Susan Beck

Timothy Culbert, MD, and Rebecca Kajander, MPH, CNP, nearly put the audience to sleep at their October 18th interactive workshop, “Replacing Pills with Skills.” But that was just what they had hoped would happen!The two staff members from the Integrative Medicine Program at Children’s Hospital and Clinics in Minneapolis demonstrated-and then had the audience practice-a variety of self-care techniques that can be taught to children to help them manage common health problems, such as pain, insomnia, anxiety, and nausea. In addition to progressive muscle relaxation (which had some attendees at this late-afternoon session close to dozing!), the skills demonstrated included biofeedback, diaphragmatic breathing, aromatherapy, acupressure, and others.

Children take naturally to self-regulation skills.

 The presenters, who are part of the longest-running integrative medicine program for kids in the country, pointed out that children and self-care skills are a remarkably good “fit”-for a number of reasons. First, children naturally strive for mastery and thus are drawn to skills that increase their sense of internal control and that make them an active participant in their own care. Second, children are better than adults at learning these skills: they are enthusiastic, they typically find the techniques fun, and consequently, they pick the skills up quickly. Finally, self-regulation skills-unlike almost any medication-are absolutely safe.Dr Kajander noted that although large randomized controlled trials may be lacking, there is some evidence of efficacy for all the skills they teach. He also pointed out that, any implications of the session title to the contrary, clinicians in the Minneapolis Children’s Hospital Program are by no means opposed to the use of medication. There is often a place in management strategies for medication as well as self-care skills, he said; integrative medicine strives to combine the best of complementary/alternative medicine with traditional medical approaches. 

 The most important self-regulation skill of all, Ms. Kajander said, was diaphragmatic (or “belly”) breathing. She had the physicians in the audience all put their hands on their abdomens and then practice using their diaphragm to inhale. Breathing in this way, she said, can help children with a wide variety of symptoms, from performance anxiety to headache to stomachache to insomnia.The presenters noted that incorporating simple objects in the performance of the skills makes them more fun for children. For example, to help children focus on exhaling completely when they are practicing belly breathing, one might have them exhale through a straw or onto a pinwheel to make it spin. Other “tools” that can be employed include Biodots (temperature-sensitive stick-on dots that children can stick to the back of their hand and get to change color by relaxing), adhesive beads for use in acupressure, and small vials of common essential oils (eg, lavender, orange, lemon, peppermint, spearmint) for use in aromatherapy.It was easy to spot which convention attendees that been to this session. They were all walking around with shiny little temperature-sensitive dots on the backs of their hands-which were uniformly blue from relaxation.

Articles

Timothy Culbert, MD, and Rebecca Kajander, MPH, CNP, nearly put the audience to sleep at their October 18th interactive workshop, “Replacing Pills with Skills.” But that was just what they had hoped would happen!The two staff members from the Integrative Medicine Program at Children’s Hospital and Clinics in Minneapolis demonstrated-and then had the audience practice-a variety of self-care techniques that can be taught to children to help them manage common health problems, such as pain, insomnia, anxiety, and nausea.

“Replacing Pills With Skills” Workshop Teaches Self-Care Techniques for Kids

In his plenary address of October 19, Dr Robert H. Lustig delivered a powerful, scientifically rigorous indictment of the central role of fructose in the current epidemic of childhood obesity. The fact that the epidemic now extends to 6-month-old infants makes clear, he said, that diet and exercise cannot be the sole culprits. Only a food exposure of some sort can explain obesity in a baby.Dr Lustig, who is a professor of pediatric endocrinology and director of the Weight Assessment for Teen and Child Health (WATCH) Program at the University of California, San Francisco, presented powerful evidence that the food exposure in question is fructose. Because of the markedly increased use of fructose – especially high-fructose corn syrup – in prepared foods and beverages, Americans’ consumption of fructose has risen astronomically in recent decades. This trend was accentuated by the demonization of dietary fat and the craze for low-fat diets. As food manufacturers took out fats, they replaced them with sugars – a large proportion of which were in the form of high-fructose corn syrup.

Fructose metabolized like fat – just as alcohol is.

 Dr Lustig did a masterful job of explaining the many ways in which fructose metabolism differs from human metabolism of glucose. When glucose is metabolized, it promotes a nice negative feedback pathway involving the liver, pancreas, and brain. The end result is that, through the suppression of ghrelin, the appetite for more glucose is suppressed and glucose consumption is kept in check. Insulin performs efficiently, and energy is stored in a usable form.Fructose metabolism takes a very different form. In fact, it is metabolized by the liver in many ways just like a fat – and 30% of fructose actually ends up as fat. By-products of fructose metabolism include uric acid (which causes hypertension), very low-density lipoprotein (VLDL) cholesterol and triglycerides (which contribute to dyslipidemia), and free fatty acids (which lead to insulin resistance). These are all components of the metabolic syndrome. In addition, fructose leads to leptin resistance, thereby setting up a positive feedback pathway in which continuous consumption is promoted. (Dr. Lustig pointed out that these problems are all minimized when fructose is consumed in the form of whole fruit, since whole fruit always contains significant amounts of fiber , and fiber works to counteract the effects of fructose in a variety of ways. “When G-d made the poison, he packaged it with the antidote,” he said.Dr Lustig noted that fructose metabolism also is strikingly similar to the way in which ethanol is metabolized. He made the graphic point that a 150-calorie can of soda and a 150-calorie beer both lead to 90 calories reaching the liver, and that both result in the toxic by-products of VLDL cholesterol and excess free fatty acids. Excess alcohol consumption and excess fructose consumption also result in many of the same health problems. Both cause hypertension, dyslipidemia, insulin resistance, and fatty liver disease.

 The American Heart Association (AHA) in recent recommendations has noted the role of added sugars in increasing the risk of heart disease. Dr Lustig called on the American Academy of Pediatrics (AAP) to follow the AHA’s lead and to update its recommendations regarding fructose consumption by children. Current AAP guidelines allow for 2 of the 4 recommended daily fruits to be consumed in the form of juice. That, he said, is unacceptable. He also noted that many currently available infant formulas have such high sugar contents that they are basically “baby milkshakes.”“We as pediatricians are on the front lines; we can fix this,” he declared. The audience rose to its feet and applauded.

In his plenary address of October 19, Dr Robert H. Lustig delivered a powerful, scientifically rigorous indictment of the central role of fructose in the current epidemic of childhood obesity.

Fructose-Obesity Connection Exposed: Can of Soda Metabolized Much Like Can of Beer, Says Lustig

Attorney General Eric Holder made a surprise appearance at Monday morning’s (Oct. 19) plenary session to talk to attendees at this year’s AAP Convention about the problem of children’s exposure to violence – and what pediatricians can do about it. His impassioned speech was met with a standing ovation from the packed DC Convention Center ballroom.


The issue has been both a personal and professional concern of the Attorney General for some time. A further motivation for the address was the release just two weeks ago of the results of a Department of Justice survey on the results of exposure to violence on children. The survey showed that the problem is indeed of epidemic proportions. More than 60% of children have been exposed to violence in the past year. Of these, half have been assaulted, 1 in 10 has been maltreated, 1 in 16 has been sexually abused, and 2 in 5 have been exposed to more than 1 type of violence.


The effects of exposure to violence – whether as a victim or as an observer – are far-ranging and profound, including physical, psychological, and emotional harm. Children exposed to violence are more likely to abuse drugs and alcohol, are more likely to be failing in school, have a higher incidence of depression and other post-traumatic stress symptoms, and have trouble forming emotional attachments. In addition, the toxic stress caused by exposure to violence actually leads to changes in children’s brains.


Attorney General Holder had especially strong words concerning the problem of domestic violence. “The abuse of women is a pediatric issue,” he asserted. He noted that the research shows a strong link between exposure to violence in childhood and involvement in domestic violence once a child is grown.


Despite the alarming statistics, Holder held out hope that the damage caused by exposure to violence can be reversed. He noted, however, that to achieve results, a public health approach is needed – because children’s exposure to violence is a public health problem. One of the key elements of such an approach, he asserted, is training for professionals within all relevant disciplines in recognizing the signs of exposure to violence and in addressing these effectively.


He noted that pediatricians play a key role. He praised pediatricians for all they do already to identify children who have been physically harmed. However, he called on them to go one step further – and learn also to recognize the signs that a child has been exposed to violence and traumatized by it. He recommended a Department of Justice publication for pediatricians that can assist them in identifying children exposed to violence; the DOJ also publishes cards that pediatricians can give to parents. Both of these are available at 


The Attorney General concluded: “we can transform America for the better – one child at a time.”

's "Child Abuse -- Or Mimic?" cases, all illustrated with high-quality, full-color clinical images, are an excellent way to further hone your skills in recognizing the signs of abuse in children.  Here is a sampling of cases from this series:

"Unusual Lesions -- Abuse or Accidental Injury?"

Sadly, pediatricians may also see teenaged girls who are already the victims of intimate partner violence (IPV). For tips on the types of injuries most commonly associated with IPV, see 

"Woman With Multiple Head and Neck Injuries

In Surprise Plenary Talk, Attorney General Holder Addresses Problem of Children Exposed to Violence

As our legislators craft their bills, the media is feeding us a relentless diet of health care debate coverage. TV, newspapers and journals, and the blogosphere report and opine tirelessly on questions of whether there will be a public option, how much health care reform will cost, how it will be financed, and others.


One question, however, is seldom addressed. Dr Steve Berman, professor of pediatrics at the University of Colorado School of Medicine, in his October 18th plenary address, “Health Care in the New Millenium: Improved Health Care for Children?” pointed out that the media aren’t asking “what about kids?” They aren’t examining the important question of whether children will be better or worse off with health care reform.


Dr Berman attempted to make up for this deficiency in the coverage of the debate by examining the probable and possible effects of proposals currently being considered by the House and Senate on 4 key cogs in the machinery of the reform:
 

•Access to care.
•Quality of care.
•Control of costs.
•Affordability.
 

Dr Berman noted that children stood to benefit from a number of components of bills currently under consideration. These include Medicaid expansion, CHIP continuation (tied to the Rockefeller amendment), the streamlining of enrollment processes, some aspects of Medicaid payment reform, and proposals that would incentivize the medical home.
 

However, there are other proposals on the table that could potentially have a negative impact on children. For example, the future of CHIP is uncertain. Also, there are concerns that some families would elect to pay the penalty and forgo coverage, that bills in their current state do not adequately address the needs of children of immigrants, and that plans may not have an appropriate pediatric benefit design. With regard to cost control, Dr Berman voiced concern that if legislators succeeded in tying Medicaid rates to those of Medicare (one proposal for controlling health care expenditures), the result would be a pyrrhic victory. Pediatricians, he pointed out, need a guarantee of adequate payment.
 

Dr Berman stressed the need for people to pay appropriate attention to these immportant and too-little-discussed issues. “No child should be worse off because of health care reform,” he concluded.
 

As our legislators craft their bills, the media is feeding us a relentless diet of health care debate coverage. TV, newspapers and journals, and the blogosphere report and opine tirelessly on questions of whether there will be a public option, how much health care reform will cost, how it wilil be financed, and others.

Susan Beck

Articles

“Replacing Pills With Skills” Workshop Teaches Self-Care Techniques for Kids

Fructose-Obesity Connection Exposed: Can of Soda Metabolized Much Like Can of Beer, Says Lustig

In Surprise Plenary Talk, Attorney General Holder Addresses Problem of Children Exposed to Violence

Health Care Reform: What’s in It for Kids?