Today’s high-tech neonatal intensive care units (NICUs) buzz with staff doing what they can to ensure the smallest and sickest of newborns survive. Yet amid the machines, equipment, and attentive nurses and doctors, there might be ordinary people, called cuddlers, softly singing to, talking to, cuddling, and gently rocking the preemies and convalescing newborns with neonatal abstinence syndrome (NAS), known as opioid withdrawal.

As it turns out, low-tech cuddling, or hugging, also plays a role in helping these babies to survive and, even, thrive, according to 

, chief of Newborn Medicine and professor of Pediatrics, Biochemistry and Molecular Biology at Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York.

“This whole concept of human contact is something that we often don’t pay attention to in the environment of a hospital and intensive care unit. Often, we become focused on lab values and blood gases because that’s keeping patients alive,” La Gamma says. “Sometimes, the aspect of humanness . . . is lost in the shuffle of intensive care.”

The need for touch is especially important for babies born prematurely or addicted to drugs like opioids. Take the babies who are born at weights below 1000 grams and earlier than 28 weeks’ gestation, for example. In the best case scenarios, those babies will be hospitalized for 2 to 3 months in order to grow from their extremely small size, La Gamma says.

These babies are exposed to many sounds, lights, and external stimuli not normally experienced in utero during normal brain development and often have problems with organization of motor function, La Gamma says.

“Normally, they would be in the uterus, rolled up like a ball, nice and quiet and in the dark,” he says. “But no matter how you provide services in intensive care, there is going to be light and much more disruption. The hugging is calming and tends to focus their attention, decrease motor activity, and embrace the sound to a human voice.”

Nurses on these units are often busy with lifesaving measures and care, and parents can’t always be there to provide that nurturing touch. So, to address the softer side of care for patients in NICUs, pediatric inpatient units and sometimes birthing pavilions and hospitals nationwide are offering cuddling programs, in which volunteer trained cuddlers maintain cuddling when parents and staff can’t.

“Volunteer cuddler programs have the potential to enhance the human caring aspects of complex technological nursing care provided premature infants,” according to a paper published in 1990.

“Although the fragile premature infant may not always appear to respond overtly, the weight gain, and social and mental development of the cuddled babies give testimony to the effectiveness of human attention. The infants' improved well-being and subsequent earlier hospital discharge as a result of cuddling are convincing rationale to implement a cuddler program,” the study authors write.

In 2015, Kimberly-Clark Corporation (Dallas, Texas), manufacturer of the Huggies diaper brand, worked with the Canadian Association of Pediatric Health Centers to summarize the evidence of the powerful and positive impact a caregiver’s touch can have on babies’ comfort and development of brains and bodies, according to 

, Baby and Child Healthcare general manager in North America. The resulting Huggies-funded white paper “

” cites research suggesting human touch offers many benefits for babies-from improved physiologic stability and regulation to enhanced immune system development and improved parent-baby bonding.

“[I]t became clear that too few babies, especially those in neonatal intensive care units (NICUs), receive the optimal amount of beneficial touch from parents or caregivers. Volunteer hugger programs can help fill this important need. And so, the No Baby Unhugged grant program launched in Canada in 2015 and was brought to the United States in 2016,” Melzl says.

No Baby Unhugged provides $10,000 grants to US hospital NICUs for hugging, or cuddling, programs. So far, 19 hospitals (15 in the United States and 4 in Canada) have received the money to launch new volunteer hugging programs or enhancing those they have.

“Huggies will continue to award grants in 2018, and hospitals interested in applying can visit HuggiesHealthcare.com to complete an application,” Melzl says.

The need for hugging programs could be on the rise, as the number of US babies who could benefit from such programs grows. During the past 25 years, preterm births in the United States have increased more than 35%, according to a study published in 2010.

Thanks to advances in care, infants can survive at 22 weeks’ gestation, but the result is spiraling healthcare costs. This makes it imperative, the same authors suggest, for hospitals to focus on making clinical improvements that not only result in healthier babies but also help to manage costs.

“Volunteer hugger programs can facilitate improved overall development of baby, improved parent-baby connection, and shorter stays in the NICU-in addition to freeing up time for nurses to continue their vital duties,” according to Melzl.

No Baby Unhugged grant recipient Maria Fareri Children’s Hospital used the $10,000 to enhance its existing cuddler program, according to Boriana Parvez, MD, IBCLC, FAAP, a neonatologist and director of the hospital’s donor milk program.

“We used [the grant] to develop a detailed education program, dedicated to the cuddlers. It’s specifically to educate them about the needs of these patients--how to pick up when the patient is becoming unstable, so they’re obviously no longer suitable to be held; how to respond to the baby’s general cues,” Parvez says. “We also used the funds to purchase new reclining chairs. Obviously, these chairs are used by the cuddlers during the day, but they’re also utilized by the parents when they come to visit their babies. We also find that these chairs are comfortable for promotion of breastfeeding.”

Although Maria Fareri Children’s Hospital, which received the Huggies’ grant in August 2017, hasn’t conducted studies looking at program outcomes, Parvez says that, anecdotally, nurses have told her they can better concentrate on the medical needs of the patients when huggers are there.

“At the same time, they feel the other needs of the babies are met. The babies are receiving the warmth and human touch that they need while their parents are not at the bedside,” Parvez says.

Parvez says the need for cuddlers is heightened for what she says are growing numbers of babies born to opioid-using mothers. In many cases, these mothers are incarcerated or they might live too far away to visit daily. Sometimes, families have to go back to work and can’t be at the bedside day and night. In other cases, family members simply need a break to take a nap or to go home, and cuddlers can relieve them.

Children’s Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire, also received the Huggies’ grant in August 2017 and used the grant to expand an existing cuddler program, according to Deirdre Sheets, RN-C, MSN, quality practice patient safety nursing specialist and cuddler program coordinator at Children’s Hospital at Dartmouth-Hitchcock.

“Our infant cuddler program had initially begun in the summer of 2013 on the inpatient pediatric unit to help support our moms and babies who were going through withdrawal. About 9 months after we started there, the intensive care nursery approached me about expanding the cuddler program, with a particular focus on the babies who were going to be there for a longer-term hospitalization, which could be anywhere from a few weeks to a few months,” Sheets says.

The grant money helped the hospital to buy special chairs, which are comfortable, and rock, recline, and slide, for the intensive care nursery. Having the right chair is important, Sheets says. Cuddlers are encouraged to read and sing to the babies, while rocking or gently moving in the chair. The soothing motion, she says, helps to calm the babies.

The grant to Children’s Hospital at Dartmouth-Hitchcock was also used to buy compact disc players and soothing music, including lullabies and soft piano, as well as snuggle wraps, which are fairly tight wraps that help to soothe babies who are going through withdrawal, according to Sheets.

“Music has also been demonstrated to help lower respiratory rates and pulses when a baby is upset,” Sheets says.

A recent study found that premature infants in a NICU who were exposed to music had lower respiratory rates, while heart rates increased in the no-music control group.

Sheets says that although the hospital has not conducted studies on whether the program helps, the fact that staff and families are requesting additional cuddlers on weekends and evenings suggests the program is a win for clinicians and patients’ families.

Words of wisdom for a good cuddler program

Training, beyond regular volunteer training at a hospital, is important for cuddlers, according to Sheets. “Our cuddlers go through regular volunteer training, but then they spend between 6 to 8 additional hours training specifically to be able to cuddle the babies,” she says.

It’s also important to have buy-in from the hospital’s volunteer services department on the cuddler program, according to Sheets.

“Volunteer services definitely has a part to play in this and does a lot of the background checks. They do the initial orientation piece, as far as patient confidentiality, hand hygiene--some of those hospital-wide things that volunteers need to know,” Sheets says.

Nurses at the Children’s Hospital then teach volunteers about what they’ll need to do on the unit with the tiny babies. Volunteers learn how to change diapers, do appropriate bottle feedings, and more.

Finally, not every well-meaning person is cut out to be a cuddler, according to Sheets. “These are very special babies. They have a lot of needs. The cuddlers are not going to be holding a baby that’s going to sleep the whole time. That’s an important piece for people out in the community to understand,” she says. “So, the screening of the cuddlers, here, is initially done by volunteer services, but all cuddlers have to interview with somebody from one of the nursing units that’s involved. Then, we can really help them to understand what it is that they’re going to be doing when they’re here.”

The importance of human touch isn’t a new concept to physicians, according to La Gamma. “The hand on the shoulder-it’s taught in medical schools,” he says. “But if we think about it, we can all relate to those feelings of personal touch--the hug you get from a loved one. There’s something about that human contact that is very necessary to anchor us in our humanity.”

1. Loewy J, Stewart K, Dassler AM, Telsey A, Homel P. The effects of music therapy on vital signs, feeding, and sleep in premature infants. 

2. Zentner M, Eerola T. Rhythmic engagement with music in infancy. 

3. Fritsch-deBruyn R, Capalbo M, Rea A, Siano B. Cuddler Program provides soothing answers. 

4. Benoit B, Boerner K, Campbell-Yeo M, Chambers C. The power of human touch for babies. Canadian Association of Paediatric Health Centres. Available at: 

https://www.huggieshealthcare.com/en-us/power-of-hugs/human-touch-for-babies

5. Kornhauser M, Schneiderman R. How plans can improve outcomes and cut costs for preterm infant care. 

6. Caparros-Gonzalez RA, de la Torre-Luque A, Diaz-Piedra C, Vico FJ, Buela-Casal G. Listening to relaxing music improves physiological responses in premature infants: a randomized controlled trial. 

7. Dore S, Esser, M, Fitzgerald F, et al; Huggies Nursing Advisory Council. Every change matters: a guide to developmental diapering care. Available at:

 https://www.huggieshealthcare.com/en-us/clinical-resources/every-change-matters/quick-guide-to-developmental-diapering-care

. Published October 6, 2016. Accessed April 5, 2018.

8. Esser M. Diaper dermatitis: What do we do next? 

Articles

Trained volunteer cuddlers provide the magic of human touch to help preemies and convalescing newborns thrive.

Hugging is healing for NICU babies

As the number of young persons developing type 2 increases, so has the awareness of clinicians on the importance of identifying children at risk to help prevent the deleterious effects of diabetes once established. Studies in adults with type 2 diabetes have identified specific risk factors for disease development, and a great deal of focus has been on identifying prediabetes in an attempt to improve prevention.

For both children and adults, obesity remains one of the key risk factors for developing type 2 diabetes. Children who are overweight or obese, therefore, are seen as potentially at risk of developing diabetes.

To date, little data are available on how to assess children at risk of developing type 2 diabetes. Assessment, therefore, has relied on data derived from adult studies and extrapolated to children. As such, the evidence base on which assessing risk of diabetes in children is limited at best and should be looked at with some caution.

This was an underlying message in a talk presented at the 2017 American Academy of Pediatrics (AAP) National Conference by 

, professor of Pediatrics and Clinical Science and section head, Endocrinology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado, titled “Not yet diabetes: Assessing and managing children at risk.”

 In his presentation, Zeitler emphasized that although type 2 diabetes is on the rise in adolescents, it is still rare and not the main complication that clinicians should be focusing on when they see a child who is obese.

“Glucose is not the most common problem in obese kids; in fact, it is pretty darn rare,” Zeitler said, emphasizing that other disorders associated with obesity such as elevated triglycerides, fatty liver, and high blood pressure are much more common. “People should be thinking about these other more common conditions and not get too lost looking for prediabetes,” he said.

In his talk, Zeitler spoke about ways to assess and manage prediabetes in children while underscoring this main message that diabetes is not the most important potential disease risk for obese children and of the need to address obesity in all children regardless of their potential diabetes risk. To help clinicians get a better footing as to the real problem of prediabetes in children, he opened his talk by defining what prediabetes is and the limits of its utility in children.

Zeitler began with a brief overview of the pathophysiology of prediabetes, citing a number of studies in children that looked at impairments in glucose homeostasis in overweight children.

Overall, he underscored the difficulty of establishing prediabetes in children based on measures such as fasting plasma glucose (FPG) and the oral glucose tolerance test (OGTT) to assess risk factors predictive of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)-the intermediate phase between normal glucose tolerance and type 2 diabetes identified as prediabetes in adults. For example, some data suggest that impairments in insulin resistance and declining Î²-cell function may indicate children at heightened risk of developing type 2 diabetes, but these data are based on glucose testing measured against the specific cutoff threshold of less than 140 mg/dL established as defining prediabetes in adults.

This cutoff point, he cautioned, is defined in adults only and does not necessarily translate to children.

Compounding the difficulty of identifying prediabetes is the evolving criteria for diabetes itself. Zeitler reminded the audience that diabetes is defined by an increased risk for microvascular complications. Initially, he said, diabetes was based on a correlation of fasting glucose with increased incidence of retinopathy. In 1979, this correlation was based on a random or OGTT of greater than 200 mg/dL or FPG test of greater than 140 mg/dL, and in 1997 this changed to a FPG of greater than 126 mg/dL and the same OGTT. In 2009, the hemoglobin A1c test became standardized with a cutoff point of greater than 6.5 indicative of diabetes.

“Prediabetes is even more squishy than diabetes,” said Zeitler. “Diabetes is based on future cardiovascular risk, but prediabetes is based on the future risk of diabetes.”

Emphasizing that all the measures currently used to define diabetes are based solely on data derived from studies on adults, Zeitler underscored the need to recognize that prediabetes risk may not be the same for children. “The future risk of diabetes is not the same if you use the same criteria in children,” he said, highlighting as well that a “high-normal” glucose and A1c may be normal in puberty.

For example, he said that although the data suggest that adults with an A1c between 5.7% and 6.5% have increased risk for development of future diabetes, he highlighted data showing that an A1c of less than 6% in children actually indicates a nearly 0% chance of progressing to diabetes in a reasonable amount of time.

This is important because many children with elevated A1c or glucose levels are likely to spontaneously regress without any intervention because of changes in insulin resistance in puberty. (This is described more fully in the section “Management of prediabetes" below.)

All said, Zeitler questioned whether prediabetes is a useful concept when applied to children because of the high regression rate in children without any intervention. More useful, he suggested and emphasized, is recognition of the other more common metabolic complications associated with obesity in children, including high blood pressure, elevated triglycerides, and fatty liver.

Despite his reservation on the utility of using a diagnosis of prediabetes in children, Zeitler spent time addressing a main question that many clinicians have when considering how to assess the diabetes risk in children. That is: What is the best measure to use for this assessment? Table 1 lists the current measures used.

Saying there is a lot of noise in the literature about which test is better, Zeitler said that none of these current tests can be considered standard in children as they were developed to diagnose prediabetes in adults. “All the approaches we use for screening children for prediabetes are flawed in that they were extrapolated from adults,” he said.

With that understanding, he nonetheless noted that both a glucose tolerance test and A1c test can be used, as some people advocate, but he cautioned that such an approach is expensive “for what turns out to be a pretty rare disorder.”

Instead, Zeitler recommended using the A1c test, citing it as an imperfect but efficient test for evaluating high-risk kids. Table 2 lists several practical benefits of the A1c test over glucose tolerance testing. However, he also cautioned that, similar to measurement of glucose tolerance, the use of A1c is limited in that it will identify prediabetes in some kids but not others. “Both glucose tolerance testing and the A1c will identify overlapping but not identical populations,” he said, emphasizing the heterogeneity of children at risk of developing diabetes. Other disadvantages of the A1c test for which clinicians should be aware are listed in Table 2.

As to the value of measuring insulin, Zeitler recommended against it, saying it is a waste of time outside the research setting as it doesn’t provide any additional information about insulin resistance that is not already found on other labs. In addition, he cited problems with the test itself because it is not standardized and may measure insulin metabolites of uncertain significance, making it unreliable as a measure of insulin resistance. Also, he emphasized that the results of the test can be misleading as often insulin levels fall right before the onset of diabetes.

“I think there is a misunderstanding among pediatricians that they should be measuring insulin levels,” he said, “but it doesn’t tell you anything you need to know.”

As to how to manage children at risk of developing diabetes, Zeitler emphasized one thing only: lose weight. “There is no magic to treating this,” he said. “It is weight loss.” The basic recipe to do this is to reduce caloric intake and increase caloric expenditure. Zeitler cited recommendations by an expert committee of the American Academy of Pediatrics (AAP) on the prevention, assessment, and treatment of overweight or obese children (Table 4).

Regarding the use of metformin, Zeitler emphatically discouraged its use, saying that there is no clear evidence for pharmacologic treatment of prediabetes in children. “A lot of people think they are supposed to [prescribe metformin], but there is no evidence supporting its use in kids,” he said.

Although some small studies suggest a minor benefit of metformin either alone or in conjunction with lifestyle interventions in select children, Zeitler underscored that the true benefit of metformin or any pharmacologic treatment of prediabetes in children needs to be weighed against the fact that most kids with high glucose or A1c levels will have spontaneous regression back to normal levels without any intervention.

“Progression rates of prediabetes are much different in children than in adults,” he said. “About 60% of kids with prediabetes will reverse on their own, so why would you start them on a drug?”

Unfortunately, Zeitler said, conducting a study to test the true benefit of metformin in children is almost impossible given this high incidence of spontaneous regression that would require a very large sample population.

To help pediatricians approach assessment and management of a child they suspect may have prediabetes, Zeitler offered a simple guide (Table 5). He underscored the need to avoid being too “glucose centric” and to recognize that prediabetes is frequently a transient disorder in children that may not require intervention. In addition, he stressed the importance of recognizing and evaluating the more common abnormalities associated with obesity, such as hypertension, hepatic steatosis, sleep disturbances, mood disorders, and other complications. Finally, he stressed the need to address obesity in all children through lifestyle intervention.

Not yet diabetes: Assessing and managing children at risk

 (F4019). Presented at: American Academy of Pediatrics National Conference and Exhibition; September 19, 2017; Chicago, IL.

Children who are overweight or obese are potentially at risk for developing diabetes, but there’s more to identifying prediabetes than just obesity.

Prediabetes: How to identify children at risk

1. If a child has had severe respiratory syncytial virus (RSV), or a febrile seizure, the parents will be very worried the next time their child is ill. Acknowledge this fear, let them know what to watch for, and assure them that after a few benign illnesses, and seeing that their child does well, they will be less anxious in the future.

2. For night terrors, scheduled awakenings can be of benefit. After determining when the terrors are likely to occur, the parent can awaken the child shortly before the expected time, for several nights in a row. This apparently interrupts the cycle and can relieve the problem.

3. Showing parents reliable images online of what you are diagnosing (eg, urate crystals in the diaper) or not diagnosing (the actual rash of erythema chronicum migrans when the family is worried about Lyme disease) is very helpful.

4. Infants and young children are much smarter than we are in some ways. Thus, an adult who has hurt his neck might try to convince his doctor that he is not really hurt, but not so for youngsters. If a child is moving his or her neck freely after an injury, he or she has not suffered a serious spinal injury, and will not need x-rays.

5. The Oralflo cup (Oralflo Technologies; Raritan, New Jersey), or others, can be useful for helping children to swallow pills.

6. TGuard, formerly ThumbGuard, devices (MED et al, Incorporated; Matthews, North Carolina) can be useful for thumb-sucking. Bitter tasting products that are applied to the thumb seem less likely to work, unless the child is motivated to stop. That is, they appear to operate more as a reminder to take the thumb out, rather than as an actual deterrent.

7. I post tidbits about children where they can be easily seen whenever I open the chart. Examples of items that might go here include how to pronounce names, the child’s accomplishments/interests, if the family brought me homegrown tomatoes, and if a parent has a serious medical condition. Most electronic health records have an easy way to do this.

8. Update your equipment when needed. Stethoscopes develop cracks that can interfere with listening. The MacroView otoscope (Welch Allyn; Skaneateles Falls, New York) is vastly superior to the ones of the previous generation.

1. Frank NC, Spirito A, Stark L, Owens-Stively J. The use of scheduled awakenings to eliminate childhood sleepwalking. 

Jon Matthew Farber, MD, shares more observations on office practice and some useful websites for patient information.

Plain talk about office practices

A 9-year-old boy presents for evaluation of white spots on his hands, elbows, knees, and legs. There is also a ring around a mole on his back. The patient’s parents first noted areas of depigmentation on his trunk and extremities, and his lesions have spread particularly in areas of trauma. The lesions were most noticeable in the summer when tanning increased the contrast between the involved and uninvolved areas of his body. 

Vitiligo is an acquired pigmentary disorder characterized by depigmented macules and patches that result from the absence of epidermal melanocytes secondary to destruction by autoimmune processes.

 Approximately 0.5% to 2% of the general population is affected, with onset from early childhood to adulthood.

Vitiligo can affect any part of the body, but usually favors areas that are more darkly pigmented and often traumatized by normal activities including the face, dorsum of hands, elbows, and knees. The development of new lesions in areas of trauma is referred to as a Koebner or isomorphic phenomenon, which is commonly noted in vitiligo.

Segmental and nonsegmental vitiligo are the 2 major forms.

 Segmental vitiligo usually does not cross the midline whereas nonsegmental lesions are usually symmetric and more widely disseminated. Nonsegmental vitiligo is the most common type seen in the pediatric population. Children with a family history of vitiligo have been shown to have an onset as early as age 7 years.

Halo nevus is a benign melanocytic nevus surrounded by a ring of well-demarcated hypopigmentation or depigmentation.

 It is commonly associated with vitiligo and probably represents a similar autoimmune process.

 Both vitiligo and halo nevus show mononuclear cell infiltrates around the melanocytes with the majority of them being CD8+ T cells.

In the presence of complete depigmentation, the differential diagnosis includes chemical or drug-induced (eg, imatinib) leukoderma, postinflammatory depigmentation, melanoma-associated leukoderma, and pityriasis versicolor.

Isolated halo nevi can be monitored clinically and usually do not require treatment. Vitiligo poses a major quality-of-life issue particularly for older children and adults. The objectives of treatment include stabilizing pigment loss and triggering factors that need to be considered before choosing a treatment modality, including extent of depigmentation, location, age, skin type, and willingness to adhere to the treatment plan.

After a treatment plan has been started, it takes a minimum of 2 to 3 months to assess the effectiveness of the therapy. Treatment options include topical corticosteroids, topical calcineurin inhibitors such as tacrolimus, narrowband ultraviolet (UV) B, and psoralen plus UVA. Supplementing children with oral vitamin D while receiving topical therapy such as tacrolimus has been shown to be more effective in achieving repigmentation.

A number of new topical and systemic agents including Janus kinase (JAK) inhibitors are also being considered. The JAK inhibitors have been shown to stabilize the autoimmune process driving the depigmentation, but addition of low-level light is required to achieve repigmentation.

The patient began treatment with a medium-potency topical steroid applied to the patches on his arms and legs. He was also advised to control sun exposure during the summer.

1. Bolognia JL, Jorizzo JJ, Schaffer JV, et al. 

. 3rd ed. London: Elsevier; 2012:1023-1035.

2. Mohammed GF, Gomaa AH, Al-Dhubaibi MS. Highlights in pathogenesis of vitiligo. 

3. Laberge G, Mailloux CM, Gowan K, et al. Early disease onset and increased risk of other autoimmune diseases in familial generalized vitiligo. 

4. Kim YY, Kim MY, Kim TY. Development of halo nevus around nevus spilus as a central nevus, and the concurrent vitiligo. 

5. KaragÃ¼zel G, Sakarya NP, Bahadir S, Yaman S, Okten A. Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: a prospective study. 

A 9-year-old boy presents for evaluation of white spots on his hands, elbows, knees, and legs. There is also a ring around a mole on his back. The patient’s parents first noted areas of depigmentation on his trunk and extremities, and his lesions have spread particularly in areas of trauma. The lesions were most noticeable in the summer when tanning increased the contrast between the involved and uninvolved areas of his body.

Boy’s white patches signal pigmentary disorder

In 1975, I published my first childcare book 

, addressing the growing epidemic of childhood obesity. The obesity problem actually dates back to the 1950s, when there was a dramatic increase in the production of inexpensive, high-density, high-calorie foods. Sugar consumption rose by nearly 33%, due primarily to the use of high-fructose corn syrup.

The book was a huge success and received a great deal of publicity, but, sad to say, it failed to even make a dent into the prevalence of childhood obesity. In fact, there has been a significant increase in the prevalence of childhood obesity in the past few decades. A large-scale study recently published in the 

 showed that over 25% of children entering kindergarten were either overweight or obese, and 2 out of 3 of these children remained obese as teenagers and beyond.

 The American Academy of Pediatrics also has pointed out a sharp rise in severe obesity among 2- to 5-year-olds as 

 in the most recent 2-year cycle data from the National Health and Nutrition Examination Survey (NHANES), 2015-2016.

Obesity Prevention for Children: Before It’s Too Late: A Program for Toddlers and Preschoolers

, “What happened during the past 40-plus years?”

1. More and more meals are eaten in “fast-food” establishments.

3. Besides TV, we now have computers, cellphones, and tablets for children, all of which increase sedentary time-what I call the SOB syndrome (Sitting On Butt syndrome).

4. Physical education time in schools has become more limited.

5. More safety issues are associated with outdoor play, such as increased automobile traffic and fear of abduction.

All these factors have resulted in the significant increase in the prevalence of childhood obesity.

Serious consequences of childhood obesity

The consequences of childhood obesity are well known. In addition to reducing overall life span, other major problems include the development of type 2 diabetes; elevated cholesterol and lipid levels; hypertension; sleep apnea; and psychologic/social difficulties attributed to a lack of self-esteem and self-worth. Further, obese children are more likely to be bullied and socially isolated.

This epidemic of childhood obesity continues unchecked despite massive attempts to stop it or at least to slow it down. What has become increasingly clear to me is that the treatment of both school-age and adolescent obesity is almost always doomed to failure. The longer a child is obese, the less likely any treatment will be effective.

I speak as a pediatrician with more than 40 years of frustration in treating overweight and obese children of all ages. Despite my best efforts, I rarely have been successful in treating an obese teenager.

The basic problem appears to be that neither the pediatric community nor the parents of young children are taking early onset obesity seriously enough. I find it difficult to convince the parents of toddlers and preschoolers who already are overweight or obese that there even is a problem. What is more upsetting is that even in high-risk families, in which 1 or both parents are obese, this lack of urgency holds true.

I firmly believe that most pediatricians do not spend enough time or effort in teaching the parents of very young children how to take the proper measures to lower the risk of obesity. Of interest is the fact that in the recommendations in the Bright Futures program of the American Academy of Pediatrics, none of the well-child visits from the 2-to 4-year list includes diet or nutrition as a priority.

The bottom line is that, in my opinion, the only way to make any significant inroads into the prevalence of childhood obesity is to 

 In other words, prevention rather than treatment is the key to success.

Parental motivation plays a strong role in predicting the effectiveness of childhood obesity intervention. Family-based intervention has been found to be most effective. The earlier this intervention is started, the greater the chance of success. This has been my experience as well as the experience of most healthcare professionals dealing with overweight and obese kids.

Pediatricians are in a position to be the strongest advocates for children. We must do more to shield and protect the next generation of infants, toddlers, and preschool children from facing the physical and emotional consequences of obesity as they grow up. We must teach the parents of young children how to prevent obesity before it’s too late.

In conclusion, follow these "10 commandments for winning the obesity battle" from the last page of 

1. Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. 

2. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999-2016. 

. 2018;141(3):e20173459. Epub ahead of print.

Pediatricians must do more to protect the next generation of children from the consequences of obesity before it’s too late.

10 commandments of obesity prevention for children

Among a variety of generic titles, parents prefer being addressed as “Mom” or “Dad” rather than “Mommy/Daddy” or “Ma’am/Sir,” according to a survey of 137 parents of children being seen or admitted to a New York State children’s hospital. Of those surveyed, 34% were fathers, 66% were mothers, and 1% were other caregivers. The vast majority of parents had been addressed by a generic title in past medical encounters: 79.9% of fathers had been called Dad or Daddy and 90% of mothers had been called Mom or Mommy.

Parents found it acceptable to be called by their first names. In fact, more than half (54%) of mothers “liked” being called by their first names as did 46% of fathers. Being called “Mrs.” or “Mr.” followed by the last name also was acceptable; 45% of mothers “liked” this appellation along with 52% of fathers. Overall, however, most parents preferred the titles Mom and Dad over the formal title of Mr. and Mrs. or their first names (Wilks-Gallo L, et al. 

I would have guessed that parents disliked being called “Mommy” and “Daddy,” as the terms sound too familiar to me, especially at a first patient encounter-really for any encounter. It surprised me, though, to read that more parents liked being called “Mom” and “Dad” than being addressed by their own first or last names. The best approach may be to give parents a choice and then to note it somewhere in the child’s record.

Among a variety of generic titles, parents prefer being addressed as “Mom” or “Dad” rather than “Mommy/Daddy” or “Ma’am/Sir,” according to a survey of 137 parents of children being seen or admitted to a New York State children’s hospital.

“Doctor, please don’t call me Mommy!”

An analysis of about 1590 stock photographs of sleeping babies found that infants often are not portrayed in a way that is consistent with American Academy of Pediatrics’ guidelines on infant sleep safety. Investigators obtained the photographs-from the top 3 stock photo websites-by using a variety of search terms, including “safety phrases” (such as “safe infant sleep”) and “generic phrases” (such as “peaceful baby sleeping”). They then analyzed the photos for consistency with infant sleep safety in 7 areas: sleep position, sleep location, sharing of sleep surface, presence of bedding, presence of stuffed animals, head covering, and pacifier use.

Of 1233 sleeping infants who were not being held or in a sitting position, only about half (50.8%) were supine, while 23% were prone, and 26.1% were on their sides. In 66.2% of images, sleeping infants were not sharing a sleep surface. Almost three-quarters (71.3%) of the images included bedding that is not consistent with safe sleep recommendations; indeed, almost half (49.4%) showed blankets. The photographs of sleeping infants also portrayed infants with covered heads (15.3% of photographs), accompanied by stuffed animals (10.5%), and in cribs with bumpers (3.3%).

Only 79 photographs (5%) were images of sleeping infants with all the correct basic elements of safe sleep, including supine position, not sharing a sleep surface, and no unsafe bedding, head covering, or stuffed animals. Investigators found only 5 photographs (0.3%) of an infant sleeping correctly in a crib-and with a pacifier (Goodstein MH, et al. 

Have you ever looked at the photographs in your waiting room magazines? It may be a good idea. These authors point out that parents of your patients may hear your advice on safe sleep practices, but they are also being exposed to subtle, perhaps unintentional, contradictory information. Maybe we need to call this out by starting safe sleep discussions with: “Even though you may hear other advice or see pictures of babies sleeping other ways, here’s the safest way to have your baby sleep.”

An analysis of about 1590 stock photographs of sleeping babies found that infants often are not portrayed in a way that is consistent with American Academy of Pediatrics’ guidelines on infant sleep safety.

Stock photos miss the boat on safe sleep environments

Youngsters who use social media for an hour a day or longer are likely to sleep for fewer hours than their peers who don’t use social media-and as media use increases, so does this likelihood.

This was the finding of a Canadian survey of about 5400 middle and high school students aged 11 to 20 years. Asked how many hours of sleep they got on an average school night, students could choose responses ranging from 4 to 10 or more hours. Investigators also asked students how many hours a day they usually spent posting or browsing on social media websites, such as Facebook, Twitter, Instagram, and My Space. Response options ranged from less than 1 hour a day to 7 or more hours a day, use on a nondaily basis, or no use at all.

Overall, 36.4% of students met or exceeded the recommended sleep duration-9 to 11 hours per night at age 11 to 13 years, 8 to 10 hours at age 14 to 17 years, and 7 to 9 hours for those aged 18 years-while 63.6% slept fewer hours than recommended. Older students were less likely to be short sleepers than those who were younger and males were more likely than females to report short sleep duration. Sleep duration also was significantly associated with many covariates, including racial background, subjective socioeconomic status, substance use, physical activity, and self-rated mental health. About 73% of students reported using social media for at least 1 hour a day, with 16% reporting use of at least 6 hours a day. Females were more likely to use social media and to use it for longer than males.

Overall, using social media for at least 1 hour a day was associated with greater odds of short sleep duration in a dose response manner, even after adjusting for covariates. Odds ratios for inadequate sleep ranged from 1.82 for social media use of 1 hour a day to 2.98 for use of 5 hours or more a day (Sampasa-Kanyinga H, et al. 

No surprise, right? It seems to make sense that time spent on social media needs to come from somewhere and, for busy adolescents, time spent sleeping may be the easiest thing to give up. The authors point out that their study does not establish the direction of causality. It could be that some teenagers use more social media because they have trouble sleeping. On the other hand, social media use may cause sleep loss either by time displacement or perhaps by another mechanism such as blue light exposure from screens suppressing melatonin. Either way, for the 16.1% of surveyed teenagers who report 5 or more hours per day of social media use, a group that is 3 times more likely to lack adequate sleep than off-line peers, I feel pretty certain that this is not a good thing.

Social media and sleep duration-there is a connection!

Few things are as important in the development of human life as ensuring adequate nutrition during the first months and years after birth. The nutrition an infant receives, particularly up to the first year of life, will have lifelong effects on the growth and developmental abilities of the child as well as susceptibility to future medical illnesses.

Given this, parents and pediatricians alike are rightly focused on providing infants with the best nutrition possible. Without question, optimal feeding for most normal, healthy term infants comes from breast milk, and organizations such as the American Academy of Pediatrics (AAP) strongly recommend it for most, if not all, infants.

However, for some infants, breast milk may not be the best option because of specific conditions that either temporarily or categorically make the infant intolerant to the breast milk. In addition, there may be personal or medical reasons why a mother may choose not to breastfeed.

In these situations, how to choose the best formula among the many available can be daunting. In a presentation at the 2017 AAP National Conference titled “So many infant formulas: How is a pediatrician to choose?,” 

, professor and chief, Division of Neonatology, Medical College of Georgia, Augusta University, Augusta, Georgia, helped pediatricians wade through the many options available. He provided a brief primer on the types of infant formulas available, how to decide on which one to choose, as well as issues related to switching formulas and transitioning from formulas/breast milk to whole foods.

However, he opened his talk with a reminder that breastfeeding remains the best option for most infants. “Breastfeeding should be the norm,” he emphasized. “If breastfeeding cannot or should not be done, then we consider infant formula appropriate for the infant.”

The standard choice of formula for most infants who are not breastfed is a cow’s milk-based (bovine) formula with iron (Table 1). These formulas account for up to 80% of formulas sold.

 Bhatia emphasized that all currently available bovine-based formulas meet the energy and nutrient requirements for healthy term infants during the first 4 to 6 months of life. After age 6 months, these formulas are used to complement the increased variety of foods introduced to infants around this age.

Bhatia, in line with recommendations by the AAP, recommended one of these formulas for any infant who is not exclusively or only partially breastfed from birth to 1 year of life.

One issue that is still unknown with these formulas, according to Bhatia, is the true beneficial effect of the addition of prebiotics and probiotics that more recent cow’s milk-based formulas (as well as other formulas) have introduced as a way to prevent allergic conditions in infants. A meta-analysis that looked at whether formulas supplemented with prebiotics could prevent allergy found some evidence of a beneficial effect on the prevention of eczema. However, the study concluded that further investigation is needed to assess whether there is a benefit on other allergic diseases including asthma, as well as for which infants these formulas are best suited.

Regardless of whether breast milk or formula milk is used, Bhatia emphasized that milk should continue to be a major part of an infant’s diet through the transition to solid foods.

For the minority of infants who cannot tolerate cow’s milk, choice of other types of formulas is based on the particular condition the infant has that precludes him or her from receiving either breast milk or cow’s milk-based formulas (Table 2). Specific conditions that Bhatia highlighted in his presentation were allergies, metabolic diseases (ie, galactosemia and phenylketonuria), infectious diseases (eg, tuberculosis, hepatitis, and human immunodeficiency virus [HIV]), malabsorption, and intestinal failure.

“There are very few babies, a small percentage, that actually need all the other types of non–cow milk-based formulae,” said Bhatia.

One of the most common reasons for choosing a non–cow milk-based formula is for infants with an allergy to lactase or to prevent allergies. As shown in Table 2, soy protein-based formulas are recommended for infants with galactosemia (a condition in which they cannot tolerate lactose) or those with hereditary lactase deficiency. Soy protein-based formula also can be used in infants in families who are vegetarian. However, Bhatia emphasized that soy-based formula should not be given as a routine formula unless indicated for these relatively rare conditions.

To prevent allergies from developing, evidence points to the benefits of a hydrolyzed formula to reduce the incidence of atopic dermatitis (but not asthma or other allergies) (Table 2).

 Infants born into a family with a history of allergies, specifically atopic dermatitis, are good candidates for this type of formula.

Infants who cannot tolerate hydrolyzed protein formulas, and have an allergy to the protein in cow’s milk along with multiple food intolerance, are good candidates for amino acid-based formulas. However, Bhatia emphasized that these formulas are not intended to be used to prevent an allergy but only for the small percentage of infants (about 5%) who have an intolerance to hydrolyzed protein formulas and cow’s milk-based formula.

Other infants for whom amino acid-based formulas may be warranted are those who cannot absorb nutrients for some reason or do not have a sufficient gut to absorb nutrients, such as infants who have undergone surgery. However, Bhatia again emphasized that this is a relatively rare situation.

For infants with other conditions, such as infections or issues with malabsorption, for which a non–cow’s-milk formula may seem indicated, Bhatia discussed specific issues to keep in mind when considering a switch from a cow’s milk-based formula to a specialty formula. In some infants, only a temporary switch to a non–cow’s milk-based formula will be needed, while in others no switch at all is needed.

Infants presenting with specific symptoms, such as diarrhea and colic, are often switched formulas based on the assumption that the symptoms are caused by the formula. For most of these infants, said Bhatia, switching formulas is needed only temporarily to help a transient problem or is not needed at all.

For example, infants may present with diarrhea caused by a transient intolerance to sugar. For these infants, it is reasonable to switch to another formula with reduced lactose until the symptoms resolve and then switch them back to the original formula.

“Most babies can be managed like this,” said Bhatia. However, he emphasized that babies with other symptoms, such as blood in their stools, will need specialty formulas.

For infants with an infection, such as HIV or active tuberculosis, switching to a formula is also warranted until the infection clears. Once cleared, the infant can be switched back to breast milk.

Bhatia cautions, however, that symptoms of diarrhea and colic often are only temporary and not due to the formula used. “For most babies with transient diarrhea and colic, switching formulas is not needed,” he said, encouraging pediatricians and parents to “wait it out.”

He urges pediatricians and parents to do some “homework” to understand better why an infant may have diarrhea or colic. One major cause of these symptoms in infants, he said, is the introduction of new foods into the diet. This occurs often between the ages of 4 to 12 months when infants are transitioning to solid foods while still using breast milk or formula as complementary nutrition.

“Just by switching formulas, the pediatrician and parent may miss something easy that is going on that is responsible for the symptom like diarrhea or colic,” he said.

Figure 1 provides an algorithm developed by Bhatia to help guide pediatricians on the feeding of term infants and the transition to solid food.

Breast milk is recommended as providing the best nutrition for most term infants. For infants for whom breast milk is not tolerated or in situations where formula is preferred, a variety of formulas are commercially available based on specific need. Most infants are fed cow’s milk-based formulas, all of which meet the energy and nutrient requirements for healthy term infants during the first 4 to 6 months of life. For the relatively few infants who require specialty formulas, soy-based and hydrolyzed formulas are available, each indicated for specific situations only and not recommended as a routine feeding alternative for otherwise healthy term infants. Amino acid-based formulas are also available for specific indications.

For infants who experience transient intolerance to breast milk or cow’s milk-based formula, switching to a different formula until symptoms such as diarrhea or colic clear is a reasonable option. For many situations, switching is not needed as the symptoms may be due to something other than the formula (ie, introduction of new foods). Pediatricians and parents can take a wait-and-see approach to better understand what may underlie a symptom such as diarrhea or colic to ensure the underlying cause is accurately identified and not simply masked over by switching formulas.

. In: Berdanier CD, Dwyer J, Feldman EB (eds). 

. 2nd ed. Boca Raton, FL: CRC Press; 2007:271-284.

2. Bhatia J. So many infant formulas: How is a pediatrician to choose? (F4004) Presented at: American Academy of Pediatrics National Conference and Exhibition; September 19, 2017; Chicago, IL.

2. American Academy of Pediatrics. Choosing a formula. HealthyChildren.org. Available at: 

https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Choosing-a-Formula.aspx

. Updated November 21, 2015. Accessed April 11, 2018.

3. Osborn DA, Sinn JK. Prebiotics in infants for prevention of allergy. 

4. Alexander DD, Cabana MD. Partially hydrolyzed 100% whey protein infant formula and reduced risk of atopic dermatitis: a meta-analysis. 

Breast milk is best, but for those babies who won’t or don’t breastfeed there are formula alternatives. Here’s a primer on infant formulas and how to decide which option is appropriate for the individual child.

Vol 35 No 05