Belilovsky Pediatrics News Blog welcomes visitor…
Belilovsky Pediatrics News Blog welcomes visitor…
I just did an interview with HealthRadio about the Winter Blues, also known as Seasonal Affective Disorder, and apparently there is great interest in this subject, so I’ll talk about it here in more detail.
SAD: Seasonal Affective Disorder. Kind of says it all: feeling sad in the winter. Think about SAD if your child starts acting like the Seven Dwarves:
Sleepy: a change in sleeping habits, inability to get out of bed, lack of interest, lack of exercise
Grumpy: Irritability, sadness, low self-esteem
Dopey: lack of concentration, difficulty in school
Bashful: lack of desire to be with other people, social isolation
Sneezy: unrelated to SAD, but it’s still flu season, isn’t it?
Happy is what you want them to be, and
Doc is who you take them to if you need help, right?
Oh, and craving for carbohydrates is a feature of SAD as well, but that’s more Sleeping Beauty, isn’t it, with the apple? And staying in bed and craving chocolates is what St Valentine’s day is all about.
And, just as in the summer, it’s not heat, it’s the humidity — with SAD, it’s not the cold, it’s the dark. When our eyes sense dim light or darkness, our brain makes more melatonin which acts like a sedative. In the winter, light may be dim all day. I’ve praised melatonin in the past as a natural replacement for sleeping pills, but in the winter the brain may be making it at a rate of a pill every hour between 4 PM and 11 AM, and that’s way too much sedation.
In addition, the light makes vitamin D in our skin; by winter’s end, almost everyone is Vitamin D deficient unless they are supplemented, especially children whose skin is dark.
The latest recommendations on Vitamin D are here:
An extensive review on vitamin D deficiency in children, with new recommendations for supplementation, was published in the August 2008 issue of Pediatrics by Misra and colleagues on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. This paper provides an excellent resource for pediatric health care providers on topics ranging from biomarkers of vitamin D deficiency to dietary sources and dosing of vitamin D products.
Based on a review of the literature, the group recommended that serum 25 (OH)D levels be maintained at least above 20 ng/mL and that daily supplementation with 400 International Units (10 mcg) of vitamin D be initiated within days of birth for all breastfed infants and in formula-fed infants and children who do not ingest at least 1 L of vitamin D-fortified milk each day. Premature infants, dark-skinned children, and children who live at higher latitudes may require larger doses of vitamin D, up to 800 International Units (20 mcg) per day. Supplementation for vitamin D insufficient or deficient children should be dosed according to the chart below:
Patient Age Dose (International Units/day)
< 1 month 1,000
1â€“12 months 1,000 to 5,000
> 12 months > 5,000
In addition to their recommendations, the authors also highlighted the need for additional studies to determine if higher levels of 25 (OH)D (> 32 ng/mL) should be considered, as well as to determine the appropriate balance of the benefits and risks of sunlight exposure.
And the light ionizes the air. Remember walking outside, breathing in, and saying, “Ahhh, spring!”? It’s negative oxygen ions you were smelling. And will again. More on that below.
The depression of SAD is made worse by a number of factors. Lack of exercise — too cold to play outside — is an important factor. There is ample evidence for the diet being a contributing factor (more on that below); and the many holidays in the winter bring our children in contact with their extended families, and no one does a greater job of making a child feel inadequate than a relative bragging about their own child, and why can’t you be like that?
What we know about SAD comes from many sources. SAD is 7 times more common in New Hampshire than in Florida. It occurs in 10% of Scandinavians and 20% of people in Ireland. Oddly, it is rare in Iceland despite a longer, darker winter (which suggested one of the effective treatments for SAD). And we know what works.
Why are we “dreaming of a white Christmas?” It fights SAD in two ways. First, you see the snow. Lots of it, all over the place, reflects light into your eyes. It is exactly the kind of bright, diffuse light that works best against SAD. Then, you get to shovel that snow. That’s exercise, and it is also very effective. No snow? Any exercise will do, and other sources of bright white (or green) light such as light boxes or bright fluorescents work, too.
Why are the Icelanders spared the worst of SAD? The only difference between them and other Northern Europeans is in the amount of fish they consume — many times more than Swedes or Danes or people in the British Isles. Fish is the only common food that is rich in Vitamin D and omega-3 fatty acids. And fish oil and Vitamin D supplementation do appear to be effective against SAD.
And ionized air? No need to wait for spring (not that far off now, but still…): there are commercially available air ionizers that have been shown to benefit people with SAD.
And, finally, brighten up their day. Say something nice to them. Praise them for something they did right — show them that you understand how hard it was to accomplish it. Maybe even throw caution to the wind and take them to Florida, or skiing. I said before, ‘don’t let your school interfere with your child’s health’; if you think a vacation will benefit your child’s health, school schedule should not stop you. The school should be happy when your child returns in better shape to study. We hope they should be happy.
With all this, what can you “Doc” do for you?”
First of all, is is really SAD? Major depression needs to be taken much more seriously. In major depression, feelings of hopelessness and worthlessness predominate, and “rumination” — obsessive thinking about the negative — occurs much of the time. If this is a concern, see your doctor right away.
It is also possible for the SAD feeling to be due to a real medical condition. Thyroid disease, hypoglycemia, anemia and mono can commonly present with depression-like symptoms; your doctor should be able to check for them, and begin treatment if they are found.
And, finally, you and your child should leave your doctor with the knowledge that, in the cold and dark in the dead of winter, you are not alone.
This is the picture that is worth 1000 words, and it is what informs the rest of this post.
The fall outbreak, nationally, is now officially worse than the spring outbreak. We are not seeing any cases here in Brighton yet, but we will soon — the outbreak map:
now shows New York in widespread brown, along with the rest of the country.
First of all, even though the H1N1 vaccine is not available to us yet, the risk of the wild flu is now high enough for the potential vaccine risks to be acceptable. I now recommend it highly, especially for the high-risk populations: pregnant, obese, young, health care workers, parents on newborns, and those and with preexisting conditions.
Secondly, there are not very many plausible explanation for the summer vacation that the flu takes. The incidence curve and the mortality curve correlate well with seasonal variations in Vitamin D levels, due to differing sunlight-to-skin exposures:
The science behind this connection is not conclusive, but it is a whole lot better than that purported for the so-called vaccine-autism connection, and the downside of “just-in-case” Vitamin D supplementation is negligible, which cannot be said for “just-in-case” vaccine refusal. So vaccine, Vitamin D, hygiene, avoiding crowds, “Dracula cough” –
and liberal school attendance policy remain my recommendation; taking Tamiflu prophylactically is not, except for the very high risk individuals.
The role for Tamiflu is in early, aggressive treatment of identified high-risk individuals who actually have flu, which means that rapid availability of urgent care is the key to minimizing complications. Looking at the so-called “Quality Indicators” by which practices are judged in New York, we find that the state is interested in many factors such as up-to-date immunizations, lead testing, weight and activity counseling — all laudable goals — but not availability. So the practice that dumps urgent care on emergency rooms to concentrate on crossing the T’s and dotting the I’s in preventive care will actually look like a higher-quality practice than one that actually takes care of sick children. I hope I am not the only one who finds this ironic.
I did a quick, preliminary count of positive Flu A tests in different vaccine recipients.Â Of about 500 Flumist recipients, 1 had a positive test for Flu A during the “regular” season (Dec 08-Mar 09), and 39Â had positive tests for Flu A during the “swine” season (Apr 09-Jun 09).Â Of about 1000 Fluzone recipients, 3 were positive for seasonal Flu A, 40 were positive for “swine” flu A.Â Without getting all technical about it, looks like the two vaccines are both very effective in protecting against seasonal Flu A.Â Since they were never intended against Swine Flu, it is not surprising that that neither has much (if any) of a protective effect against swine flu.
Take home message: use a flathead driver for flathead screws, and Philips driver for Philips screws.Â Get seasonal vaccine now, and swine vaccine when available.
As usual, it is a bit complicated:
Fluzone (injectable, dead, inactivated vaccine):
between 6 months andÂ 3 years of age — available both VFC and non-VFC (comes in 0.25 ml syringes)
over 3 years of age — available non-VFC only
Â reminder: the VFC program covers children and adolescents who are either uninsured or have a government-funded insurance or Medicaid, up to their 19th birthday.Â VFC vaccines are supplied free of charge, but are often shipped later than commercially purchased vaccines.Â Insurances do NOT pay for immunizations for VFC-eligible patients.
Flumist (live, attenuated vaccine administered as nasal spray, for persons ages 2 to 49 years who do not have a significant chronic illness)
We have non-VFC Flumist.Â As usual, we expect a delay in the shipment of the VFC vaccine.
Â Flu and flu vaccine will of course be in the news shortly; some news will be at least generally accurateÂ while others will exhibit varying degrees of departure from reality.Â
Â On a different note, I would like to thank the military families who have joined our practice recently.Â The response to my War and Peace editorial has been astounding, and the thought that they might see in our work a fleeting reminder of the dedication and professionalism their loved ones show daily in harm’s way is an inspiration.Â
Anatoly Belilovsky, MD
Hepatitis A and second chicken pox vaccines are strongly recommended by the Health Department (first chicken pox vaccine has been required for a while).Â There is, however, a nationwide shortage of the chickenpox vaccine, and we have run out.
The story is even more complicated regarding flu vaccine.Â The popular Flumist (nasal flu vaccine, not a shot) may or may not be available this season at all.Â The shots should be available, but the 6-to-36 months variety should be available first, followed by the 3-year-and-over variety, and as before, we may see big differences in VFC and non-VFC vaccine shipping times.Â We have had a number of complaints about it last year, and would urge all parties concerned to call Health Department to make VFC vaccine available as early as possible, as they are ultimately in charge of it.
As the school season approaches, I would urge everyone to read last year’s posts, either at the bottom of this page, or on the next.Â As nothing has changed in the school system, I expect to see the same problems this year as well.
In my work as a pediatrician, every once in a while I am privileged to be asked to see a child of a military or law enforcement officer. Even if sometimes they do not identify themselves as such, there is often a moment when their professional identity becomes apparent. It usually goes like this:
There are many things in my practice which I prefer to leave to experts, and it isn’t just brain surgery. Psychological and behavioral issues are complex enough to need not one but many specialties in medicine: psychology, psychiatry, behavioral and developmental pediatrics, neuropsychology — and, being a general pediatrician, I try stick to what I know.
It is said that a picture is worth a thousand words; a moving picture, then , is at least ten thousand. Not being the fastest typist, I combed the cyberspace for the finest pre-recorded answers to common questions regarding teenagers, their care and feeding, and how to survive what seems like the longest years of their — and your — lives.Â A sense of humor is essential in dealing with teens; the answers are meant to stimulate this, rather than being taken literally.Â For technical reasons the videos are embedded as comments. Enjoy!