Surprisingly, more and more people are starting to drink raw, unpasteurized cow’s milk.
Or maybe that shouldn’t be too surprising as most people associate things that are raw or natural as being safer and healthier for them, often without understand the consequences.
Unfortunately, drinking raw milk can be dangerous, especially for young children.
There are plenty of risks and no real health benefits.
Drinking Raw Milk
Just as you would have thought, is basically “straight from the cow,” and hasn’t been processed or pasteurized.
Although most experts consider pasteurization to be one of the most important health advances of the last century, some people think that it removes nutrients and kills beneficial bacteria. They also claim that raw milk can taste better than pasteurized milk, which if you believe it, is really the only possible benefit of drinking raw milk.
It’s not even a good way to avoid growth hormones in milk, as most milk is now growth hormone free anyway and is labeled rBST-free.
Is raw milk healthier than pasteurized milk? There is no research to support that raw milk is healthier or, according to the FDA, that there is a “meaningful difference between the nutrient content of pasteurized and unpasteurized milk.”
In fact, the American Academy of Pediatrics states that “substantial data suggest that pasteurized milk confers equivalent health benefits compared with raw milk, without the additional risk of bacterial infections.”
Dangers of Drinking Raw Milk
According to the FDA, raw milk can be contaminated with bacteria, including:
Enterotoxigenic Staphylococcus aureus
These bacteria can cause people to get sick, leading to symptoms such as diarrhea, vomiting, fever, stomach cramps, and headaches. The Centers for Disease Control and Prevention reports that about 200 to 300 people get sick each year from drinking raw milk or eating cheese made from raw milk.
Another big danger of drinking raw milk that some people may overlook is that raw milk is very low in vitamin D. In addition to being pasteurized, processed milk that you routinely buy in a store is typically fortified with vitamin D, which is important to keep your bones strong.
Since young children are at big risk for getting sick from any bacteria that may be in raw milk and they need vitamin D, it is important that you not give your child raw, unpasteurized cow’s milk. In fact, the American Academy of Pediatrics states that “children should not consume unpasteurized milk or products made from unpasteurized milk, such as cheese and butter, from species including cows, sheep, and goats.”
We will have to add unpasteurized camel milk to the list, as that seems to be a thing now too.
Keep in mind that kids should also avoid unpasteurized fruit juices, including unpasteurized apple juice and apple cider.
Lastly, raw milk is about the same as whole milk in terms of fat content and calories. Experts recommend that children start drinking reduced fat milk, which has less fat and calories than whole milk, beginning at age two, you won’t be able to do that if your kids are drinking raw milk.
What To Know About Drinking Raw Milk
If you are still thinking of giving your child raw milk, keep in mind that “the AAP strongly supports the position of the FDA and other national and international associations in endorsing the consumption of only pasteurized milk and milk products for pregnant women, infants, and children.”
And remember that you are basically giving raw milk to your kids because you think it tastes better, as it certainly isn’t better for them, is missing key nutrients, and it could be contaminated with dangerous bacteria.
Does your child get strep throat so often that you are thinking about getting his tonsils out?
While it is not uncommon for kids to get strep throat a few times a year once they are in school, it is even more common to get viral sore throats.
Strep throat, which can be treated with antibiotics, is caused by the group A Streptococcus (GAS) bacteria. And while a fast or rapid test can help determine if your child has strep throat or a virus, false positive (the test is positive, but the strep bacteria isn’t really making your child sick) results can sometimes confuse the picture.
Understanding Strep Throat
Before you can begin to understand why your child might be getting strep throat over and over again, you first have to understand strep throat and the current guidelines for diagnosing and treating strep.
“Diagnostic studies for GAS pharyngitis are not indicated for children less than 3 years old because acute rheumatic fever is rare in children less than 3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group.”
Infectious Diseases Society of America Guidelines
Strep throat is most common in children and teens between the ages of 5 and 15 years. While it might be possible for younger and older folks to get strep, especially if someone else in the house is sick with strep throat, since they aren’t considered to be at risk for acute rheumatic fever, it isn’t typically necessary to diagnose or treat them. It may surprise you, but strep throat does go away on its own – the main reason it is treated is so you don’t later develop rheumatic fever.
“Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers).”
Infectious Diseases Society of America Guidelines
The classic symptoms of strep throat can include the sudden onset of a sore throat, fever, red and swollen tonsils (tonsillitis), possibly with white patches (exudate) and small, red spots (petechiae) on the roof of the child’s mouth, and tender, swollen lymph glands in their neck.
Kids with strep throat might also have nausea, vomiting, stomach pain, a headache, and a rash (scarlet fever).
Kids with strep throat will not usually have a cough, runny nose, hoarse voice, mouth ulcers, or pink eye with their sore throat. Those are symptoms that suggest a virus is causing the sore throat and they should not usually be tested for strep. This helps to avoid an unnecessary antibiotic prescription if your child tests positive, but really has a virus.
So basically, try to avoid over-testing for strep. But if your child does have strep throat symptoms and has a positive test, get an antibiotic that will clear the strep bacteria and finish all of your child’s prescription.
Avoiding Strep and Other Infections
Can you avoid getting strep?
As with other infections, the best way to avoid strep throat is to teach your kids to:
wash their hands properly
avoid close contact with people that are sick (for strep, that means until they have been on their antibiotic for at least 24 hours)
avoid drinking out of other people’s cups or glasses
consider taking a water bottle to school instead of drinking out of the water fountains
not touch their eyes or put objects (fingers, pencils, clothing, etc.) in their mouth, as that helps germs get in their body
cover their coughs and sneezes to avoid getting others sick
Most importantly, don’t wait until someone is sick in your home or lots of kids are getting sick at school to encourage your kids to avoid getting sick. By then, it will likely be too late.
Is Your Child a Strep Carrier?
If your child continues to get strep, especially if their strep test is always positive, it is likely time to consider that they may be a strep carrier.
“We recommend that clinicians caring for patients with recurrent episodes of pharyngitis associated with laboratory evidence of GAS pharyngitis consider that they may be experiencing >1 episode of bona fide streptococcal pharyngitis at close intervals, but they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.”
Infectious Diseases Society of America Guidelines
What does it mean to be a strep carrier?
It simply means that the strep bacteria are living or ‘hanging out’ in the back of your child’s throat. While that sounds bad, these strep bacteria aren’t causing any problems. They aren’t making your child sick, causing any symptoms, and don’t even make your child contagious.
“…the recovery of GAS does not establish causality. The tests do not distinguish carriage of GAS in a child with pharyngitis attributable to another cause from an acute infection caused by GAS.”
“Group A Streptococci Among School-Aged Children: Clinical Characteristics and the Carrier State” Pediatrics. 2004 Nov;114(5):1212-9.
The big problem with being a strep carrier is that whenever you have a strep test, these strep carrier bacteria will make the test positive, even if they aren’t what is causing your child’s symptoms.
This is often why people get diagnosed with strep and flu or strep and mono at the same time.
If you still don’t understand strep carriers, consider that if you go to almost any school and test every child, up to 20 to 25% of the kids will test positive for strep, even though they aren’t sick and have no symptoms. They are likely just strep carriers.
“We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever).”
Infectious Diseases Society of America Guidelines
What kind of efforts are they talking about? We sometimes hear about doctors ordering antibody tests, doing rapid strep tests and cultures on kids after they finish their antibiotics, testing everyone who lives in the house, or even testing the family dog.
None of this is usually necessary.
One thing that can be helpful is that if your pediatrician thinks that your child is a strep carrier, then instead of the more typical penicillin or amoxil antibiotics, they might treat your child with a stronger antibiotic, like clindamycin. This can help ‘knock out’ the carrier bacteria.
And then learn to be much more selective about getting strep tests, avoiding them if your child has more classic viral symptoms, like a cough and runny nose.
In addition to the idea of being a chronic carrier, there are other theories about why kids get recurrent strep throat infections, including:
antibiotic resistance – although this is thought to be rare or non-existent when it comes to the GAS bacteria and penicillin, amoxicillin, and cephalosporins. There is some resistance between azithromycin and strep, which is why it should only be prescribed if your child is allergic to the other antibiotics that are used to treat strep throat.
noncompliance – not finishing your antibiotic or not taking it as prescribed
influence of other bacteria – there are theories that other bacteria may be inactivating penicillin or amoxicillin (so you need a stronger antibiotic) or even that other beneficial bacteria help to kill the GAS bacteria, but may be gone if your child is frequently on antibiotics
you are starting antibiotics too quickly – some people think that if you don’t wait a few days and let the body start to fight the strep infection on its own, then it is more likely to come back
Or if your child had true strep throat symptoms, got well quickly after being on an antibiotic, but then got strep (with classic strep symptoms) again quickly, it is possible that it is just a new infection.
“We do not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis.”
Infectious Diseases Society of America Guidelines
If it is happening over and over again, consider the possibility that your child is a strep carrier and teach him or her how to avoid getting sick as much as possible.
Why not just get your child’s tonsils out? The problem is that many studies have shown that while this might help for a year or so, after that, these kids start getting strep just as much as they did before. So unless your child also has sleep apnea or has had complications of strep infections, like a peritonsillar abscess, you probably shouldn’t rush into a tonsillectomy.
What To Know About Recurrent Strep Throat Infections
Some other fast facts to know include that:
having tonsillitis does not automatically mean that your child has strep. Remember that viruses are an even more common cause of sore throats.
you can’t tell if someone has strep just by looking at their tonsils. Even having pus (white stuff) on their tonsils doesn’t automatically mean strep. Viruses can do that too. That’s why a rapid strep test, with a backup culture for negative tests, is important to make the diagnosis.
throwing out your child’s tooth brush every time they have strep isn’t necessary, after all, you don’t do that after they have other infections, do you? Instead, encourage your kids to routinely rinse their toothbrush after each use and replace it every 3 to 4 months.
Hopefully you have a better understanding of strep throat now.
Sore throat infections, including strep throat, are common, but remember to look for other answers besides just getting your child’s tonsils out if they get strep over and over.
Could it be the “stomach flu,” food poisoning, or just an intolerance to something your child eat?
Common Causes of Diarrhea
While parents often quickly jump to the idea of “food poisoning,” infections are typically the most common cause of diarrhea in kids.
viruses – rotavirus (a vaccine preventable disease), adenovirus, and norovirus
bacteria – C. diff, Salmonella, Shigella, E. coli, Campylobacter jejuni, Bacillus cereus, Listeria, Cholera
parasites – Cryptosporidium, Giardia, Cyclospora
Not all diarrhea is caused by infections though. If the diarrhea lingers for more than a few weeks or keeps coming and going, then you might consider that your child might have a lactose intolerance, irritable bowel syndrome, Celiac disease, or other non-infectious cause.
Hints of Diarrhea Causes and Risk Factors
To help figure out what might be causing your child’s diarrhea, consider these questions and share the answers with your pediatrician:
Does your child have bloody diarrhea (sometimes a sign of a bacterial infection)?
Is your child getting dehydrated? While that doesn’t tell you want is causing the diarrhea, it is a good sign that you need to seek medical attention.
Does your younger child (under age 2 to 4 years) have bloody diarrhea that is becoming jelly-like and episodes of severe, colicky abdominal pain (sign of intussusception)?
Is your child in daycare? Has anyone else recently been sick with diarrhea or vomiting?
Has your child recently been on antibiotics (a risk for C. diff)?
Does your toddler with diarrhea drink a lot of juice (Toddler’s diarrhea)?
Have you recently traveled out of the country (Traveler’s diarrhea)? Did your child get sick a few days later (could be a bacterial or viral cause) or a few weeks later (parasites have longer incubation periods)?
Has your child recently spent time on a lake or river and possibly drank untreated water (risk for Giardia infection)?
Do you have any high risk pets, including turtles, snakes, lizards (or other reptiles); frogs, salamanders, newts (or other amphibians); chicks, chickens, ducklings, ducks, geese, and turkeys (or other poultry); mice, rats, hamsters, and guinea pigs (or other rodents); or farm animals (all can be a risk for Salmonella)?
Have you recently visited a farm or petting zoo (risk for Salmonella and E. coli)?
Has your child recently visited a water park or public swimming pool (risk for Cryptosporidium)?
Does your child drink raw milk, unpasteurized juice, raw or undercooked eggs, or undercooked beef, pork, and poultry (risk for food poisoning)?
Has your child recently eaten leftover food that had been unrefrigerated for more than two hours (risk for food poisoning)?
Is the diarrhea worse after your child drinks a lot of milk or eats a lot of dairy (a sign of lactose intolerance)?
Does your child have alternating episodes of constipation and diarrhea (irritable bowel syndrome)?
In addition to chronic diarrhea, is your child irritable, with poor weight gain and other symptoms (a sign of Celiac disease)?
Does your child also have abdominal pain or just diarrhea?
Is your child taking any medications that might cause diarrhea as a side effect?
Once you have narrowed down the possibilities, blood and stool tests, including stool culture tests for bacteria, parasites, and viruses can sometimes help to figure out what is causing your child’s diarrhea. Keep in mind that these are usually reserved for diarrhea symptoms that are severe (bloody diarrhea, fever, weight loss, etc.) or lingering for more than a few weeks.
And remember that the most common causes of diarrhea, including food poisoning and viral infections, typically go away on their own without treatment. In fact, you can make things worse if you treat some causes of diarrhea with antibiotics, including some Salmonella, Shigella, E. coli infections.
Still don’t know what is causing your child’s diarrhea? In addition to your pediatrician, a pediatric gastroenterologist can be helpful when your child has diarrhea.
What To Know About Diarrhea
While diarrhea is common in kids and we often don’t figure out the specific cause before it goes away on its own, there are clues that can help you figure out if your child’s diarrhea is caused by a virus, bacteria, parasite, or other condition.
Parents often ask for help getting their kids to fall sleep and then stay asleep all night.
At least they do when they are little.
Teens often have trouble sleeping too though, but parents often don’t recognize these sleep problems and might not think to ask for help. They do likely see some of the issues that can be caused by a poor night’s sleep though, which can include irritability, sadness, a poor attention span, and hyperactivity, etc.
Why Teens Don’t Sleep Well
From being over-scheduled and having to get up early for school to staying up late on a screen, there are many reasons why your teen might not be sleeping well.
There are also many different types of sleep problems.
To understand what is causing your child’s sleep problems, ask yourself these questions and share the answers with your pediatrician:
Does your teen sleep at least 8 1/2 to 9 1/2 hours each night?
Does your teen have trouble falling asleep or does he just wake up a lot in the middle of the night? Or does your teen seem to sleep enough, but is still always tired?
Does your teen snore loudly at night – a sign of obstructive sleep apnea?
Is your teen taking any medications that could cause insomnia, such as for ADHD (stimulant) or allergies (decongestant)?
Is your teen drinking any caffeine in the afternoon or evening?
Do you think that your teen is depressed or has anxiety, either of which could cause problems sleeping?
Have you noticed any symptoms of restless leg syndrome, including a strong urge to move his legs when he is sitting or lying down?
Does your teen have too much homework and is staying up late trying to get it all done?
What does your teen do just before going to sleep?
Does your teen fall asleep easier when he goes to bed much later than his typical bedtime or does he still have trouble falling asleep?
Are your teen’s sleep problems new?
And perhaps most importantly, what is your teen’s daily sleep schedule like? What time does he go to sleep and wake up, including weekends, and does he typically take a nap?
Treatments for Teen Sleep Problems
In addition to treating any underlining medical issues that might be causing your teen to have trouble sleeping, it will likely help if your teen learns about sleep hygiene and:
goes to bed and wakes up at about the same time each day, instead of trying to catch up on “lost sleep” on the weekends
keeps his room bright in the morning (let in the sunshine) and dark at night
avoids taking naps, or at least naps that are longer than about 30 to 45 minutes
is physically active for at least one hour each day
doesn’t eat a lot just before going to bed
turns off all screens (phone, TV, computer, video games, etc.) about 30 minutes before going to sleep
doesn’t get in bed until he is actually ready to go to sleep, which means not watching TV, reading, or doing anything else on his bed
gets out of bed if he doesn’t fall asleep after 10 to 15 minutes and reads a few pages of a book, before trying to go to sleep again
Did that work?
If you teen is still having sleep problems, encourage them to try some basic relaxation techniques, such as progressive muscle relaxation, guided imagery, and deep breathing or abdominal breathing. You do them at bedtime and again if you wake up in the middle of the night.
I especially like the idea of guided imagery for teens, as they can focus on something they like to do, whether it is building a sandcastle on the beach, or going horseback riding, surfing, hiking, or playing baseball, etc. They should focus on the details of the story they make up, coming back to it if their mind wanders, and hopefully they fall asleep as they get caught up in it.
With the deep breathing technique, they slowly breath in through their nose and out through their mouth. They can hold their breath for a few seconds or breath into their abdomen too (abdominal breathing).
Progressive muscle relaxation is another technique that might help your child relax at bedtime. They simply tense and then relax each muscle group of their body, one at a time, starting with their toes and working their way up. If they make it up to their forehead and aren’t asleep, then they should work their way down, perhaps doing 3 to 5 repetitions for each muscle group, or try another technique.
And be sure to talk to your pediatrician if your teen continues to struggle with sleep problems.
What To Know About Teen Sleep Problems
Although teen sleep problems are common, they can cause serious daytime issues for your teenager, which makes it important to learn about good sleep hygiene and that help is available from your pediatrician.
Unfortunately, like most upper respiratory tract infections, the flu is not easy to treat.
What are Flu Symptoms?
While a cold and the flu can have similar symptoms, those symptoms are generally more intense and come on more quickly when you have the flu.
These flu symptoms can include the sudden onset of:
fever and chills
runny nose or stuffy nose
feelings of fatigue
And more rarely, vomiting and diarrhea.
In contrast, cold symptoms come on more gradually and are more likely to include sneezing, stuffy nose, sore throat, and mild to moderate coughing. A cold is also less likely to include a headache, fatigue, chills, or aches. And while either might have fever, it will be more low grade with a cold.
As with other infections, flu symptoms can be very variable. While some people might have a high fever, chills, body aches, constant coughing, and can hardly get out of bed, others might have a low grade fever and much milder symptoms.
That variability also applies to how long the flu symptoms might last. Some people are sick for a good 7 to 10 days, while others start to feel better in just a few days.
Treating Flu Symptoms
Although there aren’t many good treatments for the flu, that variability in flu symptoms makes it hard to even know if any you try really work.
For kids older than 4 to 6 years and adults, you could treat symptoms as necessary, including the use of decongestants and cough suppressants.
And of course, almost everyone might benefit from pain and fever relievers, drinking extra fluids, and rest, etc.
Treating the Flu
In addition to symptomatic flu treatments, there are also antiviral drugs that can actually help treat your flu infection.
These flu medications include oseltamivir (Tamiflu), zanmivir (Relenza), and peramivir (Rapivab). Of these, oral Tamiflu is the most commonly used. It can also be used to prevent the flu if taken before or soon after you are exposed to someone with the flu.
“If liquid Tamiflu is not available and you have capsules that give the right dose (30 mg, 45 mg or 75 mg), you may pull open the Tamiflu capsules and mix the powder with a small amount of sweetened liquid such as regular or sugar-free chocolate syrup. You don’t have to use chocolate syrup but thick, sweet liquids work best at covering up the taste of the medicine.”
FDA – Tamiflu: Consumer Questions and Answers
Unfortunately, these flu drugs are not like antibiotics you might take for a bacterial infection. You don’t take Tamiflu and begin to feel better in day or two. Instead, if you take it within 48 hours of the start of your flu symptoms, you might “shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza.”
At best, you are likely only going to shorten your flu symptoms by less than a day. And considering the possible side effects of these medications and their cost, they are often reserved for high risk patients, including:
children who are less than 2 years old
adults who are at least 65 years old or older
anyone with chronic medical problems, including asthma, diabetes, seizures, muscular dystrophy, morbid obesity, immune system problems, and those receiving long-term aspirin therapy, etc.
pregnant and postpartum women
anyone who is hospitalized with the flu
anyone with severe flu symptoms
That means that most older children and teens who are otherwise healthy, but have the flu, don’t typically need a prescription for Tamiflu. The current recommendations don’t rule out treating these kids though.
“Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.”
Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza – Recommendations of the Advisory Committee on Immunization Practices (ACIP)
There is a lot of controversy surrounding the use of Tamiflu and other anti-viral flu medications, with some studies and many experts thinking that they should rarely be used, if ever, stating that they are not as useful as others claim. Others state that while they not perfect, they are all we have, and there is enough evidence to recommend their use.
Treating Hard to Control Flu Symptoms
Instead of learning about treating hard to control flu symptoms, which might require medical attention, it is probably much more important to learn how to recognize these severe flu symptoms that might be hard to control.
Your child’s flu might be getting worse and require quick medical attention if you notice:
fast or hard breathing
complaints of chest pain
that it is hard to wake up your child
irritability to the point that your child is not consolable
More people seem to be getting the message that too little vitamin D in our diets can lead to health problems. In addition to being at risk of developing rickets (extreme vitamin D deficiency), children with milder forms of vitamin D deficiency can develop weak bones and muscle weakness.
Why is vitamin D so important?
Vitamin D is a hormone that helps our bodies absorb both calcium and phosphorous, two very important minerals that help keep our bones strong.
Without enough vitamin D, we absorb 85-90% less of the calcium in our diet! And then, to keep calcium levels normal, our bodies pull more calcium out of our bones, causing osteopenia and osteoporosis.
Some experts also think that a low vitamin D level is associated with other conditions that are not linked to calcium and our bones, including some psychiatric conditions. The American Academy of Pediatrics even states that “new evidence suggests that vitamin D plays a vital role in maintaining innate immunity and has been implicated in the prevention of certain disease states including infection, autoimmune diseases (multiple sclerosis, rheumatoid arthritis), some forms of cancer (breast, ovarian, colorectal, prostate), and type 2 diabetes mellitus.”
The role of vitamin D in preventing infections, cancer, or anything else beyond preventing and treating vitamin D deficiency (extraskeletal effects) is far from proven though. In fact, a 2010 investigation by the Institute of Medicine (IOM) didn’t find any evidence to support a role for vitamin D in any other health conditions besides supporting bone health.
Surprisingly to many people, the IOM report also found that most people in North America are already getting enough calcium and vitamin D in their diet and that getting too much can be harmful. They also warned that “the number of people with vitamin D deficiency in North America may be overestimated because many laboratories appear to be using cut-points that are much higher than the committee suggests is appropriate.”
Tests for Vitamin D Deficiency
Although vitamin D testing seems to becoming part of the routine screening tests that some doctors order, it is important to keep in mind that only those at risk for having low levels should be routinely tested.
Are your kids at risk for vitamin D deficiency?
These high risk children can include:
exclusively breastfed infants who don’t get a vitamin D supplement
babies born to mothers with a vitamin D deficiency, especially premature babies
children with chronic kidney or liver disease
children with malabsorption syndromes (Crohn’s disease, inflammatory bowel disease, cystic fibrosis, etc.), as vitamin D is absorbed with fats in our diet
obese children, because vitamin D is stored in fat tissue and is not readily available for use
children with dark skin, who live at high latitudes, and/or spend a lot of time indoors (less vitamin D from sun exposure)
children taking certain medications, including antiseizure medications and oral steroids
children who simply don’t get enough vitamin D – at least 400-600 IU of vitamin D each day, depending on their age. This might include vegetarians, vegans, and children who simply don’t drink vitamin D fortified cow’s milk, soy milk, or almond milk, etc., or other foods that are high in vitamin D.
If your child falls into one or more of these risk factors for vitamin D deficiency, then talk to your pediatrician about testing his vitamin D levels.
Although different tests are available, the test that is recommended by the AAP and the Endocrine Society is the serum 25(OH)D level (25-hydroxyvitamin D). This actually measures the levels of a prehormone of vitamin D, calcifediol, but is thought to give a good idea of a person’s vitamin D status.
This vitamin D test is preferred over testing 1,25(OH)2D levels, another test that is available, as those levels can be normal or even elevated when someone has a vitamin D deficiency. Similarly, measuring vitamin D levels (the active hormone) has not been found to be helpful. Instead, we use 25(OH)D levels as a marker for vitamin D levels.
Treating Vitamin D Deficiency
Is your child’s vitamin D level low?
That question is a actually a little harder to answer than you might realize. According to the IOM, in discussing cut-points for 25(OH)D levels, or what’s low and what’s normal, “At this time, there is no central body that is responsible for establishing such values for clinical use.”
The serum 25(OH)D level is typically defined as low (vitamin D deficiency) in children if it is below 20 ng/ml. Some experts think that a 25(OH)D level above 16 ng/ml is normal for infants and children though.
Experts do agree that a level below 5 ng/ml is a sign of a severe vitamin D deficiency.
Recommendations for treating children with low vitamin D levels depend on their age, and might include:
newborns: 1,000 IU /day vitamin D2 or D3
children 1 to 12 months old: 2,000 IU /day vitamin D2 or D3
children > 12 months old: 2,000 IU /day vitamin D2 or D3
These vitamin D supplements, together with adequate amounts of calcium, are usually continued for at least 1 to 3 months, at which time the child’s serum 25(OH)D level can be repeated to make sure it is responding to treatment.
“The upper limit for vitamin D is 1,000 to 1,500 IU/day for infants, 2,500 to 3,000 IU/day for children 1-8 years, and 4,000 IU/day for children 9 years and older, adults, and pregnant and lactating teens and women. Vitamin D toxicity almost always occurs from overuse of supplements.”
NIH Vitamin D Fact Sheet for Consumers
The Endocrine Society also advises that some children can take 50,000 IU of vitamin D2 once a week as an alternative treatment for vitamin D deficiency. Since you can definitely get too much vitamin D, be sure to talk to your pediatrician and make sure your child is getting the right dose before starting a treatment regimen for vitamin D deficiency.
Preventing Vitamin D Deficiency
Once you get your child’s vitamin D levels back into a normal range, it is important to take steps so that they don’t drop again.
To prevent vitamin D deficiency, the American Academy of Pediatrics recommends that healthy infants get at least 400 IU of vitamin D each day, while older children – toddlers to teens – get at least 600 IU. This vitamin D should come from some combination of:
foods that are naturally rich in vitamin D – salmon, tuna, shitake mushrooms, etc.
foods that are fortified with vitamin D – vitamin D fortified milk, orange juice, cheese, yogurt, margarine, and cereal, etc.
a vitamin D supplement – with just vitamin D, vitamin D plus calcium, or a children’s multivitamin
What about sunlight? Can’t your kids just spend more time in the sun to boost their vitamin D levels?
Although we all have the ability to make vitamin D when we are out in the sun, it isn’t considered a good source of vitamin D. Intentional, unprotected (no sunscreen) exposure to the sun has risks of sunburn and skin cancer. And it is very hard to judge how much sun exposure is necessary to get adequate amounts of vitamin D. The intensity of the sun’s radiation varies greatly in different parts of the world and at different times of year and will also affect how much vitamin D your body makes.
Other Things To Know about Vitamin D Deficiency
Raw milk, in addition to being unprocessed and unpasteurized, is unfortified and has very little vitamin D.
Although other foods may be fortified with vitamin D, in the United States, only milk, margarine, infant formula, and “fortified-plant based beverages” are mandated by the FDA to be vitamin D fortified.
In addition to low 25(OH)D levels, children with vitamin D deficiency will often have low phosphorous, high alkaline phosphatase, and high parathyroid hormone levels. These levels might be checked and monitored when kids are treated for vitamin D deficiency.
Vitamin D2 (ergocalciferol, derived from plants) and vitamin D3 (cholecalciferol, derived from animals) are two major forms of vitamin D. Some experts think that vitamin D3 is more potent than vitamin D2, especially at higher doses. Still, these prohormones are converted to the same active form of vitamin D (calcitriol) in the liver and kidney.
Some experts think that 25(OH)D levels between 21 and 30 ng/ml are a sign of vitamin D insufficiency in children, as in adults, and are a sign that the child needs more vitamin D in their diet.
Although the use of sunscreen can block the synthesis of vitamin D by blocking UVB radiation and has been blamed for lower vitamin D levels in recent years, many people likely don’t use sunscreen properly and don’t use it consistently enough and so “sunscreen use may not actually diminish vitamin D synthesis in real world use.”
Taking high doses of vitamin D is yet another nutrition fad which has been linked to serious consequences. Mega doses of vitamin D have been linked to kidney problems and tissue damage. That makes it important to stay below the upper limit that your child can likely take each day without causing harm, which ranges from 2,500 IU/day for toddlers to 4,000 IU/day for teenagers. Most only need 400 to 600 IU/day though.
Children with severe vitamin D deficiency are often managed by a pediatric endocrinologist or a pediatric nephrologist.
Study – American Academy of Pediatrics Clinical Report. Optimizing Bone Health in Children and Adolescents. Pediatrics. Pediatrics Oct 2014, 134 (4) e1229-e1243
Study – Institute of Medicine Report. Dietary Reference Intakes for Calcium and Vitamin D. Released: November 30, 2010.
Study – The Endocrine Society. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism, July 2011, 96(7):1911–1930.
Study – Misra, M. Vitamin D Deficiency in Children and Its Management. Pediatrics, Aug 2008; 122: 398 – 417.
The price of EpiPens has been in the news a lot recently.
Most people know that they went Mylan’s EpiPen 2-Pak went from costing about $100 in 2006 to over $600 today and that there has been little or no competition.
One competing device, Auvi-Q was recalled in 2015, but it was fairly expensive too.
Good News and Bad News About EpiPens
Things have gotten better recently.
First, a generic EpiPen 2-Pak is now available. It costs $339.99. While still expensive, it does lower co-pays for many people with good insurance.
The latest news? A generic Adrenaclick injector for $109.99 at CVS pharmacies.
Even better, coupons are available that can make the injectors free for many people.
So what’s the bad news?
The directions for using the EpiPen 2-Pak and the Adrenaclick are not the same. That can cause some confusion. Do you want someone to grab one and not be sure how to use it when your child is having a life-threatening allergic reaction?
That makes it important for everyone to be familiar with both types of epinephrine injectors.
Adrenaclick vs EpiPen 2-Pak Directions
The fact that the Adrenaclick has two caps that you need to remove before use, while the EpiPen only has one, can lead to confusion. Also, the Adrenaclick injector, despite its name, doesn’t actually ‘click’ after you use it, like the EpiPen does.
EpiPen 2-Pak auto-injector directions:
Remove the EpiPen Auto-Injector from the clear carrier tube to find an EpiPen Jr (green label) or EpiPen (yellow label).
Remove the blue safety release by pulling straight up without bending or twisting it.
Swing and firmly push orange tip against mid-outer thigh until it ‘clicks’.
Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
Remove auto-injector from the thigh and massage the injection area for 10 seconds.
Remember that the orange end is the needle end! And you know that your child got your dose if you heard the click sound.
Adrenaclick epinephrine auto-injector directions:
Remove the outer case.
Remove grey caps labeled “1” and “2”.
Place red rounded tip against mid-outer thigh.
Press down hard until needle enters thigh.
Hold in place for 10 seconds. Remove from thigh.
With the Adrenaclick injector, the red tip end is the needle end! Do not touch this end or you could unintentionally inject your self. After use, the needle should be visible.
Avoiding Confusion About Your Epinephrine Injector
All of the epinephrine injectors are easy to use. At least on paper.
In the heat of the moment though, when a child is having a life-threatening allergic reaction, it may not seem so easy though.
It will likely be even more difficult if the epinephrine injector you grab is not what you are expecting. Make sure you know how to use your epinephrine injector, both when your pediatrician prescribes it and when your pharmacist dispenses it to you (in case you get a different one, which is allowed in some states).
Read the instructions.
Watch a video.
Use a trainer device.
It is also important that anyone that watches your child, whether it is a family member or the school nurse, knows how to use your child’s epinephrine injector.
“Individuals and caregivers are often reluctant to use self-injectable epinephrine in anaphylaxis despite instruction to do so.”
Pediatrics March 2007
Other things that can lead to confusion about epinephrine injectors include that you:
use an EpiPen or Adrenaclick training pen instead of the real injector with active medication when your child is having an anaphalytic reaction
use the real injector when you meant to use the training pen
don’t carry your child’s epinephrine injector with you at all times, which is why it is important to get more than one injector each time, allowing you to keep one at school, one at home, and one and travels with your child, etc., eventually allowing your child to carry his or own epinephrine injector at an age-appropriate time
forget to move to a higher dose of epinephrine as you child grows, keeping in mind that the Jr (0.15mg) dosing is only for kids under 66 pounds
aren’t sure when to use your EpiPen or Adrenaclick injector or are afraid to use it, which can lead to an unnecessary delay in your child getting a lifesaving treatment
don’t get a refill if your epinephrine injectors have expired or you actually needed to use one
understand that you still need to call 911 after you have used your epinephrine injector, even if your child begins to immediately feel better. Symptoms can return, which is why you are given two doses (2-Pack) of epinephrine.
A good Food Allergy & Anaphylaxis Emergency Care Plan can help avoid much of this confusion. In addition to easy to read instructions on when to give epinephrine, this type of plan should include directions for your child’s epinephrine injector.
When in doubt – you should usually give epinephrine if you have any concerns that your child is having an anaphylactic reaction. It is a safe medicine.
Study – Sonia Dhanjal, PharmD, Stacie Lampkin, PharmD. Confusion With Substituting Epinephrine Auto-Injectors: A Focus On Medication Counseling, Dispensing, and Patient Education. Journal of Allergy and Clinical Immunology. Volume 133, Issue 2, Supplement, February 2014.