For our big annual family health feature, we asked several doctors from the city’s top hospitals and pediatric practices to help answer common—but confusing—family health questions. We hope these answers will help your family stay healthy, safe, and happy this year. Have a health question you’d like to submit? Email [email protected].
What’s the best way to introduce my child to potential allergens—like peanuts, for example—and at what age should I do so?
First, all foods are potential allergens. However, some foods are more allergenic than others. There are eight foods that account for the majority of all reactions (aka “common food allergens”): Cow’s milk, hen’s eggs, soy, wheat, peanuts, tree nuts, fish, and shellfish. It is the introduction of these common food allergens that has been hotly debated…The American Academy of Pediatrics guidelines were modified in 2008 to recommend that solids should not be introduced before 4-6 months of age, but it is not necessary to delay the introduction of solids, including the common food allergens, after 4-6 months of age.
Currently, we recommend starting with foods that are potentially less allergenic, such as other grains, fruits, and vegetables. These should be introduced in a developmentally appropriate form to reduce the risk of choking and other swallowing hazards. Once you have introduced some of these foods, you can introduce some of the common food allergens. It’s best to introduce these foods at home, starting with a small amount and gradually increasing the amount and including it as part of the regular diet if there are no reactions. You can offer one new common food allergen at least every 3-5 days if there are no reactions. As usual, avoid introducing liquid cow’s milk until 1 year of age due to the risk for iron deficiency and kidney problems, but other milk-containing products such cheese, yogurt, and milk-based formulas may be introduced.
Earlier this year, the LEAP (Learning Early About Peanut Allergy) trial from the UK showed that the early introduction of peanuts in selected, “high-risk” infants could safely reduce the risk of developing a peanut allergy. Based on the findings from this pivotal trial, it is now recommended that babies with severe eczema and/or an egg allergy between 4 to 6 months of age be evaluated by an allergist to determine whether it is appropriate introduce peanuts early on.
Finally, it is important to understand that many of the above recommendations surrounding the introduction of solids and allergy risk primarily relate to “high-risk” infants. High-risk infants are children who are considered to already have a risk for developing an allergy due to a personal history of moderate-to-severe eczema or a parent or a sibling with allergies. It is not clear how these guidelines would apply to an infant that does not have a risk for developing an allergy. More extensive guidelines that may apply to low-risk infants and the general population are in the works and should be available in the near future.
–Joyce Yu, MD, Pediatric Allergist/Immunologist
Morgan Stanley Children’s Hospital of NewYork-Presbyterian/Columbia University Medical Center
Is flossing important for children, and what age should flossing begin for children?
Flossing is a fundamental part of practicing good oral hygiene and promoting healthy teeth and gums. The American Dental Association recommends flossing once a day to help remove plaque and food debris that accumulates between teeth where a toothbrush can’t reach. Baby teeth, like adult teeth, have the same potential to build up this plaque and bacteria between the teeth, which can lead to decay (cavities) and possible infection. Flossing a child’s teeth should begin as soon as two adjacent teeth are touching each other. This can be as early as 2.5 years old.
Flossing children’s teeth is particularly important because the pediatric dentist normally waits until a child is of 5 years of age to take first time X-rays. These X-rays help the pediatric dentist identify decay between the teeth that may not be visible to the naked eye. Until a child is able to take these X-rays, flossing their teeth can help prevent unseen decay from developing during these early years. Furthermore, the baby molars don’t fall out until anywhere between 11 to 13 years of age. So prudence dictates that it is important to floss at an early age in practicing prevention!
Children at a young age don’t have the manual dexterity to brush or floss their own teeth. As a parent, you should be flossing your child’s teeth every night before they go to sleep. The longer a parent can help floss their child’s teeth, (till around 10 years) the better the chances of them developing proper oral hygiene habits and becoming cavity-free.
–Mark Hochberg, DMD
Smiles 4 Kids Manhattan Pediatric Dental Group, PC
How important is my diet during breastfeeding? Can I drink alcohol? What kinds of foods should I avoid?
Mothers can promote their child’s development and well-being with healthy eating habits during breastfeeding, according to the American Academy of Pediatrics (AAP). The AAP recommends eating foods rich in calcium, vitamin D, protein, folic acid, and iron while breastfeeding. 1000 mg of calcium per day (8 ounces of milk) is recommended for women 18 to 50 years of age to combat the typical 3-5 percent loss of bone mass when breastfeeding. 400 IU-1000 IU of Vitamin D per day is recommended to maintain bone strength. In addition, 6-6.5 ounces of protein per day (2-3 servings of meat, poultry, or fish—other good protein sources are eggs, nuts, and dried beans) is recommended for building, repairing, and maintaining body tissue. Energy levels can also be assisted with foods rich in iron such as meats and green, leafy vegetables.
While a mother’s mammary glands have a wonderful way of regulating what your baby gets, there are a few foods that should be addressed cautiously. Caffeine (coffee, tea, chocolates, soda) in moderation is acceptable… However, consider decreasing the amount of caffeine that you are consuming if your baby starts becoming more fussy and irritable. Some studies indicate that more than five cups of coffee per day can have negative effects. Habitual and chronic use of alcohol is not advised while breastfeeding, since alcohol can pass through into breast milk. Alcohol consumption in mothers is known to change the taste of breast milk and decreases breast milk production. It is an urban myth that beer will increase breast milk production. If one chooses to occasionally have one alcoholic drink (the equivalent of a 12-ounce beer, 4-oz glass of wine, or 1-oz of hard liquor), it is strongly recommended to have it immediately after breastfeeding or pumping and to wait at least two hours before breastfeeding or pumping again. This will optimally allow the body to get rid of as much alcohol as possible.
Limit and be aware of your intake of mercury, since mercury can damage the nervous system in babies. Avoid eating fish high in mercury such as shark, swordfish, king mackerel, and tilefish. Limit your intake of albacore tuna or local fresh caught fish (if safety is not known) to 6 oz per week (one meal). But go ahead and eat a variety of fish that are lower in mercury (light tuna, salmon, shrimp, Pollock, and catfish) since fish is a great source of protein and omega-3 fatty acids.
–Shilpa Malhotra, MD, Pediatric Hospitalist
Lenox Hill Hospital
Do boys need to get the HPV vaccine too?
Yes! The HPV vaccine protects against the Human Papilloma Virus.
HPV is the most common sexually-transmitted infection. About 79 million Americans are infected with HPV. It is a viral infection that can be spread through anal, vaginal, or oral sex, or through close skin-to-skin contact during sexual activity. There are many strains of the virus, most of which are asymptomatic but transmissible. Several strains of HPV, however, can cause cancer. Close to 100 percent of cervical, 63 percent of penile, 91 percent of anal, and 72 percent of oropharyngeal (mouth and neck) cancers are caused by HPV.
Initially, the HPV vaccine was marketed to and approved for girls because of the virus’ association with cervical cancer. This left parents of boys assuming the vaccine was not necessary for their sons. This is not true. While men obviously do not get cervical cancer, they can suffer from the other cancers that can evolve after an initial HPV infection.
There are currently two HPV vaccines on the market—Cervarix and Gardasil. Currently, only Gardasil is approved for boys and recommended for ages 9-26 years. Girls can receive either vaccine and the recommended age for administration is 9-26 years as well. It is ideally administered before they become sexually active since the vaccine is a preventive measure and does not cure an already existent disease.
–Liza Natale, MD
Pediatric Associates of NYC
This past year there was a lot of discussion around the anti-vaccination movement. What are the actual risks related to childhood vaccines, and how can I ensure that my child is immunized safely?
All vaccines recommended by the CDC and the Advisory Committee on Immunization Practices (ACIP) for routine use in children have been extensively evaluated in clinical studies, and their safety is continually monitored. They have all been found to be extremely safe, although like any other medication, sometimes they can cause side effects. However, it is important to remember that the risk of acquiring and experiencing complications from a vaccine-preventable disease is much higher than the remote risk of a serious vaccine-related side effect.
The more common side effects of vaccines are fuzziness, soreness, swelling, a low-grade fever and sometimes redness at the site of the injection. Usually these symptoms resolve after one or two days and can be managed with ibuprofen or acetaminophen. Warm compresses at the site of injection or a bath with warm water can also help. Occasionally, some children can develop a high fever. The MMR (measles, mumps, and rubella) and Varicella vaccines can cause mild rashes that resolve by themselves. The rotavirus vaccine can, in rare occasions, be associated with a type of intestinal blockage called intussuception. Children with intussusception can have vomiting (which often times is green), bloody stools, and abdominal pain; sometimes they appear to be very sleepy. Seizures and allergic reactions can also happen after vaccination. Make sure you inform your child’s physician of any allergies your child has. An even rarer complication of vaccination is the Guillain-Barre syndrome, which is characterized by muscle weakness and is estimated to happen in about one in a million people who receive the influenza vaccine. This risk is much lower than the risk of serious complications due to influenza. If you think your child has one of these rare complications of vaccination you should seek medical attention immediately
–Roberto Posada, MD, Pediatric Infectious Disease Specialist
Kravis Children’s Hospital at Mount Sinai
How can I tell whether my child has a fracture or a sprain?
This is a question not only for parents, but often a dilemma for physicians. First, we should clarify that a fracture and a broken bone are the same thing. An important concern deals with stability and displacement of a fracture. A non-displaced stable fracture is the most simple to treat, but is often difficult to diagnose.
A sprain is a ligament injury. These injuries can be graded by severity, from a stretching of the ligament which is called a strain, to a partial tear, to a complete tear. Children have a unique anatomic feature called a growth plate, or physis. This is an area of cartilage sandwiched within the bone which produces layers of fresh bone as we grow. In general, the phyes are near the major joints of the extremities. These physis are a weak spot in children’s bones and can be the sites for physeal injuries. This is compounded by the fact that ligaments stabilize joints, and therefore are in and around the physis. You can see the dilemma.
There is one last wrinkle. Children’s bones are softer and more elastic than adult bones. They can bend before they break. Significant bending of a child’s bone is called plastic deformation and is, in essence, the same as a fracture.
So how do we know if a child’s bone is broken? This often comes down to the physical exam. Even an X-ray can be negative. A fracture in the physis may not be seen. Also, an incomplete crack may be difficult to visualize. Ligaments are invisible on X-rays. Since ligaments attach one bone to another at a joint, pain from a sprain should be along the course of the ligaments and not directly on the bone. Severe ligament sprains are often more swollen than minor fractures. A bone fracture, including a physeal injury, is tender directly on the bone. Swelling and pain are variable because of variation in fracture severity and stability. This rule of bone tenderness equals fracture, versus tenderness between the bones being a ligament injury, goes out of the window for avulsion fractures. This is a fracture when a ligament pulls off a piece of bone when it is sprained.
This is all very confusing—suffice it say tenderness directly on the bone is likely to be a fracture. In that case, cast or splint immobilization is the safest treatment. This is good treatment for healing of fractures or sprains. Treatment of children’s fractures is geared towards safety. If a diagnostic dilemma needs to be resolved, an MRI is key.
–Lon S. Weiner, MD, Chief of Orthopedic Trauma
Lenox Hill Hospital
Is it true that most kids today don’t get enough calcium, leading to more broken bones? How can I ensure that my child is growing strong, healthy bones?
It is true that a majority of children and teenagers do not meet their daily requirements of dietary calcium, an important mineral that helps build bone. [According to an Institute of Medicine 2010 report brief on dietary reference intakes for calcium and vitamin D], the daily recommended dietary allowance (RDA) for children ages 4-8 is 1000 milligrams of calcium daily, and 1300 milligrams for ages 9-18 years. A large national survey [U.S. Department of Agriculture, Agricultural Research Service, 2009] reported that only 10-12 percent of girls ages 9-18, and only 17 percent of boys ages 9-13 and 42 percent of older male teenagers are meeting daily dietary calcium requirements. There are many factors that affect bone health during childhood and include genetics, nutritional intake and physical activity. In addition, children with various chronic illnesses are more predisposed to low calcium and vitamin D levels and may require a higher intake than the RDA. It is important to optimize the calcium deposited in bones during this time of rapid growth for a variety of reasons.
Calcium intake is linked to bone health. Childhood and adolescence is the time of peak bone mass accrual, with our peak bone mass established from 10-20 years. Our bones actually store more than half to two thirds of our total adult bone calcium supply during this time. We should view our bones as a bank account and understand the importance of making “deposits” of calcium into our bones from an early age. These deposits are investments to help bones stay strong and to help reduce fracture risk and osteoporosis in the future. The American Academy of Pediatrics recommends 3-4 servings of calcium daily for children and adolescents to maintain strong bones, with one cup of milk having 290-mg of calcium per serving.
There are many ways to incorporate calcium into a child’s diet. In addition to drinking milk, calcium-rich foods include dairy products such as cheese and yogurt, protein options such as pinto beans and nuts, and leafy vegetables such as broccoli, kale, bok choy, and spinach. Vitamin D also plays an important role in bone health through the absorption of calcium from the small intestine and is available in diet and through synthesis from sunlight. Weight-bearing exercises also enhance bone health and include activities such as jumping, running, and walking. Bone strengthening exercises also include gymnastics, basketball, volleyball, and tennis.
Your doctor can test your child’s calcium and vitamin D levels if they believe their intake is inadequate, or if a child’s history places them at increased risk for fractures. In certain cases, referral to a bone and mineral metabolism expert may be indicated. By increasing calcium-rich dietary options and physical activity within families, we can promote strong healthy bones for our children.
–Marisa Censani, MD, Pediatric Endocrinologist
Komansky Center for Children’s Health at NewYork-Presbyterian/ Weill Cornell
How can I tell if my child is concussed? How long is the recovery process generally, and how can I support their recovery at home?
A concussion is a mild traumatic brain injury, or TBI, that can be caused by external force to the head, face, or neck, resulting in altered mental status—a period of feeling dazed, confused—or even a loss of consciousness (LOC). A concussion can result from both sports and non-sports related activities: In children, they most commonly result from falls, motor vehicle accidents, being hit by an object, and assaults. A concussion may or may not involve LOC and may not be detected by neuroimaging tests. As a result, concussions are typically diagnosed by careful clinical examination. The signs/symptoms of concussion may be apparent right after the injury and resolve quickly, while some can show up hours or days after the injury. Children and adolescents often report one or more of the common signs and symptoms, or simply say they just “don’t feel right.”
Common concussion-related symptoms can be physical (headache, nausea, vomiting, dizziness, blurred vision, sensitivity to light or noise, poor balance, fatigue, ringing in ears), cognitive (feeling “in a fog” or “slowed down,” difficulty remembering, difficulty concentrating, distractibility, slowed speech, confusion), emotional (inappropriate emotions, personality change, nervousness/anxiety, irritability, sadness), and/or sleep related (trouble falling asleep, sleeping more or less than usual). These symptoms may be difficult to assess in pre-verbal children. Parents of very young children should do their best to recognize and report any notable changes in their child’s behavior to their primary care provider.
Concussion-related symptoms usually resolve in 1-3 weeks. It is difficult to predict the length or course of recovery. Signs/symptoms should be monitored throughout the recovery period. If a child’s concussion signs or symptoms get worse, immediate medical attention should be sought from a licensed medical professional – particularly from someone trained in diagnosing and managing concussions. If symptoms do not resolve within a few weeks, a more specialized evaluation (medical, neuropsychological or psychological) may be necessary.
Concussions are best managed by a team that includes the child, family, school and medical professionals, including neurologists. During recovery, rest is necessary to help the brain recover and reduce the risk of re-injury. Strenuous physical exercise or activities that require intense concentration, such as studying, working on the computer, or playing video games are generally not recommended for symptomatic children, as these may delay recovery. Children should not return to contact sports until they are symptom free for more than 24 hours: indeed, some states, such as New York, have enacted strict guidelines for management of concussions among students . Many schools and athletic programs require clearance from a medical professional trained in brain injury. A graduated return-to-play protocol should be used when the child is ready to participate in physical activity. Return to athletics and academics should be gradual and based on upon the child’s level of symptoms.
For more information, parents and caregivers may refer to recently-issued guidelines for managing sports-related concussions from the American Academy of Neurology. You can also learn more from my colleagues at the Brain Injury Research Center of Mount Sinai.NewYork-P
And the bottom line is this: if you think something is wrong, get it checked out by a properly trained medical professional. The game can wait. Your brain can’t.
–Maria Kajankova, PhD
Neuropsychology Postdoctoral Fellow, Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
