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Health and Fitness, Nutrition, Pediatrics, Public Health

Pediatrics group issues new recommendations for building strong bones in kids

Pediatrics group issues new recommendations for building strong bones in kids

MilkshelfOur bones function as retirement-savings accounts for calcium: We deposit the mineral into our bones when we’re young, then draw on the stores as we age. Too little calcium in the “savings account” puts people at risk for osteoporosis and debilitating bone fractures later in life.

This means that, although osteoporosis is usually seen as a disease of old age, pediatricians and parents need to pay attention to bone health. This week, the American Academy of Pediatrics released updated guidelines for pediatricians on how nutrition and exercise can improve bone density in their patients. The guidelines were co-authored by Stanford’s Neville Golden, MD, who is also an adolescent medicine specialist at Lucile Packard Children’s Hospital Stanford. The report discusses calcium, which strengthens bones; vitamin D, which helps the body absorb calcium; and weight-bearing exercise, which promotes calcium deposition into the bones.

In addition to protecting against fractures in old age, the guidelines address the needs of kids whose bones are weakened by a variety of childhood and adolescent medical conditions, including juvenile osteoporosis, cystic fibrosis, lupus, celiac disease, cerebral palsy and anorexia nervosa.

A few highlights from the recommendations:

  • Children and adolescents should get their calcium mostly from food, not supplements. To meet calcium requirements, the committee recommends three or four daily servings of dairy foods (depending on the child’s age) and also suggests alternative food sources such as dark green veggies, beans, and calcium-fortified orange juice or breakfast cereals.
  • Vitamin D recommendations went up in 2011; the AAP agrees with the increased recommendations for all children and notes that kids using certain medications have even higher requirements than healthy children. Although the body can make vitamin D from sunlight, the report notes that kids are spending more time indoors and that sunscreen prevents vitamin D synthesis, making children more reliant on food and supplements to get enough vitamin D.
  • Soda often displaces milk in children’s diets, adding bone health to the list of reasons doctors should discourage soda consumption.
  • Weight-bearing exercise helps strengthen the bones. The report recommends activities such as walking, jogging, jumping and dancing over exercises such as swimming and cycling for building bone health.
  • Adolescent girls with eating disorders such as anorexia nervosa and the female athlete triad experience bone loss. In the past, some physicians have suggested that these young women could improve their bone density by taking oral contraceptives, but the report notes that randomized controlled trials have not found any evidence that oral contraceptives increase bone mass for these patients.

Previously: Goo inside bones provides structural support, study finds, New genetic regions associated with osteoporosis and bone fracture and Avoiding sun exposure may lead to vitamin D deficiency in Caucasians
Photo by Stephanie Booth

Big data, In the News, Patient Care, Pediatrics, Stanford News

Examining the potential of big data to transform health care

Examining the potential of big data to transform health care

Back in 2011, rheumatologist Jennifer Frankovich, MD, and colleagues at Lucile Packard Children’s Hospital Stanford used aggregate patient data from electronic medical records in making a difficult and quick decision in the care of a 13-year-old girl with a rare disease.

Today on San Francisco’s KQED, Frankovich discusses the unusual case and the potential of big data to transform the practice of medicine. Stanford systems-medicine chief Atul Butte, MD, PhD, also weighed in on the topic in the segment by saying, “The idea here is [that] the scientific method itself is growing obsolete.” More from the piece:

Big data is more than medical records and environmental data, Butte says. It could (or already does) include the results of every clinical trial that’s ever been done, every lab test, Google search, tweet. The data from your fitBit.

Eventually, the challenge won’t be finding the data, it’ll be figuring out how to organize it all. “I think the computational side of this is, let’s try to connect everything to everything,” Butte says.

Frankovich agrees with Butte, noting that developing systems to accurately interpret genetic, medical or other health metrics is key if such practices are going to become the standard model of care.

Previously: How efforts to mine electronic health records influence clinical care, NIH Director: “Big Data should inspire us”, Chief technology officer of the United States to speak at Big Data in Biomedicine conference and A new view of patient data: Using electronic medical records to guide treatment

CDC, In the News, Infectious Disease, Pediatrics, Public Health

Q&A about enterovirus-D68 with Stanford/Packard infectious disease expert

Q&A about enterovirus-D68 with Stanford/Packard infectious disease expert

SONY DSCToday’s New York Times features a story on the accelerating spread of enterovirus-D68, a virus that is causing severe respiratory illness in children across the country. As the Times reports, some emergency departments in the Midwest have been so swamped with cases that they’ve had to divert ambulances to other hospitals. Although California is still only lightly affected, the state’s first four cases were confirmed by the California Department of Public Health late last week, with more expected to surface.

To help parents who may be wondering how to prevent, spot and care for EV-D68 infection, Yvonne Maldonado, MD, service chief of pediatric infectious disease at Lucile Packard Children’s Hospital Stanford, answered some common questions about the virus:

Enteroviruses are not unusual. Why is there so much focus from health officials on this one, EV-D68?

The good news is that this virus comes from a very common family of viruses that cause most fever-producing illnesses in childhood. But it’s been more severe than other enteroviruses. Some hospitals in other parts of the country have had hundreds of children coming to their emergency departments with really bad respiratory symptoms. The fact that it’s been so highly symptomatic and that there has been a large volume of cases is why it has gotten so much attention.

Have any patients at Lucile Packard Children’s Hospital Stanford been affected with EV-D68?

As of today (Sept. 26), we have not yet had a documented case at our hospital. However, there have been a total of 226 confirmed cases in 38 states across the country. Some children who have this virus are probably not being tested, so the real number of cases nationwide is likely to be higher.

If your child has respiratory symptoms and you suspect EV-D68, what should you do?

The virus causes symptoms such as coughing, sneezing and runny nose. In some cases but not all, kids also have a fever. If your child has respiratory symptoms with or without a fever, especially if he or she also has a history of asthma, monitor your child at home. If you feel that he or she has been sick for a long period, is getting worse or is experiencing worsening of asthma or difficulty breathing, go see your pediatrician.

Which groups are most at risk?

Children with a history of asthma have been reported to have especially bad respiratory symptoms with this virus. It can affect kids of all ages, from infants to teens. So far, only one case has been reported in an adult, which makes sense because adults are more likely to have immunity to enteroviruses. We do worry more about young infants than older children, just because they probably haven’t seen the virus before and can get sicker with these viral infections.

How can the illness be prevented?

This virus is spread by contact with secretions such as saliva. If your children are sick, they should stay home from school to avoid spreading the illness to others. To avoid getting sick, stay at least three feet from people with symptoms such as coughing and runny nose, wash your hands frequently, and make sure your kids wash their hands often, too.

What is the treatment for EV-D68?

There is no treatment that is specific to the virus. At home, parents can manage children’s fevers with over-the-counter medications, make sure they drink lots of fluids to avoid dehydration, and help them get plenty of rest. For children who are very ill, doctors will check for secondary illnesses such as bacterial pneumonia, which would be treated with antibiotics, and may hospitalize children who need oxygen or IV hydration to help them recover.

Previously: Tips from a child on managing asthma
Photo by Michelle Brandt

Genetics, Pediatrics, Stanford News, Surgery, Transplants

Double kidney transplants leave Hawaii siblings raring to go

Double kidney transplants leave Hawaii siblings raring to go

kidney patients

Two kids; two cases of a rare, often fatal disease; and now, thanks to the work of Lucile Packard Children’s Hospital doctors, two growing kids.

Both Julia Faisca, nearly 10, and Dominic Faisca, 8, suffer from cystinosis, a genetic disease that causes an amino acid — cystine — to build up in the kidney, eye and other places in the body.

The condition retarded the siblings’ growth, and damaged their kidneys. And by May 2013, Julia’s kidneys needed to be replaced. Fortunately, just three months later, she had a new kidney. And the Faisca family received the good news that a kidney was waiting for Dominic while they were flying to California from their home in Hawaii for a routine checkup for Julia.

“We’ve been busy — two kidney transplants in less than a year,” the kids’ mom, Natasha, said in a recent Inside Stanford Medicine story:

“Since their transplants, they aren’t picky eaters anymore,” Natasha said. “I joke with the doctors that the kids are eating me out of the house now. But it’s well worth it.”

Although they’ll always be on medication to protect their new kidneys and will need to return for twice-yearly checkups at Stanford, there’s finally a sparkle in their eyes, Natasha said.

“Dominic and Julia are growing like weeds and it’s really fun to watch them turn into regular kids,” said pediatric transplant specialist Paul Grimm, MD.

Both transplants were conducted by Waldo Concepcion, MD, a specialist in multi-organ transplantation.

Becky Bach is a science-writing intern with the Office of Communications and Public Affairs.

Previously: Baby born with rare, often-fatal kidney disease “doing well” at Packard Children’s Hospital, Contact sports OK for kids with one kidney, new study says and “Delivering hope” at Packard Children’s Hospital
Photo by Norbert von der Groeben

Chronic Disease, Pediatrics, Public Health, Stanford News

Diabetes self-management program helps at-risk teens and their families make healthier choices

Diabetes self-management program helps at-risk teens and their families make healthier choices

Diabetes_coaches_classThe prevalence of Type 2 diabetes among Americans ages 12 to 19 has grown from nine percent to 23 percent in less than a decade. In an effort to reduce U.S. adolescents’ diabetes risk, researchers at Stanford developed a school-based program where medical residents train healthy at-risk teens to be self-management coaches for family members diagnosed with Type 2 diabetes.

Researchers tested the initiative, called the Stanford Youth Diabetes Coaches Program, over the course of a year at three Bay Area high-schools serving primarily ethnic minority youth of low socioeconomic status. The study involved 97 adolescents – 49 student coaches and 48 non-participant students. Student coaches participated in an eight-week training course that was taught by family medicine residents and modeled after the Stanford University Diabetes Self-Management Program for adults. All participants completed pre- and post-study questionnaires and a select group of student coaches and family members gave in-depth interviews.

The program emphasized communication skills, problem solving and setting achievable goals using action plans. Beyond providing basic diabetes knowledge, the program also included guidance on nutrition, healthy meal planning, physical activity, weight management and stress management and on developing relationships with health-care providers. Student-coaches engaged with their family members during weekly 30-minute sessions where they shared information about topics they learned in class, discussed their relatives’ experiences and goals and helped them make an action plan for the week. In discussing their findings, study authors’ wrote:

The results of the study indicate that the Stanford Youth Diabetes Coaches Program increases knowledge and psychosocial assets of participant youth … Youth participants also reported positive changes in their own lives as the coached family members, and family members emphasized the importance of student coaches’ role in encouraging healthy behaviors. Additionally youth participants reported high program satisfaction.

These results substantiate current work suggesting that school-based programs benefit adolescents and that children have potential to support the self-management of family members with diabetes. Evidence strongly suggests that school-based programs hold promise to improve the health of at-risk adolescents.

“This study really speaks to the question of: How do you engage teens about their health?,” said first author Liana Gefter, MD, a research associate in Stanford’s Center for Research and Education in Family and Community Medicine. “The effectiveness of the program is rooted in the idea of empowering students to be a leader in a setting where they are traditionally only told what to do. A lot of the students really had a transformation during the eight-week course. Our findings demonstrated that after only eight weeks, compared to non-participants, students had significant increases in self-worth and belonging – assets that have been shown to be necessary precursors for adopting healthy behaviors. In this way, we believe the program could lay the foundation for sustainable health improvement.”

During interviews with researchers, student coaches and diabetes patients said the program inspired them to improve their diet and increase their regular physical activity. Additionally, they noted that the program strengthened their relationships with each other, and students reported their appreciation for having a physician come into their classroom.

In light of the program’s success, Gefter and colleagues Nancy Morioka-Douglas MD, MPH; Eunice Rodriguez, MPH, DrPH, and Lisa Rosas, MPH, PhD, are working to expand the program to underserved schools at other sites in California and around the country. Pilots are currently underway, or will begin, at campuses in Delaware, Georgia, Washington, Ohio and Michigan.

Previously: Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert, Have you voted in the Healthy Living Innovation Awards?, Diabetes prevention program trains youth in chronic disease self-management and Stanford Diabetes Coaches Class selected as 2011 Healthy Living Innovation Awards finalist
Photo by Stanford Youth Diabetes Coaches Program

Cardiovascular Medicine, Patient Care, Pediatrics, Stanford News

A nurse puts heart into her work at Adult Congenital Heart Program

A nurse puts heart into her work at Adult Congenital Heart Program

heart_sillman_560A few decades ago, if a child was diagnosed a serious heart defect it was essentially a death sentence, but thanks to recent advances in neonatal heart surgery, most patients now live well into adulthood. And at least one of them has gone on to care for other people with congenital heart defects.

Christy Sillman, RN, is the nurse coordinator for Stanford’s Adult Congenital Heart Program and is profiled in the most recent issue of Inside Stanford Medicine. Although most people who were treated for heart defects as children don’t require continued surgical interventions as adults, doctors now know that they have other challenges that require ongoing care. Sillman went through this firsthand. After being told as a teenager that she was “cured” and going a decade without care, she learned she was suffering from cardiomyopathy, a deterioration of the heart muscle. From the article:

“At that point, my frustration with the medical care of people with congenital heart defects was elevated,” Sillman recalled. “I wouldn’t have been in such bad shape had I gotten the right care earlier. This motivated me to get more involved.”

That involvement was huge. Sillman talked with many people who shared similar stories, which inspired her to become an advocate for patients like herself. When a position was available with the program at Stanford in 2013, Sillman jumped at the chance and was hired.

“I don’t want any teenager to go through what I went through,” Sillman said. “Being told you’re cured and finding out that’s not really true? That should never happen.”

Sillman’s personal experiences are not unusual for a congenital cardiac patient of her generation, but it influenced her professional choices and now, she says, she enjoys bringing “a patient’s perspective” to her work.

Previously: Patient is “living to live instead of living to survive,” thanks to heart repair surgery
Photo by Norbert von der Groeben

Applied Biotechnology, Cancer, Genetics, Pediatrics, Research

Gene-sequencing rare tumors – and what it means for cancer research and treatment

Gene-sequencing rare tumors - and what it means for cancer research and treatment

Sequencing the genes of cancer patients’ tumors has the potential to surmount frustrating problems for those who work with rare cancers. Doctors who see patients with rare tumors are often unsure of which treatments will work. And, with few patients available, researchers are unable to assemble enough subjects to compare different therapies in gold-standard randomized clinical trials. But thanks to gene sequencing, that is about to change.

Though this specific research was not intended to shape the child’s treatment, similar sequencing could soon help doctors decide how to treat rare cancers in real time

That’s the take-away from a fascinating conversation about the implications of personalized tumor-gene sequencing that I had recently with two Stanford cancer experts. Cancer researcher Julien Sage, PhD, is the senior author of a recent scientific paper describing sequencing of a pediatric tumor that affects only one in every 5 million people. Alejandro Sweet-Cordero, MD, an oncologist who treats children with cancer at Lucile Packard Children’s Hospital Stanford, is leading one of Stanford’s several efforts to develop an efficient system for sequencing individual patients’ tumors.

In their paper, Sage’s team (led by medical student Lei Xu) analyzed the DNA and RNA of one child’s unusual liver tumor, a fibrolamellar hepatocellular carcinoma. The cause of this form of cancer has never been found. Curious about what genes drove the tumor’s proliferation, the scientists identified two genes that were likely culprits, both of which promoted cancer in petri dishes of cultured cells. One of the genes, encoding the enzyme protein kinase A, is a possible target for future cancer therapies.

Though this specific research was not intended to shape the child’s treatment, similar sequencing could soon help doctors decide how to treat rare cancers in real time. Sweet-Cordero is working to develop an efficient system for getting both the mechanics of sequencing and the labor-intensive analysis of the resulting genetic data completed in a few weeks, instead of the two to three months now required. “We’re trying to use this kind of technology  to really help patients,” Sage said. “If you’re dealing with a disease that may kill the patient very fast, you want to act on it as soon as possible.”

In addition to giving doctors clues about which chemotherapy drugs to try, gene sequencing gives them a new way to study tumors.

“What’s really important is that, instead of categorizing tumors based on how they look under a microscope, we’ll be able to categorize them based on their gene-mutation profile,” Sweet-Cordero said. Rather than setting up clinical trials based on a tumor’s histology, as doctors have done in the past, scientists will group patients for treatment trials on the basis of similar mutations in their tumors. “In my mind, as a clinical oncologist, this is the most transformative aspect of this technology,” he said. This is especially true for patients with rare tumors who might not otherwise benefit from clinical trials at all.

And for childhood cancers, knowing a tumor’s gene mutations could also help doctors avoid giving higher doses of toxic chemotherapy drugs than are truly needed.

“The way we’ve been successful in pediatric oncology is by being extremely aggressive,” Sweet-Cordero said. Oncologists take advantage of children’s natural resilience by giving extremely strong chemotherapy regimens, which beat back cancer but can also have damaging long-term side effects. “We end up over-treating significant groups of patients who could survive with less aggressive therapy,” Sweet-Cordero said. “If we can use genetic information to back off on really toxic therapies, we’ll have fewer pediatric cancer survivors with significant impairments.”

Meanwhile, Stanford cancer researchers are also tackling a related problem: the fact that not all malignant cells within a tumor may have the same genetic mutations, and they may not all be vulnerable to the same cancer drugs. Next month, the Stanford Cancer Institute is sponsoring a scientific symposium on the concept, known as tumor heterogeneity, and how it will affect the future of personalized cancer treatments.

Sage’s research was supported by the Lucile Packard Foundation for Children’s Health, Stanford NIH-NCATS-CTSA UL1 TR001085 and Child Health Research Institute of Stanford University. Sage and Sweet-Cordero are both members of the Stanford Cancer Institute, and the National Cancer Institute-designated Cancer Center.

Previously: Smoking gun or hit-and-run? How oncogenes make good cells go bad, Stanford researchers identify genes that cause disfiguring jaw tumor and Blood will tell: In Stanford study, tiny bits of circulating tumor DNA betray hidden cancers

Parenting, Pediatrics, Public Health, Research

Examining the effects of family time, screen time and parenting styles on child behavior

boardgameAs kids head back to school, many parents may be wondering what they can do to boost their children’s academic achievement. Findings recently published in the Journal of Family Psychology suggest that limiting screen time, increasing family time, and choosing parenting styles that rely on positive reinforcement are among the things that can help children perform better in school.

For The Learning Habit Study, the largest study of its kind, more than 21,000 parents across the country completed a 108-question survey about their children and family life. Among the findings: three family activities – eating regular dinners, attending religious services, and playing board games – were “significantly related to reduced screen time among children, higher GPA, and fewer emotional problems; ” parenting styles involving disciplining children when they misbehave or underperform were associated with a negative impact on children’s academic success, sleep and focus; and students’ sleep quality and grades start to decline after just 45 minutes of screen time.

From a recent WebMD story:

The good news for parents is they can easily make positive changes at home, says Robert Pressman, PhD. He’s the director of research at the New England Center for Pediatric Psychology and the study’s lead author.

Have regular family dinners, for example. They tend to happen at expected times and include conversation and information sharing. Parents can also shift their own habits and parenting styles in response to the study’s findings.

“These are all things that parents can do to make a difference,” Pressman says. “I think it’s going to change everything in terms of how we are going to interact with patients,” he adds. “We have hard data now that we didn’t have before. As a clinician, I know that I will have a greater impact.”

Previously: With school bells ringing, parents should ensure their children are doing enough sleeping, Study: Too much TV, computer could hurt kids’ mental health, Does TV watching, or prolonged sitting, contribute to child obesity rates? and Paper explores effects of electronic media on kids’ health
Photo by woodleywonderworks

Parenting, Pediatrics, Sleep

With school bells ringing, parents should ensure their children are doing enough sleeping

With school bells ringing, parents should ensure their children are doing enough sleeping

With so many schools starting today – or having recently started – it’s a good time for a reminder of the importance of sleep among children. In a recent blog post and the video above, Seattle Mama Doc (a.k.a. Wendy Sue Swanson, MD), offers guidance on how much sleep a child needs and offers five ways that parents can support good sleep:

    • Keep to an 8pm bedtime for young children. Move bedtime back slowly (move it by 30 minutes every 3-5 days) to prime your child for success and avoid battles!
    • 10pm bedtime for children age 12 & up is age-appropriate. More info here.
    • Habits: No screens 1-2 hours prior to bed, no caffeine after school, no food right before bed.
    • Exercise or move 30-60 minutes a day to help kids sleep easier
    • No sleeping with cell phones (create a docking station in the kitchen)
    • Don’t use OTC medications (cough & cold, for example) to knock your kids out and get them to sleep. Using medications that have a side effect of drowsiness can cause sleepiness to extend into daytime which can negatively affect school and sports performance.

Previously: Study shows poor sleep habits as a teenager can “stack the deck against you for obesity later in life”Stanford expert: Students shouldn’t sacrifice sleep, TV in a child’s bedroom? “No way,” says expert and Districts pushing back bells for the sake of teens’ sleep

Parenting, Pediatrics, Public Health

Study shows cavities have become the most common childhood disease

Study shows cavities have become the most common childhood disease

Kids mouthA Washington Post blog entry published earlier this week reports that cavities are the most common childhood chronic disease in the United States. Fifty-nine percent of kids between the ages of twelve and nineteen have at least one cavity, according to a recent Pediatrics paper, and the American Academy of Pediatrics in turn issued new recommendations advising parents to start brushing children’s teeth with fluoride as soon as the teeth appear. The study refers to cavities in young children as a “silent epidemic” that disproportionately affects poor, young and minority populations.

From the article:

“We’re still seeing a lot of cavities in very young children,” said Rebecca Slayton, a pediatric dentist and member of the executive committee of the academy’s section on oral health.  “Various national surveys show that we are making progress in some age groups, but in the younger age groups we are not.”

Some of the problem stems from poor and immigrant children lacking dental care, but even among parents with the resources to get their children to dentists, there is a lack of awareness that baby teeth need the same care as permanent ones. And infants, of course, can’t complain about tooth pain.

Whether it’s a lack awareness or lack of resources that is preventing parents from addressing tooth health, the article makes clear that regular dental hygiene for children is an important part of their overall health.

Jen Baxter is a freelance writer and photographer. After spending eight years working for Kaiser Permanente Health plan she took a self-imposed sabbatical to travel around South East Asia and become a blogger. She enjoys writing about nutrition, meditation, and mental health, and finding personal stories that inspire people to take responsibility for their own well-being. Her website and blog can be found at www.jenbaxter.com.

Previously: Side effects of childhood vaccines are extremely rare, new study finds, “Mountain Dew mouth” rots teeth, costs taxpayers 
Photo By: Emran Kassin

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