Should my child take sports drinks/ energy drinks after exercise?

The short answer is NO. Plain water is the BEST rehydrating solution for most children doing routine exercises / activities.

For a longer version, read on ...

In India, the fad of sports drinks and energy drinks is fast catching on. For starters, is there any difference between the two?

Yes, Sports drinks contain carbohydrates, minerals, electrolytes, and flavoring, and are intended to replace water and electrolytes lost through sweating during exercise. Although they may be useful for young athletes participating in prolonged, vigorous physical exercise, they tend to be overused and are usually unnecessary. Some brands available in India include Gatorade, Stamina (Amul) and Sofit (Godrej).

Unlike sports drinks, energy drinks contain stimulants including caffeine, guarana, and/or taurine. Rigorous review and analysis of the literature suggest that energy drinks are never appropriate for children or adolescents. Because caffeine has been associated with harmful neurologic (brain) and cardiovascular (heart) effects in children, caffeine-containing beverages, including soda, should be avoided. Energy drinks can make a normal child restless and anxious.The excessive sugar present in these drinks not only adds to the calorie counts, but also acts as a laxative. Energy drink brands available and aggressively marketed in India include Red Bull, XXX & Cloud 9.

For most children engaging in routine physical activity, plain water is the best form of rehydration. Use of sports drinks can increase the risk of obesity and tooth decay, and is not required for routine activity.

Specific AAP (American Academy of Pediatrics) recommendations regarding use of sports drinks and energy drinks in children and adolescents include the following:

• Pediatricians should educate patients and their parents regarding the potential health risks of energy drinks and sports drinks and explain the significant differences between these types of drinks. The terms should not be used interchangeably.
• Energy drinks should never be consumed by children or adolescents, because the stimulants they contain pose potential health risks.
• Children and adolescents should avoid and restrict routine consumption of carbohydrate-containing sports drinks, which can increase the risk for overweight, obesity, and dental erosion.
• For pediatric athletes, sports drinks should be consumed in combination with water during prolonged, vigorous physical activity, when rapid replenishment of carbohydrates and/or electrolytes is needed.
• For children and adolescents, water, not sports drinks, should be the principal source of hydration.

Given the increased awareness and easy availability of these drinks in the Indian Market, pediatricians and parents need to be aware of the potential risks of these drinks.

So what should an active child take if he indulges in vigorous activity?

It's better for children to drink water during and after exercise, and to have the recommended intake of juice and low-fat milk with meals. The recommended intake of juice is 6 oz (~ 180 ml/ 1 small glass) for children 1-2 years, and up to 2 glasses (6-12 oz/ 2 glasses) for older children only.

Suggested reading

http://www.medscape.com/viewarticle/743634?src=mpnews&spon=9 (accessed June 2011)

http://pediatrics.aappublications.org/content/107/5/1210.full (accessed June 2011)

An uncommonly diagnosed common problem in kids - Helping children with voiding dysfunction!

My child wants to go the toilet repeatedly!
She rushes to the toilet, and sometimes passes urine in her underwear!

This is a fairly common complaint in Pediatric Office Practice.

It is the tendency of the Pediatrician & the parent to blame this on a lazy, inattentive child who is simply too busy to stop whatever they are doing. However this can very easily be a sign of voiding dysfunction. Repeated wetting can lead to lower self esteem in a child, so this condition should not be left undiagnosed and untreated.

I am going to use this forum to provide links to some important and helpful articles that are great learning resources for parents & pediatricians.

This is an excellent primer for pediatricians regarding a common problem that we encounter in our practice, voiding dysfunction. Unfortunately we rarely investigate this thoroughly, beyond the usual urine examination, and do not seek specialist consultation, especially in India. This is due to two reasons, first a lack of awareness of the problem of voiding dysfunction, and secondly, since we lack qualified/ interested Pediatric urologist in our country.

Hopefully these articles will educate us regarding this relatively common condition.

"In a study of 7-year-old Swedish schoolchildren, 20% reported needing to get to a bathroom quickly. Additionally, it was reported that 6% of girls and 3.8% of boys continued to have problems with daytime wetting at this age. Upadhyay et al. (2003) found that half of children with dysfunctional voiding symptoms had a history of urinary tract infections."

http://www.medscape.com/viewarticle/507163

http://emedicine.medscape.com/article/1016198-overview

(Please note: Both these articles require free registration)

Dysfunctional voiding refers to an abnormality in either the storage or emptying phase of micturition and is associated with urgency, frequency, incontinence, and UTIs. It is important to distinguish dysfunctional voiding from enuresis. With enuresis, there is normal voiding with complete expulsion of urine at a socially less acceptable time or place. Enuresis occurs more frequently at night (nocturnal), can occur during the day (diurnal), and is usually self-limiting.

Recommended Audience - Pediatrician, Pediatric Urologist, and Family Physicians. While parents can read the article, they may find it technically demanding.

Top 5 things NOT to do for a Pediatrician - to save money and health !

Research among pediatricians has outlined "Top 5" practices to avoid in order to deliver better quality, more cost-effective medical care.

For pediatricians, the top 5 quality-improving activities include:

• Don’t prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus.

• Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.

• Don’t refer otitis media with effusion early in the course of the problem.

• Advise patients not to use cough and cold medications.

• Use inhaled corticosteroids to control asthma appropriately.

Source

I believe that these are excellent tips.
All of us should follow these as far as possible, diligently and conscientiously, not only for a more scientific practice, but also as the Hippocratic Principle goes "First, do no harm".
Avoiding unnecessary CT scans would reduce the radiation exposure to the developing brain of the children, while avoiding antibiotics would reduce chances of side-effects, antibiotic resistance, and even possibly allergies and reduced immunity in children (studies have correlated multiple antibiotic use with increased risk of allergies, and increased risk of recurrent infections).
Finally, it is amazing to note the stigma attached to the diagnosis of asthma in our country. Not only are parents / pediatricians unaware of the diagnosis, convincing them regarding the use of inhalation therapy is a uphill task. Inhalation is the BEST treatment for asthma, as millions of children and hundreds of studies have clearly demonstrated. It is safe, effective and does not lead to significant side-effects. Its use MUST be encouraged amongst doctors and parents alike.

List of Top Pediatric Hospitals in the USA - 2011

Published below is a list of the top Pediatric hospitals in the USA published by US News & World report. All the hospitals were scored in 3 areas: reputation among pediatric specialists, clinical outcomes, and care-related indicators of quality such as nurse–patient ratios, surgical volume, and the availability of specialized programs. For this publication, US News & World Report solicited data from 177 hospitals and received responses from 100. The magazine also asked some 1500 pediatric specialists to name the 5 best hospitals where they would send children with serious or difficult problems without regard to cost or geography.

Here are the top 3 in each category:

Cancer

1. Children's Hospital Boston and Dana-Farber Cancer Institute
2. Children's Hospital of Philadelphia
3. St. Jude Children's Research Hospital, Memphis, Tennessee

Diabetes and Endocrinology

1. Children's Hospital of Philadelphia
2. Children's Hospital Boston
3. Children's Hospital of Pittsburgh of UPMC

Gastroenterology

1. Cincinnati Children's Hospital Medical Center
2. Children's Hospital Boston
3. Children's Hospital of Philadelphia

Heart and Heart Surgery

1. Children's Hospital Boston
2. Children's Hospital of Philadelphia
3. University of Michigan C.S. Mott Children's Hospital

Kidney

1. Children's Hospital Boston
2. Seattle Children's Hospital
3. Cincinnati Children's Hospital Medical Center

Neonatology

1. Children's Hospital of Philadelphia
2. Children's Hospital Boston
3. Cincinnati Children's Hospital Medical Center

Neurology and Neurosurgery

1. Children's Hospital Boston
2. Children's Hospital of Philadelphia
3. Johns Hopkins Children's Center, Baltimore

Orthopaedics

1. Children's Hospital Boston
2. Children's Hospital of Philadelphia
3. Children's Medical Center–Texas Scottish Rite Hospital for Children, Dallas

Pulmonology

1. Children's Hospital of Philadelphia
2. Cincinnati Children's Hospital Medical Center
3. Children's Hospital Boston

Urology

1. Children's Hospital Boston
2. Children's Hospital of Philadelphia
3. Riley Hospital for Children at Indiana University Health, Indianapolis

Hospitals appearing on the 2011 to 2012 honor roll are as follows (repeated numbers indicate a tie):

1. Children's Hospital Boston

1. Children's Hospital of Philadelphia

3. Cincinnati Children's Hospital Medical Center

4. Texas Children's Hospital, Houston

5. Children's Hospital Colorado, Denver

5. Johns Hopkins Children's Center, Baltimore

7. Seattle Children's Hospital

8. Children's Hospital Los Angeles

8. Children's Hospital of Pittsburgh of UPMC

8. New York–Presbyterian Morgan Stanley-Komansky Children's Hospital

8. St. Louis Children's Hospital–Washington University

Read more here

http://www.medscape.com/viewarticle/742874?src=mpnews&spon=9 (requires free registration)

While we do have list of medical colleges ranked (a bit arbitrarily in my opinion) that is published annually by an Indian Periodical India Today, a similar study in India would be very informative and illuminating.

What are some good Internet Resources for Information about Newer Vaccines?

I understand the need for getting the latest unbiased information about the newer vaccines, since many mass media (like newspapers, TV channels etc.) are filled with horror stories regarding drugs and vaccines. Most of these reports, at least in the Indian media, are sensationalized, over simplified and have inaccurate conclusions with the intention of boosting sales. These lead to avoidable panic, and sometimes serious delays in providing appropriate vaccinations to children.

However since the internet is a very democratic medium, and virtually anyone can (& does) provide their opinion online, it can be tough for a parent to search for accurate information online. Here are a few websites that provide excellent, well researched and peer -reviewed information (checked by experts) online.

1. Indian Academy of Pediatrics - Committee on Immunization - provides latest recommendations for vaccinating children in India.
2. WHO - Immunization - WHO Position papers on vaccines
3. CDC - Vaccination
4. Immunization Action Coalition - Educational material for parents
5. Children's Hospital of Philadelphia - Information for parents, especially regarding vaccine safety
6. PATH - Excellent updated information about vaccination from different resources
7. National Network for Immunization Information

Suggested Reading

IAP Guide book on Immunization 2011 (Page 161)

Latest Indian Academy of Pediatrics (IAP) recommendations 2011 for vaccinating children in India

Iap Guide Book on Immunization Iap Immunization Time Table 2011

Finally we have the latest guidelines from the Indian Academy of Pediatrics, the official & the largest body of Pediatricians in India.

Unfortunately, in India a lot of Pediatricians, especially from the smaller cities and towns seem to be following somewhat random schedules, that are not only outdated but may lead to decreased vaccine efficacy.

I would encourage parents to download this chart, and use this as a guide for getting their children vaccinated in India

The Internet Parent series - Help, is my baby having a seizure?

Here is the typical scene - you maybe feeding your infant and you suddenly notice that he has tremors in one leg. You have heard horror stories of infant seizures, and are hence obviously concerned. So is this really a seizure?

Seizures can be tough to diagnose in an infant. However here are some clues that would suggest if your child is having a seizure, or more likely a normal behaviour like tremulousness.

1. Can the movements be controlled by touching/ holding the arms /legs gently? If so, these are more likely to be normal tremors. Seizures cannot be reduced/ stopped this way.

2. Do these movements occur only at specific times, like changing diapers (or feeding as in this case)? This would be again more likely to a normal behaviour since seizures cannot be started this way).

3. Is the child developing normally? If your baby is otherwise behaving and developing normally even after repeated movements, this would make seizures less likely.

4. Are these episodes occurring both during sleep and while the infant is awake? If so this is more likely to be a seizure.

Finally, it is more likely that bilateral (both arms or leg together) movements that are symmetrical and persistent may be seizures.

While these are some useful pointers in trying to rule out seizures, given the fact that seizures can be very subtle in newborn and infants, anytime you have a doubt regarding an abnormal movement, it is a good idea to discuss this with your pediatrician.

It may be a good idea to videotape an abnormal episode (with your mobile/ camera) since this can provide invaluable information to your pediatrician too !

Suggested Reading:

1. http://pediatrics.about.com/od/weeklyquestion/a/04_baby_tremors.htm

2. http://www.epilepsy.com/info/family_parents_newborn

TIP - How do I choose "Dr Right" pediatrician for my precious baby?

If you already have a baby, the choice may be obvious for you and quite simple.

However for the first time parents, or when moving to a new location, this may be a cause of significant anxiety.

Here are some tips to help you begin your search for the "right" Pediatrician.

1. Start searching for a pediatrician preferably a couple of months before the delivery. Some babies have no respect for the 'due date' and you do not want to be caught off guard in this situation. Talk to your friends, relatives, ob/gyn & your family doctor.

2. It is very important that your pediatrician should be located close to you, at an easily accessible location, since you are likely to visit him quite often (usually more often than you think!) especially for the first born. Remember that even in the best case scenario, you would have close to 10 visits in the first year itself, so having a convenient location would make your life easier :)

3. Have a face to face meeting with your pediatrician if possible. Many pediatricians may charge for this, so ask in advance. Your level of comfort is important since they are going to be handling your most precious possession ! Try to find out their attitude regarding vaccinations, breast feeding, antibiotic use etc. if possible. You should know the working hours, emergency contact location, and appointment schedules of the clinic, since these vary considerably in practice. Which hospital does your pediatrician admit children too? Do they attend to the emergencies themselves? Try finding about the experience and qualifications of the Pediatrician too, either by asking politely, or by looking around in the clinic. Finally since in India, almost all consultations are self-paid, you would want to be comfortable with consultation charges.

4. Even though the pediatrician is the most important person in making your decision, you would want to see if the reception staff is polite, helpful and if the waiting area is child-friendly.

Remember that choosing a pediatrician is possibly the start of a relationship that could last 18 years or more! Give yourself enough time and data to make an informed choice.

More reading here

1. http://www.babiestoday.com/articles/basic-care/picking-your-pediatrician-50/3/

2. http://pediatrics.about.com/od/choosingapediatrician/Choosing_a_Pediatrician.htm

3. http://www.parents.com/baby/care/pediatricians-medicine/checklist-choose-the-right-pediatrician/

4. http://kidshealth.org/parent/system/doctor/find_ped.html

The Internet Parent (TIP) - Guide to common childcare & parenting questions

Today I am starting a new project that should (hopefully) consist of the common questions that I am asked in my Pediatric Practice.

I will try to post a question every day, and would love to have feedback / queries from parents (& would be parents) too !

While many such resources are available online, only a few are from pediatricians, and almost none from an Indian Pediatrician.

I hope to fill this gap, and try to not only educate parents, but myself in the process, and have fun.
While I would like to provide standard advise as far as possible, we all know that no two children are alike, and no single formula (one size fits all approach) exists for parenting.

As a parent and as a pediatrician, my brief would be to provide accurate information, clear common myths, and where ever possible share my experience, so that we are able to bring up healthy and happy children.

Remember, health is not defined as just the absence of disease, but a state of complete social, mental and physical well -being (by WHO).

I would love to be a part of making your children healthy !

Best Diaper Brands in India - A Pediatrician's Personal Choice

Many parents of young children, especially NRIs (Non Resident Indians) are worried when they come over to India for vacations. They are not aware of what diaper brands are available, and whether the available brands would "suit" the sensitive skin of their toddler/ infant.

A whole range of good quality diaper brands are now available in India. Here is a small selection (in no particular order)

• Pampers
• Pampers (Active) - Imported from Saudi Arabia!
• Huggies
• Momy Poko Pants (Can be worn like an underwear - no need to fasten adhesive strips)
• Wipro Baby Soft - Cloth like feel

Many of the upscale pharmacies in bigger cities also have a wide range of Imported Diapers. Hence I rarely advise parents to carry diapers in from abroad, unless the skin of the child is very sensitive, and allergic to a large number of available brands.

My personal favorite is surprisingly an Indian Brand - Wipro's Baby Soft Diapers. There are two reasons for the same...

1. It actually has a cloth like feel and is thus probably less likely to cause a contact dermatitis / allergic rash.
2. Its drying power is phenomenal, and the diaper remains significantly drier for longer than with other brands.

Full Disclosure: I use this brand for my daughter. I have NO financial relationship with the manufacturers of any diaper brands, including the ones that I am recommending. I have to buy them just like the rest of us :)

My Radio Talk on Big 92.7 FM

Just gave a talk on the common ear problems in children, including ear pain and infections and tips on ear cleaning, to the Chandigarh edition of BIG 92.7 FM.
Some photographs from the event, I enjoyed it.
I have been planning for an audioblog/ podcast, want to spread the word around - however unsure of the potential audience, and of course the time for the same ...
Any comments would be really appreciated

The Indian Swine Flu Scare

Do we need to PANIC?

There is NEVER a need to PANIC. With the below mentioned common answers, you should be able to feel more confident about Swine Flu, especially in the Indian context. The media hype in this regard needs to be ignored.

So what are the common SWINE FLU SYMPTOMS?

The symptoms of swine flu are essentially indistinguishable from the familiar misery of seasonal flu: fever, coughing, sore throat, body aches, headache, sometimes vomiting and diarrhea. So which of us need to contact the doctor?
If you have traveled abroad to a country with a large number of Swine Flu cases in the last two weeks, and have Flu like symptoms.
OR
If you have personally met someone who was later diagnosed to have Swine Flu in the last two weeks, & you have flu like symptoms.

Only under these circumstances do you need to worry about Swine Flu in India, at the present moment.

How can I prevent SWINE FLU?

Just like regular seasonal flu virus, the swine flu virus is thought to spread on droplets emitted by coughing and sneezing or deposited on hands and surfaces, then transferred to nose or mouth. Thus, practicing the usual precautions will help prevent its spread:

* Use a tissue when you cough or sneeze, and throw it away promptly. If you don’t have a tissue, cough into your sleeve.

* Wash your hands thoroughly and often, especially after sneezing or coughing, using soap and water or an alcohol rub. I personally use non alcoholic hand sanitizer by Himalaya Pharmaceuticals called Pure Hands, this is easily available with your local chemist shop. Any good hand sanitizer would do.

* Wipe surfaces like doorknobs using a regular cleaner.

* If you’re sick with flu-like symptoms, even if you don’t feel sick enough to go to the doctor, stay home from work or school to avoid giving the virus to someone else.

The most effective way to prevent Swine Flu is by STAYING at HOME, and by regular hand washing.
Please remember that as of now there is no vaccination (though one is likely to be available by the end of 2009 or sooner), antiviral medicines are generally not needed, and the disease is generally mild in most people.

When do I need to go to the Hospital?

If you have breathing problems, then you need to go the Emergency Room. Rest, Plenty of Warm Fluids, and mild OTC medications for Fever like Crocin, Brufen etc. should help you recover within 5-7 days.

Where can I get more information about Swine Flu in India?

Swine Flu India is the central website for all information and updates.
The Ministry of Health and Family Welfare has an information page for Swine Flu. This MS Word document supplied on the above page has contact information and details of the Control Rooms and Nodal Officers/Doctors for ALL states in India.
Source

For Chandigarh J&K & Punjab, diagnostic facilities are available in PGI, Sector 12, Chandigarh.

What are the doctors / pediatricians reading ?

Here is what we doctors are reading in April 2009

Top 10 Most Read Articles by Pediatricians: 1. Rocket Fuel Chemical Found in Infant Formula CDC scientists find perchlorate in samples of powdered infant formula. 2. A 5-Year-Old Boy With an Abnormal Left Eye 3. Adenoidectomy and Tonsillectomy Linked to Subsequent Overweight in Children 4. Clinical Assessment of the Crying Infant Should Guide Decision Making 5. US Declares Swine Flu Emergency 6. Cephalosporin Use in Treatment of Patients With Penicillin Allergies 7. Presentation, Prognosis, Treatment of Most Common Newborn Rashes Reviewed 8. Parenting Practices and ADHD 9. AHA Updates Advice on Strep Throat, Preventing Rheumatic Fever 10. Pacifier Use May Not Adversely Affect Breast-Feeding Duration or Exclusivity

Top 10 Most Read Articles by All Physicians: 1. Efalizumab Withdrawn From US Market Efalizumab (Raptiva), used for the treatment of psoriasis, will no longer be available in the United States because of the risk for progressive multifocal leukoencephalopathy. 2. Hidden Malpractice Dangers in EMRs 3. The Case of the Missing Shaving Blade! 4. US Declares Swine Flu Emergency 5. Stimulus Package Could Convert More Physicians to EHRs 6. Dealing with the "Disruptive" Physician Colleague 7. A 5-Year-Old Boy With an Abnormal Left Eye 8. Progressive Neurologic Deterioration in a 23-Year-Old Man 9. WHO Raises Pandemic Level for Swine Flu, Mexican Death Toll Mounts 10. Less Is More: Simplified 4-Step Algorithm Improves BP Control

These articles are from Medscape from WebMD and may require free registration for viewing.
I specifically enjoyed tonsillectomy, crying infants, and newborn rashes amongst the articles for pediatricians, and the article on BP control among the physician read articles.