Articles by Dr. Cheryl Mutch from The Vancouver Province

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Abdominal Pain

Question:

My 9 year old daughter seems to be getting a lot of stomach aches. Iím concerned about what may be causing these. She seems to be healthy otherwise.

Answer:

Stomach aches in children are very common and can be caused by a number of different conditions  Most times, if there are no other symptoms (such as fever, diarrhea, constipation, weight loss or appetite suppression) and your daughter is otherwise well, this is called “functional abdominal pain” or “recurrent abdominal pain of childhood.” This is a type of pain that cannot be explained by medical tests. Children with this type of pain usually complain of pain in the area around the umbilicus, or belly button. The pain usually begins after the age of 6 years and can interrupt their normal activities. They will often come home from school complaining of pain. Kids with functional abdominal pain are completely well between episodes of pain. They may have a tendency to worry about things. I have found that when I see these kids in my office, they are extremely well-behaved. They often put pressure on themselves to do very well in school and in sports. I have also noticed that many of these kids have tension-type headaches at times as well.

In terms of treatment, many children will have a good response to adding more dietary fiber and water to their daily intake. Fiber can be found in fruits, vegetables, whole grains and legumes. The fiber, along with the water helps to keep the bowel movements soft and more regular and most children will notice an improvement in their pain. Eating regularly without skipping meals is also helpful for preventing this type of pain.

Of course, there are other causes of abdominal pain in children, just as there is more than one cause for headaches. Your daughter’s doctor can decide whether any testing needs to be done after a careful physical exam. Sometimes, urine and stool testing are done to rule out infection. Occasionally a blood test will also be done in order to rule out such things as inflammatory bowel disease, or lactose intolerance. Constipation can also be a common cause of abdominal pain in children.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Attention Deficit Hyperactivity Disorder or ADHD

Question:

My 10 year old son has been showing some signs of ADD. Is there anything that can help besides medication? Despite his behavioural problems, heís doing okay in school. I had problems paying attention in school, but I was never diagnosed with ADD.

Answer:

Attention Deficit Hyperactivity Disorder, or ADHD, is a common condition and affects up to 5-10 % of school aged children. The diagnosis of ADHD is based on a number of behaviours, seen in the home and at school, which impair the child and have been present for at least 6 months. The diagnosis is made by an experienced physician who will also look for other conditions that could be causing your son’s behavioural issues, including medical problems, anxiety, or environmental factors. Treatment can involve medication, but up to 30% of children will experience side effects so many parents prefer to avoid these medications.

If your son has been diagnosed with ADHD, there are a number of other things that can help with his focus and classroom behaviour.

I would first suggest that you talk to his teacher and get her insight. Teachers are often the first ones to notice behavioural problems. His teacher can help come up with a program to motivate him to listen and control his behaviour in the classroom. She may also give him short breaks during class time to allow him to move around a little.

Speaking of movement, exercise is very important for children. Children who don’t get enough can have a difficult time controlling their behaviour. Some children have more energy than others. If you have a high energy child, have him walk briskly to school, or get him there early so he can play in the school yard before class begins. Ensure he has an opportunity for physical activity during recess and lunch time too. Some children with ADHD are held inside during recess to finish up incomplete work. Often counterproductive, this can compound the difficulties your child may already be experiencing in the classroom.

Nutrition, as always, plays an important role. Children who eat breakfast do better in the classroom. Be sure to include protein, fat and or complex carbohydrates so the benefits of the breakfast stay with him throughout the morning. A recent study has shown that some children are sensitive to preservatives and artificial food dyes, so try to avoid highly processed foods. Some studies have shown that fish oil supplements can help children with learning and developmental disabilities. A benefit in ADHD has also been suggested. Some children with ADHD have low iron levels, so it’s important to look at the overall diet to be sure it is not deficient.

Sleep is vital, too. Children who don’t get enough have a difficult time coping with the extra demands placed on them. Make sure your son gets to bed early enough so that he wakes up in the morning before school with little or no prodding from you. 

We don’t really know what the effect of long hours spent on the computer, video games, or watching TV on developing brains, but until we do, it seems reasonable to set strict  limits.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Baby Bottle

Question:

When should I take my 18 month old son off the bottle? He seems really attached to it.

Answer:

This would seem like a simple question but it is one that most parents of toddlers will struggle with.  A few years back, while doing some research for a weaning statement for the Canadian Pediatric Society, I was surprised to learn that the World Health Organization recommends that the baby bottle be taken away by 15 months! When I tell that to parents in my office, they usually look at me like I have 2 heads. My own daughter had the same reaction several years back. We did eventually came to a compromise, but I still feel like a bit of a fraud every time I tow the WHO party line with my patients!

Most toddlers who drink from the bottle have their own idea about when to toss the bottle. I’m convinced that some would happily head off to Kindergarten with their bottle in tow!

Toddlers who drink milk and juice from the bottle will often get a significant disproportion of their daily food intake through the bottle. I have known some toddlers who drink 8 or more bottles of milk per day. The problem with this amount of milk drinking is that it usually comes at a cost. These children usually drink milk (which is not nutritionally complete and very low in iron) at the expense of eating other foods. They often become iron deficient and anemic. These children may be pale in appearance, clingy, irritable and sometimes constipated. If this sounds like your child, you should start by limiting the amount of milk you offer to no more than 24 ounces (750 ml) per day. Consider seeing your child’s doctor who may order some lab work to look for anemia.

Children over the age of 2 years need even less milk –not more than 16 ounces (500 ml) per day according to Canada’s Food Guide. You will find that by limiting the milk intake, your child’s appetite for other foods will increase. Parents are often reluctant to remove the bottle “cold turkey” in these older children so it’s often easier to just take away the least favourite bottle of the day first and remove another one after a few days or so. It’s best to do this when things are stable at home, that is, you’re not traveling, no one is sick, and there are no big changes afoot like the arrival of a new sibling.

Children who have unfettered access to the bottle often have problems with “baby bottle caries.” That is, cavities of the baby teeth due to constant exposure to lactose which has the same effect on teeth as sucrose or glucose. The best way to avoid this situation is by limiting the bottle to 2 or 3 times per day and always brushing your son’s teeth after the bottle. Of course, it goes without saying that a baby should never go to sleep with a bottle of milk or juice.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Body Mass Index

Question:

At a recent check-up, my daughterís doctor mentioned that her BMI is in the 75th percentile. The doctor said that's healthy although the BMI was on the 55% only 6 months ago. What BMI is considered unhealthy, on either the low or high end?

Answer:

BMI (Body mass index) for age is a screening tool that helps medical practitioners identify children over age 2  who may be either over or under weight. It is a calculation based on both weight and height. (weight[kg]/height[m2])

A normal BMI is somewhere between the 5th and 85th percentiles. A BMI below the 5th% can indicate underweight. A BMI above the 85th% can indicate a risk for being overweight and above the 95th% can indicate overweight (or obese, depending on whose terminology you wish to use.) Your daughter’s BMI, at the 75th %, is considered normal. It means that out of 100 children of the same age and sex as your child, 75 of them will have a lower BMI and 25 will have a higher BMI.

Children will move along the BMI charts for different reasons as they grow. It’s important to know that the absolute BMI normally decreases during the preschool years and then starts to increase around age 5 or 6 years. Things that can increase the BMI would be anything that increases the weight in relation to the height. So, for instance, if your child has become more physically active lately and has gained muscle mass (which is heavier and denser than fat tissue), then her BMI will increase accordingly.

You have not said how old your daughter is, but oftentimes, as children prepare for the pre-pubertal growth spurt, they seem to gain a bit of extra weight beforehand. This is a normal, physiological phenomenon and there is no need to panic.

Having said that, it’s always reasonable to keep an eye on things, particularly if there is a family history of obesity, or if your child is inactive or eats a diet high in calories. If this is the case, I suggest having another BMI checked in 3-6 months.

Let your daughter know that her changing body is normal and this will help her feel good about her body. Help her to develop lifelong habits that will protect her health. Make healthy foods an easy choice in your home and encourage her to eat well. Eat together as a family as much as possible. Limit time spent in front of the tv and computer. Remember that you are a role model so be active, eat well, and be kind to yourself. Don’t let her hear you make negative comments about your own body.

To calculate your child’s BMI, you can go to: http://apps.nccd.cdc.gov/dnpabmi. As this is an American website, so you can use weight in pounds and height in inches.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Colic

Question:

My 2 month old daughter has severe colic and Iíve heard that there is medication that can help. What do you suggest?

Answer:

Colic is a syndrome of severe crying in infants under 3 months of age. It is relatively common, and can cause extreme stress on a family. It is still not completely understood by the medical profession, which makes it even more stressful for parents who seek help in dealing with colic. Causes thought to contribute to colic include food sensitivity or allergy, difficult infant temperament as well as more recently, alterations in the normal bacterial flora of the infantís digestive tract.

Itís very important to make sure that colic is, in fact, the cause of your daughterís crying. Classically, the diagnosis of colic is based on ďthe rule of threes.Ē That is, periods of crying lasting 3 or more hours per day, for 3 or more days per week and for a minimum of 3 weeks. The crying episodes are worse in the late afternoon and evening and the peak of the crying is usually around 6 weeks of age.

The good news is that colic usually resolves by 3 months of age. If your daughter is growing well, without other signs of illness such as fever, vomiting, or rashes, then colic is the most likely explanation for her crying. Make sure that you have her checked over by her health care provider in order to rule out any other causes. It is likely that as part of the exam, she will have her urine tested in order to rule out infection.

Treatment of colic can involve several different approaches. The unfortunate thing is that many of the things that have been recommended to parents for years provide little, if any benefit.

Herbal remedies have been shown to help colic in some limited studies. This is likely due to their antispasmodic properties. Be aware, that many of these remedies contain sugar and alcohol. If you are breastfeeding, try a strict cowís milk free diet for at least a week. If the colic improves significantly, then continue with the diet while you take a calcium and vitamin D supplement. Formula fed infants might do better on a hypoallergenic formula rather than a routine cows milk or soy formula. Over the counter ďdefoamingĒ medications like simethicone (Oval) may decrease gas, but there is not much strong evidence to support its use. Probiotics have recently been shown to have promise in the treatment of colic One of the most important things to understand is that colic is self-limited and is not due to a disease or anything that you, as a parent, have done wrong. As the parent of a colicy infant, you need to get some help from family and friends in looking after your baby. Whenever the crying gets to be too much, put her in her crib and take a breather and get some help. As they say, it takes a village.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Essential Fatty Acid Supplement

Question:

Iím wondering whether my son is getting enough essential fatty acids. Iíve heard that they can help with learning and Iím worried because he doesnít like fish and he often has trouble concentrating in school. Whatís the right dose?

Answer:

Itís a great question and one to which we do not yet seem to have the full answer. Essential fatty acids (EFAs) are called essential because our bodies cannot manufacture them in sufficient quantities and they are essential to health and development. EFAís are divided into two types: omega 6 and omega 3. Sources of omega 6 fatty acids include nuts, seeds and vegetable oils such as corn oil, sunflower oil and soybean oil. Dietary sources of omega 3 fatty acids include canola oil, soybean oil, flaxseed, walnuts and FISH. There are also, of course, a number of foods supplemented with omega 3 fatty acids like omega 3 eggs. During the last century, our western diet has evolved such that we are taking in relatively more omega 6 containing foods compared with our intake of omega 3 containing foods. The recommended ratio for dietary intake of omega 6:omega 3 is approximately 6:1, whereas the typical western diet has a 20:1 ratio.

The most important omega 3 fatty acids for cognitive development are the PUFAs commonly referred to as EPA and DHA. These are now added as supplements to many infant formulas, and I have even seen them added to puppy food!

There has been a recent interest in the role that omega 3 fatty acid deficiency plays in certain neurodevelopment disorders like ADHD, dyslexia, dyspraxia, developmental coordination disorders and autism spectrum disorders. Some children with these disorders have been found to be deficient in these EFAís. Several studies indicate a positive treatment effect on ADHD as well as developmental coordination disorder. Unfortunately, the studies have either been small or have had methodological issues that prevent us from making a definitive recommendation regarding the use of EFA supplementation in these disorders.

If you decide to supplement your son with omega 3 fatty acids, in general, they are well- tolerated. Some children will complain of a ďfishyĒ after taste. And there have been a few reports of nausea and nose bleeds. The US FDA considers a daily dose of less than 3 grams of EPA + DHA to be generally safe, although dosages for children have yet to be established. A supplement may even be preferable to eating copious fatty fish as the fish can have potentially significant amounts of toxins like mercury, PCBs, and dioxins.

Itís a good idea to add more walnuts and flaxseed to your sonís diet as well as to consider the use of foods that are supplemented with omega 3 fatty acids if he is a non-fish eater. Use canola oil more in your cooking and baking as well. In general, itís not a good idea to try to hide fish in your sonís food, just offer a small amount at mealtime and donít make a big fuss about it.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Food Allergies

Question:

It seems like food allergies are becoming increasingly common. I have a 7 month old baby whom Iím breast feeding and a 2 year old. Is there anything I can do in order to prevent them from developing food allergies?

Answer:

Your question is a really good one and one that has had parents and physicians alike scratching their heads. In fact, some of the recommendations that physicians have been giving to parents for over a generation as ways to prevent allergies turn out not to be “evidence based” and therefore, may not be appropriate. One of the things that we do know, is that allergic illnesses are becoming increasingly common.

For years, pregnant and breastfeeding mothers have been cautioned against eating certain foods (such as peanut and sometimes shellfish) as a way of helping to prevent allergies in their offspring. In fact, at the present time, there really isn’t enough evidence to draw firm conclusions as to whether this will make a difference in the development of allergic diseases. The only caveat is that there may be a place for breastfeeding mothers to avoid highly allergic foods in the prevention of eczema.

There are so many positive reasons to breastfeed that this point almost seems to be a given, but there is evidence to support exclusive breastfeeding for at least 3-4 months to prevent eczema, cow milk allergy, and wheezing in the early years. If you are unable to exclusively breastfeed and your infant is at high risk for allergies (essentially meaning that Mom, Dad, brother or sister have allergies, asthma or eczema) then it’s a good idea to offer a specialized formula. These formulas have their proteins partially or fully broken down or hydrolyzed so that they are hypoallergenic. They don’t offer a benefit over exclusive breastfeeding however. It’s also important to note that soy formula does not appear to offer any benefit over cow milk formula for the prevention of allergies. If you need to supplement and your child is at high risk for allergic illness, then you should talk to your health care provider for advice on appropriate formula choice.

Many parents have been told to delay the introduction of certain solid foods in order to prevent allergies. There is no convincing evidence to delay the introduction of solid food beyond 6 months of age in order to prevent allergies. This includes such foods that are considered highly allergic, like fish, eggs and foods containing peanut protein. This is a relatively new change in recommendations and comes from a report published in January 2008 by the Committee on Nutrition and the Section on Allergy and Immunology of the American Academy of Pediatrics.

If your child develops wheezing, cough, hives, or facial swelling immediately after eating a food, have them seen by a doctor as soon as possible. While delaying the introduction of a highly allergic food does not seem to prevent an allergic reaction, it would seem reasonable to wait to introduce highly allergic foods to high risk children until they are old enough to tell you if they are feeling unwell after eating.

You may have heard of the “hygiene hypothesis” which suggests that if a child is kept too clean, that he will have a higher risk of developing allergic disease. The idea is that if a child is exposed to certain bacterial and viral illnesses early on in life, that his immune system will be stimulated in such a way as to fight diseases rather than develop allergies. Thus, it seems that children who attend daycare from an early age, have multiple siblings, are exposed to animals, and come from a lower socioeconomic background seem to have a lower risk of allergic disease. There is still much to be learned about the hygiene hypothesis, but it is certainly food for thought.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Iron Deficiency

Question:

My son was anemic as a toddler and the last time he was tested (at 5 years old) his iron levels were low. I am aware that the consequences of anemia in children can be serious and if the problem persists cognitive development may be impaired. My son is now 11 years old. He is very slim, has a relatively small appetite and although we arenít vegetarians, he rarely eats red meat. My doctor assures me that he is healthy and has told me that if I want his iron levels tested I have to pay for it. What should I do?

Answer:

Anemia can be caused by a number of different conditions, but the most common one that I see in my office is nutritional iron deficiency, caused by a lack of iron in the diet. Iron is needed by the body to make hemoglobin which carries oxygen from the lungs to all the body’s organs. Iron deficiency is more common than overt anemia, and can have little or no signs. As the deficiency worsens, anemia develops.

The most common ages for anemia to occur in the pediatric age group are during infancy, and during adolescence in girls. During infancy, once cows milk is introduced, some babies will develop a preference for it and drink it to the exclusion of iron rich foods.  Teen girls are also at high risk for anemia, due to a number of reasons including intensive exercising, losing blood during the menstrual cycle, a growth spurt, as well as consuming a diet low in iron as a way to manage their weight (think diet soda and microwave popcorn.) Teen and preteen boys eating an adequate diet are generally protected from anemia as they tend to have a robust appetite and eat almost anything they can get their hands on.

The signs to watch for that can indicate anemia include pallor of the skin along with irritability and a desire to eat unusual things like dirt or ice. In severe cases of anemia, children may have a drop in their appetite which can compound the anemia further. Iron deficiency can have effects on mental alertness, attention span and learning in infants as well as adolescents.

How much dietary iron is needed? 8-10 mg of iron is the RDA (recommended daily allowance) for the typical pre-teen boy.  This could be met by eating a bowl of instant oatmeal (enriched) at breakfast, a bagel as part of his lunch, and a serving of pasta with dinner. Adding something containing vitamin C such as orange juice or fruit, will enhance the absorption of the iron. Red meat not necessarily required.

I would suggest that you take a good look at his diet by recording what and how much he eats over a 3 day period (try a Sunday, Monday and Tuesday) and compare it to the list of iron in foods found at the dial-a-dietician website ( dialadietician.org.)  If you’re still concerned, it would be reasonable to go back to see your doctor with the food diary and the list of iron in foods in hand.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Vitamin D

Question:

I have a 2 Ĺ year old daughter who is a fairly good eater by toddler standards. She drinks about 8-12 ounces of milk per day as well as a serving of yogurt per day. I am currently giving her a multivitamin with vitamin D (400 IU.) Is this enough, or could it be too much?

Answer:

Vitamin D, also known as the sunshine vitamin is in fact, a group of hormones obtained from sun exposure, food and dietary supplements. It has long been known that vitamin D is crucial in maintaining bone and dental health, but over the past several years, there has been increasing evidence that vitamin D plays a role in the prevention of cancer, multiple sclerosis, rheumatoid arthritis, inflammatory bowel disease and diabetes.

The current recommendation for Vitamin D intake is 400 IU(international units) for babies up to age 1 year, and 200 IU from age 1-50 years. The recommended dosage increases after age 50.

It is extremely important that children as well as adults get enough vitamin D. The vitamin is readily made by the body upon exposure to sunlight. Because Canada is so far north, it can be difficult to get enough vitamin D the old fashioned way. Add to our latitudinal disadvantage the fact that we have many dark and cloudy days decreasing our exposure to UV light, the fact that children spend increasing amounts of time indoors and when they are outside, are covered up, either by clothing or sunscreen. Itís easy to see why Canadian children are at risk for Vitamin D deficiency. In 2003, a study of children in Edmonton found that at least 34% were vitamin D deficient.

Babies at highest risk of vitamin D deficiency are those who are exclusively breastfed (without a vitamin D supplement,) who have mothers who are vitamin D deficient and who have darker skin and live in Northern communities.

Foods that are good sources of vitamin D include cowís milk, fortified soy beverages, margarine, salmon, tuna, liver, and kidney.

Is there such a thing as too much vitamin D? The current knowledge on the highest daily intake that is likely to pose no risk of adverse health effects in infants up to 1 year of age is 1000 IU and for adults, that level has been set at 2000 IU per day. These levels may eventually prove to be low, however, this will depend on future studies. The Canadian Pediatric Society, recognizing that vitamin D deficiency is common among Canadian children has recommended that infants and children should be exposed to sunlight for short periods, up to 15 minutes per day.

from The Vancouver Province - written by Dr. Cheryl Mutch

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Weaning

Question:

I am starting to wean my 11 month old son from nursing him down to 4, then 3 then 2 times per day. Do I need to supplement with formula? If so, how much formula does he need? He drinks water from a sip cup. Thank you.

Answer:

Itís great to hear that you are taking a gradual rather than an abrupt (AKA ďcold turkeyĒ) approach to weaning. This is the gentlest and least emotionally traumatic way to wean a baby from breastfeeding.

It sounds as though you are planning to continue to breastfeed a few times per day, and given the timing of your question, I assume that you are planning to return to work. Many breastfeeding mothers, who are employed part and even fulltime outside the home, can continue to breastfeed for months or longer. Much depends on how you handle the weaning process and how your baby responds. Keep in mind that every mother/infant pair are different and while you may plan to stop breastfeeding at a certain time, your baby may have a completely different idea.

In terms of offering formula, I would suggest that you keep your volume expectations low. Most 11 month old babies who are accustomed to breast milk are not too keen on formula when it is first offered as it tastes entirely different. He is likely to have an easier time adjusting to the formula in the sip cup if he has had previous experience with expressed breast milk or even water from it already. Try giving it when he is a little hungry, perhaps just before a meal or snack time. I would recommend no more than 24 ounces of formula per day be offered to him. If he takes more (unlikely) then it is likely that he wonít have much of an appetite left over for his solid food. My expectation for a recently weaned baby at his age is that initially he will take far less than 24 ounces. You can make up the difference by breastfeeding him in the morning before you go to work as well as when you get home and throughout the evening hours. If you havenít had any problems with low milk supply in the past, your supply should continue. If you have concerns, see your doctor or a lactation specialist.

If you are planning to fully wean and your baby does not take to the taste of formula, then offer him water, and a few servings of full fat dairy products like yogurt and cottage cheese. Also be sure to offer him meat, chicken and fish as these are good sources of protein and iron. Keep giving him his vitamin D supplement until he is taking 16 ounces of formula per day.

At around 12 months of age, you can offer whole (3.25% milk fat) cows milk. Again, keep the amount to less than 24 ounces and, by the end of the second year, aim to get the amount to around 16 ounces, no more. A toddler who drinks excessive cowís milk runs the risk of developing severe anemia, which can affect his mood, appetite, as well as his cognitive development. This recommendation is in keeping with Canadaís Food Guide which can be downloaded from the health Canada website: www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

from The Vancouver Province - written by Dr. Cheryl Mutch

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