childrens_medical_association

AAP Autism, Folate Receptor Antibodies, and Use of Leucovorin in Children and Adolescents

Tue, 11 Nov 2025 17:35:46 GMT

What is leucovorin?

Leucovorin (folinic acid; calcium folinate) is a prescription form of reduced folic acid that does not require enzymatic activation by dihydrofolate reductase (DHFR). It readily enters the folate cycle and maintains intracellular reduced folate pools even when DHFR is inhibited or when folate metabolism or transport is impaired. Impaired folate metabolism can occur in the setting of certain genetic disorders and medication-induced impairment (eg, from methotrexate).

Because of its ready bioavailability compared with over-the-counter folate supplements, leucovorin can affect brain chemistry, and these effects can be positive, neutral, or negative, depending on an individual child’s biology. For this reason, it requires a prescription and should be prescribed under careful medical observation.

What is leucovorin used for?

Leucovorin is US Food and Drug Administration (FDA)-approved for certain indications, such as:

Reducing toxic side effects of chemotherapy agents like methotrexate
Treating megaloblastic anemia in specific circumstances

Off-label, leucovorin has been studied for:

Cerebral folate deficiency (CFD)
A subset of autistic children who test positive for folate receptor alpha autoantibodies (FRAAs)

As of September 2025, the FDA has initiated a fast-tracked approval for leucovorin for the indication of CFD. This pending approval does not pertain to autism in general.

What is cerebral folate deficiency?

CFD is a neurological condition characterized by abnormally low levels of a specific active folate metabolite in the cerebrospinal fluid (CSF) and evidence of normal folate metabolism outside of the central nervous system.

CFD typically presents in infants and young children. Clinical findings may include:

Developmental delay with developmental regression
Seizures/epilepsy
Tone/movement abnormalities (eg, hypotonia, ataxia, spasticity)
Acquired microcephaly
Autism
Myelination abnormalities on brain MRI

Causes can include:

Genetic disorders (eg, pathogenic variants in FOLR1)
FRAAs
Certain inborn errors of metabolism or mitochondrial disorders

How is CFD diagnosed?

The diagnosis of CFD is challenging, because the most definitive test, measuring CSF levels of 5-methyltetrahydrofolate (5-MTHF), is invasive and there is insufficient evidence to determine how many and which clinical features observed in CFD should prompt such evaluation.
Diagnostic testing may include:
Measuring CSF levels of 5-MTHF
Genetic testing (eg, exome or genome sequencing) that can detect pathogenic variants in genes involved in folate metabolism or transport, but this testing will not identify all patients who may have CFD
Currently available blood testing for FRAAs is not standardized, may not be covered by insurance, and may not reliably confirm CFD
Testing for common polymorphisms in MTHFR is not clinically indicated and would not confer a diagnosis of CFD. These common polymorphism variants are not considered pathogenic (disease-causing) variants (see ACMG Guideline ).

Note: Normal blood folate levels are expected in CFD.

What are folate receptor alpha autoantibodies?

FRAAs are immune system proteins (autoantibodies) that mistakenly target and bind to the body’s own folate receptor alpha (FRα). FRα is a protein responsible for transporting folate (vitamin B9 ) across cell membranes, especially across the blood–brain barrier.

When these autoantibodies bind to FRα, they may:

Block folate transport into the brain and other tissues
Lead to functional folate deficiency in the central nervous system, even when blood folate levels are normal
Contribute to CFD

Can I test for FRAAs in my autistic patients?

There are no FDA cleared or approved tests for FRAAs. Currently, testing is offered through clinical laboratories as laboratory-developed tests under CLIA (Clinical Laboratory Improvement Amendments) oversight, rather than as FDA-approved diagnostics. This means clinical interpretation standards, validation, and analytic performance are established by the performing laboratory rather than by an FDA-reviewed labeling process.

More independent studies and clear validation standards are needed for this test to be clinically useful.

Take-home message: Interpret the results within context and avoid overreliance on test results to direct clinical decision making.

What do the studies say about leucovorin in autism?

The evidence for leucovorin and use for autism is currently limited. Small studies show benefits to communication and behavior for some autistic children, specifically those with CFD or evidence of folate metabolic differences. Larger independent trials are warranted to better understand which patients may benefit. More evidence on efficacy and safety is needed before pediatricians can broadly recommend leucovorin.

Limitation of current published research:

The studies on leucovorin all include fewer than 100 patients.
There are questions about some of the study methods.
Most of the studies are from the same group of researchers, and more demonstration of reproducibility is needed.
There has not been a large multicenter phase 3 randomized controlled trial looking at the efficacy and safety of leucovorin in autistic children. Although there can be variance in how the FDA approves new pharmaceutical therapeutics, a Phase 3 trial is commonly expected before approval and incorporation into standard care recommendations.
A conclusion of all of the published studies is that more research is needed, and the AAP concurs.

Are there side effects to leucovorin?

Leucovorin’s effects can be positive, neutral, or negative, depending on the child’s biology. Prescribing clinicians should closely monitor effects.

Potential side effects include:

Irritability or behavioral activation
GI upset: nausea, vomiting, or diarrhea
Skin: dermatitis, stomatitis, alopecia
Anaphylaxis
Masking of vitamin B12 deficiency: high-dose folinic acid can mask hematologic signs of vitamin B12 deficiency while allowing neurologic damage to continue

Some of these side effects are based on reports of leucovorin given in conjunction with chemotherapy, so it may be difficult to differentiate chemotherapy-related side effects from leucovorin side effects. In studies of autistic participants receiving leucovorin, side effects have included appetite changes, diarrhea, and irritability.

Leucovorin is contraindicated in certain disorders, such as MTHFS (5,10-methenyltetrahydrofolate synthetase) deficiency. In this condition, there is deficiency of the enzyme that processes folinic acid, leading to low levels of CSF 5-MTHF but also toxicity from buildup of folinic acid. Administration of leucovorin can, therefore, worsen symptoms of this disorder of folate metabolism.

Biochemical effects are complex: leucovorin influences methylation, neurotransmitters, and mitochondrial function.

What dose is typically used in CFD?

In research studies, leucovorin dosing ranges from:

0.5 to 2 mg/kg/day
Maximum dose typically 50 mg/day

Because effects are variable, dosing is typically started low (ie, 5 mg BID or lower) and titrated slowly, with monitoring for side effects and clinical response.

What we do not know about leucovorin (summary)

We do not know how to identify who has CFD without a lumbar puncture or genetic testing.
We do not know whether autistic children without CFD benefit from leucovorin.
We do not have a best practice for dosing, nor does the FDA give guidance on this.
We do not know how long patients should take it or what the risks of long-term high-dose leucovorin are.
We do not have a validated protocol to measure responsiveness and track changes over time.

What should shared decision-making look like when considering leucovorin?

Shared decision-making should include the following steps:

Review the evidence Explain that although some studies suggest potential benefits of leucovorin in autistic children with CFD, the overall quality of evidence is limited, and findings may not apply to all autistic children.
Discuss risks, benefits, and alternatives Outline potential benefits (language and behavioral improvements in a subset of patients) and side effects. Discuss risks of prescriptions with limited evidence. Re-assess the child/youth’s use of other therapeutic and pharmacological supports for autism.
Establish goals of care Identify what the family hopes to achieve (eg, improved communication, reduced interfering behavior) and set realistic expectations for outcomes.
Involve appropriate specialists When there are clinical indicators of CFD, consultation with specialists such as pediatric neurology or genetics may be appropriate, because CSF testing and/or genetic evaluation should be considered for these patients.
Develop a monitoring plan Outline how the child’s response will be monitored, what symptoms or behaviors to track, and when to reassess treatment efficacy or make changes.

Bottom Line

Current evidence is insufficient to support prescribing leucovorin for autism in the absence of CFD.
Use shared decision-making with families who request leucovorin. Inform families of the current evidence and limitations and refer to subspecialists for diagnostic evaluation and management if CFD is suspected.
Ensure supports and services are optimized. Leucovorin or any other medication should not be a substitute for comprehensive and collaborative care planning based on the individual needs and strengths of the autistic pediatric patient.
More research is needed. Larger, well-designed, multisite trials using objective outcome measures are necessary to determine whether leucovorin is safe and effective in autism and in which subgroups it may be most beneficial for. More research is also needed to understand appropriate monitoring laboratory tests and dosing guidelines.

Caring For Your Child with Tongue Tie

Tue, 20 Aug 2024 17:44:28 GMT

Understanding Tongue Tie in Newborns: Expert Recommendations and Treatment Options for a Healthy Breastfeeding Journey

The presence of some connective tissue between the undersurface of the tongue and the floor of the mouth is normal. Tongue tie, or ankyloglossia , occurs when a tight or short band of tissue, the lingual frenulum , restricts the range of motion of the tongue. Tongue tie may interfere with breastfeeding by impeding extension and elevation of the tongue, actions required for the infant to initiate and sustain a successful latch to the nipple while suckling. The most important reason to address tongue tie is to reduce maternal pain and frustration, and promote a healthy breastfeeding experience for mother and baby.

The incidence of anklyoglossia in newborns is widely reported, at rates anywhere from 0.1% to 10.7%. Controversy exists, as there are no standard criteria for diagnosing tongue tie, no consensus for whom needs to be treated, and no research documenting clear improvement in breastfeeding outcomes with treatment. Many breastfeeding moms may express concern about maternal nipple pain and poor infant latch, even in the absence of ankyloglossia. Anatomic variations in the lingual frenulum may occur independent of difficulties with breastfeeding. That being said, more and more infants are undergoing procedures to release the lingual frenulum ( frenulotomy ): in the last decade, the rate of those procedures has gone up 400%. The following are expert recommendations presented by the American Academy of Pediatrics (AAP) August 2024 to help pediatricians guide families in the care of children with tongue tie.

The pediatrician should review the birth history, infant feeding history, and inspect the face, jaw, neck, and mouth for any atypical features. The tongue, suck reflex, and palate should be assessed. Notation should be made of the appearance of the lingual frenulum, and whether it restricts the movement of the tongue over the lower gumline or toward the roof of the mouth. A heart-shaped tongue on extension is a sign of a short/tight lingual frenulum.
Consider referral to a lactation professional for a formal assessment of latch and breastfeeding.
Consider referral to a pediatric dentist, oral surgeon or ear-nose-throat specialist for a formal assessment of anatomical/functional issues with the lingual frenulum.
The combination of a tight lingual frenulum AND concomitant difficulties with breastfeeding that do not improve with lactation support are referred to as “ symptomatic ankyloglossia ,” for which cutting of the frenulum ( frenulotomy ) may be indicated. Types of frenulotomy include the blunt-tip scissor technique, which does not require anesthesia or suturing in the newborn; and laser frenulotomy, which is more typically used by specialty physicians. There is no evidence than one is superior to the other. Rare complications include bleeding, damage to surrounding tissues, and scarring.
Other treatments, including physical therapy, craniosacral therapy and myofascial therapies, are not recommended, as there is no evidence of their efficacy in treating symptomatic ankyloglossia, and they often incur high out-of-pocket costs.
Postfrenulotomy stretching exercises, sometimes suggested to parents to open the wound in order to prevent reattachment, is not recommended by the AAP, and may cause oral aversion.
Frenulotomy is a procedure covered by insurance. If the provider you have chosen is asking to be paid cash out of pocket, contact us for a referral to a physician who accepts your insurance.
The maxillary labial frenulum is the band of tissue that tethers the upper lip to the upper jaw. The buccal frenulum is the tissue that connects the lining of the cheek to the edge of the gums. The posterior lingual frenulum is the tissue that connects the back of the tongue to the floor of the mouth. There is no evidence that lip ties or cheek ties or posterior tongue ties are related to breastfeeding issues, and their surgical correction is not recommended by the AAP.
Infants with ankyloglossia, normal feeding patterns and normal weight gain need no intervention. For many, tongue tie may resolve spontaneously with time. There is no clear evidence that persistent tongue tie is related to speech/articulation disorders or crooked/crowded teeth.

We are here for you. Reach out on the portal or schedule an appointment with your pediatrician or nurse practitioner if you have any concerns about your infant having a symptomatic tongue tie. Here are some additional resources and community partners that are available to you:

Pediatric ENT Dr. Jacob Zeiders 954-888-8997

Pediatric ENT Dr. Samuel Ostrower 954-265-1616

Pediatric dentist Dr. Abby Wilentz 954-581-7883

Pediatric dentist Dr. Francis Carmona 954-513-4599

Endodontist Dr. Kenneth Levine 954-722-1100

Oral surgeon Dr. Jason Portnoff 561-717-3660

Lactation consultant Maureen Crissy (Mama Bean) 954-548-6556

Rachelle Cohen Breast Feeding Center of Boca 561-409-3144

Loving Start Lactation Services (Anna Uribasterra) 954-435-4491

Caring For Your Child: Car Seat Safety

Tue, 09 Jul 2024 21:52:51 GMT

Child passenger safety has evolved and improved dramatically in the past decade. Current estimates indicate that child safety seats and boosters reduce the risk of injury by up to 80% compared to children in seatbelts. Despite this progress, thousands of young children in our country are injured or killed in motor vehicle crashes each year. The American Academy of Pediatrics offers these best practices to optimize your child’s safety while traveling in a traditional motor vehicle:

INFANTS AND TODDLERS should ride in the back seat, in a rear-facing infant or convertible car seat as long as possible, until they reach the highest weight and height allowed by the car seat manufacturer. Optimally this is age 2 years, weight up to 35lbs, or height up to 35 inches, depending on the model. Additional safety features available in some rear-facing car seats include load legs and anti-rebound bars to absorb the energy of a crash and reduce rotation. (Some convertible seats have higher weight limits.)
CHILDREN who have outgrown their rear-facing car seat should continue to ride in the back seat, and now use a forward-facing convertible or combination car seat with a harness for as long as possible, up to the highest weight and height recommended by the manufacturer. Optimally this is age 4 years, weight at least 40lbs or height at least 40”.
CHILDREN who have outgrown their forward-facing car seat should continue to ride in the back seat, and now use a belt-positioning booster seat until the vehicle lap and shoulder seat belt fits properly, typically when they have reached 4’9” (57”) and age between 8-12 years.
When CHILDREN are old enough and large enough to use the vehicle lap and shoulder seat belt alone, they should always be belted in for optimal safety. Remember: the safest place to ride for ALL CHILDREN YOUNGER THAN 13yr is the back seat.
CHILDREN WITH SPECIAL NEEDS (prematurity, altered muscle tone, decreased neurological control, skeletal abnormalities, airway compromise, etc.) may require specialized child restraint systems for optimal safety. Products are listed on the website for the National Center for the Safe Transportation of Children with Special Health Care Needs.

When shopping for a car seat, keep in mind:

No one seat is the “best” or “safest.” All car seats for sale in the USA have been crash-tested and must meet federally-approved standards. The best seat is the one that fits your child’s size, is correctly installed, fits well in your vehicle, and is used properly every time you drive.
Do not decide by price alone. A more expensive car seat does not mean the seat is safer or easier to use.
Avoid using a seat if you do not know its history (seats that may have been damaged in an accident are no longer safe).
Never use a car seat that is old, cracked, does not have a label with the date of manufacture and model number, does not have instructions, or has been recalled (you can find out by contacting the National Highway Traffic Safety Administration Vehicle Safety Hotline at 888-327-4236 or check the website www.safercar.gov ).

Car seats may be installed using either the vehicle’s seat belt or its LATCH system (lower anchors and tethers for children). Even if you have experience with installing and using car seats, it is important to read the vehicle owner’s manual and the car safety seat manual each time you install a new seat. Many communities have child passenger safety technicians who have completed a standardized National Highway Traffic Safety Administration course, and who can provide hands-on advice and guidance to families to ensure the child seat is properly installed. Resources available in our community include:

Coral Springs Fire Department . 2801 Coral Springs Dr. Coral Springs, FL 33065 Phone: 954.344.5934 contact: Fire Administration ( Coral Springs and Parkland )
Broward Sheriff's Office/Tamarac. 7515 N Pine Island Rd. Tamarac, FL 33321 Phone: 954.720.2225
Tamarac Fire Department . 6000 Hiatus Rd. Tamarac, FL 33321 Phone: 954.597.3800
Boca Raton Fire Rescue Services Department . 6500 Congress Ave Boca Raton, FL 33487 Phone: 561.982.4000
Plantation Fire Department . 8101 W Broward Blvd. Plantation, FL 33324 Phone: 954.797.2150
Broward Sheriff's Office Weston . 17350 Royal Palm Blvd. Weston, FL 33326 Phone: 954.389.2015
Pembroke Pines Police Dept . 9500 Pines Blvd Pembroke Pines, FL 33024 Phone: 954-436-3274 Contact: Community Affairs Unit Prenes Chevelon
Memorial Hospital Miramar . 1901 SW 172nd Ave Miramar, FL 33029 Phone: 954.538.5180

Caring For Your Adolescent: Contraception

Tue, 07 May 2024 18:39:09 GMT

As a parent of an adolescent, you are in the best position to talk with your child regarding the importance of informed and healthy choices regarding their behaviors, including those around sex. The American Academy of Pediatrics (AAP) and your pediatricians recommend you discuss abstinence (not having sexual intercourse), as well as reliable contraception and condom use to prevent sexually transmitted infections (STIs) before your adolescent prepares to become sexually active. The data are clear: almost 25% of female high school students in the U.S. are sexually active. Of these, less than one-third are using an effective method of birth control, and less than one-half are using a condom. The risk of unintended pregnancy over the course of one year in couples who do not use any method of contraception is approximately 85%. Prevention of unintended pregnancy using effective contraception in sexually active adolescents is therefore paramount . Your willingness to discuss, sanction and provide access to contraception removes many of the barriers to your adolescent obtaining birth control.

There are many factors for the adolescent and engaged parent to take into consideration when choosing the best contraceptive method. These include effectiveness, the reality of compliance, and potential side effects given the underlying health of the adolescent and family. For most adolescents, the benefit of any method of reversible contraception outweighs potential risk, though absolute contraindications to hormonal birth control do exist and will be discussed.

Here is the landscape of available contraception.

Long-acting reversible contraceptives (LARC) are the most effective reversible methods of contraception. The pregnancy rate is <1 percent per year in typical patients using this method, and fertility returns quickly after removal. LARC devices are inserted into the uterus (intrauterine devices, or IUDs), and once in place, do not require any action on the part of the adolescent. These are considered first-line options for adolescents by the AAP. LARC options include the non-hormonal copper IUD (e.g. PARAGARD), and the hormonal IUD (e.g. MIRENA) which releases the progestin hormone levonorgestrel. Contraceptive effects of the copper IUD last 10+ years, and contraceptive effects of the hormonal IUD last from 3-5 years. Noncontraceptive benefits of the hormone-releasing IUDs may include reduction in heavy menstrual bleeding, menstrual discomfort, as well as suppression of menses. Possible side effects of the copper IUD include cramping and spotting. Possible side effects of the hormonal IUD include headache, acne, breast soreness, mood changes, and irregular bleeding. The only contraindications of using IUDs for long-acting contraception include severe distortion of the uterine cavity, active pelvic infection, known or suspected pregnancy, Wilson disease (for the copper IUD), and unexplained vaginal bleeding.
Contraceptive implant is another type of LARC. It is a single flexible plastic rod placed under the skin of the upper arm, which releases the hormone etonogestrel to prevent ovulation (e.g. NEXPLANON). Contraceptive effects last up 3-5 years. It is an attractive option for adolescents who desire long-term, uninterrupted birth control, and once placed, requires no action on the part of the adolescent. The implant is as effective as the IUD, with pregnancy rates < 1% per year. Possible side effects include spotting, weight gain, headache, nausea, and breast pain (side effects diminish over time). The contraindications of using the contraceptive implant include known or suspected pregnancy, abnormal vaginal bleeding, and lupus.
Depot medroxyprogesterone acetate (DMPA)(DepoProvera) is an injectable hormonal (progestin-only) contraceptive that provides effective, reversible contraception for three months. Noncontraceptive benefits of DMPA include protection against ovarian cancer and endometrial cancer, ectopic pregnancy, benign breast disease, acne, and iron deficiency. The pregnancy rate is around 5% per year in typical patients. Possible side effects include weight gain, menstrual changes, headache, dizziness, acne, breast swelling, and changes in mood and libido. Adolescents using DMPA, whose reproductive plan includes pregnancy, ought to know that fertility may be delayed for more than a year following its use for contraception. Though unlikely in adolescents, contraindications for using DMPA include multiple risk factors for cardiovascular disease (smoking, diabetes, high blood pressure, high cholesterol) and lupus. Sides effects of DMPA may include unscheduled bleeding and decreased bone mineral density (reversible).
Oral contraceptive pills (OCPs) have been FDA-approved for use for over 60 years. Currently, there are three different types of OCPs available on the market: the combination pill (estrogen and progestin, e.g. YAZ and LOESTRIN, used for 21 or 24 days depending on the brand), the progestin-only pill (norenthindrone e.g. MICRONOR, and norgestrel e.g. OPILL, used for 28 days), and the continuous use pill (estrogen and progestin, e.g. SEASONIQUE and LYBREL, used continually for 84 days or up to 365 days). The pregnancy rate with these methods is about 5% per year in typical patients. Oral contraceptive pills require the adolescent to take a pill daily and to remember to refill their prescription. The progestin-only pill needs to be taken at roughly the same time every day, has no hormone-free interval, and its main side effect is irregular bleeding and spotting. Noncontraceptive benefits of the progestin-only pill include reduced bleeding and less painful periods, and they are safe for people with high blood pressure, migraine, and those at risk for blood clots (see below). Noncontraceptive benefits of combined hormonal contraception include improved bone density and protection against ovarian cancer, endometrial cancer, ectopic pregnancy, benign breast disease, ovarian cysts, acne, PMS and premenstrual mood disorders, and iron deficiency. Possible side effects of the combined OCP include breakthrough bleeding, nausea, headaches, abdominal cramping, breast tenderness, increased vaginal discharge or decreased libido. Nausea can be avoided by taking the medication at night before sleep. Contraindications for using combined OCPs include multiple risk factors for cardiovascular disease (smoking, diabetes, high blood pressure, high cholesterol); migraine with aura; known mutations that predispose to blood clot formation; and lupus. FYI: OPILL is the only FDA-approved, daily oral contraceptive, progestin-only, now available over the counter (without a prescription), without age restriction, in stores and online.
Transdermal contraception patch is a combined hormonal patch, containing both estrogen and progestin (ethinyl estradiol and norelgestromin, e.g. XULANE, or ethinyl estradiol and levonorgestrel, e.g. TWIRLA). It is applied weekly to the skin (at a different site) for three weeks, followed by a patch-free week (during which menstrual bleeding occurs). The contraception patch requires the adolescent to follow careful instructions in applying the patch, remember to change it weekly, and refill their prescription in a timely fashion. The pregnancy rate is around 5% per year in typical patients. Nonhormonal side-effects of the contraceptive patch include application site reactions (itching, irritation, redness) and true allergic reactions. In addition to the general contraindications for estrogen-progestin contraception described above, obesity (body mass index BMI >30 kg/m- or ≥95th percentile for age) is a contraindication for transdermal contraceptive patches: there appears to be decreasing patch effectiveness with increasing BMI, and there may be an increased risk of blood clots.
Vaginal contraception ring is a vaginal ring (e.g. NUVARING) that has combined progestin and estrogen hormones (etonogestrel/ethinyl estradiol) that prevents ovulation. It is inserted into the vagina, left in place for three weeks, and removed for a single ring-free week (during which time menses occurs). The pregnancy rate is around 5% per year in typical patients. Adolescents who choose the vaginal ring must be comfortable self-inserting it into the vagina. Noncontraceptive benefits include lighter periods, improved cramps, and reduced acne. Side effects may include headaches, nausea, vaginal discharge, breast tenderness. Contraindications are similar to the combination OCP.
Condoms are made of latex or synthetic material, designed to fit over the penis, and prevent introduction of sperm and ejaculation fluid into the vagina. Condoms are effective for pregnancy prevention and protection against STIs, as long as they are used properly. (NOTE: Natural fiber condoms will not provide protection against STIs.) With consistent and correct use of condoms, the pregnancy rate is around 2% per year, though with typical use, it is estimated to be about 15% per year (increased rate due to slipping off, breaking, etc).
Other barrier methods include diaphragms, cervical caps, and sponges, though they are less effective (pregnancy rates 15-20% per year), they require conscious action of the part of the adolescent and/or partner at the time of sexual intercourse, and they do not protect against STIs.
Contraceptive gel and spermicides are gels, creams, or foams applied inside the vagina before having sex. They contain chemicals that are toxic to sperm. They have no hormonal side effects, though they are less effective in preventing pregnancy than all the other methods discussed (pregnancy rates 20% per year), and they do not protect against STIs.
Emergency contraception (EC) refers to an immediate intervention that prevents pregnancy from occurring after an episode of unprotected intercourse. Unprotected intercourse can be a result of contraception misuse, nonuse, or can result from forced sexual activity. EC is recommended within 5 days of unprotected sex. The available types of emergency contraception are the hormone ulipristil acetate 30mg x1 dose (e.g. ELLA), the hormone levonorgestrel 1.5mg x1 dose (e.g. PLAN B ONE STEP, available over the counter without a prescription), combined OCPx 2 doses over 12 hours, and emergency insertion of the copper IUD. Side effects from the use of EC pills are similar to those of oral contraceptive pills, such as nausea and vomiting, slight irregular vaginal bleeding, and fatigue.

In addition to the use of contraceptives for birth control, there are medical conditions for which OCPs may be indicated . These include heavy menstrual bleeding, painful periods, iron deficiency anemia, irregular menstrual bleeding, acne, and polycystic ovarian syndrome (PCOS). Special circumstances in which contraception may be indicated include adolescents with physical or intellectual disability, for whom menstrual hygiene and menstrual discomfort may be challenging. For such adolescents, hormonal contraception (e.g. levonorgestrel -releasing IUD, DMPA, the contraceptive patch, or continuous or extended cycles of combined oral contraceptive pills) may be beneficial.

We are here for you. Reach out on the portal or schedule an appointment with your adolescent to come see us in the office to discuss contraception options . Here are some additional resources and community partners that are available to you:

Memorial Healthcare Adolescent Gynecology Dr. Elba Iglesias 954-265-1460

Omega Women’s Care Gynecologist Dr. Brooke Slaton 954-755-1411

Gynecologist Dr. Lona Sasser 954-340-1050

Contraception Explained: Birth Control Options For Teens & Adolescents

https://www.healthychildren.org/English/ages-stages/teen/dating-sex/Pages/Birth-Control-for-Sexually-Active-Teens.aspx

Healthy Teens | ACOG

Bedsider Birth Control Support Network

Center for Young Women's Health

Planned Parenthood | Official Site

Caring For Your Child With Obesity

Mon, 09 Jan 2023 18:14:38 GMT

Caring For Your Child With Obesity

Childhood overweight and obesity is a serious epidemic in the United States . Overweight is defined by a body mass index (BMI) greater than 85% of children that age, and obesity is defined by a BMI greater than 95% of children that age. The latest National Health and Nutrition Examination Study (NHANES) data reflect our national health from 2017-2020. In that period, for children and adolescents aged 2-19 years, the prevalence of obesity was 19.7% overall, affecting about 14.7 million American children and adolescents. For specific age groups, the obesity prevalence was 12.7% among 2- to 5-year-olds, 20.7% among 6- to 11-year-olds, and 22.2% among 12- to 19-year-olds. Yet even in the youngest age group, 20% or 1 in 5 children is already overweight. Among boys, the highest prevalence of obesity is in Hispanic boys, and among girls, obesity is highest in non-Hispanic black girls. Of note, the prevalence of obesity increases with decreasing income and decreasing level of education. Obese children generally grow up to be obese adults , and the prevalence of obesity in adults in our country is approaching 50%. Obesity-related health complications include high blood pressure, high cholesterol, insulin resistance and type 2 diabetes, hormonal imbalance, PCOS, breathing problems such as asthma and sleep apnea, joint problems, cancer, non-alcoholic fatty liver disease, chronic kidney disease, mood disorders, and dementia. A staggering 25% of obese children and adolescents are already struggling with many of these conditions, formally seen only in adults. It is a sobering fact that for the first time in recorded history, the life expectancy of today’s children is anticipated to be shorter than that of their parents, largely due to the profound health complications of obesity.

The causes of the obesity epidemic in America are multifactorial and complex. Experts identify many converging factors, including:

1. Excessive sugars and high fructose corn syrup (HFCS) in sweetened beverages (soda, juice, sports drinks, powdered drinks, chocolate milk, sweet tea, coffee, etc).

2. Excessive sugars and HFCS in sweetened foods targeting children (cereal, breakfast pastry, kids yogurt, cookies, crackers, candy, etc).

3. Excessive hydrogenated oils in fried foods, fast foods, and packaged foods (fried chicken, french fries, cheeseburgers, pepperoni pizza, potato chips, corn chips, donuts, Lunchables, etc).

4. Excessive starch in kid-friendly and low-costs foods (pizza, pasta, rice, fries, chips, cereal, bagels, white bread, crackers, cookies, etc).

5. Excessive portion sizes (“SUPER SIZE”).

6. Excessive screen time.

7. Excessive stress.

8. Insufficient brightly colored fruits and vegetables and dietary fiber.

8. Insufficient exercise.

9. Insufficient sleep. Children and adolescents who sleep less than 8 hours per night have an increased risk of overweight and obesity. Studies suggest that compensation of sleep during weekends/holidays may partly ameliorate the risk of childhood obesity.

10. Insufficient time in nature.

11. Imbalance/disruption of our intestinal microbiome, the trillions of bacteria that colonize our gut, and whose dysfunction can lead to altered digestion and absorption of nutrients, altered metabolism and hormonal balance, a dysregulated immune system, and obesity. The overuse of antibiotics to treat illness in this county and the use of antibiotics on concentrated animal feeding operations are important factors here. The microbiome is also altered by C-section, stress, sugary food and drink, hydrogenated fats, pesticides and heavy metals, etc.

12. Prenatal factors linked to obesity include prenatal stress, maternal smoking, gestational diabetes, and prenatal exposure to chemicals that alter the expression of genes relating to cell differentiation (for example stem cells committing to adipose tissue), satiety, metabolism, hormonal balance, etc.

13. Perinatal factors that increase the risk of obesity include prematurity, being born by Caesarian section, as well as being born small for gestational age (SGA), low birth weight or high birth weight.

14. Environmental factors that promote obesity include a whole category of chemicals present throughout our environment called obesogens , that disrupt our hormonal signaling, alter our satiety programming, modify our DNA, damage our mitochondria, increase our adipose tissue, and alter our microbiome. Examples of obesogens are nicotine in environmental cigarette smoke; natural and augmented hormones like estrogen in animal products; artificial sweeteners like aspartame and saccharin in diet drinks; pesticides/herbicides like glyphosate and atrazine on grains, fruits and vegetables; chemicals like phthalates and bisphenols (BPA, BPF, BPS) in plastic bottles, containers, tubing etc.; flame retardants like organophosphates in clothing, furniture, toys, etc.; heavy metals like lead and arsenic in water; parabens and BPA in skin and other personal care products; pollutants like hydrocarbons, ozone and particulate matter in air; additives like HFCS, monosodium glutamate (MSG), preservatives and emulsifiers in packaged and processed food.

15. Genetic factors, which include known syndromes like Bardot-Biedl and Prader-Willi, and an ever-expanding database of genes now being identified by whole exome sequencing, can predispose to obesity.

16. Epigenetic factors, including trauma, stress, obesogen exposure, sleep deprivation and other alterations to circadian rhythm, can dysregulate the expression of our DNA in ways that promote obesity over a lifetime and can be inherited across generations.

Evaluation of your child with obesity includes assessment for associated conditions, such as measuring blood pressure, screening urine for early signs of diabetes, checking bloodwork for insulin resistance and diabetes, screening liver tests for signs of inflammation from NAFLD, checking for thyroid dysfunction, PCOS and other markers of hormonal imbalance when indicated. Since vitamin D deficiency is more prevalent in children who are obese, vitamin D levels ought to be assessed.

Treatment of childhood obesity must address as many dietary, lifestyle, and environmental factors listed above that are in our control. Suffice it to say that just eating less calories is not enough. We must consider the quality of those calories (a 12oz can of Coca-Cola and a plate of roast chicken and broccoli may each have 320 calories, but their impact on our body is dramatically different); the nutrient density of the food (how a salad of brightly colored organic vegetables provides energy and information to our gut microbiome and our DNA, helping to balance our hormones and lowering the risk of obesity); the presence of chemicals in food (try to avoid pesticides by following the EWG guide “The Dirty Dozen” and seek out foods with no added hormones). Check out the guide “Skin Deep” to identify the safest personal care products. Aim for 1 hour of exercise per day. Take steps to mitigate the impact of stress, sleep deprivation, excess screen time, etc. For patients struggling with obesity resistant to these measures, a referral to a pediatric endocrinologist and a consideration of medication to promote weight loss may in indicated. In extreme circumstances, adolescents with severe obesity (BMI over 40) unresponsive to other weight loss strategies may benefit from gastric bypass surgery.

Prevention of childhood obesity starts prenatally, with attention to maternal health, eating a healthy, balanced diet with lots of fruits and vegetables, nuts and seeds, legumes, eggs, wild cooked fish, organic meats and dairy when possible, staying active, and carefully managing gestational diabetes and stress. During infancy and childhood, remember that what you feed your child has lasting impacts on their health as adults, so feed your child healthy foods, avoiding sugars and high carb snacks, processed foods, chemicals, pesticides, added hormones, etc. Consider the routine integration of certain vegetables, herbs and spices that reduce inflammation and aide in chemical detoxification, including broccoli, spinach and cabbage (the brassica family), tumeric, ginger, garlic, cilantro, etc. Limit the use of plastic water bottles and plastic storage containers in the home. Eliminate juices and sweetened beverages, and keep water readily available. Limit portion sizes, particularly of high carb/high fat foods. If you are driving through or bringing food in, seek out real food that is minimally processed (for example, grilled or roast chicken instead of fried chicken nuggets). Encourage your older children and adolescents to eat breakfast, as skipping breakfast has been associated with obesity. Engage your children in meal planning, food shopping, and food preparation, as they will be more curious and more invested in eating the healthy foods you serve. Try to keep snacks small and healthy, and limit unhealthy treats to “special” days (birthdays and holidays). Let dinnertime be a time to connect with one another and turn off the TV: studies actually show that people watching TV consume more food than those who do not. Start young helping your child develop a regular sleep routine, and for your older child, limit screen time at night to help them get to sleep on time. Encourage physical activities that your child enjoys, and aim for 1 hour of exercise each day. Remember that your children take their cues from you, so set a good example with your own choices: being healthier is a goal for the whole family.

We are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you want to discuss strategies to help your child with obesity. Here are some additional resources and community partners that serve our patients with obesity and their families:

Pediatric Endocrinologist Dr. Robin Nemery 954-869-5462

Pediatric Endocrinologist Dr. Bethel Steindel-Spargo 954-869-5110

Pediatric Endocrinologist Dr. Alejandro Diaz 305-662-8368

Pediatric Endocrinologist Dr. Andrea Granados 954-385-6238

Nutritionist Lucille Beseler 954-972-2123

Nutritionist Arlene Kasner 954-986-6400

Nutritionist Nicklaus Children’s Hospital 305-666-6511

HealthyChildren.org (AAP Parenting Website)

www.myplate.gov

CDC.gov

ewg.org/Dirty Dozen

ewg.org/Skin Deep

Caring For Moms With Postpartum Mood Disorders

Thu, 01 Sep 2022 19:05:31 GMT

Postpartum mood disorders are common medical conditions that can significantly impact the heath, well-being, and connection of mothers, infants, and their families. They are also a leading cause of maternal mortality in the USA. The acronym used to encompass postpartum mood disorders is PMADs, short for postpartum mood and anxiety disorders, though they include a whole spectrum of postpartum mood disorders. These include postpartum depression (low mood, sadness, feelings of helplessness and hopelessness); postpartum anxiety (constant worrying, intrusive thoughts, inability to turn off the constant chatter in the mind); postpartum obsessive compulsive disorder (OCD)(obsessive/unwanted thoughts and fears, ritualistic behavior, avoidance of triggering stimuli); postpartum post-traumatic stress disorder (PTSD)(tension, sleep disorder, flashbacks of a traumatic event regarding pregnancy/pregnancy loss/childbirth/neonatal death); and postpartum psychosis (delusions, hallucinations, paranoia, suicidal or homicidal thoughts). PMADs are estimated to affect up to 25% of all moms and birthing parents, making it the most common under-diagnosed complication of pregnancy. In the height of the COVID-19 pandemic, up to 40% of moms and birthing parents met the criteria for a postpartum mood disorder. PMADs disproportionately affect moms of color and those living in poverty (up to 50%). LGBTQIA+ moms and birthing parents are also at a higher risk for developing a PMAD.

PMADs can occur with the onset of delivery or anytime within the first four months of delivery, and last a year or longer. Risk factors for the development of PMADs are a personal history of anxiety or depression, young maternal age, social isolation and lack of support, financial stress, previous pregnancy complication or loss, traumatic birth, partner-related stress, substance abuse, negative early breastfeeding experiences, and family history of postpartum mood disorder. It is normal for most new moms to transiently experience “postpartum blues,” a brief period after delivery characterized by emotional lability, exhaustion, weight loss, anxiety, intrusive thoughts, trouble sleeping, loss of interest in usual activities, and low mood. PMADs must be considered and addressed when these symptoms occur daily, persist longer than a few weeks after delivery, and cause significant impairment in function.

PMADs can impact bonding between mother/birthing parent and infant. PMADs can interfere with breastfeeding and all forms of nourishing the infant. Lack of maternal interest, attention and attachment due to PMADs can result in safety issues for the infant, as well as emotional deprivation, poor behavioral regulation, failure to thrive, sleep disorders, developmental delay, increased risk of abuse and neglect, and subsequent mood disorders in their later childhood, adolescent and adult lives. Paternal PMADs are also of note, affecting up to 15% of dads in the first 6 months following delivery. Paternal PMADs may present differently, with substance abuse, domestic violence, and compulsive behaviors. Paternal PMADs can significantly impact relationships with their partners, and increase the risk of developmental, behavioral and psychiatric disorders in their children. It is so important that postpartum mood disorders be identified and addressed in all affected parents.

Screening for PMADs can be instituted during visits to the pediatrician and the OB-GYN. Since the first OB-GYN visit is generally not until 6-8 weeks postpartum, pediatricians are in a unique situation to screen for maternal PMADs at the 1 month well-child check. The 10-question Edinburgh Postnatal Depression Scale (EPDS) is the validated screening tool most commonly used, and available in many languages. A score of 10 or higher raises the concern of a PMAD and ought to trigger referral to resources for support, diagnosis and treatment. A score of 20 or higher raises the concern of severe depression or psychosis and ought to trigger immediate referral for an emergency psychiatric evaluation. As already discussed, there are significant consequences to mom, infant, and their family if PMADs are left untreated.

Despite the consequences of untreated PMADs and the presence of a range of options for effective therapy and treatment, most mothers/birthing parents with postpartum depression and anxiety do not seek treatment. There are many factors at play, including moms not recognizing what they are feeling is common and normal; the stigma of mental illness, particularly maternal mental illness; social isolation with COVID; the societal expectation that being a new mom is a happy, joyful experience, and the guilt/shame many moms feel when they are having a different experience; the fear that admitting thoughts/feelings of postpartum depression or anxiety could lead to the baby being taken away from the mom. Screening for perinatal and postpartum depression normalizes these conditions, illuminates their prevalence and their importance. Yet the great majority of moms suffering from PMADs fail to be screened and diagnosed, and are thus left untreated.

Treatment for PMADs includes home visits, emotional support groups, exercise, relaxation techniques, psychotherapy, natural treatments like fish oil, and pharmacological therapy when indicated. In moderate to severe postpartum depression and anxiety, the benefit of using medication far outweighs any risk to the baby while breastfeeding. Treating PMADs with appropriate medication is generally safe for the baby and does not preclude breastfeeding . Medications most often used to treat postpartum depression and anxiety are SSRIs, which block serotonin reuptake, increasing the level and availability of this “happy hormone” at the nerve synapse, improving the symptoms of depression, anxiety and OCD. Sertraline (Zoloft) is the best SSRI for breastfeeding moms, as it has the lowest concentration in breast milk and thus the lowest risk for side effects in the infant (restlessness, irritability, colic, poor feeding). SNRIs like duloxetine (Cymbalta) block the reuptake of norepinephrine at the nerve synapse: they are another option in the safe, effective treatment of PMADs. When treatment of the mother requires medication that is unsafe while breastfeeding, other feeding options should be explored, as the health and well-being of the mother must be the first priority.

Postpartum psychosis is a rare but serious PMAD, occurring in approximately 1/1000 deliveries. Moms and birthing parents with postpartum psychosis may demonstrate wide mood swings, irritability, paranoia, hallucinations, delusions, and suicidal or homicidal thoughts, placing them and their babies at risk for harm. Risk factors include personal and family history of bipolar depression and schizoaffective disorder. Hormonal shifts, sleep deprivation, environmental stress, and stopping mod-stabilizing medications are believed to be contributing factors. Postpartum psychosis is a medical emergency, often requiring hospitalization for stabilization and treatment.

We are here for you. If you have concerns about postpartum depression or anxiety and its impact on your ability to care for yourself and your child, reach out on the portal or schedule an appointment to come see us in the office. Here are some additional resources and community partners that serve our moms and birthing parents with postpartum mood disorders:

Psychiatry/Women’s Health Dr. Nicole Derish. www.derishmd.com . 786-471-6132

Therapy/Women’s Health Dr. Laura Meyer www.expeditionsinmotherhood.com

954-884-0050

Therapy/Maternal Mental Health Dr. KC Charette 561-617-3323

Therapy/Women’s Health Karyn Rosenberg, LCSW, PMH-C 561-306-0232

Therapy/Maternal Mental Health Sarah Hendin, LMHC 561-542-4709

Therapy/Women’s Health Laura Kreisler, LCSW 561-376-0164

Broward Health Coral Springs Postpartum Support Group Contact Lisa Hayes

954-346-4260 or Barbara Bolinsky 954-344-2229

Holding Space for New Mamas Support Group 786-829-5950

Broward Healthy Start Coalition. www.browardhsc.org . Call Connect 954-567-7174

Healthy Mothers, Healthy Babies Coalition: Mothers Overcoming Maternal Stress

(M.O.M.S.) www.hmhbbroward.org . 954-765-0550 ext.331

www.themotherhoodcenter.com 212-335-0034

Postpartum Support International PSI. www.postpartum.net 1-800-944-4773 or

text “Help” to 800-944-4773

SAMHSA 24/7 National Hotline: 800-662-HELP (4357)

www.2020mom.org . 310-955-1080

www.healthynewmoms.org 570-955-7821 or text HealthyMOMS to555888

www.postpartummen.com . 415-346-6719 DrWill@TheMensDoc.com

Early Steps www.Floridaearlysteps.com 954-712-0200

Henderson Behavioral Health www.hendersonbh.org 954-606-0911

24/7 Crisis 954-463-0911

Caring For Your Child With Iron Deficiency

Thu, 30 Jun 2022 20:37:43 GMT

Iron is a mineral required for numerous critical functions in the human body, including oxygen transport, gene regulation, DNA synthesis, brain function, and musculoskeletal function. Iron is ingested in various forms from food it our diet, and absorbed from the small intestine. Iron is stored as heme in red blood cells (hemoglobin) and muscle cells (myoglobin); iron is stored as ferritin in the liver, spleen, skeletal muscle and bone marrow; and to a smaller extent, iron is stored as hemosiderin deposited in various tissues. Iron deficiency refers to a state in which there is insufficient total body iron to maintain normal physiologic functions. Though the body efficiently recycles iron from aging blood cells, iron deficiency may result from increased iron need, particularly during rapid periods of growth, in the face of deficits in the ingestion or absorption of iron, or from excessive iron utilization or iron/blood loss.

The impact of Iron deficiency is monumental. Iron deficiency, independent of anemia, is estimated to affect as many as 50% of young children and female adolescents worldwide. In the United States, approximately 15% of toddlers and 5% of preschool children are iron deficient. In America, the prevalence of iron deficiency is higher among children living at or below the poverty line, and compared to white children, the prevalence of iron deficiency is higher in young Hispanic/Latin American children, in Asian American children, and children from families recently immigrating to the United States. This is of huge consequence, as iron deficiency is associated with lower IQ scores, lower assessments of emotional health, attention deficit hyperactivity disorder (ADHD), restless leg syndrome (RLS), visual and auditory deficits, immune dysfunction, impaired muscle metabolism, chronic fatigue, breath-holding spells, and thyroid dysfunction. These impairments in neurodevelopmental, cognitive, immune, and musculoskeletal function may occur prior to the diagnosis and treatment of iron deficiency anemia.

Iron deficiency is the most common nutritional deficiency in the world and results from a wide variety of causes. Inadequate dietary intake of iron-rich foods, the consumption of foods that impair iron absorption, and menstruation are the main contributing factors. Iron is stored prenatally, and iron stores are generally adequate in full-term infants until age 3-4 months. Preterm infants, infants with intrauterine growth retardation, infants of diabetic mothers, infants of moms with iron deficiency, infants who experience any hemorrhage/blood loss, and breastfed infants are at higher risk for anemia at 3 months, and should be started on iron supplementation if screening is positive for anemia. By 6 month age, infants are able to ingest iron-rich and iron-fortified foods, including fortified cereal, leafy greens like spinach, beans and lentils, liver, red meat, etc. Iron deficiency may develop in young children and adolescents who are pickey eaters; those who avoid animal products; those who consume excess (>24 oz per day) unfortified cow milk or goat milk; and those who ingest excess tannates in tea, phosphates in brain rich foods, and phytates in plant fiber, especially in seeds and grains. Those on a vegan diet are particularly at risk for iron deficiency. In addition, iron deficiency may result from excess blood loss from heavy menstruation (indicators include soaking of a pad in less than 2 hours, bleeding into clothes, or blood clots larger than 1 inch); and excess loss of blood though the gastrointestinal tract (e.g. colitis from milk allergy, inflammatory bowel disease, polyps). Iron deficiency can result from inadequate absorption of iron due to diseases of the GI tract, including celiac disease, inflammatory bowel disease, H. Pylori infection, giardiasis, and autoimmune gastritis. Overweight and obese adolescents are at risk for iron deficiency: compared to the 3% incidence of iron deficiency for adolescents with a normal BMI, overweight adolescents with a BMI of 85%-95% have an incidence of iron deficiency of 7%, and obese adolescents with a BMI over 95% have an incidence of iron deficiency of close to 10%. By complex mechanisms, athletic adolescents both utilize iron and lose iron at a higher rate, placing them at risk for iron deficiency. Finally, there are genetic mutations that result in the failure of iron absorption, even in the presence of iron deficiency, causing persistent iron deficiency resistant to oral iron supplementation.

Clinical manifestations of iron deficiency are generally mild: in fact, most infants and young children with iron deficiency are asymptomatic and found on routine labs to have a microcytic (small cell) anemia. Much less frequent are infants and children with severe anemia, who present with lethargy, pale skin, irritability, poor feeding, rapid heart rate and rapid respiratory rate, and exercise intolerance. Children with iron deficiency may exhibit pica, the intense craving for nonfood items, such as clay or dirt, rocks, starch, chalk, soap, paper, and cardboard. Craving for ice is particularly common and specific for children and adolescents with iron deficiency anemia.

Evaluation for iron insufficiency and iron deficiency anemia includes a complete blood count (CBC), measures of serum iron and iron binding capacity, and iron storage (ferritin). Iron deficiency is often defined as a serum ferritin < 15 mcg/L in all pediatric age groups, noting that ferritin will be decreased with iron depletion prior to the onset and diagnosis of iron deficiency anemia. As the production of blood cells is restricted by iron insufficiency, the hemoglobin will start to decrease, and the volume of the red blood cells (MCV) will diminish, though true anemia may not yet have occurred. Iron deficiency anemia (IDA) in children is defined in children 6 months to <5 years as ferritin <15 mcg/L and hemoglobin <10.5 g/dL; in children 5 to <12 years ferritin <15 mcg/L and hemoglobin <11.5 g/dL; and in adolescents older than 12 years ferritin <15 mcg/L and hemoglobin <12 g/dl.

Differential diagnosis includes thalassemia trait, a genetic variation in hemoglobin that causes the blood cells to mature rapidly and leave the bone marrow sooner, at a relatively smaller size (low MCV). Lead toxicity can also present with microcytic anemia. Anemia of chronic disease will also cause blood cells to be smaller, and serum iron to be lower, though inflammatory markers and ferritin are generally elevated.

At Children’s Medical Association, we check a CBC to screen for iron deficiency at 3 months, 12 months, and yearly at well child check-ups. We screen for lead toxicity between 12-24 months. Additional screening is targeted for those with heavy menstruation, those on a vegan diet, those with chronic disease, and others at high risk.

Management and treatment of iron deficiency starts with dietary interventions to improve iron intake. Increase foods rich in iron: animal products such as red meats, liver and pork, legumes such as beans and lentils, dried fruits (prunes, raisin, apricots), leafy greens (spinach, kale, Swiss chard), and iron-fortified cereals. Foods rich in vitamin C (e.g. citrus fruits, cantaloupe, strawberries, tomatoes, and dark green vegetables) are recommended to enhance iron absorption. Reduce consumption of beverages such as tea and soda that can affect iron absorption. Limit cow milk consumption to 24oz per day. For infants and children with a presumptive diagnosis of iron deficiency anemia based on the history and initial laboratory testing, the next step is a therapeutic trial of iron, consisting of ferrous sulfate, 3 mg/kg of elemental iron, once daily in the morning or in divided doses between meals. NovaFerrum is a recommended iron supplement which is allergen-free, tastes great, and is available in 15mg/ml and 25mg/ml of iron per dose. Other products include Vitamin Friends Iron Gummies (15mg), Natural Factors Easy Iron Chewable (20mg) and Prothera Iron Chewables (30mg). Iron may be given alone or with water, juice, or acidic fruits (e.g., mango, strawberries, or applesauce). Milk and/or dairy products should be avoided for approximately one hour before and two hours after each dose, as the calcium interferes with iron absorption. For adolescents with iron deficiency, with or without anemia, we recommend ferrous sulfate, providing 65 to 130 mg elemental iron daily. Typically, patients treated for iron deficiency anemia return to the office 2-3 months later for a repeat CBC, monitoring the change in hemoglobin and MCV. Treatment courses should last for at least 3 months, and even after discontinuation of iron therapy, it is reasonable to continue iron-rich foods in the diet.

Transfusion therapy is rarely needed for iron deficiency anemia in children and adolescents, unless the hemoglobin concentration is below 7 g/dl. Indications for IV iron therapy include persistent anemia with oral iron intolerance, malabsorption, or nonadherence to oral iron therapy. Transfusions are generally reserved for patients who are in distress due to anemia, with rapid heart rate, rapid respiratory rate, low blood pressure, light-headedness, and lethargy. Children with underlying gastrointestinal disease, such as short bowel syndrome or inflammatory bowel disease, may have particular difficulty tolerating oral iron and require early initiation of IV iron therapy.

Prevention of iron deficiency is supported by a well-balanced diet, including iron-rich foods detailed above. For those at increased risk for iron deficiency, more frequent screening and iron supplementation are both tools to prevent deficiency. There has been much attention to the idea of delayed cord clamping as a means of providing more placental blood and iron to the neonate, as a means to prevent iron deficiency later in infancy. Research has shown that delayed cord clamping of greater than 2 minutes leads to elevated ferritin levels and decreased risk of iron deficiency in the infant up to 8 months of age compared with early cord clamping (5-10 seconds).

We are here for you. If you have concerns about your child and iron deficiency, reach out on the portal or schedule an appointment to come see us in the office.

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Caring For Your Infant With Hemangioma

Mon, 07 Mar 2022 16:46:52 GMT

Infantile hemangiomas are “birth marks” made up of a collection of blood vessels that formed incorrectly and proliferate rapidly. They occur in as many as 5% of infants, making them the most common benign tumor of infancy. Infantile hemangiomas are more common in girls, twins, white infants, and those born premature or with low birth weight. Most are small, resolve on their own, and require no treatment. A small number of hemangiomas have the potential to cause problems, based on their size or their location, and those risk factors are important in the consideration for treatment. Careful monitoring, recognition of risk, and early intervention are key in providing the best care for your infant with hemangioma.

Infantile hemangioma may be present at birth as a superficial, small, red, vascular mark on the skin, or more commonly become evident in the weeks following birth. They have traditionally been called “strawberry hemangiomas.” There is a natural history of uncomplicated infantile hemangiomas : they typically grow rapidly during the first 3 months, most stop growing by 5 months, and most infantile hemangiomas start to involute between 5-12 months of life. The color will change from red to milky-white or gray, the lesion will flatten and shrink, and 90% heal by age 4yr. Even after involution, the skin may be left with thin blood vessels (telangiectasias), redundant skin, or a scar. Some infantile hemangiomas are deeper in the skin, and may have a blue appearance.

As stated above, most infantile hemangiomas are benign. There are well-defined categories of infantile hemangiomas with increased risk for complication : their early recognition and treatment can prevent adverse outcomes. Hemangiomas requiring treatment include:

Those in the “beard-area” or the front of the neck, which may be associated with hemangioma in the airway, which has the potential to block the airway as the hemangioma grows.

Infants with 5 or more cutaneous hemangiomas, which may alert to the possibility of hemangiomas in vital organs like the liver, and may cause strain on the body leading to cardiac failure and severe thyroid dysfunction.

Infantile hemangiomas in areas where their presence may cause functional impairment, e.g. those at the eye potentially impacting vision, and those at the lip/mouth potentially impacting feeding.

Infantile hemangiomas in areas at increased risk for ulceration/bleeding, e.g. those at the lip, upper ear, diaper area, anus, and skin folds of the neck, arm pit, and groin.

Infantile hemangiomas in areas at high risk of scarring or permanent disfigurement, e.g. those at the face and scalp, those at the breast, those with a steep step off (ledge effect), and those greater than 2cm in size or 2mm in depth.

Large, segmental (greater than 5cm) infantile hemangiomas over the head and neck, or lumbosacral area of the back, which may be associated with underlying structural anomalies of the brain, vascular system, spine or spinal cord.

It is recommended that infants with hemangiomas that are high risk for complications be seen by a specialist by 1 month of age. Depending on the location and nature of the hemangioma, specialty consultation may be arranged with a pediatric dermatologist, a pediatric plastic surgeon, and/or an otolaryngologist (ENT surgeon).

Diagnostic studies are generally unnecessary, as infantile hemangiomas are diagnosed by their clinical appearance. Rarely, if the appearance or growth or response to treatment are atypical, a biopsy may be recommended. Ultrasound of the abdomen is indicated in the setting of 5 or more cutaneous hemangiomas, to evaluate for the presence of hemangiomas within the liver. The presence of large segmental hemangiomas, for example over the head and neck or lumbosacral spine, would warrant imaging studies (MRI/MRA) of associated structures like the head, chest, spine and spinal cord.

The first-line treatment of high-risk infantile hemangiomas is oral propranolol. Studies show a mean response of 95%. The precise mechanism of action is unclear, though may be related to its ability to promote vasoconstriction and inhibit angiogenesis (new blood vessel formation). The recommended starting dose is 0.6 mg/kg given twice daily, with a gradual increase to the target dose of 2-3 mg/kg/day. Treatment is recommended for 6 months, and there may be rebound growth in 10-25% of infants when propranolol is discontinued. Propranolol is a beta-blocker, and side effects of propranolol include bradycardia (slow heart rate), hypotension (low blood pressure), hypoglycemia (low blood sugar), lethargy, poor feeding, wheezing, and sleep disturbance. Any child with known congenital heart disease and hemangioma should be seen by their cardiologist for consultation, regarding the safety of propranolol with their underlying cardiac condition. Screening EKG is only indicated for infants with a baseline low or irregular heart rate, and those with a family history of congenital heart disease or rhythm disturbance. Propranolol should be administered with or after feeds, and should be held at times of diminished feeding or vomiting to reduce the risk of hypoglycemia. Side effects , when they occur, are generally mild, and may be managed by lowering the dose of propranolol. Discontinuation of treatment is rarely necessary.

For patients in whom propranolol is contraindicated, poorly tolerated or ineffective, second-line treatment of high-risk infantile hemangiomas is steroids, either orally or by direct injection into the high-risk lesion. Prolonged use of oral steroids is associated with significant side effects (Cushingoid appearance, increased risk for infection, poor growth, high blood pressure, and mood changes), and is thus not recommended.

Low risk lesions do not require treatment , though some clinicians will recommend treating thin, superficial hemangiomas with topical timolol, also a beta-blocker, to slow growth and enhance resolution. Lesions treated with topical timolol have an estimated clearance of over 60%. Since medication may be absorbed through the skin into the bloodstream, a small percentage of infants treated with topical timolol may experience systemic symptoms, including sleep disturbance, bradycardia, and wheezing: these side effects are noted to be more prevalent in premature infants. Surgical interventions during infancy are generally avoided (risk of anesthesia and bleeding), though high-risk lesions that are not responsive to oral propranolol may require surgery. Pulse-dye-laser (PDL) treatment is being used for infantile hemangioma, though it carries the risk of bleeding, ulceration, skin atrophy, and scarring. Both surgery and PDL may be useful in managing persistent skin changes that may result from an infantile hemangioma.

We are here for you. If you have concerns about your infant’s hemangioma, particularly if it is rapidly growing between the 1 month and 2 month check-up appointments, reach out on the portal or schedule an appointment to come see us in the office. Here are some additional resources and community partners that serve our patients with infantile hemangioma:

Plastic Surgeon Dr. Eric Stelnicki (Hollywood) 954-984-1899

Plastic Surgeon Dr. Drew Schnitt (Delray Beach) 855-467-7473

Plastic Surgeon Dr. Chad Perlyn (Miami) 305-278-5951

Dermatologist Dr. Lawrence Schachner (Miami) 305-243-6704

Dermatologist Dr. Ana Duarte (Miami) 305-669-6555

Dermatologist Dr. Anna Falabella (Hollywood) 954-961-1200

ENT Dr. Samuel Ostrower (Coral Springs) 954-265-1616

ENT Dr. Steven Singer (Hollywood) 954-987-5430

ENT Dr. Sandeep Dave (Miami) 786-624-3687

https://hemangiomaeducation.org/

Society for Pediatric Dermatology https://peds derm.net/

Caring For Your Child With Concussion

Fri, 18 Feb 2022 21:21:25 GMT

Concussion is a commonly occurring traumatic brain injury, which largely occurs in children and adolescents during sports-related trauma, though concussion may be related to other forms of head trauma (accidental falls, being struck by a person or object, motor vehicle injury etc). Up to 2 million recreational concussions and sports-related concussions are reported yearly in people under 18yr in the United States. Symptoms following concussion can impact physical, emotional, academic, social, family, and athletic health, making the appropriate management of your child with concussion extremely important, both enhancing recovery and minimizing long-term complications.

Concussion may be caused by a direct blow to the head, or trauma elsewhere to the body that produces an energy force transmitted to the head, impacting the brain. The kinetics of the injury consist of forces of acceleration, deceleration, and rotation of the head. The trauma causes a chemical cascade and metabolic disturbance that impacts the brain down to the cellular level, depleting cellular energy, creating acidosis, causing oxidative stress and inflammation, all resulting in significant changes in brain function. The actual structure of the brain may not appear altered on standard Xray, CT, MRI. Decreased cerebral brain flow and the sheer force to the axons during trauma also impact brain function for days to weeks following concussive head injury.

Signs and symptoms of concussion can be divided by category, and include:

somatic (headache in over 90%, dizziness in up to 75%, nausea and vomiting, neck pain, sensitivity to light and noise)
vestibular/oculomotor (visual tracking and convergence problems, impaired balance and coordination, slow reaction time, dizziness, hearing problems and tinnitus)
cognitive (blank stare or “stunned” appearance, poor focus in over 50%, confusion and disorientation in 40%, slow processing speed, slow speech, brain fog, memory loss, impaired learning)
emotional (irritability, emotional lability, sadness)
sleep (drowsiness, fatigue, trouble falling asleep or staying asleep, sleeping too much)

The sports with the highest risk of concussion are tackle football, lacrosse, ice hockey, wrestling, soccer, field hockey, and basketball. Rates of concussion are significantly higher during competition than practice. Interestingly, girls’ soccer and basketball are associated with a higher incidence of concussion than boys’ soccer and basketball. Swimming and track are the sports with the lowest rates of concussion. Concussion may also occur with accidental trauma during recreational activities such as bicycle riding, skateboarding, ice skating and skiing.

Brief loss of consciousness in a child sustaining concussion occurs less than 10% of the time, and does not predict more significant impairment; the absence of loss of consciousness does not justify more rapid return to play or school. The initial evaluation of a conscious athlete who is suspected of having a sports-related concussion occurs on the field or on the sideline or in the locker room. The most common tool used is the Sport Concussion Assessment Tool (SCAT). Because athletes do not always show immediate symptoms or signs of deficits following trauma, it is imperative to err on the side of caution and keep the athlete from returning to play on that same day, while reassessing for evidence of concussion. In fact, all 50 states have enacted laws requiring the benching of an individual suspected of sustaining a concussion, and requiring medical evaluation before returning to play. Studies show that athletes who continue to play are nearly 10x more likely to have a prolonged recovery from this trauma, and may experience severe consequences following subsequent head trauma.

Red flags in the initial assessment that would warrant urgent referral to an emergency room include loss of consciousness, weakness or tingling in the arms or legs, severe or progressive headache, repeated episodes of vomiting, irritability or combativeness, and/or seizure. These may indicate more serious trauma, such as skull fracture, hemorrhage, or injury to the cervical spine. CT scan of the brain is routinely performed in the emergency room for a child being evaluated for head trauma, though it is generally normal for the child with concussive head injury, in the absence of signs of more serious trauma. CT does expose a child to the potentially harmful effects of ionizing radiation, and ought to be considered carefully in a child who appears well and in whom there is no evidence for deterioration over time. MRI of the brain is superior to CT scan in detecting contusion (bruising) to the brain, and ruling out other brain lesions in children with ongoing symptoms (e.g. tumor or Chiari malformation). Functional neuroimaging (PET scans, functional MRI) may soon be available in the diagnosis and management of pediatric concussive head injury. Neurocognitive testing may be beneficial in the individual with prolonged symptoms or repeated concussion, though children and adolescents with underlying diagnoses of psychiatric illness, ADHD, migraine and substance abuse may have abnormal neurocognitive testing independent of concussion.

The diagnosis of concussion is based on a history of trauma that results in rapid acceleration, deceleration and/or rotation of the brain; onset of signs of symptoms soon after the injury; a positive assessment, e.g. SCAT; exclusion of structural injuries to the brain, e.g. subdural hematoma noted on CT scan; the exclusion of other medical diagnoses with similar features, e.g., heat stroke, hypoglycemia, cardiac syncope, migraine, psychiatric disorder, etc.

The acute management of concussion involves assessment for injuries/deficits that may require rehabilitation; education about what to anticipate following the diagnosis of concussion; cognitive and physical rest; and guidance for returning back to school and play. Current recommendations include:

Immediate removal from play.
Limiting initial physical exertion to walking, keeping the intensity below a level that provokes symptoms.
Avoiding recreational activities that may result in a second head injury (cycling, skating, skiing, skateboarding, etc.) until full recovery.
Suspending screen time for at least 24 hours following the injury, then limiting screen time in individuals with light sensitivity or oculomotor deficits. Consider accommodations such as enlarged font and lower brightness.
Reducing academic workload to avoid provoking symptoms.
Suspending driving for a few days following head trauma, as focus and reaction times may be impaired.
Analgesics and anti-inflammatory medications like Tylenol and Motrin may be used in the days following injury, though prolonged use may result in rebound headaches and many complicate recovery.
Ondansetron (Zofran) may be used for nausea in the first few days following concussion. However, ondansetron itself can potentially cause headache, drowsiness and dizziness, complicating other symptoms of concussion.
Physical therapy may be useful to facilitate recovery when the concussion is accompanied by cervical strain or deficits in balance and coordination.
Occupational therapy may be useful to facilitate recovery when the concussion is accompanied by deficits in motor planning and cognition.
Oculomotor therapy may be useful to facilitate recovery when the concussion is accompanied by visual deficits in accommodation, tracking, etc.

Recovery varies among all patients, as every concussion is unique, though most children and adolescents with concussive head trauma recover within 1-4 weeks. Return to sport must be individualized, and is best accomplished by following a graduated stepwise program. Studies have consistently showed that low levels of aerobic exercise, if tolerated, initiated within days of the injury, are safe, prevent deconditioning, and improve recovery time. Athletes should not be allowed to return to contact, collision or high-risk activities until symptoms of concussion have resolved and a return-to-sport progression has been completed. Each step should take at least 24 hours, so at best, it takes about 1 week to resume full participation, as long as the athlete remains symptom-free. The return-to-sport progression may be monitored by a parent, coach, athletic trainer, or health care provider working within a specialized concussion program. Written medical clearance from a health care provider is required for any athlete with concussion to return to participation. The process is rigorous, as athletes who return too soon are at risk for a more severe subsequent injury and prolonged recovery. Return to full participation is only recommended once your child is back to baseline, is symptom-free, and has successfully returned to school.

Return to school must also be individualized, as symptoms of concussion may be worsened by cognitive effort (reading, prolonged screen time, high focus with problem solving and test taking, etc.). In addition, studies show that cognitive rest following concussion is associated with improved neurocognitive function. It is recommended to rest at least one to two days before returning to school, and then return to school when capable of sustaining 30-45 minutes of concentration without symptoms. For children and adolescents with ongoing symptoms, it is recommended to minimize cognitive activities; avoid exposure to video games, loud music and prolonged recreational screen time; and analogous to return to sport, gradually resume cognitive activities under the guidance of a concussion specialist. School adjustments may be necessary in the first few weeks (rest break in the nurses’ office, extra time in hallways, obtaining preprinted notes, etc.). Formal academic accommodations may be required to address longer-term needs beyond 3 weeks, and can be formalized in a 504 plan (extra time on work, changes in class schedule, alternate arrangements for standardized testing, etc.). Academic modifications may be necessary for prolonged post-concussive symptoms impacting school function, necessitating special education with needs specified in an individualized educational plan (IEP).

The chronic management of concussion includes addressing long-term symptoms such as headache, dizziness, fatigue, brain fog, poor focus and memory, impaired balance and coordination, insomnia, poor emotional regulation, mood disorders, and sleep disorder. Referral to a specialized concussion center is warranted. Consultation with a pediatric neurologist, neuropsychologist, and/or physiatrist may be recommended. Physical therapy, occupational therapy, vestibular therapy, oculomotor therapy, biofeedback, and cognitive-behavioral therapy with a psychologist made be necessary. Good sleep hygiene is essential, and a trial of melatonin 2-5mg may be initiated to improve sleep.

Though there are no evidence-based clinical studies to support nutritional strategies in the recovery from concussion, it makes sense to incorporate foods that reduce oxidative stress and inflammation, and support neuronal healing and growth: these include brightly colored fruits and vegetables, particularly blue and purple grapes and berries, and cruciferous vegetables like broccoli and cauliflower; wild salmon and bivalves (mussels, clams, oysters); healthy fats from eggs, nuts and seeds, avocado, coconut milk, olive oil; herbs like ginger, cilantro, and rosemary; spices like garlic, tumeric and cinnamon.

Prevention of concussion is challenging , with efforts largely focused on improving protective equipment and their fit, implementing fair rules of the game to reduce risk of head injury, and educating participants and their families for safe sports participation. Policy change is also needed: based on clear evidence that concussion risk is reduced in youth ice hockey when body checking is prohibited, the American Academy of Pediatrics recommends that body checking not be permitted in youth ice hockey until age 15yr. Exercises done to strengthen neck musculature may mitigate the impact of an injury and reduce the risk of sports-related concussion.

The prognosis for your child with concussion is good. Most pediatric patients will recover readily from concussion, and it is estimated that 90% will be symptom-free and clear to return to play within one month of the injury. The presence of a higher overall initial symptom burden has shown to be the most consistent predictor of prolonged (>28 days) recovery after a concussion. Additional risk factors for prolonged recovery include history of prior concussion, history of migraine, history of learning disabilities, history of anxiety or depression, and failure to observe the recommended periods of cognitive and physical rest. Female adolescent patients may take longer to recover.

We are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you have any concerns about your child with concussion. Here are some local resources to support our patients with concussion and their families:

Dr. John W. Kuluz

Nicklaus Children’s Hospital Concussion and Brain Injury Clinic

3100 SW 62nd Avenue

Miami, FL 33315

786-268-1789

Drs. Michael Dressing, Diana Martinez, Virmarie Quinones-Pagan

Joe DiMaggio Children’s Hospital Concussion Clinic

4651 Sheridan Street Suite 150

Hollywood, FL 33021

954- 538-5566

Sports Medicine Concussion Clinic

Nova Southeastern University

3301 College Avenue

Davie, FL 33314

954-262-5590

Head Strong Concussion Care Program

Coral Springs Medical Center

3000 Coral Hills Drive

Coral Springs, FL 33065

954-344-3180

University of Miami Concussion Program

Batchelor Children’s Research Institute

1580 NW 10th Ave. 1st Floor Clinic

Miami, FL 33136

305-243-2074

University of Miami Concussion Program

UHealth of Boca Raton

3848 FAU Boulevard, Suite 305

Boca Raton, FL 33431

561-289-5808

Caring For Your Child With Migraine Headache

Wed, 12 Jan 2022 00:46:05 GMT

Migraine is the most common acute and recurrent headache syndrome in children. Migraine prevalence estimates are around 3% of children by age seven years and about 10% by age 15 years. Before puberty, there is an equal prevalence in girls and boys, but after puberty, the prevalence is 2 to 3 times more common in girls. Early intervention is the key for managing migraine in children, to achieve fast and complete pain relief, to minimize the impact on physical and emotional health, and to promote rapid return to normal function, including participation in school, sports, family and social activities.

The diagnosis of migraine is made with the occurrence of at least 5 headaches over the last year, lasting 2-72 hours if left untreated, with additional features including moderate to severe intensity, pulsatile quality, one sided, and worsening with activity. Migraine is often accompanied by aura (a sensation, whether visual or auditory or taste or smell, that precedes headache by 5-60 minutes), nausea, vomiting, abdominal pain, sensitivity to light (photophobia), sensitivity to sound (phonophobia), and generally relieved by sleep. Chronic migraine is defined as 15 or more headache days (8 migraines) per month for 3+ months.

Triggers to migraine include environment (stress, weather changes, barometric pressure); lifestyle (stress, sleep disruption, dehydration, dietary triggers including food dye, MSG, aspartame, nitrates, caffeine, gluten); metabolism (mitochondrial dysfunction, related to energy production in our cells); hormones (neuroendocrine and menstrual, related to rapid changes in estrogen, serotonin, and inflammatory mediators like glutamate and prostaglandins). Identifying and avoiding these triggers are important steps in helping to care for your child with migraines. There are numerous genes that have been found to be associated with migraine disorders, which is one explanation to why migraines often occur in families.

Abortive treatment strategies to manage an acute migraine headache include resting in a dark, quiet, cool room; immediately offering a simple analgesic while the pain is still mild, like acetaminophen (Tylenol) or ibuprofen (Motrin or Advil) or naproxen (Naprosyn or Aleve). If there is significant nausea or vomiting, an antiemetic like ondansetron (Zofran) may be used. For children 5yr or older with moderate to severe migraine unresponsive to these first tier medications, triptans are the next line of treatment: rizatriptan (Maxalt) and zolmitriptan (Zomig) are available in oral disintegrating tablets (ODTs), sumatriptan (Imitrex) and zolmitriptan are available as nasal sprays, almotriptan (Axert) is available as an oral tablet. If one triptan fails to provide pain relief, an alternate triptan may be beneficial. For children 5yr and older and adolescents non-responsive to the above medications, combination therapy with an analgesic-triptan (e.g. sumatriptan/naproxen) is more likely to produce pain relief. For refractory migraines requiring treatment in a specialized headache center or emergency room, next tier abortive medications include dihydroergotamine (DHE), anti-emetics like prochlorperazine, subcutaneous sumatriptan, along with IV hydration.

A few cautions are worth note. Triptans are contraindicated in patients with a history of cardiovascular disease, including stroke and TIA, and cardiac conduction disorders, including WPW. Using triptans more than 9 days per month increases the risk of rebound headache, so keeping a log or headache diary is an important way to monitor the frequency of headaches and their treatment.

Preventive strategies are the mainstay in managing migraine headache in children and adolescents: these include medication, supplements, and integrative therapies. Preventive medications include anti-seizure medications like topiramate, zonisamide, and gabapentin; beta-blockers like atenolol or propanolol; tricyclic antidepressants like amitriptyline and nortriptyline; calcium channel blockers like verapamil; SNRIs like venlafaxine and duloxetine; SSRIs like fluoxetine and escitalopram. There are ongoing studies to evaluate whether Botox (onabotulinumtoxinA) reduces migraines frequency or reduces migraine days in children and adolescents with migraine. Decisions regarding the use of these preventive medications are generally made with the guidance of a pediatric neurologist or headache specialist. In addition to these pharmacological treatments, there are numerous integrative and holistic approaches to manage patients with chronic headache.

Preventive supplements include:

Magnesium (glycinate or gluconate) 10/kg/day up to 500mg/day taken with water at dinnertime. Magnesium oxide and magnesium citrate are more likely to cause diarrhea. Magnesium is active in over 300 pathways, and for headache prevention, works in reducing muscle tension, decreasing neurogenic inflammation, regulating pain, and blocking glutamate.
Riboflavin (vitamin B2) 200mg daily in young children, 400mg daily in older children and adolescents. Active in mitochondrial function. Side effects include very yellow urine.
CoQ10/ubiquinol 200mg daily, though avoid near bedtime, as it may boost energy and cause insomnia. Active in mitochondrial function and reducing inflammation.
Melatonin 3mg-10mg nightly, increasing dosage may be needed as patients can develop tolerance. Side effects include drowsiness, daytime sleepiness, and nocturnal enuresis (bedwetting). Active in reducing inflammation, reducing vasodilatation, and blocking glutamate.
Iron supplementation if labs reveal low iron/ferritin levels (the optimal ferritin level is 50-70). Low iron levels are associated with morning headaches, poor sleep, restless legs, along with anemia, fatigue and cognitive issues. The recommended dose is 2-6 mg/kg/day, 18-65mg of elemental iron daily (65mg of elemental iron is equivalent to 325mg ferrous sulfate). Taking iron with vitamin C increases the absorption.
Vitamin D3 should be optimized from 40-90 ng/ml to reduce inflammation, support immune function, optimize cell signaling, improve hormonal balance, and regulate neurotransmitter release. The target dose for young children is 2000 IU daily, for adolescents 4000-5000 IU daily.
Omega-3 fatty acids (fish oil) 2-4grams daily to reduce inflammation. The parallel recommendation is to increase dietary omega-3 fatty acids from anti-inflammatory vegetable oils (olive and flax seed), and decrease omega-6 fatty acids from pro-inflammatory vegetable oils (soybean and corn). High dose fish oil may increase burping and bleeding/bruising. DHA from algae 200-400mg is alternative for vegans or those who cannot tolerate fish oil.
Butterbur is no longer recommended due to possible liver toxicity. Popular products include Petadolex and Migravent.

Preventative therapies include:

Acupuncture (activates inhibitory pain pathways to stop pain)
Nerve blocks
Nutrition: increased omega-3s (salmon, nuts, olives, flax), avoid prolonged fasting, increase hydration up to 64oz per day, eat whole food including healthy fats (eggs, avocado, organic full fat dairy), minimize added sugars, reduce chemical exposures in food (caffeine, MSG, aspartame, nitrates, dyes), consider elimination diet (gluten).
Self-regulation techniques: biofeedback (e.g. pain center biofeedback systems, home devices like Heart Math and Apollo Neuro), meditation, mindfulness, clinical hypnosis
Movement therapies: yoga, exercise, physical therapy
Neuromodulation Devices: Cefaly, gammaCore (nerve stimulators)
Cognitive behavioral therapy for chronic pain and mood disorder

We are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you have any concerns about your child with migraine headaches. Here are some local and national resources to support our patients with migraine and their families:

Dr. Suzanne Hagler, Pediatric Neurology, Director Headache Program

Nicklaus Children’s Hospital 954-385-6276

Dr. Diana Martinez, Pediatric Neurology, Joe DiMaggio Children’s Hospital

954-265-2423

Dr. Paige Kalika, Pediatric Neurology, University of Miami Health System

305-243-3100

American Migraine Foundation americanmigrainefondation.org

856-423-0043

MAGNUM - Migraine Awareness Group: A National Understanding for

Migraineurs www.migraines.org . 703-739-9384

Miles for Migraine milesformigraine.org . 484-534-8786

National Headache Foundation headaches.org . 888-NHF-5552

Caring For Your Child With Celiac Disease

Mon, 10 Jan 2022 19:50:35 GMT

Celiac disease is a life-long, autoimmune disease, predominantly affecting the small intestine, though also affecting parts of the body outside the gastrointestinal (GI) tract. Celiac disease is triggered by ingestion of gluten, in people who have an underlying genetic susceptibility. Gluten is the major protein in wheat, though grains like barley and rye also contain gluten. Celiac disease affects people all over the world, with a prevalence of approximately 1 in 100 persons.

Celiac disease is associated with the genes HLA-DQ2 and HLA-DQ8: 95% of celiac cases are DQ2 positive. 40% of the population have one the these two genes, and therefore the genetic predisposition for celiac, though never develop disease. It is recognized that a combination of genetic and environmental factors, which include dietary gluten, viral infection, stress, toxins, etc., ultimately trigger the cascade of gut inflammation that characterizes celiac disease.

When a person with celiac disease ingests gluten, the gut immune system is activated, and ultimately destroys the intestinal villi, the small, finger-like projections in the small intestine where nutrients are absorbed from food. This causes poor weight gain, nutritional deficiencies, GI symptoms, failure to thrive, and propels systemic signs and symptoms. Elimination of gluten reverses the intestinal damage in celiac disease, and relieves gastrointestinal and systemic signs and symptoms of celiac disease.

Signs and symptoms of celiac disease include:

-diarrhea and constipation

-bloating and gas

-failure to thrive (failure to gain weight, short stature)

-abdominal pain

-nausea and vomiting

-bumpy rash around the elbows and knees (dermatitis herpetiformis)

-mouth ulcers and poor dental enamel

-anemia

-absence or loss of menstrual periods (amenorrhea), or infertility

-alopecia (hair loss)

-chronic fatigue

-thin bones (osteopenia, osteoporosis)

-brain fog and headaches

-depression and behavioral problems

The evaluation for celiac disease includes blood testing that may show elevated antibody levels to gliadin in gluten, endomysium in the gut, and tissue transglutaminase (IgA-tTg). In children younger than 2yr, additional testing against IgG-deaminated gliadin peptide is also useful. Though these are the hallmarks of celiac disease in the blood, confirmatory diagnosis is made by undergoing an upper GI endoscopy with small bowel biopsies, which reveal varying degrees of intestinal inflammation and blunting/atrophy of the intestinal villi. It is critical that gluten not be removed from the diet until the endoscopy has been completed. Other recommended lab tests at the time of diagnosis include a complete blood count (CBC), iron studies, vitamin D, thyroid and liver function testing. Interestingly, people with HLA-DQ2 may not respond to hepatitis B vaccination in infancy, so checking their antibody status during childhood is recommended, and revaccination initiated if indicated.

The only current treatment for CD is complete avoidance of gluten, meaning restricting all foods containing wheat, barley and rye from the diet. When reading food labels, this also means restricting other grains that contain gluten: bran, couscous, farina, matzo flour, panko, semolina, and udon. A gluten-free diet (GF) includes all foods that are naturally free of grain, including all fruits, vegetables, meats, eggs, fish, dairy, beans and legumes, nuts and soy protein. Gluten-free grains that are safe for people with celiac disease to consume include amaranth, buckwheat, corn, potato, gluten-free oats, quinoa, rice and teff. Beware of hidden gluten in food additives: hydrolyzed vegetable protein, modified food starch, natural flavoring and maltodextrin may come from wheat or barley. Traditional soy sauce is processed with wheat and therefore not acceptable for people with celiac disease: gluten-free soy sauce, tamari, and coconut aminos are all gluten-free alternatives. Products labeled gluten-free must adhere to strict FDA labeling rules, containing less than 20 parts per million gluten. Cross-contamination with gluten-containing foods in the home, at school, in restaurants and at social settings is risky to people with celiac disease, as even crumbs containing gluten can lead to symptoms and intestinal inflammation: utmost care must be taken to inform others and protect your child. Good handwashing with soap and water prior to eating is essential. Non-food items containing gluten, if ingested, can trigger symptoms in people with celiac disease. Therefore, particularly for young children who are prone to put things in their mouth, it is important to check for gluten exposure in medications, supplements, shampoo, cosmetics, communion wafers, and school supplies like papier-mâché and pasta used for artwork etc. A 504 plan for school can proactively plan for dietary and classroom accommodations for your child with celiac disease.

Celiac disease occurs more frequently in people with certain conditions, such as Type 1 diabetes mellitus, Down Syndrome, Williams Syndrome, Turner Syndrome, and Hashimoto (autoimmune thyroiditis). Routine screening for celiac disease is recommended for those patients, along with first-degree relatives (parents, children, siblings) of a person with celiac disease.

Non-celiac gluten sensitivity (NCGS) or gluten intolerance, is a condition where the body reacts to the inflammatory effects of gluten, though not through autoimmune mechanisms. People with NCGS may have headaches, brain fog, ADD, anxiety, irritable bowel syndrome, eczema/atopic dermatitis, etc. An elimination diet can identify if a person has gluten sensitivity.

We are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you have any concerns about your child and celiac disease. Here are some local and national resources to support our patients with celiac disease and their families:

Celiac Disease Foundation www.celiac.org 818-716-1513

Beyond Celiac: Together for a Cure www.beyondceliac.org 844-856-6692

National Celiac Association www.nationalceliac.org . 888-4-CELIAC

National Foundation for Celiac Awareness www.allergyhome.org

Dr. Carla Perez NCH Gastroenterologist 888-624-2778

Dr. Jacqueline Larson JoeD Gastroenterologist 954-265-4475

Lucille Beseler, Nutritionist, RDN/LDN 954-360-7883

Meryl Brandwein, Nutritionist, RDN/LDN 954-828-2602

Gluten Intolerance Group www.gluten.net 253-833-6655

Guide to Infant Formula

Fri, 03 Dec 2021 20:02:19 GMT

Development of infant formulas can be traced to the late 19th century, when in 1867, Liebig developed and marketed the first commercial product for infant feeding that contained cow milk, wheat flour, malt flour, and potassium bicarbonate. In 1915, Gerstenberger reported a 3-year experience using “synthetic milk, adapted” that contained nonfat cow milk, lactose, oleo oils, and vegetable oils. This product represented early understanding that cow milk required alteration to improve its acceptability for infant human consumption and is considered the precursor to modern infant formulas.

Government regulation of infant formula composition in the United States began in 1941 and underwent significant expansion with passage of the Infant Formula Act of 1980. The Infant Formula Act of 1980 and its amendments in 1986 defined minimum concentrations of 29 nutrients and established quality control standards for commercial production of infant formulas. Over the years, infant formula manufacturers resolved to develop products that mimic the complexities and performance of human milk, propelling a special committee of the Food and Nutrition Board of the Institute of Medicine to enhance regulatory and research procedures to assess the safety of potential new ingredients in infant formulas.

The landscape of infant formula in late 2021 is broad, and this guideline is meant to give you a thoughtful approach to infant formula choices, whether your baby is breast-fed and you are considering supplementation, or whether you are choosing to feed exclusively with formula. This list is comprehensive, though does not include every formula on the market. The following sections are organized according to standard formula and specialized formula, which may be indicated under certain circumstances. We always recommend you discuss these choices with your pediatrician or nurse practitioner prior to making changes in your baby’s nutrition.

STANDARD COW-MILK BASED FORMULA . Standard formula is generally based on cow-milk protein, whey and casein, in a 60:40 balance (casein is the protein that forms curds with exposure to stomach acid, and whey is the thinner protein that empties from the stomach more rapidly). Lactose in the standard carbohydrate (sugar) in standard cow-milk based infant formula. Approximately 50% of the caloric content of human milk is contained in its lipid component, which is rich in palmitic, oleic, linoleic, and linolenic fatty acids. Current formulas contain specific blends of vegetable oils designed to mimic the ratios of saturated, monounsaturated, and polyunsaturated fatty acids in human milk. Docohexaenoic acid (DHA) and arachidonic acid (ARA) are long-chain fatty acids present in human milk and have been found to accumulate rapidly in the fetal retina and brain during the last trimester of pregnancy, continuing until 2 years of age: all standard cow-milk based formulas contain DHA and ARA. All formula contains vitamins and minerals, essential for growth and wellness. Prebiotics and probiotics are added to some standard formulas to increase the concentration of bifidobacteria and lactobacilli in the stools of preterm and term infants, mimicking the pattern of the breast-fed baby. Some examples of standard cow-milk based formulas are Enfamil Lipil, Enfamil NeuroPro, Similac Advance, Similac Pro-Advance, Target Up and Up Advantage, Walmart Parents Choice Advantage, Costco Kirkland ProCare, and the organic formulas Similac Organic, Earths Best Organic, HIPP Organic, and Bobbie Organic.

MODIFIED COW-MILK BASED FORMULA . For infants who may be showing some intolerance to the carbohydrate content of standard infant formula (bloating, gas, fussiness), lactose-free formulas are available (Similac Sensitive, Similac Pro-Sensitive, Enfamil NeuroPro Sensitive, Parents Choice Sensitivity, Up and Up Sensitivity, Kirkland For Babies Sensitive to Lactose). For babies who may be who may be showing non-specific formula intolerance, Enfamil GentleEase, Earths Best Sensitivity and HIPP Comfort are good choices: they are lactose reduced and the proteins are partially broken-down (hydrolyzed) for easier digestion. For babies who may be showing some intolerance to the protein content of standard infant formula (colic, pain, mucous in the stools, respiratory congestion), casein-free formulas are available (Similac Pro-Total Comfort, HIPP Comfort, and the whole spectrum of Nestle/Gerber/Good Start Gentle formulas, which are 100% whey and partially hydrolyzed for easier digestion). For infants who are showing signs of gastroesophagel reflux (excessive spitting up, arching, discomfort with swallowing), there are several formulas that have added rice starch or locust bean gum to thicken the formula in the stomach and provide protection against reflux (Enfamil AR, Similac for Spit Up, Parent Choice Added Rice Starch, and HIPP Anti-Reflux).

HYPOALLERGENIC FORMULA . For infants who may be showing true allergy to intact milk-based formulas (blood and mucous in the stool, severe colic, severe eczema), hypoallergenic formulas are available. These are still milk-protein based, though they are extensively hydrolyzed, lactose-free, and most with added probiotics to support digestive health. Hypoallergenic formulas on the market now include Enfamil Nutramigen, Similac Alimentum, Gerber Extensive HA (100% hydrolyzed whey), and HIPP HA (100% whey, does contain lactose).

ELEMENTAL FORMULA . For infants who are still symptomatic after trying hypoallergenic formula, even more specialized formulas are available that are made from pure amino acids that require minimal digestion and do not contain allergenic/ inflammatory properties. These include Neocate, Enfamil PurAmino, and Abbott/Similac Elecare.

PLANT-BASED FORMULA . For infants raised on a vegan diet, plant-based formulas from soy protein are available. These include Enfamil Prosobee, Similac Isomil, Good Start/Gerber Soy, Parent Choice Soy, and Earths Best Organic Soy. Since soy is a natural source of plant-based estrogens, we generally do not recommend soy formula for babies who are able to breast feed or tolerate cow-milk based formula.

GOAT-MILK FORMULA . Goat milk is another mammalian source of milk, containing casein, whey and lactose similar to cow milk. Goat-milk formulas are marketed for use in babies with digestive issues, as goat milk has naturally less lactose than cow milk, and the proteins are smaller and may be easier to digest. Babies with cow-milk protein allergy or true lactose intolerance should not be on a goat milk product, as up to 90% of those that react to cow milk will react to goat milk. At Children’s Medical Association, we traditionally do NOT recommend goat-milk formula.

OTHER SPECIALTY FORMULAS . Enfamil Enfacare and Similac Neosure are infant formulas specifically designed to meet the needs of premature infants, with additional calories, protein, vitamins and minerals to support catch-up growth, bone mineralization, and improve health and development. Enfamil Reguline is a cow-milk formula featuring a blend of prebiotics and hydrolyzed proteins to ease constipation. Similac Supplementation for Breast Feeding Moms is marketed as a gentle introduction to formula for babies who otherwise breast feed.

Choosing an infant formula can be overwhelming! We are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you are wondering about how to chose the right infant formula for your baby.

Caring For Your Newborn with Jaundice

Mon, 29 Nov 2021 16:34:11 GMT

The term jaundice comes from the French word jaune , meaning yellow, and refers to a yellow discoloration of the skin and the whites of the eyes (sclera) from the deposition of the pigment called bilirubin. Bilirubin largely comes from the breakdown of hemoglobin, the protein that carries oxygen in the red blood cells. With neonatal jaundice, increase in bilirubin load resulting in hyperbilirubinemia is due to either/both an increase in bilirubin production or a decrease in bilirubin clearance. Almost all babies develop a serum bilirubin >1 mg/dl, which is the upper limit of normal for an adult. For most babies, this early rise in bilirubin is considered normal, transient and physiologic.

Bilirubin exists in the unconjugated (indirect) form, its state prior to metabolism in the liver, and the conjugated (direct) form, its state following transformation in the liver and excretion into the bile and intestines. Most neonatal jaundice is normal, unconjugated, and related to natural breakdown of fetal hemoglobin, immaturity of the newborn liver to efficiently metabolize bilirubin, low intake/dehydration from breast feeding, and reabsorption of bilirubin from the intestinal tract during sluggish elimination of stool.

It is normal for most babies to have some degree of jaundice following their birth, which often peaks around 10-12 by day 4-5, though may linger for up to two weeks of age or longer (especially in breast fed babies). All babies have their bilirubin checked, measuring over the skin (transcutaneously) or by a blood test, prior to leaving the hospital: the gestational age of the newborn, the age of the baby at the time of the test, and the height of the bilirubin all determine whether the baby is at low, medium or high risk for developing significant jaundice. Your pediatrician or nurse practitioner will continue to carefully monitor your baby for jaundice once you leave the hospital. We can clinically estimate the level of the jaundice: jaundice on the face roughly correlates to a bilirubin level of 4-8, upper trunk 5-12, lower trunk 8-16, and soles of the feet >16. For babies with notable jaundice, we will repeat bilirubin levels with a blood test in the office (same day results from Quest) to monitor the height of the total/direct bilirubin. Why does it matter? Because severely elevated total bilirubin >25 mg/dl allows bilirubin to cross into the brain, which may cause brain damage (bilirubin-induced neurologic dysfunction or BIND, formerly known as kernicterus), and elevated direct bilirubin above 2mg/dl or 20% of the total may indicate a problem with the conjugation or excretion of bilirubin anyplace within the liver/biliary system (cholestasis), which must be identified/treated quickly to minimize liver damage.

Again, most jaundice in newborns is benign and transient. Risk factors for more severe hyperbilirubinemia include prematurity; maternal diabetes; race (Asians and Native Americans); male sex; trisomy 21 (Down Syndrome); blood in the scalp following vaginal delivery (cephalohematoma); hemolysis (abnormal breakdown of blood cells, e.g., one such cause is if the baby and mom have different blood types - ABO and/or Rh - and antibodies against the baby’s blood type cross the placenta and attack red blood cells in the baby); oxytocin induction; breast feeding; delayed passage of meconium; gene mutations; and a history of siblings who had neonatal jaundice.

So what should you expect if your baby has newborn jaundice? We will take a detailed history of the pregnancy, labor and delivery, feeding and elimination patterns, review blood group incompatibilities, and obtain your family history, all for identifying risk factors for elevated bilirubin. We will perform a complete physical examination of the baby, noting the color of the skin/eyes, the size and feel of the liver and spleen, and the presence of rash or other signs of congenital infection. We will monitor your baby’s bilirubin, both clinically and with same-day blood testing (total and direct bilirubin) sent to Quest from the office. Most of the time that is sufficient, and the jaundice resolves. Occasionally babies with unconjugated hyperbilirubinemia will be treated with blue-light phototherapy in the hospital to aide in the reduction of the serum bilirubin, and that therapy may be extended with the use of a “bili blanket” upon discharge home. Putting your baby near a window with indirect light is also helpful, as is increasing the volume or frequency of feeding to improve hydration, stimulate the production of stool, and decrease reabsorption of bilirubin from the gut back to the bloodstream.

If your newborn’s examination is abnormal, if the jaundice continues past two weeks, or if there is cholestasis, we will request additional labwork to assess hemolysis, liver function, metabolic disorders, or the presence of infection. We may order an ultrasound of the liver and gall bladder to look at the structures, assess the presence/patency of bile ducts, and determine any other mechanical cause of cholestasis. Other more complex radiology studies may be necessary. Rarely, liver biopsy may be required. For newborns with persistent or pathological jaundice, we will enlist the help of a pediatric gastroenterologist to help manage the evaluation and your baby’s ongoing care.

Remember that newborn jaundice is generally normal, transient, and benign. If you have questions or concerns, we are here for you. Reach out on the portal or schedule an appointment to come see us in the office if you are wondering about how to best care for your newborn with jaundice.

Caring for Your Child with ADD

Wed, 24 Nov 2021 02:46:25 GMT

ADD/ADHD are common pediatric disorders characterized by inattention, distractibility, poor organization, impulsivity, restlessness and hyperactivity. In theory, these symptoms result from a deficit in or ineffective response to natural chemicals that promote good focus, organization, concentration and calming.

Medications are often prescribed to treat ADD/ADHD. The main stimulant medications are amphetamines (Adderall, Vyvanse) and methylphenidates (Ritalin, Concerta, Focalin), which raise the levels of neurotransmitters like norepinephrine and dopamine. These are schedule II controlled substances, and may only be prescribed monthly. Milder stimulants that work on different pathways include guanfacine (Intuniv) and atomoxetine (Strattera). Stimulant medications may affect blood pressure, appetite, weight, growth and sleep, so children being treated with these medications are followed in the office every 3 months. Rarely these medications can have cardiac side effects, so your pediatrician or nurse practitioner may recommend seeing a cardiologist if indicated (history of congenital heart disease, history of palpitations or arrhythmia, family history of sudden death, prolonged QT syndrome, hypertrophic cardiomyopathy etc.).

Natural approaches to the treatment of ADD/ADHD are guided by the nutritional support of neurotransmitter production, strengthening of cells membranes and myelin, nourishment of the intestinal microbiome which significantly contributes to neurotransmitter production, elimination of foods/chemicals that stimulate the brain in ways that promote hyperactivity and distractibility, and attention to important factors that contribute to the support of brain, mood and focus. These include:

Healthy Nutrition:

Eat a balanced diet, including multi-colored fruits and vegetables, whole

grains, nuts and seeds, healthy fats (eggs, avocado, nuts and nut butters,

olive oil, coconut milk, full fat dairy), and healthy protein (chicken, fish,

eggs, beans/legumes). Drink plenty of water, and avoid beverages that

contain chemicals that may cause brain stimulation or irritability (sugars,

food dyes, artificial flavors, chemical sweeteners like Nutrasweet, MSG,

caffeine). Consider a food elimination diet to identify food sensitivities

that may provoke ADD/ADHD symptoms: for some people, gluten and dairy

can be brain irritants. Hydrogenated oils in fast foods (chicken nuggets and

fries) make the brain less fluid, and may interfere with focus and

concentration. In addition to healthy foods, supplemental vitamins, minerals and probiotics may support the production of important chemicals that

promote focus and concentration. Omega fatty acids from fish and fish oil

may also improve focus.

Healthy Sleep:

Establish a regular sleep routine, encouraging 8-9 hours of sleep nightly.

Avoid stimulants after 4pm (medications, caffeine, chocolate). Avoid

television and other light screens (videogames, books on tablet,

cellphones) within 1 hour of bedtime, as they reduce the release of natural melatonin to promote sleep. Consider soft music, epsom salt baths,

chamomile tea, and lavender oil to promote relaxation and sleep.

Healthy Activity:

Exercise has been shown to increase oxygen to the brain and promote the

release of brain growth factors that assist in focus, concentration, learning

and memory. Try to incorporate 40-60 minutes of exercise daily and do

what you love! Consider yoga, tae kwon do, karate, and tai chi for discipline

and focused attention.

Behavioral Management:

The behavioral management of ADD/ADHD includes stress reduction (yoga,

meditation, guided imagery, prayer, Heart Math); setting goals that are

specific and achievable to promote hope and confidence; the use of charts

to assist with organization; building on strengths like creativity, art, music,

and imagination. Consider psychological treatment for mood disorder

(anxiety or depression) and to address oppositional/defiant behaviors that

may coexist with ADD/ADHD.

Caring for Your Child with Cerebral Palsy

Mon, 26 Jul 2021 18:26:43 GMT

Cerebral palsy, or CP, is an umbrella term that refers to multiple diseases and conditions that originate early in life, affect the brain, and primarily cause impairments in motor movements. It is the most common cause of severe physical disability in children, occurring in about 1 in 500 liveborn infants. Cerebral palsy results from any of numerous insults to the brain, including prenatal factors like ingestion of drugs or toxins during pregnancy, prematurity, lack of oxygen/asphyxia at birth, stroke or brain bleed, severe jaundice, sepsis or meningitis, head trauma, and an array of biochemical and genetic influences on brain function. Cerebral palsy is generally referred to according to the distribution of limb weakness and type of tone abnormality. Spastic quadriplegia is tightness and weakness in all four limbs, along with the trunk and face; spastic diplegia affects two limbs at the upper or lower body, generally the legs; spastic hemiplegia is tightness and weakness on one side of the body; ataxic CP affects balance and coordination of movement; and dyskinetic/athetoid CP is characterized by dysregulation of motor tone and movement, causing uncontrollable movement (twisting, writhing, jerking) and irregular posture. About 80% of children with CP have the spastic variety.

Whereas no two children with C.P. are exactly alike, your child may face some or all of the following conditions related to C.P.:

Floppinesss or hypotonia, low muscle tone, which makes it difficult to hold the head upright, roll over, bear weight, grab at and hold objects, walk, and achieve other milestones.
Spasticity or hypertonia, increased muscle tone, which generally increases over time, and makes it difficult to walk, run, ride a bike, etc. The increased muscle tone makes children with C.P. at risk for contractures at small and large joints, including the hip, which may dislocate.
Poor balance, coordination, and/or uncontrollable movements.
Seizures.
Feeding and swallowing difficulties, which may require the insertion of a gastrostomy/feeding tube for adequate nutrition and to protect the airway from aspiration of milk/food/secretions.
Delayed or disordered speech and language.
Visual and/or hearing deficits.
Constipation, which results from diminished tone in the colon itself and the voluntary muscles that assist in pushing out stool.
Urinary tract infection, which results from diminished tone in the bladder, incomplete emptying, and overgrowth of bacteria in the urine. Children with C.P. may not be potty trained, increasing exposure to bacteria from a soiled diaper.
Gastroparesis, which is poor stomach emptying, also related to diminished tone in the stomach, which may create nausea, wretching, pain, feeding intolerance, and slow weight gain.
Gastro-esophageal reflux, or GERD, which is backwash of food and acid from the stomach to the esophagus, also related to low tone in the lower esophageal sphincter muscle. GERD increases the risk of cough/choking/aspiration, and causes pain from acid reflux.
Neuromuscular scoliosis, which is a curve on the spine that develops commonly in children with C.P., and is due to tightening/spasticity of the back muscles, along with asymetric forces on the spine from sitting in a wheelchair, not bearing weight, etc.
Osteopenia, or low bone density, from non-weight-bearing.
Respiratory issues like asthma, poor ventilation from reduced muscle tone/strength and structural/functional impairment from scoliosis, and chronic lung disease from aspiration. Though uncommon, some children with C.P. require tracheostomy tube and assisted ventilation.
Learning disability, inattention, and cognitive deficits related to the original brain insult, biochemical disorder, or genetic variation.
Diminished ability to understand social cues and sustain social interaction.
Increased emotional lability and decreased regulation of mood.
Sleep disorders related to dysregulation of sleep cycles.
Growth deficiency related to hypothalamic and pituitary gland dysfunction.
Thyroid disorders related to hypothalamic and pituitary gland dysfunction.
Precocious or delayed puberty, also related to hypothalamic, pituitary, and adrenal dysfunction.

Screening for CP occurs at routine check-ups at CMA, as your pediatrician or nurse practitioner carefully monitors muscle tone and developmental progress throughout infancy and early childhood. The diagnosis of CP may be suspected clinically, based on the history and physical findings, though evaluation for an underlying root cause includes genetic, biochemical, and radiographic tests. Advanced neuroimaging, particularly MRI of the brain, shows abnormalities in 80-90% of children with CP.

Children with cerebral palsy are cared for by an interdisciplinary group of physicians and practitioners, including the pediatrician, geneticist, neurologist, gastroenterologist, urologist, orthopedic surgeon, endocrinologist, pulmonologist, ENT, physiatrist, and psychiatrist. Our shared goal is to accompany you on this journey, support you and your family, provide tools and resources to improve the quality of life of your child, and help create a plan to help your child reach his/her maximum potential. Children with cerebral palsy often benefit from physical therapy, occupational therapy, speech/feeding therapy, aquatherapy, hippotherapy (horse assisted), music therapy, visual therapy, behavioral therapy, braces and other assistive devices, acupuncture, massage, aromatherapy etc. Medications often include anticonvulsants to control seizures, antispasmodics to control spasticity, acid blockers to reduce the impact of GERD, nebulized bronchodilators to support respiration, stool softeners and laxatives to promote regular defecation, and sleep aides. Integrative strategies include magnesium to reduce spasticity and constipation, CBD/medical marijuana to reduce spasticity and seizures, and melatonin to promote sleep. Surgical procedures may be offered to release spastic muscles/tendons, repair hip dislocation, and address advanced scoliosis.

Children who live with C.P. and their families face many challenges, and at the same time, know the joy of each milestone achieved. Comprehensive medical management, good nutrition, positive home environment, early intervention with therapies, individualized education plans (IEP), social support, recreational activities and vocational training can significantly affect the quality of life and level of functioning of children and adolescents with cerebral palsy. You have our commitment to stand with you every step along the way in caring for your child with C.P.

The following are local and national resources that specialize in the support of children with cerebral palsy and their families:

JAFCO Children’s Ability Center jafco.org 954-215-7033

United Cerebral Palsy ucp.org 954-784-6474

March of Dimes marchofdimes.org 954-772-0013

www.floridahealth.gov/programs-and-services/people-with-disabilities

Social Security Administration ssa.gov 1-800-772-1213

Neuro Network Partners at The Dan Marino Center Weston 954-385-6276

and at Nicklaus Children’s Hospital Miami 305-666-6511

Caring for Your Child with Polycystic Ovarian Syndrome (PCOS)

Thu, 01 Jul 2021 20:31:15 GMT

Polycystic ovarian syndrome (PCOS) is a common and complex disorder of hormonal imbalance, affecting up to 10% of women in the United States, across all races, ethnicities, nationalities and socio-economic backgrounds. Despite decades of research, the etiology of PCOS is still unclear. What is known is that PCOS is a multi-factorial condition, involving alterations in ovarian function, hormonal production, carbohydrate metabolism and the status of the microbiome, all under the influence of fetal programming, genetics and epigenetics, diet and lifestyle.

Normally, in biological females, hormones released from the pituitary gland communicate with the ovaries and the adrenal gland, resulting in the production of estrogen, progesterone, and androgens like testosterone and DHEAS. Feedback loops allow the cycling of these hormones, and generally menstrual periods become regular within 2 years of the onset of menstruation. In adolescents with PCOS, this communication is disordered, driving high production of androgens, low production of estrogen and slowing/arrest of the process of ovulation, resulting in irregular or absent menses. Androgen excess also contributes to insulin resistance, an important metabolic feature of PCOS, and obesity drives further production of testosterone in fatty tissue, continuing the cycle of hormonal imbalance. There are now studies that suggest a direct impact of an altered gut microbiome on the development of the metabolic and hormonal changes seen in PCOS.

The clinical features of PCOS are directly related to this hormonal imbalance, and include irregular menses, oligomenorrhea (light and/or infrequent menses), amenorrhea (absent menses), increased body hair (hirsutism), male pattern baldness or alopecia, acne, acanthosis nigricans (darkening of the skin at the back of the neck), and often central obesity. Patents may not be diagnosed until they struggle with infertility. Laboratory findings include elevated LH, low FSH (a ratio of LH:FSH >2 may be seen), elevated testosterone and DHEAS, and elevated markers of insulin resistance, such as elevated insulin and elevated glycosylated hemoglobin (HbA1C). The accumulation of arrested follicles in the ovaries gives the appearance of “polycystic ovaries” for which the syndrome is named. Additional lab studies are often performed to rule out other causes of menstrual disorder (thyroid-related hormones TSH and thyroxine T4, adrenal-related hormones like 17-hydroxyprogesterone, and the pituitary hormone prolactin), and to assess for other conditions often associated with PCOS and obesity, such as hyperlipidemia, fatty liver, and diabetes. Long-term considerations include infertility, elevated risk for cardiovascular disease and diabetes, and increased risk for endometrial cancer.

We have many goals in caring for your adolescent with PCOS. These include improving quality of life and preserving fertility; restoring regular menses; reducing the burden of acne and hirsutism; decreasing the risk of hyperlipidemia, cardiovascular disease and diabetes; and reducing the risk of endometrial disease. Optimal treatment of PCOS uses a multimodal approach, which integrates diet, lifestyle, pharmaceuticals, supplements, topical and mechanical treatments, and mental health support. Among them are:

Weight loss to decrease androgen production and improve insulin sensitivity. This is best achieved with significant reduction in processed carbohydrates (bread, cereal, crackers, cookies, sweetened beverages etc.), avoiding excessive saturated fat from fried food and full-fat dairy, and exercise.
Eating a diet rich in brightly colored fruits and veggies, with natural fiber and phytonutrient support for a healthy microbiome.
Exercise to preserve lean body mass, promote ovulation, improve insulin sensitivity and reduce hyperlipidemia. The goal is at least 150 minutes of exercise weekly, so at least 30 minutes 5 times per week.
Estrogen and progestin combination therapy, most commonly given as an oral contraceptive pill (OCP) to restore menstrual balance, reduce androgen production, manage hirsutism and acne, protect the endometrium, and protect against unwanted pregnancy. The recommended dose of ethinyl estradiol is 30-35mcg daily, combined with a progestin with low androgen effect, such as norethindrone (LoEstrin) or drospirenone (Yasmin).
Anti-androgens like spironolactone, used in combination with some OCPs, to reduce testosterone production, mitigate acne and hirsutism, and improve insulin sensitivity
Insulin-sensitizing agents like the drug metformin, which can help improve menstruation and ovulation, reduce insulin resistance, improve glycemic control and dyslipidemia, and benefit women attempting to conceive.
N-acetylcysteine 1200-1500mg daily, a supplement shown to reduce markers of inflammation, improve BMI, improve insulin sensitivity, and reduce androgen levels in people with PCOS.
Vitamin D and probiotic support , which together have been shown to improve mental health scores, reduce testosterone and hirsutism, and reduce inflammation as measured by the C-reactive protein.
Topical medications for acne , such as retinoic acid and antibiotic gels.
Mechanical therapies to help with the excessive and unwanted hair growth, such as electrolysis, laser, waxing, shaving and bleaching.
Psychological support to address depression and related mood disorders, improve self-esteem, emotional well-being, coping skills and quality of life.
In addition to the above strategies, acupuncture has been shown to reduce testosterone and help regulate menses in women with PCOS, as well as improve mental well-being.

We are here for you. If you have concerns about your daughter’s menstrual cycle or are wondering if she has PCOS, reach out on the portal or schedule an appointment to come see us in the office.

Here are some additional resources and community partners that serve our patients with PCOS:

Adolescent Gynecology:

Dr. Brooke Slaton 954-755-1411

Dr. Lona Sasser 954-340-1050

Pediatric Endocrinology:

Dr. Kelly Seiler 954-385-6238

Dr. Bethel Steindel-Spargo 954-265-6984

Dermatology:

Dr. Channing Barnett 561-717-2271

Dr. Anna Falabella 954-961-1200

Dr. Ana Duarte 305-669-6555

Best Sunscreens for Kids

Wed, 12 May 2021 21:47:30 GMT

Environmental Working Group rates sunscreen for kids based upon their efficacy, the safety of their ingredients, and their green rating for the environment. The safest ingredients in kids sunscreen are minerals like zinc oxide. According to EWG, the best sunscreens for kids in 2021 are:

BEST:

1. Adorable Baby Sunscreen Lotion and Stick SPF 30+

2. All Terrain KidSport Sunscreen Lotion SPF 30 and 45

3. ATTITUDE Mineral Baby & Kids Vanilla Blossom SPF 30

4. Babu Botanicals Baby Skin Mienral Sunsreen lotion and stick SPF 50

5. Baby Bum Mineral Sunscreen Lotion and Stick SPF 50

6. Babyganics Sunscreen Stick SPF 50

7.. 3rd Rock Sunblock Infant SPF 35

8. Badger Kids Active Sunscreen Cream SPF 30 and 40

9. Banana Boat Kids Sport Sunscreen Stick SPF 50

10. Blue Lizard Baby Sunscreen Lotion SPF 35

11. Burt’s Bees Baby Sunscreen Lotion SF 30

12. California Baby Super Sensitive Sunscreen Stick SPF 30+

13. Caribbean Sol Sol Kid Care Sunscreen SPF 30

14. Cerave Baby Hydrating Mineral Sunscreen Lotion SPF 45

15. Coppertone Water Babies Pure and Simple Sunscreen Stick SPF 50

16. Earth Mama Kids Uber-Sensitive Mineral Sunscreen Lotion SPF 40

17. Erbaviva Organic Skincare Baby Sunscreen Lotion and Stick SPF 30

18. Hawaiian Sol Kid Kare Sunscreen Lotion SPF 30

19. Kiss My Face Organics Kids Defense Sunscreen Lotion SPF 30

20. Nurture My Body Baby Organic Sunscreen Lotion SPF 32

21. Raw Elements Baby + Kids Sunscreen Lotion SPF 30

22. Star Naturals Baby Natural Sunscreen Stick SPF 25

23. SunBiologic Kids Sunscreen Lotion and Stick SPF 30

24. SuperGoop! Sunny Screen Lotion Babies + Kiddos SPF 50

25, TruBaby Water & Play Mineral Sunscreen Lotion SPF 30+

THE WORST scoring sunscreens for kids have potentially hazardous ingredients like oxybenzone (an "endocrine disrupter," mimicking estrogen in the body), octinoxate (an endocrine disrupter and allergen), octisalate (an allergen and ecotoxin), retinyl palmitate (may promote cancer in sun-exposed skin), and SPF above 50+ (generally applies to protection against UVB, not UVA, which can penetrate the skin and damage the immune system). Aerosol sprays and powders should be avoided, as they can expose sensitive young lungs to hazardous chemicals; in addition, sprays cv provide skin coverage that is Inconsistent and potentially ineffective.

Caring for Your Child with an Eating Disorder

Fri, 09 Apr 2021 18:36:58 GMT

Eating disorders are complex mental health conditions that affect a person’s relationship with food and body image. Eating disorders are estimated to affect 1 in 11 Americans at some time in their lifetime. Awareness of overweight, desire to be thin, and fear of weight gain start in elementary school-aged children. Eating disorders typically appear during the teen years, and are the third most common chronic condition in adolescents, after obesity and asthma. Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorders, and orthorexia (see below). Eating disorders frequently coexist with other illnesses, such as depression, anxiety, substance abuse, autism, attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD). The nutritional deprivation seen with eating disorders can result in severe weight loss, electrolyte imbalance, growth retardation, delayed puberty, loss of menses (amenorrhea), decrease in bone mineral density (osteopenia), iron-deficiency anemia, lethargy, thyroid fatigue, seizures, and cognitive impairment. When severe, eating disorders can result in life-threatening cardiovascular instability from bradycardia (slow heart rate), hypotension (low blood pressure), hypothermia (low body temperature), decreased left ventricular mass and volumes, and heart arrhythmias. Significant mental health issues occur in people with eating disorders, including high rates of depression, substance abuse, and risk of suicide. Increased incidence of infertility, osteoporosis, and autoimmune conditions are longer-term concerns. Despite worrisome complications, the prognosis for eating disorders in the pediatric population is encouraging, as eating disorders have a recovery rate of about 75%.

Eating disorders have four main patterns:

Anorexia nervosa (AN) is characterized by a fear of weight gain or drive for thinness, and body dysmorphia, a distorted perception of looking fat or feeling heavy despite a normal body weight, resulting in the dangerous restriction of caloric intake and significantly low body weight/weight loss. Females make up close to 90% of adolescents with AN. There is often a family history of eating disorders and a personal drive for perfection.
Bulimia nervosa (BN) is also marked by the fear of weight gain or obsession with slimming down, though characterized by the binging of large amounts of food, followed by guilt and shame, and compensatory efforts to rid the body of the food and prevent weight gain (induced vomiting, laxative abuse, inappropriate use of enemas and diuretics, fasting, and/or excessive exercise). Unlike AN, people with bulemia are often of normal weight, though they share a similarly distorted body image.
Binge eating disorder (BED) is characterized by recurrent episodes of binge eating, the consumption of large amounts of food in one sitting, while feeling powerless to stop. BED is associated with physical discomfort and emotional distress. Unlike BN, there are no attempts to “make up” for the binges with vomiting etc. BED is almost as common in males and females.
Avoidant/restrictive food intake disorders (ARFID) are characterized by a disturbance of eating or feeding, in the absence of a desire to be thin or lose weight. They may be triggered by a choking/vomiting episode with fear of recurrence, an aversion to food based on sensory issues (smell, taste, texture), a fear of allergic reaction to foods, profound stress, etc. The eating disturbance in ARFID can lead to a decreased variety and volume of food intake, causing inadequate energy/nutritional intake, failure to grow or gain weight appropriately, and/or psychosocial impairment. ARFID may begin in infancy and last into adulthood, and they comprise up to 20% of those who seek treatment for eating disorders. As opposed to AN, children with ARFID are more likely to be male and younger (ages 4-11yr).

In addition, there is an eating disorder known as orthorexia, characterized by an obsession with eating pure/clean/organic/healthy food, in the absence of a desire to lose weight, which nevertheless results in increasingly restrictive food consumption, and may result in significant weight loss and/or malnutrition, impaired socialization, and emotional distress.

You may be wondering what causes eating disorders. Researchers are finding that eating disorders result from a complex interplay of genetic, biological, psychological and social factors. Clearly in the United States, the stigma of overweight is propelled through social media, the entertainment industry, peer pressure, and even health care providers addressing issues of overweight and obesity. Weight talk within the family and dieting itself are known to predispose to eating disorders. Eating disorders are common in young women, though affect people of all genders, races, ethnicities, ages, and socioeconomic conditions. Studies show that gay, lesbian, bisexual and trans adolescents have significantly higher rates of disordered eating that their heterosexual peers. Adolescents with chronic health conditions requiring dietary control (e.g., diabetes, cystic fibrosis, inflammatory bowel disease) may also be at increased risk for eating disorders. Individuals who participate in activities for whom weight has a significant impact on performance (e.g., wrestlers, ballet dancers, divers, runners, skaters, gymnasts etc.) are certainly more vulnerable to eating disorders. In fact, the historic term “female athlete triad” refers to female competitive athletes with inadequate caloric intake, menstrual dysfunction, and low bone mineral density with increased risk for stress fractures (with or without disordered eating). Survivors of family abuse and other childhood traumas are at risk for eating disorders.

Recognizing an eating disorder generally begins with the family or pediatrician, who may note excess talk about eating healthy, reading food labels, skipping meals or restrictive eating, body image dissatisfaction, social isolation, excessive exercise, weight loss, failure to grow adequately, loss of menstrual periods, use of dietary supplements or herbal products for weight loss, leaving during or immediately after meals to use the bathroom, depression, constipation, episodes of lightheadedness, fatigue, muscle cramping, and/or cognitive dysfunction (decrease in attention, processing speed, memory, etc.). The examination may reveal a significant drop or fluctuation in weight, slow growth, signs of dehydration (dry lips, dry skin), reduction in body temperature and heart rate, purple color to the hands and feet from poor circulation, and thinning of the hair. Additional findings specific to BN include salivary gland enlargement, calluses on the knuckles from self-induced vomiting, along with abrasions at the palate, eroded dental enamel from stomach acid in vomit, dental cavities, and inflamed gums.

The child or adolescent presenting with weight loss or growth failure may be screened for inflammatory bowel disease, esophagitis, celiac disease, thyroid disease, diabetes mellitus, depression, substance abuse, and malignancy. Medical evaluation at the time of diagnosis of an eating disorder often includes a complete blood count; urinalysis; metabolic panel assessing glucose, electrolytes, minerals like calcium and phosphorus, and liver function; iron studies; vitamin D; thyroid function testing; electrocardiogram (EKG). Bone density may be indicated for those with prolonged amenorrhea (6-12 months).

The goals of treatment of eating disorders include re-establishing a healthy relationship to food, restoring adequate nutrition, bringing weight to a healthy level, reducing excessive exercise, and stopping unhealthy eating patterns (binging, purging, restricting, etc). Treatments plans are tailored to the individual child or adolescent, as each situation is unique. Treatment of eating disorders requires a multidisciplinary team approach, including your pediatrician or pediatric nurse practitioner, a dietician/nutritionist specializing in eating disorders, a psychologist specializing in eating disorders, a psychiatrist to address medication management of depression and anxiety, an endocrinologist to manage low estrogen and hormonal imbalance, along with occupational or speech therapists who specialize in feeding, intensive outpatient programs, and inpatient/residential centers for the treatment of severe eating disorders.

Though most patients can be treated in an outpatient setting, hospitalization may be required for nutritional support for any of these eating disorders, depending upon the degree of weight loss, starvation, nutritional deprivation, and its metabolic/physiological consequences (bradycardia, hypotension, electrolyte imbalance, EKG changes, cardiovascular instability, etc). Rehydration, restoring electrolyte balance, and beginning the process of refeeding are essential. A short term feeding tube (passed from the nose to the stomach), or a long term gastrostomy tube (placed surgically into the stomach) may be required in some cases, to directly supply nutrition through the gut. Rarely, intravenous nutrition (hyperalimentation or hyperal) is also required.

Psychotherapy is essential to the treatment of eating disorders in children and adolescents, both to address the primary eating disorder, and to address associated mental health disorders (depression, anxiety, OCD, gender dysphoria). Cognitive behavioral therapy (CBT), family-based therapy (FBT), and exposure therapy are the modalities currently in use. The Maudsley approach, which empowers parents with the responsibility of feeding their child, is an effective management strategy in treatment teens with AN. Pharmacotherapy with selective seratonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) may be indicated to reduce anxiety and depressive symptoms in patients with eating disorders, allowing them to focus on the work of therapy and recovery.

Although there are no sure ways to prevent eating disorders, some strategies that can empower children and adolescents towards healthy-eating behaviors include having family meals that encourage a balanced diet and positive relationships with food; cultivating and reinforcing a positive self-image and healthy body image in yourself and your child, and avoiding weight shaming; talking to your child and your pediatrician about any concerning signs of pre-occupation with strict eating, weight, or body habitus.

We are here for you. If you have any indication that your child may be struggling with an eating disorder, reach out by phone, on the portal, or schedule an appointment to come see us in the office. Here are some national resources and local community partners that serve our patients with eating disorders and their families:

-ANAD: National Association of Anorexia Nervosa and Associated Disorders 312-262-6897 hello@ANAD.org

-NEDA: National Eating Disorders Association helpline 800-931-2237

Crisis text NEDA to 741741 nationaleatingdisorders.org

-EDC: Eating Disorders Coalition 202-543-9570 eatingdisorderscoalition.org and eatingdisorderhope.com

-F.E.A.S.T. Families Empowered and Supporting Treatment of Eating Disorders 855-50-FEAST info@feast-ed.org

-ERC: Eating Recovery Center 866-438-8604 eatingrecoverycenter.com

-Pediatric Feeding Institute of South Florida (Boca) 561-571-7557 pediatricfeedinginstitutefl.com

-Psychologists/Therapists who specialize in eating disorders:

Barbara Capp (Plantation) 954-370-0966

Alina Gastesi-deArmas (Weston) 954-384-9373

Hartiett Beitscher Campbell (Ft. Lauderdale) 954-829-5055

Allie Butters (Boca) 561-257-4202

Roy Ehrlichman (Palm Beach Gardens) 561-626-8070

Carol Flaster (Davie) 954-862-1482

Nicolle Arbelaez Lopez (Weston) 954-804-5144 www.DrNicolle.com

Sarah Ravin (Maudsley Family Based Treatment Miami) 305-668-5755

-Nutritionists who specialize in eating disorders:

Jessica Gallego 954-385-4696

Christie Caggiani (Delray) 561-278-6033

Roni Julien (Miami) 786-326-3262

Alyssa Mitola (Ft. Lauderdale) 754-702-7868

Jodi Krumholz (Boca) 954-280-3065

-Eating Disorders Support Groups:

Dr. Nicolle 954-804-5144

Joanna Kandel Alliance for Eating Disorder Awareness (WPB) 561-841-0900

FEAST Families Empowered and Supporting Treatment of E.D. 1-855-50FEAST feast-ed.org

Jamie Osborne Renfrew Center (Boca) email support@therenfrewcenter.com

Mary Lerner Milestones (Cooper City) 954-272-0806

-Residential Treatment Centers for Eating Disorders:

Renfrew Center for Eating Disorders (Coconut Creek) 1-800-736-3739

Milestones in Recovery (Cooper City, 18yr +) 1-800-347-2364

Oliver-Pyatt Center (Miami) 305-240-9903

Veritas Colaborative (various locations outside Florida) 855-607-1445

ViaMar Health (WPB) 561-293-4677

Eating Recovery Center Dr. Ovidio Bermudez Denver (303) 731-8200

Canopy Cove ED Treatment Center Tallahassee 888-245-6555

Caring for Your Transgender Child

Mon, 08 Feb 2021 18:05:08 GMT

As your pediatricians and nurse practitioners at CMA, we are here to help guide and support you, and care for your child in all ways that promote his/her/their physical, emotional, and spiritual health. Our desire is to provide information that gives family and close community the resources to meet your transgender child, wherever they are in their journey, with respect, dignity and love. Let’s start with the basics.

Gender is the term applied to the sex your child is labeled or assigned, at or before birth, which is generally determined by the physical characteristics associated with male or female gender, and/or the genetic markers of gender (XX for female, XY for male, though variations of these do occur). Gender is also the way your child identifies with a particular gender, male or female, both, or neither. Gender identity evolves as a complex interplay of genetics, epigenetics (how the expression of genes is promoted or suppressed by various factors, including prenatal exposure to hormones), biology, environment, socialization, and culture. It is normal for your child to experiment with expressions of gender. Gender identity is generally fluid until around age 3yr, by which time most children have an inherent feeling of who they are in their body (boy or girl). Yet gender identity may take time to be revealed as people discover more about themselves and the means to express it. There is no right or wrong with gender: diversity of gender identity and expression are considered normal aspects of our humanity, and despite an increased current awareness, gender diversity has been described in cultures all over the world and written about for thousands of years.

If your child identifies himself/herself as the gender assigned at birth, your child is considered cisgender. If your child identifies himself/herself as a different gender, your child is considered transgender. If your child is born male and identifies as female, your child is trans female. If your child is born female and identifies as male, your child is trans male. If you child identifies as both, the terms used for your child are gender diverse, gender fluid, or non-binary. If your child identifies as neither gender, the term used for your child is agender or non-binary. Gender identity is different from sexuality, which is who you are attracted to/who you love (straight is attraction to the opposite sex, gay/lesbian is attraction to the same sex, bi is attraction to both sexes, Q is questioning, I is intersex, asexual is attraction to none, and queer is self-identity within the groups LGBTQ+).

Gender dysphoria is the term that describes the marked incongruence between one’s assigned gender and one’s experience/expression of gender. This may present as a strong desire to be of the other gender; a desire to wear clothing, pretend play, or seek games traditionally assigned to the opposite gender; or the insistence, even at a very young age, of actually being the other gender. As children get older, gender dysphoria also expresses itself as a strong dislike for one’s sexual anatomy and a strong desire to have one’s anatomy match one’s gender identity (e.g., a transgender male expressing dislike for his breasts and a desire to have them removed).

Transgender people are estimated to constitute about 0.6% of the U.S. population. In our American adolescent population, 1.9% now identify as transgender.

You may recognize that your child is transgender, or your child may come out and disclose their gender identity to you. It is understandable that you may feel shock, upset, or disbelief. Yet it is fundamental that your child feel loved and accepted for who they are. Among the most important things you can do to show acceptance and love for your transgender child is to affirm their gender identity. Affirming gender means acknowledgement, respect, support and validation of the gender identity of your child. You may do this by supporting your child’s self-expression and being open-minded to the clothing, hairstyle, toys, and games that your child desires. You may do this by asking your child what name he/she/they wish to be called by, and by which pronoun he/she/they wish to be referred. You may further affirm gender by giving your child access to tank tops, binders, bodysuits, shapewear, gaff, packing etc. that help align the appearance of your child’s body with their gender identity. As a parent of a transgender child, affirming their gender also means standing up for them in your home, your community, your place of worship, your child’s school and camp. It means connecting them with LGBTQ+ organizations, resources and events so they know they are not alone. It means finding therapists that are gender affirming, and being open-minded about exploring their options for treatment. It means condemning “conversion therapy,” which is not only disaffirming, but deleterious to the health and well-being of your child.

Affirming gender identity among transgender and nonbinary youth is consistently associated with better mental health outcomes. Conversely, there are significant and tragic consequences of non-affirming gender. Transgender youth experience depression at 4x the rate of their non-trans peers. According to studies by The Trevor Project, 75% of transgender youth experience symptoms of generalized anxiety disorder, and over 60% have engaged in self-harm. Eating disorders and substance abuse are more common in transgender youth. Rates of bullying are significantly increased in transgender and non-binary youth. In one retrospective study, 56% of youth who identify as transgender reported previous suicidal ideation, and 31% reported a previous suicide attempt (highest in female to male transgender youth). Children whose gender identity is affirmed and who experience love and support in their transition have much better outcomes that their non-affirmed trans peers.

Caring for your transgender child is facilitated through integrating a team approach, which includes you, your extended family and friends, your pediatrician or nurse practitioner, your endocrinologist, your mental health and social service professionals, and potentially your plastic surgeon. This team works together to support you and your child through the various levels of transitioning, in order to build self-love, self-esteem, resilience, and promote physical, emotional and spiritual well-being.

What are these levels of transitioning? They begin with social transitioning, which are aspects of social affirmation of your child’s gender identity, including gender affirming hairstyles, clothing, shapewear, name and gender preferences, peer and family support, engagement with transgender outreach in the community, and support in social environments like school and summer camp. The next level is medical transitioning, which includes drug/hormonal treatment to affirm your adolescent’s gender: they are pubertal blockers like Lupron and Supprelin to halt the progression of male or female secondary sexual characteristics and decrease the dysphoria that comes with the onset of puberty (generally by 10-12yr), and estrogen/testosterone cross-hormonal therapy to align the physical body with the gender identity (generally by 14yr). (It is important to note that there are medical risks associated with sex hormone therapy, including higher risks of heart disease and cancer, making true informed consent imperative prior to undertaking medical transitioning.) The next level is surgical transitioning, generally after 16-18yr, which includes the surgical alteration of body parts in order to affirm gender (e.g. “top surgery” like breast removal or breast construction, “bottom surgery” for gender affirming reconstruction, removal of internal organs such as the ovaries or uterus, etc.). The degree of gender dysphoria generally improves progressively with each level of social, medical and surgical transitioning, though the choice of how to transition is very personal.

Reproductive options for transgender persons include harvesting/freezing of eggs or IVF with freezing of embryos for later implantation in a surrogate, and sperm banking.

Sadly, transgender or gender variant citizens experience more violence against themselves, experience discrimination in health care coverage, and further discrimination due to lack of civil rights protections in schools and the workplace. We are hopeful that politics and polices are changing on their behalf. President Biden has proposed the Equality Act of 2021, which if passed, would amend the Civil Rights Act to prohibit discrimination on the basis of sexual orientation and gender identity in employment, housing, public accommodations, public education, federal funding, credit, and the jury system. Professional organizations like the American Academy of Pediatrics are increasingly calling for equity in health care provisions, regardless of gender identity or expression. Of note, November is Transgender Awareness Month.

We are here for you. Our office is a safe space where diversity is appreciated, respected and supported. Reach out on the portal or schedule an appointment to come see us. Here are some additional resources and community partners that serve our transgender patients and their families:

SUNSERVE Youth Services (Ft. Lauderdale) www.sunserve.org . 954-462-2004 The mission of The Transgender Services Department is to provide clients with a safe place to identify, and to operate as a beacon of resources for the needs of their clients.

THE FAULK CENTER (Boca). wwwfaulkcenterforcounseling.org 561-483-5300 Mission is to promote emotional well-being through a variety of free and low-cost programs, including therapy and support groups for transgender youth and their families.

CARE RESOURCE Community Health Center (Ft. Lauderdale) www.careresource.org 954-567-7141 Through education, prevention, research, care and treatment and support services, Care Resource improves upon the health and overall quality of life of the diverse South Florida communities in need.

TRANS PROUD www.transproud.com . Outproud’s website for transgender youth. Headline news, links to other transgender sites for trans youth, loads of resources and information, stories, message boards, resources for youth and parents.

THE PRIDE CENTER at Equality Park (Wilton Manors) www.pridecenterflorida.org . 954-463-9005

Memorial Hospital Joe DiMaggio Children’s Hospital Pediatric Endocrinologist Gender Expert Dr. Beth Steindel-Spargo 954-538-4621

MERMAIDS www.mermaids.freeuk.com A family support group for children and teenagers with gender identity issues.

The Gender Program at Nicklaus Children’s Hospital www.nicklauschildrens.org 305-666-6511 with experts Dr. Gilbert Smith (Child and Adolescent Psychiatry NCH), Dr. Alejandro Diaz (Director of Pediatric Endocrinology NCH) and

Dr. Chad Perlyn (Pediatric Plastic and Reconstructive Surgery NCH)

Pamela Fero Law 1451 W. Cypress Creek Rd. Suite #300 Ft. Lauderdale bit.ly/Free15consult 954-947-0572 Works with families to resolve legal issues (name changes, changing gender markers on school records...)

University of Miami LGBTQ Clinic miamitransgender@med.miami.edu 305-243-4500

THE TREVOR PROJECT thetrevorproject.org . For transgender people in crisis, call the Trevor Lifeline, 866-4-U-TREVOR (866-488-7386), or ask for help through TrevorText (text “Trevor” to 1-202-304-1200), TrevorChat.

NATIONAL CENTER FOR TRANSGENDER EQUALITY transequality.org 202-642-4542 A social justice advocacy organization based in Washington, D.C.

TRANS YOUTH FAMILY ALLIES imatyfa.org

TYFA empowers young people and their families through support, education, and outreach about gender identity and expression.

TRANSKIDS PURPLE RAINBOW FOUNDATION tran skidspu rpler ainbow. org

TKPRF is committed to enhancing the future lives of trans children by educating schools, peers, places of worship, the medical community, government bodies, and society in general in an effort to seek fair and equal treatment of all trans youth.

TRANSPARENTCY transparentcy.org . Founded by a transgender parent and dedicated to transgender parents and their children, TransParentcy is committed to the fight to protect and honor the relationship between the two.

THE YES ISTITUTE helps to create a world where everyone thrives in a safe environment. They serve the LGBTQ+ community by providing education to parents and professionals across community groups and organizations in education, healthcare, government, workplaces, and faith communities. 305-663-7195 yesinstitute.org email info@yestinstitute.org

THERAPISTS who specialize in gender:

Dr. Deborah Grayson 954-937-6445 (Coral Springs)

Andrea Metz Sunserve 954-695-3700 (Wilton Manors)

Felicia Levine LCSW 954-657-3151 (Boca)

Dr. Jaime Joseph 954-417-3242 (Coral Springs)

Dr. Brandi Baumkirthner 561-922-9155 (Boca)

Carrie Ann Convers LMHC 754-701-2836 (Boca)

Jaki Neering MSW 561-475-4729 (West Palm Beach)

Hannah Badenoch LMHC 833-544-1365 (Delray Beach)

Caring for Your Child with Sickle Cell Disease

Tue, 29 Dec 2020 20:08:05 GMT

Sickle cell disease is a disorder of red blood cells (RBCs), first reported in the medical literature in 1910. People with sickle cell disease have a genetic variation in the production of hemoglobin, the protein that carries oxygen in red blood cells. Normal red blood cells are flexible and can move easily through blood vessels, whereas the red blood cells in people with sickle cell disease are prone to change from round to sickle-shape, which can block the flow of blood and oxygen to organs and tissues. It takes two abnormal genes to make sickle cell disease, either two sickle hemoglobin genes (SS), or a sickle gene combined with another variant of hemoglobin, e.g. sickle-beta thalassemia (SB) or sickle-hemoglobin C (SC). Those that carry one sickle gene will not be affected by sickle cell disease, though by carrying the sickle trait, they may transmit the abnormal sickle gene to their offspring. Universal newborn screening identifies babies with all forms of sickle cell disease. Most of those affected with sickle cell disease are of African ancestry. It is estimated that around 100,000 Americans are affected with sickle cell disease.

The main manifestations of sickle cell disease are related to both the abnormal shape of sickle RBCs and their tendency to cause blockage/occlusion of small blood vessels. Sickle cells are prone to hemolysis (break down), shortening their lifespan, thus causing low blood count or anemia . Sickle cells are removed from the blood by the organ called the spleen, which also functions to fight infection: the spleen in children with sickle cell disease generally fails early in life, causing infants and young children with sickle cell disease to be susceptible to serious bacterial infection . Sickle cells promote vaso-occlusion of small blood vessels, depriving the tissue of vital blood and oxygen, causing acute pain crises , most commonly in the bones. In infants and young children with sickle cell disease, painful swelling of the hands and feet ( dactylitis ) is often the first episode of pain crisis. Chronic pain can result from nerve injury and nerve inflammation. Sickled cells can damage the lining of blood vessels, causing blood cells and proteins to adhere, which predisposes to the blockage of flow of blood and oxygen to vital organs like the brain and an increased risk of stroke . Occlusion of small blood vessels in the retina causes damage from lack of oxygen, which can lead to loss of visual acuity and retinal detachment. Sickle cells can accumulate in the spleen (“ splenic sequestration ”), which can cause more profound anemia by rapidly dropping the blood count. The increased breakdown of sickle cells and the turnover of hemoglobin predisposes to the increased production of bilirubin in the liver, gallstones, and obstruction/infection in the gall bladder ( cholecystitis ). The decreased flow of blood and oxygen to the brain can predispose not only to stroke, but to developmental delay , learning disorders, educational and vocational impairment, and neuropsychiatric issues like depression and anxiety. Acute chest syndrome is a poorly understood complication of sickle cell disease, producing shortness of breath and chest pain, likely caused by a constellation of factors including infection, low oxygen, and chest inflammation. Chronic blockage of small blood vessels supplying the lung can cause an elevation in lung pressures ( pulmonary hypertension ), which can cause shortness of breath, fatigue, and strain on the heart. Over time, people with sickle cell disease develop impaired kidney function, typically impacting the ability of the kidney to concentrate urine, which results in excessive daytime urination and nighttime bedwetting, and may ultimately result in renal failure .

The management of sickle cell disease includes:

Treatment with prophylactic antibiotics to prevent severe bacterial infection, particularly from pneumococcus. Penicillin is given twice daily beginning in early infancy and continuing through at least age 5yr. Some centers recommend daily penicillin until age 18yr or longer.
Routine vaccination according to the American Academy of Pediatrics and the ACIP schedule. Because of their increased susceptibility to invasive pneumococcal disease, all infants with sickle cell disease should receive the complete series of the 13-valent pneumococcal vaccine starting at age 2 months, and supplemental vaccination with the 23-valent pneumococcal vaccine at age 2yr, with a second dose at age 5 yr.
Aggressive management of any illness involving fever, cough, chest pain etc.
Yearly screening of urine and blood pressure beginning in our practice at age 3yr.
Yearly screening of the eyes by a pediatric ophthalmologist beginning by age 10yr.
Yearly screening for abnormal blood flow in the large blood vessels in the brain, using transcranial doppler imaging, from ages 2yr-16yr. Increased velocities reflect narrowing and/or damage to the blood vessels, which increases the risk for stroke.
Transfusion of normal red blood cells allows normal hemoglobin to better deliver oxygen to the body and diminish blood vessel occlusion. Routine chronic transfusion therapy in children with sickle cell disease may be indicated in those with abnormal transcranial doppler imaging to prevent stroke, in children who have already had stroke, and in children with recurrent severe pain crises. This treatment carries with it the risk of chronic iron overload, and may need to be treated with iron chelators to prevent damage to tissues like the liver and heart.
Emergency transfusion is indicated for acute anemia (drop from baseline), which may result from parvovirus infection, worsened hemolysis from sepsis, or sequestration of blood in the liver or spleen. Emergency transfusion is also indicated in the treatment of acute chest crisis with low blood oxygen, and in case of stroke. Transfusion prior to surgery and general anesthesia reduces perioperative complications in people with sickle cell disease.
Management of acute pain crises with analgesics (NSAIDS like ibuprofen for mild episodes, opioids like oxycodone for more significant episodes) and hydration. The goals for providing adequate pain relief to improve function and quality of life must be balanced by the need to minimize the risk of opioid addiction.
Non-pharmacological approaches to manage pain in people with sickle cell disease include psychological and cognitive therapy, occupational and physical therapy, aquatherapy, massage therapy, acupuncture, meditation, and self-hypnosis.
Sickle hemoglobin cells are more likely to take on the characteristic sickle shape under conditions of low oxygen and acidosis, making hydration, exercise, good sleep, and a healthy diet rich in fruits and vegetables important adjunctive strategies in people with sickle cell disease.
Hydroxyurea is a medication that raises the levels of a non-sickling hemoglobin called fetal hemoglobin, improving blood flow, lowering the incidence of pain crises, reducing blood vessel occlusion and its complications (stroke etc.), reducing the need for transfusion, and protecting against other complications in people with sickle cell disease. Hydroxyurea has traditionally been offered to patients who have had multiple severe pain crises, stroke, or other significant complications with sickle cell disease, though pediatric hematologists are now offering hydroxyurea earlier to prevent those complications.
Bone marrow transplantation is a treatment that replaces the stem cells in the bone marrow of a patient with sickle cell disease with normal stem cells, effectively curing sickle cell disease. The difficulty finding a suitable donor, the cost, and the potential complications of this technology make it uncommonly used as a routine treatment at this time.
Emerging therapeutics include gene therapy, a process whereby scientists collect the stem cells from a patient with sickle cell disease and replace the genetically altered HBB gene (associated with sickle cell disease) with a normal gene for hemoglobin production, curing the sickle cell disease. An alternative therapy is to insert a vector/messenger into the patient’s DNA that directs their cells to re-produce fetal hemoglobin, which does not sickle, curing the sickle cell disease.

Your CMA physicians and advanced nurse practitioners will work closely with your pediatric hematologist and other specialists to be sure your child is getting the best care possible. Here is a list of local resources for you and your family:

Sickle Cell Disease Association of America sicklecelldisease.org 800 421-8453

American Sickle Cell Anemia Association ascaa.org

American Society of Hematology’s Sickle Cell Disease Initiative at cdc.gov

Sickle Cell Disease Association of Broward County sicklefreebroward.org

Sickle Cell Disease Association of Florida scdaflorida.com

Broward Health Ft. Lauderdale Dr. Hector Rodriguez-Cortes 954-355-4527

Joe DiMaggio Children’s Hospital Dr. Iftikhar Hanif 855-495-1430

Caring for Your Child with Down Syndrome

Tue, 06 Oct 2020 01:25:07 GMT

(Photo of Blake Logan from 9/1/20)

Down Syndrome is a genetic disorder caused by an extra copy of chromosome 21 (trisomy 21). Most of the time Down Syndrome is not inherited, but caused by a mistake in cell division during early fetal development, which increases with advanced maternal age. Some parents have an asymptomatic genetic error called a translocation, where they carry extra genetic material from chromosome 21, and this may be transmitted from parent to child and cause Down Syndrome.

Down Syndrome is the most common genetic chromosomal disorder, occurring about 1 in 700 newborns. It is a common cause of developmental delay, intellectual disability, and other medical conditions. It is important to state up front that every child with Down Syndrome is an individual, meaning your child with Down Syndrome is unlike any other, and with attention to the whole spectrum of care, we hope to help your child reach their highest potential for a happy, healthy, rewarding, and meaningful life.

Down Syndrome may be diagnosed prenatally, or after the child is born. Children and adults with Down Syndrome are often recognizable by common physical features, which include flattening of the face, small head, short neck, prominent tongue, upward slanting eyes, small ears, low muscle tone, increased flexibility, broad short hands with a single palmar crease, and short height. Most children with Down Syndrome have mild to moderate developmental and cognitive delays. About half of children with Down Syndrome are born with some type of congenital heart disease, some requiring surgery early in life. Some are born with intestinal blockage from atresia or Hirschsprung disease, and others are at increased risk for gastro-esophageal reflux and celiac disease. Newborns with Down Syndrome are at increased risk for congenital hypothyroidism (1%), and children with Down Syndrome are at increased risk for developing thyroid disorders like hypothyroidism (about 15%). Ear infections are common in children with Down Syndrome, and there is a significant risk of hearing loss (up to 75%). Many have cataracts and/or refractive errors requiring glasses. Over half of children with Down Syndrome develop obstructive sleep apnea (snoring, restless sleep, frequent night time wakening, excessive daytime sleepiness). Children with Down Syndrome may be born with disorders of the bone marrow that cause transient neonatal leukemia (10%), and they have an increased risk on later-onset leukemia (1%). Children with Down Syndrome are at increased risk for seizures, including infantile spasms (1-13%). Some people with Down Syndrome have a misalignment of the top two vertebrae in the neck (atlantoaxial instability), placing them at risk for spinal cord injury with overextension of the neck (caution is taken with any anesthetic or surgical procedure, some children who enter sports are screened, and any child with symptoms will be tested). As they grow and develop, children with Down Syndrome may have other developmental and behavioral disorders, like autism, ADHD, and OCD. These are all well-recognized issues that children with Down Syndrome may face, and caring for your child with Down Syndrome includes involvement of many different specialists, early integration of therapies, and routine screening for this wide range of possible medical disorders during your visits with us at Children’s Medical Association.

Comprehensive medical management, good nutrition, positive home environment, early intervention with therapies, individualized education plans (IEP), social support, recreational activities and vocational training can significantly affect the quality of life and level of functioning of children and adolescents with Down Syndrome. You have our commitment to stand with you every step along the way in caring for your child with Down Syndrome.

The following are local and national resources that specialize in the support of children with Down Syndrome and their families: JAFCO Children’s Ability Center jafco.org 954-215-7033

Broward Gold Coast bgcdownsyndrome.org 954-825-0400

Florida Department of Health BE@flhealth.gov 850-245-4465

March of Dimes www.marchofdimes.com

National Down Syndrome Congress www.ndsccenter.org

National Down Syndrome Society www.ndss.org

Brighter Tomorrows Supporting Families www.brightertomorrows.org

Caring for Your Child with Constipation

Tue, 29 Sep 2020 03:13:23 GMT

Constipation is a condition marked by infrequent, hard stools. It may or may not be associated with straining, abdominal pain, poor appetite, and the passage of blood with hard stools. If present from birth, constipation may be a sign of a rare condition called Hirschsprung’s Disease, where absence of nerve cells in the colon make it difficult to pass stool. Generally speaking, constipation is a common occurrence, and can occur at any age of life. If frequently occurs with changes in diet, and with psychological/behavioral stressors, such as the process of potty training, moving, starting school, the birth of a sibling, parental separation or divorce. There may be genetic factors, as well. The medical treatment of constipation generally includes fiber-based stool softeners, such as Benefiber and Metamucil, laxatives such as bisacodyl (Dulcolax), senna (Sennakot), and docusate (Colace), and the often-recommended polyethylene glycol (Miralax). Magnesium is a mineral that works well to soften stools and stimulate the passage of bowel movements to relieve constipation (Mommy’s Bliss Baby Constipation Ease, Natural Vitality Calm powder or gummies, and for older kids, the standard Phillips’ Milk of Magnesia). Modifications in diet and nutrition are very effective strategies in the management of constipation. These include:

Increase foods in the diet that contain natural fiber, such as whole grain breads and cereals, beans, whole wheat pasta, quinoa, and brown rice; fresh fruits such as berries, apples, pears, peaches, and grapes; dried fruits such as figs, dates, prunes, raisins and apricots; vegetables such as carrots, peas, sweet potato, beans and lentils, artichoke, okra and kale. Drink lots of water and 100% whole fruit and vegetable juices. Consider adding psyllium husk, a great bulking agent to loosen stools.
Decrease foods that are constipating, such as white bread, white pasta, white rice, fried foods, and excessive cow's milk/dairy products (coconut milk is a great alternative here).
Consider adding a daily probiotic, a nutritional supplement of healthy bacteria, which helps to balance the gut and promote healthy bowel movements (Garden of Life Infant, Udo's Choice Infant, Klaire Labs TherBiotic chewables, and gummies like Garden of Life Dr. Formulated, DinoDophilus, Renew Life Ultimate Flora, and Rainbow Light Probiolicious). Foods naturally rich in probiotics include yogurt, kefir, kombucha tea, kimchi, tempeh, and sauerkraut. Prebiotics, such as fructose oligosaccharide (prevalent in fruits and vegetables and also available in supplements) facilitate the growth of good bacteria in the gut and soften stools, thereby helping reduce constipation.
Other nutritious foods with benefit in managing constipation include ground flax and chia seeds, olive oil, coconut oil, and aloe.

Caring for Your Child with Depression

Thu, 10 Sep 2020 02:28:32 GMT

Depression is a mental health condition generally defined as a persistent sadness, lack of ability to experience joy in one's daily activities, along with low energy, disturbed sleep, change in appetite, poor focus and concentration, and low feelings of self-worth. If left untreated, depression can lead to school failure, social delinquency, eating disorders, drug and alcohol abuse, self-harm, and even suicide. Children who suffer from depression often have a family member who has experienced depression. Children with chronic illnesses are at risk for depression, as are those who are victims of abuse, neglect, or bullying; those in foster care; those who have lost a parent of loved one; those with uncertainty about or non-acceptance of their sexual attraction or gender identity; and those suffering from other traumas or natural disasters. All children are formally screened for depression at yearly check-ups starting at age 12yr with the PHQ-9, though concerns about mental health should be raised whenever they arise.

Signs and symptoms of depression in children and adolescents include persistent sad and irritable mood; loss of interest or pleasure in activities, boredom, apathy; social withdrawal and isolation; weight loss or weight gain; sleep disorders; fatigue; feelings of worthlessness; difficulty concentrating and poor school performance; vague somatic complaints (headache, abdominal pain); reckless behavior, alcohol and drug abuse; thoughts of self-harm or attempted suicide.

The good news is that depression is treatable. Sometimes, a medical evaluation will reveal an underlying biological cause, such as a significant anemia, iron deficiency, thyroid imbalance, vitamin D deficiency. If depression is suspected, consultation with a psychologist or licensed mental health worker should be initiated as soon as possible. Your pediatrician can provide you with local professionals. Be sure the home environment is safe (lock up firearms, OTC and prescription medications). If you have knowledge of any child or adolescent with suicidal thoughts, get help immediately. The National Suicide Prevention Hotline is available 24/7 at 1-800-273-TALK.

Common sense, natural strategies to approach depression include whole food nutrition, including brain foods like eggs, nuts and nut butters, avocado, wild salmon and other seafood, brightly colored fruits and vegetables like leafy greens, blueberries, etc.; restorative sleep; regular exercise; mind-body strategies like yoga and meditation; spiritual support through connection to people, animals and nature; holistic healing modalities like massage and reiki. Avoid chemical sweeteners, dyes, hormones, preservatives and pesticides in processed food as much as possible. Evidence-based, proven treatments for depression include psychotherapy, cognitive behavioral therapy (CBT), and antidepressant medications. These are drugs in the class called SSRIs (selective seratonin re-uptake inhibitors), which raise the level of the “happy hormone” seratonin. The safest and most effective SSRIs for pediatric depression are fluoxetine (Prozac), sertraline (Zoloft) and escitalopram (Lexapro). If medication is started, know that it may take 6 weeks of more to see the benefit. Your child will be monitored for common side effects like nausea, headache, insomnia, nervousness, and less common but important side effects like exacerbation of depression and mania.

As we care for your child with depression, our goals are to help support you and your child, offer effective strategies, provide resources, and ultimately to bring about the resolution of depressive symptoms and improvement of your child’s quality of life and functioning.

Caring for Your Child with Eczema

Sun, 30 Aug 2020 15:48:10 GMT

Eczema is a common, and often chronic, inflammatory disorder of the skin. It often begins in early infancy, and is related to other atopic conditions like allergies and asthma. The best approach to eczema is to consider the underlying cause of the inflammation. The common foods that contribute to inflammation in conditions like eczema are cow's milk protein, egg white, corn, wheat/gluten, soy, and shellfish. For babies who are breast feeding, it is recommended their moms eliminate trigger foods. Babies with significant eczema may be placed on a hypoallergenic formula like Nutramigen, Alimentum, Gerber HA or Neocate, and probiotics to support healthy gut flora (like Garden of Life Baby, Jarrow BabyDophilus, mommy’s bliss, Gerber Soothe or Culturelle Grow and Thrive). Older children may have allegy testing done to look for triggers, or be placed on an elimination diet to identify food sensitivities.

All people with eczema should avoid chemicals, dyes, perfumes, and harsh cleaning products on the skin. Choose cotton over wool or polyester, and prewash all clothing prior to wearing. For skin care, we recommend fragrance free, hydrating products like BabyDove, Eucerin Baby Eczema, Aveeno Eczema, Honest Organic Healing Balm, Aquaphor Baby, Cetaphil Restoraderm, or Vanicream/Vaniply products. Botanical creams with coconut oil and/or calendula are often useful. Fragrance-free laundry products should always be used. Explore mild "green" cleaning products (like Seventh Generation, Mrs. Meyers Clean Day or Ecos) for the home. For flares in eczema, we may recommend a short course of topical steroids (hydrocortisone, fluticasone, betamethasone) to reduce skin inflammation and oral antihistamines (diphenhydramine, loratidine, cetirizine) to control itch. For infants and children with more persistent eczema, other medications to block inflammation, such as pimecrolimus (Elidel), tacrolimus (Protopic), and crisaborole (Eucrisa), may be recommended

Caring for your Baby with Colic

Fri, 10 Jul 2020 20:22:25 GMT

Colic is a condition that causes crying and irritability in babies from 3 weeks to 3 months of age. All babies cry, but colic generally refers to excessive crying, defined as more than 3 hours per day, more than 3 days per week, and longer than 3 weeks duration. There is no single recognized cause of colic, but it is felt to be due to an immature gastrointestinal system, with spasm and discomfort during swallowing/digestion/peristalsis/elimination of stool, along with an immature nervous system, which is oversensitive to these and other stimuli. Food sensitivity and underlying temperament may also play a role. Responding to your baby's need for comfort is the right choice: you cannot spoil your infant at this age. Many babies find relief with movement, either bouncing, rocking in a swing, or riding in a car. White noise or music can be useful in settling down your baby, as can swaddling, gentle touch/massage, or a warm cloth on the belly.

Dietary changes are reasonable to consider for a baby with colic. If you are breast feeding, try eliminating foods that promote gas and irritability, namely spicey food; acidic food (citrus and soda); vegetables like beans, broccoli, cabbage and brussel sprouts; chocolate and caffeine. Eliminating dairy may also be of benefit. If you are formula feeding with milk-based formula, consider changing to a hypoallergenic formula like Alimentum, Nutramigen, or Gerber Extensive HA.

Simethicone is a medication used to relieve gas: it is safe for babies and may be beneficial for colic. Popular brands include Mylicon drops and Little Remedies Gas Relief drops. Probiotics may be beneficial for babies with colic, particularly babies born by C-section, whose delivery method away from the mother’s birth canal alters the normal inoculation of healthy bacteria to support the baby’s intestinal microbiome. Probiotics useful in babies with colic include BioGaia and Gerber Soothe drops (lactobacillus reuteri), Culturelle Culturelle Calm and Comfort, and Garden of Life baby probiotic drops (7 strains, 4 billion colonies).

There are many natural, plant-based remedies for colic, which act by relaxing intestinal spasm, relieving gas and bloating, and calming nervous tension. The most remarkable herb is chamomile, in use for over 2000 years, which acts to relax spasm, reduce inflammation, relieve bloating, aide digestion, and relax the nervous system. It is found in colic remedies, and may be offered as a weak tea (1-2 ounces 1-2/day). Other botanical remedies for colic include fennel, ginger, dill, peppermint, lemon balm, caraway, aloe, and dioscorea (wild yam). Gripe water is the term used for liquid colic products, but there are many varieties: avoid those that contain alcohol, dairy, chemicals and preservatives. Recommended products are "Colic Calm Gripe Water" (aloe, chamomile, ginger, lemon balm, peppermint), “Zarbee’s Colic Remedy” (chamomile, fennel, lemon balm, ginger), "Mommy's Bliss Gripe Water" (ginger, fennel, bicarbonate), "Little Remedies Advanced Colic Relief Drops" (chamomile, fennel and lemon balm), and "Hyland's Baby Colic Drops and Tablets" (chamomile, dioscorea, colocynth).

Caring for Your Child with Autism

Mon, 08 Jun 2020 01:22:09 GMT

Autism spectrum disorder (ASD or autism) is a common neurodevelopmental disorder, with a prevalence in the USA of nearly 1:60 children. Autism affects children across races and all socioeconomic groups, though in recent years the prevalence rate of autism has climbed in Black and Hispanic children. Boys are 4x more likely to be diagnosed with autism than girls. Autism is considered a spectrum disorder, as no two children with autism are the same, and there is great variability in expression of autism among affected children (some show signs from infancy, some seem neurotypical for a few years and then begin to show signs of regression, some children are merely “quirky” and some severely affected, etc.). The core features of autism include impairments in social interaction, deficits in speech and language communication, alterations in the perception of sensory input, repetitive behaviors, and restricted areas of interest. Some “red flags” include poor eye contact by 4-6 months, not responding to their name by 1 year, no imaginative play by 18 months, persistent delayed or regressed speech and language milestones by 2 years, especially in combination with repetitive behaviors (rocking, spinning, hand flapping) and unusual reactions to the way things smell, feel, sound, taste and look.

Many children with autism have co-existing conditions, including sleep disorders, seizures, ADHD, anxiety and mood disorders, intellectual disability (30%), and behavioral disorders such as food refusal, self-harm, and aggression. Many children (estimates range from 10-90%) have gastrointestinal disorders, including colic, feeding issues, food sensitivity, gastro-esophageal reflux, diarrhea, digestive disorders related to food allergies, and abdominal pain. It is speculated that many of the behavioral features of autism could be related to irritability and pain from these comorbid conditions, and the inability of children with autism to localize and communicate their discomfort. Recovery rates from autism are estimated at about 20%, though this number may not account for the progress made by children (and adults) with autism on the spectrum, the inherent diversity among children labeled autistic and neurotypical, and the potential of numerous strategies to help in the recovery process.

Current theories regarding the cause of autism point to a multifactorial etiology, which means that the interaction and momentum of difference factors can move a child onto the autism spectrum. These influences include genetic, environmental, immune, metabolic, inflammatory, and gut-related factors. There are prenatal influences associated with increased risk of autism, including exposures to medications like valproate, exposure to mercury-containing pesticides like glyphosate, exposures to infections like CMV, maternal obesity, advanced paternal age, twins or multiple pregnancy, and gestational diabetes. Perinatal factors such as prematurity, low birth weight, and lack of oxygen are associated with increased risk for ASD. Delivery by Caesarian section may also increase the risk of ASD.

The American Academy of Pediatrics recommends developmental screening for all children at all visits, and standardized autism screening tools at 18 and 24 months. At CMA, we utilize the Denver Developmental Screening Tool at 5 months, the Parental Peds Response Form at 9 months, and the Modified Check List for Autism (M-CHAT) screening at 18, 24, 30, and 36-month check-ups. If your child has developmental delay, fails a screening, or shows signs of possible autism, we are committed to early intervention, and will initiate referrals to Early Steps for speech and/or feeding therapy, occupational or physical therapy if indicated, and referral to a neurologist for further evaluation. That evaluation may include an MRI and genetic testing (chromosomal microarray, Fragile X, whole exome sequencing), which may reveal one of hundreds of known chromosomal variants in only 10% of patients, and other variants of unknown significance in up to 30% of patients. A small number of children may be tested for metabolic or mitochondrial disorders if indicated. Suffice it to say, there are no specific lab tests to confirm a diagnosis of autism, so the history and the behavioral characteristics are key. A diagnosis of autism can be earth-shattering for a family, yet we want you to know we are here to support and guide you, to work with you and your team of specialists and therapists, to help your child reach his or her unique potential. For some children with autism, this includes the development of keen intellect, special talents, unique gifts, and strengths as they grow.

Caring for your child with autism involves caring for the whole child and focusing on things that can improve quality of life and support recovery. Create an environment that is loving, accepting, safe and clean (natural is better than chemical). Offer healthy foods to provide nutrients that support energy and digestion, reduce systemic inflammation, and positively affect genetic expression (lots of brightly colored fruits and vegetables, wild salmon, eggs, nuts and seeds, herbs like rosemary and cilantro, spices like garlic and turmeric, olive oil). Follow the Dirty Dozen to avoid foods high in pesticides, and eliminate chemical sweeteners, nitrates, MSG, food dyes, and hormones wherever possible. Encourage time in nature and regular exercise. Pay attention to sleep hygiene. Provide early and consistent therapies to improve communication, sensory integration, and social interaction. Seek out resources for ABA therapy to adapt behaviors to be social, functional, and communicative. Maximize educational opportunities (with the support of an IEP and 504 accommodations) to facilitate learning and the acquisition of life-supporting skills. Stay on track with routine childhood vaccinations. Treat comorbidities like allergies, seizures, ADHD, mood disorders, etc. Integrative therapies of potential benefit in children with autism include omega-3 fatty acids/fish oil to reduce inflammation and support healthy brain cell function; probiotics to support healthy gut bacteria and to reduce intestinal permeability; magnesium to calm mood and support heathy cell function; B vitamins to support mitochondrial energy production; vitamin D to support mood and immune function; melatonin to help promote sleep; and yoga for self-regulation and stress reduction.

We are here for you. Reach out on the portal or schedule an appointment to come see us in the office.

Here are some additional resources and community partners that serve our patients with autism and their families:

Autism Speaks 888-288-4762

Center for Autism and Related Disabilities (CARD) 800-9 AUTISM

JAFCO Children’s Ability Center (CAC) 954-315-7033

Nicklaus Children’s Hospital Dan Marino Outpatient Center 866-558-6510

ASD Baudhuin Preschool at NSU Mailman Segal Center 954-262-7100

Dr. Martha Herbert “The Autism Revolution

Caring for Your Child with Acne

Sat, 23 May 2020 16:56:41 GMT

Acne is a skin condition that affects millions of people from adolescence into adulthood. It is caused by overproduction of oil and clogging of pores in the dermal layer of the skin, which leads to overgrowth of bacteria and an inflammatory response. The clinical appearance of acne can vary, though generally includes blackheads, whiteheads, and tender cysts, which may lead to scarring. Conventional treatment of acne includes OTC and prescription strength topical medicines (found in face washes, lotions, and gels) that help open pores and reduce bacterial growth, such as salicylic acid and benzoyl peroxide. Prescription medications target the overgrowth of bacteria with topical antibiotics like clindamycin, or oral antibiotics like minocycline. Vitamin A derivatives like tretinoin (topical Retin-A) and isotretinoin (oral Accutane), which stimulate dermal cell turnover, are also effective in treating acne.

In addition to these therapies, caring for your child with acne includes strategies to reduce the underlying inflammation and propensity for bacterial overgrowth. The following are recommendations to do so:

1. Eat a diet that is rich in nutrients that have antioxidant, anti-inflammatory and antibacterial properties. These include dark leafy greens, red and purple grapes and berries, omega-3 fatty acids from wild Alaskan salmon and flax/chia/hemp seeds, turmeric, garlic, coconut oil, ginger, avocado, etc. Foods high in vitamin A and zinc (spinach, carrots, nuts, seeds, oysters, beans) are specifically good for people with acne. Drink plenty of water!

2. Avoid foods that directly promote inflammation in the body. These include processed (boxed) foods, refined sugars, hydrogenated oils (fried fast food), and excess dairy. A diet high in carbohydrates and sugar also promotes acne by causing excessive release of insulin, which leads to excessive testosterone, a hormone that induces more oil secretion and acne flares.

3. Consider eating probiotic-rich foods (kefir, yogurt, fermented foods like kimchi and kombucha) or taking a supplemental probiotic to support the body's immune system and curb bacterial overgrowth in the skin.

4. Consider topical treatment with skin care products containing tree tea oil, calendula, and coconut oil, which naturally reduce inflammation.

5. Consider stress reduction techniques, such as yoga and meditation, which quiet the release of cortisol from the adrenal glands, as stress hormones like cortisol can promote acne.

Caring for Your Child with Asthma

Thu, 21 May 2020 22:52:21 GMT

Asthma is one of the most prevalent diseases of childhood, affecting nearly 10% of children. Asthma has a tremendous impact on quality of life, days out of school, and parental days out of work. There are two main factors that impact the airway in children with asthma: hyperreactivity (“twitchiness”) in the airways due to constriction of the muscles in the bronchial airway, and inflammation due the activation of immune cells and secretion of chemicals (histamine, leukotrienes etc.) in the airway. The final result is narrow, swollen, obstructed airways that make breathing a challenge. When asthmatic symptoms are intermittent, we treat your child with a rescue inhaler like ProAir or albuterol in the nebulizer: these are “bronchodilators” that relax the muscle spasm in the airway. When asthma symptoms are persistent, we treat your child with medications on a daily basis to reduce airway inflammation and minimize asthma flares: these are inhaled steroids like Q-Var and Flovent, and the oral medication montelukast (Singulair) that blocks the receptors for inflammatory leukotrienes

In addition to these core medications used to treat bronchospasm and airway inflammation, there are many natural and complementary approaches that support respiratory health through nutritional and environmental strategies. Eat a balanced diet, including many fruits and vegetables with antioxidant/anti-inflammatory effects (blueberries, oranges, apples, red grapes, spinach, beets, broccoli, kale, tomato, red bell pepper), fish, beans/legumes, herbs like thyme and oregano, spices like turmeric and garlic, and plenty of water. Botanical essential oils with eucalyptus can reduce inflammation and bronchospasm, as do lemon, honey, and star anise. Licorice has anti-inflammatory, antispasmodic and expectorant effects, and is also useful for acute episodes of asthma (Traditional Medicines Throat Coat tea or syrup, Luden's Honey Licorice Cough Drops). Avoid specific foods if there is sensitivity or food allergy (dairy, soy, egg, nuts, shellfish). Avoid sulfites in foods, which can trigger asthma symptoms (shrimp, dried fruit, processed potatoes, and beer/wine in adults). Consider supplements that support the immune system (C, zinc, selenium, omega fatty acids). Consider mind-body therapies that may help asthma by reducing stress and inflammation, including yoga, meditation, and biofeedback programs like HeartMath.

Promote a healthy environment. Most importantly, avoid all exposure (active and passive) to tobacco smoke. Remove shoes at the front door to diminish bringing pollens into the home. Avoid dust mites by encasing the bed pillow and mattress with special dust mite covers. Wash the sheets and blanket weekly in hot water, and dust/vacuum regularly. Remove pets, carpet, books, and stuffed animals from the bedroom. Reduce indoor humidity by keeping the A/C on and keeping windows closed. Change the A/C filters regularly. Avoid wood-burning stoves, kerosene heaters/lanterns, fireplaces, and unvented gas stoves. Avoid strong odors from perfume, hairspray, room deodorizers, paint, and new carpet.

CMA Education blog

Wed, 15 Apr 2020 16:32:44 GMT

Children’s Medical Association proudly maintains affiliations with academic partners across the state of Florida. Over the span of 20 years, CMA has hosted more than 300 aspiring physicians, physician assistants, and nurse practitioners. CMA’s dedication to educating the next generation of practitioners is an extension of its commitment to care for its community, generation to generation.

With pleasure, CMA exposes rotating students to all facets of outpatient care. Students are encouraged to engage in evaluating, diagnosing, and managing a wide range of pediatric conditions. CMA’s students have varying professional aspirations, and for many, this is their only exposure to pediatric medicine. Despite this reality, each student is left with a lesson in how to passionately provide patients and families with the care that they deserve. Regardless of their chosen discipline, the hope is that this lesson will last them a lifetime .

CMA’S Academic Partners Include:

The University of Miami Miller School of Medicine, The University of Florida College of Medicine, Nova Southeastern University Patel College of Allopathic Medicine, Osteopathic Medicine and Health Care Sciences, and Florida Atlantic University’s Charles E. Schmidt College of Medicine.

Immunizations

Wed, 15 Apr 2020 14:40:00 GMT

The doctors and nurse practitioners at Children’s Medical Association are honored to be your partner in your children’s health. A major component of pediatric preventive health is proper and safe vaccine administration. At Children’s Medical Association we recommend all routine childhood vaccines as per the recommendations of the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP). During routine visits your provider will discuss each immunization required and answer all questions your family may have.

Additional information regarding the importance of childhood vaccination and safety material can be found on the following links:

Vaccine Safety: The Facts

HealthyChildren.org

AAP Vaccine Information Page

www.vaccinesafety.edu

CMA Supports JAFCO

Tue, 14 Apr 2020 03:42:40 GMT

CMA has provided pro bono pediatric services to the children of JAFCO since its inception in 1992. We support JAFCO’s mission to care for abused, neglected and at-risk children, children with developmental disabilities, and students, parents, family members and faculty in the MSD/Eagles community.

JAFCO provides a full continuum of high-quality services at The Children’s Village, including the Children’s Emergency Shelter, Group Home Program, and foster care and adoptive services; at The Children’s Ability Center, including extensive therapies, support services for families of children with developmental disabilities and autism, life skills and social skills training, and respite care; and at Eagle’s Haven, including support groups, mindfulness programs, wellness activities, family and individual consultation, crisis support and school advocacy. For more information, check out jafco.org