine-containing gels pose a risk of rare but serious adverse reactions. The FDA warns that benzocaine has the potential to react chemically with hemoglobin, which is the protein in red blood cells that carries oxygen to the tissues. The altered protein produced in the reaction, called methemoglobin, can’t carry oxygen effectively, which can result in chemical suffocation. Analysis of the incidence of adverse reactions to benzocaine and dose required to produce an adverse reaction revealed 132 cases of methemoglobinemia between November 1997 and March 2002. Only 69 of the reported events specified the dose used, but of those, 37 indicated use consistent with package directions (i.e. appropriate dosing) (Moore et al). The FDA recommends that benzocaine-containing gels and sprays not be used on children younger than 2.

Clove oil-based gels are an alternative to benzocaine gels in a few over-the-counter preparations, and appeal to some parents because they are “natural” (though natural doesn’t necessarily mean safe, as evidenced by such natural substances as botulin toxin, which causes botulism, and amanita toxin, found in the death cap mushroom). Clove oil is a common dental analgesic that affects the ability of nerves in the gums to transmit pain signals (Park et al). However, the National Institutes of Health advise against using clove oil in children, on the grounds that it can cause adverse reactions including seizures and liver damage. This recommendation is based upon a few isolated cases of clove oil toxicity (see, for instance, Lane et al, Hartnoll et al). While these cases certainly demonstrate the possible risks of clove oil use, the quantities involved in these single-case studies were massive (many mLs of pure clove oil). There is limited toxicological data available for clove oil; according to Fisher Scientific (a publisher of Material Safety Data Sheets) the LD50 for rats — the dose required to kill 50% of exposed subjects — is somewhere in the range of 1300-2600 mg/kg for oral administration, but how and whether this translates to humans isn’t known. Material Safety Data Sheets from other sources (including Oxford University) indicate that there is no known health risk associated with clove oil. This lack of safety information is actually quite typical of “natural” (i.e., non-engineered) substances, because they’re regulated somewhat differently than pharmaceuticals by the FDA per the Dietary Supplement Health and Education Act of 1994. In short, the FDA does not require manufacturers of dietary supplements to prove safety or efficacy prior to distribution. Still, clove oil has a long history of use as an oral analgesic, and is incorporated into the armamentarium of the mainstream dental practitioner. It’s unlikely that occasional, judicious application will do much harm.

Science Bottom Line:* Occasional acetaminophen, used cautiously and with good communication between caregivers, is not likely to pose a risk. Evidence supports avoiding benzocaine-containing gels. Clove oil-containing gels are likely safe, particularly if they’re produced by a major national pharmaceutical company (since larger companies are more likely to produce standardized products and, in any case, have more to lose in the event of an error, which can motivate care in product production). Smaller brand clove oil gels, however, may be problematic because of the lack of FDA oversight, and carry with them the possibility of inconsistent or inaccurate active ingredient concentration.

 

What do you use to soothe tender gums?

 

References:

FDA Drug Safety Communication (OTC Benzocaine Gels). Accessed 26 Sept 2011.

FDA Dietary Supplements. Accessed 26 Sept 2011.

Fischer Scientific Material Safety Data Sheet – Clove Oil. Accessed 26 Sept 2011.

Hartnoll et al. Near fatal ingestion of oil of cloves. Arch Dis Child. 1993 Sep;69(3):392-3.

Heubi et al. Therapeutic misadventures with acetaminophen: Hepatoxicity after multiple doses in children. J Pediatr. 1998 Jan;132(1):22-7.

Krenzelok. The FDA Acetaminophen Advisory Committee Meeting – what is the future of acetaminophen in the United States? The perspective of a committee member. Clin Toxicol (Phila). 2009 Sep;47(8):784-9.

Lane et al. Clove Oil Ingestion in an Infant. Hum Exp Toxicol. 1991 Jul;10(4):291-4.

Lesko et al. The Safety of Acetaminophen and Ibuprofen Among Children Younger Than Two Years Old. Pediatrics. 1999 Oct;104(4):e39.

Moore et al. Reported Adverse Event Cases of Methemoglobinemia Associated With Benzocaine Products Arch Intern Med. 2004 Jun 14;164(11):1192-6.

National Institutes of Health — Medline Clove. Accessed 26 Sept 2011.

Oxford University Physical and Theoretical Chemistry Laboratory Material Safety Data Sheet – Clove Oil. Accessed 26 Sept 2011.

Park et al. Eugenol Inhibits Sodium Currents in Dental Afferent Neurons. J Dent Res. 2006 Oct;85(10):900-4.

Perneger et al. Risk of Kidney Failure Associated with the Use of Acetaminophen, Aspirin, and Nonsteroidal Antiinflammatory Drugs. N Engl J Med. 1994 Dec 22;331(25):1675-9.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

When Should My Child Transition From Rear-Facing To Forward-Facing In The Car?

Most baby milestones excite parents, while simultaneously making life just a little more complicated. Without a doubt, though, your baby or toddler reaching the weight/height/age to warrant graduating to a forward-­‐facing car seat makes things easier on everyone. A forward-­‐facing child is easier to entertain, possibly less likely to get carsick, has more legroom, and is easier to see from the driver’s seat. A forward-­‐facing car seat takes up less room in the car. Car seat graduation is a definite win in terms of comfort and convenience. However, the American Academy of Pediatrics (AAP) has recently updated their recommendation (previously 1 year and 20 pounds) regarding forward-­‐facing readiness, and now suggests you leave your toddler facing the rear of the vehicle until age 2, or until they reach the maximum height and weight specified by the car seat manufacturer for rear-­ facing use. Because more and more car seats available in the U.S. are now offering greater rear-­‐facing weight limits, however, this statement by the AAP presents some decision-­‐making challenges.

The major dilemma associated with interpreting the AAP’s new guidelines is that some rear-­‐facing car seats, including those available from major national brands, now allow children up to 40 pounds to face backward. While height limits aren’t as clearly defined -­‐-­‐it’s not the total height of the child so much as it is the length of the torso plus the head that determines car seat fit -­‐-­‐ larger rear-­‐facing car seats allow an average-­‐height child to ride safely well past their second birthday. Since the average (50th percentile) two-­‐year-­‐old boy weighs somewhat less than 30 pounds and the average two-­‐year-­‐old girl weighs just a bit less than her male counterpart, according to growth charts from the U.S. Centers for Disease Control and Prevention (CDC), the average two-­‐year-­‐old is still well within manufacturer weight limits for many rear-­‐facing seats. Even the average four-­‐year-­‐old weighs less than 40 pounds, according to those same growth charts, and at around 40 inches in height, the average four-­‐year-­‐old is also likely to fit into one of the newer rear-­‐facing seats. Does the AAP mean to suggest that you should turn your child around when they’re two, or when they outgrow the seat? This is a critical question, as there is clearly the potential for a major discrepancy between those points in time.

The new AAP recommendations are a little vague on which milestone takes precedence, which is probably intentional. The policy update is ostensibly in response to a study published in 2007 (Henary et al). The researchers found that (as expected) infants up to a year of age are considerably safer in a rear-­‐facing car seat than in a forward-­‐facing seat. They determined that the same is true of older babies and toddlers. The effectiveness of a rear-­‐facing car seat (calculated as the percent of cases in which its proper use prevented serious injury in a crash) was 97.2% for infants under a year, while forward-­‐facing car seats were 93.7% effective at preventing serious injury. Among 12-­‐ to 23-­‐month-­‐olds, rear-­‐facing seats were also more effective at preventing injury (86.2%), compared to forward-­‐facing seats (69.3%), though neither seat was as effective in the older age group as it was in the younger. Because the discrepancy between forward-­‐facing and rear-­‐facing effectiveness is greater for 12-­‐ to 23-­‐month-­‐olds, these data suggest that the rear-­facing orientation is actually more important for toddlers than it is for the youngest babies.

While the AAP’s press release suggests that the new recommendations are in response to “new research,” the reality is that many studies have demonstrated the safety of rear-­facing over forward-­facing car seats. In fact, the findings of the Henary study closely mirror those collected from Volvo’s Swedish accident database and reported in 1997 (Isaksson-­‐Hellman et al). Several other analyses of accident databases and collision studies using dummies have found the same (e.g., Sherwood et al, Anund et al, Emam et al).

Accident database analyses and crash-­‐test dummy data don’t just support the use of rear-­‐facing car seats up to 23 months of age, however -­‐-­‐ they actually support the rearward position up to age 4. While we’d all (adults included) be safer in a rear-­‐ facing seat in the event of a crash because the position helps to spread the impact over a larger portion of the body, babies and young children are particularly susceptible to injury in the forward-­‐facing position because of their proportionally large heads. For this very reason, children ride rear-­‐facing until 4 years of age in many European countries.

Parents may worry about the comfort or safety of an older child, given the limited legroom available in a rear-­‐facing seat. While there are no published data comparing leg injuries in rear-­‐facing and forward-­‐facing seats, the forward-­‐facing position doesn’t spare the legs in a crash. Leg injuries are common and can be severe in forward-­‐facing positions (Bennett et al). Further, however, even a severe leg injury is more reparable and less likely to be life threatening than a head or neck injury, and these are far more likely in the forward-­‐facing position. As to the matter of comfort, no studies have yet compared motion sickness rates in rear-­‐ and forward-­‐ facing passengers, but children are generally more comfortable with their legs bent than are adults, due to the greater flexibility of a child. Further, the sheer number of European children riding rear-­‐facing for extended periods (up to 75% of Swedish children ride rear-­‐facing through their 3rd birthday [Anund et al]) suggests that comfort issues -­‐-­‐ if they exist -­‐-­‐ aren’t sufficient to motivate parents to turn their children around prematurely.

There are differences between the U.S. and Europe, of course, the most notable of which is that many sprawling U.S. cities necessitate longer driving times, and the scale of cross-­‐country car travel is much greater. This means that practical considerations -­‐-­‐ including the ability to interact with a child and the reduced cargo space afforded by a rear-­‐facing seat -­‐-­‐ may be of greater significance in the U.S. Then, too, there are the questions that haven’t been (and perhaps can’t be) answered by examining crash databases. These include whether a toddler or young child is less likely to cry if forward-­‐facing, and whether a parent’s driving ability is negatively impacted by a screaming or crying child. Effectiveness of the seat orientation non-­‐withstanding, if turning a toddler to face the front of the car keeps them amused and quiet, that could be an important safety consideration.

In the end, the AAP’s new car seat guidelines seem to be a compromise between what the data support (rear-­‐facing until age 4) and what parents need (forward-­‐ facing as soon as possible). Still, they’re guidelines -­‐-­‐ not laws -­‐-­‐ so parents are free to make the decision that works best given their car, their car seat, and their child.

Science Bottom Line:* Evidence supports leaving a child rear-­‐facing as long as possible (i.e., beyond age 2), within the weight and height limits of the car seat. Evidence further supports purchasing a car seat with the maximum available rear-­‐ facing weight and height limits.
When did you or will you turn your child around in the car?

 

References:

American Academy of Pediatrics Recommendation on Car Seats. Accessed 21 Sept 2011.

Bennett et al. Crash analysis of lower extremity injuries in children restrained in forward-­‐facing car seats during front and rear impacts. J Trauma. 2006 Sep;61(3):592-­‐7.

Anund et al. Child safety in cars-­‐-­‐literature review. (VTI report 489A.) Linköping: Swedish National Road and Transport Research Institute, 2003.

Emam et al. A study of injury parameters for rearward and forward facing 3-­‐year-­‐ old child dummy using numerical simulation. International Journal of Crashworthiness 2005;10:211-­‐22. ExternalResolverBasic [Context Link]

Henary et al. Car safety seats for children: rear facing for best protection. Inj Prev. 2007 Dec;13(6):398-­‐402.

Isaksson-­‐Hellman et al. Trends and effects of child restraint systems based on Volvo’s Swedish accident database. (Report No SAE 973299.) In: Proceedings of Child Occupant Protection 2nd Symposium. Warrendale, PA: Society of Automotive Engineers, 1997:43-­‐54.

Sherwood et al. Frontal sled tests comparing rear and forward facing child restraints with 1-­‐3 year old dummies. Annu Proc Assoc Adv Automot Med 2007;51:169-­‐80.

U.S. Centers for Disease Control and Prevention Clinical Growth Charts. Accessed 21 Sept 2011.

Watson et al. Advise use of rear facing child car seats for children under 4 years old. BMJ. 2009 Jun 11;338:b1994.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

Why Experience Is Not Evidence

I’ve noticed that when I’m conversing with someone who believes something non-scientific (vaccinations are dangerous, for instance, or herbal remedies are safer than pharmaceutical drugs), the rationale they give to support their belief system generally starts along the lines of, “I knew someone who…” While it’s tempting to build our beliefs on the sum of our experience (and the experiences of others), our experiences don’t count as scientific evidence.

Here’s an example to illustrate my point. My experience is that the Earth is flat, and that the sun moves around the Earth. When I look outside, I see a flat horizon. I can watch the sun come up in the morning, move in a half-circle, and then go down at night. Clearly, the sun is circling around a flat planet. These observations of mine aren’t unique; the geocentric universe was so accepted at one time that to claim otherwise was considered heresy. It wasn’t until the 16th century, and Ferdinand Magellan’s circumnavigation of the planet, that the last of the semi-plausible arguments for a flat Earth subsided (though fringe fanatics persist to this day).

Similarly, what my experiences — or yours, or your brother’s, or a friend of a friend’s — teach me about other topics in science may or may not lead me to valid conclusions. Anti-vaccination websites are rife with stories of severe adverse reactions to vaccines; these self-reported events help to fuel the scientifically-unfounded anti-vaccination movement. However, there are logical fallacies associated with accepting anecdotal evidence in scientific decision-making. For instance, the fallacy of post hoc ergo proctor hoc is Latin for “after the fact, therefore because of it.” We fall victim to this logical fallacy when we believe that event B, which followed event A, was caused by event A. Another way to state this is correlation is not causation. If you hear of a case in which a child had his or her 12-month vaccinations (the first ones to include the oft-maligned measles, mumps, and rubella or MMR shot) and then developed autism symptoms, you’d be tempted to ascribe the symptoms to the vaccination. You’d be particularly inclined to do so if the child in question were yours, a relative’s, or the child of a close friend, because you’d be looking for a cause outside genetic predisposition. However, there are very few reliable early indicators of autism, and the disease generally goes undiagnosed until at least a year of age, per the National Institute of Neurological Disorders and Stroke. This means that in almost all cases of autism, the diagnosis will follow administration of the MMR.

Another problem with accepting self-reported experience as evidence is that self-report is a notoriously faulty way to gather information, due to differences in the ways that we each interpret and communicate what we experience and observe. For simplicity’s sake, I’ll stick with anti-vaccination sentiment. Parents who choose not to vaccinate may state that they’ve heard about too many bad vaccine reactions to justify vaccinating. Many of these “bad vaccine reactions,” however, are perfectly normal immune system responses, and pose no harm whatsoever to the vaccinated child. Fevers are normal after vaccination, and occur occasionally after a shot — for instance, they affect about 15% of children after an MMR. To refer to a fever as a “bad” reaction is to misunderstand the way the immune system (and vaccination) works. A vaccination stimulates the immune system to learn to recognize a particular pathogen, so that later exposure triggers immune “memory” cells that can quickly respond to the threat and prevent illness. When your immune system is activated, you’ll often develop a fever; this is your body’s way of helping the immune cells out, as many viruses and bacteria proliferate less effectively at elevated temperature. Similarly, muscle soreness, crankiness, headache, and many of the other mild side effects of vaccination aren’t signs that something’s gone wrong — they’re signs that everything is working as it should. The U.S. Centers for Disease Control and Prevention (CDC) — a government agency that in no way profits from vaccination development or administration — maintains data on adverse vaccine reactions. Truly bad vaccine reactions are exceedingly rare. The most common of these are allergic reactions, which vary in their prevalence with the type of vaccination. In the case of the MMR, they occur in about one child for every 1,000,000 immunized (a very small risk, particularly in light of the fact that three of every 1000 children who get the measles die of complications due to the disease). Other truly awful adverse reactions to vaccinations, such as life-threatening seizures or brain damage, occur so rarely that there’s no way to be sure such reactions are attributable to the vaccine at all. Think of it this way: you could get hit by a meteor after being vaccinated, but that wouldn’t mean that the vaccine caused the meteor strike. Similarly, just because a child has seizures in the days after a vaccination doesn’t mean the vaccination caused them.

Some anti-vaccination websites cite reactions reported on the Vaccine Adverse Event Reporting System (VAERS), another government service. It’s important to note, however, that anyone can enter anything — verified or not — into the VAERS database. Dr. James R. Laidler, for instance, rather infamously entered into the VAERS that an influenza vaccination turned him into The Incredible Hulk. He was contacted (eventually) by a representative from the database, who suggested that his reaction was quite unusual and asked his permission to delete it. Had he refused, the report would have remained. Bottom line is that the VAERS may be full of fallacious reports (intended or not), as it is an open database.

The point here is that experience — even when that experience appears completely legitimate — isn’t the same as scientific evidence. I experience that the Earth is flat, but I have to trust in the evidence that it is not. Similarly, while friends, acquaintances, and people on the Internet report adverse reactions to vaccines that scare me (and force me to remind myself of all the safety and efficacy data that supports vaccination every time I take my baby to the pediatrician), I have to remember that the post hoc ergo proctor hoc fallacy is common, meaning a bad bout of teething replete with days of crying and sleeplessness could be mistakenly attributed to 6-month vaccinations — and reported as such — by worried parents. Similarly, a parent’s natural concern for their child’s well-being may skew their perspective and could cause overstating of a mild fever or post-vaccination crankiness. Experience is interesting, and if enough people have the same experience, it warrants further investigation. Even collective experience, however, doesn’t replace true scientific evidence — with the exception of a very few astronauts and circumnavigators, we’re all just taking it on faith in science that the Earth is round.

 

What do you think it takes for experience to count as evidence?

 

References

Laidler, J. Chelation and Autism. Posted 27 July 2005, Accessed 16 Sept 2011.

National Institute of Neurological Disorders and Stroke Autism Fact Sheet. Accessed 16 Sept 2011.

U.S. Centers for Disease Control and Prevention Possible Side-Effects From Vaccines. Accessed 16 Sept 2011.

Vaccine Adverse Effect Reporting System (VAERS)

High-Fructose Corn Syrup — Big Problem or Just Another Sweetener?

High-­‐fructose corn syrup (HFCS) is ubiquitous in the American diet, and unless you make a concerted effort to avoid the stuff, your child consumes it in everything from soda to fast food to the convenient prepared snacks and juice boxes you tuck into backpacks and leave in the pantry for after school. The debate over the health effects of HFCS is intense, with the corn industry claiming that it’s essentially identical to table sugar, and healthier food companies scrambling to reformulate products so that they no longer contain the sweetener. Who’s right? Is HFCS the dietary disaster some scientists claim, or is the corn industry correct in saying it’s table sugar by another name? Should you particularly avoid feeding your child HFCS, or are all sweeteners equally unhealthy?

Obesity rates among children and adolescents are on the rise in the United States, with a disturbing 17% of America’s youth affected, according to the U.S. Centers for Disease Control and Prevention. As obesity among the young has soared, so have rates of type 2 diabetes — so much so that the disorder, which was once known as “adult-­‐onset diabetes,” had to be renamed. Because the American obesity epidemic picked up steam right around the time American consumption of HFCS increased dramatically, studies including Bray et al. have suggested that the HFCS might be to blame.

The corn industry vigorously opposes such accusations, however, on the grounds that HFCS isn’t much different from table sugar. Table sugar, formally known as sucrose, consists of two smaller sugar molecules — glucose and fructose — chemically bonded together. When you eat sucrose, your body digests it into its glucose and fructose components, and you absorb these and use them for energy. Too much sugar — or any other energy-­‐providing nutrient — in your blood, and your cells begin to convert the excess into fat. It’s therefore completely true to say that too much of any sugar can lead to obesity. With regard to chemical makeup, sucrose is 50% glucose and 50% fructose. HFCS-­‐55, the most common of the HFCS formulations, is 55% fructose, 42% glucose, and 3% larger sugar molecules (White 2008). In the end, based purely upon composition, there are significant chemical differences between table sugar and HFCS.

Two new studies particularly underscore the differences between HFCS and other calorie-­‐containing sweeteners, including table sugar. In the first of these, researchers determined that rats drinking sweetened water (sweeteners included fructose, glucose, sucrose, and HFCS) didn’t adjust the calories of rat chow they ate to account for the additional calories they were taking in (Light et al 2009). While not necessarily an indictment of HFCS in particular, it’s certainly a good argument against sweetened beverages in general. Additionally, however, the rats drinking HFCS-­‐sweetened water gained more weight than any of the other rats, despite the fact that they didn’t take in more total calories than the other rats drinking sweetened water. This demonstrates that HFCS can promote weight gain to a greater extent than other sweeteners per calorie consumed.

In the second study, rats fed HFCS and rat chow gained more weight —especially in the abdominal region, which is particularly unhealthy — than those fed table sugar and rat chow (Bocarsly et al 2010). These findings particularly impressed researchers because the HFCS-­consuming rats actually managed to gain more weight on fewer total sugar calories than the table sugar-­consuming rats. This suggests that HFCS doesn’t just promote weight gain more than table sugar does, it actually promotes the most dangerous kind.

Science Bottom Line:* Evidence suggests that too many foods with added sweeteners increase the risk of obesity, and that this is particularly true of sweetened beverages (like sodas and juice drinks). HFCS appears to be especially problematic, because it encourages the body to put on weight to a greater extent than other sweeteners on a calorie-­‐for-­‐calorie basis.
Do you worry about HFCS and other additives in your food? What do you do to encourage your children to eat a healthy diet?

 

References:

Bocarsly et al. High-­‐fructose corn syrup causes characteristics of obesity in rats: Increased body weight, body fat and triglyceride levels. Pharmacol Biochem Behav. 2010 Nov;97(1):101-­‐6.

Bray et al. Consumption of high-­‐fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. 2004 Apr;79(4):537-­‐43.

Light et al. The type of caloric sweetener added to water influences weight gain, fat mass, and reproduction in growing Sprague-­‐Dawley female rats. Exp Biol Med (Maywood). 2009 Jun;234(6):651-­‐61.

U.S. Centers for Disease Control and Prevention Overweight and Obesity Data and Statistics. Accessed 11 Sept 2011.

White, JL. Straight talk about high-­‐fructose corn syrup: what it is and what it ain’t. Am J Clin Nutr 2008;88:1716S–21S.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

Nursing and Vitamin D

The American Academy of Pediatrics (AAP) acknowledges that breast milk is the gold standard in infant nutrition, but nevertheless recommends supplementing all infants — formula- or breastfed — with a daily dose of 400 IU of vitamin D. Two things about this mystify me. First, the implication that human milk is universally low in vitamin D doesn’t seem plausible; after all, the human race survived for millennia without the benefit of store-bought supplements. Second, research increasingly suggests that the vitamin D intake recommendations are set quite low (for both adults and children), making the determination that 400 IU per day is appropriate for infants somewhat random.

If the 400 IU of vitamin D recommended by the AAP is low by an increasing body of research, how much vitamin D is appropriate for a breastfeeding infant? This is a little hard to say. Some studies suggest a dose several times that recommended by the AAP (Hypponen et al 2001; Pittard et al 1991). However, there’s the concern of toxicity, since it’s possible to take too much of the vitamin. Currently, the National Institutes of Health (NIH) has the tolerable upper limit set at 1000 IU for babies under 6 months of age, but even this number may be conservative, since the Hypponen study found a protective effect of vitamin D against type 1 diabetes at twice that dose. My analysis, after looking at the data, is that 400 IU of supplementation is probably a little low, but there’s limited evidence that supports going over 1000 IU.

However, it may not be necessary to supplement a nursing infant at all, under the right conditions. You don’t need to consume vitamin D; assuming you get enough sun exposure, you can make it yourself (this route is appropriate for adults and older children, but not for babies, as infants shouldn’t be exposed to direct sunlight). This is a good thing, because there aren’t a wide variety of foods that contain the vitamin. It takes a light-skinned individual only about 10-15 minutes per day to make adequate vitamin D, though sunscreen negatively impacts production. Also, lower-intensity sunlight (such as at higher latitudes) isn’t sufficient to produce the vitamin. Still, an increase in time spent indoors means that many nursing mothers today aren’t getting the sunlight our ancestors did. It’s not that human milk is universally low in vitamin D, it’s that most women simply don’t spend enough time in the sun. If you work or exercise outdoors — year-round — in Phoenix, AZ, you probably don’t need to supplement your nursing infant with vitamin D. If you live in Buffalo, NY, you probably do.

It seems intuitive that a breastfeeding mother who is receiving enough vitamin D from sun exposure and/or food should be able to pass adequate quantities of vitamin D into her milk, making supplementing unnecessary. Several studies support this, including an older study by Hollis et al, and one published more recently by Taylor et al. The Taylor study, in particular, found good results with very high vitamin D intake by nursing mothers, noting that maternal consumption of 6400 IU of vitamin D a day provided for nursing infant vitamin D needs and appeared safe for both mother and baby. This is somewhat above the 4000 IU per day set as the tolerable upper limit by the NIH, though a study by Hathcock et al notes no adverse effects up to 10,000 IU per day.

Science Bottom Line:* Evidence supports nursing mothers taking supplemental vitamin D in quantities of around 4000-6400 IU per day. There doesn’t appear to be any need to supplement a nursing infant with adequate maternal vitamin D intake.

 

Do you or did you supplement your nursing baby with vitamin D? Leave a comment below.

 

References:

Hathcock et al. Risk assessment for vitamin D. Am J Clin Nutr. 2007 85:6–18.

Hollis et al. Vitamin D requirements during lactation: high-­‐dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1752S-­‐8S.

Hyppönen et al. Intake of vitamin D and risk of type 1 diabetes: a birth-­‐cohort study. Lancet. 2001 358:1500–1503.

Pittard et al. How much vitamin D for neonates? Am J Dis Child. 1991 145:1147– 1149.

Taylor et al. Vitamin D Supplementation during Lactation to Support Infant and Mother. J Am Coll Nutr. 2008 Dec;27(6):690-­‐701.

*The “Science Bottom Line” at the end of each article is not intended as medical advice. It is merely my analysis of one or more papers referenced in a given post.

**”SquintMom’s Decision,” likewise, is not intended as medical advice. It’s merely what I do in my own home, based upon the results of my analysis of the information available.

Trusting Your Instincts

To a certain extent, it makes sense to trust your instincts while parenting; after all, many of us seem to have a sixth sense when it comes to our children and their safety. However, what we call “instincts” can lead us in the wrong direction. A case in point is that my instincts tell me flying on an airplane isn’t safe. I get nervous when I have to fly, and I’m particularly edgy during takeoff, landing, and any turbulence. I’m completely at ease in a car, however, despite the fact that I’m about 625,000 times more likely to die in a car crash (per mile driven) than in a plane crash (per mile flown). Sometimes our instincts steer us wrong.

If you think about it, we can’t possibly have “instincts” about the comparative safety of automobile and plane travel; these modes of transport are new in the grand scheme of human evolution. True instincts are reserved for behaviors we evolved to exhibit. They include reflexes such as the rooting of a newborn, and more complex activities — such as performance of the sexual act — that we don’t need to be taught. Similarly, while we have some true parenting instincts — the drive to protect a newborn from harm, for instance, or to pick up a crying baby and soothe it in any way necessary — most of our parenting behavior is learned, and is in response to relatively new developments in human society. In parenting, “trust your instincts” would be more properly phrased, “listen to your gut.”

Unfortunately, while your instincts are rarely wrong, your gut is far more fallible. My gut is wrong about the safety of my car, for instance. In a 1987 article published in the journal “Science,” researcher Paul Slovic notes that humans are notoriously bad at perceiving risk accurately, which explains why I’m not the only one who fidgets on an airplane. It seems that humans perceive activities as riskier when they’re new, have the potential for a delayed (as opposed to immediate) effect, aren’t easily observable, are involuntary, and are generally out of our control. Slovic went on to point out that surveyed individuals (including college students and members of the League of Women Voters) ranked nuclear power (in any permutation) as the most dangerous (number 1) of a group of 30 activities and technologies, while experts ranked it as number 20 out of 30, or less likely to cause your death than riding on a train. Similarly, college students ranked recreational swimming as the least risky of the activities, while experts ranked it as number 10 out of 30, or slightly riskier than private aviation, and quite a bit riskier than being a firefighter. On a side note, experts ranked electrical power as number 9 out of 30, but it’s nuclear plants we all tend to worry about, despite the much lower actual risk associated with them.

The point here is that many of the parenting choices we have to make (Should I vaccinate my children? Crib or co-sleep? Home birth or hospital delivery?) are ones our evolutionary ancestors wouldn’t have had to deal with, so we have no real instincts where these decisions are concerned. Instead, many parents rely upon what is — no matter what you call it — nothing more than a gut feeling to make critical parenting calls. As Slovic demonstrates so eloquently, however, our guts can err pretty dramatically.

Am I advocating ignoring gut feelings when it comes to parenting? Not at all. I am, however, suggesting that it’s a good idea to take a gut feeling with a grain of salt, at least until — and unless — you’re able to back it up with evidence.

 

Do you make more evidence-based or gut-based parenting decisions? Leave a comment below!

 

Reference:

Slovic, P. (1987). Perception of Risk. Science, 236, 280-285.